Mercy Care Advantage (HMO SNP) · Mercy Care Advantage will generally cover the drugs listed in our...

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

Formulary ID 00020345, Version 15

This formulary was updated on 10/01/2020. For more recent information or other questions, pleasecontact 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 QUECUBRIMOS BAJO ESTE PLAN

Identificación del Formulario 00020345, Versión 15

Este formulario fue actualizado en 10/01/2020. 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 al1‑877‑436‑5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visitewww.MercyCareAZ.org.

Visit/Viste www.MercyCareAZ.org

AZ-19-06-01

http://www.MercyCareAZ.org



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

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLANFormulary ID 00020345, Version 15

This formulary was updated on 10/01/2020. For more recent information or other questions, please contactMercy 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 makesure 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 10/01/2020. Foran updated formulary, please contact us. Our contact information, along with the date we last updated theformulary, 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 timeduring the year.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive noticewhen 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 careproviders, which represents the prescription therapies believed to be a necessary part of a quality treatmentprogram. Mercy Care Advantage will generally cover the drugs listed in our formulary as long as the drug ismedically necessary, the prescription is filled at a Mercy Care Advantage network pharmacy, and other plan rulesare 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 drugson the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We mustfollow Medicare rules in making these changes.

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

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacingit with a new generic drug that will appear on the same or lower cost sharing tier and with the sameor fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand namedrug 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 thatchange, 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 howto request an exception, and you can also find information in the section below entitled “How do Irequest 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 tobe unsafe or the drug’s manufacturer removes the drug from the market, we will immediately removethe 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 theformulary 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 notifyaffected members of the change at least 30 days before the change becomes effective, or at the time themember 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 includeinformation on how to request an exception, and you can also find information in the section belowentitled “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 our2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of thedrug during the 2020 coverage year except as described above. This means these drugs will remain available atthe same cost-sharing and with no new restrictions for those members taking them for the remainder of thecoverage year.

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The enclosed formulary is current as of 10/01/2020. To get updated information about the drugs covered byMercy 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 theformulary 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 ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the typeof medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listedunder the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category namein the list that begins on page 1. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 54.The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugsand generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will seethe page number where you can find coverage information. Turn to the page listed in the Index and find thename 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 FDAas having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brandname drugs.

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

• Prior Authorization: Mercy Care Advantage requires you or your physician to get prior authorization forcertain drugs. This means that you will need to get approval from Mercy Care Advantage before you fillyour 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 CareAdvantage will cover. For example, Mercy Care Advantage provides 30 EA per 30 days per prescriptionfor 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 yourmedical condition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, Mercy Care Advantage may not cover Drug B unless you try Drug Afirst. 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 beginson page 1. You can also get more information about the restrictions applied to specific covered drugs byvisiting our website. We have posted online documents that explain our prior authorization and step therapyrestrictions. You may also ask us to send you a copy. Our contact information, along with the date we lastupdated 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 theMercy 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 Servicesand 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. Whenyou receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is coveredby Mercy Care Advantage.

• You can ask Mercy Care Advantage to make an exception and cover your drug. See below for informationabout 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 ofexceptions 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 ata pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lowercost-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 drugsincluded on the plan’s formulary, or additional utilization restrictions would not be as effective in treating yourcondition 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 restrictionexception. When you request a formulary or utilization restriction exception you should submit a statementfrom your prescriber or physician supporting your request. Generally, we must make our decision within 72hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you oryour doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If yourrequest to expedite is granted, we must give you a decision no later than 24 hours after we get a supportingstatement 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, youmay be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need aprior authorization from us before you can fill your prescription. You should talk to your doctor to decide if youshould switch to an appropriate drug that we cover or request a formulary exception so that we will cover thedrug you take. While you talk to your doctor to determine the right course of action for you, we may cover yourdrug 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 covera temporary 31-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to amaximum 31-day supply of medication. After your first 31-day supply, we will not pay for these drugs, even ifyou 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 yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will covera 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 prescriptionupon admission or discharge.

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

If you have questions about Mercy Care Advantage, please contact us. Our contact information, along with thedate 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, visithttp://www.medicare.gov.

Mercy Care Advantage’s FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by Mercy CareAdvantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 54.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) andgeneric 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 onwhich 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 CoverageRider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider) lists the amount you will payfor your prescription drugs. You can also call Member Services to find out your cost sharing amount. Phonenumbers for Member Services are on the front and back cover pages.

http://www.medicare.gov

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

Abbreviation Requirements/Limits

B/D Covered under Medicare Part B or Part D. Most drugs are covered under PartD, but there are some drugs that can be covered under both Part B or Part Ddepending 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 planbefore 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 QUECUBRIMOS BAJO ESTE PLANIdentificación del Formulario 00020345, Versión 15

Este formulario fue actualizado en el 1 de octubre de 2020. Para la información más reciente o para otraspreguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602-586-1730 óal 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 visitewww.MercyCareAZ.org.

Nota para los miembros actuales: Este formulario cambió desde el año pasado. Por favor revisen estedocumento 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 MercyCare. 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 lafecha de el 1 de octubre de 2020. Para un formulario actualizado, por favor contáctenos. Nuestra informaciónde contacto, junto con la fecha en la que actualizamos por último el formulario, aparece en la portada y lacontraportada.

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 enerode 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. Ustedrecibirá 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 consultacon un equipo de proveedores del cuidado de la salud, el cual representa las terapias de prescripción/recetaque se considera son una parte necesaria de un programa de tratamiento de calidad. Generalmente, MercyCare Advantage cubrirá los medicamentos listados en nuestro formulario, siempre y cuando el medicamentosea médicamente necesario, la prescripción/receta sea surtida en una farmacia de la red de Mercy CareAdvantage, 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 CareAdvantage puede agregar o eliminar medicamentos en la Lista de Medicamentos durante el año, cambiarlosa niveles de costo compartido distintos o agregar nuevas restricciones. Nosotros debemos seguir las reglas deMedicare para hacer estos cambios.

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

• Nuevos medicamentos genéricos. Nosotros podemos eliminar inmediatamente un medicamento demarca de nuestra Lista de Medicamentos si lo estamos reemplazando con un medicamento genériconuevo que aparecerá en el mismo nivel o en un nivel más bajo de costo compartido y con las mismaso menos restricciones. Además, al agregar el nuevo medicamento genérico, nosotros podemos decidirretener el medicamento de marca en nuestra Lista de Medicamentos, pero cambiarlo inmediatamente aun nivel de costo compartido distinto o agregar nuevas restricciones. Si actualmente usted está tomandodicho medicamento de marca, es posible que nosotros no le informemos por adelantado que haremosdicho cambio, pero más tarde le proveeremos información sobre el/los cambio/s específico/s quehayamos 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 unaexcepción, 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 consideraque un medicamento en nuestro formulario no es seguro, o si el fabricante del medicamento retirael medicamento del mercado, nosotros inmediatamente retiraremos el medicamento de nuestroformulario 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 actualmentetoman un medicamento. Por ejemplo, nosotros podemos agregar un medicamento genérico que nosea nuevo en el mercado para reemplazar un medicamento de marca actualmente en el formularioo agregar nuevas restricciones al medicamento de marca o cambiarlo a un nivel de costo compartidodistinto. O podemos hacer cambios basados en nuevas directrices clínicas. Si retiramos medicamentosde nuestro formulario, o agregamos autorización previa, límites de cantidad y/o restricciones de terapiaa pasos en un medicamento, nosotros debemos notificárselo a los miembros afectados por el cambiopor lo menos 360 días antes de que el cambio entre en vigor, ó cuando el miembro pida que se levuelva a surtir el medicamento, en cuyo momento, el miembro recibirá un suministro para 31 díasdel medicamento.

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

Cambios que no le afectarán si usted está tomando actualmente el medicamento. Generalmente, si ustedestá 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 2020excepto como se describió anteriormente. Esto significa que estos medicamentos permanecerán disponiblesal mismo costo compartido y sin nuevas restricciones para aquellos miembros que los tomen durante el restodel año de la cobertura.

El formulario adjunto está vigente a partir de el 1 de octubre de 2020. Para obtener información actualizada sobrelos medicamentos cubiertos por Mercy Care Advantage, por favor póngase en contacto con nosotros. Nuestrainformación de contacto aparece en la portada y la contraportada. Si nosotros actualizamos el formulariodurante 2020 debido a un cambio al formulario que no sea de mantenimiento, se publicará una versiónactualizada del formulario y se emitirá un aviso a los miembros afectados en nuestro sitio webwww.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 MédicaEl 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 medicamentosusados 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 enla página 1. Después busque en esa categoría el nombre de su medicamento.

Listado AlfabéticoSi usted no está seguro/a bajo qué categoría buscar, debería buscar su medicamento en el Índice que empiezaen la página 54. El Índice provee una lista en orden alfabético de todos los medicamentos incluidos en estedocumento. 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 númerode la página en la que podrá encontrar información sobre la cobertura. Pase a la página listada en el Índicey 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 sussiglas en inglés) por contar con el mismo ingrediente activo que el medicamento de marca. En general, losmedicamentos 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 autorizaciónprevia para ciertos medicamentos. Esto significa que usted necesitará obtener la aprobación deMercy 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 delmedicamento que Mercy Care Advantage cubrirá. Por ejemplo, Mercy Care Advantage provee30 píldoras cada una para 30 días por cada prescripción de Simvastatin. Esto puede ser en adiciónal suministro estándar para un mes o tres meses.

• Terapia a Pasos: En algunos casos, Mercy Care Advantage requiere que usted pruebe primero ciertosmedicamentos 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 CareAdvantage 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 consultandoel formulario que empieza en la página 1. También puede obtener más información sobre las restriccionesaplicadas a medicamentos cubiertos específicos visitando nuestro sitio web. Nosotros hemos publicado undocumento en línea que explica nuestras restricciones sobre la autorización previa y la terapia a pasos. Ustedtambién puede pedirnos que le enviemos a usted una copia. Nuestra información de contacto, junto con lafecha 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 parauna lista de otros medicamentos similares que puedan tratar su condición de salud. Vea la sección “¿Cómosolicito una excepción al formulario de Mercy Care Advantage?” en la página X para información sobre cómosolicitar 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 usteddebería comunicarse con Servicios al Miembro y preguntar si su medicamento está cubierto. Si usted descubreque Mercy Care Advantage no cubre su medicamento, tiene dos opciones:

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

• Usted puede solicitar que Mercy Care Advantage haga una excepción y cubra su medicamento. Veaabajo 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. Hayvarios 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 esaprobado, dicho medicamento será cubierto a un nivel de costo compartido predeterminado, y ustedno 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 medicamentoque nosotros cubriremos. Si su medicamento tiene un límite de cantidad, usted puede pedirnos que noapliquemos 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 alternosincluidos en el formulario del plan o las restricciones adicionales para su uso no serían tan efectivos tratandosu condición y/o podrían ocasionarle efectos médicos adversos.

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

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

Para cada medicamento que no esté en nuestro formulario, o si su capacidad para obtener dicho medicamentoes limitada, nosotros cubriremos un suministro temporal para 31 días. Si su prescripción ha sido emitidapara menos días, nosotros permitiremos que la vuelva a surtir hasta que se le provea medicamento con unsuministro máximo de 31 días. Después de su primer suministro para 31 días, nosotros ya no pagaremos pordichos 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 ennuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90días como miembro de nuestro plan, nosotros cubriremos un suministro de emergencia de dicho medicamentopara 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 lesurta una prescripción ante su admisión o dada de alta.

Para más informaciónPara información más detallada sobre su cobertura de medicamentos de prescripción/receta de Mercy CareAdvantage, 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. Losusuarios de TTY deberían llamar al 1-877-486-2048. Ó visite http://www.medicare.gov.

http://www.medicare.gov

XII

Formulario de Mercy Care AdvantageEl formulario que empieza en la página 1 provee información de cobertura sobre algunos de los medicamentoscubiertos por Mercy Care Advantage. Si usted tiene problemas para encontrar su medicamento en la lista,regrese al Índice que empieza en la página 54.

En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca estánescritos 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 cantidadesde 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 dePrescripción (Cláusula LIS) lista la cantidad que usted pagará por sus medicamentos de prescripción. Ustedtambién puede llamar a Servicios al Miembro para informarse sobre la cantidad de su costo compartido. Losnúmeros 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 cualquierrequerimiento 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 losmedicamentos están cubiertos bajo la Parte D, pero hay algunos medicamentosque pueden estar cubiertos tanto bajo la Parte B como la Parte D dependiendodel 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 depíldoras despachadas.

LA Limited access / acceso limitado. Esta prescripción puede estar disponible sólo enciertas 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 necesitanobtener la aprobación de nuestro plan antes de que nosotros accedamos a cubrirel medicamento.

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

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

XIII86.03.334.1-AZ

Nondiscrimination Notice

Mercy Care d/b/a Mercy Care Advantage (HMO SNP) complies with applicable federal civil rights laws anddoes not discriminate on the basis of race, color, national origin, age, disability or sex. Mercy Care d/b/aMercy 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 interpreterso Written information in other formats (large print, audio, accessible electronic formats,

other formats)• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreterso Information written in other languages

If you need 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 theseservices 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 RightsCoordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office forCivil 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.

mailto:[email protected]

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

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


XIV86.03.335.2-AZ

Aviso de no discriminación

Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), cumple conlas 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 demanera eficaz con nosotros, como los siguientes:

o Intérpretes de lenguaje de señas calificadoso 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 calificadoso Información escrita en otros idiomas

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

Si considera que Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMOSNP), 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 deDerechos 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 parapresentar 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 ServiciosSociales de EE. UU., Oficina de Derechos Civiles, de manera electrónica a través del portal de reclamos dela Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correoo 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.

mailto:[email protected]

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


XV86.03.334.1-AZ

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

Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 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 số1-877-436-5288 (TTY: 711).

Arabic:

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wikanang 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 Hilfsdienstleistungenzur Verfügung. Rufnummer: 1-877-436-5288 (TTY: 711).

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услугиперевода. Звоните 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。

2020 Formulary (List of Covered Drugs)

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

GOUT – DRUGS TO TREAT GOUTallopurinol tab GENERICcolchicine w/ probenecid GENERICCOLCRYS OTHER QL (120 tabs / 30 days), NMMITIGARE OTHER QL (60 caps / 30 days), NMprobenecid GENERIC

NSAIDS – DRUGS TO TREAT PAIN AND INFLAMMATIONcelecoxib 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 GENERICdiflunisal TABS GENERICec-naproxen GENERICetodolac GENERICflurbiprofen TABS 100mg GENERICibu tab 600mg GENERICibu tab 800mg GENERICibuprofen SUSP GENERIC NMibuprofen TABS 400mg, 600mg, 800mg GENERICmeloxicam TABS GENERICnabumetone TABS GENERICnaproxen TABS 250mg, 375mg, 500mg GENERICnaproxen dr GENERICnaproxen sodium TABS 275mg, 550mg GENERICpiroxicam CAPS GENERICsulindac TABS GENERIC

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

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

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

1

Formulary ID 00020345 v15 10/01/2020


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Drug Name Drug Tier Requirements/Limitsendocet 7.5-325mg GENERIC QL (240 tabs / 30 days), NMendocet 10-325mg GENERIC QL (180 tabs / 30 days), NMfentanyl citrate LPOP GENERIC QL (120 lozenges / 30 days), NM,

PAfentanyl patch 12 mcg/hr GENERIC QL (10 patches / 30 days), NM, PAfentanyl patch 25 mcg/hr GENERIC QL (10 patches / 30 days), NM, PAfentanyl patch 50 mcg/hr GENERIC QL (10 patches / 30 days), NM, PAfentanyl patch 75 mcg/hr GENERIC QL (10 patches / 30 days), NM, PAfentanyl patch 100 mcg/hr GENERIC QL (10 patches / 30 days), NM, PAhydroco/apap tab 5-325mg GENERIC QL (240 tabs / 30 days), NMhydroco/apap tab 7.5-325 GENERIC QL (180 tabs / 30 days), NMhydroco/apap tab 10-325mg GENERIC QL (180 tabs / 30 days), NMhydrocodone-acetaminophen 7.5-325 mg/15ml GENERIC QL (2700 mL / 30 days), NMhydrocodone-ibuprofen tab 7.5-200 mg GENERIC QL (150 tabs / 30 days), NMhydromorphone hcl LIQD GENERIC QL (600 mL / 30 days), NMhydromorphone hcl SOLN 10mg/ml, 50mg/5ml,500mg/50ml

GENERIC B/D, NM

hydromorphone hcl TABS GENERIC QL (180 tabs / 30 days), NMHYSINGLA ER OTHER QL (30 tabs / 30 days), NM, PAlorcet hd tab 10-325mg GENERIC QL (180 tabs / 30 days), NMlorcet plus tab 7.5-325mg GENERIC QL (180 tabs / 30 days), NMlorcet tab 5-325mg GENERIC QL (240 tabs / 30 days), NMmethadone hcl SOLN 5mg/5ml, 10mg/5ml GENERIC QL (450 mL / 30 days), NM, PAmethadone hcl 5mg GENERIC QL (90 tabs / 30 days), NM, PAmethadone hcl 10mg GENERIC QL (90 tabs / 30 days), NM, PAmethadone hcl intensol GENERIC QL (90 mL / 30 days), NM, PAmorphine ext-rel tab GENERIC QL (90 tabs / 30 days), NM, PAmorphine sul inj 1mg/ml GENERIC B/D, NMMORPHINE 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, NMmorphine sulfate TABS GENERIC QL (180 tabs / 30 days), NMmorphine sulfate oral soln 10mg/5ml GENERIC QL (900 mL / 30 days), NMmorphine sulfate oral soln 20mg/5ml GENERIC QL (900 mL / 30 days), NMmorphine sulfate oral soln 100mg/5ml GENERIC QL (180 mL / 30 days), NMNUCYNTA ER OTHER QL (60 tabs / 30 days), NM, PAoxycodone hcl CAPS GENERIC QL (180 caps / 30 days), NMoxycodone hcl CONC GENERIC QL (180 mL / 30 days), NMoxycodone hcl SOLN GENERIC QL (900 mL / 30 days), NMoxycodone hcl TABS GENERIC QL (180 tabs / 30 days), NMoxycodone w/ acetaminophen 2.5-325mg GENERIC QL (360 tabs / 30 days), NMoxycodone w/ acetaminophen 5-325mg GENERIC QL (360 tabs / 30 days), NMoxycodone w/ acetaminophen 7.5-325mg GENERIC QL (240 tabs / 30 days), NMoxycodone w/ acetaminophen 10-325mg GENERIC QL (180 tabs / 30 days), NM

2

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

Formulary ID 00020345 v15 10/01/2020

3

Drug Name Drug Tier Requirements/LimitsANESTHETICS – DRUGS FOR NUMBING

LOCAL ANESTHETICSlidocaine hcl (local anesth.) GENERIC B/D, NMlidocaine inj 0.5% GENERIC B/D, NMlidocaine inj 1% GENERIC B/D, NMlidocaine inj 1.5% preservative free (pf) GENERIC B/D, NM

ANTI-INFECTIVES – DRUGS TO TREAT INFECTIONSANTI-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, PAtobramycin 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 NM

ANTI-INFECTIVES – MISCELLANEOUSalbendazole TABS GENERIC NMALINIA OTHER NMatovaquone SUSP GENERIC NMaztreonam GENERIC NMCAYSTON OTHER NM, LA, PAclindamycin 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), NMertapenem sodium GENERIC NMimipenem-cilastatin GENERIC NMivermectin TABS GENERIC NMlinezolid in sodium chloride GENERIC NMlinezolid inj GENERIC NMlinezolid susp GENERIC NM


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4

Drug Name Drug Tier Requirements/Limitslinezolid tab 600mg GENERIC NMmeropenem 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, NMpentamidine 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), NMvancomycin hcl CAPS 250mg GENERIC QL (240 caps / 30 days), NMvancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg GENERIC NMVANCOMYCIN IN NACL OTHER NM

ANTIFUNGALS – DRUGS TO TREAT FUNGAL INFECTIONSABELCET OTHER B/D, NMAMBISOME OTHER B/D, NMamphotericin b SOLR GENERIC B/D, NMcaspofungin 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, PAketoconazole TABS GENERIC NM, PAmicafungin 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), NMvoriconazole SOLR; SUSR GENERIC NM, PAvoriconazole TABS GENERIC NM


Formulary ID 00020345 v15 10/01/2020

Drug Name Drug Tier Requirements/LimitsANTIMALARIALS – DRUGS TO TREAT MALARIA

atovaquone-proguanil hcl GENERIC NMchloroquine phosphate TABS GENERICCOARTEM OTHER NMmefloquine hcl GENERICprimaquine phosphate 26.3mg GENERIC NMPRIMAQUINE PHOSPHATE 26.3mg OTHER NMquinine sulfate CAPS GENERIC NM, PA

ANTIRETROVIRAL AGENTS – DRUGS TO SUPPRESS HIV/AIDS INFECTIONabacavir 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), NMPREZISTA TABS 75mg OTHER QL (480 tabs / 30 days), NMPREZISTA TABS 150mg OTHER QL (240 tabs / 30 days), NMPREZISTA TABS 600mg OTHER QL (60 tabs / 30 days), NMPREZISTA TABS 800mg OTHER QL (30 tabs / 30 days), NMREYATAZ PACK OTHER NMritonavir GENERIC NMRUKOBIA OTHER NMSELZENTRY OTHER NMstavudine GENERIC NMtenofovir disoproxil fumarate GENERIC NMTIVICAY OTHER NM

