updated may 1, 2020 - health alliance · by your plan for their safety, cost and effectiveness....

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Standard Large Group and Self-Funded Formulary Updated May 1, 2020

For the most current list of covered medications or if you have questions, call the Customer Service number on the back of your ID card or visit YourHealthAllliance.org.

On YourHealthAlliance.org, you can also:

• Locate a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

Standard Commercial

Understanding your formulary

What is a formulary? A formulary is a list of prescribed medications chosen About this formulary by your plan for their safety, cost and effectiveness. Where differences exist between Medications are listed by categories or classes and are this formulary and your benefit plan placed into cost levels known as tiers. The formulary documents, the benefit plan documents includes both brand-name and generic prescription rule. This may not be a complete list of medications approved by the U.S. Food and Drug medications, and not all medications Administration (FDA). listed may be covered by your plan.

Please look at the benefit plan How do I use my formulary? documents provided by your employer You and your doctor can consult the formulary to or plan sponsor for full details. help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or brand name, and if special rules apply. Bring this list with you when you see your doctor. If you have questions on how your medication is covered, call the Customer Service number on the back of your ID card or visit YourHealthAlliance.org.

What are tiers? Tiers are the different cost levels you pay for a medication. Generally, the higher your medication’s tier, the more you’ll pay out of pocket for it.

When does the formulary change? • Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic equivalent becomes available.

• Medications may move to a higher tier or be excluded from coverage during the year as other formulary alternatives become available.

When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for a coverage request by calling the Customer Service number on the back of your ID card.

2

Medication tips

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. If you choose a brand-name medication after a generic version is available, you may pay the brand-name copayment plus the cost difference between the brand-name and generic medication. These medications will have a comment saying “Brand penalty applies” in the notes section.

What if my doctor writes a brand-name prescription?

Over-the-counter (OTC)medications An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.

If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and could be right for you. Generic medications are usually your lowest-cost option.

3

Reading your formulary

The formulary gives you choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you hit your deductible.

Drug Tier Includes Helpful Tips

Preventive Brands and generics used for preventive care

No out-of-pocket cost. Deductible does not apply

Tier 1 Generics Generally the lowest-cost option

Tier 2 Preferred brands Many brands have lower-cost generic options

Tier 3 Non-preferred brands Many brands have lower-cost generic options

Tier 4 Preferred specialty May be limited to a specialty pharmacy

Tier 5 Non-preferred specialty May be limited to a specialty pharmacy

Tier 6 Non-formulary specialty May be limited to a specialty pharmacy

General Medical (GM) Medical benefit Provided and administered in a doctor’s office or

hospital and not covered by the pharmacy benefit

Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

AL Age Limit – Based on government or manufacturer guidelines, these medications are only covered for certain age groups.

PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

PV Preventive – These medications are covered at $0 under preventive benefit.

PV* Preventive* – These medications may be covered as preventive care if you meet the guidelines based on your plan.

QL Quantity Limit – Medication may be limited to a certain quantity.

ST Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost medication can be covered.

4

Table of Contents

Analgesics - Drugs for Pain ...........................8Analgesics - Drugs for Pain and

Inflammation .................................................6Anesthetics ................................................... 16Anti-Addiction / Substance Abuse

Treatment Agents .......................................20Antibacterials ................................................21Anticoagulants ..............................................33Anticonvulsants - Drugs for Seizures ........ 35Antidementia Agents - Drugs for

Alzheimer's Disease and Dementia .......... 39Antidepressants ........................................... 40Antiemetics - Drugs for Nausea and

Vomiting ......................................................43Antifungals ....................................................45Antigout Agents ............................................48Anti-inflammatory Agents ............................49Antimigraine Agents .................................... 49Antimyasthenic Agents ................................51Antimycobacterials ...................................... 51Antineoplastics - Drugs for Cancer ............ 52Antiparasitics ................................................65Antiparkinson Agents .................................. 66Antiplatelets ..................................................68Antipsychotics - Drugs for Mood

Disorders .....................................................69Antivirals ....................................................... 72Anxiolytics - Drugs for Anxiety ................... 77Bipolar Agents - Drugs for Mood

Disorders .....................................................78Blood Products / Modifiers / Volume

Expanders - Drugs for Bleeding Disorders 79

Cardiovascular Agents - Drugs for Heart and Circulation Conditions ....................... 84

Central Nervous System Agents - Drugs for Attention Deficit Disorder .................100

Central Nervous System Agents - Drugs for Multiple Sclerosis ...............................103

Central Nervous System Agents - Miscellaneous ...........................................104

Dental and Oral Agents - Drugs for Mouth and Throat Conditions .............................106

Dermatological Agents - Drugs for Skin Conditions .................................................107

Diabetes - Antidiabetic Agents ..................117Diabetes - Glucose Monitoring ..................120Diabetes - Glycemic Agents ...................... 120Diabetes - Insulins ......................................121Electrolytes / Minerals / Metals / Vitamins124

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer .......................................139

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

......................................................................140Genetic or Enzyme Disorder - Drugs for

Replacement, Modification, Treatment .. 145Genitourinary Agents - Drugs for Bladder,

Genital and Kidney Conditions ...............148Genitourinary Agents - Drugs for Prostate

Conditions .................................................151Hormonal Agents - Adrenal ....................... 152Hormonal Agents - Men's Health .............. 154Hormonal Agents - Osteoporosis ............. 155Hormonal Agents - Pituitary ...................... 155Hormonal Agents - Prostaglandins .......... 159Hormonal Agents - Sex Hormones and

Birth Control ............................................. 159Hormonal Agents - Thyroid ....................... 168Immunological Agents - Drugs for

Immune System Stimulation or Suppression ..............................................169

Immunological Agents - Drugs for Vaccination ............................................... 177

Inflammatory Bowel Disease Agents ........179Metabolic Bone Disease Agents - Drugs

for Osteoporosis ...................................... 181Metabolic Bone Disease Agents - Other .. 182Miscellaneous Therapeutic Agents .......... 183Ophthalmic Agents - Drugs for Eye

Allergy, Infection and Inflammation ....... 196Ophthalmic Agents - Drugs for Glaucoma......................................................................198Ophthalmic Agents - Drugs for

Miscellaneous Eye Conditions ................200Otic Agents - Drugs for Ear Conditions ... 204Respiratory Tract / Pulmonary Agents -

Drugs for Allergies, Cough, Cold ............205Respiratory Tract / Pulmonary Agents -

Drugs for Asthma and Other Lung Conditions .................................................207

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ........................ 212

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ........213

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm .......................... 214

Sleep Disorder Agents ............................... 215Index of Drugs.............................................. 217

5

Drug NameDrug Tier

Notes

Analgesics - Drugs for Pain and Inflammation

ACTIVE-KETOPROFEN EXTERNAL CREAM 5 %

3

adult aspirin regimen oral tablet delayed release 81 mg

PV

ANJESO INTRAVENOUS INJECTABLE 30 MG/ML

GM

ARTHROTEC ORAL TABLET DELAYED RELEASE 50-0.2 MG, 75-0.2 MG

3Brand

penalty applies

aspirin adult low strength oral tablet delayed release 81 mg

PV

aspirin childrens oral tablet chewable 81 mg

PV

aspirin ec low dose oral tablet delayed release 81 mg

PV

aspirin ec low strength oral tablet delayed release 81 mg

PV

aspirin ec oral tablet delayed release 81 mg

PV

aspirin low dose oral tablet chewable 81 mg

PV

aspirin low dose oral tablet delayed release 81 mg

PV

aspirin oral tablet delayed release 81 mg

PV

BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG

3

CALDOLOR INTRAVENOUS SOLUTION 800 MG/8ML

GM

Drug NameDrug Tier

Notes

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG

3Brand

penalty applies

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

1

choline-mag trisalicylate oral liquid 500 mg/5ml

1

DAYPRO ORAL TABLET 600 MG

3Brand

penalty applies

DICLOFENAC EPOLAMINE TRANSDERMAL PATCH 1.3 %

3 ST

diclofenac potassium oral tablet 50 mg

1

diclofenac sodium er oral tablet extended release 24 hour 100 mg

1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

1

diclofenac sodium transdermal gel 1 %

1

diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg

1

DICLOSTREAM EXTERNAL THERAPY PACK 1.5-10 %

3

diflunisal oral tablet 500 mg

1

DIMENTHO EXTERNAL THERAPY PACK 1.5 & 10 %

3

EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG

3Brand

penalty applies

ec-naproxen oral tablet delayed release 375 mg, 500 mg

1

Updated May 1, 2020

PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria

6

Drug NameDrug Tier

Notes

ENOVARX-IBUPROFEN EXTERNAL CREAM 10 %

3

EQUAPAX/IBUPROFEN/MINREX ORAL THERAPY PACK 800 MG

3

etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg

1

etodolac oral capsule 200 mg, 300 mg

1

etodolac oral tablet 400 mg, 500 mg

1

FBL KIT EXTERNAL CREAM 15-4-5 %

3

FELDENE ORAL CAPSULE 10 MG, 20 MG

3Brand

penalty applies

fenoprofen calcium oral capsule 200 mg, 400 mg

1

fenoprofen calcium oral tablet 600 mg

1

fenortho oral capsule 200 mg

1

FLECTOR TRANSDERMAL PATCH 1.3 %

3 ST

flurbiprofen oral tablet 100 mg, 50 mg

1

goodsense aspirin low dose oral tablet delayed release 81 mg

PV

ibu oral tablet 400 mg, 600 mg, 800 mg

1

ibuprofen lysine intravenous solution 10 mg/ml

GM

ibuprofen oral suspension 100 mg/5ml

1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

Drug NameDrug Tier

Notes

INDOCIN ORAL SUSPENSION 25 MG/5ML

3

INDOCIN RECTAL SUPPOSITORY 50 MG

2

indomethacin er oral capsule extended release 75 mg

1

indomethacin oral capsule 25 mg, 50 mg

1

indomethacin sodium intravenous solution reconstituted 1 mg

GM

ketoprofen er oral capsule extended release 24 hour 200 mg

1

ketoprofen oral capsule 25 mg, 50 mg, 75 mg

1

ketorolac tromethamine oral tablet 10 mg

1QL (20 EA

per 30 days)

KETOROLAC-BUPIV-KETAMINE INJECTION SOLUTION PREFILLED SYRINGE 60-150-60 MG/50ML

GM

KETOROLAC-ROPIV-KETAMINE INJECTION SOLUTION PREFILLED SYRINGE 15-100-30 MG/50ML

GM

LIDOPROFEN EXTERNAL CREAM 5-5-2 %

3

LODINE ORAL TABLET 400 MG

3Brand

penalty applies

meclofenamate sodium oral capsule 100 mg, 50 mg

1

mefenamic acid oral capsule 250 mg

1

Updated May 1, 2020


7

Drug NameDrug Tier

Notes

meloxicam oral tablet 15 mg, 7.5 mg

1

MOBIC ORAL TABLET 15 MG, 7.5 MG

3Brand

penalty applies

nabumetone oral tablet 500 mg, 750 mg

1

NALFON ORAL CAPSULE 400 MG

3Brand

penalty applies

NALFON ORAL TABLET 600 MG

3Brand

penalty applies

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG

3Brand

penalty applies

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

3

NAPRO EXTERNAL CREAM 15 %

3

NAPROSYN ORAL SUSPENSION 125 MG/5ML

3Brand

penalty applies

naproxen dr oral tablet delayed release 375 mg, 500 mg

1

naproxen oral suspension 125 mg/5ml

1

naproxen oral tablet 250 mg, 375 mg, 500 mg

1

naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg

1

naproxen sodium oral tablet 275 mg, 550 mg

1

NEOPROFEN INTRAVENOUS SOLUTION 10 MG/ML

GM

Drug NameDrug Tier

Notes

oxaprozin oral tablet 600 mg

1

piroxicam oral capsule 10 mg, 20 mg

1

qc aspirin low dose oral tablet delayed release 81 mg

PV

salsalate oral tablet 500 mg, 750 mg

1

ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG

3

sulindac oral tablet 150 mg, 200 mg

1

tolmetin sodium oral capsule 400 mg

1

tolmetin sodium oral tablet 600 mg

1

VOLTAREN TRANSDERMAL GEL 1 %

3Brand

penalty applies

VOPAC KT EXTERNAL CREAM 5-5-2 %

3

Analgesics - Drugs for Pain

7T GUMMY ES ORAL TABLET CHEWABLE 500 MG

3

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 400 MCG, 600 MCG, 800 MCG

3 PA

acetaminophen-codeine #2 oral tablet 300-15 mg

1


1


1

acetaminophen-codeine oral solution 120-12 mg/5ml

1

Updated May 1, 2020


8

Drug NameDrug Tier

Notes

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg

1

ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3PA; Brand

penalty applies

alfentanil hcl intravenous solution 1000 mcg/2ml, 2500 mcg/5ml

GM

apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg

1

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG, 30 MG, 60 MG

3 PA

ascomp-codeine oral capsule 50-325-40-30 mg

1

BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG

3QL (60 EA

per 30 days)

BUPAP ORAL TABLET 50-300 MG

3Brand

penalty applies

BUPRENEX INJECTION SOLUTION 0.3 MG/ML

GM

buprenorphine hcl injection solution 0.3 mg/ml

GM

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr

1

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

3

Drug NameDrug Tier

Notes

butalbital-acetaminophen capsule 50-300 mg oral 50-300 mg

1

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL 50-300 MG

1

butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg

1

butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg

1

butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 mg

1

butalbital-apap-caffeine oral tablet 50-325-40 mg

1

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

1

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

1

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

1

butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml

GM

butorphanol tartrate nasal solution 10 mg/ml

1

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR

3Brand

penalty applies

BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

3

carisoprodol-aspirin-codeine oral tablet 200-325-16 mg

1

Updated May 1, 2020


9

Drug NameDrug Tier

Notes

clonidine hcl (analgesia) epidural solution 100 mcg/ml, 500 mcg/ml

5Specialty Medical

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg

1

DEMEROL INJECTION SOLUTION 100 MG/2ML, 100 MG/ML, 25 MG/0.5ML, 25 MG/ML, 50 MG/ML, 75 MG/1.5ML, 75 MG/ML

GM

DILAUDID INJECTION SOLUTION 1 MG/ML, 2 MG/ML

GM

DILAUDID ORAL LIQUID 1 MG/ML

3Brand

penalty applies

DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG

3Brand

penalty applies

DOLOPHINE ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 MCG

3

DURACLON EPIDURAL SOLUTION 100 MCG/ML

5Specialty Medical

DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR 100 MCG/HR

3PA; Brand

penalty applies


3PA; Brand

penalty applies


3PA; Brand

penalty applies


3PA; Brand

penalty applies

Drug NameDrug Tier

Notes


3PA; Brand

penalty applies

duramorph injection solution 0.5 mg/ml, 1 mg/ml

GM

duraxin oral capsule 300-200-20 mg

1

EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG

3 PA

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1

ESGIC ORAL CAPSULE 50-325-40 MG

3Brand

penalty applies

ESGIC ORAL TABLET 50-325-40 MG

3Brand

penalty applies

fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml

GM

fentanyl citrate (pf) injection solution cartridge 100 mcg/2ml

GM

fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

1 PA

FENTANYL CITRATE BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3 PA

Updated May 1, 2020


10

Drug NameDrug Tier

Notes

FENTANYL CITRATE INJECTION SOLUTION 1500 MCG/30ML

GM

FENTANYL CITRATE INJECTION SOLUTION PREFILLED SYRINGE 50 MCG/5ML

GM

FENTANYL CITRATE INTRAVENOUS SOLUTION 5000 MCG/100ML

GM

FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1500 MCG/30ML, 250 MCG/5ML, 2750 MCG/55ML

GM

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 1-0.9 MG/100ML-%, 1.25-0.9 MG/250ML-%, 2.5-0.9 MG/250ML-%

GM

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/2ML-%, 5-0.9 MCG/ML-%, 550-0.9 MCG/55ML-%

GM

FENTANYL CIT-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.3-0.2-0.9 MG/150ML-%

GM

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr

1 PA

Drug NameDrug Tier

Notes

FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.2-0.1-0.9 MG/100ML-%, 0.2-0.125-0.9 MG/100ML-%, 0.5-0.0625-0.9 MG/250ML-%, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125-0.9 MG/250ML-%

GM

FENTANYL-BUPIVACAINE-NACL INJECTION SOLUTION 2-0.125-0.9 MCG/ML-%-%

GM

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3 PA

FIORICET ORAL CAPSULE 50-300-40 MG

3Brand

penalty applies

FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG

3Brand

penalty applies

FIORINAL ORAL CAPSULE 50-325-40 MG

3Brand

penalty applies

FIORINAL/CODEINE #3 ORAL CAPSULE 50-325-40-30 MG

3Brand

penalty applies

hydrocodone bitartrate er oral capsule er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg

1 PA

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

1

Updated May 1, 2020


11

Drug NameDrug Tier

Notes

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

1

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

1

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg

1 PA

hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml

GM

hydromorphone hcl oral liquid 1 mg/ml

1

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg

1

hydromorphone hcl pf injection solution 1 mg/ml, 10 mg/ml, 2 mg/ml, 4 mg/ml, 50 mg/5ml, 500 mg/50ml

GM

hydromorphone hcl rectal suppository 3 mg

1

HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION 1 MG/ML

GM

hydromorphone hcl solution 1 mg/ml injection 1 mg/ml

GM

HYDROMORPHONE HCL-NACL INJECTION SOLUTION 20-0.9 MG/100ML-%

GM

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 30-0.9 MG/30ML-%

GM

Drug NameDrug Tier

Notes

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.2-0.9 MG/0.2ML-%, 0.5-0.9 MG/0.5ML-%, 1-0.9 MG/5ML-%, 1-0.9 MG/ML-%, 2-0.9 MG/ML-%, 50-0.9 MG/50ML-%, 55-0.9 MG/55ML-%, 6-0.9 MG/30ML-%

GM

HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

3 PA

INFUMORPH 200 INJECTION SOLUTION 200 MG/20ML (10 MG/ML)

GM

INFUMORPH 500 INJECTION SOLUTION 500 MG/20ML (25 MG/ML)

GM

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG

3PA; Brand

penalty applies

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG

3 PA

LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT

3 PA

levorphanol tartrate oral tablet 2 mg, 3 mg

1

lorcet hd oral tablet 10-325 mg

1

Updated May 1, 2020


12

Drug NameDrug Tier

Notes

lorcet oral tablet 5-325 mg

1

lorcet plus oral tablet 7.5-325 mg

1

LORTAB ORAL ELIXIR 10-300 MG/15ML

3

MEDI-DERM-RX EXTERNAL CREAM 0.035-5-20 %

3

MEDROX-RX EXTERNAL OINTMENT 0.05-7-20 %

3

meperidine hcl injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml

GM

meperidine hcl oral solution 50 mg/5ml

1

meperidine hcl oral tablet 100 mg, 50 mg

1

methadone hcl injection solution 10 mg/ml

GM

methadone hcl intensol oral concentrate 10 mg/ml

1

methadone hcl oral concentrate 10 mg/ml

1

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml

1

methadone hcl oral tablet 10 mg, 5 mg

1

methadone hcl oral tablet soluble 40 mg

1

METHADOSE ORAL CONCENTRATE 10 MG/ML

3Brand

penalty applies

methadose oral tablet soluble 40 mg

1

METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 MG/ML

3Brand

penalty applies

Drug NameDrug Tier

Notes

mitigo injection solution 200 mg/20ml (10 mg/ml), 500 mg/20ml (25 mg/ml)

GM

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1

morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml, 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml

GM

morphine sulfate (pf) intravenous solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml

GM

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

1 PA

morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg

1 PA

morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg

1 PA

MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML

GM

morphine sulfate injection solution 2 mg/ml, 4 mg/ml

GM

morphine sulfate intramuscular device 10 mg/0.7ml

GM

MORPHINE SULFATE INTRAVENOUS SOLUTION 0.5 MG/ML

GM

Updated May 1, 2020


13

Drug NameDrug Tier

Notes

morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

1

morphine sulfate oral tablet 15 mg, 30 mg

1

morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg

1

MORPHINE SULFATE SOLUTION 1 MG/ML INTRAVENOUS 1 MG/ML

GM

morphine sulfate solution 1 mg/ml intravenous 1 mg/ml

GM

MORPHINE SULFATE-NACL INJECTION SOLUTION PREFILLED SYRINGE 5-0.9 MG/5ML-%

GM

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION 100-0.9 MG/100ML-%, 500-0.9 MG/100ML-%

GM

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 150-0.9 MG/30ML-%, 2-0.9 MG/ML-%, 30-0.9 MG/30ML-%, 4-0.9 MG/ML-%, 55-0.9 MG/55ML-%

GM

MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 15 MG, 200 MG, 30 MG, 60 MG

3PA; Brand

penalty applies

nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml

GM

NALOCET ORAL TABLET 2.5-300 MG

3

Drug NameDrug Tier

Notes

NORCO ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG

3Brand

penalty applies

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG

3 PA

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG

3 ST

OPANA ORAL TABLET 10 MG

3Brand

penalty applies

OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG, 7.5 MG

3 PA

OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

3 PA

oxycodone hcl oral capsule 5 mg

1

oxycodone hcl oral concentrate 100 mg/5ml

1

oxycodone hcl oral solution 5 mg/5ml

1

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg

1

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-300 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1

oxycodone-aspirin oral tablet 4.8355-325 mg

1

oxycodone-ibuprofen oral tablet 5-400 mg

1

Updated May 1, 2020


14

Drug NameDrug Tier

Notes

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

3 PA

oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

1 PA

oxymorphone hcl oral tablet 10 mg, 5 mg

1

pentazocine-naloxone hcl oral tablet 50-0.5 mg

1

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG

3Brand

penalty applies

PRIALT INTRATHECAL SOLUTION 100 MCG/ML, 500 MCG/20ML, 500 MCG/5ML

GM

PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG

3

PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 74.2 MG

2

PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG

3

remifentanil hcl intravenous solution reconstituted 1 mg, 2 mg, 5 mg

GM

ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3 PA

sufentanil citrate intravenous solution 100 mcg/2ml, 250 mcg/5ml, 50 mcg/ml

GM

tencon oral tablet 50-325 mg

1

tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg

1 ST

tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg

1 ST

tramadol hcl oral tablet 100 mg, 50 mg

1

tramadol-acetaminophen oral tablet 37.5-325 mg

1

TREZIX ORAL CAPSULE 320.5-30-16 MG

3Brand

penalty applies

TYLENOL WITH CODEINE #3 ORAL TABLET 300-30 MG

3Brand

penalty applies

ULTIVA INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG

GM

ULTRACET ORAL TABLET 37.5-325 MG

3Brand

penalty applies

ULTRAM ORAL TABLET 50 MG

3Brand

penalty applies

VANATOL LQ ORAL SOLUTION 50-325-40 MG/15ML

3

Updated May 1, 2020


15

Drug NameDrug Tier

Notes

VANATOL S ORAL SOLUTION 50-325-40 MG/15ML

3

VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML

3

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG

3 PA

ZEBUTAL ORAL CAPSULE 50-325-40 MG

3Brand

penalty applies

ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG

3PA; Brand

penalty applies

Anesthetics

1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4-0.0375-5-20 %

3

7T LIDO EXTERNAL GEL 2 %

3

AGONEAZE EXTERNAL KIT 2.5-2.5 %

3

ANODYNE LPT EXTERNAL KIT 2.5-2.5 %

3

ARTICADENT DENTAL INJECTION SOLUTION CARTRIDGE 4 %-1:100000, 4 %-1:200000

GM

bupivacaine fisiopharma injection solution 2.5 mg/ml, 5 mg/ml

GM

bupivacaine hcl (pf) injection solution 0.25 %, 0.5 %, 0.75 %

GM

bupivacaine hcl injection solution 0.25 %, 0.5 %

GM

Drug NameDrug Tier

Notes

BUPIVACAINE HCL INJECTION SOLUTION 312.5 MG/10ML

GM

BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0.125 % (50 ML), 125 MG/4ML, 250 MG/8ML, 312.5 MG/10ML, 625 MG/20ML

GM

BUPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED SYRINGE 0.25-0.9 %

GM

bupivacaine in dextrose intrathecal solution 0.75-8.25 %

GM

BUPIVACAINE IN DEXTROSE SOLUTION PREFILLED SYRINGE 0.75-8.25 % (2 ML)

GM

bupivacaine spinal intrathecal solution 0.75-8.25 %

GM

bupivacaine-epinephrine (pf) injection solution 0.25% -1:200000, 0.5% -1:200000

GM

bupivacaine-epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

GM

CARBOCAINE INJECTION SOLUTION 1 %, 2 %

GM

CARBOCAINE PRESERVATIVE-FREE INJECTION SOLUTION 1 %, 1.5 %, 2 %

GM

CETACAINE EXTERNAL AEROSOL 2-2-14 %

GM

chloroprocaine hcl (pf) injection solution 2 %, 3 %

GM

Updated May 1, 2020


16

Drug NameDrug Tier

Notes

CITANEST FORTE DENTAL INJECTION SOLUTION 4% -1:200000

GM

CITANEST PLAIN DENTAL INJECTION SOLUTION 4 %

GM

CLOROTEKAL INTRATHECAL SOLUTION 50 MG/5ML

GM

COCAINE HCL NASAL SOLUTION 40 MG/ML

GM

c-topical external solution 4 %

1

DERMACINRX EMPRICAINE EXTERNAL KIT 2.5-2.5 %

3

DERMACINRX PRIZOPAK EXTERNAL KIT 2.5-2.5 %

3

ethyl chloride external aerosol

1

EXPAREL INJECTION SUSPENSION 1.3 %

GM

FLEXIN EXTERNAL PATCH 0.0375-5 %

3

glydo external prefilled syringe 2 %

1

GOPRELTO NASAL SOLUTION 40 MG/ML

GM

LETS KIT 3

LEVATIO EXTERNAL PATCH 0.03-5 %

3

LIDO BDK EXTERNAL KIT 2.5-2.5 %

3

lidocaine external ointment 5 %

1QL (50 GM

per 30 days)

lidocaine external patch 5 %

1

Drug NameDrug Tier

Notes

lidocaine hcl (cardiac) intravenous solution prefilled syringe 100 mg/5ml, 50 mg/5ml

GM

lidocaine hcl (cardiac) pf intravenous solution 100 mg/5ml

GM

lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 100 mg/5ml, 50 mg/5ml

GM

lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %, 4 %

GM

lidocaine hcl external cream 3 %

1

lidocaine hcl external lotion 3 %

1

lidocaine hcl external solution 4 %

1

lidocaine hcl injection solution 0.5 %, 1 %, 2 %

GM

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MG/ML

GM

LIDOCAINE HCL INTRADERMAL JET-INJECTOR 0.5 MG

3

lidocaine hcl urethral/mucosal external gel 2 %

1

lidocaine hcl urethral/mucosal external prefilled syringe 2 %

1

LIDOCAINE IN D5W INTRAVENOUS SOLUTION 3-5 MG/ML-%

GM

lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-%

GM

Updated May 1, 2020


17

Drug NameDrug Tier

Notes

LIDOCAINE IN DEXTROSE SOLUTION 5-7.5 %

GM

lidocaine-epinephrine injection solution 0.5 %-1:200000, 1 %-1:100000, 1.5 %-1:200000, 2 %-1:100000, 2 %-1:200000, 2 %-1:50000

GM

lidocaine-prilocaine external cream 2.5-2.5 %

1

lidocaine-prilocaine external kit 2.5-2.5 %

1

LIDOCAINE-SODIUM BICARBONATE INJECTION SOLUTION PREFILLED SYRINGE 0.9-8.4 %

GM

LIDOCAINE-TETRACAINE EXTERNAL CREAM 7-7 %

3

LIDODERM EXTERNAL PATCH 5 %

3Brand

penalty applies

LIDO-EPINEPHRINE-TETRACAINE EXTERNAL SOLUTION 4-0.05-0.5 %

GM

lidopin external cream 3 %

1

LIDOPRIL EXTERNAL KIT 2.5-2.5 %

3

LIDOPRIL XR EXTERNAL KIT 2.5-2.5 %

3

LIDO-PRILO CAINE PACK EXTERNAL KIT 2.5-2.5 %

3

LIDO-SORB EXTERNAL LOTION 3 %

3

LIDOZION EXTERNAL LOTION 3 %

3

Drug NameDrug Tier

Notes

LIVIXIL PAK EXTERNAL KIT 2.5-2.5 %

3

MARCAINE INJECTION SOLUTION 0.25 %, 0.5 %, 0.75 %

GM

MARCAINE PRESERVATIVE FREE INJECTION SOLUTION 0.25 %, 0.5 %

GM

MARCAINE SPINAL INTRATHECAL SOLUTION 0.75-8.25 %

GM

MARCAINE/EPINEPHRINE INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000

GM

MARCAINE/EPINEPHRINE PF INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000

GM

MEDI-DERM/L-RX EXTERNAL CREAM 2-0.035-5-20 %

3

MEDI-PATCH RX EXTERNAL PATCH 0.5-0.035-5-20 %

3

NAROPIN INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 5 MG/ML, 7.5 MG/ML

GM

NESACAINE INJECTION SOLUTION 1 %, 2 %

GM

NESACAINE-MPF INJECTION SOLUTION 2 %, 3 %

GM

NUMBRINO NASAL SOLUTION 40 MG/ML

GM

NUVAKAAN EXTERNAL KIT 2.5-2.5 %

3

Updated May 1, 2020


18

Drug NameDrug Tier

Notes

ORABLOC INJECTION SOLUTION CARTRIDGE 4 %-1:100000, 4 %-1:200000

GM

PAINGO KFT EXTERNAL KIT 2.5-2.5-10-30 %

GM

PLIAGLIS EXTERNAL CREAM 7-7 %

3

polocaine injection solution 1 %, 2 %

GM

polocaine-mpf injection solution 1 %, 1.5 %, 2 %

GM

premium lidocaine external ointment 5 %

1QL (50 GM

per 30 days)

PRILOLID EXTERNAL KIT 2.5-2.5 %

3

PRILOVIX EXTERNAL KIT 2.5-2.5 %

3

PRILOVIX LITE EXTERNAL KIT 2.5-2.5 %

3

PRILOVIX LITE PLUS EXTERNAL KIT 2.5-2.5 %

3

PRILOVIX PLUS EXTERNAL KIT 2.5-2.5 %

3

prilovix ultralite external kit 2.5-2.5 %

1

prilovix ultralite plus external kit 2.5-2.5 %

1

RECK SOLUTION PREFILLED SYRINGE 123-0.25-0.04- 15 MG/50ML

GM

RELADOR PAK EXTERNAL KIT 2.5-2.5 %

3

Drug NameDrug Tier

Notes

RELADOR PAK PLUS EXTERNAL KIT 2.5-2.5 %

3

RENOVO EXTERNAL PATCH 0.0375-5 %

3

ropivacaine hcl injection solution 10 mg/ml, 5 mg/ml, 7.5 mg/ml

GM

ROPIVACAINE HCL INJECTION SOLUTION 33.4 MG/ML

GM

ROPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0.2 %, 0.5 %

GM

ROPIVACAINE HCL SOLUTION 2 MG/ML INJECTION 2 MG/ML

GM

ropivacaine hcl solution 2 mg/ml injection 2 mg/ml

GM

ROPIVACAINE HCL-NACL INJECTION SOLUTION 0.2-0.9 %

GM

ROPIV-CLONIDINE-KETOROLAC SOLUTION PREFILLED SYRINGE 123-0.04-15 MG/50ML

GM

sensorcaine injection solution 0.25 %, 0.5 %

GM

sensorcaine/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

GM

sensorcaine-mpf injection solution 0.25 %, 0.5 %, 0.75 %

GM

sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

GM

Updated May 1, 2020


19

Drug NameDrug Tier

Notes

SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75-1:200000 %

GM

SYNERA EXTERNAL PATCH 70-70 MG

GM

SYNVEXIA TC EXTERNAL CREAM 4-1 %

3

VEXATROL EXTERNAL KIT 2.5-2.5 %

3

xylocaine dental injection solution 2 %-1:100000, 2 %-1:50000

GM

XYLOCAINE INJECTION SOLUTION 0.5 %, 1 %, 2 %

GM

XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 0.5 %-1:200000, 1 %-1:100000, 2 %-1:100000

GM

XYLOCAINE-MPF INJECTION SOLUTION 0.5 %, 1 %, 1.5 %, 2 %

GM

XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 1 %-1:200000, 1.5 %-1:200000, 2 %-1:200000

GM

ZERUVIA EXTERNAL PATCH 4-1 %

3

ZINGO INTRADERMAL JET-INJECTOR 0.5 MG

3

ZIONODIL 100 EXTERNAL LOTION 3 %

3

ZIONODIL EXTERNAL LOTION 3 %

3

Drug NameDrug Tier

Notes

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium oral tablet delayed release 333 mg

1

ANTABUSE ORAL TABLET 250 MG, 500 MG

2Brand

penalty applies

BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG

2

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

1

buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg

1

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg

1

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg

PV

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG

PV

CHANTIX ORAL TABLET 0.5 MG, 1 MG

PV

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42

PV

disulfiram oral tablet 250 mg, 500 mg

1

LUCEMYRA ORAL TABLET 0.18 MG

2QL (224

EA per 14 days)

Updated May 1, 2020


20

Drug NameDrug Tier

Notes

naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml

1

naloxone hcl injection solution cartridge 0.4 mg/ml

1

naloxone hcl injection solution prefilled syringe 2 mg/2ml

1

naltrexone hcl oral tablet 50 mg

1

NALTREXONE SUBCUTANEOUS IMPLANT 200-6.5 MG

2

NARCAN NASAL LIQUID 4 MG/0.1ML

2

NICORETTE MOUTH/THROAT GUM 2 MG

PV

nicotine polacrilex mouth/throat gum 2 mg, 4 mg

PV

nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

PV

nicotine step 1 transdermal patch 24 hour 21 mg/24hr

PV


PV


PV

NICOTROL INHALATION INHALER 10 MG

PV

NICOTROL NS NASAL SOLUTION 10 MG/ML

PV

Drug NameDrug Tier

Notes

SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML

2

SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG

2

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG

2

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

2

Antibacterials

AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG

3QL (12 EA

per 30 days)

ALTABAX EXTERNAL OINTMENT 1 %

3 ST

amoxicillin oral capsule 250 mg, 500 mg

1

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

1

amoxicillin oral tablet 500 mg, 875 mg

1

amoxicillin oral tablet chewable 125 mg, 250 mg

1

amoxicillin-potassium clavulanate er oral tablet extended release 12 hour 1000-62.5 mg

1

Updated May 1, 2020


21

Drug NameDrug Tier

Notes

amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

1

amoxicillin-potassium clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1

amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

1

ampicillin oral capsule 500 mg

1

ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg

GM

ampicillin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm

GM

ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm

GM

ampicillin-sulbactam sodium intravenous solution reconstituted 15 (10-5) gm

GM

ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML

6 PA

AUGMENTIN ES-600 ORAL SUSPENSION RECONSTITUTED 600-42.9 MG/5ML

3Brand

penalty applies

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

3

Drug NameDrug Tier

Notes

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML

3Brand

penalty applies

AUGMENTIN ORAL TABLET 500-125 MG

3Brand

penalty applies

AVELOX INTRAVENOUS SOLUTION 400 MG/250ML

GM

avidoxy oral tablet 100 mg

1

AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED 2.5 (2-0.5) GM

GM

AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

azithromycin intravenous solution reconstituted 500 mg

GM

azithromycin oral packet 1 gm

1

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg

1

aztreonam injection solution reconstituted 1 gm, 2 gm

GM

baciim intramuscular solution reconstituted 50000 unit

GM

bacitracin intramuscular solution reconstituted 50000 unit

GM

Updated May 1, 2020


22

Drug NameDrug Tier

Notes

BACTRIM DS ORAL TABLET 800-160 MG

3Brand

penalty applies

BACTRIM ORAL TABLET 400-80 MG

3Brand

penalty applies

BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED 300 MG

4Specialty Medical

BAXDELA ORAL TABLET 450 MG

4

benzalkonium chloride external solution , 50 %

1

BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION 900000-300000 UNIT/2ML

GM

BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML

GM

BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML

GM

cefaclor er oral tablet extended release 12 hour 500 mg

1

cefaclor oral capsule 250 mg, 500 mg

1

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

1

cefadroxil oral capsule 500 mg

1

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

1

Drug NameDrug Tier

Notes

cefadroxil oral tablet 1 gm

1

CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 2-0.9 GM/100ML-%, 3-0.9 GM/100ML-%

GM

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 300 gm, 500 mg

GM

CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE 1 GM/10ML, 2 GM/20ML

GM

cefazolin sodium intravenous solution reconstituted 1 gm

GM

cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-%, 2-4 gm/100ml-%

GM

cefazolin sodium-dextrose intravenous solution reconstituted 1-4 gm-%(50ml), 2-3 gm-%(50ml)

GM

cefdinir oral capsule 300 mg

1

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cefditoren pivoxil oral tablet 200 mg, 400 mg

1

cefepime hcl injection solution reconstituted 1 gm, 2 gm

GM

cefepime hcl intravenous solution 1 gm/50ml, 2 gm/100ml

GM

Updated May 1, 2020


23

Drug NameDrug Tier

Notes

cefepime-dextrose intravenous solution reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml)

GM

cefixime oral capsule 400 mg

1

cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

1

CEFOTAN INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM

GM

cefotaxime sodium injection solution reconstituted 1 gm, 2 gm, 500 mg

GM

cefotetan disodium injection solution reconstituted 1 gm, 2 gm

GM

cefotetan disodium-dextrose intravenous solution reconstituted 1-3.58 gm-%(50ml), 2-2.08 gm-%(50ml)

GM

cefoxitin sodium injection solution reconstituted 10 gm

GM

cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm

GM

CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML), 2-2.2 GM-%(50ML)

GM

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

1

cefpodoxime proxetil oral tablet 100 mg, 200 mg

1

Drug NameDrug Tier

Notes

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cefprozil oral tablet 250 mg, 500 mg

1

ceftazidime and dextrose intravenous solution reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml)

GM

ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm

GM

ceftriaxone sodium in dextrose intravenous solution 20 mg/ml, 40 mg/ml

GM

ceftriaxone sodium injection solution reconstituted 1 gm, 100 gm, 2 gm, 250 mg, 500 mg

GM

ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm

GM

ceftriaxone sodium-dextrose intravenous solution reconstituted 1-3.74 gm-%(50ml), 2-2.22 gm-%(50ml)

GM

cefuroxime axetil oral tablet 250 mg, 500 mg

1

cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg

GM

cefuroxime sodium intravenous solution reconstituted 1.5 gm

GM

CENTANY AT EXTERNAL KIT 2 %

2

Updated May 1, 2020


24

Drug NameDrug Tier

Notes

cephalexin oral capsule 250 mg, 500 mg, 750 mg

1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cephalexin oral tablet 250 mg, 500 mg

1

chloramphenicol sod succinate intravenous solution reconstituted 1 gm

GM

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (10%)

2

CIPRO ORAL TABLET 250 MG, 500 MG

3Brand

penalty applies

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

1

ciprofloxacin in d5w intravenous solution 200 mg/100ml, 400 mg/200ml

GM

clarithromycin er oral tablet extended release 24 hour 500 mg

1

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

clarithromycin oral tablet 250 mg, 500 mg

1

CLEOCIN ORAL CAPSULE 150 MG, 300 MG

3Brand

penalty applies

CLEOCIN ORAL CAPSULE 75 MG

2Brand

penalty applies

CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML

3Brand

penalty applies

Drug NameDrug Tier

Notes

CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML, 600 MG/4ML, 9 GM/60ML, 900 MG/6ML

GM

CLEOCIN PHOSPHATE INTRAVENOUS SOLUTION 300 MG/2ML, 600 MG/4ML, 900 MG/6ML

GM

CLEOCIN VAGINAL CREAM 2 %

3Brand

penalty applies

CLEOCIN VAGINAL SUPPOSITORY 100 MG

2

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

1

clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml

GM

clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml

GM

clindamycin phosphate vaginal cream 2 %

1

CLINDESSE VAGINAL CREAM 2 %

3

colistimethate sodium (cba) injection solution reconstituted 150 mg

GM

COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 150 MG

GM

Updated May 1, 2020


25

Drug NameDrug Tier

Notes

CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

5Specialty Medical

daptomycin intravenous solution reconstituted 350 mg, 500 mg

GM

demeclocycline hcl oral tablet 150 mg, 300 mg

1

dicloxacillin sodium oral capsule 250 mg, 500 mg

1

DIFICID ORAL TABLET 200 MG

3 ST

doxy 100 intravenous solution reconstituted 100 mg

GM

doxycycline hyclate intravenous solution reconstituted 100 mg

GM

doxycycline hyclate oral capsule 100 mg, 50 mg

1

doxycycline hyclate oral tablet 100 mg, 20 mg

1

doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 75 mg

1

doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg

1

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

1

Drug NameDrug Tier

Notes

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

1

E.E.S. 400 ORAL TABLET 400 MG

3

E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

2Brand

penalty applies

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

2Brand

penalty applies

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

2Brand

penalty applies

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

3Brand

penalty applies

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

ERYTHROCIN STEARATE ORAL TABLET 250 MG

3

erythromycin base oral capsule delayed release particles 250 mg

1

erythromycin base oral tablet 250 mg, 500 mg

1

erythromycin base oral tablet delayed release 250 mg, 333 mg, 500 mg

1

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml, 400 mg/5ml

1

Updated May 1, 2020


26

Drug NameDrug Tier

Notes

erythromycin ethylsuccinate oral tablet 400 mg

1

erythromycin oral tablet delayed release 250 mg, 333 mg, 500 mg

1

FETROJA INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

5Specialty Medical

FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 MG/ML

3

FLAGYL ORAL CAPSULE 375 MG

3Brand

penalty applies

FLAGYL ORAL TABLET 250 MG, 500 MG

3Brand

penalty applies

gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-%

GM

gentamicin sulfate external cream 0.1 %

1

gentamicin sulfate external ointment 0.1 %

1

gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml

GM

HIPREX ORAL TABLET 1 GM

3Brand

penalty applies

hydrogen peroxide solution 30 %

1

imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg

GM

Drug NameDrug Tier

Notes

iodine tincture external tincture 2 %

1

KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG

3Brand

penalty applies

LEVAQUIN ORAL TABLET 500 MG, 750 MG

3Brand

penalty applies

levofloxacin in d5w intravenous solution 250 mg/50ml, 500 mg/100ml, 750 mg/150ml

GM

levofloxacin intravenous solution 25 mg/ml

GM

levofloxacin oral solution 25 mg/ml

1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg

1

LINCOCIN INJECTION SOLUTION 300 MG/ML

GM

lincomycin hcl injection solution 300 mg/ml

GM

linezolid in sodium chloride intravenous solution 600-0.9 mg/300ml-%

4Specialty Medical

linezolid intravenous solution 600 mg/300ml

4Specialty Medical

linezolid oral suspension reconstituted 100 mg/5ml

4QL (900

ML per 30 days)

linezolid oral tablet 600 mg

4QL (60 EA

per 30 days)

MACROBID ORAL CAPSULE 100 MG

3Brand

penalty applies

MACRODANTIN ORAL CAPSULE 100 MG, 50 MG

3Brand

penalty applies

Updated May 1, 2020


27

Drug NameDrug Tier

Notes

MACRODANTIN ORAL CAPSULE 25 MG

2Brand

penalty applies

mafenide acetate external packet 5 %

1

meropenem intravenous solution reconstituted 1 gm, 500 mg

GM

MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM/50ML, 500 MG/50ML

GM

MERREM INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 500 MG

GM

methenamine hippurate oral tablet 1 gm

1

methenamine mandelate oral tablet 0.5 gm, 1 gm

1

metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, 500-0.74 mg/100ml-%, 500-0.79 mg/100ml-%

GM

metronidazole oral capsule 375 mg

1

metronidazole oral tablet 250 mg, 500 mg

1

metronidazole vaginal gel 0.75 %

1

MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

GM

MINOCIN ORAL CAPSULE 50 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

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

1

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg

1

mondoxyne nl oral capsule 100 mg, 75 mg

1

MONUROL ORAL PACKET 3 GM

3

morgidox oral capsule 100 mg

1

moxifloxacin hcl in nacl intravenous solution 400 mg/250ml

GM

MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 400 MG/250ML

GM

moxifloxacin hcl oral tablet 400 mg

1

mupirocin external ointment 2 %

1

NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/100ML

GM

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

GM

nafcillin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm

GM

neomycin sulfate oral tablet 500 mg

1

neomycin-polymyxin b gu irrigation solution 40-200000

1

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg

1

Updated May 1, 2020


28

Drug NameDrug Tier

Notes

nitrofurantoin monohydrate macrocrystals oral capsule 100 mg

1

nitrofurantoin oral suspension 25 mg/5ml

1

NUTRIDOX ORAL KIT 75 MG

3

NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5Specialty Medical

NUZYRA ORAL TABLET 150 MG

5QL (30 EA

per 14 days)

ofloxacin oral tablet 300 mg, 400 mg

1

okebo oral capsule 75 mg

1

ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED 400 MG

4Specialty Medical

OXACILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

GM

oxacillin sodium injection solution reconstituted 1 gm, 2 gm

GM

oxacillin sodium intravenous solution reconstituted 10 gm

GM

paromomycin sulfate oral capsule 250 mg

1

Drug NameDrug Tier

Notes

PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION 20000 UNIT/ML, 40000 UNIT/ML, 60000 UNIT/ML

GM

penicillin g potassium injection solution reconstituted 20000000 unit, 5000000 unit

GM

penicillin g procaine intramuscular suspension 600000 unit/ml

GM

penicillin g sodium injection solution reconstituted 5000000 unit

GM

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

1

penicillin v potassium oral tablet 250 mg, 500 mg

1

PFIZERPEN INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT

GM

piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (12-1.5) gm, 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm

GM

polymyxin b sulfate injection solution reconstituted 500000 unit

GM

Updated May 1, 2020


29

Drug NameDrug Tier

Notes

PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED 500-500 MG

GM

PRIMSOL ORAL SOLUTION 50 MG/5ML

3

RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM

5Specialty Medical

SILVADENE EXTERNAL CREAM 1 %

3Brand

penalty applies

silver nitrate external solution 0.5 %, 10 %, 25 %, 50 %

1

silver sulfadiazine external cream 1 %

1

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

5Specialty Medical

SIVEXTRO ORAL TABLET 200 MG

5QL (6 EA

per 30 days)

SOLOSEC ORAL PACKET 2 GM

3

SPECTRACEF ORAL TABLET 400 MG

3Brand

penalty applies

ssd external cream 1 % 1

streptomycin sulfate intramuscular solution reconstituted 1 gm

GM

sulfadiazine oral tablet 500 mg

1

sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5ml

GM

Drug NameDrug Tier

Notes

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

1

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

1

SULFAMYLON EXTERNAL CREAM 85 MG/GM

3

SULFAMYLON EXTERNAL PACKET 5 %

3Brand

penalty applies

sulfatrim pediatric oral suspension 200-40 mg/5ml

1

SUPRAX ORAL CAPSULE 400 MG

3Brand

penalty applies

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

3Brand

penalty applies

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

3

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG

3

SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 150-350 MG

GM

tazicef injection solution reconstituted 1 gm, 2 gm, 6 gm

GM

TAZICEF INTRAVENOUS SOLUTION 1 GM/50ML

GM

Updated May 1, 2020


30

Drug NameDrug Tier

Notes

TAZICEF SOLUTION RECONSTITUTED 1 GM INTRAVENOUS 1 GM

GM

tazicef solution reconstituted 1 gm intravenous 1 gm

GM

TAZICEF SOLUTION RECONSTITUTED 2 GM INTRAVENOUS 2 GM

GM

tazicef solution reconstituted 2 gm intravenous 2 gm

GM

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG

GM

tetracycline hcl oral capsule 250 mg, 500 mg

1

tigecycline intravenous solution reconstituted 50 mg

GM

tinidazole oral tablet 250 mg, 500 mg

1

tobramycin sulfate injection solution 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml

