2020 年 prime 處方一覽表（承保藥品清單） - health net...月 31...

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Health Net Seniority Plus Employer (HMO)

2020 年 Prime 處方一覽表（承保藥品清單）

請閱讀：本文件內含

本計畫承保藥品的相關資訊

HPMS 核准的處方一覽表檔案遞交 ID 20448，版本編號 23

本處方一覽表在 12/01/2020 更新。如需更多近期資訊或有其他問題，請與 Health Net Seniority

Plus Employer (HMO) 聯絡：1-800-275-4737，或聯絡聽障專線 711。服務時間從 10 月 1 日至 3

月 31 日，每週七天上午 8 點至晚上 8 點，從 4 月 1 日至 9 月 30 日，週一至週五上午 8 點至晚上

8 點。在非營業時間、週末及聯邦法定假日，我們將會使用留言系統，或者請瀏覽

healthnet.com。

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既有會員請注意：本處方一覽表自去年以來已有變動。請查閱本文件以確定您所服用的藥品仍

包含在內。

當本藥品清單（處方一覽表）提到「我們」或「我們的」時，均指 Health Net of California, Inc.

和 Health Net Community Solutions, Inc.。當其提到「計畫」或「我們的計畫」，均指 Health Net

Seniority Plus Employer (HMO)。

本文件包含我們的計畫之藥品清單（處方一覽表），最近更新日期為 12/01/2020。若需要更新的

處方一覽表，請與我們聯絡。我們的聯絡資訊與處方一覽表的最近更新日期都列於封面與封底。

通常，您必須使用網絡藥房才能享用您的處方藥福利。福利、處方一覽表、藥房網絡和 (或) 共

付額／共同保險金可能在 2021 年 1 月 1 日變更，並在年度當中不定時變動。

什麼是 Health Net Seniority Plus Employer (HMO) 處方一覽表？

處方一覽表是我們的計畫諮詢醫療保健服務提供者後選出的承保藥品清單，涵蓋所有我們認為高

品質治療方案之處方治療所必須的藥品。只要藥品為醫療所必需、於計畫網絡藥房領取處方以及

遵守其他計畫規定，我們通常承保在我們的處方一覽表中列出的藥品。若需有關如何獲得處方藥

的更多資訊，請查閱您的承保範圍證明。

處方一覽表（藥品清單）會變更嗎？

藥品承保範圍的大多數變更均發生在 1 月 1 日，但我們可能會在年度當中新增或移除藥品清單上

的藥品、將其移至不同的費用分攤層級，或新增限制。進行這些變更時，我們必須遵循

Medicare 規定。

今年可能影響您的變更：在下述情況下，承保範圍變更會在該年度當中對您造成影響：

• 新的普通牌藥品。如果我們以列於相同或更低分攤費用層級、且限制相同或更低的新的

普通牌藥品替換，我們可能立即將藥品清單上的品牌藥品移除。此外，在增加新的普通牌

藥品時，我們可能決定保留藥品清單上的品牌藥品，但立即將其移至不同的費用分攤層級

或新增限制。如果您目前正使用該品牌藥品，我們可能未在進行變更前事先告知，但我們

之後會提供您我們所做具體變更的相關資訊。

o 如果我們做出這類變更，您或您的開立處方者可要求我們為您進行例外處理，繼續

為您承保該品牌藥品。我們提供您的通知也將包含如何申請例外處理的資訊，且您

也可在以下章節找到資訊，標題為「我如何要求 Health Net Seniority Plus Employer

(HMO) 處方一覽表的例外情況處理？」

• 藥品遭下架。若食品藥物管理局 (Food and Drug Administration, FDA) 認為我們的處方一

覽表上的某藥品不安全或製藥商將此藥品下架，我們將立刻將此藥品從我們的處方一覽表

上除名，並通知服用此藥品的會員。

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• 其他變更。我們可能實施會影響目前用藥之會員的其他變更。例如，我們可能增加不是

新上市的普通牌藥品，以取代目前在處方一覽表上的品牌藥品，或對品牌藥品增加新的限

制或移到不同的費用分攤層級。或者，我們可能基於新的臨床準則進行變更。若我們從我

們的處方一覽表除去藥品，或對某藥品新增事先授權、數量限制和 (或) 階段療法限制

（或將某藥品轉移到較高的費用分攤層級），我們必須在變更生效至少 30 天前，或在會

員要求續配該藥品處方時，通知受影響的會員，且在續配處方時，該會員可拿到此藥品

30 天的用量。

o 如果我們做出這類其他變更，您或您的開立處方者可要求我們為您進行例外處理，

繼續為您承保該品牌藥品。我們提供您的通知也將包含如何申請例外處理的資訊，

且您也可在以下章節找到資訊，標題為「我如何要求 Health Net Seniority Plus

Employer (HMO) 處方一覽表的例外情況處理？」

如果您目前正在使用該藥物，變更就不會對您造成影響。通常，若您使用我們 2020 年處方一覽

表上在年初受承保的藥品，我們將不會在 2020 承保年度終止或減低承保，但上述情況除外。也

就是說，對於在剩餘承保年度中繼續使用此藥品的會員，這些藥物的分攤費用將維持不變，且無

新的限制。

隨附處方一覽表，最近更新日期為 12/01/2020。若要取得我們計畫承保藥品的更新資訊，請聯絡

我們。我們的聯絡資訊列於封面與封底。

如果我們對您在使用的藥品做出任何其他負面變更，我們將透過信件通知您。我們也將於我們的

網站上公告該變更。

我要如何使用處方一覽表？

有兩個方法可以在處方一覽表中找到您的藥品：

醫療狀況

處方一覽表從第 1 頁開始。本處方一覽表中藥品的分類方式，是按藥品用以治療的醫療狀況

類型而分為類別。例如，用於治療心臟病況的藥品列於此分類下：「CARDIOVASCULAR

AGENTS-MISC. - Drugs to Treat Heart and Circulation Conditions」。若您知道您的藥品用途，

請在第 1 頁開始的清單上找尋類別名稱。然後在此類別名稱下找出您的藥品。

按英文字母順序排列的清單

若您不確定要查找哪個類別，則應在 Index 1 頁開始的索引中查找您的藥名。該索引依英文

字母順序列出本文件所包含的所有藥品。品牌藥品及普通牌藥品都列在此索引中。在索引中

找出您的藥品。您將在您的藥品旁看到頁碼，此頁碼引導您找到此藥品的承保資訊。翻到索

引所標示的頁數，在清單的第一欄找到您的藥品名稱。

iii

什麼是普通牌藥品？

我們的計畫同時承保品牌藥品和普通牌藥品。普通牌藥品是經 FDA 核准與品牌藥品具備相

同活性成分的藥品。通常，普通藥品的費用低於品牌藥品。

我的承保是否有任何限制？

某些承保藥品可能在承保方面有額外要求或限制。這些要求和限制可能包括：

• 事先授權：我們的計畫要求您或您的醫師針對特定藥品取得事先授權。這表示您拿處方

箋配藥前，需得到我們的核准。如果您未獲得核准，本計畫可能無法承保該藥品。

• 藥量限制：對於某些藥品，我們的計畫限制對此藥品所承保的數量。例如，我們的計畫

提供每個 simvastatin 40 mg 處方箋每日各一錠藥。這可能是對標準一個月或三個月供應量

之外所提供的額外量。

• 階段療法：某些情況下，我們的計畫要求您在我們承保治療相同病況的其他藥品前，先

試用某些藥品治療您的醫療狀況。例如，如果藥品 A 及藥品 B 均可治療您的醫療狀況，

我們可能要求您首先嘗試藥品 A 後，才會承保藥品 B。如果藥品 A 對您無效，我們之後

才會承保藥品 B。

您可以在從第 1 頁開始的處方一覽表中找出您的藥品是否有任何額外要求或限制。您也可以瀏覽

我們的網站，得到對特定承保藥品所加限制的更多資訊。我們已在網站上發布了解釋我們的事先

授權及階段療法限制的文件。您也可要求我們將這些文件的複本寄給您。我們的聯絡資訊與處方

一覽表的最近更新日期都列於封面與封底。

您可以要求我們針對這些藥品的限制或限額，或對可能治療您健康狀況之其他、類似藥品清單做

出例外情況處理。請參閱「我如何要求 Health Net Seniority Plus Employer (HMO) 處方一覽表的

例外情況處理？」章節，其位於第 iv 頁，以了解如何要求例外處理的資訊。

如果我的藥品不在處方一覽表上怎麼辦？

如果您的藥品不包含在此處方一覽表（承保藥品清單）中，您應首先與會員服務部聯絡，詢問該

藥品是否承保。

如果您被告知我們的計畫不承保此藥品，您有兩個選項：

• 您可向會員服務部索取我們的計畫承保之類似藥品的清單。您收到此清單後，請將清單拿

給您的醫師並請其開立我們所承保之類似藥品的處方。

• 您可要求我們做出例外情況處理並承保您的藥品。請參閱下列資訊瞭解如何要求例外情況

處理。

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我如何要求 Health Net Seniority Plus Employer (HMO) 處方一覽表的例外情況處

理？

您可要求我們針對我們的承保規定進行例外情況處理。有數種類型的例外情況您可以要求我們做

出處理。

• 您可以要求我們承保某藥品，即便此藥品不在我們的處方一覽表上。若經核准，此藥品將

以預先決定的費用分攤層級承保，您不得要求我們以更低的費用分攤層級提供此藥品。

• 若處方一覽表上某藥品不屬於專科層級，您可以要求以更低的費用分攤層級來承保此藥

品。若經核准，這將會降低您必須對您的藥品付出的金額。

• 您可以要求我們取消對您藥品的承保限制或限額。例如：對於某些藥品，我們的計畫限制

對此藥品所承保的數量。若您的藥品有數量上的限制，可以要求我們取消此限制並承保較

大的數量。

通常，我們將只在下列情況下才會核准您所要求的例外情況：若該計畫處方一覽表上包括數種替

代藥品、費用分攤較低藥品或額外的使用限制會對治療您的病況無效和 (或) 可能對您造成不良

的醫療效果。

您應該聯絡我們取得關於處方一覽表、層級或使用限制例外情況的最初承保決定。您要求處方

一覽表、藥品層級或使用限制的例外情況時，應遞交支援您要求的開立處方者或醫師所提供的

聲明。通常，我們必須在收到您的開立處方者之支援聲明 72 小時內做出決定。若您或您的醫師

認為等候 72 小時才做決定對您的健康可能造成嚴重危害，您可以要求加快 (快速) 例外情況審

核。若您的加快要求得到准許，我們必須在收到您醫師或其他開立處方者的支援聲明後 24 小時

內告知您我們的決定。

在與自己的醫師討論變更我自己的藥品或要求例外情況之前，我該做什麼？

身為我們計畫的全新或續保會員，您可能正在服用未包含在我們處方一覽表上的藥品。或者，您

可能正在服用我們處方一覽表所包含的藥品，但您取得該藥時收到限制。例如，您可能需取得我

們的事先授權，才能領取您的處方藥。您應該洽詢您的醫師，決定您是否應該改用我們承保的適

合藥品，或要求處方一覽表例外情況處理以便我們承保您服用的藥品。與您的醫師討論並決定對

您來說正確的行動時，我們可能在特定情況下，在您成為我們的計畫會員最初的 90 天內承保您

的藥品。

針對您的每個非我們處方一覽表中的藥品，或您對此藥品的取得受到限制時，我們將承保暫時性

的 30 天用藥量。如果您處方開立的天數較短，我們將允許您多次續配處方，直到我們為您提供

的藥量達到 30 天份上限為止。您最初 30 天的用藥量用完後，我們將不再對這些藥品付費，即便

您成為該計畫的會員不到 90 天。

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如果您是長期照護機構的住民，且需要未含在我們處方一覽表上的藥品或如果您取得藥品的能力

受到限制，但您已成為我們的計畫會員超過 90 天，在您申請處方一覽表例外情況期間，我們將

支付該藥品 31 天的緊急情況用量。

照護層級變更

如果您的照護層級有所變更，我們將會為您承保您藥品的過渡藥量。當您從醫院出院，或遷入或

遷出長期照護機構時，就會發生照護層級變更。

• 如果您自長期照護機構或醫院遷返家中並需要過渡藥量，我們將會為您承保一次 30 天份的藥

量。如果您處方開立的天數較短，則我們將會允許您多次續配處方，直到我們為您提供的總

藥量達到 30 天份為止。

• 如果您從自家或醫院遷入長期照護機構並需要過渡藥量，我們將會為您承保一次 31 天份的藥

量。如果您處方開立的天數較短，則我們將會允許您多次續配處方，直到我們為您提供的總

藥量達到 31 天份為止。

獲取更多資訊

欲獲得有關您計畫的處方藥品承保的更多詳細資訊，請參閱您的承保範圍證明及其他計畫材料。

如果您有關於我們計畫的疑問，請聯絡我們。我們的聯絡資訊與處方一覽表的最近更新日期都列

於封面與封底。

若您對 Medicare 處方藥品承保有任何一般性疑問，請與 Medicare 聯絡，致電：

1-800-MEDICARE (1-800-633-4227)，每天 24 小時／每週 7 天提供服務。聽障專線使用者請致電

1-877-486-2048。或瀏覽 http://www.medicare.gov。

Health Net Seniority Plus Employer (HMO) 處方一覽表

第 1 頁開始的處方一覽表提供有關我們的計畫所承保藥品的承保資訊。如果您在該清單中找不到

您的藥品，您可轉到索引，從 Index 1 頁開始查閱索引。

表格第一欄所列的是藥品名稱。品牌藥品以大寫字母表示（如 ELIQUIS TABS），普通牌藥品則

以斜體小寫字母表示（如 warfarin sodium tabs）。

要求／限制欄位的資訊告訴您，我們的計畫對您藥品的承保是否有任何特殊要求。

vi

縮寫

下列為處方一覽表的要求／限制欄中可能會出現的縮寫。

縮寫定義說明

AL 年齡限制如果您的年齡不符合製藥商、FDA 或臨床建議，此類藥品可

能需要事先授權。

B/D Medicare B 部

分或 D 部分

此類藥品可能視情況屬於 Medicare B 部分或 D 部分的承保範

圍。可能需要提交資訊，說明該藥品的使用和設置情況，以

做出決定。

LA 取得來源有限該處方可能只能在特定的藥房取得。如需更多資訊，請查閱

您的醫療服務提供者與藥房名錄，或致電會員服務部，服務

時間：從 10 月 1 日至 3 月 31 日，每週七天，每天上午 8 點

至晚上 8 點；從 4 月 1 日至 9 月 30 日，週一至週五上午 8 點

至晚上 8 點。我們的聯絡資訊列於封面與封底。聽障專線使

用者請致電 711。

MO 郵購除了其他網絡藥房之外，您也可以透過我們的郵購藥房獲得

此類藥品。

NDS 不提供延長天

數藥量

此處方藥品不提供延長天數藥量。請致電會員服務部，詢問

藥品是否提供延長天數藥量。

NT Non-TrOOP 僅適用於某些 Health Net Seniority Plus Employer (HMO) 計

畫：此類處方藥通常不屬於 Medicare 處方藥計畫承保範圍。

您在為此類藥品領取處方藥時所支付的費用將不計入您的總

藥品費用中（也就是說，您所支付的費用對您取得重大傷病

承保範圍資格並沒有幫助）。此外，如果您正在接受額外協

助來支付您的處方藥費用，您將不會得到任何支付此類藥品

費用的任何額外協助。藥量限制可能適用。

PA 事先授權此類藥品需要事先授權。這表示您或您的開立處方者必須先

取得我們的核准後，您才可以獲得處方藥。如果您未獲得核

准，本計畫可能無法承保該藥品。

QL 藥量限制我們針對此類藥品設有承保藥量限制。例如，我們承保每個

simvastatin 40 mg 處方箋每日一錠。這可能是對標準一個月或

三個月供應量限制之外的附加量。

vii

縮寫定義說明

RX/OTC 處方和非處方

藥 (OTC) 藥品

此類藥品可用處方形式和 OTC 形式提供。除了某些胰島素和

胰島素用品外，只有處方藥品受到我們 Medicare D 部分計畫

承保。

SL 安全限制基於獲得 FDA 證實的安全因素考量，此類藥品有每日劑量上

限限制。這代表我們將不會承保超過每日劑量上限的藥量。

例如，FDA 規定每日劑量上限對於 ibuprofen 為 3200 毫克。

因此，我們將僅會承保每天四錠的 ibuprofen 800 mg。

ST 階段療法此類藥品需要遵守階段療法規定。這表示您必須先嘗試使用

特定藥品治療您的醫療狀況，然後我們才會為該病況承保另

一種藥品。

例如，如果藥品 A 及藥品 B 均可治療您的醫療狀況，我們可

能要求您首先嘗試藥品 A 後，才會承保藥品 B。如果藥品 A

對您無效，我們之後才會承保藥品 B。

* 額外缺口承保我們提供承保缺口中此類處方藥的額外承保。若需此類承保

的更多資訊，請參閱您的承保範圍證明。

+ 額外缺口承保僅適用於某些 Health Net Seniority Plus Employer (HMO) 計

畫：我們提供承保缺口中此類處方藥的額外承保。若需此類

承保的更多資訊，請參閱您的承保範圍證明。

viii

處方一覽表層級說明

處方藥物分類為以下五個層級之一。如欲查詢您的藥品屬於哪個層級，請查閱處方一覽表從第 1

頁開始的藥物層級欄位。欲獲得有關您處方藥品自費額的更多詳細資訊，包括任何可能適用的自

付額，請參閱您的承保範圍證明及其他計畫材料。

下表列出標準零售 30 天份藥量的共付額或共同保險費用（即您將在初始承保階段支付的藥品費

用分攤），另有註明者除外：

層級共付額／共同保險

金

說明

層級 1

（首選普通牌藥品）

層級 1 共付額包括首選普通牌藥品。

層級 2

（首選品牌藥品）

層級 2 共付額包括首選品牌藥品。

層級 3

（非首選藥品）

層級 3 共付額包括非首選品牌藥品，也可能包括部分普通牌

藥品。

層級 4

（注射藥品）

層級 4 共付額包括不符合分類至層級 5 之 CMS 費用門檻規定

的注射藥品。

層級 5

（專科層級）

層級 5 共付額或共

同保險金

包括高價品牌和普通牌藥品。此層級的藥品不

符合資格按更低層級價位付費的例外情況處

理。

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Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesamphetamine-dextroamphetamine cp24 1 MO; *

amphetamine-dextroamphetamine tabs 1 MO; *

dextroamphetamine sulfatecp24 10 mg, 15 mg, 5 mg 1 MO; *

dextroamphetamine sulfatetabs 2.5 mg, 7.5 mg, 10mg, 5 mg

1MO; *

VYVANSE CAPS 10 MG 3 SL(7 ea daily);MO; +

VYVANSE CAPS 20 MG 3 SL(3.5 eadaily); MO; +





VYVANSE CAPS 70 MG 3 SL(1 ea daily);MO; +

Attention-Deficit/Hyperactivity Disorder (ADHD)atomoxetine hcl caps 10mg 1 SL(10 ea daily);

MO; *atomoxetine hcl caps 100mg 1 SL(1 ea daily);

MO; *atomoxetine hcl caps 18mg 1 SL(5.55 ea

daily); MO; *atomoxetine hcl caps 25mg 1 SL(4 ea daily);

MO; *atomoxetine hcl caps 40mg 1 SL(2.5 ea

daily); MO; *atomoxetine hcl caps 60mg 1 SL(1.66 ea

daily); MO; *atomoxetine hcl caps 80mg 1 SL(1.25 ea

daily); MO; *

guanfacine hcl (adhd) tb24 1 AL(Up to 64 yrsold); MO; *

Dopamine and Norepinephrine Reuptake

Drug Name DrugTier

Requirements/Limits

SUNOSI TABS 150 MG 3 PA; SL(1 eadaily); MO; +

SUNOSI TABS 75 MG 3 PA; SL(2 eadaily); MO; +

Histamine H3-Receptor Antagonist/InverseWAKIX TABS 5 PA; NDS; +

Stimulants - Misc.armodafinil tabs 1 PA; MO; *

DAYTRANA PTCH 3 MO; +

dexmethylphenidate hclcp24 10 mg 1 SL(4 ea daily);

MO; *dexmethylphenidate hclcp24 15 mg 1 SL(2.66 ea

daily); MO; *dexmethylphenidate hclcp24 20 mg 1 SL(2 ea daily);

MO; *dexmethylphenidate hclcp24 25 mg 1 SL(1.6 ea

daily); MO; *dexmethylphenidate hclcp24 30 mg 1 SL(1.33 ea

daily); MO; *dexmethylphenidate hclcp24 35 mg 1 SL(1.14 ea

daily); MO; *dexmethylphenidate hclcp24 40 mg 1 SL(1 ea daily);

MO; *dexmethylphenidate hclcp24 5 mg 1 SL(8 ea daily);

MO; *dexmethylphenidate hcltabs 10 mg, 2.5 mg, 5 mg 1 MO; *

methylphenidate hcl cp2410 mg, 20 mg, 30 mg, 40mg, 60 mg

1MO; *

methylphenidate hcl cpcr20 mg 1 QL(2 ea daily);

MO; *methylphenidate hcl cpcr30 mg 1 MO; *

methylphenidate hcl cpcr40 mg, 10 mg, 50 mg, 60mg

1QL(1 ea daily);MO; *

methylphenidate hcl tabs20 mg, 10 mg, 5 mg 1 QL(3 ea daily);

MO; *methylphenidate hcl tb2418 mg, 27 mg, 36 mg, 54mg

1Non-OsmoticRelease; *

You can find information on what the symbols and abbreviations on this table mean by going topage vi.

2020 Health Net Seniority Plus Employer (HMO) Prime Formulary Updated 12/01/20201

Drug Name DrugTier

Requirements/Limits

methylphenidate hcl tbcr 18mg, 27 mg, 36 mg, 54 mg 1 MO; *

methylphenidate hcl tbcr 20mg 1 QL(3 ea daily);

MO; *

modafinil tabs 100 mg 1 PA; MO; *

modafinil tabs 200 mg 1 PA; QL(1 eadaily); MO; *

ALLERGENIC EXTRACTS/BIOLOGICALS MISC

Allergenic ExtractsORALAIR SUBL 3 PA; MO; +

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosidesamikacin sulfate soln 4 MO; +

ARIKAYCE SUSP 5 PA; NDS;MO;+

BETHKIS NEBU(tobramycin) 5 B/D; NDS; +

gentamicin in saline soln0.9 %-1 mg/ml 4 +

gentamicin sulfate soln 4 MO; +

neomycin sulfate tabs 1 MO; *

paromomycin sulfate caps 1 MO; *

TOBI PODHALER CAPS 5 NDS; +

tobramycin nebu 300mg/4ml 5 B/D; NDS; +

tobramycin nebu 300mg/5ml 1 B/D; *

tobramycin sulfate soln 1.2gm/30ml, 80 mg/2ml 4 MO; +

tobramycin sulfate solr 1.2gm 4 +

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal Antibodies

Drug Name DrugTier

Requirements/Limits

HUMIRA PEDIATRICCROHNS DISEASESTARTER PACK PSKT

5PA; NDS; +

HUMIRA PEN PNKT 5 PA; NDS; +

HUMIRA PEN-CD/UC/HSSTARTER PNKT 5 PA; NDS; +

HUMIRA PEN-PS/UVSTARTER PNKT 5 PA; NDS; +

HUMIRA PSKT 5 PA; NDS; +

SIMPONI ARIA SOLN 5 PA; NDS; +

SIMPONI SOAJ 5 PA; NDS; +

SIMPONI SOSY 5 PA; NDS; +

Antirheumatic - Enzyme InhibitorsOLUMIANT TABS 5 PA; NDS; +

RINVOQ TB24 5 PA; NDS; +

XELJANZ TABS 5 PA; NDS; +

XELJANZ XR TB24 5 PA; NDS; +

Antirheumatic AntimetabolitesOTREXUP SOAJ 4 PA; +

RASUVO SOAJ 4 PA; +

Gold CompoundsRIDAURA CAPS 5 NDS;MO; +

Interleukin-1 BlockersARCALYST SOLR 5 NDS;LA; +

Interleukin-1 Receptor Antagonist (IL-1Ra)KINERET SOSY 5 PA; NDS;MO; +

Interleukin-1beta BlockersILARIS SOLN 5 PA; NDS;LA; +

Interleukin-6 Receptor InhibitorsACTEMRA SOLN 5 PA; NDS; +



Drug Name DrugTier

Requirements/Limits

ACTEMRA SOSY 5 PA; NDS; +

KEVZARA SOAJ 5 PA; NDS; +

KEVZARA SOSY 5 PA; NDS; +

Nonsteroidal Anti-inflammatory Agents (NSAIDs)celecoxib caps 1 MO; *

diclofenac potassium tabs 1 MO; *

diclofenac sodium tb24 1 MO; *

diclofenac sodium tbec 1 MO; *

diclofenac w/ misoprostoltbec 1 MO; *

DUEXIS TABS 5 PA; NDS;MO;+

etodolac caps 1 MO; *

etodolac tabs 1 MO; *

etodolac tb24 1 MO; *

flurbiprofen tabs 100 mg 1 MO; *

ibuprofen susp 100 mg/5ml 1 RX/OTC; MO; *

ibuprofen tabs 400 mg 1 SL(8 ea daily);MO; *

ibuprofen tabs 600 mg 1 SL(5.33 eadaily); MO; *

ibuprofen tabs 800 mg 1 SL(4 ea daily);MO; *

INDOCIN SUSP OR 25MG/5ML 3 AL(Up to 64 yrs

old); MO; +indomethacin caps 25 mg,50 mg 1 AL(Up to 64 yrs

old); MO; *

indomethacin cpcr 75 mg 1 AL(Up to 64 yrsold); MO; *

ketoprofen cp24 200 mg 1 MO; *

ketorolac tromethaminesoln ij 15 mg/ml, 30 mg/ml 4 AL(Up to 64 yrs

old); MO; +ketorolac tromethaminesoln im 30 mg/ml, 60mg/2ml

4AL(Up to 64 yrsold); MO; +

Drug Name DrugTier

Requirements/Limits

ketorolac tromethaminetabs or 10 mg 1 AL(Up to 64 yrs

old); MO; *meclofenamate sodiumcaps 100 mg 1 MO; *

mefenamic acid caps 1 MO; *

meloxicam tabs 1 MO; *

nabumetone tabs 1 MO; *

NAPRELAN TB24 750 MG 3 MO; +

naproxen sodium tabs 1 MO; *

naproxen sodium tb24 1 MO; *

naproxen tabs 375 mg, 500mg, 250 mg 1 MO; *

naproxen tbec 375 mg, 500mg 1 MO; *

naproxen-esomeprazolemagnesium tbec 5 PA; NDS;MO; +

oxaprozin tabs 1 MO; *

piroxicam caps 1 MO; *

sulindac tabs 1 MO; *

tolmetin sodium caps 400mg 1 MO; *

VIMOVO TBEC (naproxen-esomeprazole magnesium) 5 PA; NDS;MO; +

ZIPSOR CAPS 3 MO; +

Phosphodiesterase 4 (PDE4) InhibitorsOTEZLA TABS 5 PA; NDS; +

OTEZLA TBPK 5 PA; NDS; +

Pyrimidine Synthesis Inhibitorsleflunomide tabs 1 MO; *

Selective Costimulation ModulatorsORENCIA CLICKJECTSOAJ 5 PA; NDS; +

ORENCIA SOLR 5 PA; NDS; +



Drug Name DrugTier

Requirements/Limits

ORENCIA SOSY 5 PA; NDS; +

Soluble Tumor Necrosis Factor Receptor AgentsENBREL MINI SOCT 5 PA; NDS; +

ENBREL SOLN 5 PA; NDS; +

ENBREL SOLR 5 PA; NDS; +

ENBREL SOSY 5 PA; NDS; +

ENBREL SURECLICKSOAJ 5 PA; NDS; +

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsSalicylatesdiflunisal tabs 1 MO; *

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid Agonists

ABSTRAL SUBL 100 MCG 3 PA; QL(16 eadaily); +

ABSTRAL SUBL 200 MCG 5 PA; NDS;QL(8ea daily); +

codeine sulfate tabs 15 mg 1 SL(24 ea daily);MO; *



fentanyl citrate lpop bu1200 mcg, 1600 mcg, 400mcg, 600 mcg, 800 mcg

5PA; NDS;QL(4ea daily); MO;+

fentanyl citrate lpop bu 200mcg 5

PA; NDS;QL(8ea daily); MO;+

fentanyl citrate tabs bu 100mcg 5

PA;NDS;QL(16 eadaily); MO; +

fentanyl citrate tabs bu 200mcg 5


fentanyl citrate tabs bu 400mcg, 600 mcg, 800 mcg 5


Drug Name DrugTier

Requirements/Limits

fentanyl pt72 100 mcg/hr,12 mcg/hr, 25 mcg/hr, 50mcg/hr, 75 mcg/hr

1

Limit 10patches permonth;QL(0.34ea daily); MO; *

FENTORA TABS 100 MCG(fentanyl citrate) 5

PA;NDS;QL(16 eadaily); MO; +

FENTORA TABS 200 MCG(fentanyl citrate) 5


FENTORA TABS 400MCG, 600 MCG, 800 MCG(fentanyl citrate)


hydrocodone bitartratecp12 10 mg, 15 mg 1 PA; QL(3 ea

daily); MO; *hydrocodone bitartratecp12 20 mg, 30 mg, 40 mg,50 mg

1PA; QL(2 eadaily); MO; *

hydromorphone hcl liqd or1 mg/ml 1 QL(50 ml

daily); MO; *hydromorphone hcl soln ij10 mg/ml, 50 mg/5ml, 500mg/50ml

4+

hydromorphone hcl soln ij 2mg/ml 4 Preservative

Free; +hydromorphone hcl soln ij 4mg/ml, 1 mg/ml, 2 mg/ml 4 MO; +

hydromorphone hcl tabs or2 mg, 4 mg 1 QL(9 ea daily);

MO; *hydromorphone hcl tabs or8 mg 1 QL(6.25 ea

daily); MO; *hydromorphone hcl tb24 or12 mg 1 QL(4.17 ea

daily); *hydromorphone hcl tb24 or16 mg 1 QL(3.14 ea



daily); *HYDROMORPHONEHYDROCHLORIDE SOLNIJ 10 MG/ML(hydromorphone hcl)

4

+

HYSINGLA ER T24A 100MG, 120 MG, 80 MG 3 PA; QL(1 ea

daily); MO; +HYSINGLA ER T24A 20MG, 30 MG, 40 MG, 60 MG 3 PA; QL(2 ea

daily); MO; +



Drug Name DrugTier

Requirements/Limits

KADIAN CP24 200 MG 3 PA; QL(2 eadaily); MO; +

LAZANDA SOLN 100MCG/ACT 5



PA; NDS; Limit15 boxes permonth ;QL(0.5ea daily); MO;+


PA; NDS; Limit8 bottles permonth;QL(0.27ea daily); MO;+

methadone hcl conc or 10mg/ml 1 QL(6.67 ml

daily); MO; *methadone hcl soln or 10mg/5ml 1 QL(33.34 ml

daily); MO; *methadone hcl soln or 5mg/5ml 1 QL(15 ml

daily); MO; *methadone hcl tabs or 5mg, 10 mg 1 QL(6 ea daily);

MO; *morphine sulfate beadscp24 120 mg 1 QL(1.67 ea

daily); MO; *morphine sulfate beadscp24 30 mg 1 QL(6.67 ea





daily); MO; *morphine sulfate cp24 or10 mg, 20 mg, 30 mg, 50mg


morphine sulfate cp24 or100 mg 5 NDS;QL(2 ea

daily); MO; +morphine sulfate cp24 or40 mg 1 PA; QL(3 ea

daily); MO; *morphine sulfate cp24 or60 mg 1 QL(3.34 ea

daily); MO; *morphine sulfate cp24 or80 mg 1 QL(2.5 ea

daily); MO; *

Drug Name DrugTier

Requirements/Limits

morphine sulfate soln ij 0.5mg/ml 4 +

morphine sulfate soln ij 1mg/ml 4 MO; +

morphine sulfate soln or 10mg/5ml 1 QL(100 ml

daily); MO; *morphine sulfate soln or100 mg/5ml, 20 mg/ml 1 QL(10 ml

daily); MO; *morphine sulfate soln or 20mg/5ml 1 QL(50 ml

daily); MO; *morphine sulfate tabs or 15mg 1 QL(13.34 ea

daily); MO; *morphine sulfate tabs or 30mg 1 QL(6.67 ea

daily); MO; *morphine sulfate tbcr or100 mg, 200 mg 1 QL(2 ea daily);

MO; *morphine sulfate tbcr or 15mg, 30 mg, 60 mg 1 QL(3 ea daily);

MO; *NUCYNTA ER TB12 100MG 2 QL(6.67 ea

daily); MO; +NUCYNTA ER TB12 150MG 2 QL(4.44 ea

daily); MO; +NUCYNTA ER TB12 200MG 2 QL(3.34 ea

daily); MO; +NUCYNTA ER TB12 250MG 2 QL(2 ea daily);

MO; +NUCYNTA ER TB12 50MG 2 QL(13.34 ea

daily); MO; +

NUCYNTA TABS 100 MG 3 QL(6.67 eadaily); MO; +



oxycodone hcl caps 5 mg 1 QL(6 ea daily);MO; *

oxycodone hcl conc 100mg/5ml 1 QL(6 ml daily);

MO; *oxycodone hcl tabs 10 mg,20 mg, 15 mg, 5 mg 1 QL(6 ea daily);

MO; *

oxycodone hcl tabs 30 mg 1 QL(4.44 eadaily); MO; *

oxymorphone hcl tabs 10mg, 5 mg 1 QL(6 ea daily);