5


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Drug Name Drug Tier Requirements/LimitsTIVICAY PD OTHER NMTROGARZO OTHER NM, LATYBOST OTHER NMVIRACEPT OTHER NMVIREAD POWD OTHER NMVIREAD TABS 150mg, 200mg, 250mg OTHER NMzidovudine cap 100mg GENERIC NMzidovudine syp 50mg/5ml GENERIC NMzidovudine tab 300mg GENERIC NM

ANTIRETROVIRAL COMBINATION AGENTS – DRUGS TO SUPPRESS HIV/AIDS INFECTIONabacavir sulfate-lamivudine GENERIC NMabacavir sulfate-lamivudine-zidovudine GENERIC NMATRIPLA OTHER NMBIKTARVY OTHER NMCIMDUO OTHER NMCOMPLERA OTHER NMDELSTRIGO OTHER NMDESCOVY OTHER NMDOVATO OTHER NMEVOTAZ OTHER NMGENVOYA OTHER NMJULUCA OTHER NMKALETRA TAB 100-25MG OTHER NMKALETRA TAB 200-50MG OTHER NMlamivudine-zidovudine GENERIC NMlopinavir-ritonavir GENERIC NMODEFSEY OTHER NMPREZCOBIX OTHER NMSTRIBILD OTHER NMSYMFI OTHER NMSYMFI LO OTHER NMSYMTUZA OTHER NMTEMIXYS OTHER NMTRIUMEQ OTHER NMTRUVADA TAB 100-150 OTHER QL (30 tabs / 30 days), NMTRUVADA TAB 133-200 OTHER QL (30 tabs / 30 days), NMTRUVADA TAB 167-250 OTHER QL (30 tabs / 30 days), NMTRUVADA TAB 200-300 OTHER QL (30 tabs / 30 days), NM

ANTITUBERCULAR AGENTS – DRUGS TO TREAT TUBERCULOSIScycloserine CAPS GENERIC NMethambutol hcl TABS GENERIC NMisoniazid TABS GENERICisoniazid syp 50mg/5ml GENERICpaser d/r GENERIC NM


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Drug Name Drug Tier Requirements/LimitsPRIFTIN OTHER NMpyrazinamide TABS GENERIC NMrifabutin GENERIC NMrifampin CAPS; SOLR GENERIC NMSIRTURO OTHER NM, LA, PATRECATOR OTHER NM

ANTIVIRALS – DRUGS TO TREAT VIRAL INFECTIONSacyclovir CAPS; SUSP; TABS GENERIC NMacyclovir sodium GENERIC B/D, NMadefovir dipivoxil GENERIC NMBARACLUDE SOLN OTHER NMentecavir GENERIC NMEPCLUSA OTHER NM, PAEPIVIR HBV SOLN OTHER NMfamciclovir TABS GENERIC NMganciclovir sodium GENERIC B/D, NMHARVONI OTHER NM, PAlamivudine (hbv) GENERIC NMMAVYRET OTHER NM, PAoseltamivir phosphate CAPS 30mg GENERIC QL (168 caps / year), NMoseltamivir phosphate CAPS 45mg, 75mg GENERIC QL (84 caps / year), NMoseltamivir phosphate SUSR GENERIC QL (1080 mL / year), NMPEGASYS OTHER NM, PAPEGASYS PROCLICK OTHER NM, PARELENZA DISKHALER OTHER QL (6 inhalers / year), NMribavirin cap 200mg GENERIC NMribavirin tab 200mg GENERIC NMrimantadine hydrochloride GENERIC NMvalacyclovir hcl TABS GENERIC NMvalganciclovir hcl GENERICVEMLIDY OTHER NMVOSEVI OTHER NM, PA

CEPHALOSPORINS – DRUGS TO TREAT INFECTIONScefaclor GENERIC NMcefaclor er tab 500mg GENERIC NMcefadroxil GENERIC NMCEFAZOLIN IN DEXTROSE 2GM/100ML-4% OTHER NMcefazolin inj GENERIC NMcefazolin sodium SOLR 1gm GENERIC NMcefazolin sodium 1 gm/50ml GENERIC NMcefdinir GENERIC NMcefepime for inj GENERIC NMcefixime SUSR GENERIC NMcefoxitin for inj GENERIC NM

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Drug Name Drug Tier Requirements/Limitscefpodoxime proxetil GENERIC NMcefprozil GENERIC NMceftazidime SOLR GENERIC NMCEFTAZIDIME/DEXTROSE OTHER NMceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg GENERIC NMcefuroxime axetil GENERIC NMcefuroxime sodium GENERIC NMcephalexin CAPS 250mg, 500mg GENERIC NMcephalexin SUSR GENERIC NMtazicef SOLR GENERIC NMTEFLARO OTHER NM

ERYTHROMYCINS/MACROLIDES – DRUGS TO TREAT INFECTIONSazithromycin PACK; SOLR; SUSR; TABS GENERIC NMclarithromycin TABS GENERIC NMclarithromycin er GENERIC NMclarithromycin for susp GENERIC NMDIFICID OTHER NMery-tab GENERIC NMerythrocin lactobionate GENERIC NMerythrocin stearate GENERIC NMerythromycin base GENERIC NMerythromycin cap 250mg ec GENERIC NMerythromycin ethylsuccinate TABS GENERIC NMerythromycin tab ec GENERIC NM

FLUOROQUINOLONES – DRUGS TO TREAT INFECTIONSCIPRO SUSR 500mg/5ml OTHER NMciprofloxacin hcl tab GENERIC NMciprofloxacin in d5w GENERIC NMlevofloxacin TABS GENERIC NMlevofloxacin in d5w GENERIC NMlevofloxacin inj 25mg/ml GENERIC NMlevofloxacin oral soln 25 mg/ml GENERIC NMmoxifloxacin hcl TABS GENERIC NM

PENICILLINS – DRUGS TO TREAT INFECTIONSamoxicillin GENERIC NMamoxicillin & pot clavulanate 200-28.5 chw tabs GENERIC NMamoxicillin & pot clavulanate 200/5ml susr GENERIC NMamoxicillin & pot clavulanate 250-125 tabs GENERIC NMamoxicillin & pot clavulanate 250/5ml susr GENERIC NMamoxicillin & pot clavulanate 400-57 chw tabs GENERIC NMamoxicillin & pot clavulanate 400/5ml susr GENERIC NMamoxicillin & pot clavulanate 500-125 tabs GENERIC NMamoxicillin & pot clavulanate 600/5ml susr GENERIC NMamoxicillin & pot clavulanate 875-125 tabs GENERIC NM


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Drug Name Drug Tier Requirements/Limitsamoxicillin & pot clavulanate er 12hr 1000-62.5 tabs GENERIC NMampicillin & sulbactam sodium GENERIC NMampicillin cap 500mg GENERIC NMampicillin inj GENERIC NMampicillin sodium GENERIC NMBICILLIN L-A OTHER NMdicloxacillin sodium GENERIC NMnafcillin sodium for inj GENERIC NMnafcillin sodium for inj 10gm GENERIC NMoxacillin sodium SOLR GENERIC NMPENICILLIN G POT IN DEXTROSE 2MU OTHER NMPENICILLIN G POT IN DEXTROSE 3MU OTHER NMpenicillin g procaine GENERIC NMpenicillin g sodium GENERIC NMpenicillin v potassium GENERIC NMpenicilln gk inj 5mu GENERIC NMpenicilln gk inj 20mu GENERIC NMpfizerpen-g inj 5mu GENERIC NMpfizerpen-g inj 20mu GENERIC NMpiper/tazoba inj 2-0.25gm GENERIC NMpiper/tazoba inj 3-0.375gm GENERIC NMpiper/tazoba inj 4-0.5gm GENERIC NMpiper/tazoba inj 12-1.5gm GENERIC NMpiper/tazoba inj 36-4.5gm GENERIC NM

TETRACYCLINES – DRUGS TO TREAT INFECTIONSdoxy 100 GENERIC NMdoxycycline (monohydrate) CAPS 50mg, 100mg GENERIC NMdoxycycline (monohydrate) TABS 50mg, 75mg, 100mg GENERIC NMdoxycycline hyclate CAPS; SOLR GENERIC NMdoxycycline hyclate 20 mg GENERIC NMdoxycycline hyclate 100 mg GENERIC NMminocycline hcl CAPS GENERIC NMmondoxyne nl cap 100mg GENERIC NMtetracycline hcl CAPS GENERIC NM

ANTINEOPLASTIC AGENTS – DRUGS TO TREAT CANCERALKYLATING AGENTS

BENDEKA OTHER B/D, NMcyclophosphamide CAPS; SOLR GENERIC B/D, NMEMCYT OTHER NMGLEOSTINE OTHER NMLEUKERAN OTHER NM

ANTHRACYCLINESadriamycin SOLN GENERIC B/D, NMdoxorubicin hcl GENERIC B/D, NM


Formulary ID 00020345 v15 10/01/2020

Drug Name Drug Tier Requirements/Limitsdoxorubicin hcl liposomal GENERIC B/D, NMepirubicin hcl GENERIC B/D, NM

ANTIMETABOLITESadrucil inj GENERIC B/D, NMALIMTA OTHER B/D, NMazacitidine GENERIC B/D, NMcytarabine 20mg/ml GENERIC B/D, NMfluorouracil SOLN GENERIC B/D, NMgemcitabine inj soln GENERIC B/D, NMgemcitabine inj solr GENERIC B/D, NMmercaptopurine TABS GENERIC NMmethotrexate sodium inj soln GENERIC B/D, NMmethotrexate sodium inj solr GENERIC B/D, NMPURIXAN OTHER NMTABLOID OTHER NM

ANTIMITOTIC, TAXOIDSABRAXANE OTHER B/D, NMdocetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml,200mg/10ml

GENERIC B/D, NM

DOCETAXEL CONC 80mg/4ml, 160mg/8ml OTHER B/D, NMdocetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml GENERIC B/D, NMDOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml OTHER B/D, NMpaclitaxel 30mg/5ml, 100mg/16.7ml, 150mg/25ml,300mg/50ml

GENERIC B/D, NM

TAXOTERE OTHER B/D, NMANTIMITOTIC, VINCA ALKALOIDS

vincristine sulfate GENERIC B/D, NMvinorelbine tartrate GENERIC B/D, NM

BIOLOGIC RESPONSE MODIFIERSAVASTIN OTHER NM, LA, PABORTEZOMIB OTHER NM, PADAURISMO OTHER NM, LA, PAERIVEDGE OTHER NM, LA, PAFARYDAK OTHER NM, LA, PAHERCEPTIN OTHER NM, PAHERCEPTIN HYLECTA OTHER NM, PAHERZUMA OTHER NM, PAIBRANCE CAPS OTHER QL (21 caps / 28 days), NM, LA, PAIBRANCE TABS OTHER QL (21 tabs / 28 days), NM, LA, PAIDHIFA OTHER QL (30 tabs / 30 days), NM, LA, PAKADCYLA OTHER B/D, NMKANJINTI OTHER NM, PAKEYTRUDA OTHER NM, PAKISQALI OTHER NM, PA

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Drug Name Drug Tier Requirements/LimitsKISQALI FEMARA 200 DOSE OTHER NM, PAKISQALI FEMARA 400 DOSE OTHER NM, PAKISQALI FEMARA 600 DOSE OTHER NM, PALYNPARZA OTHER NM, LA, PAMVASI OTHER NM, LA, PANINLARO OTHER NM, PAODOMZO OTHER NM, LA, PAOGIVRI OTHER NM, PAONTRUZANT OTHER NM, PAPHESGO OTHER NM, LA, PARITUXAN OTHER NM, LA, PARITUXAN HYCELA OTHER NM, LA, PARUBRACA OTHER NM, LA, PARUXIENCE OTHER NM, PATALZENNA OTHER NM, LA, PATECENTRIQ OTHER NM, LA, PATIBSOVO OTHER NM, LA, PATRAZIMERA OTHER NM, PATRUXIMA OTHER NM, PAVELCADE OTHER NM, PAVENCLEXTA OTHER NM, LA, PAVENCLEXTA STARTING PACK OTHER NM, LA, PAVERZENIO OTHER NM, LA, PAZEJULA OTHER NM, LA, PAZIRABEV OTHER NM, PAZOLINZA OTHER NM, PA

HORMONAL ANTINEOPLASTIC AGENTSabiraterone acetate GENERIC NM, PAanastrozole TABS GENERICbicalutamide GENERIC NMDEPO-PROVERA INJ 400/ML OTHER B/D, NMERLEADA OTHER NM, LA, PAexemestane GENERICflutamide GENERIC NMfulvestrant GENERIC B/D, NMletrozole TABS GENERICleuprolide inj 1mg/0.2 GENERIC NM, PALUPRON DEPOT (1-MONTH) 3.75mg OTHER NM, PALUPRON DEPOT INJ 11.25MG (3-MONTH) OTHER NM, PALYSODREN OTHER NMmegestrol ac sus 40mg/ml GENERIC NMmegestrol ac tab 20mg GENERIC NMmegestrol ac tab 40mg GENERIC NMmegestrol sus 625mg/5ml GENERIC PA

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Drug Name Drug Tier Requirements/Limitsnilutamide GENERIC NMNUBEQA OTHER NM, LA, PASOLTAMOX OTHERtamoxifen citrate TABS GENERICtoremifene citrate GENERICTRELSTAR DEP INJ 3.75MG OTHER NM, PATRELSTAR LA INJ 11.25MG OTHER NM, PAXTANDI OTHER NM, LA, PAZYTIGA 500mg OTHER NM, LA, PA

IMMUNOMODULATORSPOMALYST 1mg, 2mg OTHER QL (21 caps / 21 days), NM, LA, PAPOMALYST 3mg, 4mg OTHER QL (21 caps / 28 days), NM, LA, PAREVLIMID OTHER QL (28 caps / 28 days), NM, LA, PATHALOMID 50mg, 100mg OTHER QL (28 caps / 28 days), NM, PATHALOMID 150mg, 200mg OTHER QL (56 caps / 28 days), NM, PA

KINASE INHIBITORSAFINITOR 10mg OTHER QL (30 tabs / 30 days), NM, PAAFINITOR DISPERZ 2mg OTHER QL (150 tabs / 30 days), NM, PAAFINITOR DISPERZ 3mg OTHER QL (90 tabs / 30 days), NM, PAAFINITOR DISPERZ 5mg OTHER QL (60 tabs / 30 days), NM, PAALECENSA OTHER NM, LA, PAALUNBRIG OTHER NM, LA, PAAYVAKIT OTHER QL (30 tabs / 30 days), NM, LA, PABALVERSA OTHER NM, LA, PABOSULIF OTHER NM, PABRAFTOVI OTHER NM, LA, PABRUKINSA OTHER NM, LA, PACABOMETYX OTHER QL (30 tabs / 30 days), NM, LA, PACALQUENCE OTHER NM, LA, PACAPRELSA OTHER NM, LA, PACOMETRIQ OTHER NM, LA, PACOPIKTRA OTHER NM, LA, PACOTELLIC OTHER NM, LA, PAerlotinib hcl 25mg GENERIC QL (90 tabs / 30 days), NM, PAerlotinib hcl 100mg, 150mg GENERIC QL (30 tabs / 30 days), NM, PAeverolimus GENERIC QL (30 tabs / 30 days), NM, PAGILOTRIF TAB 20MG OTHER NM, LA, PAGILOTRIF TAB 30MG OTHER NM, LA, PAGILOTRIF TAB 40MG OTHER NM, LA, PAICLUSIG OTHER NM, LA, PAimatinib mesylate 100mg GENERIC QL (90 tabs / 30 days), NM, PAimatinib mesylate 400mg GENERIC QL (60 tabs / 30 days), NM, PAIMBRUVICA OTHER NM, LA, PAINLYTA 1mg OTHER QL (180 tabs / 30 days), NM, LA, PA


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Drug Name Drug Tier Requirements/LimitsINLYTA 5mg OTHER QL (120 tabs / 30 days), NM, LA, PAINREBIC OTHER NM, LA, PAIRESSA OTHER NM, LA, PAJAKAFI OTHER QL (60 tabs / 30 days), NM, LA, PALENVIMA 4 MG DAILY DOSE OTHER NM, LA, PALENVIMA 8 MG DAILY DOSE OTHER NM, LA, PALENVIMA 10 MG DAILY DOSE OTHER NM, LA, PALENVIMA 12MG DAILY DOSE OTHER NM, LA, PALENVIMA 14 MG DAILY DOSE OTHER NM, LA, PALENVIMA 18 MG DAILY DOSE OTHER NM, LA, PALENVIMA 20 MG DAILY DOSE OTHER NM, LA, PALENVIMA 24 MG DAILY DOSE OTHER NM, LA, PALORBRENA OTHER NM, LA, PAMEKINIST OTHER NM, LA, PAMEKTOVI OTHER NM, LA, PANERLYNX OTHER NM, LA, PANEXAVAR OTHER NM, LA, PAPEMAZYRE OTHER NM, LA, PAPIQRAY 200MG DAILY DOSE OTHER NM, PAPIQRAY 250MG DAILY DOSE OTHER NM, PAPIQRAY 300MG DAILY DOSE OTHER NM, PAQINLOCK OTHER NM, LA, PARETEVMO OTHER NM, LA, PAROZLYTREK OTHER NM, LA, PARYDAPT OTHER NM, PASPRYCEL OTHER NM, PASTIVARGA OTHER NM, LA, PASUTENT OTHER QL (30 caps / 30 days), NM, PATABRECTA OTHER NM, PATAFINLAR OTHER NM, LA, PATAGRISSO OTHER QL (30 tabs / 30 days), NM, LA, PATASIGNA OTHER NM, PATUKYSA OTHER NM, LA, PATURALIO OTHER NM, LA, PATYKERB OTHER NM, LA, PAVITRAKVI OTHER NM, LA, PAVIZIMPRO OTHER NM, LA, PAVOTRIENT OTHER NM, LA, PAXALKORI OTHER NM, LA, PAXOSPATA OTHER NM, LA, PAZELBORAF OTHER NM, LA, PAZYDELIG OTHER NM, LA, PAZYKADIA OTHER NM, LA, PA


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Drug Name Drug Tier Requirements/LimitsMISCELLANEOUS

bexarotene GENERIC NM, PAhydroxyurea CAPS GENERIC NMLONSURF OTHER NM, PAMATULANE OTHER NM, LASYLATRON OTHER NM, PASYNRIBO OTHER NM, PATAZVERIK OTHER NM, LA, PAtretinoin (chemotherapy) GENERIC NMXPOVIO 40 MG ONCE WEEKLY OTHER NM, LA, PAXPOVIO 40 MG TWICE WEEKLY OTHER NM, LA, PAXPOVIO 60 MG ONCE WEEKLY OTHER NM, LA, PAXPOVIO 60 MG TWICE WEEKLY OTHER NM, LA, PAXPOVIO 80 MG ONCE WEEKLY OTHER NM, LA, PAXPOVIO 80 MG TWICE WEEKLY OTHER NM, LA, PAXPOVIO 100 MG ONCE WEEKLY OTHER NM, LA, PA

PLATINUM-BASED AGENTScarboplatin GENERIC B/D, NMcisplatin SOLN GENERIC B/D, NMoxaliplatin inj 50mg GENERIC B/D, NMoxaliplatin inj 50mg/10ml GENERIC B/D, NMoxaliplatin inj 100mg GENERIC B/D, NMoxaliplatin inj 100mg/20ml GENERIC B/D, NM

PROTECTIVE AGENTSleucovorin calcium SOLN 500mg/50ml GENERIC B/D, NMleucovorin calcium SOLR GENERIC B/D, NMleucovorin calcium TABS GENERIC NMMESNEX TABS OTHER NM

TOPOISOMERASE INHIBITORSetoposide SOLN GENERIC B/D, NMirinotecan hcl GENERIC B/D, NMtoposar GENERIC B/D, NM

CARDIOVASCULAR – DRUGS TO TREAT HEART AND CIRCULATION CONDITIONSACE INHIBITOR COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSURE

amlodipine besylate-benazepril hcl cap 2.5-10 mg GENERICamlodipine besylate-benazepril hcl cap 5-10 mg GENERICamlodipine besylate-benazepril hcl cap 5-20 mg GENERICamlodipine besylate-benazepril hcl cap 5-40 mg GENERICamlodipine besylate-benazepril hcl cap 10-20 mg GENERICamlodipine besylate-benazepril hcl cap 10-40 mg GENERICbenazepril & hydrochlorothiazide GENERICcaptopril & hydrochlorothiazide GENERICenalapril maleate & hydrochlorothiazide GENERIC


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Drug Name Drug Tier Requirements/Limitsfosinopril sodium & hydrochlorothiazide GENERIClisinopril & hydrochlorothiazide GENERICquinapril-hydrochlorothiazide GENERIC

ACE INHIBITORS – DRUGS TO TREAT HIGH BLOOD PRESSUREbenazepril hcl TABS GENERICcaptopril TABS GENERICenalapril maleate TABS GENERICfosinopril sodium GENERIClisinopril TABS GENERICmoexipril hcl GENERICperindopril erbumine GENERICquinapril hcl GENERICramipril GENERICtrandolapril GENERIC

