Mercy Care Advantage (HMO SNP)...Mercy Care Advantage (HMO SNP) 2020 Formulary (List of Covered...

Mercy Care Advantage (HMO SNP) 2020 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID 00020345, Version 13

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑586‑1730 or 1‑877‑436‑5288 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org.

Mercy Care Advantage (HMO SNP) Formulario para 2020 (Lista de Medicamentos Cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS BAJO ESTE PLAN

Identificación del Formulario 00020345, Versión 13

Este formulario fue actualizado en 08/01/2020. Para la información más reciente o para otras preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑586‑1730 ó al 1‑877‑436‑5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visite www.MercyCareAZ.org.

Visit/Viste www.MercyCareAZ.org

AZ-19-06-01

http://www.MercyCareAZ.org



Mercy Care Advantage (HMO SNP) 2020 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 00020345, Version 13

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services at 602-586-1730 or 1-877-436-5288 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org.

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.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Mercy Care. When it refers to “plan” or “our plan,” it means Mercy Care Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of 08/01/2020. 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, 2021, and from time to time during the year.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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What is the Mercy Care Advantage (HMO SNP) Formulary? A formulary is a list of covered drugs selected by Mercy Care Advantage 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. Mercy Care Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Mercy Care Advantage 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 Mercy Care Advantage 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 a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Mercy Care Advantage (HMO SNP)’s Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 31-day supply of the drug. o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Mercy Care Advantage (HMO SNP)’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.

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The enclosed formulary is current as of 08/01/2020. To get updated information about the drugs covered by Mercy Care Advantage, please contact us. Our contact information appears on the front and back cover pages. If we update the formulary during 2020 due to a non-maintenance formulary change, an updated version of the formulary and the notice issued to affected members will be posted on our website at www.MercyCareAZ.org. Printed formularies will be updated with the changes using an errata notice.

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 52. 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? Mercy Care Advantage 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: Mercy Care Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Mercy Care Advantage before you fill your prescriptions. If you don’t get approval, Mercy Care Advantage may not cover the drug.

• Quantity Limits: For certain drugs, Mercy Care Advantage limits the amount of the drug that Mercy Care Advantage will cover. For example, Mercy Care Advantage provides 30 EA per 30 days per prescription for simvastatin. This may be in addition to a standard one-month or three-month supply.

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

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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You can ask Mercy Care Advantage 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 Mercy Care Advantage’s formulary?” on page IV 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 Member Services and ask if your drug is covered.

If you learn that Mercy Care Advantage does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Mercy Care Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Mercy Care Advantage.

• You can ask Mercy Care Advantage to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Mercy Care Advantage (HMO SNP) Formulary? You can ask Mercy Care Advantage 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 our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

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

Generally, Mercy Care Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, 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, or utilization restriction exception. When you request a formulary 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. 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.

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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 31-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 31-day supply of medication. After your first 31-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.

If you are admitted to or discharged from a long-term care facility, you will be allowed to refill a prescription upon admission or discharge.

For more information For more detailed information about your Mercy Care Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Mercy Care Advantage, 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/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Mercy Care Advantage’s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Mercy Care Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 52.

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

The “Drug Tier” column of the chart lists the category of each drug. Your cost sharing amounts depend on which category the drug is in:

Category Cost-sharing amount

Generic drugs (including brand drugs treated as generic) $0/$1.30/$3.60 copay

All other drugs $0/$3.90/$8.95 copay

Your copays may be less, depending on the level of “Extra Help” you are receiving. The Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider) lists the amount you will pay for your prescription drugs. You can also call Member Services to find out your cost sharing amount. Phone numbers for Member Services are on the front and back cover pages.

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http://www.medicare.gov

The information in the Requirements/Limits column tells you if Mercy Care Advantage has any special requirements for coverage of your drug.

Abbreviation Requirements/Limits

B/D Covered under Medicare Part B or Part D. Most drugs are covered under Part D, but there are some drugs that can be covered under both Part B or Part D depending on what the drug is used for and how it is administered.

EA Each. Medications listed with EA indicates number of pills dispensed.

LA Limited access. This prescription may be available only at certain pharmacies. For more information consult the Pharmacy Directory.

NM Not available at mail-order.

PA Prior authorization. You or your provider need to get approval from our plan before we will agree to cover the drug.

QL Quantity limits. The amount per fill or refill is shown.

ST Step therapy. This prescription drug requires that you’ve tried another drug first, which did not work for you.

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Mercy Care Advantage (HMO SNP) Formulario para 2020 (Lista de Medicamentos Cubiertos)

POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS BAJO ESTE PLAN Identificación del Formulario 00020345, Versión 13

Este formulario fue actualizado en el 1 de agosto de 2020. Para la información más reciente o para otras preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602-586-1730 ó al 1-877-436-5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visite www.MercyCareAZ.org.

Nota para los miembros actuales: Este formulario cambió desde el año pasado. Por favor revisen este documento para asegurarse de que todavía contenga los medicamentos que usted toma.

Cuando esta lista de medicamentos (formulario) se refiere a “nosotros” o a “nuestros”, esto significa Mercy Care. Cuando se refiere al “plan” o a “nuestro plan”, esto significa Mercy Care Advantage.

Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual está actualizada a la fecha de el 1 de agosto de 2020. Para un formulario actualizado, por favor contáctenos. Nuestra información de contacto, junto con la fecha en la que actualizamos por último el formulario, aparece en la portada y la contraportada.

Generalmente usted debe usar farmacias de la red para usar su beneficio de medicamentos de prescripción. Los beneficios, el formulario, la red de farmacias, y/o los copagos/el coseguro pueden cambiar el 1º de enero de 2021, y de tiempo en tiempo durante el año.

El formulario, la red de farmacias, y/o la red de proveedores pueden cambiar en cualquier momento. Usted recibirá aviso cuando sea necesario.

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¿Qué es el Formulario de Mercy Care Advantage (HMO SNP)? Un formulario es una lista de medicamentos cubiertos seleccionados por Mercy Care Advantage en consulta con un equipo de proveedores del cuidado de la salud, el cual representa las terapias de prescripción/receta que se considera son una parte necesaria de un programa de tratamiento de calidad. Generalmente, Mercy Care Advantage cubrirá los medicamentos listados en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la prescripción/receta sea surtida en una farmacia de la red de Mercy Care Advantage, y se sigan otras reglas del plan. Para más información sobre cómo surtir sus prescripciones/recetas, por favor revise su Evidencia de Cobertura.

¿El Formulario (lista de medicamentos) puede cambiar? La mayoría de los cambios en la cobertura de medicamentos ocurren el 1º de enero, pero Mercy Care Advantage puede agregar o eliminar medicamentos en la Lista de Medicamentos durante el año, cambiarlos a niveles de costo compartido distintos o agregar nuevas restricciones. Nosotros debemos seguir las reglas de Medicare para hacer estos cambios.

Cambios que pueden afectarle este año: En los casos a continuación, usted se verá afectado/a por los cambios a la cobertura durante el año:

• Nuevos medicamentos genéricos. Nosotros podemos eliminar inmediatamente un medicamento de marca de nuestra Lista de Medicamentos si lo estamos reemplazando con un medicamento genérico nuevo que aparecerá en el mismo nivel o en un nivel más bajo de costo compartido y con las mismas o menos restricciones. Además, al agregar el nuevo medicamento genérico, nosotros podemos decidir retener el medicamento de marca en nuestra Lista de Medicamentos, pero cambiarlo inmediatamente a un nivel de costo compartido distinto o agregar nuevas restricciones. Si actualmente usted está tomando dicho medicamento de marca, es posible que nosotros no le informemos por adelantado que haremos dicho cambio, pero más tarde le proveeremos información sobre el/los cambio/s específico/s que hayamos hecho. o Si nosotros hacemos dicho cambio, usted o la persona prescribiéndole pueden pedirnos que hagamos una excepción y que continuemos cubriendo el medicamento de marca para usted. El aviso que nosotros le proveeremos también incluirá información sobre cómo solicitar una excepción, y usted también puede encontrar información en la sección a continuación titulada “¿Cómo solicito una excepción al Formulario de Mercy Care Advantage (HMO SNP)?”

• Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos considera que un medicamento en nuestro formulario no es seguro, o si el fabricante del medicamento retira el medicamento del mercado, nosotros inmediatamente retiraremos el medicamento de nuestro formulario y les proveeremos un aviso a los miembros que estén tomando dicho medicamento.

• Otros cambios. Nosotros podemos hacer otros cambios que afecten a los miembros que actualmente toman un medicamento. Por ejemplo, nosotros podemos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca actualmente en el formulario o agregar nuevas restricciones al medicamento de marca o cambiarlo a un nivel de costo compartido distinto. O podemos hacer cambios basados en nuevas directrices clínicas. Si retiramos medicamentos de nuestro formulario, o agregamos autorización previa, límites de cantidad y/o restricciones de terapia a pasos en un medicamento, nosotros debemos notificárselo a los miembros afectados por el cambio por lo menos 360 días antes de que el cambio entre en vigor, ó cuando el miembro pida que se le vuelva a surtir el medicamento, en cuyo momento, el miembro recibirá un suministro para 31 días del medicamento.

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o Si nosotros hacemos estos otros cambios, usted o la persona prescribiéndole pueden pedirnos que hagamos una excepción y que continuemos cubriendo el medicamento de marca para usted. El aviso que le proveeremos también incluirá información sobre cómo solicitar una excepción, y usted también puede encontrar información en la sección a continuación titulada “¿Cómo solicito una excepción al Formulario de Mercy Care Advantage (HMO SNP)?”

Cambios que no le afectarán si usted está tomando actualmente el medicamento. Generalmente, si usted está tomando un medicamento listado en nuestro Formulario de 2020 que fue cubierto a principios de año, nosotros no interrumpiremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2020 excepto como se describió anteriormente. Esto significa que estos medicamentos permanecerán disponibles al mismo costo compartido y sin nuevas restricciones para aquellos miembros que los tomen durante el resto del año de la cobertura.

El formulario adjunto está vigente a partir de el 1 de agosto de 2020. Para obtener información actualizada sobre los medicamentos cubiertos por Mercy Care Advantage, por favor póngase en contacto con nosotros. Nuestra información de contacto aparece en la portada y la contraportada. Si nosotros actualizamos el formulario durante 2020 debido a un cambio al formulario que no sea de mantenimiento, se publicará una versión actualizada del formulario y se emitirá un aviso a los miembros afectados en nuestro sitio web www.MercyCareAZ.org. Los cambios a los formularios impresos se actualizarán por medio de un aviso de erratas.

¿Cómo uso el Formulario? Hay dos formas de encontrar su medicamento dentro del formulario:

Condición Médica El formulario empieza en la página 1. Los medicamentos en este formulario están agrupados en categorías, dependiendo del tipo de condiciones médicas para cuyo tratamiento de usan. Por ejemplo, los medicamentos usados para tratar una condición cardíaca están listados bajo la categoría de “Agentes Cardiovasculares”. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que empieza en la página 1. Después busque en esa categoría el nombre de su medicamento.

Listado Alfabético Si usted no está seguro/a bajo qué categoría buscar, debería buscar su medicamento en el Índice que empieza en la página 52. El Índice provee una lista en orden alfabético de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos están listados en el Índice. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, usted encontrará el número de la página en la que podrá encontrar información sobre la cobertura. Pase a la página listada en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Mercy Care Advantage cubre tanto a los medicamentos de marca como a los medicamentos genéricos. Un medicamento genérico es aprobado por la Administración de Alimentos y Medicamentos (FDA por sus siglas en inglés) por contar con el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los medicamentos de marca.

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¿Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden contar con requerimientos adicionales o límites en la cobertura. Dichos requerimientos y límites pueden incluir:

• Autorización Previa: Mercy Care Advantage requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted necesitará obtener la aprobación de Mercy Care Advantage antes de surtir sus prescripciones/recetas. Si usted no obtiene la aprobación, Mercy Care Advantage puede no cubrir el costo del medicamento.

• Límites de Cantidades: Para ciertos medicamentos, Mercy Care Advantage limita la cantidad del medicamento que Mercy Care Advantage cubrirá. Por ejemplo, Mercy Care Advantage provee 30 píldoras cada una para 30 días por cada prescripción de Simvastatin. Esto puede ser en adición al suministro estándar para un mes o tres meses.

• Terapia a Pasos: En algunos casos, Mercy Care Advantage requiere que usted pruebe primero ciertos medicamentos para tratar su condición médica antes de cubrir otro medicamento para dicha condición. Por ejemplo, si el Medicamento A y el Medicamento B tratan ambos su condición médica, Mercy Care Advantage puede no cubrir el Medicamento B a menos que usted pruebe primero el Medicamento A. Si el Medicamento A no le funciona, entonces Mercy Care Advantage cubrirá el Medicamento B.

Usted puede informarse si hay cualquier requerimiento o límite adicional para sus medicamentos consultando el formulario que empieza en la página 1. También puede obtener más información sobre las restricciones aplicadas a medicamentos cubiertos específicos visitando nuestro sitio web. Nosotros hemos publicado un documento en línea que explica nuestras restricciones sobre la autorización previa y la terapia a pasos. Usted también puede pedirnos que le enviemos a usted una copia. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en la portada y la contraportada.

Usted puede pedirle a Mercy Care Advantage que haga una excepción a estas restricciones o límites, o para una lista de otros medicamentos similares que puedan tratar su condición de salud. Vea la sección “¿Cómo solicito una excepción al formulario de Mercy Care Advantage?” en la página X para información sobre cómo solicitar una excepción.

¿Qué pasa si mi medicamento no está en el Formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero usted debería comunicarse con Servicios al Miembro y preguntar si su medicamento está cubierto. Si usted descubre que Mercy Care Advantage no cubre su medicamento, tiene dos opciones:

• Usted puede pedirle a Servicios al Miembro una lista de medicamentos similares que estén cubiertos por Mercy Care Advantage. Cuando usted reciba la lista, muéstresela a su doctor y pídale que le prescriba un medicamento similar que esté cubierto por Mercy Care Advantage.

• Usted puede solicitar que Mercy Care Advantage haga una excepción y cubra su medicamento. Vea abajo cómo solicitar una excepción.

¿Cómo solicito una excepción al Formulario de Mercy Care Advantage (HMO SNP)? Usted puede pedirle a Mercy Care Advantage que haga una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que usted puede pedir que hagamos.

• Usted nos puede pedir que cubramos un medicamento, aún si no está en nuestro formulario. Si es aprobado, dicho medicamento será cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que le proveamos dicho medicamento a un nivel de costo compartido más bajo.

• Usted puede pedir que no apliquemos las restricciones o los límites a la cobertura en su medicamento. Por ejemplo, para ciertos medicamentos, Mercy Care Advantage limita la cantidad del medicamento que nosotros cubriremos. Si su medicamento tiene un límite de cantidad, usted puede pedirnos que no apliquemos el límite y que cubramos una cantidad más grande.

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Generalmente, Mercy Care Advantage sólo aprobará su solicitud de excepción si los medicamentos alternos incluidos en el formulario del plan o las restricciones adicionales para su uso no serían tan efectivos tratando su condición y/o podrían ocasionarle efectos médicos adversos.

Usted se debería comunicar con nosotros para pedirnos una decisión inicial de cobertura para una excepción al formulario, o a la restricción de uso. Cuando usted solicite una excepción al formulario o a la restricción de uso, debería presentar una declaración de su médico o de la persona emitiendo la prescripción respaldando su solicitud. Generalmente, nosotros debemos tomar nuestra decisión dentro de 72 horas después de recibir la declaración de respaldo de la persona emitiendo la prescripción. Usted puede solicitar una excepción expedita (rápida) si usted o su doctor creen que su salud podría verse seriamente dañada por esperar 72 horas para una decisión. Si se le concede su solicitud de excepción expedita, nosotros debemos darle una decisión no más tarde de 24 horas después de recibir la declaración de respaldo de su doctor o de la otra persona emitiendo la prescripción.

¿Qué hago antes de que pueda hablar con mi doctor sobre cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o continuando de nuestro plan, usted puede estar tomando medicamentos que no estén en nuestro formulario. O usted puede estar tomando un medicamento que esté en nuestro formulario pero su capacidad para obtenerlo puede ser limitada. Por ejemplo, usted puede necesitar nuestra autorización previa antes de poder surtir su prescripción/receta. Usted debería hablar con su doctor para decidir si debería cambiar a un medicamento apropiado que nosotros cubramos, o solicitar una excepción al formulario para que nosotros cubramos el medicamento que usted toma. Mientras habla con su doctor para determinar el curso de acción apropiado para usted, en ciertos casos, nosotros podemos cubrir su medicamento durante los primeros 90 días en los que usted sea miembro de nuestro plan.

Para cada medicamento que no esté en nuestro formulario, o si su capacidad para obtener dicho medicamento es limitada, nosotros cubriremos un suministro temporal para 31 días. Si su prescripción ha sido emitida para menos días, nosotros permitiremos que la vuelva a surtir hasta que se le provea medicamento con un suministro máximo de 31 días. Después de su primer suministro para 31 días, nosotros ya no pagaremos por dichos medicamentos, aún si usted ha sido miembro del plan durante menos de 90 días.

Si usted es residente de una instalación de cuidado a largo plazo y necesita un medicamento que no esté en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días como miembro de nuestro plan, nosotros cubriremos un suministro de emergencia de dicho medicamento para 31 días, mientras usted trata de obtener una excepción al formulario.

Si a usted se le admite o se le da de alta de una instalación de cuidado a largo plazo, se le permitirá que se le surta una prescripción ante su admisión o dada de alta.

Para más información Para información más detallada sobre su cobertura de medicamentos de prescripción/receta de Mercy Care Advantage, por favor lea su Evidencia de Cobertura y otros materiales del plan.

Si tiene usted preguntas sobre Mercy Care Advantage, por favor contáctenos. Nuestra información de contacto, junto con la fecha en la que actualizamos por último el formulario, aparece en la portada y la contraportada.

Si tiene usted preguntas generales sobre la cobertura de medicamentos de prescripción/receta de Medicare, por favor llame a Medicare al 1-800-MEDICARE (1-800-633-4227) 24 horas al día, siete días de la semana. Los usuarios de TTY deberían llamar al 1-877-486-2048. Ó visite http://www.medicare.gov.

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http://www.medicare.gov

Formulario de Mercy Care Advantage El formulario que empieza en la página 1 provee información de cobertura sobre algunos de los medicamentos cubiertos por Mercy Care Advantage. Si usted tiene problemas para encontrar su medicamento en la lista, regrese al Índice que empieza en la página 52.

En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca están escritos en mayúsculas (ejem.: SYNTHROID) y los medicamentos genéricos están escritos en cursivas minúsculas (ejem.: levothyroxine).

La columna del “Nivel del Medicamento” de la tabla lista la categoría de cada medicamento. Sus cantidades de costo compartido dependen de la categoría en la que se encuentre el medicamento:

Categoría Cantidad del costo compartido

Medicamentos genéricos (incluyendo medicamentos de marca tratados

como genéricos) Copago de $0/$1.30/$3.60

El resto de los otros medicamentos Copago de $0/$3.90/$8.95

Sus copagos pueden ser más bajos, dependiendo del nivel de “Ayuda Extra” que usted esté recibiendo. La Evidencia de Cobertura para Personas que Reciben Ayuda Extra para el Pago de Sus Medicamentos de Prescripción (Cláusula LIS) lista la cantidad que usted pagará por sus medicamentos de prescripción. Usted también puede llamar a Servicios al Miembro para informarse sobre la cantidad de su costo compartido. Los números telefónicos de Servicios al Miembro están en la portada y la contraportada de este folleto.

La información en la columna de Requerimientos/Límites le indica si Mercy Care Advantage tiene cualquier requerimiento especial para la cobertura de su medicamento.

Abreviación en Inglés Requerimientos/Límites

B/D Cubierto/a bajo la Parte B o la Parte D de Medicare. La mayoría de los medicamentos están cubiertos bajo la Parte D, pero hay algunos medicamentos que pueden estar cubiertos tanto bajo la Parte B como la Parte D dependiendo del motivo por el que se esté usando el medicamento y cómo es administrado.

EA Each / cada uno/a. Los medicamentos listados con EA indican el número de píldoras despachadas.

LA Limited access / acceso limitado. Esta prescripción puede estar disponible sólo en ciertas farmacias. Para más información consulte el Directorio de Farmacias.

NM No está disponible en pedidos por correo.

PA Prior authorization / autorización previa. Usted o su proveedor necesitan obtener la aprobación de nuestro plan antes de que nosotros accedamos a cubrir el medicamento.

QL Quantity limits / límites de cantidad. Se muestra la cantidad por suministro o cada vez que se surta el medicamento.

ST Step therapy / terapia a pasos. Este medicamento de prescripción requiere que usted haya probado otro medicamento antes, el cual no le haya funcionado.

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86.03.334.1-AZ

Nondiscrimination Notice

Mercy Care d/b/a Mercy Care Advantage (HMO SNP) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Mercy Care d/b/a Mercy Care Advantage (HMO SNP) does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Mercy Care d/b/a Mercy Care Advantage (HMO SNP):

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o 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 interpreters o Information written in other languages

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe that Mercy Care d/b/a Mercy Care Advantage (HMO SNP) 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 our Civil Rights Coordinator at:

Address: Attn: Civil Rights Coordinator4500 East Cotton Center BoulevardPhoenix, AZ 85040

Telephone: 1-888-234-7358 (TTY 711) Email: [email protected]

You can file a grievance in person or by mail or email. If you need help filing a grievance, our Civil Rights Coordinator 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 Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).

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

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

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

mailto:[email protected]


86.03.335.2-AZ

Aviso de no discriminación

Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), cumple con las leyes federales de derechos civiles vigentes y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), no excluye a las personas ni las trata de manera diferente debido a cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo.

Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP):

• Brinda ayuda y servicios gratuitos a personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes: o Intérpretes de lenguaje de señas calificados o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles,

otros formatos) • Brinda servicios de idiomas gratuitos a las personas cuya lengua materna no sea inglés, como

los siguientes: o Intérpretes calificados o Información escrita en otros idiomas

Si necesita un intérprete calificado, información escrita en otros formatos, servicios de traducción u otros servicios, comuníquese con el número que aparece en su tarjeta de identificación.

Si considera que Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), no le proporcionó estos servicios o lo discriminó de alguna otra manera por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar una queja ante nuestro Coordinador de Derechos Civiles:

Dirección: Attn: Civil Rights Coordinator4500 East Cotton Center BoulevardPhoenix, AZ 85040

Teléfono: 1-888-234-7358 (TTY 711) Correo electrónico: [email protected]

Puede presentar una queja en persona o por correo, fax o correo electrónico. Si necesita ayuda para presentar una queja, nuestro Coordinador de Derechos Civiles está disponible para ayudarle.

También puede presentar un reclamo de derechos civiles ante el Departamento de Salud y Servicios Sociales de EE. UU., Oficina de Derechos Civiles, de manera electrónica a través del portal de reclamos de la Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo o teléfono a: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).

Los formularios de reclamo están disponibles en http://www.hhs.gov/ocr/office/file/index.html.

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


mailto:[email protected]

86.03.334.1-AZ

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Multi-language Interpreter Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-436-5288 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-436-5288 (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 1-877-436-5288 (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 1-877-436-5288 (TTY: 711).

Arabic:

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-436-5288 (TTY: 711).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-436-5288 (TTY: 711) 번으로 전화해 주십시오.

French: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-877-436-5288 (ATS: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-436-5288 (TTY: 711).

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. ЗвонитЗвоните 1-877-436-5288 (телетайп: 711).

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。1-877-436-5288 (TTY: 711) まで、お電話にてご連絡ください。

Persian:

Syriac: :1-877-436-5288 (TTY: 711) .

Serbo-Croatian (Serbian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-877-436-5288 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).

