UCare Connect (SNBC) • Families and Children (Prepaid ... · This list is subject to change and...

UCare Customer Service: Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free. Hours of operation: 8 am to 5 pm, Monday through Friday. The call is free. For more information visit ucare.org. UCare, 500 Stinson Blvd, Minneapolis, MN 55413

The information included in this list of covered drugs was correct as of 10/2020. To see the most current information, please visit ucare.org, or if you have questions, contact Customer Service at the number listed on this page. You can ask for a printed copy of this Medicaid List of Covered Drugs at any time.

UCare Connect counties: Aitkin, Anoka, Becker, Benton, Blue Earth, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Cook, Cottonwood, Crow Wing, Dakota, Faribault, Fillmore, Hennepin, Houston, Isanti, Itasca, Jackson, Kandiyohi, Kittson, Koochiching, Lac Qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, Mille Lacs, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Polk, Ramsey, Red Lake, Redwood, Rice, Rock, Roseau, Scott, Sherburne, St. Louis, Stearns, Swift, Washington, Watonwan, Wilkin, Winona, Wright and Yellow Medicine.

Families and Children (PMAP) counties: Anoka, Blue Earth, Carver, Chippewa, Cottonwood, Dakota, Faribault, Fillmore, Freeborn, Hennepin, Houston, Isanti, Jackson, Kandiyohi, Lac qui Parle, Lake of the Woods, LeSueur, Lincoln, Lyon, Martin, Mower, Murray, Nicollet, Nobles, Olmsted, Ramsey, Redwood, Rice, Rock, St. Louis, Scott, Sibley, Swift, Washington, Watonwan, Winona, Wright and Yellow Medicine.

MinnesotaCare counties: Anoka, Big Stone, Blue Earth, Carver, Chippewa, Cottonwood,

Dakota, Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Isanti, Jackson, Kanabec, Kandiyohi, Lac qui Parle, Lake of the Woods, LeSueur, Lincoln, Lyon, McLeod, Martin, Meeker, Morrison, Mower, Murray, Nicollet, Nobles, Olmsted, Pipestone, Pope, Ramsey, Redwood, Renville, Rice, Rock, St. Louis, Scott, Sibley, Steele, Stevens, Swift, Todd, Traverse, Wadena, Waseca, Washington, Watonwan, Winona, Wright and Yellow Medicine.

Minnesota Senior Care Plus counties: Aitkin, Anoka, Becker, Benton, Blue Earth, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Cook, Cottonwood, Crow Wing, Dakota, Dodge, Faribault, Fillmore, Freeborn, Hennepin, Houston, Isanti, Jackson, Kandiyohi, Kittson, Koochiching, Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Polk, Ramsey, Red Lake, Redwood, Rice, Rock, Roseau, Scott, Sherburne, St. Louis, Stearns, Swift, Todd, Wabasha, Wadena, Washington, Watonwan, Winona, Wright and Yellow Medicine.

2020 Medicaid List of Covered Drugs (Formulary)• UCare Connect (SNBC) • Families and Children (Prepaid Medical Assistance Program (PMAP)) • MinnesotaCare • Minnesota Senior Care Plus (MSC Plus)

DHS Approved Date 12/16/2019

This list is subject to change and is not all-inclusive. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. Note to existing members: This list of covered drugs has changed since last year. Please review this document to make sure that it still has the drugs you take. Please contact UCare Customer Service with questions: Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free. Hours of operation: 8 am to 5 pm, Monday through Friday. The call is free. For more information visit ucare.org.

Other drug coverage: If you have Medicare, you need to get most of your prescription drugs through the Medicare Prescription Drug Program (Medicare Part D). You must be enrolled in a Medicare prescription drug plan to get these services.

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your heath plan Primary Care Provider (PCP) prior to the referral.

PLEASE READ: This document contains information about the drugs we cover in these plans. Members must use network pharmacies to receive prescription drug benefits.

Table of Contents

What is a List of Covered Drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

Does the List of Covered Drugs ever change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

How are drugs listed in the List of Covered Drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

What is a Preferred Drug List? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

What are generic or biosimilar drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

What are over-the-counter (OTC) drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

What if a drug is not on the list of covered drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Are there any restrictions on my coverage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Can I request an exception to the coverage restrictions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

What will a prescription cost? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Drug List (formulary) Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Drug Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Over-the-counter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

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What is a List of Covered Drugs?A list of covered drugs includes the prescription drugs covered by UCare.The drugs on the list are selected by UCare with the help of a team of doctors and pharmacists. UCare will generally cover the drugs listed in the list of covered drugs as long as the drug is medically necessary, the prescription is filled at a UCare network pharmacy and other requirements related to the drug are followed.

Does the List of Covered Drugs ever change?The UCare list of covered drugs can change during the course of a calendar year. If changes occur which will impact the coverage of a medication you are taking, UCare will make reasonable efforts to contact you and your prescriber to inform you and your prescriber about the change and possible alternative medications which will be covered.

Examples of some changes that may occur are:

• A drug you are taking is no longer preferred.

• A drug is removed from the list of covered drugs due to safety reasons.

• Changes in prior authorization requirements.

How are drugs listed in the List of Covered Drugs?There are two ways to find your prescription drugs in the formulary. You can search by medical condition associated with your drug or by alphabetical listing.

Search by Medical ConditionDrugs listed by medical condition begin on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions they are used to treat. If you know what your drug is used for, look for the category in the list that begins on page 1. Then look under the category name for your drug.

Search by Alphabetical ListingIf you are not sure what category to look under, you can look for your drug in the Index. The Index gives an alphabetical list of all of the drugs included in the formulary. Both brand name and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information within the formulary.

What is a Preferred Drug List?In Minnesota, all managed care organizations are required to follow the Department of Human Services’ Preferred Drug List (PDL). The PDL is created by the Department of Human Services, in consultation with the Drug Formulary Committee, to let prescribers and members know about drugs or drug classes that are more or less cost effective. Generally, drugs that are listed on the PDL as preferred are more cost effective; and drugs that are listed as non-preferred on PDL are less cost effective. Preferred drugs are available to members with fewer restrictions. Non-preferred drugs will require a prior authorization. To receive a non-preferred drug, your doctor or health care provider must get prior authorization.

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The Preferred Drug List is a portion of UCare’s list of covered drugs. UCare’s list of covered drugs is a complete list of all covered drugs. The Preferred Drug List is available on the department’s website: Minnesota Fee-for-Service Medicaid Preferred Drug List (http://minnesota.magellanmedicaid.com/pdl.asp).

What are generic or biosimilar drugs?A generic drug is approved by the Food and Drug Administration (FDA) and has the same active ingredient as the brand-name drug and produces the same clinical effect as the brand-name drug.

A biosimilar drug is an FDA-approved biologic drug (most often an injectable prescription drug) that is highly similar to and has no clinically meaningful differences in terms of safety and effectiveness from an already-approved biological product. Biosimilar drugs are not the same as generic drugs, but like generics, biosimilar drugs may offer more affordable treatment options for you.

Generic or biosimilar substitution means a generic version or biosimilar version of a drug is given instead of the brand-name or non-biosimilar version of the drug.

UCare will cover the brand name or non-biosimilar version of the drug only when:

1. Your prescriber informs UCare in writing that the brand name or non-biosimilar version of the drug is medically necessary; OR

2. UCare may prefer the dispensing of the brand-name version over the generic version or non-biosimilar version over the biosimilar version of the drug; OR

3. Minnesota Law requires the dispensing of the brand-name or non-biosimilar version of the drug.

Within the list of covered drugs, brand-name drugs are capitalized (e.g. EPIPEN) and generic drugs are listed in lower-case italics (e.g. maprotiline tablet).

What are over-the-counter (OTC) drugs?Drugs and products that are available for purchase without a prescription are referred to as over-the-counter (OTC). Although an OTC product is available without a prescription, if a doctor writes a prescription for an OTC product, UCare may cover it.

What are specialty drugs?Specialty drugs are used by people with complex or chronic diseases. These drugs often require special handling, dispensing, or monitoring by a specially-trained pharmacist.

If you are prescribed a drug that is on the UCare Specialty Drug List, your prescriber will need to send the prescription of that specialty drug to UCare’s Specialty Pharmacy.

Name of Specialty Pharmacy: Fairview Specialty Pharmacy

Phone and TTY: 612-672-5260 or 1-800-595-7140 toll free TTY call the National Relay Center at 711 and ask for 1-800-595-7140.

Fax: 1-866-347-4939

Hours of operation: 24 hours a day, seven days a week

www.fairviewspecialtyrx.org

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You will also need to call the Specialty Pharmacy at 612-672-5260 or 1-800-595-7140 toll free to set up an account. You will need to have your UCare Member Identification (ID) card when you call the Specialty Pharmacy.

What if a drug is not on the list of covered drugs?Not all drugs are covered. If a drug is not listed in the list of covered drugs, you should contact UCare Customer Service for Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free and ask if the drug is covered. If not, it is considered a non-formulary drug. If you need a drug that is not included in the list of covered drugs,

• You can ask your health care provider if there is another covered drug that will work for you.

• You and/or your health care provider can ask UCare to make an “exception” and cover the drug for you or remove the restrictions or limits. If your exception request is approved, the drug will be covered at the appropriate generic or brand name copay level.

Generally, UCare will only approve your health care provider’s request for a formulary exception if the alternative drug included on UCare’s list of covered drugs would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

If your healthcare provider prescribes a drug that is not on our list of covered drugs or a drug that requires prior authorization, your provider should call Express Scripts or visit our provider website to complete a request form. Members may also find more information on ucare.org. Please call UCare Customer Service at the number listed on the front cover for help.

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

• Prior Authorization: UCare requires you or your doctor or health care provider to get prior authorization for certain drugs. This means that you will need to get approval from UCare before you fill your prescriptions. If you don’t get approval, UCare may not cover the drug.

• Quantity Limits: For certain drugs, UCare limits the amount of the drug that UCare will cover.

• Age requirements: In some cases, there are age requirements for you to try certain drugs. A prior authorization is needed depending on your age and the specific drug prescribed.

You can find out if your drug requires prior authorization, has quantity limits, or has an age requirement by looking in this list of covered drugs. A drug restriction or limit can be removed if your doctor submits a statement or documentation supporting the request. Refer to your Member Handbook for more information. You can also get more information about the restrictions applied to specific covered drugs by contacting UCare Customer Service for Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free or by visiting our website at ucare.org.

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• Excluded Drugs: Some drugs are excluded from the list of covered drugs. Excluded drugs include the following:

- Drugs used to treat sexual or erectile dysfunction

- Drugs used to enhance fertility

- Drugs used for cosmetic purposes, including drugs to treat hair loss

- Drugs or products to promote weight loss

- Drugs not clinically proven to be effective

- Investigational or experimental drugs

- Medical cannabis

Can I request an exception to the coverage restrictions?Yes. Your healthcare provider can obtain the Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions from ucare.org or by contacting, UCare Customer Service for Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free. Your provider must return this form to the fax number or address listed on the document. To facilitate a thorough review and to ensure that your healthcare provider receives a response within 24 hours, UCare asks that all information requested in the form be provided, including documentation of which medications have been tried and failed, including the dosages used, and the identified reason for failure (e.g. side effects).

What will a prescription cost?All copay information for prescriptions is listed in the Member Handbook. If you have additional questions, contact UCare Customer Service for Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free or by visiting our website at ucare.org.

Drug List (formulary) Key

Explanation of Coverage Status

P Preferred Drug Preferred drugs are covered without Prior Authorization

NP Non-Preferred Drug Non-preferred drugs require Prior Authorization from UCare

AD Additional Drugs Additional drugs covered by UCare

Explanation of Requirements

PA Prior Authorization Drugs that require approval from UCare before you fill your prescription

QL Quantity Limit There are limits to the quantity of the drug covered per month

SP Specialty Drug Specialty drugs are used for complex conditions and require Fairview Specialty Pharmacy to fill your prescription.

Drug Tier Limits or RestrictionsANTIHISTAMINE DRUGSALL DAY ALLERGY (CETIRIZINE) ORAL TABLET 10 MG P

ALL DAY ALLERGY-D ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG P

ALLERGY AND CONGESTION RELIEF ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG

P


P

ALLERGY COMPLETE-D ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG P

ALLERGY RELIEF (LORATADINE) ORAL SOLUTION 5 MG/5 ML P

ALLERGY RELIEF (LORATADINE) ORAL TABLET 10 MG P

ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING 10 MG P

ALLERGY RELIEF D-24HR ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG P

ALLERGY RELIEF,NASAL DECONGEST ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG

P

ALLERGY-CONGESTION RELIEF-D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG

P

ALLER-TEC ORAL TABLET 10 MG Pcarbinoxamine maleate oral liquid 4 mg/5 ml AD

carbinoxamine maleate oral tablet 4 mg ADcetirizine oral solution 1 mg/ml Pcetirizine oral tablet 10 mg, 5 mg Pcetirizine oral tablet,chewable 10 mg, 5 mg Pcetirizine-pseudoephedrine oral tablet extended release 12 hr 5-120 mg P

CHILDREN'S ALLERGY RELIEF(LOR) ORAL SOLUTION 5 MG/5 ML P

CHILDREN'S CETIRIZINE ORAL TABLET,CHEWABLE 10 MG, 5 MG P

CHILD'S ALL DAY ALLERGY(CETIR) ORAL SOLUTION 1 MG/ML P

UCare Comprehensive FormularyEffective: October 1, 2020

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Drug Tier Limits or RestrictionsCLARINEX ORAL SYRUP 2.5 MG/5 ML (0.5 MG/ML) NP PA

CLARINEX ORAL TABLET 5 MG NP PACLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR 2.5-120 MG NP PA

clemastine oral tablet 2.68 mg ADcyproheptadine oral syrup 2 mg/5 ml ADcyproheptadine oral tablet 4 mg ADdesloratadine oral tablet 5 mg NP PAdesloratadine oral tablet,disintegrating 2.5 mg, 5 mg NP PA

diphenhydramine hcl injection solution 50 mg/ml AD

hydroxyzine hcl intramuscular solution 25 mg/ml AD

hydroxyzine hcl oral solution 10 mg/5 ml ADhydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg AD

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg AD

levocetirizine oral solution 2.5 mg/5 ml Plevocetirizine oral tablet 5 mg PLORATA-DINE D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG P

loratadine oral solution 5 mg/5 ml Ploratadine oral tablet 10 mg PLORATADINE-D ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG P

LORATADINE-D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG P

meclizine oral tablet 12.5 mg, 25 mg ADmeclizine oral tablet,chewable 25 mg ADNON-DROWSY ALLERGY ORAL TABLET 10 MG P

promethazine injection solution 25 mg/ml, 50 mg/ml AD

promethazine oral syrup 6.25 mg/5 ml ADpromethazine oral tablet 12.5 mg, 25 mg, 50 mg AD

promethazine rectal suppository 12.5 mg, 25 mg AD


Drug Tier Limits or RestrictionsSEMPREX-D ORAL CAPSULE 8-60 MG NP PAWAL-ZYR (CETIRIZINE) ORAL TABLET 10 MG P

ANTI-INFECTIVE AGENTSabacavir oral solution 20 mg/ml ADabacavir oral tablet 300 mg ADabacavir-lamivudine oral tablet 600-300 mg AD

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg AD

acyclovir oral capsule 200 mg Pacyclovir oral suspension 200 mg/5 ml Pacyclovir oral tablet 400 mg, 800 mg Pacyclovir sodium intravenous recon soln 1,000 mg, 500 mg AD

acyclovir sodium intravenous solution 50 mg/ml AD

adefovir oral tablet 10 mg P SPAEMCOLO ORAL TABLET,DELAYED RELEASE (DR/EC) 194 MG AD

albendazole oral tablet 200 mg ADamantadine hcl oral capsule 100 mg ADamantadine hcl oral solution 50 mg/5 ml ADamantadine hcl oral tablet 100 mg ADamikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml AD

amoxicillin oral capsule 250 mg, 500 mg ADamoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

AD

amoxicillin oral tablet 500 mg, 875 mg ADamoxicillin oral tablet,chewable 125 mg, 250 mg AD

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

P

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg P

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg NP PA


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Drug Tier Limits or Restrictionsamoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg NP PA

amphotericin b injection recon soln 50 mg ADampicillin oral capsule 250 mg, 500 mg ADampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg

AD

ampicillin sodium intravenous recon soln 1 gram, 2 gram AD

ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram AD

ampicillin-sulbactam intravenous recon soln 1.5 gram, 3 gram AD

ANCOBON ORAL CAPSULE 250 MG, 500 MG NP PAAPTIVUS (WITH VITAMIN E) ORAL SOLUTION 100 MG/ML AD

APTIVUS ORAL CAPSULE 250 MG ADARIKAYCE INHALATION SUSPENSION FOR NEBULIZATION 590 MG/8.4 ML AD PA; SP

atazanavir oral capsule 150 mg, 200 mg, 300 mg AD

atovaquone oral suspension 750 mg/5 ml ADatovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg AD

ATRIPLA ORAL TABLET 600-200-300 MG ADAUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML, 250-62.5 MG/5 ML

NP PA

AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR 1,000-62.5 MG NP PA

AVELOX ORAL TABLET 400 MG NP PAazithromycin intravenous recon soln 500 mg AD

azithromycin oral packet 1 gram Pazithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml P

azithromycin oral tablet 250 mg, 500 mg, 600 mg P

aztreonam injection recon soln 1 gram ADAZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

NP PA


Drug Tier Limits or RestrictionsAZULFIDINE ORAL TABLET 500 MG NP PAbacitracin intramuscular recon soln 50,000 unit AD

BARACLUDE ORAL SOLUTION 0.05 MG/ML P SPBARACLUDE ORAL TABLET 0.5 MG, 1 MG P SPBAXDELA ORAL TABLET 450 MG NP PABENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG AD SP

BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML P SP; QL (224 per 30 days)

BIKTARVY ORAL TABLET 50-200-25 MG ADCAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML NP SP; PA; QL (84 per 30 days)

cefaclor oral capsule 250 mg, 500 mg Pcefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml P

cefaclor oral tablet extended release 12 hr 500 mg NP PA

cefadroxil oral capsule 500 mg Pcefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml P

cefadroxil oral tablet 1 gram NP PAcefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml AD

cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 20 gram, 300 g, 500 mg AD

cefazolin intravenous recon soln 1 gram ADcefdinir oral capsule 300 mg Pcefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml P

cefditoren pivoxil oral tablet 200 mg ADcefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/100 ml AD

cefepime injection recon soln 1 gram, 2 gram AD

cefixime oral capsule 400 mg NP PAcefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml NP PA

cefotaxime injection recon soln 1 gram ADcefotetan injection recon soln 1 gram, 2 gram AD


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Drug Tier Limits or Restrictionscefotetan intravenous recon soln 10 gram ADcefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/50 ml AD

cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram AD

cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml NP PA

cefpodoxime oral tablet 100 mg, 200 mg NP PAcefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml P

cefprozil oral tablet 250 mg, 500 mg Pceftazidime injection recon soln 1 gram, 2 gram, 6 gram AD

ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml, 2 gram/50 ml AD

ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg AD

ceftriaxone intravenous recon soln 1 gram, 2 gram AD

cefuroxime axetil oral tablet 250 mg, 500 mg P

cefuroxime sodium injection recon soln 750 mg AD

cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram AD

cephalexin oral capsule 250 mg, 500 mg, 750 mg P

cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml P

cephalexin oral tablet 250 mg, 500 mg ADchloramphenicol sod succinate intravenous recon soln 1 gram AD

chloroquine phosphate oral tablet 250 mg, 500 mg AD

CIMDUO ORAL TABLET 300-300 MG ADCIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML NP PA

CIPRO ORAL TABLET 250 MG, 500 MG NP PACIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 MG, 500 MG NP PA

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg NP PA


Drug Tier Limits or Restrictionsciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg P

ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml AD

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml NP PA

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml NP PA

clarithromycin oral tablet 250 mg, 500 mg Pclarithromycin oral tablet extended release 24 hr 500 mg NP PA

clindamycin hcl oral capsule 150 mg, 300 mg AD

clindamycin palmitate hcl oral recon soln 75 mg/5 ml AD

CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML AD

clindamycin phosphate injection solution 150 mg/ml AD

clindamycin phosphate intravenous solution 300 mg/2 ml, 600 mg/4 ml, 900 mg/6 ml

AD

COARTEM ORAL TABLET 20-120 MG ADcolistin (colistimethate na) injection recon soln 150 mg AD

COMBIVIR ORAL TABLET 150-300 MG NP PACOMPLERA ORAL TABLET 200-25-300 MG ADCRESEMBA ORAL CAPSULE 186 MG NP PACRIXIVAN ORAL CAPSULE 200 MG, 400 MG ADDAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG NP PA; SP

dapsone oral tablet 100 mg, 25 mg ADdaptomycin intravenous recon soln 500 mg ADDARAPRIM ORAL TABLET 25 MG AD PADAXBIA ORAL CAPSULE 333 MG NP PADELSTRIGO ORAL TABLET 100-300-300 MG AD

DESCOVY ORAL TABLET 200-25 MG ADdicloxacillin oral capsule 250 mg, 500 mg ADdidanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg

AD


7

Drug Tier Limits or RestrictionsDIFICID ORAL TABLET 200 MG ADDIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML, 40 MG/ML NP PA

DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG NP PA

DOVATO ORAL TABLET 50-300 MG ADdoxycycline hyclate oral capsule 100 mg, 50 mg AD

doxycycline hyclate oral tablet 100 mg ADdoxycycline monohydrate oral capsule 100 mg, 50 mg AD

E.E.S. 400 ORAL TABLET 400 MG PE.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML NP PA

EDURANT ORAL TABLET 25 MG ADefavirenz oral capsule 200 mg, 50 mg ADEMTRIVA ORAL CAPSULE 200 MG ADEMTRIVA ORAL SOLUTION 10 MG/ML ADentecavir oral tablet 0.5 mg, 1 mg P SPEPCLUSA ORAL TABLET 400-100 MG NP PA; SPEPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) P

EPIVIR HBV ORAL TABLET 100 MG PEPIVIR ORAL SOLUTION 10 MG/ML PEPIVIR ORAL TABLET 150 MG, 300 MG Pertapenem injection recon soln 1 gram ADERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML NP PA

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML NP PA

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG, 500 MG NP PA

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG NP PA

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml, 400 mg/5 ml

NP PA

erythromycin ethylsuccinate oral tablet 400 mg NP PA

erythromycin oral capsule,delayed release(dr/ec) 250 mg P


Drug Tier Limits or Restrictionserythromycin oral tablet 250 mg, 500 mg NP PAethambutol oral tablet 100 mg, 400 mg ADEVOTAZ ORAL TABLET 300-150 MG ADfamciclovir oral tablet 125 mg, 500 mg NP PA; QL (21 per 30 days)famciclovir oral tablet 250 mg NP PA; QL (60 per 30 days)fluconazole in dextrose(iso-o) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml AD

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml AD

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml P

fluconazole oral tablet 100 mg, 200 mg, 50 mg P

fluconazole oral tablet 150 mg P QL (2 Max Qty Per Fill Retail)flucytosine oral capsule 250 mg, 500 mg NP PAfosamprenavir oral tablet 700 mg ADFUZEON SUBCUTANEOUS RECON SOLN 90 MG AD SP

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

AD

gentamicin injection solution 20 mg/2 ml, 40 mg/ml AD

gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml AD

GENVOYA ORAL TABLET 150-150-200-10 MG AD

GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG, 68.5 MG NP PA

griseofulvin microsize oral suspension 125 mg/5 ml NP PA

griseofulvin microsize oral tablet 500 mg NP PAgriseofulvin ultramicrosize oral tablet 125 mg, 250 mg NP PA

GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 125 MG, 250 MG NP PA

HARVONI ORAL TABLET 90-400 MG NP PA; SPHEPSERA ORAL TABLET 10 MG P SPhydroxychloroquine oral tablet 200 mg ADINTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG AD


9

Drug Tier Limits or RestrictionsINTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

AD SP

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML AD SP

INVIRASE ORAL TABLET 500 MG ADISENTRESS HD ORAL TABLET 600 MG ADISENTRESS ORAL TABLET 400 MG ADISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG AD

isoniazid injection solution 100 mg/ml ADisoniazid oral solution 50 mg/5 ml ADisoniazid oral tablet 100 mg, 300 mg ADitraconazole oral capsule 100 mg NP PA; QL (30 per 30 days)itraconazole oral solution 10 mg/ml NP PAivermectin oral tablet 3 mg ADJULUCA ORAL TABLET 50-25 MG ADKALETRA ORAL TABLET 100-25 MG, 200-50 MG AD

KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG NP PA

ketoconazole oral tablet 200 mg NP PAKITABIS PAK INHALATION SOLUTION FOR NEBULIZATION 300 MG/5 ML P SP; QL (280 per 30 days)

lamivudine oral solution 10 mg/ml Plamivudine oral tablet 100 mg, 150 mg, 300 mg P

lamivudine-zidovudine oral tablet 150-300 mg AD

ledipasvir-sofosbuvir oral tablet 90-400 mg NP PA; SPLEVAQUIN ORAL TABLET 500 MG, 750 MG NP PAlevofloxacin oral solution 250 mg/10 ml Plevofloxacin oral tablet 250 mg, 500 mg, 750 mg P

LEXIVA ORAL SUSPENSION 50 MG/ML ADlinezolid in dextrose 5% intravenous piggyback 600 mg/300 ml AD

linezolid oral suspension for reconstitution 100 mg/5 ml AD

linezolid oral tablet 600 mg AD


Drug Tier Limits or Restrictionslinezolid-0.9% sodium chloride intravenous parenteral solution 600 mg/300 ml AD

lopinavir-ritonavir oral solution 400-100 mg/5 ml AD

MAVYRET ORAL TABLET 100-40 MG P PA; SPmefloquine oral tablet 250 mg ADmeropenem intravenous recon soln 1 gram, 500 mg AD

methenamine hippurate oral tablet 1 gram ADmetronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml AD

metronidazole oral capsule 375 mg ADmetronidazole oral tablet 250 mg, 500 mg ADmicafungin intravenous recon soln 100 mg, 50 mg AD

minocycline oral capsule 100 mg, 50 mg, 75 mg AD

MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 400 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7), 600-600 MG (28)-MG (28)

NP SP; PA

moxifloxacin oral tablet 400 mg NP PAnafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/100 ml AD

nafcillin injection recon soln 1 gram, 10 gram, 2 gram AD

nafcillin intravenous recon soln 1 gram, 2 gram AD

neomycin oral tablet 500 mg ADnevirapine oral suspension 50 mg/5 ml ADnevirapine oral tablet 200 mg ADnitrofurantoin macrocrystal oral capsule 100 mg, 50 mg AD

nitrofurantoin monohyd/m-cryst oral capsule 100 mg AD

NORVIR ORAL CAPSULE 100 MG ADNORVIR ORAL SOLUTION 80 MG/ML ADNOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NP PA

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG NP PA

NUZYRA ORAL TABLET 150 MG NP PAUCare Comprehensive FormularyEffective: October 1, 2020

11

Drug Tier Limits or Restrictionsnystatin oral powder 150 million unit, 500 million unit AD

nystatin oral suspension 100,000 unit/ml Pnystatin oral tablet 500,000 unit NP PAODEFSEY ORAL TABLET 200-25-25 MG ADofloxacin oral tablet 300 mg, 400 mg NP PAONMEL ORAL TABLET 200 MG NP PAoseltamivir oral capsule 30 mg P QL (20 per 30 days)oseltamivir oral capsule 45 mg, 75 mg P QL (10 per 30 days)oseltamivir oral suspension for reconstitution 6 mg/ml P QL (180 per 30 days)

oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml AD

oxacillin injection recon soln 1 gram, 10 gram, 2 gram AD

oxacillin intravenous recon soln 1 gram, 2 gram AD

paromomycin oral capsule 250 mg ADPCE ORAL TABLET, PARTICLES/CRYSTALS 333 MG, 500 MG NP PA

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML

P SP; QL (4 per 30 days)

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML P SP; QL (4 per 30 days)

PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML P SP; QL (4 per 30 days)

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML NP SP; PA

penicillin g potassium injection recon soln 20 million unit, 5 million unit AD

penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml AD

penicillin g sodium injection recon soln 5 million unit AD

penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml AD

penicillin v potassium oral tablet 250 mg, 500 mg AD

pentamidine inhalation recon soln 300 mg ADpentamidine injection recon soln 300 mg ADPIFELTRO ORAL TABLET 100 MG ADUCare Comprehensive FormularyEffective: October 1, 202012

Drug Tier Limits or Restrictionspiperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

AD

polymyxin b sulfate injection recon soln 500,000 unit AD

posaconazole oral tablet,delayed release (dr/ec) 100 mg NP PA

praziquantel oral tablet 600 mg ADpretomanid oral tablet 200 mg ADPREVYMIS INTRAVENOUS SOLUTION 240 MG/12 ML, 480 MG/24 ML AD SP

PREVYMIS ORAL TABLET 240 MG, 480 MG AD SPPREZCOBIX ORAL TABLET 800-150 MG-MG ADPREZISTA ORAL SUSPENSION 100 MG/ML ADPREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG AD

PRIFTIN ORAL TABLET 150 MG ADPYLERA ORAL CAPSULE 140-125-125 MG ADpyrazinamide oral tablet 500 mg ADquinidine gluconate oral tablet extended release 324 mg AD

quinidine sulfate oral tablet 200 mg, 300 mg AD

quinine sulfate oral capsule 324 mg ADREBETOL ORAL SOLUTION 40 MG/ML NP SP; PARELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION P QL (20 per 30 days)

RESCRIPTOR ORAL TABLET 200 MG ADRETROVIR INTRAVENOUS SOLUTION 10 MG/ML AD

RIBASPHERE ORAL TABLET 400 MG, 600 MG NP SP; PA

RIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK 600 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)

NP SP; PA

ribavirin oral capsule 200 mg P SPribavirin oral tablet 200 mg P SPrifabutin oral capsule 150 mg ADrifampin intravenous recon soln 600 mg ADrifampin oral capsule 150 mg, 300 mg AD


13

Drug Tier Limits or RestrictionsRIFATER ORAL TABLET 50-120-300 MG ADrimantadine oral tablet 100 mg ADritonavir oral tablet 100 mg ADSELZENTRY ORAL SOLUTION 20 MG/ML ADSELZENTRY ORAL TABLET 150 MG, 300 MG ADSIRTURO ORAL TABLET 100 MG, 20 MG ADSITAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG NP PA

sofosbuvir-velpatasvir oral tablet 400-100 mg NP PA; SP

SOLOSEC ORAL GRANULES DEL RELEASE IN PACKET 2 GRAM NP PA

SOVALDI ORAL TABLET 400 MG NP PA; SPSPORANOX ORAL CAPSULE 100 MG NP PASPORANOX ORAL SOLUTION 10 MG/ML NP PAstavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg AD

STRIBILD ORAL TABLET 150-150-200-300 MG AD

sulfadiazine oral tablet 500 mg ADsulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5 ml AD

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml AD

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg AD

sulfasalazine oral tablet 500 mg Psulfasalazine oral tablet,delayed release (dr/ec) 500 mg P

SUPRAX ORAL CAPSULE 400 MG PSUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML, 500 MG/5 ML

P

SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG NP PA

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG AD SP

SYMFI LO ORAL TABLET 400-300-300 MG ADSYMFI ORAL TABLET 600-300-300 MG ADSYMTUZA ORAL TABLET 800-150-200-10 MG AD


Drug Tier Limits or RestrictionsSYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5 ML AD SP

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG NP PA

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 12 MG/ML, 6 MG/ML NP PA

TECHNIVIE ORAL TABLET 12.5-75-50 MG NP PA; SPtenofovir disoproxil fumarate oral tablet 300 mg AD

terbinafine hcl oral tablet 250 mg Ptetracycline oral capsule 250 mg, 500 mg ADtinidazole oral tablet 250 mg, 500 mg ADTIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG AD

TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG AD

TOBI INHALATION SOLUTION FOR NEBULIZATION 300 MG/5 ML NP SP; PA; QL (280 per 30 days)

TOBI PODHALER INHALATION CAPSULE 28 MG NP SP; PA; QL (224 per 30 days)

TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG NP SP; PA

tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml NP SP; PA; QL (280 per 30 days)

tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml AD

tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml AD

TOLSURA ORAL CAPSULE, SOLID DISPERSION 65 MG NP PA

trimethoprim oral tablet 100 mg ADTRIUMEQ ORAL TABLET 600-50-300 MG ADTROGARZO INTRAVENOUS SOLUTION 200 MG/1.33 ML (150 MG/ML) AD

TRUVADA ORAL TABLET 200-300 MG ADvalacyclovir oral tablet 1 gram, 500 mg P QL (30 per 30 days)valganciclovir oral recon soln 50 mg/ml ADvalganciclovir oral tablet 450 mg ADVALTREX ORAL TABLET 1 GRAM, 500 MG NP PAVANCOCIN ORAL CAPSULE 125 MG, 250 MG NP PA


15

Drug Tier Limits or Restrictionsvancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg AD

vancomycin oral capsule 125 mg, 250 mg PVEMLIDY ORAL TABLET 25 MG NP SP; PAVFEND ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML (40 MG/ML)

NP PA

VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG-75 MG -50 MG/250 MG NP PA; SP

VIRACEPT ORAL TABLET 250 MG, 625 MG ADVIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) AD SP

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG AD SP

voriconazole intravenous recon soln 200 mg AD

voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) NP PA

voriconazole oral tablet 200 mg, 50 mg ADVOSEVI ORAL TABLET 400-100-100 MG P PA; SPXENLETA INTRAVENOUS SOLUTION 150 MG/15 ML AD PA

XENLETA ORAL TABLET 600 MG AD PAXIFAXAN ORAL TABLET 200 MG, 550 MG AD PAXOFLUZA ORAL TABLET 20 MG, 40 MG NP PA; QL (2 per 30 days)ZEPATIER ORAL TABLET 50-100 MG NP PA; SPzidovudine oral capsule 100 mg ADzidovudine oral syrup 10 mg/ml ADzidovudine oral tablet 300 mg ADZITHROMAX ORAL PACKET 1 GRAM NP PAZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML

NP PA

ZITHROMAX ORAL TABLET 250 MG, 500 MG NP PA

ZITHROMAX TRI-PAK ORAL TABLET 500 MG NP PA

ZOVIRAX ORAL CAPSULE 200 MG NP PAZOVIRAX ORAL SUSPENSION 200 MG/5 ML NP PAZOVIRAX ORAL TABLET 400 MG, 800 MG NP PA


Drug Tier Limits or RestrictionsANTINEOPLASTIC AGENTSabiraterone oral tablet 250 mg AD PA; SPAFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AD PA; SP

AFINITOR ORAL TABLET 10 MG AD PA; SPALECENSA ORAL CAPSULE 150 MG AD PA; SP; QL (240 per 30 days)ALUNBRIG ORAL TABLET 180 MG, 90 MG AD PA; SPALUNBRIG ORAL TABLET 30 MG AD PA; SP; QL (180 per 30 days)ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23) AD PA; SP

anastrozole oral tablet 1 mg ADAYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG AD PA; QL (30 per 30 days)

BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG AD PA

bexarotene oral capsule 75 mg AD PAbicalutamide oral tablet 50 mg ADbortezomib intravenous recon soln 3.5 mg ADBOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG AD PA; SP

BRAFTOVI ORAL CAPSULE 50 MG, 75 MG AD PA; SPBRUKINSA ORAL CAPSULE 80 MG AD PA; SPCABOMETYX ORAL TABLET 20 MG AD PA; SP; QL (30 per 30 days)CABOMETYX ORAL TABLET 40 MG, 60 MG AD PA; SPCALQUENCE ORAL CAPSULE 100 MG AD PA; SPcapecitabine oral tablet 150 mg, 500 mg AD SPCAPRELSA ORAL TABLET 100 MG, 300 MG AD PA; SPCOMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)

AD PA; SP

COPIKTRA ORAL CAPSULE 15 MG, 25 MG AD PA; SPCOTELLIC ORAL TABLET 20 MG AD PA; SP; QL (63 per 30 days)cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg AD

CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG AD

DAURISMO ORAL TABLET 100 MG, 25 MG AD PA; SPdiclofenac sodium topical gel 3 % P PA; QL (100 per 21 days)


17

Drug Tier Limits or RestrictionsDROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG AD

EMCYT ORAL CAPSULE 140 MG ADERIVEDGE ORAL CAPSULE 150 MG AD PA; SPERLEADA ORAL TABLET 60 MG AD PA; SPerlotinib oral tablet 100 mg, 150 mg, 25 mg AD PA; SP

etoposide oral capsule 50 mg ADeverolimus (antineoplastic) oral tablet 2.5 mg, 5 mg, 7.5 mg AD PA; SP; QL (30 per 30 days)

exemestane oral tablet 25 mg ADFARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG AD PA; SP

floxuridine injection recon soln 0.5 gram AD SPfluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml

AD

fluorouracil topical cream 5 % ADfluorouracil topical solution 2 %, 5 % ADflutamide oral capsule 125 mg ADGILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG AD PA; SP; QL (30 per 30 days)

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG AD

hydroxyurea oral capsule 500 mg ADIBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG AD PA; SP

ICLUSIG ORAL TABLET 15 MG AD PA; SP; QL (60 per 30 days)ICLUSIG ORAL TABLET 45 MG AD PA; SP; QL (30 per 30 days)IDHIFA ORAL TABLET 100 MG, 50 MG AD PA; SPimatinib oral tablet 100 mg AD PA; SPimatinib oral tablet 400 mg AD PA; SP; QL (60 per 30 days)IMBRUVICA ORAL CAPSULE 140 MG AD PA; SP; QL (120 per 30 days)IMBRUVICA ORAL CAPSULE 70 MG AD PA; SPIMBRUVICA ORAL TABLET 140 MG AD PA; SP; QL (120 per 30 days)IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG AD PA; SP

INLYTA ORAL TABLET 1 MG, 5 MG AD PA; SPINTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

AD SP


Drug Tier Limits or RestrictionsINTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML AD SP

IRESSA ORAL TABLET 250 MG AD PA; SPJAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG AD PA; SP

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG

AD PA; SP

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3)

AD PA; SP

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2)

AD PA; SP

letrozole oral tablet 2.5 mg ADLEUKERAN ORAL TABLET 2 MG ADleuprolide subcutaneous kit 1 mg/0.2 ml AD SPLONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG AD PA; SP