MO; *oxymorphone hcl tb12 10mg 1 QL(3 ea daily);

MO; *



Drug Name DrugTier

Requirements/Limits

oxymorphone hcl tb12 15mg 1 QL(4.44 ea

daily); MO; *oxymorphone hcl tb12 20mg 1 QL(3.34 ea

daily); MO; *oxymorphone hcl tb12 30mg 1 QL(2.22 ea

daily); MO; *oxymorphone hcl tb12 40mg 1 QL(2 ea daily);

MO; *oxymorphone hcl tb12 5mg 1 QL(13.34 ea

daily); MO; *oxymorphone hcl tb12 7.5mg 1 QL(8.89 ea

daily); MO; *

SUBSYS LIQD 100 MCG 5PA;NDS;QL(16 eadaily); MO; +

SUBSYS LIQD 1200 MCG 5 PA; NDS;QL(2ea daily); +

SUBSYS LIQD 1600 MCG,400 MCG, 600 MCG, 800MCG


SUBSYS LIQD 200 MCG 5PA; NDS;QL(8ea daily); MO;+

tramadol hcl tabs 50 mg 1 SL(8 ea daily);MO; *

tramadol hcl tb24 100 mg 1 SL(3 ea daily);MO; *

tramadol hcl tb24 200 mg 1 SL(1.5 eadaily); MO; *

tramadol hcl tb24 300 mg 1 SL(1 ea daily);MO; *

Opioid Combinations

acetaminophen w/ codeinesoln 12 mg/5ml-120mg/5ml

1

Limit 4500mlspermonth;SL(150ml daily); MO; *

acetaminophen w/ codeinetabs 15 mg-300 mg 1 SL(13.3 ea

daily); MO; *acetaminophen w/ codeinetabs 30 mg-300 mg 1 SL(12 ea daily);

MO; *acetaminophen w/ codeinetabs 300 mg-60 mg 1 SL(6 ea daily);

MO; *

butalbital-acetaminophen-caffeine w/ codeine caps 1

AL(Up to 64 yrsold); SL(6 eadaily); MO; *

Drug Name DrugTier

Requirements/Limits

butalbital-aspirin-caffeinew/cod caps 1


hydrocodone-acetaminophen soln 108mg/5ml-2.5 mg/5ml, 217mg/10ml-5 mg/10ml, 325mg/15ml-7.5 mg/15ml

1

Limit 5535mlspermonth;SL(184.5 ml daily); MO;*

hydrocodone-acetaminophen tabs 10mg-300 mg, 300 mg-5 mg,300 mg-7.5 mg

1

SL(13.3 eadaily); MO; *

hydrocodone-acetaminophen tabs 10mg-325 mg, 325 mg-5 mg,325 mg-7.5 mg

1

SL(12.3 eadaily); MO; *

hydrocodone-ibuprofentabs 200 mg-7.5 mg, 10mg-200 mg, 200 mg-5 mg


oxycodone w/acetaminophen tabs 1 SL(12.3 ea

daily); MO; *

oxycodone-aspirin tabs 1 SL(12.3 eadaily); MO; *

tramadol-acetaminophentabs 1 SL(8 ea daily);

MO; *Opioid Partial AgonistsBUNAVAIL FILM 0.3 MG-2.1 MG 3 QL(4 ea daily);

+BUNAVAIL FILM 0.7 MG-4.2 MG 3 QL(2 ea daily);

+BUNAVAIL FILM 1 MG-6.3MG 3 QL(2 ea daily);

MO; +buprenorphine hcl subl sl 2mg, 8 mg 1 QL(3 ea daily);

MO; *buprenorphine hcl-naloxone hcl dihydrate film0.5 mg-2 mg, 1 mg-4 mg, 2mg-8 mg

1

QL(3 ea daily);MO; *

buprenorphine hcl-naloxone hcl dihydrate film12 mg-3 mg


buprenorphine hcl-naloxone hcl dihydrate subl0.5 mg-2 mg, 2 mg-8 mg




Drug Name DrugTier

Requirements/Limits

buprenorphine ptwk 10mcg/hr 1

Limit 8 patchesper 28days;SL(0.29ea daily); MO; *






Limit 16patches per 28days;SL(0.58ea daily); MO; *

buprenorphine ptwk 7.5mcg/hr 1

Limit 10patches per 28days;SL(0.39ea daily); MO; *

BUTORPHANOLTARTRATE SOLN IJ 2MG/ML

4MO; +

butorphanol tartrate soln ij2 mg/ml 4 MO; +

butorphanol tartrate soln na10 mg/ml 1

Limit 210mlsper month;QL(7ml daily); MO; *

BUTRANS PTWK 7.5MCG/HR (buprenorphine) 2

Limit 10patches per 28days;SL(0.39ea daily); MO;+

ZUBSOLV SUBL 0.18 MG-0.7 MG, 0.36 MG-1.4 MG,0.71 MG-2.9 MG, 1.4 MG-5.7 MG

3

QL(3 ea daily);MO; +

ZUBSOLV SUBL 11.4 MG-2.9 MG 3 QL(1 ea daily);

MO; +ZUBSOLV SUBL 2.1 MG-8.6 MG 3 QL(2 ea daily);

MO; +ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic SteroidsANADROL-50 TABS 5 NDS;MO; +

oxandrolone tabs 10 mg 5 NDS;MO; +

Drug Name DrugTier

Requirements/Limits

oxandrolone tabs 2.5 mg 1 MO; *

AndrogensAVEED SOLN 3 LA; +

danazol caps 1 MO; *

methyltestosterone caps 1 MO; *

testosterone cypionate solnim 100 mg/ml, 200 mg/ml 4 MO; +

testosterone enanthatesoln im 4 MO; +

testosterone gel td 1.62 %,20.25 mg/1.25gm, 25mg/2.5gm, 40.5 mg/2.5gm,1 %, 1 %, 50 mg/5gm

1

MO; *

testosterone soln td 30mg/act 1 MO; *

ANORECTAL AND RELATED PRODUCTS -Rectal Drugs to Treat Pain, Swelling and ItchingIntrarectal SteroidsCORTIFOAM FOAM 3 MO; +

hydrocortisone (intrarectal)enem 1 MO; *

UCERIS FOAM RE 2MG/ACT 3 MO; +

Rectal Steroidshydrocortisone (rectal) crea 1 MO; *

Vasodilating AgentsRECTIV OINT 3 MO; +

ANTHELMINTICS - Drugs to Treat WormInfectionsAnthelminticsalbendazole tabs 1 MO; *

ivermectin tabs 1 MO; *

praziquantel tabs 1 MO; *

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial Infections



Drug Name DrugTier

Requirements/Limits

Anti-infective Agents - Misc.IMPAVIDO CAPS 5 NDS;MO; +

metronidazole caps or 375mg 1 SL(10.6 ea

daily); MO; *metronidazole in nacl soln0.79 %-5 mg/ml, 0.79 %-500 mg/100ml

4+

metronidazole tabs or 250mg 1 SL(16 ea daily);

MO; *metronidazole tabs or 500mg 1 SL(8 ea daily);

MO; *pentamidine isethionatesolr ij 4 MO; +

pentamidine isethionatesolr in 1 B/D; MO; *

tinidazole tabs 1 MO; *

trimethoprim tabs 1 MO; *

vancomycin hcl solr iv 1000mg 4 +

XIFAXAN TABS 200 MG 5 NDS;MO; +

XIFAXAN TABS 550 MG 5 NDS;QL(3 eadaily); MO; +

Anti-infective Misc. - Combinationssulfamethoxazole-trimethoprim soln iv 400mg/5ml-80 mg/5ml

4MO; +

sulfamethoxazole-trimethoprim susp or 200mg/5ml-40 mg/5ml

1MO; *

sulfamethoxazole-trimethoprim tabs or 160mg-800 mg, 400 mg-80 mg

1MO; *

Antiprotozoal AgentsALINIA TABS 500 MG 3 MO; +

atovaquone susp 5 NDS;MO; +

Carbapenemsertapenem sodium solr 4 MO; +

Drug Name DrugTier

Requirements/Limits

imipenem-cilastatin solr250 mg-250 mg, 500 mg-500 mg

1MO; *

meropenem solr 1 gm 4 MO; +

meropenem solr 500 mg 1 *

VABOMERE SOLR 4 +

Chloramphenicolschloramphenicol sodiumsuccinate solr 4 +

Cyclic Lipopeptidesdaptomycin solr 500 mg 5 NDS;MO; +

GlycopeptidesDALVANCE SOLR 5 NDS; +

FIRVANQ SOLR 25MG/ML 3 +

FIRVANQ SOLR 50MG/ML 3 MO; +

ORBACTIV SOLR 5 NDS;MO; +

vancomycin hcl caps or125 mg 3 PA; MO; +

vancomycin hcl caps or250 mg 5 PA; NDS;MO; +

vancomycin hcl solr iv 5gm, 10 gm, 750 mg, 1 gm,1000 mg

4+

vancomycin hcl solr iv 500mg 4 MO; +

VANCOMYCINHYDROCHLORIDE SOLROR 250 MG/5ML

3MO; +

VANCOMYCINHYDROCHLORIDE/DEXTROSE SOLN 1 GM/200ML-5 %, 5 %-500 MG/100ML,5 %-750 MG/150ML

4

+

Leprostaticsdapsone tabs or 100 mg,25 mg 1 MO; *

Lincosamides



Drug Name DrugTier

Requirements/Limits

clindamycin hcl caps 1 MO; *

clindamycin palmitatehydrochloride solr 1 MO; *

clindamycin phosphate ind5w soln 4 +

clindamycin phosphatesoln ij 300 mg/2ml, 9gm/60ml, 9000 mg/60ml

4+

clindamycin phosphatesoln ij 600 mg/4ml, 900mg/6ml

4MO; +

clindamycin phosphatesoln iv 300 mg/2ml, 600mg/4ml, 900 mg/6ml

4+

lincomycin hcl soln 4 MO; +

Monobactamsaztreonam solr 4 MO; +

CAYSTON SOLR 5 PA; NDS;LA; +

Oxazolidinoneslinezolid in sodium chloridesoln 5 NDS; +

linezolid soln iv 600mg/300ml 5 NDS; +

linezolid susr or 100mg/5ml 5 NDS;MO; +

linezolid tabs or 600 mg 1 MO; *

SIVEXTRO SOLR IV 5 NDS; +

SIVEXTRO TABS OR 5 NDS;MO; +

ZYVOX SOLN IV 200MG/100ML 5 NDS; +

PleuromutilinsXENLETA TABS OR 600MG 5 PA; NDS;MO;

+Polymyxinscolistimethate sodium solr 4 MO; +

polymyxin b sulfate solr 4 +

Streptogramins

Drug Name DrugTier

Requirements/Limits

SYNERCID SOLR 4 +

Urinary Anti-infectivesmethenamine hippuratetabs 1 MO; *

nitrofurantoin macrocrystalcaps 1 MO; *

nitrofurantoin monohydmacro caps 1 MO; *

nitrofurantoin susp 1 MO; *

ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-Otherranolazine tb12 1 MO; *

NitratesDILATRATE SR CPCR 3 MO; +

isosorbide dinitrate tabs 30mg, 10 mg, 20 mg, 5 mg 1 MO; *

isosorbide dinitrate tabs 40mg 5 NDS;MO; +

isosorbide mononitrate tabs 1 MO; *

isosorbide mononitratetb24 1 MO; *

NITRO-DUR PT24 0.3MG/HR, 0.8 MG/HR 3 MO; +

nitroglycerin oint td 2 % 1 MO; *

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

1MO; *

nitroglycerin soln tl 0.4mg/spray 1 MO; *

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg 1 MO; *

NITROSTAT SUBL(nitroglycerin) 2 MO; +

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.buspirone hcl tabs 1 MO; *



Drug Name DrugTier

Requirements/Limits

hydroxyzine hcl soln im 50mg/ml 4 AL(Up to 64 yrs

old); MO; +hydroxyzine hcl syrp or 10mg/5ml 1 AL(Up to 64 yrs

old); MO; *hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg 1 AL(Up to 64 yrs

old); MO; *hydroxyzine pamoate caps25 mg, 50 mg 1 AL(Up to 64 yrs

old); MO; *

meprobamate tabs 1 AL(Up to 64 yrsold); MO; *

Benzodiazepinesalprazolam tabs 1 MO; *

alprazolam tb24 1 MO; *

alprazolam tbdp 1 MO; *

clorazepate dipotassiumtabs 1 MO; *

diazepam conc or 5 mg/ml 1 MO; *

diazepam soln ij 5 mg/ml,50 mg/10ml 1 MO; *

diazepam soln or 5 mg/5ml 1 MO; *

diazepam tabs or 10 mg, 2mg, 5 mg 1 MO; *

lorazepam conc 1 MO; *

lorazepam soln 1 MO; *

lorazepam tabs 1 MO; *

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-Adisopyramide phosphatecaps 1 AL(Up to 64 yrs

old); MO; *

NORPACE CR CP12 3 AL(Up to 64 yrsold); MO; +

quinidine gluconate tbcr or324 mg 1 MO; *

quinidine sulfate tabs 1 MO; *

Antiarrhythmics Type I-B

Drug Name DrugTier

Requirements/Limits

mexiletine hcl caps 1 MO; *

Antiarrhythmics Type I-Cflecainide acetate tabs 100mg 1 SL(4 ea daily);

MO; *flecainide acetate tabs 150mg 1 SL(2.66 ea

daily); MO; *flecainide acetate tabs 50mg 1 SL(8 ea daily);

MO; *

propafenone hcl cp12 1 MO; *

propafenone hcl tabs 1 MO; *

Antiarrhythmics Type IIIamiodarone hcl tabs or 100mg, 200 mg, 400 mg 1 MO; *

dofetilide caps 1 *

MULTAQ TABS 2 MO; +

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agentscromolyn sodium nebu 1 B/D; MO; *

Antiasthmatic - Monoclonal AntibodiesCINQAIR SOLN 5 PA; NDS;LA; +

FASENRA SOSY 5 PA; NDS; +

NUCALA SOLR 100 MG 5 PA; NDS;LA; +

XOLAIR SOLR 5 PA; NDS;LA; +

XOLAIR SOSY 5 PA; NDS;LA; +

Bronchodilators - Anticholinergics

ATROVENT HFA AERS 3

Limit 2 inhalerspermonth;QL(0.86gm daily); MO;+

INCRUSE ELLIPTA AEPB 2 QL(1 ea daily);MO; +

ipratropium bromide soln 1 B/D; MO; *



Drug Name DrugTier

Requirements/Limits

SPIRIVA HANDIHALERCAPS 2 QL(1 ea daily);

MO; +

SPIRIVA RESPIMATAERS 2

Limit 1 inhalerper month (60actuations);SL(0.14 gm daily);MO; +

TUDORZA PRESSAIRAEPB 2

Limit 1 inhalerper month (60actuations);QL(0.04 ea daily);MO; +

TUDORZA PRESSAIRAEPB 2

Limit 2 inhalersper month (30actuations);QL(0.07 ea daily);MO; +

Leukotriene Modulatorsmontelukast sodium chew4 mg, 5 mg 1 QL(1 ea daily);

MO; *montelukast sodium tabs10 mg 1 QL(1 ea daily);

MO; *

zafirlukast tabs 1 MO; *

zileuton tb12 5 NDS;SL(4 eadaily); MO; +

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS 3 QL(1 ea daily);MO; +

Steroid Inhalants

ARNUITY ELLIPTA AEPB 2 SL(1 ea daily);MO; +

budesonide (inhalation)susp 0.25 mg/2ml 1 B/D; QL(8 ml

daily); MO; *budesonide (inhalation)susp 0.5 mg/2ml 1 B/D; QL(4 ml

daily); MO; *budesonide (inhalation)susp 1 mg/2ml 1 B/D; QL(2 ml

daily); MO; *FLOVENT DISKUS AEPB100 MCG/BLIST 2 SL(20 ea daily);

MO; +FLOVENT DISKUS AEPB250 MCG/BLIST 2 SL(8 ea daily);

MO; +FLOVENT DISKUS AEPB50 MCG/BLIST 2 SL(40 ea daily);

MO; +

Drug Name DrugTier

Requirements/Limits

FLOVENT HFA AERO 110MCG/ACT, 220 MCG/ACT 2

Limit 2 inhalerspermonth;QL(0.8gm daily); MO;+

FLOVENT HFA AERO 44MCG/ACT 2

Limit 1 inhalerpermonth;QL(0.36gm daily); MO;+

PULMICORT FLEXHALERAEPB 180 MCG/ACT 3

Limit 2 inhalerspermonth;QL(0.07ea daily); MO;+

PULMICORT FLEXHALERAEPB 90 MCG/ACT 3

Limit 8 inhalerspermonth;QL(0.27ea daily); MO;+

Sympathomimetics

ADVAIR HFA AERO 2 QL(4 gm daily);MO; +

albuterol sulfate nebu in0.083 %, 0.63 mg/3ml, 1.25mg/3ml, 0.5 %, 2.5mg/0.5ml

1

B/D; MO; *

albuterol sulfate syrp or 2mg/5ml 1 MO; *

albuterol sulfate tabs or 2mg, 4 mg 1 MO; *

albuterol sulfate tb12 or 4mg, 8 mg 1 MO; *

ANORO ELLIPTA AEPB 2 QL(2 ea daily);MO; +

ARCAPTA NEOHALERCAPS 3 QL(1 ea daily);

MO; +BREO ELLIPTA AEPB 100MCG/INH-25 MCG/INH,200 MCG/INH-25MCG/INH

2

Limit 1 inhalerper month;SL(2ea daily); MO;+

BREO ELLIPTA AEPB 100MCG/INH-25 MCG/INH,200 MCG/INH-25MCG/INH

2

Limit 2 inhalersper month(InstitutionalPack);SL(2 eadaily); MO; +

BROVANA NEBU 3 B/D; MO; +



Drug Name DrugTier

Requirements/Limits

COMBIVENT RESPIMATAERS 3

Limit 3 inhalersper 2months;SL(0.2gm daily); MO;+

fluticasone-salmeterol aepb100 mcg/dose-50mcg/dose, 250 mcg/dose-50 mcg/dose, 50mcg/dose-500 mcg/dose

1

QL(2 ea daily);MO; *

fluticasone-salmeterol aepb113 mcg/act-14 mcg/act,14 mcg/act-232 mcg/act,14 mcg/act-55 mcg/act

1

SL(2 ea daily);MO; *

ipratropium-albuterol soln 1 B/D; MO; *

levalbuterol hcl nebu 1 B/D; MO; *

levalbuterol tartrate aero 3 MO; +

PERFOROMIST NEBU 3 B/D; QL(4 mldaily); MO; +

PROAIR HFA AERS(albuterol sulfate) 2 MO; +

PROAIR RESPICLICKAEPB 2 MO; +

PROVENTIL HFA AERS(albuterol sulfate) 2 MO; +

SEREVENT DISKUSAEPB 2 QL(2 ea daily);

MO; +

STIOLTO RESPIMATAERS 2

Limit 1 inhalerpermonth;SL(0.14gm daily); MO;+

STRIVERDI RESPIMATAERS 2

Limit 1 inhalerper month (60actuations);SL(0.14 gm daily);MO; +

SYMBICORT AERO 160MCG/ACT-4.5 MCG/ACT(budesonide-formoterolfumarate dihydrate)

2

Limit 2 inhalersper month(InstitutionalPack);QL(0.4gm daily); MO;+

Drug Name DrugTier

Requirements/Limits

SYMBICORT AERO 160MCG/ACT-4.5 MCG/ACT,4.5 MCG/ACT-80MCG/ACT (budesonide-formoterol fumaratedihydrate)

2

Limit 1 inhalerpermonth;QL(0.34gm daily); MO;+

SYMBICORT AERO 4.5MCG/ACT-80 MCG/ACT(budesonide-formoterolfumarate dihydrate)

2

Limit 2 inhalersper month(InstitutionalPack);QL(0.46gm daily); MO;+

terbutaline sulfate tabs or2.5 mg, 5 mg 1 MO; *

TRELEGY ELLIPTA AEPB100 MCG/INH-25MCG/INH-62.5 MCG/INH

2MO; +

VENTOLIN HFA AERS(albuterol sulfate) 3 MO; +

Xanthinesaminophylline soln 4 +

theophylline tb12 300 mg,450 mg 1 MO; *

theophylline tb24 400 mg,600 mg 1 MO; *

ANTICOAGULANTS - Blood Thinners

Coumarin AnticoagulantsCOUMADIN TABS 1 MG, 4MG, 5 MG (warfarinsodium)

3MO; +

warfarin sodium tabs 1 mg,10 mg, 2.5 mg, 4 mg, 5 mg,6 mg, 7.5 mg, 2 mg, 3 mg

1MO; *

Direct Factor Xa Inhibitors

BEVYXXA CAPS 40 MG 3 QL(1 ea daily);+

BEVYXXA CAPS 80 MG 3 QL(1 ea daily);MO; +

ELIQUIS STARTER PACKTBPK 2 +

ELIQUIS TABS 2 MO; +

XARELTO STARTERPACK TBPK 2 MO; +



Drug Name DrugTier

Requirements/Limits

XARELTO TABS 2 MO; +

Heparins And Heparinoid-Like Agentsenoxaparin sodium soln ij300 mg/3ml 4 MO; +

enoxaparin sodium soln sc100 mg/ml, 120 mg/0.8ml,60 mg/0.6ml, 80 mg/0.8ml

1MO; *

enoxaparin sodium soln sc150 mg/ml, 30 mg/0.3ml,40 mg/0.4ml

4MO; +

fondaparinux sodium soln10 mg/0.8ml 4 MO; +

fondaparinux sodium soln2.5 mg/0.5ml 1 MO; *

fondaparinux sodium soln 5mg/0.4ml, 7.5 mg/0.6ml 5 NDS;MO; +

FRAGMIN SOLN 10000UNIT/ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML

3

MO; +

FRAGMIN SOLN 12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 7500UNIT/0.3ML

4

MO; +

FRAGMIN SOLN 95000UNIT/3.8ML 5 NDS;MO; +

heparin sodium (porcine)soln 4 MO; +

HEPARIN SODIUM SOLNIJ 5000 UNIT/ML 4 +

Thrombin Inhibitorsargatroban soln 250mg/2.5ml 4 +

PRADAXA CAPS 3 MO; +

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor AntagonistsFYCOMPA SUSP 3 MO; +

FYCOMPA TABS 3 MO; +

Anticonvulsants - Benzodiazepines

Drug Name DrugTier

Requirements/Limits

clobazam susp 2.5 mg/ml 1 MO; *

clobazam tabs 10 mg 1 MO; *

clobazam tabs 20 mg 5 NDS;MO; +

clonazepam tabs 0.5 mg 1 SL(40 ea daily);MO; *

clonazepam tabs 1 mg 1 SL(20 ea daily);MO; *

clonazepam tabs 2 mg 1 SL(10 ea daily);MO; *

clonazepam tbdp 0.125mg, 0.25 mg, 0.5 mg, 1 mg,2 mg

1MO; *

DIASTAT ACUDIAL GEL(diazepam(anticonvulsant))

3MO; +

DIASTAT PEDIATRIC GEL(diazepam(anticonvulsant))

3MO; +

diazepam (anticonvulsant)gel 1 MO; *

NAYZILAM SOLN 5

PA;NDS;SL(0.34ea daily); MO;+

SYMPAZAN FILM 10 MG,20 MG 5 PA; NDS;MO; +

SYMPAZAN FILM 5 MG 3 PA; MO; +

VALTOCO LIQD 5


VALTOCO LQPK 5


Anticonvulsants - Misc.APTIOM TABS 200 MG 3 MO; +

APTIOM TABS 400 MG,600 MG, 800 MG 5 NDS;MO; +

BANZEL SUSP 40 MG/ML(rufinamide) 3 MO; +



Drug Name DrugTier

Requirements/Limits

BANZEL TABS 200 MG 3 MO; +

BANZEL TABS 400 MG 5 NDS;MO; +

BRIVIACT SOLN IV 50MG/5ML 5 NDS;SL(20 ml

daily); +

BRIVIACT SOLN OR 10MG/ML 5

PA; NDS;SL(20ml daily); MO;+

BRIVIACT TABS OR 10MG 5

PA; NDS;SL(20ea daily); MO;+









carbamazepine chew 1 MO; *

carbamazepine cp12 1 MO; *

carbamazepine susp 1 MO; *

carbamazepine tabs 1 MO; *

carbamazepine tb12 1 MO; *

CARBATROL CP12(carbamazepine) 3 MO; +

EPIDIOLEX SOLN 5 PA; NDS; +

FINTEPLA SOLN 5

PA;NDS;SL(11.82ml daily); MO;+

gabapentin caps 1 MO; *

gabapentin soln 1 MO; *

gabapentin tabs 1 MO; *

Drug Name DrugTier

Requirements/Limits

LAMICTAL XR KIT 3 MO; +

lamotrigine chew 25 mg, 5mg 1 MO; *

lamotrigine kit 25 mg 1 MO; *

lamotrigine tabs 100 mg,150 mg, 200 mg, 25 mg 1 MO; *

lamotrigine tb24 100 mg,200 mg, 250 mg, 300 mg,25 mg, 50 mg

1MO; *

lamotrigine tbdp 100 mg,200 mg, 25 mg, 50 mg 1 MO; *

levetiracetam in sodiumchloride soln 4 +

levetiracetam soln iv 500mg/5ml 4 +

levetiracetam soln or 100mg/ml, 500 mg/5ml 1 MO; *

levetiracetam tabs or 250mg, 1000 mg, 500 mg, 750mg

1MO; *

levetiracetam tb24 or 500mg, 750 mg 1 MO; *

oxcarbazepine susp 1 MO; *

oxcarbazepine tabs 1 MO; *

pregabalin caps 100 mg,25 mg, 50 mg, 75 mg 1 QL(3 ea daily);

MO; *pregabalin caps 150 mg,200 mg, 225 mg 1 QL(2 ea daily);

MO; *

pregabalin caps 300 mg 1 SL(2 ea daily);MO; *

pregabalin soln 20 mg/ml 1 SL(30 ml daily);MO; *

primidone tabs 1 MO; *

rufinamide susp 1 MO; *

SPRITAM TB3D 1000 MG 3 PA; SL(3 eadaily); MO; +





Drug Name DrugTier

Requirements/Limits


TEGRETOL SUSP(carbamazepine) 3 MO; +

TEGRETOL TABS(carbamazepine) 3 MO; +

TEGRETOL-XR TB12(carbamazepine) 3 MO; +

topiramate cpsp 15 mg, 25mg 1 MO; *

topiramate tabs 100 mg,200 mg, 25 mg, 50 mg 1 MO; *

VIMPAT SOLN IV 200MG/20ML 4 +

VIMPAT SOLN OR 10MG/ML 3 MO; +

VIMPAT TABS OR 100MG, 150 MG, 200 MG, 50MG

3MO; +

zonisamide caps 1 MO; *

Carbamatesfelbamate susp 1 MO; *

felbamate tabs 1 MO; *

XCOPRI TABS 100 MG 5PA; NDS;SL(4ea daily); MO;+

XCOPRI TABS 150 MG 5




XCOPRI TBPK 5 PA; NDS, 150-200 MG ;MO; +

XCOPRI TBPK 3 PA;12.5-25MG;MO; +

XCOPRI TBPK 5PA; NDS; 350MG Daily Dose;+

Drug Name DrugTier

Requirements/Limits

XCOPRI TBPK 5PA; NDS; 250MG Daily Dose;+

XCOPRI TBPK 5 PA; NDS, 50-100 MG;MO; +

GABA Modulatorstiagabine hcl tabs 1 MO; *

vigabatrin pack 5 NDS;LA; MO; +

vigabatrin tabs 5 NDS;LA; +

HydantoinsDILANTIN INFATABSCHEW (phenytoin) 3 MO; +

DILANTIN-125 SUSP(phenytoin) 3 MO; +

fosphenytoin sodium soln100 mg pe/2ml 4 +

fosphenytoin sodium soln500 mg pe/10ml 4 MO; +

PEGANONE TABS 3 MO; +

phenytoin chew 1 MO; *

phenytoin sodium extendedcaps 1 MO; *

phenytoin sodium soln 4 +

phenytoin susp 1 MO; *

SuccinimidesCELONTIN CAPS 3 MO; +

ethosuximide caps 1 MO; *

ethosuximide soln 1 MO; *

Valproic AcidDEPAKOTE ER TB24(divalproex sodium) 3 MO; +

DEPAKOTE SPRINKLESCSDR (divalproex sodium) 3 MO; +

DEPAKOTE TBEC(divalproex sodium) 3 MO; +



Drug Name DrugTier

Requirements/Limits

divalproex sodium csdr 1 MO; *

divalproex sodium tb24 1 MO; *

divalproex sodium tbec 1 MO; *

valproate sodium soln iv100 mg/ml, 500 mg/5ml 4 +

valproate sodium soln or250 mg/5ml 1 MO; *

valproic acid caps 1 MO; *

ANTIDEPRESSANTS - Drugs to TreatDepressionAlpha-2 Receptor Antagonists (Tetracyclics)mirtazapine tabs 1 MO; *

mirtazapine tbdp 1 MO; *

Antidepressants - Misc.

