2020 Northwest Commercial Formulary (List of Covered Drugs)...What is a brand-name drug? Brand-name...

Last Updated 03/20/2020

2020 Northwest Commercial Formulary

(List of Covered Drugs)

Please Read: This document contains information about the drugs we cover when you participate in a Kaiser Permanente Commercial (non-Medicare) plan.

What is the Kaiser Permanente Northwest Commercial Formulary? A formulary is a list of covered drugs chosen by a group of Kaiser Permanente physicians and pharmacists known as the Formulary and Therapeutics Committee. This committee meets regularly to evaluate and select the safest, most effective medications for our members. What is a generic drug? Our plan 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. What is a brand-name drug? Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand-name drug expires, other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices. What are specialty-tier drugs? Specialty-tier drugs are very high-cost drugs. Kaiser Permanente Formulary The formulary list that begins on the next page provides coverage information about some of the drugs covered by our plan.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs are listed in lower-case italics (e.g. amoxicillin).

The second column will indicate what tier the drug is in. Drugs on our formulary are categorized as Generic, Preferred Brand or Specialty.

The third column of the chart will indicate any requirements or limits for that drug.

DS = A drug that is limited to no more than a 30-day supply per dispense.

PA = A drug that requires specific medical criteria be met and requires approval by the plan prior to being dispensed for benefit.

QL = A drug that is limited to no more than a specific quantity within a certain period of days.


Drug Name Drug Tier Requirements/Limits Analgesics No USP Class (Combination Product) acetaminophen-codeine #2 tabs 300-15 mg Generic acetaminophen-codeine #3 tabs 300-30 mg Generic acetaminophen-codeine soln 120-12 mg/5ml Generic hydrocodone-acetaminophen soln 7.5-325 mg/15ml Generic DS hydrocodone-acetaminophen tabs 10-325 mg Generic DS hydrocodone-acetaminophen tabs 5-325 mg Generic DS oxycodone-acetaminophen tabs 5-325 mg Generic DS Nonsteroidal Anti-Inflammatory Drugs etodolac caps 300 mg Generic etodolac tabs 400 mg Generic ibuprofen tabs 800 mg Generic indomethacin caps 25 mg Generic indomethacin caps 50 mg Generic ketorolac tromethamine soln 30 mg/ml Generic meloxicam tabs 15 mg Generic meloxicam tabs 7.5 mg Generic nabumetone tabs 500 mg Generic nabumetone tabs 750 mg Generic naproxen tabs 250 mg Generic naproxen tabs 375 mg Generic naproxen tabs 500 mg Generic sulindac tabs 150 mg Generic sulindac tabs 200 mg Generic Opioid Analgesics, Long-Acting fentanyl pt72 100 mcg/hr Generic DS fentanyl pt72 12 mcg/hr Generic DS fentanyl pt72 25 mcg/hr Generic DS fentanyl pt72 50 mcg/hr Generic DS fentanyl pt72 75 mcg/hr Generic DS methadone hcl conc 10 mg/ml Generic DS methadone hcl tabs 10 mg Generic DS methadone hcl tabs 5 mg Generic DS morphine sulfate (concentrate) soln 100 mg/5ml Generic DS morphine sulfate er tbcr 100 mg Generic DS morphine sulfate er tbcr 15 mg Generic DS morphine sulfate er tbcr 200 mg Generic DS morphine sulfate er tbcr 30 mg Generic DS morphine sulfate er tbcr 60 mg Generic DS morphine sulfate soln 10 mg/5ml Generic DS MORPHINE SULFATE TABS 15 MG Preferred Brand DS MORPHINE SULFATE TABS 30 MG Preferred Brand DS Opioid Analgesics, Short-Acting codeine sulfate tabs 30 mg Generic DS codeine sulfate tabs 60 mg Generic DS


hydromorphone hcl supp 3 mg Generic DS hydromorphone hcl tabs 2 mg Generic DS hydromorphone hcl tabs 4 mg Generic DS morphine sulfate supp 10 mg Generic DS morphine sulfate supp 20 mg Generic DS morphine sulfate supp 30 mg Generic DS oxycodone hcl soln 5 mg/5 ml Generic DS oxycodone hcl tabs 5 mg Generic DS oxycodone hcl tabs 10 mg Generic PA, DS oxycodone hcl tabs 15 mg Generic PA, DS tramadol hcl tabs 50 mg Generic Anesthetics Local Anesthetics lidocaine hcl gel 2 % Generic lidocaine hcl soln 4 % Generic lidocaine viscous soln 2 % Generic Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-Craving acamprosate calcium tbec 333 mg Generic disulfiram tabs 250 mg Generic No USP Class (Combination Product) buprenorphine hcl-naloxone hcl subl 2-0.5 mg Generic DS buprenorphine hcl-naloxone hcl subl 8-2 mg Generic DS Opioid Antagonists buprenorphine hcl subl 2 mg Generic DS buprenorphine hcl subl 8 mg Generic DS naloxone hcl sosy 2 mg/2ml Generic naltrexone hcl tabs 50 mg Generic NARCAN LIQD 4 MG/0.1ML Preferred Brand Smoking Cessation Agents bupropion hcl er (smoking det) tb12 150 mg Generic CHANTIX STARTING MONTH PAK TABS 0.5 MG X 11 & 1 MG X 42 Preferred Brand PA

CHANTIX TABS 0.5 MG Preferred Brand PA CHANTIX TABS 1 MG Preferred Brand PA gnp nicotine polacrilex lozg 2 mg Generic gnp nicotine polacrilex lozg 4 mg Generic nicotine kit 21-14-7 mg/24hr Generic nicotine polacrilex gum 2 mg Generic nicotine polacrilex gum 4 mg Generic nicotine pt24 14 mg/24hr Generic nicotine pt24 21 mg/24hr Generic nicotine pt24 7 mg/24hr Generic Antibacterials Aminoglycosides gentak oint 0.3 % Generic gentamicin sulfate crea 0.1 % Generic gentamicin sulfate oint 0.1 % Generic


gentamicin sulfate soln 0.3 % Generic neomycin sulfate tabs 500 mg Generic paromomycin sulfate caps 250 mg Generic TOBI PODHALER CAPS 28 MG Specialty tobramycin nebu 300 mg/5ml Generic tobramycin soln 0.3 % Generic Antibacterials, Other acetic acid soln 2 % Generic bacitracin oint 500 unit/gm Generic clindamycin hcl caps 150 mg Generic clindamycin hcl caps 300 mg Generic clindamycin palmitate hcl solr 75 mg/5ml Generic clindamycin phosphate gel 1 % Generic clindamycin phosphate lotn 1 % Generic clindamycin phosphate soln 1 % Generic FIRVANQ SOLR 50 MG/ML Preferred Brand linezolid susr 100 mg/5ml Generic linezolid tabs 600 mg Generic MACRODANTIN CAPS 25 MG Preferred Brand metronidazole crea 0.75 % Generic metronidazole gel 0.75 % Generic metronidazole tabs 250 mg Generic metronidazole tabs 500 mg Generic MONUROL PACK 3 GM Preferred Brand mupirocin oint 2 % Generic nitrofurantoin macrocrystal caps 100 mg Generic nitrofurantoin macrocrystal caps 50 mg Generic nitrofurantoin monohyd macro caps 100 mg Generic trimethoprim tabs 100 mg Generic vancomycin hcl caps 125 mg Generic vancomycin hcl caps 250 mg Generic vancomycin hcl solr 250 mg/5ml Generic Beta-Lactam, Cephalosporins cefadroxil caps 500 mg Generic cefdinir caps 300 mg Generic cefdinir susr 125 mg/5ml Generic cefdinir susr 250 mg/5ml Generic cefixime caps 400 mg Generic cefpodoxime proxetil susr 100 mg/5ml Generic cefpodoxime proxetil tabs 200 mg Generic cefuroxime axetil tabs 250 mg Generic cefuroxime axetil tabs 500 mg Generic cephalexin caps 250 mg Generic cephalexin caps 500 mg Generic cephalexin susr 125 mg/5ml Generic cephalexin susr 250 mg/5ml Generic Beta-Lactam, Penicillins amoxicillin caps 250 mg Generic


amoxicillin caps 500 mg Generic amoxicillin susr 125 mg/5ml Generic amoxicillin susr 250 mg/5ml Generic amoxicillin susr 400 mg/5ml Generic amoxicillin-pot clavulanate chew 200-28.5 mg Generic amoxicillin-pot clavulanate chew 400-57 mg Generic amoxicillin-pot clavulanate susr 200-28.5 mg/5ml Generic amoxicillin-pot clavulanate susr 400-57 mg/5ml Generic amoxicillin-pot clavulanate susr 600-42.9 mg/5ml Generic amoxicillin-pot clavulanate tabs 500-125 mg Generic amoxicillin-pot clavulanate tabs 875-125 mg Generic dicloxacillin sodium caps 250 mg Generic dicloxacillin sodium caps 500 mg Generic penicillin v potassium solr 125 mg/5ml Generic penicillin v potassium solr 250 mg/5ml Generic penicillin v potassium tabs 250 mg Generic penicillin v potassium tabs 500 mg Generic Macrolides azithromycin susr 100 mg/5ml Generic azithromycin susr 200 mg/5ml Generic azithromycin tabs 250 mg Generic azithromycin tabs 600 mg Generic clarithromycin tabs 500 mg Generic ery-tab tbec 250 mg Generic erythromycin ethylsuccinate susr 400 mg/5ml Generic erythromycin oint 5 mg/gm Generic erythromycin soln 2 % Generic Quinolones ciprofloxacin hcl soln 0.3 % Generic ciprofloxacin hcl tabs 250 mg Generic ciprofloxacin hcl tabs 500 mg Generic ciprofloxacin hcl tabs 750 mg Generic levofloxacin soln 25 mg/ml Generic levofloxacin tabs 250 mg Generic levofloxacin tabs 500 mg Generic levofloxacin tabs 750 mg Generic moxifloxacin hcl soln 0.5 % Generic ofloxacin soln 0.3 % Generic Sulfonamides silver sulfadiazine crea 1 % Generic sulfacetamide sodium soln 10 % Generic sulfadiazine tabs 500 mg Generic sulfamethoxazole-trimethoprim susp 200-40 mg/5ml Generic sulfamethoxazole-trimethoprim tabs 400-80 mg Generic sulfamethoxazole-trimethoprim tabs 800-160 mg Generic Tetracyclines doxycycline hyclate caps 100 mg Generic doxycycline hyclate caps 50 mg Generic


doxycycline hyclate tabs 20 mg Generic doxycycline monohydrate tabs 100 mg Generic doxycycline monohydrate tabs 50 mg Generic minocycline hcl caps 100 mg Generic minocycline hcl caps 50 mg Generic Anticonvulsants Anticonvulsants, Other levetiracetam er tb24 500 mg Generic levetiracetam er tb24 750 mg Generic levetiracetam soln 100 mg/ml Generic levetiracetam tabs 1000 mg Generic levetiracetam tabs 250 mg Generic levetiracetam tabs 500 mg Generic levetiracetam tabs 750 mg Generic Calcium Channel Modifying Agents CELONTIN CAPS 300 MG Preferred Brand ethosuximide caps 250 mg Generic ethosuximide soln 250 mg/5ml Generic zonisamide caps 100 mg Generic zonisamide caps 25 mg Generic zonisamide caps 50 mg Generic Gamma-Aminobutyric Acid (GABA) Augmenting Agents clonazepam tabs 0.5 mg Generic clonazepam tabs 1 mg Generic clonazepam tabs 2 mg Generic divalproex sodium csdr 125 mg Generic divalproex sodium er tb24 250 mg Generic divalproex sodium er tb24 500 mg Generic divalproex sodium tbec 125 mg Generic divalproex sodium tbec 250 mg Generic divalproex sodium tbec 500 mg Generic gabapentin caps 100 mg Generic gabapentin caps 300 mg Generic gabapentin caps 400 mg Generic gabapentin tabs 600 mg Generic gabapentin tabs 800 mg Generic phenobarbital elix 20 mg/5ml Generic phenobarbital tabs 16.2 mg Generic phenobarbital tabs 32.4 mg Generic phenobarbital tabs 64.8 mg Generic phenobarbital tabs 97.2 mg Generic primidone tabs 250 mg Generic primidone tabs 50 mg Generic tiagabine hcl tabs 2 mg Generic tiagabine hcl tabs 4 mg Generic tiagabine hcl tabs 12 mg Generic tiagabine hcl tabs 16 mg Generic valproic acid caps 250 mg Generic


