2021 NATIONCARE CALIFORNIA FORMULARY
329
1 Proprietary 2021 NATIONCARE CALIFORNIA FORMULARY The NationCare Program offers fully insured small and large group health insurance plans underwritten by National Health Insurance Company and administered by Meritain Health, Inc. Meritain Health administers the prescription drug benefits and claims under these health plans, it does not insure or otherwise underwrite those prescription drug benefits. Your prescription drug benefit is an "open formulary," meaning all FDA‐approved, prescription drugs are covered based on your plan’s provisions. Visit https://getnationcare.com for the most up‐to‐date information. For a summary of your coverage and benefits plan or those available in the NationCare program, log into your secure member site, or call the toll‐free number on your member ID card. For prospective members, you can find the most up‐to‐ date information for the formulary at https://getnationcare.com/Forms.html or you can contact customer service at 1.866.475.7589 for questions regarding the formulary and prescription drug benefits. The formulary is updated on a monthly basis. The formulary is subject to change. Previous versions are no longer in effect. Small employer group medical plan names to which this document applies to in the state of California are listed below. Plan documents can be found at https://getnationcare.com/Forms.html or you can click on the plan name below to access the Schedule of Benefits. CA Non‐Standard Schedules CA Bronze Choice HDHP 6900 Schedule CA Silver Prime HDHP 2000 Schedule CA Gold Standard 2000 Schedule CA Gold Select HDHP 2000 Schedule CA Gold Prime 1000 Schedule CA Platinum Prime 500 Schedule CA Standard Schedules CA STD Base 2020 ‐ Bronze 6300 CA STD Base 2020 ‐ Silver 2250 Copay CA STD Base 2020 ‐ Gold 250 Copay CA STD Base 2020 ‐ Platinum 0 Copay Large employer group medical plan names to which this document applies to in the state of California are listed below. Prospective members should contact their employer’s Human Resources Department to obtain Summary of Benefits and Coverage materials for the NationCare plans being offered during open enrollment. Existing members can access their Schedule of Benefits, Summary of Benefits and Coverage and Certificate of Coverage by logging onto www.meritain.com. NationCare PPO Plans NationCare HDHP Plans Meritain.com Effective (01/2021)
Transcript of 2021 NATIONCARE CALIFORNIA FORMULARY
1 Proprietary
2021 NATIONCARE CALIFORNIA FORMULARY The NationCare Program offers fully insured small and large group health insurance plans underwritten by National Health Insurance Company and administered by Meritain Health, Inc. Meritain Health administers the prescription drug benefits and claims under these health plans, it does not insure or otherwise underwrite those prescription drug benefits.
Your prescription drug benefit is an "open formulary," meaning all FDA‐approved, prescription drugs are covered based on your plan’s provisions. Visit https://getnationcare.com for the most up‐to‐date information. For a summary of your coverage and benefits plan or those available in the NationCare program, log into your secure member site, or call the toll‐free number on your member ID card. For prospective members, you can find the most up‐to‐ date information for the formulary at https://getnationcare.com/Forms.html or you can contact customer service at 1.866.475.7589 for questions regarding the formulary and prescription drug benefits. The formulary is updated on a monthly basis. The formulary is subject to change. Previous versions are no longer in effect. Small employer group medical plan names to which this document applies to in the state of California are listed below. Plan documents can be found at https://getnationcare.com/Forms.html or you can click on the plan name below to access the Schedule of Benefits. CA Non‐Standard Schedules CA Bronze Choice HDHP 6900 Schedule CA Silver Prime HDHP 2000 Schedule CA Gold Standard 2000 Schedule CA Gold Select HDHP 2000 Schedule CA Gold Prime 1000 Schedule CA Platinum Prime 500 Schedule CA Standard Schedules CA STD Base 2020 ‐ Bronze 6300 CA STD Base 2020 ‐ Silver 2250 Copay CA STD Base 2020 ‐ Gold 250 Copay CA STD Base 2020 ‐ Platinum 0 Copay Large employer group medical plan names to which this document applies to in the state of California are listed below. Prospective members should contact their employer’s Human Resources Department to obtain Summary of Benefits and Coverage materials for the NationCare plans being offered during open enrollment. Existing members can access their Schedule of Benefits, Summary of Benefits and Coverage and Certificate of Coverage by logging onto www.meritain.com. NationCare PPO Plans NationCare HDHP Plans
Meritain.com Effective (01/2021)
2 Proprietary
2020 NATIONCARE CALIFORNIA FORMULARY
TABLE OF CONTENTS
5‐ALPHA REDUCTASE INHIBITORS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs ......................................................... 28
5‐HT3 RECEPTOR ANTAGONISTS ‐ Drugs to Treat Vomiting .................................................................................................................... 28
5‐HT4 RECEPTOR AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ......................................................................... 28
5‐LIPOXYGENASE INHIBITORS ‐ Drugs to Treat Asthma and Breathing Disorders ................................................................................... 28
ABORTIFACIENT ‐ PROGESTERONE RECEPTOR ANTAGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
............................................................................................................................................................................................................. 28
ABORTIFACIENTS/CERVICAL RIPENING ‐ PROSTAGLANDINS ‐ Drugs to Stimulate Contraction of Uterine Smooth Muscle ................... 28
ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS ‐ Drugs to Treat High Blood Pressure ............................................... 28
ACE INHIBITORS ‐ Drugs to Treat High Blood Pressure ............................................................................................................................ 29
ACE INHIBITORS & THIAZIDE/THIAZIDE‐LIKE ‐ Drugs to Treat High Blood Pressure ................................................................................ 29
ACL INHIB‐INTESTINAL CHOLESTEROL ABSORPTION INHIB COMB ‐ Drugs for High Cholesterol ............................................................ 30
ACNE ANTIBIOTICS ‐ Drugs to Treat Skin Disorders ................................................................................................................................. 30
ACNE COMBINATIONS ‐ Drugs to Treat Skin Disorders ........................................................................................................................... 31
ACNE PRODUCTS ‐ Drugs to Treat Skin Disorders .................................................................................................................................... 32
ADENOSINE RECEPTOR ANTAGONIST ‐ Drugs to treat Parkinson's Disease ............................................................................................ 34
ADENOSINE TRIPHOSPHATE‐CITRATE LYASE (ACL) INHIBITORS ‐ Drugs for High Cholesterol ................................................................. 34
ADHD AGENT ‐ SELECTIVE ALPHA ADRENERGIC AGONISTS ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders
............................................................................................................................................................................................................. 34
ADRENERGIC COMBINATIONS ‐ Drugs to Treat Asthma and Breathing Disorders .................................................................................. 35
ADRENOLYTICS‐CENTRAL & THIAZIDE/THIAZIDE‐LIKE COMB ‐ Drugs to Treat High Blood Pressure ...................................................... 35
AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS ‐ Drugs to Treat Skin Disorders ..................................................................... 36
AGENTS FOR GAUCHER DISEASE ‐ Drugs to Treat Blood Disorders ......................................................................................................... 36
AGENTS FOR OPIOID WITHDRAWAL ‐ Drugs for diseases and disorders of the nervous system ............................................................ 36
AGENTS FOR PHEOCHROMOCYTOMA ‐ Drugs to Treat High Blood Pressure .......................................................................................... 36
ALCOHOL DETERRENTS ‐ Drugs for diseases and disorders of the nervous system ................................................................................ 36
ALKYLATING AGENTS ‐ Drugs for Treatment of Cancer ........................................................................................................................... 36
ALPHA 1‐ADRENOCEPTOR ANTAGONISTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs ............................................. 36
ALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB ‐ Drugs for Treatment of Disorders in the Eyes ...................... 37
ALPHA‐2 RECEPTOR ANTAGONISTS (TETRACYCLICS) ‐ Drugs for Depression / Other Disorders ............................................................. 37
ALPHA‐BETA BLOCKERS ‐ Drugs for High Blood Pressure / Misc Heart Disorders ................................................................................... 37
ALPHA‐GLUCOSIDASE INHIBITORS ‐ Drugs to treat Diabetes .................................................................................................................. 37
ALPHA‐PROTEINASE INHIBITOR (HUMAN) ‐ Drugs/Products to Help with Breathing ............................................................................. 37
ALS AGENTS ‐ MISCELLANEOUS ‐ Drugs to Treat Disorders that Affect the Nerves That control Voluntary Muscles ............................. 38
ALTERNATIVE MEDICINE ‐ AL'S ‐ Miscellaneous Amino Acids and Supplements .................................................................................... 38
AMEBICIDES ‐ Drugs to Treat Parasitic Amebae Infections ..................................................................................................................... 38
AMINO ACID MIXTURES ‐ Drugs/Products Used for Providing Nourishment .......................................................................................... 38
AMINO ACIDS ‐ Drugs to Treat Blood Disorders ...................................................................................................................................... 38
AMINO ACIDS‐SINGLE ‐ Drugs/Products Used for Providing Nourishment ............................................................................................. 38
AMINOGLYCOSIDES ‐ Antibiotics / Drugs for Infections .......................................................................................................................... 38
AMINOLEVULINATE SYNTHASE 1‐DIRECTED SIRNA ‐ Drugs to Treat Blood Disorders ............................................................................ 38
AMINOMETHYLCYCLINES ‐ Antibiotics / Drugs for Infections .................................................................................................................. 38
AMINOPENICILLINS ‐ Antibiotics / Drugs for Infections ........................................................................................................................... 38
AMPA GLUTAMATE RECEPTOR ANTAGONISTS ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders ............... 39
AMPHETAMINE MIXTURES ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders ................................................ 39
AMPHETAMINES ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders ................................................................ 39
ANABOLIC STEROIDS ‐ Drugs for Male Hormone Replacement ............................................................................................................... 40
ANALEPTICS ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders ....................................................................... 40
ANALGESIC COMBINATIONS ‐ Drugs to Treat Pain .................................................................................................................................. 40
3 Proprietary
ANALGESICS OTHER ‐ Drugs to Treat Pain ............................................................................................................................................... 40
ANALGESICS‐SEDATIVES ‐ Drugs to Treat Pain ......................................................................................................................................... 40
ANAPHYLAXIS THERAPY AGENTS ‐ Drugs Used to Contract (Tighten) Blood Vessels and Raise Blood Pressure ..................................... 41
ANDROGEN BIOSYNTHESIS INHIBITORS ‐ Drugs for Treatment of Cancer .............................................................................................. 41
ANDROGENS ‐ Drugs for Male Hormone Replacement ........................................................................................................................... 41
ANESTHETICS TOPICAL ORAL ‐ Drugs to Treat Mouth / Throat / Dental Disorders ................................................................................. 42
ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB ‐ Drugs to Treat High Blood Pressure .......................................... 42
ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE‐LIKE ‐ Drugs to Treat High Blood Pressure .................................................. 43
ANGIOTENSIN II RECEPTOR ANTAGONISTS ‐ Drugs to Treat High Blood Pressure .................................................................................. 43
ANGIOTENSIN II RECEPTOR ANT‐CA CHANNEL BLOCKER‐THIAZIDES ‐ Drugs to Treat High Blood Pressure ........................................... 44
ANTACIDS ‐ BICARBONATE ‐ Drugs to Treat Heartburn ........................................................................................................................... 44
ANTHELMINTICS ‐ Drugs to Treat Parasitic Worm Infections .................................................................................................................. 44
ANTI TB COMBINATIONS ‐ Drugs to Treat Infections of Mycobacterium ................................................................................................ 44
ANTIADRENALS ‐ Drugs for Treatment of Cancer .................................................................................................................................... 45
ANTIADRENERGICS ‐ CENTRALLY ACTING ‐ Drugs to Treat High Blood Pressure..................................................................................... 45
ANTIADRENERGICS ‐ PERIPHERALLY ACTING ‐ Drugs to Treat High Blood Pressure ............................................................................... 45
ANTIANDROGENS ‐ Drugs for Treatment of Cancer ................................................................................................................................ 45
ANTIANGINALS‐OTHER ‐ Drugs to Treat Heart Pain and Other Heart‐Related Disorders ....................................................................... 45
ANTIANXIETY AGENTS ‐ MISC. ‐ Drugs for Anxiety Disorders .................................................................................................................. 45
ANTIARRHYTHMICS TYPE I‐A ‐ Drugs to Treat Heart Arrhythmia ............................................................................................................ 46
ANTIARRHYTHMICS TYPE I‐B ‐ Drugs to Treat Heart Arrhythmia ............................................................................................................ 46
ANTIARRHYTHMICS TYPE I‐C ‐ Drugs to Treat Heart Arrhythmia ............................................................................................................ 46
ANTIARRHYTHMICS TYPE III ‐ Drugs to Treat Heart Arrhythmia .............................................................................................................. 46
ANTIBIOTIC STEROID COMBINATIONS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders .................................................................................. 46
ANTIBIOTICS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders .......................................................................................................................... 46
ANTI‐CATAPLECTIC AGENTS ‐ Drugs for diseases and disorders of the nervous system ......................................................................... 47
ANTICHOLINERGIC COMBINATIONS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders .................................................. 47
ANTICOAGULANTS ‐ MISC. ‐ Drugs to Treat Blood Clots.......................................................................................................................... 47
ANTICONVULSANTS ‐ BENZODIAZEPINES ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders ....................... 47
ANTICONVULSANTS ‐ MISC. ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders ............................................ 47
ANTIDEMENTIA AGENT COMBINATIONS ‐ Drugs for diseases and disorders of the nervous system ..................................................... 50
ANTIDEPRESSANTS ‐ MISC. ‐ Drugs for Depression / Other Disorders .................................................................................................... 50
ANTIDIABETIC ‐ AMYLIN ANALOGS ‐ Drugs to treat Diabetes ................................................................................................................. 50
ANTIDIARRHEAL ‐ CHLORIDE CHANNEL ANTAGONISTS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion ................................. 51
ANTIDIARRHEAL/PROBIOTIC AGENTS ‐ MISC. ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion ................................................ 51
ANTIDIARRHEAL/PROBIOTIC COMBINATIONS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion ............................................... 51
ANTIDOTES ‐ CHELATING AGENTS ‐ Drugs to Treat Poisioning ................................................................................................................ 51
ANTIDOTES AND SPECIFIC ANTAGONISTS ‐ Drugs to Treat Poisioning .................................................................................................... 51
ANTIEMETIC COMBINATIONS ‐ Drugs to Treat Vomiting ......................................................................................................................... 52
ANTIEMETICS ‐ ANTICHOLINERGIC ‐ Drugs to Treat Vomiting ................................................................................................................. 52
ANTIEMETICS ‐ MISCELLANEOUS ‐ Drugs to Treat Vomiting ................................................................................................................... 52
ANTIESTROGENS ‐ Drugs for Treatment of Cancer .................................................................................................................................. 52
ANTIFUNGALS ‐ Drugs to Treat Fungal Infections .................................................................................................................................... 52
ANTIFUNGALS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ........................................................................................................................ 52
ANTIFUNGALS ‐ TOPICAL COMBINATIONS ‐ Drugs to Treat Skin Disorders ............................................................................................. 53
ANTIHEMOPHILIC PRODUCTS ‐ Drugs to Treat Blood Disorders .............................................................................................................. 53
ANTIHEMOPHILIC PRODUCTS ‐ MONOCLONAL ANTIBODIES ‐ Drugs to Treat Blood Disorders .............................................................. 55
ANTIHISTAMINES ‐ ALKYLAMINES ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders ........................................................... 56
ANTIHISTAMINES ‐ ETHANOLAMINES ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders ..................................................... 56
ANTIHISTAMINES ‐ NON‐SEDATING ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders ........................................................ 56
ANTIHISTAMINES ‐ PHENOTHIAZINES ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders ..................................................... 56
ANTIHISTAMINES ‐ PIPERIDINES ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders .............................................................. 56
ANTIHISTAMINE‐STEROID ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems ............................................................................. 56
ANTIHYPERLIPIDEMICS ‐ MISC. ‐ Drugs for High Cholesterol ................................................................................................................... 57
4 Proprietary
ANTIHYPERTENSIVES ‐ MISC. ‐ Drugs to Treat High Blood Pressure ........................................................................................................ 57
ANTI‐IGE MONOCLONAL ANTIBODIES ‐ Drugs to Treat Asthma and Breathing Disorders ...................................................................... 57
ANTI‐INFECTIVE AGENTS ‐ MISC. ‐ Antibiotics / Drugs for Infections ...................................................................................................... 57
ANTI‐INFECTIVE GENITOURINARY IRRIGANTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs ....................................... 57
ANTI‐INFECTIVE MISC. ‐ COMBINATIONS ‐ Antibiotics / Drugs for Infections ......................................................................................... 57
ANTI‐INFECTIVES ‐ THROAT ‐ Drugs to Treat Mouth / Throat / Dental Disorders ................................................................................... 58
ANTI‐INFLAMMATORY AGENTS ‐ Drugs to Treat Asthma and Breathing Disorders ................................................................................ 58
ANTI‐INFLAMMATORY AGENTS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ............................................................................................. 58
ANTILEPROTICS ‐ Miscellaneous Drugs and Solutions ............................................................................................................................. 58
ANTIMALARIAL COMBINATIONS ‐ Drugs to Treat Malaria / Other Infections ......................................................................................... 58
ANTIMALARIALS ‐ Drugs to Treat Malaria / Other Infections .................................................................................................................. 58
ANTIMANIC AGENTS ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders .............................................................................. 59
ANTIMETABOLITES ‐ Drugs for Treatment of Cancer ............................................................................................................................... 59
ANTIMICROBIAL AGENTS ‐ Syrups, gelatin, capsules for making pharmaceuticals ................................................................................. 59
ANTIMYASTHENIC/CHOLINERGIC AGENTS ‐ Drugs to Treat Myasthenia Gravis (Skeletal Muscle Disorder) .......................................... 59
ANTIMYCOBACTERIAL AGENTS ‐ Drugs to Treat Infections of Mycobacterium ...................................................................................... 60
ANTINEOPLASTIC ‐ BCL‐2 INHIBITORS ‐ Drugs for Treatment of Cancer ................................................................................................. 60
ANTINEOPLASTIC ‐ BISPECIFIC T‐CELL ENGAGERS ‐ Drugs for Treatment of Cancer ............................................................................... 60
ANTINEOPLASTIC ‐ BRAF KINASE INHIBITORS ‐ Drugs for Treatment of Cancer ...................................................................................... 60
ANTINEOPLASTIC ‐ FGFR KINASE INHIBITORS ‐ Drugs for Treatment of Cancer ...................................................................................... 60
ANTINEOPLASTIC ‐ HEDGEHOG PATHWAY INHIBITORS ‐ Drugs for Treatment of Cancer ...................................................................... 60
ANTINEOPLASTIC ‐ HISTONE DEACETYLASE INHIBITORS ‐ Drugs for Treatment of Cancer ..................................................................... 61
ANTINEOPLASTIC ‐ IMMUNOMODULATORS ‐ Drugs for Treatment of Cancer ....................................................................................... 61
ANTINEOPLASTIC ‐ MEK INHIBITORS ‐ Drugs for Treatment of Cancer ................................................................................................... 61
ANTINEOPLASTIC ‐ METHYLTRANSFERASE INHIBITORS ‐ Drugs for Treatment of Cancer ....................................................................... 61
ANTINEOPLASTIC ‐ MONOCLONAL ANTIBODIES ‐ Drugs for Treatment of Cancer ................................................................................. 61
ANTINEOPLASTIC ‐ MTOR KINASE INHIBITORS ‐ Drugs for Treatment of Cancer .................................................................................... 62
ANTINEOPLASTIC ‐ MULTIKINASE INHIBITORS ‐ Drugs for Treatment of Cancer .................................................................................... 62
ANTINEOPLASTIC ‐ PROTEASOME INHIBITORS ‐ Drugs for Treatment of Cancer .................................................................................... 62
ANTINEOPLASTIC ‐ TROPOMYOSIN RECEPTOR KINASE INHIBITORS ‐ Drugs for Treatment of Cancer .................................................... 63
ANTINEOPLASTIC ‐ TYROSINE KINASE INHIBITORS ‐ Drugs for Treatment of Cancer .............................................................................. 63
ANTINEOPLASTIC ‐ XPO1 INHIBITORS ‐ Drugs for Treatment of Cancer .................................................................................................. 64
ANTINEOPLASTIC ALKYLATING AGENTS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ................................................................................ 64
ANTINEOPLASTIC ANTIBIOTICS ‐ Drugs for Treatment of Cancer ............................................................................................................ 64
ANTINEOPLASTIC ANTIBODY‐DRUG COMPLEXES ‐ Drugs for Treatment of Cancer ................................................................................ 64
ANTINEOPLASTIC ANTIMETABOLITES ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ................................................................................... 64
ANTINEOPLASTIC COMBINATIONS ‐ Drugs for Treatment of Cancer ...................................................................................................... 65
ANTINEOPLASTIC ENZYMES ‐ Drugs for Treatment of Cancer ................................................................................................................. 65
ANTINEOPLASTIC OR PREMALIGNANT LESIONS ‐ TOPICAL MISC. ‐ Drugs to Treat Skin Disorders ......................................................... 65
ANTINEOPLASTIC OR PREMALIGNANT LESIONS ‐ TOPICAL NSAID'S ‐ Drugs to Treat Skin Disorders ...................................................... 65
ANTINEOPLASTIC RETINOIDS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ................................................................................................ 65
ANTINEOPLASTICS ‐ INTERLEUKINS ‐ Drugs for Treatment of Cancer ..................................................................................................... 65
ANTINEOPLASTICS MISC. ‐ Drugs for Treatment of Cancer ..................................................................................................................... 65
ANTIPARKINSON ANTICHOLINERGICS ‐ Drugs to treat Parkinson's Disease ............................................................................................ 65
ANTIPARKINSON DOPAMINERGICS ‐ Drugs to treat Parkinson's Disease ................................................................................................ 66
ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS ‐ Drugs to treat Parkinson's Disease .................................................................. 66
ANTIPERISTALTIC AGENTS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion .............................................................................. 66
ANTIPROTOZOAL AGENTS ‐ Antibiotics / Drugs for Infections ................................................................................................................ 66
ANTIPRURITICS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ...................................................................................................................... 67
ANTIPSORIATICS ‐ Drugs to Treat Skin Disorders ..................................................................................................................................... 67
ANTIPSORIATICS ‐ SYSTEMIC ‐ Drugs to Treat Skin Disorders .................................................................................................................. 67
ANTIPSYCHOTICS ‐ MISC. ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders ....................................................................... 68
ANTIRETROVIRAL COMBINATIONS ‐ Drugs to Treat Viral Infections ....................................................................................................... 68
ANTIRETROVIRALS ‐ CCR5 ANTAGONISTS (ENTRY INHIBITOR) ‐ Drugs to Treat Viral Infections ............................................................. 69
5 Proprietary
ANTIRETROVIRALS ‐ FUSION INHIBITORS ‐ Drugs to Treat Viral Infections ............................................................................................. 69
ANTIRETROVIRALS ‐ INTEGRASE INHIBITORS ‐ Drugs to Treat Viral Infections ....................................................................................... 69
ANTIRETROVIRALS ‐ PROTEASE INHIBITORS ‐ Drugs to Treat Viral Infections ......................................................................................... 69
ANTIRETROVIRALS ‐ RTI‐NON‐NUCLEOSIDE ANALOGUES ‐ Drugs to Treat Viral Infections .................................................................... 70
ANTIRETROVIRALS ‐ RTI‐NUCLEOSIDE ANALOGUES‐PURINES ‐ Drugs to Treat Viral Infections .............................................................. 70
ANTIRETROVIRALS ‐ RTI‐NUCLEOSIDE ANALOGUES‐PYRIMIDINES ‐ Drugs to Treat Viral Infections ....................................................... 71
ANTIRETROVIRALS ‐ RTI‐NUCLEOSIDE ANALOGUES‐THYMIDINES ‐ Drugs to Treat Viral Infections ....................................................... 71
ANTIRETROVIRALS ‐ RTI‐NUCLEOTIDE ANALOGUES ‐ Drugs to Treat Viral Infections ............................................................................. 71
ANTIRETROVIRALS ADJUVANTS ‐ Drugs to Treat Viral Infections ............................................................................................................ 71
ANTIRHEUMATIC ‐ JANUS KINASE (JAK) INHIBITORS ‐ Drugs to Treat Pain and Inflammation ............................................................... 71
ANTIRHEUMATIC ANTIMETABOLITES ‐ Drugs to Treat Pain and Inflammation ....................................................................................... 71
ANTISEBORRHEIC COMBINATIONS ‐ Drugs to Treat Skin Disorders ........................................................................................................ 72
ANTISEBORRHEIC PRODUCTS ‐ Drugs to Treat Skin Disorders ................................................................................................................. 72
ANTISENSE OLIGONUCLEOTIDE (ASO) INHIBITOR AGENTS ‐ Drugs for diseases and disorders of the nervous system .......................... 72
ANTISEPTIC COMBINATIONS ‐ MOUTH/THROAT ‐ Drugs to Treat Mouth / Throat / Dental Disorders .................................................. 72
ANTISEPTICS ‐ MOUTH/THROAT ‐ Drugs to Treat Mouth / Throat / Dental Disorders ............................................................................ 72
ANTISEPTICS & DISINFECTANTS ‐ Drugs and Products to Prevent the Growth of Disease‐Causing Microorganisms ............................. 72
ANTISPASMODICS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders .............................................................................. 72
ANTITHYROID AGENTS ‐ Drugs to Treat Disorders of the Thyroid Gland................................................................................................. 73
ANTI‐TNF‐ALPHA ‐ MONOCLONAL ANTIBODIES ‐ Drugs to Treat Pain and Inflammation ....................................................................... 73
ANTITUSSIVE ‐ NONNARCOTIC ‐ Drugs to Treat Cough / Cold / Allergies ................................................................................................ 73
ANTITUSSIVE ‐ OPIOID ‐ Drugs to Treat Cough / Cold / Allergies ............................................................................................................ 73
ANTITUSSIVE‐EXPECTORANT ‐ Drugs to Treat Cough / Cold / Allergies .................................................................................................. 74
ANTITUSSIVE‐EXPECTORANTS‐DECONGESTANT ‐ Drugs to Treat Cough / Cold / Allergies ..................................................................... 74
ANTIVIRAL MONOCLONAL ANTIBODIES ‐ Vaccines and Drugs for the Immune System ......................................................................... 74
ANTIVIRAL TOPICAL COMBINATIONS ‐ Drugs to Treat Skin Disorders ..................................................................................................... 74
ANTIVIRALS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ............................................................................................................................ 74
ANTI‐VON WILLEBRAND FACTOR AGENTS ‐ Drugs to Treat Blood Disorders .......................................................................................... 74
APPLICATORS,COTTON BALLS,ETC ‐ Diabetic Supplies and Needles ....................................................................................................... 74
AROMATASE INHIBITORS ‐ Drugs for Treatment of Cancer ..................................................................................................................... 75
ARTIFICIAL TEAR INSERTS ‐ Drugs for Treatment of Disorders in the Eyes .............................................................................................. 75
ARTIFICIAL TEARS AND LUBRICANTS ‐ Drugs for Treatment of Disorders in the Eyes ............................................................................. 76
ASTRINGENTS ‐ Drugs to Treat Skin Disorders ......................................................................................................................................... 76
ATOPIC DERMATITIS ‐ MONOCLONAL ANTIBODIES ‐ Drugs to Treat Skin Disorders ............................................................................... 76
AZITHROMYCIN ‐ Antibiotics / Drugs for Infections ................................................................................................................................. 76
BACTERIAL VACCINES ‐ Drugs for Communicable Disease Prevention .................................................................................................... 76
BARBITURATE HYPNOTICS ‐ Drugs to Treat Problems with Sleeping ...................................................................................................... 76
BELLADONNA ALKALOIDS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders .................................................................. 77
BENZATHIAZOLES ‐ Drugs to Treat Disorders that Affect the Nerves That control Voluntary Muscles ................................................... 77
BENZISOXAZOLES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders ................................................................................... 77
BENZODIAZEPINE HYPNOTICS ‐ Drugs to Treat Problems with Sleeping ................................................................................................. 78
BENZODIAZEPINES ‐ Drugs for Anxiety Disorders .................................................................................................................................... 78
BENZODIAZEPINES & TRICYCLIC AGENTS ‐ Drugs for diseases and disorders of the nervous system ..................................................... 78
BETA ADRENERGICS ‐ Drugs to Treat Asthma and Breathing Disorders .................................................................................................. 79
BETA BLOCKER & DIURETIC COMBINATIONS ‐ Drugs to Treat High Blood Pressure ............................................................................... 79
BETA BLOCKERS CARDIO‐SELECTIVE ‐ Drugs for High Blood Pressure / Misc Heart Disorders ................................................................ 80
BETA BLOCKERS NON‐SELECTIVE ‐ Drugs for High Blood Pressure / Misc Heart Disorders ..................................................................... 80
BETA‐BLOCKERS ‐ OPHTHALMIC ‐ Drugs for Treatment of Disorders in the Eyes ................................................................................... 81
BETA‐BLOCKERS ‐ OPHTHALMIC COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes ........................................................ 81
BIGUANIDES ‐ Drugs to treat Diabetes .................................................................................................................................................... 82
BILE ACID SEQUESTRANTS ‐ Drugs for High Cholesterol .......................................................................................................................... 82
BILE ACID SYNTHESIS DISORDER AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ..................................................... 83
BIPHASIC CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ......................................................... 83
BISPHOSPHONATES ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ............................................................... 83
6 Proprietary
B‐LYMPHOCYTE STIMULATOR (BLYS)‐SPECIFIC INHIBITORS ‐ Miscellaneous Drugs and Solutions ......................................................... 84
BOWEL EVACUANT COMBINATIONS ‐ Drugs to Treat Constipation ........................................................................................................ 84
BRADYKININ B2 RECEPTOR ANTAGONISTS ‐ Drugs to Treat Blood Disorders ......................................................................................... 84
BRONCHODILATORS ‐ ANTICHOLINERGICS ‐ Drugs to Treat Asthma and Breathing Disorders ............................................................... 84
BURN PRODUCTS ‐ Drugs to Treat Skin Disorders ................................................................................................................................... 85
BUTYROPHENONES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders ................................................................................ 85
C1 INHIBITORS ‐ Drugs to Treat Blood Disorders ..................................................................................................................................... 85
CALCIMIMETIC AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ......................................................... 85
CALCITONIN GENE‐RELATED PEPTIDE RECEPTOR ANTAG (CGRP) ‐ Drugs to Treat Migraine Headaches ............................................... 85
CALCITONINS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ......................................................................... 85
CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB ‐ Drugs to Treat Disorders of the Heart and Cardiovascular
System ................................................................................................................................................................................................. 86
CALCIUM CHANNEL BLOCKER‐NSAID COMBINATIONS ‐ Drugs for High Blood Pressure / Misc Heart Disorders ................................... 86
CALCIUM CHANNEL BLOCKERS ‐ Drugs for High Blood Pressure / Misc Heart Disorders ........................................................................ 86
CALCIUM COMBINATIONS ‐ Drugs for Replacement of Minerals in the Body ......................................................................................... 88
CARBAMATES ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders .................................................................. 88
CARBONIC ANHYDRASE INHIBITORS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders ............................................... 88
CARDIAC GLYCOSIDES ‐ Drugs Used to Increase the Efficiency and Improve the Contraction of the Heart Muscle ............................... 88
CARDIOPLEGIC SOLUTIONS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System ........................................................... 88
CARNITINE REPLENISHER ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ....................................... 89
CAUTERIZING AGENT COMBINATIONS ‐ Drugs to Treat Skin Disorders .................................................................................................. 89
CAUTERIZING AGENTS ‐ Drugs to Treat Skin Disorders ........................................................................................................................... 89
CENTRAL MUSCLE RELAXANTS ‐ Drugs for diseases and disorders of the muscles, ligaments, tendons and bones ............................... 89
CENTRAL/PERIPHERAL COMT INHIBITORS ‐ Drugs to treat Parkinson's Disease ..................................................................................... 90
CEPHALOSPORINS ‐ 1ST GENERATION ‐ Antibiotics / Drugs for Infections .............................................................................................. 90
CEPHALOSPORINS ‐ 2ND GENERATION ‐ Antibiotics / Drugs for Infections ............................................................................................ 90
CEPHALOSPORINS ‐ 3RD GENERATION ‐ Antibiotics / Drugs for Infections ............................................................................................. 90
CERVICAL CAPS ‐ Diabetic Supplies and Needles ..................................................................................................................................... 91
CFTR POTENTIATORS ‐ Drugs/Products to Help with Breathing .............................................................................................................. 91
CGRP RECEPTOR ANTAGONISTS ‐ MONOCOLONAL ANTIBODIES ‐ Drugs to Treat Migraine Headaches ................................................ 91
CHELATING AGENTS ‐ Miscellaneous Drugs and Solutions ...................................................................................................................... 91
CHLORINE ANTISEPTICS ‐ Drugs and Products to Prevent the Growth of Disease‐Causing Microorganisms .......................................... 91
CHOLINOMIMETICS ‐ ACHE INHIBITORS ‐ Drugs for diseases and disorders of the nervous system ...................................................... 92
CIC AGENTS ‐ GUANYLATE CYCLASE‐C (GC‐C) AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ............................. 92
CITRATES ‐ Drugs To Treat Disorders of the Genital and Urinary Organs ................................................................................................ 92
CLARITHROMYCIN ‐ Antibiotics / Drugs for Infections ............................................................................................................................. 92
CMV AGENTS ‐ Drugs to Treat Viral Infections ........................................................................................................................................ 93
COBALAMINS ‐ Drugs to Treat Blood Disorders ....................................................................................................................................... 93
CODEINE COMBINATIONS ‐ Drugs for Treatment of Pain ........................................................................................................................ 93
COMBINATION CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ............................................... 93
COMBINATION CONTRACEPTIVES ‐ TRANSDERMAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ............................... 98
COMBINATION CONTRACEPTIVES ‐ VAGINAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders .......................................... 98
COMPLEMENT INHIBITORS ‐ Drugs to Treat Blood Disorders ................................................................................................................. 98
CONTINUOUS CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ................................................. 99
COPPER CONTRACEPTIVES ‐ IUD ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ............................................................. 99
CORTICOSTEROIDS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ................................................................................................................ 99
CORTICOTROPIN ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System .................................................................. 102
CORTISOL SYNTHESIS INHIBITORS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ....................................... 103
COUMARIN ANTICOAGULANTS ‐ Drugs to Treat Blood Clots ................................................................................................................ 103
CXCR4 RECEPTOR ANTAGONIST ‐ Drugs to Treat Blood Disorders ........................................................................................................ 103
CYCLIN‐DEPENDENT KINASES (CDK) INHIBITORS ‐ Drugs for Treatment of Cancer ............................................................................... 103
CYCLOOXYGENASE 2 (COX‐2) INHIBITORS ‐ Drugs to Treat Pain and Inflammation .............................................................................. 103
CYCLOPLEGIC MYDRIATIC COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes ................................................................. 103
CYCLOPLEGIC MYDRIATICS ‐ Drugs for Treatment of Disorders in the Eyes .......................................................................................... 103
7 Proprietary
CYCLOSPORINE ANALOGS ‐ Miscellaneous Drugs and Solutions ........................................................................................................... 104
CYSTIC FIBROSIS AGENT ‐ COMBINATIONS ‐ Drugs/Products to Help with Breathing .......................................................................... 104
CYSTINOSIS AGENTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs............................................................................. 104
CYTOTOXIC AGENTS ‐ Drugs to Treat Blood Disorders .......................................................................................................................... 105
DECARBOXYLASE INHIBITORS ‐ Drugs to treat Parkinson's Disease ...................................................................................................... 105
DECONGESTANT & ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies ..................................................................................... 105
DECONGESTANT W/ EXPECTORANT ‐ Drugs to Treat Cough / Cold / Allergies ..................................................................................... 105
DIABETIC OTHER ‐ Drugs to treat Diabetes ............................................................................................................................................ 105
DIAGNOSTIC DRUGS ‐ Products for Testing ........................................................................................................................................... 105
DIAGNOSTIC RADIOPHARMACEUTICALS ‐ GASES ‐ Products for Testing ............................................................................................... 106
DIAGNOSTIC RADIOPHARMACEUTICALS ‐ MISCELLANEOUS ‐ Products for Testing .............................................................................. 106
DIAGNOSTIC SUPPLIES ‐ Products for Testing ........................................................................................................................................ 106
DIAGNOSTIC TESTS ‐ Products for Testing ............................................................................................................................................. 106
DIAPHRAGMS ‐ Diabetic Supplies and Needles ..................................................................................................................................... 130
DIBENZODIAZEPINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders ............................................................................ 131
DIBENZO‐OXEPINO PYRROLES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders .............................................................. 131
DIBENZOTHIAZEPINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders .......................................................................... 131
DIBENZOXAZEPINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders ............................................................................. 131
DIETARY MANAGEMENT PRODUCT COMBINATIONS ‐ Products for Diet / Eating ................................................................................ 131
DIETARY MANAGEMENT PRODUCTS ‐ Products for Diet / Eating ......................................................................................................... 134
DIGESTIVE ENZYME COMBINATIONS ‐ Drugs to Aid in Digestion and Misc Stomach Disorders ........................................................... 134
DIGESTIVE ENZYMES ‐ Drugs to Aid in Digestion and Misc Stomach Disorders ..................................................................................... 134
DIGITAL THERAPY ‐ Miscellaneous Drugs and Solutions ........................................................................................................................ 135
DIHYDROCODEINE COMBINATIONS ‐ Drugs for Treatment of Pain ....................................................................................................... 135
DIHYDROINDOLONES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders ........................................................................... 135
DIPEPTIDYL PEPTIDASE‐4 (DPP‐4) INHIBITORS ‐ Drugs to treat Diabetes .............................................................................................. 135
DIPEPTIDYL PEPTIDASE‐4 INHIBITOR‐BIGUANIDE COMBINATIONS ‐ Drugs to treat Diabetes .............................................................. 135
DIRECT FACTOR XA INHIBITORS ‐ Drugs to Treat Blood Clots ................................................................................................................ 135
DIRECT MUSCLE RELAXANTS ‐ Drugs for diseases and disorders of the muscles, ligaments, tendons and bones ................................ 136
DIRECT RENIN INHIBITORS ‐ Drugs to Treat High Blood Pressure ......................................................................................................... 136
DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE‐LIKE COMB ‐ Drugs to Treat High Blood Pressure ................................................... 136
DIRECT‐ACTING P2Y12 INHIBITORS ‐ Drugs to Treat Blood Disorders ................................................................................................... 136
DIURETIC COMBINATIONS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders ............................................................. 136
DOPAMINE RECEPTOR AGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ....................................... 136
DOPAMINE RECEPTOR AGONISTS ‐ ERGOT DERIVATIVES ‐ Drugs to treat Diabetes ............................................................................. 137
DPP‐4 INHIBITOR‐THIAZOLIDINEDIONE COMBINATIONS ‐ Drugs to treat Diabetes .............................................................................. 137
DRY MOUTH AGENTS AND ARTIFICIAL SALIVA ‐ Drugs to Treat Mouth / Throat / Dental Disorders .................................................... 137
EMERGENCY CONTRACEPTIVES ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ............................................................. 137
EMOLLIENT COMBINATIONS ‐ Drugs to Treat Skin Disorders ................................................................................................................ 137
EMOLLIENT/KERATOLYTIC AGENTS ‐ Drugs to Treat Skin Disorders ..................................................................................................... 137
EMOLLIENTS ‐ Drugs to Treat Skin Disorders ......................................................................................................................................... 137
ENZYMES ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ............................................................................................................................. 138
ERGOT COMBINATIONS ‐ Drugs to Treat Migraine Headaches ............................................................................................................. 138
ERYTHROID MATURATION AGENTS ‐ Drugs to Treat Blood Disorders .................................................................................................. 138
ERYTHROMYCINS ‐ Antibiotics / Drugs for Infections ............................................................................................................................ 138
ERYTHROPOIESIS‐STIMULATING AGENTS (ESAS) ‐ Drugs to Treat Blood Disorders .............................................................................. 138
ESTROGEN & PROGESTIN ‐ Drugs for Female Hormone Replacement .................................................................................................. 139
ESTROGEN‐PROGESTIN‐GNRH ANTAGONIST ‐ Drugs for Female Hormone Replacement .................................................................... 139
ESTROGENS ‐ Drugs for Female Hormone Replacement ....................................................................................................................... 139
ESTROGENS‐ANTINEOPLASTIC ‐ Drugs for Treatment of Cancer ........................................................................................................... 140
ESTROGEN‐SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB ‐ Drugs for Female Hormone Replacement ................................. 140
EXTENDED‐CYCLE CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ......................................... 140
EYELID CLEANSERS & LUBRICANTS ‐ Drugs to Treat Skin Disorders ...................................................................................................... 141
FABRY DISEASE ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System .................................................... 141
8 Proprietary
FARNESOID X RECEPTOR (FXR) AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines.................................................. 141
FIBRIC ACID DERIVATIVES ‐ Drugs for High Cholesterol ......................................................................................................................... 141
FIBROMYALGIA AGENT ‐ SNRIS ‐ Drugs for diseases and disorders of the nervous system .................................................................. 142
FIDAXOMICIN ‐ Antibiotics / Drugs for Infections .................................................................................................................................. 142
FIXED OILS ‐ Miscellaneous Non‐Drug Compounds and Oils ................................................................................................................. 142
FLUORIDE ‐ Drugs for Replacement of Minerals in the Body ................................................................................................................. 142
FLUORIDE COMBINATIONS ‐ Drugs for Replacement of Minerals in the Body ...................................................................................... 143
FLUOROQUINOLONES ‐ Antibiotics / Drugs for Infections..................................................................................................................... 143
FOLIC ACID ANTAGONISTS RESCUE AGENTS ‐ Drugs for Treatment of Cancer...................................................................................... 143
FOLIC ACID/FOLATES ‐ Drugs to Treat Blood Disorders ......................................................................................................................... 143
FOUR PHASE CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ................................................. 143
GAA DEFICIENCY TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ............................. 143
GABA MODULATORS ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders .................................................... 143
GABA RECEPTOR MODULATOR ‐ NEUROACTIVE STEROID ‐ Drugs for Depression / Other Disorders................................................... 144
GALLSTONE SOLUBILIZING AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ........................................................... 144
GASTROINTESTINAL ANTIALLERGY AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ............................................... 144
GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS ‐ Drugs to Treat Disorders of the Stomach and Intestines ............................. 144
GASTROINTESTINAL STIMULANTS ‐ Drugs to Treat Disorders of the Stomach and Intestines .............................................................. 144
GELATIN CAPSULES (EMPTY) ‐ Syrups, gelatin, capsules for making pharmaceuticals .......................................................................... 144
GENITOURINARY IRRIGANTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs ................................................................ 145
GLUCAGON‐LIKE PEPTIDE‐2 (GLP‐2) ANALOGS ‐ Drugs to Treat Disorders of the Stomach and Intestines .......................................... 145
GLUCOCORTICOSTEROIDS ‐ Drugs to Treat Swelling and Inflammation................................................................................................ 145
GLUCOSE MONITORING TEST SUPPLIES ‐ Diabetic Supplies and Needles ............................................................................................. 147
GLYCOPEPTIDES ‐ Antibiotics / Drugs for Infections .............................................................................................................................. 148
GNRH/LHRH ANTAGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ................................................. 149
GOLD COMPOUNDS ‐ Drugs to Treat Pain and Inflammation ............................................................................................................... 149
GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS ‐ Drugs for Treatment of Cancer ..................................................... 149
GOUT AGENT COMBINATIONS ‐ Drugs to Treat Gout............................................................................................................................ 149
GOUT AGENTS ‐ Drugs to Treat Gout ..................................................................................................................................................... 149
GRANULOCYTE COLONY‐STIMULATING FACTORS (G‐CSF) ‐ Drugs to Treat Blood Disorders ................................................................ 149
GRANULOCYTE/MACROPHAGE COLONY‐STIMULATING FACTOR(GM‐CSF) ‐ Drugs to Treat Blood Disorders ...................................... 150
GROWTH HORMONE RECEPTOR ANTAGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ................. 150
GROWTH HORMONE RELEASING HORMONES (GHRH) ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ....... 150
GROWTH HORMONES ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ......................................................... 150
H‐2 ANTAGONISTS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders ........................................................................... 151
HEMATORHEOLOGIC AGENTS ‐ Drugs to Treat Blood Disorders ........................................................................................................... 151
HEMOGLOBIN S (HBS) POLYMERIZATION INHIBITORS ‐ Drugs to Treat Blood Disorders ...................................................................... 151
HEMOSTATIC COMBINATIONS ‐ TOPICAL ‐ Drugs to Treat Bleeding Disorders ..................................................................................... 151
HEMOSTATICS ‐ SYSTEMIC ‐ Drugs to Treat Bleeding Disorders ............................................................................................................ 152
HEMOSTATICS ‐ TOPICAL ‐ Drugs to Treat Bleeding Disorders .............................................................................................................. 152
HEPATITIS B AGENTS ‐ Drugs to Treat Viral Infections ........................................................................................................................... 152
HEPATITIS C AGENT ‐ COMBINATIONS ‐ Drugs to Treat Viral Infections ............................................................................................... 153
HEPATITIS C AGENTS ‐ Drugs to Treat Viral Infections ........................................................................................................................... 153
HEREDITARY OROTIC ACIDURIA TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System...... 153
HERPES AGENTS ‐ PURINE ANALOGUES ‐ Drugs to Treat Viral Infections ............................................................................................. 153
HERPES AGENTS ‐ THYMIDINE ANALOGUES ‐ Drugs to Treat Viral Infections ....................................................................................... 154
HMG COA REDUCTASE INHIBITORS ‐ Drugs for High Cholesterol .......................................................................................................... 154
HOMEOPATHIC PRODUCTS ‐ Miscellaneous Drugs and Solutions ......................................................................................................... 155
HOMOCYSTINURIA TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ......................... 155
HUMAN INSULIN ‐ Drugs to treat Diabetes ........................................................................................................................................... 155
HYDANTOINS ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders ................................................................ 158
HYDROCODONE COMBINATIONS ‐ Drugs for Treatment of Pain .......................................................................................................... 158
HYDROLYTIC ENZYMES ‐ Drugs/Products to Help with Breathing ......................................................................................................... 159
HYPERAMMONEMIA TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ...................... 159
9 Proprietary
HYPERPARATHYROID TREATMENT ‐ VITAMIN D ANALOGS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System . 159
HYPNOTICS ‐ TRICYCLIC AGENTS ‐ Drugs to Treat Problems with Sleeping ........................................................................................... 159
HYPOPHOSPHATASIA (HPP) AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ................................... 159
IBS AGENT ‐ 5‐HT4 RECEPTOR PARTIAL AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines .................................... 159
IBS AGENT ‐ GUANYLATE CYCLASE‐C (GC‐C) AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ............................. 159
IBS AGENT ‐ MU‐OPIOID RECEPTOR AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ......................................... 159
IBS AGENT ‐ SELECTIVE 5‐HT3 RECEPTOR ANTAGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines .......................... 159
IMIDAZOLE‐RELATED ANTIFUNGALS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms........................................... 160
IMIDAZOLE‐RELATED ANTIFUNGALS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ................................................................................... 160
IMIDAZOLES ‐ Drugs to Treat Fungal Infections ..................................................................................................................................... 160
IMIDAZOTETRAZINES ‐ Drugs for Treatment of Cancer ......................................................................................................................... 160
IMMUNE GLOBULIN IMMUNOSUPPRESSANTS ‐ Miscellaneous Drugs and Solutions ........................................................................... 160
IMMUNE SERUMS ‐ Vaccines and Drugs for the Immune System ......................................................................................................... 161
IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES ‐ Miscellaneous Drugs and Solutions ................................................. 162
IMMUNOMODULATORS IMIDAZOQUINOLINAMINES ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ........................................................ 162
IN VITRO/LOCK ANTICOAGULANTS ‐ Drugs to Treat Blood Clots ........................................................................................................... 163
INCRETIN MIMETIC AGENTS (GLP‐1 RECEPTOR AGONISTS) ‐ Drugs to treat Diabetes .......................................................................... 163
INFECTION TESTS ‐ Products for Testing ................................................................................................................................................ 163
INFLAMMATORY BOWEL AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines .............................................................. 163
INFLUENZA AGENTS ‐ Drugs to Treat Viral Infections ............................................................................................................................ 164
INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS ‐ Miscellaneous Drugs and Solutions ..................................................... 164
INSULIN‐INCRETIN MIMETIC COMBINATIONS ‐ Drugs to treat Diabetes .............................................................................................. 164
INSULIN‐LIKE GROWTH FACTORS (SOMATOMEDINS) ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ......... 165
INTEGRIN RECEPTOR ANTAGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines .......................................................... 165
INTERLEUKIN ANTAGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ...................................................................... 165
INTERLEUKIN‐1 BLOCKERS ‐ Drugs to Treat Pain and Inflammation ...................................................................................................... 165
INTERLEUKIN‐1 RECEPTOR ANTAGONIST (IL‐1RA) ‐ Drugs to Treat Pain and Inflammation ................................................................. 165
INTERLEUKIN‐1BETA BLOCKERS ‐ Drugs to Treat Pain and Inflammation ............................................................................................. 165
INTERLEUKIN‐5 ANTAGONISTS (IGG1 KAPPA) ‐ Drugs to Treat Asthma and Breathing Disorders ........................................................ 165
INTERLEUKIN‐5 ANTAGONISTS (IGG4 KAPPA) ‐ Drugs to Treat Asthma and Breathing Disorders ........................................................ 165
INTERLEUKIN‐6 (IL‐6) ANTAGONISTS ‐ Miscellaneous Drugs and Solutions .......................................................................................... 165
INTERLEUKIN‐6 RECEPTOR INHIBITORS ‐ Drugs to Treat Pain and Inflammation .................................................................................. 165
INTERSTITIAL CYSTITIS AGENTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs ........................................................... 166
INTEST CHOLEST ABSORP INHIB‐HMG COA REDUCTASE INHIB COMB ‐ Drugs for High Cholesterol .................................................... 166
INTESTINAL ACIDIFIERS ‐ Drugs to Treat Disorders of the Stomach and Intestines ............................................................................... 166
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ‐ Drugs for High Cholesterol ............................................................................. 166
INTRARECTAL STEROIDS ‐ Drugs to Treat Misc Rectal Problems & Disorders ....................................................................................... 166
IODINE ANTISEPTICS ‐ Drugs and Products to Prevent the Growth of Disease‐Causing Microorganisms ............................................. 166
IODINE EXPECTORANTS ‐ Drugs to Treat Cough / Cold / Allergies ........................................................................................................ 166
IODINE PRODUCTS ‐ Drugs for Replacement of Minerals in the Body ................................................................................................... 167
IRON ‐ Drugs to Treat Blood Disorders .................................................................................................................................................. 167
IRON COMBINATIONS ‐ Drugs to Treat Blood Disorders ....................................................................................................................... 167
IRON W/ FOLIC ACID ‐ Drugs to Treat Blood Disorders ......................................................................................................................... 168
IRRIGATION SOLUTIONS ‐ Miscellaneous Drugs and Solutions ............................................................................................................. 168
ISOCITRATE DEHYDROGENASE‐1 (IDH1) INHIBITORS ‐ Drugs for Treatment of Cancer ........................................................................ 168
ISOCITRATE DEHYDROGENASE‐2 (IDH2) INHIBITORS ‐ Drugs for Treatment of Cancer ........................................................................ 169
JANUS ASSOCIATED KINASE (JAK) INHIBITORS ‐ Drugs for Treatment of Cancer .................................................................................. 169
KERATOLYTIC AND/OR ANTIMITOTIC COMBINATIONS ‐ Drugs to Treat Skin Disorders........................................................................ 169
KERATOLYTIC/ANTIMITOTIC AGENTS ‐ Drugs to Treat Skin Disorders .................................................................................................. 169
LAXATIVES ‐ MISCELLANEOUS ‐ Drugs to Treat Constipation ................................................................................................................ 169
LEPROSTATICS ‐ Antibiotics / Drugs for Infections ................................................................................................................................. 170
LEPTIN ANALOGUES ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ............................................................. 170
LEUKOTRIENE RECEPTOR ANTAGONISTS ‐ Drugs to Treat Asthma and Breathing Disorders ................................................................ 170
LEVODOPA COMBINATIONS ‐ Drugs to treat Parkinson's Disease ........................................................................................................ 170
10 Proprietary
LHRH ANALOGS ‐ Drugs for Treatment of Cancer .................................................................................................................................. 171
LHRH/GNRH AGONIST ANALOG COMBINATIONS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ............... 171
LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System171
LINCOSAMIDES ‐ Antibiotics / Drugs for Infections ............................................................................................................................... 171
LINIMENTS ‐ Drugs to Treat Skin Disorders ........................................................................................................................................... 171
LIPIDS ‐ Drugs/Products Used for Providing Nourishment .................................................................................................................... 171
LIPOTROPIC COMBINATIONS ‐ Drugs/Products Used for Providing Nourishment ................................................................................ 172
LOCAL ANESTHETIC & SYMPATHOMIMETIC ‐ Drugs for Anesthesia ...................................................................................................... 172
LOCAL ANESTHETICS ‐ AMIDES ‐ Drugs for Anesthesia .......................................................................................................................... 172
LOCAL ANESTHETICS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ............................................................................................................ 172
LOOP DIURETICS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders ............................................................................ 172
LUBRICANT LAXATIVES ‐ Drugs to Treat Constipation ........................................................................................................................... 172
LYMPHOCYTE FUNCTION‐ASSOCIATED ANTIGEN‐1 (LFA‐1) ANTAG ‐ Drugs for Treatment of Disorders in the Eyes ........................... 173
LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ........ 173
MACROLIDE IMMUNOSUPPRESSANTS ‐ Miscellaneous Drugs and Solutions ....................................................................................... 173
MACROLIDE IMMUNOSUPPRESSANTS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ................................................................................ 173
MAGNESIUM COMBINATIONS ‐ Drugs for Replacement of Minerals in the Body ................................................................................ 173
MEGLITINIDE ANALOGUES ‐ Drugs to treat Diabetes ............................................................................................................................ 173
MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS ‐ Drugs for High Cholesterol ............................................................... 173
MIGRAINE PRODUCTS ‐ Drugs to Treat Migraine Headaches ................................................................................................................ 174
MIGRAINE PRODUCTS ‐ NSAIDS ‐ Drugs to Treat Migraine Headaches ................................................................................................. 174
MINERALOCORTICOIDS ‐ Drugs to Treat Swelling and Inflammation .................................................................................................... 174
MIOTICS ‐ CHOLINESTERASE INHIBITORS ‐ Drugs for Treatment of Disorders in the Eyes .................................................................... 174
MIOTICS ‐ DIRECT ACTING ‐ Drugs for Treatment of Disorders in the Eyes ........................................................................................... 174
MISC NATURAL PRODUCTS ‐ Miscellaneous Drugs and Solutions ......................................................................................................... 174
MISC. ANTI‐ULCER ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders ........................................................................... 174
MISC. ANTIVIRALS ‐ Drugs to Treat Viral Infections ............................................................................................................................... 174
MISC. DERMATOLOGICAL PRODUCTS ‐ Drugs to Treat Skin Disorders .................................................................................................. 174
MISC. NUTRITIONAL SUBSTANCES ‐ Drugs/Products Used for Providing Nourishment ........................................................................ 176
MISC. NUTRITIONAL SUBSTANCES COMBINATIONS ‐ Drugs/Products Used for Providing Nourishment ............................................. 176
MISC. RESPIRATORY INHALANTS ‐ Drugs to Treat Cough / Cold / Allergies ........................................................................................... 176
MISC. TOPICAL ‐ Drugs to Treat Skin Disorders ..................................................................................................................................... 176
MISCELLANEOUS VAGINAL COMBINATIONS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms .............................. 177
MISCELLANEOUS VAGINAL PRODUCTS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms ....................................... 177
MITOTIC INHIBITORS ‐ Drugs for Treatment of Cancer ......................................................................................................................... 177
MIXED ALLERGENIC EXTRACTS ‐ Drugs to Treat Allergies / Allergic Responses ..................................................................................... 177
MONOAMINE OXIDASE INHIBITORS (MAOIS) ‐ Drugs for Depression / Other Disorders ...................................................................... 177
MONOBACTAMS ‐ Antibiotics / Drugs for Infections ............................................................................................................................. 177
MONOCLONAL ANTIBODIES ‐ Miscellaneous Drugs and Solutions ....................................................................................................... 177
MOVEMENT DISORDER DRUG THERAPY ‐ Drugs for diseases and disorders of the nervous system .................................................... 177
MS AGENTS ‐ PYRIMIDINE SYNTHESIS INHIBITORS ‐ Drugs for diseases and disorders of the nervous system .................................... 178
MUCOLYTICS ‐ Drugs to Treat Cough / Cold / Allergies ......................................................................................................................... 178
MUCOPOLYSACCHARIDOSIS I (MPS I) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System .................. 178
MUCOPOLYSACCHARIDOSIS II (MPS II) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ................ 178
MUCOPOLYSACCHARIDOSIS IV (MPS IV) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ............. 178
MUCOPOLYSACCHARIDOSIS VI (MPS VI) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ............. 178
MUCOPOLYSACCHARIDOSIS VII (MPS VII) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ........... 178
MULTIPLE SCLEROSIS AGENTS ‐ ANTIMETABOLITES ‐ Drugs for diseases and disorders of the nervous system .................................. 178
MULTIPLE SCLEROSIS AGENTS ‐ Drugs for diseases and disorders of the nervous system ................................................................... 178
MULTIPLE SCLEROSIS AGENTS ‐ INTERFERONS ‐ Drugs for diseases and disorders of the nervous system .......................................... 178
MULTIPLE SCLEROSIS AGENTS ‐ MONOCLONAL ANTIBODIES ‐ Drugs for diseases and disorders of the nervous system .................... 179
MULTIPLE SCLEROSIS AGENTS ‐ NRF2 PATHWAY ACTIVATORS ‐ Drugs for diseases and disorders of the nervous system ................. 179
MULTIPLE SCLEROSIS AGENTS ‐ POTASSIUM CHANNEL BLOCKERS ‐ Drugs for diseases and disorders of the nervous system ........... 179
MULTIPLE URINE TESTS ‐ Products for Testing ...................................................................................................................................... 179
11 Proprietary
MUSCLE RELAXANT COMBINATIONS ‐ Drugs for diseases and disorders of the muscles, ligaments, tendons and bones ................... 179
MUSCULAR DYSTROPHY AGENTS ‐ Drugs to Treat Disorders that Affect the Nerves That control Voluntary Muscles ........................ 180
NASAL AGENTS ‐ MISC. ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems ............................................................................... 180
NASAL ANESTHETICS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems .................................................................................. 180
NASAL ANTICHOLINERGICS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems ......................................................................... 180
NASAL ANTIHISTAMINES ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems ............................................................................ 180
NASAL STEROIDS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems ......................................................................................... 180
NATURAL PENICILLINS ‐ Antibiotics / Drugs for Infections .................................................................................................................... 181
NEEDLES & SYRINGES ‐ Diabetic Supplies and Needles ......................................................................................................................... 181
NEPRILYSIN INHIB (ARNI)‐ANGIOTENSIN II RECEPT ANTAG COMB ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
........................................................................................................................................................................................................... 192
NEURAMINIDASE INHIBITORS ‐ Drugs to Treat Viral Infections ............................................................................................................ 192
NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) ‐ AGENTS ‐ Drugs Used to Contract (Tighten) Blood Vessels and Raise Blood
Pressure ............................................................................................................................................................................................. 192
NEUROMUSCULAR BLOCKING AGENT ‐ NEUROTOXINS ‐ Drugs to Treat Disorders that Affect the Nerves That control Voluntary
Muscles .............................................................................................................................................................................................. 192
NICOTINIC ACID DERIVATIVES ‐ Drugs for High Cholesterol .................................................................................................................. 193
NITRATE & VASODILATOR COMBINATIONS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System ................................ 193
NITRATE VASODILATING AGENTS ‐ Drugs to Treat Misc Rectal Problems & Disorders ......................................................................... 193
NITRATES ‐ Drugs to Treat Heart Pain and Other Heart‐Related Disorders ........................................................................................... 193
NITROGEN MUSTARDS ‐ Drugs for Treatment of Cancer ...................................................................................................................... 194
NITROSOUREAS ‐ Drugs for Treatment of Cancer .................................................................................................................................. 194
N‐METHYL‐D‐ASPARTATE (NMDA) RECEPTOR ANTAGONISTS ‐ Drugs for diseases and disorders of the nervous system ................... 194
N‐METHYL‐D‐ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS ‐ Drugs for Depression / Other Disorders ....................................... 194
NON GELATIN CAPSULES (EMPTY) ‐ Syrups, gelatin, capsules for making pharmaceuticals ................................................................. 194
NON‐BENZODIAZEPINE ‐ GABA‐RECEPTOR MODULATORS ‐ Drugs to Treat Problems with Sleeping .................................................. 195
NONERGOLINE DOPAMINE RECEPTOR AGONISTS ‐ Drugs to treat Parkinson's Disease ....................................................................... 195
NON‐NARC ANTITUSSIVE‐ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies ........................................................................... 195
NON‐NARC ANTITUSSIVE‐DECONGESTANT‐ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies ............................................... 196
NONSTEROIDAL ANTI‐INFLAMMATORY AGENT COMBINATIONS ‐ Drugs to Treat Pain and Inflammation .......................................... 196
NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS (NSAIDS) ‐ Drugs to Treat Pain and Inflammation .................................................... 196
NOT CLASSIFIED ‐ Miscellaneous Drugs and Solutions .......................................................................................................................... 197
NUTRITIONAL SUPPLEMENTS ‐ DIET AIDS ‐ Products for Diet / Eating .................................................................................................. 200
NUTRITIONAL SUPPLEMENTS ‐ Products for Diet / Eating ..................................................................................................................... 198
ONCOLYTIC VIRAL AGENTS ‐ HSV1 ‐ Drugs for Treatment of Cancer ..................................................................................................... 200
OPHTHALMIC ANTIALLERGIC ‐ Drugs for Treatment of Disorders in the Eyes ...................................................................................... 200
OPHTHALMIC ANTIBIOTICS ‐ Drugs for Treatment of Disorders in the Eyes ......................................................................................... 200
OPHTHALMIC ANTIFUNGAL ‐ Drugs for Treatment of Disorders in the Eyes ........................................................................................ 201
OPHTHALMIC ANTI‐INFECTIVE COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes ......................................................... 201
OPHTHALMIC ANTISEPTICS ‐ Drugs for Treatment of Disorders in the Eyes ......................................................................................... 201
OPHTHALMIC ANTIVIRALS ‐ Drugs for Treatment of Disorders in the Eyes ........................................................................................... 201
OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS ‐ Drugs for Treatment of Disorders in the Eyes .................................................... 201
OPHTHALMIC DIAGNOSTIC PRODUCTS ‐ Drugs for Treatment of Disorders in the Eyes ....................................................................... 202
OPHTHALMIC IMMUNOMODULATORS ‐ Drugs for Treatment of Disorders in the Eyes ....................................................................... 202
OPHTHALMIC KINASE INHIBITORS ‐ COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes ................................................. 202
OPHTHALMIC LOCAL ANESTHETICS ‐ Drugs for Treatment of Disorders in the Eyes ............................................................................ 202
OPHTHALMIC NERVE GROWTH FACTORS ‐ Drugs for Treatment of Disorders in the Eyes ................................................................... 202
OPHTHALMIC NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS ‐ Drugs for Treatment of Disorders in the Eyes ................................. 202
OPHTHALMIC PHOTOENHANCER COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes ..................................................... 203
OPHTHALMIC RHO KINASE INHIBITORS ‐ Drugs for Treatment of Disorders in the Eyes ...................................................................... 203
OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS ‐ Drugs for Treatment of Disorders in the Eyes .......................................... 203
OPHTHALMIC STEROID COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes ..................................................................... 203
OPHTHALMIC STEROIDS ‐ Drugs for Treatment of Disorders in the Eyes .............................................................................................. 205
OPHTHALMIC SULFONAMIDES ‐ Drugs for Treatment of Disorders in the Eyes .................................................................................... 206
12 Proprietary
OPHTHALMIC SURGICAL AIDS ‐ Drugs for Treatment of Disorders in the Eyes ..................................................................................... 206
OPHTHALMICS ‐ CYSTINOSIS AGENTS ‐ Drugs for Treatment of Disorders in the Eyes ......................................................................... 206
OPHTHALMICS MISC. ‐ OTHER ‐ Drugs for Treatment of Disorders in the Eyes .................................................................................... 206
OPIOID AGONISTS ‐ Drugs for Treatment of Pain .................................................................................................................................. 206
OPIOID ANTAGONISTS ‐ Drugs to Treat Poisioning ................................................................................................................................ 208
OPIOID ANTITUSSIVE‐ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies ................................................................................. 208
OPIOID ANTITUSSIVE‐DECONGESTANT‐ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies ..................................................... 209
OPIOID COMBINATIONS ‐ Drugs for Treatment of Pain ......................................................................................................................... 209
OPIOID PARTIAL AGONISTS ‐ Drugs for Treatment of Pain .................................................................................................................... 209
ORAL VEHICLES ‐ Syrups, gelatin, capsules for making pharmaceuticals............................................................................................... 210
OREXIN RECEPTOR ANTAGONISTS ‐ Drugs to Treat Problems with Sleeping ........................................................................................ 211
OTIC AGENTS ‐ MISCELLANEOUS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion ................................................................. 211
OTIC ANTI‐INFECTIVES ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion ................................................................................. 211
OTIC STEROID‐ANTI‐INFECTIVE COMBINATIONS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion ......................................... 211
OTIC STEROIDS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion ............................................................................................. 211
OVULATION STIMULANTS‐GONADOTROPINS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ..................... 212
OVULATION STIMULANTS‐SYNTHETIC ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ................................. 212
OXABOROLE‐RELATED ANTIFUNGALS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ................................................................................. 212
OXAZOLIDINONES ‐ Antibiotics / Drugs for Infections ........................................................................................................................... 212
OXYTOCICS ‐ Drugs to Stimulate Contraction of Uterine Smooth Muscle ............................................................................................. 212
PA ENDONUCLEASE INHIBITORS ‐ Drugs to Treat Viral Infections ......................................................................................................... 212
PARATHYROID HORMONE AND DERIVATIVES ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ..................... 212
PASSIVE IMMUNIZING AGENTS ‐ COMBINATIONS ‐ Vaccines and Drugs for the Immune System ....................................................... 213
PCSK9 INHIBITORS ‐ Drugs for High Cholesterol .................................................................................................................................... 213
PENICILLIN COMBINATIONS ‐ Antibiotics / Drugs for Infections ........................................................................................................... 213
PENICILLINASE‐RESISTANT PENICILLINS ‐ Antibiotics / Drugs for Infections ......................................................................................... 213
PERIPHERAL COMT INHIBITORS ‐ Drugs to treat Parkinson's Disease ................................................................................................... 213
PERIPHERAL OPIOID RECEPTOR ANTAGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ......................................... 213
PHARMACEUTICAL EXCIPIENTS ‐ Syrups, gelatin, capsules for making pharmaceuticals ...................................................................... 214
PHENOTHIAZINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders ................................................................................. 214
PHENOTHIAZINES & TRICYCLIC AGENTS ‐ Drugs for diseases and disorders of the nervous system .................................................... 214
PHENYLKETONURIA TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ........................ 214
PHOSPHATE ‐ Drugs for Replacement of Minerals in the Body ............................................................................................................. 214
PHOSPHATE BINDER AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines ..................................................................... 215
PHOSPHATES ‐ Drugs To Treat Disorders of the Genital and Urinary Organs ........................................................................................ 215
PHOSPHATIDYLINOSITOL 3‐KINASE (PI3K) INHIBITORS ‐ Drugs for Treatment of Cancer ..................................................................... 215
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS ‐ Drugs to Treat Pain and Inflammation .......................................................................... 216
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders ....................................................................... 216
PHOSPHODIESTERASE III INHIBITORS ‐ Drugs to Treat Blood Disorders ................................................................................................ 216
PHOTODYNAMIC THERAPY AGENTS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders .................................................................................... 216
PLASMA KALLIKREIN INHIBITORS ‐ Drugs to Treat Blood Disorders ...................................................................................................... 216
PLASMA KALLIKREIN INHIBITORS ‐ MONOCLONAL ANTIBODIES ‐ Drugs to Treat Blood Disorders ...................................................... 216
PLATELET AGGREGATION INHIBITOR COMBINATIONS ‐ Drugs to Treat Blood Disorders ..................................................................... 216
PLATELET AGGREGATION INHIBITORS ‐ Drugs to Treat Blood Disorders .............................................................................................. 216
PLEUROMUTILINS ‐ Antibiotics / Drugs for Infections ........................................................................................................................... 216
POLY (ADP‐RIBOSE) POLYMERASE (PARP) INHIBITORS ‐ Drugs for Treatment of Cancer ...................................................................... 217
POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS ‐ Drugs for diseases and disorders of the nervous system ............. 217
POSTHERPETIC NEURALGIA(PHN)/NEUROPATHIC PAIN COMB AGENTS ‐ Drugs for diseases and disorders of the nervous system ... 217
POTASSIUM ‐ Drugs for Replacement of Minerals in the Body ............................................................................................................. 217
POTASSIUM COMBINATIONS ‐ Drugs for Replacement of Minerals in the Body .................................................................................. 218
POTASSIUM REMOVING AGENTS ‐ Miscellaneous Drugs and Solutions ............................................................................................... 218
POTASSIUM SPARING DIURETICS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders .................................................. 218
PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS ‐ SSRIS ‐ Drugs for diseases and disorders of the nervous system ............. 218
PRENATAL MV & MIN W/FE‐FA ‐ Drugs for Vitamin Replacement ........................................................................................................ 218
13 Proprietary
PRENATAL MV & MIN W/FE‐FA‐CA‐OMEGA 3 FISH OIL ‐ Drugs for Vitamin Replacement ................................................................... 223
PRENATAL MV & MIN W/FE‐FA‐DHA ‐ Drugs for Vitamin Replacement ............................................................................................... 223
PRENATAL MV & MINERALS W/FA WITHOUT IRON ‐ Drugs for Vitamin Replacement ......................................................................... 225
PRENATAL VITAMINS ‐ Drugs for Vitamin Replacement ........................................................................................................................ 225
PROGESTERONE RECEPTOR ANTAGONISTS ‐ Drugs to treat Diabetes .................................................................................................. 225
PROGESTIN CONTRACEPTIVES ‐ IMPLANTS ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ........................................... 225
PROGESTIN CONTRACEPTIVES ‐ INJECTABLE ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ......................................... 225
PROGESTIN CONTRACEPTIVES ‐ IUD ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ...................................................... 225
PROGESTIN CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ................................................... 226
PROGESTINS ‐ Natural or Synthetic Female Hormones ......................................................................................................................... 226
PROGESTINS‐ANTINEOPLASTIC ‐ Drugs for Treatment of Cancer .......................................................................................................... 226
PROSTAGLANDIN VASODILATORS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System ............................................... 226
PROSTAGLANDINS ‐ OPHTHALMIC ‐ Drugs for Treatment of Disorders in the Eyes .............................................................................. 227
PROSTATIC HYPERTROPHY AGENT COMBINATIONS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs ........................... 227
PROTEASE‐ACTIVATED RECEPTOR‐1 (PAR‐1) ANTAGONISTS ‐ Drugs to Treat Blood Disorders ............................................................ 227
PROTECTANTS ‐ MOUTH/THROAT ‐ Drugs to Treat Mouth / Throat / Dental Disorders ....................................................................... 227
PROTON PUMP INHIBITOR‐ANTACID COMBINATIONS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders .................... 228
PROTON PUMP INHIBITORS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders ............................................................. 228
PSEUDOBULBAR AFFECT AGENT COMBINATIONS ‐ Drugs for diseases and disorders of the nervous system ..................................... 229
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. ‐ Drugs for diseases and disorders of the nervous system ................... 229
PULM HYPERTEN‐SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC) ‐ Drugs to Treat Disorders of the Heart and Cardiovascular
System ............................................................................................................................................................................................... 229
PULMONARY FIBROSIS AGENTS ‐ Drugs/Products to Help with Breathing ........................................................................................... 229
PULMONARY FIBROSIS AGENTS ‐ KINASE INHIBITORS ‐ Drugs/Products to Help with Breathing ......................................................... 229
PULMONARY HYPERTENSION ‐ ENDOTHELIN RECEPTOR ANTAGONISTS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular
System ............................................................................................................................................................................................... 229
PULMONARY HYPERTENSION ‐ PHOSPHODIESTERASE INHIBITORS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
........................................................................................................................................................................................................... 230
PULMONARY HYPERTENSION ‐ PROSTACYCLIN RECEPTOR AGONIST ‐ Drugs to Treat Disorders of the Heart and Cardiovascular
System ............................................................................................................................................................................................... 230
PURINE ANALOGS ‐ Miscellaneous Drugs and Solutions ....................................................................................................................... 230
PYRIMIDINE SYNTHESIS INHIBITORS ‐ Drugs to Treat Pain and Inflammation ...................................................................................... 230
QUATERNARY ANTICHOLINERGICS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders .................................................. 230
QUINAZOLINE AGENTS ‐ Drugs to Treat Blood Disorders ...................................................................................................................... 230
QUINOLINONE DERIVATIVES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders ................................................................ 231
RADIOGRAPHIC CONTRAST MEDIA ‐ BARIUM ‐ Products for Testing .................................................................................................... 231
RADIOGRAPHIC CONTRAST MEDIA ‐ IODINATED ‐ Products for Testing ............................................................................................... 232
RANK LIGAND (RANKL) INHIBITORS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ..................................... 232
RECTAL ANESTHETIC/STEROIDS ‐ Drugs to Treat Misc Rectal Problems & Disorders ............................................................................ 232
RECTAL STEROIDS ‐ Drugs to Treat Misc Rectal Problems & Disorders ................................................................................................. 232
RESPIRATORY AGENTS ‐ MISC. ‐ Drugs/Products to Help with Breathing ............................................................................................. 232
RESTLESS LEG SYNDROME (RLS) AGENTS ‐ Drugs for diseases and disorders of the nervous system ................................................... 233
RETINOIDS ‐ Drugs for Treatment of Cancer .......................................................................................................................................... 233
ROSACEA AGENTS ‐ Drugs to Treat Skin Disorders ................................................................................................................................ 233
RSV AGENTS ‐ NUCLEOSIDE ANALOGUES ‐ Drugs to Treat Viral Infections ........................................................................................... 233
SALICYLATES ‐ Drugs to Treat Pain ......................................................................................................................................................... 233
SALINE LAXATIVE MIXTURES ‐ Drugs to Treat Constipation .................................................................................................................. 235
SALIVA STIMULANTS ‐ Drugs to Treat Mouth / Throat / Dental Disorders ............................................................................................ 235
SCABICIDES & PEDICULICIDES ‐ Drugs to Treat Skin Disorders .............................................................................................................. 235
SCAR TREATMENT PRODUCTS ‐ COMBINATIONS ‐ Drugs to Treat Skin Disorders ................................................................................ 235
SCAR TREATMENT PRODUCTS ‐ Drugs to Treat Skin Disorders ............................................................................................................. 235
SCLEROSTIN INHIBITORS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ...................................................... 236
SEBORRHEIC KERATOSIS PRODUCTS ‐ Drugs to Treat Skin Disorders .................................................................................................... 236
SELECTIN BLOCKERS ‐ Drugs to Treat Blood Disorders .......................................................................................................................... 236
14 Proprietary
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) ‐ Drugs to Treat High Blood Pressure ................................................... 236
SELECTIVE COSTIMULATION MODULATORS ‐ Drugs to Treat Pain and Inflammation .......................................................................... 236
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System . 236
SELECTIVE MELATONIN RECEPTOR AGONISTS ‐ Drugs to Treat Problems with Sleeping ...................................................................... 236
SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS ‐ Drugs to Treat Asthma and Breathing Disorders ......................................... 236
SELECTIVE RETINOID X RECEPTOR AGONISTS ‐ Drugs for Treatment of Cancer .................................................................................... 236
SELECTIVE SEROTONIN AGONIST‐NSAID COMBINATIONS ‐ Drugs to Treat Migraine Headaches ......................................................... 236
SELECTIVE SEROTONIN AGONISTS 5‐HT(1) ‐ Drugs to Treat Migraine Headaches ................................................................................ 237
SELECTIVE SEROTONIN AGONISTS 5‐HT(1F) ‐ Drugs to Treat Migraine Headaches .............................................................................. 238
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) ‐ Drugs for Depression / Other Disorders ....................................................... 238
SELECTIVE T‐CELL COSTIMULATION BLOCKERS ‐ Miscellaneous Drugs and Solutions .......................................................................... 239
SELECTIVE VASOPRESSIN V2‐RECEPTOR ANTAGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System...... 239
SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG ‐ Drugs for diseases and disorders of the nervous system ........... 239
SEROTONIN MODULATORS ‐ Drugs for Depression / Other Disorders .................................................................................................. 239
SEROTONIN‐NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) ‐ Drugs for Depression / Other Disorders .......................................... 239
SGLT2 INHIBITOR ‐ DPP‐4 INHIBITOR ‐ BIGUANIDE COMB ‐ Drugs to treat Diabetes ............................................................................ 240
SGLT2 INHIBITOR ‐ DPP‐4 INHIBITOR COMBINATIONS ‐ Drugs to treat Diabetes ................................................................................. 240
SINUS NODE INHIBITORS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System ............................................................ 240
SKIN CLEANSERS ‐ Drugs to Treat Skin Disorders ................................................................................................................................... 240
SKIN PROTECTANTS ‐ Drugs to Treat Skin Disorders .............................................................................................................................. 240
SMALL INTERFERING RIBONUCLEIC ACID (SIRNA) AGENTS ‐ Drugs for diseases and disorders of the nervous system ....................... 240
SMOKING DETERRENTS ‐ Drugs for diseases and disorders of the nervous system .............................................................................. 240
SODIUM‐GLUCOSE CO‐TRANSPORTER 2 (SGLT2) INHIBITORS ‐ Drugs to treat Diabetes ...................................................................... 244
SODIUM‐GLUCOSE CO‐TRANSPORTER 2 INHIBITOR‐BIGUANIDE COMB ‐ Drugs to treat Diabetes ...................................................... 244
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ‐ Drugs to Treat Pain and Inflammation ..................................................... 244
SOMATOSTATIC AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ..................................................... 245
SPHINGOSINE 1‐PHOSPHATE (S1P) RECEPTOR MODULATORS ‐ Drugs for diseases and disorders of the nervous system .................. 245
SPLEEN TYROSINE KINASE (SYK) INHIBITORS ‐ Drugs to Treat Blood Disorders .................................................................................... 245
STEROID INHALANTS ‐ Drugs to Treat Asthma and Breathing Disorders ............................................................................................... 245
STEROID‐LOCAL ANESTHETIC COMBINATIONS ‐ Drugs to Treat Skin Disorders .................................................................................... 246
STEROIDS ‐ MOUTH/THROAT/DENTAL ‐ Drugs to Treat Mouth / Throat / Dental Disorders ................................................................ 246
STIMULANT LAXATIVES ‐ Drugs to Treat Constipation .......................................................................................................................... 246
STIMULANTS ‐ MISC. ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders ........................................................ 246
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS ‐ Drugs to Treat Vomiting .................................................................. 248
SUCCINIMIDES ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders .............................................................. 248
SULFONAMIDES ‐ Sulfa Drugs / Antibiotics for Infections ..................................................................................................................... 248
SULFONYLUREA‐BIGUANIDE COMBINATIONS ‐ Drugs to treat Diabetes .............................................................................................. 248
SULFONYLUREAS ‐ Drugs to treat Diabetes ........................................................................................................................................... 248
SULFONYLUREA‐THIAZOLIDINEDIONE COMBINATIONS ‐ Drugs to treat Diabetes ................................................................................ 249
SWEETENERS ‐ Products for Diet / Eating .............................................................................................................................................. 249
SYSTEMIC DECONGESTANTS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems ....................................................................... 249
TAR PRODUCTS ‐ Drugs to Treat Skin Disorders .................................................................................................................................... 249
TETRACYCLINES ‐ Antibiotics / Drugs for Infections ............................................................................................................................... 249
THIAZIDES AND THIAZIDE‐LIKE DIURETICS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders .................................... 250
THIAZOLIDINEDIONE‐BIGUANIDE COMBINATIONS ‐ Drugs to treat Diabetes ....................................................................................... 250
THIAZOLIDINEDIONES ‐ Drugs to treat Diabetes.................................................................................................................................... 250
THIENBENZODIAZEPINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders ...................................................................... 251
THIENBENZODIAZEPINES & SSRIS ‐ Drugs for diseases and disorders of the nervous system .............................................................. 251
THIENOPYRIDINE DERIVATIVES ‐ Drugs to Treat Blood Disorders ......................................................................................................... 251
THIOXANTHENES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders .................................................................................. 251
THROMBIN INHIBITORS ‐ SELECTIVE DIRECT & REVERSIBLE ‐ Drugs to Treat Blood Clots .................................................................... 251
THROMBOPOIETIN (TPO) RECEPTOR AGONISTS ‐ Drugs to Treat Blood Disorders ............................................................................... 251
THYROID HORMONES ‐ Drugs to Treat Disorders of the Thyroid Gland ................................................................................................ 252
TOPICAL ANESTHETIC COMBINATIONS ‐ Drugs to Treat Skin Disorders ................................................................................................ 253
15 Proprietary
TOPICAL ANESTHETIC GASES ‐ Drugs to Treat Skin Disorders ............................................................................................................... 253
TOPICAL DECONGESTANTS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems ......................................................................... 254
TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS ‐ Drugs to Treat Skin Disorders ....................................................................... 254
TOPICAL STEROID COMBINATIONS ‐ Drugs to Treat Skin Disorders ...................................................................................................... 254
TOPOISOMERASE I INHIBITORS ‐ Drugs for Treatment of Cancer ......................................................................................................... 254
TOXOID COMBINATIONS ‐ Vaccines and Drugs to Treat Communicable Diseases ................................................................................ 254
TRAMADOL COMBINATIONS ‐ Drugs for Treatment of Pain ................................................................................................................. 255
TRANSTHYRETIN STABILIZERS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System ..................................................... 255
TRIAZOLES ‐ Drugs to Treat Fungal Infections ....................................................................................................................................... 255
TRICYCLIC AGENTS ‐ Drugs for Depression / Other Disorders ............................................................................................................... 255
TRIPHASIC CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders ..................................................... 256
TRYPTOPHAN HYDROXYLASE INHIBITORS ‐ Drugs to Treat Disorders of the Stomach and Intestines .................................................. 257
TUMOR NECROSIS FACTOR ALPHA BLOCKERS ‐ Drugs to Treat Disorders of the Stomach and Intestines ........................................... 257
ULCER ANTI‐INFECTIVE W/ BISMUTH COMBINATIONS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders ................... 257
ULCER ANTI‐INFECTIVE W/ PROTON PUMP INHIBITORS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders ................. 257
ULCER DRUGS ‐ PROSTAGLANDINS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders .................................................. 257
UREA CYCLE DISORDER ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ........................................ 258
URICOSURICS ‐ Drugs to Treat Gout ...................................................................................................................................................... 258
URINARY ANALGESICS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs.......................................................................... 258
URINARY ANTI‐INFECTIVES ‐ Drugs to Treat Infections of the Urinary Tract ......................................................................................... 258
URINARY ANTISEPTIC‐ANTISPASMODIC &/OR ANALGESICS ‐ Drugs to Treat Infections of the Urinary Tract ...................................... 258
URINARY ANTISPASMODIC ‐ ANTIMUSCARINIC (ANTICHOLINERGIC) ‐ Drugs for Overactive Bladder and other Urinary Disorders .... 259
URINARY ANTISPASMODICS ‐ BETA‐3 ADRENERGIC AGONISTS ‐ Drugs for Overactive Bladder and other Urinary Disorders ............. 260
URINARY ANTISPASMODICS ‐ CHOLINERGIC AGONISTS ‐ Drugs for Overactive Bladder and other Urinary Disorders ........................ 260
URINARY ANTISPASMODICS ‐ DIRECT MUSCLE RELAXANTS ‐ Drugs for Overactive Bladder and other Urinary Disorders .................. 260
URINARY STONE AGENTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs ..................................................................... 260
URINARY TRACT PROTECTIVE AGENTS ‐ Drugs for Treatment of Cancer .............................................................................................. 260
VAGINAL ANTI‐INFECTIVES ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms ......................................................... 260
VAGINAL CONTRACEPTIVE PH MODULATOR ‐ COMBINATIONS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms . 260
VAGINAL ESTROGENS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms ................................................................. 260
VAGINAL PROGESTINS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms ................................................................ 261
VALPROIC ACID ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders ............................................................. 261
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS ‐ Drugs for Treatment of Disorders in the Eyes .......................... 261
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS ‐ Drugs for Treatment of Cancer ..................................................... 261
VASODILATORS ‐ Drugs to Treat High Blood Pressure ........................................................................................................................... 262
VASOMOTOR SYMPTOM AGENTS ‐ SSRIS ‐ Drugs for diseases and disorders of the nervous system .................................................. 262
VASOPRESSIN ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System ....................................................................... 262
VASOPRESSORS ‐ Drugs Used to Contract (Tighten) Blood Vessels and Raise Blood Pressure ............................................................. 262
VIRAL VACCINE COMBINATIONS ‐ Drugs for Communicable Disease Prevention ................................................................................. 262
VIRAL VACCINES ‐ Drugs for Communicable Disease Prevention .......................................................................................................... 262
VISCOSUPPLEMENTS ‐ Drugs for diseases and disorders of the muscles, ligaments, tendons and bones ............................................ 264
VITAMIN A ‐ Drugs for Vitamin Replacement ........................................................................................................................................ 264
VITAMIN B‐1 ‐ Drugs for Vitamin Replacement ..................................................................................................................................... 265
VITAMIN B‐6 ‐ Drugs for Vitamin Replacement ..................................................................................................................................... 265
VITAMIN C ‐ Drugs for Vitamin Replacement ........................................................................................................................................ 265
VITAMIN D ‐ Drugs for Vitamin Replacement ........................................................................................................................................ 265
VITAMIN E ‐ Drugs for Vitamin Replacement ........................................................................................................................................ 265
VITAMIN K ‐ Drugs for Vitamin Replacement ........................................................................................................................................ 265
VOLATILE ANESTHETICS ‐ Drugs for Anesthesia ..................................................................................................................................... 265
WOUND CARE ‐ GROWTH FACTOR AGENTS ‐ Drugs to Treat Skin Disorders ........................................................................................ 265
WOUND CARE COMBINATIONS ‐ Drugs to Treat Skin Disorders ........................................................................................................... 265
WOUND CLEANSERS/DECUBITUS ULCER THERAPY ‐ Drugs to Treat Skin Disorders ............................................................................. 266
WOUND DRESSINGS ‐ Drugs to Treat Skin Disorders ............................................................................................................................. 266
XANTHINE‐EXPECTORANTS ‐ Drugs to Treat Asthma and Breathing Disorders ..................................................................................... 268
16 Proprietary
XANTHINES ‐ Drugs to Treat Asthma and Breathing Disorders ............................................................................................................. 268
X‐LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
........................................................................................................................................................................................................... 268
ZINC ‐ Drugs for Replacement of Minerals in the Body ......................................................................................................................... 268
17 Proprietary
Definitions Brand name drug means a drug that is marketed under a proprietary, trademark‐protected name. A brand name drug is listed in this formulary in all CAPITAL letters. Coinsurance means a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment means a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible means the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If your health insurance policy has a deductible, it may have either one deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. Your insurance company pays the rest. Drug Tier means a group of prescription drugs that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a prescription drug is placed determines your portion of the cost for the drug. Exception request means a request for coverage of a non‐formulary drug. If you, your designee, or your prescribing health care provider submits a request for coverage of a non‐formulary drug, your insurer must cover the nonformulary drug when it is medically necessary for you to take the drug. Exigent circumstances means when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non‐formulary drug. Formulary or prescription drug list means the list of drugs that is covered by your health insurance policy under the prescription drug benefit of the policy. Generic drug means a drug that is the same as its brand name drug equivalent in dosage, strength, effect, how it is taken, quality, safety, and intended use. A generic drug is listed in this formulary in italicized lowercase letters. Medically Necessary means health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health care benefits that are not medically necessary. Non‐formulary drug means a prescription drug that is not listed on this formulary. Out‐of‐pocket costs means your expenses for health care benefits that aren’t reimbursed by your health insurance. Out‐of‐pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered. Plan Document means materials that explain the provisions of a your health plan, usually including the benefits provided by the plan and the rights of those who are covered under the plan. Examples include Summary of Benefits and Coverage, Schedule of Benefits, and Certificate of Coverage. Prescribing provider means a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition. Prescription means an oral, written, or electronic order from a prescribing provider authorizing a prescription drug to be provided to a specific individual. Prescription drug means a drug that by law requires a prescription. Preventative Health Drugs are Affordable Care Act (ACA) preventative health drugs, including contraceptive drugs and devices, covered at no charge when specific criteria are met. Prior Authorization means a decision by your health insurer that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in this formulary, your prescribing provider must request approval from your health insurer to cover the drug before you fill your prescription. Your health insurer must grant a prior authorization request when it is medically necessary for you to take the drug.
18 Proprietary
A prescription drug may be located by looking up the therapeutic category and class to which the drug belongs or the brand or generic name of the drug in the alphabetical index; and If a generic equivalent for a brand name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name.
• A drug is listed alphabetically by its brand and generic names in the therapeutic category and class to which it belongs;
• The generic name for a brand name drug is included after the brand name in parentheses and all lowercase italicized letters. (For example: COREG (carvedilol))
• If a generic equivalent for a brand name drug is both available and covered, the generic drug will be listed separately from the brand name drug in all lowercase italicized letters; and (For example: carvedilol)
• If a generic drug is marketed under a proprietary, trademark‐protected brand name, the brand name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. (For example: desogestrel‐ethinyl estradiol (Azurette)).
• Inclusion of a prescription drug on the formulary does not guarantee that your provider will prescribe the drug for a medical condition.
• Therapeutic categories and classes are based on the Medispan therapeutic classification system.
Your plan includes
• Brand and generic drugs that are selected for their quality and effectiveness
• A specialty pharmacy fills specialty drug prescriptions (ones that are injected, infused or taken by mouth) and provides services that include personal support, helpful resources and training, and free secure home delivery
• A home delivery pharmacy that delivers maintenance drugs to your home or wherever you choose (for drugs that are taken regularly to treat conditions like diabetes or asthma)
What you can expect to pay
With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the drug’s and medicine price after you meet your deductible, if applicable. If a pharmacy’s retail price for a prescription drug is less than your total cost share amount, you will not be required to pay more than the retail drug price. Each drug is grouped as a generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non‐preferred drug. Typically, generic drugs are less expensive than brands. Specialty prescription drugs typically include higher‐cost drugs that require special handling, special storage or monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.
Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.
Refer to the Schedule of Benefits for differences and information about the prescription drugs
covered under your Outpatient prescription drugs and medical benefit in your plan.
How to use this guide
19 Proprietary
You’re covered for all types of medicine — some more
expensive, and some less. What are drug tiers? Generic – (Tier 1): lowest cost share Preferred Brand – (including specialty) (Tier 2): a slightly higher cost share Non‐Preferred Brand – (Tier 3): a higher cost share Non‐Preferred Specialty –(Tier 4): typically, the highest cost share Zero Cost Share Preventative Drugs – (Tier 5): Available to some members at no cost with a prescription from your provider when obtained at an in‐network pharmacy. Certain limitations may apply.
Your pharmacy plan may not have all the coverage levels listed above so check your plan documents to see how much you will pay, such as your deductible, copayments, co‐insurance and maximum dollar amounts. There is a maximum cost share amount on the copayment and or coinsurance (after deductible) for orally administered anti‐cancer drugs of no more than $200 up to a 30‐day supply. There is also a maximum cost share amount on the copayment and or coinsurance (after deductible) for outpatient prescription drugs of no more than $250 up to a 30‐day supply (except for Bronze plans). For Bronze plans, the maximum cost share amount on the copayment and or coinsurance (after deductible) is $500 for up to a 30‐day supply. However, your applicable copayment may be lower than this limit. Please, see the plan Schedule of Benefits or Summary of Benefits and Coverage for the specific copays and coinsurance applicable to the plan.
NationCare plans have a prescription drug benefit with an open formulary. Prescribing physicians determine the clinically appropriate drug therapies for treatment of HIV or AIDS. There are no restrictions on HIV or AIDS medications. This includes no restrictions on combination, single‐tablet or multi‐tablet antiretroviral drug treatment regimens.
For your exact coverage and cost, and to learn more about your plan
Call the toll‐free number on your member ID card or
visit the website CVS.com, then log into your profile, where you can:
Find out the coverage and estimate of cost for specific drugs
View your deductibles and plan limits
Order medications
Check your pharmacy order status
Get a member ID card
View your claims, and more Have more questions about your pharmacy benefits?
We’re here to help. There are several ways you can learn more about your benefits:
Check your plan documents in your enrollment kit.
Call the toll‐free number on your member ID card.
Register at www.caremark.com. Be sure you have your ID Card with you when you register. You also need your member ID number.
Specialty Pharmacy Network An in‐network specialty pharmacy can fill your prescriptions for specialty drugs. These are the types of drugs that may be injected, infused or taken by mouth. They often need special storage and handling and they may need to be delivered quickly. A nurse or pharmacist may monitor your treatment, if needed. With this type of pharmacy, you can get this medicine sent right to your mailbox. How to get started with a specialty pharmacy Ordering your prescriptions through CVS specialty pharmacy is easy and we typically offer a 30‐day medicine supply. For a new prescription, your doctor can send it to us as listed below: Electronically: Through e‐prescribe Fax: 1‐800‐323‐2445 Phone: 1‐800‐237‐2767
20 Proprietary
CVS Caremark Mail Service Pharmacy®
You can have maintenance drugs sent right to your home or anywhere else you choose with CVS Caremark Mail Service Pharmacy. These are drugs that are taken regularly for chronic conditions like diabetes or asthma. Depending on your plan, you can get up to a 90‐day supply of medicine for less cost. It’s fast and convenient, and standard shipping is always free. Get started right away
You can submit your order using one of these options:
1. Online — Before submitting 90‐day prescriptions, you will need to register with CVS. Visit your secure member website and create your account. Log in to www.caremark.com. For assistance call (800) 378‐9442. There you can add or remove your prescriptions.
2. Phone — Call us toll‐free, 24/7 at 1‐866‐475‐7589. If you need the help of a telephone device for
the deaf, call 1‐877‐833‐2779. 3. Mail — Get a new prescription from your doctor. Then mail it to us with a completed order form.
You can find the form on your secure member website. The mailing address is on the form. Your doctor can submit your order using one of these options:
1. Online — They can submit your prescriptions using the e‐prescribe services on our provider website.
2. Phone — Call us toll‐free, Caremark Mail Order (800) 378‐5697 3. Fax — They can fax your prescription to 1‐800‐378‐0323. Make sure they include your member
ID number, date of birth and mailing address on the fax cover sheet. Only a doctor may fax a prescription.
21 Proprietary
Frequently asked questions
How can I save on prescriptions? Here are some tips to pay less out of pocket for your prescription drugs:
•Ask your doctor to consider prescribing drugs that are on the formulary. •Ask your doctor to consider prescribing generic drugs instead of brand‐name drugs. •Our home delivery service may save you money. For more information, visit the website on your member ID card and log in to your account.
What are generic drugs? Generic drugs are proven to be just as safe and effective as brand‐name drugs. They contain the same active ingredients in the same amounts as the brand‐name drugs and work the same way. So, they have the same risks and benefits as brand‐name drugs. However, they typically cost less. When appropriate, your doctor may decide to prescribe a generic drug or allow the pharmacist to substitute a generic drug. What is prior authorization? Prior authorization is one way that we can help you and your doctor find safe, appropriate drugs and keep costs down. Prior authorization means that you or your doctor need to get approval from the plan before certain drugs will be covered. Generally, prior authorization applies to drugs that:
•Are often taken in the wrong way •Should only be used for certain conditions •Often cost more than other drugs that are proven to be just as effective
Keep in mind that your doctor must contact us to request approval of coverage for these drugs. What are quantity limits? Quantity limits help your doctor and pharmacist make sure that you use your drug correctly and safely. We use medical guidelines and FDA‐approved recommendations from drug makers to set these coverage limits. The quantity limit program includes:
•Dose efficiency edits — Limits prescription coverage to one dose per day for drugs that have approval for once‐daily dosing •Maximum daily dose — If a prescription is lower than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy •Quantity limits over time — Limits prescription coverage to a specific number of units over a specific amount of time
How do you find a pharmacy? You can fill prescriptions at any participating (network) pharmacy. You can find a pharmacy in two ways:
•Online: By logging onto your secure member profile at Caremark.com •By phone: Call the toll‐free number on your ID card. During regular business hours, a representative can assist you.
How do you fill a prescription at a retail pharmacy? After you receive a prescription from your physician, physician assistant or nurse practitioner. You can fill prescriptions at any participating retail pharmacy. Present your benefit ID card and prescription (if needed) to the pharmacist. Pay your portion of the medication cost (if any). Also, your provider may submit your 30‐day prescription to your pharmacy by e‐scribe, fax or phone. How do you fill a prescription at a specialty pharmacy? Discuss with your provider which specialty pharmacy to use, such as the CVS Specialty Pharmacy or any participating (network) specialty pharmacies. You will also need to discuss with your provider where the medications will be administered, such as your doctor’s office, home or elsewhere. You will need to call the selected specialty pharmacy to pay your portion of medication cost (if any) and confirm the address for the medication delivery. Your provider may submit your 30‐day prescription to the specialty pharmacy by e‐scribe, fax or phone.
22
Proprietary
Are there other utilization management components other than prior authorization and quality limits? Clinical programs and administrative procedures in place are designed to ensure appropriate drug utilization, address and improve member adherence to drug therapies and promote member prescription drug safety. Below is a description of programs utilized in the NationCare plans. Opioid Abuse Prevention is a utilization management program that helps combat the national opioid crisis by focusing on ways to help you use opioids safely. This is accomplished by
•Setting coverage limits for up to seven days if you are new to therapy.
•Limiting opioid medication amounts for new or ongoing therapy covered by your plan.
•Ensuring the use of short‐acting opioids before using long‐acting ones.
•Offering patient education and counseling from CVS Pharmacists.
Specialty Guideline Management is a utilization management program that helps promote patient safety and ensure appropriate coverage of specialty medications. Components include:
•Robust clinical assessment – Coverage criteria includes diagnosis, age, safety, genetic testing and other relevant laboratory data. Criteria are continuously reviewed and updated as new safety or medical evidence becomes available.
•Generics first – Encourages plan members to try a generic medication before coverage is provided for the brand medication.
•Day 1 utilization management control – Safeguards effective and appropriate drug utilization in accordance with FDA labeling until drug specific criteria is available.
•Medical director review – Utilizes medical director to review prior authorization requests for certain drugs that are used to treat complex disease states.
Advanced Utilization Oversight is a utilization management program that contains a retrospective review of member’s clinical profile and claims history to help ensure clinically appropriate coverage. Dermatologic Management is a utilization management program for managing select dermatology drugs identified as driving trend within our book of business. Dose Optimization is a utilization management program that reviews point of sale identification of opportunities where a higher‐strength, single daily dose can be used in place of multiple daily doses, when available and clinically appropriate. Safety and Monitoring is a utilization program that helps reduce instances of fraud, waste and abuse through regular claims monitoring and timely interventions.
23
Proprietary
What if I need a drug that requires an exception to the prior authorization or quantity limits requirements? In certain cases, your prescriber can request a prior authorization for medical necessity or quantity limit requirements on your plan. Coverage determinations will be made within 72 hours of receiving non‐urgent requests. You can ask for your request to be expedited. Expedited coverage decisions are made within 24 hours following the receipts of the request. We’ll then contact you and/or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible if applicable. This amount is based on your pharmacy plan design. Medical exceptions which are approved for non‐urgent requests will cover the duration of the prescription, including refills. Approved medical exceptions for exigent circumstances will provide coverage for the duration of the exigency. If your request is denied you have the right to file an appeal using the process described in the notification letter. If a determination is not made for a prior authorization exception request within 72 hours of receiving a non‐urgent request and 24 hours of receiving a request based on exigent circumstances, the request is deemed approved and we may not deny the request thereafter.
In accordance with state law, members who are covered under small group health insurance policies and who have previously received approval from us for coverage of medications for the members’ medical conditions will continue to have those medications covered, for as long as the prescriber continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the member’s medical condition. How can your provider request a medical exception? The following options will provide detail to help request a medical exception. •Call CVS prior authorization unit at 1‐800‐294‐5979.
•Fax the completed request form to 1‐888‐836‐0730.
Pharmacy and Therapeutics (P&T) committee The services of an independent National Pharmacy and Therapeutics Committee (“P&T Committee”) are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee’s voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Voting members of the P&T Committee are not employees of CVS Caremark and must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.
24 Proprietary
Can the formulary change during the year? The formulary can change throughout the year. Some reasons why they can change include:
•New drugs are approved.
•Existing drugs are removed from the market.
•Prescription drugs may become available over the counter (without a prescription). Over the counter drugs are not generally covered in a formulary.
•Brand‐name drugs lose patent protection and generic versions become available. When this happens, the generic drug will be covered in place of the brand‐name drug. The brand‐name drug is likely to become non‐formulary or covered at a higher cost. See the “what are generic drugs?” section above for more information.
•A drug is moved to a different tier or has a utilization management requirement added or removed.
If you’re affected by a formulary change negatively you will receive a notice 30‐day prior to the formulary change. You will not be notified of positive changes such as a drug moving into a lower tier. When a drug dosage form is removed from the formulary and a drug was previously approved for coverage for your medical condition, coverage for the drug will continue if your provider continues to prescribe the drug for your condition and the drug is prescribed appropriately and is safe and effective for your condition. What is a medical benefit drug versus a drug covered under the Outpatient Prescription Drug Benefit? Outpatient prescription drugs, applicable under the
NationCare prescription drug benefit are listed in this
formulary document.
Prescription drugs applicable under the NationCare
medical benefit (such as the following that are
administered in a clinical setting: Intravenous Infusions,
Inpatient Medications, Blood Products, Continuous
Administration Solutions, Total Parenteral Nutrition,
Hydration Therapy, Physician Infusion Services
Medications, etc.), are not included in this formulary
document.
For medical benefit coverage regarding these types of
prescription drugs, contact your Medical Plan
Administrator or refer to your plan documents.
What are preventive care drugs? Preventive Care Drugs are listed on tier 5 "Zero Cost Share Preventive Drugs “. Preventative Care Drugs are Affordable Care Act (ACA) preventative health drugs, including contraceptive drugs and devices, covered at no charge when specific criteria are met. You can fill prescriptions at any participating (network) pharmacy. After you receive a prescription from your physician, physician assistant or nurse practitioner. Present your benefit ID card and prescription to the pharmacist. Pay your portion of the cost for the over the counter if applicable. What is a contraceptive drug or device? FDA‐approved contraceptive are drugs or devices, such as diaphragms or cervical caps, that help to prevent pregnancy. Most generic drug contraceptives and contraceptive devices are covered at no charge. You can fill prescriptions at any participating (network) pharmacy. After you receive a prescription from your physician, physician assistant or nurse practitioner. Present your benefit ID card and prescription to the pharmacist. Pay your portion of the cost for the over the counter if applicable. What are diabetes care and products are covered under the Outpatient Prescription Drug Benefit? FDA‐approved drugs for the treatment of diabetes are included in the formulary drug list. Diabetic testing supplies such as blood glucose test strips, urine test strips, lancets, insulin syringes/pens covered under the Outpatient Prescription Drug Benefits are also included in the formulary drug list. You can fill prescriptions at any participating (network) pharmacy.
25 Proprietary
Assis ve Technology Persons using assistive technology may not be able to fully access the following information. Click this form to complete the fields to receive a PDF document converted to an accessible PDF. If your request is an issue or question that cannot be satisfied with an accessible PDF, Meritain Health Customer Service is here to help. Need assistance or more information about our commitment to accessibility?
Call the number on the back of your member ID Card.
E‐mail [email protected].
Or call 1.888.324.5789. NOTE: This is a general line you may experience long hold times and/or need to be transferred. If your ID Card is available, please use the number on the back for faster service. Representatives are available on the general line from 7a.m.–8p.m. CST. If you are having trouble accessing information on our website, our Customer Service representatives can assist you. Please call them at the number on your member ID Card. Persons with a hearing or speech disability can use 711 for Telecommunications Relay Service (TRS).
Non‐Discrimination Notice National Health Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. National Health Insurance Company does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
National Health Insurance Company:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages
If you need these services, contact our third‐party administrator, Meritain Health at 1‐800‐847‐8361 (for TTY please dial 711). If you believe that National Health Insurance Company 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, fax, or e‐mail at the following:
Mail: National Health Insurance Company Attn: Mary Roufus, Civil Rights Coordinator P.O. Box 2070 Milwaukee, WI 53201‐2070
E‐mail: [email protected].
*Please put “Grievance Review – Non‐Discrimination” in the subject line of your e‐mail. 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, D.C. 20201
1‐800‐368‐1019, 800‐537‐7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
26 Proprietary
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-209-2933 (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 1-866-209-2933 (TTY: 711)
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-866-209-2933 (TTY: 711). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-866-209-2933
(TTY: 711) 번으로 전화해 주십시오.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-866-209-2933 (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-866-209-2933 (телетайп: 711).
(رقم هاتف الصم 2933-209-866-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم ).711والبكم:
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-209-2933 (TTY: 711). ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-866-209-2933 (ATS: 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-866-209-2933 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-866-209-2933 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-866-209-2933 (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-866-209-2933 (TTY: 711). 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。1-866-209-2933
（TTY: 711）まで、お電話にてご連絡ください。
تماس (TTY: 711) 2933‐209‐866‐1گفتگو می کنيد، تسهيلات زبانی بصورت رايگان برای شما فراهم می باشد. با فارسی: اگر به زبان توجه بگيريد.
27 Proprietary
List of Abbreviations
Tier 1: Generics Tier 2: Preferred Brands Tier 3: Non‐Preferred Brands Tier 4: Non‐Preferred Specialty Tier 5: Zero Cost Share Preventative Drugs. Preventive care drugs listed on tier 5 "Zero Cost Share Preventive Drugs" are covered without cost only if an individual qualifies, such as satisfying age or other required characteristics. If you do not qualify for the preventive benefit, then a cost share and or deductible will apply as indicated by the tier designation in the formulary. Certain limitations may apply. AL: Age Limit – Prior authorization may be required if your age does not fall within the FDA, manufacturer, or treatment guideline recommendations. OAC: Oral anti‐cancer drugs – There is a maximum cost share amount on the copayment and or coinsurance amount (after deductible) for orally administered anti‐cancer drugs of no more than $200 up to a 30‐day supply. OTC: Over the counter PA: Prior Authorization – Prior Authorization is required to determine coverage. QL: Quantity Limit – The prescription quantity covered is limited. Prior authorization is required for amounts greater than the limit. SP: Specialty Network – These drugs are available through participating pharmacies. Specialty products are limited up to a 30‐day supply.