ALDOSTERONE RECEPTOR ANTAGONISTS – DRUGS TO TREAT HIGH BLOOD PRESSUREeplerenone GENERICspironolactone TABS GENERIC

ALPHA BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSUREdoxazosin mesylate TABS GENERICprazosin hcl GENERICterazosin hcl GENERIC

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSUREamlodipine besylate-olmesartan medoxomil GENERICamlodipine besylate-valsartan tab GENERICamlodipine-valsartan-hydrochlorothiazide tab GENERICcandesartan cilexetil-hydrochlorothiazide GENERICENTRESTO OTHERirbesartan-hydrochlorothiazide GENERIClosartan-hydrochlorothiazide GENERIColmesartan medoxomil-amlodipine-hydrochlorothiazide GENERIColmesartan medoxomil-hydrochlorothiazide GENERICtelmisartan-amlodipine GENERICtelmisartan-hydrochlorothiazide GENERICvalsartan-hydrochlorothiazide GENERIC

ANGIOTENSIN II RECEPTOR ANTAGONISTS – DRUGS TO TREAT HIGH BLOOD PRESSUREcandesartan cilexetil GENERICirbesartan GENERIClosartan potassium TABS GENERIColmesartan medoxomil TABS GENERICtelmisartan GENERICvalsartan GENERIC

ANTIARRHYTHMICS – DRUGS TO CONTROL HEART RHYTHMamiodarone hcl soln GENERIC NM


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Drug Name Drug Tier Requirements/Limitsamiodarone tab 100mg GENERICamiodarone tab 200mg GENERICamiodarone tab 400mg GENERICdisopyramide phosphate GENERICdofetilide GENERIC NMflecainide acetate GENERICMULTAQ OTHERNORPACE CR OTHERpacerone GENERICpropafenone hcl GENERICpropafenone hcl 12hr GENERICquinidine sulfate GENERICsorine GENERICsotalol hcl GENERICsotalol hcl (afib/afl) GENERIC

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS – DRUGS TO TREAT HIGH CHOLESTEROLatorvastatin calcium TABS GENERIClovastatin GENERICpravastatin sodium GENERICrosuvastatin calcium GENERIC QL (30 tabs / 30 days)simvastatin TABS 5mg, 10mg, 20mg, 40mg GENERICsimvastatin TABS 80mg GENERIC QL (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS – DRUGS TO TREAT HIGH CHOLESTEROLcholestyramine GENERICcholestyramine light pack GENERICcholestyramine light powd GENERICcolesevelam hcl GENERICcolestipol hcl gran GENERICcolestipol hcl pack GENERICcolestipol hcl tabs GENERICezetimibe GENERICezetimibe-simvastatin GENERICfenofibrate TABS 48mg, 54mg, 145mg, 160mg GENERICfenofibrate micronized 67mg, 134mg, 200mg GENERICgemfibrozil TABS GENERICJUXTAPID OTHER NM, LA, PAniacin (antihyperlipidemic) GENERIC NMniacin er (antihyperlipidemic) 500mg GENERIC QL (60 tabs / 30 days)niacin er (antihyperlipidemic) 750mg, 1000mg GENERICniacor GENERIC NMPRALUENT OTHER NM, PAprevalite GENERICVASCEPA OTHER


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Drug Name Drug Tier Requirements/LimitsBETA-BLOCKER/DIURETIC COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEARTCONDITIONS

atenolol & chlorthalidone GENERICbisoprolol & hydrochlorothiazide GENERICmetoprolol & hydrochlorothiazide GENERICpropranolol & hydrochlorothiazide GENERIC

BETA-BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONSacebutolol hcl CAPS GENERICatenolol TABS GENERICbetaxolol hcl GENERICbisoprolol fumarate GENERICBYSTOLIC 2.5mg, 5mg, 10mg OTHER QL (30 tabs / 30 days)BYSTOLIC 20mg OTHER QL (60 tabs / 30 days)carvedilol GENERIClabetalol hcl TABS GENERICmetoprolol succinate GENERICmetoprolol tartrate SOCT GENERIC NMmetoprolol tartrate SOLN GENERIC NMmetoprolol tartrate TABS 25mg, 50mg, 100mg GENERICnadolol TABS GENERICpindolol GENERICpropranolol cap er GENERICpropranolol hcl TABS GENERICpropranolol oral sol GENERICtimolol maleate TABS GENERIC

CALCIUM CHANNEL BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONSamlodipine besylate TABS GENERICcartia xt GENERICdilt-xr cap GENERICdiltiazem cap 240mg cd GENERICdiltiazem cap 360mg cd GENERICdiltiazem cap er/12hr GENERICdiltiazem hcl TABS GENERICdiltiazem hcl coated beads CP24 GENERICdiltiazem hcl coated beads cap sr 24hr GENERICdiltiazem hcl extended release beads cap sr GENERICdiltiazem inj GENERIC NMfelodipine GENERICisradipine GENERICnicardipine hcl CAPS GENERICnifedipine TB24 GENERICnifedipine er GENERICnimodipine CAPS GENERIC NMNYMALIZE OTHER NM


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Drug Name Drug Tier Requirements/Limitstaztia xt GENERICtiadylt er GENERICverapamil cap er GENERICverapamil hcl SOLN GENERIC NMverapamil hcl TABS; TBCR GENERICverapamil tab er GENERIC

DIGITALIS GLYCOSIDES – DRUGS TO TREAT HEART CONDITIONSdigitek .25mg GENERIC PA; PA if 70 years and olderdigitek .125mg GENERIC QL (30 tabs / 30 days)digox 125mcg GENERIC QL (30 tabs / 30 days)digox 250mcg GENERIC PA; PA if 70 years and olderdigoxin TABS 125mcg GENERIC QL (30 tabs / 30 days)digoxin TABS 250mcg GENERIC PA; PA if 70 years and olderdigoxin inj GENERIC NMdigoxin sol 50mcg/ml GENERIC PA; PA if 70 years and older

DIURETICS – DRUGS TO TREAT HEART CONDITIONSacetazolamide CP12; TABS GENERICamiloride & hydrochlorothiazide GENERICamiloride hcl TABS GENERICbumetanide inj 0.25/ml GENERIC NMbumetanide tab GENERICchlorothiazide TABS GENERICchlorthalidone GENERICfurosemide SOLN; TABS GENERICfurosemide inj GENERIC NMhydrochlorothiazide CAPS; TABS GENERICindapamide GENERICmethazolamide TABS GENERICmetolazone GENERICspironolactone & hydrochlorothiazide GENERICtorsemide tabs GENERICtriamterene & hydrochlorothiazide cap 37.5-25 mg GENERICtriamterene & hydrochlorothiazide tabs GENERIC

MISCELLANEOUSaliskiren fumarate GENERICclonidine hcl TABS GENERICclonidine hcl ptwk GENERICCORLANOR OTHERDEMSER OTHER NM, PAhydralazine hcl SOLN GENERIC NMhydralazine hcl TABS GENERICmetyrosine GENERIC NM, PAmidodrine hcl GENERIC NMminoxidil TABS GENERIC


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Drug Name Drug Tier Requirements/LimitsNORTHERA 100mg OTHER QL (90 caps / 30 days), NM, LA, PANORTHERA 200mg, 300mg OTHER QL (180 caps / 30 days), NM, LA, PAranolazine GENERIC

NITRATES – DRUGS TO TREAT HEART CONDITIONSisosorb mononitrate tab GENERICisosorbide dinitrate 5mg, 10mg, 20mg, 30mg GENERICisosorbide mononitrate er GENERICminitran GENERICnitro-bid GENERICNITRO-DUR DIS 0.3MG/HR OTHERNITRO-DUR DIS 0.8MG/HR OTHERnitroglycerin SOLN .4mg/spray GENERICnitroglycerin SUBL GENERICnitroglycerin td patch GENERIC

PULMONARY ARTERIAL HYPERTENSION – DRUGS TO TREAT PULMONARY HYPERTENSIONADEMPAS OTHER QL (90 tabs / 30 days), NM, LA, PAambrisentan GENERIC QL (30 tabs / 30 days), NM, LA, PAbosentan 62.5mg GENERIC QL (120 tabs / 30 days), NM, LA, PAbosentan 125mg GENERIC QL (60 tabs / 30 days), NM, LA, PAOPSUMIT OTHER QL (30 tabs / 30 days), NM, LA, PAsildenafil citrate tab 20 mg (pulmonary hypertension) GENERIC QL (90 tabs / 30 days), NM, PAtreprostinil GENERIC NM, LA, PAVENTAVIS OTHER NM, PA

CENTRAL NERVOUS SYSTEM – DRUGS TO TREAT NERVOUS SYSTEM DISORDERSANTIANXIETY – DRUGS TO TREAT ANXIETY

alprazolam tab 0.5mg GENERIC QL (150 tabs / 30 days), NMalprazolam tab 0.25mg GENERIC QL (150 tabs / 30 days), NMalprazolam tab 1mg GENERIC QL (150 tabs / 30 days), NMalprazolam tab 2 mg GENERIC QL (150 tabs / 30 days), NMbuspirone hcl TABS GENERIC NMfluvoxamine maleate TABS GENERIClorazepam SOLN GENERIC NMlorazepam TABS GENERIC QL (150 tabs / 30 days), NMlorazepam intensol GENERIC QL (150 mL / 30 days), NM

ANTICONVULSANTS – DRUGS TO TREAT SEIZURESAPTIOM OTHER QL (60 tabs / 30 days)BANZEL SUS 40MG/ML OTHER PABANZEL TAB 200MG OTHER PABANZEL TAB 400MG OTHER PABRIVIACT INJ 50MG/5ML OTHER NM, PABRIVIACT SOL 10MG/ML OTHER PABRIVIACT TAB 10MG OTHER PABRIVIACT TAB 25MG OTHER PABRIVIACT TAB 50MG OTHER PA


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Drug Name Drug Tier Requirements/LimitsBRIVIACT TAB 75MG OTHER PABRIVIACT TAB 100MG OTHER PAcarbamazepine CHEW; CP12; SUSP; TABS; TB12 GENERICCELONTIN OTHERclobazam GENERIC PAclonazepam TABS 2mg GENERIC QL (300 tabs / 30 days), NMclonazepam TABS .5mg, 1mg GENERIC QL (90 tabs / 30 days), NMclonazepam TBDP 2mg GENERIC QL (300 tabs / 30 days), NMclonazepam TBDP .125mg, .25mg, .5mg, 1mg GENERIC QL (90 tabs / 30 days), NMclorazepate dipotassium GENERIC QL (180 tabs / 30 days), NM, PA;

PA if 65 years and olderDIASTAT ACUDIAL OTHER NMDIASTAT PEDIATRIC OTHER NMdiazepam TABS GENERIC QL (120 tabs / 30 days), NM, PA;

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

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

PA if 65 years and olderdilantin cap 30mg GENERICdilantin cap 100mg GENERICdilantin chew tab 50mg GENERICDILANTIN-125 SUSP OTHERdivalproex sodium CSDR; TB24; TBEC GENERICEPIDIOLEX OTHER QL (600 mL / 30 days), NM, LA,

PAepitol GENERICethosuximide CAPS; SOLN GENERICfelbamate GENERICFINTEPLA OTHER QL (360 mL / 30 days), NM, LA,

PAFYCOMPA SUSP OTHER QL (720 mL / 30 days), PAFYCOMPA TABS 2mg, 4mg, 6mg OTHER QL (60 tabs / 30 days), PAFYCOMPA TABS 8mg, 10mg, 12mg OTHER QL (30 tabs / 30 days), PAgabapentin 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 GENERIClevetiracetam SOLN GENERIC NMlevetiracetam TABS; TB24 GENERIC


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Drug Name Drug Tier Requirements/Limitslevetiracetam in sodium chloride GENERIC NMlevetiracetam oral soln 100 mg/ml GENERICNAYZILAM OTHER NMoxcarbazepine GENERICPEGANONE OTHERphenobarbital ELIX; TABS GENERIC PA; PA if 70 years and olderphenobarbital sodium SOLN GENERIC NM, PA; PA if 70 years and olderphenytek GENERICphenytoin CHEW; SUSP GENERICphenytoin sodium extended GENERICphenytoin sodium inj 50mg/ml GENERIC NMpregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg GENERIC QL (120 caps / 30 days), PApregabalin CAPS 200mg GENERIC QL (90 caps / 30 days), PApregabalin CAPS 225mg, 300mg GENERIC QL (60 caps / 30 days), PApregabalin SOLN GENERIC QL (900 mL / 30 days), PAprimidone TABS GENERICroweepra GENERICroweepra xr GENERICSPRITAM OTHERsubvenite tab GENERICSYMPAZAN OTHER PAtiagabine hcl GENERICtopiramate CPSP; TABS GENERICvalproate sodium SOLN GENERIC NMvalproate sodium oral soln GENERICvalproic acid CAPS GENERICVALTOCO OTHER NMvigabatrin powd pack 500mg GENERIC QL (180 packets / 30 days), NM,

LA, PAvigabatrin tab 500mg GENERIC QL (180 tabs / 30 days), NM, LA, PAvigadrone GENERIC QL (180 packets / 30 days), NM,

LA, PAVIMPAT 50mg OTHER QL (120 tabs / 30 days)VIMPAT 100mg, 150mg, 200mg OTHER QL (60 tabs / 30 days)VIMPAT INJ 200MG/20ML OTHER NMVIMPAT 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), NMXCOPRI PAK 50-100MG OTHER QL (28 tabs / 28 days), NMXCOPRI 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), NMzonisamide CAPS GENERIC


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Drug Name Drug Tier Requirements/LimitsANTIDEMENTIA – DRUGS TO TREAT DEMENTIA AND MEMORY LOSS

donepezil hydrochloride TABS 5mg GENERIC QL (30 tabs / 30 days)donepezil hydrochloride TABS 10mg GENERICdonepezil hydrochloride TBDP 5mg GENERIC QL (30 tabs / 30 days)donepezil hydrochloride TBDP 10mg GENERICgalantamine hydrobromide SOLN GENERICgalantamine 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 yrsmemantine soln GENERIC PA; PA if < 30 yrsmemantine tabs GENERIC PA; PA if < 30 yrsmemantine titration pak GENERIC NM, PA; PA if < 30 yrsNAMZARIC C4PK OTHER NMNAMZARIC CP24 OTHERrivastigmine 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 DEPRESSIONamitriptyline hcl TABS GENERICamoxapine GENERICbupropion hcl TABS GENERICbupropion hcl TB12 GENERICbupropion hcl TB24 150mg, 300mg GENERICcitalopram hydrobromide GENERICclomipramine hcl CAPS GENERIC PAdesipramine hcl TABS GENERICdesvenlafaxine succinate GENERIC QL (30 tabs / 30 days), PAdoxepin hcl CAPS; CONC GENERICDRIZALMA SPRINKLE 20mg, 30mg, 60mg OTHER QL (60 caps / 30 days), PADRIZALMA SPRINKLE 40mg OTHER QL (90 caps / 30 days), PAduloxetine hcl CPEP 20mg, 30mg, 60mg GENERIC QL (60 caps / 30 days)EMSAM OTHER QL (30 patches / 30 days), PAescitalopram oxalate GENERICFETZIMA 20mg, 40mg OTHER QL (60 caps / 30 days), PAFETZIMA 80mg, 120mg OTHER QL (30 caps / 30 days), PAFETZIMA TITRATION PACK OTHER NM, PAfluoxetine cap 10mg GENERICfluoxetine cap 20mg GENERICfluoxetine cap 40mg GENERICfluoxetine hcl SOLN GENERICimipramine hcl TABS GENERICmaprotiline hcl GENERIC


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Drug Name Drug Tier Requirements/LimitsMARPLAN TAB 10MG OTHER QL (180 tabs / 30 days)mirtazapine TABS; TBDP GENERICnefazodone hcl GENERICnortriptyline hcl CAPS; SOLN GENERICparoxetine hcl tabs GENERICPAXIL SUSP OTHER QL (900 mL / 30 days)phenelzine sulfate TABS GENERICprotriptyline hcl GENERICsertraline hcl CONC; TABS GENERICtranylcypromine sulfate GENERICtrazodone hcl TABS 50mg, 100mg, 150mg GENERICtrimipramine 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 GENERICVIIBRYD STARTER PACK OTHER NMVIIBRYD 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 GENERICAPOKYN OTHER QL (20 cartridges / 30 days), NM,

LA, PAbenztropine mesylate inj GENERIC NMbenztropine mesylate tab 0.5mg GENERIC PA; PA if 70 years and olderbenztropine mesylate tab 1mg GENERIC PA; PA if 70 years and olderbenztropine mesylate tab 2mg GENERIC PA; PA if 70 years and olderbromocriptine mesylate CAPS; TABS GENERICcarbidopa-levodopa GENERICcarbidopa/levodopa/entacapone GENERICentacapone GENERICNEUPRO OTHERpramipexole tab 0.5mg GENERICpramipexole tab 0.25mg GENERICpramipexole tab 0.75mg GENERICpramipexole tab 0.125mg GENERICpramipexole tab 1.5mg GENERICpramipexole tab 1mg GENERICrasagiline mesylate TABS GENERICropinirole tab 0.5mg GENERICropinirole tab 0.25mg GENERICropinirole tab 1mg GENERIC


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Drug Name Drug Tier Requirements/Limitsropinirole tab 2mg GENERICropinirole tab 3mg GENERICropinirole tab 4mg GENERICropinirole tab 5mg GENERICselegiline hcl CAPS; TABS GENERICtrihexyphenidyl hcl GENERIC PA; PA if 70 years and older

ANTIPSYCHOTICS – DRUGS TO TREAT PSYCHOSESABILIFY 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 NMCAPLYTA OTHER QL (30 caps / 30 days)chlorpromazine hcl TABS GENERICchlorpromazine inj GENERIC NMclozapine odt 12.5mg, 25mg GENERIC NM, PAclozapine 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), NMclozapine tab 200mg GENERIC QL (135 tabs / 30 days), NMFANAPT OTHER QL (60 tabs / 30 days), NM, PAFANAPT TITRATION PACK OTHER NM, PAfluphenazine decanoate SOLN GENERIC NMfluphenazine hcl CONC; ELIX; TABS GENERICfluphenazine hcl SOLN GENERIC NMGEODON SOLR OTHER QL (6 mL / 3 days), NMhaloperidol TABS GENERIChaloperidol conc 2mg/ml GENERIChaloperidol decanoate SOLN GENERIC NMhaloperidol lactate inj 5mg/ml GENERIC NMINVEGA SUST INJ 39 MG/0.25 ML OTHER QL (1 injection / 28 days), NMINVEGA SUST INJ 78 MG/0.5 ML OTHER QL (1 injection / 28 days), NMINVEGA SUST INJ 117 MG/0.75 ML OTHER QL (1 injection / 28 days), NMINVEGA SUST INJ 156MG/ML OTHER QL (1 injection / 28 days), NMINVEGA SUST INJ 234 MG/1.5 ML OTHER QL (1 injection / 28 days), NMINVEGA TRINZA OTHER QL (1 injection / 90 days), NMLATUDA 20mg, 40mg, 60mg, 120mg OTHER QL (30 tabs / 30 days)LATUDA 80mg OTHER QL (60 tabs / 30 days)loxapine succinate GENERIC


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Drug Name Drug Tier Requirements/Limitsmolindone hcl GENERICNUPLAZID CAPS OTHER QL (30 caps / 30 days), NM, LA, PANUPLAZID TABS 10MG OTHER QL (30 tabs / 30 days), NM, LA, PAolanzapine SOLR GENERIC QL (3 vials / 1 day), NMolanzapine 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 GENERICPERSERIS OTHER QL (1 injection / 30 days)pimozide GENERICquetiapine fumarate TABS GENERICquetiapine fumarate TB24 50mg, 300mg, 400mg GENERIC QL (60 tabs / 30 days), PAquetiapine fumarate TB24 150mg, 200mg GENERIC QL (30 tabs / 30 days), PAREXULTI 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), NMRISPERDAL INJ 25MG OTHER QL (2 injections / 28 days), NMRISPERDAL INJ 37.5MG OTHER QL (2 injections / 28 days), NMRISPERDAL INJ 50MG OTHER QL (2 injections / 28 days), NMrisperidone SOLN GENERIC QL (240 mL / 30 days)risperidone TABS GENERICrisperidone 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 GENERICthiothixene GENERICtrifluoperazine hcl GENERICVERSACLOZ OTHER QL (600 mL / 30 days), NM, PAVRAYLAR 1.5mg OTHER QL (60 caps / 30 days), PAVRAYLAR 3mg, 4.5mg, 6mg OTHER QL (30 caps / 30 days), PAVRAYLAR THERAPY PACK OTHER NM, PAziprasidone hcl GENERIC QL (60 caps / 30 days)ziprasidone mesylate GENERIC QL (6 injections / 3 days), NMZYPREXA RELPREVV 300mg OTHER QL (2 vials / 28 days), NM, PAZYPREXA RELPREVV 405mg OTHER QL (1 vial / 28 days), NM, PAZYPREXA RELPREVV INJ 210MG OTHER QL (2 vials / 28 days), NM, PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER – DRUGS TO TREAT ADHDamphetamine-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)


