Blue Cross Blue Shield Nebraska MA CoreSM (HMO) …Discrimination is Against the Law Blue Cross and...

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medicare.nebraskablue.com

2020 Formulary(List of covered drugs)

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

This formulary was updated on 02/24/2020. For more recent information or other questions, please contact Blue Cross and Blue Shield of Nebraska Customer Service at 1-888-488-9850 or, for TTY users, 711, between 8 a.m. to 8 p.m., Central time, seven days a week from Oct. 1 through Mar. 31; 8 a.m. to 8 p.m. Central time, Monday through Friday from Apr. 1 through Sept. 30, or visit medicare.nebraskablue.com.

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

Last updated: 02/2020Formulary 20220, Version 07

Blue Cross Blue Shield Nebraska MA CoreSM (HMO)

Blue Cross Blue Shield Nebraska MA AccessSM (PPO) Blue Cross Blue Shield Nebraska

MA ChoiceSM (HMO-POS)

2020

http://medicare.nebraskablue.com


Discrimination is Against the Law

Blue Cross and Blue Shield of Nebraska complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Nebraska does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue Cross and Blue Shield of Nebraska: • Provides free aids and services to people with disabilities to communicate effectively

with us, such as:o Qualified sign language interpreterso 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:o Qualified interpreterso Information written in other languages

If you need these services, contact Customer Service at 1-888-488-9850, TTY 711.

If you believe that Blue Cross and Blue Shield of Nebraska 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 with:

Manager, Corporate ComplianceBlue Cross and Blue Shield of NebraskaP.O. Box 3248Omaha, NE 68180-00011-888-488-9850, TTY: 711Fax: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Manager, Corporate Compliance, is available to help you.

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 Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 1-800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

http://www.hhs.gov/ocr/office/file/index.html

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

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برقم اتصل لك بالمجان. تتوافر غویة للا كنت تتحدث اذكر، اللغة فإن خدمات المساعدة ذاإ :ة ظو ملح.(711 بك م: لا و صم لا فت (رقم ھا 1-888-488-9850

اگر بھ زبان فارسی صحبت میکنید، خدمات و کمکھای زبانی رایگان برای شما موجود است. توجھ :

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1-888-488-9850 (TTY: 711)ه مارشبا تر، شیبتعاالطابسکیابر

Multi-language Interpreter Services

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-488-9850 (TTY: 711).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-488-9850 (TTY: 711).

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。

請致電 1-888-488-9850（TTY: 711）。

Arabic:

French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-488-9850 (ATS: 711).

Cushite: XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-488-9850 (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-488-9850 (TTY: 711).

Korean: 주의:한국어를사용하시는경우,언어지원서비스를무료로이용하실수있습니다.1-888-488-9850 (TTY: 711)번으로전화해주십시오.

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Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-488-9850 (телетайп: 711).

າ ທານເວາພາສາ ລາວ, ການບ ການຊວຍເຫ Laotian: ໂປດຊາບ: ຖາວ ລ ອດານພາສາ, ໂດຍບເສຽຄາ,ແມນມ ອມໃຫ ານ. ໂທຣ 1-888-488-9850 (TTY: 711).

.دریگیبساتم

Kurdish:

Persian:

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

1-888-488-9850（TTY: 711）まで、お電話にてご連絡ください。

Nepali: धयान �दनहोस: य�द तपा�ल नपाली बोलन�नछ भन, तपा�को लािग भाषा सहायता सवाह� िन:शलक उपलबधछन। 1-888-488-9850 (TTY: 711) मा फोन गनरहोस।

Multi-language Interpreter Services

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-488-9850 (TTY: 711).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-488-9850 (TTY: 711).

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。

請致電 1-888-488-9850（TTY: 711）。

:Arabicقم ربلصتالك رفاتوتةیغوللاة دعاسمالات مدخإن فة غالل، ركاذث دحتتت كنذاإ:ةظوحلم .نجاملبا

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yS:uwd:r:pU:wI tvJwtdObO,erhIuwd: unDusdmf:ymfolOymfo;

French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-488-9850 (ATS: 711).

Cushite: XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-488-9850 (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-488-9850 (TTY: 711).

Korean: 주의:한국어를사용하시는경우,언어지원서비스를무료로이용하실수있습니다.1-888-488-9850 (TTY: 711)번으로전화해주십시오.

ທພ

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-488-9850 (телетайп: 711).

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ت. ساد وجوما مشی اربن اگیاری نابزی اھککمو ت ادمخ، دنیکیمت بصحی سرافن ابزھ بر گا :ھوجت .دریگیبساتم 1-888-488-9850 (TTY: 711)ه مارشبا تر، شیبتعاالطابسکیابر

Kurdish:

Persian:

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

1-888-488-9850（TTY: 711）まで、お電話にてご連絡ください。

Nepali: धयान �दनहोस: य�द तपा�ल नपाली बोलन�नछ भन, तपा�को लािग भाषा सहायता सवाह� िन:शलक उपलबधछन। 1-888-488-9850 (TTY: 711) मा फोन गनरहोस।

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue Cross and Blue Shield of Nebraska. When it refers to “plan” or “our plan,” it means Blue Cross Blue Shield Nebraska MA Core and/or Blue Cross Blue Shield Nebraska MA Access and/or Blue Cross Blue Shield Nebraska MA Choice.

This document includes a list of the drugs (formulary) for our plan which is current as of 02/24/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

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Blue Shield Nebraska MA Choice (HMO-POS)’s Formulary?”

• Drugs removed from the market. If the Food andDrug Administration deems a drug on our formulary to beunsafe or the drug’s manufacturer removes the drug fromthe market, we will immediately remove the drug from ourformulary and provide notice to members who takethe drug.

• Other changes. We may make other changes thataffect members currently taking a drug. For instance,we may add a generic drug that is not new to market toreplace a brand name drug currently on the formulary oradd new restrictions to the brand name drug or move itto a different cost-sharing tier. Or we may make changesbased on new clinical guidelines. If we remove drugs fromour formulary, or add prior authorization, quantity limitsand/or step therapy restrictions on a drug or move adrug to a higher cost-sharing tier, we must notify affectedmembers of the change at least 30 days before thechange becomes effective, or at the time the memberrequests a refill of the drug, at which time the member willreceive a 30 day supply of the drug.

If we make these other changes, you or yourprescriber can ask us to make an exceptionand continue to cover the brand name drug foryou. The notice we provide you will also includeinformation on how to request an exception, andyou can also find information in the section belowentitled “How do I request an exception to theBlue Cross Blue Shield Nebraska MA Core (HMO),Blue Cross Blue Shield Nebraska MA Access(PPO), and Blue Cross Blue Shield Nebraska MAChoice (HMO-POS)’s Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

The enclosed formulary is current as of 02/24/2020. The formulary is updated on a monthly basis. The current version can be found at, and a printed copy requested from, medicare.nebraskablue.com/MedicareAdvantage/RXCost. To get updated information about the drugs covered by Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice, please contact us. Our contact information appears on the front and back cover pages.

What is the Blue Cross Blue Shield Nebraska MA Core, Blue Cross Blue Shield Nebraska MA Access and Blue Cross Blue Shield Nebraska MA Choice Formulary?A formulary is a list of covered drugs selected by Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue Cross and Blue Shield of Nebraska network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage

Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove abrand name drug on our Drug List if we are replacing itwith a new generic drug that will appear on the sameor lower cost sharing tier and with the same or fewerrestrictions. Also, when adding the new generic drug, wemay decide to keep the brand name drug on our DrugList, but immediately move it to a different cost-sharingtier or add new restrictions. If you are currently taking thatbrand name drug, we may not tell you in advance beforewe make that change, but we will later provide you withinformation about the specific change(s) we have made.

If we make such a change, you or your prescribercan ask us to make an exception and continueto cover the brand name drug for you. The noticewe provide you will also include information onhow to request an exception, and you can alsofind information in the section below entitled “Howdo I request an exception to the Blue Cross BlueShield Nebraska MA Core (HMO), Blue Cross BlueShield Nebraska MA Access (PPO), and Blue Cross

http://medicare.nebraskablue.com/MedicareAdvantage/RXCost

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How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 102. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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

• Prior Authorization: Blue Cross Blue ShieldNebraska MA Core or Blue Cross Blue ShieldNebraska MA Access or Blue Cross Blue ShieldNebraska MA Choice requires you or your physicianto get prior authorization for certain drugs. Thismeans that you will need to get approval fromBlue Cross Blue Shield Nebraska MA Core orBlue Cross Blue Shield Nebraska MA Access

or Blue Cross Blue Shield Nebraska MA Choice before you fill your prescriptions. If you don’t get approval, Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice may not cover the drug.

• Quantity Limits: For certain drugs, Blue CrossBlue Shield Nebraska MA Core or Blue CrossBlue Shield Nebraska MA Access or Blue CrossBlue Shield Nebraska MA Choice limits the amountof the drug that Blue Cross Blue Shield NebraskaMA Core or Blue Cross Blue Shield NebraskaMA Access or Blue Cross Blue Shield NebraskaMA Choice will cover. For example, Blue CrossBlue Shield Nebraska MA Core or Blue CrossBlue Shield Nebraska MA Access or Blue CrossBlue Shield Nebraska MA Choice provides thirtytablets per prescription for alfuzosin ER. Thismay be in addition to a standard one-month orthree-month supply.

• Step Therapy: In some cases, Blue CrossBlue Shield Nebraska MA Core or Blue CrossBlue Shield Nebraska MA Access or Blue CrossBlue Shield Nebraska MA Choice requires you tofirst try certain drugs to treat your medical conditionbefore we will cover another drug for that condition.For example, if Drug A and Drug B both treatyour medical condition, Blue Cross Blue ShieldNebraska MA Core or Blue Cross Blue ShieldNebraska MA Access or Blue Cross Blue ShieldNebraska MA Choice may not cover Drug B unlessyou try Drug A first. If Drug A does not work foryou, Blue Cross Blue Shield Nebraska MA Core orBlue Cross Blue Shield Nebraska MA Access orBlue Cross Blue Shield Nebraska MA Choice willthen cover Drug B.

You can find out if your drug has any additionalrequirements or limits by looking in the formulary thatbegins on page 1. You can also get more informationabout the restrictions applied to specific covered drugsby visiting our Web site. We have posted onlinedocuments that explain our prior authorization and steptherapy restrictions. You may also ask us to send youa copy. Our contact information, along with the date welast updated the formulary, appears on the front andback cover pages.

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You can ask Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice formulary?”on page iii for information about how to request an exception.

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugsthat are covered by Blue Cross Blue Shield NebraskaMA Core or Blue Cross Blue Shield NebraskaMA Access or Blue Cross Blue Shield NebraskaMA Choice. When you receive the list, show it to yourdoctor and ask him or her to prescribe a similar drugthat is covered by Blue Cross Blue Shield NebraskaMA Core or Blue Cross Blue Shield NebraskaMA Access or Blue Cross Blue Shield NebraskaMA Choice.

• You can ask Blue Cross Blue Shield NebraskaMA Core or Blue Cross Blue Shield NebraskaMA Access or Blue Cross Blue Shield NebraskaMA Choice to make an exception and cover yourdrug. See below for information about how to requestan exception.

How do I request an exception to the Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice Formulary?You can ask Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or

Blue Cross Blue Shield Nebraska MA Choice to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on ourformulary. If approved, this drug will be covered at apre-determined cost-sharing level, and you wouldnot be able to ask us to provide the drug at a lowercost-sharing level.

• You can ask us to cover a formulary drug at a lowercost-sharing level if this drug is not on the specialty tier.If approved this would lower the amount you must payfor your drug.

• You can ask us to waive coverage restrictions orlimits on your drug. For example, for certain drugs,Blue Cross Blue Shield Nebraska MA Core or BlueCross Blue Shield Nebraska MA Access or Blue CrossBlue Shield Nebraska MA Choice limits the amount ofthe drug that we will cover. If your drug has a quantitylimit, you can ask us to waive the limit and cover agreater amount.

Generally, Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision.

If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary.

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Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

Transition Notice• You may have changes that take you from one

treatment setting to another. During this level of carechange, drugs may be prescribed that are not coveredby your plan. If this happens, you and your doctor mustuse your plan’s exception and appeals processes.However, when you are admitted to, or discharged from,a long-term care setting, you may not have access tothe drugs you were previously given. You may get a refillupon admission or discharge to prevent a gap in care.

For more informationFor more detailed information about your Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7days a week. TTY users should call 1-877-486-2048.Or, visit http://www.medicare.gov.

Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice FormularyThe formulary below provides coverage information about the drugs covered by Blue Cross Blue Shield Nebraska MA Core and Blue Cross Blue Shield Nebraska MA Access and Blue Cross Blue Shield Nebraska MA Choice. If you have trouble finding your drug in the list, turn to the Index that begins on page 102.

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

The information in the Requirements/Limits column tells you if Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MA Access or Blue Cross Blue Shield Nebraska MA Choice has any special requirements for coverage of your drug.

http://www.medicare.gov

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Your costs (see cost-share tables below)The amount you pay for a covered drug will depend on:

• Your coverage stage. Blue Cross Blue Shield Nebraska MA Core or Blue Cross Blue Shield Nebraska MAAccess or Blue Cross Blue Shield Nebraska MA Choice has different stages of coverage. In each stage, theamount you pay for a drug may change.

• The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copayor coinsurance amount. The “Drug Tiers” chart below explains what types of drugs are included in each tier andshows how costs may change with each tier.

• The pharmacy you use. You may go to any of our network pharmacies. However, you will usually pay lessfor your three-month supply of covered drugs if you use a preferred network pharmacy or network mail orderpharmacy rather than a standard retail pharmacy. The Pharmacy Directory will tell you which of the pharmacies inour network are preferred network pharmacies and network mail order pharmacies.

Some of your drugs on our Formulary are available for mail order: Our plan’s mail-order service requires you to order no more than a 90-day supply. Tier 5 specialty drugs are limited to 30-day supply via mail order.

Description of our Formulary Drug Tiers

TierStandard retail

cost-sharing (in-network) (up to a 30-day supply)

Preferred retail (in-network) and

Mailorder cost-sharing (up to a 30-day supply)

Long-term care (LTC) cost-sharing

(up to a 31-day supply)

Cost-sharing Tier 1

(Preferred Generic Drugs)

MA Core: $14

MA Choice: $12

MA Access: $12

MA Core: $3

MA Choice: $2

MA Access: $0

MA Core: $3

MA Choice: $2

MA Access: $0

Cost-sharing Tier 2

(Generic Drugs)

MA Core: $18

MA Choice: $18

MA Access: $18

MA Core: $8MA Choice: $8

MA Access: $8

MA Core: $8MA Choice: $8

MA Access: $8

Cost-sharing Tier 3

(Preferred Brand Drugs)

MA Core: $47

MA Choice: $47

MA Access: $47

MA Core: $37

MA Choice: $37

MA Access: $37

MA Core: $37

MA Choice: $37

MA Access: $37

Cost-sharing Tier 4

(Non-preferred)

MA Core: 45%

MA Choice: 45%

MA Access: 45%

MA Core: 45%

MA Choice: 45%

MA Access: 45%

MA Core: 45%

MA Choice: 45%

MA Access: 45%

Cost-sharing Tier 5

(Specialty Drugs)

MA Core: 28%

MA Choice: 30%

MA Access: 31%

MA Core: 28%MA Choice: 30%

MA Access: 31%

MA Core: 28%MA Choice: 30%

MA Access: 31%

vi

2020 Dosage Form Abbreviations Keyact actuation

ad adsorbed

aepb aerosol powder blister

aer, aero aerosol

app applicator

ba, breath act, breath activ

breath activated

bau bioequivalent allergy units

cal calcium

cap, caps capsules

cart cartridge

cd continuous delivery

chew tab chewable tablets

conc concentrate

conj conjugate, conjugated

crys crystals

deter deterrent

disint, disintegr disintegrating

dr delayed-release

ec enteric coated

el, elu enzyme-linked immunosorbent assay

er, extend-release, extended, extended rel, xr

extended-release

ext extract

gm gram

gu genitourinary

hr hour

im intramuscular

inh, inhal inhalation

2020 Dosage Form Abbreviations Keyinj injection

ir index of reactivity

iv intravenous

l literla long actinglf, lfu flocculation unitsliq, liqd liquidmcg microgrammeq milliequivalentmg milligrammisc miscellaneousml millilitermu million unitsnebu nebulesorally disintegr tab orally disintegrating tabletsoin, oint ointmentop, ophth ophthalmicosm osmoticpah pulmonary arterial hypertensionpak packpf preservative-freepfu plaque forming unitspow, powd powderpmdd premenstrual dysphoric disorderpref, prefill prefilledpttw patch twice weeklyptwk patch weeklyrecomb recombinantrefrig refrigeratesl sublingualsol, soln solutionsqcm square centimetersupp, suppos suppositoriessus, susp suspensionsyr syringetab, tabs tabletstd transdermaltl translingualunt unitva vaginalvac vaccine

List of Abbreviations

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These drugs require prior authorization to determine coverage under Part B or Part D. Information may need to be provided that describes the use or the place where the drug is received to determine coverage.PA = Prior AuthorizationQL = Quantity LimitsST = Step Therapy* = Limited Distribution Drug. This prescription may be available only at certain pharmacies.# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower co-pay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.

2020

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

1

Drug Name Drug Tier Requirements/LimitsAnalgesicsABSTRAL - fentanyl citrate sl tab 100 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 200 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 400 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 600 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 800 mcg 5 PA, QL (120 tablets/30 days)acetaminophen w/ codeine soln 120-12 mg/5ml 3 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 3 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 3 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 3 QL (180 tablets/30 days)butalbital-acetaminophen tab 50-325 mg# 4 QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg# 4 QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg# 4 QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 4 QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 4 QL (180 capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj 1 mg/ml 3butorphanol tartrate inj 2 mg/ml 3butorphanol tartrate nasal soln 10 mg/ml 4 QL (87.5 mls/30 days)celecoxib cap 50 mg 2 QL (60 capsules/30 days)celecoxib cap 100 mg 2 QL (60 capsules/30 days)celecoxib cap 200 mg 2 QL (60 capsules/30 days)celecoxib cap 400 mg 2 QL (30 capsules/30 days)codeine sulfate tab 60 mg 3 QL (180 tablets/30 days)codeine sulfate tab 30 mg 3 QL (180 tablets/30 days)diclofenac potassium tab 50 mg 2 QL (120 tablets/30 days)diclofenac sodium gel 1% 2 PAdiclofenac sodium tab delayed release 25 mg 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg 2 QL (90 tablets/30 days)EC-NAPROXEN - naproxen tab ec 375 mg 2 QL (120 tablets/30 days)EC-NAPROXEN - naproxen tab ec 500 mg 2 QL (90 tablets/30 days)etodolac cap 200 mg 2 QL (150 capsules/30 days)etodolac cap 300 mg 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg 2 QL (60 tablets/30 days)etodolac tab er 24hr 500 mg 2 QL (60 tablets/30 days)

2020

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Name Drug Tier Requirements/Limitsetodolac tab er 24hr 600 mg 2 QL (30 tablets/30 days)etodolac tab 400 mg 2 QL (60 tablets/30 days)etodolac tab 500 mg 2 QL (60 tablets/30 days)fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 3 PA, QL (15 patches/30 days)fentanyl td patch 72hr 37.5 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 3 PA, QL (15 patches/30 days)fentanyl td patch 72hr 62.5 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 87.5 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 4 PA, QL (15 patches/30 days)flurbiprofen tab 50 mg 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg 2 QL (90 tablets/30 days)hydrocodone bitartrate cap er 12hr abuse-deterrent 10 mg 4 PA, QL (60 capsules/30 days)hydrocodone bitartrate cap er 12hr abuse-deterrent 15 mg 4 PA, QL (60 capsules/30 days)hydrocodone bitartrate cap er 12hr abuse-deterrent 20 mg 4 PA, QL (60 capsules/30 days)hydrocodone bitartrate cap er 12hr abuse-deterrent 30 mg 4 PA, QL (60 capsules/30 days)hydrocodone bitartrate cap er 12hr abuse-deterrent 40 mg 4 PA, QL (60 capsules/30 days)hydrocodone bitartrate cap er 12hr abuse-deterrent 50 mg 4 PA, QL (60 capsules/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml 4 QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg 3 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-300 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-300 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 3 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 3 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 10-300 mg 4 QL (180 tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg 4 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 7.5-200 mg 3 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 10-200 mg 4 QL (150 tablets/30 days)hydromorphone hcl inj 2 mg/ml 4 BDhydromorphone hcl liqd 1 mg/ml 4 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 2 mg/ml 4 BD

2020


3

Drug Name Drug Tier Requirements/Limitshydromorphone hcl preservative free inj 10 mg/ml 4 BDhydromorphone hcl tab 2 mg 3 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg 3 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg 3 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml 2ibuprofen tab 400 mg 1 QL (240 tablets/30 days)ibuprofen tab 600 mg 1 QL (150 tablets/30 days)ibuprofen tab 800 mg 1 QL (120 tablets/30 days)LAZANDA - fentanyl citrate nasal spray 100 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 300 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 400 mcg/act 5 PA, QL (30 bottles/30 days)LEVORPHANOL TARTRATE - levorphanol tartrate tab 3 mg 5 QL (120 tablets/30 days)levorphanol tartrate tab 2 mg 5 QL (120 tablets/30 days)meloxicam tab 7.5 mg 1 QL (60 tablets/30 days)meloxicam tab 15 mg 1 QL (30 tablets/30 days)methadone hcl tab 5 mg 3 QL (180 tablets/30 days)methadone hcl tab 10 mg 3 QL (360 tablets/30 days)morphine sulfate inj pf 0.5 mg/ml 3 BDmorphine sulfate inj pf 1 mg/ml 3 BDmorphine sulfate oral soln 10 mg/5ml 3 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 3 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 3 QL (270 mls/30 days)morphine sulfate tab er 15 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 30 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 60 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 100 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 200 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab 15 mg 4 QL (240 tablets/30 days)morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)nabumetone tab 500 mg 2 QL (120 tablets/30 days)nabumetone tab 750 mg 2 QL (60 tablets/30 days)naproxen sodium tab 275 mg 2 QL (150 tablets/30 days)naproxen sodium tab 550 mg 2 QL (90 tablets/30 days)naproxen susp 125 mg/5ml 4 QL (1800 mls/30 days)naproxen tab ec 375 mg 2 QL (120 tablets/30 days)naproxen tab ec 500 mg 2 QL (90 tablets/30 days)naproxen tab 250 mg 1 QL (180 tablets/30 days)naproxen tab 375 mg 1 QL (120 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsnaproxen tab 500 mg 1 QL (90 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 50 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 100 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 150 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 200 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 250 mg 3 PA, QL (60 tablets/30 days)oxaprozin tab 600 mg 2 QL (90 tablets/30 days)oxycodone hcl tab 5 mg 3 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 3 QL (180 tablets/30 days)oxycodone hcl tab 15 mg 3 QL (180 tablets/30 days)oxycodone hcl tab 20 mg 3 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 3 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 3 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 3 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 3 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg 3 QL (360 tablets/30 days)piroxicam cap 10 mg 2 QL (60 capsules/30 days)piroxicam cap 20 mg 2 QL (30 capsules/30 days)sulindac tab 150 mg 2 QL (60 tablets/30 days)sulindac tab 200 mg 2 QL (60 tablets/30 days)TENCON - butalbital-acetaminophen tab 50-325 mg# 4 QL (180 tablets/30 days)TOLMETIN SODIUM - tolmetin sodium cap 400 mg 3 QL (120 capsules/30 days)tramadol hcl tab er 24hr 100 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 200 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 300 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab 50 mg 3 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg 3 QL (240 tablets/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 9 mg 3 PA, QL (60 capsules/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 13.5 mg 3 PA, QL (60 capsules/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 18 mg 3 PA, QL (60 capsules/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 27 mg 3 PA, QL (60 capsules/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 36 mg 3 PA, QL (60 capsules/30 days)ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-

deterrent 10 mg4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 15 mg

4 PA, QL (60 capsules/30 days)



2020


5

Drug Name Drug Tier Requirements/LimitsZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-

deterrent 30 mg4 PA, QL (60 capsules/30 days)





AnestheticsLIDOCAINE HCL - lidocaine hcl laryngotracheal soln 4% 2lidocaine hcl local inj 1% 3lidocaine hcl local preservative free inj 1% 3lidocaine hcl soln 4% 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel prefilled syringe 2% 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel 2% 2 PA, QL (150 mls/30 days)lidocaine hcl viscous soln 2% 2lidocaine oint 5% 4 PA, QL (100 grams/30 days)lidocaine patch 5% 3 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 3 PA, QL (60 grams/30 days)Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg 2buprenorphine hcl sl tab 2 mg 2 QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg 2 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 2 QL (120 films/30 days)buprenorphine hcl-naloxone hcl sl film 4-1 mg 2 QL (30 films/30 days)buprenorphine hcl-naloxone hcl sl film 8-2 mg 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl film 12-3 mg 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 2 QL (120 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg 2 QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg 2CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3CHANTIX CONTINUING MONTH PACK - varenicline tartrate tab

1 mg3

CHANTIX STARTING MONTH PACK - varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

3

disulfiram tab 250 mg 2disulfiram tab 500 mg 2NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml 2NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml 2naloxone hcl inj 0.4 mg/ml 2naloxone hcl inj 4 mg/10ml 2

2020


Drug Name Drug Tier Requirements/Limitsnaltrexone hcl tab 50 mg 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 3NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4SUBLOCADE - buprenorphine extended release soln pref syr

100 mg/0.5ml5

SUBLOCADE - buprenorphine extended release soln pref syr300 mg/1.5ml

5

VIVITROL - naltrexone for im extended release susp 380 mg 5Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml) 3amikacin sulfate inj 1 gm/4ml (250 mg/ml) 3amoxicillin (trihydrate) cap 250 mg 1amoxicillin (trihydrate) cap 500 mg 1amoxicillin (trihydrate) for susp 125 mg/5ml 1amoxicillin (trihydrate) for susp 200 mg/5ml 2amoxicillin (trihydrate) for susp 250 mg/5ml 2amoxicillin (trihydrate) for susp 400 mg/5ml 2amoxicillin (trihydrate) tab 500 mg 1amoxicillin (trihydrate) tab 875 mg 1amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 2amoxicillin & k clavulanate for susp 400-57 mg/5ml 2amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 2amoxicillin & k clavulanate tab 250-125 mg 2amoxicillin & k clavulanate tab 500-125 mg 2amoxicillin & k clavulanate tab 875-125 mg 2AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg3

AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & kclavulanate chew tab 400-57 mg

3

AMPICILLIN - ampicillin cap 500 mg 2ampicillin & sulbactam sodium for inj 3 (2-1) gm 4AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 3ampicillin sodium for inj 250 mg 3ampicillin sodium for inj 500 mg 3ampicillin sodium for inj 1 gm 3ampicillin sodium for inj 2 gm 3ampicillin sodium for iv soln 2 gm 3ampicillin sodium for iv soln 10 gm 4

2020


7

Drug Name Drug Tier Requirements/LimitsAMPICILLIN-SULBACTAM - ampicillin & sulbactam sodium for iv

soln 3 (2-1) gm4

AZITHROMYCIN - azithromycin powd pack for susp 1 gm 4azithromycin for susp 100 mg/5ml 2azithromycin for susp 200 mg/5ml 2azithromycin iv for soln 500 mg 3azithromycin tab 250 mg 2azithromycin tab 500 mg 2azithromycin tab 600 mg 2aztreonam for inj 1 gm 4aztreonam for inj 2 gm 3BICILLIN L-A - penicillin g benzathine intramuscular susp 600000

unit/ml4

BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000unit/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000unit/4ml

4

cefaclor cap 250 mg 2cefaclor cap 500 mg 2cefadroxil cap 500 mg 2cefadroxil for susp 250 mg/5ml 2cefadroxil for susp 500 mg/5ml 2cefadroxil tab 1 gm 2CEFAZOLIN SODIUM - cefazolin sodium for iv soln 1 gm 3CEFAZOLIN SODIUM - cefazolin sodium-dextrose iv solution

1 gm/50ml-4%3

cefazolin sodium for inj 500 mg 3cefazolin sodium for inj 1 gm 3cefazolin sodium for inj 10 gm 3CEFAZOLIN SODIUM/DEXTROSE - cefazolin sodium for iv soln

1 gm and dextrose 4% (50 ml)3

cefdinir cap 300 mg 2cefdinir for susp 125 mg/5ml 2cefdinir for susp 250 mg/5ml 2CEFEPIME - cefepime hcl iv soln 1 gm/50ml 4CEFEPIME - cefepime hcl iv soln 2 gm/100ml 4cefepime hcl for inj 1 gm 4cefepime hcl for inj 2 gm 4CEFEPIME/DEXTROSE - cefepime hcl for iv soln 1 gm and

dextrose 5% (50 ml)4

2020


Drug Name Drug Tier Requirements/LimitsCEFEPIME/DEXTROSE - cefepime hcl for iv soln 2 gm and


cefixime cap 400 mg 2CEFOTAXIME SODIUM - cefotaxime sodium for inj 500 mg 3cefotaxime sodium for inj 1 gm 3CEFOXITIN SODIUM - cefoxitin sodium iv for soln 1 gm and


CEFOXITIN SODIUM - cefoxitin sodium iv for soln 2 gm anddextrose 2.2% (50 ml)

4

cefoxitin sodium for inj 10 gm 4cefoxitin sodium for iv soln 1 gm 4cefoxitin sodium for iv soln 2 gm 4cefpodoxime proxetil for susp 50 mg/5ml 2cefpodoxime proxetil for susp 100 mg/5ml 2cefpodoxime proxetil tab 100 mg 2cefpodoxime proxetil tab 200 mg 2cefprozil for susp 125 mg/5ml 2cefprozil for susp 250 mg/5ml 2cefprozil tab 250 mg 2cefprozil tab 500 mg 2ceftazidime for inj 1 gm 4ceftazidime for inj 2 gm 4ceftazidime for inj 6 gm 4CEFTAZIDIME/DEXTROSE - ceftazidime for iv soln 1 gm and

dextrose 5% (50ml)4

CEFTAZIDIME/DEXTROSE - ceftazidime for iv soln 2 gm anddextrose 5% (50ml)

4

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 20 mg/ml

3

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 40 mg/ml

3

CEFTRIAXONE SODIUM - ceftriaxone sodium (bulk) for inj 100 gm 3ceftriaxone sodium for inj 250 mg 3ceftriaxone sodium for inj 500 mg 3ceftriaxone sodium for inj 1 gm 3ceftriaxone sodium for inj 2 gm 3ceftriaxone sodium for inj 10 gm 3ceftriaxone sodium for iv soln 1 gm 3ceftriaxone sodium for iv soln 2 gm 3CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74% 50 ml3

2020


9

Drug Name Drug Tier Requirements/LimitsCEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 2 gm

and dextrose 2.22% 50 ml3

cefuroxime axetil tab 250 mg 2cefuroxime axetil tab 500 mg 2cefuroxime sodium for inj 750 mg 4cefuroxime sodium for inj 7.5 gm 3cefuroxime sodium for iv soln 1.5 gm 3cephalexin cap 250 mg 1cephalexin cap 500 mg 1cephalexin cap 750 mg 2cephalexin for susp 125 mg/5ml 2cephalexin for susp 250 mg/5ml 2CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm3

CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 4ciprofloxacin hcl tab 250 mg 1ciprofloxacin hcl tab 500 mg 1ciprofloxacin hcl tab 750 mg 2ciprofloxacin 200 mg/100ml in d5w 3ciprofloxacin 400 mg/200ml in d5w 3CLARITHROMYCIN - clarithromycin for susp 125 mg/5ml 4CLARITHROMYCIN - clarithromycin for susp 250 mg/5ml 4clarithromycin tab er 24hr 500 mg 2clarithromycin tab 250 mg 2clarithromycin tab 500 mg 2clindamycin hcl cap 75 mg 2clindamycin hcl cap 150 mg 1clindamycin hcl cap 300 mg 2clindamycin phosphate gel 1% 2clindamycin phosphate in d5w iv soln 300 mg/50ml 4clindamycin phosphate in d5w iv soln 600 mg/50ml 4clindamycin phosphate in d5w iv soln 900 mg/50ml 4clindamycin phosphate inj 300 mg/2ml 3clindamycin phosphate inj 600 mg/4ml 3clindamycin phosphate inj 900 mg/6ml 3clindamycin phosphate inj 9 gm/60ml 3clindamycin phosphate iv soln 300 mg/2ml 3clindamycin phosphate iv soln 600 mg/4ml 3clindamycin phosphate iv soln 900 mg/6ml 3

2020


Drug Name Drug Tier Requirements/Limitsclindamycin phosphate lotion 1% 2clindamycin phosphate soln 1% 2clindamycin phosphate swab 1% 2clindamycin phosphate vaginal cream 2% 2CLINDAMYCIN/SODIUM CHLORIDE - clindamycin phosphate in

nacl 0.9% iv soln 300 mg/50ml4

CLINDAMYCIN/SODIUM CHLORIDE - clindamycin phosphate innacl 0.9% iv soln 600 mg/50ml

4

CLINDAMYCIN/SODIUM CHLORIDE - clindamycin phosphate innacl 0.9% iv soln 900 mg/50ml

4

colistimethate sod for inj 150 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg 3demeclocycline hcl tab 300 mg 4dicloxacillin sodium cap 250 mg 2dicloxacillin sodium cap 500 mg 2DIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg 2doxycycline hyclate cap 100 mg 2doxycycline hyclate for inj 100 mg 4doxycycline hyclate tab 20 mg 2doxycycline hyclate tab 100 mg 2doxycycline monohydrate cap 50 mg 2doxycycline monohydrate cap 75 mg 4doxycycline monohydrate cap 100 mg 2doxycycline monohydrate cap 150 mg 4doxycycline monohydrate tab 50 mg 2doxycycline monohydrate tab 75 mg 2doxycycline monohydrate tab 100 mg 2doxycycline monohydrate tab 150 mg 2ertapenem sodium for inj 1 gm 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg4

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml 4erythromycin ethylsuccinate for susp 400 mg/5ml 4erythromycin pads 2% 2erythromycin soln 2% 2

2020


11

Drug Name Drug Tier Requirements/Limitserythromycin tab delayed release 250 mg 4erythromycin tab delayed release 333 mg 4erythromycin tab delayed release 500 mg 4erythromycin tab 250 mg 4erythromycin tab 500 mg 4gentamicin in saline inj 1.2 mg/ml 3gentamicin sulfate inj 10 mg/ml 3gentamicin sulfate inj 40 mg/ml 3GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin in

saline inj 1 mg/ml3

GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin insaline inj 1.6 mg/ml

3

imipenem-cilastatin intravenous for soln 250 mg 4imipenem-cilastatin intravenous for soln 500 mg 4IMPAVIDO - miltefosine cap 50 mg 5ISOTONIC GENTAMICIN - gentamicin in saline inj 0.8 mg/ml 3levofloxacin in d5w iv soln 250 mg/50ml 3levofloxacin in d5w iv soln 500 mg/100ml 3levofloxacin in d5w iv soln 750 mg/150ml 3levofloxacin iv soln 25 mg/ml 4levofloxacin oral soln 25 mg/ml 2levofloxacin tab 250 mg 1levofloxacin tab 500 mg 1levofloxacin tab 750 mg 1LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%4

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 4linezolid tab 600 mg 3 PAmeropenem iv for soln 500 mg 4meropenem iv for soln 1 gm 4MEROPENEM/SODIUM CHLORIDE - meropenem & sodium

chloride 0.9% for iv soln 500 mg/50ml4

MEROPENEM/SODIUM CHLORIDE - meropenem & sodiumchloride 0.9% for iv soln 1 gm/50ml

4

methenamine hippurate tab 1 gm 2METRONIDAZOLE - metronidazole iv soln 5 mg/ml 3metronidazole cap 375 mg 3metronidazole in nacl 0.74% iv soln 500 mg/100ml 3metronidazole in nacl 0.79% iv soln 500 mg/100ml 3

2020


Drug Name Drug Tier Requirements/Limitsmetronidazole tab 250 mg 2metronidazole tab 500 mg 2metronidazole vaginal gel 0.75% 2minocycline hcl cap 50 mg 2minocycline hcl cap 75 mg 2minocycline hcl cap 100 mg 2minocycline hcl tab 50 mg 2minocycline hcl tab 75 mg 3minocycline hcl tab 100 mg 2moxifloxacin hcl tab 400 mg 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 3MOXIFLOXACIN HYDROCHLORIDE - moxifloxacin hcl iv solution

400 mg/250ml3

NAFCILLIN - nafcillin sodium in dextrose inj 1 gm/50ml 4NAFCILLIN - nafcillin sodium in dextrose inj 2 gm/100ml 4NAFCILLIN SODIUM - nafcillin sodium for inj 10 gm 5NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 4NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 4nafcillin sodium for inj 1 gm 4nafcillin sodium for inj 2 gm 4nafcillin sodium for iv soln 10 gm 5neomycin sulfate tab 500 mg 2NEOMYCIN/POLYMYXIN B SULFATES - neomycin-polymyxin b gu

irrigation soln3

nitrofurantoin macrocrystalline cap 50 mg# 3nitrofurantoin macrocrystalline cap 100 mg# 3nitrofurantoin monohydrate macrocrystalline cap 100 mg# 4nitrofurantoin susp 25 mg/5ml# 4ofloxacin tab 400 mg 2paromomycin sulfate cap 250 mg 3penicillin g potassium for inj 5000000 unit 4penicillin g potassium for inj 20000000 unit 4PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

3

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

4

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 4

2020


13

Drug Name Drug Tier Requirements/LimitsPENICILLIN V POTASSIUM - penicillin v potassium for soln

125 mg/5ml2

PENICILLIN V POTASSIUM - penicillin v potassium for soln250 mg/5ml

2

penicillin v potassium tab 250 mg 1penicillin v potassium tab 500 mg 2piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 4piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 3piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 4SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 3sulfacetamide sodium lotion 10% 2SULFADIAZINE - sulfadiazine tab 500 mg 4sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 3sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 2sulfamethoxazole-trimethoprim tab 400-80 mg 1sulfamethoxazole-trimethoprim tab 800-160 mg 1SUPRAX - cefixime chew tab 100 mg 4SUPRAX - cefixime chew tab 200 mg 4SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TAZICEF - ceftazidime for iv soln 1 gm 4TAZICEF - ceftazidime for iv soln 2 gm 4TEFLARO - ceftaroline fosamil for iv soln 400 mg 5TEFLARO - ceftaroline fosamil for iv soln 600 mg 5tetracycline hcl cap 250 mg 3tetracycline hcl cap 500 mg 4tigecycline for iv soln 50 mg 5TOBRAMYCIN SULFATE - tobramycin sulfate inj 10 mg/ml 3TOBRAMYCIN SULFATE - tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)3

tobramycin sulfate for inj 1.2 gm 3tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 3tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 3trimethoprim tab 100 mg 2VANCOMYCIN - vancomycin hcl iv soln 2000 mg/400ml 4VANCOMYCIN - vancomycin hcl-sodium chloride iv soln

500 mg/100ml-0.9%4

VANCOMYCIN HCL - vancomycin hcl for iv soln 100 gm 4

2020


Drug Name Drug Tier Requirements/LimitsVANCOMYCIN HCL - vancomycin hcl-sodium chloride iv soln

1 gm/200ml-0.9%4

vancomycin hcl cap 125 mg 4 QL (120 capsules/30 days)vancomycin hcl cap 250 mg 4 QL (240 capsules/30 days)vancomycin hcl for iv soln 500 mg 3vancomycin hcl for iv soln 750 mg 3vancomycin hcl for iv soln 1 gm 4vancomycin hcl for iv soln 5 gm 3vancomycin hcl for iv soln 10 gm 4VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln

250 mg4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.25 gm

4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.5 gm

4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl iv soln500 mg/100ml

4


4


4

VANCOMYCIN HYDROCHLORIDE/DEXTROSE - vancomycin hcl-dextrose iv soln 500 mg/100ml-5%

4

VANCOMYCIN HYDROCHLORIDE/DEXTROSE - vancomycin hcl-dextrose iv soln 750 mg/150ml-5%

4

VANCOMYCIN HYDROCHLORIDE/DEXTROSE - vancomycin hcl-dextrose iv soln 1 gm/200ml-5%