Below is a list of drug name formatting patterns that may appear in the following pages. List of Patterns
lowercase italics: Generic drugs
UPPERCASE: Brand name drugs
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 28 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
5‐ALPHA REDUCTASE INHIBITORS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
AVODART CAP 0.5MG (dutasteride cap) Tier 3
dutasteride cap 0.5mg Tier 1
finasteride tab 5mg Tier 1
PROSCAR TAB 5MG (finasteride tab) Tier 3
5‐HT3 RECEPTOR ANTAGONISTS ‐ Drugs to Treat Vomiting
ALOXI INJ 0.25/2ML,0.25MG/5 (palonosetron hcl iv soln) Tier 3 QL (15 days;5 units)
ANZEMET TAB 100MG,50MG (dolasetron mesylate tab) Tier 3 QL (15 days;3 tablets)
granisetron inj 1mg/ml,4mg/4ml Tier 1 QL (15 days;1 units)
granisetron tab 1mg Tier 1 QL (15 days;6 tablets)
ondansetron inj 40/20ml,4mg/2ml Tier 1 QL (15 days;10 units)
ondansetron sol 4mg/5ml Tier 1 QL (15 days;100 units)
ondansetron tab 24mg,4mg,8mg Tier 1 QL (15 days;12 tablets)
ondansetron tab 24mg,4mg,8mg Tier 1 QL (15 days;12 tablets)
palonosetron inj 0.25/5ml,0.25mg/5 Tier 1 QL (15 days;5 units)
SANCUSO DIS 3.1MG (granisetron td patch) Tier 2 QL (15 days;1 units)
ZOFRAN TAB 4MG,8MG (ondansetron hcl tab) Tier 3 QL (15 days;12 tablets)
ZUPLENZ MIS 4MG,8MG (ondansetron oral soluble film) Tier 3 QL (15 days;12 units)
5‐HT4 RECEPTOR AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
MOTEGRITY TAB 1MG,2MG (prucalopride succinate tab) Tier 3
5‐LIPOXYGENASE INHIBITORS ‐ Drugs to Treat Asthma and Breathing Disorders
zileuton er tab 600mg Tier 1
ZYFLO TAB 600MG (zileuton tab) Tier 3
ABORTIFACIENT ‐ PROGESTERONE RECEPTOR ANTAGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
MIFEPREX TAB 200MG,300MG (mifepristone tab) Tier 3
mifepristone tab 200mg Tier 1
ABORTIFACIENTS/CERVICAL RIPENING ‐ PROSTAGLANDINS ‐ Drugs to Stimulate Contraction of Uterine Smooth Muscle
CERVIDIL VAG MIS 10MG INS (dinoprostone vaginal inserts) Tier 3
PREPIDIL GEL 0.5MG/3G (dinoprostone cervical gel) Tier 3
PROSTIN E 2 SUP 20MG (dinoprostone vaginal suppos) Tier 3
ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS ‐ Drugs to Treat High Blood Pressure
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 29 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
amlod/benazp cap 10‐20mg,10‐40mg,2.5‐10mg,5‐10mg,5‐20mg,5‐40mg
Tier 1
LOTREL CAP 10‐20MG,10‐40MG,5‐10MG,5‐20MG (amlodipine besylate‐benazepril hcl cap)
Tier 2
PRESTALIA TAB 14‐10MG,3.5‐2.5,7‐5MG (perindopril arginine‐amlodipine besylate tab)
Tier 3
TARKA TAB 2‐180 CR,2‐240 CR,4‐240 CR (trandolapril‐verapamil hcl tab er)
Tier 2
trando/verap tab 1‐240 er,2‐180 er,2‐240 er,4‐240 er Tier 1
ACE INHIBITORS ‐ Drugs to Treat High Blood Pressure
ACCUPRIL TAB 10MG,20MG,40MG,5MG (quinapril hcl tab) Tier 3
ALTACE CAP 1.25MG,10MG,2.5MG,5MG (ramipril cap) Tier 3
benazepril tab 10mg,20mg,40mg,5mg Tier 1
captopril tab 100mg,12.5mg,25mg,50mg Tier 1
enalapril tab 10mg,2.5mg,20mg,5mg Tier 1
EPANED SOL 1MG/ML (enalapril maleate oral soln) Tier 3
fosinopril tab 10mg,20mg,40mg Tier 1
lisinopril tab 10mg,2.5mg,20mg,30mg,40mg,5mg Tier 1
LOTENSIN TAB 10MG,20MG,40MG (benazepril hcl tab) Tier 3
MAVIK TAB 4MG (trandolapril tab) Tier 3
moexipril tab 15mg,7.5mg Tier 1
perindopril tab 2mg,4mg,8mg Tier 1
PRINIVIL TAB 10MG,2.5MG,20MG,30MG,40MG,5MG (lisinopril tab)
Tier 3
QBRELIS SOL 1MG/ML (lisinopril oral soln) Tier 3
quinapril tab 10mg,20mg,40mg,5mg Tier 1
ramipril cap 1.25mg,10mg,2.5mg,5mg Tier 1
trandolapril tab 1mg,2mg,4mg Tier 1
VASOTEC TAB 10MG,2.5MG,20MG,5MG (enalapril maleate tab)
Tier 3
ZESTRIL TAB 10MG,2.5MG,20MG,30MG,40MG,5MG (lisinopril tab)
Tier 3
ACE INHIBITORS & THIAZIDE/THIAZIDE‐LIKE ‐ Drugs to Treat High Blood Pressure
ACCURETIC TAB 10‐12.5,20‐12.5,20‐25MG (quinapril‐hydrochlorothiazide tab)
Tier 3
benazep/hctz tab 10‐12.5,20‐12.5,20‐25mg,5‐6.25 Tier 1
captopr/hctz tab 25‐15mg,25‐25mg,50‐15mg,50‐25mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 30 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
enalapr/hctz tab 10‐25mg,5‐12.5mg Tier 1
fosinop/hctz tab 10/12.5,20/12.5 Tier 1
lisinop/hctz tab 10‐12.5,20‐12.5,20‐25mg Tier 1
LOTENSIN HCT TAB 10‐12.5,20‐12.5,20‐25MG (benazepril & hydrochlorothiazide tab)
Tier 3
qnapril/hctz tab 10‐12.5,20‐12.5,20‐25mg Tier 1
VASERETIC TAB 10‐25MG (enalapril maleate & hydrochlorothiazide tab)
Tier 3
ZESTORETIC TAB 10‐12.5,20‐12.5,20‐25MG (lisinopril & hydrochlorothiazide tab)
Tier 3
ACL INHIB‐INTESTINAL CHOLESTEROL ABSORPTION INHIB COMB ‐ Drugs for High Cholesterol
NEXLIZET TAB 180/10MG (bempedoic acid‐ezetimibe tab) Tier 3
ACNE ANTIBIOTICS ‐ Drugs to Treat Skin Disorders
ACZONE GEL 5%,7.5% (dapsone gel) Tier 3
AMZEEQ AER 1.5%,4% (minocycline hcl micronized foam) Tier 3
CLEOCIN‐T GEL 1% (clindamycin phosphate gel) Tier 3
CLEOCIN‐T LOT 1% (clindamycin phosphate lotion) Tier 3
clindacin mis etz 1% Tier 1
clindamycin 1% (Clindacin Etz Pledgets)
clindacin‐p pad 1% Tier 1
clindamycin 1% (Clindacin‐p)
CLINDAGEL GEL 1% (clindamycin phosphate gel) Tier 3
clindamycin aer 1% Tier 1
clindamycin gel 1% Tier 1
clindamycin lot 1%,10mg/ml Tier 1
clindamycin mis 1% Tier 1
clindamycin pad 1% Tier 1
clindamycin sol 75mg/5ml Tier 1
dapsone gel 5%,7.5% Tier 1
ery pad 2% Tier 1
erythromycin pad 2% (Ery)
ERYGEL GEL 2% (erythromycin gel) Tier 3
erythromycin gel 2% Tier 1
erythromycin sol 2% Tier 1
EVOCLIN AER 1% (clindamycin phosphate foam) Tier 3
KLARON LOT 10%,9.8% (sulfacetamide sodium lotion) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 31 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
sulfacetamid lot 10% Tier 1
ACNE COMBINATIONS ‐ Drugs to Treat Skin Disorders
ACANYA GEL 1.2‐2.5%,1‐5%,1‐5%PUMP (clindamycin phosphate‐benzoyl peroxide gel)
Tier 3
adapal/ben p gel 0.1‐2.5% Tier 1
avar cleanse emu 10‐1 emu,10‐1%,10‐5% Tier 1
AVAR LS LIQ 10‐2%,9.8‐4.8% (sulfacetamide sodium w/ sulfur cleanser)
Tier 3
avar‐e emoll cre 10%‐5%,10‐2%,10‐5%,9.8‐4.8% Tier 1
avar‐e green cre 10%‐5%,10‐2%,10‐5%,9.8‐4.8% Tier 1
AVAR‐E LS CRE 10‐2%,9.8‐4.8% (sulfacetamide sodium w/ sulfur cream)
Tier 3
BENZ PER FOR LOT HC 7.5‐1 (benzoyl peroxide‐hydrocortisone lotion)
Tier 3
benz per‐ hc lot 5‐0.5% Tier 1
BENZACLIN GEL 1.2‐2.5%,1‐5%,1‐5%PUMP (clindamycin phosphate‐benzoyl peroxide gel)
Tier 3
BENZAMYCIN GEL 5‐3% (benzoyl peroxide‐erythromycin gel) Tier 3
bp 10‐1 emu,10‐1%,10‐5% Tier 1
bp cleansing emu 10‐4% Tier 1
clindam/benz gel 1.2‐2.5%,1‐5% Tier 1
clindamy/ben gel 1.2‐2.5%,1‐5% Tier 1
clindamy/ben gel 1.2‐2.5%,1‐5% Tier 1
clindamycin gel tretinoi Tier 1 AL‐34 max
EPIDUO FORTE GEL 0.1‐2.5%,0.3‐2.5% (adapalene‐benzoyl peroxide gel)
Tier 2
EPIDUO GEL 0.1‐2.5%,0.3‐2.5% (adapalene‐benzoyl peroxide gel)
Tier 2
ery/benzoyl gel 5‐3% Tier 1
neuac gel 1.2‐5% (Neuac) Tier 1
ONEXTON GEL 1.2‐3.75 (clindamycin phosphate‐benzoyl peroxide gel)
Tier 2
PLEXION CLTH PAD 9.8‐4.8% (sulfacetamide sodium w/ sulfur cleansing cloth)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 32 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PLEXION CRE 10‐2%,9.8‐4.8% (sulfacetamide sodium w/ sulfur cream)
Tier 3
PLEXION LIQ 10‐2%,9.8‐4.8% (sulfacetamide sodium w/ sulfur cleanser)
Tier 3
PLEXION LOT 9.8‐4.8% (sulfacetamide sodium w/ sulfur lotion)
Tier 3
sod sul/sulf cre 10%‐5%,10‐2%,10‐5%,9.8‐4.8% Tier 1
sod sul/sulf emu 10‐1 emu,10‐1%,10‐5% Tier 1
SOD SUL/SULF EMU 10‐5% (sulfacetamide sodium w/ sulfur emulsion)
Tier 3
sod sul/sulf liq 10‐2%,9.8‐4.8% Tier 1
sod sul/sulf liq 10‐2%,9.8‐4.8% Tier 1
sod sul/sulf liq wash 9‐4.5% Tier 1
sod sul/sulf lot 10‐5%,9.8‐4.8% Tier 1
sod sul/sulf pad 10‐4% Tier 1
sod sul/sulf sus 8‐4% Tier 1
SOD SUL/SULF SUS 10‐5% (sulfacetamide sodium w/ sulfur susp)
Tier 3
sss 10‐5 aer 10‐5% Tier 1
sss cre 10%‐5%,10‐2%,10‐5%,9.8‐4.8% Tier 1
sul sod/sulf pad 10‐4% Tier 1
sulfacleanse sus 8‐4% Tier 1
sulfamez emu 10‐1 emu,10‐1%,10‐5% Tier 1
sulfur/resor lot 5‐2% Tier 1
SUMADAN WASH LIQ 9‐4%,9‐4.5% (sulfacetamide sodium w/ sulfur wash)
Tier 3
SUMAXIN PAD 10‐4% (sulfacetamide sodium w/ sulfur cleansing pad)
Tier 3
SUMAXIN WASH LIQ 9‐4%,9‐4.5% (sulfacetamide sodium w/ sulfur wash)
Tier 3
vanoxide‐hc lot 5‐0.5% Tier 1
VELTIN GEL (clindamycin phosphate‐tretinoin gel) Tier 3 AL‐34 max
ZIANA GEL (clindamycin phosphate‐tretinoin gel) Tier 3 AL‐34 max
ACNE PRODUCTS ‐ Drugs to Treat Skin Disorders
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 33 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ABSORICA CAP 10MG,20MG,25MG,30MG,35MG,40MG (isotretinoin cap)
Tier 2 PA
ABSORICA LD CAP 16MG,24MG,32MG,8MG (isotretinoin micronized cap)
Tier 3 PA
adapalene cre 0.1% Tier 1
adapalene gel 0.1%,0.3% Tier 1
adapalene gel pmp 0.1%,0.3% Tier 1
adapalene pad 0.1%swab Tier 1
ADAPALENE SOL 0.1% (adapalene soln) Tier 3
AKLIEF CRE 0.005% (trifarotene cream) Tier 3
ALTRENO LOT 0.05% (tretinoin lotion) Tier 3
isotretinoin cap 10mg,20mg,30mg,40mg (Amnesteem) Tier 1 PA
ARAZLO LOT 0.045% (tazarotene (acne) lotion) Tier 3 PA;AL‐34 max
ATRALIN GEL 0.01%,0.025%,0.05% (tretinoin gel) Tier 3 AL‐34 max
tretinoin cre 0.025%,0.05%,0.1% (Avita) Tier 1 AL‐34 max
tretinoin gel 0.01%,0.025%,0.05% (Avita) Tier 1 AL‐34 max
AZELEX CRE 20% (azelaic acid cream) Tier 3
BENZ PEROXID GEL 2.75%,5.25%,6.5% (benzoyl peroxide gel)
Tier 3
BENZAC AC LIQ 5% WASH,6.8%,6.9% (benzoyl peroxide liq) Tier 3
benzepro aer 5.3%,9.8% Tier 1
BENZEPRO AER 5.2%,5.5%,9.5%,9.7% (benzoyl peroxide foam)
Tier 3
BENZEPRO LIQ 5% WASH,6.8%,6.9% (benzoyl peroxide liq) Tier 3
benzepro liq creamy 10% wash,2.5%,5.25%,7%,7% wash Tier 1
benzepro mis 6% Tier 1
BENZEPRO MIS 5.8% (benzoyl peroxide cloth) Tier 3
benzepro sc aer 5.3%,9.8% Tier 1
benzoyl peroxide short contact aer 5.3%,9.8% (Benzepro Short Contact)
Tier 1
BENZIQ GEL 2.75%,5.25%,6.5% (benzoyl peroxide gel) Tier 3
BENZIQ LS GEL 2.75%,5.25%,6.5% (benzoyl peroxide gel) Tier 3
benzoyl peroxide wash liq 10% wash,2.5%,5.25%,7%,7% wash (Benziq Wash)
Tier 1
benzoyl per aer 5.3%,9.8% Tier 1
benzoyl per gel 10% Tier 1
benzoyl per liq 10% wash,2.5%,5.25%,7%,7% wash Tier 1
BENZOYL PERX LIQ 5% WASH,6.8%,6.9% (benzoyl peroxide liq)
Tier 3
bp wash liq 10% wash,2.5%,5.25%,7%,7% wash Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 34 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
benzoyl peroxide wash liq 10% wash,2.5%,5.25%,7%,7% wash (Bp Wash)
isotretinoin 10mg,20mg,30mg,40mg (Claravis) Tier 1 PA
DIFFERIN CRE 0.1% (adapalene cream) Tier 3
DIFFERIN GEL 0.3% (adapalene gel) Tier 3
DIFFERIN LOT 0.1% (adapalene lotion) Tier 3
enzoclear aer 5.3%,9.8% Tier 1
FABIOR AER 0.1% (tazarotene (acne) foam) Tier 3 PA;AL‐34 max
isotretinoin cap 10mg,20mg,30mg,40mg Tier 1 PA
isotretinoin cap 10mg,20mg,30mg,40mg (Myorisan) Tier 1 PA
benzoyl peroxide wash 10% wash,2.5%,5.25%,7%,7% (Pr Benzoyl Peroxide Wash)
Tier 1
RETIN‐A CRE 0.025%,0.05%,0.1% (tretinoin cream) Tier 3 AL‐34 max
RETIN‐A GEL 0.01%,0.025%,0.05% (tretinoin gel) Tier 3 AL‐34 max
RETIN‐A MICR GEL 0.04%,0.04%PMP,0.06%,0.08%,0.1%,0.1%PUMP (tretinoin microsphere gel)
Tier 3 AL‐34 max
RIAX AER 5.2%,5.5%,9.5%,9.7% (benzoyl peroxide foam) Tier 3
tretinoin cre 0.025%,0.05%,0.1% Tier 1 AL‐34 max
tretinoin gel 0.01%,0.025%,0.05% Tier 1 AL‐34 max
tretinoin gel 0.01%,0.025%,0.05% Tier 1 AL‐34 max
ZACLIR LOT 8% (benzoyl peroxide lotion) Tier 3
isotretinoin cap 10mg,20mg,30mg,40mg (Zenatane) Tier 1 PA
ADENOSINE RECEPTOR ANTAGONIST ‐ Drugs to treat Parkinson's Disease
NOURIANZ TAB 20MG,40MG (istradefylline tab) Tier 3
ADENOSINE TRIPHOSPHATE‐CITRATE LYASE (ACL) INHIBITORS ‐ Drugs for High Cholesterol
NEXLETOL TAB 180MG (bempedoic acid tab) Tier 2
ADHD AGENT ‐ SELECTIVE ALPHA ADRENERGIC AGONISTS ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders
clonidine tab 0.1mg,0.2mg,0.3mg Tier 1
guanfacine tab 1mg,2mg Tier 1
INTUNIV TAB 1MG,2MG,3MG,4MG (guanfacine hcl tab er) Tier 3
KAPVAY TAB 0.1 MG (clonidine hcl tab er) Tier 3
ADHD AGENT ‐ SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders
atomoxetine cap 100mg,10mg,18mg,25mg,40mg,60mg,80mg
Tier 1 AL‐18 max
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 35 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
STRATTERA CAP 100MG,10MG,18MG,25MG,40MG,60MG,80MG (atomoxetine hcl cap)
Tier 3 AL‐18 max
ADRENERGIC COMBINATIONS ‐ Drugs to Treat Asthma and Breathing Disorders
ADVAIR DISKU AER 100/50,250/50,500/50 (fluticasone‐salmeterol aer powder ba)
Tier 2 QL (75 days;180 units)
ADVAIR HFA AER 115/21,230/21,45/21 (fluticasone‐salmeterol inhal aerosol)
Tier 2 QL (75 days;36 units)
AIRDUO RESPI INH 113‐14,232‐14,55‐14 (fluticasone‐salmeterol aer powder ba)
Tier 3 QL (75 days;180 units)
ANORO ELLIPT AER 62.5‐25 (umeclidinium‐vilanterol aero powd ba)
Tier 2 QL (75 days;180 units)
BEVESPI AER 9‐4.8MCG (glycopyrrolate‐formoterol fumarate aerosol)
Tier 2 QL (75 days;33 units)
BREO ELLIPTA INH 100‐25,200‐25 (fluticasone furoate‐vilanterol aero powd ba)
Tier 2
budes/formot aer 160‐4.5,80‐4.5 Tier 1 QL (75 days;33 units)
COMBIVENT AER 20‐100 (ipratropium‐albuterol inhal aerosol soln)
Tier 3 QL (75 days;24 units)
DUAKLIR AER 400/12 (aclidinium br‐formoterol fum aero pow br act)
Tier 3
DULERA AER 100‐5MCG,200‐5MCG,50‐5MCG (mometasone furoate‐formoterol fumarate aerosol)
Tier 3 QL (75 days;39 units)
flutic/salme aer 100/50,113/14,232/14,250/50,500/50,55/14
Tier 1 QL (75 days;180 units)
flutic/salme inh 100/50,113/14,232/14,250/50,500/50,55/14
Tier 1 QL (75 days;180 units)
ipratropium/ sol albuter Tier 1 QL (75 days;1620 units)
STIOLTO AER 2.5‐2.5 (tiotropium br‐olodaterol inhal aero soln)
Tier 2 QL (75 days;12 units)
SYMBICORT AER 160‐4.5,80‐4.5 (budesonide‐formoterol fumarate dihyd aerosol)
Tier 2 QL (75 days;33 units)
TRELEGY AER ELLIPTA (fluticasone‐umeclidinium‐vilanterol aepb)
Tier 2
UTIBRON CAP NEOHALER (indacaterol‐glycopyrrolate inhal cap)
Tier 3
wixela inhub aer 100/50,113/14,232/14,250/50,500/50,55/14
Tier 1 QL (75 days;180 units)
ADRENOLYTICS‐CENTRAL & THIAZIDE/THIAZIDE‐LIKE COMB ‐ Drugs to Treat High Blood Pressure
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 36 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
methyld/hctz tab 250/15,250/25 Tier 1
AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS ‐ Drugs to Treat Skin Disorders
VEREGEN OIN 15% (sinecatechins oint) Tier 3
AGENTS FOR GAUCHER DISEASE ‐ Drugs to Treat Blood Disorders
CERDELGA CAP 84MG (eliglustat tartrate cap) Tier 2 PA; SP; QL (34 days supply)
CEREZYME INJ 400UNIT (imiglucerase for inj) Tier 2 PA; SP; QL (34 days supply)
ELELYSO INJ 200UNIT (taliglucerase alfa for inj) Tier 4 PA; SP; QL (34 days supply)
miglustat cap 100mg Tier 1 PA; SP; QL (34 days supply)
VPRIV INJ 400UNIT (velaglucerase alfa for inj) Tier 4 PA; SP; QL (34 days supply)
ZAVESCA CAP 100MG (miglustat cap) Tier 4 PA; SP; QL (3 units per 1 day)
AGENTS FOR OPIOID WITHDRAWAL ‐ Drugs for diseases and disorders of the nervous system
LUCEMYRA TAB 0.18MG (lofexidine hcl tab) Tier 3
AGENTS FOR PHEOCHROMOCYTOMA ‐ Drugs to Treat High Blood Pressure
DEMSER CAP 250MG (metyrosine cap) Tier 3
DIBENZYLINE CAP 10MG (phenoxybenzamine hcl cap) Tier 3
phenoxybenza cap 10mg Tier 1
ALCOHOL DETERRENTS ‐ Drugs for diseases and disorders of the nervous system
acampro cal tab 333mg Tier 1
ANTABUSE TAB 250MG,500MG (disulfiram tab) Tier 2
disulfiram tab 250mg,500mg Tier 1
ALKYLATING AGENTS ‐ Drugs for Treatment of Cancer
BELRAPZO SOL 100/4ML (bendamustine hcl iv soln) Tier 4 PA; SP; QL (34 days supply)
BENDAMUSTINE SOL 100/4ML (bendamustine hcl iv soln) Tier 4 PA; SP; QL (34 days supply)
BENDEKA INJ 100/4ML (bendamustine hcl iv soln) Tier 4 PA; SP; QL (34 days supply)
MYLERAN TAB 2MG (busulfan tab) Tier 2 OAC
TREANDA INJ 100MG,25MG (bendamustine hcl for iv soln) Tier 4 PA; SP; QL (34 days supply)
ALPHA 1‐ADRENOCEPTOR ANTAGONISTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
alfuzosin tab 10mg er Tier 1
CARDURA XL TAB 4MG,8MG (doxazosin mesylate tab er) Tier 3
FLOMAX CAP 0.4MG (tamsulosin hcl cap) Tier 3
RAPAFLO CAP 4MG,8MG (silodosin cap) Tier 3
silodosin cap 4mg,8mg Tier 1
tamsulosin cap 0.4mg Tier 1
UROXATRAL TAB 10MG (alfuzosin hcl tab er) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 37 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB ‐ Drugs for Treatment of Disorders in the Eyes
BRIMO/DORZO SOL 0.15‐2% (brimonidine tartrate‐dorzolamide hcl ophth soln)
Tier 3
SIMBRINZA SUS 1‐0.2% (brinzolamide‐brimonidine tartrate ophth susp)
Tier 2
ALPHA‐2 RECEPTOR ANTAGONISTS (TETRACYCLICS) ‐ Drugs for Depression / Other Disorders
mirtazapine tab 15mg odt,30mg odt,45mg odt Tier 1
mirtazapine tab 15mg odt,30mg odt,45mg odt Tier 1
REMERON SLTB TAB 15MG,30MG,45MG (mirtazapine orally disintegrating tab)
Tier 3
REMERON TAB 15MG,30MG (mirtazapine tab) Tier 3
ALPHA‐BETA BLOCKERS ‐ Drugs for High Blood Pressure / Misc Heart Disorders
carvedilol cap 10mg er,20mg er,40mg er,80mg er Tier 1
carvedilol tab 12.5mg,25mg,3.125mg,6.25mg Tier 1
COREG CR CAP 10MG,20MG,40MG,80MG (carvedilol phosphate cap er)
Tier 3
COREG TAB 12.5MG,25MG,3.125MG,6.25MG (carvedilol tab)
Tier 3
labetalol tab 100mg,200mg,300mg Tier 1
ALPHA‐GLUCOSIDASE INHIBITORS ‐ Drugs to treat Diabetes
acarbose tab 100mg,25mg,50mg Tier 1
GLYSET TAB 100MG,25MG,50MG (miglitol tab) Tier 3
miglitol tab 100mg,25mg,50mg Tier 1
PRECOSE TAB 100MG,25MG,50MG (acarbose tab) Tier 2
ALPHA‐PROTEINASE INHIBITOR (HUMAN) ‐ Drugs/Products to Help with Breathing
ARALAST NP INJ 1000MG,500MG (alpha1‐proteinase inhibitor (human) for iv soln)
Tier 4 PA; SP; QL (34 days supply)
GLASSIA INJ (alpha1‐proteinase inhibitor (human) inj) Tier 4 PA; SP; QL (34 days supply)
PROLASTIN‐C INJ 1000MG (alpha1‐proteinase inhibitor (human) for iv soln)
Tier 2 PA
PROLASTIN‐C INJ 1000MG (alpha1‐proteinase inhibitor (human) inj)
Tier 2 PA
ZEMAIRA INJ 1000MG,500MG (alpha1‐proteinase inhibitor (human) for iv soln)
Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 38 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ALS AGENTS ‐ MISCELLANEOUS ‐ Drugs to Treat Disorders that Affect the Nerves That control Voluntary Muscles
RADICAVA INJ 30MG (edaravone inj) Tier 4 PA; SP; QL (34 days supply)
ALTERNATIVE MEDICINE ‐ AL'S ‐ Miscellaneous Amino Acids and Supplements
NEOKE RA LIP POW 800MG/GM (alpha‐lipoic acid (thioctic acid) oral powder)
Tier 3
AMEBICIDES ‐ Drugs to Treat Parasitic Amebae Infections
SOLOSEC GRA 2GM (secnidazole granules packet) Tier 3
AMINO ACID MIXTURES ‐ Drugs/Products Used for Providing Nourishment
aminoam cap rms Tier 1
aminorelief cap rms Tier 1
AMINO ACIDS ‐ Drugs to Treat Blood Disorders
ENDARI POW 5GM (glutamine (sickle cell) powd pack) Tier 3 PA; QL (6 units per 1 day)
AMINO ACIDS‐SINGLE ‐ Drugs/Products Used for Providing Nourishment
n‐acetyl‐l‐ cap cysteine Tier 1
NEOKE ALCAR POW (acetylcarnitine oral powder) Tier 3
TRYPTOPHAN CAP 500MG (tryptophan cap) Tier 3
AMINOGLYCOSIDES ‐ Antibiotics / Drugs for Infections
ARIKAYCE SUS (amikacin sulfate liposome inhal susp) Tier 3
BETHKIS NEB 300/4ML,300/5ML (tobramycin nebu soln) Tier 2 PA; SP; QL (34 days supply)
KITABIS PAK NEB 300/4ML,300/5ML (tobramycin nebu soln) Tier 2 PA; SP; QL (34 days supply)
neomycin tab 500mg Tier 1
paromomycin cap 250mg Tier 1
TOBI NEB 300/5ML (tobramycin nebu soln) Tier 4 PA; SP; QL (34 days supply)
TOBI PODHALR CAP 28MG (tobramycin inhal cap) Tier 2 PA; SP; QL (34 days supply)
TOBI PODHALR CAP 28MG (tobramycin inhal cap) Tier 3 PA; SP; QL (34 days supply)
tobramycin neb 300/5ml Tier 1 PA; SP; QL (34 days supply)
AMINOLEVULINATE SYNTHASE 1‐DIRECTED SIRNA ‐ Drugs to Treat Blood Disorders
GIVLAARI INJ 189MG/ML (givosiran sodium subcutaneous soln)
Tier 3 PA
AMINOMETHYLCYCLINES ‐ Antibiotics / Drugs for Infections
NUZYRA TAB 150MG (omadacycline tosylate tab) Tier 3
AMINOPENICILLINS ‐ Antibiotics / Drugs for Infections
amoxicillin cap 250mg,500mg Tier 1
amoxicillin chw 125mg,250mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 39 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
amoxicillin sus 125/5ml,200/5ml,250/5ml,250mg/5m,400/5ml
Tier 1
amoxicillin tab 500mg,875mg Tier 1
ampicillin cap 500mg Tier 1
AMPA GLUTAMATE RECEPTOR ANTAGONISTS ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders
FYCOMPA SUS 0.5MG/ML (perampanel susp) Tier 2
FYCOMPA TAB 10MG,12MG,2MG,4MG,6MG,8MG (perampanel tab)
Tier 2
AMPHETAMINE MIXTURES ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders
ADDERALL TAB 10MG,12.5MG,15MG,20MG,30MG,5MG,7.5MG (amphetamine‐dextroamphetamine tab)
Tier 3 AL‐18 max
ADDERALL XR CAP 10MG,15MG,20MG,25MG,30MG,5MG (amphetamine‐dextroamphetamine cap er)
Tier 3 AL‐18 max
amphet/dextr cap 10mg er,15mg er,20mg er,25mg er,30mg er,5mg er
Tier 1 AL‐18 max
amphet/dextr tab 10mg,12.5mg,15mg,20mg,30mg,5mg,7.5mg
Tier 1 AL‐18 max
amphetamine tab 10mg,5mg Tier 1 AL‐18 max
MYDAYIS CAP 12.5MG,25MG,37.5MG,50MG (amphetamine‐dextroamphetamine)
Tier 2 AL‐18 max
AMPHETAMINES ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders
ADZENYS ER SUS 1.25MG,2.5MG/ML (amphetamine extended release susp)
Tier 3 AL‐18 max
ADZENYS XR TAB 12.5MG,15.7 MG,18.8MG,3.1MG,6.3MG,9.4MG (amphetamine tab extended release disintegrating)
Tier 3 AL‐18 max
amphetami er sus 1.25/ml Tier 1 AL‐18 max
amphetamine tab 10mg,5mg Tier 1 AL‐18 max
DESOXYN TAB 5MG (methamphetamine hcl tab) Tier 3 AL‐18 max
DEXEDRINE CAP 10MG CR,15MG CR,5MG CR (dextroamphetamine sulfate cap er)
Tier 3 AL‐18 max
dextroamphet cap 10mg er,15mg er,5mg er Tier 1 AL‐18 max
dextroamphet sol 5mg/5ml Tier 1 AL‐18 max
dextroamphet tab 10mg,15mg,2.5mg,20mg,30mg,5mg,7.5mg
Tier 1 AL‐18 max
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 40 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
DYANAVEL XR SUS 1.25MG,2.5MG/ML (amphetamine extended release susp)
Tier 3 AL‐18 max
EVEKEO ODT TAB 10MG,15MG,20MG,5MG (amphetamine sulfate orally disintegrating tab)
Tier 3 AL‐18 max
EVEKEO TAB 10MG,5MG (amphetamine sulfate tab) Tier 3 AL‐18 max
methamphetam tab 5mg Tier 1 AL‐18 max
procentra sol 5mg/5ml Tier 1 AL‐18 max
VYVANSE CAP 10MG,20MG,30MG,40MG,50MG,60MG,70MG (lisdexamfetamine dimesylate cap)
Tier 2 AL‐18 max
VYVANSE CHW 10MG,20MG,30MG,40MG,50MG,60MG (lisdexamfetamine dimesylate chew tab)
Tier 2 AL‐18 max
dextroamphetamine tab 10mg,15mg,2.5mg,20mg,30mg,5mg,7.5mg (Zenzedi)
Tier 1 AL‐18 max
ANABOLIC STEROIDS ‐ Drugs for Male Hormone Replacement
ANADROL‐50 TAB 50MG (oxymetholone tab) Tier 3 PA
oxandrolone tab 10mg,2.5mg Tier 1 PA
ANALEPTICS ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders
caffeine cit sol 20mg/ml,60mg/3ml Tier 1
ANALGESIC COMBINATIONS ‐ Drugs to Treat Pain
duraxin cap (Duraxin) Tier 1
ANALGESICS OTHER ‐ Drugs to Treat Pain
7T GUMMY ES CHW 500MG (acetaminophen chew tab) Tier 3
ANALGESICS‐SEDATIVES ‐ Drugs to Treat Pain
ALLZITAL TAB 25‐325MG (butalbital‐acetaminophen tab) Tier 3 QL (75 days;288 tablets)
butalbital‐acetaminophen tab 25‐325mg,50‐300mg,50‐325mg (Bupap)
Tier 1 QL (75 days;144 tablets)
but/apap/caf cap Tier 1 QL (75 days;144 units)
but/apap/caf tab Tier 1 QL (75 days;144 units)
BUT/ASA/CAF TAB (butalbital‐aspirin‐caffeine tab) Tier 3 QL (75 days;144 units)
but/asa/caff cap Tier 1 QL (75 days;144 units)
butal/acetam tab 25‐325mg,50‐300mg,50‐325mg Tier 1 QL (75 days;288 tablets)
butal/apap cap 50‐300mg Tier 1 QL (75 days;144 capsules)
BUTAL/APAP CAP 50‐300MG (butalbital‐acetaminophen cap)
Tier 3 QL (75 days;144 capsules)
butal/apap tab 25‐325mg,50‐300mg,50‐325mg Tier 1 QL (75 days;144 tablets)
butalb/aceta tab 25‐325mg,50‐300mg,50‐325mg Tier 1 QL (75 days;144 tablets)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 41 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
esgic cap Tier 1 QL (75 days;144 units)
ESGIC TAB (butalbital‐acetaminophen‐caffeine tab) Tier 3 QL (75 days;144 units)
FIORICET CAP (butalbital‐acetaminophen‐caffeine cap) Tier 3 QL (75 days;144 units)
FIORINAL CAP (butalbital‐aspirin‐caffeine cap) Tier 3 QL (75 days;144 units)
butalbital‐acetaminophen tab 25‐325mg,50‐300mg,50‐325mg (Tencon)
Tier 1 QL (75 days;144 tablets)
vanatol lq sol Tier 1 QL (75 days;2160 units)
vanatol s sol Tier 1 QL (75 days;2160 units)
vtol lq sol Tier 1 QL (75 days;2160 units)
zebutal cap Tier 1 QL (75 days;144 units)
ANAPHYLAXIS THERAPY AGENTS ‐ Drugs Used to Contract (Tighten) Blood Vessels and Raise Blood Pressure
ADRENALIN INJ 1MG/ML,30/30ML (epinephrine inj) Tier 3
ADYPHREN AMP KIT 1MG/ML (*epinephrine inj kit) Tier 3
ADYPHREN II KIT 1MG/ML (*epinephrine inj kit) Tier 3
ADYPHREN KIT 1MG/ML (*epinephrine inj kit) Tier 3
AUVI‐Q INJ 0.15MG,0.1MG,0.3MG (epinephrine solution auto‐injector)
Tier 3
EPINEPHR PRO KIT 1MG/ML (*epinephrine inj kit) Tier 3
epinephrine inj 30/30ml Tier 1
epinephrine inj 30/30ml Tier 1
EPINEPHRINE KIT 1MG/ML (*epinephrine inj kit) Tier 3
EPINPHEPHRIN KIT SNAP‐V 1MG/ML (*epinephrine inj kit) Tier 3
EPIPEN 0.15MG,2‐PAK INJ 0.3MG (epinephrine solution auto‐injector)
Tier 2
EPIPEN‐JR INJ 0.15MG,2‐PAK INJ 0.3MG (epinephrine solution auto‐injector)
Tier 2
EPISNAP KIT 1MG/ML (*epinephrine inj kit) Tier 3
SYMJEPI INJ 0.15MG (epinephrine soln prefilled syringe) Tier 2
SYMJEPI INJ 0.15MG (epinephrine solution prefilled syringe) Tier 2
ANDROGEN BIOSYNTHESIS INHIBITORS ‐ Drugs for Treatment of Cancer
abiraterone tab 250mg Tier 1 PA; QL (34 days supply); OAC
YONSA TAB 125MG (abiraterone acetate tab) Tier 2 PA; SP; QL (34 days supply); OAC
ZYTIGA TAB 250MG,500MG (abiraterone acetate tab) Tier 4 PA; SP; QL (34 days supply); OAC
ANDROGENS ‐ Drugs for Male Hormone Replacement
ANDRODERM DIS 2MG/24HR,4MG/24HR (testosterone td patch)
Tier 2
ANDROGEL GEL 1%,1%(25MG),1%(50MG),1.62%,10MG/ACT (testosterone td gel)
Tier 3
AVEED INJ 750/3ML (testosterone undecanoate im inj in oil) Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 42 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
danazol cap 100mg,200mg,50mg Tier 1
DEPO‐TESTOST INJ 100MG/ML,200MG/ML (testosterone cypionate im inj in oil)
Tier 3
FORTESTA GEL 1%,1%(25MG),1%(50MG),1.62%,10MG/ACT (testosterone td gel)
Tier 3
JATENZO CAP 158MG,198MG,237MG (testosterone undecanoate cap)
Tier 3
METHITEST TAB 10MG (methyltestosterone oral tab) Tier 3
methyltestos cap 10mg Tier 1
NATESTO GEL 5.5MG (testosterone nasal gel) Tier 3
TESTIM GEL 1%,1%(25MG),1%(50MG),1.62%,10MG/ACT (testosterone td gel)
Tier 3
TESTOPEL MIS PELLETS 100MG,200MG,25MG,50MG (testosterone implant pellets)
Tier 3
testost cyp inj 100mg/ml,200mg/ml Tier 1
testost enan inj 200mg/ml Tier 1
testosterone gel 1%,1% Tier 1
testosterone gel pump 1%,1% Tier 1
TESTOSTERONE MIS 100MG,200MG,25MG,50MG (testosterone implant pellets)
Tier 3
testosterone sol 30mg/act Tier 1
VOGELXO GEL 1%,1%(25MG),1%(50MG),1.62%,10MG/ACT (testosterone td gel)
Tier 3
VOGELXO GEL PUMP 1%,1%(25MG),1%(50MG),1.62%,10MG/ACT (testosterone td gel)
Tier 3
ANESTHETICS TOPICAL ORAL ‐ Drugs to Treat Mouth / Throat / Dental Disorders
lidocaine sol 4% Tier 1
lidocaine sol 4% Tier 1
topex topcal aer anesthet Tier 1
ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB ‐ Drugs to Treat High Blood Pressure
amlod/olmesa tab 10‐20mg,10‐40mg,5‐20mg,5‐40mg Tier 1
amlod/valsar tab 10‐160mg,10‐320mg,5‐160mg,5‐320mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 43 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
AZOR TAB 10‐20MG,10‐40MG,5‐20MG,5‐40MG (amlodipine besylate‐olmesartan medoxomil tab)
Tier 3
EXFORGE TAB 10‐160MG,10‐320MG,5‐160MG,5‐320MG (amlodipine besylate‐valsartan tab)
Tier 3
telmis/amlod tab 40‐10mg,40‐5mg,80‐10mg,80‐5mg Tier 1
TWYNSTA TAB 40‐10MG,40‐5MG,80‐10MG,80‐5MG (telmisartan‐amlodipine tab)
Tier 3
ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE‐LIKE ‐ Drugs to Treat High Blood Pressure
ATACAND HCT TAB 16‐12.5,32‐12.5,32‐25MG (candesartan cilexetil‐hydrochlorothiazide tab)
Tier 3
AVALIDE TAB 150‐12.5,300‐12.5 (irbesartan‐hydrochlorothiazide tab)
Tier 3
BENICAR HCT TAB 20‐12.5,40‐12.5,40‐25MG (olmesartan medoxomil‐hydrochlorothiazide tab)
Tier 3
candesa/hctz tab 16‐12.5,32‐12.5,32‐25mg Tier 1
DIOVAN HCT TAB 160‐12.5,160‐25MG,320‐12.5,320‐25MG,80/12.5 (valsartan‐hydrochlorothiazide tab)
Tier 3
EDARBYCLOR TAB 40‐12.5,40‐25MG (azilsartan medoxomil‐chlorthalidone tab)
Tier 3
HYZAAR TAB 100‐12.5,100‐25,50‐12.5 (losartan potassium & hydrochlorothiazide tab)
Tier 3
irbesar/hctz tab 150‐12.5,300‐12.5 Tier 1
losartan/hct tab 100‐12.5,100‐25,50‐12.5 Tier 1
MICARDIS HCT TAB 40/12.5,80/12.5,80‐25MG (telmisartan‐hydrochlorothiazide tab)
Tier 3
olm med/hctz tab 20‐12.5,40‐12.5,40‐25mg Tier 1
telmisa/hctz tab 40‐12.5,80‐12.5,80‐25mg Tier 1
valsart/hctz tab 160‐12.5,160‐25mg,320‐12.5,320‐25mg,80‐12.5
Tier 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS ‐ Drugs to Treat High Blood Pressure
ATACAND TAB 16MG,32MG,4MG,8MG (candesartan cilexetil tab)
Tier 3
AVAPRO TAB 150MG,300MG,75MG (irbesartan tab) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 44 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
BENICAR TAB 20MG,40MG,5MG (olmesartan medoxomil tab)
Tier 3
candesartan tab 16mg,32mg,4mg,8mg Tier 1
COZAAR TAB 100MG,25MG,50MG (losartan potassium tab) Tier 3
DIOVAN TAB 160MG,320MG,40MG,80MG (valsartan tab) Tier 3
EDARBI TAB 40MG,80MG (azilsartan medoxomil tab) Tier 3
irbesartan tab 150mg,300mg,75mg Tier 1
losartan pot tab 100mg,25mg,50mg Tier 1
MICARDIS TAB 20MG,40MG,80MG (telmisartan tab) Tier 3
olmesa medox tab 20mg,40mg,5mg Tier 1
telmisartan tab 20mg,40mg,80mg Tier 1
valsartan tab 160mg,320mg,40mg,80mg Tier 1
ANGIOTENSIN II RECEPTOR ANT‐CA CHANNEL BLOCKER‐THIAZIDES ‐ Drugs to Treat High Blood Pressure
amlod/valsar tab /hctz Tier 1
EXFORGEH/10‐ TAB 160‐12.5,160‐25,320‐25 (amlodipine‐valsartan‐hydrochlorothiazide tab)
Tier 3
EXFORGEH/5‐ TAB 160‐12.5,160‐25,320‐25 (amlodipine‐valsartan‐hydrochlorothiazide tab)
Tier 3
olm med/amlo tab /hctz Tier 1
TRIBENZOR20‐ TAB 10‐12.5,10‐25MG,5‐12.5MG,5‐25MG (olmesartan‐amlodipine‐hydrochlorothiazide tab)
Tier 3
TRIBENZOR40‐ TAB 10‐12.5,10‐25MG,5‐12.5MG,5‐25MG (olmesartan‐amlodipine‐hydrochlorothiazide tab)
Tier 3
ANTACIDS ‐ BICARBONATE ‐ Drugs to Treat Heartburn
SODIUM POW BICARBON (*sodium bicarbonate powder**) Tier 3
ANTHELMINTICS ‐ Drugs to Treat Parasitic Worm Infections
albendazole tab 200mg Tier 1
ALBENZA TAB 200MG (albendazole tab) Tier 3
BENZNIDAZOLE TAB 100MG,12.5MG (benznidazole tab) Tier 3
BILTRICIDE TAB 600MG (praziquantel tab) Tier 3
EMVERM CHW 100MG (mebendazole chew tab) Tier 2
ivermectin tab 3mg Tier 1
praziquantel tab 600mg Tier 1
STROMECTOL TAB 3MG (ivermectin tab) Tier 3
ANTI TB COMBINATIONS ‐ Drugs to Treat Infections of Mycobacterium
RIFAMATE CAP (isoniazid & rifampin cap) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 45 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
RIFATER TAB (isoniazid‐rifampin w/ pyrazinamide tab) Tier 3
ANTIADRENALS ‐ Drugs for Treatment of Cancer
LYSODREN TAB 500MG (mitotane tab) Tier 2 OAC
ANTIADRENERGICS ‐ CENTRALLY ACTING ‐ Drugs to Treat High Blood Pressure
CATAPRES TAB 0.1MG,0.2MG,0.3MG (clonidine hcl tab) Tier 2
CATAPRES‐TTS DIS 0.1/24HR,0.2/24HR,0.3/24HR (clonidine td patch weekly)
Tier 2
clonidine dis 0.1/24hr,0.2/24hr,0.3/24hr Tier 1
clonidine tab 0.1mg,0.2mg,0.3mg Tier 1
guanfacine tab 1mg,2mg Tier 1
methyldopa tab 250mg,500mg Tier 1
ANTIADRENERGICS ‐ PERIPHERALLY ACTING ‐ Drugs to Treat High Blood Pressure
CARDURA TAB 1MG,2MG,4MG,8MG (doxazosin mesylate tab)
Tier 3
doxazosin tab 1mg,2mg,4mg,8mg Tier 1
MINIPRESS CAP 1MG,2MG,5MG (prazosin hcl cap) Tier 3
prazosin hcl cap 1mg,2mg,5mg Tier 1
terazosin cap 10mg,1mg,2mg,5mg Tier 1
ANTIANDROGENS ‐ Drugs for Treatment of Cancer
bicalutamide tab 50mg Tier 1 OAC
CASODEX TAB 50MG (bicalutamide tab) Tier 3 OAC
ERLEADA TAB 60MG (apalutamide tab) Tier 2 PA; SP; QL (34 days supply)
flutamide cap 125mg Tier 1 OAC
NILANDRON TAB 150MG (nilutamide tab) Tier 3 OAC
nilutamide tab 150mg Tier 1 OAC
NUBEQA TAB 300MG (darolutamide tab) Tier 2 PA; SP; QL (34 days supply)
XTANDI CAP 40MG (enzalutamide cap) Tier 2 PA; SP; QL (34 days supply); OAC
ANTIANGINALS‐OTHER ‐ Drugs to Treat Heart Pain and Other Heart‐Related Disorders
RANEXA TAB 1000MG,500MG (ranolazine tab er) Tier 3
ranolazine tab 1000mg,500mg er Tier 1
ANTIANXIETY AGENTS ‐ MISC. ‐ Drugs for Anxiety Disorders
buspirone tab 10mg,15mg,30mg,5mg,7.5mg Tier 1
hydroxyz hcl syp 10mg/5ml Tier 1
hydroxyz hcl tab 10mg,25mg,50mg Tier 1
hydroxyz pam cap 100mg,25mg,50mg Tier 1
meprobamate tab 200mg,400mg Tier 1
VISTARIL CAP 25MG,50MG (hydroxyzine pamoate cap) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 46 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ANTIARRHYTHMICS TYPE I‐A ‐ Drugs to Treat Heart Arrhythmia
disopyramide cap 100mg,150mg Tier 1
NORPACE CAP 100MG,150MG (disopyramide phosphate cap er)
Tier 2
NORPACE CAP 100MG,150MG (disopyramide phosphate cap er)
Tier 2
quinidine gl tab 324mg cr,324mg er Tier 1
quinidine su tab 200mg,300mg Tier 1
ANTIARRHYTHMICS TYPE I‐B ‐ Drugs to Treat Heart Arrhythmia
mexiletine cap 150mg,200mg,250mg Tier 1
ANTIARRHYTHMICS TYPE I‐C ‐ Drugs to Treat Heart Arrhythmia
flecainide tab 100mg,150mg,50mg Tier 1
propafenone cap 225mg er,325mg er,425mg er Tier 1
propafenone tab 150mg,225mg,300mg Tier 1
RYTHMOL SR CAP 225MG,325MG,425MG (propafenone hcl cap er)
Tier 2
ANTIARRHYTHMICS TYPE III ‐ Drugs to Treat Heart Arrhythmia
amiodarone tab 100mg,200mg,400mg Tier 1
dofetilide cap 125mcg,250mcg,500mcg Tier 1 PA; SP; QL (34 days supply)
MULTAQ TAB 400MG (dronedarone hcl tab) Tier 2
pacerone tab 100mg,200mg,400mg Tier 1
TIKOSYN CAP 125MCG,250MCG,500MCG (dofetilide cap) Tier 2 PA; SP; QL (34 days supply)
ANTIBIOTIC STEROID COMBINATIONS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
CORTISPORIN CRE 0.5% (neomycin‐polymyxin‐hc crm) Tier 3
CORTISPORIN OIN 1% (bacitracin‐polymyxin‐neomycin hc oint)
Tier 3
NEO‐SYNALAR CRE (neomycin sulfate‐fluocinolone acetonide cream)
Tier 3
ANTIBIOTICS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
ALTABAX OIN 1% (retapamulin oint) Tier 3
CENTANY OIN 2% (mupirocin oint) Tier 3
gentamicin cre 0.1% Tier 1
gentamicin oin 0.1% Tier 1
mupirocin cre 2% Tier 1
mupirocin oin 2% Tier 1
XEPI CRE 1% (ozenoxacin cream) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 47 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ANTI‐CATAPLECTIC AGENTS ‐ Drugs for diseases and disorders of the nervous system
XYREM SOL 500MG/ML (sodium oxybate oral solution) Tier 3 PA
ANTICHOLINERGIC COMBINATIONS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
BELLA/OPIUM SUP 16.2‐30,16.2‐60 (belladonna alkaloids & opium suppos)
Tier 3
chlord/clidi cap 5‐2.5mg Tier 1
LIBRAX CAP 5‐2.5MG (chlordiazepoxide hcl‐clidinium bromide cap)
Tier 3
pheno/bella elx alkaloid Tier 1
ANTICOAGULANTS ‐ MISC. ‐ Drugs to Treat Blood Clots
ANTICOAGULNT INJ SOD CITR (sodium citrate soln prefilled syringe)
Tier 3
ANTICONVULSANTS ‐ BENZODIAZEPINES ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders
clobazam sus 2.5mg/ml Tier 1
clobazam tab 10mg,20mg Tier 1
clonazep odt tab 0.125mg,0.25mg,0.5mg,1mg,2mg Tier 1
clonazepam tab 0.5mg,1mg,2mg Tier 1
DIASTAT ACDL GEL 12.5‐20,2.5M GEL,5‐10MG (diazepam rectal gel delivery system)
Tier 3
DIASTAT PED GEL 12.5‐20,2.5M GEL,5‐10MG (diazepam rectal gel delivery system)
Tier 3
diazepam gel 10mg,2.5mg,20mg Tier 1
KLONOPIN TAB 0.5MG,1MG,2MG (clonazepam tab) Tier 3
NAYZILAM SPR 5MG (midazolam nasal spray soln) Tier 3
ONFI SUS 2.5MG/ML (clobazam suspension) Tier 3
ONFI TAB 10MG,20MG (clobazam tab) Tier 3
SYMPAZAN MIS 10MG,20MG,5MG (clobazam oral film) Tier 3
VALTOCO LIQ 15MG,20MG (diazepam nasal spray ther pack)
Tier 3
VALTOCO SPR 10MG,5MG (diazepam nasal spray) Tier 3
ANTICONVULSANTS ‐ MISC. ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders
APTIOM TAB 200MG,400MG,600MG,800MG (eslicarbazepine acetate tab)
Tier 3
BANZEL SUS 40MG/ML (rufinamide susp) Tier 3
BANZEL TAB 200MG,400MG (rufinamide tab) Tier 3
BRIVIACT SOL 10MG/ML (brivaracetam oral soln) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 48 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
BRIVIACT TAB 100MG,10MG,25MG,50MG,75MG (brivaracetam tab)
Tier 3
carbamazepin cap 100mg er,200mg er,300mg er Tier 1
carbamazepin chw 100mg Tier 1
carbamazepin sus 100/5ml Tier 1
carbamazepin tab 200mg Tier 1
carbamazepin tab 200mg Tier 1
CARBATROL CAP 100MG,200MG,300MG (carbamazepine cap er)
Tier 3
DIACOMIT CAP 250MG,500MG (stiripentol cap) Tier 3 QL (6 units per 1 day)
DIACOMIT PAK 250MG,500MG (stiripentol packet) Tier 3 QL (12 units per 1 day)
EPIDIOLEX SOL 100MG/ML (cannabidiol soln) Tier 4 PA; SP; QL (34 days supply)
epitol tab 200mg Tier 1
gabapentin cap 100mg,300mg,400mg Tier 1
gabapentin sol 250/5ml,300/6ml Tier 1
gabapentin tab 600mg,800mg Tier 1
KEPPRA SOL 100MG/ML (levetiracetam oral soln) Tier 3
KEPPRA TAB 1000MG,250MG,500MG,750MG (levetiracetam tab)
Tier 3
KEPPRA XR TAB 500MG,750MG (levetiracetam tab er) Tier 3
LAMICTAL CHW 25MG,5MG (lamotrigine tab chewable dispersible)
Tier 3
LAMICTAL KIT START 100MG,150MG,200MG,25MG,35,49,98 (lamotrigine tab)
Tier 3
LAMICTAL ODT KIT (lamotrigine tab disint) Tier 3
LAMICTAL ODT TAB 100MG,200MG,25MG,50MG (lamotrigine orally disintegrating tab)
Tier 3
LAMICTAL TAB 100MG,150MG,200MG,25MG,35,49,98 (lamotrigine tab)
Tier 3
LAMICTAL XR KIT 100MG,200MG,250MG,25MG,300MG,50MG (lamotrigine tab er)
Tier 3
LAMICTAL XR TAB 100MG,200MG,250MG,25MG,300MG,50MG (lamotrigine tab er)
Tier 3
lamotrig odt tab 100mg,200mg,25mg odt,50mg odt Tier 1
lamotrigine chw 25mg,5mg Tier 1
lamotrigine kit start 100mg,150mg,200mg,25mg,35,49,98 Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 49 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
lamotrigine tab 100mg,200mg,25mg odt,50mg odt Tier 1
lamotrigine tab 100mg,200mg,25mg odt,50mg odt Tier 1
lamotrigine tab 100mg,200mg,25mg odt,50mg odt Tier 1
levetiraceta sol 100mg/ml,500/5ml Tier 1
levetiraceta tab 1000mg,250mg,500mg,750mg Tier 1
levetiraceta tab 1000mg,250mg,500mg,750mg Tier 1
LYRICA CAP 100MG,150MG,200MG,225MG,25MG,300MG,50MG,75MG (pregabalin cap)
Tier 3
LYRICA SOL 20MG/ML (pregabalin soln) Tier 3
MYSOLINE TAB 250MG,50MG (primidone tab) Tier 3
NEURONTIN CAP 100MG,300MG,400MG (gabapentin cap) Tier 3
NEURONTIN SOL 250/5ML (gabapentin oral soln) Tier 3
NEURONTIN TAB 600MG,800MG (gabapentin tab) Tier 3
oxcarbazepin sus 300mg/5m Tier 1
oxcarbazepin tab 150mg,300mg,600mg Tier 1
OXTELLAR XR TAB 150MG,300MG,600MG (oxcarbazepine tab er)
Tier 2
pregabalin cap 100mg,150mg,200mg,225mg,25mg,300mg,50mg,75mg
Tier 1
pregabalin sol 20mg/ml Tier 1
primidone tab 250mg,50mg Tier 1
QUDEXY XR CAP 100/24HR,150/24HR,200/24HR,25/24HR,50/24HR (topiramate cap er)
Tier 3
roweepra tab 1000mg,250mg,500mg,750mg Tier 1
roweepra xr tab 500mg er,500mg xr,750mg er,750mg xr Tier 1
SPRITAM TAB 1000MG,250MG,500MG,750MG (levetiracetam tab disintegrating soluble)
Tier 3
lamotrigine subvenite starter kit 100mg,150mg,200mg,25mg,35,49,98 (Subvenite Starter Kit)
Tier 1
TEGRETOL SUS 100/5ML (carbamazepine susp) Tier 3
TEGRETOL TAB 200MG (carbamazepine tab) Tier 3
TEGRETOL‐XR TAB 100MG,200MG,400MG (carbamazepine tab er)
Tier 3
TOPAMAX SPR CAP 15MG,25MG (topiramate sprinkle cap) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 50 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
TOPAMAX TAB 100MG,200MG,25MG,50MG (topiramate tab)
Tier 3
topiramate cap 15mg,25mg Tier 1
topiramate cap er 100mg,150mg,200mg,25mg,50mg Tier 1
topiramate tab 100mg,200mg,25mg,50mg Tier 1
TRILEPTAL SUS 300MG/5M (oxcarbazepine susp) Tier 3
TRILEPTAL TAB 150MG,300MG,600MG (oxcarbazepine tab) Tier 3
TROKENDI XR CAP 100MG,200MG,25MG,50MG (topiramate cap er)
Tier 2
VIMPAT SOL 10MG/ML (lacosamide oral solution) Tier 2
VIMPAT TAB 100MG,150MG,200MG,50MG (lacosamide tab)
Tier 2
ZONEGRAN CAP 100MG,25MG (zonisamide cap) Tier 3
zonisamide cap 100mg,25mg,50mg Tier 1
ANTIDEMENTIA AGENT COMBINATIONS ‐ Drugs for diseases and disorders of the nervous system
NAMZARIC CAP 14‐10MG,21‐10MG,28‐10MG,7‐10MG (memantine hcl‐donepezil hcl cap er)
Tier 2
NAMZARIC CAP 14‐10MG,21‐10MG,28‐10MG,7‐10MG (memantine‐donepezil cap er)
Tier 2
ANTIDEPRESSANTS ‐ MISC. ‐ Drugs for Depression / Other Disorders
APLENZIN TAB 174MG,348MG,522MG (bupropion hbr tab er)
Tier 3
bupropion tab 100mg,75mg Tier 1
bupropion tab 100mg,75mg Tier 1
bupropn hcl tab 100mg sr,150mg sr,150mg xl,200mg sr,300mg xl,450mg xl
Tier 1
FORFIVO XL TAB 100MG SR,150MG,150MG SR,200MG SR,300MG,450MG (bupropion hcl tab er)
Tier 3
maprotiline tab 25mg,50mg,75mg Tier 1
WELLBUTRIN TAB 100MG SR,150MG,150MG SR,200MG SR,300MG,450MG (bupropion hcl tab er)
Tier 3
WELLBUTRIN TAB XL 100MG SR,150MG,150MG SR,200MG SR,300MG,450MG (bupropion hcl tab er)
Tier 3
ANTIDIABETIC ‐ AMYLIN ANALOGS ‐ Drugs to treat Diabetes
SYMLINPEN 120 INJ 1000MCG,60 INJ 1000MCG (pramlintide acetate pen‐inj)
Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 51 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
SYMLNPEN 120 INJ 1000MCG,60 INJ 1000MCG (pramlintide acetate pen‐inj)
Tier 2
ANTIDIARRHEAL ‐ CHLORIDE CHANNEL ANTAGONISTS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion
MYTESI TAB 125MG (crofelemer tab delayed release) Tier 3
ANTIDIARRHEAL/PROBIOTIC AGENTS ‐ MISC. ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion
lactojen cap (Lactojen) Tier 1
PRODIGEN CAP (*probiotic product ‐ cap**) Tier 3
PROMELLA CAP PREBIOTI (*probiotic product ‐ cap**) Tier 3
PROVAD CAP (*probiotic product ‐ cap**) Tier 3
VISBIOME PAK 900BIL (*probiotic product ‐ packet**) Tier 3
VSL#3 DS PAK 900BIL (*probiotic product ‐ packet**) Tier 3
ZELAC CAP (*probiotic product ‐ cap**) Tier 3
ANTIDIARRHEAL/PROBIOTIC COMBINATIONS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion
PROBICHEW CHW (*bacillus coagulans‐inulin chew tab**) Tier 3
RESTORA RX CAP 60‐1.25 (lactobacillus casei‐folic acid cap) Tier 3
ANTIDOTES ‐ CHELATING AGENTS ‐ Drugs to Treat Poisioning
CHEMET CAP 100MG (succimer cap) Tier 3
deferasirox tab 180mg,360mg,90mg Tier 1 PA; SP; QL (34 days supply)
deferasirox tab 180mg,360mg,90mg Tier 1 PA; SP; QL (34 days supply)
EXJADE TAB 125MG,250MG,500MG (deferasirox tab for oral susp)
Tier 4 PA; SP; QL (34 days supply)
FERRIPROX SOL 100MG/ML (deferiprone oral soln) Tier 3 PA
FERRIPROX TAB 1000MG,500MG (deferiprone tab) Tier 3 PA
JADENU SPRKL GRA 180MG,360MG,90MG (deferasirox granules packet)
Tier 4 PA; SP; QL (34 days supply)
JADENU TAB 180MG,360MG,90MG (deferasirox tab) Tier 4 PA; SP; QL (34 days supply)
PENTETATE CA SOL 200MG/ML (pentetate calcium trisodium iv or inhalation soln)
Tier 3
PENTETATE ZI SOL 200MG/ML (pentetate zinc trisodium iv or inhalation soln)
Tier 3
ANTIDOTES AND SPECIFIC ANTAGONISTS ‐ Drugs to Treat Poisioning
deferox mesy inj 2gm,500mg Tier 1 PA; SP; QL (34 days supply)
deferoxamine inj 2gm,500mg Tier 1 PA; SP; QL (34 days supply)
DESFERAL INJ 500MG (deferoxamine mesylate for inj) Tier 4 PA; SP; QL (34 days supply)
RADIOGARDASE CAP 0.5GM (prussian blue insoluble cap) Tier 3
VISTOGARD PAK 10GM (uridine triacetate oral granules packet)
Tier 2 QL (5 days;20 units)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 52 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ANTIEMETIC COMBINATIONS ‐ Drugs to Treat Vomiting
AKYNZEO CAP 300‐0.5 (netupitant‐palonosetron cap) Tier 3
BONJESTA TAB 20‐20MG (doxylamine‐pyridoxine tab er) Tier 3
DICLEGIS TAB 10‐10MG (doxylamine‐pyridoxine tab delayed release)
Tier 3
doxyl/pyrid tab 10‐10mg Tier 1
ANTIEMETICS ‐ ANTICHOLINERGIC ‐ Drugs to Treat Vomiting
meclizine tab 12.5mg,25mg Tier 1
scopolamine dis 1mg/3day Tier 1
TIGAN CAP 300MG (trimethobenzamide hcl cap) Tier 3
TRANSDERM SC DIS 1MG/3DAY (scopolamine td patch) Tier 3
TRANSDERM‐SC DIS 1MG/3DAY (scopolamine td patch) Tier 3
trimethobenz cap 300mg Tier 1
ANTIEMETICS ‐ MISCELLANEOUS ‐ Drugs to Treat Vomiting
dronabinol cap 10mg,2.5mg,5mg Tier 1 QL (75 days;180 capsules)
MARINOL CAP 10MG,2.5MG,5MG (dronabinol cap) Tier 3 QL (75 days;180 capsules)
SYNDROS SOL 5MG/ML (dronabinol soln) Tier 3
ANTIESTROGENS ‐ Drugs for Treatment of Cancer
FARESTON TAB 60MG (toremifene citrate tab) Tier 3 OAC
SOLTAMOX SOL 10MG/5ML (tamoxifen citrate oral soln) Tier 3 OAC
tamoxifen citrate tab 10mg,20mg Tier 5 OAC
toremifene tab 60mg Tier 1 OAC
ANTIFUNGALS ‐ Drugs to Treat Fungal Infections
ANCOBON CAP 250MG,500MG (flucytosine cap) Tier 3
nystatin cap 1000000,500000 (Bio‐Statin) Tier 1
bio‐statin pow Tier 1
flucytosine cap 250mg,500mg Tier 1
griseofulvin sus 125/5ml Tier 1
griseofulvin tab micr 500 Tier 1
griseofulvin tab ultr 125,250 Tier 1
LAMISIL TAB 250MG (terbinafine hcl tab) Tier 3 PA
nystatin tab 500000 Tier 1
terbinafine tab 250mg Tier 1 PA
ANTIFUNGALS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
ciclopirox sol 8% (Ciclodan) Tier 1 PA
ciclopirox cre 0.77% Tier 1
ciclopirox gel 0.77% Tier 1
ciclopirox sha 1% Tier 1
ciclopirox sol 8% Tier 1 PA
ciclopirox sus 0.77% Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 53 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
LOPROX CRE 0.77% (ciclopirox olamine cream) Tier 3
LOPROX SHA 1% (ciclopirox shampoo) Tier 3
LOPROX SUS 0.77% (ciclopirox olamine susp) Tier 3
MENTAX CRE 1% (butenafine hcl cream) Tier 3
naftifine cre hcl 1%,2% Tier 1
naftifine gel 1% Tier 1
NAFTIN CRE 2% (naftifine hcl cream) Tier 2
NAFTIN GEL 1%,2% (naftifine hcl gel) Tier 2
nystatin pow 100000 (Nyamyc) Tier 1
nystatin cre 100000 Tier 1
nystatin oin 100000 Tier 1
nystatin pow 100000 Tier 1
nystatin pow 100000 (Nystop) Tier 1
ANTIFUNGALS ‐ TOPICAL COMBINATIONS ‐ Drugs to Treat Skin Disorders
clotrim/beta cre 1‐0.05% Tier 1
clotrim/beta cre diprop 1‐0.05% Tier 1
clotrim/beta lot diprop Tier 1
ECONASIL KIT (*econazole nitrate cr) Tier 3
EXODERM LOT 25‐1% (sodium thiosulfate‐salicylic acid lotion)
Tier 3
FUNGIMEZ SOL (*antifungal combination products misc ‐ solution***)
Tier 3
mico‐zn‐petr oin Tier 1
nystat/triam cre Tier 1
nystat/triam oin Tier 1
RECURA CRE (*antifungal combination products misc ‐ cream***)
Tier 3
VUSION OIN (miconazole‐zinc oxide‐white petrolatum oint) Tier 3
ANTIHEMOPHILIC PRODUCTS ‐ Drugs to Treat Blood Disorders
ADVATE INJ 1000UNIT,2000UNIT,250UNIT,3000UNIT,500UNIT (antihemophilic factor rahf‐pfm for inj)
Tier 4 PA; SP; QL (34 days supply)
ADYNOVATE INJ 1000UNIT,1500UNIT,2000UNIT,250UNIT,3000UNIT,500UNIT,750UNIT (antihemophilic factor recomb pegylated for inj)
Tier 2 PA; SP; QL (34 days supply)
AFSTYLA KIT 1000UNIT,1500UNIT,2000UNIT,2500UNIT,250UNIT,3000UNIT,500UNIT (antihemophilic fact rcmb single chain for inj kit)
Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 54 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ALPHANATE INJ VWF/HUM 2400UNIT,250‐600,500‐1200 (antihemophilic factor/vwf (human) for inj)
Tier 4 PA; SP; QL (34 days supply)
ALPHANINE SD INJ 1000UNIT,1500UNIT,500UNIT (coagulation factor ix for inj)
Tier 4 PA; SP; QL (34 days supply)
ALPROLIX INJ 1000UNIT,2000UNIT,250UNIT,3000UNIT,4000UNIT,500UNIT (coagulation factor ix (recomb) (rfixfc) for inj)
Tier 4 PA; SP; QL (34 days supply)
BENEFIX INJ 1000UNIT,2000UNIT,250UNIT,3000UNIT,500UNIT (coagulation factor ix (recombinant) for inj kit)
Tier 4 PA; SP; QL (34 days supply)
COAGADEX INJ 250UNIT,500UNIT (coagulation factor x (human) for inj)
Tier 4 PA; SP; QL (34 days supply)
ELOCTATE INJ 1000UNIT,1500UNIT,2000UNIT,250UNIT,3000UNIT,4000UNIT,5000UNIT,500UNIT,6000UNIT,750UNIT (antihemophilic factor rcmb (bdd‐rfviiifc) for inj)
Tier 4 PA; SP; QL (34 days supply)
ESPEROCT INJ 1000UNIT,1500UNIT,2000UNIT,3000UNIT,500UNIT (antihemophilic factor recomb glycopeg‐exei for inj)
Tier 4 PA; SP; QL (34 days supply)
FEIBA INJ (antiinhibitor coagulant complex for iv soln) Tier 4 PA; SP; QL (34 days supply)
HEMOFIL M INJ 1000UNIT,1700UNIT,250UNIT,500 UNIT,500UNIT (antihemophilic factor (human) for inj)
Tier 4 PA; SP; QL (34 days supply)
HUMATE‐P SOL 2400UNIT,250‐600,500‐1200 (antihemophilic factor/vwf (human) for inj)
Tier 4 PA; SP; QL (34 days supply)
IDELVION SOL 1000UNIT,2000UNIT,250UNIT,3500UNIT,500UNIT (coagulation factor ix (recomb) (rix‐fp) for inj)
Tier 4 PA; SP; QL (34 days supply)
IXINITY INJ 1000UNIT,1500UNIT,2000UNIT,250 UNIT,250UNIT,3000UNIT,500UNIT (coagulation factor ix (recombinant) for inj)
Tier 4 PA; SP; QL (34 days supply)
JIVI INJ 1000UNIT,2000UNIT,3000UNIT,500 UNIT (antihemophilic factor recom pegylated‐aucl for inj)
Tier 2 PA; SP; QL (34 days supply)
KOATE INJ 1000UNIT,1700UNIT,250UNIT,500 UNIT,500UNIT (antihemophilic factor (human) for inj)
Tier 4 PA; SP; QL (34 days supply)
KOATE‐DVI INJ 1000UNIT,1700UNIT,250UNIT,500 UNIT,500UNIT (antihemophilic factor (human) for inj)
Tier 4 PA; SP; QL (34 days supply)
KOGENATE FS INJ 1000UNIT,2000UNIT,250UNIT,3000UNIT,500UNIT (antihemophilic factor (recombinant) for inj kit)
Tier 2 PA; SP; QL (34 days supply)
KOVALTRY INJ 1000UNIT,2000UNIT,250UNIT,3000UNIT,500UNIT (antihemophilic factor rahf‐pfm for inj)
Tier 2 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 55 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MONONINE INJ 1000UNIT,1500UNIT,500UNIT (coagulation factor ix for inj)
Tier 4 PA; SP; QL (34 days supply)
NOVOEIGHT INJ 1000UNIT,1500UNIT,2000UNIT,250UNIT,3000UNIT,500UNIT (antihemophilic fact rcmb (bd trunc‐rfviii) for inj)
Tier 2 PA; SP; QL (34 days supply)
NOVOSEVEN RT INJ 1MG,2MG,5MG,8MG (coagulation factor viia (recomb) for inj)
Tier 4 PA; SP; QL (34 days supply)
NUWIQ INJ 1000UNIT,2000UNIT,2500UNIT,3000UNIT,4000UNIT (antihemophilic fact rcmb (bdd‐rfviii,sim) for inj)
Tier 2 PA; SP; QL (34 days supply)
NUWIQ INJ 1000UNIT,2000UNIT,2500UNIT,3000UNIT,4000UNIT (antihemophilic factor rcmb (bdd‐rfviii,sim) for inj)
Tier 2 PA; SP; QL (34 days supply)
NUWIQ KIT 250UNIT,500UNIT (antihemophil fact rcmb (bdd‐rfviii,sim) for inj kit)
Tier 2 PA; SP; QL (34 days supply)
NUWIQ KIT 250UNIT,500UNIT (antihemophil fact rcmb(bdd‐rfviii,sim) for inj kit)
Tier 2 PA; SP; QL (34 days supply)
OBIZUR INJ 500 UNIT (antihemophilic factor (recomb porc) rpfviii for inj)
Tier 4 PA; SP; QL (34 days supply)
PROFILNINE INJ 1000UNIT,1500UNIT,500UNIT (factor ix complex for inj)
Tier 4 PA; SP; QL (34 days supply)
REBINYN SOL 1000UNIT,2000UNIT,500UNIT (coagulation factor ix recomb glycopegylated for inj)
Tier 2 PA; SP; QL (34 days supply)
RECOMBINATE INJ 220‐400,401‐800,801‐1240 (antihemophilic factor (recombinant) for inj)
Tier 4 PA; SP; QL (34 days supply)
RIXUBIS INJ 1000UNIT,1500UNIT,2000UNIT,250 UNIT,250UNIT,3000UNIT,500UNIT (coagulation factor ix (recombinant) for inj)
Tier 4 PA; SP; QL (34 days supply)
VONVENDI INJ 1300UNIT,650UNIT (von willebrand factor (recombinant) for inj)
Tier 4 PA; SP; QL (34 days supply)
WILATE INJ 2400UNIT,250‐600,500‐1200 (antihemophilic factor/vwf (human) for inj)
Tier 4 PA; SP; QL (34 days supply)
XYNTHA INJ 1000UNIT,2000UNIT,250UNIT,3000UNIT,500UNIT (antihemophilic factor recombinant paf for inj kit)
Tier 4 PA; SP; QL (34 days supply)
XYNTHA SOLOF INJ 1000UNIT,2000UNIT,250UNIT,3000UNIT,500UNIT (antihemophilic factor recombinant paf for inj kit)
Tier 4 PA; SP; QL (34 days supply)
XYNTHA SOLOF KIT 1000UNIT,2000UNIT,250UNIT,3000UNIT,500UNIT (antihemophilic factor recombinant paf for inj kit)
Tier 4 PA; SP; QL (34 days supply)
ANTIHEMOPHILIC PRODUCTS ‐ MONOCLONAL ANTIBODIES ‐ Drugs to Treat Blood Disorders
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 56 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
HEMLIBRA INJ 105/0.7,150/ML,30MG/ML,60/0.4 (emicizumab‐kxwh subcutaneous soln)
Tier 4 PA; SP; QL (34 days supply)
ANTIHISTAMINES ‐ ALKYLAMINES ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders
brompheniram chw 12mg Tier 1
dexchlorphen syp 2mg/5ml Tier 1
ryclora syp 2mg/5ml Tier 1
ANTIHISTAMINES ‐ ETHANOLAMINES ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders
carbinoxamin sol 4mg/5ml Tier 1
carbinoxamin tab 4mg Tier 1
CARBINOXAMIN TAB 6MG (carbinoxamine maleate tab) Tier 3
clemastine tab 2.68mg Tier 1
diphenhydramine elx 12.5/5ml (Diphen) Tier 1
diphenhydram elx 12.5/5ml Tier 1
KARBINAL ER SUS 4MG/5ML (carbinoxamine maleate extended release susp)
Tier 3
RYVENT TAB 6MG (carbinoxamine maleate tab) Tier 3
ANTIHISTAMINES ‐ NON‐SEDATING ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders
cetirizine sol 1mg/ml Tier 1
CLARINEX TAB 5MG (desloratadine tab) Tier 3
desloratadin tab 5mg Tier 1
desloratadin tab 5mg Tier 1
levocetirizi sol 2.5/5ml Tier 1
levocetirizi tab 5mg Tier 1
ANTIHISTAMINES ‐ PHENOTHIAZINES ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders
promethazine sol 6.25/5ml Tier 1
promethazine sup 12.5mg,25mg,50mg Tier 1
promethazine syp 6.25/5ml Tier 1
promethazine tab 12.5mg,25mg,50mg Tier 1
promethazine sup 12.5mg,25mg,50mg (Promethegan) Tier 1
ANTIHISTAMINES ‐ PIPERIDINES ‐ Drugs for Allergies / Itching / Misc Inflammation Disorders
cyproheptad syp 2mg/5ml Tier 1
cyproheptad tab 4mg Tier 1
ANTIHISTAMINE‐STEROID ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems
azel/flutic spr 137‐50 Tier 1 QL (75 days;69 units)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 57 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
DYMISTA SPR 137‐50 (azelastine hcl‐fluticasone prop nasal spray)
Tier 2 QL (75 days;69 units)
ANTIHYPERLIPIDEMICS ‐ MISC. ‐ Drugs for High Cholesterol
LOVAZA CAP 1GM (omega‐3‐acid ethyl esters cap) Tier 3
omega‐3‐acid cap 1gm Tier 1
VASCEPA CAP 0.5GM,1GM (icosapent ethyl cap) Tier 2
ANTIHYPERTENSIVES ‐ MISC. ‐ Drugs to Treat High Blood Pressure
VECAMYL TAB 2.5MG (mecamylamine hcl tab) Tier 3
ANTI‐IGE MONOCLONAL ANTIBODIES ‐ Drugs to Treat Asthma and Breathing Disorders
XOLAIR INJ 150MG/ML,75/0.5 (omalizumab subcutaneous soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
XOLAIR SOL 150MG (omalizumab for inj) Tier 2 PA; SP; QL (34 days supply)
ANTI‐INFECTIVE AGENTS ‐ MISC. ‐ Antibiotics / Drugs for Infections
AEMCOLO TAB 194MG (rifamycin sodium tab delayed release)
Tier 3
FLAGYL CAP 375MG (metronidazole cap) Tier 3
FLAGYL TAB 250MG,500MG (metronidazole tab) Tier 3
IMPAVIDO CAP 50MG (miltefosine cap) Tier 3
metronidazol cap 375mg Tier 1
metronidazol tab 250mg,500mg Tier 1
NEBUPENT INH 300MG (pentamidine isethionate for nebulization soln)
Tier 3
pentamidine inh 300mg Tier 1
PRIMSOL SOL 50MG/5ML (trimethoprim hcl oral soln) Tier 3
tinidazole tab 250mg,500mg Tier 1
trimethoprim tab 100mg Tier 1
XIFAXAN TAB 550MG (rifaximin tab) Tier 2
XIFAXAN TAB 200MG (rifaximin tab) Tier 3
ANTI‐INFECTIVE GENITOURINARY IRRIGANTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
neo/poly gu sol 40/ml ir Tier 1
ANTI‐INFECTIVE MISC. ‐ COMBINATIONS ‐ Antibiotics / Drugs for Infections
BACTRIM DS TAB 400‐80MG,800‐160 (sulfamethoxazole‐trimethoprim tab)
Tier 2
BACTRIM TAB 400‐80MG,800‐160 (sulfamethoxazole‐trimethoprim tab)
Tier 2
smz/tmp ds tab 400‐80mg,800‐160 Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 58 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
smz‐tmp ds tab 400‐80mg,800‐160 Tier 1
smz‐tmp sus 200‐40/5 Tier 1
smz‐tmp tab 400‐80mg,800‐160 Tier 1
sulfatrim pd sus 200‐40/5 Tier 1
ANTI‐INFECTIVES ‐ THROAT ‐ Drugs to Treat Mouth / Throat / Dental Disorders
clotrimazole loz 10mg Tier 1
clotrimazole tro 10mg Tier 1
nystatin sus 100000 Tier 1
ORAVIG TAB 50MG (miconazole buccal tab) Tier 3
ANTI‐INFLAMMATORY AGENTS ‐ Drugs to Treat Asthma and Breathing Disorders
cromolyn sod neb 20mg/2ml Tier 1 QL (75 days;720 units)
ANTI‐INFLAMMATORY AGENTS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
diclofenac dis 1.3% Tier 1
diclofenac gel 3% Tier 1 PA
diclofenac sol 0.1% op Tier 1
FLECTOR DIS 1.3% (diclofenac epolamine patch) Tier 3
LICART DIS 1.3% (diclofenac epolamine patch) Tier 3
PENNSAID SOL 2% (diclofenac sodium soln) Tier 3
VOLTAREN GEL 1% (diclofenac sodium gel) Tier 3 PA
ANTILEPROTICS ‐ Miscellaneous Drugs and Solutions
THALOMID CAP 100MG,150MG,200MG,50MG (thalidomide cap)
Tier 2 PA; SP; QL (34 days supply); OAC
ANTIMALARIAL COMBINATIONS ‐ Drugs to Treat Malaria / Other Infections
atovaq/progu tab 250‐100,62.5‐25 Tier 1
COARTEM TAB 20‐120MG (artemether‐lumefantrine tab) Tier 3
MALARONE TAB 250‐100,62.5‐25 (atovaquone‐proguanil hcl tab)
Tier 2
PYRIME/LEUCO CAP 12.5/2.5,25/10MG,25/5MG,50/10MG,50/20MG,50/25MG,75/25MG (pyrimethamine‐leucovorin cap)
Tier 3 OAC
ANTIMALARIALS ‐ Drugs to Treat Malaria / Other Infections
ARAKODA TAB 100MG,150MG (tafenoquine succinate tab) Tier 3
chloroquine tab 250mg,500mg Tier 1
DARAPRIM TAB 25MG (pyrimethamine tab) Tier 3
hydroxychlor tab 200mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 59 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
KRINTAFEL TAB 100MG,150MG (tafenoquine succinate tab) Tier 3
mefloquine tab 250mg Tier 1
PLAQUENIL TAB 200MG (hydroxychloroquine sulfate tab) Tier 2
primaquine tab 26.3mg Tier 1
PRIMAQUINE TAB 26.3MG (primaquine phosphate tab) Tier 3
pyrimethamin tab 25mg Tier 1
QUALAQUIN CAP 324MG (quinine sulfate cap) Tier 3
quinine sulf cap 324mg Tier 1
ANTIMANIC AGENTS ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
lithium carb cap 150mg,300mg,600mg Tier 1
lithium carb tab 300mg Tier 1
lithium carb tab 300mg Tier 1
LITHIUM SOL 8MEQ/5ML (lithium oral solution) Tier 3
LITHOBID TAB 300MG CR (lithium carbonate tab er) Tier 2
ANTIMETABOLITES ‐ Drugs for Treatment of Cancer
azacitidine inj 100mg Tier 1 PA; SP; QL (34 days supply)
capecitabine tab 150mg,500mg Tier 1 PA; SP; QL (34 days supply); OAC
DACOGEN INJ 50MG (decitabine for inj) Tier 4 PA; SP; QL (34 days supply)
decitabine inj 50mg Tier 1 PA; SP; QL (34 days supply)
FOLOTYN INJ 20MG/ML,40MG/2ML (pralatrexate iv inj) Tier 4 PA; SP; QL (34 days supply)
mercaptopur tab 50mg Tier 1 OAC
methotrexate tab 2.5mg Tier 1 OAC
PURIXAN SUS 20MG/ML (mercaptopurine susp) Tier 4 SP; QL (34 days supply); OAC
TABLOID TAB 40MG (thioguanine tab) Tier 2 OAC
TREXALL TAB 10MG,15MG,5MG,7.5MG (methotrexate sodium tab)
Tier 2 OAC
VIDAZA INJ 100MG (azacitidine for inj) Tier 4 PA; SP; QL (34 days supply)
XATMEP SOL 2.5MG/ML (methotrexate oral soln) Tier 3 OAC
XELODA TAB 150MG,500MG (capecitabine tab) Tier 2 PA; SP; QL (34 days supply); OAC
ANTIMICROBIAL AGENTS ‐ Syrups, gelatin, capsules for making pharmaceuticals
BENZYL ALC LIQ (benzyl alcohol) Tier 3
ANTIMYASTHENIC/CHOLINERGIC AGENTS ‐ Drugs to Treat Myasthenia Gravis (Skeletal Muscle Disorder)
FIRDAPSE TAB 10MG (amifampridine phosphate tab) Tier 3 PA; QL (8 units per 1 day)
GUANIDINE TAB 125MG (guanidine hcl tab) Tier 3
MESTINON SOL 60MG/5ML (pyridostigmine bromide oral soln)
Tier 3
MESTINON TAB 60MG (pyridostigmine bromide tab) Tier 3
MESTINON TAB TIMESPAN (pyridostigmine bromide tab er) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 60 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
pyridostigm tab 30mg,60mg Tier 1
pyridostigmi sol 60mg/5ml Tier 1
pyridostigmi tab 30mg,60mg Tier 1
pyridostigmi tab er 180mg Tier 1
RUZURGI TAB 10MG (amifampridine tab) Tier 3 PA; QL (10 units per 1 day)
ANTIMYCOBACTERIAL AGENTS ‐ Drugs to Treat Infections of Mycobacterium
cycloserine cap 250mg Tier 1
ethambutol tab 100mg,400mg Tier 1
isoniazid syp 50mg/5ml Tier 1
isoniazid tab 100mg,300mg Tier 1
MYAMBUTOL TAB 400MG (ethambutol hcl tab) Tier 2
MYCOBUTIN CAP 150MG (rifabutin cap) Tier 3
PASER GRA 4GM (aminosalicylic acid er granules packet) Tier 3
PRETOMANID TAB 200MG (pretomanid tab) Tier 3
PRIFTIN TAB 150MG (rifapentine tab) Tier 3
pyrazinamide tab 500mg Tier 1
rifabutin cap 150mg Tier 1
RIFADIN CAP 150MG,300MG (rifampin cap) Tier 2
rifampin cap 150mg,300mg Tier 1
SIRTURO TAB 100MG (bedaquiline fumarate tab) Tier 3
TRECATOR TAB 250MG (ethionamide tab) Tier 3
ANTINEOPLASTIC ‐ BCL‐2 INHIBITORS ‐ Drugs for Treatment of Cancer
VENCLEXTA TAB 100MG,10MG,50MG (venetoclax tab) Tier 3 PA; QL (4 units per 1 day); OAC
VENCLEXTA TAB START PK (venetoclax tab therapy starter pack)
Tier 3 PA; QL (1.5 unit per 1 day)
ANTINEOPLASTIC ‐ BISPECIFIC T‐CELL ENGAGERS ‐ Drugs for Treatment of Cancer
BLINCYTO INJ 35MCG (blinatumomab for iv infusion) Tier 4 PA; SP; QL (34 days supply)
ANTINEOPLASTIC ‐ BRAF KINASE INHIBITORS ‐ Drugs for Treatment of Cancer
BRAFTOVI CAP 75MG (encorafenib cap) Tier 3 PA; QL (6 units per 1 day)
TAFINLAR CAP 50MG,75MG (dabrafenib mesylate cap) Tier 4 PA; SP; QL (34 days supply); OAC
ZELBORAF TAB 240MG (vemurafenib tab) Tier 4 PA; SP; QL (34 days supply); OAC
ANTINEOPLASTIC ‐ FGFR KINASE INHIBITORS ‐ Drugs for Treatment of Cancer
BALVERSA TAB 3MG,4MG,5MG (erdafitinib tab) Tier 3 PA; QL (3 units per 1 day)
PEMAZYRE TAB 13.5MG,4.5MG,9MG (pemigatinib tab) Tier 3 PA
ANTINEOPLASTIC ‐ HEDGEHOG PATHWAY INHIBITORS ‐ Drugs for Treatment of Cancer
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 61 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
DAURISMO TAB 100MG,25MG (glasdegib maleate tab) Tier 4 PA; SP; QL (34 days supply)
ERIVEDGE CAP 150MG (vismodegib cap) Tier 2 PA; SP; QL (34 days supply); OAC
ODOMZO CAP 200MG (sonidegib phosphate cap) Tier 2 PA; SP; QL (34 days supply); OAC
ANTINEOPLASTIC ‐ HISTONE DEACETYLASE INHIBITORS ‐ Drugs for Treatment of Cancer
BELEODAQ INJ 500MG (belinostat for iv inj) Tier 4 PA; SP; QL (34 days supply)
FARYDAK CAP 10MG,20MG (panobinostat lactate cap) Tier 4 PA; SP; QL (34 days supply); OAC
ISTODAX OVR INJ 10MG (romidepsin for iv inj) Tier 4 PA; SP; QL (34 days supply)
ROMIDEPSIN INJ 10MG (romidepsin iv soln) Tier 4 PA; SP; QL (34 days supply)
ROMIDEPSIN INJ 10MG (romidepsin iv soln) Tier 4 PA; SP; QL (34 days supply)
ZOLINZA CAP 100MG (vorinostat cap) Tier 2 PA; SP; QL (34 days supply); OAC
ANTINEOPLASTIC ‐ IMMUNOMODULATORS ‐ Drugs for Treatment of Cancer
POMALYST CAP 1MG,2MG,3MG,4MG (pomalidomide cap) Tier 2 PA; SP; QL (34 days supply); OAC
ANTINEOPLASTIC ‐ MEK INHIBITORS ‐ Drugs for Treatment of Cancer
COTELLIC TAB 20MG (cobimetinib fumarate tab) Tier 4 PA; SP; QL (34 days supply); OAC
KOSELUGO CAP 10MG,25MG (selumetinib sulfate cap) Tier 3 PA
MEKINIST TAB 0.5MG,2MG (trametinib dimethyl sulfoxide tab)
Tier 4 PA; SP; QL (34 days supply); OAC
MEKTOVI TAB 15MG (binimetinib tab) Tier 3 PA; QL (6 units per 1 day)
ANTINEOPLASTIC ‐ METHYLTRANSFERASE INHIBITORS ‐ Drugs for Treatment of Cancer
TAZVERIK TAB 200MG (tazemetostat hbr tab) Tier 3 PA; QL (8 units per 1 day)
ANTINEOPLASTIC ‐ MONOCLONAL ANTIBODIES ‐ Drugs for Treatment of Cancer
ARZERRA CON 100/5ML (ofatumumab conc for iv infusion) Tier 4 PA; SP; QL (34 days supply)
BAVENCIO INJ 20MG/ML (avelumab soln for iv infusion) Tier 4 PA; SP; QL (34 days supply)
DARZALEX SOL 100MG/5M,400MG/20 (daratumumab iv soln)
Tier 4 PA; SP; QL (34 days supply)
EMPLICITI INJ 300MG,400MG (elotuzumab for iv soln) Tier 4 PA; SP; QL (34 days supply)
ERBITUX INJ 100MG,200MG (cetuximab iv soln) Tier 4 PA; SP; QL (34 days supply)
GAZYVA INJ 25MG/ML (obinutuzumab soln for iv infusion) Tier 4 PA; SP; QL (34 days supply)
HERCEPTIN INJ 150MG (trastuzumab for iv soln) Tier 4 PA; SP; QL (34 days supply)
HERZUMA INJ 150MG,420MG (trastuzumab‐pkrb for iv soln)
Tier 4 PA; SP; QL (34 days supply)
IMFINZI INJ 120/2.4,500/10 (durvalumab soln for iv infusion)
Tier 4 PA; SP; QL (34 days supply)
KANJINTI INJ 150MG,420MG (trastuzumab‐anns for iv soln) Tier 4 PA; SP; QL (34 days supply)
KANJINTI SOL 150MG,420MG (trastuzumab‐anns for iv soln) Tier 4 PA; SP; QL (34 days supply)
KEYTRUDA INJ 100MG/4M (pembrolizumab iv soln) Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 62 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
LARTRUVO INJ 10MG/ML,190/19ML (olaratumab soln for iv infusion)
Tier 3 PA
LIBTAYO INJ 350/7ML (cemiplimab‐rwlc iv soln) Tier 3 PA
LUMOXITI SOL 1MG (moxetumomab pasudotox‐tdfk for iv soln)
Tier 4 PA; SP; QL (34 days supply)
OGIVRI INJ 150MG,420MG (trastuzumab‐dkst for iv soln) Tier 4 PA; SP; QL (34 days supply)
ONTRUZANT INJ 150MG,420MG (trastuzumab‐dttb for iv soln)
Tier 4 PA; SP; QL (34 days supply)
OPDIVO INJ 100MG/10,240/24,40MG/4ML (nivolumab iv soln)
Tier 4 PA; SP; QL (34 days supply)
PERJETA INJ 420/14ML (pertuzumab soln for iv infusion) Tier 2 PA; SP; QL (34 days supply)
PORTRAZZA INJ 800/50ML (necitumumab iv soln) Tier 4 PA; SP; QL (34 days supply)
POTELIGEO INJ 20MG/5ML (mogamulizumab‐kpkc iv soln) Tier 4 PA; SP; QL (34 days supply)
RITUXAN INJ 100MG,500MG (rituximab iv soln) Tier 4 PA; SP; QL (34 days supply)
RUXIENCE INJ 100/10ML,500/50ML (rituximab‐pvvr iv soln) Tier 4 PA; SP; QL (34 days supply)
SARCLISA SOL 100/5ML,500/25ML (isatuximab‐irfc iv soln) Tier 4 PA; SP; QL (34 days supply)
TECENTRIQ INJ 1200/20,840/14 (atezolizumab iv soln) Tier 4 PA; SP; QL (34 days supply)
TRAZIMERA INJ 420MG (trastuzumab‐qyyp for iv soln) Tier 4 PA; SP; QL (34 days supply)
TRUXIMA INJ 100/10ML,500/50ML (rituximab‐abbs iv soln) Tier 4 PA; SP; QL (34 days supply)
VECTIBIX INJ 100MG,400MG (panitumumab iv soln) Tier 4 PA; SP; QL (34 days supply)
YERVOY INJ 200MG,50MG (ipilimumab soln for iv infusion) Tier 4 PA; SP; QL (34 days supply)
ANTINEOPLASTIC ‐ MTOR KINASE INHIBITORS ‐ Drugs for Treatment of Cancer
AFINITOR DIS TAB 2MG,3MG,5MG (everolimus tab for oral susp)
Tier 2 PA; SP; QL (34 days supply); OAC
AFINITOR TAB 10MG,2.5MG,5MG,7.5MG (everolimus tab) Tier 2 PA; SP; QL (34 days supply); OAC
everolimus tab 0.25mg,0.5 mg,0.75mg,2.5mg,5mg,7.5mg Tier 1 PA; SP; QL (34 days supply); OAC
temsirolimus sol 25mg/ml Tier 1 PA; QL (34 days supply)
TORISEL SOL 25MG/ML (temsirolimus soln for iv infusion) Tier 4 PA; SP; QL (34 days supply)
ANTINEOPLASTIC ‐ MULTIKINASE INHIBITORS ‐ Drugs for Treatment of Cancer
NEXAVAR TAB 200MG (sorafenib tosylate tab) Tier 4 PA; SP; QL (34 days supply); OAC
RYDAPT CAP 25MG (midostaurin cap) Tier 2 PA; SP; QL (34 days supply)
STIVARGA TAB 40MG (regorafenib tab) Tier 4 PA; SP; QL (34 days supply); OAC
SUTENT CAP 12.5MG,25MG,37.5MG,50MG (sunitinib malate cap)
Tier 2 PA; SP; QL (34 days supply); OAC
ANTINEOPLASTIC ‐ PROTEASOME INHIBITORS ‐ Drugs for Treatment of Cancer
BORTEZOMIB INJ 3.5MG (bortezomib for iv inj) Tier 4 PA; SP; QL (34 days supply)
KYPROLIS SOL 10MG,30MG,60MG (carfilzomib for inj) Tier 4 PA; SP; QL (34 days supply)
NINLARO CAP 2.3MG,3MG,4MG (ixazomib citrate cap) Tier 2 PA; SP; QL (34 days supply); OAC
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 63 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
VELCADE INJ 3.5MG (bortezomib for inj) Tier 2 PA; SP; QL (34 days supply)
ANTINEOPLASTIC ‐ TROPOMYOSIN RECEPTOR KINASE INHIBITORS ‐ Drugs for Treatment of Cancer
ROZLYTREK CAP 100MG,200MG (entrectinib cap) Tier 4 PA; SP; QL (34 days supply)
VITRAKVI CAP 100MG,25MG (larotrectinib sulfate cap) Tier 4 PA; SP; QL (34 days supply)
VITRAKVI SOL 20MG/ML (larotrectinib sulfate oral soln) Tier 4 PA; SP; QL (34 days supply)
ANTINEOPLASTIC ‐ TYROSINE KINASE INHIBITORS ‐ Drugs for Treatment of Cancer
ALECENSA CAP 150MG (alectinib hcl cap) Tier 2 PA; SP; QL (34 days supply); OAC
ALUNBRIG PAK (brigatinib tab initiation therapy pack) Tier 2 PA; SP; QL (34 days supply)
ALUNBRIG TAB 180MG,30MG,90MG (brigatinib tab) Tier 2 PA; SP; QL (34 days supply)
AYVAKIT TAB 100MG,200MG,300MG (avapritinib tab) Tier 3 PA; QL (1 unit per 1 day)
BOSULIF TAB 100MG,400MG,500MG (bosutinib tab) Tier 2 PA; SP; QL (34 days supply); OAC
BRUKINSA CAP 80MG (zanubrutinib cap) Tier 3 PA; QL (4 units per 1 day)
CABOMETYX TAB 20MG,40MG,60MG (cabozantinib s‐malate tab)
Tier 2 PA; SP; QL (34 days supply); OAC
CALQUENCE CAP 100MG (acalabrutinib cap) Tier 3 PA; QL (2 units per 1 day)
CAPRELSA TAB 100MG,300MG (vandetanib tab) Tier 3 PA; QL (1 unit per 1 day); OAC
COMETRIQ KIT 100MG,140MG (cabozantinib s‐mal cap) Tier 4 PA; SP; QL (34 days supply); OAC
COMETRIQ KIT 100MG,140MG (cabozantinib s‐malate cap) Tier 4 PA; SP; QL (34 days supply); OAC
erlotinib tab 100mg,150mg,25mg Tier 1 PA; SP; QL (34 days supply); OAC
GILOTRIF TAB 20MG,30MG,40MG (afatinib dimaleate tab) Tier 3 PA; QL (1 unit per 1 day); OAC
GLEEVEC TAB 100MG,400MG (imatinib mesylate tab) Tier 4 PA; SP; QL (34 days supply); OAC
ICLUSIG TAB 15MG,45MG (ponatinib hcl tab) Tier 3 PA; QL (1 unit per 1 day); OAC
imatinib mes tab 100mg,400mg Tier 1 PA; SP; QL (34 days supply); OAC
IMBRUVICA CAP 140MG,70MG (ibrutinib cap) Tier 3 PA; QL (1 unit per 1 day); OAC
IMBRUVICA TAB 140MG,280MG,420MG,560MG (ibrutinib tab)
Tier 3 PA; QL (1 unit per 1 day); OAC
INLYTA TAB 1MG,5MG (axitinib tab) Tier 4 PA; SP; QL (34 days supply); OAC
IRESSA TAB 250MG (gefitinib tab) Tier 2 PA; SP; QL (34 days supply); OAC
LENVIMA CAP 18 MG,24 MG (lenvatinib cap ther pack) Tier 4 PA; SP; QL (34 days supply); OAC
LENVIMA CAP 18 MG,24 MG (lenvatinib cap therapy pack) Tier 4 PA; SP; QL (34 days supply); OAC
LORBRENA TAB 100MG,25MG (lorlatinib tab) Tier 4 PA; SP; QL (34 days supply)
NERLYNX TAB 40MG (neratinib maleate tab) Tier 4 PA; SP; QL (34 days supply)
QINLOCK TAB 50MG (ripretinib tab) Tier 3
RETEVMO CAP 40MG,80MG (selpercatinib cap) Tier 3 QL (34 days supply)
SPRYCEL TAB 100MG,140MG,20MG,50MG,70MG,80MG (dasatinib tab)
Tier 2 PA; SP; QL (34 days supply); OAC
TABRECTA TAB 150MG,200MG (capmatinib hcl tab) Tier 3 QL (34 days supply)
TAGRISSO TAB 40MG,80MG (osimertinib mesylate tab) Tier 4 PA; SP; QL (34 days supply); OAC
TARCEVA TAB 100MG,150MG,25MG (erlotinib hcl tab) Tier 4 PA; SP; QL (34 days supply); OAC
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 64 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
TASIGNA CAP 150MG,200MG,50MG (nilotinib hcl cap) Tier 4 PA; SP; QL (34 days supply); OAC
TUKYSA TAB 150MG,50MG (tucatinib tab) Tier 3 PA
TURALIO CAP 200MG (pexidartinib hcl cap) Tier 3 PA; QL (4 units per 1 day)
TYKERB TAB 250MG (lapatinib ditosylate tab) Tier 2 PA; SP; QL (34 days supply); OAC
VIZIMPRO TAB 15MG,30MG,45MG (dacomitinib tab) Tier 4 PA; SP; QL (34 days supply)
VOTRIENT TAB 200MG (pazopanib hcl tab) Tier 2 PA; SP; QL (34 days supply); OAC
XALKORI CAP 200MG,250MG (crizotinib cap) Tier 4 PA; SP; QL (34 days supply); OAC
XOSPATA TAB 40MG (gilteritinib fumarate tablet) Tier 2 PA; QL (3 units per 1 day)
ZYKADIA TAB 150MG (ceritinib tab) Tier 4 PA; SP; QL (34 days supply); OAC
ANTINEOPLASTIC ‐ XPO1 INHIBITORS ‐ Drugs for Treatment of Cancer
XPOVIO PAK 100MG,60MG,80MG (selinexor tab therapy pack)
Tier 3 PA; QL (1.143 unit per 1 day)
ANTINEOPLASTIC ALKYLATING AGENTS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
VALCHLOR GEL 0.016% (mechlorethamine hcl gel) Tier 3 PA; QL (4 units per 1 day)
ANTINEOPLASTIC ANTIBIOTICS ‐ Drugs for Treatment of Cancer
JELMYTO INJ 40MG (mitomycin for pyelocalyceal soln) Tier 3
MITOMYCIN SOL 20MG (mitomycin soln for intravesical instillation)
Tier 3
mitoxantron inj 2mg/ml Tier 1 PA; SP; QL (34 days supply)
valrubicin sol 40mg/ml Tier 1 SP; QL (34 days supply)
VALSTAR SOL 40MG/ML (valrubicin soln for intravesical instillation)
Tier 4 SP; QL (34 days supply)
ANTINEOPLASTIC ANTIBODY‐DRUG COMPLEXES ‐ Drugs for Treatment of Cancer
ADCETRIS INJ 50MG (brentuximab vedotin for iv soln) Tier 4 PA; SP; QL (34 days supply)
BESPONSA INJ 0.9MG (inotuzumab ozogamicin for iv soln) Tier 4 PA; SP; QL (34 days supply)
ENHERTU INJ 100MG (fam‐trastuzumab deruxtecan‐nxki for iv soln)
Tier 4 PA; SP; QL (34 days supply)
KADCYLA INJ 100MG,160MG (ado‐trastuzumab emtansine for iv soln)
Tier 4 PA; SP; QL (34 days supply)
MYLOTARG INJ 4.5MG (gemtuzumab ozogamicin for iv soln) Tier 4 PA; SP; QL (34 days supply)
PADCEV INJ 20MG,30MG (enfortumab vedotin‐ejfv for iv soln)
Tier 4 PA; SP; QL (34 days supply)
POLIVY INJ 140MG (polatuzumab vedotin‐piiq for iv solution)
Tier 4 PA; SP; QL (34 days supply)
ANTINEOPLASTIC ANTIMETABOLITES ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
CARAC CRE 0.5%,1%,5% (fluorouracil cream) Tier 3
EFUDEX CRE 0.5%,1%,5% (fluorouracil cream) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 65 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
FLUOROPLEX CRE 0.5%,1%,5% (fluorouracil cream) Tier 3
fluorouracil cre 0.5%,5% Tier 1
fluorouracil sol 2%,5% Tier 1
TOLAK CRE 4% (fluorouracil cream) Tier 2
ANTINEOPLASTIC COMBINATIONS ‐ Drugs for Treatment of Cancer
HERCEP HYLEC SOL 60‐10000 (trastuzumab‐hyaluronidase‐oysk inj)
Tier 4 PA; SP; QL (34 days supply)
KISQALI 200 PAK FEMARA,400 PAK FEMARA,600 PAK FEMARA (ribociclib)
Tier 2 PA; SP; QL (34 days supply)
LONSURF TAB 15‐6.14,20‐8.19 (trifluridine‐tipiracil tab) Tier 4 PA; SP; QL (34 days supply); OAC
RITUXAN INJ HYCELA (rituximab‐hyaluronidase human inj) Tier 4 PA; SP; QL (34 days supply)
ANTINEOPLASTIC ENZYMES ‐ Drugs for Treatment of Cancer
ASPARLAS INJ 3750/5ML (calaspargase pegol‐mknl iv soln) Tier 4 PA; SP; QL (34 days supply)
ERWINAZE INJ 10000UNT (asparaginase erwinia chrysanthemi for inj)
Tier 3 PA
ONCASPAR INJ 750/ML (pegaspargase inj) Tier 4 PA; SP; QL (34 days supply)
ANTINEOPLASTIC OR PREMALIGNANT LESIONS ‐ TOPICAL MISC. ‐ Drugs to Treat Skin Disorders
PICATO GEL 0.015%,0.05% (ingenol mebutate gel) Tier 2
ANTINEOPLASTIC OR PREMALIGNANT LESIONS ‐ TOPICAL NSAID'S ‐ Drugs to Treat Skin Disorders
diclofenac gel 3% Tier 1 PA
ANTINEOPLASTIC RETINOIDS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
PANRETIN GEL 0.1% (alitretinoin gel) Tier 3
ANTINEOPLASTICS ‐ INTERLEUKINS ‐ Drugs for Treatment of Cancer
PROLEUKIN INJ 22MU (aldesleukin for iv soln) Tier 4 PA; SP; QL (34 days supply)
ANTINEOPLASTICS MISC. ‐ Drugs for Treatment of Cancer
ACTIMMUNE INJ 2MU/0.5 (interferon gamma‐) Tier 4 PA; SP; QL (34 days supply)
HYDREA CAP 500MG (hydroxyurea cap) Tier 2 OAC
hydroxyurea cap 500mg Tier 1 OAC
INTRON A INJ 10MU,18MU,25MU,50MU (interferon alfa‐) Tier 2 PA; SP; QL (34 days supply)
MATULANE CAP 50MG (procarbazine hcl cap) Tier 2 OAC
SYLATRON KIT 180MCG/M,200MCG,300MCG,600MCG (peginterferon alfa‐)
Tier 2 PA; SP; QL (34 days supply)
SYNRIBO INJ 3.5MG (omacetaxine mepesuccinate for inj) Tier 3 PA
TICE BCG INJ (bcg live intravesical for susp) Tier 3
ANTIPARKINSON ANTICHOLINERGICS ‐ Drugs to treat Parkinson's Disease
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 66 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
benztropine tab 0.5mg,1mg,2mg Tier 1
trihexyphen sol 0.4mg/ml Tier 1
trihexyphen tab 2mg,5mg Tier 1
ANTIPARKINSON DOPAMINERGICS ‐ Drugs to treat Parkinson's Disease
amantadine cap 100mg Tier 1
amantadine syp 50mg/5ml Tier 1
amantadine tab 100mg Tier 1
bromocriptin cap 5mg Tier 1
bromocriptin tab 2.5mg Tier 1
GOCOVRI CAP 137MG,68.5MG (amantadine hcl cap er) Tier 3
INBRIJA CAP 42MG (levodopa inhal powder cap) Tier 4 PA; SP; QL (34 days supply)
OSMOLEX ER TAB 129MG,193MG,258MG (amantadine hcl tab er)
Tier 3
PARLODEL CAP 5MG (bromocriptine mesylate cap) Tier 3
PARLODEL TAB 0.8MG,2.5MG (bromocriptine mesylate tab) Tier 3
ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS ‐ Drugs to treat Parkinson's Disease
AZILECT TAB 0.5MG,1MG (rasagiline mesylate tab) Tier 3
rasagiline tab 0.5mg,1mg Tier 1
selegiline cap 5mg Tier 1
selegiline tab 5mg Tier 1
XADAGO TAB 100MG,50MG (safinamide mesylate tab) Tier 3
ZELAPAR TAB 1.25MG (selegiline hcl orally disintegrating tab)
Tier 3
ANTIPERISTALTIC AGENTS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion
diphen/atrop liq 2.5/5 Tier 1
diphen/atrop tab 2.5mg Tier 1
LOMOTIL TAB 2.5MG (diphenoxylate w/ atropine tab) Tier 2
loperamide cap 2mg Tier 1
LOPERAMIDE SOL 1/7.5ML,2MG/15ML (loperamide hcl soln)
Tier 3
MOTOFEN TAB 1‐0.025 (difenoxin w/ atropine tab) Tier 3
opium tin 10mg/ml Tier 1
ANTIPROTOZOAL AGENTS ‐ Antibiotics / Drugs for Infections
ALINIA SUS 100/5ML (nitazoxanide for susp) Tier 3
ALINIA TAB 500MG (nitazoxanide tab) Tier 3
atovaquone sus 750/5ml Tier 1
MEPRON SUS (atovaquone susp) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 67 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ANTIPRURITICS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
doxepin hcl cre 5% Tier 1
PRUDOXIN CRE 5% (doxepin hcl cream) Tier 3
ZONALON CRE 5% (doxepin hcl cream) Tier 3
ANTIPSORIATICS ‐ Drugs to Treat Skin Disorders
calcipotrien cre 0.005% Tier 1
calcipotrien oin 0.005% Tier 1
calcipotrien sol 0.005% Tier 1
calcipotriene oin 0.005% (Calcitrene) Tier 1
calcitriol oin 3mcg/gm Tier 1
DOVONEX CRE 0.005% (calcipotriene cream) Tier 3
DRITHO‐CREME CRE HP 1% (anthralin cream) Tier 3
SORILUX AER 0.005% (calcipotriene foam) Tier 3
tazarotene cre 0.1% Tier 1 PA;
TAZORAC CRE 0.05%,0.1% (tazarotene cream) Tier 2 PA;
TAZORAC GEL 0.05%,0.1% (tazarotene gel) Tier 2 PA;
VECTICAL OIN 3MCG/GM (calcitriol oint) Tier 3
ZITHRANOL SHA 1% (anthralin shampoo) Tier 3
ANTIPSORIATICS ‐ SYSTEMIC ‐ Drugs to Treat Skin Disorders
acitretin cap 10mg,17.5mg,25mg Tier 1 PA
COSENTYX INJ 300DOSE (secukinumab subcutaneous pref syr)
Tier 2 PA; SP; QL (34 days supply)
COSENTYX INJ 300DOSE (secukinumab subcutaneous soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
COSENTYX PEN INJ 300DOSE (secukinumab subcutaneous auto‐inj)
Tier 2 PA; SP; QL (34 days supply)
COSENTYX PEN INJ 300DOSE (secukinumab subcutaneous soln auto‐injector)
Tier 2 PA; SP; QL (34 days supply)
ILUMYA SOL 100MG/ML (tildrakizumab‐asmn subcutaneous soln pref syringe)
Tier 4 PA; SP; QL (34 days supply)
methoxsalen cap 10mg Tier 1
OXSORALEN‐UL CAP 10MG (methoxsalen rapid cap) Tier 3
SILIQ INJ 210/1.5 (brodalumab subcutaneous soln prefilled syringe)
Tier 4 PA; SP; QL (34 days supply)
SKYRIZI INJ 150DOSE (risankizumab‐rzaa sol prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
SORIATANE CAP 10MG,25MG (acitretin cap) Tier 3 PA
STELARA INJ 45MG/0.5 (ustekinumab inj) Tier 2 PA; SP; QL (34 days supply)
STELARA INJ 45MG/0.5 (ustekinumab soln prefilled syringe) Tier 2 PA; SP; QL (34 days supply)
TALTZ INJ 80MG/ML (ixekizumab subcutaneous soln auto‐injector)
Tier 2 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 68 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
TALTZ INJ 80MG/ML (ixekizumab subcutaneous soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
TREMFYA INJ 100MG/ML (guselkumab soln pen‐injector) Tier 2 PA; SP; QL (34 days supply)
TREMFYA INJ 100MG/ML (guselkumab soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
ANTIPSYCHOTICS ‐ MISC. ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
CAPLYTA CAP 42MG (lumateperone tosylate cap) Tier 3
EQUETRO CAP 100MG,200MG,300MG (carbamazepine (antipsychotic) cap er)
Tier 3
GEODON CAP 20MG,40MG,60MG,80MG (ziprasidone hcl cap)
Tier 3
LATUDA TAB 120MG,20MG,40MG,60MG,80MG (lurasidone hcl tab)
Tier 2
NUPLAZID CAP 34MG (pimavanserin tartrate cap) Tier 4 PA; SP; QL (34 days supply)
NUPLAZID TAB 10MG (pimavanserin tartrate tab) Tier 4 PA; SP; QL (34 days supply)
VRAYLAR CAP 1.5MG,3MG,4.5MG,6MG (cariprazine hcl cap)
Tier 2
VRAYLAR CAP 1.5MG,3MG,4.5MG,6MG (cariprazine hcl cap therapy pack)
Tier 2
ziprasidone cap 20mg,40mg,60mg,80mg Tier 1
ANTIRETROVIRAL COMBINATIONS ‐ Drugs to Treat Viral Infections
abaca/lamivu tab 600‐300 Tier 1 QL (1 unit per 1 day)
abacav/lamiv tab /zidovud Tier 1 QL (2 units per 1 day)
ATRIPLA TAB (efavirenz‐emtricitabine‐tenofovir df tab) Tier 2 QL (1 unit per 1 day)
BIKTARVY TAB (bictegravir‐emtricitabine‐tenofovir af tab) Tier 2 QL (1 unit per 1 day)
CIMDUO TAB 300‐300 (lamivudine‐tenofovir disoproxil fumarate tab)
Tier 2 QL (1 unit per 1 day)
COMBIVIR TAB 150‐300 (lamivudine‐zidovudine tab) Tier 3 QL (2 units per 1 day)
COMPLERA TAB (emtricitabine‐rilpivirine‐tenofovir df tab) Tier 2 QL (1 unit per 1 day)
DELSTRIGO TAB (doravirine‐lamivudine‐tenofovir df tab) Tier 3 QL (1 unit per 1 day)
DESCOVY TAB 200/25 (emtricitabine‐tenofovir alafenamide fumarate tab)
Tier 2 QL (1 unit per 1 day)
DOVATO TAB 50‐300MG (dolutegravir sodium‐lamivudine tab)
Tier 3 QL (1 unit per 1 day)
EPZICOM TAB 600‐300 (abacavir sulfate‐lamivudine tab) Tier 3 QL (1 unit per 1 day)
EVOTAZ TAB 300‐150 (atazanavir sulfate‐cobicistat tab) Tier 2 QL (1 unit per 1 day)
GENVOYA TAB (elvitegrav‐cobic‐emtricitab‐tenofov af tab) Tier 2 QL (1 unit per 1 day)
JULUCA TAB 50‐25MG (dolutegravir sodium‐rilpivirine hcl tab)
Tier 3 QL (1 unit per 1 day)
KALETRA SOL (lopinavir‐ritonavir soln) Tier 2 QL (13 units per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 69 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
KALETRA TAB 100‐25MG,200‐50MG (lopinavir‐ritonavir tab) Tier 2 QL (4 units per 1 day)
lamivud/zido tab 150‐300 Tier 1 QL (2 units per 1 day)
lopin/riton sol 80‐20/ml Tier 1 QL (13 units per 1 day)
ODEFSEY TAB (emtricitabine‐rilpivirine‐tenofovir af tab) Tier 2 QL (1 unit per 1 day)
PREZCOBIX TAB 800‐150 (darunavir‐cobicistat tab) Tier 2 QL (1 unit per 1 day)
STRIBILD TAB (elvitegrav‐cobic‐emtricitab‐tenofovdf tab) Tier 2 QL (1 unit per 1 day)
SYMFI LO TAB (efavirenz‐lamivudine‐tenofovir df tab) Tier 2 QL (1 unit per 1 day)
SYMFI TAB (efavirenz‐lamivudine‐tenofovir df tab) Tier 2 QL (1 unit per 1 day)
SYMTUZA TAB (darunavir‐cobic‐emtricitab‐tenofov af tab) Tier 2 QL (1 unit per 1 day)
TEMIXYS TAB 300‐300 (lamivudine‐tenofovir disoproxil fumarate tab)
Tier 2 QL (1 unit per 1 day)
TRIUMEQ TAB (abacavir‐dolutegravir‐lamivudine tab) Tier 2 QL (1 unit per 1 day)
TRIZIVIR TAB (abacavir sulfate‐lamivudine‐zidovudine tab) Tier 3 QL (2 units per 1 day)
TRUVADA TAB 100‐150,133‐200,167‐250 (emtricitabine‐tenofovir disoproxil fumarate tab)
Tier 2 QL (1 unit per 1 day)
TRUVADA TAB 200‐300 (emtricitabine‐tenofovir disoproxil fumarate tab)
Tier 5 QL (1 unit per 1 day)
ANTIRETROVIRALS ‐ CCR5 ANTAGONISTS (ENTRY INHIBITOR) ‐ Drugs to Treat Viral Infections
SELZENTRY SOL 20MG/ML (maraviroc oral soln) Tier 3 QL (61.4 units per 1 day)
SELZENTRY TAB 150MG,25MG,300MG,75MG (maraviroc tab)
Tier 3 QL (2 units per 1 day)
ANTIRETROVIRALS ‐ FUSION INHIBITORS ‐ Drugs to Treat Viral Infections
FUZEON INJ 90MG (enfuvirtide for inj) Tier 2 SP; QL (34 days supply)
ANTIRETROVIRALS ‐ INTEGRASE INHIBITORS ‐ Drugs to Treat Viral Infections
ISENTRESS CHW 100MG,25MG (raltegravir potassium chew tab)
Tier 2 QL (6 units per 1 day)
ISENTRESS HD TAB 400MG,600MG (raltegravir potassium tab)
Tier 2 QL (2 units per 1 day)
ISENTRESS POW 100MG (raltegravir potassium packet for susp)
Tier 2 QL (2 units per 1 day)
ISENTRESS TAB 400MG,600MG (raltegravir potassium tab) Tier 2 QL (4 units per 1 day)
TIVICAY PD TAB 5MG (dolutegravir sodium tab for oral susp)
Tier 3
TIVICAY TAB 10MG,25MG,50MG (dolutegravir sodium tab) Tier 2 QL (2 units per 1 day)
ANTIRETROVIRALS ‐ PROTEASE INHIBITORS ‐ Drugs to Treat Viral Infections
APTIVUS CAP 250MG (tipranavir cap) Tier 3 QL (4 units per 1 day)
APTIVUS SOL (tipranavir oral soln) Tier 3 QL (10.179 units per 1 day)
atazanavir cap 150mg,200mg,300mg Tier 1 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 70 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CRIXIVAN CAP 200MG,400MG (indinavir sulfate cap) Tier 3 QL (6 units per 1 day)
fosamprenavi tab 700mg Tier 1 QL (4 units per 1 day)
INVIRASE TAB 500MG (saquinavir mesylate tab) Tier 3 QL (4 units per 1 day)
LEXIVA SUS 50MG/ML (fosamprenavir calcium susp) Tier 3 QL (56.25 units per 1 day)
LEXIVA TAB 700MG (fosamprenavir calcium tab) Tier 3 QL (4 units per 1 day)
NORVIR POW 100MG (ritonavir powder packet) Tier 2 QL (12 units per 1 day)
NORVIR SOL 80MG/ML (ritonavir oral soln) Tier 2 QL (16 units per 1 day)
NORVIR TAB 100MG (ritonavir tab) Tier 2 QL (12 units per 1 day)
PREZISTA SUS 100MG/ML (darunavir ethanolate susp) Tier 2 QL (13.34 units per 1 day)
PREZISTA TAB 150MG,600MG,75MG,800MG (darunavir ethanolate tab)
Tier 2 QL (1 unit per 1 day)
REYATAZ CAP 150MG,200MG,300MG (atazanavir sulfate cap)
Tier 3 QL (2 units per 1 day)
REYATAZ POW 50MG (atazanavir sulfate oral powder packet)
Tier 3 QL (6 units per 1 day)
ritonavir tab 100mg Tier 1 QL (12 units per 1 day)
VIRACEPT TAB 250MG,625MG (nelfinavir mesylate tab) Tier 3 QL (10 units per 1 day)
ANTIRETROVIRALS ‐ RTI‐NON‐NUCLEOSIDE ANALOGUES ‐ Drugs to Treat Viral Infections
EDURANT TAB 25MG (rilpivirine hcl tab) Tier 2 QL (2 units per 1 day)
efavirenz cap 200mg,50mg Tier 1 QL (3 units per 1 day)
efavirenz tab 600mg Tier 1 QL (1 unit per 1 day)
INTELENCE TAB 100MG,200MG,25MG (etravirine tab) Tier 2 QL (4 units per 1 day)
nevirapine sus 50mg/5ml Tier 1 QL (40 units per 1 day)
nevirapine tab 200mg Tier 1 QL (1 unit per 1 day)
nevirapine tab 200mg Tier 1 QL (1 unit per 1 day)
PIFELTRO TAB 100MG (doravirine tab) Tier 3 QL (2 units per 1 day)
SUSTIVA CAP 200MG,50MG (efavirenz cap) Tier 3 QL (3 units per 1 day)
SUSTIVA TAB 600MG (efavirenz tab) Tier 3 QL (1 unit per 1 day)
VIRAMUNE SUS 50MG/5ML (nevirapine susp) Tier 3 QL (40 units per 1 day)
VIRAMUNE TAB 200MG (nevirapine tab) Tier 3 QL (2 units per 1 day)
VIRAMUNE XR TAB 400MG (nevirapine tab er) Tier 3 QL (1 unit per 1 day)
ANTIRETROVIRALS ‐ RTI‐NUCLEOSIDE ANALOGUES‐PURINES ‐ Drugs to Treat Viral Infections
abacavir sol 20mg/ml Tier 1 QL (30 units per 1 day)
abacavir tab 300mg Tier 1 QL (2 units per 1 day)
didanosine cap 200mg,250mg,400mg Tier 1 QL (1 unit per 1 day)
ZIAGEN SOL 20MG/ML (abacavir sulfate soln) Tier 3 QL (30 units per 1 day)
ZIAGEN TAB 300MG (abacavir sulfate tab) Tier 3 QL (2 units per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 71 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ANTIRETROVIRALS ‐ RTI‐NUCLEOSIDE ANALOGUES‐PYRIMIDINES ‐ Drugs to Treat Viral Infections
EMTRIVA CAP 200MG (emtricitabine caps) Tier 2 QL (1 unit per 1 day)
EMTRIVA SOL 10MG/ML (emtricitabine soln) Tier 2 QL (24.3 units per 1 day)
EPIVIR SOL 10MG/ML,5MG/ML (lamivudine oral soln) Tier 3 QL (30 units per 1 day)
EPIVIR TAB 100MG,150MG,300MG (lamivudine tab) Tier 3 QL (2 units per 1 day)
lamivudine sol 10mg/ml Tier 1 QL (30 units per 1 day)
lamivudine tab 100mg,150mg,300mg Tier 1 QL (1 unit per 1 day)
ANTIRETROVIRALS ‐ RTI‐NUCLEOSIDE ANALOGUES‐THYMIDINES ‐ Drugs to Treat Viral Infections
RETROVIR CAP 100MG (zidovudine cap) Tier 2 QL (6 units per 1 day)
RETROVIR SYP 50MG/5ML (zidovudine syrup) Tier 2 QL (60 units per 1 day)
stavudine cap 15mg,20mg,30mg,40mg Tier 1 QL (2 units per 1 day)
ZERIT CAP 30MG,40MG (stavudine cap) Tier 2 QL (2 units per 1 day)
zidovudine cap 100mg Tier 1 QL (6 units per 1 day)
zidovudine syp 50mg/5ml Tier 1 QL (60 units per 1 day)
zidovudine tab 300mg Tier 1
ANTIRETROVIRALS ‐ RTI‐NUCLEOTIDE ANALOGUES ‐ Drugs to Treat Viral Infections
tenofovir tab 300mg Tier 1 QL (1 unit per 1 day)
VIREAD POW 40MG/GM (tenofovir disoproxil fumarate oral powder)
Tier 2 QL (8 units per 1 day)
VIREAD TAB 150MG,200MG,250MG,300MG (tenofovir disoproxil fumarate tab)
Tier 2 QL (1 unit per 1 day)
ANTIRETROVIRALS ADJUVANTS ‐ Drugs to Treat Viral Infections
TYBOST TAB 150MG (cobicistat tab) Tier 3 QL (1 unit per 1 day)
ANTIRHEUMATIC ‐ JANUS KINASE (JAK) INHIBITORS ‐ Drugs to Treat Pain and Inflammation
OLUMIANT TAB 1MG,2MG (baricitinib tab) Tier 4 PA; SP; QL (34 days supply)
RINVOQ TAB 15MG ER (upadacitinib tab er) Tier 2 PA; SP; QL (34 days supply)
XELJANZ TAB 10MG,5MG (tofacitinib citrate tab) Tier 2 PA; SP; QL (34 days supply)
XELJANZ XR TAB 11MG,22MG (tofacitinib citrate tab er) Tier 2 PA; SP; QL (34 days supply)
ANTIRHEUMATIC ANTIMETABOLITES ‐ Drugs to Treat Pain and Inflammation
OTREXUP INJ 10MG,12.5/0.4,15MG,17.5/0.4,20MG,22.5/0.4,25MG (methotrexate soln pf auto‐injector)
Tier 4 PA; SP; QL (34 days supply)
RASUVO INJ 10MG,12.5MG,15MG,17.5MG,20MG,22.5MG,25MG,30MG,7.5MG (methotrexate soln pf auto‐injector)
Tier 2 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 72 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ANTISEBORRHEIC COMBINATIONS ‐ Drugs to Treat Skin Disorders
NUTRASEB CRE (*antiseborrheic products misc ‐ cream***) Tier 3
PROMISEB CRE (*antiseborrheic products misc ‐ cream***) Tier 3
SODIUM SULFA LIQ 10% WASH (sulfacetamide sodium liquid)
Tier 3
ANTISEBORRHEIC PRODUCTS ‐ Drugs to Treat Skin Disorders
GLYCOLIC ACD SOL 70% (glycolic acid soln) Tier 3
OVACE PLUS AER 9.8% (sulfacetamide sodium foam) Tier 3
OVACE PLUS CRE 10% (sulfacetamide sodium cream) Tier 3
OVACE PLUS GEL 10% WASH (sulfacetamide sodium cleansing gel)
Tier 3
OVACE PLUS LIQ 10%,10% WASH (sulfacetamide sodium liquid)
Tier 3
OVACE PLUS LOT 10%,9.8% (sulfacetamide sodium lotion) Tier 3
OVACE PLUS SHA 10% (sulfacetamide sodium shampoo) Tier 3
OVACE WASH LIQ 10%,10% WASH (sulfacetamide sodium liquid)
Tier 3
selenium sul lot 2.5% Tier 1
ANTISENSE OLIGONUCLEOTIDE (ASO) INHIBITOR AGENTS ‐ Drugs for diseases and disorders of the nervous system
TEGSEDI INJ 284/1.5 (inotersen sod subcutaneous pref syr) Tier 2 PA; QL (0.22 unit per 1 day)
ANTISEPTIC COMBINATIONS ‐ MOUTH/THROAT ‐ Drugs to Treat Mouth / Throat / Dental Disorders
DEBACTEROL SOL 30‐50% (sulfuric acid‐sulfonated phenolics soln)
Tier 3
ANTISEPTICS ‐ MOUTH/THROAT ‐ Drugs to Treat Mouth / Throat / Dental Disorders
chlorhex glu sol 0.12% Tier 1
chlorhexidine gluconate sol 0.12% (Paroex) Tier 1
PERIDEX SOL 0.12%,20% (chlorhexidine gluconate soln) Tier 3
chlorhexidine gluconate sol 0.12% (Periogard) Tier 1
ANTISEPTICS & DISINFECTANTS ‐ Drugs and Products to Prevent the Growth of Disease‐Causing Microorganisms
formaldehyde sol 10% Tier 1
FORMALDEHYDE SOL 37% (formaldehyde solution) Tier 3
GLUTARALDEHY SOL 25% (glutaral soln) Tier 3
hydrogen per sol 30% Tier 1
ANTISPASMODICS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
dicyclomine cap 10mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 73 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
dicyclomine sol 10mg/5ml Tier 1
dicyclomine tab 20mg Tier 1
ANTITHYROID AGENTS ‐ Drugs to Treat Disorders of the Thyroid Gland
methimazole tab 10mg,5mg Tier 1
propylthiour tab 50mg Tier 1
TAPAZOLE TAB 10MG,5MG (methimazole tab) Tier 2
ANTI‐TNF‐ALPHA ‐ MONOCLONAL ANTIBODIES ‐ Drugs to Treat Pain and Inflammation
HUMIRA INJ 10/0.1ML,10MG/0.2,20/0.2ML,20MG/0.4,40/0.4ML,40MG/0.8 (adalimumab prefilled syringe kit)
Tier 2 PA; SP; QL (34 days supply)
HUMIRA KIT 10/0.1ML,10MG/0.2,20/0.2ML,20MG/0.4,40/0.4ML,40MG/0.8 (adalimumab prefilled syringe kit)
Tier 2 PA; SP; QL (34 days supply)
HUMIRA PEDIA INJ CROHNS 10/0.1ML,10MG/0.2,20/0.2ML,20MG/0.4,40/0.4ML,40MG/0.8 (adalimumab prefilled syringe kit)
Tier 2 PA; SP; QL (34 days supply)
HUMIRA PEN INJ 40/0.4ML,40MG/0.8 (adalimumab pen‐injector kit)
Tier 2 PA; SP; QL (34 days supply)
HUMIRA PEN INJ CD/UC/HS 40/0.4ML,40MG/0.8 (adalimumab pen‐injector kit)
Tier 2 PA; SP; QL (34 days supply)
HUMIRA PEN INJ PS/UV 40/0.4ML,40MG/0.8 (adalimumab pen‐injector kit)
Tier 2 PA; SP; QL (34 days supply)
HUMIRA PEN KIT CD/UC/HS 40/0.4ML,40MG/0.8 (adalimumab pen‐injector kit)
Tier 2 PA; SP; QL (34 days supply)
HUMIRA PEN KIT PS/UV 40/0.4ML,40MG/0.8 (adalimumab pen‐injector kit)
Tier 2 PA; SP; QL (34 days supply)
SIMPONI ARIA SOL 50MG/4ML (golimumab iv soln) Tier 2 PA; SP; QL (34 days supply)
SIMPONI INJ 100MG/ML,50/0.5ML (golimumab subcutaneous soln auto‐injector)
Tier 2 PA; SP; QL (34 days supply)
SIMPONI INJ 100MG/ML,50/0.5ML (golimumab subcutaneous soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
ANTITUSSIVE ‐ NONNARCOTIC ‐ Drugs to Treat Cough / Cold / Allergies
benzonatate cap 100mg,150mg,200mg Tier 1
TESSALON PER CAP 100MG (benzonatate cap) Tier 2
ANTITUSSIVE ‐ OPIOID ‐ Drugs to Treat Cough / Cold / Allergies
hydroc/homat tab 5‐1.5mg Tier 1
hydrocod/hom syp 5‐1.5/5 Tier 1
hydrocodone/homatropine syp 5‐1.5/5 (Hydromet) Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 74 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ANTITUSSIVE‐EXPECTORANT ‐ Drugs to Treat Cough / Cold / Allergies
cheratussin syp 100‐10/5,10‐100/5 Tier 1
codeine/gg sol 100‐10/5,10‐100/5 Tier 1
g tussin ac liq 100‐10/5,10‐100/5 Tier 1
gg/codeine sol 100‐10/5,10‐100/5 Tier 1
gg/codeine syp 100‐10/5,10‐100/5 Tier 1
guaiatuss ac syp 100‐10/5,10‐100/5 Tier 1
guaiatussin syp 100‐10/5,10‐100/5 Tier 1
guaifenesin sol codeine 100‐10/5,10‐100/5 Tier 1
guaifenesin syp 100‐10/5,10‐100/5 Tier 1
maxi‐tuss ac sol 100‐10/5,10‐100/5 Tier 1
NINJACOF‐XG LIQ 200‐8/5 (guaifenesin‐codeine liquid) Tier 3
virtussin ac liq 100‐10/5,10‐100/5 Tier 1
virtussin ac sol 100‐10/5,10‐100/5 Tier 1
ANTITUSSIVE‐EXPECTORANTS‐DECONGESTANT ‐ Drugs to Treat Cough / Cold / Allergies
GILTUSS TR TAB (phenylephrine w/ dm‐gg tab) Tier 3
virtussin sol dac Tier 1
ANTIVIRAL MONOCLONAL ANTIBODIES ‐ Vaccines and Drugs for the Immune System
SYNAGIS INJ 100MG/ML,50MG (palivizumab im soln) Tier 4 PA; SP; QL (34 days supply)
ANTIVIRAL TOPICAL COMBINATIONS ‐ Drugs to Treat Skin Disorders
XERESE CRE 5‐1% (acyclovir‐hydrocortisone cream) Tier 3
ANTIVIRALS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
acyclovir cre 5% Tier 1
acyclovir oin 5% Tier 1
DENAVIR CRE 1% (penciclovir cream) Tier 3
ZOVIRAX CRE 5% (acyclovir cream) Tier 3
ZOVIRAX OIN 5% (acyclovir oint) Tier 3
ANTI‐VON WILLEBRAND FACTOR AGENTS ‐ Drugs to Treat Blood Disorders
CABLIVI KIT 11MG (caplacizumab‐yhdp for inj kit) Tier 3 PA
APPLICATORS,COTTON BALLS,ETC ‐ Diabetic Supplies and Needles
ALCOH‐GLOVE PAD CONTOURE 70% (*alcohol swabs***) Tier 3
ALCOHOL PAD 70% (*alcohol swabs***) Tier 3
ALCOHOL PAD PREP 70% (*alcohol swabs***) Tier 3
ALCOHOL PAD SWABSTIC 70% (*alcohol swabs***) Tier 3