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Drug Name Drug Tier Requirements/Limitsamphetamine-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 oldermetadate 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 INSOMNIABELSOMRA OTHER QL (30 tabs / 30 days), NMdoxepin hcl (sleep) GENERIC QL (30 tabs / 30 days), NMeszopiclone GENERIC QL (30 tabs / 30 days), NM, PA;

PA applies if 70 years and olderafter a 90 day supply in acalendar year

HETLIOZ OTHER NM, LA, PAtemazepam 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 olderafter a 90 day supply in acalendar year

zaleplon GENERIC QL (60 caps / 30 days), NM, PA;PA applies if 70 years and olderafter a 90 day supply in acalendar year


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Drug Name Drug Tier Requirements/Limitszolpidem tartrate TABS GENERIC QL (30 tabs / 30 days), NM, PA;


MIGRAINE – DRUGS TO TREAT SEVERE HEADACHESAIMOVIG OTHER QL (1 pen / 30 days), NM, PAdihydroergotamine mesylate inj 1 mg/ml GENERIC NMdihydroergotamine mesylate nasal spr 4 mg/ml GENERIC QL (8 mL / 30 days), NM, PAeletriptan hydrobromide GENERIC QL (12 tabs / 30 days), NMEMGALITY SOAJ OTHER QL (2 pens / 30 days), NM, PAEMGALITY SOSY 120mg/ml OTHER QL (2 syringes / 30 days), NM, PAergotamine w/ caffeine TABS GENERIC NMnaratriptan hcl GENERIC QL (12 tabs / 30 days), NMrizatriptan benzoate GENERIC QL (18 tabs / 30 days), NMrizatriptan benzoate odt GENERIC QL (18 tabs / 30 days), NMsumatriptan SOLN 5mg/act GENERIC QL (24 inhalers / 30 days), NMsumatriptan SOLN 20mg/act GENERIC QL (12 inhalers / 30 days), NMsumatriptan inj 4mg/0.5ml GENERIC QL (18 injections / 30 days), NMsumatriptan inj 6mg/0.5ml GENERIC QL (12 injections / 30 days), NMsumatriptan succinate TABS GENERIC QL (12 tabs / 30 days), NMzolmitriptan TABS GENERIC QL (12 tabs / 30 days), NMzolmitriptan odt GENERIC QL (12 tabs / 30 days), NM

MISCELLANEOUSAUSTEDO 6mg OTHER QL (60 tabs / 30 days), NM, PAAUSTEDO 9mg, 12mg OTHER QL (120 tabs / 30 days), NM, PAINGREZZA CAPS OTHER QL (30 caps / 30 days), NM, PAINGREZZA CPPK OTHER QL (28 caps / 28 days), NM, PAlithium carbonate CAPS; TABS GENERIClithium carbonate er GENERICLITHIUM SOLN 8MEQ/5ML OTHERLYRICA CR OTHER QL (60 tabs / 30 days), PANUEDEXTA OTHER QL (60 caps / 30 days), PApyridostigmine tab 60mg GENERIC NMriluzole GENERICtetrabenazine 12.5mg GENERIC QL (240 tabs / 30 days), NM, PAtetrabenazine 25mg GENERIC QL (120 tabs / 30 days), NM, PA

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

PAdalfampridine TB12 GENERIC NM, PAGILENYA OTHER QL (28 caps / 28 days), NM, PAglatiramer acetate 20mg/ml GENERIC QL (30 syringes / 30 days), NM,

PAglatiramer acetate 40mg/ml GENERIC QL (12 syringes / 28 days), NM, PA


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Drug Name Drug Tier Requirements/Limitsglatopa 20mg/ml GENERIC QL (30 syringes / 30 days), NM, PAglatopa 40mg/ml GENERIC QL (12 syringes / 28 days), NM, PA

MUSCULOSKELETAL THERAPY AGENTS – DRUGS TO TREAT MUSCLE SPASMSbaclofen TABS 10mg, 20mg GENERIC NMcarisoprodol TABS 350mg GENERIC QL (120 tabs / 30 days), NM, PA;

PA if 70 years and oldercyclobenzaprine hcl TABS 5mg, 10mg GENERIC NM, PA; PA if 70 years and olderdantrolene sodium CAPS GENERIC NMmethocarbamol TABS GENERIC NM, PA; PA if 70 years and oldertizanidine hcl TABS GENERIC NMvanadom GENERIC QL (120 tabs / 30 days), NM, PA;

PA if 70 years and olderNARCOLEPSY/CATAPLEXY – DRUGS FOR SLEEP DISORDERS

armodafinil 50mg GENERIC QL (90 tabs / 30 days), PAarmodafinil 150mg, 200mg, 250mg GENERIC QL (30 tabs / 30 days), PAXYREM OTHER QL (540 mL / 30 days), NM, LA, PA

PSYCHOTHERAPEUTIC-MISCacamprosate calcium GENERICbuprenorphine hcl SUBL GENERIC QL (90 tabs / 30 days), NM, PAbuprenorphine hcl-naloxone hcl dihydrate 2-0.5mg GENERIC QL (90 films / 30 days), NMbuprenorphine hcl-naloxone hcl dihydrate 4-1mg GENERIC QL (90 films / 30 days), NMbuprenorphine hcl-naloxone hcl dihydrate 8-2mg GENERIC QL (90 films / 30 days), NMbuprenorphine hcl-naloxone hcl dihydrate 12-3mg GENERIC QL (60 films / 30 days), NMbuprenorphine hcl-naloxone hcl sl GENERIC QL (90 tabs / 30 days), NMbupropion hcl (smoking deterrent) GENERIC NMCHANTIX OTHER NM, PACHANTIX CONTINUING MONTH OTHER NM, PACHANTIX STARTER PACK OTHER NM, PAdisulfiram TABS GENERICEVZIO OTHER NMnaloxone inj 0.4mg/ml GENERIC NMnaloxone inj 1mg/ml GENERIC NMnaltrexone hcl TABS GENERIC NMNARCAN OTHER NMNICOTROL INHALER OTHER NMNICOTROL NS OTHER NMVIVITROL OTHER NM

ENDOCRINE AND METABOLIC – DRUGS TO TREAT DIABETES AND REGULATE HORMONESANDROGENS – DRUGS TO REGULATE MALE HORMONES

ANADROL-50 OTHER NM, PAANDRODERM OTHER QL (30 patches / 30 days), PAoxandrolone tab 2.5mg GENERIC NM, PAoxandrolone tab 10mg GENERIC NM, PAtestosterone GEL 1%, 25mg/2.5gm, 50mg/5gm GENERIC QL (300 grams / 30 days), PA


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Drug Name Drug Tier Requirements/Limitstestosterone cypionate SOLN GENERIC NM, PAtestosterone enanthate SOLN GENERIC NM, PA

ANTIDIABETICS, INJECTABLE – DRUGS TO TREAT DIABETESBASAGLAR KWIKPEN OTHERBD 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 OTHERFIASP FLEXTOUCH OTHERFIASP PENFILL OTHERGAUZE PADS 2" X 2" OTHER NMHUMULIN R INJ U-500 OTHER B/DHUMULIN R U-500 KWIKPEN OTHERINSULIN PEN NEEDLE OTHER NMINSULIN SAFETY NEEDLES OTHER NMINSULIN SYRINGE OTHER NMLEVEMIR OTHERLEVEMIR FLEXTOUCH OTHERNOVOLIN 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 OTHERNOVOLOG 70/30 FLEXPEN OTHERNOVOLOG FLEXPEN OTHERNOVOLOG MIX 70/30 OTHERNOVOLOG PENFILL OTHEROZEMPIC 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 OTHERTRESIBA INJ OTHERTRULICITY .75mg/0.5ml, 1.5mg/0.5ml 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 DIABETESacarbose TABS GENERICFARXIGA OTHER QL (30 tabs / 30 days)glimepiride 1mg, 2mg GENERIC QL (90 tabs / 30 days)


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Drug Name Drug Tier Requirements/Limitsglimepiride 4mg GENERIC QL (60 tabs / 30 days)glip/metform tab 2.5-250mg GENERIC QL (240 tabs / 30 days)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 olderglyburide TABS 2.5mg GENERIC QL (240 tabs / 30 days), PA; PA if

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

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

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

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

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

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

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

70 years and olderGLYXAMBI 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)


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Drug Name Drug Tier Requirements/Limitsmetformin hcl TABS 1000mg GENERIC QL (75 tabs / 30 days)nateglinide GENERIC QL (90 tabs / 30 days)pioglitazone hcl GENERIC QL (30 tabs / 30 days)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 LOSSalendronate sodium soln 70mg/75ml GENERICalendronate sodium tab 5 mg GENERICalendronate sodium tab 10 mg GENERICalendronate sodium tab 35 mg GENERICalendronate sodium tab 40 mg GENERIC NMalendronate sodium tab 70 mg GENERICibandronate sodium tabs GENERIC B/Dpamidronate disodium GENERIC B/D, NMpamidronate inj 30mg GENERIC B/D, NMpamidronate inj 90mg GENERIC B/D, NMrisedronate sodium TABS 5mg, 35mg, 150mg GENERICrisedronate sodium TBEC GENERICzoledronic acid inj 4mg/100ml GENERIC B/D, NMzoledronic acid inj 5mg/100ml GENERIC B/D, NMzoledronic inj 4mg/5ml GENERIC B/D, NM

CHELATING AGENTSCHEMET OTHER NMclovique GENERIC NM, PAdeferasirox granules GENERIC NM, PA


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Drug Name Drug Tier Requirements/Limitsdeferasirox tab GENERIC NM, PAJADENU 180mg OTHER NM, LA, PAJADENU SPRINKLE OTHER NM, LA, PAkionex sus 15gm/60ml GENERIC NMLOKELMA OTHERpenicillamine TABS GENERIC NMsodium polystyrene sulfonate powder GENERIC NMsodium polystyrene sulfonate susp GENERIC NMsps susp 15gm/60ml GENERIC NMtrientine hcl GENERIC NM, PAVELTASSA OTHER LA, PA

CONTRACEPTIVES – DRUGS FOR BIRTH CONTROLaltavera tab GENERICalyacen 1/35 GENERICamethia GENERICamethia lo GENERICapri GENERICaranelle GENERICashlyna GENERICaubra GENERICaviane GENERICbalziva GENERICbekyree GENERICblisovi 24 fe GENERICblisovi fe 1.5/30 GENERICbriellyn GENERICcamila GENERICcamrese lo GENERICcaziant pak GENERICcryselle-28 GENERICcyclafem 1/35 GENERICcyclafem 7/7/7 GENERICcyred tab GENERICdasetta 1/35 GENERICdasetta 7/7/7 GENERICdeblitane GENERICdesogestrel-ethinyl estradiol (biphasic) GENERICdrospirenone-ethinyl estradiol GENERICdrospirenone-ethinyl estradiol-levomefolate calcium GENERICELLA OTHER NMeluryng GENERICemoquette GENERICenpresse-28 GENERICenskyce GENERIC


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Drug Name Drug Tier Requirements/Limitserrin GENERICestarylla tab 0.25-35 GENERICethynodiol diacet & eth estrad GENERICethynodiol tab 1-50 GENERICetonogestrel-ethinyl estradiol GENERICfalmina GENERICfayosim GENERICfemynor GENERICgianvi tab 3-0.02mg GENERIChailey 24 fe GENERICheather GENERICincassia GENERICintrovale GENERICisibloom GENERICjasmiel GENERICjolessa tab 0.15-0.03 mg GENERICjolivette GENERICjuleber GENERICjunel 1.5/30 GENERICjunel 1/20 GENERICjunel fe 1.5/30 GENERICjunel fe 1/20 GENERICjunel fe 24 GENERICkaitlib fe GENERICkariva GENERICkelnor 1/35 GENERICkelnor 1/50 GENERICkurvelo GENERIClarin 1.5/30 GENERIClarin 1/20 GENERIClarin fe 1.5/30 GENERIClarin fe 1/20 GENERIClarissia tab GENERIClayolis fe GENERICleena tab GENERIClessina GENERIClevonest GENERIClevonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est0.01mg

GENERIC

levonor/ethi tab GENERIClevonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7)

GENERIC

levonorg-eth est tab 0.15-0.03mg (84) & eth est tab0.01mg(7)

GENERIC

levonorgestrel & eth estradiol GENERIC


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Drug Name Drug Tier Requirements/Limitslevonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) GENERIClevora 0.15/30-28 GENERICloryna GENERIClow-ogestrel GENERIClutera GENERIClyza GENERICmarlissa GENERICmedroxyprogesterone acetate (contraceptive) GENERIC NMmelodetta 24 fe GENERICmibelas 24 fe GENERICmicrogestin 1.5/30 GENERICmicrogestin 1/20 GENERICmicrogestin fe 1.5/30 GENERICmicrogestin fe 1/20 GENERICmili GENERICmono-linyah tab 0.25-35 GENERICnecon 0.5/35-28 GENERICnikki GENERICnora-be tab 0.35mg GENERICnore/eth/fer chw 0.4mg-35 GENERICnoreth/ethin chw fe GENERICnorethin acet & estrad-fe GENERICnorethindrone (contraceptive) GENERICnorethindrone acet & eth estra GENERICnorgest/ethi tab 0.25/35 GENERICnorgestimate-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) GENERICnortrel 1/35 GENERICnortrel 7/7/7 GENERICocella tab 3-0.03mg GENERICorsythia GENERICphilith GENERICpimtrea GENERICpirmella 1/35 GENERICportia-28 GENERICprevifem GENERICreclipsen GENERICrivelsa GENERICsetlakin tab GENERICsharobel GENERICsprintec 28 GENERICsronyx GENERIC


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Drug Name Drug Tier Requirements/Limitssyeda GENERICtarina 24 fe GENERICtarina fe 1/20 GENERICtilia fe GENERICtri-estarylla GENERICtri-legest fe GENERICtri-linyah GENERICtri-lo marzia GENERICtri-lo-estarylla GENERICtri-lo-sprintec GENERICtri-mili GENERICtri-previfem GENERICtri-sprintec GENERICtri-vylibra GENERICtri-vylibra lo GENERICtrivora-28 GENERICtulana GENERICtydemy GENERICvelivet GENERICvienva GENERICviorele GENERICvyfemla GENERICvylibra GENERICwymzya fe GENERICxulane dis 150-35 GENERICzarah GENERICzovia 1/35e GENERIC

ENDOMETRIOSISdanazol CAPS GENERIC NMSYNAREL OTHER NM

ENZYME REPLACEMENTS – DRUGS TO TREAT ENZYME DEFICIENCIESALDURAZYME OTHER NM, LA, PACARBAGLU OTHER NM, LA, PACERDELGA OTHER NM, PACEREZYME OTHER NM, LA, PACYSTADANE OTHER NM, LACYSTAGON OTHER NM, LA, PAFABRAZYME OTHER NM, LA, PAKUVAN OTHER NM, LA, PAlevocarnitine (metabolic modifiers) GENERIC B/DLUMIZYME OTHER NM, LA, PAmiglustat GENERIC NM, PANAGLAZYME OTHER NM, LA, PAnitisinone GENERIC NM, PA


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Drug Name Drug Tier Requirements/LimitsNITYR OTHER NM, LA, PAORFADIN OTHER NM, LA, PAsodium phenylbutyrate GENERIC NM, PA

ESTROGENS – DRUGS TO REGULATE FEMALE HORMONESDELESTROGEN 10mg/ml OTHER NMestradiol PTWK; TABS GENERICestradiol vaginal cream GENERICestradiol vaginal tab GENERICestradiol valerate inj GENERIC NMfyavolv GENERICjinteli GENERICnorethindrone acetate-ethinyl estradiol GENERICyuvafem vaginal tablet 10 mcg GENERIC

GLUCOCORTICOIDS – DRUGS TO TREAT INFLAMMATORY RESPONSEcortisone acetate TABS GENERIC NMdexamethasone CONC; ELIX; SOLN; TABS GENERIC NMdexamethasone sodium phosphate GENERIC NMfludrocortisone acetate TABS GENERIChydrocortisone TABS GENERIC NMmethylpr ss inj GENERIC B/D, NMmethylpred pak 4mg GENERIC NMmethylpred tab 4mg GENERIC B/D, NMmethylpred tab 8mg GENERIC B/D, NMmethylpred tab 16mg GENERIC B/D, NMmethylpred tab 32mg GENERIC B/D, NMmethylprednisolone acetate GENERIC B/D, NMpred sod pho sol 5mg/5ml GENERIC B/D, NMprednisolone sodium phosphate SOLN 15mg/5ml GENERIC B/D, NMprednisolone sol 15mg/5ml GENERIC B/D, NMprednisolone sol 25mg/5ml GENERIC B/D, NMprednisone con 5mg/ml GENERIC B/D, NMprednisone pak 5mg GENERIC NMprednisone pak 10mg GENERIC NMprednisone sol 5mg/5ml GENERIC B/D, NMprednisone tab 1mg GENERIC B/D, NMprednisone tab 2.5mg GENERIC B/D, NMprednisone tab 5mg GENERIC B/D, NMprednisone tab 10mg GENERIC B/D, NMprednisone tab 20mg GENERIC B/D, NMprednisone tab 50mg GENERIC B/D, NMSOLU-CORTEF OTHER NM

GLUCOSE ELEVATING AGENTS – DRUGS TO TREAT LOW BLOOD SUGARdiazoxide SUSP GENERICGLUCAGEN HYPOKIT OTHER NM


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Drug Name Drug Tier Requirements/LimitsGLUCAGON EMERGENCY KIT OTHER NMGVOKE HYPOPEN 2-PACK OTHER NMGVOKE PFS OTHER NMPROGLYCEM SUS 50MG/ML OTHER

MISCELLANEOUScabergoline GENERIC NMcalcitonin (salmon) GENERIC B/Dcinacalcet hcl 30mg, 90mg GENERIC B/D, QL (120 tabs / 30 days), NMcinacalcet hcl 60mg GENERIC B/D, QL (60 tabs / 30 days), NMFORTEO OTHER NM, PAGENOTROPIN OTHER NM, PAGENOTROPIN MINIQUICK OTHER NM, PAINCRELEX OTHER NM, LA, PAKORLYM OTHER NM, LA, PALUPRON DEP-PED INJ 7.5MG OTHER NM, PALUPRON DEP-PED INJ 11.25MG (3-MONTH) OTHER NM, PALUPRON DEPOT-PED (1-MONTH OTHER NM, PALUPRON DEPOT-PED (3-MONTH OTHER NM, PANATPARA OTHER NM, PAoctreotide acetate GENERIC NM, PAOSPHENA OTHER PAPROLIA OTHER QL (1 injection / 180 days), NMraloxifene tab 60mg GENERICSIGNIFOR OTHER NM, LA, PASOMATULINE DEPOT OTHER NM, PASOMAVERT OTHER NM, LA, PATYMLOS OTHER NM, PAXGEVA OTHER NM, PA

PHOSPHATE BINDER AGENTS – DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELSAURYXIA OTHER QL (360 tabs / 30 days), PAcalcium 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 HORMONESmedroxyprogesterone acetate tab GENERICnorethindrone acetate TABS GENERIC

THYROID AGENTS – DRUGS TO REGULATE THYROID LEVELSeuthyrox GENERIClevo-t GENERIClevothyroxine sodium TABS GENERIClevoxyl GENERICliothyronine sodium TABS GENERIC


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Drug Name Drug Tier Requirements/Limitsmethimazole TABS GENERICpropylthiouracil TABS GENERICSYNTHROID OTHERunithroid GENERIC

VASOPRESSINS – DRUGS TO REGULATE PITUITARY HORMONESdesmopressin acetate spray GENERICdesmopressin acetate spray refrigerated GENERICdesmopressin acetate tabs GENERICdesmopressin inj 4mcg/ml GENERIC NMSTIMATE OTHER NM

GASTROINTESTINAL – DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERSANTIEMETICS – DRUGS FOR NAUSEA AND VOMITING

aprepitant GENERIC B/D, NMaprepitant pak 80mg & 125mg GENERIC B/D, NMcompro supp GENERIC NMdronabinol GENERIC B/D, QL (60 caps / 30 days), NMEMEND SUSR OTHER B/D, NMgranisetron hcl SOLN GENERIC NMgranisetron hcl TABS GENERIC B/D, NMmeclizine hcl TABS GENERIC NMmetoclopramide hcl SOLN; TABS GENERIC NMmetoclopramide hcl inj GENERIC NMondansetron hcl TABS GENERIC B/D, NMondansetron hcl inj GENERIC NMondansetron hcl oral soln GENERIC B/D, NMondansetron odt GENERIC B/D, NMprochlorperazine inj GENERIC NMprochlorperazine maleate TABS GENERICprochlorperazine supp GENERIC NMpromethazine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and olderpromethazine hcl inj GENERIC NM, PA; PA if 70 years and olderscopolamine GENERIC QL (10 patches / 30 days), NM,

PA; PA if 70 years and olderANTISPASMODICS – DRUGS FOR STOMACH SPASMS

dicyclomine hcl cap 10mg GENERIC NMdicyclomine hcl soln 10mg/5ml GENERIC NMdicyclomine hcl tab 20mg GENERIC NMglycopyrrolate tab 1mg GENERIC NMglycopyrrolate tab 2mg GENERIC NM

