UCare Connect (SNBC) • Families and Children (Prepaid ...

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 10/2021. To see the most current information, please visit ucare.org. If you have questions, contact UCare 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.

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.

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, Le Sueur, 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, Le Sueur, 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.

2021 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 12/22/2020

Effective October 1, 2021

http://ucare.org

http://ucare.org

Note to existing members: This list of covered drugs has changed since last year and may change throughout the year. Please review this document to make sure that it still has the drugs you take. The drugs you take may change throughout the year. 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.

You can also find updates to this list at ucare.org.

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 Medicare prescription drug benefits.

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

http://ucare.org

CB5 (MBOs) (5-2020)

Civil Rights NoticeDiscrimination is against the law. UCare does not discriminate on the basis of any of the following: • race • color • national origin • creed • religion • sexual orientation

• public assistance status • age• disability (including

physical or mental impairment)

• sex (including sex

stereotypes and gender identity)

• marital status• political beliefs• medical condition• health status

• receipt of health care services

• claims experience• medical history• genetic information

Auxiliary Aids and ServicesUCare provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner, to ensure an equal opportunity to participate in our health care programs. Contact UCare at 612-676-3200 (voice) or 1-800-203-7225 (voice), 612-676-6810 (TTY) or 1-800-688-2534 (TTY).

Language Assistance ServicesUCare provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact UCare at 612-676-3200 (voice) or 1-800-203-7225 (voice), 612-676-6810 (TTY) or 1-800-688-2534 (TTY).

Civil Rights ComplaintsYou have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by UCare. You may contact any of the following four agencies directly to file a discrimination complaint.

U.S. Department of Health and Human Services’ Office for Civil Rights (OCR)You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following: • race• color• national origin

• age• disability• sex

• religion (in some cases)

Contact the OCR directly to file a complaint: U.S. Department of Health and Human Services’ Office for Civil Rights 200 Independence Avenue SW Room 515F HHH Building Washington, DC 20201

Customer Response Center: Toll-free: 800-368-1019 TDD 800-537-7697 Email: [email protected]

Minnesota Department of Human Rights (MDHR)In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following: • race • color • national origin • religion

• creed • sex • sexual orientation • marital status

• public assistance status • disability

Contact the MDHR directly to file a complaint: Minnesota Department of Human Rights 540 Fairview Avenue North, Suite 201 St. Paul, MN 55104

651-539-1100 (voice) 800-657-3704 (toll free) 711 or 1-800-627-3529 (MN Relay) 651-296-9042 (Fax) [email protected] (Email)

Minnesota Department of Human Services (DHS)You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following: • race • color • national origin • creed • religion • sexual orientation

• public assistance status • age • disability (including

physical or mental impairment)

• sex (including sex

stereotypes and gender identity)

• marital status• political beliefs• medical condition• health status

• receipt of health care services

• claims experience• medical history• genetic information

Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint.

DHS will notify you in writing of the investigation’s outcome. You have the right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome. Be brief and state why you disagree with the decision. Include additional information you think is important.

If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administrative actions.

Contact DHS directly to file a discrimination complaint: Civil Rights Coordinator Minnesota Department of Human Services Equal Opportunity and Access Division

P.O. Box 64997 St. Paul, MN 55164-0997 651-431-3040 (voice) or use your preferred relay service

UCare Complaint NoticeYou have the right to file a complaint with UCare if you believe you have been discriminated against in our health care programs because of any of the following:• medical condition• health status• receipt of health care

services• claims experience• medical history

• genetic information• disability (including

mental or physical impairment)

• marital status• age

• sex (including sex stereotypes and gender identity)

• sexual orientation• national origin• race

• color• religion• creed• public assistance status• political belief

You can file a complaint and ask for help in filing a complaint in person or by mail, phone, fax, or email at:

UCare Attn: Appeals and GrievancesPO Box 52 Minneapolis, MN 55440-0052

Toll free: 1-800-203-7225TTY: 1-800-688-2534Fax: 612-884-2021 Email: [email protected]

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 primary care provider prior to the referral.

DHS approved 06/29/2020

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 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 (formulary) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

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

Over-the-counter (OTC) Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191

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IMPORTANT INFORMATION

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 affect the coverage of a drug you are taking, UCare will make reasonable efforts to contact you and your prescriber to tell you about the change. UCare will also tell you about alternative drugs that are covered.

Examples of some changes that may occur are:

• A drug you are taking is no longer preferred (See “What is a Preferred Drug List?” below).

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

• Prior authorization requirements have changed. (See “Are there any restrictions on my coverage?”

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 health plans are required to use the Minnesota Department of Human Services’ (DHS) Preferred Drug List (PDL). The PDL is created by DHS, in consultation with the Drug Formulary Committee, to let prescribers and members know about drugs or drug classes that are cost effective. Generally, drugs that are “preferred” are more cost effective and drugs that are “non-preferred” are less cost effective. Preferred drugs are available to members with fewer restrictions. Non-preferred drugs require a prior authorization. To get a non-preferred drug, your doctor or health care provider must get

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prior authorization. The PDL is included as part of UCare’s list of covered drugs. UCare’s complete list of covered drugs includes other drugs in addition to those on the PDL. The PDL is available on DHS’s website at 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 ingredients as the brand name drug. It 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 an already-approved biological product. It has no clinically meaningful differences in terms of safety and effectiveness. Biosimilar drugs are not the same as generic drugs, but like generics, biosimilar drugs may offer more affordable treatment options.

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 certain brand-name version over the generic 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. sertraline tablet).

What are over-the-counter 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. Within the list of covered drugs, OTC drugs and products are listed after the index in a separate over-the-counter (OTC) drug list.

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 to UCare’s specialty pharmacy.

Name of Specialty Pharmacy: Fairview Specialty PharmacyPhone 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: 1-866-347-4939Hours of operation: 24 hours a day, seven days a weekwww.fairviewspecialtyrx.org

http://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, TTY call the National Relay Center at 711 and ask for 1-800-595-7140, 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 prescription. 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: Some drugs have age requirements. 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. An exception to a drug restriction or limit can be made if your doctor submits a statement or documentation supporting the request. See Section 7: Covered Services (Prescription Drugs) in your Member Handbook for more information. You can also get more information about the restrictions applied to specific covered drugs by calling UCare Customer Service or Families and Children (PMAP), MinnesotaCare, and MSC+ Members at 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. Also see “Can I ask for an exception to the coverage restrictions?”

http://ucare.org

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• Excluded Drugs: Some drugs are excluded from the list of covered drugs. This means they are not covered. 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. You or 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 allow for a thorough review and to ensure that you or your healthcare provider gets a response within 24 hours, all information requested in the form should be provided, including documentation of which medications have been tried and failed, including the dosages used and the reason for failure (e.g. side effects).

What will a prescription cost?All copay information for prescriptions is listed in the Member Handbook in Section 6: Cost-Sharing. 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 visit 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.

http://ucare.org

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 NP PAcetirizine-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 NP PA

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 PA

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Drug Tier Limits or RestrictionsCLARINEX-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

SEMPREX-D ORAL CAPSULE 8-60 MG NP PAWAL-ZYR (CETIRIZINE) ORAL TABLET 10 MG P

ANTI-INFECTIVE AGENTSabacavir oral solution 20 mg/ml AD

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Drug Tier Limits or Restrictionsabacavir oral tablet 300 mg ADabacavir-lamivudine oral tablet 600-300 mg AD

abacavir-lamivudine-zidovudine oral tablet300-150-300 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 soln1,000 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

amoxicillin-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

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Drug Tier Limits or Restrictionsampicillin sodium intravenous recon soln 1 gram, 2 gram AD

ampicillin-sulbactam injection recon soln1.5 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

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

AZULFIDINE 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 ML per 30 days)

BIKTARVY ORAL TABLET 50-200-25 MG AD

4

Drug Tier Limits or RestrictionsCABENUVA INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE 400 MG/2 ML- 600 MG/2 ML

AD QL (1 Kit per 30 days)

CABENUVA INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE 600 MG/3 ML- 900 MG/3 ML

AD QL (1 Kit per 365 days)

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML NP SP; PA; QL (84 ML per 30

days)cefaclor oral capsule 250 mg, 500 mg Pcefaclor oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml P

cefaclor oral tablet extended release 12 hr500 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 reconstitution125 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 reconstitution100 mg/5 ml, 200 mg/5 ml NP PA

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

cefotetan 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 PA

5

Drug Tier Limits or Restrictionscefprozil oral suspension for reconstitution125 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 soln1.5 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 NP PAchloramphenicol 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

ciprofloxacin 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 P

6

Drug Tier Limits or Restrictionsclarithromycin oral tablet extended release 24 hr 500 mg NP PA

clindamycin hcl oral capsule 150 mg, 300 mg AD

clindamycin palmitate hcl oral recon soln75 mg/5 ml AD

CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML AD

clindamycin phosphate injection solution150 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 350 mg, 500 mg AD

DARAPRIM ORAL TABLET 25 MG AD 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

DIFICID ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML AD

DIFICID 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 AD

7

Drug Tier Limits or Restrictionsdoxycycline 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 ADefavirenz-emtricitabin-tenofov oral tablet600-200-300 mg AD

efavirenz-lamivu-tenofov disop oral tablet400-300-300 mg, 600-300-300 mg AD

emtricitabine oral capsule 200 mg ADemtricitabine-tenofovir (tdf) oral tablet100-150 mg, 133-200 mg, 167-250 mg, 200-300 mg

AD

EMTRIVA 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 SP

EPIVIR HBV ORAL TABLET 100 MG P SPEPIVIR 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

erythromycin oral tablet 250 mg, 500 mg NP PAethambutol oral tablet 100 mg, 400 mg ADetravirine oral tablet 100 mg, 200 mg ADEVOTAZ ORAL TABLET 300-150 MG AD

8

Drug Tier Limits or Restrictionsfamciclovir oral tablet 125 mg, 500 mg NP PA; QL (21 EA per 30 days)famciclovir oral tablet 250 mg NP PA; QL (60 EA 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 EA Max Qty Per Fill Retail)

flucytosine oral capsule 250 mg, 500 mg NP PAfosamprenavir oral tablet 700 mg ADfosfomycin tromethamine oral packet 3 gram AD

FUZEON 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 PELLETS IN PACKET 33.75-150 MG, 45-200 MG NP PA

HARVONI ORAL TABLET 45-200 MG NP PAHARVONI ORAL TABLET 90-400 MG NP PA; SPHEPSERA ORAL TABLET 10 MG P SPhydroxychloroquine oral tablet 200 mg ADINTELENCE ORAL TABLET 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 EA per 30 days)itraconazole oral solution 10 mg/ml NP PAivermectin oral tablet 3 mg ADJULUCA ORAL TABLET 50-25 MG ADKEFLEX 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 ML per 30 days)

lamivudine oral solution 10 mg/ml Plamivudine oral tablet 100 mg P SPlamivudine oral tablet 150 mg, 300 mg Plamivudine-zidovudine oral tablet 150-300 mg AD

LAMPIT ORAL TABLET 120 MG, 30 MG ADledipasvir-sofosbuvir oral tablet 90-400 mg NP PA; SPlevofloxacin 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 reconstitution100 mg/5 ml AD

linezolid oral tablet 600 mg ADlinezolid-0.9% sodium chloride intravenous parenteral solution 600 mg/300 ml AD

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

10

Drug Tier Limits or Restrictionslopinavir-ritonavir oral tablet 100-25 mg, 200-50 mg 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 capsule100 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 PAnystatin oral powder 150 million unit, 500 million unit AD

nystatin oral suspension 100,000 unit/ml P

11

Drug Tier Limits or Restrictionsnystatin 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 EA per 30 days)oseltamivir oral capsule 45 mg, 75 mg P QL (10 EA per 30 days)oseltamivir oral suspension for reconstitution 6 mg/ml P QL (180 ML 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 ML per 30 days)

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

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

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

penicillin g potassium injection recon soln20 million unit, 5 million unit AD

penicillin g procaine intramuscular syringe1.2 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 ADpiperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

AD

polymyxin b sulfate injection recon soln500,000 unit AD

12

Drug Tier Limits or Restrictionsposaconazole oral tablet,delayed release (dr/ec) 100 mg NP PA

praziquantel oral tablet 600 mg ADpretomanid oral tablet 200 mg ADPREZCOBIX 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 EA 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 ADRIFATER ORAL TABLET 50-120-300 MG ADrimantadine oral tablet 100 mg ADritonavir oral tablet 100 mg ADRUKOBIA ORAL TABLET EXTENDED RELEASE 12 HR 600 MG AD

SELZENTRY ORAL SOLUTION 20 MG/ML ADSELZENTRY ORAL TABLET 150 MG, 300 MG ADSIRTURO ORAL TABLET 100 MG, 20 MG AD

13

Drug Tier Limits or RestrictionsSITAVIG 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 PELLETS IN PACKET 150 MG, 200 MG NP PA

SOVALDI ORAL TABLET 200 MG NP PASOVALDI 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 tablet400-80 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

NP PA

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

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

SYMTUZA ORAL TABLET 800-150-200-10 MG AD

SYNAGIS 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

tenofovir disoproxil fumarate oral tablet300 mg AD

14

Drug Tier Limits or Restrictionsterbinafine 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 ML per 30

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

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

tobramycin inhalation solution for nebulization 300 mg/4 ml NP PA

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

tobramycin with nebulizer inhalation solution for nebulization 300 mg/5 ml NP PA

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

valacyclovir oral tablet 1 gram, 500 mg P QL (30 EA 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

vancomycin 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

15

Drug Tier Limits or RestrictionsVIRACEPT 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 EA per 30 days)XOFLUZA ORAL TABLET 80 MG NP PAZEPATIER 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 PAANTINEOPLASTIC AGENTS

abiraterone oral tablet 250 mg AD PA; SP; QL (120 EA per 30 days)

abiraterone oral tablet 500 mg AD PA; SP; QL (60 EA per 30 days)

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AD PA; SP; QL (30 EA per 30

days)

AFINITOR ORAL TABLET 10 MG AD PA; SP; QL (30 EA per 30 days)

ALECENSA ORAL CAPSULE 150 MG AD PA; SP; QL (240 EA per 30 days)

16

Drug Tier Limits or RestrictionsALUNBRIG ORAL TABLET 180 MG, 90 MG AD PA; SP

ALUNBRIG ORAL TABLET 30 MG AD PA; SP; QL (180 EA 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, 25 MG, 300 MG, 50 MG AD PA; QL (30 EA per 30 days)

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

bexarotene oral capsule 75 mg AD PA; SPbicalutamide 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; SP

CABOMETYX ORAL TABLET 20 MG AD PA; SP; QL (30 EA 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; SP

COTELLIC ORAL TABLET 20 MG AD PA; SP; QL (63 EA per 30 days)

cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg AD

CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG AD

cyclophosphamide oral tablet 25 mg, 50 mg AD

DAURISMO ORAL TABLET 100 MG, 25 MG AD PA; SPdiclofenac sodium topical gel 3 % AD PA; QL (100 GM per 21 days)DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG P

ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG AD PA

17

Drug Tier Limits or RestrictionsELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG AD PA

ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG AD PA

ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) AD PA

EMCYT ORAL CAPSULE 140 MG AD SPERIVEDGE 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 EA per 30

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

fluorouracil 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 ADGAVRETO ORAL CAPSULE 100 MG AD PAGILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG AD PA; SP; QL (30 EA per 30

days)GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG AD SP

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

ICLUSIG ORAL TABLET 10 MG, 15 MG, 30 MG, 45 MG AD PA; SP; QL (30 EA per 30

days)IDHIFA ORAL TABLET 100 MG, 50 MG AD PA; SPimatinib oral tablet 100 mg AD PA; SP

imatinib oral tablet 400 mg AD PA; SP; QL (60 EA per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG AD PA; SP; QL (120 EA per 30 days)

IMBRUVICA ORAL CAPSULE 70 MG AD PA; SP

IMBRUVICA ORAL TABLET 140 MG AD PA; SP; QL (120 EA per 30 days)

18

Drug Tier Limits or RestrictionsIMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG AD PA; SP

INLYTA ORAL TABLET 1 MG, 5 MG AD PA; SPINQOVI ORAL TABLET 35-100 MG AD PA; QL (5 EA per 30 days)

INREBIC ORAL CAPSULE 100 MG AD PA; SP; QL (120 EA per 30 days)

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 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

KOSELUGO ORAL CAPSULE 10 MG, 25 MG AD PA; SPlapatinib oral tablet 250 mg AD PA; SPLENVIMA 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

19

Drug Tier Limits or RestrictionsLUPRON 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

megestrol 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 PA

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 solution25 mg/ml AD

methotrexate sodium injection solution 25 mg/ml AD

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

NUBEQA ORAL TABLET 300 MG AD PA; SP; QL (120 EA per 30 days)

ONUREG ORAL TABLET 200 MG, 300 MG AD PA; SP; QL (14 EA Max Qty Per Fill Retail)

ORGOVYX ORAL TABLET 120 MG AD PA; QL (30 EA per 30 days)OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 22.5 MG/0.4 ML NP PA

PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG AD PA; SP; QL (14 EA per 30

days)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

20

Drug Tier Limits or RestrictionsPOMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG AD SP

QINLOCK ORAL TABLET 50 MG AD PA; QL (90 EA per 30 days)

RETEVMO ORAL CAPSULE 40 MG AD PA; SP; QL (180 EA per 30 days)

RETEVMO ORAL CAPSULE 80 MG AD PA; SP; QL (120 EA per 30 days)

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG AD PA; SP; QL (30 EA per 30

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

AD PA; SP

ROZLYTREK ORAL CAPSULE 100 MG AD PA; SP; QL (30 EA per 30 days)

ROZLYTREK ORAL CAPSULE 200 MG AD PA; SP; QL (90 EA 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 NP PASPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG AD PA; SP

STIVARGA ORAL TABLET 40 MG AD PA; SPSUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) AD PA

SUTENT 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 AD SPTABRECTA ORAL TABLET 150 MG, 200 MG AD PA; SP

TAFINLAR ORAL CAPSULE 50 MG, 75 MG AD PA; SP; QL (120 EA per 30 days)

TAGRISSO ORAL TABLET 40 MG, 80 MG AD PA; SP; QL (30 EA per 30 days)

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG AD PA; SPtamoxifen oral tablet 10 mg, 20 mg ADTARGRETIN TOPICAL GEL 1 % AD SPTASIGNA 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

TEPMETKO ORAL TABLET 225 MG AD PA; QL (60 EA per 30 days)

21

Drug Tier Limits or RestrictionsTIBSOVO ORAL TABLET 250 MG AD PA; SPtoremifene oral tablet 60 mg AD SPtretinoin (antineoplastic) oral capsule 10 mg AD SP

TUKYSA ORAL TABLET 150 MG AD PA; SP; QL (300 EA per 30 days)

TUKYSA ORAL TABLET 50 MG AD PA; SP; QL (120 EA per 30 days)

TURALIO ORAL CAPSULE 200 MG AD PA; QL (120 EA per 30 days)VALCHLOR TOPICAL GEL 0.016 % AD SPVANTAS IMPLANT KIT 50 MG (50 MCG/DAY) AD PA

VECTIBIX 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; SPXPOVIO 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 100 MG/WEEK (50 MG X 2), 40 MG/WEEK (20 MG X 2), 40 MG/WEEK (40 MG X 1), 40MG TWICE WEEK (40 MG X 2), 40MG TWICE WEEK (80 MG/WEEK), 60 MG/WEEK (60 MG X 1), 60MG TWICE WEEK (120 MG/WEEK), 80 MG/WEEK (40 MG X 2)

AD PA

XTANDI ORAL CAPSULE 40 MG AD PA; SP; QL (120 EA Max Qty Per Fill Retail)

XTANDI ORAL TABLET 40 MG AD PA; SP; QL (120 EA Max Qty Per Fill Retail)

22

Drug Tier Limits or Restrictions

XTANDI ORAL TABLET 80 MG AD PA; SP; QL (60 EA Max Qty Per Fill Retail)

YONDELIS INTRAVENOUS RECON SOLN 1 MG AD PA

ZEJULA ORAL CAPSULE 100 MG AD PA; SP; QL (90 EA 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; 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

bcg vaccine, live (pf) percutaneous suspension for reconstitution 50 mg AD

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

BIOTHRAX INTRAMUSCULAR SUSPENSION 0.5 ML/DOSE 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

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML

AD

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

23

Drug Tier Limits or RestrictionsENGERIX-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

GAMASTAN 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

24

Drug Tier Limits or RestrictionsGAMUNEX-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 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

IXIARO (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

MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG/0.5 ML AD

25

Drug Tier Limits or RestrictionsMENVEO 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

ODACTRA SUBLINGUAL TABLET 12 SQ-HDM AD PA

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

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

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

Retail)PALFORZIA INITIAL DOSE ORAL CAPSULE, SPRINKLE 0.5/1/1.5/3/6 MG AD PA; QL (13 EA Max Qty Per Fill

Retail)PALFORZIA LEVEL 11 MAINTENANCE ORAL POWDER IN PACKET 300 MG AD PA; QL (30 EA 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

26

Drug Tier Limits or RestrictionsPENTACEL (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

SHINGRIX 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

27

Drug Tier Limits or Restrictionstetanus,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

TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 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

VAXCHORA ACTIVE COMPONENT ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF UNIT

AD

VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF UNIT

AD

VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG/0.5 ML

AD

VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG/0.5 ML AD

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 EA Max Qty Per Fill Retail)

28

Drug Tier Limits or RestrictionsADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION

P QL (12 GM per 30 days)

AIRDUO RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113-14 MCG/ACTUATION, 232-14 MCG/ACTUATION, 55-14 MCG/ACTUATION

NP PA; QL (1 EA per 30 days)

albuterol hfa 90 mcg inhaler 90 mcg/actuation NP PA; Ventolin Generics; QL (36

GM Max Qty Per Fill Retail)albuterol hfa 90 mcg inhaler 90 mcg/actuation NP PA; Proventil Generics; QL (14

GM Max Qty Per Fill Retail)albuterol hfa 90 mcg inhaler 90 mcg/actuation NP PA; Proair Generics; QL (17

GM Max Qty Per Fill Retail)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 hr10 mg P



P


P




P


P

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

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

29

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 NP PA

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 GM per 30 days)

bisoprolol fumarate oral tablet 10 mg, 5 mg P

bisoprolol-hydrochlorothiazide oral tablet10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg NP PA