LORBRENA ORAL TABLET 100 MG, 25 MG AD PA; SPLUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG

AD PA; SP

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG AD PA; SP


LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG AD PA; SP

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 30 MG

AD PA; SP

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED) AD PA; SP

LYNPARZA ORAL TABLET 100 MG, 150 MG AD PA; SPMATULANE ORAL CAPSULE 50 MG AD SPMEGACE ES ORAL SUSPENSION 625 MG/5 ML (125 MG/ML) NP PA


19

Drug Tier Limits or Restrictionsmegestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml)

P PA

megestrol oral suspension 625 mg/5 ml (125 mg/ml) NP

megestrol oral tablet 20 mg, 40 mg P PAMEKINIST ORAL TABLET 0.5 MG, 2 MG AD PA; SPMEKTOVI ORAL TABLET 15 MG AD PA; SPmercaptopurine oral tablet 50 mg ADmethotrexate sodium (pf) injection recon soln 1 gram AD

methotrexate sodium (pf) injection solution 25 mg/ml AD

methotrexate sodium injection solution 25 mg/ml AD

methotrexate sodium oral tablet 2.5 mg ADMYLERAN ORAL TABLET 2 MG ADNERLYNX ORAL TABLET 40 MG AD PA; SPNEXAVAR ORAL TABLET 200 MG AD PA; SPnilutamide oral tablet 150 mg ADNINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG AD PA; SP; QL (3 per 30 days)

OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 22.5 MG/0.4 ML NP PA

PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1), 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)

AD PA; SP

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG AD SP

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG AD PA; SP

RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (120 MG/ML), 1600 MG/13.4 ML (120 MG/ML)

AD PA

ROZLYTREK ORAL CAPSULE 100 MG AD PA; SP; QL (30 per 30 days)ROZLYTREK ORAL CAPSULE 200 MG AD PA; SP; QL (90 per 30 days)RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG AD PA; SP

RYDAPT ORAL CAPSULE 25 MG AD PA; SPSIKLOS ORAL TABLET 1,000 MG, 100 MG ADSPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG AD PA; SP


Drug Tier Limits or RestrictionsSTIVARGA ORAL TABLET 40 MG AD PA; SPSUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG AD PA; SP

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG AD SP

TABLOID ORAL TABLET 40 MG ADTAFINLAR ORAL CAPSULE 50 MG, 75 MG AD PA; SP; QL (120 per 30 days)TAGRISSO ORAL TABLET 40 MG, 80 MG AD PA; SP; QL (30 per 30 days)TALZENNA ORAL CAPSULE 0.25 MG, 1 MG AD PA; SPtamoxifen oral tablet 10 mg, 20 mg ADTARGRETIN TOPICAL GEL 1 % ADTASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG AD PA; SP

TAZVERIK ORAL TABLET 200 MG AD PAtemozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg AD SP

TIBSOVO ORAL TABLET 250 MG AD PA; SPtoremifene oral tablet 60 mg ADtretinoin (antineoplastic) oral capsule 10 mg AD

TYKERB ORAL TABLET 250 MG AD PA; SPVALCHLOR TOPICAL GEL 0.016 % AD SPVECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML)

AD SP

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG AD PA; SP

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG

AD PA; SP

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG AD PA; SP

VITRAKVI ORAL CAPSULE 100 MG, 25 MG AD PA; SPVITRAKVI ORAL SOLUTION 20 MG/ML AD PA; SPVIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG AD PA; SP

VOTRIENT ORAL TABLET 200 MG AD PA; SPXALKORI ORAL CAPSULE 200 MG, 250 MG AD PA; SPXOSPATA ORAL TABLET 40 MG AD PA; SP


21

Drug Tier Limits or RestrictionsXPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5), 60 MG/WEEK (20 MG X 3), 80 MG/WEEK (20 MG X 4), 80MG TWICE WEEK (160 MG/WEEK)

AD PA; SP

XPOVIO ORAL TABLET 40 MG/WEEK (20 MG X 2), 40MG TWICE WEEK (80 MG/WEEK), 60MG TWICE WEEK (120 MG/WEEK)

AD PA

XTANDI ORAL CAPSULE 40 MG AD PA; SPYONDELIS INTRAVENOUS RECON SOLN 1 MG AD PA

ZEJULA ORAL CAPSULE 100 MG AD PA; QL (90 per 30 days)ZELBORAF ORAL TABLET 240 MG AD PA; SPZOLINZA ORAL CAPSULE 100 MG AD SPZYDELIG ORAL TABLET 100 MG, 150 MG AD PAZYKADIA ORAL CAPSULE 150 MG AD PA; SPZYTIGA ORAL TABLET 500 MG AD PA; SPANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINESACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML AD

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

AD

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

AD

AFLURIA QD 2020-21(3YR UP)(PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

AD

AFLURIA QD 2020-21(6-35MO)(PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML

AD

AFLURIA QUAD 2020-2021(6MO UP) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

AD

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML AD

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML AD

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML AD


Drug Tier Limits or RestrictionsDAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML

AD

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML AD

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML AD

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML AD

FLUAD 2020-2021 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

AD

FLUAD QUAD 2020-21(65Y UP)(PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

AD

FLUARIX QUAD 2020-2021 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

AD

FLUBLOK QUAD 2020-2021 (PF) INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)/0.5 ML

AD

FLUCELVAX QUAD 2020-2021 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

AD

FLUCELVAX QUAD 2020-2021 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

AD

FLULAVAL QUAD 2020-2021 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

AD

FLUMIST QUAD 2020-2021 NASAL NASAL SPRAY SYRINGE 10EXP6.5-7.5 FF UNIT/0.2 ML

AD

FLUZONE HIGHDOSE QUAD 20-21 PF INTRAMUSCULAR SYRINGE 240 MCG/0.7 ML

AD

FLUZONE QUAD 2020-2021 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

AD

FLUZONE QUAD 2020-2021 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

AD

FLUZONE QUAD 2020-2021 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

AD


23

Drug Tier Limits or RestrictionsGAMASTAN S/D INTRAMUSCULAR SOLUTION 15-18 % RANGE AD SP

GAMMAGARD LIQUID INJECTION SOLUTION 10 % AD SP

GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM

AD SP

GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %)

AD SP

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML AD

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML AD

HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

AD

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

AD

HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION 20 MCG/0.5 ML AD

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML AD

HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)

AD SP

HIZENTRA SUBCUTANEOUS SYRINGE 1 GRAM/5 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)

AD SP

HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE 110 UNIT/0.5 ML

AD SP

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT AD

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML AD

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF/0.5ML AD

IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML AD


Drug Tier Limits or RestrictionsIXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML AD

KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML AD

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML AD

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML AD

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML AD

MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG /0.5 ML (FINAL)

AD

MENVEO MENCYW-135 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X 3/ 0.5 ML (FINAL)

AD

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML AD

PALFORZIA (LEVEL 1) ORAL CAPSULE, SPRINKLE 3 MG (1 MG X 3) AD PA; QL (45 Max Qty Per Fill

Retail)PALFORZIA (LEVEL 2) ORAL CAPSULE, SPRINKLE 6 MG (1 MG X 6) AD PA; QL (90 Max Qty Per Fill

Retail)PALFORZIA (LEVEL 3) ORAL CAPSULE, SPRINKLE 12 MG (1 MG X 2, 10 MG X 1) AD PA; QL (45 Max Qty Per Fill

Retail)PALFORZIA (LEVEL 4) ORAL CAPSULE, SPRINKLE 20 MG AD PA; QL (15 Max Qty Per Fill



Retail)PALFORZIA (LEVEL 7) ORAL CAPSULE, SPRINKLE 120 MG (20 MG X 1, 100 MG X 1)

AD PA; QL (30 Max Qty Per Fill Retail)

PALFORZIA (LEVEL 8) ORAL CAPSULE, SPRINKLE 160 MG (20 MG X 3, 100 MG X1)


PALFORZIA (LEVEL 9) ORAL CAPSULE, SPRINKLE 200 MG (100 MG X 2) AD PA; QL (30 Max Qty Per Fill

Retail)PALFORZIA (LEVEL 10) ORAL CAPSULE, SPRINKLE 240 MG (20 MG X 2, 100 MG X 2)


PALFORZIA (LEVEL 11 UP-DOSE) ORAL POWDER IN PACKET 300 MG AD PA; QL (15 Max Qty Per Fill

Retail)


25

Drug Tier Limits or RestrictionsPALFORZIA INITIAL DOSE ORAL CAPSULE, SPRINKLE 0.5/1/1.5/3/6 MG AD PA; QL (13 Max Qty Per Fill

Retail)PALFORZIA LEVEL 11 MAINTENANCE ORAL POWDER IN PACKET 300 MG AD PA; QL (30 Max Qty Per Fill

Retail)PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML AD

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML AD

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML AD

PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML

AD

PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

AD

PNEUMOVAX-23 INJECTION SOLUTION 25 MCG/0.5 ML AD

PNEUMOVAX-23 INJECTION SYRINGE 25 MCG/0.5 ML AD

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 0.5 ML AD

PRIVIGEN INTRAVENOUS SOLUTION 10 % AD SPPROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5

AD

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

AD

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT

AD

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML

AD

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML AD

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML AD

ROTATEQ VACCINE ORAL SOLUTION 2 ML ADSHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML

AD


Drug Tier Limits or RestrictionsSHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG

AD

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,000 UNIT/0.5 ML

AD

TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML AD

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML AD

tetanus,diphtheria tox ped(pf) intramuscular suspension 5-25 lf unit/0.5 ml

AD

tetanus-diphtheria toxoids-td intramuscular suspension 2-2 lf unit/0.5 ml AD

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML AD

TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML AD

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML AD

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML AD

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML

AD

VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2 ML NP PA

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2 BILLION UNIT AD

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML

AD

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML

AD

AUTONOMIC DRUGSacebutolol oral capsule 200 mg, 400 mg NP PAADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

P QL (1 Max Qty Per Fill Retail)

ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION

P QL (12 per 30 days)


27

Drug Tier Limits or RestrictionsAIRDUO RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113-14 MCG/ACTUATION, 232-14 MCG/ACTUATION, 55-14 MCG/ACTUATION

NP PA; QL (1 per 30 days)

albuterol hfa 90 mcg inhaler 90 mcg/actuation P Prasco; QL (36 Max Qty Per

Fill Retail)albuterol hfa 90 mcg inhaler 90 mcg/actuation P Par; QL (14 Max Qty Per Fill

Retail)albuterol hfa 90 mcg inhaler 90 mcg/actuation P Teva; QL (17 Max Qty Per Fill

Retail)albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation P QL (14 per 30 days)

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

P

albuterol sulfate oral syrup 2 mg/5 ml Palbuterol sulfate oral tablet 2 mg, 4 mg NP PAalbuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg NP PA

alfuzosin oral tablet extended release 24 hr 10 mg P



P


P




P

ALLERGY-CONGESTION RELIEF-D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG

P

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION NP PA

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG NP PA; QL (30 per 30 days)


Drug Tier Limits or RestrictionsARICEPT ORAL TABLET 10 MG, 23 MG, 5 MG NP PA

atenolol oral tablet 100 mg, 25 mg, 50 mg Patenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg AD

atropine injection solution 0.4 mg/ml, 1 mg/ml AD

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml AD

baclofen oral tablet 10 mg, 20 mg ADbenztropine injection solution 1 mg/ml ADbenztropine oral tablet 0.5 mg, 1 mg, 2 mg ADBETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG NP PA

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NP PA

betaxolol oral tablet 10 mg, 20 mg NP PAbethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg AD

BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-4.8 MCG NP PA; QL (11 per 30 days)

bisoprolol fumarate oral tablet 10 mg, 5 mg P

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg AD

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

NP PA

brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg/5 ml AD

BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML NP PA; QL (120 per 30 days)

budesonide-formoterol inhalation hfa aerosol inhaler 160-4.5 mcg/actuation, 80-4.5 mcg/actuation

NP PA

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG NP PA

BYVALSON ORAL TABLET 5-80 MG NP PACARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG NP PA

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 4 MG, 8 MG NP PA


29

Drug Tier Limits or Restrictionscarisoprodol-aspirin-codeine oral tablet 200-325-16 mg AD PA

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg P

carvedilol phosphate oral capsule, er multiphase 24 hr 10 mg, 20 mg, 40 mg, 80 mg

NP PA

cetirizine-pseudoephedrine oral tablet extended release 12 hr 5-120 mg P

cevimeline oral capsule 30 mg ADCHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG P

CHANTIX ORAL TABLET 0.5 MG PCHANTIX ORAL TABLET 1 MG ADCHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

P

chlorzoxazone oral tablet 500 mg ADCLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR 2.5-120 MG NP PA

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg AD

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr AD QL (4 per 30 days)

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION P QL (8 per 30 days)

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG

NP PA

COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG NP PA

CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG NP PA

CORZIDE ORAL TABLET 40-5 MG, 80-5 MG NP PAcyclobenzaprine oral tablet 10 mg, 5 mg ADdantrolene oral capsule 100 mg, 25 mg, 50 mg AD

dicyclomine oral capsule 10 mg ADdicyclomine oral solution 10 mg/5 ml ADdicyclomine oral tablet 20 mg ADdiphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml AD


Drug Tier Limits or Restrictionsdiphenoxylate-atropine oral tablet 2.5-0.025 mg AD

donepezil oral tablet 10 mg, 5 mg Pdonepezil oral tablet 23 mg NP PAdonepezil oral tablet,disintegrating 10 mg, 5 mg P

doxazosin oral tablet 1 mg, 2 mg, 4 mg P QL (30 per 30 days)doxazosin oral tablet 8 mg P QL (60 per 30 days)DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION


epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml NP PA; Non-Mylan; QL (2 per 30

days)epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml P Mylan; QL (2 per 30 days)

epinephrine injection solution 1 mg/ml, 1 mg/ml (1 ml) AD

epinephrine injection syringe 0.1 mg/ml ADEPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML NP PA; QL (2 per 30 days)

EPIPEN INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML NP PA; QL (2 per 30 days)

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML NP PA; QL (2 per 30 days)

EPIPEN JR INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML NP PA; QL (2 per 30 days)

ergoloid oral tablet 1 mg ADEXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24 HOUR, 4.6 MG/24 HR, 9.5 MG/24 HR

NP PA

FLOMAX ORAL CAPSULE 0.4 MG NP PAfluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation


fluticasone propion-salmeterol inhalation blister with device 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose


galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg NP PA

galantamine oral solution 4 mg/ml NP PAgalantamine oral tablet 12 mg, 4 mg, 8 mg NP PA


31

Drug Tier Limits or Restrictionsglycopyrrolate oral tablet 1 mg, 2 mg ADguanidine oral tablet 125 mg ADHEMANGEOL ORAL SOLUTION 4.28 MG/ML NP PAhyoscyamine sulfate oral elixir 0.125 mg/5 ml AD

hyoscyamine sulfate oral tablet 0.125 mg ADhyoscyamine sulfate oral tablet extended release 12 hr 0.375 mg AD

hyoscyamine sulfate oral tablet,disintegrating 0.125 mg AD

hyoscyamine sulfate sublingual tablet 0.125 mg AD

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION NP PA; QL (1 per 30 days)

INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 160 MG, 60 MG, 80 MG

NP PA

INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG NP PA

INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG NP PA

ipratropium bromide inhalation solution 0.02 % P

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

P

JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR 0.5-0.4 MG NP PA

KAPSPARGO SPRINKLE ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 200 MG, 25 MG, 50 MG

NP PA

labetalol intravenous solution 5 mg/ml ADlabetalol oral tablet 100 mg, 200 mg, 300 mg P

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml

NP PA

levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation NP PA

LONHALA MAGNAIR REFILL INHALATION SOLUTION FOR NEBULIZATION 25 MCG/ML NP PA; QL (60 per 30 days)

LONHALA MAGNAIR STARTER INHALATION SOLUTION FOR NEBULIZATION 25 MCG/ML NP PA


Drug Tier Limits or RestrictionsLOPRESSOR ORAL TABLET 100 MG, 50 MG NP PALORATA-DINE D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG P



metaproterenol oral syrup 10 mg/5 ml ADmetaproterenol oral tablet 10 mg, 20 mg NP PAmetaxalone oral tablet 800 mg ADmethocarbamol oral tablet 500 mg, 750 mg AD

methscopolamine oral tablet 2.5 mg, 5 mg ADmethyldopa oral tablet 250 mg, 500 mg ADmethyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg AD

methyldopate intravenous solution 250 mg/5 ml AD

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

P

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg, 50-25 mg AD

metoprolol tartrate intravenous solution 5 mg/5 ml AD

metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg P

midodrine oral tablet 10 mg, 2.5 mg, 5 mg ADnadolol oral tablet 20 mg, 40 mg, 80 mg PNAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NP PA

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

NP PA

NICORELIEF BUCCAL GUM 2 MG, 4 MG Pnicotine (polacrilex) buccal gum 2 mg, 4 mg P

nicotine (polacrilex) buccal lozenge 2 mg, 4 mg P

nicotine (polacrilex) buccal mini lozenge 2 mg, 4 mg P


33

Drug Tier Limits or Restrictionsnicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr P

NICOTROL INHALATION CARTRIDGE 10 MG NP PA

NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML NP PA

orphenadrine citrate injection solution 30 mg/ml AD

orphenadrine citrate oral tablet extended release 100 mg AD

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML NP PA; QL (120 per 30 days)

pilocarpine hcl oral tablet 5 mg, 7.5 mg ADpindolol oral tablet 10 mg, 5 mg Pprazosin oral capsule 1 mg, 2 mg, 5 mg ADPROAIR DIGIHALER INHALATION AERO POWDR BREATH ACT W/SENSOR 90 MCG/ACTUATION

NP PA

PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION P QL (17 per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION

P PA; QL (2 per 30 days)

propranolol intravenous solution 1 mg/ml ADpropranolol oral capsule,extended release 24 hr 120 mg, 160 mg NP PA

propranolol oral capsule,extended release 24 hr 60 mg, 80 mg P

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) P

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg P

propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25 mg AD

PROVENTIL HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION P

pyridostigmine bromide oral tablet 60 mg ADRAPAFLO ORAL CAPSULE 4 MG, 8 MG NP PARAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR 16 MG, 24 MG, 8 MG NP PA

RAZADYNE ORAL TABLET 12 MG, 4 MG, 8 MG NP PA


Drug Tier Limits or Restrictionsrivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg NP PA

rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr

NP PA

SEEBRI NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 15.6 MCG NP PA; QL (60 per 30 days)

SEMPREX-D ORAL CAPSULE 8-60 MG NP PASEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE P

silodosin oral capsule 4 mg, 8 mg NP PASORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG AD

SOTALOL AF ORAL TABLET 120 MG, 160 MG, 80 MG P

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg P

SOTYLIZE ORAL SOLUTION 5 MG/ML NP PASPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION


SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG P QL (90 per 30 days)

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION P QL (4 per 30 days)

STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION NP PA; QL (4 per 30 days)

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION

P

SYMJEPI INJECTION SYRINGE 0.15 MG/0.3 ML, 0.3 MG/0.3 ML P QL (2 per 30 days)

tamsulosin oral capsule 0.4 mg PTENORETIC 100 ORAL TABLET 100-25 MG NP PATENORETIC 50 ORAL TABLET 50-25 MG NP PATENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG NP PA

terazosin oral capsule 1 mg, 2 mg, 5 mg P QL (30 per 30 days)terazosin oral capsule 10 mg P QL (60 per 30 days)terbutaline oral tablet 2.5 mg, 5 mg ADterbutaline subcutaneous solution 1 mg/ml AD


35

Drug Tier Limits or Restrictionstimolol maleate oral tablet 10 mg, 20 mg, 5 mg NP PA

tizanidine oral capsule 2 mg, 4 mg, 6 mg ADtizanidine oral tablet 2 mg, 4 mg ADTOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 200 MG, 25 MG, 50 MG

NP PA

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG NP PA

trihexyphenidyl oral elixir 0.4 mg/ml ADtrihexyphenidyl oral tablet 2 mg, 5 mg ADUTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 27.5-15.6 MCG

NP PA

VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION P QL (8 per 30 days)

WIXELA INHUB INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


XOPENEX CONCENTRATE INHALATION SOLUTION FOR NEBULIZATION 1.25 MG/0.5 ML

NP PA

XOPENEX HFA INHALATION HFA AEROSOL INHALER 45 MCG/ACTUATION P

XOPENEX INHALATION SOLUTION FOR NEBULIZATION 0.31 MG/3 ML, 0.63 MG/3 ML, 1.25 MG/3 ML

NP PA

YUPELRI INHALATION SOLUTION FOR NEBULIZATION 175 MCG/3 ML NP PA; QL (30 per 30 days)

ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG NP PA

BLOOD FORMATION, COAGULATION, THROMBOSISADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT

AD SP

ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT

AD


Drug Tier Limits or RestrictionsAFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/-) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/-) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE

AD SP

AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR 25-200 MG P

ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML

AD SP

ALPHANINE SD INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT

AD SP

ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT

AD

anagrelide oral capsule 0.5 mg, 1 mg ADARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

P SP

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML

P SP

ARIXTRA SUBCUTANEOUS SYRINGE 10 MG/0.8 ML, 2.5 MG/0.5 ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML

P SP

aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg NP PA

BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR 27-1-430 MG AD

BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT

AD SP

BEVYXXA ORAL CAPSULE 40 MG, 80 MG NP PABRILINTA ORAL TABLET 60 MG, 90 MG NP PAbutalbital-aspirin-caffeine oral capsule 50-325-40 mg AD

butalbital-aspirin-caffeine oral tablet 50-325-40 mg AD


37

Drug Tier Limits or RestrictionsCABLIVI INJECTION KIT 11 MG AD PA; SPCABLIVI INJECTION RECON SOLN 11 MG AD PA; SPCATHFLO ACTIVASE INTRA-CATHETER RECON SOLN 2 MG AD

cilostazol oral tablet 100 mg, 50 mg ADclopidogrel oral tablet 300 mg, 75 mg PCOAGADEX INTRAVENOUS RECON SOLN 250 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE

AD

COMPLETE NATAL DHA ORAL COMBO PACK 29-1-250-200 MG AD

desmopressin injection solution 4 mcg/ml ADdesmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) AD

desmopressin oral tablet 0.1 mg, 0.2 mg ADdipyridamole oral tablet 25 mg, 50 mg, 75 mg P

EFFIENT ORAL TABLET 10 MG, 5 MG NP PAELIQUIS DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 5 MG (74 TABS) NP PA

ELIQUIS ORAL TABLET 2.5 MG, 5 MG NP PAELITE-OB 400 ORAL CAPSULE 35-5-1.2-400 MG AD

ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT

AD SP

enoxaparin subcutaneous solution 300 mg/3 ml P SP

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

P SP

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

P PA; SP

ESPEROCT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

AD SP


Drug Tier Limits or RestrictionsFEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 400-650 UNIT, 651-1,200 UNIT

AD SP

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

NP PA

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML

P SP

FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML AD PA; SP; QL (2 per 30 days)

GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6 ML AD SP

GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML AD SP

HELIXATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

AD SP

HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7 ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4 ML

AD PA; SP

HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1,500 UNIT AD SP

HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT AD SP

HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT AD SP

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1,501-2,000 UNIT AD SP

HEP FLUSH-10 (PF) INTRAVENOUS SOLUTION 10 UNIT/ML AD

heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

AD

heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml

AD

heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) AD


39

Drug Tier Limits or Restrictionsheparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml

AD

heparin flush(porcine)-0.9nacl intravenous kit 100 unit/ml AD

heparin lock flush (porcine) intravenous syringe 100 unit/ml AD

HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 10 UNIT/ML AD

HEPARIN LOCK INTRAVENOUS SOLUTION 100 UNIT/ML AD

HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 10 UNIT/ML, 100 UNIT/ML

AD

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

AD

heparin, porcine (pf) injection solution 1,000 unit/ml, 5,000 unit/0.5 ml AD

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml AD

heparin, porcine (pf) intravenous syringe 1 unit/ml, 100 unit/ml AD

HUMATE-P INTRAVENOUS RECON SOLN 1,000-2,400 UNIT, 250-600 UNIT, 500-1,200 UNIT

AD SP

IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,500 (+/-) UNIT, 500 (+/-) UNIT

AD SP

IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT

AD SP

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

P

JIVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

AD SP

KOATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

AD SP


Drug Tier Limits or RestrictionsKOGENATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

AD SP

KOVALTRY INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

AD SP

LEUKINE INJECTION RECON SOLN 250 MCG AD SP

LOVENOX SUBCUTANEOUS SOLUTION 300 MG/3 ML NP SP; PA

LOVENOX SUBCUTANEOUS SYRINGE 100 MG/ML, 120 MG/0.8 ML, 150 MG/ML, 30 MG/0.3 ML, 40 MG/0.4 ML, 60 MG/0.6 ML, 80 MG/0.8 ML

NP SP; PA

MONOCLATE-P INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT AD SP

MONONINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT AD SP

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) AD SP

MYNATAL ORAL CAPSULE 65 MG IRON- 1 MG AD

MYNATAL PLUS ORAL TABLET 65 MG IRON- 1 MG AD

MYNATAL-Z ORAL TABLET 65 MG IRON- 1 MG AD

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML AD PA; SP; QL (2 per 30 days)

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML AD PA; SP; QL (2 per 30 days)

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML AD PA; SP

NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML AD PA; SP

NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML AD PA; SP

NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML AD PA; SP

NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

AD


41

Drug Tier Limits or RestrictionsNOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG)

AD SP

NUWIQ INTRAVENOUS RECON SOLN 1000 (+/-) UNIT, 2,000 (+/-) UNIT, 2,500 UNIT, 250 (+/-) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT

AD SP

OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE AD

pentoxifylline oral tablet extended release 400 mg AD

PLAVIX ORAL TABLET 300 MG, 75 MG NP PAPNV OB+DHA ORAL COMBO PACK 27-1-50-250 MG AD

PNV-DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG AD

PNV-OMEGA ORAL CAPSULE 28-1-300 MG ADPNV-SELECT ORAL TABLET 27-1 MG ADPR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR 29-1-400 MG AD

PR NATAL 400 ORAL COMBO PACK 29-1-400 MG AD

PR NATAL 430 EC ORAL COMBO PACK,TABLET AND CAP,DR 29-1-430 MG AD

PR NATAL 430 ORAL COMBO PACK 29 MG IRON-1 MG -430 MG AD

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG P

prasugrel oral tablet 10 mg, 5 mg NP PAPRENATABS FA ORAL TABLET 29-1 MG ADPRENATABS RX ORAL TABLET 29 MG IRON- 1 MG AD

PRENATAL LOW IRON ORAL TABLET 27 MG IRON- 1 MG AD

PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 27 MG IRON- 1 MG AD

PRENATAL PLUS ORAL TABLET 29 MG IRON- 1 MG AD

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

NP SP; PA


Drug Tier Limits or RestrictionsPROFILNINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT

AD SP

PROMACTA ORAL POWDER IN PACKET 12.5 MG AD PA; SP

PROMACTA ORAL POWDER IN PACKET 25 MG AD SP

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG AD PA; SP

REBINYN INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 500 (+/-) UNIT

AD SP

REBLOZYL SUBCUTANEOUS RECON SOLN 25 MG, 75 MG NP PA

RECOMBINATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

AD SP

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

P PA; SP

RIXUBIS INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT

AD SP

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG NP PA

SE-NATAL 19 CHEWABLE ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG AD

TL-SELECT ORAL CAPSULE 29-1.25-55-325 MG AD

tranexamic acid oral tablet 650 mg ADTRIADVANCE ORAL TABLET 90-1-50 MG ADTRINATAL RX 1 ORAL TABLET 60 MG IRON-1 MG AD

TRINATE ORAL TABLET 28 MG IRON- 1 MG ADTRIVEEN-ONE ORAL CAPSULE 27 MG IRON-1 MG -250 MG AD

TRIVEEN-PRX RNF ORAL CAPSULE 26-1.2-55-300 MG AD

UDENYCA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML AD PA; SP; QL (2 per 30 days)

VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR 27-1-430 MG AD


43

Drug Tier Limits or RestrictionsVINACAL ORAL TABLET 27-1-50 MG ADVINATE CARE ORAL TABLET,CHEWABLE 40 MG IRON- 1 MG AD

VINATE GT ORAL TABLET 90-1-50 MG ADVINATE M ORAL TABLET 27 MG IRON-1 MG ADVINATE ONE ORAL TABLET 60 MG IRON-1 MG AD

VINATE ULTRA ORAL TABLET 90-1-50 MG ADVIRT-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG AD

VIRT-PN ORAL TABLET 27-1 MG ADVIRT-PN PLUS ORAL CAPSULE 28-1-300 MG AD

VIRT-SELECT ORAL CAPSULE 29-1.25-55-325 MG AD

VITAFOL-OB ORAL TABLET 65-1 MG ADVOL-NATE ORAL TABLET 28 MG IRON- 1 MG AD

VONVENDI INTRAVENOUS RECON SOLN 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE

AD

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg AD

WILATE INTRAVENOUS RECON SOLN 1,000-1,000 UNIT, 450-450 UNIT, 500-500 UNIT, 900-900 UNIT

AD SP

XARELTO DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9)

NP PA

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG P

XARELTO ORAL TABLET 2.5 MG NP PAXYNTHA INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

AD SP

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

AD SP

YOSPRALA ORAL TABLET,IR,DELAYED REL,BIPHASIC 325-40 MG, 81-40 MG NP PA

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML AD PA; SP


Drug Tier Limits or RestrictionsZATEAN-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG AD

ZATEAN-PN PLUS ORAL CAPSULE 28-1-300 MG AD

ZONTIVITY ORAL TABLET 2.08 MG NP PACARDIOVASCULAR DRUGSACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG NP PA

ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG NP PA

acebutolol oral capsule 200 mg, 400 mg NP PAacetazolamide oral capsule, extended release 500 mg AD

acetazolamide oral tablet 125 mg, 250 mg ADacetazolamide sodium injection recon soln 500 mg AD

ADALAT CC ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG, 90 MG NP PA

ADCIRCA ORAL TABLET 20 MG NP PA; SP; QL (60 per 30 days)ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG NP PA


aliskiren oral tablet 150 mg, 300 mg NP PAALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG NP PA

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 20 MG, 40 MG, 60 MG NP PA

ALYQ ORAL TABLET 20 MG NP PAambrisentan oral tablet 10 mg, 5 mg NP PAamiloride oral tablet 5 mg ADamiloride-hydrochlorothiazide oral tablet 5-50 mg AD

amiodarone intravenous solution 50 mg/ml ADamiodarone oral tablet 100 mg, 200 mg, 400 mg AD

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg P

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

NP PA


45

Drug Tier Limits or Restrictionsamlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

P

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg NP PA

amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg P

amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

P

ANTARA ORAL CAPSULE 30 MG, 90 MG NP PAaspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg NP PA

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32-25 MG NP PA

ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG NP PA

atenolol oral tablet 100 mg, 25 mg, 50 mg Patenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg AD

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg P

AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG NP PA

AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG NP PA

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG NP PA

benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg P

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

P

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG NP PA

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG NP PA

BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG NP PA

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NP PA

betaxolol oral tablet 10 mg, 20 mg NP PABIDIL ORAL TABLET 20-37.5 MG AD


Drug Tier Limits or Restrictionsbisoprolol fumarate oral tablet 10 mg, 5 mg P


bosentan oral tablet 125 mg, 62.5 mg NP PAbumetanide injection solution 0.25 mg/ml ADbumetanide oral tablet 0.5 mg, 1 mg, 2 mg ADBYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG NP PA

BYVALSON ORAL TABLET 5-80 MG NP PACADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

NP PA

CALAN ORAL TABLET 120 MG NP PACALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 180 MG, 240 MG NP PA

candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg NP PA

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg NP PA

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg P

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg P

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

NP PA

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

NP PA

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG NP PA

CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG NP PA

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 4 MG, 8 MG NP PA

CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG

AD

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg P


47

Drug Tier Limits or Restrictionscarvedilol phosphate oral capsule, er multiphase 24 hr 10 mg, 20 mg, 40 mg, 80 mg

NP PA

chlorothiazide oral tablet 250 mg, 500 mg ADchlorthalidone oral tablet 25 mg, 50 mg ADcholestyramine (with sugar) oral powder 4 gram P

cholestyramine (with sugar) oral powder in packet 4 gram P

CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM P

CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM P

cilostazol oral tablet 100 mg, 50 mg ADclonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg AD

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr AD QL (4 per 30 days)

colesevelam oral powder in packet 3.75 gram NP PA

colesevelam oral tablet 625 mg NP PACOLESTID FLAVORED ORAL PACKET 7.5 GRAM NP PA

COLESTID ORAL GRANULES 5 GRAM NP PACOLESTID ORAL PACKET 5 GRAM NP PACOLESTID ORAL TABLET 1 GRAM NP PAcolestipol oral granules 5 gram Pcolestipol oral packet 5 gram Pcolestipol oral tablet 1 gram PCOREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG

NP PA

COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG NP PA

CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG NP PA

CORLANOR ORAL SOLUTION 5 MG/5 ML AD PACORLANOR ORAL TABLET 5 MG, 7.5 MG AD PACORZIDE ORAL TABLET 40-5 MG, 80-5 MG NP PACOZAAR ORAL TABLET 100 MG, 25 MG, 50 MG NP PA


Drug Tier Limits or RestrictionsCRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG NP PA

DIGOX ORAL TABLET 125 MCG (0.125 MG), 250 MCG (0.25 MG) AD

digoxin injection solution 250 mcg/ml (0.25 mg/ml) AD

digoxin injection syringe 250 mcg/ml (0.25 mg/ml) AD

digoxin oral solution 50 mcg/ml (0.05 mg/ml) AD

digoxin oral tablet 125 mcg (0.125 mg), 250 mcg (0.25 mg) AD

DILANTIN EXTENDED ORAL CAPSULE 100 MG P

DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG NP PA

DILANTIN ORAL CAPSULE 30 MG PDILANTIN-125 ORAL SUSPENSION 125 MG/5 ML NP PA

diltiazem hcl intravenous recon soln 100 mg AD

diltiazem hcl intravenous solution 5 mg/ml ADdiltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg P

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg P

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

P

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

P

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg P

diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

P

DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG P

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG

NP PA


49

Drug Tier Limits or RestrictionsDIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG NP PA

dipyridamole oral tablet 25 mg, 50 mg, 75 mg P

disopyramide phosphate oral capsule 100 mg, 150 mg AD

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg AD

doxazosin oral tablet 1 mg, 2 mg, 4 mg P QL (30 per 30 days)doxazosin oral tablet 8 mg P QL (60 per 30 days)EDARBI ORAL TABLET 40 MG, 80 MG NP PAEDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG NP PA

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg P

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg P

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG NP PA; QL (60 per 30 days)

eplerenone oral tablet 25 mg, 50 mg ADepoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg AD SP

eprosartan oral tablet 600 mg NP PAEXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG

NP PA

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 5-320 MG NP PA

EZALLOR SPRINKLE ORAL CAPSULE, SPRINKLE 10 MG, 20 MG, 40 MG, 5 MG NP PA

ezetimibe oral tablet 10 mg P QL (30 per 30 days)ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg NP PA

felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg P

fenofibrate micronized oral capsule 130 mg, 43 mg NP PA

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg P

fenofibrate nanocrystallized oral tablet 145 mg, 160 mg, 48 mg NP PA

fenofibrate oral capsule 150 mg, 50 mg NP PA


Drug Tier Limits or Restrictionsfenofibrate oral tablet 120 mg, 160 mg, 40 mg NP PA

fenofibrate oral tablet 54 mg Pfenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg

NP PA

fenofibric acid oral tablet 105 mg, 35 mg NP PAFENOGLIDE ORAL TABLET 120 MG, 40 MG NP PAFIBRICOR ORAL TABLET 105 MG, 35 MG NP PAflecainide oral tablet 100 mg, 150 mg, 50 mg AD

fluvastatin oral capsule 20 mg, 40 mg NP PAfluvastatin oral tablet extended release 24 hr 80 mg NP PA

fosinopril oral tablet 10 mg, 20 mg, 40 mg Pfosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg P

furosemide injection solution 10 mg/ml ADfurosemide injection syringe 10 mg/ml ADfurosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) AD

furosemide oral tablet 20 mg, 40 mg, 80 mg AD

gemfibrozil oral tablet 600 mg Pguanfacine oral tablet 1 mg, 2 mg ADguanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg P

HEMANGEOL ORAL SOLUTION 4.28 MG/ML NP PAhydralazine injection solution 20 mg/ml ADhydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg AD

hydrochlorothiazide oral capsule 12.5 mg ADhydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg AD

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG NP PA

indapamide oral tablet 1.25 mg, 2.5 mg ADINDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 160 MG, 60 MG, 80 MG

NP PA


51

Drug Tier Limits or RestrictionsINDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG NP PA

INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG NP PA

INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR 1 MG, 2 MG, 3 MG, 4 MG NP PA

irbesartan oral tablet 150 mg, 300 mg, 75 mg P

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg P

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg AD

isosorbide dinitrate oral tablet extended release 40 mg AD

isosorbide mononitrate oral tablet 10 mg, 20 mg AD

isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg

AD

isradipine oral capsule 2.5 mg, 5 mg PJUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG NP PA

KAPSPARGO SPRINKLE ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 200 MG, 25 MG, 50 MG

NP PA

labetalol intravenous solution 5 mg/ml ADlabetalol oral tablet 100 mg, 200 mg, 300 mg P

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR 80 MG NP PA

LETAIRIS ORAL TABLET 10 MG, 5 MG P PA; SPlidocaine (pf) intravenous solution 20 mg/ml (2 %) AD

LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG NP PA

LIPOFEN ORAL CAPSULE 150 MG, 50 MG NP PAlisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg P

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg P

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG NP PALOPID ORAL TABLET 600 MG NP PA


Drug Tier Limits or RestrictionsLOPRESSOR ORAL TABLET 100 MG, 50 MG NP PAlosartan oral tablet 100 mg, 25 mg, 50 mg Plosartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg P

LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG NP PA

LOTENSIN ORAL TABLET 20 MG, 40 MG NP PALOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG NP PA

lovastatin oral tablet 10 mg P QL (30 per 30 days)lovastatin oral tablet 20 mg, 40 mg P QL (60 per 30 days)LOVAZA ORAL CAPSULE 1 GRAM NP PAmagnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)

AD

magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %)

AD

magnesium sulfate injection solution 4 meq/ml (50 %) AD

magnesium sulfate injection syringe 4 meq/ml AD

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

P

methyldopa oral tablet 250 mg, 500 mg ADmethyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg AD

methyldopate intravenous solution 250 mg/5 ml AD

metolazone oral tablet 10 mg, 2.5 mg, 5 mg AD

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

P


metoprolol tartrate intravenous solution 5 mg/5 ml AD

metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg P

mexiletine oral capsule 150 mg, 200 mg, 250 mg AD


53

Drug Tier Limits or RestrictionsMICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG NP PA

MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG NP PA

minoxidil oral tablet 10 mg, 2.5 mg ADmoexipril oral tablet 15 mg, 7.5 mg Pmoexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg P

nadolol oral tablet 20 mg, 40 mg, 80 mg Pniacin oral capsule, extended release 250 mg, 500 mg P

niacin oral tablet 100 mg, 500 mg Pniacin oral tablet extended release 1,000 mg, 750 mg P

niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg P

NIACOR ORAL TABLET 500 MG NP PANIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 1,000 MG, 500 MG, 750 MG

P

nicardipine intravenous solution 25 mg/10 ml AD

nicardipine oral capsule 20 mg, 30 mg Pnifedipine oral capsule 10 mg, 20 mg Pnifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg P

nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg P

nimodipine oral capsule 30 mg NP PAnisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

NP PA

NITRO-BID TRANSDERMAL OINTMENT 2 % ADnitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) AD

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg AD

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

AD

nitroglycerin translingual spray,non-aerosol 400 mcg/spray AD


Drug Tier Limits or RestrictionsNITROMIST TRANSLINGUAL AEROSOL,SPRAY 400 MCG/SPRAY NP PA

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG NP PA

NYMALIZE ORAL SOLUTION 30 MG/10 ML, 60 MG/20 ML NP PA

olmesartan oral tablet 20 mg, 40 mg, 5 mg NP PAolmesartan-amlodipin-hcthiazid oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

NP PA

olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg NP PA

omega-3 acid ethyl esters oral capsule 1 gram NP PA

OPSUMIT ORAL TABLET 10 MG NP PAORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG

NP PA

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg P

PHENYTEK ORAL CAPSULE 200 MG, 300 MG P

phenytoin oral suspension 100 mg/4 ml, 125 mg/5 ml P

phenytoin oral tablet,chewable 50 mg Pphenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg P

phenytoin sodium intravenous solution 50 mg/ml AD

pindolol oral tablet 10 mg, 5 mg PPRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML NP PA; SP

PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG NP PA

pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg P

prazosin oral capsule 1 mg, 2 mg, 5 mg ADPRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG NP PA

PREVALITE ORAL POWDER 4 GRAM PPREVALITE ORAL POWDER IN PACKET 4 GRAM P


55

Drug Tier Limits or RestrictionsPRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG NP PA

procainamide injection solution 100 mg/ml, 500 mg/ml AD

PROCARDIA ORAL CAPSULE 10 MG NP PAPROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG, 60 MG, 90 MG NP PA

propafenone oral tablet 150 mg, 225 mg, 300 mg AD






QBRELIS ORAL SOLUTION 1 MG/ML NP PAQUESTRAN LIGHT ORAL POWDER 4 GRAM NP PAQUESTRAN ORAL POWDER 4 GRAM NP PAQUESTRAN ORAL POWDER IN PACKET 4 GRAM NP PA

quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg P

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg P

quinidine gluconate oral tablet extended release 324 mg AD

quinidine sulfate oral tablet 200 mg, 300 mg AD

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg P

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG P

ranolazine oral tablet extended release 12 hr 1,000 mg, 500 mg AD

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML NP PA; SP


Drug Tier Limits or RestrictionsREPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML NP PA; SP

REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML NP PA; SP

REVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML NP PA; SP; QL (112 per 30 days)

REVATIO ORAL TABLET 20 MG NP PA; SP; QL (90 per 30 days)rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg P QL (30 per 30 days)

sildenafil (pulm.hypertension) intravenous solution 10 mg/12.5 ml AD PA; SP

sildenafil (pulm.hypertension) oral suspension for reconstitution 10 mg/ml AD PA; SP

sildenafil (pulm.hypertension) oral tablet 20 mg P PA; SP

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg P

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG AD

SOTALOL AF ORAL TABLET 120 MG, 160 MG, 80 MG P

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg P

SOTYLIZE ORAL SOLUTION 5 MG/ML NP PAspironolactone oral tablet 100 mg, 25 mg, 50 mg AD

spironolacton-hydrochlorothiaz oral tablet 25-25 mg AD

SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG NP PA

tadalafil (pulm. hypertension) oral tablet 20 mg NP PA; SP; QL (60 per 30 days)

TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR 2-180 MG, 2-240 MG, 4-240 MG NP PA

TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

P

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG P

TEKTURNA ORAL TABLET 150 MG, 300 MG NP PAtelmisartan oral tablet 20 mg, 40 mg, 80 mg NP PA


57

Drug Tier Limits or Restrictionstelmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg NP PA

telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg NP PA

TENORETIC 100 ORAL TABLET 100-25 MG NP PATENORETIC 50 ORAL TABLET 50-25 MG NP PATENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG NP PA

terazosin oral capsule 1 mg, 2 mg, 5 mg P QL (30 per 30 days)terazosin oral capsule 10 mg P QL (60 per 30 days)theophylline oral solution 80 mg/15 ml ADtheophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg AD

theophylline oral tablet extended release 24 hr 400 mg, 600 mg AD

TIAZAC ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

NP PA

timolol maleate oral tablet 10 mg, 20 mg, 5 mg NP PA

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 200 MG, 25 MG, 50 MG

NP PA

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg AD

TRACLEER ORAL TABLET 125 MG, 62.5 MG P PA; SPTRACLEER ORAL TABLET FOR SUSPENSION 32 MG NP PA; SP

trandolapril oral tablet 1 mg, 2 mg, 4 mg Ptriamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg AD

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg AD

TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG

NP PA

TRICOR ORAL TABLET 145 MG, 48 MG NP PATRIGLIDE ORAL TABLET 160 MG NP PATRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/EC) 135 MG, 45 MG NP PA

TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80-5 MG NP PA


Drug Tier Limits or RestrictionsTYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)

NP PA

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML

NP PA

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)

NP PA

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML

NP PA

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

NP PA

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) NP PA

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg P

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

P

VASCEPA ORAL CAPSULE 0.5 GRAM, 1 GRAM NP PA

VASERETIC ORAL TABLET 10-25 MG NP PAVASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG NP PA

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML NP PA

verapamil intravenous solution 2.5 mg/ml ADverapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg P

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg P

verapamil oral tablet 120 mg, 40 mg, 80 mg P

verapamil oral tablet extended release 120 mg, 180 mg, 240 mg P

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR 120 MG, 180 MG, 240 MG, 360 MG

NP PA

VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT 100 MG, 200 MG, 300 MG NP PA

VYNDAMAX ORAL CAPSULE 61 MG AD PA; SP


59

Drug Tier Limits or RestrictionsVYNDAQEL ORAL CAPSULE 20 MG AD PA; SPVYTORIN 10-10 ORAL TABLET 10-10 MG NP PAVYTORIN 10-20 ORAL TABLET 10-20 MG NP PAVYTORIN 10-40 ORAL TABLET 10-40 MG NP PAVYTORIN 10-80 ORAL TABLET 10-80 MG NP PAWELCHOL ORAL TABLET 625 MG NP PAZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG NP PA

ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG NP PA

ZETIA ORAL TABLET 10 MG NP PAZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG NP PA

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG NP PA

ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG NP PA

CENTRAL NERVOUS SYSTEM AGENTSABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG

P

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG

P

ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG

NP PA

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG NP PA

acamprosate oral tablet,delayed release (dr/ec) 333 mg AD

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

AD QL (4500 per 30 days)

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg AD QL (360 per 30 days)

acetaminophen-codeine oral tablet 300-60 mg AD QL (180 per 30 days)

ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG

NP PA


Drug Tier Limits or RestrictionsADHANSIA XR ORAL CAPSULE, ER BIPHASIC 20-80 25 MG, 35 MG, 45 MG, 55 MG, 70 MG, 85 MG

NP PA

ADZENYS ER ORAL SUSPEN, IR - ER, BIPHASIC 24HR 1.25 MG/ML NP PA

ADZENYS XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG

NP PA


AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML NP PA; QL (1 per 30 days)

AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML NP PA; QL (2 per 30 days)

AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG/1.5 ML P PA

AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG/1.5 ML P PA

almotriptan malate oral tablet 12.5 mg, 6.25 mg NP PA

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg AD

amantadine hcl oral capsule 100 mg ADamantadine hcl oral solution 50 mg/5 ml ADamantadine hcl oral tablet 100 mg ADAMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE 12.5 MG, 6.25 MG NP PA

AMBIEN ORAL TABLET 10 MG, 5 MG NP PAAMERGE ORAL TABLET 1 MG, 2.5 MG NP PAamitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg AD

amitriptyline-chlordiazepoxide oral tablet 12.5-5 mg, 25-10 mg AD

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg AD

amphetamine sulfate oral tablet 10 mg, 5 mg NP PA

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG NP PA

APTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC 40-60 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

NP PA


61

Drug Tier Limits or RestrictionsAPTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG NP PA

aripiprazole oral solution 1 mg/ml Paripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg P QL (30 per 30 days)

aripiprazole oral tablet 5 mg P QL (60 per 30 days)aripiprazole oral tablet,disintegrating 10 mg, 15 mg NP PA; QL (60 per 30 days)

ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML

NP PA

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML

NP PA

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg NP PA

ARYMO ER ORAL TABLET,ORAL ONLY,EXTND RELEASE 15 MG, 30 MG, 60 MG

NP PA

ASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG AD QL (180 per 30 days)

aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg NP PA

atomoxetine oral capsule 10 mg P QL (300 per 30 days)atomoxetine oral capsule 100 mg P QL (30 per 30 days)atomoxetine oral capsule 18 mg P QL (166 per 30 days)atomoxetine oral capsule 25 mg P QL (120 per 30 days)atomoxetine oral capsule 40 mg P QL (75 per 30 days)atomoxetine oral capsule 60 mg P QL (50 per 30 days)atomoxetine oral capsule 80 mg P QL (37 per 30 days)AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG AD PA; SP

BANZEL ORAL SUSPENSION 40 MG/ML NP PABANZEL ORAL TABLET 200 MG, 400 MG NP PABELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG

P PA

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG NP PA

benztropine injection solution 1 mg/ml ADbenztropine oral tablet 0.5 mg, 1 mg, 2 mg AD


Drug Tier Limits or RestrictionsBRINTELLIX ORAL TABLET 20 MG NP PABRISDELLE ORAL CAPSULE 7.5 MG NP PABRIVIACT ORAL SOLUTION 10 MG/ML NP PABRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG NP PA

bromocriptine oral tablet 2.5 mg ADBUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG NP PA

buprenorphine hcl sublingual tablet 2 mg, 8 mg NP PA; QL (90 per 30 days)

buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour


buprenorphine transdermal patch weekly 7.5 mcg/hour NP PA

buprenorphine-naloxone sublingual film 12-3 mg NP PA; QL (60 per 30 days)

buprenorphine-naloxone sublingual film 2-0.5 mg, 8-2 mg NP PA

buprenorphine-naloxone sublingual film 4-1 mg NP PA; QL (180 per 30 days)

buprenorphine-naloxone sublingual tablet 2-0.5 mg P QL (360 per 30 days)

buprenorphine-naloxone sublingual tablet 8-2 mg P QL (90 per 30 days)

bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg P QL (60 per 30 days)

bupropion hcl oral tablet 100 mg, 75 mg Pbupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg P QL (30 per 30 days)

bupropion hcl oral tablet extended release 24 hr 450 mg P

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg, 200 mg P QL (60 per 30 days)

buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg AD

BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE 30-50-325-40 MG AD QL (180 per 30 days)

butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg AD QL (180 per 30 days)

butalbital-acetaminophen oral tablet 50-325 mg AD QL (180 per 30 days)


63

Drug Tier Limits or Restrictionsbutalbital-acetaminophen-caff oral capsule 50-325-40 mg AD QL (180 per 30 days)

butalbital-acetaminophen-caff oral tablet 50-325-40 mg AD QL (180 per 30 days)

butalbital-aspirin-caffeine oral capsule 50-325-40 mg AD

cabergoline oral tablet 0.5 mg ADCAPITAL WITH CODEINE ORAL SUSPENSION 120-12 MG/5 ML AD PA

CAPLYTA ORAL CAPSULE 42 MG NP PAcarbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg NP PA

carbamazepine oral suspension 100 mg/5 ml P

carbamazepine oral tablet 200 mg Pcarbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg P

carbamazepine oral tablet,chewable 100 mg P

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

NP PA

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg P

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg P

carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg

P

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

AD

carisoprodol-aspirin-codeine oral tablet 200-325-16 mg AD PA

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG NP PA

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg P

CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG NP PA

CELONTIN ORAL CAPSULE 300 MG Pchlorpromazine injection solution 25 mg/ml AD


Drug Tier Limits or Restrictionschlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg AD

choline,magnesium salicylate oral liquid 500 mg/5 ml AD

citalopram oral solution 10 mg/5 ml Pcitalopram oral tablet 10 mg, 20 mg, 40 mg P QL (30 per 30 days)

clobazam oral suspension 2.5 mg/ml NP PAclobazam oral tablet 10 mg, 20 mg Pclomipramine oral capsule 25 mg, 50 mg, 75 mg AD

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg ADclonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg AD

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg AD

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg P

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg P

CLOZARIL ORAL TABLET 100 MG, 25 MG NP PACOMPRO RECTAL SUPPOSITORY 25 MG ADCONCERTA ORAL TABLET EXTENDED RELEASE 24HR 18 MG, 27 MG, 36 MG, 54 MG

NP PA

COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 17.3 MG, 25.9 MG, 8.6 MG

NP PA

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 30 MG, 60 MG NP PA

DAYPRO ORAL TABLET 600 MG NP PADAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR

NP PA

DEPAKENE ORAL CAPSULE 250 MG NP PADEPAKENE ORAL SOLUTION 250 MG/5 ML NP PADEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 250 MG, 500 MG NP PA

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG, 250 MG, 500 MG

NP PA


65

Drug Tier Limits or RestrictionsDEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 125 MG NP PA

desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg AD

desvenlafaxine fumarate oral tablet extended release 24hr 100 mg, 50 mg NP PA

desvenlafaxine oral tablet extended release 24 hr 100 mg, 50 mg NP PA

desvenlafaxine oral tablet extended release 24hr 50 mg NP PA

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg


DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 10 MG, 15 MG, 5 MG NP PA

dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

NP PA

dexmethylphenidate oral tablet 10 mg P QL (60 per 30 days)dexmethylphenidate oral tablet 2.5 mg P QL (240 per 30 days)dexmethylphenidate oral tablet 5 mg P QL (120 per 30 days)dextroamphetamine oral capsule, extended release 10 mg P QL (180 per 30 days)

dextroamphetamine oral capsule, extended release 15 mg P QL (120 per 30 days)

dextroamphetamine oral capsule, extended release 5 mg P QL (360 per 30 days)

dextroamphetamine oral solution 5 mg/5 ml NP PA

dextroamphetamine oral tablet 10 mg P QL (180 per 30 days)dextroamphetamine oral tablet 5 mg P QL (360 per 30 days)dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg P QL (180 per 30 days)

dextroamphetamine-amphetamine oral capsule,extended release 24hr 15 mg P QL (120 per 30 days)






Drug Tier Limits or Restrictionsdextroamphetamine-amphetamine oral tablet 10 mg P QL (180 per 30 days)

dextroamphetamine-amphetamine oral tablet 12.5 mg P QL (144 per 30 days)

dextroamphetamine-amphetamine oral tablet 15 mg P QL (120 per 30 days)




dextroamphetamine-amphetamine oral tablet 7.5 mg P QL (240 per 30 days)

DIACOMIT ORAL CAPSULE 250 MG, 500 MG NP PA

DIACOMIT ORAL POWDER IN PACKET 250 MG, 500 MG NP PA

DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG, 5-7.5-10 MG P

DIASTAT RECTAL KIT 2.5 MG Pdiazepam injection solution 5 mg/ml ADdiazepam injection syringe 5 mg/ml ADDIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML AD

diazepam oral solution 5 mg/5 ml (1 mg/ml), 5 mg/5 ml (1 mg/ml, 5 ml) AD

diazepam oral tablet 10 mg, 2 mg, 5 mg ADdiazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg NP PA

diclofenac epolamine transdermal patch 12 hour 1.3 % NP PA; QL (60 per 30 days)

diclofenac potassium oral tablet 50 mg ADdiclofenac sodium oral tablet extended release 24 hr 100 mg P

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg P

diclofenac sodium topical gel 1 % P QL (500 per 21 days)diflunisal oral tablet 500 mg ADDILANTIN EXTENDED ORAL CAPSULE 100 MG P


67

Drug Tier Limits or RestrictionsDILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG NP PA

DILANTIN ORAL CAPSULE 30 MG PDILANTIN-125 ORAL SUSPENSION 125 MG/5 ML NP PA

divalproex oral capsule, delayed rel sprinkle 125 mg P

divalproex oral tablet extended release 24 hr 250 mg, 500 mg P

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg P

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg AD

doxepin oral concentrate 10 mg/ml ADDUEXIS ORAL TABLET 800-26.6 MG NP PAduloxetine oral capsule,delayed release(dr/ec) 20 mg P QL (60 per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 30 mg, 40 mg, 60 mg P QL (30 per 30 days)

DURAGESIC TRANSDERMAL PATCH 72 HOUR 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR

NP PA

DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR 2.5 MG/ML NP PA

EC-NAPROXEN ORAL TABLET,DELAYED RELEASE (DR/EC) 375 MG, 500 MG P

EDLUAR SUBLINGUAL TABLET 10 MG, 5 MG NP PA

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG, 37.5 MG, 75 MG NP PA

eletriptan oral tablet 20 mg, 40 mg NP PAEMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG

NP PA

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML P PA

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML P PA

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML (100 MG/ML X 3) AD PA

ENDOCET ORAL TABLET 10-325 MG AD QL (180 per 30 days)


Drug Tier Limits or RestrictionsENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG AD QL (360 per 30 days)

ENDOCET ORAL TABLET 7.5-325 MG AD QL (240 per 30 days)entacapone oral tablet 200 mg ADEPIDIOLEX ORAL SOLUTION 100 MG/ML NP SP; PAEPITOL ORAL TABLET 200 MG Pescitalopram oxalate oral solution 5 mg/5 ml P

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg P QL (30 per 30 days)

eszopiclone oral tablet 1 mg, 2 mg, 3 mg P QL (30 per 30 days)ethosuximide oral capsule 250 mg Pethosuximide oral solution 250 mg/5 ml Petodolac oral capsule 200 mg, 300 mg ADetodolac oral tablet 400 mg, 500 mg ADetodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg AD

EVEKEO ORAL TABLET 10 MG, 5 MG NP PAEXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 16 MG, 32 MG, 8 MG

NP PA

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG NP PA

FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2) NP PA

FAZACLO ORAL TABLET,DISINTEGRATING 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG NP PA

felbamate oral suspension 600 mg/5 ml Pfelbamate oral tablet 400 mg, 600 mg PFELBATOL ORAL SUSPENSION 600 MG/5 ML P

FELBATOL ORAL TABLET 400 MG, 600 MG NP PAfenoprofen oral capsule 400 mg NP PAfenoprofen oral tablet 600 mg NP PAfentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 400 mcg, 600 mcg, 800 mcg

AD PA; QL (30 per 30 days)

fentanyl citrate buccal lozenge on a handle 200 mcg AD PA; QL (90 per 30 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 75 mcg/hr NP PA; QL (10 per 30 days)


69

Drug Tier Limits or Restrictionsfentanyl transdermal patch 72 hour 25 mcg/hr, 50 mcg/hr P PA; QL (10 per 30 days)

fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour NP PA

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) NP PA

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG

NP PA

FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % NP PA

fluoxetine oral capsule 10 mg P QL (30 per 30 days)fluoxetine oral capsule 20 mg Pfluoxetine oral capsule 40 mg P QL (60 per 30 days)fluoxetine oral capsule,delayed release(dr/ec) 90 mg NP PA

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) P

fluoxetine oral tablet 10 mg, 20 mg, 60 mg NP PAfluphenazine decanoate injection solution 25 mg/ml AD

fluphenazine hcl injection solution 2.5 mg/ml AD

fluphenazine hcl oral concentrate 5 mg/ml ADfluphenazine hcl oral elixir 2.5 mg/5 ml ADfluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg AD

flurbiprofen oral tablet 100 mg, 50 mg Pfluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg NP PA

fluvoxamine oral tablet 100 mg P QL (90 per 30 days)fluvoxamine oral tablet 25 mg P QL (30 per 30 days)fluvoxamine oral tablet 50 mg P QL (60 per 30 days)FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG NP PA

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG

P

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG NP PA

fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml AD


Drug Tier Limits or RestrictionsFROVA ORAL TABLET 2.5 MG NP PAfrovatriptan oral tablet 2.5 mg NP PAFYCOMPA ORAL SUSPENSION 0.5 MG/ML NP PAFYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG NP PA

gabapentin oral capsule 100 mg, 300 mg, 400 mg P

gabapentin oral solution 250 mg/5 ml (5 ml) AD

gabapentin oral solution 250 mg/5 ml, 300 mg/6 ml (6 ml) P

gabapentin oral tablet 600 mg, 800 mg PGABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG P

GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) NP PA

GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG NP PA

GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG, 68.5 MG NP PA

GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR 300 MG (9)- 600 MG (69)

NP PA

GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 600 MG NP PA

guanfacine oral tablet 1 mg, 2 mg ADguanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg P

haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml AD

haloperidol lactate injection solution 5 mg/ml AD

haloperidol lactate oral concentrate 2 mg/ml AD

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg AD

HEMANGEOL ORAL SOLUTION 4.28 MG/ML NP PAHETLIOZ ORAL CAPSULE 20 MG NP PAHORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG NP PA

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml AD QL (5400 per 30 days)


71

Drug Tier Limits or Restrictionshydrocodone-acetaminophen oral tablet 10-300 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg


hydrocodone-acetaminophen oral tablet 10-325 mg AD QL (270 per 30 days)

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg AD QL (150 per 30 days)

hydromorphone oral liquid 1 mg/ml AD QL (675 per 30 days)hydromorphone oral tablet 2 mg AD QL (180 per 30 days)hydromorphone oral tablet 4 mg AD QL (150 per 30 days)hydromorphone oral tablet 8 mg AD QL (60 per 30 days)hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg NP PA

hydroxyzine hcl intramuscular solution 25 mg/ml AD

hydroxyzine hcl oral solution 10 mg/5 ml ADhydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg AD

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg AD

HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

NP PA

ibuprofen oral tablet 400 mg, 600 mg, 800 mg P

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg AD

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg AD

IMITREX NASAL SPRAY,NON-AEROSOL 20 MG/ACTUATION, 5 MG/ACTUATION NP PA

IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG NP PA

INBRIJA INHALATION CAPSULE 42 MG NP PAINBRIJA INHALATION CAPSULE, W/INHALATION DEVICE 42 MG NP PA

INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 160 MG, 60 MG, 80 MG

NP PA

INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG NP PA

indomethacin oral capsule 25 mg, 50 mg P


Drug Tier Limits or RestrictionsINNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG NP PA

INTERMEZZO SUBLINGUAL TABLET 1.75 MG, 3.5 MG NP PA

INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR 1 MG, 2 MG, 3 MG, 4 MG NP PA

INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 6 MG, 9 MG NP PA

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML

P

INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML

P

JORNAY PM ORAL CAPSULE,DEL REL,EXT REL SPRINK 100 MG, 20 MG, 40 MG, 60 MG, 80 MG

NP PA

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG

NP PA

KEPPRA ORAL SOLUTION 100 MG/ML NP PAKEPPRA ORAL TABLET 1,000 MG, 250 MG, 500 MG, 750 MG NP PA

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG NP PA

ketoprofen oral capsule 25 mg, 50 mg, 75 mg P

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg AD

ketorolac oral tablet 10 mg P QL (20 per 30 days)KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 50 MG NP PA

LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG, 200 MG, 25 MG, 50 MG

NP PA

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG (21) -50 MG (7)

NP PA

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 MG (42) -100 MG (14)

NP PA


73

Drug Tier Limits or RestrictionsLAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 25 MG(14)-50 MG (14)-100 MG (7)

NP PA

LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG NP PA

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG NP PA

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 25 MG (35) NP PA

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 25 MG (84) -100 MG (14)

NP PA

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 25 MG (42) -100 MG (7)

NP PA

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG

NP PA

LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 25 MG (21) -50 MG (7)

NP PA

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(14)-100MG (14)-200 MG (7)

NP PA

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 25MG (14)-50 MG (14)-100MG (7)

NP PA

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg P

lamotrigine oral tablet disintegrating, dose pk 25 mg (21) -50 mg (7), 25 mg(14)-50 mg (14)-100 mg (7), 50 mg (42) -100 mg (14)

NP PA

lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

P

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg P

lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg NP PA

lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) -100 mg (7), 25 mg (84) -100 mg (14)

P

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG P QL (30 per 30 days)


Drug Tier Limits or RestrictionsLATUDA ORAL TABLET 80 MG P QL (60 per 30 days)LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY

NP PA

levetiracetam intravenous solution 500 mg/5 ml AD

levetiracetam oral solution 100 mg/ml, 500 mg/5 ml (5 ml) P

levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg P

levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg P

levorphanol tartrate oral tablet 2 mg AD QL (120 per 30 days)LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG NP PA

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg AD

lithium carbonate oral tablet 300 mg ADlithium carbonate oral tablet extended release 300 mg, 450 mg AD

lithium citrate oral solution 8 meq/5 ml ADLORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML AD

lorazepam oral concentrate 2 mg/ml ADlorazepam oral tablet 0.5 mg, 1 mg, 2 mg ADLORCET (HYDROCODONE) ORAL TABLET 5-325 MG AD QL (360 per 30 days)

LORCET HD ORAL TABLET 10-325 MG AD QL (360 per 30 days)loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg AD

LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG NP PALYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 330 MG, 82.5 MG NP PA

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG


LYRICA ORAL SOLUTION 20 MG/ML NP PAmagnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)

AD


75

Drug Tier Limits or Restrictionsmagnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %)

AD



maprotiline oral tablet 25 mg, 50 mg, 75 mg AD

MAXALT ORAL TABLET 10 MG NP PAMAXALT-MLT ORAL TABLET,DISINTEGRATING 10 MG, 5 MG NP PA

mefenamic acid oral capsule 250 mg NP PAmeloxicam oral suspension 7.5 mg/5 ml ADmeloxicam oral tablet 15 mg Pmeloxicam oral tablet 7.5 mg P QL (30 per 30 days)memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 mg, 7 mg NP PA

memantine oral solution 2 mg/ml NP PAmemantine oral tablet 10 mg, 5 mg Pmemantine oral tablets,dose pack 5-10 mg PMETADATE ER ORAL TABLET EXTENDED RELEASE 20 MG AD QL (90 per 30 days)

methadone oral concentrate 10 mg/ml NP PA; QL (60 per 30 days)methadone oral solution 10 mg/5 ml NP PA; QL (300 per 30 days)methadone oral solution 5 mg/5 ml NP PA; QL (600 per 30 days)methadone oral tablet 10 mg NP PA; QL (60 per 30 days)methadone oral tablet 5 mg NP PA; QL (120 per 30 days)methadone oral tablet,soluble 40 mg NP PA; QL (30 per 30 days)METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 MG/5 ML NP PA

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg P QL (180 per 30 days)






Drug Tier Limits or Restrictionsmethylphenidate hcl oral capsule, er biphasic 30-70 60 mg P QL (30 per 30 days)

methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

NP PA

methylphenidate hcl oral solution 10 mg/5 ml NP PA; QL (180 per 30 days)

methylphenidate hcl oral solution 5 mg/5 ml NP PA; QL (360 per 30 days)

methylphenidate hcl oral tablet 10 mg P QL (180 per 30 days)methylphenidate hcl oral tablet 20 mg P QL (90 per 30 days)methylphenidate hcl oral tablet 5 mg P QL (360 per 30 days)methylphenidate hcl oral tablet extended release 10 mg P QL (180 per 30 days)

methylphenidate hcl oral tablet extended release 20 mg P QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 24hr 18 mg P QL (120 per 30 days)




methylphenidate hcl oral tablet extended release 24hr 72 mg P

methylphenidate hcl oral tablet,chewable 10 mg P QL (180 per 30 days)

methylphenidate hcl oral tablet,chewable 2.5 mg P QL (720 per 30 days)

methylphenidate hcl oral tablet,chewable 5 mg P QL (360 per 30 days)

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG

NP PA

MIRAPEX ORAL TABLET 0.125 MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG NP PA

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg P

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg P

MOBIC ORAL TABLET 15 MG, 7.5 MG NP PAmodafinil oral tablet 100 mg, 200 mg ADUCare Comprehensive FormularyEffective: October 1, 2020

77

Drug Tier Limits or RestrictionsMORPHABOND ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 100 MG, 15 MG, 30 MG, 60 MG

NP PA

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) AD QL (135 per 30 days)

morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

NP PA

morphine oral capsule,extend.release pellets 10 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg

NP PA

morphine oral solution 10 mg/5 ml AD QL (900 per 30 days)morphine oral solution 20 mg/5 ml (4 mg/ml) AD QL (675 per 30 days)

morphine oral tablet 15 mg AD PA; QL (180 per 30 days)morphine oral tablet 30 mg AD QL (90 per 30 days)morphine oral tablet extended release 100 mg, 200 mg, 60 mg P PA; QL (30 per 30 days)

morphine oral tablet extended release 15 mg P PA; QL (120 per 30 days)

morphine oral tablet extended release 30 mg P PA; QL (90 per 30 days)

MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 15 MG, 200 MG, 30 MG, 60 MG

NP PA

MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR 12.5 MG, 25 MG, 37.5 MG, 50 MG NP PA

MYSOLINE ORAL TABLET 250 MG, 50 MG NP PAnabumetone oral tablet 500 mg, 750 mg Pnalbuphine injection solution 10 mg/ml, 20 mg/ml AD

NALFON ORAL CAPSULE 400 MG NP PANALFON ORAL TABLET 600 MG NP PAnaloxone injection auto-injector 2 mg/0.4 ml AD

naloxone injection solution 0.4 mg/ml Pnaloxone injection syringe 0.4 mg/ml, 1 mg/ml P

naltrexone oral tablet 50 mg ADNAMENDA ORAL TABLET 10 MG, 5 MG NP PANAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK 5-10 MG NP PA


Drug Tier Limits or RestrictionsNAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG NP PA

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG NP PA

NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NP PA

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

NP PA

naproxen oral suspension 125 mg/5 ml ADnaproxen oral tablet 250 mg, 375 mg, 500 mg P

naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg P

naproxen sodium oral tablet 275 mg, 550 mg P

naratriptan oral tablet 1 mg, 2.5 mg NP PANARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION P

NAYZILAM NASAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML) NP PA

nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg P

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG NP PA

NEURONTIN ORAL SOLUTION 250 MG/5 ML NP PANEURONTIN ORAL TABLET 600 MG, 800 MG NP PA

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg AD

nortriptyline oral solution 10 mg/5 ml ADNOURIANZ ORAL TABLET 20 MG, 40 MG NP PANUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG

NP PA

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG NP PA

NUEDEXTA ORAL CAPSULE 20-10 MG AD PA; QL (60 per 30 days)NUPLAZID ORAL CAPSULE 34 MG NP PANUPLAZID ORAL TABLET 10 MG, 17 MG NP PAolanzapine intramuscular recon soln 10 mg P


79

Drug Tier Limits or Restrictionsolanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg P QL (30 per 30 days)

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg NP PA; QL (30 per 30 days)

olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

NP PA

ONFI ORAL SUSPENSION 2.5 MG/ML NP PAONFI ORAL TABLET 10 MG, 20 MG NP PAONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG NP PA

OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG

NP PA

oxaprozin oral tablet 600 mg NP PAoxazepam oral capsule 10 mg, 15 mg, 30 mg AD

oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) P

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg P

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG NP PA

oxycodone oral capsule 5 mg AD QL (360 per 30 days)oxycodone oral concentrate 20 mg/ml AD QL (90 per 30 days)oxycodone oral solution 5 mg/5 ml AD QL (1200 per 30 days)oxycodone oral tablet 10 mg AD QL (180 per 30 days)oxycodone oral tablet 15 mg AD QL (120 per 30 days)oxycodone oral tablet 20 mg AD QL (90 per 30 days)oxycodone oral tablet 30 mg AD QL (60 per 30 days)oxycodone oral tablet 5 mg AD QL (360 per 30 days)OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG


OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 30 MG NP PA; QL (60 per 30 days)

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG, 60 MG, 80 MG


oxycodone-acetaminophen oral tablet 10-325 mg AD QL (180 per 30 days)


Drug Tier Limits or Restrictionsoxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg AD QL (360 per 30 days)

oxycodone-acetaminophen oral tablet 7.5-325 mg AD QL (240 per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg AD QL (360 per 30 days)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG


OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 30 MG NP PA; QL (60 per 30 days)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG, 60 MG, 80 MG


oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

NP PA

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg NP PA; QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 6 mg NP PA; QL (60 per 30 days)

paroxetine hcl oral tablet 10 mg, 40 mg P QL (30 per 30 days)paroxetine hcl oral tablet 20 mg, 30 mg P QL (60 per 30 days)paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg NP PA; QL (60 per 30 days)

paroxetine mesylate(menop.sym) oral capsule 7.5 mg NP PA

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG, 25 MG, 37.5 MG NP PA

PAXIL ORAL SUSPENSION 10 MG/5 ML NP PAPAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NP PA

PEGANONE ORAL TABLET 250 MG Pperphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg AD

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg AD

PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSION,EXTEND REL SYR KIT 120 MG, 90 MG

NP PA

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NP PA

phenelzine oral tablet 15 mg AD


81

Drug Tier Limits or Restrictionsphenobarbital oral elixir 20 mg/5 ml (4 mg/ml) AD

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

AD

PHENYTEK ORAL CAPSULE 200 MG, 300 MG P

phenytoin oral suspension 100 mg/4 ml, 125 mg/5 ml P

phenytoin oral tablet,chewable 50 mg Pphenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg P

phenytoin sodium intravenous solution 50 mg/ml AD

piroxicam oral capsule 10 mg, 20 mg ADPOTIGA ORAL TABLET 200 MG, 400 MG, 50 MG NP PA

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg P

pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

NP PA

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

P

pregabalin oral solution 20 mg/ml NP PAprimidone oral tablet 250 mg, 50 mg PPRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG NP PA

PROBUPHINE SUBDERMAL IMPLANT 74.2 MG NP PA

PROCENTRA ORAL SOLUTION 5 MG/5 ML NP PAprochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) AD

prochlorperazine maleate oral tablet 10 mg, 5 mg AD

prochlorperazine rectal suppository 25 mg ADpromethazine injection solution 25 mg/ml, 50 mg/ml AD



Drug Tier Limits or Restrictionspromethazine rectal suppository 12.5 mg, 25 mg AD





protriptyline oral tablet 10 mg, 5 mg ADPROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG NP PA

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

NP PA

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg P QL (90 per 30 days)

quetiapine oral tablet 300 mg, 400 mg P QL (60 per 30 days)quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg


QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG NP PA

QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) NP PA

ramelteon oral tablet 8 mg NP PA; QL (30 per 30 days)RELPAX ORAL TABLET 20 MG, 40 MG PREMERON ORAL TABLET 15 MG, 30 MG NP PAREMERON SOLTAB ORAL TABLET,DISINTEGRATING 15 MG, 30 MG, 45 MG

NP PA

REQUIP ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG NP PA

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

NP PA

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG NP PA

riluzole oral tablet 50 mg AD


83

Drug Tier Limits or RestrictionsRISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML

P

RISPERDAL ORAL SOLUTION 1 MG/ML NP PARISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG NP PA

risperidone oral solution 1 mg/ml Prisperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg P QL (60 per 30 days)

risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg P QL (60 per 30 days)

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 20 MG, 30 MG, 40 MG P

RITALIN ORAL TABLET 10 MG, 20 MG, 5 MG NP PA

rizatriptan oral tablet 10 mg, 5 mg Prizatriptan oral tablet,disintegrating 10 mg, 5 mg P

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg P

ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg NP PA

ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG P

ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG P

ROZEREM ORAL TABLET 8 MG P QL (30 per 30 days)RYTARY ORAL CAPSULE, EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

NP PA

SABRIL ORAL POWDER IN PACKET 500 MG NP PASABRIL ORAL TABLET 500 MG NP PAsalsalate oral tablet 500 mg, 750 mg ADSAPHRIS SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG NP PA

SARAFEM ORAL TABLET 10 MG, 20 MG NP PASAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG P QL (60 per 30 days)

SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) P QL (55 per 30 days)


Drug Tier Limits or RestrictionsSECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24 HOUR, 5.7 MG/24 HOUR, 7.6 MG/24 HOUR


selegiline hcl oral capsule 5 mg ADselegiline hcl oral tablet 5 mg ADSEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG NP PA

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG

NP PA

sertraline oral concentrate 20 mg/ml Psertraline oral tablet 100 mg, 50 mg P QL (60 per 30 days)sertraline oral tablet 25 mg P QL (30 per 30 days)SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG, 50-200 MG NP PA

SINEMET ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG NP PA

SONATA ORAL CAPSULE 10 MG, 5 MG NP PASPRAVATO NASAL SPRAY,NON-AEROSOL 28 MG, 56 MG (28 MG X 2), 84 MG (28 MG X 3)