4

ZOSYN - piperacillin sod-tazobactam na for inj 3.375 gm(3-0.375 gm)

4

ZOSYN - piperacillin sod-tazobactam sod for inj 2.25 gm(2-0.25 gm)

4

ZOSYN - piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 4ZOSYN - piperacillin sod-tazobactam sod in dex iv soln

2-0.25gm/50ml4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln4-0.5gm/100ml

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

4

AnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 5APTIOM - eslicarbazepine acetate tab 400 mg 5APTIOM - eslicarbazepine acetate tab 600 mg 5APTIOM - eslicarbazepine acetate tab 800 mg 5

2020


15

Drug Name Drug Tier Requirements/LimitsBANZEL - rufinamide susp 40 mg/ml 5BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5BRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5BRIVIACT - brivaracetam tab 75 mg 5BRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap er 12hr 100 mg 2carbamazepine cap er 12hr 200 mg 2carbamazepine cap er 12hr 300 mg 2carbamazepine chew tab 100 mg 2carbamazepine susp 100 mg/5ml 2carbamazepine tab er 12hr 100 mg 2carbamazepine tab er 12hr 200 mg 2carbamazepine tab er 12hr 400 mg 3carbamazepine tab 200 mg 2CELONTIN - methsuximide cap 300 mg 4clobazam suspension 2.5 mg/ml 4 PA, QL (480 mls/30 days)clobazam tab 10 mg 2 PA, QL (60 tablets/30 days)clobazam tab 20 mg 2 PA, QL (60 tablets/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

2.5 mg4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system10 mg

4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system20 mg

4 QL (5 twin pack(s)/30 days)

DILANTIN - phenytoin sodium extended cap 30 mg 4divalproex sodium cap delayed release sprinkle 125 mg 2divalproex sodium tab delayed release 125 mg 2divalproex sodium tab delayed release 250 mg 2divalproex sodium tab delayed release 500 mg 2divalproex sodium tab er 24 hr 250 mg 2divalproex sodium tab er 24 hr 500 mg 2

2020


Drug Name Drug Tier Requirements/LimitsEPIDIOLEX - cannabidiol soln 100 mg/ml* 5 PAethosuximide cap 250 mg 2ethosuximide soln 250 mg/5ml 2felbamate susp 600 mg/5ml 5felbamate tab 400 mg 4felbamate tab 600 mg 4fosphenytoin sodium inj 100 mg/2ml 3fosphenytoin sodium inj 500 mg/10ml 3FYCOMPA - perampanel susp 0.5 mg/ml 5FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 5FYCOMPA - perampanel tab 6 mg 5FYCOMPA - perampanel tab 8 mg 5FYCOMPA - perampanel tab 10 mg 5FYCOMPA - perampanel tab 12 mg 5gabapentin cap 100 mg 2 QL (1080 capsules/30 days)gabapentin cap 300 mg 2 QL (360 capsules/30 days)gabapentin cap 400 mg 2 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml 2 QL (2160 mls/30 days)gabapentin tab 600 mg 2 QL (180 tablets/30 days)gabapentin tab 800 mg 2 QL (135 tablets/30 days)lamotrigine tab chewable dispersible 5 mg 2lamotrigine tab chewable dispersible 25 mg 2lamotrigine tab 25 mg 2lamotrigine tab 100 mg 1lamotrigine tab 150 mg 1lamotrigine tab 200 mg 1levetiracetam in sodium chloride iv soln 500 mg/100ml 3levetiracetam in sodium chloride iv soln 1000 mg/100ml 3levetiracetam in sodium chloride iv soln 1500 mg/100ml 3levetiracetam inj 500 mg/5ml (100 mg/ml) 4levetiracetam oral soln 100 mg/ml 2levetiracetam tab er 24hr 500 mg 2levetiracetam tab er 24hr 750 mg 2levetiracetam tab 250 mg 2levetiracetam tab 500 mg 2levetiracetam tab 750 mg 2levetiracetam tab 1000 mg 2

2020


17

Drug Name Drug Tier Requirements/LimitsNAYZILAM - midazolam nasal spray soln 5 mg/0.1 ml 4 QL (10 bottles/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) 3oxcarbazepine tab 150 mg 2oxcarbazepine tab 300 mg 2oxcarbazepine tab 600 mg 2PEGANONE - ethotoin tab 250 mg 4phenobarbital elixir 20 mg/5ml# 4PHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ml# 4PHENOBARBITAL SODIUM - phenobarbital sodium inj 130 mg/ml# 4phenobarbital tab 15 mg# 4phenobarbital tab 16.2 mg# 4phenobarbital tab 30 mg# 4phenobarbital tab 32.4 mg# 4phenobarbital tab 60 mg# 4phenobarbital tab 64.8 mg# 4phenobarbital tab 97.2 mg# 4phenobarbital tab 100 mg# 4phenytoin chew tab 50 mg 2phenytoin sodium extended cap 100 mg 2phenytoin sodium extended cap 200 mg 2phenytoin sodium extended cap 300 mg 2phenytoin susp 125 mg/5ml 2pregabalin cap 25 mg 3 QL (90 capsules/30 days)pregabalin cap 50 mg 3 QL (90 capsules/30 days)pregabalin cap 75 mg 3 QL (90 capsules/30 days)pregabalin cap 100 mg 3 QL (90 capsules/30 days)pregabalin cap 150 mg 3 QL (90 capsules/30 days)pregabalin cap 200 mg 3 QL (90 capsules/30 days)pregabalin cap 225 mg 3 QL (60 capsules/30 days)pregabalin cap 300 mg 3 QL (60 capsules/30 days)pregabalin soln 20 mg/ml 3 QL (900 mls/30 days)primidone tab 50 mg 2primidone tab 250 mg 2SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 4SPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4SYMPAZAN - clobazam oral film 5 mg 5 PA, QL (240 films/30 days)

2020


Drug Name Drug Tier Requirements/LimitsSYMPAZAN - clobazam oral film 10 mg 5 PA, QL (60 films/30 days)SYMPAZAN - clobazam oral film 20 mg 5 PA, QL (60 films/30 days)tiagabine hcl tab 2 mg 3tiagabine hcl tab 4 mg 4tiagabine hcl tab 12 mg 4tiagabine hcl tab 16 mg 4topiramate sprinkle cap 15 mg 2topiramate sprinkle cap 25 mg 2topiramate tab 25 mg 1topiramate tab 50 mg 1topiramate tab 100 mg 2topiramate tab 200 mg 2valproate sodium inj 100 mg/ml 4valproate sodium oral soln 250 mg/5ml 2valproic acid cap 250 mg 2vigabatrin powd pack 500 mg* 5 QL (180 packets/30 days)vigabatrin tab 500 mg* 5 QL (180 tablets/30 days)VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3zonisamide cap 25 mg 2zonisamide cap 50 mg 2zonisamide cap 100 mg 2Antidementia Agentsdonepezil hydrochloride orally disintegrating tab 5 mg 2donepezil hydrochloride orally disintegrating tab 10 mg 2donepezil hydrochloride tab 5 mg 1donepezil hydrochloride tab 10 mg 1donepezil hydrochloride tab 23 mg 2ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 4GALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml4

galantamine hydrobromide cap er 24hr 8 mg 2galantamine hydrobromide cap er 24hr 16 mg 2galantamine hydrobromide cap er 24hr 24 mg 2galantamine hydrobromide tab 4 mg 2

2020


19

Drug Name Drug Tier Requirements/Limitsgalantamine hydrobromide tab 8 mg 2galantamine hydrobromide tab 12 mg 2memantine hcl oral solution 2 mg/ml 4 PAmemantine hcl tab 5 mg 2 PAmemantine hcl tab 10 mg 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak 2 PArivastigmine tartrate cap 1.5 mg 2rivastigmine tartrate cap 3 mg 2rivastigmine tartrate cap 4.5 mg 2rivastigmine tartrate cap 6 mg 2rivastigmine td patch 24hr 4.6 mg/24hr 3rivastigmine td patch 24hr 9.5 mg/24hr 3rivastigmine td patch 24hr 13.3 mg/24hr 3Antidepressantsamitriptyline hcl tab 10 mg# 4amitriptyline hcl tab 25 mg# 4amitriptyline hcl tab 50 mg# 4amitriptyline hcl tab 75 mg# 4amitriptyline hcl tab 100 mg# 4amitriptyline hcl tab 150 mg# 4AMOXAPINE - amoxapine tab 25 mg# 4AMOXAPINE - amoxapine tab 50 mg# 4AMOXAPINE - amoxapine tab 100 mg# 4AMOXAPINE - amoxapine tab 150 mg# 4bupropion hcl tab er 12hr 100 mg 2 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg 2 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg 2 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg 2 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg 2 QL (30 tablets/30 days)bupropion hcl tab 75 mg 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg 2 QL (120 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 4clomipramine hcl cap 50 mg# 4clomipramine hcl cap 75 mg# 4

2020


Drug Name Drug Tier Requirements/Limitsdesipramine hcl tab 10 mg# 3desipramine hcl tab 25 mg# 3desipramine hcl tab 50 mg# 3desipramine hcl tab 75 mg# 3desipramine hcl tab 100 mg# 3desipramine hcl tab 150 mg# 3desvenlafaxine succinate tab er 24hr 25 mg 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 50 mg 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg 2 QL (30 tablets/30 days)DOXEPIN HCL - doxepin hcl cap 150 mg# 4doxepin hcl cap 10 mg# 4doxepin hcl cap 25 mg# 4doxepin hcl cap 50 mg# 4doxepin hcl cap 75 mg# 4doxepin hcl cap 100 mg# 4doxepin hcl conc 10 mg/ml# 4DRIZALMA SPRINKLE - duloxetine hcl cap delayed release

sprinkle 20 mg4 QL (60 capsules/30 days)

DRIZALMA SPRINKLE - duloxetine hcl cap delayed releasesprinkle 30 mg

4 QL (90 capsules/30 days)





duloxetine hcl enteric coated pellets cap 20 mg 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 2 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg 2 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 4 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &

40 mg therapy pack4 QL (28 capsules/28 days)

2020


21

Drug Name Drug Tier Requirements/LimitsFLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg 1 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg 1 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg 2 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg 2 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 4imipramine hcl tab 25 mg# 4imipramine hcl tab 50 mg# 4MAPROTILINE HCL - maprotiline hcl tab 25 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 3 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 4mirtazapine orally disintegrating tab 15 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg 2 QL (30 tablets/30 days)mirtazapine tab 15 mg 1 QL (45 tablets/30 days)mirtazapine tab 30 mg 1 QL (30 tablets/30 days)mirtazapine tab 45 mg 2 QL (30 tablets/30 days)NEFAZODONE HCL - nefazodone hcl tab 100 mg 3NEFAZODONE HCL - nefazodone hcl tab 150 mg 3nefazodone hcl tab 250 mg 2nefazodone hcl tab 50 mg 2NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 200 mg 3NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml# 4nortriptyline hcl cap 10 mg# 4nortriptyline hcl cap 25 mg# 4nortriptyline hcl cap 50 mg# 4nortriptyline hcl cap 75 mg# 4paroxetine hcl tab 10 mg# 4 PA, QL (45 tablets/30 days)paroxetine hcl tab 20 mg# 4 PA, QL (30 tablets/30 days)paroxetine hcl tab 30 mg# 4 PA, QL (60 tablets/30 days)paroxetine hcl tab 40 mg# 4 PA, QL (45 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsPAXIL - paroxetine hcl oral susp 10 mg/5ml# 4 PA, QL (900 mls/30 days)phenelzine sulfate tab 15 mg 2protriptyline hcl tab 5 mg# 4protriptyline hcl tab 10 mg# 4sertraline hcl oral concentrate for solution 20 mg/ml 2 QL (300 mls/30 days)sertraline hcl tab 25 mg 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg 1 QL (60 tablets/30 days)SPRAVATO 56MG DOSE - esketamine hcl nasal soln 28 mg/device

x 2 (56 mg dose pack)5 PA, QL (16 bottles/28 days)

SPRAVATO 84MG DOSE - esketamine hcl nasal soln 28 mg/devicex 3 (84 mg dose pack)

5 PA, QL (24 bottles/28 days)

tranylcypromine sulfate tab 10 mg 3trazodone hcl tab 50 mg 1trazodone hcl tab 100 mg 1trazodone hcl tab 150 mg 2trazodone hcl tab 300 mg 2trimipramine maleate cap 25 mg# 4trimipramine maleate cap 50 mg# 4trimipramine maleate cap 100 mg# 4TRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg 1 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg 2 QL (30 capsules/30 days)venlafaxine hcl tab er 24hr 37.5 mg 2 QL (60 tablets/30 days)venlafaxine hcl tab er 24hr 75 mg 3 QL (90 tablets/30 days)venlafaxine hcl tab er 24hr 150 mg 2 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

2020


23

Drug Name Drug Tier Requirements/LimitsAntiemeticsaprepitant capsule therapy pack 80 & 125 mg 4 BDaprepitant capsule 40 mg 4 BDaprepitant capsule 80 mg 4 BDaprepitant capsule 125 mg 4 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg 4 PAchlorpromazine hcl tab 25 mg 4 PAchlorpromazine hcl tab 50 mg 4 PAchlorpromazine hcl tab 100 mg 4 PAchlorpromazine hcl tab 200 mg 4 PAdronabinol cap 2.5 mg 3 BDdronabinol cap 5 mg 4 BDdronabinol cap 10 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4fosaprepitant dimeglumine for iv infusion 150 mg 4granisetron hcl inj 1 mg/ml 3granisetron hcl inj 4 mg/4ml (1 mg/ml) 3granisetron hcl tab 1 mg 4 BDmeclizine hcl tab 12.5 mg# 4meclizine hcl tab 25 mg# 4ondansetron hcl inj 4 mg/2ml (2 mg/ml) 3ondansetron hcl inj 40 mg/20ml (2 mg/ml) 3ondansetron hcl oral soln 4 mg/5ml 2 BDondansetron hcl tab 4 mg 2 BDondansetron hcl tab 8 mg 2 BDondansetron hcl tab 24 mg 2 BDondansetron orally disintegrating tab 4 mg 2 BDondansetron orally disintegrating tab 8 mg 2 BDpalonosetron hcl iv soln pref syr 0.25 mg/5ml 5palonosetron hcl iv soln 0.25 mg/5ml 5PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln

0.25 mg/2ml5

perphenazine tab 2 mg 3 PAperphenazine tab 4 mg 3 PAperphenazine tab 8 mg 3 PAperphenazine tab 16 mg 3 PA

2020


Drug Name Drug Tier Requirements/LimitsPROCHLORPERAZINE EDISYLATE - prochlorperazine edisylate

inj 50 mg/10ml4

prochlorperazine edisylate inj 10 mg/2ml 4prochlorperazine maleate tab 5 mg 3prochlorperazine maleate tab 10 mg 3prochlorperazine suppos 25 mg 3promethazine hcl suppos 12.5 mg# 4 PApromethazine hcl suppos 25 mg# 4 PApromethazine hcl syrup 6.25 mg/5ml# 4 PApromethazine hcl tab 12.5 mg# 4 PApromethazine hcl tab 25 mg# 4 PApromethazine hcl tab 50 mg# 4 PAAntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for iv soln 50 mg 4 BDcaspofungin acetate for iv soln 50 mg 5caspofungin acetate for iv soln 70 mg 5ciclopirox gel 0.77% 2ciclopirox olamine cream 0.77% 2ciclopirox olamine susp 0.77% 2ciclopirox shampoo 1% 2ciclopirox solution 8% 2clotrimazole cream 1% 2clotrimazole troche 10 mg 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PAeconazole nitrate cream 1% 2fluconazole for susp 10 mg/ml 2fluconazole for susp 40 mg/ml 2fluconazole in dextrose inj 200 mg/100ml 3fluconazole in dextrose inj 400 mg/200ml 3fluconazole in nacl 0.9% inj 200 mg/100ml 3fluconazole in nacl 0.9% inj 400 mg/200ml 3fluconazole tab 50 mg 2fluconazole tab 100 mg 2fluconazole tab 150 mg 2fluconazole tab 200 mg 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5

2020


25

Drug Name Drug Tier Requirements/Limitsgriseofulvin microsize susp 125 mg/5ml 3griseofulvin ultramicrosize tab 125 mg 3griseofulvin ultramicrosize tab 250 mg 3itraconazole cap 100 mg 4ketoconazole cream 2% 2ketoconazole shampoo 2% 2ketoconazole tab 200 mg 2MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin cream 100000 unit/gm 2nystatin oint 100000 unit/gm 2nystatin susp 100000 unit/ml 2nystatin tab 500000 unit 2nystatin topical powder 100000 unit/gm 2posaconazole tab delayed release 100 mg 5 PAterbinafine hcl tab 250 mg 1TERCONAZOLE - terconazole vaginal cream 0.8% 3terconazole vaginal cream 0.4% 2terconazole vaginal suppos 80 mg 2voriconazole for inj 200 mg 4 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PAAntigout Agentsallopurinol sodium for inj 500 mg 3allopurinol tab 100 mg 1allopurinol tab 300 mg 1colchicine w/ probenecid tab 0.5-500 mg 2COLCRYS - colchicine tab 0.6 mg 3probenecid tab 500 mg 2Antimigraine AgentsAIMOVIG - erenumab-aooe subcutaneous soln auto-injector 70 mg/

ml3 PA, QL (2 pens/30 days)

AIMOVIG - erenumab-aooe subcutaneous soln auto-injector140 mg/ml

3 PA, QL (1 pen/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln auto-injector120 mg/ml

3 PA, QL (2 pens/30 days)

2020


Drug Name Drug Tier Requirements/LimitsEMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr

100 mg/ml3 PA, QL (3 syringes/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr120 mg/ml

3 PA, QL (2 syringes/30 days)

ergotamine w/ caffeine tab 1-100 mg 3MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 5MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml 3 QL (8 mls/28 days)naratriptan hcl tab 1 mg 2 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg 2 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act 4 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act 4 QL (12 units (2

packages)/30 days)SUMATRIPTAN SUCCINATE - sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml4

sumatriptan succinate inj 6 mg/0.5ml 4sumatriptan succinate solution auto-injector 4 mg/0.5ml 4sumatriptan succinate solution auto-injector 6 mg/0.5ml 4sumatriptan succinate solution cartridge 4 mg/0.5ml 4sumatriptan succinate solution cartridge 6 mg/0.5ml 4sumatriptan succinate tab 25 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg 2 QL (18 tablets/30 days)Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl tab 125 mg 3pyridostigmine bromide oral soln 60 mg/5ml 5pyridostigmine bromide tab er 180 mg 4pyridostigmine bromide tab 60 mg 2AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4cycloserine cap 250 mg 5dapsone tab 25 mg 2dapsone tab 100 mg 2ethambutol hcl tab 100 mg 2ethambutol hcl tab 400 mg 2ISONIAZID - isoniazid inj 100 mg/ml 3

2020


27

Drug Name Drug Tier Requirements/Limitsisoniazid tab 100 mg 1isoniazid tab 300 mg 1PASER - aminosalicylic acid er granules packet 4 gm 4PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg 3rifabutin cap 150 mg 4rifampin cap 150 mg 2rifampin cap 300 mg 2rifampin for inj 600 mg 5SIRTURO - bedaquiline fumarate tab 100 mg* 5TRECATOR - ethionamide tab 250 mg 4Antineoplasticsabiraterone acetate tab 250 mg 5 PA, QL (120 tablets/30 days)ABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5 PAADRIAMYCIN - doxorubicin hcl for inj 10 mg 4 BDADRIAMYCIN - doxorubicin hcl for inj 50 mg 4 BDAFINITOR - everolimus tab 2.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg 5 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg 5 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 5 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 5 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 5 PAALIMTA - pemetrexed disodium for iv soln 500 mg 5 PAALIQOPA - copanlisib hcl for iv soln 60 mg 5 PAALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg* 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 30 mg* 5 PA, QL (120 tablets/30 days)ALUNBRIG - brigatinib tab 90 mg* 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 180 mg* 5 PA, QL (30 tablets/30 days)anastrozole tab 1 mg 2ARRANON - nelarabine iv soln 5 mg/ml 5 PAarsenic trioxide iv soln 10 mg/10ml (1 mg/ml) 4arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 5 PAARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* 5 PAAVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 5 PA

2020


Drug Name Drug Tier Requirements/LimitsAVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 5 PABALVERSA - erdafitinib tab 3 mg 5 PA, QL (90 tablets/30 days)BALVERSA - erdafitinib tab 4 mg 5 PA, QL (60 tablets/30 days)BALVERSA - erdafitinib tab 5 mg 5 PA, QL (30 tablets/30 days)BAVENCIO - avelumab soln for iv infusion 200 mg/10ml (20 mg/ml) 5 PABELEODAQ - belinostat for iv inj 500 mg 5 PABENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 5 PAbexarotene cap 75 mg 5 PAbicalutamide tab 50 mg 2bleomycin sulfate for inj 15 unit 3 BDbleomycin sulfate for inj 30 unit 3 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5 BD, PABOSULIF - bosutinib tab 100 mg 5 PA, QL (180 tablets/30 days)BOSULIF - bosutinib tab 400 mg 5 PA, QL (30 tablets/30 days)BOSULIF - bosutinib tab 500 mg 5 PA, QL (30 tablets/30 days)BRAFTOVI - encorafenib cap 75 mg 5 PA, QL (180 capsules/30 days)BRUKINSA - zanubrutinib cap 80 mg 5 PA, QL (120 capsules/30 days)busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg* 5 PA, QL (30 tablets/30 days)CALQUENCE - acalabrutinib cap 100 mg* 5 PA, QL (60 capsules/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml 3carboplatin iv soln 150 mg/15ml 3carboplatin iv soln 450 mg/45ml 3carboplatin iv soln 600 mg/60ml 3carmustine for inj 100 mg 4CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 3cisplatin inj 50 mg/50ml (1 mg/ml) 3cisplatin inj 100 mg/100ml (1 mg/ml) 3cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

dose) kit*5 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140dose) kit*


2020


29

Drug Name Drug Tier Requirements/LimitsCOMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)

kit*5 PA, QL (84 capsules/28 days)

COPIKTRA - duvelisib cap 15 mg 5 PA, QL (56 capsules/28 days)COPIKTRA - duvelisib cap 25 mg 5 PA, QL (56 capsules/28 days)COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)cyclophosphamide cap 25 mg 3 BDcyclophosphamide cap 50 mg 3 BDcyclophosphamide for inj 500 mg 5cyclophosphamide for inj 1 gm 5cyclophosphamide for inj 2 gm 5CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion)* 5 PACYRAMZA - ramucirumab iv soln 500 mg/50ml (for infusion)* 5 PACYTARABINE - cytarabine inj 20 mg/ml 3 BDcytarabine inj pf 20 mg/ml 3 BDcytarabine inj pf 100 mg/ml 3 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg 3dactinomycin for inj 0.5 mg 5DARZALEX - daratumumab iv soln 100 mg/5ml* 5 PADARZALEX - daratumumab iv soln 400 mg/20ml* 5 PAdaunorubicin hcl iv soln 20 mg/4ml 3DAUNORUBICIN HYDROCHLORIDE - daunorubicin hcl iv soln

50 mg/10ml3

DAURISMO - glasdegib maleate tab 25 mg 5 PA, QL (60 tablets/30 days)DAURISMO - glasdegib maleate tab 100 mg 5 PA, QL (30 tablets/30 days)decitabine for inj 50 mg 5dexrazoxane hcl for inj 250 mg 5dexrazoxane hcl for inj 500 mg 5DOCETAXEL - docetaxel for inj conc 200 mg/10ml (20 mg/ml) 5docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5docetaxel for inj conc 160 mg/8ml (20 mg/ml) 5docetaxel soln for iv infusion 20 mg/2ml 5docetaxel soln for iv infusion 80 mg/8ml 5docetaxel soln for iv infusion 160 mg/16ml 5doxorubicin hcl for inj 10 mg 4 BDdoxorubicin hcl for inj 50 mg 4 BDdoxorubicin hcl inj 2 mg/ml 3 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 5 BD, PA

2020


Drug Name Drug Tier Requirements/LimitsELITEK - rasburicase for iv soln 1.5 mg 5ELITEK - rasburicase for iv soln 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 5EMPLICITI - elotuzumab for iv soln 300 mg 5 PAEMPLICITI - elotuzumab for iv soln 400 mg 5 PAENHERTU - fam-trastuzumab deruxtecan-nxki for iv soln 100 mg 5 PAepirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 3epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 3ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 5 PAERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 5 PAERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERLEADA - apalutamide tab 60 mg* 5 PA, QL (120 tablets/30 days)erlotinib hcl tab 25 mg 5 PA, QL (60 tablets/30 days)erlotinib hcl tab 100 mg 5 PA, QL (30 tablets/30 days)erlotinib hcl tab 150 mg 5 PA, QL (30 tablets/30 days)ERWINAZE - asparaginase erwinia chrysanthemi for inj 10000 unit 5ETHYOL - amifostine for inj 500 mg 5ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4etoposide inj 100 mg/5ml (20 mg/ml) 3etoposide inj 500 mg/25ml (20 mg/ml) 3etoposide inj 1 gm/50ml (20 mg/ml) 3everolimus tab 2.5 mg 5 PA, QL (30 tablets/30 days)everolimus tab 5 mg 5 PA, QL (30 tablets/30 days)everolimus tab 7.5 mg 5 PA, QL (30 tablets/30 days)EVOMELA - melphalan hcl for inj 50 mg (propylene glycol (pg) free) 5exemestane tab 25 mg 3FARYDAK - panobinostat lactate cap 10 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg* 5 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 5 PAfludarabine phosphate for inj 50 mg 4fludarabine phosphate inj 25 mg/ml 3fluorouracil iv soln 500 mg/10ml (50 mg/ml) 3 BDfluorouracil iv soln 1 gm/20ml (50 mg/ml) 3 BDfluorouracil iv soln 2.5 gm/50ml (50 mg/ml) 3 BDfluorouracil iv soln 5 gm/100ml (50 mg/ml) 3 BDflutamide cap 125 mg 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5 PA

2020


31

Drug Name Drug Tier Requirements/LimitsFOLOTYN - pralatrexate iv inj 40 mg/2ml 5 PAfulvestrant inj 250 mg/5ml 5 PAGAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5 PA

gemcitabine hcl for inj 200 mg 3gemcitabine hcl for inj 1 gm 3gemcitabine hcl for inj 2 gm 3gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) 3gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) 3gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) 3GILOTRIF - afatinib dimaleate tab 20 mg* 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg* 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg* 5 PA, QL (30 tablets/30 days)GLEOSTINE - lomustine cap 10 mg 4GLEOSTINE - lomustine cap 40 mg 4GLEOSTINE - lomustine cap 100 mg 5HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5 PAHERCEPTIN - trastuzumab for iv soln 150 mg* 5 PAHERCEPTIN HYLECTA - trastuzumab-hyaluronidase-oysk inj

600-10000 mg-unit/5ml*5 PA

hydroxyurea cap 500 mg 2IBRANCE - palbociclib cap 75 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 100 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg* 5 PA, QL (21 capsules/28 days)ICLUSIG - ponatinib hcl tab 15 mg* 5 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg* 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5IDHIFA - enasidenib mesylate tab 50 mg* 5 PA, QL (30 tablets/30 days)IDHIFA - enasidenib mesylate tab 100 mg* 5 PA, QL (30 tablets/30 days)IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm 3ifosfamide iv inj 1 gm/20ml (50 mg/ml) 3ifosfamide iv inj 3 gm/60ml (50 mg/ml) 3imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 70 mg* 5 PA, QL (30 capsules/30 days)

2020


Drug Name Drug Tier Requirements/LimitsIMBRUVICA - ibrutinib cap 140 mg* 5 PA, QL (120 capsules/30 days)IMBRUVICA - ibrutinib tab 140 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 280 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 420 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 560 mg* 5 PA, QL (30 tablets/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml) 5 PAIMFINZI - durvalumab soln for iv infusion 500 mg/10ml (50 mg/ml) 5 PAIMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/

ml4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml

5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)INREBIC - fedratinib hcl cap 100 mg 5 PA, QL (120 capsules/30 days)IRESSA - gefitinib tab 250 mg* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 3irinotecan hcl inj 40 mg/2ml (20 mg/ml) 3irinotecan hcl inj 100 mg/5ml (20 mg/ml) 3ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5 PAIXEMPRA KIT - ixabepilone for iv infusion 15 mg 5IXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5 PAKANJINTI - trastuzumab-anns for iv soln 150 mg 5 PAKANJINTI - trastuzumab-anns for iv soln 420 mg 5 PAKEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml) 5 PAKISQALI - ribociclib succinate tab pack 200 mg daily dose 5 PA, QL (21 tablets/28 days)KISQALI - ribociclib succinate tab pack 400 mg daily dose (200 mg

tab)5 PA, QL (42 tablets/28 days)

KISQALI - ribociclib succinate tab pack 600 mg daily dose (200 mgtab)

5 PA, QL (63 tablets/28 days)

KISQALI FEMARA 200 DOSE - ribociclib 200 mg dose (200 mgtab) & letrozole 2.5 mg tbpk


2020


33

Drug Name Drug Tier Requirements/LimitsKISQALI FEMARA 400 DOSE - ribociclib 400 mg dose (200 mg

tab) & letrozole 2.5 mg tbpk5 PA, QL (70 tablets/28 days)

KISQALI FEMARA 600 DOSE - ribociclib 600 mg dose (200 mgtab) & letrozole 2.5 mg tbpk


KYPROLIS - carfilzomib for inj 10 mg 5 PAKYPROLIS - carfilzomib for inj 30 mg 5 PAKYPROLIS - carfilzomib for inj 60 mg 5 PALARTRUVO - olaratumab soln for iv infusion 190 mg/19ml (10 mg/

ml)5 PA

LARTRUVO - olaratumab soln for iv infusion 500 mg/50ml (10 mg/ml)

5 PA

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack10 mg*


LENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 4(3) mg*


LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 mg*


LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 (2) mg*


LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10(2) mg*


LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2)& 4 mg*


LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg* 5 PA, QL (30 capsules/30 days)LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4

(2) mg*5 PA, QL (60 capsules/30 days)

letrozole tab 2.5 mg 2LEUCOVORIN CALCIUM - leucovorin calcium inj 100 mg/10ml

(10 mg/ml)4

LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 3LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 3leucovorin calcium for inj 50 mg 3leucovorin calcium for inj 100 mg 3leucovorin calcium for inj 200 mg 3leucovorin calcium for inj 350 mg 3leucovorin calcium for inj 500 mg 3leucovorin calcium inj 500 mg/50ml (10 mg/ml) 4leucovorin calcium tab 5 mg 2leucovorin calcium tab 25 mg 3LEUKERAN - chlorambucil tab 2 mg 5LIBTAYO - cemiplimab-rwlc iv soln 350 mg/7ml (50 mg/ml)* 5 PALONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)

2020


Drug Name Drug Tier Requirements/LimitsLONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LORBRENA - lorlatinib tab 25 mg 5 PA, QL (90 tablets/30 days)LORBRENA - lorlatinib tab 100 mg 5 PA, QL (30 tablets/30 days)LUMOXITI - moxetumomab pasudotox-tdfk for iv soln 1 mg* 5 PALYNPARZA - olaparib tab 100 mg* 5 PA, QL (120 tablets/30 days)LYNPARZA - olaparib tab 150 mg* 5 PA, QL (120 tablets/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)MEKTOVI - binimetinib tab 15 mg 5 PA, QL (180 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg 2mesna inj 100 mg/ml 3MESNEX - mesna tab 400 mg 5mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg 5mitomycin for iv soln 40 mg 5mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 3mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 3mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 3MVASI - bevacizumab-awwb iv soln 100 mg/4ml (for infusion) 5 PAMVASI - bevacizumab-awwb iv soln 400 mg/16ml (for infusion) 5 PAMYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 5 PANERLYNX - neratinib maleate tab 40 mg* 5 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg* 5 PA, QL (120 tablets/30 days)nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5NUBEQA - darolutamide tab 300 mg 5 PA, QL (120 tablets/30 days)ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)OGIVRI - trastuzumab-dkst for iv soln 150 mg 5 PAOGIVRI - trastuzumab-dkst for iv soln 420 mg 5 PAONCASPAR - pegaspargase inj 750 unit/ml 5ONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5 PAOPDIVO - nivolumab iv soln 40 mg/4ml 5 PA

2020


35

Drug Name Drug Tier Requirements/LimitsOPDIVO - nivolumab iv soln 100 mg/10ml 5 PAOPDIVO - nivolumab iv soln 240 mg/24ml 5 PAoxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml 4oxaliplatin iv soln 100 mg/20ml 4PACLITAXEL - paclitaxel iv conc 150 mg/25ml (6 mg/ml) 3paclitaxel iv conc 30 mg/5ml (6 mg/ml) 3paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 3paclitaxel iv conc 300 mg/50ml (6 mg/ml) 3PADCEV - enfortumab vedotin-ejfv for iv soln 20 mg 5 PAPADCEV - enfortumab vedotin-ejfv for iv soln 30 mg 5 PAPANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5 PA

PIQRAY 200MG DAILY DOSE - alpelisib tab therapy pack 200 mgdaily dose


PIQRAY 250MG DAILY DOSE - alpelisib tab pack 250 mg dailydose (200 mg & 50 mg tabs)


PIQRAY 300MG DAILY DOSE - alpelisib tab pack 300 mg dailydose (2x150 mg tab)


POLIVY - polatuzumab vedotin-piiq for iv solution 140 mg 5 PAPOMALYST - pomalidomide cap 1 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml)* 5 PAPOTELIGEO - mogamulizumab-kpkc iv soln 20 mg/5ml (4 mg/ml) 5 PAPROLEUKIN - aldesleukin for iv soln 22000000 unit 5PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 5 PA, QL (21 capsules/28 days)RITUXAN - rituximab iv soln 100 mg/10ml* 5 PARITUXAN - rituximab iv soln 500 mg/50ml* 5 PARITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml*5 PA

2020


Drug Name Drug Tier Requirements/LimitsRITUXAN HYCELA - rituximab-hyaluronidase human inj

1600-26800 mg-unit/13.4ml*5 PA

ROZLYTREK - entrectinib cap 100 mg 5 PA, QL (150 capsules/30 days)ROZLYTREK - entrectinib cap 200 mg 5 PA, QL (90 capsules/30 days)RUBRACA - rucaparib camsylate tab 200 mg* 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 250 mg* 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 300 mg* 5 PA, QL (120 tablets/30 days)RYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 5SPRYCEL - dasatinib tab 20 mg 5 PA, QL (90 tablets/30 days)SPRYCEL - dasatinib tab 50 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 80 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg 5 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg 5 PA, QL (30 capsules/30 days)SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5 PATABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate cap 50 mg* 5 PA, QL (120 capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg* 5 PA, QL (120 capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg* 5 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg* 5 PA, QL (30 tablets/30 days)TALZENNA - talazoparib tosylate cap 0.25 mg* 5 PA, QL (90 capsules/30 days)TALZENNA - talazoparib tosylate cap 1 mg* 5 PA, QL (30 capsules/30 days)tamoxifen citrate tab 10 mg 2tamoxifen citrate tab 20 mg 2TARGRETIN - bexarotene gel 1% 5TASIGNA - nilotinib hcl cap 50 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 150 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TECENTRIQ - atezolizumab iv soln 840 mg/14ml* 5 PATECENTRIQ - atezolizumab iv soln 1200 mg/20ml* 5 PATEMODAR - temozolomide for iv soln 100 mg 5temsirolimus soln for iv infusion 25 mg/ml 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)

2020


37

Drug Name Drug Tier Requirements/LimitsTHALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 5TIBSOVO - ivosidenib tab 250 mg 5 PA, QL (60 tablets/30 days)topotecan hcl for inj 4 mg 4topotecan hcl inj 4 mg/4ml (for infusion) 4toremifene citrate tab 60 mg 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5TRUXIMA - rituximab-abbs iv soln 100 mg/10ml (10 mg/ml) 5 PATRUXIMA - rituximab-abbs iv soln 500 mg/50ml (10 mg/ml) 5 PATURALIO - pexidartinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml) 5 PAVALCHLOR - mechlorethamine hcl gel 0.016%* 5VECTIBIX - panitumumab iv soln 100 mg/5ml 5 PAVECTIBIX - panitumumab iv soln 400 mg/20ml 5 PAVELCADE - bortezomib for inj 3.5 mg 5 PAVENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg* 5 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (180 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg*5 PA, QL (1 pack (42

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 100 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 150 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 200 mg* 5 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 3 BDvincristine sulfate iv soln 1 mg/ml 3 BDvinorelbine tartrate inj 10 mg/ml 3vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) 3VITRAKVI - larotrectinib sulfate cap 25 mg 5 PA, QL (180 capsules/30 days)VITRAKVI - larotrectinib sulfate cap 100 mg 5 PA, QL (60 capsules/30 days)VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml 5 PA, QL (300 mls/30 days)VIZIMPRO - dacomitinib tab 15 mg* 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 30 mg* 5 PA, QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsVIZIMPRO - dacomitinib tab 45 mg* 5 PA, QL (30 tablets/30 days)VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5 PAXALKORI - crizotinib cap 200 mg* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 5 PA, QL (60 capsules/30 days)XOSPATA - gilteritinib fumarate tablet 40 mg 5 PA, QL (90 tablets/30 days)XPOVIO 100 MG ONCE WEEKLY - selinexor tab therapy pack

20 mg (100 mg once weekly)5 PA, QL (1 box/28 days)

XPOVIO 60 MG ONCE WEEKLY - selinexor tab therapy pack20 mg (60 mg once weekly)

5 PA, QL (1 box/28 days)

XPOVIO 80 MG ONCE WEEKLY - selinexor tab therapy pack20 mg (80 mg once weekly)


XPOVIO 80 MG TWICE WEEKLY - selinexor tab therapy pack20 mg (80 mg twice weekly)


XTANDI - enzalutamide cap 40 mg* 5 PA, QL (120 capsules/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* 5 PAYERVOY - ipilimumab soln for iv infusion 200 mg/40ml (5 mg/ml)* 5 PAYONDELIS - trabectedin for inj 1 mg 5 PAYONSA - abiraterone acetate tab 125 mg* 5 PA, QL (120 tablets/30 days)ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 5 PAZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 5 PAZANOSAR - streptozocin for inj 1 gm 4ZEJULA - niraparib tosylate cap 100 mg* 5 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 5 PA, QL (60 tablets/30 days)ZYDELIG - idelalisib tab 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib tab 150 mg* 5 PA, QL (90 tablets/30 days)ZYTIGA - abiraterone acetate tab 500 mg* 5 PA, QL (60 tablets/30 days)Antiparasiticsalbendazole tab 200 mg 5ALINIA - nitazoxanide for susp 100 mg/5ml 5ALINIA - nitazoxanide tab 500 mg 5atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab 62.5-25 mg 2atovaquone-proguanil hcl tab 250-100 mg 2BENZNIDAZOLE - benznidazole tab 12.5 mg 4BENZNIDAZOLE - benznidazole tab 100 mg 4CHLOROQUINE PHOSPHATE - chloroquine phosphate tab

250 mg3

2020


39

Drug Name Drug Tier Requirements/Limitschloroquine phosphate tab 500 mg 2COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 5hydroxychloroquine sulfate tab 200 mg 2ivermectin tab 3 mg 2LINDANE - lindane shampoo 1% 3malathion lotion 0.5% 4MEFLOQUINE HCL - mefloquine hcl tab 250 mg 2NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 BDPENTAM 300 - pentamidine isethionate for soln 300 mg 4pentamidine isethionate for nebulization soln 300 mg 3 BDpentamidine isethionate for soln 300 mg 3permethrin cream 5% 4praziquantel tab 600 mg 4primaquine phosphate tab 26.3 mg 3Antiparkinson Agentsamantadine hcl cap 100 mg 2amantadine hcl syrup 50 mg/5ml 2amantadine hcl tab 100 mg 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)benztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg 3bromocriptine mesylate tab 2.5 mg 2carbidopa & levodopa orally disintegrating tab 10-100 mg 2carbidopa & levodopa orally disintegrating tab 25-100 mg 2carbidopa & levodopa orally disintegrating tab 25-250 mg 2carbidopa & levodopa tab er 25-100 mg 2carbidopa & levodopa tab er 50-200 mg 2carbidopa & levodopa tab 10-100 mg 2carbidopa & levodopa tab 25-100 mg 2carbidopa & levodopa tab 25-250 mg 2carbidopa tab 25 mg 4CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg4