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


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Drug Name Drug Tier Requirements/Limitsnizatidine CAPS GENERIC

INFLAMMATORY BOWEL DISEASEbalsalazide disodium GENERIC NMbudesonide ec GENERIC NMcolocort GENERIC NMhydrocortisone (enema) GENERIC NMmesalamine CPDR GENERICmesalamine ENEM GENERIC NMmesalamine SUPP GENERIC NMmesalamine TBEC 1.2gm GENERICmesalamine w/ cleanser GENERIC NMsulfasalazine TABS GENERICsulfasalazine ec GENERIC

LAXATIVESconstulose GENERICenulose GENERICgavilyte-c GENERIC NMgavilyte-g GENERIC NMgavilyte-n/flavor pack GENERIC NMgenerlac GENERICGOLYTELY OTHER NMlactulose SOLN GENERIClactulose (encephalopathy) GENERICNULYTELY/FLAVOR PACKS OTHER NMpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate GENERIC NMpeg 3350-potassium chloride-sod bicarbonate-sod chloride GENERIC NMPLENVU OTHER NMSUPREP BOWEL PREP KIT OTHER NMtrilyte GENERIC NM

MISCELLANEOUSalosetron hcl GENERIC PAAMITIZA CAP 8MCG OTHER QL (180 caps / 30 days)AMITIZA CAP 24MCG OTHER QL (60 caps / 30 days)cromolyn sodium (mastocytosis) GENERICdiphenoxylate w/ atropine GENERIC NMGATTEX OTHER NM, LA, PALINZESS OTHER QL (30 caps / 30 days)loperamide hcl CAPS GENERIC NMmisoprostol TABS GENERICMOVANTIK 12.5mg OTHER QL (60 tabs / 30 days), NMMOVANTIK 25mg OTHER QL (30 tabs / 30 days), NMRELISTOR SOLN OTHER NM, PAsucralfate TABS GENERICursodiol CAPS; TABS GENERIC


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Drug Name Drug Tier Requirements/LimitsXIFAXAN 550mg OTHER PA

PANCREATIC ENZYMESCREON OTHERZENPEP OTHER

PROTON PUMP INHIBITORS – DRUGS FOR ULCERS AND STOMACH ACIDDEXILANT OTHER QL (30 caps / 30 days)esomeprazole magnesium CPDR GENERIC QL (30 caps / 30 days), STlansoprazole CPDR GENERIC QL (30 caps / 30 days)omeprazole cap 10mg GENERIComeprazole cap 20mg GENERIComeprazole cap 40mg GENERICpantoprazole sodium SOLR GENERIC NMpantoprazole sodium tbec GENERICrabeprazole sodium GENERIC QL (30 tabs / 30 days)

GENITOURINARY – DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONSBENIGN 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 GENERICtamsulosin hcl GENERIC

MISCELLANEOUSbethanechol chloride TABS GENERIC NMpotassium 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), STtolterodine tartrate TABS GENERIC STTOVIAZ OTHER QL (30 tabs / 30 days)trospium chloride TABS GENERIC QL (60 tabs / 30 days)

VAGINAL ANTI-INFECTIVESclindamycin phosphate vaginal GENERIC NMmetronidazole vaginal GENERIC NMterconazole vaginal GENERIC NMvandazole GENERIC NM

HEMATOLOGIC – DRUGS TO TREAT BLOOD DISORDERSANTICOAGULANTS – BLOOD THINNERS

COUMADIN OTHERELIQUIS 2.5mg OTHER QL (60 tabs / 30 days)


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Drug Name Drug Tier Requirements/LimitsELIQUIS 5mg OTHER QL (74 tabs / 30 days)ELIQUIS STARTER PACK OTHER QL (74 tabs / 30 days)enoxaparin sodium GENERIC NMfondaparinux sodium GENERIC NMheparin sod (porcine) in d5w GENERIC NMheparin sod inj 1000/ml GENERIC B/D, NMheparin sod inj 5000/ml GENERIC B/D, NMheparin sod inj 10000/ml GENERIC B/D, NMheparin sod inj 20000/ml GENERIC B/D, NMHEPARIN SODIUM/NACL 0.45% OTHER NMjantoven GENERICPRADAXA OTHER QL (60 caps / 30 days)warfarin sodium GENERICXARELTO 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 FACTORSPROCRIT OTHER NM, PAZARXIO OTHER NM, PA

MISCELLANEOUSanagrelide hcl GENERICBERINERT OTHER QL (24 boxes / 30 days), NM, LA, PAcilostazol GENERICDROXIA OTHERENDARI OTHER NM, LA, PAHAEGARDA 2000unit OTHER QL (30 vials / 30 days), NM, LA, PAHAEGARDA 3000unit OTHER QL (20 vials / 30 days), NM, LA, PAicatibant acetate GENERIC QL (9 syringes / 30 days), NM, PApentoxifylline TBCR GENERICPROMACTA PACK 12.5mg OTHER QL (360 packets / 30 days), NM,

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

LA, PAPROMACTA TABS 12.5mg, 25mg OTHER QL (30 tabs / 30 days), NM, LA, PAPROMACTA TABS 50mg, 75mg OTHER QL (60 tabs / 30 days), NM, LA, PAtranexamic acid SOLN; TABS GENERIC NM

PLATELET AGGREGATION INHIBITORSaspirin-dipyridamole GENERICBRILINTA OTHERclopidogrel tab 75mg GENERICprasugrel hcl GENERIC

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

ENBREL SOLR OTHER QL (16 vials / 28 days), NM, PA


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Drug Name Drug Tier Requirements/LimitsENBREL SOSY 25mg/0.5ml OTHER QL (16 syringes / 28 days), NM, PAENBREL SOSY 50mg/ml OTHER QL (8 syringes / 28 days), NM, PAENBREL MINI OTHER QL (8 injections / 28 days), NM, PAENBREL SURECLICK OTHER QL (8 injections / 28 days), NM, PAHUMIRA 10mg/0.1ml, 20mg/0.2ml OTHER QL (2 injections / 28 days), NM, PAHUMIRA 40mg/0.4ml OTHER QL (6 injections / 28 days), NM, PAHUMIRA INJ 10MG/0.2ML OTHER QL (2 syringes / 28 days), NM, PAHUMIRA KIT 20MG/0.4ML OTHER QL (2 syringes / 28 days), NM, PAHUMIRA KIT 40MG/0.8ML OTHER QL (6 syringes / 28 days), NM, PAHUMIRA PEDIATRIC CROHNS DISEASE OTHER NM, PAHUMIRA PEN OTHER QL (6 pens / 28 days), NM, PAHUMIRA PEN CD/UC/HS STARTER OTHER NM, PAHUMIRA PEN INJ CD/UC/HS STARTER OTHER NM, PAHUMIRA PEN INJ PS/UV STARTER OTHER NM, PAHUMIRA PEN-PS/UV STARTER OTHER NM, PAhydroxychloroquine sulfate GENERICleflunomide TABS GENERIC QL (30 tabs / 30 days)methotrexate sodium tabs GENERIC NMREMICADE OTHER NM, PARENFLEXIS OTHER NM, LA, PARINVOQ OTHER QL (30 tabs / 30 days), NM, PASKYRIZI OTHER QL (7 kits / year), NM, PASTELARA SOLN 45mg/0.5ml OTHER QL (1 vial / 28 days), NM, LA, PASTELARA SOSY OTHER QL (1 syringe / 28 days), NM, PAXATMEP OTHER B/D, NMXELJANZ OTHER QL (60 tabs / 30 days), NM, PAXELJANZ XR OTHER QL (30 tabs / 30 days), NM, PA

IMMUNOGLOBULINSBIVIGAM OTHER NM, PAFLEBOGAMMA DIF 2.5gm/50ml, 5gm/100ml, 5gm/50ml,10gm/100ml, 10gm/200ml, 20gm/200ml, 20gm/400ml

OTHER NM, PA

GAMASTAN OTHER B/D, NMGAMMAGARD LIQUID OTHER NM, PAGAMMAGARD S/D OTHER NM, PAGAMMAKED OTHER NM, PAGAMMAPLEX OTHER NM, PAGAMMAPLEX 10GM/100ML OTHER NM, PAGAMUNEX-C OTHER NM, PAOCTAGAM OTHER NM, PAPANZYGA OTHER NM, PAPRIVIGEN OTHER NM, PA

IMMUNOMODULATORSACTIMMUNE OTHER NM, LA, PAARCALYST OTHER NM, PA


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Drug Name Drug Tier Requirements/LimitsINTRON-A INJ 10MU OTHER B/D, NMINTRON-A INJ 18MU OTHER B/D, NMINTRON-A INJ 25MU OTHER B/D, NMINTRON-A INJ 50MU OTHER B/D, NM

IMMUNOSUPPRESSANTSazathioprine TABS GENERIC B/DBENLYSTA OTHER NM, PAcyclosporine CAPS; SOLN GENERIC B/D, NMcyclosporine modified (for microemulsion) GENERIC B/D, NMeverolimus (immunosuppressant) GENERIC B/D, NMgengraf GENERIC B/D, NMmycophenolate mofetil CAPS; SUSR; TABS GENERIC B/D, NMmycophenolate sodium tbec GENERIC B/D, NMNULOJIX OTHER B/D, NMPROGRAF PACK OTHER B/D, NMSANDIMMUNE SOLN 100mg/ml OTHER B/D, NMsirolimus SOLN; TABS GENERIC B/D, NMtacrolimus CAPS GENERIC B/D, NMZORTRESS TAB 0.5MG OTHER B/D, NMZORTRESS TAB 0.25MG OTHER B/D, NMZORTRESS TAB 0.75MG OTHER B/D, NMZORTRESS TAB 1MG OTHER B/D, NM

VACCINESACTHIB OTHER NMADACEL OTHER NMBCG VACCINE OTHER NMBEXSERO OTHER NMBOOSTRIX OTHER NMDAPTACEL OTHER NMDIPHTHERIA/TETANUS TOXOID OTHER B/D, NMENGERIX-B SUSP OTHER B/D, NMGARDASIL 9 OTHER NMHAVRIX OTHER NMHIBERIX OTHER NMIMOVAX RABIES (H.D.C.V.) OTHER B/D, NMINFANRIX OTHER NMIPOL INACTIVATED IPV OTHER NMIXIARO OTHER NMKINRIX OTHER NMM-M-R II OTHER NMMENACTRA OTHER NMMENVEO OTHER NMPEDIARIX OTHER NMPEDVAX HIB OTHER NM


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Drug Name Drug Tier Requirements/LimitsPENTACEL OTHER NMPROQUAD OTHER NMQUADRACEL OTHER NMRABAVERT OTHER B/D, NMRECOMBIVAX HB OTHER B/D, NMROTARIX OTHER NMROTATEQ OTHER NMSHINGRIX OTHER QL (2 vials per lifetime), NMTDVAX OTHER B/D, NMTENIVAC OTHER B/D, NMTRUMENBA OTHER NMTWINRIX INJ OTHER NMTYPHIM VI OTHER NMVAQTA OTHER NMVARIVAX OTHER NMYF-VAX OTHER NMZOSTAVAX OTHER QL (1 vial per lifetime), NM

NUTRITIONAL/SUPPLEMENTS – VITAMINS AND SUPPLEMENTSELECTROLYTES

klor-con 8 GENERICklor-con 10 GENERICklor-con m10 GENERICklor-con m15 GENERICklor-con m20 GENERICklor-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 NMmagnesium sulfate in dextrose GENERIC NMmagnesium sulfate inj 50% GENERIC NMpotassium chloride CPCR GENERICpotassium chloride PACK GENERICpotassium chloride SOLN 10%, 20% GENERICpotassium chloride TBCR GENERICpotassium chloride microencapsulated crystals er GENERICsodium chloride SOLN 2.5meq/ml GENERIC NMsodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln GENERIC NMTPN ELECTROLYTES OTHER B/D, NM

IV NUTRITIONAMINOSYN II INJ 10% OTHER B/D, NM


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Drug Name Drug Tier Requirements/LimitsAMINOSYN-PF 7% OTHER B/D, NMCLINIMIX 4.25%/DEXTROSE 5% OTHER B/D, NMCLINIMIX 5%/DEXTROSE 15% OTHER B/D, NMCLINIMIX 5%/DEXTROSE 20% OTHER B/D, NMCLINIMIX INJ 4.25/D10 OTHER B/D, NMclinisol sf 15% GENERIC B/D, NMCLINOLIPID OTHER B/D, NMFREAMINE HBC 6.9% OTHER B/D, NMFREAMINE III OTHER B/D, NMhepatamine GENERIC B/D, NMINTRALIPID 30% OTHER B/D, NMintralipid inj 20% GENERIC B/D, NMNEPHRAMINE OTHER B/D, NMnutrilipid inj 20% GENERIC B/D, NMplenamine GENERIC B/D, NMpremasol 10% GENERIC B/D, NMPROCALAMINE OTHER B/D, NMPROSOL OTHER B/D, NMTRAVASOL OTHER B/D, NMTROPHAMINE INJ 10% OTHER B/D, NM

IV REPLACEMENT SOLUTIONSdextrose 2.5%/nacl 0.45% GENERIC NMdextrose 5% GENERIC NMDEXTROSE 5% /ELECTROLYTE OTHER NMdextrose 5%/nacl 0.2% GENERIC NMDEXTROSE 5%/NACL 0.3% OTHER NMdextrose 5%/nacl 0.9% GENERIC NMdextrose 5%/nacl 0.45% GENERIC NMdextrose 5%/potassium chl GENERIC NMdextrose 10% flex contain GENERIC NMDEXTROSE 10% W/ SODIUM CHLORIDE 0.2% OTHER NMdextrose 10%/nacl 0.45% GENERIC NMdextrose 50% GENERIC NMdextrose in lactated ringers GENERIC NMdextrose inj 70% GENERIC NMISOLYTE P OTHER NMISOLYTE S OTHER NMkcl0.15%/d5w/nacl0.2% GENERIC NMKCL 0.3%/D5W/NACL 0.9% OTHER NMkcl 0.3%/d5w/nacl 0.45% GENERIC NMkcl 0.15%/d5w/nacl 0.9% GENERIC NMKCL 0.15%/D5W/NACL 0.225% OTHER NMkcl 0.075%/d5w/nacl 0.45% GENERIC NMkcl/d5w/nacl inj 0.22%/0.45% GENERIC NM


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Drug Name Drug Tier Requirements/Limitskcl/d5w/nacl inj .15/.45% GENERIC NMkcl/nacl inj 0.3-0.9 GENERIC NMkcl/nacl inj 0.15%-0.9% GENERIC NMlactated ringer's GENERIC NMNORMOSOL-M IN D5W OTHER NMNORMOSOL-R OTHER NMPLASMA-LYTE A OTHER NMPLASMA-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

VITAMINScalcitriol CAPS GENERIC B/Dcalcitriol inj GENERIC B/D, NMcalcitriol oral soln 1 mcg/ml GENERIC B/DM-NATAL PLUS OTHER NMONE VITE WOMENS PRENATAL OTHER NMparicalcitol CAPS GENERIC B/DPNV FOLIC ACID + IRON MUL OTHER NMPRENATAL OTHER NMPRENATAL PLUS OTHER NMPRENATAL PLUS LOW IRON OTHER NMRAYALDEE OTHERTRICARE OTHER NM

OPHTHALMIC – DRUGS TO TREAT EYE CONDITIONSANTI-INFECTIVE/ANTI-INFLAMMATORY – DRUGS TO TREAT INFECTIONS AND INFLAMMATION

bacitracin-poly-neomycin-hc GENERIC NMblephamide OINT GENERIC NMneomycin-polymy-dexameth GENERIC NMneomycin-polymyxin-hc (ophth) GENERIC NMsulfacetamide sod-prednisolone GENERIC NMTOBRADEX OINT OTHER NMTOBRADEX ST OTHER NMtobramycin-dexamethasone GENERIC NMZYLET OTHER NM

ANTI-INFECTIVES – DRUGS TO TREAT INFECTIONSAZASITE OTHER NMbacitracin (ophthalmic) GENERIC NMbacitracin-polymyxin b (ophth) GENERIC NM


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Drug Name Drug Tier Requirements/LimitsBESIVANCE OTHER NMCILOXAN OINT OTHER NMciprofloxacin hcl (ophth) GENERIC NMerythromycin (ophth) GENERIC NMgatifloxacin (ophth) GENERIC NMgentak GENERIC NMgentamicin sulfate soln (ophth) GENERIC NMMOXEZA OTHER NMmoxifloxacin hcl (ophth) GENERIC NMNATACYN OTHER NMneomycin-bacitracin zn-polymyxin GENERIC NMneomycin-polymyxin-gramicidin GENERIC NMofloxacin (ophth) GENERIC NMpolymyxin b-trimethoprim GENERIC NMsulfacetamide sodium (ophth) GENERIC NMtobramycin (ophth) GENERIC NMtrifluridine GENERIC NMZIRGAN OTHER NM

ANTI-INFLAMMATORIES – DRUGS TO TREAT INFLAMMATIONALREX OTHER NMbromfenac sodium (ophth) GENERIC NMBROMSITE OTHER NMdexamethasone sodium phosphate (ophth) GENERIC NMdiclofenac sodium (ophth) GENERIC NMDUREZOL OTHER NMFLAREX OTHER NMfluorometholone GENERIC NMflurbiprofen sodium GENERIC NMILEVRO OTHER NMketorolac tromethamine (ophth) GENERIC NMLOTEMAX GEL; OINT OTHER NMloteprednol etabonate GENERIC NMprednisolone acetate (ophth) GENERIC NMprednisolone sodium phosphate (ophth) GENERIC NMPROLENSA OTHER NM

ANTIALLERGICS – DRUGS TO TREAT ALLERGIESazelastine drop 0.05% GENERIC NMBEPREVE OTHER NMcromolyn sodium (ophth) GENERIC NMLASTACAFT OTHER NMolopatadine hcl 0.2% GENERIC NMPAZEO OTHER NMZERVIATE OTHER NM


Formulary ID 00020345 v15 10/01/2020

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Drug Name Drug Tier Requirements/LimitsANTIGLAUCOMA – DRUGS TO TREAT GLAUCOMA

ALPHAGAN P SOL 0.1% OTHERAZOPT OTHERbetaxolol hcl (ophth) GENERICBETOPTIC-S OTHERbrimonidine sol 0.2% GENERICbrimonidine sol 0.15% GENERICcarteolol hcl (ophth) GENERICCOMBIGAN OTHERdorzolamide hcl GENERICdorzolamide hcl-timolol maleate GENERIClatanoprost SOLN GENERIClevobunolol hcl GENERICLUMIGAN OTHERPHOSPHOLINE IODIDE OTHERpilocarpine hcl SOLN GENERICRHOPRESSA OTHERSIMBRINZA OTHERtimolol maleate (ophth) soln GENERICtimolol maleate gel GENERICtimolol maleate ophth soln 0.5% (once-daily) GENERICtravoprost GENERIC

MISCELLANEOUSATROPINE SULFATE SOLN 1% OTHERCYSTARAN OTHER NM, LA, PAproparacaine hcl SOLN GENERIC NMRESTASIS OTHER QL (60 single use vials / 30 days)RESTASIS MULTIDOSE OTHER QL (1 bottle / 30 days)

RESPIRATORY – DRUGS TO TREAT BREATHING DISORDERSANTICHOLINERGIC/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/DTRELEGY ELLIPTA OTHER QL (60 blisters / 30 days)

ANTICHOLINERGICS – DRUGS TO TREAT COPDATROVENT HFA OTHER QL (2 inhalers / 30 days)INCRUSE ELLIPTA OTHER QL (30 blisters / 30 days)ipratropium bromide SOLN GENERIC B/Dipratropium bromide (nasal) GENERIC

ANTIHISTAMINES – DRUGS TO TREAT ALLERGIESazelastine spr 0.1% GENERIC NMazelastine spr 0.15% GENERIC NM


Formulary ID 00020345 v15 10/01/2020

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Drug Name Drug Tier Requirements/Limitscetirizine syrup GENERIC NMcyproheptadine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and olderdiphenhydramine hcl inj 50mg/ml GENERIC NMhydroxyzine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and olderhydroxyzine hcl inj GENERIC NM, PA; PA if 70 years and olderhydroxyzine pamoate CAPS 25mg, 50mg GENERIC NM, PA; PA if 70 years and olderlevocetirizine dihydrochloride GENERIC NM

BETA AGONISTS – DRUGS TO TREAT ASTHMA AND COPDalbuterol 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 GENERICalbuterol sulfate TABS GENERICalbuterol sulfate TB12 GENERIClevalbuterol hcl NEBU GENERIC B/Dlevalbuterol hcl soln nebu conc 1.25 mg/0.5ml GENERIC B/Dlevalbuterol tartrate hfa GENERIC QL (2 inhalers / 30 days)SEREVENT DISKUS OTHER QL (60 inhalations / 30 days)terbutaline sulfate TABS GENERICVENTOLIN HFA OTHER QL (2 inhalers / 30 days)

LEUKOTRIENE MODULATORSmontelukast sodium CHEW; PACK; TABS GENERICzafirlukast GENERIC

MAST CELL STABILIZERS – DRUGS TO TREAT ALLERGIEScromolyn sod neb 20mg/2ml GENERIC B/D