ALCOHOL PREP PAD 70% (*alcohol swabs***) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 75 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ALCOHOL PREP PAD MED 70% (*alcohol swabs***) Tier 3
ALCOHOL PREP PAD PADS 70% (*alcohol swabs***) Tier 3
ALCOHOL SWAB PAD 70% (*alcohol swabs***) Tier 3
ALCOHOL SWAB PAD EX‐THICK 70% (*alcohol swabs***) Tier 3
ALCOHOL WIPE PAD 70% (*alcohol swabs***) Tier 3
ALCOH‐WIPE MIS 12"X12" (*alcohol sheets***) Tier 3
APLICARE ALC PAD SWABSTIC 70% (*alcohol swabs***) Tier 3
BD SWAB BFLY PAD SNGL USE 70% (*alcohol swabs***) Tier 3
CARETOUCH PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
CURITY PREP PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
CURITY SWABS PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
EASY COMFORT PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
FIFTY50 PREP PAD PADS 70% (*alcohol swabs***) Tier 3
GLOBAL PREP PAD PADS 70% (*alcohol swabs***) Tier 3
GNP ALCOHOL PAD SWABS 70% (*alcohol swabs***) Tier 3
HM STERILE PAD ALCHOL 70% (*alcohol swabs***) Tier 3
INCONTROL PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
PREP PADS PAD 70% (*alcohol swabs***) Tier 3
PRO COMFORT PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
PURE COMFORT PAD 70% (*alcohol swabs***) Tier 3
QC ALCOHOL PAD SWABS 70% (*alcohol swabs***) Tier 3
RA ALCOHOL PAD SWABS 70% (*alcohol swabs***) Tier 3
REALITY SWAB PAD 70% (*alcohol swabs***) Tier 3
SAPS CARE PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
SAPS HEALTH PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
SB ALCOHOL PAD PREP 70% (*alcohol swabs***) Tier 3
SM ALCOHOL PAD PREP 70% (*alcohol swabs***) Tier 3
ULTICARE PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
ULTILET PAD ALCOHOL 70% (*alcohol swabs***) Tier 3
WEBCOL PREP PAD LARGE 70% (*alcohol swabs***) Tier 3
WEBCOL PREP PAD MEDIUM 70% (*alcohol swabs***) Tier 3
AROMATASE INHIBITORS ‐ Drugs for Treatment of Cancer
anastrozole tab 1mg Tier 1 OAC
ARIMIDEX TAB 1MG (anastrozole tab) Tier 2 OAC
AROMASIN TAB 25MG (exemestane tab) Tier 2 OAC
exemestane tab 25mg Tier 1 OAC
FEMARA TAB 2.5MG (letrozole tab) Tier 2 OAC
letrozole tab 2.5mg Tier 1 OAC
ARTIFICIAL TEAR INSERTS ‐ Drugs for Treatment of Disorders in the Eyes
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 76 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
LACRISERT MIS 5MG OP (*artificial tear ophth insert***) Tier 3
ARTIFICIAL TEARS AND LUBRICANTS ‐ Drugs for Treatment of Disorders in the Eyes
ASTRINGENTS ‐ Drugs to Treat Skin Disorders
XERAC‐AC SOL 6.25% (aluminum chloride in alcohol solution)
Tier 3
ATOPIC DERMATITIS ‐ MONOCLONAL ANTIBODIES ‐ Drugs to Treat Skin Disorders
DUPIXENT INJ 200/1.14,300/2ML (dupilumab subcutaneous soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
AZITHROMYCIN ‐ Antibiotics / Drugs for Infections
azithromycin pow 1gm pak Tier 1
azithromycin sus 100/5ml,200/5ml Tier 1
azithromycin tab 250mg,500mg,600mg Tier 1
ZITHROMAX POW 1GM PAK (azithromycin powd pack for susp)
Tier 3
ZITHROMAX SUS 100/5ML,200/5ML (azithromycin for susp) Tier 3
ZITHROMAX TAB 250MG,500MG (azithromycin tab) Tier 3
ZITHROMAX TAB TRI‐PAK 250MG,500MG (azithromycin tab)
Tier 3
ZITHROMAX TAB Z‐PAK 250MG,500MG (azithromycin tab) Tier 3
BACTERIAL VACCINES ‐ Drugs for Communicable Disease Prevention
ACTHIB INJ (haemophilus b polysaccharide conjugate vaccine for inj)
Tier 5 AL‐18 max
BEXSERO INJ (meningococcal vac b (recomb omv adjuv) inj prefilled syringe)
Tier 5 AL‐18 min
BIOTHRAX INJ (anthrax vaccine adsorbed inj) Tier 5 AL‐18 min
HIBERIX SOL 10MCG (haemophilus b polysaccharide conjugate vac for inj)
Tier 5 AL‐18 max
MENACTRA INJ (meningococcal (a, c, y, and w‐) Tier 5 AL‐18 min
MENVEO INJ (meningococcal (a, c, y, and w‐) Tier 5 AL‐18 min
PEDVAX HIB INJ (haemophilus b polysaccharide conj vac im susp)
Tier 5 AL‐18 max
PNEUMOVAX 23 INJ 25/0.5 (pneumococcal vaccine polyvalent inj)
Tier 5 AL‐18 min
PREVNAR 13 INJ (pneumococcal) Tier 5 AL‐18 min
TRUMENBA INJ (meningococcal group b vac (recomb) im susp prefilled syr)
Tier 5 AL‐18 min
TYPHIM VI INJ (typhoid vi polysaccharide intramuscular vac inj)
Tier 5 AL‐18 min
BARBITURATE HYPNOTICS ‐ Drugs to Treat Problems with Sleeping
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 77 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
phenobarb elx 20mg/5ml Tier 1
phenobarb sol 20mg/5ml Tier 1
phenobarb tab 100mg,15mg,16.2mg,30mg,32.4mg,60mg,64.8mg,97.2mg
Tier 1
SECONAL SOD CAP 100MG (secobarbital sodium cap) Tier 3
BELLADONNA ALKALOIDS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
ANASPAZ TAB 0.125MG (hyoscyamine sulfate tab disint) Tier 2
ed‐spaz tab 0.125mg Tier 1
hyoscyamine dro 0.125/ml Tier 1
hyoscyamine elx 0.125/5 Tier 1
hyoscyamine sub 0.125mg Tier 1
hyoscyamine tab 0.125mg Tier 1
hyoscyamine tab 0.125mg Tier 1
hyoscyamine tab 0.125mg Tier 1
LEVBID TAB 0.375 ER (hyoscyamine sulfate tab er) Tier 2
LEVSIN TAB 0.125MG (hyoscyamine sulfate tab) Tier 2
LEVSIN/SL SUB 0.125MG (hyoscyamine sulfate sl tab) Tier 2
hyoscyamine tab 0.125mg (Nulev) Tier 1
hyoscyamine sr tab 0.375 er,0.375 sr,0.375mg (Oscimin Sr) Tier 1
hyoscyamine tab 0.125mg (Oscimin) Tier 1
SYMAX DUOTAB TAB (hyoscyamine sulfate tab er) Tier 3
hyoscyamine tab 0.375 er,0.375 sr,0.375mg (Symax‐sr) Tier 1
BENZATHIAZOLES ‐ Drugs to Treat Disorders that Affect the Nerves That control Voluntary Muscles
RILUTEK TAB 50MG (riluzole tab) Tier 3
riluzole tab 50mg Tier 1
TIGLUTIK SUS 50/10ML (riluzole susp) Tier 3
BENZISOXAZOLES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
FANAPT PAK 10MG,12MG,1MG,2MG,4MG,6MG,8MG (iloperidone tab)
Tier 3
FANAPT TAB 10MG,12MG,1MG,2MG,4MG,6MG,8MG (iloperidone tab)
Tier 3
INVEGA TAB 1.5MG,3MG,6MG,9MG (paliperidone tab er) Tier 3
paliperidone tab er 1.5mg,3mg,6mg,9mg Tier 1
RISPERDAL SOL 1MG/ML (risperidone soln) Tier 3
RISPERDAL TAB 0.5MG,1MG,2MG,3MG,4MG (risperidone tab)
Tier 3
risperidone sol 1mg/ml Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 78 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
risperidone tab 0.25 odt,0.5mg od,1mg odt,2mg odt,3mg odt,4mg odt
Tier 1
risperidone tab 0.25 odt,0.5mg od,1mg odt,2mg odt,3mg odt,4mg odt
Tier 1
BENZODIAZEPINE HYPNOTICS ‐ Drugs to Treat Problems with Sleeping
DORAL TAB 15MG (quazepam tab) Tier 3 QL (1 unit per 1 day)
estazolam tab 1mg,2mg Tier 1 QL (1 unit per 1 day)
flurazepam cap 15mg,30mg Tier 1 QL (1 unit per 1 day)
HALCION TAB 0.25MG (triazolam tab) Tier 3 QL (1 unit per 1 day)
midazolam syp 2mg/ml Tier 1
quazepam tab 15mg Tier 1 QL (1 unit per 1 day)
RESTORIL CAP 15MG,22.5MG,30MG,7.5MG (temazepam cap)
Tier 3 QL (1 unit per 1 day)
temazepam cap 15mg,22.5mg,30mg,7.5mg Tier 1 QL (1 unit per 1 day)
triazolam tab 0.125mg,0.25mg Tier 1 QL (1 unit per 1 day)
BENZODIAZEPINES ‐ Drugs for Anxiety Disorders
ALPRAZOLAM CON 1 MG/ML (alprazolam conc) Tier 3
alprazolam tab 0.25 odt,0.5mg od,1mg odt,2mg odt Tier 1
alprazolam tab 0.25 odt,0.5mg od,1mg odt,2mg odt Tier 1
alprazolam tab 0.25 odt,0.5mg od,1mg odt,2mg odt Tier 1
ATIVAN TAB 0.5MG,1MG,2MG (lorazepam tab) Tier 2
chlordiazep cap 10mg,25mg,5mg Tier 1
cloraz dipot tab 15mg,3.75mg,7.5mg Tier 1
diazepam con 5mg/ml Tier 1
diazepam sol 5mg/5ml Tier 1
diazepam tab 10mg,2mg,5mg Tier 1
lorazepam con 2mg/ml Tier 1
lorazepam tab 0.5mg,1mg,2mg Tier 1
oxazepam cap 10mg,15mg,30mg Tier 1
TRANXENE T TAB 7.5MG (clorazepate dipotassium tab) Tier 3
VALIUM TAB 10MG,2MG,5MG (diazepam tab) Tier 2
XANAX TAB 0.25MG,0.5MG,1MG,2MG (alprazolam tab) Tier 3
XANAX XR TAB 0.5MG,1MG,2MG,3MG (alprazolam tab er) Tier 3
BENZODIAZEPINES & TRICYCLIC AGENTS ‐ Drugs for diseases and disorders of the nervous system
cdp/amitrip tab 10‐25mg,5‐12.5mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 79 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
BETA ADRENERGICS ‐ Drugs to Treat Asthma and Breathing Disorders
albuterol aer hfa Tier 1 QL (25 days;36 units)
albuterol neb 0.083%,0.5%,0.63mg/3,1.25mg/3 Tier 1 QL (25 days;360 units)
albuterol syp 2mg/5ml Tier 1
albuterol tab 2mg,4mg Tier 1
albuterol tab 2mg,4mg Tier 1
ARCAPTA CAP 75MCG (indacaterol maleate inhal powder cap)
Tier 3 QL (75 days;90 capsules)
BROVANA NEB 15MCG (arformoterol tartrate soln nebu) Tier 3 QL (75 days;360 units)
levalbuterol aer 45/act Tier 1 QL (75 days;90 units)
levalbuterol neb 0.31mg,0.63mg,1.25mg Tier 1 QL (25 days;288 units)
levalbuterol neb 0.31mg,0.63mg,1.25mg Tier 1 QL (25 days;288 units)
metaproteren syp 10mg/5ml Tier 1
PERFOROMIST NEB 20MCG (formoterol fumarate soln nebu)
Tier 2 QL (75 days;360 units)
PROAIR DIGIH AER 108MCG (albuterol sulfate aer pow ba) Tier 3 QL (75 days;6 units)
PROAIR HFA AER (albuterol sulfate inhal aero) Tier 3 QL (25 days;17 units)
PROAIR RESPI AER 108MCG (albuterol sulfate aer pow ba) Tier 3 QL (75 days;6 units)
PROVENTIL AER HFA (albuterol sulfate inhal aero) Tier 3 QL (25 days;14 units)
SEREVENT DIS AER 50MCG (salmeterol xinafoate aer pow ba)
Tier 2 QL (75 days;180 units)
STRIVERDI AER 2.5MCG (olodaterol hcl inhal aerosol soln) Tier 2 QL (75 days;12 units)
terbutaline tab 2.5mg,5mg Tier 1
VENTOLIN HFA AER (albuterol sulfate inhal aero) Tier 3 QL (25 days;36 units)
XOPENEX CONC NEB 1.25/0.5 (levalbuterol hcl soln nebu conc)
Tier 3 QL (75 days;270 units)
XOPENEX HFA AER (levalbuterol tartrate inhal aerosol) Tier 3 QL (75 days;90 units)
XOPENEX NEB 0.31MG,0.63MG,1.25/3ML (levalbuterol hcl soln nebu)
Tier 3 QL (25 days;288 units)
BETA BLOCKER & DIURETIC COMBINATIONS ‐ Drugs to Treat High Blood Pressure
atenol/chlor tab 100‐25mg,50‐25mg Tier 1
bisoprl/hctz tab 10/6.25,2.5/6.25,5‐6.25mg Tier 1
DUTOPROL TAB 100‐12.5,25‐12.5,50‐12.5 (metoprolol & hydrochlorothiazide tab er)
Tier 3
LOPRESS HCT TAB 50‐25MG (metoprolol & hydrochlorothiazide tab)
Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 80 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
metoprl/hctz tab 100‐25mg,100‐50mg,50‐25mg Tier 1
propran/hctz tab 40/25,80/25 Tier 1
TENORETIC TAB 100,50 (atenolol & chlorthalidone tab) Tier 3
ZIAC TAB 10/6.25,2.5/6.25,5‐6.25MG (bisoprolol & hydrochlorothiazide tab)
Tier 2
BETA BLOCKERS CARDIO‐SELECTIVE ‐ Drugs for High Blood Pressure / Misc Heart Disorders
acebutolol cap 200mg,400mg Tier 1
atenolol tab 100mg,25mg,50mg Tier 1
betaxolol tab 10mg,20mg Tier 1
bisoprol fum tab 10mg,5mg Tier 1
BYSTOLIC TAB 10MG,2.5MG,20MG,5MG (nebivolol hcl tab) Tier 2
KAPSPARGO CAP 100MG,200MG,25MG,50MG (metoprolol succ cap er)
Tier 3
LOPRESSOR TAB 100MG,50MG (metoprolol tartrate tab) Tier 3
metoprol suc tab 100mg er,200mg er,25mg er,50mg er Tier 1
metoprol tar tab 100mg,25mg,37.5mg,50mg,75mg Tier 1
metoprolol tab 100mg er,200mg er,25mg er,50mg er Tier 1
metoprolol tab 100mg er,200mg er,25mg er,50mg er Tier 1
TENORMIN TAB 100MG,25MG,50MG (atenolol tab) Tier 3
TOPROL XL TAB 100MG,200MG,25MG,50MG (metoprolol succinate tab er)
Tier 3
BETA BLOCKERS NON‐SELECTIVE ‐ Drugs for High Blood Pressure / Misc Heart Disorders
BETAPACE AF TAB 120MG,160MG,80MG (sotalol hcl (afib/afl) tab)
Tier 3
BETAPACE TAB 120MG,160MG,80MG (sotalol hcl tab) Tier 3
CORGARD TAB 20MG,40MG,80MG (nadolol tab) Tier 3
HEMANGEOL SOL 4.28/ML (propranolol hcl oral soln) Tier 3
INDERAL LA CAP 120MG,160MG,60MG,80MG (propranolol hcl cap er)
Tier 3
INDERAL XL CAP 120MG,80MG (propranolol hcl sustained‐release beads cap er)
Tier 3
INNOPRAN XL CAP 120MG,80MG (propranolol hcl sustained‐release beads cap er)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 81 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
nadolol tab 20mg,40mg,80mg Tier 1
pindolol tab 10mg,5mg Tier 1
propranolol cap 120mg er,160mg er,60mg er,80mg er Tier 1
propranolol sol 20mg/5ml,40mg/5ml Tier 1
propranolol tab 10mg,20mg,40mg,60mg,80mg Tier 1
sorine tab 120mg,160mg,240mg,80mg Tier 1
sotalol af tab 120mg,160mg,80mg Tier 1
sotalol hcl tab 120mg,160mg,240mg,80mg Tier 1
sotalol tab 120mg,160mg,240mg,80mg Tier 1
SOTYLIZE SOL 5MG/ML (sotalol hcl oral solution) Tier 3
timolol mal tab 10mg,20mg,5mg Tier 1
BETA‐BLOCKERS ‐ OPHTHALMIC ‐ Drugs for Treatment of Disorders in the Eyes
betaxolol sol 0.5% op Tier 1
BETIMOL SOL 0.25%,0.5% (timolol ophth soln) Tier 2
BETOPTIC‐S SUS 0.25% OP (betaxolol hcl ophth susp) Tier 2
carteolol sol 1% op Tier 1
ISTALOL SOL 0.25% OP,0.5% OP (timolol maleate ophth soln)
Tier 3
levobunolol sol 0.5% op Tier 1
timolol gel sol 0.25% op,0.5% op Tier 1
timolol mal sol 0.25% op,0.5%,0.5% op Tier 1
timolol male sol 0.25% op,0.5%,0.5% op Tier 1
TIMOPTIC OCU SOL 0.25% OP,0.5% OP (timolol maleate preservative free ophth soln)
Tier 3
TIMOPTIC SOL 0.25% OP,0.5% OP (timolol maleate ophth soln)
Tier 3
TIMOPTIC‐XE SOL 0.25% OP,0.5% OP (timolol maleate ophth gel forming soln)
Tier 3
BETA‐BLOCKERS ‐ OPHTHALMIC COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes
COMBIGAN SOL 0.2/0.5% (brimonidine tartrate‐timolol maleate ophth soln)
Tier 2
COSOPT PF SOL 2%‐0.5% (dorzolamide hcl‐timolol maleate ophth sol)
Tier 3
COSOPT SOL 22.3‐6.8 (dorzolamide hcl‐timolol maleate ophth soln)
Tier 3
dorzol/timol sol 2%‐0.5% Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 82 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
dorzol/timol sol 2%‐0.5% Tier 1
TIM/BRIM/DOR SOL (timolol‐brimonidine‐dorzolamide ophth soln)
Tier 3
TIM/DORZ/LAT SOL (timolol‐dorzolamide‐latanoprost ophth soln)
Tier 3
TIMOL/BRIM SOL DORZ/LAT (timolol‐brimon‐dorzol‐latanoprost oph soln)
Tier 3
TIMOL/LATAN SOL (latanoprost‐timolol maleate ophth soln)
Tier 3
BIGUANIDES ‐ Drugs to treat Diabetes
FORTAMET TAB 1000MG,500MG (metformin hcl tab er) Tier 3
GLUMETZA TAB 1000MG,500MG (metformin hcl tab er) Tier 3
metformin er tab 1000 er,1000mg,500mg er,750mg er Tier 1
metformin sol 500/5ml Tier 1
metformin tab 1000mg,500mg,850mg Tier 1
metformin tab 1000mg,500mg,850mg Tier 1
RIOMET ER SUS 500/5ML (metformin hcl for oral er susp) Tier 3
RIOMET SOL 500/5ML (metformin hcl oral soln) Tier 3
BILE ACID SEQUESTRANTS ‐ Drugs for High Cholesterol
cholestyram pow 4gm,4gm lite Tier 1
cholestyram pow 4gm,4gm lite Tier 1
cholestyram pow 4gm,4gm lite Tier 1
cholestyram pow 4gm,4gm lite Tier 1
colesevelam pak 3.75,3.75gm Tier 1
colesevelam tab 625mg Tier 1
COLESTID FLA GRA 5/7.5GM,5GM (colestipol hcl granule packets)
Tier 3
COLESTID FLA GRA 5/7.5GM,5GM (colestipol hcl granules) Tier 3
COLESTID GRA 5GM (colestipol hcl granules) Tier 3
COLESTID POW 5/7.5GM,5GM (colestipol hcl granule packets)
Tier 3
COLESTID TAB 1GM (colestipol hcl tab) Tier 3
colestipol gra 5gm Tier 1
colestipol gra 5gm Tier 1
colestipol tab 1gm Tier 1
cholestyramine pow 4gm,4mg lite (Prevalite) Tier 1
QUESTRAN POW 4GM LITE (cholestyramine powder packets)
Tier 3
QUESTRAN POW 4GM LITE (cholestyramine powder packets)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 83 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
QUESTRAN POW 4GM LITE (cholestyramine powder packets)
Tier 3
WELCHOL PAK 3.75GM (colesevelam hcl packet for susp) Tier 3
WELCHOL TAB 625MG (colesevelam hcl tab) Tier 3
BILE ACID SYNTHESIS DISORDER AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
CHOLBAM CAP 250MG,50MG (cholic acid cap) Tier 3 PA
BIPHASIC CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
desogest‐eth estrad & eth estrad tab 28 day (Azurette) Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab 28 day (Bekyree) Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab 28 day Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab 28 day (Kariva) Tier 5 QL (1 unit per 1 day)
LO LOESTRIN TAB 1‐10‐10 (norethin‐eth estradiol‐fe tab) Tier 5 QL (1 unit per 1 day)
MIRCETTE TAB 28 DAY (desogest‐eth estrad & eth estrad tab)
Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab 28 day (Pimtrea) Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab 28 day (Simliya) Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab 28 day (Viorele) Tier 5 QL (1 unit per 1 day)
VOLNEA TAB 28 DAY (desogest‐eth estrad & eth estrad tab) Tier 5 QL (1 unit per 1 day)
BISPHOSPHONATES ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
ACTONEL TAB 150MG,30MG,35MG,5MG (risedronate sodium tab)
Tier 3
alendronate sol 70/75ml Tier 1
alendronate tab 10mg,35mg,5mg,70mg Tier 1
ATELVIA TAB (risedronate sodium tab delayed release) Tier 3
BINOSTO TAB 70MG (alendronate sodium effervescent tab) Tier 3
BONIVA TAB 150MG (ibandronate sodium tab) Tier 3
FOSAMAX + D TAB 70‐2800,70‐5600 (alendronate sodium‐cholecalciferol tab)
Tier 3
FOSAMAX TAB 70MG (alendronate sodium tab) Tier 3
ibandronate tab 150mg Tier 1
RECLAST INJ 4/100ML,4MG/100,5/100ML (zoledronic acid iv soln)
Tier 4 PA; SP; QL (34 days supply)
risedron sod tab 35mg dr Tier 1
risedronate tab 150mg,30mg,35mg,5mg Tier 1
zoledronic inj 4mg/5ml Tier 1 PA; SP; QL (34 days supply)
zoledronic inj 4mg/5ml Tier 1 PA; SP; QL (34 days supply)
ZOLEDRONIC INJ 4/100ML,4MG/100,5/100ML (zoledronic acid inj conc for iv infusion)
Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 84 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
B‐LYMPHOCYTE STIMULATOR (BLYS)‐SPECIFIC INHIBITORS ‐ Miscellaneous Drugs and Solutions
BENLYSTA INJ 120MG,400MG (belimumab for iv soln) Tier 4 PA; SP; QL (34 days supply)
BENLYSTA INJ 120MG,400MG (belimumab subcutaneous solution prefilled syringe)
Tier 4 PA; SP; QL (34 days supply)
BENLYSTA INJ 120MG,400MG (belimumab subcutaneous solution prefilled syringe)
Tier 4 PA; SP; QL (34 days supply)
BOWEL EVACUANT COMBINATIONS ‐ Drugs to Treat Constipation
CLENPIQ SOL (sod picosulfate‐mg ox‐citric ac sol) Tier 5
polyethylene glycol‐electrolyte solution ‐c sol (Gavilyte‐c) Tier 1
polyethylene glycol‐electrolyte solution‐g (Gavilyte‐g sol) Tier 1
polyethylene glycol‐electrolyte solution‐bisacodyl kit (Gavilyte‐h)
Tier 5
polyethylene glycol‐electrolyte solution ‐n/flavor pack sol (Gavilyte‐n/flavor Pack)
Tier 1
GOLYTELY SOL (peg) Tier 3
GOLYTELY SOL PINEAPPL (peg) Tier 3
MOVIPREP SOL (peg) Tier 5
NULYTELY SOL FLAV PKS (peg) Tier 3
peg‐3350 sol electrol Tier 1
peg‐3350/kcl sol /sodium Tier 1
PEG‐PREP KIT (bisacodyl tab & peg) Tier 5
PLENVU SOL (peg) Tier 5
SUPREP BOWEL SOL PREP KIT (sod sulfate‐pot sulf‐mg sulf oral sol)
Tier 5
polyethylene glycol‐electrolyte solution sol (Trilyte) Tier 1
BRADYKININ B2 RECEPTOR ANTAGONISTS ‐ Drugs to Treat Blood Disorders
FIRAZYR INJ 30MG/3ML (icatibant acetate inj) Tier 2 PA; SP; QL (34 days supply)
icatibant inj 30mg/3ml Tier 1 PA; SP; QL (34 days supply)
BRONCHODILATORS ‐ ANTICHOLINERGICS ‐ Drugs to Treat Asthma and Breathing Disorders
ATROVENT HFA AER 17MCG (ipratropium bromide hfa inhal aerosol)
Tier 2 QL (75 days;78 units)
INCRUSE ELPT INH 62.5MCG (umeclidinium br aero powd breath act)
Tier 2 QL (75 days;90 units)
ipratropium sol 0.02%inh Tier 1 QL (75 days;939 units)
LONHALA MAGN SOL 25MCG (glycopyrrolate inhal solution) Tier 3
SEEBRI NEOHA CAP 15.6MCG (glycopyrrolate inhal cap) Tier 3
SPIRIVA AER 1.25MCG,2.5MCG (tiotropium bromide monohydrate inhal aerosol)
Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 85 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
SPIRIVA CAP HANDIHLR (tiotropium bromide monohydrate inhal cap)
Tier 2 QL (75 days;90 capsules)
SPIRIVA SPR 1.25MCG,2.5MCG (tiotropium bromide monohydrate inhal aerosol)
Tier 2
TUDORZA PRES AER 400/ACT (aclidinium bromide aerosol powd breath activated)
Tier 3 QL (75 days;3 units)
YUPELRI SOL (revefenacin inhalation solution) Tier 2
BURN PRODUCTS ‐ Drugs to Treat Skin Disorders
mafenide ace pak 5% Tier 1
SILVADENE CRE 1% (silver sulfadiazine cream) Tier 2
silver sulfa cre 1% Tier 1
silver sulfadiazine cream 1% (Ssd) Tier 1
SULFAMYLON CRE 85MG/GM (mafenide acetate cream) Tier 3
SULFAMYLON PAK 5% (mafenide acetate packet for topical soln)
Tier 3
BUTYROPHENONES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
haloperidol con 2mg/ml Tier 1
haloperidol tab 0.5mg,10mg,1mg,20mg,2mg,5mg Tier 1
C1 INHIBITORS ‐ Drugs to Treat Blood Disorders
BERINERT INJ 500UNIT (c1 esterase inhibitor (human) for iv inj kit)
Tier 4 PA; SP; QL (34 days supply)
CINRYZE SOL 500 UNIT (c1 esterase inhibitor (human) for iv inj)
Tier 4 PA; SP; QL (34 days supply)
HAEGARDA INJ 2000UNIT,3000UNIT (c1 esterase inhibitor (human) for subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
RUCONEST INJ 2100UNIT (c1 esterase inhibitor (recombinant) for iv inj)
Tier 2 PA; SP; QL (34 days supply)
CALCIMIMETIC AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
cinacalcet tab 30mg,60mg,90mg Tier 1 PA; SP; QL (34 days supply)
PARSABIV INJ 10MG/2ML,2.5‐0.5,5MG/ML (etelcalcetide hcl iv solution)
Tier 4 PA; SP; QL (34 days supply)
SENSIPAR TAB 30MG,60MG,90MG (cinacalcet hcl tab) Tier 4 PA; SP; QL (34 days supply)
CALCITONIN GENE‐RELATED PEPTIDE RECEPTOR ANTAG (CGRP) ‐ Drugs to Treat Migraine Headaches
NURTEC TAB 75MG ODT (rimegepant sulfate tab disint) Tier 2
UBRELVY TAB 100MG,50MG (ubrogepant tab) Tier 2
CALCITONINS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
calcitonin spr 200/act Tier 1
MIACALCIN SPR 200/ACT (calcitonin (salmon) nasal soln) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 86 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
amlod/atorva tab 10‐10mg,10‐20mg,10‐40mg,10‐80mg,2.5‐10mg,2.5‐20mg,2.5‐40mg,5‐10mg,5‐20mg,5‐40mg,5‐80mg
Tier 1
CADUET TAB 10‐10MG,10‐20MG,10‐40MG,10‐80MG,5‐10MG,5‐20MG,5‐40MG,5‐80MG (amlodipine besylate‐atorvastatin calcium tab)
Tier 3
CALCIUM CHANNEL BLOCKER‐NSAID COMBINATIONS ‐ Drugs for High Blood Pressure / Misc Heart Disorders
CONSENSI TAB 10‐200MG,2.5‐200,5‐200MG (amlodipine besylate‐celecoxib tab)
Tier 3
CALCIUM CHANNEL BLOCKERS ‐ Drugs for High Blood Pressure / Misc Heart Disorders
afeditab tab 30mg cr,30mg er,60mg,60mg cr,60mg er,90mg er
Tier 1
amlodipine tab 10mg,2.5mg,5mg Tier 1
CALAN SR TAB 120MG,180MG,240MG (verapamil hcl tab er)
Tier 3
CARDIZEM CD CAP 120MG/24,180MG/24,240MG/24,300MG/24,360MG/24 (diltiazem hcl coated beads cap er)
Tier 3
CARDIZEM LA TAB 120MG,180MG,240MG,300MG/24,360MG,420MG/24 (diltiazem hcl coated beads tab er)
Tier 3
CARDIZEM TAB 120MG,30MG,60MG (diltiazem hcl tab) Tier 3
diltiazem xt cap 120/24hr,120mg er,180/24hr,180mg cd,180mg ER,240/24hr,240mg cd,240mg hr,300/24hr,300mg hr,360mg,360mg cd,360mg hr (Cartia Xt)
Tier 1
diltiazem cap 120mg,120mg er,180mg,240mg,60mg er,90mg er
Tier 1
diltiazem cap 120mg,120mg er,180mg,240mg,60mg er,90mg er
Tier 1
diltiazem cap 120mg,120mg er,180mg,240mg,60mg er,90mg er
Tier 1
diltiazem er cap 120/24hr,120mg er,180/24hr,180mg cd,180mg er,240/24hr,240mg cd,240mg er,300/24hr,300mg er,360mg,360mg cd,360mg er
Tier 1
diltiazem er tab 180mg,180mg/24,240mg,240mg/24,300mg,300mg/24,360mg,360mg/24,420mg,420mg/24
Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 87 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
diltiazem tab 120mg,30mg,60mg,90mg Tier 1
diltiazem‐xr cap 120mg,120mg er,180mg,240mg,60mg er,90mg er (Dilt‐xr)
Tier 1
felodipine tab 10mg er,2.5mg er,5mg er Tier 1
ISOPTIN SR TAB 120MG,180MG,240MG (verapamil hcl tab er)
Tier 3
isradipine cap 2.5mg,5mg Tier 1
KATERZIA SUS 1MG/ML (amlodipine benzoate oral susp) Tier 3
matzim la tab 180mg,180mg/24,240mg,240mg/24,300mg,300mg/24,360mg,360mg/24,420mg,420mg/24
Tier 1
nicardipine cap 20mg,30mg Tier 1
nifedical xl tab 30mg cr,30mg er,60mg,60mg cr,60mg er,90mg er
Tier 1
nifedipine cap 10mg,20mg Tier 1
nifedipine tab 30mg cr,30mg er,60mg,60mg cr,60mg er,90mg er
Tier 1
nimodipine cap 30mg Tier 1
nisoldipine tab 17mg er,20mg er,25.5mg,30mg er,34mg er,40mg er,8.5mg er
Tier 1
NORVASC TAB 10MG,2.5MG,5MG (amlodipine besylate tab) Tier 3
NYMALIZE SOL (nimodipine oral soln) Tier 3
PROCARDIA CAP 10MG (nifedipine cap) Tier 3
PROCARDIA XL TAB 30MG CR,60MG CR,90MG CR (nifedipine tab er)
Tier 3
SULAR TAB 17MG,34MG,8.5MG (nisoldipine tab er) Tier 3
diltiazem xt cap 120mg er,120mg/24,180mg er,180mg/24,240mg er,240mg/24,300mg er,300mg/24,360mg er,360mg/24,420mg/24 (Taztia Xt )
Tier 1
diltiazem er cap 120mg er,120mg/24,180mg er,180mg/24,240mg er,240mg/24,300mg er,300mg/24,360mg er,360mg/24,420mg/24 (Tiadylt Er)
Tier 1
TIAZAC CAP 120MG/24,180MG/24,240MG/24,300MG/24,360MG/24,420MG/24 (diltiazem hcl extended release beads cap er)
Tier 3
verapamil cap 100mg er,120mg er,120mg sr,180mg er,180mg sr,200mg er,240mg er,240mg sr,300mg er,360mg sr
Tier 1
verapamil tab 120mg,40mg,80mg Tier 1
verapamil tab 120mg,40mg,80mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 88 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
VERELAN CAP 100MG ER,120MG SR,180MG SR,200MG ER,240MG SR,300MG ER,360MG SR (verapamil hcl cap er)
Tier 3
VERELAN PM CAP 100MG ER,120MG SR,180MG SR,200MG ER,240MG SR,300MG ER,360MG SR (verapamil hcl cap er)
Tier 3
CALCIUM COMBINATIONS ‐ Drugs for Replacement of Minerals in the Body
CALCIFOL WAF (ca carb‐folic acid‐vit d‐b) Tier 3
CALCIUM‐FA WAF PLUS D (ca carb‐folic acid‐vit d‐b) Tier 3
CARBAMATES ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders
felbamate sus 600/5ml Tier 1
felbamate tab 400mg,600mg Tier 1
FELBATOL SUS 600/5ML (felbamate susp) Tier 3
FELBATOL TAB 400MG,600MG (felbamate tab) Tier 3
XCOPRI PAK 150‐200,50‐200MG (cenobamate tab pack) Tier 3
XCOPRI PAK 150‐200,50‐200MG (cenobamate tab titration pack)
Tier 3
XCOPRI TAB 100MG,150MG,200MG,50MG (cenobamate tab)
Tier 3
XCOPRI TAB 100MG,150MG,200MG,50MG (cenobamate tab pack)
Tier 3
CARBONIC ANHYDRASE INHIBITORS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders
acetazolamid cap 500mg er Tier 1
acetazolamid tab 125mg,250mg Tier 1
KEVEYIS TAB 50MG (dichlorphenamide tab) Tier 3 PA; QL (4 units per 1 day)
methazolamid tab 25mg,50mg Tier 1
CARDIAC GLYCOSIDES ‐ Drugs Used to Increase the Efficiency and Improve the Contraction of the Heart Muscle
digoxin tab 0.125mg,0.25mg (Digitek) Tier 1
digoxin tab 0.125mg,0.25mg (Digox) Tier 1
digoxin sol 50mcg/ml Tier 1
digoxin tab 0.125mg,0.25mg Tier 1
LANOXIN TAB 0.0625MG (digoxin tab) Tier 2
LANOXIN TAB 0.125MG,0.25MG (digoxin tab) Tier 3
CARDIOPLEGIC SOLUTIONS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
CARDIOPL IND SOL 4,4:1,8,8:1 (*cardioplegic soln**) Tier 3
CARDIOPL IND SOL LOW DEX 4,4:1,8,8:1 (*cardioplegic soln**)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 89 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CARDIOPL IND SOL NON‐EN 4,4:1,8,8:1 (*cardioplegic soln**)
Tier 3
CARDIOPL IND SOL PLASMA 4,4:1,8,8:1 (*cardioplegic soln**)
Tier 3
CARDIOPL IND SOL PLS/TROM 4,4:1,8,8:1 (*cardioplegic soln**)
Tier 3
CARDIOPL MN SOL 4,4:1,8,8:1 (*cardioplegic soln**) Tier 3
CARDIOPL MN SOL PLS/TROM 4,4:1,8,8:1 (*cardioplegic soln**)
Tier 3
CARDIOPL REP SOL 4,4:1,8,8:1 (*cardioplegic soln**) Tier 3
CARDIOPLE MN SOL LOW TROM 4,4:1,8,8:1 (*cardioplegic soln**)
Tier 3
CARDIOPLEGI SOL DEL NIDO 4,4:1,8,8:1 (*cardioplegic soln**)
Tier 3
CARDIOPLEGIA SOL MAIN 4,4:1,8,8:1 (*cardioplegic soln**) Tier 3
cardioplegic sol Tier 1
MICROPLEGIA INJ MSA/MSG 4,4:1,8,8:1 (*cardioplegic soln**)
Tier 3
PLEGISOL SOL 4,4:1,8,8:1 (*cardioplegic soln**) Tier 3
CARNITINE REPLENISHER ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
CARNITOR SF SOL 1GM/10ML (levocarnitine oral soln) Tier 3
CARNITOR SOL 1GM/10ML (levocarnitine oral soln) Tier 3
CARNITOR TAB 330MG (levocarnitine tab) Tier 3
levocarnitin sol 1gm/10ml Tier 1
levocarnitin tab 330mg Tier 1
CAUTERIZING AGENT COMBINATIONS ‐ Drugs to Treat Skin Disorders
arzol silver mis nitr app Tier 1
grafco silvr mis nit appl Tier 1
CAUTERIZING AGENTS ‐ Drugs to Treat Skin Disorders
SILVER NITRA SOL 0.5%,10%,25%,50% (silver nitrate soln) Tier 3
TRI‐CHLOR LIQ 80% (trichloroacetic acid liqd) Tier 3
CENTRAL MUSCLE RELAXANTS ‐ Drugs for diseases and disorders of the muscles, ligaments, tendons and bones
AMRIX CAP 15MG,30MG (cyclobenzaprine hcl cap er) Tier 3
baclofen tab 10mg,20mg,5mg Tier 1
carisoprodol tab 250mg,350mg Tier 1
chlorzoxazon tab 375mg,500mg,750mg Tier 1
CHLORZOXAZON TAB 250MG (chlorzoxazone tab) Tier 3
cyclobenzapr cap 15mg er,30mg er Tier 1
cyclobenzapr tab 10mg,5mg,7.5mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 90 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
fexmid tab 10mg,5mg,7.5mg Tier 1
FEXMID TAB 7.5MG (cyclobenzaprine hcl tab) Tier 3
lorzone tab 375mg,500mg,750mg Tier 1
metaxalone tab 400mg,800mg Tier 1
methocarbam tab 500mg,750mg Tier 1
orphenadrine tab 100mg er Tier 1
OZOBAX SOL 5MG/5ML (baclofen oral soln) Tier 3
ROBAXIN‐750 TAB 750MG (methocarbamol tab) Tier 2
SKELAXIN TAB 800MG (metaxalone tab) Tier 2
SOMA TAB 250MG,350MG (carisoprodol tab) Tier 3
tizanidine cap 2mg,4mg,6mg Tier 1
tizanidine tab 2mg,4mg Tier 1
vanadom tab 250mg,350mg Tier 1
ZANAFLEX CAP 2MG,4MG,6MG (tizanidine hcl cap) Tier 3
ZANAFLEX TAB 4MG (tizanidine hcl tab) Tier 3
CENTRAL/PERIPHERAL COMT INHIBITORS ‐ Drugs to treat Parkinson's Disease
TASMAR TAB 100MG (tolcapone tab) Tier 3
tolcapone tab 100mg Tier 1
CEPHALOSPORINS ‐ 1ST GENERATION ‐ Antibiotics / Drugs for Infections
cefadroxil cap 500mg Tier 1
cefadroxil sus 250/5ml,500/5ml Tier 1
cefadroxil tab 1gm Tier 1
cephalexin cap 250mg,500mg,750mg Tier 1
cephalexin sus 125/5ml,250/5ml Tier 1
cephalexin tab 250mg,500mg Tier 1
KEFLEX CAP 250MG,500MG,750MG (cephalexin cap) Tier 3
CEPHALOSPORINS ‐ 2ND GENERATION ‐ Antibiotics / Drugs for Infections
cefaclor cap 250mg,500mg Tier 1
CEFACLOR ER TAB 500MG (cefaclor monohydrate tab er) Tier 3
cefaclor sus 125/5ml,250/5ml,375/5ml Tier 1
cefprozil sus 125/5ml,250/5ml Tier 1
cefprozil tab 250mg,500mg Tier 1
cefuroxime tab 250mg,500mg Tier 1
CEPHALOSPORINS ‐ 3RD GENERATION ‐ Antibiotics / Drugs for Infections
cefdinir cap 300mg Tier 1
cefdinir sus 125/5ml,250/5ml Tier 1
cefditoren tab 200mg,400mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 91 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
cefixime cap 400mg Tier 1
cefixime sus 100/5ml,200/5ml Tier 1
cefpodo prox sus 100/5ml,50mg/5ml Tier 1
cefpodoxime tab 100mg,200mg Tier 1
SPECTRACEF TAB 400MG (cefditoren pivoxil tab) Tier 3
SUPRAX CAP 400MG (cefixime cap) Tier 2
SUPRAX CHW 100MG,200MG (cefixime chew tab) Tier 2
SUPRAX SUS 100/5ML,200/5ML,500/5ML (cefixime for susp)
Tier 2
CERVICAL CAPS ‐ Diabetic Supplies and Needles
FEMCAP MIS 22MM,26MM,30MM (cervical cap) Tier 5 QL (1 unit per 1 day)
CFTR POTENTIATORS ‐ Drugs/Products to Help with Breathing
KALYDECO PAK 25MG,50MG,75MG (ivacaftor packet) Tier 3 PA; QL (2 units per 1 day)
KALYDECO TAB 150MG (ivacaftor tab) Tier 3 PA; QL (2 units per 1 day)
CGRP RECEPTOR ANTAGONISTS ‐ MONOCOLONAL ANTIBODIES ‐ Drugs to Treat Migraine Headaches
AIMOVIG INJ 140MG/ML,70MG/ML (erenumab‐aooe subcutaneous soln auto‐injector)
Tier 2
AJOVY INJ 225/1.5 (fremanezumab‐vfrm subcutaneous soln auto‐inj)
Tier 2
AJOVY INJ 225/1.5 (fremanezumab‐vfrm subcutaneous soln pref syr)
Tier 2
EMGALITY INJ 120MG/ML (galcanezumab‐gnlm subcutaneous soln auto‐injector)
Tier 2
EMGALITY INJ 120MG/ML (galcanezumab‐gnlm subcutaneous soln prefilled syr)
Tier 2
VYEPTI INJ 100MG/ML (eptinezumab‐jjmr iv soln) Tier 3
CHELATING AGENTS ‐ Miscellaneous Drugs and Solutions
Trientine Hydrochloride cap 25mg (Clovique) Tier 1
CUPRIMINE CAP 250MG (penicillamine cap) Tier 3
DEPEN TITRA TAB 250MG (penicillamine tab) Tier 3
penicillamin cap 250mg Tier 1
penicillamin tab 250mg Tier 1
SYPRINE CAP 250MG (trientine hcl cap) Tier 3
trientine cap 250mg Tier 1
CHLORINE ANTISEPTICS ‐ Drugs and Products to Prevent the Growth of Disease‐Causing Microorganisms
BENZALKONIUM SOL 50% (benzalkonium chloride soln) Tier 3
BENZALKONIUM SOL NF 50% (benzalkonium chloride soln) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 92 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CHLORHEX GLU SOL 0.12%,20% (chlorhexidine gluconate soln)
Tier 3
CHOLINOMIMETICS ‐ ACHE INHIBITORS ‐ Drugs for diseases and disorders of the nervous system
ARICEPT TAB 10MG,23MG,5MG (donepezil hydrochloride tab)
Tier 3
donepezil tab 10mg,10mg odt,5mg,5mg odt Tier 1
donepezil tab 10mg,10mg odt,5mg,5mg odt Tier 1
donepezil tab hcl 10mg,23mg,5mg Tier 1
donepezil tab odt 10mg,10mg odt,5mg,5mg odt Tier 1
EXELON DIS 13.3/24,4.6MG/24,9.5MG/24 (rivastigmine td patch)
Tier 3
galantamine cap 16mg er,24mg er,8mg er Tier 1
galantamine sol 4mg/ml Tier 1
galantamine tab 12mg,4mg,8mg Tier 1
RAZADYNE ER CAP 16MG,24MG,8MG (galantamine hydrobromide cap er)
Tier 3
RAZADYNE TAB 4MG (galantamine hydrobromide tab) Tier 3
rivastigmine cap 1.5mg,3mg,4.5mg,6mg Tier 1
rivastigmine dis 13.3/24,4.6mg/24,9.5mg/24 Tier 1
CIC AGENTS ‐ GUANYLATE CYCLASE‐C (GC‐C) AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
TRULANCE TAB 3MG (plecanatide tab) Tier 3
CITRATES ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
Potassium Citrate/Citric Acid crystals (Cytra K Crystals) Tier 1
k citrate sol citr acd Tier 1
k/na citrate sol citr acd Tier 1
ORACIT SOL (sodium citrate & citric acid soln) Tier 3
pot citrate tab 1080mg,1620mg,540mg er Tier 1
sod citrate sol citr acd Tier 1
taron gra crystals Tier 1
tricitrates sol Tier 1
UROCIT‐K 10 TAB,15 TAB,5 TAB (potassium citrate tab er) Tier 2
CLARITHROMYCIN ‐ Antibiotics / Drugs for Infections
BIAXIN XL TAB 500,500MG (clarithromycin tab er) Tier 3
BIAXIN XL TAB PAC 500,500MG (clarithromycin tab er) Tier 3
clarithromyc sus 125/5ml,250/5ml Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 93 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
clarithromyc tab 250mg,500mg Tier 1
clarithromyc tab 250mg,500mg Tier 1
CMV AGENTS ‐ Drugs to Treat Viral Infections
PREVYMIS TAB 240MG,480MG (letermovir tab) Tier 3
VALCYTE SOL 50MG/ML (valganciclovir hcl for soln) Tier 3 QL (35 units per 1 day)
VALCYTE TAB 450MG (valganciclovir hcl tab) Tier 3 QL (3.4 units per 1 day)
valganciclov sol 50mg/ml Tier 1 QL (35 units per 1 day)
valganciclov tab 450mg Tier 1 QL (3.4 units per 1 day)
COBALAMINS ‐ Drugs to Treat Blood Disorders
cyanocobalam inj 1000mcg Tier 1
CYANOCOBALAM SOL 2000MCG (cyanocobalamin inj) Tier 3
hydroxocobal inj 1000mcg Tier 1
METHYLCOBALA INJ 10000MCG,50000MCG (methylcobalamin for inj)
Tier 3
METHYLCOBALA INJ 10000MCG,50000MCG (methylcobalamin inj)
Tier 3
NASCOBAL SPR 500MCG (cyanocobalamin nasal spray) Tier 3
CODEINE COMBINATIONS ‐ Drugs for Treatment of Pain
apap/codeine sol 120‐12/5 Tier 1 PA; QL (75 days;8100 units)
apap/codeine tab 300‐15mg,300‐30mg,300‐60mg,30‐300mg,60‐300mg
Tier 1 PA; QL (75 days;1080 tablets)
butalbital/aspirin/caffeine/codeine phosphate cap 30mg (Ascomp/codeine)
Tier 1 QL (75 days;144 capsules)
but/apap/caf cap codeine Tier 1 QL (75 days;144 capsules)
but/asa/caf/ cap cod 30mg Tier 1 QL (75 days;144 capsules)
but/asa/caf/ cap codeine 30mg Tier 1 QL (75 days;144 capsules)
codeine/apap tab 300‐15mg,300‐30mg,300‐60mg,30‐300mg,60‐300mg
Tier 1 PA; QL (75 days;540 tablets)
FIORICET CAP CODEINE (butalbital‐acetaminophen‐caff w/ cod cap)
Tier 3 QL (75 days;144 capsules)
FIORINAL/COD CAP 30MG (butalbital‐aspirin‐caff w/ codeine cap)
Tier 3 QL (75 days;144 capsules)
TYLENOL/COD TAB # 3 (acetaminophen w/ codeine tab) Tier 3 PA; QL (75 days;1080 tablets)
COMBINATION CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Afirmelle)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Altavera)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 1/35 (Alyacen 1/35) Tier 5 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 94 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
desogestrel & ethinyl estradiol tab (Apri) Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Aubra Eq)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Aubra)
Tier 5 QL (1 unit per 1 day)
norethindrone ace‐ethinyl estradiol‐fe tab ,24 tab 1/20,24 tab fe,24 tab fe 1/20 (Aurovela 24 Fe)
norethindrone ace & ethinyl estradiol‐fe tab 1/20 (Aurovela Fe 1/20)
Tier 5
norethindrone ace & ethinyl estradiol tab 1.5/30,1.5/30 tab,1/20,1/20 tab (Aurovela)
Tier 5
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Aviane)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Ayuna)
Tier 5 QL (1 unit per 1 day)
BALCOLTRA TAB 0.1‐20 (levonorgestrel‐ethinyl estradiol‐fe tab)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 0.4‐35,0.5/35,1/35 (Balziva)
Tier 5 QL (1 unit per 1 day)
BEYAZ TAB (drospirenone‐ethinyl estrad‐levomefolate tab) Tier 5 QL (1 unit per 1 day)
norethindrone ace‐ethinyl estradiol‐fe tab 24 tab 1/20,24 tab fe,24 tab fe 1/20 (Blisovi 24 Fe)
Tier 5 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol‐fe tab 1.5/30,1/20,1/20 eq (Blisovi Fe)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 0.4‐35,0.5/35,1/35 (Briellyn)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab eq 0.1‐0.02,0.1‐20,0.15/30 (Chateal Eq)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Chateal)
Tier 5 QL (1 unit per 1 day)
norgestrel & ethinyl estradiol tab 28 tabs (Cryselle‐28) Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 1/35 tab 1/35 (Cyclafem 1/35)
Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol eq tab (Cyred Eq) Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab (Cyred) Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 1/35 (Dasetta 1/35) Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Delyla)
Tier 5 QL (1 unit per 1 day)
desogest‐eth estrad & eth estrad tab 28 day Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estrad‐levomefolate tab Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 3‐0.02mg,‐0.03mg Tier 5 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 95 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
drospirenone‐ethinyl estrad‐levomefolate tab Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 3‐0.02mg,3‐0.03mg Tier 5 QL (1 unit per 1 day)
norgestrel & ethinyl estradiol 28 tabs (Elinest) Tier 5 QL (1 unit per 1 day)
EMOQUETTE TAB (desogestrel & ethinyl estradiol tab) Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab (Enskyce) Tier 5 QL (1 unit per 1 day)
norgestimate & ethinyl estradiol tab 0.25/35,0.25‐35,28 tab 28 day (Estarylla)
Tier 5 QL (1 unit per 1 day)
ethinyl estradiol & ethynodiol diacetate tab 1/35,1/35E,1/50,1‐35,1‐50
Tier 5 QL (1 unit per 1 day)
ethynodiol diacetate & ethinyl estradiol tab 1/35,1/35E,1/50,1‐35,1‐50
Tier 5 QL (1 unit per 1 day)
FALESSA KIT (*levonorgest‐eth estrad tab) Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Falmina)
Tier 5 QL (1 unit per 1 day)
norgestimate & ethinyl estradiol tab 0.25/35,0.25‐35,28 tab 28 day (Femynor)
Tier 5 QL (1 unit per 1 day)
GENERESS FE CHW (norethindrone & ethinyl estradiol‐fe chew tab)
Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 3‐0.02mg,3‐0.03mg (Gianvi)
Tier 5 QL (1 unit per 1 day)
norethindrone ace‐ethinyl estradiol‐fe tab 24 (Hailey 24 Fe) Tier 5 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol tab 1.5/30,1/20 (Hailey Fe 1.5/30)
Tier 1 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol 1.5/30 tab (Hailey 1.5/30)
Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab (Isibloom) Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab (Jasmiel) Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab (Juleber) Tier 5 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol 1.5/30,1.5/30 tab,1/20,1/20 tab (Junel 1.5/30)
Tier 5 QL (1 unit per 1 day)
norethindrone ace‐ethinyl estradiol‐fe tab 1/20,24 tab fe,24 tab fe 1/20 (Junel Fe 24)
Tier 5 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol‐fe tab 1.5/30,1/20,1/20 eq (Junel FE)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol‐fe chew tab 0.4mg‐35 (Kaitlib Fe)
Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab (Kalliga) Tier 5 QL (1 unit per 1 day)
ethynodiol diacetate & ethinyl estradiol tab 1/35, 1/50 (Kelnor 1/35)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Kurvelo)
Tier 5 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 96 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
norethindrone ace‐ethinyl estradiol‐fe tab 1.5/30,tab fe 1/20 (Larin 24 FE)
Tier 5 QL (1 unit per 1 day)
LARIN FE TAB 1.5/30,1/20,1/20 EQ (norethindrone ace & ethinyl estradiol‐fe tab)
Tier 5 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol tab 1.5/30,1.5/30 tab,1/20,1/20 tab (Larin)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Larissia)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol‐fe chew tab chw 0.4mg‐35 (Layolis Fe)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Lessina)
Tier 5 QL (1 unit per 1 day)
levonorgestrel‐eth estra tab 0.1‐0.02,0.1‐20,0.15/30 Tier 5 QL (1 unit per 1 day)
levonor‐eth esttadio Tier 5 QL (91 days supply)
levonorgestrel & ethinyl estradiol tab 0.15/30‐28 (Levora 0.15/30‐28)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Lillow)
Tier 5 QL (1 unit per 1 day)
LOESTRIN 1/20‐21,21 TAB 1.5/30 (norethindrone ace & ethinyl estradiol tab)
Tier 5 QL (1 unit per 1 day)
LOESTRIN FE TAB 1.5/30,1/20 (norethindrone ace & ethinyl estradiol‐fe tab)
Tier 5 QL (1 unit per 1 day)
LOESTRIN TAB 1/20‐21,21 TAB 1.5/30 (norethindrone ace & ethinyl estradiol tab)
Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 3‐0.02mg,3‐0.03mg (Loryna)
Tier 5 QL (1 unit per 1 day)
norgestrel & ethinyl estradiol tab 28 tabs (Low‐ogestrel) Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 3‐0.02mg,3‐0.03mg (Lo‐zumandimine)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Lutera)
Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Marlissa)
Tier 5 QL (1 unit per 1 day)
norethindrone ace‐eth estradiol‐fe chew tab (Melodetta 24 Fe)
Tier 5 QL (1 unit per 1 day)
norethindrone ace‐eth estradiol‐fe chew tab 24 fe chw (Mibelas 24 Fe)
Tier 5 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol tab 1.5/30 tab, 1/20 tab (Microgestin 1.5/30)
Tier 5 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol‐fe 1.5/30 tab (Microgestin Fe 1.5/30)
Tier 5 QL (1 unit per 1 day)
norgestimate & ethinyl estradiol tab 0.25/35,0.25‐35,28 tab 28 day (Mili)
Tier 5 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 97 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MINASTRIN 24 CHW FE (norethindrone ace‐eth estradiol‐fe chew tab)
Tier 5 QL (1 unit per 1 day)
norgestimate & ethinyl estradiol tab 0.25/35,0.25‐35,28 tab 28 day (Mono‐linyah)
Tier 5 QL (1 unit per 1 day)
MONONESSA TAB 0.25/35,0.25‐35,28 TAB 28 DAY (norgestimate & ethinyl estradiol tab)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 0.4‐35,0.5/35,1/35 (Necon)
Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 3‐0.02mg,3‐0.03mg (Nikki)
Tier 5 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol‐fe tab 1.5/30,1/20,1/20
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol‐fe chew tab 0.4mg‐35 Tier 5 QL (1 unit per 1 day)
norethindrone ace‐eth estradiol‐fe chew tab 0.4mg‐35 Tier 5 QL (1 unit per 1 day)
norethindrone ace‐eth estradiol‐fe chew tab 0.4mg‐35 Tier 5 QL (1 unit per 1 day)
norethindrone acetate‐ethinyl estradiol tab 1.5/30,1.5/30 tab ,1/20,1/20 tab
Tier 5
norethindrone ace & ethinyl estradiol‐fe tab 1.5/30,1/20,1/20 eq
Tier 5 QL (1 unit per 1 day)
norgestimate & ethinyl estradiol tab 0.25/35,0.25‐35,28 tab 28 day
Tier 5 QL (1 unit per 1 day)
NORTREL TAB 0.4‐35,0.5/35,1/35 (norethindrone & ethinyl estradiol tab)
Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 3‐0.02mg,3‐0.03mg (Ocella)
Tier 5 QL (1 unit per 1 day)
ORSYTHIA TAB 0.1‐0.02,0.1‐20,0.15/30 (levonorgestrel & ethinyl estradiol tab)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 0.4‐35,0.5/35,1/35 (Philith)
Tier 5 QL (1 unit per 1 day)
norethindrone‐eth estradiol tab 1/35 (Pirmella 1/35) Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol 28 tab 0.1‐0.02,0.1‐20,0.15/30 (Portia‐28)
Tier 5 QL (1 unit per 1 day)
norgestimate & ethinyl estradiol tab 0.25/35,0.25‐35,28 tab 28 day (Previfem)
Tier 5 QL (1 unit per 1 day)
desogestrel & ethinyl estradiol tab (Reclipsen) Tier 5 QL (1 unit per 1 day)
SAFYRAL TAB (drospirenone‐ethinyl estrad‐levomefolate tab)
Tier 5 QL (1 unit per 1 day)
SOLIA TAB (desogestrel & ethinyl estradiol tab) Tier 5 QL (1 unit per 1 day)
norgestimate & ethinyl estradiol 28 tab (Sprintec 28) Tier 5 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 98 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Sronyx)
Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 3‐0.02mg,3‐0.03mg (Syeda)
Tier 5 QL (1 unit per 1 day)
norethindrone ace‐ethinyl estradiol‐fe tab , 24 tab fe 1/20 (Tarina 24 Fe)
Tier 5 QL (1 unit per 1 day)
norethindrone ace & ethinyl estradiol‐fe 1/20 eq tab (Tarina Fe 1/20 Eq)
Tier 5 QL (1 unit per 1 day)
TAYTULLA CAP 1MG/20MC (norethindrone ace‐ethinyl estradiol‐fe cap)
Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estrad‐levomefolate tab (Tydemy) Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30 (Vienva)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 0.4‐35,0.5/35,1/35 (Vyfemla)
Tier 5 QL (1 unit per 1 day)
VYLIBRA TAB 0.25/35,0.25‐35,28 TAB 28 DAY (norgestimate & ethinyl estradiol tab)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 0.25/35,0.25‐35,28 tab 28 day (Vyfemla)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 0.4‐35,0.5/35,1/35 (Wera)
Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol‐fe chew tab 0.4mg‐35 (Wymzya Fe)
Tier 5 QL (1 unit per 1 day)
YASMIN 28 TAB 3‐0.03MG,3‐0.02MG (drospirenone‐ethinyl estradiol tab)
Tier 5 QL (1 unit per 1 day)
YAZ TAB 28 TAB 3‐0.03MG,3‐0.02MG (drospirenone‐ethinyl estradiol tab)
Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 0.02mg,3‐0.03mg (Zarah) Tier 5 QL (1 unit per 1 day)
ethynodiol diacetate & ethinyl estradiol 1/35e tab (Zovia 1/35e)
Tier 5 QL (1 unit per 1 day)
drospirenone‐ethinyl estradiol tab 3‐0.02mg,3‐0.03mg (Zumandimine)
Tier 5 QL (1 unit per 1 day)
COMBINATION CONTRACEPTIVES ‐ TRANSDERMAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
norelgestromin‐ethinyl estradiol td ptwk150‐35 (Xulane) Tier 5 QL (1 unit per 1 day)
COMBINATION CONTRACEPTIVES ‐ VAGINAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
ANNOVERA MIS (segesterone ace‐ethinyl estradiol va ring) Tier 5 QL (1 unit per 1 day)
ELURYNG MIS (etonogestrel‐ethinyl estradiol va ring) Tier 5 QL (1 unit per 1 day)
etonogestrel‐ethinyl estradiol va ring Tier 5 QL (1 unit per 1 day)
NUVARING MIS (etonogestrel‐ethinyl estradiol va ring) Tier 5 QL (1 unit per 1 day)
COMPLEMENT INHIBITORS ‐ Drugs to Treat Blood Disorders
SOLIRIS INJ 10MG/ML (eculizumab iv soln) Tier 2 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 99 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ULTOMIRIS INJ 300/30ML (ravulizumab‐cwvz iv soln) Tier 4 PA; SP; QL (34 days supply)
CONTINUOUS CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
levonorgestrel‐ethinyl estradiol (continuous) tab 90‐20mcg (Amethyst)
Tier 5 QL (1 unit per 1 day)
levonorgestrel‐ethinyl estradiol (continuous) tab 90‐20mcg Tier 5 QL (1 unit per 1 day)
COPPER CONTRACEPTIVES ‐ IUD ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
PARAGARD IUD T 380A (*copper iud**) Tier 3
CORTICOSTEROIDS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
ALA SCALP LOT 2% (hydrocortisone lotion) Tier 3
hydrocortisone cre 1%,2.5% (Ala‐cort) Tier 1
alclometason cre 0.05% Tier 1
alclometason oin 0.05% Tier 1
amcinonide cre 0.1% Tier 1
amcinonide lot 0.1% Tier 1
AMCINONIDE OIN 0.1% (amcinonide oint) Tier 3
APEXICON E CRE 0.05% (diflorasone diacetate emollient base cream)
Tier 3
aug betamet cre 0.05% Tier 1
aug betamet gel 0.05% Tier 1
aug betamet lot 0.05% Tier 1
aug betamet oin 0.05% Tier 1
betamethasone lot 0.05% (Beser) Tier 1
betameth dip cre 0.05% Tier 1
betameth dip lot 0.05% Tier 1
betameth dip oin 0.05% Tier 1
betameth val aer 0.12% Tier 1
betameth val cre 0.1% Tier 1
betameth val lot 0.1% Tier 1
betameth val oin 0.1% Tier 1
BRYHALI LOT 0.01% (halobetasol propionate lotion) Tier 2
CAPEX SHA 0.01% (fluocinolone acetonide shampoo) Tier 2
clobetasol aer 0.05% Tier 1
clobetasol aer 0.05% Tier 1
clobetasol cre 0.05% Tier 1
clobetasol e cre 0.05% Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 100 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
clobetasol gel 0.05% Tier 1
clobetasol lot 0.05% Tier 1
clobetasol oin 0.05% Tier 1
clobetasol sha 0.05% Tier 1
clobetasol sol 0.05% Tier 1
clobetasol spr 0.05% Tier 1
CLOBEX LOT 0.05% (clobetasol propionate lotion) Tier 2
CLOBEX SHA 0.05% (clobetasol propionate shampoo) Tier 2
CLOBEX SPR 0.05% (clobetasol propionate spray) Tier 3
clocortolone cre 0.1% Tier 1
Clobetasol Propionate sha 0.05% (Clodan) Tier 1
CLODERM CRE 0.1% (clocortolone pivalate cream) Tier 3
CORDRAN 80X3 TAP 4MCG/CM (flurandrenolide tape) Tier 3
CORDRAN CRE 0.025%,0.05% (flurandrenolide cream) Tier 3
CORDRAN LOT 0.05% (flurandrenolide lotion) Tier 3
CORDRAN OIN 0.05% (flurandrenolide oint) Tier 3
CUTIVATE LOT 0.05% (fluticasone propionate lotion) Tier 3
DERMA‐SMOOTH OIL /FS BODY (fluocinolone acetonide oil) Tier 2
DERMA‐SMOOTH OIL /FS SCLP (fluocinolone acetonide oil) Tier 2
DESONATE GEL 0.05% (desonide gel) Tier 3
desonide cre 0.05% Tier 1
desonide gel 0.05% Tier 1
desonide lot 0.05% Tier 1
desonide oin 0.05% Tier 1
DESOWEN CRE 0.05% (desonide cream) Tier 2
desoximetas cre 0.05%,0.25% Tier 1
desoximetas gel 0.05% Tier 1
desoximetas oin 0.05%,0.25% Tier 1
desoximetaso spr 0.25% Tier 1
diflorasone cre 0.05% Tier 1
diflorasone oin 0.05% Tier 1
DIPROLENE AF CRE 0.05% (betamethasone dipropionate augmented cream)
Tier 3
DIPROLENE OIN 0.05% (betamethasone dipropionate augmented oint)
Tier 2
fluocin acet cre 0.01%,0.025% Tier 1
fluocin acet oil 0.01% Tier 1
fluocin acet oil body 0.01% sc,0.01%bdy Tier 1
fluocin acet oil scalp 0.01% sc,0.01%bdy Tier 1
fluocin acet oin 0.025% Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 101 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
fluocin acet sol 0.01% Tier 1
fluocinonide cre 0.05%,0.1% Tier 1
fluocinonide cre e 0.05% Tier 1
fluocinonide gel 0.05% Tier 1
fluocinonide oin 0.05% Tier 1
fluocinonide sol 0.05% Tier 1
flurandrenol cre 0.05% Tier 1
flurandrenol lot 0.05% Tier 1
flurandrenol oin 0.05% Tier 1
fluticasone cre 0.05% Tier 1
fluticasone lot 0.05% Tier 1
fluticasone oin 0.005% Tier 1
halcinonide cre 0.1% Tier 1
HALOBETASOL AER 0.05% (halobetasol propionate foam) Tier 3
halobetasol cre 0.05% Tier 1
halobetasol oin 0.05% Tier 1
HALOG CRE 0.1% (halcinonide cream) Tier 3
HALOG OIN 0.1% (halcinonide oint) Tier 3
HALOG SOL 0.1% (halcinonide soln) Tier 3
hc butyrate cre 0.1% Tier 1
hc butyrate cre 0.1% Tier 1
hc butyrate oin 0.1% Tier 1
hc butyrate sol 0.1% Tier 1
hc valerate cre 0.2% Tier 1
hc valerate oin 0.2% Tier 1
hydrocort cre 1%,2.5% Tier 1
hydrocort lot 2.5% Tier 1
hydrocort oin 1%,2.5% Tier 1
hydrocortiso lot 0.1% Tier 1
IMPOYZ CRE 0.025%,0.05% (clobetasol propionate cream) Tier 3
KENALOG AER SPRAY (triamcinolone acetonide aerosol soln)
Tier 3
LEXETTE AER 0.05% (halobetasol propionate foam) Tier 3
LOCOID LIPO CRE 0.1% (hydrocortisone butyrate hydrophilic lipo base cream)
Tier 3
LOCOID LOT 0.1% (hydrocortisone butyrate lotion) Tier 3
LUXIQ AER 0.12% (betamethasone valerate aerosol foam) Tier 3
mometasone cre 0.1% Tier 1
mometasone oin 0.1% Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 102 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
mometasone sol 0.1% Tier 1
nolix cre 0.05% Tier 1
Flurandrenolide topical cre 0.05% (Nolix) Tier 1
Flurandrenolide topical lot 0.05% Tier 1
NUCORT LOT 2% (hydrocortisone acetate lotion) Tier 3
OLUX AER 0.05% (clobetasol propionate foam) Tier 3
OLUX‐E AER 0.05% (clobetasol propionate emulsion foam) Tier 3
PANDEL CRE 0.1% (hydrocortisone probutate cream) Tier 3
prednicarbat cre 0.1% Tier 1
prednicarbat oin 0.1% Tier 1
PSORCON CRE 0.05% (diflorasone diacetate cream) Tier 3
SERNIVO SPR 0.05% (betamethasone dipropionate spray emulsion)
Tier 3
SYNALAR CRE 0.025% (fluocinolone acetonide cream) Tier 3
SYNALAR OIN 0.025% (fluocinolone acetonide oint) Tier 3
SYNALAR SOL 0.01% (fluocinolone acetonide soln) Tier 2
SYNALAR SOL 0.01% (fluocinolone acetonide soln) Tier 3
TEMOVATE CRE 0.05% (clobetasol propionate cream) Tier 2
TEMOVATE CRE 0.025%,0.05% (clobetasol propionate cream)
Tier 3
TEMOVATE OIN 0.05% (clobetasol propionate oint) Tier 2
TEXACORT SOL 2.5% (hydrocortisone soln) Tier 2
TOPICORT CRE 0.05%,0.25% (desoximetasone cream) Tier 3
TOPICORT GEL 0.05% (desoximetasone gel) Tier 3
TOPICORT OIN 0.05%,0.25% (desoximetasone oint) Tier 3
TOPICORT SPR 0.25% (desoximetasone spray) Tier 3
clobetasol propionate topical aer 0.05% (Tovet) Tier 1
triamcinolon aer spray Tier 1
triamcinolon cre 0.025%,0.1%,0.5% Tier 1
triamcinolon lot 0.025%,0.1% Tier 1
triamcinolon oin 0.025%,0.05%,0.1%,0.5% Tier 1
trianex oin 0.025%,0.05%,0.1%,0.5% Tier 1
triamcinolone acetonide topical cre 0.025%,0.1%,0.5% (Triderm)
Tier 1
TRIDESILON CRE 0.05% (desonide cream) Tier 2
ULTRAVATE LOT 0.05% (halobetasol propionate lotion) Tier 3
VANOS CRE 0.1% (fluocinonide cream) Tier 3
VERDESO AER 0.05% (desonide foam) Tier 3
CORTICOTROPIN ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 103 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ACTHAR INJ 80UNIT (corticotropin inj gel) Tier 4 PA; SP; QL (34 days supply)
CORTISOL SYNTHESIS INHIBITORS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
ISTURISA TAB 10MG,1MG,5MG (osilodrostat phosphate tab)
Tier 3 PA; QL (8 units per 1 day)
COUMARIN ANTICOAGULANTS ‐ Drugs to Treat Blood Clots
COUMADIN TAB 1MG,2.5MG,5MG,6MG,7.5MG (warfarin sodium tab)
Tier 3
warfarin sodium oral tab 10mg,1mg,2.5mg,2mg,3mg,4mg,5mg,6mg,7.5mg (Jantoven)
Tier 1
warfarin tab 10mg,1mg,2.5mg,2mg,3mg,4mg,5mg,6mg,7.5mg
Tier 1
CXCR4 RECEPTOR ANTAGONIST ‐ Drugs to Treat Blood Disorders
MOZOBIL INJ (plerixafor subcutaneous inj) Tier 2 PA; SP; QL (34 days supply)
CYCLIN‐DEPENDENT KINASES (CDK) INHIBITORS ‐ Drugs for Treatment of Cancer
IBRANCE CAP 100MG,125MG,75MG (palbociclib cap) Tier 2 PA; SP; QL (34 days supply); OCA
IBRANCE TAB 100MG,125MG,75MG (palbociclib tab) Tier 2 PA; SP; QL (34 days supply); OCA
KISQALI TAB 200DOSE,400DOSE,600DOSE (ribociclib succinate tab pack)
Tier 2 PA; SP; QL (34 days supply)
VERZENIO TAB 100MG,150MG,200MG,50MG (abemaciclib tab)
Tier 4 PA; SP; QL (34 days supply)
CYCLOOXYGENASE 2 (COX‐2) INHIBITORS ‐ Drugs to Treat Pain and Inflammation
CELEBREX CAP 100MG,200MG,400MG,50MG (celecoxib cap)
Tier 3
celecoxib cap 100mg,200mg,400mg,50mg Tier 1
CYCLOPLEGIC MYDRIATIC COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes
CYCLOMYDRIL SOL OP (cyclopentolate w/ phenylephrine ophth soln)
Tier 3
TROP‐CYC‐PE DRO 1‐1‐2.5 (tropicamide‐cyclopentolate‐phenylephrine ophth soln)
Tier 3
TROP‐PHENYL SOL 1‐2.5% (tropicamide w/ phenylephrine ophth soln)
Tier 3
TROP‐PROP‐PE DRO KETO (tropicamide‐proparaca‐pe‐ketorolac ophth soln)
Tier 3
CYCLOPLEGIC MYDRIATICS ‐ Drugs for Treatment of Disorders in the Eyes
altafrin sol 10% op,2.5% op Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 104 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ATROPINE SUL OIN 1% OP (atropine sulfate ophth oint) Tier 3
ATROPINE SUL SOL 0.01%,1% OP (atropine sulfate ophth soln)
Tier 3
CYCLOGYL SOL 0.5% OP,1% OP,2% OP (cyclopentolate hcl ophth soln)
Tier 3
cyclopentol sol 0.5%,1% op,2% op Tier 1
cyclopentola sol 0.5%,1% op,2% op Tier 1
homatropaire sol 5% op Tier 1
ISOPTO ATROP SOL 0.01%,1% OP (atropine sulfate ophth soln)
Tier 3
MYDRIACYL SOL 1% OP (tropicamide ophth soln) Tier 3
phenylephrin sol 10% op,2.5% op Tier 1
tropicamide sol 0.5% op,1% op Tier 1
CYCLOSPORINE ANALOGS ‐ Miscellaneous Drugs and Solutions
cyclosporine cap 100mg,25mg Tier 1
cyclosporine cap 100mg,25mg Tier 1
cyclosporine inj 50mg/ml Tier 1
cyclosporine sol modified 100mg/ml Tier 1
gengraf cap 100mg,100mg md,25mg,25mg mod,50mg mod Tier 1
gengraf sol 100mg/ml Tier 1
NEORAL CAP 100MG,25MG (cyclosporine modified cap) Tier 3
NEORAL SOL 100MG/ML (cyclosporine modified oral soln) Tier 3
SANDIMMUNE CAP 100MG,25MG (cyclosporine cap) Tier 3
SANDIMMUNE INJ 50MG/ML (cyclosporine iv soln) Tier 3
SANDIMMUNE SOL 100MG/ML (cyclosporine oral soln) Tier 3
CYSTIC FIBROSIS AGENT ‐ COMBINATIONS ‐ Drugs/Products to Help with Breathing
ORKAMBI GRA 100‐125,150‐188 (lumacaftor‐ivacaftor granules packet)
Tier 3 PA; QL (2 units per 1 day)
ORKAMBI TAB 100‐125,200‐125 (lumacaftor‐ivacaftor tab) Tier 3 PA; QL (4 units per 1 day)
SYMDEKO TAB 100‐150,50‐75MG (tezacaftor‐ivacaftor) Tier 3 PA; QL (2 units per 1 day)
TRIKAFTA TAB (elexacaf‐tezacaf‐ivacaf) Tier 3 PA; QL (3 units per 1 day)
CYSTINOSIS AGENTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
CYSTAGON CAP 150MG,50MG (cysteamine bitartrate cap) Tier 4 PA; SP; QL (34 days supply)
PROCYSBI CAP 25MG,75MG (cysteamine bitartrate cap delayed release)
Tier 3 PA; QL (25 units per 1 day)
PROCYSBI GRA 300MG,75MG (cysteamine bitartrate delayed release granules packet)
Tier 3 PA; QL (6 units per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 105 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CYTOTOXIC AGENTS ‐ Drugs to Treat Blood Disorders
DROXIA CAP 200MG,300MG,400MG (hydroxyurea cap) Tier 3 OAC
SIKLOS TAB 1000MG,100MG (hydroxyurea tab) Tier 3 OAC
DECARBOXYLASE INHIBITORS ‐ Drugs to treat Parkinson's Disease
carbidopa tab 25mg Tier 1
LODOSYN TAB 25MG (carbidopa tab) Tier 3
DECONGESTANT & ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies
CLARINEX‐D TAB 2.5‐120 (desloratadine & pseudoephedrine tab er)
Tier 3
prometh/pe syp 6.25‐5/5 Tier 1
SEMPREX‐D CAP 8‐60MG (acrivastine & pseudoephedrine cap)
Tier 3
DECONGESTANT W/ EXPECTORANT ‐ Drugs to Treat Cough / Cold / Allergies
GILPHEX TR TAB 10‐388MG (phenylephrine‐guaifenesin tab) Tier 3
DIABETIC OTHER ‐ Drugs to treat Diabetes
BAQSIMI ONE POW 3MG/DOSE (glucagon nasal powder) Tier 2
BAQSIMI TWO POW 3MG/DOSE (glucagon nasal powder) Tier 2
diazoxide sus 50mg/ml Tier 1
GLUCAGEN INJ HYPOKIT (glucagon hcl (rdna) for inj) Tier 2
GLUCAGON EMR SOL 1MG (glucagon hcl for inj) Tier 3
GLUCAGON KIT 1MG (glucagon (rdna) for inj kit) Tier 2
GVOKE HYPO 1 INJ .5/.1ML,1 INJ 1MG/.2ML,2 INJ .5/.1ML,2 INJ 1MG/.2ML (glucagon subcutaneous solution auto‐injector)
Tier 2
GVOKE PFS INJ (glucagon subcutaneous soln pref syringe) Tier 2
PROGLYCEM SUS 50MG/ML (diazoxide susp) Tier 3
DIAGNOSTIC DRUGS ‐ Products for Testing
ARIDOL KIT (mannitol (diagnostic) inhalation powder capsule kit)
Tier 3
CYSVIEW INJ 100MG (hexaminolevulinate hcl for soln) Tier 3
D‐XYLOSE POW (d‐xylose powder) Tier 3
GLEOLAN SOL 1500MG (aminolevulinic acid hcl for oral solution)
Tier 3
MACRILEN PAK 60MG (macimorelin acetate pack for oral soln)
Tier 3
METOPIRONE CAP 250MG (metyrapone cap) Tier 3
PROVOCHOLINE SOL 100MG (methacholine chloride inhal for soln)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 106 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
DIAGNOSTIC RADIOPHARMACEUTICALS ‐ GASES ‐ Products for Testing
XENON XE 133 GAS 10MCI,133 GAS 20MCI (xenon xe) Tier 3
DIAGNOSTIC RADIOPHARMACEUTICALS ‐ MISCELLANEOUS ‐ Products for Testing
SULFUR COLLO KIT 99M (technetium tc) Tier 3
TECHNELITE KIT HEU 99M (technetium tc) Tier 3
TECHNELITE KIT LEU 99M (technetium tc) Tier 3
DIAGNOSTIC SUPPLIES ‐ Products for Testing
CERVICAL MIS SPECIMEN (*cervical specimen collection ‐ swab***)
Tier 3
DIAGNOSTIC TESTS ‐ Products for Testing
12‐PANEL POC KIT TOXICOLO (*drug assay (urine) test kit**)
Tier 3
ACCU‐CHEK TES AVIVA PL (glucose blood test strip) Tier 2
ACCU‐CHEK TES COMPACT (glucose blood test strip) Tier 2
ACCU‐CHEK TES GUIDE (glucose blood test strip) Tier 2
ACCU‐CHEK TES GUIDE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ACCU‐CHEK TES SMART (glucose blood test strip) Tier 2
ACCUTREND TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ADVANCE TES INTUITIO 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ADVANCE TES MICRO‐DW 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 107 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ADVOCATE TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ADVOCATE TES REDI‐COD 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ADVOCATE TES REDICODE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
AGAMATRIX TES AMP 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
AGAMATRIX TES JAZZ 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
AGAMATRIX TES KEYNOTE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
AGAMATRIX TES PRESTO 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 108 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ASSURE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ASSURE II TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ASSURE II TES CHECK 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ASSURE PRISM TES MULTI 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ASSURE PRO TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ASSURE TES PLATINUM 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
AUTOCODE TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 109 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
BIOSCANNER TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
BLOOD GLUCOS TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
BLOOD GLUCOS TES LE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
BLOOD GLUCOS TES PREMIUM 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
BLOOD GLUCOS TES STRIPS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CARESENS N TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CARETOUCH MIS TST STRP 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CHEMSTRIP K TES (acetone (urine) test strip) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 110 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CLEVER CHEK TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CLEVER CHEK TES AUTO CD 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CLEVER CHEK TES TALK 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CLEVER CHEK TES VOICE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CLEVER CHOIC TES MICRO 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CLEVR CHOICE TES AUTO‐CD 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CLEVR CHOICE TES NOCODE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 111 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CONFIRM/MICR TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CONTOUR TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CONTOUR TES NEXT 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
COOL BLOOD TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CVS ADVANCED TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
CVS GLUCOSE TES TEST STR 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
D‐CARE BLOOD TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
DIASTIX TES STRIPS (glucose urine test‐(glucose oxidase) strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 112 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
DIATHRIVE MIS TEST STR 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
DIATRUE PLUS TES STRIPS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
DUO‐CARE TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASY PLUS II TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASY STEP TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASY TALK TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASY TOUCH TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 113 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
EASY TOUCH TES STRIPS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASY TRAK II TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASY TRAK TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASYGLUCO TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASYGLUCO TES PLUS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASYMAX 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASYMAX TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 114 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
EASYPRO PLUS TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EASYPRO TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ELEMENT TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ELEMNT COMPA TES STRIPS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EMBRACE EVO TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EMBRACE PRO TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EMBRACE TALK TES STRIPS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 115 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
EMBRACE TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EVENCARE + TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EVENCARE G 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EVENCARE TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EVENCARE TES MINI 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EVENCARE TES PROVIEW 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EVOLUTION TES AUTOCODE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 116 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
EXACTECH TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EXACTECH TES R‐S‐G 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EZ SMART PLS TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
EZ SMART TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FIFTY50 GLUC TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FORA BLOOD TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FORA D 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 117 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
FORA G 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FORA GD 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FORA GTEL TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FORA GTEL TES KETONE (ketone blood test strip) Tier 3
FORA TN'G TES TN'G VOI 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FORA V 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FORACARE TES GD 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FORACARE TES PREM V 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 118 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
FORACARE TES TST N GO 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FORTISCARE TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FREESTYLE TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FREESTYLE TES INSULINX 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FREESTYLE TES LITE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
FREESTYLE TES PREC NEO 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GE100 BLOOD TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 119 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
GENULTIMATE TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GHT TEST TES STRIPS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GLUCO PERFEC TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GLUCOCARD 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GLUCOCARD TES EXPRESSI 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GLUCOCARD TES SHINE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GLUCOCARD TES VITAL 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 120 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
GLUCOCARD TES X‐SENSOR 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GLUCOCOM TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GLUCONAVII TES STRIPS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GLUCOSE TES STRIPS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GOJJI BLOOD TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
GOJJI BLOOD TES KETONE (ketone blood test strip) Tier 3
GOJJI STRIPS MIS W/LANCET 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
HARMONY TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 121 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
HW EMBRACE TES PRO 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
HW EMBRACE TES STRIPS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
IGLUCOSE TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
IN TOUCH TES BLOOD 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
INFINITY TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
INFINITY TES VOICE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
KETONE TES (acetone (urine) test strip) Tier 3
KETONE TEST TES (acetone (urine) test strip) Tier 3
KETOSTIX TES STRIP (acetone (urine) test strip) Tier 3
KROGER BLOOD TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 122 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
KROGER TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
LIBERTY NEXT TES GEN 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
LIBERTY TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
MEIJER BLOOD TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
MEIJER TES TRUETEST 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
MEIJER TES TRUETRAC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
MICRODOT TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 123 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MICRODOT TES XTRA 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
MYGLUCOHEALT TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
NEUTEK 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
NO CODING TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
NOVA MAX PLS TES KETONE (ketone blood test strip) Tier 3
NOVA MAX TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ON CALL PLUS TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ON CALL TES EXPRESS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 124 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ON CALL VIVD TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ONE DROP TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ONETOUCH TES ULTRA (glucose blood test strip) Tier 2
ONETOUCH TES VERIO (glucose blood test strip) Tier 2
OPTIUM TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
OPTIUMEZ TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
OPTUMRX TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PH STRIPS TES PH 0‐14 (ph test) Tier 3
POCKETCHEM TES EZ 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PRECISION PT TES OF CARE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 125 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PRECISION TES PCX 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PRECISION TES PCX PLUS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PRECISION TES QID 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PRECISION TES SOF‐TACT 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PRECISION TES XTRA 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PRECISN XTRA TES KETONE (ketone blood test strip) Tier 3
PREMIUM BLOO MIS GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PRO VOICE TES V 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 126 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PRODIGY NO TES CODING 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PTS PANELS TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
PTS PANELS TES KETONE (ketone blood test strip) Tier 3
QUICKTEK TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
QUINTET AC TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
QUINTET TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
RA TRUETEST TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
REFUAH PLUS TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 127 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
RELION BLOOD TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
RELION KETON TES (acetone (urine) test strip) Tier 3
RELION PREMI TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
RELION PRIME TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
RELION PRIME TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
RELION TES KETONE (acetone (urine) test strip) Tier 3
RELION TES ULTIMA 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
REVEAL TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
RIGHTEST TES GS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 128 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
SMART SENSE TES TEST 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
SMARTEST TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
SOLUS V 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
SUPREME TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
SURE EDGE TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
SURECHEK TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
SURE‐TEST TES EASYPLUS 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 129 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
TELCARE TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
TOXICOLOGY KIT MEDICATE (*drug assay (urine) test kit**) Tier 3
TRUE FOCUS MIS BLOOD 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
TRUE METRIX TES GLUCOSE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
TRUETEST TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
TRUETRACK TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
TRUETRACK TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ULTIMA TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 130 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ULTRATRAK TES ULTIMATE 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
ULTRATRK PRO TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
UNISTRIP1 TES GENERIC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
VERASENS TES 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
VICTORY TES AGM‐ 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
VIVAGUARD TES INO 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
VOCAL POINT TES BLD GLUC 01 TES PLUS,01 TES SENSOR,1,10,10 TES BLD GLUC,100,12 TES BLD GLUC,15 TES,15G TES BLD GLUC,2 TES,2 TES AUDIBLE,2.0,20 TES BLD GLUC,2TEK TES STRIPS,3,3 TES,30/V10 TES BLD GLUC,300,30A TES BLD GLUC,4 TES,40,40/G31 TES GLUCOSE,4000,50 TES,550,8/V9 (glucose blood test strip)
Tier 3
DIAPHRAGMS ‐ Diabetic Supplies and Needles
CAYA DPR (*diaphragm arc‐spring***) Tier 5 QL (1 unit per 1 day)
OMNIFLEX DPR Tier 5 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 131 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
WIDE‐SEAL DPR KIT 60,65,70,75,80,85,90,95 (diaphragm wide seal)
Tier 5 QL (1 unit per 1 day)
DIBENZODIAZEPINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
clozapine tab 100/odt,12.5/odt,150/odt,200/odt,25mg odt Tier 1
clozapine tab 100/odt,12.5/odt,150/odt,200/odt,25mg odt Tier 1
CLOZARIL TAB 100MG,200MG,25MG,50MG (clozapine tab) Tier 3
VERSACLOZ SUS 50MG/ML (clozapine susp) Tier 3
DIBENZO‐OXEPINO PYRROLES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
SAPHRIS SUB 10MG,2.5MG,5MG (asenapine maleate sl tab) Tier 3
SECUADO DIS 3.8MG,5.7MG,7.6MG (asenapine td patch) Tier 3
DIBENZOTHIAZEPINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
quetiapine tab 100mg,200mg,25mg,300mg,400mg,50mg Tier 1
quetiapine tab 100mg,200mg,25mg,300mg,400mg,50mg Tier 1
SEROQUEL TAB 100MG,200MG,25MG,300MG,400MG,50MG (quetiapine fumarate tab)
Tier 3
SEROQUEL XR TAB 150MG,200MG,300MG,400MG,50MG (quetiapine fumarate tab er)
Tier 3
DIBENZOXAZEPINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
ADASUVE INH 10MG (loxapine aerosol powder breath activated)
Tier 3
loxapine cap 10mg,25mg,50mg,5mg Tier 1
DIETARY MANAGEMENT PRODUCT COMBINATIONS ‐ Products for Diet / Eating
ASTAMED MYO CAP (*astaxanthin‐tocotrienol‐zinc‐cholecalciferol capsule***)
Tier 3
av‐vite fb tab 2.5‐25‐2 Tier 1
AXONA POW (*dietary management product ‐ packet***) Tier 3
CEREFOLIN TAB 3‐35‐2MG,6‐B12 (*l‐methylfolate w/ vit b) Tier 3
CEREFOLIN TAB NAC (*l‐methylfolate‐algae‐b12‐acetylcyst tab)
Tier 3
DEPLIN 15,15 CAP,7.5 CAP (*l‐methylfolate‐algae cap) Tier 3
ELFOLATE PLU TAB 3‐35‐2MG,6‐B12 (*l‐methylfolate w/ vit b)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 132 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ENLYTE CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
FOLBIC RF TAB 3‐35‐2MG,6‐B12 (*l‐methylfolate w/ vit b) Tier 3
folbic tab 2.5‐25‐2 Tier 1
FOLTANX RF CAP 5P (*l‐methylfolate‐algae‐vit b) Tier 3
FOLTANX TAB 3‐35‐2MG,6‐B12 (*l‐methylfolate w/ vit b) Tier 3
FOLTX TAB 3‐35‐2MG,6‐B12 (*l‐methylfolate w/ vit b) Tier 3
FOSTEUM CAP (*genistein‐zinc amino acid chelate‐vitamin d cap***)
Tier 3
FOSTEUM PLUS CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
FOVEX CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
GABADONE CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
HYPERTENSA CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
LDL CARE POW 5P POW (*dietary management product ‐ powder***)
Tier 3
LEVOMEFOLATE CAP ALGAL 15,15 CAP,7.5 CAP (*l‐methylfolate‐algae cap)
Tier 3
LIMBREL250 CAP 250‐50MG,500‐50MG (flavocoxid‐citrated zinc bisglycinate cap)
Tier 3
LIMBREL500 CAP 250‐50MG,500‐50MG (flavocoxid‐citrated zinc bisglycinate cap)
Tier 3
LIPICHOL 540 CAP (*dietary management product ‐ caps***)
Tier 3
LISTER‐V CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
L‐METHYL‐ TAB B 3‐35‐2MG,6‐B12 (*l‐methylfolate w/ vit b) Tier 3
L‐METHYLFOLA CAP ALGAL 15,15 CAP,7.5 CAP (*l‐methylfolate‐algae cap)
Tier 3
L‐METHYLFOLA CAP FORTE 15,15 CAP,7.5 CAP (*l‐methylfolate‐algae cap)
Tier 3
L‐METHYL‐MC TAB 3‐35‐2MG,6‐B12 (*l‐methylfolate w/ vit b)
Tier 3
L‐METHYL‐MC TAB NAC (*l‐methylfolate‐methylcobalamin‐acetylcyst tab)
Tier 3
LORMATE CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
MACUTEK TAB (*dietary management product ‐ tab disint***)
Tier 3
METAFOLBIC TAB 3‐35‐2MG,6‐B12 (*l‐methylfolate w/ vit b)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 133 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
METAFOLBIC TAB PLUS (*l‐methylfolate‐methylcobalamin‐acetylcyst tab)
Tier 3
METAFOLBIC TAB PLUS RF (*l‐methylfolate‐algae‐b12‐acetylcyst tab)
Tier 3
METANX CAP 5P (*l‐methylfolate‐algae‐vit b) Tier 3
METHAVER CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
METHYLFOL/CA TAB ME‐CBL (*l‐methylfolate‐algae‐b12‐acetylcyst tab)
Tier 3
METHYLFOL/ME CAP CBL/P 5P (*l‐methylfolate‐algae‐vit b) Tier 3
NEOKE BHB POW 5P POW (*dietary management product ‐ powder***)
Tier 3
NEUREPA CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
NICAPRIN TAB (*dietary management product ‐ tabs***) Tier 3
NICAZYME TAB (*dietary management product ‐ tabs***) Tier 3
OMNIVEX TAB (*dietary management product ‐ tabs***) Tier 3
PERCURA CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
PODIAPN CAP (*l‐methylfolate w/ vitamin b) Tier 3
PROLEVA TAB (*dietary management product ‐ tabs***) Tier 3
PROTEOLIN TAB (*dietary management product ‐ tabs***) Tier 3
PULMONA CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
RHEUMATE CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
RIBOZEL CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
SENTRA AM CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
SENTRA PM CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
THERAMINE CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
THERAMINE POW PLUS (*dietary management product ‐ packet***)
Tier 3
TL‐ICARE CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
TOBAIKIENT CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
TREPADONE CAP 540 CAP (*dietary management product ‐ caps***)
Tier 3
T‐SUPPORT CAP MAX 540 CAP (*dietary management product ‐ caps***)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 134 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
VASCULERA TAB (*dietary management product ‐ tabs***) Tier 3
VB6 P 5P POW (*dietary management product ‐ powder***)
Tier 3
westab max tab 2.5‐25‐2 Tier 1
XYZBAC TAB (*dietary management product ‐ tabs***) Tier 3
ZYVEXOL TAB (*dietary management product ‐ tabs***) Tier 3
ZYVIT TAB (*dietary management product ‐ tabs***) Tier 3
DIETARY MANAGEMENT PRODUCTS ‐ Products for Diet / Eating
AVAILNEX CHW 750MG (carbocysteine chew tab) Tier 3
ELFOLATE TAB 15MG,7.5MG (*l‐methylfolate tab) Tier 3
ENTERAGAM POW 5GM (serum‐derived bovine immunoglob/protein isolate)
Tier 3
GALAXTRA POW (*galactose oral powder**) Tier 3
LIMBREL CAP 250MG,500MG (flavocoxid cap) Tier 3
l‐methylfola tab 15mg,7.5mg Tier 1
VASCAZEN CAP 1GM (omega‐3‐acid ethyl esters (dietary management) cap)
Tier 3
XAQUIL XR TAB 30MG (levomefolate glucosamine tab er) Tier 3
DIGESTIVE ENZYME COMBINATIONS ‐ Drugs to Aid in Digestion and Misc Stomach Disorders
ENZADYNE CAP (*digestive enzyme cap***) Tier 3
DIGESTIVE ENZYMES ‐ Drugs to Aid in Digestion and Misc Stomach Disorders
CREON CAP 10000UNT,12000UNT,15000UNT,20000UNT,24000UNT,25000,3000UNIT,36000UNT,40000,5000UNIT,6000UNIT (pancrelipase (lip‐prot‐amyl) dr cap)
Tier 2
PANCREAZE CAP 10500UNT,16000U,16800UNT,21000UNT,24000U,2600UNIT,4000UNIT,4200UNIT,8000UNIT (pancrelipase (lip‐prot‐amyl) dr cap)
Tier 3
PERTZYE CAP 10500UNT,16000U,16800UNT,21000UNT,24000U,2600UNIT,4000UNIT,4200UNIT,8000UNIT (pancrelipase (lip‐prot‐amyl) dr cap)
Tier 3
SUCRAID SOL 8500/ML (sacrosidase soln) Tier 3
VIOKACE TAB 10440,20880 (pancrelipase (lip‐prot‐amyl) tab)
Tier 2
ZENPEP CAP 10000UNT,12000UNT,15000UNT,20000UNT,24000UNT,25000,3000UNIT,36000UNT,40000,5000UNIT,6000UNIT (pancrelipase (lip‐prot‐amyl) dr cap)
Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 135 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
DIGITAL THERAPY ‐ Miscellaneous Drugs and Solutions
RESET APP MIS IOS/ANDR (*digital therapy application***) Tier 3
RESET‐O MIS IOS/ANDR (*digital therapy application***) Tier 3
DIHYDROCODEINE COMBINATIONS ‐ Drugs for Treatment of Pain
apap/caffein tab dihydroc Tier 1 PA; QL (75 days;900 tablets)
apap‐caffein cap dihydroc Tier 1 PA; QL (75 days;900 capsules)
acetaminophen/caffeine/dihydrocodeine bitartrate tab (Dvorah)
Tier 1
acetaminophen/caffeine/dihydrocodeine bitartrate cap (Trezix)
Tier 1 PA; QL (75 days;900 units)
DIHYDROINDOLONES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
molindone tab hcl 10mg,25mg,5mg Tier 1
DIPEPTIDYL PEPTIDASE‐4 (DPP‐4) INHIBITORS ‐ Drugs to treat Diabetes
alogliptin tab 12.5mg,25mg,6.25mg Tier 1
JANUVIA TAB 100MG,25MG,50MG (sitagliptin phosphate tab)
Tier 2
NESINA TAB 12.5MG,25MG,6.25MG (alogliptin benzoate tab)
Tier 3
ONGLYZA TAB 2.5MG,5MG (saxagliptin hcl tab) Tier 3
TRADJENTA TAB 5MG (linagliptin tab) Tier 2
DIPEPTIDYL PEPTIDASE‐4 INHIBITOR‐BIGUANIDE COMBINATIONS ‐ Drugs to treat Diabetes
alogliptin/ tab metform Tier 1
JANUMET TAB 50‐1000,50‐500MG (sitagliptin‐metformin hcl tab)
Tier 2
JANUMET XR TAB 100‐1000,50‐1000,50‐500MG (sitagliptin‐metformin hcl tab er)
Tier 2
JENTADUETO TAB 2.5‐1000,2.5‐500,2.5‐850 (linagliptin‐metformin hcl tab)
Tier 2
JENTADUETO TAB XR (linagliptin‐metformin hcl tab er) Tier 2
KAZANO 12.5‐ TAB 1000MG,12.5‐ TAB 500MG (alogliptin‐metformin hcl tab)
Tier 3
KOMBIGLYZ XR TAB 2.5‐1000,5‐1000MG,5‐500MG (saxagliptin‐metformin hcl tab er)
Tier 3
DIRECT FACTOR XA INHIBITORS ‐ Drugs to Treat Blood Clots
ELIQUIS ST P TAB 2.5MG,5MG (apixaban tab) Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 136 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ELIQUIS TAB 2.5MG,5MG (apixaban tab) Tier 2
SAVAYSA TAB 15MG,30MG,60MG (edoxaban tosylate tab) Tier 3
XARELTO STAR TAB 15/20MG (rivaroxaban tab starter therapy pack)
Tier 2
XARELTO TAB 10MG,15MG,2.5MG,20MG (rivaroxaban tab) Tier 2
DIRECT MUSCLE RELAXANTS ‐ Drugs for diseases and disorders of the muscles, ligaments, tendons and bones
DANTRIUM CAP 25MG,50MG (dantrolene sodium cap) Tier 2
dantrolene cap 100mg,25mg,50mg Tier 1
DIRECT RENIN INHIBITORS ‐ Drugs to Treat High Blood Pressure
aliskiren tab 150mg,300mg Tier 1
TEKTURNA TAB 150MG,300MG (aliskiren fumarate tab) Tier 3
DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE‐LIKE COMB ‐ Drugs to Treat High Blood Pressure
TEKTURNA HCT TAB 150‐12.5,150‐25MG,300‐12.5,300‐25MG (aliskiren‐hydrochlorothiazide tab)
Tier 2
DIRECT‐ACTING P2Y12 INHIBITORS ‐ Drugs to Treat Blood Disorders
BRILINTA TAB 60MG,90MG (ticagrelor tab) Tier 2
DIURETIC COMBINATIONS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders
ALDACTAZIDE TAB 25/25,50/50 (spironolactone & hydrochlorothiazide tab)
Tier 3
amilor/hctz tab 5‐50 Tier 1
DYAZIDE CAP 37.5‐25 (triamterene & hydrochlorothiazide cap)
Tier 3
MAXZIDE TAB 75‐50 (triamterene & hydrochlorothiazide tab)
Tier 3
MAXZIDE‐25 TAB 75‐50 (triamterene & hydrochlorothiazide tab)
Tier 3
spirono/hctz tab 25/25 Tier 1
triamt/hctz cap 37.5‐25 Tier 1
triamt/hctz tab 37.5‐25,75‐50mg Tier 1
DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS) ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders
SUNOSI TAB 150MG,75MG (solriamfetol hcl tab) Tier 2
DOPAMINE RECEPTOR AGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
cabergoline tab 0.5mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 137 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
DOPAMINE RECEPTOR AGONISTS ‐ ERGOT DERIVATIVES ‐ Drugs to treat Diabetes
CYCLOSET TAB 0.8MG,2.5MG (bromocriptine mesylate tab) Tier 3
DPP‐4 INHIBITOR‐THIAZOLIDINEDIONE COMBINATIONS ‐ Drugs to treat Diabetes
alog/pioglit tab 12.5‐15,12.5‐30,12.5‐45,25‐15mg,25‐30mg,25‐45mg
Tier 1
OSENI TAB 12.5‐15,12.5‐30,12.5‐45,25‐15MG,25‐30MG,25‐45MG (alogliptin‐pioglitazone tab)
Tier 3
DRY MOUTH AGENTS AND ARTIFICIAL SALIVA ‐ Drugs to Treat Mouth / Throat / Dental Disorders
AQUORAL SPR (*artificial saliva ‐ solution***) Tier 3
BOCASAL POW (*artificial saliva ‐ packet***) Tier 3
CAPHOSOL SOL (*artificial saliva ‐ solution***) Tier 3
MUCOSITISRX POW (*artificial saliva ‐ packet***) Tier 3
NEUTRASAL POW (*artificial saliva ‐ packet***) Tier 3
NUMOISYN LIQ (*artificial saliva ‐ solution***) Tier 3
NUMOISYN LOZ (*artificial saliva ‐ lozenge***) Tier 3
SALIVAMAX POW (*artificial saliva ‐ packet***) Tier 3
XEROSTOMIA SOL RELIEF (*artificial saliva ‐ solution***) Tier 3
EMERGENCY CONTRACEPTIVES ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
ELLA TAB 30MG (ulipristal acetate tab) Tier 5
EMOLLIENT COMBINATIONS ‐ Drugs to Treat Skin Disorders
lactic acid cre /vit e Tier 1
lactic acid cre e Tier 1
EMOLLIENT/KERATOLYTIC AGENTS ‐ Drugs to Treat Skin Disorders
CEM‐UREA SOL 45% (urea soln) Tier 3
KERALAC CRE 41%,47% (urea cream) Tier 3
urea cream 39%,41%,45%,47% Tier 1
urea (carbamide) cre 39%,41%,45%,47% (Uredeb) Tier 1
UTOPIC CRE 41%,47% (urea cream) Tier 3
xurea cre 39%,41%,45%,47% Tier 1
EMOLLIENTS ‐ Drugs to Treat Skin Disorders
ammonium lac cre 12% Tier 1
ammonium lac lot 10%,12% Tier 1
HPR PLUS MB KIT HYDROGEL (*emollient foam & wound dressing gel kit***)
Tier 3
hyaluronate gel 0.2% Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 138 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
lactic acid lot 10%,12% Tier 1
ENZYMES ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
SANTYL OIN 250/GM (collagenase oint) Tier 3
ERGOT COMBINATIONS ‐ Drugs to Treat Migraine Headaches
CAFERGOT TAB 1‐100MG (ergotamine w/ caffeine tab) Tier 3
ergot/caffen tab 1‐100mg Tier 1
migergot sup 2/100 Tier 1
ERYTHROID MATURATION AGENTS ‐ Drugs to Treat Blood Disorders
REBLOZYL INJ 25MG,75MG (luspatercept‐aamt for subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
ERYTHROMYCINS ‐ Antibiotics / Drugs for Infections
erythromycin ethylsuccinate tab 400mg,400mg (E.e.s. 400) Tier 1
E.E.S. GRAN SUS 200/5ML,400/5ML (erythromycin ethylsuccinate for susp)
Tier 3
ERYPED SUS 200/5ML,400/5ML (erythromycin ethylsuccinate for susp)
Tier 3
erythromycin tab 250mg ec,333mg ec,500mg ec (Ery‐tab) Tier 1
erythromycin stearate tab 250mg (Erythrocin Stearate) Tier 1
erythrom eth sus 200/5ml,400/5ml Tier 1
erythrom eth tab 400 tab 400mg,400mg Tier 1
erythromycin cap 250mg ec Tier 1
erythromycin tab 250mg bs,500mg bs Tier 1
erythromycin tab 250mg bs,500mg bs Tier 1
ERYTHROPOIESIS‐STIMULATING AGENTS (ESAS) ‐ Drugs to Treat Blood Disorders
ARANESP INJ 100MCG,200MCG,25MCG,300MCG,40MCG,60MCG (darbepoetin alfa soln inj)
Tier 2 PA; SP; QL (34 days supply)
ARANESP INJ 100MCG,200MCG,25MCG,300MCG,40MCG,60MCG (darbepoetin alfa soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
EPOGEN INJ 10000/ML,2000/ML,20000/ML,3000/ML,4000/ML (epoetin alfa inj)
Tier 4 PA; SP; QL (34 days supply)
MIRCERA INJ 100MCG,150/0.3,200MCG,30/0.3ML,50MCG,75MCG (methoxy peg‐epoetin beta soln prefilled syr)
Tier 3 PA
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 139 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MIRCERA SOL 100MCG,150/0.3,200MCG,30/0.3ML,50MCG,75MCG (methoxy peg‐epoetin beta soln prefilled syr)
Tier 3 PA
PROCRIT INJ 10000/ML,2000/ML,20000/ML,3000/ML,4000/ML,40000/ML (epoetin alfa inj)
Tier 2 PA; SP; QL (34 days supply)
RETACRIT INJ 10000UNT,2000UNIT,3000UNIT,40000UNT,4000UNIT (epoetin alfa‐epbx inj)
Tier 2 PA; SP; QL (34 days supply)
ESTROGEN & PROGESTIN ‐ Drugs for Female Hormone Replacement
ACTIVELLA TAB 1‐0.5MG (estradiol & norethindrone acetate tab)
Tier 3
estrogen/progestin tab 0.5‐0.1,1‐0.5mg (Amabelz) Tier 1
ANGELIQ TAB 0.25‐0.5,0.5‐1MG (drospirenone‐estradiol tab)
Tier 3
BIJUVA CAP 1‐100MG (estradiol‐progesterone cap) Tier 3
CLIMARA PRO DIS WEEKLY (estradiol‐levonorgestrel td patch weekly)
Tier 2
COMBIPATCH DIS (estradiol‐norethindrone ace td pttw) Tier 2
estra/noreth tab 0.5‐0.1,1‐0.5mg Tier 1
FEMHRT TAB 0.5‐2.5 (norethindrone acetate‐ethinyl estradiol tab)
Tier 3
norethindrone acetate/ethinyl estradio tab 0.5‐2.5,1‐5,1mg‐5mcg (Fyavolv)
Tier 1
norethindrone acetate/ethinyl estradiol tab 0.5‐2.5,1‐5,1mg‐5mcg (Jinteli)
Tier 1
ethinyl estradiol /norethindrone acetate tab 0.5‐0.1,1‐0.5mg (Lopreeza)
Tier 1
estradiol/norethindrone acetate tab 0.5‐0.1,1‐0.5mg (Mimvey)
Tier 1
noreth/ethin tab 0.5‐2.5,1‐5,1mg‐5mcg Tier 1
PREFEST TAB 0.5MG,1MG,2MG (estradiol tab) Tier 3
PREMPHASE TAB (conj est) Tier 2
PREMPRO TAB 0.3‐1.5,0.45‐1.5,0.625‐5 (conjugated estrogen‐medroxyprogest acetate tab)
Tier 2
ESTROGEN‐PROGESTIN‐GNRH ANTAGONIST ‐ Drugs for Female Hormone Replacement
ORIAHNN CAP (elagolix‐estrad‐noreth) Tier 3
ESTROGENS ‐ Drugs for Female Hormone Replacement
ALORA DIS 0.025MG,0.0375MG,0.05MG,0.075MG,0.1MG (estradiol td patch twice weekly)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 140 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CLIMARA DIS 0.025MG,0.0375MG,0.05MG,0.06MG,0.075MG,0.1MG,14MCG (estradiol td patch weekly)
Tier 3
DIVIGEL GEL 0.25MG,0.5MG,0.75MG,1.25MG,1MG/GM (estradiol td gel)
Tier 2
dotti dis 0.025mg,0.0375mg,0.05mg,0.075mg,0.1mg Tier 1
ELESTRIN GEL 0.06% (estradiol gel) Tier 3
ESTRACE TAB 0.5MG,1MG,2MG (estradiol tab) Tier 3
estradiol dis 0.025mg,0.0375mg,0.05mg,0.075mg,0.1mg Tier 1
estradiol dis 0.025mg,0.0375mg,0.05mg,0.075mg,0.1mg Tier 1
estradiol tab 0.5mg,1mg,2mg Tier 1
ESTROGEL GEL 0.06% (estradiol gel) Tier 3
EVAMIST SPR 1.53MG (estradiol transdermal spray) Tier 2
MENEST TAB 0.3MG,0.625MG,1.25MG (esterified estrogens tab)
Tier 3
MENOSTAR DIS 0.025MG,0.0375MG,0.05MG,0.06MG,0.075MG,0.1MG,14MCG (estradiol td patch weekly)
Tier 3
MINIVELLE DIS 0.025MG,0.0375MG,0.05MG,0.075MG,0.1MG (estradiol td patch twice weekly)
Tier 3
PREMARIN TAB 0.3MG,0.45MG,0.625MG,0.9MG,1.25MG (estrogens, conjugated tab)
Tier 2
VIVELLE‐DOT DIS 0.025MG,0.0375MG,0.05MG,0.075MG,0.1MG (estradiol td patch twice weekly)
Tier 3
ESTROGENS‐ANTINEOPLASTIC ‐ Drugs for Treatment of Cancer
EMCYT CAP 140MG (estramustine phosphate sodium cap) Tier 2 OAC
ESTROGEN‐SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB ‐ Drugs for Female Hormone Replacement
DUAVEE TAB 0.45‐20 (conjugated estrogens‐bazedoxifene tab)
Tier 2
EXTENDED‐CYCLE CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
AMETHIA LO TAB (levonorg‐eth est tab) Tier 5 QL (91 days supply)
levonorg‐eth est tab (Amethia) Tier 5 QL (91 days supply)
levonorg‐eth est tab (Ashlyna) Tier 5 QL (91 days supply)
levonorg‐eth est lo tab (Camrese Lo) Tier 5 QL (91 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 141 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
levonorg‐eth est tab (Camrese) Tier 5 QL (91 days supply)
DAYSEE TAB (levonorg‐eth est tab) Tier 5 QL (91 days supply)
levonor‐eth est tab (Fayosim) Tier 5 QL (91 days supply)
levonorgestrel & ethinyl estradiol tab (Introvale) Tier 5 QL (91 days supply)
IAIMIESS TAB (levonorg‐eth est tab) Tier 5 QL (91 days supply)
levonorgestrel & ethinyl estradiol tab (Jolessa) Tier 5 QL (91 days supply)
levonor‐eth est tab Tier 5 QL (91 days supply)
levonorg‐eth est tab Tier 5 QL (91 days supply)
levonorg‐eth estradio tab Tier 5 QL (91 days supply)
LOJAIMIESS TAB (levonorg‐eth est tab) Tier 5 QL (91 days supply)
LOSEASONIQUE TAB (levonorg‐eth est tab) Tier 5 QL (91 days supply)
QUARTETTE TAB (levonor‐eth est tab) Tier 5 QL (91 days supply)
levonor‐eth est tab (Rivelsa) Tier 5 QL (91 days supply)
SEASONIQUE TAB (levonorg‐eth est tab) Tier 5 QL (91 days supply)
levonorgestrel & ethinyl estradiol tab (Setlakin) Tier 5 QL (91 days supply)
SIMPESSE TAB (levonorg‐eth est tab) Tier 5 QL (91 days supply)
EYELID CLEANSERS & LUBRICANTS ‐ Drugs to Treat Skin Disorders