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

4

2020


Drug Name Drug Tier Requirements/LimitsCARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 25-100-200 mg4


4


4

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 50-200-200 mg

4

entacapone tab 200 mg 3INBRIJA - levodopa inhal powder cap 42 mg 5 PA, QL (300 capsules/30 days)pramipexole dihydrochloride tab 0.125 mg 1pramipexole dihydrochloride tab 0.25 mg 1pramipexole dihydrochloride tab 0.5 mg 1pramipexole dihydrochloride tab 0.75 mg 2pramipexole dihydrochloride tab 1 mg 1pramipexole dihydrochloride tab 1.5 mg 2rasagiline mesylate tab 0.5 mg 4rasagiline mesylate tab 1 mg 4ropinirole hydrochloride tab 0.25 mg 2ropinirole hydrochloride tab 0.5 mg 2ropinirole hydrochloride tab 1 mg 2ropinirole hydrochloride tab 2 mg 2ropinirole hydrochloride tab 3 mg 2ropinirole hydrochloride tab 4 mg 2ropinirole hydrochloride tab 5 mg 2RYTARY - carbidopa & levodopa cap er 23.75-95 mg 4RYTARY - carbidopa & levodopa cap er 36.25-145 mg 4RYTARY - carbidopa & levodopa cap er 48.75-195 mg 4RYTARY - carbidopa & levodopa cap er 61.25-245 mg 4selegiline hcl cap 5 mg 2selegiline hcl tab 5 mg 2tolcapone tab 100 mg 5AntipsychoticsADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml 4 QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 QL (60 tablets/30 days)aripiprazole tab 2 mg 3 QL (45 tablets/30 days)aripiprazole tab 5 mg 3 QL (45 tablets/30 days)aripiprazole tab 10 mg 3 QL (30 tablets/30 days)

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41

Drug Name Drug Tier Requirements/Limitsaripiprazole tab 15 mg 3 QL (30 tablets/30 days)aripiprazole tab 20 mg 3 QL (30 tablets/30 days)aripiprazole tab 30 mg 3 QL (30 tablets/30 days)ARISTADA - aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml5 QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml

5 QL (1 syringe/28 days)





ARISTADA INITIO - aripiprazole lauroxil im er susp prefilled syr675 mg/2.4ml


clozapine orally disintegrating tab 12.5 mg 3 QL (90 tablets/30 days)clozapine orally disintegrating tab 25 mg 3 QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg 4 QL (270 tablets/30 days)clozapine tab 25 mg 3 QL (90 tablets/30 days)clozapine tab 50 mg 3 QL (90 tablets/30 days)clozapine tab 100 mg 3 QL (270 tablets/30 days)clozapine tab 200 mg 3 QL (120 tablets/30 days)FANAPT - iloperidone tab 1 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 5 QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 QL (7 packs (56 tablets)/28 days)

fluphenazine decanoate inj 25 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 4 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 3 PAfluphenazine hcl tab 1 mg 3 PAfluphenazine hcl tab 2.5 mg 3 PAfluphenazine hcl tab 5 mg 3 PAfluphenazine hcl tab 10 mg 3 PAFLUPHENAZINE HYDROCHLORIDE - fluphenazine hcl elixir

2.5 mg/5ml3 PA

GEODON - ziprasidone mesylate for inj 20 mg 4 QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 3 PA

2020


Drug Name Drug Tier Requirements/Limitshaloperidol decanoate im soln 100 mg/ml 3 PAhaloperidol lactate inj 5 mg/ml 3 PAhaloperidol lactate oral conc 2 mg/ml 2 PAhaloperidol tab 0.5 mg 2 PAhaloperidol tab 1 mg 2 PAhaloperidol tab 2 mg 2 PAhaloperidol tab 5 mg 2 PAhaloperidol tab 10 mg 2 PAhaloperidol tab 20 mg 2 PAINVEGA SUSTENNA - paliperidone palmitate er susp pref syr

39 mg/0.25ml4 QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate er susp pref syr78 mg/0.5ml

5 QL (1 kit/28 days)



INVEGA SUSTENNA - paliperidone palmitate er susp pref syr156 mg/ml




INVEGA TRINZA - paliperidone palmitate er susp pref syr273 mg/0.875ml








LATUDA - lurasidone hcl tab 20 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 QL (30 tablets/30 days)loxapine succinate cap 5 mg 2 PAloxapine succinate cap 10 mg 2 PAloxapine succinate cap 25 mg 2 PAloxapine succinate cap 50 mg 2 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 10 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 25 mg 4 PANUPLAZID - pimavanserin tartrate cap 34 mg* 5 PA, QL (30 capsules/30 days)NUPLAZID - pimavanserin tartrate tab 10 mg* 5 PA, QL (30 tablets/30 days)

2020


43

Drug Name Drug Tier Requirements/Limitsolanzapine for im inj 10 mg 4 QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg 2 QL (30 tablets/30 days)olanzapine tab 2.5 mg 2 QL (45 tablets/30 days)olanzapine tab 5 mg 2 QL (45 tablets/30 days)olanzapine tab 7.5 mg 2 QL (45 tablets/30 days)olanzapine tab 10 mg 2 QL (45 tablets/30 days)olanzapine tab 15 mg 2 QL (30 tablets/30 days)olanzapine tab 20 mg 2 QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg 4 QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg 4 QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg 4 QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 5 QL (30 tablets/30 days)PERSERIS - risperidone subcutaneous for er susp prefilled syr

90 mg5 QL (1 syringe/30 days)

PERSERIS - risperidone subcutaneous for er susp prefilled syr120 mg


PIMOZIDE - pimozide tab 1 mg 2PIMOZIDE - pimozide tab 2 mg 2quetiapine fumarate tab er 24hr 50 mg 2 QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg 2 QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 200 mg 2 QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 300 mg 2 QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 400 mg 2 QL (60 tablets/30 days)quetiapine fumarate tab 25 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 50 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 100 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 200 mg 2 QL (120 tablets/30 days)quetiapine fumarate tab 300 mg 2 QL (60 tablets/30 days)quetiapine fumarate tab 400 mg 2 QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsRISPERDAL CONSTA - risperidone microspheres for im extended

rel susp 12.5 mg4 QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 25 mg

5 QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 37.5 mg


RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 50 mg


RISPERIDONE ODT - risperidone orally disintegrating tab 0.25 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 3 QL (120 tablets/30 days)risperidone soln 1 mg/ml 2 QL (480 mls/30 days)risperidone tab 0.25 mg 2 QL (60 tablets/30 days)risperidone tab 0.5 mg 2 QL (60 tablets/30 days)risperidone tab 1 mg 2 QL (60 tablets/30 days)risperidone tab 2 mg 2 QL (60 tablets/30 days)risperidone tab 3 mg 2 QL (60 tablets/30 days)risperidone tab 4 mg 2 QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 QL (60 tablets/30 days)SECUADO - asenapine td patch 24 hr 3.8 mg/24hr 5 QL (30 patches/30 days)SECUADO - asenapine td patch 24 hr 5.7 mg/24hr 5 QL (30 patches/30 days)SECUADO - asenapine td patch 24 hr 7.6 mg/24hr 5 QL (30 patches/30 days)thioridazine hcl tab 10 mg 3 PAthioridazine hcl tab 25 mg 3 PAthioridazine hcl tab 50 mg 3 PAthioridazine hcl tab 100 mg 3 PAthiothixene cap 1 mg 2 PAthiothixene cap 2 mg 2 PAthiothixene cap 5 mg 2 PAthiothixene cap 10 mg 2 PAtrifluoperazine hcl tab 1 mg 3 PAtrifluoperazine hcl tab 2 mg 3 PAtrifluoperazine hcl tab 5 mg 3 PAtrifluoperazine hcl tab 10 mg 3 PA

2020


45

Drug Name Drug Tier Requirements/LimitsVERSACLOZ - clozapine susp 50 mg/ml 5 QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 4 QL (30 capsules/30 days)ziprasidone hcl cap 20 mg 2 QL (90 capsules/30 days)ziprasidone hcl cap 40 mg 2 QL (90 capsules/30 days)ziprasidone hcl cap 60 mg 2 QL (60 capsules/30 days)ziprasidone hcl cap 80 mg 2 QL (60 capsules/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg5 QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 300 mg


ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg 2baclofen tab 20 mg 2dantrolene sodium cap 25 mg 2dantrolene sodium cap 50 mg 2dantrolene sodium cap 100 mg 2tizanidine hcl cap 2 mg 2tizanidine hcl cap 4 mg 2tizanidine hcl cap 6 mg 3tizanidine hcl tab 2 mg 2tizanidine hcl tab 4 mg 2Antiviralsabacavir sulfate soln 20 mg/ml 3 QL (960 mls/30 days)abacavir sulfate tab 300 mg 3 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 4 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg 2acyclovir oint 5% 4 PAacyclovir sodium iv soln 50 mg/ml 3 BDacyclovir susp 200 mg/5ml 3acyclovir tab 400 mg 2acyclovir tab 800 mg 2adefovir dipivoxil tab 10 mg 5APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)

2020


Drug Name Drug Tier Requirements/Limitsatazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)ATRIPLA - efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 5BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 50-200-25 mg 5 QL (30 tablets/30 days)cidofovir iv inj 75 mg/ml 5CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg 5 QL (30 tablets/30 days)COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg5 QL (30 tablets/30 days)

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)CRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)DELSTRIGO - doravirine-lamivudine-tenofovir df tab

100-300-300 mg5 QL (30 tablets/30 days)

DENAVIR - penciclovir cream 1% 5DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

didanosine delayed release capsule 200 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg 3 QL (30 capsules/30 days)DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg 5 QL (30 tablets/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)efavirenz cap 50 mg 2 QL (90 capsules/30 days)efavirenz cap 200 mg 5 QL (120 capsules/30 days)efavirenz tab 600 mg 5 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 4 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg 4entecavir tab 1 mg 4EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 5 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)famciclovir tab 125 mg 2famciclovir tab 250 mg 2famciclovir tab 500 mg 2fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg 4 BD

2020


47

Drug Name Drug Tier Requirements/LimitsGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 45-200 mg 5 PAHARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 5 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 5 QL (30 tablets/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 4 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml 2 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 3lamivudine tab 150 mg 2 QL (60 tablets/30 days)lamivudine tab 300 mg 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 3 QL (60 tablets/30 days)LEDIPASVIR/SOFOSBUVIR - ledipasvir-sofosbuvir tab 90-400 mg 5 PALEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg 5 PAnevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg 3 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg 3 QL (30 tablets/30 days)nevirapine tab 200 mg 2 QL (60 tablets/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir powder packet 100 mg 4 QL (360 packets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)oseltamivir phosphate cap 30 mg 2oseltamivir phosphate cap 45 mg 2

2020


Drug Name Drug Tier Requirements/Limitsoseltamivir phosphate cap 75 mg 2oseltamivir phosphate for susp 6 mg/ml 3PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPIFELTRO - doravirine tab 100 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 240 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 480 mg 5 QL (30 tablets/30 days)PREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)RELENZA DISKHALER - zanamivir aero powder breath activated

5 mg/blister4

RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)ribavirin cap 200 mg 2ribavirin tab 200 mg 2ritonavir tab 100 mg 3 QL (360 tablets/30 days)SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOFOSBUVIR/VELPATASVIR - sofosbuvir-velpatasvir tab

400-100 mg5 PA

SOVALDI - sofosbuvir tab 200 mg 5 PASOVALDI - sofosbuvir tab 400 mg 5 PAstavudine cap 15 mg 2 QL (60 capsules/30 days)stavudine cap 20 mg 2 QL (60 capsules/30 days)stavudine cap 30 mg 2 QL (60 capsules/30 days)stavudine cap 40 mg 2 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab


SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PA

2020


49

Drug Name Drug Tier Requirements/LimitsSYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYMFI - efavirenz-lamivudine-tenofovir df tab 600-300-300 mg 5 QL (30 tablets/30 days)SYMFI LO - efavirenz-lamivudine-tenofovir df tab 400-300-300 mg 5 QL (30 tablets/30 days)SYMTUZA - darunavir-cobic-emtricitab-tenofov af tab


TEMIXYS - lamivudine-tenofovir disoproxil fumarate tab300-300 mg

5 QL (30 tablets/30 days)

tenofovir disoproxil fumarate tab 300 mg 4 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TROGARZO - ibalizumab-uiyk iv soln 200 mg/1.33ml (150 mg/ml) 5 QL (14 vials/28 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab


TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab133-200 mg






TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)valacyclovir hcl tab 500 mg 2valacyclovir hcl tab 1 gm 2valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 5VIDEX - didanosine for soln 2 gm 4 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 4 QL (1200 mls/30 days)VIDEX EC - didanosine delayed release capsule 125 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 200 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 250 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 400 mg 4 QL (30 capsules/30 days)VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak 12.5-75-50

& 250 mg5 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsVOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg 5 PAXOFLUZA - baloxavir marboxil tab therapy pack 20 (2) mg (40 mg

dose)4

XOFLUZA - baloxavir marboxil tab therapy pack 40 (2) mg (80 mgdose)

4

ZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PAzidovudine cap 100 mg 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml 3 QL (1920 mls/30 days)zidovudine tab 300 mg 2 QL (60 tablets/30 days)Anxiolyticsalprazolam tab 0.25 mg 3 QL (120 tablets/30 days)alprazolam tab 0.5 mg 3 QL (120 tablets/30 days)alprazolam tab 1 mg 3 QL (120 tablets/30 days)alprazolam tab 2 mg 3 QL (150 tablets/30 days)buspirone hcl tab 5 mg 1buspirone hcl tab 7.5 mg 2buspirone hcl tab 10 mg 1buspirone hcl tab 15 mg 1buspirone hcl tab 30 mg 2clonazepam orally disintegrating tab 0.125 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 2 QL (300 tablets/30 days)clonazepam tab 0.5 mg 1 QL (120 tablets/30 days)clonazepam tab 1 mg 1 QL (120 tablets/30 days)clonazepam tab 2 mg 1 QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg 2 PA, QL (360 tablets/30 days)clorazepate dipotassium tab 15 mg 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 3 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml 2 PA, QL (240 mls/30 days)diazepam tab 2 mg 1 PA, QL (120 tablets/30 days)diazepam tab 5 mg 1 PA, QL (120 tablets/30 days)diazepam tab 10 mg 1 PA, QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PA

2020


51

Drug Name Drug Tier Requirements/Limitslorazepam tab 0.5 mg 1 PA, QL (120 tablets/30 days)lorazepam tab 1 mg 1 PA, QL (120 tablets/30 days)lorazepam tab 2 mg 1 PA, QL (150 tablets/30 days)Bipolar AgentsLITHIUM - lithium oral solution 8 meq/5ml 3lithium carbonate cap 150 mg 2lithium carbonate cap 300 mg 1lithium carbonate cap 600 mg 2lithium carbonate tab er 300 mg 2lithium carbonate tab er 450 mg 2lithium carbonate tab 300 mg 2Blood Glucose Regulatorsacarbose tab 25 mg 2 QL (360 tablets/30 days)acarbose tab 50 mg 2 QL (180 tablets/30 days)acarbose tab 100 mg 2 QL (90 tablets/30 days)ALCOHOL SWABS 3BAQSIMI ONE PACK - glucagon nasal powder 3 mg/dose 4BAQSIMI TWO PACK - glucagon nasal powder 3 mg/dose 4BASAGLAR KWIKPEN - insulin glargine soln pen-injector 100 unit/

ml4 QL (20 pens/30 days)

BYDUREON BCISE - exenatide extended release susp auto-injector 2 mg/0.85ml

3 QL (4 pens/28 days), ST

BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg

3 QL (4 pens/28 days), ST

CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)GAUZE PADS 2" X 2" 3glimepiride tab 1 mg 1 QL (240 tablets/30 days)glimepiride tab 2 mg 1 QL (120 tablets/30 days)glimepiride tab 4 mg 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg 1 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg 1 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg 2 QL (60 tablets/30 days)glipizide tab 5 mg 1 QL (240 tablets/30 days)glipizide tab 10 mg 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg 2 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 4GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg 4 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsGLYXAMBI - empagliflozin-linagliptin tab 25-5 mg 4 QL (30 tablets/30 days)HUMALOG - insulin lispro inj 100 unit/ml 3 QL (60 mls/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml 3 QL (20 cartridges/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100

unit/ml (0.5 unit dial)3 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml(1 unit dial)

3 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml 3 QL (20 pens/30 days)HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100

unit/ml (50-50)3 QL (6 vials/30 days)

HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)


HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml(75-25)


HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)


HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 3 QL (60 mls/30 days)HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml3 QL (20 pens/30 days)

HUMULIN R - insulin regular (human) inj 100 unit/ml 3 QL (60 mls/30 days)HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml3 BD

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml


HUMULIN 70/30 - insulin nph isophane & regular human inj 100unit/ml (70-30)

3 QL (60 mls/30 days)

HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100unit/ml (70-30)


INSULIN INJECTION DEVICE 3INSULIN SYRINGE/NEEDLE 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr


INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr50-1000 mg






INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)

2020


53

Drug Name Drug Tier Requirements/LimitsINVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)JENTADUETO XR - linagliptin-metformin hcl tab er 24hr

2.5-1000 mg4 QL (60 tablets/30 days)

JENTADUETO XR - linagliptin-metformin hcl tab er 24hr 5-1000 mg 4 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr

2.5-1000 mg3 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr 5-500 mg 3 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr


LANTUS - insulin glargine inj 100 unit/ml 3 QL (6 vials/30 days)LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 3 QL (20 pens/30 days)LEVEMIR - insulin detemir inj 100 unit/ml 3 QL (6 vials/30 days)LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/

ml3 QL (20 pens/30 days)

metformin hcl tab er 24hr 500 mg 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg 1 QL (60 tablets/30 days)metformin hcl tab 500 mg 1 QL (150 tablets/30 days)metformin hcl tab 850 mg 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg 1 QL (75 tablets/30 days)nateglinide tab 60 mg 2 QL (180 tablets/30 days)nateglinide tab 120 mg 2 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose

(2 mg/1.5ml)3 QL (1 pen/28 days), ST

OZEMPIC - semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml) 3 QL (2 pens/28 days), STpioglitazone hcl tab 15 mg 1 QL (90 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitspioglitazone hcl tab 30 mg 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg 3 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg 3 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg 2 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg 2 QL (90 tablets/30 days)PROGLYCEM - diazoxide susp 50 mg/ml 4repaglinide tab 0.5 mg 2 QL (960 tablets/30 days)repaglinide tab 1 mg 2 QL (480 tablets/30 days)repaglinide tab 2 mg 2 QL (240 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)5

SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

5

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr10-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr12.5-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr25-1000 mg


TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300unit/ml (2 unit dial)


TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml (1 unit dial)


TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)TRESIBA - insulin degludec inj 100 unit/ml 3 QL (6 vials/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100

unit/ml3 QL (20 pens/30 days)

TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 200unit/ml


TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml 3 QL (4 pens/28 days), STTRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml 3 QL (4 pens/28 days), STVICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days), STBlood Products/Modifiers/Volume Expandersanagrelide hcl cap 0.5 mg 2

2020


55

Drug Name Drug Tier Requirements/Limitsanagrelide hcl cap 1 mg 2ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe25 mcg/0.42ml

4 PA


4 PA


5 PA


5 PA


5 PA


5 PA


5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe500 mcg/ml

5 PA

aspirin-dipyridamole cap er 12hr 25-200 mg 3azacitidine for inj 100 mg 5BEVYXXA - betrixaban maleate cap 40 mg 4 QL (43 capsules/42 days)BEVYXXA - betrixaban maleate cap 80 mg 4 QL (43 capsules/42 days)BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg 2cilostazol tab 100 mg 2clopidogrel bisulfate tab 75 mg 1COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4

2020


Drug Name Drug Tier Requirements/LimitsCOUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4dipyridamole tab 25 mg# 4dipyridamole tab 50 mg# 4dipyridamole tab 75 mg# 4ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (74 tablets/30 days)ELIQUIS STARTER PACK - apixaban tab 5 mg 3 QL (74 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 4 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PAEPOGEN - epoetin alfa inj 3000 unit/ml 4 PAEPOGEN - epoetin alfa inj 4000 unit/ml 4 PAEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 5 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)FULPHILA - pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml 5 PAGRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5 PAGRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5 PAGRANIX - tbo-filgrastim subcutaneous inj 300 mcg/ml 5 PAGRANIX - tbo-filgrastim subcutaneous inj 480 mcg/1.6ml (300 mcg/

ml)5 PA

HEPARIN SODIUM - heparin sodium (porcine) inj soln pref syr5000 unit/0.5ml

3

HEPARIN SODIUM - heparin sodium (porcine) pf inj 5000 unit/ml 3heparin sodium (porcine) inj 1000 unit/ml 3heparin sodium (porcine) inj 5000 unit/ml 3heparin sodium (porcine) inj 10000 unit/ml 3heparin sodium (porcine) inj 20000 unit/ml 3heparin sodium (porcine) pf inj 5000 unit/0.5ml 3

2020


57

Drug Name Drug Tier Requirements/LimitsHEPARIN SODIUM/D5W - heparin sodium (porcine)-dextrose iv sol

20000 unit/500ml-5%3

LEUKINE - sargramostim lyophilized for inj 250 mcg 5 PAMOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5NIVESTYM - filgrastim-aafi inj 300 mcg/ml 5 PANIVESTYM - filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml) 5 PANIVESTYM - filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml 5 PANIVESTYM - filgrastim-aafi soln prefilled syringe 480 mcg/0.8ml 5 PAPRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)prasugrel hcl tab 5 mg 3prasugrel hcl tab 10 mg 3PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PAPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine powder pack for susp 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PAPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PARETACRIT - epoetin alfa-epbx inj 2000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 3000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 4000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 10000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 40000 unit/ml 4 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 4tranexamic acid tab 650 mg 2UDENYCA - pegfilgrastim-cbqv soln prefilled syringe 6 mg/0.6ml 5 PAwarfarin sodium tab 1 mg 1warfarin sodium tab 2 mg 1warfarin sodium tab 2.5 mg 1warfarin sodium tab 3 mg 1warfarin sodium tab 4 mg 1warfarin sodium tab 5 mg 1warfarin sodium tab 6 mg 2

2020


Drug Name Drug Tier Requirements/Limitswarfarin sodium tab 7.5 mg 1warfarin sodium tab 10 mg 1XARELTO - rivaroxaban tab 2.5 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 10 mg 3 QL (30 tablets/30 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

ZONTIVITY - vorapaxar sulfate tab 2.08 mg 4Cardiovascular Agentsacebutolol hcl cap 200 mg 2acebutolol hcl cap 400 mg 2acetazolamide cap er 12hr 500 mg 3acetazolamide tab 125 mg 3acetazolamide tab 250 mg 3aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)amiloride & hydrochlorothiazide tab 5-50 mg 2amiloride hcl tab 5 mg 2amiodarone hcl tab 200 mg 1amiodarone hcl tab 400 mg 2amlodipine besylate tab 2.5 mg 1amlodipine besylate tab 5 mg 1amlodipine besylate tab 10 mg 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg 2amlodipine besylate-atorvastatin calcium tab 2.5-20 mg 2amlodipine besylate-atorvastatin calcium tab 2.5-40 mg 3amlodipine besylate-atorvastatin calcium tab 5-10 mg 2amlodipine besylate-atorvastatin calcium tab 5-20 mg 2amlodipine besylate-atorvastatin calcium tab 5-40 mg 2amlodipine besylate-atorvastatin calcium tab 5-80 mg 2amlodipine besylate-atorvastatin calcium tab 10-10 mg 2amlodipine besylate-atorvastatin calcium tab 10-20 mg 2amlodipine besylate-atorvastatin calcium tab 10-40 mg 2amlodipine besylate-atorvastatin calcium tab 10-80 mg 2amlodipine besylate-benazepril hcl cap 2.5-10 mg 2amlodipine besylate-benazepril hcl cap 5-10 mg 2amlodipine besylate-benazepril hcl cap 5-20 mg 2amlodipine besylate-benazepril hcl cap 5-40 mg 2

2020


59

Drug Name Drug Tier Requirements/Limitsamlodipine besylate-benazepril hcl cap 10-20 mg 2amlodipine besylate-benazepril hcl cap 10-40 mg 2amlodipine besylate-valsartan tab 5-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg 2 QL (30 tablets/30 days)atenolol & chlorthalidone tab 50-25 mg 2atenolol & chlorthalidone tab 100-25 mg 2atenolol tab 25 mg 2atenolol tab 50 mg 2atenolol tab 100 mg 2atorvastatin calcium tab 10 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg 1 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg 2benazepril & hydrochlorothiazide tab 10-12.5 mg 2benazepril & hydrochlorothiazide tab 20-12.5 mg 2benazepril & hydrochlorothiazide tab 20-25 mg 2benazepril hcl tab 5 mg 1benazepril hcl tab 10 mg 1benazepril hcl tab 20 mg 1benazepril hcl tab 40 mg 1betaxolol hcl tab 10 mg 2betaxolol hcl tab 20 mg 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 1bisoprolol & hydrochlorothiazide tab 5-6.25 mg 1bisoprolol & hydrochlorothiazide tab 10-6.25 mg 1bisoprolol fumarate tab 5 mg 2bisoprolol fumarate tab 10 mg 2bumetanide inj 0.25 mg/ml 3bumetanide tab 0.5 mg 2bumetanide tab 1 mg 2

2020


Drug Name Drug Tier Requirements/Limitsbumetanide tab 2 mg 2BYSTOLIC - nebivolol hcl tab 2.5 mg 4BYSTOLIC - nebivolol hcl tab 5 mg 4BYSTOLIC - nebivolol hcl tab 10 mg 4BYSTOLIC - nebivolol hcl tab 20 mg 4candesartan cilexetil tab 4 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 8 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 16 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg 2 QL (30 tablets/30 days)captopril tab 12.5 mg 2captopril tab 25 mg 2captopril tab 50 mg 2captopril tab 100 mg 2carvedilol tab 3.125 mg 1carvedilol tab 6.25 mg 1carvedilol tab 12.5 mg 1carvedilol tab 25 mg 1CHLOROTHIAZIDE - chlorothiazide tab 250 mg 3chlorothiazide tab 500 mg 2chlorthalidone tab 25 mg 2chlorthalidone tab 50 mg 2cholestyramine light powder packets 4 gm 2cholestyramine light powder 4 gm/dose 2cholestyramine powder packets 4 gm 2cholestyramine powder 4 gm/dose 2choline fenofibrate cap dr 45 mg 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg 1clonidine hcl tab 0.2 mg 1clonidine hcl tab 0.3 mg 1clonidine td patch weekly 0.1 mg/24hr 2clonidine td patch weekly 0.2 mg/24hr 2clonidine td patch weekly 0.3 mg/24hr 2colestipol hcl granule packets 5 gm 2colestipol hcl granules 5 gm 2

2020


61

Drug Name Drug Tier Requirements/Limitscolestipol hcl tab 1 gm 2CORLANOR - ivabradine hcl oral soln 5 mg/5ml 3 PA, QL (600 mls/30 days)CORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)DEMSER - metyrosine cap 250 mg 5digoxin oral soln 0.05 mg/ml# 3 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)# 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 4 QL (30 tablets/30 days)diltiazem hcl cap er 24hr 120 mg 2diltiazem hcl cap er 12hr 60 mg 2diltiazem hcl cap er 12hr 90 mg 2diltiazem hcl cap er 12hr 120 mg 2diltiazem hcl cap er 24hr 180 mg 2diltiazem hcl cap er 24hr 240 mg 2diltiazem hcl coated beads cap er 24hr 120 mg 2diltiazem hcl coated beads cap er 24hr 180 mg 2diltiazem hcl coated beads cap er 24hr 240 mg 2diltiazem hcl coated beads cap er 24hr 300 mg 2diltiazem hcl coated beads cap er 24hr 360 mg 3diltiazem hcl coated beads tab er 24hr 180 mg 2diltiazem hcl coated beads tab er 24hr 240 mg 2diltiazem hcl coated beads tab er 24hr 300 mg 2diltiazem hcl coated beads tab er 24hr 360 mg 2diltiazem hcl coated beads tab er 24hr 420 mg 2diltiazem hcl extended release beads cap er 24hr 120 mg 2diltiazem hcl extended release beads cap er 24hr 180 mg 2diltiazem hcl extended release beads cap er 24hr 240 mg 2diltiazem hcl extended release beads cap er 24hr 300 mg 2diltiazem hcl extended release beads cap er 24hr 360 mg 3diltiazem hcl extended release beads cap er 24hr 420 mg 2diltiazem hcl tab 30 mg 2diltiazem hcl tab 60 mg 2diltiazem hcl tab 90 mg 2diltiazem hcl tab 120 mg 2dofetilide cap 125 mcg (0.125 mg) 4dofetilide cap 250 mcg (0.25 mg) 4dofetilide cap 500 mcg (0.5 mg) 4doxazosin mesylate tab 1 mg 2 QL (60 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsdoxazosin mesylate tab 2 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg 2 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1enalapril maleate & hydrochlorothiazide tab 10-25 mg 2enalapril maleate tab 2.5 mg 2enalapril maleate tab 5 mg 2enalapril maleate tab 10 mg 2enalapril maleate tab 20 mg 2ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 QL (180 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 3 QL (60 tablets/30 days)eplerenone tab 25 mg 2eplerenone tab 50 mg 2ezetimibe tab 10 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-20 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-40 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-80 mg 2 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg 2felodipine tab er 24hr 5 mg 2felodipine tab er 24hr 10 mg 2fenofibrate micronized cap 67 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 134 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg 2 QL (30 capsules/30 days)fenofibrate tab 48 mg 2 QL (60 tablets/30 days)fenofibrate tab 54 mg 2 QL (60 tablets/30 days)fenofibrate tab 145 mg 2 QL (30 tablets/30 days)fenofibrate tab 160 mg 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg 2flecainide acetate tab 100 mg 2flecainide acetate tab 150 mg 2fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 2fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 2fosinopril sodium tab 10 mg 1fosinopril sodium tab 20 mg 1fosinopril sodium tab 40 mg 1furosemide inj 10 mg/ml 3

2020


63

Drug Name Drug Tier Requirements/Limitsfurosemide oral soln 10 mg/ml 2furosemide tab 20 mg 1furosemide tab 40 mg 1furosemide tab 80 mg 1gemfibrozil tab 600 mg 2 QL (60 tablets/30 days)hydralazine hcl tab 10 mg 1hydralazine hcl tab 25 mg 2hydralazine hcl tab 50 mg 2hydralazine hcl tab 100 mg 2hydrochlorothiazide cap 12.5 mg 1hydrochlorothiazide tab 12.5 mg 1hydrochlorothiazide tab 25 mg 1hydrochlorothiazide tab 50 mg 1indapamide tab 1.25 mg 2indapamide tab 2.5 mg 2irbesartan tab 75 mg 1 QL (30 tablets/30 days)irbesartan tab 150 mg 1 QL (30 tablets/30 days)irbesartan tab 300 mg 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg 2 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg 2 QL (30 tablets/30 days)isosorbide dinitrate tab 5 mg 2isosorbide dinitrate tab 10 mg 2isosorbide dinitrate tab 20 mg 2isosorbide dinitrate tab 30 mg 2isosorbide mononitrate tab er 24hr 30 mg 2isosorbide mononitrate tab er 24hr 60 mg 2isosorbide mononitrate tab er 24hr 120 mg 2isosorbide mononitrate tab 10 mg 2isosorbide mononitrate tab 20 mg 2isradipine cap 2.5 mg 2isradipine cap 5 mg 2labetalol hcl tab 100 mg 2labetalol hcl tab 200 mg 2labetalol hcl tab 300 mg 2LIDOCAINE HCL - lidocaine hcl (cardiac) iv pf soln pref syr

50 mg/5ml(1%)4

LIDOCAINE HCL - lidocaine hcl (cardiac) iv soln pref syr 50 mg/5ml(1%)

4

lisinopril & hydrochlorothiazide tab 10-12.5 mg 1

2020


Drug Name Drug Tier Requirements/Limitslisinopril & hydrochlorothiazide tab 20-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-25 mg 1lisinopril tab 2.5 mg 1lisinopril tab 5 mg 1lisinopril tab 10 mg 1lisinopril tab 20 mg 1lisinopril tab 30 mg 1lisinopril tab 40 mg 1losartan potassium & hydrochlorothiazide tab 50-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg 1 QL (30 tablets/30 days)losartan potassium tab 25 mg 1 QL (60 tablets/30 days)losartan potassium tab 50 mg 1 QL (60 tablets/30 days)losartan potassium tab 100 mg 1 QL (30 tablets/30 days)lovastatin tab 10 mg 1 QL (60 tablets/30 days)lovastatin tab 20 mg 1 QL (60 tablets/30 days)lovastatin tab 40 mg 1 QL (60 tablets/30 days)methazolamide tab 25 mg 3methazolamide tab 50 mg 4metolazone tab 2.5 mg 2metolazone tab 5 mg 2metolazone tab 10 mg 2metoprolol & hydrochlorothiazide tab 50-25 mg 2metoprolol & hydrochlorothiazide tab 100-25 mg 2metoprolol succinate tab er 24hr 25 mg 2metoprolol succinate tab er 24hr 50 mg 2metoprolol succinate tab er 24hr 100 mg 2metoprolol succinate tab er 24hr 200 mg 2metoprolol tartrate tab 25 mg 1metoprolol tartrate tab 50 mg 1metoprolol tartrate tab 100 mg 1MEXILETINE HCL - mexiletine hcl cap 150 mg 3MEXILETINE HCL - mexiletine hcl cap 200 mg 3MEXILETINE HCL - mexiletine hcl cap 250 mg 3midodrine hcl tab 2.5 mg 2midodrine hcl tab 5 mg 2midodrine hcl tab 10 mg 2minoxidil tab 2.5 mg 2

2020


65

Drug Name Drug Tier Requirements/Limitsminoxidil tab 10 mg 2moexipril hcl tab 7.5 mg 2moexipril hcl tab 15 mg 2MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg 2nadolol tab 40 mg 2nadolol tab 80 mg 2niacin tab er 500 mg 2 QL (30 tablets/30 days)niacin tab er 750 mg 2 QL (60 tablets/30 days)niacin tab er 1000 mg 2 QL (60 tablets/30 days)nicardipine hcl cap 20 mg 2nicardipine hcl cap 30 mg 2nifedipine tab er 24hr 30 mg 2nifedipine tab er 24hr 60 mg 2nifedipine tab er 24hr 90 mg 2nifedipine tab er 24hr osmotic release 30 mg 2nifedipine tab er 24hr osmotic release 60 mg 2nifedipine tab er 24hr osmotic release 90 mg 2nimodipine cap 30 mg 5NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 3nisoldipine tab er 24hr 8.5 mg 3nisoldipine tab er 24hr 17 mg 3nisoldipine tab er 24hr 34 mg 3NITRO-BID - nitroglycerin oint 2% 4nitroglycerin sl tab 0.3 mg 2nitroglycerin sl tab 0.4 mg 2nitroglycerin sl tab 0.6 mg 2nitroglycerin td patch 24hr 0.1 mg/hr 2nitroglycerin td patch 24hr 0.2 mg/hr 2nitroglycerin td patch 24hr 0.4 mg/hr 2nitroglycerin td patch 24hr 0.6 mg/hr 2nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 2NORTHERA - droxidopa cap 100 mg* 5 PANORTHERA - droxidopa cap 200 mg* 5 PANORTHERA - droxidopa cap 300 mg* 5 PAolmesartan medoxomil tab 5 mg 2 QL (60 tablets/30 days)olmesartan medoxomil tab 20 mg 2 QL (30 tablets/30 days)olmesartan medoxomil tab 40 mg 2 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsolmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg 2 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg 2 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg 2 QL (30 tablets/30 days)omega-3-acid ethyl esters cap 1 gm 2pentoxifylline tab er 400 mg 2perindopril erbumine tab 2 mg 2perindopril erbumine tab 4 mg 2perindopril erbumine tab 8 mg 2phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg 2pindolol tab 10 mg 2pravastatin sodium tab 10 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 20 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 40 mg 2 QL (45 tablets/30 days)pravastatin sodium tab 80 mg 2 QL (30 tablets/30 days)prazosin hcl cap 1 mg 2prazosin hcl cap 2 mg 2prazosin hcl cap 5 mg 2propafenone hcl cap er 12hr 225 mg 3propafenone hcl cap er 12hr 325 mg 4propafenone hcl cap er 12hr 425 mg 4propafenone hcl tab 150 mg 2propafenone hcl tab 225 mg 2propafenone hcl tab 300 mg 2propranolol hcl cap er 24hr 60 mg 2propranolol hcl cap er 24hr 80 mg 2propranolol hcl cap er 24hr 120 mg 2propranolol hcl cap er 24hr 160 mg 2propranolol hcl inj 1 mg/ml 3propranolol hcl tab 10 mg 2propranolol hcl tab 20 mg 2propranolol hcl tab 40 mg 2propranolol hcl tab 60 mg 2propranolol hcl tab 80 mg 2quinapril hcl tab 5 mg 1quinapril hcl tab 10 mg 1quinapril hcl tab 20 mg 1quinapril hcl tab 40 mg 1

2020


67

Drug Name Drug Tier Requirements/Limitsquinapril-hydrochlorothiazide tab 10-12.5 mg 2quinapril-hydrochlorothiazide tab 20-12.5 mg 2quinapril-hydrochlorothiazide tab 20-25 mg 2quinidine gluconate tab er 324 mg 4QUINIDINE SULFATE - quinidine sulfate tab 200 mg 3QUINIDINE SULFATE - quinidine sulfate tab 300 mg 3ramipril cap 1.25 mg 1ramipril cap 2.5 mg 1ramipril cap 5 mg 1ramipril cap 10 mg 1ranolazine tab er 12hr 500 mg 3 QL (60 tablets/30 days)ranolazine tab er 12hr 1000 mg 3 QL (60 tablets/30 days)RECTIV - nitroglycerin oint 0.4% 4REPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml3 PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

3 PA, QL (1 system/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml

3 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg 1 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg 1 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg 1 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg 1 QL (30 tablets/30 days)simvastatin tab 5 mg 1 QL (45 tablets/30 days)simvastatin tab 10 mg 1 QL (45 tablets/30 days)simvastatin tab 20 mg 1 QL (60 tablets/30 days)simvastatin tab 40 mg 1 QL (45 tablets/30 days)simvastatin tab 80 mg 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg 2sotalol hcl (afib/afl) tab 120 mg 2sotalol hcl (afib/afl) tab 160 mg 2sotalol hcl tab 80 mg 2sotalol hcl tab 120 mg 2sotalol hcl tab 160 mg 2sotalol hcl tab 240 mg 2spironolactone & hydrochlorothiazide tab 25-25 mg 2spironolactone tab 25 mg 2spironolactone tab 50 mg 2spironolactone tab 100 mg 2

2020


Drug Name Drug Tier Requirements/LimitsTEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg 2 QL (30 tablets/30 days)telmisartan tab 40 mg 2 QL (30 tablets/30 days)telmisartan tab 80 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg 2 QL (30 tablets/30 days)terazosin hcl cap 1 mg 1 QL (90 capsules/30 days)terazosin hcl cap 2 mg 1 QL (60 capsules/30 days)terazosin hcl cap 5 mg 1 QL (60 capsules/30 days)terazosin hcl cap 10 mg 1 QL (60 capsules/30 days)TIMOLOL MALEATE - timolol maleate tab 10 mg 3TIMOLOL MALEATE - timolol maleate tab 20 mg 3timolol maleate tab 5 mg 2torsemide tab 5 mg 1torsemide tab 10 mg 1torsemide tab 20 mg 1torsemide tab 100 mg 2trandolapril tab 1 mg 2trandolapril tab 2 mg 2trandolapril tab 4 mg 2triamterene & hydrochlorothiazide cap 37.5-25 mg 1triamterene & hydrochlorothiazide tab 37.5-25 mg 1triamterene & hydrochlorothiazide tab 75-50 mg 1valsartan tab 40 mg 1 QL (60 tablets/30 days)valsartan tab 80 mg 1 QL (60 tablets/30 days)valsartan tab 160 mg 1 QL (60 tablets/30 days)valsartan tab 320 mg 1 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg 1 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-25 mg 2 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3