valproic acid soln 250 mg/5ml Generic Glutamate Reducing Agents lamotrigine chew 25 mg Generic lamotrigine chew 5 mg Generic lamotrigine tabs 100 mg Generic lamotrigine tabs 150 mg Generic lamotrigine tabs 200 mg Generic lamotrigine tabs 25 mg Generic topiramate cpsp 15 mg Generic topiramate cpsp 25 mg Generic topiramate tabs 100 mg Generic topiramate tabs 200 mg Generic topiramate tabs 25 mg Generic topiramate tabs 50 mg Generic Sodium Channel Agents carbamazepine chew 100 mg Generic carbamazepine er cp12 100 mg Generic carbamazepine er cp12 200 mg Generic carbamazepine er cp12 300 mg Generic carbamazepine er tb12 100 mg Generic carbamazepine er tb12 200 mg Generic carbamazepine er tb12 400 mg Generic carbamazepine susp 100 mg/5ml Generic carbamazepine tabs 200 mg Generic dilantin caps 30 mg Generic oxcarbazepine susp 300 mg/5ml Generic oxcarbazepine tabs 150 mg Generic oxcarbazepine tabs 300 mg Generic oxcarbazepine tabs 600 mg Generic phenytoin chew 50 mg Generic phenytoin sodium extended caps 100 mg Generic phenytoin susp 125 mg/5ml Generic Antidementia Agents Cholinesterase Inhibitors donepezil hcl tabs 10 mg Generic donepezil hcl tabs 5 mg Generic galantamine hydrobromide er cp24 16 mg Generic galantamine hydrobromide er cp24 24 mg Generic galantamine hydrobromide er cp24 8 mg Generic galantamine hydrobromide tabs 12 mg Generic galantamine hydrobromide tabs 4 mg Generic galantamine hydrobromide tabs 8 mg Generic N-Methyl-D-Aspartate (NMDA) Receptor Antagonists memantine hcl tabs 10 mg Generic memantine hcl tabs 5 mg Generic Antidepressants Antidepressants, Other aripiprazole tabs 10 mg Generic


aripiprazole tabs 15 mg Generic aripiprazole tabs 2 mg Generic aripiprazole tabs 20 mg Generic aripiprazole tabs 30 mg Generic aripiprazole tabs 5 mg Generic bupropion hcl er (sr) tb12 100 mg Generic bupropion hcl er (sr) tb12 150 mg Generic bupropion hcl er (sr) tb12 200 mg Generic bupropion hcl er (xl) tb24 150 mg Generic bupropion hcl er (xl) tb24 300 mg Generic bupropion hcl tabs 100 mg Generic bupropion hcl tabs 75 mg Generic mirtazapine tabs 15 mg Generic mirtazapine tabs 30 mg Generic mirtazapine tabs 45 mg Generic trazodone hcl tabs 100 mg Generic trazodone hcl tabs 50 mg Generic Monoamine Oxidase Inhibitors phenelzine sulfate tabs 15 mg Generic tranylcypromine sulfate tabs 10 mg Generic Serotonin/Norepinephrine Reuptake Inhibitors citalopram hydrobromide soln 10 mg/5ml Generic citalopram hydrobromide tabs 10 mg Generic citalopram hydrobromide tabs 20 mg Generic citalopram hydrobromide tabs 40 mg Generic desvenlafaxine succinate er tb24 25 mg Generic desvenlafaxine succinate er tb24 50 mg Generic desvenlafaxine succinate er tb24 100 mg Generic duloxetine hcl cpep 20 mg Generic duloxetine hcl cpep 30 mg Generic duloxetine hcl cpep 60 mg Generic escitalopram oxalate tabs 10 mg Generic escitalopram oxalate tabs 20 mg Generic escitalopram oxalate tabs 5 mg Generic fluoxetine hcl caps 10 mg Generic fluoxetine hcl caps 20 mg Generic fluoxetine hcl caps 40 mg Generic fluoxetine hcl soln 20 mg/5ml Generic fluvoxamine maleate tabs 100 mg Generic fluvoxamine maleate tabs 25 mg Generic fluvoxamine maleate tabs 50 mg Generic paroxetine hcl tabs 10 mg Generic paroxetine hcl tabs 20 mg Generic paroxetine hcl tabs 30 mg Generic paroxetine hcl tabs 40 mg Generic sertraline hcl tabs 100 mg Generic sertraline hcl tabs 25 mg Generic sertraline hcl tabs 50 mg Generic


venlafaxine hcl er cp24 150 mg Generic venlafaxine hcl er cp24 37.5 mg Generic venlafaxine hcl er cp24 75 mg Generic venlafaxine hcl tabs 100 mg Generic venlafaxine hcl tabs 25 mg Generic venlafaxine hcl tabs 37.5 mg Generic venlafaxine hcl tabs 50 mg Generic venlafaxine hcl tabs 75 mg Generic Tricyclics amitriptyline hcl tabs 10 mg Generic amitriptyline hcl tabs 100 mg Generic amitriptyline hcl tabs 150 mg Generic amitriptyline hcl tabs 25 mg Generic amitriptyline hcl tabs 50 mg Generic amitriptyline hcl tabs 75 mg Generic desipramine hcl tabs 10 mg Generic desipramine hcl tabs 25 mg Generic desipramine hcl tabs 50 mg Generic desipramine hcl tabs 75 mg Generic desipramine hcl tabs 100 mg Generic desipramine hcl tabs 150 mg Generic doxepin hcl caps 10 mg Generic doxepin hcl caps 25 mg Generic doxepin hcl caps 50 mg Generic doxepin hcl conc 10 mg/ml Generic nortriptyline hcl caps 10 mg Generic nortriptyline hcl caps 25 mg Generic nortriptyline hcl caps 50 mg Generic nortriptyline hcl caps 75 mg Generic protriptyline hcl tabs 10 mg Generic protriptyline hcl tabs 5 mg Generic Antiemetics Antiemetics, Other chlorpromazine hcl tabs 10 mg Generic chlorpromazine hcl tabs 100 mg Generic chlorpromazine hcl tabs 200 mg Generic chlorpromazine hcl tabs 25 mg Generic chlorpromazine hcl tabs 50 mg Generic hydroxyzine hcl soln 10 mg/5ml Generic hydroxyzine hcl soln 50 mg/ml Generic hydroxyzine hcl tabs 10 mg Generic hydroxyzine hcl tabs 25 mg Generic hydroxyzine hcl tabs 50 mg Generic hydroxyzine pamoate caps 25 mg Generic hydroxyzine pamoate caps 50 mg Generic metoclopramide hcl soln 5 mg/5ml Generic metoclopramide hcl tabs 10 mg Generic metoclopramide hcl tabs 5 mg Generic


perphenazine tabs 16 mg Generic perphenazine tabs 2 mg Generic perphenazine tabs 4 mg Generic perphenazine tabs 8 mg Generic prochlorperazine maleate tabs 10 mg Generic prochlorperazine maleate tabs 5 mg Generic prochlorperazine supp 25 mg Generic promethazine hcl syrp 6.25 mg/5ml Generic promethazine hcl tabs 25 mg Generic promethegan supp 12.5 mg Generic promethegan supp 25 mg Generic scopolamine pt72 1 mg/3days Generic TRANSDERM-SCOP (1.5 MG) PT72 1 MG/3DAYS Preferred Brand Emetogenic Therapy Adjuncts AKYNZEO CAPS 300-0.5 MG Preferred Brand DS ondansetron hcl tabs 4 mg Generic ondansetron hcl tabs 8 mg Generic ondansetron tbdp 4 mg Generic ondansetron tbdp 8 mg Generic Antifungals clotrimazole troc 10 mg Generic fluconazole tabs 100 mg Generic fluconazole tabs 150 mg Generic fluconazole tabs 200 mg Generic fluconazole tabs 50 mg Generic FLUCYTOSINE CAPS 250 MG Specialty FLUCYTOSINE CAPS 500 MG Specialty griseofulvin microsize susp 125 mg/5ml Generic griseofulvin ultramicrosize tabs 125 mg Generic griseofulvin ultramicrosize tabs 250 mg Generic ketoconazole crea 2 % Generic ketoconazole sham 2 % Generic ketoconazole tabs 200 mg Generic NATACYN SUSP 5 % Preferred Brand NOXAFIL SUSP 40 MG/ML Specialty nystatin crea 100000 unit/gm Generic nystatin oint 100000 unit/gm Generic nystatin susp 100000 unit/ml Generic nystop powd 100000 unit/gm Generic posaconazole tbec 100 mg Specialty terbinafine hcl tabs 250 mg Generic voriconazole tabs 200 mg Generic voriconazole tabs 50 mg Generic Antigout Agents allopurinol tabs 100 mg Generic allopurinol tabs 300 mg Generic probenecid tabs 500 mg Generic colchicine-probenecid tabs 0.5-500 mg Generic


Antimigraine Agents Ergot Alkaloids dihydroergotamine mesylate soln 1 mg/ml Generic DS dihydroergotamine mesylate soln 4 mg/ml Generic No USP Class (Combination Product) MIGERGOT SUPP 2-100 MG Preferred Brand Serotonin (5-HT) 1B/1D Receptor Agonists naratriptan hcl tabs 1 mg Generic naratriptan hcl tabs 2.5 mg Generic rizatriptan benzoate tabs 10 mg Generic rizatriptan benzoate tabs 5 mg Generic rizatriptan benzoate tbdp 10 mg Generic rizatriptan benzoate tbdp 5 mg Generic sumatriptan soln 20 mg/act Generic sumatriptan succinate refill soct 6 mg/0.5ml Generic sumatriptan succinate soaj 6 mg/0.5ml Generic sumatriptan succinate soln 6 mg/0.5ml Generic sumatriptan succinate tabs 100 mg Generic sumatriptan succinate tabs 25 mg Generic sumatriptan succinate tabs 50 mg Generic Antimyasthenic Agents Parasympathomimetics pyridostigmine bromide er tbcr 180 mg Generic pyridostigmine bromide tabs 60 mg Generic Antimycobacterials Antimycobacterials, Other dapsone tabs 100 mg Generic dapsone tabs 25 mg Generic rifabutin caps 150 mg Generic Antituberculars ethambutol hcl tabs 100 mg Generic ethambutol hcl tabs 400 mg Generic isoniazid syrp 50 mg/5ml Generic isoniazid tabs 100 mg Generic isoniazid tabs 300 mg Generic pyrazinamide tabs 500 mg Generic rifamate caps 150-300 mg Generic rifampin caps 150 mg Generic rifampin caps 300 mg Generic TRECATOR TABS 250 MG Preferred Brand Antineoplastics Alkylating Agents cyclophosphamide caps 25 mg Generic cyclophosphamide caps 50 mg Generic GLEOSTINE CAPS 10 MG Preferred Brand GLEOSTINE CAPS 40 MG Specialty GLEOSTINE CAPS 100 MG Specialty HEXALEN CAPS 50 MG Specialty DS