Thai:

PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020

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2020 Formulary (List of Covered Drugs)

Drug Name Drug Tier Requirements/Limits ANALGESICS – DRUGS TO TREAT PAIN AND INFLAMMATION

GOUT – DRUGS TO TREAT GOUT allopurinol tab GENERIC colchicine w/ probenecid GENERIC COLCRYS OTHER QL (120 tabs / 30 days), NM MITIGARE OTHER QL (60 caps / 30 days), NM probenecid GENERIC

NSAIDS – DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib CAPS 50mg GENERIC QL (240 caps / 30 days) celecoxib CAPS 100mg GENERIC QL (120 caps / 30 days) celecoxib CAPS 200mg GENERIC QL (60 caps / 30 days) celecoxib CAPS 400mg GENERIC QL (30 caps / 30 days) diclofenac potassium GENERIC QL (120 tabs / 30 days) diclofenac sodium TB24; TBEC GENERIC diflunisal TABS GENERIC etodolac GENERIC flurbiprofen TABS 100mg GENERIC ibu tab 600mg GENERIC ibu tab 800mg GENERIC ibuprofen SUSP GENERIC NM ibuprofen TABS 400mg, 600mg, 800mg GENERIC meloxicam TABS GENERIC nabumetone TABS GENERIC naproxen TABS 250mg, 375mg, 500mg GENERIC naproxen dr GENERIC naproxen sodium TABS 275mg, 550mg GENERIC piroxicam CAPS GENERIC sulindac TABS GENERIC

OPIOID ANALGESICS – DRUGS TO TREAT PAIN acetaminophen w/ codeine 300-15mg GENERIC QL (400 tabs / 30 days), NM acetaminophen w/ codeine 300-30mg GENERIC QL (360 tabs / 30 days), NM acetaminophen w/ codeine 300-60mg GENERIC QL (180 tabs / 30 days), NM acetaminophen w/ codeine soln GENERIC QL (2700 mL / 30 days), NM butorphanol tartrate SOLN 1mg/ml, 2mg/ml GENERIC NM nalbuphine hcl SOLN GENERIC NM tramadol hcl tab 50 mg GENERIC QL (240 tabs / 30 days), NM tramadol-acetaminophen GENERIC QL (240 tabs / 30 days), NM

OPIOID ANALGESICS, CII – DRUGS TO TREAT PAIN endocet 2.5-325mg GENERIC QL (360 tabs / 30 days), NM endocet 5-325mg GENERIC QL (360 tabs / 30 days), NM


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Drug Name Drug Tier Requirements/Limits endocet 7.5-325mg GENERIC QL (240 tabs / 30 days), NM endocet 10-325mg GENERIC QL (180 tabs / 30 days), NM fentanyl citrate LPOP GENERIC QL (120 lozenges / 30 days), NM, PA fentanyl patch 12 mcg/hr GENERIC QL (10 patches / 30 days), NM, PA fentanyl patch 25 mcg/hr GENERIC QL (10 patches / 30 days), NM, PA fentanyl patch 50 mcg/hr GENERIC QL (10 patches / 30 days), NM, PA fentanyl patch 75 mcg/hr GENERIC QL (10 patches / 30 days), NM, PA fentanyl patch 100 mcg/hr GENERIC QL (10 patches / 30 days), NM, PA hydroco/apap tab 5-325mg GENERIC QL (240 tabs / 30 days), NM hydroco/apap tab 7.5-325 GENERIC QL (180 tabs / 30 days), NM hydroco/apap tab 10-325mg GENERIC QL (180 tabs / 30 days), NM hydrocodone-acetaminophen 7.5-325 mg/15ml GENERIC QL (2700 mL / 30 days), NM hydrocodone-ibuprofen tab 7.5-200 mg GENERIC QL (150 tabs / 30 days), NM hydromorphone hcl LIQD GENERIC QL (600 mL / 30 days), NM hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

GENERIC B/D, NM

hydromorphone hcl TABS GENERIC QL (180 tabs / 30 days), NM HYSINGLA ER OTHER QL (30 tabs / 30 days), NM, PA lorcet hd tab 10-325mg GENERIC QL (180 tabs / 30 days), NM lorcet plus tab 7.5-325 GENERIC QL (180 tabs / 30 days), NM lorcet tab 5-325mg GENERIC QL (240 tabs / 30 days), NM methadone hcl SOLN 5mg/5ml, 10mg/5ml GENERIC QL (450 mL / 30 days), NM, PA methadone hcl 5mg GENERIC QL (90 tabs / 30 days), NM, PA methadone hcl 10mg GENERIC QL (90 tabs / 30 days), NM, PA methadone hcl intensol GENERIC QL (90 mL / 30 days), NM, PA morphine ext-rel tab GENERIC QL (90 tabs / 30 days), NM, PA morphine sul inj 1mg/ml GENERIC B/D, NM MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

OTHER B/D, NM

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml GENERIC B/D, NM morphine sulfate TABS GENERIC QL (180 tabs / 30 days), NM morphine sulfate oral soln 10mg/5ml GENERIC QL (900 mL / 30 days), NM morphine sulfate oral soln 20mg/5ml GENERIC QL (900 mL / 30 days), NM morphine sulfate oral soln 100mg/5ml GENERIC QL (180 mL / 30 days), NM NUCYNTA ER OTHER QL (60 tabs / 30 days), NM, PA oxycodone hcl CAPS GENERIC QL (180 caps / 30 days), NM oxycodone hcl CONC GENERIC QL (180 mL / 30 days), NM oxycodone hcl SOLN GENERIC QL (900 mL / 30 days), NM oxycodone hcl TABS GENERIC QL (180 tabs / 30 days), NM oxycodone w/ acetaminophen 2.5-325mg GENERIC QL (360 tabs / 30 days), NM oxycodone w/ acetaminophen 5-325mg GENERIC QL (360 tabs / 30 days), NM oxycodone w/ acetaminophen 7.5-325mg GENERIC QL (240 tabs / 30 days), NM oxycodone w/ acetaminophen 10-325mg GENERIC QL (180 tabs / 30 days), NM


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Drug Name Drug Tier Requirements/Limits ANESTHETICS – DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine hcl (local anesth.) GENERIC B/D, NM lidocaine inj 0.5% GENERIC B/D, NM lidocaine inj 1% GENERIC B/D, NM lidocaine inj 1.5% preservative free (pf) GENERIC B/D, NM ANTI-INFECTIVES – DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS – MISCELLANEOUS amikacin sulfate SOLN GENERIC NMgentamicin in saline GENERIC NMgentamicin sulfate SOLN GENERIC NMneomycin sulfate TABS GENERIC NMparomomycin sulfate CAPS GENERIC NMstreptomycin sulfate SOLR GENERIC NMsulfadiazine TABS GENERIC NMtobramycin NEBU GENERIC NM, PA tobramycin inj 1.2 gm/30ml GENERIC NMtobramycin inj 1.2gm GENERIC NMtobramycin inj 10mg/ml GENERIC NMtobramycin inj 80mg/2ml GENERIC NMtobramycin sulfate SOLN GENERIC NMANTI-INFECTIVES – MISCELLANEOUS albendazole TABS GENERIC NMALINIA OTHER NMatovaquone SUSP GENERIC NMaztreonam GENERIC NMCAYSTON OTHER NM, LA, PA clindamycin cap 75mg GENERIC NMclindamycin cap 300 mg GENERIC NMclindamycin hcl cap 150 mg GENERIC NMclindamycin phosphate in d5w GENERIC NMCLINDAMYCIN PHOSPHATE IN NACL OTHER NMclindamycin phosphate inj GENERIC NMclindamycin soln 75mg/5ml GENERIC NMcolistimethate sodium SOLR GENERIC NMdapsone TABS GENERICdaptomycin GENERIC NMemverm GENERIC QL (12 tabs / 365 days), NM ertapenem sodium GENERIC NMimipenem-cilastatin GENERIC NMivermectin TABS GENERIC NMlinezolid in sodium chloride GENERIC NMlinezolid inj GENERIC NMlinezolid susp GENERIC NMlinezolid tab 600mg GENERIC NM


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Drug Name Drug Tier Requirements/Limits meropenem GENERIC NMmethenamine hippurate GENERIC NMmetronidazole TABS GENERIC NMmetronidazole in nacl GENERIC NMnitrofurantoin macrocrystal 50mg, 100mg GENERIC NMnitrofurantoin monohyd macro GENERIC NMpentamidine isethionate inh GENERIC B/D, NM pentamidine isethionate inj GENERIC NMpraziquantel TABS GENERIC NMSIVEXTRO OTHER NMsulfamethoxazole-trimethop ds GENERIC NMsulfamethoxazole-trimethoprim inj GENERIC NMsulfamethoxazole-trimethoprim susp GENERIC NMsulfamethoxazole-trimethoprim tab 400-80mg GENERIC NMSYNERCID OTHER NMtigecycline GENERIC NMtrimethoprim TABS GENERIC NMvancomycin hcl CAPS 125mg GENERIC QL (120 caps / 30 days), NM vancomycin hcl CAPS 250mg GENERIC QL (240 caps / 30 days), NM vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg GENERIC NMVANCOMYCIN IN NACL OTHER NMANTIFUNGALS – DRUGS TO TREAT FUNGAL INFECTIONS ABELCET OTHER B/D, NM AMBISOME OTHER B/D, NM amphotericin b SOLR GENERIC B/D, NM caspofungin acetate GENERIC NMfluconazole SUSR; TABS GENERIC NMfluconazole inj nacl 200 GENERIC NMfluconazole inj nacl 400 GENERIC NMflucytosine CAPS GENERIC NMgriseofulvin microsize GENERIC NMgriseofulvin ultramicrosize GENERIC NMitraconazole CAPS GENERIC NM, PA ketoconazole TABS GENERIC NM, PA micafungin sodium GENERIC NMMYCAMINE OTHER NMNOXAFIL SUSP OTHER QL (630 mL / 30 days) nystatin TABS GENERIC NMposaconazole GENERIC QL (93 tabs / 30 days) terbinafine hcl TABS GENERIC QL (90 tabs / year), NM voriconazole SOLR; SUSR GENERIC NM, PA voriconazole TABS GENERIC NMANTIMALARIALS – DRUGS TO TREAT MALARIA atovaquone-proguanil hcl GENERIC NMchloroquine phosphate TABS GENERIC


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Drug Name Drug Tier Requirements/Limits COARTEM OTHER NMmefloquine hcl GENERIC primaquine phosphate 26.3mg GENERIC NMPRIMAQUINE PHOSPHATE 26.3mg OTHER NMquinine sulfate CAPS GENERIC NM, PA ANTIRETROVIRAL AGENTS – DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate GENERIC NMAPTIVUS OTHER NMatazanavir sulfate GENERIC NMCRIXIVAN OTHER NMdidanosine GENERIC NMEDURANT OTHER NMefavirenz GENERIC NMEMTRIVA OTHER NMfosamprenavir tab 700 mg GENERIC NMFUZEON OTHER NMINTELENCE OTHER NMINVIRASE OTHER NMISENTRESS OTHER NMISENTRESS HD OTHER NMlamivudine GENERIC NMLEXIVA SUSP OTHER NMnevirapine susp 50 mg/5ml GENERIC NMnevirapine tab 100mg er GENERIC NMnevirapine tab 200mg GENERIC NMnevirapine tab 400mg er GENERIC NMNORVIR PACK OTHER NMNORVIR SOLN OTHER NMPIFELTRO OTHER NMPREZISTA SUSP OTHER QL (400 mL / 30 days), NM PREZISTA TABS 75mg OTHER QL (480 tabs / 30 days), NM PREZISTA TABS 150mg OTHER QL (240 tabs / 30 days), NM PREZISTA TABS 600mg OTHER QL (60 tabs / 30 days), NM PREZISTA TABS 800mg OTHER QL (30 tabs / 30 days), NM REYATAZ PACK OTHER NMritonavir GENERIC NMSELZENTRY OTHER NMstavudine GENERIC NMtenofovir disoproxil fumarate GENERIC NMTIVICAY OTHER NMTROGARZO OTHER NM, LA TYBOST OTHER NMVIRACEPT OTHER NMVIREAD POWD OTHER NMVIREAD TABS 150mg, 200mg, 250mg OTHER NM


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Drug Name Drug Tier Requirements/Limits zidovudine cap 100mg GENERIC NM zidovudine syp 50mg/5ml GENERIC NM zidovudine tab 300mg GENERIC NM ANTIRETROVIRAL COMBINATION AGENTS – DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine GENERIC NM abacavir sulfate-lamivudine-zidovudine GENERIC NM ATRIPLA OTHER NM BIKTARVY OTHER NM CIMDUO OTHER NM COMPLERA OTHER NM DELSTRIGO OTHER NM DESCOVY OTHER NM DOVATO OTHER NM EVOTAZ OTHER NM GENVOYA OTHER NM JULUCA OTHER NM KALETRA TAB 100-25MG OTHER NM KALETRA TAB 200-50MG OTHER NM lamivudine-zidovudine GENERIC NM lopinavir-ritonavir GENERIC NM ODEFSEY OTHER NM PREZCOBIX OTHER NM STRIBILD OTHER NM SYMFI OTHER NM SYMFI LO OTHER NM SYMTUZA OTHER NM TEMIXYS OTHER NM TRIUMEQ OTHER NM TRUVADA TAB 100-150 OTHER QL (30 tabs / 30 days), NM TRUVADA TAB 133-200 OTHER QL (30 tabs / 30 days), NM TRUVADA TAB 167-250 OTHER QL (30 tabs / 30 days), NM TRUVADA TAB 200-300 OTHER QL (30 tabs / 30 days), NM ANTITUBERCULAR AGENTS – DRUGS TO TREAT TUBERCULOSIS cycloserine CAPS GENERIC NM ethambutol hcl TABS GENERIC NM isoniazid TABS GENERIC isoniazid syp 50mg/5ml GENERIC paser d/r GENERIC NM PRIFTIN OTHER NM pyrazinamide TABS GENERIC NM rifabutin GENERIC NM rifampin CAPS; SOLR GENERIC NM RIFATER OTHER NM SIRTURO 100mg OTHER NM, LA, PA TRECATOR OTHER NM


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Drug Name Drug Tier Requirements/Limits ANTIVIRALS – DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS; SUSP; TABS GENERIC NM acyclovir sodium GENERIC B/D, NM adefovir dipivoxil GENERIC NM BARACLUDE SOLN OTHER NM entecavir GENERIC NM EPCLUSA OTHER NM, PA EPIVIR HBV SOLN OTHER NM famciclovir TABS GENERIC NM ganciclovir sodium GENERIC B/D, NM HARVONI OTHER NM, PA lamivudine (hbv) GENERIC NM MAVYRET OTHER NM, PA oseltamivir phosphate CAPS 30mg GENERIC QL (168 caps / year), NM oseltamivir phosphate CAPS 45mg, 75mg GENERIC QL (84 caps / year), NM oseltamivir phosphate SUSR GENERIC QL (1080 mL / year), NM PEGASYS OTHER NM, PA PEGASYS PROCLICK OTHER NM, PA RELENZA DISKHALER OTHER QL (6 inhalers / year), NM ribavirin cap 200mg GENERIC NM ribavirin tab 200mg GENERIC NM rimantadine hydrochloride GENERIC NM valacyclovir hcl TABS GENERIC NM valganciclovir hcl GENERIC VEMLIDY OTHER NM VOSEVI OTHER NM, PA CEPHALOSPORINS – DRUGS TO TREAT INFECTIONS cefaclor GENERIC NM cefaclor er tab 500mg GENERIC NM cefadroxil GENERIC NM CEFAZOLIN IN DEXTROSE 2GM/100ML-4% OTHER NM cefazolin inj GENERIC NM cefazolin sodium SOLR 1gm GENERIC NM cefazolin sodium 1 gm/50ml GENERIC NM cefdinir GENERIC NM cefepime for inj GENERIC NM cefixime SUSR GENERIC NM cefoxitin for inj GENERIC NM cefpodoxime proxetil GENERIC NM cefprozil GENERIC NM ceftazidime SOLR GENERIC NM CEFTAZIDIME/DEXTROSE OTHER NM ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg GENERIC NM cefuroxime axetil GENERIC NM cefuroxime sodium GENERIC NM


8

Drug Name Drug Tier Requirements/Limits cephalexin CAPS 250mg, 500mg GENERIC NM cephalexin SUSR GENERIC NM tazicef SOLR GENERIC NM TEFLARO OTHER NM ERYTHROMYCINS/MACROLIDES – DRUGS TO TREAT INFECTIONS azithromycin PACK; SOLR; SUSR; TABS GENERIC NM clarithromycin TABS GENERIC NM clarithromycin er GENERIC NM clarithromycin for susp GENERIC NM DIFICID OTHER NM e.e.s. 400 GENERIC NM ery-tab GENERIC NM erythrocin lactobionate GENERIC NM erythrocin stearate GENERIC NM erythromycin base GENERIC NM erythromycin cap 250mg ec GENERIC NM erythromycin ethylsuccinate TABS GENERIC NM erythromycin tab ec GENERIC NM FLUOROQUINOLONES – DRUGS TO TREAT INFECTIONS CIPRO SUSR 500mg/5ml OTHER NM ciprofloxacin hcl tab GENERIC NM ciprofloxacin in d5w GENERIC NM levofloxacin TABS GENERIC NM levofloxacin in d5w GENERIC NM levofloxacin inj 25mg/ml GENERIC NM levofloxacin oral soln 25 mg/ml GENERIC NM moxifloxacin hcl TABS GENERIC NM PENICILLINS – DRUGS TO TREAT INFECTIONS amoxicillin GENERIC NM amoxicillin & pot clavulanate 200-28.5 chw tabs GENERIC NM amoxicillin & pot clavulanate 200/5ml susr GENERIC NM amoxicillin & pot clavulanate 250-125 tabs GENERIC NM amoxicillin & pot clavulanate 250/5ml susr GENERIC NM amoxicillin & pot clavulanate 400-57 chw tabs GENERIC NM amoxicillin & pot clavulanate 400/5ml susr GENERIC NM amoxicillin & pot clavulanate 500-125 tabs GENERIC NM amoxicillin & pot clavulanate 600/5ml susr GENERIC NM amoxicillin & pot clavulanate 875-125 tabs GENERIC NM amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs GENERIC NM ampicillin & sulbactam sodium GENERIC NM ampicillin cap 500mg GENERIC NM ampicillin inj GENERIC NM ampicillin sodium GENERIC NM BICILLIN L-A OTHER NM dicloxacillin sodium GENERIC NM


9

Drug Name Drug Tier Requirements/Limits nafcillin sodium for inj GENERIC NM nafcillin sodium for inj 10gm GENERIC NM oxacillin sodium SOLR GENERIC NM PENICILLIN G POT IN DEXTROSE 2MU OTHER NM PENICILLIN G POT IN DEXTROSE 3MU OTHER NM penicillin g procaine GENERIC NM penicillin g sodium GENERIC NM penicillin v potassium GENERIC NM penicilln gk inj 5mu GENERIC NM penicilln gk inj 20mu GENERIC NM pfizerpen-g inj 5mu GENERIC NM pfizerpen-g inj 20mu GENERIC NM piper/tazoba inj 2-0.25gm GENERIC NM piper/tazoba inj 3-0.375gm GENERIC NM piper/tazoba inj 4-0.5gm GENERIC NM piper/tazoba inj 12-1.5gm GENERIC NM piper/tazoba inj 36-4.5gm GENERIC NM TETRACYCLINES – DRUGS TO TREAT INFECTIONS doxy 100 GENERIC NM doxycycline (monohydrate) CAPS 50mg, 100mg GENERIC NM doxycycline (monohydrate) TABS 50mg, 75mg, 100mg GENERIC NM doxycycline hyclate CAPS; SOLR GENERIC NM doxycycline hyclate 20 mg GENERIC NM doxycycline hyclate 100 mg GENERIC NM minocycline hcl CAPS GENERIC NM mondoxyne nl cap 100mg GENERIC NM tetracycline hcl CAPS GENERIC NM ANTINEOPLASTIC AGENTS – DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA OTHER B/D, NM cyclophosphamide CAPS; SOLR GENERIC B/D, NM EMCYT OTHER NM GLEOSTINE OTHER NM LEUKERAN OTHER NM ANTHRACYCLINES adriamycin SOLN GENERIC B/D, NM doxorubicin hcl GENERIC B/D, NM doxorubicin hcl liposomal GENERIC B/D, NM epirubicin hcl GENERIC B/D, NM ANTIMETABOLITES adrucil inj GENERIC B/D, NM ALIMTA OTHER B/D, NM azacitidine GENERIC B/D, NM cytarabine 20mg/ml GENERIC B/D, NM fluorouracil SOLN GENERIC B/D, NM


10

Drug Name Drug Tier Requirements/Limits gemcitabine inj soln GENERIC B/D, NM gemcitabine inj solr GENERIC B/D, NM mercaptopurine TABS GENERIC NM methotrexate sodium inj soln GENERIC B/D, NM methotrexate sodium inj solr GENERIC B/D, NM PURIXAN OTHER NM TABLOID OTHER NM ANTIMITOTIC, TAXOIDS ABRAXANE OTHER B/D, NM docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml, 200mg/10ml

GENERIC B/D, NM

DOCETAXEL CONC 80mg/4ml, 160mg/8ml OTHER B/D, NM docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml GENERIC B/D, NM DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml OTHER B/D, NM paclitaxel GENERIC B/D, NM TAXOTERE OTHER B/D, NM ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate GENERIC B/D, NM vinorelbine tartrate GENERIC B/D, NM BIOLOGIC RESPONSE MODIFIERS AVASTIN OTHER NM, LA, PA BORTEZOMIB OTHER NM, PA DAURISMO OTHER NM, LA, PA ERIVEDGE OTHER NM, LA, PA FARYDAK OTHER NM, LA, PA HERCEPTIN OTHER NM, PA HERCEPTIN HYLECTA OTHER NM, PA HERZUMA OTHER NM, PA IBRANCE CAPS OTHER QL (21 caps / 28 days), NM, LA, PA IBRANCE TABS OTHER QL (21 tabs / 28 days), NM, LA, PA IDHIFA OTHER QL (30 tabs / 30 days), NM, LA, PA KADCYLA OTHER B/D, NM KANJINTI OTHER NM, PA KEYTRUDA OTHER NM, PA KISQALI OTHER NM, PA KISQALI FEMARA 200 DOSE OTHER NM, PA KISQALI FEMARA 400 DOSE OTHER NM, PA KISQALI FEMARA 600 DOSE OTHER NM, PA LYNPARZA OTHER NM, LA, PA MVASI OTHER NM, LA, PA NINLARO OTHER NM, PA ODOMZO OTHER NM, LA, PA OGIVRI OTHER NM, PA ONTRUZANT OTHER NM, PA RITUXAN OTHER NM, LA, PA


11

Drug Name Drug Tier Requirements/Limits RITUXAN HYCELA OTHER NM, LA, PA RUBRACA OTHER NM, LA, PA RUXIENCE OTHER NM, PA TALZENNA OTHER NM, LA, PA TECENTRIQ OTHER NM, LA, PA TIBSOVO OTHER NM, LA, PA TRAZIMERA OTHER NM, PA TRUXIMA OTHER NM, PA VELCADE OTHER NM, PA VENCLEXTA OTHER NM, LA, PA VENCLEXTA STARTING PACK OTHER NM, LA, PA VERZENIO OTHER NM, LA, PA ZEJULA OTHER NM, LA, PA ZIRABEV OTHER NM, PA ZOLINZA OTHER NM, PA HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate GENERIC NM, PA anastrozole TABS GENERIC bicalutamide GENERIC NM DEPO-PROVERA INJ 400/ML OTHER B/D, NM ERLEADA OTHER NM, LA, PA exemestane GENERIC flutamide GENERIC NM fulvestrant GENERIC B/D, NM letrozole TABS GENERIC leuprolide inj 1mg/0.2 GENERIC NM, PA LUPRON DEPOT (1-MONTH) 3.75mg OTHER NM, PA LUPRON DEPOT INJ 11.25MG (3-MONTH) OTHER NM, PA LYSODREN OTHER NM megestrol ac sus 40mg/ml GENERIC NM megestrol ac tab 20mg GENERIC NM megestrol ac tab 40mg GENERIC NM megestrol sus 625mg/5ml GENERIC PA nilutamide GENERIC NM NUBEQA OTHER NM, LA, PA SOLTAMOX OTHER tamoxifen citrate TABS GENERIC toremifene citrate GENERIC TRELSTAR DEP INJ 3.75MG OTHER NM, PA TRELSTAR LA INJ 11.25MG OTHER NM, PA XTANDI OTHER NM, LA, PA ZYTIGA 500mg OTHER NM, LA, PA IMMUNOMODULATORS POMALYST 1mg, 2mg OTHER QL (21 caps / 21 days), NM, LA, PA POMALYST 3mg, 4mg OTHER QL (21 caps / 28 days), NM, LA, PA

PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access

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Drug Name Drug Tier Requirements/Limits REVLIMID OTHER QL (28 caps / 28 days), NM, LA, PA THALOMID 50mg, 100mg OTHER QL (28 caps / 28 days), NM, PA THALOMID 150mg, 200mg OTHER QL (56 caps / 28 days), NM, PA KINASE INHIBITORS AFINITOR 10mg OTHER QL (30 tabs / 30 days), NM, PA AFINITOR DISPERZ 2mg OTHER QL (150 tabs / 30 days), NM, PA AFINITOR DISPERZ 3mg OTHER QL (90 tabs / 30 days), NM, PA AFINITOR DISPERZ 5mg OTHER QL (60 tabs / 30 days), NM, PA ALECENSA OTHER NM, LA, PA ALUNBRIG OTHER NM, LA, PA AYVAKIT OTHER QL (30 tabs / 30 days), NM, LA, PA BALVERSA OTHER NM, LA, PA BOSULIF OTHER NM, PA BRAFTOVI OTHER NM, LA, PA BRUKINSA OTHER NM, LA, PA CABOMETYX OTHER QL (30 tabs / 30 days), NM, LA, PA CALQUENCE OTHER NM, LA, PA CAPRELSA OTHER NM, LA, PA COMETRIQ OTHER NM, LA, PA COPIKTRA OTHER NM, LA, PA COTELLIC OTHER NM, LA, PA erlotinib hcl 25mg GENERIC QL (90 tabs / 30 days), NM, PA erlotinib hcl 100mg, 150mg GENERIC QL (30 tabs / 30 days), NM, PA everolimus GENERIC QL (30 tabs / 30 days), NM, PA GILOTRIF TAB 20MG OTHER NM, LA, PA GILOTRIF TAB 30MG OTHER NM, LA, PA GILOTRIF TAB 40MG OTHER NM, LA, PA ICLUSIG OTHER NM, LA, PA imatinib mesylate 100mg GENERIC QL (90 tabs / 30 days), NM, PA imatinib mesylate 400mg GENERIC QL (60 tabs / 30 days), NM, PA IMBRUVICA OTHER NM, LA, PA INLYTA 1mg OTHER QL (180 tabs / 30 days), NM, LA, PA INLYTA 5mg OTHER QL (120 tabs / 30 days), NM, LA, PA INREBIC OTHER NM, LA, PA IRESSA OTHER NM, LA, PA JAKAFI OTHER QL (60 tabs / 30 days), NM, LA, PA LENVIMA 4 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 8 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 10 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 12MG DAILY DOSE OTHER NM, LA, PA LENVIMA 14 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 18 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 20 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 24 MG DAILY DOSE OTHER NM, LA, PA LORBRENA OTHER NM, LA, PA