2020


69

Drug Name Drug Tier Requirements/Limitsverapamil hcl cap er 24hr 120 mg 2verapamil hcl cap er 24hr 180 mg 2verapamil hcl cap er 24hr 200 mg 2verapamil hcl cap er 24hr 240 mg 2verapamil hcl cap er 24hr 300 mg 2VERAPAMIL HCL ER- verapamil hcl cap er 24hr 100 mg 4VERAPAMIL HCL SR - verapamil hcl cap er 24hr 360 mg 2verapamil hcl tab er 120 mg 2verapamil hcl tab er 180 mg 2verapamil hcl tab er 240 mg 2verapamil hcl tab 40 mg 2verapamil hcl tab 80 mg 1verapamil hcl tab 120 mg 1VYNDAMAX - tafamidis cap 61 mg 5 PA, QL (30 capsules/30 days)VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg 5 PA, QL (120 capsules/30 days)Central Nervous System Agentsamphetamine-dextroamphetamine cap er 24hr 5 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg 3 QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg 3 QL (60 tablets/30 days)atomoxetine hcl cap 10 mg 4 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 80 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 100 mg 3 QL (30 capsules/30 days)AUBAGIO - teriflunomide tab 7 mg* 5 PA, QL (30 tablets/30 days)AUBAGIO - teriflunomide tab 14 mg* 5 PA, QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsAVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab er 12hr 0.1 mg 3 QL (120 tablets/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)dalfampridine tab er 12hr 10 mg 5 PAdexmethylphenidate hcl tab 2.5 mg 3 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 3 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg 3 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg 3 QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg 3 QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg 3 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 3 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 3 QL (180 tablets/30 days)fluoxetine hcl (pmdd) tab 10 mg 2GILENYA - fingolimod hcl cap 0.5 mg 5 PA, QL (30 capsules/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)MAVENCLAD - cladribine tab therapy pack 10 mg (4 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (5 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (6 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (7 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (8 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (9 tabs) 5 PAMAVENCLAD - cladribine tab therapy pack 10 mg (10 tabs) 5 PAMAYZENT - siponimod fumarate tab 0.25 mg 5 PA, QL (120 tablets/30 days)MAYZENT - siponimod fumarate tab 2 mg 5 PA, QL (30 tablets/30 days)methylphenidate hcl tab er 20 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 3 QL (90 tablets/30 days)NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3 PA, QL (60 capsules/30 days)

PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 PA, QL (2 syringes/28 days)PLEGRIDY - peginterferon beta-1a soln prefilled syringe

125 mcg/0.5ml5 PA, QL (2 syringes/28 days)

2020


71

Drug Name Drug Tier Requirements/LimitsPLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj

63 & 94 mcg/0.5ml pack5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack


REBIF - interferon beta-1a soln pref syr 22 mcg/0.5ml (12mu/ml) 5 PA, QL (12 syringes/28 days)REBIF - interferon beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml) 5 PA, QL (12 syringes/28 days)REBIF REBIDOSE - interferon beta-1a soln auto-inj 22 mcg/0.5ml

(12mu/ml)5 PA, QL (12 syringes/28 days)

REBIF REBIDOSE - interferon beta-1a soln auto-inj 44 mcg/0.5ml(24mu/ml)


REBIF REBIDOSE TITRATION PACK - interferon beta-1a auto-inj6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml


REBIF TITRATION PACK - interferon beta-1a pref syr6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml


riluzole tab 50 mg 3TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 PA, QL (60 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 5 PA, QL (60 capsules/30 days)TECFIDERA STARTER PACK - dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg5 PA, QL (60 capsules/30 days)

tetrabenazine tab 12.5 mg 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PADental and Oral Agentschlorhexidine gluconate soln 0.12% 1KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg 2pilocarpine hcl tab 7.5 mg 2triamcinolone acetonide dental paste 0.1% 2Dermatological Agentsacitretin cap 10 mg 4acitretin cap 17.5 mg 4acitretin cap 25 mg 4alclometasone dipropionate cream 0.05% 2 QL (120 grams/30 days)alclometasone dipropionate oint 0.05% 2 QL (120 grams/30 days)AUGMENTED BETAMETHASONE DIPROPIONATE -

betamethasone dipropionate augmented gel 0.05%3 QL (200 grams/28 days)

azelaic acid gel 15% 3AZELEX - azelaic acid cream 20% 4benzoyl peroxide-erythromycin gel 5-3% 3betamethasone dipropionate augmented cream 0.05% 2 QL (200 grams/28 days)betamethasone dipropionate augmented lotion 0.05% 2 QL (210 mls/30 days)

2020


Drug Name Drug Tier Requirements/Limitsbetamethasone dipropionate augmented oint 0.05% 2 QL (200 grams/28 days)betamethasone dipropionate cream 0.05% 2 QL (135 grams/30 days)betamethasone dipropionate lotion 0.05% 2 QL (120 mls/30 days)betamethasone dipropionate oint 0.05% 2 QL (135 grams/30 days)betamethasone valerate cream 0.1% 2 QL (135 grams/30 days)betamethasone valerate lotion 0.1% 2 QL (120 mls/30 days)betamethasone valerate oint 0.1% 2 QL (135 grams/30 days)calcipotriene cream 0.005% 4calcipotriene oint 0.005% 4calcipotriene soln 0.005% (50 mcg/ml) 3CARAC - fluorouracil cream 0.5% 5clindamycin phosphate-benzoyl peroxide gel 1-5% 3clobetasol propionate cream 0.05% 2 QL (210 grams/28 days)clobetasol propionate emollient base cream 0.05% 2 QL (210 grams/28 days)clobetasol propionate gel 0.05% 2 QL (210 grams/28 days)clobetasol propionate oint 0.05% 2 QL (210 grams/28 days)clobetasol propionate soln 0.05% 2 QL (200 mls/28 days)clotrimazole w/ betamethasone cream 1-0.05% 2clotrimazole w/ betamethasone lotion 1-0.05% 2desonide cream 0.05% 2 QL (120 grams/30 days)desonide lotion 0.05% 3 QL (118 mls/30 days)desonide oint 0.05% 2 QL (120 grams/30 days)desoximetasone cream 0.05% 3 QL (120 grams/30 days)desoximetasone cream 0.25% 2 QL (120 grams/30 days)desoximetasone gel 0.05% 3 QL (120 grams/30 days)desoximetasone oint 0.25% 2 QL (120 grams/30 days)diclofenac sodium (actinic keratoses) gel 3% 4diflorasone diacetate oint 0.05% 4 QL (120 grams/30 days)FINACEA - azelaic acid foam 15% 3fluocinolone acetonide cream 0.01% 2 QL (120 grams/30 days)fluocinonide cream 0.05% 2 QL (120 grams/30 days)fluocinonide emulsified base cream 0.05% 2 QL (120 grams/30 days)fluocinonide gel 0.05% 2 QL (120 grams/30 days)fluocinonide oint 0.05% 2 QL (120 grams/30 days)fluocinonide soln 0.05% 2 QL (120 mls/30 days)FLUOROURACIL - fluorouracil cream 0.5% 5FLUOROURACIL - fluorouracil soln 2% 2FLUOROURACIL - fluorouracil soln 5% 2

2020


73

Drug Name Drug Tier Requirements/Limitsfluorouracil cream 5% 2fluticasone propionate cream 0.05% 2 QL (120 grams/30 days)fluticasone propionate oint 0.005% 2 QL (120 grams/30 days)gentamicin sulfate cream 0.1% 2gentamicin sulfate oint 0.1% 2halobetasol propionate cream 0.05% 2 QL (200 grams/28 days)halobetasol propionate oint 0.05% 2 QL (200 grams/28 days)hydrocortisone butyrate cream 0.1% 2 QL (135 grams/30 days)hydrocortisone butyrate hydrophilic lipo base cream 0.1% 2 QL (120 grams/30 days)hydrocortisone butyrate oint 0.1% 2 QL (135 grams/30 days)hydrocortisone butyrate soln 0.1% 2 QL (120 mls/30 days)hydrocortisone cream 1% 1hydrocortisone cream 2.5% 2 QL (454 grams/30 days)hydrocortisone lotion 2.5% 2 QL (118 mls/30 days)hydrocortisone oint 1% 1hydrocortisone oint 2.5% 1 QL (454 grams/30 days)hydrocortisone valerate cream 0.2% 2 QL (120 grams/30 days)hydrocortisone valerate oint 0.2% 2 QL (120 grams/30 days)imiquimod cream 5% 2 PAisotretinoin cap 10 mg 3isotretinoin cap 20 mg 4isotretinoin cap 30 mg 4isotretinoin cap 40 mg 4lactic acid (ammonium lactate) cream 12% 2lactic acid (ammonium lactate) lotion 12% 2methoxsalen rapid cap 10 mg 5metronidazole cream 0.75% 2metronidazole gel 0.75% 2metronidazole gel 1% 3metronidazole lotion 0.75% 2mometasone furoate cream 0.1% 2 QL (135 grams/28 days)mometasone furoate oint 0.1% 2 QL (135 grams/28 days)mometasone furoate solution 0.1% (lotion) 2 QL (120 mls/30 days)mupirocin oint 2% 2nystatin-triamcinolone cream 100000-0.1 unit/gm-% 2nystatin-triamcinolone oint 100000-0.1 unit/gm-% 2ORACEA - doxycycline (rosacea) cap delayed release 40 mg 4PICATO - ingenol mebutate gel 0.015% 3 QL (3 tubes/30 days)

2020


Drug Name Drug Tier Requirements/LimitsPICATO - ingenol mebutate gel 0.05% 3 QL (2 tubes/30 days)pimecrolimus cream 1% 4 PApodofilox soln 0.5% 2PREDNICARBATE - prednicarbate cream 0.1% 2 QL (120 grams/30 days)PREDNICARBATE - prednicarbate oint 0.1% 2 QL (120 grams/30 days)REGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)SANTYL - collagenase oint 250 unit/gm 3 QL (180 grams/30 days)selenium sulfide lotion 2.5% 2silver sulfadiazine cream 1% 2SOOLANTRA - ivermectin cream 1% 3tacrolimus oint 0.03% 4 PAtacrolimus oint 0.1% 4 PAtazarotene cream 0.1% 4 PATAZORAC - tazarotene cream 0.05% 4 PATAZORAC - tazarotene gel 0.05% 4 PATAZORAC - tazarotene gel 0.1% 4 PAtretinoin cream 0.025% 2 PAtretinoin cream 0.05% 3 PAtretinoin cream 0.1% 3 PAtretinoin gel 0.01% 2 PAtretinoin gel 0.025% 2 PAtriamcinolone acetonide cream 0.025% 1 QL (454 grams/30 days)triamcinolone acetonide cream 0.1% 1 QL (454 grams/30 days)triamcinolone acetonide cream 0.5% 2 QL (454 grams/30 days)triamcinolone acetonide lotion 0.025% 2 QL (120 mls/30 days)triamcinolone acetonide lotion 0.1% 2 QL (120 mls/30 days)triamcinolone acetonide oint 0.025% 2 QL (454 grams/30 days)triamcinolone acetonide oint 0.1% 2 QL (454 grams/30 days)triamcinolone acetonide oint 0.5% 2 QL (120 grams/30 days)Electrolytes/Minerals/Metals/Vitaminsamino acid infusion 6% 3 BDamino acid infusion 15% 3 BDAURYXIA - ferric citrate tab 1 gm (210 mg ferric iron) 5 PA, QL (360 tablets/30 days)calcium acetate cap 667 mg 2calcium acetate tab 667 mg 2CARBAGLU - carglumic acid tab 200 mg* 5 PACHEMET - succimer cap 100 mg 5deferasirox tab for oral susp 125 mg 5 PA

2020


75

Drug Name Drug Tier Requirements/Limitsdeferasirox tab for oral susp 250 mg 5 PAdeferasirox tab for oral susp 500 mg 5 PAdeferasirox tab 90 mg 5 PAdeferasirox tab 360 mg 5 PAdextrose inj 5% 3dextrose inj 10% 3DEXTROSE 2.5%/NACL 0.45% - dextrose 2.5% w/ sodium chloride

0.45%3

dextrose 5% in lactated ringers 3dextrose 5% w/ sodium chloride 0.2% 3dextrose 5% w/ sodium chloride 0.33% 3dextrose 5% w/ sodium chloride 0.45% 3dextrose 5% w/ sodium chloride 0.9% 3fomepizole inj 1 gm/ml (for iv infusion) 5FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5 QL (180 packets/30 days)FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5 QL (120 packets/30 days)HEPATAMINE - amino acid infusion 8% 3 BDINTRALIPID - fat emulsion plant based iv emulsion 20% 4 BDJADENU - deferasirox tab 90 mg* 5 PAJADENU - deferasirox tab 180 mg* 5 PAJADENU - deferasirox tab 360 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 90 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 180 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 360 mg* 5 PAKCL 0.15%/D5W/NACL 0.225% - kcl 20 meq/l (0.15%) in dextrose

5% & nacl 0.225% inj3

kcl 20 meq/l (0.15%) in nacl 0.45% inj 3kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 4kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 3kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 3kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 4lactated ringer's solution 3lanthanum carbonate chew tab 500 mg 5 QL (90 tablets/30 days)lanthanum carbonate chew tab 750 mg 5 QL (180 tablets/30 days)lanthanum carbonate chew tab 1000 mg 5 QL (120 tablets/30 days)levocarnitine oral soln 1 gm/10ml (10%) 2levocarnitine tab 330 mg 2magnesium sulfate inj 50% 3

2020


Drug Name Drug Tier Requirements/LimitsNORMOSOL-M IN D5W - electrolyte-m in d5w soln 4NUTRILIPID - fat emulsion plant based iv emulsion 20% 4 BDPHOSLYRA - calcium acetate oral soln 667 mg/5ml 3potassium chloride cap er 8 meq 2potassium chloride cap er 10 meq 2potassium chloride inj 2 meq/ml 3potassium chloride microencapsulated crys er tab 10 meq 2potassium chloride microencapsulated crys er tab 20 meq 2potassium chloride oral soln 10% (20 meq/15ml) 3potassium chloride tab er 8 meq (600 mg) 2potassium chloride tab er 10 meq 2potassium chloride tab er 20 meq (1500 mg) 2potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 3POTASSIUM CHLORIDE/DEXTROSE - potassium chloride 40

meq/l (0.3%) in dextrose 5% inj3

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 20 meq/l (0.15%) in d5w lactated ringers

3

potassium citrate tab er 5 meq (540 mg) 2potassium citrate tab er 10 meq (1080 mg) 2potassium citrate tab er 15 meq (1620 mg) 2SAMSCA - tolvaptan tab 15 mg 5 PASAMSCA - tolvaptan tab 30 mg 5 PAsevelamer carbonate packet 0.8 gm 5 QL (270 packets/30 days)sevelamer carbonate packet 2.4 gm 5 QL (90 packets/30 days)sevelamer carbonate tab 800 mg 4 QL (270 tablets/30 days)sodium chloride irrigation soln 0.9% 2sodium chloride iv soln 0.45% 3sodium chloride iv soln 0.9% 3sodium chloride preservative free inj 0.9% 3sodium polystyrene sulfonate oral susp 15 gm/60ml 2sodium polystyrene sulfonate powder 2sodium polystyrene sulfonate rectal susp 30 gm/120ml 2trientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)VELPHORO - sucroferric oxyhydroxide chew tab 500 mg 5 QL (180 tablets/30 days)VELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm 5VELTASSA - patiromer sorbitex calcium for susp packet 16.8 gm 5VELTASSA - patiromer sorbitex calcium for susp packet 25.2 gm 5water for irrigation, sterile irrigation soln 2

2020


77

Drug Name Drug Tier Requirements/LimitsGastrointestinal Agentsalosetron hcl tab 0.5 mg 5 PA, QL (60 tablets/30 days)alosetron hcl tab 1 mg 5 PA, QL (60 tablets/30 days)AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PACHENODAL - chenodiol tab 250 mg* 5 PACIMETIDINE HCL - cimetidine hcl soln 300 mg/5ml 2cimetidine tab 200 mg 2cimetidine tab 300 mg 2cimetidine tab 400 mg 2cimetidine tab 800 mg 2cromolyn sodium oral conc 100 mg/5ml 3dicyclomine hcl cap 10 mg# 3 PAdicyclomine hcl tab 20 mg# 4 PAesomeprazole magnesium cap delayed release 20 mg 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg 2 QL (30 capsules/30 days)esomeprazole sodium for intravenous soln 40 mg 3famotidine for susp 40 mg/5ml 2famotidine inj 20 mg/2ml 3famotidine inj 40 mg/4ml 3famotidine inj 200 mg/20ml 3famotidine tab 20 mg 1famotidine tab 40 mg 1GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAglycopyrrolate tab 1 mg 2glycopyrrolate tab 2 mg 2lactulose (encephalopathy) solution 10 gm/15ml 2lactulose solution 10 gm/15ml 2lansoprazole cap delayed release 15 mg 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg 3 PALINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg 2methscopolamine bromide tab 2.5 mg 2methscopolamine bromide tab 5 mg 2metoclopramide hcl inj 5 mg/ml 3metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 2

2020


Drug Name Drug Tier Requirements/Limitsmetoclopramide hcl tab 5 mg 1metoclopramide hcl tab 10 mg 1misoprostol tab 100 mcg 2misoprostol tab 200 mcg 2MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

MYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PANEXIUM - esomeprazole magnesium for delayed release susp

packet 5 mg4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 10 mg

4 QL (30 packets/30 days)





NEXIUM - esomeprazole magnesium for delayed release susppack 2.5 mg


nizatidine cap 150 mg 2nizatidine cap 300 mg 2omeprazole cap delayed release 10 mg 2 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg 1 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg 1 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg 1 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg 1 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg 3peg 3350-kcl-sod bicarb-nacl for soln 420 gm 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 2PYLERA - bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg5

rabeprazole sodium ec tab 20 mg 2 QL (30 tablets/30 days)ranitidine hcl cap 150 mg 2ranitidine hcl cap 300 mg 2ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2ranitidine hcl tab 150 mg 1ranitidine hcl tab 300 mg 1RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide tab 150 mg 5 PAsucralfate tab 1 gm 2

2020


79

Drug Name Drug Tier Requirements/LimitsSUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/177ml4

ursodiol cap 300 mg 4ursodiol tab 250 mg 2ursodiol tab 500 mg 2XIFAXAN - rifaximin tab 550 mg 5 PA, QL (90 tablets/30 days)Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

CEREZYME - imiglucerase for inj 400 unit* 5 PACREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 3CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000

unit3

CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit

3

CRYSVITA - burosumab-twza inj 10 mg/ml 5 PACRYSVITA - burosumab-twza inj 20 mg/ml 5 PACRYSVITA - burosumab-twza inj 30 mg/ml 5 PACYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg* 4 PACYSTAGON - cysteamine bitartrate cap 150 mg* 4 PAELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml) 5ELELYSO - taliglucerase alfa for inj 200 unit* 5 PAFABRAZYME - agalsidase beta for iv soln 5 mg* 5FABRAZYME - agalsidase beta for iv soln 35 mg* 5KUVAN - sapropterin dihydrochloride powder packet 100 mg* 5 PAKUVAN - sapropterin dihydrochloride powder packet 500 mg* 5 PAKUVAN - sapropterin dihydrochloride soluble tab 100 mg* 5 PALUMIZYME - alglucosidase alfa for iv soln 50 mg* 5miglustat cap 100 mg* 5 PA, QL (90 capsules/30 days)NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5nitisinone cap 2 mg* 5nitisinone cap 5 mg* 5nitisinone cap 10 mg* 5OCALIVA - obeticholic acid tab 5 mg* 5 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg* 5 PA, QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5ORFADIN - nitisinone cap 10 mg* 5ORFADIN - nitisinone cap 20 mg* 5ORFADIN - nitisinone susp 4 mg/ml* 5PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe

2.5 mg/0.5ml5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe10 mg/0.5ml

5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe20 mg/ml

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln1000 mg*

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) inj1000 mg/20ml*

5 PA

REVCOVI - elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 mg/ml) 5sodium phenylbutyrate oral powder 3 gm/teaspoonful 5 PAsodium phenylbutyrate tab 500 mg 5 PASTRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 5 PAVPRIV - velaglucerase alfa for inj 400 unit 5 PAZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000unit

3


3


3


3


3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit

3

Genitourinary Agentsalfuzosin hcl tab er 24hr 10 mg 2 QL (30 tablets/30 days)bethanechol chloride tab 5 mg 2bethanechol chloride tab 10 mg 2bethanechol chloride tab 25 mg 2

2020


81

Drug Name Drug Tier Requirements/Limitsbethanechol chloride tab 50 mg 2DEPEN TITRATABS - penicillamine tab 250 mg 5dutasteride cap 0.5 mg 2 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg 2 QL (30 capsules/30 days)finasteride tab 5 mg 1 QL (30 tablets/30 days)methylergonovine maleate tab 0.2 mg 5MYRBETRIQ - mirabegron tab er 24 hr 25 mg 4 QL (30 tablets/30 days)MYRBETRIQ - mirabegron tab er 24 hr 50 mg 4 QL (30 tablets/30 days)oxybutynin chloride syrup 5 mg/5ml 2 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg 2 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg 2 QL (90 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 2 QL (120 tablets/30 days)penicillamine tab 250 mg 5sildenafil citrate tab 25 mg (generic for Viagra)‡ 1 QL (4 tablets/30 days)sildenafil citrate tab 50 mg (generic for Viagra)‡ 1 QL (4 tablets/30 days)sildenafil citrate tab 100 mg (generic for Viagra)‡ 1 QL (4 tablets/30 days)silodosin cap 4 mg 3 QL (30 capsules/30 days)silodosin cap 8 mg 3 QL (30 capsules/30 days)solifenacin succinate tab 5 mg 4 QL (30 tablets/30 days)solifenacin succinate tab 10 mg 4 QL (30 tablets/30 days)tamsulosin hcl cap 0.4 mg 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 3 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap er 24hr 60 mg 2 QL (30 capsules/30 days)trospium chloride tab 20 mg 2 QL (60 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)ACTHAR - corticotropin inj gel 80 unit/ml* 5 PACORTISONE ACETATE - cortisone acetate tab 25 mg 3DEXAMETHASONE - dexamethasone soln 0.5 mg/5ml 2DEXAMETHASONE - dexamethasone tab 1 mg 3DEXAMETHASONE - dexamethasone tab 2 mg 3dexamethasone elixir 0.5 mg/5ml 2dexamethasone sodium phosphate inj 4 mg/ml 3

2020


Drug Name Drug Tier Requirements/Limitsdexamethasone sodium phosphate inj 20 mg/5ml 3dexamethasone sodium phosphate inj 120 mg/30ml 3dexamethasone tab therapy pack 1.5 mg (21) 1dexamethasone tab therapy pack 1.5 mg (35) 1dexamethasone tab therapy pack 1.5 mg (51) 1dexamethasone tab 0.5 mg 1dexamethasone tab 0.75 mg 1dexamethasone tab 1.5 mg 1dexamethasone tab 4 mg 2dexamethasone tab 6 mg 2fludrocortisone acetate tab 0.1 mg 2hydrocortisone tab 5 mg 2hydrocortisone tab 10 mg 2hydrocortisone tab 20 mg 2methylprednisolone sod succ for inj 40 mg 3methylprednisolone sod succ for inj 125 mg 3methylprednisolone sod succ for inj 500 mg 3methylprednisolone sod succ for inj 1000 mg 3methylprednisolone tab therapy pack 4 mg (21) 2methylprednisolone tab 4 mg 2methylprednisolone tab 8 mg 2methylprednisolone tab 16 mg 2methylprednisolone tab 32 mg 2prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) 2prednisolone sod phosphate oral soln 15 mg/5ml 2prednisolone syrup 15 mg/5ml 2PREDNISONE - prednisone oral soln 5 mg/5ml 3prednisone tab therapy pack 5 mg (21) 2prednisone tab therapy pack 5 mg (48) 2prednisone tab therapy pack 10 mg (21) 2prednisone tab therapy pack 10 mg (48) 2prednisone tab 1 mg 2prednisone tab 2.5 mg 1prednisone tab 5 mg 2prednisone tab 10 mg 2prednisone tab 20 mg 1prednisone tab 50 mg 2

2020


83

Drug Name Drug Tier Requirements/LimitsHormonal Agents, Stimulant/Replacement/Modifying (Pituitary)CHORIONIC GONADOTROPIN - chorionic gonadotropin for im inj

10000 unit3 PA

desmopressin acetate inj 4 mcg/ml 3desmopressin acetate nasal spray soln 0.01% 3desmopressin acetate nasal spray soln 0.01% (refrigerated) 3desmopressin acetate tab 0.1 mg 2desmopressin acetate tab 0.2 mg 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAEGRIFTA SV - tesamorelin acetate for inj 2 mg* 5 PAINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg 5 PAOMNITROPE - somatropin inj 5 mg/1.5ml 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml 5 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL -

chorionic gonadotropin for im inj 10000 unit3 PA

STIMATE - desmopressin acetate nasal soln 1.5 mg/ml 5Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.14 mg/

day#4

COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.25 mg/day#

4

danazol cap 50 mg 3 PAdanazol cap 100 mg 3 PAdanazol cap 200 mg 3 PADEPO-PROVERA - medroxyprogesterone acetate im susp 400 mg/

ml4

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 3desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 3desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)# 4DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 4DIVIGEL - estradiol td gel 0.75 mg/0.75gm (0.1%)# 4DIVIGEL - estradiol td gel 1 mg/gm (0.1%)# 4DIVIGEL - estradiol td gel 1.25 mg/1.25gm (0.1%)# 4drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg 3drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg 3

2020


Drug Name Drug Tier Requirements/Limitsdrospirenone-ethinyl estradiol tab 3-0.02 mg 3drospirenone-ethinyl estradiol tab 3-0.03 mg 3DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg# 4ELLA - ulipristal acetate tab 30 mg 3estradiol & norethindrone acetate tab 0.5-0.1 mg# 4estradiol & norethindrone acetate tab 1-0.5 mg# 4estradiol tab 0.5 mg# 4estradiol tab 1 mg# 4estradiol tab 2 mg# 4estradiol td patch twice weekly 0.025 mg/24hr# 4estradiol td patch twice weekly 0.0375 mg/24hr# 4estradiol td patch twice weekly 0.05 mg/24hr# 4estradiol td patch twice weekly 0.075 mg/24hr# 4estradiol td patch twice weekly 0.1 mg/24hr# 4estradiol td patch weekly 0.025 mg/24hr# 4estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)# 4estradiol td patch weekly 0.05 mg/24hr# 4estradiol td patch weekly 0.06 mg/24hr# 4estradiol td patch weekly 0.075 mg/24hr# 4estradiol td patch weekly 0.1 mg/24hr# 4estradiol vaginal cream 0.1 mg/gm 2estradiol vaginal tab 10 mcg 2ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 3ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg 3HYDROXYPROGESTERONE CAPROATE - hydroxyprogesterone

caproate im in oil 1.25 gm/5ml5

hydroxyprogesterone caproate im in oil 250 mg/ml 5levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 3levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) 3levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 3levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 3levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 3levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 3medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 3medroxyprogesterone acetate im susp 150 mg/ml 3medroxyprogesterone acetate tab 2.5 mg 1medroxyprogesterone acetate tab 5 mg 1medroxyprogesterone acetate tab 10 mg 2

2020


85

Drug Name Drug Tier Requirements/Limitsmegestrol acetate susp 40 mg/ml# 4 PAmegestrol acetate tab 20 mg# 4 PAmegestrol acetate tab 40 mg# 4 PAMENEST - esterified estrogens tab 0.3 mg# 4MENEST - esterified estrogens tab 0.625 mg# 4MENEST - esterified estrogens tab 1.25 mg# 4METHYLTESTOSTERONE - methyltestosterone cap 10 mg 5 PAnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 3norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 3norethindrone & ethinyl estradiol tab 1 mg-35 mcg 3norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 3norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 3norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 3norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 3norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 3norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) 3norethindrone acetate tab 5 mg 2norethindrone tab 0.35 mg 3norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 3norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 3norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 3norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg 3norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg 3norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 3oxandrolone tab 2.5 mg 4 PAoxandrolone tab 10 mg 5 PAPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMARIN - estrogens, conjugated tab 0.3 mg# 3PREMARIN - estrogens, conjugated tab 0.45 mg# 3PREMARIN - estrogens, conjugated tab 0.625 mg# 3PREMARIN - estrogens, conjugated tab 0.9 mg# 3PREMARIN - estrogens, conjugated tab 1.25 mg# 3PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#3

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg#

3

2020


Drug Name Drug Tier Requirements/LimitsPREMPRO - conjugated estrogen-medroxyprogest acetate tab

0.45-1.5 mg#3

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-2.5 mg#

3

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-5 mg#

3

progesterone micronized cap 100 mg 2progesterone micronized cap 200 mg 2raloxifene hcl tab 60 mg 2testosterone cypionate im inj in oil 100 mg/ml 3 PAtestosterone cypionate im inj in oil 200 mg/ml 3 PAtestosterone enanthate im inj in oil 200 mg/ml 3 PAtestosterone td gel 12.5 mg/act (1%) 3 PA, QL (4 pump bottles/30 days)testosterone td gel 25 mg/2.5gm (1%) 3 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%) 3 PA, QL (60 units/30 days)testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)testosterone td soln 30 mg/act 4 PA, QL (2 pump bottles/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg (euthyrox, levo-t, levoxyl,

unithroid)2

levothyroxine sodium tab 50 mcg (euthyrox, levo-t, levoxyl,unithroid)

2


2


2


2


2


2


2


2


2


2

levothyroxine sodium tab 300 mcg (levo-t, unithroid) 2

2020


87

Drug Name Drug Tier Requirements/Limitsliothyronine sodium tab 5 mcg 2liothyronine sodium tab 25 mcg 2liothyronine sodium tab 50 mcg 2SYNTHROID - levothyroxine sodium tab 25 mcg 4SYNTHROID - levothyroxine sodium tab 50 mcg 4SYNTHROID - levothyroxine sodium tab 75 mcg 4SYNTHROID - levothyroxine sodium tab 88 mcg 4SYNTHROID - levothyroxine sodium tab 100 mcg 4SYNTHROID - levothyroxine sodium tab 112 mcg 4SYNTHROID - levothyroxine sodium tab 125 mcg 4SYNTHROID - levothyroxine sodium tab 137 mcg 4SYNTHROID - levothyroxine sodium tab 150 mcg 4SYNTHROID - levothyroxine sodium tab 175 mcg 4SYNTHROID - levothyroxine sodium tab 200 mcg 4SYNTHROID - levothyroxine sodium tab 300 mcg 4Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 3Hormonal Agents, Suppressant (Pituitary)cabergoline tab 0.5 mg 2ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit30 mg

4

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit45 mg

4

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4FIRMAGON - degarelix acetate for inj 80 mg 4FIRMAGON - degarelix acetate for inj 120 mg 5leuprolide acetate inj kit 5 mg/ml 5LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg5

LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit 7.5 mg 5LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj

kit 11.25 mg5

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 22.5 mg

5

LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for injkit 30 mg

5

LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for injkit 45 mg

5

2020


Drug Name Drug Tier Requirements/LimitsLUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for inj

pediatric kit 7.5 mg5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 11.25 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 15 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 11.25 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 30 mg

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 4 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 4 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 4 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 4 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 10 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 30 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PASOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj90 mg/0.3ml

5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PASOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5 PAHormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg 1methimazole tab 10 mg 2

2020


89

Drug Name Drug Tier Requirements/Limitspropylthiouracil tab 50 mg 2Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 3ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5 PA

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 3ARCALYST - rilonacept for inj 220 mg* 5 PAATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 4 BDAZASAN - azathioprine tab 100 mg 4 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 3 BDazathioprine tab 50 mg 2 BDBCG VACCINE - bcg vaccine inj 3BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

BENLYSTA - belimumab subcutaneous solution prefilled syringe200 mg/ml

5 PA

BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilledsyringe

3

BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

3

CABLIVI - caplacizumab-yhdp for inj kit 11 mg 5CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)COSENTYX - secukinumab subcutaneous pref syr 150 mg/ml

(300 mg dose)*5 PA

COSENTYX - secukinumab subcutaneous soln prefilled syringe150 mg/ml*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneousauto-inj 150 mg/ml (300 mg dose)*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneoussoln auto-injector 150 mg/ml*

5 PA

cyclosporine cap 25 mg 3 BDcyclosporine cap 100 mg 4 BDcyclosporine iv soln 50 mg/ml 3 BDcyclosporine modified cap 25 mg 2 BDcyclosporine modified cap 50 mg 3 BDcyclosporine modified cap 100 mg 2 BDcyclosporine modified oral soln 100 mg/ml 3 BD

2020


Drug Name Drug Tier Requirements/LimitsDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 3DIPHTHERIA/TETANUS TOXOIDS ADSORBED - diphtheria-

tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml3

DUPIXENT - dupilumab subcutaneous soln prefilled syringe200 mg/1.14ml

5 PA

DUPIXENT - dupilumab subcutaneous soln prefilled syringe300 mg/2ml

5 PA

ENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml5 PA

ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 PAENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/

ml5 PA

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml

5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 3 BDENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 3 BDGAMMAGARD LIQUID - immune globulin (human) iv or

subcutaneous soln 1 gm/10ml5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 2.5 gm/25ml

5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 5 gm/50ml

5 BD, PA


5 BD, PA


5 BD, PA


5 BD, PA

GAMMAGARD S/D - immune globulin (human) iv for soln 5 gm 5 BD, PAGAMMAGARD S/D - immune globulin (human) iv for soln 10 gm 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/200ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/400ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/50ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/200ml 5 BD, PAGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

1 gm/10ml5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln2.5 gm/25ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln5 gm/50ml

5 BD, PA

2020


91

Drug Name Drug Tier Requirements/LimitsGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

10 gm/100ml5 BD, PA


5 BD, PA


5 BD, PA

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac imsusp

3

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

3

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj2000 unit*

5 PA, QL (24 vials/30 days)

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj3000 unit*

5 PA, QL (16 vials/30 days)

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 3HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 3HIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg3

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml 5 PAHUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.4ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 40 mg/0.8ml5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml

5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml & 40 mg/0.4ml

5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 5 PAHUMIRA PEN - adalimumab pen-injector kit 40 mg/0.4ml 5 PAHUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit

40 mg/0.8ml5 PA

HUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit80 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit40 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4ml

5 PA

icatibant acetate inj 30 mg/3ml 5 PA, QL (6 syringes/30 days)ILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 3 BD

2020


Drug Name Drug Tier Requirements/LimitsINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 3IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 3IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 3KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 3leflunomide tab 10 mg 2leflunomide tab 20 mg 2M-M-R II - measles-mumps-rubella virus vaccines for inj soln 3MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj3

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 3METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)2

methotrexate sodium for inj 1 gm 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 2methotrexate sodium inj 50 mg/2ml (25 mg/ml) 2methotrexate sodium tab 2.5 mg 2mycophenolate mofetil cap 250 mg 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil hcl for iv soln 500 mg 3 BDmycophenolate mofetil tab 500 mg 2 BDmycophenolate sodium tab dr 180 mg 4 BDmycophenolate sodium tab dr 360 mg 4 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDORENCIA - abatacept for iv soln 250 mg 5 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml

5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml

5 PA

ORENCIA CLICKJECT - abatacept subcutaneous soln auto-injector125 mg/ml

5 PA

OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg &30 mg*

5 PA

OTEZLA - apremilast tab 30 mg* 5 PAPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj 3

2020


93

Drug Name Drug Tier Requirements/LimitsPEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml3

PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac forim susp

3

PROGRAF - tacrolimus inj 5 mg/ml 4 BDPROGRAF - tacrolimus packet for susp 0.2 mg 4 BDPROGRAF - tacrolimus packet for susp 1 mg 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for

susp3

QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vacinj

3

RABAVERT - rabies vaccine, pcec for inj 3 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml3 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp10 mcg/ml

3 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp40 mcg/ml

3 BD

RENFLEXIS - infliximab-abda for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 5RINVOQ - upadacitinib tab er 24hr 15 mg 5 PAROTARIX - rotavirus vaccine, live for oral susp 3ROTATEQ - rotavirus vaccine, live oral pentavalent soln 3SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSHINGRIX - zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml3 QL (2 vaccines/lifetime)

SIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus oral soln 1 mg/ml 5 BDsirolimus tab 0.5 mg 3 BDsirolimus tab 1 mg 4 BDsirolimus tab 2 mg 5 BDSKYRIZI - risankizumab-rzaa sol prefilled syringe 2 x 75 mg/0.83ml

kit5 PA

STAMARIL - yellow fever vaccine for inj suspension 3STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYLVANT - siltuximab for iv infusion 100 mg 5

2020


Drug Name Drug Tier Requirements/LimitsSYLVANT - siltuximab for iv infusion 400 mg 5SYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg 2 BDtacrolimus cap 1 mg 2 BDtacrolimus cap 5 mg 3 BDTDVAX - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 3 BDTENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 3 BDTHYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg

(lymphocyte ig)5 BD

TREMFYA - guselkumab soln pen-injector 100 mg/ml 5 PATREMFYA - guselkumab soln prefilled syringe 100 mg/ml 5 PATRUMENBA - meningococcal group b vac (recomb) im susp

prefilled syr3

TWINRIX - hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml 3TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj

25 mcg/0.5ml3

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 3VAQTA - hepatitis a vaccine inj susp 50 unit/ml 3VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml3

XATMEP - methotrexate oral soln 2.5 mg/ml 4 BDXELJANZ - tofacitinib citrate tab 5 mg 5 PAXELJANZ - tofacitinib citrate tab 10 mg 5 PAXOLAIR - omalizumab for inj 150 mg* 5 PAXOLAIR - omalizumab subcutaneous soln prefilled syringe

75 mg/0.5ml*5 PA

XOLAIR - omalizumab subcutaneous soln prefilled syringe 150 mg/ml*

5 PA

YF-VAX - yellow fever vaccine subcutaneous inj 3ZORTRESS - everolimus tab 0.25 mg 5 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZORTRESS - everolimus tab 1 mg 5 BDZOSTAVAX - zoster vaccine live for subcutaneous susp 19400

unit/0.65ml3 QL (1 vaccine/lifetime)

Inflammatory Bowel Disease AgentsAPRISO - mesalamine cap er 24hr 0.375 gm 4 QL (120 capsules/30 days)balsalazide disodium cap 750 mg 2budesonide delayed release particles cap 3 mg 4 QL (90 capsules/30 days)DIPENTUM - olsalazine sodium cap 250 mg 5

2020


95

Drug Name Drug Tier Requirements/Limitshydrocortisone enema 100 mg/60ml 2hydrocortisone rectal cream 1% 1hydrocortisone rectal cream 2.5% 2mesalamine cap dr 400 mg 3 QL (180 capsules/30 days)mesalamine cap er 24hr 0.375 gm 4 QL (120 capsules/30 days)mesalamine enema 4 gm 4mesalamine rectal enema 4 gm & cleanser wipe kit 4mesalamine suppos 1000 mg 3mesalamine tab delayed release 800 mg 4 QL (180 tablets/30 days)mesalamine tab delayed release 1.2 gm 4 QL (120 tablets/30 days)PENTASA - mesalamine cap er 250 mg 4 QL (480 capsules/30 days)PENTASA - mesalamine cap er 500 mg 4 QL (240 capsules/30 days)sulfasalazine tab delayed release 500 mg 2sulfasalazine tab 500 mg 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg 1 QL (4 tablets/28 days)alendronate sodium tab 70 mg 1 QL (4 tablets/28 days)calcitonin (salmon) nasal soln 200 unit/act 2CALCITRIOL - calcitriol inj 1 mcg/ml 3calcitriol cap 0.25 mcg 2calcitriol cap 0.5 mcg 2calcitriol oral soln 1 mcg/ml 3cinacalcet hcl tab 30 mg 5 PAcinacalcet hcl tab 60 mg 5 PAcinacalcet hcl tab 90 mg 5 PAFORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAibandronate sodium iv soln 3 mg/3ml 3ibandronate sodium tab 150 mg 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 5NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg*5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge50 mcg*