LEUKERAN TABS 2 MG Preferred Brand LOMUSTINE CAPS 100 MG Preferred Brand MATULANE CAPS 50 MG Specialty DS melphalan tabs 2 mg Generic MYLERAN TABS 2 MG Preferred Brand temozolomide caps 100 mg Generic temozolomide caps 140 mg Generic temozolomide caps 180 mg Generic temozolomide caps 20 mg Generic temozolomide caps 250 mg Generic temozolomide caps 5 mg Generic Antiangiogenic Agents

REVLIMID CAPS 2.5 MG Specialty DS, QL (28 PER 28 DAYS)

REVLIMID CAPS 5 MG Specialty DS, QL (28 PER 28 DAYS)




REVLIMID CAPS 25 MG Specialty DS, QL (21 PER 28 DAYS) Antiestrogens/Modifiers tamoxifen citrate tabs 10 mg Generic tamoxifen citrate tabs 20 mg Generic Antimetabolites capecitabine tabs 150 mg Generic DS capecitabine tabs 500 mg Generic DS hydroxyurea caps 500 mg Generic LONSURF TABS 15-6.14 MG Specialty DS LONSURF TABS 20-8.19 MG Specialty DS PURIXAN SUSP 2000 MG/100ML Specialty DS TABLOID TABS 40 MG Preferred Brand Antineoplastics, Other etoposide caps 50 mg Generic JAKAFI TABS 10 MG Specialty DS JAKAFI TABS 15 MG Specialty DS JAKAFI TABS 20 MG Specialty DS JAKAFI TABS 25 MG Specialty DS JAKAFI TABS 5 MG Specialty DS leucovorin calcium tabs 25 mg Generic leucovorin calcium tabs 5 mg Generic

ODOMZO CAPS 200 MG Specialty PA, DS, QL (30 PER 30 DAYS) Aromatase Inhibitors, 3rd Generation anastrozole tabs 1 mg Generic


letrozole tabs 2.5 mg Generic Enzyme Inhibitors ALECENSA CAPS 150 MG Specialty DS

COTELLIC TABS 20 MG Specialty DS, QL (63 PER 28 DAYS)

IBRANCE CAPS 75 MG Specialty DS, QL (21 PER 28 DAYS)

IBRANCE CAPS 100 MG Specialty DS, QL (21 PER 28 DAYS)

IBRANCE CAPS 125 MG Specialty DS, QL (21 PER 28 DAYS) IRESSA TABS 250 MG Specialty DS LENVIMA 4 MG DAILY DOSE CPPK 4 MG Specialty PA, DS LENVIMA 10 MG DAILY DOSE CPPK 10 MG Specialty PA, DS LENVIMA 12 MG DAILY DOSE CPPK 3 X 4 MG Specialty PA, DS LENVIMA 14 MG DAILY DOSE CPPK 10 & 4 MG Specialty PA, DS LENVIMA 20 MG DAILY DOSE CPPK 10 (2) MG Specialty PA, DS LENVIMA 24 MG DAILY DOSE CPPK 10 (2) & 4 MG Specialty PA, DS LORBRENA TABS 25 MG Specialty PA, DS LORBRENA TABS 100 MG Specialty PA, DS LYNPARZA TABS 100 MG Specialty DS LYNPARZA TABS 150 MG Specialty DS MEKINIST TABS 0.5 MG Specialty DS MEKINIST TABS 2 MG Specialty DS NINLARO CAPS 2.3 MG Specialty DS NINLARO CAPS 3 MG Specialty DS NINLARO CAPS 4 MG Specialty DS RYDAPT CAPS 25 MG Specialty DS

TAFINLAR CAPS 50 MG Specialty DS, QL (120 PER 30 DAYS)

TAFINLAR CAPS 75 MG Specialty DS, QL (120 PER 30 DAYS) TAGRISSO TABS 40 MG Specialty DS TAGRISSO TABS 80 MG Specialty DS VELCADE SOLR 3.5 MG Preferred Brand ZEJULA CAPS 100 MG Specialty DS Molecular Target Inhibitors AFINITOR TABS 10 MG Specialty DS AFINITOR TABS 2.5 MG Specialty DS AFINITOR TABS 5 MG Specialty DS AFINITOR TABS 7.5 MG Specialty DS

erlotinib hcl tabs 25 mg Generic DS, QL (90 PER 30 DAYS)

erlotinib hcl tabs 100 mg Generic DS, QL (30 PER 30 DAYS)

erlotinib hcl tabs 150 mg Generic DS, QL (30 PER 30 DAYS) everolimus tabs 2.5 mg Specialty DS


everolimus tabs 5 mg Specialty DS everolimus tabs 7.5 mg Specialty DS imatinib mesylate tabs 100 mg Generic imatinib mesylate tabs 400 mg Generic

IMBRUVICA CAPS 140 MG Specialty DS, QL (90 PER 30 DAYS) IMBRUVICA TABS 140 MG Specialty DS

IMBRUVICA TABS 280 MG Specialty DS, QL (30 PER 30 DAYS)



NEXAVAR TABS 200 MG Specialty DS, QL (30 PER 30 DAYS)

SPRYCEL TABS 100 MG Specialty DS, QL (30 PER 30 DAYS)




SPRYCEL TABS 70 MG Specialty DS, QL (30 PER 30 DAYS) SUTENT CAPS 12.5 MG Specialty DS SUTENT CAPS 25 MG Specialty DS SUTENT CAPS 50 MG Specialty DS

TYKERB TABS 250 MG Specialty DS, QL (180 PER 30 DAYS) VOTRIENT TABS 200 MG Specialty DS ZELBORAF TABS 240 MG Specialty DS Monoclonal Antibodies HERCEPTIN SOLR 440 MG Preferred Brand No USP Class MESNEX TABS 400 MG Preferred Brand DS

XTANDI CAPS 40 MG Specialty DS, QL (120 PER 30 DAYS) Retinoids RETIN-A CREA 0.025 % Preferred Brand RETIN-A CREA 0.05 % Preferred Brand RETIN-A CREA 0.1 % Preferred Brand RETIN-A GEL 0.01 % Preferred Brand RETIN-A GEL 0.025 % Preferred Brand RETIN-A MICRO GEL 0.1 % Preferred Brand tretinoin caps 10 mg Generic DS Antiparasitics Anthelmintics


albendazole tabs 200 mg Generic DS ivermectin tabs 3 mg Generic praziquantel tabs 600 mg Generic Antiprotozoals ALINIA SUSR 100 MG/5ML Preferred Brand atovaquone susp 750 mg/5ml Generic atovaquone-proguanil hcl tabs 250-100 mg Generic atovaquone-proguanil hcl tabs 62.5-25 mg Generic chloroquine phosphate tabs 500 mg Generic COARTEM TABS 20-120 MG Preferred Brand DARAPRIM TABS 25 MG Preferred Brand DS hydroxychloroquine sulfate tabs 200 mg Generic KRINTAFEL TABS 150 MG Preferred Brand mefloquine hcl tabs 250 mg Generic primaquine phosphate tabs 26.3 mg Generic YODOXIN TABS 650 MG Preferred Brand Pediculicides/Scabicides permethrin crea 5 % Generic Antiparkinson Agents Anticholinergics benztropine mesylate tabs 0.5 mg Generic benztropine mesylate tabs 1 mg Generic benztropine mesylate tabs 2 mg Generic trihexyphenidyl hcl tabs 2 mg Generic trihexyphenidyl hcl tabs 5 mg Generic Antiparkinson Agents, Other amantadine hcl caps 100 mg Generic amantadine hcl syrp 50 mg/5ml Generic amantadine hcl tabs 100 mg Generic entacapone tabs 200 mg Generic Dopamine Agonists bromocriptine mesylate tabs 2.5 mg Generic pramipexole dihydrochloride tabs 0.125 mg Generic pramipexole dihydrochloride tabs 0.25 mg Generic pramipexole dihydrochloride tabs 0.5 mg Generic pramipexole dihydrochloride tabs 0.75 mg Generic pramipexole dihydrochloride tabs 1 mg Generic pramipexole dihydrochloride tabs 1.5 mg Generic ropinirole hcl tabs 0.25 mg Generic ropinirole hcl tabs 0.5 mg Generic ropinirole hcl tabs 1 mg Generic ropinirole hcl tabs 2 mg Generic ropinirole hcl tabs 3 mg Generic ropinirole hcl tabs 4 mg Generic ropinirole hcl tabs 5 mg Generic Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors carbidopa-levodopa er tbcr 25-100 mg Generic carbidopa-levodopa er tbcr 50-200 mg Generic


carbidopa-levodopa tabs 10-100 mg Generic carbidopa-levodopa tabs 25-100 mg Generic carbidopa-levodopa tabs 25-250 mg Generic LODOSYN TABS 25 MG Preferred Brand Monoamine Oxidase B (MAO-B) Inhibitors selegiline hcl caps 5 mg Generic No USP Class (Combination Product) carbidopa-levodopa-entacapone tabs 12.5-50-200 mg Generic carbidopa-levodopa-entacapone tabs 18.75-75-200 mg Generic carbidopa-levodopa-entacapone tabs 25-100-200 mg Generic carbidopa-levodopa-entacapone tabs 31.25-125-200 mg Generic carbidopa-levodopa-entacapone tabs 37.5-150-200 mg Generic carbidopa-levodopa-entacapone tabs 50-200-200 mg Generic Antipsychotics 1st Generation/Typical fluphenazine hcl tabs 1 mg Generic fluphenazine hcl tabs 10 mg Generic fluphenazine hcl tabs 2.5 mg Generic fluphenazine hcl tabs 5 mg Generic haloperidol lactate conc 2 mg/ml Generic haloperidol tabs 0.5 mg Generic haloperidol tabs 1 mg Generic haloperidol tabs 10 mg Generic haloperidol tabs 2 mg Generic haloperidol tabs 5 mg Generic loxapine succinate caps 10 mg Generic loxapine succinate caps 25 mg Generic loxapine succinate caps 5 mg Generic loxapine succinate caps 50 mg Generic molindone hcl tabs 25 mg Generic thiothixene caps 1 mg Generic thiothixene caps 10 mg Generic thiothixene caps 2 mg Generic thiothixene caps 5 mg Generic trifluoperazine hcl tabs 1 mg Generic trifluoperazine hcl tabs 10 mg Generic trifluoperazine hcl tabs 2 mg Generic trifluoperazine hcl tabs 5 mg Generic 2nd Generation/Atypical olanzapine tabs 10 mg Generic olanzapine tabs 15 mg Generic olanzapine tabs 2.5 mg Generic olanzapine tabs 20 mg Generic olanzapine tabs 5 mg Generic olanzapine tabs 7.5 mg Generic quetiapine fumarate er tb24 50 mg Generic quetiapine fumarate er tb24 200 mg Generic quetiapine fumarate er tb24 300 mg Generic


quetiapine fumarate er tb24 400 mg Generic quetiapine fumarate tabs 100 mg Generic quetiapine fumarate tabs 200 mg Generic quetiapine fumarate tabs 25 mg Generic quetiapine fumarate tabs 300 mg Generic quetiapine fumarate tabs 400 mg Generic quetiapine fumarate tabs 50 mg Generic risperidone soln 1 mg/ml Generic risperidone tabs 0.25 mg Generic risperidone tabs 0.5 mg Generic risperidone tabs 1 mg Generic risperidone tabs 2 mg Generic risperidone tabs 3 mg Generic risperidone tabs 4 mg Generic ziprasidone hcl caps 20 mg Generic ziprasidone hcl caps 40 mg Generic ziprasidone hcl caps 60 mg Generic ziprasidone hcl caps 80 mg Generic Treatment-Resistant clozapine tabs 100 mg Generic clozapine tabs 200 mg Generic clozapine tabs 25 mg Generic clozapine tabs 50 mg Generic Antispasticity Agents baclofen tabs 10 mg Generic baclofen tabs 20 mg Generic dantrolene sodium caps 100 mg Generic dantrolene sodium caps 25 mg Generic dantrolene sodium caps 50 mg Generic tizanidine hcl tabs 2 mg Generic tizanidine hcl tabs 4 mg Generic Antivirals Anti-Cytomegalovirus (CMV) Agents VALCYTE SOLR 50 MG/ML Preferred Brand DS valganciclovir hcl tabs 450 mg Generic DS Antihepatitis Agents adefovir dipivoxil tabs 10 mg Generic entecavir tabs 0.5 mg Generic entecavir tabs 1 mg Generic