AD PA; SP

SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG, 750 MG NP PA

STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG NP PA

SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 300 MG/1.5 ML

NP PA

SUBOXONE SUBLINGUAL FILM 12-3 MG P QL (60 per 30 days)SUBOXONE SUBLINGUAL FILM 2-0.5 MG P QL (360 per 30 days)SUBOXONE SUBLINGUAL FILM 4-1 MG P QL (180 per 30 days)SUBOXONE SUBLINGUAL FILM 8-2 MG P QL (90 per 30 days)sulindac oral tablet 150 mg, 200 mg Psumatriptan nasal spray,non-aerosol 20 mg/actuation P QL (18 per 30 days)

sumatriptan nasal spray,non-aerosol 5 mg/actuation P QL (36 per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg P QL (18 per 30 days)

sumatriptan succinate oral tablet 50 mg Psumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml AD QL (8 per 30 days)


85

Drug Tier Limits or Restrictionssumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml AD QL (8 per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml AD QL (8 per 30 days)

sumatriptan-naproxen oral tablet 85-500 mg NP PA

SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 3-25 MG, 6-25 MG, 6-50 MG NP PA

TEGRETOL ORAL SUSPENSION 100 MG/5 ML NP PA

TEGRETOL ORAL TABLET 200 MG NP PATEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 400 MG NP PA

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg AD

tetrabenazine oral tablet 12.5 mg, 25 mg AD PA; SPthioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg AD

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg AD

tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg NP PA

timolol maleate oral tablet 10 mg, 20 mg, 5 mg NP PA

tolmetin oral capsule 400 mg ADtolmetin oral tablet 200 mg, 600 mg ADTOPAMAX ORAL CAPSULE, SPRINKLE 15 MG, 25 MG NP PA

TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG NP PA

topiramate oral capsule, sprinkle 15 mg, 25 mg P

topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 mg, 50 mg NP PA

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg P

TOSYMRA NASAL SPRAY,NON-AEROSOL 10 MG/ACTUATION NP PA

tramadol oral tablet 50 mg AD QL (240 per 30 days)tramadol-acetaminophen oral tablet 37.5-325 mg AD QL (240 per 30 days)

tranylcypromine oral tablet 10 mg AD


Drug Tier Limits or Restrictionstrazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg P

TREXIMET ORAL TABLET 10-60 MG, 85-500 MG NP PA

triazolam oral tablet 0.125 mg, 0.25 mg ADtrifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg AD

trihexyphenidyl oral elixir 0.4 mg/ml ADtrihexyphenidyl oral tablet 2 mg, 5 mg ADTRILEPTAL ORAL SUSPENSION 300 MG/5 ML (60 MG/ML) NP PA

TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG NP PA

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG NP PA; QL (30 per 30 days)

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG

NP PA

valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) AD

valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml) AD

valproic acid (as sodium salt) oral solution 250 mg/5 ml, 500 mg/10 ml (10 ml) P

valproic acid oral capsule 250 mg Pvenlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg P QL (30 per 30 days)

venlafaxine oral capsule,extended release 24hr 75 mg P

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg P QL (90 per 30 days)

venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg NP PA

VERSACLOZ ORAL SUSPENSION 50 MG/ML NP PAvigabatrin oral powder in packet 500 mg NP PAvigabatrin oral tablet 500 mg NP PAVIGADRONE ORAL POWDER IN PACKET 500 MG NP PA

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG NP PA; QL (30 per 30 days)

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) NP PA; QL (30 per 30 days)


87

Drug Tier Limits or RestrictionsVIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC 375-20 MG, 500-20 MG NP PA

VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML AD

VIMPAT ORAL SOLUTION 10 MG/ML NP PAVIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG NP PA

VIMPAT ORAL TABLETS,DOSE PACK 50 MG (14)- 100 MG (14) NP PA

VOLTAREN TOPICAL GEL 1 % NP PAVRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG NP PA

VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) NP PA

VYVANSE ORAL CAPSULE 10 MG P QL (210 per 30 days)VYVANSE ORAL CAPSULE 20 MG P QL (105 per 30 days)VYVANSE ORAL CAPSULE 30 MG P QL (70 per 30 days)VYVANSE ORAL CAPSULE 40 MG P QL (52 per 30 days)VYVANSE ORAL CAPSULE 50 MG P QL (42 per 30 days)VYVANSE ORAL CAPSULE 60 MG P QL (35 per 30 days)VYVANSE ORAL CAPSULE 70 MG P QL (30 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 10 MG NP PA; QL (210 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 20 MG NP PA; QL (105 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 30 MG NP PA; QL (70 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 40 MG NP PA; QL (52 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 50 MG NP PA; QL (42 per 30 days)VYVANSE ORAL TABLET,CHEWABLE 60 MG NP PA; QL (35 per 30 days)WELLBUTRIN SR ORAL TABLET SUSTAINED-RELEASE 12 HR 100 MG, 150 MG, 200 MG

NP PA

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG NP PA

XADAGO ORAL TABLET 100 MG, 50 MG NP PAXTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG

NP PA


zaleplon oral capsule 10 mg P QL (60 per 30 days)zaleplon oral capsule 5 mg P QL (30 per 30 days)ZARONTIN ORAL CAPSULE 250 MG NP PAUCare Comprehensive FormularyEffective: October 1, 202088

Drug Tier Limits or RestrictionsZARONTIN ORAL SOLUTION 250 MG/5 ML NP PAZEMBRACE SYMTOUCH SUBCUTANEOUS PEN INJECTOR 3 MG/0.5 ML NP PA

ZENZEDI ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 30 MG, 5 MG, 7.5 MG NP PA

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg P QL (60 per 30 days)

ziprasidone mesylate intramuscular recon soln 20 mg/ml (final conc.) NP PA

ZIPSOR ORAL CAPSULE 25 MG NP PAZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG

NP PA

zolmitriptan oral tablet 2.5 mg, 5 mg NP PA; QL (18 per 30 days)zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg NP PA; QL (18 per 30 days)

ZOLOFT ORAL CONCENTRATE 20 MG/ML NP PAZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG NP PA

zolpidem oral tablet 10 mg, 5 mg P QL (30 per 30 days)zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg NP PA; QL (30 per 30 days)

zolpidem sublingual tablet 1.75 mg, 3.5 mg NP PA

ZOLPIMIST ORAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML) NP PA

ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG, 5 MG NP PA

ZOMIG ORAL TABLET 2.5 MG, 5 MG NP PAZOMIG ZMT ORAL TABLET,DISINTEGRATING 2.5 MG, 5 MG NP PA

zonisamide oral capsule 100 mg, 25 mg, 50 mg P

ZORVOLEX ORAL CAPSULE 18 MG NP PA; QL (90 per 30 days)ZORVOLEX ORAL CAPSULE 35 MG NP PAZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

NP PA

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR 150 MG NP PA

ZYPREXA INTRAMUSCULAR RECON SOLN 10 MG NP PA


89

Drug Tier Limits or RestrictionsZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG NP PA

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG, 405 MG

NP PA

ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING 10 MG, 15 MG, 20 MG, 5 MG

NP PA

DEVICESACCU-CHEK AVIVA PLUS METER PACCU-CHEK GUIDE GLUCOSE METER PACCU-CHEK GUIDE ME GLUCOSE MTR PACCU-CHEK NANO PCLEO 90 INFUSION SET 24" INFUSION SET ADCOMFORT SHORT INFUSION SET 23" INFUSION SET AD

CONTOUR METER PCONTOUR METER KIT PCONTOUR NEXT EZ METER PCONTOUR NEXT EZ METER KIT PCONTOUR NEXT METER PCONTOUR NEXT ONE METER PDEXCOM G5 RECEIVER NP PADEXCOM G5 TRANSMITTER DEVICE NP PADEXCOM G5-G4 SENSOR DEVICE NP PADEXCOM G6 RECEIVER PDEXCOM G6 SENSOR DEVICE PDEXCOM G6 TRANSMITTER DEVICE PECLIPSE SYRINGE SYRINGE 3 ML 21 GAUGE X 1" AD

FORA G20 KIT NP PAFREESTYLE FREEDOM LITE KIT NP PAFREESTYLE INSULINX NP PAFREESTYLE LIBRE 10 DAY READER ADFREESTYLE LIBRE 10 DAY SENSOR KIT ADFREESTYLE LIBRE 14 DAY READER PFREESTYLE LIBRE 14 DAY SENSOR KIT PFREESTYLE LITE METER KIT NP PAGLUCOCARD EXPRESSION NP PA


Drug Tier Limits or RestrictionsGLUCOCARD EXPRESSION KIT NP PAGLUCOCARD SHINE METER NP PAGLUCOCARD SHINE METER KIT KIT NP PAGLUCOCARD SHINE XL METER NP PAHEP FLUSH-10 (PF) INTRAVENOUS SOLUTION 10 UNIT/ML AD

heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml

AD

heparin flush(porcine)-0.9nacl intravenous kit 100 unit/ml AD

heparin lock flush (porcine) intravenous syringe 100 unit/ml AD

HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 10 UNIT/ML AD

HEPARIN LOCK INTRAVENOUS SOLUTION 100 UNIT/ML AD

HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 10 UNIT/ML, 100 UNIT/ML

AD

heparin, porcine (pf) intravenous syringe 1 unit/ml, 100 unit/ml AD

MONOJECT MAGELLAN SYRINGE SYRINGE 3 ML 20 GAUGE X 1" AD

MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE AD

NORMAL SALINE FLUSH INJECTION SYRINGE AD

ONETOUCH ULTRA2 METER NP PAONETOUCH ULTRA2 METER KIT NP PAONETOUCH ULTRAMINI KIT NP PAONETOUCH VERIO FLEX METER NP PAONETOUCH VERIO IQ METER NP PAONETOUCH VERIO IQ METER KIT NP PAONETOUCH VERIO METER NP PAPRECISION XTRA KETONE-GLUCOSE KIT NP PAPRECISION XTRA MONITOR NP PAPRODIGY POCKET METER KIT NP PAPRODIGY VOICE GLUCOSE METER KIT NP PAsodium chloride 0.9 % (flush) injection syringe AD


91

Drug Tier Limits or Restrictionssyringe with needle, safety syringe 1 ml 25 gauge x 5/8" AD

T:SLIM SUBCUTANEOUS CARTRIDGE ADTRUE METRIX AIR GLUCOSE METER NP PATRUE METRIX AIR GLUCOSE METER KIT NP PATRUE METRIX GLUCOSE METER NP PAWAVESENSE PRESTO NP PAWAVESENSE PRESTO KIT NP PADIAGNOSTIC AGENTSACCU-CHEK AVIVA PLUS TEST STRP STRIP PACCU-CHEK COMPACT PLUS TEST STRIP PACCU-CHEK GUIDE TEST STRIPS STRIP PACCU-CHEK SMARTVIEW TEST STRIP STRIP P

CONTOUR NEXT TEST STRIPS STRIP PCONTOUR TEST STRIPS STRIP Pcosyntropin intravenous solution 0.25 mg/ml AD

FORA G20 STRIP NP PAFREESTYLE INSULINX STRIP NP PAFREESTYLE INSULINX TEST STRIPS STRIP NP PAFREESTYLE LITE STRIPS STRIP NP PAFREESTYLE TEST STRIP NP PAGLUCAGON HCL INJECTION RECON SOLN 1 MG/ML AD

GLUCOCARD EXPRESSION STRIP NP PAGLUCOCARD SHINE TEST STRIPS STRIP NP PAONETOUCH ULTRA BLUE TEST STRIP STRIP NP PAONETOUCH VERIO TEST STRIPS STRIP NP PAPRECISION XTRA TEST STRIP NP PAPRODIGY NO CODING STRIP NP PATRUE METRIX GLUCOSE TEST STRIP STRIP NP PAVARIBAR THIN LIQUID ORAL POWDER 40 % (W/V) AD

WAVESENSE PRESTO STRIP NP PAELECTROLYTIC, CALORIC, AND WATER BALANCEACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG NP PA


Drug Tier Limits or Restrictionsacetazolamide oral capsule, extended release 500 mg AD


acetic acid irrigation solution 0.25 % ADamiloride oral tablet 5 mg ADamiloride-hydrochlorothiazide oral tablet 5-50 mg AD

amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

P

ammonium chloride intravenous solution 5 meq/ml AD

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32-25 MG NP PA

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg AD

AURYXIA ORAL TABLET 210 MG IRON NP PAAVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG NP PA

BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR 27-1-430 MG AD

BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE AD

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

P

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG NP PA


bumetanide injection solution 0.25 mg/ml ADbumetanide oral tablet 0.5 mg, 1 mg, 2 mg ADcalcium acetate(phosphat bind) oral capsule 667 mg P

calcium acetate(phosphat bind) oral tablet 667 mg P

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg NP PA

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg P


93

Drug Tier Limits or RestrictionsCARBAGLU ORAL TABLET, DISPERSIBLE 200 MG AD SP

chlorothiazide oral tablet 250 mg, 500 mg ADchlorthalidone oral tablet 25 mg, 50 mg ADchromium chloride intravenous solution 4 mcg/ml AD

COMPLETE NATAL DHA ORAL COMBO PACK 29-1-250-200 MG AD

CONSTULOSE ORAL SOLUTION 10 GRAM/15 ML AD

CORZIDE ORAL TABLET 40-5 MG, 80-5 MG NP PACRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 MG/ML, 30 MG/ML AD PA; SP

dextrose 5 %-lactated ringers intravenous parenteral solution AD

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG

NP PA

EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG NP PA

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg P

ENULOSE ORAL SOLUTION 10 GRAM/15 ML ADEXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG

NP PA

fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg P

FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG NP PA

FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG NP PA

furosemide injection solution 10 mg/ml ADfurosemide injection syringe 10 mg/ml ADfurosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) AD

furosemide oral tablet 20 mg, 40 mg, 80 mg AD

GENERLAC ORAL SOLUTION 10 GRAM/15 ML AD

glycine urologic solution irrigation solution 1.5 % AD


Drug Tier Limits or Restrictionshydrochlorothiazide oral capsule 12.5 mg ADhydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg AD

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG NP PA

indapamide oral tablet 1.25 mg, 2.5 mg ADIONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % AD

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % AD

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg P

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

AD

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION AD

JYNARQUE ORAL TABLET 15 MG, 30 MG AD PA; SPJYNARQUE ORAL TABLETS, SEQUENTIAL 15 MG (AM)/ 15 MG (PM), 30 MG (AM)/ 15 MG (PM)

AD

JYNARQUE ORAL TABLETS, SEQUENTIAL 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM)

AD PA; SP

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ AD

KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ AD

KLOR-CON M10 ORAL TABLET,ER PARTICLES/CRYSTALS 10 MEQ AD



KLOR-CON ORAL PACKET 20 MEQ ADlactated ringers intravenous parenteral solution AD

lactated ringers irrigation solution ADlactulose oral solution 10 gram/15 ml, 10 gram/15 ml (15 ml), 20 gram/30 ml AD

lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg NP PA


95

Drug Tier Limits or Restrictionslisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg P

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg P

LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG NP PA

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg AD

metolazone oral tablet 10 mg, 2.5 mg, 5 mg AD


MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG NP PA

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg P




NORMAL SALINE FLUSH INJECTION SYRINGE AD

NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION AD

NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

AD

NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION AD

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION AD

olmesartan-amlodipin-hcthiazid oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

NP PA

olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg NP PA

PHOSLO ORAL CAPSULE 667 MG NP PAPHOSLO ORAL TABLET 667 MG NP PAPHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML P


Drug Tier Limits or RestrictionsPHOSPHA 250 NEUTRAL ORAL TABLET 250 MG AD

PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQ/L AD

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION AD

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION AD

PNV OB+DHA ORAL COMBO PACK 27-1-50-250 MG AD

PNV-OMEGA ORAL CAPSULE 28-1-300 MG ADpotassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l

AD

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

AD

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l AD

potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l, 40 meq/l AD

potassium chloride in water intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml

AD

potassium chloride intravenous solution 2 meq/ml AD

potassium chloride oral capsule, extended release 10 meq, 8 meq AD

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml AD

potassium chloride oral tablet extended release 10 meq, 8 meq AD

potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq AD

potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l AD

potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

AD

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l AD


97

Drug Tier Limits or Restrictionspotassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

AD

potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg)

AD





PRENATABS FA ORAL TABLET 29-1 MG ADPRENATABS RX ORAL TABLET 29 MG IRON- 1 MG AD

PRENATAL LOW IRON ORAL TABLET 27 MG IRON- 1 MG AD



probenecid oral tablet 500 mg ADprobenecid-colchicine oral tablet 500-0.5 mg AD


quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg P

RAVICTI ORAL LIQUID 1.1 GRAM/ML AD SPRENAGEL ORAL TABLET 400 MG, 800 MG PRENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM NP PA

RENVELA ORAL TABLET 800 MG NP PAringer's intravenous parenteral solution ADringer's irrigation solution ADsevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram NP PA

sevelamer carbonate oral tablet 800 mg NP PAsevelamer hcl oral tablet 400 mg, 800 mg NP PA


Drug Tier Limits or Restrictionssodium bicarbonate intravenous solution 1 meq/ml (8.4 %), 4.2 % AD

sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 4.2 % (0.5 meq/ml), 7.5 % (0.9 meq/ml), 8.4 % (1 meq/ml)

AD

sodium chlor 0.9% bacteriostat injection solution 0.9 % AD

sodium chloride 0.45 % intravenous parenteral solution 0.45 % AD

sodium chloride 0.9 % (flush) injection syringe AD

sodium chloride 0.9 % injection solution ADsodium chloride 0.9 % intravenous parenteral solution AD

sodium chloride 0.9 % intravenous piggyback AD

sodium chloride 3 % intravenous parenteral solution 3 % AD

sodium chloride 5 % intravenous parenteral solution 5 % AD

sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml AD

sodium chloride irrigation solution 0.9 % ADsodium citrate-citric acid oral solution 500-334 mg/5 ml AD

sodium lactate intravenous solution 5 meq/ml AD

sodium phenylbutyrate oral powder 0.94 gram/gram AD SP

sodium phenylbutyrate oral tablet 500 mg AD SPsodium polystyrene sulfonate oral powder ADsodium polystyrene sulfonate rectal enema 30 gram/120 ml AD

spironolactone oral tablet 100 mg, 25 mg, 50 mg AD

spironolacton-hydrochlorothiaz oral tablet 25-25 mg AD

SPS (WITH SORBITOL) ORAL SUSPENSION 15-20 GRAM/60 ML AD

SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML AD

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG P


99

Drug Tier Limits or Restrictionstelmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg NP PA

TENORETIC 100 ORAL TABLET 100-25 MG NP PATENORETIC 50 ORAL TABLET 50-25 MG NP PAtheophylline oral solution 80 mg/15 ml ADtheophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg AD


torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg AD

TRIADVANCE ORAL TABLET 90-1-50 MG ADtriamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg AD

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg AD

TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG

NP PA

TRICITRATES ORAL SOLUTION 550-500-334 MG/5 ML AD

TRINATAL RX 1 ORAL TABLET 60 MG IRON-1 MG AD



valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

P

VASERETIC ORAL TABLET 10-25 MG NP PAVELPHORO ORAL TABLET,CHEWABLE 500 MG NP PA

VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM AD SP


VINACAL ORAL TABLET 27-1-50 MG ADVINATE ONE ORAL TABLET 60 MG IRON-1 MG AD

VINATE ULTRA ORAL TABLET 90-1-50 MG AD


Drug Tier Limits or RestrictionsVIRT-PN PLUS ORAL CAPSULE 28-1-300 MG AD


VITAFOL-OB ORAL TABLET 65-1 MG ADVOL-NATE ORAL TABLET 28 MG IRON- 1 MG AD

water for irrigation, sterile irrigation solution AD


ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG NP PA

ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG NP PA

ENZYMESCATHFLO ACTIVASE INTRA-CATHETER RECON SOLN 2 MG AD

ELELYSO INTRAVENOUS RECON SOLN 200 UNIT AD PA; SP

FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG AD PA; SP

LUMIZYME INTRAVENOUS RECON SOLN 50 MG AD PA; SP

PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML, 2.5 MG/0.5 ML, 20 MG/ML AD PA; SP

PULMOZYME INHALATION SOLUTION 1 MG/ML AD SP

REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5 ML (1.6 MG/ML) AD PA; SP

STRENSIQ SUBCUTANEOUS SOLUTION 40 MG/ML, 80 MG/0.8 ML AD PA

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) AD SP

VPRIV INTRAVENOUS RECON SOLN 400 UNIT AD PA; SP

EYE, EAR, NOSE AND THROAT (EENT) PREPS.acetazolamide oral capsule, extended release 500 mg AD



101

Drug Tier Limits or Restrictionsacetic acid otic (ear) solution 2 % ADACULAR LS OPHTHALMIC (EYE) DROPS 0.4 % NP PA

ACULAR OPHTHALMIC (EYE) DROPS 0.5 % NP PAACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 0.45 % NP PA

ALAWAY OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %) P

ALOCRIL OPHTHALMIC (EYE) DROPS 2 % NP PAALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % NP PA

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %, 0.15 % P

ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % NP PA

apraclonidine ophthalmic (eye) drops 0.5 % NP PA

ASTEPRO NASAL SPRAY,NON-AEROSOL 0.15 % (205.5 MCG) NP PA

atropine ophthalmic (eye) drops 1 % ADAZASITE OPHTHALMIC (EYE) DROPS 1 % NP PAazelastine nasal aerosol,spray 137 mcg (0.1 %) P QL (60 per 30 days)

azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) P QL (60 per 30 days)

azelastine ophthalmic (eye) drops 0.05 % NP PAAZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % NP PA

bacitracin ophthalmic (eye) ointment 500 unit/gram AD

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram AD

BALANCED SALT INTRAOCULAR SOLUTION ADBECONASE AQ NASAL SPRAY,NON-AEROSOL 42 MCG (0.042 %) NP PA

BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % NP PA

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % NP PA

betaxolol ophthalmic (eye) drops 0.5 % PBETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % NP PA


Drug Tier Limits or Restrictionsbimatoprost ophthalmic (eye) drops 0.03 % NP PA

BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-0.2 % AD

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 % AD

brimonidine ophthalmic (eye) drops 0.15 % NP PA

brimonidine ophthalmic (eye) drops 0.2 % Pbromfenac ophthalmic (eye) drops 0.09 % NP PABROMSITE OPHTHALMIC (EYE) DROPS 0.075 % NP PA

budesonide nasal spray,non-aerosol 32 mcg/actuation NP PA

carteolol ophthalmic (eye) drops 1 % NP PACHILDREN'S ALAWAY OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %) P

chlorhexidine gluconate mucous membrane mouthwash 0.12 % AD

CILOXAN OPHTHALMIC (EYE) DROPS 0.3 % NP PA

CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % NP PA

CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 % P

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 % P

ciprofloxacin hcl ophthalmic (eye) drops 0.3 % P

ciprofloxacin hcl otic (ear) dropperette 0.2 % NP PA

COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 % P

COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE 2-0.5 % NP PA

COSOPT OPHTHALMIC (EYE) DROPS 22.3-6.8 MG/ML NP PA

cromolyn ophthalmic (eye) drops 4 % PCYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % AD SP

dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % AD


103

Drug Tier Limits or Restrictionsdiclofenac sodium ophthalmic (eye) drops 0.1 % P

dorzolamide ophthalmic (eye) drops 2 % Pdorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-0.5 % NP PA

dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml P

doxycycline hyclate oral tablet 20 mg ADDYMISTA NASAL SPRAY,NON-AEROSOL 137-50 MCG/SPRAY NP PA

ELESTAT OPHTHALMIC (EYE) DROPS 0.05 % NP PA

EMADINE OPHTHALMIC (EYE) DROPS 0.05 % NP PA

epinastine ophthalmic (eye) drops 0.05 % NP PAerythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) AD

EYE ITCH RELIEF OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %) P

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) NP PA; QL (50 per 30 days)

fluorometholone ophthalmic (eye) drops,suspension 0.1 % AD

flurbiprofen sodium ophthalmic (eye) drops 0.03 % NP PA

gatifloxacin ophthalmic (eye) drops 0.5 % NP PAGENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) AD

gentamicin ophthalmic (eye) drops 0.3 % ADgentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram) AD

hydrocortisone-acetic acid otic (ear) drops 1-2 % AD

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1 % NP PA

IOPIDINE OPHTHALMIC (EYE) DROPS 0.5 % NP PA

ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %) P QL (30 per 30 days)

ISTALOL OPHTHALMIC (EYE) DROPS, ONCE DAILY 0.5 % NP PA


Drug Tier Limits or Restrictionsketorolac ophthalmic (eye) drops 0.4 %, 0.5 % P

ketotifen fumarate ophthalmic (eye) drops 0.025 % (0.035 %) P

LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % NP PA

latanoprost ophthalmic (eye) drops 0.005 % P

levobunolol ophthalmic (eye) drops 0.5 % NP PAlevofloxacin ophthalmic (eye) drops 0.5 % NP PAlidocaine hcl mucous membrane jelly 2 % ADlidocaine hcl mucous membrane jelly in applicator 2 % AD

lidocaine hcl mucous membrane solution 4 % (40 mg/ml) AD

loteprednol etabonate ophthalmic (eye) drops,suspension 0.5 % AD

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % NP PA

metipranolol ophthalmic (eye) drops 0.3 % ADmometasone nasal spray,non-aerosol 50 mcg/actuation P

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % NP PA

moxifloxacin ophthalmic (eye) drops 0.5 % NP PANASONEX NASAL SPRAY,NON-AEROSOL 50 MCG/ACTUATION NP PA

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % AD

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

AD

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

AD

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %

AD

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

AD


105

Drug Tier Limits or Restrictionsneomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

AD

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit-mg/ml

AD

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

P

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-% P

NEO-POLYCIN HC OPHTHALMIC (EYE) OINTMENT 3.5-400-10,000 MG-UNIT/G-1%

AD

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % NP PA

OCUFLOX OPHTHALMIC (EYE) DROPS 0.3 % NP PA

ofloxacin ophthalmic (eye) drops 0.3 % Pofloxacin otic (ear) drops 0.3 % ADolopatadine nasal spray,non-aerosol 0.6 % NP PAolopatadine ophthalmic (eye) drops 0.1 %, 0.2 % P

OMNARIS NASAL SPRAY,NON-AEROSOL 50 MCG NP PA

OTIPRIO INTRATYMPANIC SUSPENSION 6 % (6 MG/0.1 ML) NP PA

OTOVEL OTIC (EAR) SOLUTION 0.3-0.025 % (0.25 ML) NP PA

OXERVATE OPHTHALMIC (EYE) DROPS 0.002 % AD PA; SP

PATADAY OPHTHALMIC (EYE) DROPS 0.2 % NP PA

PATANASE NASAL SPRAY,NON-AEROSOL 0.6 % NP PA

PATANOL OPHTHALMIC (EYE) DROPS 0.1 % NP PA

PAZEO OPHTHALMIC (EYE) DROPS 0.7 % PPHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 % AD

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % AD


Drug Tier Limits or RestrictionsPOLYCIN OPHTHALMIC (EYE) OINTMENT 500-10,000 UNIT/GRAM AD

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml AD

prednisolone acetate ophthalmic (eye) drops,suspension 1 % AD

prednisolone sodium phosphate ophthalmic (eye) drops 1 % AD

PROLENSA OPHTHALMIC (EYE) DROPS 0.07 % NP PA

proparacaine ophthalmic (eye) drops 0.5 % AD

QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION, 80 MCG/ACTUATION NP PA

RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS 0.05 % AD PA; QL (6 per 30 days)

RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % AD PA; QL (60 per 30 days)

RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 % NP PA

ROCKLATAN OPHTHALMIC (EYE) DROPS 0.02-0.005 % NP PA

SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION 1-0.2 % NP PA

SINUVA SINUS IMPLANT 1,350 MCG NP PAsulfacetamide sodium ophthalmic (eye) drops 10 % AD

sulfacetamide sodium ophthalmic (eye) ointment 10 % AD

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) AD

tetracaine hcl ophthalmic (eye) drops 0.5 % AD

TICANASE NASAL KIT,SPRAY SUSPENSION AND SPRAY 50 MCG- 0.9 % NP PA

timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % P

timolol maleate ophthalmic (eye) drops, once daily 0.5 % NP PA

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % P

TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE 0.25 %, 0.5 % NP PA


107

Drug Tier Limits or RestrictionsTIMOPTIC OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 % NP PA

TIMOPTIC-XE OPHTHALMIC (EYE) GEL FORMING SOLUTION 0.25 %, 0.5 % NP PA

TOBRADEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.1 % P

tobramycin ophthalmic (eye) drops 0.3 % ADtobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 % AD

TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 % P

travoprost ophthalmic (eye) drops 0.004 % ADTRUSOPT OPHTHALMIC (EYE) DROPS 2 % NP PAVERAMYST NASAL SPRAY,SUSPENSION 27.5 MCG/ACTUATION NP PA

VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 % P

VYZULTA OPHTHALMIC (EYE) DROPS 0.024 % NP PA

XALATAN OPHTHALMIC (EYE) DROPS 0.005 % NP PA

XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCG/ACTUATION NP PA

ZADITOR OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %) NP PA

ZETONNA NASAL HFA AEROSOL INHALER 37 MCG/ACTUATION NP PA

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE 0.0015 % NP PA

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % ADZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.5 % AD

ZYMAXID OPHTHALMIC (EYE) DROPS 0.5 % NP PA

GASTROINTESTINAL DRUGSACIPHEX ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG NP PA

ACIPHEX SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 10 MG, 5 MG NP PA; QL (30 per 30 days)

AKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG NP PA

alosetron oral tablet 0.5 mg, 1 mg AD


Drug Tier Limits or RestrictionsAMITIZA ORAL CAPSULE 24 MCG, 8 MCG ADANZEMET ORAL TABLET 100 MG, 50 MG NP PAaprepitant oral capsule 125 mg, 40 mg AD QL (1 per 30 days)aprepitant oral capsule 80 mg AD QL (2 per 30 days)aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) AD QL (3 per 30 days)

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM NP PA

ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG NP PA

AVSOLA INTRAVENOUS RECON SOLN 100 MG NP PA

AZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

NP PA

AZULFIDINE ORAL TABLET 500 MG NP PAbalsalazide oral capsule 750 mg PCANASA RECTAL SUPPOSITORY 1,000 MG PCARAFATE ORAL SUSPENSION 100 MG/ML ADCESAMET ORAL CAPSULE 1 MG NP PAcimetidine hcl oral solution 300 mg/5 ml AD PAcimetidine oral tablet 200 mg ADcimetidine oral tablet 300 mg, 400 mg, 800 mg AD PA

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

NP SP; PA; QL (2 per 21 days)

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)


CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) NP SP; PA; QL (2 per 21 days)

COLAZAL ORAL CAPSULE 750 MG NP PACOMPRO RECTAL SUPPOSITORY 25 MG ADCREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

P

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG P


109

Drug Tier Limits or RestrictionsDEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 30 MG NP PA; QL (30 per 30 days)

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 60 MG NP PA

DIPENTUM ORAL CAPSULE 250 MG NP PAdiphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml AD

diphenoxylate-atropine oral tablet 2.5-0.025 mg AD

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg AD

DUEXIS ORAL TABLET 800-26.6 MG NP PAENDARI ORAL POWDER IN PACKET 5 GRAM AD PAENTYVIO INTRAVENOUS RECON SOLN 300 MG NP SP; PA

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg NP PA; QL (30 per 30 days)

esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg NP PA

esomeprazole strontium oral capsule,delayed release(dr/ec) 49.3 mg NP PA

famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml AD

famotidine intravenous solution 10 mg/ml ADfamotidine oral suspension 40 mg/5 ml (8 mg/ml) AD

famotidine oral tablet 10 mg, 20 mg, 40 mg AD

GAVILYTE-C ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM AD

GAVILYTE-G ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM AD

GAVILYTE-N ORAL RECON SOLN 420 GRAM ADGIAZO ORAL TABLET 1.1 GRAM NP PAGOLYTELY ORAL POWDER IN PACKET 227.1-21.5-6.36 GRAM AD

GOLYTELY ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM AD

granisetron (pf) intravenous solution 100 mcg/ml AD

granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) AD


Drug Tier Limits or Restrictionsgranisetron hcl oral tablet 1 mg NP PA; QL (6 per 30 days)HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

P PA; SP; QL (2 per 30 days)

HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML P PA; SP; QL (2 per 30 days)

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML P PA; SP; QL (2 per 30 days)

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML


HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML P PA; SP; QL (2 per 30 days)


HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML


INFLECTRA INTRAVENOUS RECON SOLN 100 MG NP SP; PA

lansoprazole oral capsule,delayed release(dr/ec) 15 mg, 30 mg NP PA; QL (30 per 30 days)

lansoprazole oral tablet,disintegrat, delay rel 15 mg NP PA; QL (30 per 30 days)

lansoprazole oral tablet,disintegrat, delay rel 30 mg NP PA

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM NP PA

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG AD

meclizine oral tablet 12.5 mg, 25 mg ADmeclizine oral tablet,chewable 25 mg AD


111

Drug Tier Limits or Restrictionsmesalamine oral capsule (with del rel tablets) 400 mg NP PA

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram, 800 mg NP PA

mesalamine rectal enema 4 gram/60 ml Pmesalamine rectal suppository 1,000 mg NP PAmesalamine with cleansing wipe rectal enema kit 4 gram/60 ml P

metoclopramide hcl injection solution 5 mg/ml AD

metoclopramide hcl oral solution 5 mg/5 ml AD

metoclopramide hcl oral tablet 10 mg, 5 mg AD

misoprostol oral tablet 100 mcg, 200 mcg ADMOVANTIK ORAL TABLET 12.5 MG, 25 MG AD PANEXIUM IV INTRAVENOUS RECON SOLN 40 MG NP PA

NEXIUM ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 40 MG NP PA

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG, 5 MG


NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 40 MG P

nizatidine oral capsule 150 mg, 300 mg AD PAnizatidine oral solution 150 mg/10 ml AD PAOCALIVA ORAL TABLET 10 MG, 5 MG AD PA; SPomeprazole oral capsule,delayed release(dr/ec) 10 mg P QL (30 per 30 days)

omeprazole oral capsule,delayed release(dr/ec) 20 mg, 40 mg P

omeprazole-sodium bicarbonate oral capsule 20-1.1 mg-gram, 40-1.1 mg-gram NP PA

omeprazole-sodium bicarbonate oral packet 20-1,680 mg NP PA; QL (30 per 30 days)

omeprazole-sodium bicarbonate oral packet 40-1,680 mg NP PA

ondansetron hcl (pf) injection solution 4 mg/2 ml AD

ondansetron hcl intravenous solution 2 mg/ml AD


Drug Tier Limits or Restrictionsondansetron hcl oral solution 4 mg/5 ml Pondansetron hcl oral tablet 24 mg ADondansetron hcl oral tablet 4 mg, 8 mg Pondansetron oral tablet,disintegrating 4 mg, 8 mg P

palonosetron intravenous solution 0.25 mg/2 ml, 0.25 mg/5 ml AD

palonosetron intravenous syringe 0.25 mg/5 ml NP PA

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT

NP PA

pantoprazole oral tablet,delayed release (dr/ec) 20 mg P QL (30 per 30 days)

pantoprazole oral tablet,delayed release (dr/ec) 40 mg P

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram, 240-22.72-6.72 -5.84 gram

AD

peg-electrolyte soln oral recon soln 420 gram AD

PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG P

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 24,000-86,250- 90,750 UNIT, 4,000-14,375- 15,125 UNIT, 8,000-28,750- 30,250 UNIT

NP PA

PNV OB+DHA ORAL COMBO PACK 27-1-50-250 MG AD

PREVACID ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG, 30 MG NP PA

PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL 15 MG, 30 MG

NP PA

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 10 MG NP PA; QL (30 per 30 days)

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 2.5 MG NP PA; QL (60 per 30 days)

prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) AD


113

Drug Tier Limits or Restrictionsprochlorperazine maleate oral tablet 10 mg, 5 mg AD

prochlorperazine rectal suppository 25 mg ADPROTONIX ORAL GRANULES DR FOR SUSP IN PACKET 40 MG NP PA

PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG, 40 MG NP PA

PYLERA ORAL CAPSULE 140-125-125 MG ADrabeprazole oral capsule, delayed rel sprinkle 10 mg NP PA

rabeprazole oral tablet,delayed release (dr/ec) 20 mg NP PA

REMICADE INTRAVENOUS RECON SOLN 100 MG NP SP; PA

RENFLEXIS INTRAVENOUS RECON SOLN 100 MG NP PA

ROWASA RECTAL ENEMA 4 GRAM/60 ML NP PAROWASA RECTAL ENEMA KIT 4 GRAM/60 ML NP PA

SANCUSO TRANSDERMAL PATCH WEEKLY 3.1 MG/24 HOUR NP PA

SFROWASA RECTAL ENEMA 4 GRAM/60 ML NP PASIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML NP SP; PA

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML NP SP; PA

SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML NP SP; PA

sucralfate oral suspension 100 mg/ml ADsucralfate oral tablet 1 gram ADsulfasalazine oral tablet 500 mg Psulfasalazine oral tablet,delayed release (dr/ec) 500 mg P


trimethobenzamide oral capsule 300 mg ADTRIVEEN-PRX RNF ORAL CAPSULE 26-1.2-55-300 MG AD

ursodiol oral capsule 300 mg ADursodiol oral tablet 250 mg, 500 mg ADVIBERZI ORAL TABLET 100 MG, 75 MG AD


Drug Tier Limits or RestrictionsVIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC 375-20 MG, 500-20 MG NP PA

VINACAL ORAL TABLET 27-1-50 MG ADVINATE ULTRA ORAL TABLET 90-1-50 MG ADVIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT NP PA



ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

P

ZOFRAN ODT ORAL TABLET,DISINTEGRATING 4 MG, 8 MG NP PA

ZOFRAN ORAL SOLUTION 4 MG/5 ML NP PAZOFRAN ORAL TABLET 4 MG, 8 MG NP PAZUPLENZ ORAL FILM 4 MG, 8 MG NP PAHEAVY METAL ANTAGONISTSCHEMET ORAL CAPSULE 100 MG ADdeferasirox oral granules in packet 180 mg, 360 mg, 90 mg AD PA

deferasirox oral tablet 180 mg, 360 mg, 90 mg AD PA; SP

deferasirox oral tablet, dispersible 125 mg, 250 mg, 500 mg AD PA; SP

FERRIPROX ORAL TABLET 1,000 MG AD PAFERRIPROX ORAL TABLET 500 MG AD PA; SPpenicillamine oral capsule 250 mg AD SPpenicillamine oral tablet 250 mg AD SPHORMONES AND SYNTHETIC SUBSTITUTESacarbose oral tablet 100 mg, 25 mg, 50 mg P