APLENZIN TB24 174 MG 3 ST; SL(3 eadaily); MO; +

APLENZIN TB24 348 MG 3 ST; SL(1.5 eadaily); MO; +

APLENZIN TB24 522 MG 3 ST; SL(1 eadaily); MO; +

bupropion hcl tabs 100 mg 1 SL(4.5 eadaily); MO; *

bupropion hcl tabs 75 mg 1 SL(6 ea daily);MO; *

bupropion hcl tb12 100 mg 1 SL(4 ea daily);MO; *

bupropion hcl tb12 150 mg 1 SL(2.66 eadaily); MO; *



bupropion hcl tb24 300 mg 1 SL(1.5 eadaily); MO; *

bupropion hcl tb24 450 mg 1 ST; MO; *

FORFIVO XL TB24(bupropion hcl) 3 ST; MO; +

maprotiline hcl tabs 1 MO; *

Drug Name DrugTier

Requirements/Limits

GABA Receptor Modulator - Neuroactive SteroidZULRESSO SOLN 5 PA; NDS; +

Monoamine Oxidase Inhibitors (MAOIs)EMSAM PT24 5 NDS;MO; +

MARPLAN TABS 3 MO; +

phenelzine sulfate tabs 1 MO; *

tranylcypromine sulfatetabs 1 MO; *

N-Methyl-D-aspartic acid (NMDA) ReceptorSPRAVATO 56MG DOSESOPK 5 PA; NDS;MO; +

SPRAVATO 84MG DOSESOPK 5 PA; NDS;MO; +

Selective Serotonin Reuptake Inhibitors (SSRIs)citalopram hydrobromidesoln 10 mg/5ml 1 SL(20 ml daily);

MO; *citalopram hydrobromidetabs 10 mg 1 SL(4 ea daily);



MO; *

escitalopram oxalate soln 1 MO; *

escitalopram oxalate tabs 1 MO; *

fluoxetine hcl caps 1 MO; *

fluoxetine hcl cpdr 1 MO; *

fluoxetine hcl soln 1 MO; *

fluoxetine hcl tabs 1 MO; *

fluvoxamine maleate cp24 1 MO; *

fluvoxamine maleate tabs 1 MO; *

paroxetine hcl tabs 1 MO; *

paroxetine hcl tb24 1 MO; *



Drug Name DrugTier

Requirements/Limits

PAXIL SUSP 10 MG/5ML 3 MO; +

PEXEVA TABS 3 ST; MO; +

sertraline hcl conc 1 MO; *

sertraline hcl tabs 1 MO; *

Serotonin Modulatorsnefazodone hcl tabs 1 MO; *

trazodone hcl tabs 1 MO; *

TRINTELLIX TABS 10 MG 3 ST; QL(2 eadaily); MO; +



VIIBRYD STARTER PACKKIT 3 ST; MO; +

VIIBRYD TABS 3 ST; MO; +

Serotonin-Norepinephrine Reuptake InhibitorsDESVENLAFAXINE ERTB24 3 ST; MO; +

desvenlafaxine succinatetb24 1 MO; *

DRIZALMA SPRINKLECSDR 20 MG 3 ST; SL(6 ea

daily); MO; +DRIZALMA SPRINKLECSDR 30 MG 3 ST; SL(4 ea



daily); MO; +duloxetine hcl cpep 20 mg,30 mg, 60 mg 1 MO; *

FETZIMA CP24 120 MG,40 MG, 80 MG 3 ST; QL(1 ea

daily); MO; +

FETZIMA CP24 20 MG 3 ST; QL(2 eadaily); MO; +

FETZIMA TITRATIONPACK C4PK 3 ST; MO; +

venlafaxine hcl cp24 150mg 1 SL(1.5 ea

daily); MO; *

Drug Name DrugTier

Requirements/Limits

venlafaxine hcl cp24 37.5mg 1 SL(6 ea daily);

MO; *

venlafaxine hcl cp24 75 mg 1 SL(3 ea daily);MO; *

venlafaxine hcl tabs 100mg 1 SL(3.75 ea

daily); MO; *

venlafaxine hcl tabs 25 mg 1 SL(15 ea daily);MO; *

venlafaxine hcl tabs 37.5mg 1 SL(10 ea daily);

MO; *

venlafaxine hcl tabs 50 mg 1 SL(7.5 eadaily); MO; *

venlafaxine hcl tabs 75 mg 1 SL(5 ea daily);MO; *

venlafaxine hcl tb24 150mg 1 SL(1.5 ea

daily); MO; *venlafaxine hcl tb24 225mg 1 ST; SL(1 ea

daily); MO; *venlafaxine hcl tb24 37.5mg 1 SL(6 ea daily);

MO; *

venlafaxine hcl tb24 75 mg 1 SL(3 ea daily);MO; *

Tricyclic Agents

amitriptyline hcl tabs 1 AL(Up to 64 yrsold); MO; *

amoxapine tabs 1 MO; *

clomipramine hcl caps 1 AL(Up to 64 yrsold); MO; *

desipramine hcl tabs 1 MO; *

doxepin hcl caps 1 AL(Up to 64 yrsold); MO; *

doxepin hcl conc 1 AL(Up to 64 yrsold); MO; *

imipramine hcl tabs 1 AL(Up to 64 yrsold); MO; *

imipramine pamoate caps 1 AL(Up to 64 yrsold); MO; *

nortriptyline hcl caps 1 MO; *

nortriptyline hcl soln 1 MO; *

protriptyline hcl tabs 1 MO; *



Drug Name DrugTier

Requirements/Limits

trimipramine maleate caps 1 AL(Up to 64 yrsold); MO; *

ANTIDIABETICS - Drugs to Regulate BloodSugarAlpha-Glucosidase Inhibitors

acarbose tabs 1 QL(3 ea daily);MO; *

miglitol tabs 1 QL(3 ea daily);MO; *

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN 4

PA; Limit 12mlspermonth;QL(0.4ml daily); MO;+

SYMLINPEN 60 SOPN 4

PA; Limit 12mlspermonth;QL(0.4ml daily); MO;+

Antidiabetic CombinationsACTOPLUS MET XR TB241000 MG-15 MG 2 SL(2 ea daily);

+ACTOPLUS MET XR TB241000 MG-30 MG 2 SL(1.5 ea

daily); +glipizide-metformin hcl tabs2.5 mg-250 mg 1 SL(8 ea daily);

MO; *glipizide-metformin hcl tabs2.5 mg-500 mg, 5 mg-500mg

1SL(4 ea daily);MO; *

glyburide-metformin tabs1.25 mg-250 mg 1


glyburide-metformin tabs2.5 mg-500 mg, 5 mg-500mg

1AL(Up to 64 yrsold); SL(4 eadaily); MO; *

INVOKAMET TABS 1000MG-150 MG, 1000 MG-50MG, 150 MG-500 MG

2SL(2 ea daily);MO; +

INVOKAMET TABS 50MG-500 MG 2 SL(4 ea daily);

MO; +INVOKAMET XR TB241000 MG-150 MG, 1000MG-50 MG, 150 MG-500MG

2

SL(2 ea daily);MO; +

Drug Name DrugTier

Requirements/Limits

INVOKAMET XR TB24 50MG-500 MG 2 SL(4 ea daily);

MO; +

JANUMET TABS 2 SL(2 ea daily);MO; +

JANUMET XR TB24 100MG-1000 MG 2 SL(1 ea daily);

MO; +JANUMET XR TB24 1000MG-50 MG, 50 MG-500MG


JENTADUETO TABS 2 SL(2 ea daily);MO; +

JENTADUETO XR TB241000 MG-2.5 MG 2 SL(2 ea daily);

MO; +JENTADUETO XR TB241000 MG-5 MG 2 SL(1 ea daily);

MO; +pioglitazone hcl-glimepiridetabs 1 SL(1.5 ea

daily); MO; *pioglitazone hcl-metforminhcl tabs 1 SL(3 ea daily);

MO; *SYNJARDY TABS 1000MG-12.5 MG, 1000 MG-5MG


SYNJARDY TABS 12.5MG-500 MG, 5 MG-500MG


SYNJARDY XR TB24 10MG-1000 MG, 1000 MG-12.5 MG, 1000 MG-5 MG


SYNJARDY XR TB24 1000MG-25 MG 2 SL(1 ea daily);

MO; +Biguanidesmetformin hcl soln 500mg/5ml 1 SL(25.5 ml

daily); MO; *metformin hcl tabs 1000mg 1 SL(2.55 ea

daily); MO; *

metformin hcl tabs 500 mg 1 SL(5.1 eadaily); MO; *

metformin hcl tabs 850 mg 1 SL(3 ea daily);MO; *

metformin hcl tb24 500 mg 1(GLUCOPHAGE XR);SL(4 eadaily); MO; *

metformin hcl tb24 750 mg 1(GLUCOPHAGE XR);SL(2.66ea daily); MO; *

Diabetic Other



Drug Name DrugTier

Requirements/Limits

BAQSIMI ONE PACKPOWD 3 MO; +

BAQSIMI TWO PACKPOWD 3 MO; +

diazoxide susp 1 MO; *

GLUCAGEN HYPOKITSOLR 2 MO; +

GLUCAGONEMERGENCY KIT KIT 2 MO; +

GVOKE HYPOPEN 1-PACK SOAJ 3 MO; +

GVOKE HYPOPEN 2-PACK SOAJ 3 MO; +

GVOKE PFS SOSY 3 MO; +

KORLYM TABS 3PA; SL(4 eadaily); LA; MO;+

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

JANUVIA TABS 100 MG 2 QL(1 ea daily);MO; +



TRADJENTA TABS 2 QL(1 ea daily);MO; +

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET TABS 3 QL(6 ea daily);MO; +

Incretin Mimetic Agents (GLP-1 ReceptorBYDUREON BCISE AUIJ 2 MO; +

BYDUREON PEN PEN 2 MO; +

BYDUREON SRER 2 +

BYETTA SOPN 3 MO; +

OZEMPIC SOPN 2 MO; +

TRULICITY SOPN 0.75MG/0.5ML, 1.5 MG/0.5ML 3 MO; +

TRULICITY SOPN 3MG/0.5ML, 4.5 MG/0.5ML 3 +

Drug Name DrugTier

Requirements/Limits

VICTOZA SOPN 2Limit 9mls permonth;QL(0.3ml daily); MO; +

Insulin Sensitizing Agents

AVANDIA TABS 2 MG 2 SL(4 ea daily);MO; +

AVANDIA TABS 4 MG 2 SL(2 ea daily);MO; +

pioglitazone hcl tabs 15 mg 1 SL(3 ea daily);MO; *

pioglitazone hcl tabs 30 mg 1 SL(1.5 eadaily); MO; *

pioglitazone hcl tabs 45 mg 1 SL(1 ea daily);MO; *

Insulin

FIASP FLEXTOUCHSOPN 3

Limit 45mls permonth;QL(1.5ml daily); MO; +

FIASP PENFILL SOCT 3 QL(1.5 mldaily); MO; +

FIASP SOLN 3Limit 45mls permonth;QL(1.5ml daily); MO; +

HUMALOG JUNIORKWIKPEN SOPN 2


HUMALOG KWIKPENSOPN 2


HUMALOG MIX 50/50KWIKPEN SUPN 2


HUMALOG MIX 50/50SUSP 2


HUMALOG MIX 75/25KWIKPEN SUPN 2


HUMALOG MIX 75/25SUSP 2


HUMALOG SOCT 2Limit 45mls permonth;QL(1.5ml daily); MO; +



Drug Name DrugTier

Requirements/Limits

HUMALOG SOLN 2

Limit 45mls permonth;QL(1.5ml daily); MO;+

HUMULIN 70/30 KWIKPENSUPN 2


HUMULIN 70/30 SUSP 2


HUMULIN N KWIKPENSUPN 2


HUMULIN N SUSP 2


HUMULIN R SOLN 2


HUMULIN R U-500(CONCENTRATED) SOLN 2


HUMULIN R U-500KWIKPEN SOPN 2


INSULIN LISPRO JUNIORKWIKPEN SOPN 2


INSULIN LISPROPROTAMINE/INSULINLISPRO KWIKPEN SUPN

2


LANTUS SOLN 2


LANTUS SOLOSTARSOPN 2


Drug Name DrugTier

Requirements/Limits

LEVEMIR FLEXTOUCHSOPN 2


LEVEMIR SOLN 2Limit 45mls permonth;QL(1.5ml daily); MO; +

TOUJEO MAX SOLOSTARSOPN 2


TOUJEO SOLOSTARSOPN 2


TRESIBA FLEXTOUCHSOPN 100 UNIT/ML 2


TRESIBA FLEXTOUCHSOPN 200 UNIT/ML 2


TRESIBA SOLN 2 QL(1.5 mldaily); MO; +

Meglitinide Analogues

nateglinide tabs 1 QL(3 ea daily);MO; *

repaglinide tabs 0.5 mg 1 SL(32 ea daily);MO; *

repaglinide tabs 1 mg 1 SL(16 ea daily);MO; *

repaglinide tabs 2 mg 1 SL(8 ea daily);MO; *

Sodium-Glucose Co-Transporter 2 (SGLT2)INVOKANA TABS 2 MO; +

JARDIANCE TABS 2 MO; +

Sulfonylureas

glimepiride tabs 1 mg 1AL(Up to 64 yrsold); SL(8 eadaily); MO; *



glipizide tabs 10 mg 1 SL(4 ea daily);MO; *



Drug Name DrugTier

Requirements/Limits

glipizide tabs 5 mg 1 SL(8 ea daily);MO; *

glipizide tb24 10 mg 1 SL(2 ea daily);MO; *

glipizide tb24 2.5 mg 1 SL(8 ea daily);MO; *

glipizide tb24 5 mg 1 SL(4 ea daily);MO; *

glyburide micronized tabs1.5 mg 1


glyburide micronized tabs 3mg 1


glyburide micronized tabs 6mg 1


glyburide tabs 1.25 mg 1AL(Up to 64 yrsold); SL(16 eadaily); MO; *

glyburide tabs 2.5 mg 1AL(Up to 64 yrsold); SL(8 eadaily); MO; *

glyburide tabs 5 mg 1AL(Up to 64 yrsold); SL(4 eadaily); MO; *

tolbutamide tabs 1 SL(6 ea daily);MO; *

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat DiarrheaAntidiarrheal - Chloride Channel Antagonists

MYTESI TBEC 3 PA; QL(2 eadaily); MO; +

Antiperistaltic Agentsdiphenoxylate w/ atropinetabs 0.025 mg-2.5 mg 1 MO; *

loperamide hcl caps 1 RX/OTC; MO; *

MOTOFEN TABS 3 MO; +

opium tincture tinc 5 NDS;MO; +

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

Drug Name DrugTier

Requirements/Limits

CHEMET CAPS 3 MO; +

deferasirox pack 5 NDS; +

deferasirox tabs 5 NDS; +

deferasirox tbso 5 NDS; +

deferiprone tabs 5 PA; NDS;LA;MO; +

FERRIPROX TABS 1000MG 5 PA; NDS;LA;

MO; +FERRIPROX TWICE-A-DAY TABS 5 PA; NDS;MO; +

Antidotes and Specific AntagonistsVISTOGARD PACK 5 NDS;MO; +

Opioid AntagonistsEVZIO SOAJ 3 PA; MO; +

naloxone hcl soaj 2mg/0.4ml 1 PA; MO; *

naloxone hcl sosy 2mg/2ml 1 *

naltrexone hcl tabs 1 MO; *

NARCAN LIQD 3

1box=15DS,2boxes=30DS,Max 4ea/month;QL(0.134 ea daily);MO; +

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor Antagonistsgranisetron hcl tabs or 1mg 1 B/D; MO; *

ondansetron hcl soln ij 40mg/20ml, 4 mg/2ml 4 MO; +

ondansetron hcl soln or 4mg/5ml 1 MO; *

ondansetron hcl tabs or 24mg 1 *

ondansetron hcl tabs or 4mg, 8 mg 1 MO; *



Drug Name DrugTier

Requirements/Limits

ondansetron tbdp 1 MO; *

SANCUSO PTCH 5 NDS;MO; +

Antiemetics - Anticholinergicmeclizine hcl tabs 12.5 mg,25 mg 1 RX/OTC; MO; *

scopolamine pt72 1 MO; *

TIGAN SOLN IM 100MG/ML 4 MO; +

TRANSDERM SCOP PT72(scopolamine) 3 MO; +

TRANSDERM-SCOP PT72(scopolamine) 3 MO; +

trimethobenzamide hclcaps 1 MO; *

Antiemetics - MiscellaneousAKYNZEO CAPS OR 0.5MG-300 MG 3 B/D; +

dronabinol caps 1 B/D; MO; *

SYNDROS SOLN 5 B/D; NDS;MO;+

Substance P/Neurokinin 1 (NK1) Receptoraprepitant caps 125 mg, 80mg 1 B/D; MO; *

aprepitant caps 40 mg 1 PA; MO; *

VARUBI TBPK 3 B/D; +

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis InhibitorsERAXIS SOLR 4 +

micafungin sodium solr 100mg 5 NDS; +

micafungin sodium solr 50mg 5 NDS;MO; +

AntifungalsABELCET SUSP 4 PA; +

AMBISOME SUSR 4 PA; +

Drug Name DrugTier

Requirements/Limits

amphotericin b solr 4 PA; MO; +

flucytosine caps 1 MO; *

griseofulvin microsize susp 1 MO; *

griseofulvin microsize tabs 1 MO; *

griseofulvin ultramicrosizetabs 1 MO; *

nystatin tabs 1 MO; *

terbinafine hcl tabs 1 MO; *

Imidazole-Related AntifungalsCRESEMBA CAPS OR186 MG 5 NDS;MO; +

CRESEMBA SOLR IV 372MG 5 NDS; +

fluconazole in nacl soln 4 +

fluconazole susr 1 MO; *

fluconazole tabs 1 MO; *

itraconazole caps 100 mg 1 MO; *

itraconazole soln 10 mg/ml 5 NDS;MO; +

ketoconazole tabs 1 MO; *

NOXAFIL SOLN IV 300MG/16.7ML 5 NDS; +

NOXAFIL SUSP OR 40MG/ML 5 NDS;MO; +

posaconazole tbec 5 NDS;MO; +

TOLSURA CAPS 5 PA; NDS;MO; +

voriconazole solr iv 200 mg 1 *

voriconazole susr or 40mg/ml 1 MO; *

voriconazole tabs or 200mg, 50 mg 5 NDS;MO; +

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Ethanolamines



Drug Name DrugTier

Requirements/Limits

carbinoxamine maleatesoln 4 mg/5ml 1 AL(Up to 64 yrs

old); MO; *carbinoxamine maleatetabs 4 mg 1 AL(Up to 64 yrs

old); MO; *

clemastine fumarate tabs 1 AL(Up to 64 yrsold); MO; *

diphenhydramine hcl soln ij50 mg/ml 4 MO; +

Antihistamines - Non-Sedatingcetirizine hcl soln 1 mg/ml,5 mg/5ml 1 RX/OTC; MO; *

desloratadine tabs 5 mg 1 MO; *

desloratadine tbdp 5 mg 1 MO; *

levocetirizinedihydrochloride soln 1 RX/OTC; MO; *

levocetirizinedihydrochloride tabs 1 RX/OTC; MO; *

Antihistamines - Phenothiazinespromethazine hcl soln ij 50mg/ml, 25 mg/ml 4 AL(Up to 64 yrs

old); MO; +promethazine hcl soln or6.25 mg/5ml 1 AL(Up to 64 yrs

old); MO; *promethazine hcl supp re12.5 mg, 25 mg 1 AL(Up to 64 yrs

old); MO; *promethazine hcl syrp or6.25 mg/5ml 1 AL(Up to 64 yrs

old); MO; *promethazine hcl tabs or12.5 mg, 25 mg, 50 mg 1 AL(Up to 64 yrs

old); MO; *Antihistamines - Piperidines

cyproheptadine hcl syrp 1 AL(Up to 64 yrsold); MO; *

cyproheptadine hcl tabs 1 AL(Up to 64 yrsold); MO; *

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - Combinationsezetimibe-simvastatin tabs10 mg-10 mg 1 QL(8 ea daily);

MO; *ezetimibe-simvastatin tabs10 mg-20 mg 1 QL(4 ea daily);

MO; *ezetimibe-simvastatin tabs10 mg-40 mg 1 QL(2 ea daily);

MO; *

Drug Name DrugTier

Requirements/Limits

ezetimibe-simvastatin tabs10 mg-80 mg 1 QL(1 ea daily);

MO; *Antihyperlipidemics - Misc.icosapent ethyl caps 1 ST; MO; *

omega-3-acid ethyl esterscaps 1 MO; *

VASCEPA CAPS 0.5 GM 3 ST; MO; +

VASCEPA CAPS 1 GM(icosapent ethyl) 3 ST; MO; +

Bile Acid Sequestrantscholestyramine light pack 1 MO; *

cholestyramine light powd 1 MO; *

cholestyramine pack 1 MO; *

cholestyramine powd 1 MO; *

colesevelam hcl pack 1 MO; *

colesevelam hcl tabs 1 MO; *

colestipol hcl gran 1 MO; *

colestipol hcl pack 1 MO; *

colestipol hcl tabs 1 MO; *

Fibric Acid Derivatives

ANTARA CAPS 30 MG 3 SL(4.33 eadaily); MO; +

ANTARA CAPS 90 MG 3 SL(1.44 eadaily); MO; +

choline fenofibrate cpdr 1 MO; *

fenofibrate caps 150 mg,50 mg 1 MO; *

fenofibrate micronized caps130 mg 1 SL(1 ea daily);

MO; *fenofibrate micronized caps134 mg, 200 mg, 67 mg 1 MO; *

fenofibrate micronized caps43 mg 1 SL(3.02 ea

daily); MO; *



Drug Name DrugTier

Requirements/Limits

fenofibrate tabs 120 mg, 40mg, 145 mg, 48 mg, 54 mg,160 mg

1MO; *

fenofibric acid tabs 105 mg,35 mg 1 *

FIBRICOR TABS 105 MG,35 MG (fenofibric acid) 3 +

gemfibrozil tabs 1 MO; *

LIPOFEN CAPS(fenofibrate) 3 MO; +

HMG CoA Reductase InhibitorsALTOPREV TB24 3 MO; +

atorvastatin calcium tabs 1 MO; *

fluvastatin sodium caps 20mg 1 QL(3 ea daily);

MO; *fluvastatin sodium caps 40mg 1 QL(2 ea daily);

MO; *fluvastatin sodium tb24 80mg 1 MO; *

LIVALO TABS 3 MO; +

lovastatin tabs 10 mg, 20mg 1 QL(1 ea daily);

MO; *

lovastatin tabs 40 mg 1 QL(2 ea daily);MO; *

pravastatin sodium tabs 1 QL(1 ea daily);MO; *

rosuvastatin calcium tabs 1 QL(1 ea daily);MO; *

simvastatin tabs 10 mg, 20mg, 40 mg, 5 mg 1 QL(1 ea daily);

MO; *

simvastatin tabs 80 mg 1 SL(1 ea daily);MO; *

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs 1 QL(1 ea daily);MO; *

Microsomal Triglyceride Transfer Protein (MTP)

JUXTAPID CAPS 10 MG 5PA; NDS;SL(6ea daily); LA;MO; +


Drug Name DrugTier

Requirements/Limits


JUXTAPID CAPS 40 MG 5

PA;NDS;SL(1.5 eadaily); LA; MO;+



Nicotinic Acid Derivativesniacin (antihyperlipidemic)tbcr 1000 mg, 500 mg, 750mg

1MO; *

Proprotein Convertase Subtilisin/Kexin Type 9

PRALUENT SOAJ 150MG/ML 4

PA; Limit 2mlsper 28days;SL(0.08ml daily); MO; +

PRALUENT SOAJ 75MG/ML 4

PA; Limit 4mlsper 28days;SL(0.15ml daily); MO; +

REPATHA PUSHTRONEXSYSTEM SOCT 4 PA; MO; +

REPATHA SOSY 4 PA; MO; +

REPATHA SURECLICKSOAJ 4 PA; MO; +

ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE Inhibitorsbenazepril hcl tabs 1 MO; *

captopril tabs 1 MO; *

enalapril maleate tabs 10mg 1 SL(4 ea daily);

MO; *enalapril maleate tabs 2.5mg 1 SL(16 ea daily);

MO; *enalapril maleate tabs 20mg 1 SL(2 ea daily);

MO; *



Drug Name DrugTier

Requirements/Limits

enalapril maleate tabs 5mg 1 SL(8 ea daily);

MO; *

fosinopril sodium tabs 1 MO; *

lisinopril tabs 1 MO; *

moexipril hcl tabs 1 MO; *

perindopril erbumine tabs 2mg 1 SL(8 ea daily);

MO; *perindopril erbumine tabs 4mg 1 SL(4 ea daily);

MO; *perindopril erbumine tabs 8mg 1 SL(2 ea daily);

MO; *

quinapril hcl tabs 1 MO; *

ramipril caps 1 MO; *

trandolapril tabs 1 MO; *

Agents for PheochromocytomaDEMSER CAPS(metyrosine) 5 NDS;MO; +

metyrosine caps 5 NDS;MO; +

phenoxybenzamine hclcaps 1 MO; *

Angiotensin II Receptor Antagonistscandesartan cilexetil tabs 1 MO; *

EDARBI TABS 3 QL(1 ea daily);MO; +

irbesartan tabs 1 MO; *

losartan potassium tabs 1 MO; *

olmesartan medoxomil tabs 1 MO; *

telmisartan tabs 1 MO; *

valsartan tabs 1 MO; *

Antiadrenergic Antihypertensivesclonidine hcl tabs 1 MO; *

clonidine ptwk 1 MO; *

Drug Name DrugTier

Requirements/Limits

doxazosin mesylate tabs 1 MO; *

guanfacine hcl tabs 1 AL(Up to 64 yrsold); MO; *

methyldopa tabs 1 AL(Up to 64 yrsold); MO; *

prazosin hcl caps 1 MO; *

terazosin hcl caps 1 MO; *

Antihypertensive Combinationsamlodipine besylate-benazepril hcl caps 1 MO; *

amlodipine besylate-olmesartan medoxomil tabs 1 MO; *

amlodipine besylate-valsartan tabs 10 mg-160mg, 10 mg-320 mg, 320mg-5 mg

1


amlodipine besylate-valsartan tabs 160 mg-5mg


amlodipine-valsartan-hydrochlorothiazide tabs 10mg-12.5 mg-160 mg, 10mg-160 mg-25 mg, 10 mg-25 mg-320 mg, 160 mg-25mg-5 mg

1


amlodipine-valsartan-hydrochlorothiazide tabs12.5 mg-160 mg-5 mg


atenolol & chlorthalidonetabs 1 MO; *

benazepril &hydrochlorothiazide tabs 1 MO; *

bisoprolol &hydrochlorothiazide tabs 1 MO; *

candesartan cilexetil-hydrochlorothiazide tabs 1 MO; *

captopril &hydrochlorothiazide tabs 1 MO; *

EDARBYCLOR TABS 3 QL(1 ea daily);MO; +

enalapril maleate &hydrochlorothiazide tabs 1 MO; *

fosinopril sodium &hydrochlorothiazide tabs 1 MO; *



Drug Name DrugTier

Requirements/Limits

irbesartan-hydrochlorothiazide tabs 1 MO; *

lisinopril &hydrochlorothiazide tabs 1 MO; *

losartan potassium &hydrochlorothiazide tabs 1 MO; *

metoprolol &hydrochlorothiazide tabs 1 MO; *

nadolol &bendroflumethiazide tabs 1 *

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

1MO; *

olmesartan medoxomil-hydrochlorothiazide tabs 1 MO; *

propranolol &hydrochlorothiazide tabs 1 MO; *

quinapril-hydrochlorothiazide tabs 1 MO; *

TEKTURNA HCT TABS 2 MO; +

telmisartan-amlodipine tabs 1 MO; *

telmisartan-hydrochlorothiazide tabs 1 MO; *

trandolapril-verapamil hcltbcr 2 mg-240 mg, 240 mg-4 mg

1MO; *

valsartan-hydrochlorothiazide tabs12.5 mg-80 mg, 12.5 mg-160 mg

1


valsartan-hydrochlorothiazide tabs160 mg-25 mg, 25 mg-320mg, 12.5 mg-320 mg

1


Direct Renin Inhibitorsaliskiren fumarate tabs 1 MO; *

Selective Aldosterone Receptor Antagonistseplerenone tabs 1 MO; *

Vasodilatorshydralazine hcl tabs or 10mg, 100 mg, 50 mg, 25 mg 1 MO; *

Drug Name DrugTier

Requirements/Limits

minoxidil tabs 1 MO; *

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinationsatovaquone-proguanil hcltabs 1 MO; *

COARTEM TABS 3 MO; +

Antimalarialschloroquine phosphate tabs250 mg, 500 mg 1 MO; *

hydroxychloroquine sulfatetabs 1 MO; *

KRINTAFEL TABS 3 QL(0.067 eadaily); +

mefloquine hcl tabs 1 MO; *

primaquine phosphate tabs 1 MO; *

PRIMAQUINEPHOSPHATE TABS(primaquine phosphate)

3MO; +

pyrimethamine tabs 1 MO; *

quinine sulfate caps 1 PA; MO; *

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents

FIRDAPSE TABS 5PA; NDS;SL(8ea daily); LA;MO; +

GUANIDINE HCL TABS 2 +

pyridostigmine bromidetabs 60 mg 1 MO; *

pyridostigmine bromide tbcr180 mg 1 MO; *

RUZURGI TABS 5PA; NDS;SL(10ea daily); MO;+

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Antimycobacterial Agents



Drug Name DrugTier

Requirements/Limits

aminosalicylic acid pack 1 MO; *

CAPASTAT SULFATESOLR 4 +

ethambutol hcl tabs 1 MO; *

isoniazid tabs or 100 mg,300 mg 1 MO; *

PRETOMANID TABS 3 PA; +

PRIFTIN TABS 3 MO; +

pyrazinamide tabs 1 MO; *

rifabutin caps 5 NDS;MO; +

rifampin caps or 150 mg,300 mg 1 MO; *

rifampin solr iv 600 mg 4 +

SIRTURO TABS 5 NDS;LA; +

TRECATOR TABS 3 MO; +

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating AgentsBENDEKA SOLN 5 NDS; +

busulfan soln 4 +

carboplatin soln 1000mg/100ml 4 +

carboplatin soln 450mg/45ml, 50 mg/5ml, 600mg/60ml, 150 mg/15ml, 50mg/5ml

1

*

carmustine solr 4 +

cisplatin soln 100mg/100ml, 200 mg/200ml,50 mg/50ml

4+

cyclophosphamide caps or25 mg, 50 mg 1 B/D; MO; *

CYCLOPHOSPHAMIDESOLN IV 1 GM/5ML, 500MG/2.5ML

5NDS; +

Drug Name DrugTier

Requirements/Limits

EVOMELA SOLR 5 NDS; +

GLEOSTINE CAPS 3 MO; +

IFEX SOLR 3 GM 4 +

ifosfamide soln 1 gm/20ml,3 gm/60ml 4 +

ifosfamide solr 1 gm 4 +

IFOSFAMIDE SOLR 3 GM 4 +

LEUKERAN TABS 3 MO; +

melphalan hcl solr 4 +

melphalan tabs 1 B/D; MO; *

oxaliplatin soln 100mg/20ml 1 *

oxaliplatin soln 200mg/40ml 4 +

oxaliplatin soln 50 mg/10ml 5 NDS; +

oxaliplatin solr 100 mg, 50mg 5 NDS; +

TEMODAR SOLR 5 NDS; +

thiotepa solr 15 mg 5 NDS; +

TREANDA SOLR 5 NDS; +

YONDELIS SOLR 5 NDS;LA; +

ZANOSAR SOLR 4 MO; +

ZEPZELCA SOLR 5 NDS; +

AntimetabolitesALIMTA SOLR 5 NDS; +

ARRANON SOLN 5 NDS; +

azacitidine susr 5 NDS; +

cladribine soln 4 PA; +

clofarabine soln 4 +



Drug Name DrugTier

Requirements/Limits

cytarabine soln 4 PA; +

decitabine solr 1 *

fludarabine phosphate solr50 mg 1 *

fluorouracil soln 4 PA; +

FOLOTYN SOLN 5 NDS; +

gemcitabine hcl soln 1gm/10ml, 2 gm/20ml, 200mg/2ml

1*

gemcitabine hcl soln 200mg/5.26ml, 1 gm/26.3ml, 2gm/52.6ml

5NDS; +

gemcitabine hcl solr 2 gm,1 gm 1 *

gemcitabine hcl solr 200mg 5 NDS; +

GEMCITABINE SOLN(gemcitabine hcl) 5 NDS; +

INFUGEM SOLN 5 NDS; +

mercaptopurine tabs 1 MO; *

methotrexate sodium soln ij1 gm/40ml 4 +

methotrexate sodium soln ij250 mg/10ml, 50 mg/2ml,250 mg/10ml, 50 mg/2ml

4MO; +

methotrexate sodium solr ij1 gm 4 +

methotrexate sodium tabsor 10 mg, 15 mg, 5 mg, 7.5mg, 2.5 mg

1MO; *

ONUREG TABS 5 PA; NDS; +

PURIXAN SUSP 5 PA; NDS; +

TABLOID TABS 2 MO; +

XATMEP SOLN 3 PA; MO; +

Antineoplastic - Angiogenesis InhibitorsAVASTIN SOLN 5 PA; NDS; +

Drug Name DrugTier

Requirements/Limits

CYRAMZA SOLN 5 NDS;LA; +

MVASI SOLN 5 NDS; +

ZALTRAP SOLN 5 PA; NDS; +

ZIRABEV SOLN 5 NDS; +

Antineoplastic - AntibodiesARZERRA CONC 5 NDS; +

BAVENCIO SOLN 5 NDS;LA; +

BESPONSA SOLR 5 NDS; +

BLENREP SOLR 5 NDS;MO; +

BLINCYTO SOLR 5 NDS; +

CAMPATH SOLN 5 NDS; +

DARZALEX SOLN 5 NDS;LA; +

EMPLICITI SOLR 5 NDS; +

ENHERTU SOLR 5 NDS; +

ERBITUX SOLN 5 NDS; +

GAZYVA SOLN 5 NDS;LA; +

HERCEPTIN SOLR 5 PA; NDS; +

IMFINZI SOLN 5 NDS;LA; +

KADCYLA SOLR 5 PA; NDS; +

KANJINTI SOLR 5 NDS; +

KEYTRUDA SOLN 5 PA; NDS; +

LARTRUVO SOLN 5 NDS;LA; MO; +

LIBTAYO SOLN 5 NDS;LA; MO; +

LUMOXITI SOLR 5 NDS;LA; +

MONJUVI SOLR 5 NDS;MO; +



Drug Name DrugTier

Requirements/Limits

MYLOTARG SOLR 5 NDS; +

OGIVRI SOLR 5 NDS; +

OPDIVO SOLN 5 NDS; +

PADCEV SOLR 20 MG 5 NDS;SL(7 eadaily); +

PADCEV SOLR 30 MG 5 NDS;SL(5 eadaily); +

PERJETA SOLN 5 NDS; +

POLIVY SOLR 140 MG 5 NDS; +

PORTRAZZA SOLN 5 NDS; +

POTELIGEO SOLN 5 NDS; +

RITUXAN SOLN 5 PA; NDS; +

RUXIENCE SOLN 5 NDS; +

SARCLISA SOLN 5 NDS; +

TECENTRIQ SOLN 5 PA; NDS; +

TRAZIMERA SOLR 5 NDS; +

TRODELVY SOLR 5 NDS;MO; +

TRUXIMA SOLN 5 NDS; +

VECTIBIX SOLN 5 NDS; +

YERVOY SOLN 5 PA; NDS; +

Antineoplastic - BCL-2 InhibitorsVENCLEXTA STARTINGPACK TBPK 3 PA; LA; MO; +

VENCLEXTA TABS 3 PA; LA; MO; +

Antineoplastic - Hedgehog Pathway InhibitorsDAURISMO TABS 5 PA; NDS; +

ERIVEDGE CAPS 5 NDS;LA; +

ODOMZO CAPS 5 PA; NDS;LA; +

Drug Name DrugTier

Requirements/Limits

Antineoplastic - Hormonal and Related Agentsabiraterone acetate tabs 5 PA; NDS; +

anastrozole tabs 1 MO; *

bicalutamide tabs 1 MO; *

DEPO-PROVERA SUSP 4 MO; +

ELIGARD KIT 4 +

EMCYT CAPS 3 MO; +

ERLEADA TABS 5 PA; NDS; +

exemestane tabs 1 MO; *

FASLODEX SOLN(fulvestrant) 5 NDS;MO; +

FIRMAGON SOLR 120MG/VIAL 5 NDS; +

FIRMAGON SOLR 80 MG 4 +

flutamide caps 1 MO; *

fulvestrant soln 5 NDS;MO; +

hydroxyprogesteronecaproate (antineoplastic)soln

5NDS; +

letrozole tabs 1 MO; *

leuprolide acetate kit 4 +

LUPRON DEPOT (1-MONTH) KIT 3.75 MG 4 +

LUPRON DEPOT (1-MONTH) KIT 7.5 MG 5 NDS; +

LUPRON DEPOT (3-MONTH) KIT 5 NDS; +



LYSODREN TABS 2 +

megestrol acetate susp 1 AL(Up to 64 yrsold); MO; *



Drug Name DrugTier

Requirements/Limits

megestrol acetate tabs 1 AL(Up to 64 yrsold); MO; *

nilutamide tabs 1 MO; *

NUBEQA TABS 5 PA; NDS; +

SOLTAMOX SOLN 3 MO; +

tamoxifen citrate tabs 1 MO; *

toremifene citrate tabs 5 NDS;MO; +

TRELSTAR MIXJECTSUSR 11.25 MG, 3.75 MG 4 +

TRELSTAR MIXJECTSUSR 22.5 MG 5 NDS; +

VANTAS KIT 5 NDS; +

XTANDI CAPS 5 PA; NDS;LA; +

YONSA TABS 5 PA; NDS; +

ZOLADEX IMPL 3 +

ZYTIGA TABS 500 MG 5 PA; NDS; +

Antineoplastic - ImmunomodulatorsPOMALYST CAPS 5 NDS;LA; +

Antineoplastic - XPO1 InhibitorsXPOVIO 100 MG ONCEWEEKLY TBPK 5 PA; NDS;MO;