EPCLUSA TABS 400-100 MG Preferred Brand DS, QL (28 PER 28 DAYS) HARVONI TABS 45-200 MG Preferred Brand DS

HARVONI TABS 90-400 MG Preferred Brand DS, QL (28 PER 28 DAYS) INTRON A SOLN 10000000 UNIT/ML Preferred Brand DS PEGASYS PROCLICK SOLN 180 MCG/0.5ML Preferred Brand DS PEGASYS SOLN 180 MCG/0.5ML Preferred Brand DS PEGINTRON KIT 50 MCG/0.5ML Specialty


PEGINTRON KIT 80 MCG/0.5ML Preferred Brand PEG-INTRON REDIPEN KIT 80 MCG/0.5ML Preferred Brand PEG-INTRON REDIPEN KIT 120 MCG/0.5ML Preferred Brand ribavirin caps 200 mg Generic SOVALDI TABS 400 MG Preferred Brand DS

VOSEVI TABS 400-100-100 MG Preferred Brand DS, QL (28 PER 28 DAYS) Antiherpetic Agents acyclovir caps 200 mg Generic acyclovir susp 200 mg/5ml Generic acyclovir tabs 400 mg Generic acyclovir tabs 800 mg Generic trifluridine soln 1 % Generic Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors EDURANT TABS 25 MG Preferred Brand efavirenz caps 50 mg Generic efavirenz caps 200 mg Generic efavirenz tabs 600 mg Generic INTELENCE TABS 100 MG Preferred Brand INTELENCE TABS 200 MG Preferred Brand nevirapine tabs 200 mg Generic PIFELTRO TABS 100 MG Preferred Brand RESCRIPTOR TABS 100 MG Preferred Brand RESCRIPTOR TABS 200 MG Preferred Brand Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate tabs 300 mg Generic abacavir sulfate-lamivudine tabs 600-300 mg Generic abacavir-lamivudine-zidovudine tabs 300-150-300 mg Generic didanosine cpdr 200 mg Generic didanosine cpdr 250 mg Generic didanosine cpdr 400 mg Generic EMTRIVA SOLN 10 MG/ML Preferred Brand lamivudine soln 10 mg/ml Generic lamivudine tabs 100 mg Generic lamivudine tabs 150 mg Generic lamivudine tabs 300 mg Generic lamivudine-zidovudine tabs 150-300 mg Generic tenofovir disoproxil fumarate tabs 300 mg Generic TRUVADA TABS 200-300 MG Preferred Brand VIREAD POWD 40 MG/GM Preferred Brand VIREAD TABS 150 MG Preferred Brand ZIAGEN SOLN 20 MG/ML Preferred Brand zidovudine caps 100 mg Generic zidovudine syrp 50 mg/5ml Generic zidovudine tabs 300 mg Generic Anti-HIV Agents, Other FUZEON SOLR 90 MG Preferred Brand DS ISENTRESS CHEW 100 MG Preferred Brand


ISENTRESS CHEW 25 MG Preferred Brand ISENTRESS PACK 100 MG Preferred Brand ISENTRESS TABS 400 MG Preferred Brand ISENTRESS HD TABS 600 MG Preferred Brand JULUCA TABS 50-25 MG Preferred Brand SELZENTRY TABS 25 MG Preferred Brand SELZENTRY TABS 75 MG Preferred Brand SELZENTRY TABS 150 MG Preferred Brand SELZENTRY TABS 300 MG Preferred Brand SYMTUZA TABS 800-150-200-10 MG Preferred Brand TIVICAY TABS 50 MG Preferred Brand Anti-HIV Agents, Protease Inhibitors atazanavir sulfate caps 150 mg Generic atazanavir sulfate caps 200 mg Generic atazanavir sulfate caps 300 mg Generic EVOTAZ TABS 300-150 MG Preferred Brand KALETRA TABS 100-25 MG Preferred Brand KALETRA TABS 200-50 MG Preferred Brand lopinavir-ritonavir soln 400-100 mg/5ml Generic NORVIR SOLN 80 MG/ML Preferred Brand PREZCOBIX TABS 800-150 MG Preferred Brand PREZISTA TABS 150 MG Preferred Brand PREZISTA TABS 600 MG Preferred Brand PREZISTA TABS 75 MG Preferred Brand PREZISTA TABS 800 MG Preferred Brand ritonavir tabs 100 mg Generic VIRACEPT TABS 250 MG Preferred Brand VIRACEPT TABS 625 MG Preferred Brand Anti-Influenza Agents oseltamivir phosphate caps 30 mg Generic oseltamivir phosphate caps 75 mg Generic RELENZA DISKHALER AEPB 5 MG/BLISTER Preferred Brand rimantadine hcl tabs 100 mg Generic TAMIFLU SUSR 6 MG/ML Preferred Brand No USP Class (Combination Product) ATRIPLA TABS 600-200-300 MG Preferred Brand BIKTARVY TABS 50-200-25 MG Preferred Brand COMPLERA TABS 200-25-300 MG Preferred Brand PA DESCOVY TABS 200-25 MG Preferred Brand PA DOVATO TABS 50-300 MG Preferred Brand GENVOYA TABS 150-150-200-10 MG Preferred Brand ODEFSEY TABS 200-25-25 MG Preferred Brand STRIBILD TABS 150-150-200-300 MG Preferred Brand PA SYMFI TABS 600-300-300 MG Preferred Brand TRIUMEQ TABS 600-50-300 MG Preferred Brand Anxiolytics Anxiolytics, Other alprazolam tabs 0.25 mg Generic


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JARDIANCE TABS 25 MG Preferred Brand PA, QL (30 PER 30 DAYS) metformin hcl er tb24 500 mg Generic metformin hcl er tb24 750 mg Generic metformin hcl tabs 1000 mg Generic metformin hcl tabs 500 mg Generic metformin hcl tabs 850 mg Generic OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN 2 MG/1.5ML Preferred Brand PA OZEMPIC (1 MG/DOSE) SOPN 2 MG/1.5ML Preferred Brand PA pioglitazone hcl tabs 15 mg Generic pioglitazone hcl tabs 30 mg Generic pioglitazone hcl tabs 45 mg Generic repaglinide tabs 0.5 mg Generic repaglinide tabs 1 mg Generic repaglinide tabs 2 mg Generic tolazamide tabs 250 mg Generic tolazamide tabs 500 mg Generic tolbutamide tabs 500 mg Generic VICTOZA SOPN 18 MG/3ML Preferred Brand PA Glycemic Agents GLUCAGON EMERGENCY KIT 1 MG Preferred Brand Insulins HUMALOG SOLN 100 UNIT/ML Preferred Brand PA HUMULIN 70/30 SUSP (70-30) 100 UNIT/ML Preferred Brand HUMULIN N SUSP 100 UNIT/ML Preferred Brand HUMULIN R SOLN 100 UNIT/ML Preferred Brand LANTUS SOLN 100 UNIT/ML Preferred Brand PA Blood Products/Modifiers/Volume Expanders Anticoagulants enoxaparin sodium soln 100 mg/ml Generic DS enoxaparin sodium soln 120 mg/0.8ml Generic DS enoxaparin sodium soln 150 mg/ml Generic DS enoxaparin sodium soln 30 mg/0.3ml Generic DS enoxaparin sodium soln 300 mg/3ml Generic DS enoxaparin sodium soln 40 mg/0.4ml Generic DS enoxaparin sodium soln 60 mg/0.6ml Generic DS enoxaparin sodium soln 80 mg/0.8ml Generic DS

PRADAXA CAPS 75 MG Preferred Brand QL (60 PER 30 DAYS

PRADAXA CAPS 110 MG Preferred Brand QL (60 PER 30 DAYS)

PRADAXA CAPS 150 MG Preferred Brand QL (60 PER 30 DAYS) warfarin sodium tabs 1 mg Generic warfarin sodium tabs 10 mg Generic warfarin sodium tabs 2 mg Generic warfarin sodium tabs 2.5 mg Generic warfarin sodium tabs 3 mg Generic


warfarin sodium tabs 4 mg Generic warfarin sodium tabs 5 mg Generic warfarin sodium tabs 6 mg Generic warfarin sodium tabs 7.5 mg Generic

XARELTO TABS 10 MG Preferred Brand PA, QL (30 PER 30 DAYS)

XARELTO TABS 15 MG Preferred Brand PA, QL (60 PER 30 DAYS)

XARELTO TABS 20 MG Preferred Brand PA, QL (30 PER 30 DAYS) Blood Formation Modifiers anagrelide hcl caps 0.5 mg Generic PROCRIT SOLN 2000 UNIT/ML Preferred Brand DS PROCRIT SOLN 3000 UNIT/ML Preferred Brand DS PROCRIT SOLN 4000 UNIT/ML Preferred Brand DS PROCRIT SOLN 10000 UNIT/ML Preferred Brand DS PROCRIT SOLN 20000 UNIT/ML Preferred Brand DS PROCRIT SOLN 40000 UNIT/ML Preferred Brand DS

PROMACTA TABS 25 MG Specialty PA, DS, QL (60 PER 30 DAYS)

PROMACTA TABS 50 MG Specialty PA, DS, QL (90 PER 30 DAYS)

PROMACTA TABS 75 MG Specialty PA, DS, QL (60 PER 30 DAYS) VENOFER SOLN 20 MG/ML Preferred Brand ZARXIO SOSY 300 MCG/0.5ML Specialty DS ZARXIO SOSY 480 MCG/0.8ML Specialty DS Coagulants AMICAR TABS 500 MG Brand aminocaproic acid tabs 500 mg Generic BENEFIX KIT 250 UNIT Preferred Brand DS BENEFIX KIT 500 UNIT Preferred Brand DS BENEFIX KIT 1000 UNIT Preferred Brand DS BENEFIX KIT 2000 UNIT Preferred Brand DS BENEFIX KIT 3000 UNIT Preferred Brand DS HEMLIBRA SOLN 30 MG/ML Specialty DS HEMLIBRA SOLN 60 MG/0.4ML Specialty DS HEMLIBRA SOLN 105 MG/0.7ML Specialty DS HEMLIBRA SOLN 150 MG/ML Specialty DS HUMATE-P SOLR 1000-2400 UNIT Preferred Brand DS HUMATE-P SOLR 250-600 UNIT Preferred Brand DS HUMATE-P SOLR 500-1200 UNIT Preferred Brand DS KOVALTRY SOLR 250 UNIT Preferred Brand DS KOVALTRY SOLR 500 UNIT Preferred Brand DS KOVALTRY SOLR 1000 UNIT Preferred Brand DS KOVALTRY SOLR 2000 UNIT Preferred Brand DS KOVALTRY SOLR 3000 UNIT Preferred Brand DS phytonadione tabs 5 mg Generic