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 ML 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

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

30

Drug Tier Limits or Restrictionscarvedilol 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 hcl oral tablet extended release 12 hr 0.1 mg AD

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

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION P QL (8 GM 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

diphenoxylate-atropine oral tablet 2.5-0.025 mg AD

donepezil oral tablet 10 mg, 5 mg Pdonepezil oral tablet 23 mg NP PA

31

Drug Tier Limits or Restrictionsdonepezil oral tablet,disintegrating 10 mg, 5 mg P

doxazosin oral tablet 1 mg, 2 mg, 4 mg P QL (30 EA per 30 days)doxazosin oral tablet 8 mg P QL (60 EA per 30 days)DUAKLIR PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400-12 MCG/ACTUATION

NP PA

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION


epinephrine hcl (pf) injection solution 1 mg/ml (1 ml) AD

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml NP PA; Non-Mylan Manufacturer;

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

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 EA per 30 days)

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

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

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

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

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 PAglycopyrrolate oral tablet 1 mg, 2 mg ADguanidine oral tablet 125 mg AD

32

Drug Tier Limits or RestrictionsHEMANGEOL 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 tablet0.125 mg AD

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION NP PA; QL (1 EA 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 solution0.02 % 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 ML per 30 days)

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

LOPRESSOR ORAL TABLET 100 MG, 50 MG NP PALORATA-DINE D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG P

33

Drug Tier Limits or RestrictionsLORATADINE-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 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 tablet250-15 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 tablet100-25 mg, 100-50 mg, 50-25 mg NP PA

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

nicotine 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

34

Drug Tier Limits or Restrictionsorphenadrine 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 ML 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 GM per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION


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 tablet40-25 mg, 80-25 mg AD

PROVENTIL HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION NP PA

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

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg NP PA

rivastigmine transdermal patch 24 hour13.3 mg/24 hour, 4.6 mg/24 hour, 9.5 mg/24 hour

NP PA

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

SEMPREX-D ORAL CAPSULE 8-60 MG NP PA

35

Drug Tier Limits or RestrictionsSEREVENT 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 EA per 30 days)

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

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION (28 ACTUAT) P

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

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION P QL (2 inhalers per 30 days)

SYMBICORT INHALATION HFA AEROSOL INHALER 80-4.5 MCG/ACTUATION P QL (2 inhlaers per 30 days)

SYMJEPI INJECTION SYRINGE 0.15 MG/0.3 ML, 0.3 MG/0.3 ML P QL (2 EA 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 EA per 30 days)terazosin oral capsule 10 mg P QL (60 EA per 30 days)terbutaline oral tablet 2.5 mg, 5 mg ADterbutaline subcutaneous solution 1 mg/ml ADtimolol 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

trihexyphenidyl oral elixir 0.4 mg/ml AD

36

Drug Tier Limits or Restrictionstrihexyphenidyl 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 GM per 30 days)

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

AD QL (60 EA per 30 days)

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 ML per 30 days)

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

BLOOD FORMATION, COAGULATION, THROMBOSISADAKVEO INTRAVENOUS SOLUTION 10 MG/ML P PA; SP

ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT

P SP

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

NP PA

AFSTYLA 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

NP SP; PA

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

P SP

ALPHANATE INTRAVENOUS RECON SOLN 1,250 (+/-) UNIT, 375 (+/-) UNIT P

37

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

NP SP; PA

ALPHANINE SD INTRAVENOUS RECON SOLN 812 (+/-) UNIT NP PA

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

NP PA

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 PA; 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 PA; 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

P SP

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

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

CABLIVI 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

P SP

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

38

Drug Tier Limits or RestrictionsCORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 UNIT P SP

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) P

ELIQUIS ORAL TABLET 2.5 MG, 5 MG PELITE-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

NP SP; PA

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

NP SP; PA

FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 350-650 UNIT, 400-650 UNIT, 651-1,200 UNIT, 700-1,300 UNIT

P 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 ML per 30

days)

39

Drug Tier Limits or RestrictionsGRANIX 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 P SP

HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1,700 UNIT P

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

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

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

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1,701-2,000 UNIT P

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 2,000 unit/1,000 ml AD

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

heparin (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

40

Drug Tier Limits or RestrictionsHEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 10 UNIT/ML, 100 UNIT/ML

AD

heparin, porcine (pf) injection solution1,000 unit/ml, 5,000 unit/0.5 ml AD

heparin, porcine (pf) injection syringe5,000 unit/0.5 ml AD

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

HUMATE-P INTRAVENOUS KIT 1,000-2,000 UNIT, 250-500 UNIT, 500-1,000 UNIT P

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

P SP

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

NP SP; PA

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

NP SP; PA

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

NP SP; PA

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

P SP

KOATE-DVI INTRAVENOUS KIT 500 (+/-) UNIT P

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

P

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

NP SP; PA

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

NP SP; PA

LEUKINE INJECTION RECON SOLN 250 MCG AD SP

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

41

Drug Tier Limits or RestrictionsLOVENOX 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 KIT 500 (+/-) UNIT P

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

MONONINE INTRAVENOUS RECON SOLN 250 (+/-) UNIT P

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 ONPRO SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML

AD PA; SP; QL (2 ML per 30 days)

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML AD PA; SP; QL (2 ML 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

P SP

NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG)

NP SP; PA

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

P SP

42

Drug Tier Limits or RestrictionsOBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE NP PA

OXBRYTA ORAL TABLET 500 MG P PA; SPpentoxifylline oral tablet extended release400 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 PPRENATABS 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

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

P SP

PROFILNINE INTRAVENOUS RECON SOLN 1,200 (+/-) UNIT P

PROMACTA ORAL POWDER IN PACKET 12.5 MG AD PA; SP

PROMACTA ORAL POWDER IN PACKET 25 MG AD SP

43

Drug Tier Limits or RestrictionsPROMACTA 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

NP SP; PA

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

NP SP; PA

RETACRIT 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

P PA; SP

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

NP SP; PA

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

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

tranexamic acid oral tablet 650 mg ADTRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT P SP

TRIADVANCE 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

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

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

VINATE 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

VIRT-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG AD

VIRT-PN ORAL TABLET 27-1 MG AD

44

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

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

NP PA

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

P 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

P SP

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

P SP

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

ZATEAN-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 soln500 mg AD

45

Drug Tier Limits or RestrictionsADALAT CC ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG, 90 MG NP PA

ADCIRCA ORAL TABLET 20 MG NP PA; SP; QL (60 EA 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 P 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

amlodipine-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 tablet10-160-12.5 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 NP PA

46

Drug Tier Limits or Restrictionsatorvastatin 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 tablet10-12.5 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 ADbisoprolol 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 tablet16-12.5 mg, 32-12.5 mg, 32-25 mg NP PA

47

Drug Tier Limits or Restrictionscaptopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg P

captopril-hydrochlorothiazide oral tablet25-15 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

carvedilol 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 hcl oral tablet extended release 12 hr 0.1 mg AD

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

colesevelam oral powder in packet 3.75 gram NP PA

colesevelam oral tablet 625 mg NP PA

48

Drug Tier Limits or RestrictionsCOLESTID 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

CRESTOR 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

49

Drug Tier Limits or Restrictionsdiltiazem 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

DIOVAN 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 EA per 30 days)doxazosin oral tablet 8 mg P QL (60 EA 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 tablet10-25 mg, 5-12.5 mg P

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG P QL (60 EA 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

50

Drug Tier Limits or RestrictionsEXFORGE 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 EA 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 PAfenofibrate 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 tablet10-12.5 mg, 20-12.5 mg P

furosemide injection solution 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 PA

51

Drug Tier Limits or Restrictionshydralazine 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


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 tablet150-12.5 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 PKAPSPARGO 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 NP PA; SP; PAlidocaine (pf) intravenous solution 20 mg/ml (2 %) AD

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

52

Drug Tier Limits or RestrictionsLIPOFEN 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 tablet10-12.5 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 PALOPRESSOR ORAL TABLET 100 MG, 50 MG NP PAlosartan oral tablet 100 mg, 25 mg, 50 mg Plosartan-hydrochlorothiazide oral tablet100-12.5 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 EA per 30 days)lovastatin oral tablet 20 mg, 40 mg P QL (60 EA 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

NP PA

methyldopa oral tablet 250 mg, 500 mg ADmethyldopa-hydrochlorothiazide oral tablet250-15 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


53

Drug Tier Limits or Restrictionsmetoprolol 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

MICARDIS 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 Pnadolol oral tablet 20 mg, 40 mg, 80 mg PNEXLETOL ORAL TABLET 180 MG NP PANEXLIZET ORAL TABLET 180-10 MG NP PAniacin 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 hr1,000 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

54

Drug Tier Limits or Restrictionsnitroglycerin transdermal patch 24 hour0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

AD

nitroglycerin translingual spray,non-aerosol400 mcg/spray AD

NITROMIST 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 tablet20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

NP PA

olmesartan-hydrochlorothiazide oral tablet20-12.5 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 capsule100 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 SP; PA

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 ADPRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG NP PA

55

Drug Tier Limits or Restrictionsprocainamide 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 tablet10-12.5 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 SP; PA

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML NP SP; PA

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

56

Drug Tier Limits or RestrictionsREVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML P PA; SP; QL (112 ML per 30

days)

REVATIO ORAL TABLET 20 MG NP PA; SP; QL (90 EA per 30 days)

rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg P QL (30 EA 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 NP PA; SP

sildenafil (pulm.hypertension) oral tablet20 mg P PA; SP; QL (90 EA per 30

days)simvastatin oral tablet 10 mg P 90 Dayssimvastatin oral tablet 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 tablet25-25 mg AD

SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG NP PA

tadalafil (pulm. hypertension) oral tablet20 mg NP PA; SP; QL (60 EA 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

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg NP PA

telmisartan-hydrochlorothiazid oral tablet40-12.5 mg, 80-12.5 mg, 80-25 mg NP PA

TENORETIC 100 ORAL TABLET 100-25 MG NP PA

57

Drug Tier Limits or RestrictionsTENORETIC 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 EA per 30 days)terazosin oral capsule 10 mg P QL (60 EA 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 Ptrandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

NP PA

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg AD

triamterene-hydrochlorothiazid oral tablet37.5-25 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

TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)

NP PA

58

Drug Tier Limits or RestrictionsTYVASO 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 tablet160-12.5 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 ct100 mg, 200 mg, 300 mg P

verapamil oral capsule,ext rel. pellets 24 hr120 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; SPVYNDAQEL 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 PA

59

Drug Tier Limits or RestrictionsVYTORIN 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 ML per 30 days)

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg AD QL (360 EA per 30 days)

acetaminophen-codeine oral tablet 300-60 mg AD QL (180 EA per 30 days)

ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG

P

ADHANSIA 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

60

Drug Tier Limits or RestrictionsAIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML NP PA; QL (1 ML per 30 days)

AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML NP PA; QL (2 ML 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 tablet12.5-5 mg, 25-10 mg AD

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg AD

amphetamine oral suspen, ir - er, biphasic 24hr 1.25 mg/ml NP PA

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

APTIOM 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 EA per 30 days)

aripiprazole oral tablet 5 mg P QL (60 EA per 30 days)aripiprazole oral tablet,disintegrating 10 mg, 15 mg NP PA; QL (60 EA per 30 days)

61

Drug Tier Limits or RestrictionsARISTADA 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 AD

ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC 50-200 MG-MCG 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 EA per 30 days)

asenapine maleate sublingual tablet 10 mg, 2.5 mg, 5 mg NP PA

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

atomoxetine oral capsule 10 mg P QL (300 EA per 30 days)atomoxetine oral capsule 100 mg P QL (30 EA per 30 days)atomoxetine oral capsule 18 mg P QL (166 EA per 30 days)atomoxetine oral capsule 25 mg P QL (120 EA per 30 days)atomoxetine oral capsule 40 mg P QL (75 EA per 30 days)atomoxetine oral capsule 60 mg P QL (50 EA per 30 days)atomoxetine oral capsule 80 mg P QL (37 EA 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 ADBRINTELLIX ORAL TABLET 20 MG NP PABRISDELLE ORAL CAPSULE 7.5 MG NP PABRIVIACT ORAL SOLUTION 10 MG/ML NP PA

62

Drug Tier Limits or RestrictionsBRIVIACT 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 EA per 30 days)

buprenorphine transdermal patch weekly10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour


buprenorphine transdermal patch weekly7.5 mcg/hour NP PA

buprenorphine-naloxone sublingual film12-3 mg NP PA; QL (60 EA 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 EA per 30 days)

buprenorphine-naloxone sublingual tablet2-0.5 mg P QL (360 EA per 30 days)

buprenorphine-naloxone sublingual tablet8-2 mg P QL (90 EA per 30 days)

bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg P QL (60 EA 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 EA per 30 days)

bupropion hcl oral tablet extended release 24 hr 450 mg NP PA

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg, 200 mg P QL (60 EA 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 EA per 30 days)

butalbital-acetaminop-caf-cod oral capsule50-325-40-30 mg AD QL (180 EA per 30 days)

butalbital-acetaminophen oral tablet 50-325 mg AD QL (180 EA per 30 days)

butalbital-acetaminophen-caff oral capsule50-325-40 mg AD QL (180 EA per 30 days)

butalbital-acetaminophen-caff oral tablet50-325-40 mg AD QL (180 EA per 30 days)

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

63

Drug Tier Limits or Restrictionscabergoline oral tablet 0.5 mg ADCAPITAL WITH CODEINE ORAL SUSPENSION 120-12 MG/5 ML AD

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 tablet12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

P

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 ADchlorpromazine oral concentrate 100 mg/ml, 30 mg/ml AD

chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg AD

choline,magnesium salicylate oral liquid500 mg/5 ml AD

citalopram oral solution 10 mg/5 ml Pcitalopram oral tablet 10 mg, 20 mg, 40 mg P QL (30 EA per 30 days)

clobazam oral suspension 2.5 mg/ml NP PA

64

Drug Tier Limits or Restrictionsclobazam 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 PACONCERTA ORAL TABLET EXTENDED RELEASE 24HR 18 MG, 27 MG, 36 MG, 54 MG

P

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

DAYVIGO ORAL TABLET 10 MG, 5 MG NP PADEPAKENE 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

DEPAKOTE 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

65

Drug Tier Limits or Restrictionsdesvenlafaxine 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 EA per 30 days)dexmethylphenidate oral tablet 2.5 mg P QL (240 EA per 30 days)dexmethylphenidate oral tablet 5 mg P QL (120 EA per 30 days)dextroamphetamine oral capsule, extended release 10 mg P QL (180 EA per 30 days)

dextroamphetamine oral capsule, extended release 15 mg P QL (120 EA per 30 days)

dextroamphetamine oral capsule, extended release 5 mg P QL (360 EA per 30 days)

dextroamphetamine oral solution 5 mg/5 ml NP PA

dextroamphetamine oral tablet 10 mg P QL (180 EA per 30 days)dextroamphetamine oral tablet 5 mg P QL (360 EA per 30 days)dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg NP PA; QL (180 EA per 30 days)

dextroamphetamine-amphetamine oral capsule,extended release 24hr 15 mg NP PA; QL (120 EA per 30 days)





dextroamphetamine-amphetamine oral tablet 10 mg P QL (180 EA per 30 days)

dextroamphetamine-amphetamine oral tablet 12.5 mg P QL (144 EA per 30 days)





66

Drug Tier Limits or Restrictionsdextroamphetamine-amphetamine oral tablet 7.5 mg P QL (240 EA 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 EA 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 % AD QL (500 GM per 21 days)diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg

NP PA

diflunisal oral tablet 500 mg ADDILANTIN 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

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

67

Drug Tier Limits or Restrictionsdoxepin 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 EA per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 30 mg, 40 mg, 60 mg P QL (30 EA 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 EA per 30 days)ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG AD QL (360 EA per 30 days)

ENDOCET ORAL TABLET 7.5-325 MG AD QL (240 EA per 30 days)entacapone oral tablet 200 mg PEPIDIOLEX 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 EA per 30 days)

eszopiclone oral tablet 1 mg, 2 mg, 3 mg P QL (30 EA per 30 days)ethosuximide oral capsule 250 mg Pethosuximide oral solution 250 mg/5 ml P

68

Drug Tier Limits or Restrictionsetodolac oral capsule 200 mg, 300 mg ADetodolac oral tablet 400 mg, 500 mg ADetodolac oral tablet extended release 24 hr400 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 handle1,200 mcg, 1,600 mcg, 400 mcg, 600 mcg, 800 mcg

AD PA; QL (30 EA per 30 days)

fentanyl citrate buccal lozenge on a handle200 mcg AD PA; QL (90 EA per 30 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 75 mcg/hr NP PA; QL (10 EA per 30 days)

fentanyl transdermal patch 72 hour 25 mcg/hr, 50 mcg/hr P PA; QL (10 EA 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

FINTEPLA ORAL SOLUTION 2.2 MG/ML NPFLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % P QL (60 EA per 30 days)

fluoxetine oral capsule 10 mg P QL (30 EA per 30 days)fluoxetine oral capsule 20 mg Pfluoxetine oral capsule 40 mg P QL (60 EA per 30 days)

69

Drug Tier Limits or Restrictionsfluoxetine 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 solution25 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 EA per 30 days)fluvoxamine oral tablet 25 mg P QL (30 EA per 30 days)fluvoxamine oral tablet 50 mg P QL (60 EA 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

FROVA 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

70

Drug Tier Limits or RestrictionsGEODON 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 bitartrate oral capsule, oral only, er 12hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg

NP PA

hydrocodone bitartrate oral tablet,oral only,ext.rel.24 hr 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

NP PA

hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml AD QL (5400 ML per 30 days)

hydrocodone-acetaminophen oral tablet10-300 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg


hydrocodone-acetaminophen oral tablet10-325 mg AD QL (270 EA per 30 days)

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg AD QL (150 EA per 30 days)

hydromorphone oral liquid 1 mg/ml AD QL (675 ML per 30 days)hydromorphone oral tablet 2 mg AD QL (180 EA per 30 days)hydromorphone oral tablet 4 mg AD QL (150 EA per 30 days)hydromorphone oral tablet 8 mg AD QL (60 EA per 30 days)hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg NP PA

71

Drug Tier Limits or Restrictionshydroxyzine 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 P

IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG NP PA

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML, 6 MG/0.5 ML P

IMITREX STATDOSE REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML, 6 MG/0.5 ML

P

IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5 ML P

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


indomethacin oral capsule 25 mg, 50 mg PINNOPRAN 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

72

Drug Tier Limits or RestrictionsINVEGA 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 EA per 30 days)KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 50 MG NP PA

KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 30 MG NP SP; PA

KYNMOBI SUBLINGUAL FILM 10-15-20-25-30 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

LAMICTAL 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

73

Drug Tier Limits or RestrictionsLAMICTAL 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)

NP PA

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG P QL (30 EA per 30 days)

LATUDA ORAL TABLET 80 MG P QL (60 EA 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

74

Drug Tier Limits or Restrictionslevetiracetam 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, 3 mg AD QL (120 EA 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 EA per 30 days)

LORCET HD ORAL TABLET 10-325 MG AD QL (360 EA 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


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

75

Drug Tier Limits or Restrictionsmefenamic 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 EA per 30 days)memantine oral capsule,sprinkle,er 24hr14 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 Pmethadone oral concentrate 10 mg/ml NP PA; QL (60 ML per 30 days)methadone oral solution 10 mg/5 ml NP PA; QL (300 ML per 30 days)methadone oral solution 5 mg/5 ml NP PA; QL (600 ML per 30 days)methadone oral tablet 10 mg NP PA; QL (60 EA per 30 days)methadone oral tablet 5 mg NP PA; QL (120 EA per 30 days)methadone oral tablet,soluble 40 mg NP PA; QL (30 EA per 30 days)METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 MG/5 ML P

methylphenidate 10 mg/5 ml sol 10 mg/5 ml NP PA

methylphenidate 5 mg/5 ml soln 5 mg/5 ml NP PA

methylphenidate hcl oral cap,er sprinkle,biphasic 40-60 10 mg, 15 mg, 30 mg, 40 mg, 50 mg, 60 mg

NP PA

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg NP PA; QL (180 EA 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 P QL (180 ML per 30 days)

methylphenidate hcl oral solution 5 mg/5 ml P QL (360 ML per 30 days)

76

Drug Tier Limits or Restrictionsmethylphenidate hcl oral tablet 10 mg P QL (180 EA per 30 days)methylphenidate hcl oral tablet 20 mg P QL (90 EA per 30 days)methylphenidate hcl oral tablet 5 mg P QL (360 EA per 30 days)methylphenidate hcl oral tablet extended release 10 mg P QL (180 EA per 30 days)

methylphenidate hcl oral tablet extended release 20 mg P QL (90 EA per 30 days)

methylphenidate hcl oral tablet extended release 24hr 18 mg NP PA; QL (120 EA per 30 days)




methylphenidate hcl oral tablet extended release 24hr 72 mg NP PA

methylphenidate hcl oral tablet,chewable10 mg NP PA; QL (180 EA per 30 days)

methylphenidate hcl oral tablet,chewable2.5 mg NP PA; QL (720 EA per 30 days)

methylphenidate hcl oral tablet,chewable 5 mg NP PA; QL (360 EA 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 ADMORPHABOND 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 ML per 30 days)

morphine oral capsule, er multiphase 24 hr120 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

77

Drug Tier Limits or Restrictionsmorphine oral solution 10 mg/5 ml AD QL (900 ML per 30 days)morphine oral solution 20 mg/5 ml (4 mg/ml) AD QL (675 ML per 30 days)

morphine oral tablet 15 mg AD PA; QL (180 EA per 30 days)morphine oral tablet 30 mg AD QL (90 EA per 30 days)morphine oral tablet extended release 100 mg, 200 mg, 60 mg P PA; QL (30 EA per 30 days)

morphine oral tablet extended release 15 mg P PA; QL (120 EA per 30 days)

morphine oral tablet extended release 30 mg P PA; QL (90 EA 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

NAMENDA 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

78

Drug Tier Limits or Restrictionsnaproxen 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; PA

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG NP PA

NUEDEXTA ORAL CAPSULE 20-10 MG AD PA; QL (60 EA per 30 days)NUPLAZID ORAL CAPSULE 34 MG NP PANUPLAZID ORAL TABLET 10 MG, 17 MG NP PANURTEC ODT ORAL TABLET,DISINTEGRATING 75 MG NP PA; QL (16 EA per 28 days)

olanzapine intramuscular recon soln 10 mg Polanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg P QL (30 EA per 30 days)