+XPOVIO 40 MG ONCEWEEKLY TBPK 5 PA; NDS;MO;

+XPOVIO 40 MG TWICEWEEKLY TBPK 5 PA; NDS;MO;





+Antineoplastic Antibioticsbleomycin sulfate solr 4 PA; +

Drug Name DrugTier

Requirements/Limits

dactinomycin solr 4 +

daunorubicin hcl soln 4 +

DAUNORUBICINHYDROCHLORIDE SOLN20 MG/4ML (daunorubicinhcl)

4

+

DAUNORUBICINHYDROCHLORIDE SOLN50 MG/10ML

5NDS; +

doxorubicin hcl liposomalinj 1 *

doxorubicin hcl soln 4 +

doxorubicin hcl solr 4 +

epirubicin hcl soln 4 +

idarubicin hcl soln 4 +

mitomycin solr 4 +

mitoxantrone hcl conc 1 *

valrubicin soln 5 NDS; +

VALSTAR SOLN(valrubicin) 5 NDS; +

Antineoplastic CombinationsDARZALEX FASPROSOLN 5 NDS;LA; +

HERCEPTIN HYLECTASOLN 5 NDS; +

INQOVI TABS 5 PA; NDS; +

KISQALI FEMARA 200DOSE TBPK 5 PA; NDS; +



LONSURF TABS 5 PA; NDS; +

PHESGO SOLN 5 NDS; +

RITUXAN HYCELA SOLN 5 NDS; +



Drug Name DrugTier

Requirements/Limits

VYXEOS SUSR 5 NDS;MO; +

Antineoplastic Enzyme InhibitorsAFINITOR DISPERZ TBSO 5 PA; NDS; +

AFINITOR TABS 10 MG 5 PA; NDS; +

ALECENSA CAPS 5 PA; NDS;LA; +

ALIQOPA SOLR 5 NDS;MO; +

ALUNBRIG TABS 5 PA; NDS;LA; +

ALUNBRIG TBPK 5 PA; NDS;LA; +

AYVAKIT TABS 5 PA; NDS;MO;+

BALVERSA TABS 5 PA; NDS;LA;MO; +

BELEODAQ SOLR 5 PA; NDS; +

BORTEZOMIB SOLR 5 NDS; +

BOSULIF TABS 5 PA; NDS; +

BRAFTOVI CAPS 75 MG 5 PA; NDS;MO;+

BRUKINSA CAPS 5 PA; NDS;MO;+

CABOMETYX TABS 5 PA; NDS; +

CALQUENCE CAPS 5 PA; NDS;LA;MO; +

CAPRELSA TABS 100 MG 5 PA; NDS;MO;+

CAPRELSA TABS 300 MG 5 PA; NDS;LA;MO; +

COMETRIQ KIT 5 PA; NDS;LA; +

COPIKTRA CAPS 5 PA; NDS;MO;+

COTELLIC TABS 5 PA; NDS;LA; +

erlotinib hcl tabs 1 PA; *

everolimus tabs 5 PA; NDS; +

Drug Name DrugTier

Requirements/Limits

FARYDAK CAPS 5 PA; NDS;LA; +

GAVRETO CAPS 5 PA; NDS;MO; +

GILOTRIF TABS 5 PA; NDS;LA;MO; +

IBRANCE CAPS 5 NDS;LA; +

IBRANCE TABS 5 NDS;LA; +

ICLUSIG TABS 15 MG, 45MG 5 PA; NDS;LA;

MO; +

IDHIFA TABS 5 PA; NDS; +

imatinib mesylate tabs 1 PA; *

IMBRUVICA CAPS 5 PA; NDS;LA;MO; +

IMBRUVICA TABS 5 PA; NDS;LA;MO; +

INLYTA TABS 5 PA; NDS;LA; +

INREBIC CAPS 5 PA; NDS;LA; +

IRESSA TABS 5 NDS;LA; +

ISTODAX (OVERFILL)SOLR 5 NDS; +

JAKAFI TABS 5 PA; NDS;LA; +

KISQALI TBPK 5 PA; NDS; +

KOSELUGO CAPS 5 PA; NDS;MO; +

KYPROLIS SOLR 5 NDS; +

lapatinib ditosylate tabs 5 NDS; +

LENVIMA 10 MG DAILYDOSE CPPK 5 PA; NDS; +

LENVIMA 12MG DAILYDOSE CPPK 5 PA; NDS; +






Drug Name DrugTier

Requirements/Limits




LORBRENA TABS 5 PA; NDS; +

LYNPARZA TABS 5 PA; NDS;LA; +

MEKINIST TABS 5 PA; NDS; +

MEKTOVI TABS 5 PA; NDS; +

NERLYNX TABS 5 PA; NDS;LA; +

NEXAVAR TABS 5 NDS;LA; +

NINLARO CAPS 5 PA; NDS; +

PEMAZYRE TABS 5 PA; NDS;MO;+

PIQRAY 200MG DAILYDOSE TBPK 5 PA; NDS; +



QINLOCK TABS 5 PA; NDS;LA;MO; +

RETEVMO CAPS 5 PA; NDS; +

ROMIDEPSIN SOLN 27.5MG/5.5ML 5 NDS; +

ROMIDEPSIN SOLR 10MG 5 NDS; +

ROZLYTREK CAPS 5 PA; NDS; +

RUBRACA TABS 5 PA; NDS;LA; +

RYDAPT CAPS 5 PA; NDS; +

SPRYCEL TABS 5 PA; NDS; +

STIVARGA TABS 5 PA; NDS;LA; +

SUTENT CAPS 5 NDS; +

Drug Name DrugTier

Requirements/Limits

TABRECTA TABS 5 PA; NDS; +

TAFINLAR CAPS 5 NDS; +

TAGRISSO TABS 5 PA; NDS;LA; +

TALZENNA CAPS 5 PA; NDS; +

TASIGNA CAPS 5 PA; NDS; +

TAZVERIK TABS 5 PA; NDS;MO; +

temsirolimus soln 5 NDS; +

TIBSOVO TABS 5 PA; NDS;LA; +

TUKYSA TABS 5 PA; NDS;MO; +

TURALIO CAPS 5 PA; NDS;LA;MO; +

TYKERB TABS (lapatinibditosylate) 5 NDS; +

VELCADE SOLR 5 NDS; +

VERZENIO TABS 5 PA; NDS; +

VITRAKVI CAPS 5 PA; NDS; +

VITRAKVI SOLN 5 PA; NDS; +

VIZIMPRO TABS 5 PA; NDS; +

VOTRIENT TABS 5 PA; NDS; +

XALKORI CAPS 5 PA; NDS; +

XOSPATA TABS 5 PA; NDS;LA;MO; +

ZEJULA CAPS 5 PA; NDS;LA;MO; +

ZELBORAF TABS 5 PA; NDS;LA; +

ZOLINZA CAPS 5 NDS; +

ZYDELIG TABS 5 PA; NDS;LA; +

ZYKADIA TABS 5 PA; NDS;LA; +

Antineoplastic Enzymes



Drug Name DrugTier

Requirements/Limits

ERWINAZE SOLR 5 NDS; +

Antineoplastics Misc.ACTIMMUNE SOLN 5 NDS;LA; +

arsenic trioxide soln 5 NDS; +

bexarotene caps 5 NDS; +

dacarbazine solr 4 +

hydroxyurea caps 1 MO; *

INTRON A SOLN 10MU/ML 5 NDS; +

INTRON A SOLN 6000000UNIT/ML 4 +

INTRON A SOLR 10 MU,18 MU, 50 MU 5 NDS; +

MATULANE CAPS 5 NDS;LA; +

NIPENT SOLR 4 +

PROLEUKIN SOLR 5 NDS; +

SYLATRON KIT 5 NDS; +

SYNRIBO SOLR 5 NDS;MO; +

TICE BCG SUSR 5 NDS; +

tretinoin (chemotherapy)caps 5 NDS;MO; +

Chemotherapy AdjunctsELITEK SOLR 5 NDS; +

KEPIVANCE SOLR 5 NDS; +

Chemotherapy Rescue/Antidote Agentsdexrazoxane hcl solr 4 +

KHAPZORY SOLR 5 NDS; +

leucovorin calcium solr ij100 mg, 200 mg, 350 mg,50 mg, 500 mg

4+

leucovorin calcium tabs or25 mg, 5 mg, 10 mg, 15 mg 1 MO; *

Drug Name DrugTier

Requirements/Limits

levoleucovorin calcium soln250 mg/25ml, 175mg/17.5ml

5NDS; +

levoleucovorin calcium solr50 mg 4 +

mesna soln 4 +

MESNEX TABS OR 400MG 5 NDS;MO; +

Mitotic InhibitorsABRAXANE SUSR 5 NDS;MO; +

docetaxel conc 20 mg/ml,80 mg/4ml 5 NDS; +

docetaxel soln 160mg/16ml, 20 mg/2ml, 80mg/8ml

5NDS; +

ETOPOPHOS SOLR 4 +

etoposide soln 4 +

HALAVEN SOLN 5 NDS; +

IXEMPRA KIT SOLR 5 NDS; +

JEVTANA SOLN 5 NDS; +

MARQIBO SUSP 5 NDS;MO; +

paclitaxel conc 150mg/25ml, 100 mg/16.7ml,30 mg/5ml, 300 mg/50ml, 6mg/ml

4

+

vinblastine sulfate soln 4 PA; MO; +

vincristine sulfate soln 4 PA; MO; +

vinorelbine tartrate soln 10mg/ml 4 +

vinorelbine tartrate soln 50mg/5ml 4 MO; +

Oncolytic Viral Agents

IMLYGIC SUSP 4 1000000Unit/ML;MO; +

IMLYGIC SUSP 5NDS;100000000Unit/ML;MO; +



Drug Name DrugTier

Requirements/Limits

Topoisomerase I Inhibitorsirinotecan hcl soln 300mg/15ml 4 +

irinotecan hcl soln 500mg/25ml, 40 mg/2ml, 100mg/5ml

1*

ONIVYDE INJ 5 NDS;MO; +

topotecan hcl solr 4 mg 5 NDS; +

ANTIPARKINSON AND RELATED THERAPYAGENTS - Drugs to Treat Parkinson's DiseaseAntiparkinson Adjunctive Therapycarbidopa tabs 1 MO; *

Antiparkinson Anticholinergicsbenztropine mesylate solnij 1 mg/ml 4 MO; +

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg 1 AL(Up to 64 yrs

old); MO; *

trihexyphenidyl hcl soln 1 AL(Up to 64 yrsold); MO; *

trihexyphenidyl hcl tabs 1 AL(Up to 64 yrsold); MO; *

Antiparkinson COMT Inhibitors

entacapone tabs 1 SL(8 ea daily);MO; *

tolcapone tabs 1 MO; *

Antiparkinson Dopaminergicsamantadine hcl caps 1 MO; *

amantadine hcl syrp 1 MO; *

amantadine hcl tabs 1 MO; *

APOKYN SOCT 5 NDS;LA; +

bromocriptine mesylatecaps 1 MO; *

bromocriptine mesylatetabs 1 MO; *

carbidopa-levodopa tabs 1 MO; *

carbidopa-levodopa tbcr 1 MO; *

Drug Name DrugTier

Requirements/Limits

carbidopa-levodopa tbdp 1 MO; *

carbidopa-levodopa-entacapone tabs 1 MO; *

DUOPA SUSP 3 B/D; MO; +

GOCOVRI CP24 5 PA; NDS;MO; +

NEUPRO PT24 3 MO; +

OSMOLEX ER TB24 129MG, 193 MG, 258 MG 3 PA; SL(1 ea

daily); MO; +pramipexoledihydrochloride tabs 1 MO; *

pramipexoledihydrochloride tb24 1 MO; *

ropinirole hydrochloridetabs 1 MO; *

ropinirole hydrochloridetb24 1 MO; *

RYTARY CPCR 3 MO; +

STALEVO 100 TABS(carbidopa-levodopa-entacapone)

3MO; +


3MO; +


3MO; +


3MO; +


3MO; +


3MO; +

Antiparkinson Monoamine Oxidase Inhibitorsrasagiline mesylate tabs 1 MO; *

selegiline hcl caps 1 MO; *

selegiline hcl tabs 1 MO; *



Drug Name DrugTier

Requirements/Limits

ZELAPAR TBDP 3 MO; +

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agentslithium carbonate caps 1 MO; *

lithium carbonate tabs 1 MO; *

lithium carbonate tbcr 1 MO; *

LITHIUM SOLN 2 MO; +

Antipsychotics - Misc.

CAPLYTA CAPS 5 PA; NDS;MO;+

EQUETRO CP12 3 MO; +

LATUDA TABS 120 MG 5


LATUDA TABS 20 MG 5PA; NDS;SL(8ea daily); MO;+


LATUDA TABS 60 MG 5



NUPLAZID CAPS 34 MG 5 PA; NDS;LA; +

NUPLAZID TABS 10 MG 5 PA; NDS;LA; +

NUPLAZID TABS 17 MG 5 PA; NDS; +

VRAYLAR CAPS 1.5 MG 3 PA; SL(4 eadaily); MO; +

VRAYLAR CAPS 3 MG 3 PA; SL(2 eadaily); MO; +

VRAYLAR CAPS 4.5 MG 3 PA; SL(1.4 eadaily); MO; +

Drug Name DrugTier

Requirements/Limits

VRAYLAR CAPS 6 MG 3 PA; SL(1 eadaily); MO; +

VRAYLAR CPPK 3 PA; MO; +

ziprasidone hcl caps 1 MO; *

ziprasidone mesylate solr 4 MO; +

BenzisoxazolesFANAPT TABS 1 MG, 10MG, 2 MG, 4 MG 3 MO; +

FANAPT TABS 12 MG, 6MG, 8 MG 5 NDS;MO; +

FANAPT TITRATIONPACK TABS 3 MO; +

INVEGA SUSTENNASUSY 4 MO; +

INVEGA TRINZA SUSY 4 +

paliperidone tb24 1.5 mg 1 SL(8 ea daily);MO; *

paliperidone tb24 3 mg 1 SL(4 ea daily);MO; *

paliperidone tb24 6 mg 1 SL(2 ea daily);MO; *

paliperidone tb24 9 mg 5NDS;SL(1.33ea daily); MO;+

PERSERIS PRSY 5 PA; NDS; +

RISPERDAL CONSTASRER 12.5 MG 4

Limit 8 vials per28days;SL(0.29ea daily); MO;+

RISPERDAL CONSTASRER 25 MG 4

Limit 4 vials per28days;SL(0.15ea daily); MO;+

RISPERDAL CONSTASRER 37.5 MG 5

NDS; Limit 4vials per 42days;SL(0.1 eadaily); MO; +



Drug Name DrugTier

Requirements/Limits

RISPERDAL CONSTASRER 50 MG 5

NDS; Limit 2vials per 28days;SL(0.08ea daily); MO;+

risperidone soln 1 MO; *

risperidone tabs 1 MO; *

risperidone tbdp 1 MO; *

Butyrophenoneshaloperidol decanoate soln 1 MO; *

haloperidol lactate conc 1 MO; *

haloperidol lactate soln 1 MO; *

haloperidol tabs 1 MO; *

Dibenzapinesclozapine tabs 100 mg, 200mg, 25 mg, 50 mg 1 *

clozapine tbdp 100 mg,12.5 mg, 25 mg, 150 mg 1 *

clozapine tbdp 200 mg 5 NDS; +

CLOZARIL TABS 50 MG(clozapine) 3 +

loxapine succinate caps 1 MO; *

olanzapine solr 1 MO; *

olanzapine tabs 1 MO; *

olanzapine tbdp 1 MO; *

quetiapine fumarate tabs100 mg, 200 mg, 25 mg,300 mg, 400 mg, 50 mg

1MO; *

quetiapine fumarate tb24150 mg, 200 mg, 300 mg,400 mg, 50 mg

1PA; MO; *

SAPHRIS SUBL 10 MG 5 NDS;SL(2 eadaily); MO; +

SAPHRIS SUBL 2.5 MG 3 SL(8 ea daily);MO; +

Drug Name DrugTier

Requirements/Limits

SAPHRIS SUBL 5 MG 3 SL(4 ea daily);MO; +

SECUADO PT24 3.8MG/24HR 5 PA; NDS;SL(2

ea daily); +

SECUADO PT24 5.7MG/24HR 5

PA;NDS;SL(1.34ea daily); +

SECUADO PT24 7.6MG/24HR 5 PA; NDS;SL(1

ea daily); +

VERSACLOZ SUSP 5 PA; NDS;SL(18ml daily); +

ZYPREXA RELPREVVSUSR 4 +

Dihydroindolonesmolindone hcl tabs 1 *

Phenothiazineschlorpromazine hcl soln ij25 mg/ml 4 MO; +

CHLORPROMAZINE HCLSOLN IJ 50 MG/2ML 4 +

chlorpromazine hcl tabs or10 mg, 200 mg, 25 mg, 100mg, 50 mg

1MO; *

CHLORPROMAZINEHYDROCHLORIDE SOLN 4 +

fluphenazine decanoatesoln 4 MO; +

fluphenazine hcl conc or 5mg/ml 1 MO; *

fluphenazine hcl soln ij 2.5mg/ml 4 MO; +

fluphenazine hcl tabs or 1mg, 10 mg, 2.5 mg, 5 mg 1 MO; *

perphenazine tabs 1 MO; *

prochlorperazine edisylatesoln 10 mg/2ml 4 MO; +

prochlorperazine edisylatesoln 50 mg/10ml 4 +

prochlorperazine maleatetabs 1 MO; *

prochlorperazine supp 1 MO; *

thioridazine hcl tabs 1 MO; *



Drug Name DrugTier

Requirements/Limits

trifluoperazine hcl tabs 1 MO; *

Quinolinone DerivativesABILIFY MAINTENA PRSY 5 NDS;MO; +

ABILIFY MAINTENA SRER 5 NDS;MO; +

aripiprazole soln 1 mg/ml 1 SL(30 ml daily);MO; *

aripiprazole tabs 10 mg 1 SL(3 ea daily);MO; *



aripiprazole tabs 20 mg 3 SL(1.5 eadaily); MO; +

aripiprazole tabs 30 mg 3 SL(1 ea daily);MO; +


aripiprazole tbdp 10 mg 5 NDS;SL(3 eadaily); MO; +

aripiprazole tbdp 15 mg 5 NDS;SL(2 eadaily); MO; +

ARISTADA INITIO PRSY 5 NDS; +

ARISTADA PRSY 5 NDS; +

REXULTI TABS 0.25 MG 5PA; NDS;SL(16ea daily); MO;+

REXULTI TABS 0.5 MG 5PA; NDS;SL(8ea daily); MO;+

REXULTI TABS 1 MG 5PA; NDS;SL(4ea daily); MO;+


REXULTI TABS 3 MG 5


Drug Name DrugTier

Requirements/Limits


Thioxanthenesthiothixene caps 1 MO; *

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretroviralsabacavir sulfate soln 1 MO; *

abacavir sulfate tabs 1 MO; *

abacavir sulfate-lamivudinetabs 1 MO; *

abacavir sulfate-lamivudine-zidovudine tabs 5 NDS;MO; +

APTIVUS CAPS 250 MG 2 MO; +

APTIVUS SOLN 100MG/ML 2 +

atazanavir sulfate caps 5 NDS;MO; +

ATRIPLA TABS (efavirenz-emtricitabine-tenofovirdisoproxil fumarate)

2MO; +

BIKTARVY TABS 5 NDS;MO; +

CIMDUO TABS 5 NDS;MO; +

COMPLERA TABS 5 NDS;MO; +

CRIXIVAN CAPS 3 MO; +

DELSTRIGO TABS 5 NDS;MO; +

DESCOVY TABS 5 NDS;MO; +

didanosine cpdr 1 MO; *

DOVATO TABS 5 NDS;MO; +

EDURANT TABS 5 NDS;MO; +

efavirenz caps 1 MO; *

efavirenz tabs 1 MO; *



Drug Name DrugTier

Requirements/Limits

efavirenz-emtricitabine-tenofovir disoproxilfumarate tabs

1MO; *

efavirenz-lamivudine-tenofovir disoproxilfumarate tabs

5NDS;MO; +

emtricitabine caps 1 MO; *

emtricitabine-tenofovirdisoproxil fumarate tabs 1 MO; *

EMTRIVA SOLN 10MG/ML 3 MO; +

EVOTAZ TABS 5 NDS;MO; +

fosamprenavir calcium tabs 5 NDS;MO; +

FUZEON SOLR 5 NDS; +

GENVOYA TABS 5 NDS;MO; +

INTELENCE TABS 100MG 2 MO; +

INTELENCE TABS 200MG 5 NDS;MO; +

INTELENCE TABS 25 MG 3 +

INVIRASE TABS 500 MG 5 NDS;MO; +

ISENTRESS CHEW 100MG 2 SL(6 ea daily);

MO; +

ISENTRESS CHEW 25 MG 2 SL(24 ea daily);MO; +

ISENTRESS HD TABS 5 NDS;MO; +

ISENTRESS PACK 100MG 3 SL(2 ea daily);

MO; +ISENTRESS TABS 400MG 5 NDS;MO; +

JULUCA TABS 5 NDS;MO; +

KALETRA TABS 100 MG-25 MG 3 MO; +

KALETRA TABS 200 MG-50 MG 2 MO; +

lamivudine soln 1 MO; *

lamivudine tabs 1 MO; *

Drug Name DrugTier

Requirements/Limits

lamivudine-zidovudine tabs 1 MO; *

LEXIVA SUSP 50 MG/ML 2 MO; +

lopinavir-ritonavir soln 1 MO; *

nevirapine susp 50 mg/5ml 1 MO; *

nevirapine tabs 200 mg 1 MO; *

nevirapine tb24 100 mg 1 *

nevirapine tb24 400 mg 1 MO; *

NORVIR PACK 100 MG 3 MO; +

NORVIR SOLN 80 MG/ML 2 MO; +

ODEFSEY TABS 5 NDS;MO; +

PIFELTRO TABS 5 NDS;MO; +

PREZCOBIX TABS 5 NDS;MO; +

PREZISTA SUSP 100MG/ML 5 NDS;MO; +

PREZISTA TABS 150 MG,600 MG, 800 MG 5 NDS;MO; +

PREZISTA TABS 75 MG 3 MO; +

RETROVIR IV INFUSIONSOLN 4 +

REYATAZ PACK 50 MG 5 NDS;MO; +

ritonavir tabs 1 MO; *

RUKOBIA TB12 5 NDS;MO; +

SELZENTRY SOLN 20MG/ML 2 +

SELZENTRY TABS 150MG, 300 MG 2 MO; +

SELZENTRY TABS 25MG, 75 MG 2 +

stavudine caps 1 MO; *

STRIBILD TABS 5 NDS;MO; +



Drug Name DrugTier

Requirements/Limits

SYMFI LO TABS(efavirenz-lamivudine-tenofovir disoproxilfumarate)

5

NDS;MO; +

SYMFI TABS (efavirenz-lamivudine-tenofovirdisoproxil fumarate)

5NDS;MO; +

SYMTUZA TABS 5 NDS;MO; +

TEMIXYS TABS 5 NDS;MO; +

tenofovir disoproxilfumarate tabs 1 MO; *

TIVICAY PD TBSO 3 MO; +

TIVICAY TABS 10 MG 3 MO; +

TIVICAY TABS 25 MG, 50MG 5 NDS;MO; +

TRIUMEQ TABS 5 NDS;MO; +

TROGARZO SOLN 5 NDS; +

TRUVADA TABS 100 MG-150 MG, 133 MG-200 MG,167 MG-250 MG

5NDS;MO; +

TRUVADA TABS 200 MG-300 MG (emtricitabine-tenofovir disoproxilfumarate)

2

MO; +

TYBOST TABS 3 MO; +

VIDEX EC CPDR 125 MG 3 MO; +

VIDEXPEDIATRIC SOLR 2GM 3 MO; +

VIRACEPT TABS 5 NDS;MO; +

VIREAD POWD 40 MG/GM 5 NDS;MO; +

VIREAD TABS 150 MG,200 MG, 250 MG 5 NDS;MO; +

zidovudine caps 1 MO; *

zidovudine syrp 1 MO; *

zidovudine tabs 1 MO; *

Drug Name DrugTier

Requirements/Limits

CMV Agentscidofovir soln 5 NDS; +

ganciclovir sodium solr 1 PA; *

PREVYMIS TABS OR 240MG, 480 MG 5 PA; NDS;MO; +

valganciclovir hcl solr 5 NDS;MO; +

valganciclovir hcl tabs 5 NDS;MO; +

Hepatitis Agentsadefovir dipivoxil tabs 5 NDS;MO; +

BARACLUDE SOLN 0.05MG/ML 2 MO; +

entecavir tabs 1 MO; *

EPCLUSA TABS 100 MG-400 MG 5 PA; NDS; +

EPIVIR HBV SOLN 5MG/ML 2 MO; +

HARVONI PACK 150 MG-33.75 MG, 200 MG-45 MG 5 PA; NDS; +

HARVONI TABS 200 MG-45 MG, 400 MG-90 MG 5 PA; NDS; +

lamivudine (hbv) tabs 1 MO; *

MAVYRET TABS 5 PA; NDS; +

PEGASYS PROCLICKSOLN 180 MCG/0.5ML 5 NDS; +

PEGASYS SOLN 5 NDS; +

PEGINTRON KIT 5 NDS; +

REBETOL SOLN 40MG/ML 2 +

ribavirin (hepatitis c) caps200 mg 1 *

ribavirin (hepatitis c) tabs200 mg 1 *

SOVALDI TABS 200 MG,400 MG 5 PA; NDS; +

VEMLIDY TABS 5 ST; NDS;MO; +



Drug Name DrugTier

Requirements/Limits

VOSEVI TABS 5 PA; NDS; +

ZEPATIER TABS 5 PA; NDS; +

Herpes Agentsacyclovir caps 1 MO; *

acyclovir sodium soln 4 PA; +

acyclovir susp 1 MO; *

acyclovir tabs 1 MO; *

famciclovir tabs 1 MO; *

valacyclovir hcl tabs 1 MO; *

Influenza Agentsoseltamivir phosphate capsor 30 mg 1 QL(4 ea daily);

MO; *oseltamivir phosphate capsor 45 mg, 75 mg 1 MO; *

oseltamivir phosphate susror 6 mg/ml 1 MO; *

RELENZA DISKHALERAEPB 3 MO; +

rimantadine hydrochloridetabs 1 MO; *

Respiratory Syncytial Virus (RSV) Agentsribavirin solr 1 *

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockerscarvedilol phosphate cp24 1 MO; *

carvedilol tabs 12.5 mg 1 SL(8 ea daily);MO; *

carvedilol tabs 25 mg 1 SL(4 ea daily);MO; *



labetalol hcl tabs or 100mg, 200 mg, 300 mg 1 MO; *

Drug Name DrugTier

Requirements/Limits

Beta Blockers Cardio-Selectiveacebutolol hcl caps 1 MO; *

atenolol tabs 1 MO; *

betaxolol hcl tabs 1 MO; *

bisoprolol fumarate tabs 1 MO; *

BYSTOLIC TABS 10 MG,2.5 MG, 5 MG 3 QL(1 ea daily);

MO; +

BYSTOLIC TABS 20 MG 3 QL(2 ea daily);MO; +

metoprolol succinate tb24 1 MO; *

metoprolol tartrate tabs or37.5 mg, 75 mg, 100 mg,25 mg, 50 mg

1MO; *

Beta Blockers Non-SelectiveHEMANGEOL SOLN 3 +

nadolol tabs 1 MO; *

pindolol tabs 1 MO; *

propranolol hcl cp24 or 120mg, 160 mg, 60 mg, 80 mg 1 MO; *

propranolol hcl soln or 20mg/5ml, 40 mg/5ml 1 MO; *

propranolol hcl tabs or 10mg, 80 mg, 20 mg, 40 mg,60 mg

1MO; *

sotalol hcl (afib/afl) tabs 1 MO; *

sotalol hcl tabs 1 MO; *

SOTYLIZE SOLN 3 MO; +

timolol maleate tabs 10 mg 1 SL(6 ea daily);MO; *



CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel Blockers



Drug Name DrugTier

Requirements/Limits

amlodipine besylate tabs10 mg 1 SL(1 ea daily);

MO; *amlodipine besylate tabs2.5 mg 1 SL(4 ea daily);

MO; *amlodipine besylate tabs 5mg 1 SL(2 ea daily);

MO; *CARDIZEM LA TB24 120MG 2 MO; +

diltiazem hcl coated beadscp24 1 MO; *

diltiazem hcl coated beadstb24 1 MO; *

diltiazem hcl cp12 or 120mg, 60 mg, 90 mg 1 MO; *

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg 1 MO; *

diltiazem hcl extendedrelease beads cp24 1 MO; *

diltiazem hcl tabs or 120mg, 60 mg, 30 mg, 90 mg 1 MO; *

felodipine tb24 1 MO; *

nicardipine hcl caps or 20mg, 30 mg 1 MO; *

nifedipine caps 20 mg 1 AL(Up to 64 yrsold); MO; *

nifedipine tb24 30 mg, 60mg, 90 mg 1 MO; *

nimodipine caps 1 MO; *

nisoldipine tb24 17 mg, 34mg, 8.5 mg 1 MO; *

NYMALIZE SOLN 5 NDS; +

verapamil hcl cp24 or 360mg, 100 mg, 120 mg, 180mg, 200 mg, 240 mg, 300mg

1

MO; *

verapamil hcl tabs or 40mg, 120 mg, 80 mg 1 MO; *

verapamil hcl tbcr or 120mg, 180 mg, 240 mg 1 MO; *

VERELAN PM CP24 300MG (verapamil hcl) 1 MO; *

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Drug Name DrugTier

Requirements/Limits

Cardiac Glycosidesdigoxin soln or 0.05 mg/ml 1 MO; *

digoxin tabs or 0.25 mg,250 mcg, 0.125 mg, 125mcg

1MO; *

LANOXIN PEDIATRICSOLN 4 +

LANOXIN TABS OR 62.5MCG 3 MO; +

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - Combinationsamlodipine besylate-atorvastatin calcium tabs 1 MO; *

BIDIL TABS 3 MO; +

ENTRESTO TABS 3 PA; MO; +

Impotence Agents

CAVERJECT IMPULSEKIT 2

Check plan forcoverage; Limit4 boxes permonth;QL(0.1429 ea daily);MO; NT; +

CAVERJECT SOLR 20MCG 2


CAVERJECT SOLR 40MCG 2

Check plan forcoverage; Limit4 vials permonth;QL(0.1429 ea daily);MO; NT; +

CIALIS TABS 5 MG(tadalafil) 3

PA; Check planforcoverage;MO;+



Drug Name DrugTier

Requirements/Limits

EDEX KIT 2


MUSE PLLT 2


sildenafil citrate tabs 1

Check plan forcoverage;QL(0.1429 ea daily);MO; NT; *

tadalafil tabs 10 mg, 20 mg 1


tadalafil tabs 2.5 mg, 5 mg 1PA; Check planforcoverage;MO; *

vardenafil hcl tabs 1


vardenafil hcl tbdp 1


Prostaglandin VasodilatorsORENITRAM TBCR 0.125MG 3 PA; +

ORENITRAM TBCR 0.25MG, 1 MG, 2.5 MG, 5 MG 5 PA; NDS; +

treprostinil soln 5 B/D; NDS;LA; +

TYVASO REFILL SOLN 5 B/D; NDS;LA; +

TYVASO SOLN 5 B/D; NDS;LA; +

TYVASO STARTER SOLN 5 B/D; NDS;LA; +

VENTAVIS SOLN 10MCG/ML 2 B/D; LA; +

VENTAVIS SOLN 20MCG/ML 5 B/D; NDS;LA; +

Drug Name DrugTier

Requirements/Limits

Pulmonary Hypertension - Endothelin Receptorambrisentan tabs 5 NDS;LA; +

bosentan tabs 5 NDS;LA; +

OPSUMIT TABS 5 PA; NDS; +

TRACLEER TBSO 32 MG 5 NDS;LA; +

Pulmonary Hypertension - Phosphodiesterasesildenafil citrate (pulmonaryhypertension) soln iv 10mg/12.5ml

5PA; NDS; +

sildenafil citrate (pulmonaryhypertension) tabs or 20mg

1PA; *

tadalafil (pulmonaryhypertension) tabs 5 PA; NDS; +

Pulmonary Hypertension - Prostacyclin ReceptorUPTRAVI TABS 5 PA; NDS;LA; +

UPTRAVI TBPK 5 PA; NDS;LA; +

Pulmonary Hypertension - Sol Guanylate Cyclase

ADEMPAS TABS 0.5 MG 5 PA; NDS;SL(15ea daily); +

ADEMPAS TABS 1 MG 5PA;NDS;SL(7.5 eadaily); +


ADEMPAS TABS 2 MG 5PA;NDS;SL(3.75ea daily); +


Sinus Node InhibitorsCORLANOR SOLN 5MG/5ML 3 SL(15 ml daily);