Platelet Modifying Agents aspirin-dipyridamole er cp 12 25-200 mg Generic BRILINTA TABS 60 MG Preferred Brand PA BRILINTA TABS 90 MG Preferred Brand PA cilostazol tabs 100 mg Generic cilostazol tabs 50 mg Generic clopidogrel bisulfate tabs 75 mg Generic dipyridamole tabs 25 mg Generic dipyridamole tabs 50 mg Generic dipyridamole tabs 75 mg Generic prasugrel hcl tabs 5 mg Generic prasugrel hcl tabs 10 mg Generic Cardiovascular Agents Alpha-Adrenergic Agonists clonidine hcl tabs 0.1 mg Generic clonidine hcl tabs 0.2 mg Generic clonidine hcl tabs 0.3 mg Generic guanfacine hcl tabs 1 mg Generic guanfacine hcl tabs 2 mg Generic methyldopa tabs 250 mg Generic methyldopa tabs 500 mg Generic midodrine hcl tabs 2.5 mg Generic midodrine hcl tabs 5 mg Generic midodrine hcl tabs 10 mg Generic Alpha-Adrenergic Blocking Agents doxazosin mesylate tabs 1 mg Generic doxazosin mesylate tabs 2 mg Generic doxazosin mesylate tabs 4 mg Generic doxazosin mesylate tabs 8 mg Generic phenoxybenzamine hcl caps 10 mg Generic prazosin hcl caps 1 mg Generic prazosin hcl caps 2 mg Generic prazosin hcl caps 5 mg Generic terazosin hcl caps 1 mg Generic terazosin hcl caps 10 mg Generic terazosin hcl caps 2 mg Generic terazosin hcl caps 5 mg Generic Angiotensin II Receptor Antagonists losartan potassium tabs 100 mg Generic losartan potassium tabs 25 mg Generic losartan potassium tabs 50 mg Generic valsartan tabs 160 mg Generic valsartan tabs 320 mg Generic valsartan tabs 40 mg Generic valsartan tabs 80 mg Generic Angiotensin-Converting Enzyme (ACE) Inhibitors benazepril hcl tabs 10 mg Generic benazepril hcl tabs 20 mg Generic


benazepril hcl tabs 40 mg Generic benazepril hcl tabs 5 mg Generic EPANED SOLR 1 MG/ML Preferred Brand lisinopril tabs 10 mg Generic lisinopril tabs 2.5 mg Generic lisinopril tabs 20 mg Generic lisinopril tabs 30 mg Generic lisinopril tabs 40 mg Generic lisinopril tabs 5 mg Generic Antiarrhythmics amiodarone hcl tabs 200 mg Generic disopyramide phosphate caps 100 mg Generic disopyramide phosphate caps 150 mg Generic dofetilide caps 125 mcg Generic dofetilide caps 250 mcg Generic dofetilide caps 500 mcg Generic flecainide acetate tabs 100 mg Generic flecainide acetate tabs 150 mg Generic flecainide acetate tabs 50 mg Generic mexiletine hcl caps 150 mg Generic mexiletine hcl caps 200 mg Generic mexiletine hcl caps 250 mg Generic NORPACE CR CP12 100 MG Preferred Brand NORPACE CR CP12 150 MG Preferred Brand propafenone hcl tabs 150 mg Generic propafenone hcl tabs 225 mg Generic propafenone hcl tabs 300 mg Generic quinidine gluconate er tbcr 324 mg Generic quinidine sulfate tabs 200 mg Generic Beta-Adrenergic Blocking Agents acebutolol hcl caps 200 mg Generic acebutolol hcl caps 400 mg Generic atenolol tabs 100 mg Generic atenolol tabs 25 mg Generic atenolol tabs 50 mg Generic bisoprolol fumarate tabs 10 mg Generic bisoprolol fumarate tabs 5 mg Generic carvedilol tabs 12.5 mg Generic carvedilol tabs 25 mg Generic carvedilol tabs 3.125 mg Generic carvedilol tabs 6.25 mg Generic labetalol hcl tabs 100 mg Generic labetalol hcl tabs 200 mg Generic labetalol hcl tabs 300 mg Generic metoprolol succinate er tb24 25 mg Generic metoprolol succinate er tb24 50 mg Generic metoprolol succinate er tb24 100 mg Generic metoprolol succinate er tb24 200 mg Generic


metoprolol tartrate tabs 100 mg Generic metoprolol tartrate tabs 25 mg Generic metoprolol tartrate tabs 50 mg Generic nadolol tabs 20 mg Generic nadolol tabs 40 mg Generic nadolol tabs 80 mg Generic propranolol hcl soln 20 mg/5ml Generic propranolol hcl tabs 10 mg Generic propranolol hcl tabs 20 mg Generic propranolol hcl tabs 40 mg Generic propranolol hcl tabs 60 mg Generic propranolol hcl tabs 80 mg Generic propranolol hcl er cp24 60 mg Generic propranolol hcl er cp24 80 mg Generic propranolol hcl er cp24 120 mg Generic propranolol hcl er cp24 160 mg Generic sotalol hcl (af) tabs 120 mg Generic sotalol hcl (af) tabs 160 mg Generic sotalol hcl (af) tabs 80 mg Generic sotalol hcl tabs 120 mg Generic sotalol hcl tabs 160 mg Generic sotalol hcl tabs 80 mg Generic SOTYLIZE SOLN 5 MG/ML Preferred Brand Calcium Channel Blocking Agents amlodipine besylate tabs 10 mg Generic amlodipine besylate tabs 2.5 mg Generic amlodipine besylate tabs 5 mg Generic diltiazem hcl tabs 120 mg Generic diltiazem hcl tabs 30 mg Generic diltiazem hcl tabs 60 mg Generic diltiazem hcl tabs 90 mg Generic dilt-xr cp24 120 mg Generic dilt-xr cp24 180 mg Generic dilt-xr cp24 240 mg Generic KATERZIA SUSP 1 MG/ML Brand PA nifedipine er osmotic release tb24 30 mg Generic nifedipine er osmotic release tb24 60 mg Generic nifedipine er osmotic release tb24 90 mg Generic nifedipine er tb24 90 mg Generic nimodipine caps 30 mg Generic verapamil hcl er tbcr 180 mg Generic verapamil hcl er tbcr 240 mg Generic verapamil hcl tabs 120 mg Generic verapamil hcl tabs 80 mg Generic Cardiovascular Agents, Other DIGOXIN SOLN 0.05 MG/ML Preferred Brand digoxin tabs 125 mcg Generic digoxin tabs 250 mcg Generic


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pravastatin sodium tabs 10 mg Generic pravastatin sodium tabs 20 mg Generic pravastatin sodium tabs 40 mg Generic pravastatin sodium tabs 80 mg Generic rosuvastatin calcium tabs 5 mg Generic rosuvastatin calcium tabs 10 mg Generic rosuvastatin calcium tabs 20 mg Generic rosuvastatin calcium tabs 40 mg Generic simvastatin tabs 10 mg Generic simvastatin tabs 20 mg Generic simvastatin tabs 40 mg Generic simvastatin tabs 80 mg Generic Dyslipidemics, Other cholestyramine pack 4 gm Generic cholestyramine powd 4 gm/dose Generic colestipol hcl gran 5 gm Generic colestipol hcl tabs 1 gm Generic ezetimibe tabs 10 mg Generic niacin tabs 100 mg Generic niacin tabs 500 mg Generic niacin er (antihyperlipidemic) tbcr 500 mg Generic prevalite powd 4 gm/dose Generic No USP Class (Combination Product) atenolol-chlorthalidone tabs 100-25 mg Generic atenolol-chlorthalidone tabs 50-25 mg Generic bisoprolol-hydrochlorothiazide tabs 10-6.25 mg Generic bisoprolol-hydrochlorothiazide tabs 2.5-6.25 mg Generic bisoprolol-hydrochlorothiazide tabs 5-6.25 mg Generic lisinopril-hydrochlorothiazide tabs 10-12.5 mg Generic lisinopril-hydrochlorothiazide tabs 20-12.5 mg Generic lisinopril-hydrochlorothiazide tabs 20-25 mg Generic losartan potassium-hctz tabs 100-12.5 mg Generic losartan potassium-hctz tabs 100-25 mg Generic losartan potassium-hctz tabs 50-12.5 mg Generic spironolactone-hctz tabs 25-25 mg Generic triamterene-hctz tabs 37.5-25 mg Generic triamterene-hctz tabs 75-50 mg Generic valsartan-hydrochlorothiazide tabs 80-12.5 mg Generic valsartan-hydrochlorothiazide tabs 160-12.5 mg Generic valsartan-hydrochlorothiazide tabs 160-25 mg Generic valsartan-hydrochlorothiazide tabs 320-12.5 mg Generic valsartan-hydrochlorothiazide tabs 320-25 mg Generic Vasodilators, Direct-Acting Arterial hydralazine hcl tabs 10 mg Generic hydralazine hcl tabs 100 mg Generic hydralazine hcl tabs 25 mg Generic hydralazine hcl tabs 50 mg Generic Vasodilators, Direct-Acting Arterial/Venous


ISORDIL TITRADOSE TABS 40 MG Preferred Brand isosorbide dinitrate er tbcr 40 mg Generic isosorbide dinitrate tabs 10 mg Generic isosorbide dinitrate tabs 20 mg Generic isosorbide dinitrate tabs 5 mg Generic isosorbide mononitrate er tb24 120 mg Generic isosorbide mononitrate er tb24 30 mg Generic isosorbide mononitrate er tb24 60 mg Generic nitro-bid oint 2 % Generic nitroglycerin pt24 0.1 mg/hr Generic nitroglycerin pt24 0.2 mg/hr Generic nitroglycerin pt24 0.4 mg/hr Generic nitroglycerin pt24 0.6 mg/hr Generic nitroglycerin subl 0.3 mg Generic nitroglycerin subl 0.4 mg Generic nitroglycerin subl 0.6 mg Generic Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines ADDERALL XR CP24 10 MG Preferred Brand ADDERALL XR CP24 15 MG Preferred Brand ADDERALL XR CP24 20 MG Preferred Brand ADDERALL XR CP24 25 MG Preferred Brand ADDERALL XR CP24 30 MG Preferred Brand ADDERALL XR CP24 5 MG Preferred Brand amphetamine-dextroamphetamine tabs 10 mg Generic amphetamine-dextroamphetamine tabs 20 mg Generic amphetamine-dextroamphetamine tabs 30 mg Generic amphetamine-dextroamphetamine tabs 5 mg Generic dextroamphetamine sulfate er cp24 10 mg Generic PA dextroamphetamine sulfate er cp24 15 mg Generic PA dextroamphetamine sulfate er cp24 5 mg Generic PA dextroamphetamine sulfate tabs 10 mg Generic dextroamphetamine sulfate tabs 5 mg Generic Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines atomoxetine hcl caps 10 mg Generic atomoxetine hcl caps 18 mg Generic atomoxetine hcl caps 25 mg Generic atomoxetine hcl caps 40 mg Generic atomoxetine hcl caps 60 mg Generic atomoxetine hcl caps 80 mg Generic atomoxetine hcl caps 100 mg Generic guanfacine hcl er tb24 1 mg Generic guanfacine hcl er tb24 2 mg Generic guanfacine hcl er tb24 3 mg Generic guanfacine hcl er tb24 4 mg Generic methylphenidate hcl er (cd) cpcr 10 mg Generic methylphenidate hcl er (cd) cpcr 20 mg Generic methylphenidate hcl er (cd) cpcr 30 mg Generic