ACUICYN SOL 0.01% (*eyelid cleansers ‐ solution***) Tier 3
AVENOVA SOL 0.01% (*eyelid cleansers ‐ solution***) Tier 3
HYPOCYN SPR 0.01% (*eyelid cleansers ‐ solution***) Tier 3
FABRY DISEASE ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
FABRAZYME INJ 35MG,5MG (agalsidase beta for iv soln) Tier 4 PA; SP; QL (34 days supply)
GALAFOLD CAP 123MG (migalastat hcl cap) Tier 3 PA; QL (0.5 unit per 1 day)
FARNESOID X RECEPTOR (FXR) AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
OCALIVA TAB 10MG,5MG (obeticholic acid tab) Tier 4 PA; SP; QL (34 days supply)
FIBRIC ACID DERIVATIVES ‐ Drugs for High Cholesterol
ANTARA CAP 30MG,90MG (fenofibrate micronized cap) Tier 3
fenofibrate cap 150mg,50mg Tier 1
fenofibrate cap 150mg,50mg Tier 1
fenofibrate tab 120mg,145mg,160mg,40mg,48mg,54mg Tier 1
fenofibric cap 135mg dr,45mg dr Tier 1
FENOFIBRIC TAB 105MG,35MG (fenofibric acid tab) Tier 3
FENOGLIDE TAB 120MG,145MG,160MG,40MG,48MG (fenofibrate tab)
Tier 3
FIBRICOR TAB 105MG,35MG (fenofibric acid tab) Tier 3
gemfibrozil tab 600mg Tier 1
LIPOFEN CAP 150MG,50MG (fenofibrate cap) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 142 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
LOPID TAB 600MG (gemfibrozil tab) Tier 3
TRICOR TAB 120MG,145MG,160MG,40MG,48MG (fenofibrate tab)
Tier 3
TRIGLIDE TAB 120MG,145MG,160MG,40MG,48MG (fenofibrate tab)
Tier 3
TRILIPIX CAP 135MG,45MG (choline fenofibrate cap dr) Tier 3
FIBROMYALGIA AGENT ‐ SNRIS ‐ Drugs for diseases and disorders of the nervous system
SAVELLA MIS TITR PAK 100MG,12.5MG,25MG,50MG (milnacipran hcl tab)
Tier 2
SAVELLA TAB 100MG,12.5MG,25MG,50MG (milnacipran hcl tab)
Tier 2
FIDAXOMICIN ‐ Antibiotics / Drugs for Infections
DIFICID TAB 200MG (fidaxomicin tab) Tier 2
FIXED OILS ‐ Miscellaneous Non‐Drug Compounds and Oils
ALMOND OIL (almond oil (sweet)) Tier 3
ALMOND OIL SWEET (almond oil (sweet)) Tier 3
BASE G ALMON OIL SWEET (almond oil (sweet)) Tier 3
CASTOR OIL (castor oil) Tier 3
LINSEED OIL RAW (flaxseed oil (linseed oil)) Tier 3
OLIVE OIL (olive oil) Tier 3
FLUORIDE ‐ Drugs for Replacement of Minerals in the Body
FLUORABON DRO (sodium fluoride soln) Tier 5
fluoride chw 1mg f,2.2mg Tier 1
sodium fluoride chew tab 0.25mg f,0.5mg f,1.1mg Tier 5
fluoritab chw 1mg f,2.2mg Tier 1
FLUORITAB CHW 0.25MG F,0.5MG F,1.1MG (sodium fluoride chew tab)
Tier 5
FLUORITAB DRO 0.125MG,0.25MG F,0.5MG/ML (sodium fluoride soln)
Tier 5
FLURA‐DROPS DRO 0.125MG,0.25MG F,0.5MG/ML (sodium fluoride soln)
Tier 5
ludent chw 1mg f,2.2mg Tier 1
LUDENT CHW 0.25MG F,0.5MG F,1.1MG (sodium fluoride chew tab)
Tier 5
nafrinse chw 1mg f,2.2mg Tier 1
NAFRINSE DRO 0.125MG,0.25MG F,0.5MG/ML (sodium fluoride soln)
Tier 5
sod fluoride chw 1mg f,2.2mg Tier 1
sodium fluoride chew tab 0.25mg f,0.5mg f,1.1mg Tier 5
sodium fluoride soln dro 0.125mg,0.25mg f,0.5mg/ml Tier 5
sod fluoride tab 1mg f Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 143 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
sodium fluoride tab 0.5mg f Tier 5
FLUORIDE COMBINATIONS ‐ Drugs for Replacement of Minerals in the Body
FLORIVA DRO 0.25MG (sodium fluoride‐vitamin d liqd drops)
Tier 3
FLUOROQUINOLONES ‐ Antibiotics / Drugs for Infections
BAXDELA TAB 450MG (delafloxacin meglumine tab) Tier 3
CIPRO ( 10%) SUS 500MG/5,5%) SUS 250MG/5 (ciprofloxacin for oral susp)
Tier 3
CIPRO TAB 250MG,500MG (ciprofloxacin hcl tab) Tier 3
ciprofloxacn tab 100mg,250mg,500mg,750mg Tier 1
LEVAQUIN TAB 250MG,500MG,750MG (levofloxacin tab) Tier 3
levofloxacin sol 0.5% Tier 1
levofloxacin tab 250mg,500mg,750mg Tier 1
moxifloxacin tab 400mg Tier 1
ofloxacin tab 300mg,400mg Tier 1
FOLIC ACID ANTAGONISTS RESCUE AGENTS ‐ Drugs for Treatment of Cancer
KHAPZORY SOL 175MG,300MG (levoleucovorin for iv soln) Tier 4 PA; SP; QL (34 days supply); OAC
leucovor ca tab 10mg,15mg,25mg,5mg Tier 1 OAC
levoleucovor inj 50mg Tier 1 PA; SP; QL (34 days supply); OAC
levoleucovor inj 50mg Tier 1 PA; SP; QL (34 days supply); OAC
levoleucovor sol 250mg/25 Tier 1 PA; SP; QL (34 days supply); OAC
FOLIC ACID/FOLATES ‐ Drugs to Treat Blood Disorders
FA‐8 CAP 800MCG (folic acid cap) Tier 5 AL‐55 max; QL (100 chewables)
FA‐8 TAB 0.8MG,400MCG,800MCG (folic acid tab) Tier 5 AL‐55 max; QL (100 tablets)
FOLATE TAB 0.8MG,400MCG,800MCG (folic acid tab) Tier 5 AL‐55 max; QL (100 tablets)
folic acid cap 800mcg Tier 5 AL‐55 max; QL (100 chewables)
folic acid inj 50/10ml,5mg/ml Tier 1
folic acid tab 1000mcg,1mg,800mcg Tier 1 AL‐55 max; QL (100 tablets)
folic acid tab 0.8mg,400mcg,800mcg Tier 5 AL‐55 max; QL (100 tablets)
SM FOLIC ACD TAB 0.8MG,400MCG,800MCG (folic acid tab) Tier 5 AL‐55 max; QL (100 tablets)
YL FOLIC ACI TAB 0.8MG,400MCG,800MCG (folic acid tab) Tier 5 AL‐55 max; QL (100 tablets)
FOUR PHASE CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
NATAZIA TAB (estradiol valerate‐dienogest tab) Tier 5 QL (1 unit per 1 day)
GAA DEFICIENCY TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
LUMIZYME INJ 50MG (alglucosidase alfa for iv soln) Tier 4 PA; SP; QL (34 days supply)
GABA MODULATORS ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 144 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
GABITRIL TAB 12MG,16MG,2MG,4MG (tiagabine hcl tab) Tier 3
SABRIL POW 500MG (vigabatrin powd pack) Tier 4 PA; SP; QL (34 days supply)
SABRIL TAB 500MG (vigabatrin tab) Tier 4 PA; SP; QL (34 days supply)
tiagabine tab 12mg,16mg,2mg,4mg Tier 1
vigabatrin pak 500mg Tier 1 PA; SP; QL (34 days supply)
vigabatrin tab 500mg Tier 1 PA; SP; QL (34 days supply)
vigabatrin pow 500mg (Vigadrone) Tier 1 PA; SP; QL (6 units per 1 day)
GABA RECEPTOR MODULATOR ‐ NEUROACTIVE STEROID ‐ Drugs for Depression / Other Disorders
ZULRESSO INJ 100/20ML (brexanolone iv soln) Tier 4 PA; SP; QL (34 days supply)
GALLSTONE SOLUBILIZING AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
ACTIGALL CAP 300MG (ursodiol cap) Tier 2
CHENODAL TAB 250MG (chenodiol tab) Tier 3
URSO 250 TAB 250MG,500MG (ursodiol tab) Tier 2
URSO FORTE TAB 250 TAB 250MG,500MG (ursodiol tab) Tier 2
ursodiol cap 300mg Tier 1
ursodiol tab 250mg,500mg Tier 1
GASTROINTESTINAL ANTIALLERGY AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
cromolyn sod con 100/5ml Tier 1
GASTROCROM CON 100/5ML (cromolyn sodium oral conc) Tier 3
GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS ‐ Drugs to Treat Disorders of the Stomach and Intestines
AMITIZA CAP 24MCG,8MCG (lubiprostone cap) Tier 2
GASTROINTESTINAL STIMULANTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
metoclopram sol 10/10ml,5mg/5ml Tier 1
metoclopram tab 5mg odt Tier 1
metoclopram tab 5mg odt Tier 1
METOCLOPRAMI TAB 10MG ODT (metoclopramide hcl orally disintegrating tab)
Tier 3
REGLAN TAB 10MG,5MG (metoclopramide hcl tab) Tier 3
GELATIN CAPSULES (EMPTY) ‐ Syrups, gelatin, capsules for making pharmaceuticals
CAPSULE CONI CAP ‐SN # 0,00,000,1,2,3,4,5,7,600MG,2"X2",3" DISK,4"X4",4"X8" (*gelatin capsules (empty)**)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 145 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CAPSULE CONI CAP ‐SNAP # 0,00,000,1,2,3,4,5,7,600MG,2"X2",3" DISK,4"X4",4"X8" (*non gelatin capsules (empty)**)
Tier 3
CAPSULE CONI CAP ‐SNAP# 0,00,000,1,2,3,4,5,7,600MG,2"X2",3" DISK,4"X4",4"X8" (*gelatin capsules (empty)**)
Tier 3
CAPSULE EZFT CAP # 0,00,000,1,2,3,4,5,7,600MG,2"X2",3" DISK,4"X4",4"X8" (*gelatin capsules (empty)**)
Tier 3
DRCAPS CLEAR CAP SIZE 0,00,000,1,2,3,4,5,7,600MG,2"X2",3" DISK,4"X4",4"X8" (*gelatin capsules (empty)**)
Tier 3
EMPTY CAPSUL CAP SIZE 0,00,000,1,2,3,4,5,7,600MG,2"X2",3" DISK,4"X4",4"X8" (*non gelatin capsules (empty)**)
Tier 3
GENITOURINARY IRRIGANTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
acetic acid sol 0.25%irr Tier 1
aminoac acid sol 1.5% irr Tier 1
argyl saline sol 0.9%,0.9% irr Tier 1
curity salin sol 0.9%,0.9% irr Tier 1
glycine sol 1.5% irr Tier 1
RENACIDIN SOL (*citric acid‐gluconolactone‐magnesium carbonate soln**)
Tier 3
RESECTISOL SOL 5% (mannitol irrigation soln) Tier 3
sodium chlor sol 0.9%,0.9% irr Tier 1
SORBITOL SOL 3% IRR,3.3% IRR (sorbitol irrigation soln) Tier 3
SORBITOL‐MAN SOL (sorbitol‐mannitol irrigation soln) Tier 3
GLUCAGON‐LIKE PEPTIDE‐2 (GLP‐2) ANALOGS ‐ Drugs to Treat Disorders of the Stomach and Intestines
GATTEX KIT 5MG (teduglutide (rdna) for inj kit) Tier 4 PA; SP; QL (34 days supply)
GLUCOCORTICOSTEROIDS ‐ Drugs to Treat Swelling and Inflammation
budesonide cap 3mg,3mg dr Tier 1
budesonide tab er 9mg Tier 1
CORTEF TAB 10MG,20MG,5MG (hydrocortisone tab) Tier 3
cortisone ac tab 25mg Tier 1
dexamethasone tab 0.5mg,0.75mg,1.5mg,1mg,2mg,4mg,6mg (Decadron)
Tier 1
DEXABLISS TAB 1.5MG,11‐DAY PAK 1.5MG (dexamethasone tab therapy pack)
Tier 3
DEXAMETHASON CON 1MG/ML (dexamethasone conc) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 146 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
dexamethason elx 0.5/5ml Tier 1
dexamethason sol 0.5/5ml Tier 1
dexamethason tab 0.5mg,0.75mg,1.5mg,1mg,2mg,4mg,6mg
Tier 1
dexamethason tab 0.5mg,0.75mg,1.5mg,1mg,2mg,4mg,6mg
Tier 1
DEXONTO 0.4% SOL 20MG/5ML (dexamethasone sodium phosphate iontophoresis soln)
Tier 3
DXEVO 1.5MG,11‐DAY PAK 1.5MG (dexamethasone tab therapy pack)
Tier 3
EMFLAZA SUS 22.75/ML (deflazacort susp) Tier 3 PA; QL (1.8 unit per 1 day)
EMFLAZA TAB 18MG,30MG,36MG,6MG (deflazacort tab) Tier 3 PA; QL (1 unit per 1 day)
ENTOCORT EC CAP 3MG DR (budesonide delayed release particles cap)
Tier 3
dexamethasone 6‐day (Hidex 6‐day) Tier 1
hydrocort tab 10mg,20mg,5mg Tier 1
MEDROL TAB 16MG,2MG,32MG,4MG,8MG (methylprednisolone tab)
Tier 3
MEDROL TAB 16MG,2MG,32MG,4MG,8MG (methylprednisolone tab therapy pack)
Tier 3
methylpred tab 16mg,32mg,4mg,8mg Tier 1
methylpred tab 16mg,32mg,4mg,8mg Tier 1
MILLIPRED DP PAK 5MG (prednisolone tab therapy pack) Tier 3
MILLIPRED TAB 5MG (prednisolone tab) Tier 3
ORAPRED ODT TAB 10MG,15MG,30MG (prednisolone sod phos orally disintegr tab)
Tier 2
PEDIAPRED SOL 5MG/5ML (prednisolone sod phosph oral soln)
Tier 3
pred sod pho sol 5mg/5ml Tier 1
prednisolone sol 10mg/5ml,15mg/5ml,20mg/5ml Tier 1
prednisolone sol 10mg/5ml,15mg/5ml,20mg/5ml Tier 1
prednisolone sol 10mg/5ml,15mg/5ml,20mg/5ml Tier 1
prednisolone syp 15mg/5ml Tier 1
prednisolone tab 10mg odt,15mg odt,30mg odt Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 147 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PREDNISONE CON 5MG/ML (prednisone conc) Tier 3
prednisone pak 10mg,5mg Tier 1
prednisone sol 5mg/5ml Tier 1
prednisone tab 10mg,1mg,2.5mg,20mg,50mg,5mg Tier 1
RAYOS TAB 1MG,2MG,5MG (prednisone tab delayed release)
Tier 3
taperdex pak 10‐day,12‐day,13‐day,6 day,6‐day,6‐day pak 1.5mg,7‐day
Tier 1
UCERIS TAB 9MG (budesonide tab er) Tier 3
GLUCOSE MONITORING TEST SUPPLIES ‐ Diabetic Supplies and Needles
DEXCOM G 5 MIS RECEIVER,6 MIS RECEIVER (*continuous blood glucose system receiver***)
Tier 2
DEXCOM G 5 MIS RECEIVER,6 MIS RECEIVER (*continuous blood glucose system transmitter***)
Tier 2
DEXCOM G 5 MIS RECEIVER,6 MIS RECEIVER (*continuous blood glucose system transmitter***)
Tier 2
DIASCREEN 10 MIS,1B,1G,1K,2GK,2GP,3 MIS,4NL,4OBL,4PH,5 MIS,6 MIS,7 MIS,8 MIS,9 MIS (*urine glucose monitoring supplies***)
Tier 3
DIASCREEN MIS 10 MIS,1B,1G,1K,2GK,2GP,3 MIS,4NL,4OBL,4PH,5 MIS,6 MIS,7 MIS,8 MIS,9 MIS (*urine glucose monitoring supplies***)
Tier 3
DIASCREEN MIS CONTROL 10 MIS,1B,1G,1K,2GK,2GP,3 MIS,4NL,4OBL,4PH,5 MIS,6 MIS,7 MIS,8 MIS,9 MIS (*urine glucose monitoring supplies***)
Tier 3
ENLITE GLUCO MIS SENSOR 3 (*continuous blood glucose system sensor***)
Tier 3
EVERSENSE MIS SENSOR 3 (*continuous blood glucose system sensor***)
Tier 3
EVERSENSE MIS TRANSMTR 3 (*continuous blood glucose system transmitter***)
Tier 3
FREESTY LIBR KIT 2 SENSOR (*continuous blood glucose system sensor***)
Tier 3
FREESTY LIBR MIS 2 READER (*continuous blood glucose system receiver***)
Tier 3
FREESTYLE KIT SENSOR 6 MIS SENSOR (*continuous blood glucose system sensor***)
Tier 2
FREESTYLE MIS READER 5 MIS RECEIVER,6 MIS RECEIVER (*continuous blood glucose system receiver***)
Tier 2
G4 PLAT PED MIS RVC/SHAR 5 MIS RECEIVER,6 MIS RECEIVER (*continuous blood glucose system receiver***)
Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 148 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
G4 PLATINUM MIS PEDIATRC 5 MIS RECEIVER,6 MIS RECEIVER (*continuous blood glucose system receiver***)
Tier 2
G4 PLATINUM MIS RCV/SHAR 5 MIS RECEIVER,6 MIS RECEIVER (*continuous blood glucose system receiver***)
Tier 2
G4 PLATINUM MIS RECEIVER 5 MIS RECEIVER,6 MIS RECEIVER (*continuous blood glucose system receiver***)
Tier 2
G4 PLATINUM MIS TRANSMIT 5 MIS TRANSMIT,6 MIS TRANSMIT (*continuous blood glucose system transmitter***)
Tier 2
G4 SENSOR MIS 6 MIS SENSOR (*continuous blood glucose system sensor***)
Tier 2
G5/G4 MIS SENSOR 6 MIS SENSOR (*continuous blood glucose system sensor***)
Tier 2
GUARDIAN CON MIS TRANSMIT 3 (*continuous blood glucose system transmitter***)
Tier 3
GUARDIAN MIS LINK 3 (*continuous blood glucose system transmitter***)
Tier 3
GUARDIAN MIS SENSOR 3 (*continuous blood glucose system sensor***)
Tier 3
GUARDIAN MIS TRANSMTR 3 (*continuous blood glucose system transmitter***)
Tier 3
GUARDIAN RT KIT (*continuous blood glucose monitor system/components kit***)
Tier 3
GUARDIAN RT KIT STARTER (*continuous blood glucose monitor system/components kit***)
Tier 3
GUARDIAN RT KIT SYST PED (*continuous blood glucose monitor system/components kit***)
Tier 3
GUARDIAN RT KIT SYSTEM (*continuous blood glucose monitor system/components kit***)
Tier 3
GUARDIAN RT MIS REPL PED (*continuous blood glucose system receiver***)
Tier 3
GUARDIAN RT MIS REPLACE (*continuous blood glucose system receiver***)
Tier 3
MINIMED MIS SENSOR 3 (*continuous blood glucose system sensor***)
Tier 3
REAL‐TIME KIT (*continuous blood glucose monitor system/components kit***)
Tier 3
SOF‐SENSOR MIS 3 (*continuous blood glucose system sensor***)
Tier 3
GLYCOPEPTIDES ‐ Antibiotics / Drugs for Infections
FIRVANQ SOL 250/5ML,25MG/ML,50MG/ML (vancomycin hcl for oral soln)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 149 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
VANCOCIN CAP 125MG,250MG (vancomycin hcl cap) Tier 2
VANCOCIN HCL CAP 125MG,250MG (vancomycin hcl cap) Tier 2
vancomycin cap 125mg,250mg Tier 1
VANCOMYCIN SOL 250/5ML,25MG/ML,50MG/ML (vancomycin hcl for oral soln)
Tier 3
GNRH/LHRH ANTAGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
CETROTIDE KIT 0.25MG (cetrorelix acetate for inj kit) Tier 2 SP; QL (34 days supply)
ganirelix ac inj 250/0.5 Tier 1 SP; QL (34 days supply)
GANIRELIX AC INJ 250/0.5 (ganirelix acetate soln prefilled syringe)
Tier 4 SP; QL (34 days supply)
ORILISSA TAB 150MG,200MG (elagolix sodium tab) Tier 2
GOLD COMPOUNDS ‐ Drugs to Treat Pain and Inflammation
RIDAURA CAP 3MG (auranofin cap) Tier 3
GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS ‐ Drugs for Treatment of Cancer
FIRMAGON INJ 120MG,80MG (degarelix acetate for inj) Tier 4 PA; SP; QL (34 days supply)
GOUT AGENT COMBINATIONS ‐ Drugs to Treat Gout
proben/colch tab 500‐0.5 Tier 1
GOUT AGENTS ‐ Drugs to Treat Gout
allopurinol tab 100mg,300mg Tier 1
colchicine cap 0.6mg Tier 1
colchicine tab 0.6mg Tier 1
COLCRYS TAB 0.6MG (colchicine tab) Tier 3
febuxostat tab 40mg,80mg Tier 1
GLOPERBA SOL 0.6/5ML (colchicine oral soln) Tier 3
KRYSTEXXA INJ 8MG/ML (pegloticase inj) Tier 4 PA; SP; QL (34 days supply)
MITIGARE CAP 0.6MG (colchicine cap) Tier 3
ULORIC TAB 40MG,80MG (febuxostat tab) Tier 3
ZYLOPRIM TAB 100MG,300MG (allopurinol tab) Tier 3
GRANULOCYTE COLONY‐STIMULATING FACTORS (G‐CSF) ‐ Drugs to Treat Blood Disorders
FULPHILA INJ 6/0.6ML (pegfilgrastim‐jmdb soln prefilled syringe)
Tier 4 PA; SP; QL (34 days supply)
GRANIX INJ 300/0.5,480/0.8 (tbo‐filgrastim soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
GRANIX INJ 300/0.5,480/0.8 (tbo‐filgrastim subcutaneous inj)
Tier 2 PA; SP; QL (34 days supply)
NEULASTA INJ 6MG/0.6M (pegfilgrastim soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 150 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NEULASTA KIT 6MG/0.6M (pegfilgrastim soln prefilled syringe kit)
Tier 2 PA; SP; QL (34 days supply)
NEUPOGEN INJ 300MCG,480MCG (filgrastim inj) Tier 2 PA; SP; QL (34 days supply)
NEUPOGEN INJ 300MCG,480MCG (filgrastim soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
NIVESTYM INJ 300MCG,480MCG (filgrastim‐aafi inj) Tier 2 PA; SP; QL (34 days supply)
NIVESTYM INJ 300MCG,480MCG (filgrastim‐aafi soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
UDENYCA INJ 6MG/.6ML (pegfilgrastim‐cbqv soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
ZARXIO INJ 300/0.5,480/0.8 (filgrastim‐sndz soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
ZIEXTENZO INJ 6/0.6ML (pegfilgrastim‐bmez soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
GRANULOCYTE/MACROPHAGE COLONY‐STIMULATING FACTOR(GM‐CSF) ‐ Drugs to Treat Blood Disorders
LEUKINE INJ 250MCG (sargramostim lyophilized for inj) Tier 4 PA; SP; QL (34 days supply)
GROWTH HORMONE RECEPTOR ANTAGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
SOMAVERT INJ 10MG,15MG,20MG,25MG,30MG (pegvisomant for inj)
Tier 2 PA; SP; QL (34 days supply)
GROWTH HORMONE RELEASING HORMONES (GHRH) ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
EGRIFTA SOL 1MG,2MG (tesamorelin acetate for inj) Tier 4 PA; SP; QL (34 days supply)
EGRIFTA SV INJ 1MG,2MG (tesamorelin acetate for inj) Tier 4 PA; SP; QL (34 days supply)
GROWTH HORMONES ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
GENOTROPIN INJ 0.2MG,0.4MG,0.6MG,0.8MG,1.2MG,1.4MG,1.6MG,1.8MG,10MG,12MG,1MG,2MG,5.8MG (somatropin for inj)
Tier 4 PA; SP; QL (34 days supply)
GENOTROPIN INJ 0.2MG,0.4MG,0.6MG,0.8MG,1.2MG,1.4MG,1.6MG,1.8MG,10MG,12MG,1MG,2MG,5.8MG (somatropin for subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
HUMATROPE INJ 12MG,24MG,5MG,6MG (somatropin for inj)
Tier 2 PA; SP; QL (34 days supply)
NORDITROPIN INJ 10/1.5ML,15/1.5ML,30/3ML,5/1.5ML (somatropin inj)
Tier 2 PA; SP; QL (34 days supply)
NUTROPIN AQ INJ 10/1.5ML,10MG/2ML,20MG/2ML,5,5/1.5ML (somatropin inj)
Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 151 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NUTROPIN AQ INJ NUSPIN 10/1.5ML,10MG/2ML,20MG/2ML,5,5/1.5ML (somatropin inj)
Tier 4 PA; SP; QL (34 days supply)
OMNITROPE INJ 0.2MG,0.4MG,0.6MG,0.8MG,1.2MG,1.4MG,1.6MG,1.8MG,10MG,12MG,1MG,2MG,5.8MG (somatropin for inj)
Tier 4 PA; SP; QL (34 days supply)
OMNITROPE INJ 0.2MG,0.4MG,0.6MG,0.8MG,1.2MG,1.4MG,1.6MG,1.8MG,10MG,12MG,1MG,2MG,5.8MG (somatropin inj)
Tier 4 PA; SP; QL (34 days supply)
SAIZEN INJ 5MG,8.8MG (somatropin (non‐refrigerated) for inj)
Tier 4 PA; SP; QL (34 days supply)
SAIZENPREP INJ 5MG,8.8MG (somatropin (non‐refrigerated) for inj)
Tier 4 PA; SP; QL (34 days supply)
SEROSTIM INJ 4MG,5MG,6MG,8.8MG (somatropin (non‐refrigerated) for subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
ZOMACTON INJ 0.2MG,0.4MG,0.6MG,0.8MG,1.2MG,1.4MG,1.6MG,1.8MG,10MG,12MG,1MG,2MG,5.8MG (somatropin for inj)
Tier 4 PA; SP; QL (34 days supply)
ZOMACTON INJ 0.2MG,0.4MG,0.6MG,0.8MG,1.2MG,1.4MG,1.6MG,1.8MG,10MG,12MG,1MG,2MG,5.8MG (somatropin for subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
ZORBTIVE INJ 4MG,5MG,6MG,8.8MG (somatropin (non‐refrigerated) for subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
H‐2 ANTAGONISTS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
cimetidine sol 300/5ml Tier 1
cimetidine tab 200mg,300mg,400mg,800mg Tier 1
famotidine sus 40mg/5ml Tier 1
famotidine tab 20mg,40mg Tier 1
nizatidine cap 150mg,300mg Tier 1
nizatidine sol 15mg/ml Tier 1
PEPCID TAB 20MG,40MG (famotidine tab) Tier 3
HEMATORHEOLOGIC AGENTS ‐ Drugs to Treat Blood Disorders
pentoxifylli tab 400mg er Tier 1
HEMOGLOBIN S (HBS) POLYMERIZATION INHIBITORS ‐ Drugs to Treat Blood Disorders
OXBRYTA TAB 500MG (voxelotor tab) Tier 4 PA; SP; QL (34 days supply)
HEMOSTATIC COMBINATIONS ‐ TOPICAL ‐ Drugs to Treat Bleeding Disorders
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 152 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ARTISS SOL 10ML,2ML,4ML (*fibrin sealant component solution***)
Tier 3
GEL‐FLOW KIT (*gelatin absorbable powder & thrombin for soln kit***)
Tier 3
GELFOAM‐JMI KIT POWDER (*gelatin absorbable powder & thrombin for soln kit***)
Tier 3
GELFOAM‐JMI KIT SPONGE (*gelatin absorbable sponge & thrombin for soln kit***)
Tier 3
TISSEEL KIT 10ML,2ML,4ML (*fibrin sealant component kit) Tier 3
TISSEEL SOL 10ML,2ML,4ML (*fibrin sealant component solution***)
Tier 3
HEMOSTATICS ‐ SYSTEMIC ‐ Drugs to Treat Bleeding Disorders
AMICAR SOL 0.25/ML (aminocaproic acid oral soln) Tier 3
AMICAR TAB 1000MG,500MG (aminocaproic acid tab) Tier 3
aminocapr ac tab 1000mg,500mg Tier 1
aminocaproic sol 0.25/ml Tier 1
LYSTEDA TAB 650MG (tranexamic acid tab) Tier 3
tranex acid tab 650mg Tier 1
HEMOSTATICS ‐ TOPICAL ‐ Drugs to Treat Bleeding Disorders
MONSELS FERR SOL SUBSULF (*ferric subsulfate soln**) Tier 3
RECOTHROM SOL 20000UNT,5000UNIT (thrombin (recombinant) for soln)
Tier 3
TACHOSIL PAD 4.8X4.8,9.5X4.8 (*absorbable fibrin sealant patch)
Tier 3
THROMBIN KIT 10000UNT,20000UNT,5000UNIT (thrombin for soln kit)
Tier 3
THROMBIN‐JMI KIT 10000UNT,20000UNT,5000UNIT (thrombin for soln kit)
Tier 3
THROMBIN‐JMI SOL 10000UNT,1000UNIT,20000UNT,5000UNIT (thrombin for soln)
Tier 3
THROMBOGEN KIT 10000UNT,20000UNT,5000UNIT (thrombin for soln kit)
Tier 3
THROMBOGEN SOL 10000UNT,1000UNIT,20000UNT,5000UNIT (thrombin for soln)
Tier 3
HEPATITIS B AGENTS ‐ Drugs to Treat Viral Infections
adefov dipiv tab 10mg Tier 1
BARACLUDE SOL (entecavir oral soln) Tier 2
BARACLUDE TAB 0.5MG,1MG (entecavir tab) Tier 3
entecavir tab 0.5mg,1mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 153 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
EPIVIR HBV SOL 10MG/ML,5MG/ML (lamivudine oral soln) Tier 3
EPIVIR HBV TAB 100MG,150MG,300MG (lamivudine tab) Tier 3
HEPSERA TAB 10MG (adefovir dipivoxil tab) Tier 3
lamivudine tab 100mg,150mg,300mg Tier 1 QL (1 unit per 1 day)
VEMLIDY TAB 25MG (tenofovir alafenamide fumarate tab) Tier 2 QL (1 unit per 1 day)
HEPATITIS C AGENT ‐ COMBINATIONS ‐ Drugs to Treat Viral Infections
EPCLUSA TAB 400‐100 (sofosbuvir‐velpatasvir tab) Tier 2 PA; SP; QL (34 days supply)
HARVONI PAK 45‐200MG (ledipasvir‐sofosbuvir pellet pack) Tier 2 PA; QL (34 days supply)
HARVONI TAB 45‐200MG,90‐400MG (ledipasvir‐sofosbuvir tab)
Tier 2 PA; SP; QL (34 days supply)
LEDIP‐SOFOSB TAB 90‐400MG (ledipasvir‐sofosbuvir tab) Tier 4 PA; SP; QL (34 days supply)
MAVYRET TAB 100‐40MG (glecaprevir‐pibrentasvir tab) Tier 4 PA; SP; QL (34 days supply)
SOFOS/VELPAT TAB 400‐100 (sofosbuvir‐velpatasvir tab) Tier 4 PA; SP; QL (34 days supply)
VIEKIRA PAK TAB (ombitas‐paritapre‐riton & dasab tab pak)
Tier 4 PA; SP; QL (34 days supply)
VOSEVI TAB (sofosbuvir‐velpatasvir‐voxilaprevir tab) Tier 2 PA; SP; QL (34 days supply)
ZEPATIER TAB 50‐100MG (elbasvir‐grazoprevir tab) Tier 4 PA; SP; QL (34 days supply)
HEPATITIS C AGENTS ‐ Drugs to Treat Viral Infections
PEGASYS INJ 180MCG/M,200MCG,300MCG,600MCG (peginterferon alfa‐)
Tier 2 PA; SP; QL (34 days supply)
PEGASYS INJ PROCLICK 180MCG/M,200MCG,300MCG,600MCG (peginterferon alfa‐)
Tier 2 PA; SP; QL (34 days supply)
ribavirin cap 200mg Tier 1 PA; SP; QL (34 days supply)
ribavirin tab 200mg Tier 1 PA; SP; QL (34 days supply)
SOVALDI PAK 150MG,200MG (sofosbuvir pellet pack) Tier 3 PA; QL (34 days supply)
SOVALDI TAB 200MG,400MG (sofosbuvir tab) Tier 4 PA; SP; QL (34 days supply)
HEREDITARY OROTIC ACIDURIA TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
XURIDEN POW 2GM (uridine triacetate oral granules packet)
Tier 3 QL (4 units per 1 day)
HEREDITARY TYROSINEMIA TYPE 1 (HT‐1) TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
nitisinone cap 10mg,2mg,5mg Tier 1 PA
NITYR TAB 10MG,2MG,5MG (nitisinone tab) Tier 3 PA
ORFADIN CAP 10MG,20MG,2MG,5MG (nitisinone cap) Tier 3 PA
ORFADIN SUS 4MG/ML (nitisinone susp) Tier 3 PA
HERPES AGENTS ‐ PURINE ANALOGUES ‐ Drugs to Treat Viral Infections
acyclovir cap 200mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 154 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
acyclovir sus 200/5ml Tier 1
acyclovir tab 400mg,800mg Tier 1
SITAVIG TAB 50MG (acyclovir buccal tab) Tier 3
valacyclovir tab 1gm,500mg Tier 1
VALTREX TAB 1GM,500MG (valacyclovir hcl tab) Tier 3
ZOVIRAX SUS 200/5ML (acyclovir susp) Tier 3
ZOVIRAX TAB 400MG,800MG (acyclovir tab) Tier 3
HERPES AGENTS ‐ THYMIDINE ANALOGUES ‐ Drugs to Treat Viral Infections
famciclovir tab 125mg,250mg,500mg Tier 1
HISTAMINE H3‐RECEPTOR ANTAGONIST/INVERSE AGONISTS ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders
WAKIX TAB 17.8MG,4.45MG (pitolisant hcl tab) Tier 4 PA; SP; QL (34 days supply)
HMG COA REDUCTASE INHIBITORS ‐ Drugs for High Cholesterol
ALTOPREV TAB 20MG ER,40MG ER,60MG ER (lovastatin tab er)
Tier 3
atorvastatin tab 10mg,20mg,40mg,80mg Tier 1
atorvastatin calcium tab 10mg,20mg Tier 5
CRESTOR TAB 10MG,20MG,40MG,5MG (rosuvastatin calcium tab)
Tier 5
EZALLOR SPR CAP 10MG,20MG,40MG,5MG (rosuvastatin calcium sprinkle cap)
Tier 3
FLOLIPID SUS 20MG/5ML,40MG/5ML (simvastatin susp) Tier 3
fluvastatin sodium cap 20mg,40mg Tier 5
fluvastatin sodium tab 80mg er Tier 5
LESCOL XL TAB 80MG (fluvastatin sodium tab er) Tier 5
LIPITOR TAB 10MG,20MG,40MG,80MG (atorvastatin calcium tab)
Tier 5
LIVALO TAB 1MG,2MG,4MG (pitavastatin calcium tab) Tier 3
lovastatin tab 10mg,20mg,40mg Tier 5
PRAVACHOL TAB 20MG,40MG (pravastatin sodium tab) Tier 5
pravastatin sodium tab 10mg,20mg,40mg,80mg Tier 5
rosuvastatin tab 20mg,40mg Tier 1
rosuvastatin calcium tab 10mg,5mg Tier 5
simvastatin tab 80mg Tier 1
simvastatin tab 10mg,20mg,40mg,5mg Tier 5
ZOCOR TAB 10MG,20MG,40MG,5MG,80MG (simvastatin tab)
Tier 5
ZYPITAMAG TAB 1MG,2MG,4MG (pitavastatin magnesium tab)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 155 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
HOMEOPATHIC PRODUCTS ‐ Miscellaneous Drugs and Solutions
ACUNOL TAB 600MG (*homeopathic products ‐ tab**) Tier 3
BHI URI‐ TAB CONTROL 600MG (*homeopathic products ‐ tab**)
Tier 3
COLCIGEL GEL (*homeopathic products ‐ gel**) Tier 3
ECZEMOL TAB 600MG (*homeopathic products ‐ tab**) Tier 3
HYLAFEM SUP (*homeopathic products ‐ vag supp**) Tier 3
MORCIN CRE (*homeopathic products ‐ cream**) Tier 3
PSORIZIDE TAB FORTE 600MG (*homeopathic products ‐ tab**)
Tier 3
PSORIZIDE TAB ULTRA 600MG (*homeopathic products ‐ tab**)
Tier 3
RAPID GEL RX GEL (*homeopathic products ‐ gel**) Tier 3
SPEEDGEL RX GEL (*homeopathic products ‐ gel**) Tier 3
TRANZGEL GEL (*homeopathic products ‐ gel**) Tier 3
TRAUMANIL GEL (*homeopathic products ‐ gel**) Tier 3
TRAUMEEL OIN (*homeopathic products ‐ oint**) Tier 3
TRAUMEEL TAB 600MG (*homeopathic products ‐ tab**) Tier 3
WELLMIND TAB VERTIGO 600MG (*homeopathic products ‐ tab**)
Tier 3
HOMOCYSTINURIA TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
CYSTADANE POW (*betaine powder for oral solution***) Tier 3
HUMAN INSULIN ‐ Drugs to treat Diabetes
ADMELOG INJ 100/ML,100U/ML (insulin lispro inj) Tier 3
ADMELOG SOLO INJ 100/ML,100U/ML (insulin lispro soln pen‐injector)
Tier 3
AFREZZA POW 4‐8‐12,8‐12UNIT (insulin regular (human) inh powd)
Tier 3
AFREZZA POW 4‐8‐12,8‐12UNIT (insulin regular (human) inhalation powder)
Tier 3
AFREZZA POW 4‐8‐12,8‐12UNIT (insulin regular (human) inhalation powder)
Tier 3
APIDRA INJ SOLOSTAR (insulin glulisine soln pen‐injector inj)
Tier 3
APIDRA INJ U‐ 100 (insulin glulisine inj) Tier 3
BASAGLAR INJ 100/ML,100UNIT,300IU/ML (insulin glargine soln pen‐injector)
Tier 2
FIASP FLEX INJ TOUCH (insulin aspart (with niacinamide) sol pen‐inj)
Tier 2
FIASP INJ 100/ML (insulin aspart (with niacinamide) inj) Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 156 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
FIASP PENFIL INJ U‐ 100 (insulin aspart (with niacinamide) soln cartridge)
Tier 2
HUMALOG INJ 100/ML (insulin lispro inj) Tier 2
HUMALOG INJ 100/ML (insulin lispro inj) Tier 2
HUMALOG INJ 100/ML,100U/ML (insulin lispro inj) Tier 3
HUMALOG JR INJ 100/ML,100U/ML (insulin lispro soln pen‐injector)
Tier 3
HUMALOG KWIK INJ 100/ML,200/ML (insulin lispro soln pen‐injector)
Tier 2
HUMALOG KWIK INJ 100/ML,100U/ML (insulin lispro soln pen‐injector)
Tier 3
HUMALOG MIX INJ 50/50KWP,75/25KWP (insulin lispro prot & lispro sus pen‐inj)
Tier 2
HUMALOG MIX INJ 50/50KWP,75/25KWP (insulin lispro protamine & lispro inj)
Tier 2
HUMALOG MIX SUS 75/25 (insulin lispro prot & lispro inj) Tier 2
HUMULIN INJ 70/30 FP,70/30KWP (insulin nph & regular susp pen‐inj)
Tier 2
HUMULIN INJ 70/30 FP,70/30KWP (insulin nph isophane & regular human inj)
Tier 2
HUMULIN N INJ U‐ 100 (insulin nph (human) (isophane) inj) Tier 2
HUMULIN N INJ U‐ 100 (insulin nph (human) (isophane) inj) Tier 2
HUMULIN N INJ U‐ 100 (insulin nph (human) (isophane) inj) Tier 3
HUMULIN R INJ U‐ 100,500 (insulin regular (human) inj) Tier 2
HUMULIN R INJ U‐ 100,500 (insulin regular (human) soln pen‐injector)
Tier 2
INS ASP PROT INJ FLEXPEN (insulin aspart prot & aspart sus pen‐inj)
Tier 3
INSULIN ASPA INJ 100/ML (insulin aspart inj) Tier 3
INSULIN ASPA INJ 100/ML (insulin aspart prot & aspart (human) inj)
Tier 3
INSULIN ASPA INJ FLEXPEN (insulin aspart soln pen‐injector)
Tier 3
INSULIN ASPA INJ PENFILL (insulin aspart soln cartridge) Tier 3
INSULIN LISP INJ 100/ML (insulin lispro inj) Tier 2
INSULIN LISP INJ 100/ML (insulin lispro soln pen‐injector) Tier 2
INSULIN LISP INJ JUNIOR 100/ML,200/ML (insulin lispro soln pen‐injector)
Tier 2
INSULIN LISP INJ PROTAMIN 50/50KWP,75/25KWP (insulin lispro prot & lispro sus pen‐inj)
Tier 2
LANTUS INJ 100/ML (insulin glargine inj) Tier 2
LANTUS SOLOS INJ 100/ML,100UNIT,300IU/ML (insulin glargine soln pen‐injector)
Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 157 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
LEVEMIR INJ (insulin detemir inj) Tier 2
LEVEMIR INJ FLEXTOUC (insulin detemir soln pen‐injector) Tier 2
LYUMJEV INJ 100UT/ML (insulin lispro‐aabc inj) Tier 2
LYUMJEV KWPN INJ 100UT/ML (insulin lispro‐aabc soln pen‐inj)
Tier 2
LYUMJEV KWPN INJ 100UT/ML (insulin lispro‐aabc soln pen‐injector)
Tier 2
MYXREDLIN SOL 1UNIT/ML (insulin regular (human) in nacl) Tier 3
NOVOLIN INJ 70/30 FP,70/30KWP (insulin nph & regular susp pen‐inj)
Tier 2
NOVOLIN INJ 70/30 FP,70/30KWP (insulin nph isophane & regular human inj)
Tier 2
NOVOLIN INJ 70/30 FP (insulin nph isophane & regular human inj)
Tier 3
NOVOLIN INJ 70/30 FP (insulin nph isophane & regular human inj)
Tier 3
NOVOLIN N INJ 100 UNIT,100KWP (insulin nph (human) (isophane) susp pen‐injector)
Tier 2
NOVOLIN N INJ 100 UNIT (insulin nph (human) (isophane) susp pen‐injector)
Tier 3
NOVOLIN N INJ RELION 100 (insulin nph (human) (isophane) inj)
Tier 3
NOVOLIN N INJ U‐ 100 (insulin nph (human) (isophane) inj) Tier 2
NOVOLIN N INJ U‐ 100 (insulin nph (human) (isophane) inj) Tier 3
NOVOLIN R INJ 100 UNIT,500 (insulin regular (human) soln pen‐injector)
Tier 2
NOVOLIN R INJ 100 UNIT (insulin regular (human) soln pen‐injector)
Tier 3
NOVOLIN R INJ RELION 100 (insulin regular (human) inj) Tier 3
NOVOLIN R INJ U‐ 100,500 (insulin regular (human) inj) Tier 2
NOVOLIN R INJ U‐ 100 (insulin regular (human) inj) Tier 3
NOVOLIN70/30 INJ RELION 70/30 (insulin nph isophane & regular human inj)
Tier 3
NOVOLOG INJ 100/ML (insulin aspart inj) Tier 2
NOVOLOG INJ 100/ML (insulin aspart inj) Tier 3
NOVOLOG INJ FLEXPEN (insulin aspart soln pen‐injector) Tier 2
NOVOLOG INJ FLEXPEN (insulin aspart soln pen‐injector) Tier 3
NOVOLOG INJ PENFILL (insulin aspart soln cartridge) Tier 2
NOVOLOG INJ PENFILL (insulin aspart soln cartridge) Tier 3
NOVOLOG MIX INJ 70/30 (insulin aspart prot & aspart (human) inj)
Tier 2
NOVOLOG MIX INJ 70/30 (insulin aspart prot & aspart (human) inj)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 158 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NOVOLOG MIX INJ FLEXPEN (insulin aspart prot & aspart sus pen‐inj)
Tier 2
NOVOLOG MIX INJ FLEXPEN (insulin aspart prot & aspart sus pen‐inj)
Tier 3
TOUJEO MAX INJ 100/ML,100UNIT,300IU/ML (insulin glargine soln pen‐injector)
Tier 2
TOUJEO SOLO INJ 100/ML,100UNIT,300IU/ML (insulin glargine soln pen‐injector)
Tier 2
TRESIBA FLEX INJ 100UNIT,200UNIT (insulin degludec soln pen‐injector)
Tier 2
TRESIBA INJ 100UNIT (insulin degludec inj) Tier 2
HYDANTOINS ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders
DILANTIN CAP 100MG,200MG,300MG,30MG (phenytoin sodium extended cap)
Tier 3
DILANTIN CHW 50MG (phenytoin chew tab) Tier 3
DILANTIN‐125 SUS 125/5ML (phenytoin susp) Tier 3
PEGANONE TAB 250MG (ethotoin tab) Tier 3
PHENYTEK CAP 100MG,200MG,300MG,30MG (phenytoin sodium extended cap)
Tier 3
phenytoin chw 50mg Tier 1
phenytoin ex cap 100mg,200mg,300mg Tier 1
phenytoin sus 100/4ml,125/5ml Tier 1
HYDROCODONE COMBINATIONS ‐ Drugs for Treatment of Pain
HYDRO/ACETA SOL 10‐300MG,10‐325MG (hydrocodone‐acetaminophen soln)
Tier 3 PA; QL (75 days;8100 units)
hydroco/apap sol 7.5‐325 Tier 1 PA; QL (75 days;8100 units)
hydroco/apap tab 10‐300mg,10‐325mg,5‐300mg,5‐325mg,7.5‐300,7.5‐325
Tier 1 PA; QL (75 days;540 tablets)
hydrocod/ibu tab 10‐200mg,5‐200mg,7.5‐200 Tier 1 PA; QL (75 days;50 tablets)
hydrocodone bitartrate/acetaminophen tab 10‐300mg,10‐325mg,5‐300mg,5‐325mg,7.5‐300,7.5‐325 (Lorcet)
Tier 1 PA; QL (75 days;540 tablets)
hydrocodone bitartrate/acetaminophen 10‐300mg,10‐325mg,5‐300mg,5‐325mg,7.5‐300,7.5‐325 (Lorcet Plus)
Tier 1 PA; QL (75 days;540 tablets)
hydrocodone bitartrate/acetaminophen tab 10‐300mg,10‐325mg,5‐300mg,5‐325mg,7.5‐300,7.5‐325 (Lorcet)
Tier 1 PA; QL (75 days;720 tablets)
LORTAB ELX 10‐300MG,10‐325MG (hydrocodone‐acetaminophen soln)
Tier 3 PA; QL (75 days;6075 units)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 159 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NORCO TAB 10‐325MG,5‐300MG,5‐325MG,7.5‐325 (hydrocodone‐acetaminophen tab)
Tier 3 PA; QL (75 days;720 tablets)
XODOL TAB 10‐325MG,5‐300MG,5‐325MG,7.5‐325 (hydrocodone‐acetaminophen tab)
Tier 3 PA; QL (75 days;720 tablets)
HYDROLYTIC ENZYMES ‐ Drugs/Products to Help with Breathing
PULMOZYME SOL 1MG/ML (dornase alfa inhal soln) Tier 2 PA; SP; QL (34 days supply)
HYPERAMMONEMIA TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
CARBAGLU TAB 200MG (carglumic acid tab) Tier 3 PA
HYPERPARATHYROID TREATMENT ‐ VITAMIN D ANALOGS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
calcitriol cap 0.25mcg,0.5mcg Tier 1
calcitriol sol 1mcg/ml Tier 1
doxercalcif cap 0.5mcg,1mcg,2.5mcg Tier 1
paricalcitol cap 1 mcg,2 mcg,4 mcg Tier 1
RAYALDEE CAP 30MCG (calcifediol cap er) Tier 3
ROCALTROL CAP 0.25MCG,0.5MCG (calcitriol cap) Tier 2
ROCALTROL SOL 1MCG/ML (calcitriol oral soln) Tier 2
ZEMPLAR CAP 1MCG,2MCG (paricalcitol cap) Tier 2
HYPNOTICS ‐ TRICYCLIC AGENTS ‐ Drugs to Treat Problems with Sleeping
doxepin tab 3mg,6mg Tier 1
SILENOR TAB 3MG,6MG (doxepin hcl (sleep) tab) Tier 2
HYPOPHOSPHATASIA (HPP) AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
STRENSIQ INJ 18/0.45,28/0.7ML,40MG/ML,80/0.8ML (asfotase alfa subcutaneous inj)
Tier 3 PA
IBS AGENT ‐ 5‐HT4 RECEPTOR PARTIAL AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
ZELNORM TAB 6MG (tegaserod maleate tab) Tier 3
IBS AGENT ‐ GUANYLATE CYCLASE‐C (GC‐C) AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
LINZESS CAP 145MCG,290MCG,72MCG (linaclotide cap) Tier 2
IBS AGENT ‐ MU‐OPIOID RECEPTOR AGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
VIBERZI TAB 100MG,75MG (eluxadoline tab) Tier 2
IBS AGENT ‐ SELECTIVE 5‐HT3 RECEPTOR ANTAGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
alosetron tab 0.5mg,1mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 160 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
LOTRONEX TAB 0.5MG,1MG (alosetron hcl tab) Tier 3
IMIDAZOLE‐RELATED ANTIFUNGALS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms
GYNAZOLE‐1 CRE 2% (butoconazole nitrate (one dose) vaginal cream)
Tier 3
miconazole 3 sup 200mg Tier 1
terconazole cre 0.4%,0.8% Tier 1
terconazole sup 80mg Tier 1
IMIDAZOLE‐RELATED ANTIFUNGALS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
clotrimazole cre 1% Tier 1
clotrimazole sol 1% Tier 1
econazole cre 1% Tier 1
ECOZA AER 1% (econazole nitrate foam) Tier 3
ERTACZO CRE 2% (sertaconazole nitrate cream) Tier 3
EXELDERM CRE 1% (sulconazole nitrate cream) Tier 3
EXELDERM SOL 1% (sulconazole nitrate solution) Tier 3
EXTINA AER 2% (ketoconazole foam) Tier 3
JUBLIA SOL 10% (efinaconazole soln) Tier 3 PA
ketoconazole aer 2% Tier 1
ketoconazole cre 2% Tier 1
ketoconazole sha 2% Tier 1
ketodan aer 2% Tier 1
luliconazole cre 1% Tier 1
LUZU CRE 1% (luliconazole cream) Tier 3
oxiconazole cre nitrate Tier 1
OXISTAT CRE 1% (oxiconazole nitrate cream) Tier 3
OXISTAT LOT 1% (oxiconazole nitrate lotion) Tier 3
sulconazole cre 1% Tier 1
sulconazole sol 1% Tier 1
XOLEGEL GEL 2% (ketoconazole gel) Tier 3
IMIDAZOLES ‐ Drugs to Treat Fungal Infections
ketoconazole tab 200mg Tier 1
IMIDAZOTETRAZINES ‐ Drugs for Treatment of Cancer
TEMODAR CAP 100MG,140MG,180MG,20MG,250MG,5MG (temozolomide cap)
Tier 2 PA; SP; QL (34 days supply); OAC
TEMODAR INJ 100MG (temozolomide for iv soln) Tier 4 PA; SP; QL (34 days supply)
temozolomide cap 100mg,140mg,180mg,20mg,250mg,5mg Tier 1 PA; SP; QL (34 days supply); OAC
IMMUNE GLOBULIN IMMUNOSUPPRESSANTS ‐ Miscellaneous Drugs and Solutions
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 161 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ATGAM INJ 250MG (lymphocyte immune globulin anti‐thymocyte g inj)
Tier 3
THYMOGLOBULN INJ 25MG (anti‐thymocyte globulin for iv soln)
Tier 3
IMMUNE SERUMS ‐ Vaccines and Drugs for the Immune System
ASCENIV INJ 10% (immune globulin (human)‐slra iv soln) Tier 4 PA; SP; QL (34 days supply)
BIVIGAM INJ 10%,10/100ML,10/200ML,10GM,10GRAMS,1GM,2.5GM,20/200ML,20/400ML,20GRAMS,25GM,2GM/20ML,30/300ML,40GRAMS,5 GRAMS,5%,5GM,5GM/50ML (immune globulin (human) iv soln)
Tier 4 PA; SP; QL (34 days supply)
CARIMUNE NF INJ 10GM HU,12GM,5GM HU,6GM (immune globulin (human) iv for soln)
Tier 4 PA; SP; QL (34 days supply)
CUTAQUIG SOL 1.65GM,1GM,2GM,3.3GM,4GM,8GM (immune globulin (human)‐hipp subcutaneous inj)
Tier 3 PA
CUVITRU INJ 10/50ML,10GM/50M,1GM/5ML,2GM/10ML,4GM/20ML,8GM/40ML (immune globulin (human) subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
CUVITRU SOL 10/50ML,10GM/50M,1GM/5ML,2GM/10ML,4GM/20ML,8GM/40ML (immune globulin (human) subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
FLEBOGAMMA INJ 10%,10/100ML,10/200ML,10GM,10GRAMS,1GM,2.5GM,20/200ML,20/400ML,20GRAMS,25GM,2GM/20ML,30/300ML,40GRAMS,5 GRAMS,5%,5GM,5GM/50ML (immune globulin (human) iv soln)
Tier 4 PA; SP; QL (34 days supply)
FLEBOGAMMA INJ DIF 10%,10/100ML,10/200ML,10GM,10GRAMS,1GM,2.5GM,20/200ML,20/400ML,20GRAMS,25GM,2GM/20ML,30/300ML,40GRAMS,5 GRAMS,5%,5GM,5GM/50ML (immune globulin (human) iv soln)
Tier 4 PA; SP; QL (34 days supply)
GAMASTAN INJ (immune globulin (human) im inj) Tier 4 PA; SP; QL (34 days supply)
GAMASTAN S/D INJ (immune globulin (human) im inj) Tier 4 PA; SP; QL (34 days supply)
GAMMAGARD INJ 10GM/100,1GM/10ML,2.5GM/25,20GM/200,30GM/300,40/400ML,5GM/50ML (immune globulin (human) iv or subcutaneous soln)
Tier 4 PA; SP; QL (34 days supply)
GAMMAGARD SD INJ 10GM HU,12GM,5GM HU,6GM (immune globulin (human) iv for soln)
Tier 4 PA; SP; QL (34 days supply)
GAMMAKED INJ 10GM/100,1GM/10ML,2.5GM/25,20GM/200,30GM/300,40/400ML,5GM/50ML (immune globulin (human) iv or subcutaneous soln)
Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 162 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
GAMMAPLEX INJ 10%,10/100ML,10/200ML,10GM,10GRAMS,1GM,2.5GM,20/200ML,20/400ML,20GRAMS,25GM,2GM/20ML,30/300ML,40GRAMS,5 GRAMS,5%,5GM,5GM/50ML (immune globulin (human) iv soln)
Tier 4 PA; SP; QL (34 days supply)
GAMUNEX‐C INJ 10GM/100,1GM/10ML,2.5GM/25,20GM/200,30GM/300,40/400ML,5GM/50ML (immune globulin (human) iv or subcutaneous soln)
Tier 4 PA; SP; QL (34 days supply)
HIZENTRA INJ 10/50ML,10GM/50M,1GM/5ML,2GM/10ML,4GM/20ML,8GM/40ML (immune globulin (human) subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
HIZENTRA INJ 10/50ML,10GM/50M,1GM/5ML,2GM/10ML,4GM/20ML,8GM/40ML (immune globulin (human) subcutaneous soln pref syr)
Tier 4 PA; SP; QL (34 days supply)
HIZENTRA SOL 1GM/5ML,20%,2GM/10ML (immune globulin (human) subcutaneous soln pref syr)
Tier 4 PA; SP; QL (34 days supply)
OCTAGAM INJ 10%,10/100ML,10/200ML,10GM,10GRAMS,1GM,2.5GM,20/200ML,20/400ML,20GRAMS,25GM,2GM/20ML,30/300ML,40GRAMS,5 GRAMS,5%,5GM,5GM/50ML (immune globulin (human) iv soln)
Tier 4 PA; SP; QL (34 days supply)
PANZYGA SOL 10/100ML,1GM/10ML,2.5/25ML,20/200ML,30/300ML,5GM/50ML (immune globulin (human)‐ifas iv soln)
Tier 4 PA; SP; QL (34 days supply)
PRIVIGEN INJ 10%,10/100ML,10/200ML,10GM,10GRAMS,1GM,2.5GM,20/200ML,20/400ML,20GRAMS,25GM,2GM/20ML,30/300ML,40GRAMS,5 GRAMS,5%,5GM,5GM/50ML (immune globulin (human) iv soln)
Tier 4 PA; SP; QL (34 days supply)
XEMBIFY INJ 10G/50ML,1GM/5ML,2GM/10ML,4GM/20ML (immune globulin (human)‐klhw subcutaneous inj)
Tier 4 PA; SP; QL (34 days supply)
IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES ‐ Miscellaneous Drugs and Solutions
REVLIMID CAP 10MG,15MG,20MG,25MG,5MG (lenalidomide cap)
Tier 2 PA; SP; QL (34 days supply); OAC
REVLIMID CAP 10MG,15MG,20MG,25MG,5MG (lenalidomide caps)
Tier 2 PA; SP; QL (34 days supply); OAC
IMMUNOMODULATORS IMIDAZOQUINOLINAMINES ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
ALDARA CRE 5% (imiquimod cream) Tier 3
imiquimod cre 3.75%pmp,5% Tier 1
ZYCLARA CRE 2.5%,3.75% (imiquimod cream) Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 163 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ZYCLARA PUMP CRE 2.5%,3.75% (imiquimod cream) Tier 2
IN VITRO/LOCK ANTICOAGULANTS ‐ Drugs to Treat Blood Clots
ACD FORMULA SOL A (*anticoagulant citrate dextrose solution a**)
Tier 3
ANTICOAG CIT SOL DEX SOL (*anticoagulant citrate dextrose solution a**)
Tier 3
ANTICOAGULNT SOL SOD CITR (anticoagulant sodium citrate soln)
Tier 3
NOCLOT‐50 SOL ACD‐A (*anticoagulant citrate dextrose solution a**)
Tier 3
TRICITRASOL CON (anticoagulant sodium citrate concentrate)
Tier 3
INCRETIN MIMETIC AGENTS (GLP‐1 RECEPTOR AGONISTS) ‐ Drugs to treat Diabetes
ADLYXIN INJ 10/20MCG (lixisenatide pen‐inj starter kit) Tier 3
ADLYXIN INJ 10/20MCG (lixisenatide soln pen‐injector) Tier 3
BYDUREON BC INJ 2/0.85ML (exenatide extended release susp auto‐injector)
Tier 3
BYDUREON PEN INJ 2MG (exenatide extended release for susp pen‐injector)
Tier 3
BYETTA INJ 10MCG,5MCG (exenatide soln pen‐injector) Tier 3
OZEMPIC INJ 2/1.5ML (semaglutide soln pen‐inj) Tier 2
RYBELSUS TAB 14MG,3MG,7MG (semaglutide tab) Tier 2
TRULICITY INJ 0.75/0.5,1.5/0.5 (dulaglutide soln pen‐injector)
Tier 2
VICTOZA INJ 18MG/3ML (liraglutide soln pen‐injector) Tier 2
INFECTION TESTS ‐ Products for Testing
ID NOW CONTR KIT COVID‐ 19 (covid‐19 control test kit) Tier 3
ID NOW KIT COVID‐ 19 (covid‐19 test kit) Tier 3
INFLAMMATORY BOWEL AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
APRISO CAP 0.375GM (mesalamine cap er) Tier 3
ASACOL HD TAB 800MG (mesalamine tab delayed release) Tier 3
AZULFIDINE TAB 500MG (sulfasalazine tab) Tier 3
AZULFIDINE TAB 500MG (sulfasalazine tab delayed release) Tier 3
balsalazide cap 750mg Tier 1
CANASA SUP 1000MG (mesalamine suppos) Tier 3
COLAZAL CAP 750MG (balsalazide disodium cap) Tier 3
DELZICOL CAP 400MG (mesalamine cap dr) Tier 3
DIPENTUM CAP 250MG (olsalazine sodium cap) Tier 3
LIALDA TAB 1.2GM (mesalamine tab delayed release) Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 164 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
mesalamine cap 400mg dr Tier 1
mesalamine cap 400mg dr Tier 1
mesalamine ene 4gm Tier 1
mesalamine kit 4gm Tier 1
mesalamine sup 1000mg Tier 1
mesalamine tab 1.2gm,800mg dr Tier 1
PENTASA CAP 250MG CR,500MG CR (mesalamine cap er) Tier 2
ROWASA KIT 4GM (*mesalamine rectal enema) Tier 3
SFROWASA ENE 4GM (mesalamine sulfite‐free (sf) enema) Tier 3
sulfasalazin tab 500mg Tier 1
sulfasalazin tab 500mg Tier 1
sulfazine tab 500mg Tier 1
INFLUENZA AGENTS ‐ Drugs to Treat Viral Infections
rimantadine tab 100mg Tier 1
INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS ‐ Miscellaneous Drugs and Solutions
CELLCEPT CAP 250MG (mycophenolate mofetil cap) Tier 3
CELLCEPT IV INJ 500MG (mycophenolate mofetil hcl for iv soln)
Tier 3
CELLCEPT SUS 200MG/ML (mycophenolate mofetil for oral susp)
Tier 3
CELLCEPT TAB 500MG (mycophenolate mofetil tab) Tier 3
mycophenolat cap 250mg Tier 1
mycophenolat inj 500mg Tier 1
mycophenolat sus 200mg/ml Tier 1
mycophenolat tab 500mg Tier 1
mycophenolic tab 180mg dr,360mg dr Tier 1
MYFORTIC TAB 180MG,360MG (mycophenolate sodium tab dr)
Tier 3
INSULIN‐INCRETIN MIMETIC COMBINATIONS ‐ Drugs to treat Diabetes
SOLIQUA INJ 100/33 (insulin glargine‐lixisenatide sol pen‐inj)
Tier 2
XULTOPHY INJ 100/3.6 (insulin degludec‐liraglutide sol pen‐inj)
Tier 2
INSULIN‐LIKE GROWTH FACTOR‐1 RECEPTOR INHIBITORS(IGF‐1R) ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
TEPEZZA INJ 500MG (teprotumumab‐trbw for iv soln) Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 165 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
INSULIN‐LIKE GROWTH FACTORS (SOMATOMEDINS) ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
INCRELEX INJ 40MG/4ML (mecasermin inj) Tier 4 PA; SP; QL (34 days supply)
INTEGRIN RECEPTOR ANTAGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
ENTYVIO INJ 300MG (vedolizumab for iv solution) Tier 4 PA; SP; QL (34 days supply)
INTERLEUKIN ANTAGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
STELARA INJ 45MG/0.5 (ustekinumab inj) Tier 2 PA; SP; QL (34 days supply)
INTERLEUKIN‐1 BLOCKERS ‐ Drugs to Treat Pain and Inflammation
ARCALYST INJ 220MG (rilonacept for inj) Tier 4 PA; SP; QL (34 days supply)
INTERLEUKIN‐1 RECEPTOR ANTAGONIST (IL‐1RA) ‐ Drugs to Treat Pain and Inflammation
KINERET INJ (anakinra subcutaneous soln prefilled syringe) Tier 3 PA; QL (0.67 unit per 1 day)
INTERLEUKIN‐1BETA BLOCKERS ‐ Drugs to Treat Pain and Inflammation
ILARIS INJ 150MG/ML (canakinumab subcutaneous inj) Tier 2 PA; SP; QL (34 days supply)
INTERLEUKIN‐5 ANTAGONISTS (IGG1 KAPPA) ‐ Drugs to Treat Asthma and Breathing Disorders
FASENRA INJ 30MG/ML (benralizumab subcutaneous soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
FASENRA PEN INJ 30MG/ML (benralizumab subcutaneous soln auto‐injector)
Tier 2 PA; SP; QL (34 days supply)
NUCALA INJ 100MG (mepolizumab for inj) Tier 2 PA; SP; QL (34 days supply)
NUCALA INJ 100MG (mepolizumab subcutaneous solution pref syringe)
Tier 2 PA; SP; QL (34 days supply)
NUCALA INJ 100MG (mepolizumab subcutaneous solution pref syringe)
Tier 2 PA; SP; QL (34 days supply)
INTERLEUKIN‐5 ANTAGONISTS (IGG4 KAPPA) ‐ Drugs to Treat Asthma and Breathing Disorders
CINQAIR INJ (reslizumab iv infusion soln) Tier 4 PA; SP; QL (34 days supply)
INTERLEUKIN‐6 (IL‐6) ANTAGONISTS ‐ Miscellaneous Drugs and Solutions
SYLVANT SOL 100MG,400MG (siltuximab for iv infusion) Tier 4 PA; SP; QL (34 days supply)
INTERLEUKIN‐6 RECEPTOR INHIBITORS ‐ Drugs to Treat Pain and Inflammation
ACTEMRA INJ 200/10ML,400/20ML,80MG/4ML (tocilizumab iv inj)
Tier 4 PA; SP; QL (34 days supply)
ACTEMRA INJ 200/10ML,400/20ML,80MG/4ML (tocilizumab subcutaneous soln prefilled syringe)
Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 166 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ACTEMRA INJ ACTPEN (tocilizumab subcutaneous soln auto‐injector)
Tier 4 PA; SP; QL (34 days supply)
KEVZARA INJ 150/1.14,200/1.14 (sarilumab subcutaneous soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
KEVZARA INJ 150/1.14,200/1.14 (sarilumab subcutaneous solution auto‐injector)
Tier 2 PA; SP; QL (34 days supply)
INTERSTITIAL CYSTITIS AGENTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
ELMIRON CAP 100MG (pentosan polysulfate sodium caps) Tier 3
PENTOSAN CAP 150MG,200MG (pentosan polysulfate sodium cap delayed release)
Tier 3
RIMSO‐50 SOL 50% (dimethyl sulfoxide soln) Tier 3
INTEST CHOLEST ABSORP INHIB‐HMG COA REDUCTASE INHIB COMB ‐ Drugs for High Cholesterol
ezetim/simva tab 10‐10mg,10‐20mg,10‐40mg,10‐80mg Tier 1
VYTORIN TAB 10‐10MG,10‐20MG,10‐40MG,10‐80MG (ezetimibe‐simvastatin tab)
Tier 3
INTESTINAL ACIDIFIERS ‐ Drugs to Treat Disorders of the Stomach and Intestines
lactulose sol 10gm/15 (Enulose) Tier 1
lactulose sol 10gm/15 (Generlac) Tier 1
lactulose sol 10gm/15 Tier 1
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ‐ Drugs for High Cholesterol
ezetimibe tab 10mg Tier 1
ZETIA TAB 10MG (ezetimibe tab) Tier 3
INTRARECTAL STEROIDS ‐ Drugs to Treat Misc Rectal Problems & Disorders
hydrocortisone rectal ene 100mg (Colocort) Tier 1
CORTENEMA ENE 100MG (hydrocortisone enema) Tier 3
CORTIFOAM AER 90MG (hydrocortisone acetate perianal foam)
Tier 2
hydrocort ene 100mg Tier 1
UCERIS AER 2MG/ACT (budesonide rectal foam) Tier 3
IODINE ANTISEPTICS ‐ Drugs and Products to Prevent the Growth of Disease‐Causing Microorganisms
IODINE TIN 2% (*iodine tincture**) Tier 3
IODINE EXPECTORANTS ‐ Drugs to Treat Cough / Cold / Allergies
SSKI SOL 1GM/ML (potassium iodide oral soln) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 167 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
IODINE PRODUCTS ‐ Drugs for Replacement of Minerals in the Body
iodine sol strong Tier 1
IRON ‐ Drugs to Treat Blood Disorders
TRIFERIC POW 272MG (ferric pyrophosphate citrate pack) Tier 3
TRIFERIC SOL 27.2/5ML (ferric pyrophosphate citrate soln) Tier 3
IRON COMBINATIONS ‐ Drugs to Treat Blood Disorders
ACTIVE FE TAB 75‐1.25 (*fe carbonyl‐fa‐b complex‐a‐c‐d‐e‐min tab)
Tier 3
chromagen cap Tier 1
corvita 150 tab Tier 1
CORVITE 150 TAB (*iron combination tab***) Tier 3
CORVITE 150 TAB (iron‐folic acid‐vit c‐vit b) Tier 3
CORVITE FE TAB 150 TAB (*iron combination tab***) Tier 3
FERIVAFA CAP 110‐1MG (*iron‐c‐fa‐b12‐biotin‐copper‐docusate cap)
Tier 3
ferocon cap Tier 1
ferotrinsic cap Tier 1
FERRO‐PLEX TAB (*fe fum‐dss‐vit c‐vit e‐vit b) Tier 3
FERROTRIN CAP (iron w/ b) Tier 3
FOLIVANE‐PLS CAP (*fe fum‐iron polysacch complex‐fa‐b complex‐c‐biotin cap***)
Tier 3
foltrin cap Tier 1
FOLVITE‐FE TAB (iron‐vit c‐vit b) Tier 3
FUSION PLUS CAP (*fe fum‐iron poly cmplx‐fa‐b cmplx‐c‐biotin‐probiotic cap***)
Tier 3
hematogen cap Tier 1
hematogen cap forte Tier 1
HEMATOGEN FA CAP (fe fumarate‐vit c‐vit b) Tier 3
HEMATRON‐AF TAB (*iron‐docusate‐b12‐folic acid‐c‐e‐cu‐biotin tab)
Tier 3
ICAR‐C PLUS TAB (iron‐vit c‐vit b) Tier 3
iferex 150 cap forte,150 fort Tier 1
INTEGRA PLUS CAP (*fe fum‐iron polysacch complex‐fa‐b complex‐c‐biotin cap***)
Tier 3
IROSPAN 24/6 MIS (*fe bisglyc‐fe polys‐succ acd‐b cmplx‐c‐ca‐fa tab ther pk**)
Tier 3
IS 24/6 MIS (*fe bisglyc‐fe polys‐succ acd‐b cmplx‐c‐ca‐fa tab ther pk**)
Tier 3
k‐tan plus cap Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 168 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MULTIGEN PLS TAB (*fe aspart gly‐fe fum‐succ acd‐c‐threonic acd‐b)
Tier 3
MULTIGEN TAB (*fe asparto gly‐succ acd‐c‐threonic acd‐b) Tier 3
MULTIGEN TAB FOLIC (*fe asparto gly‐succinic acd‐vit c‐threonic acd‐b)
Tier 3
myferon 150 cap forte,150 fort Tier 1
NEPHRON FA TAB (*ferrous fumarate w/ fa‐dss‐b complex‐vit c tab***)
Tier 3
NIFEREX TAB 150 TAB (*iron combination tab***) Tier 3
NUFERA TAB 150 TAB (*iron combination tab***) Tier 3
poly‐iron cap 150 cap forte,150 fort Tier 1
polysacchari cap iron 150 cap forte,150 fort Tier 1
purevit dual cap fe plus Tier 1
se‐tan plus cap Tier 1
TARON FORTE CAP (*fe bisglycinate‐fe polysacch‐vit c‐vit b) Tier 3
tl‐hem 150 tab Tier 1
tricon cap Tier 1
trigels‐f cap forte Tier 1
VIRT‐FEFA CAP PLUS (*fe fum‐iron polysacch complex‐fa‐b complex‐c‐biotin cap***)
Tier 3
IRON W/ FOLIC ACID ‐ Drugs to Treat Blood Disorders
FOLIVANE‐F CAP (*fe fum‐fe poly‐fa‐c‐b) Tier 3
FUSION PAK SPRINKLE (*fe fum‐fe polys cmplx‐fa‐c‐probiotic pack)
Tier 3
hematinic/fa tab Tier 1
hemocyte‐f tab Tier 1
INTEGRA F CAP (*fe fum‐fe poly‐fa‐c‐b) Tier 3
IRRIGATION SOLUTIONS ‐ Miscellaneous Drugs and Solutions
argyl saline sol 0.9%,0.9% irr Tier 1
lactated rin sol irrigat Tier 1
physiosol sol irrigat Tier 1
ringers irr sol Tier 1
steril water sol irrig 100ml Tier 1
tis‐u‐sol sol Tier 1
tis‐u‐sol sol Tier 1
ISOCITRATE DEHYDROGENASE‐1 (IDH1) INHIBITORS ‐ Drugs for Treatment of Cancer
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 169 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
TIBSOVO TAB 250MG (ivosidenib tab) Tier 3 PA; QL (2 units per 1 day)
ISOCITRATE DEHYDROGENASE‐2 (IDH2) INHIBITORS ‐ Drugs for Treatment of Cancer
IDHIFA TAB 100MG,50MG (enasidenib mesylate tab) Tier 4 PA; SP; QL (34 days supply)
JANUS ASSOCIATED KINASE (JAK) INHIBITORS ‐ Drugs for Treatment of Cancer
INREBIC CAP 100MG (fedratinib hcl cap) Tier 4 PA; SP; QL (34 days supply)
JAKAFI TAB 10MG,15MG,20MG,25MG,5MG (ruxolitinib phosphate tab)
Tier 4 PA; SP; QL (34 days supply); OAC
KERATOLYTIC AND/OR ANTIMITOTIC COMBINATIONS ‐ Drugs to Treat Skin Disorders
BENSAL HP OIN (salicylic acid & benzoic acid oint) Tier 3
GORDOFILM SOL (salicylic & lactic acids soln) Tier 3
PYROGALL ACD OIN (pyrogallol‐chlorobutanol oint) Tier 3
KERATOLYTIC/ANTIMITOTIC AGENTS ‐ Drugs to Treat Skin Disorders
CANTHARIDIN SOL 0.7% (cantharidin soln) Tier 3
CONDYLOX GEL 0.5% (podofilox gel) Tier 2
KERALYT GEL 6% (salicylic acid gel) Tier 3
PODOCON SOL 25% (podophyllum resin soln) Tier 3
podofilox sol 0.5% Tier 1
SALEX SHA 6% (salicylic acid shampoo) Tier 3
salicylic ac cre 6% Tier 1
salicylic ac gel 6% Tier 1
salicylic ac liq 27.5% Tier 1
salicylic ac lot 6% Tier 1
salicylic ac sha 6% Tier 1
salicylic ac sol 28.5% er Tier 1
salicylic ac sol 28.5% er Tier 1
salicylic aer 6% Tier 1
salimez cre 6% Tier 1
SALIMEZ FORT CRE 10% (salicylic acid cream) Tier 3
SALVAX AER 6% (salicylic acid foam) Tier 3
ULTRASAL‐ER SOL 28%,28.5% (salicylic acid er film‐forming soln)
Tier 3
VIRASAL LIQ 27.5% (salicylic acid film forming liquid) Tier 3
XALIX SOL 28%,28.5% (salicylic acid er film‐forming soln) Tier 3
LAXATIVES ‐ MISCELLANEOUS ‐ Drugs to Treat Constipation
constulose sol 10gm/15,20gm/30 Tier 1
KRISTALOSE PAK 10GM,20GM (lactulose oral crystal packet) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 170 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
LACTULOSE PAK 10GM,20GM (lactulose oral crystal packet) Tier 3
lactulose sol 10gm/15 Tier 1
LEPROSTATICS ‐ Antibiotics / Drugs for Infections
dapsone tab 100mg,25mg Tier 1
LEPTIN ANALOGUES ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
MYALEPT INJ 11.3MG (metreleptin for subcutaneous inj) Tier 3 PA; QL (1 unit per 1 day)
LEUKOTRIENE RECEPTOR ANTAGONISTS ‐ Drugs to Treat Asthma and Breathing Disorders
ACCOLATE TAB 10MG,20MG (zafirlukast tab) Tier 3
montelukast chw 4mg,5mg Tier 1
montelukast gra 4mg Tier 1
montelukast tab 10mg Tier 1
SINGULAIR CHW 4MG,5MG (montelukast sodium chew tab) Tier 3
SINGULAIR GRA 4MG (montelukast sodium oral granules packet)
Tier 3
SINGULAIR TAB 10MG (montelukast sodium tab) Tier 3
zafirlukast tab 10mg,20mg Tier 1
LEVODOPA COMBINATIONS ‐ Drugs to treat Parkinson's Disease
carb/levo 50 tab /entacap,75 tab /entacap Tier 1
carb/levo er tab 25‐100mg,50‐200mg Tier 1
carb/levo tab 10‐100mg,25‐100mg,25‐250mg Tier 1
carb/levo tab 10‐100mg,25‐100mg,25‐250mg Tier 1
carb/levo100 tab /entacap 50 tab /entacap,75 tab /entacap Tier 1
carb/levo125 tab /entacap 50 tab /entacap,75 tab /entacap Tier 1
carb/levo150 tab /entacap 50 tab /entacap,75 tab /entacap Tier 1
carb/levo200 tab /entacap 50 tab /entacap,75 tab /entacap Tier 1
DUOPA SUS 4.63‐20 (carbidopa‐levodopa enteral susp) Tier 3
RYTARY CAP 145MG,195MG,245MG,95MG (carbidopa & levodopa cap er)
Tier 3
SINEMET TAB 10‐100MG,25‐100MG,25‐250MG (carbidopa & levodopa tab)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 171 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
STALEVO 100 TAB,125 TAB,150 TAB,200 TAB,50 TAB,75 TAB (carbidopa‐levodopa‐entacapone tabs)
Tier 3
LHRH ANALOGS ‐ Drugs for Treatment of Cancer
ELIGARD INJ 11.25MG,22.5MG,30MG,45MG (leuprolide acetate)
Tier 2 PA; SP; QL (34 days supply)
ELIGARD INJ 11.25MG,22.5MG,30MG,45MG (leuprolide acetate for subcutaneous inj kit)
Tier 2 PA; SP; QL (34 days supply)
leuprolide inj 1mg/0.2 Tier 1 PA; SP; QL (34 days supply)
LUPRON DEPOT INJ 11.25MG,22.5MG,30MG,45MG (leuprolide acetate)
Tier 2 PA; SP; QL (34 days supply)
LUPRON DEPOT INJ 11.25MG,22.5MG,30MG,45MG (leuprolide acetate for inj kit)
Tier 2 PA; SP; QL (34 days supply)
TRELSTAR MIX INJ 11.25MG,22.5MG,3.75MG (triptorelin pamoate for im susp)
Tier 4 PA; SP; QL (34 days supply)
VANTAS KIT 50MG (histrelin acetate implant kit) Tier 4 PA; SP; QL (34 days supply)
ZOLADEX IMP 10.8MG,3.6MG (goserelin acetate implant) Tier 4 PA; SP; QL (34 days supply)
LHRH/GNRH AGONIST ANALOG COMBINATIONS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
LUPANETA KIT 11.25‐5,3.75‐5 (leuprolide) Tier 4 PA; SP; QL (34 days supply)
LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
LUPR DEP‐PED INJ 11.25MG,3M 30MG (leuprolide acetate) Tier 4 PA; SP; QL (34 days supply)
LUPR DEP‐PED INJ 11.25MG,3M 30MG (leuprolide acetate for inj pediatric kit)
Tier 4 PA; SP; QL (34 days supply)
SUPPRELIN LA KIT 50MG (histrelin acetate (cpp) implant kit) Tier 4 PA; SP; QL (34 days supply)
SYNAREL SOL 2MG/ML (nafarelin acetate nasal soln) Tier 3
TRIPTODUR SUS 22.5MG (triptorelin pamoate for im er susp)
Tier 3 PA
LINCOSAMIDES ‐ Antibiotics / Drugs for Infections
CLEOCIN CAP 150MG,300MG,75MG (clindamycin hcl cap) Tier 2
CLEOCIN PED SOL 75MG/5ML (clindamycin palmitate hcl for soln)
Tier 2
clindamycin cap 150mg,300mg,75mg Tier 1
clindamycin sol 75mg/5ml Tier 1
LINIMENTS ‐ Drugs to Treat Skin Disorders
TURPENTINE SOL SPIRITS (turpentine spirit) Tier 3
LIPIDS ‐ Drugs/Products Used for Providing Nourishment
NEOKE MCT 70 POW (medium chain triglycerides oral powder)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 172 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
LIPOTROPIC COMBINATIONS ‐ Drugs/Products Used for Providing Nourishment
LECITHIN GRA (lecithin granules) Tier 3
LOCAL ANESTHETIC & SYMPATHOMIMETIC ‐ Drugs for Anesthesia
RECK INJ (ropiv‐epi‐clonid‐ketorolac pref syr) Tier 3
ROP‐CLON‐KET INJ 15/50ML (ropivacaine‐clonidine‐ketorolac pref syr)
Tier 3
LOCAL ANESTHETICS ‐ AMIDES ‐ Drugs for Anesthesia
LIDO/DEXTROS INJ 5‐7.5% (lidocaine) Tier 3
LOCAL ANESTHETICS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
lidocaine 7t gel 2% (7T Lido) Tier 1 QL (25 days;30 units)
ANACAINE OIN (benzocaine oint) Tier 3
ASTERO GEL 4% (lidocaine hcl gel) Tier 3 QL (25 days;30 units)
c‐topical sol 4% Tier 1
lidocaine gel 2%,2% jelly (Glydo) Tier 1 QL (25 days;60 units)
LDO PLUS GEL 4% (lidocaine hcl gel) Tier 3 QL (25 days;30 units)
lidocaine gel 2% jelly Tier 1 QL (25 days;60 units)
lidocaine gel 2% jelly Tier 1 QL (25 days;60 units)
lidocaine oin 5% Tier 1 QL (25 days;50 units)
lidocaine pad 5% Tier 1 PA
lidocaine sol 4% Tier 1
LIDODERM DIS 5% (lidocaine patch) Tier 2 PA
pramoxine hydrochloride gel 1% (Pramox Gel) Tier 1
QUTENZA KIT 8% 1‐PCH,8% 2‐PCH (capsaicin patch) Tier 3
ZTLIDO PAD 1.8% (lidocaine patch) Tier 3 PA
LOOP DIURETICS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders
bumetanide tab 0.5mg,1mg,2mg Tier 1
BUMEX TAB 0.5MG,1MG,2MG (bumetanide tab) Tier 3
EDECRIN TAB 25MG (ethacrynic acid tab) Tier 3
ethacrynic tab acd 25mg Tier 1
furosemide sol 10mg/ml,8mg/ml Tier 1
furosemide tab 20mg,40mg,80mg Tier 1
LASIX TAB 20MG,40MG,80MG (furosemide tab) Tier 3
torsemide tab 100mg,10mg,20mg,5mg Tier 1
LUBRICANT LAXATIVES ‐ Drugs to Treat Constipation
mineral oil heavy Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 173 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
LYMPHOCYTE FUNCTION‐ASSOCIATED ANTIGEN‐1 (LFA‐1) ANTAG ‐ Drugs for Treatment of Disorders in the Eyes
XIIDRA DRO 5% (lifitegrast ophth soln) Tier 2
LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
KANUMA INJ 20/10ML (sebelipase alfa iv soln) Tier 4 PA; SP; QL (34 days supply)
MACROLIDE IMMUNOSUPPRESSANTS ‐ Miscellaneous Drugs and Solutions
ASTAGRAF XL CAP 0.5MG,1MG,5MG (tacrolimus cap er) Tier 3
ENVARSUS XR TAB 0.75MG,1MG,4MG (tacrolimus tab er) Tier 3
everolimus tab 0.25mg,0.5 mg,0.75mg,2.5mg,5mg,7.5mg Tier 1 PA; SP; QL (34 days supply); OAC
PROGRAF CAP 0.5MG,1MG,5MG (tacrolimus cap) Tier 3
PROGRAF GRA 0.2MG,1MG (tacrolimus packet for susp) Tier 3
PROGRAF INJ 5MG/ML (tacrolimus inj) Tier 3
RAPAMUNE SOL 1MG/ML (sirolimus oral soln) Tier 3
RAPAMUNE TAB 0.5MG,1MG,2MG (sirolimus tab) Tier 3
sirolimus sol 1mg/ml Tier 1
sirolimus tab 0.5mg,1mg,2mg Tier 1
tacrolimus cap 0.5mg,1mg,5mg Tier 1
ZORTRESS TAB 0.25MG,0.5MG,0.75MG,1MG (everolimus tab)
Tier 3 OAC
MACROLIDE IMMUNOSUPPRESSANTS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
ELIDEL CRE 1% (pimecrolimus cream) Tier 3 PA
pimecrolimus cre 1% Tier 1 PA
PROTOPIC OIN 0.03%,0.1% (tacrolimus oint) Tier 3 PA
TACROLIMUS CRE MONOHYDR (tacrolimus cream) Tier 3 PA
tacrolimus oin 0.03%,0.1% Tier 1 PA
MAGNESIUM COMBINATIONS ‐ Drugs for Replacement of Minerals in the Body
MAGNEBIND TAB 400 (magnesium‐calcium‐folic acid tab) Tier 3
MEGLITINIDE ANALOGUES ‐ Drugs to treat Diabetes
nateglinide tab 120mg,60mg Tier 1
repaglinide tab 0.5mg,1mg,2mg Tier 1
STARLIX TAB 120MG,60MG (nateglinide tab) Tier 3
MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS ‐ Drugs for High Cholesterol
JUXTAPID CAP 10MG,20MG,30MG,40MG,5MG,60MG (lomitapide mesylate cap)
Tier 3 PA; QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 174 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MIGRAINE PRODUCTS ‐ Drugs to Treat Migraine Headaches
D.H.E. 45 INJ 1MG/ML (dihydroergotamine mesylate inj) Tier 2
dihydroergot inj 1mg/ml Tier 1
dihydroergot spr 4mg/ml Tier 1 QL (75 days;24 units)
ERGOMAR SUB 2MG (ergotamine tartrate sl tab) Tier 3
MIGRANAL SPR 4MG/ML (dihydroergotamine mesylate nasal spray)
Tier 3 QL (75 days;24 units)
MIGRAINE PRODUCTS ‐ NSAIDS ‐ Drugs to Treat Migraine Headaches
CAMBIA POW 50MG (diclofenac potassium packet) Tier 3
MINERALOCORTICOIDS ‐ Drugs to Treat Swelling and Inflammation
fludrocort tab 0.1mg Tier 1
MIOTICS ‐ CHOLINESTERASE INHIBITORS ‐ Drugs for Treatment of Disorders in the Eyes
PHOSPHOLINE SOL 0.125%OP (echothiophate iodide ophth for soln)
Tier 3
MIOTICS ‐ DIRECT ACTING ‐ Drugs for Treatment of Disorders in the Eyes
ISOPTO CARP SOL 1% OP,2% OP,4% OP (pilocarpine hcl ophth soln)
Tier 3
pilocarpine sol 1% op,2% op,4% op Tier 1
MISC NATURAL PRODUCTS ‐ Miscellaneous Drugs and Solutions
AZALGIA CAP (*misc natural products cap**) Tier 3
MISC. ANTI‐ULCER ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
CARAFATE SUS 1GM/10ML (sucralfate susp) Tier 3
CARAFATE TAB 1GM (sucralfate tab) Tier 3
sucralfate sus 1gm/10ml Tier 1
SUCRALFATE SUS 1GM/10ML (sucralfate susp) Tier 2
sucralfate tab 1gm Tier 1
MISC. ANTIVIRALS ‐ Drugs to Treat Viral Infections
FAVIPIRAVIR TAB 200MG (favipiravir tab) Tier 3
MISC. DERMATOLOGICAL PRODUCTS ‐ Drugs to Treat Skin Disorders
ALEVAMAX CRE (*dermatological products misc ‐ cream**) Tier 3
ALEVICYN GEL (*dermatological products misc ‐ gel**) Tier 3
ALEVICYN SG GEL ANTIPRUR (*dermatological products misc ‐ gel**)
Tier 3
ATOPADERM CRE (*dermatological products misc ‐ cream**)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 175 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ATOPICLAIR CRE (*dermatological products misc ‐ cream**)
Tier 3
CERACADE EMU (*dermatological products misc ‐ emulsion**)
Tier 3
CERAMAX CRE (*dermatological products misc ‐ cream**) Tier 3
CERAMAX LOT (*dermatological products misc ‐ lotion**) Tier 3
DEXERYL CRE (*dermatological products misc ‐ cream**) Tier 3
ELETONE CRE (*dermatological products misc ‐ cream**) Tier 3
EMULSION SB EMU (*dermatological products misc ‐ emulsion**)
Tier 3
ENTTY EMU SPRAY (*dermatological products misc ‐ emulsion**)
Tier 3
EPICERAM EMU (*dermatological products misc ‐ emulsion**)
Tier 3
GENADUR LIQ (*dermatological products misc ‐ liquid**) Tier 3
HALUCORT GEL (*dermatological products misc ‐ gel**) Tier 3
HPR AER (*dermatological products, misc. ‐ aerosol foam**)
Tier 3
HPR PLUS AER (*dermatological products, misc. ‐ aerosol foam**)
Tier 3
HPR PLUS CRE (*dermatological products misc ‐ cream**) Tier 3
HPR PLUS KIT (*dermatological products misc ‐ kit**) Tier 3
HYLAGUARD CRE (*dermatological products misc ‐ cream**)
Tier 3
HYLATOPIC AER PLUS (*dermatological products, misc. ‐ aerosol foam**)
Tier 3
HYLATOPIC CRE PLUS (*dermatological products misc ‐ cream**)
Tier 3
HYLATOPIC LOT PLUS (*dermatological products misc ‐ lotion**)
Tier 3
ILIDERM SPR (*dermatological products misc ‐ emulsion**) Tier 3
KAMDOY EMU (*dermatological products misc ‐ emulsion**)
Tier 3
KIVIK EMU (*dermatological products misc ‐ emulsion**) Tier 3
LEVICYN GEL (*dermatological products misc ‐ gel**) Tier 3
LOYON SOL 16% (*dermatological products misc ‐ solution**)
Tier 3
MB HYDROGEL KIT (*dermatological products misc ‐ kit**) Tier 3
MIMYX CRE (*dermatological products misc ‐ cream**) Tier 3
NEOCERA CRE (*dermatological products misc ‐ cream**) Tier 3
NEOSALUS AER (*dermatological products, misc. ‐ aerosol foam**)
Tier 3
NEOSALUS CP CRE (*dermatological products misc ‐ cream**)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 176 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NEOSALUS CRE (*dermatological products misc ‐ cream**) Tier 3
NEOSALUS LOT (*dermatological products misc ‐ lotion**) Tier 3
NIVATOPIC CRE PLUS (*dermatological products misc ‐ cream**)
Tier 3
NUVAIL SOL 16% (*dermatological products misc ‐ solution**)
Tier 3
PENLEN EMU SPRAY (*dermatological products misc ‐ emulsion**)
Tier 3
PHLAG SPR (*dermatological products misc ‐ emulsion**) Tier 3
PR CREAM KIT (*dermatological products misc ‐ kit**) Tier 3
PRESERA AER (*dermatological products, misc. ‐ aerosol foam**)
Tier 3
PRUCLAIR CRE (*dermatological products misc ‐ cream**) Tier 3
PRUMYX CRE (*dermatological products misc ‐ cream**) Tier 3
REMIGEN CREA CRE (*dermatological products misc ‐ cream**)
Tier 3
SEBUDERM GEL (*dermatological products misc ‐ gel**) Tier 3
STRATA CTX GEL (*dermatological products misc ‐ gel**) Tier 3
STRATA XRT GEL (*dermatological products misc ‐ gel**) Tier 3
SUVICORT EMU (*dermatological products misc ‐ emulsion**)
Tier 3
SYNERDERM EMU (*dermatological products misc ‐ emulsion**)
Tier 3
TETRIX CRE (*dermatological products misc ‐ cream**) Tier 3
XERALUX CRE (*dermatological products misc ‐ cream**) Tier 3
MISC. NUTRITIONAL SUBSTANCES ‐ Drugs/Products Used for Providing Nourishment
CYTOTINE POW (creatine monohydrate oral powder) Tier 3
MISC. NUTRITIONAL SUBSTANCES COMBINATIONS ‐ Drugs/Products Used for Providing Nourishment
CARDIOVID CAP PLUS (dha‐epa‐vit b) Tier 3
MISC. RESPIRATORY INHALANTS ‐ Drugs to Treat Cough / Cold / Allergies
HYPERSAL NEB 3.5%,6%,7% (sodium chloride soln nebu) Tier 3
HYPER‐SAL NEB 3.5%,6%,7% (sodium chloride soln nebu) Tier 3
hydrocodone bitartrate/homatropine methylbromide (Hydromet)
Tier 1
sodium chloride soln 3.5%,6%,7% (Nebusal) Tier 1
sodium chloride soln neb 0.9%,10%,3%,7% (Pulmosal) Tier 1
sod chloride neb 0.9%,10%,3%,7% Tier 1
sodium chlor neb 0.9%,10%,3%,7% Tier 1
MISC. TOPICAL ‐ Drugs to Treat Skin Disorders
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 177 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ARNICA TIN FLOWER (*arnica ‐ tincture***) Tier 3
BORIC ACID GRA (boric acid granules) Tier 3
DRYSOL SOL 20% (aluminum chloride soln) Tier 3
QBREXZA PAD 2.4% (glycopyrronium tosylate pad) Tier 3
MISCELLANEOUS VAGINAL COMBINATIONS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms
TRIMO‐SAN GEL (oxyquinoline sulfate‐sod lauryl sulfate vag gel)
Tier 3
MISCELLANEOUS VAGINAL PRODUCTS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms
INTRAROSA SUP 6.5MG (prasterone vaginal insert) Tier 3
MITOTIC INHIBITORS ‐ Drugs for Treatment of Cancer
etoposide cap 50mg Tier 1 OAC
HALAVEN INJ 1MG/2ML (eribulin mesylate inj) Tier 4 PA; SP; QL (34 days supply)
IXEMPRA KIT INJ 15MG,45MG (ixabepilone for iv infusion) Tier 4 PA; SP; QL (34 days supply)
JEVTANA INJ 60/1.5ML (cabazitaxel inj) Tier 4 PA; SP; QL (34 days supply)
MIXED ALLERGENIC EXTRACTS ‐ Drugs to Treat Allergies / Allergic Responses
ODACTRA SUB (*dust mite mixed ext sl tab) Tier 3 PA
MONOAMINE OXIDASE INHIBITORS (MAOIS) ‐ Drugs for Depression / Other Disorders
EMSAM DIS 12MG/24H,6MG/24HR,9MG/24HR (selegiline td patch)
Tier 3
MARPLAN TAB 10MG (isocarboxazid tab) Tier 3
NARDIL TAB 15MG (phenelzine sulfate tab) Tier 2
PARNATE TAB 10MG (tranylcypromine sulfate tab) Tier 2
phenelzine tab 15mg Tier 1
tranylcyprom tab 10mg Tier 1
MONOBACTAMS ‐ Antibiotics / Drugs for Infections
CAYSTON INH 75MG (aztreonam lysine for inhal soln) Tier 4 PA; SP; QL (34 days supply)
MONOCLONAL ANTIBODIES ‐ Miscellaneous Drugs and Solutions
SIMULECT INJ 10MG,20MG (basiliximab for iv soln) Tier 3
MOVEMENT DISORDER DRUG THERAPY ‐ Drugs for diseases and disorders of the nervous system
AUSTEDO TAB 12MG,6MG,9MG (deutetrabenazine tab) Tier 2 PA; SP; QL (34 days supply)
INGREZZA CAP 40MG,80MG (valbenazine tosylate cap) Tier 2 PA
INGREZZA CAP 40MG,80MG (valbenazine tosylate cap therapy pack)
Tier 2 PA
tetrabenazin tab 12.5mg,25mg Tier 1 PA; SP; QL (34 days supply)
XENAZINE TAB 12.5MG,25MG (tetrabenazine tab) Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 178 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MS AGENTS ‐ PYRIMIDINE SYNTHESIS INHIBITORS ‐ Drugs for diseases and disorders of the nervous system
AUBAGIO TAB 14MG,7MG (teriflunomide tab) Tier 2 PA; SP; QL (34 days supply)
MUCOLYTICS ‐ Drugs to Treat Cough / Cold / Allergies
acetylcyst sol 10%,20% Tier 1
MUCOPOLYSACCHARIDOSIS I (MPS I) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
ALDURAZYME INJ 2.9MG/5M (laronidase soln for iv infusion)
Tier 4 PA; SP; QL (34 days supply)
MUCOPOLYSACCHARIDOSIS II (MPS II) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
ELAPRASE INJ 6MG/3ML (idursulfase soln for iv infusion) Tier 4 PA; SP; QL (34 days supply)
MUCOPOLYSACCHARIDOSIS IV (MPS IV) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
VIMIZIM INJ 5MG/5ML (elosulfase alfa soln for iv infusion) Tier 4 PA; SP; QL (34 days supply)
MUCOPOLYSACCHARIDOSIS VI (MPS VI) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
NAGLAZYME INJ 1MG/ML (galsulfase soln for iv infusion) Tier 4 PA; SP; QL (34 days supply)
MUCOPOLYSACCHARIDOSIS VII (MPS VII) ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
MEPSEVII INJ 10MG/5ML (vestronidase alfa‐vjbk iv soln) Tier 3 PA
MULTIPLE SCLEROSIS AGENTS ‐ Drugs for diseases and disorders of the nervous system
COPAXONE INJ 20MG/ML,40MG/ML (glatiramer acetate soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
glatiramer inj 20mg/ml,40mg/ml Tier 1 PA; SP; QL (34 days supply)
glatiramer acetate inj 20mg/ml (Glatopa) Tier 1 PA; SP; QL (34 days supply)
MULTIPLE SCLEROSIS AGENTS ‐ ANTIMETABOLITES ‐ Drugs for diseases and disorders of the nervous system
MAVENCLAD PAK 10MG(10),10MG(4),10MG(5),10MG(6),10MG(7),10MG(8),10MG(9) (cladribine tab therapy pack)
Tier 4 PA; SP; QL (34 days supply)
MULTIPLE SCLEROSIS AGENTS ‐ INTERFERONS ‐ Drugs for diseases and disorders of the nervous system
AVONEX PEN KIT 0.3MG,30MCG (interferon beta‐) Tier 4 PA; SP; QL (34 days supply)
AVONEX PREFL KIT 0.3MG,30MCG (interferon beta‐) Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 179 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
BETASERON INJ 0.3MG,22/0.5,44/0.5 (interferon beta‐) Tier 2 PA; SP; QL (34 days supply)
EXTAVIA INJ 0.3MG,30MCG (interferon beta‐) Tier 4 PA; SP; QL (34 days supply)
PLEGRIDY INJ (peginterferon beta‐) Tier 4 PA; SP; QL (34 days supply)
PLEGRIDY INJ PEN (peginterferon beta‐) Tier 4 PA; SP; QL (34 days supply)
PLEGRIDY INJ STARTER (peginterferon beta‐) Tier 4 PA; SP; QL (34 days supply)
PLEGRIDY PEN INJ STARTER (peginterferon beta‐) Tier 4 PA; SP; QL (34 days supply)
REBIF INJ 0.3MG,22/0.5,44/0.5 (interferon beta‐) Tier 2 PA; SP; QL (34 days supply)
REBIF REBIDO INJ 0.3MG,22/0.5,44/0.5 (interferon beta‐) Tier 2 PA; SP; QL (34 days supply)
REBIF REBIDO INJ TITRATN 0.3MG,22/0.5,44/0.5 (interferon beta‐)
Tier 2 PA; SP; QL (34 days supply)
REBIF TITRTN INJ PACK 0.3MG,22/0.5,44/0.5 (interferon beta‐)
Tier 2 PA; SP; QL (34 days supply)
MULTIPLE SCLEROSIS AGENTS ‐ MONOCLONAL ANTIBODIES ‐ Drugs for diseases and disorders of the nervous system
LEMTRADA INJ 12/1.2ML (alemtuzumab iv inj) Tier 4 PA; SP; QL (34 days supply)
OCREVUS INJ 300/10ML (ocrelizumab soln for iv infusion) Tier 2 PA; SP; QL (34 days supply)
TYSABRI INJ 300/15ML (natalizumab for iv inj conc) Tier 2 PA; SP; QL (34 days supply)
MULTIPLE SCLEROSIS AGENTS ‐ NRF2 PATHWAY ACTIVATORS ‐ Drugs for diseases and disorders of the nervous system
TECFIDERA CAP 120MG,240MG (dimethyl fumarate capsule delayed release)
Tier 3 PA; SP; QL (34 days supply)
TECFIDERA MIS STARTER (dimethyl fumarate capsule dr starter pack)
Tier 3 PA; SP; QL (34 days supply)
VUMERITY CAP 231MG (diroximel fumarate capsule delayed release)
Tier 2 PA; SP; QL (34 days supply)
VUMERITY CAP 231MG (diroximel fumarate capsule dr starter bottle)
Tier 2 PA; SP; QL (34 days supply)
MULTIPLE SCLEROSIS AGENTS ‐ POTASSIUM CHANNEL BLOCKERS ‐ Drugs for diseases and disorders of the nervous system
AMPYRA TAB 10MG (dalfampridine tab er) Tier 4 PA; SP; QL (34 days supply)
dalfampridin tab 10mg er Tier 1 PA; SP; QL (34 days supply)
MULTIPLE URINE TESTS ‐ Products for Testing
CHEMSTRIP TES UGK (*urine glucose‐ketones test strips***)
Tier 3
CVS KETONE TES CARE (*urine glucose‐ketones test strips***)
Tier 3
KETO‐DIASTIX TES (*urine glucose‐ketones test strips***) Tier 3
MUSCLE RELAXANT COMBINATIONS ‐ Drugs for diseases and disorders of the muscles, ligaments, tendons and bones
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 180 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
carisopr/asa tab 200‐325 Tier 1
carisoprodol tab asa/cod Tier 1
NORGESIC TAB FORTE (orphenadrine w/ aspirin & caffeine tab)
Tier 3
ORPH/ASA/CAF TAB (orphenadrine w/ aspirin & caffeine tab)
Tier 3
orphengesic tab forte Tier 1
MUSCULAR DYSTROPHY AGENTS ‐ Drugs to Treat Disorders that Affect the Nerves That control Voluntary Muscles
EXONDYS 51 SOL 100/2ML,51 SOL 500/10ML (eteplirsen iv soln)
Tier 3 PA
VYONDYS 53 INJ 100/2ML (golodirsen iv soln) Tier 3 PA
NASAL AGENTS ‐ MISC. ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems
ALZAIR NASAL SPR 800MG (*hypromellose nasal powder**) Tier 3
NASAL ANESTHETICS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems
COCAINE HCL SOL 40MG/ML (cocaine hcl nasal soln) Tier 3
GOPRELTO SOL 40MG/ML (cocaine hcl nasal soln) Tier 3
NUMBRINO SOL 40MG/ML (cocaine hcl nasal soln) Tier 3
NASAL ANTICHOLINERGICS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems
ipratropium spr 0.03%,0.06% Tier 1
NASAL ANTIHISTAMINES ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems
azelastine spr 0.1%,0.15% Tier 1 QL (75 days;180 units)
olopatadine spr 0.6% Tier 1 QL (75 days;93 units)
PATANASE SPR 0.6% (olopatadine hcl nasal soln) Tier 3 QL (75 days;93 units)
NASAL STEROIDS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems
BECONASE AQ SUS 0.042% (beclomethasone dipropionate monohyd nasal susp)
Tier 3 QL (75 days;150 units)
flunisolide spr 0.025% Tier 1 QL (75 days;225 units)
fluticasone spr 50mcg Tier 1 QL (75 days;48 units)
mometasone spr 50mcg Tier 1 QL (75 days;102 units)
NASONEX SPR 50MCG/AC (mometasone furoate nasal susp) Tier 3 QL (75 days;102 units)
OMNARIS SPR (ciclesonide nasal susp) Tier 3 QL (75 days;39 units)
QNASL AER 40MCG,80MCG (beclomethasone dipropionate nasal aerosol)
Tier 3 QL (75 days;31.8 units)
QNASL CHILD SPR 40MCG,80MCG (beclomethasone dipropionate nasal aerosol)
Tier 3 QL (75 days;20.4 units)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 181 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
SINUVA IMP 1350MCG (mometasone furoate sinus implant) Tier 3
XHANCE MIS 93MCG (fluticasone propionate nasal exhaler susp)
Tier 3 QL (75 days;48 units)
ZETONNA AER 37MCG (ciclesonide nasal aerosol soln) Tier 3 QL (75 days;18.3 units)
NATURAL PENICILLINS ‐ Antibiotics / Drugs for Infections
penicilln vk sol 125/5ml,250/5ml Tier 1
penicilln vk tab 250mg,500mg Tier 1
NEEDLES & SYRINGES ‐ Diabetic Supplies and Needles
1ML SYRINGE MIS 0.3/29G,0.3/30G,0.3/31G,0.3ML/30,0.3ML/31,0.5/27G,0.5/28G,0.5/29G,0.5/30G,0.5/31G,0.5/32G,1/2ML/30,1/2ML/31,1ML/25G,1ML/27G,1ML/28G,1ML/29G,1ML/30G,1ML/31G,1ML/32G,1MLX30G,27GX1/2,27GX1/2",28GX1/2",29G,29GX1/2",30G,30GX1/2",30GX5/16,30GX8MM,30X12.7,31GX5/16,31GX6MM,31GX8MM (insulin syringe/needle u‐)
Tier 3
1ST TIER UNI MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
ABOUTTIME MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
ASSURE ID MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
AUTOPEN MIS 1 UNIT,100EL MIS BLUE,100EL MIS GRAY,100EL MIS PINK,100NN MIS BLUE,100NN MIS GREY,100NN MIS PINK,1‐21UNIT,2 UNIT,2‐42UNIT,2U (injection device for insulin)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 182 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
AUTOSHIELD MIS 29GX12.7,29X3/16",29X5/16",30GX5MM,31GX5MM,31GX8MM,32GX4MM,32GX5/32,32GX6MM (insulin pen needle)
Tier 2
BD PEN MINI MIS 1 UNIT,100EL MIS BLUE,100EL MIS GRAY,100EL MIS PINK,100NN MIS BLUE,100NN MIS GREY,100NN MIS PINK,1‐21UNIT,2 UNIT,2‐42UNIT,2U (injection device for insulin)
Tier 3
BD PEN MIS 1 UNIT,100EL MIS BLUE,100EL MIS GRAY,100EL MIS PINK,100NN MIS BLUE,100NN MIS GREY,100NN MIS PINK,1‐21UNIT,2 UNIT,2‐42UNIT,2U (injection device for insulin)
Tier 3
BD PEN NEEDL MIS 29GX12.7,29X3/16",29X5/16",30GX5MM,31GX5MM,31GX8MM,32GX4MM,32GX5/32,32GX6MM (insulin pen needle)
Tier 2
BD U‐ 0.3/29G,0.3/30G,0.3/31G,0.5/28G,0.5/29G,0.5/30G,0.5/31G,1ML/25G,1ML/26G,1ML/27G,1ML/28G,1ML/29G,1ML/30G,1ML/31G,2/27.5G,500 MIS 31GX6MM (insulin syringe/needle u‐)
Tier 2
CAREFINE MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
CARETOUCH MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
CEQUR SIMPL KIT PATCH 1 UNIT,100EL MIS BLUE,100EL MIS GRAY,100EL MIS PINK,100NN MIS BLUE,100NN MIS GREY,100NN MIS PINK,1‐21UNIT,2 UNIT,2‐42UNIT,2U (injection device for insulin)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 183 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CLICKFINE MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
COMFORT EZ MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin syringe/needle u‐)
Tier 3
COMFORT EZ MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin syringe/needle u‐)
Tier 3
DROPLET MICR MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
EASY COMFORT MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 184 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
EASY TOUCH MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
FIFTY50 MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
FIFTY50 PEN MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
HM INSULIN S MIS 0.3/29G,0.3/30G,0.3/31G,0.3ML/30,0.3ML/31,0.5/27G,0.5/28G,0.5/29G,0.5/30G,0.5/31G,0.5/32G,1/2ML/30,1/2ML/31,1ML/25G,1ML/27G,1ML/28G,1ML/29G,1ML/30G,1ML/31G,1ML/32G,1MLX30G,27GX1/2,27GX1/2",28GX1/2",29G,29GX1/2",30G,30GX1/2",30GX5/16,30GX8MM,30X12.7,31GX5/16,31GX6MM,31GX8MM (insulin syringe/needle u‐)
Tier 3
HM ULTICARE MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 185 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
IN CONTROL MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
INCONTROL MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
INPEN 1 UNIT,100EL MIS BLUE,100EL MIS GRAY,100EL MIS PINK,100NN MIS BLUE,100NN MIS GREY,100NN MIS PINK,1‐21UNIT,2 UNIT,2‐42UNIT,2U (injection device for insulin)
Tier 3
INSULIN PEN MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
INSULIN SRYG MIS 0.3/29G,0.3/30G,0.3/31G,0.3ML/30,0.3ML/31,0.5/27G,0.5/28G,0.5/29G,0.5/30G,0.5/31G,0.5/32G,1/2ML/30,1/2ML/31,1ML/25G,1ML/27G,1ML/28G,1ML/29G,1ML/30G,1ML/31G,1ML/32G,1MLX30G,27GX1/2,27GX1/2",28GX1/2",29G,29GX1/2",30G,30GX1/2",30GX5/16,30GX8MM,30X12.7,31GX5/16,31GX6MM,31GX8MM (insulin syringe/needle u‐)
Tier 3
INSULIN SYRG MIS 1ML (insulin syringe (disp) u‐) Tier 2
INSULIN SYRG MIS 1ML (insulin syringe/needle u‐) Tier 2
INSULIN SYRG MIS 0.3/30G,0.5/29G,0.5/30G,1ML,1ML/29G (insulin syringe/needle u‐)
Tier 3
INSULIN SYRG MIS 0.3/30G,0.5/29G,0.5/30G,1ML,1ML/29G (insulin syringe/needle u‐)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 186 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
INSULIN SYRI MIS 0.3/29G,0.3/30G,0.3/31G,0.3ML/30,0.3ML/31,0.5/27G,0.5/28G,0.5/29G,0.5/30G,0.5/31G,0.5/32G,1/2ML/30,1/2ML/31,1ML/25G,1ML/27G,1ML/28G,1ML/29G,1ML/30G,1ML/31G,1ML/32G,1MLX30G,27GX1/2,27GX1/2",28GX1/2",29G,29GX1/2",30G,30GX1/2",30GX5/16,30GX8MM,30X12.7,31GX5/16,31GX6MM,31GX8MM (insulin syringe/needle u‐)
Tier 3
INSUPEN MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
INSUPEN SENS MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
INSUPEN ULTR MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
LITETOUCH MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 187 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MAXICOMFORT MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin syringe/needle u‐)
Tier 3
MAXICOMFORT MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin syringe/needle u‐)
Tier 3
MM PENTIPS MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
NOVOFINE AUT MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
NOVOFINE MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 188 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NOVOFINE PLS MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
NOVOPEN ECHO MIS 1 UNIT,100EL MIS BLUE,100EL MIS GRAY,100EL MIS PINK,100NN MIS BLUE,100NN MIS GREY,100NN MIS PINK,1‐21UNIT,2 UNIT,2‐42UNIT,2U (injection device for insulin)
Tier 3
NOVOTWIST MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
PEN NEEDLE MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
PEN NEEDLES MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
PENTIPS MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 189 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PREVENT SAFE MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
PRO COMFORT MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin syringe/needle u‐)
Tier 3
PRO COMFORT MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin syringe/needle u‐)
Tier 3
PURE COMFORT MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
RA PEN NEEDL MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 190 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
RELION PEN MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
SECURESAFE MIS 0.3/29G,0.3/30G,0.3/31G,0.3ML/30,0.3ML/31,0.5/27G,0.5/28G,0.5/29G,0.5/30G,0.5/31G,0.5/32G,1/2ML/30,1/2ML/31,1ML/25G,1ML/27G,1ML/28G,1ML/29G,1ML/30G,1ML/31G,1ML/32G,1MLX30G,27GX1/2,27GX1/2",28GX1/2",29G,29GX1/2",30G,30GX1/2",30GX5/16,30GX8MM,30X12.7,31GX5/16,31GX6MM,31GX8MM (insulin syringe/needle u‐)
Tier 3
SURE COMFORT MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
SURE COMFORT MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin syringe/needle u‐)
Tier 3
SURE‐FINE MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
SYRINGE MIS 0.3/29G,0.3/30G,0.3/31G,0.3ML/30,0.3ML/31,0.5/27G,0.5/28G,0.5/29G,0.5/30G,0.5/31G,0.5/32G,1/2ML/30,1/2ML/31,1ML/25G,1ML/27G,1ML/28G,1ML/29G,1ML/30G,1ML/31G,1ML/32G,1MLX30G,27GX1/2,27GX1/2",28GX1/2",29G,29GX1/2",30G,30GX1/2",30GX5/16,30GX8MM,30X12.7,31GX5/16,31GX6MM,31GX8MM (insulin syringe/needle u‐)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 191 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
TIER UNI PLS MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
ULTICARE MIC MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
ULTICARE PEN MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
ULTIGUARD MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
ULTILET INSU MIS 0.3/29G,0.3/30G,0.3/31G,0.3ML/30,0.3ML/31,0.5/27G,0.5/28G,0.5/29G,0.5/30G,0.5/31G,0.5/32G,1/2ML/30,1/2ML/31,1ML/25G,1ML/27G,1ML/28G,1ML/29G,1ML/30G,1ML/31G,1ML/32G,1MLX30G,27GX1/2,27GX1/2",28GX1/2",29G,29GX1/2",30G,30GX1/2",30GX5/16,30GX8MM,30X12.7,31GX5/16,31GX6MM,31GX8MM (insulin syringe/needle u‐)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 192 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ULTILET PEN MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
UNFINE PNTP MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
UNIFINE PNTP MIS 29GX1/2",29GX10MM,29GX12.7,29GX12MM,29GX3/16,29GX5/16,29GX5MM,29GX8MM,30GX3/16,30GX5/16,30GX5MM,30GX8MM,31GX1/4",31GX3/16,31GX4MM,31GX5/16,31GX5MM,31GX6MM,31GX8MM,32GX1/4,32GX1/4",32GX3/16,32GX4MM,32GX5/16,32GX5/32,32GX5MM,32GX6MM,32GX8MM,33GX4MM,33GX5/32,33GX5MM,33GX6MM,33GX8MM,34GX9/64 (insulin pen needle)
Tier 3
NEPRILYSIN INHIB (ARNI)‐ANGIOTENSIN II RECEPT ANTAG COMB ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
ENTRESTO TAB 24‐26MG,49‐51MG,97‐103MG (sacubitril‐valsartan tab)
Tier 2
NEURAMINIDASE INHIBITORS ‐ Drugs to Treat Viral Infections
oseltamivir cap 30mg,45mg,75mg Tier 1 QL (90 days;14 capsules)
oseltamivir sus 6mg/ml Tier 1 QL (90 days;180 units)
RELENZA MIS DISKHALE (zanamivir aero powder breath activated)
Tier 2 QL (90 days;40 units)
TAMIFLU CAP 30MG,45MG,75MG (oseltamivir phosphate cap)
Tier 3 QL (90 days;28 capsules)
TAMIFLU SUS 6MG/ML (oseltamivir phosphate for susp) Tier 3 QL (90 days;180 units)
NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) ‐ AGENTS ‐ Drugs Used to Contract (Tighten) Blood Vessels and Raise Blood Pressure
NORTHERA CAP 100MG,200MG,300MG (droxidopa cap) Tier 4 PA; SP; QL (34 days supply)
NEUROMUSCULAR BLOCKING AGENT ‐ NEUROTOXINS ‐ Drugs to Treat Disorders that Affect the Nerves That control Voluntary Muscles
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 193 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
BOTOX INJ 100UNIT,200UNIT (onabotulinumtoxina for inj) Tier 3 PA
DYSPORT INJ 300UNIT,500UNIT (abobotulinumtoxina for im inj)
Tier 3 PA
MYOBLOC INJ 10000/2,2500/0.5,5000/ML (rimabotulinumtoxinb im inj)
Tier 3 PA
XEOMIN INJ 100UNIT,200UNIT,50 UNIT (incobotulinumtoxina for im inj)
Tier 3 PA
NICOTINIC ACID DERIVATIVES ‐ Drugs for High Cholesterol
niacin er tab 1000mg,500mg,500mg er,750mg Tier 1
niacin tab 500mg Tier 1
niacin tab 500mg Tier 1
niacin tab 500mg (Niacor) Tier 1
NIASPAN TAB 1000 ER,500MG ER,750MG ER (niacin tab er) Tier 3
NITRATE & VASODILATOR COMBINATIONS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
BIDIL TAB (isosorbide dinitrate‐hydralazine hcl tab) Tier 2
NITRATE VASODILATING AGENTS ‐ Drugs to Treat Misc Rectal Problems & Disorders
RECTIV OIN 0.4%,2% (nitroglycerin oint) Tier 3
NITRATES ‐ Drugs to Treat Heart Pain and Other Heart‐Related Disorders
DILATRATE SR CAP 40MG (isosorbide dinitrate cap er) Tier 3
GONITRO POW 400MCG (nitroglycerin sublingual powder packet)
Tier 3
ISORDIL TAB 40MG,5MG (isosorbide dinitrate tab) Tier 3
isosorb din tab 10mg,20mg,30mg,40mg,5mg Tier 1
isosorb mono tab 10mg,20mg Tier 1
isosorb mono tab 10mg,20mg Tier 1
minitran dis 0.1mg/hr,0.2mg/hr,0.4mg/hr,0.6mg/hr Tier 1
NITRO‐BID OIN 0.4%,2% (nitroglycerin oint) Tier 3
NITRO‐DUR DIS 0.1MG/HR,0.2MG/HR,0.3MG/HR,0.4MG/HR,0.6MG/HR,0.8MG/HR (nitroglycerin td patch)
Tier 2
nitroglycer dis 0.1mg/hr,0.2mg/hr,0.4mg/hr,0.6mg/hr Tier 1
nitroglyceri sub 0.3mg,0.4mg,0.6mg Tier 1
nitroglycern sub 0.3mg,0.4mg,0.6mg Tier 1
nitroglycrn spr 0.4mg Tier 1
NITROLINGUAL SPR PUMPSPRA (nitroglycerin tl soln) Tier 3
NITROMIST AER 400MCG (nitroglycerin lingual aerosol) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 194 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NITROSTAT SUB 0.3MG,0.4MG,0.6MG (nitroglycerin sl tab) Tier 3
nitro‐time cap 6.5mg cr,9mg cr Tier 1
NITROGEN MUSTARDS ‐ Drugs for Treatment of Cancer
ALKERAN TAB 2MG (melphalan tab) Tier 2 OAC
cyclophosph cap 25mg,50mg Tier 1 OAC
LEUKERAN TAB 2MG (chlorambucil tab) Tier 2 OAC
melphalan tab 2mg Tier 1 OAC
NITROSOUREAS ‐ Drugs for Treatment of Cancer
GLEOSTINE CAP 100MG,10MG,40MG (lomustine cap) Tier 3 OAC
GLIADEL WAF 7.7MG (carmustine in polifeprosan intracranial implant wafer)
Tier 3
N‐METHYL‐D‐ASPARTATE (NMDA) RECEPTOR ANTAGONISTS ‐ Drugs for diseases and disorders of the nervous system
memant titra pak 10mg,5‐10mg,5mg Tier 1
memantine hc cap 14mg er,21mg er,28mg er,7mg er Tier 1
memantine hc sol 10mg/5ml,2mg/ml Tier 1
memantine sol 10mg/5ml,2mg/ml Tier 1
memantine tab hcl 10mg,5‐10mg,5mg Tier 1
NAMENDA TAB 10MG,5‐10MG,5MG (memantine hcl tab) Tier 3
NAMENDA XR CAP 14MG,21MG,28MG,7MG (memantine hcl cap er)
Tier 3
NAMENDA XR CAP TITRATIO 14MG,21MG,28MG,7MG (memantine hcl cap er)
Tier 3
N‐METHYL‐D‐ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS ‐ Drugs for Depression / Other Disorders
SPRAVATO SOL 56MG DOS,84MG DOS (esketamine hcl nasal soln)
Tier 3 PA
NON GELATIN CAPSULES (EMPTY) ‐ Syrups, gelatin, capsules for making pharmaceuticals
CAPSULE 0,0 CAP CLR DR,0 WHITE,00 WHIT,1,1 GREEN,1 WHITE,2 WHITE,3,3 WHITE,4 WHITE (*non gelatin capsules (empty)**)
Tier 3
CAPSULE CONI CAP ‐SNAP # 0,00,000,1,2,3,4,5,7,600MG,2"X2",3" DISK,4"X4",4"X8" (*gelatin capsules (empty)**)
Tier 3
EMPTY CAPSUL CAP SIZE 0,00,000,1,2,3,4,5,7,600MG,2"X2",3" DISK,4"X4",4"X8" (*non gelatin capsules (empty)**)
Tier 3
VEG CAPSULE CAP # 0,0 CAP CLR DR,0 WHITE,00 WHIT,1,1 GREEN,1 WHITE,2 WHITE,3,3 WHITE,4 WHITE (*non gelatin capsules (empty)**)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 195 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NON‐BENZODIAZEPINE ‐ GABA‐RECEPTOR MODULATORS ‐ Drugs to Treat Problems with Sleeping
AMBIEN CR TAB 12.5MG,6.25MG (zolpidem tartrate tab er) Tier 3 QL (1 unit per 1 day)
AMBIEN TAB 10MG,5MG (zolpidem tartrate tab) Tier 3 QL (1 unit per 1 day)
EDLUAR SUB 1.75MG,10MG,5MG (zolpidem tartrate sl tab) Tier 3
eszopiclone tab 1mg,2mg,3mg Tier 1 QL (1 unit per 1 day)
INTERMEZZO SUB 1.75MG,10MG,5MG (zolpidem tartrate sl tab)
Tier 3
LUNESTA TAB 1MG,2MG,3MG (eszopiclone tab) Tier 3 QL (1 unit per 1 day)
zaleplon cap 10mg,5mg Tier 1 QL (1 unit per 1 day)
zolpidem er tab 12.5mg,6.25mg Tier 1 QL (1 unit per 1 day)
zolpidem tab 10mg,5mg Tier 1 QL (1 unit per 1 day)
zolpidem tar sub 1.75mg,3.5mg Tier 1
ZOLPIMIST SPR 5MG (zolpidem tartrate oral spray) Tier 3
NONERGOLINE DOPAMINE RECEPTOR AGONISTS ‐ Drugs to treat Parkinson's Disease
APOKYN INJ 10MG/ML (apomorphine hcl soln cartridge) Tier 4 PA; SP; QL (34 days supply)
KYNMOBI MIS 10MG,15MG,20MG,25MG,30MG (apomorphine hydrochloride film)
Tier 3 PA
MIRAPEX ER TAB 0.375MG,0.75MG,1.5MG,2.25MG,3.75MG,3MG,4.5MG (pramipexole dihydrochloride tab er)
Tier 3
MIRAPEX TAB 0.125MG,0.5MG,0.75MG,1MG (pramipexole dihydrochloride tab)
Tier 3
NEUPRO DIS 1MG/24HR,2MG/24HR,3MG/24HR,4MG/24HR,6MG/24HR,8MG/24HR (rotigotine td patch)
Tier 2
pramipexole tab 0.125mg,0.25mg,0.5mg,0.75mg,1.5mg,1mg
Tier 1
pramipexole tab 0.125mg,0.25mg,0.5mg,0.75mg,1.5mg,1mg
Tier 1
REQUIP XL TAB 12MG,6MG (ropinirole hydrochloride tab er) Tier 3
ropinirole tab 0.25mg,0.5mg,1mg,2mg,3mg,4mg,5mg Tier 1
ropinirole tab 0.25mg,0.5mg,1mg,2mg,3mg,4mg,5mg Tier 1
NON‐NARC ANTITUSSIVE‐ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies
promethazine sol dm Tier 1
promethazine syp dm Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 196 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NON‐NARC ANTITUSSIVE‐DECONGESTANT‐ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies
brom/pse/dm syp Tier 1
brompheniramine maleate/pseudoephedrine hydrochloride/dextromethorphan hydrobromide syp (Bromfed Dm)
Tier 1
NEOTUSS PLUS LIQ (phenylephrine‐chlorphen‐dm liquid) Tier 3
NONSTEROIDAL ANTI‐INFLAMMATORY AGENT COMBINATIONS ‐ Drugs to Treat Pain and Inflammation
ARTHROTEC 50 TAB,75 TAB (diclofenac w/ misoprostol tab delayed release)
Tier 3
diclo/misopr tab 50‐0.2mg,75‐0.2mg Tier 1
DUEXIS TAB 800‐26.6 (ibuprofen‐famotidine tab) Tier 3
naprox‐esom tab 375‐20mg,500‐20mg Tier 1
VIMOVO TAB 375‐20MG,500‐20MG (naproxen‐esomeprazole magnesium tab dr)
Tier 3
NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS (NSAIDS) ‐ Drugs to Treat Pain and Inflammation
ANAPROX DS TAB 550MG (naproxen sodium tab) Tier 2
DAYPRO TAB 600MG (oxaprozin tab) Tier 3
diclofen pot tab 50mg Tier 1
diclofenac tab 25mg dr,50mg dr,75mg dr Tier 1
diclofenac tab 25mg dr,50mg dr,75mg dr Tier 1
EC‐NAPROSYN TAB 375MG,500MG (naproxen tab ec) Tier 3
EC‐NAPROXEN TAB 375MG,500MG (naproxen tab ec) Tier 3