5 PA, QL (2 cartridges/28 days)





paricalcitol cap 1 mcg 3

2020


Drug Name Drug Tier Requirements/Limitsparicalcitol cap 2 mcg 3paricalcitol cap 4 mcg 3paricalcitol iv soln 2 mcg/ml 3paricalcitol iv soln 5 mcg/ml 3PROLIA - denosumab inj soln prefilled syringe 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg 2 QL (30 tablets/30 days)risedronate sodium tab 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg 2 QL (1 tablet/28 days)TYMLOS - abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml5 PA

XGEVA - denosumab inj 120 mg/1.7ml 5 PAzoledronic acid inj conc for iv infusion 4 mg/5ml 4zoledronic acid iv soln 5 mg/100ml 3Ophthalmic AgentsALPHAGAN P - brimonidine tartrate ophth soln 0.1% 3azelastine hcl ophth soln 0.05% 2AZOPT - brinzolamide ophth susp 1% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 3bacitracin-polymyxin b ophth oint 2bacitracin-polymyxin-neomycin-hc ophth oint 1% 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4betaxolol hcl ophth soln 0.5% 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4bimatoprost ophth soln 0.03% 2brimonidine tartrate ophth soln 0.15% 2brimonidine tartrate ophth soln 0.2% 2bromfenac sodium ophth soln 0.09% (once-daily) 2carteolol hcl ophth soln 1% 2ciprofloxacin hcl ophth soln 0.3% 2COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

cromolyn sodium ophth soln 4% 2CYSTARAN - cysteamine hcl ophth soln 0.44%* 5 PADEXAMETHASONE SODIUM PHOSPHATE - dexamethasone

sodium phosphate ophth soln 0.1%3

diclofenac sodium ophth soln 0.1% 2dorzolamide hcl ophth soln 2% 2

2020


97

Drug Name Drug Tier Requirements/Limitsdorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 2DUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05% 2erythromycin ophth oint 5 mg/gm 2fluorometholone ophth susp 0.1% 2FLURBIPROFEN SODIUM - flurbiprofen sodium ophth soln 0.03% 4GENTAK - gentamicin sulfate ophth oint 0.3% 2gentamicin sulfate ophth soln 0.3% 2ILEVRO - nepafenac ophth susp 0.3% 3ketorolac tromethamine ophth soln 0.4% 2ketorolac tromethamine ophth soln 0.5% 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005% 2levobunolol hcl ophth soln 0.5% 1LUMIGAN - bimatoprost ophth soln 0.01% 3MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4moxifloxacin hcl ophth soln 0.5% 2NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 2neomycin-polymyxin-dexamethasone ophth oint 0.1% 2neomycin-polymyxin-dexamethasone ophth susp 0.1% 2NEOMYCIN/POLYMYXIN/GRAMICIDIN - neomycin-polymy-

gramicid op sol 1.75-10000-0.025mg-unt-mg/ml2

ofloxacin ophth soln 0.3% 2olopatadine hcl ophth soln 0.1% 2olopatadine hcl ophth soln 0.2% 2PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1% 2pilocarpine hcl ophth soln 2% 2pilocarpine hcl ophth soln 4% 2polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 1PREDNISOLONE ACETATE - prednisolone acetate ophth susp 1% 4PROLENSA - bromfenac sodium ophth soln 0.07% 4RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)RHOPRESSA - netarsudil dimesylate ophth soln 0.02% 3 STSIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3

2020


Drug Name Drug Tier Requirements/Limitssulfacetamide sodium ophth soln 10% 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 2timolol maleate ophth soln 0.25% 1timolol maleate ophth soln 0.5% 1timolol maleate ophth soln 0.5% (once-daily) 2TIMOLOL MALEATE OPHTHALMIC GEL FORMING - timolol

maleate ophth gel forming soln 0.25%2

TIMOLOL MALEATE OPHTHALMIC GEL FORMING - timololmaleate ophth gel forming soln 0.5%

2

TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4tobramycin ophth soln 0.3% 2tobramycin-dexamethasone ophth susp 0.3-0.1% 2TRAVATAN Z - travoprost ophth soln 0.004% 3travoprost ophth soln 0.004% 3TRIFLURIDINE - trifluridine ophth soln 1% 3Otic Agentsacetic acid otic soln 2% 2fluocinolone acetonide (otic) oil 0.01% 2hydrocortisone w/ acetic acid otic soln 1-2% 2neomycin-polymyxin-hc otic soln 1% 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 2ofloxacin otic soln 0.3% 2Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10% 2 BDacetylcysteine inhal soln 20% 2 BDADEMPAS - riociguat tab 0.5 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg* 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba250-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba500-50 mcg/dose


ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 3 QL (1 canister/30 days)ALBUTEROL SULFATE ER - albuterol sulfate tab er 12hr 4 mg 2

2020


99

Drug Name Drug Tier Requirements/LimitsALBUTEROL SULFATE ER - albuterol sulfate tab er 12hr 8 mg 2albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml) 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml 2 BDalbuterol sulfate syrup 2 mg/5ml 2albuterol sulfate tab 2 mg 3albuterol sulfate tab 4 mg 3ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 50 mcg/act

3 QL (30 blisters/30 days)





ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act


ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh












ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act

4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 2 QL (2 bottles/30 days)bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh3 QL (1 package/30 days)

2020


Drug Name Drug Tier Requirements/LimitsBREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

200-25 mcg/inh3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml 4 BDbudesonide inhalation susp 0.5 mg/2ml 4 BDbudesonide inhalation susp 1 mg/2ml 4 BDcaffeine citrate oral soln 60 mg/3ml 2CLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 4 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

cromolyn sodium soln nebu 20 mg/2ml 3 BDDALIRESP - roflumilast tab 250 mcg 4 PA, QL (30 tablets/30 days)DALIRESP - roflumilast tab 500 mcg 4 PA, QL (30 tablets/30 days)diphenhydramine hcl inj 50 mg/ml 3DULERA - mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act4 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act


epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 3epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (generic

for EpiPen 2-Pak)3

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister


FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act(50/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act(250/valve)


fluticasone propionate nasal susp 50 mcg/act 2 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-

salmeterol aer powder ba 55-14 mcg/act3 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 113-14 mcg/act


FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 232-14 mcg/act


2020


101

Drug Name Drug Tier Requirements/LimitsINCRUSE ELLIPTA - umeclidinium br aero powd breath act

62.5 mcg/inh3 QL (30 blisters/30 days)

ipratropium bromide inhal soln 0.02% 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray) 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray) 2 QL (3 bottles/30 days)KALYDECO - ivacaftor packet 25 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)levocetirizine dihydrochloride tab 5 mg 1mometasone furoate nasal susp 50 mcg/act 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg 2montelukast sodium chew tab 5 mg 2montelukast sodium oral granules packet 4 mg 2montelukast sodium tab 10 mg 1OFEV - nintedanib esylate cap 100 mg* 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6% 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORALAIR - grass mixed pollen ext sl tab 300 ir 4 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 100-125 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 150-188 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 5 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 5 PA, QL (120 tablets/30 days)PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BDQVAR REDIHALER - beclomethasone diprop hfa breath act inh aer

40 mcg/act3 QL (1 canister/30 days)

QVAR REDIHALER - beclomethasone diprop hfa breath act inh aer80 mcg/act


REMODULIN - treprostinil inj soln 20 mg/20ml (1 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 100 mg/20ml (5 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 200 mg/20ml (10 mg/ml)* 5 BDribavirin for inhal soln 6 gm 5SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg 3 PA, QL (90 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsSPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act


SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 2.5 mcg/act


STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln2.5-2.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act


SYMDEKO - tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tabtbpk


SYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mgtab tbpk


tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)terbutaline sulfate tab 2.5 mg 3terbutaline sulfate tab 5 mg 4theophylline tab er 12hr 300 mg 2theophylline tab er 12hr 450 mg 2theophylline tab er 24hr 400 mg 2theophylline tab er 24hr 600 mg 2tobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/inh3 QL (60 blisters/30 days)

treprostinil inj soln 20 mg/20ml (1 mg/ml)* 5 BDtreprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 5 BDtreprostinil inj soln 100 mg/20ml (5 mg/ml)* 5 BDtreprostinil inj soln 200 mg/20ml (10 mg/ml)* 5 BDTRIKAFTA - elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor

150 mg tbpk5 PA, QL (90 tablets/30 days)

UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg(60)*

5 PA, QL (1 pack (200tablets)/28 days)

UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)

2020


103

Drug Name Drug Tier Requirements/LimitsUPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)zafirlukast tab 10 mg 2zafirlukast tab 20 mg 2Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 3 PAcyclobenzaprine hcl tab 10 mg# 3 PAmethocarbamol tab 500 mg# 4methocarbamol tab 750 mg# 4Sleep Disorder Agentsarmodafinil tab 50 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 150 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 200 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 250 mg 3 PA, QL (30 tablets/30 days)BELSOMRA - suvorexant tab 5 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 10 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 15 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 20 mg 3 QL (30 tablets/30 days)doxepin hcl (sleep) tab 3 mg 3 QL (30 tablets/30 days)doxepin hcl (sleep) tab 6 mg 3 QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg 3 PA, QL (30 tablets/30 days)modafinil tab 200 mg 3 PA, QL (30 tablets/30 days)ramelteon tab 8 mg 2 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)temazepam cap 15 mg 3 QL (30 capsules/30 days)temazepam cap 30 mg 3 QL (30 capsules/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 4 QL (30 capsules/30 days)zaleplon cap 10 mg# 4 QL (60 capsules/30 days)zolpidem tartrate tab 5 mg# 4 QL (30 tablets/30 days)zolpidem tartrate tab 10 mg# 4 QL (30 tablets/30 days)

2020

104

INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................45abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................45abacavir sulfate soln 20 mg/ml.................................. 45abacavir sulfate tab 300 mg.......................................45abiraterone acetate tab 250 mg.................................27ABRAXANE...................................................................27ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1acamprosate calcium tab delayed release 333

mg..................................................................................5acarbose tab 100 mg.................................................. 51acarbose tab 25 mg.................................................... 51acarbose tab 50 mg.................................................... 51acebutolol hcl cap 200 mg..........................................58acebutolol hcl cap 400 mg..........................................58acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

mg..................................................................................1acetaminophen w/ codeine tab 300-30

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................58acetazolamide tab 125 mg......................................... 58acetazolamide tab 250 mg......................................... 58acetic acid otic soln 2%.............................................. 98acetylcysteine inhal soln 10%.................................... 98acetylcysteine inhal soln 20%.................................... 98acitretin cap 10 mg......................................................71acitretin cap 17.5 mg...................................................71acitretin cap 25 mg......................................................71ACTHAR........................................................................81ACTHIB..........................................................................89ACTIMMUNE................................................................ 89acyclovir cap 200 mg.................................................. 45acyclovir oint 5%..........................................................45acyclovir sodium iv soln 50 mg/ml.............................45acyclovir susp 200 mg/5ml......................................... 45acyclovir tab 400 mg................................................... 45acyclovir tab 800 mg................................................... 45ADACEL........................................................................ 89ADASUVE..................................................................... 40

adefovir dipivoxil tab 10 mg........................................45ADEMPAS..................................................................... 98ADEMPAS..................................................................... 98ADEMPAS..................................................................... 98ADEMPAS..................................................................... 98ADEMPAS..................................................................... 98ADRIAMYCIN............................................................... 27ADRIAMYCIN............................................................... 27ADVAIR DISKUS..........................................................98ADVAIR DISKUS..........................................................98ADVAIR DISKUS..........................................................98ADVAIR HFA.................................................................98ADVAIR HFA.................................................................98ADVAIR HFA.................................................................98AFINITOR......................................................................27AFINITOR......................................................................27AFINITOR......................................................................27AFINITOR......................................................................27AFINITOR DISPERZ................................................... 27AFINITOR DISPERZ................................................... 27AFINITOR DISPERZ................................................... 27AIMOVIG....................................................................... 25AIMOVIG....................................................................... 25albendazole tab 200 mg............................................. 38ALBUTEROL SULFATE ER....................................... 98ALBUTEROL SULFATE ER....................................... 99albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).......................................................................99albuterol sulfate soln nebu 0.5% (5 mg/

ml)................................................................................99albuterol sulfate soln nebu 0.63

mg/3ml........................................................................ 99albuterol sulfate soln nebu 1.25

mg/3ml........................................................................ 99albuterol sulfate syrup 2 mg/5ml................................99albuterol sulfate tab 2 mg...........................................99albuterol sulfate tab 4 mg...........................................99alclometasone dipropionate cream

0.05%..........................................................................71alclometasone dipropionate oint

0.05%..........................................................................71ALCOHOL SWABS......................................................51ALDURAZYME............................................................. 79ALECENSA................................................................... 27alendronate sodium tab 10 mg.................................. 95alendronate sodium tab 35 mg.................................. 95alendronate sodium tab 5 mg.................................... 95alendronate sodium tab 70 mg.................................. 95alfuzosin hcl tab er 24hr 10 mg................................. 80ALIMTA.......................................................................... 27ALIMTA.......................................................................... 27ALINIA............................................................................38

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ALINIA............................................................................38ALIQOPA....................................................................... 27aliskiren fumarate tab 150 mg....................................58aliskiren fumarate tab 300 mg....................................58allopurinol sodium for inj 500 mg...............................25allopurinol tab 100 mg.................................................25allopurinol tab 300 mg.................................................25alosetron hcl tab 0.5 mg............................................. 77alosetron hcl tab 1 mg................................................ 77ALPHAGAN P...............................................................96alprazolam tab 0.25 mg.............................................. 50alprazolam tab 0.5 mg................................................ 50alprazolam tab 1 mg....................................................50alprazolam tab 2 mg....................................................50ALUNBRIG....................................................................27ALUNBRIG....................................................................27ALUNBRIG....................................................................27ALUNBRIG....................................................................27amantadine hcl cap 100 mg.......................................39amantadine hcl syrup 50 mg/5ml...............................39amantadine hcl tab 100 mg........................................39AMBISOME...................................................................24ambrisentan tab 10 mg............................................... 99ambrisentan tab 5 mg................................................. 99amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................6amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................6amiloride & hydrochlorothiazide tab 5-50

mg................................................................................58amiloride hcl tab 5 mg.................................................58amino acid infusion 15%.............................................74amino acid infusion 6%...............................................74amiodarone hcl tab 200 mg........................................58amiodarone hcl tab 400 mg........................................58AMITIZA.........................................................................77AMITIZA.........................................................................77amitriptyline hcl tab 100 mg....................................... 19amitriptyline hcl tab 10 mg..........................................19amitriptyline hcl tab 150 mg....................................... 19amitriptyline hcl tab 25 mg..........................................19amitriptyline hcl tab 50 mg..........................................19amitriptyline hcl tab 75 mg..........................................19amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................58amlodipine besylate-atorvastatin calcium tab 10-20



mg................................................................................58

amlodipine besylate-atorvastatin calcium tab 2.5-10mg................................................................................58



amlodipine besylate-atorvastatin calcium tab 5-10mg................................................................................58




amlodipine besylate-benazepril hcl cap 10-20mg................................................................................59


amlodipine besylate-benazepril hcl cap 2.5-10mg................................................................................58




amlodipine besylate tab 10 mg..................................58amlodipine besylate tab 2.5 mg.................................58amlodipine besylate tab 5 mg.................................... 58amlodipine besylate-valsartan tab 10-160

mg................................................................................59amlodipine besylate-valsartan tab 10-320



mg................................................................................59amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg.........................................................59amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg............................................................59amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg............................................................59amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg...........................................................59amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg.............................................................. 59AMOXAPINE.................................................................19AMOXAPINE.................................................................19AMOXAPINE.................................................................19AMOXAPINE.................................................................19

2020

106

AMOXICILLIN/CLAVULANATEPOTASSIUM................................................................ 6

AMOXICILLIN/CLAVULANATEPOTASSIUM................................................................ 6

amoxicillin (trihydrate) cap 250 mg..............................6amoxicillin (trihydrate) cap 500 mg..............................6amoxicillin (trihydrate) for susp 125

mg/5ml.......................................................................... 6amoxicillin (trihydrate) for susp 200



mg/5ml.......................................................................... 6amoxicillin (trihydrate) tab 500 mg...............................6amoxicillin (trihydrate) tab 875 mg...............................6amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 400-57

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 600-42.9

mg/5ml.......................................................................... 6amoxicillin & k clavulanate tab 250-125

mg..................................................................................6amoxicillin & k clavulanate tab 500-125

mg..................................................................................6amoxicillin & k clavulanate tab 875-125

mg..................................................................................6amphetamine-dextroamphetamine cap er 24hr 10

mg................................................................................69amphetamine-dextroamphetamine cap er 24hr 15





mg................................................................................69amphetamine-dextroamphetamine tab 10

mg................................................................................69amphetamine-dextroamphetamine tab 12.5





mg................................................................................69

amphetamine-dextroamphetamine tab 7.5mg................................................................................69

AMPHOTERICIN B......................................................24AMPICILLIN.................................................................... 6ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................6AMPICILLIN SODIUM................................................... 6ampicillin sodium for inj 1 gm.......................................6ampicillin sodium for inj 250 mg...................................6ampicillin sodium for inj 2 gm.......................................6ampicillin sodium for inj 500 mg...................................6ampicillin sodium for iv soln 10 gm..............................6ampicillin sodium for iv soln 2 gm................................6AMPICILLIN-SULBACTAM........................................... 7ANADROL-50............................................................... 83anagrelide hcl cap 0.5 mg.......................................... 54anagrelide hcl cap 1 mg............................................. 55anastrozole tab 1 mg...................................................27ANDRODERM.............................................................. 83ANDRODERM.............................................................. 83ANORO ELLIPTA.........................................................99APOKYN........................................................................39aprepitant capsule 125 mg.........................................23aprepitant capsule 40 mg........................................... 23aprepitant capsule 80 mg........................................... 23aprepitant capsule therapy pack 80 & 125

mg................................................................................23APRISO......................................................................... 94APTIOM......................................................................... 14APTIOM......................................................................... 14APTIOM......................................................................... 14APTIOM......................................................................... 14APTIVUS....................................................................... 45APTIVUS....................................................................... 45ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARCALYST....................................................................89aripiprazole orally disintegrating tab 10

mg................................................................................40

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107

aripiprazole orally disintegrating tab 15mg................................................................................40

aripiprazole oral solution 1 mg/ml..............................40aripiprazole tab 10 mg................................................ 40aripiprazole tab 15 mg................................................ 41aripiprazole tab 20 mg................................................ 41aripiprazole tab 2 mg...................................................40aripiprazole tab 30 mg................................................ 41aripiprazole tab 5 mg...................................................40ARISTADA.....................................................................41ARISTADA.....................................................................41ARISTADA.....................................................................41ARISTADA.....................................................................41ARISTADA INITIO........................................................41armodafinil tab 150 mg............................................. 103armodafinil tab 200 mg............................................. 103armodafinil tab 250 mg............................................. 103armodafinil tab 50 mg............................................... 103ARNUITY ELLIPTA......................................................99ARNUITY ELLIPTA......................................................99ARNUITY ELLIPTA......................................................99ARRANON.................................................................... 27arsenic trioxide iv soln 10 mg/10ml (1 mg/

ml)................................................................................27arsenic trioxide iv soln 12 mg/6ml (2 mg/

ml)................................................................................27ARZERRA..................................................................... 27ARZERRA..................................................................... 27ASMANEX HFA............................................................99ASMANEX HFA............................................................99ASMANEX TWISTHALER 120 METERED

DOSES....................................................................... 99ASMANEX TWISTHALER 14 METERED





DOSES....................................................................... 99aspirin-dipyridamole cap er 12hr 25-200

mg................................................................................55atazanavir sulfate cap 150 mg...................................46atazanavir sulfate cap 200 mg...................................46atazanavir sulfate cap 300 mg...................................46atenolol & chlorthalidone tab 100-25

mg................................................................................59atenolol & chlorthalidone tab 50-25 mg.................... 59atenolol tab 100 mg.....................................................59atenolol tab 25 mg.......................................................59

atenolol tab 50 mg.......................................................59ATGAM.......................................................................... 89atomoxetine hcl cap 100 mg...................................... 69atomoxetine hcl cap 10 mg........................................ 69atomoxetine hcl cap 18 mg........................................ 69atomoxetine hcl cap 25 mg........................................ 69atomoxetine hcl cap 40 mg........................................ 69atomoxetine hcl cap 60 mg........................................ 69atomoxetine hcl cap 80 mg........................................ 69atorvastatin calcium tab 10 mg.................................. 59atorvastatin calcium tab 20 mg.................................. 59atorvastatin calcium tab 40 mg.................................. 59atorvastatin calcium tab 80 mg.................................. 59atovaquone-proguanil hcl tab 250-100

mg................................................................................38atovaquone-proguanil hcl tab 62.5-25

mg................................................................................38atovaquone susp 750 mg/5ml....................................38ATRIPLA........................................................................ 46ATROVENT HFA..........................................................99AUBAGIO...................................................................... 69AUBAGIO...................................................................... 69AUGMENTED BETAMETHASONE

DIPROPIONATE....................................................... 71AURYXIA.......................................................................74AVASTIN........................................................................27AVASTIN........................................................................28AVONEX........................................................................ 70AVONEX PEN.............................................................. 70azacitidine for inj 100 mg............................................55AZASAN........................................................................ 89AZASAN........................................................................ 89AZATHIOPRINE........................................................... 89azathioprine tab 50 mg............................................... 89azelaic acid gel 15%................................................... 71azelastine hcl nasal spray 0.1% (137 mcg/

spray)..........................................................................99azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)..........................................................................99azelastine hcl ophth soln 0.05%................................ 96AZELEX......................................................................... 71AZITHROMYCIN............................................................ 7azithromycin for susp 100 mg/5ml...............................7azithromycin for susp 200 mg/5ml...............................7azithromycin iv for soln 500 mg................................... 7azithromycin tab 250 mg...............................................7azithromycin tab 500 mg...............................................7azithromycin tab 600 mg...............................................7AZOPT........................................................................... 96aztreonam for inj 1 gm.................................................. 7aztreonam for inj 2 gm.................................................. 7

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108

BBACITRACIN................................................................ 96bacitracin-polymyxin b ophth oint.............................. 96bacitracin-polymyxin-neomycin-hc ophth oint

1%............................................................................... 96baclofen tab 10 mg......................................................45baclofen tab 20 mg......................................................45balsalazide disodium cap 750 mg............................. 94BALVERSA....................................................................28BALVERSA....................................................................28BALVERSA....................................................................28BANZEL.........................................................................15BANZEL.........................................................................15BANZEL.........................................................................15BAQSIMI ONE PACK..................................................51BAQSIMI TWO PACK................................................. 51BARACLUDE................................................................ 46BASAGLAR KWIKPEN............................................... 51BAVENCIO.................................................................... 28BCG VACCINE.............................................................89BELEODAQ.................................................................. 28BELSOMRA................................................................ 103BELSOMRA................................................................ 103BELSOMRA................................................................ 103BELSOMRA................................................................ 103benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................59benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................59benazepril & hydrochlorothiazide tab 20-25

mg................................................................................59benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................59benazepril hcl tab 10 mg............................................ 59benazepril hcl tab 20 mg............................................ 59benazepril hcl tab 40 mg............................................ 59benazepril hcl tab 5 mg.............................................. 59BENDEKA..................................................................... 28BENLYSTA.................................................................... 89BENLYSTA.................................................................... 89BENLYSTA.................................................................... 89BENLYSTA.................................................................... 89BENZNIDAZOLE..........................................................38BENZNIDAZOLE..........................................................38benzoyl peroxide-erythromycin gel

5-3%............................................................................71benztropine mesylate tab 0.5 mg.............................. 39benztropine mesylate tab 1 mg..................................39benztropine mesylate tab 2 mg..................................39BESIVANCE..................................................................96BESPONSA.................................................................. 28

betamethasone dipropionate augmented cream0.05%..........................................................................71

betamethasone dipropionate augmented lotion0.05%..........................................................................71

betamethasone dipropionate augmented oint0.05%..........................................................................72

betamethasone dipropionate cream0.05%..........................................................................72

betamethasone dipropionate lotion0.05%..........................................................................72

betamethasone dipropionate oint0.05%..........................................................................72

betamethasone valerate cream 0.1%....................... 72betamethasone valerate lotion 0.1%.........................72betamethasone valerate oint 0.1%............................72BETASERON................................................................ 70betaxolol hcl ophth soln 0.5%.................................... 96betaxolol hcl tab 10 mg...............................................59betaxolol hcl tab 20 mg...............................................59bethanechol chloride tab 10 mg.................................80bethanechol chloride tab 25 mg.................................80bethanechol chloride tab 50 mg.................................81bethanechol chloride tab 5 mg...................................80BETOPTIC-S.................................................................96BEVYXXA......................................................................55BEVYXXA......................................................................55bexarotene cap 75 mg................................................ 28BEXSERO..................................................................... 89bicalutamide tab 50 mg...............................................28BICILLIN L-A...................................................................7BICILLIN L-A...................................................................7BICILLIN L-A...................................................................7BIKTARVY..................................................................... 46bimatoprost ophth soln 0.03%................................... 96bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................59bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg................................................................................59bisoprolol & hydrochlorothiazide tab 5-6.25

mg................................................................................59bisoprolol fumarate tab 10 mg................................... 59bisoprolol fumarate tab 5 mg..................................... 59bleomycin sulfate for inj 15 unit................................. 28bleomycin sulfate for inj 30 unit................................. 28BLINCYTO.....................................................................28BOOSTRIX....................................................................89bosentan tab 125 mg.................................................. 99bosentan tab 62.5 mg................................................. 99BOSULIF....................................................................... 28BOSULIF....................................................................... 28BOSULIF....................................................................... 28BRAFTOVI.....................................................................28

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109

BREO ELLIPTA............................................................ 99BREO ELLIPTA..........................................................100BRILINTA.......................................................................55BRILINTA.......................................................................55brimonidine tartrate ophth soln 0.15%...................... 96brimonidine tartrate ophth soln 0.2%........................ 96BRIVIACT......................................................................15BRIVIACT......................................................................15BRIVIACT......................................................................15BRIVIACT......................................................................15BRIVIACT......................................................................15BRIVIACT......................................................................15BRIVIACT......................................................................15bromfenac sodium ophth soln 0.09% (once-

daily)............................................................................96bromocriptine mesylate cap 5 mg..............................39bromocriptine mesylate tab 2.5 mg........................... 39BRUKINSA....................................................................28budesonide delayed release particles cap 3

mg................................................................................94budesonide inhalation susp 0.25

mg/2ml......................................................................100budesonide inhalation susp 0.5

mg/2ml......................................................................100budesonide inhalation susp 1 mg/2ml.....................100bumetanide inj 0.25 mg/ml......................................... 59bumetanide tab 0.5 mg............................................... 59bumetanide tab 1 mg.................................................. 59bumetanide tab 2 mg.................................................. 60buprenorphine hcl-naloxone hcl sl film 12-3

mg..................................................................................5buprenorphine hcl-naloxone hcl sl film 2-0.5

mg..................................................................................5buprenorphine hcl-naloxone hcl sl film 4-1

mg..................................................................................5buprenorphine hcl-naloxone hcl sl film 8-2

mg..................................................................................5buprenorphine hcl-naloxone hcl sl tab 2-0.5

mg..................................................................................5buprenorphine hcl-naloxone hcl sl tab 8-2

mg..................................................................................5buprenorphine hcl sl tab 2 mg......................................5buprenorphine hcl sl tab 8 mg......................................5bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................5bupropion hcl tab 100 mg...........................................19bupropion hcl tab 75 mg.............................................19bupropion hcl tab er 12hr 100 mg............................. 19bupropion hcl tab er 12hr 150 mg............................. 19bupropion hcl tab er 12hr 200 mg............................. 19bupropion hcl tab er 24hr 150 mg............................. 19bupropion hcl tab er 24hr 300 mg............................. 19

buspirone hcl tab 10 mg............................................. 50buspirone hcl tab 15 mg............................................. 50buspirone hcl tab 30 mg............................................. 50buspirone hcl tab 5 mg............................................... 50buspirone hcl tab 7.5 mg............................................ 50busulfan inj 6 mg/ml.................................................... 28butalbital-acetaminophen-caffeine cap 50-300-40

mg..................................................................................1butalbital-acetaminophen-caffeine cap 50-325-40

mg..................................................................................1butalbital-acetaminophen-caffeine tab 50-325-40

mg..................................................................................1butalbital-acetaminophen tab 50-325

mg..................................................................................1butalbital-aspirin-caffeine cap 50-325-40

mg..................................................................................1BUTORPHANOL TARTRATE.......................................1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BYDUREON BCISE.....................................................51BYDUREON PEN........................................................ 51BYSTOLIC.....................................................................60BYSTOLIC.....................................................................60BYSTOLIC.....................................................................60BYSTOLIC.....................................................................60Ccabergoline tab 0.5 mg............................................... 87CABLIVI......................................................................... 89CABOMETYX............................................................... 28CABOMETYX............................................................... 28CABOMETYX............................................................... 28caffeine citrate oral soln 60 mg/3ml........................ 100calcipotriene cream 0.005%.......................................72calcipotriene oint 0.005%............................................72calcipotriene soln 0.005% (50 mcg/ml).....................72calcitonin (salmon) nasal soln 200 unit/

act................................................................................95CALCITRIOL.................................................................95calcitriol cap 0.25 mcg................................................ 95calcitriol cap 0.5 mcg...................................................95calcitriol oral soln 1 mcg/ml........................................95calcium acetate cap 667 mg...................................... 74calcium acetate tab 667 mg....................................... 74CALQUENCE................................................................28candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................60candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................60candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................60

2020

110

candesartan cilexetil tab 16 mg................................. 60candesartan cilexetil tab 32 mg................................. 60candesartan cilexetil tab 4 mg................................... 60candesartan cilexetil tab 8 mg................................... 60CAPASTAT SULFATE..................................................26CAPRELSA................................................................... 28CAPRELSA................................................................... 28captopril tab 100 mg....................................................60captopril tab 12.5 mg...................................................60captopril tab 25 mg......................................................60captopril tab 50 mg......................................................60CARAC.......................................................................... 72CARBAGLU.................................................................. 74carbamazepine cap er 12hr 100 mg......................... 15carbamazepine cap er 12hr 200 mg......................... 15carbamazepine cap er 12hr 300 mg......................... 15carbamazepine chew tab 100 mg..............................15carbamazepine susp 100 mg/5ml..............................15carbamazepine tab 200 mg........................................15carbamazepine tab er 12hr 100 mg.......................... 15carbamazepine tab er 12hr 200 mg.......................... 15carbamazepine tab er 12hr 400 mg.......................... 15CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................39CARBIDOPA/LEVODOPA/





ENTACAPONE..........................................................40carbidopa & levodopa orally disintegrating tab

10-100 mg..................................................................39carbidopa & levodopa orally disintegrating tab

25-100 mg..................................................................39carbidopa & levodopa orally disintegrating tab

25-250 mg..................................................................39carbidopa & levodopa tab 10-100 mg....................... 39carbidopa & levodopa tab 25-100 mg....................... 39carbidopa & levodopa tab 25-250 mg....................... 39carbidopa & levodopa tab er 25-100

mg................................................................................39carbidopa & levodopa tab er 50-200

mg................................................................................39carbidopa tab 25 mg................................................... 39carboplatin iv soln 150 mg/15ml................................ 28carboplatin iv soln 450 mg/45ml................................ 28carboplatin iv soln 50 mg/5ml.................................... 28carboplatin iv soln 600 mg/60ml................................ 28

carmustine for inj 100 mg...........................................28carteolol hcl ophth soln 1%........................................ 96carvedilol tab 12.5 mg.................................................60carvedilol tab 25 mg....................................................60carvedilol tab 3.125 mg...............................................60carvedilol tab 6.25 mg.................................................60caspofungin acetate for iv soln 50 mg...................... 24caspofungin acetate for iv soln 70 mg...................... 24cefaclor cap 250 mg......................................................7cefaclor cap 500 mg......................................................7cefadroxil cap 500 mg...................................................7cefadroxil for susp 250 mg/5ml....................................7cefadroxil for susp 500 mg/5ml....................................7cefadroxil tab 1 gm........................................................ 7CEFAZOLIN SODIUM................................................... 7CEFAZOLIN SODIUM................................................... 7CEFAZOLIN SODIUM/DEXTROSE............................ 7cefazolin sodium for inj 10 gm..................................... 7cefazolin sodium for inj 1 gm....................................... 7cefazolin sodium for inj 500 mg................................... 7cefdinir cap 300 mg....................................................... 7cefdinir for susp 125 mg/5ml........................................7cefdinir for susp 250 mg/5ml........................................7CEFEPIME...................................................................... 7CEFEPIME...................................................................... 7CEFEPIME/DEXTROSE............................................... 7CEFEPIME/DEXTROSE............................................... 8cefepime hcl for inj 1 gm.............................................. 7cefepime hcl for inj 2 gm.............................................. 7cefixime cap 400 mg..................................................... 8CEFOTAXIME SODIUM................................................8cefotaxime sodium for inj 1 gm.................................... 8CEFOXITIN SODIUM.................................................... 8CEFOXITIN SODIUM.................................................... 8cefoxitin sodium for inj 10 gm...................................... 8cefoxitin sodium for iv soln 1 gm................................. 8cefoxitin sodium for iv soln 2 gm................................. 8cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 8cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 8cefpodoxime proxetil tab 100 mg.................................8cefpodoxime proxetil tab 200 mg.................................8cefprozil for susp 125 mg/5ml...................................... 8cefprozil for susp 250 mg/5ml...................................... 8cefprozil tab 250 mg......................................................8cefprozil tab 500 mg......................................................8CEFTAZIDIME/DEXTROSE......................................... 8CEFTAZIDIME/DEXTROSE......................................... 8ceftazidime for inj 1 gm.................................................8ceftazidime for inj 2 gm.................................................8ceftazidime for inj 6 gm.................................................8

2020

111

CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE/DEXTROSE....................................... 9CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 8CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 8CEFTRIAXONE SODIUM............................................. 8ceftriaxone sodium for inj 10 gm..................................8ceftriaxone sodium for inj 1 gm....................................8ceftriaxone sodium for inj 250 mg................................8ceftriaxone sodium for inj 2 gm....................................8ceftriaxone sodium for inj 500 mg................................8ceftriaxone sodium for iv soln 1 gm.............................8ceftriaxone sodium for iv soln 2 gm.............................8cefuroxime axetil tab 250 mg....................................... 9cefuroxime axetil tab 500 mg....................................... 9cefuroxime sodium for inj 7.5 gm.................................9cefuroxime sodium for inj 750 mg................................9cefuroxime sodium for iv soln 1.5 gm..........................9celecoxib cap 100 mg................................................... 1celecoxib cap 200 mg................................................... 1celecoxib cap 400 mg................................................... 1celecoxib cap 50 mg......................................................1CELONTIN.................................................................... 15cephalexin cap 250 mg.................................................9cephalexin cap 500 mg.................................................9cephalexin cap 750 mg.................................................9cephalexin for susp 125 mg/5ml..................................9cephalexin for susp 250 mg/5ml..................................9CEREZYME.................................................................. 79CHANTIX......................................................................... 5CHANTIX......................................................................... 5CHANTIX CONTINUING MONTH

PACK.............................................................................5CHANTIX STARTING MONTH PACK.........................5CHEMET........................................................................74CHENODAL.................................................................. 77CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................9chlorhexidine gluconate soln 0.12%..........................71CHLOROQUINE PHOSPHATE................................. 38chloroquine phosphate tab 500 mg...........................39CHLOROTHIAZIDE..................................................... 60chlorothiazide tab 500 mg.......................................... 60CHLORPROMAZINE HCL..........................................23CHLORPROMAZINE HCL..........................................23chlorpromazine hcl tab 100 mg..................................23chlorpromazine hcl tab 10 mg....................................23chlorpromazine hcl tab 200 mg..................................23chlorpromazine hcl tab 25 mg....................................23chlorpromazine hcl tab 50 mg....................................23chlorthalidone tab 25 mg............................................ 60

chlorthalidone tab 50 mg............................................ 60cholestyramine light powder 4 gm/

dose............................................................................ 60cholestyramine light powder packets 4

gm................................................................................60cholestyramine powder 4 gm/dose............................60cholestyramine powder packets 4 gm.......................60choline fenofibrate cap dr 135 mg............................. 60choline fenofibrate cap dr 45 mg............................... 60CHORIONIC GONADOTROPIN................................83ciclopirox gel 0.77%.................................................... 24ciclopirox olamine cream 0.77%................................24ciclopirox olamine susp 0.77%...................................24ciclopirox shampoo 1%............................................... 24ciclopirox solution 8%..................................................24cidofovir iv inj 75 mg/ml.............................................. 46cilostazol tab 100 mg.................................................. 55cilostazol tab 50 mg.................................................... 55CIMDUO........................................................................ 46CIMETIDINE HCL........................................................ 77cimetidine tab 200 mg.................................................77cimetidine tab 300 mg.................................................77cimetidine tab 400 mg.................................................77cimetidine tab 800 mg.................................................77cinacalcet hcl tab 30 mg.............................................95cinacalcet hcl tab 60 mg.............................................95cinacalcet hcl tab 90 mg.............................................95CINRYZE.......................................................................89ciprofloxacin 200 mg/100ml in d5w............................. 9ciprofloxacin 400 mg/200ml in d5w............................. 9CIPROFLOXACIN HCL.................................................9ciprofloxacin hcl ophth soln 0.3%.............................. 96ciprofloxacin hcl tab 250 mg.........................................9ciprofloxacin hcl tab 500 mg.........................................9ciprofloxacin hcl tab 750 mg.........................................9CISPLATIN.................................................................... 28cisplatin inj 100 mg/100ml (1 mg/ml).........................28cisplatin inj 50 mg/50ml (1 mg/ml).............................28citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 19citalopram hydrobromide tab 10 mg..........................19citalopram hydrobromide tab 20 mg..........................19citalopram hydrobromide tab 40 mg..........................19cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................28CLARITHROMYCIN.......................................................9CLARITHROMYCIN.......................................................9clarithromycin tab 250 mg............................................ 9clarithromycin tab 500 mg............................................ 9clarithromycin tab er 24hr 500 mg...............................9CLEMASTINE FUMARATE......................................100CLINDAMYCIN/SODIUM CHLORIDE...................... 10

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CLINDAMYCIN/SODIUM CHLORIDE...................... 10CLINDAMYCIN/SODIUM CHLORIDE...................... 10clindamycin hcl cap 150 mg......................................... 9clindamycin hcl cap 300 mg......................................... 9clindamycin hcl cap 75 mg........................................... 9clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................72clindamycin phosphate gel 1%.................................... 9clindamycin phosphate in d5w iv soln 300

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 600

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 900

mg/50ml........................................................................ 9clindamycin phosphate inj 300 mg/2ml....................... 9clindamycin phosphate inj 600 mg/4ml....................... 9clindamycin phosphate inj 900 mg/6ml....................... 9clindamycin phosphate inj 9 gm/60ml......................... 9clindamycin phosphate iv soln 300

mg/2ml.......................................................................... 9clindamycin phosphate iv soln 600

mg/4ml.......................................................................... 9clindamycin phosphate iv soln 900

mg/6ml.......................................................................... 9clindamycin phosphate lotion 1%.............................. 10clindamycin phosphate soln 1%................................ 10clindamycin phosphate swab 1%.............................. 10clindamycin phosphate vaginal cream

2%............................................................................... 10clobazam suspension 2.5 mg/ml............................... 15clobazam tab 10 mg....................................................15clobazam tab 20 mg....................................................15clobetasol propionate cream 0.05%..........................72clobetasol propionate emollient base cream