methylphenidate hcl er (cd) cpcr 40 mg Generic methylphenidate hcl er (cd) cpcr 50 mg Generic methylphenidate hcl er (cd) cpcr 60 mg Generic methylphenidate hcl er tbcr 10 mg Generic methylphenidate hcl er tbcr 20 mg Generic methylphenidate hcl er tbcr 18 mg Generic methylphenidate hcl er tbcr 27 mg Generic methylphenidate hcl er tbcr 36 mg Generic methylphenidate hcl er tbcr 54 mg Generic methylphenidate hcl tabs 10 mg Generic methylphenidate hcl tabs 20 mg Generic methylphenidate hcl tabs 5 mg Generic Central Nervous System Agents, Other riluzole tabs 50 mg Generic Ergot Alkaloids CAFERGOT TABS 1-100 MG Preferred Brand Multiple Sclerosis Agents AVONEX KIT 30 MCG Specialty PA, DS AVONEX PEN AJKT 30 MCG/0.5ML Specialty PA, DS AVONEX PREFILLED PSKT 30 MCG/0.5ML Specialty PA, DS EXTAVIA KIT 0.3 MG Preferred Brand DS glatopa sosy 20 mg/ml Generic DS No USP Class ketorolac tromethamine soln 60 mg/2ml Generic Dental and Oral Agents chlorhexidine gluconate soln 0.12 % Generic denta 5000 plus crea 1.1 % Generic pilocarpine hcl tabs 5 mg Generic PREVIDENT GEL 1.1 % Preferred Brand Dermatological Agents acitretin caps 10 mg Generic DS acitretin caps 25 mg Generic DS adapalene gel 0.1 % Generic adapalene gel 0.3 % Generic azelaic acid gel 15 % Generic AZELEX CREA 20 % Preferred Brand betamethasone dipropionate aug gel 0.05 % Generic calcipotriene soln 0.005 % Generic claravis caps 10 mg Generic DS claravis caps 20 mg Generic DS claravis caps 30 mg Generic DS claravis caps 40 mg Generic DS

COSENTYX SENSOREADY PEN SOAJ 150 MG/ML Specialty PA, DS, QL (2 PER 28 DAYS)

COSENTYX SOSY 150 MG/ML Specialty PA, DS, QL (2 PER 28 DAYS) DIFFERIN CREA 0.1 % Preferred Brand DRITHO-CRÈME HP CREA 1 % Preferred Brand


DRYSOL SOLN 20 % Preferred Brand fluocinolone acetonide scalp oil 0.01% Generic fluorouracil crea 5 % Generic fluorouracil soln 2 % Generic fluorouracil soln 5 % Generic hydrocortisone lotn 2.5 % Generic imiquimod crea 5 % Generic methoxsalen rapid caps 10 mg Generic nystatin-triamcinolone crea 100000-0.1 unit/gm-% Generic nystatin-triamcinolone oint 100000-0.1 unit/gm-% Generic pimecrolimus crea 1 % Generic podofilox soln 0.5 % Generic RECTIV OINT 0.4 % Preferred Brand SANTYL OINT 250 UNIT/GM Preferred Brand selenium sulfide lotn 2.5 % Generic STELARA SOLN 130 MG/26ML Specialty PA

STELARA SOSY 45 MG/0.5ML Specialty PA, QL (0.5 PER 84 DAYS)

STELARA SOSY 90 MG/ML Specialty PA, QL (1 PER 56 DAYS) sulfacetamide sodium-sulfur emul 10-5 % Generic tacrolimus oint 0.03 % Generic tacrolimus oint 0.1 % Generic tazarotene crea 0.1 % Generic TAZORAC CREA 0.05 % Preferred Brand TAZORAC GEL 0.05 % Preferred Brand TAZORAC GEL 0.1 % Preferred Brand VECTICAL OINT 3 MCG/GM Preferred Brand XERAC AC SOLN 6.25 % Preferred Brand Enzyme Replacement/Modifiers CERDELGA CAPS 84 MG Specialty DS ZENPEP CPEP 5000-24000 UNIT Preferred Brand ZENPEP CPEP 10000-32000 UNIT Preferred Brand ZENPEP CPEP 15000-47000 UNIT Preferred Brand ZENPEP CPEP 20000-63000 UNIT Preferred Brand ZENPEP CPEP 25000-79000 UNIT Preferred Brand ZENPEP CPEP 40000-126000 UNIT Preferred Brand Gastrointestinal Agents Antispasmodics, Gastrointestinal dicyclomine hcl caps 10 mg Generic dicyclomine hcl soln 10 mg/5ml Generic dicyclomine hcl tabs 20 mg Generic glycopyrrolate tabs 1 mg Generic glycopyrrolate tabs 2 mg Generic Gastrointestinal Agents, Other diphenoxylate-atropine liqd 2.5-0.025 mg/5ml Generic diphenoxylate-atropine tabs 2.5-0.025 mg Generic propantheline bromide tabs 15 mg Generic


READI-CAT 2 SUSP 2 % Preferred Brand ursodiol tabs 250 mg Generic ursodiol tabs 500 mg Generic Histamine-2 (H2) Receptor Antagonists cimetidine hcl soln 300 mg/5ml Generic ranitidine hcl syrp 75 mg/5ml Generic ranitidine hcl tabs 300 mg Generic Irritable Bowel Syndrome Agents mesalamine enem 4 gm Generic salsalate tabs 500 mg Generic salsalate tabs 750 mg Generic Laxatives gavilyte-c solr 240 gm Generic lactulose soln 10 gm/15ml Generic Protectants misoprostol tabs 100 mcg Generic misoprostol tabs 200 mcg Generic sucralfate tabs 1 gm Generic Proton Pump Inhibitors pantoprazole sodium tbec 20 mg Generic pantoprazole sodium tbec 40 mg Generic Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride er tb24 10 mg Generic oxybutynin chloride er tb24 15 mg Generic oxybutynin chloride er tb24 5 mg Generic oxybutynin chloride syrp 5 mg/5ml Generic oxybutynin chloride tabs 5 mg Generic solifenacin succinate tabs 5 mg Generic solifenacin succinate tabs 10 mg Generic tolterodine tartrate tabs 1 mg Generic tolterodine tartrate tabs 2 mg Generic trospium chloride tabs 20 mg Generic Benign Prostatic Hypertrophy Agents finasteride tabs 5 mg Generic tamsulosin hcl caps 0.4 mg Generic Genitourinary Agents, Other bethanechol chloride tabs 5 mg Generic bethanechol chloride tabs 10 mg Generic bethanechol chloride tabs 25 mg Generic DEPEN TITRATABS TABS 250 MG Preferred Brand ELMIRON CAPS 100 MG Preferred Brand No USP Class methylergonovine maleate tabs 0.2 mg Generic Phosphate Binders calcium acetate (phos binder) caps 667 mg Generic PHOSLYRA SOLN 667 MG/5ML Preferred Brand sevelamer carbonate pack 0.8 gm Generic


sevelamer carbonate pack 2.4 gm Generic sevelamer carbonate tabs 800 mg Generic sevelamer hcl tabs 800 mg Generic Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Glucocorticoids/Mineralocorticoids alclometasone dipropionate crea 0.05 % Generic alclometasone dipropionate oint 0.05 % Generic betamethasone dipropionate aug crea 0.05 % Generic betamethasone dipropionate aug oint 0.05 % Generic betamethasone dipropionate crea 0.05 % Generic betamethasone dipropionate lotn 0.05 % Generic betamethasone dipropionate oint 0.05 % Generic betamethasone valerate crea 0.1 % Generic betamethasone valerate lotn 0.1 % Generic betamethasone valerate oint 0.1 % Generic budesonide cpep 3 mg Generic clobetasol propionate e crea 0.05 % Generic clobetasol propionate lotn 0.05 % Generic clobetasol propionate oint 0.05 % Generic clobetasol propionate soln 0.05 % Generic CLOBEX SHAM 0.05 % Preferred Brand CLOBEX SPRAY LIQD 0.05 % Preferred Brand colocort enem 100 mg/60ml Generic CORDRAN TAPE 4 MCG/SQCM Preferred Brand desoximetasone crea 0.25 % Generic dexamethasone elix 0.5 mg/5ml Generic dexamethasone intensol conc 1 mg/ml Generic dexamethasone soln 0.5 mg/5ml Generic dexamethasone tabs 0.5 mg Generic dexamethasone tabs 0.75 mg Generic dexamethasone tabs 1.5 mg Generic dexamethasone tabs 4 mg Generic fludrocortisone acetate tabs 0.1 mg Generic fluocinolone acetonide crea 0.01 % Generic fluocinolone acetonide crea 0.025 % Generic fluocinolone acetonide oint 0.025 % Generic fluocinolone acetonide soln 0.01 % Generic fluocinonide gel 0.05 % Generic fluocinonide oint 0.05 % Generic fluocinonide soln 0.05 % Generic hydrocortisone butyr lipo base crea 0.1 % Generic hydrocortisone crea 2.5 % Generic hydrocortisone enem 100 mg/60ml Generic hydrocortisone oint 2.5 % Generic hydrocortisone tabs 10 mg Generic hydrocortisone tabs 20 mg Generic hydrocortisone tabs 5 mg Generic mometasone furoate crea 0.1 % Generic


mometasone furoate oint 0.1 % Generic mometasone furoate soln 0.1 % Generic prednicarbate crea 0.1 % Generic prednisolone sodium phosphate soln 15 mg/5ml Generic prednisone tabs 1 mg Generic prednisone tabs 10 mg Generic prednisone tabs 2.5 mg Generic prednisone tabs 20 mg Generic prednisone tabs 5 mg Generic prednisone tabs 50 mg Generic prednisone tbpk 5 mg (21) Generic SOLU-CORTEF SOLR 100 MG Preferred Brand triamcinolone acetonide aers 0.147 mg/gm Generic triamcinolone acetonide crea 0.025 % Generic triamcinolone acetonide crea 0.1 % Generic triamcinolone acetonide crea 0.5 % Generic triamcinolone acetonide oint 0.025 % Generic triamcinolone acetonide oint 0.1 % Generic triamcinolone acetonide oint 0.5 % Generic triamcinolone acetonide pste 0.1 % Generic Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin ace rhinal tube soln 0.01 % Generic desmopressin acetate spray soln 0.01 % Generic desmopressin acetate tabs 0.1 mg Generic desmopressin acetate tabs 0.2 mg Generic novarel solr 10000 unit Generic OMNITROPE SOLN 10 MG/1.5ML Preferred Brand DS OMNITROPE SOLN 5 MG/1.5ML Preferred Brand DS OMNITROPE SOLR 5.8 MG Preferred Brand DS Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Androgens danazol caps 100 mg Generic danazol caps 200 mg Generic danazol caps 50 mg Generic DEPO-TESTOSTERONE SOLN 100 MG/ML Preferred Brand PA DEPO-TESTOSTERONE SOLN 200 MG/ML Preferred Brand PA methitest tabs 10 mg Generic testosterone enanthate soln 200 mg/ml Generic PA testosterone gel 25 mg/2.5gm (1%) Generic PA testosterone gel 50 mg/5gm (1%) Generic PA Estrogens CLIMARA PTWK 0.025 MG/24HR Preferred Brand CLIMARA PTWK 0.0375 MG/24HR Preferred Brand CLIMARA PTWK 0.05 MG/24HR Preferred Brand CLIMARA PTWK 0.06 MG/24HR Preferred Brand CLIMARA PTWK 0.075 MG/24HR Preferred Brand CLIMARA PTWK 0.1 MG/24HR Preferred Brand depo-estradiol oil 5 mg/ml Generic