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg NP PA; QL (30 EA 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 PAONGENTYS ORAL CAPSULE 25 MG, 50 MG NP PAONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG NP PA

79

Drug Tier Limits or RestrictionsOPANA 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 EA per 30 days)oxycodone oral concentrate 20 mg/ml AD QL (90 ML per 30 days)oxycodone oral solution 5 mg/5 ml AD QL (1200 ML per 30 days)oxycodone oral tablet 10 mg AD QL (180 EA per 30 days)oxycodone oral tablet 15 mg AD QL (120 EA per 30 days)oxycodone oral tablet 20 mg AD QL (90 EA per 30 days)oxycodone oral tablet 30 mg AD QL (60 EA per 30 days)oxycodone oral tablet 5 mg AD QL (360 EA 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 EA 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 EA per 30 days)

oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg AD QL (360 EA per 30 days)

oxycodone-acetaminophen oral tablet 7.5-325 mg AD QL (240 EA per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg AD QL (360 EA 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 EA per 30 days)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG, 60 MG, 80 MG


80

Drug Tier Limits or Restrictionsoxymorphone 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 EA per 30 days)

paliperidone oral tablet extended release 24hr 6 mg NP PA; QL (60 EA per 30 days)

paroxetine hcl oral tablet 10 mg, 40 mg P QL (30 EA per 30 days)paroxetine hcl oral tablet 20 mg, 30 mg P QL (60 EA per 30 days)paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg NP PA; QL (60 EA 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,EXTENDED REL SYRING 120 MG, 90 MG

NP PA

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NP PA

phenelzine oral tablet 15 mg ADphenobarbital 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 capsule100 mg, 200 mg, 300 mg P

phenytoin sodium intravenous solution 50 mg/ml AD

piroxicam oral capsule 10 mg, 20 mg AD

81

Drug Tier Limits or RestrictionsPOTIGA 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


promethazine 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

82

Drug Tier Limits or Restrictionsquetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg P QL (90 EA per 30 days)

quetiapine oral tablet 300 mg, 400 mg P QL (60 EA per 30 days)quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

P QL (60 EA per 30 days)

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 EA 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

REYVOW ORAL TABLET 100 MG, 50 MG NP PAriluzole oral tablet 50 mg ADRISPERDAL 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 EA per 30 days)

risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg P QL (60 EA 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

83

Drug Tier Limits or Restrictionsropinirole 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 EA per 30 days)rufinamide oral suspension 40 mg/ml NP PARYTARY 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 EA per 30 days)

SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) P QL (55 EA per 30 days)

SECUADO 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 EA per 30 days)sertraline oral tablet 25 mg P QL (30 EA 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

84

Drug Tier Limits or RestrictionsSPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG, 750 MG NP PA

STALEVO 100 ORAL TABLET 25-100-200 MG NP PA

STALEVO 125 ORAL TABLET 31.25-125-200 MG NP PA


STALEVO 200 ORAL TABLET 50-200-200 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 EA per 30 days)SUBOXONE SUBLINGUAL FILM 2-0.5 MG P QL (360 EA per 30 days)SUBOXONE SUBLINGUAL FILM 4-1 MG P QL (180 EA per 30 days)SUBOXONE SUBLINGUAL FILM 8-2 MG P QL (90 EA per 30 days)sulindac oral tablet 150 mg, 200 mg Psumatriptan nasal spray,non-aerosol 20 mg/actuation NP PA; QL (18 EA per 30 days)

sumatriptan nasal spray,non-aerosol 5 mg/actuation NP PA; QL (36 EA per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg P QL (18 EA per 30 days)

sumatriptan succinate oral tablet 50 mg Psumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml NP PA; QL (8 ML per 30 days)

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml NP PA; QL (8 ML per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml NP PA; QL (8 ML per 30 days)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml NP PA

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

85

Drug Tier Limits or RestrictionsSYMPAZAN ORAL FILM 10 MG, 20 MG, 5 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

tolcapone oral tablet 100 mg NP PAtolmetin 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 24hr100 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 EA per 30 days)tramadol-acetaminophen oral tablet 37.5-325 mg AD QL (240 EA per 30 days)

tranylcypromine oral tablet 10 mg ADtrazodone 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

86

Drug Tier Limits or Restrictionstrihexyphenidyl 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 EA per 30 days)

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG

NP PA

UBRELVY ORAL TABLET 100 MG, 50 MG P PAvalproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) AD

valproic acid (as sodium salt) oral solution250 mg/5 ml (5 ml) AD

valproic acid (as sodium salt) oral solution250 mg/5 ml, 500 mg/10 ml (10 ml) P

valproic acid oral capsule 250 mg PVALTOCO NASAL SPRAY,NON-AEROSOL 10 MG/SPRAY (0.1 ML), 15 MG/2 SPRAY (7.5/0.1ML X 2), 20 MG/2 SPRAY (10MG/0.1ML X2), 5 MG/SPRAY (0.1 ML)

P

venlafaxine oral capsule,extended release 24hr 150 mg P QL (60 EA per 30 days)

venlafaxine oral capsule,extended release 24hr 37.5 mg P QL (30 EA 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 EA 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 EA per 30 days)

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) NP PA; QL (30 EA per 30 days)

VIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC 375-20 MG, 500-20 MG NP PA

87

Drug Tier Limits or RestrictionsVIMPAT 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

VRAYLAR 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

VYEPTI INTRAVENOUS SOLUTION 100 MG/ML NP PA

VYVANSE ORAL CAPSULE 10 MG P QL (210 EA per 30 days)VYVANSE ORAL CAPSULE 20 MG P QL (105 EA per 30 days)VYVANSE ORAL CAPSULE 30 MG P QL (70 EA per 30 days)VYVANSE ORAL CAPSULE 40 MG P QL (52 EA per 30 days)VYVANSE ORAL CAPSULE 50 MG P QL (42 EA per 30 days)VYVANSE ORAL CAPSULE 60 MG P QL (35 EA per 30 days)VYVANSE ORAL CAPSULE 70 MG P QL (30 EA per 30 days)VYVANSE ORAL TABLET,CHEWABLE 10 MG NP PA; QL (210 EA per 30 days)VYVANSE ORAL TABLET,CHEWABLE 20 MG NP PA; QL (105 EA per 30 days)VYVANSE ORAL TABLET,CHEWABLE 30 MG NP PA; QL (70 EA per 30 days)VYVANSE ORAL TABLET,CHEWABLE 40 MG NP PA; QL (52 EA per 30 days)VYVANSE ORAL TABLET,CHEWABLE 50 MG NP PA; QL (42 EA per 30 days)VYVANSE ORAL TABLET,CHEWABLE 60 MG NP PA; QL (35 EA 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 PAXCOPRI MAINTENANCE PACK ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 350 MG/DAY (200 MG X1-150MG X1)

NP PA

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

XCOPRI TITRATION PACK ORAL TABLETS,DOSE PACK 12.5 MG (14)- 25 MG (14), 150 MG (14)- 200 MG (14), 50 MG (14)- 100 MG (14)

NP PA

XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG

NP PA

88

Drug Tier Limits or Restrictionszaleplon oral capsule 10 mg P QL (60 EA per 30 days)zaleplon oral capsule 5 mg P QL (30 EA per 30 days)ZARONTIN ORAL CAPSULE 250 MG NP PAZARONTIN 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 EA 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 nasal spray,non-aerosol 2.5 mg, 5 mg NP PA

zolmitriptan oral tablet 2.5 mg, 5 mg NP PA; QL (18 EA per 30 days)zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg NP PA; QL (18 EA 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 EA per 30 days)zolpidem oral tablet,ext release multiphase12.5 mg, 6.25 mg NP PA; QL (30 EA 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 EA 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

89

Drug Tier Limits or RestrictionsZYBAN ORAL TABLET EXTENDED RELEASE 12 HR 150 MG NP PA

ZYPREXA INTRAMUSCULAR RECON SOLN 10 MG NP PA

ZYPREXA 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 PCONTOUR METER PCONTOUR METER KIT PCONTOUR NEXT EZ METER PCONTOUR NEXT EZ METER KIT PCONTOUR NEXT GLUCOSE METER KIT ADCONTOUR NEXT LINK 2.4 KIT ADCONTOUR NEXT LINK KIT ADCONTOUR NEXT METER PCONTOUR NEXT ONE METER PDEXCOM G5 RECEIVER NP PADEXCOM G5 TRANSMITTER DEVICE NP PADEXCOM G5-G4 SENSOR DEVICE NP PADEXCOM G6 RECEIVER P QL (1 EA per 365 days)DEXCOM G6 SENSOR DEVICE P QL (3 EA per 30 days)DEXCOM G6 TRANSMITTER DEVICE P QL (1 EA per 90 days)FORA G20 KIT NP PAFREESTYLE FREEDOM LITE KIT NP PAFREESTYLE INSULINX NP PAFREESTYLE LIBRE 14 DAY READER P QL (1 EA per 365 days)FREESTYLE LIBRE 14 DAY SENSOR KIT P QL (2 EA per 28 days)FREESTYLE LIBRE 2 READER P QL (1 EA per 365 days)FREESTYLE LIBRE 2 SENSOR KIT P QL (2 EA per 28 days)FREESTYLE LITE METER KIT NP PAGLUCOCARD EXPRESSION NP PA

90

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 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

INPEN (FOR HUMALOG) SUBCUTANEOUS INSULIN PEN AD

INPEN (FOR NOVOLOG OR FIASP) SUBCUTANEOUS INSULIN PEN AD

NORMAL SALINE FLUSH INJECTION SYRINGE AD

OMNIPOD DASH 5 PACK POD SUBCUTANEOUS CARTRIDGE AD PA; QL (15 EA per 30 days)

OMNIPOD INSULIN MANAGEMENT AD PA; QL (1 EA per 365 days)OMNIPOD INSULIN REFILL SUBCUTANEOUS CARTRIDGE AD PA; QL (15 EA per 30 days)

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 PA

91

Drug Tier Limits or Restrictionssodium chloride 0.9 % (flush) injection syringe AD

TRUE 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 TEST 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 PAWAVESENSE PRESTO STRIP NP PAELECTROLYTIC, CALORIC, AND WATER BALANCEACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG NP PA

acetazolamide oral capsule, extended release 500 mg AD


92

Drug Tier Limits or Restrictionsacetic acid irrigation solution 0.25 % ADamiloride oral tablet 5 mg ADamiloride-hydrochlorothiazide oral tablet 5-50 mg AD

amlodipine-valsartan-hcthiazid oral tablet10-160-12.5 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 NP PA

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 tablet10-12.5 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 tablet667 mg P

candesartan-hydrochlorothiazid oral tablet16-12.5 mg, 32-12.5 mg, 32-25 mg NP PA

captopril-hydrochlorothiazide oral tablet25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg P

CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG AD PA; SP

chlorothiazide oral tablet 250 mg, 500 mg ADchlorthalidone oral tablet 25 mg, 50 mg ADCLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

AD

93

Drug Tier Limits or RestrictionsCLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

AD

CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

AD

CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

AD

CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

AD

CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 %

AD

CLINIMIX 6%-D5W (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 6-5 %

AD

CLINIMIX 8%-D10W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 8-10 %

AD

CLINIMIX 8%-D14W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 8-14 %

AD

CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %

AD

CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

AD

CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

AD

CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

AD

CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

AD

CLINIMIX E 8%-D10W SULFITEFREE INTRAVENOUS PARENTERAL SOLUTION 8-10 %

AD

CLINIMIX E 8%-D14W SULFITEFREE INTRAVENOUS PARENTERAL SOLUTION 8-14 %

AD

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

94

Drug Tier Limits or RestrictionsCONSTULOSE 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 tablet10-25 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 tablet10-12.5 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 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 solution1.5 % 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 ADIONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % AD

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % AD

irbesartan-hydrochlorothiazide oral tablet150-12.5 mg, 300-12.5 mg P

95

Drug Tier Limits or RestrictionsISOLYTE-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

lisinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg P

losartan-hydrochlorothiazide oral tablet100-12.5 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 tablet250-15 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

96

Drug Tier Limits or RestrictionsMYNATAL ORAL CAPSULE 65 MG IRON- 1 MG AD



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 tablet20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

NP PA

olmesartan-hydrochlorothiazide oral tablet20-12.5 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

PHOSPHA 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

97

Drug Tier Limits or Restrictionspotassium 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

potassium 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




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

PRENATABS FA ORAL TABLET 29-1 MG ADPRENATABS RX ORAL TABLET 29 MG IRON- 1 MG AD




98

Drug Tier Limits or Restrictionsprobenecid oral tablet 500 mg ADprobenecid-colchicine oral tablet 500-0.5 mg AD


quinapril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg P

RAVICTI ORAL LIQUID 1.1 GRAM/ML AD PA; SPRENAGEL ORAL TABLET 400 MG, 800 MG NP PARENVELA 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 packet0.8 gram, 2.4 gram NP PA

sevelamer carbonate oral tablet 800 mg Psevelamer hcl oral tablet 400 mg, 800 mg NP PAsodium 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

99

Drug Tier Limits or Restrictionssodium 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 enema30 gram/120 ml AD

spironolactone oral tablet 100 mg, 25 mg, 50 mg AD

spironolacton-hydrochlorothiaz oral tablet25-25 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

telmisartan-hydrochlorothiazid oral tablet40-12.5 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 tablet37.5-25 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


100

Drug Tier Limits or Restrictionsvalsartan-hydrochlorothiazide oral tablet160-12.5 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

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

VINATE ONE ORAL TABLET 60 MG IRON-1 MG AD

VIRT-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 18 MG/0.45 ML, 28 MG/0.7 ML, 40 MG/ML, 80 MG/0.8 ML

AD PA

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) AD SP

101

Drug Tier Limits or RestrictionsVPRIV INTRAVENOUS RECON SOLN 400 UNIT AD PA; SP

EYE, EAR, NOSE AND THROAT (EENT) PREPS.acetazolamide oral capsule, extended release 500 mg AD


acetic 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 ML per 30 days)

azelastine nasal spray,non-aerosol 205.5 mcg (0.15 %) P QL (60 ML 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

102

Drug Tier Limits or RestrictionsBEPREVE 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

bimatoprost 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) drops0.3 % P

ciprofloxacin hcl otic (ear) dropperette 0.2 % NP PA

ciprofloxacin-fluocinolone otic (ear) solution 0.3-0.025 % (0.25 ml) NP PA

COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 % P

COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE 2-0.5 % NP PA

103

Drug Tier Limits or RestrictionsCOSOPT 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

diclofenac sodium ophthalmic (eye) drops0.1 % 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 ML per 30 days)

fluorometholone ophthalmic (eye) drops,suspension 0.1 % P

flurbiprofen sodium ophthalmic (eye) drops0.03 % 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) drops1-2 % AD

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1 % NP PA

IOPIDINE OPHTHALMIC (EYE) DROPS 0.5 % NP PA

104

Drug Tier Limits or Restrictionsipratropium bromide nasal spray,non-aerosol 21 mcg (0.03 %), 42 mcg (0.06 %)

P QL (30 ML per 30 days)

ISTALOL OPHTHALMIC (EYE) DROPS, ONCE DAILY 0.5 % NP PA

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % P

ketotifen fumarate ophthalmic (eye) drops0.025 % (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,gel 0.5 % 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 % PNASONEX 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,suspension3.5mg/ml-10,000 unit/ml-0.1 %

AD

105

Drug Tier Limits or Restrictionsneomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

AD

neomycin-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) solution3.5-10,000-1 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

106

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 % P

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 ML per 30 days)

RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % AD PA; QL (60 EA 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) drops0.25 %, 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

TIMOPTIC OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 % NP PA

107

Drug Tier Limits or RestrictionsTIMOPTIC-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 % NP PA

VYZULTA OPHTHALMIC (EYE) DROPS 0.024 % NP PA

XALATAN OPHTHALMIC (EYE) DROPS 0.005 % NP PA

XELPROS OPHTHALMIC (EYE) DROPS, EMULSION 0.005 % NP PA

XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCG/ACTUATION NP PA

ZADITOR OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %) NP PA

ZERVIATE OPHTHALMIC (EYE) DROPPERETTE 0.24 % 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 EA per 30 days)

AKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG NP PA

alosetron oral tablet 0.5 mg, 1 mg AD

108

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 EA per 30 days)aprepitant oral capsule 80 mg AD QL (2 EA per 30 days)aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) AD QL (3 EA 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 PCESAMET ORAL CAPSULE 1 MG NP PAcimetidine hcl oral solution 300 mg/5 ml ADcimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg AD

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

NP SP; PA; QL (2 EA 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 EA per 21 days)

COLAZAL ORAL CAPSULE 750 MG NP PACREON 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

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 30 MG NP PA; QL (30 EA per 30 days)

109

Drug Tier Limits or RestrictionsDEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 60 MG NP PA

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg

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 P PA; SPENTYVIO INTRAVENOUS RECON SOLN 300 MG NP SP; PA

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg, 40 mg


esomeprazole magnesium oral granules dr for susp in packet 10 mg, 20 mg, 40 mg NP PA

esomeprazole strontium oral capsule,delayed release(dr/ec) 49.3 mg NP PA; QL (30 EA per 30 days)

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 PAGIMOTI NASAL SPRAY WITH PUMP 15 MG/SPRAY NP PA

GOLYTELY 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

110

Drug Tier Limits or Restrictionsgranisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) AD

granisetron hcl oral tablet 1 mg NP PA; QL (6 EA per 30 days)HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

P PA; SP; QL (2 EA 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 EA 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 EA 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 PEDIATRIC UC 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 EA 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 P QL (30 EA per 30 days)

lansoprazole oral tablet,disintegrat, delay rel 15 mg NP PA; QL (30 EA 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

meclizine oral tablet 12.5 mg, 25 mg AD

111

Drug Tier Limits or Restrictionsmeclizine oral tablet,chewable 25 mg ADmesalamine oral capsule (with del rel tablets) 400 mg NP PA

mesalamine oral capsule,extended release 24hr 0.375 gram 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

metoclopramide hcl oral tablet,disintegrating 10 mg, 5 mg NP PA

misoprostol oral tablet 100 mcg, 200 mcg ADMOVANTIK ORAL TABLET 12.5 MG, 25 MG ADNEXIUM 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 ADnizatidine oral solution 150 mg/10 ml ADOCALIVA ORAL TABLET 10 MG, 5 MG AD PA; SPomeprazole oral capsule,delayed release(dr/ec) 10 mg P QL (30 EA 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 EA per 30 days)

omeprazole-sodium bicarbonate oral packet 40-1,680 mg NP PA

112

Drug Tier Limits or Restrictionsondansetron hcl (pf) injection solution 4 mg/2 ml AD

ondansetron hcl intravenous solution 2 mg/ml AD

ondansetron 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, 2,600-8,800- 15,200 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 EA 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 EA per 30 days)

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 2.5 MG NP PA; QL (60 EA per 30 days)

113

Drug Tier Limits or Restrictionsprochlorperazine 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 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

scopolamine base transdermal patch 3 day1 mg over 3 days AD

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 ADursodiol oral capsule 300 mg ADursodiol oral tablet 250 mg, 500 mg ADVARUBI INTRAVENOUS EMULSION 166.5 MG/92.5 ML NP PA

VARUBI ORAL TABLET 90 MG NP PA

114

Drug Tier Limits or RestrictionsVIBERZI ORAL TABLET 100 MG, 75 MG ADVIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC 375-20 MG, 500-20 MG NP PA

VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT NP PA

ZEGERID ORAL CAPSULE 20-1.1 MG-GRAM, 40-1.1 MG-GRAM NP PA

ZEGERID ORAL PACKET 20-1,680 MG, 40-1,680 MG NP PA

ZEGERID OTC ORAL CAPSULE 20-1.1 MG-GRAM 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; SP

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

deferiprone oral tablet 500 mg AD PA; SPFERRIPROX ORAL TABLET 1,000 MG AD PApenicillamine oral capsule 250 mg AD PA; SPpenicillamine oral tablet 250 mg AD PA; 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 EA per 30 days)

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1,000 MG NP PA; QL (30 EA 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

NP PA; QL (6 ML per 30 days)

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


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


AEROSPAN INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION NP PA; QL (2 GM 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

AFTERA ORAL TABLET 1.5 MG ADAIRDUO 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 EA per 30 days)

alogliptin-metformin oral tablet 12.5-1,000 mg NP PA; QL (30 EA per 30 days)

alogliptin-metformin oral tablet 12.5-500 mg NP PA; QL (60 EA 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 EA 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 GM 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

AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG NP PA

116

Drug Tier Limits or RestrictionsAMETHIA 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 EA per 30 days)

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

P PA; QL (150 GM per 30 days)

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

NP PA; QL (13 GM per 30 days)

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 EA per 30 days)AVIANE ORAL TABLET 0.1-20 MG-MCG AD

117

Drug Tier Limits or RestrictionsAXIRON TRANSDERMAL SOLUTION IN METERED PUMP W/APP 30 MG/ACTUATION (1.5 ML)

NP PA; QL (180 ML per 30 days)

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 ML per 30 days)

budesonide inhalation suspension for nebulization 1 mg/2 ml P QL (60 ML 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 P QL (4 ML per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML P QL (3 ML per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML P QL (2 ML 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 EA per 84 days)

118

Drug Tier Limits or RestrictionsCAMRESE 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 tablet0.15-0.03 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 ADdexamethasone 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 tablet3-0.03 mg AD

DUETACT ORAL TABLET 30-2 MG, 30-4 MG NP PA; QL (30 EA per 30 days)

119

Drug Tier Limits or RestrictionsDULERA 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 EA Max Qty Per Fill Retail)

ECONTRA ONE-STEP ORAL TABLET 1.5 MG ADELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG AD PA



ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) AD PA

ELINEST ORAL TABLET 0.3-30 MG-MCG ADELLA ORAL TABLET 30 MG AD QL (1 EA 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 semiweekly0.025 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 tablet0.5-0.1 mg, 1-0.5 mg AD

etonogestrel-ethinyl estradiol vaginal ring0.12-0.015 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 EA per 30 days)FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG AD

120

Drug Tier Limits or RestrictionsFEMYNOR 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 EA per 30 days)



FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION P QL (12 GM 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 (600MCG/2.4ML), 20 MCG/DOSE (620MCG/2.48ML)