0.05%..........................................................................72clobetasol propionate gel 0.05%................................72clobetasol propionate oint 0.05%.............................. 72clobetasol propionate soln 0.05%..............................72clofarabine iv soln 1 mg/ml.........................................28clomipramine hcl cap 25 mg...................................... 19clomipramine hcl cap 50 mg...................................... 19clomipramine hcl cap 75 mg...................................... 19clonazepam orally disintegrating tab 0.125

mg................................................................................50clonazepam orally disintegrating tab 0.25

mg................................................................................50clonazepam orally disintegrating tab 0.5

mg................................................................................50clonazepam orally disintegrating tab 1

mg................................................................................50clonazepam orally disintegrating tab 2

mg................................................................................50

clonazepam tab 0.5 mg.............................................. 50clonazepam tab 1 mg..................................................50clonazepam tab 2 mg..................................................50clonidine hcl tab 0.1 mg..............................................60clonidine hcl tab 0.2 mg..............................................60clonidine hcl tab 0.3 mg..............................................60clonidine hcl tab er 12hr 0.1 mg................................ 70clonidine td patch weekly 0.1 mg/24hr......................60clonidine td patch weekly 0.2 mg/24hr......................60clonidine td patch weekly 0.3 mg/24hr......................60clopidogrel bisulfate tab 75 mg..................................55clorazepate dipotassium tab 15 mg...........................50clorazepate dipotassium tab 3.75 mg....................... 50clorazepate dipotassium tab 7.5 mg......................... 50clotrimazole cream 1%................................................24clotrimazole troche 10 mg.......................................... 24clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 72clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 72clozapine orally disintegrating tab 100

mg................................................................................41clozapine orally disintegrating tab 12.5

mg................................................................................41clozapine orally disintegrating tab 25

mg................................................................................41clozapine tab 100 mg..................................................41clozapine tab 200 mg..................................................41clozapine tab 25 mg....................................................41clozapine tab 50 mg....................................................41COARTEM.....................................................................39codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................25COLCRYS..................................................................... 25colestipol hcl granule packets 5 gm.......................... 60colestipol hcl granules 5 gm.......................................60colestipol hcl tab 1 gm................................................ 61colistimethate sod for inj 150 mg...............................10COMBIGAN...................................................................96COMBIPATCH.............................................................. 83COMBIPATCH.............................................................. 83COMBIVENT RESPIMAT......................................... 100COMETRIQ...................................................................28COMETRIQ...................................................................28COMETRIQ...................................................................29COMPLERA.................................................................. 46COPAXONE.................................................................. 70COPAXONE.................................................................. 70COPIKTRA....................................................................29COPIKTRA....................................................................29

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CORLANOR..................................................................61CORLANOR..................................................................61CORLANOR..................................................................61CORTISONE ACETATE..............................................81COSENTYX.................................................................. 89COSENTYX.................................................................. 89COSENTYX SENSOREADY PEN............................ 89COSENTYX SENSOREADY PEN............................ 89COTELLIC.....................................................................29COUMADIN...................................................................55COUMADIN...................................................................55COUMADIN...................................................................55COUMADIN...................................................................55COUMADIN...................................................................55COUMADIN...................................................................55COUMADIN...................................................................55COUMADIN...................................................................56COUMADIN...................................................................56CREON..........................................................................79CREON..........................................................................79CREON..........................................................................79CREON..........................................................................79CREON..........................................................................79CRESEMBA.................................................................. 24CRESEMBA.................................................................. 24CRIXIVAN......................................................................46CRIXIVAN......................................................................46cromolyn sodium ophth soln 4%................................96cromolyn sodium oral conc 100

mg/5ml........................................................................ 77cromolyn sodium soln nebu 20

mg/2ml......................................................................100CRYSVITA.....................................................................79CRYSVITA.....................................................................79CRYSVITA.....................................................................79cyclobenzaprine hcl tab 10 mg................................ 103cyclobenzaprine hcl tab 5 mg.................................. 103cyclophosphamide cap 25 mg................................... 29cyclophosphamide cap 50 mg................................... 29cyclophosphamide for inj 1 gm.................................. 29cyclophosphamide for inj 2 gm.................................. 29cyclophosphamide for inj 500 mg..............................29cycloserine cap 250 mg..............................................26CYCLOSET...................................................................51cyclosporine cap 100 mg............................................89cyclosporine cap 25 mg..............................................89cyclosporine iv soln 50 mg/ml....................................89cyclosporine modified cap 100 mg............................ 89cyclosporine modified cap 25 mg.............................. 89cyclosporine modified cap 50 mg.............................. 89cyclosporine modified oral soln 100 mg/

ml.................................................................................89

CYRAMZA.....................................................................29CYRAMZA.....................................................................29CYSTADANE................................................................ 79CYSTAGON.................................................................. 79CYSTAGON.................................................................. 79CYSTARAN...................................................................96CYTARABINE............................................................... 29cytarabine inj pf 100 mg/ml........................................ 29cytarabine inj pf 20 mg/ml.......................................... 29DDACARBAZINE............................................................ 29dacarbazine for inj 200 mg.........................................29dactinomycin for inj 0.5 mg........................................ 29dalfampridine tab er 12hr 10 mg................................70DALIRESP.................................................................. 100DALIRESP.................................................................. 100DALVANCE................................................................... 10danazol cap 100 mg....................................................83danazol cap 200 mg....................................................83danazol cap 50 mg......................................................83dantrolene sodium cap 100 mg................................. 45dantrolene sodium cap 25 mg....................................45dantrolene sodium cap 50 mg....................................45dapsone tab 100 mg................................................... 26dapsone tab 25 mg......................................................26DAPTACEL....................................................................90daptomycin for iv soln 500 mg...................................10DARAPRIM................................................................... 39DARZALEX................................................................... 29DARZALEX................................................................... 29daunorubicin hcl iv soln 20 mg/4ml........................... 29DAUNORUBICIN HYDROCHLORIDE......................29DAURISMO...................................................................29DAURISMO...................................................................29decitabine for inj 50 mg.............................................. 29deferasirox tab 360 mg............................................... 75deferasirox tab 90 mg................................................. 75deferasirox tab for oral susp 125 mg.........................74deferasirox tab for oral susp 250 mg.........................75deferasirox tab for oral susp 500 mg.........................75DELSTRIGO................................................................. 46demeclocycline hcl tab 150 mg..................................10demeclocycline hcl tab 300 mg..................................10DEMSER....................................................................... 61DENAVIR.......................................................................46DEPEN TITRATABS.................................................... 81DEPO-PROVERA........................................................ 83DESCOVY.....................................................................46desipramine hcl tab 100 mg.......................................20desipramine hcl tab 10 mg......................................... 20desipramine hcl tab 150 mg.......................................20

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desipramine hcl tab 25 mg......................................... 20desipramine hcl tab 50 mg......................................... 20desipramine hcl tab 75 mg......................................... 20desmopressin acetate inj 4 mcg/ml...........................83desmopressin acetate nasal spray soln

0.01%..........................................................................83desmopressin acetate nasal spray soln 0.01%

(refrigerated).............................................................. 83desmopressin acetate tab 0.1 mg............................. 83desmopressin acetate tab 0.2 mg............................. 83desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 83desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................83

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................83

desonide cream 0.05%............................................... 72desonide lotion 0.05%.................................................72desonide oint 0.05%....................................................72desoximetasone cream 0.05%...................................72desoximetasone cream 0.25%...................................72desoximetasone gel 0.05%........................................ 72desoximetasone oint 0.25%....................................... 72desvenlafaxine succinate tab er 24hr 100

mg................................................................................20desvenlafaxine succinate tab er 24hr 25

mg................................................................................20desvenlafaxine succinate tab er 24hr 50

mg................................................................................20DEXAMETHASONE.................................................... 81DEXAMETHASONE.................................................... 81DEXAMETHASONE.................................................... 81dexamethasone elixir 0.5 mg/5ml..............................81DEXAMETHASONE SODIUM

PHOSPHATE.............................................................96dexamethasone sodium phosphate inj 120

mg/30ml......................................................................82dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 82dexamethasone sodium phosphate inj 4 mg/

ml.................................................................................81dexamethasone tab 0.5 mg........................................82dexamethasone tab 0.75 mg......................................82dexamethasone tab 1.5 mg........................................82dexamethasone tab 4 mg...........................................82dexamethasone tab 6 mg...........................................82dexamethasone tab therapy pack 1.5 mg

(21)..............................................................................82dexamethasone tab therapy pack 1.5 mg

(35)..............................................................................82

dexamethasone tab therapy pack 1.5 mg(51)..............................................................................82

dexmethylphenidate hcl tab 10 mg............................70dexmethylphenidate hcl tab 2.5 mg...........................70dexmethylphenidate hcl tab 5 mg..............................70dexrazoxane hcl for inj 250 mg..................................29dexrazoxane hcl for inj 500 mg..................................29dextroamphetamine sulfate cap er 24hr 10

mg................................................................................70dextroamphetamine sulfate cap er 24hr 15

mg................................................................................70dextroamphetamine sulfate cap er 24hr 5

mg................................................................................70dextroamphetamine sulfate tab 10 mg......................70dextroamphetamine sulfate tab 5 mg........................70DEXTROSE 2.5%/NACL 0.45%................................ 75dextrose 5% in lactated ringers................................. 75dextrose 5% w/ sodium chloride 0.2%...................... 75dextrose 5% w/ sodium chloride

0.33%..........................................................................75dextrose 5% w/ sodium chloride

0.45%..........................................................................75dextrose 5% w/ sodium chloride 0.9%...................... 75dextrose inj 10%.......................................................... 75dextrose inj 5%.............................................................75DIASTAT ACUDIAL......................................................15DIASTAT ACUDIAL......................................................15DIASTAT PEDIATRIC..................................................15DIAZEPAM.................................................................... 50diazepam conc 5 mg/ml..............................................50DIAZEPAM RECTAL GEL.......................................... 15DIAZEPAM RECTAL GEL.......................................... 15DIAZEPAM RECTAL GEL.......................................... 15diazepam tab 10 mg....................................................50diazepam tab 2 mg......................................................50diazepam tab 5 mg......................................................50diclofenac potassium tab 50 mg.................................. 1diclofenac sodium (actinic keratoses) gel

3%............................................................................... 72diclofenac sodium gel 1%.............................................1diclofenac sodium ophth soln 0.1%...........................96diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 50

mg..................................................................................1diclofenac sodium tab delayed release 75

mg..................................................................................1diclofenac sodium tab er 24hr 100 mg........................1diclofenac w/ misoprostol tab delayed release 50-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 75-0.2

mg..................................................................................1

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dicloxacillin sodium cap 250 mg................................ 10dicloxacillin sodium cap 500 mg................................ 10dicyclomine hcl cap 10 mg......................................... 77dicyclomine hcl tab 20 mg..........................................77didanosine delayed release capsule 200

mg................................................................................46didanosine delayed release capsule 250

mg................................................................................46didanosine delayed release capsule 400

mg................................................................................46DIFICID..........................................................................10diflorasone diacetate oint 0.05%................................72digoxin oral soln 0.05 mg/ml...................................... 61digoxin tab 125 mcg (0.125 mg)................................61digoxin tab 250 mcg (0.25 mg).................................. 61DILANTIN...................................................................... 15diltiazem hcl cap er 12hr 120 mg.............................. 61diltiazem hcl cap er 12hr 60 mg.................................61diltiazem hcl cap er 12hr 90 mg.................................61diltiazem hcl cap er 24hr 120 mg.............................. 61diltiazem hcl cap er 24hr 180 mg.............................. 61diltiazem hcl cap er 24hr 240 mg.............................. 61diltiazem hcl coated beads cap er 24hr 120

mg................................................................................61diltiazem hcl coated beads cap er 24hr 180




mg................................................................................61diltiazem hcl coated beads tab er 24hr 180





mg................................................................................61diltiazem hcl extended release beads cap er 24hr

120 mg....................................................................... 61diltiazem hcl extended release beads cap er 24hr




360 mg....................................................................... 61

diltiazem hcl extended release beads cap er 24hr420 mg....................................................................... 61

diltiazem hcl tab 120 mg.............................................61diltiazem hcl tab 30 mg...............................................61diltiazem hcl tab 60 mg...............................................61diltiazem hcl tab 90 mg...............................................61DIPENTUM....................................................................94diphenhydramine hcl inj 50 mg/ml...........................100DIPHTHERIA/TETANUS TOXOIDS

ADSORBED...............................................................90dipyridamole tab 25 mg.............................................. 56dipyridamole tab 50 mg.............................................. 56dipyridamole tab 75 mg.............................................. 56disulfiram tab 250 mg....................................................5disulfiram tab 500 mg....................................................5divalproex sodium cap delayed release sprinkle 125

mg................................................................................15divalproex sodium tab delayed release 125



mg................................................................................15divalproex sodium tab er 24 hr 250 mg.....................15divalproex sodium tab er 24 hr 500 mg.....................15DIVIGEL.........................................................................83DIVIGEL.........................................................................83DIVIGEL.........................................................................83DIVIGEL.........................................................................83DIVIGEL.........................................................................83DOCETAXEL.................................................................29docetaxel for inj conc 160 mg/8ml (20 mg/

ml)................................................................................29docetaxel for inj conc 20 mg/ml................................. 29docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................29docetaxel soln for iv infusion 160

mg/16ml......................................................................29docetaxel soln for iv infusion 20

mg/2ml........................................................................ 29docetaxel soln for iv infusion 80

mg/8ml........................................................................ 29dofetilide cap 125 mcg (0.125 mg)............................61dofetilide cap 250 mcg (0.25 mg).............................. 61dofetilide cap 500 mcg (0.5 mg)................................ 61donepezil hydrochloride orally disintegrating tab 10

mg................................................................................18donepezil hydrochloride orally disintegrating tab 5

mg................................................................................18donepezil hydrochloride tab 10 mg........................... 18donepezil hydrochloride tab 23 mg........................... 18donepezil hydrochloride tab 5 mg..............................18

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dorzolamide hcl ophth soln 2%..................................96dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml.......................................................................... 97DOVATO........................................................................ 46doxazosin mesylate tab 1 mg.................................... 61doxazosin mesylate tab 2 mg.................................... 62doxazosin mesylate tab 4 mg.................................... 62doxazosin mesylate tab 8 mg.................................... 62DOXEPIN HCL............................................................. 20doxepin hcl (sleep) tab 3 mg....................................103doxepin hcl (sleep) tab 6 mg....................................103doxepin hcl cap 100 mg..............................................20doxepin hcl cap 10 mg................................................20doxepin hcl cap 25 mg................................................20doxepin hcl cap 50 mg................................................20doxepin hcl cap 75 mg................................................20doxepin hcl conc 10 mg/ml.........................................20doxorubicin hcl for inj 10 mg...................................... 29doxorubicin hcl for inj 50 mg...................................... 29doxorubicin hcl inj 2 mg/ml.........................................29doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................29doxycycline hyclate cap 100 mg................................10doxycycline hyclate cap 50 mg..................................10doxycycline hyclate for inj 100 mg.............................10doxycycline hyclate tab 100 mg.................................10doxycycline hyclate tab 20 mg...................................10doxycycline monohydrate cap 100 mg......................10doxycycline monohydrate cap 150 mg......................10doxycycline monohydrate cap 50 mg........................10doxycycline monohydrate cap 75 mg........................10doxycycline monohydrate tab 100 mg...................... 10doxycycline monohydrate tab 150 mg...................... 10doxycycline monohydrate tab 50 mg.........................10doxycycline monohydrate tab 75 mg.........................10DRIZALMA SPRINKLE............................................... 20DRIZALMA SPRINKLE............................................... 20DRIZALMA SPRINKLE............................................... 20DRIZALMA SPRINKLE............................................... 20dronabinol cap 10 mg................................................. 23dronabinol cap 2.5 mg................................................ 23dronabinol cap 5 mg....................................................23drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................84drospirenone-ethinyl estradiol tab 3-0.03

mg................................................................................84drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................83drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg........................................................83DUAVEE........................................................................ 84DULERA......................................................................100

DULERA......................................................................100duloxetine hcl enteric coated pellets cap 20

mg................................................................................20duloxetine hcl enteric coated pellets cap 30

mg................................................................................20duloxetine hcl enteric coated pellets cap 60

mg................................................................................20DUPIXENT.................................................................... 90DUPIXENT.................................................................... 90DUREZOL..................................................................... 97dutasteride cap 0.5 mg............................................... 81dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................81EEC-NAPROXEN............................................................. 1EC-NAPROXEN............................................................. 1econazole nitrate cream 1%.......................................24EDURANT..................................................................... 46efavirenz cap 200 mg..................................................46efavirenz cap 50 mg....................................................46efavirenz tab 600 mg...................................................46EGRIFTA....................................................................... 83EGRIFTA SV.................................................................83ELAPRASE................................................................... 79ELELYSO.......................................................................79ELIGARD.......................................................................87ELIGARD.......................................................................87ELIGARD.......................................................................87ELIGARD.......................................................................87ELIQUIS.........................................................................56ELIQUIS.........................................................................56ELIQUIS STARTER PACK......................................... 56ELITEK...........................................................................30ELITEK...........................................................................30ELLA...............................................................................84EMCYT.......................................................................... 30EMEND..........................................................................23EMGALITY.................................................................... 25EMGALITY.................................................................... 26EMGALITY.................................................................... 26EMPLICITI.....................................................................30EMPLICITI.....................................................................30EMSAM..........................................................................20EMSAM..........................................................................20EMSAM..........................................................................20EMTRIVA.......................................................................46EMTRIVA.......................................................................46enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................62enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................62enalapril maleate tab 10 mg.......................................62

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enalapril maleate tab 2.5 mg......................................62enalapril maleate tab 20 mg.......................................62enalapril maleate tab 5 mg.........................................62ENBREL........................................................................ 90ENBREL........................................................................ 90ENBREL........................................................................ 90ENBREL MINI...............................................................90ENBREL SURECLICK................................................ 90ENGERIX-B.................................................................. 90ENGERIX-B.................................................................. 90ENHERTU..................................................................... 30enoxaparin sodium inj 100 mg/ml..............................56enoxaparin sodium inj 120 mg/0.8ml........................ 56enoxaparin sodium inj 150 mg/ml..............................56enoxaparin sodium inj 300 mg/3ml............................56enoxaparin sodium inj 30 mg/0.3ml...........................56enoxaparin sodium inj 40 mg/0.4ml...........................56enoxaparin sodium inj 60 mg/0.6ml...........................56enoxaparin sodium inj 80 mg/0.8ml...........................56entacapone tab 200 mg..............................................40entecavir tab 0.5 mg....................................................46entecavir tab 1 mg.......................................................46ENTRESTO...................................................................62ENTRESTO...................................................................62ENTRESTO...................................................................62EPCLUSA......................................................................46EPIDIOLEX................................................................... 16epinastine hcl ophth soln 0.05%................................97epinephrine solution auto-injector 0.15 mg/0.3ml

(1:2000).................................................................... 100epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000) (generic for EpiPen 2-Pak).................... 100epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................30epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................30EPIVIR HBV..................................................................46eplerenone tab 25 mg.................................................62eplerenone tab 50 mg.................................................62EPOGEN....................................................................... 56EPOGEN....................................................................... 56EPOGEN....................................................................... 56EPOGEN....................................................................... 56EPOGEN....................................................................... 56ERBITUX....................................................................... 30ERBITUX....................................................................... 30ERGOLOID MESYLATES...........................................18ergotamine w/ caffeine tab 1-100 mg........................26ERIVEDGE....................................................................30ERLEADA......................................................................30erlotinib hcl tab 100 mg.............................................. 30erlotinib hcl tab 150 mg.............................................. 30

erlotinib hcl tab 25 mg.................................................30ertapenem sodium for inj 1 gm.................................. 10ERWINAZE................................................................... 30ERYTHROCIN LACTOBIONATE...............................10ERYTHROCIN STEARATE........................................ 10erythromycin ethylsuccinate for susp 200

mg/5ml........................................................................ 10erythromycin ethylsuccinate for susp 400

mg/5ml........................................................................ 10erythromycin ophth oint 5 mg/gm.............................. 97erythromycin pads 2%.................................................10erythromycin soln 2%..................................................10erythromycin tab 250 mg............................................ 11erythromycin tab 500 mg............................................ 11erythromycin tab delayed release 250

mg................................................................................11erythromycin tab delayed release 333

mg................................................................................11erythromycin tab delayed release 500

mg................................................................................11ESBRIET..................................................................... 100ESBRIET..................................................................... 100ESBRIET..................................................................... 100escitalopram oxalate soln 5 mg/5ml..........................20escitalopram oxalate tab 10 mg.................................20escitalopram oxalate tab 20 mg.................................20escitalopram oxalate tab 5 mg...................................20esomeprazole magnesium cap delayed release 20

mg................................................................................77esomeprazole magnesium cap delayed release 40

mg................................................................................77esomeprazole sodium for intravenous soln 40

mg................................................................................77estradiol & norethindrone acetate tab 0.5-0.1

mg................................................................................84estradiol & norethindrone acetate tab 1-0.5

mg................................................................................84estradiol tab 0.5 mg.....................................................84estradiol tab 1 mg........................................................84estradiol tab 2 mg........................................................84estradiol td patch twice weekly 0.025

mg/24hr...................................................................... 84estradiol td patch twice weekly 0.0375




mg/24hr...................................................................... 84estradiol td patch weekly 0.025

mg/24hr...................................................................... 84

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estradiol td patch weekly 0.0375 mg/24hr (37.5mcg/24hr)................................................................... 84

estradiol td patch weekly 0.05 mg/24hr.................... 84estradiol td patch weekly 0.06 mg/24hr.................... 84estradiol td patch weekly 0.075

mg/24hr...................................................................... 84estradiol td patch weekly 0.1 mg/24hr...................... 84estradiol vaginal cream 0.1 mg/gm........................... 84estradiol vaginal tab 10 mcg...................................... 84ethambutol hcl tab 100 mg.........................................26ethambutol hcl tab 400 mg.........................................26ethosuximide cap 250 mg...........................................16ethosuximide soln 250 mg/5ml.................................. 16ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................84ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg..............................................................................84ETHYOL........................................................................ 30etodolac cap 200 mg.....................................................1etodolac cap 300 mg.....................................................1etodolac tab 400 mg......................................................2etodolac tab 500 mg......................................................2etodolac tab er 24hr 400 mg........................................ 1etodolac tab er 24hr 500 mg........................................ 1etodolac tab er 24hr 600 mg........................................ 2ETOPOPHOS............................................................... 30etoposide inj 100 mg/5ml (20 mg/ml)........................30etoposide inj 1 gm/50ml (20 mg/ml).......................... 30etoposide inj 500 mg/25ml (20 mg/ml)......................30everolimus tab 2.5 mg.................................................30everolimus tab 5 mg....................................................30everolimus tab 7.5 mg.................................................30EVOMELA..................................................................... 30EVOTAZ.........................................................................46exemestane tab 25 mg............................................... 30ezetimibe-simvastatin tab 10-10 mg..........................62ezetimibe-simvastatin tab 10-20 mg..........................62ezetimibe-simvastatin tab 10-40 mg..........................62ezetimibe-simvastatin tab 10-80 mg..........................62ezetimibe tab 10 mg....................................................62FFABRAZYME................................................................ 79FABRAZYME................................................................ 79famciclovir tab 125 mg................................................46famciclovir tab 250 mg................................................46famciclovir tab 500 mg................................................46famotidine for susp 40 mg/5ml...................................77famotidine inj 200 mg/20ml........................................ 77famotidine inj 20 mg/2ml.............................................77famotidine inj 40 mg/4ml.............................................77famotidine tab 20 mg...................................................77

famotidine tab 40 mg...................................................77FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT TITRATION PACK....................................... 41FARYDAK......................................................................30FARYDAK......................................................................30FARYDAK......................................................................30FASLODEX................................................................... 30felbamate susp 600 mg/5ml....................................... 16felbamate tab 400 mg................................................. 16felbamate tab 600 mg................................................. 16felodipine tab er 24hr 10 mg...................................... 62felodipine tab er 24hr 2.5 mg..................................... 62felodipine tab er 24hr 5 mg........................................ 62fenofibrate micronized cap 134 mg........................... 62fenofibrate micronized cap 200 mg........................... 62fenofibrate micronized cap 67 mg............................. 62fenofibrate tab 145 mg................................................62fenofibrate tab 160 mg................................................62fenofibrate tab 48 mg.................................................. 62fenofibrate tab 54 mg.................................................. 62fentanyl citrate lozenge on a handle 1200

mcg................................................................................2fentanyl citrate lozenge on a handle 1600





mcg................................................................................2fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 37.5 mcg/hr..............................2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 62.5 mcg/hr..............................2fentanyl td patch 72hr 75 mcg/hr................................. 2fentanyl td patch 72hr 87.5 mcg/hr..............................2FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA TITRATION PACK......................................20FINACEA....................................................................... 72

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finasteride tab 5 mg.....................................................81FIRMAGON...................................................................87FIRMAGON...................................................................87flecainide acetate tab 100 mg....................................62flecainide acetate tab 150 mg....................................62flecainide acetate tab 50 mg...................................... 62FLOVENT DISKUS....................................................100FLOVENT DISKUS....................................................100FLOVENT DISKUS....................................................100FLOVENT HFA...........................................................100FLOVENT HFA...........................................................100FLOVENT HFA...........................................................100fluconazole for susp 10 mg/ml................................... 24fluconazole for susp 40 mg/ml................................... 24fluconazole in dextrose inj 200

mg/100ml....................................................................24fluconazole in dextrose inj 400

mg/200ml....................................................................24fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................24fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................24fluconazole tab 100 mg...............................................24fluconazole tab 150 mg...............................................24fluconazole tab 200 mg...............................................24fluconazole tab 50 mg.................................................24flucytosine cap 250 mg............................................... 24flucytosine cap 500 mg............................................... 24fludarabine phosphate for inj 50 mg..........................30fludarabine phosphate inj 25 mg/ml.......................... 30fludrocortisone acetate tab 0.1 mg............................ 82fluocinolone acetonide (otic) oil 0.01%..................... 98fluocinolone acetonide cream 0.01%........................ 72fluocinonide cream 0.05%.......................................... 72fluocinonide emulsified base cream

0.05%..........................................................................72fluocinonide gel 0.05%................................................72fluocinonide oint 0.05%...............................................72fluocinonide soln 0.05%..............................................72fluorometholone ophth susp 0.1%.............................97FLUOROURACIL......................................................... 72FLUOROURACIL......................................................... 72FLUOROURACIL......................................................... 72fluorouracil cream 5%................................................. 73fluorouracil iv soln 1 gm/20ml (50 mg/

ml)................................................................................30fluorouracil iv soln 2.5 gm/50ml (50 mg/

ml)................................................................................30fluorouracil iv soln 500 mg/10ml (50 mg/

ml)................................................................................30fluorouracil iv soln 5 gm/100ml (50 mg/

ml)................................................................................30

FLUOXETINE DR........................................................ 21fluoxetine hcl (pmdd) tab 10 mg................................ 70fluoxetine hcl cap 10 mg.............................................21fluoxetine hcl cap 20 mg.............................................21fluoxetine hcl cap 40 mg.............................................21fluoxetine hcl solution 20 mg/5ml.............................. 21fluoxetine hcl tab 10 mg..............................................21fluoxetine hcl tab 20 mg..............................................21fluphenazine decanoate inj 25 mg/ml........................41FLUPHENAZINE HCL.................................................41FLUPHENAZINE HCL.................................................41fluphenazine hcl tab 10 mg........................................ 41fluphenazine hcl tab 1 mg.......................................... 41fluphenazine hcl tab 2.5 mg....................................... 41fluphenazine hcl tab 5 mg.......................................... 41FLUPHENAZINE HYDROCHLORIDE...................... 41FLURBIPROFEN SODIUM.........................................97flurbiprofen tab 100 mg.................................................2flurbiprofen tab 50 mg................................................... 2flutamide cap 125 mg..................................................30FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 100FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 100FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 100fluticasone propionate cream 0.05%.........................73fluticasone propionate nasal susp 50 mcg/

act..............................................................................100fluticasone propionate oint 0.005%........................... 73fluvoxamine maleate tab 100 mg...............................21fluvoxamine maleate tab 25 mg.................................21fluvoxamine maleate tab 50 mg.................................21FOLOTYN......................................................................30FOLOTYN......................................................................31fomepizole inj 1 gm/ml (for iv infusion)......................75fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................56fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................56fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................56fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................56FORTEO........................................................................95fosamprenavir calcium tab 700 mg........................... 46fosaprepitant dimeglumine for iv infusion 150

mg................................................................................23fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................62fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................62

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fosinopril sodium tab 10 mg....................................... 62fosinopril sodium tab 20 mg....................................... 62fosinopril sodium tab 40 mg....................................... 62fosphenytoin sodium inj 100 mg/2ml.........................16fosphenytoin sodium inj 500 mg/10ml.......................16FOSRENOL.................................................................. 75FOSRENOL.................................................................. 75FULPHILA..................................................................... 56fulvestrant inj 250 mg/5ml...........................................31furosemide inj 10 mg/ml..............................................62furosemide oral soln 10 mg/ml...................................63furosemide tab 20 mg................................................. 63furosemide tab 40 mg................................................. 63furosemide tab 80 mg................................................. 63FUZEON........................................................................46FYCOMPA.....................................................................16FYCOMPA.....................................................................16FYCOMPA.....................................................................16FYCOMPA.....................................................................16FYCOMPA.....................................................................16FYCOMPA.....................................................................16FYCOMPA.....................................................................16Ggabapentin cap 100 mg.............................................. 16gabapentin cap 300 mg.............................................. 16gabapentin cap 400 mg.............................................. 16gabapentin oral soln 250 mg/5ml.............................. 16gabapentin tab 600 mg............................................... 16gabapentin tab 800 mg............................................... 16GALANTAMINE HYDROBROMIDE.......................... 18galantamine hydrobromide cap er 24hr 16

mg................................................................................18galantamine hydrobromide cap er 24hr 24

mg................................................................................18galantamine hydrobromide cap er 24hr 8

mg................................................................................18galantamine hydrobromide tab 12 mg...................... 19galantamine hydrobromide tab 4 mg.........................18galantamine hydrobromide tab 8 mg.........................19GAMMAGARD LIQUID............................................... 90GAMMAGARD LIQUID............................................... 90GAMMAGARD LIQUID............................................... 90GAMMAGARD LIQUID............................................... 90GAMMAGARD LIQUID............................................... 90GAMMAGARD LIQUID............................................... 90GAMMAGARD S/D......................................................90GAMMAGARD S/D......................................................90GAMMAPLEX............................................................... 90GAMMAPLEX............................................................... 90GAMMAPLEX............................................................... 90GAMMAPLEX............................................................... 90

GAMMAPLEX............................................................... 90GAMMAPLEX............................................................... 90GAMUNEX-C................................................................ 90GAMUNEX-C................................................................ 90GAMUNEX-C................................................................ 90GAMUNEX-C................................................................ 91GAMUNEX-C................................................................ 91GAMUNEX-C................................................................ 91ganciclovir sodium for inj 500 mg.............................. 46GARDASIL 9.................................................................91GARDASIL 9.................................................................91GATTEX.........................................................................77GAUZE PADS 2" X 2".................................................51GAZYVA.........................................................................31gemcitabine hcl for inj 1 gm....................................... 31gemcitabine hcl for inj 200 mg...................................31gemcitabine hcl for inj 2 gm....................................... 31gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................31gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................31gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................31gemfibrozil tab 600 mg............................................... 63GENTAK........................................................................ 97gentamicin in saline inj 1.2 mg/ml............................. 11GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE.................................................................11GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE.................................................................11gentamicin sulfate cream 0.1%..................................73gentamicin sulfate inj 10 mg/ml................................. 11gentamicin sulfate inj 40 mg/ml................................. 11gentamicin sulfate oint 0.1%...................................... 73gentamicin sulfate ophth soln 0.3%...........................97GENVOYA.....................................................................47GEODON.......................................................................41GILENYA....................................................................... 70GILOTRIF......................................................................31GILOTRIF......................................................................31GILOTRIF......................................................................31glatiramer acetate soln prefilled syringe 20 mg/

ml.................................................................................70glatiramer acetate soln prefilled syringe 40 mg/

ml.................................................................................70GLEOSTINE..................................................................31GLEOSTINE..................................................................31GLEOSTINE..................................................................31glimepiride tab 1 mg....................................................51glimepiride tab 2 mg....................................................51glimepiride tab 4 mg....................................................51glipizide-metformin hcl tab 2.5-250 mg.....................51

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glipizide-metformin hcl tab 2.5-500 mg.....................51glipizide-metformin hcl tab 5-500 mg........................ 51glipizide tab 10 mg...................................................... 51glipizide tab 5 mg.........................................................51glipizide tab er 24hr 10 mg.........................................51glipizide tab er 24hr 2.5 mg........................................51glipizide tab er 24hr 5 mg...........................................51GLUCAGEN HYPOKIT............................................... 51GLUCAGON EMERGENCY KIT............................... 51glycopyrrolate tab 1 mg.............................................. 77glycopyrrolate tab 2 mg.............................................. 77GLYXAMBI.................................................................... 51GLYXAMBI.................................................................... 52granisetron hcl inj 1 mg/ml......................................... 23granisetron hcl inj 4 mg/4ml (1 mg/ml)......................23granisetron hcl tab 1 mg.............................................23GRANIX......................................................................... 56GRANIX......................................................................... 56GRANIX......................................................................... 56GRANIX......................................................................... 56griseofulvin microsize susp 125

mg/5ml........................................................................ 25griseofulvin ultramicrosize tab 125 mg......................25griseofulvin ultramicrosize tab 250 mg......................25GUANIDINE HCL.........................................................26HHAEGARDA.................................................................. 91HAEGARDA.................................................................. 91HALAVEN...................................................................... 31halobetasol propionate cream 0.05%........................73halobetasol propionate oint 0.05%............................ 73haloperidol decanoate im soln 100 mg/

ml.................................................................................42haloperidol decanoate im soln 50 mg/

ml.................................................................................41haloperidol lactate inj 5 mg/ml................................... 42haloperidol lactate oral conc 2 mg/ml........................42haloperidol tab 0.5 mg................................................ 42haloperidol tab 10 mg................................................. 42haloperidol tab 1 mg....................................................42haloperidol tab 20 mg................................................. 42haloperidol tab 2 mg....................................................42haloperidol tab 5 mg....................................................42HARVONI...................................................................... 47HARVONI...................................................................... 47HAVRIX..........................................................................91HAVRIX..........................................................................91HEPARIN SODIUM......................................................56HEPARIN SODIUM......................................................56HEPARIN SODIUM/D5W............................................57

heparin sodium (porcine) inj 10000 unit/ml.................................................................................56




heparin sodium (porcine) pf inj 5000unit/0.5ml....................................................................56

HEPATAMINE............................................................... 75HERCEPTIN................................................................. 31HERCEPTIN HYLECTA.............................................. 31HETLIOZ..................................................................... 103HIBERIX........................................................................ 91HUMALOG.................................................................... 52HUMALOG.................................................................... 52HUMALOG JUNIOR KWIKPEN.................................52HUMALOG KWIKPEN.................................................52HUMALOG KWIKPEN.................................................52HUMALOG MIX 50/50.................................................52HUMALOG MIX 50/50 KWIKPEN............................. 52HUMALOG MIX 75/25.................................................52HUMALOG MIX 75/25 KWIKPEN............................. 52HUMIRA.........................................................................91HUMIRA.........................................................................91HUMIRA.........................................................................91HUMIRA.........................................................................91HUMIRA.........................................................................91HUMIRA.........................................................................91HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................91HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................91HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................91HUMIRA PEN............................................................... 91HUMIRA PEN............................................................... 91HUMIRA PEN-CD/UC/HS STARTER........................91HUMIRA PEN-CD/UC/HS STARTER........................91HUMIRA PEN-PS/UV STARTER...............................91HUMIRA PEN-PS/UV STARTER...............................91HUMULIN 70/30...........................................................52HUMULIN 70/30 KWIKPEN....................................... 52HUMULIN N..................................................................52HUMULIN N KWIKPEN.............................................. 52HUMULIN R..................................................................52HUMULIN R U-500 (CONCENTRATE).....................52HUMULIN R U-500 KWIKPEN...................................52hydralazine hcl tab 100 mg........................................ 63hydralazine hcl tab 10 mg.......................................... 63hydralazine hcl tab 25 mg.......................................... 63

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hydralazine hcl tab 50 mg.......................................... 63hydrochlorothiazide cap 12.5 mg...............................63hydrochlorothiazide tab 12.5 mg................................63hydrochlorothiazide tab 25 mg...................................63hydrochlorothiazide tab 50 mg...................................63hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 2hydrocodone-acetaminophen tab 10-300

mg..................................................................................2hydrocodone-acetaminophen tab 10-325



mg..................................................................................2hydrocodone-acetaminophen tab 7.5-300

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................2hydrocodone bitartrate cap er 12hr abuse-deterrent

10 mg............................................................................2hydrocodone bitartrate cap er 12hr abuse-deterrent





50 mg............................................................................2hydrocodone-ibuprofen tab 10-200 mg.......................2hydrocodone-ibuprofen tab 5-200 mg......................... 2hydrocodone-ibuprofen tab 7.5-200 mg......................2hydrocortisone butyrate cream 0.1%........................ 73hydrocortisone butyrate hydrophilic lipo base cream

0.1%............................................................................73hydrocortisone butyrate oint 0.1%.............................73hydrocortisone butyrate soln 0.1%............................ 73hydrocortisone cream 1%...........................................73hydrocortisone cream 2.5%........................................73hydrocortisone enema 100 mg/60ml.........................95hydrocortisone lotion 2.5%......................................... 73hydrocortisone oint 1%............................................... 73hydrocortisone oint 2.5%............................................ 73hydrocortisone rectal cream 1%................................ 95hydrocortisone rectal cream 2.5%.............................95hydrocortisone tab 10 mg...........................................82hydrocortisone tab 20 mg...........................................82hydrocortisone tab 5 mg............................................. 82hydrocortisone valerate cream 0.2%.........................73hydrocortisone valerate oint 0.2%............................. 73

hydrocortisone w/ acetic acid otic soln1-2%............................................................................98

hydromorphone hcl inj 2 mg/ml....................................2hydromorphone hcl liqd 1 mg/ml..................................2hydromorphone hcl preservative free inj 10 mg/

ml................................................................................... 3hydromorphone hcl preservative free inj 2 mg/

ml................................................................................... 2hydromorphone hcl tab 2 mg....................................... 3hydromorphone hcl tab 4 mg....................................... 3hydromorphone hcl tab 8 mg....................................... 3hydroxychloroquine sulfate tab 200 mg.................... 39HYDROXYPROGESTERONE

CAPROATE................................................................84hydroxyprogesterone caproate im in oil 250 mg/

ml.................................................................................84hydroxyurea cap 500 mg............................................ 31hydroxyzine hcl syrup 10 mg/5ml.............................. 50hydroxyzine hcl tab 10 mg..........................................50hydroxyzine hcl tab 25 mg..........................................50hydroxyzine hcl tab 50 mg..........................................50Iibandronate sodium iv soln 3 mg/3ml........................95ibandronate sodium tab 150 mg................................ 95IBRANCE.......................................................................31IBRANCE.......................................................................31IBRANCE.......................................................................31ibuprofen susp 100 mg/5ml.......................................... 3ibuprofen tab 400 mg.................................................... 3ibuprofen tab 600 mg.................................................... 3ibuprofen tab 800 mg.................................................... 3icatibant acetate inj 30 mg/3ml.................................. 91ICLUSIG........................................................................ 31ICLUSIG........................................................................ 31idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................31idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................31idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................31IDHIFA............................................................................31IDHIFA............................................................................31IFEX............................................................................... 31IFOSFAMIDE................................................................ 31ifosfamide for inj 1 gm.................................................31ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 31ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 31ILARIS............................................................................91ILEVRO..........................................................................97imatinib mesylate tab 100 mg.................................... 31imatinib mesylate tab 400 mg.................................... 31IMBRUVICA.................................................................. 31

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IMBRUVICA.................................................................. 32IMBRUVICA.................................................................. 32IMBRUVICA.................................................................. 32IMBRUVICA.................................................................. 32IMBRUVICA.................................................................. 32IMFINZI..........................................................................32IMFINZI..........................................................................32imipenem-cilastatin intravenous for soln 250

mg................................................................................11imipenem-cilastatin intravenous for soln 500

mg................................................................................11imipramine hcl tab 10 mg........................................... 21imipramine hcl tab 25 mg........................................... 21imipramine hcl tab 50 mg........................................... 21imiquimod cream 5%...................................................73IMLYGIC........................................................................ 32IMLYGIC........................................................................ 32IMOVAX RABIES (H.D.C.V.)...................................... 91IMPAVIDO..................................................................... 11INBRIJA......................................................................... 40INCRELEX.................................................................... 83INCRUSE ELLIPTA................................................... 101indapamide tab 1.25 mg............................................. 63indapamide tab 2.5 mg............................................... 63INFANRIX......................................................................92INLYTA...........................................................................32INLYTA...........................................................................32INREBIC........................................................................ 32INSULIN INJECTION DEVICE...................................52INSULIN SYRINGE/NEEDLE.....................................52INTELENCE.................................................................. 47INTELENCE.................................................................. 47INTELENCE.................................................................. 47INTRALIPID.................................................................. 75INTRON A.....................................................................47INTRON A.....................................................................47INTRON A.....................................................................47INTRON A.....................................................................47INTRON A.....................................................................47INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42INVEGA TRINZA..........................................................42INVEGA TRINZA..........................................................42INVEGA TRINZA..........................................................42INVEGA TRINZA..........................................................42INVIRASE......................................................................47INVOKAMET.................................................................52INVOKAMET.................................................................52INVOKAMET.................................................................52