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG NP PA; QL (60 per 30 days)

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1,000 MG NP PA; QL (30 per 30 days)


115

Drug Tier Limits or RestrictionsADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML


ADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

NP PA

ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS SOLUTION 100 UNIT/ML NP PA

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE




AEROSPAN INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION NP PA; QL (2 per 30 days)

AFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8 UNIT, 8 UNIT (90)/ 12 UNIT (90)

NP PA

AIRDUO RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113-14 MCG/ACTUATION, 232-14 MCG/ACTUATION, 55-14 MCG/ACTUATION


alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg NP PA; QL (30 per 30 days)

alogliptin-metformin oral tablet 12.5-1,000 mg NP PA; QL (30 per 30 days)

alogliptin-metformin oral tablet 12.5-500 mg NP PA; QL (60 per 30 days)

alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg


alogliptin-pioglitazone oral tablet 25-45 mg NP PA; QL (60 per 30 days)ALTAVERA (28) ORAL TABLET 0.15-0.03 MG AD

ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION NP PA; QL (13 per 30 days)


ALYACEN 1/35 (28) ORAL TABLET 1-35 MG-MCG AD

ALYACEN 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG AD


Drug Tier Limits or RestrictionsAMARYL ORAL TABLET 1 MG, 2 MG, 4 MG NP PAAMETHIA LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) AD

AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) AD

AMETHYST (28) ORAL TABLET 90-20 MCG (28) AD

anastrozole oral tablet 1 mg ADANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR P PA; QL (30 per 30 days)

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)


ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1.62 % (20.25 MG/1.25 GRAM)


ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM), 1.62 % (40.5 MG/2.5 GRAM)


APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

NP PA

APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NP PA

APRI ORAL TABLET 0.15-0.03 MG ADARANELLE (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG AD

ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 232 MCG/ACTUATION, 55 MCG/ACTUATION


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION


ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)


AUBRA ORAL TABLET 0.1-20 MG-MCG ADAVANDIA ORAL TABLET 2 MG, 4 MG NP PA; QL (60 per 30 days)


117

Drug Tier Limits or RestrictionsAVIANE ORAL TABLET 0.1-20 MG-MCG ADAXIRON TRANSDERMAL SOLUTION IN METERED PUMP W/APP 30 MG/ACTUATION (1.5 ML)


AZURETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 AD

BALZIVA (28) ORAL TABLET 0.4-35 MG-MCG AD

BAQSIMI NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION AD

BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

NP PA

BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) AD

BLISOVI FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) AD

BLISOVI FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) AD

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

NP PA

BRIELLYN ORAL TABLET 0.4-35 MG-MCG ADbudesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml P QL (120 per 30 days)

budesonide inhalation suspension for nebulization 1 mg/2 ml P QL (60 per 30 days)

budesonide oral capsule,delayed,extend.release 3 mg NP PA

budesonide oral tablet,delayed and ext.release 9 mg NP PA


NP PA

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML NP PA; QL (4 per 30 days)

BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML P QL (4 per 30 days)

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG P QL (4 per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML P QL (3 per 30 days)


Drug Tier Limits or RestrictionsBYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML P QL (2 per 30 days)

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation P

CAMILA ORAL TABLET 0.35 MG ADCAMRESE LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) AD QL (84 per 84 days)

CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) AD

CAZIANT (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG AD

CHATEAL (28) ORAL TABLET 0.15-0.03 MG ADcolesevelam oral tablet 625 mg NP PAcortisone oral tablet 25 mg ADCRYSELLE (28) ORAL TABLET 0.3-30 MG-MCG AD

CYCLAFEM 1/35 (28) ORAL TABLET 1-35 MG-MCG AD

CYCLAFEM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG AD

cyred oral tablet 0.15-0.03 mg ADdanazol oral capsule 100 mg, 200 mg, 50 mg AD

DASETTA 1/35 (28) ORAL TABLET 1-35 MG-MCG AD

DASETTA 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG AD

DAYSEE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) AD

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML AD

desmopressin injection solution 4 mcg/ml ADdesmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) AD

desmopressin oral tablet 0.1 mg, 0.2 mg ADdesogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg AD

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML AD

dexamethasone oral elixir 0.5 mg/5 ml ADdexamethasone oral solution 0.5 mg/5 ml AD


119

Drug Tier Limits or Restrictionsdexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg AD

dexamethasone sodium phos (pf) injection solution 10 mg/ml AD

dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml AD

diazoxide oral suspension 50 mg/ml ADdrospirenone-ethinyl estradiol oral tablet 3-0.03 mg AD

DUETACT ORAL TABLET 30-2 MG, 30-4 MG NP PA; QL (30 per 30 days)DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION


ECONTRA EZ ORAL TABLET 1.5 MG AD QL (1 Max Qty Per Fill Retail)ELINEST ORAL TABLET 0.3-30 MG-MCG ADELLA ORAL TABLET 30 MG AD QL (1 per 30 days)ELURYNG VAGINAL RING 0.12-0.015 MG/24 HR AD

EMOQUETTE ORAL TABLET 0.15-0.03 MG ADENPRESSE ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) AD

ENSKYCE ORAL TABLET 0.15-0.03 MG ADERRIN ORAL TABLET 0.35 MG ADESTARYLLA ORAL TABLET 0.25-35 MG-MCG AD

estradiol oral tablet 0.5 mg, 1 mg, 2 mg ADestradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr


estradiol vaginal cream 0.01 % (0.1 mg/gram) AD

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml AD

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg AD

etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24 hr AD

EVISTA ORAL TABLET 60 MG NP PAexemestane oral tablet 25 mg ADFALMINA (28) ORAL TABLET 0.1-20 MG-MCG AD

FARXIGA ORAL TABLET 10 MG, 5 MG P QL (30 per 30 days)UCare Comprehensive FormularyEffective: October 1, 2020120

Drug Tier Limits or RestrictionsFEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG AD

FEMYNOR ORAL TABLET 0.25-35 MG-MCG ADFIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

NP PA

FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML (3 ML)

NP PA

FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NP PA

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION P QL (1 per 30 days)



FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION P QL (12 per 30 days)



fludrocortisone oral tablet 0.1 mg ADfluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation




FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML P SP

FORTESTA TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0.5 GRAM /ACTUATION


GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

NP PA; SP


121

Drug Tier Limits or RestrictionsGENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)

NP PA; SP

GIANVI (28) ORAL TABLET 3-0.02 MG ADglimepiride oral tablet 1 mg P QL (240 per 30 days)glimepiride oral tablet 2 mg P QL (120 per 30 days)glimepiride oral tablet 4 mg P QL (60 per 30 days)glipizide oral tablet 10 mg P QL (180 per 30 days)glipizide oral tablet 5 mg Pglipizide oral tablet extended release 24hr 10 mg, 5 mg P QL (60 per 30 days)

glipizide oral tablet extended release 24hr 2.5 mg P QL (300 per 30 days)

glipizide-metformin oral tablet 2.5-250 mg AD QL (240 per 30 days)glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg AD QL (120 per 30 days)

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG AD

GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG AD

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG AD

GLUCAGON HCL INJECTION RECON SOLN 1 MG/ML AD

GLUCOTROL ORAL TABLET 10 MG, 5 MG NP PAGLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG, 2.5 MG, 5 MG NP PA

glyburide micronized oral tablet 1.5 mg, 3 mg P

glyburide micronized oral tablet 6 mg P QL (60 per 30 days)glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg P

glyburide-metformin oral tablet 1.25-250 mg AD QL (240 per 30 days)

glyburide-metformin oral tablet 2.5-500 mg AD QL (180 per 30 days)

glyburide-metformin oral tablet 5-500 mg AD QL (120 per 30 days)GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG NP PA

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG P


Drug Tier Limits or RestrictionsGLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG NP PA; QL (30 per 30 days)

HAILEY 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) AD

HAILEY FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) AD

HEATHER ORAL TABLET 0.35 MG ADHUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML

NP PA

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML)

NP PA

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50)

P

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)

NP PA

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)

NP PA

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)

P

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NP PA

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML P

HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT)

NP PA; SP

HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG NP PA; SP

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

P

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

NP PA

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

NP PA


123

Drug Tier Limits or RestrictionsHUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML

P

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML P

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML P

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)

NP PA

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg AD

hydroxyprogest(pf)(preg presv) intramuscular oil 250 mg/ml (1 ml) AD PA; SP

hydroxyprogesterone cap(ppres) intramuscular oil 250 mg/ml AD PA; SP

hydroxyprogesterone capr(bulk) powder 100 % AD PA; SP

hydroxyprogesterone caproate intramuscular oil 250 mg/ml AD PA; SP

insulin lispro subcutaneous insulin pen 100 unit/ml NP PA

insulin lispro subcutaneous solution 100 unit/ml NP PA

INTROVALE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91) AD

INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG NP PA; QL (60 per 30 days)

INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG

NP PA

INVOKANA ORAL TABLET 100 MG, 300 MG P QL (30 per 30 days)JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG P QL (60 per 30 days)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-500 MG


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG NP PA; QL (60 per 30 days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG P QL (30 per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG P QL (30 per 30 days)JENCYCLA ORAL TABLET 0.35 MG AD


Drug Tier Limits or RestrictionsJENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG P QL (60 per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG NP PA; QL (60 per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG NP PA; QL (30 per 30 days)

JINTELI ORAL TABLET 1-5 MG-MCG ADJOLESSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91) AD

JOLIVETTE ORAL TABLET 0.35 MG ADJULEBER ORAL TABLET 0.15-0.03 MG ADJUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG AD

JUNEL 1/20 (21) ORAL TABLET 1-20 MG-MCG AD

JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) AD

JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) AD

JUNEL FE 24 ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) AD

KAITLIB FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4) AD

KARIVA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 AD

KAZANO ORAL TABLET 12.5-1,000 MG, 12.5-500 MG NP PA

KELNOR 1/35 (28) ORAL TABLET 1-35 MG-MCG AD

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG

AD PA; SP

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG P QL (60 per 30 days)

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG P QL (30 per 30 days)

KURVELO (28) ORAL TABLET 0.15-0.03 MG ADl norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7)

AD


125

Drug Tier Limits or RestrictionsLANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

P

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML P

LARIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG AD

LARIN 1/20 (21) ORAL TABLET 1-20 MG-MCG AD

LARIN 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) AD

LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) AD

LARIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) AD

LARISSIA ORAL TABLET 0.1-20 MG-MCG ADLAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4) AD

LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG AD

LESSINA ORAL TABLET 0.1-20 MG-MCG ADletrozole oral tablet 2.5 mg ADleuprolide subcutaneous kit 1 mg/0.2 ml AD SPLEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

P

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML P

LEVONEST (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) AD

levonorgestrel oral tablet 1.5 mg AD QL (1 Max Qty Per Fill Retail)levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg, 90-20 mcg (28)

AD

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)

AD

levonorg-eth estrad triphasic oral tablet 50-30 (6)/75-40 (5)/125-30(10) AD

LEVORA-28 ORAL TABLET 0.15-0.03 MG AD


Drug Tier Limits or Restrictionslevothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

AD

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

AD

LILETTA INTRAUTERINE INTRAUTERINE DEVICE 20.1 MCG/24 HRS (6 YRS) 52 MG AD

liothyronine intravenous solution 10 mcg/ml AD

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg AD

LORYNA (28) ORAL TABLET 3-0.02 MG ADLOW-OGESTREL (28) ORAL TABLET 0.3-30 MG-MCG AD

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG

AD PA; SP



LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG AD PA; SP

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 30 MG

AD PA; SP

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED) AD PA; SP

LUTERA (28) ORAL TABLET 0.1-20 MG-MCG AD

LYZA ORAL TABLET 0.35 MG ADMARLISSA (28) ORAL TABLET 0.15-0.03 MG AD

medroxyprogesterone intramuscular suspension 150 mg/ml AD

medroxyprogesterone intramuscular syringe 150 mg/ml AD QL (1 per 30 days)

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg AD

MEGACE ES ORAL SUSPENSION 625 MG/5 ML (125 MG/ML) NP PA


127

Drug Tier Limits or Restrictionsmegestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml)

P PA

megestrol oral suspension 625 mg/5 ml (125 mg/ml) NP

megestrol oral tablet 20 mg, 40 mg P PAmetformin oral tablet 1,000 mg ADmetformin oral tablet 500 mg AD QL (150 per 30 days)metformin oral tablet 850 mg AD QL (90 per 30 days)metformin oral tablet extended release 24 hr 500 mg AD QL (150 per 30 days)

metformin oral tablet extended release 24 hr 750 mg AD QL (60 per 30 days)

metformin oral tablet extended release 24hr 500 mg AD QL (150 per 30 days)

methimazole oral tablet 10 mg, 5 mg ADmethylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml AD

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg AD

methylprednisolone oral tablets,dose pack 4 mg AD

methylprednisolone sodium succ injection recon soln 125 mg, 40 mg AD

methylprednisolone sodium succ intravenous recon soln 1,000 mg, 500 mg AD

MIACALCIN INJECTION SOLUTION 200 UNIT/ML P

MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG AD

MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG AD

MICROGESTIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) AD

MICROGESTIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) AD

miglitol oral tablet 100 mg, 25 mg, 50 mg NP PAMONO-LINYAH ORAL TABLET 0.25-35 MG-MCG AD

MONONESSA (28) ORAL TABLET 0.25-35 MG-MCG AD

MY WAY ORAL TABLET 1.5 MG AD QL (1 Max Qty Per Fill Retail)


Drug Tier Limits or RestrictionsMYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.) AD PA

nateglinide oral tablet 120 mg, 60 mg PNATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE

AD PA

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG AD

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG NP PA

NEXPLANON SUBDERMAL IMPLANT 68 MG AD SPnikki (28) oral tablet 3-0.02 mg ADNORA-BE ORAL TABLET 0.35 MG ADNORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)

P PA; SP

noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7), 0.8mg-25mcg(24) and 75 mg (4)

AD

norethindrone (contraceptive) oral tablet 0.35 mg AD

norethindrone acetate oral tablet 5 mg ADnorethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-20 mg-mcg, 1-5 mg-mcg

AD

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4)

AD

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

AD

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG AD

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG (21) AD

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG AD

NORTREL 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG AD

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

P


129

Drug Tier Limits or RestrictionsNOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

NP PA

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML

P

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML P

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

P

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)

P

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

P

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML P

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML P

NP THYROID ORAL TABLET 120 MG, 15 MG, 30 MG, 60 MG, 90 MG AD

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML)

P PA; SP

OCELLA ORAL TABLET 3-0.03 MG ADoctreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

AD SP

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)

AD SP

OGESTREL (28) ORAL TABLET 0.5-50 MG-MCG AD

OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)

NP PA; SP

OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG NP PA; SP

ONGLYZA ORAL TABLET 2.5 MG, 5 MG P QL (30 per 30 days)OPCICON ONE-STEP ORAL TABLET 1.5 MG AD QL (1 Max Qty Per Fill Retail)ORILISSA ORAL TABLET 150 MG, 200 MG AD PA; SP


Drug Tier Limits or RestrictionsORSYTHIA ORAL TABLET 0.1-20 MG-MCG ADOSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG

NP PA

oxandrolone oral tablet 10 mg, 2.5 mg AD PAOZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML) NP PA; QL (1 per 30 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML) NP PA; QL (2 per 30 days)

PHILITH ORAL TABLET 0.4-35 MG-MCG ADPIMTREA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 AD

pioglitazone oral tablet 15 mg, 30 mg, 45 mg P QL (30 per 30 days)

pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg NP PA

pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg NP PA; QL (90 per 30 days)

PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 MCG, 1-35 MG-MCG AD

PORTIA 28 ORAL TABLET 0.15-0.03 MG ADPRANDIN ORAL TABLET 0.5 MG, 1 MG, 2 MG P

PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG NP PA

prednisolone oral solution 15 mg/5 ml ADprednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

AD

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML AD

prednisone oral solution 5 mg/5 ml ADprednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg AD

prednisone oral tablets,dose pack 10 mg, 5 mg AD

PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14) AD

PREVIFEM ORAL TABLET 0.25-35 MG-MCG ADprogesterone micronized oral capsule 100 mg, 200 mg AD


131

Drug Tier Limits or Restrictionspropylthiouracil oral tablet 50 mg ADPULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION


PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION


PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 0.25 MG/2 ML, 0.5 MG/2 ML, 1 MG/2 ML

NP PA

QTERN ORAL TABLET 10-5 MG NP PAQVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION


QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 80 MCG/ACTUATION


raloxifene oral tablet 60 mg PRECLIPSEN (28) ORAL TABLET 0.15-0.03 MG AD

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg Prepaglinide-metformin oral tablet 1-500 mg, 2-500 mg NP PA; QL (150 per 30 days)

RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG AD PA; QL (30 per 30 days)

SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.)

NP PA

SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG NP PA; SP

SEGLUROMET ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 7.5-1,000 MG, 7.5-500 MG NP PA; QL (60 per 30 days)

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG NP PA; SP

SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91) AD

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)

AD PA; SP

SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML NP PA; QL (15 per 30 days)

SOLU-CORTEF ACT-O-VIAL (PF) INJECTION RECON SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/4 ML

AD


Drug Tier Limits or RestrictionsSOLU-CORTEF INJECTION RECON SOLN 100 MG AD

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML

AD PA; SP

SPRINTEC (28) ORAL TABLET 0.25-35 MG-MCG AD

SRONYX ORAL TABLET 0.1-20 MG-MCG ADSTEGLATRO ORAL TABLET 15 MG NP PA; QL (30 per 30 days)STEGLATRO ORAL TABLET 5 MG NP PA; QL (5 per 30 days)STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG NP PA; QL (30 per 30 days)

STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR 30 MG NP PA; QL (60 per 30 days)

SYEDA ORAL TABLET 3-0.03 MG ADSYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION

P

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML P QL (19 per 30 days)

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML P QL (11 per 30 days)

SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML AD

SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG NP PA; QL (60 per 30 days)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG NP PA; QL (30 per 30 days)

tamoxifen oral tablet 10 mg, 20 mg ADtarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) AD

TESTIM TRANSDERMAL GEL 50 MG/5 GRAM (1 %) NP PA; QL (60 per 30 days)

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml AD

testosterone enanthate intramuscular oil 200 mg/ml AD

TESTOSTERONE TRANSDERMAL GEL 50 MG/5 GRAM (1 %) NP PA


133

Drug Tier Limits or Restrictionstestosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %), 20.25 mg/1.25 gram (1.62 %)

NP PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram), 1.62 % (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)

NP PA

testosterone transdermal solution in metered pump w/app 30 mg/actuation (1.5 ml)

NP PA

TILIA FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) AD

tolazamide oral tablet 250 mg AD QL (120 per 30 days)tolazamide oral tablet 500 mg AD QL (60 per 30 days)tolbutamide oral tablet 500 mg ADTOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML)

NP PA

TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML)

NP PA

TRADJENTA ORAL TABLET 5 MG P QL (30 per 30 days)TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

NP PA

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML)

NP PA

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) AD

TRI-LEGEST FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) AD

TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) AD

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg AD

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg AD

TRI-PREVIFEM (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) AD

TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG

AD PA; SP


Drug Tier Limits or RestrictionsTRI-SPRINTEC (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) AD

TRIVORA (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) AD

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML NP PA; QL (2 per 30 days)

TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG/24 HR AD

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) NP PA; SP; QL (1 per 30 days)

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE 9 MG NP PA

UCERIS RECTAL FOAM 2 MG/ACTUATION NP PAUNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

AD

unithroid oral tablet 137 mcg ADvasopressin injection solution 20 unit/ml ADVELIVET TRIPHASIC REGIMEN (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG AD

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) P QL (6 per 30 days)

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) P QL (9 per 30 days)

VIENVA ORAL TABLET 0.1-20 MG-MCG ADVIORELE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 AD

VOGELXO TRANSDERMAL GEL 50 MG/5 GRAM (1 %) NP PA; QL (60 per 30 days)

VOGELXO TRANSDERMAL GEL IN METERED-DOSE PUMP 12.5 MG/ 1.25 GRAM (1 %)


VOGELXO TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM) NP PA; QL (60 per 30 days)

WELCHOL ORAL POWDER IN PACKET 3.75 GRAM NP PA

WELCHOL ORAL TABLET 625 MG NP PAWERA (28) ORAL TABLET 0.5-35 MG-MCG ADWIXELA INHUB INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE



135

Drug Tier Limits or RestrictionsWYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7) AD

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-500 MG


XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG


XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24 HR AD

XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML) NP PA; QL (15 per 30 days)

yuvafem vaginal tablet 10 mcg ADZARAH ORAL TABLET 3-0.03 MG ADZENCHENT (28) ORAL TABLET 0.4-35 MG-MCG AD

ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG, 5 MG NP PA; SP

ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG NP PA; SP

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG AD

LOCAL ANESTHETICS (PARENTERAL)lidocaine (pf) injection solution 10 mg/ml (1 %), 15 mg/ml (1.5 %), 20 mg/ml (2 %), 40 mg/ml (4 %)

AD

lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) AD

MISCELLANEOUS THERAPEUTIC AGENTSacetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) AD

ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML NP PA

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)

NP SP; PA

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML AD PA; SP; QL (2 per 30 days)

ACTONEL ORAL TABLET 150 MG, 35 MG NP PAACTONEL ORAL TABLET 5 MG NP PA; QL (30 per 30 days)alendronate oral solution 70 mg/75 ml P QL (300 per 30 days)


Drug Tier Limits or Restrictionsalendronate oral tablet 10 mg, 40 mg, 5 mg P QL (30 per 30 days)

alendronate oral tablet 35 mg, 70 mg P QL (4 per 30 days)allopurinol oral tablet 100 mg, 300 mg ADamifostine crystalline intravenous recon soln 500 mg AD

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG NP PA

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG NP SP; PA

ATELVIA ORAL TABLET,DELAYED RELEASE (DR/EC) 35 MG NP PA

AUBAGIO ORAL TABLET 14 MG, 7 MG P PA; SPAVODART ORAL CAPSULE 0.5 MG NP PAAVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG P PA; SP; QL (4 per 30 days)

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML P PA; SP; QL (4 per 30 days)

AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML P PA; SP; QL (4 per 30 days)

AVSOLA INTRAVENOUS RECON SOLN 100 MG NP PA

AZASAN ORAL TABLET 100 MG, 75 MG NP PAazathioprine oral tablet 50 mg PAZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

NP PA

AZULFIDINE ORAL TABLET 500 MG NP PABAQSIMI NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION AD

BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) P PA; SP

BERINERT INTRAVENOUS RECON SOLN 500 UNIT (10 ML) P PA

BETASERON SUBCUTANEOUS KIT 0.3 MG P PA; SPBETASERON SUBCUTANEOUS RECON SOLN 0.3 MG P PA

BINOSTO ORAL TABLET, EFFERVESCENT 70 MG NP PA

BONIVA INTRAVENOUS SYRINGE 3 MG/3 ML NP SP; PA

BONIVA ORAL TABLET 150 MG NP PA


137

Drug Tier Limits or Restrictionscalcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation P

CELLCEPT ORAL CAPSULE 250 MG NP SP; PACELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 200 MG/ML NP SP; PA

CELLCEPT ORAL TABLET 500 MG NP SP; PACERDELGA ORAL CAPSULE 84 MG ADCHEMET ORAL CAPSULE 100 MG ADCIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)


CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)


CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) NP SP; PA; QL (2 per 21 days)

cinacalcet oral tablet 30 mg, 60 mg, 90 mg AD SPCINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) NP PA; SP

colchicine oral capsule 0.6 mg ADcolchicine oral tablet 0.6 mg ADCOPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML P PA; SP; QL (30 per 30 days)

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML NP SP; PA; QL (12 per 30 days)

cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg AD

CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG AD

cyclosporine intravenous solution 250 mg/5 ml AD

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg P SP

cyclosporine modified oral solution 100 mg/ml P SP

cyclosporine oral capsule 100 mg, 25 mg PCYSTAGON ORAL CAPSULE 150 MG, 50 MG ADdalfampridine oral tablet extended release 12 hr 10 mg AD PA; SP

DENTA 5000 PLUS DENTAL CREAM 1.1 % ADDENTAGEL DENTAL GEL 1.1 % ADdisulfiram oral tablet 250 mg, 500 mg ADUCare Comprehensive FormularyEffective: October 1, 2020138

Drug Tier Limits or Restrictionsdutasteride oral capsule 0.5 mg Pdutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg NP PA

EC-NAPROXEN ORAL TABLET,DELAYED RELEASE (DR/EC) 375 MG, 500 MG P

ELIDEL TOPICAL CREAM 1 % PELMIRON ORAL CAPSULE 100 MG ADENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML) NP SP; PA; QL (4 per 30 days)

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) P PA; SP; QL (8 per 30 days)

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) P PA; SP; QL (5 per 30 days)

ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) P PA; SP; QL (4 per 30 days)

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) P PA; SP; QL (4 per 30 days)

ENDARI ORAL POWDER IN PACKET 5 GRAM AD PAENTYVIO INTRAVENOUS RECON SOLN 300 MG NP SP; PA

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG NP SP; PA

etidronate disodium oral tablet 200 mg, 400 mg NP PA

EVISTA ORAL TABLET 60 MG NP PAEVOTAZ ORAL TABLET 300-150 MG ADEXTAVIA SUBCUTANEOUS KIT 0.3 MG NP SP; PAEXTAVIA SUBCUTANEOUS RECON SOLN 0.3 MG NP SP; PA

finasteride oral tablet 5 mg PFIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML NP PA; SP; QL (9 Max Qty Per Fill

Retail)FIRDAPSE ORAL TABLET 10 MG AD PA; SPfluoride (sodium) dental gel 1.1 % ADfluoride (sodium) oral drops 0.5 mg (1.1 mg sod.fluorid)/ml AD

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 1 mg (2.2 mg sod. fluoride)

AD

FLUORITAB ORAL TABLET,CHEWABLE 0.5 MG (1.1 MG SODIUM FLUORID), 1 MG (2.2 MG SOD. FLUORIDE)

AD


139

Drug Tier Limits or Restrictionsfomepizole intravenous solution 1 gram/ml ADFOSAMAX ORAL TABLET 70 MG NP PAFOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT NP PA

FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG NP PA

FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG NP PA

GENGRAF ORAL CAPSULE 100 MG, 25 MG PGENGRAF ORAL SOLUTION 100 MG/ML PGILENYA ORAL CAPSULE 0.5 MG P PA; SPglatiramer subcutaneous syringe 20 mg/ml NP SP; PA; QL (30 per 30 days)glatiramer subcutaneous syringe 40 mg/ml NP SP; PA; QL (12 per 30 days)GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML NP SP; PA; QL (30 per 30 days)

GLATOPA SUBCUTANEOUS SYRINGE 40 MG/ML NP SP; PA; QL (12 per 30 days)

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG AD

GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG AD

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG AD

HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT NP PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML








HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML



Drug Tier Limits or RestrictionsHUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML








hydroxychloroquine oral tablet 200 mg ADibandronate oral tablet 150 mg P QL (1 per 30 days)icatibant subcutaneous syringe 30 mg/3 ml NP SP; PAILARIS (PF) SUBCUTANEOUS RECON SOLN 150 MG/ML, 180 MG/1.2 ML (150 MG/ML) NP PA

ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML NP PA

IMURAN ORAL TABLET 50 MG NP PAindomethacin oral capsule 25 mg, 50 mg PINFLECTRA INTRAVENOUS RECON SOLN 100 MG NP SP; PA

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

AD SP

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML AD SP

JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR 0.5-0.4 MG NP PA

KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML (1 ML) NP PA

KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG/1.14 ML, 200 MG/1.14 ML NP SP; PA; QL (2.28 per 21 days)

KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, 200 MG/1.14 ML NP SP; PA; QL (2.28 per 21 days)

KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML NP SP; PA

lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg NP PA

leflunomide oral tablet 10 mg, 20 mg AD QL (30 per 30 days)


141

Drug Tier Limits or Restrictionsleucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg AD SP

levocarnitine (with sugar) oral solution 100 mg/ml AD

levocarnitine oral tablet 330 mg ADlevoleucovorin calcium intravenous recon soln 175 mg AD SP

LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID), 1 MG (2.2 MG SOD. FLUORIDE)

AD

magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)

AD

magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %)

AD



MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG NP PA







MAYZENT ORAL TABLET 0.25 MG, 2 MG NP SP; PA; QL (30 per 30 days)MAYZENT STARTER PACK ORAL TABLETS,DOSE PACK 0.25 MG (12 TABS) NP PA

mercaptopurine oral tablet 50 mg ADmesna intravenous solution 100 mg/ml ADMESNEX ORAL TABLET 400 MG AD SPmethotrexate sodium (pf) injection recon soln 1 gram AD


Drug Tier Limits or Restrictionsmethotrexate sodium (pf) injection solution 25 mg/ml AD

methotrexate sodium injection solution 25 mg/ml AD

methotrexate sodium oral tablet 2.5 mg ADMIACALCIN INJECTION SOLUTION 200 UNIT/ML P

miglustat oral capsule 100 mg AD SPMITIGARE ORAL CAPSULE 0.6 MG ADMULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG

AD

MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG AD

MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 1 MG AD

mycophenolate mofetil (hcl) intravenous recon soln 500 mg AD SP

mycophenolate mofetil oral capsule 250 mg P SP

mycophenolate mofetil oral suspension for reconstitution 200 mg/ml NP SP; PA

mycophenolate mofetil oral tablet 500 mg P SPmycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NP SP; PA

MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) 180 MG, 360 MG NP SP; PA

naloxone injection auto-injector 2 mg/0.4 ml AD

naloxone injection solution 0.4 mg/ml Pnaloxone injection syringe 0.4 mg/ml, 1 mg/ml P

naltrexone oral tablet 50 mg ADnaproxen oral suspension 125 mg/5 ml ADnaproxen oral tablet 250 mg, 375 mg, 500 mg P

naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg P

naproxen sodium oral tablet 275 mg, 550 mg P

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION P


143

Drug Tier Limits or RestrictionsNATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE

AD PA

NEORAL ORAL CAPSULE 100 MG, 25 MG NP SP; PANEORAL ORAL SOLUTION 100 MG/ML NP SP; PAnitisinone oral capsule 10 mg, 2 mg, 5 mg ADOCREVUS INTRAVENOUS SOLUTION 30 MG/ML AD PA

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

AD SP

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)

AD SP

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG NP SP; PA

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML NP SP; PA

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML NP SP; PA

OTEZLA ORAL TABLET 30 MG NP SP; PA; QL (60 per 30 days)OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19)


OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 22.5 MG/0.4 ML NP PA

pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml)

AD

penicillamine oral capsule 250 mg AD SPpenicillamine oral tablet 250 mg AD SPphytonadione (vitamin k1) oral tablet 5 mg ADpimecrolimus topical cream 1 % NP PAPLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

NP SP; PA

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

NP SP; PA

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG AD SP

PREZCOBIX ORAL TABLET 800-150 MG-MG ADprobenecid oral tablet 500 mg ADUCare Comprehensive FormularyEffective: October 1, 2020144

Drug Tier Limits or Restrictionsprobenecid-colchicine oral tablet 500-0.5 mg AD

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG NP SP; PA

PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML NP SP; PA

PROSCAR ORAL TABLET 5 MG NP PAraloxifene oral tablet 60 mg PRAPAMUNE ORAL SOLUTION 1 MG/ML NP SP; PARAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG NP SP; PA

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML P PA; SP; QL (6 per 30 days)

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML P PA; SP; QL (6 per 30 days)

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)


REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)


REMICADE INTRAVENOUS RECON SOLN 100 MG NP SP; PA

RENAGEL ORAL TABLET 400 MG, 800 MG PRENFLEXIS INTRAVENOUS RECON SOLN 100 MG NP PA

RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM NP PA

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG AD PA; SP

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG NP PA

risedronate oral tablet 150 mg, 30 mg, 35 mg, 5 mg NP PA

risedronate oral tablet,delayed release (dr/ec) 35 mg NP PA

RUCONEST INTRAVENOUS RECON SOLN 2,100 UNIT NP PA

RUZURGI ORAL TABLET 10 MG AD PASANDIMMUNE ORAL CAPSULE 100 MG, 25 MG NP SP; PA

SANDIMMUNE ORAL SOLUTION 100 MG/ML NP SP; PA


145

Drug Tier Limits or Restrictionssevelamer carbonate oral tablet 800 mg NP PASF 5000 PLUS DENTAL CREAM 1.1 % ADSF DENTAL GEL 1.1 % ADSIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML NP SP; PA

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML NP SP; PA

SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML NP SP; PA

sirolimus oral solution 1 mg/ml NP PAsirolimus oral tablet 0.5 mg, 1 mg, 2 mg NP PAsodium polystyrene sulfonate oral powder ADsodium polystyrene sulfonate rectal enema 30 gram/120 ml AD

SPS (WITH SORBITOL) ORAL SUSPENSION 15-20 GRAM/60 ML AD

SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML AD

STELARA INTRAVENOUS SOLUTION 130 MG/26 ML NP SP; PA

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML NP SP; PA

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML NP SP; PA

sulfasalazine oral tablet 500 mg Psulfasalazine oral tablet,delayed release (dr/ec) 500 mg P

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg P SP

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML (150 MG/ML) NP PA

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG

NP SP; PA

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG AD PA; SP

TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

AD

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) NP PA; SP; QL (1 per 30 days)


Drug Tier Limits or RestrictionsVISTOGARD ORAL GRANULES IN PACKET 10 GRAM AD

VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML AD

XELJANZ ORAL TABLET 10 MG, 5 MG NP SP; PA; QL (60 per 30 days)XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG NP SP; PA; QL (30 per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 22 MG NP PA; QL (30 per 30 days)

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG NP SP; PA

OXYTOCICSmifepristone oral tablet 200 mg ADPHARMACEUTICAL AIDSbiotin (bulk) powder ADD-BIOTIN POWDER ADDILUENT FOR ACTHIB INTRAMUSCULAR SOLUTION 0.4 % AD

DILUENT FOR IMOVAX INTRAMUSCULAR SYRINGE AD

DILUENT FOR RABAVERT INTRAMUSCULAR SYRINGE AD

DILUENT FOR ROTARIX ORAL SYRINGE ADSHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION AD

RESPIRATORY TRACT AGENTSACCOLATE ORAL TABLET 10 MG, 20 MG NP PAacetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) AD

ADCIRCA ORAL TABLET 20 MG NP PA; SP; QL (60 per 30 days)ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG NP PA

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE




AEROSPAN INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION NP PA; QL (2 per 30 days)


147

Drug Tier Limits or RestrictionsAIRDUO RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113-14 MCG/ACTUATION, 232-14 MCG/ACTUATION, 55-14 MCG/ACTUATION


albuterol hfa 90 mcg inhaler 90 mcg/actuation P Prasco; QL (36 per 30 days)

albuterol hfa 90 mcg inhaler 90 mcg/actuation P Par; QL (14 Max Qty Per Fill

Retail)albuterol hfa 90 mcg inhaler 90 mcg/actuation P Teva; QL (17 Max Qty Per Fill

Retail)albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation P QL (14 per 30 days)

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

P

albuterol sulfate oral syrup 2 mg/5 ml Palbuterol sulfate oral tablet 2 mg, 4 mg NP PAalbuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg NP PA

ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET 10 MG P



P


P


ALLERGY RELIEF (LORATADINE) ORAL SOLUTION 5 MG/5 ML P

ALLERGY RELIEF (LORATADINE) ORAL TABLET 10 MG P

ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING 10 MG P



P


Drug Tier Limits or RestrictionsALLERGY-CONGESTION RELIEF-D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG

P

ALLER-TEC ORAL TABLET 10 MG PALOCRIL OPHTHALMIC (EYE) DROPS 2 % NP PAALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION NP PA; QL (13 per 30 days)


ALYQ ORAL TABLET 20 MG NP PAambrisentan oral tablet 10 mg, 5 mg NP PAaminophylline intravenous solution 250 mg/10 ml, 500 mg/20 ml AD

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG NP PA; QL (30 per 30 days)

ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 232 MCG/ACTUATION, 55 MCG/ACTUATION


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION


ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)


atropine injection solution 0.4 mg/ml, 1 mg/ml AD

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml AD

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION P QL (26 per 30 days)

BECONASE AQ NASAL SPRAY,NON-AEROSOL 42 MCG (0.042 %) NP PA

benzonatate oral capsule 100 mg, 150 mg, 200 mg AD

BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-4.8 MCG NP PA; QL (11 per 30 days)

bosentan oral tablet 125 mg, 62.5 mg NP PA


149

Drug Tier Limits or RestrictionsBREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

NP PA

brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg/5 ml AD

BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML NP PA; QL (120 per 30 days)

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml P QL (120 per 30 days)

budesonide inhalation suspension for nebulization 1 mg/2 ml P QL (60 per 30 days)

budesonide nasal spray,non-aerosol 32 mcg/actuation NP PA


NP PA

carbinoxamine maleate oral liquid 4 mg/5 ml AD

carbinoxamine maleate oral tablet 4 mg ADcetirizine oral solution 1 mg/ml Pcetirizine oral tablet 10 mg, 5 mg Pcetirizine oral tablet,chewable 10 mg, 5 mg Pcetirizine-pseudoephedrine oral tablet extended release 12 hr 5-120 mg P

CHILDREN'S ALLERGY RELIEF(LOR) ORAL SOLUTION 5 MG/5 ML P

CHILDREN'S CETIRIZINE ORAL TABLET,CHEWABLE 10 MG, 5 MG P

CHILD'S ALL DAY ALLERGY(CETIR) ORAL SOLUTION 1 MG/ML P

CLARINEX ORAL SYRUP 2.5 MG/5 ML (0.5 MG/ML) NP PA

CLARINEX ORAL TABLET 5 MG NP PACLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR 2.5-120 MG NP PA

clemastine oral tablet 2.68 mg ADCOMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION P QL (8 per 30 days)

cromolyn ophthalmic (eye) drops 4 % Pcromolyn oral concentrate 100 mg/5 ml ADcyproheptadine oral syrup 2 mg/5 ml ADcyproheptadine oral tablet 4 mg AD