estradiol crea 0.1 mg/gm Generic estradiol tabs 0.5 mg Generic estradiol tabs 1 mg Generic estradiol tabs 2 mg Generic ESTRING RING 2 MG Preferred Brand No USP Class (Combination Product) aranelle tabs 0.5/1/0.5-35 mg-mcg Generic eluryng ring 0.12-0.015 mg/24hr Generic est estrogens-methyltest hs tabs 0.625-1.25 mg Generic est estrogens-methyltest tabs 1.25-2.5 mg Generic kelnor 1/50 tabs 1-50 mg-mcg Generic levora 0.15/30 (28) tabs 0.15-30 mg-mcg Generic microgestin fe 1.5/30 tabs 1.5-30 mg-mcg Generic microgestin fe 1/20 tabs 1-20 mg-mcg Generic necon 0.5/35 (28) tabs 0.5-35 mg-mcg Generic nortrel 1/35 (28) tabs 1-35 mg-mcg Generic NUVARING RING 0.12-0.015 MG/24HR Preferred Brand sprintec 28 tabs 0.25-35 mg-mcg Generic tri-sprintec tabs 0.18/0.215/0.25 mg-35 mcg Generic trivora (28) tabs Generic XULANE PTWK 150 35 MCG/24HR Preferred Brand zovia 1/35e (28) tabs 1-35 mg-mcg Generic Progestins ELLA TABS 30 MG Preferred Brand hydroxyprogesterone caproate oil 250 mg/ml Generic DS medroxyprogesterone acetate susp 150 mg/ml Generic medroxyprogesterone acetate tabs 10 mg Generic medroxyprogesterone acetate tabs 2.5 mg Generic medroxyprogesterone acetate tabs 5 mg Generic megestrol acetate susp 40 mg/ml Generic megestrol acetate tabs 20 mg Generic megestrol acetate tabs 40 mg Generic MIRENA (52 MG) IUD 20 MCG/24HR Preferred Brand NEXPLANON IMPL 68 MG Preferred Brand nora-be tabs 0.35 mg Generic norethindrone acetate tabs 5 mg Generic plan b one-step tabs 1.5 mg Generic Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium tabs 100 mcg Generic levothyroxine sodium tabs 112 mcg Generic levothyroxine sodium tabs 125 mcg Generic levothyroxine sodium tabs 137 mcg Generic levothyroxine sodium tabs 150 mcg Generic levothyroxine sodium tabs 175 mcg Generic levothyroxine sodium tabs 200 mcg Generic levothyroxine sodium tabs 25 mcg Generic levothyroxine sodium tabs 300 mcg Generic levothyroxine sodium tabs 50 mcg Generic


levothyroxine sodium tabs 75 mcg Generic levothyroxine sodium tabs 88 mcg Generic liothyronine sodium tabs 25 mcg Generic liothyronine sodium tabs 5 mcg Generic liothyronine sodium tabs 50 mcg Generic Hormonal Agents, Suppressant (Adrenal) LYSODREN TABS 500 MG Preferred Brand DS Hormonal Agents, Suppressant (Pituitary) cabergoline tabs 0.5 mg Generic octreotide acetate soln 100 mcg/ml Generic octreotide acetate soln 1000 mcg/ml Generic octreotide acetate soln 200 mcg/ml Generic octreotide acetate soln 500 mcg/ml Generic SYNAREL SOLN 2 MG/ML Preferred Brand Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Antiandrogens

abiraterone acetate tabs 250 mg Specialty DS, QL (120 PER 30 DAYS) bicalutamide tabs 50 mg Generic flutamide caps 125 mg Generic ZYTIGA TABS 500 MG Specialty DS Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole tabs 10 mg Generic methimazole tabs 5 mg Generic propylthiouracil tabs 50 mg Generic Immunological Agents Immune Suppressants azathioprine tabs 50 mg Generic

ENBREL SOLR 25 MG Preferred Brand PA, DS, QL (8 PER 28 DAYS)

ENBREL SOSY 25 MG/0.5ML Preferred Brand PA, DS, QL (4.08 PER 28 DAYS)

ENBREL SOSY 50 MG/ML Preferred Brand PA, DS, QL (4 PER 28 DAYS)

ENBREL SURECLICK SOAJ 50 MG/ML Preferred Brand PA, DS, QL (4 PER 28 DAYS) gengraf caps 100 mg Generic gengraf caps 25 mg Generic

HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML Preferred Brand PA, DS, QL (3 PER 365 DAYS) HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML & 40MG/0.4ML Preferred Brand

PA, DS, QL (2 PER 365 DAYS)

HUMIRA PEN PNKT 40 MG/0.4ML Preferred Brand PA, DS, QL (2 PER 28 DAYS)

HUMIRA PEN PNKT 40 MG/0.8ML Preferred Brand PA, DS, QL (2 PER 28 DAYS)


HUMIRA PSKT 10 MG/0.1ML Preferred Brand DS, QL (2 PER 28 DAYS)



HUMIRA PSKT 40 MG/0.4ML Preferred Brand PA, DS, QL (2 PER 28 DAYS)

HUMIRA PSKT 40 MG/0.8ML Preferred Brand PA, DS, QL (2 PER 28 DAYS) mercaptopurine tabs 50 mg Generic methotrexate sodium (pf) soln 50 mg/2ml Generic methotrexate sodium soln 50 mg/2ml Generic methotrexate tabs 2.5 mg Generic mycophenolate mofetil caps 250 mg Generic mycophenolate mofetil tabs 500 mg Generic NEORAL SOLN 100 MG/ML Preferred Brand

ORENCIA CLICKJECT SOAJ 125 MG/ML Preferred Brand PA, DS, QL (4 PER 28 DAYS) ORENCIA SOLR 250 MG Preferred Brand DS

ORENCIA SOSY 125 MG/ML Preferred Brand PA, DS, QL (4 PER 28 DAYS) RASUVO SOAJ 10 MG/0.2ML Preferred Brand RASUVO SOAJ 12.5 MG/0.25ML Preferred Brand RASUVO SOAJ 15 MG/0.3ML Preferred Brand RASUVO SOAJ 17.5 MG/0.35ML Preferred Brand RASUVO SOAJ 20 MG/0.4ML Preferred Brand RASUVO SOAJ 22.5 MG/0.45ML Preferred Brand RASUVO SOAJ 25 MG/0.5ML Preferred Brand RASUVO SOAJ 27.5 MG/0.55ML Preferred Brand RASUVO SOAJ 30 MG/0.6ML Preferred Brand RASUVO SOAJ 7.5 MG/0.15ML Preferred Brand SANDIMMUNE CAPS 100 MG Preferred Brand SANDIMMUNE CAPS 25 MG Preferred Brand sirolimus tabs 0.5 mg Generic sirolimus tabs 1 mg Generic sirolimus tabs 2 mg Generic sirolimus soln 1 mg/ml Generic tacrolimus caps 0.5 mg Generic tacrolimus caps 1 mg Generic tacrolimus caps 5 mg Generic

XELJANZ TABS 10 MG Preferred Brand PA, DS, QL (60 PER 30 DAYS) ZORTRESS TABS 0.25 MG Preferred Brand ZORTRESS TABS 0.5 MG Specialty ZORTRESS TABS 0.75 MG Specialty Immunizing Agents, Passive VIVOTIF CPDR Preferred Brand


Immunomodulators leflunomide tabs 10 mg Generic leflunomide tabs 20 mg Generic

OTEZLA TABS 30 MG Specialty PA, DS, QL (60 PER 30 DAYS)

OTEZLA TBPK 10 & 20 & 30 MG Specialty PA, DS, QL (55 PER 365 DAYS) RIDAURA CAPS 3 MG Preferred Brand No USP Class HAEGARDA SOLR 2000 UNIT Specialty DS HAEGARDA SOLR 3000 UNIT Specialty DS TAKHZYRO SOLN 300 MG/2ML Specialty PA, DS Inflammatory Bowel Disease Agents Aminosalicylates ASACOL TBEC 400 MG Preferred Brand balsalazide disodium caps 750 mg Generic mesalamine-cleanser kit 4 gm Generic mesalamine supp 1000 mg Generic mesalamine tbec 1.2 gm Generic Sulfonamides sulfasalazine tabs 500 mg Generic sulfasalazine tbec 500 mg Generic Metabolic Bone Disease Agents alendronate sodium tabs 10 mg Generic alendronate sodium tabs 40 mg Generic alendronate sodium tabs 70 mg Generic calcitonin (salmon) soln 200 unit/act Generic calcitriol caps 0.25 mcg Generic calcitriol caps 0.5 mcg Generic calcitriol soln 1 mcg/ml Generic etidronate disodium tabs 200 mg Generic etidronate disodium tabs 400 mg Generic MIACALCIN SOLN 200 UNIT/ML Preferred Brand No Designated Placement on USP Model Guidelines V5.0 acetic acid soln 0.25 % Generic BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 0.3 ML Preferred Brand

BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 0.5 ML Preferred Brand

BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 1 ML Preferred Brand

BD INSULIN SYRINGE U-500 MISC 31G X 6MM 0.5 ML Preferred Brand bd magni-guide magnifier misc Generic bd pen needle mini u/f misc 31g x 5 mm Generic bd safetyglide insulin syringe misc 29g x 1/2" 0.5 ml Generic CERDELGA CAPS 84 MG Specialty DS fluoridex pste 1.1 % Generic KETOSTIX STRP Preferred Brand