etodolac cap 200mg,300mg Tier 1
etodolac er tab 400mg,500mg,600mg Tier 1
etodolac tab 400mg,500mg Tier 1
FELDENE CAP 10MG,20MG (piroxicam cap) Tier 3
fenoprofen cap 200mg,400mg Tier 1
FENOPROFEN CAP 200MG,400MG (fenoprofen calcium cap) Tier 3
fenoprofen tab 600mg Tier 1
FENORTHO CAP 200MG,400MG (fenoprofen calcium cap) Tier 3
flurbiprofen tab 100mg,50mg Tier 1
ibu tab 400mg,600mg,800mg Tier 1
ibuprofen sus 100/5ml Tier 1
ibuprofen tab 400mg,600mg,800mg Tier 1
INDOCIN SUP 50MG (indomethacin suppos) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 197 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
INDOCIN SUS 25MG/5ML (indomethacin susp) Tier 3
indomethacin cap 20mg,25mg,50mg Tier 1
indomethacin cap 20mg,25mg,50mg Tier 1
ketoprofen cap 25mg,50mg,75mg Tier 1
ketoprofen cap 25mg,50mg,75mg Tier 1
ketorolac tab 10mg Tier 1
LODINE TAB 400MG (etodolac tab) Tier 3
meclofen sod cap 100mg,50mg Tier 1
mefenam acid cap 250mg Tier 1
meloxicam tab 15mg,7.5mg Tier 1
MOBIC TAB 15MG,7.5MG (meloxicam tab) Tier 3
nabumetone tab 500mg,750mg Tier 1
NALFON CAP 200MG,400MG (fenoprofen calcium cap) Tier 3
NALFON TAB 600MG (fenoprofen calcium tab) Tier 3
NAPRELAN TAB 375MG CR,500MG CR,750MG CR (naproxen sodium tab er)
Tier 3
NAPROSYN SUS 125/5ML (naproxen susp) Tier 3
NAPROSYN TAB 250MG (naproxen tab) Tier 2
naproxen dr tab 375mg,500mg Tier 1
naproxen sod tab 275mg,550mg Tier 1
naproxen sod tab 275mg,550mg Tier 1
naproxen sus 125/5ml Tier 1
naproxen tab 250mg,375mg,500mg Tier 1
oxaprozin tab 600mg Tier 1
piroxicam cap 10mg,20mg Tier 1
QMIIZ ODT TAB 15 MG,7.5MG (meloxicam orally disintegrating tab)
Tier 3
RELAFEN DS TAB 1000MG (nabumetone tab) Tier 3
SPRIX SPR 15.75MG (ketorolac tromethamine nasal spray) Tier 3
sulindac tab 150mg,200mg Tier 1
TIVORBEX CAP 20MG (indomethacin cap) Tier 3
tolmetin sod cap 400mg Tier 1
tolmetin sod tab 600mg Tier 1
VIVLODEX CAP 10MG,5MG (meloxicam cap) Tier 3
ZIPSOR CAP 25MG (diclofenac potassium cap) Tier 3
ZORVOLEX CAP 18MG,35MG (diclofenac cap) Tier 3
NOT CLASSIFIED ‐ Miscellaneous Drugs and Solutions
ACCU‐CHEK KIT AVIVA PL (*Unclassified**) Tier 3
ACCU‐CHEK KIT NANO (*Unclassified**) Tier 3
md denied new rx Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 198 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NGR BRAND TAB (*Unclassified**) Tier 3
pve drug tab Tier 1
UNKNOWN DRUG TAB (*Unclassified**) Tier 3
NUTRITIONAL SUPPLEMENTS ‐ Products for Diet / Eating
AMINO PM RMS CAP (*nutritional supplement caps**) Tier 3
asilnasal cap rms Tier 1
BETTERMILK PAK GLYTACTI 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
BETTERMILK15 POW GLYTACTN 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
CAM PRO COMP BAR GLYTACTI 10PE,15 PE (*nutritional supplement bar**)
Tier 3
EQUACARE JR POW CHOCO (*nutritional supplement powder**)
Tier 3
EQUACARE JR POW UNFLAVOR (*nutritional supplement powder**)
Tier 3
EQUACARE JR POW VANILLA (*nutritional supplement powder**)
Tier 3
ESSENTIAL POW CARE JR (*nutritional supplement powder**)
Tier 3
FIBERSOUR HN LIQ 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
GLYTAC COMPL BAR 10PE,15 PE (*nutritional supplement bar**)
Tier 3
GLYTACTIN 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
GLYTACTIN LIQ RES/LITE 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
GLYTACTIN LIQ RESTORE 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
GLYTACTIN LIQ RTD 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
GLYTACTIN PAK SWIRL 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
GLYTACTIN POW APPLE 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
GLYTACTIN POW BLD 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
GLYTACTIN POW BLD PKU 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
GLYTACTIN POW PUNCH 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 199 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
GLYTACTIN POW RESTOR 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
GLYTACTIN POW TROPICAL 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
HCU EASY TAB (*nutritional supplement tabs**) Tier 3
HOMACTIN AA LIQ PLUS 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
ISOVACTIN AA LIQ PLUS 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
KETOVIE LIQ 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
KETOVIE LIQ CHOCOLAT 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
KETOVIE LIQ PEPTIDE 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
KETOVIE LIQ VANILLA 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
MSUD EASY TAB (*nutritional supplement tabs**) Tier 3
NOURISH LIQ 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
PHENACTIN AA LIQ PLUS 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
PKU EASY TAB (*nutritional supplement tabs**) Tier 3
PKU EASY TAB MICROTAB (*nutritional supplement tabs delayed release**)
Tier 3
PROMACTIN AA SUS PLUS (*nutritional supplement susp**) Tier 3
THRIVACIN 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
THRIVACIN LIQ DETOX 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
TYLACTIN COM BAR 10PE,15 PE (*nutritional supplement bar**)
Tier 3
TYLACTIN LIQ REST 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
TYLACTIN LIQ RTD 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
TYLACTIN POW BLD 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
TYLACTIN POW RESTOR 10,10PE,15,20PE,5 (*nutritional supplement pack**)
Tier 3
TYR EASY TAB (*nutritional supplement tabs**) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 200 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
VILACTIN AA LIQ PLUS 10,15,15 LIQ RTD LITE,30 LIQ (*nutritional supplement liquid**)
Tier 3
NUTRITIONAL SUPPLEMENTS ‐ DIET AIDS ‐ Products for Diet / Eating
APP SLIM RMS CAP (*nutritional supplement ‐ diet aids cap***)
Tier 3
ONCOLYTIC VIRAL AGENTS ‐ HSV1 ‐ Drugs for Treatment of Cancer
IMLYGIC INJ (talimogene laherparepvec intralesional inj) Tier 3 PA
OPHTHALMIC ANTIALLERGIC ‐ Drugs for Treatment of Disorders in the Eyes
ALOCRIL SOL 2% (nedocromil sodium ophth soln) Tier 3
ALOMIDE SOL 0.1% OP (lodoxamide tromethamine ophth soln)
Tier 3
azelastine dro 0.05% Tier 1
BEPREVE DRO 1.5% (bepotastine besilate ophth soln) Tier 3
cromolyn sod sol 4% op Tier 1
epinastine dro 0.05% Tier 1
LASTACAFT SOL 0.25% (alcaftadine ophth soln) Tier 2
olopatadine dro 0.1%,0.2% Tier 1
olopatadine sol 0.1%,0.2% Tier 1
PAZEO DRO 0.7% (olopatadine hcl ophth soln) Tier 2
ZERVIATE DRO 0.24% (cetirizine hcl ophth soln) Tier 3
OPHTHALMIC ANTIBIOTICS ‐ Drugs for Treatment of Disorders in the Eyes
AZASITE SOL 1% (azithromycin ophth soln) Tier 3
bacitracin oin op Tier 1
BESIVANCE SUS 0.6% (besifloxacin hcl ophth susp) Tier 2
CILOXAN OIN 0.3% OP (ciprofloxacin hcl ophth oint) Tier 2
CILOXAN SOL 0.3% OP (ciprofloxacin hcl ophth soln) Tier 3
ciprofloxacn sol 0.3% op Tier 1
erythromycin oin 5mg/gm Tier 1
erythromycin oin op 5mg/gm Tier 1
gatifloxacin sol 0.5% Tier 1
gentak oin 0.3% op Tier 1
gentamicin sol 0.3% op Tier 1
KLARITY‐A DRO 1% (azithromycin ophth soln) Tier 3
levofloxacin sol 0.5% Tier 1
MITOSOL KIT 0.2MG (mitomycin for ophth soln kit) Tier 3
MOXEZA SOL 0.5% (moxifloxacin hcl ophth soln) Tier 2
moxifloxacin sol 0.5% Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 201 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
moxifloxacin sol hcl 0.5% Tier 1
OCUFLOX DRO 0.3% OP (ofloxacin ophth soln) Tier 3
ofloxacin dro 0.3% op Tier 1
tobramycin sol 0.3% op Tier 1
TOBREX OIN 0.3% OP (tobramycin ophth oint) Tier 3
TOBREX SOL 0.3% OP (tobramycin ophth soln) Tier 3
VIGAMOX DRO 0.5% (moxifloxacin hcl ophth soln) Tier 3
ZYMAXID SOL 0.5% (gatifloxacin ophth soln) Tier 3
OPHTHALMIC ANTIFUNGAL ‐ Drugs for Treatment of Disorders in the Eyes
NATACYN SUS 5% OP (natamycin ophth susp) Tier 3
OPHTHALMIC ANTI‐INFECTIVE COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes
ak‐poly‐bac oin op Tier 1
bacit/polymy oin op Tier 1
MOXIFLOXACIN INJ 1MG/ML (moxifloxacin hcl in bss intravitreal soln)
Tier 3
neo/bac/poly oin op Tier 1
neo/poly/bac oin op Tier 1
neo/poly/gra sol op Tier 1
neomycin sulfate/polymyxin b sulfate/bacitracin zinc oin op (Neo‐polycin)
Tier 1
bacitracin zinc/polymyxin b sulfate oin op (Polycin) Tier 1
polymyxin b/ sol trimethp Tier 1
POLYTRIM SOL OP (polymyxin b‐trimethoprim ophth soln) Tier 3
trimethoprim sol polymyxn Tier 1
OPHTHALMIC ANTISEPTICS ‐ Drugs for Treatment of Disorders in the Eyes
BETADINE SOL 5%,5% OP (povidone‐iodine ophth soln) Tier 3
POVIDONE IOD SOL 5%,5% OP (povidone‐iodine ophth soln) Tier 3
OPHTHALMIC ANTIVIRALS ‐ Drugs for Treatment of Disorders in the Eyes
trifluridine sol 1% op Tier 1
ZIRGAN GEL 0.15% (ganciclovir ophth gel) Tier 3
OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS ‐ Drugs for Treatment of Disorders in the Eyes
AZOPT SUS 1% OP (brinzolamide ophth susp) Tier 2
dorzolamide sol 2% op Tier 1
DORZOLAMIDE SOL 2%,2% OP (dorzolamide hcl ophth soln) Tier 3
TRUSOPT SOL 2%,2% OP (dorzolamide hcl ophth soln) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 202 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
OPHTHALMIC DIAGNOSTIC PRODUCTS ‐ Drugs for Treatment of Disorders in the Eyes
altafluor‐be sol 0.25‐0.4 Tier 1
bio glo tes 1mg op Tier 1
flucaine sol 0.25‐0.5 Tier 1
fluore‐benox sol 0.25‐0.4 Tier 1
fluorescein/ sol proparac 0.25‐0.5 Tier 1
fluor‐i‐stri tes 1mg op Tier 1
FLURA‐SAFE SOL (fluorexon‐benoxinate ophth soln) Tier 3
ful‐glo tes 1mg op Tier 1
FUL‐GLO TES 0.6MG OP (fluorescein sodium ophth strips) Tier 3
glostrips mis 1mg op Tier 1
green glo mis 1.5mg Tier 1
lissamine gr tes 1.5mg Tier 1
PAREMYD SOL 1‐0.25% (hydroxyamphetamine‐tropicamide ophth soln)
Tier 3
ROSE GLO TES 1.5MG (rose bengal strips) Tier 3
OPHTHALMIC IMMUNOMODULATORS ‐ Drugs for Treatment of Disorders in the Eyes
CEQUA SOL 0.09% (cyclosporine (ophth) soln) Tier 3
CYCLOSPORINE EMU 0.1% (cyclosporine (ophth) emulsion) Tier 3
RESTASIS EMU 0.05% (cyclosporine (ophth) emulsion) Tier 2
RESTASIS MUL EMU 0.05% (cyclosporine (ophth) emulsion) Tier 2
OPHTHALMIC KINASE INHIBITORS ‐ COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes
ROCKLATAN DRO (netarsudil dimesylate‐latanoprost ophth soln)
Tier 2
OPHTHALMIC LOCAL ANESTHETICS ‐ Drugs for Treatment of Disorders in the Eyes
AKTEN GEL 3.5% (lidocaine hcl ophth gel) Tier 3
ALCAINE SOL 0.5% OP (proparacaine hcl ophth soln) Tier 3
tetracaine hydrochloride sol 0.5% op (Altacaine) Tier 1
proparacaine sol 0.5% op Tier 1
tetracaine sol 0.5% op Tier 1
OPHTHALMIC NERVE GROWTH FACTORS ‐ Drugs for Treatment of Disorders in the Eyes
OXERVATE SOL 20MCG/ML (cenegermin‐bkbj ophth soln) Tier 3 PA; QL (365 days;112 units)
OPHTHALMIC NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS ‐ Drugs for Treatment of Disorders in the Eyes
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 203 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ACULAR LS SOL 0.4%,0.5% OP (ketorolac tromethamine ophth soln)
Tier 3
ACULAR SOL 0.4%,0.5% OP (ketorolac tromethamine ophth soln)
Tier 3
ACUVAIL SOL 0.45% (ketorolac tromethamine (pf) ophth soln)
Tier 2
bromfenac sol 0.09% op Tier 1
BROMSITE DRO 0.07%,0.075% (bromfenac sodium ophth soln)
Tier 3
diclofenac sol 0.1% op Tier 1
flurbiprofen sol 0.03% op Tier 1
ILEVRO DRO 0.1%,0.3% OP (nepafenac ophth susp) Tier 2
ketorolac sol 0.4%,0.5% Tier 1
NEVANAC SUS 0.1%,0.3% OP (nepafenac ophth susp) Tier 2
PROLENSA SOL 0.07%,0.075% (bromfenac sodium ophth soln)
Tier 3
OPHTHALMIC PHOTOENHANCER COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes
PHOTREXA VIS SOL 0.146‐20 (riboflavin) Tier 3
PHOTREXA/PHO SOL VISC KIT (riboflav) Tier 3
OPHTHALMIC RHO KINASE INHIBITORS ‐ Drugs for Treatment of Disorders in the Eyes
RHOPRESSA SOL 0.02% (netarsudil dimesylate ophth soln) Tier 2
OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS ‐ Drugs for Treatment of Disorders in the Eyes
ALPHAGAN P SOL 0.1%,0.15% (brimonidine tartrate ophth soln)
Tier 2
apraclonidin sol 0.5% op Tier 1
brimonidine sol 0.15%,0.2% op Tier 1
IOPIDINE SOL 1% OP (apraclonidine hcl ophth soln) Tier 3
OPHTHALMIC STEROID COMBINATIONS ‐ Drugs for Treatment of Disorders in the Eyes
BLEPHAMIDE OIN S.O.P. (sulfacetamide sodium‐prednisolone ophth oint)
Tier 3
BLEPHAMIDE SUS OP (sulfacetamide sodium‐prednisolone ophth susp)
Tier 3
MAXITROL OIN 0.1% OP (neomycin‐polymyxin‐dexamethasone ophth oint)
Tier 3
MAXITROL SUS 0.1% OP (neomycin‐polymyxin‐dexamethasone ophth susp)
Tier 3
neo/poly/bac oin /hc 1%op Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 204 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
neo/poly/dex oin 0.1% op Tier 1
neo/poly/dex sus 0.1% op Tier 1
neo/poly/hc sus op Tier 1
bacitracin/neomycin/polymyxin b/hydrocortisone hc oin hc 1% op (Neo‐polycin Hc)
Tier 1
PRED MOXIFLO SOL 1‐0.5% (prednisolone‐moxifloxacin opth soln)
Tier 3
PRED MOXIFLO SUS BROMFEN (prednisolone ace‐moxifloxacin‐bromfenac op susp)
Tier 3
PRED/NEPAFEN DRO 1‐0.1% (prednisolone acetate‐nepafenac ophth susp)
Tier 3
PRED‐G S.O.P OIN OP (gentamicin‐prednisolone ace ophth oint)
Tier 3
PRED‐G SUS OP (gentamicin‐prednisolone ace ophth susp) Tier 3
PRED‐GAT‐BRO INJ (prednisolone‐gatifloxacin‐bromfenac ophth soln)
Tier 3
PRED‐GATI SUS 1‐0.5% (prednisolone‐gatifloxacin ophth susp)
Tier 3
PRED‐GATIFL‐ SUS BROMFENA (prednisolone‐gatifloxacin‐bromfenac ophth susp)
Tier 3
PREDNI/MOXI/ DRO NEPAFENA (prednisolone‐moxifloxacin‐nepafenac ophth susp)
Tier 3
PREDNI/MOXIF DRO 1‐0.5% (prednisolone acetate‐moxifloxacin opth susp)
Tier 3
PREDNIS/BROM SUS 1‐0.075% (prednisolone‐bromfenac ophth susp)
Tier 3
PREDNISOLONE SOL MOX‐BROM (prednisolone‐moxifloxacin‐bromfenac opth sol)
Tier 3
PRENIS‐BROMF SOL 1‐0.075% (prednisolone‐bromfenac ophth soln)
Tier 3
sulf/pred na sol op Tier 1
SULF/PREDNIS SUS OP (sulfacetamide sodium‐prednisolone ophth susp)
Tier 3
tobra/dexame sus 0.3‐0.1% Tier 1
TOBRADEX OIN 0.3‐0.1% (tobramycin‐dexamethasone ophth oint)
Tier 2
TOBRADEX ST SUS 0.3‐0.05 (tobramycin‐dexamethasone ophth susp)
Tier 2
TOBRADEX SUS 0.3‐0.1% (tobramycin‐dexamethasone ophth susp)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 205 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ZYLET SUS 0.5‐0.3% (loteprednol etabonate‐tobramycin ophth susp)
Tier 3
OPHTHALMIC STEROIDS ‐ Drugs for Treatment of Disorders in the Eyes
ALREX SUS 0.2%,0.5%,1% (loteprednol etabonate ophth susp)
Tier 3
dexameth pho sol 0.1% op Tier 1
DEXTENZA MIS 0.4MG (dexamethasone (ophth) insert) Tier 3
DUREZOL EMU 0.05% (difluprednate ophth emulsion) Tier 2
FLAREX SUS 0.1% OP (fluorometholone acetate ophth susp) Tier 3
fluoromethol sus 0.1% op Tier 1
FML FORTE SUS 0.25% OP (fluorometholone ophth susp) Tier 2
FML LIQUIFLM SUS 0.1% OP (fluorometholone ophth susp) Tier 3
FML OIN 0.1% OP (fluorometholone ophth oint) Tier 2
ILUVIEN IMP 0.19MG (fluocinolone acetonide intravitreal implant)
Tier 4 SP; QL (34 days supply)
INVELTYS SUS 0.2%,0.5%,1% (loteprednol etabonate ophth susp)
Tier 3
KLARITY‐B DRO 0.1% (betamethasone sodium phosphate ophth soln)
Tier 3
KLARITY‐L DRO 0.2%,0.5% (loteprednol etabonate ophth emulsion)
Tier 3
LOTEMAX GEL 0.38%,0.5% (loteprednol etabonate ophth gel)
Tier 3
LOTEMAX OIN 0.5% (loteprednol etabonate ophth oint) Tier 3
LOTEMAX SM GEL 0.38%,0.5% (loteprednol etabonate ophth gel)
Tier 3
LOTEMAX SUS 0.2%,0.5%,1% (loteprednol etabonate ophth susp)
Tier 3
loteprednol sus 0.5% Tier 1
MAXIDEX SUS 0.1% OP (dexamethasone ophth susp) Tier 2
OZURDEX IMP 0.7MG (dexamethasone intravitreal implant) Tier 3
PRED FORTE SUS 1%,1% OP (prednisolone acetate ophth susp)
Tier 3
PRED MILD SUS 0.12% OP (prednisolone acetate ophth susp)
Tier 2
PRED SOD PHO SOL 1% OP (prednisolone sod phosph oral soln)
Tier 3
prednisolone sus 1% op Tier 1
PREDNISOLONE SUS 1%,1% OP (prednisolone acetate ophth susp)
Tier 3
RETISERT IMP 0.18MG,0.59MG (fluocinolone acetonide intravitreal implant)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 206 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
YUTIQ IMP 0.18MG,0.59MG (fluocinolone acetonide intravitreal implant)
Tier 3
OPHTHALMIC SULFONAMIDES ‐ Drugs for Treatment of Disorders in the Eyes
BLEPH‐10 SOL 10% OP (sulfacetamide sodium ophth soln) Tier 3
sod sulfacet sol 10% op Tier 1
sulfacet sod oin 10% op Tier 1
sulfacet sod sol 10% op Tier 1
OPHTHALMIC SURGICAL AIDS ‐ Drugs for Treatment of Disorders in the Eyes
GELFILM MIS OP (gelatin adsorbable ophth film) Tier 3
MEMBRANEBLUE SOL 0.06%,0.15% (trypan blue ophth soln) Tier 3
VISIONBLUE SOL 0.06%,0.15% (trypan blue ophth soln) Tier 3
OPHTHALMICS ‐ CYSTINOSIS AGENTS ‐ Drugs for Treatment of Disorders in the Eyes
CYSTARAN SOL 0.44% (cysteamine hcl ophth soln) Tier 3 PA; QL (2.143 units per 1 day)
OPHTHALMICS MISC. ‐ OTHER ‐ Drugs for Treatment of Disorders in the Eyes
CHONDROITIN SOL (chondroitin sulfate ophth soln) Tier 3
OPIOID AGONISTS ‐ Drugs for Treatment of Pain
ABSTRAL SUB 400MCG,600MCG,800MCG (fentanyl citrate sl tab)
Tier 3 PA
ACTIQ LOZ 1200MCG,1600MCG,200MCG,400MCG,600MCG,800MCG (fentanyl citrate lozenge on a handle)
Tier 3 PA
ARYMO ER TAB 15MG,30MG,60MG (morphine sulfate tab er abuse‐deterrent)
Tier 3 PA
codeine sulf tab 30mg Tier 1 PA
CODEINE SULF TAB 15MG,30MG,60MG (codeine sulfate tab)
Tier 3 PA
CONZIP CAP 100MG,200MG,300MG (tramadol hcl cap er) Tier 3 PA
DILAUDID LIQ 1MG/ML (hydromorphone hcl liqd) Tier 3 PA
DILAUDID TAB 2MG,4MG,8MG (hydromorphone hcl tab) Tier 3 PA
DOLOPHINE TAB 10MG,5MG (methadone hcl tab) Tier 3 PA
DURAGESIC DIS 100MCG/H,12MCG/HR,25MCG/HR,50MCG/HR,75MCG/HR (fentanyl td patch)
Tier 3 PA
fentanyl cit tab 100mcg,200mcg,400mcg,600mcg,800mcg Tier 1 PA
fentanyl dis 100mcg/h,12mcg/hr,25mcg/hr,37.5mcg,50mcg/hr,62.5mcg,75mcg/hr,87.5mcg
Tier 1 PA
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 207 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
fentanyl ot loz 1200mcg,1600mcg,200mcg,400mcg,600mcg,800mcg
Tier 1 PA
FENTORA TAB 100MCG,200MCG,400MCG,600MCG,800MCG (fentanyl citrate buccal tab)
Tier 3 PA
hydrocodone cap 10mg er,15mg er,20mg er,30mg er,40mg er,50mg er
Tier 1 PA
hydromorphon liq 1mg/ml Tier 1 PA
HYDROMORPHON SUP 3MG (hydromorphone hcl suppos) Tier 3 PA
hydromorphon tab 2mg,4mg,8mg Tier 1 PA
hydromorphon tab 2mg,4mg,8mg Tier 1 PA
HYSINGLA ER TAB 100 MG,120 MG,20 MG,30 MG,40 MG,60 MG,80 MG (hydrocodone bitartrate tab er)
Tier 2 PA
KADIAN CAP 100MG ER,10MG ER,200MG ER,20MG ER,30MG ER,40MG ER,50MG ER,60MG ER,80MG ER (morphine sulfate cap er)
Tier 3 PA
LAZANDA SPR 100MCG,300MCG,400MCG (fentanyl citrate nasal spray)
Tier 3 PA
levorphanol tab 2mg,3mg Tier 1 PA
meperidine sol 50mg/5ml Tier 1 PA
meperidine tab 100mg,50mg Tier 1 PA
methadone con 10mg/ml Tier 1
methadone inj 10mg/ml Tier 1 PA
METHADONE INJ 10MG/ML (methadone hcl inj) Tier 3 PA
methadone sol 10mg/5ml,5mg/5ml Tier 1 PA
methadone tab 10mg,5mg Tier 1 PA
methadone tab 10mg,5mg Tier 1 PA
METHADOSE CON 10MG/ML (methadone hcl conc) Tier 3
METHADOSE SF CON 10MG/ML (methadone hcl conc) Tier 3
methadone hydrochloride tab 40mg (Methadose) Tier 1
morphine sul cap 120mg er,30mg er,45mg er,60mg er,75mg er,90mg er
Tier 1 PA
morphine sul cap 120mg er,30mg er,45mg er,60mg er,75mg er,90mg er
Tier 1 PA
morphine sul sol 100/5ml,10mg/5ml,20mg/5ml,20mg/ml Tier 1 PA
morphine sul sup 10mg,20mg,30mg,5mg Tier 1 PA
morphine sul tab 15mg,30mg Tier 1 PA
morphine sul tab 15mg,30mg Tier 1 PA
MS CONTIN TAB 100MG ER,15MG ER,200MG ER,30MG ER,60MG ER (morphine sulfate tab er)
Tier 3 PA
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 208 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NUCYNTA ER TAB 100MG,150MG,200MG,250MG,50MG (tapentadol hcl tab er)
Tier 2 PA
NUCYNTA TAB 100MG,50MG,75MG (tapentadol hcl tab) Tier 2 PA
OPANA TAB 10MG (oxymorphone hcl tab) Tier 3 PA
OXAYDO TAB 5MG,7.5MG (oxycodone hcl tab abuse deter) Tier 3 PA
oxycodone cap 5mg Tier 1 PA
oxycodone cap hcl 5mg Tier 1 PA
oxycodone con 10/0.5ml,100/5ml Tier 1 PA
oxycodone sol 5mg/5ml Tier 1 PA
oxycodone tab 10mg,15mg,20mg,30mg,5mg Tier 1 PA
oxycodone tab 10mg,15mg,20mg,30mg,5mg Tier 1 PA
OXYCONTIN TAB 10MG CR,15MG CR,20MG CR,30MG CR,40MG CR,60MG CR,80MG CR (oxycodone hcl tab er)
Tier 2 PA; QL (75 days;360 tablets)
oxymorphone tab 10mg er,15mg er,20mg er,30mg er,40mg er,5mg er,7.5mg er
Tier 1 PA
oxymorphone tab hcl 10mg,5mg Tier 1 PA
ROXICODONE TAB 15MG,30MG,5MG (oxycodone hcl tab) Tier 3 PA
SUBSYS SPR 100MCG,1200MCG,1600MCG,200MCG,400MCG,600MCG,800MCG (fentanyl sublingual spray)
Tier 2 PA
tramadol hcl cap 100mg,150mg er,200mg,300mg Tier 1 PA
tramadol hcl cap er 100mg,150mg er,200mg,300mg Tier 1 PA
tramadol hcl tab 100mg,50mg Tier 1 PA
tramadol hcl tab 100mg,50mg Tier 1 PA
ULTRAM TAB 50MG (tramadol hcl tab) Tier 3 PA
XTAMPZA ER CAP 13.5MG,18MG,27MG,36MG,9MG (oxycodone cap er)
Tier 2 PA
ZOHYDRO ER CAP 10MG,15MG,20MG,30MG,40MG,50MG (hydrocodone bitartrate cap er)
Tier 3 PA
OPIOID ANTAGONISTS ‐ Drugs to Treat Poisioning
EVZIO INJ 2/0.4ML (naloxone hcl solution auto‐injector) Tier 3 PA; QL (180 days;1.6 units)
naloxone inj 2mg Tier 1 PA; QL (180 days;1.6 units)
naltrexone tab 50mg Tier 1
NARCAN SPR (naloxone hcl nasal spray) Tier 2 QL (180 days;4 units)
VIVITROL INJ 380MG (naltrexone for im extended release susp)
Tier 3 PA; QL (0.04 unit per 1 day)
OPIOID ANTITUSSIVE‐ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies
hyd pol/cpm sus 10‐8/5ml Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 209 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
prometh/cod sol 6.25‐10 Tier 1
prometh/cod syp 6.25‐10 Tier 1
TUSSICAPS CAP 10‐8MG (hydrocod polst‐chlorphen polst cap er)
Tier 3
TUXARIN ER TAB 54.3‐8MG (codeine phos‐chlorpheniramine maleate tab er)
Tier 3
TUZISTRA XR SUS (codeine polist‐chlorphen polist er susp) Tier 3
OPIOID ANTITUSSIVE‐DECONGESTANT‐ANTIHISTAMINE ‐ Drugs to Treat Cough / Cold / Allergies
prometh/pe/ syp codeine Tier 1
OPIOID COMBINATIONS ‐ Drugs for Treatment of Pain
APADAZ TAB 4.08‐325,6.12‐325,8.16‐325 (benzhydrocodone hcl‐acetaminophen tab)
Tier 3 PA; QL (75 days;168 tablets)
BENZHY/ACETA TAB 4.08‐325,6.12‐325,8.16‐325 (benzhydrocodone hcl‐acetaminophen tab)
Tier 3 PA; QL (75 days;168 tablets)
oxycodone/acetaminophen tab 10‐325mg,2.5‐300,2.5‐325,5‐325mg,7.5‐325 (Endocet)
Tier 1 PA; QL (75 days;720 tablets)
nalocet tab 10‐325mg,2.5‐300,2.5‐325,5‐325mg,7.5‐325 Tier 1 PA; QL (75 days;1080 tablets)
oxycod/apap tab 10‐325mg,2.5‐300,2.5‐325,5‐325mg,7.5‐325
Tier 1 PA; QL (75 days;1080 tablets)
oxycod/asa tab Tier 1 PA; QL (75 days;1080 units)
oxycod‐apap tab 10‐325mg,2.5‐300,2.5‐325,5‐325mg,7.5‐325
Tier 1 PA; QL (75 days;1080 tablets)
PERCOCET TAB 10‐300MG,10‐325MG,2.5‐325,5‐300MG,5‐325MG,7.5‐300,7.5‐325 (oxycodone w/ acetaminophen tab)
Tier 3 PA; QL (75 days;540 tablets)
PRIMLEV TAB 10‐300MG,10‐325MG,2.5‐325,5‐300MG,5‐325MG,7.5‐300,7.5‐325 (oxycodone w/ acetaminophen tab)
Tier 3 PA; QL (75 days;1080 tablets)
PROLATE TAB 10‐300MG,10‐325MG,2.5‐325,5‐300MG,5‐325MG,7.5‐300,7.5‐325 (oxycodone w/ acetaminophen tab)
Tier 3 PA; QL (75 days;720 tablets)
OPIOID PARTIAL AGONISTS ‐ Drugs for Treatment of Pain
BELBUCA MIS 150MCG,300MCG,450MCG,600MCG,750MCG,75MCG,900MCG (buprenorphine hcl buccal film)
Tier 2 PA
BUNAVAIL MIS 2.1‐0.3,4.2‐0.7,6.3‐1MG (buprenorphine‐naloxone buccal film)
Tier 2 QL (75 days;180 units)
bupren/nalox mis 12‐3mg,2‐0.5mg,4‐1mg,8‐2mg Tier 1 QL (75 days;270 units)
bupren/nalox sub 2‐0.5mg,8‐2mg Tier 1 QL (75 days;270 units)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 210 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
buprenorphin dis 10mcg/hr,15mcg/hr,20mcg/hr,5mcg/hr,7.5/hr
Tier 1 PA
buprenorphin sub 2mg,8mg Tier 1 PA
butorphanol sol 10mg/ml Tier 1 QL (75 days;15 units)
BUTRANS DIS 10MCG/HR,15MCG/HR,20MCG/HR,5MCG/HR,7.5/HR (buprenorphine td patch weekly)
Tier 3 PA
pentaz/nalox tab 50‐0.5mg Tier 1 PA
SUBOXONE MIS 12‐3MG,2‐0.5MG,4‐1MG,8‐2MG (buprenorphine hcl‐naloxone hcl sl film)
Tier 3 QL (75 days;270 units)
ZUBSOLV SUB 0.7‐0.18,1.4‐0.36,11.4‐2.9,2.9‐0.71,5.7‐1.4,8.6‐2.1 (buprenorphine hcl‐naloxone hcl sl tab)
Tier 2 QL (75 days;270 units)
ORAL VEHICLES ‐ Syrups, gelatin, capsules for making pharmaceuticals
CHERRY SYP (cherry syrup) Tier 3
CORN SYP (corn syrup) Tier 3
FLAVOR BLEND SUS (*oral vehicles ‐ susp***) Tier 3
FLAVOR PLUS LIQ (*oral vehicles***) Tier 3
FLAVOR SWEET SYP (*oral vehicles ‐ syrup***) Tier 3
FLAVOR SWEET SYP S/F (*oral vehicles ‐ syrup***) Tier 3
MOUTH WASH LIQ GP (*mouthwash compounding base ‐ liquid***)
Tier 3
MOUTHWASH LIQ AF (*mouthwash compounding base ‐ liquid***)
Tier 3
MOUTHWASH LIQ OM (*mouthwash compounding base ‐ liquid***)
Tier 3
ORA‐BLEND SF SUS (*oral vehicles ‐ susp***) Tier 3
ORA‐BLEND SUS (*oral vehicles ‐ susp***) Tier 3
ORA‐PLUS LIQ (*oral vehicles***) Tier 3
ORA‐SWEET SF SYP (*oral vehicles ‐ syrup***) Tier 3
ORA‐SWEET SYP (*oral vehicles ‐ syrup***) Tier 3
PCCA SWEET SYP ‐SF (*oral vehicles ‐ syrup***) Tier 3
PCCA SYRUP SYP VEHICLE (*oral vehicles ‐ syrup***) Tier 3
PCCA‐PLUS SUS (*oral vehicles ‐ susp***) Tier 3
PURIFIED LIQ WATER (*distilled water***) Tier 3
SIMPLE SYP (simple ‐ syrup) Tier 3
SORBITOL SOL 3% IRR,3.3% IRR (sorbitol irrigation soln) Tier 3
SUSPENDRX SUS SWEET (*oral vehicles ‐ susp***) Tier 3
SUSPENDRX SUS UNSWEET (*oral vehicles ‐ susp***) Tier 3
SUSPENSION SUS VEHICLE (*oral vehicles ‐ susp***) Tier 3
SYRPALTA SYP (*oral vehicles ‐ syrup***) Tier 3
SYRPALTA SYP (simple ‐ syrup) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 211 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
SYRPALTA SYP CLEAR (simple ‐ syrup) Tier 3
SYRSPEND SF LIQ (*oral vehicles***) Tier 3
SYRSPEND SF SUS PH 4 (*oral vehicles for susp***) Tier 3
SYRUP SF SYP VEHICLE (*oral vehicles ‐ syrup***) Tier 3
SYRUP SYP VEHICLE (*oral vehicles ‐ syrup***) Tier 3
UNISPEND ANH SUS SWEETENE (*oral vehicles ‐ susp***) Tier 3
VERSAFREE SYP (*oral vehicles ‐ syrup***) Tier 3
VERSAPLUS SYP (*oral vehicles ‐ syrup***) Tier 3
OREXIN RECEPTOR ANTAGONISTS ‐ Drugs to Treat Problems with Sleeping
BELSOMRA TAB 10MG,15MG,20MG,5MG (suvorexant tab) Tier 2
DAYVIGO TAB 10MG,5MG (lemborexant tab) Tier 3
OTIC AGENTS ‐ MISCELLANEOUS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion
acetic acid sol 0.25%irr Tier 1
OTIC ANTI‐INFECTIVES ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion
CETRAXAL SOL 0.2% (ciprofloxacin hcl otic soln) Tier 3
ciprofloxacn sol 0.3% op Tier 1
ofloxacin dro 0.3% op Tier 1
OTIPRIO SUS 60MG/ML (ciprofloxacin intratympanic susp) Tier 3
OTIC STEROID‐ANTI‐INFECTIVE COMBINATIONS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion
antibiot ear sol 1% otic Tier 1
CIPRO HC SUS OTIC (ciprofloxacin‐hydrocortisone otic susp) Tier 3
cipro/fluoc dro pf Tier 1
CIPRODEX SUS 0.3‐0.1% (ciprofloxacin‐dexamethasone otic susp)
Tier 2
CORTISPORIN SUS ‐TC OTIC (neomycin‐colistin‐hc‐thonzonium otic susp)
Tier 3
neo/poly/hc sol 1% otic Tier 1
neo/poly/hc sus 1% otic Tier 1
OTOVEL DRO (ciprofloxacin‐fluocinolone aceton (pf) otic soln)
Tier 3
OTIC STEROIDS ‐ Drugs/Products to Treat Diarrhea and Aid in Digestion
acetasol hc sol otic Tier 1
DERMOTIC OIL 0.01% (fluocinolone acetonide (otic) oil) Tier 3
fluocinolone acetonide oil 0.01% (Flac) Tier 1
fluocin acet oil 0.01% Tier 1
fluocin acet oil ear 0.01% Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 212 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
hc/acet acid sol otic Tier 1
OVULATION STIMULANTS‐GONADOTROPINS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
CHOR GONADOT INJ 10000UNT,5000UNIT (chorionic gonadotropin for im inj)
Tier 4 SP; QL (34 days supply)
FOLLISTIM AQ INJ 300UNIT,600UNIT,900UNIT (follitropin beta inj)
Tier 4 SP; QL (34 days supply)
GONAL‐F INJ 1050UNIT,450UNIT (follitropin alfa for inj) Tier 2 SP; QL (34 days supply)
GONAL‐F RFF INJ 75UNIT (follitropin alfa for subcutaneous inj)
Tier 2 SP; QL (34 days supply)
GONAL‐F RFF INJ 75UNIT (follitropin alfa inj) Tier 2 SP; QL (34 days supply)
MENOPUR INJ 75UNIT (menotropins for subcutaneous inj) Tier 4 SP; QL (34 days supply)
NOVAREL INJ 10000UNT,5000UNIT (chorionic gonadotropin for im inj)
Tier 4 SP; QL (34 days supply)
OVIDREL INJ (choriogonadotropin alfa inj) Tier 2 SP; QL (34 days supply)
PREGNYL INJ 10000UNT,5000UNIT (chorionic gonadotropin for im inj)
Tier 4 SP; QL (34 days supply)
OVULATION STIMULANTS‐SYNTHETIC ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
clomiphene tab 50mg Tier 1
OXABOROLE‐RELATED ANTIFUNGALS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
KERYDIN SOL 5% (tavaborole soln) Tier 3 PA
OXAZOLIDINONES ‐ Antibiotics / Drugs for Infections
linezolid sus 100/5ml Tier 1
linezolid tab 600mg Tier 1
SIVEXTRO TAB 200MG (tedizolid phosphate tab) Tier 3
ZYVOX SUS 100MG/5M (linezolid for susp) Tier 3
ZYVOX TAB 600MG (linezolid tab) Tier 3
OXYTOCICS ‐ Drugs to Stimulate Contraction of Uterine Smooth Muscle
methylergonovine maleate tab 0.2mg (Methergine) Tier 1
methylergon tab 0.2mg Tier 1
PA ENDONUCLEASE INHIBITORS ‐ Drugs to Treat Viral Infections
XOFLUZA TAB 20MG,40MG (baloxavir marboxil tab therapy pack)
Tier 3
PARATHYROID HORMONE AND DERIVATIVES ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
FORTEO SOL 600/2.4 (teriparatide (recombinant) soln pen‐inj)
Tier 2 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 213 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
NATPARA INJ 100MCG,25MCG,50MCG,75MCG (parathyroid hormone (recombinant) for inj cartridge)
Tier 4 PA; SP; QL (34 days supply)
TERIPARATIDE INJ (teriparatide (recombinant) soln pen‐inj) Tier 4 PA; SP; QL (34 days supply)
TYMLOS INJ (abaloparatide subcutaneous soln pen‐injector)
Tier 2 PA; SP; QL (34 days supply)
PASSIVE IMMUNIZING AGENTS ‐ COMBINATIONS ‐ Vaccines and Drugs for the Immune System
HYQVIA INJ 10‐800,2.5‐200,20‐1600,30‐2400,5‐400 (immun glob inj)
Tier 4 PA; SP; QL (34 days supply)
PCSK9 INHIBITORS ‐ Drugs for High Cholesterol
PRALUENT INJ 150MG/ML,75MG/ML (alirocumab subcutaneous solution auto‐injector)
Tier 2 PA; QL (0.072 unit per 1 day)
REPATHA INJ 140MG/ML (evolocumab subcutaneous soln prefilled syringe)
Tier 2 PA; QL (0.08 unit per 1 day)
REPATHA PUSH INJ 420/3.5 (evolocumab subcutaneous soln cartridge/infusor)
Tier 2 PA; QL (0.13 unit per 1 day)
REPATHA SURE INJ 140MG/ML (evolocumab subcutaneous soln auto‐injector)
Tier 2 PA; QL (0.08 unit per 1 day)
PENICILLIN COMBINATIONS ‐ Antibiotics / Drugs for Infections
amox/k clav chw 200mg,400mg Tier 1
amox/k clav sus 200/5ml,250/5ml,400/5ml,600/5ml Tier 1
amox/k clav tab 250‐125,500‐125,875‐125 Tier 1
amox‐pot cla tab er Tier 1
AUGMENTIN SUS 125/5ML,250/5ML,600 (amoxicillin & k clavulanate for susp)
Tier 3
AUGMENTIN SUS ES‐ 125/5ML,250/5ML,600 (amoxicillin & k clavulanate for susp)
Tier 3
AUGMENTIN TAB 500MG (amoxicillin & k clavulanate tab) Tier 3
PENICILLINASE‐RESISTANT PENICILLINS ‐ Antibiotics / Drugs for Infections
dicloxacill cap 250mg,500mg Tier 1
PERIPHERAL COMT INHIBITORS ‐ Drugs to treat Parkinson's Disease
COMTAN TAB 200MG (entacapone tab) Tier 3
entacapone tab 200mg Tier 1
PERIPHERAL OPIOID RECEPTOR ANTAGONISTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
ENTEREG CAP 12MG (alvimopan cap) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 214 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MOVANTIK TAB 12.5MG,25MG (naloxegol oxalate tab) Tier 2
RELISTOR TAB 150MG (methylnaltrexone bromide tab) Tier 3
SYMPROIC TAB 0.2MG (naldemedine tosylate tab) Tier 3
PHARMACEUTICAL EXCIPIENTS ‐ Syrups, gelatin, capsules for making pharmaceuticals
BASE X MIS (hydrogenated vegetable oil flakes) Tier 3
COCOA BUTTER MIS (cocoa butter) Tier 3
POLYPEG SUP MIS BASE (*suppository base**) Tier 3
SPG SUPPOSI‐ MIS BASE (*suppository base ‐ pellets**) Tier 3
SUPPOSI‐PURE MIS (*suppository base**) Tier 3
SUPPOSITORY MIS BLEND (*suppository base ‐ pellets**) Tier 3
WITEPSOL H 15 MIS BASE F (hydrogenated vegetable oil pellets)
Tier 3
WITEPSOL MIS (hydrogenated vegetable oil wax) Tier 3
PHENOTHIAZINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
chlorpromaz tab 100mg,10mg,200mg,25mg,50mg Tier 1
prochlorperazine rectal sup 25mg (Compro) Tier 1
fluphenazine con 5mg/ml Tier 1
fluphenazine elx 2.5/5ml Tier 1
fluphenazine tab 10mg,1mg,2.5mg,5mg Tier 1
perphenazine tab 16mg,2mg,4mg,8mg Tier 1
prochlorper sup 25mg Tier 1
prochlorper tab 10mg,5mg Tier 1
thioridazine tab 100mg,10mg,25mg,50mg Tier 1
trifluoperaz tab 10mg,1mg,2mg,5mg Tier 1
PHENOTHIAZINES & TRICYCLIC AGENTS ‐ Drugs for diseases and disorders of the nervous system
perphen/amit tab 2‐10mg,2‐25mg,4‐10mg,4‐25mg,4‐50mg Tier 1
PHENYLKETONURIA TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
KUVAN POW 100MG,500MG (sapropterin dihydrochloride powder packet)
Tier 2 PA; SP; QL (34 days supply)
KUVAN TAB 100MG (sapropterin dihydrochloride soluble tab)
Tier 2 PA; SP; QL (34 days supply)
PALYNZIQ INJ 10/0.5ML,2.5/0.5,20MG/ML (pegvaliase‐pqpz subcutaneous soln pref syringe)
Tier 4 PA; SP; QL (34 days supply)
PHOSPHATE ‐ Drugs for Replacement of Minerals in the Body
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 215 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
K‐PHOS TAB (potassium phosphate monobasic tab) Tier 3
K‐PHOS TAB NEUTRAL (pot phos monobasic w/sod phos di & monobas tab)
Tier 3
phospha 250 neut,250 tab neutral Tier 1
phosphorous tab 250 neut,250 tab neutral Tier 1
phospho‐trin tab 250 neut,250 tab neutral Tier 1
virt‐phos tab 250 neut,250 tab neutral Tier 1
PHOSPHATE BINDER AGENTS ‐ Drugs to Treat Disorders of the Stomach and Intestines
AURYXIA TAB 210MG (ferric citrate tab) Tier 3
calc acetate cap 667mg Tier 1
calc acetate tab 667mg Tier 1
FOSRENOL CHW 1000MG,500MG,750MG (lanthanum carbonate chew tab)
Tier 3
FOSRENOL POW 1000MG,750MG (lanthanum carbonate oral powder pack)
Tier 3
lanthanum chw 1000mg,500mg,750mg Tier 1
PHOSLO CAP 667MG (calcium acetate (phosphate binder) cap)
Tier 3
PHOSLYRA SOL (calcium acetate (phosphate binder) oral soln)
Tier 2
RENAGEL TAB 800MG (sevelamer hcl tab) Tier 3
RENVELA POW 0.8GM,2.4GM (sevelamer carbonate packet) Tier 3
RENVELA TAB 800MG (sevelamer carbonate tab) Tier 3
sevelamer pow 0.8gm,2.4gm Tier 1
sevelamer tab 800mg Tier 1
sevelamer tab 800mg Tier 1
VELPHORO CHW 500MG (sucroferric oxyhydroxide chew tab)
Tier 2
PHOSPHATES ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
K‐PHOS TAB NO 2 (potassium & sodium acid phosphates tab)
Tier 3
PHOSPHATIDYLINOSITOL 3‐KINASE (PI3K) INHIBITORS ‐ Drugs for Treatment of Cancer
ALIQOPA INJ 60MG (copanlisib hcl for iv soln) Tier 3 PA
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 216 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
COPIKTRA CAP 15MG,25MG (duvelisib cap) Tier 3 PA; QL (2 units per 1 day)
PIQRAY 250MG TAB DOSE,300MG TAB DOSE (alpelisib tab pack)
Tier 4 PA; SP; QL (34 days supply)
PIQRAY 250MG TAB DOSE,300MG TAB DOSE (alpelisib tab therapy pack)
Tier 4 PA; SP; QL (34 days supply)
ZYDELIG TAB 100MG,150MG (idelalisib tab) Tier 4 PA; SP; QL (34 days supply); OAC
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS ‐ Drugs to Treat Pain and Inflammation
OTEZLA TAB 30MG (apremilast tab) Tier 2 PA; QL (34 days supply)
OTEZLA TAB 30MG (apremilast tab starter therapy pack) Tier 2 PA; QL (34 days supply)
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
EUCRISA OIN 2% (crisaborole oint) Tier 2
PHOSPHODIESTERASE III INHIBITORS ‐ Drugs to Treat Blood Disorders
cilostazol tab 100mg,50mg Tier 1
PHOTODYNAMIC THERAPY AGENTS ‐ TOPICAL ‐ Drugs to Treat Skin Disorders
AMELUZ GEL 10% (aminolevulinic acid hcl gel) Tier 3
LEVULAN KERA SOL 20% (aminolevulinic acid hcl for soln) Tier 3
PLASMA KALLIKREIN INHIBITORS ‐ Drugs to Treat Blood Disorders
KALBITOR INJ 10MG/ML (ecallantide inj) Tier 4 PA; SP; QL (34 days supply)
PLASMA KALLIKREIN INHIBITORS ‐ MONOCLONAL ANTIBODIES ‐ Drugs to Treat Blood Disorders
TAKHZYRO INJ 300/2ML (lanadelumab‐flyo inj) Tier 2 PA; SP; QL (34 days supply)
PLATELET AGGREGATION INHIBITOR COMBINATIONS ‐ Drugs to Treat Blood Disorders
AGGRENOX CAP 25‐200MG (aspirin‐dipyridamole cap er) Tier 3
asa/dipyrida cap 25‐200mg Tier 1
ASA/OMEPRAZO TAB 325‐40MG,81‐40MG (aspirin‐omeprazole tab delayed release)
Tier 3
ASP/OMEPRAZO TAB 325‐40MG,81‐40MG (aspirin‐omeprazole tab delayed release)
Tier 3
YOSPRALA TAB 325‐40MG,81‐40MG (aspirin‐omeprazole tab delayed release)
Tier 3
PLATELET AGGREGATION INHIBITORS ‐ Drugs to Treat Blood Disorders
dipyridamole tab 25mg,50mg,75mg Tier 1
DURLAZA CAP 162.5MG (aspirin capsule er) Tier 3
PLEUROMUTILINS ‐ Antibiotics / Drugs for Infections
XENLETA TAB 600MG (lefamulin acetate tab) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 217 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
POLY (ADP‐RIBOSE) POLYMERASE (PARP) INHIBITORS ‐ Drugs for Treatment of Cancer
LYNPARZA TAB 100MG,150MG (olaparib tab) Tier 2 PA; SP; QL (34 days supply); OAC
RUBRACA TAB 200MG,250MG,300MG (rucaparib camsylate tab)
Tier 2 PA; SP; QL (34 days supply)
TALZENNA CAP 0.25MG,1MG (talazoparib tosylate cap) Tier 4 PA; SP; QL (34 days supply)
ZEJULA CAP 100MG (niraparib tosylate cap) Tier 2 PA; QL (3 units per 1 day)
POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS ‐ Drugs for diseases and disorders of the nervous system
GRALISE STAR MIS 300/600 (gabapentin (once‐daily) tab pack)
Tier 2
GRALISE TAB 300MG,600MG (gabapentin (once‐daily) tab) Tier 2
LYRICA CR TAB 165MG,330MG,82.5MG (pregabalin tab er) Tier 2
POSTHERPETIC NEURALGIA(PHN)/NEUROPATHIC PAIN COMB AGENTS ‐ Drugs for diseases and disorders of the nervous system
LIPRITIN PAK (*gabapentin cap) Tier 3
POTASSIUM ‐ Drugs for Replacement of Minerals in the Body
potassium tab 25meq ef,25meq fr (Effer‐k) Tier 1
Potassium m 10 tab 10meq er,10meq cr,10meq er,20meq er,8 tab 8meq er,8meq er,8meq sr (Klor‐con M10)
Tier 1
potassium 10 tab 10meq er,10meq cr,10meq er,15 tab 15meq er,20 tab 20meq er,20meq er (Klor‐con M)
Tier 1
potassium pak 20meq (Klor‐con) Tier 1
potassium sprinkle cap 10meq,10meq er,8meq,8meq er (Klor‐con Sprinkle)
Tier 1
potassium tab 25meq ef,25meq fr (Klor‐con EF) Tier 1
potassium tab 25meq ef,25meq fr FR (K‐prime) Tier 1
K‐TAB TAB 10MEQ CR (potassium chloride tab er) Tier 2
K‐TAB TAB 20MEQ,8MEQ CR (potassium chloride tab er) Tier 3
pot chloride cap 10meq,10meq er,8meq,8meq er Tier 1
pot chloride pow 20meq Tier 1
pot chloride sol 10%,20% Tier 1
pot chloride tab 10 tab 10meq er,10meq cr,10meq er,15 tab 15meq er,20 tab 20meq er,20meq er
Tier 1
pot chloride tab 10 tab 10meq er,10meq cr,10meq er,15 tab 15meq er,20 tab 20meq er,20meq er
Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 218 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
pot cl micro tab 10 tab 10meq er,10meq cr,10meq er,15 tab 15meq er,20 tab 20meq er,20meq er
Tier 1
potassium tab 25meq ef,25meq fr Tier 1
POTASSIUM COMBINATIONS ‐ Drugs for Replacement of Minerals in the Body
EFFER‐K TAB 10MEQ,20MEQ (potassium bicarbonate effer tab)
Tier 3
pot/chloride tab 25meq ef Tier 1
POTASSIUM REMOVING AGENTS ‐ Miscellaneous Drugs and Solutions
sodium polystyrene sulfonate sus (Kionex) Tier 1
LOKELMA PAK 10GM,5GM (sodium zirconium cyclosilicate for susp packet)
Tier 2
sod poly sul pow Tier 1
sod poly sul sus 15gm/60 Tier 1
sod poly sul sus 15gm/60 Tier 1
sod polystyr pow sulfonat Tier 1
sps sus 15gm/60 Tier 1
VELTASSA POW 16.8GM,25.2GM,8.4GM (patiromer sorbitex calcium for susp packet)
Tier 2
POTASSIUM SPARING DIURETICS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders
ALDACTONE TAB 100MG,25MG,50MG (spironolactone tab) Tier 2
amiloride tab 5mg Tier 1
CAROSPIR SUS 25MG/5ML (spironolactone susp) Tier 3
DYRENIUM CAP 100MG,50MG (triamterene cap) Tier 3
spironolact tab 100mg,25mg,50mg Tier 1
triamterene cap 100mg,50mg Tier 1
PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS ‐ SSRIS ‐ Drugs for diseases and disorders of the nervous system
fluoxetine tab 10mg,20mg Tier 1
SARAFEM TAB 10MG,20MG (fluoxetine hcl (pmdd) tab) Tier 3
PRENATAL MV & MIN W/FE‐FA ‐ Drugs for Vitamin Replacement
ATABEX EC TAB 29‐1MG (*prenatal vit w/ dss‐iron carbonyl‐fa tab dr)
Tier 3
ATABEX OB TAB 29‐1MG (*prenatal vit w/ fe bisglycinate chelate‐fa tab)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 219 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
AZESCHEW CHW 13‐1MG,29‐1MG (*prenatal w/o a vit w/ fe fum‐fa tab chew)
Tier 3
AZESCO TAB 12‐1MG,13‐1MG (*prenatal vit w/ fe gluconate‐fa tab)
Tier 3
BAL‐CARE MIS DHA 400 MIS 25‐1‐400 (*prenat w/fe poly‐na fered‐fa tab)
Tier 3
CITRANATAL MIS B‐CALM (*prenat w/o a w/fecbn‐feglu‐fa tab)
Tier 2
CITRANATAL TAB BLOOM (*prenatal vit w/ dss‐fe cbn‐fe gluc‐fa tab)
Tier 2
CITRANATAL TAB RX (*prenatal w/o a w/ fe carbonyl‐fe gluc‐dss‐fa tab)
Tier 2
C‐NATE DHA CAP 28‐1‐200 (*prenatal vit w/ fe fum‐fa‐omega)
Tier 3
COMPLETENATE CHW 19 CHW,19 CHW 29‐1MG (*prenatal vit w/ fe fumarate‐fa chew tab)
Tier 3
CO‐NATAL FA TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
CONCEPT DHA CAP (*prenatal w/fe fum‐fe poly ‐fa‐omega) Tier 3
CONCEPT OB CAP (*prenatal w/o a w/fe fum‐fe poly‐fa cap)
Tier 3
DUET DHA 400 MIS 25‐1‐400 (*prenat w/fe poly‐na fered‐fa tab)
Tier 3
DUET DHA MIS BALANCED 400 MIS 25‐1‐400 (*prenat w/fe poly‐na fered‐fa tab)
Tier 3
prenatal vitamins with minerals tab (Elite‐ob) Tier 1
ENBRACE HR CAP (*prenatal vit w/ fe gly cys‐fa‐omega) Tier 3
FOLIVANE‐OB CAP (*prenatal w/o a w/fe fum‐fe poly‐fa cap)
Tier 3
prenatal vitamins with minerals gt tab (Inatal Gt) Tier 1
KOSHR PRENAT TAB 29‐1MG,30‐1MG (*prenatal vit w/ iron carbonyl‐fa tab)
Tier 3
MARNATAL‐F CAP (*prenatal w/o vit a w/ fe polysac cmplx‐fa cap)
Tier 3
M‐NATAL PLUS TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
M‐VIT TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
MYNATAL CAP (*prenatal multivitamins & minerals w/ iron & fa cap)
Tier 3
MYNATAL PLUS TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
MYNATAL TAB (*prenatal vit w/ dss‐iron carbonyl‐fa tab) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 220 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
MYNATAL TAB ADVANCE (*prenatal vit w/ dss‐iron carbonyl‐fa tab)
Tier 3
MYNATAL‐Z TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
MYNATE 90 TAB PLUS (*prenatal vit w/ dss‐fe fumarate‐fa tab er)
Tier 3
NATACHEW CHW (*prenatal vit w/ fe fum‐fe bisglycin‐fa chew tab)
Tier 3
NATALVIT TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
NEEVO DHA CAP 27‐1.13 (*prenat w/o a w/fefum‐methylfol‐omegas cap)
Tier 3
NEONATAL PLS TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
NEONATAL TAB COMPLTE 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
NESTABS DHA PAK (*prenat w/o a w/ fe bisglyc‐fa tab) Tier 3
NESTABS TAB (*prenatal vit w/o vit a w/ fe bisglycinate‐fa tab)
Tier 3
NIVA‐PLUS TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
OB COMPLETE CAP ONE (*prenatal w/o a w/fecbn‐fe asp glyc‐fa‐fish cap)
Tier 3
OB COMPLETE CAP PETITE (*prenat w/o a w/fecbn‐feaspglyc‐fa‐omega cap)
Tier 3
OB COMPLETE TAB 29‐1MG,30‐1MG (*prenatal vit w/ iron carbonyl‐fa tab)
Tier 3
OB COMPLETE TAB PREMIER (*prenatal vit w/ fe cbn‐fe asp glyc‐fa tab)
Tier 3
OB COMPLETE/ CAP DHA (*prenat w/ iron cbn‐fe asp glyc‐fa‐omega cap)
Tier 3
OBSTETRIX EC TAB (*prenatal vit w/ dss‐iron carbonyl‐fa tab)
Tier 3
OBSTETRIX PAK DHA (*prenat w/fecbn‐fa‐dss tab) Tier 3
O‐CAL TAB PRENATAL 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
ONE VITE TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
PNV FOLIC AC TAB + IRON 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
PNV PRENATAL TAB PLUS 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 221 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PNV TABS TAB 29‐1MG,30‐1MG (*prenatal vit w/ iron carbonyl‐fa tab)
Tier 3
PNV‐OMEGA CAP (*prenat w/o a w/ fe fumerate‐methylfolate‐fa‐omega)
Tier 3
prenatal vitamins with minerals tab (Pnv‐select) Tier 1
PREGENNA TAB (*prenat vit w/fe bisglyc chelate‐fa tab) Tier 3
PRENA1 PEARL CAP (*prenat w/oa w/fefum‐na fered‐fa‐dha cap er)
Tier 3
PRENARA CAP PRENATAL (*prenatal vit w/ fe fumarate‐fa cap)
Tier 3
PRENATA CHW 13‐1MG,29‐1MG (*prenatal w/o a vit w/ fe fum‐fa tab chew)
Tier 3
prenatal vitamins with minerals rx tab (Prenatabs Rx) Tier 1
prenatal vitamins with minerals 19 tab (Prenatal 19) Tier 1
PRENATAL 19 TAB,19 TAB 29‐1MG (*prenatal vit w/ fe fumarate‐fa chew tab)
Tier 3
PRENATAL 19 TAB,19 TAB 29‐1MG (*prenatal vit w/ fe fumarate‐fa chew tab)
Tier 3
PRENATAL PLS MIS MV + DHA (*prenat w/ fe fum‐fa tab) Tier 3
PRENATAL TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
PRENATAL TAB LOW IRON 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
PRENATAL TAB PLUS 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
prenatal tab plus/fe Tier 1
PRENATAL TAB PLUS/FE 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
PRENATAL VIT TAB LOW IRON 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
prenatal/fa tab Tier 1
PRENATAL+FE TAB 29‐1MG,30‐1MG (*prenatal vit w/ iron carbonyl‐fa tab)
Tier 3
PRENATAL‐U CAP 106.5‐1 (*prenatal w/o a vit w/ fe fumarate‐fa cap)
Tier 3
PRENATE TAB ELITE (*prenatal w/ fe asp gly‐l methylfol‐fa tab)
Tier 3
PRENATVITE TAB COMPLETE (*prenatal multivitamins & minerals w/ iron & fa tab)
Tier 3
PRENATVITE TAB PLUS (*prenatal multivitamins & minerals w/ iron & fa tab)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 222 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PRENATVITE TAB RX (*prenatal multivitamins & minerals w/iron & fa tab)
Tier 3
PREPLUS TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
PRETAB TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
PRIMACARE CAP (*prenat w/o a w/feasp‐methlf‐fa‐omeg cap)
Tier 3
PROVIDA OB CAP (*prenatal w/o a w/fe fum‐fe poly‐fa cap)
Tier 3
RELNATE DHA CAP 28‐1‐200 (*prenatal vit w/ fe fum‐fa‐omega)
Tier 3
SELECT‐OB CHW (*prenat w/ fepolycmplx‐methylfol‐fa chew tab)
Tier 3
SELECT‐OB CHW (*prenatal vit w/ fe polysac cmplx‐fa chew tab)
Tier 3
SE‐NATAL 19 TAB,19 TAB 29‐1MG (*prenatal vit w/ dss‐fe fumarate‐fa tab)
Tier 3
SE‐NATAL 19 TAB,19 TAB 29‐1MG (*prenatal vit w/ fe fumarate‐fa chew tab)
Tier 3
TARON‐C DHA CAP (*prenatal w/fe fum‐fe poly ‐fa‐omega) Tier 3
THRIVITE RX TAB 29‐1MG,30‐1MG (*prenatal vit w/ iron carbonyl‐fa tab)
Tier 3
TRICARE PRE CAP 27‐1‐500 (*prenatal w/fe fumarate‐fa‐dss‐fish oil cap)
Tier 3
TRICARE TAB PRENATAL 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
TRINATAL RX TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
prenatal vitamins with minerals tab (Trinate) Tier 1
TRINAZ TAB 12‐1MG,13‐1MG (*prenatal vit w/ fe gluconate‐fa tab)
Tier 3
TRI‐TABS DHA MIS (*prenat w/o a w/ fe bisglyc‐fa tab) Tier 3
VINATE DHA CAP 27‐1.13 (*prenat w/o a w/fefum‐methylfol‐omegas cap)
Tier 3
VINATE II TAB 29‐1MG (*prenatal vit w/ fe bisglycinate chelate‐fa tab)
Tier 3
VINATE ONE TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
VIRT‐C DHA CAP (*prenatal w/fe fum‐fe poly ‐fa‐omega) Tier 3
VIRT‐NATE CAP DHA 28‐1‐200 (*prenatal vit w/ fe fum‐fa‐omega)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 223 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
VIRT‐PN PLUS CAP (*prenat w/o a w/ fe fumerate‐methylfolate‐fa‐omega)
Tier 3
VITAFOL CHW GUMMIES (*prenat vit w/ fe phos‐fa‐omega chew tab)
Tier 3
VITAFOL‐NANO TAB (*prenatal w/o a w/ fefum‐l methylfol‐fa tab)
Tier 3
VITAFOL‐OB TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
VITAPEARL CAP (*prenat w/oa w/fefum‐na fered‐fa‐dha cap er)
Tier 3
VITATHELY TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
VIVA DHA CAP 28‐1‐200 (*prenatal vit w/ fe fum‐fa‐omega) Tier 3
VOL‐PLUS TAB 1,1MG PLUS,27‐1MG,29‐1MG,65‐1MG,75‐1MG (*prenatal vit w/ fe fumarate‐fa tab)
Tier 3
VOL‐TAB RX TAB 29‐1MG,30‐1MG (*prenatal vit w/ iron carbonyl‐fa tab)
Tier 3
VP‐HEME OB MIS + DHA (*prenat‐fe poly cmplx‐fe heme poly‐fa tab & omega)
Tier 3
VP‐PNV‐DHA CAP 28‐1‐200 (*prenatal vit w/ fe fum‐fa‐omega)
Tier 3
ZALVIT TAB 12‐1MG,13‐1MG (*prenatal vit w/ fe gluconate‐fa tab)
Tier 3
ZATEAN‐PN CAP PLUS (*prenat w/o a w/ fe fumerate‐methylfolate‐fa‐omega)
Tier 3
PRENATAL MV & MIN W/FE‐FA‐CA‐OMEGA 3 FISH OIL ‐ Drugs for Vitamin Replacement
COMPLETE NAT PAK DHA 400 PAK,430 PAK (*prenat‐fe bis‐fe prot succ‐fa‐ca tab & omega)
Tier 3
PR NATAL 400 PAK,430 PAK (*prenat‐fe bis‐fe prot succ‐fa‐ca tab & omega cap dr)
Tier 3
PR NATAL 400 PAK,430 PAK (*prenat‐fe bis‐fe prot succ‐fa‐ca tab & omega cap dr)
Tier 3
TRIVEEN‐DUO PAK DHA 400 PAK,430 PAK (*prenat‐fe bis‐fe prot succ‐fa‐ca tab & omega)
Tier 3
PRENATAL MV & MIN W/FE‐FA‐DHA ‐ Drugs for Vitamin Replacement
CITRANATAL CAP HARMONY (*prenat w/o a w/fe fum‐fe cbn‐dss‐fa‐dha cap)
Tier 2
CITRANATAL CAP MEDLEY (*prenat w/o a w/fe fum‐fe cbn‐fa‐dha cap)
Tier 2
CITRANATAL MIS 90 DHA (*prenat w/o a w/fecbn‐fegl‐dss‐fa tab)
Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 224 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CITRANATAL PAK ASSURE (*prenat w/o a w/fecbn‐fegl‐dss‐fa tab & dha cap)
Tier 2
CITRANATAL PAK DHA (*prenat w/o a w/fecbn‐fegl‐dss‐fa tab & dha cap)
Tier 2
NESTABS ONE CAP (*prenat w/o a w/fecbn‐bisg‐methylf‐dha cap)
Tier 3
OBSTETRX ONE CAP 38‐1‐225 (*prenat w/o a w/fecbn‐bisg‐methylf‐dss‐dha cap)
Tier 3
prenatal vitamins with minerals cap (Pnv‐dha) Tier 1
PNV‐DHA CAP DOCUSATE (*prenatal w/o vit a w/ fe fum‐dss‐fa‐dha cap)
Tier 3
PRENA 1 TRUE MIS (*prenat w/o a w/fe chel‐fa tab) Tier 3
PRENAISSANCE CAP (*prenatal w/o vit a w/ fe fum‐dss‐fa‐dha cap)
Tier 3
PRENAISSANCE CAP PLUS (*prenatal w/o a w/fe cbn‐dss‐fa‐dha cap)
Tier 3
PRENATE CAP ENHANCE (*prenat w/o a w/fefum‐methfol‐fa‐dha cap)
Tier 3
PRENATE CAP ESSENT (*prenat w/o a w/feaspg‐methfol‐fa‐dha cap)
Tier 3
PRENATE CAP PIXIE (*prenat w/o a w/feaspg‐methfol‐fa‐dha cap)
Tier 3
PRENATE CAP RESTORE (*prenat w/o a w/fefum‐methfol‐fa‐dha cap)
Tier 3
PRENATE DHA CAP (*prenat w/o a w/feaspg‐methfol‐fa‐dha cap)
Tier 3
PRENATE MINI CAP (*prenat w/oa w/fecb‐feasp‐meth‐fa‐dha cap)
Tier 3
R‐NATAL OB CAP 20‐1‐320 (*prenatal w/o a w/fe cbn‐fa‐dha cap)
Tier 3
SELECT‐OB+ PAK DHA (*prenatal mv w/fe poly‐fa chw) Tier 3
TARON‐PREX CAP (*prenatal w/o vit a w/ fe fum‐dss‐fa‐dha cap)
Tier 3
TRISTART DHA CAP 35‐1‐215 (*prenat w/o a w/fecbn‐methylf‐fa‐dha cap)
Tier 3
TRISTART ONE CAP 35‐1‐215 (*prenat w/o a w/fecbn‐methylf‐fa‐dha cap)
Tier 3
VIRT‐PN DHA CAP (*prenat w/o a w/fefum‐methfol‐fa‐dha cap)
Tier 3
VITAFOL CAP ULTRA (*prenat w/fe poly‐methylfol‐fa‐dha cap)
Tier 3
VITAFOL FE+ CAP (*prenat w/fe poly‐methylfol‐fa‐dha cap) Tier 3
VITAFOL‐OB PAK +DHA (*prenatal mv w/fe fum‐fa tab) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 225 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
VITAFOL‐ONE CAP (*prenatal mv w/ fe polysac cmplx‐fa‐dha cap)
Tier 3
VITAMEDMD CAP ONE RX (*prenat w/o a w/fefum‐methfol‐fa‐dha cap)
Tier 3
VITATRUE MIS 1 TRUE MIS (*prenat w/o a w/fe chel‐fa tab) Tier 3
ZATEAN‐PN CAP DHA (*prenat w/o a w/fefum‐methfol‐fa‐dha cap)
Tier 3
PRENATAL MV & MINERALS W/FA WITHOUT IRON ‐ Drugs for Vitamin Replacement
PRENATE CHW 0.6‐0.4 (*prenat mv & min w/ l‐methylfolate‐fa chew tab)
Tier 3
PRENATAL VITAMINS ‐ Drugs for Vitamin Replacement
PREMESISRX TAB 1MG (*prenatal w/ calcium‐vit b) Tier 3
PRENA1 CHW (*prenat w/ b) Tier 3
PRENATE AM TAB 1MG (*prenatal w/ calcium‐vit b) Tier 3
REDICHEW RX CHW (*prenat w/ b) Tier 3
VITAFOL STRP MIS 1MG (*prenatal w/ b) Tier 3
PROGESTERONE RECEPTOR ANTAGONISTS ‐ Drugs to treat Diabetes
KORLYM TAB 200MG,300MG (mifepristone tab) Tier 3 PA; QL (4 units per 1 day)
PROGESTIN CONTRACEPTIVES ‐ IMPLANTS ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
NEXPLANON IMP 68MG (etonogestrel subdermal implant) Tier 3
PROGESTIN CONTRACEPTIVES ‐ INJECTABLE ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
DEPO‐PROVERA INJ 150MG/ML (medroxyprogesterone acetate im susp prefilled syr)
Tier 5 QL (90 days supply)
DEPO‐PROVERA INJ 150MG/ML (medroxyprogesterone acetate im susp prefilled syr)
Tier 5 QL (90 days supply)
DEPO‐SQ PROV INJ 104 (medroxyprogesterone acetate susp pref syr)
Tier 5 QL (90 days supply)
medroxyprogesterone acetate im susp 150mg/ml Tier 5 QL (90 days supply)
medroxyprogesterone acetate im susp prefilled syr 150mg/ml
Tier 5 QL (90 days supply)
PROGESTIN CONTRACEPTIVES ‐ IUD ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
KYLEENA IUD 13.5MG,19.5MG (levonorgestrel releasing iud)
Tier 5 QL (1 unit per 1 day)
LILETTA IUD 52MG (levonorgestrel releasing iud) Tier 5 QL (1 unit per 1 day)
MIRENA IUD SYSTEM 13.5MG,19.5MG (levonorgestrel releasing iud)
Tier 5 QL (1 unit per 1 day)
SKYLA IUD 13.5MG,19.5MG (levonorgestrel releasing iud) Tier 5 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 226 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PROGESTIN CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
norethindrone tab 0.35MG (Camila) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg (Deblitane) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg (Errin) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg (Heather) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg (Incassia) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg(Jencycla) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg (Lyza) Tier 5 QL (1 unit per 1 day)
norethindrone tab ‐be tab 0.35mg (Nora‐be) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg (Norlyda) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg (Norlyroc) Tier 5 QL (1 unit per 1 day)
ORTHO MICRON TAB 0.35MG (norethindrone tab) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg (Sharobel) Tier 5 QL (1 unit per 1 day)
SLYND TAB 4MG (drospirenone tab) Tier 5 QL (1 unit per 1 day)
norethindrone tab 0.35mg (Tulana) Tier 5 QL (1 unit per 1 day)
PROGESTINS ‐ Natural or Synthetic Female Hormones
AYGESTIN TAB 5MG (norethindrone acetate tab) Tier 3
hydroxyprog inj 250mg/ml Tier 1 SP; QL (34 days supply)
MAKENA INJ 250MG/ML (hydroxyprogesterone caproate soln auto‐injector)
Tier 4 PA; SP; QL (34 days supply)
MAKENA INJ 250MG/ML (hydroxyprogesterone caproate soln auto‐injector)
Tier 4 PA; SP; QL (34 days supply)
medroxypr ac tab 10mg,2.5mg,5mg Tier 1
megestrol sus 400mg/10,40mg/ml,625/5ml,625mg/5m Tier 1 OAC
norethin ace tab 5mg Tier 1
progesterone cap 100mg,200mg Tier 1
PROMETRIUM CAP 100MG,200MG (progesterone micronized cap)
Tier 3
PROVERA TAB 10MG,2.5MG,5MG (medroxyprogesterone acetate tab)
Tier 3
PROGESTINS‐ANTINEOPLASTIC ‐ Drugs for Treatment of Cancer
megestrol ac sus 400mg/10,40mg/ml,625/5ml,625mg/5m Tier 1 OAC
megestrol ac tab 20mg,40mg Tier 1 OAC
PROSTAGLANDIN VASODILATORS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 227 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
epoprostenol inj 0.5mg,1.5mg Tier 1 PA; SP; QL (34 days supply)
FLOLAN INJ 0.5MG,1.5MG (epoprostenol sodium for inj) Tier 2 PA; SP; QL (34 days supply)
ORENITRAM TAB 0.125MG,0.25MG,1MG,2.5MG,5MG (treprostinil diolamine tab er)
Tier 2 PA; SP; QL (34 days supply)
REMODULIN INJ 10MG/ML,1MG/ML,2.5MG/ML,5MG/ML (treprostinil inj soln)
Tier 4 PA; SP; QL (34 days supply)
treprostinil inj 10mg/ml,1mg/ml,2.5mg/ml,5mg/ml Tier 1 PA; SP; QL (34 days supply)
TYVASO REFIL SOL 0.6MG/ML (treprostinil inhalation solution)
Tier 4 PA; SP; QL (34 days supply)
TYVASO SOL 0.6MG/ML (treprostinil inhalation solution) Tier 4 PA; SP; QL (34 days supply)
TYVASO START SOL 0.6MG/ML (treprostinil inhalation solution)
Tier 4 PA; SP; QL (34 days supply)
VELETRI INJ 0.5MG,1.5MG (epoprostenol sodium for inj) Tier 4 PA; SP; QL (34 days supply)
VENTAVIS SOL 10MCG/ML,20MCG/ML (iloprost inhalation solution)
Tier 4 PA; SP; QL (34 days supply)
PROSTAGLANDINS ‐ OPHTHALMIC ‐ Drugs for Treatment of Disorders in the Eyes
bimatoprost sol 0.03% Tier 1
latanoprost sol 0.005% Tier 1
LUMIGAN SOL 0.01% (bimatoprost ophth soln) Tier 2
TRAVATAN Z DRO 0.004% (travoprost ophth soln) Tier 2
travoprost dro 0.004% Tier 1
VYZULTA SOL 0.024% (latanoprostene bunod ophth soln) Tier 3
XALATAN SOL 0.005% (latanoprost ophth soln) Tier 3
XELPROS EMU 0.005% (latanoprost ophth emulsion) Tier 3
ZIOPTAN DRO 0.0015% (tafluprost preservative free (pf) ophth soln)
Tier 2
PROSTATIC HYPERTROPHY AGENT COMBINATIONS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
dutast/tamsu cap 0.5‐0.4 Tier 1
JALYN CAP (dutasteride‐tamsulosin hcl cap) Tier 3
PROTEASE‐ACTIVATED RECEPTOR‐1 (PAR‐1) ANTAGONISTS ‐ Drugs to Treat Blood Disorders
ZONTIVITY TAB 2.08MG (vorapaxar sulfate tab) Tier 3
PROTECTANTS ‐ MOUTH/THROAT ‐ Drugs to Treat Mouth / Throat / Dental Disorders
GELCLAIR GEL (*povidone‐sodium hyaluronate‐glycyrrhetinic acid gel***)
Tier 3
ORAFATE PST 10% (*sucralfate‐malate paste) Tier 3
PROTHELIAL PST 10% (*sucralfate‐malate paste) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 228 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PROTON PUMP INHIBITOR‐ANTACID COMBINATIONS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
omepra/bicar cap 20‐1100,40‐1100 Tier 1 QL (1 unit per 1 day)
omepra/bicar pow 20‐1680,40‐1680 Tier 1 QL (1 unit per 1 day)
ZEGERID CAP 20‐1100,40‐1100 (omeprazole‐sodium bicarbonate cap)
Tier 3 QL (1 unit per 1 day)
ZEGERID POW 20‐1680,40‐1680 (omeprazole‐sodium bicarbonate powd pack for susp)
Tier 3 QL (1 unit per 1 day)
PROTON PUMP INHIBITORS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
ACIPHEX SPR CAP 10MG,10MG DR,5MG (rabeprazole sodium capsule sprinkle dr)
Tier 3 QL (1 unit per 1 day)
ACIPHEX TAB 20MG (rabeprazole sodium ec tab) Tier 3 QL (1 unit per 1 day)
DEXILANT CAP 30MG DR,60MG DR (dexlansoprazole cap delayed release)
Tier 2 QL (1 unit per 1 day)
esomepra mag cap 20mg dr,40mg dr Tier 1 QL (1 unit per 1 day)
ESOMEPRAZOLE CAP 49.3MG (esomeprazole strontium cap delayed release)
Tier 3 QL (1 unit per 1 day)
esomeprazole gra 10mg dr,20mg dr,40mg dr Tier 1 QL (1 unit per 1 day)
esomeprazole inj 40mg Tier 1 QL (1 unit per 1 day)
lansoprazole cap 15mg dr,30mg dr Tier 1 QL (1 unit per 1 day)
lansoprazole tab 15mg,15mg odt,30mg,30mg odt Tier 1 QL (1 unit per 1 day)
NEXIUM CAP 20MG,40MG (esomeprazole magnesium cap delayed release)
Tier 3 QL (1 unit per 1 day)
NEXIUM GRA 2.5MG DR (esomeprazole magnesium for delayed release susp pack)
Tier 3 QL (1 unit per 1 day)
NEXIUM GRA 2.5MG DR (esomeprazole magnesium for delayed release susp packet)
Tier 3 QL (1 unit per 1 day)
NEXIUM I.V. INJ 40MG (esomeprazole sodium for intravenous soln)
Tier 3 QL (1 unit per 1 day)
omeprazole cap 10mg,10mg dr,20mg,20mg dr,40mg Tier 1 QL (1 unit per 1 day)
pantoprazole inj sod 40mg Tier 1 QL (1 unit per 1 day)
pantoprazole tab 20mg,20mg dr,40mg,40mg dr Tier 1 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 229 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PREVACID CAP 15MG DR,30MG DR (lansoprazole cap delayed release)
Tier 3 QL (1 unit per 1 day)
PREVACID TAB 15MG STB,30MG STB (lansoprazole tab delayed release orally disintegrating)
Tier 3 QL (1 unit per 1 day)
PRILOSEC POW 10MG,2.5MG (omeprazole magnesium for delayed release susp packet)
Tier 3 QL (1 unit per 1 day)
PROTONIX INJ 40MG (pantoprazole sodium for iv soln) Tier 3 QL (1 unit per 1 day)
PROTONIX PAK (pantoprazole sodium for delayed release susp packet)
Tier 3 QL (1 unit per 1 day)
PROTONIX TAB 20MG,40MG (pantoprazole sodium ec tab) Tier 3 QL (1 unit per 1 day)
RABEPRAZOLE CAP 10MG,10MG DR,5MG (rabeprazole sodium capsule sprinkle dr)
Tier 3 QL (1 unit per 1 day)
rabeprazole tab 20mg Tier 1 QL (1 unit per 1 day)
PSEUDOBULBAR AFFECT AGENT COMBINATIONS ‐ Drugs for diseases and disorders of the nervous system
NUEDEXTA CAP 20‐10MG (dextromethorphan hbr‐quinidine sulfate cap)
Tier 2
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. ‐ Drugs for diseases and disorders of the nervous system
ergoloid mes tab 1mg oral Tier 1
pimozide tab 1mg,2mg Tier 1
PULM HYPERTEN‐SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC) ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
ADEMPAS TAB 0.5MG,1.5MG,1MG,2.5MG,2MG (riociguat tab)
Tier 2 PA; SP; QL (34 days supply)
PULMONARY FIBROSIS AGENTS ‐ Drugs/Products to Help with Breathing
ESBRIET CAP 267MG (pirfenidone cap) Tier 2 PA; SP; QL (34 days supply)
ESBRIET TAB 267MG,801MG (pirfenidone tab) Tier 2 PA; SP; QL (34 days supply)
PULMONARY FIBROSIS AGENTS ‐ KINASE INHIBITORS ‐ Drugs/Products to Help with Breathing
OFEV CAP 100MG,150MG (nintedanib esylate cap) Tier 2 PA; SP; QL (34 days supply)
PULMONARY HYPERTENSION ‐ ENDOTHELIN RECEPTOR ANTAGONISTS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
ambrisentan tab 10mg,5mg Tier 1 PA; SP; QL (34 days supply)
bosentan tab 125mg,62.5mg Tier 1 PA; SP; QL (34 days supply)
LETAIRIS TAB 10MG,5MG (ambrisentan tab) Tier 4 PA; SP; QL (34 days supply)
OPSUMIT TAB 10MG (macitentan tab) Tier 2 PA; SP; QL (34 days supply)
TRACLEER TAB 125MG,62.5MG (bosentan tab) Tier 4 PA; SP; QL (34 days supply)
TRACLEER TAB 125MG,62.5MG (bosentan tab for oral susp) Tier 4 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 230 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PULMONARY HYPERTENSION ‐ PHOSPHODIESTERASE INHIBITORS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
ADCIRCA TAB 20MG (tadalafil tab) Tier 4 PA; SP; QL (34 days supply)
alyq tab 20mg Tier 1 PA; SP; QL (34 days supply)
REVATIO INJ (sildenafil citrate iv soln) Tier 4 PA; SP; QL (34 days supply)
REVATIO SUS 10MG/ML (sildenafil citrate for suspension) Tier 4 PA; SP; QL (34 days supply)
REVATIO TAB 20MG (sildenafil citrate tab) Tier 4 PA; SP; QL (34 days supply)
sildenafil inj Tier 1 PA; SP; QL (34 days supply)
sildenafil sus 10mg/ml Tier 1 PA; SP; QL (34 days supply)
sildenafil tab 20mg Tier 1 PA; SP; QL (34 days supply)
tadalafil tab 20mg Tier 1 PA; SP; QL (34 days supply)
PULMONARY HYPERTENSION ‐ PROSTACYCLIN RECEPTOR AGONIST ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
UPTRAVI TAB 1000MCG,1200MCG,1400MCG,1600MCG,200MCG,400MCG,600MCG,800MCG (selexipag tab)
Tier 2 PA; SP; QL (34 days supply)
UPTRAVI TAB 1000MCG,1200MCG,1400MCG,1600MCG,200MCG,400MCG,600MCG,800MCG (selexipag tab therapy pack)
Tier 2 PA; SP; QL (34 days supply)
PURINE ANALOGS ‐ Miscellaneous Drugs and Solutions
AZASAN TAB 100MG,50MG,75 MG (azathioprine tab) Tier 2
AZATHIOPRINE INJ 100MG (azathioprine sodium for inj) Tier 3
azathioprine tab 50mg Tier 1
IMURAN TAB 100MG,50MG,75 MG (azathioprine tab) Tier 2
PYRIMIDINE SYNTHESIS INHIBITORS ‐ Drugs to Treat Pain and Inflammation
ARAVA TAB 10MG,20MG (leflunomide tab) Tier 2
leflunomide tab 10mg,20mg Tier 1
QUATERNARY ANTICHOLINERGICS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
CUVPOSA SOL 1MG/5ML (glycopyrrolate oral soln) Tier 3
GLYCATE TAB 1.5MG (glycopyrrolate tab) Tier 3
glycopyrrol tab 1mg,2mg Tier 1
GLYCOPYRROLA TAB 1.5MG (glycopyrrolate tab) Tier 3
methscopolam tab 2.5mg,5mg Tier 1
propanthelin tab 15mg Tier 1
QUINAZOLINE AGENTS ‐ Drugs to Treat Blood Disorders
AGRYLIN CAP 0.5MG (anagrelide hcl cap) Tier 2
anagrelide cap 0.5mg,1mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 231 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
QUINOLINONE DERIVATIVES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
ABILIFY MYCI TAB 10MG,15MG,20MG,2MG,30MG,5MG (aripiprazole tab)
Tier 3
ABILIFY TAB 10MG,15MG,20MG,2MG,30MG,5MG (aripiprazole tab)
Tier 3
aripiprazole sol 1mg/ml Tier 1
aripiprazole tab 10mg odt,15mg odt Tier 1
aripiprazole tab 10mg odt,15mg odt Tier 1
REXULTI TAB 0.25MG,0.5MG,1MG,2MG,3MG,4MG (brexpiprazole tab)
Tier 3
RADIOGRAPHIC CONTRAST MEDIA ‐ BARIUM ‐ Products for Testing
BARIUM POW SULFATE (barium sulfate powder) Tier 3
ENTERO VU SUS 0.1%,2 SUS,2 SUS BANANA,2 SUS BERRY,2 SUS MOCHACCI,2 SUS VANILLA,24%,40%,60% (barium sulfate susp)
Tier 3
E‐Z‐DISK TAB 700MG (barium sulfate tab) Tier 3
E‐Z‐HD SUS 96%,98% (barium sulfate for susp) Tier 3
E‐Z‐PAQUE SUS 96%,98% (barium sulfate susp) Tier 3
E‐Z‐PAQUE SUS 96%,98% (barium sulfate susp) Tier 3
E‐Z‐PASTE CRE 60% (barium sulfate oral cream) Tier 3
NEULUMEX SUS 0.1%,2 SUS,2 SUS BANANA,2 SUS BERRY,2 SUS MOCHACCI,2 SUS VANILLA,24%,40%,60% (barium sulfate susp)
Tier 3
POLIBAR PLUS SUS 105% (barium sulfate oral/rectal susp) Tier 3
READI‐CAT 0.1%,2 SUS,2 SUS BANANA,2 SUS BERRY,2 SUS MOCHACCI,2 SUS VANILLA,24%,40%,60% (barium sulfate susp)
Tier 3
SITZMARKS CAP (barium sulfate (o‐ring) cap) Tier 3
SITZMARKS CAP (barium sulfate cap therapy pack (o‐ring, dd, tri‐chamber))
Tier 3
TAGITOL V SUS 0.1%,2 SUS,2 SUS BANANA,2 SUS BERRY,2 SUS MOCHACCI,2 SUS VANILLA,24%,40%,60% (barium sulfate susp)
Tier 3
VARIBAR HONE SUS 0.1%,2 SUS,2 SUS BANANA,2 SUS BERRY,2 SUS MOCHACCI,2 SUS VANILLA,24%,40%,60% (barium sulfate susp)
Tier 3
VARIBAR NECT SUS 0.1%,2 SUS,2 SUS BANANA,2 SUS BERRY,2 SUS MOCHACCI,2 SUS VANILLA,24%,40%,60% (barium sulfate susp)
Tier 3
VARIBAR PST PUDDING (barium sulfate oral paste) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 232 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
VARIBAR THIN SUS HONEY 0.1%,2 SUS,2 SUS BANANA,2 SUS BERRY,2 SUS MOCHACCI,2 SUS VANILLA,24%,40%,60% (barium sulfate susp)
Tier 3
VARIBAR THIN SUS LIQUID 96%,98% (barium sulfate for susp)
Tier 3
VOLUMEN SUS 0.1%,2 SUS,2 SUS BANANA,2 SUS BERRY,2 SUS MOCHACCI,2 SUS VANILLA,24%,40%,60% (barium sulfate susp)
Tier 3
RADIOGRAPHIC CONTRAST MEDIA ‐ IODINATED ‐ Products for Testing
CYSTO‐CONRAY INJ II 17.2% (iothalamate meglumine inj) Tier 3
CYSTOGRAFIN INJ 30% (diatrizoate meglumine urethral soln)
Tier 3
CYSTOGRAFIN‐ INJ DILUTE (diatrizoate meglumine inj) Tier 3
GASTROGRAFIN SOL 66‐10% (diatrizoate meglumine & sodium oral soln)
Tier 3
md‐gastrovie sol 66‐10% Tier 1
OMNIPAQUE SOL 12MG/ML,9MG/ML (iohexol oral soln) Tier 3
RANK LIGAND (RANKL) INHIBITORS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
PROLIA SOL 60MG/ML (denosumab inj soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
XGEVA INJ (denosumab inj) Tier 4 PA; SP; QL (34 days supply)
RECTAL ANESTHETIC/STEROIDS ‐ Drugs to Treat Misc Rectal Problems & Disorders
hc pramoxine cre 1‐1% Tier 1
PROCTOFOAM AER HC 1% (hydrocortisone acetate w/ pramoxine perianal foam)
Tier 2
RECTAL STEROIDS ‐ Drugs to Treat Misc Rectal Problems & Disorders
ANUSOL‐HC CRE 2.5% (hydrocortisone perianal cream) Tier 2
hydrocort cre 1%,2.5% Tier 1
hydrocortiso cre 1%,2.5% Tier 1
PROCTOCORT CRE 1% (hydrocortisone perianal cream) Tier 3
procto‐med cre hc 1%,2.5% Tier 1
hydrocortisone topical cre 1%,2.5% (Procto‐pak) Tier 1
hydrocortisone topical hc cre 1%,2.5% (Proctosol Hc) Tier 1
hydrocortisone topical hc cre 1%,2.5% (Proctozone‐hc) Tier 1
RESPIRATORY AGENTS ‐ MISC. ‐ Drugs/Products to Help with Breathing
CUROSURF SUS 120/1.5,240/3ML (poractant alfa intratracheal susp)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 233 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
INFASURF SUS 35MG/ML (calfactant in nacl) Tier 3
SURVANTA INH (beractant in nacl) Tier 3
RESTLESS LEG SYNDROME (RLS) AGENTS ‐ Drugs for diseases and disorders of the nervous system
HORIZANT TAB 300MG ER,600MG ER (gabapentin enacarbil tab er)
Tier 3
RETINOIDS ‐ Drugs for Treatment of Cancer
tretinoin cap 10mg Tier 1 OAC
ROSACEA AGENTS ‐ Drugs to Treat Skin Disorders
azelaic acid gel 15% Tier 1
doxycycline cap 40mg Tier 1
FINACEA AER 15% (azelaic acid foam) Tier 2
FINACEA GEL 15% (azelaic acid gel) Tier 3
METROCREAM CRE 0.75%,1% (metronidazole cream) Tier 3
METROGEL GEL 1% (metronidazole gel) Tier 3
METROLOTION LOT 0.75% (metronidazole lotion) Tier 3
metronidazol cre 0.75% Tier 1
metronidazol gel 0.75%,1% Tier 1
metronidazol lot 0.75% Tier 1
MIRVASO GEL 0.33% (brimonidine tartrate gel) Tier 3
NORITATE CRE 0.75%,1% (metronidazole cream) Tier 3
ORACEA CAP 40MG (doxycycline (rosacea) cap delayed release)
Tier 3
RHOFADE CRE 1% (oxymetazoline hcl cream) Tier 3
rosadan cre 0.75% Tier 1
rosadan gel 0.75%,1% Tier 1
SOOLANTRA CRE 1% (ivermectin cream) Tier 2
ZILXI AER 1.5%,4% (minocycline hcl micronized foam) Tier 3
RSV AGENTS ‐ NUCLEOSIDE ANALOGUES ‐ Drugs to Treat Viral Infections
ribavirin inh 6gm Tier 1
VIRAZOLE INH 6GM (ribavirin for inhal soln) Tier 3
SALICYLATES ‐ Drugs to Treat Pain
aspirin tab delayed release 81mg ec,81mg Tier 5 QL (100 tablets)
aspirin tab delayed release adlt 81mg ec Tier 5 QL (100 tablets)
ASPIRIN CHLD CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
ASPIRIN CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
ASPIRIN LOW CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
ASPIRIN LOW TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 234 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
aspirin tab 81mg ec Tier 1 QL (100 tablets)
ASPIRIN TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
ASPIRIN‐81 CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
aspirin low tab delayed release 81mg ec Tier 5 QL (100 tablets)
BAYER LOW CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
BAYER LOW TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
CHILD ASA CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
CHILD ASA LS CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
CVS ASPIRIN TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
diflunisal tab 500mg Tier 1
ECOTRIN LOW TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
EQ CHILD ASA CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
EQL ASPIRIN CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
GNP ASPIRIN CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
gnp aspirin tab 81mg ec Tier 1 QL (100 tablets)
GNP ASPIRIN TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
HM ASPIRIN CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
KLS ASPIRIN TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
KP ASPIRIN TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
LOW DOSE ASA TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
MINIPRIN LOW TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
PX ASPIRIN CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
PX ASPIRIN TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
QC CHILD ASA CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
RA ASPIRIN CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
RA ASPIRIN TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
RA CHILD ASA CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
salsalate tab 500mg,750mg Tier 1
SB CHILD ASA CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 235 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
SM ASPIRIN CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
SM ASPIRIN TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
SM CHILD ASA CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
ST JOSEPH CHW LOW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
TGT ASPIRIN CHW 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
TGT ASPIRIN CHW CHILD 81MG (aspirin chew tab) Tier 5 QL (100 chewables)
TGT ASPIRIN TAB 81 TAB 81MG EC,81MG,81MG EC (aspirin tab delayed release)
Tier 5 QL (100 tablets)
SALINE LAXATIVE MIXTURES ‐ Drugs to Treat Constipation
OSMOPREP TAB 1.5GM (sod phos mono‐sod phos di tabs) Tier 3
SALIVA STIMULANTS ‐ Drugs to Treat Mouth / Throat / Dental Disorders
cevimeline cap 30mg Tier 1
EVOXAC CAP 30MG (cevimeline hcl cap) Tier 2
pilocarpine tab 5mg,7.5mg Tier 1
SALAGEN TAB 5MG,7.5MG (pilocarpine hcl tab) Tier 2
SCABICIDES & PEDICULICIDES ‐ Drugs to Treat Skin Disorders
crotamiton topical lot 10% (Crotan) Tier 1
ELIMITE CRE 5% (permethrin cream) Tier 2
lindane sha 1% Tier 1
malathion lot 0.5% Tier 1
NATROBA SUS 0.9% (spinosad susp) Tier 3
OVIDE LOT 0.5% (malathion lotion) Tier 2
permethrin cre 5% Tier 1
SKLICE LOT 0.5% (ivermectin lotion) Tier 3
spinosad sus 0.9% Tier 1
SULF LIME SOL (sulfurated lime solution) Tier 3
SCAR TREATMENT PRODUCTS ‐ Drugs to Treat Skin Disorders
BEAU RX GEL (*scar treatment products ‐ gel**) Tier 3
celacyn gel Tier 1
COPASIL GEL (*scar treatment products ‐ gel**) Tier 3
KELARX GEL (*scar treatment products ‐ gel**) Tier 3
RECEDO GEL (*scar treatment products ‐ gel**) Tier 3
SCARCIN GEL (*scar treatment products ‐ gel**) Tier 3
SCARCIN LIQ ROLL‐ON (*scar treatment products ‐ liquid**) Tier 3
SCARSILK GEL (*scar treatment products ‐ gel**) Tier 3
SCAR TREATMENT PRODUCTS ‐ COMBINATIONS ‐ Drugs to Treat Skin Disorders
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 236 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
SILIPAC KIT (*dimethicone gel & silicone patch kit***) Tier 3
SCLEROSTIN INHIBITORS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
EVENITY INJ 105MG (romosozumab‐aqqg inj soln prefilled syringe)
Tier 4 PA; SP; QL (34 days supply)
SEBORRHEIC KERATOSIS PRODUCTS ‐ Drugs to Treat Skin Disorders
ESKATA SOL 40% (hydrogen peroxide soln) Tier 3
SELECTIN BLOCKERS ‐ Drugs to Treat Blood Disorders
ADAKVEO INJ 100/10ML (crizanlizumab‐tmca iv soln) Tier 4 PA; SP; QL (34 days supply)
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) ‐ Drugs to Treat High Blood Pressure
eplerenone tab 25mg,50mg Tier 1
INSPRA TAB 25MG,50MG (eplerenone tab) Tier 2
SELECTIVE COSTIMULATION MODULATORS ‐ Drugs to Treat Pain and Inflammation
ORENCIA CLCK INJ 125MG/ML (abatacept subcutaneous soln auto‐injector)
Tier 4 PA; SP; QL (34 days supply)
ORENCIA INJ 250MG (abatacept for iv soln) Tier 4 PA; SP; QL (34 days supply)
ORENCIA INJ 250MG (abatacept subcutaneous soln prefilled syringe)
Tier 4 PA; SP; QL (34 days supply)
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
EVISTA TAB 60MG (raloxifene hcl tab) Tier 5
OSPHENA TAB 60MG (ospemifene tab) Tier 2
raloxifene hcl tab 60mg Tier 5
SELECTIVE MELATONIN RECEPTOR AGONISTS ‐ Drugs to Treat Problems with Sleeping
HETLIOZ CAP 20MG (tasimelteon capsule) Tier 3 PA; QL (1 unit per 1 day)
ramelteon tab 8mg Tier 1 QL (1 unit per 1 day)
ROZEREM TAB 8MG (ramelteon tab) Tier 3 QL (1 unit per 1 day)
SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS ‐ Drugs to Treat Asthma and Breathing Disorders
DALIRESP TAB 250MCG,500MCG (roflumilast tab) Tier 2
SELECTIVE RETINOID X RECEPTOR AGONISTS ‐ Drugs for Treatment of Cancer
bexarotene cap 75mg Tier 1 PA; SP; QL (34 days supply); OAC
TARGRETIN CAP 75MG (bexarotene cap) Tier 2 PA; SP; QL (34 days supply); OAC
SELECTIVE SEROTONIN AGONIST‐NSAID COMBINATIONS ‐ Drugs to Treat Migraine Headaches
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 237 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
sumat‐naprox tab 85‐500mg Tier 1 QL (75 days;36 tablets)
TREXIMET TAB 85‐500MG (sumatriptan‐naproxen sodium tab)
Tier 3 QL (75 days;36 tablets)
SELECTIVE SEROTONIN AGONISTS 5‐HT(1) ‐ Drugs to Treat Migraine Headaches
almotrip mal tab 12.5mg,6.25mg Tier 1 QL (75 days;36 tablets)
almotriptan tab 12.5mg,6.25mg Tier 1 QL (75 days;36 tablets)
AMERGE TAB 1MG,2.5MG (naratriptan hcl tab) Tier 3 QL (75 days;36 tablets)
eletriptan tab 20mg,40mg Tier 1 QL (75 days;36 tablets)
FROVA TAB 2.5MG (frovatriptan succinate tab) Tier 3 QL (75 days;54 tablets)
frovatriptan tab 2.5mg Tier 1 QL (75 days;54 tablets)
IMITREX INJ 6MG/0.5 (sumatriptan succinate inj) Tier 3 QL (75 days;40 units)
IMITREX INJ 6MG/0.5 (sumatriptan succinate solution cartridge)
Tier 3 QL (75 days;40 units)
IMITREX INJ 6MG/0.5 (sumatriptan succinate solution cartridge)
Tier 3 QL (75 days;40 units)
IMITREX SPR 10MG,20MG/ACT,5MG/ACT (sumatriptan nasal spray)
Tier 3 QL (75 days;36 units)
IMITREX TAB 100MG,25MG,50MG (sumatriptan succinate tab)
Tier 3 QL (75 days;36 tablets)
MAXALT TAB 10MG (rizatriptan benzoate tab) Tier 3 QL (75 days;54 tablets)
MAXALT‐MLT TAB 10MG (rizatriptan benzoate oral disintegrating tab)
Tier 3 QL (75 days;54 tablets)
naratriptan tab 1mg,2.5mg Tier 1 QL (75 days;36 tablets)
ONZETRA XSAI MIS 11MG (sumatriptan succinate exhaler powder)
Tier 2 QL (75 days;64 units)
RELPAX TAB 20MG,40MG (eletriptan hydrobromide tab) Tier 3 QL (75 days;36 tablets)
rizatriptan tab 10mg odt,5mg odt Tier 1 QL (75 days;54 tablets)
rizatriptan tab 10mg odt,5mg odt Tier 1 QL (75 days;54 tablets)
sumatriptan inj 6/0.5ml,6mg/0.5 Tier 1 QL (75 days;18 units)
sumatriptan inj 6/0.5ml,6mg/0.5 Tier 1 QL (75 days;18 units)
sumatriptan inj 6/0.5ml,6mg/0.5 Tier 1 QL (75 days;18 units)
sumatriptan inj 6/0.5ml,6mg/0.5 Tier 1 QL (75 days;18 units)
sumatriptan spr 20mg/act,5mg/act Tier 1 QL (75 days;72 units)
sumatriptan tab 100mg,25mg,50mg Tier 1 QL (75 days;36 tablets)
TOSYMRA SOL 10MG,20MG/ACT,5MG/ACT (sumatriptan nasal spray)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 238 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ZEMBRACE SYM INJ 3/0.5ML (sumatriptan succinate solution auto‐injector)
Tier 2 QL (75 days;36 units)
zolmitriptan tab 2.5 mg,5mg odt Tier 1 QL (75 days;36 tablets)
zolmitriptan tab 2.5 mg,5mg odt Tier 1 QL (75 days;36 tablets)
ZOMIG SPR 2.5MG,5MG (zolmitriptan nasal spray) Tier 2 QL (75 days;36 units)
ZOMIG TAB 2.5MG,5MG (zolmitriptan tab) Tier 3 QL (75 days;36 tablets)
ZOMIG ZMT TAB 2.5 MG,5MG ODT (zolmitriptan orally disintegrating tab)
Tier 3 QL (75 days;36 tablets)
SELECTIVE SEROTONIN AGONISTS 5‐HT(1F) ‐ Drugs to Treat Migraine Headaches
REYVOW TAB 100MG,50MG (lasmiditan succinate tab) Tier 2
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) ‐ Drugs for Depression / Other Disorders
CELEXA TAB 10MG,20MG,40MG (citalopram hydrobromide tab)
Tier 3
citalopram sol 10mg/5ml Tier 1
citalopram tab 10mg,20mg,40mg Tier 1
escitalop ox sol 10/10ml,5mg/5ml Tier 1
escitalopram sol 10/10ml,5mg/5ml Tier 1
escitalopram tab 10mg,20mg,5mg Tier 1
fluoxetine cap 10mg,20mg,40mg Tier 1
fluoxetine cap 10mg,20mg,40mg Tier 1
fluoxetine sol 20mg/5ml Tier 1
fluoxetine tab 10mg,20mg Tier 1
FLUOXETINE TAB 60MG (fluoxetine hcl (pmdd) tab) Tier 3
fluvoxamine cap 100mg er,150mg er Tier 1
fluvoxamine tab 100mg,25mg,50mg Tier 1
LEXAPRO TAB 10MG,20MG,5MG (escitalopram oxalate tab) Tier 3
paroxetin er tab 12.5mg,25mg er,37.5mg Tier 1
paroxetine tab 10mg,20mg,30mg,40mg Tier 1
paroxetine tab 10mg,20mg,30mg,40mg Tier 1
PAXIL CR TAB 12.5MG,25MG,37.5MG (paroxetine hcl tab er)
Tier 3
PAXIL SUS 10MG/5ML (paroxetine hcl oral susp) Tier 3
PAXIL TAB 10MG,20MG,30MG,40MG (paroxetine hcl tab) Tier 3
PEXEVA TAB 10MG,20MG,30MG,40MG (paroxetine mesylate tab)
Tier 3
PROZAC CAP 10MG,20MG,40MG (fluoxetine hcl cap) Tier 3
sertraline con 20mg/ml Tier 1
sertraline tab 100mg,25mg,50mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 239 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ZOLOFT CON 20MG/ML (sertraline hcl oral concentrate for solution)
Tier 3
ZOLOFT TAB 100MG,25MG,50MG (sertraline hcl tab) Tier 3
SELECTIVE T‐CELL COSTIMULATION BLOCKERS ‐ Miscellaneous Drugs and Solutions
NULOJIX INJ 250MG (belatacept for iv infusion) Tier 3
SELECTIVE VASOPRESSIN V2‐RECEPTOR ANTAGONISTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
JYNARQUE PAK 15MG,30‐15MG,45‐15MG,60‐30MG,90‐30MG (tolvaptan tab therapy pack)
Tier 3 PA; QL (2 units per 1 day)
JYNARQUE TAB 15MG,30‐15MG,45‐15MG,60‐30MG,90‐30MG (tolvaptan tab)
Tier 3 SP; QL (2 units per 1 day)
JYNARQUE TAB 15MG,30MG (tolvaptan tab therapy pack) Tier 4 SP; QL (2 units per 1 day)
SAMSCA TAB 15MG,30MG (tolvaptan tab) Tier 4 PA; SP; QL (34 days supply)
tolvaptan tab 30mg Tier 1 PA; QL (34 days supply)
SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG ‐ Drugs for diseases and disorders of the nervous system
ADDYI TAB 100MG (flibanserin tab) Tier 3
SEROTONIN MODULATORS ‐ Drugs for Depression / Other Disorders
nefazodone tab 100mg,150mg,200mg,250mg,50mg Tier 1
trazodone tab 100mg,150mg,300mg,50mg Tier 1
TRINTELLIX TAB 10MG,20MG,5MG (vortioxetine hbr tab) Tier 2
VIIBRYD KIT STARTER (vilazodone hcl tab starter kit) Tier 2
VIIBRYD TAB 10MG,20MG,40MG (vilazodone hcl tab) Tier 2
SEROTONIN‐NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) ‐ Drugs for Depression / Other Disorders
CYMBALTA CAP 20MG,30MG,60MG (duloxetine hcl enteric coated pellets cap)
Tier 3
desvenlafax tab 100mg er,25mg er,50mg er Tier 1
DESVENLAFAX TAB 100MG ER,50MG ER (desvenlafaxine succinate tab er)
Tier 3
DRIZALMA CAP 20MG DR,30MG DR,40MG DR,60MG DR (duloxetine hcl cap delayed release sprinkle)
Tier 3
duloxetine cap 20mg,30mg,40mg,60mg Tier 1
EFFEXOR XR CAP 150MG,37.5MG,75MG (venlafaxine hcl cap er)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 240 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
FETZIMA CAP 120MG,20MG,40MG,80MG (levomilnacipran hcl cap er)
Tier 2
FETZIMA CAP TITRATIO 120MG,20MG,40MG,80MG (levomilnacipran hcl cap er)
Tier 2
PRISTIQ TAB 100MG,25MG,50MG (desvenlafaxine succinate tab er)
Tier 3
venlafaxine cap 150mg er,37.5 er,75mg er Tier 1
venlafaxine tab 100mg,25mg,37.5mg,50mg,75mg Tier 1
venlafaxine tab 100mg,25mg,37.5mg,50mg,75mg Tier 1
SGLT2 INHIBITOR ‐ DPP‐4 INHIBITOR ‐ BIGUANIDE COMB ‐ Drugs to treat Diabetes
TRIJARDY XR TAB (empagliflozin‐linaglip‐metformin tab er) Tier 3
TRIJARDY XR TAB (empagliflozin‐linagliptin‐metformin tab er)
Tier 3
SGLT2 INHIBITOR ‐ DPP‐4 INHIBITOR COMBINATIONS ‐ Drugs to treat Diabetes
GLYXAMBI TAB 10‐5 MG,25‐5 MG (empagliflozin‐linagliptin tab)
Tier 2
QTERN TAB 10MG/5MG,5‐5MG (dapagliflozin‐saxagliptin tab)
Tier 2
STEGLUJAN TAB 15‐100MG,5‐100MG (ertugliflozin‐sitagliptin tab)
Tier 3
SINUS NODE INHIBITORS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
CORLANOR SOL 5MG/5ML (ivabradine hcl oral soln) Tier 3
CORLANOR TAB 5MG,7.5MG (ivabradine hcl tab) Tier 2
SKIN CLEANSERS ‐ Drugs to Treat Skin Disorders
EPICYN SPR 800MG (*hypochlorous acid soln***) Tier 3
ESSENTRA MIS 9X9" (isopropyl alcohol wipes) Tier 3
HYCLODEX SOL 0.012% (hypochlorous acid soln) Tier 3
SKIN PROTECTANTS ‐ Drugs to Treat Skin Disorders
BENZOIN TIN NF (benzoin tincture) Tier 3
SMALL INTERFERING RIBONUCLEIC ACID (SIRNA) AGENTS ‐ Drugs for diseases and disorders of the nervous system
ONPATTRO SOL 10MG/5ML (patisiran sodium iv soln) Tier 4 PA; SP; QL (34 days supply)
SMOKING DETERRENTS ‐ Drugs for diseases and disorders of the nervous system
bupropion hcl (smoking deterrent) tab er 150mg sr Tier 5
CHANTIX PAK 0.5& 1MG,0.5MG,1MG (varenicline tartrate tab)
Tier 5 QL (168 units per year)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 241 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CHANTIX TAB 0.5& 1MG,0.5MG,1MG (varenicline tartrate tab)
Tier 5 QL (168 tablets per year)
CVS NICOTINE DIS 1,14MG/24H,21MG/24H,7MG/24HR (nicotine td patch)
Tier 5 QL (168 units per year)
CVS NICOTINE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
CVS NICOTINE LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
EQ NICOTINE DIS 1,14MG/24H,21MG/24H,7MG/24HR (nicotine td patch)
Tier 5 QL (168 units per year)
EQ NICOTINE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
EQ NICOTINE LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
EQL NICOTINE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
EQL NICOTINE LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
GNP NICOTINE DIS 1,14MG/24H,21MG/24H,7MG/24HR (nicotine td patch)
Tier 5 QL (168 units per year)
GNP NICOTINE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
GNP NICOTINE LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
GNP NICOTINE LOZ MINI 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 242 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
HM NICOTINE DIS 1,14MG/24H,21MG/24H,7MG/24HR (nicotine td patch)
Tier 5 QL (168 units per year)
HM NICOTINE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
HM NICOTINE LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
KLS QUIT 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
KLS QUIT 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
NICORELIEF GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
nicotine td patch 1,14mg/24h,21mg/24h,7mg/24hr Tier 5 QL (168 units per year)
nicotine td patch dis step 1,14mg/24h,21mg/24h,7mg/24hr Tier 5 QL (168 units per year)
nicotine gum 2mg,4mg Tier 1 QL (168 units per year)
nicotine polacrilex gum 2 ,2mg,2mg,2mg cinn,2mg mint,2mg orig,2mg ref,2mg strt,2mg fruit,4 gum 4mg,4mg,4mg cinn,4mg frt,4mg fruit,4mg mint,4mg orig,4mg ref,4mg strt,4mgfruit
Tier 5 QL (168 units per year)
nicotine loz 2mg mint,4mg mint Tier 1 QL (168 units per year)
nicotine polacrilex lozenge 2 loz 2mg,2mg,2mg cher,2mg chry,2mg cinn,2mg mint,4 loz 4mg,4mg,4mg chry ,4mg cinn,4mg mint
Tier 5 QL (168 units per year)
nicotine polacrilex lozenge mini 2 loz 2mg,2mg,2mg cher,2mg chry,2mg cinn,2mg mint,4 loz 4mg,4mg,4mg chry,4mg cinn,4mg mint
Tier 5 QL (168 units per year)
NICOTINE POL GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 243 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
nicotine pol loz 2mg mint,4mg mint Tier 1 QL (168 units per year)
NICOTINE POL LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
NICOTINE TD DIS 1,14MG/24H,21MG/24H,7MG/24HR (nicotine td patch)
Tier 5 QL (168 units per year)
NICOTROL INH (nicotine inhaler system) Tier 5
NICOTROL NS SPR 10MG/ML (nicotine nasal spray) Tier 5
RA NICOTINE DIS 1,14MG/24H,21MG/24H,7MG/24HR (nicotine td patch)
Tier 5 QL (168 units per year)
RA NICOTINE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
RA NICOTINE LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
SM NICOTINE DIS 1,14MG/24H,21MG/24H,7MG/24HR (nicotine td patch)
Tier 5 QL (168 units per year)
SM NICOTINE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
SM NICOTINE LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
SR NICOTINE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
STOP SMOKING GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
STOP SMOKING LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
TGT NICOTINE DIS 1,14MG/24H,21MG/24H,7MG/24HR (nicotine td patch)
Tier 5 QL (168 units per year)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 244 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
TGT NICOTINE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
TGT NICOTINE LOZ 2 LOZ 2MG,2MG,2MG CHER,2MG CHRY,2MG CINN,2MG MINT,4 LOZ 4MG,4MG,4MG CHRY,4MG CINN,4MG MINT (nicotine polacrilex lozenge)
Tier 5 QL (168 units per year)
THRIVE GUM 2 GUM 2MG,2MG,2MG CINN,2MG MINT,2MG ORIG,2MG REF,2MG STRT,2MGFRUIT,4 GUM 4MG,4MG,4MG CINN,4MG FRT,4MG FRUT,4MG MINT,4MG ORIG,4MG REF,4MG STRT,4MGFRUIT (nicotine polacrilex gum)
Tier 5 QL (168 units per year)
SODIUM‐GLUCOSE CO‐TRANSPORTER 2 (SGLT2) INHIBITORS ‐ Drugs to treat Diabetes
FARXIGA TAB 10MG,5MG (dapagliflozin propanediol tab) Tier 2
INVOKANA TAB 100MG,300MG (canagliflozin tab) Tier 2
JARDIANCE TAB 10MG,25MG (empagliflozin tab) Tier 2
STEGLATRO TAB 15MG,5MG (ertugliflozin l‐pyroglutamic acid tab)
Tier 3
SODIUM‐GLUCOSE CO‐TRANSPORTER 2 INHIBITOR‐BIGUANIDE COMB ‐ Drugs to treat Diabetes
INVOKAMET TAB 150‐1000,150‐500,50‐1000,50‐500MG (canagliflozin‐metformin hcl tab)
Tier 2
INVOKAMET XR TAB 150‐1000,150‐500,50‐1000,50‐500MG (canagliflozin‐metformin hcl tab er)
Tier 2
SEGLUROMET TAB 2.5‐1000,2.5‐500,7.5‐1000,7.5‐500 (ertugliflozin‐metformin hcl tab)
Tier 3
SYNJARDY TAB 12.5‐500,5‐1000MG,5‐500MG (empagliflozin‐metformin hcl tab)
Tier 2
SYNJARDY XR TAB 10‐1000,25‐1000,5‐1000MG (empagliflozin‐metformin hcl tab er)
Tier 2
XIGDUO XR TAB 10‐1000,10‐500MG,2.5‐1000,5‐1000MG,5‐500MG (dapagliflozin‐metformin hcl tab er)
Tier 2
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ‐ Drugs to Treat Pain and Inflammation
ENBREL INJ 25MG (etanercept for subcutaneous inj) Tier 2 PA; SP; QL (34 days supply)
ENBREL INJ 25MG (etanercept subcutaneous soln prefilled syringe)
Tier 2 PA; SP; QL (34 days supply)
ENBREL MINI INJ 50MG/ML (etanercept subcutaneous solution cartridge)
Tier 2 PA; SP; QL (34 days supply)
ENBREL SRCLK INJ 50MG/ML (etanercept subcutaneous solution auto‐injector)
Tier 2 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 245 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
SOMATOSTATIC AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
BYNFEZIA PEN INJ 2500MCG (octreotide acetate soln pen‐injector)
Tier 3 QL (34 days supply)
octreotide inj 1000/5ml,1000mcg,100mcg,200mcg,5000/5ml,500mcg,50mcg/ml
Tier 1 PA; SP; QL (34 days supply)
SANDOSTATIN INJ 100MCG,500MCG,50MCG/ML (octreotide acetate inj)
Tier 4 PA; SP; QL (34 days supply)
SANDOSTATIN KIT LAR 10MG,20MG,30MG (octreotide acetate for im inj kit)
Tier 4 PA; SP; QL (34 days supply)
SIGNIFOR INJ 0.3MG/ML,0.6MG/ML,0.9MG/ML (pasireotide diaspartate inj)
Tier 3 PA; QL (2 units per 1 day)
SIGNIFOR LAR INJ 10MG,20MG,30MG,40MG,60MG (pasireotide pamoate for im er susp)
Tier 3 PA; QL (0.04 unit per 1 day)
SOMATULINE INJ 120/.5ML,60/0.2ML,90/0.3ML (lanreotide acetate extended release inj)
Tier 2 PA; SP; QL (34 days supply)
SPHINGOSINE 1‐PHOSPHATE (S1P) RECEPTOR MODULATORS ‐ Drugs for diseases and disorders of the nervous system
GILENYA CAP 0.5MG (fingolimod hcl cap) Tier 2 PA; SP; QL (34 days supply)
MAYZENT TAB 0.25MG,2MG (siponimod fumarate tab) Tier 2 PA; SP; QL (34 days supply)
ZEPOSIA 7DAY CAP STR PACK (ozanimod cap pack) Tier 3 QL (34 days supply)
ZEPOSIA CAP . 92MG (ozanimod hcl cap) Tier 3 QL (34 days supply)
ZEPOSIA CAP STR KIT 7DAY CAP STR PACK (ozanimod cap pack)
Tier 3 QL (34 days supply)
SPLEEN TYROSINE KINASE (SYK) INHIBITORS ‐ Drugs to Treat Blood Disorders
TAVALISSE TAB 100MG,150MG (fostamatinib disodium tab) Tier 3 PA; QL (2 units per 1 day)
STEROID INHALANTS ‐ Drugs to Treat Asthma and Breathing Disorders
ALVESCO AER 160MCG,80MCG (ciclesonide inhal aerosol) Tier 3 QL (75 days;36.6 units)
ARNUITY ELPT INH 100MCG,200MCG,50MCG (fluticasone furoate aerosol powder breath activ)
Tier 2
ASMANEX 120 AER 220MCG,14 AER 220MCG,30 AER 110MCG,30 AER 220MCG,60 AER 220MCG,7 AER 110MCG (mometasone furoate inhal powd)
Tier 2
ASMANEX HFA AER 100 MCG,200 MCG,50MCG (mometasone furoate inhal aerosol suspension)
Tier 2
budesonide sus 0.25mg/2,0.5mg/2,1mg/2ml Tier 1 QL (75 days;360 units)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 246 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
FLOVENT DISK AER 100MCG,250MCG,50MCG (fluticasone propionate aer pow ba)
Tier 2 QL (75 days;540 units)
FLOVENT HFA AER 110MCG,220MCG (fluticasone propionate hfa inhal aer)
Tier 2 QL (75 days;72 units)
FLOVENT HFA AER 110MCG,220MCG (fluticasone propionate hfa inhal aero)
Tier 2 QL (75 days;72 units)
PULMICORT INH 180MCG,90MCG (budesonide inhal aero powd)
Tier 2 QL (75 days;6 units)
PULMICORT SUS 0.25MG/2,0.5MG/2,1MG/2ML (budesonide inhalation susp)
Tier 3 QL (75 days;540 units)
QVAR REDIHA AER 40MCG,80MCG (beclomethasone diprop hfa breath act inh aer)
Tier 2 QL (75 days;63.6 units)
QVAR REDIHAL AER 40MCG,80MCG (beclomethasone diprop hfa breath act inh aer)
Tier 2 QL (75 days;63.6 units)
STEROID‐LOCAL ANESTHETIC COMBINATIONS ‐ Drugs to Treat Skin Disorders
EPIFOAM AER 1% (pramoxine‐hc aerosol foam) Tier 3
STEROIDS ‐ MOUTH/THROAT/DENTAL ‐ Drugs to Treat Mouth / Throat / Dental Disorders
triamcinolone acetonide dental paste 0.1% (Oralone Dental Paste)
Tier 1
triamcinolon pst den 0.1% Tier 1
STIMULANT LAXATIVES ‐ Drugs to Treat Constipation
CASCARA EXT SAGRADA (cascara sagrada fl ext) Tier 3
STIMULANTS ‐ MISC. ‐ Drugs for Attention Deficit Disorder / Sleep Disorders / Eating Disorders
ADHANSIA XR CAP 10MG,15MG,20MG,25MG,30MG,35MG,40MG,45MG,50MG,55MG,60MG,70MG,85MG (methylphenidate hcl cap er)
Tier 3 AL‐18 max
APTENSIO XR CAP 10MG,15MG,20MG,25MG,30MG,35MG,40MG,45MG,50MG,55MG,60MG,70MG,85MG (methylphenidate hcl cap er)
Tier 3 AL‐18 max
armodafinil tab 150mg,200mg,250mg,50mg Tier 1 PA
CONCERTA TAB 18MG,27MG,36MG,54MG,72MG,72MG ER (methylphenidate hcl tab er osmotic release (osm))
Tier 3 AL‐18 max
COTEMPLA TAB 17.3MG,25.9MG,8.6MG (methylphenidate tab extended release disintegrating)
Tier 3 AL‐18 max
DAYTRANA DIS 10MG/9HR,15MG/9HR,20MG/9HR,30MG/9HR (methylphenidate td patch)
Tier 3 AL‐18 max
dexmethylph cap 10mg er,15mg er,20mg er,25mg,30mg er,35mg,40mg er,5mg er
Tier 1 AL‐18 max
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 247 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
dexmethylph tab 10mg,2.5mg,5mg Tier 1 AL‐18 max
dexmethylphe cap 10mg er,15mg er,20mg er,25mg,30mg er,35mg,40mg er,5mg er
Tier 1 AL‐18 max
dexmethylphe cap er 10mg er,15mg er,20mg er,25mg,30mg er,35mg,40mg er,5mg er
Tier 1 AL‐18 max
FOCALIN TAB 10MG,2.5MG,5MG (dexmethylphenidate hcl tab)
Tier 3 AL‐18 max
FOCALIN XR CAP 10MG,15MG,20MG,25MG,30MG,35MG,40MG,5MG (dexmethylphenidate hcl cap er)
Tier 3 AL‐18 max
JORNAY PM CAP 100MG ER,20MG ER,40MG ER,60MG ER,80MG ER (methylphenidate hcl cap delayed er)
Tier 3 AL‐18 max
metadate tab 10mg er,18mg er,20mg er,27mg er,36mg er,54mg er
Tier 1 AL‐18 max
methlphenida chw 10mg,2.5mg,5mg Tier 1 AL‐18 max
METHYLIN SOL 10MG/5ML,5MG/5ML (methylphenidate hcl soln)
Tier 3 AL‐18 max
methylphenid cap 10mg,10mg er,15mg er,20mg,20mg er,30mg,30mg er,40mg er,50mg,50mg er,60mg,60mg er,60mg la
Tier 1 AL‐18 max
methylphenid chw 10mg,2.5mg,5mg Tier 1 AL‐18 max
methylphenid sol 10mg/5ml,5mg/5ml Tier 1 AL‐18 max
methylphenid tab 10mg,20mg,5mg Tier 1 AL‐18 max