MISCELLANEOUSacetylcysteine SOLN 10%, 20% GENERIC B/D, NMARALAST NP OTHER NM, LA, PADALIRESP OTHERepinephrine (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, PAFASENRA OTHER NM, LA, PAFASENRA PEN OTHER NM, LA, PAKALYDECO OTHER NM, PANUCALA OTHER NM, LA, PAOFEV OTHER NM, PAORKAMBI OTHER NM, PAPROLASTIN-C OTHER NM, LA, PAPULMOZYME OTHER NM, PASYMDEKO OTHER NM, LA, PA


Formulary ID 00020345 v15 10/01/2020

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Drug Name Drug Tier Requirements/LimitsSYMJEPI OTHER NMtheo-24 GENERICtheophylline GENERICtheophylline tab er 12hr 300 mg GENERICtheophylline tab er 12hr 450 mg GENERICtheophylline tab sr 24hr GENERICTRIKAFTA OTHER NM, LA, PAXOLAIR OTHER NM, LA, PAZEMAIRA OTHER NM, LA, PA

NASAL STEROIDS – DRUGS TO TREAT ALLERGIESflunisolide (nasal) GENERIC QL (3 bottles / 30 days), NMfluticasone propionate (nasal) GENERIC QL (1 bottle / 30 days), NM

STEROID INHALANTS – DRUGS TO TREAT ASTHMAARNUITY ELLIPTA OTHER QL (30 inhalations / 30 days)budesonide (inhalation) .25mg/2ml, .5mg/2ml GENERIC B/DFLOVENT 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 COPDADVAIR DISKUS OTHER QL (60 inhalations / 30 days)ADVAIR HFA OTHER QL (1 inhaler / 30 days)BREO ELLIPTA OTHER QL (60 blisters / 30 days)SYMBICORT OTHER QL (1 inhaler / 30 days)

TOPICAL – DRUGS TO TREAT EAR AND SKIN CONDITIONSDERMATOLOGY, ACNE

amnesteem GENERIC NM, PAavita GENERIC QL (45 grams / 30 days), NM, PAbenzoyl peroxide-erythromycin GENERIC NMclaravis GENERIC NM, PAclindamycin phosphate (topical) GEL GENERIC QL (75 grams / 30 days), NMclindamycin phosphate (topical) LOTN GENERIC NMclindamycin phosphate (topical) SOLN GENERIC QL (60 mL / 30 days), NMery pad 2% GENERIC NMerythromycin (acne aid) GENERIC NMisotretinoin CAPS GENERIC NM, PAmyorisan GENERIC NM, PAsulfacetamide sodium (acne) GENERIC NMtretinoin CREA GENERIC QL (45 grams / 30 days), NM, PAtretinoin GEL .01%, .025% GENERIC QL (45 grams / 30 days), NM, PAzenatane GENERIC NM, PA

DERMATOLOGY, ANTIBIOTICSgentamicin sulfate (topical) GENERIC NM


Formulary ID 00020345 v15 10/01/2020

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Drug Name Drug Tier Requirements/Limitsmupirocin OINT GENERIC QL (220 grams / 30 days), NMsilver sulfadiazine CREA GENERIC NMssd GENERIC NMSULFAMYLON CREA OTHER NM

DERMATOLOGY, ANTIFUNGALSciclopirox CREA GENERIC QL (90 grams / 30 days), NMciclopirox SUSP GENERIC QL (60 mL / 30 days), NMclotrimazole (topical) CREA GENERIC NMclotrimazole (topical) SOLN GENERIC QL (30 mL / 30 days), NMclotrimazole w/ betamethasone CREA GENERIC NMketoconazole cream GENERIC QL (60 grams / 30 days), NMnyamyc GENERIC QL (60 grams / 30 days), NMnystatin (topical) CREA; OINT GENERIC NMnystatin (topical) POWD GENERIC QL (60 grams / 30 days), NMnystop GENERIC QL (60 grams / 30 days), NM

DERMATOLOGY, ANTIPSORIATICSacitretin GENERIC NM, PAcalcipotriene CREA; OINT GENERIC QL (120 grams / 30 days), NM, PAcalcipotriene SOLN GENERIC QL (120 mL / 30 days), NM, PAcalcitrene GENERIC QL (120 grams / 30 days), NM, PAtazarotene CREA GENERIC QL (60 grams / 30 days), NM, PATAZORAC CREA .05% OTHER QL (60 grams / 30 days), NM, PA

DERMATOLOGY, ANTISEBORRHEICSketoconazole shampoo GENERIC NMselenium sulfide LOTN GENERIC NM

DERMATOLOGY, CORTICOSTEROIDSala-cort GENERIC NMalclometasone dipropionate GENERIC NMbetamethasone dipropionate (topical) GENERIC NMbetamethasone dipropionate augmented GENERIC NMbetamethasone valerate CREA; LOTN; OINT GENERIC NMENSTILAR OTHER QL (120 grams / 30 days), NM, PAfluocinolone acetonide CREA; OIL; OINT GENERIC NMfluocinolone acetonide SOLN GENERIC QL (90 mL / 30 days), NMfluocinolone acetonide oil body GENERIC NMfluocinonide CREA .05% GENERIC QL (120 grams / 30 days), NMfluocinonide GEL GENERIC QL (60 grams / 30 days), NMfluocinonide OINT GENERIC QL (60 grams / 30 days), NMfluocinonide SOLN GENERIC QL (60 mL / 30 days), NMfluocinonide emulsified base GENERIC QL (120 grams / 30 days), NMfluticasone propionate CREA; OINT GENERIC NMhalobetasol propionate CREA; OINT GENERIC QL (50 grams / 30 days), NMhydrocortisone (topical) cream 1% GENERIC NMhydrocortisone (topical) cream 2.5% GENERIC NM


Formulary ID 00020345 v15 10/01/2020

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Drug Name Drug Tier Requirements/Limitshydrocortisone (topical) lotion 2.5% GENERIC NMhydrocortisone (topical) oint 2.5% GENERIC NMhydrocortisone butyrate cream 0.1% GENERIC QL (45 grams / 30 days), NMhydrocortisone butyrate oint 0.1% GENERIC QL (45 grams / 30 days), NMmometasone furoate CREA; OINT; SOLN GENERIC NMtexacort soln 2.5% GENERIC NMtriamcinolone acetonide (topical) CREA .1% GENERIC QL (454 grams / 30 days), NMtriamcinolone acetonide (topical) CREA .025%, .5% GENERIC NMtriamcinolone acetonide (topical) LOTN GENERIC NMtriamcinolone acetonide (topical) OINT .025%, .1%, .5% GENERIC NM

DERMATOLOGY, LOCAL ANESTHETICSglydo GENERIC QL (30 mL / 30 days), NM, PAlidocaine PTCH 5% GENERIC QL (3 patches / 1 day), NM, PAlidocaine hcl GEL GENERIC QL (30 mL / 30 days), NM, PAlidocaine hcl SOLN 4% GENERIC QL (50 mL / 30 days), NM, PAlidocaine oint 5% GENERIC QL (50 grams / 30 days), NM, PAlidocaine-prilocaine GENERIC QL (30 grams / 30 days), NM, PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANEammonium lactate CREA; LOTN GENERIC NMdiclofenac sodium (topical) 1% gel GENERIC QL (1000 grams / 30 days), NM, PAfluorouracil (topical) CREA 5% GENERIC QL (40 grams / 30 days), NMfluorouracil (topical) SOLN GENERIC QL (10 mL / 30 days), NMimiquimod CREA 5% GENERIC QL (24 packets / 30 days), NMmetronidazole (topical) CREA; LOTN GENERIC NMmetronidazole gel 0.75% GENERIC NMPANRETIN OTHER QL (60 grams / 30 days), NMPICATO .05% OTHER QL (2 tubes / 30 days), NMPICATO .015% OTHER QL (3 tubes / 30 days), NMpodofilox SOLN GENERIC NMprocto-med hc GENERIC NMprocto-pak GENERIC NMproctosol hc cre 2.5% GENERIC NMproctozone-hc GENERIC NMRECTIV OTHER QL (30 grams / 30 days), NMrosadan cre 0.75% GENERIC NMtacrolimus (topical) GENERIC QL (100 grams / 30 days), NMTARGRETIN GEL OTHER QL (60 grams / 30 days), NM, PAVALCHLOR OTHER QL (60 grams / 30 days), NM, LA,

PADERMATOLOGY, SCABICIDES AND PEDICULIDES

malathion GENERIC NMpermethrin cre 5% GENERIC NM

DERMATOLOGY, WOUND CARE AGENTSacetic acid .25% GENERIC NM

Formulary ID 00020345 v15 10/01/2020

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Drug Name Drug Tier Requirements/LimitsREGRANEX OTHER QL (30 grams / 30 days), NM, PASANTYL OTHER NMsodium chlor sol 0.9% irr GENERIC NMwater for irrigation, sterile GENERIC NM

MOUTH/THROAT/DENTAL AGENTScevimeline hcl GENERICchlorhexidine gluconate (mouth-throat) GENERIC NMclotrimazole TROC GENERIC NMlidocaine hcl (mouth-throat) GENERIC NMnystatin (mouth-throat) GENERIC NMparoex sol 0.12% GENERIC NMperiogard GENERIC NMpilocarpine hcl (oral) GENERICtriamcinolone acetonide (mouth) GENERIC NM

OTIC – DRUGS TO TREAT CONDITIONS OF THE EARacetic acid (otic) GENERIC NMCIPRODEX OTHER NMflac GENERIC NMfluocinolone acetonide (otic) GENERIC NMneomycin-polymyxin-hc (otic) GENERIC NMofloxacin (otic) GENERIC NM


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Index

abacavir sulfate 5abacavir sulfate-lamivudine 6abacavir sulfate-lamivudine-zidovudine 6ABELCET 4ABILIFY MAINTENA 24abiraterone acetate 11ABRAXANE 10acamprosate calcium 28acarbose .29acebutolol hcl 17acetaminophen w/ codeine 300-15mg 1acetaminophen w/ codeine 300-30mg 1acetaminophen w/ codeine 300-60mg 1acetaminophen w/ codeine soln 1acetazolamide 18acetic acid 52acetic acid (otic) 53acetylcysteine 49acitretin 51ACTHIB 43ACTIMMUNE 42acyclovir 7acyclovir sodium 7ADACEL 43adefovir dipivoxil 7ADEMPAS 19adriamycin 9adrucil inj 10ADVAIR DISKUS 50ADVAIR HFA 50AFINITOR 12AFINITOR DISPERZ 12AIMOVIG .27ala-cort 51albendazole 3albuterol sulfate 49alclometasone dipropionate 51ALDURAZYME 35ALECENSA 12alendronate sodium soln 70mg/75ml 31alendronate sodium tab 10 mg 31alendronate sodium tab 35 mg 31alendronate sodium tab 40 mg 31alendronate sodium tab 5 mg .31alendronate sodium tab 70 mg 31alfuzosin hcl 40ALIMTA 10ALINIA 3

aliskiren fumarate 18allopurinol tab 1alosetron hcl 39ALPHAGAN P SOL 0.1% 48alprazolam tab 0.25mg 19alprazolam tab 0.5mg 19alprazolam tab 1mg 19alprazolam tab 2 mg 19ALREX 47altavera tab 32ALUNBRIG 12alyacen 1/35 32amantadine hcl 23AMBISOME 4ambrisentan 19amethia 32amethia lo 32amikacin sulfate 3amiloride & hydrochlorothiazide 18amiloride hcl 18AMINOSYN II INJ 10% 44AMINOSYN-PF 7% 45amiodarone hcl soln 15amiodarone tab 100mg 16amiodarone tab 200mg 16amiodarone tab 400mg 16AMITIZA CAP 24MCG 39AMITIZA CAP 8MCG 39amitriptyline hcl 22amlodipine 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 52amnesteem 50amoxapine 22amoxicillin 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 8

54

55

amoxicillin & pot clavulanate 400-57 chw tabs 8amoxicillin & pot clavulanate 500-125 tabs 8amoxicillin & pot clavulanate 600/5ml susr 8amoxicillin & pot clavulanate 875-125 tabs 8amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs 9amphetamine-dextroamphetamine cap sr 24hr

10 mg 25amphetamine-dextroamphetamine cap sr 24hr

15 mg .

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25amphetamine-dextroamphetamine cap sr 24hr




5 mg 25amphetamine-dextroamphetamine tab 10 mg 26amphetamine-dextroamphetamine tab 12.5 mg 26amphetamine-dextroamphetamine tab 15 mg 26amphetamine-dextroamphetamine tab 20 mg 26amphetamine-dextroamphetamine tab 30 mg 26amphetamine-dextroamphetamine tab 5 mg 26amphetamine-dextroamphetamine tab 7.5 mg 26amphotericin b 4ampicillin & sulbactam sodium ..9ampicillin cap 500mg 9ampicillin inj 9ampicillin sodium 9ANADROL-50 28anagrelide hcl 41anastrozole 11ANDRODERM 28ANORO ELLIPTA 48APOKYN 23aprepitant 38aprepitant pak 80mg & 125mg 38apri 32APTIOM 19APTIVUS 5ARALAST NP 49aranelle 32ARCALYST 42aripiprazole odt 24aripiprazole oral solution 1 mg/ml 24aripiprazole tab 24ARISTADA 24ARISTADA INITIO 24armodafinil 28ARNUITY ELLIPTA 50ashlyna 32

.......... aspirin-dipyridamole 41atazanavir sulfate 5atenolol 17atenolol & chlorthalidone 17atomoxetine hcl 26atorvastatin calcium 16atovaquone 3atovaquone-proguanil hcl 5ATRIPLA 6ATROPINE SULFATE 48ATROVENT HFA 48aubra 32AURYXIA 37AUSTEDO 27AVASTIN 10aviane 32avita 50AYVAKIT 12azacitidine 10AZASITE 46azathioprine 43azelastine drop 0.05% 47azelastine spr 0.1% 48azelastine spr 0.15% 48azithromycin 8AZOPT 48aztreonam 3bacitracin (ophthalmic) 46bacitracin-polymyxin b (ophth) 46bacitracin-poly-neomycin-hc 46baclofen 28balsalazide disodium 39BALVERSA 12balziva 32BANZEL SUS 40MG/ML 19BANZEL TAB 200MG 19BANZEL TAB 400MG 19BARACLUDE 7BASAGLAR KWIKPEN 29BCG VACCINE 43BD ALCOHOL SWABS 29BD ULTRAFINE INSULIN SYRINGE 29BD ULTRAFINE/NANO PEN NEEDLES 29bekyree 32BELSOMRA 26benazepril & hydrochlorothiazide 14benazepril hcl 15BENDEKA ..

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9BENLYSTA 43benzoyl peroxide-erythromycin 50benztropine mesylate inj 23

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benztropine mesylate tab 0.5mg 23benztropine mesylate tab 1mg 23benztropine mesylate tab 2mg 23BEPREVE 47BERINERT 41BESIVANCE 47betamethasone dipropionate (topical) 51betamethasone dipropionate augmented 51betamethasone valerate 51BETASERON 27betaxolol hcl 17betaxolol hcl (ophth) 48bethanechol chloride 40BETOPTIC-S 48BEVESPI AEROSPHERE 48bexarotene 14BEXSERO 43bicalutamide 11BICILLIN L-A 9BIKTARVY 6bisoprolol & hydrochlorothiazide 17bisoprolol fumarate 17BIVIGAM 42blephamide 46blisovi 24 fe 32blisovi fe 1.5/30 32BOOSTRIX 43BORTEZOMIB 10bosentan 19BOSULIF 12BRAFTOVI 12BREO ELLIPTA 50briellyn 32BRILINTA 41brimonidine sol 0.15% 48brimonidine sol 0.2% 48BRIVIACT INJ 50MG/5ML 19BRIVIACT SOL 10MG/ML 19BRIVIACT TAB 100MG 20BRIVIACT TAB 10MG 19BRIVIACT TAB 25MG 19BRIVIACT TAB 50MG 19BRIVIACT TAB 75MG 20bromfenac sodium (ophth) 47bromocriptine mesylate 23BROMSITE 47BRUKINSA 12budesonide (inhalation) 50budesonide ec 39bumetanide inj 0.25/ml 18bumetanide tab 18

buprenorphine hcl 28buprenorphine hcl-naloxone hcl dihydrate 12-3mg 28buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg.28buprenorphine hcl-naloxone hcl dihydrate 4-1mg 28buprenorphine hcl-naloxone hcl dihydrate 8-2mg 28buprenorphine hcl-naloxone hcl sl 28bupropion hcl 22bupropion hcl (smoking deterrent) 28buspirone hcl 19butorphanol tartrate 1BYDUREON BCISE 29BYDUREON PEN 29BYETTA 29BYSTOLIC 17cabergoline 37CABOMETYX 12calcipotriene 51calcitonin (salmon) 37calcitrene 51calcitriol 46calcitriol inj 46calcitriol oral soln 1 mcg/ml 46calcium acetate (phosphate binder) 37CALQUENCE 12camila 32camrese lo 32candesartan cilexetil 15candesartan cilexetil-hydrochlorothiazide 15CAPLYTA 24CAPRELSA 12captopril 15captopril & hydrochlorothiazide 14CARBAGLU 35carbamazepine 20carbidopa/levodopa/entacapone 23carbidopa-levodopa 23carboplatin 14carisoprodol 28carteolol hcl (ophth) 48cartia xt 17carvedilol 17caspofungin acetate 4CAYSTON 3caziant pak 32cefaclor 7cefaclor er tab 500mg 7cefadroxil 7CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 7cefazolin inj 7cefazolin sodium 7cefazolin sodium 1 gm/50ml 7

56

57

................................cefdinir 7cefepime for inj 7cefixime 7cefoxitin for inj 7cefpodoxime proxetil 8cefprozil 8ceftazidime 8CEFTAZIDIME/DEXTROSE 8ceftriaxone sodium 8cefuroxime axetil 8cefuroxime sodium 8celecoxib ...

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1CELONTIN 20cephalexin .8CERDELGA 35CEREZYME 35cetirizine syrup 49cevimeline hcl 53CHANTIX .28CHANTIX CONTINUING MONTH 28CHANTIX STARTER PACK 28CHEMET 31chlorhexidine gluconate (mouth-throat) 53chloroquine phosphate 5chlorothiazide 18chlorpromazine hcl 24chlorpromazine inj 24chlorthalidone 18cholestyramine 16cholestyramine light pack 16cholestyramine light powd 16ciclopirox 51cilostazol 41CILOXAN 47CIMDUO 6cinacalcet hcl 37CIPRO 8CIPRODEX 53ciprofloxacin hcl (ophth) 47ciprofloxacin hcl tab 8ciprofloxacin in d5w 8cisplatin 14citalopram hydrobromide 22claravis 50clarithromycin 8clarithromycin er 8clarithromycin for susp 8clindamycin cap 300 mg 3clindamycin cap 75mg 3clindamycin hcl cap 150 mg 3clindamycin phosphate (topical) 50

clindamycin phosphate in d5w 3CLINDAMYCIN PHOSPHATE IN NACL 3clindamycin phosphate inj 3clindamycin phosphate vaginal 40clindamycin soln 75mg/5ml 3CLINIMIX 4.25%/DEXTROSE 5% 45CLINIMIX 5%/DEXTROSE 15% 45CLINIMIX 5%/DEXTROSE 20% 45CLINIMIX INJ 4.25/D10 45clinisol sf 15% 45CLINOLIPID 45clobazam 20clomipramine hcl 22clonazepam 20clonidine hcl 18clonidine hcl ptwk 18clopidogrel tab 75mg 41clorazepate dipotassium 20clotrimazole 53clotrimazole (topical) 51clotrimazole w/ betamethasone 51clovique 31clozapine odt 24clozapine tab 100mg 24clozapine tab 200mg 24clozapine tab 25mg 24clozapine tab 50mg 24COARTEM .5colchicine w/ probenecid 1COLCRYS 1colesevelam hcl 16colestipol hcl gran 16colestipol hcl pack 16colestipol hcl tabs 16colistimethate sodium 3colocort 39COMBIGAN 48COMBIVENT RESPIMAT 48COMETRIQ 12COMPLERA 6compro supp 38constulose 39COPIKTRA 12CORLANOR 18cortisone acetate 36COTELLIC 12COUMADIN 40CREON 40CRIXIVAN 5cromolyn sod neb 20mg/2ml 49cromolyn sodium (mastocytosis) 39

58

................................cromolyn sodium (ophth) 47cryselle-28 32cyclafem 1/35 32cyclafem 7/7/7 32cyclobenzaprine hcl 28cyclophosphamide 9cycloserine 6cyclosporine 43cyclosporine modified (for microemulsion) 43cyproheptadine hcl 49cyred tab 32CYSTADANE 35CYSTAGON 35CYSTARAN 48cytarabine 10dalfampridine 27DALIRESP 49danazol 35dantrolene sodium 28dapsone 3DAPTACEL 43daptomycin 3dasetta 1/35 32dasetta 7/7/7 32DAURISMO 10deblitane .32deferasirox granules 31deferasirox tab 32DELESTROGEN 36DELSTRIGO 6DEMSER 18DEPO-PROVERA INJ 400/ML 11DESCOVY ..