+

CORLANOR TABS 5 MG 3 SL(3 ea daily);MO; +

CORLANOR TABS 7.5 MG 3 SL(2 ea daily);MO; +

Transthyretin Stabilizers



Drug Name DrugTier

Requirements/Limits

VYNDAMAX CAPS 5 PA; NDS;QL(1ea daily); +

VYNDAQEL CAPS 5 PA; NDS;QL(4ea daily); +

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generationcefadroxil caps 1 MO; *

cefadroxil susr 1 MO; *

cefadroxil tabs 1 MO; *

cefazolin sodium solr ij 500mg, 1 gm, 10 gm 4 MO; +

cephalexin caps 1 MO; *

cephalexin susr 1 MO; *

cephalexin tabs 1 MO; *

Cephalosporins - 2nd Generationcefaclor caps 250 mg, 500mg 1 MO; *

cefaclor monohydrate tb12 1 MO; *

cefoxitin sodium solr ij 10gm 4 +

cefoxitin sodium solr iv 1gm, 2 gm 4 +

cefprozil susr 1 MO; *

cefprozil tabs 1 MO; *

cefuroxime axetil tabs 1 MO; *

cefuroxime sodium solr ij7.5 gm 4 +

cefuroxime sodium solr ij750 mg 4 MO; +

cefuroxime sodium solr iv1.5 gm 4 +

Cephalosporins - 3rd Generationcefdinir caps 1 MO; *

cefdinir susr 1 MO; *

Drug Name DrugTier

Requirements/Limits

cefixime caps 1 MO; *

cefixime susr 1 MO; *

cefpodoxime proxetil susr 1 MO; *

cefpodoxime proxetil tabs 1 MO; *

ceftazidime solr ij 2 gm, 1gm 4 MO; +

ceftazidime solr ij 6 gm 4 +

ceftriaxone sodium indextrose soln 20 mg/ml 4 SL(200 ml

daily); +ceftriaxone sodium solr ij 1gm 4 SL(4 ea daily);

MO; +ceftriaxone sodium solr ij 2gm 4 SL(2 ea daily);

MO; +ceftriaxone sodium solr ij250 mg 4 SL(16 ea daily);

MO; +ceftriaxone sodium solr ij500 mg 4 SL(8 ea daily);

MO; +ceftriaxone sodium solr iv 1gm 4 SL(4 ea daily);

+ceftriaxone sodium solr iv10 gm 4 MO; +

ceftriaxone sodium solr iv 2gm 4 SL(2 ea daily);

MO; +Cephalosporins - 4th Generationcefepime hcl solr 4 MO; +

CEFEPIME SOLN 4 +

Cephalosporins - 5th GenerationTEFLARO SOLR 4 +

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - Oraldesogestrel & ethinylestradiol tabs 1 MO; *

desogestrel-ethinylestradiol (biphasic) tabs 1 MO; *

drospirenone-ethinylestradiol tabs 1 MO; *



Drug Name DrugTier

Requirements/Limits

drospirenone-ethinylestradiol-levomefolatecalcium tabs

1MO; *

ethynodiol diacet & ethestrad tabs 1 MO; *

levonorgestrel & ethestradiol tabs 1 MO; *

levonorgestrel-eth estradiol(triphasic) tabs 1 MO; *

levonorgestrel-ethinylestradiol (91-day) tabs 1 (QUARTETTE);

MO; *levonorgestrel-ethinylestradiol (91-day) tabs 1 biphasic;MO; *

levonorgestrel-ethinylestradiol (continuous) tabs 1 MO; *

LO LOESTRIN FE TABS 3 MO; +

norethin acet & estrad-fechew 1 MO; *

norethin acet & estrad-fetabs 1 MO; *

norethindrone & ethestradiol tabs 1 MO; *

norethindrone & ethinylestradiol-fe chew 1 MO; *

norethindrone acet & ethestra tabs 1 MO; *

norethindrone-eth estradiol(triphasic) tabs 1 MO; *

norgestimate-ethinylestradiol (triphasic) tabs 1 MO; *

norgestimate-ethinylestradiol tabs 1 MO; *

norgestrel & ethinylestradiol tabs 0.3 mg-30mcg

1MO; *

norgestrel & ethinylestradiol tabs 0.5 mg-50mcg

1*

TAYTULLA CAPS 3 MO; +

Combination Contraceptives - Transdermalnorelgestromin-ethinylestradiol ptwk 1 MO; *

Combination Contraceptives - Vaginal

Drug Name DrugTier

Requirements/Limits

etonogestrel-ethinylestradiol ring 1 MO; *

Emergency ContraceptivesELLA TABS 2 +

Progestin Contraceptives - InjectableDEPO-SUBQ PROVERA104 SUSY 4 MO; +

medroxyprogesteroneacetate (contraceptive)susp

4MO; +

medroxyprogesteroneacetate (contraceptive)susy

4MO; +

Progestin Contraceptives - Oralnorethindrone(contraceptive) tabs 1 MO; *

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroidsbetamethasone sodphosphate & acetate susp 4 MO; +

budesonide cpep 3 mg 1 MO; *

budesonide tb24 9 mg 5 NDS;MO; +

cortisone acetate tabs 1 MO; *

DEPO-MEDROL SUSP 20MG/ML 4 MO; +

dexamethasone elix 0.5mg/5ml 1 MO; *

dexamethasone sodiumphosphate soln ij 10 mg/ml 4 +

dexamethasone sodiumphosphate soln ij 10 mg/ml 4 Preservative

Free;MO; +dexamethasone sodiumphosphate soln ij 100mg/10ml, 120 mg/30ml, 20mg/5ml, 4 mg/ml

4

MO; +

dexamethasone soln 0.5mg/5ml 1 MO; *

dexamethasone tabs 1 mg,1.5 mg, 2 mg, 0.5 mg, 0.75mg, 4 mg, 6 mg

1MO; *



Drug Name DrugTier

Requirements/Limits

dexamethasone tbpk 1.5mg, 1.5 mg 1 MO; *

EMFLAZA SUSP 5 PA; NDS;MO;+

EMFLAZA TABS 5 PA; NDS;MO;+

hydrocortisone tabs 1 MO; *

KENALOG-10 SUSP 4 MO; +

MEDROL TABS 2 MG 2 MO; +

methylprednisolone acetatesusp 80 mg/ml, 40 mg/ml 1 MO; *

methylprednisolone sodsucc solr 1 MO; *

methylprednisolone tabs 1 MO; *

methylprednisolone tbpk 1 MO; *

prednisolone sodiumphosphate soln or 15mg/5ml, 5 mg/5ml, 25mg/5ml

1

MO; *

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

1MO; *

prednisolone soln 1 MO; *

prednisolone tabs 1 MO; *

prednisone conc 1 MO; *

prednisone soln 1 MO; *

prednisone tabs 1 MO; *

prednisone tbpk 1 MO; *

SOLU-CORTEF SOLR 100MG, 250 MG, 500 MG 4 MO; +

SOLU-CORTEF SOLR1000 MG 4 +

SOLU-MEDROL SOLR 2GM 4 +

triamcinolone acetonidesusp 40 mg/ml, 400mg/10ml

4MO; +

Drug Name DrugTier

Requirements/Limits

Mineralocorticoidsfludrocortisone acetate tabs 1 MO; *

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsAntitussivesbenzonatate caps 150 mg,100 mg, 200 mg 1 MO; NT; *

Cough/Cold/Allergy CombinationsCLARINEX-D 12 HOURTB12 3 MO; +

hydrocodone polistirex-chlorpheniramine polistirexsuer

1AL(Up to 64 yrsold); MO; NT; *

promethazine &phenylephrine syrp 1 AL(Up to 64 yrs

old); MO; *promethazine-phenylephrine-codeine syrp 1 AL(Up to 64 yrs

old); NT; *

SEMPREX-D CAPS 3 MO; +

Mucolyticsacetylcysteine soln 1 B/D; MO; *

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne ProductsABSORICA CAPS 25 MG,35 MG, 10 MG, 20 MG, 40MG

3+

adapalene crea 0.1 % 1 MO; *

adapalene gel 0.1 % 1 RX/OTC; MO; *

adapalene gel 0.3 % 1 MO; *

adapalene-benzoylperoxide gel 1 MO; *

AZELEX CREA 3 MO; +

benzoyl peroxide-erythromycin gel 1 MO; *

CLINDAGEL GEL(clindamycin phosphate(topical))

3MO; +



Drug Name DrugTier

Requirements/Limits

clindamycin phosphate(topical) foam 1 MO; *

clindamycin phosphate(topical) gel 1 MO; *

clindamycin phosphate(topical) lotn 1 MO; *

clindamycin phosphate(topical) soln 1 QL(2 ml daily);

MO; *clindamycin phosphate(topical) swab 1 MO; *

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

1MO; *

clindamycin phosphate-benzoyl peroxide gel 1 MO; *

clindamycin phosphate-tretinoin gel 1 MO; *

erythromycin (acne aid) gel 1 MO; *

erythromycin (acne aid)soln 1 MO; *

FABIOR FOAM 3

Limit 100gmspermonth;QL(3.34gm daily); MO;+

isotretinoin caps 1 *

RETIN-A MICRO PUMPGEL 0.08 % 3 MO; +

sulfacetamide sodium(acne) lotn 1 MO; *

tretinoin crea 1 MO; *

tretinoin gel 1 MO; *

tretinoin microsphere gel 1 MO; *

Anti-inflammatory Agents - Topicaldiclofenac epolamine ptch 1 PA; MO; *

diclofenac sodium (topical)gel 1 % 1

SL(33.34 gmdaily); RX/OTC;MO; *

diclofenac sodium (topical)soln 1.5 % 1 QL(15 ml

daily); MO; *

Drug Name DrugTier

Requirements/Limits

FLECTOR PTCH 3 PA; MO; +

FLECTOR PTCH(diclofenac epolamine) 3 PA; MO; +

PENNSAID SOLN 5PA; NDS;QL(8gm daily); MO;+

Antibiotics - Topical

CENTANY OINT 3 QL(0.74 gmdaily); MO; +

CORTISPORIN CREA 2 MO; +

CORTISPORIN OINT 2 MO; +

gentamicin sulfate (topical)crea 1 MO; *

mupirocin calcium (topical)crea 1 QL(1 gm daily);

MO; *

mupirocin oint 1 QL(0.74 gmdaily); MO; *

Antifungals - Topicalciclopirox gel 0.77 % 1 MO; *

ciclopirox olamine crea 1 MO; *

ciclopirox olamine susp 1 MO; *

ciclopirox sham 1 % 1 MO; *

clotrimazole (topical) crea 1 RX/OTC; MO; *

clotrimazole (topical) soln 1 RX/OTC; MO; *

econazole nitrate crea 1 QL(3 gm daily);MO; *

ERTACZO CREA 3 MO; +

JUBLIA SOLN 3 PA; MO; +

KERYDIN SOLN(tavaborole) 3 PA; MO; +

ketoconazole (topical) crea 1 QL(2 gm daily);MO; *

ketoconazole (topical) foam 1 QL(3.34 gmdaily); MO; *

ketoconazole (topical)sham 1 QL(4 ml daily);

MO; *



Drug Name DrugTier

Requirements/Limits

luliconazole crea 1 MO; *

LUZU CREA (luliconazole) 3 MO; +

MENTAX CREA 2 RX/OTC; MO;+

naftifine hcl crea 1 %, 2 % 1 MO; *

naftifine hcl gel 1 % 1 MO; *

NAFTIN GEL 1 % (naftifinehcl) 3 MO; +

NAFTIN GEL 2 % 3 MO; +

nystatin (topical) crea 1 QL(2 gm daily);MO; *

nystatin (topical) oint 1 QL(2 gm daily);MO; *

nystatin (topical) powd 1 QL(2 gm daily);MO; *

nystatin-triamcinolone crea 1 MO; *

nystatin-triamcinolone oint 1 MO; *

oxiconazole nitrate crea 1 MO; *

OXISTAT LOTN 3 MO; +

tavaborole soln 1 PA; MO; *

Antineoplastic or Premalignant Lesion Agents -CARAC CREA (fluorouracil(topical)) 5 NDS;MO; +

diclofenac sodium (actinickeratoses) gel 3

PA; QL(3.34gm daily); MO;+

fluorouracil (topical) crea0.5 % 5 NDS;MO; +

fluorouracil (topical) crea 5% 1 MO; *

fluorouracil (topical) soln 2%, 5 % 1 MO; *

PANRETIN GEL 2 +

PICATO GEL 5 NDS;MO; +

Drug Name DrugTier

Requirements/Limits

TARGRETIN GEL EX 1 % 5 PA; NDS;QL(2gm daily); +

VALCHLOR GEL 5 PA; NDS;MO; +

Antipruritics - Topicaldoxepin hcl (antipruritic)crea 3 PA; QL(1.5 gm

daily); MO; +PRUDOXIN CREA(doxepin hcl (antipruritic)) 3 PA; QL(1.5 gm

daily); MO; +ZONALON CREA (doxepinhcl (antipruritic)) 3 PA; QL(1.5 gm

daily); MO; +Antipsoriaticsacitretin caps 10 mg, 25 mg 1 MO; *

acitretin caps 17.5 mg 5 NDS;MO; +

calcipotriene crea 1 QL(4 gm daily);MO; *

calcipotriene oint 1 MO; *

calcipotriene soln 1 MO; *

calcitriol (topical) oint 1 MO; *

COSENTYXSENSOREADY PEN SOAJ 5 PA; NDS;LA; +

COSENTYX SOSY 5 PA; NDS;LA; +

ILUMYA SOSY 5 PA; NDS; +

methoxsalen rapid caps 5 NDS;MO; +

SILIQ SOSY 5 PA; NDS; +

SKYRIZI PSKT 5 PA; NDS; +

SORILUX FOAM 3 MO; +

STELARA SOLN 5 PA; NDS; +

STELARA SOSY 5 PA; NDS; +

TALTZ SOAJ 5 PA; NDS; +

TALTZ SOSY 5 PA; NDS; +

tazarotene crea 1 MO; *



Drug Name DrugTier

Requirements/Limits

TAZORAC CREA 0.05 % 2 MO; +

TAZORAC GEL 0.05 %,0.1 % 2 MO; +

TREMFYA SOPN 5 PA; NDS; +

TREMFYA SOSY 5 PA; NDS; +

VECTICAL OINT (calcitriol(topical)) 3 MO; +

Antiseborrheic Productsselenium sulfide lotn 2.5 % 1 MO; *

Antivirals - Topicalacyclovir topical crea 5 NDS;MO; +

acyclovir topical oint 1 MO; *

DENAVIR CREA 5 NDS;MO; +

XERESE CREA 3 MO; +

Burn Productssilver sulfadiazine crea 1 MO; *

SULFAMYLON CREA 85MG/GM 3 MO; +

Corticosteroids - Topicalalclometasone dipropionatecrea 1 MO; *

alclometasone dipropionateoint 1 MO; *

amcinonide crea 1 MO; *

betamethasonedipropionate (topical) crea 1 MO; *

betamethasonedipropionate (topical) lotn 1 MO; *

betamethasonedipropionate (topical) oint 1 MO; *

betamethasonedipropionate augmentedcrea

1MO; *

betamethasonedipropionate augmentedgel

1MO; *

Drug Name DrugTier

Requirements/Limits

betamethasonedipropionate augmentedlotn

1MO; *

betamethasonedipropionate augmentedoint

1MO; *

betamethasone valeratecrea 1 MO; *

betamethasone valeratefoam 1 MO; *

betamethasone valeratelotn 1 MO; *

betamethasone valerateoint 1 MO; *

calcipotriene-betamethasonedipropionate oint

5NDS;SL(14.28gm daily); MO;+

calcipotriene-betamethasonedipropionate susp

5NDS;SL(14.28gm daily); MO;+

CAPEX SHAM 3 MO; +

clobetasol propionate crea 1 MO; *

clobetasol propionateemollient base crea 1 MO; *

clobetasol propionate foam 1 Non-emulsion;MO; *

clobetasol propionate gel 1 MO; *

clobetasol propionate liqd 1 MO; *

clobetasol propionate lotn 1 MO; *

clobetasol propionate oint 1 MO; *

clobetasol propionate sham 1 MO; *

clobetasol propionate soln 1 MO; *

clocortolone pivalate crea 1 MO; *

CLODERM CREA 3 MO; +

CLODERM CREA(clocortolone pivalate) 3 MO; +

CLODERM PUMP CREA 3 MO; +



Drug Name DrugTier

Requirements/Limits

CORDRAN TAPE 4MCG/SQCM 3 MO; +

desonide crea 1 QL(2 gm daily);MO; *

desonide lotn 1 QL(3.94 mldaily); MO; *

desonide oint 1 QL(2 gm daily);MO; *

desoximetasone crea 0.05%, 0.25 % 1 MO; *

desoximetasone gel 0.05% 1 MO; *

desoximetasone liqd 0.25% 1 MO; *

desoximetasone oint 0.05%, 0.25 % 1 MO; *

diflorasone diacetate crea 1 MO; *

diflorasone diacetate oint 1 MO; *

ENSTILAR FOAM 5 NDS;SL(15 gmdaily); MO; +

fluocinolone acetonide crea 1 MO; *

fluocinolone acetonide oil 1 MO; *

fluocinolone acetonide oint 1 MO; *

fluocinolone acetonide soln 1 MO; *

fluocinonide crea 0.05 % 1 MO; *

fluocinonide emulsifiedbase crea 1 MO; *

fluocinonide gel 0.05 % 1 MO; *

fluocinonide oint 0.05 % 1 MO; *

fluocinonide soln 0.05 % 1 MO; *

flurandrenolide crea 1 MO; *

flurandrenolide lotn 1 MO; *

fluticasone propionate crea 1 MO; *

fluticasone propionate lotn 1 MO; *

Drug Name DrugTier

Requirements/Limits

fluticasone propionate oint 1 MO; *

halcinonide crea 1 MO; *

halobetasol propionatecrea 1 MO; *

halobetasol propionate oint 1 MO; *

hydrocortisone (topical)crea 1 % 1 RX/OTC; MO; *

hydrocortisone (topical)crea 2.5 % 1 MO; *

hydrocortisone (topical) lotn2.5 % 1 MO; *

hydrocortisone (topical) oint1 % 1 RX/OTC; MO; *

hydrocortisone (topical) oint2.5 % 1 MO; *

hydrocortisone butyratecrea 1 QL(1.5 gm

daily); MO; *hydrocortisone butyratehydrophilic lipo base crea 1 QL(1.5 gm

daily); MO; *hydrocortisone butyratelotn 1 QL(3.94 ml

daily); MO; *hydrocortisone butyrateoint 1 QL(1.5 gm

daily); MO; *hydrocortisone butyratesoln 1 QL(2 ml daily);

MO; *hydrocortisone valeratecrea 1 MO; *

hydrocortisone valerate oint 1 MO; *

mometasone furoate crea 1 MO; *

mometasone furoate oint 1 MO; *

mometasone furoate soln 1 MO; *

prednicarbate crea 1 MO; *

TACLONEX SUSP(calcipotriene-betamethasonedipropionate)

5

NDS;SL(14.28gm daily); MO;+

triamcinolone acetonide(topical) aers 0.147 mg/gm 1 MO; *



Drug Name DrugTier

Requirements/Limits

triamcinolone acetonide(topical) crea 0.025 %, 0.5%, 0.1 %

1MO; *

triamcinolone acetonide(topical) lotn 0.025 %, 0.1%

1MO; *

triamcinolone acetonide(topical) oint 0.025 %, 0.1%, 0.5 %

1MO; *

ULTRAVATE LOTN 5 PA; NDS;MO;+

Emollientslactic acid (ammoniumlactate) crea 1 RX/OTC; MO; *

lactic acid (ammoniumlactate) lotn 1 RX/OTC; MO; *

Enzymes - TopicalSANTYL OINT 3 MO; +

Immunomodulating Agents - Topicalimiquimod crea 3.75 % 5 NDS;MO; +

imiquimod crea 5 % 1 MO; *

ZYCLARA CREA(imiquimod) 5 NDS;MO; +

ZYCLARA PUMP CREA2.5 % 5 NDS;MO; +

ZYCLARA PUMP CREA3.75 % (imiquimod) 5 NDS;MO; +

Immunosuppressive Agents - Topicalpimecrolimus crea 1 PA; MO; *

tacrolimus (topical) oint 1 PA; MO; *

Keratolytic/Antimitotic AgentsCONDYLOX GEL 3 MO; +

podofilox soln 1 MO; *

Local Anesthetics - Topicallidocaine hcl gel ex 2 % 1 MO; *

lidocaine hcl prsy ex 2 % 1 MO; *

Drug Name DrugTier

Requirements/Limits

lidocaine hcl soln ex 4 % 1 QL(6.67 mldaily); MO; *

lidocaine oint 1 QL(5 gm daily);MO; *

lidocaine ptch 1 PA; SL(3 eadaily); MO; *

lidocaine-prilocaine crea 1 QL(2 gm daily);MO; *

Rosacea Agentsazelaic acid gel 1 MO; *

doxycycline (rosacea) cpdr 1 MO; *

FINACEA FOAM 3 MO; +

ivermectin (rosacea) crea 1 MO; *

metronidazole (topical)crea 1 MO; *

metronidazole (topical) gel 1 MO; *

metronidazole (topical) lotn 1 MO; *

MIRVASO GEL 3 PA; MO; +

NORITATE CREA 5 NDS;MO; +

ORACEA CPDR(doxycycline (rosacea)) 3 MO; +

Scabicides & Pediculicidescrotamiton lotn 1 MO; *

malathion lotn 1 MO; *

permethrin crea 1 MO; *

Wound Care ProductsREGRANEX GEL 5 NDS;MO; +

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive Enzymes



Drug Name DrugTier

Requirements/Limits

CREON CPEP 114000UNIT-180000 UNIT-36000UNIT, 12000 UNIT-38000UNIT-60000 UNIT, 15000UNIT-3000 UNIT-9500UNIT, 19000 UNIT-30000UNIT-6000 UNIT

2

MO; +

CREON CPEP 120000UNIT-24000 UNIT-76000UNIT

3MO; +

PANCREAZE CPEP 2 MO; +

PERTZYE CPEP 3 MO; +

SUCRAID SOLN 3 LA; MO; +

VIOKACE TABS 3 MO; +

ZENPEP CPEP 10000UNIT-14000 UNIT-3000UNIT, 10000 UNIT-32000UNIT-42000 UNIT, 105000UNIT-25000 UNIT-79000UNIT, 15000 UNIT-47000UNIT-63000 UNIT, 17000UNIT-24000 UNIT-5000UNIT, 20000 UNIT-63000UNIT-84000 UNIT

3

MO; +

ZENPEP CPEP 126000UNIT-168000 UNIT-40000UNIT

5NDS;MO; +

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitorsacetazolamide cp12 1 MO; *

acetazolamide tabs 1 MO; *

KEVEYIS TABS 5PA; NDS;SL(4ea daily); MO;+

methazolamide tabs 1 MO; *

Diuretic CombinationsALDACTAZIDE TABS 50MG-50 MG 2 MO; +

amiloride &hydrochlorothiazide tabs 1 MO; *

Drug Name DrugTier

Requirements/Limits

spironolactone &hydrochlorothiazide tabs 1 MO; *

triamterene &hydrochlorothiazide caps 1 MO; *

triamterene &hydrochlorothiazide tabs 1 MO; *

Loop Diureticsbumetanide tabs or 0.5 mg,1 mg, 2 mg 1 MO; *

ethacrynic acid tabs 5 NDS;MO; +

furosemide soln ij 10 mg/ml 4 MO; +

furosemide soln or 10mg/ml 1 MO; *

furosemide tabs or 20 mg,40 mg, 80 mg 1 MO; *

torsemide tabs 1 MO; *

Potassium Sparing Diureticsamiloride hcl tabs 1 MO; *

spironolactone tabs 1 MO; *

triamterene caps 1 MO; *

Thiazides and Thiazide-Like Diureticschlorothiazide tabs 250 mg,500 mg 1 MO; *

chlorthalidone tabs 1 MO; *

hydrochlorothiazide caps 1 MO; *

hydrochlorothiazide tabs 1 MO; *

indapamide tabs 1 MO; *

metolazone tabs 1 MO; *

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density Regulatorsalendronate sodium tabs10 mg 1 MO; *



Drug Name DrugTier

Requirements/Limits

alendronate sodium tabs35 mg, 70 mg 1 QL(0.15 ea

daily); MO; *alendronate sodium tabs 5mg 1 *

calcitonin (salmon) soln 1 MO; *

FORTEO SOPN 5

PA; NDS; Limit2.4mls per 28days;QL(0.09ml daily); +

FOSAMAX PLUS D TABS 3 QL(0.15 eadaily); MO; +

ibandronate sodium soln iv3 mg/3ml 4 QL(0.036 ml

daily); MO; +

ibandronate sodium tabs or150 mg 1

Limit 1 tab per28 days (3 per84);QL(0.036ea daily); MO; *

MIACALCIN SOLN 4 MO; +

NATPARA CART 5 PA; NDS;LA; +

PROLIA SOSY 2 PA; QL(0.006ml daily); +

risedronate sodium tabs150 mg 1 QL(0.04 ea

daily); MO; *risedronate sodium tabs 30mg, 5 mg 1 QL(1 ea daily);

MO; *risedronate sodium tabs 35mg 1 QL(0.15 ea

daily); MO; *risedronate sodium tbec 35mg 1 QL(0.15 ea

daily); MO; *

TYMLOS SOPN 5 PA; NDS; +

XGEVA SOLN 5

NDS; Limit6.8mls per 28days;QL(0.243ml daily); +

zoledronic acid conc 4mg/5ml 4 +

zoledronic acid soln 5mg/100ml 1

Limit 1 doseperyear;QL(0.28ml daily); *

CorticotropinACTHAR GEL 5 PA; NDS;LA; +

Drug Name DrugTier

Requirements/Limits

Fertility RegulatorsCHORIONICGONADOTROPIN SOLR 4 PA; +

NOVAREL SOLR 4 PA; +

PREGNYL W/DILUENTBENZYLALCOHOL/NACLSOLR

4PA; +

GnRH/LHRH AntagonistsORILISSA TABS 5 PA; NDS;MO; +

Growth Hormone Receptor AntagonistsSOMAVERT SOLR 5 PA; NDS;LA; +

Growth Hormone Releasing Hormones (GHRH)EGRIFTA SV SOLR 5 NDS; +

Growth HormonesGENOTROPIN MINIQUICKSOLR 0.4 MG 4 PA; +

GENOTROPIN SOLR 5MG 4 PA; +

HUMATROPE COMBOPACK SOLR 5 PA; NDS; +

HUMATROPE SOLR 12MG, 24 MG 5 PA; NDS; +

HUMATROPE SOLR 6 MG 4 PA; +

NORDITROPIN FLEXPROSOPN 10 MG/1.5ML, 5MG/1.5ML

5PA; NDS; +

NUTROPIN AQ NUSPIN20 SOPN 5 PA; NDS; +

OMNITROPE SOCT 10MG/1.5ML, 5 MG/1.5ML 5 PA; NDS; +

SEROSTIM SOLR 4 MG, 6MG 5 PA; NDS; +

ZOMACTON SOLR 5 MG 4 PA; +

Hormone Receptor ModulatorsOSPHENA TABS 3 MO; +

raloxifene hcl tabs 1 QL(1 ea daily);MO; *

Insulin-Like Growth Factor Receptor Inhibitors



Drug Name DrugTier

Requirements/Limits

TEPEZZA SOLR 5 PA; NDS; +

Insulin-Like Growth Factors (Somatomedins)INCRELEX SOLN 4 LA; +

LHRH/GnRH Agonist Analog PituitaryFENSOLVI KIT 4 MO; +

LUPANETA PACK KIT 5 NDS; +

LUPRON DEPOT-PED (1-MONTH) KIT 11.25 MG, 15MG

4+

LUPRON DEPOT-PED (1-MONTH) KIT 7.5 MG 5 NDS; +

LUPRON DEPOT-PED (3-MONTH) KIT 5 NDS; +

SYNAREL SOLN 5 NDS;MO; +

TRIPTODUR SRER 5 NDS;MO; +

Metabolic Modifierscalcitriol caps or 0.25 mcg,0.5 mcg 1 MO; *

calcitriol soln or 1 mcg/ml 1 MO; *

CARBAGLU TABS 3 LA; MO; +

cinacalcet hcl tabs 30 mg 1 *

cinacalcet hcl tabs 60 mg,90 mg 5 NDS; +

CRYSVITA SOLN 5 PA; NDS;LA; +

CYSTADANE POWD 3 LA; MO; +

doxercalciferol caps or 0.5mcg, 1 mcg, 2.5 mcg 1 MO; *

FABRAZYME SOLR 5 NDS;LA; +

GALAFOLD CAPS 5 PA; NDS;LA; +

KANUMA SOLN 5 NDS;LA; +

KUVAN PACK (sapropterindihydrochloride) 5 PA; NDS;LA; +

Drug Name DrugTier

Requirements/Limits

KUVAN TBSO (sapropterindihydrochloride) 5 PA; NDS;LA; +

levocarnitine (metabolicmodifiers) tabs 330 mg 1 MO; *

LUMIZYME SOLR 5 NDS;LA; +

MYALEPT SOLR 5 NDS;LA; MO; +

NAGLAZYME SOLN 5 NDS;LA; +

nitisinone caps 1 MO; *

ORFADIN CAPS 20 MG 2 LA; MO; +

PALYNZIQ SOSY 5 PA; NDS;LA; +

paricalcitol caps or 1 mcg,2 mcg, 4 mcg 1 MO; *

RAVICTI LIQD 3 LA; +

RAYALDEE CPCR 3 PA; MO; +

REVCOVI SOLN 5 PA; NDS;LA;MO; +

sapropterin dihydrochloridepack 5 PA; NDS;LA; +

sapropterin dihydrochloridetbso 5 PA; NDS;LA; +

STRENSIQ SOLN 5 PA; NDS;LA;MO; +

VIMIZIM SOLN 5 NDS;LA; +

XURIDEN PACK 5 NDS;SL(4 eadaily); MO; +

Posterior Pituitary Hormonesdesmopressin acetate solnij 4 mcg/ml 4 MO; +

desmopressin acetatespray refrigerated soln 1 MO; *

desmopressin acetatespray soln 1 MO; *

desmopressin acetate tabsor 0.1 mg, 0.2 mg 1 MO; *

STIMATE SOLN 3 +

Prolactin Inhibitors



Drug Name DrugTier

Requirements/Limits

cabergoline tabs 1 MO; *

Somatostatic Agentsoctreotide acetate soln 100mcg/ml, 500 mcg/ml, 1000mcg/ml, 50 mcg/ml, 1000mcg/5ml, 200 mcg/ml

4

+

SANDOSTATIN LARDEPOT KIT 5 NDS; +

SIGNIFOR LAR SRER 10MG 5

NDS; Limit 6vials per 28days;SL(0.22ea daily); LA;MO; +








NDS; Limit 1vial per 28days;SL(0.036ea daily); LA;MO; +

SIGNIFOR SOLN 5 NDS;LA; MO; +

SOMATULINE DEPOTSOLN 5 NDS; +

Vasopressin Receptor AntagonistsJYNARQUE TABS 15 MG,30 MG 5 NDS;MO; +

JYNARQUE TBPK 5 PA; NDS;LA; +

JYNARQUE TBPK 15 MG, 5 PA; NDS;LA;MO; +

SAMSCA TABS 15 MG 5 NDS;MO; +

Drug Name DrugTier

Requirements/Limits

tolvaptan tabs 15 mg, 30mg 5 NDS;MO; +

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen Combinations

CLIMARA PRO PTWK 3 AL(Up to 64 yrsold); MO; +

COMBIPATCH PTTW 3 AL(Up to 64 yrsold); MO; +

DUAVEE TABS 3 AL(Up to 64 yrsold); MO; +

estradiol & norethindroneacetate tabs 1 AL(Up to 64 yrs

old); MO; *norethindrone acetate-ethinyl estradiol tabs 0.5mg-2.5 mcg

1AL(Up to 64 yrsold); MO; *

PREMPHASE TABS 3 AL(Up to 64 yrsold); MO; +

PREMPRO TABS 3 AL(Up to 64 yrsold); MO; +

EstrogensDELESTROGEN OIL 10MG/ML 4 MO; +

DIVIGEL GEL 3 AL(Up to 64 yrsold); MO; +

ELESTRIN GEL 3 AL(Up to 64 yrsold); MO; +

estradiol pttw td 0.025mg/24hr, 0.0375 mg/24hr,0.05 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr

1

AL(Up to 64 yrsold); MO; *

estradiol ptwk td 0.05mg/24hr, 0.06 mg/24hr,0.075 mg/24hr, 0.1mg/24hr, 37.5 mcg/24hr,0.025 mg/24hr

1

AL(Up to 64 yrsold); MO; *

estradiol tabs or 0.5 mg, 1mg, 2 mg 1 AL(Up to 64 yrs

old); MO; *

estradiol valerate oil 4 MO; +

EVAMIST SOLN 3 AL(Up to 64 yrsold); MO; +

MENOSTAR PTWK 3 AL(Up to 64 yrsold); MO; +



Drug Name DrugTier

Requirements/Limits

PREMARIN TABS OR 0.3MG, 0.45 MG, 0.625 MG,0.9 MG, 1.25 MG

3AL(Up to 64 yrsold); MO; +

FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesBAXDELA SOLR IV 300MG 5 PA; NDS; +

BAXDELA TABS OR 450MG 5 ST; NDS;MO; +

CIPRO SUSR 5GM/100ML, 500 MG/5ML 3 MO; +

ciprofloxacin hcl tabs 1 MO; *

ciprofloxacin in d5w soln200 mg/100ml-5 % 4 +

ciprofloxacin in d5w soln400 mg/200ml-5 % 4 MO; +

ciprofloxacin susr 1 MO; *

levofloxacin in d5w soln 4 +

levofloxacin soln iv 25mg/ml 4 +

levofloxacin soln or 25mg/ml 1 MO; *

levofloxacin tabs or 250mg, 500 mg, 750 mg 1 MO; *

moxifloxacin hcl tabs 1 MO; *

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsFarnesoid X Receptor (FXR) Agonists