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Drug Name Drug Tier Requirements/Limits MEKINIST OTHER NM, LA, PA MEKTOVI OTHER NM, LA, PA NERLYNX OTHER NM, LA, PA NEXAVAR OTHER NM, LA, PA PEMAZYRE OTHER NM, LA, PA PIQRAY 200MG DAILY DOSE OTHER NM, PA PIQRAY 250MG DAILY DOSE OTHER NM, PA PIQRAY 300MG DAILY DOSE OTHER NM, PA ROZLYTREK OTHER NM, LA, PA RYDAPT OTHER NM, PA SPRYCEL OTHER NM, PA STIVARGA OTHER NM, LA, PA SUTENT OTHER QL (30 caps / 30 days), NM, PA TAFINLAR OTHER NM, LA, PA TAGRISSO OTHER QL (30 tabs / 30 days), NM, LA, PA TASIGNA OTHER NM, PA TUKYSA OTHER NM, LA, PA TURALIO OTHER NM, LA, PA TYKERB OTHER NM, LA, PA VITRAKVI OTHER NM, LA, PA VIZIMPRO OTHER NM, LA, PA VOTRIENT OTHER NM, LA, PA XALKORI OTHER NM, LA, PA XOSPATA OTHER NM, LA, PA ZELBORAF OTHER NM, LA, PA ZYDELIG OTHER NM, LA, PA ZYKADIA OTHER NM, LA, PA MISCELLANEOUS bexarotene GENERIC NM, PA hydroxyurea CAPS GENERIC NM LONSURF OTHER NM, PA MATULANE OTHER NM, LA SYLATRON OTHER NM, PA SYNRIBO OTHER NM, PA TAZVERIK OTHER NM, LA, PA tretinoin (chemotherapy) GENERIC NM XPOVIO 60 MG ONCE WEEKLY OTHER NM, LA, PA XPOVIO 80 MG ONCE WEEKLY OTHER NM, LA, PA XPOVIO 80 MG TWICE WEEKLY OTHER NM, LA, PA XPOVIO 100 MG ONCE WEEKLY OTHER NM, LA, PA PLATINUM-BASED AGENTS carboplatin GENERIC B/D, NM cisplatin SOLN GENERIC B/D, NM oxaliplatin inj 50mg GENERIC B/D, NM oxaliplatin inj 50mg/10ml GENERIC B/D, NM


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Drug Name Drug Tier Requirements/Limits oxaliplatin inj 100mg GENERIC B/D, NM oxaliplatin inj 100mg/20ml GENERIC B/D, NM PROTECTIVE AGENTS leucovorin calcium SOLN 500mg/50ml GENERIC B/D, NM leucovorin calcium SOLR GENERIC B/D, NM leucovorin calcium TABS GENERIC NM MESNEX TABS OTHER NM TOPOISOMERASE INHIBITORS etoposide SOLN GENERIC B/D, NM irinotecan hcl GENERIC B/D, NM toposar GENERIC B/D, NM CARDIOVASCULAR – DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-benazepril hcl cap 2.5-10 mg GENERIC amlodipine besylate-benazepril hcl cap 5-10 mg GENERIC amlodipine besylate-benazepril hcl cap 5-20 mg GENERIC amlodipine besylate-benazepril hcl cap 5-40 mg GENERIC amlodipine besylate-benazepril hcl cap 10-20 mg GENERIC amlodipine besylate-benazepril hcl cap 10-40 mg GENERIC benazepril & hydrochlorothiazide GENERIC captopril & hydrochlorothiazide GENERIC enalapril maleate & hydrochlorothiazide GENERIC fosinopril sodium & hydrochlorothiazide GENERIC lisinopril & hydrochlorothiazide GENERIC quinapril-hydrochlorothiazide GENERIC ACE INHIBITORS – DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS GENERIC captopril TABS GENERIC enalapril maleate TABS GENERIC fosinopril sodium GENERIC lisinopril TABS GENERIC moexipril hcl GENERIC perindopril erbumine GENERIC quinapril hcl GENERIC ramipril GENERIC trandolapril GENERIC ALDOSTERONE RECEPTOR ANTAGONISTS – DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone GENERIC spironolactone TABS GENERIC ALPHA BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate TABS GENERIC prazosin hcl GENERIC terazosin hcl GENERIC


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Drug Name Drug Tier Requirements/Limits

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-olmesartan medoxomil GENERIC amlodipine besylate-valsartan tab GENERIC amlodipine-valsartan-hydrochlorothiazide tab GENERIC candesartan cilexetil-hydrochlorothiazide GENERIC ENTRESTO OTHER irbesartan-hydrochlorothiazide GENERIC losartan-hydrochlorothiazide GENERIC olmesartan medoxomil-amlodipine-hydrochlorothiazide GENERIC olmesartan medoxomil-hydrochlorothiazide GENERIC telmisartan-amlodipine GENERIC telmisartan-hydrochlorothiazide GENERIC valsartan-hydrochlorothiazide GENERIC ANGIOTENSIN II RECEPTOR ANTAGONISTS – DRUGS TO TREAT HIGH BLOOD PRESSURE candesartan cilexetil GENERIC irbesartan GENERIC losartan potassium TABS GENERIC olmesartan medoxomil TABS GENERIC telmisartan GENERIC valsartan GENERIC ANTIARRHYTHMICS – DRUGS TO CONTROL HEART RHYTHM amiodarone hcl soln GENERIC NM amiodarone tab 100mg GENERIC amiodarone tab 200mg GENERIC amiodarone tab 400mg GENERIC disopyramide phosphate GENERIC dofetilide GENERIC NM flecainide acetate GENERIC MULTAQ OTHER NORPACE CR OTHER pacerone GENERIC propafenone hcl GENERIC propafenone hcl 12hr GENERIC quinidine sulfate GENERIC sorine GENERIC sotalol hcl GENERIC sotalol hcl (afib/afl) GENERIC ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS – DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium TABS GENERIC lovastatin GENERIC pravastatin sodium GENERIC rosuvastatin calcium GENERIC QL (30 tabs / 30 days) simvastatin TABS 5mg, 10mg, 20mg, 40mg GENERIC simvastatin TABS 80mg GENERIC QL (30 tabs / 30 days)


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits ANTILIPEMICS, MISCELLANEOUS – DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine GENERIC cholestyramine light pack GENERIC cholestyramine light powd GENERIC colesevelam hcl GENERIC colestipol hcl gran GENERIC colestipol hcl pack GENERIC colestipol hcl tabs GENERIC ezetimibe GENERIC ezetimibe-simvastatin GENERIC fenofibrate TABS 48mg, 54mg, 145mg, 160mg GENERIC fenofibrate micronized 67mg, 134mg, 200mg GENERIC gemfibrozil TABS GENERIC JUXTAPID OTHER NM, LA, PA niacin (antihyperlipidemic) GENERIC NM niacin er (antihyperlipidemic) 500mg GENERIC QL (60 tabs / 30 days) niacin er (antihyperlipidemic) 750mg, 1000mg GENERIC niacor GENERIC NM PRALUENT OTHER NM, PA prevalite GENERIC VASCEPA OTHER BETA-BLOCKER/DIURETIC COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone GENERIC bisoprolol & hydrochlorothiazide GENERIC metoprolol & hydrochlorothiazide GENERIC propranolol & hydrochlorothiazide GENERIC BETA-BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS GENERIC atenolol TABS GENERIC betaxolol hcl GENERIC bisoprolol fumarate GENERIC BYSTOLIC 2.5mg, 5mg, 10mg OTHER QL (30 tabs / 30 days) BYSTOLIC 20mg OTHER QL (60 tabs / 30 days) carvedilol GENERIC labetalol hcl TABS GENERIC metoprolol succinate GENERIC metoprolol tartrate SOCT GENERIC NM metoprolol tartrate SOLN GENERIC NM metoprolol tartrate TABS 25mg, 50mg, 100mg GENERIC nadolol TABS GENERIC pindolol GENERIC propranolol cap er GENERIC propranolol hcl TABS GENERIC propranolol oral sol GENERIC timolol maleate TABS GENERIC

16


17

Drug Name Drug Tier Requirements/Limits

CALCIUM CHANNEL BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate TABS GENERIC cartia xt GENERIC dilt-xr cap GENERIC diltiazem cap 240mg cd GENERIC diltiazem cap 360mg cd GENERIC diltiazem cap er/12hr GENERIC diltiazem hcl TABS GENERIC diltiazem hcl coated beads CP24 GENERIC diltiazem hcl coated beads cap sr 24hr GENERIC diltiazem hcl extended release beads cap sr GENERIC diltiazem inj GENERIC NM felodipine GENERIC isradipine GENERIC nicardipine hcl CAPS GENERIC nifedipine TB24 GENERIC nifedipine er GENERIC nimodipine CAPS GENERIC NM NYMALIZE OTHER NM taztia xt GENERIC tiadylt er GENERIC verapamil cap er GENERIC verapamil hcl SOLN GENERIC NM verapamil hcl TABS; TBCR GENERIC verapamil tab er GENERIC DIGITALIS GLYCOSIDES – DRUGS TO TREAT HEART CONDITIONS digitek .25mg GENERIC PA; PA if 70 years and older digitek .125mg GENERIC QL (30 tabs / 30 days) digox 125mcg GENERIC QL (30 tabs / 30 days) digox 250mcg GENERIC PA; PA if 70 years and older digoxin TABS 125mcg GENERIC QL (30 tabs / 30 days) digoxin TABS 250mcg GENERIC PA; PA if 70 years and older digoxin inj GENERIC NM digoxin sol 50mcg/ml GENERIC PA; PA if 70 years and older DIURETICS – DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS GENERIC amiloride & hydrochlorothiazide GENERIC amiloride hcl TABS GENERIC bumetanide inj 0.25/ml GENERIC NM bumetanide tab GENERIC chlorothiazide TABS GENERIC chlorthalidone GENERIC furosemide SOLN; TABS GENERIC furosemide inj GENERIC NM hydrochlorothiazide CAPS; TABS GENERIC


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Drug Name Drug Tier Requirements/Limits indapamide GENERIC methazolamide TABS GENERIC metolazone GENERIC spironolactone & hydrochlorothiazide GENERIC torsemide tabs GENERIC triamterene & hydrochlorothiazide cap 37.5-25 mg GENERIC triamterene & hydrochlorothiazide tabs GENERIC MISCELLANEOUS aliskiren fumarate GENERIC clonidine hcl TABS GENERIC clonidine hcl ptwk GENERIC CORLANOR OTHER DEMSER OTHER NM, PA hydralazine hcl SOLN GENERIC NM hydralazine hcl TABS GENERIC midodrine hcl GENERIC NM minoxidil TABS GENERIC NORTHERA 100mg OTHER QL (90 caps / 30 days), NM, LA, PA NORTHERA 200mg, 300mg OTHER QL (180 caps / 30 days), NM, LA, PA ranolazine GENERIC NITRATES – DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab GENERIC isosorbide dinitrate 5mg, 10mg, 20mg, 30mg GENERIC isosorbide mononitrate er GENERIC minitran GENERIC nitro-bid GENERIC NITRO-DUR DIS 0.3MG/HR OTHER NITRO-DUR DIS 0.8MG/HR OTHER nitroglycerin SOLN .4mg/spray GENERIC nitroglycerin SUBL GENERIC nitroglycerin td patch GENERIC PULMONARY ARTERIAL HYPERTENSION – DRUGS TO TREAT PULMONARY HYPERTENSION ADEMPAS OTHER QL (90 tabs / 30 days), NM, LA, PA ambrisentan GENERIC QL (30 tabs / 30 days), NM, LA, PA bosentan 62.5mg GENERIC QL (120 tabs / 30 days), NM, LA, PA bosentan 125mg GENERIC QL (60 tabs / 30 days), NM, LA, PA OPSUMIT OTHER QL (30 tabs / 30 days), NM, LA, PA sildenafil citrate tab 20 mg (pulmonary hypertension) GENERIC QL (90 tabs / 30 days), NM, PA treprostinil GENERIC NM, LA, PA VENTAVIS OTHER NM, PA CENTRAL NERVOUS SYSTEM – DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY – DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg GENERIC QL (150 tabs / 30 days), NM alprazolam tab 0.25mg GENERIC QL (150 tabs / 30 days), NM alprazolam tab 1mg GENERIC QL (150 tabs / 30 days), NM


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Drug Name Drug Tier Requirements/Limits alprazolam tab 2 mg GENERIC QL (150 tabs / 30 days), NM buspirone hcl TABS GENERIC NM fluvoxamine maleate TABS GENERIC lorazepam SOLN GENERIC NM lorazepam TABS GENERIC QL (150 tabs / 30 days), NM lorazepam intensol GENERIC QL (150 mL / 30 days), NM ANTICONVULSANTS – DRUGS TO TREAT SEIZURES APTIOM OTHER QL (60 tabs / 30 days) BANZEL SUS 40MG/ML OTHER PA BANZEL TAB 200MG OTHER PA BANZEL TAB 400MG OTHER PA BRIVIACT INJ 50MG/5ML OTHER NM, PA BRIVIACT SOL 10MG/ML OTHER PA BRIVIACT TAB 10MG OTHER PA BRIVIACT TAB 25MG OTHER PA BRIVIACT TAB 50MG OTHER PA BRIVIACT TAB 75MG OTHER PA BRIVIACT TAB 100MG OTHER PA carbamazepine CHEW; CP12; SUSP; TABS; TB12 GENERIC CELONTIN OTHER clobazam GENERIC PA clonazepam TABS 2mg GENERIC QL (300 tabs / 30 days), NM clonazepam TABS .5mg, 1mg GENERIC QL (90 tabs / 30 days), NM clonazepam TBDP 2mg GENERIC QL (300 tabs / 30 days), NM clonazepam TBDP .125mg, .25mg, .5mg, 1mg GENERIC QL (90 tabs / 30 days), NM clorazepate dipotassium GENERIC QL (180 tabs / 30 days), NM, PA;

PA if 65 years and older DIASTAT ACUDIAL OTHER NM DIASTAT PEDIATRIC OTHER NM diazepam TABS GENERIC QL (120 tabs / 30 days), NM, PA;

PA if 65 years and older diazepam gel GENERIC NM diazepam inj GENERIC NM diazepam intensol GENERIC QL (240 mL / 30 days), NM, PA;

PA if 65 years and older diazepam oral soln 1 mg/ml GENERIC QL (1200 mL / 30 days), NM, PA;

PA if 65 years and older dilantin cap 30mg GENERIC dilantin cap 100mg GENERIC dilantin chew tab 50mg GENERIC DILANTIN-125 SUSP OTHER divalproex sodium CSDR; TB24; TBEC GENERIC EPIDIOLEX OTHER QL (600 mL / 30 days), NM, LA, PAepitol GENERIC ethosuximide CAPS; SOLN GENERIC

PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 20 B/D – Covered under Medicare B or D LA – Limited Access

Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits felbamate GENERIC FYCOMPA SUSP OTHER QL (720 mL / 30 days), PA FYCOMPA TABS 2mg, 4mg, 6mg OTHER QL (60 tabs / 30 days), PA FYCOMPA TABS 8mg, 10mg, 12mg OTHER QL (30 tabs / 30 days), PA gabapentin CAPS 100mg GENERIC QL (1080 caps / 30 days) gabapentin CAPS 300mg GENERIC QL (360 caps / 30 days) gabapentin CAPS 400mg GENERIC QL (270 caps / 30 days) gabapentin SOLN GENERIC QL (2160 mL / 30 days) gabapentin TABS 600mg GENERIC QL (180 tabs / 30 days) gabapentin TABS 800mg GENERIC QL (120 tabs / 30 days) lamotrigine CHEW; TABS; TB24 GENERIC levetiracetam SOLN GENERIC NM levetiracetam TABS; TB24 GENERIC levetiracetam in sodium chloride GENERIC NM levetiracetam oral soln 100 mg/ml GENERIC NAYZILAM OTHER NMoxcarbazepine GENERIC PEGANONE OTHER phenobarbital ELIX; TABS GENERIC PA; PA if 70 years and older phenobarbital sodium SOLN GENERIC NM, PA; PA if 70 years and older phenytek GENERIC

phenytoin CHEW; SUSP GENERIC phenytoin sodium extended GENERIC phenytoin sodium inj 50mg/ml GENERIC NM pregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg GENERIC QL (120 caps / 30 days), PA pregabalin CAPS 200mg GENERIC QL (90 caps / 30 days), PA pregabalin CAPS 225mg, 300mg GENERIC QL (60 caps / 30 days), PA pregabalin SOLN GENERIC QL (900 mL / 30 days), PA primidone TABS GENERIC roweepra GENERIC roweepra xr GENERIC SPRITAM OTHER subvenite tab GENERIC SYMPAZAN OTHER PA tiagabine hcl GENERIC topiramate CPSP; TABS GENERIC valproate sodium SOLN GENERIC NM valproate sodium oral soln GENERIC valproic acid CAPS GENERIC VALTOCO OTHER NM vigabatrin powd pack 500mg GENERIC QL (180 packets / 30 days), NM,

LA, PA vigabatrin tab 500mg GENERIC QL (180 tabs / 30 days), NM, LA, PA vigadrone GENERIC QL (180 packets / 30 days), NM,

LA, PA VIMPAT 50mg OTHER QL (120 tabs / 30 days)

PA – Prior Authorization QL – Quantity Limits ST – Step Therapy B/D – Covered under Medicare B or D LA – Limited Access

NM – Not available at mail-order 21

Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits VIMPAT 100mg, 150mg, 200mg OTHER QL (60 tabs / 30 days) VIMPAT INJ 200MG/20ML OTHER NM VIMPAT SOL 10MG/ML OTHER QL (1200 mL / 30 days) XCOPRI MAINTENANCE PAK 150-200MG OTHER QL (56 tabs / 28 days) XCOPRI PAK 12.5-25MG OTHER QL (28 tabs / 28 days), NM XCOPRI PAK 50-100MG OTHER QL (28 tabs / 28 days), NM XCOPRI PAK 50-200MG OTHER QL (56 tabs / 28 days) XCOPRI TABS 50mg OTHER QL (90 tabs / 30 days) XCOPRI TABS 100mg, 150mg, 200mg OTHER QL (60 tabs / 30 days) XCOPRI TITRATION PAK 150-200MG OTHER QL (28 tabs / 28 days), NM zonisamide CAPS GENERIC ANTIDEMENTIA – DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride TABS 5mg GENERIC QL (30 tabs / 30 days) donepezil hydrochloride TABS 10mg GENERIC donepezil hydrochloride TBDP 5mg GENERIC QL (30 tabs / 30 days) donepezil hydrochloride TBDP 10mg GENERIC galantamine hydrobromide SOLN GENERIC galantamine hydrobromide TABS GENERIC QL (60 tabs / 30 days) galantamine hydrobromide er GENERIC QL (30 caps / 30 days) memantine hcl cp24 GENERIC PA; PA if < 30 yrs memantine soln GENERIC PA; PA if < 30 yrs memantine tabs GENERIC PA; PA if < 30 yrs memantine titration pak GENERIC NM, PA; PA if < 30 yrs NAMZARIC C4PK OTHER NM NAMZARIC CP24 OTHER rivastigmine tartrate 1.5mg, 3mg GENERIC QL (90 caps / 30 days) rivastigmine tartrate 4.5mg, 6mg GENERIC QL (60 caps / 30 days) rivastigmine td patch 24hr 4.6 mg/24hr GENERIC QL (30 patches / 30 days) rivastigmine td patch 24hr 9.5 mg/24hr GENERIC QL (30 patches / 30 days) rivastigmine td patch 24hr 13.3 mg/24hr GENERIC QL (30 patches / 30 days) ANTIDEPRESSANTS – DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS GENERICamoxapine GENERIC bupropion hcl TABS GENERIC bupropion hcl TB12 GENERIC bupropion hcl TB24 150mg, 300mg GENERIC citalopram hydrobromide GENERIC clomipramine hcl CAPS GENERIC PA desipramine hcl TABS GENERIC

desvenlafaxine succinate GENERIC QL (30 tabs / 30 days), PA doxepin hcl CAPS; CONC GENERIC DRIZALMA SPRINKLE 20mg, 30mg, 60mg OTHER QL (60 caps / 30 days), PA DRIZALMA SPRINKLE 40mg OTHER QL (90 caps / 30 days), PA duloxetine hcl CPEP 20mg, 30mg, 60mg GENERIC QL (60 caps / 30 days)

EMSAM OTHER QL (30 patches / 30 days), PA


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits escitalopram oxalate GENERIC FETZIMA 20mg, 40mg OTHER QL (60 caps / 30 days), PA FETZIMA 80mg, 120mg OTHER QL (30 caps / 30 days), PA FETZIMA TITRATION PACK OTHER NM, PA fluoxetine cap 10mg GENERIC fluoxetine cap 20mg GENERIC fluoxetine cap 40mg GENERIC fluoxetine hcl SOLN GENERIC imipramine hcl TABS GENERIC maprotiline hcl GENERIC MARPLAN TAB 10MG OTHER QL (180 tabs / 30 days)

mirtazapine TABS; TBDP GENERIC nefazodone hcl GENERIC nortriptyline hcl CAPS; SOLN GENERIC paroxetine hcl tabs GENERIC PAXIL SUSP OTHER QL (900 mL / 30 days) phenelzine sulfate TABS GENERIC protriptyline hcl GENERIC sertraline hcl CONC; TABS GENERIC tranylcypromine sulfate GENERIC trazodone hcl TABS 50mg, 100mg, 150mg GENERIC trimipramine maleate CAPS 25mg GENERIC QL (240 caps / 30 days) trimipramine maleate CAPS 50mg GENERIC QL (120 caps / 30 days) trimipramine maleate CAPS 100mg GENERIC QL (60 caps / 30 days) TRINTELLIX 5mg OTHER QL (120 tabs / 30 days) TRINTELLIX 10mg OTHER QL (60 tabs / 30 days) TRINTELLIX 20mg OTHER QL (30 tabs / 30 days) venlafaxine hcl CP24; TABS GENERIC VIIBRYD STARTER PACK OTHER NM VIIBRYD TAB OTHER QL (30 tabs / 30 days) ANTIPARKINSONIAN AGENTS – DRUGS TO TREAT PARKINSONS DISEASEamantadine hcl CAPS GENERIC QL (120 caps / 30 days) amantadine hcl SYRP; TABS GENERIC

APOKYN OTHER QL (20 cartridges / 30 days), NM, LA, PA

benztropine mesylate inj GENERIC NM benztropine mesylate tab 0.5mg GENERIC PA; PA if 70 years and older

benztropine mesylate tab 1mg GENERIC PA; PA if 70 years and older benztropine mesylate tab 2mg GENERIC PA; PA if 70 years and older bromocriptine mesylate CAPS; TABS GENERIC

carbidopa-levodopa GENERIC carbidopa/levodopa/entacapone GENERIC

entacapone GENERIC NEUPRO OTHER

pramipexole tab 0.5mg GENERIC



Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits pramipexole tab 0.25mg GENERIC

pramipexole tab 0.75mg GENERIC pramipexole tab 0.125mg GENERIC pramipexole tab 1.5mg GENERIC pramipexole tab 1mg GENERIC rasagiline mesylate TABS GENERIC ropinirole tab 0.5mg GENERIC ropinirole tab 0.25mg GENERIC ropinirole tab 1mg GENERIC ropinirole tab 2mg GENERIC ropinirole tab 3mg GENERIC ropinirole tab 4mg GENERIC ropinirole tab 5mg GENERIC selegiline hcl CAPS; TABS GENERIC

trihexyphenidyl hcl GENERIC PA; PA if 70 years and older ANTIPSYCHOTICS – DRUGS TO TREAT PSYCHOSES