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6desipramine hcl 22desmopressin acetate spray 38desmopressin acetate spray refrigerated 38desmopressin acetate tabs 38desmopressin inj 4mcg/ml 38desogestrel-ethinyl estradiol (biphasic) 32desvenlafaxine succinate 22dexamethasone 36dexamethasone sodium phosphate 36dexamethasone sodium phosphate (ophth) 47DEXILANT 40dexmethylphenidate hcl 26dextrose 10% flex contain 45DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% 45dextrose 10%/nacl 0.45% 45dextrose 2.5%/nacl 0.45% 45dextrose 5% 45DEXTROSE 5% /ELECTROLYTE 45

dextrose 5%/nacl 0.2% 45DEXTROSE 5%/NACL 0.3% 45dextrose 5%/nacl 0.45% 45dextrose 5%/nacl 0.9% 45dextrose 5%/potassium chl 45dextrose 50% 45dextrose in lactated ringers 45dextrose inj 70% 45DIASTAT ACUDIAL 20DIASTAT PEDIATRIC 20diazepam 20diazepam gel 20diazepam inj 20diazepam intensol 20diazepam oral soln 1 mg/ml 20diazoxide 36diclofenac potassium 1diclofenac sodium 1diclofenac sodium (ophth) 47diclofenac sodium (topical) 1% gel 52dicloxacillin sodium 9dicyclomine hcl cap 10mg 38dicyclomine hcl soln 10mg/5ml 38dicyclomine hcl tab 20mg 38didanosine 5DIFICID 8diflunisal 1digitek 18digox 18digoxin 18digoxin inj 18digoxin sol 50mcg/ml 18dihydroergotamine mesylate inj 1 mg/ml 27dihydroergotamine mesylate nasal spr 4 mg/ml 27dilantin cap 100mg 20dilantin cap 30mg 20dilantin chew tab 50mg 20DILANTIN-125 SUSP 20diltiazem 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 49diphenoxylate w/ atropine 39DIPHTHERIA/TETANUS TOXOID 43disopyramide phosphate 16

59

................................disulfiram 28divalproex sodium 20docetaxel 10DOCETAXEL 10dofetilide 16donepezil hydrochloride 22dorzolamide hcl 48dorzolamide hcl-timolol maleate 48DOVATO 6doxazosin mesylate 15doxepin hcl 22doxepin hcl (sleep) 26doxorubicin hcl 9doxorubicin hcl liposomal 10doxy 100 9doxycycline (monohydrate) 9doxycycline hyclate 9doxycycline hyclate 100 mg 9doxycycline hyclate 20 mg 9DRIZALMA SPRINKLE 22dronabinol 38drospirenone-ethinyl estradiol 32drospirenone-ethinyl estradiol-levomefolate

calcium 32DROXIA 41duloxetine hcl 22DUREZOL 47dutasteride 40dutasteride-tamsulosin hcl 40ec-naproxen 1EDURANT 5efavirenz 5eletriptan hydrobromide 27ELIQUIS 40-41ELIQUIS STARTER PACK 41ELLA 32eluryng 32EMCYT 9EMEND 38EMGALITY 27emoquette 32EMSAM 22EMTRIVA 5emverm 3enalapril maleate 15enalapril maleate & hydrochlorothiazide 14ENBREL 41-42ENBREL MINI 42ENBREL SURECLICK 42ENDARI 41endocet 10-325mg 2

endocet 2.5-325mg 1endocet 5-325mg 1endocet 7.5-325mg 2ENGERIX-B 43enoxaparin sodium 41enpresse-28 32enskyce 32ENSTILAR 51entacapone 23entecavir 7ENTRESTO 15enulose 39EPCLUSA 7EPIDIOLEX 20epinephrine (anaphylaxis) 49epirubicin hcl 10epitol 20EPIVIR HBV 7eplerenone 15ergotamine w/ caffeine 27ERIVEDGE 10ERLEADA 11erlotinib hcl 12errin 33ertapenem sodium 3ery pad 2% 50ery-tab 8erythrocin lactobionate 8erythrocin stearate 8erythromycin (acne aid) 50erythromycin (ophth) 47erythromycin base 8erythromycin cap 250mg ec 8erythromycin ethylsuccinate 8erythromycin tab ec 8ESBRIET 49escitalopram oxalate 22esomeprazole magnesium 40estarylla tab 0.25-35 33estradiol 36estradiol vaginal cream 36estradiol vaginal tab 36estradiol valerate inj 36eszopiclone 26ethambutol hcl 6ethosuximide 20ethynodiol diacet & eth estrad 33ethynodiol tab 1-50 33etodolac 1etonogestrel-ethinyl estradiol 33etoposide 14

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60

................................euthyrox 37everolimus 12everolimus (immunosuppressant) 43EVOTAZ 6EVZIO 28exemestane 11ezetimibe 16ezetimibe-simvastatin 16FABRAZYME 35falmina 33famciclovir 7famotidine 38famotidine in nacl 38famotidine inj 38FANAPT 24FANAPT TITRATION PACK 24FARXIGA 29FARYDAK 10FASENRA 49FASENRA PEN 49fayosim 33felbamate 20felodipine 17femynor 33fenofibrate 16fenofibrate micronized 16fentanyl citrate 2fentanyl patch 100 mcg/hr 2fentanyl patch 12 mcg/hr 2fentanyl patch 25 mcg/hr 2fentanyl patch 50 mcg/hr 2fentanyl patch 75 mcg/hr 2FETZIMA 22FETZIMA TITRATION PACK 22FIASP 29FIASP FLEXTOUCH 29FIASP PENFILL 29finasteride 40FINTEPLA 20flac 53FLAREX 47FLEBOGAMMA DIF 42flecainide acetate 16FLOVENT DISKUS 50FLOVENT HFA 50fluconazole 4fluconazole inj nacl 200 4fluconazole inj nacl 400 4flucytosine 4fludrocortisone acetate 36flunisolide (nasal) 50

fluocinolone acetonide 51fluocinolone acetonide (otic) 53fluocinolone acetonide oil body 51fluocinonide 51fluocinonide emulsified base 51fluorometholone 47fluorouracil 10fluorouracil (topical) 52fluoxetine cap 10mg 22fluoxetine cap 20mg 22fluoxetine cap 40mg 22fluoxetine hcl 22fluphenazine decanoate 24fluphenazine hcl 24flurbiprofen 1flurbiprofen sodium 47flutamide 11fluticasone propionate 51fluticasone propionate (nasal) .50fluvoxamine maleate 19fondaparinux sodium 41FORTEO 37fosamprenavir tab 700 mg 5fosinopril sodium 15fosinopril sodium & hydrochlorothiazide 15FREAMINE HBC 6.9% 45FREAMINE III 45fulvestrant 11furosemide 18furosemide inj 18FUZEON 5fyavolv 36FYCOMPA 20gabapentin 20galantamine hydrobromide 22galantamine hydrobromide er 22GAMASTAN 42GAMMAGARD LIQUID 42GAMMAGARD S/D 42GAMMAKED 42GAMMAPLEX 42GAMMAPLEX 10GM/100ML 42GAMUNEX-C 42ganciclovir sodium 7GARDASIL 9 43gatifloxacin (ophth) 47GATTEX 39GAUZE PADS 2 29gavilyte-c 39gavilyte-g 39gavilyte-n/flavor pack 39

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61

gemcitabine inj soln 10gemcitabine inj solr 10gemfibrozil 16generlac 39gengraf 43GENOTROPIN 37GENOTROPIN MINIQUICK 37gentak 47gentamicin in saline 3gentamicin sulfate 3gentamicin sulfate (topical) 50gentamicin sulfate soln (ophth) 47GENVOYA ..6GEODON 24gianvi tab 3-0.02mg 33GILENYA 27GILOTRIF TAB 20MG 12GILOTRIF TAB 30MG 12GILOTRIF TAB 40MG 12glatiramer acetate 20mg/ml 27glatiramer acetate 40mg/ml 27glatopa 28GLEOSTINE 9glimepiride 29, 30glip/metform tab 2.5-250mg 30glip/metform tab 2.5-500mg 30glip/metform tab 5-500mg 30glipizide 30glipizide xl 30GLUCAGEN HYPOKIT 36GLUCAGON EMERGENCY KIT 37glyburide 30glyburide micronized 30glyburide-metformin tab 1.25-250 mg 30glyburide-metformin tab 2.5-500 mg 30glyburide-metformin tab 5-500mg 30glycopyrrolate tab 1mg 38glycopyrrolate tab 2mg 38glydo 52GLYXAMBI 30GOLYTELY 39granisetron hcl 38griseofulvin microsize 4griseofulvin ultramicrosize 4guanfacine er (adhd) 26GVOKE HYPOPEN 2-PACK 37GVOKE PFS 37HAEGARDA 41hailey 24 fe 33halobetasol propionate 51haloperidol 24

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haloperidol conc 2mg/ml 24haloperidol decanoate 24haloperidol lactate inj 5mg/ml 24HARVONI ..7HAVRIX 43heather 33heparin sod (porcine) in d5w 41heparin sod inj 1000/ml 41heparin sod inj 10000/ml 41heparin sod inj 20000/ml 41heparin sod inj 5000/ml 41HEPARIN SODIUM/NACL 0.45% 41hepatamine 45HERCEPTIN 10HERCEPTIN HYLECTA 10HERZUMA 10HETLIOZ 26HIBERIX 43HUMIRA 42HUMIRA INJ 10MG/0.2ML 42HUMIRA KIT 20MG/0.4ML 42HUMIRA KIT 40MG/0.8ML 42HUMIRA PEDIATRIC CROHNS DISEASE 42HUMIRA PEN 42HUMIRA PEN CD/UC/HS STARTER 42HUMIRA PEN INJ CD/UC/HS STARTER 42HUMIRA PEN INJ PS/UV STARTER 42HUMIRA PEN-PS/UV STARTER 42HUMULIN R INJ U-500 29HUMULIN R U-500 KWIKPEN 29hydralazine hcl 18hydrochlorothiazide 18hydroco/apap tab 10-325mg 2hydroco/apap tab 5-325mg 2hydroco/apap tab 7.5-325 2hydrocodone-acetaminophen 7.5-325 mg/15ml 2hydrocodone-ibuprofen tab 7.5-200 mg 2hydrocortisone 36hydrocortisone (enema) 39hydrocortisone (topical) cream 1% 51hydrocortisone (topical) cream 2.5% 51hydrocortisone (topical) lotion 2.5% 52hydrocortisone (topical) oint 2.5% 52hydrocortisone butyrate cream 0.1% 52hydrocortisone butyrate oint 0.1% 52hydromorphone hcl 2hydroxychloroquine sulfate 42hydroxyurea 14hydroxyzine hcl 49hydroxyzine hcl inj 49hydroxyzine pamoate 49

62

................................HYSINGLA ER 2ibandronate sodium tabs 31IBRANCE 10ibu tab 600mg 1ibu tab 800mg 1ibuprofen 1icatibant acetate 41ICLUSIG 12IDHIFA 10ILEVRO 47imatinib mesylate 12IMBRUVICA 12imipenem-cilastatin 3imipramine hcl 22imiquimod 52IMOVAX RABIES (H.D.C.V.) 43incassia 33INCRELEX 37INCRUSE ELLIPTA 48indapamide 18INFANRIX 43INGREZZA 27INLYTA 12, 13INREBIC 13INSULIN PEN NEEDLE 29INSULIN SAFETY NEEDLES 29INSULIN SYRINGE 29INTELENCE 5INTRALIPID 30% 45intralipid inj 20% 45INTRON-A INJ 10MU 43INTRON-A INJ 18MU 43INTRON-A INJ 25MU 43INTRON-A INJ 50MU 43introvale .33INVEGA 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 24INVEGA SUST INJ 78 MG/0.5 ML 24INVEGA TRINZA 24INVIRASE ...

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5IPOL INACTIVATED IPV 43ipratropium bromide 48ipratropium bromide (nasal) 48ipratropium-albuterol nebu 48irbesartan 15irbesartan-hydrochlorothiazide 15IRESSA 13irinotecan hcl 14ISENTRESS .5

ISENTRESS HD 5isibloom 33ISOLYTE P 45ISOLYTE S 45isoniazid 6isoniazid syp 50mg/5ml 6isosorb mononitrate tab 19isosorbide dinitrate 19isosorbide mononitrate er 19isotretinoin 50isradipine 17itraconazole 4ivermectin .3IXIARO 43JADENU 32JADENU SPRINKLE 32JAKAFI 13jantoven .41JANUMET 30JANUMET XR TAB 100-1000 30JANUMET XR TAB 50-1000 30JANUMET XR TAB 50-500MG 30JANUVIA 30JARDIANCE 30jasmiel 33JENTADUETO 30JENTADUETO TAB XR 2.5-1000 MG 30JENTADUETO TAB XR 5-1000 MG 30jinteli 36jolessa tab 0.15-0.03 mg 33jolivette 33juleber 33JULUCA 6junel 1.5/30 33junel 1/20 33junel fe 1.5/30 33junel fe 1/20 33junel fe 24 33JUXTAPID 16KADCYLA 10kaitlib fe 33KALETRA TAB 100-25MG 6KALETRA TAB 200-50MG 6KALYDECO 49KANJINTI 10kariva 33kcl 0.075%/d5w/nacl 0.45% 45KCL 0.15%/D5W/NACL 0.225% 45kcl 0.15%/d5w/nacl 0.9% 45kcl 0.3%/d5w/nacl 0.45% 45KCL 0.3%/D5W/NACL 0.9% 45

63

................................kcl/d5w/nacl inj .15/.45% 46kcl/d5w/nacl inj 0.22%/0.45% .45kcl/nacl inj 0.15%-0.9% 46kcl/nacl inj 0.3-0.9 46kcl0.15%/d5w/nacl0.2% 45kelnor 1/35 33kelnor 1/50 33ketoconazole 4ketoconazole cream 51ketoconazole shampoo 51ketorolac tromethamine (ophth) 47KEYTRUDA 10KINRIX 43kionex sus 15gm/60ml 32KISQALI 10KISQALI FEMARA 200 DOSE 11KISQALI FEMARA 400 DOSE 11KISQALI FEMARA 600 DOSE 11klor-con 10 44klor-con 8 44klor-con m10 44klor-con m15 44klor-con m20 44klor-con pak 20meq 44klor-con spr cap 10meq 44klor-con spr cap 8meq 44KORLYM 37kurvelo 33KUVAN 35labetalol hcl 17lactated ringer's 46lactulose .39lactulose (encephalopathy) 39lamivudine 5lamivudine (hbv) 7lamivudine-zidovudine 6lamotrigine 20lansoprazole 40larin 1.5/30 33larin 1/20 33larin fe 1.5/30 33larin fe 1/20 33larissia tab 33LASTACAFT 47latanoprost 48LATUDA 24layolis fe .

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33leena tab 33leflunomide 42LENVIMA 10 MG DAILY DOSE 13LENVIMA 12MG DAILY DOSE 13

LENVIMA 14 MG DAILY DOSE 13LENVIMA 18 MG DAILY DOSE 13LENVIMA 20 MG DAILY DOSE 13LENVIMA 24 MG DAILY DOSE 13LENVIMA 4 MG DAILY DOSE 13LENVIMA 8 MG DAILY DOSE 13lessina 33letrozole 11leucovorin calcium 14LEUKERAN 9leuprolide inj 1mg/0.2 11levalbuterol hcl 49levalbuterol hcl soln nebu conc 1.25 mg/0.5ml 49levalbuterol tartrate hfa 49LEVEMIR 29LEVEMIR FLEXTOUCH 29levetiracetam 20levetiracetam in sodium chloride 21levetiracetam oral soln 100 mg/ml 21levobunolol hcl 48levocarnitine (metabolic modifiers) 35levocetirizine dihydrochloride 49levofloxacin 8levofloxacin in d5w 8levofloxacin inj 25mg/ml 8levofloxacin oral soln 25 mg/ml 8levonest 33levonor/ethi tab 33levonor-eth est tab 0.15-0.02/0.025/0.03mg

& eth est 0.01mg 33levonorgestrel & eth estradiol .33levonorgestrel-ethinyl estradiol 0.15-0.03mg

(91-day) 34levonorg-eth est tab 0.1-0.02mg(84) &

eth est tab 0.01mg(7) 33levonorg-eth est tab 0.15-0.03mg (84) &

eth est tab 0.01mg(7) 33levora 0.15/30-28 34levo-t 37levothyroxine sodium 37levoxyl 37LEXIVA 5lidocaine 52lidocaine hcl 52lidocaine hcl (local anesth.) 3lidocaine hcl (mouth-throat) 53lidocaine inj 0.5% 3lidocaine inj 1.5% preservative free (pf) 3lidocaine inj 1% 3lidocaine oint 5% 52lidocaine-prilocaine 52

linezolid in sodium chloride 3linezolid inj 3linezolid susp 3linezolid tab 600mg 4LINZESS ...

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39liothyronine sodium 37lisinopril 15lisinopril & hydrochlorothiazide 15lithium carbonate 27lithium carbonate er 27LITHIUM SOLN 8MEQ/5ML 27LOKELMA 32LONSURF 14loperamide hcl 39lopinavir-ritonavir 6lorazepam 19lorazepam intensol 19LORBRENA 13lorcet hd tab 10-325mg 2lorcet plus tab 7.5-325mg 2lorcet tab 5-325mg 2loryna 34losartan potassium 15losartan-hydrochlorothiazide 15LOTEMAX 47loteprednol etabonate 47lovastatin 16low-ogestrel 34loxapine succinate 24LUMIGAN 48LUMIZYME 35LUPRON DEPOT (1-MONTH) 11LUPRON DEPOT INJ 11.25MG (3-MONTH) 11LUPRON DEPOT-PED (1-MONTH 37LUPRON DEPOT-PED (3-MONTH 37LUPRON DEP-PED INJ 11.25MG (3-MONTH) 37LUPRON DEP-PED INJ 7.5MG 37lutera 34LYNPARZA 11LYRICA CR 27LYSODREN 11lyza 34magnesium sulfate 44MAGNESIUM SULFATE 44MAGNESIUM SULFATE IN D5W 44magnesium sulfate in dextrose 44magnesium sulfate inj 50% 44malathion 52maprotiline hcl 22marlissa 34MARPLAN TAB 10MG 23

MATULANE 14MAVYRET 7meclizine hcl 38medroxyprogesterone acetate (contraceptive) 34medroxyprogesterone acetate tab 37mefloquine hcl 5megestrol ac sus 40mg/ml 11megestrol ac tab 20mg 11megestrol ac tab 40mg 11megestrol sus 625mg/5ml 11MEKINIST 13MEKTOVI 13melodetta 24 fe 34meloxicam 1memantine hcl cp24 22memantine soln 22memantine tabs 22memantine titration pak 22MENACTRA 43MENVEO .43mercaptopurine 10meropenem 4mesalamine 39mesalamine w/ cleanser 39MESNEX 14metadate er tab 20mg 26metformin er 30metformin hcl 30, 31methadone hcl 2methadone hcl 10mg 2methadone hcl 5mg 2methadone hcl intensol 2methazolamide 18methenamine hippurate 4methimazole 38methocarbamol 28methotrexate sodium inj soln 10methotrexate sodium inj solr 10methotrexate sodium tabs 42methylphenidate hcl 26methylphenidate hcl oral soln 26methylphenidate hcl tbcr 10 mg 26methylphenidate hcl tbcr 20mg 26methylpr ss inj 36methylpred pak 4mg 36methylpred tab 16mg 36methylpred tab 32mg 36methylpred tab 4mg 36methylpred tab 8mg 36methylprednisolone acetate 36metoclopramide hcl 38

64

metoclopramide hcl inj 38metolazone 18metoprolol & hydrochlorothiazide 17metoprolol succinate 17metoprolol tartrate 17metronidazole 4metronidazole (topical) 52metronidazole gel 0.75% 52metronidazole in nacl 4metronidazole vaginal 40metyrosine 18mibelas 24 fe 34micafungin sodium 4microgestin 1.5/30 34microgestin 1/20 34microgestin fe 1.5/30 34microgestin fe 1/20 34midodrine hcl 18miglustat 35mili 34minitran 19minocycline hcl 9minoxidil .18mirtazapine 23misoprostol 39MITIGARE .

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1M-M-R II 43M-NATAL PLUS 46moexipril hcl 15molindone hcl 25mometasone furoate 52mondoxyne nl cap 100mg 9mono-linyah tab 0.25-35 34montelukast sodium 49morphine ext-rel tab 2morphine sul inj 1mg/ml 2morphine sulfate 2MORPHINE SULFATE 2morphine sulfate oral soln 100mg/5ml 2morphine sulfate oral soln 10mg/5ml 2morphine sulfate oral soln 20mg/5ml 2MOVANTIK 39MOXEZA 47moxifloxacin hcl 8moxifloxacin hcl (ophth) 47MULTAQ .16mupirocin 51MVASI 11MYCAMINE 4mycophenolate mofetil 43mycophenolate sodium tbec 43

myorisan .