GM

tobramycin sulfate injection solution reconstituted 1.2 gm

GM

trimethoprim oral tablet 100 mg

1

TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

UNASYN INJECTION SOLUTION RECONSTITUTED 1.5 (1-0.5) GM, 3 (2-1) GM

GM

Drug NameDrug Tier

Notes

UNASYN INTRAVENOUS SOLUTION RECONSTITUTED 15 (10-5) GM

GM

VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 2 (1-1) GM

GM

VANCOCIN HCL ORAL CAPSULE 125 MG

3Brand

penalty applies

VANCOCIN ORAL CAPSULE 250 MG

3Brand

penalty applies

VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1.25-5 GM/250ML-%, 1.5-5 GM/250ML-%

GM

vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-%

GM

vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%

GM

VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/250ML-%, 1.25-0.9 GM/250ML-%, 1.5-0.9 GM/250ML-%, 1.75-0.9 GM/250ML-%, 2-0.9 GM/500ML-%

GM

VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML-% INTRAVENOUS 750-0.9 MG/150ML-%

GM

Updated May 1, 2020


31

Drug NameDrug Tier

Notes

vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous 750-0.9 mg/150ml-%

GM

VANCOMYCIN HCL INTRAVENOUS SOLUTION 1000 MG/10ML, 1250 MG/12.5ML, 1500 MG/15ML, 1750 MG/17.5ML, 2000 MG/20ML, 750 MG/7.5ML

GM

vancomycin hcl intravenous solution 1000 mg/200ml, 1500 mg/300ml, 2000 mg/400ml, 500 mg/100ml

GM

vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 1.5 gm, 10 gm, 5 gm, 500 mg, 750 mg

GM

vancomycin hcl oral capsule 125 mg, 250 mg

1

vancomycin hcl oral solution reconstituted 250 mg/5ml

1

vandazole vaginal gel 0.75 %

1

VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 MG

GM

VIBRAMYCIN ORAL CAPSULE 100 MG

3Brand

penalty applies

VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 MG/5ML

3Brand

penalty applies

VIBRAMYCIN ORAL SYRUP 50 MG/5ML

2

Drug NameDrug Tier

Notes

XENLETA INTRAVENOUS SOLUTION 150 MG/15ML

5Specialty Medical

XENLETA ORAL TABLET 600 MG

5

XEPI EXTERNAL CREAM 1 %

3 ST

XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

4Specialty Medical

XIFAXAN ORAL TABLET 200 MG, 550 MG

4 PA

ZEMDRI INTRAVENOUS SOLUTION 500 MG/10ML

5Specialty Medical

ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM

GM

ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

ZITHROMAX ORAL PACKET 1 GM

3

ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

3Brand

penalty applies

ZITHROMAX ORAL TABLET 250 MG, 500 MG

3Brand

penalty applies

ZITHROMAX TRI-PAK ORAL TABLET 500 MG

3Brand

penalty applies

ZITHROMAX Z-PAK ORAL TABLET 250 MG

3Brand

penalty applies

Updated May 1, 2020


32

Drug NameDrug Tier

Notes

ZOSYN INTRAVENOUS SOLUTION 2-0.25 GM/50ML, 3-0.375 GM/50ML, 4-0.5 GM/100ML

GM

ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML, 600 MG/300ML

4Specialty Medical

ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

4QL (900

ML per 30 days)

ZYVOX ORAL TABLET 600 MG

4QL (60 EA

per 30 days)

Anticoagulants

ACD FORMULA A IN VITRO SOLUTION 0.73-2.45-2.2 GM/100ML

3

ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 GM/100ML

3

ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

ANGIOMAX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

GM

anticoagulant cit dext soln a in vitro solution 0.8-2.45-2.2 gm/100ml

1

anticoagulant sodium citrate in vitro solution 4 gm/100ml

1

argatroban in sodium chloride intravenous solution 50-0.9 mg/50ml-%

GM

Drug NameDrug Tier

Notes

argatroban intravenous solution 250 mg/2.5ml, 50 mg/50ml

GM

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

3Brand

penalty applies

BEVYXXA ORAL CAPSULE 40 MG, 80 MG

3QL (30 EA

per 30 days)

bivalirudin trifluoroacetate intravenous solution reconstituted 250 mg

GM

BIVALIRUDIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 250-0.9 MG/50ML-%, 500-0.9 MG/100ML-%

5Specialty Medical

CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 2 MG

GM

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

2

DEFITELIO INTRAVENOUS SOLUTION 200 MG/2.5ML

GM

ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 MG

2

ELIQUIS ORAL TABLET 2.5 MG, 5 MG

2

enoxaparin sodium injection solution 300 mg/3ml

1

Updated May 1, 2020


33

Drug NameDrug Tier

Notes

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

1

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

1

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

2

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 500-0.9 UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-%

GM

heparin (porcine) in nacl intravenous solution 25000-0.45 ut/500ml-%

GM

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

1

heparin sodium (porcine) injection solution prefilled syringe 5000 unit/0.5ml

GM

heparin sodium (porcine) pf injection solution 5000 unit/0.5ml

1

Drug NameDrug Tier

Notes

heparin sodium (porcine) pf injection solution 5000 unit/ml

GM

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

1

LOVENOX INJECTION SOLUTION 300 MG/3ML

2Brand

penalty applies

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

3Brand

penalty applies

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

3

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG

3 ST

SODIUM CITRATE IN VITRO SOLUTION PREFILLED SYRINGE 4 %

GM

SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION PREFILLED SYRINGE 120 MG/3ML

GM

SODIUM CITRATE-GENTAMICIN SULF INTRAVENOUS SOLUTION 4-320 %-MCG/ML

GM

THROMBATE III INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT

GM PA

Updated May 1, 2020


34

Drug NameDrug Tier

Notes

TNKASE INTRAVENOUS KIT 50 MG

GM

TRICITRASOL IN VITRO CONCENTRATE 46.7 %

3

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

1

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG

2

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG

2

Anticonvulsants - Drugs for Seizures

APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG

3 ST

BANZEL ORAL SUSPENSION 40 MG/ML

3

BANZEL ORAL TABLET 200 MG, 400 MG

3

BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML

GM ST

BRIVIACT ORAL SOLUTION 10 MG/ML

3 ST

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG

3 ST

carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg

1

carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg

1

Drug NameDrug Tier

Notes

carbamazepine oral suspension 100 mg/5ml

1

carbamazepine oral tablet 200 mg

1

carbamazepine oral tablet chewable 100 mg

1

CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

3

CELONTIN ORAL CAPSULE 300 MG

3

CEREBYX INJECTION SOLUTION 100 MG PE/2ML, 500 MG PE/10ML

GM

clobazam oral suspension 2.5 mg/ml

1

clobazam oral tablet 10 mg, 20 mg

1

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 250 MG, 500 MG

3

DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 MG, 500 MG

3

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE 125 MG

3

DIACOMIT ORAL CAPSULE 250 MG, 500 MG

3

DIACOMIT ORAL PACKET 250 MG, 500 MG

3

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG

3

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG

3

Updated May 1, 2020


35

Drug NameDrug Tier

Notes

diazepam rectal gel 10 mg, 2.5 mg, 20 mg

1

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG

2

DILANTIN ORAL CAPSULE 100 MG, 30 MG

2

DILANTIN ORAL SUSPENSION 125 MG/5ML

3

divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg

1

divalproex sodium oral capsule delayed release sprinkle 125 mg

1

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

1

EPIDIOLEX ORAL SOLUTION 100 MG/ML

5 PA

epitol oral tablet 200 mg 1

ethosuximide oral capsule 250 mg

1

ethosuximide oral solution 250 mg/5ml

1

felbamate oral suspension 600 mg/5ml

1

felbamate oral tablet 400 mg, 600 mg

1

FELBATOL ORAL SUSPENSION 600 MG/5ML

2

FELBATOL ORAL TABLET 400 MG, 600 MG

2

fosphenytoin sodium injection solution 100 mg pe/2ml, 500 mg pe/10ml

GM

Drug NameDrug Tier

Notes

FYCOMPA ORAL SUSPENSION 0.5 MG/ML

3

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

3

gabapentin oral capsule 100 mg, 300 mg, 400 mg

1

gabapentin oral solution 250 mg/5ml, 300 mg/6ml

1

gabapentin oral tablet 600 mg, 800 mg

1

GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG

3

KEPPRA INTRAVENOUS SOLUTION 500 MG/5ML

GM

KEPPRA ORAL SOLUTION 100 MG/ML

3

KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 MG

3

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG

3

LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG

3

LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 MG, 25 MG, 50 MG

3

LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG

3

LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG

3

Updated May 1, 2020


36

Drug NameDrug Tier

Notes

LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG

3

LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 50 & 100 & 200 MG

3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG

3

lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

1

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

1

lamotrigine oral tablet chewable 25 mg, 5 mg

1

lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg

1

lamotrigine starter kit-blue oral kit 35 x 25 mg

1

lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg

1

lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg

1

levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg

1

levetiracetam in nacl intravenous solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml

GM

Drug NameDrug Tier

Notes

levetiracetam intravenous solution 500 mg/5ml

GM

levetiracetam oral solution 100 mg/ml

1

levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg

1

MYSOLINE ORAL TABLET 250 MG, 50 MG

3

NAYZILAM NASAL SOLUTION 5 MG/0.1ML

3

NEMBUTAL INJECTION SOLUTION 50 MG/ML

GM

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG

2

NEURONTIN ORAL SOLUTION 250 MG/5ML

2

NEURONTIN ORAL TABLET 600 MG, 800 MG

2

ONFI ORAL SUSPENSION 2.5 MG/ML

3

ONFI ORAL TABLET 10 MG, 20 MG

3

oxcarbazepine oral suspension 300 mg/5ml

1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG

3

PEGANONE ORAL TABLET 250 MG

3

pentobarbital sodium injection solution 50 mg/ml

GM

phenobarbital oral elixir 20 mg/5ml

1

Updated May 1, 2020


37

Drug NameDrug Tier

Notes

phenobarbital oral solution 20 mg/5ml

1

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

1

phenobarbital sodium injection solution 130 mg/ml, 65 mg/ml

GM

PHENYTEK ORAL CAPSULE 200 MG, 300 MG

3

phenytoin infatabs oral tablet chewable 50 mg

1

phenytoin oral suspension 125 mg/5ml

1

phenytoin oral tablet chewable 50 mg

1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

1

phenytoin sodium injection solution 50 mg/ml

GM

primidone oral tablet 250 mg, 50 mg

1

QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

3 PA

roweepra oral tablet 1000 mg, 500 mg, 750 mg

1

roweepra xr oral tablet extended release 24 hour 500 mg, 750 mg

1

SABRIL ORAL PACKET 500 MG

5 PA

SABRIL ORAL TABLET 500 MG

5 PA

Drug NameDrug Tier

Notes

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG

3 ST

subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg

1

subvenite starter kit-blue oral kit 35 x 25 mg

1

subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg

1

subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg

1

SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG

3

TEGRETOL ORAL SUSPENSION 100 MG/5ML

3

TEGRETOL ORAL TABLET 200 MG

3

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 400 MG

3

tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg

1

TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG

2

TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 MG

2

topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

1 PA

topiramate oral capsule sprinkle 15 mg, 25 mg

1

Updated May 1, 2020


38

Drug NameDrug Tier

Notes

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

1

TRILEPTAL ORAL SUSPENSION 300 MG/5ML

3

TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG

3

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

3 PA

valproate sodium intravenous solution 100 mg/ml, 500 mg/5ml

GM

valproic acid oral capsule 250 mg

1

valproic acid oral solution 250 mg/5ml

1

VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML

3

VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PACK 7.5 MG/0.1ML

3

VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PACK 10 MG/0.1ML

3

VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML

3

vigabatrin oral packet 500 mg

4 PA

vigabatrin oral tablet 500 mg

4 PA

vigadrone oral packet 500 mg

4 PA

Drug NameDrug Tier

Notes

VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML

GM

VIMPAT ORAL SOLUTION 10 MG/ML

3

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

3

ZARONTIN ORAL CAPSULE 250 MG

3

ZARONTIN ORAL SOLUTION 250 MG/5ML

3

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

3

zonisamide oral capsule 100 mg, 25 mg, 50 mg

1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

ARICEPT ORAL TABLET 23 MG

2Brand

penalty applies

donepezil hcl oral tablet 10 mg, 23 mg, 5 mg

1

donepezil hcl oral tablet dispersible 10 mg, 5 mg

1

EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR

2Brand

penalty applies

galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg

1

galantamine hydrobromide oral solution 4 mg/ml

1

Updated May 1, 2020


39

Drug NameDrug Tier

Notes

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

1

memantine hcl er oral capsule extended release 24 hour 14 mg, 21 mg, 28 mg, 7 mg

1

memantine hcl oral solution 10 mg/5ml, 2 mg/ml

1

memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg

1

NAMENDA ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 10 MG

3Brand

penalty applies

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG

3Brand

penalty applies

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21

3

NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28 -10 MG

3

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

3

RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 MG, 24 MG, 8 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

RAZADYNE ORAL TABLET 4 MG

3Brand

penalty applies

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

1

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

1

Antidepressants

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

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

1

ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG

3Brand

penalty applies

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG, 348 MG, 522 MG

3ST; QL (30 EA per 30

days)

bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg

1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1

bupropion hcl oral tablet 100 mg, 75 mg

1

CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG

3Brand

penalty applies

chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

1

citalopram hydrobromide oral solution 10 mg/5ml

1

Updated May 1, 2020


40

Drug NameDrug Tier

Notes

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

1

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

1

CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG, 30 MG, 60 MG

3Brand

penalty applies

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG

3 PA

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg

1 PA

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

doxepin hcl oral concentrate 10 mg/ml

1

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

1

EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 37.5 MG, 75 MG

3Brand

penalty applies

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR

2

escitalopram oxalate oral solution 5 mg/5ml

1

Drug NameDrug Tier

Notes

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

1

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG

3 PA

FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG

3

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg

1

fluoxetine hcl oral capsule delayed release 90 mg

1

fluoxetine hcl oral solution 20 mg/5ml

1

fluoxetine hcl oral tablet 10 mg, 20 mg

1

fluvoxamine maleate er oral capsule extended release 24 hour 100 mg, 150 mg

1

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg

1

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg

1

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

1

LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG

3Brand

penalty applies

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg

1

MARPLAN ORAL TABLET 10 MG

3

Updated May 1, 2020


41

Drug NameDrug Tier

Notes

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

1

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg

1

NARDIL ORAL TABLET 15 MG

3Brand

penalty applies

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

1

NORPRAMIN ORAL TABLET 10 MG, 25 MG

3Brand

penalty applies

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

1

nortriptyline hcl oral solution 10 mg/5ml

1

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

1 ST

PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG

3Brand

penalty applies

PARNATE ORAL TABLET 10 MG

3Brand

penalty applies

paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg

1

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

1

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

PAXIL ORAL SUSPENSION 10 MG/5ML

2

PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

3Brand

penalty applies

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

1

phenelzine sulfate oral tablet 15 mg

1

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG

3PA; Brand

penalty applies

protriptyline hcl oral tablet 10 mg, 5 mg

1

PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG

3Brand

penalty applies

REMERON ORAL TABLET 15 MG, 30 MG

3Brand

penalty applies

REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG, 45 MG

3Brand

penalty applies

sertraline hcl oral concentrate 20 mg/ml

1

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg

1

SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PACK 28 MG/DEVICE

5PA;

Specialty Medical

SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PACK 28 MG/DEVICE

5PA;

Specialty Medical

Updated May 1, 2020


42

Drug NameDrug Tier

Notes

SYMBYAX ORAL CAPSULE 12-50 MG, 3-25 MG, 6-25 MG, 6-50 MG

3ST; Brand

penalty applies

tranylcypromine sulfate oral tablet 10 mg

1

trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

1

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

1

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG

3 PA

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

1

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

1

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

3 PA

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG

3 PA

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG

3Brand

penalty applies

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG

3Brand

penalty applies

ZOLOFT ORAL CONCENTRATE 20 MG/ML

3Brand

penalty applies

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 235-0.25 MG

GM

AKYNZEO ORAL CAPSULE 300-0.5 MG

3QL (3 EA

per 21 days)

ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML

GM

ANZEMET ORAL TABLET 100 MG, 50 MG

2

aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg

1QL (6 EA

per 30 days)

BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG

3

CINVANTI INTRAVENOUS EMULSION 130 MG/18ML

GMQL (6 ML

per 30 days)

compro rectal suppository 25 mg

1

dimenhydrinate injection solution 50 mg/ml

GM

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg

1

droperidol injection solution 2.5 mg/ml

GM

EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

GM PA

EMEND ORAL CAPSULE 40 MG, 80 MG

3

Brand penalty

applies; QL (6 EA per 30 days)

Updated May 1, 2020


43

Drug NameDrug Tier

Notes

EMEND ORAL SUSPENSION RECONSTITUTED 125 MG

2QL (6 EA

per 30 days)

EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG

3

Brand penalty


fosaprepitant dimeglumine intravenous solution reconstituted 150 mg

GM PA

granisetron hcl intravenous solution 1 mg/ml, 4 mg/4ml

GM

granisetron hcl oral tablet 1 mg

1

meclizine hcl oral tablet 12.5 mg, 25 mg

1

metoclopramide hcl injection solution 5 mg/ml

GM

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

1

metoclopramide hcl oral tablet 10 mg, 5 mg

1

metoclopramide hcl oral tablet dispersible 10 mg, 5 mg

1

ondansetron hcl injection solution 40 mg/20ml

GM

ondansetron hcl oral solution 4 mg/5ml

1

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg

1

ONDANSETRON HCL SOLUTION 4 MG/2ML INJECTION 4 MG/2ML

GM

ondansetron hcl solution 4 mg/2ml injection 4 mg/2ml

GM

Drug NameDrug Tier

Notes

ondansetron odt oral tablet dispersible 4 mg, 8 mg

1

palonosetron hcl intravenous solution 0.25 mg/2ml, 0.25 mg/5ml

GM

palonosetron hcl intravenous solution prefilled syringe 0.25 mg/5ml

GM

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

1

prochlorperazine edisylate injection solution 10 mg/2ml, 50 mg/10ml

GM

prochlorperazine maleate oral tablet 10 mg, 5 mg

1

prochlorperazine rectal suppository 25 mg

1

REGLAN ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR

2QL (1 EA

per 30 days)

scopolamine transdermal patch 72 hour 1 mg/3days

1

SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 MG/0.4ML

5QL (2 ML

per 30 days)

SYNDROS ORAL SOLUTION 5 MG/ML

3

TIGAN INTRAMUSCULAR SOLUTION 100 MG/ML

GM

TIGAN ORAL CAPSULE 300 MG

3Brand

penalty applies

Updated May 1, 2020


44

Drug NameDrug Tier

Notes

TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR 1 MG/3DAYS

3Brand

penalty applies

TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR 1 MG/3DAYS

3Brand

penalty applies

trimethobenzamide hcl oral capsule 300 mg

1

VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK 2 X 90 MG

3QL (2 EA

per 30 days)

VARUBI ORAL TABLET 90 MG

3QL (2 EA

per 30 days)

ZOFRAN ORAL TABLET 4 MG, 8 MG

3Brand

penalty applies

ZUPLENZ ORAL FILM 4 MG, 8 MG

3

Antifungals

ABELCET INTRAVENOUS SUSPENSION 5 MG/ML

GM

ALA-QUIN EXTERNAL CREAM 3-0.5 %

3

ALCORTIN A EXTERNAL GEL 1-2-1 %

3

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG

GM

amphotericin b intravenous solution reconstituted 50 mg

GM

ANCOBON ORAL CAPSULE 250 MG, 500 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

BIO-STATIN ORAL CAPSULE 1000000 UNIT, 500000 UNIT

3

bio-statin oral powder 1

CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG

GM

caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg

GM

ciclodan external solution 8 %

1QL (13.2

ML per 30 days)

ciclopirox external gel 0.77 %

1

ciclopirox external shampoo 1 %

1

ciclopirox external solution 8 %

1QL (13.2

ML per 30 days)

ciclopirox olamine external cream 0.77 %

1

ciclopirox olamine external suspension 0.77 %

1

clotrimazole external cream 1 %

1

clotrimazole external solution 1 %

1

clotrimazole mouth/throat lozenge 10 mg

1

clotrimazole mouth/throat troche 10 mg

1

clotrimazole-betamethasone external cream 1-0.05 %

1

clotrimazole-betamethasone external lotion 1-0.05 %

1

Updated May 1, 2020


45

Drug NameDrug Tier

Notes

CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 372 MG

5PA;

Specialty Medical

CRESEMBA ORAL CAPSULE 186 MG

5 PA

dermazene external cream 1-1 %

1

DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 MG/ML, 40 MG/ML

3Brand

penalty applies

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

3Brand

penalty applies

econazole nitrate external cream 1 %

1

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

ERTACZO EXTERNAL CREAM 2 %

3 ST

EXELDERM EXTERNAL CREAM 1 %

3 ST

EXELDERM EXTERNAL SOLUTION 1 %

3 ST

EXODERM EXTERNAL LOTION 25-1 %

3

EXTINA EXTERNAL FOAM 2 %

3Brand

penalty applies

fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-%

GM

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

1

Drug NameDrug Tier

Notes

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

1

flucytosine oral capsule 250 mg, 500 mg

1

FUNGIMEZ EXTERNAL SOLUTION

3

griseofulvin microsize oral suspension 125 mg/5ml

1

griseofulvin microsize oral tablet 500 mg

1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

1

GYNAZOLE-1 VAGINAL CREAM 2 %

3

hydrocortisone-iodoquinol external cream 1-1 %

1

IODOQUIMEZ-HC EXTERNAL CREAM 1-1.9 %

3

iodoquinol-hc-aloe polysacch external gel 1-2-1 %

1

iodoquinol-hydrocortisone-aloe external cream 1-1.9 %

1

itraconazole oral capsule 100 mg

1

itraconazole oral solution 10 mg/ml

1

JUBLIA EXTERNAL SOLUTION 10 %

3 PA

KERYDIN EXTERNAL SOLUTION 5 %

3 PA

ketoconazole external cream 2 %

1

ketoconazole external foam 2 %

1

Updated May 1, 2020


46

Drug NameDrug Tier

Notes

ketoconazole external shampoo 2 %

1

ketoconazole oral tablet 200 mg

1

ketodan external foam 2 %

1

LOPROX EXTERNAL CREAM 0.77 %

3Brand

penalty applies

LOPROX EXTERNAL SHAMPOO 1 %

3Brand

penalty applies

LOPROX EXTERNAL SUSPENSION 0.77 %

3Brand

penalty applies

LULICONAZOLE EXTERNAL CREAM 1 %

3 ST

LUZU EXTERNAL CREAM 1 %

3 ST

MENTAX EXTERNAL CREAM 1 %

3 ST

miconazole 3 vaginal suppository 200 mg

1

MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL OINTMENT 0.25-15-81.35 %

3

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

GM

naftifine hcl external cream 1 %, 2 %

1 ST

naftifine hcl external gel 1 %

1 ST

NAFTIN EXTERNAL CREAM 2 %

3ST; Brand

penalty applies

NAFTIN EXTERNAL GEL 1 %

3ST; Brand

penalty applies

Drug NameDrug Tier

Notes

NAFTIN EXTERNAL GEL 2 %

3 ST

NIZORAL EXTERNAL SHAMPOO 2 %

3Brand

penalty applies

NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7ML

5Specialty Medical

NOXAFIL ORAL SUSPENSION 40 MG/ML

5

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG

5

nystatin external cream 100000 unit/gm

1

nystatin external ointment 100000 unit/gm

1

nystatin external powder 100000 unit/gm

1

nystatin mouth/throat suspension 100000 unit/ml

1

nystatin oral tablet 500000 unit

1

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

1

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

1

nystop external powder 100000 unit/gm

1

ORAVIG BUCCAL TABLET 50 MG

3

oxiconazole nitrate external cream 1 %

1 ST

OXISTAT EXTERNAL CREAM 1 %

3ST; Brand

penalty applies

Updated May 1, 2020


47

Drug NameDrug Tier

Notes

OXISTAT EXTERNAL LOTION 1 %

3 ST

posaconazole oral tablet delayed release 100 mg

5

QUINJA EXTERNAL GEL 1.25-1 %

3

RECURA EXTERNAL CREAM

3

SPORANOX ORAL CAPSULE 100 MG

3Brand

penalty applies

SPORANOX ORAL SOLUTION 10 MG/ML

3Brand

penalty applies

SPORANOX PULSEPAK ORAL CAPSULE 100 MG

3Brand

penalty applies

SULCONAZOLE NITRATE EXTERNAL CREAM 1 %

3 ST

SULCONAZOLE NITRATE EXTERNAL SOLUTION 1 %

3 ST

terbinafine hcl oral tablet 250 mg

1

terconazole vaginal cream 0.4 %, 0.8 %

1

terconazole vaginal suppository 80 mg

1

VFEND IV INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

4Specialty Medical

VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML

5

VFEND ORAL TABLET 200 MG, 50 MG

5

Drug NameDrug Tier

Notes

voriconazole intravenous solution reconstituted 200 mg

4Specialty Medical

voriconazole oral suspension reconstituted 40 mg/ml

4

voriconazole oral tablet 200 mg, 50 mg

4

VUSION EXTERNAL OINTMENT 0.25-15-81.35 %

3

VYTONE EXTERNAL CREAM 1-1.9 %

3

XOLEGEL COREPAK EXTERNAL KIT 2 & 1 %

3

XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 %

3

XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 %

3

XOLEGEL EXTERNAL GEL 2 %

3

Antigout Agents

allopurinol oral tablet 100 mg, 300 mg

1

allopurinol sodium intravenous solution reconstituted 500 mg

GM

ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

COLCHICINE ORAL CAPSULE 0.6 MG

2

colchicine tablet 0.6 mg oral 0.6 mg

1

COLCHICINE TABLET 0.6 MG ORAL 0.6 MG

2

colchicine-probenecid oral tablet 0.5-500 mg

1

Updated May 1, 2020


48

Drug NameDrug Tier

Notes

COLCRYS ORAL TABLET 0.6 MG

2

febuxostat oral tablet 40 mg, 80 mg

1

GLOPERBA ORAL SOLUTION 0.6 MG/5ML

3

KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML

5PA;

Specialty Medical

MITIGARE ORAL CAPSULE 0.6 MG

2

probenecid oral tablet 500 mg

1

ULORIC ORAL TABLET 40 MG, 80 MG

3Brand

penalty applies

ZYLOPRIM ORAL TABLET 100 MG, 300 MG

3Brand

penalty applies

Anti-inflammatory Agents

EMFLAZA ORAL SUSPENSION 22.75 MG/ML

6 PA

EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG

6 PA

Antimigraine Agents

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML

3PA; QL (1 ML per 28

days)

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 MG/ML


days)

AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 225 MG/1.5ML

3PA; QL

(1.5 ML per 28 days)

Drug NameDrug Tier

Notes

AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 225 MG/1.5ML

3PA; QL


almotriptan malate oral tablet 12.5 mg, 6.25 mg

1QL (9 EA

per 30 days)

AMERGE ORAL TABLET 1 MG, 2.5 MG

3

Brand penalty


CAFERGOT ORAL TABLET 1-100 MG

2Brand

penalty applies

CAMBIA ORAL PACKET 50 MG

3

D.H.E. 45 INJECTION SOLUTION 1 MG/ML

GM

dihydroergotamine mesylate injection solution 1 mg/ml

GM

dihydroergotamine mesylate nasal solution 4 mg/ml


days)

eletriptan hydrobromide oral tablet 20 mg, 40 mg

1QL (9 EA

per 30 days)

EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML


days)

EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120 MG/ML


days)

EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 120 MG/ML


days)

Updated May 1, 2020


49

Drug NameDrug Tier

Notes

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG

3

ergotamine-caffeine oral tablet 1-100 mg

1

FROVA ORAL TABLET 2.5 MG

3

Brand penalty


frovatriptan succinate oral tablet 2.5 mg

1QL (9 EA

per 30 days)

IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT

2

Brand penalty


IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG

3

Brand penalty


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

3

Brand penalty

applies; QL (2 ML per 30 days)

IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 MG/0.5ML, 6 MG/0.5ML

3

Brand penalty


IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5ML

3

Brand penalty


Drug NameDrug Tier

Notes

MAXALT ORAL TABLET 10 MG

3

Brand penalty


MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG

3

Brand penalty


MIGERGOT RECTAL SUPPOSITORY 2-100 MG

3

MIGRANAL NASAL SOLUTION 4 MG/ML

3

PA; Brand penalty


naratriptan hcl oral tablet 1 mg, 2.5 mg

1QL (9 EA

per 30 days)

RELPAX ORAL TABLET 20 MG, 40 MG

3

Brand penalty


rizatriptan benzoate oral tablet 10 mg, 5 mg

1QL (12 EA

per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

1QL (12 EA

per 30 days)

sumatriptan nasal solution 20 mg/act, 5 mg/act

1QL (6 EA

per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

1QL (9 EA

per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml

1QL (2 ML

per 30 days)

Updated May 1, 2020


50

Drug NameDrug Tier

Notes

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

1QL (2 ML

per 30 days)

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml

1QL (2 ML

per 30 days)

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml

1QL (2 ML

per 30 days)

VYEPTI INTRAVENOUS SOLUTION 100 MG/ML

6PA;

Specialty Medical

zolmitriptan oral tablet 2.5 mg, 5 mg

1QL (9 EA

per 30 days)

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg

1QL (9 EA

per 30 days)

ZOMIG NASAL SOLUTION 2.5 MG, 5 MG

3QL (6 EA

per 30 days)

ZOMIG ORAL TABLET 2.5 MG, 5 MG

3

Brand penalty


ZOMIG ZMT ORAL TABLET DISPERSIBLE 2.5 MG, 5 MG

3

Brand penalty


Antimyasthenic Agents

BLOXIVERZ INTRAVENOUS SOLUTION 10 MG/10ML, 5 MG/10ML

GM

GUANIDINE HCL ORAL TABLET 125 MG

3

MESTINON ORAL SOLUTION 60 MG/5ML

2Brand

penalty applies

Drug NameDrug Tier

Notes

MESTINON ORAL TABLET 60 MG

3Brand

penalty applies

MESTINON ORAL TABLET EXTENDED RELEASE 180 MG

2Brand

penalty applies

neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml

GM

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 3 MG/3ML, 5 MG/5ML

GM

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 MG/3ML, 4 MG/4ML

GM

pyridostigmine bromide er oral tablet extended release 180 mg

1

pyridostigmine bromide oral solution 60 mg/5ml

1

pyridostigmine bromide oral tablet 30 mg, 60 mg

1

REGONOL INTRAVENOUS SOLUTION 10 MG/2ML

GM

Antimycobacterials

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM

GM

cycloserine oral capsule 250 mg

1

dapsone oral tablet 100 mg, 25 mg

1

ethambutol hcl oral tablet 100 mg, 400 mg

1

isoniazid injection solution 100 mg/ml

GM

Updated May 1, 2020


51

Drug NameDrug Tier

Notes

isoniazid oral syrup 50 mg/5ml

1

isoniazid oral tablet 100 mg, 300 mg

1

MYAMBUTOL ORAL TABLET 400 MG

3Brand

penalty applies

MYCOBUTIN ORAL CAPSULE 150 MG

2Brand

penalty applies

PASER ORAL PACKET 4 GM

3

PRETOMANID ORAL TABLET 200 MG

3PA; QL (30 EA per 30

days)

PRIFTIN ORAL TABLET 150 MG

3

pyrazinamide oral tablet 500 mg

1

rifabutin oral capsule 150 mg

1

RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED 600 MG

GM

RIFADIN ORAL CAPSULE 150 MG, 300 MG

3Brand

penalty applies

RIFAMATE ORAL CAPSULE 150-300 MG

3

rifampin intravenous solution reconstituted 600 mg

GM

rifampin oral capsule 150 mg, 300 mg

1

RIFATER ORAL TABLET 50-120-300 MG

3

SIRTURO ORAL TABLET 100 MG

5 PA

TRECATOR ORAL TABLET 250 MG

3

Drug NameDrug Tier

Notes

Antineoplastics - Drugs for Cancer

abiraterone acetate oral tablet 250 mg

4 PA

ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG

5PA;

Specialty Medical

ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

5PA;

Specialty Medical

adriamycin intravenous solution 2 mg/ml

GM PA

adriamycin intravenous solution reconstituted 10 mg, 50 mg

GM PA

adrucil intravenous solution 2.5 gm/50ml, 500 mg/10ml

GM PA

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG

5 PA

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

5 PA

ALECENSA ORAL CAPSULE 150 MG

5 PA

ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 500 MG

5PA;

Specialty Medical

ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 MG

5PA;

Specialty Medical

Updated May 1, 2020


52

Drug NameDrug Tier

Notes

ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

5PA;

Specialty Medical

ALKERAN ORAL TABLET 2 MG

2PA; Brand

penalty applies

ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG

5 PA

ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG

5 PA

anastrozole oral tablet 1 mg

1

ARIMIDEX ORAL TABLET 1 MG

3Brand

penalty applies

AROMASIN ORAL TABLET 25 MG

3Brand

penalty applies

ARRANON INTRAVENOUS SOLUTION 5 MG/ML

5PA;

Specialty Medical

arsenic trioxide intravenous solution 10 mg/10ml

5PA;

Specialty Medical

ARZERRA INTRAVENOUS CONCENTRATE 100 MG/5ML, 1000 MG/50ML

5PA;

Specialty Medical

ASPARLAS INTRAVENOUS SOLUTION 3750 UNIT/5ML

5PA;

Specialty Medical

AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

5PA;

Specialty Medical

AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG

5 PA

Drug NameDrug Tier

Notes

azacitidine injection suspension reconstituted 100 mg

5PA;

Specialty Medical

AZEDRA DOSIMETRIC INTRAVENOUS SOLUTION 15 MCI/ML

GM

AZEDRA THERAPEUTIC INTRAVENOUS SOLUTION 15 MCI/ML

GM

BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG

5 PA

BAVENCIO INTRAVENOUS SOLUTION 200 MG/10ML

GM

BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

5PA;

Specialty Medical

BELRAPZO INTRAVENOUS SOLUTION 100 MG/4ML

5PA;

Specialty Medical

BENDAMUSTINE HCL INTRAVENOUS SOLUTION 100 MG/4ML

5PA;

Specialty Medical

BENDEKA INTRAVENOUS SOLUTION 100 MG/4ML

5PA;

Specialty Medical

BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED 0.9 MG

5PA;

Specialty Medical

bexarotene oral capsule 75 mg

5 PA

bicalutamide oral tablet 50 mg

1

Updated May 1, 2020


53

Drug NameDrug Tier

Notes

BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5PA;

Specialty Medical

bleomycin sulfate injection solution reconstituted 15 unit, 30 unit

5PA;

Specialty Medical

BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 35 MCG

5PA;

Specialty Medical

BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED 3.5 MG

5PA;

Specialty Medical

BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG


days)

BRAFTOVI ORAL CAPSULE 75 MG

5 PA

BRUKINSA ORAL CAPSULE 80 MG

5 PA

busulfan intravenous solution 6 mg/ml

5PA;

Specialty Medical

BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML

5PA;

Specialty Medical

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

5 PA

CALQUENCE ORAL CAPSULE 100 MG

5 PA

CAMPATH INTRAVENOUS SOLUTION 30 MG/ML

5PA;

Specialty Medical

Drug NameDrug Tier

Notes

CAMPTOSAR INTRAVENOUS SOLUTION 100 MG/5ML, 300 MG/15ML, 40 MG/2ML

GM PA

capecitabine oral tablet 150 mg, 500 mg

3 PA

CAPRELSA ORAL TABLET 100 MG, 300 MG

5 PA

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

GM PA

carmustine intravenous solution reconstituted 100 mg

5PA;

Specialty Medical

CASODEX ORAL TABLET 50 MG

3Brand

penalty applies

cisplatin intravenous solution 100 mg/100ml, 200 mg/200ml, 50 mg/50ml

GM PA

cladribine intravenous solution 10 mg/10ml

5PA;

Specialty Medical

clofarabine intravenous solution 1 mg/ml

5PA;

Specialty Medical

CLOLAR INTRAVENOUS SOLUTION 1 MG/ML

5PA;

Specialty Medical

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG

5 PA

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG

5 PA

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG

5 PA

Updated May 1, 2020


54

Drug NameDrug Tier

Notes

COPIKTRA ORAL CAPSULE 15 MG, 25 MG

5 PA

COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG

5PA;

Specialty Medical

COTELLIC ORAL TABLET 20 MG

5 PA

cyclophosphamide injection solution reconstituted 1 gm, 2 gm, 500 mg

5PA;

Specialty Medical

cyclophosphamide oral capsule 25 mg, 50 mg

1 PA

CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML

5PA;

Specialty Medical

cytarabine (pf) injection solution 100 mg/ml, 20 mg/ml

5PA;

Specialty Medical

cytarabine injection solution 20 mg/ml

5PA;

Specialty Medical

dacarbazine intravenous solution reconstituted 100 mg, 200 mg

5PA;

Specialty Medical

DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

5PA;

Specialty Medical

dactinomycin intravenous solution reconstituted 0.5 mg

5PA;

Specialty Medical

DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML

5PA;

Specialty Medical

Drug NameDrug Tier

Notes

daunorubicin hcl intravenous solution 20 mg/4ml, 50 mg/10ml

GM PA

DAURISMO ORAL TABLET 100 MG, 25 MG

5 PA

decitabine intravenous solution reconstituted 50 mg

5PA;

Specialty Medical

dexrazoxane hcl intravenous solution reconstituted 250 mg, 500 mg

GM

docetaxel intravenous concentrate 160 mg/8ml, 20 mg/ml, 200 mg/10ml, 80 mg/4ml

5PA;

Specialty Medical

docetaxel intravenous solution 160 mg/16ml, 20 mg/2ml, 80 mg/8ml

5PA;

Specialty Medical

DOXIL INTRAVENOUS INJECTABLE 2 MG/ML

5PA;

Specialty Medical

doxorubicin hcl intravenous solution 2 mg/ml

GM PA

doxorubicin hcl liposomal intravenous injectable 2 mg/ml

5PA;

Specialty Medical

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

3

ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG

5Specialty Medical

ELLENCE INTRAVENOUS SOLUTION 200 MG/100ML, 50 MG/25ML

5PA;

Specialty Medical

ELZONRIS INTRAVENOUS SOLUTION 1000 MCG/ML

5PA;

Specialty Medical

Updated May 1, 2020


55

Drug NameDrug Tier

Notes

EMCYT ORAL CAPSULE 140 MG

2 PA

EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG

5PA;

Specialty Medical

ENHERTU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5PA;

Specialty Medical

epirubicin hcl intravenous solution 200 mg/100ml, 50 mg/25ml

5PA;

Specialty Medical

ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML, 200 MG/100ML

5PA;

Specialty Medical

ERIVEDGE ORAL CAPSULE 150 MG

5 PA

ERLEADA ORAL TABLET 60 MG

5 PA

erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg

4 PA

ERWINAZE INJECTION SOLUTION RECONSTITUTED 10000 UNIT

5PA;

Specialty Medical

ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5PA;

Specialty Medical

etoposide intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

GM PA

etoposide oral capsule 50 mg

1 PA

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg

5

Drug NameDrug Tier

Notes

EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

exemestane oral tablet 25 mg

1

FARESTON ORAL TABLET 60 MG

2PA; Brand

penalty applies

FARYDAK ORAL CAPSULE 10 MG, 20 MG

6 PA

FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML

5PA;

Specialty Medical

FEMARA ORAL TABLET 2.5 MG

3Brand

penalty applies

floxuridine injection solution reconstituted 0.5 gm

5PA;

Specialty Medical

fludarabine phosphate intravenous solution 50 mg/2ml

5PA;

Specialty Medical

fludarabine phosphate intravenous solution reconstituted 50 mg

5PA;

Specialty Medical

fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml

GM PA

flutamide oral capsule 125 mg

1 PA

FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML, 40 MG/2ML

5PA;

Specialty Medical

fulvestrant intramuscular solution 250 mg/5ml

5PA;

Specialty Medical

Updated May 1, 2020


56

Drug NameDrug Tier

Notes

GAZYVA INTRAVENOUS SOLUTION 1000 MG/40ML

5PA;

Specialty Medical

gemcitabine hcl intravenous solution 1 gm/10ml, 1.5 gm/15ml, 2 gm/20ml, 200 mg/2ml

GM

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

GM PA

gemcitabine hcl intravenous solution reconstituted 1 gm, 2 gm, 200 mg

GM PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

5 PA

GLEEVEC ORAL TABLET 100 MG


days)

GLEEVEC ORAL TABLET 400 MG


days)

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

5 PA

GLIADEL WAFER IMPLANT WAFER 7.7 MG

GM

HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML

5PA;

Specialty Medical

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600-10000 MG-UNT/5ML

5 PA

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

5PA;

Specialty Medical

Drug NameDrug Tier

Notes

HERZUMA INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG

4PA;

Specialty Medical

HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED 4 MG

GM PA

HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG

3 PA

HYDREA ORAL CAPSULE 500 MG

3Brand

penalty applies

hydroxyurea oral capsule 500 mg

1

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

5 PA

IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG

5 PA

ICLUSIG ORAL TABLET 15 MG, 45 MG


days)

IDAMYCIN PFS INTRAVENOUS SOLUTION 10 MG/10ML, 20 MG/20ML, 5 MG/5ML

5PA;

Specialty Medical

idarubicin hcl intravenous solution 10 mg/10ml, 20 mg/20ml, 5 mg/5ml

5PA;

Specialty Medical

IDHIFA ORAL TABLET 100 MG, 50 MG

5 PA

IFEX INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 3 GM

5PA;

Specialty Medical

ifosfamide intravenous solution 1 gm/20ml, 3 gm/60ml

5PA;

Specialty Medical

Updated May 1, 2020


57

Drug NameDrug Tier

Notes

ifosfamide intravenous solution reconstituted 1 gm, 3 gm

5PA;

Specialty Medical

imatinib mesylate oral tablet 100 mg


days)

imatinib mesylate oral tablet 400 mg


days)

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG

5 PA

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG

5 PA

IMLYGIC INTRALESIONAL SUSPENSION 1000000 UNIT/ML, 100000000 UNIT/ML

5PA;

Specialty Medical

INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML-%, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 MG/160ML-%, 1700-0.9 MG/170ML-%, 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-%

5PA;

Specialty Medical

INLYTA ORAL TABLET 1 MG, 5 MG

5 PA

INREBIC ORAL CAPSULE 100 MG

5 PA

IRESSA ORAL TABLET 250 MG

5 PA

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

GM PA

Drug NameDrug Tier

Notes

ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

5PA;

Specialty Medical

IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 15 MG, 45 MG

5PA;

Specialty Medical

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

5 PA

JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML

5PA;

Specialty Medical

KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 160 MG

5PA;

Specialty Medical

KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG

4PA;

Specialty Medical

KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML

5PA;

Specialty Medical

KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED 175 MG, 300 MG

5PA;

Specialty Medical

KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK 200 MG

5 PA


5 PA

Updated May 1, 2020


58

Drug NameDrug Tier

Notes


5 PA

KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 10 MG, 30 MG, 60 MG

5PA;

Specialty Medical

LARTRUVO INTRAVENOUS SOLUTION 190 MG/19ML, 500 MG/50ML

5PA;

Specialty Medical

LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 MG

5 PA

LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 3 X 4 MG

5 PA

LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 & 4 MG

5 PA

LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 MG & 2 X 4 MG

5 PA


5 PA

LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 X 10 MG & 4 MG

5 PA

LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 4 MG

5 PA


5 PA

Drug NameDrug Tier

Notes

letrozole oral tablet 2.5 mg

1

leucovorin calcium injection solution 100 mg/10ml, 500 mg/50ml

GM PA

leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg, 50 mg, 500 mg

GM PA

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

1

LEUKERAN ORAL TABLET 2 MG

2 PA

levoleucovorin calcium intravenous solution reconstituted 50 mg

5PA;

Specialty Medical

levoleucovorin calcium pf intravenous solution 175 mg/17.5ml, 250 mg/25ml

5PA;

Specialty Medical

LIBTAYO INTRAVENOUS SOLUTION 350 MG/7ML

5PA;

Specialty Medical

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG

5 PA

LORBRENA ORAL TABLET 100 MG, 25 MG

5 PA

LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

5PA;

Specialty Medical

LYNPARZA ORAL CAPSULE 50 MG

5 PA

LYNPARZA ORAL TABLET 100 MG, 150 MG

5 PA

LYSODREN ORAL TABLET 500 MG

2 PA

Updated May 1, 2020


59

Drug NameDrug Tier

Notes

MARQIBO INTRAVENOUS SUSPENSION 5 MG/31ML

5PA;

Specialty Medical

MATULANE ORAL CAPSULE 50 MG

5 PA

MEKINIST ORAL TABLET 0.5 MG, 2 MG

5 PA

MEKTOVI ORAL TABLET 15 MG

5 PA

melphalan hcl intravenous solution reconstituted 50 mg

5PA;

Specialty Medical

melphalan oral tablet 2 mg

1 PA

mercaptopurine oral tablet 50 mg

1

mesna intravenous solution 100 mg/ml

5Specialty Medical

MESNEX INTRAVENOUS SOLUTION 100 MG/ML

5Specialty Medical

MESNEX ORAL TABLET 400 MG

2

mitomycin intravenous solution reconstituted 20 mg, 40 mg, 5 mg

GM PA

MITOMYCIN INTRAVESICAL SOLUTION PREFILLED SYRINGE 20 MG/40ML

GM

mitoxantrone hcl intravenous concentrate 20 mg/10ml, 25 mg/12.5ml, 30 mg/15ml

5Specialty Medical

mutamycin intravenous solution reconstituted 20 mg, 40 mg, 5 mg

GM PA

MVASI INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

4PA;

Specialty Medical

Drug NameDrug Tier

Notes

MYLERAN ORAL TABLET 2 MG

2

MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG

5PA;

Specialty Medical

NAVELBINE INTRAVENOUS SOLUTION 10 MG/ML, 50 MG/5ML

5PA;

Specialty Medical

NERLYNX ORAL TABLET 40 MG

5 PA

NEXAVAR ORAL TABLET 200 MG

5 PA

NILANDRON ORAL TABLET 150 MG

2Brand

penalty applies

nilutamide oral tablet 150 mg

1

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG

5 PA

NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

5PA;

Specialty Medical

NUBEQA ORAL TABLET 300 MG

5 PA

ODOMZO ORAL CAPSULE 200 MG

5 PA

OGIVRI INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG

4PA;

Specialty Medical

ONCASPAR INJECTION SOLUTION 750 UNIT/ML

5PA;

Specialty Medical

ONIVYDE INTRAVENOUS INJECTABLE 43 MG/10ML

5PA;

Specialty Medical

Updated May 1, 2020


60

Drug NameDrug Tier

Notes

OPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 240 MG/24ML, 40 MG/4ML

5PA;

Specialty Medical

oxaliplatin intravenous solution 100 mg/20ml, 50 mg/10ml

GM PA

oxaliplatin intravenous solution reconstituted 100 mg, 50 mg

GM PA

paclitaxel intravenous concentrate 100 mg/16.7ml, 150 mg/25ml, 30 mg/5ml, 300 mg/50ml

5PA;

Specialty Medical

PADCEV INTRAVENOUS SOLUTION RECONSTITUTED 20 MG, 30 MG

5PA;

Specialty Medical

PANRETIN EXTERNAL GEL 0.1 %

3

paraplatin intravenous solution 150 mg/15ml, 450 mg/45ml, 50 mg/5ml, 600 mg/60ml

GM PA

PERJETA INTRAVENOUS SOLUTION 420 MG/14ML

5PA;

Specialty Medical

PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED 75 MG

5PA;

Specialty Medical

PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK 200 MG

5 PA

PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 200 & 50 MG

5 PA

Drug NameDrug Tier

Notes

PIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK 2 X 150 MG

5 PA

POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 140 MG

5PA;

Specialty Medical

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

5 PA

PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50ML

5PA;

Specialty Medical

POTELIGEO INTRAVENOUS SOLUTION 20 MG/5ML

5PA;

Specialty Medical

PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 22000000 UNIT

5PA;