ABILIFY MAINTENA OTHER QL (1 injection / 28 days) aripiprazole odt GENERIC QL (60 tabs / 30 days) aripiprazole oral solution 1 mg/ml GENERIC QL (900 mL / 30 days) aripiprazole tab GENERIC QL (30 tabs / 30 days) ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml OTHER QL (1 injection / 28 days) ARISTADA 1064mg/3.9ml OTHER QL (1 injection / 56 days) ARISTADA INITIO OTHER NM CAPLYTA OTHER QL (30 caps / 30 days) chlorpromazine hcl TABS GENERIC chlorpromazine inj GENERIC NM clozapine odt 12.5mg, 25mg GENERIC NM, PA clozapine odt 100mg GENERIC QL (270 tabs / 30 days), NM, PAclozapine odt 150mg GENERIC QL (180 tabs / 30 days), NM, PAclozapine odt 200mg GENERIC QL (135 tabs / 30 days), NM, PAclozapine tab 25mg GENERIC NMclozapine tab 50mg GENERIC NMclozapine tab 100mg GENERIC QL (270 tabs / 30 days), NM clozapine tab 200mg GENERIC QL (135 tabs / 30 days), NM FANAPT OTHER QL (60 tabs / 30 days), NM, PA FANAPT TITRATION PACK OTHER NM, PA fluphenazine decanoate SOLN GENERIC NM fluphenazine hcl CONC; ELIX; TABS GENERIC fluphenazine hcl SOLN GENERIC NM

GEODON SOLR OTHER QL (6 mL / 3 days), NM haloperidol TABS GENERIC haloperidol conc 2mg/ml GENERIC haloperidol decanoate SOLN GENERIC NM haloperidol lactate inj 5mg/ml GENERIC NM INVEGA SUST INJ 39 MG/0.25 ML OTHER QL (1 injection / 28 days), NM



Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits INVEGA SUST INJ 78 MG/0.5 ML OTHER QL (1 injection / 28 days), NM INVEGA SUST INJ 117 MG/0.75 ML OTHER QL (1 injection / 28 days), NM INVEGA SUST INJ 156MG/ML OTHER QL (1 injection / 28 days), NM INVEGA SUST INJ 234 MG/1.5 ML OTHER QL (1 injection / 28 days), NM INVEGA TRINZA OTHER QL (1 injection / 90 days), NM LATUDA 20mg, 40mg, 60mg, 120mg OTHER QL (30 tabs / 30 days) LATUDA 80mg OTHER QL (60 tabs / 30 days) loxapine succinate GENERIC molindone hcl GENERIC NUPLAZID CAPS OTHER QL (30 caps / 30 days), NM, LA, PA NUPLAZID TABS 10MG OTHER QL (30 tabs / 30 days), NM, LA, PA olanzapine SOLR GENERIC QL (3 vials / 1 day), NM olanzapine TABS 2.5mg, 5mg, 10mg GENERIC QL (60 tabs / 30 days) olanzapine TABS 7.5mg, 15mg, 20mg GENERIC QL (30 tabs / 30 days) olanzapine TBDP 5mg, 15mg, 20mg GENERIC QL (30 tabs / 30 days) olanzapine TBDP 10mg GENERIC QL (60 tabs / 30 days) paliperidone 1.5mg, 3mg, 9mg GENERIC QL (30 tabs / 30 days) paliperidone 6mg GENERIC QL (60 tabs / 30 days) perphenazine TABS GENERIC PERSERIS OTHER QL (1 injection / 30 days) pimozide GENERIC quetiapine fumarate TABS GENERIC quetiapine fumarate TB24 50mg, 300mg, 400mg GENERIC QL (60 tabs / 30 days), PA quetiapine fumarate TB24 150mg, 200mg GENERIC QL (30 tabs / 30 days), PA REXULTI 3mg, 4mg OTHER QL (30 tabs / 30 days) REXULTI .25mg, .5mg, 1mg, 2mg OTHER QL (60 tabs / 30 days) RISPERDAL INJ 12.5MG OTHER QL (2 injections / 28 days), NM RISPERDAL INJ 25MG OTHER QL (2 injections / 28 days), NM RISPERDAL INJ 37.5MG OTHER QL (2 injections / 28 days), NM RISPERDAL INJ 50MG OTHER QL (2 injections / 28 days), NM risperidone SOLN GENERIC QL (240 mL / 30 days) risperidone TABS GENERIC risperidone TBDP 1mg, 2mg, 3mg, 4mg GENERIC QL (60 tabs / 30 days) risperidone TBDP .25mg, .5mg GENERIC QL (90 tabs / 30 days) SAPHRIS OTHER QL (60 tabs / 30 days) SECUADO OTHER QL (30 patches / 30 days) thioridazine hcl TABS GENERIC thiothixene GENERIC

trifluoperazine hcl GENERIC VERSACLOZ OTHER QL (600 mL / 30 days), NM, PA

VRAYLAR 1.5mg OTHER QL (60 caps / 30 days), PA VRAYLAR 3mg, 4.5mg, 6mg OTHER QL (30 caps / 30 days), PA VRAYLAR THERAPY PACK OTHER NM, PA ziprasidone hcl GENERIC QL (60 caps / 30 days) ziprasidone mesylate GENERIC QL (6 injections / 3 days), NM


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits ZYPREXA RELPREVV 300mg OTHER QL (2 vials / 28 days), NM, PA ZYPREXA RELPREVV 405mg OTHER QL (1 vial / 28 days), NM, PA ZYPREXA RELPREVV INJ 210MG OTHER QL (2 vials / 28 days), NM, PA ATTENTION DEFICIT HYPERACTIVITY DISORDER – DRUGS TO TREAT ADHD

amphetamine-dextroamphetamine cap sr 24hr 5 mg GENERIC QL (90 caps / 30 days) amphetamine-dextroamphetamine cap sr 24hr 10 mg GENERIC QL (90 caps / 30 days) amphetamine-dextroamphetamine cap sr 24hr 15 mg GENERIC QL (30 caps / 30 days) amphetamine-dextroamphetamine cap sr 24hr 20 mg GENERIC QL (30 caps / 30 days) amphetamine-dextroamphetamine cap sr 24hr 25 mg GENERIC QL (30 caps / 30 days) amphetamine-dextroamphetamine cap sr 24hr 30 mg GENERIC QL (30 caps / 30 days) amphetamine-dextroamphetamine tab 5 mg GENERIC QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 7.5 mg GENERIC QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 10 mg GENERIC QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 12.5 mg GENERIC QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 15 mg GENERIC QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 20 mg GENERIC QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 30 mg GENERIC QL (60 tabs / 30 days) atomoxetine hcl 10mg, 18mg, 25mg GENERIC QL (120 caps / 30 days) atomoxetine hcl 40mg GENERIC QL (60 caps / 30 days) atomoxetine hcl 60mg, 80mg, 100mg GENERIC QL (30 caps / 30 days) dexmethylphenidate hcl TABS 2.5mg, 5mg GENERIC QL (120 tabs / 30 days) dexmethylphenidate hcl TABS 10mg GENERIC QL (60 tabs / 30 days) guanfacine er (adhd) GENERIC PA; PA if 70 years and older metadate er tab 20mg GENERIC QL (90 tabs / 30 days) methylphenidate hcl TABS 5mg, 10mg GENERIC QL (180 tabs / 30 days) methylphenidate hcl TABS 20mg GENERIC QL (90 tabs / 30 days) methylphenidate hcl oral soln 5mg/5ml GENERIC QL (1800 mL / 30 days) methylphenidate hcl oral soln 10mg/5ml GENERIC QL (900 mL / 30 days) methylphenidate hcl tbcr 10 mg GENERIC QL (90 tabs / 30 days) methylphenidate hcl tbcr 20mg GENERIC QL (90 tabs / 30 days) HYPNOTICS – DRUGS TO TREAT INSOMNIA BELSOMRA OTHER QL (30 tabs / 30 days), NM doxepin hcl (sleep) GENERIC QL (30 tabs / 30 days), NM eszopiclone GENERIC QL (30 tabs / 30 days), NM, PA;

PA applies if 70 years and older after a 90-day supply in a calendar year

HETLIOZ OTHER NM, LA, PA temazepam 7.5mg GENERIC QL (30 caps / 30 days), NM, PA;


temazepam 15mg GENERIC QL (60 caps / 30 days), NM, PA; PA applies if 65 years and older after a 90-day supply in a calendar year

Drug Name Drug Tier Requirements/Limits zaleplon GENERIC QL (60 caps / 30 days), NM, PA;


zolpidem tartrate TABS GENERIC QL (30 tabs / 30 days), NM, PA; PA applies if 70 years and older after a 90-day supply in a calendar year

MIGRAINE – DRUGS TO TREAT SEVERE HEADACHES AIMOVIG OTHER QL (1 pen / 30 days), NM, PA

dihydroergotamine mesylate inj 1 mg/ml GENERIC NM dihydroergotamine mesylate nasal spr 4 mg/ml GENERIC QL (8 mL / 30 days), NM, PA

eletriptan hydrobromide GENERIC QL (12 tabs / 30 days), NM EMGALITY SOAJ OTHER QL (2 pens / 30 days), NM, PA EMGALITY SOSY 120mg/ml OTHER QL (2 syringes / 30 days), NM, PA

ergotamine w/ caffeine TABS GENERIC NM naratriptan hcl GENERIC QL (12 tabs / 30 days), NM

rizatriptan benzoate GENERIC QL (18 tabs / 30 days), NM rizatriptan benzoate odt GENERIC QL (18 tabs / 30 days), NM

sumatriptan SOLN 5mg/act GENERIC QL (24 inhalers / 30 days), NM sumatriptan SOLN 20mg/act GENERIC QL (12 inhalers / 30 days), NM sumatriptan inj 4mg/0.5ml GENERIC QL (18 injections / 30 days), NM sumatriptan inj 6mg/0.5ml GENERIC QL (12 injections / 30 days), NM sumatriptan succinate TABS GENERIC QL (12 tabs / 30 days), NM zolmitriptan TABS GENERIC QL (12 tabs / 30 days), NM zolmitriptan odt GENERIC QL (12 tabs / 30 days), NM

MISCELLANEOUS AUSTEDO 6mg OTHER QL (60 tabs / 30 days), NM, PA AUSTEDO 9mg, 12mg OTHER QL (120 tabs / 30 days), NM, PA INGREZZA CAPS OTHER QL (30 caps / 30 days), NM, PA INGREZZA CPPK OTHER QL (28 caps / 28 days), NM, PA

lithium carbonate CAPS; TABS GENERIC lithium carbonate er GENERIC

LITHIUM SOLN 8MEQ/5ML OTHER LYRICA CR OTHER QL (60 tabs / 30 days), PA

NUEDEXTA OTHER QL (60 caps / 30 days), PA pyridostigmine tab 60mg GENERIC NM

riluzole GENERIC tetrabenazine 12.5mg GENERIC QL (240 tabs / 30 days), NM, PA tetrabenazine 25mg GENERIC QL (120 tabs / 30 days), NM, PA

MULTIPLE SCLEROSIS AGENTS – DRUGS TO TREAT MULTIPLE SCLEROSIS BETASERON OTHER QL (14 syringes / 28 days), NM,

PA dalfampridine TB12 GENERIC NM, PA

GILENYA OTHER QL (28 caps / 28 days), NM, PA


Formulary ID 00020345 v13 08/01/2020

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Formulary ID 00020345 v13 08/01/2020

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Drug Name Drug Tier Requirements/Limits glatiramer acetate 20mg/ml GENERIC QL (30 syringes / 30 days), NM, PA

glatiramer acetate 40mg/ml GENERIC QL (12 syringes / 28 days), NM, PA glatopa 20mg/ml GENERIC QL (30 syringes / 30 days), NM, PA glatopa 40mg/ml GENERIC QL (12 syringes / 28 days), NM, PA

MUSCULOSKELETAL THERAPY AGENTS – DRUGS TO TREAT MUSCLE SPASMS baclofen TABS 10mg, 20mg GENERIC NM

carisoprodol TABS 350mg GENERIC QL (120 tabs / 30 days), NM, PA; PA if 70 years and older

cyclobenzaprine hcl TABS 5mg, 10mg GENERIC NM, PA; PA if 70 years and older dantrolene sodium CAPS GENERIC NM

methocarbamol TABS GENERIC NM, PA; PA if 70 years and older tizanidine hcl TABS GENERIC NM

NARCOLEPSY/CATAPLEXY – DRUGS FOR SLEEP DISORDERS armodafinil 50mg GENERIC QL (90 tabs / 30 days), PA

armodafinil 150mg, 200mg, 250mg GENERIC QL (30 tabs / 30 days), PA XYREM OTHER QL (540 mL / 30 days), NM, LA, PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium GENERIC

buprenorphine hcl SUBL GENERIC QL (90 tabs / 30 days), NM, PA buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg GENERIC QL (90 films / 30 days), NM

buprenorphine hcl-naloxone hcl dihydrate 4-1mg GENERIC QL (90 films / 30 days), NM buprenorphine hcl-naloxone hcl dihydrate 8-2mg GENERIC QL (90 films / 30 days), NM buprenorphine hcl-naloxone hcl dihydrate 12-3mg GENERIC QL (60 films / 30 days), NM

buprenorphine hcl-naloxone hcl sl GENERIC QL (90 tabs / 30 days), NM bupropion hcl (smoking deterrent) GENERIC NM

CHANTIX OTHER NM, PA CHANTIX CONTINUING MONTH OTHER NM, PA

CHANTIX STARTER PACK OTHER NM, PA disulfiram TABS GENERIC

EVZIO OTHER NM naloxone inj 0.4mg/ml GENERIC NM naloxone inj 1mg/ml GENERIC NM

naltrexone hcl TABS GENERIC NM NARCAN OTHER NM

NICOTROL INHALER OTHER NM NICOTROL NS OTHER NM

VIVITROL OTHER NM ENDOCRINE AND METABOLIC – DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS – DRUGS TO REGULATE MALE HORMONES

ANADROL-50 OTHER NM, PA ANDRODERM OTHER QL (30 patches / 30 days), PA

oxandrolone tab 2.5mg GENERIC NM, PA oxandrolone tab 10mg GENERIC NM, PA testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm GENERIC QL (300 grams / 30 days), PA

testosterone cypionate SOLN GENERIC NM, PA


Formulary ID 00020345 v13 08/01/2020

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Drug Name Drug Tier Requirements/Limits testosterone enanthate SOLN GENERIC NM, PA ANTIDIABETICS, INJECTABLE – DRUGS TO TREAT DIABETESBASAGLAR KWIKPEN OTHER BD ALCOHOL SWABS OTHER NMBD ULTRAFINE INSULIN SYRINGE OTHER NMBD ULTRAFINE/NANO PEN NEEDLES OTHER NMBYDUREON BCISE OTHER QL (4 pens / 28 days)

BYDUREON PEN OTHER QL (4 pens / 28 days)BYETTA OTHER QL (1 pen / 30 days)

FIASP OTHER FIASP FLEXTOUCH OTHER FIASP PENFILL OTHER

GAUZE PADS 2" X 2" OTHER NM HUMULIN R INJ U-500 OTHER B/D HUMULIN R U-500 KWIKPEN OTHER INSULIN PEN NEEDLE OTHER NM

INSULIN SAFETY NEEDLES OTHER NM INSULIN SYRINGE OTHER NM LEVEMIR OTHER LEVEMIR FLEXTOUCH OTHER

NOVOLIN 70/30 OTHER (brand RELION not covered) NOVOLIN 70/30 FLEXPEN OTHER (brand RELION not covered)

NOVOLIN N OTHER (brand RELION not covered) NOVOLIN N FLEXPEN OTHER (brand RELION not covered)

NOVOLIN R OTHER (brand RELION not covered) NOVOLIN R FLEXPEN OTHER (brand RELION not covered)

NOVOLOG OTHER NOVOLOG 70/30 FLEXPEN OTHER NOVOLOG FLEXPEN OTHER NOVOLOG MIX 70/30 OTHER NOVOLOG PENFILL OTHER

OZEMPIC INJ 0.25 OR 0.5MG/DOSE OTHER QL (1 pen / 28 days) OZEMPIC INJ 1MG/DOSE OTHER QL (2 pens / 28 days) SOLIQUA 100/33 OTHER QL (10 pens / 30 days)

TRESIBA FLEXTOUCH OTHER TRESIBA INJ OTHER

TRULICITY OTHER QL (4 pens / 28 days) VICTOZA OTHER QL (3 pens / 30 days)

XULTOPHY 100/3.6 OTHER QL (5 pens / 30 days) ANTIDIABETICS, ORAL – DRUGS TO TREAT DIABETES

acarbose TABS GENERIC FARXIGA OTHER QL (30 tabs / 30 days)

glimepiride 1mg, 2mg GENERIC QL (90 tabs / 30 days) glimepiride 4mg GENERIC QL (60 tabs / 30 days)

glip/metform tab 2.5-250mg GENERIC QL (240 tabs / 30 days)

8


Formulary ID 00020345 v13 08/01/2020

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Drug Name Drug Tier Requirements/Limits glip/metform tab 2.5-500mg GENERIC QL (120 tabs / 30 days) glip/metform tab 5-500mg GENERIC QL (120 tabs / 30 days)

glipizide TABS 5mg GENERIC QL (240 tabs / 30 days) glipizide TABS 10mg GENERIC QL (120 tabs / 30 days) glipizide TB24 2.5mg, 5mg GENERIC QL (90 tabs / 30 days) glipizide TB24 10mg GENERIC QL (60 tabs / 30 days) glipizide xl 2.5mg, 5mg GENERIC QL (90 tabs / 30 days) glipizide xl 10mg GENERIC QL (60 tabs / 30 days) glyburide TABS 1.25mg GENERIC QL (480 tabs / 30 days), PA;

PA if 70 years and older glyburide TABS 2.5mg GENERIC QL (240 tabs / 30 days), PA;

PA if 70 years and older glyburide TABS 5mg GENERIC QL (120 tabs / 30 days), PA;

PA if 70 years and older glyburide micronized 1.5mg GENERIC QL (240 tabs / 30 days), PA;

PA if 70 years and older glyburide micronized 3mg GENERIC QL (120 tabs / 30 days), PA;

PA if 70 years and older glyburide micronized 6mg GENERIC QL (60 tabs / 30 days), PA;

PA if 70 years and older glyburide-metformin tab 1.25-250 mg GENERIC QL (240 tabs / 30 days), PA;

PA if 70 years and older glyburide-metformin tab 2.5-500 mg GENERIC QL (120 tabs / 30 days), PA;

PA if 70 years and older glyburide-metformin tab 5-500mg GENERIC QL (120 tabs / 30 days), PA;

PA if 70 years and older GLYXAMBI OTHER QL (30 tabs / 30 days)

JANUMET OTHER QL (60 tabs / 30 days) JANUMET XR TAB 50-500MG OTHER QL (60 tabs / 30 days) JANUMET XR TAB 50-1000 OTHER QL (60 tabs / 30 days) JANUMET XR TAB 100-1000 OTHER QL (30 tabs / 30 days)

JANUVIA OTHER QL (30 tabs / 30 days) JARDIANCE 10mg OTHER QL (60 tabs / 30 days) JARDIANCE 25mg OTHER QL (30 tabs / 30 days)

JENTADUETO OTHER QL (60 tabs / 30 days) JENTADUETO TAB XR 2.5-1000 MG OTHER QL (60 tabs / 30 days) JENTADUETO TAB XR 5-1000 MG OTHER QL (30 tabs / 30 days) metformin er 500mg GENERIC QL (120 tabs / 30 days);

(generic of GLUCOPHAGE XR) metformin er 750mg GENERIC QL (60 tabs / 30 days);

(generic of GLUCOPHAGE XR) metformin hcl TABS 500mg GENERIC QL (150 tabs / 30 days) metformin hcl TABS 850mg GENERIC QL (90 tabs / 30 days) metformin hcl TABS 1000mg GENERIC QL (75 tabs / 30 days)

nateglinide GENERIC QL (90 tabs / 30 days) pioglitazone hcl GENERIC QL (30 tabs / 30 days)


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits repaglinide 2mg GENERIC QL (240 tabs / 30 days) repaglinide .5mg, 1mg GENERIC QL (120 tabs / 30 days) RYBELSUS OTHER QL (30 tabs / 30 days) SYNJARDY TAB 5-500MG OTHER QL (120 tabs / 30 days) SYNJARDY TAB 5-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY TAB 12.5-500MG OTHER QL (60 tabs / 30 days) SYNJARDY TAB 12.5-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 5-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 10-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 12.5-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 25-1000MG OTHER QL (30 tabs / 30 days) TRADJENTA OTHER QL (30 tabs / 30 days) TRIJARDY XR TAB ER 24HR 5-2.5-1000MG OTHER QL (60 tabs / 30 days) TRIJARDY XR TAB ER 24HR 10-5-1000 MG OTHER QL (30 tabs / 30 days) TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG OTHER QL (60 tabs / 30 days) TRIJARDY XR TAB ER 24HR 25-5-1000 MG OTHER QL (30 tabs / 30 days) XIGDUO XR TAB 2.5-1000MG OTHER QL (60 tabs / 30 days) XIGDUO XR TAB 5-500MG OTHER QL (60 tabs / 30 days) XIGDUO XR TAB 5-1000MG OTHER QL (60 tabs / 30 days) XIGDUO XR TAB 10-500MG OTHER QL (30 tabs / 30 days) XIGDUO XR TAB 10-1000MG OTHER QL (30 tabs / 30 days) BISPHOSPHONATES – DRUGS TO TREAT BONE LOSS alendronate sodium soln 70mg/75ml GENERIC alendronate sodium tab 5 mg GENERIC alendronate sodium tab 10 mg GENERIC alendronate sodium tab 35 mg GENERIC

alendronate sodium tab 40 mg GENERIC NMalendronate sodium tab 70 mg GENERIC ibandronate sodium tabs GENERIC B/D pamidronate disodium GENERIC B/D, NM pamidronate inj 30mg GENERIC B/D, NM pamidronate inj 90mg GENERIC B/D, NM risedronate sodium TABS 5mg, 35mg, 150mg GENERIC risedronate sodium TBEC GENERIC zoledronic acid inj 4mg/100ml GENERIC B/D, NM zoledronic acid inj 5mg/100ml GENERIC B/D, NM zoledronic inj 4mg/5ml GENERIC B/D, NM CHELATING AGENTS CHEMET OTHER NM clovique GENERIC NM, PA deferasirox tab GENERIC NM, PA JADENU 180mg OTHER NM, LA, PA JADENU SPRINKLE OTHER NM, LA, PA kionex sus 15gm/60ml GENERIC NM LOKELMA OTHER


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits penicillamine TABS GENERIC NM sodium polystyrene sulfonate powder GENERIC NM sodium polystyrene sulfonate susp GENERIC NM sps susp 15gm/60ml GENERIC NM trientine hcl GENERIC NM, PA VELTASSA OTHER LA, PA CONTRACEPTIVES – DRUGS FOR BIRTH CONTROL altavera tab GENERIC alyacen 1/35 GENERIC amethia GENERIC amethia lo GENERIC apri GENERIC aranelle GENERIC

ashlyna GENERIC aubra GENERIC aviane GENERIC balziva GENERIC bekyree GENERIC

blisovi 24 fe GENERIC blisovi fe 1.5/30 GENERIC briellyn GENERIC

camila GENERIC camrese lo GENERIC

caziant pak GENERIC cryselle-28 GENERIC

cyclafem 1/35 GENERIC cyclafem 7/7/7 GENERIC

cyred tab GENERIC dasetta 1/35 GENERIC dasetta 7/7/7 GENERIC

deblitane GENERIC desogestrel & ethinyl estradiol GENERIC

desogestrel-ethinyl estradiol (biphasic) GENERIC drospirenone-ethinyl estradiol GENERIC drospirenone-ethinyl estradiol-levomefolate calcium GENERIC

ELLA OTHER NM eluryng GENERIC

emoquette GENERIC enpresse-28 GENERIC

enskyce GENERIC errin GENERIC

estarylla tab 0.25-35 GENERIC ethynodiol diacet & eth estrad GENERIC ethynodiol tab 1-50 GENERIC

etonogestrel-ethinyl estradiol GENERIC



Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits falmina GENERIC fayosim GENERIC femynor GENERIC

gianvi tab 3-0.02mg GENERIC hailey 24 fe GENERIC

heather GENERIC incassia GENERIC introvale GENERIC isibloom GENERIC

jasmiel GENERIC jolessa tab 0.15-0.03 mg GENERIC

jolivette GENERIC juleber GENERIC

junel 1.5/30 GENERIC junel 1/20 GENERIC junel fe 1.5/30 GENERIC junel fe 1/20 GENERIC junel fe 24 GENERIC

kaitlib fe GENERIC kariva GENERIC kelnor 1/35 GENERIC kelnor 1/50 GENERIC kurvelo GENERIC

larin 1.5/30 GENERIC larin 1/20 GENERIC larin fe 1.5/30 GENERIC larin fe 1/20 GENERIC

larissia tab GENERIC layolis fe GENERIC

leena tab GENERIC lessina GENERIC

levonest GENERIC levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg

GENERIC

levonor/ethi tab GENERIC levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)

GENERIC

levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7)