NP SP; PA

FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE (750 MCG/3 ML) NP PA

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

GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)

NP PA; SP

121

Drug Tier Limits or RestrictionsGIANVI (28) ORAL TABLET 3-0.02 MG ADglimepiride oral tablet 1 mg P QL (240 EA per 30 days)glimepiride oral tablet 2 mg P QL (120 EA per 30 days)glimepiride oral tablet 4 mg P QL (60 EA per 30 days)glipizide oral tablet 10 mg P QL (180 EA per 30 days)glipizide oral tablet 5 mg Pglipizide oral tablet extended release 24hr10 mg, 5 mg P QL (60 EA per 30 days)

glipizide oral tablet extended release 24hr2.5 mg P QL (300 EA per 30 days)

glipizide-metformin oral tablet 2.5-250 mg AD QL (240 EA per 30 days)glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg AD QL (120 EA 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 EA 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 EA per 30 days)

glyburide-metformin oral tablet 2.5-500 mg AD QL (180 EA per 30 days)

glyburide-metformin oral tablet 5-500 mg AD QL (120 EA per 30 days)GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG NP PA

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG NP PA

GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG NP PA; QL (30 EA 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

122

Drug Tier Limits or RestrictionsHEATHER ORAL TABLET 0.35 MG ADHUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML

P

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

P

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 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)

P

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)

P

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)

P

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML P

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

HUMULIN 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

123

Drug Tier Limits or RestrictionsHUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)

P

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) powder100 % AD PA; SP

hydroxyprogesterone caproate intramuscular oil 250 mg/ml AD PA; SP

insulin asp prt-insulin aspart subcutaneous insulin pen 100 unit/ml (70-30) NP PA

insulin asp prt-insulin aspart subcutaneous solution 100 unit/ml (70-30) NP PA

insulin aspart u-100 subcutaneous cartridge 100 unit/ml NP PA

insulin aspart u-100 subcutaneous insulin pen 100 unit/ml (3 ml) NP PA

insulin aspart u-100 subcutaneous solution100 unit/ml NP PA

insulin lispro protamin-lispro subcutaneous insulin pen 100 unit/ml (75-25) NP PA

insulin lispro subcutaneous insulin pen 100 unit/ml P

insulin lispro subcutaneous insulin pen, half-unit 100 unit/ml NP PA

insulin lispro subcutaneous solution 100 unit/ml P

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 EA 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 EA per 30 days)JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG P QL (60 EA per 30 days)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-500 MG


124

Drug Tier Limits or RestrictionsJANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG NP PA; QL (60 EA per 30 days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG P QL (30 EA per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG P QL (30 EA per 30 days)JENCYCLA ORAL TABLET 0.35 MG ADJENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG P QL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG NP PA; QL (60 EA per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG NP PA; QL (30 EA 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 EA per 30 days)

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG P QL (30 EA per 30 days)

KURVELO (28) ORAL TABLET 0.15-0.03 MG AD

125

Drug Tier Limits or Restrictionsl 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

LANTUS 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 EA Max Qty Per Fill Retail)

levonorgestrel-ethinyl estrad oral tablet0.1-20 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 tablet50-30 (6)/75-40 (5)/125-30(10) AD

LEVORA-28 ORAL TABLET 0.15-0.03 MG AD

126

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

LYUMJEV KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

NP PA

LYUMJEV KWIKPEN U-200 INSULIN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML)

NP PA

LYUMJEV U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NP PA

LYZA ORAL TABLET 0.35 MG ADMARLISSA (28) ORAL TABLET 0.15-0.03 MG AD

medroxyprogesterone intramuscular suspension 150 mg/ml AD

127

Drug Tier Limits or Restrictionsmedroxyprogesterone intramuscular syringe 150 mg/ml AD QL (1 ML 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

megestrol 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 PA

megestrol oral tablet 20 mg, 40 mg P PAmetformin oral tablet 1,000 mg ADmetformin oral tablet 500 mg AD QL (150 EA per 30 days)metformin oral tablet 850 mg AD QL (90 EA per 30 days)metformin oral tablet extended release 24 hr 500 mg AD QL (150 EA per 30 days)

metformin oral tablet extended release 24 hr 750 mg AD QL (60 EA 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 pack4 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

128

Drug Tier Limits or RestrictionsMONONESSA (28) ORAL TABLET 0.25-35 MG-MCG AD

MY CHOICE ORAL TABLET 1.5 MG AD

MY WAY ORAL TABLET 1.5 MG AD QL (1 EA Max Qty Per Fill Retail)

MYALEPT 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

NEW DAY ORAL TABLET 1.5 MG ADNEXPLANON 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 tablet0.35 mg AD

norethindrone acetate oral tablet 5 mg ADnorethindrone ac-eth estradiol oral tablet0.5-2.5 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 tablet0.18/0.215/0.25 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

129

Drug Tier Limits or RestrictionsNORTREL 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

NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

NP PA

NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) NP PA

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML

P

NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) NP PA

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

130

Drug Tier Limits or RestrictionsOMNITROPE 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 EA per 30 days)

OPCICON ONE-STEP ORAL TABLET 1.5 MG AD QL (1 EA Max Qty Per Fill Retail)

OPTION-2 ORAL TABLET 1.5 MG ADORGOVYX ORAL TABLET 120 MG AD PA; QL (30 EA per 30 days)ORIAHNN ORAL CAPSULE, SEQUENTIAL 300-1-0.5MG(AM) /300 MG(PM) AD PA

ORILISSA ORAL TABLET 150 MG, 200 MG AD PA; SPORSYTHIA 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 ML per 30 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML) NP PA; QL (2 ML 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 EA 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 EA per 30 days)

PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 MCG, 1-35 MG-MCG AD

PLAN B ONE-STEP ORAL TABLET 1.5 MG ADPORTIA 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

131

Drug Tier Limits or RestrictionsPREDNISONE 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

propylthiouracil 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 EA per 30 days)

RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG NP PA; QL (30 EA 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 EA per 30 days)

132

Drug Tier Limits or RestrictionsSEMGLEE PEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

NP PA

SEMGLEE U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NP PA

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 ML 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

SOLU-CORTEF INJECTION RECON SOLN 100 MG AD

SOLU-MEDROL (PF) INJECTION RECON SOLN 125 MG/2 ML, 40 MG/ML AD

SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 1,000 MG/8 ML, 500 MG/4 ML AD

SOLU-MEDROL INJECTION RECON SOLN 125 MG, 125 MG/2 ML, 40 MG, 40 MG/ML AD

SOLU-MEDROL INTRAVENOUS RECON SOLN 1,000 MG, 1,000 MG/8 ML, 2 GRAM, 500 MG, 500 MG/4 ML

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 EA per 30 days)STEGLATRO ORAL TABLET 5 MG NP PA; QL (5 EA per 30 days)STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG NP PA; QL (30 EA per 30 days)

STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR 30 MG NP PA; QL (60 EA per 30 days)

SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) AD PA

SYEDA ORAL TABLET 3-0.03 MG ADSYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION P QL (2 inhalers per 30 days)

133

Drug Tier Limits or RestrictionsSYMBICORT INHALATION HFA AEROSOL INHALER 80-4.5 MCG/ACTUATION P QL (2 inhlaers per 30 days)

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML P QL (19 ML per 30 days)

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML P QL (11 ML per 30 days)

SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG NP PA; QL (60 EA 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 EA per 30 days)

TAKE ACTION ORAL TABLET 1.5 MG ADtamoxifen oral tablet 10 mg, 20 mg ADtarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) AD

teriparatide subcutaneous pen injector 20 mcg/dose (620mcg/2.48ml) P PA

TESTIM TRANSDERMAL GEL 50 MG/5 GRAM (1 %) NP PA; QL (60 GM per 30 days)

testosterone cypionate intramuscular oil100 mg/ml, 200 mg/ml AD

testosterone enanthate intramuscular oil200 mg/ml AD

TESTOSTERONE TRANSDERMAL GEL 50 MG/5 GRAM (1 %) NP PA

testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 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

THYQUIDITY ORAL SOLUTION 20 MCG/ML ADTILIA FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) AD

tolazamide oral tablet 250 mg AD QL (120 EA per 30 days)tolazamide oral tablet 500 mg AD QL (60 EA per 30 days)tolbutamide oral tablet 500 mg AD

134

Drug Tier Limits or RestrictionsTOUJEO 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 EA 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

TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NP PA

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) AD

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-5-1,000 MG, 12.5-2.5-1,000 MG, 25-5-1,000 MG, 5-2.5-1,000 MG

NP PA

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

TRI-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 ML per 30 days)

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) NP SP; PA; QL (1 ML per 30

days)UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE 9 MG NP PA

UCERIS RECTAL FOAM 2 MG/ACTUATION NP PA

135

Drug Tier Limits or RestrictionsUNITHROID 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 ADVANTAS IMPLANT KIT 50 MG (50 MCG/DAY) AD PA

vasopressin 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 ML per 30 days)

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) P QL (9 ML 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 GM 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 GM 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


WYMZYA 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 ML per 30 days)

yuvafem vaginal tablet 10 mcg ADZARAH ORAL TABLET 3-0.03 MG AD

136

Drug Tier Limits or RestrictionsZENCHENT (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 NP PA

ACTONEL ORAL TABLET 150 MG, 35 MG NP PAACTONEL ORAL TABLET 5 MG NP PA; QL (30 EA per 30 days)alendronate oral solution 70 mg/75 ml P QL (300 ML per 30 days)alendronate oral tablet 10 mg, 40 mg, 5 mg P QL (30 EA per 30 days)

alendronate oral tablet 35 mg, 70 mg P QL (4 EA 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; SP; QL (30 EA per 30 days)

AVODART ORAL CAPSULE 0.5 MG NP PA

137

Drug Tier Limits or RestrictionsAVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG P PA; SP; QL (4 EA per 30 days)

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML P PA; SP; QL (4 EA per 30 days)

AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML P PA; SP; QL (4 EA 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 PABAFIERTAM ORAL CAPSULE,DELAYED RELEASE(DR/EC) 95 MG NP PA

BAQSIMI NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION AD

BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG AD PA

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML AD PA; QL (4 ML per 30 days)

BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML AD PA; QL (4 ML per 30 days)

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 PAcalcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation P

CELLCEPT ORAL CAPSULE 250 MG NP SP; PACELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 200 MG/ML P SP

CELLCEPT ORAL TABLET 500 MG NP SP; PACERDELGA ORAL CAPSULE 84 MG AD SPCHEMET ORAL CAPSULE 100 MG AD

138

Drug Tier Limits or RestrictionsCIMZIA 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 EA per 21 days)

CINRYZE 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 ML per 30

days)COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML NP SP; PA; QL (12 ML 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 NP PA; SP; PA

DENTA 5000 PLUS DENTAL CREAM 1.1 % ADDENTAGEL DENTAL GEL 1.1 % ADdimethyl fumarate oral capsule,delayed release(dr/ec) 120 mg, 120 mg (14)- 240 mg (46), 240 mg

NP PA

disulfiram oral tablet 250 mg, 500 mg ADdutasteride 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 % NP PAELMIRON ORAL CAPSULE 100 MG AD

139

Drug Tier Limits or RestrictionsENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML) P PA; SP; QL (4 ML per 30

days)ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) P PA; SP; QL (8 EA per 30 days)

ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5 ML P PA; QL (8 units per 21 days)

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) P PA; SP; QL (5 ML per 30

days)ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) P PA; SP; QL (4 ML per 30

days)ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) P PA; SP; QL (4 ML per 30

days)ENDARI ORAL POWDER IN PACKET 5 GRAM P PA; SPENSPRYNG SUBCUTANEOUS SYRINGE 120 MG/ML AD PA; SP

ENTYVIO 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

everolimus (immunosuppressive) oral tablet 0.25 mg, 0.5 mg, 0.75 mg NP PA

EVISTA ORAL TABLET 60 MG NP PAEVOTAZ ORAL TABLET 300-150 MG ADEVRYSDI ORAL RECON SOLN 0.75 MG/ML AD PA; QL (8 ML per 1 day)EXTAVIA 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 ML Max Qty Per

Fill Retail)FIRDAPSE ORAL TABLET 10 MG AD PA; SPfluoride (sodium) dental gel 1.1 % ADfluoride (sodium) dental solution 0.2 % 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

fomepizole intravenous solution 1 gram/ml AD

140

Drug Tier Limits or RestrictionsFORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE (600MCG/2.4ML), 20 MCG/DOSE (620MCG/2.48ML)

NP SP; PA

FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE (750 MCG/3 ML) NP PA

FOSAMAX 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 P

GILENYA ORAL CAPSULE 0.5 MG P PA; SP; QL (30 EA per 30 days)

glatiramer subcutaneous syringe 20 mg/ml NP SP; PA; QL (30 ML per 30 days)

glatiramer subcutaneous syringe 40 mg/ml NP SP; PA; QL (12 ML per 30 days)

GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML NP SP; PA; QL (30 ML per 30

days)GLATOPA SUBCUTANEOUS SYRINGE 40 MG/ML NP SP; PA; QL (12 ML 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 PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML P PA; SP; QL (2 EA per 30 days)


141

Drug Tier Limits or RestrictionsHUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML












hydroxychloroquine oral tablet 200 mg ADibandronate oral tablet 150 mg P QL (1 EA per 30 days)icatibant subcutaneous syringe 30 mg/3 ml NP SP; PAILARIS (PF) SUBCUTANEOUS RECON SOLN 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


ISTURISA ORAL TABLET 1 MG AD PA; QL (240 EA per 30 days)ISTURISA ORAL TABLET 10 MG AD PA; QL (180 EA per 30 days)ISTURISA ORAL TABLET 5 MG AD PA; QL (60 EA per 30 days)JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR 0.5-0.4 MG NP PA

KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML (1 ML) NP PA

KESIMPTA PEN SUBCUTANEOUS PEN INJECTOR 20 MG/0.4 ML NP PA

142

Drug Tier Limits or RestrictionsKEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG/1.14 ML, 200 MG/1.14 ML NP SP; PA; QL (2.28 ML per 21

days)KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, 200 MG/1.14 ML NP SP; PA; QL (2.28 ML 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 EA per 30 days)LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML NP PA

leucovorin 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 ADLUDENT 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


AD



MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG NP PA







143


MAYZENT ORAL TABLET 0.25 MG, 2 MG NP SP; PA; QL (30 EA 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

methotrexate sodium (pf) injection solution25 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 AD

144

Drug Tier Limits or Restrictionsnaproxen 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

NATPARA 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 AD SPOCREVUS INTRAVENOUS SOLUTION 30 MG/ML NP PA

OLUMIANT ORAL TABLET 1 MG, 2 MG NP PAORENCIA (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 EA 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 PA; SPpenicillamine oral tablet 250 mg AD PA; 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

145

Drug Tier Limits or RestrictionsPREZCOBIX ORAL TABLET 800-150 MG-MG ADprobenecid oral tablet 500 mg ADprobenecid-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 ML per 30

days)REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML P PA; SP; QL (6 ML per 30

days)REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

P PA; SP; QL (5 ML per 30 days)

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)

P PA; SP; QL (5 ML per 30 days)

REMICADE INTRAVENOUS RECON SOLN 100 MG NP SP; PA

RENAGEL ORAL TABLET 400 MG, 800 MG NP PARENFLEXIS 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

146

Drug Tier Limits or Restrictionssevelamer carbonate oral powder in packet0.8 gram, 2.4 gram NP PA

sevelamer carbonate oral tablet 800 mg Psevelamer hcl oral tablet 400 mg, 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 enema30 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

teriparatide subcutaneous pen injector 20 mcg/dose (620mcg/2.48ml) P PA

THALOMID ORAL CAPSULE 100 MG, 50 MG AD PA; SP; QL (30 EA per 30 days)

THALOMID ORAL CAPSULE 150 MG, 200 MG AD PA; SP; QL (60 EA per 30

days)tiopronin oral tablet 100 mg AD PA

147

Drug Tier Limits or RestrictionsTRI-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 ML per 30

days)TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML NP PA

VISTOGARD ORAL GRANULES IN PACKET 10 GRAM AD

VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML AD

VUMERITY ORAL CAPSULE,DELAYED RELEASE(DR/EC) 231 MG NP PA

XELJANZ ORAL SOLUTION 1 MG/ML NP PA

XELJANZ ORAL TABLET 10 MG, 5 MG NP SP; PA; QL (60 EA per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG NP SP; PA; QL (30 EA per 30

days)XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 22 MG NP PA; QL (30 EA per 30 days)

ZEPOSIA ORAL CAPSULE 0.92 MG NP PAZEPOSIA STARTER KIT ORAL CAPSULE,DOSE PACK 0.23-0.46-0.92 MG NP PA

ZEPOSIA STARTER PACK ORAL CAPSULE,DOSE PACK 0.23 MG (4)- 0.46 MG (3)

NP PA

ZOKINVY ORAL CAPSULE 50 MG, 75 MG AD PAZORTRESS 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 ADSHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION AD

VAXCHORA BUFFER COMPONENT ORAL SUSPENSION FOR RECONSTITUTION 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 EA per 30 days)

148

Drug Tier Limits or RestrictionsADEMPAS 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


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


AEROSPAN INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION NP PA; QL (2 GM per 30 days)

AIRDUO 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 NP PA; Ventolin Generics; QL (36

GM Max Qty Per Fill Retail)albuterol hfa 90 mcg inhaler 90 mcg/actuation NP PA; Proventil Generics; QL (14

GM Max Qty Per Fill Retail)albuterol hfa 90 mcg inhaler 90 mcg/actuation NP PA; Proair Generics; QL (17

GM Max Qty Per Fill Retail)albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation NP PA; QL (14 GM 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

149

Drug Tier Limits or RestrictionsALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING 10 MG P



P


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 GM per 30 days)


ALYQ ORAL TABLET 20 MG NP PAambrisentan oral tablet 10 mg, 5 mg P PAaminophylline intravenous solution 250 mg/10 ml, 500 mg/20 ml AD

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

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


ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION P QL (26 GM 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

150

Drug Tier Limits or RestrictionsBEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-4.8 MCG NP PA; QL (11 GM per 30 days)

bosentan oral tablet 125 mg, 62.5 mg NP PABREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

NP PA

BREZTRI AEROSPHERE INHALATION HFA AEROSOL INHALER 160-9-4.8 MCG/ACTUATION

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 ML per 30 days)

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml P QL (120 ML per 30 days)

budesonide inhalation suspension for nebulization 1 mg/2 ml P QL (60 ML 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 NP PAcetirizine-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 NP PA

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 GM per 30 days)

151

Drug Tier Limits or Restrictionscromolyn ophthalmic (eye) drops 4 % Pcromolyn oral concentrate 100 mg/5 ml ADcyproheptadine oral syrup 2 mg/5 ml ADcyproheptadine oral tablet 4 mg ADDALIRESP ORAL TABLET 250 MCG NP PA; QL (30 EA 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

DUAKLIR PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400-12 MCG/ACTUATION

NP PA

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION


DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 200 MG/1.14 ML, 300 MG/2 ML NP PA

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG/1.14 ML NP PA

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 Manufacturer;

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

per 30 days)epinephrine injection auto-injector 0.3 mg/0.3 ml NP PA; Non-Mylan Manufacturer

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 EA per 30 days)

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

ESBRIET ORAL TABLET 267 MG AD PA; SP; QL (270 EA per 30 days)

152


ESBRIET ORAL TABLET 801 MG AD PA; SP; QL (90 EA per 30 days)

FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MG/ML AD PA

FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML AD PA; SP







flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) NP PA; QL (50 ML per 30 days)

fluticasone propionate nasal spray,suspension 50 mcg/actuation P QL (16 GM 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 EA per 30 days)

ipratropium bromide inhalation solution0.02 % 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 EA per 28

days)

KALYDECO ORAL TABLET 150 MG AD PA; SP; QL (60 EA per 30 days)

LETAIRIS ORAL TABLET 10 MG, 5 MG NP 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

153

Drug Tier Limits or Restrictionslevalbuterol 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

loratadine 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 ML per 21

days)NUCALA SUBCUTANEOUS RECON SOLN 100 MG AD PA; SP; QL (1 EA per 21 days)

NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML AD PA; SP; QL (1 ML per 21

days)NUEDEXTA ORAL CAPSULE 20-10 MG AD PA; QL (60 EA per 30 days)

OFEV ORAL CAPSULE 100 MG, 150 MG AD PA; SP; QL (60 EA 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 EA per 28

days)ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG AD PA; SP; QL (112 EA per 28

days)

154

Drug Tier Limits or RestrictionsPERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML NP PA; QL (120 ML per 30 days)

PROAIR 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 GM 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 SP

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


PROVENTIL HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION NP PA





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 P PA; SP; QL (112 ML per 30

days)

REVATIO ORAL TABLET 20 MG NP PA; SP; QL (90 EA per 30 days)

SEMPREX-D ORAL CAPSULE 8-60 MG NP PA

155

Drug Tier Limits or RestrictionsSEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE P

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

sildenafil (pulm.hypertension) oral suspension for reconstitution 10 mg/ml NP PA; SP

sildenafil (pulm.hypertension) oral tablet20 mg P PA; SP; QL (90 EA per 30

days)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 EA per 30 days)

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

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION (28 ACTUAT) P

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

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION P QL (2 inhalers per 30 days)

SYMBICORT INHALATION HFA AEROSOL INHALER 80-4.5 MCG/ACTUATION P QL (2 inhlaers per 30 days)

SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N)

AD PA; SP; QL (56 EA 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 EA per 30 days)

tadalafil (pulm. hypertension) oral tablet20 mg NP PA; SP; QL (60 EA 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

156

Drug Tier Limits or RestrictionsTRACLEER 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; SP; QL (84 EA per 28

days)TRIKAFTA ORAL TABLETS, SEQUENTIAL 50-25-37.5 MG (D)/75 MG (N) AD PA

TRIKAFTA ORAL TABLETS, SEQUENTIAL 50-25-37.5 MG (D)/75 MG (N) AD PA; QL (84 EA per 28 days)

TUDORZA 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 GM 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


157

Drug Tier Limits or RestrictionsXHANCE 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

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

zafirlukast oral tablet 10 mg, 20 mg PZETONNA NASAL HFA AEROSOL INHALER 37 MCG/ACTUATION NP PA

zileuton oral tablet, er multiphase 12 hr600 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 PA