Drug Tier Limits or RestrictionsDALIRESP ORAL TABLET 250 MCG NP PA; QL (30 per 30 days)DALIRESP ORAL TABLET 500 MCG NP PAdesloratadine oral tablet 5 mg NP PAdesloratadine oral tablet,disintegrating 2.5 mg, 5 mg NP PA

diphenhydramine hcl injection solution 50 mg/ml AD

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml AD

diphenoxylate-atropine oral tablet 2.5-0.025 mg AD

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION


DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG/2 ML NP PA; SP

DYMISTA NASAL SPRAY,NON-AEROSOL 137-50 MCG/SPRAY NP PA

epinephrine injection auto-injector 0.15 mg/0.15 ml NP PA; Non-Mylan; QL (2 per 30

days)epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml P Mylan; QL (2 per 30 days)

epinephrine injection auto-injector 0.3 mg/0.3 ml NP PA; Non-Mylan

epinephrine injection solution 1 mg/ml, 1 mg/ml (1 ml) AD

epinephrine injection syringe 0.1 mg/ml ADEPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML NP PA; QL (2 per 30 days)

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML NP PA; QL (2 per 30 days)

epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg AD SP

ESBRIET ORAL CAPSULE 267 MG AD PA; SP; QL (270 per 30 days)ESBRIET ORAL TABLET 267 MG AD PA; SP; QL (270 per 30 days)ESBRIET ORAL TABLET 801 MG AD PA; SP; QL (90 per 30 days)FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MG/ML AD PA

FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML AD PA; SP



151

Drug Tier Limits or RestrictionsFLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION P QL (4 per 30 days)





flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) NP PA; QL (50 per 30 days)

fluticasone propionate nasal spray,suspension 50 mcg/actuation P QL (16 per 30 days)

fluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation




INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION NP PA; QL (1 per 30 days)

ipratropium bromide inhalation solution 0.02 % P

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

P

KALYDECO ORAL GRANULES IN PACKET 25 MG AD SP

KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG AD PA; SP; QL (56 per 28 days)

KALYDECO ORAL TABLET 150 MG AD PA; SP; QL (60 per 30 days)LETAIRIS ORAL TABLET 10 MG, 5 MG P PA; SPlevalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml

NP PA

levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation NP PA

levocetirizine oral solution 2.5 mg/5 ml Plevocetirizine oral tablet 5 mg PLORATA-DINE D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG P


Drug Tier Limits or Restrictionsloratadine oral solution 5 mg/5 ml Ploratadine oral tablet 10 mg PLORATADINE-D ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG P


metaproterenol oral syrup 10 mg/5 ml ADmetaproterenol oral tablet 10 mg, 20 mg NP PAmometasone nasal spray,non-aerosol 50 mcg/actuation P

montelukast oral granules in packet 4 mg NP PAmontelukast oral tablet 10 mg Pmontelukast oral tablet,chewable 4 mg, 5 mg P

NASONEX NASAL SPRAY,NON-AEROSOL 50 MCG/ACTUATION NP PA

NON-DROWSY ALLERGY ORAL TABLET 10 MG P

NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML AD PA; SP; QL (1 per 21 days)

NUCALA SUBCUTANEOUS RECON SOLN 100 MG AD PA; SP; QL (1 per 21 days)

NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML AD PA; SP; QL (1 per 21 days)

NUEDEXTA ORAL CAPSULE 20-10 MG AD PA; QL (60 per 30 days)OFEV ORAL CAPSULE 100 MG, 150 MG AD PA; SP; QL (60 per 30 days)OMNARIS NASAL SPRAY,NON-AEROSOL 50 MCG NP PA

OPSUMIT ORAL TABLET 10 MG NP PAORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG

NP PA

ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG AD PA; SP; QL (56 per 28 days)

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG AD PA; SP; QL (112 per 28 days)

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML NP PA; QL (120 per 30 days)

PROAIR DIGIHALER INHALATION AERO POWDR BREATH ACT W/SENSOR 90 MCG/ACTUATION

NP PA


153

Drug Tier Limits or RestrictionsPROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION P QL (17 per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION


PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG AD SP

PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/-)/20 ML AD

promethazine injection solution 25 mg/ml, 50 mg/ml AD


PROVENTIL HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION P





PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 0.25 MG/2 ML, 0.5 MG/2 ML, 1 MG/2 ML

NP PA

PULMOZYME INHALATION SOLUTION 1 MG/ML AD SP

QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION, 80 MCG/ACTUATION NP PA





REVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML NP PA; SP; QL (112 per 30 days)

REVATIO ORAL TABLET 20 MG NP PA; SP; QL (90 per 30 days)SEMPREX-D ORAL CAPSULE 8-60 MG NP PASEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE P

sildenafil (pulm.hypertension) intravenous solution 10 mg/12.5 ml AD PA; SP


Drug Tier Limits or Restrictionssildenafil (pulm.hypertension) oral tablet 20 mg P PA; SP

SINGULAIR ORAL GRANULES IN PACKET 4 MG NP PA

SINGULAIR ORAL TABLET 10 MG NP PASINGULAIR ORAL TABLET,CHEWABLE 4 MG, 5 MG NP PA

SINUVA SINUS IMPLANT 1,350 MCG NP PASPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION


SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG P QL (90 per 30 days)

STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION NP PA; QL (4 per 30 days)

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION

P

SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N)

AD PA; SP; QL (56 per 28 days)

SYMJEPI INJECTION SYRINGE 0.15 MG/0.3 ML P

SYMJEPI INJECTION SYRINGE 0.3 MG/0.3 ML P QL (2 per 30 days)

tadalafil (pulm. hypertension) oral tablet 20 mg NP PA; SP; QL (60 per 30 days)

terbutaline oral tablet 2.5 mg, 5 mg ADterbutaline subcutaneous solution 1 mg/ml ADtheophylline oral solution 80 mg/15 ml ADtheophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg AD

TICANASE NASAL KIT,SPRAY SUSPENSION AND SPRAY 50 MCG- 0.9 % NP PA

TRACLEER ORAL TABLET 125 MG, 62.5 MG P PA; SPTRACLEER ORAL TABLET FOR SUSPENSION 32 MG NP PA; SP

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG NP PA

TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 MG(D) /150 MG (N) AD PA; QL (90 per 30 days)


155

Drug Tier Limits or RestrictionsTUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION


TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)

NP PA

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML

NP PA

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)

NP PA

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML

NP PA

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

NP PA

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) NP PA

UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 27.5-15.6 MCG

NP PA

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML NP PA

VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION P QL (8 per 30 days)

VERAMYST NASAL SPRAY,SUSPENSION 27.5 MCG/ACTUATION NP PA

WAL-ZYR (CETIRIZINE) ORAL TABLET 10 MG P

WIXELA INHUB INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCG/ACTUATION NP PA

XOLAIR SUBCUTANEOUS RECON SOLN 150 MG AD PA; SP

XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/0.5 ML AD PA; SP

XOPENEX CONCENTRATE INHALATION SOLUTION FOR NEBULIZATION 1.25 MG/0.5 ML

NP PA


Drug Tier Limits or RestrictionsXOPENEX HFA INHALATION HFA AEROSOL INHALER 45 MCG/ACTUATION P

XOPENEX INHALATION SOLUTION FOR NEBULIZATION 0.31 MG/3 ML, 0.63 MG/3 ML, 1.25 MG/3 ML

NP PA

zafirlukast oral tablet 10 mg, 20 mg PZETONNA NASAL HFA AEROSOL INHALER 37 MCG/ACTUATION NP PA

zileuton oral tablet, er multiphase 12 hr 600 mg NP PA

ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR 600 MG NP PA

ZYFLO ORAL TABLET 600 MG NP PASKIN AND MUCOUS MEMBRANE AGENTSacitretin oral capsule 10 mg, 17.5 mg, 25 mg AD SP

ACNE MEDICATION TOPICAL GEL 5 % PACNE MEDICATION TOPICAL LOTION 10 %, 5 % P

acyclovir topical cream 5 % NP PAacyclovir topical ointment 5 % Padapalene topical cream 0.1 % NP PAadapalene topical gel 0.1 %, 0.3 % NP PAadapalene topical gel with pump 0.3 % NP PAadapalene topical solution 0.1 % NP PAAKLIEF TOPICAL CREAM 0.005 % NP PAalclometasone topical cream 0.05 % ADalclometasone topical ointment 0.05 % ADANTIFUNGAL (CLOTRIMAZOLE) TOPICAL CREAM 1 % P

ANTIFUNGAL CREAM (MICONAZOLE) TOPICAL CREAM 2 % P

AVAR-E LS TOPICAL CREAM 10-2 % NP PAAVITA TOPICAL CREAM 0.025 % NP PAAVITA TOPICAL GEL 0.025 % NP PAAVSOLA INTRAVENOUS RECON SOLN 100 MG NP PA

azelaic acid topical gel 15 % ADAZELEX TOPICAL CREAM 20 % P


157

Drug Tier Limits or RestrictionsBENZACLIN PUMP TOPICAL GEL WITH PUMP 1-5 % NP PA

BENZACLIN TOPICAL GEL 1-5 % NP PABENZAMYCIN TOPICAL GEL 3-5 % NP PAbenzoyl peroxide topical cleanser 10 %, 5 %, 6 % P

benzoyl peroxide topical foam 5.3 %, 9.8 % P

benzoyl peroxide topical gel 5 % Pbetamethasone dipropionate topical cream 0.05 % AD

betamethasone dipropionate topical lotion 0.05 % AD

betamethasone valerate topical cream 0.1 % AD

betamethasone valerate topical lotion 0.1 % AD

betamethasone valerate topical ointment 0.1 % AD

betamethasone, augmented topical cream 0.05 % AD

betamethasone, augmented topical gel 0.05 % AD

betamethasone, augmented topical lotion 0.05 % AD

betamethasone, augmented topical ointment 0.05 % AD

BP 10-1 TOPICAL CLEANSER 10-1 % ADBPO TOPICAL GEL 4 %, 8 % Pcalcipotriene topical cream 0.005 % ADCENTANY AT TOPICAL OINTMENT KIT 2 % NP PACENTANY TOPICAL OINTMENT 2 % NP PAciclopirox topical cream 0.77 % Pciclopirox topical gel 0.77 % NP PAciclopirox topical shampoo 1 % NP PAciclopirox topical solution 8 % Pciclopirox topical suspension 0.77 % PCLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG AD

CLEANSING WASH TOPICAL CLEANSER 10-4-10 % AD


Drug Tier Limits or Restrictionsclindamycin phosphate topical foam 1 % ADclindamycin phosphate topical gel 1 % ADclindamycin phosphate topical lotion 1 % ADclindamycin phosphate topical solution 1 % ADclindamycin phosphate topical swab 1 % ADclindamycin phosphate vaginal cream 2 % ADclindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 % base) -5 % NP PA

clindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 % base) -5 % P

clindamycin-benzoyl peroxide topical gel with pump 1.2-2.5 % P

clindamycin-benzoyl peroxide topical gel with pump 1-5 %, 1.2-2.5 % NP PA

clindamycin-tretinoin topical gel 1.2-0.025 % NP PA

clobetasol scalp solution 0.05 % ADclobetasol topical cream 0.05 % ADclobetasol topical foam 0.05 % ADclobetasol topical gel 0.05 % ADclobetasol topical ointment 0.05 % ADclobetasol-emollient topical cream 0.05 % ADclobetasol-emollient topical foam 0.05 % ADclotrimazole mucous membrane troche 10 mg AD

clotrimazole topical cream 1 % Pclotrimazole topical solution 1 % Pclotrimazole-betamethasone topical cream 1-0.05 % P

clotrimazole-betamethasone topical lotion 1-0.05 % NP PA

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML NP SP; PA

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML NP SP; PA

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML NP SP; PA

COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML NP SP; PA

DENAVIR TOPICAL CREAM 1 % Pdesonide topical cream 0.05 % ADUCare Comprehensive FormularyEffective: October 1, 2020

159

Drug Tier Limits or Restrictionsdesonide topical lotion 0.05 % ADdesonide topical ointment 0.05 % ADdiclofenac epolamine transdermal patch 12 hour 1.3 % NP PA; QL (60 per 30 days)

diclofenac sodium topical gel 1 % P QL (500 per 21 days)diclofenac sodium topical gel 3 % P PA; QL (100 per 21 days)DIFFERIN TOPICAL CREAM 0.1 % PDIFFERIN TOPICAL GEL 0.1 %, 0.3 % PDIFFERIN TOPICAL GEL WITH PUMP 0.3 % PDIFFERIN TOPICAL LOTION 0.1 % PDUAC TOPICAL GEL 1.2 %(1 % BASE) -5 % NP PA

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG/2 ML NP PA; SP

econazole topical cream 1 % PELIDEL TOPICAL CREAM 1 % PENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML) NP SP; PA; QL (4 per 30 days)

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) P PA; SP; QL (8 per 30 days)

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) P PA; SP; QL (5 per 30 days)

ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) P PA; SP; QL (4 per 30 days)

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) P PA; SP; QL (4 per 30 days)

EPIDUO FORTE TOPICAL GEL WITH PUMP 0.3-2.5 % NP PA

EPIDUO TOPICAL GEL WITH PUMP 0.1-2.5 % NP PA

ERY PADS TOPICAL SWAB 2 % ADerythromycin with ethanol topical gel 2 % ADerythromycin with ethanol topical solution 2 % AD

ethyl chloride topical aerosol,spray 100 % ADEUCRISA TOPICAL OINTMENT 2 % NP PAEXELDERM TOPICAL CREAM 1 % NP PAEXELDERM TOPICAL SOLUTION 1 % NP PAFABIOR TOPICAL FOAM 0.1 % NP PAfinasteride oral tablet 1 mg P


Drug Tier Limits or RestrictionsFLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % NP PA

fluocinolone and shower cap scalp oil 0.01 % AD

fluocinolone topical cream 0.01 %, 0.025 % AD

fluocinolone topical oil 0.01 % ADfluocinolone topical ointment 0.025 % ADfluocinolone topical solution 0.01 % ADfluocinonide topical cream 0.05 %, 0.1 % ADfluocinonide topical gel 0.05 % ADfluocinonide topical ointment 0.05 % ADfluocinonide topical solution 0.05 % ADFLUOCINONIDE-E TOPICAL CREAM 0.05 % ADfluorouracil topical cream 5 % ADfluorouracil topical solution 2 %, 5 % ADfluticasone propionate topical cream 0.05 % AD

fluticasone propionate topical ointment 0.005 % AD

gentamicin topical cream 0.1 % ADgentamicin topical ointment 0.1 % ADhalobetasol propionate topical cream 0.05 % AD

halobetasol propionate topical ointment 0.05 % AD

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML








HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML



161

Drug Tier Limits or RestrictionsHUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML








hydrocortisone acetate rectal suppository 25 mg, 30 mg AD

hydrocortisone rectal enema 100 mg/60 ml ADhydrocortisone topical cream 2.5 % ADhydrocortisone topical lotion 2.5 % ADhydrocortisone topical ointment 2.5 % ADILUMYA SUBCUTANEOUS SYRINGE 100 MG/ML NP PA

imiquimod topical cream in packet 5 % ADINFLECTRA INTRAVENOUS RECON SOLN 100 MG NP SP; PA

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg AD

JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10 % NP PA

ketoconazole topical cream 2 % ADketoconazole topical foam 2 % NP PAketoconazole topical shampoo 2 % PLICE KILLING TOPICAL SHAMPOO 0.33-4 % P

LICE SOLUTION TOPICAL KIT 4-0.33-0.5 % P

LICE TREATMENT (PERMETHRIN) TOPICAL LIQUID 1 % P

LICE TREATMENT TOPICAL SHAMPOO 0.33-4 % P

LIDOCAINE PAIN RELIEF TOPICAL ADHESIVE PATCH,MEDICATED 4 % AD


Drug Tier Limits or Restrictionslidocaine topical adhesive patch,medicated 5 % NP PA

lidocaine topical ointment 5 % ADlidocaine-hydrocortisone-aloe rectal kit 2-2 %, 3-2.5 % (7 gram) AD

lidocaine-prilocaine topical cream 2.5-2.5 % AD

lidocaine-prilocaine topical kit 2.5-2.5 % ADLIDODERM TOPICAL ADHESIVE PATCH,MEDICATED 5 % NP PA

LIDOPURE PATCH TOPICAL COMBO PACK 5 % NP PA

lindane topical shampoo 1 % NP PALOPROX (AS OLAMINE) TOPICAL CREAM 0.77 % NP PA

LOPROX (AS OLAMINE) TOPICAL SUSPENSION 0.77 % NP PA

LOPROX KIT TOPICAL COMBO PACK 0.77 % NP PA

LOPROX KIT TOPICAL KIT, SUSPENSION AND CLEANSER 0.77 % NP PA

LOPROX TOPICAL GEL 0.77 % NP PALOPROX TOPICAL SHAMPOO 1 % NP PALUZU TOPICAL CREAM 1 % NP PAmalathion topical lotion 0.5 % NP PAmethoxsalen oral capsule,liqd-filled,rapid rel 10 mg AD SP

metronidazole topical cream 0.75 % ADmetronidazole topical gel 0.75 % ADmetronidazole topical lotion 0.75 % ADmetronidazole vaginal gel 0.75 % ADmiconazole nitrate topical aerosol powder 2 % P

MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG AD QL (3 per 30 days)

mometasone topical cream 0.1 % ADmometasone topical ointment 0.1 % ADmometasone topical solution 0.1 % ADmupirocin calcium topical cream 2 % NP PAmupirocin topical ointment 2 % P


163

Drug Tier Limits or RestrictionsMYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG AD

naftifine topical cream 1 %, 2 % NP PANAFTIN TOPICAL CREAM 2 % NP PANAFTIN TOPICAL GEL 1 %, 2 % NP PANATROBA TOPICAL SUSPENSION 0.9 % Pneomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml AD

NEUAC KIT TOPICAL COMBO PACK,CREAM AND GEL 1.2-5 % NP PA

NEUAC TOPICAL GEL 1.2 %(1 % BASE) -5 % NP PA

NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM AD

nystatin topical cream 100,000 unit/gram Pnystatin topical ointment 100,000 unit/gram P

nystatin topical powder 100,000 unit/gram Pnystatin-triamcinolone topical cream 100,000-0.1 unit/g-% P

nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-% NP PA

NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM AD

ONEXTON TOPICAL GEL 1.2 %(1 % BASE) -3.75 % NP PA

ONEXTON TOPICAL GEL WITH PUMP 1.2 %(1 % BASE) -3.75 % NP PA

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG NP PA

OTEZLA ORAL TABLET 30 MG NP SP; PA; QL (60 per 30 days)OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19)


OVIDE TOPICAL LOTION 0.5 % NP PAoxiconazole topical cream 1 % NP PAOXISTAT TOPICAL CREAM 1 % NP PAPENLAC TOPICAL SOLUTION 8 % NP PApermethrin topical cream 5 % Pphenazopyridine oral tablet 100 mg, 200 mg AD


Drug Tier Limits or Restrictionspimecrolimus topical cream 1 % NP PApodofilox topical solution 0.5 % ADprednicarbate topical cream 0.1 % ADprednicarbate topical ointment 0.1 % ADPROCTOFOAM HC RECTAL FOAM 1-1 % ADPROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR 1 % AD

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % AD

PROTOPIC TOPICAL OINTMENT 0.03 %, 0.1 % P

QUTENZA TOPICAL KIT 8 % NP PARECTIV RECTAL OINTMENT 0.4 % (W/W) ADREMICADE INTRAVENOUS RECON SOLN 100 MG NP SP; PA

RENFLEXIS INTRAVENOUS RECON SOLN 100 MG NP PA

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.04 %, 0.06 %, 0.08 %, 0.1 % NP PA

RETIN-A MICRO TOPICAL GEL 0.04 %, 0.1 % NP PA

RETIN-A TOPICAL CREAM 0.025 %, 0.05 %, 0.1 % NP PA

RETIN-A TOPICAL GEL 0.01 %, 0.025 % NP PAsalicylic acid topical cream 6 % ADsalicylic acid topical cream,extended release 6 % AD

salicylic acid topical gel 6 % ADsalicylic acid topical lotion 6 % ADsalicylic acid topical lotion,extended release 6 % AD

salicylic acid topical shampoo 6 % ADSANTYL TOPICAL OINTMENT 250 UNIT/GRAM AD PA; SP; QL (180 per 30 days)

SILIQ SUBCUTANEOUS SYRINGE 210 MG/1.5 ML NP SP; PA

silver nitrate topical ointment 10 % ADsilver nitrate topical solution 0.5 %, 25 %, 50 % AD

silver sulfadiazine topical cream 1 % ADSKLICE TOPICAL LOTION 0.5 % NP PA


165

Drug Tier Limits or Restrictionsspinosad topical suspension 0.9 % NP PASSD TOPICAL CREAM 1 % ADSSS 10-5 TOPICAL CREAM 10-5 % (W/W) ADSTELARA INTRAVENOUS SOLUTION 130 MG/26 ML NP SP; PA

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML NP SP; PA

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML NP SP; PA

sulfacetamide sodium (acne) topical suspension 10 % AD

sulfacetamide sodium topical cleanser 10 % AD

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) AD

sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) AD

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w) AD

sulfacetamide sodium-sulfur topical suspension 10-5 % AD

sulfacetamide sod-sulfur-urea topical cleanser 10-5-10 % AD

tacrolimus topical ointment 0.03 %, 0.1 % NP PATALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML

NP SP; PA

TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML

NP SP; PA

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML NP SP; PA

TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML NP SP; PA

TARGRETIN TOPICAL GEL 1 % ADtazarotene topical cream 0.1 % NP PATAZORAC TOPICAL CREAM 0.05 %, 0.1 % PTAZORAC TOPICAL GEL 0.05 %, 0.1 % Pterbinafine hcl topical cream 1 % Pterconazole vaginal cream 0.4 %, 0.8 % ADterconazole vaginal suppository 80 mg AD QL (3 per 30 days)tolnaftate topical cream 1 % PUCare Comprehensive FormularyEffective: October 1, 2020166

Drug Tier Limits or RestrictionsTREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML NP SP; PA

TREMFYA SUBCUTANEOUS SYRINGE 100 MG/ML NP SP; PA

tretinoin microspheres topical gel 0.04 %, 0.1 % NP PA

tretinoin microspheres topical gel with pump 0.04 %, 0.1 % NP PA

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % P

tretinoin topical gel 0.01 %, 0.025 % Ptretinoin topical gel 0.05 % NP PAtriamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 % AD

triamcinolone acetonide topical lotion 0.025 %, 0.1 % AD

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % AD

urea topical cream 50 % ADurea topical lotion 40 % ADVALCHLOR TOPICAL GEL 0.016 % AD SPVANDAZOLE VAGINAL GEL 0.75 % ADVOLTAREN TOPICAL GEL 1 % NP PAVUSION TOPICAL OINTMENT 0.25-15-81.35 % NP PA

XERESE TOPICAL CREAM 5-1 % NP PAZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG AD

ZIANA TOPICAL GEL 1.2-0.025 % NP PAZOVIRAX TOPICAL CREAM 5 % NP PAZOVIRAX TOPICAL OINTMENT 5 % NP PASMOOTH MUSCLE RELAXANTSaminophylline intravenous solution 250 mg/10 ml, 500 mg/20 ml AD

darifenacin oral tablet extended release 24 hr 15 mg, 7.5 mg NP PA

DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR 2 MG, 4 MG NP PA

DETROL ORAL TABLET 1 MG, 2 MG NP PADITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG, 5 MG NP PA


167

Drug Tier Limits or RestrictionsENABLEX ORAL TABLET EXTENDED RELEASE 24 HR 15 MG, 7.5 MG NP PA

flavoxate oral tablet 100 mg NP PAGELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)


GELNIQUE TRANSDERMAL GEL IN PACKET 10 % (100 MG/GRAM) NP PA; QL (30 per 30 days)

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG NP PA

oxybutynin chloride oral syrup 5 mg/5 ml Poxybutynin chloride oral tablet 5 mg Poxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg P

OXYTROL TRANSDERMAL PATCH SEMIWEEKLY 3.9 MG/24 HR P

solifenacin oral tablet 10 mg, 5 mg Ptheophylline oral solution 80 mg/15 ml ADtheophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg AD

tolterodine oral capsule,extended release 24hr 2 mg, 4 mg P

tolterodine oral tablet 1 mg, 2 mg PTOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG P

trospium oral capsule,extended release 24hr 60 mg NP PA

trospium oral tablet 20 mg NP PAVESICARE ORAL TABLET 10 MG, 5 MG NP PAVITAMINSBAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR 27-1-430 MG AD

calcitriol intravenous solution 1 mcg/ml ADcalcitriol oral capsule 0.25 mcg, 0.5 mcg ADcalcitriol oral solution 1 mcg/ml ADCOMPLETE NATAL DHA ORAL COMBO PACK 29-1-250-200 MG AD

COMPLETENATE ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG AD

cyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml AD


Drug Tier Limits or RestrictionsELITE OB WITH DHA ORAL CAPSULE 28-1.25-200 MG AD

ELITE-OB 400 ORAL CAPSULE 35-5-1.2-400 MG AD

ergocalciferol (vitamin d2) oral capsule 1,250 mcg (50,000 unit) AD

FOLBIC RF ORAL TABLET 2-1.13-25 MG ADfolic acid injection solution 5 mg/ml ADFOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT NP PA

MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG

AD

MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG AD

MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 1 MG AD




phytonadione (vitamin k1) oral tablet 5 mg ADPNV OB+DHA ORAL COMBO PACK 27-1-50-250 MG AD

PNV-DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG AD

PNV-OMEGA ORAL CAPSULE 28-1-300 MG ADPNV-SELECT ORAL TABLET 27-1 MG ADPR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR 29-1-400 MG AD




PRENATABS FA ORAL TABLET 29-1 MG ADPRENATABS RX ORAL TABLET 29 MG IRON- 1 MG AD


169

Drug Tier Limits or RestrictionsPRENATAL LOW IRON ORAL TABLET 27 MG IRON- 1 MG AD



PRENATAL-U ORAL CAPSULE 106.5-1 MG ADRENAL CAPS ORAL CAPSULE 1 MG ADRENA-VITE RX ORAL TABLET 1-60-300 MG-MG-MCG AD

RENO CAPS ORAL CAPSULE 1 MG ADSE-NATAL 19 CHEWABLE ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG AD


TRIADVANCE ORAL TABLET 90-1-50 MG ADTRINATAL RX 1 ORAL TABLET 60 MG IRON-1 MG AD



TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

AD


VINACAL ORAL TABLET 27-1-50 MG ADVINATE CARE ORAL TABLET,CHEWABLE 40 MG IRON- 1 MG AD

VINATE GT ORAL TABLET 90-1-50 MG ADVINATE II ORAL TABLET 29 MG IRON- 1 MG AD

VINATE M ORAL TABLET 27 MG IRON-1 MG ADVINATE ONE ORAL TABLET 60 MG IRON-1 MG AD

VINATE PN CARE ORAL TABLET 30-1-50 MG AD

VINATE ULTRA ORAL TABLET 90-1-50 MG ADVIRT-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG AD


Drug Tier Limits or RestrictionsVIRT-PN ORAL TABLET 27-1 MG ADVIRT-PN PLUS ORAL CAPSULE 28-1-300 MG AD


VITAFOL-OB ORAL TABLET 65-1 MG ADVITAMIN D2 ORAL CAPSULE 1,250 MCG (50,000 UNIT) AD

VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML AD

VOL-NATE ORAL TABLET 28 MG IRON- 1 MG AD

ZATEAN-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG AD



171

Indexabacavir............................ 3abacavir-lamivudine............ 3abacavir-lamivudine-zidovudine......................... 3ABILIFY............................60ABILIFY MAINTENA............60ABILIFY MYCITE................ 60abiraterone.......................17acamprosate.....................60acarbose........................ 115ACCOLATE...................... 147ACCU-CHEK AVIVA PLUS METER............................. 90ACCU-CHEK AVIVA PLUS TEST STRP....................... 92ACCU-CHEK COMPACT PLUS TEST....................... 92ACCU-CHEK GUIDE GLUCOSE METER...............90ACCU-CHEK GUIDE ME GLUCOSE MTR.................. 90ACCU-CHEK GUIDE TEST STRIPS............................ 92ACCU-CHEK NANO.............90ACCU-CHEK SMARTVIEW TEST STRIP...................... 92ACCUPRIL........................ 45ACCURETIC.................45, 92acebutolol...................27, 45acetaminophen-codeine..... 60acetazolamide...... 45, 93, 101acetazolamide sodium.......................... 45, 93, 101acetic acid.................93, 102acetylcysteine..........136, 147ACIPHEX........................ 108ACIPHEX SPRINKLE..........108acitretin......................... 157ACNE MEDICATION..........157ACTEMRA....................... 136ACTEMRA ACTPEN........... 136ACTHIB (PF)..................... 22ACTONEL........................136ACTOPLUS MET XR.......... 115ACULAR..........................102ACULAR LS..................... 102ACUVAIL (PF)..................102acyclovir.....................3, 157acyclovir sodium................. 3ADACEL(TDAP ADOLESN/ADULT)(PF)........22

ADALAT CC.......................45adapalene...................... 157ADCIRCA.................. 45, 147ADDERALL XR................... 60adefovir............................. 3ADEMPAS..................45, 147ADHANSIA XR...................61ADLYXIN........................ 116ADMELOG SOLOSTAR U-100 INSULIN...................116ADMELOG U-100 INSULIN LISPRO.......................... 116ADVAIR DISKUS. 27, 116, 147ADVAIR HFA.......27, 116, 147ADVATE........................... 36ADYNOVATE..................... 36ADZENYS ER.....................61ADZENYS XR-ODT............. 61AEMCOLO.......................... 3AEROSPAN.............. 116, 147AFINITOR.........................17AFINITOR DISPERZ........... 17AFLURIA QD 2020-21(3YR UP)(PF)............................22AFLURIA QD 2020-21(6-35MO)(PF)....................... 22AFLURIA QUAD 2020-2021(6MO UP).................. 22AFREZZA........................116AFSTYLA.......................... 37AGGRENOX............37, 45, 61AIMOVIG AUTOINJECTOR... 61AIRDUO RESPICLICK........................ 28, 116, 148AJOVY AUTOINJECTOR....... 61AJOVY SYRINGE................ 61AKLIEF...........................157AKYNZEO (NETUPITANT).. 108ALAWAY......................... 102albendazole........................3albuterol sulfate.........28, 148alclometasone.................157ALECENSA........................17alendronate............. 136, 137alfuzosin.......................... 28aliskiren...........................45ALL DAY ALLERGY (CETIRIZINE).............. 1, 148ALL DAY ALLERGY-D............................1, 28, 148

ALLERGY AND CONGESTION RELIEF............................1, 28, 148ALLERGY COMPLETE-D............................1, 28, 148ALLERGY RELIEF (LORATADINE)............ 1, 148ALLERGY RELIEF D-24HR............................1, 28, 148ALLERGY RELIEF,NASAL DECONGEST.......... 1, 28, 148ALLERGY-CONGESTION RELIEF-D.............. 1, 28, 149ALLER-TEC..................1, 149allopurinol...................... 137almotriptan malate............ 61ALOCRIL................. 102, 149alogliptin........................ 116alogliptin-metformin........ 116alogliptin-pioglitazone...... 116ALOMIDE........................102alosetron........................108ALPHAGAN P................... 102ALPHANATE...................... 37ALPHANINE SD................. 37alprazolam....................... 61ALPROLIX.........................37ALREX............................102ALTACE............................45ALTAVERA (28)............... 116ALTOPREV........................ 45ALUNBRIG........................17ALVESCO................ 116, 149ALYACEN 1/35 (28)..........116ALYACEN 7/7/7 (28)........ 116ALYQ........................45, 149amantadine hcl............. 3, 61AMARYL......................... 117AMBIEN........................... 61AMBIEN CR.......................61ambrisentan.............. 45, 149AMERGE...........................61AMETHIA........................117AMETHIA LO................... 117AMETHYST (28)...............117amifostine crystalline....... 137amikacin............................3amiloride.................... 45, 93amiloride-hydrochlorothiazide......45, 93aminophylline.......... 149, 167


173

amiodarone...................... 45AMITIZA.........................109amitriptyline..................... 61amitriptyline-chlordiazepoxide............... 61amlodipine....................... 45amlodipine-atorvastatin..... 45amlodipine-benazepril........46amlodipine-olmesartan.......46amlodipine-valsartan......... 46amlodipine-valsartan-hcthiazid.....................46, 93ammonium chloride........... 93amoxapine....................... 61amoxicillin..........................3amoxicillin-pot clavulanate3, 4amphetamine sulfate......... 61amphotericin b................... 4ampicillin........................... 4ampicillin sodium................ 4ampicillin-sulbactam............4AMPYRA......................... 137anagrelide........................ 37anastrozole............... 17, 117ANCOBON.......................... 4ANDRODERM.................. 117ANDROGEL..................... 117ANORO ELLIPTA................ 28ANTARA........................... 46ANTIFUNGAL (CLOTRIMAZOLE)............ 157ANTIFUNGAL CREAM (MICONAZOLE)............... 157ANZEMET....................... 109APIDRA SOLOSTAR U-100 INSULIN.........................117APIDRA U-100 INSULIN....117APLENZIN........................ 61apraclonidine.................. 102aprepitant...................... 109APRI.............................. 117APRISO.......................... 109APTENSIO XR................... 61APTIOM............................62APTIVUS............................ 4APTIVUS (WITH VITAMIN E)..................................... 4ARANELLE (28)............... 117ARANESP (IN POLYSORBATE)................. 37ARCAPTA NEOHALER.. 28, 149ARICEPT.......................... 29

ARIKAYCE.......................... 4aripiprazole...................... 62ARISTADA........................ 62ARISTADA INITIO..............62ARIXTRA.......................... 37armodafinil.......................62ARMONAIR RESPICLICK..............................117, 149ARNUITY ELLIPTA.....117, 149ARYMO ER........................62ASACOL HD.................... 109ASCOMP WITH CODEINE.... 62ASMANEX HFA......... 117, 149ASMANEX TWISTHALER..............................117, 149aspirin-dipyridamole............................37, 46, 62ASTAGRAF XL................. 137ASTEPRO........................102ATACAND......................... 46ATACAND HCT.............46, 93atazanavir..........................4ATELVIA.........................137atenolol...................... 29, 46atenolol-chlorthalidone............................29, 46, 93atomoxetine..................... 62atorvastatin......................46atovaquone........................ 4atovaquone-proguanil..........4ATRIPLA............................ 4atropine.............29, 102, 149ATROVENT HFA............... 149AUBAGIO........................137AUBRA........................... 117AUGMENTIN....................... 4AUGMENTIN XR.................. 4AURYXIA.......................... 93AUSTEDO.........................62AVALIDE.....................46, 93AVANDIA........................117AVAPRO........................... 46AVAR-E LS......................157AVELOX............................. 4AVIANE.......................... 118AVITA............................ 157AVODART....................... 137AVONEX......................... 137AVONEX (WITH ALBUMIN) 137AVSOLA........... 109, 137, 157AXIRON..........................118AYVAKIT.......................... 17

AZASAN......................... 137AZASITE.........................102azathioprine....................137azelaic acid.....................157azelastine.......................102AZELEX.......................... 157azithromycin...................... 4AZOPT........................... 102AZOR...............................46aztreonam......................... 4AZULFIDINE.........5, 109, 137AZULFIDINE EN-TABS.......................... 4, 109, 137AZURETTE (28)............... 118bacitracin....................5, 102bacitracin-polymyxin b..... 102baclofen...........................29BALANCED SALT..............102BAL-CARE DHA.....37, 93, 168balsalazide..................... 109BALVERSA........................17BALZIVA (28)..................118BANZEL........................... 62BAQSIMI................. 118, 137BARACLUDE....................... 5BASAGLAR KWIKPEN U-100 INSULIN...................118BAXDELA........................... 5BD PRE-FILLED NORMAL SALINE............................ 93BECONASE AQ......... 102, 149BELBUCA..........................62BELSOMRA....................... 62benazepril........................ 46benazepril-hydrochlorothiazide......46, 93BENEFIX.......................... 37BENICAR..........................46BENICAR HCT..............46, 93BENZACLIN.....................158BENZACLIN PUMP............ 158BENZAMYCIN.................. 158BENZNIDAZOLE.................. 5benzonatate....................149benzoyl peroxide............. 158benztropine.................29, 62BEPREVE........................ 102BERINERT.......................137BESIVANCE.....................102betamethasone dipropionate................... 158betamethasone valerate... 158


betamethasone, augmented..................... 158BETAPACE...................29, 46BETAPACE AF.............. 29, 46BETASERON....................137betaxolol............. 29, 46, 102bethanechol chloride..........29BETHKIS............................5BETOPTIC S....................102BEVESPI AEROSPHERE29, 149BEVYXXA..........................37bexarotene.......................17BEXSERO......................... 22bicalutamide.....................17BIDIL...............................46BIKTARVY.......................... 5bimatoprost.................... 103BINOSTO........................137biotin (bulk)....................147bisoprolol fumarate...... 29, 47bisoprolol-hydrochlorothiazide 29, 47, 93BLEPHAMIDE...................103BLEPHAMIDE S.O.P..........103BLISOVI 24 FE................ 118BLISOVI FE 1.5/30 (28)....118BLISOVI FE 1/20 (28)...... 118BONIVA..........................137BOOSTRIX TDAP............... 22bortezomib.......................17bosentan...................47, 149BOSULIF.......................... 17BP 10-1..........................158BPO............................... 158BRAFTOVI........................ 17BREO ELLIPTA.... 29, 118, 150BRIELLYN....................... 118BRILINTA......................... 37brimonidine.................... 103BRINTELLIX......................63BRISDELLE.......................63BRIVIACT.........................63bromfenac...................... 103bromocriptine................... 63brompheniramine-pseudoeph-dm...........29, 150BROMSITE......................103BROVANA..................29, 150BRUKINSA........................17budesonide...... 103, 118, 150

budesonide-formoterol........................ 29, 118, 150bumetanide.................47, 93BUNAVAIL........................ 63buprenorphine.................. 63buprenorphine hcl............. 63buprenorphine-naloxone.....63bupropion hcl....................63bupropion hcl (smoking deter)..............................63buspirone.........................63BUTALBITAL COMPOUND W/CODEINE......................63butalbital-acetaminop-caf-cod..................................63butalbital-acetaminophen... 63butalbital-acetaminophen-caff................................. 64butalbital-aspirin-caffeine................................. 37, 64BYDUREON..................... 118BYDUREON BCISE............118BYETTA...................118, 119BYSTOLIC................... 29, 47BYVALSON.................. 29, 47cabergoline.......................64CABLIVI........................... 38CABOMETYX..................... 17CADUET........................... 47CALAN............................. 47CALAN SR........................ 47calcipotriene................... 158calcitonin (salmon)... 119, 138calcitriol......................... 168calcium acetate(phosphat bind)............................... 93CALQUENCE..................... 17CAMILA.......................... 119CAMRESE....................... 119CAMRESE LO...................119CANASA......................... 109candesartan..................... 47candesartan-hydrochlorothiazid....... 47, 93capecitabine..................... 17CAPITAL WITH CODEINE.... 64CAPLYTA.......................... 64CAPRELSA........................ 17captopril.......................... 47captopril-hydrochlorothiazide......47, 93CARAFATE...................... 109