GENERIC

levonorgestrel & eth estradiol GENERIC levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) GENERIC

levora 0.15/30-28 GENERIC loryna GENERIC

low-ogestrel GENERIC lutera GENERIC

lyza GENERIC


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits marlissa GENERIC

medroxyprogesterone acetate (contraceptive) GENERIC NM melodetta 24 fe GENERIC mibelas 24 fe GENERIC

microgestin 1.5/30 GENERIC microgestin 1/20 GENERIC

microgestin fe 1.5/30 GENERIC microgestin fe 1/20 GENERIC

mili GENERIC mono-linyah tab 0.25-35 GENERIC

necon 0.5/35-28 GENERIC nikki GENERIC

nora-be tab 0.35mg GENERIC nore/eth/fer chw 0.4mg-35 GENERIC

noreth/ethin chw fe GENERIC norethin acet & estrad-fe GENERIC norethindrone (contraceptive) GENERIC norethindrone acet & eth estra GENERIC

norgest/ethi tab 0.25/35 GENERIC norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

GENERIC

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

GENERIC

nortrel 0.5/35 (28) GENERIC nortrel 1/35 GENERIC nortrel 7/7/7 GENERIC

ocella tab 3-0.03mg GENERIC orsythia GENERIC

philith GENERIC pimtrea GENERIC

pirmella 1/35 GENERIC portia-28 GENERIC previfem GENERIC reclipsen GENERIC

rivelsa GENERIC setlakin tab GENERIC sharobel GENERIC

sprintec 28 GENERIC sronyx GENERIC

syeda GENERIC tarina 24 fe GENERIC

tarina fe 1/20 GENERIC tilia fe GENERIC

tri-estarylla GENERIC tri-legest fe GENERIC tri-linyah GENERIC



Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits tri-lo marzia GENERIC

tri-lo-estarylla GENERIC tri-lo-sprintec GENERIC

tri-mili GENERIC tri-previfem GENERIC

tri-sprintec GENERIC tri-vylibra GENERIC tri-vylibra lo GENERIC trivora-28 GENERIC

tulana GENERIC tydemy GENERIC

velivet GENERIC vienva GENERIC viorele GENERIC

vyfemla GENERIC vylibra GENERIC

wymzya fe GENERIC xulane dis 150-35 GENERIC zarah GENERIC zovia 1/35e GENERIC ENDOMETRIOSIS danazol CAPS GENERIC NM SYNAREL OTHER NM ENZYME REPLACEMENTS – DRUGS TO TREAT ENZYME DEFICIENCIES ALDURAZYME OTHER NM, LA, PA CARBAGLU OTHER NM, LA, PA CERDELGA OTHER NM, PA CEREZYME OTHER NM, LA, PA CYSTADANE OTHER NM, LA CYSTAGON OTHER NM, LA, PA FABRAZYME OTHER NM, LA, PA KUVAN OTHER NM, LA, PA levocarnitine (metabolic modifiers) GENERIC B/D LUMIZYME OTHER NM, LA, PA miglustat GENERIC NM, PA NAGLAZYME OTHER NM, LA, PA nitisinone GENERIC NM, PA NITYR OTHER NM, LA, PA ORFADIN OTHER NM, LA, PA sodium phenylbutyrate GENERIC NM, PA ESTROGENS – DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN 10mg/ml OTHER NM estradiol PTWK; TABS GENERIC estradiol vaginal cream GENERIC estradiol vaginal tab GENERIC


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits estradiol valerate inj GENERIC NM

fyavolv GENERIC jinteli GENERIC

norethindrone acetate-ethinyl estradiol GENERIC yuvafem vaginal tablet 10 mcg GENERIC

GLUCOCORTICOIDS – DRUGS TO TREAT INFLAMMATORY RESPONSE

cortisone acetate TABS GENERIC NM

dexamethasone CONC; ELIX; SOLN; TABS GENERIC NM dexamethasone sodium phosphate GENERIC NM

fludrocortisone acetate TABS GENERIC hydrocortisone TABS GENERIC NM methylpr ss inj GENERIC B/D, NM

methylpred pak 4mg GENERIC NM methylpred tab 4mg GENERIC B/D, NM methylpred tab 8mg GENERIC B/D, NM

methylpred tab 16mg GENERIC B/D, NM methylpred tab 32mg GENERIC B/D, NM

methylprednisolone acetate GENERIC B/D, NM pred sod pho sol 5mg/5ml GENERIC B/D, NM prednisolone sodium phosphate SOLN 15mg/5ml GENERIC B/D, NM prednisolone sol 15mg/5ml GENERIC B/D, NM prednisolone sol 25mg/5ml GENERIC B/D, NM

prednisone con 5mg/ml GENERIC B/D, NM prednisone pak 5mg GENERIC NM prednisone pak 10mg GENERIC NM prednisone sol 5mg/5ml GENERIC B/D, NM prednisone tab 1mg GENERIC B/D, NM prednisone tab 2.5mg GENERIC B/D, NM prednisone tab 5mg GENERIC B/D, NM prednisone tab 10mg GENERIC B/D, NM prednisone tab 20mg GENERIC B/D, NM prednisone tab 50mg GENERIC B/D, NM

SOLU-CORTEF OTHER NM GLUCOSE ELEVATING AGENTS – DRUGS TO TREAT LOW BLOOD SUGAR

diazoxide SUSP GENERIC

GLUCAGEN HYPOKIT OTHER NM GLUCAGON EMERGENCY KIT OTHER NM

GVOKE HYPOPEN 2-PACK OTHER NM GVOKE PFS OTHER NM

PROGLYCEM SUS 50MG/ML OTHERMISCELLANEOUS

cabergoline GENERIC NM calcitonin (salmon) GENERIC B/D cinacalcet hcl 30mg, 90mg GENERIC B/D, QL (120 tabs / 30 days), NM cinacalcet hcl 60mg GENERIC B/D, QL (60 tabs / 30 days), NM



Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits FORTEO OTHER NM, PA

GENOTROPIN OTHER NM, PA GENOTROPIN MINIQUICK OTHER NM, PA

INCRELEX OTHER NM, LA, PAKORLYM OTHER NM, LA, PA

LUPRON DEP-PED INJ 7.5MG OTHER NM, PA LUPRON DEP-PED INJ 11.25MG (3-MONTH) OTHER NM, PA LUPRON DEPOT-PED (1-MONTH) OTHER NM, PA LUPRON DEPOT-PED (3-MONTH) OTHER NM, PA

NATPARA OTHER NM, PA octreotide acetate GENERIC NM, PA OSPHENA OTHER PA

PROLIA OTHER QL (1 injection / 180 days), NM raloxifene tab 60mg GENERIC SIGNIFOR OTHER NM, LA, PA

SOMATULINE DEPOT OTHER NM, PA SOMAVERT OTHER NM, LA, PA

TYMLOS OTHER NM, PA XGEVA OTHER NM, PA

PHOSPHATE BINDER AGENTS – DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS

AURYXIA OTHER QL (360 tabs / 30 days), PA calcium acetate (phosphate binder) CAPS GENERIC QL (360 caps / 30 days) calcium acetate (phosphate binder) TABS GENERIC QL (360 tabs / 30 days)

sevelamer carbonate PACK 2.4gm GENERIC QL (180 packets / 30 days) sevelamer carbonate PACK .8gm GENERIC QL (540 packets / 30 days) sevelamer carbonate TABS GENERIC QL (540 tabs / 30 days)

PROGESTINS – DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab GENERIC

norethindrone acetate TABS GENERIC THYROID AGENTS – DRUGS TO REGULATE THYROID LEVELS euthyrox GENERIC

levo-t GENERIC levothyroxine sodium TABS GENERIC

levoxyl GENERIC liothyronine sodium TABS GENERIC methimazole TABS GENERIC

propylthiouracil TABS GENERIC SYNTHROID OTHER

unithroid GENERIC VASOPRESSINS – DRUGS TO REGULATE PITUITARY HORMONES

desmopressin acetate spray GENERIC desmopressin acetate spray refrigerated GENERIC desmopressin acetate tabs GENERIC

desmopressin inj 4mcg/ml GENERIC NM STIMATE OTHER NM


Formulary ID 00020345 v13 08/01/2020

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Drug Name Drug Tier Requirements/Limits GASTROINTESTINAL – DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTIEMETICS – DRUGS FOR NAUSEA AND VOMITING

aprepitant GENERIC B/D, NM aprepitant pak 80mg & 125mg GENERIC B/D, NM

compro supp GENERIC NM dronabinol GENERIC B/D, QL (60 caps / 30 days), NM

EMEND SUSR OTHER B/D, NM granisetron hcl SOLN GENERIC NM granisetron hcl TABS GENERIC B/D, NM

meclizine hcl TABS GENERIC NM metoclopramide hcl SOLN; TABS GENERIC NM

metoclopramide hcl inj GENERIC NM ondansetron hcl TABS GENERIC B/D, NM ondansetron hcl inj GENERIC NM ondansetron hcl oral soln GENERIC B/D, NM ondansetron odt GENERIC B/D, NM

prochlorperazine inj GENERIC NM prochlorperazine maleate TABS GENERIC prochlorperazine supp GENERIC NM

promethazine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and older promethazine hcl inj GENERIC NM, PA; PA if 70 years and older

scopolamine GENERIC QL (10 patches / 30 days), NM, PA; PA if 70 years and older

ANTISPASMODICS – DRUGS FOR STOMACH SPASMS dicyclomine hcl cap 10mg GENERIC NM

dicyclomine hcl soln 10mg/5ml GENERIC NM dicyclomine hcl tab 20mg GENERIC NM

glycopyrrolate tab 1mg GENERIC NM glycopyrrolate tab 2mg GENERIC NM

H2-RECEPTOR ANTAGONISTS – DRUGS FOR ULCERS AND STOMACH ACID famotidine SUSR GENERIC famotidine TABS 20mg, 40mg GENERIC famotidine in nacl GENERIC NM famotidine inj GENERIC NM

nizatidine CAPS GENERIC INFLAMMATORY BOWEL DISEASE

balsalazide disodium GENERIC NM budesonide ec GENERIC NM

colocort GENERIC NM hydrocortisone (enema) GENERIC NM

mesalamine CPDR GENERIC mesalamine ENEM GENERIC NM mesalamine SUPP GENERIC NM mesalamine TBEC 1.2gm GENERIC

mesalamine w/ cleanser GENERIC NM



Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits sulfasalazine TABS GENERIC sulfasalazine ec GENERIC

LAXATIVES constulose GENERIC

enulose GENERIC gavilyte-c GENERIC NM gavilyte-g GENERIC NM

gavilyte-n/flavor pack GENERIC NM generlac GENERIC

GOLYTELY OTHER NM lactulose SOLN GENERIC lactulose (encephalopathy) GENERIC

NULYTELY/FLAVOR PACKS OTHER NM peg 3350-kcl-sod bicarb-sod chloride-sod sulfate GENERIC NM

peg 3350-potassium chloride-sod bicarbonate-sod chloride GENERIC NM PLENVU OTHER NM SUPREP BOWEL PREP KIT OTHER NM

trilyte GENERIC NM MISCELLANEOUS

alosetron hcl GENERIC PA AMITIZA CAP 8MCG OTHER QL (180 caps / 30 days) AMITIZA CAP 24MCG OTHER QL (60 caps / 30 days)

cromolyn sodium (mastocytosis) GENERIC diphenoxylate w/ atropine GENERIC NM

GATTEX OTHER NM, LA, PA LINZESS OTHER QL (30 caps / 30 days)

loperamide hcl CAPS GENERIC NM misoprostol TABS GENERIC MOVANTIK 12.5mg OTHER QL (60 tabs / 30 days), NM MOVANTIK 25mg OTHER QL (30 tabs / 30 days), NM

RELISTOR SOLN OTHER NM, PA sucralfate TABS GENERIC

ursodiol CAPS; TABS GENERIC XIFAXAN 550mg OTHER PA

PANCREATIC ENZYMES CREON OTHER ZENPEP OTHER

PROTON PUMP INHIBITORS – DRUGS FOR ULCERS AND STOMACH ACID DEXILANT OTHER QL (30 caps / 30 days)

esomeprazole magnesium CPDR GENERIC QL (30 caps / 30 days), ST lansoprazole CPDR GENERIC QL (30 caps / 30 days)

omeprazole cap 10mg GENERIC omeprazole cap 20mg GENERIC omeprazole cap 40mg GENERIC

pantoprazole sodium SOLR GENERIC NM


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits pantoprazole sodium tbec GENERIC rabeprazole sodium GENERIC QL (30 tabs / 30 days)

GENITOURINARY – DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA – DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl GENERIC QL (30 tabs / 30 days) dutasteride CAPS GENERIC QL (30 caps / 30 days) dutasteride-tamsulosin hcl GENERIC QL (30 caps / 30 days) finasteride TABS 5mg GENERIC tamsulosin hcl GENERIC

MISCELLANEOUS

bethanechol chloride TABS GENERIC NM potassium citrate (alkalinizer) er tabs GENERIC NM URINARY ANTISPASMODICS – DRUGS TO TREAT URINARY INCONTINENCEMYRBETRIQ OTHER QL (30 tabs / 30 days) oxybutynin chloride SYRP GENERICoxybutynin chloride TABS GENERICoxybutynin chloride TB24 5mg GENERIC QL (30 tabs / 30 days) oxybutynin chloride TB24 10mg, 15mg GENERIC QL (60 tabs / 30 days) tolterodine tartrate CP24 GENERIC QL (30 caps / 30 days), ST tolterodine tartrate TABS GENERIC ST TOVIAZ OTHER QL (30 tabs / 30 days) trospium chloride TABS GENERIC QL (60 tabs / 30 days) VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal GENERIC NM metronidazole vaginal GENERIC NM terconazole vaginal GENERIC NM vandazole GENERIC NM

HEMATOLOGIC – DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS – BLOOD THINNERS COUMADIN OTHER ELIQUIS 2.5mg OTHER QL (60 tabs / 30 days) ELIQUIS 5mg OTHER QL (74 tabs / 30 days) ELIQUIS STARTER PACK OTHER QL (74 tabs / 30 days) enoxaparin sodium GENERIC NM fondaparinux sodium GENERIC NM heparin sod (porcine) in d5w GENERIC NM heparin sod inj 1000/ml GENERIC B/D, NM heparin sod inj 5000/ml GENERIC B/D, NM heparin sod inj 10000/ml GENERIC B/D, NM heparin sod inj 20000/ml GENERIC B/D, NM HEPARIN SODIUM/NACL 0.45% OTHER NM jantoven GENERIC PRADAXA OTHER QL (60 caps / 30 days) warfarin sodium GENERIC



Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits XARELTO 2.5mg OTHER QL (60 tabs / 30 days) XARELTO 10mg, 15mg, 20mg OTHER QL (30 tabs / 30 days) XARELTO STARTER PACK OTHER QL (51 tabs / 30 days), NM HEMATOPOIETIC GROWTH FACTORS PROCRIT OTHER NM, PA ZARXIO OTHER NM, PA MISCELLANEOUS anagrelide hcl GENERICBERINERT OTHER QL (24 boxes / 30 days), NM, LA, PA cilostazol GENERIC DROXIA OTHER ENDARI OTHER NM, LA, PA HAEGARDA 2000unit OTHER QL (30 vials / 30 days), NM, LA, PA HAEGARDA 3000unit OTHER QL (20 vials / 30 days), NM, LA, PA icatibant acetate GENERIC QL (9 syringes / 30 days), NM, PA pentoxifylline TBCR GENERIC PROMACTA PACK 12.5mg OTHER QL (360 packets / 30 days), NM,

LA, PA PROMACTA PACK 25mg OTHER QL (180 packets / 30 days), NM,

LA, PA PROMACTA TABS 12.5mg, 25mg OTHER QL (30 tabs / 30 days), NM, LA, PA PROMACTA TABS 50mg, 75mg OTHER QL (60 tabs / 30 days), NM, LA, PA

tranexamic acid SOLN; TABS GENERIC NM PLATELET AGGREGATION INHIBITORS

aspirin-dipyridamole GENERIC BRILINTA OTHER

clopidogrel tab 75mg GENERIC prasugrel hcl GENERIC

IMMUNOLOGIC AGENTS – DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) – DRUGS TO TREAT RHEUMATOID ARTHRITIS

ENBREL SOLR OTHER QL (16 vials / 28 days), NM, PA ENBREL SOSY 25mg/0.5ml OTHER QL (16 syringes / 28 days), NM, PA ENBREL SOSY 50mg/ml OTHER QL (8 syringes / 28 days), NM, PA ENBREL MINI OTHER QL (8 injections / 28 days), NM, PA ENBREL SURECLICK OTHER QL (8 injections / 28 days), NM, PA HUMIRA 10mg/0.1ml, 20mg/0.2ml OTHER QL (2 injections / 28 days), NM, PA HUMIRA 40mg/0.4ml OTHER QL (6 injections / 28 days), NM, PA HUMIRA INJ 10MG/0.2ML OTHER QL (2 syringes / 28 days), NM, PA HUMIRA KIT 20MG/0.4ML OTHER QL (2 syringes / 28 days), NM, PA HUMIRA KIT 40MG/0.8ML OTHER QL (6 syringes / 28 days), NM, PA HUMIRA PEDIATRIC CROHNS DISEASE OTHER NM, PA HUMIRA PEN OTHER QL (6 pens / 28 days), NM, PA

HUMIRA PEN CD/UC/HS STARTER OTHER NM, PA HUMIRA PEN INJ CD/UC/HS STARTER OTHER NM, PA HUMIRA PEN INJ PS/UV STARTER OTHER NM, PA


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Drug Name Drug Tier Requirements/Limits HUMIRA PEN-PS/UV STARTER OTHER NM, PA

hydroxychloroquine sulfate GENERIC leflunomide TABS GENERIC QL (30 tabs / 30 days)

methotrexate sodium tabs GENERIC NM REMICADE OTHER NM, PA RENFLEXIS OTHER NM, LA, PA

RINVOQ OTHER QL (30 tabs / 30 days), NM, PA SKYRIZI OTHER QL (7 kits / year), NM, PA

STELARA SOLN 45mg/0.5ml OTHER QL (1 vial / 28 days), NM, LA, PA STELARA SOSY OTHER QL (1 syringe / 28 days), NM, PA XATMEP OTHER B/D, NM XELJANZ OTHER QL (60 tabs / 30 days), NM, PA XELJANZ XR OTHER QL (30 tabs / 30 days), NM, PA

IMMUNOGLOBULINS BIVIGAM OTHER NM, PA

GAMASTAN S/D OTHER B/D, NM GAMMAGARD LIQUID OTHER NM, PA GAMMAGARD S/D OTHER NM, PA

GAMMAKED OTHER NM, PA GAMMAPLEX OTHER NM, PA GAMMAPLEX 10GM/100ML OTHER NM, PA

GAMUNEX-C OTHER NM, PA OCTAGAM OTHER NM, PA

PANZYGA OTHER NM, PA PRIVIGEN OTHER NM, PA

IMMUNOMODULATORS ACTIMMUNE OTHER NM, LA, PA

ARCALYST OTHER NM, PA INTRON-A INJ 10MU OTHER B/D, NM INTRON-A INJ 18MU OTHER B/D, NM INTRON-A INJ 25MU OTHER B/D, NM INTRON-A INJ 50MU OTHER B/D, NM

IMMUNOSUPPRESSANTS azathioprine TABS GENERIC B/D

BENLYSTA OTHER NM, PA cyclosporine CAPS; SOLN GENERIC B/D, NM cyclosporine modified (for microemulsion) GENERIC B/D, NM

everolimus (immunosuppressan t) GENERIC B/D, NM gengraf GENERIC B/D, NM

mycophenolate mofetil CAPS; SUSR; TABS GENERIC B/D, NM mycophenolate sodium tbec GENERIC B/D, NM

NULOJIX OTHER B/D, NM PROGRAF PACK OTHER B/D, NM

SANDIMMUNE SOLN 100mg/ml OTHER B/D, NM sirolimus SOLN; TABS GENERIC B/D, NM

Drug Name Drug Tier Requirements/Limits tacrolimus CAPS GENERIC B/D, NM ZORTRESS TAB 0.5MG OTHER B/D, NM ZORTRESS TAB 0.25MG OTHER B/D, NM ZORTRESS TAB 0.75MG OTHER B/D, NM ZORTRESS TAB 1MG OTHER B/D, NM VACCINES

ACTHIB OTHER NM ADACEL OTHER NM

BCG VACCINE OTHER NM BEXSERO OTHER NM BOOSTRIX OTHER NM DAPTACEL OTHER NM

DIPHTHERIA/TETANUS TOXOID OTHER B/D, NM ENGERIX-B SUSP OTHER B/D, NM

GARDASIL 9 OTHER NM HAVRIX OTHER NM HIBERIX OTHER NM

IMOVAX RABIES (H.D.C.V.) OTHER B/D, NM INFANRIX OTHER NM

IPOL INACTIVATED IPV OTHER NM IXIARO OTHER NM KINRIX OTHER NM

M-M-R II OTHER NM MENACTRA OTHER NM

MENVEO OTHER NM PEDIARIX OTHER NM

PEDVAX HIB OTHER NM PENTACEL OTHER NM PROQUAD OTHER NM

QUADRACEL OTHER NM RABAVERT OTHER B/D, NM

RECOMBIVAX HB OTHER B/D, NM ROTARIX OTHER NM ROTATEQ OTHER NM SHINGRIX OTHER QL (2 vials per lifetime), NM

TDVAX OTHER B/D, NM TENIVAC OTHER B/D, NM

TRUMENBA OTHER NM

TWINRIX INJ OTHER NM TYPHIM VI OTHER NM

VAQTA OTHER NM VARIVAX OTHER NM

YF-VAX OTHER NM ZOSTAVAX OTHER QL (1 vial per lifetime), NM


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Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits NUTRITIONAL/SUPPLEMENTS – VITAMINS AND SUPPLEMENTS ELECTROLYTES

klor-con 8 GENERIC klor-con 10 GENERIC klor-con m10 GENERIC klor-con m15 GENERIC klor-con m20 GENERIC

klor-con pak 20meq GENERICklor-con spr cap 8meq GENERICklor-con spr cap 10meq GENERICMAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml,4gm/50ml, 20gm/500ml, 40gm/1000ml

OTHER NM

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

GENERIC NM

MAGNESIUM SULFATE IN D5W OTHER NM magnesium sulfate in dextrose GENERIC NM

magnesium sulfate inj 50% GENERIC NM potassium chloride CPCR GENERIC potassium chloride PACK GENERIC potassium chloride SOLN 10%, 20% GENERIC potassium chloride TBCR GENERIC potassium chloride microencapsulated crystals er GENERIC

sodium chloride SOLN 2.5meq/ml GENERIC NM sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln GENERIC NM

TPN ELECTROLYTES OTHER B/D, NM

IV NUTRITION AMINOSYN II INJ 10% OTHER B/D, NM

AMINOSYN-PF 7% OTHER B/D, NM CLINIMIX 4.25%/DEXTROSE 5% OTHER B/D, NM CLINIMIX 5%/DEXTROSE 15% OTHER B/D, NM CLINIMIX 5%/DEXTROSE 20% OTHER B/D, NM CLINIMIX INJ 4.25/D10 OTHER B/D, NM

clinisol sf 15% GENERIC B/D, NM CLINOLIPID OTHER B/D, NM FREAMINE HBC 6.9% OTHER B/D, NM FREAMINE III OTHER B/D, NM

hepatamine GENERIC B/D, NM INTRALIPID 30% OTHER B/D, NM

intralipid inj 20% GENERIC B/D, NM NEPHRAMINE OTHER B/D, NM

nutrilipid inj 20% GENERIC B/D, NM plenamine GENERIC B/D, NM

premasol 10% GENERIC B/D, NM PROCALAMINE OTHER B/D, NM

PROSOL OTHER B/D, NM


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits TRAVASOL OTHER B/D, NM

TROPHAMINE INJ 10% OTHER B/D, NM IV REPLACEMENT SOLUTIONS

dextrose 2.5%/nacl 0.45% GENERIC NM dextrose 5% GENERIC NM

DEXTROSE 5% /ELECTROLYTE OTHER NM dextrose 5%/nacl 0.2% GENERIC NM

DEXTROSE 5%/NACL 0.3% OTHER NM dextrose 5%/nacl 0.9% GENERIC NM dextrose 5%/nacl 0.45% GENERIC NM dextrose 5%/nacl 0.225% GENERIC NM dextrose 5%/potassium chl GENERIC NM dextrose 10% flex contain GENERIC NM

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% OTHER NM dextrose 10%/nacl 0.45% GENERIC NM dextrose 50% GENERIC NM dextrose in lactated ringers GENERIC NM dextrose inj 70% GENERIC NM

ISOLYTE P OTHER NM ISOLYTE S OTHER NM

kcl0.15%/d5w/nacl0.2% GENERIC NM KCL 0.3%/D5W/NACL 0.9% OTHER NM

kcl 0.3%/d5w/nacl 0.45% GENERIC NM kcl 0.15%/d5w/nacl 0.9% GENERIC NM KCL 0.15%/D5W/NACL 0.225% OTHER NM

kcl 0.075%/d5w/nacl 0.45% GENERIC NM kcl/d5w inj 0.3% GENERIC NM

kcl/d5w/nacl inj 0.22%/0.45% GENERIC NM kcl/d5w/nacl inj .15/.45% GENERIC NM

kcl/nacl inj 0.3-0.9 GENERIC NM kcl/nacl inj 0.15%-0.9% GENERIC NM lactated ringer's GENERIC NM