158

Drug Tier Limits or RestrictionsAVITA TOPICAL CREAM 0.025 % NP PAAVITA TOPICAL GEL 0.025 % NP PAAVSOLA INTRAVENOUS RECON SOLN 100 MG NP PA

azelaic acid topical gel 15 % ADBENZACLIN 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 cream0.05 % AD

betamethasone dipropionate topical lotion0.05 % AD

betamethasone valerate topical cream 0.1 % AD

betamethasone valerate topical lotion 0.1 % AD

betamethasone valerate topical ointment0.1 % AD

betamethasone, augmented topical cream0.05 % AD

betamethasone, augmented topical gel0.05 % AD

betamethasone, augmented topical lotion0.05 % 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 % P

159

Drug Tier Limits or RestrictionsCLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG AD

CLEANSING WASH TOPICAL CLEANSER 10-4-10 % AD

clindamycin 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 cream1-0.05 % P

clotrimazole-betamethasone topical lotion1-0.05 % 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

160

Drug Tier Limits or RestrictionsCOSENTYX SUBCUTANEOUS SYRINGE 75 MG/0.5 ML NP PA

CROTAN TOPICAL LOTION 10 % NP PADENAVIR TOPICAL CREAM 1 % Pdesonide topical cream 0.05 % ADdesonide topical lotion 0.05 % ADdesonide topical ointment 0.05 % ADdiclofenac epolamine transdermal patch 12 hour 1.3 % NP PA; QL (60 EA per 30 days)

diclofenac sodium topical gel 1 % AD QL (500 GM per 21 days)diclofenac sodium topical gel 3 % AD PA; QL (100 GM per 21 days)DIFFERIN TOPICAL CREAM 0.1 % PDIFFERIN TOPICAL GEL 0.1 %, 0.3 % NP PADIFFERIN TOPICAL GEL WITH PUMP 0.3 % PDIFFERIN TOPICAL LOTION 0.1 % PDUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 200 MG/1.14 ML, 300 MG/2 ML NP PA

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG/1.14 ML NP PA

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG/2 ML NP PA; SP

econazole topical cream 1 % PELIDEL TOPICAL CREAM 1 % NP PAENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML) P PA; SP; QL (4 ML per 30

days)ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) P PA; SP; QL (8 EA per 30 days)

ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5 ML P PA; QL (8 units per 21 days)

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) P PA; SP; QL (5 ML per 30

days)ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) P PA; SP; QL (4 ML per 30

days)ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) P PA; SP; QL (4 ML per 30

days)EPIDUO FORTE TOPICAL GEL WITH PUMP 0.3-2.5 % NP PA

ERY PADS TOPICAL SWAB 2 % ADerythromycin with ethanol topical gel 2 % ADerythromycin with ethanol topical solution2 % AD

erythromycin-benzoyl peroxide topical gel3-5 % P

161

Drug Tier Limits or Restrictionsethyl chloride topical aerosol,spray 100 % ADEUCRISA TOPICAL OINTMENT 2 % NP PAEURAX TOPICAL LOTION 10 % NP PAEXELDERM TOPICAL CREAM 1 % NP PAEXELDERM TOPICAL SOLUTION 1 % NP PAFABIOR TOPICAL FOAM 0.1 % NP PAfinasteride oral tablet 1 mg PFLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % P QL (60 EA per 30 days)

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 ointment0.005 % AD

gentamicin topical cream 0.1 % ADgentamicin topical ointment 0.1 % ADhalobetasol propionate topical cream 0.05 % AD

halobetasol propionate topical ointment0.05 % AD

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML






162

Drug Tier Limits or RestrictionsHUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML P PA; SP; QL (2 EA per 30 days)


HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML












hydrocortisone acetate rectal suppository25 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, 25 mg, 30 mg, 35 mg, 40 mg AD

JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10 % NP PA

KERYDIN TOPICAL SOLUTION WITH APPLICATOR 5 % NP PA

ketoconazole topical cream 2 % Pketoconazole topical foam 2 % NP PAketoconazole topical shampoo 2 % PLICE KILLING TOPICAL SHAMPOO 0.33-4 % P

163

Drug Tier Limits or RestrictionsLICE 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

lidocaine topical adhesive patch,medicated5 % NP PA

lidocaine topical ointment 5 % ADlidocaine-prilocaine topical cream 2.5-2.5 % AD

lidocaine-prilocaine topical kit 2.5-2.5 % ADLIDODERM TOPICAL ADHESIVE PATCH,MEDICATED 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 EA per 30 days)

mometasone topical cream 0.1 % ADmometasone topical ointment 0.1 % ADmometasone topical solution 0.1 % ADmupirocin calcium topical cream 2 % NP PA

164

Drug Tier Limits or Restrictionsmupirocin topical ointment 2 % PMYORISAN 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 cream100,000-0.1 unit/g-% P

nystatin-triamcinolone topical ointment100,000-0.1 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 EA 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

165

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 % P

RETIN-A TOPICAL GEL 0.01 %, 0.025 % Psalicylic 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 release6 % AD

SANTYL TOPICAL OINTMENT 250 UNIT/GRAM AD PA; SP; QL (180 GM 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 PASKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MG/ML NP PA

166

Drug Tier Limits or RestrictionsSKYRIZI SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/0.83 ML NP PA

SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG/1.66ML(75 MG/0.83 ML X2) NP PA

spinosad 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 cream10-5 % (w/w) AD

sulfacetamide sodium-sulfur topical lotion10-5 % (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 % AD SPtavaborole topical solution with applicator5 % NP PA

tazarotene topical cream 0.1 % NP PATAZORAC TOPICAL CREAM 0.05 %, 0.1 % PTAZORAC TOPICAL GEL 0.05 %, 0.1 % P

167

Drug Tier Limits or Restrictionsterbinafine hcl topical cream 1 % Pterconazole vaginal cream 0.4 %, 0.8 % ADterconazole vaginal suppository 80 mg AD QL (3 EA per 30 days)tolnaftate topical cream 1 % PTREMFYA 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 % NP PA

tretinoin topical gel 0.01 %, 0.025 %, 0.05 % NP PA

triamcinolone acetonide topical cream0.025 %, 0.1 %, 0.5 % AD

triamcinolone acetonide topical lotion0.025 %, 0.1 % AD

triamcinolone acetonide topical ointment0.025 %, 0.1 %, 0.5 % AD

urea topical cream 50 % ADurea topical lotion 40 % ADVALCHLOR TOPICAL GEL 0.016 % AD SPVANDAZOLE VAGINAL GEL 0.75 % ADVUSION TOPICAL OINTMENT 0.25-15-81.35 % NP PA

XEPI TOPICAL CREAM 1 % NP PAXERESE 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 PAZTLIDO TOPICAL ADHESIVE PATCH,MEDICATED 1.8 % NP PA

SMOOTH 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

168

Drug Tier Limits or RestrictionsDETROL 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

ENABLEX 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 GM per 30 days)

MYRBETRIQ ORAL SUSPENSION,EXTENDED REL RECON 8 MG/ML NP PA

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 LS ORAL SUSPENSION 1 MG/ML 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 AD

169

Drug Tier Limits or RestrictionsCOMPLETE 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

ELITE 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 capsule1,250 mcg (50,000 unit) AD

FOLBIC ORAL TABLET 2.5-25-2 MG ADFOLBIC 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

MYNATAL ORAL CAPSULE 65 MG IRON- 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



170

Drug Tier Limits or RestrictionsPR NATAL 430 ORAL COMBO PACK 29 MG IRON-1 MG -430 MG AD

PRENATABS FA ORAL TABLET 29-1 MG ADPRENATABS RX ORAL TABLET 29 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

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

VINATE 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

VIRT-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

171

Drug Tier Limits or RestrictionsVITAFOL-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


172

Indexabacavir.........................2, 3abacavir-lamivudine............ 3abacavir-lamivudine-zidovudine......................... 3ABILIFY............................60ABILIFY MAINTENA............60ABILIFY MYCITE................ 60abiraterone.......................16acamprosate.....................60acarbose........................ 115ACCOLATE...................... 148ACCU-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...................28, 45acetaminophen-codeine..... 60acetazolamide...... 45, 92, 102acetazolamide sodium.......................... 45, 92, 102acetic acid.................93, 102acetylcysteine..........137, 148ACIPHEX........................ 108ACIPHEX SPRINKLE..........108acitretin......................... 158ACNE MEDICATION..........158ACTEMRA....................... 137ACTEMRA ACTPEN........... 137ACTHIB (PF)..................... 23ACTONEL........................137ACTOPLUS MET XR.......... 115ACULAR..........................102ACULAR LS..................... 102ACUVAIL (PF)..................102acyclovir.....................3, 158acyclovir sodium................. 3ADACEL(TDAP ADOLESN/ADULT)(PF)........23ADAKVEO.........................37ADALAT CC.......................46

adapalene...................... 158ADCIRCA.................. 46, 148ADDERALL XR................... 60adefovir............................. 3ADEMPAS..................46, 149ADHANSIA XR...................60ADLYXIN........................ 116ADMELOG SOLOSTAR U-100 INSULIN...................116ADMELOG U-100 INSULIN LISPRO.......................... 116ADVAIR DISKUS. 28, 116, 149ADVAIR HFA.......29, 116, 149ADVATE........................... 37ADYNOVATE..................... 37ADZENYS ER.....................60ADZENYS XR-ODT............. 60AEMCOLO.......................... 3AEROSPAN.............. 116, 149AFINITOR.........................16AFINITOR DISPERZ........... 16AFLURIA QD 2020-21(3YR UP)(PF)............................23AFLURIA QD 2020-21(6-35MO)(PF)....................... 23AFLURIA QUAD 2020-2021(6MO UP).................. 23AFREZZA........................116AFSTYLA.......................... 37AFTERA.......................... 116AIMOVIG AUTOINJECTOR... 61AIRDUO RESPICLICK........................ 29, 116, 149AJOVY AUTOINJECTOR....... 61AJOVY SYRINGE................ 61AKLIEF...........................158AKYNZEO (NETUPITANT).. 108ALAWAY......................... 102albendazole........................3albuterol sulfate.........29, 149alclometasone.................158ALECENSA........................16alendronate.................... 137alfuzosin.......................... 29aliskiren...........................46ALL DAY ALLERGY (CETIRIZINE).............. 1, 149ALL DAY ALLERGY-D............................1, 29, 149

ALLERGY AND CONGESTION RELIEF............................1, 29, 149ALLERGY COMPLETE-D............................1, 29, 149ALLERGY RELIEF (LORATADINE)..... 1, 149, 150ALLERGY RELIEF D-24HR............................1, 29, 150ALLERGY RELIEF,NASAL DECONGEST.......... 1, 29, 150ALLERGY-CONGESTION RELIEF-D.............. 1, 29, 150ALLER-TEC..................1, 150allopurinol...................... 137almotriptan malate............ 61ALOCRIL................. 102, 150alogliptin........................ 116alogliptin-metformin........ 116alogliptin-pioglitazone...... 116ALOMIDE........................102alosetron........................108ALPHAGAN P................... 102ALPHANATE...................... 37ALPHANINE SD................. 38alprazolam....................... 61ALPROLIX.........................38ALREX............................102ALTACE............................46ALTAVERA (28)............... 116ALTOPREV........................ 46ALUNBRIG........................17ALVESCO................ 116, 150ALYACEN 1/35 (28)..........116ALYACEN 7/7/7 (28)........ 116ALYQ........................46, 150amantadine hcl............. 3, 61AMARYL......................... 116AMBIEN........................... 61AMBIEN CR.......................61ambrisentan.............. 46, 150AMERGE...........................61AMETHIA........................117AMETHIA LO................... 117AMETHYST (28)...............117amifostine crystalline....... 137amikacin............................3amiloride.................... 46, 93amiloride-hydrochlorothiazide......46, 93aminophylline.......... 150, 168amiodarone...................... 46AMITIZA.........................109

173

amitriptyline..................... 61amitriptyline-chlordiazepoxide............... 61amlodipine....................... 46amlodipine-atorvastatin..... 46amlodipine-benazepril........46amlodipine-olmesartan.......46amlodipine-valsartan......... 46amlodipine-valsartan-hcthiazid.....................46, 93ammonium chloride........... 93amoxapine....................... 61amoxicillin..........................3amoxicillin-pot clavulanate... 3amphetamine................... 61amphetamine sulfate......... 61amphotericin b................... 3ampicillin........................... 3ampicillin sodium............ 3, 4ampicillin-sulbactam............4AMPYRA......................... 137anagrelide........................ 38anastrozole............... 17, 117ANCOBON.......................... 4ANDRODERM.................. 117ANDROGEL..................... 117ANORO ELLIPTA.........29, 150ANTARA........................... 46ANTIFUNGAL (CLOTRIMAZOLE)............ 158ANTIFUNGAL CREAM (MICONAZOLE)............... 158ANZEMET....................... 109APIDRA SOLOSTAR U-100 INSULIN.........................117APIDRA U-100 INSULIN....117APLENZIN........................ 61apraclonidine.................. 102aprepitant...................... 109APRI.............................. 117APRISO.......................... 109APTENSIO XR................... 61APTIOM............................61APTIVUS............................ 4APTIVUS (WITH VITAMIN E)..................................... 4ARANELLE (28)............... 117ARANESP (IN POLYSORBATE)................. 38ARCAPTA NEOHALER.. 29, 150ARICEPT.......................... 30ARIKAYCE.......................... 4aripiprazole...................... 61ARISTADA........................ 62

ARISTADA INITIO..............62ARIXTRA.......................... 38armodafinil.......................62ARMONAIR RESPICLICK..............................117, 150ARNUITY ELLIPTA.....117, 150ARTHROTEC 50..........62, 109ARTHROTEC 75..........62, 109ARYMO ER........................62ASACOL HD.................... 109ASCOMP WITH CODEINE.... 62asenapine maleate............ 62ASMANEX HFA......... 117, 150ASMANEX TWISTHALER..............................117, 150aspirin-dipyridamole............................38, 46, 62ASTAGRAF XL................. 137ASTEPRO........................102ATACAND......................... 46ATACAND HCT.............46, 93atazanavir..........................4ATELVIA.........................137atenolol...................... 30, 46atenolol-chlorthalidone............................30, 46, 93atomoxetine..................... 62atorvastatin......................47atovaquone........................ 4atovaquone-proguanil..........4atropine....................30, 102ATROVENT HFA............... 150AUBAGIO........................137AUBRA........................... 117AUGMENTIN XR.................. 4AURYXIA.......................... 93AUSTEDO.........................62AVALIDE.....................47, 93AVANDIA........................117AVAPRO........................... 47AVAR-E LS......................158AVELOX............................. 4AVIANE.......................... 117AVITA............................ 159AVODART....................... 137AVONEX......................... 138AVONEX (WITH ALBUMIN) 138AVSOLA........... 109, 138, 159AXIRON..........................118AYVAKIT.......................... 17AZASAN......................... 138AZASITE.........................102azathioprine....................138azelaic acid.....................159

azelastine.......................102azithromycin...................... 4AZOPT........................... 102AZOR...............................47aztreonam......................... 4AZULFIDINE.........4, 109, 138AZULFIDINE EN-TABS.......................... 4, 109, 138AZURETTE (28)............... 118bacitracin....................4, 102bacitracin-polymyxin b..... 102baclofen...........................30BAFIERTAM.....................138BALANCED SALT..............102BAL-CARE DHA.....38, 93, 169balsalazide..................... 109BALVERSA........................17BALZIVA (28)..................118BANZEL........................... 62BAQSIMI................. 118, 138BARACLUDE....................... 4BASAGLAR KWIKPEN U-100 INSULIN...................118BAXDELA........................... 4bcg vaccine, live (pf)......... 23BD PRE-FILLED NORMAL SALINE............................ 93BECONASE AQ......... 102, 150BELBUCA..........................62BELSOMRA....................... 62benazepril........................ 47benazepril-hydrochlorothiazide......47, 93BENEFIX.......................... 38BENICAR..........................47BENICAR HCT..............47, 93BENLYSTA...................... 138BENZACLIN.....................159BENZACLIN PUMP............ 159BENZAMYCIN.................. 159BENZNIDAZOLE.................. 4benzonatate....................150benzoyl peroxide............. 159benztropine.................30, 62BEPREVE........................ 103BERINERT.......................138BESIVANCE.....................103betamethasone dipropionate................... 159betamethasone valerate... 159betamethasone, augmented..................... 159BETAPACE...................30, 47BETAPACE AF.............. 30, 47

174

BETASERON....................138betaxolol............. 30, 47, 103bethanechol chloride..........30BETHKIS............................4BETOPTIC S....................103BEVESPI AEROSPHERE30, 151BEVYXXA..........................38bexarotene.......................17BEXSERO......................... 23bicalutamide.....................17BIDIL...............................47BIKTARVY.......................... 4bimatoprost.................... 103BINOSTO........................138BIOTHRAX........................23biotin (bulk)....................148bisoprolol fumarate...... 30, 47bisoprolol-hydrochlorothiazide 30, 47, 93BLEPHAMIDE...................103BLEPHAMIDE S.O.P..........103BLISOVI 24 FE................ 118BLISOVI FE 1.5/30 (28)....118BLISOVI FE 1/20 (28)...... 118BONIVA..........................138BOOSTRIX TDAP............... 23bortezomib.......................17bosentan...................47, 151BOSULIF.......................... 17BP 10-1..........................159BPO............................... 159BRAFTOVI........................ 17BREO ELLIPTA.... 30, 118, 151BREZTRI AEROSPHERE.....151BRIELLYN....................... 118BRILINTA......................... 38brimonidine.................... 103BRINTELLIX......................62BRISDELLE.......................62BRIVIACT................... 62, 63bromfenac...................... 103bromocriptine................... 63brompheniramine-pseudoeph-dm...........30, 151BROMSITE......................103BROVANA..................30, 151BRUKINSA........................17budesonide...... 103, 118, 151budesonide-formoterol........................ 30, 118, 151bumetanide.................47, 93BUNAVAIL........................ 63buprenorphine.................. 63buprenorphine hcl............. 63

buprenorphine-naloxone.....63bupropion hcl....................63bupropion hcl (smoking deter)..............................63buspirone.........................63BUTALBITAL COMPOUND W/CODEINE......................63butalbital-acetaminop-caf-cod..................................63butalbital-acetaminophen... 63butalbital-acetaminophen-caff................................. 63butalbital-aspirin-caffeine................................. 38, 63BYDUREON BCISE............118BYETTA.......................... 118BYSTOLIC................... 30, 47BYVALSON.................. 30, 47CABENUVA.........................5cabergoline.......................64CABLIVI........................... 38CABOMETYX..................... 17CADUET........................... 47CALAN............................. 47CALAN SR........................ 47calcipotriene................... 159calcitonin (salmon)... 118, 138calcitriol......................... 169calcium acetate(phosphat bind)............................... 93CALQUENCE..................... 17CAMILA.......................... 118CAMRESE....................... 119CAMRESE LO...................118CANASA......................... 109candesartan..................... 47candesartan-hydrochlorothiazid....... 47, 93capecitabine..................... 17CAPITAL WITH CODEINE.... 64CAPLYTA.......................... 64CAPRELSA........................ 17captopril.......................... 48captopril-hydrochlorothiazide......48, 93CARBAGLU....................... 93carbamazepine..................64CARBATROL......................64carbidopa-levodopa........... 64carbidopa-levodopa-entacapone...................... 64carbinoxamine maleate.1, 151CARDIZEM....................... 48CARDIZEM CD.................. 48

CARDIZEM LA................... 48CARDURA................... 30, 48CARDURA XL............... 30, 48carteolol.........................103CARTIA XT....................... 48carvedilol....................30, 48carvedilol phosphate.... 31, 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........................... 5cefoxitin............................ 5cefoxitin in dextrose, iso-osm.................................. 5cefpodoxime.......................5cefprozil.............................6ceftazidime........................ 6ceftriaxone.........................6ceftriaxone in dextrose,iso-os..................................... 6cefuroxime axetil................ 6cefuroxime sodium..............6CELEBREX........................ 64celecoxib..........................64CELEXA............................64CELLCEPT....................... 138CELONTIN........................ 64CENTANY........................159CENTANY AT................... 159cephalexin......................... 6CERDELGA......................138CESAMET....................... 109cetirizine.....................1, 151cetirizine-pseudoephedrine............................1, 31, 151cevimeline........................31CHANTIX..........................31CHANTIX CONTINUING MONTH BOX..................... 31CHANTIX STARTING MONTH BOX..................... 31CHATEAL (28)................. 119

175

CHEMET.................. 115, 138CHILDREN'S ALAWAY....... 103CHILDREN'S ALLERGY RELIEF(LOR)............... 1, 151CHILDREN'S CETIRIZINE................................. 1, 151CHILD'S ALL DAY ALLERGY(CETIR)..........1, 151chloramphenicol sod succinate........................... 6chlorhexidine gluconate....103chloroquine phosphate.........6chlorothiazide..............48, 93chlorpromazine................. 64chlorthalidone............. 48, 93chlorzoxazone...................31cholestyramine (with sugar)............................. 48CHOLESTYRAMINE LIGHT... 48choline,magnesium salicylate..........................64ciclopirox........................159cilostazol.................... 38, 48CILOXAN........................ 103CIMDUO............................ 6cimetidine...................... 109cimetidine hcl..................109CIMZIA................... 109, 139CIMZIA POWDER FOR RECONST................ 109, 139CIMZIA STARTER KIT109, 139CINRYZE........................ 139CIPRO............................... 6CIPRO HC.......................103CIPRO XR...........................6CIPRODEX...................... 103ciprofloxacin.......................6ciprofloxacin (mixture).........6ciprofloxacin hcl...........6, 103ciprofloxacin in 5 % dextrose............................ 6ciprofloxacin-fluocinolone..103citalopram........................64CLARAVIS.......................160CLARINEX...................1, 151CLARINEX-D 12 HOUR............................2, 31, 151clarithromycin.................6, 7CLEANSING WASH...........160clemastine.................. 2, 151clindamycin hcl................... 7clindamycin palmitate hcl..... 7CLINDAMYCIN PEDIATRIC.... 7clindamycin phosphate. 7, 160

clindamycin-benzoyl peroxide.........................160clindamycin-tretinoin....... 160CLINIMIX 5%/D15W SULFITE FREE...................93CLINIMIX 5%/D25W SULFITE-FREE...................94CLINIMIX 4.25%/D10W SULF FREE....................... 94CLINIMIX 4.25%/D5W SULFIT FREE.....................94CLINIMIX 4.25%-D25W SULF-FREE....................... 94CLINIMIX 5%-D20W(SULFITE-FREE)........94CLINIMIX 6%-D5W (SULFITE-FREE)................ 94CLINIMIX 8%-D10W(SULFITE-FREE)........94CLINIMIX 8%-D14W(SULFITE-FREE)........94CLINIMIX E 2.75%/D5W SULF FREE....................... 94CLINIMIX E 4.25%/D10W SUL FREE......................... 94CLINIMIX E 4.25%/D5W SULF FREE....................... 94CLINIMIX E 5%/D15W SULFIT FREE.....................94CLINIMIX E 5%/D20W SULFIT FREE.....................94CLINIMIX E 8%-D10W SULFITEFREE....................94CLINIMIX E 8%-D14W SULFITEFREE....................94clobazam.................... 64, 65clobetasol.......................160clobetasol-emollient.........160clomipramine....................65clonazepam...................... 65clonidine.....................31, 48clonidine hcl................31, 48clopidogrel....................... 38clorazepate dipotassium..... 65clotrimazole.................... 160clotrimazole-betamethasone............... 160clozapine..........................65CLOZARIL........................ 65COAGADEX.......................38COARTEM...........................7COLAZAL........................109colchicine....................... 139colesevelam.............. 48, 119