Specialty Medical

PURIXAN ORAL SUSPENSION 2000 MG/100ML

3

QUADRAMET INTRAVENOUS SOLUTION 1850 MBQ/ML

5Specialty Medical

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

5 PA

RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400-23400 MG -UT/11.7ML, 1600-26800 MG -UT/13.4ML

5PA;

Specialty Medical

RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML

5PA;

Specialty Medical

Updated May 1, 2020


61

Drug NameDrug Tier

Notes

ROMIDEPSIN INTRAVENOUS SOLUTION RECONSTITUTED 10 MG

5PA;

Specialty Medical

ROZLYTREK ORAL CAPSULE 100 MG, 200 MG

5 PA

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG

5 PA

RUXIENCE INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML

4PA;

Specialty Medical

RYDAPT ORAL CAPSULE 25 MG

5 PA

SARCLISA INTRAVENOUS SOLUTION 100 MG/5ML, 500 MG/25ML

5PA;

Specialty Medical

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

5 PA

STIVARGA ORAL TABLET 40 MG

5 PA

STRONTIUM CHLORIDE SR-89 INTRAVENOUS SOLUTION 1 MCI/ML

GM

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

5 PA

SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 400 MG

5PA;

Specialty Medical

SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG

5 PA

Drug NameDrug Tier

Notes

TABLOID ORAL TABLET 40 MG

2

TAFINLAR ORAL CAPSULE 50 MG, 75 MG

5 PA

TAGRISSO ORAL TABLET 40 MG, 80 MG

5 PA

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG

5 PA

tamoxifen citrate oral tablet 10 mg, 20 mg

PV

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

5 PA

TARGRETIN EXTERNAL GEL 1 %

5 PA

TARGRETIN ORAL CAPSULE 75 MG

5 PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG


days)

TASIGNA ORAL CAPSULE 50 MG

3

TAXOTERE INTRAVENOUS CONCENTRATE 80 MG/4ML

5PA;

Specialty Medical

TAZVERIK ORAL TABLET 200 MG

5 PA

TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML, 840 MG/14ML

5PA;

Specialty Medical

TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5PA;

Specialty Medical

TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG

5 PA

Updated May 1, 2020


62

Drug NameDrug Tier

Notes

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

4 PA

teniposide intravenous solution 10 mg/ml

5PA;

Specialty Medical

TEPADINA INJECTION SOLUTION RECONSTITUTED 100 MG, 15 MG

5PA;

Specialty Medical

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

5 PA

thiotepa injection solution reconstituted 100 mg, 15 mg

5PA;

Specialty Medical

TIBSOVO ORAL TABLET 250 MG

5 PA

toposar intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

GM PA

topotecan hcl intravenous solution 4 mg/4ml

GM PA

topotecan hcl intravenous solution reconstituted 4 mg

GM PA

toremifene citrate oral tablet 60 mg

1 PA

TOTECT INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 420 MG

4PA;

Specialty Medical

Drug NameDrug Tier

Notes

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 25 MG

5PA;

Specialty Medical

tretinoin oral capsule 10 mg

1 PA

TRUXIMA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML

5PA;

Specialty Medical

TURALIO ORAL CAPSULE 200 MG

5 PA

TYKERB ORAL TABLET 250 MG

5 PA

UNITUXIN INTRAVENOUS SOLUTION 17.5 MG/5ML

5PA;

Specialty Medical

VALCHLOR EXTERNAL GEL 0.016 %

6 PA

valrubicin intravesical solution 40 mg/ml

5PA;

Specialty Medical

VALSTAR INTRAVESICAL SOLUTION 40 MG/ML

5PA;

Specialty Medical

VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML

5PA;

Specialty Medical

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG

5PA;

Specialty Medical

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG

5 PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG

5 PA

Updated May 1, 2020


63

Drug NameDrug Tier

Notes

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

5 PA

VIDAZA INJECTION SUSPENSION RECONSTITUTED 100 MG

5PA;

Specialty Medical

vinblastine sulfate intravenous solution 1 mg/ml

5PA;

Specialty Medical

vincristine sulfate intravenous solution 1 mg/ml

GM PA

vinorelbine tartrate intravenous solution 10 mg/ml, 50 mg/5ml

5PA;

Specialty Medical

VITRAKVI ORAL CAPSULE 100 MG, 25 MG

5 PA

VITRAKVI ORAL SOLUTION 20 MG/ML

5 PA

VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG

5 PA

VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

GM

VOTRIENT ORAL TABLET 200 MG

5 PA

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG

5PA;

Specialty Medical

XALKORI ORAL CAPSULE 200 MG, 250 MG

5 PA

XELODA ORAL TABLET 150 MG, 500 MG

6 PA

Drug NameDrug Tier

Notes

XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML

5PA;

Specialty Medical

XOSPATA ORAL TABLET 40 MG

5 PA

XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 20 MG

5 PA


5 PA


5 PA

XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 20 MG

5 PA

XTANDI ORAL CAPSULE 40 MG

5 PA

YERVOY INTRAVENOUS SOLUTION 200 MG/40ML, 50 MG/10ML

5PA;

Specialty Medical

YESCARTA INTRAVENOUS SUSPENSION

6PA;

Specialty Medical

YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

5PA;

Specialty Medical

YONSA ORAL TABLET 125 MG

5 PA

ZALTRAP INTRAVENOUS SOLUTION 100 MG/4ML, 200 MG/8ML

5PA;

Specialty Medical

Updated May 1, 2020


64

Drug NameDrug Tier

Notes

ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

5PA;

Specialty Medical

ZEJULA ORAL CAPSULE 100 MG

5 PA

ZELBORAF ORAL TABLET 240 MG

5 PA

ZEVALIN Y-90 INTRAVENOUS KIT 3.2 MG/2ML

5Specialty Medical

ZINECARD INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG

GM

ZIRABEV INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

4PA;

Specialty Medical

ZOLINZA ORAL CAPSULE 100 MG

5 PA

ZYDELIG ORAL TABLET 100 MG, 150 MG

6 PA

ZYKADIA ORAL TABLET 150 MG

5 PA

ZYTIGA ORAL TABLET 250 MG, 500 MG

5 PA

Antiparasitics

albendazole oral tablet 200 mg

1

ALBENZA ORAL TABLET 200 MG

3Brand

penalty applies

ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

3

ALINIA ORAL TABLET 500 MG

3

ARAKODA ORAL TABLET 100 MG

2

Drug NameDrug Tier

Notes

atovaquone oral suspension 750 mg/5ml

1

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

1

BENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG

3

BILTRICIDE ORAL TABLET 600 MG

3Brand

penalty applies

chloroquine phosphate oral tablet 250 mg, 500 mg

1

COARTEM ORAL TABLET 20-120 MG

2

crotan external lotion 10 %

1 PA

DARAPRIM ORAL TABLET 25 MG

6

ELIMITE EXTERNAL CREAM 5 %

3Brand

penalty applies

EMVERM ORAL TABLET CHEWABLE 100 MG

3

hydroxychloroquine sulfate oral tablet 200 mg

1

IMPAVIDO ORAL CAPSULE 50 MG

6 PA

ivermectin oral tablet 3 mg

1

KRINTAFEL ORAL TABLET 150 MG

2QL (2 EA

per 30 days)

lindane external shampoo 1 %

1

MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG

3Brand

penalty applies

malathion external lotion 0.5 %

1

Updated May 1, 2020


65

Drug NameDrug Tier

Notes

mefloquine hcl oral tablet 250 mg

1

MEPRON ORAL SUSPENSION 750 MG/5ML

2Brand

penalty applies

NATROBA EXTERNAL SUSPENSION 0.9 %

3Brand

penalty applies

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

3Brand

penalty applies

OVIDE EXTERNAL LOTION 0.5 %

3Brand

penalty applies

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG

GM

pentamidine isethionate inhalation solution reconstituted 300 mg

1

pentamidine isethionate injection solution reconstituted 300 mg

GM

permethrin external cream 5 %

1

PLAQUENIL ORAL TABLET 200 MG

3Brand

penalty applies

praziquantel oral tablet 600 mg

1

primaquine phosphate oral tablet 26.3 mg

1

pyrimethamine oral tablet 25 mg

6

PYRIMETHAMINE-LEUCOVORIN ORAL CAPSULE 12.5-2.5 MG, 25-10 MG, 25-5 MG, 50-10 MG, 50-20 MG, 50-25 MG, 75-25 MG

3

Drug NameDrug Tier

Notes

QUALAQUIN ORAL CAPSULE 324 MG

3Brand

penalty applies

quinine sulfate oral capsule 324 mg

1

SKLICE EXTERNAL LOTION 0.5 %

3

spinosad external suspension 0.9 %

1

STROMECTOL ORAL TABLET 3 MG

3Brand

penalty applies

sulfurated lime external solution

1

Antiparkinson Agents

amantadine hcl oral capsule 100 mg

1

amantadine hcl oral syrup 50 mg/5ml

1

amantadine hcl oral tablet 100 mg

1

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML

5 PA

AZILECT ORAL TABLET 0.5 MG, 1 MG

3Brand

penalty applies

benztropine mesylate injection solution 1 mg/ml

GM

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

1

bromocriptine mesylate oral capsule 5 mg

1

bromocriptine mesylate oral tablet 2.5 mg

1

carbidopa oral tablet 25 mg

1

Updated May 1, 2020


66

Drug NameDrug Tier

Notes

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

1

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg

1

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

1

COGENTIN INJECTION SOLUTION 1 MG/ML

GM

COMTAN ORAL TABLET 200 MG

3Brand

penalty applies

entacapone oral tablet 200 mg

1

INBRIJA INHALATION CAPSULE 42 MG

5 PA

LODOSYN ORAL TABLET 25 MG

3Brand

penalty applies

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG

3Brand

penalty applies

MIRAPEX ORAL TABLET 0.125 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR

3

NOURIANZ ORAL TABLET 20 MG, 40 MG

6 PA

PARLODEL ORAL CAPSULE 5 MG

3Brand

penalty applies

PARLODEL ORAL TABLET 2.5 MG

3Brand

penalty applies

pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

1

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

1

rasagiline mesylate oral tablet 0.5 mg, 1 mg

1

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HOUR 12 MG, 6 MG

3Brand

penalty applies

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

1

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

1

RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

3

Updated May 1, 2020


67

Drug NameDrug Tier

Notes

selegiline hcl oral capsule 5 mg

1

selegiline hcl oral tablet 5 mg

1

SINEMET ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG

3Brand

penalty applies

STALEVO 100 ORAL TABLET 25-100-200 MG

3Brand

penalty applies

STALEVO 125 ORAL TABLET 31.25-125-200 MG

3Brand

penalty applies


3Brand

penalty applies

STALEVO 200 ORAL TABLET 50-200-200 MG

3Brand

penalty applies


3Brand

penalty applies


3Brand

penalty applies

TASMAR ORAL TABLET 100 MG

3Brand

penalty applies

tolcapone oral tablet 100 mg

1

trihexyphenidyl hcl oral solution 0.4 mg/ml

1

trihexyphenidyl hcl oral tablet 2 mg, 5 mg

1

XADAGO ORAL TABLET 100 MG, 50 MG

3

ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG

3

Drug NameDrug Tier

Notes

Antiplatelets

AGGRASTAT INTRAVENOUS CONCENTRATE 3.75 MG/15ML

GM

AGGRASTAT INTRAVENOUS SOLUTION 12.5-0.9 MG/250ML-%, 5-0.9 MG/100ML-%

GM

AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG

3Brand

penalty applies

aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg

1

BRILINTA ORAL TABLET 60 MG, 90 MG

2

CABLIVI INJECTION KIT 11 MG

5 PA

cilostazol oral tablet 100 mg, 50 mg

1

clopidogrel bisulfate oral tablet 300 mg, 75 mg

1

dipyridamole oral tablet 25 mg, 50 mg, 75 mg

1

EFFIENT ORAL TABLET 10 MG, 5 MG

3ST; Brand

penalty applies

eptifibatide intravenous solution 20 mg/10ml, 200 mg/100ml, 75 mg/100ml

GM

INTEGRILIN INTRAVENOUS SOLUTION 20 MG/10ML, 200 MG/100ML, 75 MG/100ML

GM

Updated May 1, 2020


68

Drug NameDrug Tier

Notes

KENGREAL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

PLAVIX ORAL TABLET 75 MG

3Brand

penalty applies

prasugrel hcl oral tablet 10 mg, 5 mg

1 ST

ZONTIVITY ORAL TABLET 2.08 MG

3 ST

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG

4

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG

4

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG

3

Brand penalty


ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED 10 MG

GM

aripiprazole oral solution 1 mg/ml

1

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

1QL (30 EA

per 30 days)

aripiprazole oral tablet dispersible 10 mg, 15 mg

1QL (30 EA

per 30 days)

Drug NameDrug Tier

Notes

ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 675 MG/2.4ML

4

ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML

4

CAPLYTA ORAL CAPSULE 42 MG

3 PA

chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml

GM

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

1

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

1

clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg

1

CLOZARIL ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG

3Brand

penalty applies

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

3 PA

FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG

3 PA

fluphenazine decanoate injection solution 25 mg/ml

GM

fluphenazine hcl injection solution 2.5 mg/ml

GM

fluphenazine hcl oral concentrate 5 mg/ml

1

Updated May 1, 2020


69

Drug NameDrug Tier

Notes

fluphenazine hcl oral elixir 2.5 mg/5ml

1

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

1

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG

GM

GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG

3Brand

penalty applies

HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML

GM

HALDOL INJECTION SOLUTION 5 MG/ML

GM

haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml

GM

haloperidol lactate injection solution 5 mg/ml

GM

haloperidol lactate oral concentrate 2 mg/ml

1

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

1

INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR 1.5 MG, 3 MG, 6 MG, 9 MG

3

Brand penalty


INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML

4

Drug NameDrug Tier

Notes

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML

4

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG

3 PA

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

1

molindone hcl oral tablet 10 mg, 25 mg, 5 mg

1

NUPLAZID ORAL CAPSULE 34 MG

3 PA

NUPLAZID ORAL TABLET 10 MG

3 PA

olanzapine intramuscular solution reconstituted 10 mg

GM

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

1

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

1

paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 6 mg, 9 mg

1QL (30 EA

per 30 days)

PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG, 90 MG

4

pimozide oral tablet 1 mg, 2 mg

1

Updated May 1, 2020


70

Drug NameDrug Tier

Notes

quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

1QL (30 EA

per 30 days)

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

1

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

3 PA

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, 37.5 MG, 50 MG

4

RISPERDAL ORAL SOLUTION 1 MG/ML

3Brand

penalty applies

RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

3Brand

penalty applies

risperidone oral solution 1 mg/ml

1

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

1

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

1

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG

3 PA

SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24HR, 5.7 MG/24HR, 7.6 MG/24HR

3 PA

Drug NameDrug Tier

Notes

SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG

3Brand

penalty applies

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG

3

Brand penalty


thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

1

VERSACLOZ ORAL SUSPENSION 50 MG/ML

3

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG

3 PA

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG

3 PA

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

1

ziprasidone mesylate intramuscular solution reconstituted 20 mg

GM

ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED 10 MG

GM

ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG

3Brand

penalty applies

Updated May 1, 2020


71

Drug NameDrug Tier

Notes

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 MG

4

ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 20 MG, 5 MG

3Brand

penalty applies

Antivirals

abacavir sulfate oral solution 20 mg/ml

1

abacavir sulfate oral tablet 300 mg

1

abacavir sulfate-lamivudine oral tablet 600-300 mg

1

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

5

acyclovir external cream 5 %

1

acyclovir external ointment 5 %

1QL (15 GM

per 30 days)

acyclovir oral capsule 200 mg

1

acyclovir oral suspension 200 mg/5ml

1

acyclovir oral tablet 400 mg, 800 mg

1

acyclovir sodium intravenous solution 50 mg/ml

GM

adefovir dipivoxil oral tablet 10 mg

1 PA

APTIVUS ORAL CAPSULE 250 MG

2

APTIVUS ORAL SOLUTION 100 MG/ML

2

Drug NameDrug Tier

Notes

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

1

ATRIPLA ORAL TABLET 600-200-300 MG

5

BARACLUDE ORAL SOLUTION 0.05 MG/ML

3 PA

BARACLUDE ORAL TABLET 0.5 MG, 1 MG

3PA; Brand

penalty applies

BIKTARVY ORAL TABLET 50-200-25 MG

5

cidofovir intravenous solution 75 mg/ml

GM

CIMDUO ORAL TABLET 300-300 MG

5

COMBIVIR ORAL TABLET 150-300 MG

2Brand

penalty applies

COMPLERA ORAL TABLET 200-25-300 MG

5

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

2

CYTOVENE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

DELSTRIGO ORAL TABLET 100-300-300 MG

5

DENAVIR EXTERNAL CREAM 1 %

3 ST

DESCOVY ORAL TABLET 200-25 MG

5

didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg

1

DOVATO ORAL TABLET 50-300 MG

5

Updated May 1, 2020


72

Drug NameDrug Tier

Notes

EDURANT ORAL TABLET 25 MG

3

efavirenz oral capsule 200 mg, 50 mg

1

efavirenz oral tablet 600 mg

1

EMTRIVA ORAL CAPSULE 200 MG

2

EMTRIVA ORAL SOLUTION 10 MG/ML

2

entecavir oral tablet 0.5 mg, 1 mg

1 PA

EPCLUSA ORAL TABLET 400-100 MG

4 PA

EPIVIR HBV ORAL SOLUTION 5 MG/ML

3

EPIVIR HBV ORAL TABLET 100 MG

2Brand

penalty applies

EPIVIR ORAL SOLUTION 10 MG/ML

3Brand

penalty applies

EPIVIR ORAL TABLET 150 MG, 300 MG

2Brand

penalty applies

EPZICOM ORAL TABLET 600-300 MG

3Brand

penalty applies

EVOTAZ ORAL TABLET 300-150 MG

5

famciclovir oral tablet 125 mg, 250 mg, 500 mg

1

fosamprenavir calcium oral tablet 700 mg

1

FOSCAVIR INTRAVENOUS SOLUTION 6000 MG/250ML

GM

Drug NameDrug Tier

Notes

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

5

GANCICLOVIR INTRAVENOUS SOLUTION 500 MG/250ML

GM

ganciclovir sodium intravenous solution 500 mg/10ml

GM

ganciclovir sodium intravenous solution reconstituted 500 mg

GM

GENVOYA ORAL TABLET 150-150-200-10 MG

5

HARVONI ORAL TABLET 45-200 MG, 90-400 MG

4 PA

HEPSERA ORAL TABLET 10 MG

3PA; Brand

penalty applies

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

3

INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML

5PA;

Specialty Medical

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

5PA;

Specialty Medical

INVIRASE ORAL TABLET 500 MG

2

ISENTRESS HD ORAL TABLET 600 MG

2

ISENTRESS ORAL PACKET 100 MG

3

Updated May 1, 2020


73

Drug NameDrug Tier

Notes

ISENTRESS ORAL TABLET 400 MG

2

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG

3

JULUCA ORAL TABLET 50-25 MG

5

KALETRA ORAL SOLUTION 400-100 MG/5ML

2Brand

penalty applies

KALETRA ORAL TABLET 100-25 MG, 200-50 MG

2

lamivudine oral solution 10 mg/ml

1

lamivudine oral tablet 100 mg, 150 mg, 300 mg

1

lamivudine-zidovudine oral tablet 150-300 mg

1

LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG

4 PA

LEXIVA ORAL SUSPENSION 50 MG/ML

3

LEXIVA ORAL TABLET 700 MG

3Brand

penalty applies

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

1

MAVYRET ORAL TABLET 100-40 MG

4 PA

nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg

1

nevirapine oral suspension 50 mg/5ml

1

nevirapine oral tablet 200 mg

1

NORVIR ORAL PACKET 100 MG

3

Drug NameDrug Tier

Notes

NORVIR ORAL SOLUTION 80 MG/ML

2

NORVIR ORAL TABLET 100 MG

3Brand

penalty applies

ODEFSEY ORAL TABLET 200-25-25 MG

5

oseltamivir phosphate oral capsule 30 mg

1QL (20 EA

per 180 days)

oseltamivir phosphate oral capsule 45 mg, 75 mg

1QL (10 EA

per 180 days)

oseltamivir phosphate oral suspension reconstituted 6 mg/ml

1QL (120

ML per 180 days)

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML

5 PA

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML

5 PA

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML

5 PA

PIFELTRO ORAL TABLET 100 MG

3

PREVYMIS INTRAVENOUS SOLUTION 240 MG/12ML, 480 MG/24ML

5PA;

Specialty Medical

PREVYMIS ORAL TABLET 240 MG, 480 MG

5 PA

PREZCOBIX ORAL TABLET 800-150 MG

5

PREZISTA ORAL SUSPENSION 100 MG/ML

3

Updated May 1, 2020


74

Drug NameDrug Tier

Notes

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

3

RAPIVAB INTRAVENOUS SOLUTION 200 MG/20ML

GM

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

3QL (20 EA

per 180 days)

RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

GM

RETROVIR ORAL CAPSULE 100 MG

3Brand

penalty applies

RETROVIR ORAL SYRUP 50 MG/5ML

3Brand

penalty applies

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

2Brand

penalty applies

REYATAZ ORAL PACKET 50 MG

2

ribavirin inhalation solution reconstituted 6 gm

5PA;

Specialty Medical

ribavirin oral capsule 200 mg

4 PA

ribavirin oral tablet 200 mg

4 PA

rimantadine hcl oral tablet 100 mg

1

ritonavir oral tablet 100 mg

1

SELZENTRY ORAL SOLUTION 20 MG/ML

5

SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG

5

Drug NameDrug Tier

Notes

SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG

4 PA

SOVALDI ORAL TABLET 200 MG, 400 MG

6 PA

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

1

STRIBILD ORAL TABLET 150-150-200-300 MG

5

SUSTIVA ORAL CAPSULE 200 MG, 50 MG

2Brand

penalty applies

SUSTIVA ORAL TABLET 600 MG

2Brand

penalty applies

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

5PA;

Specialty Medical

SYMFI LO ORAL TABLET 400-300-300 MG

5

SYMFI ORAL TABLET 600-300-300 MG

5

SYMTUZA ORAL TABLET 800-150-200-10 MG

5

TAMIFLU ORAL CAPSULE 30 MG

3

Brand penalty


TAMIFLU ORAL CAPSULE 45 MG, 75 MG

3

Brand penalty


Updated May 1, 2020


75

Drug NameDrug Tier

Notes

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

3

Brand penalty


TEMIXYS ORAL TABLET 300-300 MG

5

tenofovir disoproxil fumarate oral tablet 300 mg

1

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG

5

TRIUMEQ ORAL TABLET 600-50-300 MG

5

TRIZIVIR ORAL TABLET 300-150-300 MG

5

TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33ML

5Specialty Medical

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

5

TYBOST ORAL TABLET 150 MG

3 ST

valacyclovir hcl oral tablet 1 gm, 500 mg

1

VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML

6

VALCYTE ORAL TABLET 450 MG

6

valganciclovir hcl oral solution reconstituted 50 mg/ml

4

valganciclovir hcl oral tablet 450 mg

4

VALTREX ORAL TABLET 1 GM, 500 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

VEMLIDY ORAL TABLET 25 MG

4 PA

VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50

5 PA

VIRACEPT ORAL TABLET 250 MG, 625 MG

3

VIRAMUNE ORAL SUSPENSION 50 MG/5ML

3Brand

penalty applies

VIRAMUNE ORAL TABLET 200 MG

3Brand

penalty applies

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 400 MG

3Brand

penalty applies

VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM

5PA;

Specialty Medical

VIREAD ORAL POWDER 40 MG/GM

2

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

VIREAD ORAL TABLET 300 MG

2Brand

penalty applies

VOSEVI ORAL TABLET 400-100-100 MG

6 PA

XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 2 X 20 MG

3QL (2 EA per 180 days)

XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 2 X 40 MG


ZEPATIER ORAL TABLET 50-100 MG

5 PA

Updated May 1, 2020


76

Drug NameDrug Tier

Notes

ZIAGEN ORAL SOLUTION 20 MG/ML

3Brand

penalty applies

ZIAGEN ORAL TABLET 300 MG

3Brand

penalty applies

zidovudine oral capsule 100 mg

1

zidovudine oral syrup 50 mg/5ml

1

zidovudine oral tablet 300 mg

1

ZOVIRAX EXTERNAL CREAM 5 %

2Brand

penalty applies

ZOVIRAX EXTERNAL OINTMENT 5 %

2

Brand penalty

applies; QL (15 GM per

30 days)

ZOVIRAX ORAL SUSPENSION 200 MG/5ML

3Brand

penalty applies

Anxiolytics - Drugs for Anxiety

alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg

1

alprazolam intensol oral concentrate 1 mg/ml

1

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

1

alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

1 ST

alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg

1

Drug NameDrug Tier

Notes

ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML

GM

ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG

3Brand

penalty applies

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

1

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg

1

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

1

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

1

diazepam intensol oral concentrate 5 mg/ml

1

diazepam oral concentrate 5 mg/ml

1

diazepam oral solution 5 mg/5ml

1

diazepam oral tablet 10 mg, 2 mg, 5 mg

1

diazepam solution 5 mg/ml injection 5 mg/ml

GM

DIAZEPAM SOLUTION 5 MG/ML INJECTION 5 MG/ML

GM

DORAL ORAL TABLET 15 MG

3Brand

penalty applies

estazolam oral tablet 1 mg, 2 mg

1

HALCION ORAL TABLET 0.25 MG

3Brand

penalty applies

Updated May 1, 2020


77

Drug NameDrug Tier

Notes

hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml

GM

hydroxyzine hcl oral syrup 10 mg/5ml

1

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

1

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

1

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

3

lorazepam injection solution 2 mg/ml, 4 mg/ml

GM

lorazepam intensol oral concentrate 2 mg/ml

1

lorazepam oral concentrate 2 mg/ml

1

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg

1

meprobamate oral tablet 200 mg, 400 mg

1

midazolam hcl (pf) injection solution 10 mg/2ml, 2 mg/2ml, 5 mg/5ml, 5 mg/ml

GM

midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml

GM

MIDAZOLAM HCL INTRAVENOUS SOLUTION 150 MG/30ML

GM

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 50-0.9 MG/50ML-%

GM

Drug NameDrug Tier

Notes

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 2-0.9 MG/2ML-%, 5-0.9 MG/5ML-%, 55-0.9 MG/55ML-%

GM

MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 50-0.9 MG/50ML-%

GM

oxazepam oral capsule 10 mg, 15 mg, 30 mg

1

quazepam oral tablet 15 mg

1

TRANXENE-T ORAL TABLET 7.5 MG

3Brand

penalty applies

triazolam oral tablet 0.125 mg, 0.25 mg

1

VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG

3Brand

penalty applies

VISTARIL ORAL CAPSULE 25 MG, 50 MG

3Brand

penalty applies

XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG

3Brand

penalty applies

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 2 MG, 3 MG

3Brand

penalty applies

Bipolar Agents - Drugs for Mood Disorders

EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

3

Updated May 1, 2020


78

Drug NameDrug Tier

Notes

lithium carbonate er oral tablet extended release 300 mg, 450 mg

1

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

1

lithium carbonate oral tablet 300 mg

1

lithium oral solution 8 meq/5ml

1

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG

2

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

5Specialty Medical

ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT, 750 UNIT

5Specialty Medical

ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 3000 UNIT

5PA;

Specialty Medical

AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

Drug NameDrug Tier

Notes

AGRYLIN ORAL CAPSULE 0.5 MG

3Brand

penalty applies

ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

5Specialty Medical

ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT

5Specialty Medical

ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

5Specialty Medical

AMICAR ORAL SOLUTION 0.25 GM/ML

3Brand

penalty applies

AMICAR ORAL TABLET 1000 MG, 500 MG

3Brand

penalty applies

aminocaproic acid intravenous solution 250 mg/ml

GM

aminocaproic acid oral solution 0.25 gm/ml

1

aminocaproic acid oral tablet 1000 mg, 500 mg

1

anagrelide hcl oral capsule 0.5 mg, 1 mg

1

Updated May 1, 2020


79

Drug NameDrug Tier

Notes

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

5

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML

5

BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

CEPROTIN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT

GM

COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT

5Specialty Medical

CORIFACT INTRAVENOUS KIT 1000-1600 UNIT

5Specialty Medical

CYKLOKAPRON INTRAVENOUS SOLUTION 1000 MG/10ML

GM

DOPTELET ORAL TABLET 20 MG

6 PA

Drug NameDrug Tier

Notes

ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT

5Specialty Medical

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

5

ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT

5Specialty Medical

FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED

GM

FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

4

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

4

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

4

Updated May 1, 2020


80

Drug NameDrug Tier

Notes

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

GM

HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT

5Specialty Medical

HESPAN INTRAVENOUS SOLUTION 6-0.9 %

GM

hetastarch-nacl intravenous solution 6-0.9 %

GM

HEXTEND INTRAVENOUS SOLUTION 6 %

GM

HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

5Specialty Medical

IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3500 UNIT, 500 UNIT

5Specialty Medical

IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

Drug NameDrug Tier

Notes

KCENTRA INTRAVENOUS KIT 1000 UNIT, 500 UNIT

GM

KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT

5Specialty Medical

KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT

5Specialty Medical

KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

LEUKINE INJECTION SOLUTION RECONSTITUTED 250 MCG

5Specialty Medical

LMD IN D5W INTRAVENOUS SOLUTION 10-5 %

GM

LMD IN NACL INTRAVENOUS SOLUTION 10-0.9 %

GM

LYSTEDA ORAL TABLET 650 MG

2Brand

penalty applies

Updated May 1, 2020


81

Drug NameDrug Tier

Notes

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML

3

MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

5Specialty Medical

MONSELS FERRIC SUBSULFATE EXTERNAL SOLUTION

3

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML

5PA;

Specialty Medical

MULPLETA ORAL TABLET 3 MG

6 PA

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 6 MG/0.6ML

5

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

5

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

5

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

5

NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

4

Drug NameDrug Tier

Notes

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

4

NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG

5Specialty Medical

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG, 250 MCG, 500 MCG

5PA;

Specialty Medical

NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

5Specialty Medical

NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

5Specialty Medical

OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

5Specialty Medical

PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

GM

Updated May 1, 2020


82

Drug NameDrug Tier

Notes

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

5

PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT

5Specialty Medical

PROFILNINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT

5Specialty Medical

PROMACTA ORAL PACKET 25 MG

5 PA

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG

5 PA

protamine sulfate intravenous solution 10 mg/ml

GM

REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT

GM

REBLOZYL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG, 75 MG

6PA;

Specialty Medical

RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT

5Specialty Medical

Drug NameDrug Tier

Notes

RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT

3

RECOTHROM SPRAY KIT EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT

3

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

4

RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED

GM

RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML

5PA;

Specialty Medical

TAVALISSE ORAL TABLET 100 MG, 150 MG

6 PA

THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 UNIT

3

THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 UNIT

3

THROMBIN-JMI EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT

3

Updated May 1, 2020


83

Drug NameDrug Tier

Notes

THROMBOGEN EXTERNAL KIT 10000 UNIT

3

THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 1000 UNIT, 10000 UNIT

3

tranexamic acid intravenous solution 1000 mg/10ml

GM

tranexamic acid oral tablet 650 mg

1

TRANEXAMIC ACID-NACL INTRAVENOUS SOLUTION 1000-0.7 MG/100ML-%

GM

TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 2000-3125 UNIT

5Specialty Medical

UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

4

ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/30ML

5PA;

Specialty Medical

VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT

5Specialty Medical

WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT

5Specialty Medical

XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

5Specialty Medical

Drug NameDrug Tier

Notes

XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5Specialty Medical

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

4

ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

4

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG

3Brand

penalty applies

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

3Brand

penalty applies

acebutolol hcl oral capsule 200 mg, 400 mg

1

acetazolamide sodium injection solution reconstituted 500 mg

GM

ADENOCARD INTRAVENOUS SOLUTION 6 MG/2ML

GM

adenosine intravenous solution 12 mg/4ml, 6 mg/2ml

GM

AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML

GM

ALDACTAZIDE ORAL TABLET 25-25 MG

3Brand

penalty applies

ALDACTAZIDE ORAL TABLET 50-50 MG

2

Updated May 1, 2020


84

Drug NameDrug Tier

Notes

ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

aliskiren fumarate oral tablet 150 mg, 300 mg

1

alprostadil injection solution 500 mcg/ml

GM

ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG

3Brand

penalty applies

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR 20 MG, 40 MG, 60 MG

3 PA

amiloride hcl oral tablet 5 mg

1

amiloride-hydrochlorothiazide oral tablet 5-50 mg

1

amiodarone hcl intravenous solution 150 mg/3ml, 450 mg/9ml, 900 mg/18ml

GM

amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg

1

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

1

amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

1

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

1

Drug NameDrug Tier

Notes

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

1

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

1

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

1

ANTARA ORAL CAPSULE 30 MG, 90 MG

3

ASCLERA INTRAVENOUS SOLUTION 0.5 %, 1 %

GM

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

3Brand

penalty applies

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

3Brand

penalty applies

atenolol oral tablet 100 mg, 25 mg, 50 mg

1

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

1

atorvastatin calcium oral tablet 10 mg, 20 mg

1 PV*

atorvastatin calcium oral tablet 40 mg, 80 mg

1

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

3Brand

penalty applies

AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG

3Brand

penalty applies

Updated May 1, 2020


85

Drug NameDrug Tier

Notes

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

3Brand

penalty applies

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

1

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

1

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

2Brand

penalty applies

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG

2Brand

penalty applies

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

3Brand

penalty applies

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG

3Brand

penalty applies

betaxolol hcl oral tablet 10 mg, 20 mg

1

BIDIL ORAL TABLET 20-37.5 MG

3

BIORPHEN INTRAVENOUS SOLUTION 0.5 MG/5ML

GM

bisoprolol fumarate oral tablet 10 mg, 5 mg

1

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

1

BREVIBLOC IN NACL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML

GM

Drug NameDrug Tier

Notes

BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10ML

GM

BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION 2000 MG/100ML

GM

BREVIBLOC PREMIXED INTRAVENOUS SOLUTION 2500 MG/250ML

GM

bumetanide injection solution 0.25 mg/ml

GM

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg

1

BUMEX ORAL TABLET 0.5 MG, 1 MG, 2 MG

3Brand

penalty applies

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

2

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

3Brand

penalty applies

CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 180 MG, 240 MG

3Brand

penalty applies

candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

1

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

1

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

1

Updated May 1, 2020


86

Drug NameDrug Tier

Notes

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

1

CARDENE IV INTRAVENOUS SOLUTION 20-0.86 MG/200ML-%, 20-4.8 MG/200ML-%, 40-0.83 MG/200ML-%

GM

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

3Brand

penalty applies

CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 360 MG

2Brand

penalty applies

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

3

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

3Brand

penalty applies

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG

3Brand

penalty applies

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

3Brand

penalty applies

cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

1

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

1

Drug NameDrug Tier

Notes

carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg

1

CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG

3Brand

penalty applies

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24HR

3Brand

penalty applies


3Brand

penalty applies


3Brand

penalty applies

chlorothiazide oral tablet 250 mg, 500 mg

1

chlorothiazide sodium intravenous solution reconstituted 500 mg

GM

chlorthalidone oral tablet 25 mg, 50 mg

1

cholestyramine light oral packet 4 gm

1

cholestyramine light oral powder 4 gm/dose

1

cholestyramine oral packet 4 gm

1

cholestyramine oral powder 4 gm/dose

1

CLEVIPREX INTRAVENOUS EMULSION 25 MG/50ML, 50 MG/100ML

GM

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

1

clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr

1

Updated May 1, 2020


87

Drug NameDrug Tier

Notes

colesevelam hcl oral packet 3.75 gm

1

colesevelam hcl oral tablet 625 mg

1

COLESTID FLAVORED ORAL GRANULES 5 GM

3Brand

penalty applies

COLESTID FLAVORED ORAL PACKET 5 GM

3Brand

penalty applies

COLESTID ORAL GRANULES 5 GM

3Brand

penalty applies

COLESTID ORAL PACKET 5 GM

3Brand

penalty applies

COLESTID ORAL TABLET 1 GM

3Brand

penalty applies

colestipol hcl oral granules 5 gm

1

colestipol hcl oral packet 5 gm

1

colestipol hcl oral tablet 1 gm

1

COREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 80 MG

3Brand

penalty applies

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

3Brand

penalty applies

CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG

3Brand

penalty applies

CORLANOR ORAL SOLUTION 5 MG/5ML

3 PA

CORLANOR ORAL TABLET 5 MG, 7.5 MG

3 PA

Drug NameDrug Tier

Notes

CORLOPAM INTRAVENOUS SOLUTION 10 MG/ML, 20 MG/2ML

GM

CORVERT INTRAVENOUS SOLUTION 1 MG/10ML

GM

COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG

3Brand

penalty applies

DEMSER ORAL CAPSULE 250 MG

3

DIBENZYLINE ORAL CAPSULE 10 MG

3

PA; Brand penalty


digitek oral tablet 125 mcg, 250 mcg

1

digox oral tablet 125 mcg, 250 mcg

1

digoxin injection solution 0.25 mg/ml

GM

digoxin oral solution 0.05 mg/ml

1

digoxin oral tablet 125 mcg, 250 mcg

1

DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG

2

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1

Updated May 1, 2020


88

Drug NameDrug Tier

Notes

diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

1

diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, 50 mg/10ml

GM

diltiazem hcl intravenous solution reconstituted 100 mg

GM

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

1

DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 125-0.7 MG/125ML-%, 125-0.9 MG/125ML-%

GM

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

1

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

3Brand

penalty applies

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG

3Brand

penalty applies

disopyramide phosphate oral capsule 100 mg, 150 mg

1

DIURIL ORAL SUSPENSION 250 MG/5ML

3

dobutamine hcl intravenous solution 250 mg/20ml

GM

Drug NameDrug Tier

Notes

dobutamine in d5w intravenous solution 1-5 mg/ml-%, 2 mg/ml, 4-5 mg/ml-%

GM

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

1

dopamine hcl intravenous solution 40 mg/ml

GM

dopamine in d5w intravenous solution 0.8-5 mg/ml-%, 1.6-5 mg/ml-%, 3.2-5 mg/ml-%

GM

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

1

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG

3

DYAZIDE ORAL CAPSULE 37.5-25 MG

3Brand

penalty applies

DYRENIUM ORAL CAPSULE 100 MG, 50 MG

3Brand

penalty applies

EDARBI ORAL TABLET 40 MG, 80 MG

3

EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG

3

EDECRIN ORAL TABLET 25 MG

3Brand

penalty applies

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

1

enalaprilat intravenous injectable 1.25 mg/ml

GM

Updated May 1, 2020


89

Drug NameDrug Tier

Notes

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

1

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

3 ST

EPANED ORAL SOLUTION 1 MG/ML

3

EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION PREFILLED SYRINGE 25 MG/5ML, 50 MG/5ML

GM

ephedrine sulfate injection solution 50 mg/ml

GM

ephedrine sulfate intravenous solution 50 mg/ml

GM

EPHEDRINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 25 MG/5ML

GM

EPINEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION 4-5 MG/250ML-%

GM

EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 8-0.9 MG/250ML-%

GM

epinephrine pf injection solution 1 mg/ml

GM

epinephrine solution prefilled syringe 1 mg/10ml injection 1 mg/10ml

GM

EPINEPHRINE SOLUTION PREFILLED SYRINGE 1 MG/10ML INJECTION 1 MG/10ML

GM

Drug NameDrug Tier

Notes

EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 2-5 MG/250ML-%

GM

EPINEPHRINE-NACL INTRAVENOUS SOLUTION 2-0.9 MG/250ML-%

GM

EPINEPHRINE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 MG/10ML-%

GM

eplerenone oral tablet 25 mg, 50 mg

1

EQUAPAX/ATORVASTATIN/COQ10 ORAL THERAPY PACK 20 & 100 MG

3

esmolol hcl intravenous solution 100 mg/10ml

GM

ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML

GM

esmolol hcl-sodium chloride intravenous solution 2000 mg/100ml, 2500 mg/250ml

GM

ethacrynate sodium intravenous solution reconstituted 50 mg

GM

ethacrynic acid oral tablet 25 mg

1

EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG

3Brand

penalty applies

Updated May 1, 2020


90

Drug NameDrug Tier

Notes

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

3Brand

penalty applies

ezetimibe oral tablet 10 mg

1

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

1

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

1

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg

1

fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 mg, 67 mg

1

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

1

fenofibric acid oral capsule delayed release 135 mg, 45 mg

1

fenofibric acid oral tablet 105 mg

1

FIBRICOR ORAL TABLET 105 MG, 35 MG

3

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

1

fluvastatin sodium er oral tablet extended release 24 hour 80 mg

1 PA

fluvastatin sodium oral capsule 20 mg, 40 mg

1

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg

1

Drug NameDrug Tier

Notes

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

1

FUROSEMIDE IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.9 MG/100ML-%

GM

furosemide injection solution 10 mg/ml

GM

furosemide oral solution 10 mg/ml, 8 mg/ml

1

furosemide oral tablet 20 mg, 40 mg, 80 mg

1

gemfibrozil oral tablet 600 mg

1

guanfacine hcl oral tablet 1 mg, 2 mg

1

hydralazine hcl injection solution 20 mg/ml

GM

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1

hydrochlorothiazide oral capsule 12.5 mg

1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

1

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

3Brand

penalty applies

ibutilide fumarate intravenous solution 1 mg/10ml

GM

indapamide oral tablet 1.25 mg, 2.5 mg

1

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

3Brand

penalty applies

Updated May 1, 2020


91

Drug NameDrug Tier

Notes

INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG

3

INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG

3

INSPRA ORAL TABLET 25 MG, 50 MG

3Brand

penalty applies

irbesartan oral tablet 150 mg, 300 mg, 75 mg

1

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

1

isoproterenol hcl injection solution 0.2 mg/ml

GM

ISORDIL TITRADOSE ORAL TABLET 40 MG

2Brand

penalty applies

ISORDIL TITRADOSE ORAL TABLET 5 MG

3Brand

penalty applies

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

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

1

isosorbide mononitrate oral tablet 10 mg, 20 mg

1

isoxsuprine hcl oral tablet 10 mg, 20 mg

1

isradipine oral capsule 2.5 mg, 5 mg

1

ISUPREL INJECTION SOLUTION 0.2 MG/ML

GM

Drug NameDrug Tier

Notes

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG

6 PA

LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 20 MG/4ML

GM

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg

1

labetalol hcl solution 5 mg/ml intravenous 5 mg/ml

GM

LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 MG/ML

GM

LANOXIN INJECTION SOLUTION 0.25 MG/ML

GM

LANOXIN ORAL TABLET 125 MCG, 250 MCG

2

LANOXIN ORAL TABLET 62.5 MCG

3

LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML

GM

LASIX ORAL TABLET 20 MG, 40 MG, 80 MG

3Brand

penalty applies

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 80 MG

3PA; Brand

penalty applies

LEVOPHED INTRAVENOUS SOLUTION 1 MG/ML

GM

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

3Brand

penalty applies

LIPOFEN ORAL CAPSULE 150 MG, 50 MG

3

Updated May 1, 2020


92

Drug NameDrug Tier

Notes

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

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

1

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG

3 PA

LOPID ORAL TABLET 600 MG

3Brand

penalty applies

LOPRESSOR HCT ORAL TABLET 50-25 MG

3Brand

penalty applies

LOPRESSOR ORAL TABLET 100 MG, 50 MG

3Brand

penalty applies

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

1

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

1

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

3Brand

penalty applies

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG

3Brand

penalty applies

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG

3Brand

penalty applies

lovastatin oral tablet 10 mg, 20 mg, 40 mg

1 PV*

LOVAZA ORAL CAPSULE 1 GM

3PA; Brand

penalty applies

mannitol intravenous solution 20 %, 25 %

GM

Drug NameDrug Tier

Notes

matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

MAXZIDE ORAL TABLET 75-50 MG

3Brand

penalty applies

MAXZIDE-25 ORAL TABLET 37.5-25 MG

3Brand

penalty applies

methyldopa oral tablet 250 mg, 500 mg

1

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg

1

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

1

metoprolol tartrate intravenous solution 5 mg/5ml

GM

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

1

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

1

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

1

MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG

3Brand

penalty applies

MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG

3Brand

penalty applies

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg

1

Updated May 1, 2020


93

Drug NameDrug Tier

Notes

milrinone lactate in dextrose intravenous solution 20-5 mg/100ml-%, 40-5 mg/200ml-%

GM

milrinone lactate intravenous solution 10 mg/10ml, 20 mg/20ml, 50 mg/50ml

GM

MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG

3Brand

penalty applies

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

1

minoxidil oral tablet 10 mg, 2.5 mg

1

moexipril hcl oral tablet 15 mg, 7.5 mg

1

MULTAQ ORAL TABLET 400 MG

2

nadolol oral tablet 20 mg, 40 mg, 80 mg

1

NEXTERONE INTRAVENOUS SOLUTION 150-4.21 MG/100ML-%, 360-4.14 MG/200ML-%

GM

niacin (antihyperlipidemic) oral tablet 500 mg

1

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

1

niacor oral tablet 500 mg 1

NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 500 MG, 750 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

nicardipine hcl intravenous solution 2.5 mg/ml

GM

nicardipine hcl oral capsule 20 mg, 30 mg

1

nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

1

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

1

nifedipine oral capsule 10 mg, 20 mg

1

nimodipine oral capsule 30 mg

1

NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 50-0.9 MG/100ML-%

GM

nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

1

NITRO-BID TRANSDERMAL OINTMENT 2 %

2

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

2Brand

penalty applies

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

2

nitroglycerin in d5w intravenous solution 100-5 mcg/ml-%, 200-5 mcg/ml-%, 400-5 mcg/ml-%

GM

Updated May 1, 2020


94

Drug NameDrug Tier

Notes

nitroglycerin intravenous solution 5 mg/ml

GM

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

1

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

1

nitroglycerin translingual solution 0.4 mg/spray

1

NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 MG/SPRAY

3Brand

penalty applies

NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 MCG/SPRAY

2

NITROPRESS INTRAVENOUS SOLUTION 25 MG/ML

GM

nitroprusside sodium intravenous solution 25 mg/ml

GM

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG

2Brand

penalty applies

nitro-time oral capsule extended release 2.5 mg, 6.5 mg, 9 mg

1

norepinephrine bitartrate intravenous solution 1 mg/ml

GM

NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 8-5 MG/500ML-%

GM

Drug NameDrug Tier

Notes

NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 16-0.9 MG/250ML-%

GM

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG

2

NORPACE ORAL CAPSULE 100 MG, 150 MG

3Brand

penalty applies

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

5 PA

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG

3Brand

penalty applies

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

3

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

1

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

1

olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

1

omega-3-acid ethyl esters oral capsule 1 gm

1 PA

OSMITROL INTRAVENOUS SOLUTION 10 %, 5 %

GM

osmitrol intravenous solution 15 %, 20 %

GM

PACERONE ORAL TABLET 100 MG, 400 MG

3Brand

penalty applies

Updated May 1, 2020


95

Drug NameDrug Tier

Notes

pacerone oral tablet 200 mg

1

pentoxifylline er oral tablet extended release 400 mg

1

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

1

phenoxybenzamine hcl oral capsule 10 mg


days)

phentolamine mesylate injection solution reconstituted 5 mg

GM

PHENYLEPHRINE HCL (PRESSORS) INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.5 MG/5ML, 1 MG/10ML

GM

phenylephrine hcl intravenous solution 10 mg/ml

GM

PHENYLEPHRINE HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4 MG/10ML, 0.8 MG/10ML, 1 MG/10ML

GM

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 10-0.9 MG/250ML-%, 20-0.9 MG/250ML-%, 40-0.9 MG/250ML-%, 50-0.9 MG/250ML-%, 80-0.9 MG/250ML-%