NORMOSOL-M IN D5W OTHER NMNORMOSOL-R OTHER NM

NORMOSOL-R IN D5W OTHER NM PLASMA-LYTE A OTHER NM

PLASMA-LYTE-148 OTHER NMpot chloride inj 2meq/ml GENERIC NMpotassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

GENERIC NM

potassium chloride in nacl GENERIC NMsodium chloride SOLN 3%, 5% GENERIC NMsodium chloride 0.45% GENERIC NMsodium chloride inj 0.9% GENERIC NM

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Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits VITAMINS calcitriol CAPS GENERIC B/D calcitriol inj GENERIC B/D, NM calcitriol oral soln 1 mcg/ml GENERIC B/D M-NATAL PLUS OTHER NM paricalcitol CAPS GENERIC B/D PNV FOLIC ACID + IRON MUL OTHER NM PRENATAL OTHER NM PRENATAL PLUS OTHER NM PRENATAL PLUS LOW IRON OTHER NM RAYALDEE OTHER TRICARE OTHER NM OPHTHALMIC – DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY – DRUGS TO TREAT INFECTIONS AND INFLAMMATION

bacitracin-poly-neomycin-hc GENERIC NM blephamide OINT GENERIC NM

neomycin-polymy-dexameth GENERIC NM neomycin-polymyxin-hc (ophth) GENERIC NM

sulfacetamide sod-prednisolone GENERIC NM TOBRADEX OINT OTHER NM

TOBRADEX ST OTHER NM tobramycin-dexamethasone GENERIC NM

ZYLET OTHER NM ANTI-INFECTIVES – DRUGS TO TREAT INFECTIONS

AZASITE OTHER NM bacitracin (ophthalmic) GENERIC NM

bacitracin-polymyxin b (ophth) GENERIC NM BESIVANCE OTHER NM

CILOXAN OINT OTHER NM ciprofloxacin hcl (ophth) GENERIC NM erythromycin (ophth) GENERIC NM

gatifloxacin (ophth) GENERIC NM gentak GENERIC NM

gentamicin sulfate soln (ophth) GENERIC NM MOXEZA OTHER NM

moxifloxacin hcl (ophth) GENERIC NM NATACYN OTHER NM

neomycin-bacitracin zn-polymyxin GENERIC NM neomycin-polymyxin-gramicidin GENERIC NM

ofloxacin (ophth) GENERIC NM polymyxin b-trimethoprim GENERIC NM

sulfacetamide sodium (ophth) GENERIC NM tobramycin (ophth) GENERIC NM

trifluridine GENERIC NM ZIRGAN OTHER NM



Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits ANTI-INFLAMMATORIES – DRUGS TO TREAT INFLAMMATION ALREX OTHER NM bromfenac sodium (ophth) GENERIC NM BROMSITE OTHER NM dexamethasone sodium phosphate (ophth) GENERIC NM diclofenac sodium (ophth) GENERIC NM DUREZOL OTHER NM FLAREX OTHER NM fluorometholone GENERIC NM flurbiprofen sodium GENERIC NM ILEVRO OTHER NM ketorolac tromethamine (ophth) GENERIC NM LOTEMAX GEL; OINT OTHER NM loteprednol etabonate GENERIC NM prednisolone acetate (ophth) GENERIC NM prednisolone sodium phosphate (ophth) GENERIC NM PROLENSA OTHER NM ANTIALLERGICS – DRUGS TO TREAT ALLERGIES azelastine drop 0.05% GENERIC NM BEPREVE OTHER NM cromolyn sodium (ophth) GENERIC NM LASTACAFT OTHER NM olopatadine hcl 0.2% GENERIC NM PAZEO OTHER NM

ZERVIATE OTHER NM ANTIGLAUCOMA – DRUGS TO TREAT GLAUCOMA

ALPHAGAN P SOL 0.1% OTHER AZOPT OTHER

betaxolol hcl (ophth) GENERIC BETOPTIC-S OTHER brimonidine sol 0.2% GENERIC brimonidine sol 0.15% GENERIC

carteolol hcl (ophth) GENERIC COMBIGAN OTHER

dorzolamide hcl GENERIC dorzolamide hcl-timolol maleate GENERIC

latanoprost SOLN GENERIC levobunolol hcl GENERIC LUMIGAN OTHER

PHOSPHOLINE IODIDE OTHER pilocarpine hcl SOLN GENERIC RHOPRESSA OTHER

SIMBRINZA OTHERtimolol maleate (ophth) soln GENERICtimolol maleate gel G ENERIC


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits timolol maleate ophth soln 0.5% (once-daily) GENERIC travoprost GENERIC MISCELLANEOUS ATROPINE SULFATE SOLN 1% OTHER CYSTARAN OTHER NM, LA, PA proparacaine hcl SOLN GENERIC NM

RESTASIS OTHER QL (60 single use vials / 30 days) RESTASIS MULTIDOSE OTHER QL (1 bottle / 30 days)

RESPIRATORY – DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS – DRUGS TO TREAT COPD ANORO ELLIPTA OTHER QL (60 blisters / 30 days)BEVESPI AEROSPHERE OTHER QL (1 inhaler / 30 days)COMBIVENT RESPIMAT OTHER QL (2 inhalers / 30 days)ipratropium-albuterol nebu GENERIC B/D

TRELEGY ELLIPTA OTHER QL (60 blisters / 30 days)ANTICHOLINERGICS – DRUGS TO TREAT COPD ATROVENT HFA OTHER QL (2 inhalers / 30 days) INCRUSE ELLIPTA OTHER QL (30 blisters / 30 days) ipratropium bromide SOLN GENERIC B/D ipratropium bromide (nasal) GENERIC ANTIHISTAMINES – DRUGS TO TREAT ALLERGIES azelastine spr 0.1% GENERIC NM azelastine spr 0.15% GENERIC NM cetirizine syrup GENERIC NM cyproheptadine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and older diphenhydramine hcl inj 50mg/ml GENERIC NM hydroxyzine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and older hydroxyzine hcl inj GENERIC NM, PA; PA if 70 years and older hydroxyzine pamoate CAPS 25mg, 50mg GENERIC NM, PA; PA if 70 years and older levocetirizine dihydrochloride GENERIC NM BETA AGONISTS – DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate AERS 108mcg/act GENERIC QL (2 inhalers / 30 days);

(generic of Proair HFA) albuterol sulfate AERS 108mcg/act GENERIC QL (2 inhalers / 30 days);

(generic of Ventolin HFA) albuterol sulfate NEBU .083%, .63mg/3ml, 1.25mg/3ml, 2.5mg/0.5ml

GENERIC B/D

albuterol sulfate SYRP GENERIC albuterol sulfate TABS GENERIC albuterol sulfate TB12 GENERIC levalbuterol hcl NEBU GENERIC B/D levalbuterol hcl soln nebu conc 1.25 mg/0.5ml GENERIC B/D levalbuterol tartrate hfa GENERIC QL (2 inhalers / 30 days) SEREVENT DISKUS OTHER QL (60 inhalations / 30 days) terbutaline sulfate TABS GENERIC


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits VENTOLIN HFA OTHER QL (2 inhalers / 30 days) LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK; TABS GENERIC zafirlukast GENERIC MAST CELL STABILIZERS – DRUGS TO TREAT ALLERGIES cromolyn sod neb 20mg/2ml GENERIC B/D MISCELLANEOUS acetylcysteine SOLN 10%, 20% GENERIC B/D, NM ARALAST NP OTHER NM, LA, PA DALIRESP OTHER epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml GENERIC NM; (generic of EpiPen) epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml GENERIC NM; (generic of Adrenaclick) ESBRIET OTHER NM, PA FASENRA OTHER NM, LA, PA FASENRA PEN OTHER NM, LA, PA KALYDECO OTHER NM, PA NUCALA OTHER NM, LA, PA OFEV OTHER NM, PA ORKAMBI OTHER NM, PA PROLASTIN-C OTHER NM, LA, PA PULMOZYME OTHER NM, PA SYMDEKO OTHER NM, LA, PA

SYMJEPI OTHER NM theo-24 GENERIC

theophylline GENERICtheophylline tab er 12hr 300 mg GENERICtheophylline tab er 12hr 450 mg GENERICtheophylline tab sr 24hr GENERICTRIKAFTA OTHER NM, LA, PA XOLAIR OTHER NM, LA, PA ZEMAIRA OTHER NM, LA, PA NASAL STEROIDS – DRUGS TO TREAT ALLERGIES flunisolide (nasal) GENERIC QL (3 bottles / 30 days), NM fluticasone propionate (nasal) GENERIC QL (1 bottle / 30 days), NM STEROID INHALANTS – DRUGS TO TREAT ASTHMA

ARNUITY ELLIPTA OTHER QL (30 inhalations / 30 days)

budesonide (inhalation) .25mg/2ml, .5mg/2ml GENERIC B/D FLOVENT DISKUS 50mcg/blist, 100mcg/blist OTHER QL (120 inhalations / 30 days) FLOVENT DISKUS 250mcg/blist OTHER QL (240 inhalations / 30 days) FLOVENT HFA OTHER QL (2 inhalers / 30 days)

PULMICORT FLEXHALER OTHER QL (2 inhalers / 30 days)STEROID/BETA-AGONIST COMBINATIONS – DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS OTHER QL (60 inhalations / 30 days)

ADVAIR HFA OTHER QL (1 inhaler / 30 days)


Formulary ID 00020345 v13 08/01/2020

Drug Name Drug Tier Requirements/Limits BREO ELLIPTA OTHER QL (60 blisters / 30 days) SYMBICORT OTHER QL (1 inhaler / 30 days) TOPICAL – DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE amnesteem GENERIC NM, PA avita GENERIC QL (45 grams / 30 days), NM, PA benzoyl peroxide-erythromycin GENERIC NM claravis GENERIC NM, PA clindamycin phosphate (topical) GEL GENERIC QL (75 grams / 30 days), NM clindamycin phosphate (topical) LOTN GENERIC NM clindamycin phosphate (topical) SOLN GENERIC QL (60 mL / 30 days), NM ery pad 2% GENERIC NM erythromycin (acne aid) GENERIC NM isotretinoin CAPS GENERIC NM, PA

myorisan GENERIC NM, PA sulfacetamide sodium (acne) GENERIC NM

tretinoin CREA GENERIC QL (45 grams / 30 days), NM, PA tretinoin GEL .01%, .025% GENERIC QL (45 grams / 30 days), NM, PA zenatane GENERIC NM, PA

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) GENERIC NM

mupirocin OINT GENERIC QL (220 grams / 30 days), NM silver sulfadiazine CREA GENERIC NM ssd GENERIC NM SULFAMYLON CREA OTHER NM DERMATOLOGY, ANTIFUNGALS ciclopirox CREA GENERIC QL (90 grams / 30 days), NM ciclopirox SUSP GENERIC QL (60 mL / 30 days), NM clotrimazole (topical) CREA GENERIC NM clotrimazole (topical) SOLN GENERIC QL (30 mL / 30 days), NM clotrimazole w/ betamethasone CREA GENERIC NM ketoconazole cream GENERIC QL (60 grams / 30 days), NM nyamyc GENERIC QL (60 grams / 30 days), NM nystatin (topical) CREA; OINT GENERIC NM nystatin (topical) POWD GENERIC QL (60 grams / 30 days), NM nystop GENERIC QL (60 grams / 30 days), NM DERMATOLOGY, ANTIPSORIATICS acitretin GENERIC NM, PA calcipotriene CREA; OINT GENERIC QL (120 grams / 30 days), NM, PA calcipotriene SOLN GENERIC QL (120 mL / 30 days), NM, PA calcitrene GENERIC QL (120 grams / 30 days), NM, PA tazarotene CREA GENERIC QL (60 grams / 30 days), NM, PA TAZORAC CREA .05% OTHER QL (60 grams / 30 days), NM, PA


Formulary ID 00020345 v13 08/01/2020

50

Drug Name Drug Tier Requirements/Limits DERMATOLOGY, ANTISEBORRHEICS

ketoconazole shampoo GENERIC NM selenium sulfide LOTN GENERIC NM

DERMATOLOGY, CORTICOSTEROIDS ala-cort GENERIC NM

alclometasone dipropionate GENERIC NM betamethasone dipropionate (topical) GENERIC NM betamethasone dipropionate augmented GENERIC NM betamethasone valerate CREA; LOTN; OINT GENERIC NM

ENSTILAR OTHER QL (120 grams / 30 days), NM, PA fluocinolone acetonide CREA; OIL; OINT GENERIC NM fluocinolone acetonide SOLN GENERIC QL (90 mL / 30 days), NM fluocinolone acetonide oil body GENERIC NM fluocinonide CREA .05% GENERIC QL (120 grams / 30 days), NM fluocinonide GEL GENERIC QL (60 grams / 30 days), NM fluocinonide OINT GENERIC QL (60 grams / 30 days), NM fluocinonide SOLN GENERIC QL (60 mL / 30 days), NM fluocinonide emulsified base GENERIC QL (120 grams / 30 days), NM

fluticasone propionate CREA; OINT GENERIC NM halobetasol propionate CREA; OINT GENERIC QL (50 grams / 30 days), NM

hydrocortisone (topical) cream 1% GENERIC NM hydrocortisone (topical) cream 2.5% GENERIC NM hydrocortisone (topical) lotion 2.5% GENERIC NM hydrocortisone (topical) oint 2.5% GENERIC NM hydrocortisone butyrate cream 0.1% GENERIC QL (45 grams / 30 days), NM hydrocortisone butyrate oint 0.1% GENERIC QL (45 grams / 30 days), NM

mometasone furoate CREA; OINT; SOLN GENERIC NM texacort soln 2.5% GENERIC NM

triamcinolone acetonide (topical) CREA .1% GENERIC QL (454 grams / 30 days), NM triamcinolone acetonide (topical) CREA .025%, .5% GENERIC NM triamcinolone acetonide (topical) LOTN GENERIC NM triamcinolone acetonide (topical) OINT .025%, .1%, .5% GENERIC NM

DERMATOLOGY, LOCAL ANESTHETICS glydo GENERIC QL (30 mL / 30 days), NM, PA

lidocaine PTCH 5% GENERIC QL (3 patches / 1 day), NM, PA lidocaine hcl GEL GENERIC QL (30 mL / 30 days), NM, PA lidocaine hcl SOLN 4% GENERIC QL (50 mL / 30 days), NM, PA lidocaine oint 5% GENERIC QL (50 grams / 30 days), NM, PA

lidocaine-prilocaine GENERIC QL (30 grams / 30 days), NM, PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE

ammonium lactate CREA; LOTN GENERIC NM diclofenac sodium (topical) 1% gel GENERIC QL (1000 grams / 30 days), NM,

PA fluorouracil (topical) CREA 5% GENERIC QL (40 grams / 30 days), NM

fluorouracil (topical) SOLN GENERIC QL (10 mL / 30 days), NM

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Drug Name Drug Tier Requirements/Limits imiquimod CREA 5% GENERIC QL (24 packets / 30 days), NM metronidazole (topical) CREA; LOTN GENERIC NM metronidazole gel 0.75% GENERIC NM PANRETIN OTHER QL (60 grams / 30 days), NM PICATO .05% OTHER QL (2 tubes / 30 days), NM PICATO .015% OTHER QL (3 tubes / 30 days), NM podofilox SOLN GENERIC NM procto-med hc GENERIC NM procto-pak GENERIC NM proctosol hc cre 2.5% GENERIC NM proctozone-hc GENERIC NM RECTIV OTHER QL (30 grams / 30 days), N M rosadan cre 0.75% GENERIC NM tacrolimus (topical) GENERIC QL (100 grams / 30 days), NM TARGRETIN GEL OTHER QL (60 grams / 30 days), NM, PA VALCHLOR OTHER QL (60 grams / 30 days), NM, LA,

PA DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion GENERIC NM permethrin cre 5% GENERIC NM DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% GENERIC NM REGRANEX OTHER QL (30 grams / 30 days), NM, PA SANTYL OTHER NM sodium chlor sol 0.9% irr GENERIC NM water for irrigation, sterile GENERIC NM MOUTH/THROAT/DENTAL AGENTS cevimeline hcl GENERIC chlorhexidine gluconate (mouth-throat) GENERIC NM clotrimazole LOZG GENERIC NM lidocaine hcl (mouth-throat) GENERIC NM nystatin (mouth-throat) GENERIC NM paroex sol 0.12% GENERIC NM periogard GENERIC NM pilocarpine hcl (oral) GENERIC

triamcinolone acetonide (mouth) GENERIC NMOTIC – DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid (otic) GENERIC NM

CIPRODEX OTHER NM flac GENERIC NM

fluocinolone acetonide (otic) GENERIC NM neomycin-polymyxin-hc (otic) GENERIC NM

ofloxacin (otic) GENERIC NM


Formulary I D 00020345 v13 08/01/2020

Index

abacavir sulfate 5abacavir sulfate-lamivudine 6abacavir sulfate-lamivudine-zidovudine 6ABELCET 4ABILIFY MAINTENA 23abiraterone acetate 11ABRAXANE 10acamprosate calcium 27acarbose 28acebutolol hcl 16acetaminophen w/ codeine 300-15mg 1acetaminophen w/ codeine 300-30mg 1acetaminophen w/ codeine 300-60mg 1acetaminophen w/ codeine soln 1acetazolamide 17acetic acid 51acetic acid (otic) 51acetylcysteine 48acitretin 49ACTHIB 42ACTIMMUNE . 41acyclovir 7acyclovir sodium 7ADACEL 42adefovir dipivoxil 7ADEMPAS 18adriamycin 9adrucil inj 9ADVAIR DISKUS 48ADVAIR HFA 48AFINITOR 12AFINITOR DISPERZ 12AIMOVIG 26ala-cort 50albendazole 3albuterol sulfate 47alclometasone dipropionate 50ALDURAZYME 34ALECENSA 12alendronate sodium soln 70mg/75ml 30alendronate sodium tab 10 mg 30alendronate sodium tab 35 mg 30alendronate sodium tab 40 mg 30alendronate sodium tab 5 mg 30alendronate sodium tab 70 mg 30alfuzosin hcl 39ALIMTA 9ALINIA 3aliskiren fumarate 18

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allopurinol tab . 1alosetron hcl ..

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38ALPHAGAN P SOL 0.1% 46alprazolam tab 0.25mg 18alprazolam tab 0.5mg 18alprazolam tab 1mg 18alprazolam tab 2 mg 19ALREX 46altavera tab 31ALUNBRIG 12alyacen 1/35 31amantadine hcl 22AMBISOME 4ambrisentan 18amethia 31amethia lo 31amikacin sulfate 3amiloride & hydrochlorothiazide 17amiloride hcl 17AMINOSYN II INJ 10% 43AMINOSYN-PF 7% 43amiodarone hcl soln 15amiodarone tab 100mg 15amiodarone tab 200mg 15amiodarone tab 400mg 15AMITIZA CAP 24MCG 38AMITIZA CAP 8MCG 38amitriptyline hcl. 21amlodipine besylate 17amlodipine besylate-benazepril hcl cap 10-20 mg 14amlodipine besylate-benazepril hcl cap 10-40 mg 14amlodipine besylate-benazepril hcl cap 2.5-10 mg 14amlodipine besylate-benazepril hcl cap 5-10 mg 14amlodipine besylate-benazepril hcl cap 5-20 mg 14amlodipine besylate-benazepril hcl cap 5-40 mg 14amlodipine besylate-olmesartan medoxomil 15amlodipine besylate-valsartan tab 15amlodipine-valsartan-hydrochlorothiazide tab 15ammonium lactate . 50amnesteem 49amoxapine 21amoxicillin 8amoxicillin & pot clavulanate 200/5ml susr 8amoxicillin & pot clavulanate 200-28.5 chw tabs 8amoxicillin & pot clavulanate 250/5ml susr 8amoxicillin & pot clavulanate 250-125 tabs 8amoxicillin & pot clavulanate 400/5ml susr 8amoxicillin & pot clavulanate 400-57 chw tabs 8amoxicillin & pot clavulanate 500-125 tabs 8

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amoxicillin & pot clavulanate 600/5ml susr 8amoxicillin & pot clavulanate 875-125 tabs 8amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs 8amphetamine-dextroamphetamine cap sr 24hr 10 mg. 25amphetamine-dextroamphetamine cap sr 24hr 15 mg. 25amphetamine-dextroamphetamine cap sr 24hr 20 mg. 25amphetamine-dextroamphetamine cap sr 24hr 25 mg. 25amphetamine-dextroamphetamine cap sr 24hr 30 mg. 25amphetamine-dextroamphetamine cap sr 24hr 5 mg 25amphetamine-dextroamphetamine tab 10 mg 25amphetamine-dextroamphetamine tab 12.5 mg 25amphetamine-dextroamphetamine tab 15 mg 25amphetamine-dextroamphetamine tab 20 mg 25amphetamine-dextroamphetamine tab 30 mg 25amphetamine-dextroamphetamine tab 5 mg 25amphetamine-dextroamphetamine tab 7.5 mg 25amphotericin b 4ampicillin & sulbactam sodium 8ampicillin cap 500mg 8ampicillin inj 8ampicillin sodium 8ANADROL-50 . 27anagrelide hcl 40anastrozole 11ANDRODERM 27ANORO ELLIPTA 47APOKYN 22aprepitant 37aprepitant pak 80mg & 125mg 37apri 31APTIOM 19APTIVUS 5ARALAST NP 48aranelle 31ARCALYST 41aripiprazole odt 23aripiprazole oral solution 1 mg/ml 23aripiprazole tab 23ARISTADA 23ARISTADA INITIO 23armodafinil 27ARNUITY ELLIPTA 48ashlyna 31aspirin-dipyridamole 40atazanavir sulfate 5atenolol 16atenolol & chlorthalidone 16atomoxetine hcl 25atorvastatin calcium 15atovaquone 3atovaquone-proguanil hcl 4ATRIPLA 6

ATROPINE SULFATE 47ATROVENT HFA 47aubra 31AURYXIA 36AUSTEDO 26AVASTIN 10aviane 31avita 49AYVAKIT 12azacitidine 9AZASITE 45azathioprine 41azelastine drop 0.05% 46azelastine spr 0.1% 47azelastine spr 0.15% 47azithromycin 8AZOPT 46aztreonam 3bacitracin (ophthalmic) 45bacitracin-polymyxin b (ophth) 45bacitracin-poly-neomycin-hc 45baclofen 27balsalazide disodium 37BALVERSA 12balziva 31BANZEL SUS 40MG/ML 19BANZEL TAB 200MG 19BANZEL TAB 400MG 19BARACLUDE 7BASAGLAR KWIKPEN 28BCG VACCINE 42BD ALCOHOL SWABS 28BD ULTRAFINE INSULIN SYRINGE 28BD ULTRAFINE/NANO PEN NEEDLES 28bekyree 31BELSOMRA 25benazepril & hydrochlorothiazide 14benazepril hcl 14BENDEKA 9BENLYSTA 41benzoyl peroxide-erythromycin 49benztropine mesylate inj 22benztropine mesylate tab 0.5mg 22benztropine mesylate tab 1mg 22benztropine mesylate tab 2mg 22BEPREVE 46BERINERT 40BESIVANCE 45betamethasone dipropionate (topical) 50betamethasone dipropionate augmented 50betamethasone valerate 50BETASERON 26

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betaxolol hcl 16betaxolol hcl (ophth) 46bethanechol chloride 39BETOPTIC-S 46BEVESPI AEROSPHERE 47bexarotene 13BEXSERO 42bicalutamide . 11BICILLIN L-A 8BIKTARVY 6bisoprolol & hydrochlorothiazide 16bisoprolol fumarate 16BIVIGAM 41blephamide 45blisovi 24 fe 31blisovi fe 1.5/30 31BOOSTRIX 42BORTEZOMIB 10bosentan 18BOSULIF 12BRAFTOVI 12BREO ELLIPTA 49briellyn 31BRILINTA 40brimonidine sol 0.15% 46brimonidine sol 0.2% 46BRIVIACT INJ 5 0MG/5ML 19BRIVIACT SOL 10MG/ML 19BRIVIACT TAB 100MG 19BRIVIACT TAB 10MG 19BRIVIACT TAB 25MG 19BRIVIACT TAB 50MG 19BRIVIACT TAB 75MG 19bromfenac sodium (ophth) 46bromocriptine mesylate 22BROMSITE 46BRUKINSA 12budesonide (inhalation) 48budesonide ec 37bumetanide inj 0.25/ml 17bumetanide tab 17buprenorphine hcl 27buprenorphine hcl-naloxone hcl dihydrate 12-3mg 27buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg 27buprenorphine hcl-naloxone hcl dihydrate 4-1mg 27buprenorphine hcl-naloxone hcl dihydrate 8-2mg 27buprenorphine hcl-naloxone hcl sl . 27bupropion hcl 21bupropion hcl (smoking deterrent) 27buspirone hcl . 19butorphanol tartrate 1BYDUREON BCISE 28