COLESTID........................ 49COLESTID FLAVORED........ 49colestipol......................... 49colistin (colistimethate na)... 7COMBIGAN..................... 103COMBIVENT RESPIMAT............................... 31, 151COMBIVIR..........................7COMETRIQ....................... 17COMPLERA......................... 7COMPLETE NATAL DHA.......................... 38, 94, 170COMPLETENATE...............170CONCERTA....................... 65CONSTULOSE................... 95CONTOUR METER.............. 90CONTOUR NEXT EZ METER. 90CONTOUR NEXT GLUCOSE METER............................. 90CONTOUR NEXT LINK.........90CONTOUR NEXT LINK 2.4... 90CONTOUR NEXT METER......90CONTOUR NEXT ONE METER............................. 90CONTOUR NEXT TEST STRIPS............................ 92CONTOUR TEST STRIPS..... 92COPAXONE..................... 139COPIKTRA........................ 17COREG....................... 31, 49COREG CR.................. 31, 49CORGARD...................31, 49CORIFACT........................ 39CORLANOR.......................49cortisone........................ 119CORZIDE...............31, 49, 95COSENTYX.............. 160, 161COSENTYX (2 SYRINGES). 160COSENTYX PEN............... 160COSENTYX PEN (2 PENS)..160COSOPT......................... 104COSOPT (PF).................. 103cosyntropin...................... 92COTELLIC.........................17COTEMPLA XR-ODT............65COZAAR...........................49CREON...........................109CRESEMBA.........................7CRESTOR......................... 49CRIXIVAN.......................... 7cromolyn.................104, 152CROTAN......................... 161CRYSELLE (28)................119CRYSVITA........................ 95

176

cyanocobalamin (vitamin b-12)............................. 170CYCLAFEM 1/35 (28)........119CYCLAFEM 7/7/7 (28)...... 119cyclobenzaprine................ 31cyclophosphamide......17, 139CYCLOPHOSPHAMIDE. 17, 139cyclosporine....................139cyclosporine modified.......139CYMBALTA........................65cyproheptadine............2, 152cyred............................. 119CYSTAGON..................... 139CYSTARAN......................104DAKLINZA..........................7dalfampridine..................139DALIRESP.......................152danazol.......................... 119dantrolene........................31dapsone.............................7DAPTACEL (DTAP PEDIATRIC) (PF)............... 23daptomycin........................ 7DARAPRIM......................... 7darifenacin..................... 168DASETTA 1/35 (28)......... 119DASETTA 7/7/7 (28)........ 119DAURISMO....................... 17DAYPRO........................... 65DAYSEE..........................119DAYTRANA....................... 65DAYVIGO......................... 65D-BIOTIN....................... 148deferasirox..................... 115deferiprone.....................115DELSTRIGO........................7DELZICOL.......................109DENAVIR........................161DENTA 5000 PLUS........... 139DENTAGEL......................139DEPAKENE........................65DEPAKOTE....................... 65DEPAKOTE ER...................65DEPAKOTE SPRINKLES.......65DEPO-PROVERA...............119DESCOVY...........................7desipramine......................65desloratadine.............. 2, 152desmopressin............ 39, 119desogestrel-ethinyl estradiol.........................119desonide........................ 161desvenlafaxine..................65desvenlafaxine fumarate.... 65

desvenlafaxine succinate.... 66DETROL......................... 169DETROL LA..................... 169dexamethasone...............119DEXAMETHASONE INTENSOL...................... 119dexamethasone sodium phos (pf)........................ 119dexamethasone sodium phosphate............... 104, 119DEXCOM G5 RECEIVER...... 90DEXCOM G5 TRANSMITTER.90DEXCOM G5-G4 SENSOR....90DEXCOM G6 RECEIVER...... 90DEXCOM G6 SENSOR.........90DEXCOM G6 TRANSMITTER.90DEXEDRINE SPANSULE...... 66DEXILANT............... 109, 110dexmethylphenidate.......... 66dextroamphetamine...........66dextroamphetamine-amphetamine.............. 66, 67dextrose 5 %-lactated ringers.............................95DIACOMIT........................ 67DIASTAT.......................... 67DIASTAT ACUDIAL.............67diazepam......................... 67DIAZEPAM INTENSOL.........67diazoxide........................119diclofenac epolamine.. 67, 161diclofenac potassium..........67diclofenac sodium...................17, 67, 104, 161diclofenac-misoprostol 67, 110dicloxacillin........................ 7dicyclomine...................... 31didanosine......................... 7DIFFERIN....................... 161DIFICID............................. 7DIFLUCAN..........................7diflunisal.......................... 67DIGOX............................. 49digoxin............................ 49DILANTIN................... 49, 67DILANTIN EXTENDED... 49, 67DILANTIN INFATABS.... 49, 67DILANTIN-125.............49, 67diltiazem hcl................49, 50DILT-XR...........................50dimethyl fumarate........... 139DIOVAN........................... 50DIOVAN HCT............... 50, 95DIPENTUM......................110

diphenhydramine hcl.... 2, 152diphenoxylate-atropine............................... 31, 110dipyridamole............... 39, 50disopyramide phosphate.....50disulfiram....................... 139DITROPAN XL..................169divalproex........................ 67dofetilide..........................50donepezil....................31, 32dorzolamide....................104dorzolamide-timolol......... 104dorzolamide-timolol (pf)... 104DOVATO............................ 7doxazosin................... 32, 50doxepin............................68doxycycline hyclate...... 7, 104doxycycline monohydrate.....8dronabinol...................... 110drospirenone-ethinyl estradiol.........................119DROXIA........................... 17DUAKLIR PRESSAIR....32, 152DUETACT........................119DUEXIS.................... 68, 110DULERA.............32, 120, 152duloxetine........................ 68DUPIXENT PEN.........152, 161DUPIXENT SYRINGE..152, 161DURAGESIC......................68dutasteride..................... 139dutasteride-tamsulosin.....139DYANAVEL XR...................68DYMISTA.................104, 152E.E.S. 400..........................8E.E.S. GRANULES................8EC-NAPROXEN........... 68, 139econazole....................... 161ECONTRA EZ...................120ECONTRA ONE-STEP........ 120EDARBI............................50EDARBYCLOR.............. 50, 95EDLUAR........................... 68EDURANT...........................8efavirenz............................8efavirenz-emtricitabin-tenofov..............................8efavirenz-lamivu-tenofov disop.................................8EFFEXOR XR..................... 68EFFIENT...........................39ELELYSO........................ 101ELESTAT........................ 104eletriptan......................... 68

177

ELIDEL....................139, 161ELIGARD...................18, 120ELIGARD (3 MONTH).. 17, 120ELIGARD (4 MONTH).. 18, 120ELIGARD (6 MONTH).. 18, 120ELINEST.........................120ELIQUIS...........................39ELIQUIS DVT-PE TREAT 30D START.......................39ELITE OB WITH DHA........ 170ELITE-OB 400............39, 170ELLA.............................. 120ELMIRON........................139ELOCTATE........................ 39ELURYNG........................120EMADINE........................104EMBEDA...........................68EMCYT............................. 18EMGALITY PEN..................68EMGALITY SYRINGE...........68EMOQUETTE................... 120emtricitabine...................... 8emtricitabine-tenofovir (tdf)..................................8EMTRIVA............................8ENABLEX........................ 169enalapril maleate...............50enalapril-hydrochlorothiazide......50, 95ENBREL...................140, 161ENBREL MINI........... 140, 161ENBREL SURECLICK..140, 161ENDARI...................110, 140ENDOCET......................... 68ENGERIX-B (PF).......... 23, 24ENGERIX-B PEDIATRIC (PF).................................24enoxaparin....................... 39ENPRESSE...................... 120ENSKYCE........................120ENSPRYNG......................140entacapone...................... 68entecavir........................... 8ENTRESTO........................50ENTYVIO................. 110, 140ENULOSE......................... 95ENVARSUS XR.................140EPCLUSA............................8EPIDIOLEX....................... 68EPIDUO FORTE................161epinastine...................... 104epinephrine............... 32, 152epinephrine hcl (pf)........... 32EPIPEN............................ 32

EPIPEN 2-PAK............32, 152EPIPEN JR........................ 32EPIPEN JR 2-PAK........32, 152EPITOL............................ 68EPIVIR...............................8EPIVIR HBV........................8eplerenone....................... 50EPOGEN...........................39epoprostenol (glycine) 50, 152eprosartan....................... 50ergocalciferol (vitamin d2) 170ergoloid........................... 32ERIVEDGE........................ 18ERLEADA..........................18erlotinib........................... 18ERRIN............................120ertapenem......................... 8ERY PADS.......................161ERYPED 200....................... 8ERYPED 400....................... 8ERY-TAB............................ 8ERYTHROCIN (AS STEARATE)........................ 8erythromycin...............8, 104erythromycin ethylsuccinate.................... 8erythromycin with ethanol 161erythromycin-benzoyl peroxide.........................161ESBRIET................. 152, 153escitalopram oxalate..........68esomeprazole magnesium.110esomeprazole strontium... 110ESPEROCT........................39ESTARYLLA.....................120estradiol.........................120estradiol valerate.............120estradiol-norethindrone acet...............................120eszopiclone.......................68ethambutol........................ 8ethosuximide.................... 68ethyl chloride.................. 162etidronate disodium......... 140etodolac...........................69etonogestrel-ethinyl estradiol.........................120etoposide......................... 18etravirine...........................8EUCRISA........................ 162EURAX........................... 162EVEKEO........................... 69everolimus (antineoplastic).18

everolimus (immunosuppressive).......140EVISTA................... 120, 140EVOTAZ......................8, 140EVRYSDI........................ 140EXALGO ER...................... 69EXELDERM......................162EXELON PATCH................. 32exemestane.............. 18, 120EXFORGE......................... 51EXFORGE HCT............. 50, 95EXTAVIA.........................140EYE ITCH RELIEF............. 104EZALLOR SPRINKLE........... 51ezetimibe......................... 51ezetimibe-simvastatin........ 51FABIOR.......................... 162FABRAZYME....................101FALMINA (28)................. 120famciclovir......................... 9famotidine...................... 110famotidine (pf)-nacl (iso-os)................................ 110FANAPT............................69FARXIGA........................ 120FARYDAK......................... 18FASENRA........................153FASENRA PEN................. 153FAZACLO..........................69FEIBA NF..........................39felbamate.........................69FELBATOL........................ 69felodipine......................... 51FEMHRT LOW DOSE......... 120FEMYNOR....................... 121fenofibrate....................... 51fenofibrate micronized....... 51fenofibrate nanocrystallized 51fenofibric acid................... 51fenofibric acid (choline)......51FENOGLIDE...................... 51fenoprofen....................... 69fentanyl........................... 69fentanyl citrate................. 69FERRIPROX.....................115FETZIMA.......................... 69FIASP FLEXTOUCH U-100 INSULIN.........................121FIASP PENFILL U-100 INSULIN.........................121FIASP U-100 INSULIN...... 121FIBRICOR.........................51finasteride...............140, 162FINTEPLA......................... 69

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FIRAZYR.........................140FIRDAPSE.......................140flavoxate........................ 169flecainide......................... 51FLECTOR...................69, 162FLOMAX........................... 32FLOVENT DISKUS.....121, 153FLOVENT HFA.......... 121, 153FLUAD 2020-2021 (65 YR UP)(PF)............................24FLUAD QUAD 2020-21(65Y UP)(PF)............................24FLUARIX QUAD 2020-2021 (PF).................................24FLUBLOK QUAD 2020-2021 (PF).................................24FLUCELVAX QUAD 2020-2021............................... 24FLUCELVAX QUAD 2020-2021 (PF).........................24fluconazole.........................9fluconazole in dextrose(iso-o)..................................... 9fluconazole in nacl (iso-osm)................................. 9flucytosine......................... 9fludrocortisone................ 121FLULAVAL QUAD 2020-2021 (PF).........................24FLUMIST QUAD 2020-2021.24flunisolide................104, 153fluocinolone.................... 162fluocinolone and shower cap................................162fluocinonide.................... 162FLUOCINONIDE-E............ 162fluoride (sodium).............140FLUORITAB.....................140fluorometholone.............. 104fluorouracil................18, 162fluoxetine................... 69, 70fluphenazine decanoate......70fluphenazine hcl................ 70flurbiprofen...................... 70flurbiprofen sodium..........104flutamide......................... 18fluticasone propionate..............................153, 162fluticasone propion-salmeterol..........32, 121, 153fluvastatin........................51fluvoxamine......................70FLUZONE HIGHDOSE QUAD 20-21 PF.......................... 24

FLUZONE QUAD 2020-2021 24FLUZONE QUAD 2020-2021 (PF).................................24FOCALIN.......................... 70FOCALIN XR..................... 70FOLBIC.......................... 170FOLBIC RF...................... 170folic acid.........................170fomepizole......................140fondaparinux.................... 39FORA G20...................90, 92FORFIVO XL......................70FORTEO.................. 121, 141FORTESTA...................... 121FOSAMAX....................... 141FOSAMAX PLUS D.....141, 170fosamprenavir.................... 9fosfomycin tromethamine.....9fosinopril..........................51fosinopril-hydrochlorothiazide......51, 95fosphenytoin.....................70FOSRENOL................ 95, 141FRAGMIN......................... 39FREESTYLE FREEDOM LITE. 90FREESTYLE INSULINX...90, 92FREESTYLE INSULINX TEST STRIPS............................ 92FREESTYLE LIBRE 14 DAY READER........................... 90FREESTYLE LIBRE 14 DAY SENSOR...........................90FREESTYLE LIBRE 2 READER........................... 90FREESTYLE LIBRE 2 SENSOR...........................90FREESTYLE LITE METER..... 90FREESTYLE LITE STRIPS.....92FREESTYLE TEST............... 92FROVA............................. 70frovatriptan...................... 70FULPHILA......................... 39furosemide..................51, 95FUZEON.............................9FYCOMPA......................... 70gabapentin....................... 70GABITRIL......................... 70galantamine..................... 32GAMASTAN S/D................ 24GAMMAGARD LIQUID.........24GAMMAGARD S-D (IGA < 1 MCG/ML)..........................24GAMUNEX-C..................... 25GARDASIL 9 (PF).............. 25

gatifloxacin.....................104GAVILYTE-C....................110GAVILYTE-G....................110GAVILYTE-N....................110GAVRETO......................... 18GELNIQUE...................... 169gemfibrozil....................... 51GENERLAC....................... 95GENGRAF....................... 141GENOTROPIN.................. 121GENOTROPIN MINIQUICK. 121GENTAK......................... 104gentamicin...........9, 104, 162gentamicin in nacl (iso-osm)................................. 9gentamicin sulfate (ped) (pf)................................... 9GENVOYA...........................9GEODON.....................70, 71GIANVI (28)................... 122GIAZO........................... 110GILENYA........................ 141GILOTRIF......................... 18GIMOTI.......................... 110glatiramer...................... 141GLATOPA........................141GLEOSTINE...................... 18glimepiride..................... 122glipizide......................... 122glipizide-metformin..........122GLUCAGEN HYPOKIT.122, 141GLUCAGON (HCL) EMERGENCY KIT...... 122, 141GLUCAGON EMERGENCY KIT (HUMAN)...........122, 141GLUCAGON 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..... 95glycopyrrolate...................32GLYNASE........................122GLYSET.......................... 122

179

GLYXAMBI...................... 122GOCOVRI..................... 9, 71GOLYTELY...................... 110GRALISE.......................... 71GRALISE 30-DAY STARTER PACK............................... 71granisetron (pf)...............110granisetron hcl................ 111GRANIX........................... 40griseofulvin microsize.......... 9griseofulvin ultramicrosize....9GRIS-PEG (ULTRAMICROSIZE)............ 9guanfacine..................51, 71guanidine......................... 32HAEGARDA..................... 141HAILEY 24 FE..................122HAILEY FE 1.5/30 (28)..... 122halobetasol propionate..... 162haloperidol....................... 71haloperidol decanoate........ 71haloperidol lactate.............71HARVONI........................... 9HAVRIX (PF).....................25HEATHER........................123HELIXATE FS.................... 40HEMANGEOL..........33, 51, 71HEMLIBRA........................40HEMOFIL M HIGH.............. 40HEMOFIL M LOW............... 40HEMOFIL M MID................ 40HEMOFIL M SUPER HIGH.... 40HEP FLUSH-10 (PF)...... 40, 91heparin (porcine).............. 40heparin (porcine) in 5 % dex................................. 40heparin (porcine) in nacl (pf)............................40, 91heparin flush(porcine)-0.9nacl.......................40, 91HEPARIN LOCK............ 40, 91HEPARIN LOCK FLUSH.. 40, 91heparin lock flush (porcine)................................. 40, 91HEPARIN LOCKFLUSH(PORCINE)(PF)................................. 41, 91heparin, porcine (pf).... 41, 91HEPLISAV-B (PF)...............25HEPSERA........................... 9HETLIOZ.......................... 71HIBERIX (PF)....................25HIZENTRA........................ 25HORIZANT........................71

HUMALOG 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 123HUMATE-P........................41HUMATROPE................... 123HUMIRA...........111, 141, 163HUMIRA PEDIATRIC CROHNS START 111, 141, 162HUMIRA PEN.... 111, 141, 163HUMIRA PEN CROHNS-UC-HS START........ 111, 141, 162HUMIRA PEN PSOR-UVEITS-ADOL HS...................... 111, 141, 162HUMIRA(CF).....111, 142, 163HUMIRA(CF) PEDI CROHNS STARTER..........111, 142, 163HUMIRA(CF) PEN...................... 111, 142, 163HUMIRA(CF) PEN CROHNS-UC-HS............. 111, 142, 163HUMIRA(CF) PEN PEDIATRIC UC.. 111, 142, 163HUMIRA(CF) PEN PSOR-UV-ADOL HS.... 111, 142, 163HUMULIN 70/30 U-100 INSULIN.........................123HUMULIN 70/30 U-100 KWIKPEN........................123HUMULIN N NPH INSULIN KWIKPEN........................123HUMULIN N NPH U-100 INSULIN.........................123HUMULIN R REGULAR U-100 INSULN....................123HUMULIN R U-500 (CONC) INSULIN.........................123HUMULIN R U-500 (CONC) KWIKPEN........................124hydralazine.......................52hydrochlorothiazide......52, 95hydrocodone bitartrate.......71hydrocodone-acetaminophen................. 71

hydrocodone-ibuprofen...... 71hydrocortisone......... 124, 163hydrocortisone acetate..... 163hydrocortisone-acetic acid 104hydromorphone................ 71hydroxychloroquine......9, 142hydroxyprogest(pf)(preg presv)............................124hydroxyprogesterone cap(ppres)......................124hydroxyprogesterone capr(bulk)...................... 124hydroxyprogesterone caproate.........................124hydroxyurea..................... 18hydroxyzine hcl............. 2, 72hydroxyzine pamoate.....2, 72hyoscyamine sulfate.......... 33HYPERHEP B NEONATAL..... 25HYSINGLA ER................... 72HYZAAR......................52, 95ibandronate.................... 142IBRANCE..........................18ibuprofen......................... 72icatibant.........................142ICLUSIG...........................18IDELVION.........................41IDHIFA............................ 18ILARIS (PF).................... 142ILUMYA.......................... 163imatinib........................... 18IMBRUVICA.................18, 19imipramine hcl.................. 72imipramine pamoate..........72imiquimod...................... 163IMITREX...........................72IMITREX STATDOSE PEN.... 72IMITREX STATDOSE REFILL 72IMOVAX RABIES VACCINE (PF).................................25IMURAN......................... 142INBRIJA........................... 72INCRUSE ELLIPTA...... 33, 153indapamide................. 52, 95INDERAL LA...........33, 52, 72INDERAL XL...........33, 52, 72indomethacin.............72, 142INFANRIX (DTAP) (PF)....... 25INFLECTRA.......111, 142, 163INLYTA............................ 19INNOPRAN XL........ 33, 52, 72INPEN (FOR HUMALOG)......91INPEN (FOR NOVOLOG OR FIASP)............................. 91

180

INQOVI............................19INREBIC...........................19insulin asp prt-insulin aspart............................ 124insulin aspart u-100.........124insulin lispro................... 124insulin lispro protamin-lispro............................. 124INTELENCE.........................9INTERMEZZO....................72INTRON A............10, 19, 142INTROVALE.....................124INTUNIV ER................ 52, 72INVEGA............................72INVEGA SUSTENNA........... 73INVEGA TRINZA................ 73INVIRASE.........................10INVOKAMET....................124INVOKAMET XR............... 124INVOKANA......................124IONOSOL-B IN D5W.......... 95IONOSOL-MB IN D5W........ 95IOPIDINE....................... 104IPOL................................25ipratropium bromide........................ 33, 105, 153ipratropium-albuterol..33, 153irbesartan........................ 52irbesartan-hydrochlorothiazide......52, 95IRESSA............................ 19ISENTRESS...................... 10ISENTRESS HD................. 10ISOLYTE-P IN 5 % DEXTROSE....................... 96ISOLYTE-S....................... 96isoniazid.......................... 10isosorbide dinitrate............52isosorbide mononitrate.......52isotretinoin..................... 163isradipine......................... 52ISTALOL.........................105ISTURISA....................... 142itraconazole......................10ivermectin........................10IXIARO (PF)......................25IXINITY............................41JAKAFI.............................19JALYN.......................33, 142JANTOVEN........................41JANUMET........................124JANUMET XR............124, 125JANUVIA.........................125JARDIANCE.....................125