OCALIVA TABS 10 MG 5 PA; NDS;SL(1ea daily); +

OCALIVA TABS 5 MG 5 PA; NDS;SL(2ea daily); +

Gallstone Solubilizing AgentsCHENODAL TABS 5 NDS;LA; +

ursodiol caps 1 MO; *

ursodiol tabs 1 MO; *

Gastrointestinal Antiallergy Agents

Drug Name DrugTier

Requirements/Limits

cromolyn sodium(mastocytosis) conc 1 MO; *

Gastrointestinal Chloride Channel ActivatorsAMITIZA CAPS 2 MO; +

Gastrointestinal Stimulantsmetoclopramide hcl soln ij5 mg/ml 4 MO; +

metoclopramide hcl soln or10 mg/10ml, 5 mg/5ml 1 MO; *

metoclopramide hcl tabs or5 mg, 10 mg 1 MO; *

Inflammatory Bowel Agentsbalsalazide disodium caps 1 MO; *

CIMZIA KIT 5 PA; NDS; +

CIMZIA STARTER KIT KIT 5 PA; NDS; +

DIPENTUM CAPS 5 NDS;MO; +

ENTYVIO SOLR 5 PA; NDS; +

INFLECTRA SOLR 5 PA; NDS; +

mesalamine cp24 or 0.375gm 1 MO; *

mesalamine cpdr or 400mg 1 MO; *

mesalamine enem re 4 gm 1 MO; *

mesalamine supp re 1000mg 5 NDS;MO; +

mesalamine tbec or 1.2gm, 800 mg 1 MO; *

mesalamine w/ cleanser kit 1 MO; *

REMICADE SOLR 5 PA; NDS; +

RENFLEXIS SOLR 5 PA; NDS; +

STELARA SOLN 5 PA; NDS; +

sulfasalazine tabs 1 MO; *

sulfasalazine tbec 1 MO; *



Drug Name DrugTier

Requirements/Limits

Intestinal Acidifierslactulose (encephalopathy)soln 1 MO; *

Irritable Bowel Syndrome (IBS) Agents

alosetron hcl tabs 5 PA; NDS;MO;+

LINZESS CAPS 2 MO; +

VIBERZI TABS 5 PA; NDS;MO;+

Peripheral Opioid Receptor AntagonistsMOVANTIK TABS 3 MO; +

RELISTOR SOLN SC 12MG/0.6ML, 8 MG/0.4ML 5 NDS;MO; +

RELISTOR TABS OR 150MG 5 PA; NDS;MO;

+Phosphate Binder Agentscalcium acetate (phosphatebinder) caps 1 MO; *

calcium acetate (phosphatebinder) tabs 1 RX/OTC; MO; *

lanthanum carbonate chew 1 MO; *

sevelamer carbonate pack0.8 gm, 2.4 gm 5 NDS;MO; +

sevelamer carbonate tabs800 mg 1 MO; *

Short Bowel Syndrome (SBS) AgentsGATTEX KIT 5 PA; NDS;LA; +

Tryptophan Hydroxylase Inhibitors

XERMELO TABS 5 PA; NDS;LA;MO; +

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizerspotassium citrate(alkalinizer) tbcr 1 MO; *

Cystinosis AgentsCYSTAGON CAPS 3 +

Drug Name DrugTier

Requirements/Limits

PROCYSBI CPDR 25 MG,75 MG 3 +

Genitourinary Irrigantsacetic acid soln 1 MO; *

neomycin/polymyxin b gusoln 1 MO; *

sodium chloride (guirrigant) soln 1 MO; *

Interstitial Cystitis AgentsELMIRON CAPS 3 MO; +

Prostatic Hypertrophy Agentsalfuzosin hcl tb24 1 MO; *

CARDURA XL TB24 3 MO; +

dutasteride caps 1 MO; *

dutasteride-tamsulosin hclcaps 1 MO; *

finasteride tabs 1 MO; *

silodosin caps 1 MO; *

tamsulosin hcl caps 1 MO; *

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinationscolchicine w/ probenecidtabs 1 MO; *

Gout Agents

allopurinol tabs 100 mg 1 SL(8 ea daily);MO; *

allopurinol tabs 300 mg 1 SL(2.66 eadaily); MO; *

colchicine tabs 1 MO; *

febuxostat tabs 1 MO; *

Uricosuricsprobenecid tabs 1 MO; *

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders



Drug Name DrugTier

Requirements/Limits

Aminolevulinate Synthase 1-Directed siRNA

GIVLAARI SOLN 5 PA; NDS;MO;+

Bradykinin B2 Receptor Antagonistsicatibant acetate soln 5 PA; NDS; +

Complement InhibitorsBERINERT KIT 5 NDS;LA; +

CINRYZE SOLR 5 PA; NDS;LA; +

HAEGARDA SOLR 5 PA; NDS; +

RUCONEST SOLR 5 NDS; +

Hemataologic - Tyrosine Kinase InhibitorsTAVALISSE TABS 5 PA; NDS; +

Hematorheologic Agentspentoxifylline tbcr 1 MO; *

Plasma Kallikrein InhibitorsKALBITOR SOLN 5 NDS; +

TAKHZYRO SOLN 5 PA; NDS; +

Platelet Aggregation Inhibitorsanagrelide hcl caps 1 MO; *

aspirin-dipyridamole cp12 1 MO; *

BRILINTA TABS 2 MO; +

CABLIVI KIT 5 PA; NDS;MO;+

cilostazol tabs 1 MO; *

clopidogrel bisulfate tabs 1 MO; *

dipyridamole tabs 1 AL(Up to 64 yrsold); MO; *

prasugrel hcl tabs 1 MO; *

ZONTIVITY TABS 2 MO; +

Drug Name DrugTier

Requirements/Limits

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher DiseaseCERDELGA CAPS 5 PA; NDS; +

CEREZYME SOLR 5 PA; NDS;LA; +

ELELYSO SOLR 5 NDS; +

miglustat caps 5 NDS;LA; MO; +

VPRIV SOLR 5 NDS; +

Agents for Sickle Cell DiseaseADAKVEO SOLN 5 PA; NDS; +

DROXIA CAPS 3 MO; +

ENDARI PACK 5 PA; NDS;MO; +

OXBRYTA TABS 5 PA; NDS;LA; +

Cobalaminscyanocobalamin soln 4 MO; NT; +

NASCOBAL SOLN 3 MO; NT; +

Folic Acid/Folates

folic acid tabs 1 RX/OTC; MO;NT; *

Hematopoietic Growth FactorsARANESP ALBUMINFREE SOLN 100 MCG/ML,25 MCG/ML, 40 MCG/ML,60 MCG/ML

4

PA; +

ARANESP ALBUMINFREE SOLN 200 MCG/ML,300 MCG/ML

5PA; NDS; +

ARANESP ALBUMINFREE SOSY 10MCG/0.4ML, 100MCG/0.5ML, 25MCG/0.42ML, 40MCG/0.4ML, 60MCG/0.3ML

4

PA; +



Drug Name DrugTier

Requirements/Limits

ARANESP ALBUMINFREE SOSY 150MCG/0.3ML, 200MCG/0.4ML, 300MCG/0.6ML, 500 MCG/ML

5

PA; NDS; +

DOPTELET TABS 5 PA; NDS;LA; +

EPOGEN SOLN 10000UNIT/ML 3 PA; +

EPOGEN SOLN 2000UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML

4PA; +

EPOGEN SOLN 20000UNIT/ML 5 PA; NDS; +

GRANIX SOSY 300MCG/0.5ML, 480MCG/0.8ML

5PA; NDS; +

LEUKINE SOLR 5 PA; NDS; +

MULPLETA TABS 5 PA; NDS; +

NEULASTA ONPRO KITPSKT 5 PA; NDS; +

NEULASTA SOSY 5 PA; NDS; +

NEUPOGEN SOLN 5 PA; NDS; +

NEUPOGEN SOSY 5 PA; NDS; +

NIVESTYM SOSY 300MCG/0.5ML, 480MCG/0.8ML

5PA; NDS; +

PROCRIT SOLN 10000UNIT/ML, 2000 UNIT/ML,3000 UNIT/ML, 4000UNIT/ML

2

PA; +

PROCRIT SOLN 20000UNIT/ML, 40000 UNIT/ML 5 PA; NDS; +

PROMACTA PACK 12.5MG 5 PA; NDS;SL(12

ea daily); LA; +

PROMACTA PACK 25 MG 5 PA; NDS;SL(6ea daily); LA; +

PROMACTA TABS 12.5MG 5 PA; NDS;SL(12

ea daily); LA; +

PROMACTA TABS 25 MG 5 PA; NDS;SL(6ea daily); LA; +


Drug Name DrugTier

Requirements/Limits


REBLOZYL SOLR 5 PA; NDS; +

RETACRIT SOLN 10000UNIT/ML, 2000 UNIT/ML,3000 UNIT/ML, 4000UNIT/ML, 40000 UNIT/ML

4

PA; +

ZARXIO SOSY 5 PA; NDS; +

Stem Cell MobilizersMOZOBIL SOLN 5 PA; NDS; +

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - Systemicaminocaproic acid soln or0.25 gm/ml 5 NDS;MO; +

aminocaproic acid tabs or1000 mg 5 NDS;MO; +

aminocaproic acid tabs or500 mg 1 MO; *

tranexamic acid soln iv1000 mg/10ml 1 *

tranexamic acid tabs or 650mg 1 MO; *

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSBarbiturate Hypnotics

phenobarbital elix 1 AL(Up to 64 yrsold); MO; *

phenobarbital soln 1 AL(Up to 64 yrsold); MO; *

phenobarbital tabs 1 AL(Up to 64 yrsold); MO; *

Hypnotics - Tricyclic Agentsdoxepin hcl (sleep) tabs 3mg 1 QL(2 ea daily);

MO; *doxepin hcl (sleep) tabs 6mg 1 QL(1 ea daily);

MO; *Non-Barbiturate Hypnotics

EDLUAR SUBL 10 MG 3 SL(1 ea daily);MO; +



Drug Name DrugTier

Requirements/Limits

EDLUAR SUBL 5 MG 3 SL(2 ea daily);MO; +

eszopiclone tabs 1 MO; *

temazepam caps 1 MO; *

zaleplon caps 1 MO; *

zolpidem tartrate subl sl1.75 mg 1 SL(2 ea daily);

MO; *zolpidem tartrate subl sl 3.5mg 1 SL(1 ea daily);

MO; *zolpidem tartrate tabs or 10mg 1 SL(1 ea daily);

MO; *zolpidem tartrate tabs or 5mg 1 SL(2 ea daily);

MO; *zolpidem tartrate tbcr or12.5 mg 1 SL(1 ea daily);

MO; *zolpidem tartrate tbcr or6.25 mg 1 SL(2 ea daily);

MO; *Orexin Receptor Antagonists

BELSOMRA TABS 10 MG 3 PA; SL(2 eadaily); MO; +

BELSOMRA TABS 15 MG 3 PA; SL(1.33 eadaily); MO; +



Selective Melatonin Receptor Agonists

HETLIOZ CAPS 5 PA; NDS;MO;+

ramelteon tabs 1 MO; *

LAXATIVES - Bowel Treatment Drugs

Laxative Combinationsbisacodyl-peg 3350-potchloride-sod bicarb-sodchloride kit

1*

CLENPIQ SOLN 3 MO; +

GOLYTELY SOLR 2.82GM-21.5 GM-227.1 GM-5.53 GM-6.36 GM

3MO; +

Drug Name DrugTier

Requirements/Limits

peg 3350-kcl-nacl-nasulfate-na ascorbate-ascorbic acid solr

1MO; *

peg 3350-kcl-sod bicarb-sod chloride-sod sulfatesolr

1MO; *

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

1MO; *

PLENVU SOLR 3 MO; +

SUPREP BOWEL PREPKIT SOLN 3 MO; +

Laxatives - Miscellaneouslactulose soln 10 gm/15ml,20 gm/30ml 1 MO; *

Saline LaxativesOSMOPREP TABS 3 MO; +

LOCAL ANESTHETICS-Parenteral - Drugs forNumbingLocal Anesthetics - Amideslidocaine hcl (local anesth.)soln 4 +

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycinazithromycin pack or 1 gm 1 MO; *

azithromycin solr iv 500 mg 4 MO; +

azithromycin susr or 100mg/5ml, 200 mg/5ml 1 MO; *

azithromycin tabs or 250mg, 500 mg 1 MO; *

azithromycin tabs or 600mg 1 QL(0.29 ea

daily); MO; *ZITHROMAX PACK OR 1GM (azithromycin) 2 MO; +

Clarithromycinclarithromycin susr 250mg/5ml 1 MO; *

clarithromycin tabs 250 mg,500 mg 1 MO; *



Drug Name DrugTier

Requirements/Limits

clarithromycin tb24 500 mg 1 MO; *

ErythromycinsERYTHROCINLACTOBIONATE SOLR 4 SL(8 ea daily);

+erythromycin base cpep250 mg 1 SL(16 ea daily);

MO; *erythromycin base tabs250 mg 1 SL(16 ea daily);

MO; *erythromycin base tabs500 mg 1 SL(8 ea daily);

MO; *erythromycinethylsuccinate susr 200mg/5ml

1SL(100 mldaily); MO; *

erythromycinethylsuccinate susr 400mg/5ml

1SL(50 ml daily);MO; *

erythromycinethylsuccinate tabs 400 mg 1 SL(10 ea daily);

MO; *FidaxomicinDIFICID TABS 5 NDS;MO; +

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-Tapegauze pads 2" x 2" 1 RX/OTC; MO; *

Misc. Devices

ALCOHOL PADS 2 RX/OTC; MO;+

Parenteral Therapy SuppliesINSULIN SYRINGES ANDPEN NEEDLES 2 RX/OTC; MO;

+MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesCalcitonin Gene-Related Peptide (CGRP)AIMOVIG SOAJ 4 PA; MO; +

AJOVY SOSY 4 PA; MO; +

EMGALITY SOAJ 120MG/ML 4 PA; MO; +

EMGALITY SOSY 100MG/ML 5 PA; NDS;MO;

+

Drug Name DrugTier

Requirements/Limits

EMGALITY SOSY 120MG/ML 4 PA; MO; +

Migraine Combinationsergotamine w/ caffeinesupp 1 MO; *

ergotamine w/ caffeine tabs 1 MO; *

sumatriptan-naproxensodium tabs 1 MO; *

TREXIMET TABS 10 MG-60 MG 3 +

Migraine Products - NSAIDsCAMBIA PACK 3 MO; +

Migraine Productsdihydroergotaminemesylate soln ij 1 mg/ml 1 MO; *

dihydroergotaminemesylate soln na 4 mg/ml 5 NDS;MO; +

ergotamine tartrate subl 1 *

MIGRANAL SOLN(dihydroergotaminemesylate)

5NDS;MO; +

Serotonin Agonists

almotriptan malate tabs 1 QL(0.4 eadaily); MO; *

eletriptan hydrobromidetabs 1 QL(0.2 ea

daily); MO; *

frovatriptan succinate tabs 1 QL(0.6 eadaily); MO; *

naratriptan hcl tabs 1 QL(0.3 eadaily); MO; *

rizatriptan benzoate tabs 1 QL(0.4 eadaily); MO; *

rizatriptan benzoate tbdp 1 QL(0.4 eadaily); MO; *

sumatriptan soln 20 mg/act 1 QL(0.4 eadaily); MO; *

sumatriptan soln 5 mg/act 1 QL(0.6 eadaily); MO; *

sumatriptan succinate soajsc 4 mg/0.5ml, 6 mg/0.5ml 4

Auto-injector;Limit 4mls permonth;QL(0.14ml daily); MO; +



Drug Name DrugTier

Requirements/Limits

sumatriptan succinate soctsc 4 mg/0.5ml, 6 mg/0.5ml 4

Solutioncartridge;Limit4mls permonth;QL(0.14ml daily); MO;+

sumatriptan succinate solnsc 6 mg/0.5ml 4


sumatriptan succinate sosysc 6 mg/0.5ml 4

Limit 4mls permonth;QL(0.14ml daily); +

sumatriptan succinate tabsor 100 mg, 25 mg, 50 mg 1 QL(0.3 ea

daily); MO; *ZEMBRACE SYMTOUCHSOAJ 4 SL(2 ml daily);

MO; +

zolmitriptan tabs 2.5 mg 1 SL(4 ea daily);MO; *

zolmitriptan tabs 5 mg 1 SL(2 ea daily);MO; *

zolmitriptan tbdp 2.5 mg 1 SL(4 ea daily);MO; *

zolmitriptan tbdp 5 mg 1 SL(2 ea daily);MO; *

ZOMIG SOLN NA 2.5 MG 3 SL(4 ea daily);MO; +

ZOMIG SOLN NA 5 MG 3 SL(2 ea daily);MO; +

MINERALS & ELECTROLYTES

Electrolyte Mixturesdextrose in lactated ringerssoln 4 +

dextrose w/ sodiumchloride soln 0.2 %-5 %,0.45 %-2.5 %, 0.33 %-5 %,0.45 %-5 %

4

+

dextrose w/ sodiumchloride soln 0.9 %-5 % 4 MO; +

lactated ringer's soln 109meq/l-130 meq/l-28 meq/l-3meq/l-4 meq/l, 20mg/100ml-30 mg/100ml-310 mg/100ml-600mg/100ml

4

+

Drug Name DrugTier

Requirements/Limits

parenteral electrolytes conc 4 B/D; +

potassium chloride indextrose & sodium chloridesoln 0.15 %-0.45 %-5 %,0.45 %-20 meq/l-5 %

4

+

TPN ELECTROLYTESCONC 4 B/D; +

Magnesiummagnesium sulfate soln ij50 % 4 +

PotassiumK-TAB TBCR 20 MEQ, 8MEQ (potassium chloride) 3 MO; +

potassium chloride cpcr or10 meq, 8 meq 1 MO; *

potassium chloridemicroencapsulated crystalser tbcr 20 meq, 10 meq

1MO; *

potassium chloride soln iv 2meq/ml 4 MO; +

potassium chloride soln or20 %, 10 % 1 MO; *

potassium chloride tbcr or20 meq, 10 meq, 8 meq 1 MO; *

Sodiumsodium chloride soln iv0.45 % 4 +

sodium chloride soln iv 3%, 5 %, 0.9 % 4 MO; +

ZincGALZIN CAPS 3 MO; NT; +

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agentspenicillamine tabs 1 MO; *

trientine hcl caps 5 NDS;MO; +

EnzymesXIAFLEX SOLR 5 NDS;MO; +

Immunomodulators



Drug Name DrugTier

Requirements/Limits

REVLIMID CAPS 5 PA; NDS;LA; +

THALOMID CAPS 2 +

Immunosuppressive AgentsASTAGRAF XL CP24 3 B/D; MO; +

ATGAM INJ 4 B/D; +

AZATHIOPRINE SOLR IJ100 MG 4 B/D; +

azathioprine tabs or 100mg, 50 mg, 75 mg 1 B/D; MO; *

cyclosporine caps or 100mg, 25 mg 1 B/D; MO; *

cyclosporine modified (formicroemulsion) caps 1 B/D; MO; *

cyclosporine modified (formicroemulsion) soln 1 B/D; MO; *

cyclosporine soln iv 50mg/ml 4 B/D; MO; +

ENVARSUS XR TB24 3 B/D; MO; +

everolimus(immunosuppressant) tabs0.25 mg

1B/D; MO; *

everolimus(immunosuppressant) tabs0.5 mg, 0.75 mg

5B/D; NDS;MO;+

mycophenolate mofetilcaps 250 mg 1 B/D; MO; *

mycophenolate mofetil hclsolr 4 B/D; MO; +

mycophenolate mofetil susr200 mg/ml 5 B/D; NDS;MO;

+mycophenolate mofetil tabs500 mg 1 B/D; MO; *

mycophenolate sodiumtbec 1 B/D; MO; *

NULOJIX SOLR 5 B/D; NDS; +

PROGRAF PACK OR 0.2MG 5 B/D; NDS;MO;

+PROGRAF PACK OR 1MG 3 B/D; MO; +

PROGRAF SOLN IV 5MG/ML 4 B/D; +

Drug Name DrugTier

Requirements/Limits

SANDIMMUNE SOLN OR100 MG/ML 3 B/D; MO; +

SIMULECT SOLR 5 B/D; NDS; +

sirolimus soln 1 B/D; MO; *

sirolimus tabs 1 B/D; MO; *

tacrolimus caps 1 B/D; MO; *

THYMOGLOBULIN SOLR 2 B/D; +

ZORTRESS TABS 1 MG 5 B/D; NDS;MO;+

Irrigation Solutionsirrigation solutions,physiological soln 1 *

water for irrigation, sterilesoln 1 MO; *

Potassium Removing AgentsLOKELMA PACK 3 ST; MO; +

sodium polystyrenesulfonate powd or 1 MO; *

sodium polystyrenesulfonate susp or 15gm/60ml

1MO; *

VELTASSA PACK 16.8 GM 3ST; SL(1.5 eadaily); LA; MO;+

VELTASSA PACK 25.2 GM 3ST; SL(1 eadaily); LA; MO;+

VELTASSA PACK 8.4 GM 5ST; NDS;SL(3ea daily); LA;MO; +

Systemic Lupus Erythematosus AgentsBENLYSTA SOAJ 5 PA; NDS; +

BENLYSTA SOLR 5 PA; NDS; +

BENLYSTA SOSY 5 PA; NDS; +

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral



Drug Name DrugTier

Requirements/Limits

lidocaine hcl (mouth-throat)soln 2 % 1 MO; *

Anti-infectives - Throatclotrimazole troc 1 MO; *

nystatin (mouth-throat)susp 1 MO; *

Antiseptics - Mouth/Throatchlorhexidine gluconate(mouth-throat) soln 1 MO; *

Steroids - Mouth/Throat/Dentaltriamcinolone acetonide(mouth) pste 1 MO; *

Throat Products - Misc.cevimeline hcl caps 1 MO; *

pilocarpine hcl (oral) tabs 1 MO; *

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxants

baclofen tabs or 10 mg 1 SL(8 ea daily);MO; *



carisoprodol tabs 1 AL(Up to 64 yrsold); MO; *

chlorzoxazone tabs 500 mg 1 AL(Up to 64 yrsold); MO; *

cyclobenzaprine hcl cp2415 mg, 30 mg 1 AL(Up to 64 yrs

old); MO; *cyclobenzaprine hcl tabs10 mg, 5 mg, 7.5 mg 1 AL(Up to 64 yrs

old); MO; *metaxalone tabs 400 mg,800 mg 1 AL(Up to 64 yrs

old); MO; *methocarbamol tabs or 500mg, 750 mg 1 AL(Up to 64 yrs

old); MO; *orphenadrine citrate tb12or 100 mg 1 AL(Up to 64 yrs

old); MO; *

tizanidine hcl caps 2 mg 1 SL(18 ea daily);MO; *

Drug Name DrugTier

Requirements/Limits



tizanidine hcl tabs 2 mg 1 SL(18 ea daily);MO; *

tizanidine hcl tabs 4 mg 1 SL(9 ea daily);MO; *

Direct Muscle Relaxantsdantrolene sodium caps 1 MO; *

Muscle Relaxant Combinationscarisoprodol w/ aspirin &codeine tabs 1 AL(Up to 64 yrs

old); MO; *NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agent Combinationsazelastine hcl-fluticasonepropionate susp 1 MO; *

Nasal Antiallergyazelastine hcl soln 1 MO; *

olopatadine hcl (nasal) soln 1 MO; *

Nasal Anticholinergicsipratropium bromide (nasal)soln 1 MO; *

Nasal SteroidsBECONASE AQ SUSP 3 MO; +

flunisolide (nasal) soln 1 MO; *

fluticasone propionate(nasal) susp 1 RX/OTC; MO; *

mometasone furoate(nasal) susp 1 MO; *

OMNARIS SUSP 3 MO; +

QNASL AERS 3 MO; +

QNASL CHILDRENSAERS 3 MO; +

ZETONNA AERS 3 MO; +



Drug Name DrugTier

Requirements/Limits

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS AgentsRADICAVA SOLN 5 PA; NDS; +

riluzole tabs 1 MO; *

Muscular Dystrophy Agents

EXONDYS 51 SOLN 5 PA; NDS;LA;MO; +

VYONDYS 53 SOLN 5 PA; NDS;LA;MO; +

Neuromuscular Blocking Agent - NeurotoxinsBOTOX SOLR 100 UNIT 4 PA; MO; +

BOTOX SOLR 200 UNIT 3 PA; MO; +

XEOMIN SOLR 4 PA; MO; +

NUTRIENTS

Carbohydratesdextrose soln 10 %, 70 %,50 % 4 B/D; +

dextrose soln 5 % 4 B/D; MO; +

Lipidsfat emulsion plant basedemul 4 B/D; +

Proteinsamino acid infusion 15% 4 B/D; MO; +

CLINIMIX4.25%/DEXTROSE 5%SOLN

4B/D; +

PROSOL SOLN 4 B/D; +

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Beta-blockers - Ophthalmicbetaxolol hcl (ophth) soln 1 MO; *

BETIMOL SOLN 3 MO; +

BETOPTIC-S SUSP 2 MO; +

Drug Name DrugTier

Requirements/Limits

carteolol hcl (ophth) soln 1 MO; *

COMBIGAN SOLN 2 MO; +

dorzolamide hcl-timololmaleate soln 0.5 %-2 %, 20mg/ml-5 mg/ml, 22.3mg/ml-6.8 mg/ml

1

MO; *

levobunolol hcl soln 1 MO; *

timolol maleate (ophth) solg 1 MO; *

timolol maleate (ophth) soln 1 MO; *

TIMOPTIC OCUDOSESOLN 3 MO; +

TIMOPTIC-XE SOLG 0.25% (timolol maleate (ophth)) 3 MO; +

Cycloplegic Mydriaticscyclopentolate hcl soln 1 MO; *

MioticsPHOSPHOLINE IODIDESOLR 3 +

pilocarpine hcl soln 1 MO; *

Ophthalmic - Angiogenesis InhibitorsBEOVU SOLN 5 PA; NDS; +

EYLEA SOLN 5 PA; NDS;LA; +

EYLEA SOSY 5 PA; NDS;LA; +

Ophthalmic Adrenergic AgentsALPHAGAN P SOLN 0.1 % 2 MO; +

apraclonidine hcl soln 1 MO; *

brimonidine tartrate soln 1 MO; *

SIMBRINZA SUSP 2 MO; +

Ophthalmic Anti-infectivesAZASITE SOLN 3 MO; +

bacitracin (ophthalmic) oint 1 MO; *



Drug Name DrugTier

Requirements/Limits

bacitracin-polymyxin b(ophth) oint 1 MO; *

BESIVANCE SUSP 3 MO; +

CILOXAN OINT 3 MO; +

ciprofloxacin hcl (ophth)soln 1 MO; *

erythromycin (ophth) oint 1 MO; *

gatifloxacin (ophth) soln 1 MO; *

gentamicin sulfate (ophth)oint 1 MO; *

gentamicin sulfate (ophth)soln 1 MO; *

levofloxacin (ophth) soln 1 MO; *

MOXEZA SOLN(moxifloxacin hcl (ophth)) 2 MO; +

moxifloxacin hcl (ophth)soln 1 MO; *

NATACYN SUSP 2 MO; +

neomycin-bacitracin zn-polymyxin oint 1 MO; *

neomycin-polymyxin-gramicidin soln 1 MO; *

ofloxacin (ophth) soln 1 MO; *

polymyxin b-trimethoprimsoln 1 MO; *

sulfacetamide sodium(ophth) oint 1 MO; *

sulfacetamide sodium(ophth) soln 1 MO; *

tobramycin (ophth) soln 1 MO; *

TOBREX OINT 3 MO; +

trifluridine soln 1 MO; *

ZIRGAN GEL 3 MO; +

Ophthalmic ImmunomodulatorsRESTASIS EMUL 2 MO; +

Drug Name DrugTier

Requirements/Limits

RESTASIS MULTIDOSEEMUL 2 MO; +

Ophthalmic Local Anestheticsproparacaine hcl soln 1 MO; *

Ophthalmic Nerve Growth FactorsOXERVATE SOLN 5 PA; NDS;MO; +

Ophthalmic SteroidsALREX SUSP 3 MO; +

bacitracin-poly-neomycin-hc oint 1 MO; *

BLEPHAMIDE SUSP 3 MO; +

dexamethasone sodiumphosphate (ophth) soln 1 MO; *

DUREZOL EMUL 2 MO; +

FLAREX SUSP 2 MO; +

fluorometholone (ophth)susp 1 MO; *

FML FORTE SUSP 2 MO; +

FML OINT 2 MO; +

LOTEMAX GEL 3 MO; +

LOTEMAX OINT 3 MO; +

LOTEMAX SM GEL 3 MO; +

loteprednol etabonate susp 1 MO; *

MAXIDEX SUSP 3 MO; +

neomycin-polymy-dexameth oint 1 MO; *

neomycin-polymy-dexameth susp 1 MO; *

PRED MILD SUSP 2 MO; +

prednisolone acetate(ophth) susp 1 MO; *

sulfacetamide sod-prednisolone soln 1 MO; *



Drug Name DrugTier

Requirements/Limits

TOBRADEX OINT 3 MO; +

TOBRADEX ST SUSP 3 MO; +

tobramycin-dexamethasone susp 1 MO; *

ZYLET SUSP 2 MO; +

Ophthalmics - Misc.ACUVAIL SOLN 3 MO; +

ALOCRIL SOLN 3 MO; +

ALOMIDE SOLN 3 MO; +

azelastine hcl (ophth) soln 1 MO; *

AZOPT SUSP 2 MO; +

BEPREVE SOLN 3 MO; +

bromfenac sodium (ophth)soln 1 Once daily

dosing;MO; *cromolyn sodium (ophth)soln 1 MO; *

CYSTARAN SOLN 3

Limit 60mls per28days;QL(2.15ml daily); LA;MO; +

diclofenac sodium (ophth)soln 1 MO; *

dorzolamide hcl soln 1 MO; *

epinastine hcl (ophth) soln 1 MO; *

flurbiprofen sodium soln 1 MO; *

ILEVRO SUSP 2 MO; +

ketorolac tromethamine(ophth) soln 1 MO; *

LASTACAFT SOLN 3 MO; +

NEVANAC SUSP 2 MO; +

olopatadine hcl soln 1 RX/OTC; MO; *

Drug Name DrugTier

Requirements/Limits

PROLENSA SOLN 3 MO; +

Prostaglandins - Ophthalmicbimatoprost soln 1 MO; *

latanoprost soln 1 MO; *

LUMIGAN SOLN 2 MO; +

TRAVATAN Z SOLN(travoprost) 2 MO; +

ZIOPTAN SOLN 3 MO; +

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneousacetic acid (otic) soln 1 MO; *

Otic Anti-infectivesCETRAXAL SOLN(ciprofloxacin hcl (otic)) 3 MO; +

ciprofloxacin hcl (otic) soln 1 MO; *

ofloxacin (otic) soln 1 MO; *

Otic CombinationsCIPRO HC SUSP 3 MO; +

ciprofloxacin-dexamethasone susp 1 MO; *

CORTISPORIN-TC SUSP 3 MO; +

neomycin-polymyxin-hc(otic) soln 1 MO; *

neomycin-polymyxin-hc(otic) susp 1 MO; *

Otic Steroidsfluocinolone acetonide(otic) oil 1 MO; *

hydrocortisone w/aceticacid soln 1 MO; *

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocics



Drug Name DrugTier

Requirements/Limits

methylergonovine maleatetabs 1 MO; *

PASSIVE IMMUNIZING AND TREATMENTAGENTS - Antibody Drugs to Treat Low ImmuneSystemImmune SerumsBIVIGAM SOLN 5 B/D; NDS; +