GM

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.5-0.9 MG/5ML-%

GM

pindolol oral tablet 10 mg, 5 mg

1

Drug NameDrug Tier

Notes

POLIDOCANOL INTRAVENOUS SOLUTION 5 %

GM

PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML, 75 MG/ML

5 PA

PRAVACHOL ORAL TABLET 20 MG, 40 MG

3Brand

penalty applies

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

1 PV*

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg

1

PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG

3

prevalite oral packet 4 gm

1

prevalite oral powder 4 gm/dose

1

PRINIVIL ORAL TABLET 10 MG, 20 MG

3Brand

penalty applies

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

GM

PROCARDIA ORAL CAPSULE 10 MG

3Brand

penalty applies

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

3Brand

penalty applies

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

1

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

1

Updated May 1, 2020


96

Drug NameDrug Tier

Notes

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

1

propranolol hcl intravenous solution 1 mg/ml

GM

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

1

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

1

propranolol-hctz oral tablet 40-25 mg, 80-25 mg

1

PROSTIN VR INJECTION SOLUTION 500 MCG/ML

GM

QBRELIS ORAL SOLUTION 1 MG/ML

3

QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE

3Brand

penalty applies

QUESTRAN ORAL PACKET 4 GM

3Brand

penalty applies

QUESTRAN ORAL POWDER 4 GM/DOSE

3Brand

penalty applies

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

1

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

1

quinidine gluconate er oral tablet extended release 324 mg

1

quinidine sulfate oral tablet 200 mg, 300 mg

1

Drug NameDrug Tier

Notes

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

1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG

3Brand

penalty applies

ranolazine er oral tablet extended release 12 hour 1000 mg, 500 mg

1

RECTIV RECTAL OINTMENT 0.4 %

3

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML

5 PA

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML

5 PA

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML

5 PA

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1

RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 MG, 325 MG, 425 MG

3Brand

penalty applies

simvastatin oral tablet 10 mg, 20 mg, 40 mg

1 PV*

simvastatin oral tablet 5 mg, 80 mg

1

SODIUM DIURIL INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

Updated May 1, 2020


97

Drug NameDrug Tier

Notes

SODIUM EDECRIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

GM

sodium tetradecyl sulfate intravenous solution 3 %

GM

sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg

1

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg

1

SOTALOL HCL INTRAVENOUS SOLUTION 150 MG/10ML

GM

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

1

SOTRADECOL INTRAVENOUS SOLUTION 1 %, 3 %

GM

SOTYLIZE ORAL SOLUTION 5 MG/ML

3

spironolactone oral tablet 100 mg, 25 mg, 50 mg

1

spironolactone-hctz oral tablet 25-25 mg

1

SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 34 MG, 8.5 MG

3Brand

penalty applies

TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2-240 MG, 4-240 MG

3Brand

penalty applies

taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1

TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG

2

Drug NameDrug Tier

Notes

TEKTURNA ORAL TABLET 150 MG, 300 MG

2Brand

penalty applies

telmisartan oral tablet 20 mg, 40 mg, 80 mg

1

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

1

telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

1

TENORETIC 100 ORAL TABLET 100-25 MG

3Brand

penalty applies

TENORETIC 50 ORAL TABLET 50-25 MG

3Brand

penalty applies

TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

3Brand

penalty applies

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

3Brand

penalty applies

timolol maleate oral tablet 10 mg, 20 mg, 5 mg

1

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

3Brand

penalty applies

Updated May 1, 2020


98

Drug NameDrug Tier

Notes

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

1

trandolapril oral tablet 1 mg, 2 mg, 4 mg

1

trandolapril-verapamil hcl er oral tablet extended release 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

1

triamterene oral capsule 100 mg, 50 mg

1

triamterene-hctz oral capsule 37.5-25 mg

1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg

1

TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG

3Brand

penalty applies

TRICOR ORAL TABLET 145 MG, 48 MG

3Brand

penalty applies

TRIGLIDE ORAL TABLET 160 MG

3

TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 MG, 45 MG

3Brand

penalty applies

TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80-5 MG

3Brand

penalty applies

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1

Drug NameDrug Tier

Notes

VARITHENA INTRAVENOUS FOAM 180 MG/18ML

GM

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM

3 PA

VASERETIC ORAL TABLET 10-25 MG

3Brand

penalty applies

VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

3Brand

penalty applies

VAZCULEP INTRAVENOUS SOLUTION 10 MG/ML

GM

VECAMYL ORAL TABLET 2.5 MG

3

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

1

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

1

verapamil hcl intravenous solution 2.5 mg/ml

GM

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg

1

VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG

3Brand

penalty applies

VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

3Brand

penalty applies

VYNDAMAX ORAL CAPSULE 61 MG

6 PA

VYNDAQEL ORAL CAPSULE 20 MG

6 PA

Updated May 1, 2020


99

Drug NameDrug Tier

Notes

VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG

3Brand

penalty applies

WELCHOL ORAL PACKET 3.75 GM

3Brand

penalty applies

WELCHOL ORAL TABLET 625 MG

3Brand

penalty applies

ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

3Brand

penalty applies

ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG

3Brand

penalty applies

ZETIA ORAL TABLET 10 MG

3Brand

penalty applies

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

3Brand

penalty applies

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

3Brand

penalty applies

ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG

3 PA

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG

3

Brand penalty


ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

3

Brand penalty


Drug NameDrug Tier

Notes

ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 25 MG, 30 MG

3

Brand penalty


amphetamine-dextroamphetamine er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

1QL (30 EA

per 30 days)

amphetamine-dextroamphetamine er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg

1QL (60 EA

per 30 days)

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

1QL (90 EA

per 30 days)

APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

3

atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg

1QL (60 EA

per 30 days)

atomoxetine hcl oral capsule 100 mg, 40 mg, 60 mg, 80 mg

1QL (30 EA

per 30 days)

clonidine hcl er oral tablet extended release 12 hour 0.1 mg

1

CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 54 MG

3

Brand penalty


Updated May 1, 2020


100

Drug NameDrug Tier

Notes

CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG

3

Brand penalty


DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR

3QL (30 EA

per 30 days)

DESOXYN ORAL TABLET 5 MG

3Brand

penalty applies

DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

3

Brand penalty


dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

1QL (30 EA

per 30 days)

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg

1QL (90 EA

per 30 days)

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

1QL (150

EA per 30 days)

dextroamphetamine sulfate oral solution 5 mg/5ml

1

dextroamphetamine sulfate oral tablet 10 mg, 5 mg

1QL (180

EA per 30 days)

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 2.5 MG/ML

3

PA; AL (Min 6

Years and Max 12 Years)

Drug NameDrug Tier

Notes

FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG

3

Brand penalty


FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG

3

Brand penalty


guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg

1

INTUNIV ORAL TABLET EXTENDED RELEASE 24 HOUR 1 MG, 2 MG, 3 MG, 4 MG

3Brand

penalty applies

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 MG

3Brand

penalty applies

metadate er oral tablet extended release 20 mg

1QL (90 EA

per 30 days)

methamphetamine hcl oral tablet 5 mg

1

METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML

3

Brand penalty


methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

1QL (30 EA

per 30 days)

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

1QL (30 EA

per 30 days)

Updated May 1, 2020


101

Drug NameDrug Tier

Notes

methylphenidate hcl er oral tablet extended release 10 mg

1

methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg

1QL (30 EA

per 30 days)


1QL (90 EA

per 30 days)

methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg

1


1QL (60 EA

per 30 days)


1QL (1 EA per 1 day)

methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml

1QL (900

ML per 30 days)

methylphenidate hcl oral tablet 10 mg

1QL (180

EA per 30 days)


1


1QL (90 EA

per 30 days)

methylphenidate hcl oral tablet chewable 10 mg

1

methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg

1QL (90 EA

per 30 days)

PROCENTRA ORAL SOLUTION 5 MG/5ML

3Brand

penalty applies

Drug NameDrug Tier

Notes

QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG

3

PA; AL (Min 6


QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 25 MG/5ML

3

PA; QL (180 ML per 30 days)

relexxii oral tablet extended release 72 mg


RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG

3

Brand penalty


RITALIN ORAL TABLET 10 MG

3

Brand penalty



3Brand

penalty applies


3

Brand penalty


STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG

3

Brand penalty


STRATTERA ORAL CAPSULE 100 MG, 40 MG, 60 MG, 80 MG

3

Brand penalty


VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

3QL (30 EA

per 30 days)

Updated May 1, 2020


102

Drug NameDrug Tier

Notes

VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

3

PA; QL (30 EA per 30 days); AL

(Min 6 Years and

Max 12 Years)

ZENZEDI ORAL TABLET 10 MG, 5 MG

3

Brand penalty

applies; QL (2 EA per 1

day)

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

3QL (60 EA

per 30 days)

Central Nervous System Agents - Drugs for Multiple Sclerosis

AUBAGIO ORAL TABLET 14 MG, 7 MG

4

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML

4

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

4

AVONEX VIAL INTRAMUSCULAR KIT INTRAMUSCULAR KIT 30 MCG

4

BETASERON SUBCUTANEOUS KIT 0.3 MG

4

dalfampridine er oral tablet extended release 12 hour 10 mg

6 PA

EXTAVIA SUBCUTANEOUS KIT 0.3 MG

4

GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG

5

Drug NameDrug Tier

Notes

glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

4

glatopa subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

4

LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2ML

5PA;

Specialty Medical

MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK 10 MG

6 PA


6 PA


6 PA


6 PA


6 PA


6 PA


6 PA

MAYZENT ORAL TABLET 0.25 MG, 2 MG

5

MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 0.25 MG

5

OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML

5PA;

Specialty Medical

Updated May 1, 2020


103

Drug NameDrug Tier

Notes

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML

4

PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 125 MCG/0.5ML

4

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML

4

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG

4

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML

4

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG

4

TECFIDERA ORAL 120 & 240 MG

4

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG

4

TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML

5PA;

Specialty Medical

Drug NameDrug Tier

Notes

VUMERITY (STARTER) ORAL CAPSULE DELAYED RELEASE 231 MG

6 PA

VUMERITY ORAL CAPSULE DELAYED RELEASE 231 MG

6 PA

Central Nervous System Agents - Miscellaneous

ANECTINE INJECTION SOLUTION 20 MG/ML

GM

atracurium besylate intravenous solution 100 mg/10ml, 50 mg/5ml

GM

AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG

6 PA

CAFCIT INTRAVENOUS SOLUTION 60 MG/3ML

GM

caffeine citrate intravenous solution 60 mg/3ml

GM

caffeine citrate oral solution 20 mg/ml, 60 mg/3ml

1

cisatracurium besylate (pf) intravenous solution 10 mg/5ml, 200 mg/20ml

GM

cisatracurium besylate intravenous solution 20 mg/10ml

GM

DOPRAM INTRAVENOUS SOLUTION 20 MG/ML

GM

GRALISE ORAL TABLET 300 MG, 600 MG

3 ST

GRALISE STARTER ORAL 300 & 600 MG

3 ST

Updated May 1, 2020


104

Drug NameDrug Tier

Notes

HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG

3 ST

INGREZZA ORAL CAPSULE 40 MG, 80 MG

5 PA

INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 MG

5 PA

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 165 MG, 330 MG, 82.5 MG

3

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

3

LYRICA ORAL SOLUTION 20 MG/ML

3

NIMBEX INTRAVENOUS SOLUTION 10 MG/5ML, 20 MG/10ML, 200 MG/20ML

GM

ONPATTRO INTRAVENOUS SOLUTION 10 MG/5ML

6PA;

Specialty Medical

pancuronium bromide intravenous solution 1 mg/ml

GM

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

1

pregabalin oral solution 20 mg/ml

1

QUELICIN INJECTION SOLUTION 20 MG/ML

GM

RADICAVA INTRAVENOUS SOLUTION 30 MG/100ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

RILUTEK ORAL TABLET 50 MG

5

riluzole oral tablet 50 mg 5

rocuronium bromide intravenous solution 100 mg/10ml, 50 mg/5ml

GM

ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MG/10ML, 75 MG/7.5ML

GM

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

3 PA

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

3 PA

succinylcholine chloride injection solution 20 mg/ml

GM

SUCCINYLCHOLINE CHLORIDE INJECTION SOLUTION PREFILLED SYRINGE 100 MG/5ML, 140 MG/7ML, 200 MG/10ML

GM

TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 284 MG/1.5ML

6 PA

tetrabenazine oral tablet 12.5 mg, 25 mg

4 PA

TIGLUTIK ORAL SUSPENSION 50 MG/10ML

5

vecuronium bromide intravenous solution reconstituted 10 mg, 20 mg

GM

Updated May 1, 2020


105

Drug NameDrug Tier

Notes

XENAZINE ORAL TABLET 12.5 MG, 25 MG

6 PA

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

ARESTIN DENTAL 1 MG GM

BOCASAL MOUTH/THROAT PACKET

3

cavarest dental gel 1.1 % 1

cevimeline hcl oral capsule 30 mg

1

chlorhexidine gluconate mouth/throat solution 0.12 %

1

clinpro 5000 dental paste 1.1 %

1

DEBACTEROL MOUTH/THROAT SOLUTION 30-50 %

3

denta 5000 plus dental cream 1.1 %

1

dentagel dental gel 1.1 % 1

easygel dental gel 0.4 % 1

EVOXAC ORAL CAPSULE 30 MG

3Brand

penalty applies

FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION

3

fluoridex daily renewal mouth/throat concentrate 0.63 %

1

fluoridex dental paste 1.1 %

1

fluoridex enhanced whitening dental paste 1.1 %

1

fluoridex sensitivity relief dental paste 1.1-5 %

1

Drug NameDrug Tier

Notes

KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG

5PA;

Specialty Medical

lidocaine viscous hcl mouth/throat solution 2 %

1

MI PASTE DENTAL PASTE

3

MI PASTE PLUS DENTAL PASTE

3

MUCOSITISRX MOUTH/THROAT PACKET

3

NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML

3

NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION RECONSTITUTED 0.05 %

3

NAFRINSE WEEKLY MOUTH/THROAT SOLUTION RECONSTITUTED 0.2 %

3

neutral sodium fluoride mouth/throat solution 0.2 %

1

NEUTRASAL MOUTH/THROAT PACKET

3

NUMOISYN MOUTH/THROAT LOZENGE

3

oralone mouth/throat paste 0.1 %

1

paroex mouth/throat solution 0.12 %

1

Updated May 1, 2020


106

Drug NameDrug Tier

Notes

PERIDEX MOUTH/THROAT SOLUTION 0.12 %

3Brand

penalty applies

periogard mouth/throat solution 0.12 %

1

pilocarpine hcl oral tablet 5 mg, 7.5 mg

1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 %

3

PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 %

3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 %

3

PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE 1.1 %

3

PREVIDENT 5000 PLUS DENTAL CREAM 1.1 %

3

PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 %

3

PREVIDENT DENTAL GEL 1.1 %

3

prevident mouth/throat solution 0.2 %

1

REMESENSE DENTAL 3 %

3

SALAGEN ORAL TABLET 5 MG, 7.5 MG

3Brand

penalty applies

SALIVAMAX MOUTH/THROAT PACKET

3

sf 5000 plus dental cream 1.1 %

1

sf dental gel 1.1 % 1

sodium fluoride 5000 plus dental cream 1.1 %

1

Drug NameDrug Tier

Notes

sodium fluoride 5000 ppm dental cream 1.1 %

1

sodium fluoride dental cream 1.1 %

1

sodium fluoride dental gel 1.1 %

1

TOPEX TOPICAL ANESTHETIC MOUTH/THROAT AEROSOL 20 %

3

triamcinolone acetonide mouth/throat paste 0.1 %

1

XEROSTOMIA RELIEF SPRAY MOUTH/THROAT SOLUTION

3

Dermatological Agents - Drugs for Skin Conditions

ABSORICA LD ORAL CAPSULE 16 MG, 24 MG, 32 MG, 8 MG

3 PA

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG

3 PA

acitretin oral capsule 10 mg, 17.5 mg, 25 mg

1

ACZONE EXTERNAL GEL 5 %

3Brand

penalty applies

adapalene external cream 0.1 %

1

adapalene external gel 0.1 %, 0.3 %

1

ALA SCALP EXTERNAL LOTION 2 %

3

ala-cort external cream 1 %, 2.5 %

1

alclometasone dipropionate external cream 0.05 %

1

Updated May 1, 2020


107

Drug NameDrug Tier

Notes

alclometasone dipropionate external ointment 0.05 %

1

ALCOHOL PREP PADS EXTERNAL 70 %

3

amcinonide external cream 0.1 %

1

amcinonide external lotion 0.1 %

1

amcinonide external ointment 0.1 %

1

ammonium lactate external cream 12 %

1

ammonium lactate external lotion 12 %

1

amnesteem oral capsule 10 mg, 20 mg, 40 mg


ANACAINE EXTERNAL OINTMENT 10 %

3

APEXICON E EXTERNAL CREAM 0.05 %

3

AQUACEL AG BURN EXTERNAL PAD 4"X5"

3

arzol silver nit applicators external 75-25 %

1

ATRAPRO DERMAL SPRAY EXTERNAL LIQUID

3

avar cleanser external emulsion 10-5 %

1

AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 %

3

AVAR-E GREEN EXTERNAL CREAM 10-5 %

3

avita external cream 0.025 %

1

avita external gel 0.025 %

1

Drug NameDrug Tier

Notes

azelaic acid external gel 15 %

1 PA

AZELEX EXTERNAL CREAM 20 %

3 PA

balsam peru-castor oil external ointment

1

BENSAL HP EXTERNAL OINTMENT 3-6 %

3

benzoin compound external tincture

1

benzoin external tincture 1

beser external lotion 0.05 %

1

betamethasone dipropionate aug external cream 0.05 %

1

betamethasone dipropionate aug external gel 0.05 %

1

betamethasone dipropionate aug external lotion 0.05 %

1

betamethasone dipropionate aug external ointment 0.05 %

1

betamethasone dipropionate external cream 0.05 %

1

betamethasone dipropionate external lotion 0.05 %

1

betamethasone dipropionate external ointment 0.05 %

1

betamethasone valerate external cream 0.1 %

1

betamethasone valerate external lotion 0.1 %

1

betamethasone valerate external ointment 0.1 %

1

bp 10-1 external emulsion 10-1 %

1

Updated May 1, 2020


108

Drug NameDrug Tier

Notes

BP CLEANSING WASH EXTERNAL EMULSION 10-4 %

3 PA

BPCO EXTERNAL OINTMENT

3

calcipotriene external cream 0.005 %

1

calcipotriene external ointment 0.005 %

1

calcipotriene external solution 0.005 %

1

calcipotriene-betameth diprop external ointment 0.005-0.064 %

1 ST

CALCITRENE EXTERNAL OINTMENT 0.005 %

3Brand

penalty applies

calcitriol external ointment 3 mcg/gm

1 ST

CAPEX EXTERNAL SHAMPOO 0.01 %

3

cem-urea external solution 45 %

1

cerovel external lotion 40 %

1

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg


clindacin etz external swab 1 %

1

clindacin-p external swab 1 %

1

clindamycin phosphate external foam 1 %

1

clindamycin phosphate external gel 1 %

1

clindamycin phosphate external lotion 1 %

1

clindamycin phosphate external solution 1 %

1

Drug NameDrug Tier

Notes

clindamycin phosphate external swab 1 %

1

clobetasol prop emollient base external cream 0.05 %

1

clobetasol propionate e external cream 0.05 %

1

clobetasol propionate emulsion external foam 0.05 %

1

clobetasol propionate external cream 0.05 %

1

clobetasol propionate external foam 0.05 %

1

clobetasol propionate external gel 0.05 %

1

clobetasol propionate external lotion 0.05 %

1

clobetasol propionate external ointment 0.05 %

1

clobetasol propionate external shampoo 0.05 %

1

clobetasol propionate external solution 0.05 %

1

CLOBEX EXTERNAL LOTION 0.05 %

3Brand

penalty applies

CLOBEX EXTERNAL SHAMPOO 0.05 %

3Brand

penalty applies

clocortolone pivalate external cream 0.1 %

1

clodan external shampoo 0.05 %

1

CLODERM EXTERNAL CREAM 0.1 %

3Brand

penalty applies

coal tar external solution 20 %

1

CONDYLOX EXTERNAL GEL 0.5 %

2

Updated May 1, 2020


109

Drug NameDrug Tier

Notes

CORDRAN EXTERNAL CREAM 0.025 %

3

CORDRAN EXTERNAL CREAM 0.05 %

3Brand

penalty applies

CORDRAN EXTERNAL LOTION 0.05 %

3Brand

penalty applies

CORDRAN EXTERNAL OINTMENT 0.05 %

3Brand

penalty applies

CORDRAN EXTERNAL TAPE 4 MCG/SQCM

3

CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML

3

CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5

3

CORTISPORIN EXTERNAL OINTMENT 1 %

3

CUTIVATE EXTERNAL LOTION 0.05 %

3Brand

penalty applies

dapsone external gel 5 % 1

DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 %

3Brand

penalty applies

DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 %

3Brand

penalty applies

DERMULCERA EXTERNAL OINTMENT

3

DESONATE EXTERNAL GEL 0.05 %

3

desonide external cream 0.05 %

1

desonide external lotion 0.05 %

1

desonide external ointment 0.05 %

1

Drug NameDrug Tier

Notes

DESOWEN EXTERNAL CREAM 0.05 %

3Brand

penalty applies

desoximetasone external cream 0.05 %, 0.25 %

1

desoximetasone external gel 0.05 %

1

desoximetasone external liquid 0.25 %

1

desoximetasone external ointment 0.05 %, 0.25 %

1

diclofenac sodium transdermal gel 3 %

1

diflorasone diacetate external cream 0.05 %

1

diflorasone diacetate external ointment 0.05 %

1

DIPROLENE AF EXTERNAL CREAM 0.05 %

3Brand

penalty applies

DIPROLENE EXTERNAL OINTMENT 0.05 %

3Brand

penalty applies

doxepin hcl external cream 5 %

1

DRITHO-CREME HP EXTERNAL CREAM 1 %

2

DRYSOL EXTERNAL SOLUTION 20 %

2

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML, 300 MG/2ML

5 PA

ELIDEL EXTERNAL CREAM 1 %

3Brand

penalty applies

EPIFOAM EXTERNAL FOAM 1-1 %

3

ery external pad 2 % 1

Updated May 1, 2020


110

Drug NameDrug Tier

Notes

erythromycin external gel 2 %

1

erythromycin external solution 2 %

1

EUCRISA EXTERNAL OINTMENT 2 %

3 PA

FINACEA EXTERNAL FOAM 15 %

3 PA

FINACEA EXTERNAL GEL 15 %

3PA; Brand

penalty applies

fluocinolone acetonide body external oil 0.01 %

1

fluocinolone acetonide external cream 0.01 %, 0.025 %

1

fluocinolone acetonide external ointment 0.025 %

1

fluocinolone acetonide external solution 0.01 %

1

fluocinolone acetonide scalp external oil 0.01 %

1

fluocinonide emulsified base external cream 0.05 %

1

fluocinonide external cream 0.05 %

1

fluocinonide external gel 0.05 %

1

fluocinonide external ointment 0.05 %

1

fluocinonide external solution 0.05 %

1

fluorouracil external cream 5 %

1

fluorouracil external solution 2 %, 5 %

1

flurandrenolide external cream 0.05 %

1

Drug NameDrug Tier

Notes

flurandrenolide external lotion 0.05 %

1

flurandrenolide external ointment 0.05 %

1

fluticasone propionate external cream 0.05 %

1

fluticasone propionate external lotion 0.05 %

1

fluticasone propionate external ointment 0.005 %

1

glycolic acid solution 70 %

1

GORDOFILM EXTERNAL SOLUTION 16.7-16.7 %

3

grafco silver nit applicator external 75-25 %

1

halcinonide external cream 0.1 %

1

halobetasol propionate external cream 0.05 %

1

halobetasol propionate external ointment 0.05 %

1

HALOG EXTERNAL CREAM 0.1 %

3Brand

penalty applies

HALOG EXTERNAL OINTMENT 0.1 %

3

hydrocortisone ace-pramoxine external cream 2.5-1 %

1

hydrocortisone butyr lipo base external cream 0.1 %

1

hydrocortisone butyrate external cream 0.1 %

1

hydrocortisone butyrate external lotion 0.1 %

1

hydrocortisone butyrate external ointment 0.1 %

1

Updated May 1, 2020


111

Drug NameDrug Tier

Notes

hydrocortisone butyrate external solution 0.1 %

1

hydrocortisone external cream 1 %, 2.5 %

1

hydrocortisone external lotion 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

hydrocortisone valerate external cream 0.2 %

1

hydrocortisone valerate external ointment 0.2 %

1

imiquimod external cream 5 %

1

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg


ivermectin external cream 1 %

1 PA

KENALOG EXTERNAL AEROSOL SOLUTION 0.147 MG/GM

3Brand

penalty applies

KERALYT EXTERNAL GEL 6 %

3

KERALYT SCALP EXTERNAL KIT 6 %

3

KERAMATRIX REPLICINE 5CMX5CM EXTERNAL SHEET

3

lactic acid e external cream 10-3500 %-unt/30gm

1

lactic acid external lotion 10 %

1

LATRIX XM EXTERNAL EMULSION 45 %

3

LEVULAN KERASTICK EXTERNAL SOLUTION RECONSTITUTED 20 %

GM

LOCOID EXTERNAL CREAM 0.1 %

3Brand

penalty applies

Drug NameDrug Tier

Notes

LOCOID EXTERNAL LOTION 0.1 %

3Brand

penalty applies

LOCOID EXTERNAL SOLUTION 0.1 %

3Brand

penalty applies

LOCOID LIPOCREAM EXTERNAL CREAM 0.1 %

3Brand

penalty applies

LOYON EXTERNAL SOLUTION

3

methoxsalen rapid oral capsule 10 mg

1

methyl salicylate external liquid

1

metronidazole external cream 0.75 %

1

metronidazole external gel 0.75 %, 1 %

1

metronidazole external lotion 0.75 %

1

MICROCYN EXTERNAL LIQUID 0.023 %

3

MIRVASO EXTERNAL GEL 0.33 %

3 PA

mometasone furoate external cream 0.1 %

1

mometasone furoate external ointment 0.1 %

1

mometasone furoate external solution 0.1 %

1

myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg


NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 %

3

nolix external cream 0.05 %

1

nolix external lotion 0.05 %

1

Updated May 1, 2020


112

Drug NameDrug Tier

Notes

NUCORT EXTERNAL LOTION 2 %

3

NUVAIL EXTERNAL SOLUTION

3

OLUX EXTERNAL FOAM 0.05 %

3Brand

penalty applies

OLUX-E EXTERNAL FOAM 0.05 %

3Brand

penalty applies

OVACE PLUS EXTERNAL CREAM 10 %

3

OVACE PLUS EXTERNAL SHAMPOO 10 %

3

OVACE PLUS WASH EXTERNAL LIQUID 10 %

3

OVACE WASH EXTERNAL LIQUID 10 %

3

OXSORALEN ULTRA ORAL CAPSULE 10 MG

2Brand

penalty applies

PANDEL EXTERNAL CREAM 0.1 %

3

PICATO EXTERNAL GEL 0.015 %, 0.05 %

3 PA

pimecrolimus external cream 1 %

1

podocon external solution 25 %

1

podofilox external solution 0.5 %

1

PRAMOSONE EXTERNAL CREAM 1-1 %, 1-2.5 %

3

PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 %

2

Drug NameDrug Tier

Notes

PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 %

2

pramox external gel 1 % 1

PRE & POST SX POUCH EXTERNAL THERAPY PACK 4 & 2 & 5 %

3

prednicarbate external cream 0.1 %

1

prednicarbate external ointment 0.1 %

1

PRUDOXIN EXTERNAL CREAM 5 %

3Brand

penalty applies

PSORCON EXTERNAL CREAM 0.05 %

3

PURAPLY EXTERNAL SHEET 6X9CM

GM

PYROGALLIC ACID EXTERNAL OINTMENT 25-2 %

3

QBREXZA EXTERNAL PAD 2.4 %

3 PA

QUTENZA (2 PATCH) EXTERNAL KIT 8 %

5Specialty Medical

QUTENZA EXTERNAL KIT 8 %

5Specialty Medical

REGRANEX EXTERNAL GEL 0.01 %

3 PA

RESORCINOL-SULFUR EXTERNAL LOTION 2-5 %

3

RETIN-A EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 %

3Brand

penalty applies

RETIN-A EXTERNAL GEL 0.01 %, 0.025 %

3Brand

penalty applies

RETIN-A MICRO EXTERNAL GEL 0.1 %

3Brand

penalty applies

Updated May 1, 2020


113

Drug NameDrug Tier

Notes

RETIN-A MICRO PUMP EXTERNAL GEL 0.1 %

3Brand

penalty applies

RHOFADE EXTERNAL CREAM 1 %

3 PA

rosadan external cream 0.75 %

1

rosadan external gel 0.75 %

1

SALEX EXTERNAL KIT 6 % (CREAM), 6 % (LOTION)

3

SALEX EXTERNAL SHAMPOO 6 %

3

salicylic acid external cream 6 %

1

salicylic acid external foam 6 %

1

salicylic acid external gel 6 %

1

salicylic acid external liquid 27.5 %

1

salicylic acid external lotion 6 %

1

salicylic acid external shampoo 6 %

1

salicylic acid external solution 26 %

1

salicylic acid wart remover external liquid 27.5 %

1

salicylic acid-cleanser external kit 6 % (cream), 6 % (lotion)

1

salimez external cream 6 %

1

SALIMEZ FORTE EXTERNAL CREAM 10 %

3

SALVAX DUO PLUS EXTERNAL KIT 6 & 35 %

3

Drug NameDrug Tier

Notes

SALVAX EXTERNAL FOAM 6 %

3

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

3

SCALACORT DK EXTERNAL KIT 2 & 2-2 %

3

SCENESSE SUBCUTANEOUS IMPLANT 16 MG

6PA;

Specialty Medical

selenium sulfide external lotion 2.5 %

1

selenium sulfide external shampoo 2.25 %, 2.3 %

1

SELRX EXTERNAL SHAMPOO 2.3 %

3

sodium sulfacetamide external shampoo 10 %

1

sodium sulfacetamide wash liquid 10 % external 10 %

1

SODIUM SULFACETAMIDE WASH LIQUID 10 % EXTERNAL 10 %

3

SOOLANTRA EXTERNAL CREAM 1 %

3PA; Brand

penalty applies

SORIATANE ORAL CAPSULE 10 MG, 25 MG

2Brand

penalty applies

sss 10-5 external cream 10-5 %

1

sulfacetamide sodium (acne) external lotion 10 %

1

sulfacetamide sodium external liquid 10 %

1

sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %

1

Updated May 1, 2020


114

Drug NameDrug Tier

Notes

sulfacetamide sodium-sulfur external emulsion 10-5 %

1

sulfacetamide sodium-sulfur external lotion 10-5 %, 9.8-4.8 %

1

sulfacetamide sodium-sulfur external pad 10-4 %

1

sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 %

1

sulfacetamide-sulfur in urea external emulsion 10-5 %

1

sulfacleanse 8/4 external suspension 8-4 %

1

sulfamez wash external emulsion 10-1 %

1

SYNALAR EXTERNAL CREAM 0.025 %

3Brand

penalty applies

SYNALAR EXTERNAL OINTMENT 0.025 %

3Brand

penalty applies

SYNALAR EXTERNAL SOLUTION 0.01 %

3Brand

penalty applies

tacrolimus external ointment 0.03 %, 0.1 %

1

tazarotene external cream 0.1 %

1 PA

TAZORAC EXTERNAL CREAM 0.05 %

3 PA

TAZORAC EXTERNAL CREAM 0.1 %

3PA; Brand

penalty applies

TAZORAC EXTERNAL GEL 0.05 %, 0.1 %

3 PA

Drug NameDrug Tier

Notes

TEMOVATE EXTERNAL CREAM 0.05 %

3Brand

penalty applies

TEMOVATE EXTERNAL OINTMENT 0.05 %

3Brand

penalty applies

TEXACORT EXTERNAL SOLUTION 2.5 %

3

THERAHONEY EXTERNAL SHEET

3

TOPICORT EXTERNAL CREAM 0.05 %, 0.25 %

3Brand

penalty applies

TOPICORT EXTERNAL GEL 0.05 %

3Brand

penalty applies

TOPICORT EXTERNAL OINTMENT 0.05 %, 0.25 %

2Brand

penalty applies

TOPICORT SPRAY EXTERNAL LIQUID 0.25 %

3Brand

penalty applies

tovet external foam 0.05 %

1

tretinoin external cream 0.025 %, 0.05 %, 0.1 %

1

tretinoin external gel 0.01 %, 0.025 %

1

tretinoin microsphere external gel 0.04 %, 0.1 %

1

tretinoin microsphere pump external gel 0.04 %, 0.1 %

1

triamcinolone acetonide external aerosol solution 0.147 mg/gm

1

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

1

Updated May 1, 2020


115

Drug NameDrug Tier

Notes

triamcinolone acetonide external lotion 0.025 %, 0.1 %

1

triamcinolone acetonide external ointment 0.025 %, 0.05 %, 0.1 %, 0.5 %

1

trianex external ointment 0.05 %

1

TRI-CHLOR EXTERNAL LIQUID 80 %

3

triderm external cream 0.1 %, 0.5 %

1

TRIDESILON EXTERNAL CREAM 0.05 %

3Brand

penalty applies

turpentine external spirit 1

urea external cream 39 %, 40 %, 41 %, 45 %

1

urea external lotion 40 % 1

urea external suspension 40 %

1

urea hydrating external foam 35 %

1

urea nail external gel 45 %

1

urea-c40 external lotion 40 %

1

uredeb external cream 39 %

1

uremez-40 external cream 40 %

1

VECTICAL EXTERNAL OINTMENT 3 MCG/GM

3ST; Brand

penalty applies

VENELEX EXTERNAL OINTMENT

3

VERDESO EXTERNAL FOAM 0.05 %

3

VEREGEN EXTERNAL OINTMENT 15 %

3

Drug NameDrug Tier

Notes

VIRASAL EXTERNAL LIQUID 27.5 %

3

XERAC AC EXTERNAL SOLUTION 6.25 %

3

XEROFORM OIL EMULSION 2"X2" EXTERNAL PAD

3

XEROFORM OIL EMULSION GAUZE EXTERNAL PAD

3

XEROFORM OIL EMULSION STRIP EXTERNAL

3

XEROFORM OIL ROLL 4"X9' EXTERNAL 3 %

3

XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL

3

XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL

3

XEROFORM PETROLAT PATCH 2"X2" EXTERNAL PAD

3

XEROFORM PETROLAT PATCH 4"X4" EXTERNAL PAD

3

XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL

3

xurea external cream 39 %

1

zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg


ZITHRANOL EXTERNAL SHAMPOO 1 %

3

ZONALON EXTERNAL CREAM 5 %

3Brand

penalty applies

Updated May 1, 2020


116

Drug NameDrug Tier

Notes

Diabetes - Antidiabetic Agents

acarbose oral tablet 100 mg, 25 mg, 50 mg

1

ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG

3Brand

penalty applies

ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG

3Brand

penalty applies

ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT 10 & 20 MCG/0.2ML

3 PA

ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 MCG/0.2ML

3 PA

ALOGLIPTIN BENZOATE ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


days)

ALOGLIPTIN-METFORMIN HCL ORAL TABLET 12.5-1000 MG, 12.5-500 MG


days)

ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


days)

AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG

3Brand

penalty applies

AVANDIA ORAL TABLET 2 MG, 4 MG

3 ST

BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML

2PA; QL


Drug NameDrug Tier

Notes

BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG


days)

BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG


days)

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML

2PA; QL


BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML

2PA; QL


CYCLOSET ORAL TABLET 0.8 MG

3

DUETACT ORAL TABLET 30-2 MG, 30-4 MG

2Brand

penalty applies

FARXIGA ORAL TABLET 10 MG, 5 MG


days)

glimepiride oral tablet 1 mg, 2 mg, 4 mg

1

glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

1

glipizide oral tablet 10 mg, 5 mg

1

glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

1

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

1

GLUCOTROL ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

Updated May 1, 2020


117

Drug NameDrug Tier

Notes

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 2.5 MG, 5 MG

3Brand

penalty applies

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg

1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

1

GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG

3Brand

penalty applies

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG


days)

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


days)

INVOKANA ORAL TABLET 100 MG, 300 MG


days)

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG


days)

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-500 MG


days)

Drug NameDrug Tier

Notes

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50-1000 MG


days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


days)

JARDIANCE ORAL TABLET 10 MG, 25 MG


days)

JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG


days)

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG


days)

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG


days)

KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG


days)

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG


days)

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG, 5-500 MG


days)

metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

1

METFORMIN HCL ORAL SOLUTION 500 MG/5ML

3

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

1

miglitol oral tablet 100 mg, 25 mg, 50 mg

1

Updated May 1, 2020


118

Drug NameDrug Tier

Notes

nateglinide oral tablet 120 mg, 60 mg

1

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG


days)

ONGLYZA ORAL TABLET 2.5 MG, 5 MG


days)

OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


days)

OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

2PA; QL


OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML


days)

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg

1

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

1

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

1

PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG

3Brand

penalty applies

QTERN ORAL TABLET 10-5 MG


days)

QTERN ORAL TABLET 5-5 MG

3PA; QL (1 EA per 1

day)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg

1

RIOMET ORAL SOLUTION 500 MG/5ML

3

Drug NameDrug Tier

Notes

SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5-1000 MG, 7.5-500 MG


days)

SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/ML


days)

STARLIX ORAL TABLET 120 MG, 60 MG

3Brand

penalty applies

STEGLATRO ORAL TABLET 15 MG, 5 MG


days)

STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG


days)

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML

3 ST

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML

3 ST

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG


days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG


days)

tolbutamide oral tablet 500 mg

1

TRADJENTA ORAL TABLET 5 MG


days)

Updated May 1, 2020


119

Drug NameDrug Tier

Notes

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML


days)

VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 18 MG/3ML


days)

VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 18 MG/3ML


days)

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-500 MG


days)

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG

3 PA

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG


days)

XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML


days)

Diabetes - Glucose Monitoring

FREESTYLE INSULINX TEST IN VITRO STRIP

2QL (150

EA per 30 days)

FREESTYLE LITE TEST IN VITRO STRIP

2QL (150

EA per 30 days)

Drug NameDrug Tier

Notes

FREESTYLE PRECISION NEO TEST IN VITRO STRIP

2QL (150

EA per 30 days)

FREESTYLE TEST IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION PCX PLUS TEST IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION QID TEST IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION SOF-TACT TEST IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP

2QL (150

EA per 30 days)

PRECISION XTRA KETONE IN VITRO STRIP

2

Diabetes - Glycemic Agents

BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE

3

BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE

3

diazoxide oral suspension 50 mg/ml

1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG

2

GLUCAGON EMERGENCY KIT INJECTION KIT 1 MG

2

GLUCAGON EMERGENCY KIT INJECTION SOLUTION RECONSTITUTED 1 MG/ML

GM

Updated May 1, 2020


120

Drug NameDrug Tier

Notes

GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML

3

PROGLYCEM ORAL SUSPENSION 50 MG/ML

3

Diabetes - Insulins

ABOUTTIME PEN NEEDLE 30G X 8 MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM

2

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3ST; QL (60 ML per 30

days)

ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT

3QL (60 EA

per 30 days)

AFREZZA INHALATION POWDER 4 UNIT

3QL (180

EA per 30 days)

AFREZZA INHALATION POWDER 90 X 8 UNIT & 90X12 UNIT

3

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)

APIDRA VIAL INJECTION SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3QL (60 ML

per 30 days)

Drug NameDrug Tier

Notes

BD AUTOSHIELD DUO PEN NEEDLES 30G X 5 MM

2

BD ULTRA-FINE INSULIN SYRINGES 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML, 31G X 6MM 0.5 ML

2

BD ULTRA-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

2

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


days)

FIASP PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML


days)

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

2QL (60 ML

per 30 days)

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML

2QL (60 ML

per 30 days)

Updated May 1, 2020


121

Drug NameDrug Tier

Notes

HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML

2QL (60 ML

per 30 days)

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

2QL (60 ML

per 30 days)

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

2QL (60 ML

per 30 days)

HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 UNIT/ML

2QL (60 ML

per 30 days)

Drug NameDrug Tier

Notes

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN R U-500 VIAL (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML

2QL (60 ML

per 30 days)

HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML

2QL (60 ML

per 30 days)

INSULIN ASP PROT & ASP FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

INSULIN ASPART FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


days)

INSULIN ASPART PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML


days)

INSULIN ASPART PROT & ASPART SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

Updated May 1, 2020


122

Drug NameDrug Tier

Notes

INSULIN PEN NEEDLES 29G X 12.7MM , 29G X 12MM , 29G X 5MM , 29G X 8MM , 30G X 5 MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM

2

INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G 0.3 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

2

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

2QL (60 ML

per 30 days)

LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML

2QL (60 ML

per 30 days)

LEVEMIR U-100 FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

2QL (60 ML

per 30 days)

LEVEMIR U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML

2QL (60 ML

per 30 days)

MAXICOMFORT SYR 27G X 1/2" 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML

2

Drug NameDrug Tier

Notes

MICRODOT PEN NEEDLE 31G X 6 MM , 33G X 4 MM

2

MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 UT/100ML-%

GM

NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8 MM

2

NOVOFINE PEN NEEDLE 32G X 6 MM

2

NOVOFINE PLUS PEN NEEDLE 32G X 4 MM

2

NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

NOVOLIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML


days)

NOVOLIN N VIAL SUBCUTANEOUS SUSPENSION 100 UNIT/ML


days)

Updated May 1, 2020


123

Drug NameDrug Tier

Notes

NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML


days)

NOVOLIN R VIAL INJECTION SOLUTION 100 UNIT/ML


days)

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


days)

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


days)

NOVOLOG MIX 70/30 VIAL SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


days)

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML


days)

NOVOLOG U-100 VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML


days)

NOVOTWIST PEN NEEDLE 32G X 5 MM

2

PURE COMFORT PEN NEEDLE 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 32G X 8 MM

2

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

2QL (60 ML

per 30 days)

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

2QL (60 ML

per 30 days)

Drug NameDrug Tier

Notes

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

3QL (60 ML

per 30 days)

TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML

3QL (60 ML

per 30 days)

ULTIGUARD SAFEPACK PEN NEEDLE 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

2

ULTRA FLO INSULIN PEN NEEDLES 29G X 12MM

2

ULTRA FLO INSULIN SYRINGE 29G X 1/2" 0.3 ML

2

UNIFINE SAFECONTROL PEN NEEDLE 30G X 5 MM

2

Electrolytes / Minerals / Metals / Vitamins

ABANEU-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG

3

ACTIVE FE ORAL TABLET 75-1.25 MG

3

ACTIVITE ORAL TABLET 1 MG

3

adc/f (0.5mg/ml) oral solution 0.5 mg/ml

1

ADRENAL C FORMULA ORAL TABLET

3

AMINO ACID INTRAVENOUS SOLUTION 10 %

GM

aminoamrms oral capsule

1

Updated May 1, 2020


124

Drug NameDrug Tier

Notes

aminobenzoate potassium oral packet 2 gm

1

aminoreliefrms oral capsule

1

AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 %

GM

AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 %

GM

ANIMI-3 ORAL CAPSULE 1 MG

3

ANIMI-3/VITAMIN D ORAL CAPSULE 1 MG

3

AQUASOL A INTRAMUSCULAR SOLUTION 15 MG/ML

GM

ARGININE HCL INJECTION SOLUTION 6 GM/30ML

GM

argyle sterile saline irrigation solution 0.9 %

1

argyle sterile water irrigation solution

1

ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML

GM

ASCORBIC ACID INTRAVENOUS SOLUTION 15000 MG/30ML

GM

ATABEX OB ORAL TABLET 29-1 MG

3

b-6 folic acid oral capsule 8.333-100-1 mg

1

BACMIN ORAL TABLET 3

biocel oral tablet 1

bp vit 3 oral capsule 1 mg

1

b-plex oral tablet 1

Drug NameDrug Tier

Notes

b-plex plus oral tablet 1

CALCIFOL ORAL WAFER 1342-1.6 MG

3

CALCIUM CHLORIDE SOLUTION 10 % INTRAVENOUS 10 %

GM

calcium chloride solution 10 % intravenous 10 %

GM

CALCIUM GLUCONATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1000 MG/10ML

GM

CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1-0.675 GM/50ML-%, 2-0.675 GM/100ML-%

GM

CALCIUM-FOLIC ACID PLUS D ORAL WAFER 1342-1 MG

3

CARBAGLU ORAL TABLET 200 MG

6 PA

CARDIOPLEGIA DEL NIDO FORMULA PERFUSION SOLUTION

GM

CARDIOPLEGIA IND PLASMA HIGH K PERFUSION SOLUTION

GM

CARDIOPLEGIA IND PLASMA-TROMET PERFUSION SOLUTION

GM

CARDIOPLEGIA INDUCTION HIGH K PERFUSION SOLUTION

GM

CARDIOPLEGIA INDUCTION LOW DEX PERFUSION SOLUTION

GM

CARDIOPLEGIA INDUCTION NON-ENR PERFUSION SOLUTION

GM

Updated May 1, 2020


125

Drug NameDrug Tier

Notes

CARDIOPLEGIA MAIN LOW DEXTROSE PERFUSION SOLUTION

GM

CARDIOPLEGIA MAIN LOW TROMETHA PERFUSION SOLUTION

GM

CARDIOPLEGIA MAIN PLASMA-TROME PERFUSION SOLUTION

GM

CARDIOPLEGIA MAINTENANCE PERFUSION SOLUTION

GM

CARDIOPLEGIA REPERFUSATE 4:1 PERFUSION SOLUTION

GM

CARDIOPLEGIC SOLUTION PERFUSION

GM

cardioplegic solution perfusion

GM

CARNITOR INTRAVENOUS SOLUTION 200 MG/ML

GM

CARNITOR ORAL SOLUTION 1 GM/10ML

3Brand

penalty applies

CARNITOR ORAL TABLET 330 MG

3Brand

penalty applies

CARNITOR SF ORAL SOLUTION 1 GM/10ML

3Brand

penalty applies

CENTRATEX ORAL CAPSULE 106-1 MG

3

CHEMET ORAL CAPSULE 100 MG

3

chromagen oral capsule 1

chromic chloride intravenous solution 40 mcg/10ml

GM

CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG

3

Drug NameDrug Tier

Notes

CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 %

GM


GM


GM

CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %

GM

CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 %

GM

CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 %

GM

CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 %

GM

CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %

GM

CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 %

GM

CLINISOL SF INTRAVENOUS SOLUTION 15 %

GM

CLINOLIPID INTRAVENOUS EMULSION 20 %

GM

clovique oral capsule 250 mg

5 PA

cod liver oil oral oil 1

corvita 150 oral tablet 150-1.25 mg

1

corvita oral tablet 1.25 mg

1

Updated May 1, 2020


126

Drug NameDrug Tier

Notes

CORVITE 150 ORAL TABLET , 150-1.25 MG

3

CORVITE FE ORAL TABLET

3

CUPRIC CHLORIDE INTRAVENOUS SOLUTION 0.4 MG/ML

GM

curity sterile saline irrigation solution 0.9 %

1

cyanocobalamin injection solution 1000 mcg/ml

1

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

GM

cytra k crystals oral packet 3300-1002 mg

1

DECARA ORAL CAPSULE 1.25 MG (50000 UT)

3

deferasirox oral tablet 360 mg, 90 mg

4 PA

deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg

4 PA

DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L

3


3


3

delflex-sm/1.5% dextrose intraperitoneal solution 347 mosm/l

1

delflex-sm/2.5% dextrose intraperitoneal solution 398 mosm/l

1

Drug NameDrug Tier

Notes

dexifol oral tablet 5 mg 1

DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS SOLUTION

GM

dextrose in lactated ringers intravenous solution 5 %

GM

dextrose intravenous solution 10 %, 20 %, 30 %, 40 %, 5 %, 70 %

GM

DEXTROSE SOLUTION 250 MG/ML INTRAVENOUS 250 MG/ML

GM

dextrose solution 250 mg/ml intravenous 250 mg/ml

GM

DEXTROSE SOLUTION 50 % INTRAVENOUS 50 %

GM

dextrose solution 50 % intravenous 50 %

GM

dextrose-nacl intravenous solution 10-0.2 %, 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.3 %, 5-0.33 %, 5-0.45 %, 5-0.9 %