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BYDUREON PEN 28BYETTA 28BYSTOLIC 16cabergoline 35CABOMETYX 12calcipotriene 49calcitonin (salmon) 35calcitrene 49calcitriol 45calcitriol inj 45calcitriol oral soln 1 mcg/ml 45calcium acetate (phosphate binder) 36CALQUENCE 12camila 31camrese lo 31candesartan cilexetil 15candesartan cilexetil-hydrochlorothiazide 15CAPLYTA 23CAPRELSA 12captopril 14captopril & hydrochlorothiazide 14CARBAGLU 34carbamazepine 19carbidopa/levodopa/entacapone 22carbidopa-levodopa 22carboplatin 13carisoprodol 27carteolol hcl (ophth) 46cartia xt 17carvedilol 16caspofungin acetate 4CAYSTON 3caziant pak 31cefaclor 7cefaclor er tab 500mg 7cefadroxil 7CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 7cefazolin inj 7cefazolin sodium 7cefazolin sodium 1 gm/50ml 7cefdinir 7cefepime for inj 7cefixime 7cefoxitin for inj . 7cefpodoxime proxetil 7cefprozil 7ceftazidime 7CEFTAZIDIME/DEXTROSE 7ceftriaxone sodium 7cefuroxime axetil 7cefuroxime sodium 7celecoxib 1

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CELONTIN 19cephalexin 8CERDELGA 34CEREZYME 34cetirizine syrup 47cevimeline hcl 51CHANTIX 27CHANTIX CONTINUING MONTH 27CHANTIX STARTER PACK 27CHEMET 30chlorhexidine gluconate (mouth-throat) 51chloroquine phosphate 4chlorothiazide 17chlorpromazine hcl 23chlorpromazine inj 23chlorthalidone 17cholestyramine 16cholestyramine light pack 16cholestyramine light powd 16ciclopirox 49cilostazol 40CILOXAN 45CIMDUO 6cinacalcet hcl 35CIPRO 8CIPRODEX 51ciprofloxacin hcl (ophth) 45ciprofloxacin hcl tab 8ciprofloxacin in d5w 8cisplatin 13citalopram hydrobromide 21claravis 49clarithromycin 8clarithromycin er 8clarithromycin for susp 8clindamycin cap 300 mg 3clindamycin cap 75mg 3clindamycin hcl cap 150 mg 3clindamycin phosphate (topical) 49clindamycin phosphate in d5w 3CLINDAMYCIN PHOSPHATE IN NACL 3clindamycin phosphate inj 3clindamycin phosphate vaginal 39clindamycin soln 75mg/5ml 3CLINIMIX 4.25%/DEXTROSE 5% 43CLINIMIX 5%/DEXTROSE 15% 43CLINIMIX 5%/DEXTROSE 20% 43CLINIMIX INJ 4.25/D10 43clinisol sf 15% 43CLINOLIPID 43clobazam 19clomipramine hcl 21

clonazepam 19clonidine hcl 18clonidine hcl ptwk 18clopidogrel tab 75mg 40clorazepate dipotassium 19clotrimazole 51clotrimazole (topical) 49clotrimazole w/ betamethasone 49clovique 30clozapine odt 23clozapine tab 100mg 23clozapine tab 200mg 23clozapine tab 25mg 23clozapine tab 50mg 23COARTEM 5colchicine w/ probenecid 1COLCRYS 1colesevelam hcl 16colestipol hcl gran 16colestipol hcl pack 16colestipol hcl tabs 16colistimethate sodium 3colocort 37COMBIGAN 46COMBIVENT RESPIMAT 47COMETRIQ 12COMPLERA 6compro supp 37constulose 38COPIKTRA 12CORLANOR 18cortisone acetate 35COTELLIC 12COUMADIN 39CREON 38CRIXIVAN 5cromolyn sod neb 20mg/2ml 48cromolyn sodium (mastocytosis) 38cromolyn sodium (ophth) 46cryselle-28 31cyclafem 1/35 31cyclafem 7/7/7 31cyclobenzaprine hcl 27cyclophosphamide 9cycloserine 6cyclosporine 41cyclosporine modified (for microemulsion) 41cyproheptadine hcl 47cyred tab 31CYSTADANE 34CYSTAGON 34CYSTARAN 47

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9dalfampridine 26DALIRESP . 48danazol 34dantrolene sodium 27dapsone 3DAPTACEL 42daptomycin . 3dasetta 1/35 31dasetta 7/7/7 31DAURISMO 10deblitane . 31deferasirox tab 30DELESTROGEN 34DELSTRIGO . . 6DEMSER 18DEPO-PROVERA INJ 400/ML 11DESCOVY . 6desipramine hcl . 21desmopressin acetate spray 36desmopressin acetate spray refrigerated 36desmopressin acetate tabs 36desmopressin inj 4mcg/ml 36desogestrel & ethinyl estradiol 31desogestrel-ethinyl estradiol (biphasic) 31desvenlafaxine succinate . 21dexamethasone 35dexamethasone sodium phosphate 35dexamethasone sodium phosphate (ophth) 46DEXILANT . 38dexmethylphenidate hcl 25dextrose 10% flex contain 44DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% 44dextrose 10%/nacl 0.45% 44dextrose 2.5%/nacl 0.45% 44dextrose 5% . 44DEXTROSE 5% /ELECTROLYTE 44dextrose 5%/nacl 0.2% . 44dextrose 5%/nacl 0.225% . 44DEXTROSE 5%/NACL 0.3% 44dextrose 5%/nacl 0.45% 44dextrose 5%/nacl 0.9% 44dextrose 5%/potassium chl . 44dextrose 50% 44dextrose in lactated ringers . 44dextrose inj 70% 44DIASTAT ACUDIAL 19DIASTAT PEDIATRIC 19diazepam 19diazepam gel 19diazepam inj 19diazepam intensol 19

diazepam oral soln 1 mg/ml . 19diazoxide . 35diclofenac potassium . 1diclofenac sodium . 1diclofenac sodium (ophth) 46diclofenac sodium (topical) 1% gel 50dicloxacillin sodium . 8dicyclomine hcl cap 10mg 37dicyclomine hcl soln 10mg/5ml 37dicyclomine hcl tab 20mg . 37didanosine .. 5DIFICID . 8diflunisal . 1digitek 17digox . 17digoxin 17digoxin inj 17digoxin sol 50mcg/ml 17dihydroergotamine mesylate inj 1 mg/ml 26dihydroergotamine mesylate nasal spr 4 mg/ml 26dilantin cap 100mg. 19dilantin cap 30mg 19dilantin chew tab 50mg 19DILANTIN-125 SUSP 19diltiazem cap 240mg cd 17diltiazem cap 360mg cd 17diltiazem cap er/12hr 17diltiazem hcl . 17diltiazem hcl coated beads . 17diltiazem hcl coated beads cap sr 24hr 17diltiazem hcl extended release beads cap sr . 17diltiazem inj 17dilt-xr cap 17diphenhydramine hcl inj 50mg/ml 47diphenoxylate w/ atropine 38DIPHTHERIA/TETANUS TOXOID 42disopyramide phosphate 15disulfiram 27divalproex sodium 19docetaxel . 10DOCETAXEL 10dofetilide 15donepezil hydrochloride 21dorzolamide hcl 46dorzolamide hcl-timolol maleate .. 46DOVATO .. 6doxazosin mesylate 14doxepin hcl . 21doxepin hcl (sleep) .. 25doxorubicin hcl . 9doxorubicin hcl liposomal 9doxy 100 9

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9doxycycline hyclate. 9doxycycline hyclate 100 mg 9doxycycline hyclate 20 mg . 9DRIZALMA SPRINKLE 21dronabinol 37drospirenone-ethinyl estradiol 31drospirenone-ethinyl estradiol-levomefolate calcium 31DROXIA 40duloxetine hcl 21DUREZOL . 46dutasteride 39dutasteride-tamsulosin hcl 39e.e.s. 4 00 . 8EDURANT . 5efavirenz 5eletriptan hydrobromide 26ELIQUIS 39ELIQUIS STARTER PACK 39ELLA 31eluryng . 31EMCYT 9EMEND 37EMGALITY 26emoquette 31EMSAM 21EMTRIVA . . 5emverm . 3enalapril maleate 14enalapril maleate & hydrochlorothiazide 14ENBREL 40ENBREL MINI . 40ENBREL SURECLICK 40ENDARI 40endocet 10-325mg . 2endocet 2.5-325mg 1endocet 5-325mg 1endocet 7.5-325mg 2ENGERIX-B. 42enoxaparin sodium. 39enpresse-28 31enskyce 31ENSTILAR 50entacapone 22entecavir 7ENTRESTO 15enulose 38EPCLUSA 7EPIDIOLEX 19epinephrine (anaphylaxis) 48epirubicin hcl . 9epitol 19

EPIVIR HBV . 7 eplerenone 14 ergotamine w/ caffeine 26 ERIVEDGE 10 ERLEADA 11 erlotinib hcl 12 errin 31 ertapenem sodium . 3 ery p ad 2% 49 ery-tab 8 erythrocin lactobionate 8 erythrocin stearate 8 erythromycin (acne aid) 49 erythromycin (ophth) 45 erythromycin base 8 erythromycin cap 250mg ec 8 erythromycin ethylsuccinate 8 erythromycin tab ec . 8 ESBRIET 48 escitalopram oxalate . 22 esomeprazole magnesium . 38 estarylla tab 0.25-35 31 estradiol 34 estradiol vaginal cream 34 estradiol vaginal tab 34 estradiol valerate inj 35 eszopiclone 25 ethambutol hcl .. 6 ethosuximide 19 ethynodiol diacet & eth estrad . 31 ethynodiol tab 1-50 31 etodolac .. 1 etonogestrel-ethinyl estradiol . 31 etoposide 14 euthyrox 36 everolimus .. 12 everolimus (immunosuppressant) 41 EVOTAZ .. 6 EVZIO .. 27 exemestane . 11 ezetimibe 16 ezetimibe-simvastatin 16 FABRAZYME 34 falmina 32 famciclovir . 7 famotidine 37 famotidine in nacl . 37 famotidine inj 37 FANAPT 23 FANAPT TITRATION PACK 23 FARXIGA 28 FARYDAK 10

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FASENRA 48FASENRA PEN 48fayosim 32felbamate 20felodipine 17femynor 32fenofibrate 16fenofibrate micronized 16fentanyl citrate 2fentanyl patch 1 00 mcg/hr 2fentanyl patch 1 2 mcg/hr 2fentanyl patch 2 5 mcg/hr 2fentanyl patch 5 0 mcg/hr 2fentanyl patch 7 5 mcg/hr 2FETZIMA 22FETZIMA TITRATION PACK 22FIASP 28FIASP FLEXTOUCH 28FIASP PENFILL 28finasteride 39flac 51FLAREX 46flecainide acetate 15FLOVENT DISKUS 48FLOVENT HFA 48fluconazole 4fluconazole inj nacl 200 4fluconazole inj nacl 400 4flucytosine 4fludrocortisone acetate 35flunisolide (nasal) 48fluocinolone acetonide 50fluocinolone acetonide (otic) 51fluocinolone acetonide oil body 50fluocinonide 50fluocinonide emulsified base 50fluorometholone 46fluorouracil 9fluorouracil (topical) 50fluoxetine cap 1 0mg 22fluoxetine cap 2 0mg 22fluoxetine cap 4 0mg 22fluoxetine hcl . 22fluphenazine decanoate 23fluphenazine hcl 23flurbiprofen 1flurbiprofen s odium 46flutamide 11fluticasone propionate 50fluticasone propionate (nasal) 48fluvoxamine maleate 19fondaparinux sodium 39

FORTEO 36fosamprenavir tab 7 00 mg 5fosinopril sodium 14fosinopril sodium & hydrochlorothiazide 14FREAMINE HBC 6.9% 43FREAMINE III . 43fulvestrant 11furosemide 17furosemide inj 17FUZEON 5fyavolv 35FYCOMPA 20gabapentin 20galantamine hydrobromide 21galantamine hydrobromide er 21GAMASTAN S/D 41GAMMAGARD LIQUID 41GAMMAGARD S/D 41GAMMAKED .. 41GAMMAPLEX 41GAMMAPLEX 10GM/100ML 41GAMUNEX-C . 41ganciclovir sodium 7GARDASIL 9 42gatifloxacin (ophth) 45GATTEX 38GAUZE PADS 2 28gavilyte-c 38gavilyte-g 38gavilyte-n/flavor pack 38gemcitabine inj soln 10gemcitabine inj solr 10gemfibrozil 16generlac 38gengraf 41GENOTROPIN 36GENOTROPIN MINIQUICK 36gentak 45gentamicin in saline 3gentamicin sulfate 3gentamicin sulfate (topical) 49gentamicin sulfate soln (ophth) 45GENVOYA 6GEODON 23gianvi tab 3-0.02mg 32GILENYA 26GILOTRIF TAB 20MG 12GILOTRIF TAB 30MG 12GILOTRIF TAB 40MG 12glatiramer acetate 20mg/ml 27glatiramer acetate 40mg/ml 27glatopa 27

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GLEOSTINE 9 glimepiride 28 glip/metform tab 2.5-250mg 28 glip/metform tab 2.5-500mg 29 glip/metform tab 5-500mg 29 glipizide 29 glipizide xl 29 GLUCAGEN HYPOKIT 35 GLUCAGON EMERGENCY KIT 35 glyburide 29 glyburide micronized 29 glyburide-metformin tab 1.25-250 mg 29 glyburide-metformin tab 2.5-500 mg 29 glyburide-metformin tab 5-500mg 29 glycopyrrolate tab 1mg 37 glycopyrrolate tab 2mg 37 glydo 50 GLYXAMBI 29 GOLYTELY 38 granisetron hcl 37 griseofulvin microsize 4 griseofulvin ultramicrosize 4 guanfacine er (adhd) 25 GVOKE HYPOPEN 2-PACK 35 GVOKE PFS 35 HAEGARDA 40 hailey 24 fe 32 halobetasol propionate 50 haloperidol 23 haloperidol conc 2mg/ml 23 haloperidol decanoate 23 haloperidol lactate inj 5mg/ml 23 HARVONI 7 HAVRIX 42 heather 32 heparin sod (porcine) in d5w 39 heparin sod inj 1000/ml 39 heparin sod inj 10000/ml 39 heparin sod inj 20000/ml 39 heparin sod inj 5000/ml 39 HEPARIN SODIUM/NACL 0.45% 39 hepatamine 43 HERCEPTIN 10 HERCEPTIN HYLECTA 10 HERZUMA 10 HETLIOZ 25 HIBERIX 42 HUMIRA 40 HUMIRA INJ 10MG/0.2ML 40 HUMIRA KIT 20MG/0.4ML 40 HUMIRA KIT 40MG/0.8ML 40 HUMIRA PEDIATRIC CROHNS DISEASE 40

HUMIRA PEN 40 HUMIRA PEN CD/UC/HS STARTER 40 HUMIRA PEN INJ CD/UC/HS STARTER 40 HUMIRA PEN INJ PS/UV STARTER 40 HUMIRA PEN-PS/UV STARTER 41 HUMULIN R INJ U-500 28 HUMULIN R U-500 KWIKPEN 28 hydralazine hcl 18 hydrochlorothiazide 17 hydroco/apap tab 10-325mg 2 hydroco/apap tab 5-325mg 2 hydroco/apap tab 7.5-325 2 hydrocodone-acetaminophen 7.5-325 mg/15ml 2 hydrocodone-ibuprofen tab 7.5-200 mg 2 hydrocortisone 35hydrocortisone (enema) 37hydrocortisone (topical) cream 1% 50hydrocortisone (topical) cream 2.5% 50hydrocortisone (topical) lotion 2.5% 50hydrocortisone (topical) oint 2.5% 50hydrocortisone butyrate cream 0.1% 50hydrocortisone butyrate oint 0.1% 50hydromorphone hcl 2hydroxychloroquine sulfate 41hydroxyurea 13hydroxyzine hcl 47hydroxyzine hcl inj 47hydroxyzine pamoate 47HYSINGLA ER 2ibandronate sodium tabs 30IBRANCE 10ibu tab 600mg . 1ibu tab 800mg . 1ibuprofen 1icatibant acetate 40ICLUSIG 12IDHIFA 10ILEVRO 46imatinib mesylate 12IMBRUVICA 12imipenem-cilastatin 3imipramine hcl 22imiquimod 51IMOVAX RABIES (H.D.C.V.) 42incassia 32INCRELEX 36INCRUSE ELLIPTA 47indapamide 18INFANRIX 42INGREZZA 26INLYTA 12INREBIC 12

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INSULIN PEN NEEDLE 28INSULIN SAFETY NEEDLES 28INSULIN SYRINGE 28INTELENCE 5INTRALIPID 30% 43intralipid inj 20% 43INTRON-A INJ 10MU 41INTRON-A INJ 18MU 41INTRON-A INJ 25MU 41INTRON-A INJ 50MU 41introvale 32INVEGA SUST INJ 117 MG/0.75 ML 24INVEGA SUST INJ 156MG/ML 24INVEGA SUST INJ 234 MG/1.5 ML . 24INVEGA SUST INJ 39 MG/0.25 ML . 23INVEGA SUST INJ 78 MG/0.5 ML 24INVEGA TRINZA 24INVIRASE 5IPOL INACTIVATED IPV 42ipratropium bromide 47ipratropium bromide (nasal) 47ipratropium-albuterol nebu 47irbesartan 15irbesartan-hydrochlorothiazide 15IRESSA 12irinotecan hcl . 14ISENTRESS 5ISENTRESS HD . 5isibloom 32ISOLYTE P 44ISOLYTE S 44isoniazid 6isoniazid syp 50mg/5ml 6isosorb mononitrate tab 18isosorbide dinitrate 18isosorbide mononitrate er 18isotretinoin 49isradipine 17itraconazole 4ivermectin 3IXIARO 42JADENU 30JADENU SPRINKLE 30JAKAFI 12jantoven 39JANUMET 29JANUMET XR TAB 100-1000 29JANUMET XR TAB 50-1000 29JANUMET XR TAB 50-500MG 29JANUVIA 29JARDIANCE 29jasmiel 32

JENTADUETO . 29JENTADUETO TAB XR 2.5-1000 MG 29JENTADUETO TAB XR 5-1000 MG 29jinteli 35jolessa tab 0.15-0.03 mg 32jolivette 32juleber 32JULUCA 6junel 1.5/30 32junel 1/20 32junel fe 1.5/30 32junel fe 1/20 32junel fe 24 32JUXTAPID 16KADCYLA 10kaitlib fe 32KALETRA TAB 100-25MG 6KALETRA TAB 200-50MG 6KALYDECO 48KANJINTI 10kariva 32kcl 0.075%/d5w/nacl 0.45% 44KCL 0.15%/D5W/NACL 0.225% 44kcl 0.15%/d5w/nacl 0.9% 44kcl 0.3%/d5w/nacl 0.45% 44KCL 0.3%/D5W/NACL 0.9% 44kcl/d5w inj 0.3% 44kcl/d5w/nacl inj .15/.45% 44kcl/d5w/nacl inj 0.22%/0.45% 44kcl/nacl inj 0.15%-0.9% 44kcl/nacl inj 0.3-0.9 44kcl0.15%/d5w/nacl0.2% 44kelnor 1/35 32kelnor 1/50 32ketoconazole 4ketoconazole cream 49ketoconazole shampoo 50ketorolac tromethamine (ophth) 46KEYTRUDA 10KINRIX 42kionex sus 15gm/60ml 30KISQALI 10KISQALI FEMARA 200 DOSE 10KISQALI FEMARA 400 DOSE 10KISQALI FEMARA 600 DOSE 10klor-con 10 43klor-con 8 43klor-con m10 . 43klor-con m15 . 43klor-con m20 . 43klor-con pak 20meq 43klor-con spr cap 10meq 43

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klor-con spr cap 8meq 43 KORLYM 36 kurvelo 32 KUVAN 34 labetalol hcl 16 lactated ringer's 44 lactulose 38 lactulose (encephalopathy) 38 lamivudine 5 lamivudine (hbv) 7 lamivudine-zidovudine 6 lamotrigine 20 lansoprazole 38 larin 1.5/30 32 larin 1/20 32 larin fe 1.5/30 32 larin fe 1/20 32 larissia tab 32 LASTACAFT 46 latanoprost 46 LATUDA 24 layolis fe 32 leena tab 32 leflunomide 41 LENVIMA 10 MG DAILY DOSE 12 LENVIMA 12MG DAILY DOSE 12 LENVIMA 14 MG DAILY DOSE 12 LENVIMA 18 MG DAILY DOSE 12 LENVIMA 20 MG DAILY DOSE 12 LENVIMA 24 MG DAILY DOSE 12 LENVIMA 4 MG DAILY DOSE 12 LENVIMA 8 MG DAILY DOSE 12 lessina 32 letrozole 11 leucovorin calcium 14 LEUKERAN 9 leuprolide inj 1mg/0.2 11 levalbuterol hcl 47 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml 47 levalbuterol tartrate hfa 47 LEVEMIR 28 LEVEMIR FLEXTOUCH 28 levetiracetam 20 levetiracetam in sodium chloride 20 levetiracetam oral soln 100 mg/ml 20 levobunolol hcl 46 levocarnitine (metabolic modifiers) 34 levocetirizine dihydrochloride 47 levofloxacin 8 levofloxacin in d5w 8 levofloxacin inj 25mg/ml 8 levofloxacin oral soln 25 mg/ml 8

levonest 32 levonor/ethi tab 32 levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est

0.01mg 32 levonorgestrel & eth estradiol 32 levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) .. 32 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7) 32 levonorg-eth est tab 0.15-0.03mg (84) & eth est tab

0.01mg(7) 32 levora 0.15/30-28 32 levo-t 36 levothyroxine sodium 36 levoxyl 36 LEXIVA 5 lidocaine 50 lidocaine hcl 50 lidocaine hcl (local anesth.) 3 lidocaine hcl (mouth-throat) 51 lidocaine inj 0.5% 3 lidocaine inj 1.5% preservative free (pf) 3 lidocaine inj 1% 3 lidocaine oint 5% 50 lidocaine-prilocaine 50 linezolid in sodium chloride 3 linezolid inj 3 linezolid susp 3 linezolid tab 600mg 3 LINZESS 38 liothyronine sodium 36 lisinopril 14 lisinopril & hydrochlorothiazide 14 lithium carbonate 26 lithium carbonate er 26 LITHIUM SOLN 8MEQ/5ML 26 LOKELMA 30 LONSURF 13 loperamide hcl 38 lopinavir-ritonavir 6 lorazepam 19 lorazepam intensol 19 LORBRENA 12 lorcet hd tab 10-325mg 2 lorcet plus tab 7.5-325 2 lorcet tab 5-325mg 2 loryna 32 losartan potassium 15 losartan-hydrochlorothiazide 15 LOTEMAX 46 loteprednol etabonate 46 lovastatin 15 low-ogestrel 32

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loxapine succinate 24 LUMIGAN 46 LUMIZYME 34 LUPRON DEPOT (1-MONTH) 11 LUPRON DEPOT INJ 11.25MG (3-MONTH) 11 LUPRON DEPOT-PED (1-MONTH 36 LUPRON DEPOT-PED (3-MONTH 36 LUPRON DEP-PED INJ 11.25MG (3-MONTH) 36 LUPRON DEP-PED INJ 7.5MG 36 lutera 32 LYNPARZA 10 LYRICA CR 26 LYSODREN 11 lyza 32 magnesium sulfate 43 MAGNESIUM SULFATE 43 MAGNESIUM SULFATE IN D5W 43 magnesium sulfate in dextrose 43 magnesium sulfate inj 50% 43 malathion 51 maprotiline hcl 22 marlissa 33 MARPLAN TAB 10MG 22 MATULANE 13 MAVYRET 7 meclizine hcl 37 medroxyprogesterone acetate (contraceptive) 33 medroxyprogesterone acetate tab 36 mefloquine hcl . 5 megestrol ac sus 40mg/ml 11 megestrol ac tab 20mg 11 megestrol ac tab 40mg 11 megestrol sus 625mg/5ml 11 MEKINIST 13 MEKTOVI 13 melodetta 24 fe 33 meloxicam 1 memantine hcl cp24 21 memantine soln 21 memantine tabs 21 memantine titration pak 21 MENACTRA 42 MENVEO 42 mercaptopurine 10 meropenem 4 mesalamine 37 mesalamine w/ cleanser 37 MESNEX 14 metadate er tab 20mg 25 metformin er . 29 metformin hcl 29 methadone hcl 2

methadone hcl 10mg 2 methadone hcl 5mg 2 methadone hcl intensol 2 methazolamide 18 methenamine hippurate 4 methimazole . 36 methocarbamol 27 methotrexate sodium inj soln 10 methotrexate sodium inj solr 10 methotrexate sodium tabs 41 methylphenidate hcl 25 methylphenidate hcl oral soln 25 methylphenidate hcl tbcr 10 mg 25 methylphenidate hcl tbcr 20mg 25 methylpr ss inj 35 methylpred pak 4mg 35 methylpred tab 16mg 35 methylpred tab 32mg 35 methylpred tab 4mg 35 methylpred tab 8mg 35 methylprednisolone acetate 35 metoclopramide hcl 37 metoclopramide hcl inj 37 metolazone 18 metoprolol & hydrochlorothiazide . 16 metoprolol succinate 16 metoprolol tartrate 16 metronidazole . 4 metronidazole (topical) 51 metronidazole gel 0.75% 51 metronidazole in nacl 4 metronidazole vaginal 39 mibelas 24 fe . 33 micafungin sodium 4 microgestin 1.5/30 33 microgestin 1/20 33 microgestin fe 1.5/30 33 microgestin fe 1/20 33 midodrine hcl . 18 miglustat 34 mili 33 minitran 18 minocycline hcl 9 minoxidil 18 mirtazapine 22 misoprostol 38 MITIGARE 1 M-M-R II 42 M-NATAL PLUS 45 moexipril hcl 14 molindone hcl 24 mometasone furoate 50