INVOKAMET.................................................................52INVOKAMET XR..........................................................52INVOKAMET XR..........................................................52INVOKAMET XR..........................................................52INVOKAMET XR..........................................................52INVOKANA....................................................................52INVOKANA....................................................................53IPOL INACTIVATED IPV.............................................92ipratropium bromide inhal soln 0.02%.....................101ipratropium bromide nasal soln 0.03% (21 mcg/

spray)........................................................................101ipratropium bromide nasal soln 0.06% (42 mcg/

spray)........................................................................101irbesartan-hydrochlorothiazide tab 150-12.5

mg................................................................................63irbesartan-hydrochlorothiazide tab 300-12.5

mg................................................................................63irbesartan tab 150 mg.................................................63irbesartan tab 300 mg.................................................63irbesartan tab 75 mg................................................... 63IRESSA..........................................................................32IRINOTECAN................................................................32irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................32irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 32ISENTRESS..................................................................47ISENTRESS..................................................................47ISENTRESS..................................................................47ISENTRESS..................................................................47ISENTRESS HD...........................................................47ISONIAZID.................................................................... 26isoniazid tab 100 mg................................................... 27isoniazid tab 300 mg................................................... 27isosorbide dinitrate tab 10 mg....................................63isosorbide dinitrate tab 20 mg....................................63isosorbide dinitrate tab 30 mg....................................63isosorbide dinitrate tab 5 mg......................................63isosorbide mononitrate tab 10 mg............................. 63isosorbide mononitrate tab 20 mg............................. 63isosorbide mononitrate tab er 24hr 120

mg................................................................................63isosorbide mononitrate tab er 24hr 30

mg................................................................................63isosorbide mononitrate tab er 24hr 60

mg................................................................................63ISOTONIC GENTAMICIN........................................... 11isotretinoin cap 10 mg.................................................73isotretinoin cap 20 mg.................................................73isotretinoin cap 30 mg.................................................73isotretinoin cap 40 mg.................................................73isradipine cap 2.5 mg..................................................63isradipine cap 5 mg..................................................... 63

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ISTODAX (OVERFILL)................................................32itraconazole cap 100 mg............................................ 25ivermectin tab 3 mg.....................................................39IXEMPRA KIT...............................................................32IXEMPRA KIT...............................................................32IXIARO...........................................................................92JJADENU........................................................................ 75JADENU........................................................................ 75JADENU........................................................................ 75JADENU SPRINKLE................................................... 75JADENU SPRINKLE................................................... 75JADENU SPRINKLE................................................... 75JAKAFI...........................................................................32JAKAFI...........................................................................32JAKAFI...........................................................................32JAKAFI...........................................................................32JAKAFI...........................................................................32JANUMET......................................................................53JANUMET......................................................................53JANUMET XR...............................................................53JANUMET XR...............................................................53JANUMET XR...............................................................53JANUVIA........................................................................53JANUVIA........................................................................53JANUVIA........................................................................53JARDIANCE..................................................................53JARDIANCE..................................................................53JENTADUETO.............................................................. 53JENTADUETO.............................................................. 53JENTADUETO.............................................................. 53JENTADUETO XR....................................................... 53JENTADUETO XR....................................................... 53JEVTANA.......................................................................32JULUCA.........................................................................47KKADCYLA......................................................................32KADCYLA......................................................................32KALETRA...................................................................... 47KALETRA...................................................................... 47KALYDECO.................................................................101KALYDECO.................................................................101KALYDECO.................................................................101KALYDECO.................................................................101KANJINTI.......................................................................32KANJINTI.......................................................................32KCL 0.15%/D5W/NACL 0.225%................................75kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 75kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%

inj................................................................................. 75

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45%inj................................................................................. 75

kcl 20 meq/l (0.15%) in nacl 0.45% inj......................75kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%

inj................................................................................. 75kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45%

inj................................................................................. 75KEPIVANCE..................................................................71ketoconazole cream 2%..............................................25ketoconazole shampoo 2%........................................ 25ketoconazole tab 200 mg........................................... 25ketorolac tromethamine ophth soln

0.4%............................................................................97ketorolac tromethamine ophth soln

0.5%............................................................................97KEYTRUDA...................................................................32KINERET....................................................................... 92KINRIX........................................................................... 92KISQALI.........................................................................32KISQALI.........................................................................32KISQALI.........................................................................32KISQALI FEMARA 200 DOSE...................................32KISQALI FEMARA 400 DOSE...................................33KISQALI FEMARA 600 DOSE...................................33KOMBIGLYZE XR........................................................53KOMBIGLYZE XR........................................................53KOMBIGLYZE XR........................................................53KORLYM........................................................................87KUVAN...........................................................................79KUVAN...........................................................................79KUVAN...........................................................................79KYPROLIS.................................................................... 33KYPROLIS.................................................................... 33KYPROLIS.................................................................... 33Llabetalol hcl tab 100 mg..............................................63labetalol hcl tab 200 mg..............................................63labetalol hcl tab 300 mg..............................................63LACRISERT.................................................................. 97lactated ringer's solution............................................. 75lactic acid (ammonium lactate) cream

12%............................................................................. 73lactic acid (ammonium lactate) lotion

12%............................................................................. 73lactulose (encephalopathy) solution 10

gm/15ml......................................................................77lactulose solution 10 gm/15ml....................................77lamivudine oral soln 10 mg/ml................................... 47lamivudine tab 100 mg (hbv)......................................47lamivudine tab 150 mg................................................47lamivudine tab 300 mg................................................47

2020

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lamivudine-zidovudine tab 150-300 mg.................... 47lamotrigine tab 100 mg............................................... 16lamotrigine tab 150 mg............................................... 16lamotrigine tab 200 mg............................................... 16lamotrigine tab 25 mg................................................. 16lamotrigine tab chewable dispersible 25

mg................................................................................16lamotrigine tab chewable dispersible 5

mg................................................................................16lansoprazole cap delayed release 15

mg................................................................................77lansoprazole cap delayed release 30

mg................................................................................77lanthanum carbonate chew tab 1000 mg

(elemental)................................................................. 75lanthanum carbonate chew tab 500

mg................................................................................75lanthanum carbonate chew tab 750

mg................................................................................75LANTUS.........................................................................53LANTUS SOLOSTAR..................................................53LARTRUVO...................................................................33LARTRUVO...................................................................33latanoprost ophth soln 0.005%.................................. 97LATUDA.........................................................................42LATUDA.........................................................................42LATUDA.........................................................................42LATUDA.........................................................................42LATUDA.........................................................................42LAZANDA........................................................................ 3LAZANDA........................................................................ 3LAZANDA........................................................................ 3LEDIPASVIR/SOFOSBUVIR...................................... 47leflunomide tab 10 mg.................................................92leflunomide tab 20 mg.................................................92LENVIMA 10 MG DAILY DOSE.................................33LENVIMA 12MG DAILY DOSE..................................33LENVIMA 14 MG DAILY DOSE.................................33LENVIMA 18 MG DAILY DOSE.................................33LENVIMA 20 MG DAILY DOSE.................................33LENVIMA 24 MG DAILY DOSE.................................33LENVIMA 4 MG DAILY DOSE...................................33LENVIMA 8 MG DAILY DOSE...................................33letrozole tab 2.5 mg.....................................................33LEUCOVORIN CALCIUM...........................................33LEUCOVORIN CALCIUM...........................................33LEUCOVORIN CALCIUM...........................................33leucovorin calcium for inj 100 mg.............................. 33leucovorin calcium for inj 200 mg.............................. 33leucovorin calcium for inj 350 mg.............................. 33leucovorin calcium for inj 500 mg.............................. 33leucovorin calcium for inj 50 mg................................ 33

leucovorin calcium inj 500 mg/50ml (10 mg/ml)................................................................................33

leucovorin calcium tab 25 mg.................................... 33leucovorin calcium tab 5 mg.......................................33LEUKERAN...................................................................33LEUKINE....................................................................... 57leuprolide acetate inj kit 5 mg/ml............................... 87LEVEMIR.......................................................................53LEVEMIR FLEXTOUCH..............................................53levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................16levetiracetam in sodium chloride iv soln 1000

mg/100ml....................................................................16levetiracetam in sodium chloride iv soln 1500

mg/100ml....................................................................16levetiracetam in sodium chloride iv soln 500

mg/100ml....................................................................16levetiracetam oral soln 100 mg/ml.............................16levetiracetam tab 1000 mg......................................... 16levetiracetam tab 250 mg........................................... 16levetiracetam tab 500 mg........................................... 16levetiracetam tab 750 mg........................................... 16levetiracetam tab er 24hr 500 mg..............................16levetiracetam tab er 24hr 750 mg..............................16levobunolol hcl ophth soln 0.5%................................ 97levocarnitine oral soln 1 gm/10ml

(10%).......................................................................... 75levocarnitine tab 330 mg............................................ 75levocetirizine dihydrochloride tab 5

mg............................................................................. 101levofloxacin in d5w iv soln 250

mg/50ml......................................................................11levofloxacin in d5w iv soln 500

mg/100ml....................................................................11levofloxacin in d5w iv soln 750

mg/150ml....................................................................11levofloxacin iv soln 25 mg/ml..................................... 11levofloxacin oral soln 25 mg/ml..................................11levofloxacin tab 250 mg..............................................11levofloxacin tab 500 mg..............................................11levofloxacin tab 750 mg..............................................11levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 84levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................84levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................84levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................84levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................84

2020

126

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7)...................................................................84

levonorg-eth est tab 0.15-0.03mg(84) & eth est tab0.01mg(7)...................................................................84

LEVORPHANOL TARTRATE....................................... 3levorphanol tartrate tab 2 mg....................................... 3levothyroxine sodium tab 100 mcg (euthyrox, levo-t,

levoxyl, unithroid)......................................................86levothyroxine sodium tab 112 mcg (euthyrox, levo-t,







levoxyl, unithroid)......................................................86levothyroxine sodium tab 300 mcg (levo-t,

unithroid).....................................................................86levothyroxine sodium tab 50 mcg (euthyrox, levo-t,



levoxyl, unithroid)......................................................86LEXIVA...........................................................................47LIBTAYO........................................................................ 33LIDOCAINE HCL............................................................5LIDOCAINE HCL..........................................................63LIDOCAINE HCL..........................................................63lidocaine hcl local inj 1%...............................................5lidocaine hcl local preservative free inj

1%..................................................................................5lidocaine hcl soln 4%.....................................................5lidocaine hcl urethral/mucosal gel 2%.........................5lidocaine hcl urethral/mucosal gel prefilled syringe

2%..................................................................................5lidocaine hcl viscous soln 2%.......................................5lidocaine oint 5%............................................................5lidocaine patch 5%.........................................................5lidocaine-prilocaine cream 2.5-2.5%........................... 5LINDANE....................................................................... 39LINEZOLID....................................................................11linezolid for susp 100 mg/5ml.................................... 11linezolid iv soln 600 mg/300ml (2 mg/

ml)................................................................................11linezolid tab 600 mg.................................................... 11

LINZESS........................................................................77LINZESS........................................................................77LINZESS........................................................................77liothyronine sodium tab 25 mcg.................................87liothyronine sodium tab 50 mcg.................................87liothyronine sodium tab 5 mcg................................... 87lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................63lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................64lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................64lisinopril tab 10 mg...................................................... 64lisinopril tab 2.5 mg..................................................... 64lisinopril tab 20 mg...................................................... 64lisinopril tab 30 mg...................................................... 64lisinopril tab 40 mg...................................................... 64lisinopril tab 5 mg.........................................................64LITHIUM........................................................................ 51lithium carbonate cap 150 mg....................................51lithium carbonate cap 300 mg....................................51lithium carbonate cap 600 mg....................................51lithium carbonate tab 300 mg.....................................51lithium carbonate tab er 300 mg................................51lithium carbonate tab er 450 mg................................51LONSURF..................................................................... 33LONSURF..................................................................... 34loperamide hcl cap 2 mg............................................ 77lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................47lorazepam tab 0.5 mg................................................. 51lorazepam tab 1 mg.................................................... 51lorazepam tab 2 mg.................................................... 51LORBRENA.................................................................. 34LORBRENA.................................................................. 34losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 64losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................64losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................64losartan potassium tab 100 mg..................................64losartan potassium tab 25 mg....................................64losartan potassium tab 50 mg....................................64lovastatin tab 10 mg....................................................64lovastatin tab 20 mg....................................................64lovastatin tab 40 mg....................................................64loxapine succinate cap 10 mg....................................42loxapine succinate cap 25 mg....................................42loxapine succinate cap 50 mg....................................42loxapine succinate cap 5 mg......................................42LUMIGAN...................................................................... 97

2020

127

LUMIZYME....................................................................79LUMOXITI......................................................................34LUPRON DEPOT (1-MONTH)...................................87LUPRON DEPOT (1-MONTH)...................................87LUPRON DEPOT (3-MONTH)...................................87LUPRON DEPOT (3-MONTH)...................................87LUPRON DEPOT (4-MONTH)...................................87LUPRON DEPOT (6-MONTH)...................................87LUPRON DEPOT-PED (1-MONTH)..........................88LUPRON DEPOT-PED (1-MONTH)..........................88LUPRON DEPOT-PED (1-MONTH)..........................88LUPRON DEPOT-PED (3-MONTH)..........................88LUPRON DEPOT-PED (3-MONTH)..........................88LYNPARZA....................................................................34LYNPARZA....................................................................34LYSODREN...................................................................87Mmagnesium sulfate inj 50%........................................ 75malathion lotion 0.5%..................................................39MAPROTILINE HCL.................................................... 21MAPROTILINE HCL.................................................... 21MAPROTILINE HCL.................................................... 21MARPLAN..................................................................... 21MARQIBO......................................................................34MATULANE...................................................................34MAVENCLAD................................................................70MAVENCLAD................................................................70MAVENCLAD................................................................70MAVENCLAD................................................................70MAVENCLAD................................................................70MAVENCLAD................................................................70MAVENCLAD................................................................70MAVYRET..................................................................... 47MAYZENT......................................................................70MAYZENT......................................................................70meclizine hcl tab 12.5 mg...........................................23meclizine hcl tab 25 mg..............................................23medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................84medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 84medroxyprogesterone acetate tab 10

mg................................................................................84medroxyprogesterone acetate tab 2.5

mg................................................................................84medroxyprogesterone acetate tab 5

mg................................................................................84MEFLOQUINE HCL.....................................................39megestrol acetate susp 40 mg/ml..............................85megestrol acetate tab 20 mg..................................... 85megestrol acetate tab 40 mg..................................... 85MEKINIST......................................................................34

MEKINIST......................................................................34MEKTOVI.......................................................................34meloxicam tab 15 mg....................................................3meloxicam tab 7.5 mg...................................................3melphalan hcl for inj 50 mg........................................ 34memantine hcl oral solution 2 mg/ml.........................19memantine hcl tab 10 mg...........................................19memantine hcl tab 5 mg............................................. 19memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................19MENACTRA.................................................................. 92MENEST........................................................................85MENEST........................................................................85MENEST........................................................................85MENVEO....................................................................... 92mercaptopurine tab 50 mg......................................... 34MEROPENEM/SODIUM CHLORIDE........................11MEROPENEM/SODIUM CHLORIDE........................11meropenem iv for soln 1 gm...................................... 11meropenem iv for soln 500 mg.................................. 11mesalamine cap dr 400 mg........................................95mesalamine cap er 24hr 0.375 gm............................95mesalamine enema 4 gm........................................... 95mesalamine rectal enema 4 gm & cleanser wipe

kit................................................................................. 95mesalamine suppos 1000 mg.................................... 95mesalamine tab delayed release 1.2

gm................................................................................95mesalamine tab delayed release 800

mg................................................................................95mesna inj 100 mg/ml...................................................34MESNEX........................................................................34metformin hcl tab 1000 mg.........................................53metformin hcl tab 500 mg...........................................53metformin hcl tab 850 mg...........................................53metformin hcl tab er 24hr 500 mg............................. 53metformin hcl tab er 24hr 750 mg............................. 53methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg............................................... 3methazolamide tab 25 mg.......................................... 64methazolamide tab 50 mg.......................................... 64methenamine hippurate tab 1 gm..............................11methimazole tab 10 mg.............................................. 88methimazole tab 5 mg.................................................88methocarbamol tab 500 mg..................................... 103methocarbamol tab 750 mg..................................... 103METHOTREXATE SODIUM.......................................92methotrexate sodium for inj 1 gm.............................. 92methotrexate sodium inj 50 mg/2ml (25 mg/

ml)................................................................................92methotrexate sodium inj pf 1000 mg/40ml (25 mg/

ml)................................................................................92

2020

128

methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)................................................................................92

methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)................................................................................92

methotrexate sodium tab 2.5 mg............................... 92methoxsalen rapid cap 10 mg....................................73methscopolamine bromide tab 2.5 mg......................77methscopolamine bromide tab 5 mg......................... 77methylergonovine maleate tab 0.2 mg......................81methylphenidate hcl tab 10 mg..................................70methylphenidate hcl tab 20 mg..................................70methylphenidate hcl tab 5 mg....................................70methylphenidate hcl tab er 20 mg............................. 70methylprednisolone sod succ for inj 1000

mg................................................................................82methylprednisolone sod succ for inj 125



mg................................................................................82methylprednisolone tab 16 mg...................................82methylprednisolone tab 32 mg...................................82methylprednisolone tab 4 mg.....................................82methylprednisolone tab 8 mg.....................................82methylprednisolone tab therapy pack 4 mg

(21)..............................................................................82METHYLTESTOSTERONE........................................ 85metoclopramide hcl inj 5 mg/ml................................. 77metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................77metoclopramide hcl tab 10 mg...................................78metoclopramide hcl tab 5 mg.....................................78metolazone tab 10 mg................................................ 64metolazone tab 2.5 mg............................................... 64metolazone tab 5 mg...................................................64metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................64metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................64metoprolol succinate tab er 24hr 100




mg................................................................................64metoprolol tartrate tab 100 mg...................................64metoprolol tartrate tab 25 mg.....................................64metoprolol tartrate tab 50 mg.....................................64METRONIDAZOLE...................................................... 11

metronidazole cap 375 mg.........................................11metronidazole cream 0.75%.......................................73metronidazole gel 0.75%............................................ 73metronidazole gel 1%..................................................73metronidazole in nacl 0.74% iv soln 500

mg/100ml....................................................................11metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................11metronidazole lotion 0.75%........................................ 73metronidazole tab 250 mg..........................................12metronidazole tab 500 mg..........................................12metronidazole vaginal gel 0.75%...............................12MEXILETINE HCL....................................................... 64MEXILETINE HCL....................................................... 64MEXILETINE HCL....................................................... 64MIACALCIN...................................................................95midodrine hcl tab 10 mg............................................. 64midodrine hcl tab 2.5 mg............................................ 64midodrine hcl tab 5 mg............................................... 64MIGERGOT...................................................................26miglustat cap 100 mg..................................................79MIGRANAL....................................................................26minocycline hcl cap 100 mg.......................................12minocycline hcl cap 50 mg......................................... 12minocycline hcl cap 75 mg......................................... 12minocycline hcl tab 100 mg........................................12minocycline hcl tab 50 mg..........................................12minocycline hcl tab 75 mg..........................................12minoxidil tab 10 mg..................................................... 65minoxidil tab 2.5 mg.................................................... 64mirtazapine orally disintegrating tab 15

mg................................................................................21mirtazapine orally disintegrating tab 30

mg................................................................................21mirtazapine orally disintegrating tab 45

mg................................................................................21mirtazapine tab 15 mg................................................ 21mirtazapine tab 30 mg................................................ 21mirtazapine tab 45 mg................................................ 21mirtazapine tab 7.5 mg............................................... 21misoprostol tab 100 mcg............................................ 78misoprostol tab 200 mcg............................................ 78mitomycin for iv soln 20 mg....................................... 34mitomycin for iv soln 40 mg....................................... 34mitomycin for iv soln 5 mg..........................................34mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................34mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................34mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................34M-M-R II........................................................................ 92

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129

modafinil tab 100 mg.................................................103modafinil tab 200 mg.................................................103moexipril hcl tab 15 mg...............................................65moexipril hcl tab 7.5 mg..............................................65MOLINDONE HYDROCHLORIDE............................ 42MOLINDONE HYDROCHLORIDE............................ 42MOLINDONE HYDROCHLORIDE............................ 42mometasone furoate cream 0.1%............................. 73mometasone furoate nasal susp 50 mcg/

act..............................................................................101mometasone furoate oint 0.1%..................................73mometasone furoate solution 0.1%

(lotion).........................................................................73montelukast sodium chew tab 4 mg........................101montelukast sodium chew tab 5 mg........................101montelukast sodium oral granules packet 4

mg............................................................................. 101montelukast sodium tab 10 mg................................101morphine sulfate inj pf 0.5 mg/ml.................................3morphine sulfate inj pf 1 mg/ml....................................3morphine sulfate oral soln 100 mg/5ml (20 mg/

ml)..................................................................................3morphine sulfate oral soln 10 mg/5ml......................... 3morphine sulfate oral soln 20 mg/5ml......................... 3morphine sulfate tab 15 mg..........................................3morphine sulfate tab 30 mg..........................................3morphine sulfate tab er 100 mg...................................3morphine sulfate tab er 15 mg..................................... 3morphine sulfate tab er 200 mg...................................3morphine sulfate tab er 30 mg..................................... 3morphine sulfate tab er 60 mg..................................... 3MOVIPREP................................................................... 78MOXEZA........................................................................97moxifloxacin hcl 400 mg/250ml in sodium chloride

0.8% inj.......................................................................12moxifloxacin hcl ophth soln 0.5%.............................. 97moxifloxacin hcl tab 400 mg.......................................12MOXIFLOXACIN HYDROCHLORIDE...................... 12MOZOBIL...................................................................... 57MULTAQ........................................................................ 65mupirocin oint 2%........................................................ 73MVASI............................................................................ 34MVASI............................................................................ 34MYALEPT...................................................................... 78MYCAMINE...................................................................25MYCAMINE...................................................................25mycophenolate mofetil cap 250 mg...........................92mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................92mycophenolate mofetil hcl for iv soln 500

mg................................................................................92mycophenolate mofetil tab 500 mg........................... 92

mycophenolate sodium tab dr 180 mg......................92mycophenolate sodium tab dr 360 mg......................92MYLOTARG.................................................................. 34MYRBETRIQ.................................................................81MYRBETRIQ.................................................................81Nnabumetone tab 500 mg...............................................3nabumetone tab 750 mg...............................................3nadolol tab 20 mg........................................................65nadolol tab 40 mg........................................................65nadolol tab 80 mg........................................................65NAFCILLIN....................................................................12NAFCILLIN....................................................................12NAFCILLIN SODIUM...................................................12NAFCILLIN SODIUM...................................................12NAFCILLIN SODIUM...................................................12nafcillin sodium for inj 1 gm........................................12nafcillin sodium for inj 2 gm........................................12nafcillin sodium for iv soln 10 gm.............................. 12NAGLAZYME................................................................79NALOXONE HCL........................................................... 5NALOXONE HCL........................................................... 5naloxone hcl inj 0.4 mg/ml............................................5naloxone hcl inj 4 mg/10ml...........................................5naltrexone hcl tab 50 mg.............................................. 6naproxen sodium tab 275 mg.......................................3naproxen sodium tab 550 mg.......................................3naproxen susp 125 mg/5ml.......................................... 3naproxen tab 250 mg.................................................... 3naproxen tab 375 mg.................................................... 3naproxen tab 500 mg.................................................... 4naproxen tab ec 375 mg...............................................3naproxen tab ec 500 mg...............................................3naratriptan hcl tab 1 mg..............................................26naratriptan hcl tab 2.5 mg...........................................26NARCAN..........................................................................6NATACYN......................................................................97nateglinide tab 120 mg............................................... 53nateglinide tab 60 mg..................................................53NATPARA...................................................................... 95NATPARA...................................................................... 95NATPARA...................................................................... 95NATPARA...................................................................... 95NAYZILAM.....................................................................17NEBUPENT...................................................................39NEFAZODONE HCL....................................................21NEFAZODONE HCL....................................................21nefazodone hcl tab 250 mg........................................21nefazodone hcl tab 50 mg..........................................21NEFAZODONE HYDROCHLORIDE.........................21

2020

130

NEOMYCIN/POLYMYXIN/GRAMICIDIN............................................................. 97

NEOMYCIN/POLYMYXIN BSULFATES................................................................. 12

neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin..........................97

neomycin-polymyxin-dexamethasone ophth oint0.1%............................................................................97

neomycin-polymyxin-dexamethasone ophth susp0.1%............................................................................97

neomycin-polymyxin-hc otic soln 1%........................ 98neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%.................................................................. 98neomycin sulfate tab 500 mg.....................................12NERLYNX......................................................................34nevirapine susp 50 mg/5ml........................................ 47nevirapine tab 200 mg................................................ 47nevirapine tab er 24hr 100 mg...................................47nevirapine tab er 24hr 400 mg...................................47NEXAVAR......................................................................34NEXIUM.........................................................................78NEXIUM.........................................................................78NEXIUM.........................................................................78NEXIUM.........................................................................78NEXIUM.........................................................................78niacin tab er 1000 mg................................................. 65niacin tab er 500 mg................................................... 65niacin tab er 750 mg................................................... 65nicardipine hcl cap 20 mg...........................................65nicardipine hcl cap 30 mg...........................................65NICOTROL INHALER................................................... 6NICOTROL NS............................................................... 6nifedipine tab er 24hr 30 mg...................................... 65nifedipine tab er 24hr 60 mg...................................... 65nifedipine tab er 24hr 90 mg...................................... 65nifedipine tab er 24hr osmotic release 30

mg................................................................................65nifedipine tab er 24hr osmotic release 60

mg................................................................................65nifedipine tab er 24hr osmotic release 90

mg................................................................................65nilutamide tab 150 mg.................................................34nimodipine cap 30 mg.................................................65NINLARO.......................................................................34NINLARO.......................................................................34NINLARO.......................................................................34NIPENT..........................................................................34NISOLDIPINE ER........................................................ 65nisoldipine tab er 24hr 17 mg.................................... 65nisoldipine tab er 24hr 34 mg.................................... 65nisoldipine tab er 24hr 8.5 mg................................... 65nitisinone cap 10 mg................................................... 79

nitisinone cap 2 mg..................................................... 79nitisinone cap 5 mg..................................................... 79NITRO-BID....................................................................65nitrofurantoin macrocrystalline cap 100

mg................................................................................12nitrofurantoin macrocrystalline cap 50

mg................................................................................12nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................12nitrofurantoin susp 25 mg/5ml....................................12nitroglycerin sl tab 0.3 mg.......................................... 65nitroglycerin sl tab 0.4 mg.......................................... 65nitroglycerin sl tab 0.6 mg.......................................... 65nitroglycerin td patch 24hr 0.1 mg/hr.........................65nitroglycerin td patch 24hr 0.2 mg/hr.........................65nitroglycerin td patch 24hr 0.4 mg/hr.........................65nitroglycerin td patch 24hr 0.6 mg/hr.........................65nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................65NIVESTYM....................................................................57NIVESTYM....................................................................57NIVESTYM....................................................................57NIVESTYM....................................................................57nizatidine cap 150 mg.................................................78nizatidine cap 300 mg.................................................78norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................85norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................85norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................85norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg..............................................................................85norethindrone & ethinyl estradiol tab 1 mg-35

mcg..............................................................................85norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg.................................................................85norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg..............................................................................85norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg..............................................................................85norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg..............................................................................85norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24).....................................................................85norethindrone acetate tab 5 mg.................................85norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................85norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................85norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35

mg-mcg.......................................................................85

2020

131

norethindrone tab 0.35 mg......................................... 85norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................85norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................85norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................85norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................85NORMOSOL-M IN D5W............................................. 76NORTHERA.................................................................. 65NORTHERA.................................................................. 65NORTHERA.................................................................. 65NORTRIPTYLINE HCL............................................... 21nortriptyline hcl cap 10 mg......................................... 21nortriptyline hcl cap 25 mg......................................... 21nortriptyline hcl cap 50 mg......................................... 21nortriptyline hcl cap 75 mg......................................... 21NORVIR.........................................................................47NORVIR.........................................................................47NOXAFIL....................................................................... 25NOXAFIL....................................................................... 25NOXAFIL....................................................................... 25NUBEQA........................................................................34NUCYNTA ER.................................................................4NUCYNTA ER.................................................................4NUCYNTA ER.................................................................4NUCYNTA ER.................................................................4NUCYNTA ER.................................................................4NUEDEXTA...................................................................70NULOJIX........................................................................92NUPLAZID.....................................................................42NUPLAZID.....................................................................42NUTRILIPID.................................................................. 76nystatin cream 100000 unit/gm..................................25nystatin oint 100000 unit/gm...................................... 25nystatin susp 100000 unit/ml......................................25nystatin tab 500000 unit..............................................25nystatin topical powder 100000 unit/

gm................................................................................25nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................73nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................73OOCALIVA....................................................................... 79OCALIVA....................................................................... 79octreotide acetate inj 1000 mcg/ml (1 mg/

ml)................................................................................88octreotide acetate inj 100 mcg/ml (0.1 mg/

ml)................................................................................88

octreotide acetate inj 200 mcg/ml (0.2 mg/ml)................................................................................88



ODEFSEY..................................................................... 47ODOMZO...................................................................... 34OFEV........................................................................... 101OFEV........................................................................... 101ofloxacin ophth soln 0.3%...........................................97ofloxacin otic soln 0.3%.............................................. 98ofloxacin tab 400 mg...................................................12OGIVRI.......................................................................... 34OGIVRI.......................................................................... 34olanzapine for im inj 10 mg........................................ 43olanzapine orally disintegrating tab 10

mg................................................................................43olanzapine orally disintegrating tab 15



mg................................................................................43olanzapine tab 10 mg..................................................43olanzapine tab 15 mg..................................................43olanzapine tab 2.5 mg.................................................43olanzapine tab 20 mg..................................................43olanzapine tab 5 mg....................................................43olanzapine tab 7.5 mg.................................................43olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg.................................................................66olmesartan medoxomil-hydrochlorothiazide tab

40-12.5 mg.................................................................66olmesartan medoxomil-hydrochlorothiazide tab

40-25 mg....................................................................66olmesartan medoxomil tab 20 mg............................. 65olmesartan medoxomil tab 40 mg............................. 65olmesartan medoxomil tab 5 mg............................... 65olopatadine hcl nasal soln 0.6%..............................101olopatadine hcl ophth soln 0.1%................................97olopatadine hcl ophth soln 0.2%................................97omega-3-acid ethyl esters cap 1 gm.........................66omeprazole cap delayed release 10

mg................................................................................78omeprazole cap delayed release 20

mg................................................................................78omeprazole cap delayed release 40

mg................................................................................78OMNITROPE................................................................ 83OMNITROPE................................................................ 83OMNITROPE................................................................ 83

2020

132

ONCASPAR.................................................................. 34ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................23ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................23ondansetron hcl oral soln 4 mg/5ml.......................... 23ondansetron hcl tab 24 mg.........................................23ondansetron hcl tab 4 mg...........................................23ondansetron hcl tab 8 mg...........................................23ondansetron orally disintegrating tab 4

mg................................................................................23ondansetron orally disintegrating tab 8

mg................................................................................23ONGLYZA......................................................................53ONGLYZA......................................................................53ONIVYDE...................................................................... 34OPDIVO.........................................................................34OPDIVO.........................................................................35OPDIVO.........................................................................35OPSUMIT....................................................................101ORACEA........................................................................73ORALAIR.....................................................................101ORENCIA...................................................................... 92ORENCIA...................................................................... 92ORENCIA...................................................................... 92ORENCIA...................................................................... 92ORENCIA CLICKJECT............................................... 92ORFADIN.......................................................................80ORFADIN.......................................................................80ORFADIN.......................................................................80ORFADIN.......................................................................80ORFADIN.......................................................................80ORKAMBI....................................................................101ORKAMBI....................................................................101ORKAMBI....................................................................101ORKAMBI....................................................................101oseltamivir phosphate cap 30 mg..............................47oseltamivir phosphate cap 45 mg..............................47oseltamivir phosphate cap 75 mg..............................48oseltamivir phosphate for susp 6 mg/

ml.................................................................................48OTEZLA.........................................................................92OTEZLA.........................................................................92oxaliplatin for iv inj 100 mg.........................................35oxaliplatin for iv inj 50 mg...........................................35oxaliplatin iv soln 100 mg/20ml..................................35oxaliplatin iv soln 50 mg/10ml....................................35oxandrolone tab 10 mg............................................... 85oxandrolone tab 2.5 mg..............................................85oxaprozin tab 600 mg....................................................4oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................17

oxcarbazepine tab 150 mg.........................................17oxcarbazepine tab 300 mg.........................................17oxcarbazepine tab 600 mg.........................................17oxybutynin chloride syrup 5 mg/5ml..........................81oxybutynin chloride tab 5 mg..................................... 81oxybutynin chloride tab er 24hr 10 mg......................81oxybutynin chloride tab er 24hr 15 mg......................81oxybutynin chloride tab er 24hr 5 mg........................81oxycodone-aspirin tab 4.8355-325 mg........................4oxycodone hcl tab 10 mg..............................................4oxycodone hcl tab 15 mg..............................................4oxycodone hcl tab 20 mg..............................................4oxycodone hcl tab 30 mg..............................................4oxycodone hcl tab 5 mg................................................4oxycodone w/ acetaminophen tab 10-325

mg..................................................................................4oxycodone w/ acetaminophen tab 2.5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 7.5-325

mg..................................................................................4OZEMPIC...................................................................... 53OZEMPIC...................................................................... 53PPACLITAXEL.................................................................35paclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................35paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................35paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................35PADCEV........................................................................ 35PADCEV........................................................................ 35paliperidone tab er 24hr 1.5 mg.................................43paliperidone tab er 24hr 3 mg....................................43paliperidone tab er 24hr 6 mg....................................43paliperidone tab er 24hr 9 mg....................................43palonosetron hcl iv soln 0.25 mg/5ml........................23palonosetron hcl iv soln pref syr 0.25

mg/5ml........................................................................ 23PALONOSETRON

HYDROCHLORIDE.................................................. 23PALYNZIQ..................................................................... 80PALYNZIQ..................................................................... 80PALYNZIQ..................................................................... 80PANRETIN.....................................................................35pantoprazole sodium ec tab 20 mg........................... 78pantoprazole sodium ec tab 40 mg........................... 78pantoprazole sodium for iv soln 40 mg..................... 78paricalcitol cap 1 mcg................................................. 95paricalcitol cap 2 mcg................................................. 96

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paricalcitol cap 4 mcg................................................. 96paricalcitol iv soln 2 mcg/ml....................................... 96paricalcitol iv soln 5 mcg/ml....................................... 96paromomycin sulfate cap 250 mg..............................12paroxetine hcl tab 10 mg............................................ 21paroxetine hcl tab 20 mg............................................ 21paroxetine hcl tab 30 mg............................................ 21paroxetine hcl tab 40 mg............................................ 21PASER........................................................................... 27PAXIL............................................................................. 22PAZEO........................................................................... 97PEDIARIX......................................................................92PEDVAX HIB................................................................ 93peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................78peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................78peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................78PEGANONE..................................................................17PEGASYS..................................................................... 48PEGASYS..................................................................... 48PEGASYS PROCLICK................................................48penicillamine tab 250 mg............................................81penicillin g potassium for inj 20000000

unit...............................................................................12penicillin g potassium for inj 5000000

unit...............................................................................12PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 12PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 12PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 12PENICILLIN G SODIUM............................................. 12PENICILLIN V POTASSIUM...................................... 13PENICILLIN V POTASSIUM...................................... 13penicillin v potassium tab 250 mg............................. 13penicillin v potassium tab 500 mg............................. 13PENTACEL....................................................................93PENTAM 300................................................................39pentamidine isethionate for nebulization soln 300

mg................................................................................39pentamidine isethionate for soln 300

mg................................................................................39PENTASA...................................................................... 95PENTASA...................................................................... 95pentoxifylline tab er 400 mg....................................... 66perindopril erbumine tab 2 mg................................... 66perindopril erbumine tab 4 mg................................... 66perindopril erbumine tab 8 mg................................... 66PERJETA.......................................................................35

permethrin cream 5%..................................................39perphenazine tab 16 mg.............................................23perphenazine tab 2 mg............................................... 23perphenazine tab 4 mg............................................... 23perphenazine tab 8 mg............................................... 23PERSERIS.................................................................... 43PERSERIS.................................................................... 43phenelzine sulfate tab 15 mg.....................................22phenobarbital elixir 20 mg/5ml...................................17PHENOBARBITAL SODIUM...................................... 17PHENOBARBITAL SODIUM...................................... 17phenobarbital tab 100 mg...........................................17phenobarbital tab 15 mg.............................................17phenobarbital tab 16.2 mg..........................................17phenobarbital tab 30 mg.............................................17phenobarbital tab 32.4 mg..........................................17phenobarbital tab 60 mg.............................................17phenobarbital tab 64.8 mg..........................................17phenobarbital tab 97.2 mg..........................................17phenoxybenzamine hcl cap 10 mg............................66phenytoin chew tab 50 mg......................................... 17phenytoin sodium extended cap 100

mg................................................................................17phenytoin sodium extended cap 200

mg................................................................................17phenytoin sodium extended cap 300

mg................................................................................17phenytoin susp 125 mg/5ml....................................... 17PHOSLYRA...................................................................76PHOSPHOLINE IODIDE.............................................97PICATO..........................................................................73PICATO..........................................................................74PIFELTRO..................................................................... 48pilocarpine hcl ophth soln 1%.................................... 97pilocarpine hcl ophth soln 2%.................................... 97pilocarpine hcl ophth soln 4%.................................... 97pilocarpine hcl tab 5 mg..............................................71pilocarpine hcl tab 7.5 mg.......................................... 71pimecrolimus cream 1%..............................................74PIMOZIDE..................................................................... 43PIMOZIDE..................................................................... 43pindolol tab 10 mg....................................................... 66pindolol tab 5 mg......................................................... 66pioglitazone hcl-glimepiride tab 30-2

mg................................................................................54pioglitazone hcl-glimepiride tab 30-4

mg................................................................................54pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................54pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................54pioglitazone hcl tab 15 mg..........................................53

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pioglitazone hcl tab 30 mg..........................................54pioglitazone hcl tab 45 mg..........................................54piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................13piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 13piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 13PIQRAY 200MG DAILY DOSE...................................35PIQRAY 250MG DAILY DOSE...................................35PIQRAY 300MG DAILY DOSE...................................35piroxicam cap 10 mg..................................................... 4piroxicam cap 20 mg..................................................... 4PLEGRIDY.................................................................... 70PLEGRIDY.................................................................... 70PLEGRIDY STARTER PACK..................................... 71PLEGRIDY STARTER PACK..................................... 71podofilox soln 0.5%..................................................... 74POLIVY..........................................................................35polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%...................................................................... 97POMALYST...................................................................35POMALYST...................................................................35POMALYST...................................................................35POMALYST...................................................................35PORTRAZZA................................................................ 35posaconazole tab delayed release 100

mg................................................................................25POTASSIUM CHLORIDE/DEXTROSE.....................76POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................76potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj................................................................................. 76potassium chloride cap er 10 meq............................ 76potassium chloride cap er 8 meq...............................76potassium chloride inj 2 meq/ml................................ 76potassium chloride microencapsulated crys er tab 10

meq............................................................................. 76potassium chloride microencapsulated crys er tab 20

meq............................................................................. 76potassium chloride oral soln 10% (20

meq/15ml).................................................................. 76potassium chloride tab er 10 meq............................. 76potassium chloride tab er 20 meq (1500

mg).............................................................................. 76potassium chloride tab er 8 meq (600

mg).............................................................................. 76potassium citrate tab er 10 meq (1080

mg).............................................................................. 76potassium citrate tab er 15 meq (1620

mg).............................................................................. 76

potassium citrate tab er 5 meq (540mg).............................................................................. 76