GM

dextrose-sodium chloride intravenous solution 5-0.225 %, 5-0.3 %, 5-0.45 %, 5-0.9 %

GM

DIALYVITE 3000 ORAL TABLET 3 MG

3

DIALYVITE 5000 ORAL TABLET 5 MG

3

dialyvite oral tablet 1

DIALYVITE SUPREME D ORAL TABLET 3 MG

3

DIALYVITE/ZINC ORAL TABLET

3

Updated May 1, 2020


127

Drug NameDrug Tier

Notes

DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION 344 MOSM/L

3


3


3

DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 346 MOSM/L

3


3


3

DILUENT FOR LEFAMULIN INTRAVENOUS SOLUTION 0.9 %

GM

DRISDOL ORAL CAPSULE 1.25 MG (50000 UT)

3Brand

penalty applies

d-vite pediatric oral liquid 10 mcg/ml

PVAL (Min 65

Years)

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

3

effer-k oral tablet effervescent 25 meq

1

ELITE-OB ORAL TABLET 50-1.25 MG

3

ELLIOTTS B INTRATHECAL SOLUTION

GM

Drug NameDrug Tier

Notes

ENBRACE HR ORAL CAPSULE

3

ergocalciferol oral capsule 1.25 mg (50000 ut)

1

EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG

5 PA

EXTRANEAL INTRAPERITONEAL SOLUTION 7.5 %

3

fabb oral tablet 2.2-25-1 mg

1

fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg

1

FERAHEME INTRAVENOUS SOLUTION 510 MG/17ML

GM

FERIVAFA ORAL CAPSULE 110-1 MG

3

ferocon oral capsule 1

ferotrinsic oral capsule 1

FERRALET 90 ORAL TABLET 90-1 MG

3

FERRAPLUS 90 ORAL TABLET 90-1 MG

3

FERRIPROX ORAL SOLUTION 100 MG/ML

5 PA

FERRIPROX ORAL TABLET 1000 MG, 500 MG

5 PA

FERRLECIT INTRAVENOUS SOLUTION 12.5 MG/ML

GM

FERRO-PLEX HEMATINIC ORAL TABLET 115-1 MG

3

FERROTRIN ORAL CAPSULE

3

Updated May 1, 2020


128

Drug NameDrug Tier

Notes

FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML

3

FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML

3

fluoritab oral solution 0.275 (0.125 f) mg/drop

PV

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP

3

folbee plus oral tablet 1

FOLGARD OS ORAL TABLET 500-1.1 MG

3

FOLGARD RX ORAL TABLET 2.2-25-1 MG

3

folic acid injection solution 5 mg/ml

GM

folic acid oral tablet 1 mg 1

folic acid oral tablet 400 mcg, 800 mcg

PV

FOLIVANE-F ORAL CAPSULE 125-1 MG

3

FOLIVANE-PLUS ORAL CAPSULE

3

folplex 2.2 oral tablet 2.2-25-0.5 mg

1

FOLTRATE ORAL TABLET 500-1 MCG-MG

3

foltrin oral capsule 1

FORTAVIT ORAL CAPSULE

3

FREAMINE HBC INTRAVENOUS SOLUTION 6.9 %

GM

FREAMINE III INTRAVENOUS SOLUTION 10 %

GM

Drug NameDrug Tier

Notes

FUSION PLUS ORAL CAPSULE

3

GALZIN ORAL CAPSULE 25 MG, 50 MG

2

GENICIN VITA-S ORAL TABLET 1 MG

3

GLUTATHIONE INJECTION SOLUTION 200 MG/ML, 6 GM/30ML

GM

GLUTATHIONE INTRAVENOUS SOLUTION 6 GM/30ML

GM

GLYCINE INJECTION SOLUTION 50 MG/ML

GM

gnp folic acid oral tablet 400 mcg

PV

hematinic/folic acid oral tablet 324-1 mg

1

HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG

3

hematogen forte oral capsule 460-60-0.01-1 mg

1

hematogen oral capsule 1

HEMATRON-AF ORAL TABLET 150-1 MG

3

HEMOCYTE PLUS ORAL CAPSULE 106-1 MG

3

hemocyte-f oral tablet 324-1 mg

1

HEPATAMINE INTRAVENOUS SOLUTION 8 %

GM

hydroxocobalamin acetate intramuscular solution 1000 mcg/ml

GM

HYLAVITE ORAL TABLET

3

Updated May 1, 2020


129

Drug NameDrug Tier

Notes

HYPERLYTE-CR INTRAVENOUS CONCENTRATE

GM

ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG

3

iferex 150 forte oral capsule 150-25-1 mg-mcg-mg

1

INFUVITE ADULT INTRAVENOUS INJECTABLE

GM

INFUVITE PEDIATRIC INTRAVENOUS SOLUTION

GM

INJECTAFER INTRAVENOUS SOLUTION 750 MG/15ML

GM

INTEGRA F ORAL CAPSULE 125-1 MG

3

INTEGRA PLUS ORAL CAPSULE

3

intralipid intravenous emulsion 20 %

GM

INTRALIPID INTRAVENOUS EMULSION 30 %

GM

iodine strong oral solution 5 %

1

IONOSOL-MB IN D5W INTRAVENOUS SOLUTION

GM

IROSPAN 24/6 ORAL 3

IS 24/6 ORAL 3

ISOLYTE-P IN D5W INTRAVENOUS SOLUTION

GM

ISOLYTE-S INTRAVENOUS SOLUTION

GM

Drug NameDrug Tier

Notes

ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION

GM

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG

5 PA

JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG

5 PA

JYNARQUE ORAL TABLET 15 MG, 30 MG

5 PA

JYNARQUE ORAL TABLET THERAPY PACK 45 & 15 MG, 60 & 30 MG, 90 & 30 MG

5 PA

KABIVEN INTRAVENOUS EMULSION 3.3-9.8-3.9-0.7 %

GM

kcl in dextrose-nacl intravenous solution 0.15-5-0.45 %, 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.225 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

GM

kcl-lactated ringers-d5w intravenous solution 20 meq/l

GM

KCL-LIDOCAINE-NACL INTRAVENOUS SOLUTION 10-10 MEQ-MG /100ML

GM

kionex oral suspension 15 gm/60ml

1

klor-con 10 oral tablet extended release 10 meq

1

klor-con m10 oral tablet extended release 10 meq

1

Updated May 1, 2020


130

Drug NameDrug Tier

Notes

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ

3

klor-con m20 oral tablet extended release 20 meq

1

klor-con oral packet 20 meq

1

klor-con oral tablet extended release 8 meq

1

klor-con sprinkle oral capsule extended release 10 meq, 8 meq

1

klor-con/ef oral tablet effervescent 25 meq

1

K-PHOS NO 2 ORAL TABLET 305-700 MG

3

K-PHOS ORAL TABLET 500 MG

3

K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG

3

k-prime oral tablet effervescent 25 meq

1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ

3Brand

penalty applies

k-tan plus oral capsule 162-115.2-1 mg

1

lactated ringers intravenous solution

GM

lactated ringers irrigation solution

1

LEVOCARNITINE INJECTION SOLUTION 500 MG/ML

GM

levocarnitine oral solution 1 gm/10ml

1

levocarnitine oral tablet 330 mg

1

levocarnitine sf oral solution 1 gm/10ml

1

Drug NameDrug Tier

Notes

LIPO INTRAMUSCULAR SOLUTION 50-50-25 MG/ML

GM

LIPO-C INTRAMUSCULAR SOLUTION

GM

LIQUIVIDA HYDRATION INTRAVENOUS KIT 0.9 %

GM

LORID ORAL TABLET 1 MG

3

ludent oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

LYSINE HCL INJECTION SOLUTION 100 MG/ML

GM

lysiplex plus oral tablet 1

M.V.I. ADULT INTRAVENOUS INJECTABLE

GM

M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED

GM

MAGNEBIND 400 ORAL TABLET 400-200-1 MG

3

magnesium sulfate in d5w intravenous solution 1-5 gm/100ml-%

GM

MAGNESIUM SULFATE INTRAVENOUS SOLUTION 1000 MG/1.6ML, 2000 MG/3.2ML, 3000 MG/4.8ML, 4000 MG/6.4ML

GM

magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml

GM

Updated May 1, 2020


131

Drug NameDrug Tier

Notes

MAGNESIUM SULFATE-NACL INTRAVENOUS SOLUTION 2-0.9 GM/50ML-%

GM

MANGANESE CHLORIDE INTRAVENOUS SOLUTION 0.1 MG/ML

GM

MEPHYTON ORAL TABLET 5 MG

3Brand

penalty applies

METHYLCOBALAMIN INJECTION SOLUTION 150 MG/30ML, 30 MG/30ML, 300 MG/30ML

GM

METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED 10000 MCG, 50000 MCG

GM

MIC-L-CARNITINE INJECTION SOLUTION 25-50-50-50 MG/ML

GM

MICROPLEGIA MSA-MSG PERFUSION SOLUTION

GM

MIFEPREX ORAL TABLET 200 MG

3Brand

penalty applies

mifepristone oral tablet 200 mg

1

M-NATAL PLUS ORAL TABLET 27-1 MG


MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG

3

MULTIGEN ORAL TABLET 70 MG

3

MULTIGEN PLUS ORAL TABLET 50-101-1 MG

3

multi-vit/iron/fluoride oral solution 0.25-10 mg/ml

1

Drug NameDrug Tier

Notes

multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

1

multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

1

multivitamin/fluoride oral tablet chewable 0.25 mg, 1 mg

1

multivitamin/fluoride/iron oral solution 0.25-10 mg/ml

1

multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml

1

mvc-fluoride oral tablet chewable 0.25 mg, 1 mg

1

myferon 150 forte oral capsule 150-25-1 mg-mcg-mg

1

mynephrocaps oral capsule 1 mg

1

mynephron oral capsule 1 mg

1

na ferric gluc cplx in sucrose intravenous solution 12.5 mg/ml

GM

n-acetyl-l-cysteine oral capsule 600 mg

1

nafrinse drops oral solution 0.275 (0.125 f) mg/drop

PV

nafrinse oral tablet chewable 2.2 (1 f) mg

PV

NASCOBAL NASAL SOLUTION 500 MCG/0.1ML

2

NEONATAL COMPLETE ORAL TABLET 27-1 MG


NEONATAL PLUS ORAL TABLET 27-1 MG


Updated May 1, 2020


132

Drug NameDrug Tier

Notes

NEOVITE ORAL TABLET

3

NEPHPLEX RX ORAL TABLET

3

NEPHRAMINE INTRAVENOUS SOLUTION 5.4 %

GM

NEPHRON FA ORAL TABLET

3

nephronex oral tablet 1

NEPHRO-VITE RX ORAL TABLET 1 MG

3

NESTABS ORAL TABLET 32-1 MG

3

NEURIN-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG

3

NICADAN ORAL TABLET

3

NICAZEL FORTE ORAL TABLET

3

NICAZEL ORAL TABLET 3

NICOMIDE ORAL TABLET 750-27-2-0.5 MG

3

NIFEREX ORAL TABLET

3

NORMOSOL-M IN D5W INTRAVENOUS SOLUTION

GM

NORMOSOL-R IN D5W INTRAVENOUS SOLUTION

GM

NORMOSOL-R INTRAVENOUS SOLUTION

GM

NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION

GM

NUFERA ORAL TABLET 3

Drug NameDrug Tier

Notes

NUTRICAP ORAL TABLET

3

nutrifac zx oral tablet 1

nutrilipid intravenous emulsion 20 %

GM

NUTRIVIT ORAL LIQUID 3

OMEGAVEN INTRAVENOUS EMULSION 10 GM/100ML, 5 GM/50ML

6PA;

Specialty Medical

ONEVITE ORAL TABLET 1 MG

3

ORACIT ORAL SOLUTION 490-640 MG/5ML

2

PERIKABIVEN INTRAVENOUS EMULSION 2.4-6.8-3.5-0.5 %

GM

phospha 250 neutral oral tablet 155-852-130 mg

1

phosphorous oral tablet 155-852-130 mg

1

phospho-trin 250 neutral oral tablet 155-852-130 mg

1

PHYSIOLYTE IRRIGATION SOLUTION

3

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

3

phytonadione injection solution 1 mg/0.5ml, 10 mg/ml

GM

phytonadione oral tablet 5 mg

1

PLASMA-LYTE 148 INTRAVENOUS SOLUTION

GM

PLASMA-LYTE A INTRAVENOUS SOLUTION

GM

Updated May 1, 2020


133

Drug NameDrug Tier

Notes

PLEGISOL PERFUSION SOLUTION

GM

PLENAMINE INTRAVENOUS SOLUTION 15 %

GM

pnv prenatal plus multivit+dha oral 27-1 & 312 mg

1

poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg

1

polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg

1

POLY-VI-FLOR FS ORAL STRIP 0.25 MG, 0.5 MG, 1 MG

3

POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML

3

POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG

3

POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML

3

POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG

3

pot bicarb-pot chloride oral tablet effervescent 25 meq

1

POTABA ORAL CAPSULE 500 MG

3

potassium acetate intravenous solution 2 meq/ml

GM

potassium bicarbonate oral tablet effervescent 25 meq

1

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

1

Drug NameDrug Tier

Notes

potassium chloride er oral capsule extended release 10 meq, 8 meq

1

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq

1

potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-%

GM

potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%

GM

potassium chloride intravenous solution 10 meq/100ml, 10 meq/50ml, 2 meq/ml, 20 meq/100ml, 20 meq/50ml, 40 meq/100ml

GM

POTASSIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MEQ/5ML

GM

potassium chloride oral packet 20 meq

1

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

1

potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)

1

potassium citrate-citric acid oral solution 1100-334 mg/5ml

1

potassium phosphates(71 meq k) intravenous solution 45 mmole/15ml

GM

Updated May 1, 2020


134

Drug NameDrug Tier

Notes

PREMASOL INTRAVENOUS SOLUTION 10 %

GM

PREMESISRX ORAL TABLET 1 MG

3

PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG

3

PRENATA ORAL TABLET CHEWABLE 29-1 MG

3

prenatal oral tablet 27-1 mg


prenatal plus iron oral tablet 29-1 mg

1

PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG

3

PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG

3

PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG

3

PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG

3

PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG

3

PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG

3

PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG

3

PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG

3

PRENATVITE COMPLETE ORAL TABLET 1 MG

3

Drug NameDrug Tier

Notes

PRENATVITE PLUS ORAL TABLET 1 MG

3

PRENATVITE RX ORAL TABLET 0.8 MG

3

PRISMASOL B22GK 4/0 INTRAVENOUS SOLUTION 22-4 MEQ/L

GM

PRISMASOL BGK 0/2.5 INTRAVENOUS SOLUTION 32-2.5 MEQ/L

GM

PRISMASOL BGK 2/0 INTRAVENOUS SOLUTION 32-2 MEQ/L

GM

PRISMASOL BGK 2/3.5 INTRAVENOUS SOLUTION 32-2-3.5 MEQ/L

GM

PRISMASOL BGK 4/2.5 INTRAVENOUS SOLUTION 32-4-2.5 MEQ/L

GM

PRISMASOL BK 0/0/1.2 INTRAVENOUS SOLUTION 32-1.2 MEQ/L

GM

PROCALAMINE INTRAVENOUS SOLUTION 3 %

GM

PROSOL INTRAVENOUS SOLUTION 20 %

GM

purevit dualfe plus oral capsule 162-115.2-1 mg

1

PYRIDOXAL-5 PHOSPHATE INJECTION SOLUTION 100 MG/ML

GM

PYRIDOXINE HCL SOLUTION 100 MG/ML INJECTION 100 MG/ML

GM

Updated May 1, 2020


135

Drug NameDrug Tier

Notes

pyridoxine hcl solution 100 mg/ml injection 100 mg/ml

GM

QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML

3

QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 1 MG

3

RELNATE DHA ORAL CAPSULE 28-1-200 MG

3

REMEDIENT ORAL CAPSULE 1 MG

3

renal oral capsule 1 mg 1

RENATABS ORAL TABLET 1 MG

3

RENATABS WITH IRON ORAL 1 & 100 MG

3

REQ 49+ ORAL TABLET 3

ringers intravenous solution

GM

ringers irrigation irrigation solution

1

saline bacteriostatic injection solution 0.9 %

GM

SALINE-PHENOL INJECTION SOLUTION 0.4-0.9 %

GM

SAMSCA ORAL TABLET 15 MG, 30 MG

5 PA

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

3

SELENIOUS ACID INTRAVENOUS SOLUTION 60 MCG/ML

GM

se-tan plus oral capsule 162-115.2-1 mg

1

SIDEROL ORAL TABLET

3

Drug NameDrug Tier

Notes

SMOFLIPID INTRAVENOUS EMULSION 20 %

GM

sod citrate-citric acid oral solution 500-334 mg/5ml

1

sodium acetate intravenous solution 2 meq/ml

GM

SODIUM BICARBONATE SOLUTION 8.4 % INTRAVENOUS 8.4 %

GM

sodium bicarbonate solution 8.4 % intravenous 8.4 %

GM

sodium chloride (pf) injection solution 0.9 %

GM

sodium chloride bacteriostatic injection solution 0.9 %

GM

sodium chloride injection solution 2.5 meq/ml

GM

sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 %

GM

sodium chloride irrigation solution 0.9 %

1

sodium fluoride oral solution 1.1 (0.5 f) mg/ml

PV

sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

PV

sodium polystyrene sulfonate oral powder

1

sodium polystyrene sulfonate oral suspension 15 gm/60ml

1

Updated May 1, 2020


136

Drug NameDrug Tier

Notes

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml

1

sps oral suspension 15 gm/60ml

1

sterile water for irrigation irrigation solution

1

STROVITE FORTE ORAL SYRUP

3

STROVITE FORTE ORAL TABLET

3

STROVITE ONE ORAL TABLET

3

SUPERVITE ORAL LIQUID

3

SUPPORT ORAL LIQUID

3

SUPPORT-500 ORAL CAPSULE

3

SYNAGEX ORAL CAPSULE 1.25 MG

3

SYNATEK ORAL CAPSULE 1.25 MG

3

SYNTHAMIN 17 INTRAVENOUS SOLUTION 10 %

GM

SYPRINE ORAL CAPSULE 250 MG

5 PA

TALIVA ORAL CAPSULE 1 MG

3

TARON FORTE ORAL CAPSULE

3

taron-crystals oral packet 3300-1002 mg

1

TAURINE INJECTION SOLUTION 50 MG/ML

GM

thiamine hcl injection solution 100 mg/ml

GM

tis-u-sol irrigation solution 1

Drug NameDrug Tier

Notes

tl-hem 150 oral tablet 150-1 mg

1

tpn electrolytes intravenous concentrate

GM

TRAVASOL INTRAVENOUS SOLUTION 10 %

GM

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG

3

tricitrates oral solution 550-500-334 mg/5ml

1

tricon oral capsule 1

trientine hcl oral capsule 250 mg

5 PA

trigels-f forte oral capsule 460-60-0.01-1 mg

1

trinate oral tablet 1

triphrocaps oral capsule 1 mg

1

TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML

3

TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML

3

tri-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

1

tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

1

TRONVITE ORAL TABLET 1 MG

3

TROPHAMINE INTRAVENOUS SOLUTION 10 %, 6 %

GM

tryptophan oral capsule 500 mg

1

UDAMIN SP ORAL TABLET 1 MG

3

Updated May 1, 2020


137

Drug NameDrug Tier

Notes

ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL SOLUTION 346 MOSM/L

3

ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL SOLUTION 396 MOSM/L

3

ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL SOLUTION 485 MOSM/L

3

ULTRABAG/DIANEAL/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L

3

ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 395 MOSM/L

3

ULTRABAG/DIANEAL/4.25% DEX INTRAPERITONEAL SOLUTION 483 MOSM/L

3

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ (1080 MG)

2Brand

penalty applies


2Brand

penalty applies


2Brand

penalty applies

urosex oral tablet 1

v-c forte oral capsule 1

VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM

3 PA

Drug NameDrug Tier

Notes

VENOFER INTRAVENOUS SOLUTION 20 MG/ML

GM

vic-forte oral capsule 1

virt-caps oral capsule 1 mg

1

VIRT-FEFA PLUS ORAL CAPSULE

3

virt-gard oral tablet 2.2-25-1 mg

1

virt-phos 250 neutral oral tablet 155-852-130 mg

1

vita s forte oral tablet 1

vitacel oral tablet 1

VITAFOL ORAL TABLET 3

VITAFOL-OB+DHA ORAL 65-1 & 250 MG

3

VITAL-D RX ORAL TABLET 1 MG

3

VITAMAX PEDIATRIC ORAL SOLUTION

3

VITAMEZ ORAL CAPSULE 1 MG

3

vitamin d (cholecalciferol) oral capsule 10 mcg (400 unit)

PVAL (Min 65

Years)

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

vitamin d3 oral tablet 10 mcg (400 unit)

PVAL (Min 65

Years)

vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml

GM

vita-min oral capsule 1

vitamins acd-fluoride oral solution 0.25 mg/ml

1

VITAROCA PLUS ORAL TABLET

3

Updated May 1, 2020


138

Drug NameDrug Tier

Notes

VITA-RX DIABETIC VITAMIN ORAL CAPSULE

3

VITASURE ORAL TABLET 1 MG

3

VITATHELY WITH GINGER ORAL TABLET 27-1 MG


vp-pnv-dha oral capsule 28-1-215.8 mg

1

vp-vite rx oral tablet 1 mg 1

water for irrigation, sterile irrigation solution

1

weekly-d oral capsule 1.25 mg (50000 ut)

1

wheat germ oil oral oil 1

XVITE ORAL TABLET 1 MG

3

ZINC CHLORIDE INTRAVENOUS SOLUTION 1 MG/ML

GM

ZINC SULFATE INTRAVENOUS SOLUTION 3 MG/ML

GM

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG

3Brand

penalty applies

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 5 MG

3

CARAFATE ORAL SUSPENSION 1 GM/10ML

2Brand

penalty applies

CARAFATE ORAL TABLET 1 GM

3Brand

penalty applies

cimetidine hcl oral solution 300 mg/5ml

1

Drug NameDrug Tier

Notes

cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg

1

CYTOTEC ORAL TABLET 100 MCG, 200 MCG

3Brand

penalty applies

DEXILANT ORAL CAPSULE DELAYED RELEASE 60 MG

3 PA

esomeprazole sodium intravenous solution reconstituted 40 mg

GM

famotidine intravenous solution 20 mg/2ml, 200 mg/20ml, 40 mg/4ml

GM

famotidine oral suspension reconstituted 40 mg/5ml

1

famotidine oral tablet 20 mg, 40 mg

1

famotidine premixed intravenous solution 20-0.9 mg/50ml-%

GM

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML

3

FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML

3

lansoprazole oral capsule delayed release 15 mg, 30 mg

1

lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg

1

misoprostol oral tablet 100 mcg, 200 mcg

1

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE 20 MG

1QL (120

EA per 30 days)

NEXIUM 24HR ORAL TABLET DELAYED RELEASE 20 MG

1QL (120

EA per 30 days)

Updated May 1, 2020


139

Drug NameDrug Tier

Notes

NEXIUM I.V. INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

nizatidine oral capsule 150 mg, 300 mg

1

nizatidine oral solution 15 mg/ml

1

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

1

OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 MG/ML

3

pantoprazole sodium intravenous solution reconstituted 40 mg

GM

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

1

PEPCID ORAL TABLET 20 MG, 40 MG

3Brand

penalty applies

PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG, 30 MG

3Brand

penalty applies

PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE DISPERSIBLE 15 MG, 30 MG

3Brand

penalty applies

PRILOSEC ORAL PACKET 10 MG, 2.5 MG

3

PROTONIX INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

PROTONIX ORAL PACKET 40 MG

3

Drug NameDrug Tier

Notes

PROTONIX ORAL TABLET DELAYED RELEASE 20 MG, 40 MG

3Brand

penalty applies

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE 10 MG

3

rabeprazole sodium oral tablet delayed release 20 mg

1

ranitidine hcl oral capsule 150 mg, 300 mg

1

ranitidine hcl oral syrup 15 mg/ml, 150 mg/10ml, 75 mg/5ml

1

ranitidine hcl oral tablet 150 mg, 300 mg

1

sucralfate oral suspension 1 gm/10ml

1

sucralfate oral tablet 1 gm

1

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL ORAL CAPSULE 300 MG

3Brand

penalty applies

alosetron hcl oral tablet 0.5 mg, 1 mg

1

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG

2QL (60 EA

per 30 days)

amoxicill-clarithro-lansopraz oral

1

ANASPAZ ORAL TABLET DISPERSIBLE 0.125 MG

3

ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1.2 MG/3ML

GM

Updated May 1, 2020


140

Drug NameDrug Tier

Notes

belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2-60 mg

1

BENTYL INTRAMUSCULAR SOLUTION 10 MG/ML

GM

CHENODAL ORAL TABLET 250 MG

6

chlordiazepoxide-clidinium oral capsule 5-2.5 mg

1

clearlax oral powder

1

PV*; QL (1 GM per

365 days); AL (Min 50 Years and

Max 75 Years)

CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML

3

constulose oral solution 10 gm/15ml

1

cromolyn sodium oral concentrate 100 mg/5ml

1

CUVPOSA ORAL SOLUTION 1 MG/5ML

3

dicyclomine hcl intramuscular solution 10 mg/ml

GM

dicyclomine hcl oral capsule 10 mg

1

dicyclomine hcl oral solution 10 mg/5ml

1

dicyclomine hcl oral tablet 20 mg

1

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

1

diphenoxylate-atropine oral tablet 2.5-0.025 mg

1

Drug NameDrug Tier

Notes

DONNATAL ORAL ELIXIR 16.2 MG/5ML

3

DONNATAL ORAL TABLET 16.2 MG

3

ed-spaz oral tablet dispersible 0.125 mg

1

ENTEREG ORAL CAPSULE 12 MG

3

enulose oral solution 10 gm/15ml

1

GASTROCROM ORAL CONCENTRATE 100 MG/5ML

3Brand

penalty applies

GATTEX SUBCUTANEOUS KIT 5 MG

6 PA

gavilax oral powder

1

PV*; QL (1 GM per


Max 75 Years)

gavilyte-c oral solution reconstituted 240 gm

1

PV*; QL (1 ML per 365 days); AL (Min 50


gavilyte-g oral solution reconstituted 236 gm

1



gavilyte-h oral kit 5-210 mg-gm

1

Updated May 1, 2020


141

Drug NameDrug Tier

Notes

gavilyte-n with flavor pack oral solution reconstituted 420 gm

1



generlac oral solution 10 gm/15ml

1

glycolax oral powder

1

PV*; QL (1 GM per


Max 75 Years)

glycopyrrolate injection solution 0.2 mg/ml, 0.4 mg/2ml, 1 mg/5ml, 4 mg/20ml

GM

GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE 0.6 MG/3ML, 1 MG/5ML

GM

glycopyrrolate oral tablet 1 mg, 2 mg

1

glycopyrrolate pf injection solution prefilled syringe 0.2 mg/ml, 0.4 mg/2ml

GM

GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 MG/2ML

GM

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

3

QL (1 EA per 365

days); AL (Min 50


Drug NameDrug Tier

Notes

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

3

Brand penalty

applies; QL (1 ML per 365 days); AL (Min 50 Years and

Max 75 Years)

healthylax oral packet

1

PV*; QL (1 EA per 365 days); AL (Min 50


hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg

1

hyoscyamine sulfate oral elixir 0.125 mg/5ml

1

hyoscyamine sulfate oral solution 0.125 mg/ml

1

hyoscyamine sulfate oral tablet 0.125 mg

1

hyoscyamine sulfate oral tablet dispersible 0.125 mg

1

hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg

1

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg

1

hyosyne oral elixir 0.125 mg/5ml

1

hyosyne oral solution 0.125 mg/ml

1

KRISTALOSE ORAL PACKET 10 GM, 20 GM

3

lactulose encephalopathy oral solution 10 gm/15ml

1

Updated May 1, 2020


142

Drug NameDrug Tier

Notes

lactulose oral packet 10 gm

1

lactulose oral solution 10 gm/15ml, 20 gm/30ml

1

LEVBID ORAL TABLET EXTENDED RELEASE 12 HOUR 0.375 MG

3

LEVSIN ORAL TABLET 0.125 MG

3

LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG

3

LIBRAX ORAL CAPSULE 5-2.5 MG

3Brand

penalty applies

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

2QL (30 EA

per 30 days)

LOMOTIL ORAL TABLET 2.5-0.025 MG

3Brand

penalty applies

loperamide hcl oral capsule 2 mg

1

LOTRONEX ORAL TABLET 0.5 MG, 1 MG

3Brand

penalty applies

methscopolamine bromide oral tablet 2.5 mg, 5 mg

1

mineral oil heavy oral oil 1

MOTEGRITY ORAL TABLET 1 MG, 2 MG

3QL (30 EA

per 30 days)

MOTOFEN ORAL TABLET 1-0.025 MG

3

MOVANTIK ORAL TABLET 12.5 MG, 25 MG

3QL (30 EA

per 30 days)

MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM

3

Drug NameDrug Tier

Notes

MYTESI ORAL TABLET DELAYED RELEASE 125 MG

3 PA

nulev oral tablet dispersible 0.125 mg

1

NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 420 GM

3

Brand penalty

applies; QL (1 ML per 365 days); AL (Min 50 Years and

Max 75 Years)

OMECLAMOX-PAK ORAL 500-500-20 MG

3

opium oral tincture 10 mg/ml (1%)

1

oscimin oral tablet 0.125 mg

1

oscimin sr oral tablet extended release 12 hour 0.375 mg

1

oscimin sublingual tablet sublingual 0.125 mg

1

OSMOPREP ORAL TABLET 1.102-0.398 GM

3

pb-hyoscy-atropine-scopolamine oral elixir 16.2 mg/5ml

1

pb-hyoscy-atropine-scopolamine oral tablet 16.2 mg

1

peg 3350 oral packet

1



Updated May 1, 2020


143

Drug NameDrug Tier

Notes

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

1



peg-3350/electrolytes oral solution reconstituted 236 gm

1



peg-prep oral kit 5-210 mg-gm

1

phenobarbital-belladonna alk oral elixir 16.2 mg/5ml

1

phenohytro oral elixir 16.2 mg/5ml

1

phenohytro oral tablet 16.2 mg

1

polyethylene glycol 3350 oral packet 17 gm

1



PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM

3

propantheline bromide oral tablet 15 mg

1

PYLERA ORAL CAPSULE 140-125-125 MG

3

RELISTOR ORAL TABLET 150 MG

2 PA

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 MG/0.4ML

2 PA

Drug NameDrug Tier

Notes

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG

5 PA

sodium bicarbonate oral powder

1

SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 GM/177ML

3

SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 MG

3

symax-sl sublingual tablet sublingual 0.125 mg

1

symax-sr oral tablet extended release 12 hour 0.375 mg

1

SYMPROIC ORAL TABLET 0.2 MG

3QL (30 EA

per 30 days)

trilyte oral solution reconstituted 420 gm

1



TRULANCE ORAL TABLET 3 MG

3QL (30 EA

per 30 days)

URSO 250 ORAL TABLET 250 MG

3Brand

penalty applies

URSO FORTE ORAL TABLET 500 MG

3Brand

penalty applies

ursodiol oral capsule 300 mg

1

ursodiol oral tablet 250 mg, 500 mg

1

Updated May 1, 2020


144

Drug NameDrug Tier

Notes

VIBERZI ORAL TABLET 100 MG, 75 MG

4 PA

XERMELO ORAL TABLET 250 MG

5 PA

ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 8.8 MG

5 PA

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML

5PA;

Specialty Medical

AMMONUL INTRAVENOUS SOLUTION 10-10 %

GM

BRINEURA KIT 2 X 150 MG/5ML

6PA;

Specialty Medical

BUPHENYL ORAL POWDER 3 GM/TSP

3Brand

penalty applies

BUPHENYL ORAL TABLET 500 MG

3Brand

penalty applies

CERDELGA ORAL CAPSULE 84 MG

5 PA

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

6PA;

Specialty Medical

CHOLBAM ORAL CAPSULE 250 MG, 50 MG

6 PA

Drug NameDrug Tier

Notes

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

2

CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 MG/ML, 30 MG/ML

6PA;

Specialty Medical

CYSTADANE ORAL POWDER

3

CYSTAGON ORAL CAPSULE 150 MG, 50 MG

3

ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML

6PA;

Specialty Medical

ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT

6PA;

Specialty Medical

ENZADYNE ORAL CAPSULE

3

FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG, 5 MG

6PA;

Specialty Medical

GALAFOLD ORAL CAPSULE 123 MG

6 PA

KANUMA INTRAVENOUS SOLUTION 20 MG/10ML

6PA;

Specialty Medical

KUVAN ORAL PACKET 100 MG, 500 MG

6 PA

KUVAN ORAL TABLET SOLUBLE 100 MG

6 PA

Updated May 1, 2020


145

Drug NameDrug Tier

Notes

LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

6PA;

Specialty Medical

MEPSEVII INTRAVENOUS SOLUTION 10 MG/5ML

6PA;

Specialty Medical

miglustat oral capsule 100 mg

6 PA

MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 11.3 MG

6 PA

NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML

6PA;

Specialty Medical

nitisinone oral capsule 10 mg, 2 mg, 5 mg

6

NITYR ORAL TABLET 10 MG, 2 MG, 5 MG

6 PA

OCALIVA ORAL TABLET 10 MG, 5 MG

6 PA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG

6 PA

ORFADIN ORAL SUSPENSION 4 MG/ML

6 PA

PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML

6 PA

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 UNIT, 4200 UNIT

3

Drug NameDrug Tier

Notes

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 24000-86250 UNIT, 4000 UNIT, 8000 UNIT

3

PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 MG

6 PA

RAVICTI ORAL LIQUID 1.1 GM/ML

6 PA

REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5ML

6PA;

Specialty Medical

sod benz-sod phenylacet intravenous solution 10-10 %

GM

sodium phenylbutyrate oral powder 3 gm/tsp

1

sodium phenylbutyrate oral tablet 500 mg

1

STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML

6PA;

Specialty Medical

SUCRAID ORAL SOLUTION 8500 UNIT/ML

6 PA

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML

6PA;

Specialty Medical

VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT

3

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

6PA;

Specialty Medical

Updated May 1, 2020


146

Drug NameDrug Tier

Notes

XURIDEN ORAL PACKET 2 GM

6 PA

ZAVESCA ORAL CAPSULE 100 MG

6 PA

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT

2

ZOLGENSMA 10.1-10.5 KG INTRAVENOUS KIT 7X8.3 ML

6PA;

Specialty Medical

ZOLGENSMA 10.6-11.0 KG INTRAVENOUS KIT 2X5.5ML & 6X8.3ML

6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical

Drug NameDrug Tier

Notes


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical


6PA;

Specialty Medical

Updated May 1, 2020


147

Drug NameDrug Tier

Notes

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation solution 0.25 %

1

aminoacetic acid irrigation solution 1.5 %

1

AURYXIA ORAL TABLET 1 GM 210 MG(FE)

3

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

1

BI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-5 MG

GM

calcium acetate (phos binder) oral capsule 667 mg

1

calcium acetate (phos binder) oral tablet 667 mg

1

calcium acetate oral tablet 667 mg

1

CAVERJECT IMPULSE INTRACAVERNOSAL KIT 10 MCG, 20 MCG

3

QL (4 EA per 30

days); AL (Min 18 Years)

CAVERJECT INTRACAVERNOSAL SOLUTION RECONSTITUTED 40 MCG

3

QL (4 EA per 30


CERVIDIL VAGINAL INSERT 10 MG

3

Drug NameDrug Tier

Notes

CIALIS ORAL TABLET 10 MG, 20 MG

3

Brand penalty

applies; QL (4 EA per 30 days);

AL (Min 18 Years)

CIALIS ORAL TABLET 2.5 MG, 5 MG

3

ST; Brand penalty


AL (Min 18 Years)

darifenacin hydrobromide er oral tablet extended release 24 hour 15 mg, 7.5 mg

1

DEPEN TITRATABS ORAL TABLET 250 MG

4

DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 MG, 4 MG

3Brand

penalty applies

DETROL ORAL TABLET 1 MG, 2 MG

3Brand

penalty applies

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 5 MG

3Brand

penalty applies

EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40 MCG

3

QL (4 EA per 30


ELMIRON ORAL CAPSULE 100 MG

3

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG

3Brand

penalty applies

FEM PH VAGINAL GEL 0.9-0.025 %

3

Updated May 1, 2020


148

Drug NameDrug Tier

Notes

flavoxate hcl oral tablet 100 mg

1

FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG

3Brand

penalty applies

GELNIQUE TRANSDERMAL GEL 10 %

3

glycine irrigation solution 1.5 %

1

glycine urologic irrigation solution 1.5 %

1

hyophen oral tablet 81.6 mg

1

INTRAROSA VAGINAL INSERT 6.5 MG

3

lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg

1

LEVITRA ORAL TABLET 10 MG, 20 MG

3

Brand penalty


AL (Min 18 Years)

LITHOSTAT ORAL TABLET 250 MG

3

me/naphos/mb/hyo1 oral tablet 81.6 mg

1

MUSE URETHRAL PELLET 1000 MCG, 125 MCG, 250 MCG, 500 MCG

3

QL (4 EA per 30


MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG

2

Drug NameDrug Tier

Notes

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

1

oxybutynin chloride oral syrup 5 mg/5ml

1

oxybutynin chloride oral tablet 5 mg

1

penicillamine oral tablet 250 mg

4

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

PHENYLEPHRINE HCL INTRACAVERNOSAL SOLUTION 2 MG/2ML

GM

PHOSLYRA ORAL SOLUTION 667 MG/5ML

3

phosphasal oral tablet 81.6 mg

1

PREPIDIL VAGINAL GEL 0.5 MG/3GM

3

PROSTIN E2 VAGINAL SUPPOSITORY 20 MG

3

PYRIDIUM ORAL TABLET 100 MG, 200 MG

3

QUAD-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-10-0.1-1 MG

GM

RENACIDIN IRRIGATION SOLUTION

3

RENAGEL ORAL TABLET 800 MG

3Brand

penalty applies

RENVELA ORAL PACKET 0.8 GM, 2.4 GM

3Brand

penalty applies

Updated May 1, 2020


149

Drug NameDrug Tier

Notes

RENVELA ORAL TABLET 800 MG

3Brand

penalty applies

RIMSO-50 INTRAVESICAL SOLUTION 50 %

GM

sevelamer carbonate oral packet 0.8 gm, 2.4 gm

1

sevelamer carbonate oral tablet 800 mg

1

sevelamer hcl oral tablet 400 mg, 800 mg

1

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

1

QL (4 EA per 30


solifenacin succinate oral tablet 10 mg, 5 mg

1

STAXYN ORAL TABLET DISPERSIBLE 10 MG

3

Brand penalty


AL (Min 18 Years)

STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG

3

QL (4 EA per 30


SUPER BI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-10 MG

GM

SUPER QUAD-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-20-0.2-2 MG

GM

Drug NameDrug Tier

Notes

SUPER TRI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 150-10-100 MG-MG-MCG

GM

tadalafil oral tablet 10 mg, 20 mg

1

QL (4 EA per 30


tadalafil oral tablet 2.5 mg, 5 mg

1

ST; QL (30 EA per 30 days); AL (Min 18 Years)

THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG, 300 MG

3 PA

THIOLA ORAL TABLET 100 MG

3 PA

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

1

tolterodine tartrate oral tablet 1 mg, 2 mg

1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG

3

trospium chloride er oral capsule extended release 24 hour 60 mg

1

trospium chloride oral tablet 20 mg

1

URECHOLINE ORAL TABLET 25 MG, 50 MG

3Brand

penalty applies

URELLE ORAL TABLET 81 MG

3

uretron d/s oral tablet 1

uribel oral capsule 118 mg

1

Updated May 1, 2020


150

Drug NameDrug Tier

Notes

URIMAR-T ORAL TABLET 120 MG

3

urin ds oral tablet 1

URO-458 ORAL TABLET 81 MG

3

UROGESIC-BLUE ORAL TABLET 81.6 MG

3

uro-mp oral capsule 118 mg

1

URYL ORAL TABLET 81.6 MG

3

ustell oral capsule 120 mg

1

uticap oral capsule 120 mg

1

utira-c oral tablet 81.6 mg 1

utrona-c oral tablet 81.6 mg

1

vardenafil hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

1

QL (4 EA per 30


vardenafil hcl oral tablet dispersible 10 mg

1

QL (4 EA per 30


VELPHORO ORAL TABLET CHEWABLE 500 MG

5

VESICARE ORAL TABLET 10 MG, 5 MG

2Brand

penalty applies

VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG

3

Brand penalty


AL (Min 18 Years)

Drug NameDrug Tier

Notes

vilamit mb oral capsule 118 mg

1

VILEVEV MB ORAL TABLET 81 MG

3

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er oral tablet extended release 24 hour 10 mg

1

AVODART ORAL CAPSULE 0.5 MG

3Brand

penalty applies

CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG

2

dutasteride oral capsule 0.5 mg

1

dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg

1

finasteride oral tablet 5 mg

1

FLOMAX ORAL CAPSULE 0.4 MG

3Brand

penalty applies

JALYN ORAL CAPSULE 0.5-0.4 MG

3Brand

penalty applies

PROSCAR ORAL TABLET 5 MG

3Brand

penalty applies

RAPAFLO ORAL CAPSULE 4 MG, 8 MG

3Brand

penalty applies

silodosin oral capsule 4 mg, 8 mg

1

tamsulosin hcl oral capsule 0.4 mg

1

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1

Updated May 1, 2020


151

Drug NameDrug Tier

Notes

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG

3Brand

penalty applies

Hormonal Agents - Adrenal

BETAMETHASONE COMBO INJECTION SUSPENSION 6 (3-3) MG/ML

GM

BETAMETHASONE SOD PHOS & ACET SUSPENSION 6 (3-3) MG/ML INJECTION 6 (3-3) MG/ML

GM

betamethasone sod phos & acet suspension 6 (3-3) mg/ml injection 6 (3-3) mg/ml

GM

BETAMETHASONE SODIUM PHOSPHATE INJECTION SOLUTION 12 MG/2ML, 6 MG/ML

GM

CELESTONE SOLUSPAN INJECTION SUSPENSION 6 (3-3) MG/ML

GM

CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG

3Brand

penalty applies

cortisone acetate oral tablet 25 mg

1

DECADRON ORAL TABLET 0.5 MG, 0.75 MG, 4 MG, 6 MG

3

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML, 40 MG/ML, 80 MG/ML

GM

dexamethasone intensol oral concentrate 1 mg/ml

1

Drug NameDrug Tier

Notes

dexamethasone oral elixir 0.5 mg/5ml

1

dexamethasone oral solution 0.5 mg/5ml

1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

1

dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51)

1

DEXAMETHASONE SOD PHOS-BUPIV INJECTION SOLUTION PREFILLED SYRINGE 0.01-0.375 %

GM

dexamethasone sod phosphate pf injection solution 10 mg/ml

GM

dexamethasone sod phosphate pf injection solution prefilled syringe 10 mg/ml

GM

dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4 mg/ml

GM

DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 MG/5ML

GM

DEXPAK 10 DAY ORAL TABLET THERAPY PACK 1.5 MG (35)

3Brand

penalty applies


3Brand

penalty applies


3Brand

penalty applies

fludrocortisone acetate oral tablet 0.1 mg

1

Updated May 1, 2020


152

Drug NameDrug Tier

Notes

HIDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21)

3

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

1

KENALOG INJECTION SUSPENSION 10 MG/ML, 40 MG/ML

GM

KENALOG-80 INJECTION SUSPENSION 80 MG/ML

GM

LIDOCIDEX I INJECTION SOLUTION 5-10 MG/1.5ML

GM

MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

2Brand

penalty applies

MEDROL ORAL TABLET 2 MG

2

MEDROL ORAL TABLET THERAPY PACK 4 MG

3Brand

penalty applies

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MG/ML

GM

METHYLPREDNISOLONE ACETATE SUSPENSION 40 MG/ML INJECTION 40 MG/ML

GM

methylprednisolone acetate suspension 40 mg/ml injection 40 mg/ml

GM

METHYLPREDNISOLONE ACETATE SUSPENSION 80 MG/ML INJECTION 80 MG/ML

GM

methylprednisolone acetate suspension 80 mg/ml injection 80 mg/ml

GM

Drug NameDrug Tier

Notes

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

1

methylprednisolone oral tablet therapy pack 4 mg

1

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg, 500 mg

GM

METHYLPREDNISOLONE-BUPIVACAINE INJECTION SUSPENSION 40-5 MG/ML, 80-5 MG/ML

GM

MILLIPRED DP 12-DAY ORAL TABLET THERAPY PACK 5 MG (48)

3

MILLIPRED DP ORAL TABLET THERAPY PACK 5 MG (21), 5 MG (48)

3

MILLIPRED ORAL TABLET 5 MG

2

ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 30 MG

3Brand

penalty applies

PEDIAPRED ORAL SOLUTION 6.7 (5 BASE) MG/5ML

3Brand

penalty applies

prednisolone oral solution 15 mg/5ml

1

prednisolone oral syrup 15 mg/5ml

1

prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

Updated May 1, 2020


153

Drug NameDrug Tier

Notes

prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg

1

prednisone intensol oral concentrate 5 mg/ml

1

prednisone oral solution 5 mg/5ml

1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

1

prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)

1

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG, 250 MG, 500 MG

GM

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 1000 MG, 125 MG, 2 GM, 40 MG, 500 MG

GM

TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG, 1.5 MG (21)

3

triamcinolone acetonide suspension 40 mg/ml injection 40 mg/ml

GM

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION 40 MG/ML

GM

TRIAMCINOLONE-BUPIVACAINE INJECTION SUSPENSION 40-5 MG/ML

GM

Drug NameDrug Tier

Notes

ZILRETTA INTRA-ARTICULAR SUSPENSION RECONSTITUTED ER 32 MG

GM

Hormonal Agents - Men's Health

ANADROL-50 ORAL TABLET 50 MG

3

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR

3 PA

ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)

2PA; Brand

penalty applies

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

2PA; Brand

penalty applies

ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%)

3PA; Brand

penalty applies

danazol oral capsule 100 mg, 200 mg, 50 mg

1

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML

3Brand

penalty applies

FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%)

3PA; Brand

penalty applies

JATENZO ORAL CAPSULE 158 MG, 198 MG, 237 MG

3 PA

METHITEST ORAL TABLET 10 MG

3

methyltestosterone oral capsule 10 mg

1

NATESTO NASAL GEL 5.5 MG/ACT

3 PA

Updated May 1, 2020


154

Drug NameDrug Tier

Notes

oxandrolone oral tablet 10 mg, 2.5 mg

1

STRIANT BUCCAL 30 MG

3 PA

TESTIM TRANSDERMAL GEL 50 MG/5GM (1%)

3PA; Brand

penalty applies

TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML

3

TESTOPEL IMPLANT PELLET 75 MG

GM PA

TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 MG/ML

3

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

1

testosterone enanthate intramuscular solution 200 mg/ml

1

testosterone transdermal gel 1.62 %, 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

1 PA

testosterone transdermal solution 30 mg/act

1 PA

VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%)

3PA; Brand

penalty applies

VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%)

3PA; Brand

penalty applies

Hormonal Agents - Osteoporosis

EVISTA ORAL TABLET 60 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

OSPHENA ORAL TABLET 60 MG

3

raloxifene hcl oral tablet 60 mg

PV

Hormonal Agents - Pituitary

ACTHAR INJECTION GEL 80 UNIT/ML

6 PA

cabergoline oral tablet 0.5 mg

1

carboprost tromethamine intramuscular solution 250 mcg/ml

GM

CETROTIDE SUBCUTANEOUS KIT 0.25 MG

5 PA

chorionic gonadotropin intramuscular solution reconstituted 10000 unit

5 PA

clomiphene citrate oral tablet 50 mg

1 PA

DDAVP INJECTION SOLUTION 4 MCG/ML

GM

DDAVP NASAL SOLUTION 0.01 %

3Brand

penalty applies

DDAVP ORAL TABLET 0.1 MG, 0.2 MG

3Brand

penalty applies

DDAVP RHINAL TUBE NASAL SOLUTION 0.01 %

3

desmopressin ace spray refrig nasal solution 0.01 %

1

desmopressin acetate injection solution 4 mcg/ml

GM

desmopressin acetate oral tablet 0.1 mg, 0.2 mg

1

Updated May 1, 2020


155

Drug NameDrug Tier

Notes

desmopressin acetate spray nasal solution 0.01 %

1

EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED 1 MG

6 PA

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG

5PA;