ONETOUCH ULTRA BLUE STRP Preferred Brand PARAGARD INTRAUTERINE COPPER IUD Preferred Brand PRECISION XTRA KETONE STRP Preferred Brand proctozone-hc crea 2.5 % Generic sodium benzoate powd Generic WIDE-SEAL DIAPHRAGM 60 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 65 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 70 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 75 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 80 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 85 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 90 DPRH 2 % Preferred Brand WIDE-SEAL DIAPHRAGM 95 DPRH 2 % Preferred Brand Ophthalmic Agents No USP Class (Combination Product) bacitracin-polymyxin b oint 500-10000 unit/gm Generic bacitra-neomycin-polymyxin-hc oint 1 % Generic blephamide s.o.p. oint 10-0.2 % Generic neomycin-bacitracin zn-polymyx oint 5-400-10000 Generic neomycin-polymyxin-dexameth oint 3.5-10000-0.1 Generic neomycin-polymyxin-dexameth susp 3.5-10000-0.1 Generic polymyxin b-trimethoprim soln 10000-0.1 unit/ml-% Generic PRED-G SUSP 0.3-1 % Preferred Brand sulfacetamide-prednisolone soln 10-0.23 % Generic Ophthalmic Agents, Other ATROPINE SULFATE OINT 1 % Preferred Brand ATROPINE SULFATE SOLN 1 % Preferred Brand cyclopentolate hcl soln 0.5 % Generic cyclopentolate hcl soln 1 % Generic cyclopentolate hcl soln 2 % Generic homatropaire soln 5 % Generic ISOPTO CARBACHOL SOLN 1.5 % Preferred Brand ISOPTO CARBACHOL SOLN 3 % Preferred Brand tropicamide soln 0.5 % Generic tropicamide soln 1 % Generic VISUDYNE SOLR 15 MG Preferred Brand Ophthalmic Anti-Allergy Agents cromolyn sodium soln 4 % Generic olopatadine hcl soln 0.1 % Generic Ophthalmic Antiglaucoma Agents betaxolol hcl soln 0.5 % Generic brimonidine tartrate soln 0.2 % Generic dorzolamide hcl soln 2 % Generic dorzolamide hcl-timolol mal soln 22.3-6.8 mg/ml Generic levobunolol hcl soln 0.5 % Generic phenylephrine hcl soln 2.5 % Generic PHOSPHOLINE IODIDE SOLR 0.125 % Preferred Brand timolol maleate soln 0.25 % Generic


timolol maleate soln 0.5 % Generic Ophthalmic Anti-Inflammatories dexamethasone sodium phosphate soln 0.1 % Generic diclofenac sodium soln 0.1 % Generic fluorometholone susp 0.1 % Generic flurbiprofen sodium soln 0.03 % Generic FML OINT 0.1 % Preferred Brand PRED MILD SUSP 0.12 % Preferred Brand prednisolone acetate susp 1 % Generic Ophthalmic Prostaglandin and Prostamide Analogs latanoprost soln 0.005 % Generic Otic Agents acetic acid-aluminum acetate soln 2 % Generic CIPRODEX SUSP 0.3-0.1 % Preferred Brand neomycin-polymyxin-hc soln 1 % Generic Respiratory Tract Agents Antihistamines azelastine hcl soln 0.1 % Generic cyproheptadine hcl syrp 2 mg/5ml Generic cyproheptadine hcl tabs 4 mg Generic Anti-Inflammatories, Inhaled Corticosteroids ALVESCO AERS 80 MCG/ACT Preferred Brand ALVESCO AERS 160 MCG/ACT Preferred Brand ASMANEX 120 METERED DOSES AEPB 220 MCG/INH Preferred Brand ASMANEX 30 METERED DOSES AEPB 110 MCG/INH Preferred Brand ASMANEX 60 METERED DOSES AEPB 220 MCG/INH Preferred Brand ASMANEX HFA AERO 100 MCG/ACT Preferred Brand ASMANEX HFA AERO 200 MCG/ACT Preferred Brand FLOVENT HFA AERO 44 MCG/ACT Preferred Brand flunisolide soln 25 mcg/act (0.025%) Generic Antileukotrienes montelukast sodium chew 4 mg Generic montelukast sodium chew 5 mg Generic montelukast sodium tabs 10 mg Generic Bronchodilators, Anticholinergic ATROVENT HFA AERS 17 MCG/ACT Preferred Brand ipratropium bromide soln 0.02 % Generic ipratropium bromide soln 0.03 % Generic ipratropium bromide soln 0.06 % Generic SPIRIVA RESPIMAT AERS 2.5 MCG/ACT Preferred Brand Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) theophylline er tb12 300 mg Generic theophylline er tb24 400 mg Generic Bronchodilators, Sympathomimetic albuterol sulfate nebu (2.5 mg/3ml) 0.083% Generic albuterol sulfate nebu (5 mg/ml) 0.5% Generic epinephrine soaj 0.15 mg/0.15ml Generic DS epinephrine soaj 0.3 mg/0.3ml Generic DS


SEREVENT DISKUS AEPB 50 MCG/DOSE Preferred Brand STRIVERDI RESPIMAT AERS 2.5 MCG/ACT Preferred Brand terbutaline sulfate tabs 2.5 mg Generic terbutaline sulfate tabs 5 mg Generic VENTOLIN HFA AERS 108 (90 Base) MCG/ACT Preferred Brand No USP Class benzonatate caps 100 mg Generic HYPERSAL NEBU 7 % Preferred Brand PULMOZYME SOLN 1 MG/ML Specialty sodium chloride nebu 0.9 % Generic sodium chloride nebu 10 % Generic No USP Class (Combination Product) ADVAIR DISKUS AEPB 100-50 MCG/DOSE Preferred Brand ADVAIR DISKUS AEPB 250-50 MCG/DOSE Preferred Brand ADVAIR DISKUS AEPB 500-50 MCG/DOSE Preferred Brand ADVAIR HFA AERO 45-21 MCG/ACT Preferred Brand PA ADVAIR HFA AERO 115-21 MCG/ACT Preferred Brand PA ADVAIR HFA AERO 230-21 MCG/ACT Preferred Brand PA COMBIVENT RESPIMAT AERS 20-100 MCG/ACT Preferred Brand fluticasone-salmeterol aepb 55-14 mcg/act Generic fluticasone-salmeterol aepb 113-14 mcg/act Generic fluticasone-salmeterol aepb 232-14 mcg/act Generic hydrocodone-homatropine syrp 5-1.5 mg/5ml Generic DS ipratropium-albuterol soln 0.5-2.5 (3) mg/3ml Generic promethazine vc plain syrp 6.25-5 mg/5ml Generic promethazine vc/codeine syrp 6.25-5-10 mg/5ml Generic promethazine-codeine syrp 6.25-10 mg/5ml Generic promethazine-dm syrp 6.25-15 mg/5ml Generic STIOLTO RESPIMAT AERS 2.5-2.5 MCG/ACT Preferred Brand Pulmonary Antihypertensives LETAIRIS TABS 10 MG Specialty PA, DS LETAIRIS TABS 5 MG Specialty PA, DS TRACLEER TABS 125 MG Specialty PA, DS TRACLEER TABS 62.5 MG Specialty PA, DS VELETRI SOLR 1.5 MG Preferred Brand Respiratory Tract Agents, Other acetylcysteine soln 10 % Generic acetylcysteine soln 20 % Generic cheratussin dac soln 30-10-100 mg/5ml Generic FASENRA PEN SOAJ 30 MG/ML Specialty PA, DS FASENRA SOSY 30 MG/ML Specialty PA, DS guaifenesin-codeine soln 100-10 mg/5ml Generic TRIKAFTA TBPK 100-50-75 & 150 MG Specialty PA, DS Skeletal Muscle Relaxants cyclobenzaprine hcl tabs 10 mg Generic cyclobenzaprine hcl tabs 5 mg Generic methocarbamol tabs 500 mg Generic methocarbamol tabs 750 mg Generic


Sleep Disorder Agents GABA Receptor Modulators eszopiclone tabs 1 mg Generic eszopiclone tabs 2 mg Generic eszopiclone tabs 3 mg Generic zolpidem tartrate tabs 10 mg Generic zolpidem tartrate tabs 5 mg Generic Sleep Disorders, Other armodafinil tabs 50 mg Generic armodafinil tabs 150 mg Generic armodafinil tabs 200 mg Generic armodafinil tabs 250 mg Generic modafinil tabs 100 mg Generic modafinil tabs 200 mg Generic temazepam caps 15 mg Generic temazepam caps 30 mg Generic Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers deferasirox tabs 90 mg Specialty DS deferasirox tabs 360 mg Specialty DS deferoxamine mesylate solr 500 mg Generic deferoxamine mesylate solr 2 gm Generic JADENU TABS 180 MG Specialty DS JADENU TABS 360 MG Specialty DS JADENU TABS 90 MG Specialty DS kionex susp 15 gm/60ml Generic sodium polystyrene sulfonate powd Generic sodium polystyrene sulfonate susp 15 gm/60ml Generic sps susp 15 gm/60ml Generic SSKI SOLN 1 GM/ML Preferred Brand Electrolyte/Mineral Replacement citric acid-sodium citrate soln 334-500 mg/5ml Generic klor-con m20 tbcr 20 meq Generic K-PHOS TABS 500 MG Preferred Brand K-TAB TBCR 10 MEQ Preferred Brand PHOSPHA 250 NEUTRAL TABS 155-852-130 MG Preferred Brand potassium chloride soln 20 meq/15ml (10%) Generic PA potassium citrate er tbcr 5 meq (540 mg) Generic potassium citrate er tbcr 10 meq (1080 mg) Generic potassium citrate er tbcr 15 meq (1620 mg) Generic potassium citrate-citric acid soln 1100-334 mg/5ml Generic sodium fluoride chew 0.55 (0.25 f) mg Generic sodium fluoride chew 1.1 (0.5 f) mg Generic sodium fluoride chew 2.2 (1 f) mg Generic sodium fluoride soln 1.1 (0.5 f) mg/ml Generic No USP Class cyanocobalamin soln 1000 mcg/ml Generic multi-vit/fluoride soln 0.25 mg/ml Generic


multi-vit/fluoride soln 0.5 mg/ml Generic multi-vit/fluoride/iron soln 0.25-10 mg/ml Generic multivitamin/fluoride chew 0.25 mg Generic multivitamin/fluoride chew 1 mg Generic polyvitamin/fluoride dro 0.5mg/ml Generic poly-vit drops w/fluoride dro 0.25mg Generic poly-vitamin/iron/fluoride dro /fl 0.25 Generic tri-vit/fluoride soln 0.25 mg/ml Generic tri-vit/fluoride soln 0.5 mg/ml Generic tri-vit/fluoride/iron soln 0.25-10 mg/ml Generic vitamin d (ergocalciferol) caps 50000 unit Generic


NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan of the Northwest (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us,

such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and accessible electronic

formats

• Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, call 1-800-813-2000 (TTY: 711) If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at: Member Relations, Attention: Kaiser Civil Rights Coordinator, 500 NE Multnomah St. Ste 100, Portland, OR 97232, telephone number: 1-800-813-2000. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

____________________________________________________________________

HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-813-2000 (TTY: 711).

አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-813-2000 (TTY: 711).

-1 ، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقمالعربیةإذا كنت تتحدث : ملحوظة (Arabic) العربیة800-813-2000 )TTY :711.(

中文 (Chinese) 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1-800-813-2000（TTY：711）。

اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما فراھم می توجھ: (Farsi) فارسی تماس بگیرید. TTY) 1-800-813-2000: 711) باشد. با

Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-813-2000 (TTY: 711).

Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-813-2000 (TTY: 711).

日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-813-2000（TTY: 711）まで、お電話にてご連絡ください。


ែខ�រ (Khmer) ្របយ័ត�៖ េបើសិន�អ�កនិ�យ ��ែខ�រ, េស�ជំនួយែផ�ក�� េ�យមិនគិតឈ� �ល គឺ�ច�នសំ�ប់បំេរ �អ�ក។ ចូរ ទូរស័ព� 1-800-813-2000 (TTY: 711)។

한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-813-2000 (TTY: 711) 번으로 전화해 주십시오.

ລາວ (Laotian) ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ້ົາພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫືຼອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-813-2000 (TTY: 711).

Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dé̖é̖’, t’áá jiik’eh, éí ná hóló̖, koji̖’ hódíílnih 1-800-813-2000 (TTY: 711).

Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-813-2000 (TTY: 711).

ਪੰਜਾਬੀ (Punjabi) ਿਧਆਨ ਿਦਓ: ਜੇ ਤਸੁ� ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤ� ਭਾਸ਼ਾ ਿਵੱਚ ਸਹਾਇਤਾ ਸਵੇਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-800-813-2000 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।

Română (Romanian) ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-813-2000 (TTY: 711).

Pусский (Russian) ВНИМАНИЕ: если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-813-2000 (TTY: 711).

Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-813-2000 (TTY: 711).

Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-813-2000 (TTY: 711).

ไทย (Thai) เรยีน: ถา้คณุพูดภาษาไทย คณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ีโทร 1-800-813-2000 (TTY: 711).

Українська (Ukrainian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-813-2000 (TTY: 711).

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-813-2000 (TTY: 711).

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