methylphenid tab 10mg,20mg,5mg Tier 1 AL‐18 max
methylphenid tab 10mg,20mg,5mg Tier 1 AL‐18 max
METHYLPHENID TAB 18MG,27MG,36MG,54MG,72MG,72MG ER (methylphenidate hcl tab er)
Tier 3 AL‐18 max
methyphenid cap 10mg,10mg er,15mg er,20mg,20mg er,30mg,30mg er,40mg er,50mg,50mg er,60mg,60mg er,60mg la
Tier 1 AL‐18 max
modafinil tab 100mg,200mg Tier 1 PA
NUVIGIL TAB 150MG,200MG,250MG,50MG (armodafinil tab)
Tier 3 PA
PROVIGIL TAB 100MG,200MG (modafinil tab) Tier 3 PA
QUILLICHEW CHW 20MG ER,30MG ER,40MG ER (methylphenidate hcl chew tab extended release)
Tier 3 AL‐18 max
QUILLIVANT SUS 25MG/5ML (methylphenidate hcl for er susp)
Tier 3 AL‐18 max
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 248 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
RELEXXII TAB 18MG,27MG,36MG,54MG,72MG,72MG ER (methylphenidate hcl tab er osmotic release (osm))
Tier 3 AL‐18 max
RITALIN LA CAP 10MG,15MG,20MG,25MG,30MG,35MG,40MG,45MG,50MG,55MG,60MG,70MG,85MG (methylphenidate hcl cap er)
Tier 3 AL‐18 max
RITALIN TAB 10MG,20MG,5MG (methylphenidate hcl tab) Tier 3 AL‐18 max
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS ‐ Drugs to Treat Vomiting
aprepitant cap 125mg,40mg,80mg Tier 1 QL (21 days;2 capsules)
aprepitant pak 80 & 125 Tier 1 QL (21 days;6 units)
EMEND CAP 40MG,80MG (aprepitant capsule) Tier 3 QL (180 days;3 capsules)
EMEND SOL 150MG (fosaprepitant dimeglumine for iv infusion)
Tier 3 QL (15 days;1 units)
EMEND SUS 125MG (aprepitant for oral susp) Tier 3 QL (21 days;6 units)
EMEND TRIPAC PAK 80 & 125 (aprepitant capsule therapy pack)
Tier 3 QL (21 days;6 units)
fosaprepitan sol 150mg Tier 1 QL (15 days;1 units)
VARUBI TAB 90MG (rolapitant hcl tab therapy pack) Tier 2 QL (21 days;4 tablets)
SUCCINIMIDES ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders
CELONTIN CAP 300MG (methsuximide cap) Tier 3
ethosuximide cap 250mg Tier 1
ethosuximide sol 250/5ml Tier 1
ZARONTIN CAP 250MG (ethosuximide cap) Tier 3
ZARONTIN SOL 250/5ML (ethosuximide soln) Tier 3
SULFONAMIDES ‐ Sulfa Drugs / Antibiotics for Infections
SULFADIAZINE TAB 500MG (sulfadiazine tab) Tier 3
SULFONYLUREA‐BIGUANIDE COMBINATIONS ‐ Drugs to treat Diabetes
glip/metform tab 2.5‐250m,2.5‐500m,5‐500mg Tier 1
glyb/metform tab 1.25‐250,2.5‐500,5‐500mg Tier 1
SULFONYLUREAS ‐ Drugs to treat Diabetes
AMARYL TAB 1MG,2MG,4MG (glimepiride tab) Tier 3
glimepiride tab 1mg,2mg,4mg Tier 1
glipizide er tab 10mg,2.5mg,5mg Tier 1
glipizide tab 10mg,5mg Tier 1
glipizide xl tab 10mg,2.5mg,5mg Tier 1
glipizide xl tab 10mg,2.5mg,5mg (Glipizide Xl) Tier 1
GLUCOTROL TAB 10MG,5MG (glipizide tab) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 249 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
GLUCOTROL XL TAB 10MG,2.5MG,5MG (glipizide tab er) Tier 3
glyburid mcr tab 1.5mg,3mg,6mg Tier 1
glyburide tab 1.25mg,2.5mg,5mg Tier 1
GLYNASE TAB 1.5MG,3MG,6MG (glyburide micronized tab) Tier 3
tolbutamide tab 500mg Tier 1
SULFONYLUREA‐THIAZOLIDINEDIONE COMBINATIONS ‐ Drugs to treat Diabetes
DUETACT TAB 30‐2MG,30‐4MG (pioglitazone hcl‐glimepiride tab)
Tier 3
pioglit/glim tab 30‐2mg,30‐4mg Tier 1
SWEETENERS ‐ Products for Diet / Eating
SACCHARIN POW SODIUM (sodium saccharin powder) Tier 3
SOD SACCHARI GRA (sodium saccharin granules) Tier 3
SYSTEMIC DECONGESTANTS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems
TAR PRODUCTS ‐ Drugs to Treat Skin Disorders
coal tar sol 20% Tier 1
TETRACYCLINES ‐ Antibiotics / Drugs for Infections
ACTICLATE TAB 150MG,50MG,75MG (doxycycline hyclate tab)
Tier 3
doxycycline tab 100mg,150mg,50mg,75mg (Avidoxy) Tier 1
coremino tab 105mg er,115mg er,135mg,135mg er,45mg,45mg er,55mg er,65mg er,80mg er,90mg,90mg er
Tier 1
demeclocycl tab 150mg,300mg Tier 1
DORYX MPC TAB 120MG,200MG,50MG (doxycycline hyclate tab delayed release)
Tier 3
DORYX TAB 120MG,200MG,50MG (doxycycline hyclate tab delayed release)
Tier 3
doxycyc mono cap 100mg,150mg,50mg,75mg Tier 1
doxycyc mono tab 100mg,150mg,50mg,75mg Tier 1
doxycycl hyc cap 100mg,1x100mg,2x100mg,50mg Tier 1
doxycycl hyc tab 100mg,150mg,20mg,50mg,75mg Tier 1
doxycycl hyc tab 100mg,150mg,20mg,50mg,75mg Tier 1
doxycycline sus 25mg/5ml Tier 1
doxycycline tab 100mg,150mg,20mg,50mg,75mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 250 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
doxycycline tab 100mg,150mg,20mg,50mg,75mg Tier 1
MINOCIN CAP 100MG (minocycline hcl cap) Tier 3
minocycline cap 100mg,50mg,75mg Tier 1
minocycline cap 100mg,50mg,75mg Tier 1
minocycline tab 100mg,50mg,75mg Tier 1
minocycline tab 100mg,50mg,75mg Tier 1
MINOLIRA TAB 105MG,115MG,135MG,55MG,65MG,80MG (minocycline hcl tab er)
Tier 3
doxycycline cap 100mg,150mg,50mg,75mg (Mondoxyne Nl)
Tier 1
doxycycline cap 1x100mg, 2X100mg (Morgidox) Tier 1
SEYSARA TAB 100MG,150MG,60MG (sarecycline hcl tab) Tier 3
SOLODYN TAB 105MG,115MG,135MG,55MG,65MG,80MG (minocycline hcl tab er)
Tier 3
TARGADOX TAB 150MG,50MG,75MG (doxycycline hyclate tab)
Tier 3
tetracycline cap 250mg,500mg Tier 1
VIBRAMYCIN CAP 100MG (doxycycline hyclate cap) Tier 3
VIBRAMYCIN SUS 25MG/5ML (doxycycline monohydrate for susp)
Tier 2
VIBRAMYCIN SYP 50MG/5ML (doxycycline calcium syrup) Tier 2
XIMINO CAP 135MG ER,45MG ER,90MG ER (minocycline hcl cap er)
Tier 3
THIAZIDES AND THIAZIDE‐LIKE DIURETICS ‐ Drugs for Fluid Retention / High Blood Pressure/Misc Disorders
chlorothiaz tab 250mg,500mg Tier 1
chlorthalid tab 25mg,50mg Tier 1
DIURIL SUS 250/5ML (chlorothiazide susp) Tier 3
hydrochlorot cap 12.5mg Tier 1
hydrochlorot tab 12.5mg,25mg,50mg Tier 1
indapamide tab 1.25mg,2.5mg Tier 1
metolazone tab 10mg,2.5mg,5mg Tier 1
THIAZOLIDINEDIONE‐BIGUANIDE COMBINATIONS ‐ Drugs to treat Diabetes
ACTOPLUS MET TAB 15‐500MG,15‐850MG (pioglitazone hcl‐metformin hcl tab)
Tier 3
pioglita/met tab 15‐500mg,15‐850mg Tier 1
THIAZOLIDINEDIONES ‐ Drugs to treat Diabetes
ACTOS TAB 15MG,30MG,45MG (pioglitazone hcl tab) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 251 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
AVANDIA TAB 2MG,4MG (rosiglitazone maleate tab) Tier 3
pioglitazone tab 15mg,30mg,45mg Tier 1
THIENBENZODIAZEPINES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
olanzapine tab 10mg odt,15mg odt,20mg odt,5mg odt Tier 1
olanzapine tab 10mg odt,15mg odt,20mg odt,5mg odt Tier 1
ZYPREXA TAB 10MG,15MG,2.5MG,20MG,5MG,7.5MG (olanzapine tab)
Tier 3
ZYPREXA ZYDI TAB 10MG,15MG,20MG,5MG (olanzapine orally disintegrating tab)
Tier 3
THIENBENZODIAZEPINES & SSRIS ‐ Drugs for diseases and disorders of the nervous system
olanza/fluox cap 12‐25mg,12‐50mg,3‐25mg,6‐25mg,6‐50mg
Tier 1
SYMBYAX CAP 12‐50MG,3‐25MG,6‐25MG,6‐50MG (olanzapine‐fluoxetine hcl cap)
Tier 3
THIENOPYRIDINE DERIVATIVES ‐ Drugs to Treat Blood Disorders
clopidogrel tab 300mg,75mg Tier 1
EFFIENT TAB 10MG,5MG (prasugrel hcl tab) Tier 3
PLAVIX TAB 75MG (clopidogrel bisulfate tab) Tier 3
prasugrel tab 10mg,5mg Tier 1
THIOXANTHENES ‐ Drugs for Psychosis / Bi‐Polar Disorder and other Disorders
thiothixene cap 10mg,1mg,2mg,5mg Tier 1
THROMBIN INHIBITORS ‐ SELECTIVE DIRECT & REVERSIBLE ‐ Drugs to Treat Blood Clots
PRADAXA CAP 110MG,150MG,75MG (dabigatran etexilate mesylate cap)
Tier 3
THROMBOPOIETIN (TPO) RECEPTOR AGONISTS ‐ Drugs to Treat Blood Disorders
DOPTELET TAB 20MG (avatrombopag maleate tab) Tier 2 SP; QL (34 days supply)
MULPLETA TAB 3MG (lusutrombopag tab) Tier 2 SP; QL (34 days supply)
NPLATE INJ 125MCG,250MCG,500MCG (romiplostim for inj) Tier 4 PA; SP; QL (34 days supply)
PROMACTA PAK 12.5MG,25MG (eltrombopag olamine powder pack for susp)
Tier 3 PA; SP; QL (34 days supply)
PROMACTA POW 12.5MG,25MG (eltrombopag olamine powder pack for susp)
Tier 3 PA; SP; QL (34 days supply)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 252 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PROMACTA TAB 12.5MG,25MG,50MG,75MG (eltrombopag olamine tab)
Tier 3 PA; SP; QL (34 days supply)
THYROID HORMONES ‐ Drugs to Treat Disorders of the Thyroid Gland
ARMOUR THYRO TAB 113.75MG,120MG,130MG,146.25MG,15MG,16.25MG,162.5MG,180MG,195MG,240MG,260MG,300MG,30MG,32.5MG,325MG,48.75MG,60MG,65MG,81.25MG,90MG,97.5MG (thyroid tab)
Tier 3
CYTOMEL TAB 25MCG,50MCG,5MCG (liothyronine sodium tab)
Tier 2
levothyroxine sodium tab 100mcg,112mcg,125mcg,137mcg,150mcg,175mcg,200 mcg,200mcg,25mcg,300 mcg,300mcg,50mcg,75mcg,88mc (Euthyrox)
Tier 1
levothyroxine sodium tab 100mcg,112mcg,125mcg,137mcg,150mcg,175mcg,200 mcg,200mcg,25mcg,300 mcg,300mcg,50mcg,75mcg,88mcg (Levo‐t)
Tier 1
levothyroxin tab 100mcg,112mcg,125mcg,137mcg,150mcg,175mcg,200 mcg,200mcg,25mcg,300 mcg,300mcg,50mcg,75mcg,88mcg
Tier 1
levothyroxine sodium tab 100mcg,1120mcg,1250mcg,1370mcg,1500mcg,1750mcg,200 0mcg,2000mcgG,250mcg,300 0mcg,3000mcg,500mcg,750mcg,880mcg (Levoxyl)
Tier 1
liothyronine tab 25mcg,50mcg,5mcg Tier 1
NATURE THROI TAB 113.75MG,120MG,130MG,146.25MG,15MG,16.25MG,162.5MG,180MG,195MG,240MG,260MG,300MG,30MG,32.5MG,325MG,48.75MG,60MG,65MG,81.25MG,90MG,97.5MG (thyroid tab)
Tier 3
NATURE‐THROI TAB 113.75MG,120MG,130MG,146.25MG,15MG,16.25MG,162.5MG,180MG,195MG,240MG,260MG,300MG,30MG,32.5MG,325MG,48.75MG,60MG,65MG,81.25MG,90MG,97.5MG (thyroid tab)
Tier 3
np thyroid tab 120mg,15mg,30mg,60mg,90mg Tier 1
SYNTHROID TAB 100MCG,112MCG,125MCG,137MCG,150MCG,175MCG,200MCG,25MCG,300MCG,50MCG,75MCG,88MCG (levothyroxine sodium tab)
Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 253 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
THYROID TAB 113.75MG,120MG,130MG,146.25MG,15MG,16.25MG,162.5MG,180MG,195MG,240MG,260MG,300MG,30MG,32.5MG,325MG,48.75MG,60MG,65MG,81.25MG,90MG,97.5MG (thyroid tab)
Tier 3
TIROSINT CAP 100MCG,112MCG,125MCG,137MCG,13MCG,150MCG,175MCG,200,25MCG,50MCG,75MCG,88MCG (levothyroxine sodium cap)
Tier 3
TIROSINT‐SOL SOL 100MCG,112MCG,125MCG,137MCG,13MCG/ML,150MCG,175MCG,200MCG,25MCG/ML,50MCG/ML,75MCG/ML,88MCG/ML (levothyroxine sodium oral solution)
Tier 3
unithroid tab 100mcg,112mcg,125mcg,137mcg,150mcg,175mcg,200 mcg,200mcg,25mcg,300 mcg,300mcg,50mcg,75mcg,88mcg
Tier 1
WESTHROID TAB 113.75MG,120MG,130MG,146.25MG,15MG,16.25MG,162.5MG,180MG,195MG,240MG,260MG,300MG,30MG,32.5MG,325MG,48.75MG,60MG,65MG,81.25MG,90MG,97.5MG (thyroid tab)
Tier 3
WP THYROID TAB 113.75MG,120MG,130MG,146.25MG,15MG,16.25MG,162.5MG,180MG,195MG,240MG,260MG,300MG,30MG,32.5MG,325MG,48.75MG,60MG,65MG,81.25MG,90MG,97.5MG (thyroid tab)
Tier 3
TOPICAL ANESTHETIC COMBINATIONS ‐ Drugs to Treat Skin Disorders
lido/prilocn cre 2.5‐2.5% Tier 1 QL (25 days;30 units)
LIDOCAINE CRE TETRACAI 7‐7% (lidocaine‐tetracaine cream)
Tier 3 QL (25 days;30 units)
lidocaine‐pr cre 2.5‐2.5% Tier 1 QL (25 days;30 units)
PLIAGLIS CRE 7‐7% (lidocaine‐tetracaine cream) Tier 3 QL (25 days;30 units)
SYNERA DIS 70‐70MG (lidocaine‐tetracaine topical patch) Tier 3 QL (25 days;2 units)
TOPICAL ANESTHETIC GASES ‐ Drugs to Treat Skin Disorders
ethyl chlor aer fine pin Tier 1
ETHYL CHLOR AER FN STRM (ethyl chloride aerosol spray) Tier 3
ethyl chlor aer med jet Tier 1
ETHYL CHLOR AER MED STRM (ethyl chloride aerosol spray) Tier 3
ethyl chlor aer mist Tier 1
ethyl chlor aer spray Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 254 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
GEBAUERS SPR AER /STRETCH (pentafluoropropane‐tetrafluoroethane aero spray)
Tier 3
PAIN EASE AER MD STRM (pentafluoropropane‐tetrafluoroethane aero spray)
Tier 3
PAIN EASE AER MIST (pentafluoropropane‐tetrafluoroethane aero spray)
Tier 3
TOPICAL DECONGESTANTS ‐ Drugs to Treat Misc Nose / Sinus Disorders & Problems
ADRENALIN SOL 1:1000 (epinephrine hcl nasal soln) Tier 3
TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS ‐ Drugs to Treat Skin Disorders
TARGRETIN GEL 1% (bexarotene gel) Tier 4 PA; SP; QL (34 days supply); OAC
TOPICAL STEROID COMBINATIONS ‐ Drugs to Treat Skin Disorders
calcip/betam sus Tier 1
calcipotrien oin betameth Tier 1
DUOBRII LOT (halobetasol propionate‐tazarotene lotion) Tier 3
ENSTILAR AER (calcipotriene‐betamethasone dipropionate foam)
Tier 2
FLUOPAR KIT 0.1% (fluocinonide cream) Tier 3
TACLONEX OIN (calcipotriene‐betamethasone dipropionate oint)
Tier 3
TACLONEX SUS (calcipotriene‐betamethasone dipropionate susp)
Tier 2
TOPOISOMERASE I INHIBITORS ‐ Drugs for Treatment of Cancer
HYCAMTIN CAP 0.25MG,1MG (topotecan hcl cap) Tier 2 PA; SP; QL (34 days supply); OAC
TOXOID COMBINATIONS ‐ Vaccines and Drugs to Treat Communicable Diseases
ADACEL INJ (tet tox‐diph‐acell pertuss ad inj) Tier 5 AL‐18 min
BOOSTRIX INJ (tet tox‐diph‐acell pertuss ad inj) Tier 5 AL‐18 min
DAPTACEL INJ (diph, acellular pert & tet tox inj) Tier 5 AL‐18 max
DIP/TET PED INJ 25‐5LFU (diphtheria‐tetanus tox adsorbed (dt) im inj)
Tier 5 AL‐18 max
INFANRIX INJ (diph, acellular pert & tet tox inj) Tier 5 AL‐18 max
KINRIX INJ (diph‐tetanus tox ad‐acell pert & polio virus, ipv vac inj)
Tier 5 AL‐18 max
PEDIARIX INJ 0.5ML (diph‐tetanus tox‐acell pert‐hepatitis b‐polio ipv vac inj)
Tier 5 AL‐18 max
PENTACEL INJ (diph‐ac per‐tet tox ad‐poliov‐haemoph b poly vac for im susp)
Tier 5 AL‐18 max
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 255 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
QUADRACEL INJ (diph‐tetanus tox ad‐acell pert & polio virus, ipv vac inj)
Tier 5 AL‐18 max
TDVAX INJ 2‐2 LF,5‐2LF (tetanus‐diphtheria toxoids (td) inj) Tier 5 AL‐18 min
TENIVAC INJ 2‐2 LF,5‐2LF (tetanus‐diphtheria toxoids (td) inj)
Tier 5 AL‐18 min
TRAMADOL COMBINATIONS ‐ Drugs for Treatment of Pain
tramadl/apap tab 37.5‐325 Tier 1 PA; QL (75 days;40 tablets)
ULTRACET TAB 37.5‐325 (tramadol‐acetaminophen tab) Tier 3 PA; QL (75 days;40 tablets)
TRANSTHYRETIN STABILIZERS ‐ Drugs to Treat Disorders of the Heart and Cardiovascular System
VYNDAMAX CAP 61MG (tafamidis cap) Tier 4 PA; SP; QL (34 days supply)
VYNDAQEL CAP 20MG (tafamidis meglumine (cardiac) cap) Tier 4 PA; SP; QL (34 days supply)
TRIAZOLES ‐ Drugs to Treat Fungal Infections
CRESEMBA CAP 186 MG (isavuconazonium sulfate cap) Tier 3
DIFLUCAN SUS 10MG/ML,40MG/ML (fluconazole for susp) Tier 3
DIFLUCAN TAB 100MG,150MG,200MG,50MG (fluconazole tab)
Tier 3
fluconazole sus 10mg/ml,40mg/ml Tier 1
fluconazole tab 100mg,150mg,200mg,50mg Tier 1
itraconazole cap 100mg Tier 1 PA
itraconazole sol 10mg/ml Tier 1
NOXAFIL SUS 40MG/ML (posaconazole susp) Tier 3
NOXAFIL TAB 100MG (posaconazole tab delayed release) Tier 3
posaconazole tab 100mg dr Tier 1
SPORANOX CAP 100MG,65MG (itraconazole cap) Tier 3 PA
SPORANOX CAP PULSEPAK 100MG,65MG (itraconazole cap) Tier 3 PA
SPORANOX SOL 10MG/ML (itraconazole oral soln) Tier 3
TOLSURA CAP 100MG,65MG (itraconazole cap) Tier 3 PA
VFEND SUS 40MG/ML (voriconazole for susp) Tier 2
VFEND TAB 200MG,50MG (voriconazole tab) Tier 2
voriconazole sus 40mg/ml Tier 1
voriconazole tab 200mg,50mg Tier 1
TRICYCLIC AGENTS ‐ Drugs for Depression / Other Disorders
amitriptylin tab 100mg,10mg,150mg,25mg,50mg,75mg Tier 1
amoxapine tab 100mg,150mg,25mg,50mg Tier 1
ANAFRANIL CAP 25MG,50MG,75MG (clomipramine hcl cap) Tier 2
clomipramine cap 25mg,50mg,75mg Tier 1
desipramine tab 100mg,10mg,150mg,25mg,50mg,75mg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 256 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
doxepin hcl cap 100mg,10mg,150mg,25mg,50mg,75mg Tier 1
doxepin hcl con 10mg/ml Tier 1
imipram hcl tab 10mg,25mg,50mg Tier 1
imipram pam cap 100mg,125mg,150mg,75mg Tier 1
NORPRAMIN TAB 10MG,25MG (desipramine hcl tab) Tier 2
nortriptylin cap 10mg,25mg,50mg,75mg Tier 1
nortriptylin sol 10mg/5ml Tier 1
PAMELOR CAP 10MG,25MG,50MG,75MG (nortriptyline hcl cap)
Tier 2
protriptylin tab 10mg,5mg Tier 1
trimipramine cap 100mg,25mg,50mg Tier 1
TRIPHASIC CONTRACEPTIVES ‐ ORAL ‐ Drugs for Pregnancy Prevention / Gynecological Disorders
norethindrone & ethinyl estradiol 1/35 tab 1/35 (Alyacen 1/35)
Tier 5 QL (1 unit per 1 day)
norethindrone‐eth estradiol tab (Aranelle) Tier 5 QL (1 unit per 1 day)
desogest‐ethin est tab pak (Caziant) Tier 5 QL (1 unit per 1 day)
CESIA PAK (desogest‐ethin est tab) Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 1/35 tab 1/35 (Cyclafem 1/35)
Tier 5 QL (1 unit per 1 day)
norethindrone‐eth estradiol tab 1/35 tab 1/35 (Dasetta 1/35)
Tier 5 QL (1 unit per 1 day)
levonorgestrel‐eth estra 28 tab (Enpresse‐28) Tier 5 QL (1 unit per 1 day)
ESTROSTEP FE TAB (norethindrone ac‐ethinyl estrad‐fe tab) Tier 5 QL (1 unit per 1 day)
norethindrone‐eth estradiol tab 7/7/7 (Leena) Tier 5 QL (1 unit per 1 day)
levonorgestrel‐eth estra tab (Levonest) Tier 5 QL (1 unit per 1 day)
levonorgestrel & ethinyl estradiol tab 0.1‐0.02,0.1‐20,0.15/30
Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 0.5/35, 1/35 (Nortrel) Tier 5 QL (1 unit per 1 day)
ORTHO TRI‐ TAB CYCLN LO (norgestimate‐eth estrad tab) Tier 5 QL (1 unit per 1 day)
norethindrone & ethinyl estradiol tab 1/35 (Pirmella 1/35) Tier 5 QL (1 unit per 1 day)
norethindrone ac‐ethinyl estrad‐fe tab (Tilia Fe) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri Femynor) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri‐estarylla) Tier 5 QL (1 unit per 1 day)
norethindrone ac‐ethinyl estrad‐fe tab (Tri‐legest Fe) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri‐linyah) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri‐lo‐estarylla) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri‐lo‐marzia) Tier 5 QL (1 unit per 1 day)
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 257 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
norgestimate‐eth estrad tab (Tri‐lo‐sprintec) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri‐lo‐mili) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri‐mili) Tier 5 QL (1 unit per 1 day)
TRINESSA TAB (norgestimate‐eth estrad tab) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri‐previfem) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri‐sprintec) Tier 5 QL (1 unit per 1 day)
levonorgestrel‐eth estra 28 tab (Trivora‐28) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab (Tri‐vylibra) Tier 5 QL (1 unit per 1 day)
norgestimate‐eth estrad tab lo (Tri‐vylibra Lo) Tier 5 QL (1 unit per 1 day)
desogest‐ethin est tab pak (Velivet) Tier 5 QL (1 unit per 1 day)
TRYPTOPHAN HYDROXYLASE INHIBITORS ‐ Drugs to Treat Disorders of the Stomach and Intestines
XERMELO TAB 250MG (telotristat etiprate tab) Tier 3 PA; QL (3 units per 1 day)
TUMOR NECROSIS FACTOR ALPHA BLOCKERS ‐ Drugs to Treat Disorders of the Stomach and Intestines
AVSOLA INJ 100MG (infliximab‐axxq for iv inj) Tier 3 PA; QL (34 days supply)
CIMZIA KIT (certolizumab pegol for inj kit) Tier 4 PA; SP; QL (34 days supply)
CIMZIA KIT STARTER 200MG/ML (certolizumab pegol inj kit) Tier 4 PA; SP; QL (34 days supply)
CIMZIA PREFL KIT 200MG/ML (certolizumab pegol inj kit) Tier 4 PA; SP; QL (34 days supply)
INFLECTRA INJ 100MG (infliximab‐dyyb for iv inj) Tier 4 PA; SP; QL (34 days supply)
REMICADE INJ 100MG (infliximab for iv inj) Tier 2 PA; SP; QL (34 days supply)
RENFLEXIS INJ 100MG (infliximab‐abda for iv inj) Tier 4 PA; SP; QL (34 days supply)
ULCER ANTI‐INFECTIVE W/ BISMUTH COMBINATIONS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
HELIDAC MIS THERAPY (metronidaz tab‐tetracyc cap‐bis subsal chew tab therapy pack)
Tier 3
PYLERA CAP (bismuth subcit‐metronidazole‐tetracycline cap)
Tier 2
ULCER ANTI‐INFECTIVE W/ PROTON PUMP INHIBITORS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
lansopr/amox mis /clarith Tier 1
OMECLAMOX‐ MIS PAK (amoxicillin cap‐clarithro tab w/ omepraz cap dr therapy pack)
Tier 3
TALICIA CAP (amoxicillin‐rifabutin‐omeprazole cap dr) Tier 3
ULCER DRUGS ‐ PROSTAGLANDINS ‐ Drugs for Stomach Disorders / Misc Bodily Function Disorders
CYTOTEC TAB 100MCG,200MCG (misoprostol tab) Tier 2
misoprostol tab 100mcg,200mcg Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 258 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
UREA CYCLE DISORDER ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
BUPHENYL POW (sodium phenylbutyrate oral powder) Tier 4 PA; SP; QL (34 days supply)
BUPHENYL TAB 500MG (sodium phenylbutyrate tab) Tier 4 PA; SP; QL (34 days supply)
phenylbutyra pow sodium Tier 1 PA; SP; QL (34 days supply)
RAVICTI LIQ 1.1GM/ML (glycerol phenylbutyrate liquid) Tier 4 PA; SP; QL (34 days supply)
sodium pheny tab 500mg Tier 1 PA; SP; QL (34 days supply)
URICOSURICS ‐ Drugs to Treat Gout
probenecid tab 500mg Tier 1
URINARY ANALGESICS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
phenazopyridine tab 100mg,200mg (Phenazo) Tier 1
phenazopyrid tab 100mg,200mg Tier 1
PYRIDIUM TAB 100MG,200MG (phenazopyridine hcl tab) Tier 3
URINARY ANTI‐INFECTIVES ‐ Drugs to Treat Infections of the Urinary Tract
HIPREX TAB 1GM (methenamine hippurate tab) Tier 3
MACROBID CAP 100MG (nitrofurantoin monohydrate macrocrystalline cap)
Tier 2
MACRODANTIN CAP 100MG,25MG,50MG (nitrofurantoin macrocrystalline cap)
Tier 3
methenam hip tab 1gm Tier 1
methenam man tab 1000mg,1gm,500mg Tier 1
MONUROL PAK GRANULES (fosfomycin tromethamine powd pack)
Tier 3
nitrofur mac cap 100mg,25mg,50mg Tier 1
nitrofurantn cap 100mg,25mg,50mg Tier 1
nitrofurantn cap 100mg,25mg,50mg Tier 1
nitrofurantn sus 25mg/5ml Tier 1
nitrofuranto cap 100mg,25mg,50mg Tier 1
URINARY ANTISEPTIC‐ANTISPASMODIC &/OR ANALGESICS ‐ Drugs to Treat Infections of the Urinary Tract
hyophen tab Tier 1
me/naphos/mb tab hyo 1 Tier 1
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 259 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
phosphasal tab Tier 1
methenamine combinations tab (Uretron D/s) Tier 1
methenamine combinations cap 118mg (Uribel) Tier 1
methenamine combinations tab 81mg (Urimar‐t) Tier 1
methenamine combinations d/s tab (Urin D/s) Tier 1
methenamine combinations 81mg (Uro‐458) Tier 1
UROGESIC‐ TAB BLUE (*methenamine‐hyoscamine‐meth blue‐sod phos tab)
Tier 3
methenamine combinations cap 118mg (Uro‐mp) Tier 1
methenamine combinations tab 1 (Uryl) Tier 1
ustell cap 118mg Tier 1
methenamine combinations cap 118mg (Uticap) Tier 1
methenamine combinations tab (Utira‐c) Tier 1
methenamine combinations tab (Utrona‐c) Tier 1
methenamine combinations cap 118mg (Vilamit Mb) Tier 1
methenamine combinations mb tab 81mg (Vilevev Mb) Tier 1
URINARY ANTISPASMODIC ‐ ANTIMUSCARINIC (ANTICHOLINERGIC) ‐ Drugs for Overactive Bladder and other Urinary Disorders
darifenacin tab 15mg,7.5mg Tier 1
DETROL LA CAP 2MG,4MG (tolterodine tartrate cap er) Tier 3
DETROL TAB 1MG,2MG (tolterodine tartrate tab) Tier 3
DITROPAN XL TAB 10MG,5MG (oxybutynin chloride tab er) Tier 3
ENABLEX TAB 15MG,7.5MG (darifenacin hydrobromide tab er)
Tier 3
GELNIQUE GEL 10% (oxybutynin chloride td gel) Tier 3
oxybutynin syp 5mg/5ml Tier 1
oxybutynin tab 5mg Tier 1
oxybutynin tab 5mg Tier 1
OXYTROL DIS 3.9MG/24 (oxybutynin td patch twice weekly) Tier 3
solifenacin tab 10mg,5mg Tier 1
tolterodine cap 2mg er,4mg er Tier 1
tolterodine tab 1mg,2mg Tier 1
TOVIAZ TAB 4MG,8MG (fesoterodine fumarate tab er) Tier 2
trospium chl cap 60mg er Tier 1
trospium cl tab 20mg Tier 1
VESICARE TAB 10MG,5MG (solifenacin succinate tab) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 260 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
URINARY ANTISPASMODICS ‐ BETA‐3 ADRENERGIC AGONISTS ‐ Drugs for Overactive Bladder and other Urinary Disorders
MYRBETRIQ TAB 25MG,50MG (mirabegron tab er) Tier 2
URINARY ANTISPASMODICS ‐ CHOLINERGIC AGONISTS ‐ Drugs for Overactive Bladder and other Urinary Disorders
bethanechol tab 10mg,25mg,50mg,5mg Tier 1
URINARY ANTISPASMODICS ‐ DIRECT MUSCLE RELAXANTS ‐ Drugs for Overactive Bladder and other Urinary Disorders
flavoxate tab 100mg Tier 1
URINARY STONE AGENTS ‐ Drugs To Treat Disorders of the Genital and Urinary Organs
LITHOSTAT TAB 250MG (acetohydroxamic acid tab) Tier 3
THIOLA EC TAB 100MG,300MG (tiopronin tab delayed release)
Tier 3
THIOLA TAB 100MG (tiopronin tab) Tier 3
URINARY TRACT PROTECTIVE AGENTS ‐ Drugs for Treatment of Cancer
MESNEX TAB 400MG (mesna tab) Tier 3 OAC
VAGINAL ANTI‐INFECTIVES ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms
CLEOCIN CRE 2% VAG (clindamycin phosphate vaginal cream)
Tier 2
CLEOCIN SUP 100MG (clindamycin phosphate vaginal suppos)
Tier 3
clindamycin cre 2% vag Tier 1
CLINDESSE CRE 2% (clindamycin phosphate (one dose) vaginal cream)
Tier 3
metronidazol gel 0.75%,1% Tier 1
NUVESSA GEL 1.3% (metronidazole vaginal gel) Tier 3
metronidazole vaginal gel 0.75%,0.75%vag (Vandazole) Tier 1
VAGINAL CONTRACEPTIVE PH MODULATOR ‐ COMBINATIONS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms
PHEXXI GEL (lactic acid‐citric acid‐potassium bitartrate gel) Tier 3
VAGINAL ESTROGENS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms
ESTRACE VAG CRE 0.01% (estradiol vaginal cream) Tier 3
estradiol cre 0.01% Tier 1
estradiol tab 0.5mg,1mg,2mg Tier 1
ESTRING MIS 2MG (estradiol vaginal ring) Tier 2
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 261 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
FEMRING MIS 0.05/24H,0.1MG/24 (estradiol acetate vaginal ring)
Tier 3
IMVEXXY MAIN SUP 10MCG,4MCG (estradiol vaginal insert) Tier 3
IMVEXXY STRT SUP 10MCG,4MCG (estradiol vaginal insert starter pack)
Tier 3
PREMARIN VAG CRE 0.625MG (estrogens, conjugated vaginal cream)
Tier 2
VAGIFEM TAB 10MCG (estradiol vaginal tab) Tier 3
estradiol vaginal tab 10mcg (Yuvafem) Tier 1
VAGINAL PROGESTINS ‐ Drugs and Products to Treat Vaginal Issues/Disorders/Symptoms
CRINONE GEL 4% VAG,8% VAG (progesterone vaginal gel) Tier 2
ENDOMETRIN SUP 100MG (progesterone vaginal insert) Tier 2
VALPROIC ACID ‐ Drugs to Treat Seizure Disorder / Migraines / Misc Neurological Disorders
DEPAKOTE ER TAB 250MG,500MG (divalproex sodium tab er)
Tier 3
DEPAKOTE SPR CAP 125MG (divalproex sodium cap delayed release sprinkle)
Tier 3
DEPAKOTE TAB 125MG DR,250MG DR,500MG DR (divalproex sodium tab delayed release)
Tier 3
divalproex cap 125mg Tier 1
divalproex tab 125mg dr,250mg dr,500mg dr Tier 1
divalproex tab 125mg dr,250mg dr,500mg dr Tier 1
valproic acd cap 250mg Tier 1
valproic acd sol 250/5ml Tier 1
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS ‐ Drugs for Treatment of Disorders in the Eyes
BEOVU INJ 6/0.05ML (brolucizumab‐dbll intravitreal soln) Tier 4 PA; SP; QL (34 days supply)
BEVACIZUMAB INJ 2.5/.1ML,3.25/.13,3.75/.15 (bevacizumab intravitreal soln pref syr)
Tier 3
EYLEA INJ 2/0.05ML (aflibercept intravitreal inj) Tier 2 PA; SP; QL (34 days supply)
EYLEA INJ 2/0.05ML (aflibercept intravitreal soln pref syr) Tier 2 PA; SP; QL (34 days supply)
LUCENTIS INJ 0.3MG,0.5MG (ranibizumab intravitreal soln pref syr)
Tier 2 PA; SP; QL (34 days supply)
LUCENTIS SOL 0.3MG,0.5MG (ranibizumab intravitreal inj) Tier 2 PA; SP; QL (34 days supply)
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS ‐ Drugs for Treatment of Cancer
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 262 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
AVASTIN INJ 400/16ML (bevacizumab iv soln) Tier 4 PA; SP; QL (34 days supply)
CYRAMZA INJ 100/10ML,500/50ML (ramucirumab iv soln) Tier 4 PA; SP; QL (34 days supply)
MVASI INJ 100MG,400MG (bevacizumab‐awwb iv soln) Tier 4 PA; SP; QL (34 days supply)
ZALTRAP INJ 100/4ML,200/8ML (ziv‐aflibercept iv soln) Tier 4 PA; SP; QL (34 days supply)
ZIRABEV INJ 100/4ML,400/16ML (bevacizumab‐bvzr iv soln) Tier 4 PA; SP; QL (34 days supply)
VASODILATORS ‐ Drugs to Treat High Blood Pressure
hydralazine tab 100mg,10mg,25mg,50mg Tier 1
minoxidil tab 10mg,2.5mg Tier 1
VASOMOTOR SYMPTOM AGENTS ‐ SSRIS ‐ Drugs for diseases and disorders of the nervous system
BRISDELLE CAP 7.5MG (paroxetine mesylate cap) Tier 3
paroxetine cap 7.5mg Tier 1
VASOPRESSIN ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
DDAVP SOL 0.01% (desmopressin acetate nasal soln) Tier 2
DDAVP SPR 0.01% (desmopressin acetate nasal spray soln) Tier 2
DDAVP TAB 0.1MG,0.2MG (desmopressin acetate tab) Tier 2
desmopressin spr 0.01% Tier 1
desmopressin tab 0.1mg,0.2mg Tier 1
NOCDURNA SUB 27.7MCG,55.3MCG (desmopressin acetate sublingual tab)
Tier 3
STIMATE SOL 1.5MG/ML (desmopressin acetate nasal soln) Tier 4 PA; SP; QL (34 days supply)
VASOPRESSORS ‐ Drugs Used to Contract (Tighten) Blood Vessels and Raise Blood Pressure
midodrine tab 10mg,2.5mg,5mg Tier 1
VIRAL VACCINE COMBINATIONS ‐ Drugs for Communicable Disease Prevention
M‐M‐R II INJ (measles‐mumps‐rubella virus vaccines for inj soln)
Tier 5 AL‐18 min
PROQUAD INJ (measles‐mumps‐rubella‐varicella virus vaccines for susp)
Tier 5 AL‐18 max
TWINRIX INJ (hep a‐hep b vaccine susp pref syr) Tier 5 AL‐18 min
VIRAL VACCINES ‐ Drugs for Communicable Disease Prevention
AFLURIA QUAD INJ 2019‐20 (influenza virus vac split quadrivalent susp pref syr)
Tier 5
AFLURIA QUAD INJ 2019‐20 (influenza virus vaccine split quadrivalent im inj)
Tier 5
ENGERIX‐B INJ 10/0.5ML,20MCG/ML (hepatitis b vaccine (recombinant) susp)
Tier 5 AL‐18 min
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 263 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
ENGERIX‐B INJ 10/0.5ML,20MCG/ML (hepatitis b vaccine (recombinant) susp)
Tier 5 AL‐18 min
FLUAD INJ 2019‐20 (influenza vac type a&b surface ant adj susp pref syr)
Tier 5
FLUARIX QUAD INJ 2019‐20 (influenza virus vac split quadrivalent susp pref syr)
Tier 5
FLUBLOK QUAD INJ 2019‐20 (influenza vac recomb ha quad pf soln pref syr)
Tier 5
FLUCLVX QUAD INJ 2019‐20 (influenza vac tissue‐cultured subunit quadrivalent im susp)
Tier 5
FLULAVAL QUA INJ 2019‐20 (influenza virus vac split quadrivalent susp pref syr)
Tier 5
FLULAVAL QUA INJ 2019‐20 (influenza virus vaccine split quadrivalent im inj)
Tier 5
FLUZONE HD INJ PF 19‐20 (influenza virus vac split high‐dose pf susp pref syr)
Tier 5
FLUZONE QUAD INJ 2019‐20 (influenza virus vac split quadrivalent susp pref syr)
Tier 5
FLUZONE QUAD INJ 2019‐20 (influenza virus vaccine split quadrivalent inj)
Tier 5
GARDASIL 9 INJ (human papillomavirus (hpv)) Tier 5 AL‐18 min
HAVRIX INJ 1440UNIT,25/0.5ML,50UNT/ML,720UNIT (hepatitis a vaccine inj susp)
Tier 5 AL‐18 min
HEPLISAV‐B INJ 20/0.5ML (hepatitis b vaccine recomb adjuvanted pref syr)
Tier 5 AL‐18 min
IMOVAX RABIE INJ 2.5/ML (rabies virus vaccine, hdc inj) Tier 5 AL‐18 min
IPOL INJ INACTIVE (poliovirus vaccine, ipv injection) Tier 5 AL‐18 max
IXIARO INJ (japanese encephalitis vaccine inactivated adsorbed inj)
Tier 5 AL‐18 min
RABAVERT INJ (rabies vaccine, pcec for inj) Tier 5 AL‐18 min
RECOMBIVA‐HB INJ 10/0.5ML,10MCG/ML,20MCG/ML,40MCG/ML,5MCG/0.5 (hepatitis b vaccine (recombinant) susp)
Tier 5 AL‐18 min
ROTARIX SUS (rotavirus vaccine, live for oral susp) Tier 5 AL‐18 max
ROTATEQ SOL (rotavirus vaccine, live oral pentavalent soln) Tier 5 AL‐18 max
SHINGRIX INJ 50/0.5ML (zoster vac recombinant adjuvanted for im inj)
Tier 5 AL‐18 min
VAQTA INJ 1440UNIT,25/0.5ML,50UNT/ML,720UNIT (hepatitis a vaccine inj susp)
Tier 5 AL‐18 min
VARIVAX INJ (varicella virus vac live for subcutaneous inj) Tier 5 AL‐18 min
YF‐VAX INJ (yellow fever vaccine subcutaneous inj) Tier 5 AL‐18 min
ZOSTAVAX INJ (zoster vaccine live for subcutaneous susp) Tier 5 AL‐18 min
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 264 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
VISCOSUPPLEMENTS ‐ Drugs for diseases and disorders of the muscles, ligaments, tendons and bones
DUROLANE INJ 60MG/3ML (sodium hyaluronate intra‐articular gel pref syr)
Tier 2 PA
EUFLEXXA INJ 10MG/ML,20MG/2ML,25/2.5ML,850 INJ 25/2.5 (sodium hyaluronate intra‐articular soln pref syr)
Tier 2 PA
GEL‐ONE INJ 30MG/3ML (cross‐linked hyaluronate gel prefilled syringe)
Tier 3 PA
GELSYN‐3 INJ 16.8/2ML,25/2.5ML (sodium hyaluronate intra‐articular soln pref syr)
Tier 2 PA
GENVISC 10MG/ML,20MG/2ML,25/2.5ML,850 INJ 25/2.5 (sodium hyaluronate intra‐articular soln pref syr)
Tier 3 PA
HYALGAN INJ 20MG/2ML (sodium hyaluronate intra‐articular inj)
Tier 3 PA
HYALGAN INJ 20MG/2ML (sodium hyaluronate intra‐articular soln pref syr)
Tier 3 PA
HYMOVIS INJ 15MG/ML,24MG/3ML,88MG/4ML (hyaluronan intra‐articular soln prefilled syringe)
Tier 3 PA
MONOVISC INJ 15MG/ML,24MG/3ML,88MG/4ML (hyaluronan intra‐articular soln prefilled syringe)
Tier 3 PA
ORTHOVISC INJ 15MG/ML,24MG/3ML,88MG/4ML (hyaluronan intra‐articular soln prefilled syringe)
Tier 3 PA
SODIUM HYALU INJ 10MG/ML,20MG/2ML,25/2.5ML,850 INJ 25/2.5 (sodium hyaluronate intra‐articular soln pref syr)
Tier 3 PA
SUPARTZ FX INJ 16.8/2ML,25/2.5ML (sodium hyaluronate intra‐articular soln pref syr)
Tier 2 PA
SYNVISC INJ 8MG/ML (hylan intra‐articular solution prefilled syringe)
Tier 3 PA
SYNVISC ONE INJ 8MG/ML (hylan intra‐articular solution prefilled syringe)
Tier 3 PA
TRILURON INJ 10MG/ML,20MG/2ML,25/2.5ML,850 INJ 25/2.5 (sodium hyaluronate intra‐articular soln pref syr)
Tier 3 PA
TRIVISC INJ 10MG/ML,20MG/2ML,25/2.5ML,850 INJ 25/2.5 (sodium hyaluronate intra‐articular soln pref syr)
Tier 3 PA
VISCO‐3 INJ 16.8/2ML,25/2.5ML (sodium hyaluronate intra‐articular soln pref syr)
Tier 3 PA
VITAMIN A ‐ Drugs for Vitamin Replacement
AQUASOL A INJ 50000/ML (vitamin a inj) Tier 3
VITAMIN B‐1 ‐ Drugs for Vitamin Replacement
thiamine hcl inj 100mg/ml Tier 1
VITAMIN B‐6 ‐ Drugs for Vitamin Replacement
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 265 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PYRIDOXAL‐5‐ INJ PHOSPHAT (pyridoxal‐5 phosphate inj soln)
Tier 3
pyridoxine inj 100mg/ml Tier 1
VITAMIN C ‐ Drugs for Vitamin Replacement
ASCOR SOL 25000MG,500MG/ML (ascorbic acid iv soln) Tier 3
ascorbic acd inj 500mg/ml Tier 1
ASCORBIC ACI SOL 25000MG,500MG/ML (ascorbic acid iv soln)
Tier 3
VITAMIN D ‐ Drugs for Vitamin Replacement
DRISDOL CAP 50000UNT (ergocalciferol cap) Tier 2
ERGOCAL CAP 2500UNIT (ergocalciferol cap) Tier 3
vitamin d cap 1.25mg,50000,50000unt Tier 1
VITAMIN E ‐ Drugs for Vitamin Replacement
WHEAT GERM OIL (*wheat germ ‐ oil***) Tier 3
VITAMIN K ‐ Drugs for Vitamin Replacement
MEPHYTON TAB 5MG (phytonadione tab) Tier 3
phytonadione inj 1 inj 10mg/ml,1 inj 1mg/0.5,10mg/ml,1mg/0.5
Tier 1
phytonadione tab 5mg Tier 1
vitamin k 1 inj 10mg/ml,1 inj 1mg/0.5,10mg/ml,1mg/0.5 Tier 1
VOLATILE ANESTHETICS ‐ Drugs for Anesthesia
desflurane sol Tier 1
FORANE SOL (isoflurane inhal soln) Tier 3
isoflurane sol Tier 1
sevoflurane sol Tier 1
SUPRANE INH (desflurane inhal soln) Tier 3
SUPRANE SOL (desflurane inhal soln) Tier 3
ULTANE SOL (sevoflurane inhal soln) Tier 3
WOUND CARE ‐ GROWTH FACTOR AGENTS ‐ Drugs to Treat Skin Disorders
REGRANEX GEL 0.01% (becaplermin gel) Tier 3
WOUND CARE COMBINATIONS ‐ Drugs to Treat Skin Disorders
BALSAM PERU OIN CASTOR (*balsam peru‐castor oil oint***)
Tier 3
BPCO OIN (*balsam peru‐castor oil oint***) Tier 3
DERMULCERA OIN (*balsam peru‐castor oil oint***) Tier 3
LIDOTREX GEL 2% (lidocaine hcl‐collagen‐aloe vera gel) Tier 3 QL (25 days;30 units)
REGENECARE GEL 2% (lidocaine hcl‐collagen‐aloe vera gel) Tier 3 QL (25 days;30 units)
VENELEX OIN (*balsam peru‐castor oil oint***) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 266 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
XEROFORM OIL MIS 1"X8",4"X9',4X9,5"X9" (*bismuth tribromophenate‐petrolatum dressing ‐ misc***)
Tier 3
XEROFORM OIL MIS ROLL 1"X8",4"X9',4X9,5"X9" (*bismuth tribromophenate‐petrolatum dressing ‐ misc***)
Tier 3
XEROFORM OIL PAD 2"X2",4"X4",5"X9" (*bismuth tribromophenate‐petrolatum dressing pads***)
Tier 3
XEROFRM GAUZ MIS 1"X8",4"X9',4X9,5"X9" (*bismuth tribromophenate‐petrolatum dressing ‐ misc***)
Tier 3
XEROFRM GAUZ PAD 2"X2",4"X4",5"X9" (*bismuth tribromophenate‐petrolatum dressing pads***)
Tier 3
XEROFRM PETR PAD 2"X2",4"X4",5"X9" (*bismuth tribromophenate‐petrolatum dressing pads***)
Tier 3
XEROFRM ROLL MIS 1"X8",4"X9',4X9,5"X9" (*bismuth tribromophenate‐petrolatum dressing ‐ misc***)
Tier 3
WOUND CLEANSERS/DECUBITUS ULCER THERAPY ‐ Drugs to Treat Skin Disorders
ALEVICYN SOL DERMAL (*wound cleansers ‐ solution**) Tier 3
ATRAPRO DERM SPR (*wound cleansers ‐ liquid**) Tier 3
DELUO SPR (*wound cleansers ‐ solution**) Tier 3
LEVICYN SOL DERMAL (*wound cleansers ‐ solution**) Tier 3
MICROCYN LIQ (*wound cleansers ‐ liquid**) Tier 3
VASHE CLEANS SOL (*wound cleansers ‐ solution**) Tier 3
WOUND DRESSINGS ‐ Drugs to Treat Skin Disorders
ACTCT FLEX 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
ALLEVYN GENT PAD 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
AMORPH WOUND GEL DRESSING (*wound dressings ‐ gel***)
Tier 3
AQUACEL AG PAD 5"X4" (*silver‐carboxymethylcellulose sodium dressing)
Tier 3
ATRAPRO CP KIT (*wound dressings ‐ kit***) Tier 3
ATRAPRO GEL HYDROGEL (*wound dressings ‐ gel***) Tier 3
CA ALGINATE MIS 1/2"X15',12" ROPE (*wound dressings ‐ misc***)
Tier 3
CA ALGINATE PAD 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 267 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
CARRASYN GEL DRESSING (*wound dressings ‐ gel***) Tier 3
CURITY HYPER MIS 1/2"X15',12" ROPE (*wound dressings ‐ misc***)
Tier 3
CURITY NACL PAD 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
DIAB F.D.G. GEL (*wound dressings ‐ gel***) Tier 3
DIAB GEL (*wound dressings ‐ gel***) Tier 3
HYDRFRA BLUE PAD RDY 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
HYDRFRA MRF PAD 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
HYDROFERA PAD BLUE 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
HYDROFERA PAD MRF 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
HYDROFRA MRF PAD 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
HYDROG WOUND MIS 2"X2",3" DISK,4"X4",4"X8",4‐3/4" (*hydroactive (sterile) dressing***)
Tier 3
HYDROGEL GAU PAD 2"X2",3" DISK,4"X4",4"X8",4‐3/4" (*hydroactive (sterile) dressing***)
Tier 3
KERAGEL GEL WOUND (*wound dressings ‐ gel***) Tier 3
KERAGELT GEL (*wound dressings ‐ gel***) Tier 3
KERAMATRIX MIS 10X10CM,4"X5",5X5CM (*wound dressings ‐ sheet***)
Tier 3
LUXAMEND CRE (*wound dressings ‐ cream***) Tier 3
MEDIHONEY GEL WOUND (*wound dressings ‐ gel***) Tier 3
MEDIHONEY PAD 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
MEDIHONEY PST WOUND (*wound dressings ‐ paste***) Tier 3
This formulary is January 2021. The formulary is updated on a monthly basis Tier 1=Generics | Tier 2=Preferred Brands | Tier 3=Non‐Preferred Brands | Tier 4=Non‐Preferred Specialty | Tier 5=Zero Cost Share Preventative Drugs | AL=Age Limits | OAC=Oral anti‐cancer drug cost share limit | OTC=Over the counter | PA=Prior Authorization | QL=Quantity Limits | SP=Specialty Network; 30 day supply 268 Proprietary
PRESCRIPTION DRUG NAME DRUG TIER COVERAGE REQUIREMENTS and LIMITS
PICO WOUND KIT THER SYS (*wound dressings ‐ kit***) Tier 3
RADIAGEL GEL (*wound dressings ‐ gel***) Tier 3
RADIAPLEXRX GEL (*wound dressings ‐ gel***) Tier 3
THERAHONEY GEL (*wound dressings ‐ gel***) Tier 3
THERAHONEY MIS 10X10CM,4"X5",5X5CM (*wound dressings ‐ sheet***)
Tier 3
VASCUDERM GEL HYDROGEL (*wound dressings ‐ gel***) Tier 3
VEXASYN GEL (*wound dressings ‐ gel***) Tier 3
WOUND CARE PAD 2" X 2",2"X2",2"X2.75",2.5",2‐1/4X8",2X2,3 PAD 4"X4",3/4"X12",4" X 4",4" X 5",4"X4,4"X4",4"X5",4"X8",4X4,4X5",6"X6‐3/4,6X6,8"X8",8X8",9MM (*wound dressings ‐ pads***)
Tier 3
ZANABIN GEL HYDROGEL (*wound dressings ‐ gel***) Tier 3
XANTHINE‐EXPECTORANTS ‐ Drugs to Treat Asthma and Breathing Disorders
difil‐g fort liq 100‐100 Tier 1
XANTHINES ‐ Drugs to Treat Asthma and Breathing Disorders
ELIXOPHYLLIN ELX 80/15ML (theophylline elixir) Tier 3
THEO‐24 CAP 100MG CR,200MG CR,300MG CR,400MG ER (theophylline cap er)
Tier 3
theophylline sol 80/15ml Tier 1
theophylline tab 300mg er,400mg er,450mg er,600mg er Tier 1
X‐LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT ‐ AGENTS ‐ Drugs to Treat Diabetes and other Disorders of the Endocrine System
CRYSVITA INJ 10MG/ML,20MG/ML,30MG/ML (burosumab‐twza inj)
Tier 4 PA; SP; QL (34 days supply)
ZINC ‐ Drugs for Replacement of Minerals in the Body
GALZIN CAP 25MG,50MG (zinc acetate cap) Tier 3
269
Index
1
12‐PANEL POC KIT TOXICOLO ............................... 106
1ML SYRINGE MIS ................................................. 181
1ST TIER UNI MIS .................................................. 181
7
7T GUMMY ES CHW ................................................ 40
7T Lido .................................................................. 172
A
abacavir sulfate soln ............................................... 70
abacavir sulfate tab ................................................ 70
abacavir sulfate‐lamivudine tab ............................. 68
abacavir sulfate‐lamivudine‐zidovudine tab........... 69
abacavir‐dolutegravir‐lamivudine tab .................... 69
abaloparatide subcutaneous soln pen‐injector .... 213
abatacept for iv soln ............................................. 236
abatacept subcutaneous soln auto‐injector ......... 236
abemaciclib tab .................................................... 103
ABILIFY MYCI TAB ................................................. 231
ABILIFY TAB ........................................................... 231
abiraterone acetate tab .......................................... 41
abobotulinumtoxina for im inj .............................. 193
ABOUTTIME MIS ................................................... 181
ABSORICA CAP ........................................................ 33
ABSORICA LD CAP ................................................... 33
ABSTRAL SUB ........................................................ 206
acalabrutinib cap .................................................... 63
ACANYA GEL ........................................................... 31
acarbose tab ........................................................... 37
ACCOLATE TAB ...................................................... 170
ACCU‐CHEK KIT AVIVA PL ...................................... 197
ACCU‐CHEK KIT NANO .......................................... 197
ACCU‐CHEK TES AVIVA PL ..................................... 106
ACCU‐CHEK TES COMPACT ................................... 106
ACCU‐CHEK TES GUIDE ......................................... 106
ACCU‐CHEK TES SMART ........................................ 106
ACCUPRIL TAB ......................................................... 29
ACCURETIC TAB ...................................................... 29
ACCUTREND TES GLUCOSE ................................... 106
ACD FORMULA SOL A ........................................... 163
acetaminophen chew tab ....................................... 40
acetaminophen w/ codeine tab .............................. 93
acetaminophen/caffeine/dihydrocodeine bitartrate
cap .................................................................... 135
acetaminophen/caffeine/dihydrocodeine bitartrate
tab .................................................................... 135
acetohydroxamic acid tab .................................... 260
acetone (urine) test strip ...................... 109, 121, 127
acetylcarnitine oral powder .................................... 38
ACIPHEX SPR CAP .................................................. 228
ACIPHEX TAB ......................................................... 228
acitretin cap ............................................................ 67
aclidinium br‐formoterol fum aero pow br act ....... 35
aclidinium bromide aerosol powd breath activated ....
85
acrivastine & pseudoephedrine cap ...................... 105
ACTCT FLEX ........................................................... 266
ACTEMRA INJ ................................................ 165, 166
ACTEMRA INJ ACTPEN .......................................... 166
ACTHAR INJ ........................................................... 103
ACTHIB INJ .............................................................. 76
ACTICLATE TAB ..................................................... 249
ACTIGALL CAP ....................................................... 144
ACTIMMUNE INJ ..................................................... 65
ACTIQ LOZ ............................................................. 206
ACTIVE FE TAB ...................................................... 167
ACTIVELLA TAB ..................................................... 139
ACTONEL TAB.......................................................... 83
ACTOPLUS MET TAB ............................................. 250
ACTOS TAB ............................................................ 250
ACUICYN SOL ........................................................ 141
ACULAR LS SOL ..................................................... 203
ACULAR SOL .......................................................... 203
ACUNOL TAB ......................................................... 155
ACUVAIL SOL ......................................................... 203
acyclovir buccal tab .............................................. 154
acyclovir cap ......................................................... 153
acyclovir cream ....................................................... 74
acyclovir oint ........................................................... 74
acyclovir susp ........................................................ 154
acyclovir tab .......................................................... 154
acyclovir‐hydrocortisone cream .............................. 74
ACZONE GEL ............................................................ 30
ADACEL INJ ........................................................... 254
ADAKVEO INJ ........................................................ 236
adalimumab pen‐injector kit .................................. 73
adalimumab prefilled syringe kit ............................ 73
adapalene cream .................................................... 34
adapalene gel ................................................... 33, 34
adapalene lotion ..................................................... 34
270
ADAPALENE SOL ..................................................... 33
adapalene soln ........................................................ 33
adapalene‐benzoyl peroxide gel ............................. 31
ADASUVE INH ....................................................... 131
ADCETRIS INJ........................................................... 64
ADCIRCA TAB ........................................................ 230
ADDERALL TAB ........................................................ 39
ADDERALL XR CAP ................................................... 39
ADDYI TAB ............................................................. 239
adefovir dipivoxil tab ............................................ 153
ADEMPAS TAB ...................................................... 229
ADHANSIA XR CAP ................................................ 246
ADLYXIN INJ .......................................................... 163
ADMELOG INJ ....................................................... 155
ADMELOG SOLO INJ .............................................. 155
ado‐trastuzumab emtansine for iv soln .................. 64
ADRENALIN INJ ....................................................... 41
ADRENALIN SOL .................................................... 254
ADVAIR DISKU AER ................................................. 35
ADVAIR HFA AER ..................................................... 35
ADVANCE TES INTUITIO ........................................ 106
ADVANCE TES MICRO‐DW .................................... 106
ADVATE INJ ............................................................. 53
ADVOCATE TES ..................................................... 107
ADVOCATE TES REDI‐COD ..................................... 107
ADVOCATE TES REDICODE .................................... 107
ADYNOVATE INJ ...................................................... 53
ADYPHREN AMP KIT ................................................ 41
ADYPHREN II KIT ..................................................... 41
ADYPHREN KIT ........................................................ 41
ADZENYS ER SUS ..................................................... 39
ADZENYS XR TAB ..................................................... 39
AEMCOLO TAB ........................................................ 57
afatinib dimaleate tab ............................................ 63
AFINITOR DIS TAB ................................................... 62
AFINITOR TAB ......................................................... 62
Afirmelle ................................................................. 93
aflibercept intravitreal inj ..................................... 261
AFLURIA QUAD INJ ................................................ 262
AFREZZA POW ....................................................... 155
AFSTYLA KIT ............................................................ 53
agalsidase beta for iv soln .................................... 141
AGAMATRIX TES AMP ........................................... 107
AGAMATRIX TES JAZZ ........................................... 107
AGAMATRIX TES KEYNOTE .................................... 107
AGAMATRIX TES PRESTO ...................................... 107
AGGRENOX CAP .................................................... 216
AGRYLIN CAP ........................................................ 230
AIMOVIG INJ ........................................................... 91
AIRDUO RESPI INH .................................................. 35
AJOVY INJ ................................................................ 91
AKLIEF CRE .............................................................. 33
AKTEN GEL ............................................................ 202
AKYNZEO CAP ......................................................... 52
ALA SCALP LOT ........................................................ 99
Ala‐cort ................................................................... 99
albendazole tab ...................................................... 44
ALBENZA TAB .......................................................... 44
albuterol sulfate aer pow ba................................... 79
albuterol sulfate inhal aero .................................... 79
alcaftadine ophth soln .......................................... 200
ALCAINE SOL ......................................................... 202
ALCOH‐GLOVE PAD CONTOURE ............................. 74
ALCOHOL PAD ................................................... 74, 75
ALCOHOL PAD PREP .......................................... 74, 75
ALCOHOL PAD SWABSTIC ....................................... 74
ALCOHOL PREP PAD .......................................... 74, 75
ALCOHOL PREP PAD MED ....................................... 75
ALCOHOL PREP PAD PADS ...................................... 75
ALCOHOL SWAB PAD .............................................. 75
ALCOHOL SWAB PAD EX‐THICK .............................. 75
ALCOHOL WIPE PAD ............................................... 75
ALCOH‐WIPE MIS .................................................... 75
ALDACTAZIDE TAB ................................................ 136
ALDACTONE TAB ................................................... 218
ALDARA CRE .......................................................... 162
aldesleukin for iv soln ............................................. 65
ALDURAZYME INJ .................................................. 178
ALECENSA CAP ........................................................ 63
alectinib hcl cap ...................................................... 63
alemtuzumab iv inj ............................................... 179
alendronate sodium effervescent tab ..................... 83
alendronate sodium tab ......................................... 83
alendronate sodium‐cholecalciferol tab ................. 83
ALEVAMAX CRE ..................................................... 174
ALEVICYN GEL ....................................................... 174
ALEVICYN SG GEL ANTIPRUR ................................ 174
ALEVICYN SOL DERMAL ........................................ 266
alfuzosin hcl tab er .................................................. 36
alglucosidase alfa for iv soln ................................. 143
ALINIA SUS .............................................................. 66
ALINIA TAB .............................................................. 66
ALIQOPA INJ .......................................................... 215
alirocumab subcutaneous solution auto‐injector . 213
aliskiren fumarate tab .......................................... 136
aliskiren‐hydrochlorothiazide tab ......................... 136
alitretinoin gel ........................................................ 65
ALKERAN TAB ........................................................ 194
271
ALLEVYN GENT PAD .............................................. 266
allopurinol tab ...................................................... 149
ALLZITAL TAB .......................................................... 40
ALMOND OIL ......................................................... 142
almond oil (sweet) ................................................ 142
ALMOND OIL SWEET ............................................. 142
ALOCRIL SOL ......................................................... 200
alogliptin benzoate tab ......................................... 135
alogliptin‐metformin hcl tab ................................. 135
alogliptin‐pioglitazone tab ................................... 137
ALOMIDE SOL ........................................................ 200
ALORA DIS ............................................................. 139
alosetron hcl tab ................................................... 160
ALOXI INJ ................................................................. 28
alpelisib tab pack .................................................. 216
alpha1‐proteinase inhibitor (human) for iv soln ..... 37
alpha1‐proteinase inhibitor (human) inj ................. 37
ALPHAGAN P SOL .................................................. 203
alpha‐lipoic acid (thioctic acid) oral powder ........... 38
ALPHANATE INJ VWF/HUM .................................... 54
ALPHANINE SD INJ .................................................. 54
ALPRAZOLAM CON ................................................. 78
alprazolam conc ...................................................... 78
alprazolam tab ........................................................ 78
alprazolam tab er ................................................... 78
ALPROLIX INJ ........................................................... 54
ALREX SUS ............................................................. 205
ALTABAX OIN .......................................................... 46
Altacaine ............................................................... 202
ALTACE CAP ............................................................ 29
Altavera .................................................................. 93
ALTOPREV TAB ...................................................... 154
ALTRENO LOT .......................................................... 33
aluminum chloride in alcohol solution .................... 76
aluminum chloride soln......................................... 177
ALUNBRIG PAK ........................................................ 63
ALUNBRIG TAB ........................................................ 63
ALVESCO AER ........................................................ 245
alvimopan cap ...................................................... 213
Alyacen 1/35 ................................................... 93, 256
ALZAIR NASAL SPR ................................................ 180
Amabelz ................................................................ 139
amantadine hcl cap ................................................ 66
amantadine hcl cap er ............................................ 66
amantadine hcl tab ................................................. 66
amantadine hcl tab er ............................................ 66
AMARYL TAB ......................................................... 248
AMBIEN CR TAB .................................................... 195
AMBIEN TAB ......................................................... 195
ambrisentan tab ................................................... 229
AMCINONIDE OIN ................................................... 99
amcinonide oint ...................................................... 99
AMELUZ GEL ......................................................... 216
AMERGE TAB ........................................................ 237
Amethia ................................................................ 140
AMETHIA LO TAB .................................................. 140
Amethyst ................................................................ 99
AMICAR SOL .......................................................... 152
AMICAR TAB ......................................................... 152
amifampridine phosphate tab ................................ 59
amifampridine tab .................................................. 60
amikacin sulfate liposome inhal susp ..................... 38
AMINO PM RMS CAP ............................................ 198
aminocaproic acid oral soln .................................. 152
aminocaproic acid tab .......................................... 152
aminolevulinic acid hcl for oral solution ............... 105
aminolevulinic acid hcl for soln ............................. 216
aminolevulinic acid hcl gel .................................... 216
aminosalicylic acid er granules packet ................... 60
AMITIZA CAP ......................................................... 144
amlodipine benzoate oral susp ............................... 87
amlodipine besylate tab ................................... 29, 87
amlodipine besylate‐atorvastatin calcium tab ....... 86
amlodipine besylate‐benazepril hcl cap .................. 29
amlodipine besylate‐celecoxib tab ......................... 86
amlodipine besylate‐olmesartan medoxomil tab ... 43
amlodipine besylate‐valsartan tab ......................... 43
amlodipine‐valsartan‐hydrochlorothiazide tab ...... 44
Amnesteem ............................................................ 33
AMORPH WOUND GEL DRESSING ........................ 266
amoxapine tab ...................................................... 255
amoxicillin & k clavulanate for susp ..................... 213
amoxicillin & k clavulanate tab ............................. 213
amoxicillin cap‐clarithro tab w/ omepraz cap dr
therapy pack ..................................................... 257
amoxicillin‐rifabutin‐omeprazole cap dr ............... 257
amphetamine extended release susp ............... 39, 40
amphetamine sulfate orally disintegrating tab ...... 40
amphetamine sulfate tab ....................................... 40
amphetamine tab extended release disintegrating 39
amphetamine‐dextroamphetamine ....................... 39
amphetamine‐dextroamphetamine cap er ............. 39
amphetamine‐dextroamphetamine tab ................. 39
ampicillin cap .......................................................... 39
AMPYRA TAB ......................................................... 179
AMRIX CAP .............................................................. 89
AMZEEQ AER ........................................................... 30
ANACAINE OIN ...................................................... 172
272
ANADROL‐50 TAB ................................................... 40
ANAFRANIL CAP .................................................... 255
anagrelide hcl cap ................................................. 230
anakinra subcutaneous soln prefilled syringe ....... 165
ANAPROX DS TAB ................................................. 196
ANASPAZ TAB ......................................................... 77
anastrozole tab ....................................................... 75
ANCOBON CAP ........................................................ 52
ANDRODERM DIS .................................................... 41
ANDROGEL GEL ....................................................... 41
ANGELIQ TAB ........................................................ 139
ANNOVERA MIS ...................................................... 98
ANORO ELLIPT AER ................................................. 35
ANTABUSE TAB ....................................................... 36
ANTARA CAP ......................................................... 141
anthralin cream ...................................................... 67
anthralin shampoo ................................................. 67
anthrax vaccine adsorbed inj .................................. 76
ANTICOAG CIT SOL DEX SOL ................................. 163
anticoagulant sodium citrate concentrate ........... 163
anticoagulant sodium citrate soln ........................ 163
ANTICOAGULNT INJ SOD CITR ................................ 47
ANTICOAGULNT SOL SOD CITR ............................. 163
antihemophil fact rcmb (bdd‐rfviii,sim) for inj kit ... 55
antihemophilic fact rcmb (bd trunc‐rfviii) for inj ..... 55
antihemophilic fact rcmb (bdd‐rfviii,sim) for inj ..... 55
antihemophilic fact rcmb single chain for inj kit ..... 53
antihemophilic factor (human) for inj ..................... 54
antihemophilic factor (recomb porc) rpfviii for inj .. 55
antihemophilic factor (recombinant) for inj ..... 54, 55
antihemophilic factor (recombinant) for inj kit ...... 54
antihemophilic factor rahf‐pfm for inj .............. 53, 54
antihemophilic factor rcmb (bdd‐rfviiifc) for inj ...... 54
antihemophilic factor recom pegylated‐aucl for inj 54
antihemophilic factor recomb glycopeg‐exei for inj 54
antihemophilic factor recomb pegylated for inj ..... 53
antihemophilic factor recombinant paf for inj kit ... 55
antihemophilic factor/vwf (human) for inj ....... 54, 55
antiinhibitor coagulant complex for iv soln ............ 54
anti‐thymocyte globulin for iv soln ....................... 161
ANUSOL‐HC CRE.................................................... 232
ANZEMET TAB ......................................................... 28
APADAZ TAB ......................................................... 209
apalutamide tab ..................................................... 45
APEXICON E CRE ..................................................... 99
APIDRA INJ SOLOSTAR .......................................... 155
APIDRA INJ U‐ ....................................................... 155
apixaban tab ................................................. 135, 136
APLENZIN TAB ......................................................... 50
APLICARE ALC PAD SWABSTIC ................................ 75
APOKYN INJ ........................................................... 195
apomorphine hcl soln cartridge ............................ 195
apomorphine hydrochloride film .......................... 195
APP SLIM RMS CAP ............................................... 200
apraclonidine hcl ophth soln ................................. 203
apremilast tab ...................................................... 216
aprepitant capsule ................................................ 248
aprepitant capsule therapy pack .......................... 248
aprepitant for oral susp ........................................ 248
Apri ......................................................................... 94
APRISO CAP ........................................................... 163
APTENSIO XR CAP ................................................. 246
APTIOM TAB ........................................................... 47
APTIVUS CAP ........................................................... 69
APTIVUS SOL ........................................................... 69
AQUACEL AG PAD ................................................. 266
AQUASOL A INJ ..................................................... 264
AQUORAL SPR ....................................................... 137
ARAKODA TAB ........................................................ 58
ARALAST NP INJ ...................................................... 37
Aranelle................................................................. 256
ARANESP INJ ......................................................... 138
ARAVA TAB ........................................................... 230
ARAZLO LOT ............................................................ 33
ARCALYST INJ ........................................................ 165
ARCAPTA CAP ......................................................... 79
arformoterol tartrate soln nebu ............................. 79
ARICEPT TAB ........................................................... 92
ARIDOL KIT ............................................................ 105
ARIKAYCE SUS ......................................................... 38
ARIMIDEX TAB ........................................................ 75
aripiprazole tab..................................................... 231
armodafinil tab ............................................. 246, 247
ARMOUR THYRO TAB ........................................... 252
ARNICA TIN FLOWER ............................................ 177
ARNUITY ELPT INH ................................................ 245
AROMASIN TAB ...................................................... 75
artemether‐lumefantrine tab ................................. 58
ARTHROTEC .......................................................... 196
ARTISS SOL ............................................................ 152
ARYMO ER TAB ..................................................... 206
ARZERRA CON ......................................................... 61
ASA/OMEPRAZO TAB ............................................ 216
ASACOL HD TAB .................................................... 163
ASCENIV INJ .......................................................... 161
Ascomp/codeine ..................................................... 93
ASCOR SOL ............................................................ 265
ASCORBIC ACI SOL ................................................ 265
273
ascorbic acid iv soln .............................................. 265
asenapine maleate sl tab ...................................... 131
asenapine td patch ............................................... 131
asfotase alfa subcutaneous inj ............................. 159
Ashlyna ................................................................. 140
ASMANEX .............................................................. 245
ASMANEX HFA AER ............................................... 245
ASP/OMEPRAZO TAB ............................................ 216
asparaginase erwinia chrysanthemi for inj ............. 65
ASPARLAS INJ .......................................................... 65
ASPIRIN ................................................. 233, 234, 235
aspirin capsule er .................................................. 216
aspirin chew tab ................................... 233, 234, 235
ASPIRIN CHLD CHW .............................................. 233
ASPIRIN CHW ........................................ 233, 234, 235
ASPIRIN LOW CHW ............................................... 233
ASPIRIN LOW TAB ................................................. 233
ASPIRIN TAB .................................................. 234, 235
aspirin tab delayed release ................... 233, 234, 235
ASPIRIN‐81 CHW ................................................... 234
aspirin‐dipyridamole cap er .................................. 216
aspirin‐omeprazole tab delayed release ............... 216
ASSURE ................................................. 108, 181, 224
ASSURE ID MIS ...................................................... 181
ASSURE II TES ........................................................ 108
ASSURE II TES CHECK ............................................ 108
ASSURE PRISM TES MULTI .................................... 108
ASSURE PRO TES ................................................... 108
ASSURE TES PLATINUM ........................................ 108
ASTAGRAF XL CAP ................................................. 173
ASTAMED MYO CAP .............................................. 131
ASTERO GEL .......................................................... 172
ATABEX EC TAB ..................................................... 218
ATABEX OB TAB .................................................... 218
ATACAND HCT TAB ................................................. 43
ATACAND TAB ......................................................... 43
atazanavir sulfate cap ............................................ 70
atazanavir sulfate oral powder packet ................... 70
atazanavir sulfate‐cobicistat tab ............................ 68
ATELVIA TAB ........................................................... 83
atenolol & chlorthalidone tab ................................. 80
atenolol tab ............................................................ 80
atezolizumab iv soln ............................................... 62
ATGAM INJ ............................................................ 161
ATIVAN TAB ............................................................ 78
atomoxetine hcl cap ............................................... 35
ATOPADERM CRE .................................................. 174
ATOPICLAIR CRE .................................................... 175
atorvastatin calcium tab ................................. 86, 154
atovaquone susp ..................................................... 66
atovaquone‐proguanil hcl tab ................................ 58
ATRALIN GEL ........................................................... 33
ATRAPRO CP KIT ................................................... 266
ATRAPRO DERM SPR ............................................. 266
ATRAPRO GEL HYDROGEL ..................................... 266
ATRIPLA TAB ........................................................... 68
ATROPINE SUL OIN ............................................... 104
ATROPINE SUL SOL ............................................... 104
atropine sulfate ophth oint ................................... 104
atropine sulfate ophth soln ................................... 104
ATROVENT HFA AER ............................................... 84
AUBAGIO TAB ....................................................... 178
Aubra ...................................................................... 94
Aubra Eq ................................................................. 94
AUGMENTIN SUS .................................................. 213
AUGMENTIN SUS ES‐ ............................................ 213
AUGMENTIN TAB .................................................. 213
auranofin cap ........................................................ 149
Aurovela.................................................................. 94
Aurovela 24 Fe ........................................................ 94
Aurovela Fe 1/20 .................................................... 94
AURYXIA TAB ........................................................ 215
AUSTEDO TAB ....................................................... 177
AUTOCODE TES BLD GLUC .................................... 108
AUTOPEN MIS ....................................................... 181
AUTOSHIELD MIS .................................................. 182
AUVI‐Q INJ .............................................................. 41
AVAILNEX CHW ..................................................... 134
AVALIDE TAB ........................................................... 43
AVANDIA TAB........................................................ 251
avapritinib tab ........................................................ 63
AVAPRO TAB ........................................................... 43
AVAR LS LIQ ............................................................ 31
AVAR‐E LS CRE ........................................................ 31
AVASTIN INJ .......................................................... 262
avatrombopag maleate tab .................................. 251
AVEED INJ ............................................................... 41
avelumab soln for iv infusion .................................. 61
AVENOVA SOL ....................................................... 141
Aviane ..................................................................... 94
Avidoxy ................................................................. 249
Avita ........................................................................ 33
AVODART CAP ......................................................... 28
AVONEX PEN KIT ................................................... 178
AVONEX PREFL KIT ................................................ 178
AVSOLA INJ ........................................................... 257
axitinib tab .............................................................. 63
AXONA POW ......................................................... 131
274
AYGESTIN TAB ....................................................... 226
Ayuna ...................................................................... 94
AYVAKIT TAB ........................................................... 63
azacitidine for inj .................................................... 59
AZALGIA CAP ......................................................... 174
AZASAN TAB .......................................................... 230
AZASITE SOL .......................................................... 200
AZATHIOPRINE INJ ................................................ 230
azathioprine sodium for inj ................................... 230
azathioprine tab ................................................... 230
azelaic acid cream .................................................. 33
azelaic acid foam .................................................. 233
azelaic acid gel ...................................................... 233
azelastine hcl‐fluticasone prop nasal spray ............ 57
AZELEX CRE ............................................................. 33
AZESCHEW CHW ................................................... 219
AZESCO TAB .......................................................... 219
AZILECT TAB ............................................................ 66
azilsartan medoxomil tab ....................................... 44
azilsartan medoxomil‐chlorthalidone tab ............... 43
azithromycin for susp .............................................. 76
azithromycin ophth soln ....................................... 200
azithromycin powd pack for susp ........................... 76
azithromycin tab ..................................................... 76
AZOPT SUS ............................................................ 201
AZOR TAB ................................................................ 43
aztreonam lysine for inhal soln ............................. 177
AZULFIDINE TAB.................................................... 163
Azurette ............................................................ 18, 83
B
bacitracin zinc/polymyxin b sulfate oin op ........... 201
bacitracin/neomycin/polymyxin b/hydrocortisone hc
oin hc ................................................................ 204
bacitracin‐polymyxin‐neomycin hc oint .................. 46
baclofen oral soln ................................................... 90
baclofen tab ............................................................ 89
BACTRIM DS TAB .................................................... 57
BACTRIM TAB .......................................................... 57
BAL‐CARE MIS DHA ............................................... 219
BALCOLTRA TAB ...................................................... 94
baloxavir marboxil tab therapy pack .................... 212
balsalazide disodium cap ...................................... 163
BALSAM PERU OIN CASTOR .................................. 265
BALVERSA TAB ........................................................ 60
Balziva ..................................................................... 94
BANZEL SUS ............................................................ 47
BANZEL TAB ............................................................ 47
BAQSIMI ONE POW .............................................. 105
BAQSIMI TWO POW.............................................. 105
BARACLUDE SOL ................................................... 152
BARACLUDE TAB ................................................... 152
baricitinib tab ......................................................... 71
BARIUM POW SULFATE ........................................ 231
barium sulfate (o‐ring) cap ................................... 231
barium sulfate for susp ................................. 231, 232
barium sulfate oral cream .................................... 231
barium sulfate oral paste ...................................... 231
barium sulfate oral/rectal susp............................. 231
barium sulfate powder ......................................... 231
barium sulfate susp ...................................... 231, 232
barium sulfate tab ................................................ 231
BASAGLAR INJ ....................................................... 155
BASE G ALMON OIL SWEET ................................... 142
BASE X MIS ............................................................ 214
basiliximab for iv soln ........................................... 177
BAVENCIO INJ ......................................................... 61
BAXDELA TAB ........................................................ 143
BAYER LOW CHW .................................................. 234
BAYER LOW TAB ................................................... 234
bcg live intravesical for susp ................................... 65
BD PEN MINI MIS .................................................. 182
BD PEN MIS ........................................................... 182
BD PEN NEEDL MIS ............................................... 182
BD SWAB BFLY PAD SNGL USE ................................ 75
BD U‐ ..................................................................... 182
BEAU RX GEL ......................................................... 235
becaplermin gel .................................................... 265
beclomethasone diprop hfa breath act inh aer .... 246
beclomethasone dipropionate monohyd nasal susp ...
180
beclomethasone dipropionate nasal aerosol ........ 180
BECONASE AQ SUS ................................................ 180
bedaquiline fumarate tab ....................................... 60
Bekyree ................................................................... 83
belatacept for iv infusion ...................................... 239
BELBUCA MIS ........................................................ 209
BELEODAQ INJ ........................................................ 61
belimumab for iv soln ............................................. 84
belinostat for iv inj .................................................. 61
BELLA/OPIUM SUP .................................................. 47
belladonna alkaloids & opium suppos .................... 47
BELRAPZO SOL ........................................................ 36
BELSOMRA TAB ..................................................... 211
bempedoic acid tab ................................................ 34
bempedoic acid‐ezetimibe tab ................................ 30
benazepril & hydrochlorothiazide tab .................... 30
benazepril hcl tab ................................................... 29
275
bendamustine hcl for iv soln ................................... 36
bendamustine hcl iv soln ........................................ 36
BENDAMUSTINE SOL .............................................. 36
BENDEKA INJ ........................................................... 36
BENEFIX INJ ............................................................. 54
BENICAR HCT TAB ................................................... 43
BENICAR TAB .......................................................... 44
BENLYSTA INJ .......................................................... 84
benralizumab subcutaneous soln auto‐injector .... 165
benralizumab subcutaneous soln prefilled syringe ......
165
BENSAL HP OIN ..................................................... 169
BENZ PER FOR LOT HC ............................................ 31
BENZ PEROXID GEL ................................................. 33
BENZAC AC LIQ ....................................................... 33
BENZACLIN GEL ....................................................... 31
benzalkonium chloride soln .................................... 91
BENZALKONIUM SOL .............................................. 91
BENZALKONIUM SOL NF ......................................... 91
BENZAMYCIN GEL ................................................... 31
BENZEPRO AER ....................................................... 33
BENZEPRO LIQ ........................................................ 33
BENZEPRO MIS ........................................................ 33
Benzepro Short Contact .......................................... 33
BENZHY/ACETA TAB .............................................. 209
benzhydrocodone hcl‐acetaminophen tab ........... 209
BENZIQ GEL ............................................................. 33
BENZIQ LS GEL ........................................................ 33
Benziq Wash ........................................................... 33
benznidazole tab ..................................................... 44
benzocaine oint ..................................................... 172
BENZOIN TIN NF .................................................... 240
benzoin tincture .................................................... 240
benzonatate cap ..................................................... 73
benzoyl peroxide short contact aer ....................... 33
benzoyl peroxide cloth ............................................ 33
benzoyl peroxide foam ...................................... 33, 34
benzoyl peroxide gel ......................................... 31, 33
benzoyl peroxide liq ................................................ 33
benzoyl peroxide lotion ........................................... 34
benzoyl peroxide wash ..................................... 33, 34
benzoyl peroxide‐erythromycin gel ......................... 31
benzoyl peroxide‐hydrocortisone lotion ................. 31
BENZOYL PERX LIQ .................................................. 33
BENZYL ALC LIQ ....................................................... 59
benzyl alcohol ......................................................... 59
BEOVU INJ ............................................................. 261
bepotastine besilate ophth soln ............................ 200
BEPREVE DRO ....................................................... 200
beractant in nacl ................................................... 233
BERINERT INJ .......................................................... 85
Beser ....................................................................... 99
besifloxacin hcl ophth susp ................................... 200
BESIVANCE SUS ..................................................... 200
BESPONSA INJ ......................................................... 64
BETADINE SOL ....................................................... 201
betamethasone dipropionate augmented cream . 100
betamethasone dipropionate augmented oint ..... 100
betamethasone dipropionate spray emulsion ...... 102
betamethasone lot ................................................. 99
betamethasone sodium phosphate ophth soln .... 205
betamethasone valerate aerosol foam................. 101
BETAPACE AF TAB ................................................... 80
BETAPACE TAB ........................................................ 80
BETASERON INJ ..................................................... 179
betaxolol hcl ophth susp ......................................... 81
BETHKIS NEB ........................................................... 38
BETIMOL SOL .......................................................... 81
BETOPTIC‐S SUS ...................................................... 81
BETTERMILK PAK GLYTACTI .................................. 198
BETTERMILK15 POW GLYTACTN ........................... 198
BEVACIZUMAB INJ ................................................ 261
bevacizumab intravitreal soln pref syr .................. 261
bevacizumab iv soln .............................................. 262
bevacizumab‐awwb iv soln ................................... 262
bevacizumab‐bvzr iv soln ...................................... 262
BEVESPI AER ........................................................... 35
bexarotene cap ..................................................... 236
bexarotene gel ...................................................... 254
BEXSERO INJ............................................................ 76
BEYAZ TAB .............................................................. 94
BHI URI‐ TAB CONTROL ......................................... 155
BIAXIN XL TAB ......................................................... 92
BIAXIN XL TAB PAC .................................................. 92
bicalutamide tab ..................................................... 45
bictegravir‐emtricitabine‐tenofovir af tab .............. 68
BIDIL TAB .............................................................. 193
BIJUVA CAP ........................................................... 139
BIKTARVY TAB ......................................................... 68
BILTRICIDE TAB ....................................................... 44
bimatoprost ophth soln ........................................ 227
binimetinib tab ....................................................... 61
BINOSTO TAB .......................................................... 83
BIOSCANNER TES GLUCOSE .................................. 109
Bio‐Statin ................................................................ 52
BIOTHRAX INJ.......................................................... 76
bisacodyl tab & peg ................................................ 84
bismuth subcit‐metronidazole‐tetracycline cap ... 257
276
bisoprolol & hydrochlorothiazide tab ..................... 80
BIVIGAM INJ .......................................................... 161
BLEPH‐10 SOL ....................................................... 206
BLEPHAMIDE OIN S.O.P. ....................................... 203
BLEPHAMIDE SUS OP ............................................ 203
blinatumomab for iv infusion.................................. 60
BLINCYTO INJ .......................................................... 60
Blisovi 24 Fe ............................................................ 94
BLOOD GLUCOS TES .............................................. 109
BLOOD GLUCOS TES LE ......................................... 109
BLOOD GLUCOS TES PREMIUM ............................ 109
BLOOD GLUCOS TES STRIPS .................................. 109
BOCASAL POW ...................................................... 137
BONIVA TAB ............................................................ 83
BONJESTA TAB ........................................................ 52
BOOSTRIX INJ ........................................................ 254
BORIC ACID GRA ................................................... 177
boric acid granules ................................................ 177
bortezomib for inj ................................................... 63
bortezomib for iv inj ................................................ 62
BORTEZOMIB INJ .................................................... 62
bosentan tab ......................................................... 229
BOSULIF TAB ........................................................... 63
bosutinib tab ........................................................... 63
BOTOX INJ ............................................................. 193
Bp Wash .................................................................. 34
BPCO OIN .............................................................. 265
BRAFTOVI CAP ........................................................ 60
brentuximab vedotin for iv soln .............................. 64
BREO ELLIPTA INH ................................................... 35
brexanolone iv soln ............................................... 144
brexpiprazole tab .................................................. 231
Briellyn .................................................................... 94
brigatinib tab .......................................................... 63
brigatinib tab initiation therapy pack ..................... 63
BRILINTA TAB ........................................................ 136
BRIMO/DORZO SOL ................................................ 37
brimonidine tartrate gel ....................................... 233
brimonidine tartrate ophth soln ........................... 203
brimonidine tartrate‐dorzolamide hcl ophth soln ... 37
brimonidine tartrate‐timolol maleate ophth soln ... 81
brinzolamide ophth susp ....................................... 201
brinzolamide‐brimonidine tartrate ophth susp ...... 37
BRISDELLE CAP ...................................................... 262
brivaracetam oral soln ............................................ 47
brivaracetam tab .................................................... 48
BRIVIACT SOL .......................................................... 47
BRIVIACT TAB .......................................................... 48
brodalumab subcutaneous soln prefilled syringe ... 67
brolucizumab‐dbll intravitreal soln ....................... 261
Bromfed Dm ......................................................... 196
bromfenac sodium ophth soln .............................. 203
bromocriptine mesylate cap ................................... 66
bromocriptine mesylate tab ........................... 66, 137
brompheniramine maleate/pseudoephedrine
hydrochloride/dextromethorphan hydrobromide
syp .................................................................... 196
BROMSITE DRO ..................................................... 203
BROVANA NEB ........................................................ 79
BRUKINSA CAP ........................................................ 63
BRYHALI LOT ........................................................... 99
budesonide delayed release particles cap ............ 146
budesonide inhal aero powd ................................. 246
budesonide inhalation susp .................................. 246
budesonide rectal foam ........................................ 166
budesonide tab er ......................................... 145, 147
budesonide‐formoterol fumarate dihyd aerosol ..... 35
bumetanide tab .................................................... 172
BUMEX TAB ........................................................... 172
BUNAVAIL MIS ...................................................... 209
Bupap ...................................................................... 40
BUPHENYL POW.................................................... 258
BUPHENYL TAB ..................................................... 258
buprenorphine hcl buccal film .............................. 209
buprenorphine hcl‐naloxone hcl sl film ................. 210
buprenorphine hcl‐naloxone hcl sl tab .................. 210
buprenorphine td patch weekly ............................ 210
buprenorphine‐naloxone buccal film .................... 209
bupropion hbr tab er ............................................... 50
bupropion hcl (smoking deterrent) tab er ............. 240
bupropion hcl tab .................................................... 50
bupropion hcl tab er ............................................... 50
burosumab‐twza inj .............................................. 268
busulfan tab ............................................................ 36
BUT/ASA/CAF TAB .................................................. 40
BUTAL/APAP CAP .................................................... 40
butalbital/aspirin/caffeine/codeine phosphate cap ....