Specialty Medical

FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG/VIAL

5PA;

Specialty Medical

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

5PA;

Specialty Medical

FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300 UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML

4 PA

ganirelix acetate subcutaneous solution prefilled syringe 250 mcg/0.5ml

5 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG

5 PA

Drug NameDrug Tier

Notes

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 12 MG, 5 MG

5 PA

GONAL-F INJECTION SOLUTION RECONSTITUTED 1050 UNIT, 450 UNIT

5 PA

GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 UNIT/1.5ML

5 PA

GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT

5 PA

HEMABATE INTRAMUSCULAR SOLUTION 250 MCG/ML

GM

HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG

5 PA

INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML

5 PA

leuprolide acetate injection kit 1 mg/0.2ml

5 PA

LEUPROLIDE ACETATE-BUPIVACAINE INTRAMUSCULAR SOLUTION 25-5 MG/ML

GM

LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, 3.75 & 5 MG

5PA;

Specialty Medical

Updated May 1, 2020


156

Drug NameDrug Tier

Notes

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG

5PA;

Specialty Medical

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG

5PA;

Specialty Medical

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG INTRAMUSCULAR KIT 30 MG

5PA;

Specialty Medical

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG INTRAMUSCULAR KIT 45 MG

5PA;

Specialty Medical

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG

5PA;

Specialty Medical

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

5PA;

Specialty Medical

MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT

5 PA

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

5 PA

novarel intramuscular solution reconstituted 10000 unit

5 PA

Drug NameDrug Tier

Notes

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

5 PA

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 MG/2ML

5 PA


5 PA


5 PA

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

4 PA

OMNITROPE SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 5 MG/1.5ML

5 PA

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED 5.8 MG

5 PA

ORILISSA ORAL TABLET 150 MG, 200 MG

3 PA

OVIDREL SUBCUTANEOUS INJECTABLE 250 MCG/0.5ML

5 PA

oxytocin injection solution 10 unit/ml

GM

OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 20 UNIT/L

GM

Updated May 1, 2020


157

Drug NameDrug Tier

Notes

OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 15-0.9 UT/250ML-%, 30-0.9 UT/500ML-%

GM

PITOCIN INJECTION SOLUTION 10 UNIT/ML

GM

pregnyl intramuscular solution reconstituted 10000 unit

5 PA

SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 MG

5 PA

SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 MG

5 PA

SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 MCG/ML, 500 MCG/ML

5 PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

5PA;

Specialty Medical

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG

6PA;

Specialty Medical

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

6 PA

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

5PA;

Specialty Medical

Drug NameDrug Tier

Notes

SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

6 PA

STIMATE NASAL SOLUTION 1.5 MG/ML

2

SUPPRELIN LA SUBCUTANEOUS KIT 50 MG

6PA;

Specialty Medical

SYNAREL NASAL SOLUTION 2 MG/ML

2

TEPEZZA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

5PA;

Specialty Medical

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG

5PA;

Specialty Medical

TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 22.5 MG

5PA;

Specialty Medical

VANTAS SUBCUTANEOUS KIT 50 MG

5PA;

Specialty Medical

VAPRISOL INTRAVENOUS SOLUTION 20-5 MG/100ML-%

GM

VASOSTRICT INTRAVENOUS SOLUTION 20 UNIT/ML

GM

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 MG

5PA;

Specialty Medical

Updated May 1, 2020


158

Drug NameDrug Tier

Notes

ZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 5 MG

5 PA

Hormonal Agents - Prostaglandins

KORLYM ORAL TABLET 300 MG

5 PA

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA ORAL TABLET 1-0.5 MG

3Brand

penalty applies

afirmelle oral tablet 0.1-20 mg-mcg

PV

ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

3

altavera oral tablet 0.15-30 mg-mcg

PV

alyacen 1/35 oral tablet 1-35 mg-mcg

PV

alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg

1

amethia lo oral tablet 0.1-0.02 & 0.01 mg

PV

amethia oral tablet 0.15-0.03 &0.01 mg

PV

amethyst oral tablet 90-20 mcg

PV

ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG

3

ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR

3

Drug NameDrug Tier

Notes

apri oral tablet 0.15-30 mg-mcg

PV

aranelle oral tablet 0.5/1/0.5-35 mg-mcg

PV

ashlyna oral tablet 0.15-0.03 &0.01 mg

PV

aubra eq oral tablet 0.1-20 mg-mcg

PV

aubra oral tablet 0.1-20 mg-mcg

PV

aurovela 1.5/30 oral tablet 1.5-30 mg-mcg

PV

aurovela 1/20 oral tablet 1-20 mg-mcg

PV

aurovela 24 fe oral tablet 1-20 mg-mcg(24)

PV

aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

aurovela fe 1/20 oral tablet 1-20 mg-mcg

PV

aviane oral tablet 0.1-20 mg-mcg

PV

AYGESTIN ORAL TABLET 5 MG

3Brand

penalty applies

ayuna oral tablet 0.15-30 mg-mcg

PV

azurette oral tablet 0.15-0.02/0.01 mg (21/5)

PV

BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21)

3

balziva oral tablet 0.4-35 mg-mcg

PV

bekyree oral tablet 0.15-0.02/0.01 mg (21/5)

PV

BEYAZ ORAL TABLET 3-0.02-0.451 MG

3Brand

penalty applies

blisovi 24 fe oral tablet 1-20 mg-mcg(24)

PV

Updated May 1, 2020


159

Drug NameDrug Tier

Notes

blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

blisovi fe 1/20 oral tablet 1-20 mg-mcg

PV

briellyn oral tablet 0.4-35 mg-mcg

PV

camila oral tablet 0.35 mg

PV

camrese lo oral tablet 0.1-0.02 & 0.01 mg

PV

camrese oral tablet 0.15-0.03 &0.01 mg

PV

caziant oral tablet 0.1/0.125/0.15 -0.025 mg

PV

chateal eq oral tablet 0.15-30 mg-mcg

PV

chateal oral tablet 0.15-30 mg-mcg

PV

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/DAY

3

CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

3Brand

penalty applies

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

3

covaryx hs oral tablet 0.625-1.25 mg

1

covaryx oral tablet 1.25-2.5 mg

1

CRINONE VAGINAL GEL 4 %, 8 %

3

Drug NameDrug Tier

Notes

cryselle-28 oral tablet 0.3-30 mg-mcg

PV

cyclafem 1/35 oral tablet 1-35 mg-mcg

PV

cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

cyred eq oral tablet 0.15-30 mg-mcg

PV

cyred oral tablet 0.15-30 mg-mcg

PV

dasetta 1/35 oral tablet 1-35 mg-mcg

PV

dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

daysee oral tablet 0.15-0.03 &0.01 mg

PV

deblitane oral tablet 0.35 mg

PV

DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

3

DELESTROGEN INTRAMUSCULAR OIL 20 MG/ML, 40 MG/ML

3Brand

penalty applies

delyla oral tablet 0.1-20 mg-mcg

PV

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML

GM

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

3Brand

penalty applies

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

GM

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML

3Brand

penalty applies

Updated May 1, 2020


160

Drug NameDrug Tier

Notes

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML

3

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg

PV

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM

3

dotti transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

1

drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg

PV

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg

PV

DUAVEE ORAL TABLET 0.45-20 MG

3

EC-RX PROGESTERONE TRANSDERMAL CREAM 10 %

3

eemt hs oral tablet 0.625-1.25 mg

1

eemt oral tablet 1.25-2.5 mg

1

ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%)

3

elinest oral tablet 0.3-30 mg-mcg

PV

Drug NameDrug Tier

Notes

ELLA ORAL TABLET 30 MG

PV

eluryng vaginal ring 0.12-0.015 mg/24hr

PV

emoquette oral tablet 0.15-30 mg-mcg

PV

ENDOMETRIN VAGINAL INSERT 100 MG

2

enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg

PV

enskyce oral tablet 0.15-30 mg-mcg

PV

errin oral tablet 0.35 mg PV

est estrogens-methyltest ds oral tablet 1.25-2.5 mg

1

est estrogens-methyltest hs oral tablet 0.625-1.25 mg

1

est estrogens-methyltest oral tablet 1.25-2.5 mg

1

estarylla oral tablet 0.25-35 mg-mcg

PV

ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG

3Brand

penalty applies

ESTRACE VAGINAL CREAM 0.1 MG/GM

2Brand

penalty applies

estradiol oral tablet 0.5 mg, 1 mg, 2 mg

1

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

1

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

1

Updated May 1, 2020


161

Drug NameDrug Tier

Notes

estradiol vaginal cream 0.1 mg/gm

1

estradiol vaginal tablet 10 mcg

1

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

1

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

1

ESTRING VAGINAL RING 2 MG

2

ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%)

3

ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

3Brand

penalty applies

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg

PV

etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24hr

PV

EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY

3

FALESSA ORAL KIT 20-1-0.1 MCG-MG

3

falmina oral tablet 0.1-20 mg-mcg

PV

fayosim oral tablet 42-21-21-7 days

PV

FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG

2Brand

penalty applies

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR

3

Drug NameDrug Tier

Notes

femynor oral tablet 0.25-35 mg-mcg

PV

FIRST-PROGESTERONE VGS VAGINAL SUPPOSITORY 100 MG, 200 MG

3

fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

1

GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG

3Brand

penalty applies

gianvi oral tablet 3-0.02 mg

PV

hailey 1.5/30 oral tablet 1.5-30 mg-mcg

PV

hailey 24 fe oral tablet 1-20 mg-mcg(24)

PV

heather oral tablet 0.35 mg

PV

hydroxyprogesterone caproate intramuscular oil 250 mg/ml

5PA;

Specialty Medical

hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml

4 PA

incassia oral tablet 0.35 mg

PV

introvale oral tablet 0.15-0.03 mg

PV

isibloom oral tablet 0.15-30 mg-mcg

PV

jaimiess oral tablet 0.15-0.03 &0.01 mg

PV

jasmiel oral tablet 3-0.02 mg

PV

jencycla oral tablet 0.35 mg

PV

jinteli oral tablet 1-5 mg-mcg

1

jolessa oral tablet 0.15-0.03 mg

PV

Updated May 1, 2020


162

Drug NameDrug Tier

Notes

juleber oral tablet 0.15-30 mg-mcg

PV

junel 1.5/30 oral tablet 1.5-30 mg-mcg

PV

junel 1/20 oral tablet 1-20 mg-mcg

PV

junel fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

junel fe 1/20 oral tablet 1-20 mg-mcg

PV

junel fe 24 oral tablet 1-20 mg-mcg(24)

PV

kaitlib fe oral tablet chewable 0.8-25 mg-mcg

PV

kalliga oral tablet 0.15-30 mg-mcg

PV

kariva oral tablet 0.15-0.02/0.01 mg (21/5)

PV

kelnor 1/35 oral tablet 1-35 mg-mcg

PV

kelnor 1/50 oral tablet 1-50 mg-mcg

PV

kurvelo oral tablet 0.15-30 mg-mcg

PV

KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG

GM PV

larin 1.5/30 oral tablet 1.5-30 mg-mcg

PV

larin 1/20 oral tablet 1-20 mg-mcg

PV

larin 24 fe oral tablet 1-20 mg-mcg(24)

PV

larin fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

larin fe 1/20 oral tablet 1-20 mg-mcg

PV

larissia oral tablet 0.1-20 mg-mcg

PV

Drug NameDrug Tier

Notes

layolis fe oral tablet chewable 0.8-25 mg-mcg

PV

leena oral tablet 0.5/1/0.5-35 mg-mcg

PV

lessina oral tablet 0.1-20 mg-mcg

PV

levonest oral tablet 50-30/75-40/ 125-30 mcg

PV

levonorgest-eth est & eth est oral tablet 42-21-21-7 days

PV

levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg

PV

levonorgestrel oral tablet 1.5 mg

PV

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg, 90-20 mcg

PV

levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 mcg

PV

levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg

PV

LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 19.5 MCG/DAY

GM PV

lillow oral tablet 0.15-30 mg-mcg

PV

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG

3

LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

3Brand

penalty applies

LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG

3Brand

penalty applies

Updated May 1, 2020


163

Drug NameDrug Tier

Notes

LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3Brand

penalty applies

LOESTRIN FE 1/20 ORAL TABLET 1-20 MG-MCG

3Brand

penalty applies

lojaimiess oral tablet 0.1-0.02 & 0.01 mg

PV

lopreeza oral tablet 1-0.5 mg

1

loryna oral tablet 3-0.02 mg

PV

LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG

3Brand

penalty applies

low-ogestrel oral tablet 0.3-30 mg-mcg

PV

lo-zumandimine oral tablet 3-0.02 mg

PV

lutera oral tablet 0.1-20 mg-mcg

PV

lyza oral tablet 0.35 mg PV

MAKENA INTRAMUSCULAR OIL 250 MG/ML

5PA;

Specialty Medical

MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/1.1ML

5 PA

marlissa oral tablet 0.15-30 mg-mcg

PV

medroxyprogesterone acetate intramuscular suspension 150 mg/ml

PV

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml

PV

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

1

Drug NameDrug Tier

Notes

MEGACE ES ORAL SUSPENSION 625 MG/5ML

3Brand

penalty applies

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

1

megestrol acetate oral tablet 20 mg, 40 mg

1

melodetta 24 fe oral tablet chewable 1-20 mg-mcg(24)

PV

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

2

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24HR

2

mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24)

PV

microgestin 1.5/30 oral tablet 1.5-30 mg-mcg

PV

microgestin 1/20 oral tablet 1-20 mg-mcg

PV

microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg

PV

microgestin fe 1/20 oral tablet 1-20 mg-mcg

PV

mili oral tablet 0.25-35 mg-mcg

PV

mimvey oral tablet 1-0.5 mg

1

MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24)

3Brand

penalty applies

MINIVELLE PATCH TWICE WEEKLY 0.025 MG/24HR TRANSDERMAL 0.025 MG/24HR

2

Updated May 1, 2020


164

Drug NameDrug Tier

Notes


3


2


3


2


3


2


3


2


3

Drug NameDrug Tier

Notes

MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5)

3Brand

penalty applies

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24HR

GM PV

mono-linyah oral tablet 0.25-35 mg-mcg

PV

NATAZIA ORAL TABLET 3/2-2/2-3/1 MG

PV

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg

PV

NEXPLANON SUBCUTANEOUS IMPLANT 68 MG

GM PV

nikki oral tablet 3-0.02 mg

PV

nora-be oral tablet 0.35 mg

PV

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1-20 mg-mcg(24), 1.5-30 mg-mcg

PV

norethin ace-eth estrad-fe oral tablet chewable 1-20 mg-mcg(24)

PV

norethindrone acetate oral tablet 5 mg

1

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

PV

norethindrone oral tablet 0.35 mg

PV

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

1

norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 0.8-25 mg-mcg

PV

Updated May 1, 2020


165

Drug NameDrug Tier

Notes

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

PV

norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg

PV

norlyda oral tablet 0.35 mg

PV

norlyroc oral tablet 0.35 mg

PV

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg

PV

nortrel 1/35 (21) oral tablet 1-35 mg-mcg

PV

nortrel 1/35 (28) oral tablet 1-35 mg-mcg

PV

nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

NUVARING VAGINAL RING 0.12-0.015 MG/24HR

3Brand

penalty applies

ocella oral tablet 3-0.03 mg

PV

ogestrel oral tablet 0.5-50 mg-mcg

PV

orsythia oral tablet 0.1-20 mg-mcg

PV

ORTHO MICRONOR ORAL TABLET 0.35 MG

3Brand

penalty applies

ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.215/0.25 MG-25 MCG

3Brand

penalty applies

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 0.5/0.75/1-35 MG-MCG

3Brand

penalty applies

Drug NameDrug Tier

Notes

PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

GM PV

philith oral tablet 0.4-35 mg-mcg

PV

pimtrea oral tablet 0.15-0.02/0.01 mg (21/5)

PV

pirmella 1/35 oral tablet 1-35 mg-mcg

PV

pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

PV

PLAN B ONE-STEP ORAL TABLET 1.5 MG

3

portia-28 oral tablet 0.15-30 mg-mcg

PV

PREFEST ORAL TABLET 1/1-0.09 MG (15/15)

3

PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

GM

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

3

PREMARIN VAGINAL CREAM 0.625 MG/GM

3

PREMPHASE ORAL TABLET 0.625-5 MG

3

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

3

preventeza oral tablet 1.5 mg

PV

previfem oral tablet 0.25-35 mg-mcg

PV

Updated May 1, 2020


166

Drug NameDrug Tier

Notes

progesterone intramuscular oil 50 mg/ml

1

progesterone micronized oral capsule 100 mg, 200 mg

1

progesterone micronized transdermal cream 10 %

1

PROMETRIUM ORAL CAPSULE 100 MG, 200 MG

3Brand

penalty applies

PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG

3Brand

penalty applies

QUARTETTE ORAL TABLET 42-21-21-7 DAYS

3Brand

penalty applies

reclipsen oral tablet 0.15-30 mg-mcg

PV

rivelsa oral tablet 42-21-21-7 days

PV

SAFYRAL ORAL TABLET 3-0.03-0.451 MG

3Brand

penalty applies

SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG

3Brand

penalty applies

setlakin oral tablet 0.15-0.03 mg

PV

sharobel oral tablet 0.35 mg

PV

simliya oral tablet 0.15-0.02/0.01 mg (21/5)

PV

simpesse oral tablet 0.15-0.03 &0.01 mg

PV

SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG

GM PV

SLYND ORAL TABLET 4 MG

PV

sprintec 28 oral tablet 0.25-35 mg-mcg

PV

Drug NameDrug Tier

Notes

sronyx oral tablet 0.1-20 mg-mcg

PV

syeda oral tablet 3-0.03 mg

PV

tarina 24 fe oral tablet 1-20 mg-mcg(24)

PV

tarina fe 1/20 eq oral tablet 1-20 mg-mcg

PV

tarina fe 1/20 oral tablet 1-20 mg-mcg

PV

TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24)

3

tilia fe oral tablet 1-20/1-30/1-35 mg-mcg

PV

tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg

PV

tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

Updated May 1, 2020


167

Drug NameDrug Tier

Notes

tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

trivora (28) oral tablet 50-30/75-40/ 125-30 mcg

PV

tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg

PV

tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg

PV

tulana oral tablet 0.35 mg PV

tydemy oral tablet 3-0.03-0.451 mg

PV

VAGIFEM VAGINAL TABLET 10 MCG

3Brand

penalty applies

velivet oral tablet 0.1/0.125/0.15 -0.025 mg

PV

vienva oral tablet 0.1-20 mg-mcg

PV

viorele oral tablet 0.15-0.02/0.01 mg (21/5)

PV

VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

3Brand

penalty applies

volnea oral tablet 0.15-0.02/0.01 mg (21/5)

PV

vyfemla oral tablet 0.4-35 mg-mcg

PV

vylibra oral tablet 0.25-35 mg-mcg

PV

wera oral tablet 0.5-35 mg-mcg

PV

Drug NameDrug Tier

Notes

wymzya fe oral tablet chewable 0.4-35 mg-mcg

PV

xulane transdermal patch weekly 150-35 mcg/24hr

PV

YASMIN 28 ORAL TABLET 3-0.03 MG

3Brand

penalty applies

YAZ ORAL TABLET 3-0.02 MG

3Brand

penalty applies

yuvafem vaginal tablet 10 mcg

1

zarah oral tablet 3-0.03 mg

PV

zovia 1/35e (28) oral tablet 1-35 mg-mcg

PV

zumandimine oral tablet 3-0.03 mg

PV

Hormonal Agents - Thyroid

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

2

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG

3Brand

penalty applies

euthyrox oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

levothyroxine sodium intravenous solution 100 mcg/5ml, 200 mcg/5ml, 500 mcg/5ml

GM

Updated May 1, 2020


168

Drug NameDrug Tier

Notes

levothyroxine sodium intravenous solution reconstituted 100 mcg, 200 mcg, 500 mcg

GM

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

liothyronine sodium intravenous solution 10 mcg/ml

GM

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

1

methimazole oral tablet 10 mg, 5 mg

1

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

3

np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

1

propylthiouracil oral tablet 50 mg

1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

2

Drug NameDrug Tier

Notes

TAPAZOLE ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

1

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

3

TRIOSTAT INTRAVENOUS SOLUTION 10 MCG/ML

GM

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG

3

WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

3

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 162 MG/0.9ML

5 PA

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, 400 MG/20ML, 80 MG/4ML

5PA;

Specialty Medical

Updated May 1, 2020


169

Drug NameDrug Tier

Notes

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML

5 PA

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML

5 PA

ALFERON N INJECTION SOLUTION 5000000 UNIT/ML

5PA;

Specialty Medical

ARAVA ORAL TABLET 10 MG, 20 MG

3Brand

penalty applies

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG

5 PA

ASCENIV INTRAVENOUS SOLUTION 5 GM/50ML

5PA;

Specialty Medical

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 5 MG

3

ATGAM INTRAVENOUS INJECTABLE 50 MG/ML

5PA;

Specialty Medical

AZASAN ORAL TABLET 100 MG, 75 MG

3

azathioprine oral tablet 50 mg

1

azathioprine sodium injection solution reconstituted 100 mg

GM

BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG

5PA;

Specialty Medical

Drug NameDrug Tier

Notes

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML

5 PA

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML

5 PA

BERINERT INTRAVENOUS KIT 500 UNIT

6PA;

Specialty Medical

BIVIGAM INTRAVENOUS SOLUTION 5 GM/50ML

5PA;

Specialty Medical

CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM

5PA;

Specialty Medical

CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

GM

CELLCEPT ORAL CAPSULE 250 MG

2

CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML

2

CELLCEPT ORAL TABLET 500 MG

2

CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 MG/ML

4 PA

CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML

4 PA

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG

4 PA

Updated May 1, 2020


170

Drug NameDrug Tier

Notes

CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

6PA;

Specialty Medical

COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

5 PA

COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

5 PA

COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

5 PA

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

5 PA

CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 GM/48ML

5 PA

CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML

5 PA

cyclosporine intravenous solution 50 mg/ml

GM

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

1

cyclosporine modified oral solution 100 mg/ml

1

Drug NameDrug Tier

Notes

cyclosporine oral capsule 100 mg, 25 mg

1

CYTOGAM INTRAVENOUS INJECTABLE 50 MG/ML

5Specialty Medical

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML

4 PA

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

4 PA

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG

4 PA

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

4 PA

ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 300 MG

5PA;

Specialty Medical

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, 1 MG, 4 MG

3

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg

5

FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML


days)

Updated May 1, 2020


171

Drug NameDrug Tier

Notes

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

5PA;

Specialty Medical

GAMASTAN INTRAMUSCULAR INJECTABLE

5PA;

Specialty Medical

GAMASTAN S/D INTRAMUSCULAR INJECTABLE

5PA;

Specialty Medical

GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML, 50 MG/10ML

6PA;

Specialty Medical

GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

5PA;

Specialty Medical

GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM

5PA;

Specialty Medical

GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

5PA;

Specialty Medical

Drug NameDrug Tier

Notes

GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML

5PA;

Specialty Medical

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

5PA;

Specialty Medical

gengraf oral capsule 100 mg, 25 mg

1

gengraf oral solution 100 mg/ml

1

HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT

6 PA

HEPAGAM B INJECTION SOLUTION

GM

HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

5 PA

HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML

5 PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

4 PA

Updated May 1, 2020


172

Drug NameDrug Tier

Notes

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML

4 PA

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML

4 PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

4 PA

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML

4 PA

HYPERHEP B S/D INTRAMUSCULAR SOLUTION

GM

HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML, 900 UNIT/3ML

GM

HYPERRAB S/D INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT, 250 UNIT

5Specialty Medical

HYPERTET S/D INTRAMUSCULAR INJECTABLE 250 UNIT/ML

GM

Drug NameDrug Tier

Notes

icatibant acetate subcutaneous solution 30 mg/3ml


days)

ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML

5 PA

ILUMYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

5 PA

IMOGAM RABIES-HT INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

IMURAN ORAL TABLET 50 MG

3Brand

penalty applies

INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

4PA;

Specialty Medical

KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML

6PA;

Specialty Medical

KEDRAB INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

GM

KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML, 200 MG/1.14ML

5 PA

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/1.14ML, 200 MG/1.14ML

5 PA

Updated May 1, 2020


173

Drug NameDrug Tier

Notes

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML

5 PA

KYMRIAH INTRAVENOUS SUSPENSION

6PA;

Specialty Medical

leflunomide oral tablet 10 mg, 20 mg

1

methotrexate oral tablet 2.5 mg

1

methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml

1

methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml

1

methotrexate sodium injection solution reconstituted 1 gm

5Specialty Medical

methotrexate sodium oral tablet 2.5 mg

1

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT

5Specialty Medical

mycophenolate mofetil hcl intravenous solution reconstituted 500 mg

GM

mycophenolate mofetil oral capsule 250 mg

1

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

1

mycophenolate mofetil oral tablet 500 mg

1

mycophenolate sodium oral tablet delayed release 180 mg, 360 mg

1

Drug NameDrug Tier

Notes

MYFORTIC ORAL TABLET DELAYED RELEASE 180 MG, 360 MG

3Brand

penalty applies

NABI-HB INTRAMUSCULAR SOLUTION

GM

NEORAL ORAL CAPSULE 100 MG, 25 MG

2

NEORAL ORAL SOLUTION 100 MG/ML

2

NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

GM

OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 GM/500ML, 5 GM/100ML, 5 GM/50ML

5PA;

Specialty Medical

OLUMIANT ORAL TABLET 1 MG, 2 MG

5 PA

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML

5 PA

ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

5PA;

Specialty Medical

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML

5 PA

Updated May 1, 2020


174

Drug NameDrug Tier

Notes

OTEZLA ORAL TABLET 30 MG

4 PA

OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG

4 PA

PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

5PA;

Specialty Medical

PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

5PA;

Specialty Medical

PROGRAF INTRAVENOUS SOLUTION 5 MG/ML

GM

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG

2

PROVENGE INTRAVENOUS SUSPENSION

6PA;

Specialty Medical

RAPAMUNE ORAL SOLUTION 1 MG/ML

2

RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG

2

REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5PA;

Specialty Medical

RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

4PA;

Specialty Medical

Drug NameDrug Tier

Notes

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

5Specialty Medical

RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 1500 UNIT/2ML

5Specialty Medical

RIDAURA ORAL CAPSULE 3 MG

2

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG

4 PA

RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT

6PA;

Specialty Medical

SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML

GM

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG

2

SANDIMMUNE ORAL SOLUTION 100 MG/ML

2

SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 210 MG/1.5ML

5 PA

SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML

4PA;

Specialty Medical

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML

4 PA

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML

4 PA

Updated May 1, 2020


175

Drug NameDrug Tier

Notes

SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG, 20 MG

GM

sirolimus oral solution 1 mg/ml

1

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg

1

SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT 75 MG/0.83ML

4 PA

STELARA INTRAVENOUS SOLUTION 130 MG/26ML

5PA;

Specialty Medical

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML

5 PA

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML

5 PA

SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5ML

5PA;

Specialty Medical

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg

1

TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2ML


days)

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80 MG/ML

5 PA

TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 80 MG/ML

5 PA

Drug NameDrug Tier

Notes

temsirolimus intravenous solution 25 mg/ml

5PA;

Specialty Medical

THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

GM

TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED 50 MG

GM PA

TORISEL INTRAVENOUS SOLUTION 25 MG/ML

5PA;

Specialty Medical

TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 MG/ML

4 PA

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

4 PA

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG

2

WINRHO SDF INJECTION SOLUTION 1500 UNIT/1.3ML, 15000 UNIT/13ML, 2500 UNIT/2.2ML, 5000 UNIT/4.4ML

5Specialty Medical

XELJANZ ORAL TABLET 10 MG, 5 MG

4 PA

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG, 22 MG

4 PA

XEMBIFY SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

5 PA

Updated May 1, 2020


176

Drug NameDrug Tier

Notes

ZINPLAVA INTRAVENOUS SOLUTION 1000 MG/40ML

GM

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG

5

Immunological Agents - Drugs for Vaccination

ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED

PVAL (Max 6

Years)

ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF-MCG/0.5

PV

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML

PV

BCG VACCINE INJECTION INJECTABLE

GM

BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV

BIOTHRAX INTRAMUSCULAR SUSPENSION

GM

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF-MCG/0.5

PV

DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5

PV

Drug NameDrug Tier

Notes

DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR SUSPENSION 25-5 LFU/0.5ML

PV

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML

PV

ENGERIX-B INTRAMUSCULAR INJECTABLE 10 MCG/0.5ML, 20 MCG/ML

PV

FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 0.5 ML

PV

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 0.5 ML

PV

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION

PV

Updated May 1, 2020


177

Drug NameDrug Tier

Notes

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

PV

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION , 0.5 ML

PV

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML

PV

GARDASIL 9 INTRAMUSCULAR SUSPENSION

PV

AL (Min 9 Years and

Max 27 Years)

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV

AL (Min 9 Years and

Max 27 Years)

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML

PV

HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 20 MCG/0.5ML

PVAL (Min 18

Years)

HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG

PVAL (Max 6

Years)

Drug NameDrug Tier

Notes

IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML

GM

INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10

PV

IPOL INJECTION INJECTABLE

PVAL (Max 17

Years)

IXIARO INTRAMUSCULAR SUSPENSION

GM

KINRIX INTRAMUSCULAR SUSPENSION

PV

MENACTRA INTRAMUSCULAR INJECTABLE

PV

MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED

PV

M-M-R II INJECTION SOLUTION RECONSTITUTED

PV

PEDIARIX INTRAMUSCULAR SUSPENSION

PV

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML

PVAL (Max 6

Years)

PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED

PV

PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML

PV

PREVNAR 13 INTRAMUSCULAR SUSPENSION

PV

Updated May 1, 2020


178

Drug NameDrug Tier

Notes

PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED

PV

QUADRACEL INTRAMUSCULAR SUSPENSION

PV

RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED

GM

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

PV

ROTARIX ORAL SUSPENSION RECONSTITUTED

PVAL (Max 8 Months)

ROTATEQ ORAL SOLUTION

PVAL (Max 8 Months)

SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

PV

QL (2 EA per 1

lifetime); AL (Min 50

Years)

STAMARIL INJECTION SUSPENSION RECONSTITUTED

GM

TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF/0.5ML

PV

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU

PV

TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

PV

Drug NameDrug Tier

Notes

TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 720-20 ELU-MCG/ML

PV

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML

GM

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

PV

VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML

PV

VIVOTIF ORAL CAPSULE DELAYED RELEASE


YF-VAX SUBCUTANEOUS INJECTABLE

GM

Inflammatory Bowel Disease Agents

ana-lex rectal kit 2-2 % 1

ANALPRAM HC EXTERNAL CREAM 2.5-1 %

2

ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 %

2

ANALPRAM-HC EXTERNAL CREAM 1-1 %

2

ANALPRAM-HC EXTERNAL LOTION 2.5-1 %

3

anucort-hc rectal suppository 25 mg

1

ANUSOL-HC EXTERNAL CREAM 2.5 %

3Brand

penalty applies

Updated May 1, 2020


179

Drug NameDrug Tier

Notes

anusol-hc rectal suppository 25 mg

1

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

2Brand

penalty applies

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG

3Brand

penalty applies

AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 500 MG

3Brand

penalty applies

AZULFIDINE ORAL TABLET 500 MG

3Brand

penalty applies

balsalazide disodium oral capsule 750 mg

1

budesonide er oral tablet extended release 24 hour 9 mg

4 PA

budesonide oral capsule delayed release particles 3 mg

4

CANASA RECTAL SUPPOSITORY 1000 MG

2Brand

penalty applies

COLAZAL ORAL CAPSULE 750 MG

3Brand

penalty applies

colocort rectal enema 100 mg/60ml

1

CORTENEMA RECTAL ENEMA 100 MG/60ML

3Brand

penalty applies

CORTIFOAM EXTERNAL FOAM 10 %

2

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG

2Brand

penalty applies

DIPENTUM ORAL CAPSULE 250 MG

2

Drug NameDrug Tier

Notes

ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES 3 MG

6

hemmorex-hc rectal suppository 25 mg

1

hydrocortisone (perianal) external cream 1 %, 2.5 %

1

hydrocortisone ace-pramoxine external cream 1-1 %

1

hydrocortisone acetate rectal suppository 25 mg, 30 mg

1

hydrocortisone rectal enema 100 mg/60ml

1

hydrocort-pramoxine (perianal) external cream 2.5-1 %

1

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM

3Brand

penalty applies

lidocaine-hydrocort (perianal) external cream 3-0.5 %

1

lidocaine-hydrocortisone ace rectal cream 3-0.5 %

1

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL 2.8-0.55 %

3

lidocaine-hydrocortisone ace rectal kit 2-2 %, 3-0.5 %, 3-1 %, 3-2.5 %

1

mesalamine er oral capsule extended release 24 hour 0.375 gm

1

mesalamine oral capsule delayed release 400 mg

1

Updated May 1, 2020


180

Drug NameDrug Tier

Notes

mesalamine oral tablet delayed release 1.2 gm, 800 mg

1

mesalamine rectal enema 4 gm

1

mesalamine rectal suppository 1000 mg

1

mesalamine-cleanser rectal kit 4 gm

1

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG

3

PROCORT EXTERNAL CREAM 1.85-1.15 %

3

PROCTOCORT EXTERNAL CREAM 1 %

3Brand

penalty applies

PROCTOCORT RECTAL SUPPOSITORY 30 MG

3

PROCTOFOAM HC EXTERNAL FOAM 1-1 %

3

procto-med hc external cream 2.5 %

1

procto-pak external cream 1 %

1

proctosol hc external cream 2.5 %

1

proctozone-hc external cream 2.5 %

1

ROWASA RECTAL KIT 4 GM

3Brand

penalty applies

SFROWASA RECTAL ENEMA 4 GM/60ML

2

sulfasalazine oral tablet 500 mg

1

sulfasalazine oral tablet delayed release 500 mg

1

UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 MG

6 PA

Drug NameDrug Tier

Notes

UCERIS RECTAL FOAM 2 MG/ACT

3

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG, 30 MG, 35 MG, 5 MG

3ST; Brand

penalty applies

alendronate sodium oral solution 70 mg/75ml

1

alendronate sodium oral tablet 10 mg, 5 mg

1

alendronate sodium oral tablet 35 mg, 70 mg

1QL (4 EA

per 28 days)

ATELVIA ORAL TABLET DELAYED RELEASE 35 MG

3ST; Brand

penalty applies

BINOSTO ORAL TABLET EFFERVESCENT 70 MG

3 ST

BONIVA INTRAVENOUS SOLUTION 3 MG/3ML

GM

BONIVA ORAL TABLET 150 MG

3Brand

penalty applies

calcitonin (salmon) nasal solution 200 unit/act

1

EVENITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 105 MG/1.17ML

6 PA

FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 600 MCG/2.4ML

5 PA

FOSAMAX ORAL TABLET 70 MG

3

Brand penalty


Updated May 1, 2020


181

Drug NameDrug Tier

Notes

FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70-5600 MG-UNIT

3

ibandronate sodium intravenous solution 3 mg/3ml

GM

ibandronate sodium oral tablet 150 mg

1

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

2

pamidronate disodium intravenous solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml

4Specialty Medical

pamidronate disodium intravenous solution reconstituted 30 mg, 90 mg

4Specialty Medical

PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 60 MG/ML

5Specialty Medical

RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 MCG

5 PA

RECLAST INTRAVENOUS SOLUTION 5 MG/100ML

6Specialty Medical

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg

1 ST

risedronate sodium oral tablet delayed release 35 mg

1 ST

TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 MCG/2.48ML

5 PA

Drug NameDrug Tier

Notes

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML

5 PA

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML

5Specialty Medical

zoledronic acid intravenous concentrate 4 mg/5ml

4Specialty Medical

zoledronic acid intravenous solution 4 mg/100ml, 5 mg/100ml

4Specialty Medical

Metabolic Bone Disease Agents - Other

calcitriol intravenous solution 1 mcg/ml

GM

calcitriol oral capsule 0.25 mcg, 0.5 mcg

1

calcitriol oral solution 1 mcg/ml

1

cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg

4 PA

doxercalciferol intravenous solution 4 mcg/2ml

GM

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

1 PA

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML, 4 MCG/2ML

GM

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 MCG, 50 MCG, 75 MCG

6PA;

Specialty Medical

paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml

GM

Updated May 1, 2020


182

Drug NameDrug Tier

Notes

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg

1 ST

PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5 MG/0.5ML, 5 MG/ML

5Specialty Medical

ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG

3Brand

penalty applies

ROCALTROL ORAL SOLUTION 1 MCG/ML

3Brand

penalty applies

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG

5 PA

ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML

GM

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG

3ST; Brand

penalty applies

Miscellaneous Therapeutic Agents

ACACIA SUBCUTANEOUS SOLUTION 1:20

GM

ACETADOTE INTRAVENOUS SOLUTION 200 MG/ML

GM

acetylcysteine intravenous solution 200 mg/ml

GM

ACREMONIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

ACTHREL INTRAVENOUS SOLUTION RECONSTITUTED 100 MCG

GM

Drug NameDrug Tier

Notes

ADAKVEO INTRAVENOUS SOLUTION 100 MG/10ML

5PA;

Specialty Medical

adenosine (diagnostic) intravenous solution 3 mg/ml

GM

adenosine intravenous solution 3 mg/ml

GM

ALBUKED 25 INTRAVENOUS SOLUTION 25 %

GM

ALBUKED 5 INTRAVENOUS SOLUTION 5 %

GM

albumin human intravenous solution 25 %, 5 %

GM

ALBUMINEX INTRAVENOUS SOLUTION 25 %, 5 %

GM

albumin-zlb intravenous solution 25 %, 5 %

GM

alburx intravenous solution 5 %

GM

ALBUTEIN INTRAVENOUS SOLUTION 25 %, 5 %

GM

ALDER SUBCUTANEOUS SOLUTION 1:20

GM

ALPHA-LIPOIC ACID INJECTION SOLUTION 25 MG/ML

GM

ALTERNARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

AMD FOAM DRESSING PAD 3-1/2"X3" , 4"X4" , 6"X6"

3

AMD FOAM DRESSING TOPSHEET PAD 4"X4"

3

Updated May 1, 2020


183

Drug NameDrug Tier

Notes

AMERICAN BEECH SUBCUTANEOUS SOLUTION 1:20

GM

AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 1:20

GM

AMERICAN ELM SUBCUTANEOUS SOLUTION 1:20

GM

AMERICAN SYCAMORE SUBCUTANEOUS SOLUTION 1:20

GM

AMIDATE INTRAVENOUS SOLUTION 2 MG/ML

GM

AMPHADASE INJECTION SOLUTION 150 UNIT/ML

GM

ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED

GM

ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED

6Specialty Medical

ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 200 MG

5Specialty Medical

ANESTHESIA S/I-40 INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-40A INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-40H INTRAVENOUS KIT 200 MG/20ML

GM

ANESTHESIA S/I-40S INTRAVENOUS KIT 200 MG/20ML

GM

Drug NameDrug Tier

Notes

ANESTHESIA S/I-60 INTRAVENOUS KIT 200 MG/20ML

GM

ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION RECONSTITUTED

GM

APP SLIM RMS ORAL CAPSULE

3

ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 1:20

GM

arnica flower tincture 1

ARTISS EXTERNAL SOLUTION

3

AUREOBASIDIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 1:20

GM

BACTERIOSTATIC WATER(BENZ ALC) INJECTION SOLUTION

GM

BAHIA SUBCUTANEOUS SOLUTION 1:20

GM

bal in oil intramuscular solution 100 mg/ml

GM

BALD CYPRESS SUBCUTANEOUS SOLUTION 1:20

GM

BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION 1:20

GM

BERMUDA GRASS SUBCUTANEOUS SOLUTION 10000 BAU/ML

GM

Updated May 1, 2020


184

Drug NameDrug Tier

Notes

BIOFREQUENCY INSOLES

3

BIOGUARD GAUZE SPONGES PAD 4"X4"

3

BIOGUARD ISLAND DRESSINGS PAD 4"X10" , 4"X14" , 4"X5"

3

BIOGUARD NON-ADHERENT DRESSING PAD 3"X4" , 3"X8"

3

BLACK WALNUT POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

BLACK WILLOW SUBCUTANEOUS SOLUTION 1:20

GM

BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT

GM PA

BOTRYTIS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

BOX ELDER SUBCUTANEOUS SOLUTION 1:20

GM

BREVITAL SODIUM INJECTION SOLUTION RECONSTITUTED 2.5 GM, 500 MG

GM

BRIDION INTRAVENOUS SOLUTION 200 MG/2ML, 500 MG/5ML

GM

BROME SUBCUTANEOUS SOLUTION 1:20

GM

CALCIUM DISODIUM VERSENATE INJECTION SOLUTION 1 GM/5ML

GM

Drug NameDrug Tier

Notes

CALIFORNIA PEPPER TREE SUBCUTANEOUS SOLUTION 1:20

GM

CANDIDA ALBICANS EXTRACT INJECTION SOLUTION 100 MG/ML

GM

CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

CARDIOVID PLUS ORAL CAPSULE

3

CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 10000 BAU/ML

GM

CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20

GM

CAYA VAGINAL DIAPHRAGM

3

CEDAR ELM SUBCUTANEOUS SOLUTION 1:20

GM

CHIRHOSTIM INTRAVENOUS SOLUTION RECONSTITUTED 16 MCG

GM

CHLORHEXIDINE GLUCONATE SOLUTION 20 %

3

CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

Updated May 1, 2020


185

Drug NameDrug Tier

Notes

COCKLEBUR SUBCUTANEOUS SOLUTION 1:20

GM

CONDOMSPV

QL (3 EA per 30 days)

CORN POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

CORTROSYN INJECTION SOLUTION RECONSTITUTED 0.25 MG

GM

cosyntropin injection solution reconstituted 0.25 mg

GM

CROFAB INTRAVENOUS SOLUTION RECONSTITUTED

GM

CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4"

3

CURITY AMD ANTIMICROBIAL STRIP

3

CURITY IODOFORM PACKING STRIP

3

CURVULARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

CYANOKIT INTRAVENOUS SOLUTION RECONSTITUTED 5 GM

GM

CYSVIEW INTRAVESICAL SOLUTION RECONSTITUTED 100 MG

GM

DANDELION SUBCUTANEOUS SOLUTION 1:20

GM

Drug NameDrug Tier

Notes

deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg

GM

DEFLUX INJECTION PREFILLED SYRINGE 50-15 MG/ML

GM

DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG

GM

dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 400 mcg/100ml, 80 mcg/20ml

GM

DEXMEDETOMIDINE HCL INTRAVENOUS SOLUTION 1000 MCG/10ML, 400 MCG/4ML

GM

dexmedetomidine hcl intravenous solution 200 mcg/2ml

GM

DEXMEDETOMIDINE HCL-DEXTROSE INTRAVENOUS SOLUTION 200MCG/50ML -5%, 400MCG/100ML -5%

GM

DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 MG

GM

diluent for treprostinil intravenous solution

GM

DIMERCAPTOPROPANE-SULFONATE INJECTION SOLUTION 250 MG/5ML

GM

Updated May 1, 2020


186

Drug NameDrug Tier

Notes

DIPRIVAN INTRAVENOUS EMULSION 100 MG/10ML, 1000 MG/100ML, 200 MG/20ML, 500 MG/50ML

GM

dipyridamole intravenous solution 5 mg/ml

GM

DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

DOG FENNEL SUBCUTANEOUS SOLUTION 1:20

GM

DRECHSLERA SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR 2.1-600 MG

GM

DUREX EXTRA SENSITIVE DEVICE

PVQL (3 EA

per 30 days)

DUROLANE INTRA-ARTICULAR PREFILLED SYRINGE 60 MG/3ML

GM

DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS SOLUTION 10000 AU/ML

GM

DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT

GM PA

EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION 1:20

GM

Drug NameDrug Tier

Notes

ENCARE VAGINAL SUPPOSITORY 100 MG

PV

ENDARI ORAL PACKET 5 GM

3

ENGLISH PLANTAIN SUBCUTANEOUS SOLUTION 1:20

GM

EPICOCCUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

ergoloid mesylates oral tablet 1 mg

1

EROS-CTD DEVICE 3

etomidate intravenous solution 2 mg/ml

GM

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

EXCILON AMD DRAIN SPONGES PAD 4"X4"

3

FC FEMALE CONDOMPV


FC2 FEMALE CONDOMPV


FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM

3

FIRE ANT SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

FLEXBUMIN INTRAVENOUS SOLUTION 25 %, 5 %

GM

flumazenil intravenous solution 0.5 mg/5ml, 1 mg/10ml

GM

fomepizole intravenous solution 1.5 gm/1.5ml

GM

Updated May 1, 2020


187

Drug NameDrug Tier

Notes

formaldehyde external solution 10 %, 37 %

1

fresenius propoven intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml

GM

FUSARIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

GELFOAM-JMI SPONGE EXTERNAL KIT

3

GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE 30 MG/3ML

GM

GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16.8 MG/2ML

GM

GENVISC 850 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

GERMAN COCKROACH SUBCUTANEOUS SOLUTION 1:20

GM

GIVLAARI SUBCUTANEOUS SOLUTION 189 MG/ML

6 PA

GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 GM

GM

GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED 1 MG

GM

GLUCAGON HCL (DIAGNOSTIC) INJECTION SOLUTION RECONSTITUTED 1 MG

GM

Drug NameDrug Tier

Notes

glutaraldehyde external solution 25 %

1

GOLDENROD SUBCUTANEOUS SOLUTION 1:20

GM

GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU

2

HACKBERRY SUBCUTANEOUS SOLUTION 1:20

GM

HISTATROL INJECTION SOLUTION 2.75 MG/ML

GM

HONEY BEE VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

HONEY BEE VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

HUMAN ALBUMIN GRIFOLS INTRAVENOUS SOLUTION 25 %

GM

HYALGAN INTRA-ARTICULAR SOLUTION 20 MG/2ML

GM

HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

HYLENEX INJECTION SOLUTION 150 UNIT/ML

GM

HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 24 MG/3ML

GM

Updated May 1, 2020


188

Drug NameDrug Tier

Notes

IC GREEN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

GM

indocyanine green intravenous solution reconstituted 25 mg

GM

INFED INJECTION SOLUTION 50 MG/ML

GM

isosulfan blue subcutaneous solution 1 %

GM

IV STABILIZER FOR LUMOXITI INTRAVENOUS SOLUTION 0.7-6.5-6.4 MG/ML

GM

JOHNSON GRASS SUBCUTANEOUS SOLUTION 1:20

GM

JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

KAPOK SUBCUTANEOUS SOLUTION 1:20

GM

kedbumin intravenous solution 25 %

GM

KERLIX AMD ANTIMICROBIAL

3

KERLIX AMD SUPER SPONGES PAD 6"X6-3/4"