CUVITRU SOLN 1GM/5ML 3 B/D; LA; +

CUVITRU SOLN 10GM/50ML 5 B/D; NDS; +

CUVITRU SOLN 2GM/10ML, 4 GM/20ML 4 B/D; LA; +

CUVITRU SOLN 8GM/40ML 5 B/D; NDS;LA; +

FLEBOGAMMA DIF SOLN0.5 GM/10ML, 10GM/100ML, 10 GM/200ML,2.5 GM/50ML, 20GM/200ML, 20 GM/400ML,5 GM/100ML

5

B/D; NDS; +

FLEBOGAMMA DIF SOLN5 GM/50ML 5 B/D; NDS; 5

GM/50 ML; +

GAMASTAN INJ 4 B/D; +

GAMMAGARD LIQUIDSOLN 5 B/D; NDS; +

GAMMAKED SOLN 5 B/D; NDS; +

GAMMAPLEX SOLN 5 B/D; NDS; +

GAMUNEX-C SOLN 5 B/D; NDS; +

HIZENTRA SOLN 1GM/5ML 3 B/D; LA; +

HIZENTRA SOLN 10GM/50ML 5 B/D; NDS; +

HIZENTRA SOLN 2GM/10ML, 4 GM/20ML 4 B/D; LA; +

HIZENTRA SOSY 1GM/5ML, 2 GM/10ML, 4GM/20ML

5B/D; NDS; +

HYPERRAB S/D SOLN 4 +

IMOGAM RABIES-HTSOLN 300 UNIT/2ML 4 +

Drug Name DrugTier

Requirements/Limits

KEDRAB SOLN 4 +

OCTAGAM SOLN 5 B/D; NDS; +

PRIVIGEN SOLN 5 B/D; NDS; +

VARIZIG SOLN 5 NDS; +

Monoclonal AntibodiesSYNAGIS SOLN 5 NDS; +

ZINPLAVA SOLN 5 PA; NDS; +

Passive Immunizing Agents - CombinationsHYQVIA KIT 5 B/D; NDS; +

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillinsamoxicillin caps 1 MO; *

amoxicillin chew 1 MO; *

amoxicillin susr 1 MO; *

amoxicillin tabs 1 MO; *

ampicillin caps 1 MO; *

ampicillin sodium solr ij 2gm, 500 mg, 1 gm 4 MO; +

ampicillin sodium solr ij 250mg 4 +

ampicillin sodium solr iv 10gm, 2 gm 4 +

Natural PenicillinsBICILLIN L-A SUSP 4 MO; +

penicillin g potassium solr5000000 unit, 20 mu,20000000 unit

4MO; +

penicillin v potassium solr250 mg/5ml 1 MO; *

penicillin v potassium tabs250 mg, 500 mg 1 MO; *

Penicillin Combinations



Drug Name DrugTier

Requirements/Limits

amoxicillin & potclavulanate chew 1 MO; *

amoxicillin & potclavulanate susr 1 MO; *

amoxicillin & potclavulanate tabs 1 MO; *

amoxicillin & potclavulanate tb12 1 MO; *

ampicillin & sulbactamsodium solr ij 0.5 gm-1 gm 4 +

ampicillin & sulbactamsodium solr ij 1 gm-2 gm 4 MO; +

ampicillin & sulbactamsodium solr iv 10 gm-5 gm 4 +

piperacillin sodium-tazobactam sodium solr 4 +

ZOSYN SOLN 0.25GM/50ML-2 GM/50ML-5%, 0.375 GM/50ML-3GM/50ML-5 %, 0.5GM/100ML-4 GM/100ML-5%

4

+

Penicillinase-Resistant Penicillinsdicloxacillin sodium caps 1 MO; *

nafcillin sodium solr ij 1 gm 4 +

NAFCILLIN SODIUMSOLR IJ 10 GM 5 NDS; +

nafcillin sodium solr ij 2 gm 4 MO; +

nafcillin sodium solr iv 10gm 5 NDS; +

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestinsmedroxyprogesteroneacetate tabs 1 MO; *

megestrol acetate(appetite) susp 1 AL(Up to 64 yrs

old); MO; *

norethindrone acetate tabs 1 MO; *

progesterone micronizedcaps 1 MO; *

Drug Name DrugTier

Requirements/Limits

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependencyacamprosate calcium tbec 1 MO; *

disulfiram tabs 1 MO; *

LUCEMYRA TABS 5PA; NDS;SL(16ea daily); MO;+

Anti-Cataplectic AgentsXYREM SOLN 5 NDS;LA; MO; +

Antidementia Agentsdonepezil hydrochloridetabs 1 MO; *

donepezil hydrochloridetbdp 1 MO; *

galantamine hydrobromidecp24 1 MO; *

galantamine hydrobromidesoln 1 MO; *

galantamine hydrobromidetabs 1 MO; *

memantine hcl cp24 14 mg 1AL(At least 60yrs old); SL(2ea daily); MO; *

memantine hcl cp24 21 mg 1

AL(At least 60yrs old);SL(1.33 eadaily); MO; *



memantine hcl soln 10mg/5ml, 2 mg/ml 1 AL(At least 60

yrs old); MO; *memantine hcl tabs 10 mg,5 mg 1 MO; *

NAMENDA XR TITRATIONPACK CP24 3 AL(At least 60

yrs old); MO; +

rivastigmine pt24 1 MO; *



Drug Name DrugTier

Requirements/Limits

rivastigmine tartrate caps 1 MO; *

Combination Psychotherapeuticschlordiazepoxide-amitriptyline tabs 1 AL(Up to 64 yrs

old); MO; *olanzapine-fluoxetine hclcaps 1 MO; *

perphenazine-amitriptylinetabs 1 AL(Up to 64 yrs

old); MO; *Fibromyalgia AgentsSAVELLA TABS 3 PA; MO; +

SAVELLA TITRATIONPACK MISC 3 PA; MO; +

Movement Disorder Drug Therapy

AUSTEDO TABS 12 MG 5 PA; NDS;SL(4ea daily); LA; +

AUSTEDO TABS 6 MG 5 PA; NDS;SL(8ea daily); LA; +

AUSTEDO TABS 9 MG 5PA;NDS;SL(5.33ea daily); LA; +

INGREZZA CAPS 5 PA; NDS;LA;MO; +

INGREZZA CPPK 5 PA; NDS;LA;MO; +

tetrabenazine tabs 5 PA; NDS; +

Multiple Sclerosis AgentsAUBAGIO TABS 5 PA; NDS; +

AVONEX PEN AJKT 5

PA; NDS;Limited to 1box per 28days;QL(0.036ea daily); +

AVONEX PSKT 5

PA; NDS;Limited to 1box per 28days;QL(0.036ml daily); +

BETASERON KIT 5 PA; NDS; +

dalfampridine tb12 5 PA; NDS; +

Drug Name DrugTier

Requirements/Limits

EXTAVIA KIT 5 PA; NDS; +

GILENYA CAPS 0.5 MG 5 PA; NDS; +

glatiramer acetate sosy 5 PA; NDS; +

LEMTRADA SOLN 5 PA; NDS;LA; +

MAVENCLAD TBPK 5 PA; NDS; 10Tabs; +

MAVENCLAD TBPK 5 PA; NDS;LA; +

MAYZENT TABS 5 PA; NDS; +

OCREVUS SOLN 5 PA; NDS; +

PLEGRIDY SOPN 5 PA; NDS; +

PLEGRIDY SOSY 5 PA; NDS; +

PLEGRIDY STARTERPACK SOPN 5 PA; NDS; +

PLEGRIDY STARTERPACK SOSY 5 PA; NDS; +

REBIF REBIDOSE SOAJ 5 PA; NDS; +

REBIF REBIDOSETITRATIONPACK SOAJ 5 PA; NDS; +

REBIF SOSY 5 PA; NDS; +

REBIF TITRATION PACKSOSY 5 PA; NDS; +

TECFIDERA CPDR(dimethyl fumarate) 5 PA; NDS; +

TECFIDERA STARTERPACK MISC (dimethylfumarate)

5PA; NDS; +

TYSABRI CONC 5 PA; NDS; +

VUMERITY CPDR 5 PA; NDS;Starter Bottle; +

VUMERITY CPDR 5 PA; NDS;QL(4ea daily); +

Postherpetic Neuralgia (PHN)/Neuropathic PainGRALISE TABS 3 MO; +

Pseudobulbar Affect (PBA) Agents



Drug Name DrugTier

Requirements/Limits

NUEDEXTA CAPS 3 PA; MO; +

Psychotherapeutic and Neurological Agents -

ergoloid mesylates tabs 1 AL(Up to 64 yrsold); MO; *

pimozide tabs 1 MO; *

Restless Leg Syndrome (RLS) AgentsHORIZANT TBCR 3 MO; +

Smoking Deterrentsbupropion hcl (smokingdeterrent) tb12 1 SL(2 ea daily);

MO; *CHANTIX CONTINUINGMONTHPAK TABS 3 MO; +

CHANTIX STARTINGMONTH PAK TABS 3 MO; +

CHANTIX TABS 3 MO; +

NICOTROL INHALERINHA 3

Limit 3 boxespermonth;SL(16.8ea daily); MO;+

NICOTROL NS SOLN 2 MO; +

Transthyretin Amyloidosis Agents

TEGSEDI SOSY 5 PA; NDS;LA;MO; +

Vasomotor Symptom Agentsparoxetine mesylate(vasomotor) caps 1 MO; *

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsAlpha-Proteinase Inhibitor (Human)ARALAST NP SOLR 1000MG 5 NDS;LA; MO; +

ARALAST NP SOLR 500MG 5 NDS;LA; +

GLASSIA SOLN 4 LA; +

PROLASTIN-C SOLN 1000MG/20ML 5 PA; NDS;LA;

MO; +PROLASTIN-C SOLR 1000MG 5 NDS;LA; MO; +

Drug Name DrugTier

Requirements/Limits

ZEMAIRA SOLR 5 NDS;LA; MO; +

Cystic Fibrosis AgentsKALYDECO PACK 5 PA; NDS;MO; +

KALYDECO TABS 5 PA; NDS;MO; +

ORKAMBI PACK 5 PA; NDS;LA;MO; +

ORKAMBI TABS 5 PA; NDS;LA;MO; +

PULMOZYME SOLN 2 B/D; +

SYMDEKO TBPK 5 PA; NDS;LA; +

TRIKAFTA TBPK 5 PA; NDS;LA;MO; +

Pulmonary Fibrosis AgentsESBRIET CAPS 5 PA; NDS;LA; +

ESBRIET TABS 5 PA; NDS;LA; +

OFEV CAPS 5 PA; NDS;LA; +

SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamidessulfadiazine tabs 1 MO; *

TETRACYCLINES - Drugs to Treat BacterialInfectionsAminomethylcyclinesNUZYRA TABS OR 150MG 5 PA; NDS;MO; +

Glycylcyclinestigecycline solr 5 NDS; +

Tetracyclinesdemeclocycline hcl tabs 1 MO; *

doxycycline (monohydrate)caps 1 MO; *

doxycycline (monohydrate)susr 1 MO; *



Drug Name DrugTier

Requirements/Limits

doxycycline (monohydrate)tabs 1 MO; *

doxycycline hyclate caps or50 mg, 100 mg 1 MO; *

doxycycline hyclate solr iv100 mg 4 QL(2 ea daily);

MO; +doxycycline hyclate tabs or100 mg, 20 mg 1 MO; *

doxycycline hyclate tbec or100 mg, 150 mg, 200 mg 1 MO; *

minocycline hcl caps 50mg, 75 mg, 100 mg 1 MO; *

minocycline hcl tabs 100mg, 50 mg, 75 mg 1 MO; *

tetracycline hcl caps 1 MO; *

VIBRAMYCIN SYRP 50MG/5ML 2 MO; +

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agentsmethimazole tabs 1 MO; *

propylthiouracil tabs 1 MO; *

Thyroid Hormoneslevothyroxine sodium tabsor 300 mcg, 100 mcg, 112mcg, 125 mcg, 137 mcg,150 mcg, 175 mcg, 200mcg, 25 mcg, 50 mcg, 75mcg, 88 mcg

1

MO; *

liothyronine sodium tabs or25 mcg, 5 mcg, 50 mcg 1 MO; *

SYNTHROID TABS(levothyroxine sodium) 3 MO; +

TOXOIDS

Toxoid CombinationsADACEL SUSP 1 *

BOOSTRIX SUSP 1 *

DAPTACEL SUSP 4 +

Drug Name DrugTier

Requirements/Limits

DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC SUSP

4B/D; +

INFANRIX SUSP 4 +

KINRIX SUSP 4 +

PEDIARIX SUSP 4 +

PENTACEL SUSR 4 +

QUADRACEL SUSP 4 +

TDVAX SUSP 4 B/D; +

TENIVAC INJ 4 B/D; +

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsdicyclomine hcl caps or 10mg 1 MO; *

dicyclomine hcl tabs or 20mg 1 MO; *

glycopyrrolate soln ij 0.2mg/ml, 1 mg/5ml, 4mg/20ml

4MO; +

glycopyrrolate soln ij 0.4mg/2ml 4 +

glycopyrrolate tabs or 1 mg 1 SL(8 ea daily);MO; *

glycopyrrolate tabs or 2 mg 1 SL(4 ea daily);MO; *

methscopolamine bromidetabs 1 MO; *

H-2 Antagonistscimetidine tabs 200 mg 1 RX/OTC; MO; *

cimetidine tabs 300 mg,400 mg, 800 mg 1 MO; *

famotidine soln iv 20mg/2ml, 200 mg/20ml, 40mg/4ml

4+

famotidine susr or 40mg/5ml 1 MO; *

famotidine tabs or 20 mg 1 RX/OTC; MO; *



Drug Name DrugTier

Requirements/Limits

famotidine tabs or 40 mg 1 MO; *

nizatidine caps 150 mg,300 mg 1 MO; *

Misc. Anti-Ulcersucralfate susp 1 MO; *

sucralfate tabs 1 MO; *

Proton Pump InhibitorsDEXILANT CPDR 2 ST; MO; +

esomeprazole magnesiumcpdr 20 mg 1 RX/OTC; MO; *

esomeprazole magnesiumcpdr 40 mg 1 MO; *

esomeprazole magnesiumpack 10 mg, 20 mg, 40 mg 1 ST; MO; *

esomeprazole sodium solr40 mg 4 +

lansoprazole cpdr 15 mg 1 RX/OTC; MO; *

lansoprazole cpdr 30 mg 1 MO; *

lansoprazole tbdd 15 mg 1 RX/OTC; MO; *

lansoprazole tbdd 30 mg 1 MO; *

NEXIUM PACK 2.5 MG, 5MG 3 ST; MO; +

omeprazole cpdr 10 mg, 40mg 1 MO; *

omeprazole cpdr 20 mg 1 RX/OTC; MO; *

pantoprazole sodium packor 40 mg 1 QL(1 ea daily);

MO; *pantoprazole sodium solr iv40 mg 1 *

pantoprazole sodium tbecor 20 mg, 40 mg 1 MO; *

Ulcer Drugs - Prostaglandinsmisoprostol tabs 1 MO; *

Ulcer Therapy Combinationsamoxicillin-clarithromycinw/ lansoprazole misc 3 MO; +

Drug Name DrugTier

Requirements/Limits

omeprazole-sodiumbicarbonate caps 1100 mg-20 mg

1RX/OTC; MO; *

omeprazole-sodiumbicarbonate caps 1100 mg-40 mg

1MO; *

omeprazole-sodiumbicarbonate pack 1680 mg-20 mg

1ST; 20MG-1680 MG;MO; *

omeprazole-sodiumbicarbonate pack 1680 mg-40 mg

1MO; *

PYLERA CAPS 3 MO; +

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infectivesnitrofurantoin monohydmacro caps 1 MO; *

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - Antimuscarinicsdarifenacin hydrobromidetb24 1 MO; *

GELNIQUE GEL 3 MO; +

oxybutynin chloride syrp 1 MO; *

oxybutynin chloride tabs 1 MO; *

oxybutynin chloride tb24 1 MO; *

OXYTROL PTTW 3 RX/OTC; MO;+

tolterodine tartrate cp24 1 MO; *

tolterodine tartrate tabs 1 MO; *

TOVIAZ TB24 2 MO; +

trospium chloride cp24 1 MO; *

trospium chloride tabs 1 MO; *

VESICARE TABS(solifenacin succinate) 2 MO; +



Drug Name DrugTier

Requirements/Limits

Urinary Antispasmodics - Beta-3 AdrenergicMYRBETRIQ TB24 3 MO; +

Urinary Antispasmodics - Cholinergic Agonistsbethanechol chloride tabs 1 MO; *

Urinary Antispasmodics - Direct Muscle Relaxantsflavoxate hcl tabs 1 MO; *

VACCINES

Bacterial VaccinesACTHIB SOLR 4 +

BCG VACCINE INJ 4 +

BEXSERO SUSY 4 +

HIBERIX SOLR 4 +

MENACTRA INJ 4 +

MENQUADFI INJ 4 +

MENVEO SOLR 4 +

PEDVAX HIB SUSP 4 +

TRUMENBA SUSY 4 +

TYPHIM VI SOLN 4 +

Viral VaccinesENGERIX-B SUSP IJ 10MCG/0.5ML, 20 MCG/ML 4 B/D; +

GARDASIL 9 SUSP 4 +

GARDASIL 9 SUSY 4 +

HAVRIX SUSP 4 +

IMOVAX RABIES(H.D.C.V.) INJ 4 B/D; +

IPOL INACTIVATED IPVINJ 4 +

IXIARO SUSP 4 +

Drug Name DrugTier

Requirements/Limits

M-M-R II SOLR 4 +

PROQUAD SUSR 4 +

RABAVERT SUSR 4 B/D; +

RECOMBIVAX HB SUSP 4 B/D; +

ROTARIX SUSR 3 +

ROTATEQ SOLN 2 +

SHINGRIX SUSR 2 +

TWINRIX SUSP 4 +

TWINRIX SUSY 4 +

VAQTA SUSP 4 +

VARIVAX INJ 4 +

YF-VAX INJ 4 +

ZOSTAVAX SUSR 2 +

VAGINAL AND RELATED PRODUCTS

Vaginal Anti-infectivesCLEOCIN SUPP VA 100MG 3 MO; +

clindamycin phosphatevaginal crea 1 MO; *

metronidazole vaginal gel 1 MO; *

miconazole nitrate vaginalsupp 1 MO; *

terconazole vaginal crea 1 MO; *

terconazole vaginal supp 1 MO; *

Vaginal Estrogensestradiol vaginal tabs 10mcg 1 MO; *

ESTRING RING 3 MO; +

FEMRING RING 3 MO; +



Drug Name DrugTier

Requirements/Limits

PREMARIN CREA VA0.625 MG/GM 2 MO; +

Vaginal ProgestinsCRINONE GEL 3 PA; MO; +

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy Agentsepinephrine (anaphylaxis)soaj 0.15 mg/0.15ml, 0.15mg/0.3ml, 0.3 mg/0.3ml

1MO; *

EPIPEN-JR 2-PAK SOAJ(epinephrine (anaphylaxis)) 2 MO; +

Neurogenic Orthostatic Hypotension (NOH) -NORTHERA CAPS 100MG 5 PA; NDS;SL(18

ea daily); +NORTHERA CAPS 200MG 5 PA; NDS;SL(9

ea daily); +NORTHERA CAPS 300MG 5 PA; NDS;SL(6

ea daily); +VasopressorsDOBUTAMINE HCL SOLN 4 +

dobutamine hcl soln 4 +

midodrine hcl tabs 1 MO; *

VITAMINS

Oil Soluble Vitaminsergocalciferol caps 1.25mg, 50000 unit 1 MO; NT; *

phytonadione tabs 1 MO; NT; *



Index of Drugsabacavir sulfate 37abacavir sulfate-lamivudine 37abacavir sulfate-lamivudine-zidovudine 37ABELCET 22ABILIFY MAINTENA 37abiraterone acetate 29ABRAXANE 33ABSORICA 45ABSTRAL 4acamprosate calcium 68acarbose 18acebutolol hcl 40acetaminophen w/ codeine 6acetazolamide 51acetic acid 56acetic acid (otic) 66acetylcysteine 45acitretin 47ACTEMRA 2ACTHAR 52ACTHIB 73ACTIMMUNE 33ACTOPLUS MET XR 18ACUVAIL 66acyclovir 40acyclovir sodium 40acyclovir topical 48ADACEL 71ADAKVEO 57adapalene 45adapalene-benzoyl peroxide 45adefovir dipivoxil 39ADEMPAS 42ADVAIR HFA 11AFINITOR 31AFINITOR DISPERZ 31AIMOVIG 60AJOVY 60AKYNZEO 22albendazole 7albuterol sulfate 11alclometasone dipropionate 48ALCOHOL PADS 60ALDACTAZIDE 51ALECENSA 31

alendronate sodium 51,52alfuzosin hcl 56ALIMTA 27ALINIA 8ALIQOPA 31aliskiren fumarate 26allopurinol 56almotriptan malate 60ALOCRIL 66ALOMIDE 66alosetron hcl 56ALPHAGAN P 64alprazolam 10ALREX 65ALTOPREV 24ALUNBRIG 31amantadine hcl 34AMBISOME 22ambrisentan 42amcinonide 48amikacin sulfate 2amiloride &hydrochlorothiazide 51amiloride hcl 51amino acid infusion 15% 64aminocaproic acid 58aminophylline 12aminosalicylic acid 27amiodarone hcl 10AMITIZA 55amitriptyline hcl 17amlodipine besylate 41amlodipine besylate-atorvastatin calcium 41amlodipine besylate-benazeprilhcl 25amlodipine besylate-olmesartanmedoxomil 25amlodipine besylate-valsartan 25amlodipine-valsartan-hydrochlorothiazide 25amoxapine 17amoxicillin 67amoxicillin & potclavulanate 68amoxicillin-clarithromycin w/lansoprazole 72amphetamine-dextroamphetamine 1

amphotericin b 22ampicillin 67ampicillin & sulbactamsodium 68ampicillin sodium 67ANADROL-50 7anagrelide hcl 57anastrozole 29ANORO ELLIPTA 11ANTARA 23APLENZIN 16APOKYN 34apraclonidine hcl 64aprepitant 22APTIOM 13APTIVUS 37ARALAST NP 70ARANESP ALBUMINFREE 57,58ARCALYST 2ARCAPTA NEOHALER 11argatroban 13ARIKAYCE 2aripiprazole 37ARISTADA 37ARISTADA INITIO 37armodafinil 1ARNUITY ELLIPTA 11ARRANON 27arsenic trioxide 33ARZERRA 28aspirin-dipyridamole 57ASTAGRAF XL 62atazanavir sulfate 37atenolol 40atenolol & chlorthalidone 25ATGAM 62atomoxetine hcl 1atorvastatin calcium 24atovaquone 8atovaquone-proguanil hcl 26ATRIPLA 37ATROVENT HFA 10AUBAGIO 69AUSTEDO 69AVANDIA 19AVASTIN 28

Index 1

AVEED 7AVONEX 69AVONEX PEN 69AYVAKIT 31azacitidine 27AZASITE 64AZATHIOPRINE 62azathioprine 62azelaic acid 50azelastine hcl 63azelastine hcl (ophth) 66azelastine hcl-fluticasonepropionate 63AZELEX 45azithromycin 59AZOPT 66aztreonam 9bacitracin (ophthalmic) 64bacitracin-poly-neomycin-hc 65bacitracin-polymyxin b(ophth) 65baclofen 63balsalazide disodium 55BALVERSA 31BANZEL 13,14BAQSIMI ONE PACK 19BAQSIMI TWO PACK 19BARACLUDE 39BAVENCIO 28BAXDELA 55BCG VACCINE 73BECONASE AQ 63BELEODAQ 31BELSOMRA 59benazepril &hydrochlorothiazide 25benazepril hcl 24BENDEKA 27BENLYSTA 62benzonatate 45benzoyl peroxide-erythromycin 45benztropine mesylate 34BEOVU 64BEPREVE 66BERINERT 57BESIVANCE 65BESPONSA 28

betamethasone dipropionate(topical) 48betamethasone dipropionateaugmented 48betamethasone sod phosphate& acetate 44betamethasone valerate 48BETASERON 69betaxolol hcl 40betaxolol hcl (ophth) 64bethanechol chloride 73BETHKIS 2BETIMOL 64BETOPTIC-S 64BEVYXXA 12bexarotene 33BEXSERO 73bicalutamide 29BICILLIN L-A 67BIDIL 41BIKTARVY 37bimatoprost 66bisacodyl-peg 3350-potchloride-sod bicarb-sodchloride 59bisoprolol &hydrochlorothiazide 25bisoprolol fumarate 40BIVIGAM 67BLENREP 28bleomycin sulfate 30BLEPHAMIDE 65BLINCYTO 28BOOSTRIX 71BORTEZOMIB 31bosentan 42BOSULIF 31BOTOX 64BRAFTOVI 31BREO ELLIPTA 11BRILINTA 57brimonidine tartrate 64BRIVIACT 14bromfenac sodium (ophth) 66bromocriptine mesylate 34BROVANA 11BRUKINSA 31budesonide 44

budesonide (inhalation) 11bumetanide 51BUNAVAIL 6buprenorphine 7buprenorphine hcl 6buprenorphine hcl-naloxone hcldihydrate 6bupropion hcl 16bupropion hcl (smokingdeterrent) 70buspirone hcl 9busulfan 27butalbital-acetaminophen-caffeine w/ codeine 6butalbital-aspirin-caffeinew/cod 6BUTORPHANOL TARTRATE 7butorphanol tartrate 7BUTRANS 7BYDUREON 19BYDUREON BCISE 19BYDUREON PEN 19BYETTA 19BYSTOLIC 40cabergoline 54CABLIVI 57CABOMETYX 31calcipotriene 47calcipotriene-betamethasonedipropionate 48calcitonin (salmon) 52calcitriol 53calcitriol (topical) 47calcium acetate (phosphatebinder) 56CALQUENCE 31CAMBIA 60CAMPATH 28candesartan cilexetil 25candesartan cilexetil-hydrochlorothiazide 25CAPASTAT SULFATE 27CAPEX 48CAPLYTA 35CAPRELSA 31captopril 24captopril &hydrochlorothiazide 25CARAC 47CARBAGLU 53

Index 2

carbamazepine 14CARBATROL 14carbidopa 34carbidopa-levodopa 34carbidopa-levodopa-entacapone

34carbinoxamine maleate 23carboplatin 27CARDIZEM LA 41CARDURA XL 56carisoprodol 63carisoprodol w/ aspirin &codeine 63carmustine 27carteolol hcl (ophth) 64carvedilol 40carvedilol phosphate 40CAVERJECT 41CAVERJECT IMPULSE 41CAYSTON 9cefaclor 43cefaclor monohydrate 43cefadroxil 43cefazolin sodium 43cefdinir 43CEFEPIME 43cefepime hcl 43cefixime 43cefoxitin sodium 43cefpodoxime proxetil 43cefprozil 43ceftazidime 43ceftriaxone sodium 43ceftriaxone sodium indextrose 43cefuroxime axetil 43cefuroxime sodium 43celecoxib 3CELONTIN 15CENTANY 46cephalexin 43CERDELGA 57CEREZYME 57cetirizine hcl 23CETRAXAL 66cevimeline hcl 63CHANTIX 70

CHANTIX CONTINUINGMONTHPAK 70CHANTIX STARTING MONTHPAK 70CHEMET 21CHENODAL 55chloramphenicol sodiumsuccinate 8chlordiazepoxide-amitriptyline

69chlorhexidine gluconate(mouth-throat) 63chloroquine phosphate 26chlorothiazide 51chlorpromazine hcl 36CHLORPROMAZINE HCL 36chlorpromazine hcl 36CHLORPROMAZINEHYDROCHLORIDE 36chlorthalidone 51chlorzoxazone 63cholestyramine 23cholestyramine light 23choline fenofibrate 23CHORIONICGONADOTROPIN 52CIALIS 41ciclopirox 46ciclopirox olamine 46cidofovir 39cilostazol 57CILOXAN 65CIMDUO 37cimetidine 71CIMZIA 55CIMZIA STARTER KIT 55cinacalcet hcl 53CINQAIR 10CINRYZE 57CIPRO 55CIPRO HC 66ciprofloxacin 55ciprofloxacin hcl 55ciprofloxacin hcl (ophth) 65ciprofloxacin hcl (otic) 66ciprofloxacin in d5w 55ciprofloxacin-dexamethasone

66cisplatin 27citalopram hydrobromide 16

cladribine 27CLARINEX-D 12 HOUR 45clarithromycin 59,60clemastine fumarate 23CLENPIQ 59CLEOCIN 73CLIMARA PRO 54CLINDAGEL 45clindamycin hcl 9clindamycin palmitatehydrochloride 9clindamycin phosphate 9clindamycin phosphate(topical) 46clindamycin phosphate in d5w9clindamycin phosphatevaginal 73clindamycin phosphate-benzoylperoxide 46clindamycin phosphate-benzoylperoxide (refrigerate) 46clindamycin phosphate-tretinoin 46CLINIMIX 4.25%/DEXTROSE5% 64clobazam 13clobetasol propionate 48clobetasol propionate emollientbase 48clocortolone pivalate 48CLODERM 48CLODERM PUMP 48clofarabine 27clomipramine hcl 17clonazepam 13clonidine 25clonidine hcl 25clopidogrel bisulfate 57clorazepate dipotassium 10clotrimazole 63clotrimazole (topical) 46clozapine 36CLOZARIL 36COARTEM 26codeine sulfate 4colchicine 56colchicine w/ probenecid 56colesevelam hcl 23colestipol hcl 23colistimethate sodium 9

Index 3

COMBIGAN 64COMBIPATCH 54COMBIVENT RESPIMAT 12COMETRIQ 31COMPLERA 37CONDYLOX 50COPIKTRA 31CORDRAN 49CORLANOR 42CORTIFOAM 7cortisone acetate 44CORTISPORIN 46CORTISPORIN-TC 66COSENTYX 47COSENTYX SENSOREADYPEN 47COTELLIC 31COUMADIN 12CREON 51CRESEMBA 22CRINONE 74CRIXIVAN 37cromolyn sodium 10cromolyn sodium(mastocytosis) 55cromolyn sodium (ophth) 66crotamiton 50CRYSVITA 53CUVITRU 67cyanocobalamin 57cyclobenzaprine hcl 63cyclopentolate hcl 64cyclophosphamide 27CYCLOPHOSPHAMIDE 27CYCLOSET 19cyclosporine 62cyclosporine modified (formicroemulsion) 62cyproheptadine hcl 23CYRAMZA 28CYSTADANE 53CYSTAGON 56CYSTARAN 66cytarabine 28dacarbazine 33dactinomycin 30dalfampridine 69

DALIRESP 11DALVANCE 8danazol 7dantrolene sodium 63dapsone 8DAPTACEL 71daptomycin 8darifenacin hydrobromide 72DARZALEX 28DARZALEX FASPRO 30daunorubicin hcl 30DAUNORUBICINHYDROCHLORIDE 30DAURISMO 29DAYTRANA 1decitabine 28deferasirox 21deferiprone 21DELESTROGEN 54DELSTRIGO 37demeclocycline hcl 70DEMSER 25DENAVIR 48DEPAKOTE 15DEPAKOTE ER 15DEPAKOTE SPRINKLES 15DEPO-MEDROL 44DEPO-PROVERA 29DEPO-SUBQ PROVERA104 44DESCOVY 37desipramine hcl 17desloratadine 23desmopressin acetate 53desmopressin acetatespray 53desmopressin acetate sprayrefrigerated 53desogestrel & ethinylestradiol 43desogestrel-ethinyl estradiol(biphasic) 43desonide 49desoximetasone 49DESVENLAFAXINE ER 17desvenlafaxine succinate 17dexamethasone 44,45dexamethasone sodiumphosphate 44

dexamethasone sodiumphosphate (ophth) 65DEXILANT 72dexmethylphenidate hcl 1dexrazoxane hcl 33dextroamphetamine sulfate 1dextrose 64dextrose in lactated ringers 61dextrose w/ sodium chloride 61DIASTAT ACUDIAL 13DIASTAT PEDIATRIC 13diazepam 10diazepam (anticonvulsant) 13diazoxide 19diclofenac epolamine 46diclofenac potassium 3diclofenac sodium 3diclofenac sodium (actinickeratoses) 47diclofenac sodium (ophth) 66diclofenac sodium (topical) 46diclofenac w/ misoprostol 3dicloxacillin sodium 68dicyclomine hcl 71didanosine 37DIFICID 60diflorasone diacetate 49diflunisal 4digoxin 41dihydroergotamine mesylate 60DILANTIN INFATABS 15DILANTIN-125 15DILATRATE SR 9diltiazem hcl 41diltiazem hcl coated beads 41diltiazem hcl extended releasebeads 41DIPENTUM 55diphenhydramine hcl 23diphenoxylate w/ atropine 21DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC 71dipyridamole 57disopyramide phosphate 10disulfiram 68divalproex sodium 16DIVIGEL 54

Index 4

DOBUTAMINE HCL 74dobutamine hcl 74docetaxel 33dofetilide 10donepezil hydrochloride 68DOPTELET 58dorzolamide hcl 66dorzolamide hcl-timololmaleate 64DOVATO 37doxazosin mesylate 25doxepin hcl 17doxepin hcl (antipruritic) 47doxepin hcl (sleep) 58doxercalciferol 53doxorubicin hcl 30doxorubicin hcl liposomal 30doxycycline (monohydrate) 70doxycycline (rosacea) 50doxycycline hyclate 71DRIZALMA SPRINKLE 17dronabinol 22drospirenone-ethinylestradiol 43drospirenone-ethinyl estradiol-levomefolate calcium 44DROXIA 57DUAVEE 54DUEXIS 3duloxetine hcl 17DUOPA 34DUREZOL 65dutasteride 56dutasteride-tamsulosin hcl 56econazole nitrate 46EDARBI 25EDARBYCLOR 25EDEX 42EDLUAR 58,59EDURANT 37efavirenz 37efavirenz-emtricitabine-tenofovirdisoproxil fumarate 38efavirenz-lamivudine-tenofovirdisoproxil fumarate 38EGRIFTA SV 52ELELYSO 57ELESTRIN 54

eletriptan hydrobromide 60ELIGARD 29ELIQUIS 12ELIQUIS STARTER PACK 12ELITEK 33ELLA 44ELMIRON 56EMCYT 29EMFLAZA 45EMGALITY 60EMPLICITI 28EMSAM 16emtricitabine 38emtricitabine-tenofovirdisoproxil fumarate 38EMTRIVA 38enalapril maleate 24,25enalapril maleate &hydrochlorothiazide 25ENBREL 4ENBREL MINI 4ENBREL SURECLICK 4ENDARI 57ENGERIX-B 73ENHERTU 28enoxaparin sodium 13ENSTILAR 49entacapone 34entecavir 39ENTRESTO 41ENTYVIO 55ENVARSUS XR 62EPCLUSA 39EPIDIOLEX 14epinastine hcl (ophth) 66epinephrine (anaphylaxis) 74EPIPEN-JR 2-PAK 74epirubicin hcl 30EPIVIR HBV 39eplerenone 26EPOGEN 58EQUETRO 35ERAXIS 22ERBITUX 28ergocalciferol 74ergoloid mesylates 70ergotamine tartrate 60

ergotamine w/ caffeine 60ERIVEDGE 29ERLEADA 29erlotinib hcl 31ERTACZO 46ertapenem sodium 8ERWINAZE 33ERYTHROCINLACTOBIONATE 60erythromycin (acne aid) 46erythromycin (ophth) 65erythromycin base 60erythromycin ethylsuccinate 60ESBRIET 70escitalopram oxalate 16esomeprazole magnesium 72esomeprazole sodium 72estradiol 54estradiol & norethindroneacetate 54estradiol vaginal 73estradiol valerate 54ESTRING 73eszopiclone 59ethacrynic acid 51ethambutol hcl 27ethosuximide 15ethynodiol diacet & ethestrad 44etodolac 3etonogestrel-ethinyl estradiol44ETOPOPHOS 33etoposide 33EVAMIST 54everolimus 31everolimus(immunosuppressant) 62EVOMELA 27EVOTAZ 38EVZIO 21exemestane 29EXONDYS 51 64EXTAVIA 69EYLEA 64ezetimibe 24ezetimibe-simvastatin 23FABIOR 46FABRAZYME 53