93
butalbital‐acetaminophen cap ............................... 40
butalbital‐acetaminophen tab .......................... 40, 41
butalbital‐acetaminophen‐caff w/ cod cap ............ 93
butalbital‐acetaminophen‐caffeine cap ................. 41
butalbital‐acetaminophen‐caffeine tab .................. 41
butalbital‐aspirin‐caff w/ codeine cap .................... 93
butalbital‐aspirin‐caffeine cap ................................ 41
butalbital‐aspirin‐caffeine tab ................................ 40
butenafine hcl cream .............................................. 53
butoconazole nitrate (one dose) vaginal cream ... 160
277
BUTRANS DIS ........................................................ 210
BYDUREON BC INJ ................................................. 163
BYDUREON PEN INJ .............................................. 163
BYETTA INJ ............................................................ 163
BYNFEZIA PEN INJ ................................................. 245
BYSTOLIC TAB ......................................................... 80
C
c1 esterase inhibitor (human) for iv inj ................... 85
c1 esterase inhibitor (human) for iv inj kit .............. 85
c1 esterase inhibitor (human) for subcutaneous inj 85
c1 esterase inhibitor (recombinant) for iv inj .......... 85
CA ALGINATE MIS ................................................. 266
CA ALGINATE PAD ................................................. 266
ca carb‐folic acid‐vit d‐b ......................................... 88
cabazitaxel inj ....................................................... 177
cabergoline tab ..................................................... 136
CABLIVI KIT .............................................................. 74
CABOMETYX TAB .................................................... 63
cabozantinib s‐mal cap ........................................... 63
cabozantinib s‐malate tab ...................................... 63
CADUET TAB ........................................................... 86
CAFERGOT TAB ..................................................... 138
CALAN SR TAB ......................................................... 86
calaspargase pegol‐mknl iv soln ............................. 65
calcifediol cap er ................................................... 159
CALCIFOL WAF ........................................................ 88
calcipotriene cream ................................................ 67
calcipotriene foam .................................................. 67
calcipotriene oin ..................................................... 67
calcipotriene‐betamethasone dipropionate foam 254
calcipotriene‐betamethasone dipropionate oint .. 254
calcipotriene‐betamethasone dipropionate susp . 254
calcitonin (salmon) nasal soln ................................ 85
Calcitrene ................................................................ 67
calcitriol cap .......................................................... 159
calcitriol oint ........................................................... 67
calcitriol oral soln .................................................. 159
calcium acetate (phosphate binder) cap .............. 215
calcium acetate (phosphate binder) oral soln ...... 215
CALCIUM‐FA WAF PLUS D ....................................... 88
calfactant in nacl .................................................. 233
CALQUENCE CAP ..................................................... 63
CAM PRO COMP BAR GLYTACTI ............................ 198
CAMBIA POW ........................................................ 174
Camila ................................................................... 226
Camrese ........................................................ 140, 141
Camrese Lo ........................................................... 140
canagliflozin tab ................................................... 244
canagliflozin‐metformin hcl tab ............................ 244
canagliflozin‐metformin hcl tab er ....................... 244
canakinumab subcutaneous inj ............................ 165
CANASA SUP ......................................................... 163
candesartan cilexetil tab ......................................... 43
candesartan cilexetil‐hydrochlorothiazide tab ....... 43
cannabidiol soln ...................................................... 48
CANTHARIDIN SOL ................................................ 169
cantharidin soln .................................................... 169
capecitabine tab ..................................................... 59
CAPEX SHA .............................................................. 99
CAPHOSOL SOL ..................................................... 137
caplacizumab‐yhdp for inj kit.................................. 74
CAPLYTA CAP .......................................................... 68
capmatinib hcl tab .................................................. 63
CAPRELSA TAB ........................................................ 63
capsaicin patch ..................................................... 172
CAPSULE................................................ 144, 145, 194
CAPSULE CONI CAP ‐SN # ...................................... 144
CAPSULE CONI CAP ‐SNAP # ......................... 145, 194
CAPSULE CONI CAP ‐SNAP# .................................. 145
CAPSULE EZFT CAP # ............................................. 145
captopril tab ........................................................... 29
CARAC CRE .............................................................. 64
CARAFATE SUS ...................................................... 174
CARAFATE TAB ...................................................... 174
CARBAGLU TAB ..................................................... 159
carbamazepine (antipsychotic) cap er .................... 68
carbamazepine cap er............................................. 48
carbamazepine susp ............................................... 49
carbamazepine tab ................................................. 49
carbamazepine tab er ............................................. 49
CARBATROL CAP ..................................................... 48
carbidopa & levodopa cap er ................................ 170
carbidopa & levodopa tab .................................... 170
carbidopa tab ....................................................... 105
carbidopa‐levodopa enteral susp ......................... 170
carbidopa‐levodopa‐entacapone tabs .................. 171
CARBINOXAMIN TAB .............................................. 56
carbinoxamine maleate extended release susp ...... 56
carbinoxamine maleate tab .................................... 56
carbocysteine chew tab ........................................ 134
CARDIOPL IND SOL ............................................ 88, 89
CARDIOPL IND SOL LOW DEX .................................. 88
CARDIOPL IND SOL NON‐EN ................................... 89
CARDIOPL IND SOL PLASMA ................................... 89
CARDIOPL IND SOL PLS/TROM ................................ 89
CARDIOPL MN SOL .................................................. 89
CARDIOPL MN SOL PLS/TROM ................................ 89
278
CARDIOPL REP SOL .................................................. 89
CARDIOPLE MN SOL LOW TROM ............................ 89
CARDIOPLEGI SOL DEL NIDO ................................... 89
CARDIOPLEGIA SOL MAIN ....................................... 89
CARDIOPLEGIC SOL ................................................. 88
CARDIOVID CAP PLUS ........................................... 176
CARDIZEM CD CAP .................................................. 86
CARDIZEM LA TAB ................................................... 86
CARDIZEM TAB ....................................................... 86
CARDURA TAB ......................................................... 45
CARDURA XL TAB .................................................... 36
CAREFINE MIS ....................................................... 182
CARESENS N TES ................................................... 109
CARETOUCH MIS ........................................... 109, 182
CARETOUCH MIS TST STRP ................................... 109
CARETOUCH PAD ALCOHOL .................................... 75
carfilzomib for inj .................................................... 62
carglumic acid tab ................................................ 159
CARIMUNE NF INJ ................................................. 161
cariprazine hcl cap .................................................. 68
carisoprodol tab ........................................ 89, 90, 180
carmustine in polifeprosan intracranial implant
wafer ................................................................ 194
CARNITOR SF SOL .................................................... 89
CARNITOR SOL ........................................................ 89
CARNITOR TAB ........................................................ 89
CAROSPIR SUS ....................................................... 218
CARRASYN GEL DRESSING .................................... 267
Cartia Xt .................................................................. 86
carvedilol phosphate cap er .................................... 37
carvedilol tab .......................................................... 37
CASCARA EXT SAGRADA ....................................... 246
cascara sagrada fl ext ........................................... 246
CASODEX TAB ......................................................... 45
castor oil ....................................................... 142, 265
CATAPRES TAB ........................................................ 45
CATAPRES‐TTS DIS .................................................. 45
CAYA DPR .............................................................. 130
CAYSTON INH ........................................................ 177
Caziant .................................................................. 256
cefaclor cap ............................................................. 90
CEFACLOR ER TAB ................................................... 90
cefaclor monohydrate tab er .................................. 90
cefadroxil cap .......................................................... 90
cefadroxil tab .......................................................... 90
cefdinir cap ............................................................. 90
cefditoren pivoxil tab .............................................. 91
cefixime cap ............................................................ 91
cefixime chew tab ................................................... 91
cefixime for susp ..................................................... 91
cefprozil tab ............................................................ 90
CELEBREX CAP ....................................................... 103
celecoxib cap ......................................................... 103
CELEXA TAB ........................................................... 238
CELLCEPT CAP ....................................................... 164
CELLCEPT IV INJ ..................................................... 164
CELLCEPT SUS ....................................................... 164
CELLCEPT TAB ....................................................... 164
CELONTIN CAP ...................................................... 248
cemiplimab‐rwlc iv soln .......................................... 62
CEM‐UREA SOL ..................................................... 137
cenegermin‐bkbj ophth soln ................................. 202
cenobamate tab ...................................................... 88
cenobamate tab pack ............................................. 88
CENTANY OIN.......................................................... 46
cephalexin cap ........................................................ 90
cephalexin tab ........................................................ 90
CEQUA SOL ........................................................... 202
CEQUR SIMPL KIT PATCH ...................................... 182
CERACADE EMU .................................................... 175
CERAMAX CRE ....................................................... 175
CERAMAX LOT ....................................................... 175
CERDELGA CAP ........................................................ 36
CEREFOLIN TAB ..................................................... 131
CEREFOLIN TAB NAC ............................................. 131
CEREZYME INJ ......................................................... 36
ceritinib tab ............................................................. 64
certolizumab pegol for inj kit ................................ 257
certolizumab pegol inj kit ..................................... 257
cervical cap ....................................................... 24, 91
CERVICAL MIS SPECIMEN ...................................... 106
CERVIDIL VAG MIS .................................................. 28
CESIA PAK ............................................................. 256
cetirizine hcl ophth soln ........................................ 200
CETRAXAL SOL ...................................................... 211
cetrorelix acetate for inj kit ................................... 149
CETROTIDE KIT ...................................................... 149
cetuximab iv soln .................................................... 61
cevimeline hcl cap ................................................. 235
CHANTIX PAK ........................................................ 240
CHANTIX TAB ........................................................ 241
Chateal .................................................................... 94
Chateal Eq ............................................................... 94
CHEMET CAP ........................................................... 51
CHEMSTRIP K TES.................................................. 109
CHEMSTRIP TES UGK ............................................ 179
CHENODAL TAB ..................................................... 144
chenodiol tab ........................................................ 144
279
CHERRY SYP .......................................................... 210
cherry syrup .......................................................... 210
CHILD ASA CHW ............................................ 234, 235
CHILD ASA LS CHW ................................................ 234
chlorambucil tab ................................................... 194
chlordiazepoxide hcl‐clidinium bromide cap ........... 47
CHLORHEX GLU SOL ................................................ 92
chlorhexidine gluconate sol .............................. 72, 92
chlorhexidine gluconate soln ............................ 72, 92
chlorothiazide susp ............................................... 250
chlorthalidone tab ............................................ 43, 80
CHLORZOXAZON TAB .............................................. 89
chlorzoxazone tab ................................................... 89
CHOLBAM CAP ........................................................ 83
cholestyramine pow ......................................... 82, 83
cholic acid cap ......................................................... 83
choline fenofibrate cap dr ..................................... 142
CHONDROITIN SOL ............................................... 206
chondroitin sulfate ophth soln .............................. 206
CHOR GONADOT INJ ............................................. 212
choriogonadotropin alfa inj .................................. 212
chorionic gonadotropin for im inj ......................... 212
ciclesonide inhal aerosol ....................................... 245
ciclesonide nasal aerosol soln ............................... 181
ciclesonide nasal susp ........................................... 180
Ciclodan .................................................................. 52
ciclopirox gel ........................................................... 52
ciclopirox olamine cream ........................................ 53
ciclopirox olamine susp ........................................... 53
ciclopirox shampoo ................................................. 53
ciclopirox sol ........................................................... 52
cilostazol tab ......................................................... 216
CILOXAN OIN ......................................................... 200
CILOXAN SOL ......................................................... 200
CIMDUO TAB ........................................................... 68
cimetidine tab ....................................................... 151
CIMZIA KIT ............................................................ 257
CIMZIA KIT STARTER ............................................. 257
CIMZIA PREFL KIT .................................................. 257
cinacalcet hcl tab .................................................... 85
CINQAIR INJ .......................................................... 165
CINRYZE SOL ........................................................... 85
CIPRO ( .................................................................. 143
CIPRO HC SUS OTIC ............................................... 211
CIPRO TAB ............................................................. 143
CIPRODEX SUS ...................................................... 211
ciprofloxacin for oral susp ..................................... 143
ciprofloxacin hcl ophth oint .................................. 200
ciprofloxacin hcl ophth soln .................................. 200
ciprofloxacin hcl otic soln ...................................... 211
ciprofloxacin hcl tab .............................................. 143
ciprofloxacin intratympanic susp .......................... 211
ciprofloxacin‐dexamethasone otic susp ................ 211
ciprofloxacin‐fluocinolone aceton (pf) otic soln .... 211
ciprofloxacin‐hydrocortisone otic susp ................. 211
citalopram hydrobromide tab ............................... 238
CITRANATAL CAP HARMONY ................................ 223
CITRANATAL CAP MEDLEY .................................... 223
CITRANATAL MIS ........................................... 219, 223
CITRANATAL MIS B‐CALM ..................................... 219
CITRANATAL PAK ASSURE ..................................... 224
CITRANATAL PAK DHA .......................................... 224
CITRANATAL TAB BLOOM ..................................... 219
CITRANATAL TAB RX ............................................. 219
cladribine tab therapy pack .................................. 178
Claravis ................................................................... 34
CLARINEX TAB ......................................................... 56
CLARINEX‐D TAB ................................................... 105
clarithromycin tab .................................................. 92
clarithromycin tab er .............................................. 92
CLENPIQ SOL ........................................................... 84
CLEOCIN CAP ......................................................... 171
CLEOCIN CRE ......................................................... 260
CLEOCIN PED SOL .................................................. 171
CLEOCIN SUP ......................................................... 260
CLEOCIN‐T GEL ........................................................ 30
CLEOCIN‐T LOT ........................................................ 30
CLEVER CHEK TES .................................................. 110
CLEVER CHEK TES AUTO CD .................................. 110
CLEVER CHEK TES TALK ......................................... 110
CLEVER CHEK TES VOICE ....................................... 110
CLEVER CHOIC TES MICRO .................................... 110
CLEVR CHOICE TES AUTO‐CD ................................ 110
CLEVR CHOICE TES NOCODE ................................. 110
CLICKFINE MIS ....................................................... 183
CLIMARA DIS ......................................................... 140
CLIMARA PRO DIS WEEKLY ................................... 139
Clindacin Etz Pledgets ............................................. 30
Clindacin‐p .............................................................. 30
CLINDAGEL GEL ....................................................... 30
clindamycin ................................. 30, 31, 32, 171, 260
clindamycin hcl cap ............................................... 171
clindamycin palmitate hcl for soln ........................ 171
clindamycin phosphate (one dose) vaginal cream 260
clindamycin phosphate foam .................................. 30
clindamycin phosphate gel ..................................... 30
clindamycin phosphate lotion ................................. 30
clindamycin phosphate vaginal cream ................. 260
280
clindamycin phosphate vaginal suppos ................ 260
clindamycin phosphate‐benzoyl peroxide gel ......... 31
clindamycin phosphate‐tretinoin gel ...................... 32
CLINDESSE CRE ...................................................... 260
clobazam oral film .................................................. 47
clobazam suspension .............................................. 47
clobazam tab .......................................................... 47
clobetasol propionate cream ........................ 101, 102
clobetasol propionate emulsion foam .................. 102
clobetasol propionate foam .................................. 102
clobetasol propionate lotion ................................. 100
clobetasol propionate oint .................................... 102
Clobetasol Propionate sha .................................... 100
clobetasol propionate shampoo ........................... 100
clobetasol propionate spray ................................. 100
clobetasol propionate topical aer ......................... 102
CLOBEX LOT .......................................................... 100
CLOBEX SHA .......................................................... 100
CLOBEX SPR .......................................................... 100
clocortolone pivalate cream ................................. 100
Clodan ................................................................... 100
CLODERM CRE ...................................................... 100
clomipramine hcl cap ............................................ 255
clonazepam tab ...................................................... 47
clonidine hcl tab ................................................ 34, 45
clonidine hcl tab er .................................................. 34
clonidine td patch weekly ....................................... 45
clopidogrel bisulfate tab ....................................... 251
clorazepate dipotassium tab .................................. 78
Clovique .................................................................. 91
clozapine susp ....................................................... 131
clozapine tab ......................................................... 131
CLOZARIL TAB ....................................................... 131
C‐NATE DHA CAP .................................................. 219
COAGADEX INJ ........................................................ 54
coagulation factor ix (recomb) (rfixfc) for inj .......... 54
coagulation factor ix (recomb) (rix‐fp) for inj ......... 54
coagulation factor ix (recombinant) for inj ....... 54, 55
coagulation factor ix (recombinant) for inj kit ........ 54
coagulation factor ix for inj............................... 54, 55
coagulation factor ix recomb glycopegylated for inj ...
55
coagulation factor viia (recomb) for inj .................. 55
coagulation factor x (human) for inj ....................... 54
COARTEM TAB ........................................................ 58
cobicistat tab .............................................. 68, 69, 71
cobimetinib fumarate tab ....................................... 61
cocaine hcl nasal soln ........................................... 180
COCAINE HCL SOL ................................................. 180
cocoa butter .......................................................... 214
COCOA BUTTER MIS ............................................. 214
codeine phos‐chlorpheniramine maleate tab er ... 209
codeine polist‐chlorphen polist er susp ................. 209
CODEINE SULF TAB ............................................... 206
codeine sulfate tab ............................................... 206
COLAZAL CAP ........................................................ 163
colchicine cap ........................................................ 149
colchicine oral soln ................................................ 149
colchicine tab ........................................................ 149
COLCIGEL GEL ....................................................... 155
COLCRYS TAB ........................................................ 149
colesevelam hcl packet for susp .............................. 83
colesevelam hcl tab ................................................ 83
COLESTID FLA GRA .................................................. 82
COLESTID GRA ......................................................... 82
COLESTID POW ....................................................... 82
COLESTID TAB ......................................................... 82
colestipol hcl granule packets ................................. 82
colestipol hcl granules ............................................ 82
colestipol hcl tab ..................................................... 82
collagenase oint .................................................... 138
Colocort ................................................................ 166
COMBIGAN SOL ...................................................... 81
COMBIPATCH DIS .................................................. 139
COMBIVENT AER ..................................................... 35
COMBIVIR TAB ........................................................ 68
COMETRIQ KIT ........................................................ 63
COMFORT EZ MIS ................................................. 183
COMPLERA TAB ...................................................... 68
COMPLETE NAT PAK DHA ..................................... 223
COMPLETENATE CHW ........................................... 219
Compro ................................................................. 214
COMTAN TAB ........................................................ 213
CO‐NATAL FA TAB ................................................. 219
CONCEPT DHA CAP ............................................... 219
CONCEPT OB CAP .................................................. 219
CONCERTA TAB ..................................................... 246
CONDYLOX GEL ..................................................... 169
CONFIRM/MICR TES GLUCOSE ............................. 111
conj est .................................................................. 139
conjugated estrogen‐medroxyprogest acetate tab .....
139
conjugated estrogens‐bazedoxifene tab .............. 140
CONSENSI TAB ........................................................ 86
CONTOUR TES BLD GLUC ...................................... 111
CONTOUR TES NEXT ............................................. 111
CONZIP CAP .......................................................... 206
COOL BLOOD TES GLUCOSE .................................. 111
281
copanlisib hcl for iv soln ........................................ 215
COPASIL GEL ......................................................... 235
COPAXONE INJ ...................................................... 178
COPIKTRA CAP ...................................................... 216
CORDRAN .............................................................. 100
CORDRAN CRE ...................................................... 100
CORDRAN LOT ...................................................... 100
CORDRAN OIN....................................................... 100
COREG CR CAP ........................................................ 37
COREG TAB ............................................................. 37
CORGARD TAB ........................................................ 80
CORLANOR SOL ..................................................... 240
CORLANOR TAB .................................................... 240
CORN SYP .............................................................. 210
corn syrup ............................................................. 210
CORTEF TAB .......................................................... 145
CORTENEMA ENE .................................................. 166
corticotropin inj gel ............................................... 103
CORTIFOAM AER ................................................... 166
CORTISPORIN CRE ................................................... 46
CORTISPORIN OIN ................................................... 46
CORTISPORIN SUS ‐TC OTIC .................................. 211
CORVITE ................................................................ 167
CORVITE FE TAB .................................................... 167
COSENTYX INJ ......................................................... 67
COSENTYX PEN INJ .................................................. 67
COSOPT PF SOL ....................................................... 81
COSOPT SOL ............................................................ 81
COTELLIC TAB .......................................................... 61
COTEMPLA TAB ..................................................... 246
COUMADIN TAB .................................................... 103
covid‐19 control test kit ........................................ 163
covid‐19 test kit .................................................... 163
COZAAR TAB ........................................................... 44
creatine monohydrate oral powder ...................... 176
CREON CAP ........................................................... 134
CRESEMBA CAP ..................................................... 255
CRESTOR TAB ........................................................ 154
CRINONE GEL ........................................................ 261
crisaborole oint ..................................................... 216
CRIXIVAN CAP ......................................................... 70
crizanlizumab‐tmca iv soln ................................... 236
crizotinib cap ........................................................... 64
crofelemer tab delayed release .............................. 51
cromolyn sodium oral conc ................................... 144
cross‐linked hyaluronate gel prefilled syringe ...... 264
crotamiton topical lot 10% ................................... 235
Crotan ................................................................... 235
Cryselle‐28 .............................................................. 94
CRYSVITA INJ ......................................................... 268
CUPRIMINE CAP ...................................................... 91
CURITY HYPER MIS ................................................ 267
CURITY NACL PAD ................................................. 267
CURITY PREP PAD ALCOHOL ................................... 75
CURITY SWABS PAD ALCOHOL ................................ 75
CUROSURF SUS ..................................................... 232
CUTAQUIG SOL ..................................................... 161
CUTIVATE LOT ....................................................... 100
CUVITRU INJ .......................................................... 161
CUVITRU SOL ........................................................ 161
CUVPOSA SOL ....................................................... 230
CVS ADVANCED TES GLUCOSE .............................. 111
CVS ASPIRIN TAB ................................................... 234
CVS GLUCOSE TES TEST STR .................................. 111
CVS KETONE TES CARE .......................................... 179
CVS NICOTINE DIS ................................................. 241
CVS NICOTINE GUM .............................................. 241
CVS NICOTINE LOZ ................................................ 241
CYANOCOBALAM SOL ............................................. 93
cyanocobalamin inj ................................................. 93
cyanocobalamin nasal spray .................................. 93
Cyclafem 1/35 ................................................. 94, 256
cyclobenzaprine hcl cap er ...................................... 89
cyclobenzaprine hcl tab .......................................... 90
CYCLOGYL SOL ...................................................... 104
CYCLOMYDRIL SOL OP .......................................... 103
cyclopentolate hcl ophth soln ............................... 104
cyclopentolate w/ phenylephrine ophth soln........ 103
cycloserine cap ........................................................ 60
CYCLOSET TAB....................................................... 137
cyclosporine (ophth) emulsion .............................. 202
cyclosporine (ophth) soln ...................................... 202
cyclosporine cap ................................................... 104
CYCLOSPORINE EMU ............................................. 202
cyclosporine iv soln ............................................... 104
cyclosporine modified cap .................................... 104
cyclosporine modified oral soln ............................ 104
cyclosporine oral soln ........................................... 104
CYMBALTA CAP ..................................................... 239
CYRAMZA INJ ........................................................ 262
Cyred ....................................................................... 94
Cyred Eq .................................................................. 94
CYSTADANE POW ................................................. 155
CYSTAGON CAP ..................................................... 104
CYSTARAN SOL ...................................................... 206
cysteamine bitartrate cap ..................................... 104
cysteamine bitartrate cap delayed release ........... 104
282
cysteamine bitartrate delayed release granules
packet ............................................................... 104
cysteamine hcl ophth soln .................................... 206
CYSTO‐CONRAY INJ II ............................................ 232
CYSTOGRAFIN INJ ................................................. 232
CYSTOGRAFIN‐ INJ DILUTE .................................... 232
CYSVIEW INJ .......................................................... 105
CYTOMEL TAB ....................................................... 252
CYTOTEC TAB ........................................................ 257
CYTOTINE POW ..................................................... 176
Cytra K Crystals ....................................................... 92
D
D.H.E. .................................................................... 174
dabigatran etexilate mesylate cap ....................... 251
dabrafenib mesylate cap ........................................ 60
DACOGEN INJ .......................................................... 59
dacomitinib tab ....................................................... 64
dalfampridine tab er ............................................. 179
DALIRESP TAB ....................................................... 236
danazol cap ............................................................. 42
DANTRIUM CAP .................................................... 136
dantrolene sodium cap ......................................... 136
dapagliflozin propanediol tab ............................... 244
dapagliflozin‐metformin hcl tab er ....................... 244
dapagliflozin‐saxagliptin tab ................................ 240
dapsone gel ............................................................. 30
dapsone tab .......................................................... 170
DAPTACEL INJ ....................................................... 254
DARAPRIM TAB ....................................................... 58
daratumumab iv soln .............................................. 61
darbepoetin alfa soln inj ....................................... 138
darifenacin hydrobromide tab er .......................... 259
darolutamide tab .................................................... 45
darunavir ethanolate susp ...................................... 70
darunavir ethanolate tab ........................................ 70
darunavir‐cobic‐emtricitab‐tenofov af tab ............. 69
darunavir‐cobicistat tab ......................................... 69
DARZALEX SOL ........................................................ 61
dasatinib tab ........................................................... 63
Dasetta 1/35 ................................................... 94, 256
DAURISMO TAB ...................................................... 61
DAYPRO TAB ......................................................... 196
DAYSEE TAB .......................................................... 141
DAYTRANA DIS ...................................................... 246
DAYVIGO TAB ........................................................ 211
D‐CARE BLOOD TES GLUCOSE ............................... 111
DDAVP SOL ........................................................... 262
DDAVP SPR ............................................................ 262
DDAVP TAB ........................................................... 262
DEBACTEROL SOL .................................................... 72
Deblitane .............................................................. 226
Decadron .............................................................. 145
decitabine for inj ..................................................... 59
deferasirox granules packet ................................... 51
deferasirox tab ........................................................ 51
deferasirox tab for oral susp ................................... 51
deferiprone oral soln ............................................... 51
deferiprone tab ....................................................... 51
deferoxamine mesylate for inj ................................ 51
deflazacort susp .................................................... 146
deflazacort tab ...................................................... 146
degarelix acetate for inj ........................................ 149
delafloxacin meglumine tab ................................. 143
DELSTRIGO TAB ....................................................... 68
DELUO SPR ............................................................ 266
Delyla ...................................................................... 94
DELZICOL CAP ....................................................... 163
DEMSER CAP ........................................................... 36
DENAVIR CRE .......................................................... 74
denosumab inj ...................................................... 232
denosumab inj soln prefilled syringe .................... 232
DEPAKOTE ER TAB ................................................ 261
DEPAKOTE SPR CAP .............................................. 261
DEPAKOTE TAB ..................................................... 261
DEPEN TITRA TAB.................................................... 91
DEPLIN .................................................................. 131
DEPO‐PROVERA INJ .............................................. 225
DEPO‐SQ PROV INJ ............................................... 225
DEPO‐TESTOST INJ .................................................. 42
DERMA‐SMOOTH OIL /FS BODY ........................... 100
DERMA‐SMOOTH OIL /FS SCLP ............................. 100
DERMOTIC OIL ...................................................... 211
DERMULCERA OIN ................................................ 265
DESCOVY TAB .......................................................... 68
DESFERAL INJ .......................................................... 51
desflurane inhal soln ............................................. 265
desipramine hcl tab .............................................. 256
desloratadine & pseudoephedrine tab er ............. 105
desloratadine tab .................................................... 56
desmopressin acetate nasal soln .......................... 262
desmopressin acetate nasal spray soln ................ 262
desmopressin acetate sublingual tab ................... 262
desmopressin acetate tab ..................................... 262
desogest‐eth estrad & eth estrad tab ............... 83, 94
desogest‐eth estrad & eth estrad tab 28 day ... 83, 94
desogest‐ethin est tab .................................. 256, 257
desogest‐ethin est tab pak ................................... 256
283
desogestrel & ethinyl estradiol tab ....... 83, 94, 95, 97
DESONATE GEL ..................................................... 100
desonide cream ............................................. 100, 102
desonide foam ...................................................... 102
desonide gel .......................................................... 100
DESOWEN CRE ...................................................... 100
desoximetasone cream ......................................... 102
desoximetasone gel .............................................. 102
desoximetasone oint ............................................. 102
desoximetasone spray .......................................... 102
DESOXYN TAB ......................................................... 39
DESVENLAFAX TAB ................................................ 239
desvenlafaxine succinate tab er .................... 239, 240
DETROL LA CAP ..................................................... 259
DETROL TAB .......................................................... 259
deutetrabenazine tab ........................................... 177
DEXABLISS TAB ..................................................... 145
DEXAMETHASON CON .......................................... 145
dexamethasone (ophth) insert.............................. 205
dexamethasone 6‐day .......................................... 146
dexamethasone conc ............................................ 145
dexamethasone intravitreal implant .................... 205
dexamethasone ophth susp .................. 203, 204, 205
dexamethasone sodium phosphate iontophoresis
soln ................................................................... 146
dexamethasone tab ...................................... 145, 146
dexamethasone tab therapy pack ................ 145, 146
DEXCOM G ............................................................ 147
DEXEDRINE CAP ...................................................... 39
DEXERYL CRE ......................................................... 175
DEXILANT CAP ....................................................... 228
dexlansoprazole cap delayed release ................... 228
dexmethylphenidate hcl cap er ............................. 247
dexmethylphenidate hcl tab ................................. 247
DEXONTO .............................................................. 146
DEXTENZA MIS ...................................................... 205
dextroamphetamine sulfate cap er ........................ 39
dextroamphetamine tab ................................... 39, 40
dextromethorphan hbr‐quinidine sulfate cap ....... 229
dha‐epa‐vit b ........................................................ 176
DIAB F.D.G. GEL .................................................... 267
DIAB GEL ............................................................... 267
DIACOMIT CAP ........................................................ 48
DIACOMIT PAK ........................................................ 48
diaphragm wide seal ............................................ 131
DIASCREEN ............................................................ 147
DIASCREEN MIS ..................................................... 147
DIASCREEN MIS CONTROL .................................... 147
DIASTAT ACDL GEL .................................................. 47
DIASTAT PED GEL .................................................... 47
DIASTIX TES STRIPS ............................................... 111
DIATHRIVE MIS TEST STR ...................................... 112
diatrizoate meglumine & sodium oral soln ........... 232
diatrizoate meglumine inj ..................................... 232
diatrizoate meglumine urethral soln .................... 232
DIATRUE PLUS TES STRIPS .................................... 112
diazepam nasal spray ............................................. 47
diazepam nasal spray ther pack ............................. 47
diazepam rectal gel delivery system ....................... 47
diazepam tab .......................................................... 78
diazoxide susp ....................................................... 105
DIBENZYLINE CAP.................................................... 36
dichlorphenamide tab ............................................. 88
DICLEGIS TAB .......................................................... 52
diclofenac cap ....................................................... 197
diclofenac epolamine patch .................................... 58
diclofenac potassium cap ..................................... 197
diclofenac potassium packet ................................ 174
diclofenac sodium gel ............................................. 58
diclofenac sodium soln............................................ 58
diclofenac w/ misoprostol tab delayed release .... 196
difenoxin w/ atropine tab ....................................... 66
DIFFERIN CRE .......................................................... 34
DIFFERIN GEL .......................................................... 34
DIFFERIN LOT .......................................................... 34
DIFICID TAB ........................................................... 142
diflorasone diacetate cream ................................. 102
diflorasone diacetate emollient base cream ........... 99
DIFLUCAN SUS ...................................................... 255
DIFLUCAN TAB ...................................................... 255
diflunisal tab ......................................................... 234
difluprednate ophth emulsion .............................. 205
Digitek ..................................................................... 88
Digox ....................................................................... 88
digoxin tab .............................................................. 88
dihydroergotamine mesylate inj ........................... 174
dihydroergotamine mesylate nasal spray ............ 174
DILANTIN CAP ....................................................... 158
DILANTIN CHW ..................................................... 158
DILANTIN‐125 SUS ................................................ 158
DILATRATE SR CAP ................................................ 193
DILAUDID LIQ ........................................................ 206
DILAUDID TAB ....................................................... 206
diltiazem hcl coated beads cap er ........................... 86
diltiazem hcl coated beads tab er ........................... 86
diltiazem hcl extended release beads cap er .......... 87
diltiazem hcl tab ..................................................... 86
diltiazem xt cap ................................................. 86, 87
284
dimethyl fumarate capsule delayed release ......... 179
dimethyl fumarate capsule dr starter pack .......... 179
dimethyl sulfoxide soln ......................................... 166
dinoprostone cervical gel ........................................ 28
dinoprostone vaginal inserts .................................. 28
dinoprostone vaginal suppos .................................. 28
DIOVAN HCT TAB .................................................... 43
DIOVAN TAB ........................................................... 44
DIP/TET PED INJ .................................................... 254
DIPENTUM CAP ..................................................... 163
diph, acellular pert & tet tox inj ............................ 254
diph‐ac per‐tet tox ad‐poliov‐haemoph b poly vac for
im susp ............................................................. 254
Diphen .................................................................... 56
diphenhydramine elx .............................................. 56
diphenoxylate w/ atropine tab ............................... 66
diph‐tetanus tox ad‐acell pert & polio virus, ipv vac
inj .............................................................. 254, 255
diph‐tetanus tox‐acell pert‐hepatitis b‐polio ipv vac
inj ...................................................................... 254
diphtheria‐tetanus tox adsorbed (dt) im inj .......... 254
DIPROLENE AF CRE ............................................... 100
DIPROLENE OIN .................................................... 100
dipyridamole tab ................................................... 216
diroximel fumarate capsule delayed release ........ 179
disopyramide phosphate cap .................................. 46
disulfiram tab .......................................................... 36
DITROPAN XL TAB ................................................. 259
DIURIL SUS ............................................................ 250
divalproex sodium cap delayed release sprinkle ... 261
divalproex sodium tab delayed release ................ 261
divalproex sodium tab er ...................................... 261
DIVIGEL GEL .......................................................... 140
dofetilide cap .......................................................... 46
dolasetron mesylate tab ......................................... 28
DOLOPHINE TAB ................................................... 206
dolutegravir sodium tab ......................................... 69
dolutegravir sodium tab for oral susp .................... 69
dolutegravir sodium‐lamivudine tab ...................... 68
dolutegravir sodium‐rilpivirine hcl tab .................... 68
donepezil hydrochloride tab ................................... 92
DOPTELET TAB ...................................................... 251
DORAL TAB ............................................................. 78
doravirine tab ......................................................... 70
doravirine‐lamivudine‐tenofovir df tab .................. 68
dornase alfa inhal soln .......................................... 159
DORYX MPC TAB ................................................... 249
DORYX TAB ........................................................... 249
dorzolamide hcl ophth soln ............................. 37, 201
dorzolamide hcl‐timolol maleate ophth sol ............ 81
dorzolamide hcl‐timolol maleate ophth soln .......... 81
DORZOLAMIDE SOL .............................................. 201
DOVATO TAB .......................................................... 68
DOVONEX CRE ........................................................ 67
doxazosin mesylate tab .................................... 36, 45
doxazosin mesylate tab er ...................................... 36
doxepin hcl (sleep) tab .......................................... 159
doxepin hcl cap ..................................................... 256
doxepin hcl cream ................................................... 67
doxycycline tab .................................................... 249
doxycycline (rosacea) cap delayed release ........... 233
doxycycline calcium syrup ..................................... 250
doxycycline cap ............................................. 233, 250
doxycycline hyclate cap ........................................ 250
doxycycline hyclate tab ................................. 249, 250
doxycycline hyclate tab delayed release ............... 249
doxycycline monohydrate for susp ....................... 250
doxylamine‐pyridoxine tab delayed release ........... 52
doxylamine‐pyridoxine tab er ................................. 52
DRCAPS CLEAR CAP SIZE ....................................... 145
DRISDOL CAP ........................................................ 265
DRITHO‐CREME CRE HP .......................................... 67
DRIZALMA CAP ..................................................... 239
dronabinol cap ........................................................ 52
dronabinol soln ....................................................... 52
dronedarone hcl tab ............................................... 46
DROPLET MICR MIS .............................................. 183
drospirenone tab .................................................. 226
drospirenone‐estradiol tab ................................... 139
drospirenone‐ethinyl estradiol tab . 94, 95, 96, 97, 98
drospirenone‐ethinyl estrad‐levomefolate tab 94, 95,
97, 98
DROXIA CAP .......................................................... 105
droxidopa cap ....................................................... 192
DRYSOL SOL .......................................................... 177
DUAKLIR AER .......................................................... 35
DUAVEE TAB ......................................................... 140
DUET DHA ............................................................. 219
DUET DHA MIS BALANCED ................................... 219
DUETACT TAB ....................................................... 249
DUEXIS TAB ........................................................... 196
dulaglutide soln pen‐injector ................................ 163
DULERA AER ............................................................ 35
duloxetine hcl cap delayed release sprinkle .......... 239
duloxetine hcl enteric coated pellets cap .............. 239
DUOBRII LOT ......................................................... 254
DUO‐CARE TES ...................................................... 112
DUOPA SUS ........................................................... 170
285
dupilumab subcutaneous soln prefilled syringe ...... 76
DUPIXENT INJ .......................................................... 76
DURAGESIC DIS ..................................................... 206
Duraxin ................................................................... 40
duraxin cap ............................................................. 40
DUREZOL EMU ...................................................... 205
DURLAZA CAP ....................................................... 216
DUROLANE INJ ...................................................... 264
durvalumab soln for iv infusion .............................. 61
dutasteride cap ....................................................... 28
dutasteride‐tamsulosin hcl cap ............................. 227
DUTOPROL TAB ....................................................... 79
duvelisib cap ......................................................... 216
Dvorah .................................................................. 135
DXEVO ................................................................... 146
D‐XYLOSE POW ..................................................... 105
d‐xylose powder .................................................... 105
DYANAVEL XR SUS .................................................. 40
DYAZIDE CAP ......................................................... 136
DYMISTA SPR .......................................................... 57
DYRENIUM CAP ..................................................... 218
DYSPORT INJ ......................................................... 193
E
E.E.S. ..................................................................... 138
E.e.s. 400 ............................................................... 138
E.E.S. GRAN SUS .................................................... 138
EASY COMFORT MIS ............................................. 183
EASY COMFORT PAD ALCOHOL .............................. 75
EASY PLUS II TES BLD GLUC ................................... 112
EASY STEP TES ....................................................... 112
EASY TALK TES BLD GLUC ...................................... 112
EASY TOUCH MIS .................................................. 184
EASY TOUCH TES GLUCOSE ................................... 112
EASY TOUCH TES STRIPS ....................................... 113
EASY TRAK II TES BLD GLUC .................................. 113
EASY TRAK TES BLD GLUC ..................................... 113
EASYGLUCO TES .................................................... 113
EASYGLUCO TES PLUS ........................................... 113
EASYMAX .............................................................. 113
EASYMAX TES ........................................................ 113
EASYPRO PLUS TES ................................................ 114
EASYPRO TES BLD GLUC ........................................ 114
ecallantide inj ....................................................... 216
echothiophate iodide ophth for soln ..................... 174
EC‐NAPROSYN TAB ............................................... 196
EC‐NAPROXEN TAB ............................................... 196
ECONASIL KIT .......................................................... 53
econazole nitrate foam ......................................... 160
ECOTRIN LOW TAB ................................................ 234
ECOZA AER ............................................................ 160
eculizumab iv soln ................................................... 98
ECZEMOL TAB ....................................................... 155
edaravone inj .......................................................... 38
EDARBI TAB ............................................................. 44
EDARBYCLOR TAB ................................................... 43
EDECRIN TAB......................................................... 172
EDLUAR SUB ......................................................... 195
edoxaban tosylate tab .......................................... 136
EDURANT TAB ......................................................... 70
efavirenz cap ........................................................... 70
efavirenz tab ........................................................... 70
efavirenz‐emtricitabine‐tenofovir df tab ................ 68
efavirenz‐lamivudine‐tenofovir df tab .................... 69
Effer‐k ................................................................... 217
EFFER‐K TAB .......................................................... 218
EFFEXOR XR CAP ................................................... 239
EFFIENT TAB .......................................................... 251
efinaconazole soln ................................................ 160
EFUDEX CRE ............................................................ 64
EGRIFTA SOL ......................................................... 150
EGRIFTA SV INJ ...................................................... 150
elagolix sodium tab ............................................... 149
elagolix‐estrad‐noreth .......................................... 139
ELAPRASE INJ ........................................................ 178
elbasvir‐grazoprevir tab ........................................ 153
ELELYSO INJ ............................................................. 36
ELEMENT TES ........................................................ 114
ELEMNT COMPA TES STRIPS ................................. 114
ELESTRIN GEL ........................................................ 140
ELETONE CRE ........................................................ 175
eletriptan hydrobromide tab ................................ 237
elexacaf‐tezacaf‐ivacaf ......................................... 104
ELFOLATE PLU TAB ................................................ 131
ELFOLATE TAB ....................................................... 134
ELIDEL CRE ............................................................ 173
ELIGARD INJ .......................................................... 171
eliglustat tartrate cap ............................................. 36
ELIMITE CRE .......................................................... 235
Elinest ..................................................................... 95
ELIQUIS ST P TAB .................................................. 135
ELIQUIS TAB .......................................................... 136
Elite‐ob ................................................................. 219
ELIXOPHYLLIN ELX ................................................. 268
ELLA TAB ............................................................... 137
ELMIRON CAP ....................................................... 166
ELOCTATE INJ .......................................................... 54
elosulfase alfa soln for iv infusion ......................... 178
286
elotuzumab for iv soln ............................................ 61
eltrombopag olamine powder pack for susp ........ 251
eltrombopag olamine tab ..................................... 252
ELURYNG MIS.......................................................... 98
eluxadoline tab ..................................................... 159
elvitegrav‐cobic‐emtricitab‐tenofov af tab ............. 68
elvitegrav‐cobic‐emtricitab‐tenofovdf tab .............. 69
EMBRACE EVO TES ................................................ 114
EMBRACE PRO TES ................................................ 114
EMBRACE TALK TES STRIPS ................................... 114
EMBRACE TES BLD GLUC ...................................... 115
EMCYT CAP ........................................................... 140
EMEND CAP .......................................................... 248
EMEND SOL ........................................................... 248
EMEND SUS ........................................................... 248
EMEND TRIPAC PAK .............................................. 248
EMFLAZA SUS ........................................................ 146
EMFLAZA TAB ....................................................... 146
EMGALITY INJ .......................................................... 91
emicizumab‐kxwh subcutaneous soln .................... 56
EMOQUETTE TAB .................................................... 95
empagliflozin tab .................................................. 244
empagliflozin‐linaglip‐metformin tab er ............... 240
empagliflozin‐linagliptin tab ................................. 240
empagliflozin‐metformin hcl tab .......................... 244
empagliflozin‐metformin hcl tab er ...................... 244
EMPLICITI INJ .......................................................... 61
EMPTY CAPSUL CAP SIZE .............................. 145, 194
EMSAM DIS ........................................................... 177
emtricitabine caps .................................................. 71
emtricitabine soln ................................................... 71
emtricitabine‐rilpivirine‐tenofovir af tab ................ 69
emtricitabine‐rilpivirine‐tenofovir df tab ................ 68
emtricitabine‐tenofovir alafenamide fumarate tab 68
emtricitabine‐tenofovir disoproxil fumarate tab .... 69
EMTRIVA CAP .......................................................... 71
EMTRIVA SOL .......................................................... 71
EMULSION SB EMU ............................................... 175
EMVERM CHW ........................................................ 44
ENABLEX TAB ........................................................ 259
enalapril maleate & hydrochlorothiazide tab ......... 30
enalapril maleate oral soln ..................................... 29
enalapril maleate tab ............................................. 29
enasidenib mesylate tab ....................................... 169
ENBRACE HR CAP .................................................. 219
ENBREL INJ ............................................................ 244
ENBREL MINI INJ ................................................... 244
ENBREL SRCLK INJ ................................................. 244
encorafenib cap ...................................................... 60
ENDARI POW .......................................................... 38
Endocet ................................................................. 209
ENDOMETRIN SUP ................................................ 261
enfortumab vedotin‐ejfv for iv soln ........................ 64
enfuvirtide for inj .................................................... 69
ENGERIX‐B INJ ............................................... 262, 263
ENHERTU INJ ........................................................... 64
ENLITE GLUCO MIS SENSOR .................................. 147
ENLYTE CAP ........................................................... 132
Enpresse‐28 .......................................................... 256
Enskyce ................................................................... 95
ENSTILAR AER ....................................................... 254
entacapone tab ............................................. 171, 213
entecavir oral soln ................................................ 152
entecavir tab ......................................................... 152
ENTERAGAM POW ................................................ 134
ENTEREG CAP ........................................................ 213
ENTERO VU SUS .................................................... 231
ENTOCORT EC CAP ................................................ 146
entrectinib cap ........................................................ 63
ENTRESTO TAB ...................................................... 192
ENTTY EMU SPRAY ................................................ 175
ENTYVIO INJ .......................................................... 165
Enulose ................................................................. 166
ENVARSUS XR TAB ................................................ 173
ENZADYNE CAP ..................................................... 134
enzalutamide cap ................................................... 45
EPANED SOL ............................................................ 29
EPCLUSA TAB ........................................................ 153
EPICERAM EMU .................................................... 175
EPICYN SPR ........................................................... 240
EPIDIOLEX SOL ........................................................ 48
EPIDUO FORTE GEL ................................................. 31
EPIDUO GEL ............................................................ 31
EPIFOAM AER ........................................................ 246
EPINEPHR PRO KIT .................................................. 41
epinephrine hcl nasal soln .................................... 254
epinephrine inj ........................................................ 41
EPINEPHRINE KIT .................................................... 41
epinephrine soln prefilled syringe ........................... 41
epinephrine solution auto‐injector ......................... 41
EPINPHEPHRIN KIT SNAP‐V ..................................... 41
EPIPEN .................................................................... 41
EPIPEN‐JR INJ .......................................................... 41
EPISNAP KIT ............................................................ 41
EPIVIR HBV SOL ..................................................... 153
EPIVIR HBV TAB .................................................... 153
EPIVIR SOL ............................................................... 71
EPIVIR TAB .............................................................. 71
287
eplerenone tab ...................................................... 236
epoetin alfa inj .............................................. 138, 139
epoetin alfa‐epbx inj ............................................. 139
EPOGEN INJ ........................................................... 138
epoprostenol sodium for inj .................................. 227
eptinezumab‐jjmr iv soln ........................................ 91
EPZICOM TAB .......................................................... 68
EQ CHILD ASA CHW .............................................. 234
EQ NICOTINE DIS ................................................... 241
EQ NICOTINE GUM ............................................... 241
EQ NICOTINE LOZ .................................................. 241
EQL ASPIRIN CHW ................................................. 234
EQL NICOTINE GUM .............................................. 241
EQL NICOTINE LOZ ................................................ 241
EQUACARE JR POW CHOCO .................................. 198
EQUACARE JR POW UNFLAVOR ............................ 198
EQUACARE JR POW VANILLA ................................ 198
EQUETRO CAP ......................................................... 68
ERBITUX INJ ............................................................ 61
erdafitinib tab ......................................................... 60
erenumab‐aooe subcutaneous soln auto‐injector .. 91
ERGOCAL CAP ....................................................... 265
ergocalciferol cap ................................................. 265
ERGOMAR SUB ..................................................... 174
ergotamine tartrate sl tab .................................... 174
ergotamine w/ caffeine tab .................................. 138
eribulin mesylate inj .............................................. 177
ERIVEDGE CAP ........................................................ 61
ERLEADA TAB .......................................................... 45
erlotinib hcl tab ....................................................... 63
Errin ...................................................................... 226
ERTACZO CRE ........................................................ 160
ertugliflozin l‐pyroglutamic acid tab ..................... 244
ertugliflozin‐metformin hcl tab ............................. 244
ertugliflozin‐sitagliptin tab ................................... 240
ERWINAZE INJ ......................................................... 65
Ery ................................................................... 30, 138
ERYGEL GEL ............................................................. 30
ERYPED SUS .......................................................... 138
Ery‐tab .................................................................. 138
Erythrocin Stearate ............................................... 138
erythromycin ethylsuccinate tab ........................ 138
erythromycin ethylsuccinate for susp ................... 138
erythromycin gel ............................................... 30, 31
erythromycin pad ................................................... 30
erythromycin stearate tab .................................... 138
erythromycin tab .................................................. 138
ESBRIET CAP .......................................................... 229
ESBRIET TAB .......................................................... 229
escitalopram oxalate tab ...................................... 238
ESGIC TAB ............................................................... 41
ESKATA SOL ........................................................... 236
esketamine hcl nasal soln ..................................... 194
eslicarbazepine acetate tab .................................... 47
ESOMEPRAZOLE CAP ............................................ 228
esomeprazole magnesium cap delayed release ... 228
esomeprazole magnesium for delayed release susp
pack .................................................................. 228
esomeprazole magnesium for delayed release susp
packet ............................................................... 228
esomeprazole sodium for intravenous soln .......... 228
esomeprazole strontium cap delayed release ...... 228
ESPEROCT INJ .......................................................... 54
ESSENTIAL POW CARE JR ...................................... 198
ESSENTRA MIS ...................................................... 240
Estarylla .................................................................. 95
estazolam tab ......................................................... 78
esterified estrogens tab ........................................ 140
ESTRACE TAB ........................................................ 140
ESTRACE VAG CRE ................................................. 260
estradiol & norethindrone acetate tab ................. 139
estradiol acetate vaginal ring ............................... 261
estradiol gel .......................................................... 140
estradiol tab 83, 93, 94, 95, 96, 97, 98, 139, 140, 141,
260
estradiol td gel ...................................................... 140
estradiol td patch twice weekly .................... 139, 140
estradiol td patch weekly ...................................... 140
estradiol transdermal spray .................................. 140
estradiol vaginal cream ........................................ 260
estradiol vaginal insert ......................................... 261
estradiol vaginal insert starter pack ..................... 261
estradiol vaginal ring ............................................ 260
estradiol vaginal tab ............................................. 261
estradiol valerate‐dienogest tab .......................... 143
estradiol/norethindrone acetate tab.................... 139
estradiol‐levonorgestrel td patch weekly ............. 139
estradiol‐norethindrone ace td pttw .................... 139
estradiol‐progesterone cap ................................... 139
estramustine phosphate sodium cap .................... 140
ESTRING MIS ......................................................... 260
ESTROGEL GEL ...................................................... 140
estrogen/progestin tab ......................................... 139
estrogens, conjugated tab .................................... 140
estrogens, conjugated vaginal cream ................... 261
ESTROSTEP FE TAB ................................................ 256
eszopiclone tab ..................................................... 195
etanercept for subcutaneous inj ........................... 244
288
etanercept subcutaneous solution auto‐injector .. 244
etanercept subcutaneous solution cartridge ........ 244
etelcalcetide hcl iv solution ..................................... 85
eteplirsen iv soln ................................................... 180
ethacrynic acid tab ............................................... 172
ethambutol hcl tab ................................................. 60
ethinyl estradiol /norethindrone acetate tab ....... 139
ethionamide tab ..................................................... 60
ethosuximide cap .................................................. 248
ethosuximide soln ................................................. 248
ethotoin tab .......................................................... 158
ETHYL CHLOR AER FN STRM ................................. 253
ETHYL CHLOR AER MED STRM .............................. 253
ethyl chloride aerosol spray .................................. 253
ethynodiol diacetate & ethinyl estradiol .......... 95, 98
ethynodiol diacetate & ethinyl estradiol tab .......... 95
etodolac cap ......................................................... 196
etodolac tab .................................................. 196, 197
etonogestrel subdermal implant .......................... 225
etonogestrel‐ethinyl estradiol va ring ..................... 98
etoposide cap ........................................................ 177
etravirine tab .......................................................... 70
EUCRISA OIN ......................................................... 216
EUFLEXXA INJ ........................................................ 264
Euthyrox................................................................ 252
EVAMIST SPR ........................................................ 140
EVEKEO ODT TAB .................................................... 40
EVEKEO TAB ............................................................ 40
EVENCARE + TES BLD GLUC .................................. 115
EVENCARE G ......................................................... 115
EVENCARE TES BLD GLUC ..................................... 115
EVENCARE TES MINI ............................................. 115
EVENCARE TES PROVIEW ...................................... 115
EVENITY INJ ........................................................... 236
everolimus tab ................................................ 62, 173
everolimus tab for oral susp ................................... 62
EVERSENSE MIS SENSOR ....................................... 147
EVERSENSE MIS TRANSMTR ................................. 147
EVISTA TAB ........................................................... 236
EVOCLIN AER .......................................................... 30
evolocumab subcutaneous soln auto‐injector ...... 213
evolocumab subcutaneous soln cartridge/infusor 213
evolocumab subcutaneous soln prefilled syringe . 213
EVOLUTION TES AUTOCODE ................................. 115
EVOTAZ TAB ............................................................ 68
EVOXAC CAP ......................................................... 235
EVZIO INJ ............................................................... 208
EXACTECH TES ...................................................... 116
EXACTECH TES R‐S‐G ............................................. 116
EXELDERM CRE ..................................................... 160
EXELDERM SOL ..................................................... 160
EXELON DIS ............................................................. 92
exemestane tab ...................................................... 75
exenatide extended release for susp pen‐injector 163
exenatide extended release susp auto‐injector .... 163
exenatide soln pen‐injector .................................. 163
EXFORGE TAB .......................................................... 43
EXFORGEH/10‐ TAB ................................................ 44
EXFORGEH/5‐ TAB .................................................. 44
EXJADE TAB ............................................................. 51
EXODERM LOT ........................................................ 53
EXONDYS ............................................................... 180
EXTAVIA INJ .......................................................... 179
EXTINA AER ........................................................... 160
EYLEA INJ .............................................................. 261
EZ SMART PLS TES BLD GLUC ................................ 116
EZ SMART TES BLD GLUC ...................................... 116
EZALLOR SPR CAP ................................................. 154
E‐Z‐DISK TAB ......................................................... 231
ezetimibe tab .................................................. 30, 166
ezetimibe‐simvastatin tab .................................... 166
E‐Z‐HD SUS ............................................................ 231
E‐Z‐PAQUE SUS ..................................................... 231
E‐Z‐PASTE CRE ....................................................... 231
F
FA‐8 CAP ............................................................... 143
FA‐8 TAB ............................................................... 143
FABIOR AER ............................................................. 34
FABRAZYME INJ .................................................... 141
factor ix complex for inj .......................................... 55
FALESSA KIT ............................................................ 95
Falmina ................................................................... 95
famciclovir tab ...................................................... 154
famotidine tab .............................................. 151, 196
fam‐trastuzumab deruxtecan‐nxki for iv soln ......... 64
FANAPT PAK ............................................................ 77
FANAPT TAB ............................................................ 77
FARESTON TAB ....................................................... 52
FARXIGA TAB......................................................... 244
FARYDAK CAP .......................................................... 61
FASENRA INJ ......................................................... 165
FASENRA PEN INJ .................................................. 165
favipiravir tab ....................................................... 174
Fayosim ................................................................. 141
fe fumarate‐vit c‐vit b ........................................... 167
febuxostat tab ...................................................... 149
fedratinib hcl cap .................................................. 169
289
FEIBA INJ ................................................................. 54
felbamate susp ....................................................... 88
felbamate tab ......................................................... 88
FELBATOL SUS ......................................................... 88
FELBATOL TAB ......................................................... 88
FELDENE CAP ........................................................ 196
FEMARA TAB ........................................................... 75
FEMCAP MIS ........................................................... 91
FEMHRT TAB ......................................................... 139
FEMRING MIS ....................................................... 261
Femynor .................................................................. 95
fenofibrate cap ............................................. 141, 142
fenofibrate micronized cap ................................... 141
fenofibrate tab .............................................. 141, 142
fenofibric acid tab ................................................. 141
FENOFIBRIC TAB ................................................... 141
FENOGLIDE TAB .................................................... 141
fenoprofen calcium cap ................................ 196, 197
fenoprofen calcium tab ......................................... 197
FENOPROFEN CAP ................................................ 196
FENORTHO CAP .................................................... 196
fentanyl citrate buccal tab .................................... 207
fentanyl citrate lozenge on a handle .................... 206
fentanyl citrate nasal spray .................................. 207
fentanyl citrate sl tab ............................................ 206
fentanyl sublingual spray ...................................... 208
fentanyl td patch .................................................. 206
FENTORA TAB ....................................................... 207
FERIVAFA CAP ....................................................... 167
ferric citrate tab .................................................... 215
ferric pyrophosphate citrate pack ......................... 167
ferric pyrophosphate citrate soln .......................... 167
FERRIPROX SOL ....................................................... 51
FERRIPROX TAB ....................................................... 51
FERRO‐PLEX TAB ................................................... 167
FERROTRIN CAP .................................................... 167
fesoterodine fumarate tab er ............................... 259
FETZIMA CAP ........................................................ 240
FETZIMA CAP TITRATIO ......................................... 240
FEXMID TAB ............................................................ 90
FIASP FLEX INJ TOUCH .......................................... 155
FIASP INJ ............................................................... 155
FIASP PENFIL INJ U‐ ............................................... 156
FIBERSOUR HN LIQ ................................................ 198
FIBRICOR TAB ........................................................ 141
fidaxomicin tab ..................................................... 142
FIFTY50 GLUC TES ................................................. 116
FIFTY50 MIS .......................................................... 184
FIFTY50 PEN MIS ................................................... 184
FIFTY50 PREP PAD PADS ......................................... 75
filgrastim inj .......................................................... 150
filgrastim‐aafi inj .................................................. 150
filgrastim‐sndz soln prefilled syringe .................... 150
FINACEA AER ......................................................... 233
FINACEA GEL ......................................................... 233
finasteride tab ........................................................ 28
fingolimod hcl cap ................................................. 245
FIORICET CAP .................................................... 41, 93
FIORICET CAP CODEINE .......................................... 93
FIORINAL CAP ......................................................... 41
FIORINAL/COD CAP ................................................. 93
FIRAZYR INJ ............................................................. 84
FIRDAPSE TAB ......................................................... 59
FIRMAGON INJ ...................................................... 149
FIRVANQ SOL ........................................................ 148
Flac ........................................................................ 211
FLAGYL CAP ............................................................. 57
FLAGYL TAB ............................................................. 57
FLAREX SUS ........................................................... 205
flavocoxid cap ....................................................... 134
flavocoxid‐citrated zinc bisglycinate cap .............. 132
FLAVOR BLEND SUS .............................................. 210
FLAVOR PLUS LIQ .................................................. 210
FLAVOR SWEET SYP .............................................. 210
FLAVOR SWEET SYP S/F ........................................ 210
flaxseed oil (linseed oil) ......................................... 142
FLEBOGAMMA INJ ................................................ 161
FLEBOGAMMA INJ DIF .......................................... 161
FLECTOR DIS............................................................ 58
flibanserin tab ....................................................... 239
FLOLAN INJ ............................................................ 227
FLOLIPID SUS ......................................................... 154
FLOMAX CAP ........................................................... 36
FLORIVA DRO ........................................................ 143
FLOVENT DISK AER ................................................ 246
FLOVENT HFA AER ................................................ 246
FLUAD INJ ............................................................. 263
FLUARIX QUAD INJ ................................................ 263
FLUBLOK QUAD INJ ............................................... 263
FLUCLVX QUAD INJ ............................................... 263
fluconazole for susp .............................................. 255
fluconazole tab ..................................................... 255
flucytosine cap ........................................................ 52
FLULAVAL QUA INJ ................................................ 263
fluocinolone acetonide (otic) oil............................ 211
fluocinolone acetonide cream......................... 46, 102
fluocinolone acetonide intravitreal implant . 205, 206
fluocinolone acetonide oil ............................. 100, 211
290
fluocinolone acetonide oint .................................. 102
fluocinolone acetonide shampoo ............................ 99
fluocinolone acetonide soln .................................. 102
fluocinonide cream ....................................... 102, 254
fluocinonide gel .................................................... 101
FLUOPAR KIT ......................................................... 254
FLUORABON DRO ................................................. 142
fluorescein sodium ophth strips ............................ 202
fluorexon‐benoxinate ophth soln .......................... 202
FLUORITAB CHW ................................................... 142
FLUORITAB DRO .................................................... 142
fluorometholone acetate ophth susp.................... 205
fluorometholone ophth oint ................................. 205
fluorometholone ophth susp ................................. 205
FLUOROPLEX CRE .................................................... 65
fluorouracil cream ............................................ 64, 65
fluoxetine hcl (pmdd) tab .............................. 218, 238
fluoxetine hcl cap .................................................. 238
FLUOXETINE TAB ................................................... 238
FLURA‐DROPS DRO ............................................... 142
flurandrenolide cream .......................................... 100
flurandrenolide lotion ........................................... 100
flurandrenolide oint .............................................. 100
flurandrenolide tape ............................................. 100
Flurandrenolide topical cre................................... 102
FLURA‐SAFE SOL ................................................... 202
flurbiprofen tab ..................................................... 196
flutamide cap .......................................................... 45
fluticasone furoate aerosol powder breath activ.. 245
fluticasone furoate‐vilanterol aero powd ba .......... 35
fluticasone propionate aer pow ba ....................... 246
fluticasone propionate hfa inhal aer .................... 246
fluticasone propionate lotion ................................ 100
fluticasone propionate nasal exhaler susp ........... 181
fluticasone‐salmeterol aer powder ba .................... 35
fluticasone‐salmeterol inhal aerosol....................... 35
fluticasone‐umeclidinium‐vilanterol aepb .............. 35
fluvastatin sodium cap .......................................... 154
fluvastatin sodium tab er ...................................... 154
FLUZONE HD INJ PF ............................................... 263
FLUZONE QUAD INJ .............................................. 263
FML FORTE SUS ..................................................... 205
FML LIQUIFLM SUS ............................................... 205
FML OIN ................................................................ 205
FOCALIN TAB ......................................................... 247
FOCALIN XR CAP ................................................... 247
FOLATE TAB .......................................................... 143
FOLBIC RF TAB ...................................................... 132
folic acid cap ................................................... 51, 143
folic acid inj ........................................................... 143
folic acid tab ................................................. 143, 173
FOLIVANE‐F CAP ................................................... 168
FOLIVANE‐OB CAP ................................................ 219
FOLIVANE‐PLS CAP ................................................ 167
FOLLISTIM AQ INJ ................................................. 212
follitropin alfa for inj ............................................. 212
follitropin alfa for subcutaneous inj ...................... 212
follitropin beta inj ................................................. 212
FOLOTYN INJ ........................................................... 59
FOLTANX RF CAP ................................................... 132
FOLTANX TAB ........................................................ 132
FOLTX TAB ............................................................. 132
FOLVITE‐FE TAB .................................................... 167
FORA BLOOD TES GLUCOSE .................................. 116
FORA D .................................................................. 116
FORA G .................................................................. 117
FORA GD ............................................................... 117
FORA GTEL TES BLD GLUC ..................................... 117
FORA GTEL TES KETONE ........................................ 117
FORA TN'G TES TN'G VOI ...................................... 117
FORA V .................................................................. 117
FORACARE TES GD ................................................ 117
FORACARE TES PREM V ........................................ 117
FORACARE TES TST N GO ...................................... 118
FORANE SOL .......................................................... 265
FORFIVO XL TAB ...................................................... 50
FORMALDEHYDE SOL .............................................. 72
formaldehyde solution ............................................ 72
formoterol fumarate soln nebu .............................. 79
FORTAMET TAB ....................................................... 82
FORTEO SOL .......................................................... 212
FORTESTA GEL ........................................................ 42
FORTISCARE TES BLD GLUC ................................... 118
FOSAMAX + D TAB .................................................. 83
FOSAMAX TAB ........................................................ 83
fosamprenavir calcium susp ................................... 70
fosamprenavir calcium tab ..................................... 70
fosaprepitant dimeglumine for iv infusion ............ 248
fosfomycin tromethamine powd pack .................. 258
FOSRENOL CHW .................................................... 215
FOSRENOL POW .................................................... 215
fostamatinib disodium tab.................................... 245
FOSTEUM CAP ...................................................... 132
FOSTEUM PLUS CAP.............................................. 132
FOVEX CAP ............................................................ 132
FREESTY LIBR KIT ................................................... 147
FREESTY LIBR MIS ................................................. 147
FREESTYLE KIT SENSOR ......................................... 147
291
FREESTYLE MIS READER ........................................ 147
FREESTYLE TES ...................................................... 118
FREESTYLE TES INSULINX ...................................... 118
FREESTYLE TES LITE ............................................... 118
FREESTYLE TES PREC NEO ..................................... 118
fremanezumab‐vfrm subcutaneous soln auto‐inj ... 91
FROVA TAB............................................................ 237
frovatriptan succinate tab .................................... 237
FUL‐GLO TES ......................................................... 202
FULPHILA INJ ......................................................... 149
FUNGIMEZ SOL ....................................................... 53
furosemide tab ...................................................... 172
FUSION PAK SPRINKLE .......................................... 168
FUSION PLUS CAP ................................................. 167
FUZEON INJ ............................................................. 69
Fyavolv .................................................................. 139
FYCOMPA SUS ......................................................... 39
FYCOMPA TAB ........................................................ 39
G
G4 PLAT PED MIS RVC/SHAR ................................ 147
G4 PLATINUM MIS PEDIATRC ............................... 148
G4 PLATINUM MIS RCV/SHAR .............................. 148
G4 PLATINUM MIS RECEIVER ................................ 148
G4 PLATINUM MIS TRANSMIT .............................. 148
G4 SENSOR MIS .................................................... 148
G5/G4 MIS SENSOR .............................................. 148
GABADONE CAP .................................................... 132
gabapentin (once‐daily) tab ................................. 217
gabapentin (once‐daily) tab pack ......................... 217
gabapentin cap ......................................... 48, 49, 217
gabapentin enacarbil tab er ................................. 233
gabapentin oral soln ............................................... 49
gabapentin tab ................................................. 48, 49
GABITRIL TAB ........................................................ 144
GALAFOLD CAP ..................................................... 141
galantamine hydrobromide cap er ......................... 92
galantamine hydrobromide tab .............................. 92
GALAXTRA POW .................................................... 134
galcanezumab‐gnlm subcutaneous soln auto‐injector
91
galsulfase soln for iv infusion ................................ 178
GALZIN CAP ........................................................... 268
GAMASTAN INJ ..................................................... 161
GAMASTAN S/D INJ .............................................. 161
GAMMAGARD INJ ................................................. 161
GAMMAGARD SD INJ ............................................ 161
GAMMAKED INJ .................................................... 161
GAMMAPLEX INJ ................................................... 162
GAMUNEX‐C INJ .................................................... 162
ganciclovir ophth gel ............................................ 201
GANIRELIX AC INJ .................................................. 149
ganirelix acetate soln prefilled syringe ................. 149
GARDASIL .............................................................. 263
GASTROCROM CON .............................................. 144
GASTROGRAFIN SOL ............................................. 232
gatifloxacin ophth soln ......................................... 201
GATTEX KIT ........................................................... 145
Gavilyte‐c ................................................................ 84
Gavilyte‐h................................................................ 84
Gavilyte‐n/flavor Pack ............................................ 84
GAZYVA INJ ............................................................. 61
GE100 BLOOD TES GLUCOSE ................................ 118
GEBAUERS SPR AER /STRETCH .............................. 254
gefitinib tab ............................................................ 63
gelatin adsorbable ophth film .............................. 206
GELCLAIR GEL ........................................................ 227
GELFILM MIS OP ................................................... 206
GEL‐FLOW KIT ....................................................... 152
GELFOAM‐JMI KIT POWDER ................................. 152
GELFOAM‐JMI KIT SPONGE................................... 152
GELNIQUE GEL ...................................................... 259
GEL‐ONE INJ .......................................................... 264
GELSYN‐3 INJ ......................................................... 264
gemfibrozil tab .............................................. 141, 142
gemtuzumab ozogamicin for iv soln ....................... 64
GENADUR LIQ ....................................................... 175
GENERESS FE CHW .................................................. 95
Generlac ................................................................ 166
GENOTROPIN INJ .................................................. 150
gentamicin‐prednisolone ace ophth oint .............. 204
gentamicin‐prednisolone ace ophth susp ............. 204
GENULTIMATE TES ................................................ 119
GENVISC ................................................................ 264
GENVOYA TAB ......................................................... 68
GEODON CAP .......................................................... 68
GHT TEST TES STRIPS ............................................ 119
Gianvi ...................................................................... 95
GILENYA CAP ......................................................... 245
GILOTRIF TAB .......................................................... 63
GILPHEX TR TAB .................................................... 105
gilteritinib fumarate tablet ..................................... 64
GILTUSS TR TAB ...................................................... 74
GIVLAARI INJ ........................................................... 38
givosiran sodium subcutaneous soln ...................... 38
glasdegib maleate tab ............................................ 61
GLASSIA INJ ............................................................. 37
glatiramer acetate inj .......................................... 178
292
glatiramer acetate soln prefilled syringe .............. 178
Glatopa ................................................................. 178
glecaprevir‐pibrentasvir tab ................................. 153
GLEEVEC TAB .......................................................... 63
GLEOLAN SOL ........................................................ 105
GLEOSTINE CAP ..................................................... 194
GLIADEL WAF ........................................................ 194
glimepiride tab ...................................................... 248
glipizide tab .................................................. 248, 249
glipizide tab er ...................................................... 249
Glipizide Xl ............................................................ 248
glipizide xl tab ....................................................... 248
GLOBAL PREP PAD PADS ......................................... 75
GLOPERBA SOL ...................................................... 149
GLUCAGEN INJ HYPOKIT ....................................... 105
glucagon (rdna) for inj kit ..................................... 105
GLUCAGON EMR SOL ............................................ 105
glucagon hcl (rdna) for inj ..................................... 105
glucagon hcl for inj ............................................... 105
GLUCAGON KIT ..................................................... 105
glucagon nasal powder ......................................... 105
glucagon subcutaneous soln pref syringe ............. 105
glucagon subcutaneous solution auto‐injector ..... 105
GLUCO PERFEC TES ............................................... 119
GLUCOCARD ................................................. 119, 120
GLUCOCARD TES EXPRESSI ................................... 119
GLUCOCARD TES SHINE ........................................ 119
GLUCOCARD TES VITAL ......................................... 119
GLUCOCARD TES X‐SENSOR .................................. 120
GLUCOCOM TES .................................................... 120
GLUCONAVII TES STRIPS ....................................... 120
glucose blood test strip 106, 107, 108, 109, 110, 111,
112, 113, 114, 115, 116, 117, 118, 119, 120, 121,
122, 123, 124, 125, 126, 127, 128, 129, 130
GLUCOSE TES STRIPS ............................................ 120
glucose urine test‐(glucose oxidase) strip ............. 111
GLUCOTROL TAB ................................................... 248
GLUCOTROL XL TAB .............................................. 249
GLUMETZA TAB....................................................... 82
glutamine (sickle cell) powd pack ........................... 38
glutaral soln ............................................................ 72
GLUTARALDEHY SOL ............................................... 72
glyburide micronized tab ...................................... 249
glyburide tab ......................................................... 249
GLYCATE TAB ........................................................ 230
glycerol phenylbutyrate liquid .............................. 258
GLYCOLIC ACD SOL .................................................. 72
glycolic acid soln ..................................................... 72
GLYCOPYRROLA TAB ............................................. 230
glycopyrrolate inhal cap ................................... 35, 84
glycopyrrolate inhal solution .................................. 84
glycopyrrolate oral soln ........................................ 230
glycopyrrolate tab ................................................ 230
glycopyrrolate‐formoterol fumarate aerosol .......... 35
glycopyrronium tosylate pad ................................ 177
Glydo ..................................................................... 172
GLYNASE TAB ........................................................ 249
GLYSET TAB ............................................................. 37
GLYTAC COMPL BAR ............................................. 198
GLYTACTIN .................................................... 198, 199
GLYTACTIN LIQ RES/LITE ....................................... 198
GLYTACTIN LIQ RESTORE ...................................... 198
GLYTACTIN LIQ RTD .............................................. 198
GLYTACTIN PAK SWIRL .......................................... 198
GLYTACTIN POW APPLE ........................................ 198
GLYTACTIN POW BLD ............................................ 198
GLYTACTIN POW BLD PKU .................................... 198
GLYTACTIN POW PUNCH ...................................... 198
GLYTACTIN POW RESTOR ..................................... 199
GLYTACTIN POW TROPICAL .................................. 199
GLYXAMBI TAB ...................................................... 240
GNP ALCOHOL PAD SWABS .................................... 75
GNP ASPIRIN CHW ................................................ 234
GNP ASPIRIN TAB .................................................. 234
GNP NICOTINE DIS ................................................ 241
GNP NICOTINE GUM ............................................. 241
GNP NICOTINE LOZ ............................................... 241
GNP NICOTINE LOZ MINI ...................................... 241
GOCOVRI CAP ......................................................... 66
GOJJI BLOOD TES GLUCOSE .................................. 120
GOJJI BLOOD TES KETONE .................................... 120
GOJJI STRIPS MIS W/LANCET ................................ 120
golimumab iv soln ................................................... 73
golimumab subcutaneous soln auto‐injector ......... 73
golodirsen iv soln .................................................. 180
GOLYTELY SOL ......................................................... 84
GOLYTELY SOL PINEAPPL ........................................ 84
GONAL‐F INJ.......................................................... 212
GONAL‐F RFF INJ ................................................... 212
GONITRO POW ..................................................... 193
GOPRELTO SOL ..................................................... 180
GORDOFILM SOL ................................................... 169
goserelin acetate implant ..................................... 171
GRALISE STAR MIS ................................................ 217
GRALISE TAB ......................................................... 217
granisetron td patch ............................................... 28
GRANIX INJ ............................................................ 149
guaifenesin‐codeine liquid ...................................... 74
293
guanfacine hcl tab .................................................. 34
guanfacine hcl tab er .............................................. 34
guanidine hcl tab .................................................... 59
GUANIDINE TAB ...................................................... 59
GUARDIAN CON MIS TRANSMIT ........................... 148
GUARDIAN MIS LINK ............................................. 148
GUARDIAN MIS SENSOR ....................................... 148
GUARDIAN MIS TRANSMTR .................................. 148
GUARDIAN RT KIT ................................................. 148
GUARDIAN RT KIT STARTER .................................. 148
GUARDIAN RT KIT SYST PED.................................. 148
GUARDIAN RT KIT SYSTEM.................................... 148
GUARDIAN RT MIS REPL PED ................................ 148
GUARDIAN RT MIS REPLACE ................................. 148
guselkumab soln pen‐injector ................................. 68
GVOKE HYPO ......................................................... 105
GVOKE PFS INJ ...................................................... 105
GYNAZOLE‐1 CRE .................................................. 160
H
HAEGARDA INJ ........................................................ 85
haemophilus b polysaccharide conj vac im susp ..... 76
haemophilus b polysaccharide conjugate vac for inj ...
76
haemophilus b polysaccharide conjugate vaccine for
inj ........................................................................ 76
Hailey ...................................................................... 95
Hailey 24 Fe ............................................................ 95
Hailey Fe ................................................................. 95
HALAVEN INJ ......................................................... 177
halcinonide cream ................................................ 101
halcinonide oint .................................................... 101
halcinonide soln .................................................... 101
HALCION TAB .......................................................... 78
HALOBETASOL AER ............................................... 101
halobetasol propionate foam ............................... 101
halobetasol propionate lotion ........................ 99, 102
halobetasol propionate‐tazarotene lotion ............ 254
HALOG CRE ........................................................... 101
HALOG OIN ........................................................... 101
HALOG SOL ........................................................... 101
haloperidol tab ....................................................... 85
HALUCORT GEL ..................................................... 175
HARMONY TES BLD GLUC ..................................... 120
HARVONI PAK ....................................................... 153
HARVONI TAB ....................................................... 153
HAVRIX INJ ............................................................ 263
HCU EASY TAB ....................................................... 199
Heather ................................................................. 226
HELIDAC MIS THERAPY ......................................... 257
HEMANGEOL SOL .................................................... 80
HEMATOGEN FA CAP ............................................ 167
HEMATRON‐AF TAB .............................................. 167
HEMLIBRA INJ ......................................................... 56
HEMOFIL M INJ ....................................................... 54
hep a‐hep b vaccine susp pref syr ......................... 262
hepatitis a vaccine inj susp ................................... 263
hepatitis b vaccine (recombinant) ................ 262, 263
hepatitis b vaccine (recombinant) susp ........ 262, 263
hepatitis b vaccine recomb adjuvanted pref syr ... 263
HEPLISAV‐B INJ ..................................................... 263
HEPSERA TAB ........................................................ 153
HERCEP HYLEC SOL ................................................. 65
HERCEPTIN INJ ........................................................ 61
HERZUMA INJ .......................................................... 61
HETLIOZ CAP ......................................................... 236
hexaminolevulinate hcl for soln ............................ 105
HIBERIX SOL ............................................................ 76
Hidex 6‐day ........................................................... 146
HIPREX TAB ........................................................... 258
histrelin acetate (cpp) implant kit ......................... 171
histrelin acetate implant kit .................................. 171
HIZENTRA INJ ........................................................ 162
HIZENTRA SOL ....................................................... 162
HM ASPIRIN CHW ................................................. 234
HM INSULIN S MIS ................................................ 184
HM NICOTINE DIS ................................................. 242
HM NICOTINE GUM .............................................. 242
HM NICOTINE LOZ ................................................ 242
HM STERILE PAD ALCHOL ....................................... 75
HM ULTICARE MIS ................................................ 184
HOMACTIN AA LIQ PLUS ....................................... 199
HORIZANT TAB ...................................................... 233
HPR AER ................................................................ 175
HPR PLUS AER ....................................................... 175
HPR PLUS CRE ....................................................... 175
HPR PLUS KIT ........................................................ 175
HPR PLUS MB KIT HYDROGEL ............................... 137
HUMALOG INJ ....................................................... 156
HUMALOG JR INJ .................................................. 156
HUMALOG KWIK INJ ............................................. 156
HUMALOG MIX INJ ............................................... 156
HUMALOG MIX SUS .............................................. 156
human papillomavirus (hpv) ................................. 263
HUMATE‐P SOL ....................................................... 54
HUMATROPE INJ ................................................... 150
HUMIRA INJ ............................................................ 73
HUMIRA KIT ............................................................ 73
294
HUMIRA PEDIA INJ CROHNS ................................... 73
HUMIRA PEN INJ ..................................................... 73
HUMIRA PEN INJ CD/UC/HS ................................... 73
HUMIRA PEN INJ PS/UV .......................................... 73
HUMIRA PEN KIT CD/UC/HS ................................... 73
HUMIRA PEN KIT PS/UV .......................................... 73
HUMULIN INJ ........................................................ 156
HUMULIN N INJ U‐ ................................................ 156
HUMULIN R INJ U‐ ................................................ 156
HW EMBRACE TES PRO ......................................... 121
HW EMBRACE TES STRIPS ..................................... 121
HYALGAN INJ ........................................................ 264
hyaluronan intra‐articular soln prefilled syringe .. 264
HYCAMTIN CAP ..................................................... 254
HYCLODEX SOL ...................................................... 240
hydralazine hcl tab................................................ 193
HYDREA CAP ........................................................... 65
HYDRFRA BLUE PAD RDY ...................................... 267
HYDRFRA MRF PAD ............................................... 267
HYDRO/ACETA SOL ............................................... 158
hydrochlorothiazide cap ....................................... 136
hydrochlorothiazide tab .... 29, 30, 43, 44, 79, 80, 136
hydrocod polst‐chlorphen polst cap er ................. 209
hydrocodone bitartrate cap er .............................. 208
hydrocodone bitartrate tab er .............................. 207
hydrocodone bitartrate/acetaminophen tab ...... 158
hydrocodone bitartrate/acetaminophen tab ....... 158
hydrocodone/homatropine syp 5‐1.5/5 ................. 73
hydrocodone‐acetaminophen soln ....................... 158
hydrocodone‐acetaminophen tab ........................ 159
hydrocortisone acetate lotion ............................... 102
hydrocortisone acetate perianal foam ................. 166
hydrocortisone acetate w/ pramoxine perianal foam .
232
hydrocortisone butyrate hydrophilic lipo base cream .
101
hydrocortisone butyrate lotion ............................. 101
hydrocortisone cre ........................................... 74, 99
hydrocortisone cream ............................................. 74
hydrocortisone enema .......................................... 166
hydrocortisone lotion ........................................ 31, 99
hydrocortisone perianal cream ............................. 232
hydrocortisone probutate cream .......................... 102
hydrocortisone rectal ene .................................... 166
hydrocortisone soln .............................................. 102
hydrocortisone tab ................................................ 145
hydrocortisone topical cre .................................... 232
hydrocortisone topical hc cre ............................... 232
HYDROFERA PAD BLUE ......................................... 267
HYDROFERA PAD MRF .......................................... 267
HYDROFRA MRF PAD ............................................ 267
HYDROG WOUND MIS .......................................... 267
HYDROGEL GAU PAD ............................................ 267
hydrogen peroxide soln ........................................ 236
hydrogenated vegetable oil flakes ........................ 214
hydrogenated vegetable oil pellets ....................... 214
hydrogenated vegetable oil wax .......................... 214
Hydromet ........................................................ 73, 176
HYDROMORPHON SUP ......................................... 207
hydromorphone hcl liqd ........................................ 206
hydromorphone hcl suppos .................................. 207
hydromorphone hcl tab ........................................ 206
hydroxyamphetamine‐tropicamide ophth soln .... 202
hydroxychloroquine sulfate tab .............................. 59
hydroxyurea cap ............................................. 65, 105
hydroxyurea tab .................................................... 105
hydroxyzine pamoate cap ....................................... 45
HYLAFEM SUP ....................................................... 155
HYLAGUARD CRE................................................... 175
hylan intra‐articular solution prefilled syringe ..... 264
HYLATOPIC AER PLUS ............................................ 175
HYLATOPIC CRE PLUS ............................................ 175
HYLATOPIC LOT PLUS ............................................ 175
HYMOVIS INJ ......................................................... 264
hyoscyamine tab .................................................... 77
hyoscyamine sr tab ................................................. 77
hyoscyamine sulfate sl tab ...................................... 77
hyoscyamine sulfate tab ......................................... 77
hyoscyamine sulfate tab disint ............................... 77
hyoscyamine sulfate tab er ..................................... 77
hyoscyamine tab ..................................................... 77
HYPERSAL NEB ...................................................... 176
HYPER‐SAL NEB ..................................................... 176
HYPERTENSA CAP ................................................. 132
hypochlorous acid soln ......................................... 240
HYPOCYN SPR ....................................................... 141
HYQVIA INJ ............................................................ 213
HYSINGLA ER TAB ................................................. 207
HYZAAR TAB ............................................................ 43
I
ibandronate sodium tab ......................................... 83
IBRANCE CAP ........................................................ 103
IBRANCE TAB ........................................................ 103
ibrutinib cap ............................................................ 63
ibrutinib tab ............................................................ 63
ibuprofen tab ........................................................ 196
ibuprofen‐famotidine tab ..................................... 196
295
ICAR‐C PLUS TAB ................................................... 167
icatibant acetate inj ................................................ 84
ICLUSIG TAB ............................................................ 63
icosapent ethyl cap ................................................. 57
ID NOW CONTR KIT COVID‐ .................................. 163
ID NOW KIT COVID‐ .............................................. 163
idelalisib tab.......................................................... 216
IDELVION SOL ......................................................... 54
IDHIFA TAB ............................................................ 169
idursulfase soln for iv infusion .............................. 178
IGLUCOSE TES ....................................................... 121
ILARIS INJ .............................................................. 165
ILEVRO DRO .......................................................... 203
ILIDERM SPR ......................................................... 175
iloperidone tab ........................................................ 77
iloprost inhalation solution ................................... 227
ILUMYA SOL ............................................................ 67
ILUVIEN IMP .......................................................... 205
imatinib mesylate tab ............................................. 63
IMBRUVICA CAP ...................................................... 63
IMBRUVICA TAB ...................................................... 63
IMFINZI INJ .............................................................. 61
imiglucerase for inj ................................................. 36
imiquimod cream .......................................... 162, 163
IMITREX INJ ........................................................... 237
IMITREX SPR .......................................................... 237
IMITREX TAB ......................................................... 237
IMLYGIC INJ ........................................................... 200
immun glob inj ...................................................... 213
immune globulin (human) im inj ........................... 161
immune globulin (human) iv for soln .................... 161
immune globulin (human) iv or subcutaneous soln .....
161, 162
immune globulin (human) iv soln ................. 161, 162
immune globulin (human) subcutaneous inj 161, 162
immune globulin (human) subcutaneous soln pref syr
162
immune globulin (human)‐hipp subcutaneous inj 161
immune globulin (human)‐ifas iv soln .................. 162
immune globulin (human)‐klhw subcutaneous inj 162
immune globulin (human)‐slra iv soln .................. 161
IMOVAX RABIE INJ ................................................ 263
IMPAVIDO CAP ........................................................ 57
IMPOYZ CRE .......................................................... 101
IMURAN TAB ......................................................... 230
IMVEXXY MAIN SUP .............................................. 261
IMVEXXY STRT SUP ............................................... 261
IN CONTROL MIS ................................................... 185
IN TOUCH TES BLOOD ........................................... 121
Inatal Gt ................................................................ 219
INBRIJA CAP ............................................................ 66
Incassia ................................................................. 226
incobotulinumtoxina for im inj ............................. 193
INCONTROL MIS .................................................... 185
INCONTROL PAD ALCOHOL ..................................... 75
INCRELEX INJ ......................................................... 165
INCRUSE ELPT INH .................................................. 84
indacaterol maleate inhal powder cap ................... 79
indacaterol‐glycopyrrolate inhal cap ...................... 35
indapamide tab ..................................................... 250
INDERAL LA CAP ...................................................... 80
INDERAL XL CAP ...................................................... 80
indinavir sulfate cap ............................................... 70
INDOCIN SUP ........................................................ 196
INDOCIN SUS ......................................................... 197
indomethacin cap ................................................. 197
indomethacin suppos ............................................ 196
indomethacin susp ................................................ 197
INFANRIX INJ ......................................................... 254
INFASURF SUS ....................................................... 233
INFINITY TES BLD GLUC ......................................... 121
INFINITY TES VOICE ............................................... 121
INFLECTRA INJ ....................................................... 257
infliximab for iv inj ................................................ 257
infliximab‐abda for iv inj ....................................... 257
infliximab‐axxq for iv inj ....................................... 257
infliximab‐dyyb for iv inj ....................................... 257
influenza vac recomb ha quad pf soln pref syr ..... 263
influenza vac tissue‐cultured subunit quadrivalent im
susp .................................................................. 263
influenza vac type a&b surface ant adj susp pref syr ..
263
influenza virus vac split high‐dose pf susp pref syr ......
263
influenza virus vac split quadrivalent susp pref syr .....
262, 263
ingenol mebutate gel .............................................. 65
INGREZZA CAP ...................................................... 177
injection device for insulin ............ 181, 182, 185, 188
INLYTA TAB ............................................................. 63
INNOPRAN XL CAP .................................................. 80
inotersen sod subcutaneous pref syr ...................... 72
inotuzumab ozogamicin for iv soln ......................... 64
INPEN .................................................................... 185
INREBIC CAP .......................................................... 169
INS ASP PROT INJ FLEXPEN ................................... 156
INSPRA TAB ........................................................... 236
INSULIN ASPA INJ .................................................. 156
296
INSULIN ASPA INJ FLEXPEN ................................... 156
INSULIN ASPA INJ PENFILL .................................... 156
insulin aspart (with niacinamide) inj ..................... 155
insulin aspart (with niacinamide) sol pen‐inj ........ 155
insulin aspart (with niacinamide) soln cartridge .. 156
insulin aspart inj ........................................... 156, 157
insulin aspart prot & aspart (human) inj ...... 156, 157
insulin aspart prot & aspart sus pen‐inj ........ 156, 158
insulin aspart soln cartridge ......................... 156, 157
insulin aspart soln pen‐injector ..................... 156, 157
insulin degludec inj ............................................... 158
insulin degludec soln pen‐injector ........................ 158
insulin degludec‐liraglutide sol pen‐inj ................. 164
insulin detemir inj ................................................. 157
insulin detemir soln pen‐injector .......................... 157
insulin glargine inj ................................................. 156
insulin glargine soln pen‐injector .......... 155, 156, 158
insulin glargine‐lixisenatide sol pen‐inj ................. 164
insulin glulisine inj ................................................. 155
insulin glulisine soln pen‐injector inj ..................... 155
INSULIN LISP INJ .................................................... 156
INSULIN LISP INJ JUNIOR ....................................... 156
INSULIN LISP INJ PROTAMIN ................................. 156
insulin lispro inj ............................................. 155, 156
insulin lispro prot & lispro inj ................................ 156
insulin lispro prot & lispro sus pen‐inj ................... 156
insulin lispro soln pen‐injector ...................... 155, 156
insulin lispro‐aabc inj ............................................ 157
insulin lispro‐aabc soln pen‐inj ............................. 157
insulin nph & regular susp pen‐inj ................ 156, 157
insulin nph (human) (isophane) inj ............... 156, 157
insulin nph (human) (isophane) susp pen‐injector 157
insulin nph isophane & regular human inj .... 156, 157
INSULIN PEN MIS .................................................. 185
insulin pen needle 181, 182, 183, 184, 185, 186, 187,
188, 189, 190, 191, 192
insulin regular (human) in nacl ............................. 157
insulin regular (human) inh powd ......................... 155
insulin regular (human) inj ............................ 156, 157
insulin regular (human) soln pen‐injector ..... 156, 157
INSULIN SRYG MIS ................................................ 185
INSULIN SYRG MIS ................................................ 185
INSULIN SYRI MIS .................................................. 186
insulin syringe (disp) u‐ ......................................... 185
insulin syringe/needle u‐ ...... 181, 182, 183, 184, 185,
186, 187, 189, 190, 191
INSUPEN MIS ........................................................ 186
INSUPEN SENS MIS ............................................... 186
INSUPEN ULTR MIS ............................................... 186
INTEGRA F CAP ..................................................... 168
INTEGRA PLUS CAP ............................................... 167
INTELENCE TAB ....................................................... 70
interferon alfa‐ ........................................................ 65
interferon beta‐ ............................................ 178, 179
interferon gamma‐ ................................................. 65
INTERMEZZO SUB ................................................. 195
INTRAROSA SUP .................................................... 177
INTRON A INJ .......................................................... 65
Introvale ............................................................... 141
INTUNIV TAB ........................................................... 34
INVEGA TAB ............................................................ 77
INVELTYS SUS ........................................................ 205
INVIRASE TAB .......................................................... 70
INVOKAMET TAB ................................................... 244
INVOKAMET XR TAB ............................................. 244
INVOKANA TAB ..................................................... 244
IODINE TIN ............................................................ 166
iohexol oral soln .................................................... 232
IOPIDINE SOL ........................................................ 203
iothalamate meglumine inj ................................... 232
ipilimumab soln for iv infusion ................................ 62
IPOL INJ INACTIVE ................................................. 263
ipratropium bromide hfa inhal aerosol ................... 84
ipratropium‐albuterol inhal aerosol soln ................ 35
irbesartan tab ................................................... 43, 44
irbesartan‐hydrochlorothiazide tab ........................ 43
IRESSA TAB .............................................................. 63
iron w/ b ............................................................... 167
iron‐folic acid‐vit c‐vit b ........................................ 167
iron‐vit c‐vit b ........................................................ 167
IROSPAN ............................................................... 167
IS 167, 219
isatuximab‐irfc iv soln ............................................. 62
isavuconazonium sulfate cap ................................ 255
ISENTRESS CHW ...................................................... 69
ISENTRESS HD TAB .................................................. 69
ISENTRESS POW ...................................................... 69
ISENTRESS TAB ........................................................ 69
Isibloom .................................................................. 95
isocarboxazid tab .................................................. 177
isoflurane inhal soln .............................................. 265
isoniazid & rifampin cap ......................................... 44
isoniazid tab ............................................................ 60
isoniazid‐rifampin w/ pyrazinamide tab ................. 45
isopropyl alcohol wipes ......................................... 240
ISOPTIN SR TAB ....................................................... 87
ISOPTO ATROP SOL ............................................... 104
ISOPTO CARP SOL ................................................. 174
297
ISORDIL TAB .......................................................... 193
isosorbide dinitrate cap er .................................... 193
isosorbide dinitrate tab ......................................... 193
isosorbide dinitrate‐hydralazine hcl tab ............... 193
isotretinoin ....................................................... 33, 34
isotretinoin cap ................................................. 33, 34
isotretinoin micronized cap ..................................... 33
ISOVACTIN AA LIQ PLUS ........................................ 199
isradipine cap .......................................................... 87
ISTALOL SOL ............................................................ 81
ISTODAX OVR INJ .................................................... 61
istradefylline tab ..................................................... 34
ISTURISA TAB ........................................................ 103
itraconazole cap.................................................... 255
itraconazole oral soln ........................................... 255
ivabradine hcl oral soln ......................................... 240
ivabradine hcl tab ................................................. 240
ivacaftor packet ...................................................... 91
ivacaftor tab ................................................... 91, 104
ivermectin cream .................................................. 233
ivermectin lotion ................................................... 235
ivermectin tab ......................................................... 44
ivosidenib tab ........................................................ 169
ixabepilone for iv infusion ..................................... 177
ixazomib citrate cap ................................................ 62
ixekizumab subcutaneous soln auto‐injector .......... 67
IXEMPRA KIT INJ ................................................... 177
IXIARO INJ ............................................................. 263
IXINITY INJ ............................................................... 54
J
JADENU SPRKL GRA ................................................ 51
JADENU TAB ............................................................ 51
JAKAFI TAB ............................................................ 169
JALYN CAP ............................................................. 227
Jantoven ............................................................... 103
JANUMET TAB ....................................................... 135
JANUMET XR TAB .................................................. 135
JANUVIA TAB ........................................................ 135
japanese encephalitis vaccine inactivated adsorbed
inj ...................................................................... 263
JARDIANCE TAB ..................................................... 244
Jasmiel .................................................................... 95
JATENZO CAP .......................................................... 42
JELMYTO INJ ........................................................... 64
Jencycla ................................................................. 226
JENTADUETO TAB ................................................. 135
JENTADUETO TAB XR ............................................ 135
JEVTANA INJ .......................................................... 177
Jinteli ..................................................................... 139
JIVI INJ ..................................................................... 54
Jolessa ................................................................... 141
JORNAY PM CAP ................................................... 247
JUBLIA SOL ............................................................ 160
Juleber .................................................................... 95
JULUCA TAB ............................................................ 68
Junel ........................................................................ 95
Junel Fe 24 .............................................................. 95
JUXTAPID CAP ....................................................... 173
JYNARQUE PAK ..................................................... 239
JYNARQUE TAB ..................................................... 239
K
KADCYLA INJ ........................................................... 64
KADIAN CAP .......................................................... 207
Kaitlib Fe ................................................................. 95
KALBITOR INJ ........................................................ 216
KALETRA SOL ........................................................... 68
KALETRA TAB .......................................................... 69
Kalliga ..................................................................... 95
KALYDECO PAK ........................................................ 91
KALYDECO TAB ........................................................ 91
KAMDOY EMU ...................................................... 175
KANJINTI INJ ............................................................ 61
KANJINTI SOL .......................................................... 61
KANUMA INJ ......................................................... 173
KAPSPARGO CAP ..................................................... 80
KAPVAY TAB ............................................................ 34
KARBINAL ER SUS .................................................... 56
Kariva ...................................................................... 83
KATERZIA SUS ......................................................... 87
KAZANO ................................................................ 135
KEFLEX CAP ............................................................. 90
KELARX GEL ........................................................... 235
Kelnor 1/35 ............................................................. 95
KENALOG AER SPRAY ............................................ 101
KEPPRA SOL ............................................................ 48
KEPPRA TAB ............................................................ 48
KEPPRA XR TAB ....................................................... 48
KERAGEL GEL WOUND .......................................... 267
KERAGELT GEL ...................................................... 267
KERALAC CRE ........................................................ 137
KERALYT GEL ......................................................... 169
KERAMATRIX MIS .................................................. 267
KERYDIN SOL ......................................................... 212
ketoconazole foam ............................................... 160
ketoconazole gel ................................................... 160
ketoconazole tab .................................................. 160
298
KETO‐DIASTIX TES ................................................. 179
ketone blood test strip .......... 117, 120, 123, 125, 126
KETONE TES .................................................. 121, 179
KETONE TEST TES .................................................. 121
ketoprofen cap ...................................................... 197
ketorolac tromethamine (pf) ophth soln .............. 203
ketorolac tromethamine nasal spray .................... 197
ketorolac tromethamine ophth soln ..................... 203
KETOSTIX TES STRIP .............................................. 121
KETOVIE LIQ .......................................................... 199
KETOVIE LIQ CHOCOLAT ....................................... 199
KETOVIE LIQ PEPTIDE ............................................ 199
KETOVIE LIQ VANILLA ........................................... 199
KEVEYIS TAB ............................................................ 88
KEVZARA INJ ......................................................... 166
KEYTRUDA INJ ......................................................... 61
KHAPZORY SOL ..................................................... 143
KINERET INJ ........................................................... 165
KINRIX INJ ............................................................. 254
Kionex ................................................................... 218
KISQALI ........................................................... 65, 103
KISQALI TAB .......................................................... 103
KITABIS PAK NEB ..................................................... 38
KIVIK EMU ............................................................. 175
KLARITY‐A DRO ..................................................... 200
KLARITY‐B DRO ..................................................... 205
KLARITY‐L DRO ...................................................... 205
KLARON LOT ........................................................... 30
KLONOPIN TAB ....................................................... 47
Klor‐con ................................................................ 217
Klor‐con M10 ........................................................ 217
Klor‐con Sprinkle ................................................... 217
KLS ASPIRIN TAB ................................................... 234
KLS QUIT ............................................................... 242
KOATE INJ ............................................................... 54
KOATE‐DVI INJ ........................................................ 54
KOGENATE FS INJ .................................................... 54
KOMBIGLYZ XR TAB .............................................. 135
KORLYM TAB ......................................................... 225
KOSELUGO CAP ....................................................... 61
KOSHR PRENAT TAB .............................................. 219
KOVALTRY INJ ......................................................... 54
KP ASPIRIN TAB ..................................................... 234
K‐PHOS TAB .......................................................... 215
K‐PHOS TAB NEUTRAL .......................................... 215
K‐PHOS TAB NO .................................................... 215
K‐prime ................................................................. 217
KRINTAFEL TAB ....................................................... 59
KRISTALOSE PAK ................................................... 169
KROGER BLOOD TES GLUCOSE ............................. 121
KROGER TES .......................................................... 122
KRYSTEXXA INJ ...................................................... 149
K‐TAB TAB ............................................................. 217
Kurvelo .................................................................... 95
KUVAN POW ......................................................... 214
KUVAN TAB ........................................................... 214
KYLEENA IUD ......................................................... 225
KYNMOBI MIS ....................................................... 195
KYPROLIS SOL .......................................................... 62
L
lacosamide oral solution ......................................... 50
lacosamide tab ....................................................... 50
LACRISERT MIS ........................................................ 76
lactic acid‐citric acid‐potassium bitartrate gel ..... 260
lactobacillus casei‐folic acid cap ............................. 51
Lactojen .................................................................. 51
lactojen cap ............................................................ 51
lactulose oral crystal packet ......................... 169, 170
LACTULOSE PAK .................................................... 170
lactulose sol .................................................. 166, 170
LAMICTAL CHW ....................................................... 48
LAMICTAL KIT START ............................................... 48
LAMICTAL ODT KIT .................................................. 48
LAMICTAL ODT TAB ................................................ 48
LAMICTAL TAB ........................................................ 48
LAMICTAL XR KIT ..................................................... 48
LAMICTAL XR TAB ................................................... 48
LAMISIL TAB ............................................................ 52
lamivudine oral soln ........................................ 71, 153
lamivudine tab .................................... 68, 69, 71, 153
lamivudine‐tenofovir disoproxil fumarate tab .. 68, 69
lamivudine‐zidovudine tab ............................... 68, 69
lamotrigine orally disintegrating tab ...................... 48
lamotrigine subvenite starter kit ............................ 49
lamotrigine tab ................................................. 48, 49
lamotrigine tab chewable dispersible ..................... 48
lamotrigine tab disint ............................................. 48
lamotrigine tab er ................................................... 48
lanadelumab‐flyo inj ............................................. 216
LANOXIN TAB .......................................................... 88
lanreotide acetate extended release inj ............... 245
lansoprazole cap delayed release ......................... 229
lansoprazole tab delayed release orally
disintegrating ................................................... 229
lanthanum carbonate chew tab ........................... 215
lanthanum carbonate oral powder pack .............. 215
LANTUS INJ ........................................................... 156
299
LANTUS SOLOS INJ ................................................ 156
lapatinib ditosylate tab ........................................... 64
Larin ........................................................................ 96
LARIN ...................................................................... 96
Larin 24 FE .............................................................. 96
LARIN FE TAB .......................................................... 96
Larissia .................................................................... 96
laronidase soln for iv infusion ............................... 178
larotrectinib sulfate cap .......................................... 63
larotrectinib sulfate oral soln .................................. 63
LARTRUVO INJ ......................................................... 62
LASIX TAB .............................................................. 172
lasmiditan succinate tab ....................................... 238
LASTACAFT SOL ..................................................... 200
latanoprost ophth emulsion ................................. 227
latanoprost ophth soln ........................... 82, 202, 227
latanoprostene bunod ophth soln......................... 227
latanoprost‐timolol maleate ophth soln ................. 82
LATUDA TAB ........................................................... 68
Layolis Fe ................................................................ 96
LAZANDA SPR ........................................................ 207
LDL CARE POW ...................................................... 132
LDO PLUS GEL ....................................................... 172
LECITHIN GRA ....................................................... 172
lecithin granules ................................................... 172
ledipasvir‐sofosbuvir pellet pack........................... 153
ledipasvir‐sofosbuvir tab....................................... 153
LEDIP‐SOFOSB TAB ............................................... 153
Leena .................................................................... 256
lefamulin acetate tab ........................................... 216
leflunomide tab ..................................................... 230
lemborexant tab ................................................... 211
LEMTRADA INJ ...................................................... 179
lenalidomide cap ................................................... 162
lenvatinib cap ther pack ......................................... 63
LENVIMA CAP ......................................................... 63
LESCOL XL TAB ...................................................... 154
Lessina .................................................................... 96
LETAIRIS TAB ......................................................... 229
letermovir tab ......................................................... 93
letrozole tab ............................................................ 75
LEUKERAN TAB ..................................................... 194
LEUKINE INJ........................................................... 150
levalbuterol hcl soln nebu ....................................... 79
levalbuterol hcl soln nebu conc ............................... 79
levalbuterol tartrate inhal aerosol .......................... 79
LEVAQUIN TAB ...................................................... 143
LEVBID TAB ............................................................. 77
LEVEMIR INJ .......................................................... 157
LEVEMIR INJ FLEXTOUC ........................................ 157
levetiracetam oral soln ........................................... 48
levetiracetam tab ............................................. 48, 49
levetiracetam tab disintegrating soluble ................ 49
levetiracetam tab er ............................................... 48
LEVICYN GEL ......................................................... 175
LEVICYN SOL DERMAL ........................................... 266
levocarnitine oral soln ............................................ 89
levocarnitine tab ..................................................... 89
levodopa inhal powder cap ..................................... 66
levofloxacin tab .................................................... 143
levoleucovorin for iv soln ...................................... 143
LEVOMEFOLATE CAP ALGAL ................................. 132
levomefolate glucosamine tab er ......................... 134
levomilnacipran hcl cap er .................................... 240
Levonest ............................................................... 256
levonor‐eth est tab ............................................... 141
levonorgestrel & ethinyl estradiol tab . 93, 94, 95, 96,
97, 98, 141, 256
levonorgestrel releasing iud ................................. 225
levonorgestrel‐eth estra tab ........................... 96, 256
levonorgestrel‐ethinyl estradiol ....................... 94, 99
levonorgestrel‐ethinyl estradiol (continuous) tab ... 99
levonorgestrel‐ethinyl estradiol‐fe tab ................... 94
levonorg‐eth est lo tab ......................................... 140
levonorg‐eth est tab ..................................... 140, 141
Levora ..................................................................... 96
Levo‐t .................................................................... 252
levothyroxine sodium cap ..................................... 253
levothyroxine sodium oral solution ....................... 253
levothyroxine sodium tab ..................................... 252
Levoxyl .................................................................. 252
LEVSIN TAB ............................................................. 77
LEVSIN/SL SUB ........................................................ 77
LEVULAN KERA SOL ............................................... 216
LEXAPRO TAB ........................................................ 238
LEXETTE AER ......................................................... 101
LEXIVA SUS .............................................................. 70
LEXIVA TAB ............................................................. 70
LIALDA TAB ........................................................... 163
LIBERTY NEXT TES GEN ......................................... 122
LIBERTY TES ........................................................... 122
LIBRAX CAP ............................................................. 47
LIBTAYO INJ ............................................................. 62
LICART DIS ............................................................... 58
LIDO/DEXTROS INJ ................................................ 172
lidocaine.................................. 42, 172, 202, 253, 265
lidocaine 7t gel...................................................... 172
LIDOCAINE CRE TETRACAI ..................................... 253
300
lidocaine gel .......................................................... 172
lidocaine hcl gel .................................................... 172
lidocaine hcl ophth gel .......................................... 202
lidocaine hcl‐collagen‐aloe vera gel ..................... 265
lidocaine patch...................................................... 172
lidocaine‐tetracaine cream ................................... 253
lidocaine‐tetracaine topical patch ........................ 253
LIDODERM DIS ...................................................... 172
LIDOTREX GEL ....................................................... 265
lifitegrast ophth soln ............................................. 173
LILETTA IUD ........................................................... 225
Lillow ....................................................................... 96
LIMBREL CAP ......................................................... 134
LIMBREL250 CAP ................................................... 132
LIMBREL500 CAP ................................................... 132
linaclotide cap ....................................................... 159
linagliptin tab ................................................ 135, 240
linagliptin‐metformin hcl tab ................................ 135
linagliptin‐metformin hcl tab er ............................ 135
linezolid for susp ................................................... 212
linezolid tab .......................................................... 212
LINSEED OIL RAW ................................................. 142
LINZESS CAP .......................................................... 159
liothyronine sodium tab ........................................ 252
LIPICHOL ............................................................... 132
LIPITOR TAB .......................................................... 154
LIPOFEN CAP ......................................................... 141
LIPRITIN PAK ......................................................... 217
liraglutide soln pen‐injector .................................. 163
lisdexamfetamine dimesylate cap .......................... 40
lisdexamfetamine dimesylate chew tab ................. 40
lisinopril & hydrochlorothiazide tab ........................ 30
lisinopril oral soln .................................................... 29
lisinopril tab ............................................................ 29
LISTER‐V CAP ......................................................... 132
LITETOUCH MIS ..................................................... 186
lithium carbonate tab ............................................. 59
lithium carbonate tab er ......................................... 59
lithium oral solution ................................................ 59
LITHIUM SOL ........................................................... 59
LITHOBID TAB ......................................................... 59
LITHOSTAT TAB ..................................................... 260
LIVALO TAB ........................................................... 154
lixisenatide pen‐inj starter kit ............................... 163
L‐METHYL‐ TAB B .................................................. 132
L‐METHYLFOLA CAP ALGAL ................................... 132
L‐METHYLFOLA CAP FORTE ................................... 132
L‐METHYL‐MC TAB ................................................ 132
L‐METHYL‐MC TAB NAC ........................................ 132
LO LOESTRIN TAB .................................................... 83
LOCOID LIPO CRE .................................................. 101
LOCOID LOT .......................................................... 101
LODINE TAB .......................................................... 197
LODOSYN TAB ....................................................... 105
lodoxamide tromethamine ophth soln ................. 200
LOESTRIN .......................................................... 83, 96
LOESTRIN FE TAB .................................................... 96
LOESTRIN TAB ................................................... 83, 96
lofexidine hcl tab ..................................................... 36
LOJAIMIESS TAB .................................................... 141
LOKELMA PAK ....................................................... 218
lomitapide mesylate cap ....................................... 173
LOMOTIL TAB .......................................................... 66
lomustine cap ....................................................... 194
LONHALA MAGN SOL .............................................. 84
LONSURF TAB ......................................................... 65
loperamide hcl soln ................................................. 66
LOPERAMIDE SOL ................................................... 66
LOPID TAB ............................................................. 142
lopinavir‐ritonavir soln ............................................ 68
lopinavir‐ritonavir tab ............................................. 69
Lopreeza ............................................................... 139
LOPRESS HCT TAB ................................................... 79
LOPRESSOR TAB ...................................................... 80
LOPROX CRE ............................................................ 53
LOPROX SHA ........................................................... 53
LOPROX SUS ............................................................ 53
lorazepam tab ......................................................... 78
LORBRENA TAB ....................................................... 63
Lorcet .................................................................... 158
lorlatinib tab ........................................................... 63
LORMATE CAP ....................................................... 132
LORTAB ELX ........................................................... 158
Loryna ..................................................................... 96
losartan potassium & hydrochlorothiazide tab ...... 43
losartan potassium tab ........................................... 44
LOSEASONIQUE TAB ............................................. 141
LOTEMAX GEL ....................................................... 205
LOTEMAX OIN ....................................................... 205
LOTEMAX SM GEL ................................................. 205
LOTEMAX SUS ....................................................... 205
LOTENSIN HCT TAB ................................................. 30
LOTENSIN TAB ......................................................... 29
loteprednol etabonate ophth emulsion ................ 205
loteprednol etabonate ophth gel .......................... 205
loteprednol etabonate ophth oint ........................ 205
loteprednol etabonate ophth susp ....................... 205
loteprednol etabonate‐tobramycin ophth susp .... 205
301
LOTREL CAP ............................................................. 29
LOTRONEX TAB ..................................................... 160
lovastatin tab ........................................................ 154
lovastatin tab er .................................................... 154
LOVAZA CAP ............................................................ 57
LOW DOSE ASA TAB .............................................. 234
Low‐ogestrel ........................................................... 96
loxapine aerosol powder breath activated ........... 131
LOYON SOL............................................................ 175
Lo‐zumandimine ..................................................... 96
lubiprostone cap ................................................... 144
LUCEMYRA TAB ....................................................... 36
LUCENTIS INJ ......................................................... 261
LUCENTIS SOL ....................................................... 261
LUDENT CHW ........................................................ 142
luliconazole cream ................................................ 160
lumacaftor‐ivacaftor granules packet .................. 104
lumacaftor‐ivacaftor tab ...................................... 104
lumateperone tosylate cap ..................................... 68
LUMIGAN SOL ....................................................... 227
LUMIZYME INJ ...................................................... 143
LUMOXITI SOL ......................................................... 62
LUNESTA TAB ........................................................ 195
LUPANETA KIT ....................................................... 171
LUPR DEP‐PED INJ ................................................. 171
LUPRON DEPOT INJ ............................................... 171
lurasidone hcl tab ................................................... 68
luspatercept‐aamt for subcutaneous inj ............... 138
lusutrombopag tab ............................................... 251
Lutera ...................................................................... 96
LUXAMEND CRE .................................................... 267
LUXIQ AER ............................................................. 101
LUZU CRE .............................................................. 160
lymphocyte immune globulin anti‐thymocyte g inj .....
161
LYNPARZA TAB ...................................................... 217
LYRICA CAP ............................................................. 49
LYRICA CR TAB ...................................................... 217
LYRICA SOL .............................................................. 49
LYSODREN TAB ....................................................... 45
LYSTEDA TAB ......................................................... 152
LYUMJEV INJ ......................................................... 157
LYUMJEV KWPN INJ .............................................. 157
Lyza ....................................................................... 226
M
macimorelin acetate pack for oral soln ................ 105
macitentan tab ..................................................... 229
MACRILEN PAK...................................................... 105
MACROBID CAP .................................................... 258
MACRODANTIN CAP ............................................. 258
MACUTEK TAB ...................................................... 132
mafenide acetate cream ......................................... 85
mafenide acetate packet for topical soln ............... 85
MAGNEBIND TAB .................................................. 173
magnesium‐calcium‐folic acid tab ........................ 173
MAKENA INJ .......................................................... 226
MALARONE TAB ...................................................... 58
malathion lotion ................................................... 235
mannitol (diagnostic) inhalation powder capsule kit ..
105
mannitol irrigation soln ........................................ 145
maraviroc oral soln ................................................. 69
maraviroc tab ......................................................... 69
MARINOL CAP ......................................................... 52
Marlissa .................................................................. 96
MARNATAL‐F CAP ................................................. 219
MARPLAN TAB ...................................................... 177
MATULANE CAP ...................................................... 65
MAVENCLAD PAK .................................................. 178
MAVIK TAB .............................................................. 29
MAVYRET TAB ....................................................... 153
MAXALT TAB ......................................................... 237
MAXALT‐MLT TAB ................................................. 237
MAXICOMFORT MIS ............................................. 187
MAXIDEX SUS ........................................................ 205
MAXITROL OIN ...................................................... 203
MAXITROL SUS ...................................................... 203
MAXZIDE TAB ........................................................ 136
MAXZIDE‐25 TAB .................................................. 136
MAYZENT TAB ....................................................... 245
MB HYDROGEL KIT ................................................ 175
measles‐mumps‐rubella virus vaccines for inj soln ......
262
measles‐mumps‐rubella‐varicella virus vaccines for
susp .................................................................. 262
mebendazole chew tab ........................................... 44
mecamylamine hcl tab ............................................ 57
mecasermin inj ...................................................... 165
mechlorethamine hcl gel ........................................ 64
MEDIHONEY GEL WOUND .................................... 267
MEDIHONEY PAD .................................................. 267
MEDIHONEY PST WOUND .................................... 267
medium chain triglycerides oral powder .............. 171
MEDROL TAB ........................................................ 146
medroxyprogesterone acetate im susp ................ 225
medroxyprogesterone acetate im susp prefilled syr ....
225
302
medroxyprogesterone acetate susp pref syr ........ 225
medroxyprogesterone acetate tab ....................... 226
MEIJER BLOOD TES GLUCOSE ............................... 122
MEIJER TES TRUETEST ........................................... 122
MEIJER TES TRUETRAC .......................................... 122
MEKINIST TAB ......................................................... 61
MEKTOVI TAB ......................................................... 61
Melodetta 24 Fe ..................................................... 96
meloxicam cap ...................................................... 197
meloxicam orally disintegrating tab ..................... 197
meloxicam tab ...................................................... 197
melphalan tab ....................................................... 194
memantine hcl cap er ........................................... 194
memantine hcl tab ................................................ 194
memantine hcl‐donepezil hcl cap er ....................... 50
MEMBRANEBLUE SOL ........................................... 206
MENACTRA INJ ........................................................ 76
MENEST TAB ......................................................... 140
meningococcal (a, c, y, and w‐ ................................ 76
meningococcal group b vac (recomb) im susp
prefilled syr ......................................................... 76
meningococcal vac b (recomb omv adjuv) inj prefilled
syringe ................................................................ 76
MENOPUR INJ ....................................................... 212
MENOSTAR DIS ..................................................... 140
menotropins for subcutaneous inj ........................ 212
MENTAX CRE ........................................................... 53
MENVEO INJ............................................................ 76
MEPHYTON TAB .................................................... 265
mepolizumab for inj .............................................. 165
meprobamate tab ................................................... 45
MEPRON SUS .......................................................... 66
MEPSEVII INJ ......................................................... 178
mercaptopurine susp .............................................. 59
mesalamine cap dr ............................................... 163
mesalamine cap er ........................................ 163, 164
mesalamine sulfite‐free (sf) enema ...................... 164
mesalamine suppos .............................................. 163
mesalamine tab delayed release .......................... 163
mesna tab ............................................................. 260
MESNEX TAB ......................................................... 260
MESTINON SOL ....................................................... 59
MESTINON TAB ....................................................... 59
MESTINON TAB TIMESPAN ..................................... 59
METAFOLBIC TAB .......................................... 132, 133
METAFOLBIC TAB PLUS ......................................... 133
METAFOLBIC TAB PLUS RF .................................... 133
METANX CAP ........................................................ 133
metaxalone tab ....................................................... 90
metformin hcl for oral er susp ................................ 82
metformin hcl oral soln ........................................... 82
metformin hcl tab ................................... 82, 135, 244
metformin hcl tab er ............................... 82, 135, 244
methacholine chloride inhal for soln .................... 105
methadone hcl conc .............................................. 207
methadone hcl inj ................................................. 207
methadone hcl tab ................................................ 206
methadone hydrochloride tab .............................. 207
METHADONE INJ ................................................... 207
Methadose ............................................................ 207
METHADOSE CON ................................................. 207
METHADOSE SF CON ............................................ 207
methamphetamine hcl tab ..................................... 39
METHAVER CAP .................................................... 133
methenamine combinations cap ......................... 259
methenamine combinations d/s tab ................... 259
methenamine combinations tab ......................... 259
methenamine combinations cap .......................... 259
methenamine combinations tab .......................... 259
methenamine hippurate tab ................................. 258
Methergine ........................................................... 212
methimazole tab ..................................................... 73
METHITEST TAB ...................................................... 42
methocarbamol tab ................................................ 90
methotrexate oral soln ........................................... 59
methotrexate sodium tab ....................................... 59
methotrexate soln pf auto‐injector ......................... 71
methoxsalen rapid cap ........................................... 67
methoxy peg‐epoetin beta soln prefilled syr. 138, 139
methsuximide cap ................................................. 248
METHYLCOBALA INJ ................................................ 93
methylcobalamin for inj .......................................... 93
methyldopa tab ...................................................... 45
methylergonovine maleate tab ............................ 212
METHYLFOL/CA TAB ME‐CBL ................................ 133
METHYLFOL/ME CAP CBL/P .................................. 133
METHYLIN SOL ...................................................... 247
methylnaltrexone bromide tab ............................. 214
METHYLPHENID TAB ............................................. 247
methylphenidate hcl cap delayed er ..................... 247
methylphenidate hcl cap er .......................... 246, 248
methylphenidate hcl chew tab ............................. 247
methylphenidate hcl chew tab extended release . 247
methylphenidate hcl for er susp ........................... 247
methylphenidate hcl soln ...................................... 247
methylphenidate hcl tab ....................... 246, 247, 248
methylphenidate hcl tab er ................... 246, 247, 248
303
methylphenidate hcl tab er osmotic release (osm) ......