3

KETALAR INJECTION SOLUTION 10 MG/ML, 100 MG/ML, 50 MG/ML

GM

KETAMINE HCL INJECTION SOLUTION 0.6 MG/ML, 1 MG/ML

GM

Drug NameDrug Tier

Notes

ketamine hcl injection solution 10 mg/ml, 100 mg/ml, 50 mg/ml

GM

KETAMINE HCL INJECTION SOLUTION PREFILLED SYRINGE 30 MG/3ML, 50 MG/5ML, 50 MG/ML, 60 MG/20ML

GM

KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/ML-%

GM

KINEVAC INJECTION SOLUTION RECONSTITUTED 5 MCG

GM

KOCHIA SUBCUTANEOUS SOLUTION 1:20

GM

LAMBS QUARTERS SUBCUTANEOUS SOLUTION 1:20

GM

LENSCALE SUBCUTANEOUS SOLUTION 1:20

GM

LEXISCAN INTRAVENOUS SOLUTION 0.4 MG/5ML

GM

MACI INTRA-ARTICULAR SHEET

GM

MACRILEN ORAL PACKET 60 MG

6

MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

MELALEUCA SUBCUTANEOUS SOLUTION 1:20

GM

Updated May 1, 2020


189

Drug NameDrug Tier

Notes

MESQUITE SUBCUTANEOUS SOLUTION 1:20

GM

methergine oral tablet 0.2 mg

1

methylergonovine maleate injection solution 0.2 mg/ml

GM

methylergonovine maleate oral tablet 0.2 mg

1

MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 10000 AU/ML

GM

MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION 10000 AU/ML

GM

MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

MIXED FEATHERS SUBCUTANEOUS SOLUTION 1:20

GM

MIXED RAGWEED SUBCUTANEOUS SOLUTION 1:20

GM

MIXED VESPID VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550-550-550 MCG

GM

mixed vespid venom protein subcutaneous solution reconstituted 1100-1100-1100 mcg

GM

Drug NameDrug Tier

Notes

MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 120-120-120 MCG

GM

MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 88 MG/4ML

GM

MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 1:20

GM

MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20

GM

MUCOR SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

MUGWORT SUBCUTANEOUS SOLUTION 1:20

GM

MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT/2ML, 2500 UNIT/0.5ML, 5000 UNIT/ML

GM PA

NITHIODOTE INTRAVENOUS KIT 300MG/10ML&12.5 GM/50ML

GM

OCTAPLAS BLOOD GROUP A INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP AB INTRAVENOUS SOLUTION

GM

Updated May 1, 2020


190

Drug NameDrug Tier

Notes

OCTAPLAS BLOOD GROUP B INTRAVENOUS SOLUTION

GM

OCTAPLAS BLOOD GROUP O INTRAVENOUS SOLUTION

GM

ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM

3

OLIVE TREE SUBCUTANEOUS SOLUTION 1:20

GM

OPTIONS CONCEPTROL VAGINAL GEL 4 %

PV

ORAFATE MOUTH/THROAT PASTE 10 %

3

ORALAIR ADULT SAMPLE KIT SUBLINGUAL TABLET SUBLINGUAL 300 IR

3

ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET SUBLINGUAL 300 IR

3

ORALAIR CHILDRENS SAMPLE KIT SUBLINGUAL THERAPY PACK 3 X 100 IR & 6 X 300 IR

3

ORALAIR CHILDRENS STARTER PACK SUBLINGUAL TABLET SUBLINGUAL 100 IR

3

ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR

3

Drug NameDrug Tier

Notes

ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 30 MG/2ML

GM

OXBRYTA ORAL TABLET 500 MG

5 PA

PECAN POLLEN SUBCUTANEOUS SOLUTION 1:20

GM

PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 PNU/ML

GM

PERENNIAL RYE GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

PHENOL INJECTION SOLUTION 6 %

GM

PHOMA EXIGUA SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146-20 %

6 PA

PLASBUMIN-25 INTRAVENOUS SOLUTION 25 %

GM

PLASBUMIN-5 INTRAVENOUS SOLUTION 5 %

GM

PLASMANATE INTRAVENOUS SOLUTION 5 %

GM

Updated May 1, 2020


191

Drug NameDrug Tier

Notes

pralidoxime chloride intramuscular solution auto-injector 600 mg/2ml

GM

PRAXBIND INTRAVENOUS SOLUTION 2.5 GM/50ML

GM

PRECEDEX INTRAVENOUS SOLUTION 200 MCG/2ML, 200 MCG/50ML, 400 MCG/100ML, 80 MCG/20ML

GM

PREMIUM CONDOMS LUBRICATED

PVQL (3 EA

per 30 days)

PRIVET SUBCUTANEOUS SOLUTION 1:20

GM

propofol intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml

GM

PROTHELIAL MOUTH/THROAT PASTE 10 %

3

PROTOPAM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

GM

PROVAYBLUE INTRAVENOUS SOLUTION 50 MG/10ML

GM

QUEEN PALM SUBCUTANEOUS SOLUTION 1:20

GM

RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20

GM

RADIOGARDASE ORAL CAPSULE 0.5 GM

5 PA

Drug NameDrug Tier

Notes

RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 1-U

2

RAPPORT RLS KIT 3

RAPPORT VTD KIT 3

RED BIRCH SUBCUTANEOUS SOLUTION 1:20

GM

RED CEDAR SUBCUTANEOUS SOLUTION 1:20

GM

RED MAPLE SUBCUTANEOUS SOLUTION 1:20

GM

RED MULBERRY SUBCUTANEOUS SOLUTION 1:20

GM

RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

R-GENE 10 INTRAVENOUS SOLUTION 10 %

GM

RHIZOPUS SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 1:20

GM

ROUGH PIGWEED SUBCUTANEOUS SOLUTION 1:20

GM

RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 1:20

GM

RUZURGI ORAL TABLET 10 MG

6 PA

Updated May 1, 2020


192

Drug NameDrug Tier

Notes

SACCHAROMYCES CEREVISIAE SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

SAGEBRUSH SUBCUTANEOUS SOLUTION 1:20

GM

SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 1:20

GM

SHEEP SORREL SUBCUTANEOUS SOLUTION 1:20

GM

SHORT RAGWEED POLLEN EXT SUBCUTANEOUS SOLUTION 1:20

GM

SODIUM HYALURONATE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

sodium nitrite intravenous solution 30 mg/ml

GM

sodium saccharin powder 1

sodium thiosulfate intravenous solution 25 %

GM

SOLESTA INJECTION GEL 50-15 MG/ML

GM

SORBITOL IRRIGATION SOLUTION 3 %

3

sorbitol irrigation solution 3.3 %

1

sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml

1

SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 1:20

GM

Drug NameDrug Tier

Notes

SPINRAZA INTRATHECAL SOLUTION 12 MG/5ML

6PA;

Specialty Medical

SPINY PIGWEED SUBCUTANEOUS SOLUTION 1:20

GM

STEMPHYLIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

STERILE DILUENT FLOLAN PH 12 INTRAVENOUS SOLUTION

GM

sterile diluent/epoprostenol intravenous solution

GM

sterile water for injection injection solution

GM

sterile water for injection intravenous solution

GM

SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

SWEET GUM SUBCUTANEOUS SOLUTION 1:20

GM

SWEET VERNAL GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

GM

SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16 MG/2ML

GM

SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 48 MG/6ML

GM

Updated May 1, 2020


193

Drug NameDrug Tier

Notes

TALL RAGWEED SUBCUTANEOUS SOLUTION 1:20

GM

TELFA AMD ISLAND DRESSING PAD 4"X5" , 4"X8"

3

TELFA AMD NON-ADHERENT PAD 3"X8"

3

THYROGEN INTRAMUSCULAR SOLUTION RECONSTITUTED 1.1 MG

GM

TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS SOLUTION 10000 BAU/ML, 100000 BAU/ML

GM

TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML

3

TISSEEL EXTERNAL SOLUTION

3

TODAY SPONGE VAGINAL 1000 MG

PV

TRICHOPHYTON SUBCUTANEOUS SOLUTION 20000 PNU/ML

GM

TRILURON INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

GM

TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 %

PV

vcf vaginal contraceptive vaginal gel 4 %

PV

Drug NameDrug Tier

Notes

VENOMIL MIXED VESPID VENOM INJECTION SOLUTION RECONSTITUTED 550-550-550 MCG

GM

VIRGINIA LIVE OAK SUBCUTANEOUS SOLUTION 1:20

GM

VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

GM

VISTOGARD ORAL PACKET 10 GM

6

VITRASE INJECTION SOLUTION 200 UNIT/ML

GM

WASP VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

WESTERN JUNIPER SUBCUTANEOUS SOLUTION 1:20

GM

WHITE ASH SUBCUTANEOUS SOLUTION 1:20

GM

WHITE BIRCH SUBCUTANEOUS SOLUTION 1:20

GM

WHITE FACED HORNET VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

Updated May 1, 2020


194

Drug NameDrug Tier

Notes

WHITE MULBERRY SUBCUTANEOUS SOLUTION 1:20

GM

WHITE OAK SUBCUTANEOUS SOLUTION 1:20

GM

WHITE PINE SUBCUTANEOUS SOLUTION 1:20

GM

WHITE-FACED HORNET VENOM INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 %

3


3


3


3


3


3


3

Drug NameDrug Tier

Notes


3

XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT

GM PA

XIAFLEX INJECTION SOLUTION RECONSTITUTED 0.9 MG

6PA;

Specialty Medical

YELLOW DOCK SUBCUTANEOUS SOLUTION 1:20

GM

YELLOW HORNET VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG, 120 MCG

GM

YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 550 MCG

GM

YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MCG

GM

Updated May 1, 2020


195

Drug NameDrug Tier

Notes

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR LS OPHTHALMIC SOLUTION 0.4 %

3Brand

penalty applies

ACULAR OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

ACUVAIL OPHTHALMIC SOLUTION 0.45 %

3

ALOCRIL OPHTHALMIC SOLUTION 2 %

3

ALOMIDE OPHTHALMIC SOLUTION 0.1 %

2

ALREX OPHTHALMIC SUSPENSION 0.2 %

3

AZASITE OPHTHALMIC SOLUTION 1 %

3

azelastine hcl ophthalmic solution 0.05 %

1

bacitracin ophthalmic ointment 500 unit/gm

1

BEPREVE OPHTHALMIC SOLUTION 1.5 %

3

BESIVANCE OPHTHALMIC SUSPENSION 0.6 %

3

BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 %

3

BLEPH-10 OPHTHALMIC SOLUTION 10 %

3Brand

penalty applies

bromfenac sodium (once-daily) ophthalmic solution 0.09 %

1

Drug NameDrug Tier

Notes

BROMSITE OPHTHALMIC SOLUTION 0.075 %

3

CILOXAN OPHTHALMIC OINTMENT 0.3 %

3

CILOXAN OPHTHALMIC SOLUTION 0.3 %

3Brand

penalty applies

ciprofloxacin hcl ophthalmic solution 0.3 %

1

cromolyn sodium ophthalmic solution 4 %

1

dexamethasone sodium phosphate ophthalmic solution 0.1 %

1

DEXYCU INTRAOCULAR SUSPENSION 9 %

4

diclofenac sodium ophthalmic solution 0.1 %

1

DUREZOL OPHTHALMIC EMULSION 0.05 %

3

epinastine hcl ophthalmic solution 0.05 %

1

erythromycin ophthalmic ointment 5 mg/gm

1

FLAREX OPHTHALMIC SUSPENSION 0.1 %

2

fluorometholone ophthalmic suspension 0.1 %

1

flurbiprofen sodium ophthalmic solution 0.03 %

1

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

2

Updated May 1, 2020


196

Drug NameDrug Tier

Notes

FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 %

3Brand

penalty applies

FML OPHTHALMIC OINTMENT 0.1 %

2

gatifloxacin ophthalmic solution 0.5 %

1

gentak ophthalmic ointment 0.3 %

1

gentamicin sulfate ophthalmic solution 0.3 %

1

ILEVRO OPHTHALMIC SUSPENSION 0.3 %

3

ILUVIEN INTRAVITREAL IMPLANT 0.19 MG

3

INVELTYS OPHTHALMIC SUSPENSION 1 %

3

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

1

KLARITY-A OPHTHALMIC SOLUTION 1 %

3

levofloxacin ophthalmic solution 0.5 %

1

LOTEMAX OPHTHALMIC GEL 0.5 %

3

LOTEMAX OPHTHALMIC OINTMENT 0.5 %

3

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

3Brand

penalty applies

LOTEMAX SM OPHTHALMIC GEL 0.38 %

3

loteprednol etabonate ophthalmic suspension 0.5 %

1

Drug NameDrug Tier

Notes

MAXIDEX OPHTHALMIC SUSPENSION 0.1 %

3

MITOSOL OPHTHALMIC KIT 0.2 MG

GM

MOXEZA OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

moxifloxacin hcl (2x day) ophthalmic solution 0.5 %

1

MOXIFLOXACIN HCL INTRAOCULAR SOLUTION 1 MG/ML, 5 MG/ML

GM

MOXIFLOXACIN HCL INTRAOCULAR SOLUTION PREFILLED SYRINGE 0.3 MG/0.3ML

GM

moxifloxacin hcl ophthalmic solution 0.5 %

1

NATACYN OPHTHALMIC SUSPENSION 5 %

3

NEVANAC OPHTHALMIC SUSPENSION 0.1 %

3

OCUFLOX OPHTHALMIC SOLUTION 0.3 %

3Brand

penalty applies

ofloxacin ophthalmic solution 0.3 %

1

olopatadine hcl ophthalmic solution 0.1 %, 0.2 %

1

OZURDEX INTRAVITREAL IMPLANT 0.7 MG

5Specialty Medical

PAZEO OPHTHALMIC SOLUTION 0.7 %

3

POVIDONE-IODINE OPHTHALMIC SOLUTION 5 %

3

Updated May 1, 2020


197

Drug NameDrug Tier

Notes

PRED FORTE OPHTHALMIC SUSPENSION 1 %

3Brand

penalty applies

PRED MILD OPHTHALMIC SUSPENSION 0.12 %

2

PREDNISOL ACE-MOXIFLOX-BROMFEN OPHTHALMIC SUSPENSION 1-0.5-0.075 %

3

prednisolone acetate ophthalmic suspension 1 %

1

prednisolone acetate p-f ophthalmic suspension 1 %

1

prednisolone sodium phosphate ophthalmic solution 1 %

1

PROLENSA OPHTHALMIC SOLUTION 0.07 %

3

sulfacetamide sodium ophthalmic ointment 10 %

1

sulfacetamide sodium ophthalmic solution 10 %

1

tobramycin ophthalmic solution 0.3 %

1

TOBREX OPHTHALMIC OINTMENT 0.3 %

2

TOBREX OPHTHALMIC SOLUTION 0.3 %

3Brand

penalty applies

TRIESENCE INTRAOCULAR SUSPENSION 40 MG/ML

3

trifluridine ophthalmic solution 1 %

1

Drug NameDrug Tier

Notes

TRIPLE PMB OPHTHALMIC SOLUTION RECONSTITUTED 1-0.5-0.09 %

3

TRIPLE PMK OPHTHALMIC SOLUTION RECONSTITUTED 1-0.5-0.5 %

3

VIGAMOX OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

ZERVIATE OPHTHALMIC SOLUTION 0.24 %

3

ZIRGAN OPHTHALMIC GEL 0.15 %

3

ZYMAXID OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er oral capsule extended release 12 hour 500 mg

1

acetazolamide oral tablet 125 mg, 250 mg

1

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

2

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 %

2Brand

penalty applies

apraclonidine hcl ophthalmic solution 0.5 %

1

AZOPT OPHTHALMIC SUSPENSION 1 %

3

betaxolol hcl ophthalmic solution 0.5 %

1

Updated May 1, 2020


198

Drug NameDrug Tier

Notes

BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 %

3

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

2

bimatoprost ophthalmic solution 0.03 %

1

brimonidine tartrate ophthalmic solution 0.15 %, 0.2 %

1

BRIMONIDINE-DORZOLAMIDE OPHTHALMIC SOLUTION 0.15-2 %

3

carteolol hcl ophthalmic solution 1 %

1

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %

3

COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML

3Brand

penalty applies

COSOPT PF OPHTHALMIC SOLUTION 2-0.5 %

3Brand

penalty applies

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC 2 %

3

dorzolamide hcl solution 2 % ophthalmic 2 %

1

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml

1

dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 %

1

IOPIDINE OPHTHALMIC SOLUTION 1 %

3

ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 %, 4 %

3Brand

penalty applies

Drug NameDrug Tier

Notes

ISTALOL OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

KEVEYIS ORAL TABLET 50 MG

6 PA

latanoprost ophthalmic solution 0.005 %

1

LATANOPROST-TIMOLOL MALEATE OPHTHALMIC SOLUTION 0.005-0.5 %

3

levobunolol hcl ophthalmic solution 0.5 %

1

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

2

methazolamide oral tablet 25 mg, 50 mg

1

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

2

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

1

RHOPRESSA OPHTHALMIC SOLUTION 0.02 %

3

ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 %

3

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

3

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

1

timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % (daily)

1

Updated May 1, 2020


199

Drug NameDrug Tier

Notes

TIMOLOL-BRIMON-DORZOL-LATANOPR OPHTHALMIC SOLUTION 0.5-0.15-2 -0.005%

3

TIMOLOL-BRIMONIDINE-DORZOLAMID OPHTHALMIC SOLUTION 0.5-0.15-2 %

3

TIMOLOL-DORZOLAMID-LATANOPROST OPHTHALMIC SOLUTION 0.5-0.15-0.005 %

3

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 %, 0.5 %

2

TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 %

2Brand

penalty applies

TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 %, 0.5 %

3Brand

penalty applies

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

2Brand

penalty applies

travoprost (bak free) ophthalmic solution 0.004 %

1

TRUSOPT OPHTHALMIC SOLUTION 2 %

3Brand

penalty applies

VYZULTA OPHTHALMIC SOLUTION 0.024 %

3

XALATAN OPHTHALMIC SOLUTION 0.005 %

3Brand

penalty applies

ZIOPTAN OPHTHALMIC SOLUTION 0.0015 %

3

Drug NameDrug Tier

Notes

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-fluor intravenous solution 10 %, 25 %

GM

ak-poly-bac ophthalmic ointment 500-10000 unit/gm

1

AKTEN OPHTHALMIC GEL 3.5 %

3

ALCAINE OPHTHALMIC SOLUTION 0.5 %

3Brand

penalty applies

altacaine ophthalmic solution 0.5 %

1

altafrin ophthalmic solution 10 %, 2.5 %

1

AMVISC INTRAOCULAR SOLUTION 12 MG/ML

3

AMVISC PLUS INTRAOCULAR SOLUTION 16 MG/ML

3

atropine sulfate ophthalmic ointment 1 %

1

ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 %

3

atropine sulfate ophthalmic solution 1 %

1

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

1

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

1

balanced salt intraocular solution

1

BEOVU INTRAVITREAL SOLUTION 6 MG/0.05ML

5Specialty Medical

Updated May 1, 2020


200

Drug NameDrug Tier

Notes

BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED SYRINGE 2.75 MG/0.11ML, 3.75 MG/0.15ML

5PA;

Specialty Medical

BEVACIZUMAB INTRAVITREAL SOLUTION PREFILLED SYRINGE 2.5 MG/0.1ML, 3.25 MG/0.13ML, 3.75 MG/0.15ML

5PA;

Specialty Medical

BIOLON INTRAOCULAR SOLUTION 10 MG/ML

3

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

2

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %

2

bss intraocular solution 1

CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 1 %, 2 %

2Brand

penalty applies

CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 %

2

cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 %

1

CYCLOSPORINE IN KLARITY OPHTHALMIC EMULSION 0.1 %

3

DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR SOLUTION 1-5 MG/ML

GM

Drug NameDrug Tier

Notes

DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR SOLUTION 1-0.5-0.4 MG/ML

GM

EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML

5Specialty Medical

EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE 2 MG/0.05ML

5Specialty Medical

FLUORESCITE INTRAVENOUS SOLUTION 10 %

GM

GELFILM OPHTHALMIC FILM

3

HEALON GV INTRAOCULAR SOLUTION 14 MG/ML

3

HEALON INTRAOCULAR SOLUTION 10 MG/ML

3

HEALON PRO INTRAOCULAR SOLUTION 10 MG/ML

3

HEALON5 INTRAOCULAR SOLUTION 23 MG/ML

3

HEALON5 PRO INTRAOCULAR SOLUTION 23 MG/ML

3

homatropaire ophthalmic solution 5 %

1

HYALURONIDASE (INTRAOCULAR) INTRAOCULAR SOLUTION 175 UNIT/ML

GM

ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 %

3

Updated May 1, 2020


201

Drug NameDrug Tier

Notes

JETREA INTRAVITREAL SOLUTION 0.375 MG/0.3ML

5PA;

Specialty Medical

LACRISERT OPHTHALMIC INSERT 5 MG

3

LASTACAFT OPHTHALMIC SOLUTION 0.25 %

3

LIDOCAINE-EPINEPHRINE INTRAOCULAR SOLUTION 7.5-0.25 MG/ML

GM

LIDOCAINE-PHENYLEPHRINE INTRAOCULAR SOLUTION 1-1.5 %

GM

LIDOCAINE-PHENYLEPHRINE-BSS INTRAOCULAR SOLUTION PREFILLED SYRINGE 1-1.5 % (1ML)

GM

LUCENTIS INTRAVITREAL SOLUTION 0.3 MG/0.05ML, 0.5 MG/0.05ML

5Specialty Medical

LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.3 MG/0.05ML

3

LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.5 MG/0.05ML

5Specialty Medical

LUXTURNA INTRAOCULAR SUSPENSION 5000000000000 VG/ML

6PA;

Specialty Medical

Drug NameDrug Tier

Notes

MACUGEN INTRAOCULAR SOLUTION 0.3 MG

5Specialty Medical

MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1

3Brand

penalty applies

MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1

3Brand

penalty applies

MEMBRANEBLUE OPHTHALMIC SOLUTION 0.15 %

GM

MIOCHOL-E INTRAOCULAR SOLUTION RECONSTITUTED 20 MG

3

MIOSTAT INTRAOCULAR SOLUTION 0.01 %

3

MOXIFLOXACIN HCL-BSS INTRAVITREAL SOLUTION 1 MG/ML

GM

neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400-10000 , 5-400-10000

1

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

1

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

1

Updated May 1, 2020


202

Drug NameDrug Tier

Notes

neo-polycin hc ophthalmic ointment 1 %

1

neo-polycin ophthalmic ointment 3.5-400-10000

1

OMIDRIA INTRAOCULAR SOLUTION 1-0.3 %

GM

OXERVATE OPHTHALMIC SOLUTION 0.002 %

6 PA

phenylephrine hcl ophthalmic solution 10 %, 2.5 %

1

polycin ophthalmic ointment 500-10000 unit/gm

1

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

1

POLYTRIM OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-%

3Brand

penalty applies

PRED-G OPHTHALMIC SUSPENSION 0.3-1 %

2

PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 %

2

PREDNISOLONE-BROMFENAC OPHTHALMIC SOLUTION 1-0.075 %

3

PREDNISOLONE-BROMFENAC OPHTHALMIC SUSPENSION 1-0.075 %

GM

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SUSPENSION 1-0.5 %

3

Drug NameDrug Tier

Notes

PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-0.5-0.075 %

3

PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC SUSPENSION 1-0.5-0.075 %

3

PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-0.5-0.075 %

3

proparacaine hcl ophthalmic solution 0.5 %

1

PROVISC INTRAOCULAR SOLUTION 10 MG/ML

3

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

2

RESTASIS OPHTHALMIC EMULSION 0.05 %

2

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

1

tetracaine hcl ophthalmic solution 0.5 %

1

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

2

TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 %

2Brand

penalty applies

Updated May 1, 2020


203

Drug NameDrug Tier

Notes

TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 %

2

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

1

TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR SUSPENSION 15-1 MG/ML

GM

TROPICAMIDE-CYCLOPENTOLATE-PE OPHTHALMIC SOLUTION 1-1-2.5 %

3

TROPICAMIDE-PHENYLEPHRINE OPHTHALMIC SOLUTION 1-2.5 %

3

TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC SOLUTION 1-0.5-2.5-0.5 %

3

VISIONBLUE OPHTHALMIC SOLUTION 0.06 %

GM

VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 15 MG

5Specialty Medical

XIIDRA OPHTHALMIC SOLUTION 5 %

3

ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 %

3

Otic Agents - Drugs for Ear Conditions

acetic acid otic solution 2 %

1

Drug NameDrug Tier

Notes

CETRAXAL OTIC SOLUTION 0.2 %

3Brand

penalty applies

CIPRO HC OTIC SUSPENSION 0.2-1 %

3

CIPRODEX OTIC SUSPENSION 0.3-0.1 %

3

ciprofloxacin hcl otic solution 0.2 %

1

CIPROFLOXACIN-FLUOCINOLONE PF OTIC SOLUTION 0.3-0.025 %

3

COLY-MYCIN S OTIC SUSPENSION 3.3-3-10-0.5 MG/ML

3

cortic-nd otic solution 10-10-1 mg/ml

1

DERMOTIC OTIC OIL 0.01 %

3Brand

penalty applies

exotic-hc otic solution 10-10-1 mg/ml

1

flac otic oil 0.01 % 1

fluocinolone acetonide otic oil 0.01 %

1

hydrocortisone-acetic acid otic solution 1-2 %

1

neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1

1

neomycin-polymyxin-hc otic suspension 3.5-10000-1

1

ofloxacin otic solution 0.3 %

1

OTICIN HC NR OTIC SOLUTION 10-10-1 MG/ML

3

OTIPRIO INTRATYMPANIC SUSPENSION 6 %

3

Updated May 1, 2020


204

Drug NameDrug Tier

Notes

OTOVEL OTIC SOLUTION 0.3-0.025 %

3

PRAMOTIC OTIC LIQUID 1-0.1 %

3

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

ADRENALIN NASAL SOLUTION 0.1 %

3

azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray

1

BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY

3

benzonatate oral capsule 100 mg, 150 mg, 200 mg

1

bromfed dm oral syrup 30-2-10 mg/5ml

1

brompheniramine tannate oral tablet chewable 12 mg

1

budesonide nasal suspension 32 mcg/act

1

carbinoxamine maleate oral solution 4 mg/5ml

1

carbinoxamine maleate oral tablet 4 mg

1

CINQAIR INTRAVENOUS SOLUTION 100 MG/10ML

5PA;

Specialty Medical

clemastine fumarate oral tablet 2.68 mg

1

CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML, 240 MG/3ML

3

cyproheptadine hcl oral syrup 2 mg/5ml

1

Drug NameDrug Tier

Notes

cyproheptadine hcl oral tablet 4 mg

1

desloratadine oral tablet 5 mg

1

desloratadine oral tablet dispersible 2.5 mg, 5 mg

1

dexchlorpheniramine maleate oral solution 2 mg/5ml

1

diphen oral elixir 12.5 mg/5ml

1

diphenhydramine hcl oral elixir 12.5 mg/5ml

1

FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 30 MG/ML

5 PA

FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML

5PA;

Specialty Medical

flunisolide nasal solution 25 mcg/act (0.025%)

1

fluticasone propionate nasal suspension 50 mcg/act

1

GILPHEX TR ORAL TABLET 10-388 MG

3

GILTUSS TR ORAL TABLET 10-28-388 MG

3

guaiatussin ac oral syrup 100-10 mg/5ml

1

guaifenesin ac oral syrup 100-10 mg/5ml

1

hydrocodone polst-cpm polst er oral suspension extended release 10-8 mg/5ml

1

hydrocodone-homatropine oral syrup 5-1.5 mg/5ml

1

Updated May 1, 2020


205

Drug NameDrug Tier

Notes

hydrocodone-homatropine oral tablet 5-1.5 mg

1

hydromet oral syrup 5-1.5 mg/5ml

1

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 7 %

3

INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-%

3

ipratropium bromide nasal solution 0.03 %, 0.06 %

1

KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 MG/5ML

3

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

1

levocetirizine dihydrochloride oral tablet 5 mg

1

mometasone furoate nasal suspension 50 mcg/act

1

NASONEX NASAL SUSPENSION 50 MCG/ACT

3Brand

penalty applies

nebusal inhalation nebulization solution 3 %

1

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

3

NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML

3

Drug NameDrug Tier

Notes

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML

5 PA

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

5 PA

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG

5PA;

Specialty Medical

olopatadine hcl nasal solution 0.6 %

1

OMNARIS NASAL SUSPENSION 50 MCG/ACT

3

PATANASE NASAL SOLUTION 0.6 %

3Brand

penalty applies

phenadoz rectal suppository 12.5 mg, 25 mg

1

promethazine hcl oral solution 6.25 mg/5ml

1

promethazine hcl oral syrup 6.25 mg/5ml

1

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

1

promethazine hcl rectal suppository 12.5 mg, 25 mg

1

promethazine-codeine oral solution 6.25-10 mg/5ml

1

promethazine-codeine oral syrup 6.25-10 mg/5ml

1

promethazine-dm oral syrup 6.25-15 mg/5ml

1

Updated May 1, 2020


206

Drug NameDrug Tier

Notes

promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml

1

promethazine-phenylephrine oral syrup 6.25-5 mg/5ml

1

promethegan rectal suppository 12.5 mg, 25 mg, 50 mg

1

pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml

1

pulmosal inhalation nebulization solution 7 %

1

QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 MCG/ACT

3

QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT

3

QUZYTTIR INTRAVENOUS SOLUTION 10 MG/ML

GM

RYCLORA ORAL SOLUTION 2 MG/5ML

3Brand

penalty applies

SINUVA NASAL IMPLANT 1350 MCG

4Specialty Medical

sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %

1

SSKI ORAL SOLUTION 1 GM/ML

3

SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 MG/ML-%

3

TESSALON PERLES ORAL CAPSULE 100 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10-8 MG

3

TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 54.3-8 MG

3

TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 14.7-2.8 MG/5ML

3

virtussin ac w/alc oral liquid 100-10 mg/5ml

1

XHANCE NASAL EXHALER SUSPENSION 93 MCG/ACT

3

XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5ML

5PA;

Specialty Medical

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG

5PA;

Specialty Medical

ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT

3

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE ORAL TABLET 10 MG, 20 MG

3Brand

penalty applies

acetylcysteine inhalation solution 10 %, 20 %

1

ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 MG/30ML

GMQL (4 ML

per 30 days)

Updated May 1, 2020


207

Drug NameDrug Tier

Notes

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

3PA; Brand

penalty applies

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

3 PA

ADYPHREN AMP II INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

ADYPHREN AMP INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

ADYPHREN II INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

ADYPHREN INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg

1

albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act

1QL (3 GM

per 30 days)

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

1

albuterol sulfate oral syrup 2 mg/5ml

1

albuterol sulfate oral tablet 2 mg, 4 mg

1

Drug NameDrug Tier

Notes

ALVESCO INHALATION AEROSOL SOLUTION 160 MCG/ACT, 80 MCG/ACT

3

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

3

ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG

6PA;

Specialty Medical

ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG

3QL (30 EA

per 30 days)

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

3 PA

ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

2QL (1 EA

per 30 days)


2QL (1 EA

per 30 days)

ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH

2QL (1 EA

per 30 days)

Updated May 1, 2020


208

Drug NameDrug Tier

Notes


2QL (1 EA

per 30 days)


2QL (1 EA

per 30 days)

ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

2

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT

2

BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT

3

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH

3 PA

BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML

3

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

1

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT

2

cromolyn sodium inhalation nebulization solution 20 mg/2ml

1

Drug NameDrug Tier

Notes

DALIRESP ORAL TABLET 250 MCG, 500 MCG

3 PA

difil-g forte oral liquid 100-100 mg/5ml

1

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT

2

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML

2

epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 mg/0.3ml, 0.3 mg/0.3ml

1QL (4 EA

per 30 days)

EPINEPHRINE PROFESSIONAL INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

EPINEPHRINESNAP-EMS INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML

3

Brand penalty


EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML

3

Brand penalty


EPISNAP INJECTION KIT 1 MG/ML

3QL (4 EA

per 30 days)

ESBRIET ORAL CAPSULE 267 MG

6 PA

ESBRIET ORAL TABLET 267 MG, 801 MG

6 PA

Updated May 1, 2020


209

Drug NameDrug Tier

Notes

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

3

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT

3QL (24 GM

per 30 days)

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

1

GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML

6PA;

Specialty Medical

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

2

ipratropium bromide inhalation solution 0.02 %

1

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

1

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

1

Drug NameDrug Tier

Notes

metaproterenol sulfate oral syrup 10 mg/5ml

1

montelukast sodium oral packet 4 mg

1

montelukast sodium oral tablet 10 mg

1

montelukast sodium oral tablet chewable 4 mg, 5 mg

1

OFEV ORAL CAPSULE 100 MG, 150 MG

6 PA

PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML

3

PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

1QL (3 GM

per 30 days)

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT

3QL (3 EA

per 30 days)

PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG/20ML

6PA;

Specialty Medical

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

6PA;

Specialty Medical

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT

2

Updated May 1, 2020


210

Drug NameDrug Tier

Notes

PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML

3Brand

penalty applies

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT

2

SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL POWDER 4 GM

3

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE

2

SINGULAIR ORAL PACKET 4 MG

3Brand

penalty applies

SINGULAIR ORAL TABLET 10 MG

3Brand

penalty applies

SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG

3Brand

penalty applies

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG

2

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

2

STERILE TALC POWDER INTRAPLEURAL SUSPENSION RECONSTITUTED 5 GM

3

Drug NameDrug Tier

Notes

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

3

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

2

SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT

2

terbutaline sulfate injection solution 1 mg/ml

GM

terbutaline sulfate oral tablet 2.5 mg, 5 mg

1

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG

2

theophylline er oral tablet extended release 12 hour 300 mg, 450 mg

1

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

1

theophylline in d5w intravenous solution 0.8-5 mg/ml-%

GM

theophylline oral solution 80 mg/15ml

1

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH

3

TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT

2

Updated May 1, 2020


211

Drug NameDrug Tier

Notes

UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 MCG

3

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

1QL (3 GM

per 30 days)

wixela inhub inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

XOPENEX CONCENTRATE INHALATION NEBULIZATION SOLUTION 1.25 MG/0.5ML

3Brand

penalty applies

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

3Brand

penalty applies

YUPELRI INHALATION SOLUTION 175 MCG/3ML

5 PA

zafirlukast oral tablet 10 mg, 20 mg

1

ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

6PA;

Specialty Medical

zileuton er oral tablet extended release 12 hour 600 mg

4

ZYFLO ORAL TABLET 600 MG

4

Drug NameDrug Tier

Notes

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML

5 PA

CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG

5 PA

KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG

5 PA

KALYDECO ORAL TABLET 150 MG

5 PA

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML

5 PA

ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG

5 PA

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

5 PA

PULMOZYME INHALATION SOLUTION 1 MG/ML

5 PA

SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG, 50-75 & 75 MG

6 PA

TOBI NEBULIZER INHALATION NEBULIZATION SOLUTION 300 MG/5ML

6 PA

TOBI PODHALER INHALATION CAPSULE 28 MG

5 PA

tobramycin nebulization solution 300 mg/5ml inhalation 300 mg/5ml

4 PA

Updated May 1, 2020


212

Drug NameDrug Tier

Notes

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION 300 MG/5ML

5 PA

TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 MG

5 PA

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA ORAL TABLET 20 MG

6 PA

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG

5 PA

alyq oral tablet 20 mg 4 PA

ambrisentan oral tablet 10 mg, 5 mg

4 PA

bosentan oral tablet 125 mg, 62.5 mg

4 PA

epoprostenol sodium intravenous solution reconstituted 0.5 mg, 1.5 mg

4PA;

Specialty Medical

FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

5PA;

Specialty Medical

LETAIRIS ORAL TABLET 10 MG, 5 MG

5 PA

OPSUMIT ORAL TABLET 10 MG

5 PA

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG

5 PA

Drug NameDrug Tier

Notes

REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 MG/20ML, 200 MG/20ML, 50 MG/20ML

5PA;

Specialty Medical

REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML

6PA;

Specialty Medical

REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML

5 PA

REVATIO ORAL TABLET 20 MG

6 PA

sildenafil citrate intravenous solution 10 mg/12.5ml

4PA;

Specialty Medical

sildenafil citrate oral suspension reconstituted 10 mg/ml

5 PA

sildenafil citrate oral tablet 20 mg

4 PA

tadalafil (pah) oral tablet 20 mg

4 PA

TRACLEER ORAL TABLET 125 MG, 62.5 MG

5 PA

TRACLEER ORAL TABLET SOLUBLE 32 MG

5 PA

treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 mg/20ml, 50 mg/20ml

5PA;

Specialty Medical

TYVASO INHALATION SOLUTION 0.6 MG/ML

5 PA

TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML

5 PA

TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML

5 PA

Updated May 1, 2020


213

Drug NameDrug Tier

Notes

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

5 PA

UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG

3

VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG

5PA;

Specialty Medical

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML

5 PA

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

baclofen intrathecal solution 10 mg/20ml, 40 mg/20ml

GM

baclofen oral tablet 10 mg, 20 mg, 5 mg

1

carisoprodol oral tablet 250 mg, 350 mg

1

carisoprodol-aspirin oral tablet 200-325 mg

1

chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg

1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg

1

DANTRIUM INTRAVENOUS SOLUTION RECONSTITUTED 20 MG

GM

Drug NameDrug Tier

Notes

DANTRIUM ORAL CAPSULE 25 MG, 50 MG

3Brand

penalty applies

dantrolene sodium intravenous solution reconstituted 20 mg

GM

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg

1

FEXMID ORAL TABLET 7.5 MG

3Brand

penalty applies

GABLOFEN INTRATHECAL SOLUTION 10000 MCG/20ML, 40000 MCG/20ML

GM

LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML, 10 MG/20ML, 10 MG/5ML, 40 MG/20ML

GM

LORZONE ORAL TABLET 375 MG, 750 MG

3Brand

penalty applies

metaxalone oral tablet 400 mg, 800 mg

1

methocarbamol injection solution 1000 mg/10ml

GM

methocarbamol oral tablet 500 mg, 750 mg

1

NORGESIC FORTE ORAL TABLET 50-770-60 MG

3

orphenadrine citrate er oral tablet extended release 12 hour 100 mg

1

orphenadrine citrate injection solution 30 mg/ml

GM

orphenadrine-aspirin-caffeine oral tablet 50-770-60 mg

1

Updated May 1, 2020


214

Drug NameDrug Tier

Notes

ORPHENGESIC FORTE ORAL TABLET 770-60-50 MG

3

revonto intravenous solution reconstituted 20 mg

GM

ROBAXIN INJECTION SOLUTION 1000 MG/10ML

GM

ROBAXIN-750 ORAL TABLET 750 MG

3Brand

penalty applies

RYANODEX INTRAVENOUS SUSPENSION RECONSTITUTED 250 MG

GM

SKELAXIN ORAL TABLET 800 MG

3Brand

penalty applies

SOMA ORAL TABLET 250 MG, 350 MG

3Brand

penalty applies

tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg

1

tizanidine hcl oral tablet 2 mg, 4 mg

1

ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG

3Brand

penalty applies

ZANAFLEX ORAL TABLET 4 MG

3Brand

penalty applies

Sleep Disorder Agents

AMBIEN CR ORAL TABLET EXTENDED RELEASE 12.5 MG, 6.25 MG

3Brand

penalty applies

AMBIEN ORAL TABLET 10 MG, 5 MG

3Brand

penalty applies

Drug NameDrug Tier

Notes

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

1

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG

3

doxepin hcl oral tablet 3 mg, 6 mg

1

eszopiclone oral tablet 1 mg, 2 mg, 3 mg

1

flurazepam hcl oral capsule 15 mg, 30 mg

1

HETLIOZ ORAL CAPSULE 20 MG

6 PA

LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG

3Brand

penalty applies

modafinil oral tablet 100 mg, 200 mg

1

NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG

3Brand

penalty applies

PROVIGIL ORAL TABLET 100 MG, 200 MG

3Brand

penalty applies

ramelteon oral tablet 8 mg

1

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG

3Brand

penalty applies

ROZEREM ORAL TABLET 8 MG

3Brand

penalty applies

SECONAL ORAL CAPSULE 100 MG

3

SILENOR ORAL TABLET 3 MG, 6 MG

3Brand

penalty applies

SUNOSI ORAL TABLET 150 MG, 75 MG


days)

Updated May 1, 2020


215

Drug NameDrug Tier

Notes

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

1

WAKIX ORAL TABLET 17.8 MG, 4.45 MG

6 PA

XYREM ORAL SOLUTION 500 MG/ML

6 PA

zaleplon oral capsule 10 mg, 5 mg

1

zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg

1

zolpidem tartrate oral tablet 10 mg, 5 mg

1

Updated May 1, 2020


216

Index of Drugs

1ST MEDX-PATCH/ LIDOCAINE........................ 167T GUMMY ES..................... 87T LIDO.............................. 16abacavir sulfate...................72abacavir sulfate-lamivudine 72abacavir-lamivudine-zidovudine...........................72ABANEU-SL..................... 124ABELCET........................... 45ABILIFY.............................. 69ABILIFY MAINTENA...........69abiraterone acetate.............52ABOUTTIME PEN NEEDLE........................... 121ABRAXANE........................ 52ABSORICA....................... 107ABSORICA LD..................107ABSTRAL............................. 8ACACIA............................ 183acamprosate calcium..........20acarbose........................... 117ACCOLATE...................... 207ACCUPRIL..........................84ACCURETIC.......................84ACD FORMULA A.............. 33ACD-A NOCLOT-50........... 33acebutolol hcl......................84ACETADOTE....................183acetaminophen-codeine... 8, 9acetaminophen-codeine #2.. 8acetaminophen-codeine #3.. 8acetaminophen-codeine #4.. 8acetazolamide...................198acetazolamide er.............. 198acetazolamide sodium........ 84acetic acid.................148, 204acetylcysteine........... 183, 207ACIPHEX.......................... 139ACIPHEX SPRINKLE....... 139acitretin............................. 107ACREMONIUM.................183ACTEMRA................ 169, 170ACTEMRA ACTPEN.........169ACTHAR........................... 155ACTHIB.............................177ACTHREL......................... 183ACTIGALL........................ 140ACTIMMUNE.................... 170ACTIQ...................................9ACTIVASE.......................... 33ACTIVE FE....................... 124ACTIVE-KETOPROFEN.......6

ACTIVELLA...................... 159ACTIVITE..........................124ACTONEL.........................181ACTOPLUS MET..............117ACTOS............................. 117ACULAR........................... 196ACULAR LS......................196ACUVAIL.......................... 196acyclovir..............................72acyclovir sodium................. 72ACZONE...........................107ADACEL........................... 177ADAKVEO........................ 183adapalene......................... 107ADASUVE...........................69adc/f (0.5mg/ml)................124ADCETRIS..........................52ADCIRCA..........................213ADDERALL.......................100ADDERALL XR.................100adefovir dipivoxil ................. 72ADEMPAS........................ 213ADENOCARD.....................84adenosine................... 84, 183adenosine (diagnostic)......183ADLYXIN.......................... 117ADLYXIN STARTER PACK................................ 117ADMELOG........................121ADMELOG SOLOSTAR... 121ADRENAL C FORMULA...124ADRENALIN............. 205, 207adriamycin.......................... 52adrucil ................................. 52adult aspirin regimen............ 6ADVAIR DISKUS.............. 208ADVAIR HFA.................... 208ADVATE............................. 79ADYNOVATE......................79ADYPHREN......................208ADYPHREN AMP............. 208ADYPHREN AMP II.......... 208ADYPHREN II...................208AEMCOLO..........................21AFINITOR........................... 52AFINITOR DISPERZ.......... 52afirmelle............................ 159AFLURIA QUADRIVALENT..............177AFREZZA......................... 121AFSTYLA............................79AGGRASTAT......................68AGGRENOX....................... 68

AGONEAZE........................16AGRYLIN............................ 79AIMOVIG............................ 49AJOVY................................ 49ak-fluor..............................200AKOVAZ............................. 84ak-poly-bac....................... 200AKTEN..............................200AKYNZEO...........................43ALA SCALP...................... 107ala-cort..............................107ALA-QUIN...........................45albendazole........................ 65ALBENZA........................... 65ALBUKED 25.................... 183ALBUKED 5...................... 183albumin human................. 183ALBUMINEX..................... 183albumin-zlb....................... 183alburx................................ 183ALBUTEIN........................ 183albuterol sulfate................ 208albuterol sulfate er............ 208albuterol sulfate hfa.......... 208ALCAINE.......................... 200alclometasone dipropionate.............. 107, 108ALCOHOL PREP PADS... 108ALCORTIN A...................... 45ALDACTAZIDE................... 84ALDACTONE......................85ALDER..............................183ALDURAZYME................. 145ALECENSA.........................52alendronate sodium.......... 181alfentanil hcl..........................9ALFERON N..................... 170alfuzosin hcl er..................151ALIMTA...............................52ALINIA................................ 65ALIQOPA............................ 52aliskiren fumarate............... 85ALKERAN........................... 53allopurinol........................... 48allopurinol sodium...............48almotriptan malate.............. 49ALOCRIL.......................... 196ALOGLIPTIN BENZOATE 117ALOGLIPTIN-METFORMIN HCL............117ALOGLIPTIN-PIOGLITAZONE............... 117ALOMIDE..........................196

217

ALOPRIM............................48ALORA..............................159alosetron hcl..................... 140ALOXI................................. 43ALPHAGAN P...................198ALPHA-LIPOIC ACID....... 183ALPHANATE/VWF COMPLEX/HUMAN............ 79ALPHANINE SD................. 79alprazolam.......................... 77alprazolam er...................... 77alprazolam intensol.............77alprazolam xr...................... 77ALPROLIX.......................... 79alprostadil ........................... 85ALREX.............................. 196ALTABAX............................21altacaine........................... 200ALTACE..............................85altafrin............................... 200altavera............................. 159ALTERNARIA................... 183ALTOPREV.........................85ALUNBRIG......................... 53ALVESCO.........................208alyacen 1/35..................... 159alyacen 7/7/7.................... 159alyq................................... 213amabelz............................ 159amantadine hcl................... 66AMARYL........................... 117AMBIEN............................ 215AMBIEN CR......................215AMBISOME........................ 45ambrisentan...................... 213amcinonide....................... 108AMD FOAM DRESSING...183AMD FOAM DRESSING TOPSHEET...................... 183AMERGE............................ 49AMERICAN BEECH......... 184AMERICAN COCKROACH.......................................... 184AMERICAN ELM.............. 184AMERICAN SYCAMORE. 184amethia............................. 159amethia lo......................... 159amethyst........................... 159AMICAR..............................79AMIDATE..........................184amiloride hcl........................85amiloride-hydrochlorothiazide.............85

AMINO ACID.................... 124aminoacetic acid............... 148aminoamrms..................... 124aminobenzoate potassium 125aminocaproic acid...............79aminoreliefrms.................. 125AMINOSYN II....................125AMINOSYN-PF.................125amiodarone hcl................... 85AMITIZA............................140amitriptyline hcl................... 40amlodipine besylate............ 85amlodipine besylate-benazepril hcl......................85amlodipine besylate-valsartan............................. 85amlodipine-atorvastatin.......85amlodipine-olmesartan....... 85amlodipine-valsartan-hctz...85ammonium lactate............ 108AMMONUL....................... 145amnesteem....................... 108amoxapine.......................... 40amoxicill-clarithro-lansopraz.......................... 140amoxicillin........................... 21amoxicillin-potassium clavulanate..........................22amoxicillin-potassium clavulanate er..................... 21AMPHADASE................... 184amphetamine-dextroamphetamine.......... 100amphetamine-dextroamphetamine er......100amphotericin b.................... 45ampicillin............................. 22ampicillin sodium................ 22ampicillin-sulbactam sodium................................ 22AMVISC............................ 200AMVISC PLUS..................200ANACAINE....................... 108ANADROL-50................... 154ANAFRANIL........................40anagrelide hcl..................... 79ana-lex.............................. 179ANALPRAM HC................179ANALPRAM HC SINGLES179ANALPRAM-HC................179ANASCORP......................184ANASPAZ......................... 140anastrozole......................... 53