CARBAGLU....................... 94carbamazepine..................64CARBATROL......................64carbidopa-levodopa........... 64carbidopa-levodopa-entacapone...................... 64carbinoxamine maleate.1, 150CARDIZEM....................... 47CARDIZEM CD.................. 47CARDIZEM LA................... 47CARDURA................... 29, 47CARDURA XL............... 29, 47carisoprodol-aspirin-codeine...................... 30, 64carteolol.........................103CARTIA XT....................... 47carvedilol....................30, 47carvedilol phosphate.... 30, 48CATHFLO ACTIVASE... 38, 101CAYSTON...........................5CAZIANT (28)................. 119cefaclor............................. 5cefadroxil...........................5cefazolin............................ 5cefazolin in dextrose (iso-os)....................................5cefdinir.............................. 5cefditoren pivoxil................ 5cefepime............................5cefepime in dextrose,iso-osm.................................. 5cefixime.............................5cefotaxime......................... 5cefotetan........................5, 6cefoxitin............................ 6cefoxitin in dextrose, iso-osm.................................. 6cefpodoxime.......................6cefprozil.............................6ceftazidime........................ 6ceftriaxone.........................6ceftriaxone in dextrose,iso-os..................................... 6cefuroxime axetil................ 6cefuroxime sodium..............6CELEBREX........................ 64celecoxib..........................64CELEXA............................64CELLCEPT....................... 138CELONTIN........................ 64CENTANY........................158CENTANY AT................... 158


175

cephalexin......................... 6CERDELGA......................138CESAMET....................... 109cetirizine.....................1, 150cetirizine-pseudoephedrine............................1, 30, 150cevimeline........................30CHANTIX..........................30CHANTIX CONTINUING MONTH BOX..................... 30CHANTIX STARTING MONTH BOX..................... 30CHATEAL (28)................. 119CHEMET.................. 115, 138CHILDREN'S ALAWAY....... 103CHILDREN'S ALLERGY RELIEF(LOR)............... 1, 150CHILDREN'S CETIRIZINE................................. 1, 150CHILD'S ALL DAY ALLERGY(CETIR)..........1, 150chloramphenicol sod succinate........................... 6chlorhexidine gluconate....103chloroquine phosphate.........6chlorothiazide..............48, 94chlorpromazine............64, 65chlorthalidone............. 48, 94chlorzoxazone...................30cholestyramine (with sugar)............................. 48CHOLESTYRAMINE LIGHT... 48choline,magnesium salicylate..........................65chromium chloride.............94ciclopirox........................158cilostazol.................... 38, 48CILOXAN........................ 103CIMDUO............................ 6cimetidine...................... 109cimetidine hcl..................109CIMZIA................... 109, 138CIMZIA POWDER FOR RECONST................ 109, 138CIMZIA STARTER KIT109, 138cinacalcet....................... 138CINRYZE........................ 138CIPRO............................... 6CIPRO HC.......................103CIPRO XR...........................6CIPRODEX...................... 103ciprofloxacin.......................7

ciprofloxacin (mixture).........6ciprofloxacin hcl...........7, 103ciprofloxacin in 5 % dextrose............................ 7citalopram........................65CLARAVIS.......................158CLARINEX...................2, 150CLARINEX-D 12 HOUR............................2, 30, 150clarithromycin.................... 7CLEANSING WASH...........158clemastine.................. 2, 150CLEO 90 INFUSION SET 24"..................................90clindamycin hcl................... 7clindamycin palmitate hcl..... 7CLINDAMYCIN PEDIATRIC.... 7clindamycin phosphate. 7, 159clindamycin-benzoyl peroxide.........................159clindamycin-tretinoin....... 159clobazam......................... 65clobetasol.......................159clobetasol-emollient.........159clomipramine....................65clonazepam...................... 65clonidine.....................30, 48clonidine hcl................30, 48clopidogrel....................... 38clorazepate dipotassium..... 65clotrimazole.................... 159clotrimazole-betamethasone............... 159clozapine..........................65CLOZARIL........................ 65COAGADEX.......................38COARTEM...........................7COLAZAL........................109colchicine....................... 138colesevelam.............. 48, 119COLESTID........................ 48COLESTID FLAVORED........ 48colestipol......................... 48colistin (colistimethate na)... 7COMBIGAN..................... 103COMBIVENT RESPIMAT............................... 30, 150COMBIVIR..........................7COMETRIQ....................... 17COMFORT SHORT INFUSION SET 23"............ 90COMPLERA......................... 7

COMPLETE NATAL DHA.......................... 38, 94, 168COMPLETENATE...............168COMPRO................... 65, 109CONCERTA....................... 65CONSTULOSE................... 94CONTOUR METER.............. 90CONTOUR NEXT EZ METER. 90CONTOUR NEXT METER......90CONTOUR NEXT ONE METER............................. 90CONTOUR NEXT TEST STRIPS............................ 92CONTOUR TEST STRIPS..... 92COPAXONE..................... 138COPIKTRA........................ 17COREG....................... 30, 48COREG CR.................. 30, 48CORGARD...................30, 48CORLANOR.......................48cortisone........................ 119CORZIDE...............30, 48, 94COSENTYX......................159COSENTYX (2 SYRINGES). 159COSENTYX PEN............... 159COSENTYX PEN (2 PENS)..159COSOPT......................... 103COSOPT (PF).................. 103cosyntropin...................... 92COTELLIC.........................17COTEMPLA XR-ODT............65COZAAR...........................48CREON...........................109CRESEMBA.........................7CRESTOR......................... 49CRIXIVAN.......................... 7cromolyn.................103, 150CRYSELLE (28)................119CRYSVITA........................ 94cyanocobalamin (vitamin b-12)............................. 168CYCLAFEM 1/35 (28)........119CYCLAFEM 7/7/7 (28)...... 119cyclobenzaprine................ 30cyclophosphamide......17, 138CYCLOPHOSPHAMIDE. 17, 138cyclosporine....................138cyclosporine modified.......138CYMBALTA........................65cyproheptadine............2, 150cyred............................. 119CYSTAGON..................... 138


CYSTARAN......................103DAKLINZA..........................7dalfampridine..................138DALIRESP.......................151danazol.......................... 119dantrolene........................30dapsone.............................7DAPTACEL (DTAP PEDIATRIC) (PF)............... 23daptomycin........................ 7DARAPRIM......................... 7darifenacin..................... 167DASETTA 1/35 (28)......... 119DASETTA 7/7/7 (28)........ 119DAURISMO....................... 17DAXBIA............................. 7DAYPRO........................... 65DAYSEE..........................119DAYTRANA....................... 65D-BIOTIN....................... 147deferasirox..................... 115DELSTRIGO........................7DELZICOL.......................109DENAVIR........................159DENTA 5000 PLUS........... 138DENTAGEL......................138DEPAKENE........................65DEPAKOTE....................... 65DEPAKOTE ER...................65DEPAKOTE SPRINKLES.......66DEPO-PROVERA...............119DESCOVY...........................7desipramine......................66desloratadine.............. 2, 151desmopressin............ 38, 119desogestrel-ethinyl estradiol.........................119desonide................. 159, 160desvenlafaxine..................66desvenlafaxine fumarate.... 66desvenlafaxine succinate.... 66DETROL......................... 167DETROL LA..................... 167dexamethasone........119, 120DEXAMETHASONE INTENSOL...................... 119dexamethasone sodium phos (pf)........................ 120dexamethasone sodium phosphate............... 103, 120DEXCOM G5 RECEIVER...... 90DEXCOM G5 TRANSMITTER.90

DEXCOM G5-G4 SENSOR....90DEXCOM G6 RECEIVER...... 90DEXCOM G6 SENSOR.........90DEXCOM G6 TRANSMITTER.90DEXEDRINE SPANSULE...... 66DEXILANT.......................110dexmethylphenidate.......... 66dextroamphetamine...........66dextroamphetamine-amphetamine.............. 66, 67dextrose 5 %-lactated ringers.............................94DIACOMIT........................ 67DIASTAT.......................... 67DIASTAT ACUDIAL.............67diazepam......................... 67DIAZEPAM INTENSOL.........67diazoxide........................120diclofenac epolamine.. 67, 160diclofenac potassium..........67diclofenac sodium...................17, 67, 104, 160dicloxacillin........................ 7dicyclomine...................... 30didanosine......................... 7DIFFERIN....................... 160DIFICID............................. 8DIFLUCAN..........................8diflunisal.......................... 67DIGOX............................. 49digoxin............................ 49DILANTIN................... 49, 68DILANTIN EXTENDED... 49, 67DILANTIN INFATABS.... 49, 68DILANTIN-125.............49, 68diltiazem hcl..................... 49DILT-XR...........................49DILUENT FOR ACTHIB...... 147DILUENT FOR IMOVAX..... 147DILUENT FOR RABAVERT.. 147DILUENT FOR ROTARIX.... 147DIOVAN........................... 50DIOVAN HCT............... 49, 94DIPENTUM......................110diphenhydramine hcl.... 2, 151diphenoxylate-atropine...................30, 31, 110, 151dipyridamole............... 38, 50disopyramide phosphate.....50disulfiram....................... 138DITROPAN XL..................167divalproex........................ 68

dofetilide..........................50donepezil......................... 31dorzolamide....................104dorzolamide-timolol......... 104dorzolamide-timolol (pf)... 104DOVATO............................ 8doxazosin................... 31, 50doxepin............................68doxycycline hyclate...... 8, 104doxycycline monohydrate.....8dronabinol...................... 110drospirenone-ethinyl estradiol.........................120DROXIA........................... 18DUAC.............................160DUETACT........................120DUEXIS.................... 68, 110DULERA.............31, 120, 151duloxetine........................ 68DUPIXENT SYRINGE..151, 160DURAGESIC......................68dutasteride..................... 139dutasteride-tamsulosin.....139DYANAVEL XR...................68DYMISTA.................104, 151E.E.S. 400..........................8E.E.S. GRANULES................8ECLIPSE SYRINGE............. 90EC-NAPROXEN........... 68, 139econazole....................... 160ECONTRA EZ...................120EDARBI............................50EDARBYCLOR.............. 50, 94EDLUAR........................... 68EDURANT...........................8efavirenz........................... 8EFFEXOR XR..................... 68EFFIENT...........................38ELELYSO........................ 101ELESTAT........................ 104eletriptan......................... 68ELIDEL....................139, 160ELINEST.........................120ELIQUIS...........................38ELIQUIS DVT-PE TREAT 30D START.......................38ELITE OB WITH DHA........ 169ELITE-OB 400............38, 169ELLA.............................. 120ELMIRON........................139ELOCTATE........................ 38ELURYNG........................120


177

EMADINE........................104EMBEDA...........................68EMCYT............................. 18EMGALITY PEN..................68EMGALITY SYRINGE...........68EMOQUETTE................... 120EMTRIVA............................8ENABLEX........................ 168enalapril maleate...............50enalapril-hydrochlorothiazide......50, 94ENBREL...................139, 160ENBREL MINI........... 139, 160ENBREL SURECLICK..139, 160ENDARI...................110, 139ENDOCET................... 68, 69ENGERIX-B (PF)................ 23ENGERIX-B PEDIATRIC (PF).................................23enoxaparin....................... 38ENPRESSE...................... 120ENSKYCE........................120entacapone...................... 69entecavir........................... 8ENTRESTO........................50ENTYVIO................. 110, 139ENULOSE......................... 94ENVARSUS XR.................139EPCLUSA............................8EPIDIOLEX....................... 69EPIDUO..........................160EPIDUO FORTE................160epinastine...................... 104epinephrine............... 31, 151EPIPEN............................ 31EPIPEN 2-PAK............31, 151EPIPEN JR........................ 31EPIPEN JR 2-PAK........31, 151EPITOL............................ 69EPIVIR...............................8EPIVIR HBV........................8eplerenone....................... 50EPOGEN...........................38epoprostenol (glycine) 50, 151eprosartan....................... 50ergocalciferol (vitamin d2) 169ergoloid........................... 31ERIVEDGE........................ 18ERLEADA..........................18erlotinib........................... 18ERRIN............................120ertapenem......................... 8

ERY PADS.......................160ERYPED 200....................... 8ERYPED 400....................... 8ERY-TAB............................ 8ERYTHROCIN (AS STEARATE)........................ 8erythromycin...........8, 9, 104erythromycin ethylsuccinate.................... 8erythromycin with ethanol 160ESBRIET.........................151escitalopram oxalate..........69esomeprazole magnesium.110esomeprazole strontium... 110ESPEROCT........................38ESTARYLLA.....................120estradiol.........................120estradiol valerate.............120estradiol-norethindrone acet...............................120eszopiclone.......................69ethambutol........................ 9ethosuximide.................... 69ethyl chloride.................. 160etidronate disodium......... 139etodolac...........................69etonogestrel-ethinyl estradiol.........................120etoposide......................... 18EUCRISA........................ 160EVEKEO........................... 69everolimus (antineoplastic).18EVISTA................... 120, 139EVOTAZ......................9, 139EXALGO ER...................... 69EXELDERM......................160EXELON........................... 31exemestane.............. 18, 120EXFORGE......................... 50EXFORGE HCT............. 50, 94EXTAVIA.........................139EYE ITCH RELIEF............. 104EZALLOR SPRINKLE........... 50ezetimibe......................... 50ezetimibe-simvastatin........ 50FABIOR.......................... 160FABRAZYME....................101FALMINA (28)................. 120famciclovir......................... 9famotidine...................... 110famotidine (pf)-nacl (iso-os)................................ 110

FANAPT............................69FARXIGA........................ 120FARYDAK......................... 18FASENRA........................151FASENRA PEN................. 151FAZACLO..........................69FEIBA NF..........................39felbamate.........................69FELBATOL........................ 69felodipine......................... 50FEMHRT LOW DOSE......... 121FEMYNOR....................... 121fenofibrate.................. 50, 51fenofibrate micronized....... 50fenofibrate nanocrystallized 50fenofibric acid................... 51fenofibric acid (choline)......51FENOGLIDE...................... 51fenoprofen....................... 69fentanyl......................69, 70fentanyl citrate................. 69FERRIPROX.....................115FETZIMA.......................... 70FIASP FLEXTOUCH U-100 INSULIN.........................121FIASP PENFILL U-100 INSULIN.........................121FIASP U-100 INSULIN...... 121FIBRICOR.........................51finasteride...............139, 160FIRAZYR.........................139FIRDAPSE.......................139flavoxate........................ 168flecainide......................... 51FLECTOR...................70, 161FLOMAX........................... 31FLOVENT DISKUS...................... 121, 151, 152FLOVENT HFA.......... 121, 152floxuridine........................18FLUAD 2020-2021 (65 YR UP)(PF)............................23FLUAD QUAD 2020-21(65Y UP)(PF)............................23FLUARIX QUAD 2020-2021 (PF).................................23FLUBLOK QUAD 2020-2021 (PF).................................23FLUCELVAX QUAD 2020-2021............................... 23FLUCELVAX QUAD 2020-2021 (PF).........................23


fluconazole.........................9fluconazole in dextrose(iso-o)..................................... 9fluconazole in nacl (iso-osm)................................. 9flucytosine......................... 9fludrocortisone................ 121FLULAVAL QUAD 2020-2021 (PF).........................23FLUMIST QUAD 2020-2021.23flunisolide................104, 152fluocinolone.................... 161fluocinolone and shower cap................................161fluocinonide.................... 161FLUOCINONIDE-E............ 161fluoride (sodium).............139FLUORITAB.....................139fluorometholone.............. 104fluorouracil................18, 161fluoxetine.........................70fluphenazine decanoate......70fluphenazine hcl................ 70flurbiprofen...................... 70flurbiprofen sodium..........104flutamide......................... 18fluticasone propionate..............................152, 161fluticasone propion-salmeterol..........31, 121, 152fluvastatin........................51fluvoxamine......................70FLUZONE HIGHDOSE QUAD 20-21 PF.......................... 23FLUZONE QUAD 2020-2021 23FLUZONE QUAD 2020-2021 (PF).................................23FOCALIN.......................... 70FOCALIN XR..................... 70FOLBIC RF...................... 169folic acid.........................169fomepizole......................140fondaparinux.................... 39FORA G20...................90, 92FORFIVO XL......................70FORTEO......................... 121FORTESTA...................... 121FOSAMAX....................... 140FOSAMAX PLUS D.....140, 169fosamprenavir.................... 9fosinopril..........................51

fosinopril-hydrochlorothiazide......51, 94fosphenytoin.....................70FOSRENOL................ 94, 140FRAGMIN......................... 39FREESTYLE FREEDOM LITE. 90FREESTYLE INSULINX...90, 92FREESTYLE INSULINX TEST STRIPS............................ 92FREESTYLE LIBRE 10 DAY READER........................... 90FREESTYLE LIBRE 10 DAY SENSOR...........................90FREESTYLE LIBRE 14 DAY READER........................... 90FREESTYLE LIBRE 14 DAY SENSOR...........................90FREESTYLE LITE METER..... 90FREESTYLE LITE STRIPS.....92FREESTYLE TEST............... 92FROVA............................. 71frovatriptan...................... 71FULPHILA......................... 39furosemide..................51, 94FUZEON.............................9FYCOMPA......................... 71gabapentin....................... 71GABITRIL......................... 71galantamine..................... 31GAMASTAN S/D................ 24GAMMAGARD LIQUID.........24GAMMAGARD S-D (IGA < 1 MCG/ML)..........................24GAMUNEX-C..................... 24GARDASIL 9 (PF).............. 24gatifloxacin.....................104GAVILYTE-C....................110GAVILYTE-G....................110GAVILYTE-N....................110GELNIQUE...................... 168gemfibrozil....................... 51GENERLAC....................... 94GENGRAF....................... 140GENOTROPIN.................. 122GENOTROPIN MINIQUICK. 121GENTAK......................... 104gentamicin...........9, 104, 161gentamicin in nacl (iso-osm)................................. 9gentamicin sulfate (ped) (pf)................................... 9GENVOYA...........................9

GEODON.......................... 71GIANVI (28)................... 122GIAZO........................... 110GILENYA........................ 140GILOTRIF......................... 18glatiramer...................... 140GLATOPA........................140GLEOSTINE...................... 18glimepiride..................... 122glipizide......................... 122glipizide-metformin..........122GLUCAGEN HYPOKIT.122, 140GLUCAGON (HCL) EMERGENCY KIT...... 122, 140GLUCAGON EMERGENCY KIT (HUMAN)...........122, 140GLUCAGON HCL.........92, 122GLUCOCARD EXPRESSION............................90, 91, 92GLUCOCARD SHINE METER.91GLUCOCARD SHINE METER KIT..................................91GLUCOCARD SHINE TEST STRIPS............................ 92GLUCOCARD SHINE XL METER............................. 91GLUCOTROL....................122GLUCOTROL XL............... 122glyburide........................122glyburide micronized........122glyburide-metformin........ 122glycine urologic solution..... 94glycopyrrolate...................32GLYNASE........................122GLYSET.......................... 122GLYXAMBI...................... 123GOCOVRI..................... 9, 71GOLYTELY...................... 110GRALISE.......................... 71GRALISE 30-DAY STARTER PACK............................... 71granisetron (pf)...............110granisetron hcl.........110, 111GRANIX........................... 39griseofulvin microsize.......... 9griseofulvin ultramicrosize....9GRIS-PEG (ULTRAMICROSIZE)............ 9guanfacine..................51, 71guanidine......................... 32HAEGARDA..................... 140HAILEY 24 FE..................123


179

HAILEY FE 1.5/30 (28)..... 123halobetasol propionate..... 161haloperidol....................... 71haloperidol decanoate........ 71haloperidol lactate.............71HARVONI........................... 9HAVRIX (PF).....................24HEATHER........................123HELIXATE FS.................... 39HEMANGEOL..........32, 51, 71HEMLIBRA........................39HEMOFIL M HIGH.............. 39HEMOFIL M LOW............... 39HEMOFIL M MID................ 39HEMOFIL M SUPER HIGH.... 39HEP FLUSH-10 (PF)...... 39, 91heparin (porcine)......... 39, 40heparin (porcine) in 5 % dex................................. 39heparin (porcine) in nacl (pf)............................39, 91heparin flush(porcine)-0.9nacl.......................40, 91HEPARIN LOCK............ 40, 91HEPARIN LOCK FLUSH.. 40, 91heparin lock flush (porcine)................................. 40, 91HEPARIN LOCKFLUSH(PORCINE)(PF)................................. 40, 91heparin(porcine) in 0.45% nacl.................................40heparin, porcine (pf).... 40, 91HEPLISAV-B (PF)...............24HEPSERA........................... 9HETLIOZ.......................... 71HIBERIX (PF)....................24HIZENTRA........................ 24HORIZANT........................71HUMALOG JUNIOR KWIKPEN U-100.............. 123HUMALOG KWIKPEN INSULIN.........................123HUMALOG MIX 50-50 INSULN U-100................ 123HUMALOG MIX 50-50 KWIKPEN........................123HUMALOG MIX 75-25 KWIKPEN........................123HUMALOG MIX 75-25(U-100)INSULN................... 123HUMALOG U-100 INSULIN 123

HUMATE-P........................40HUMATROPE................... 123HUMIRA...........111, 140, 161HUMIRA PEDIATRIC CROHNS START 111, 140, 161HUMIRA PEN.... 111, 140, 161HUMIRA PEN CROHNS-UC-HS START........ 111, 140, 161HUMIRA PEN PSOR-UVEITS-ADOL HS...................... 111, 140, 161HUMIRA(CF).....111, 141, 162HUMIRA(CF) PEDI CROHNS STARTER..........111, 140, 161HUMIRA(CF) PEN...................... 111, 141, 162HUMIRA(CF) PEN CROHNS-UC-HS............. 111, 141, 162HUMIRA(CF) PEN PSOR-UV-ADOL HS.... 111, 141, 162HUMULIN 70/30 U-100 INSULIN.........................123HUMULIN 70/30 U-100 KWIKPEN........................123HUMULIN N NPH INSULIN KWIKPEN........................123HUMULIN N NPH U-100 INSULIN.........................124HUMULIN R REGULAR U-100 INSULN....................124HUMULIN R U-500 (CONC) INSULIN.........................124HUMULIN R U-500 (CONC) KWIKPEN........................124hydralazine.......................51hydrochlorothiazide......51, 95hydrocodone-acetaminophen............71, 72hydrocodone-ibuprofen...... 72hydrocortisone......... 124, 162hydrocortisone acetate..... 162hydrocortisone-acetic acid 104hydromorphone................ 72hydroxychloroquine......9, 141hydroxyprogest(pf)(preg presv)............................124hydroxyprogesterone cap(ppres)......................124hydroxyprogesterone capr(bulk)...................... 124hydroxyprogesterone caproate.........................124

hydroxyurea..................... 18hydroxyzine hcl............. 2, 72hydroxyzine pamoate.....2, 72hyoscyamine sulfate.......... 32HYPERHEP B S-D NEONATAL....................... 24HYSINGLA ER................... 72HYZAAR......................51, 95ibandronate.................... 141IBRANCE..........................18ibuprofen......................... 72icatibant.........................141ICLUSIG...........................18IDELVION.........................40IDHIFA............................ 18ILARIS (PF).................... 141ILUMYA.......................... 162imatinib........................... 18IMBRUVICA...................... 18imipramine hcl.................. 72imipramine pamoate..........72imiquimod...................... 162IMITREX...........................72IMOVAX RABIES VACCINE (PF).................................24IMURAN......................... 141INBRIJA........................... 72INCRUSE ELLIPTA...... 32, 152indapamide................. 51, 95INDERAL LA...........32, 51, 72INDERAL XL...........32, 52, 72indomethacin.............72, 141INFANRIX (DTAP) (PF)....... 24INFLECTRA.......111, 141, 162INLYTA............................ 18INNOPRAN XL........ 32, 52, 73insulin lispro................... 124INTELENCE.........................9INTERMEZZO....................73INTRON A...... 10, 18, 19, 141INTROVALE.....................124INTUNIV ER................ 52, 73INVEGA............................73INVEGA SUSTENNA........... 73INVEGA TRINZA................ 73INVIRASE.........................10INVOKAMET....................124INVOKAMET XR............... 124INVOKANA......................124IONOSOL-B IN D5W.......... 95IONOSOL-MB IN D5W........ 95IOPIDINE....................... 104


IPOL................................24ipratropium bromide........................ 32, 104, 152ipratropium-albuterol..32, 152irbesartan........................ 52irbesartan-hydrochlorothiazide......52, 95IRESSA............................ 19ISENTRESS...................... 10ISENTRESS HD................. 10ISOLYTE-P IN 5 % DEXTROSE....................... 95ISOLYTE-S....................... 95isoniazid.......................... 10isosorbide dinitrate............52isosorbide mononitrate.......52isotretinoin..................... 162isradipine......................... 52ISTALOL.........................104itraconazole......................10ivermectin........................10IXIARO (PF)......................25IXINITY............................40JAKAFI.............................19JALYN.......................32, 141JANTOVEN........................40JANUMET........................124JANUMET XR................... 124JANUVIA.........................124JARDIANCE.....................124JENCYCLA.......................124JENTADUETO.................. 125JENTADUETO XR..............125JINTELI.......................... 125JIVI................................. 40JOLESSA........................ 125JOLIVETTE......................125JORNAY PM...................... 73JUBLIA........................... 162JULEBER.........................125JULUCA............................10JUNEL 1.5/30 (21)...........125JUNEL 1/20 (21)..............125JUNEL FE 1.5/30 (28).......125JUNEL FE 1/20 (28)......... 125JUNEL FE 24................... 125JUXTAPID.........................52JYNARQUE........................95KADIAN........................... 73KAITLIB FE..................... 125KALBITOR.......................141KALETRA..........................10

KALYDECO......................152KAPSPARGO SPRINKLE. 32, 52KARIVA (28)................... 125KAZANO.........................125KEFLEX............................ 10KELNOR 1/35 (28)........... 125KEPPRA............................73KEPPRA XR.......................73ketoconazole............. 10, 162ketoprofen....................... 73ketorolac.................. 73, 105ketotifen fumarate...........105KEVZARA........................141KHEDEZLA........................73KINERET........................ 141KINRIX (PF)......................25KISQALI...........................19KISQALI FEMARA CO-PACK............................... 19, 125KITABIS PAK.................... 10KLOR-CON....................... 95KLOR-CON 10................... 95KLOR-CON 8.....................95KLOR-CON M10.................95KLOR-CON M15.................95KLOR-CON M20.................95KOATE............................. 40KOGENATE FS...................41KOMBIGLYZE XR............. 125KOVALTRY........................41KURVELO (28).................125l norgest/e.estradiol-e.estrad......................... 125labetalol..................... 32, 52lactated ringers.................95lactulose.......................... 95LAMICTAL........................ 74LAMICTAL ODT..................73LAMICTAL ODT STARTER (BLUE).............................73LAMICTAL ODT STARTER (GREEN).......................... 73LAMICTAL ODT STARTER (ORANGE)........................ 74LAMICTAL STARTER (BLUE) KIT..................................74LAMICTAL STARTER (GREEN) KIT.....................74LAMICTAL STARTER (ORANGE) KIT.................. 74LAMICTAL XR....................74

LAMICTAL XR STARTER (BLUE).............................74LAMICTAL XR STARTER (GREEN).......................... 74LAMICTAL XR STARTER (ORANGE)........................ 74lamivudine....................... 10lamivudine-zidovudine....... 10lamotrigine.......................74lansoprazole................... 111lanthanum................ 95, 141LANTUS SOLOSTAR U-100 INSULIN.........................126LANTUS U-100 INSULIN... 126LARIN 1.5/30 (21)........... 126LARIN 1/20 (21)..............126LARIN 24 FE................... 126LARIN FE 1.5/30 (28).......126LARIN FE 1/20 (28)......... 126LARISSIA....................... 126LASTACAFT.....................105latanoprost..................... 105LATUDA......................74, 75LAYOLIS FE.....................126LAZANDA......................... 75ledipasvir-sofosbuvir..........10LEENA 28....................... 126leflunomide.....................141LENVIMA..........................19LESCOL XL....................... 52LESSINA.........................126LETAIRIS.................. 52, 152letrozole................... 19, 126leucovorin calcium........... 142LEUKERAN........................19LEUKINE.......................... 41leuprolide..................19, 126levalbuterol hcl.......... 32, 152levalbuterol tartrate... 32, 152LEVAQUIN........................ 10LEVEMIR FLEXTOUCH U-100 INSULN....................126LEVEMIR U-100 INSULIN.. 126levetiracetam....................75levobunolol..................... 105levocarnitine................... 142levocarnitine (with sugar). 142levocetirizine...............2, 152levofloxacin...............10, 105levoleucovorin calcium..... 142LEVONEST (28)............... 126levonorgestrel................. 126


181

levonorgestrel-ethinyl estrad............................ 126levonorg-eth estrad triphasic.........................126LEVORA-28.....................126levorphanol tartrate...........75levothyroxine..................127LEVOXYL........................ 127LEXAPRO..........................75LEXIVA............................ 10LIALDA...........................111LICE KILLING..................162LICE SOLUTION...............162LICE TREATMENT.............162LICE TREATMENT (PERMETHRIN)................162lidocaine.........................163lidocaine (pf)............. 52, 136lidocaine hcl............ 105, 136LIDOCAINE PAIN RELIEF...162lidocaine-hydrocortisone-aloe............................... 163lidocaine-prilocaine.......... 163LIDODERM......................163LIDOPURE PATCH............ 163LILETTA......................... 127lindane...........................163linezolid........................... 10linezolid in dextrose 5%..... 10linezolid-0.9% sodium chloride............................11LINZESS.........................111liothyronine.................... 127LIPITOR........................... 52LIPOFEN...........................52lisinopril...........................52lisinopril-hydrochlorothiazide......52, 96lithium carbonate.............. 75lithium citrate................... 75LIVALO............................ 52LONHALA MAGNAIR REFILL.32LONHALA MAGNAIR STARTER..........................32LONSURF......................... 19LOPID..............................52lopinavir-ritonavir..............11LOPRESSOR................ 33, 53LOPROX......................... 163LOPROX (AS OLAMINE).... 163LOPROX KIT....................163loratadine................... 2, 153

LORATA-DINE D..... 2, 33, 152LORATADINE-D...... 2, 33, 153lorazepam........................ 75LORAZEPAM INTENSOL...... 75LORBRENA....................... 19LORCET (HYDROCODONE)..75LORCET HD...................... 75LORYNA (28).................. 127losartan........................... 53losartan-hydrochlorothiazide......53, 96LOTENSIN........................ 53LOTENSIN HCT............ 53, 96loteprednol etabonate...... 105LOTREL............................53lovastatin......................... 53LOVAZA........................... 53LOVENOX......................... 41LOW-OGESTREL (28)....... 127loxapine succinate............. 75LUDENT FLUORIDE.......... 142LUMIGAN........................105LUMIZYME...................... 101LUNESTA..........................75LUPRON DEPOT..........19, 127LUPRON DEPOT (3 MONTH)............................... 19, 127LUPRON DEPOT (4 MONTH)............................... 19, 127LUPRON DEPOT (6 MONTH)............................... 19, 127LUPRON DEPOT-PED...19, 127LUPRON DEPOT-PED (3 MONTH)....................19, 127LUTERA (28)................... 127LUZU............................. 163LYNPARZA........................19LYRICA............................ 75LYRICA CR........................75LYZA..............................127magnesium sulfate53, 76, 142magnesium sulfate in water............ 53, 75, 76, 142malathion....................... 163maprotiline.......................76MARLISSA (28)............... 127MATULANE....................... 19MATZIM LA.......................53MAVENCLAD (10 TABLET PACK)............................ 142MAVENCLAD (4 TABLET PACK)............................ 142

MAVENCLAD (5 TABLET PACK)............................ 142MAVENCLAD (6 TABLET PACK)............................ 142MAVENCLAD (7 TABLET PACK)............................ 142MAVENCLAD (8 TABLET PACK)............................ 142MAVENCLAD (9 TABLET PACK)............................ 142MAVYRET......................... 11MAXALT........................... 76MAXALT-MLT.................... 76MAYZENT....................... 142MAYZENT STARTER PACK. 142meclizine.................... 2, 111medroxyprogesterone...... 127mefenamic acid.................76mefloquine....................... 11MEGACE ES...............19, 127megestrol................. 20, 128MEKINIST........................ 20MEKTOVI..........................20meloxicam........................76memantine.......................76MENACTRA (PF)................ 25MENVEO A-C-Y-W-135-DIP (PF).................................25MENVEO MENA COMPONENT (PF).............. 25MENVEO MENCYW-135 COMPNT (PF)....................25mercaptopurine......... 20, 142meropenem......................11mesalamine.................... 112mesalamine with cleansing wipe.............................. 112mesna........................... 142MESNEX......................... 142METADATE ER...................76metaproterenol..........33, 153metaxalone...................... 33metformin...................... 128methadone.......................76methenamine hippurate..... 11methimazole................... 128methocarbamol.................33methotrexate sodium..20, 143methotrexate sodium (pf)........................ 20, 142, 143methoxsalen................... 163methscopolamine.............. 33


methyldopa.................33, 53methyldopa-hydrochlorothiazide 33, 53, 96methyldopate.............. 33, 53METHYLIN........................ 76methylphenidate hcl.....76, 77methylprednisolone......... 128methylprednisolone acetate.....................................128methylprednisolone sodium succ...............................128metipranolol................... 105metoclopramide hcl..........112metolazone................. 53, 96metoprolol succinate.... 33, 53metoprolol ta-hydrochlorothiaz.... 33, 53, 96metoprolol tartrate.......33, 53metronidazole............11, 163metronidazole in nacl (iso-os).................................. 11mexiletine........................ 53MIACALCIN..............128, 143micafungin....................... 11MICARDIS........................ 54MICARDIS HCT............ 54, 96miconazole nitrate........... 163MICONAZOLE-3...............163MICROGESTIN 1.5/30 (21)128MICROGESTIN 1/20 (21).. 128MICROGESTIN FE 1.5/30 (28)...............................128MICROGESTIN FE 1/20 (28)...............................128midodrine.........................33mifepristone................... 147miglitol.......................... 128miglustat........................143minocycline...................... 11minoxidil.......................... 54MIRAPEX..........................77MIRAPEX ER..................... 77mirtazapine...................... 77misoprostol.....................112MITIGARE.......................143M-M-R II (PF)................... 25MOBIC............................. 77modafinil..........................77MODERIBA DOSE PACK...... 11moexipril..........................54moexipril-hydrochlorothiazide......54, 96

mometasone.... 105, 153, 163MONOCLATE-P.................. 41MONOJECT MAGELLAN SYRINGE..........................91MONOJECT SYRINGE..........91MONO-LINYAH................ 128MONONESSA (28)............128MONONINE.......................41montelukast....................153MORPHABOND ER..............78morphine......................... 78morphine concentrate........ 78MOVANTIK......................112MOXEZA.........................105moxifloxacin..............11, 105MOZOBIL......................... 41MS CONTIN...................... 78MULTIVITAMIN WITH FLUORIDE............... 143, 169MULTI-VITAMIN WITH FLUORIDE............... 143, 169MULTIVITAMINS WITH FLUORIDE............... 143, 169mupirocin....................... 163mupirocin calcium............163MY WAY......................... 128MYALEPT........................ 129mycophenolate mofetil..... 143mycophenolate mofetil (hcl).............................. 143mycophenolate sodium.....143MYDAYIS..........................78MYFORTIC...................... 143MYLERAN......................... 20MYNATAL.............41, 96, 169MYNATAL PLUS.....41, 96, 169MYNATAL-Z..........41, 96, 169MYORISAN......................164MYRBETRIQ.................... 168MYSOLINE........................78nabumetone..................... 78nadolol....................... 33, 54nafcillin............................11nafcillin in dextrose iso-osm.................................11naftifine......................... 164NAFTIN.......................... 164nalbuphine....................... 78NALFON........................... 78naloxone...................78, 143naltrexone................ 78, 143NAMENDA........................ 78

NAMENDA TITRATION PAK..78NAMENDA XR....................79NAMZARIC.................. 33, 79naproxen.................. 79, 143naproxen sodium....... 79, 143naratriptan....................... 79NARCAN................... 79, 143NASONEX................105, 153NATACYN....................... 105nateglinide..................... 129NATPARA................ 129, 144NATROBA....................... 164NAYZILAM........................ 79NECON 0.5/35 (28)..........129nefazodone.......................79neomycin......................... 11neomycin-bacitracin-poly-hc................................. 105neomycin-bacitracin-polymyxin...................... 105neomycin-polymyxin b gu.164neomycin-polymyxin b-dexameth.......................105neomycin-polymyxin-gramicidin...................... 106neomycin-polymyxin-hc....106NEO-POLYCIN HC............ 106NEORAL......................... 144NERLYNX..........................20NESINA..........................129NEUAC........................... 164NEUAC KIT..................... 164NEULASTA........................41NEUPOGEN.......................41NEURONTIN......................79NEVANAC....................... 106nevirapine........................ 11NEXAVAR......................... 20NEXIUM......................... 112NEXIUM IV..................... 112NEXIUM PACKET..............112NEXPLANON....................129niacin.............................. 54NIACOR........................... 54NIASPAN EXTENDED-RELEASE.......................... 54nicardipine....................... 54NICORELIEF..................... 33nicotine............................34nicotine (polacrilex)........... 33NICOTROL........................34NICOTROL NS...................34