246, 248
methylphenidate tab extended release disintegrating
246
methylphenidate td patch .................................... 246
methylprednisolone tab ........................................ 146
methyltestosterone oral tab ................................... 42
METOCLOPRAMI TAB ........................................... 144
metoclopramide hcl orally disintegrating tab ...... 144
metoclopramide hcl tab ........................................ 144
metolazone tab ..................................................... 250
METOPIRONE CAP ................................................ 105
metoprolol & hydrochlorothiazide tab ................... 79
metoprolol & hydrochlorothiazide tab er ............... 79
metoprolol succ cap er ............................................ 80
metoprolol succinate tab er .................................... 80
metoprolol tartrate tab .......................................... 80
metreleptin for subcutaneous inj .......................... 170
METROCREAM CRE ............................................... 233
METROGEL GEL ..................................................... 233
METROLOTION LOT .............................................. 233
metronidaz tab‐tetracyc cap‐bis subsal chew tab
therapy pack ..................................................... 257
metronidazole cap .................................................. 57
metronidazole cream ............................................ 233
metronidazole gel ................................................. 233
metronidazole lotion ............................................. 233
metronidazole tab .................................................. 57
metronidazole vaginal gel .................................... 260
metyrapone cap .................................................... 105
metyrosine cap ....................................................... 36
MIACALCIN SPR ....................................................... 85
Mibelas 24 Fe .......................................................... 96
MICARDIS HCT TAB ................................................. 43
MICARDIS TAB ........................................................ 44
miconazole buccal tab ............................................ 58
miconazole‐zinc oxide‐white petrolatum oint ........ 53
MICROCYN LIQ ...................................................... 266
MICRODOT TES ............................................. 122, 123
MICRODOT TES XTRA ............................................ 123
Microgestin 1.5/30 ................................................. 96
Microgestin Fe 1.5/30 ............................................. 96
MICROPLEGIA INJ MSA/MSG .................................. 89
midazolam nasal spray soln .................................... 47
midostaurin cap ...................................................... 62
MIFEPREX TAB ........................................................ 28
mifepristone tab ............................................. 28, 225
migalastat hcl cap ................................................ 141
miglitol tab ............................................................. 37
miglustat cap .......................................................... 36
MIGRANAL SPR ..................................................... 174
Mili .......................................................................... 96
MILLIPRED DP PAK ................................................ 146
MILLIPRED TAB ..................................................... 146
milnacipran hcl tab ............................................... 142
miltefosine cap ....................................................... 57
Mimvey ................................................................. 139
MIMYX CRE ........................................................... 175
MINASTRIN ............................................................. 97
mineral oil ............................................................. 172
MINIMED MIS SENSOR ......................................... 148
MINIPRESS CAP ....................................................... 45
MINIPRIN LOW TAB .............................................. 234
MINIVELLE DIS ...................................................... 140
MINOCIN CAP ....................................................... 250
minocycline hcl cap ............................................... 250
minocycline hcl cap er ........................................... 250
minocycline hcl micronized foam .................... 30, 233
minocycline hcl tab ............................................... 250
minocycline hcl tab er ........................................... 250
MINOLIRA TAB ...................................................... 250
minoxidil tab ......................................................... 262
mirabegron tab er ................................................. 260
MIRAPEX ER TAB ................................................... 195
MIRAPEX TAB ........................................................ 195
MIRCERA INJ ......................................................... 138
MIRCERA SOL ........................................................ 139
MIRCETTE TAB ........................................................ 83
MIRENA IUD SYSTEM ............................................ 225
mirtazapine orally disintegrating tab ..................... 37
mirtazapine tab ...................................................... 37
MIRVASO GEL ....................................................... 233
misoprostol tab ............................................. 196, 257
MITIGARE CAP ...................................................... 149
mitomycin for ophth soln kit ................................. 200
mitomycin for pyelocalyceal soln ............................ 64
MITOMYCIN SOL ..................................................... 64
mitomycin soln for intravesical instillation ............. 64
MITOSOL KIT ......................................................... 200
mitotane tab ........................................................... 45
MM PENTIPS MIS .................................................. 187
M‐M‐R II INJ .......................................................... 262
M‐NATAL PLUS TAB .............................................. 219
MOBIC TAB ........................................................... 197
modafinil tab ........................................................ 247
mogamulizumab‐kpkc iv soln ................................. 62
mometasone furoate inhal aerosol suspension .... 245
mometasone furoate inhal powd ......................... 245
304
mometasone furoate nasal susp........................... 180
mometasone furoate sinus implant ...................... 181
mometasone furoate‐formoterol fumarate aerosol ....
35
Mondoxyne Nl ...................................................... 250
Mono‐linyah ........................................................... 97
MONONESSA TAB ................................................... 97
MONONINE INJ ....................................................... 55
MONOVISC INJ ...................................................... 264
MONSELS FERR SOL SUBSULF ............................... 152
montelukast sodium chew tab .............................. 170
montelukast sodium oral granules packet ............ 170
montelukast sodium tab ....................................... 170
MONUROL PAK GRANULES ................................... 258
MORCIN CRE ......................................................... 155
Morgidox .............................................................. 250
morphine sulfate cap er ........................................ 207
morphine sulfate tab .................................... 206, 207
morphine sulfate tab er ................................ 206, 207
morphine sulfate tab er abuse‐deterrent ............. 206
MOTEGRITY TAB ..................................................... 28
MOTOFEN TAB ........................................................ 66
MOUTH WASH LIQ GP .......................................... 210
MOUTHWASH LIQ AF ............................................ 210
MOUTHWASH LIQ OM .......................................... 210
MOVANTIK TAB..................................................... 214
MOVIPREP SOL ....................................................... 84
moxetumomab pasudotox‐tdfk for iv soln .............. 62
MOXEZA SOL ......................................................... 200
moxifloxacin hcl in bss intravitreal soln ................ 201
moxifloxacin hcl ophth soln .......................... 200, 201
MOXIFLOXACIN INJ ............................................... 201
MOZOBIL INJ ......................................................... 103
MS CONTIN TAB .................................................... 207
MSUD EASY TAB .................................................... 199
MUCOSITISRX POW .............................................. 137
MULPLETA TAB ..................................................... 251
MULTAQ TAB .......................................................... 46
MULTIGEN PLS TAB ............................................... 168
MULTIGEN TAB ..................................................... 168
MULTIGEN TAB FOLIC ........................................... 168
mupirocin oint ......................................................... 46
MVASI INJ ............................................................. 262
M‐VIT TAB ............................................................. 219
MYALEPT INJ ......................................................... 170
MYAMBUTOL TAB ................................................... 60
MYCOBUTIN CAP .................................................... 60
mycophenolate mofetil cap .................................. 164
mycophenolate mofetil for oral susp .................... 164
mycophenolate mofetil hcl for iv soln ................... 164
mycophenolate mofetil tab .................................. 164
mycophenolate sodium tab dr .............................. 164
MYDAYIS CAP .......................................................... 39
MYDRIACYL SOL .................................................... 104
MYFORTIC TAB ...................................................... 164
MYGLUCOHEALT TES BLD GLUC ........................... 123
MYLERAN TAB ......................................................... 36
MYLOTARG INJ ........................................................ 64
MYNATAL CAP....................................................... 219
MYNATAL PLUS TAB .............................................. 219
MYNATAL TAB ............................................... 219, 220
MYNATAL TAB ADVANCE ...................................... 220
MYNATAL‐Z TAB ................................................... 220
MYNATE ................................................................ 220
MYOBLOC INJ ........................................................ 193
Myorisan ................................................................. 34
MYRBETRIQ TAB ................................................... 260
MYSOLINE TAB ........................................................ 49
MYTESI TAB ............................................................. 51
MYXREDLIN SOL .................................................... 157
N
nabumetone tab ................................................... 197
nadolol tab ........................................................ 80, 81
nafarelin acetate nasal soln.................................. 171
NAFRINSE DRO ...................................................... 142
naftifine hcl cream .................................................. 53
naftifine hcl gel ....................................................... 53
NAFTIN CRE ............................................................. 53
NAFTIN GEL ............................................................. 53
NAGLAZYME INJ .................................................... 178
naldemedine tosylate tab ..................................... 214
NALFON CAP ......................................................... 197
NALFON TAB ......................................................... 197
naloxegol oxalate tab ........................................... 214
naloxone hcl nasal spray ....................................... 208
naloxone hcl solution auto‐injector ...................... 208
naltrexone for im extended release susp .............. 208
NAMENDA TAB ..................................................... 194
NAMENDA XR CAP ................................................ 194
NAMENDA XR CAP TITRATIO ................................ 194
NAMZARIC CAP ....................................................... 50
NAPRELAN TAB ..................................................... 197
NAPROSYN SUS ..................................................... 197
NAPROSYN TAB ............................................. 196, 197
naproxen sodium tab ............................ 196, 197, 237
naproxen sodium tab er ........................................ 197
naproxen susp ....................................................... 197
305
naproxen tab ................................................ 196, 197
naproxen tab ec .................................................... 196
naproxen‐esomeprazole magnesium tab dr ......... 196
naratriptan hcl tab ................................................ 237
NARCAN SPR ......................................................... 208
NARDIL TAB ........................................................... 177
NASCOBAL SPR ....................................................... 93
NASONEX SPR ....................................................... 180
NATACHEW CHW .................................................. 220
NATACYN SUS ....................................................... 201
natalizumab for iv inj conc .................................... 179
NATALVIT TAB ....................................................... 220
natamycin ophth susp ........................................... 201
NATAZIA TAB ........................................................ 143
nateglinide tab ...................................................... 173
NATESTO GEL .......................................................... 42
NATPARA INJ ......................................................... 213
NATROBA SUS ....................................................... 235
NATURE THROI TAB .............................................. 252
NATURE‐THROI TAB .............................................. 252
NAYZILAM SPR ........................................................ 47
nebivolol hcl tab ...................................................... 80
NEBUPENT INH ....................................................... 57
Nebusal ................................................................. 176
necitumumab iv soln ............................................... 62
Necon ...................................................................... 97
nedocromil sodium ophth soln ............................. 200
NEEVO DHA CAP ................................................... 220
nelfinavir mesylate tab ........................................... 70
NEOCERA CRE ....................................................... 175
NEOKE ALCAR POW ................................................ 38
NEOKE BHB POW .................................................. 133
NEOKE MCT .......................................................... 171
NEOKE RA LIP POW ................................................. 38
neomycin sulfate/polymyxin b sulfate/bacitracin zinc
oin op ............................................................... 201
neomycin sulfate‐fluocinolone acetonide cream .... 46
neomycin‐colistin‐hc‐thonzonium otic susp .......... 211
neomycin‐polymyxin‐dexamethasone ophth oint 203
neomycin‐polymyxin‐dexamethasone ophth susp 203
neomycin‐polymyxin‐hc crm ................................... 46
NEONATAL PLS TAB .............................................. 220
NEONATAL TAB COMPLTE .................................... 220
Neo‐polycin ................................................... 201, 204
Neo‐polycin Hc...................................................... 204
NEORAL CAP ......................................................... 104
NEORAL SOL .......................................................... 104
NEOSALUS AER ..................................................... 175
NEOSALUS CP CRE ................................................ 175
NEOSALUS CRE ...................................................... 176
NEOSALUS LOT ...................................................... 176
NEO‐SYNALAR CRE .................................................. 46
NEOTUSS PLUS LIQ ............................................... 196
nepafenac ophth susp ................................... 203, 204
NEPHRON FA TAB ................................................. 168
neratinib maleate tab ............................................. 63
NERLYNX TAB .......................................................... 63
NESINA TAB .......................................................... 135
NESTABS DHA PAK ................................................ 220
NESTABS ONE CAP ................................................ 224
NESTABS TAB ........................................................ 220
netarsudil dimesylate ophth soln .......................... 203
netarsudil dimesylate‐latanoprost ophth soln ...... 202
netupitant‐palonosetron cap .................................. 52
Neuac ...................................................................... 31
neuac gel ................................................................. 31
NEULASTA INJ ....................................................... 149
NEULASTA KIT ....................................................... 150
NEULUMEX SUS .................................................... 231
NEUPOGEN INJ ..................................................... 150
NEUPRO DIS .......................................................... 195
NEUREPA CAP ....................................................... 133
NEURONTIN CAP ..................................................... 49
NEURONTIN SOL ..................................................... 49
NEURONTIN TAB ..................................................... 49
NEUTEK ................................................................. 123
NEUTRASAL POW .................................................. 137
NEVANAC SUS ....................................................... 203
nevirapine susp ....................................................... 70
nevirapine tab ......................................................... 70
nevirapine tab er ..................................................... 70
NEXAVAR TAB ......................................................... 62
NEXIUM CAP ......................................................... 228
NEXIUM GRA ......................................................... 228
NEXIUM I.V. INJ ..................................................... 228
NEXLETOL TAB ........................................................ 34
NEXLIZET TAB .......................................................... 30
NEXPLANON IMP .................................................. 225
NGR BRAND TAB ................................................... 198
niacin tab .............................................................. 193
niacin tab er .......................................................... 193
Niacor ................................................................... 193
NIASPAN TAB ........................................................ 193
NICAPRIN TAB ....................................................... 133
NICAZYME TAB ...................................................... 133
NICORELIEF GUM .................................................. 242
NICOTINE DIS ........................................ 241, 242, 243
NICOTINE GUM ............................. 241, 242, 243, 244
306
nicotine inhaler system ......................................... 243
NICOTINE LOZ ............................... 241, 242, 243, 244
NICOTINE LOZ MINI .............................................. 241
nicotine nasal spray .............................................. 243
NICOTINE POL GUM .............................................. 242
NICOTINE POL LOZ ................................................ 243
nicotine polacrilex gum ................. 241, 242, 243, 244
nicotine polacrilex lozenge ........... 241, 242, 243, 244
NICOTINE TD DIS ................................................... 243
nicotine td patch ................................... 241, 242, 243
NICOTROL INH ...................................................... 243
NICOTROL NS SPR ................................................. 243
nifedipine cap ......................................................... 87
nifedipine tab er ...................................................... 87
NIFEREX TAB ......................................................... 168
Nikki ........................................................................ 97
NILANDRON TAB ..................................................... 45
nilotinib hcl cap ....................................................... 64
nilutamide tab ........................................................ 45
nimodipine cap ....................................................... 87
nimodipine oral soln ............................................... 87
NINJACOF‐XG LIQ .................................................... 74
NINLARO CAP .......................................................... 62
nintedanib esylate cap .......................................... 229
niraparib tosylate cap ........................................... 217
nisoldipine tab er .................................................... 87
nitazoxanide for susp .............................................. 66
nitazoxanide tab ..................................................... 66
nitisinone cap ........................................................ 153
nitisinone susp ...................................................... 153
nitisinone tab ........................................................ 153
NITRO‐BID OIN ...................................................... 193
NITRO‐DUR DIS ..................................................... 193
nitrofurantoin macrocrystalline cap ..................... 258
nitrofurantoin monohydrate macrocrystalline cap......
258
nitroglycerin lingual aerosol ................................. 193
nitroglycerin oint .................................................. 193
nitroglycerin sl tab ................................................ 194
nitroglycerin sublingual powder packet................ 193
nitroglycerin td patch ........................................... 193
nitroglycerin tl soln ............................................... 193
NITROLINGUAL SPR PUMPSPRA ........................... 193
NITROMIST AER .................................................... 193
NITROSTAT SUB .................................................... 194
NITYR TAB ............................................................. 153
NIVA‐PLUS TAB ..................................................... 220
NIVATOPIC CRE PLUS ............................................ 176
NIVESTYM INJ ....................................................... 150
nivolumab iv soln .................................................... 62
nizatidine cap ........................................................ 151
NO CODING TES BLD GLUC ................................... 123
NOCDURNA SUB ................................................... 262
NOCLOT‐50 SOL ACD‐A ......................................... 163
Nolix ...................................................................... 102
Nora‐be ................................................................. 226
NORCO TAB ........................................................... 159
NORDITROPIN INJ ................................................. 150
norelgestromin‐ethinyl estradiol td ptwk ............... 98
norelgestromin‐ethinyl estradiol td ptwk150‐35 ... 98
norethindrone & ethinyl estradiol . 93, 94, 95, 96, 97,
98, 256
norethindrone & ethinyl estradiol tab . 93, 94, 97, 98,
256
norethindrone & ethinyl estradiol‐fe chew tab 95, 96,
97, 98
norethindrone ace & ethinyl estradiol 94, 95, 96, 97,
98
norethindrone ace & ethinyl estradiol tab .. 94, 95, 96
norethindrone ace & ethinyl estradiol‐fe .. 94, 95, 96,
97, 98
norethindrone ace & ethinyl estradiol‐fe tab .. 94, 95,
96, 97
norethindrone ace‐eth estradiol‐fe chew tab ... 96, 97
norethindrone ace‐ethinyl estradiol‐fe cap ............ 98
norethindrone ace‐ethinyl estradiol‐fe tab 94, 95, 96,
98
norethindrone ace‐ethinyl estradiol‐fe tab 24 . 94, 95
norethindrone acetate tab ............................ 139, 226
norethindrone acetate/ethinyl estradio tab ........ 139
norethindrone acetate‐ethinyl estradiol tab .. 97, 139
norethindrone ac‐ethinyl estrad‐fe tab ................ 256
norethindrone tab ................................................. 226
norethindrone tab ‐be tab .................................... 226
norethindrone‐eth estradiol tab ..................... 97, 256
norethin‐eth estradiol‐fe tab .................................. 83
NORGESIC TAB FORTE ........................................... 180
norgestimate & ethinyl estradiol tab .... 95, 96, 97, 98
norgestimate‐eth estrad tab ........................ 256, 257
norgestrel & ethinyl estradiol tab ..................... 94, 96
NORITATE CRE ...................................................... 233
Norlyda ................................................................. 226
Norlyroc ................................................................ 226
NORPACE CAP ......................................................... 46
NORPRAMIN TAB .................................................. 256
NORTHERA CAP .................................................... 192
Nortrel .................................................................. 256
NORTREL TAB .......................................................... 97
307
nortriptyline hcl cap .............................................. 256
NORVASC TAB ......................................................... 87
NORVIR POW .......................................................... 70
NORVIR SOL ............................................................ 70
NORVIR TAB ............................................................ 70
NOURIANZ TAB ....................................................... 34
NOURISH LIQ......................................................... 199
NOVA MAX PLS TES KETONE ................................. 123
NOVA MAX TES GLUCOSE ..................................... 123
NOVAREL INJ ......................................................... 212
NOVOEIGHT INJ ...................................................... 55
NOVOFINE AUT MIS .............................................. 187
NOVOFINE MIS ..................................................... 187
NOVOFINE PLS MIS ............................................... 188
NOVOLIN INJ ......................................................... 157
NOVOLIN N INJ ..................................................... 157
NOVOLIN N INJ RELION ......................................... 157
NOVOLIN N INJ U‐ ................................................. 157
NOVOLIN R INJ ...................................................... 157
NOVOLIN R INJ RELION ......................................... 157
NOVOLIN R INJ U‐ ................................................. 157
NOVOLIN70/30 INJ RELION................................... 157
NOVOLOG INJ ....................................................... 157
NOVOLOG INJ FLEXPEN ........................................ 157
NOVOLOG INJ PENFILL .......................................... 157
NOVOLOG MIX INJ ........................................ 157, 158
NOVOLOG MIX INJ FLEXPEN ................................. 158
NOVOPEN ECHO MIS ............................................ 188
NOVOSEVEN RT INJ ................................................. 55
NOVOTWIST MIS ................................................... 188
NOXAFIL SUS ......................................................... 255
NOXAFIL TAB ......................................................... 255
NPLATE INJ ............................................................ 251
NUBEQA TAB .......................................................... 45
NUCALA INJ ........................................................... 165
NUCORT LOT ......................................................... 102
NUCYNTA ER TAB .................................................. 208
NUCYNTA TAB ....................................................... 208
NUEDEXTA CAP ..................................................... 229
NUFERA TAB ......................................................... 168
Nulev ....................................................................... 77
NULOJIX INJ .......................................................... 239
NULYTELY SOL FLAV PKS ......................................... 84
NUMBRINO SOL .................................................... 180
NUMOISYN LIQ ..................................................... 137
NUMOISYN LOZ .................................................... 137
NUPLAZID CAP ........................................................ 68
NUPLAZID TAB ........................................................ 68
NURTEC TAB ........................................................... 85
NUTRASEB CRE ....................................................... 72
NUTROPIN AQ INJ ......................................... 150, 151
NUTROPIN AQ INJ NUSPIN ................................... 151
NUVAIL SOL ........................................................... 176
NUVARING MIS ....................................................... 98
NUVESSA GEL ........................................................ 260
NUVIGIL TAB ......................................................... 247
NUWIQ INJ .............................................................. 55
NUWIQ KIT .............................................................. 55
NUZYRA TAB ........................................................... 38
Nyamyc ................................................................... 53
NYMALIZE SOL ........................................................ 87
nystatin pow .......................................................... 53
nystatin cap ............................................................ 52
nystatin tab ............................................................. 52
Nystop ..................................................................... 53
O
OB COMPLETE CAP ONE ....................................... 220
OB COMPLETE CAP PETITE .................................... 220
OB COMPLETE TAB ............................................... 220
OB COMPLETE TAB PREMIER ................................ 220
OB COMPLETE/ CAP DHA ...................................... 220
obeticholic acid tab ............................................... 141
obinutuzumab soln for iv infusion ........................... 61
OBIZUR INJ .............................................................. 55
OBSTETRIX EC TAB ................................................ 220
OBSTETRIX PAK DHA ............................................. 220
OBSTETRX ONE CAP .............................................. 224
O‐CAL TAB PRENATAL ........................................... 220
OCALIVA TAB ........................................................ 141
Ocella ...................................................................... 97
ocrelizumab soln for iv infusion ............................ 179
OCREVUS INJ ......................................................... 179
OCTAGAM INJ ....................................................... 162
octreotide acetate for im inj kit ............................ 245
octreotide acetate inj ............................................ 245
octreotide acetate soln pen‐injector ..................... 245
OCUFLOX DRO ...................................................... 201
ODACTRA SUB ....................................................... 177
ODEFSEY TAB .......................................................... 69
ODOMZO CAP ......................................................... 61
ofatumumab conc for iv infusion ............................ 61
OFEV CAP .............................................................. 229
ofloxacin ophth soln .............................................. 201
ofloxacin tab ......................................................... 143
OGIVRI INJ ............................................................... 62
olanzapine orally disintegrating tab ..................... 251
olanzapine tab ...................................................... 251
308
olanzapine‐fluoxetine hcl cap ............................... 251
olaparib tab .......................................................... 217
olaratumab soln for iv infusion ............................... 62
olive oil .................................................................. 142
olmesartan medoxomil tab ............................... 43, 44
olmesartan medoxomil‐hydrochlorothiazide tab ... 43
olmesartan‐amlodipine‐hydrochlorothiazide tab ... 44
olodaterol hcl inhal aerosol soln ............................. 79
olopatadine hcl nasal soln .................................... 180
olopatadine hcl ophth soln ................................... 200
olsalazine sodium cap ........................................... 163
OLUMIANT TAB ....................................................... 71
OLUX AER .............................................................. 102
OLUX‐E AER ........................................................... 102
omacetaxine mepesuccinate for inj ........................ 65
omadacycline tosylate tab ...................................... 38
omalizumab for inj .................................................. 57
omalizumab subcutaneous soln prefilled syringe ... 57
ombitas‐paritapre‐riton & dasab tab pak ............ 153
OMECLAMOX‐ MIS PAK ........................................ 257
omega‐3‐acid ethyl esters (dietary management) cap
134
omega‐3‐acid ethyl esters cap ................................ 57
omeprazole magnesium for delayed release susp
packet ............................................................... 229
omeprazole‐sodium bicarbonate cap ................... 228
omeprazole‐sodium bicarbonate powd pack for susp .
228
OMNARIS SPR ....................................................... 180
OMNIFLEX DPR ..................................................... 130
OMNIPAQUE SOL .................................................. 232
OMNITROPE INJ .................................................... 151
OMNIVEX TAB ....................................................... 133
ON CALL PLUS TES BLD GLUC ................................ 123
ON CALL TES EXPRESS ........................................... 123
ON CALL VIVD TES BLD GLUC ................................ 124
onabotulinumtoxina for inj ................................... 193
ONCASPAR INJ ........................................................ 65
ondansetron hcl tab ................................................ 28
ondansetron oral soluble film ................................. 28
ONE DROP TES BLD GLUC ..................................... 124
ONE VITE TAB........................................................ 220
ONETOUCH TES ULTRA ......................................... 124
ONETOUCH TES VERIO .......................................... 124
ONEXTON GEL ......................................................... 31
ONFI SUS ................................................................. 47
ONFI TAB ................................................................. 47
ONGLYZA TAB ....................................................... 135
ONPATTRO SOL ..................................................... 240
ONTRUZANT INJ ...................................................... 62
ONZETRA XSAI MIS ............................................... 237
OPANA TAB ........................................................... 208
OPDIVO INJ ............................................................. 62
OPSUMIT TAB ....................................................... 229
OPTIUM TES .......................................................... 124
OPTIUMEZ TES ...................................................... 124
OPTUMRX TES BLD GLUC ...................................... 124
ORA‐BLEND SF SUS ............................................... 210
ORA‐BLEND SUS .................................................... 210
ORACEA CAP ......................................................... 233
ORACIT SOL ............................................................. 92
ORAFATE PST ........................................................ 227
Oralone Dental Paste ............................................ 246
ORA‐PLUS LIQ ....................................................... 210
ORAPRED ODT TAB ............................................... 146
ORA‐SWEET SF SYP ............................................... 210
ORA‐SWEET SYP .................................................... 210
ORAVIG TAB ............................................................ 58
ORENCIA CLCK INJ ................................................. 236
ORENCIA INJ .......................................................... 236
ORENITRAM TAB ................................................... 227
ORFADIN CAP ........................................................ 153
ORFADIN SUS ........................................................ 153
ORIAHNN CAP ....................................................... 139
ORILISSA TAB ........................................................ 149
ORKAMBI GRA ...................................................... 104
ORKAMBI TAB ....................................................... 104
ORPH/ASA/CAF TAB .............................................. 180
orphenadrine w/ aspirin & caffeine tab ................ 180
ORSYTHIA TAB ........................................................ 97
ORTHO MICRON TAB ............................................ 226
ORTHO TRI‐ TAB CYCLN LO ................................... 256
ORTHOVISC INJ ..................................................... 264
Oscimin ................................................................... 77
Oscimin Sr ............................................................... 77
oseltamivir phosphate cap .................................... 192
oseltamivir phosphate for susp ............................. 192
OSENI TAB ............................................................. 137
osilodrostat phosphate tab ................................... 103
osimertinib mesylate tab ........................................ 63
OSMOLEX ER TAB .................................................... 66
OSMOPREP TAB .................................................... 235
ospemifene tab ..................................................... 236
OSPHENA TAB ....................................................... 236
OTEZLA TAB .......................................................... 216
OTIPRIO SUS ......................................................... 211
OTOVEL DRO ......................................................... 211
OTREXUP INJ ........................................................... 71
309
OVACE PLUS AER .................................................... 72
OVACE PLUS CRE ..................................................... 72
OVACE PLUS GEL ..................................................... 72
OVACE PLUS LIQ ..................................................... 72
OVACE PLUS LOT ..................................................... 72
OVACE PLUS SHA .................................................... 72
OVACE WASH LIQ ................................................... 72
OVIDE LOT ............................................................. 235
OVIDREL INJ .......................................................... 212
oxandrolone tab ..................................................... 40
oxaprozin tab ................................................ 196, 197
OXAYDO TAB ......................................................... 208
oxazepam cap ......................................................... 78
OXBRYTA TAB ....................................................... 151
oxcarbazepine susp ................................................. 50
oxcarbazepine tab ............................................ 49, 50
oxcarbazepine tab er .............................................. 49
OXERVATE SOL ...................................................... 202
oxiconazole nitrate cream .................................... 160
oxiconazole nitrate lotion ..................................... 160
OXISTAT CRE ......................................................... 160
OXISTAT LOT ......................................................... 160
OXSORALEN‐UL CAP ............................................... 67
OXTELLAR XR TAB ................................................... 49
oxybutynin chloride tab ........................................ 259
oxybutynin chloride tab er .................................... 259
oxybutynin chloride td gel .................................... 259
oxybutynin td patch twice weekly ........................ 259
oxycodone cap er .................................................. 208
oxycodone hcl tab ................................................. 208
oxycodone hcl tab abuse deter ............................. 208
oxycodone hcl tab er ............................................. 208
oxycodone w/ acetaminophen tab ....................... 209
oxycodone/acetaminophen tab ........................... 209
OXYCONTIN TAB ................................................... 208
oxymetazoline hcl cream ...................................... 233
oxymetholone tab ................................................... 40
oxymorphone hcl tab ............................................ 208
oxyquinoline sulfate‐sod lauryl sulfate vag gel ..... 177
OXYTROL DIS ......................................................... 259
ozanimod cap pack ............................................... 245
ozanimod hcl cap .................................................. 245
OZEMPIC INJ ......................................................... 163
ozenoxacin cream ................................................... 46
OZOBAX SOL ........................................................... 90
OZURDEX IMP ....................................................... 205
P
PADCEV INJ ............................................................. 64
PAIN EASE AER MD STRM ..................................... 254
PAIN EASE AER MIST ............................................. 254
palbociclib cap ...................................................... 103
palbociclib tab ...................................................... 103
paliperidone tab er ................................................. 77
palivizumab im soln ................................................ 74
palonosetron hcl iv soln .......................................... 28
PALYNZIQ INJ ........................................................ 214
PAMELOR CAP ...................................................... 256
PANCREAZE CAP ................................................... 134
pancrelipase (lip‐prot‐amyl) dr cap ...................... 134
pancrelipase (lip‐prot‐amyl) tab ........................... 134
PANDEL CRE .......................................................... 102
panitumumab iv soln .............................................. 62
panobinostat lactate cap ........................................ 61
PANRETIN GEL ........................................................ 65
pantoprazole sodium ec tab ................................. 229
pantoprazole sodium for delayed release susp packet
229
pantoprazole sodium for iv soln ........................... 229
PANZYGA SOL ....................................................... 162
PARAGARD IUD T .................................................... 99
parathyroid hormone (recombinant) for inj cartridge .
213
PAREMYD SOL ....................................................... 202
paricalcitol cap...................................................... 159
PARLODEL CAP ........................................................ 66
PARLODEL TAB ........................................................ 66
PARNATE TAB ....................................................... 177
Paroex ..................................................................... 72
paroxetine hcl oral susp ........................................ 238
paroxetine hcl tab ................................................. 238
paroxetine hcl tab er ............................................. 238
paroxetine mesylate cap ....................................... 262
paroxetine mesylate tab ....................................... 238
PARSABIV INJ .......................................................... 85
PASER GRA .............................................................. 60
pasireotide diaspartate inj .................................... 245
pasireotide pamoate for im er susp ...................... 245
PATANASE SPR ...................................................... 180
patiromer sorbitex calcium for susp packet .......... 218
patisiran sodium iv soln ........................................ 240
PAXIL CR TAB ........................................................ 238
PAXIL SUS .............................................................. 238
PAXIL TAB .............................................................. 238
PAZEO DRO ........................................................... 200
pazopanib hcl tab ................................................... 64
PCCA SWEET SYP ‐SF ............................................. 210
PCCA SYRUP SYP VEHICLE ..................................... 210
310
PCCA‐PLUS SUS ..................................................... 210
PEDIAPRED SOL ..................................................... 146
PEDIARIX INJ ......................................................... 254
PEDVAX HIB INJ ....................................................... 76
peg .......................................................... 84, 138, 139
PEGANONE TAB .................................................... 158
pegaspargase inj ..................................................... 65
PEGASYS INJ .......................................................... 153
PEGASYS INJ PROCLICK ......................................... 153
pegfilgrastim soln prefilled syringe ............... 149, 150
pegfilgrastim soln prefilled syringe kit .................. 150
pegfilgrastim‐bmez soln prefilled syringe ............. 150
pegfilgrastim‐cbqv soln prefilled syringe .............. 150
pegfilgrastim‐jmdb soln prefilled syringe ............. 149
peginterferon alfa‐ .......................................... 65, 153
peginterferon beta‐ .............................................. 179
pegloticase inj ....................................................... 149
PEG‐PREP KIT .......................................................... 84
pegvaliase‐pqpz subcutaneous soln pref syringe.. 214
pegvisomant for inj ............................................... 150
PEMAZYRE TAB ....................................................... 60
pembrolizumab iv soln ............................................ 61
pemigatinib tab ...................................................... 60
PEN NEEDLE MIS ................................................... 188
PEN NEEDLES MIS ................................................. 188
penciclovir cream .................................................... 74
penicillamine cap .................................................... 91
penicillamine tab .................................................... 91
PENLEN EMU SPRAY ............................................. 176
PENNSAID SOL ........................................................ 58
PENTACEL INJ ........................................................ 254
pentafluoropropane‐tetrafluoroethane aero spray .....
254
pentamidine isethionate for nebulization soln ....... 57
PENTASA CAP ........................................................ 164
PENTETATE CA SOL ................................................. 51
pentetate calcium trisodium iv or inhalation soln .. 51
PENTETATE ZI SOL ................................................... 51
pentetate zinc trisodium iv or inhalation soln ........ 51
PENTIPS MIS ................................................. 187, 188
PENTOSAN CAP ..................................................... 166
pentosan polysulfate sodium cap delayed release 166
pentosan polysulfate sodium caps ........................ 166
PEPCID TAB ........................................................... 151
perampanel susp .................................................... 39
perampanel tab ...................................................... 39
PERCOCET TAB ...................................................... 209
PERCURA CAP ....................................................... 133
PERFOROMIST NEB ................................................. 79
PERIDEX SOL ........................................................... 72
perindopril arginine‐amlodipine besylate tab ........ 29
Periogard ................................................................ 72
PERJETA INJ ............................................................. 62
permethrin cream ................................................. 235
perphenazine tab .................................................. 214
pertuzumab soln for iv infusion .............................. 62
PERTZYE CAP ......................................................... 134
PEXEVA TAB .......................................................... 238
pexidartinib hcl cap ................................................. 64
PH STRIPS TES PH .................................................. 124
ph test ................................................................... 124
PHENACTIN AA LIQ PLUS ...................................... 199
Phenazo ................................................................ 258
phenazopyridine hcl tab........................................ 258
phenazopyridine tab ............................................. 258
phenelzine sulfate tab ........................................... 177
phenoxybenzamine hcl cap ..................................... 36
phenylephrine w/ dm‐gg tab .................................. 74
phenylephrine‐chlorphen‐dm liquid ...................... 196
phenylephrine‐guaifenesin tab ............................. 105
PHENYTEK CAP ...................................................... 158
phenytoin chew tab .............................................. 158
phenytoin sodium extended cap ........................... 158
phenytoin susp ...................................................... 158
PHEXXI GEL ........................................................... 260
Philith ...................................................................... 97
PHLAG SPR ............................................................ 176
PHOSLO CAP ......................................................... 215
PHOSLYRA SOL ...................................................... 215
PHOSPHOLINE SOL ................................................ 174
PHOTREXA VIS SOL ............................................... 203
PHOTREXA/PHO SOL VISC KIT ............................... 203
phytonadione inj ................................................... 265
phytonadione tab ................................................. 265
PICATO GEL ............................................................. 65
PICO WOUND KIT THER SYS .................................. 268
PIFELTRO TAB ......................................................... 70
pilocarpine hcl ophth soln ..................................... 174
pilocarpine hcl tab ................................................ 235
pimavanserin tartrate cap ...................................... 68
pimavanserin tartrate tab ...................................... 68
pimecrolimus cream ............................................. 173
pimozide tab ......................................................... 229
Pimtrea ................................................................... 83
pindolol tab ............................................................. 81
pioglitazone hcl tab .............................................. 250
pioglitazone hcl‐glimepiride tab ........................... 249
pioglitazone hcl‐metformin hcl tab ....................... 250
311
PIQRAY .................................................................. 216
pirfenidone cap ..................................................... 229
pirfenidone tab ..................................................... 229
Pirmella 1/35 .................................................. 97, 256
piroxicam cap................................................ 196, 197
pitavastatin calcium tab ....................................... 154
pitavastatin magnesium tab ................................. 154
pitolisant hcl tab ................................................... 154
PKU EASY TAB ....................................................... 199
PKU EASY TAB MICROTAB ..................................... 199
PLAQUENIL TAB ...................................................... 59
PLAVIX TAB ........................................................... 251
plecanatide tab ....................................................... 92
PLEGISOL SOL .......................................................... 89
PLEGRIDY INJ ......................................................... 179
PLEGRIDY INJ PEN ................................................. 179
PLEGRIDY INJ STARTER ......................................... 179
PLEGRIDY PEN INJ STARTER .................................. 179
PLENVU SOL ............................................................ 84
plerixafor subcutaneous inj................................... 103
PLEXION CLTH PAD ................................................. 31
PLEXION CRE ........................................................... 32
PLEXION LIQ ............................................................ 32
PLEXION LOT ........................................................... 32
PLIAGLIS CRE ......................................................... 253
pneumococcal ......................................................... 76
pneumococcal vaccine polyvalent inj...................... 76
PNEUMOVAX .......................................................... 76
PNV FOLIC AC TAB + IRON .................................... 220
PNV PRENATAL TAB PLUS ..................................... 220
PNV TABS TAB ....................................................... 221
Pnv‐dha ................................................................. 224
PNV‐DHA CAP ............................................... 223, 224
PNV‐DHA CAP DOCUSATE ..................................... 224
PNV‐OMEGA CAP .................................................. 221
Pnv‐select ............................................................. 221
POCKETCHEM TES EZ ............................................ 124
PODIAPN CAP ........................................................ 133
PODOCON SOL ...................................................... 169
podofilox gel ......................................................... 169
podophyllum resin soln ......................................... 169
polatuzumab vedotin‐piiq for iv solution ................ 64
POLIBAR PLUS SUS ................................................ 231
poliovirus vaccine, ipv injection ............................ 263
POLIVY INJ ............................................................... 64
Polycin .................................................................. 201
polyethylene glycol ................................................. 84
polyethylene glycol‐electrolyte solution ‐c sol ....... 84
polyethylene glycol‐electrolyte solution ‐n/flavor
pack sol ............................................................... 84
polyethylene glycol‐electrolyte solution sol ........... 84
polyethylene glycol‐electrolyte solution‐bisacodyl kit
84
polymyxin b‐trimethoprim ophth soln .................. 201
POLYPEG SUP MIS BASE ........................................ 214
POLYTRIM SOL OP ................................................. 201
pomalidomide cap .................................................. 61
POMALYST CAP ....................................................... 61
ponatinib hcl tab ..................................................... 63
poractant alfa intratracheal susp ......................... 232
Portia‐28 ................................................................. 97
PORTRAZZA INJ ....................................................... 62
posaconazole susp ................................................ 255
posaconazole tab delayed release ........................ 255
pot phos monobasic w/sod phos di & monobas tab ....
215
Potassium ....................................................... 92, 217
potassium tab ...................................................... 217
potassium & sodium acid phosphates tab ............ 215
potassium bicarbonate effer tab .......................... 218
potassium chloride tab er ..................................... 217
potassium citrate tab er ......................................... 92
Potassium Citrate/Citric Acid crystals ..................... 92
potassium iodide oral soln .................................... 166
potassium pak ....................................................... 217
potassium phosphate monobasic tab ................... 215
potassium sprinkle cap ......................................... 217
potassium tab ................................... 44, 69, 217, 218
POTELIGEO INJ ........................................................ 62
POVIDONE IOD SOL .............................................. 201
povidone‐iodine ophth soln .................................. 201
Pr Benzoyl Peroxide Wash ...................................... 34
PR CREAM KIT ....................................................... 176
PR NATAL .............................................................. 223
PRADAXA CAP ....................................................... 251
pralatrexate iv inj .................................................... 59
PRALUENT INJ ....................................................... 213
pramipexole dihydrochloride tab .......................... 195
pramipexole dihydrochloride tab er ...................... 195
pramlintide acetate pen‐inj .............................. 50, 51
Pramox Gel ........................................................... 172
pramoxine hydrochloride gel................................ 172
pramoxine‐hc aerosol foam .................................. 246
prasterone vaginal insert ...................................... 177
prasugrel hcl tab ................................................... 251
PRAVACHOL TAB ................................................... 154
pravastatin sodium tab ......................................... 154
312
praziquantel tab ..................................................... 44
prazosin hcl cap ...................................................... 45
PRECISION PT TES OF CARE .................................. 124
PRECISION TES PCX ............................................... 125
PRECISION TES PCX PLUS ...................................... 125
PRECISION TES QID ............................................... 125
PRECISION TES SOF‐TACT ..................................... 125
PRECISION TES XTRA ............................................. 125
PRECISN XTRA TES KETONE .................................. 125
PRECOSE TAB .......................................................... 37
PRED FORTE SUS ................................................... 205
PRED MILD SUS ..................................................... 205
PRED MOXIFLO SOL .............................................. 204
PRED MOXIFLO SUS BROMFEN ............................. 204
PRED SOD PHO SOL............................................... 205
PRED/NEPAFEN DRO ............................................. 204
PRED‐G S.O.P OIN OP ............................................ 204
PRED‐G SUS OP ..................................................... 204
PRED‐GAT‐BRO INJ ................................................ 204
PRED‐GATI SUS ..................................................... 204
PRED‐GATIFL‐ SUS BROMFENA ............................. 204
PREDNI/MOXI/ DRO NEPAFENA ........................... 204
PREDNI/MOXIF DRO ............................................. 204
PREDNIS/BROM SUS ............................................. 204
prednisolone ace‐moxifloxacin‐bromfenac op susp.....
204
prednisolone acetate ophth susp .......................... 205
prednisolone acetate‐moxifloxacin opth susp ...... 204
prednisolone acetate‐nepafenac ophth susp ........ 204
prednisolone sod phos orally disintegr tab ........... 146
prednisolone sod phosph oral soln ............... 146, 205
PREDNISOLONE SOL .............................................. 204
PREDNISOLONE SOL MOX‐BROM ......................... 204
PREDNISOLONE SUS ............................................. 205
prednisolone tab ................................................... 146
prednisolone tab therapy pack ............................. 146
prednisolone‐bromfenac ophth soln ..................... 204
prednisolone‐bromfenac ophth susp .................... 204
prednisolone‐gatifloxacin ophth susp ................... 204
prednisolone‐gatifloxacin‐bromfenac ophth soln . 204
prednisolone‐gatifloxacin‐bromfenac ophth susp 204
prednisolone‐moxifloxacin opth soln .................... 204
prednisolone‐moxifloxacin‐bromfenac opth sol ... 204
prednisolone‐moxifloxacin‐nepafenac ophth susp ......
204
PREDNISONE CON ................................................. 147
prednisone conc .................................................... 147
prednisone tab ...................................................... 147
prednisone tab delayed release ............................ 147
PREFEST TAB ......................................................... 139
pregabalin cap ........................................................ 49
pregabalin soln ....................................................... 49
pregabalin tab er .................................................. 217
PREGENNA TAB ..................................................... 221
PREGNYL INJ ......................................................... 212
PREMARIN TAB ..................................................... 140
PREMARIN VAG CRE ............................................. 261
PREMESISRX TAB .................................................. 225
PREMIUM BLOO MIS GLUCOSE ............................ 125
PREMPHASE TAB ................................................... 139
PREMPRO TAB ...................................................... 139
PRENA ................................................... 221, 222, 224
PRENA1 CHW ........................................................ 225
PRENA1 PEARL CAP ............................................... 221
PRENAISSANCE CAP .............................................. 224
PRENAISSANCE CAP PLUS ..................................... 224
PRENARA CAP PRENATAL ..................................... 221
PRENATA CHW ...................................................... 221
Prenatabs Rx ......................................................... 221
PRENATAL ..................... 218, 220, 221, 222, 223, 225
Prenatal 19 ........................................................... 221
PRENATAL PLS MIS MV + DHA .............................. 221
PRENATAL TAB .............................................. 220, 221
PRENATAL TAB LOW IRON .................................... 221
PRENATAL TAB PLUS ..................................... 220, 221
PRENATAL TAB PLUS/FE ....................................... 221
PRENATAL VIT TAB LOW IRON .............................. 221
prenatal vitamins with minerals 19 tab ................ 221
prenatal vitamins with minerals cap .................... 224
prenatal vitamins with minerals gt tab ................. 219
prenatal vitamins with minerals rx tab ................. 221
prenatal vitamins with minerals tab ..... 219, 221, 222
PRENATAL+FE TAB ................................................ 221
PRENATAL‐U CAP .................................................. 221
PRENATE AM TAB ................................................. 225
PRENATE CAP ENHANCE ....................................... 224
PRENATE CAP ESSENT ........................................... 224
PRENATE CAP PIXIE ............................................... 224
PRENATE CAP RESTORE ........................................ 224
PRENATE CHW ...................................................... 225
PRENATE DHA CAP ................................................ 224
PRENATE MINI CAP ............................................... 224
PRENATE TAB ELITE .............................................. 221
PRENATVITE TAB COMPLETE ................................ 221
PRENATVITE TAB PLUS .......................................... 221
PRENATVITE TAB RX ............................................. 222
PRENIS‐BROMF SOL .............................................. 204
PREP PADS PAD ....................................................... 75
313
PREPIDIL GEL ........................................................... 28
PREPLUS TAB ........................................................ 222
PRESERA AER ........................................................ 176
PRESTALIA TAB ....................................................... 29
PRETAB TAB .......................................................... 222
pretomanid tab ....................................................... 60
PREVACID CAP ...................................................... 229
PREVACID TAB ...................................................... 229
Prevalite .................................................................. 82
PREVENT SAFE MIS ............................................... 189
Previfem ................................................................. 97
PREVNAR ................................................................. 76
PREVYMIS TAB ........................................................ 93
PREZCOBIX TAB ....................................................... 69
PREZISTA SUS .......................................................... 70
PREZISTA TAB .......................................................... 70
PRIFTIN TAB ............................................................ 60
PRILOSEC POW ..................................................... 229
PRIMACARE CAP ................................................... 222
primaquine phosphate tab ..................................... 59
PRIMAQUINE TAB ................................................... 59
primidone tab ......................................................... 49
PRIMLEV TAB ........................................................ 209
PRIMSOL SOL .......................................................... 57
PRINIVIL TAB ........................................................... 29
PRISTIQ TAB .......................................................... 240
PRIVIGEN INJ ......................................................... 162
PRO COMFORT MIS .............................................. 189
PRO COMFORT PAD ALCOHOL ............................... 75
PRO VOICE TES V ................................................... 125
PROAIR DIGIH AER .................................................. 79
PROAIR HFA AER ..................................................... 79
PROAIR RESPI AER................................................... 79
probenecid tab ...................................................... 258
PROBICHEW CHW ................................................... 51
procarbazine hcl cap ............................................... 65
PROCARDIA CAP ..................................................... 87
PROCARDIA XL TAB ................................................. 87
prochlorperazine rectal sup .................................. 214
PROCRIT INJ .......................................................... 139
PROCTOCORT CRE ................................................ 232
PROCTOFOAM AER HC .......................................... 232
Procto‐pak ............................................................ 232
Proctosol Hc .......................................................... 232
Proctozone‐hc ....................................................... 232
PROCYSBI CAP ....................................................... 104
PROCYSBI GRA ...................................................... 104
PRODIGEN CAP ....................................................... 51
PRODIGY NO TES CODING .................................... 126
PROFILNINE INJ ....................................................... 55
progesterone micronized cap ............................... 226
progesterone vaginal gel ...................................... 261
progesterone vaginal insert .................................. 261
PROGLYCEM SUS .................................................. 105
PROGRAF CAP ....................................................... 173
PROGRAF GRA ...................................................... 173
PROGRAF INJ ......................................................... 173
PROLASTIN‐C INJ ..................................................... 37
PROLATE TAB ........................................................ 209
PROLENSA SOL ...................................................... 203
PROLEUKIN INJ ........................................................ 65
PROLEVA TAB ........................................................ 133
PROLIA SOL ........................................................... 232
PROMACTA PAK .................................................... 251
PROMACTA POW .................................................. 251
PROMACTA TAB .................................................... 252
PROMACTIN AA SUS PLUS .................................... 199
PROMELLA CAP PREBIOTI ....................................... 51
promethazine sup ................................................... 56
Promethegan .......................................................... 56
PROMETRIUM CAP ............................................... 226
PROMISEB CRE ........................................................ 72
propafenone hcl cap er ........................................... 46
proparacaine hcl ophth soln ................................. 202
propranolol hcl cap er ............................................. 80
propranolol hcl oral soln ......................................... 80
propranolol hcl sustained‐release beads cap er ..... 80
PROQUAD INJ ....................................................... 262
PROSCAR TAB ......................................................... 28
PROSTIN E ............................................................... 28
PROTEOLIN TAB .................................................... 133
PROTHELIAL PST ................................................... 227
PROTONIX INJ ....................................................... 229
PROTONIX PAK ...................................................... 229
PROTONIX TAB ...................................................... 229
PROTOPIC OIN ...................................................... 173
PROVAD CAP ........................................................... 51
PROVENTIL AER HFA ............................................... 79
PROVERA TAB ....................................................... 226
PROVIDA OB CAP .................................................. 222
PROVIGIL TAB ....................................................... 247
PROVOCHOLINE SOL ............................................. 105
PROZAC CAP ......................................................... 238
prucalopride succinate tab ..................................... 28
PRUCLAIR CRE ....................................................... 176
PRUDOXIN CRE ....................................................... 67
PRUMYX CRE ......................................................... 176
prussian blue insoluble cap ..................................... 51
314
PSORCON CRE ....................................................... 102
PSORIZIDE TAB FORTE .......................................... 155
PSORIZIDE TAB ULTRA .......................................... 155
PTS PANELS TES GLUCOSE .................................... 126
PTS PANELS TES KETONE ...................................... 126
PULMICORT INH.................................................... 246
PULMICORT SUS ................................................... 246
PULMONA CAP ..................................................... 133
Pulmosal ............................................................... 176
PULMOZYME SOL .................................................. 159
PURE COMFORT MIS ............................................. 189
PURE COMFORT PAD .............................................. 75
PURIFIED LIQ WATER ............................................ 210
PURIXAN SUS .......................................................... 59
PX ASPIRIN CHW ................................................... 234
PX ASPIRIN TAB ..................................................... 234
PYLERA CAP ........................................................... 257
pyrazinamide tab .............................................. 45, 60
PYRIDIUM TAB ...................................................... 258
pyridostigmine bromide oral soln ........................... 59
pyridostigmine bromide tab ................................... 59
pyridostigmine bromide tab er ............................... 59
PYRIDOXAL‐5‐ INJ PHOSPHAT ............................... 265
pyridoxal‐5 phosphate inj soln .............................. 265
PYRIME/LEUCO CAP ................................................ 58
pyrimethamine tab ................................................. 58
pyrimethamine‐leucovorin cap ............................... 58
PYROGALL ACD OIN .............................................. 169
pyrogallol‐chlorobutanol oint ............................... 169
Q
QBRELIS SOL............................................................ 29
QBREXZA PAD ....................................................... 177
QC ALCOHOL PAD SWABS ....................................... 75
QC CHILD ASA CHW .............................................. 234
QINLOCK TAB .......................................................... 63
QMIIZ ODT TAB ..................................................... 197
QNASL AER ............................................................ 180
QNASL CHILD SPR ................................................. 180
QTERN TAB ........................................................... 240
QUADRACEL INJ .................................................... 255
QUALAQUIN CAP .................................................... 59
QUARTETTE TAB ................................................... 141
quazepam tab ......................................................... 78
QUDEXY XR CAP ...................................................... 49
QUESTRAN POW ............................................... 82, 83
quetiapine fumarate tab ....................................... 131
quetiapine fumarate tab er .................................. 131
QUICKTEK TES ....................................................... 126
QUILLICHEW CHW ................................................ 247
QUILLIVANT SUS ................................................... 247
quinapril hcl tab ...................................................... 29
quinapril‐hydrochlorothiazide tab .......................... 29
quinine sulfate cap .................................................. 59
QUINTET AC TES BLD GLUC ................................... 126
QUINTET TES BLD GLUC ........................................ 126
QUTENZA KIT ........................................................ 172
QVAR REDIHA AER ................................................ 246
QVAR REDIHAL AER .............................................. 246
R
RA ALCOHOL PAD SWABS ....................................... 75
RA ASPIRIN CHW ................................................... 234
RA ASPIRIN TAB .................................................... 234
RA CHILD ASA CHW ............................................... 234
RA NICOTINE DIS ................................................... 243
RA NICOTINE GUM................................................ 243
RA NICOTINE LOZ .................................................. 243
RA PEN NEEDL MIS ............................................... 189
RA TRUETEST TES .................................................. 126
RABAVERT INJ ....................................................... 263
RABEPRAZOLE CAP ............................................... 229
rabeprazole sodium capsule sprinkle dr ....... 228, 229
rabeprazole sodium ec tab ................................... 228
rabies vaccine, pcec for inj .................................... 263
rabies virus vaccine, hdc inj .................................. 263
RADIAGEL GEL ....................................................... 268
RADIAPLEXRX GEL ................................................. 268
RADICAVA INJ ......................................................... 38
RADIOGARDASE CAP ............................................... 51
raloxifene hcl tab .................................................. 236
raltegravir potassium chew tab .............................. 69
raltegravir potassium packet for susp .................... 69
raltegravir potassium tab ....................................... 69
ramelteon tab ....................................................... 236
ramipril cap ............................................................. 29
ramucirumab iv soln ............................................. 262
RANEXA TAB ........................................................... 45
ranibizumab intravitreal inj .................................. 261
ranibizumab intravitreal soln pref syr ................... 261
ranolazine tab er ..................................................... 45
RAPAFLO CAP .......................................................... 36
RAPAMUNE SOL .................................................... 173
RAPAMUNE TAB ................................................... 173
RAPID GEL RX GEL ................................................. 155
rasagiline mesylate tab........................................... 66
RASUVO INJ............................................................. 71
RAVICTI LIQ ........................................................... 258
315
ravulizumab‐cwvz iv soln ........................................ 99
RAYALDEE CAP ...................................................... 159
RAYOS TAB ............................................................ 147
RAZADYNE ER CAP .................................................. 92
RAZADYNE TAB ....................................................... 92
READI‐CAT ............................................................. 231
REALITY SWAB PAD ................................................. 75
REAL‐TIME KIT....................................................... 148
REBIF INJ ............................................................... 179
REBIF REBIDO INJ .................................................. 179
REBIF REBIDO INJ TITRATN ................................... 179
REBIF TITRTN INJ PACK ......................................... 179
REBINYN SOL ........................................................... 55
REBLOZYL INJ ........................................................ 138
RECEDO GEL .......................................................... 235
RECK INJ ................................................................ 172
RECLAST INJ ............................................................ 83
Reclipsen ................................................................. 97
RECOMBINATE INJ .................................................. 55
RECOMBIVA‐HB INJ .............................................. 263
RECOTHROM SOL.................................................. 152
RECTIV OIN ........................................................... 193
RECURA CRE ............................................................ 53
REDICHEW RX CHW .............................................. 225
REFUAH PLUS TES BLD GLUC ................................ 126
REGENECARE GEL ................................................. 265
REGLAN TAB .......................................................... 144
regorafenib tab ....................................................... 62
REGRANEX GEL ..................................................... 265
RELAFEN DS TAB ................................................... 197
RELENZA MIS DISKHALE ........................................ 192
RELEXXII TAB ......................................................... 248
RELION BLOOD TES GLUCOSE ............................... 127
RELION KETON TES ............................................... 127
RELION PEN MIS ................................................... 190
RELION PREMI TES GLUCOSE ................................ 127
RELION PRIME TES ................................................ 127
RELION PRIME TES GLUCOSE ................................ 127
RELION TES KETONE ............................................. 127
RELION TES ULTIMA .............................................. 127
RELISTOR TAB ....................................................... 214
RELNATE DHA CAP ................................................ 222
RELPAX TAB .......................................................... 237
REMERON SLTB TAB ............................................... 37
REMERON TAB ........................................................ 37
REMICADE INJ ....................................................... 257
REMIGEN CREA CRE .............................................. 176
REMODULIN INJ .................................................... 227
RENACIDIN SOL ..................................................... 145
RENAGEL TAB ........................................................ 215
RENFLEXIS INJ ....................................................... 257
RENVELA POW ...................................................... 215
RENVELA TAB ........................................................ 215
repaglinide tab ...................................................... 173
REPATHA INJ ......................................................... 213
REPATHA PUSH INJ ............................................... 213
REPATHA SURE INJ ................................................ 213
REQUIP XL TAB ...................................................... 195
RESECTISOL SOL .................................................... 145
RESET APP MIS IOS/ANDR .................................... 135
RESET‐O MIS IOS/ANDR ........................................ 135
reslizumab iv infusion soln .................................... 165
RESTASIS EMU ...................................................... 202
RESTASIS MUL EMU .............................................. 202
RESTORA RX CAP ..................................................... 51
RESTORIL CAP ......................................................... 78
RETACRIT INJ ......................................................... 139
retapamulin oint ..................................................... 46
RETEVMO CAP ........................................................ 63
RETIN‐A CRE ............................................................ 34
RETIN‐A GEL ............................................................ 34
RETIN‐A MICR GEL .................................................. 34
RETISERT IMP ........................................................ 205
RETROVIR CAP ........................................................ 71
RETROVIR SYP ......................................................... 71
REVATIO INJ .......................................................... 230
REVATIO SUS ......................................................... 230
REVATIO TAB ........................................................ 230
REVEAL TES BLD GLUC .......................................... 127
revefenacin inhalation solution .............................. 85
REVLIMID CAP ....................................................... 162
REXULTI TAB ......................................................... 231
REYATAZ CAP .......................................................... 70
REYATAZ POW ........................................................ 70
REYVOW TAB ........................................................ 238
RHEUMATE CAP .................................................... 133
RHOFADE CRE ....................................................... 233
RHOPRESSA SOL .................................................... 203
RIAX AER ................................................................. 34
ribavirin cap .......................................................... 153
ribavirin for inhal soln ........................................... 233
ribavirin tab .......................................................... 153
ribociclib.......................................................... 65, 103
ribociclib succinate tab pack ................................. 103
riboflav .................................................................. 203
riboflavin ............................................................... 203
RIBOZEL CAP ......................................................... 133
RIDAURA CAP ........................................................ 149
316
rifabutin cap ........................................................... 60
RIFADIN CAP ........................................................... 60
RIFAMATE CAP ........................................................ 44
rifampin cap ...................................................... 44, 60
rifamycin sodium tab delayed release .................... 57
rifapentine tab ........................................................ 60
RIFATER TAB ........................................................... 45
rifaximin tab ........................................................... 57
RIGHTEST TES GS .................................................. 127
rilonacept for inj ................................................... 165
rilpivirine hcl tab ............................................... 68, 70
RILUTEK TAB ........................................................... 77
riluzole susp ............................................................ 77
riluzole tab .............................................................. 77
rimabotulinumtoxinb im inj .................................. 193
rimegepant sulfate tab disint ................................. 85
RIMSO‐50 SOL ....................................................... 166
RINVOQ TAB ........................................................... 71
riociguat tab ......................................................... 229
RIOMET ER SUS ....................................................... 82
RIOMET SOL ............................................................ 82
ripretinib tab ........................................................... 63
risankizumab‐rzaa sol prefilled syringe .................. 67
risedronate sodium tab ........................................... 83
risedronate sodium tab delayed release ................. 83
RISPERDAL SOL ....................................................... 77
RISPERDAL TAB ....................................................... 77
risperidone soln ...................................................... 77
risperidone tab .................................................. 77, 78
RITALIN LA CAP ..................................................... 248
RITALIN TAB .......................................................... 248
ritonavir oral soln.................................................... 70
ritonavir powder packet ......................................... 70
ritonavir tab ...................................................... 69, 70
RITUXAN INJ ...................................................... 62, 65
RITUXAN INJ HYCELA .............................................. 65
rituximab iv soln ..................................................... 62
rituximab‐abbs iv soln ............................................. 62
rituximab‐hyaluronidase human inj ........................ 65
rituximab‐pvvr iv soln ............................................. 62
rivaroxaban tab .................................................... 136
rivaroxaban tab starter therapy pack ................... 136
rivastigmine td patch .............................................. 92
Rivelsa ................................................................... 141
RIXUBIS INJ ............................................................. 55
rizatriptan benzoate oral disintegrating tab ........ 237
rizatriptan benzoate tab ....................................... 237
R‐NATAL OB CAP ................................................... 224
ROBAXIN‐750 TAB ................................................... 90
ROCALTROL CAP ................................................... 159
ROCALTROL SOL .................................................... 159
ROCKLATAN DRO .................................................. 202
roflumilast tab ...................................................... 236
rolapitant hcl tab therapy pack ............................ 248
romidepsin for iv inj ................................................ 61
ROMIDEPSIN INJ ..................................................... 61
romiplostim for inj ................................................ 251
romosozumab‐aqqg inj soln prefilled syringe ....... 236
ROP‐CLON‐KET INJ ................................................ 172
ropinirole hydrochloride tab ................................. 195
ropinirole hydrochloride tab er ............................. 195
ropivacaine‐clonidine‐ketorolac pref syr .............. 172
ropiv‐epi‐clonid‐ketorolac pref syr ........................ 172
rose bengal strips .................................................. 202
ROSE GLO TES ....................................................... 202
rosiglitazone maleate tab ..................................... 251
rosuvastatin calcium sprinkle cap ......................... 154
rosuvastatin calcium tab ...................................... 154
ROTARIX SUS ......................................................... 263
ROTATEQ SOL ....................................................... 263
rotavirus vaccine, live for oral susp....................... 263
rotavirus vaccine, live oral pentavalent soln ........ 263
rotigotine td patch ................................................ 195
ROWASA KIT ......................................................... 164
ROXICODONE TAB................................................. 208
ROZEREM TAB ....................................................... 236
ROZLYTREK CAP ...................................................... 63
RUBRACA TAB ....................................................... 217
rucaparib camsylate tab ....................................... 217
RUCONEST INJ......................................................... 85
rufinamide susp ...................................................... 47
rufinamide tab ........................................................ 47
RUXIENCE INJ .......................................................... 62
ruxolitinib phosphate tab ...................................... 169
RUZURGI TAB .......................................................... 60
RYBELSUS TAB ....................................................... 163
RYDAPT CAP ............................................................ 62
RYTARY CAP .......................................................... 170
RYTHMOL SR CAP.................................................... 46
RYVENT TAB ............................................................ 56
S
SABRIL POW .......................................................... 144
SABRIL TAB ............................................................ 144
SACCHARIN POW SODIUM ................................... 249
sacrosidase soln .................................................... 134
sacubitril‐valsartan tab ......................................... 192
safinamide mesylate tab ........................................ 66
317
SAFYRAL TAB ........................................................... 97
SAIZEN INJ ............................................................. 151
SAIZENPREP INJ ..................................................... 151
SALAGEN TAB ........................................................ 235
SALEX SHA ............................................................. 169
salicylic & lactic acids soln .................................... 169
salicylic acid & benzoic acid oint ........................... 169
salicylic acid cream ............................................... 169
salicylic acid er film‐forming soln.......................... 169
salicylic acid film forming liquid ............................ 169
salicylic acid foam ................................................. 169
salicylic acid gel .................................................... 169
salicylic acid lotion .................................................. 53
salicylic acid shampoo .......................................... 169
SALIMEZ FORT CRE ............................................... 169
SALIVAMAX POW .................................................. 137
salmeterol xinafoate aer pow ba ............................ 79
salsalate tab ......................................................... 234
SALVAX AER .......................................................... 169
SAMSCA TAB ......................................................... 239
SANCUSO DIS .......................................................... 28
SANDIMMUNE CAP ............................................... 104
SANDIMMUNE INJ ................................................ 104
SANDIMMUNE SOL ............................................... 104
SANDOSTATIN INJ ................................................. 245
SANDOSTATIN KIT LAR .......................................... 245
SANTYL OIN ........................................................... 138
SAPHRIS SUB ......................................................... 131
sapropterin dihydrochloride powder packet ......... 214
sapropterin dihydrochloride soluble tab ............... 214
SAPS CARE PAD ALCOHOL ...................................... 75
SAPS HEALTH PAD ALCOHOL .................................. 75
saquinavir mesylate tab.......................................... 70
SARAFEM TAB ....................................................... 218
SARCLISA SOL .......................................................... 62
sarecycline hcl tab ................................................ 250
sargramostim lyophilized for inj ........................... 150
sarilumab subcutaneous soln prefilled syringe ..... 166
SAVAYSA TAB ........................................................ 136
SAVELLA MIS TITR PAK .......................................... 142
SAVELLA TAB ......................................................... 142
saxagliptin hcl tab ................................................. 135
saxagliptin‐metformin hcl tab er .......................... 135
SB ALCOHOL PAD PREP ........................................... 75
SB CHILD ASA CHW ............................................... 234
SCARCIN GEL ......................................................... 235
SCARCIN LIQ ROLL‐ON .......................................... 235
SCARSILK GEL ........................................................ 235
scopolamine td patch ............................................. 52
SEASONIQUE TAB ................................................. 141
sebelipase alfa iv soln ........................................... 173
SEBUDERM GEL ..................................................... 176
secnidazole granules packet ................................... 38
secobarbital sodium cap ......................................... 77
SECONAL SOD CAP .................................................. 77
SECUADO DIS ........................................................ 131
secukinumab subcutaneous auto‐inj ...................... 67
secukinumab subcutaneous pref syr ....................... 67
SECURESAFE MIS .................................................. 190
SEEBRI NEOHA CAP ................................................. 84
segesterone ace‐ethinyl estradiol va ring ............... 98
SEGLUROMET TAB ................................................ 244
SELECT‐OB CHW.................................................... 222
SELECT‐OB+ PAK DHA ........................................... 224
selegiline hcl orally disintegrating tab .................... 66
selegiline td patch ................................................. 177
selexipag tab ......................................................... 230
selinexor tab therapy pack ...................................... 64
selpercatinib cap ..................................................... 63
selumetinib sulfate cap ........................................... 61
SELZENTRY SOL ....................................................... 69
SELZENTRY TAB ....................................................... 69
semaglutide soln pen‐inj ....................................... 163
semaglutide tab .................................................... 163
SEMPREX‐D CAP .................................................... 105
SE‐NATAL .............................................................. 222
SENSIPAR TAB ......................................................... 85
SENTRA AM CAP ................................................... 133
SENTRA PM CAP .................................................... 133
SEREVENT DIS AER .................................................. 79
SERNIVO SPR ......................................................... 102
SEROQUEL TAB ..................................................... 131
SEROQUEL XR TAB ................................................ 131
SEROSTIM INJ ........................................................ 151
sertaconazole nitrate cream ................................. 160
sertraline hcl oral concentrate for solution........... 239
sertraline hcl tab ................................................... 239
serum‐derived bovine immunoglob/protein isolate ....
134
Setlakin ................................................................. 141
sevelamer carbonate packet ................................ 215
sevelamer carbonate tab ...................................... 215
sevelamer hcl tab .................................................. 215
sevoflurane inhal soln ........................................... 265
SEYSARA TAB ........................................................ 250
SFROWASA ENE .................................................... 164
Sharobel ................................................................ 226
SHINGRIX INJ ......................................................... 263
318
SIGNIFOR INJ ......................................................... 245
SIGNIFOR LAR INJ .................................................. 245
SIKLOS TAB ............................................................ 105
sildenafil citrate for suspension ............................ 230
sildenafil citrate iv soln ......................................... 230
sildenafil citrate tab .............................................. 230
SILENOR TAB ......................................................... 159
SILIPAC KIT ............................................................ 236
SILIQ INJ .................................................................. 67
silodosin cap ........................................................... 36
siltuximab for iv infusion ....................................... 165
SILVADENE CRE ....................................................... 85
SILVER NITRA SOL ................................................... 89
silver nitrate soln .................................................... 89
silver sulfadiazine cream......................................... 85
SIMBRINZA SUS ....................................................... 37
Simliya..................................................................... 83
SIMPESSE TAB ....................................................... 141
simple ‐ syrup ................................................ 210, 211
SIMPLE SYP ........................................................... 210
SIMPONI ARIA SOL .................................................. 73
SIMPONI INJ ............................................................ 73
SIMULECT INJ ........................................................ 177
simvastatin susp ................................................... 154
simvastatin tab ............................................. 154, 166
sinecatechins oint ................................................... 36
SINEMET TAB ........................................................ 170
SINGULAIR CHW ................................................... 170
SINGULAIR GRA ..................................................... 170
SINGULAIR TAB ..................................................... 170
SINUVA IMP .......................................................... 181
siponimod fumarate tab ....................................... 245
sirolimus oral soln ................................................. 173
sirolimus tab ......................................................... 173
SIRTURO TAB .......................................................... 60
sitagliptin phosphate tab ...................................... 135
sitagliptin‐metformin hcl tab ................................ 135
sitagliptin‐metformin hcl tab er ............................ 135
SITAVIG TAB .......................................................... 154
SITZMARKS CAP .................................................... 231
SIVEXTRO TAB ....................................................... 212
SKELAXIN TAB ......................................................... 90
SKLICE LOT ............................................................ 235
SKYLA IUD ............................................................. 225
SKYRIZI INJ .............................................................. 67
SLYND TAB ............................................................ 226
SM ALCOHOL PAD PREP .......................................... 75
SM ASPIRIN CHW .................................................. 235
SM ASPIRIN TAB .................................................... 235
SM CHILD ASA CHW .............................................. 235
SM FOLIC ACD TAB ................................................ 143
SM NICOTINE DIS .................................................. 243
SM NICOTINE GUM ............................................... 243
SM NICOTINE LOZ ................................................. 243
SMART SENSE TES TEST ........................................ 128
SMARTEST TES BLD GLUC ..................................... 128
sod phos mono‐sod phos di tabs........................... 235
sod picosulfate‐mg ox‐citric ac sol .......................... 84
SOD SACCHARI GRA .............................................. 249
SOD SUL/SULF EMU ................................................ 32
SOD SUL/SULF SUS .................................................. 32
sod sulfate‐pot sulf‐mg sulf oral sol ........................ 84
sodium chloride soln............................................. 176
sodium chloride soln neb ..................................... 176
sodium chloride soln nebu .................................... 176
sodium citrate & citric acid soln .............................. 92
sodium citrate soln prefilled syringe ....................... 47
sodium fluoride chew tab ..................................... 142
sodium fluoride soln ............................................. 142
sodium fluoride tab ............................................... 143
sodium fluoride‐vitamin d liqd drops .................... 143
SODIUM HYALU INJ ............................................... 264
sodium hyaluronate intra‐articular gel pref syr .... 264
sodium hyaluronate intra‐articular inj .................. 264
sodium hyaluronate intra‐articular soln pref syr .. 264
sodium oxybate oral solution.................................. 47
sodium phenylbutyrate oral powder .................... 258
sodium phenylbutyrate tab................................... 258
sodium polystyrene sulfonate sus ........................ 218
SODIUM POW BICARBON ....................................... 44
sodium saccharin granules ................................... 249
sodium saccharin powder ..................................... 249
SODIUM SULFA LIQ ................................................. 72
sodium thiosulfate‐salicylic acid lotion ................... 53
sodium zirconium cyclosilicate for susp packet .... 218
SOFOS/VELPAT TAB .............................................. 153
sofosbuvir pellet pack ........................................... 153
sofosbuvir tab ....................................................... 153
sofosbuvir‐velpatasvir tab .................................... 153
sofosbuvir‐velpatasvir‐voxilaprevir tab ................ 153
SOF‐SENSOR MIS .................................................. 148
SOLIA TAB ............................................................... 97
solifenacin succinate tab ...................................... 259
SOLIQUA INJ .......................................................... 164
SOLIRIS INJ .............................................................. 98
SOLODYN TAB ....................................................... 250
SOLOSEC GRA ......................................................... 38
solriamfetol hcl tab ............................................... 136
319
SOLTAMOX SOL ...................................................... 52
SOLUS V ................................................................ 128
SOMA TAB............................................................... 90
somatropin (non‐refrigerated) for inj ................... 151
somatropin (non‐refrigerated) for subcutaneous inj ...
151
somatropin for inj ......................................... 150, 151
somatropin inj ............................................... 150, 151
SOMATULINE INJ .................................................. 245
SOMAVERT INJ ...................................................... 150
sonidegib phosphate cap ........................................ 61
SOOLANTRA CRE ................................................... 233
sorafenib tosylate tab ............................................. 62
sorbitol irrigation soln................................... 145, 210
SORBITOL SOL ............................................... 145, 210
SORBITOL‐MAN SOL ............................................. 145
sorbitol‐mannitol irrigation soln ........................... 145
SORIATANE CAP ...................................................... 67
SORILUX AER ........................................................... 67
sotalol hcl (afib/afl) tab .......................................... 80
sotalol hcl oral solution ........................................... 81
sotalol hcl tab ................................................... 80, 81
SOTYLIZE SOL .......................................................... 81
SOVALDI PAK ......................................................... 153
SOVALDI TAB ......................................................... 153
SPECTRACEF TAB .................................................... 91
SPEEDGEL RX GEL.................................................. 155
SPG SUPPOSI‐ MIS BASE ....................................... 214
spinosad susp ........................................................ 235
SPIRIVA AER ............................................................ 84
SPIRIVA CAP HANDIHLR .......................................... 85
SPIRIVA SPR ............................................................ 85
spironolactone & hydrochlorothiazide tab ........... 136
spironolactone susp .............................................. 218
spironolactone tab ................................................ 218
SPORANOX CAP .................................................... 255
SPORANOX CAP PULSEPAK ................................... 255
SPORANOX SOL ..................................................... 255
SPRAVATO SOL ..................................................... 194
Sprintec 28 .............................................................. 97
SPRITAM TAB .......................................................... 49
SPRIX SPR .............................................................. 197
SPRYCEL TAB ........................................................... 63
SR NICOTINE GUM ................................................ 243
Sronyx ..................................................................... 98
Ssd .......................................................................... 85
SSKI SOL ................................................................ 166
ST JOSEPH CHW LOW ........................................... 235
STALEVO ............................................................... 171
STARLIX TAB .......................................................... 173
stavudine cap .......................................................... 71
STEGLATRO TAB .................................................... 244
STEGLUJAN TAB .................................................... 240
STELARA INJ .................................................... 67, 165
STIMATE SOL ......................................................... 262
STIOLTO AER ........................................................... 35
stiripentol cap ......................................................... 48
stiripentol packet .................................................... 48
STIVARGA TAB ........................................................ 62
STOP SMOKING GUM ........................................... 243
STOP SMOKING LOZ .............................................. 243
STRATA CTX GEL.................................................... 176
STRATA XRT GEL ................................................... 176
STRATTERA CAP ...................................................... 35
STRENSIQ INJ ........................................................ 159
STRIBILD TAB .......................................................... 69
STRIVERDI AER ........................................................ 79
STROMECTOL TAB .................................................. 44
SUBOXONE MIS .................................................... 210
SUBSYS SPR ........................................................... 208
Subvenite Starter Kit ............................................... 49
succimer cap ........................................................... 51
SUCRAID SOL ......................................................... 134
SUCRALFATE SUS .................................................. 174
sucralfate susp ...................................................... 174
sucralfate tab ........................................................ 174
sucroferric oxyhydroxide chew tab ....................... 215
SULAR TAB .............................................................. 87
sulconazole nitrate cream .................................... 160
sulconazole nitrate solution .................................. 160
SULF LIME SOL ...................................................... 235
SULF/PREDNIS SUS OP .......................................... 204
sulfacetamide sodium cleansing gel ....................... 72
sulfacetamide sodium cream .................................. 72
sulfacetamide sodium foam ................................... 72
sulfacetamide sodium liquid ................................... 72
sulfacetamide sodium lotion............................. 30, 72
sulfacetamide sodium ophth soln ......................... 206
sulfacetamide sodium shampoo ............................. 72
sulfacetamide sodium w/ sulfur cleanser ......... 31, 32
sulfacetamide sodium w/ sulfur cleansing cloth ..... 31
sulfacetamide sodium w/ sulfur cleansing pad ...... 32
sulfacetamide sodium w/ sulfur cream ............ 31, 32
sulfacetamide sodium w/ sulfur emulsion .............. 32
sulfacetamide sodium w/ sulfur lotion ................... 32
sulfacetamide sodium w/ sulfur susp ..................... 32
sulfacetamide sodium w/ sulfur wash .................... 32
sulfacetamide sodium‐prednisolone ophth oint ... 203
320
sulfacetamide sodium‐prednisolone ophth susp . 203,
204
sulfadiazine tab .................................................... 248
sulfamethoxazole‐trimethoprim tab ....................... 57
SULFAMYLON CRE .................................................. 85
SULFAMYLON PAK .................................................. 85
sulfasalazine tab ................................................... 163
SULFUR COLLO KIT ................................................ 106
sulfurated lime solution ........................................ 235
sulfuric acid‐sulfonated phenolics soln ................... 72
sulindac tab .......................................................... 197
SUMADAN WASH LIQ ............................................. 32
sumatriptan nasal spray ....................................... 237
sumatriptan succinate exhaler powder ................ 237
sumatriptan succinate inj ..................................... 237
sumatriptan succinate solution auto‐injector ....... 238
sumatriptan succinate tab .................................... 237
sumatriptan‐naproxen sodium tab ....................... 237
SUMAXIN PAD ......................................................... 32
SUMAXIN WASH LIQ ............................................... 32
sunitinib malate cap ............................................... 62
SUNOSI TAB .......................................................... 136
SUPARTZ FX INJ ..................................................... 264
SUPPOSI‐PURE MIS ............................................... 214
SUPPOSITORY MIS BLEND ..................................... 214
SUPPRELIN LA KIT ................................................. 171
SUPRANE INH ........................................................ 265
SUPRANE SOL ........................................................ 265
SUPRAX CAP ............................................................ 91
SUPRAX CHW .......................................................... 91
SUPRAX SUS ............................................................ 91
SUPREME TES........................................................ 128
SUPREP BOWEL SOL PREP KIT ................................. 84
SURE COMFORT MIS ............................................. 190
SURE EDGE TES ..................................................... 128
SURECHEK TES BLD GLUC ..................................... 128
SURE‐FINE MIS ...................................................... 190
SURE‐TEST TES EASYPLUS ..................................... 128
SURVANTA INH ..................................................... 233
SUSPENDRX SUS SWEET ....................................... 210
SUSPENDRX SUS UNSWEET .................................. 210
SUSPENSION SUS VEHICLE .................................... 210
SUSTIVA CAP ........................................................... 70
SUSTIVA TAB ........................................................... 70
SUTENT CAP ............................................................ 62
SUVICORT EMU ..................................................... 176
suvorexant tab ...................................................... 211
Syeda ...................................................................... 98
SYLATRON KIT ......................................................... 65
SYLVANT SOL ........................................................ 165
SYMAX DUOTAB TAB .............................................. 77
Symax‐sr ................................................................. 77
SYMBICORT AER ...................................................... 35
SYMBYAX CAP ....................................................... 251
SYMDEKO TAB ...................................................... 104
SYMFI LO TAB ......................................................... 69
SYMFI TAB ............................................................... 69
SYMJEPI INJ ............................................................. 41
SYMLINPEN ............................................................. 50
SYMLNPEN .............................................................. 51
SYMPAZAN MIS ....................................................... 47
SYMPROIC TAB ...................................................... 214
SYMTUZA TAB ......................................................... 69
SYNAGIS INJ ............................................................ 74
SYNALAR CRE .................................................. 46, 102
SYNALAR OIN ........................................................ 102
SYNALAR SOL ........................................................ 102
SYNAREL SOL ......................................................... 171
SYNDROS SOL .......................................................... 52
SYNERA DIS ........................................................... 253
SYNERDERM EMU ................................................. 176
SYNJARDY TAB ...................................................... 244
SYNJARDY XR TAB ................................................. 244
SYNRIBO INJ ............................................................ 65
SYNTHROID TAB .................................................... 252
SYNVISC INJ ........................................................... 264
SYNVISC ONE INJ ................................................... 264
SYPRINE CAP ........................................................... 91
SYRINGE MIS ................................................. 181, 190
SYRPALTA SYP ............................................... 210, 211
SYRPALTA SYP CLEAR ............................................ 211
SYRSPEND SF LIQ .................................................. 211
SYRSPEND SF SUS PH ............................................ 211
SYRUP SF SYP VEHICLE .......................................... 211
SYRUP SYP VEHICLE ...................................... 210, 211
T
TABLOID TAB ........................................................... 59
TABRECTA TAB ........................................................ 63
TACHOSIL PAD ...................................................... 152
TACLONEX OIN ...................................................... 254
TACLONEX SUS ...................................................... 254
tacrolimus cap ...................................................... 173
tacrolimus cap er .................................................. 173
TACROLIMUS CRE MONOHYDR ............................ 173
tacrolimus cream .................................................. 173
tacrolimus inj ........................................................ 173
tacrolimus oint ...................................................... 173
321
tacrolimus packet for susp .................................... 173
tacrolimus tab er................................................... 173
tadalafil tab .......................................................... 230
tafamidis cap ........................................................ 255
tafamidis meglumine (cardiac) cap ...................... 255
tafenoquine succinate tab ................................ 58, 59
TAFINLAR CAP ......................................................... 60
tafluprost preservative free (pf) ophth soln .......... 227
TAGITOL V SUS ...................................................... 231
TAGRISSO TAB ........................................................ 63
TAKHZYRO INJ ....................................................... 216
talazoparib tosylate cap ....................................... 217
TALICIA CAP .......................................................... 257
taliglucerase alfa for inj .......................................... 36
talimogene laherparepvec intralesional inj .......... 200
TALTZ INJ ........................................................... 67, 68
TALZENNA CAP ..................................................... 217
TAMIFLU CAP ........................................................ 192
TAMIFLU SUS ........................................................ 192
tamoxifen citrate oral soln ...................................... 52
tamoxifen citrate tab .............................................. 52
tamsulosin hcl cap .......................................... 36, 227
TAPAZOLE TAB ........................................................ 73
tapentadol hcl tab ................................................ 208
tapentadol hcl tab er ............................................ 208
TARCEVA TAB .......................................................... 63
TARGADOX TAB .................................................... 250
TARGRETIN CAP .................................................... 236
TARGRETIN GEL .................................................... 254
Tarina 24 Fe ............................................................ 98
Tarina Fe 1/20 Eq .................................................... 98
TARKA TAB .............................................................. 29
TARON FORTE CAP ................................................ 168
TARON‐C DHA CAP ................................................ 222
TARON‐PREX CAP .................................................. 224
TASIGNA CAP .......................................................... 64
tasimelteon capsule .............................................. 236
TASMAR TAB ........................................................... 90
tavaborole soln ..................................................... 212
TAVALISSE TAB ...................................................... 245
TAYTULLA CAP ........................................................ 98
tazarotene (acne) foam .......................................... 34
tazarotene (acne) lotion ......................................... 33
tazarotene cream ................................................... 67
tazarotene gel ......................................................... 67
tazemetostat hbr tab .............................................. 61
TAZORAC CRE .......................................................... 67
TAZORAC GEL .......................................................... 67
TAZVERIK TAB ......................................................... 61
tbo‐filgrastim soln prefilled syringe ...................... 149
TDVAX INJ ............................................................. 255
TECENTRIQ INJ ........................................................ 62
TECFIDERA CAP ..................................................... 179
TECFIDERA MIS STARTER ...................................... 179
TECHNELITE KIT HEU ............................................. 106
TECHNELITE KIT LEU.............................................. 106
technetium tc ........................................................ 106
tedizolid phosphate tab ........................................ 212
teduglutide (rdna) for inj kit ................................. 145
tegaserod maleate tab ......................................... 159
TEGRETOL SUS ........................................................ 49
TEGRETOL TAB ........................................................ 49
TEGRETOL‐XR TAB ................................................... 49
TEGSEDI INJ ............................................................. 72
TEKTURNA HCT TAB .............................................. 136
TEKTURNA TAB ..................................................... 136
TELCARE TES BLD GLUC ........................................ 129
telmisartan tab ....................................................... 44
telmisartan‐amlodipine tab .................................... 43
telmisartan‐hydrochlorothiazide tab ...................... 43
telotristat etiprate tab .......................................... 257
temazepam cap ...................................................... 78
TEMIXYS TAB ........................................................... 69
TEMODAR CAP ...................................................... 160
TEMODAR INJ ....................................................... 160
TEMOVATE CRE ..................................................... 102
TEMOVATE OIN ..................................................... 102
temozolomide cap ................................................ 160
temozolomide for iv soln ...................................... 160
temsirolimus soln for iv infusion ............................. 62
Tencon .................................................................... 41
TENIVAC INJ .......................................................... 255
tenofovir alafenamide fumarate tab .............. 68, 153
tenofovir disoproxil fumarate oral powder ............. 71
tenofovir disoproxil fumarate tab ............... 68, 69, 71
TENORETIC TAB ...................................................... 80
TENORMIN TAB ...................................................... 80
TEPEZZA INJ .......................................................... 164
teprotumumab‐trbw for iv soln ............................ 164
terbinafine hcl tab .................................................. 52
teriflunomide tab .................................................. 178
teriparatide (recombinant) soln pen‐inj ........ 212, 213
TERIPARATIDE INJ ................................................. 213
tesamorelin acetate for inj ................................... 150
TESSALON PER CAP ................................................. 73
TESTIM GEL ............................................................. 42
TESTOPEL MIS PELLETS ........................................... 42
testosterone cypionate im inj in oil ......................... 42
322
testosterone implant pellets ................................... 42
TESTOSTERONE MIS ................................................ 42
testosterone nasal gel ............................................ 42
testosterone td gel ............................................ 41, 42
testosterone td patch ............................................. 41
testosterone undecanoate cap ............................... 42
testosterone undecanoate im inj in oil ................... 41
tet tox‐diph‐acell pertuss ad inj ............................ 254
tetanus‐diphtheria toxoids (td) inj ........................ 255
tetrabenazine tab ................................................. 177
tetracaine hydrochloride sol ................................. 202
TETRIX CRE ............................................................ 176
TEXACORT SOL ...................................................... 102
tezacaftor‐ivacaftor .............................................. 104
TGT ASPIRIN CHW ................................................. 235
TGT ASPIRIN CHW CHILD ...................................... 235
TGT ASPIRIN TAB................................................... 235
TGT NICOTINE DIS ................................................. 243
TGT NICOTINE GUM .............................................. 244
TGT NICOTINE LOZ ................................................ 244
thalidomide cap ...................................................... 58
THALOMID CAP ....................................................... 58
THEO‐24 CAP ........................................................ 268
theophylline cap er ............................................... 268
theophylline elixir.................................................. 268
THERAHONEY GEL ................................................. 268
THERAHONEY MIS................................................. 268
THERAMINE CAP ................................................... 133
THERAMINE POW PLUS ........................................ 133
thiamine hcl inj ..................................................... 264
thioguanine tab ...................................................... 59
THIOLA EC TAB ...................................................... 260
THIOLA TAB ........................................................... 260
thiothixene cap ..................................................... 251
THRIVACIN ............................................................ 199
THRIVACIN LIQ DETOX .......................................... 199
THRIVE GUM ......................................................... 244
THRIVITE RX TAB ................................................... 222
thrombin (recombinant) for soln .......................... 152
thrombin for soln .................................................. 152
thrombin for soln kit ............................................. 152
THROMBIN KIT ...................................................... 152
THROMBIN‐JMI KIT ............................................... 152
THROMBIN‐JMI SOL .............................................. 152
THROMBOGEN KIT ................................................ 152
THROMBOGEN SOL ............................................... 152
THYMOGLOBULN INJ ............................................ 161
thyroid tab .................................................... 252, 253
tiagabine hcl tab ................................................... 144
TIAZAC CAP ............................................................. 87
TIBSOVO TAB ........................................................ 169
ticagrelor tab ........................................................ 136
TICE BCG INJ ............................................................ 65
TIER UNI PLS MIS .................................................. 191
TIGAN CAP .............................................................. 52
TIGLUTIK SUS .......................................................... 77
TIKOSYN CAP ........................................................... 46
tildrakizumab‐asmn subcutaneous soln pref syringe ..
67
Tilia Fe ................................................................... 256
TIM/BRIM/DOR SOL ................................................ 82
TIM/DORZ/LAT SOL ................................................. 82
TIMOL/BRIM SOL DORZ/LAT ................................... 82
TIMOL/LATAN SOL .................................................. 82
timolol maleate ophth gel forming soln ................. 81
timolol maleate ophth soln ............................... 81, 82
timolol maleate preservative free ophth soln ......... 81
timolol ophth soln ................................................... 81
timolol‐brimon‐dorzol‐latanoprost oph soln .......... 82
timolol‐brimonidine‐dorzolamide ophth soln ......... 82
timolol‐dorzolamide‐latanoprost ophth soln .......... 82
TIMOPTIC OCU SOL ................................................. 81
TIMOPTIC SOL ......................................................... 81
TIMOPTIC‐XE SOL .................................................... 81
tinidazole tab .......................................................... 57
tiopronin tab ......................................................... 260
tiopronin tab delayed release ............................... 260
tiotropium br‐olodaterol inhal aero soln ................ 35
tiotropium bromide monohydrate inhal aerosol ... 84,
85
tiotropium bromide monohydrate inhal cap .......... 85
tipranavir cap.......................................................... 69
tipranavir oral soln ................................................. 69
TIROSINT CAP ........................................................ 253
TIROSINT‐SOL SOL ................................................. 253
TISSEEL KIT ............................................................ 152
TISSEEL SOL ........................................................... 152
tis‐u‐sol sol ............................................................ 168
TIVICAY PD TAB ....................................................... 69
TIVICAY TAB ............................................................ 69
TIVORBEX CAP ...................................................... 197
tizanidine hcl cap .................................................... 90
tizanidine hcl tab .................................................... 90
TL‐ICARE CAP ........................................................ 133
TOBAIKIENT CAP ................................................... 133
TOBI NEB ................................................................. 38
TOBI PODHALR CAP ................................................ 38
TOBRADEX OIN ..................................................... 204
323
TOBRADEX ST SUS ................................................. 204
TOBRADEX SUS ..................................................... 204
tobramycin inhal cap .............................................. 38
tobramycin nebu soln ............................................. 38
tobramycin ophth oint .......................................... 201
tobramycin ophth soln .......................................... 201
tobramycin‐dexamethasone ophth oint ............... 204
tobramycin‐dexamethasone ophth susp .............. 204
TOBREX OIN .......................................................... 201
TOBREX SOL .......................................................... 201
tocilizumab iv inj ................................................... 165
tocilizumab subcutaneous soln auto‐injector ....... 166
tofacitinib citrate tab .............................................. 71
tofacitinib citrate tab er .......................................... 71
TOLAK CRE .............................................................. 65
tolbutamide tab .................................................... 249
tolcapone tab .......................................................... 90
TOLSURA CAP ........................................................ 255
tolterodine tartrate cap er .................................... 259
tolterodine tartrate tab ........................................ 259
tolvaptan tab ........................................................ 239
tolvaptan tab therapy pack .................................. 239
TOPAMAX SPR CAP ................................................. 49
TOPAMAX TAB ........................................................ 50
TOPICORT CRE ...................................................... 102
TOPICORT GEL ...................................................... 102
TOPICORT OIN ...................................................... 102
TOPICORT SPR ....................................................... 102
topiramate cap er ............................................. 49, 50
topiramate sprinkle cap .......................................... 49
topiramate tab........................................................ 50
topotecan hcl cap ................................................. 254
TOPROL XL TAB ....................................................... 80
toremifene citrate tab............................................. 52
TORISEL SOL ............................................................ 62
torsemide tab ....................................................... 172
TOSYMRA SOL ....................................................... 237
TOUJEO MAX INJ ................................................... 158
TOUJEO SOLO INJ .................................................. 158
Tovet ..................................................................... 102
TOVIAZ TAB ........................................................... 259
TOXICOLOGY KIT MEDICATE ................................. 129
TRACLEER TAB ...................................................... 229
TRADJENTA TAB .................................................... 135
tramadol hcl cap er ....................................... 206, 208
tramadol hcl tab ................................................... 208
tramadol‐acetaminophen tab .............................. 255
trametinib dimethyl sulfoxide tab........................... 61
trandolapril tab ....................................................... 29
trandolapril‐verapamil hcl tab er ............................ 29
tranexamic acid tab .............................................. 152
TRANSDERM SC DIS ................................................ 52
TRANSDERM‐SC DIS ................................................ 52
TRANXENE T TAB .................................................... 78
tranylcypromine sulfate tab ................................. 177
TRANZGEL GEL ...................................................... 155
trastuzumab for iv soln ........................................... 61
trastuzumab‐anns for iv soln .................................. 61
trastuzumab‐dkst for iv soln ................................... 62
trastuzumab‐dttb for iv soln ................................... 62
trastuzumab‐hyaluronidase‐oysk inj ...................... 65
trastuzumab‐pkrb for iv soln................................... 61
trastuzumab‐qyyp for iv soln .................................. 62
TRAUMANIL GEL ................................................... 155
TRAUMEEL OIN ..................................................... 155
TRAUMEEL TAB ..................................................... 155
TRAVATAN Z DRO ................................................. 227
travoprost ophth soln ........................................... 227
TRAZIMERA INJ ....................................................... 62
TREANDA INJ ........................................................... 36
TRECATOR TAB ....................................................... 60
TRELEGY AER ELLIPTA ............................................. 35
TRELSTAR MIX INJ ................................................. 171
TREMFYA INJ ........................................................... 68
TREPADONE CAP ................................................... 133
treprostinil diolamine tab er ................................. 227
treprostinil inhalation solution ............................. 227
treprostinil inj soln ................................................ 227
TRESIBA FLEX INJ................................................... 158
TRESIBA INJ ........................................................... 158
tretinoin cre ........................................................... 33
tretinoin cap ......................................................... 233
tretinoin cream ....................................................... 34
tretinoin gel ................................................ 32, 33, 34
tretinoin lotion ........................................................ 33
tretinoin microsphere gel ........................................ 34
TREXALL TAB ........................................................... 59
TREXIMET TAB ...................................................... 237
Trezix .................................................................... 135
Tri Femynor .......................................................... 256
triamcinolone acetonide aerosol soln ................... 101
triamcinolone acetonide dental paste .................. 246
triamcinolone acetonide topical cre ..................... 102
triamterene & hydrochlorothiazide cap ................ 136
triamterene & hydrochlorothiazide tab ................ 136
triamterene cap .................................................... 218
triazolam tab .......................................................... 78
TRIBENZOR20‐ TAB ................................................. 44
324
TRIBENZOR40‐ TAB ................................................. 44
TRICARE PRE CAP .................................................. 222
TRICARE TAB PRENATAL ....................................... 222
TRI‐CHLOR LIQ ........................................................ 89
trichloroacetic acid liqd .......................................... 89
TRICITRASOL CON ................................................. 163
TRICOR TAB ........................................................... 142
Triderm ................................................................. 102
TRIDESILON CRE .................................................... 102
trientine hcl cap ...................................................... 91
Trientine Hydrochloride cap ................................... 91
Tri‐estarylla ........................................................... 256
trifarotene cream .................................................... 33
TRIFERIC POW ....................................................... 167
TRIFERIC SOL ......................................................... 167
trifluridine‐tipiracil tab ........................................... 65
TRIGLIDE TAB ........................................................ 142
TRIJARDY XR TAB .................................................. 240
TRIKAFTA TAB ....................................................... 104
Tri‐legest Fe .......................................................... 256
TRILEPTAL SUS ........................................................ 50
TRILEPTAL TAB ........................................................ 50
Tri‐linyah ............................................................... 256
TRILIPIX CAP .......................................................... 142
Tri‐lo‐estarylla ....................................................... 256
Tri‐lo‐marzia ......................................................... 256
Tri‐lo‐mili .............................................................. 257
Tri‐lo‐sprintec ....................................................... 257
TRILURON INJ ........................................................ 264
Trilyte ...................................................................... 84
trimethobenzamide hcl cap .................................... 52
trimethoprim hcl oral soln ...................................... 57
trimethoprim tab .................................................... 57
Tri‐mili ................................................................... 257
TRIMO‐SAN GEL .................................................... 177
TRINATAL RX TAB .................................................. 222
Trinate .................................................................. 222
TRINAZ TAB ........................................................... 222
TRINESSA TAB ....................................................... 257
TRINTELLIX TAB ..................................................... 239
Tri‐previfem .......................................................... 257
TRIPTODUR SUS .................................................... 171
triptorelin pamoate for im er susp ........................ 171
triptorelin pamoate for im susp ............................ 171
Tri‐sprintec............................................................ 257
TRISTART DHA CAP ............................................... 224
TRISTART ONE CAP ............................................... 224
TRI‐TABS DHA MIS ................................................ 222
TRIUMEQ TAB ......................................................... 69
TRIVEEN‐DUO PAK DHA ........................................ 223
TRIVISC INJ ............................................................ 264
Trivora‐28 ............................................................. 257
Tri‐vylibra .............................................................. 257
Tri‐vylibra Lo ......................................................... 257
TRIZIVIR TAB ........................................................... 69
TROKENDI XR CAP ................................................... 50
TROP‐CYC‐PE DRO ................................................ 103
tropicamide ophth soln ................................. 104, 202
tropicamide w/ phenylephrine ophth soln ............ 103
tropicamide‐cyclopentolate‐phenylephrine ophth
soln ................................................................... 103
tropicamide‐proparaca‐pe‐ketorolac ophth soln .. 103
TROP‐PHENYL SOL ................................................ 103
TROP‐PROP‐PE DRO KETO .................................... 103
TRUE FOCUS MIS BLOOD ...................................... 129
TRUE METRIX TES GLUCOSE ................................. 129
TRUETEST TES ............................................... 126, 129
TRUETRACK TES .................................................... 129
TRUETRACK TES BLD GLUC ................................... 129
TRULANCE TAB ....................................................... 92
TRULICITY INJ ........................................................ 163
TRUMENBA INJ ....................................................... 76
TRUSOPT SOL ........................................................ 201
TRUVADA TAB ......................................................... 69
TRUXIMA INJ ........................................................... 62
trypan blue ophth soln .......................................... 206
tryptophan cap ....................................................... 38
T‐SUPPORT CAP MAX ............................................ 133
tucatinib tab ........................................................... 64
TUDORZA PRES AER ................................................ 85
TUKYSA TAB ............................................................ 64
Tulana ................................................................... 226
TURALIO CAP .......................................................... 64
TURPENTINE SOL SPIRITS ...................................... 171
turpentine spirit .................................................... 171
TUSSICAPS CAP ..................................................... 209
TUXARIN ER TAB ................................................... 209
TUZISTRA XR SUS .................................................. 209
TWINRIX INJ .......................................................... 262
TWYNSTA TAB ......................................................... 43
TYBOST TAB ............................................................ 71
Tydemy ................................................................... 98
TYKERB TAB ............................................................ 64
TYLACTIN COM BAR .............................................. 199
TYLACTIN LIQ REST................................................ 199
TYLACTIN LIQ RTD ................................................. 199
TYLACTIN POW BLD .............................................. 199
TYLACTIN POW RESTOR ........................................ 199
325
TYLENOL/COD TAB # ............................................... 93
TYMLOS INJ ........................................................... 213
TYPHIM VI INJ ......................................................... 76
typhoid vi polysaccharide intramuscular vac inj ..... 76
TYR EASY TAB ........................................................ 199
TYSABRI INJ ........................................................... 179
TYVASO REFIL SOL ................................................. 227
TYVASO SOL .......................................................... 227
TYVASO START SOL ............................................... 227
U
UBRELVY TAB .......................................................... 85
ubrogepant tab ....................................................... 85
UCERIS AER ........................................................... 166
UCERIS TAB ........................................................... 147
UDENYCA INJ ........................................................ 150
ulipristal acetate tab ............................................. 137
ULORIC TAB ........................................................... 149
ULTANE SOL .......................................................... 265
ULTICARE MIC MIS ................................................ 191
ULTICARE PAD ALCOHOL ........................................ 75
ULTICARE PEN MIS ................................................ 191
ULTIGUARD MIS .................................................... 191
ULTILET INSU MIS ................................................. 191
ULTILET PAD ALCOHOL ........................................... 75
ULTILET PEN MIS ................................................... 192
ULTIMA TES........................................................... 129
ULTOMIRIS INJ ........................................................ 99
ULTRACET TAB ...................................................... 255
ULTRAM TAB ......................................................... 208
ULTRASAL‐ER SOL ................................................. 169
ULTRATRAK TES ULTIMATE ................................... 130
ULTRATRK PRO TES ............................................... 130
ULTRAVATE LOT .................................................... 102
umeclidinium br aero powd breath act .................. 84
umeclidinium‐vilanterol aero powd ba ................... 35
UNFINE PNTP MIS ................................................. 192
UNIFINE PNTP MIS ................................................ 192
UNISPEND ANH SUS SWEETENE ........................... 211
UNISTRIP1 TES GENERIC ....................................... 130
UNKNOWN DRUG TAB .......................................... 198
upadacitinib tab er ................................................. 71
UPTRAVI TAB ........................................................ 230
urea (carbamide) .................................................. 137
urea cream ............................................................ 137
urea soln ............................................................... 137
Uredeb .................................................................. 137
Uretron D/s ........................................................... 259
Uribel .................................................................... 259
uridine triacetate oral granules packet .......... 51, 153
Urimar‐t ................................................................ 259
Urin D/s ................................................................. 259
Uro‐458 ................................................................. 259
UROCIT‐K ................................................................ 92
UROGESIC‐ TAB BLUE ............................................ 259
Uro‐mp ................................................................. 259
UROXATRAL TAB ..................................................... 36
URSO ..................................................................... 144
URSO FORTE TAB .................................................. 144
ursodiol cap .......................................................... 144
ursodiol tab ........................................................... 144
Uryl ....................................................................... 259
ustekinumab inj .............................................. 67, 165
UTIBRON CAP NEOHALER ....................................... 35
Uticap ................................................................... 259
Utira‐c ................................................................... 259
UTOPIC CRE ........................................................... 137
Utrona‐c ................................................................ 259
V
VAGIFEM TAB ....................................................... 261
valacyclovir hcl tab ............................................... 154
valbenazine tosylate cap ...................................... 177
VALCHLOR GEL ........................................................ 64
VALCYTE SOL ........................................................... 93
VALCYTE TAB........................................................... 93
valganciclovir hcl for soln ....................................... 93
valganciclovir hcl tab .............................................. 93
VALIUM TAB............................................................ 78
valrubicin soln for intravesical instillation .............. 64
valsartan tab ............................................. 43, 44, 192
valsartan‐hydrochlorothiazide tab ................... 43, 44
VALSTAR SOL........................................................... 64
VALTOCO LIQ .......................................................... 47
VALTOCO SPR ......................................................... 47
VALTREX TAB ........................................................ 154
VANCOCIN CAP ..................................................... 149
VANCOCIN HCL CAP .............................................. 149
vancomycin hcl cap ............................................... 149
vancomycin hcl for oral soln ......................... 148, 149
VANCOMYCIN SOL ................................................ 149
Vandazole ............................................................. 260
vandetanib tab ....................................................... 63
VANOS CRE ........................................................... 102
VANTAS KIT ........................................................... 171
VAQTA INJ ............................................................. 263
varenicline tartrate tab ................................. 240, 241
VARIBAR HONE SUS .............................................. 231
326
VARIBAR NECT SUS ............................................... 231
VARIBAR PST PUDDING ........................................ 231
VARIBAR THIN SUS HONEY ................................... 232
VARIBAR THIN SUS LIQUID ................................... 232
varicella virus vac live for subcutaneous inj .......... 263
VARIVAX INJ .......................................................... 263
VARUBI TAB .......................................................... 248
VASCAZEN CAP ..................................................... 134
VASCEPA CAP .......................................................... 57
VASCUDERM GEL HYDROGEL ............................... 268
VASCULERA TAB .................................................... 134
VASERETIC TAB ....................................................... 30
VASHE CLEANS SOL ............................................... 266
VASOTEC TAB .......................................................... 29
VB6 P ..................................................................... 134
VECAMYL TAB ......................................................... 57
VECTIBIX INJ ............................................................ 62
VECTICAL OIN .......................................................... 67
vedolizumab for iv solution ................................... 165
VEG CAPSULE CAP # .............................................. 194
velaglucerase alfa for inj ......................................... 36
VELCADE INJ ............................................................ 63
VELETRI INJ ........................................................... 227
Velivet ................................................................... 257
VELPHORO CHW ................................................... 215
VELTASSA POW ..................................................... 218
VELTIN GEL .............................................................. 32
VEMLIDY TAB ........................................................ 153
vemurafenib tab ..................................................... 60
VENCLEXTA TAB ...................................................... 60
VENCLEXTA TAB START PK ...................................... 60
VENELEX OIN......................................................... 265
venetoclax tab ........................................................ 60
venetoclax tab therapy starter pack ....................... 60
venlafaxine hcl cap er ........................................... 239
VENTAVIS SOL ....................................................... 227
VENTOLIN HFA AER ................................................. 79
verapamil hcl cap er ................................................ 88
verapamil hcl tab ........................................ 29, 86, 87
verapamil hcl tab er .................................... 29, 86, 87
VERASENS TES ....................................................... 130
VERDESO AER ....................................................... 102
VEREGEN OIN .......................................................... 36
VERELAN CAP .......................................................... 88
VERELAN PM CAP ................................................... 88
VERSACLOZ SUS .................................................... 131
VERSAFREE SYP ..................................................... 211
VERSAPLUS SYP ..................................................... 211
VERZENIO TAB ...................................................... 103
VESICARE TAB ....................................................... 259
vestronidase alfa‐vjbk iv soln ................................ 178
VEXASYN GEL ........................................................ 268
VFEND SUS ............................................................ 255
VFEND TAB ............................................................ 255
VIBERZI TAB .......................................................... 159
VIBRAMYCIN CAP .................................................. 250
VIBRAMYCIN SUS .................................................. 250
VIBRAMYCIN SYP .................................................. 250
VICTORY TES AGM‐ ............................................... 130
VICTOZA INJ .......................................................... 163
VIDAZA INJ .............................................................. 59
VIEKIRA PAK TAB ................................................... 153
Vienva ..................................................................... 98
vigabatrin pow ...................................................... 144
vigabatrin powd pack ........................................... 144
vigabatrin tab ....................................................... 144
Vigadrone ............................................................. 144
VIGAMOX DRO ...................................................... 201
VIIBRYD KIT STARTER ............................................ 239
VIIBRYD TAB .......................................................... 239
VILACTIN AA LIQ PLUS .......................................... 200
Vilamit Mb ............................................................ 259
vilazodone hcl tab ................................................. 239
vilazodone hcl tab starter kit ................................ 239
Vilevev Mb ............................................................ 259
VIMIZIM INJ .......................................................... 178
VIMOVO TAB......................................................... 196
VIMPAT SOL ............................................................ 50
VIMPAT TAB ............................................................ 50
VINATE DHA CAP .................................................. 222
VINATE II TAB ........................................................ 222
VINATE ONE TAB ................................................... 222
VIOKACE TAB ........................................................ 134
Viorele .................................................................... 83
VIRACEPT TAB ......................................................... 70
VIRAMUNE SUS ....................................................... 70
VIRAMUNE TAB....................................................... 70
VIRAMUNE XR TAB ................................................. 70
VIRASAL LIQ .......................................................... 169
VIRAZOLE INH ....................................................... 233
VIREAD POW ........................................................... 71
VIREAD TAB ............................................................. 71
VIRT‐C DHA CAP .................................................... 222
VIRT‐FEFA CAP PLUS ............................................. 168
VIRT‐NATE CAP DHA ............................................. 222
VIRT‐PN DHA CAP ................................................. 224
VIRT‐PN PLUS CAP ................................................ 223
VISBIOME PAK ........................................................ 51
327
VISCO‐3 INJ ........................................................... 264
VISIONBLUE SOL ................................................... 206
vismodegib cap ....................................................... 61
VISTARIL CAP .......................................................... 45
VISTOGARD PAK ...................................................... 51
VITAFOL CAP ULTRA ............................................. 224
VITAFOL CHW GUMMIES ...................................... 223
VITAFOL FE+ CAP .................................................. 224
VITAFOL STRP MIS ................................................ 225
VITAFOL‐NANO TAB .............................................. 223
VITAFOL‐OB PAK +DHA ......................................... 224
VITAFOL‐OB TAB ................................................... 223
VITAFOL‐ONE CAP ................................................. 225
VITAMEDMD CAP ONE RX .................................... 225
vitamin a inj .......................................................... 264
VITAMIN K ............................................................. 265
VITAPEARL CAP ..................................................... 223
VITATHELY TAB ..................................................... 223
VITATRUE MIS ....................................................... 225
VITRAKVI CAP .......................................................... 63
VITRAKVI SOL .......................................................... 63
VIVA DHA CAP ....................................................... 223
VIVAGUARD TES INO............................................. 130
VIVELLE‐DOT DIS ................................................... 140
VIVITROL INJ ......................................................... 208
VIVLODEX CAP ...................................................... 197
VIZIMPRO TAB ........................................................ 64
VOCAL POINT TES BLD GLUC ................................ 130
VOGELXO GEL ......................................................... 42
VOGELXO GEL PUMP .............................................. 42
VOLNEA TAB ........................................................... 83
VOL‐PLUS TAB ....................................................... 223
VOL‐TAB RX TAB ................................................... 223
VOLTAREN GEL........................................................ 58
VOLUMEN SUS ...................................................... 232
von willebrand factor (recombinant) for inj ............ 55
VONVENDI INJ ......................................................... 55
vorapaxar sulfate tab ........................................... 227
voriconazole for susp ............................................ 255
voriconazole tab ................................................... 255
vorinostat cap ......................................................... 61
vortioxetine hbr tab .............................................. 239
VOSEVI TAB ........................................................... 153
VOTRIENT TAB ........................................................ 64
voxelotor tab ......................................................... 151
VP‐HEME OB MIS + DHA ....................................... 223
VP‐PNV‐DHA CAP .................................................. 223
VPRIV INJ................................................................. 36
VRAYLAR CAP .......................................................... 68
VSL#3 DS PAK .......................................................... 51
VUMERITY CAP ..................................................... 179
VUSION OIN ............................................................ 53
VYEPTI INJ ............................................................... 91
Vyfemla ................................................................... 98
VYLIBRA TAB ........................................................... 98
VYNDAMAX CAP ................................................... 255
VYNDAQEL CAP ..................................................... 255
VYONDYS .............................................................. 180
VYTORIN TAB ........................................................ 166
VYVANSE CAP .......................................................... 40
VYVANSE CHW ........................................................ 40
VYZULTA SOL ........................................................ 227
W
WAKIX TAB ............................................................ 154
warfarin sodium oral tab ..................................... 103
warfarin sodium tab ............................................. 103
WEBCOL PREP PAD LARGE ...................................... 75
WEBCOL PREP PAD MEDIUM.................................. 75
WELCHOL PAK ......................................................... 83
WELCHOL TAB ......................................................... 83
WELLBUTRIN TAB ................................................... 50
WELLBUTRIN TAB XL ............................................... 50
WELLMIND TAB VERTIGO ..................................... 155
Wera ....................................................................... 98
WESTHROID TAB ................................................... 253
WHEAT GERM OIL ................................................. 265
WIDE‐SEAL DPR KIT ............................................... 131
WILATE INJ .............................................................. 55
WITEPSOL H .......................................................... 214
WITEPSOL MIS ...................................................... 214
WOUND CARE PAD ............................................... 268
WP THYROID TAB .................................................. 253
Wymzya Fe ............................................................. 98
X
XADAGO TAB .......................................................... 66
XALATAN SOL ........................................................ 227
XALIX SOL .............................................................. 169
XALKORI CAP ........................................................... 64
XANAX TAB ............................................................. 78
XANAX XR TAB ........................................................ 78
XAQUIL XR TAB ..................................................... 134
XARELTO STAR TAB ............................................... 136
XARELTO TAB ........................................................ 136
XATMEP SOL ........................................................... 59
XCOPRI PAK ............................................................. 88
XCOPRI TAB ............................................................. 88
328
XELJANZ TAB ........................................................... 71
XELJANZ XR TAB ...................................................... 71
XELODA TAB ............................................................ 59
XELPROS EMU ....................................................... 227
XEMBIFY INJ .......................................................... 162
XENAZINE TAB ...................................................... 177
XENLETA TAB ........................................................ 216
xenon xe ................................................................ 106
XEOMIN INJ ........................................................... 193
XEPI CRE .................................................................. 46
XERAC‐AC SOL ......................................................... 76
XERALUX CRE ........................................................ 176
XERESE CRE ............................................................. 74
XERMELO TAB ....................................................... 257
XEROFORM OIL MIS .............................................. 266
XEROFORM OIL MIS ROLL ..................................... 266
XEROFORM OIL PAD ............................................. 266
XEROFRM GAUZ MIS ............................................. 266
XEROFRM GAUZ PAD ............................................ 266
XEROFRM PETR PAD ............................................. 266
XEROFRM ROLL MIS .............................................. 266
XEROSTOMIA SOL RELIEF ...................................... 137
XGEVA INJ ............................................................. 232
XHANCE MIS ......................................................... 181
XIFAXAN TAB ........................................................... 57
XIGDUO XR TAB .................................................... 244
XIIDRA DRO ........................................................... 173
XIMINO CAP .......................................................... 250
XODOL TAB ........................................................... 159
XOFLUZA TAB ........................................................ 212
XOLAIR INJ .............................................................. 57
XOLAIR SOL ............................................................. 57
XOLEGEL GEL ......................................................... 160
XOPENEX CONC NEB ............................................... 79
XOPENEX HFA AER .................................................. 79
XOPENEX NEB ......................................................... 79
XOSPATA TAB .......................................................... 64
XPOVIO PAK ............................................................ 64
XTAMPZA ER CAP .................................................. 208
XTANDI CAP ............................................................ 45
Xulane ..................................................................... 98
XULTOPHY INJ ....................................................... 164
XURIDEN POW ...................................................... 153
XYNTHA INJ ............................................................. 55
XYNTHA SOLOF INJ ................................................. 55
XYNTHA SOLOF KIT ................................................. 55
XYREM SOL ............................................................. 47
XYZBAC TAB .......................................................... 134
Y
YASMIN ................................................................... 98
YAZ TAB ................................................................... 98
yellow fever vaccine subcutaneous inj .................. 263
YERVOY INJ ............................................................. 62
YF‐VAX INJ ............................................................. 263
YL FOLIC ACI TAB ................................................... 143
YONSA TAB ............................................................. 41
YOSPRALA TAB ...................................................... 216
YUPELRI SOL ............................................................ 85
YUTIQ IMP............................................................. 206
Yuvafem ................................................................ 261
Z
ZACLIR LOT .............................................................. 34
zafirlukast tab ....................................................... 170
zaleplon cap .......................................................... 195
ZALTRAP INJ .......................................................... 262
ZALVIT TAB ............................................................ 223
ZANABIN GEL HYDROGEL ...................................... 268
ZANAFLEX CAP ........................................................ 90
ZANAFLEX TAB ........................................................ 90
zanamivir aero powder breath activated ............. 192
zanubrutinib cap ..................................................... 63
Zarah ....................................................................... 98
ZARONTIN CAP ...................................................... 248
ZARONTIN SOL ...................................................... 248
ZARXIO INJ ............................................................ 150
ZATEAN‐PN CAP DHA ............................................ 225
ZATEAN‐PN CAP PLUS ........................................... 223
ZAVESCA CAP .......................................................... 36
ZEGERID CAP ......................................................... 228
ZEGERID POW ....................................................... 228
ZEJULA CAP ........................................................... 217
ZELAC CAP ............................................................... 51
ZELAPAR TAB .......................................................... 66
ZELBORAF TAB ........................................................ 60
ZELNORM TAB ...................................................... 159
ZEMAIRA INJ ........................................................... 37
ZEMBRACE SYM INJ .............................................. 238
ZEMPLAR CAP ....................................................... 159
Zenatane ................................................................. 34
ZENPEP CAP .......................................................... 134
Zenzedi ................................................................... 40
ZEPATIER TAB ....................................................... 153
ZEPOSIA ................................................................ 245
ZEPOSIA CAP . ....................................................... 245
ZEPOSIA CAP STR KIT ............................................ 245
ZERIT CAP ................................................................ 71