POTELIGEO................................................................. 35PRADAXA..................................................................... 57PRADAXA..................................................................... 57PRADAXA..................................................................... 57pramipexole dihydrochloride tab 0.125

mg................................................................................40pramipexole dihydrochloride tab 0.25




mg................................................................................40pramipexole dihydrochloride tab 1 mg...................... 40prasugrel hcl tab 10 mg..............................................57prasugrel hcl tab 5 mg................................................ 57pravastatin sodium tab 10 mg....................................66pravastatin sodium tab 20 mg....................................66pravastatin sodium tab 40 mg....................................66pravastatin sodium tab 80 mg....................................66praziquantel tab 600 mg............................................. 39prazosin hcl cap 1 mg.................................................66prazosin hcl cap 2 mg.................................................66prazosin hcl cap 5 mg.................................................66PREDNICARBATE.......................................................74PREDNICARBATE.......................................................74PREDNISOLONE ACETATE......................................97prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 82prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................82prednisolone syrup 15 mg/5ml...................................82PREDNISONE.............................................................. 82prednisone tab 10 mg................................................. 82prednisone tab 1 mg................................................... 82prednisone tab 2.5 mg................................................ 82prednisone tab 20 mg................................................. 82prednisone tab 50 mg................................................. 82prednisone tab 5 mg................................................... 82prednisone tab therapy pack 10 mg

(21)..............................................................................82prednisone tab therapy pack 10 mg

(48)..............................................................................82prednisone tab therapy pack 5 mg (21).................... 82prednisone tab therapy pack 5 mg (48).................... 82pregabalin cap 100 mg............................................... 17pregabalin cap 150 mg............................................... 17pregabalin cap 200 mg............................................... 17pregabalin cap 225 mg............................................... 17

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pregabalin cap 25 mg................................................. 17pregabalin cap 300 mg............................................... 17pregabalin cap 50 mg................................................. 17pregabalin cap 75 mg................................................. 17pregabalin soln 20 mg/ml........................................... 17PREGNYL W/DILUENT BENZYL ALCOHOL/

NACL.......................................................................... 83PREMARIN................................................................... 85PREMARIN................................................................... 85PREMARIN................................................................... 85PREMARIN................................................................... 85PREMARIN................................................................... 85PREMARIN................................................................... 85PREMPHASE............................................................... 85PREMPRO.................................................................... 85PREMPRO.................................................................... 86PREMPRO.................................................................... 86PREMPRO.................................................................... 86PREVYMIS....................................................................48PREVYMIS....................................................................48PREZCOBIX................................................................. 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PRIFTIN.........................................................................27primaquine phosphate tab 26.3 mg...........................39primidone tab 250 mg................................................. 17primidone tab 50 mg................................................... 17PROAIR HFA..............................................................101PROAIR RESPICLICK..............................................101probenecid tab 500 mg............................................... 25PROCHLORPERAZINE EDISYLATE....................... 24prochlorperazine edisylate inj 10

mg/2ml........................................................................ 24prochlorperazine maleate tab 10 mg.........................24prochlorperazine maleate tab 5 mg...........................24prochlorperazine suppos 25 mg................................ 24PROCRIT...................................................................... 57PROCRIT...................................................................... 57PROCRIT...................................................................... 57PROCRIT...................................................................... 57PROCRIT...................................................................... 57PROCRIT...................................................................... 57progesterone micronized cap 100 mg.......................86progesterone micronized cap 200 mg.......................86PROGLYCEM............................................................... 54PROGRAF.....................................................................93PROGRAF.....................................................................93PROGRAF.....................................................................93PROLASTIN-C..............................................................80

PROLASTIN-C..............................................................80PROLENSA...................................................................97PROLEUKIN................................................................. 35PROLIA..........................................................................96PROMACTA.................................................................. 57PROMACTA.................................................................. 57PROMACTA.................................................................. 57PROMACTA.................................................................. 57PROMACTA.................................................................. 57promethazine hcl suppos 12.5 mg............................ 24promethazine hcl suppos 25 mg................................24promethazine hcl syrup 6.25 mg/5ml........................ 24promethazine hcl tab 12.5 mg....................................24promethazine hcl tab 25 mg.......................................24promethazine hcl tab 50 mg.......................................24propafenone hcl cap er 12hr 225 mg........................ 66propafenone hcl cap er 12hr 325 mg........................ 66propafenone hcl cap er 12hr 425 mg........................ 66propafenone hcl tab 150 mg...................................... 66propafenone hcl tab 225 mg...................................... 66propafenone hcl tab 300 mg...................................... 66propranolol hcl cap er 24hr 120 mg.......................... 66propranolol hcl cap er 24hr 160 mg.......................... 66propranolol hcl cap er 24hr 60 mg.............................66propranolol hcl cap er 24hr 80 mg.............................66propranolol hcl inj 1 mg/ml......................................... 66propranolol hcl tab 10 mg...........................................66propranolol hcl tab 20 mg...........................................66propranolol hcl tab 40 mg...........................................66propranolol hcl tab 60 mg...........................................66propranolol hcl tab 80 mg...........................................66propylthiouracil tab 50 mg.......................................... 89PROQUAD.................................................................... 93protriptyline hcl tab 10 mg.......................................... 22protriptyline hcl tab 5 mg............................................ 22PULMOZYME.............................................................101PURIXAN.......................................................................35PYLERA.........................................................................78pyrazinamide tab 500 mg........................................... 27pyridostigmine bromide oral soln 60

mg/5ml........................................................................ 26pyridostigmine bromide tab 60 mg............................ 26pyridostigmine bromide tab er 180 mg......................26QQUADRACEL................................................................93quetiapine fumarate tab 100 mg................................43quetiapine fumarate tab 200 mg................................43quetiapine fumarate tab 25 mg..................................43quetiapine fumarate tab 300 mg................................43quetiapine fumarate tab 400 mg................................43quetiapine fumarate tab 50 mg..................................43

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quetiapine fumarate tab er 24hr 150mg................................................................................43




quetiapine fumarate tab er 24hr 50 mg.....................43quinapril hcl tab 10 mg............................................... 66quinapril hcl tab 20 mg............................................... 66quinapril hcl tab 40 mg............................................... 66quinapril hcl tab 5 mg..................................................66quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................67quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................67quinapril-hydrochlorothiazide tab 20-25

mg................................................................................67quinidine gluconate tab er 324 mg............................ 67QUINIDINE SULFATE................................................. 67QUINIDINE SULFATE................................................. 67QVAR REDIHALER................................................... 101QVAR REDIHALER................................................... 101RRABAVERT................................................................... 93rabeprazole sodium ec tab 20 mg............................. 78raloxifene hcl tab 60 mg............................................. 86ramelteon tab 8 mg................................................... 103ramipril cap 1.25 mg....................................................67ramipril cap 10 mg.......................................................67ramipril cap 2.5 mg......................................................67ramipril cap 5 mg.........................................................67ranitidine hcl cap 150 mg........................................... 78ranitidine hcl cap 300 mg........................................... 78ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................78ranitidine hcl tab 150 mg............................................ 78ranitidine hcl tab 300 mg............................................ 78ranolazine tab er 12hr 1000 mg.................................67ranolazine tab er 12hr 500 mg...................................67rasagiline mesylate tab 0.5 mg.................................. 40rasagiline mesylate tab 1 mg..................................... 40REBIF.............................................................................71REBIF.............................................................................71REBIF REBIDOSE.......................................................71REBIF REBIDOSE.......................................................71REBIF REBIDOSE TITRATION PACK......................71REBIF TITRATION PACK...........................................71RECOMBIVAX HB....................................................... 93RECOMBIVAX HB....................................................... 93

RECOMBIVAX HB....................................................... 93RECTIV..........................................................................67REGRANEX.................................................................. 74RELENZA DISKHALER.............................................. 48RELISTOR.....................................................................78RELISTOR.....................................................................78RELISTOR.....................................................................78REMODULIN.............................................................. 101REMODULIN.............................................................. 101REMODULIN.............................................................. 101REMODULIN.............................................................. 101RENFLEXIS.................................................................. 93repaglinide tab 0.5 mg................................................ 54repaglinide tab 1 mg....................................................54repaglinide tab 2 mg....................................................54REPATHA...................................................................... 67REPATHA PUSHTRONEX SYSTEM........................67REPATHA SURECLICK.............................................. 67RESCRIPTOR.............................................................. 48RESTASIS.....................................................................97RESTASIS MULTIDOSE.............................................97RETACRIT.....................................................................57RETACRIT.....................................................................57RETACRIT.....................................................................57RETACRIT.....................................................................57RETACRIT.....................................................................57RETROVIR IV INFUSION...........................................48REVCOVI...................................................................... 80REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REYATAZ.......................................................................48RHOPRESSA............................................................... 97ribavirin cap 200 mg....................................................48ribavirin for inhal soln 6 gm......................................101ribavirin tab 200 mg.....................................................48RIDAURA...................................................................... 93rifabutin cap 150 mg....................................................27rifampin cap 150 mg....................................................27rifampin cap 300 mg....................................................27rifampin for inj 600 mg................................................ 27riluzole tab 50 mg........................................................ 71RINVOQ.........................................................................93

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risedronate sodium tab 150 mg................................. 96risedronate sodium tab 30 mg................................... 96risedronate sodium tab 35 mg................................... 96risedronate sodium tab 5 mg..................................... 96risedronate sodium tab delayed release 35

mg................................................................................96RISPERDAL CONSTA................................................ 44RISPERDAL CONSTA................................................ 44RISPERDAL CONSTA................................................ 44RISPERDAL CONSTA................................................ 44RISPERIDONE ODT................................................... 44risperidone orally disintegrating tab 0.5

mg................................................................................44risperidone orally disintegrating tab 1




mg................................................................................44risperidone soln 1 mg/ml............................................ 44risperidone tab 0.25 mg..............................................44risperidone tab 0.5 mg................................................ 44risperidone tab 1 mg................................................... 44risperidone tab 2 mg................................................... 44risperidone tab 3 mg................................................... 44risperidone tab 4 mg................................................... 44ritonavir tab 100 mg.................................................... 48RITUXAN.......................................................................35RITUXAN.......................................................................35RITUXAN HYCELA......................................................35RITUXAN HYCELA......................................................36rivastigmine tartrate cap 1.5 mg................................ 19rivastigmine tartrate cap 3 mg....................................19rivastigmine tartrate cap 4.5 mg................................ 19rivastigmine tartrate cap 6 mg....................................19rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 19rivastigmine td patch 24hr 4.6 mg/24hr.....................19rivastigmine td patch 24hr 9.5 mg/24hr.....................19rizatriptan benzoate oral disintegrating tab 10

mg................................................................................26rizatriptan benzoate oral disintegrating tab 5

mg................................................................................26rizatriptan benzoate tab 10 mg.................................. 26rizatriptan benzoate tab 5 mg.................................... 26ropinirole hydrochloride tab 0.25 mg.........................40ropinirole hydrochloride tab 0.5 mg...........................40ropinirole hydrochloride tab 1 mg.............................. 40ropinirole hydrochloride tab 2 mg.............................. 40ropinirole hydrochloride tab 3 mg.............................. 40

ropinirole hydrochloride tab 4 mg.............................. 40ropinirole hydrochloride tab 5 mg.............................. 40rosuvastatin calcium tab 10 mg................................. 67rosuvastatin calcium tab 20 mg................................. 67rosuvastatin calcium tab 40 mg................................. 67rosuvastatin calcium tab 5 mg................................... 67ROTARIX.......................................................................93ROTATEQ......................................................................93ROZLYTREK.................................................................36ROZLYTREK.................................................................36RUBRACA.....................................................................36RUBRACA.....................................................................36RUBRACA.....................................................................36RYDAPT........................................................................ 36RYTARY.........................................................................40RYTARY.........................................................................40RYTARY.........................................................................40RYTARY.........................................................................40SSAMSCA........................................................................76SAMSCA........................................................................76SANDIMMUNE............................................................. 93SANTYL.........................................................................74SAPHRIS.......................................................................44SAPHRIS.......................................................................44SAPHRIS.......................................................................44SECUADO.....................................................................44SECUADO.....................................................................44SECUADO.....................................................................44selegiline hcl cap 5 mg............................................... 40selegiline hcl tab 5 mg................................................ 40selenium sulfide lotion 2.5%.......................................74SELZENTRY.................................................................48SELZENTRY.................................................................48SELZENTRY.................................................................48SELZENTRY.................................................................48SELZENTRY.................................................................48SEREVENT DISKUS.................................................101sertraline hcl oral concentrate for solution 20 mg/

ml.................................................................................22sertraline hcl tab 100 mg............................................ 22sertraline hcl tab 25 mg.............................................. 22sertraline hcl tab 50 mg.............................................. 22sevelamer carbonate packet 0.8 gm......................... 76sevelamer carbonate packet 2.4 gm......................... 76sevelamer carbonate tab 800 mg..............................76SHINGRIX..................................................................... 93SIGNIFOR..................................................................... 88SIGNIFOR..................................................................... 88SIGNIFOR..................................................................... 88SIGNIFOR LAR............................................................88SIGNIFOR LAR............................................................88

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SIGNIFOR LAR............................................................88SIGNIFOR LAR............................................................88SIGNIFOR LAR............................................................88sildenafil citrate tab 100 mg (generic for

Viagra)........................................................................ 81sildenafil citrate tab 20 mg....................................... 101sildenafil citrate tab 25 mg (generic for

Viagra)........................................................................ 81sildenafil citrate tab 50 mg (generic for

Viagra)........................................................................ 81SILENOR.....................................................................103SILENOR.....................................................................103silodosin cap 4 mg.......................................................81silodosin cap 8 mg.......................................................81silver sulfadiazine cream 1%......................................74SIMBRINZA...................................................................97SIMULECT.................................................................... 93SIMULECT.................................................................... 93simvastatin tab 10 mg.................................................67simvastatin tab 20 mg.................................................67simvastatin tab 40 mg.................................................67simvastatin tab 5 mg................................................... 67simvastatin tab 80 mg.................................................67sirolimus oral soln 1 mg/ml.........................................93sirolimus tab 0.5 mg.................................................... 93sirolimus tab 1 mg....................................................... 93sirolimus tab 2 mg....................................................... 93SIRTURO.......................................................................27SIVEXTRO.................................................................... 13SIVEXTRO.................................................................... 13SKYRIZI.........................................................................93sodium chloride irrigation soln 0.9%......................... 76sodium chloride iv soln 0.45%................................... 76sodium chloride iv soln 0.9%..................................... 76sodium chloride preservative free inj

0.9%............................................................................76sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................80sodium phenylbutyrate tab 500 mg........................... 80sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................76sodium polystyrene sulfonate powder.......................76sodium polystyrene sulfonate rectal susp 30

gm/120ml....................................................................76SOFOSBUVIR/VELPATASVIR...................................48solifenacin succinate tab 10 mg.................................81solifenacin succinate tab 5 mg...................................81SOLTAMOX...................................................................36SOMATULINE DEPOT................................................88SOMATULINE DEPOT................................................88SOMATULINE DEPOT................................................88SOMAVERT.................................................................. 88

SOMAVERT.................................................................. 88SOMAVERT.................................................................. 88SOMAVERT.................................................................. 88SOMAVERT.................................................................. 88SOOLANTRA................................................................74sotalol hcl (afib/afl) tab 120 mg..................................67sotalol hcl (afib/afl) tab 160 mg..................................67sotalol hcl (afib/afl) tab 80 mg....................................67sotalol hcl tab 120 mg.................................................67sotalol hcl tab 160 mg.................................................67sotalol hcl tab 240 mg.................................................67sotalol hcl tab 80 mg...................................................67SOVALDI....................................................................... 48SOVALDI....................................................................... 48SPIRIVA HANDIHALER............................................102SPIRIVA RESPIMAT................................................. 102SPIRIVA RESPIMAT................................................. 102spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................67spironolactone tab 100 mg.........................................67spironolactone tab 25 mg........................................... 67spironolactone tab 50 mg........................................... 67SPRAVATO 56MG DOSE........................................... 22SPRAVATO 84MG DOSE........................................... 22SPRITAM.......................................................................17SPRITAM.......................................................................17SPRITAM.......................................................................17SPRITAM.......................................................................17SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36STAMARIL.....................................................................93stavudine cap 15 mg...................................................48stavudine cap 20 mg...................................................48stavudine cap 30 mg...................................................48stavudine cap 40 mg...................................................48STELARA...................................................................... 93STELARA...................................................................... 93STELARA...................................................................... 93STELARA...................................................................... 93STIMATE....................................................................... 83STIOLTO RESPIMAT................................................ 102STIVARGA.....................................................................36STRENSIQ....................................................................80STRENSIQ....................................................................80STRENSIQ....................................................................80STRENSIQ....................................................................80STREPTOMYCIN SULFATE...................................... 13STRIBILD...................................................................... 48

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SUBLOCADE.................................................................. 6SUBLOCADE.................................................................. 6sucralfate tab 1 gm......................................................78sulfacetamide sodium lotion 10%.............................. 13sulfacetamide sodium ophth soln 10%..................... 98sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%..........................................................98SULFADIAZINE............................................................ 13sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml........................................................................ 13sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 13sulfamethoxazole-trimethoprim tab 400-80

mg................................................................................13sulfamethoxazole-trimethoprim tab 800-160

mg................................................................................13sulfasalazine tab 500 mg............................................95sulfasalazine tab delayed release 500

mg................................................................................95sulindac tab 150 mg...................................................... 4sulindac tab 200 mg...................................................... 4sumatriptan nasal spray 20 mg/act........................... 26sumatriptan nasal spray 5 mg/act..............................26SUMATRIPTAN SUCCINATE.....................................26sumatriptan succinate inj 6 mg/0.5ml........................26sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................26sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................26sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................26sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................26sumatriptan succinate tab 100 mg............................ 26sumatriptan succinate tab 25 mg...............................26sumatriptan succinate tab 50 mg...............................26SUPRAX........................................................................13SUPRAX........................................................................13SUPREP BOWEL PREP KIT.....................................79SUTENT........................................................................ 36SUTENT........................................................................ 36SUTENT........................................................................ 36SUTENT........................................................................ 36SYLATRON................................................................... 48SYLATRON................................................................... 48SYLATRON................................................................... 49SYLVANT.......................................................................93SYLVANT.......................................................................94SYMBICORT...............................................................102SYMBICORT...............................................................102SYMDEKO.................................................................. 102SYMDEKO.................................................................. 102

SYMFI............................................................................ 49SYMFI LO..................................................................... 49SYMLINPEN 120......................................................... 54SYMLINPEN 60............................................................54SYMPAZAN...................................................................17SYMPAZAN...................................................................18SYMPAZAN...................................................................18SYMTUZA..................................................................... 49SYNAGIS.......................................................................94SYNAGIS.......................................................................94SYNAREL......................................................................88SYNERCID....................................................................13SYNJARDY................................................................... 54SYNJARDY................................................................... 54SYNJARDY................................................................... 54SYNJARDY................................................................... 54SYNJARDY XR............................................................ 54SYNJARDY XR............................................................ 54SYNJARDY XR............................................................ 54SYNJARDY XR............................................................ 54SYNRIBO...................................................................... 36SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87TTABLOID........................................................................36tacrolimus cap 0.5 mg.................................................94tacrolimus cap 1 mg....................................................94tacrolimus cap 5 mg....................................................94tacrolimus oint 0.03%..................................................74tacrolimus oint 0.1%.................................................... 74tadalafil tab 20 mg (pah)...........................................102TAFINLAR..................................................................... 36TAFINLAR..................................................................... 36TAGRISSO.................................................................... 36TAGRISSO.................................................................... 36TALZENNA....................................................................36TALZENNA....................................................................36tamoxifen citrate tab 10 mg........................................36tamoxifen citrate tab 20 mg........................................36tamsulosin hcl cap 0.4 mg..........................................81TARGRETIN..................................................................36TASIGNA....................................................................... 36

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TASIGNA....................................................................... 36TASIGNA....................................................................... 36tazarotene cream 0.1%...............................................74TAZICEF........................................................................ 13TAZICEF........................................................................ 13TAZORAC......................................................................74TAZORAC......................................................................74TAZORAC......................................................................74TDVAX........................................................................... 94TECENTRIQ................................................................. 36TECENTRIQ................................................................. 36TECFIDERA..................................................................71TECFIDERA..................................................................71TECFIDERA STARTER PACK...................................71TEFLARO......................................................................13TEFLARO......................................................................13TEKTURNA HCT......................................................... 68TEKTURNA HCT......................................................... 68TEKTURNA HCT......................................................... 68TEKTURNA HCT......................................................... 68telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................68telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................68telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................68telmisartan tab 20 mg................................................. 68telmisartan tab 40 mg................................................. 68telmisartan tab 80 mg................................................. 68temazepam cap 15 mg............................................. 103temazepam cap 30 mg............................................. 103TEMIXYS.......................................................................49TEMODAR.................................................................... 36temsirolimus soln for iv infusion 25 mg/

ml.................................................................................36TENCON..........................................................................4TENIVAC....................................................................... 94tenofovir disoproxil fumarate tab 300

mg................................................................................49terazosin hcl cap 10 mg..............................................68terazosin hcl cap 1 mg................................................68terazosin hcl cap 2 mg................................................68terazosin hcl cap 5 mg................................................68terbinafine hcl tab 250 mg..........................................25terbutaline sulfate tab 2.5 mg.................................. 102terbutaline sulfate tab 5 mg......................................102TERCONAZOLE...........................................................25terconazole vaginal cream 0.4%................................25terconazole vaginal suppos 80 mg............................25testosterone cypionate im inj in oil 100 mg/

ml.................................................................................86

testosterone cypionate im inj in oil 200 mg/ml.................................................................................86

testosterone enanthate im inj in oil 200 mg/ml.................................................................................86

testosterone td gel 12.5 mg/act (1%)........................ 86testosterone td gel 20.25 mg/1.25gm

(1.62%)....................................................................... 86testosterone td gel 20.25 mg/act

(1.62%)....................................................................... 86testosterone td gel 25 mg/2.5gm (1%)......................86testosterone td gel 40.5 mg/2.5gm

(1.62%)....................................................................... 86testosterone td gel 50 mg/5gm (1%).........................86testosterone td soln 30 mg/act...................................86tetrabenazine tab 12.5 mg..........................................71tetrabenazine tab 25 mg.............................................71tetracycline hcl cap 250 mg........................................13tetracycline hcl cap 500 mg........................................13THALOMID....................................................................36THALOMID....................................................................37THALOMID....................................................................37THALOMID....................................................................37theophylline tab er 12hr 300 mg..............................102theophylline tab er 12hr 450 mg..............................102theophylline tab er 24hr 400 mg..............................102theophylline tab er 24hr 600 mg..............................102thioridazine hcl tab 100 mg........................................ 44thioridazine hcl tab 10 mg.......................................... 44thioridazine hcl tab 25 mg.......................................... 44thioridazine hcl tab 50 mg.......................................... 44thiotepa for inj 15 mg.................................................. 37thiothixene cap 10 mg.................................................44thiothixene cap 1 mg...................................................44thiothixene cap 2 mg...................................................44thiothixene cap 5 mg...................................................44THYMOGLOBULIN......................................................94tiagabine hcl tab 12 mg.............................................. 18tiagabine hcl tab 16 mg.............................................. 18tiagabine hcl tab 2 mg.................................................18tiagabine hcl tab 4 mg.................................................18TIBSOVO.......................................................................37tigecycline for iv soln 50 mg.......................................13TIMOLOL MALEATE................................................... 68TIMOLOL MALEATE................................................... 68TIMOLOL MALEATE OPHTHALMIC GEL

FORMING.................................................................. 98TIMOLOL MALEATE OPHTHALMIC GEL

FORMING.................................................................. 98timolol maleate ophth soln 0.25%..............................98timolol maleate ophth soln 0.5%................................98timolol maleate ophth soln 0.5% (once-

daily)............................................................................98

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timolol maleate tab 5 mg............................................ 68TIVICAY......................................................................... 49TIVICAY......................................................................... 49TIVICAY......................................................................... 49tizanidine hcl cap 2 mg............................................... 45tizanidine hcl cap 4 mg............................................... 45tizanidine hcl cap 6 mg............................................... 45tizanidine hcl tab 2 mg................................................45tizanidine hcl tab 4 mg................................................45TOBRADEX...................................................................98tobramycin-dexamethasone ophth susp

0.3-0.1%..................................................................... 98tobramycin nebu soln 300 mg/5ml.......................... 102tobramycin ophth soln 0.3%.......................................98TOBRAMYCIN SULFATE........................................... 13TOBRAMYCIN SULFATE........................................... 13tobramycin sulfate for inj 1.2 gm................................13tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................13tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................13tolcapone tab 100 mg................................................. 40TOLMETIN SODIUM..................................................... 4tolterodine tartrate cap er 24hr 2 mg.........................81tolterodine tartrate cap er 24hr 4 mg.........................81tolterodine tartrate tab 1 mg.......................................81tolterodine tartrate tab 2 mg.......................................81topiramate sprinkle cap 15 mg...................................18topiramate sprinkle cap 25 mg...................................18topiramate tab 100 mg................................................18topiramate tab 200 mg................................................18topiramate tab 25 mg.................................................. 18topiramate tab 50 mg.................................................. 18topotecan hcl for inj 4 mg........................................... 37topotecan hcl inj 4 mg/4ml (for

infusion)...................................................................... 37toremifene citrate tab 60 mg...................................... 37torsemide tab 100 mg................................................. 68torsemide tab 10 mg................................................... 68torsemide tab 20 mg................................................... 68torsemide tab 5 mg......................................................68TOUJEO MAX SOLOSTAR........................................54TOUJEO SOLOSTAR..................................................54TOVIAZ.......................................................................... 81TOVIAZ.......................................................................... 81TRACLEER.................................................................102TRADJENTA................................................................. 54tramadol-acetaminophen tab 37.5-325

mg..................................................................................4tramadol hcl tab 50 mg................................................. 4tramadol hcl tab er 24hr 100 mg..................................4tramadol hcl tab er 24hr 200 mg..................................4

tramadol hcl tab er 24hr 300 mg..................................4trandolapril tab 1 mg................................................... 68trandolapril tab 2 mg................................................... 68trandolapril tab 4 mg................................................... 68tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................57tranexamic acid tab 650 mg.......................................57tranylcypromine sulfate tab 10 mg............................ 22TRAVATAN Z................................................................ 98travoprost ophth soln 0.004%.................................... 98trazodone hcl tab 100 mg...........................................22trazodone hcl tab 150 mg...........................................22trazodone hcl tab 300 mg...........................................22trazodone hcl tab 50 mg.............................................22TREANDA..................................................................... 37TREANDA..................................................................... 37TRECATOR...................................................................27TRELEGY ELLIPTA...................................................102TRELSTAR MIXJECT..................................................88TRELSTAR MIXJECT..................................................88TRELSTAR MIXJECT..................................................88TREMFYA......................................................................94TREMFYA......................................................................94treprostinil inj soln 100 mg/20ml (5 mg/

ml)............................................................................. 102treprostinil inj soln 200 mg/20ml (10 mg/

ml)............................................................................. 102treprostinil inj soln 20 mg/20ml (1 mg/

ml)............................................................................. 102treprostinil inj soln 50 mg/20ml (2.5 mg/

ml)............................................................................. 102TRESIBA....................................................................... 54TRESIBA FLEXTOUCH.............................................. 54TRESIBA FLEXTOUCH.............................................. 54tretinoin cap 10 mg......................................................37tretinoin cream 0.025%............................................... 74tretinoin cream 0.05%................................................. 74tretinoin cream 0.1%................................................... 74tretinoin gel 0.01%.......................................................74tretinoin gel 0.025%.....................................................74triamcinolone acetonide cream

0.025%........................................................................74triamcinolone acetonide cream 0.1%........................74triamcinolone acetonide cream 0.5%........................74triamcinolone acetonide dental paste

0.1%............................................................................71triamcinolone acetonide lotion 0.025%..................... 74triamcinolone acetonide lotion 0.1%..........................74triamcinolone acetonide oint 0.025%........................ 74triamcinolone acetonide oint 0.1%.............................74triamcinolone acetonide oint 0.5%.............................74

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triamterene & hydrochlorothiazide cap 37.5-25mg................................................................................68

triamterene & hydrochlorothiazide tab 37.5-25mg................................................................................68

triamterene & hydrochlorothiazide tab 75-50mg................................................................................68

trientine hcl cap 250 mg............................................. 76trifluoperazine hcl tab 10 mg......................................44trifluoperazine hcl tab 1 mg........................................44trifluoperazine hcl tab 2 mg........................................44trifluoperazine hcl tab 5 mg........................................44TRIFLURIDINE.............................................................98TRIKAFTA................................................................... 102trimethoprim tab 100 mg.............................................13trimipramine maleate cap 100 mg............................. 22trimipramine maleate cap 25 mg............................... 22trimipramine maleate cap 50 mg............................... 22TRINTELLIX..................................................................22TRINTELLIX..................................................................22TRINTELLIX..................................................................22TRISENOX....................................................................37TRIUMEQ......................................................................49TROGARZO..................................................................49trospium chloride cap er 24hr 60 mg.........................81trospium chloride tab 20 mg.......................................81TRULICITY....................................................................54TRULICITY....................................................................54TRUMENBA.................................................................. 94TRUVADA......................................................................49TRUVADA......................................................................49TRUVADA......................................................................49TRUVADA......................................................................49TRUXIMA...................................................................... 37TRUXIMA...................................................................... 37TURALIO....................................................................... 37TWINRIX........................................................................94TYBOST........................................................................ 49TYKERB........................................................................ 37TYMLOS........................................................................96TYPHIM VI.................................................................... 94TYSABRI....................................................................... 71UUDENYCA.....................................................................57UNITUXIN......................................................................37UPTRAVI..................................................................... 102UPTRAVI..................................................................... 102UPTRAVI..................................................................... 102UPTRAVI..................................................................... 102UPTRAVI..................................................................... 102UPTRAVI..................................................................... 102UPTRAVI..................................................................... 102UPTRAVI..................................................................... 103

UPTRAVI..................................................................... 103ursodiol cap 300 mg....................................................79ursodiol tab 250 mg.....................................................79ursodiol tab 500 mg.....................................................79Vvalacyclovir hcl tab 1 gm............................................ 49valacyclovir hcl tab 500 mg........................................49VALCHLOR................................................................... 37valganciclovir hcl for soln 50 mg/ml.......................... 49valganciclovir hcl tab 450 mg.....................................49valproate sodium inj 100 mg/ml.................................18valproate sodium oral soln 250 mg/5ml.................... 18valproic acid cap 250 mg............................................18valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................68valsartan-hydrochlorothiazide tab 160-25

mg................................................................................68valsartan-hydrochlorothiazide tab 320-12.5

mg................................................................................68valsartan-hydrochlorothiazide tab 320-25

mg................................................................................68valsartan-hydrochlorothiazide tab 80-12.5

mg................................................................................68valsartan tab 160 mg...................................................68valsartan tab 320 mg...................................................68valsartan tab 40 mg.....................................................68valsartan tab 80 mg.....................................................68VANCOMYCIN..............................................................13VANCOMYCIN..............................................................13VANCOMYCIN HCL.................................................... 13VANCOMYCIN HCL.................................................... 14vancomycin hcl cap 125 mg.......................................14vancomycin hcl cap 250 mg.......................................14vancomycin hcl for iv soln 10 gm.............................. 14vancomycin hcl for iv soln 1 gm.................................14vancomycin hcl for iv soln 500 mg............................ 14vancomycin hcl for iv soln 5 gm.................................14vancomycin hcl for iv soln 750 mg............................ 14VANCOMYCIN HYDROCHLORIDE..........................14VANCOMYCIN HYDROCHLORIDE..........................14VANCOMYCIN HYDROCHLORIDE..........................14VANCOMYCIN HYDROCHLORIDE..........................14VANCOMYCIN HYDROCHLORIDE..........................14VANCOMYCIN HYDROCHLORIDE..........................14VANCOMYCIN HYDROCHLORIDE/

DEXTROSE............................................................... 14VANCOMYCIN HYDROCHLORIDE/

DEXTROSE............................................................... 14VANCOMYCIN HYDROCHLORIDE/

DEXTROSE............................................................... 14VAQTA........................................................................... 94

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VAQTA........................................................................... 94VARIVAX........................................................................94VASCEPA...................................................................... 68VASCEPA...................................................................... 68VECTIBIX...................................................................... 37VECTIBIX...................................................................... 37VELCADE......................................................................37VELPHORO.................................................................. 76VELTASSA.................................................................... 76VELTASSA.................................................................... 76VELTASSA.................................................................... 76VENCLEXTA.................................................................37VENCLEXTA.................................................................37VENCLEXTA.................................................................37VENCLEXTA STARTING PACK................................ 37venlafaxine hcl cap er 24hr 150 mg.......................... 22venlafaxine hcl cap er 24hr 37.5 mg......................... 22venlafaxine hcl cap er 24hr 75 mg............................ 22venlafaxine hcl tab 100 mg........................................ 22venlafaxine hcl tab 25 mg...........................................22venlafaxine hcl tab 37.5 mg....................................... 22venlafaxine hcl tab 50 mg...........................................22venlafaxine hcl tab 75 mg...........................................22venlafaxine hcl tab er 24hr 150 mg........................... 22venlafaxine hcl tab er 24hr 37.5 mg..........................22venlafaxine hcl tab er 24hr 75 mg............................. 22VENTAVIS................................................................... 103VENTAVIS................................................................... 103VENTOLIN HFA......................................................... 103verapamil hcl cap er 24hr 120 mg.............................69verapamil hcl cap er 24hr 180 mg.............................69verapamil hcl cap er 24hr 200 mg.............................69verapamil hcl cap er 24hr 240 mg.............................69verapamil hcl cap er 24hr 300 mg.............................69VERAPAMIL HCL ER..................................................69VERAPAMIL HCL SR..................................................69verapamil hcl tab 120 mg........................................... 69verapamil hcl tab 40 mg............................................. 69verapamil hcl tab 80 mg............................................. 69verapamil hcl tab er 120 mg.......................................69verapamil hcl tab er 180 mg.......................................69verapamil hcl tab er 240 mg.......................................69VERSACLOZ................................................................ 45VERZENIO....................................................................37VERZENIO....................................................................37VERZENIO....................................................................37VERZENIO....................................................................37VICTOZA....................................................................... 54VIDEX............................................................................ 49VIDEX............................................................................ 49VIDEX EC..................................................................... 49VIDEX EC..................................................................... 49

VIDEX EC..................................................................... 49VIDEX EC..................................................................... 49VIEKIRA PAK................................................................49vigabatrin powd pack 500 mg.................................... 18vigabatrin tab 500 mg................................................. 18VIIBRYD.........................................................................22VIIBRYD.........................................................................22VIIBRYD.........................................................................22VIIBRYD STARTER PACK......................................... 22VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VINBLASTINE SULFATE............................................37vincristine sulfate iv soln 1 mg/ml..............................37vinorelbine tartrate inj 10 mg/ml.................................37vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................37VIRACEPT.................................................................... 49VIRACEPT.................................................................... 49VIREAD..........................................................................49VIREAD..........................................................................49VIREAD..........................................................................49VIREAD..........................................................................49VITRAKVI...................................................................... 37VITRAKVI...................................................................... 37VITRAKVI...................................................................... 37VIVITROL........................................................................ 6VIZIMPRO..................................................................... 37VIZIMPRO..................................................................... 37VIZIMPRO..................................................................... 38voriconazole for inj 200 mg........................................ 25voriconazole for susp 40 mg/ml.................................25voriconazole tab 200 mg............................................ 25voriconazole tab 50 mg...............................................25VOSEVI..........................................................................50VOTRIENT.................................................................... 38VPRIV............................................................................ 80VRAYLAR...................................................................... 45VRAYLAR...................................................................... 45VRAYLAR...................................................................... 45VRAYLAR...................................................................... 45VYNDAMAX.................................................................. 69VYNDAQEL...................................................................69VYXEOS........................................................................38Wwarfarin sodium tab 10 mg.........................................58warfarin sodium tab 1 mg...........................................57warfarin sodium tab 2.5 mg........................................57warfarin sodium tab 2 mg...........................................57

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warfarin sodium tab 3 mg...........................................57warfarin sodium tab 4 mg...........................................57warfarin sodium tab 5 mg...........................................57warfarin sodium tab 6 mg...........................................57warfarin sodium tab 7.5 mg........................................58water for irrigation, sterile irrigation

soln..............................................................................76XXALKORI....................................................................... 38XALKORI....................................................................... 38XARELTO...................................................................... 58XARELTO...................................................................... 58XARELTO...................................................................... 58XARELTO...................................................................... 58XARELTO STARTER PACK.......................................58XATMEP........................................................................ 94XELJANZ.......................................................................94XELJANZ.......................................................................94XGEVA...........................................................................96XIFAXAN........................................................................79XOFLUZA......................................................................50XOFLUZA......................................................................50XOLAIR..........................................................................94XOLAIR..........................................................................94XOLAIR..........................................................................94XOPENEX HFA..........................................................103XOSPATA...................................................................... 38XPOVIO 100 MG ONCE WEEKLY............................38XPOVIO 60 MG ONCE WEEKLY..............................38XPOVIO 80 MG ONCE WEEKLY..............................38XPOVIO 80 MG TWICE WEEKLY.............................38XTAMPZA ER................................................................. 4XTAMPZA ER................................................................. 4XTAMPZA ER................................................................. 4XTAMPZA ER................................................................. 4XTAMPZA ER................................................................. 4XTANDI.......................................................................... 38XYREM........................................................................103YYERVOY........................................................................38YERVOY........................................................................38YF-VAX.......................................................................... 94YONDELIS.................................................................... 38YONSA.......................................................................... 38Zzafirlukast tab 10 mg.................................................103zafirlukast tab 20 mg.................................................103zaleplon cap 10 mg...................................................103zaleplon cap 5 mg..................................................... 103ZALTRAP.......................................................................38

ZALTRAP.......................................................................38ZANOSAR..................................................................... 38ZEJULA..........................................................................38ZELBORAF................................................................... 38ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZEPATIER..................................................................... 50zidovudine cap 100 mg...............................................50zidovudine syrup 10 mg/ml.........................................50zidovudine tab 300 mg................................................50ziprasidone hcl cap 20 mg..........................................45ziprasidone hcl cap 40 mg..........................................45ziprasidone hcl cap 60 mg..........................................45ziprasidone hcl cap 80 mg..........................................45ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5zoledronic acid inj conc for iv infusion 4

mg/5ml........................................................................ 96zoledronic acid iv soln 5 mg/100ml........................... 96ZOLINZA........................................................................38zolpidem tartrate tab 10 mg..................................... 103zolpidem tartrate tab 5 mg....................................... 103zonisamide cap 100 mg..............................................18zonisamide cap 25 mg................................................18zonisamide cap 50 mg................................................18ZONTIVITY....................................................................58ZORTRESS...................................................................94ZORTRESS...................................................................94ZORTRESS...................................................................94ZORTRESS...................................................................94ZOSTAVAX....................................................................94ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................14ZYDELIG....................................................................... 38ZYDELIG....................................................................... 38ZYKADIA....................................................................... 38ZYPREXA RELPREVV............................................... 45ZYPREXA RELPREVV............................................... 45ZYPREXA RELPREVV............................................... 45

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ZYTIGA..........................................................................38

7NE 16078 20v7 Y0139_20NECompFrm_C FVNR 0919

This formulary was updated on 02/24/2020. For more recent information or other questions, please contact Blue Cross and Blue Shield of Nebraska Customer Service at 1-888-488-9850 or, for TTY users, 711, between 8 a.m. to 8 p.m., Central time, seven days a week from Oct. 1 through Mar. 31; 8 a.m. to 8 p.m. Central time, Monday through Friday from Apr. 1 through Sept. 30, or visit medicare.nebraskablue.com

Medicare Member Services: 1-800-MEDICARE (TTY/TDD 1-877-486-2048) 24 hours a day/seven days a week


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