Index 5

famciclovir 40famotidine 71,72FANAPT 35FANAPT TITRATION PACK 35FARYDAK 31FASENRA 10FASLODEX 29fat emulsion plant based 64febuxostat 56felbamate 15felodipine 41FEMRING 73fenofibrate 23,24fenofibrate micronized 23fenofibric acid 24FENSOLVI 53fentanyl 4fentanyl citrate 4FENTORA 4FERRIPROX 21FERRIPROX TWICE-A-DAY 21FETZIMA 17FETZIMA TITRATION PACK17FIASP 19FIASP FLEXTOUCH 19FIASP PENFILL 19FIBRICOR 24FINACEA 50finasteride 56FINTEPLA 14FIRDAPSE 26FIRMAGON 29FIRVANQ 8FLAREX 65flavoxate hcl 73FLEBOGAMMA DIF 67flecainide acetate 10FLECTOR 46FLOVENT DISKUS 11FLOVENT HFA 11fluconazole 22fluconazole in nacl 22flucytosine 22fludarabine phosphate 28fludrocortisone acetate 45flunisolide (nasal) 63

fluocinolone acetonide 49fluocinolone acetonide(otic) 66fluocinonide 49fluocinonide emulsifiedbase 49fluorometholone (ophth) 65fluorouracil 28fluorouracil (topical) 47fluoxetine hcl 16fluphenazine decanoate 36fluphenazine hcl 36flurandrenolide 49flurbiprofen 3flurbiprofen sodium 66flutamide 29fluticasone propionate 49fluticasone propionate(nasal) 63fluticasone-salmeterol 12fluvastatin sodium 24fluvoxamine maleate 16FML 65FML FORTE 65folic acid 57FOLOTYN 28fondaparinux sodium 13FORFIVO XL 16FORTEO 52FOSAMAX PLUS D 52fosamprenavir calcium 38fosinopril sodium 25fosinopril sodium &hydrochlorothiazide 25fosphenytoin sodium 15FRAGMIN 13frovatriptan succinate 60fulvestrant 29furosemide 51FUZEON 38FYCOMPA 13gabapentin 14GALAFOLD 53galantamine hydrobromide 68GALZIN 61GAMASTAN 67GAMMAGARD LIQUID 67GAMMAKED 67

GAMMAPLEX 67GAMUNEX-C 67ganciclovir sodium 39GARDASIL 9 73gatifloxacin (ophth) 65GATTEX 56gauze pads 2" X 2" 60GAVRETO 31GAZYVA 28GELNIQUE 72GEMCITABINE 28gemcitabine hcl 28gemfibrozil 24GENOTROPIN 52GENOTROPIN MINIQUICK 52gentamicin in saline 2gentamicin sulfate 2gentamicin sulfate (ophth) 65gentamicin sulfate (topical) 46GENVOYA 38GILENYA 69GILOTRIF 31GIVLAARI 57GLASSIA 70glatiramer acetate 69GLEOSTINE 27glimepiride 20glipizide 20,21glipizide-metformin hcl 18GLUCAGEN HYPOKIT 19GLUCAGON EMERGENCYKIT 19glyburide 21glyburide micronized 21glyburide-metformin 18glycopyrrolate 71GOCOVRI 34GOLYTELY 59GRALISE 69granisetron hcl 21GRANIX 58griseofulvin microsize 22griseofulvin ultramicrosize 22guanfacine hcl 25guanfacine hcl (adhd) 1GUANIDINE HCL 26

Index 6

GVOKE HYPOPEN 1-PACK 19GVOKE HYPOPEN 2-PACK 19GVOKE PFS 19HAEGARDA 57HALAVEN 33halcinonide 49halobetasol propionate 49haloperidol 36haloperidol decanoate 36haloperidol lactate 36HARVONI 39HAVRIX 73HEMANGEOL 40HEPARIN SODIUM 13heparin sodium (porcine) 13HERCEPTIN 28HERCEPTIN HYLECTA 30HETLIOZ 59HIBERIX 73HIZENTRA 67HORIZANT 70HUMALOG 19HUMALOG JUNIORKWIKPEN 19HUMALOG KWIKPEN 19HUMALOG MIX 50/50 19HUMALOG MIX 50/50KWIKPEN 19HUMALOG MIX 75/25 19HUMALOG MIX 75/25KWIKPEN 19HUMATROPE 52HUMATROPE COMBOPACK 52HUMIRA 2HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 2HUMIRA PEN 2HUMIRA PEN-CD/UC/HSSTARTER 2HUMIRA PEN-PS/UVSTARTER 2HUMULIN 70/30 20HUMULIN 70/30 KWIKPEN 20HUMULIN N 20HUMULIN N KWIKPEN 20HUMULIN R 20HUMULIN R U-500(CONCENTRATED) 20

HUMULIN R U-500KWIKPEN 20hydralazine hcl 26hydrochlorothiazide 51hydrocodone bitartrate 4hydrocodone polistirex-chlorpheniramine polistirex 45hydrocodone-acetaminophen 6hydrocodone-ibuprofen 6hydrocortisone 45hydrocortisone (intrarectal) 7hydrocortisone (rectal) 7hydrocortisone (topical) 49hydrocortisone butyrate 49hydrocortisone butyratehydrophilic lipo base 49hydrocortisone valerate 49hydrocortisone w/aceticacid 66hydromorphone hcl 4HYDROMORPHONEHYDROCHLORIDE 4hydroxychloroquine sulfate 26hydroxyprogesterone caproate(antineoplastic) 29hydroxyurea 33hydroxyzine hcl 10hydroxyzine pamoate 10HYPERRAB S/D 67HYQVIA 67HYSINGLA ER 4ibandronate sodium 52IBRANCE 31ibuprofen 3icatibant acetate 57ICLUSIG 31icosapent ethyl 23idarubicin hcl 30IDHIFA 31IFEX 27ifosfamide 27IFOSFAMIDE 27ILARIS 2ILEVRO 66ILUMYA 47imatinib mesylate 31IMBRUVICA 31IMFINZI 28

imipenem-cilastatin 8imipramine hcl 17imipramine pamoate 17imiquimod 50IMLYGIC 33IMOGAM RABIES-HT 67IMOVAX RABIES (H.D.C.V.) 73IMPAVIDO 8INCRELEX 53INCRUSE ELLIPTA 10indapamide 51INDOCIN 3indomethacin 3INFANRIX 71INFLECTRA 55INFUGEM 28INGREZZA 69INLYTA 31INQOVI 30INREBIC 31INSULIN LISPRO JUNIORKWIKPEN 20INSULIN LISPROPROTAMINE/INSULIN LISPROKWIKPEN 20INSULIN SYRINGES AND PENNEEDLES 60INTELENCE 38INTRON A 33INVEGA SUSTENNA 35INVEGA TRINZA 35INVIRASE 38INVOKAMET 18INVOKAMET XR 18INVOKANA 20IPOL INACTIVATED IPV 73ipratropium bromide 10ipratropium bromide (nasal) 63ipratropium-albuterol 12irbesartan 25irbesartan-hydrochlorothiazide

26IRESSA 31irinotecan hcl 34irrigation solutions,physiological 62ISENTRESS 38ISENTRESS HD 38

Index 7

isoniazid 27isosorbide dinitrate 9isosorbide mononitrate 9isotretinoin 46ISTODAX (OVERFILL) 31itraconazole 22ivermectin 7ivermectin (rosacea) 50IXEMPRA KIT 33IXIARO 73JAKAFI 31JANUMET 18JANUMET XR 18JANUVIA 19JARDIANCE 20JENTADUETO 18JENTADUETO XR 18JEVTANA 33JUBLIA 46JULUCA 38JUXTAPID 24JYNARQUE 54K-TAB 61KADCYLA 28KADIAN 5KALBITOR 57KALETRA 38KALYDECO 70KANJINTI 28KANUMA 53KEDRAB 67KENALOG-10 45KEPIVANCE 33KERYDIN 46ketoconazole 22ketoconazole (topical) 46ketoprofen 3ketorolac tromethamine 3ketorolac tromethamine(ophth) 66KEVEYIS 51KEVZARA 3KEYTRUDA 28KHAPZORY 33KINERET 2KINRIX 71

KISQALI 31KISQALI FEMARA 200DOSE 30KISQALI FEMARA 400DOSE 30KISQALI FEMARA 600DOSE 30KORLYM 19KOSELUGO 31KRINTAFEL 26KUVAN 53KYPROLIS 31labetalol hcl 40lactated ringer's 61lactic acid (ammoniumlactate) 50lactulose 59lactulose (encephalopathy)56LAMICTAL XR 14lamivudine 38lamivudine (hbv) 39lamivudine-zidovudine 38lamotrigine 14LANOXIN 41LANOXIN PEDIATRIC 41lansoprazole 72lanthanum carbonate 56LANTUS 20LANTUS SOLOSTAR 20lapatinib ditosylate 31LARTRUVO 28LASTACAFT 66latanoprost 66LATUDA 35LAZANDA 5leflunomide 3LEMTRADA 69LENVIMA 10 MG DAILYDOSE 31LENVIMA 12MG DAILYDOSE 31LENVIMA 14 MG DAILYDOSE 31LENVIMA 18 MG DAILYDOSE 31LENVIMA 20 MG DAILYDOSE 31LENVIMA 24 MG DAILYDOSE 32LENVIMA 4 MG DAILYDOSE 32

LENVIMA 8 MG DAILYDOSE 32letrozole 29leucovorin calcium 33LEUKERAN 27LEUKINE 58leuprolide acetate 29levalbuterol hcl 12levalbuterol tartrate 12LEVEMIR 20LEVEMIR FLEXTOUCH 20levetiracetam 14levetiracetam in sodiumchloride 14levobunolol hcl 64levocarnitine (metabolicmodifiers) 53levocetirizine dihydrochloride23levofloxacin 55levofloxacin (ophth) 65levofloxacin in d5w 55levoleucovorin calcium 33levonorgestrel & ethestradiol 44levonorgestrel-eth estradiol(triphasic) 44levonorgestrel-ethinyl estradiol(91-day) 44levonorgestrel-ethinyl estradiol(continuous) 44levothyroxine sodium 71LEXIVA 38LIBTAYO 28lidocaine 50lidocaine hcl 50lidocaine hcl (local anesth.) 59lidocaine hcl (mouth-throat) 63lidocaine-prilocaine 50lincomycin hcl 9linezolid 9linezolid in sodium chloride 9LINZESS 56liothyronine sodium 71LIPOFEN 24lisinopril 25lisinopril &hydrochlorothiazide 26LITHIUM 35lithium carbonate 35LIVALO 24

Index 8

LO LOESTRIN FE 44LOKELMA 62LONSURF 30loperamide hcl 21lopinavir-ritonavir 38lorazepam 10LORBRENA 32losartan potassium 25losartan potassium &hydrochlorothiazide 26LOTEMAX 65LOTEMAX SM 65loteprednol etabonate 65lovastatin 24loxapine succinate 36LUCEMYRA 68luliconazole 47LUMIGAN 66LUMIZYME 53LUMOXITI 28LUPANETA PACK 53LUPRON DEPOT (1-MONTH) 29LUPRON DEPOT (3-MONTH) 29LUPRON DEPOT (4-MONTH) 29LUPRON DEPOT (6-MONTH) 29LUPRON DEPOT-PED (1-MONTH) 53LUPRON DEPOT-PED (3-MONTH) 53LUZU 47LYNPARZA 32LYSODREN 29M-M-R II 73magnesium sulfate 61malathion 50maprotiline hcl 16MARPLAN 16MARQIBO 33MATULANE 33MAVENCLAD 69MAVYRET 39MAXIDEX 65MAYZENT 69meclizine hcl 22meclofenamate sodium 3

MEDROL 45medroxyprogesteroneacetate 68medroxyprogesterone acetate(contraceptive) 44mefenamic acid 3mefloquine hcl 26megestrol acetate 29megestrol acetate(appetite) 68MEKINIST 32MEKTOVI 32meloxicam 3melphalan 27melphalan hcl 27memantine hcl 68MENACTRA 73MENOSTAR 54MENQUADFI 73MENTAX 47MENVEO 73meprobamate 10mercaptopurine 28meropenem 8mesalamine 55mesalamine w/ cleanser 55mesna 33MESNEX 33metaxalone 63metformin hcl 18methadone hcl 5methazolamide 51methenamine hippurate 9methimazole 71methocarbamol 63methotrexate sodium 28methoxsalen rapid 47methscopolamine bromide 71methyldopa 25methylergonovine maleate 67methylphenidate hcl 1methylprednisolone 45methylprednisoloneacetate 45methylprednisolone sodsucc 45methyltestosterone 7metoclopramide hcl 55

metolazone 51metoprolol &hydrochlorothiazide 26metoprolol succinate 40metoprolol tartrate 40metronidazole 8metronidazole (topical) 50metronidazole in nacl 8metronidazole vaginal 73metyrosine 25mexiletine hcl 10MIACALCIN 52micafungin sodium 22miconazole nitrate vaginal 73midodrine hcl 74miglitol 18miglustat 57MIGRANAL 60minocycline hcl 71minoxidil 26mirtazapine 16MIRVASO 50misoprostol 72mitomycin 30mitoxantrone hcl 30modafinil 2moexipril hcl 25molindone hcl 36mometasone furoate 49mometasone furoate (nasal) 63MONJUVI 28montelukast sodium 11morphine sulfate 5morphine sulfate beads 5MOTOFEN 21MOVANTIK 56MOXEZA 65moxifloxacin hcl 55moxifloxacin hcl (ophth) 65MOZOBIL 58MULPLETA 58MULTAQ 10mupirocin 46mupirocin calcium (topical) 46MUSE 42MVASI 28

Index 9

MYALEPT 53mycophenolate mofetil 62mycophenolate mofetil hcl 62mycophenolate sodium 62MYLOTARG 29MYRBETRIQ 73MYTESI 21nabumetone 3nadolol 40nadolol &bendroflumethiazide 26nafcillin sodium 68NAFCILLIN SODIUM 68nafcillin sodium 68naftifine hcl 47NAFTIN 47NAGLAZYME 53naloxone hcl 21naltrexone hcl 21NAMENDA XR TITRATIONPACK 68NAPRELAN 3naproxen 3naproxen sodium 3naproxen-esomeprazolemagnesium 3naratriptan hcl 60NARCAN 21NASCOBAL 57NATACYN 65nateglinide 20NATPARA 52NAYZILAM 13nefazodone hcl 17neomycin sulfate 2neomycin-bacitracin zn-polymyxin 65neomycin-polymy-dexameth 65neomycin-polymyxin-gramicidin

65neomycin-polymyxin-hc(otic) 66neomycin/polymyxin b gu 56NERLYNX 32NEULASTA 58NEULASTA ONPRO KIT 58NEUPOGEN 58NEUPRO 34NEVANAC 66

nevirapine 38NEXAVAR 32NEXIUM 72niacin (antihyperlipidemic) 24nicardipine hcl 41NICOTROL INHALER 70NICOTROL NS 70nifedipine 41nilutamide 30nimodipine 41NINLARO 32NIPENT 33nisoldipine 41nitisinone 53NITRO-DUR 9nitrofurantoin 9nitrofurantoin macrocrystal 9nitrofurantoin monohydmacro 9nitroglycerin 9NITROSTAT 9NIVESTYM 58nizatidine 72NORDITROPIN FLEXPRO52norelgestromin-ethinylestradiol 44norethin acet & estrad-fe 44norethindrone & ethestradiol 44norethindrone & ethinylestradiol-fe 44norethindrone(contraceptive) 44norethindrone acet & ethestra 44norethindrone acetate 68norethindrone acetate-ethinylestradiol 54norethindrone-eth estradiol(triphasic) 44norgestimate-ethinylestradiol 44norgestimate-ethinyl estradiol(triphasic) 44norgestrel & ethinylestradiol 44NORITATE 50NORPACE CR 10NORTHERA 74nortriptyline hcl 17NORVIR 38

NOVAREL 52NOXAFIL 22NUBEQA 30NUCALA 10NUCYNTA 5NUCYNTA ER 5NUEDEXTA 70NULOJIX 62NUPLAZID 35NUTROPIN AQ NUSPIN 20 52NUZYRA 70NYMALIZE 41nystatin 22nystatin (mouth-throat) 63nystatin (topical) 47nystatin-triamcinolone 47OCALIVA 55OCREVUS 69OCTAGAM 67octreotide acetate 54ODEFSEY 38ODOMZO 29OFEV 70ofloxacin (ophth) 65ofloxacin (otic) 66OGIVRI 29olanzapine 36olanzapine-fluoxetine hcl 69olmesartan medoxomil 25olmesartan medoxomil-amlodipine-hydrochlorothiazide

26olmesartan medoxomil-hydrochlorothiazide 26olopatadine hcl 66olopatadine hcl (nasal) 63OLUMIANT 2omega-3-acid ethyl esters 23omeprazole 72omeprazole-sodiumbicarbonate 72OMNARIS 63OMNITROPE 52ondansetron 22ondansetron hcl 21ONIVYDE 34ONUREG 28OPDIVO 29

Index 10

opium tincture 21OPSUMIT 42ORACEA 50ORALAIR 2ORBACTIV 8ORENCIA 3ORENCIA CLICKJECT 3ORENITRAM 42ORFADIN 53ORILISSA 52ORKAMBI 70orphenadrine citrate 63oseltamivir phosphate 40OSMOLEX ER 34OSMOPREP 59OSPHENA 52OTEZLA 3OTREXUP 2oxaliplatin 27oxandrolone 7oxaprozin 3OXBRYTA 57oxcarbazepine 14OXERVATE 65oxiconazole nitrate 47OXISTAT 47oxybutynin chloride 72oxycodone hcl 5oxycodone w/ acetaminophen 6oxycodone-aspirin 6oxymorphone hcl 5,6OXYTROL 72OZEMPIC 19paclitaxel 33PADCEV 29paliperidone 35PALYNZIQ 53PANCREAZE 51PANRETIN 47pantoprazole sodium 72parenteral electrolytes 61paricalcitol 53paromomycin sulfate 2paroxetine hcl 16paroxetine mesylate(vasomotor) 70

PAXIL 17PEDIARIX 71PEDVAX HIB 73peg 3350-kcl-nacl-na sulfate-naascorbate-ascorbic acid 59peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 59peg 3350-potassium chloride-sod bicarbonate-sodchloride 59PEGANONE 15PEGASYS 39PEGASYS PROCLICK 39PEGINTRON 39PEMAZYRE 32penicillamine 61penicillin g potassium 67penicillin v potassium 67PENNSAID 46PENTACEL 71pentamidine isethionate 8pentoxifylline 57PERFOROMIST 12perindopril erbumine 25PERJETA 29permethrin 50perphenazine 36perphenazine-amitriptyline 69PERSERIS 35PERTZYE 51PEXEVA 17phenelzine sulfate 16phenobarbital 58phenoxybenzamine hcl 25phenytoin 15phenytoin sodium 15phenytoin sodiumextended 15PHESGO 30PHOSPHOLINE IODIDE 64phytonadione 74PICATO 47PIFELTRO 38pilocarpine hcl 64pilocarpine hcl (oral) 63pimecrolimus 50pimozide 70pindolol 40

pioglitazone hcl 19pioglitazone hcl-glimepiride 18pioglitazone hcl-metforminhcl 18piperacillin sodium-tazobactamsodium 68PIQRAY 200MG DAILYDOSE 32PIQRAY 250MG DAILYDOSE 32PIQRAY 300MG DAILYDOSE 32piroxicam 3PLEGRIDY 69PLEGRIDY STARTERPACK 69PLENVU 59podofilox 50POLIVY 29polymyxin b sulfate 9polymyxin b-trimethoprim 65POMALYST 30PORTRAZZA 29posaconazole 22potassium chloride 61potassium chloride in dextrose &sodium chloride 61potassium chloridemicroencapsulated crystalser 61potassium citrate(alkalinizer) 56POTELIGEO 29PRADAXA 13PRALUENT 24pramipexole dihydrochloride 34prasugrel hcl 57pravastatin sodium 24praziquantel 7prazosin hcl 25PRED MILD 65prednicarbate 49prednisolone 45prednisolone acetate (ophth) 65prednisolone sodiumphosphate 45prednisone 45pregabalin 14PREGNYL W/DILUENTBENZYLALCOHOL/NACL 52PREMARIN 55,74

Index 11

PREMPHASE 54PREMPRO 54PRETOMANID 27PREVYMIS 39PREZCOBIX 38PREZISTA 38PRIFTIN 27primaquine phosphate 26PRIMAQUINE PHOSPHATE26primidone 14PRIVIGEN 67PROAIR HFA 12PROAIR RESPICLICK 12probenecid 56prochlorperazine 36prochlorperazine edisylate 36prochlorperazine maleate 36PROCRIT 58PROCYSBI 56progesterone micronized 68PROGRAF 62PROLASTIN-C 70PROLENSA 66PROLEUKIN 33PROLIA 52PROMACTA 58promethazine &phenylephrine 45promethazine hcl 23promethazine-phenylephrine-codeine 45propafenone hcl 10proparacaine hcl 65propranolol &hydrochlorothiazide 26propranolol hcl 40propylthiouracil 71PROQUAD 73PROSOL 64protriptyline hcl 17PROVENTIL HFA 12PRUDOXIN 47PULMICORT FLEXHALER 11PULMOZYME 70PURIXAN 28PYLERA 72pyrazinamide 27

pyridostigmine bromide 26pyrimethamine 26QINLOCK 32QNASL 63QNASL CHILDRENS 63QUADRACEL 71quetiapine fumarate 36quinapril hcl 25quinapril-hydrochlorothiazide

26quinidine gluconate 10quinidine sulfate 10quinine sulfate 26RABAVERT 73RADICAVA 64raloxifene hcl 52ramelteon 59ramipril 25ranolazine 9rasagiline mesylate 34RASUVO 2RAVICTI 53RAYALDEE 53REBETOL 39REBIF 69REBIF REBIDOSE 69REBIF REBIDOSETITRATIONPACK 69REBIF TITRATION PACK 69REBLOZYL 58RECOMBIVAX HB 73RECTIV 7REGRANEX 50RELENZA DISKHALER 40RELISTOR 56REMICADE 55RENFLEXIS 55repaglinide 20REPATHA 24REPATHA PUSHTRONEXSYSTEM 24REPATHA SURECLICK 24RESTASIS 65RESTASIS MULTIDOSE 65RETACRIT 58RETEVMO 32RETIN-A MICRO PUMP 46

RETROVIR IV INFUSION 38REVCOVI 53REVLIMID 62REXULTI 37REYATAZ 38ribavirin 40ribavirin (hepatitis c) 39RIDAURA 2rifabutin 27rifampin 27riluzole 64rimantadine hydrochloride 40RINVOQ 2risedronate sodium 52RISPERDAL CONSTA 35,36risperidone 36ritonavir 38RITUXAN 29RITUXAN HYCELA 30rivastigmine 68rivastigmine tartrate 69rizatriptan benzoate 60ROMIDEPSIN 32ropinirole hydrochloride 34rosuvastatin calcium 24ROTARIX 73ROTATEQ 73ROZLYTREK 32RUBRACA 32RUCONEST 57rufinamide 14RUKOBIA 38RUXIENCE 29RUZURGI 26RYDAPT 32RYTARY 34SAMSCA 54SANCUSO 22SANDIMMUNE 62SANDOSTATIN LARDEPOT 54SANTYL 50SAPHRIS 36sapropterin dihydrochloride 53SARCLISA 29SAVELLA 69

Index 12

SAVELLA TITRATIONPACK 69scopolamine 22SECUADO 36selegiline hcl 34selenium sulfide 48SELZENTRY 38SEMPREX-D 45SEREVENT DISKUS 12SEROSTIM 52sertraline hcl 17sevelamer carbonate 56SHINGRIX 73SIGNIFOR 54SIGNIFOR LAR 54sildenafil citrate 42sildenafil citrate (pulmonaryhypertension) 42SILIQ 47silodosin 56silver sulfadiazine 48SIMBRINZA 64SIMPONI 2SIMPONI ARIA 2SIMULECT 62simvastatin 24sirolimus 62SIRTURO 27SIVEXTRO 9SKYRIZI 47sodium chloride 61sodium chloride (gu irrigant) 56sodium polystyrenesulfonate 62SOLTAMOX 30SOLU-CORTEF 45SOLU-MEDROL 45SOMATULINE DEPOT 54SOMAVERT 52SORILUX 47sotalol hcl 40sotalol hcl (afib/afl) 40SOTYLIZE 40SOVALDI 39SPIRIVA HANDIHALER 11SPIRIVA RESPIMAT 11spironolactone 51

spironolactone &hydrochlorothiazide 51SPRAVATO 56MG DOSE 16SPRAVATO 84MG DOSE 16SPRITAM 14,15SPRYCEL 32STALEVO 100 34STALEVO 125 34STALEVO 150 34STALEVO 200 34STALEVO 50 34STALEVO 75 34stavudine 38STELARA 47STIMATE 53STIOLTO RESPIMAT 12STIVARGA 32STRENSIQ 53STRIBILD 38STRIVERDI RESPIMAT 12SUBSYS 6SUCRAID 51sucralfate 72sulfacetamide sod-prednisolone 65sulfacetamide sodium(acne) 46sulfacetamide sodium(ophth) 65sulfadiazine 70sulfamethoxazole-trimethoprim 8SULFAMYLON 48sulfasalazine 55sulindac 3sumatriptan 60sumatriptan succinate 60,61sumatriptan-naproxensodium 60SUNOSI 1SUPREP BOWEL PREPKIT 59SUTENT 32SYLATRON 33SYMBICORT 12SYMDEKO 70SYMFI 39SYMFI LO 39SYMLINPEN 120 18

SYMLINPEN 60 18SYMPAZAN 13SYMTUZA 39SYNAGIS 67SYNAREL 53SYNDROS 22SYNERCID 9SYNJARDY 18SYNJARDY XR 18SYNRIBO 33SYNTHROID 71TABLOID 28TABRECTA 32TACLONEX 49tacrolimus 62tacrolimus (topical) 50tadalafil 42tadalafil (pulmonaryhypertension) 42TAFINLAR 32TAGRISSO 32TAKHZYRO 57TALTZ 47TALZENNA 32tamoxifen citrate 30tamsulosin hcl 56TARGRETIN 47TASIGNA 32tavaborole 47TAVALISSE 57TAYTULLA 44tazarotene 47TAZORAC 48TAZVERIK 32TDVAX 71TECENTRIQ 29TECFIDERA 69TECFIDERA STARTERPACK 69TEFLARO 43TEGRETOL 15TEGRETOL-XR 15TEGSEDI 70TEKTURNA HCT 26telmisartan 25telmisartan-amlodipine 26

Index 13

telmisartan-hydrochlorothiazide26

temazepam 59TEMIXYS 39TEMODAR 27temsirolimus 32TENIVAC 71tenofovir disoproxil fumarate 39TEPEZZA 53terazosin hcl 25terbinafine hcl 22terbutaline sulfate 12terconazole vaginal 73testosterone 7testosterone cypionate 7testosterone enanthate 7tetrabenazine 69tetracycline hcl 71THALOMID 62theophylline 12thioridazine hcl 36thiotepa 27thiothixene 37THYMOGLOBULIN 62tiagabine hcl 15TIBSOVO 32TICE BCG 33TIGAN 22tigecycline 70timolol maleate 40timolol maleate (ophth) 64TIMOPTIC OCUDOSE 64TIMOPTIC-XE 64tinidazole 8TIVICAY 39TIVICAY PD 39tizanidine hcl 63TOBI PODHALER 2TOBRADEX 66TOBRADEX ST 66tobramycin 2tobramycin (ophth) 65tobramycin sulfate 2tobramycin-dexamethasone 66TOBREX 65tolbutamide 21

tolcapone 34tolmetin sodium 3TOLSURA 22tolterodine tartrate 72tolvaptan 54topiramate 15topotecan hcl 34toremifene citrate 30torsemide 51TOUJEO MAXSOLOSTAR 20TOUJEO SOLOSTAR 20TOVIAZ 72TPN ELECTROLYTES 61TRACLEER 42TRADJENTA 19tramadol hcl 6tramadol-acetaminophen 6trandolapril 25trandolapril-verapamil hcl 26tranexamic acid 58TRANSDERM SCOP 22TRANSDERM-SCOP 22tranylcypromine sulfate 16TRAVATAN Z 66TRAZIMERA 29trazodone hcl 17TREANDA 27TRECATOR 27TRELEGY ELLIPTA 12TRELSTAR MIXJECT 30TREMFYA 48treprostinil 42TRESIBA 20TRESIBA FLEXTOUCH 20tretinoin 46tretinoin (chemotherapy) 33tretinoin microsphere 46TREXIMET 60triamcinolone acetonide 45triamcinolone acetonide(mouth) 63triamcinolone acetonide(topical) 49,50triamterene 51triamterene &hydrochlorothiazide 51trientine hcl 61

trifluoperazine hcl 37trifluridine 65trihexyphenidyl hcl 34TRIKAFTA 70trimethobenzamide hcl 22trimethoprim 8trimipramine maleate 18TRINTELLIX 17TRIPTODUR 53TRIUMEQ 39TRODELVY 29TROGARZO 39trospium chloride 72TRULICITY 19TRUMENBA 73TRUVADA 39TRUXIMA 29TUDORZA PRESSAIR 11TUKYSA 32TURALIO 32TWINRIX 73TYBOST 39TYKERB 32TYMLOS 52TYPHIM VI 73TYSABRI 69TYVASO 42TYVASO REFILL 42TYVASO STARTER 42UCERIS 7ULTRAVATE 50UPTRAVI 42ursodiol 55VABOMERE 8valacyclovir hcl 40VALCHLOR 47valganciclovir hcl 39valproate sodium 16valproic acid 16valrubicin 30valsartan 25valsartan-hydrochlorothiazide

26VALSTAR 30VALTOCO 13vancomycin hcl 8

Index 14

VANCOMYCINHYDROCHLORIDE 8VANCOMYCINHYDROCHLORIDE/DEXTROSE

8VANTAS 30VAQTA 73vardenafil hcl 42VARIVAX 73VARIZIG 67VARUBI 22VASCEPA 23VECTIBIX 29VECTICAL 48VELCADE 32VELTASSA 62VEMLIDY 39VENCLEXTA 29VENCLEXTA STARTINGPACK 29venlafaxine hcl 17VENTAVIS 42VENTOLIN HFA 12verapamil hcl 41VERELAN PM 41VERSACLOZ 36VERZENIO 32VESICARE 72VIBERZI 56VIBRAMYCIN 71VICTOZA 19VIDEX EC 39VIDEXPEDIATRIC 39vigabatrin 15VIIBRYD 17VIIBRYD STARTER PACK 17VIMIZIM 53VIMOVO 3VIMPAT 15vinblastine sulfate 33vincristine sulfate 33vinorelbine tartrate 33VIOKACE 51VIRACEPT 39VIREAD 39VISTOGARD 21VITRAKVI 32VIZIMPRO 32

voriconazole 22VOSEVI 40VOTRIENT 32VPRIV 57VRAYLAR 35VUMERITY 69VYNDAMAX 43VYNDAQEL 43VYONDYS 53 64VYVANSE 1VYXEOS 31WAKIX 1warfarin sodium 12water for irrigation, sterile 62XALKORI 32XARELTO 13XARELTO STARTERPACK 12XATMEP 28XCOPRI 15XELJANZ 2XELJANZ XR 2XENLETA 9XEOMIN 64XERESE 48XERMELO 56XGEVA 52XIAFLEX 61XIFAXAN 8XOLAIR 10XOSPATA 32XPOVIO 100 MG ONCEWEEKLY 30XPOVIO 40 MG ONCEWEEKLY 30XPOVIO 40 MG TWICEWEEKLY 30XPOVIO 60 MG ONCEWEEKLY 30XPOVIO 60 MG TWICEWEEKLY 30XPOVIO 80 MG ONCEWEEKLY 30XPOVIO 80 MG TWICEWEEKLY 30XTANDI 30XURIDEN 53XYREM 68YERVOY 29YF-VAX 73

YONDELIS 27YONSA 30zafirlukast 11zaleplon 59ZALTRAP 28ZANOSAR 27ZARXIO 58ZEJULA 32ZELAPAR 35ZELBORAF 32ZEMAIRA 70ZEMBRACE SYMTOUCH 61ZENPEP 51ZEPATIER 40ZEPZELCA 27ZETONNA 63zidovudine 39zileuton 11ZINPLAVA 67ZIOPTAN 66ziprasidone hcl 35ziprasidone mesylate 35ZIPSOR 3ZIRABEV 28ZIRGAN 65ZITHROMAX 59ZOLADEX 30zoledronic acid 52ZOLINZA 32zolmitriptan 61zolpidem tartrate 59ZOMACTON 52ZOMIG 61ZONALON 47zonisamide 15ZONTIVITY 57ZORTRESS 62ZOSTAVAX 73ZOSYN 68ZUBSOLV 7ZULRESSO 16ZYCLARA 50ZYCLARA PUMP 50ZYDELIG 32ZYKADIA 32ZYLET 66

Index 15

ZYPREXA RELPREVV 36ZYTIGA 30ZYVOX 9

Index 16

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