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50MYRBETRIQ 40nabumetone 1nadolol 17nafcillin sodium for inj 9nafcillin sodium for inj 10gm 9NAGLAZYME 35nalbuphine hcl 1naloxone inj 0.4mg/ml 28naloxone inj 1mg/ml 28naltrexone hcl 28NAMZARIC 22naproxen 1naproxen dr 1naproxen sodium 1naratriptan hcl 27NARCAN .28NATACYN 47nateglinide 31NATPARA 37NAYZILAM 21necon 0.5/35-28 34nefazodone hcl 23neomycin sulfate 3neomycin-bacitracin zn-polymyxin 47neomycin-polymy-dexameth 46neomycin-polymyxin-gramicidin 47neomycin-polymyxin-hc (ophth) 46neomycin-polymyxin-hc (otic) 53NEPHRAMINE 45NERLYNX 13NEUPRO 23nevirapine susp 50 mg/5ml 5nevirapine tab 100mg er 5nevirapine tab 200mg 5nevirapine tab 400mg er 5NEXAVAR 13niacin (antihyperlipidemic) 16niacin er (antihyperlipidemic) 16niacor 16nicardipine hcl 17NICOTROL INHALER 28NICOTROL NS 28nifedipine 17nifedipine er 17nikki 34nilutamide 12nimodipine 17NINLARO 11nitisinone 35nitro-bid 19

65

NITRO-DUR DIS 0.3MG/HR 19NITRO-DUR DIS 0.8MG/HR 19nitrofurantoin macrocrystal 4nitrofurantoin monohyd macro .4nitroglycerin 19nitroglycerin td patch 19NITYR 36nizatidine 39nora-be tab 0.35mg 34nore/eth/fer chw 0.4mg-35 34noreth/ethin chw fe 34norethin acet & estrad-fe 34norethindrone (contraceptive) .34norethindrone acet & eth estra 34norethindrone acetate 37norethindrone acetate-ethinyl estradiol 36norgest/ethi tab 0.25/35 34norgestimate-ethinyl estradiol (triphasic) 0.18-

25/0.215-25/0.25-25 mg-mcg 34norgestimate-ethinyl estradiol (triphasic) 0.18-

35/0.215-35/0.25-35 mg-mcg 34NORMOSOL-M IN D5W 46NORMOSOL-R 46NORPACE CR 16NORTHERA 19nortrel 0.5/35 (28) 34nortrel 1/35 34nortrel 7/7/7 34nortriptyline hcl 23NORVIR PACK 5NORVIR SOLN 5NOVOLIN 70/30 29NOVOLIN 70/30 FLEXPEN 29NOVOLIN N 29NOVOLIN N FLEXPEN 29NOVOLIN R 29NOVOLIN R FLEXPEN 29NOVOLOG 29NOVOLOG 70/30 FLEXPEN 29NOVOLOG FLEXPEN 29NOVOLOG MIX 70/30 29NOVOLOG PENFILL 29NOXAFIL 4NUBEQA .

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12NUCALA 49NUCYNTA ER 2NUEDEXTA 27NULOJIX 43NULYTELY/FLAVOR PACKS 39NUPLAZID CAPS 25NUPLAZID TABS 10MG 25

nutrilipid inj 20% 45nyamyc 51NYMALIZE 17nystatin 4nystatin (mouth-throat) 53nystatin (topical) 51nystop 51ocella tab 3-0.03mg 34OCTAGAM 42octreotide acetate 37ODEFSEY 6ODOMZO 11OFEV 49ofloxacin (ophth) 47ofloxacin (otic) 53OGIVRI 11olanzapine 25olmesartan medoxomil 15olmesartan medoxomil-amlodipine-

hydrochlorothiazide 15olmesartan medoxomil-hydrochlorothiazide 15olopatadine hcl 0.2% 47omeprazole cap 10mg 40omeprazole cap 20mg 40omeprazole cap 40mg 40ondansetron hcl 38ondansetron hcl inj 38ondansetron hcl oral soln 38ondansetron odt 38ONE VITE WOMENS PRENATAL 46ONTRUZANT 11OPSUMIT 19ORFADIN 36ORKAMBI 49orsythia 34oseltamivir phosphate 7OSPHENA 37oxacillin sodium 9oxaliplatin inj 100mg 14oxaliplatin inj 100mg/20ml 14oxaliplatin inj 50mg 14oxaliplatin inj 50mg/10ml 14oxandrolone tab 10mg 28oxandrolone tab 2.5mg 28oxcarbazepine 21oxybutynin chloride 40oxycodone hcl 2oxycodone w/ acetaminophen 10-325mg 2oxycodone w/ acetaminophen 2.5-325mg 2oxycodone w/ acetaminophen 5-325mg 2oxycodone w/ acetaminophen 7.5-325mg 2

66

OZEMPIC INJ 0.25 OR 0.5MG/DOSE 29OZEMPIC INJ 1MG/DOSE 29pacerone .

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16paclitaxel 10paliperidone 25pamidronate disodium 31pamidronate inj 30mg 31pamidronate inj 90mg 31PANRETIN 52pantoprazole sodium 40pantoprazole sodium tbec 40PANZYGA 42paricalcitol 46paroex sol 0.12% 53paromomycin sulfate 3paroxetine hcl tabs 23paser d/r 6PAXIL 23PAZEO 47PEDIARIX .43PEDVAX HIB 43peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 39peg 3350-potassium chloride-sod bicarbonate-

sod chloride 39PEGANONE 21PEGASYS 7PEGASYS PROCLICK 7PEMAZYRE 13penicillamine 32PENICILLIN G POT IN DEXTROSE 2MU 9PENICILLIN G POT IN DEXTROSE 3MU 9penicillin g procaine 9penicillin g sodium 9penicillin v potassium 9penicilln gk inj 20mu 9penicilln gk inj 5mu 9PENTACEL 44pentamidine isethionate inh 4pentamidine isethionate inj 4pentoxifylline 41perindopril erbumine 15periogard 53permethrin cre 5% 52perphenazine 25PERSERIS .25pfizerpen-g inj 20mu 9pfizerpen-g inj 5mu 9phenelzine sulfate 23phenobarbital 21phenobarbital sodium 21phenytek .21

......................... phenytoin 21phenytoin sodium extended 21phenytoin sodium inj 50mg/ml 21PHESGO 11philith 34PHOSPHOLINE IODIDE 48PICATO 52PIFELTRO 5pilocarpine hcl 48pilocarpine hcl (oral) 53pimozide .25pimtrea 34pindolol 17pioglitazone hcl 31piper/tazoba inj 12-1.5gm 9piper/tazoba inj 2-0.25gm 9piper/tazoba inj 3-0.375gm 9piper/tazoba inj 36-4.5gm 9piper/tazoba inj 4-0.5gm 9PIQRAY 200MG DAILY DOSE 13PIQRAY 250MG DAILY DOSE 13PIQRAY 300MG DAILY DOSE 13pirmella 1/35 34piroxicam 1PLASMA-LYTE A 46PLASMA-LYTE-148 46plenamine 45PLENVU 39PNV FOLIC ACID + IRON MUL 46podofilox 52polymyxin b-trimethoprim 47POMALYST 12portia-28 34posaconazole 4pot chloride inj 2meq/ml 46potassium chloride 44, 46potassium chloride in nacl 46potassium chloride microencapsulated crystals er 44potassium citrate (alkalinizer) er tabs 40PRADAXA 41PRALUENT 16pramipexole tab 0.125mg 23pramipexole tab 0.25mg 23pramipexole tab 0.5mg 23pramipexole tab 0.75mg 23pramipexole tab 1.5mg 23pramipexole tab 1mg 23prasugrel hcl 41pravastatin sodium 16praziquantel 4prazosin hcl 15

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pred sod pho sol 5mg/5ml 36prednisolone acetate (ophth) ..

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47prednisolone sodium phosphate 36prednisolone sodium phosphate (ophth) 47prednisolone sol 15mg/5ml 36prednisolone sol 25mg/5ml 36prednisone con 5mg/ml 36prednisone pak 10mg 36prednisone pak 5mg 36prednisone sol 5mg/5ml 36prednisone tab 10mg 36prednisone tab 1mg 36prednisone tab 2.5mg 36prednisone tab 20mg 36prednisone tab 50mg 36prednisone tab 5mg 36pregabalin 21premasol 10% 45PRENATAL 46PRENATAL PLUS 46PRENATAL PLUS LOW IRON 46prevalite 16previfem 34PREZCOBIX 6PREZISTA 5PRIFTIN 7primaquine phosphate 5PRIMAQUINE PHOSPHATE 5primidone 21PRIVIGEN 42probenecid 1PROCALAMINE 45prochlorperazine inj 38prochlorperazine maleate 38prochlorperazine supp 38PROCRIT 41procto-med hc 52procto-pak 52proctosol hc cre 2.5% 52proctozone-hc 52PROGLYCEM SUS 50MG/ML 37PROGRAF 43PROLASTIN-C 49PROLENSA 47PROLIA 37PROMACTA 41promethazine hcl 38promethazine hcl inj 38propafenone hcl 16propafenone hcl 12hr 16proparacaine hcl 48

................................ propranolol & hydrochlorothiazide 17propranolol cap er 17propranolol hcl 17propranolol oral sol 17propylthiouracil 38PROQUAD 44PROSOL ..

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45protriptyline hcl 23PULMICORT FLEXHALER 50PULMOZYME 49PURIXAN .10pyrazinamide 7pyridostigmine tab 60mg 27QINLOCK 13QUADRACEL 44quetiapine fumarate 25quinapril hcl 15quinapril-hydrochlorothiazide 15quinidine sulfate 16quinine sulfate 5RABAVERT 44rabeprazole sodium 40raloxifene tab 60mg 37ramipril 15ranolazine 19rasagiline mesylate 23RAYALDEE 46reclipsen 34RECOMBIVAX HB 44RECTIV 52REGRANEX 53RELENZA DISKHALER 7RELISTOR 39REMICADE 42RENFLEXIS 42repaglinide 31RESTASIS .48RESTASIS MULTIDOSE 48RETEVMO 13REVLIMID 12REXULTI 25REYATAZ 5RHOPRESSA 48ribavirin cap 200mg 7ribavirin tab 200mg 7rifabutin 7rifampin 7riluzole 27rimantadine hydrochloride 7RINVOQ 42risedronate sodium 31

68

RISPERDAL INJ 12.5MG 25RISPERDAL INJ 25MG 25RISPERDAL INJ 37.5MG 25RISPERDAL INJ 50MG 25risperidone 25ritonavir 5RITUXAN .

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11RITUXAN HYCELA 11rivastigmine tartrate 22rivastigmine td patch 24hr 13.3 mg/24hr 22rivastigmine td patch 24hr 4.6 mg/24hr 22rivastigmine td patch 24hr 9.5 mg/24hr 22rivelsa 34rizatriptan benzoate 27rizatriptan benzoate odt 27ropinirole tab 0.25mg 23ropinirole tab 0.5mg 23ropinirole tab 1mg 23ropinirole tab 2mg 24ropinirole tab 3mg 24ropinirole tab 4mg 24ropinirole tab 5mg 24rosadan cre 0.75% 52rosuvastatin calcium 16ROTARIX 44ROTATEQ 44roweepra 21roweepra xr 21ROZLYTREK 13RUBRACA 11RUKOBIA 5RUXIENCE 11RYBELSUS 31RYDAPT 13SANDIMMUNE 43SANTYL 53SAPHRIS ..25scopolamine 38SECUADO 25selegiline hcl 24selenium sulfide 51SELZENTRY 5SEREVENT DISKUS 49sertraline hcl 23setlakin tab 34sevelamer carbonate 37sharobel 34SHINGRIX 44SIGNIFOR 37sildenafil citrate tab 20 mg (pulmonary hypertension)

19

silver sulfadiazine 51SIMBRINZA 48simvastatin 16sirolimus .

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43SIRTURO 7SIVEXTRO 4SKYRIZI 42sodium chlor sol 0.9% irr 53sodium chloride 44, 46sodium chloride 0.45% 46sodium chloride inj 0.9% 46sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln 44sodium phenylbutyrate 36sodium polystyrene sulfonate powder 32sodium polystyrene sulfonate susp 32SOLIQUA 100/33 29SOLTAMOX 12SOLU-CORTEF 36SOMATULINE DEPOT 37SOMAVERT 37sorine 16sotalol hcl 16sotalol hcl (afib/afl) 16spironolactone 15spironolactone & hydrochlorothiazide 18sprintec 28 34SPRITAM 21SPRYCEL 13sps susp 15gm/60ml 32sronyx 34ssd 51stavudine 5STELARA 42STIMATE 38STIVARGA 13streptomycin sulfate 3STRIBILD 6subvenite tab 21sucralfate 39sulfacetamide sodium (acne) 50sulfacetamide sodium (ophth) 47sulfacetamide sod-prednisolone 46sulfadiazine 3sulfamethoxazole-trimethop ds .4sulfamethoxazole-trimethoprim inj 4sulfamethoxazole-trimethoprim susp 4sulfamethoxazole-trimethoprim tab 400-80mg 4SULFAMYLON 51sulfasalazine 39sulfasalazine ec 39sulindac 1

69

sumatriptan 27sumatriptan inj 4mg/0.5ml 27sumatriptan inj 6mg/0.5ml 27sumatriptan succinate 27SUPREP BOWEL PREP KIT 39SUTENT 13syeda 35SYLATRON 14SYMBICORT 50SYMDEKO 49SYMFI 6SYMFI LO 6SYMJEPI 50SYMPAZAN 21SYMTUZA 6SYNAREL .35SYNERCID 4SYNJARDY TAB 12.5-1000MG 31SYNJARDY TAB 12.5-500MG 31SYNJARDY TAB 5-1000MG 31SYNJARDY TAB 5-500MG 31SYNJARDY XR TAB 10-1000MG 31SYNJARDY XR TAB 12.5-1000MG 31SYNJARDY XR TAB 25-1000MG 31SYNJARDY XR TAB 5-1000MG 31SYNRIBO .

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14SYNTHROID 38TABLOID 10TABRECTA 13tacrolimus 43tacrolimus (topical) 52TAFINLAR 13TAGRISSO 13TALZENNA 11tamoxifen citrate 12tamsulosin hcl 40TARGRETIN 52tarina 24 fe 35tarina fe 1/20 35TASIGNA 13TAXOTERE 10tazarotene 51tazicef 8TAZORAC 51taztia xt 18TAZVERIK 14TDVAX 44TECENTRIQ 11TEFLARO 8telmisartan 15telmisartan-amlodipine 15

telmisartan-hydrochlorothiazide 15temazepam 26TEMIXYS 6TENIVAC .

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44tenofovir disoproxil fumarate 5terazosin hcl 15terbinafine hcl 4terbutaline sulfate 49terconazole vaginal 40testosterone 28testosterone cypionate 29testosterone enanthate 29tetrabenazine 27tetracycline hcl 9texacort soln 2.5% 52THALOMID 12theo-24 50theophylline 50theophylline tab er 12hr 300 mg 50theophylline tab er 12hr 450 mg 50theophylline tab sr 24hr 50thioridazine hcl 25thiothixene 25tiadylt er 18tiagabine hcl 21TIBSOVO 11tigecycline 4tilia fe 35timolol maleate 17timolol maleate (ophth) soln 48timolol maleate gel 48timolol maleate ophth soln 0.5% (once-daily) 48TIVICAY 5TIVICAY PD 6tizanidine hcl 28TOBRADEX 46TOBRADEX ST 46tobramycin 3tobramycin (ophth) 47tobramycin inj 1.2 gm/30ml 3tobramycin inj 1.2gm 3tobramycin inj 10mg/ml 3tobramycin inj 80mg/2ml 3tobramycin sulfate 3tobramycin-dexamethasone 46tolterodine tartrate 40topiramate 21toposar 14toremifene citrate 12torsemide tabs 18TOVIAZ 40

70

TPN ELECTROLYTES 44TRADJENTA 31tramadol hcl tab 50 mg 1tramadol-acetaminophen 1trandolapril 15tranexamic acid 41tranylcypromine sulfate 23TRAVASOL 45travoprost 48TRAZIMERA 11trazodone hcl 23TRECATOR .7TRELEGY ELLIPTA 48TRELSTAR DEP INJ 3.75MG 12TRELSTAR LA INJ 11.25MG 12treprostinil 19TRESIBA FLEXTOUCH 29TRESIBA INJ 29tretinoin 50tretinoin (chemotherapy) 14triamcinolone acetonide (mouth) 53triamcinolone acetonide (topical) 52triamterene & hydrochlorothiazide cap 37.5-25 mg.18triamterene & hydrochlorothiazide tabs 18TRICARE ..46trientine hcl 32tri-estarylla 35trifluoperazine hcl 25trifluridine 47trihexyphenidyl hcl 24TRIJARDY XR TAB ER 24HR 10-5-1000 MG 31TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG 31TRIJARDY XR TAB ER 24HR 25-5-1000 MG 31TRIJARDY XR TAB ER 24HR 5-2.5-1000MG 31TRIKAFTA 50tri-legest fe 35tri-linyah .35tri-lo marzia 35tri-lo-estarylla 35tri-lo-sprintec 35trilyte 39trimethoprim 4tri-mili 35trimipramine maleate 23TRINTELLIX 23tri-previfem 35tri-sprintec 35TRIUMEQ ..6trivora-28 35tri-vylibra 35tri-vylibra lo 35

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TROGARZO 6TROPHAMINE INJ 10% 45trospium chloride 40TRULICITY 29TRUMENBA 44TRUVADA TAB 100-150 6TRUVADA TAB 133-200 6TRUVADA TAB 167-250 6TRUVADA TAB 200-300 6TRUXIMA 11TUKYSA 13tulana 35TURALIO .13TWINRIX INJ 44TYBOST 6tydemy 35TYKERB 13TYMLOS 37TYPHIM VI 44unithroid .38ursodiol 39valacyclovir hcl 7VALCHLOR 52valganciclovir hcl 7valproate sodium 21valproate sodium oral soln 21valproic acid 21valsartan 15valsartan-hydrochlorothiazide 15VALTOCO 21vanadom 28vancomycin hcl 4VANCOMYCIN IN NACL 4vandazole 40VAQTA 44VARIVAX 44VASCEPA 16VELCADE 11velivet 35VELTASSA 32VEMLIDY 7VENCLEXTA 11VENCLEXTA STARTING PACK 11venlafaxine hcl 23VENTAVIS 19VENTOLIN HFA 49verapamil cap er 18verapamil hcl 18verapamil tab er 18VERSACLOZ 25VERZENIO 11

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VICTOZA 29vienva 35vigabatrin powd pack 500mg 21vigabatrin tab 500mg 21vigadrone 21VIIBRYD STARTER PACK 23VIIBRYD TAB 23VIMPAT 21VIMPAT INJ 200MG/20ML 21VIMPAT SOL 10MG/ML 21vincristine sulfate 10vinorelbine tartrate 10viorele 35VIRACEPT 6VIREAD 6VITRAKVI 13VIVITROL 28VIZIMPRO 13voriconazole 4VOSEVI 7VOTRIENT 13VRAYLAR 25VRAYLAR THERAPY PACK 25vyfemla 35vylibra 35warfarin sodium 41water for irrigation, sterile 53wymzya fe 35XALKORI 13XARELTO 41XARELTO STARTER PACK 41XATMEP 42XCOPRI MAINTENANCE PAK 150-200MG 21XCOPRI PAK 12.5-25MG 21XCOPRI PAK 50-100MG 21XCOPRI PAK 50-200MG 21XCOPRI TABS 21XCOPRI TITRATION PAK 150-200MG 21XELJANZ 42XELJANZ XR 42XGEVA 37XIFAXAN 40XIGDUO XR TAB 10-1000MG 31XIGDUO XR TAB 10-500MG 31XIGDUO XR TAB 2.5-1000MG 31XIGDUO XR TAB 5-1000MG 31XIGDUO XR TAB 5-500MG 31XOLAIR 50XOSPATA 13XPOVIO 100 MG ONCE WEEKLY 14

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XPOVIO 40 MG ONCE WEEKLY 14XPOVIO 40 MG TWICE WEEKLY 14XPOVIO 60 MG ONCE WEEKLY 14XPOVIO 60 MG TWICE WEEKLY 14XPOVIO 80 MG ONCE WEEKLY 14XPOVIO 80 MG TWICE WEEKLY 14XTANDI 12xulane dis 150-35 35XULTOPHY 100/3.6 29XYREM 28YF-VAX 44yuvafem vaginal tablet 10 mcg 36zafirlukast 49zaleplon 26zarah 35ZARXIO 41ZEJULA 11ZELBORAF 13ZEMAIRA 50zenatane 50ZENPEP 40ZERVIATE 47zidovudine cap 100mg 6zidovudine syp 50mg/5ml 6zidovudine tab 300mg 6ziprasidone hcl 25ziprasidone mesylate 25ZIRABEV 11ZIRGAN 47zoledronic acid inj 4mg/100ml 31zoledronic acid inj 5mg/100ml 31zoledronic inj 4mg/5ml 31ZOLINZA 11zolmitriptan 27zolmitriptan odt 27zolpidem tartrate 27zonisamide 21ZORTRESS TAB 0.25MG 43ZORTRESS TAB 0.5MG 43ZORTRESS TAB 0.75MG 43ZORTRESS TAB 1MG 43ZOSTAVAX 44zovia 1/35e 35ZYDELIG 13ZYKADIA 13ZYLET 46ZYPREXA RELPREVV 25ZYPREXA RELPREVV INJ 210MG 25ZYTIGA 12

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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 10/01/2020. 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 10/01/2020. 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 will generally cover the drugs listed in our...

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