JENCYCLA.......................125JENTADUETO.................. 125JENTADUETO XR..............125JINTELI.......................... 125JIVI................................. 41JOLESSA........................ 125JOLIVETTE......................125JORNAY PM...................... 73JUBLIA........................... 163JULEBER.........................125JULUCA............................10JUNEL 1.5/30 (21)...........125JUNEL 1/20 (21)..............125JUNEL FE 1.5/30 (28).......125JUNEL FE 1/20 (28)......... 125JUNEL FE 24................... 125JYNARQUE........................96KADIAN........................... 73KAITLIB FE..................... 125KALBITOR.......................142KALYDECO......................153KAPSPARGO SPRINKLE. 33, 52KARIVA (28)................... 125KAZANO.........................125KEFLEX............................ 10KELNOR 1/35 (28)........... 125KEPPRA............................73KEPPRA XR.......................73KERYDIN........................ 163KESIMPTA PEN................ 142ketoconazole............. 10, 163ketoprofen....................... 73ketorolac.................. 73, 105ketotifen fumarate........... 105KEVZARA........................143KHEDEZLA........................73KINERET........................ 143KINRIX (PF)......................25KISQALI...........................19KISQALI FEMARA CO-PACK............................... 19, 125KITABIS PAK.................... 10KLOR-CON....................... 96KLOR-CON 10................... 96KLOR-CON 8.....................96KLOR-CON M10.................96KLOR-CON M15.................96KLOR-CON M20.................96KOATE............................. 41KOATE-DVI.......................41KOGENATE FS...................41KOMBIGLYZE XR............. 125KOSELUGO.......................19KOVALTRY........................41

KURVELO (28).................125KYNMOBI......................... 73l norgest/e.estradiol-e.estrad......................... 126labetalol..................... 33, 52lactated ringers.................96lactulose.......................... 96LAMICTAL........................ 73LAMICTAL ODT..................73LAMICTAL ODT STARTER (BLUE).............................73LAMICTAL ODT STARTER (GREEN).......................... 73LAMICTAL ODT STARTER (ORANGE)........................ 73LAMICTAL STARTER (BLUE) KIT..................................74LAMICTAL STARTER (GREEN) KIT.....................74LAMICTAL STARTER (ORANGE) KIT.................. 74LAMICTAL XR....................74LAMICTAL XR STARTER (BLUE).............................74LAMICTAL XR STARTER (GREEN).......................... 74LAMICTAL XR STARTER (ORANGE)........................ 74lamivudine....................... 10lamivudine-zidovudine....... 10lamotrigine.......................74LAMPIT............................ 10lansoprazole................... 111lanthanum................ 96, 143LANTUS SOLOSTAR U-100 INSULIN.........................126LANTUS U-100 INSULIN... 126lapatinib...........................19LARIN 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........................... 74LAYOLIS FE.....................126LAZANDA......................... 74ledipasvir-sofosbuvir..........10LEENA 28....................... 126leflunomide.....................143LEMTRADA......................143LENVIMA..........................19

181

LESCOL XL....................... 52LESSINA.........................126LETAIRIS.................. 52, 153letrozole................... 19, 126leucovorin calcium........... 143LEUKERAN........................19LEUKINE.......................... 41leuprolide..................19, 126levalbuterol hcl.......... 33, 153levalbuterol tartrate... 33, 154LEVEMIR FLEXTOUCH U-100 INSULN....................126LEVEMIR U-100 INSULIN.. 126levetiracetam.............. 74, 75levobunolol..................... 105levocarnitine................... 143levocarnitine (with sugar). 143levocetirizine...............2, 154levofloxacin...............10, 105LEVONEST (28)............... 126levonorgestrel................. 126levonorgestrel-ethinyl estrad............................ 126levonorg-eth estrad triphasic.........................126LEVORA-28.....................126levorphanol tartrate...........75levothyroxine..................127LEVOXYL........................ 127LEXAPRO..........................75LEXIVA............................ 10LIALDA...........................111LICE KILLING..................163LICE SOLUTION...............164LICE TREATMENT.............164LICE TREATMENT (PERMETHRIN)................164lidocaine.........................164lidocaine (pf)............. 52, 137lidocaine hcl............ 105, 137LIDOCAINE PAIN RELIEF...164lidocaine-prilocaine.......... 164LIDODERM......................164LILETTA......................... 127lindane...........................164linezolid........................... 10linezolid in dextrose 5%..... 10linezolid-0.9% sodium chloride............................10liothyronine.................... 127LIPITOR........................... 52LIPOFEN...........................53lisinopril...........................53

lisinopril-hydrochlorothiazide......53, 96lithium carbonate.............. 75lithium citrate................... 75LIVALO............................ 53LONHALA MAGNAIR REFILL.33LONHALA MAGNAIR STARTER..........................33LONSURF......................... 19LOPID..............................53lopinavir-ritonavir........ 10, 11LOPRESSOR................ 33, 53LOPROX......................... 164LOPROX (AS OLAMINE).... 164LOPROX KIT....................164loratadine................... 2, 154LORATA-DINE D..... 2, 33, 154LORATADINE-D...... 2, 34, 154lorazepam........................ 75LORAZEPAM INTENSOL...... 75LORBRENA....................... 19LORCET (HYDROCODONE)..75LORCET HD...................... 75LORYNA (28).................. 127losartan........................... 53losartan-hydrochlorothiazide......53, 96LOTENSIN........................ 53LOTENSIN HCT............ 53, 96loteprednol etabonate...... 105LOTREL............................53lovastatin......................... 53LOVAZA........................... 53LOVENOX....................41, 42LOW-OGESTREL (28)....... 127loxapine succinate............. 75LUDENT FLUORIDE.......... 143LUMIGAN........................105LUMIZYME...................... 101LUNESTA..........................75LUPRON DEPOT..........19, 127LUPRON DEPOT (3 MONTH)............................... 19, 127LUPRON DEPOT (4 MONTH)............................... 19, 127LUPRON DEPOT (6 MONTH)............................... 19, 127LUPRON DEPOT-PED...20, 127LUPRON DEPOT-PED (3 MONTH)....................20, 127LUTERA (28)................... 127LUZU............................. 164LYNPARZA........................20LYRICA............................ 75

LYRICA CR........................75LYUMJEV KWIKPEN U-100 INSULIN.........................127LYUMJEV KWIKPEN U-200 INSULIN.........................127LYUMJEV U-100 INSULIN.. 127LYZA..............................127magnesium sulfate53, 75, 143magnesium sulfate in water.................. 53, 75, 143malathion....................... 164maprotiline.......................75MARLISSA (28)............... 127MATULANE....................... 20MATZIM LA.......................53MAVENCLAD (10 TABLET PACK)............................ 143MAVENCLAD (4 TABLET PACK)............................ 143MAVENCLAD (5 TABLET PACK)............................ 143MAVENCLAD (6 TABLET PACK)............................ 143MAVENCLAD (7 TABLET PACK)............................ 143MAVENCLAD (8 TABLET PACK)............................ 143MAVENCLAD (9 TABLET PACK)............................ 143MAVYRET......................... 11MAXALT........................... 75MAXALT-MLT.................... 75MAYZENT....................... 144MAYZENT STARTER PACK. 144meclizine.............2, 111, 112medroxyprogesterone..............................127, 128mefenamic acid.................76mefloquine....................... 11MEGACE ES...............20, 128megestrol................. 20, 128MEKINIST........................ 20MEKTOVI..........................20meloxicam........................76memantine.......................76MENACTRA (PF)................ 25MENQUADFI (PF)...............25MENVEO A-C-Y-W-135-DIP (PF).................................26MENVEO MENA COMPONENT (PF).............. 26MENVEO MENCYW-135 COMPNT (PF)....................26mercaptopurine......... 20, 144

182

meropenem......................11mesalamine.................... 112mesalamine with cleansing wipe.............................. 112mesna........................... 144MESNEX......................... 144metaproterenol..........34, 154metaxalone...................... 34metformin...................... 128methadone.......................76methenamine hippurate..... 11methimazole................... 128methocarbamol.................34methotrexate sodium..20, 144methotrexate sodium (pf)............................... 20, 144methoxsalen................... 164methscopolamine.............. 34methyldopa.................34, 53methyldopa-hydrochlorothiazide 34, 53, 96methyldopate.............. 34, 53METHYLIN........................ 76methylphenidate hcl.....76, 77methylprednisolone..........128methylprednisolone acetate.....................................128methylprednisolone sodium succ...............................128metipranolol................... 105metoclopramide hcl..........112metolazone................. 53, 96metoprolol succinate.... 34, 53metoprolol ta-hydrochlorothiaz.... 34, 53, 96metoprolol tartrate.......34, 54metronidazole............11, 164metronidazole in nacl (iso-os).................................. 11mexiletine........................ 54MIACALCIN..............128, 144micafungin....................... 11MICARDIS........................ 54MICARDIS HCT............ 54, 96miconazole nitrate........... 164MICONAZOLE-3...............164MICROGESTIN 1.5/30 (21)128MICROGESTIN 1/20 (21).. 128MICROGESTIN FE 1.5/30 (28)...............................128MICROGESTIN FE 1/20 (28)...............................128midodrine.........................34mifepristone................... 148

miglitol.......................... 128miglustat........................144minocycline...................... 11minoxidil.......................... 54MIRAPEX..........................77MIRAPEX ER..................... 77mirtazapine...................... 77misoprostol.....................112MITIGARE.......................144M-M-R II (PF)................... 26MOBIC............................. 77modafinil..........................77MODERIBA DOSE PACK...... 11moexipril..........................54mometasone.... 105, 154, 164MONOCLATE-P.................. 42MONO-LINYAH................ 128MONONESSA (28)............129MONONINE.......................42montelukast....................154MORPHABOND ER..............77morphine....................77, 78morphine concentrate........ 77MOVANTIK......................112MOXEZA.........................105moxifloxacin..............11, 105MOZOBIL......................... 42MS CONTIN...................... 78MULTIVITAMIN WITH FLUORIDE............... 144, 170MULTI-VITAMIN WITH FLUORIDE............... 144, 170MULTIVITAMINS WITH FLUORIDE............... 144, 170mupirocin....................... 165mupirocin calcium............164MY CHOICE.....................129MY WAY......................... 129MYALEPT........................ 129mycophenolate mofetil..... 144mycophenolate mofetil (hcl).............................. 144mycophenolate sodium.....144MYDAYIS..........................78MYFORTIC...................... 144MYLERAN......................... 20MYNATAL.............42, 97, 170MYNATAL PLUS.....42, 97, 170MYNATAL-Z..........42, 97, 170MYORISAN......................165MYRBETRIQ.................... 169MYSOLINE........................78nabumetone..................... 78nadolol....................... 34, 54

nafcillin............................11nafcillin in dextrose iso-osm.................................11naftifine......................... 165NAFTIN.......................... 165nalbuphine....................... 78NALFON........................... 78naloxone...................78, 144naltrexone................ 78, 144NAMENDA........................ 78NAMENDA TITRATION PAK..78NAMENDA XR....................78NAMZARIC.................. 34, 78naproxen......78, 79, 144, 145naproxen sodium....... 79, 145naratriptan....................... 79NARCAN................... 79, 145NASONEX................105, 154NATACYN....................... 105nateglinide..................... 129NATPARA................ 129, 145NATROBA....................... 165NAYZILAM........................ 79NECON 0.5/35 (28)..........129nefazodone.......................79neomycin......................... 11neomycin-bacitracin-poly-hc................................. 105neomycin-bacitracin-polymyxin...................... 105neomycin-polymyxin b gu.165neomycin-polymyxin b-dexameth................105, 106neomycin-polymyxin-gramicidin...................... 106neomycin-polymyxin-hc....106NEO-POLYCIN HC............ 106NEORAL......................... 145NERLYNX..........................20NESINA..........................129NEUAC........................... 165NEUAC KIT..................... 165NEULASTA........................42NEULASTA ONPRO.............42NEUPOGEN.......................42NEURONTIN......................79NEVANAC....................... 106nevirapine........................ 11NEW DAY....................... 129NEXAVAR......................... 20NEXIUM......................... 112NEXIUM IV..................... 112NEXIUM PACKET..............112NEXLETOL........................ 54

183

NEXLIZET.........................54NEXPLANON....................129niacin.............................. 54NIACOR........................... 54NIASPAN EXTENDED-RELEASE.......................... 54nicardipine....................... 54NICORELIEF..................... 34nicotine............................34nicotine (polacrilex)........... 34NICOTROL........................34NICOTROL NS...................34nifedipine......................... 54nikki (28)....................... 129nilutamide........................20nimodipine....................... 54NINLARO..........................20nisoldipine........................54nitisinone....................... 145NITRO-BID....................... 54nitrofurantoin macrocrystal.11nitrofurantoin monohyd/m-cryst................................11nitroglycerin................54, 55NITROMIST...................... 55NIVESTYM........................ 42nizatidine....................... 112NON-DROWSY ALLERGY2, 154NORA-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, 97NORMOSOL-M IN 5 % DEXTROSE....................... 97NORMOSOL-R................... 97NORMOSOL-R IN 5 % DEXTROSE....................... 97NORMOSOL-R PH 7.4.........97NORTREL 0.5/35 (28)...... 129NORTREL 1/35 (21)......... 129NORTREL 1/35 (28)......... 129NORTREL 7/7/7 (28)........ 130nortriptyline..................... 79NORVASC.........................55

NORVIR........................... 11NOURIANZ....................... 79NOVOEIGHT..................... 42NOVOLIN 70/30 U-100 INSULIN.........................130NOVOLIN 70-30 FLEXPEN U-100............................ 130NOVOLIN N FLEXPEN....... 130NOVOLIN N NPH U-100 INSULIN.........................130NOVOLIN R FLEXPEN........130NOVOLIN 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................... 130NUBEQA...........................20NUCALA......................... 154NUCYNTA......................... 79NUCYNTA ER.................... 79NUEDEXTA................ 79, 154NUPLAZID........................ 79NURTEC ODT.................... 79NUTROPIN AQ NUSPIN..... 130NUWIQ............................ 42NUZYRA........................... 11NYAMYC......................... 165NYMALIZE........................ 55nystatin...............11, 12, 165nystatin-triamcinolone......165NYSTOP......................... 165OBIZUR........................... 43OCALIVA........................ 112OCELLA..........................130OCREVUS....................... 145octreotide acetate............130OCUFLOX....................... 106ODACTRA.........................26ODEFSEY......................... 12OFEV............................. 154ofloxacin................... 12, 106OGESTREL (28)...............130olanzapine........................79olanzapine-fluoxetine.........79

olmesartan....................... 55olmesartan-amlodipin-hcthiazid.....................55, 97olmesartan-hydrochlorothiazide......55, 97olopatadine.....................106OLUMIANT......................145omega-3 acid ethyl esters.. 55omeprazole.....................112omeprazole-sodium bicarbonate.................... 112OMNARIS................ 106, 154OMNIPOD DASH 5 PACK POD................................ 91OMNIPOD INSULIN MANAGEMENT...................91OMNIPOD INSULIN REFILL..91OMNITROPE....................131ondansetron................... 113ondansetron hcl...............113ondansetron hcl (pf)........ 113ONETOUCH ULTRA TEST.....92ONETOUCH ULTRA2 METER 91ONETOUCH ULTRAMINI......91ONETOUCH VERIO FLEX METER............................. 91ONETOUCH VERIO IQ METER............................. 91ONETOUCH VERIO METER.. 91ONETOUCH VERIO TEST STRIPS............................ 92ONEXTON.......................165ONFI............................... 79ONGENTYS....................... 79ONGLYZA....................... 131ONMEL.............................12ONUREG.......................... 20ONZETRA XSAIL................79OPANA ER........................ 80OPCICON ONE-STEP........ 131OPSUMIT.................. 55, 154OPTION-2.......................131ORAVIG..........................165ORENCIA........................145ORENCIA (WITH MALTOSE).....................................145ORENCIA CLICKJECT........145ORENITRAM.............. 55, 154ORGOVYX................. 20, 131ORIAHNN....................... 131ORILISSA....................... 131ORKAMBI....................... 154orphenadrine citrate.......... 35ORSYTHIA...................... 131

184

oseltamivir....................... 12OSENI............................131OTEZLA...................145, 165OTEZLA STARTER.....145, 165OTIPRIO.........................106OTOVEL......................... 106OTREXUP (PF)........... 20, 145OVIDE............................165oxacillin........................... 12oxacillin in dextrose(iso-osm)............................... 12oxandrolone....................131oxaprozin......................... 80oxazepam........................ 80OXBRYTA......................... 43oxcarbazepine...................80OXERVATE......................106oxiconazole.....................165OXISTAT........................ 165OXTELLAR XR................... 80oxybutynin chloride......... 169oxycodone........................80OXYCODONE.................... 80oxycodone-acetaminophen. 80oxycodone-aspirin............. 80OXYCONTIN......................80oxymorphone................... 81OXYTROL........................169OZEMPIC........................131PALFORZIA (LEVEL 1)....... 26PALFORZIA (LEVEL 2)....... 26PALFORZIA (LEVEL 3)....... 26PALFORZIA (LEVEL 4)....... 26PALFORZIA (LEVEL 5)....... 26PALFORZIA (LEVEL 6)....... 26PALFORZIA (LEVEL 7)....... 26PALFORZIA (LEVEL 8)....... 26PALFORZIA (LEVEL 9)....... 26PALFORZIA (LEVEL 10)...... 26PALFORZIA (LEVEL 11 UP-DOSE)............................. 26PALFORZIA INITIAL DOSE.. 26PALFORZIA LEVEL 11 MAINTENANCE..................26paliperidone..................... 81palonosetron...................113PALYNZIQ.......................101pamidronate................... 145PANCREAZE.................... 113pantoprazole...................113paromomycin....................12paroxetine hcl...................81paroxetine mesylate(menop.sym)....... 81

PATADAY........................106PATANASE...................... 106PATANOL........................106PAXIL.............................. 81PAXIL CR......................... 81PAZEO........................... 106PCE................................. 12PEDIARIX (PF).................. 26PEDVAX HIB (PF).............. 26peg 3350-electrolytes...... 113PEGANONE....................... 81PEGASYS..........................12PEGASYS PROCLICK.......... 12peg-electrolyte soln......... 113PEGINTRON......................12PEMAZYRE........................20penicillamine........... 115, 145penicillin g potassium.........12penicillin g procaine........... 12penicillin g sodium.............12penicillin v potassium.........12PENLAC..........................165PENTACEL (PF)................. 27PENTACEL ACTHIB COMPONENT (PF).............. 27PENTACEL DTAP-IPV COMPNT (PF)....................27pentamidine..................... 12PENTASA........................113pentoxifylline.................... 43PERFOROMIST........... 35, 155perindopril erbumine..........55permethrin..................... 165perphenazine....................81perphenazine-amitriptyline. 81PERSERIS.........................81PERTZYE........................ 113PEXEVA............................81phenazopyridine.............. 165phenelzine........................81phenobarbital................... 81PHENYTEK.................. 55, 81phenytoin................... 55, 81phenytoin sodium........ 55, 81phenytoin sodium extended.................... 55, 81PHILITH......................... 131PHOSLO........................... 97PHOSLYRA........................97PHOSPHA 250 NEUTRAL..... 97PHOSPHOLINE IODIDE..... 106PHYSIOLYTE..................... 97

phytonadione (vitamin k1)..............................145, 170PIFELTRO......................... 12pilocarpine hcl........... 35, 106pimecrolimus........... 145, 166PIMTREA (28)................. 131pindolol...................... 35, 55pioglitazone.................... 131pioglitazone-glimepiride....131pioglitazone-metformin.... 131piperacillin-tazobactam...... 12PIQRAY............................ 20PIRMELLA....................... 131piroxicam......................... 81PLAN B ONE-STEP............131PLASMA-LYTE 148............. 97PLASMA-LYTE A................ 97PLAVIX............................ 43PLEGRIDY.......................145PNEUMOVAX-23................ 27PNV OB+DHA43, 97, 113, 170PNV-DHA.................. 43, 170PNV-OMEGA.........43, 97, 170PNV-SELECT..............43, 170podofilox........................ 166POLYCIN........................ 107polymyxin b sulfate........... 12polymyxin b sulf-trimethoprim...................107POMALYST................ 21, 145PORTIA 28......................131posaconazole.................... 13potassium chlorid-d5-0.45%nacl........................97potassium chloride............ 98potassium chloride in 0.9%nacl......................... 97potassium chloride in 5 % dex................................. 97potassium chloride in lr-d5. 98potassium chloride in water 98potassium chloride-0.45 % nacl.................................98potassium chloride-d5-0.2%nacl......................... 98potassium chloride-d5-0.3%nacl......................... 98potassium chloride-d5-0.9%nacl......................... 98potassium citrate.............. 98POTIGA............................82PR NATAL 400...... 43, 98, 170PR NATAL 400 EC. 43, 98, 170PR NATAL 430...... 43, 98, 171

185

PR NATAL 430 EC. 43, 98, 170PRADAXA......................... 43PRALUENT PEN................. 55pramipexole..................... 82PRANDIN........................131prasugrel......................... 43PRAVACHOL......................55pravastatin.......................55praziquantel..................... 13prazosin..................... 35, 55PRECISION XTRA KETONE-GLUCOSE......................... 91PRECISION XTRA MONITOR 91PRECISION XTRA TEST...... 92PRECOSE........................131prednicarbate..................166prednisolone................... 131prednisolone acetate........107prednisolone sodium phosphate............... 107, 131prednisone..................... 132PREDNISONE INTENSOL... 132pregabalin........................82PREMPHASE....................132PRENATABS FA.....43, 98, 171PRENATABS RX.... 43, 98, 171PRENATAL LOW IRON.......................... 43, 98, 171PRENATAL PLUS... 43, 98, 171PRENATAL PLUS (CALCIUM CARB).................43, 98, 171PRENATAL-U................... 171pretomanid.......................13PREVACID...................... 113PREVACID SOLUTAB........ 113PREVIFEM.......................132PREVNAR 13 (PF).............. 27PREZCOBIX............... 13, 146PREZISTA.........................13PRIFTIN........................... 13PRILOSEC.......................113primidone.........................82PRINIVIL..........................55PRISTIQ...........................82PRIVIGEN.........................27PROAIR DIGIHALER....35, 155PROAIR HFA.............. 35, 155PROAIR RESPICLICK...35, 155probenecid................ 99, 146probenecid-colchicine. 99, 146PROBUPHINE.................... 82procainamide....................56PROCARDIA......................56PROCARDIA XL................. 56