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mondoxyne nl cap 100mg 9mono-linyah tab 0.25-35 33montelukast sodium 48morphine ext-rel tab 2morphine sul inj 1mg/ml, 2 morphine sulfate 2MORPHINE SULFATE 2morphine sulfate oral soln 100mg/5ml 2morphine sulfate oral soln 10mg/5ml 2morphine sulfate oral soln 20mg/5ml 2MOVANTIK 38MOXEZA 45moxifloxacin hcl 8moxifloxacin hcl (ophth) 45MULTAQ 15mupirocin 49MVASI 10MYCAMINE 4mycophenolate mofetil 41mycophenolate sodium tbec 41myorisan 49MYRBETRIQ 39nabumetone 1nadolol 16nafcillin sodium for inj 9nafcillin sodium for inj 10gm 9NAGLAZYME . 34nalbuphine hcl . 1naloxone inj 0.4mg/ml 27naloxone inj 1mg/ml 27naltrexone hcl 27NAMZARIC 21naproxen 1naproxen dr 1naproxen sodium 1naratriptan hcl 26NARCAN 27NATACYN 45nateglinide 29NATPARA 36NAYZILAM 20necon 0.5/35-28 33nefazodone hcl 22neomycin sulfate 3neomycin-bacitracin zn-polymyxin 45neomycin-polymy-dexameth 45neomycin-polymyxin-gramicidin 45neomycin-polymyxin-hc (ophth) 45neomycin-polymyxin-hc (otic) 51NEPHRAMINE 43NERLYNX 13NEUPRO 22

nevirapine susp 50 mg/5ml 5 nevirapine tab 100mg er 5 nevirapine tab 200mg 5 nevirapine tab 400mg er 5 NEXAVAR 13 niacin (antihyperlipidemic) 16 niacin er (antihyperlipidemic) 16 niacor 16 nicardipine hcl 17 NICOTROL INHALER 27 NICOTROL NS 27 nifedipine 17 nifedipine er .. 17 nikki 33 nilutamide 11 nimodipine 17 NINLARO 10 nitisinone 34 nitro-bid 18 NITRO-DUR DIS 0.3MG/HR 18 NITRO-DUR DIS 0.8MG/HR 18 nitrofurantoin macrocrystal 4 nitrofurantoin monohyd macro 4 nitroglycerin 18 nitroglycerin td patch 18 NITYR 34 nizatidine 37 nora-be tab 0.35mg 33 nore/eth/fer chw 0.4mg-35 33 noreth/ethin chw fe 33 norethin acet & estrad-fe 33 norethindrone (contraceptive) 33 norethindrone acet & eth estra 33 norethindrone acetate 36 norethindrone acetate-ethinyl estradiol 35 norgest/ethi tab 0.25/35 33 norgestimate-ethinyl estradiol (triphasic)

0.18-25/0.215-25/0.25-25 mg-mcg 33 norgestimate-ethinyl estradiol (triphasic)

0.18-35/0.215-35/0.25-35 mg-mcg 33 NORMOSOL-M IN D5W 44 NORMOSOL-R 44 NORMOSOL-R IN D5W 44 NORPACE CR . 15 NORTHERA 18 nortrel 0.5/35 (28) 33 nortrel 1/35 33 nortrel 7/7/7 33 nortriptyline hcl 22 NORVIR PACK .. 5 NORVIR SOLN 5 NOVOLIN 70/30 28

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NOVOLIN 70/30 FLEXPEN 28 NOVOLIN N 28 NOVOLIN N FLEXPEN . 28 NOVOLIN R 28 NOVOLIN R FLEXPEN 28 NOVOLOG 28 NOVOLOG 70/30 FLEXPEN 28 NOVOLOG FLEXPEN 28 NOVOLOG MIX 70/30 28 NOVOLOG PENFILL 28 NOXAFIL 4 NUBEQA 11 NUCALA 48 NUCYNTA ER 2 NUEDEXTA 26 NULOJIX 41 NULYTELY/FLAVOR PACKS 38 NUPLAZID CAPS 24 NUPLAZID TABS 10MG 24 nutrilipid inj 20% 43 nyamyc 49 NYMALIZE 17 nystatin 4 nystatin (mouth-throat) 51 nystatin (topical) 49 nystop 49 ocella tab 3-0.03mg 33 OCTAGAM 41 octreotide acetate 36 ODEFSEY 6 ODOMZO 10 OFEV 48 ofloxacin (ophth) 45 ofloxacin (otic) 51 OGIVRI 10 olanzapine 24 olmesartan medoxomil 15 olmesartan medoxomil-amlodipine-

hydrochlorothiazide 15 olmesartan medoxomil-hydrochlorothiazide 15 olopatadine hcl 0.2% 46 omeprazole cap 10mg 38 omeprazole cap 20mg 38 omeprazole cap 40mg 38 ondansetron hcl 37 ondansetron hcl inj 37 ondansetron hcl oral soln 37 ondansetron odt 37 ONTRUZANT 10 OPSUMIT 18 ORFADIN 34 ORKAMBI 48

orsythia 33oseltamivir phosphate 7OSPHENA 36oxacillin sodium 9oxaliplatin inj 100mg 14oxaliplatin inj 100mg/20ml 14oxaliplatin inj 50mg 13oxaliplatin inj 50mg/10ml 13oxandrolone tab 10mg 27oxandrolone tab 2.5mg 27oxcarbazepine 20oxybutynin chloride 39oxycodone hcl .. 2oxycodone w/ acetaminophen 10-325mg 2oxycodone w/ acetaminophen 2.5-325mg 2oxycodone w/ acetaminophen 5-325mg 2oxycodone w/ acetaminophen 7.5-325mg 2OZEMPIC INJ 0.25 OR 0.5MG/DOSE 28OZEMPIC INJ 1MG/DOSE 28pacerone 15paclitaxel 10paliperidone 24pamidronate disodium 30pamidronate inj 30mg 30pamidronate inj 90mg 30PANRETIN 51pantoprazole sodium 38pantoprazole sodium tbec 39PANZYGA 41paricalcitol 45paroex sol 0.12% 51paromomycin sulfate 3paroxetine hcl tabs 22paser d/r 6PAXIL 22PAZEO 46PEDIARIX 42PEDVAX HIB 42peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 38peg 3350-potassium chloride-sod bicarbonate-

sod chloride 38PEGANONE 20PEGASYS 7PEGASYS PROCLICK 7PEMAZYRE 13penicillamine 31PENICILLIN G POT IN DEXTROSE 2MU 9PENICILLIN G POT IN DEXTROSE 3MU 9penicillin g procaine 9penicillin g sodium 9penicillin v potassium 9penicilln gk inj 20mu 9

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penicilln gk inj 5mu 9 PENTACEL 42 pentamidine isethionate inh 4 pentamidine isethionate inj 4 pentoxifylline . 40 perindopril erbumine 14 periogard 51 permethrin cre 5% 51 perphenazine 24 PERSERIS 24 pfizerpen-g inj 20mu 9 pfizerpen-g inj 5mu 9 phenelzine sulfate 22 phenobarbital 20 phenobarbital sodium 20 phenytek 20 phenytoin 20 phenytoin sodium extended 20 phenytoin sodium inj 50mg/ml 20 philith 33 PHOSPHOLINE IODIDE 46 PICATO 51 PIFELTRO 5 pilocarpine hcl 46 pilocarpine hcl (oral) 51 pimozide 24 pimtrea 33 pindolol 16 pioglitazone hcl 29 piper/tazoba inj 12-1.5gm 9 piper/tazoba inj 2-0.25gm 9 piper/tazoba inj 3-0.375gm 9 piper/tazoba inj 36-4.5gm 9 piper/tazoba inj 4-0.5gm 9 PIQRAY 200MG DAILY DOSE 13 PIQRAY 250MG DAILY DOSE 13 PIQRAY 300MG DAILY DOSE 13 pirmella 1/35 . 33 piroxicam 1 PLASMA-LYTE A 44 PLASMA-LYTE-148 44 plenamine 43 PLENVU 38 PNV FOLIC ACID + IRON MUL 45 podofilox 51 polymyxin b-trimethoprim 45 POMALYST 11 portia-28 33 posaconazole .. 4 pot chloride inj 2meq/ml 44 potassium chloride 43-44 potassium chloride in nacl 44

potassium chloride microencapsulated crystals er 43 potassium citrate (alkalinizer) er tabs 39 PRADAXA 39 PRALUENT 16 pramipexole tab 0.125mg 23 pramipexole tab 0.25mg 23 pramipexole tab 0.5mg 22 pramipexole tab 0.75mg 23 pramipexole tab 1.5mg 23 pramipexole tab 1mg 23 prasugrel hcl 40 pravastatin sodium 15 praziquantel 4 prazosin hcl 14 pred sod pho sol 5mg/5ml 35 prednisolone acetate (ophth) 46 prednisolone sodium phosphate 35 prednisolone sodium phosphate (ophth) 46 prednisolone sol 15mg/5ml 35 prednisolone sol 25mg/5ml 35 prednisone con 5mg/ml 35 prednisone pak 10mg 35 prednisone pak 5mg 35 prednisone sol 5mg/5ml 35 prednisone tab 10mg 35 prednisone tab 1mg 35 prednisone tab 2.5mg 35 prednisone tab 20mg 35 prednisone tab 50mg 35 prednisone tab 5mg 35 pregabalin 20 premasol 10% 43 PRENATAL 45 PRENATAL PLUS 45 PRENATAL PLUS LOW IRON 45 prevalite 16 previfem 33 PREZCOBIX 6 PREZISTA 5 PRIFTIN 6 primaquine phosphate 5 PRIMAQUINE PHOSPHATE 5 primidone 20 PRIVIGEN 41 probenecid 1 PROCALAMINE 43 prochlorperazine inj 37 prochlorperazine maleate 37 prochlorperazine supp 37 PROCRIT 40 procto-med hc 51 procto-pak 51

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proctosol hc cre 2.5% 51proctozone-hc 51PROGLYCEM SUS 50MG/ML 35PROGRAF 41PROLASTIN-C . 48PROLENSA 46PROLIA 36PROMACTA 40promethazine hcl 37promethazine hcl inj 37propafenone hcl 15propafenone hcl 12hr 15proparacaine hcl 47propranolol & hydrochlorothiazide 16propranolol cap er 16propranolol hcl 16propranolol oral sol 16propylthiouracil 36PROQUAD 42PROSOL 43protriptyline hcl 22PULMICORT FLEXHALER 48PULMOZYME 48PURIXAN 10pyrazinamide .. 6pyridostigmine tab 60mg 26QUADRACEL 42quetiapine fumarate 24quinapril hcl 14quinapril-hydrochlorothiazide 14quinidine sulfate 15quinine sulfate . 5RABAVERT 42rabeprazole sodium 39raloxifene tab 60mg 36ramipril 14ranolazine 18rasagiline mesylate 23RAYALDEE 45reclipsen 33RECOMBIVAX HB 42RECTIV 51REGRANEX 51RELENZA DISKHALER 7RELISTOR 38REMICADE 41RENFLEXIS 41repaglinide 30RESTASIS 47RESTASIS MULTIDOSE 47REVLIMID 12REXULTI 24

REYATAZ 5RHOPRESSA 46ribavirin cap 200mg 7ribavirin tab 200mg 7rifabutin 6rifampin 6RIFATER 6riluzole 26rimantadine hydrochloride 7RINVOQ 41risedronate sodium 30RISPERDAL INJ 12.5MG 24RISPERDAL INJ 25MG 24RISPERDAL INJ 37.5MG 24RISPERDAL INJ 50MG 24risperidone 24ritonavir 5RITUXAN 10RITUXAN HYCELA 11rivastigmine tartrate 21rivastigmine td patch 24hr 13.3 mg/24hr 21rivastigmine td patch 24hr 4.6 mg/24hr 21rivastigmine td patch 24hr 9.5 mg/24hr 21rivelsa 33rizatriptan benzoate 26rizatriptan benzoate odt 26ropinirole tab 0.25mg 23ropinirole tab 0.5mg 23ropinirole tab 1mg 23ropinirole tab 2mg 23ropinirole tab 3mg 23ropinirole tab 4mg 23ropinirole tab 5mg 23rosadan cre 0.75% 51rosuvastatin calcium 15ROTARIX 42ROTATEQ 42roweepra 20roweepra xr 20ROZLYTREK 13RUBRACA 11RUXIENCE 11RYBELSUS 30RYDAPT 13SANDIMMUNE 41SANTYL 51SAPHRIS 24scopolamine 37SECUADO 24selegiline hcl 23selenium sulfide 50SELZENTRY 5

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................................SEREVENT DISKUS 47 sertraline hcl .. 22 setlakin tab 33 sevelamer carbonate 36 sharobel 33 SHINGRIX 42 SIGNIFOR 36 sildenafil citrate tab 20 mg (pulmonary hypertension) .. 18 silver sulfadiazine 49 SIMBRINZA 46 simvastatin 15 sirolimus 41 SIRTURO 6 SIVEXTRO 4 SKYRIZI 41 sodium chlor sol 0.9% irr 51 sodium chloride 43-44 sodium chloride 0.45% 44 sodium chloride inj 0.9% 44 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln 43 sodium phenylbutyrate 34 sodium polystyrene sulfonate powder 31 sodium polystyrene sulfonate susp 31 SOLIQUA 100/33 28 SOLTAMOX 11 SOLU-CORTEF 35 SOMATULINE DEPOT 36 SOMAVERT 36 sorine 15 sotalol hcl 15 sotalol hcl (afib/afl) 15 spironolactone 14 spironolactone & hydrochlorothiazide 18 sprintec 28 33 SPRITAM 20 SPRYCEL 13 sps susp 15gm/60ml 31 sronyx 33 ssd 49 stavudine 5 STELARA 41 STIMATE 36 STIVARGA 13 streptomycin sulfate 3 STRIBILD 6 subvenite tab . 20 sucralfate 38 sulfacetamide sodium (acne) 49 sulfacetamide sodium (ophth) 45 sulfacetamide sod-prednisolone 45 sulfadiazine 3 sulfamethoxazole-trimethop ds 4

sulfamethoxazole-trimethoprim inj . 4 sulfamethoxazole-trimethoprim susp 4 sulfamethoxazole-trimethoprim tab 400-80mg 4 SULFAMYLON 49 sulfasalazine 38 sulfasalazine ec 38 sulindac 1 sumatriptan 26 sumatriptan inj 4mg/0.5ml 26 sumatriptan inj 6mg/0.5ml 26 sumatriptan succinate 26 SUPREP BOWEL PREP KIT 38 SUTENT 13 syeda 33 SYLATRON 13 SYMBICORT 49 SYMDEKO 48 SYMFI 6 SYMFI LO 6 SYMJEPI 48 SYMPAZAN 20 SYMTUZA 6 SYNAREL 34 SYNERCID 4 SYNJARDY TAB 12.5-1000MG 30 SYNJARDY TAB 12.5-500MG 30 SYNJARDY TAB 5-1000MG 30 SYNJARDY TAB 5-500MG 30 SYNJARDY XR TAB 10-1000MG 30 SYNJARDY XR TAB 12.5-1000MG 30 SYNJARDY XR TAB 25-1000MG 30 SYNJARDY XR TAB 5-1000MG 30 SYNRIBO 13 SYNTHROID 36 TABLOID 10 tacrolimus 42 tacrolimus (topical) 51 TAFINLAR 13 TAGRISSO 13 TALZENNA 11 tamoxifen citrate 11 tamsulosin hcl 39 TARGRETIN 51 tarina 24 fe 33 tarina fe 1/20 33 TASIGNA 13 TAXOTERE 10 tazarotene 49 tazicef 8 TAZORAC 49 taztia xt 17 TAZVERIK 13

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TDVAX 42TECENTRIQ 11TEFLARO 8telmisartan 15telmisartan-amlodipine 15telmisartan-hydrochlorothiazide 15temazepam 25TEMIXYS 6TENIVAC 42tenofovir disoproxil fumarate 5terazosin hcl .. 14terbinafine hcl . 4terbutaline sulfate 47terconazole vaginal 39testosterone .. 27testosterone cypionate 27testosterone enanthate 28tetrabenazine 26tetracycline hcl 9texacort soln 2.5% 50THALOMID 12theo-24 48theophylline 48theophylline tab er 12hr 300 mg 48theophylline tab er 12hr 450 mg 48theophylline tab sr 24hr 48thioridazine hcl 24thiothixene 24tiadylt er 17tiagabine hcl 20TIBSOVO 11tigecycline 4tilia fe 33timolol maleate 16timolol maleate (ophth) soln 46timolol maleate gel 46timolol maleate ophth soln 0.5% (once-daily) 47TIVICAY 5tizanidine hcl . 27TOBRADEX 45TOBRADEX ST 45tobramycin 3tobramycin (ophth) 45tobramycin inj 1.2 gm/30ml 3tobramycin inj 1.2gm 3tobramycin inj 10mg/ml 3tobramycin inj 80mg/2ml 3tobramycin sulfate 3tobramycin-dexamethasone 45tolterodine tartrate 39topiramate 20toposar 14

toremifene citrate 11torsemide tabs 18TOVIAZ 39TPN ELECTROLYTES 43TRADJENTA 30tramadol hcl tab 50 mg 1tramadol-acetaminophen 1trandolapril 14tranexamic acid 40tranylcypromine sulfate 22TRAVASOL 44travoprost 47TRAZIMERA 11trazodone hcl . 22TRECATOR 6TRELEGY ELLIPTA 47TRELSTAR DEP INJ 3.75MG 11TRELSTAR LA INJ 11.25MG 11treprostinil 18TRESIBA FLEXTOUCH 28TRESIBA INJ 28tretinoin 49tretinoin (chemotherapy) 13triamcinolone acetonide (mouth) 51triamcinolone acetonide (topical) 50triamterene & hydrochlorothiazide cap 37.5-25 mg 18triamterene & hydrochlorothiazide tabs 18TRICARE 45trientine hcl 31tri-estarylla 33trifluoperazine hcl 24trifluridine 45trihexyphenidyl hcl 23TRIJARDY XR TAB ER 24HR 10-5-1000 MG 30TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG 30TRIJARDY XR TAB ER 24HR 25-5-1000 MG 30TRIJARDY XR TAB ER 24HR 5-2.5-1000MG 30TRIKAFTA 48tri-legest fe 33tri-linyah 33tri-lo marzia 34tri-lo-estarylla 34tri-lo-sprintec . 34trilyte 38trimethoprim 4tri-mili 34trimipramine maleate 22TRINTELLIX 22tri-previfem 34tri-sprintec 34TRIUMEQ 6trivora-28 34

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tri-vylibra 34 tri-vylibra lo 34 TROGARZO 5 TROPHAMINE INJ 10% 44 trospium chloride 39 TRULICITY 28 TRUMENBA 42 TRUVADA TAB 100-150 6 TRUVADA TAB 133-200 6 TRUVADA TAB 167-250 6 TRUVADA TAB 200-300 6 TRUXIMA 11 TUKYSA 13 tulana 34 TURALIO 13 TWINRIX INJ 42 TYBOST 5 tydemy 34 TYKERB 13 TYMLOS 36 TYPHIM VI 42 unithroid 36 ursodiol 38 valacyclovir hcl 7 VALCHLOR 51 valganciclovir hcl 7 valproate sodium 20 valproate sodium oral soln 20 valproic acid 20 valsartan 15 valsartan-hydrochlorothiazide 15 VALTOCO 20 vancomycin h cl 4 VANCOMYCIN IN NACL 4 vandazole 39 VAQTA 42 VARIVAX 42 VASCEPA 16 VELCADE 11 velivet 34 VELTASSA 31 VEMLIDY 7 VENCLEXTA 11 VENCLEXTA STARTING PACK 11 venlafaxine hcl 22 VENTAVIS 18 VENTOLIN HFA 48 verapamil cap er 17 verapamil hcl . 17 verapamil tab er 17 VERSACLOZ 24 VERZENIO 11

VICTOZA 28 vienva 34 vigabatrin p owd pack 500mg 20 vigabatrin tab 500mg 20 vigadrone 20 VIIBRYD STARTER PACK 22 VIIBRYD TAB .. 22 VIMPAT 20-21 VIMPAT INJ 200MG/20ML 21 VIMPAT SOL 10MG/ML 21 vincristine sulfate 10 vinorelbine tartrate 10 viorele 34 VIRACEPT 5 VIREAD 5 VITRAKVI 13 VIVITROL 27 VIZIMPRO 13 voriconazole 4 VOSEVI 7 VOTRIENT 13 VRAYLAR 24 VRAYLAR THERAPY PACK 24 vyfemla 34 vylibra 34 warfarin sodium 39 water for irrigation, sterile 51 wymzya fe 34 XALKORI 13 XARELTO 40 XARELTO STARTER PACK 40 XATMEP 41 XCOPRI MAINTENANCE PAK 150-200MG 21 XCOPRI PAK 12.5-25MG 21 XCOPRI PAK 50-100MG 21 XCOPRI PAK 50-200MG 21 XCOPRI TABS . 21 XCOPRI TITRATION PAK 150-200MG 21 XELJANZ 41 XELJANZ XR 41 XGEVA 36 XIFAXAN 38 XIGDUO XR TAB 10-1000MG 30 XIGDUO XR TAB 10-500MG 30 XIGDUO XR TAB 2.5-1000MG 30 XIGDUO XR TAB 5-1000MG 30 XIGDUO XR TAB 5-500MG 30 XOLAIR 48 XOSPATA 13 XPOVIO 100 MG ONCE WEEKLY 13 XPOVIO 60 MG ONCE WEEKLY 13 XPOVIO 80 MG ONCE WEEKLY 13

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XPOVIO 80 MG TWICE WEEKLY 13 XTANDI 11 xulane dis 150-35 34 XULTOPHY 100/3.6 28 XYREM 27 YF-VAX 42 yuvafem vaginal tablet 10 mcg 35 zafirlukast 48 zaleplon 26 zarah 34 ZARXIO 40 ZEJULA 11 ZELBORAF 13 ZEMAIRA 48 zenatane 49 ZENPEP 38 ZERVIATE 46 zidovudine cap 100mg 6 zidovudine syp 50mg/5ml 6 zidovudine tab 300mg 6 ziprasidone hcl 24 ziprasidone mesylate 24

ZIRABEV 11ZIRGAN 45zoledronic acid inj 4mg/100ml 30zoledronic acid inj 5mg/100ml 30zoledronic inj 4mg/5ml 30ZOLINZA 11zolmitriptan 26zolmitriptan odt 26zolpidem tartrate 26zonisamide 21ZORTRESS TAB 0.25MG 42ZORTRESS TAB 0.5MG 42ZORTRESS TAB 0.75MG 42ZORTRESS TAB 1MG 42ZOSTAVAX 42zovia 1/35e 34ZYDELIG 13ZYKADIA 13ZYLET 45ZYPREXA RELPREVV 25ZYPREXA RELPREVV INJ 210MG 25ZYTIGA 11

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Mercy Care Advantage (HMO SNP) Member Services Call 602‑586‑1730 or 1‑877‑436‑5288

Calls to these numbers are free. 8:00 a.m. – 8:00 p.m., 7 days a week.

Member Services also has free language interpreter services available for non-English speakers.

TTY 711 Calls to this number are free. 8:00 a.m. – 8:00 p.m., 7 days a week.

Write Mercy Care Advantage (HMO SNP) 4755 S. 44th Place Phoenix, AZ 85040

Website www.MercyCareAZ.org

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑586‑1730 or 1‑877‑436‑5288 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org.

Servicios al Miembro de Mercy Care Advantage (HMO SNP) Llame 602‑586‑1730 o 1‑877‑436‑5288

Las llamadas a estos números son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.

Servicios al Miembro también tiene servicios gratuitos de interpretación de idiomas disponibles para personas que no hablan inglés.

TTY 711 Las llamadas a este número son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.

Escriba Mercy Care Advantage (HMO SNP) 4755 S. 44th Place Phoenix, AZ 85040

Sitio Web www.MercyCareAZ.org

Este formulario fue actualizado en 08/01/2020. Para la información más reciente o para otras preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑586‑1730 ó al 1‑877‑436‑5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visite www.MercyCareAZ.org.





Mercy Care Advantage (HMO SNP)...Mercy Care Advantage (HMO SNP) 2020 Formulary (List of Covered...

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Transcript of Mercy Care Advantage (HMO SNP)...Mercy Care Advantage (HMO SNP) 2020 Formulary (List of Covered...