183

nifedipine......................... 54nikki (28)....................... 129nilutamide........................20nimodipine....................... 54NINLARO..........................20nisoldipine........................54nitisinone....................... 144NITRO-BID....................... 54nitrofurantoin macrocrystal.11nitrofurantoin monohyd/m-cryst................................11nitroglycerin..................... 54NITROMIST...................... 55NIVESTYM........................ 41nizatidine....................... 112NON-DROWSY ALLERGY2, 153NORA-BE........................129NORDITROPIN FLEXPRO... 129noreth-ethinyl estradiol-iron............................... 129norethindrone (contraceptive)................129norethindrone acetate...... 129norethindrone ac-eth estradiol.........................129norethindrone-e.estradiol-iron............................... 129norgestimate-ethinyl estradiol.........................129NORMAL SALINE FLUSH 91, 96NORMOSOL-M IN 5 % DEXTROSE....................... 96NORMOSOL-R................... 96NORMOSOL-R IN 5 % DEXTROSE....................... 96NORMOSOL-R PH 7.4.........96NORTREL 0.5/35 (28)...... 129NORTREL 1/35 (21)......... 129NORTREL 1/35 (28)......... 129NORTREL 7/7/7 (28)........ 129nortriptyline..................... 79NORVASC.........................55NORVIR........................... 11NOURIANZ....................... 79NOVOEIGHT..................... 41NOVOLIN 70/30 U-100 INSULIN.........................129NOVOLIN 70-30 FLEXPEN U-100............................ 130NOVOLIN N NPH U-100 INSULIN.........................130

NOVOLIN R REGULAR U-100 INSULN....................130NOVOLOG FLEXPEN U-100 INSULIN.........................130NOVOLOG MIX 70-30 U-100 INSULN....................130NOVOLOG MIX 70-30FLEXPEN U-100........... 130NOVOLOG PENFILL U-100 INSULIN.........................130NOVOLOG U-100 INSULIN ASPART..........................130NOVOSEVEN RT................ 42NOXAFIL.......................... 11NP THYROID................... 130NUCALA......................... 153NUCYNTA......................... 79NUCYNTA ER.................... 79NUEDEXTA................ 79, 153NUPLAZID........................ 79NUTROPIN AQ NUSPIN..... 130NUWIQ............................ 42NUZYRA........................... 11NYAMYC......................... 164NYMALIZE........................ 55nystatin.................... 12, 164nystatin-triamcinolone......164NYSTOP......................... 164OBIZUR........................... 42OCALIVA........................ 112OCELLA..........................130OCREVUS....................... 144octreotide acetate.... 130, 144OCUFLOX....................... 106ODEFSEY......................... 12OFEV............................. 153ofloxacin................... 12, 106OGESTREL (28)...............130olanzapine.................. 79, 80olanzapine-fluoxetine.........80olmesartan....................... 55olmesartan-amlodipin-hcthiazid.....................55, 96olmesartan-hydrochlorothiazide......55, 96olopatadine.....................106omega-3 acid ethyl esters.. 55omeprazole.....................112omeprazole-sodium bicarbonate.................... 112OMNARIS................ 106, 153OMNITROPE....................130

ondansetron................... 113ondansetron hcl....... 112, 113ondansetron hcl (pf)........ 112ONETOUCH ULTRA BLUE TEST STRIP...................... 92ONETOUCH ULTRA2 METER 91ONETOUCH ULTRAMINI......91ONETOUCH VERIO FLEX METER............................. 91ONETOUCH VERIO IQ METER............................. 91ONETOUCH VERIO METER.. 91ONETOUCH VERIO TEST STRIPS............................ 92ONEXTON.......................164ONFI............................... 80ONGLYZA....................... 130ONMEL.............................12ONZETRA XSAIL................80OPANA ER........................ 80OPCICON ONE-STEP........ 130OPSUMIT.................. 55, 153ORAVIG..........................164ORENCIA........................144ORENCIA (WITH MALTOSE).....................................144ORENCIA CLICKJECT........144ORENITRAM.............. 55, 153ORILISSA....................... 130ORKAMBI....................... 153orphenadrine citrate.......... 34ORSYTHIA...................... 131oseltamivir....................... 12OSENI............................131OTEZLA...................144, 164OTEZLA STARTER.....144, 164OTIPRIO.........................106OTOVEL......................... 106OTREXUP (PF)........... 20, 144OVIDE............................164oxacillin........................... 12oxacillin in dextrose(iso-osm)............................... 12oxandrolone....................131oxaprozin......................... 80oxazepam........................ 80oxcarbazepine...................80OXERVATE......................106oxiconazole.....................164OXISTAT........................ 164OXTELLAR XR................... 80oxybutynin chloride......... 168


oxycodone........................80OXYCODONE.................... 80oxycodone-acetaminophen................................. 80, 81oxycodone-aspirin............. 81OXYCONTIN......................81oxymorphone................... 81OXYTROL........................168OZEMPIC........................131PALFORZIA (LEVEL 1)....... 25PALFORZIA (LEVEL 2)....... 25PALFORZIA (LEVEL 3)....... 25PALFORZIA (LEVEL 4)....... 25PALFORZIA (LEVEL 5)....... 25PALFORZIA (LEVEL 6)....... 25PALFORZIA (LEVEL 7)....... 25PALFORZIA (LEVEL 8)....... 25PALFORZIA (LEVEL 9)....... 25PALFORZIA (LEVEL 10)...... 25PALFORZIA (LEVEL 11 UP-DOSE)............................. 25PALFORZIA INITIAL DOSE.. 26PALFORZIA LEVEL 11 MAINTENANCE..................26paliperidone..................... 81palonosetron...................113PALYNZIQ.......................101pamidronate................... 144PANCREAZE.................... 113pantoprazole...................113paromomycin....................12paroxetine hcl...................81paroxetine mesylate(menop.sym)....... 81PATADAY........................106PATANASE...................... 106PATANOL........................106PAXIL.............................. 81PAXIL CR......................... 81PAZEO........................... 106PCE................................. 12PEDIARIX (PF).................. 26PEDVAX HIB (PF).............. 26peg 3350-electrolytes...... 113PEGANONE....................... 81PEGASYS..........................12PEGASYS PROCLICK.......... 12peg-electrolyte soln......... 113PEGINTRON......................12penicillamine........... 115, 144penicillin g potassium.........12penicillin g procaine........... 12

penicillin g sodium.............12penicillin v potassium.........12PENLAC..........................164PENTACEL (PF)................. 26PENTACEL ACTHIB COMPONENT (PF).............. 26PENTACEL DTAP-IPV COMPNT (PF)....................26pentamidine..................... 12PENTASA........................113pentoxifylline.................... 42PERFOROMIST........... 34, 153perindopril erbumine..........55permethrin..................... 164perphenazine....................81perphenazine-amitriptyline. 81PERSERIS.........................81PERTZYE........................ 113PEXEVA............................81phenazopyridine.............. 164phenelzine........................81phenobarbital................... 82PHENYTEK.................. 55, 82phenytoin................... 55, 82phenytoin sodium........ 55, 82phenytoin sodium extended.................... 55, 82PHILITH......................... 131PHOSLO........................... 96PHOSLYRA........................96PHOSPHA 250 NEUTRAL..... 97PHOSPHOLINE IODIDE..... 106PHYSIOLYTE..................... 97phytonadione (vitamin k1)..............................144, 169PIFELTRO......................... 12pilocarpine hcl........... 34, 106pimecrolimus........... 144, 165PIMTREA (28)................. 131pindolol...................... 34, 55pioglitazone.................... 131pioglitazone-glimepiride....131pioglitazone-metformin.... 131piperacillin-tazobactam...... 13PIQRAY............................ 20PIRMELLA....................... 131piroxicam......................... 82PLASMA-LYTE 148............. 97PLASMA-LYTE A................ 97PLAVIX............................ 42PLEGRIDY.......................144PNEUMOVAX-23................ 26

PNV OB+DHA42, 97, 113, 169PNV-DHA.................. 42, 169PNV-OMEGA.........42, 97, 169PNV-SELECT..............42, 169podofilox........................ 165POLYCIN........................ 107polymyxin b sulfate........... 13polymyxin b sulf-trimethoprim...................107POMALYST................ 20, 144PORTIA 28......................131posaconazole.................... 13potassium chlorid-d5-0.45%nacl........................97potassium chloride............ 97potassium chloride in 0.9%nacl......................... 97potassium chloride in 5 % dex................................. 97potassium chloride in lr-d5. 97potassium chloride in water 97potassium chloride-0.45 % nacl.................................97potassium chloride-d5-0.2%nacl......................... 97potassium chloride-d5-0.3%nacl......................... 97potassium chloride-d5-0.9%nacl......................... 98potassium citrate.............. 98POTIGA............................82PR NATAL 400...... 42, 98, 169PR NATAL 400 EC. 42, 98, 169PR NATAL 430...... 42, 98, 169PR NATAL 430 EC. 42, 98, 169PRADAXA......................... 42PRALUENT PEN................. 55pramipexole..................... 82PRANDIN........................131prasugrel......................... 42PRAVACHOL......................55pravastatin.......................55praziquantel..................... 13prazosin..................... 34, 55PRECISION XTRA KETONE-GLUCOSE......................... 91PRECISION XTRA MONITOR 91PRECISION XTRA TEST...... 92PRECOSE........................131prednicarbate..................165prednisolone................... 131prednisolone acetate........107


185

prednisolone sodium phosphate............... 107, 131prednisone..................... 131PREDNISONE INTENSOL... 131pregabalin........................82PREMPHASE....................131PRENATABS FA.....42, 98, 169PRENATABS RX.... 42, 98, 169PRENATAL LOW IRON.......................... 42, 98, 170PRENATAL PLUS... 42, 98, 170PRENATAL PLUS (CALCIUM CARB).................42, 98, 170PRENATAL-U................... 170PRESTALIA....................... 55pretomanid.......................13PREVACID...................... 113PREVACID SOLUTAB........ 113PREVALITE....................... 55PREVIFEM.......................131PREVNAR 13 (PF).............. 26PREVYMIS........................ 13PREZCOBIX............... 13, 144PREZISTA.........................13PRIFTIN........................... 13PRILOSEC.......................113primidone.........................82PRINIVIL..........................56PRISTIQ...........................82PRIVIGEN.........................26PROAIR DIGIHALER....34, 153PROAIR HFA.............. 34, 154PROAIR RESPICLICK...34, 154probenecid................ 98, 144probenecid-colchicine. 98, 145PROBUPHINE.................... 82procainamide....................56PROCARDIA......................56PROCARDIA XL................. 56PROCENTRA..................... 82prochlorperazine........ 82, 114prochlorperazine edisylate............................... 82, 113prochlorperazine maleate............................... 82, 114PROCRIT.......................... 42PROCTOFOAM HC............ 165PROCTO-PAK.................. 165PROCTOZONE-HC............ 165PRODIGY NO CODING........92PRODIGY POCKET METER... 91

PRODIGY VOICE GLUCOSE METER............................. 91PROFILNINE..................... 43progesterone micronized.. 131PROGRAF....................... 145PROLASTIN-C..................154PROLENSA......................107PROLIA.......................... 145PROMACTA....................... 43promethazine... 2, 82, 83, 154propafenone..................... 56proparacaine...................107propranolol............34, 56, 83propranolol-hydrochlorothiazid.. 34, 56, 98propylthiouracil............... 132PROQUAD (PF)..................26PROSCAR....................... 145PROTONIX...................... 114PROTOPIC...................... 165protriptyline......................83PROVENTIL HFA.........34, 154PROZAC........................... 83PULMICORT............. 132, 154PULMICORT FLEXHALER..............................132, 154PULMOZYME............ 101, 154PYLERA.....................13, 114pyrazinamide....................13pyridostigmine bromide......34QBRELIS.......................... 56QNASL.................... 107, 154QTERN........................... 132QUADRACEL (PF)...............26QUDEXY XR...................... 83QUESTRAN....................... 56QUESTRAN LIGHT..............56quetiapine........................ 83QUILLICHEW ER................83QUILLIVANT XR.................83quinapril.......................... 56quinapril-hydrochlorothiazide......56, 98quinidine gluconate...... 13, 56quinidine sulfate.......... 13, 56quinine sulfate.................. 13QUTENZA....................... 165QVAR REDIHALER.....132, 154RABAVERT (PF).................26rabeprazole.................... 114raloxifene................132, 145ramelteon........................ 83

ramipril............................56RANEXA........................... 56ranolazine........................ 56RAPAFLO..........................34RAPAMUNE..................... 145RAVICTI...........................98RAZADYNE....................... 34RAZADYNE ER...................34REBETOL..........................13REBIF (WITH ALBUMIN)... 145REBIF REBIDOSE.............145REBIF TITRATION PACK....145REBINYN..........................43REBLOZYL........................ 43RECLIPSEN (28).............. 132RECOMBINATE.................. 43RECOMBIVAX HB (PF)........ 26RECTIV.......................... 165RELENZA DISKHALER.........13RELPAX............................83REMERON.........................83REMERON SOLTAB.............83REMICADE....... 114, 145, 165RENAGEL.................. 98, 145RENAL CAPS................... 170RENA-VITE RX.................170RENFLEXIS.......114, 145, 165RENO CAPS.................... 170RENVELA.................. 98, 145repaglinide..................... 132repaglinide-metformin......132REPATHA PUSHTRONEX......56REPATHA SURECLICK.........57REPATHA SYRINGE............ 57REQUIP............................83REQUIP XL....................... 83RESCRIPTOR.................... 13RESTASIS.......................107RESTASIS MULTIDOSE..... 107RETACRIT........................ 43RETIN-A......................... 165RETIN-A MICRO...............165RETIN-A MICRO PUMP...... 165RETROVIR........................ 13REVATIO...................57, 154REVCOVI........................ 101REVLIMID................. 20, 145REXULTI.......................... 83RHOPRESSA....................107RIBASPHERE.....................13RIBASPHERE RIBAPAK....... 13ribavirin........................... 13


rifabutin...........................13rifampin........................... 13RIFATER...........................14riluzole............................ 83rimantadine......................14ringer's............................ 98RINVOQ......................... 145risedronate..................... 145RISPERDAL.......................84RISPERDAL CONSTA.......... 84risperidone....................... 84RITALIN........................... 84RITALIN LA.......................84ritonavir...........................14RITUXAN HYCELA.............. 20rivastigmine..................... 35rivastigmine tartrate..........35RIXUBIS.......................... 43rizatriptan........................ 84ROCKLATAN....................107ropinirole......................... 84rosuvastatin..................... 57ROTARIX..........................26ROTATEQ VACCINE............26ROWASA........................ 114ROWEEPRA.......................84ROWEEPRA XR..................84ROZEREM.........................84ROZLYTREK...................... 20RUBRACA......................... 20RUCONEST..................... 145RUZURGI........................145RYBELSUS...................... 132RYDAPT........................... 20RYTARY............................84SABRIL............................ 84SAIZEN.......................... 132SAIZEN SAIZENPREP........132salicylic acid....................165salsalate.......................... 84SANCUSO.......................114SANDIMMUNE................. 145SANTYL..........................165SAPHRIS.......................... 84SARAFEM......................... 84SAVAYSA......................... 43SAVELLA.......................... 84SECUADO.........................85SEEBRI NEOHALER............ 35SEGLUROMET..................132selegiline hcl.....................85SELZENTRY...................... 14

SEMPREX-D........... 3, 35, 154SE-NATAL 19 CHEWABLE............................... 43, 170SEREVENT DISKUS.....35, 154SEROQUEL....................... 85SEROQUEL XR.................. 85SEROSTIM......................132sertraline......................... 85SETLAKIN.......................132sevelamer carbonate.. 98, 146sevelamer hcl................... 98SF................................. 146SF 5000 PLUS................. 146SFROWASA.....................114SHINGRIX (PF)................. 26SHINGRIX ADJUVANT COMPONENT-PF.............. 147SHINGRIX GE ANTIGEN COMPONENT.....................27SIGNIFOR.......................132SIKLOS............................20sildenafil (pulm.hypertension)........................ 57, 154, 155SILIQ.............................165silodosin.......................... 35silver nitrate................... 165silver sulfadiazine............ 165SIMBRINZA.....................107SIMPONI................. 114, 146SIMPONI ARIA......... 114, 146simvastatin.......................57SINEMET..........................85SINEMET CR..................... 85SINGULAIR..................... 155SINUVA...................107, 155sirolimus........................ 146SIRTURO..........................14SITAVIG...........................14SKLICE...........................165sodium bicarbonate........... 99sodium chlor 0.9% bacteriostat...................... 99sodium chloride.................99sodium chloride 0.45 %..... 99sodium chloride 0.9 %....... 99sodium chloride 0.9 % (flush)........................91, 99sodium chloride 3 %.......... 99sodium chloride 5 %.......... 99sodium citrate-citric acid.... 99sodium lactate.................. 99

sodium phenylbutyrate.......99sodium polystyrene sulfonate...................99, 146sofosbuvir-velpatasvir........14solifenacin...................... 168SOLIQUA 100/33.............132SOLOSEC......................... 14SOLU-CORTEF.................133SOLU-CORTEF ACT-O-VIAL (PF)...............................132SOMATULINE DEPOT........133SONATA...........................85SORINE...................... 35, 57sotalol........................35, 57SOTALOL AF................35, 57SOTYLIZE................... 35, 57SOVALDI..........................14spinosad.........................166SPIRIVA RESPIMAT.... 35, 155SPIRIVA WITH HANDIHALER.............35, 155spironolactone.............57, 99spironolacton-hydrochlorothiaz..........57, 99SPORANOX.......................14SPRAVATO....................... 85SPRINTEC (28)................133SPRITAM..........................85SPRYCEL.......................... 20SPS (WITH SORBITOL)99, 146SRONYX......................... 133SSD...............................166SSS 10-5........................166STAMARIL (PF)................. 27stavudine......................... 14STEGLATRO.................... 133STEGLUJAN.................... 133STELARA................. 146, 166STIOLTO RESPIMAT...........35STIVARGA........................ 21STRATTERA...................... 85STRENSIQ...................... 101STRIANT........................ 133STRIBILD......................... 14STRIVERDI RESPIMAT.35, 155SUBLOCADE..................... 85SUBOXONE.......................85sucralfate....................... 114SULAR............................. 57sulfacetamide sodium107, 166sulfacetamide sodium (acne)............................166


187

sulfacetamide sodium-sulfur.............................166sulfacetamide sod-sulfur-urea.............................. 166sulfacetamide-prednisolone.....................................107sulfadiazine...................... 14sulfamethoxazole-trimethoprim.................... 14sulfasalazine...... 14, 114, 146sulindac........................... 85sumatriptan......................85sumatriptan succinate.. 85, 86sumatriptan-naproxen....... 86SUPRAX........................... 14SUTENT........................... 21SYEDA........................... 133SYLATRON.................. 14, 21SYMBICORT....... 35, 133, 155SYMBYAX......................... 86SYMDEKO.......................155SYMFI..............................14SYMFI LO......................... 14SYMJEPI................... 35, 155SYMLINPEN 120.............. 133SYMLINPEN 60................ 133SYMTUZA......................... 14SYNAGIS..........................15SYNAREL........................ 133SYNJARDY...................... 133SYNJARDY XR................. 133syringe with needle, safety. 92T:SLIM.............................92TABLOID.......................... 21tacrolimus............... 146, 166tadalafil (pulm. hypertension)............ 57, 155TAFINLAR.........................21TAGRISSO........................21TAKHZYRO..................... 146TALTZ AUTOINJECTOR..... 166TALTZ AUTOINJECTOR (2 PACK)............................ 166TALTZ AUTOINJECTOR (3 PACK)............................ 166TALTZ SYRINGE.............. 166TALZENNA........................21TAMIFLU.......................... 15tamoxifen................. 21, 133tamsulosin....................... 35TARGRETIN............... 21, 166tarina fe 1/20 (28)...........133

TARKA............................. 57TASIGNA..........................21tazarotene......................166TAZORAC....................... 166TAZTIA XT........................57TAZVERIK........................ 21TECFIDERA.....................146TECHNIVIE....................... 15TEGRETOL........................86TEGRETOL XR................... 86TEKTURNA....................... 57TEKTURNA HCT........... 57, 99telmisartan.......................57telmisartan-amlodipine...... 58telmisartan-hydrochlorothiazid......58, 100temazepam...................... 86temozolomide................... 21TENIVAC (PF)................... 27tenofovir disoproxil fumarate..........................15TENORETIC 100... 35, 58, 100TENORETIC 50..... 35, 58, 100TENORMIN..................35, 58terazosin.................... 35, 58terbinafine hcl........... 15, 166terbutaline................ 35, 155terconazole.....................166TESTIM.......................... 133TESTOSTERONE.............. 133testosterone................... 134testosterone cypionate..... 133testosterone enanthate.... 133tetanus,diphtheria tox ped(pf)............................ 27tetanus-diphtheria toxoids-td....................................27tetrabenazine................... 86tetracaine hcl..................107tetracycline...................... 15THALOMID......................146theophylline 58, 100, 155, 168thioridazine...................... 86thiothixene....................... 86tiagabine..........................86TIAZAC............................ 58TIBSOVO..........................21TICANASE............... 107, 155TILIA FE......................... 134timolol maleate.................... 36, 58, 86, 107TIMOPTIC.......................108

TIMOPTIC OCUDOSE (PF). 107TIMOPTIC-XE.................. 108tinidazole......................... 15TIVICAY........................... 15TIVICAY PD...................... 15tizanidine......................... 36TL-SELECT..43, 100, 114, 170TOBI............................... 15TOBI PODHALER............... 15TOBRADEX..................... 108tobramycin..................... 108tobramycin in 0.225 % nacl.................................15tobramycin in 0.9 % nacl... 15tobramycin sulfate.............15tobramycin-dexamethasone...............108tolazamide......................134tolbutamide.................... 134tolmetin........................... 86tolnaftate....................... 166TOLSURA......................... 15tolterodine......................168TOPAMAX.........................86topiramate....................... 86TOPROL XL................. 36, 58toremifene....................... 21torsemide................. 58, 100TOSYMRA.........................86TOUJEO MAX U-300 SOLOSTAR......................134TOUJEO SOLOSTAR U-300 INSULIN.........................134TOVIAZ.......................... 168TRACLEER.................58, 155TRADJENTA.................... 134tramadol.......................... 86tramadol-acetaminophen....86trandolapril.......................58tranexamic acid................ 43tranylcypromine................ 86TRAVATAN Z................... 108travoprost...................... 108trazodone.........................87TRELEGY ELLIPTA.......36, 155TREMFYA........................167TRESIBA FLEXTOUCH U-100............................... 134TRESIBA FLEXTOUCH U-200............................... 134tretinoin......................... 167tretinoin (antineoplastic).... 21


tretinoin microspheres......167TREXIMET........................ 87TRIADVANCE......43, 100, 170triamcinolone acetonide....167triamterene-hydrochlorothiazid......58, 100triazolam..........................87TRIBENZOR...............58, 100TRICITRATES.................. 100TRICOR............................58TRI-ESTARYLLA...............134trifluoperazine.................. 87TRIGLIDE......................... 58trihexyphenidyl............36, 87TRIKAFTA....................... 155TRI-LEGEST FE................134TRILEPTAL........................87TRI-LINYAH.................... 134TRILIPIX.......................... 58tri-lo-estarylla................. 134tri-lo-sprintec..................134trimethobenzamide..........114trimethoprim.................... 15TRINATAL RX 1...43, 100, 170TRINATE............43, 100, 170TRINTELLIX...................... 87TRI-PREVIFEM (28)..........134TRIPTODUR.................... 134TRI-SPRINTEC (28)..........135TRIUMEQ......................... 15TRIVEEN-ONE.....43, 100, 170TRIVEEN-PRX RNF................. 43, 100, 114, 170TRI-VITAMIN WITH FLUORIDE............... 146, 170TRIVORA (28)................. 135TROGARZO.......................15TROKENDI XR...................87trospium........................ 168TRUE METRIX AIR GLUCOSE METER...............92TRUE METRIX GLUCOSE METER............................. 92TRUE METRIX GLUCOSE TEST STRIP...................... 92TRULICITY......................135TRUMENBA.......................27TRUSOPT........................108TRUVADA......................... 15TUDORZA PRESSAIR........ 156TWINRIX (PF)................... 27TWIRLA..........................135

TWYNSTA.........................58TYKERB............................21TYMLOS.................. 135, 146TYVASO.................... 59, 156TYVASO INSTITUTIONAL START KIT................ 59, 156TYVASO REFILL KIT....59, 156TYVASO STARTER KIT.59, 156UCERIS.......................... 135UDENYCA......................... 43UNITHROID.................... 135unithroid........................ 135UPTRAVI................... 59, 156urea.............................. 167ursodiol..........................114UTIBRON NEOHALER.. 36, 156valacyclovir...................... 15VALCHLOR................ 21, 167valganciclovir....................15valproate sodium.............. 87valproic acid..................... 87valproic acid (as sodium salt)................................ 87valsartan..........................59valsartan-hydrochlorothiazide.... 59, 100VALTREX..........................15VANCOCIN....................... 15vancomycin...................... 16VANDAZOLE....................167VAQTA (PF)...................... 27VARIBAR THIN LIQUID.......92VARIVAX (PF)................... 27VARIZIG.......................... 27VASCEPA..........................59VASERETIC............... 59, 100vasopressin.................... 135VASOTEC......................... 59VECTIBIX......................... 21VELIVET TRIPHASIC REGIMEN (28).................135VELPHORO......................100VELTASSA...................... 100VEMLIDY.......................... 16VENA-BAL DHA...43, 100, 170VENCLEXTA...................... 21VENCLEXTA STARTING PACK............................... 21venlafaxine.......................87VENTAVIS................. 59, 156VENTOLIN HFA.......... 36, 156VERAMYST.............. 108, 156

verapamil.........................59VERELAN..........................59VERELAN PM.....................59VERSACLOZ......................87VERZENIO........................21VESICARE.......................168VFEND............................. 16VIBERZI......................... 114VICTOZA 2-PAK...............135VICTOZA 3-PAK...............135VIEKIRA PAK.................... 16VIENVA.......................... 135vigabatrin.........................87VIGADRONE..................... 87VIGAMOX....................... 108VIIBRYD...........................87VIMIZIM.........................101VIMOVO....................88, 115VIMPAT............................88VINACAL.... 44, 100, 115, 170VINATE CARE............ 44, 170VINATE GT................ 44, 170VINATE II....................... 170VINATE M................. 44, 170VINATE ONE.......44, 100, 170VINATE PN CARE............. 170VINATE ULTRA................. 44, 100, 115, 170VIOKACE........................ 115VIORELE (28)..................135VIRACEPT.........................16VIREAD............................16VIRT-PN....................44, 171VIRT-PN DHA.............44, 170VIRT-PN PLUS.... 44, 101, 171VIRT-SELECT................. 44, 101, 115, 171VISTOGARD....................147VITAFOL-OB.......44, 101, 171VITAMIN D2....................171VITAMINS A,C,D AND FLUORIDE............... 147, 171VITRAKVI......................... 21VIVOTIF...........................27VIZIMPRO........................ 21VOGELXO....................... 135VOL-NATE..........44, 101, 171VOLTAREN................ 88, 167VONVENDI....................... 44voriconazole..................... 16VOSEVI............................16VOTRIENT........................ 21


189

VPRIV............................ 101VRAYLAR..........................88VUSION......................... 167VYNDAMAX.......................59VYNDAQEL....................... 60VYTORIN 10-10.................60VYTORIN 10-20.................60VYTORIN 10-40.................60VYTORIN 10-80.................60VYVANSE......................... 88VYZULTA........................ 108WAL-ZYR (CETIRIZINE) 3, 156warfarin........................... 44water for irrigation, sterile 101WAVESENSE PRESTO.........92WELCHOL..................60, 135WELLBUTRIN SR............... 88WELLBUTRIN XL................88WERA (28)..................... 135WILATE............................44WIXELA INHUB...36, 135, 156WYMZYA FE.................... 136XADAGO.......................... 88XALATAN........................108XALKORI.......................... 21XARELTO..........................44XARELTO DVT-PE TREAT 30D START.......................44XELJANZ........................ 147XELJANZ XR....................147XENLETA..........................16XERESE..........................167XHANCE..................108, 156XIFAXAN.......................... 16XIGDUO XR.................... 136XOFLUZA......................... 16XOLAIR.......................... 156XOPENEX.................. 36, 157XOPENEX CONCENTRATE............................... 36, 156XOPENEX HFA............36, 157XOSPATA......................... 21XPOVIO........................... 22XTAMPZA ER.....................88XTANDI............................22XULANE..........................136XULTOPHY 100/3.6.......... 136XYNTHA........................... 44XYNTHA SOLOFUSE........... 44YF-VAX (PF)......................27YONDELIS........................ 22YOSPRALA........... 44, 88, 115

YUPELRI...........................36yuvafem.........................136ZADITOR........................108zafirlukast...................... 157zaleplon........................... 88ZARAH........................... 136ZARONTIN.................. 88, 89ZARXIO............................44ZATEAN-PN DHA........ 45, 171ZATEAN-PN PLUS 45, 101, 171ZEJULA............................ 22ZELBORAF........................22ZEMBRACE SYMTOUCH...... 89ZENATANE......................167ZENCHENT (28)...............136ZENPEP..........................115ZENZEDI..........................89ZEPATIER.........................16ZESTORETIC............. 60, 101ZESTRIL...........................60ZETIA.............................. 60ZETONNA................ 108, 157ZIAC...................36, 60, 101ZIANA............................167zidovudine........................16zileuton..........................157ZIOPTAN (PF)................. 108ziprasidone hcl..................89ziprasidone mesylate......... 89ZIPSOR............................89ZIRGAN..........................108ZITHROMAX..................... 16ZITHROMAX TRI-PAK......... 16ZOCOR............................ 60ZOFRAN......................... 115ZOFRAN ODT.................. 115ZOHYDRO ER....................89ZOLINZA..........................22zolmitriptan......................89ZOLOFT........................... 89zolpidem.......................... 89ZOLPIMIST....................... 89ZOMACTON.....................136ZOMIG.............................89ZOMIG ZMT......................89zonisamide....................... 89ZONTIVITY....................... 45ZORBTIVE...................... 136ZORTRESS......................147ZORVOLEX....................... 89ZOSTAVAX (PF).................27ZOVIA 1/35E (28)............136

ZOVIRAX.................. 16, 167ZUBSOLV......................... 89ZUPLENZ........................115ZYBAN............................. 89ZYDELIG.......................... 22ZYFLO............................157ZYFLO CR....................... 157ZYKADIA..........................22ZYLET............................ 108ZYMAXID........................108ZYPITAMAG...................... 60ZYPREXA.................... 89, 90ZYPREXA RELPREVV...........90ZYPREXA ZYDIS................ 90ZYTIGA............................ 22


Over-the-Counter (OTC) Drug List

The following list of over-the-counter (OTC) drugs are covered by UCare for State Public Program members. The list only includes the generic version of products. Some brand products are listed in parentheses for reference purposes only. This list is subject to change.

ANALGESICS AND ANTI-INFLAMMATORY DRUGS

acetaminophen (TYLENOL) acetaminophen / pyrilamine / caffeine aspirin (BAYER) aspirin / acetaminophen/ caffeine (EXCEDRIN) aspirin / buffers (BUFFERIN) ibuprofen (MOTRIN) naproxen (ALEVE)

COUGH AND COLD MEDICATIONS ANTIHISTAMINES

cetirizine (ZYRTEC) chlorpheniramine (CHLOR-TRIMETON) diphenhydramine (BENADRYL) loratadine (CLARITIN)

DECONGESTANTS phenylephrine (SUDAFED PE) pseudoephedrine (SUDAFED)

ANTIHISTAMINE / DECONGESTANT COMBINATIONS brompheniramine / pseudoephedrine brompheniramine / phenylephrine cetirizine / pseudoephedrine (ZYRTEC - D) chlorpheniramine / phenylephrine chlorpheniramine / phenylephrine / acetaminophen chlorpheniramine / phenylephrine / dextromethorphan / acetaminophen chlorpheniramine / pseudoephedrine loratadine / pseudoephedrine (CLARITIN - D) phenylephrine / acetaminophen phenylephrine / guaifenesin pseudoephedrine / ibuprofen psueodoephedrine / acetaminophen

ANTITUSSIVES AND EXPECTORANT DRUGS dextromethorphan (ROBITUSSIN) dextromethorphan / chlorpheniramine dextromethorphan / phenylephrine

dextromethorphan / phenylephrine / acetaminophen dextromethorphan / pseudoephedrine / acetaminophen


dextromethorphan / pseudoephedrine / brompheniramine dextromethorphan / pseudoephedrine / chlorpheniramine guaifenesin (MUCINEX) guaifenesin / dextromethorphan (MUCINEX DM) guaifenesin / dextromethorphan / phenylephrine guaifenesin / dextromethorphan / pseudoephedrine guaifenesin / phenylephrine guaifenesin / pseudoephedrine

DERMATOLOGICAL DRUGS ANTIACNE DRUGS

benzoyl peroxide benzoyl peroxide / aloe vera

KEROLYTIC DRUGS salicylic acid SCABICIDES

permethrin (NIX) piperonyl / pyrethrins (RID)

TOPICAL ANESTHETICS pramoxine (PROCTO-FOAM)

TOPICAL ANTIBACTERIAL DRUGS bacitracin bacitracin / polymyxin b (POLYSPORIN) chlorhexidine neomycin / bacitracin / polymixin (NEOSPORIN) neomycin / bacitracin / polymixin / pramoxine (NEOSPORIN PLUS)

TOPICAL ANTIFUNGALS clotrimazole (LOTRIMIN) miconazole (MICATIN) terbinafine (LAMISIL) tolnaftate (TINACTIN)

TOPICAL CORTICOSTEROIDS hydrocortisone / aloe vera hydrocortisone

OTHER TOPICAL DERMATOLOGICAL DRUGS ammonium lactate (AMLACTIN) calamine / zinc oxide capsaicin (ZOSTRIX) chloroxylenol Diphenhydramine diphenhydramine / zinc hydrogen peroxide methyl salicylate / menthol / camphor (BENGAY) salonpas mineral oil / petrolatum (AQUAPHOR, EUCERIN) petrolatum (VASELINE)


pramoxine / calamine povidone-iodine (BETADINE) trolamine salicylate (MYOFLEX) urea (CARMOL) zinc oxide (DESITIN)

EAR / NOSE / THROAT MEDICATIONS DRUGS AFFECTING THE EAR carbamide peroxide (DEBROX) DRUGS AFFECTING THE NOSE

cromolyn (NASALCROM) triamcinolone acetonide oxymetazoline (AFRIN) phenylephrine (NEO-SYNEPHRINE) sodium chloride

DRUGS AFFECTING THE THROAT Zinc

GASTROINTESTINAL DRUGS ANTACIDS

aluminum hydroxide (ALTERNAGEL) calcium carbonate (TUMS) calcium carbonate / magnesium hydroxide (MYLANTA SUPREME) magnesium carbonate / aluminum hydroxide (GAVISCON) magnesium hydroxide / aluminum hydroxide / simethicone (MYLANTA) magnesium hydroxide / aluminum hydroxide (MAALOX) magnesium oxide (URO-MAG) sodium bicarbonate

ANTIDIARRHEAL DRUGS bismuth subsalicylate (PEPTO-BISMOL) loperamide (IMMODIUM)

ANTIULCER DRUGS famotidine (PEPCID) lansoprazole (PREVACID) ranitidine (ZANTAC) omeprazole (PRILOSEC)

LAXATIVES AND CATHARTICS bisacodyl (DULCOLAX) docusate calcium (SURFAK) docusate sodium (COLACE) glycerin magnesium citrate (CITROMA) magnesium hydroxide (PHILLIPS' MOM) methylcellulose (CITRUCEL) mineral oil polycarbophil polyethylene glycol 3350 (MIRALAX)


psyllium (METAMUCIL) senna / docusate sodium (PERI-COLACE)

OTHER GI DRUGS lactase (LACTAID) phenylephrine phenylephrine / shark liver / petrolatum (PREPARATION H) simethicone (MYLICON) sorbitol witch hazel

MISCELLANEOUS (OTHER) PRODUCTS dimenhydrinate (DRAMAMINE) levorgestestrel (PLAN B) meclizine phenazopyridine (AZO)

OPHTHALMIC DRUGS propylene glycol PEGS (SYSTANE ULTRA) sodium chloride sodium chloride / petrolatum / mineral oil (REFRESH PM) tetrahydrazoline drops (VISINE)

SEDATIVE / HYPNOTIC DRUGS acetaminophen / diphenhydramine (TYLENOL PM) doxylamine (UNISOM)

SMOKING CESSATION PRODUCTS nicotine (NICODERM) nicotine gum nicotine polacrilex (COMMIT)

VAGINAL ANTIFUNGALS Clotrimazole (GYNE-LOTRIMIN) miconazole (MONISTAT)

VITAMINS AND RELATED PRODUCTS MINERALS/ELECTROLYTES calcium carbonate calcium citrate calcium glubionate

calcium gluconate calcium lactate calcium / magnesium


calcium / magnesium / zinc chromium electrolyte solution (pediatric) ferrous gluconate ferrous sulfate magnesium chloride magnesium gluconate magnesium oxide potassium chloride potassium gluconate selenium sodium chloride zinc gluconate zinc sulfate

MISCELLANEOUS NUTRIENTS beta-carotene biotin glucose

VITAMINS cyanocobalmin (vitamin b12) niacinamide pantothenic acid pyridoxine (vitamin b6) riboflavin (vitamin b2) thiamine (vitamin b1) vitamin a vitamin c vitamin d vitamin e

VITAMIN COMBINATION PRODUCTS calcium carbonate / vitamin d calcium carbonate / vitamin d / minerals folic acid / vitamin b complex / vitamin c multivitamins multivitamins / iron multivitamins / minerals multivitamins / minerals / iron prenatal vitamin vitamin a / vitamin c / vitamin d vitamin a / vitamin d vitamin b complex / folic acid vitamin b complex / vitamin c

U3984 (10/2020)

PO Box 52 Minneapolis, MN 55440-0052

612-676-3200 1-800-203-7225 toll free

TTY/Hearing impaired 612-676-6810

1-800-688-2534 toll free

8 am – 5 pm Monday – Friday

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