PROCENTRA..................... 82prochlorperazine........ 82, 114prochlorperazine edisylate............................... 82, 114prochlorperazine maleate............................... 82, 114PROCRIT.......................... 43PROCTOFOAM HC............ 166PROCTO-PAK.................. 166PROCTOZONE-HC............ 166PRODIGY NO CODING........92PRODIGY POCKET METER... 91PRODIGY VOICE GLUCOSE METER............................. 91PROFILNINE..................... 43progesterone micronized.. 132PROGRAF....................... 146PROLASTIN-C..................155PROLENSA......................107PROLIA.......................... 146PROMACTA..................43, 44promethazine.........2, 82, 155propafenone..................... 56proparacaine...................107propranolol............35, 56, 82propranolol-hydrochlorothiazid.. 35, 56, 99propylthiouracil............... 132PROQUAD (PF)..................27PROSCAR....................... 146PROTONIX...................... 114PROTOPIC...................... 166protriptyline......................82PROVENTIL HFA.........35, 155PROZAC........................... 82PULMICORT............. 132, 155PULMICORT FLEXHALER..............................132, 155PULMOZYME............ 101, 155PYLERA.....................13, 114pyrazinamide....................13pyridostigmine bromide......35QBRELIS.......................... 56QINLOCK......................... 21QNASL.................... 107, 155QTERN........................... 132QUADRACEL (PF)...............27QUDEXY XR...................... 82QUESTRAN....................... 56QUESTRAN LIGHT..............56quetiapine........................ 83QUILLICHEW ER................83QUILLIVANT XR.................83quinapril.......................... 56

quinapril-hydrochlorothiazide......56, 99quinidine gluconate...... 13, 56quinidine sulfate.......... 13, 56quinine sulfate.................. 13QUTENZA....................... 166QVAR REDIHALER.....132, 155RABAVERT (PF)................. 27rabeprazole.................... 114raloxifene................132, 146ramelteon........................ 83ramipril............................56RANEXA........................... 56ranolazine........................ 56RAPAFLO..........................35RAPAMUNE..................... 146RAVICTI...........................99RAZADYNE....................... 35RAZADYNE ER...................35REBETOL..........................13REBIF (WITH ALBUMIN)... 146REBIF REBIDOSE.............146REBIF TITRATION PACK....146REBINYN..........................44REBLOZYL........................ 44RECLIPSEN (28).............. 132RECOMBINATE.................. 44RECOMBIVAX HB (PF)........ 27RECTIV.......................... 166RELENZA DISKHALER.........13RELPAX............................83REMERON.........................83REMERON SOLTAB.............83REMICADE....... 114, 146, 166RENAGEL.................. 99, 146RENAL CAPS................... 171RENA-VITE RX.................171RENFLEXIS.......114, 146, 166RENO CAPS.................... 171RENVELA.................. 99, 146repaglinide..................... 132repaglinide-metformin......132REPATHA PUSHTRONEX......56REPATHA SURECLICK.........56REPATHA SYRINGE............ 56REQUIP............................83REQUIP XL....................... 83RESCRIPTOR.................... 13RESTASIS.......................107RESTASIS MULTIDOSE..... 107RETACRIT........................ 44RETEVMO......................... 21RETIN-A......................... 166RETIN-A MICRO...............166

186

RETIN-A MICRO PUMP...... 166RETROVIR........................ 13REVATIO...................57, 155REVCOVI........................ 101REVLIMID................. 21, 146REXULTI.......................... 83REYVOW.......................... 83RHOPRESSA....................107RIBASPHERE.....................13RIBASPHERE RIBAPAK....... 13ribavirin........................... 13rifabutin...........................13rifampin........................... 13RIFATER...........................13riluzole............................ 83rimantadine......................13ringer's............................ 99RINVOQ......................... 146risedronate..................... 146RISPERDAL.......................83RISPERDAL CONSTA.......... 83risperidone....................... 83RITALIN........................... 83RITALIN LA.......................83ritonavir...........................13RITUXAN HYCELA.............. 21rivastigmine..................... 35rivastigmine tartrate..........35RIXUBIS.......................... 44rizatriptan........................ 83ROCKLATAN....................107ropinirole......................... 84rosuvastatin..................... 57ROTARIX..........................27ROTATEQ VACCINE............27ROWASA........................ 114ROWEEPRA.......................84ROWEEPRA XR..................84ROZEREM.........................84ROZLYTREK...................... 21RUBRACA......................... 21RUCONEST..................... 146rufinamide........................84RUKOBIA......................... 13RUZURGI........................146RYBELSUS...................... 132RYDAPT........................... 21RYTARY............................84SABRIL............................ 84SAIZEN.......................... 132SAIZEN SAIZENPREP........132salicylic acid....................166salsalate.......................... 84SANCUSO.......................114

SANDIMMUNE................. 146SANTYL..........................166SAPHRIS.......................... 84SARAFEM......................... 84SAVAYSA......................... 44SAVELLA.......................... 84scopolamine base............ 114SECUADO.........................84SEEBRI NEOHALER............ 35SEGLUROMET..................132selegiline hcl.....................84SELZENTRY...................... 13SEMGLEE PEN U-100 INSULIN.........................133SEMGLEE U-100 INSULIN. 133SEMPREX-D........... 2, 35, 155SE-NATAL 19 CHEWABLE............................... 44, 171SEREVENT DISKUS.....36, 156SEROQUEL....................... 84SEROQUEL XR.................. 84SEROSTIM......................133sertraline......................... 84SETLAKIN.......................133sevelamer carbonate.. 99, 147sevelamer hcl............ 99, 147SF................................. 147SF 5000 PLUS................. 147SFROWASA.....................114SHINGRIX (PF)................. 27SHINGRIX ADJUVANT COMPONENT-PF.............. 148SHINGRIX GE ANTIGEN COMPONENT.....................27SIGNIFOR.......................133SIKLOS............................21sildenafil (pulm.hypertension)...57, 156SILIQ.............................166silodosin.......................... 36silver nitrate................... 166silver sulfadiazine............ 166SIMBRINZA.....................107SIMPONI................. 114, 147SIMPONI ARIA......... 114, 147simvastatin.......................57SINEMET..........................84SINEMET CR..................... 84SINGULAIR..................... 156SINUVA...................107, 156sirolimus........................ 147SIRTURO..........................13SITAVIG...........................14SKLICE...........................166

SKYRIZI..................166, 167sodium bicarbonate........... 99sodium chlor 0.9% bacteriostat...................... 99sodium chloride.................99sodium chloride 0.45 %..... 99sodium chloride 0.9 %....... 99sodium chloride 0.9 % (flush)........................92, 99sodium chloride 3 %.......... 99sodium chloride 5 %.......... 99sodium citrate-citric acid.... 99sodium lactate................ 100sodium phenylbutyrate.....100sodium polystyrene sulfonate.................100, 147sofosbuvir-velpatasvir........14solifenacin...................... 169SOLIQUA 100/33.............133SOLOSEC......................... 14SOLU-CORTEF.................133SOLU-CORTEF ACT-O-VIAL (PF)...............................133SOLU-MEDROL................ 133SOLU-MEDROL (PF)......... 133SOMATULINE DEPOT........133SONATA...........................84SORINE...................... 36, 57sotalol........................36, 57SOTALOL AF................36, 57SOTYLIZE................... 36, 57SOVALDI..........................14spinosad.........................167SPIRIVA RESPIMAT.... 36, 156SPIRIVA WITH HANDIHALER.............36, 156spironolactone........... 57, 100spironolacton-hydrochlorothiaz........ 57, 100SPORANOX.......................14SPRAVATO....................... 84SPRINTEC (28)................133SPRITAM..........................85SPRYCEL.......................... 21SPS (WITH SORBITOL)..............................100, 147SRONYX......................... 133SSD...............................167SSS 10-5........................167STALEVO 100................... 85STALEVO 125................... 85STALEVO 150................... 85STALEVO 200................... 85STALEVO 50..................... 85

187

STALEVO 75..................... 85STAMARIL (PF)................. 27stavudine......................... 14STEGLATRO.................... 133STEGLUJAN.................... 133STELARA................. 147, 167STIOLTO RESPIMAT....36, 156STIVARGA........................ 21STRATTERA...................... 85STRENSIQ...................... 101STRIANT........................ 133STRIBILD......................... 14STRIVERDI RESPIMAT.36, 156SUBLOCADE..................... 85SUBOXONE.......................85sucralfate....................... 114SULAR............................. 57sulfacetamide sodium107, 167sulfacetamide sodium (acne)............................167sulfacetamide sodium-sulfur.............................167sulfacetamide sod-sulfur-urea.............................. 167sulfacetamide-prednisolone.....................................107sulfadiazine...................... 14sulfamethoxazole-trimethoprim.................... 14sulfasalazine...... 14, 114, 147sulindac........................... 85sumatriptan......................85sumatriptan succinate........85sumatriptan-naproxen....... 85SUPPRELIN LA........... 21, 133SUPRAX........................... 14SUTENT........................... 21SYEDA........................... 133SYLATRON.................. 14, 21SYMBICORT 36, 133, 134, 156SYMBYAX......................... 85SYMDEKO.......................156SYMJEPI................... 36, 156SYMLINPEN 120.............. 134SYMLINPEN 60................ 134SYMPAZAN....................... 86SYMTUZA......................... 14SYNAGIS..........................14SYNJARDY...................... 134SYNJARDY XR................. 134TABLOID.......................... 21TABRECTA........................21tacrolimus............... 147, 167

tadalafil (pulm. hypertension)............ 57, 156TAFINLAR.........................21TAGRISSO........................21TAKE ACTION..................134TAKHZYRO..................... 147TALTZ AUTOINJECTOR..... 167TALTZ AUTOINJECTOR (2 PACK)............................ 167TALTZ AUTOINJECTOR (3 PACK)............................ 167TALTZ SYRINGE.............. 167TALZENNA........................21TAMIFLU.......................... 14tamoxifen................. 21, 134tamsulosin....................... 36TARGRETIN............... 21, 167tarina fe 1/20 (28)...........134TARKA............................. 57TASIGNA..........................21tavaborole...................... 167tazarotene......................167TAZORAC....................... 167TAZTIA XT........................57TAZVERIK........................ 21TECFIDERA.....................147TEGRETOL........................86TEGRETOL XR................... 86TEKTURNA....................... 57TEKTURNA HCT..........57, 100telmisartan.......................57telmisartan-amlodipine...... 57telmisartan-hydrochlorothiazid......57, 100temazepam...................... 86temozolomide................... 21TENIVAC (PF)................... 27tenofovir disoproxil fumarate..........................14TENORETIC 100... 36, 57, 100TENORETIC 50..... 36, 58, 100TENORMIN..................36, 58TEPMETKO....................... 21terazosin.................... 36, 58terbinafine hcl........... 15, 168terbutaline................ 36, 156terconazole.....................168teriparatide............. 134, 147TESTIM.......................... 134TESTOSTERONE.............. 134testosterone................... 134testosterone cypionate..... 134testosterone enanthate.... 134

tetanus,diphtheria tox ped(pf)............................ 28tetanus-diphtheria toxoids-td....................................28tetrabenazine................... 86tetracaine hcl..................107tetracycline...................... 15THALOMID......................147theophylline 58, 100, 156, 169thioridazine...................... 86thiothixene....................... 86THYQUIDITY................... 134tiagabine..........................86TIAZAC............................ 58TIBSOVO..........................22TICANASE............... 107, 156TILIA FE......................... 134timolol maleate.................... 36, 58, 86, 107TIMOPTIC.......................107TIMOPTIC OCUDOSE (PF). 107TIMOPTIC-XE.................. 108tinidazole......................... 15tiopronin........................ 147TIVICAY........................... 15TIVICAY PD...................... 15tizanidine......................... 36TOBI............................... 15TOBI PODHALER............... 15TOBRADEX..................... 108tobramycin................15, 108tobramycin in 0.225 % nacl.................................15tobramycin in 0.9 % nacl... 15tobramycin sulfate.............15tobramycin with nebulizer...15tobramycin-dexamethasone...............108tolazamide......................134tolbutamide.................... 134tolcapone......................... 86tolmetin........................... 86tolnaftate....................... 168TOLSURA......................... 15tolterodine......................169TOPAMAX.........................86topiramate....................... 86TOPROL XL................. 36, 58toremifene....................... 22torsemide................. 58, 100TOSYMRA.........................86TOUJEO MAX U-300 SOLOSTAR......................135

188

TOUJEO SOLOSTAR U-300 INSULIN.........................135TOVIAZ.......................... 169TRACLEER.................58, 157TRADJENTA.................... 135tramadol.......................... 86tramadol-acetaminophen....86trandolapril.......................58trandolapril-verapamil........58tranexamic acid................ 44tranylcypromine................ 86TRAVATAN Z................... 108travoprost...................... 108trazodone.........................86TRELEGY ELLIPTA............ 157TREMFYA........................168TRESIBA FLEXTOUCH U-100............................... 135TRESIBA FLEXTOUCH U-200............................... 135TRESIBA U-100 INSULIN.. 135tretinoin......................... 168tretinoin (antineoplastic).... 22tretinoin microspheres......168TRETTEN..........................44TREXIMET........................ 86TRIADVANCE......44, 100, 171triamcinolone acetonide....168triamterene-hydrochlorothiazid......58, 100triazolam..........................86TRIBENZOR...............58, 100TRICITRATES.................. 100TRICOR............................58TRI-ESTARYLLA...............135trifluoperazine.................. 86TRIGLIDE......................... 58trihexyphenidyl...... 36, 37, 87TRIJARDY XR.................. 135TRIKAFTA....................... 157TRI-LEGEST FE................135TRILEPTAL........................87TRI-LINYAH.................... 135TRILIPIX.......................... 58tri-lo-estarylla................. 135tri-lo-sprintec..................135trimethobenzamide..........114trimethoprim.................... 15TRINATAL RX 1...44, 100, 171TRINATE............44, 100, 171TRINTELLIX...................... 87TRI-PREVIFEM (28)..........135TRIPTODUR.................... 135TRI-SPRINTEC (28)..........135

TRIUMEQ......................... 15TRIVEEN-ONE.....44, 100, 171TRI-VITAMIN WITH FLUORIDE............... 148, 171TRIVORA (28)................. 135TROGARZO.......................15TROKENDI XR...................87trospium........................ 169TRUE METRIX AIR GLUCOSE METER...............92TRUE METRIX GLUCOSE METER............................. 92TRUE METRIX GLUCOSE TEST STRIP...................... 92TRULICITY......................135TRUMENBA.......................28TRUSOPT........................108TUDORZA PRESSAIR........ 157TUKYSA........................... 22TURALIO.......................... 22TWINRIX (PF)................... 28TWYNSTA.........................58TYMLOS.................. 135, 148TYPHIM VI........................28TYSABRI.........................148TYVASO.................... 58, 157TYVASO INSTITUTIONAL START KIT................ 59, 157TYVASO REFILL KIT....59, 157TYVASO STARTER KIT.59, 157UBRELVY..........................87UCERIS.......................... 135UDENYCA......................... 44UNITHROID.................... 136unithroid........................ 136UPTRAVI................... 59, 157urea.............................. 168ursodiol..........................114UTIBRON NEOHALER.. 37, 157valacyclovir...................... 15VALCHLOR................ 22, 168valganciclovir....................15valproate sodium.............. 87valproic acid..................... 87valproic acid (as sodium salt)................................ 87valsartan..........................59valsartan-hydrochlorothiazide.... 59, 101VALTOCO......................... 87VALTREX..........................15VANCOCIN....................... 15vancomycin...................... 15VANDAZOLE....................168

VANTAS....................22, 136VAQTA (PF)...................... 28VARIVAX (PF)................... 28VARIZIG.......................... 28VARUBI..........................114VASCEPA..........................59VASERETIC............... 59, 101vasopressin.................... 136VASOTEC......................... 59VAXCHORA ACTIVE COMPONENT.....................28VAXCHORA BUFFER COMPONENT...................148VAXCHORA VACCINE......... 28VAXELIS (PF)....................28VECTIBIX......................... 22VELIVET TRIPHASIC REGIMEN (28).................136VELPHORO......................101VELTASSA...................... 101VEMLIDY.......................... 15VENA-BAL DHA...44, 101, 171VENCLEXTA...................... 22VENCLEXTA STARTING PACK............................... 22venlafaxine.......................87VENTAVIS................. 59, 157VENTOLIN HFA.......... 37, 157VERAMYST.............. 108, 157verapamil.........................59VERELAN..........................59VERELAN PM.....................59VERSACLOZ......................87VERZENIO........................22VESICARE.......................169VESICARE LS.................. 169VFEND............................. 15VIBERZI......................... 115VICTOZA 2-PAK...............136VICTOZA 3-PAK...............136VIEKIRA PAK.................... 15VIENVA.......................... 136vigabatrin.........................87VIGADRONE..................... 87VIGAMOX....................... 108VIIBRYD...........................87VIMIZIM.........................101VIMOVO....................87, 115VIMPAT............................88VINATE CARE............ 44, 171VINATE GT................ 44, 171VINATE II....................... 171VINATE M................. 44, 171VINATE ONE.......44, 101, 171

189

VINATE PN CARE............. 171VIOKACE........................ 115VIORELE (28)..................136VIRACEPT.........................16VIREAD............................16VIRT-PN....................44, 171VIRT-PN DHA.............44, 171VIRT-PN PLUS.... 45, 101, 171VISTOGARD....................148VITAFOL-OB.......45, 101, 172VITAMIN D2....................172VITAMINS A,C,D AND FLUORIDE............... 148, 172VITRAKVI......................... 22VIVOTIF...........................28VIZIMPRO........................ 22VOGELXO....................... 136VOL-NATE..........45, 101, 172VONVENDI....................... 45voriconazole..................... 16VOSEVI............................16VOTRIENT........................ 22VPRIV............................ 102VRAYLAR..........................88VUMERITY...................... 148VUSION......................... 168VYEPTI.............................88VYNDAMAX.......................59VYNDAQEL....................... 59VYTORIN 10-10.................59VYTORIN 10-20.................59VYTORIN 10-40.................59VYTORIN 10-80.................60VYVANSE......................... 88VYZULTA........................ 108WAL-ZYR (CETIRIZINE) 2, 157warfarin........................... 45water for irrigation, sterile 101WAVESENSE PRESTO.........92WELCHOL..................60, 136WELLBUTRIN SR............... 88WELLBUTRIN XL................88WERA (28)..................... 136WILATE............................45WIXELA INHUB...37, 136, 157WYMZYA FE.................... 136XADAGO.......................... 88XALATAN........................108XALKORI.......................... 22XARELTO..........................45XARELTO DVT-PE TREAT 30D START.......................45XCOPRI............................88

XCOPRI MAINTENANCE PACK............................... 88XCOPRI TITRATION PACK... 88XELJANZ........................ 148XELJANZ XR....................148XELPROS........................108XENLETA..........................16XEPI.............................. 168XERESE..........................168XHANCE..................108, 158XIFAXAN.......................... 16XIGDUO XR.................... 136XOFLUZA......................... 16XOLAIR.......................... 158XOPENEX.................. 37, 158XOPENEX CONCENTRATE............................... 37, 158XOPENEX HFA............37, 158XOSPATA......................... 22XPOVIO........................... 22XTAMPZA ER.....................88XTANDI...................... 22, 23XULANE..........................136XULTOPHY 100/3.6.......... 136XYNTHA........................... 45XYNTHA SOLOFUSE........... 45YF-VAX (PF)......................28YONDELIS........................ 23YUPELRI...........................37yuvafem.........................136ZADITOR........................108zafirlukast...................... 158zaleplon........................... 89ZARAH........................... 136ZARONTIN........................89ZARXIO............................45ZATEAN-PN DHA........ 45, 172ZATEAN-PN PLUS 45, 101, 172ZEGERID........................ 115ZEGERID OTC................. 115ZEJULA............................ 23ZELBORAF........................23ZEMBRACE SYMTOUCH...... 89ZENATANE......................168ZENCHENT (28)...............137ZENPEP..........................115ZENZEDI..........................89ZEPATIER.........................16ZEPOSIA........................ 148ZEPOSIA STARTER KIT.....148ZEPOSIA STARTER PACK.. 148ZERVIATE.......................108ZESTORETIC............. 60, 101ZESTRIL...........................60

ZETIA.............................. 60ZETONNA................ 108, 158ZIAC...................37, 60, 101ZIANA............................168zidovudine........................16zileuton..........................158ZIOPTAN (PF)................. 108ziprasidone hcl..................89ziprasidone mesylate......... 89ZIPSOR............................89ZIRGAN..........................108ZITHROMAX..................... 16ZITHROMAX TRI-PAK......... 16ZOCOR............................ 60ZOFRAN......................... 115ZOFRAN ODT.................. 115ZOHYDRO ER....................89ZOKINVY........................148ZOLINZA..........................23zolmitriptan......................89ZOLOFT........................... 89zolpidem.......................... 89ZOLPIMIST....................... 89ZOMACTON.....................137ZOMIG.............................89ZOMIG ZMT......................89zonisamide....................... 89ZONTIVITY....................... 45ZORBTIVE...................... 137ZORTRESS......................148ZORVOLEX....................... 89ZOSTAVAX (PF).................28ZOVIA 1/35E (28)............137ZOVIRAX.................. 16, 168ZTLIDO.......................... 168ZUBSOLV......................... 89ZUPLENZ........................115ZYBAN............................. 90ZYDELIG.......................... 23ZYFLO............................158ZYFLO CR....................... 158ZYKADIA..........................23ZYLET............................ 108ZYMAXID........................108ZYPITAMAG...................... 60ZYPREXA..........................90ZYPREXA RELPREVV...........90ZYPREXA ZYDIS................ 90

190

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) 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) levonorgestrel (PLAN B) meclizine phenazopyridine (AZO) male condoms

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 (09/2021)

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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