ANAVIP.............................184ANCOBON..........................45ANDEXXA.........................184ANDRODERM.................. 154ANDROGEL......................154ANDROGEL PUMP.......... 154ANECTINE........................104ANESTHESIA S/I-40........ 184ANESTHESIA S/I-40A...... 184ANESTHESIA S/I-40H......184ANESTHESIA S/I-40S...... 184ANESTHESIA S/I-60........ 184ANGELIQ..........................159ANGIOMAX........................ 33ANIMI-3.............................125ANIMI-3/VITAMIN D......... 125ANJESO............................... 6ANNOVERA......................159ANODYNE LPT.................. 16ANORO ELLIPTA............. 208ANTABUSE........................ 20ANTARA............................. 85anticoagulant cit dext soln a..........................................33anticoagulant sodium citrate.................................. 33ANTIVENIN MICRURUS FULVIUS...........................184anucort-hc.........................179ANUSOL-HC.....................179anusol-hc.......................... 180ANZEMET...........................43apap-caff-dihydrocodeine..... 9APEXICON E....................108APIDRA SOLOSTAR........121APIDRA VIAL....................121APLENZIN.......................... 40APOKYN.............................66APP SLIM RMS................ 184apraclonidine hcl...............198aprepitant............................43apri....................................159APRISO............................ 180APTENSIO XR..................100APTIOM.............................. 35APTIVUS............................ 72AQUACEL AG BURN....... 108AQUASOL A..................... 125ARAKODA.......................... 65ARALAST NP................... 208aranelle............................. 159ARANESP (ALBUMIN FREE)................................. 80

218

ARAVA..............................170ARCALYST.......................170ARCAPTA NEOHALER.... 208ARESTIN.......................... 106argatroban.......................... 33argatroban in sodium chloride............................... 33ARGININE HCL................ 125argyle sterile saline........... 125argyle sterile water............125ARICEPT............................ 39ARIKAYCE..........................22ARIMIDEX.......................... 53aripiprazole......................... 69ARISTADA..........................69ARISTADA INITIO.............. 69ARIXTRA............................ 33ARIZONA CYPRESS........184armodafinil ........................ 215ARMOUR THYROID.........168arnica flower..................... 184ARNUITY ELLIPTA...........208AROMASIN.........................53ARRANON..........................53arsenic trioxide....................53ARTHROTEC....................... 6ARTICADENT DENTAL......16ARTISS.............................184ARYMO ER...........................9ARZERRA...........................53arzol silver nit applicators. 108ASACOL HD..................... 180ASCENIV.......................... 170ASCLERA........................... 85ascomp-codeine................... 9ASCOR............................. 125ASCORBIC ACID............. 125ashlyna............................. 159ASMANEX (120 METERED DOSES)......... 208ASMANEX (14 METERED DOSES)............................ 208ASMANEX (30 METERED DOSES)............................ 208ASMANEX (60 METERED DOSES)............................ 209ASMANEX (7 METERED DOSES)............................ 209ASMANEX HFA................ 209ASPARLAS.........................53aspirin................................... 6aspirin adult low strength...... 6aspirin childrens....................6

aspirin ec.............................. 6aspirin ec low dose............... 6aspirin ec low strength.......... 6aspirin low dose.................... 6aspirin-dipyridamole er....... 68ASTAGRAF XL................. 170ATABEX OB..................... 125ATACAND...........................85ATACAND HCT.................. 85atazanavir sulfate................72ATELVIA........................... 181atenolol............................... 85atenolol-chlorthalidone........85ATGAM............................. 170ATIVAN...............................77atomoxetine hcl.................100atorvastatin calcium............ 85atovaquone......................... 65atovaquone-proguanil hcl... 65atracurium besylate.......... 104ATRAPRO DERMAL SPRAY..............................108ATRIPLA.............................72ATROPINE SULFATE.................................. 140, 200atropine sulfate................. 200ATROVENT HFA.............. 209AUBAGIO......................... 103aubra.................................159aubra eq............................159AUGMENTIN...................... 22AUGMENTIN ES-600......... 22AUREOBASIDIUM............184aurovela 1.5/30................. 159aurovela 1/20.................... 159aurovela 24 fe................... 159aurovela fe 1.5/30............. 159aurovela fe 1/20................ 159AURYXIA.......................... 148AUSTEDO........................ 104AUSTRALIAN PINE..........184AVALIDE.............................85AVANDIA.......................... 117AVAPRO.............................85avar cleanser.................... 108AVAR-E EMOLLIENT....... 108AVAR-E GREEN...............108AVASTIN............................ 53AVELOX............................. 22aviane............................... 159avidoxy................................22avita.................................. 108AVODART........................ 151

AVONEX PEN.................. 103AVONEX PREFILLED...... 103AVONEX VIAL INTRAMUSCULAR KIT... 103AVYCAZ............................. 22AYGESTIN........................159ayuna................................ 159AYVAKIT.............................53azacitidine...........................53AZACTAM...........................22AZASAN........................... 170AZASITE...........................196azathioprine...................... 170azathioprine sodium..........170AZEDRA DOSIMETRIC......53AZEDRA THERAPEUTIC...53azelaic acid....................... 108azelastine hcl............ 196, 205AZELEX............................ 108AZILECT............................. 66azithromycin........................22AZOPT..............................198AZOR..................................86aztreonam...........................22AZULFIDINE.....................180AZULFIDINE EN-TABS.... 180azurette.............................159b-6 folic acid......................125baciim................................. 22bacitracin.................... 22, 196bacitracin-polymyxin b...... 200bacitra-neomycin-polymyxin-hc.....................200baclofen............................ 214BACMIN............................125BACTERIOSTATIC WATER(BENZ ALC).........184BACTRIM............................23BACTRIM DS......................23BAHIA............................... 184bal in oil .............................184balanced salt.....................200BALCOLTRA.................... 159BALD CYPRESS.............. 184balsalazide disodium........ 180balsam peru-castor oil ...... 108BALVERSA.........................53balziva...............................159BANZEL..............................35BAQSIMI ONE PACK....... 120BAQSIMI TWO PACK.......120BARACLUDE......................72BASAGLAR KWIKPEN.....121

219

BAVENCIO......................... 53BAXDELA........................... 23BAYBERRY (WAX MYRTLE).......................... 184BAYER ASPIRIN EC LOW DOSE....................................6BCG VACCINE................. 177BD AUTOSHIELD DUO PEN NEEDLES.................121BD ULTRA-FINE INSULIN SYRINGES....................... 121BD ULTRA-FINE PEN NEEDLES......................... 121BECONASE AQ................205bekyree............................. 159BELBUCA............................. 9BELEODAQ........................ 53belladonna alkaloids-opium.......................................... 141BELRAPZO.........................53BELSOMRA......................215benazepril hcl......................86benazepril-hydrochlorothiazide.............86BENDAMUSTINE HCL....... 53BENDEKA...........................53BENEFIX............................ 80BENICAR............................86BENICAR HCT................... 86BENLYSTA....................... 170BENSAL HP......................108BENTYL............................141benzalkonium chloride........ 23BENZNIDAZOLE................ 65benzoin............................. 108benzoin compound........... 108benzonatate...................... 205benztropine mesylate..........66BEOVU............................. 200BEPREVE.........................196BERINERT........................170BERMUDA GRASS.......... 184beser.................................108BESIVANCE..................... 196BESPONSA........................ 53BETADINE OPHTHALMIC PREP................................ 196BETAMETHASONE COMBO............................ 152betamethasone dipropionate...................... 108betamethasone dipropionate aug............... 108

BETAMETHASONE SOD PHOS & ACET..................152betamethasone sod phos & acet................................152BETAMETHASONE SODIUM PHOSPHATE.... 152betamethasone valerate... 108BETAPACE.........................86BETAPACE AF................... 86BETASERON....................103betaxolol hcl................86, 198bethanechol chloride.........148BETHKIS.......................... 212BETIMOL.......................... 199BETOPTIC-S.................... 199BEVACIZUMAB................ 201BEVESPI AEROSPHERE 209BEVYXXA........................... 33bexarotene..........................53BEXSERO........................ 177BEYAZ.............................. 159bicalutamide........................53BICILLIN C-R......................23BICILLIN C-R 900/300........23BICILLIN L-A.......................23BICNU.................................54BIDIL...................................86BIKTARVY.......................... 72BILTRICIDE........................ 65bimatoprost....................... 199BI-MIX...............................148BINOSTO..........................181biocel................................ 125BIOFREQUENCY INSOLES.......................... 185BIOGUARD GAUZE SPONGES........................ 185BIOGUARD ISLAND DRESSINGS.....................185BIOGUARD NON-ADHERENT DRESSING.. 185BIOLON............................ 201BIORPHEN......................... 86BIO-STATIN........................45bio-statin............................. 45BIOTHRAX....................... 177bisoprolol fumarate............. 86bisoprolol-hydrochlorothiazide.............86bivalirudin trifluoroacetate...33BIVALIRUDIN-SODIUM CHLORIDE......................... 33BIVIGAM...........................170

BLACK WALNUT POLLEN.......................................... 185BLACK WILLOW.............. 185bleomycin sulfate................ 54BLEPH-10.........................196BLEPHAMIDE...................201BLEPHAMIDE S.O.P........ 201BLINCYTO..........................54blisovi 24 fe.......................159blisovi fe 1.5/30.................160blisovi fe 1/20....................160BLOXIVERZ........................51BOCASAL.........................106BONIVA............................ 181BONJESTA.........................43BOOSTRIX....................... 177BORTEZOMIB.................... 54bosentan........................... 213BOSULIF............................ 54BOTOX............................. 185BOTRYTIS........................185BOX ELDER..................... 185bp 10-1..............................108BP CLEANSING WASH... 109bp vit 3.............................. 125BPCO................................109b-plex................................ 125b-plex plus........................ 125BRAFTOVI..........................54BREO ELLIPTA................ 209BREVIBLOC....................... 86BREVIBLOC IN NACL........ 86BREVIBLOC PREMIXED... 86BREVIBLOC PREMIXED DS.......................................86BREVITAL SODIUM......... 185BRIDION...........................185briellyn.............................. 160BRILINTA............................68brimonidine tartrate...........199BRIMONIDINE-DORZOLAMIDE............... 199BRINEURA....................... 145BRIVIACT........................... 35BROME.............................185bromfed dm.......................205bromfenac sodium (once-daily)................................. 196bromocriptine mesylate.......66brompheniramine tannate.205BROMSITE....................... 196BROVANA........................ 209BRUKINSA......................... 54

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bss.................................... 201budesonide....... 180, 205, 209budesonide er................... 180bumetanide......................... 86BUMEX............................... 86BUNAVAIL.......................... 20BUPAP..................................9BUPHENYL...................... 145bupivacaine fisiopharma..... 16bupivacaine hcl................... 16BUPIVACAINE HCL........... 16bupivacaine hcl (pf).............16BUPIVACAINE HCL-NACL.16bupivacaine in dextrose...... 16BUPIVACAINE IN DEXTROSE........................ 16bupivacaine spinal.............. 16bupivacaine-epinephrine.....16bupivacaine-epinephrine (pf)...................................... 16BUPRENEX.......................... 9buprenorphine.......................9BUPRENORPHINE.............. 9buprenorphine hcl........... 9, 20buprenorphine hcl-naloxone hcl........................20bupropion hcl...................... 40bupropion hcl er (smoking det)......................................20bupropion hcl er (sr)............40bupropion hcl er (xl)............ 40buspirone hcl...................... 77busulfan.............................. 54BUSULFEX.........................54butalbital-acetaminophen......9BUTALBITAL-ACETAMINOPHEN.............. 9butalbital-apap-caff-cod........ 9butalbital-apap-caffeine........ 9butalbital-asa-caff-codeine....9butalbital-aspirin-caffeine......9butorphanol tartrate.............. 9BUTRANS.............................9BYDUREON..................... 117BYDUREON BCISE AUTOINJECTOR..............117BYETTA 10 MCG PEN..... 117BYETTA 5 MCG PEN....... 117BYSTOLIC.......................... 86cabergoline....................... 155CABLIVI.............................. 68CABOMETYX..................... 54CADUET............................. 86

CAFCIT.............................104CAFERGOT........................49caffeine citrate.................. 104CALAN SR..........................86CALCIFOL........................ 125calcipotriene......................109calcipotriene-betameth diprop................................109calcitonin (salmon)............181CALCITRENE................... 109calcitriol.....................109, 182calcium acetate.................148calcium acetate (phos binder)...............................148CALCIUM CHLORIDE...... 125calcium chloride................ 125CALCIUM DISODIUM VERSENATE.................... 185CALCIUM GLUCONATE.. 125CALCIUM GLUCONATE-NACL................................ 125CALCIUM-FOLIC ACID PLUS D.............................125CALDOLOR.......................... 6CALIFORNIA PEPPER TREE................................ 185CALQUENCE..................... 54CAMBIA.............................. 49camila............................... 160CAMPATH.......................... 54CAMPTOSAR..................... 54camrese............................ 160camrese lo........................ 160CANASA........................... 180CANCIDAS......................... 45candesartan cilexetil ........... 86candesartan cilexetil-hctz... 86CANDIDA ALBICANS EXTRACT......................... 185CAPASTAT SULFATE........51capecitabine........................54CAPEX..............................109CAPLYTA........................... 69CAPRELSA.........................54captopril .............................. 86captopril-hydrochlorothiazide.............87CARAFATE.......................139CARBAGLU...................... 125carbamazepine................... 35carbamazepine er............... 35CARBATROL......................35carbidopa............................ 66

carbidopa-levodopa............ 67carbidopa-levodopa er........ 67carbidopa-levodopa-entacapone......................... 67carbinoxamine maleate.....205CARBOCAINE.................... 16CARBOCAINE PRESERVATIVE-FREE..... 16carboplatin.......................... 54carboprost tromethamine..155CARDENE IV......................87CARDIOPLEGIA DEL NIDO FORMULA.............. 125CARDIOPLEGIA IND PLASMA HIGH K..............125CARDIOPLEGIA IND PLASMA-TROMET...........125CARDIOPLEGIA INDUCTION HIGH K........ 125CARDIOPLEGIA INDUCTION LOW DEX.... 125CARDIOPLEGIA INDUCTION NON-ENR.... 125CARDIOPLEGIA MAIN LOW DEXTROSE.............126CARDIOPLEGIA MAIN LOW TROMETHA............ 126CARDIOPLEGIA MAIN PLASMA-TROME............. 126CARDIOPLEGIA MAINTENANCE................126CARDIOPLEGIA REPERFUSATE 4:1......... 126CARDIOPLEGIC...............126cardioplegic.......................126CARDIOVID PLUS........... 185CARDIZEM......................... 87CARDIZEM CD...................87CARDIZEM LA....................87CARDURA.......................... 87CARDURA XL...................151CARIMUNE NF.................170carisoprodol...................... 214carisoprodol-aspirin.......... 214carisoprodol-aspirin-codeine................................. 9carmustine.......................... 54CARNITOR....................... 126CARNITOR SF................. 126carteolol hcl.......................199cartia xt............................... 87carvedilol.............................87carvedilol phosphate er.......87

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CASODEX.......................... 54caspofungin acetate............45CAT HAIR EXTRACT....... 185CATAPRES........................ 87CATAPRES-TTS-1............. 87CATAPRES-TTS-2............. 87CATAPRES-TTS-3............. 87CATHFLO ACTIVASE........ 33CATTLE EPITHELIUM..... 185cavarest............................ 106CAVERJECT.................... 148CAVERJECT IMPULSE....148CAYA................................ 185CAYSTON........................ 212caziant.............................. 160CEDAR ELM.....................185cefaclor............................... 23cefaclor er........................... 23cefadroxil ............................ 23CEFAZOLIN IN SODIUM CHLORIDE......................... 23cefazolin sodium................. 23CEFAZOLIN SODIUM........ 23cefazolin sodium-dextrose.. 23cefdinir................................ 23cefditoren pivoxil ................. 23cefepime hcl........................23cefepime-dextrose.............. 24cefixime...............................24CEFOTAN...........................24cefotaxime sodium..............24cefotetan disodium..............24cefotetan disodium-dextrose.............................. 24cefoxitin sodium.................. 24CEFOXITIN SODIUM-DEXTROSE........................ 24cefpodoxime proxetil ...........24cefprozil .............................. 24ceftazidime..........................24ceftazidime and dextrose....24ceftriaxone sodium..............24ceftriaxone sodium in dextrose.............................. 24ceftriaxone sodium-dextrose.............................. 24cefuroxime axetil .................24cefuroxime sodium..............24CELEBREX...........................6celecoxib...............................6CELESTONE SOLUSPAN152CELEXA..............................40CELLCEPT....................... 170

CELLCEPT INTRAVENOUS................170CELONTIN..........................35cem-urea...........................109CENTANY AT..................... 24CENTRATEX.................... 126cephalexin...........................25CEPROTIN......................... 80CERDELGA...................... 145CEREBYX...........................35CEREZYME......................145cerovel.............................. 109CERVIDIL......................... 148CETACAINE....................... 16CETRAXAL.......................204CETROTIDE..................... 155cevimeline hcl................... 106CHANTIX............................ 20CHANTIX CONTINUING MONTH PAK...................... 20CHANTIX STARTING MONTH PAK...................... 20chateal.............................. 160chateal eq......................... 160CHEMET...........................126CHENODAL......................141CHIRHOSTIM................... 185chloramphenicol sod succinate.............................25chlordiazepoxide hcl........... 77chlordiazepoxide-amitriptyline.........................40chlordiazepoxide-clidinium141chlorhexidine gluconate.... 106CHLORHEXIDINE GLUCONATE................... 185chloroprocaine hcl (pf)........ 16chloroquine phosphate....... 65chlorothiazide......................87chlorothiazide sodium......... 87chlorpromazine hcl..............69chlorthalidone..................... 87chlorzoxazone...................214CHOLBAM........................ 145cholestyramine....................87cholestyramine light............ 87choline-mag trisalicylate....... 6chorionic gonadotropin..... 155chromagen........................126chromic chloride................126CIALIS.............................. 148ciclodan...............................45ciclopirox.............................45

ciclopirox olamine............... 45cidofovir.............................. 72cilostazol............................. 68CILOXAN.......................... 196CIMDUO............................. 72cimetidine..........................139cimetidine hcl.................... 139CIMZIA..............................170CIMZIA PREFILLED KIT.. 170CIMZIA STARTER KIT..... 170cinacalcet hcl.................... 182CINQAIR...........................205CINRYZE.......................... 171CINVANTI........................... 43CIPRO................................ 25CIPRO HC........................ 204CIPRODEX....................... 204ciprofloxacin hcl.. 25, 196, 204ciprofloxacin in d5w............ 25CIPROFLOXACIN-FLUOCINOLONE PF........204cisatracurium besylate...... 104cisatracurium besylate (pf)104cisplatin...............................54citalopram hydrobromide...................................... 40, 41CITANEST FORTE DENTAL..............................17CITANEST PLAIN DENTAL..............................17CITRANATAL MEDLEY....126CLADOSPORIUM CLADOSPORIOIDES....... 185CLADOSPORIUM SPHAEROSPERMUM......185cladribine............................ 54claravis..............................109clarithromycin......................25clarithromycin er................. 25clearlax............................. 141clemastine fumarate......... 205CLENPIQ.......................... 141CLEOCIN............................25CLEOCIN PHOSPHATE.....25CLEVIPREX........................87CLIMARA..........................160CLIMARA PRO................. 160clindacin etz...................... 109clindacin-p.........................109clindamycin hcl................... 25clindamycin palmitate hcl....25clindamycin phosphate25, 109

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clindamycin phosphate in d5w..................................... 25CLINDESSE....................... 25CLINIMIX E/DEXTROSE (2.75/5)............................. 126CLINIMIX E/DEXTROSE (4.25/10)........................... 126CLINIMIX E/DEXTROSE (4.25/5)............................. 126CLINIMIX E/DEXTROSE (5/15)................................ 126CLINIMIX E/DEXTROSE (5/20)................................ 126CLINIMIX/DEXTROSE (4.25/10)........................... 126CLINIMIX/DEXTROSE (4.25/5)............................. 126CLINIMIX/DEXTROSE (5/15)................................ 126CLINIMIX/DEXTROSE (5/20)................................ 126CLINISOL SF....................126CLINOLIPID......................126clinpro 5000...................... 106clobazam............................ 35clobetasol prop emollient base.................................. 109clobetasol propionate........109clobetasol propionate e.....109clobetasol propionate emulsion........................... 109CLOBEX........................... 109clocortolone pivalate......... 109clodan............................... 109CLODERM........................109clofarabine.......................... 54CLOLAR............................. 54clomiphene citrate.............155clomipramine hcl.................41clonazepam........................ 77clonidine..............................87clonidine hcl........................ 87clonidine hcl (analgesia)..... 10clonidine hcl er..................100clopidogrel bisulfate............ 68clorazepate dipotassium..... 77CLOROTEKAL....................17clotrimazole.........................45clotrimazole-betamethasone................... 45clovique.............................126clozapine.............................69CLOZARIL.......................... 69

COAGADEX....................... 80coal tar.............................. 109COARTEM..........................65COCAINE HCL................... 17COCKLEBUR................... 186cod liver oil ........................126codeine sulfate....................10COGENTIN.........................67COLAZAL......................... 180COLCHICINE......................48colchicine............................ 48colchicine-probenecid......... 48COLCRYS.......................... 49colesevelam hcl.................. 88COLESTID..........................88COLESTID FLAVORED..... 88colestipol hcl....................... 88colistimethate sodium (cba)....................................25colocort............................. 180COLY-MYCIN M................. 25COLY-MYCIN S................204COMBIGAN...................... 199COMBIPATCH..................160COMBIVENT RESPIMAT. 209COMBIVIR.......................... 72COMETRIQ (100 MG DAILY DOSE)..................... 54COMETRIQ (140 MG DAILY DOSE)..................... 54COMETRIQ (60 MG DAILY DOSE)..................... 54COMPLERA........................72compro................................43COMTAN............................ 67CONCERTA..............100, 101CONDOMS....................... 186CONDYLOX......................109constulose.........................141COPIKTRA......................... 55CORDRAN........................110COREG...............................88COREG CR........................ 88CORGARD......................... 88CORIFACT......................... 80CORLANOR....................... 88CORLOPAM....................... 88CORN POLLEN................ 186CORTANE-B.....................110CORTEF........................... 152CORTENEMA...................180cortic-nd............................ 204CORTIFOAM.................... 180

cortisone acetate.............. 152CORTISPORIN.................110CORTROSYN...................186CORVERT.......................... 88corvita............................... 126corvita 150........................ 126CORVITE 150...................127CORVITE FE.................... 127COSENTYX (300 MG DOSE).............................. 171COSENTYX 150 MG/ML.. 171COSENTYX SENSOREADY (300 MG).171COSENTYX SENSOREADY PEN........ 171COSMEGEN.......................55COSOPT...........................199COSOPT PF..................... 199cosyntropin....................... 186COTELLIC.......................... 55COUMADIN........................ 33covaryx............................. 160covaryx hs.........................160COZAAR.............................88CREON.............................145CRESEMBA........................46CRESTOR.......................... 88CRINONE......................... 160CRIXIVAN...........................72CROFAB...........................186cromolyn sodium.......................... 141, 196, 209crotan..................................65cryselle-28........................ 160CRYSVITA........................145c-topical.............................. 17CUBICIN............................. 26CUBICIN RF....................... 26CUPRIC CHLORIDE........ 127CURITY AMD ANTIMICROBIAL SPNGE 186CURITY AMD ANTIMICROBIAL STRIP.. 186CURITY IODOFORM PACKING STRIP.............. 186curity sterile saline............ 127CUROSURF..................... 205CURVULARIA...................186CUTAQUIG.......................171CUTIVATE........................ 110CUVITRU..........................171CUVPOSA........................ 141cyanocobalamin................127

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CYANOCOBALAMIN........127CYANOKIT....................... 186cyclafem 1/35....................160cyclafem 7/7/7...................160cyclobenzaprine hcl.......... 214CYCLOGYL...................... 201CYCLOMYDRIL................201cyclopentolate hcl............. 201cyclophosphamide.............. 55cycloserine..........................51CYCLOSET...................... 117cyclosporine......................171CYCLOSPORINE IN KLARITY...........................201cyclosporine modified....... 171CYKLOKAPRON................ 80CYMBALTA........................ 41cyproheptadine hcl............205CYRAMZA.......................... 55cyred................................. 160cyred eq............................ 160CYSTADANE....................145CYSTAGON......................145CYSVIEW......................... 186cytarabine........................... 55cytarabine (pf).....................55CYTOGAM........................171CYTOMEL........................ 168CYTOTEC.........................139CYTOVENE........................ 72cytra k crystals.................. 127D.H.E. 45............................ 49dacarbazine........................ 55DACOGEN..........................55dactinomycin.......................55dalfampridine er................ 103DALIRESP........................ 209DALVANCE........................ 26danazol............................. 154DANDELION.....................186DANTRIUM.......................214dantrolene sodium............ 214dapsone...................... 51, 110DAPTACEL.......................177daptomycin......................... 26DARAPRIM.........................65darifenacin hydrobromide er.......................................148DARZALEX.........................55dasetta 1/35...................... 160dasetta 7/7/7..................... 160daunorubicin hcl..................55DAURISMO........................ 55

DAYPRO...............................6daysee.............................. 160DAYTRANA...................... 101DDAVP............................. 155DDAVP RHINAL TUBE.....155DEBACTEROL................. 106deblitane........................... 160DECADRON..................... 152DECARA...........................127decitabine........................... 55deferasirox........................ 127deferoxamine mesylate.....186DEFITELIO......................... 33DEFLUX............................186DELESTROGEN...............160DELFLEX-LC/1.5% DEXTROSE...................... 127DELFLEX-LC/2.5% DEXTROSE...................... 127DELFLEX-LC/4.25% DEXTROSE...................... 127delflex-sm/1.5% dextrose. 127delflex-sm/2.5% dextrose. 127DELSTRIGO....................... 72delyla................................ 160DELZICOL........................ 180demeclocycline hcl..............26DEMEROL.......................... 10DEMSER............................ 88DENAVIR............................72denta 5000 plus................ 106dentagel............................ 106DEPAKOTE........................ 35DEPAKOTE ER.................. 35DEPAKOTE SPRINKLES... 35DEPEN TITRATABS.........148DEPO-ESTRADIOL.......... 160DEPO-MEDROL............... 152DEPO-PROVERA.............160DEPO-SUBQ PROVERA 104....................................161DEPO-TESTOSTERONE. 154DERMACINRX EMPRICAINE..................... 17DERMACINRX PRIZOPAK 17DERMA-SMOOTHE/FS BODY................................110DERMA-SMOOTHE/FS SCALP.............................. 110dermazene..........................46DERMOTIC.......................204DERMULCERA.................110DESCOVY.......................... 72

DESFERAL.......................186desipramine hcl...................41desloratadine.................... 205desmopressin ace spray refrig..................................155desmopressin acetate.......155desmopressin acetate spray................................. 156desogestrel-ethinyl estradiol............................ 161DESONATE...................... 110desonide........................... 110DESOWEN....................... 110desoximetasone................110DESOXYN........................ 101DESVENLAFAXINE ER......41desvenlafaxine succinate er.........................................41DETROL........................... 148DETROL LA......................148dexamethasone................ 152dexamethasone intensol...152DEXAMETHASONE SOD PHOS-BUPIV....................152dexamethasone sod phosphate pf..................... 152dexamethasone sodium phosphate................. 152, 196DEXAMETHASONE-MOXIFLOXACIN...............201DEXAMETH-MOXIFLOX-KETOROLAC....................201dexchlorpheniramine maleate............................. 205DEXEDRINE.....................101dexifol............................... 127DEXILANT........................ 139DEXMEDETOMIDINE HCL.......................................... 186dexmedetomidine hcl........186dexmedetomidine hcl in nacl................................... 186DEXMEDETOMIDINE HCL-DEXTROSE..............186dexmethylphenidate hcl.... 101dexmethylphenidate hcl er 101DEXONTO 0.4%...............152DEXPAK 10 DAY..............152DEXPAK 13 DAY..............152DEXPAK 6 DAY................152dexrazoxane hcl..................55

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dextroamphetamine sulfate.......................................... 101dextroamphetamine sulfate er.......................................101dextrose............................ 127DEXTROSE...................... 127DEXTROSE 5%/ELECTROLYTE #48...127dextrose in lactated ringers.......................................... 127dextrose-nacl.................... 127dextrose-sodium chloride..127DEXYCU...........................196DIACOMIT.......................... 35dialyvite.............................127DIALYVITE 3000.............. 127DIALYVITE 5000.............. 127DIALYVITE SUPREME D. 127DIALYVITE/ZINC.............. 127DIANEAL LOW CALCIUM/1.5% DEX........ 128DIANEAL LOW CALCIUM/2.5% DEX........ 128DIANEAL LOW CALCIUM/4.25% DEX...... 128DIANEAL PD-2/1.5% DEXTROSE...................... 128DIANEAL PD-2/2.5% DEXTROSE...................... 128DIANEAL PD-2/4.25% DEXTROSE...................... 128DIASTAT ACUDIAL............ 35DIASTAT PEDIATRIC........ 35diazepam...................... 36, 77DIAZEPAM......................... 77diazepam intensol...............77diazoxide...........................120DIBENZYLINE.................... 88DICLOFENAC EPOLAMINE.........................6diclofenac potassium............ 6diclofenac sodium. 6, 110, 196diclofenac sodium er.............6diclofenac-misoprostol.......... 6DICLOSTREAM....................6dicloxacillin sodium............. 26dicyclomine hcl................. 141didanosine.......................... 72DIFICID...............................26difil-g forte......................... 209diflorasone diacetate.........110DIFLUCAN..........................46diflunisal................................6

DIGIFAB........................... 186digitek................................. 88digox................................... 88digoxin................................ 88dihydroergotamine mesylate............................. 49DILANTIN........................... 36DILANTIN INFATABS.........36DILATRATE-SR..................88DILAUDID........................... 10diltiazem hcl........................ 89diltiazem hcl er....................89diltiazem hcl er beads......... 88diltiazem hcl er coated beads............................ 88, 89DILTIAZEM HCL-SODIUM CHLORIDE......................... 89dilt-xr................................... 89DILUENT FOR LEFAMULIN......................128diluent for treprostinil ........ 186dimenhydrinate................... 43DIMENTHO...........................6DIMERCAPTOPROPANE-SULFONATE.................... 186DIOVAN.............................. 89DIOVAN HCT......................89DIPENTUM....................... 180diphen............................... 205diphenhydramine hcl.........205diphenoxylate-atropine..... 141DIPHTHERIA-TETANUS TOXOIDS DT....................177DIPRIVAN.........................187DIPROLENE..................... 110DIPROLENE AF............... 110dipyridamole............... 68, 187disopyramide phosphate.....89disulfiram............................ 20DITROPAN XL..................148DIURIL................................ 89divalproex sodium...............36divalproex sodium er...........36DIVIGEL............................161dobutamine hcl................... 89dobutamine in d5w..............89docetaxel............................ 55dofetilide............................. 89DOG EPITHELIUM........... 187DOG FENNEL.................. 187DOLOPHINE.......................10donepezil hcl.......................39DONNATAL...................... 141

dopamine hcl...................... 89dopamine in d5w.................89DOPRAM.......................... 104DOPTELET.........................80DORAL............................... 77DORZOLAMIDE HCL....... 199dorzolamide hcl.................199dorzolamide hcl-timolol mal.......................................... 199dorzolamide hcl-timolol mal pf.......................................199dotti ................................... 161DOVATO.............................72doxazosin mesylate............ 89doxepin hcl..........41, 110, 215doxercalciferol...................182DOXIL................................. 55doxorubicin hcl....................55doxorubicin hcl liposomal....55doxy 100............................. 26doxycycline hyclate.............26doxycycline monohydrate... 26DRECHSLERA................. 187DRISDOL..........................128DRITHO-CREME HP........110dronabinol........................... 43droperidol............................43drospiren-eth estrad-levomefol.......................... 161drospirenone-ethinyl estradiol............................ 161DROXIA.............................. 55DRYSOL........................... 110DSUVIA.............................. 10DUAVEE........................... 161DUETACT.........................117DULERA........................... 209duloxetine hcl......................41DUODOTE........................187DUPIXENT........................110DURACLON........................10DURAGESIC-100............... 10DURAGESIC-12................. 10DURAGESIC-25................. 10DURAGESIC-50................. 10DURAGESIC-75................. 10duramorph.......................... 10duraxin................................ 10DUREX EXTRA SENSITIVE....................... 187DUREZOL.........................196DUROLANE......................187

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DUST MITE MIXED ALLERGEN EXT...............187dutasteride........................ 151dutasteride-tamsulosin hcl 151DUTOPROL........................89d-vite pediatric.................. 128DYANAVEL XR.................101DYAZIDE............................ 89DYRENIUM.........................89DYSPORT........................ 187E.E.S. 400...........................26E.E.S. GRANULES.............26EASTERN COTTONWOOD............... 187easygel............................. 106EC-NAPROSYN................... 6ec-naproxen..........................6econazole nitrate................ 46EC-RX PROGESTERONE161EDARBI.............................. 89EDARBYCLOR................... 89EDECRIN............................89EDEX................................ 148ed-spaz............................. 141EDURANT.......................... 73eemt..................................161eemt hs............................. 161efavirenz............................. 73EFFER-K.......................... 128effer-k................................128EFFEXOR XR.....................41EFFIENT.............................68EGRIFTA.......................... 156ELAPRASE.......................145ELELYSO......................... 145ELESTRIN........................ 161eletriptan hydrobromide...... 49ELIDEL............................. 110ELIGARD.......................... 156ELIMITE..............................65elinest............................... 161ELIQUIS..............................33ELIQUIS DVT/PE STARTER PACK................ 33ELITEK............................... 55ELITE-OB......................... 128ELIXOPHYLLIN................ 209ELLA................................. 161ELLENCE........................... 55ELLIOTTS B..................... 128ELMIRON......................... 148ELOCTATE.........................80eluryng.............................. 161

ELZONRIS..........................55EMBEDA.............................10EMCYT............................... 56EMEND.........................43, 44EMEND TRI-PACK............. 44EMFLAZA........................... 49EMGALITY..........................49EMGALITY (300 MG DOSE)................................ 49emoquette.........................161EMPLICITI.......................... 56EMSAM...............................41EMTRIVA............................73EMVERM............................ 65ENABLEX......................... 148enalapril maleate................ 89enalaprilat........................... 89enalapril-hydrochlorothiazide.............90ENBRACE HR.................. 128ENBREL........................... 171ENBREL MINI...................171ENBREL SURECLICK......171ENCARE...........................187ENDARI............................ 187endocet............................... 10ENDOMETRIN..................161ENGERIX-B...................... 177ENGLISH PLANTAIN....... 187ENHERTU.......................... 56ENOVARX-IBUPROFEN...... 7enoxaparin sodium....... 33, 34enpresse-28......................161enskyce.............................161entacapone......................... 67entecavir............................. 73ENTEREG........................ 141ENTOCORT EC................180ENTRESTO........................ 90ENTYVIO.......................... 171enulose............................. 141ENVARSUS XR................ 171ENZADYNE...................... 145EPANED............................. 90EPCLUSA........................... 73ephedrine sulfate................ 90EPHEDRINE SULFATE......90EPHEDRINE SULFATE (PRESSORS)..................... 90EPICOCCUM....................187EPIDIOLEX.........................36EPIFOAM..........................110epinastine hcl....................196

epinephrine................. 90, 209EPINEPHRINE................... 90EPINEPHRINE HCL-DEXTROSE........................ 90EPINEPHRINE HCL-NACL 90epinephrine pf..................... 90EPINEPHRINE PROFESSIONAL..............209EPINEPHRINE-DEXTROSE........................ 90EPINEPHRINE-NACL.........90EPINEPHRINESNAP-EMS.......................................... 209EPINEPHRINESNAP-V.... 209EPIPEN 2-PAK................. 209EPIPEN JR 2-PAK............209epirubicin hcl.......................56EPISNAP.......................... 209epitol................................... 36EPIVIR................................ 73EPIVIR HBV........................73eplerenone..........................90EPOGEN............................ 80epoprostenol sodium........ 213eptifibatide.......................... 68EPZICOM........................... 73EQUAPAX/ATORVASTATIN/COQ10............................ 90EQUAPAX/IBUPROFEN/MINREX...................................7EQUETRO.......................... 78ERAXIS...............................46ERBITUX............................ 56ergocalciferol.................... 128ergoloid mesylates............187ERGOMAR......................... 50ergotamine-caffeine............ 50ERIVEDGE......................... 56ERLEADA........................... 56erlotinib hcl..........................56EROS-CTD....................... 187errin...................................161ERTACZO...........................46ERWINAZE.........................56ery.....................................110ERYPED 200...................... 26ERYPED 400...................... 26ERY-TAB............................ 26ERYTHROCIN LACTOBIONATE................ 26ERYTHROCIN STEARATE.........................26erythromycin....... 27, 111, 196

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erythromycin base.............. 26erythromycin ethylsuccinate............... 26, 27ESBRIET.......................... 209escitalopram oxalate...........41ESGIC.................................10esmolol hcl..........................90ESMOLOL HCL.................. 90esmolol hcl-sodium chloride............................... 90esomeprazole sodium.......139ESPEROCT........................ 80est estrogens-methyltest...161est estrogens-methyltest ds...................................... 161est estrogens-methyltest hs...................................... 161estarylla............................ 161estazolam........................... 77ESTRACE.........................161estradiol.................... 161, 162estradiol valerate.............. 162estradiol-norethindrone acet................................... 162ESTRING..........................162ESTROGEL...................... 162ESTROSTEP FE.............. 162eszopiclone.......................215ethacrynate sodium............ 90ethacrynic acid....................90ethambutol hcl.................... 51ethosuximide.......................36ethyl chloride.......................17ethynodiol diac-eth estradiol............................ 162etodolac................................ 7etodolac er............................ 7etomidate.......................... 187etonogestrel-ethinyl estradiol............................ 162ETOPOPHOS..................... 56etoposide............................ 56EUCRISA..........................111EUFLEXXA....................... 187euthyrox............................ 168EVAMIST.......................... 162EVENITY.......................... 181everolimus.................. 56, 171EVISTA............................. 155EVOMELA.......................... 56EVOTAZ............................. 73EVOXAC...........................106

EXCILON AMD DRAIN SPONGES........................ 187EXELDERM........................ 46EXELON............................. 39exemestane........................ 56EXFORGE.......................... 91EXFORGE HCT..................90EXJADE............................128EXODERM..........................46exotic-hc........................... 204EXPAREL........................... 17EXTAVIA...........................103EXTINA...............................46EXTRANEAL.................... 128EYLEA.............................. 201ezetimibe............................ 91ezetimibe-simvastatin......... 91fabb...................................128FABRAZYME....................145FALESSA..........................162falmina.............................. 162famciclovir...........................73famotidine......................... 139famotidine premixed......... 139FANAPT..............................69FANAPT TITRATION PACK.................................. 69FARESTON........................ 56FARXIGA.......................... 117FARYDAK...........................56FASENRA.........................205FASENRA PEN................ 205FASLODEX.........................56fa-vitamin b-6-vitamin b-12128fayosim............................. 162FBL KIT.................................7FC FEMALE CONDOM.... 187FC2 FEMALE CONDOM.. 187febuxostat........................... 49FEIBA................................. 80felbamate............................ 36FELBATOL......................... 36FELDENE............................. 7felodipine er........................ 91FEM PH............................ 148FEMARA.............................56FEMCAP...........................187FEMHRT LOW DOSE...... 162FEMRING......................... 162femynor.............................162fenofibrate...........................91fenofibrate micronized........ 91fenofibric acid......................91

fenoprofen calcium............... 7fenortho.................................7fentanyl............................... 11fentanyl citrate.................... 10FENTANYL CITRATE...10, 11fentanyl citrate (pf).............. 10FENTANYL CITRATE-NACL.................................. 11FENTANYL CIT-ROPIVACAINE-NACL........ 11FENTANYL-BUPIVACAINE-NACL.........11FENTORA...........................11FERAHEME......................128FERIVAFA........................ 128ferocon..............................128ferotrinsic.......................... 128FERRALET 90.................. 128FERRAPLUS 90............... 128FERRIPROX.....................128FERRLECIT......................128FERRO-PLEX HEMATINIC...................... 128FERROTRIN.....................128FETROJA........................... 27FETZIMA............................ 41FETZIMA TITRATION........ 41FEXMID............................ 214FIASP............................... 121FIASP FLEXTOUCH.........121FIASP PENFILL................121FIBRICOR...........................91FIBRYGA............................ 80FINACEA.......................... 111finasteride......................... 151FIORICET........................... 11FIORICET/CODEINE..........11FIORINAL........................... 11FIORINAL/CODEINE #3.....11FIRAZYR.......................... 171FIRE ANT......................... 187FIRMAGON...................... 156FIRMAGON (240 MG DOSE).............................. 156FIRST-LANSOPRAZOLE. 139FIRST-MOUTHWASH BLM.................................. 106FIRST-OMEPRAZOLE..... 139FIRST-PROGESTERONE VGS.................................. 162FIRVANQ............................27flac.................................... 204FLAGYL.............................. 27

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FLAREX............................196flavoxate hcl......................149FLEBOGAMMA DIF..........172flecainide acetate................91FLECTOR............................. 7FLEXBUMIN..................... 187FLEXIN............................... 17FLOLAN............................213FLOMAX........................... 151FLORIVA PLUS................ 129FLOVENT DISKUS...........210FLOVENT HFA................. 210floxuridine........................... 56FLUAD.............................. 177FLUAD QUADRIVALENT. 177FLUARIX QUADRIVALENT..............177FLUBLOK QUADRIVALENT..............177FLUCELVAX QUADRIVALENT..............177fluconazole..........................46fluconazole in sodium chloride............................... 46flucytosine...........................46fludarabine phosphate........ 56fludrocortisone acetate..... 152FLULAVAL QUADRIVALENT......177, 178flumazenil ..........................187flunisolide..........................205fluocinolone acetonide.................................. 111, 204fluocinolone acetonide body.................................. 111fluocinolone acetonide scalp................................. 111fluocinonide.......................111fluocinonide emulsified base.................................. 111FLUORABON................... 129FLUORESCITE.................201fluoridex............................ 106fluoridex daily renewal...... 106fluoridex enhanced whitening...........................106fluoridex sensitivity relief...106fluoritab............................. 129fluorometholone................ 196fluorouracil .................. 56, 111fluoxetine hcl.......................41fluphenazine decanoate......69fluphenazine hcl............69, 70

FLURA-DROPS................ 129flurandrenolide.................. 111flurazepam hcl.................. 215flurbiprofen............................7flurbiprofen sodium........... 196flutamide............................. 56fluticasone propionate.................................. 111, 205fluticasone-salmeterol.......210FLUTICASONE-SALMETEROL..................210fluvastatin sodium............... 91fluvastatin sodium er...........91fluvoxamine maleate...........41fluvoxamine maleate er.......41FLUZONE HIGH-DOSE....178FLUZONE QUADRIVALENT..............178FML...................................197FML FORTE..................... 196FML LIQUIFILM................ 197FOCALIN.......................... 101FOCALIN XR.................... 101folbee plus........................ 129FOLGARD OS.................. 129FOLGARD RX.................. 129folic acid............................129FOLIVANE-F.....................129FOLIVANE-PLUS............. 129FOLLISTIM AQ................. 156FOLOTYN...........................56folplex 2.2......................... 129FOLTRATE....................... 129foltrin................................. 129fomepizole........................ 187fondaparinux sodium.......... 34formaldehyde.................... 188FORTAVIT........................ 129FORTEO...........................181FORTESTA.......................154FOSAMAX........................ 181FOSAMAX PLUS D.......... 182fosamprenavir calcium........73fosaprepitant dimeglumine..44FOSCAVIR......................... 73fosinopril sodium.................91fosinopril sodium-hctz......... 91fosphenytoin sodium...........36FOSRENOL...................... 149FRAGMIN........................... 34FREAMINE HBC...............129FREAMINE III ................... 129

FREESTYLE INSULINX TEST.................................120FREESTYLE LITE TEST.. 120FREESTYLE PRECISION NEO TEST........................120FREESTYLE TEST...........120fresenius propoven........... 188FROVA............................... 50frovatriptan succinate..........50FULPHILA...........................80fulvestrant........................... 56FUNGIMEZ......................... 46furosemide.......................... 91FUROSEMIDE IN SODIUM CHLORIDE..........91FUSARIUM....................... 188FUSION PLUS..................129FUZEON............................. 73fyavolv...............................162FYCOMPA.......................... 36gabapentin.......................... 36GABITRIL........................... 36GABLOFEN...................... 214GALAFOLD.......................145galantamine hydrobromide...................................... 39, 40galantamine hydrobromide er.........................................39GALZIN.............................129GAMASTAN......................172GAMASTAN S/D...............172GAMIFANT....................... 172GAMMAGARD..................172GAMMAGARD S/D LESS IGA....................................172GAMMAKED.....................172GAMMAPLEX................... 172GAMUNEX-C....................172GANCICLOVIR................... 73ganciclovir sodium.............. 73ganirelix acetate................156GARDASIL 9.....................178GASTROCROM................141gatifloxacin........................197GATTEX........................... 141gavilax...............................141gavilyte-c...........................141gavilyte-g.......................... 141gavilyte-h.......................... 141gavilyte-n with flavor pack.142GAZYVA............................. 57GELFILM.......................... 201GELFOAM-JMI SPONGE.188

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GELNIQUE....................... 149GEL-ONE..........................188GELSYN-3........................ 188gemcitabine hcl...................57gemfibrozil .......................... 91GENERESS FE................ 162generlac............................ 142gengraf..............................172GENICIN VITA-S.............. 129GENOTROPIN..................156GENOTROPIN MINIQUICK.......................156gentak............................... 197gentamicin in saline............ 27gentamicin sulfate.......27, 197GENVISC 850...................188GENVOYA.......................... 73GEODON............................70GERMAN COCKROACH..188gianvi................................ 162GILENYA.......................... 103GILOTRIF........................... 57GILPHEX TR.................... 205GILTUSS TR.....................205GIVLAARI......................... 188GLASSIA.......................... 210glatiramer acetate............. 103glatopa.............................. 103GLEEVEC...........................57GLEOLAN.........................188GLEOSTINE....................... 57GLIADEL WAFER...............57glimepiride........................ 117glipizide.............................117glipizide er.........................117glipizide xl......................... 117glipizide-metformin hcl...... 117GLOPERBA........................ 49GLUCAGEN DIAGNOSTIC.......................................... 188GLUCAGEN HYPOKIT.....120GLUCAGON EMERGENCY KIT............ 120GLUCAGON HCL (DIAGNOSTIC)................. 188GLUCOTROL................... 117GLUCOTROL XL.............. 118glutaraldehyde.................. 188GLUTATHIONE................ 129glyburide........................... 118glyburide micronized.........118glyburide-metformin.......... 118GLYCINE.......................... 129

glycine...............................149glycine urologic................. 149glycolax.............................142glycolic acid...................... 111glycopyrrolate................... 142GLYCOPYRROLATE....... 142glycopyrrolate pf............... 142glydo................................... 17GLYNASE.........................118GLYRX-PF........................142GLYSET............................118GLYXAMBI....................... 118gnp folic acid.....................129GOLDENROD...................188GOLYTELY.......................142GONAL-F..........................156GONAL-F RFF..................156GONAL-F RFF REDIJECT156goodsense aspirin low dose...................................... 7GOPRELTO........................17GORDOFILM.................... 111grafco silver nit applicator. 111GRALISE.......................... 104GRALISE STARTER........ 104granisetron hcl.................... 44GRANIX.............................. 80GRASTEK.........................188griseofulvin microsize......... 46griseofulvin ultramicrosize.. 46guaiatussin ac...................205guaifenesin ac...................205guanfacine hcl.....................91guanfacine hcl er.............. 101GUANIDINE HCL................51GVOKE PFS..................... 121GYNAZOLE-1..................... 46HACKBERRY................... 188HAEGARDA......................172hailey 1.5/30..................... 162hailey 24 fe....................... 162HALAVEN........................... 57halcinonide........................111HALCION............................77HALDOL............................. 70HALDOL DECANOATE...... 70halobetasol propionate..... 111HALOG............................. 111haloperidol.......................... 70haloperidol decanoate........ 70haloperidol lactate...............70HARVONI........................... 73HAVRIX............................ 178

HEALON........................... 201HEALON GV.....................201HEALON PRO.................. 201HEALON5......................... 201HEALON5 PRO................ 201healthylax..........................142heather..............................162HECTOROL......................182HEMABATE...................... 156hematinic/folic acid........... 129hematogen........................129HEMATOGEN FA............. 129hematogen forte................129HEMATRON-AF............... 129HEMLIBRA......................... 81hemmorex-hc....................180HEMOCYTE PLUS........... 129hemocyte-f........................ 129HEMOFIL M........................81HEPAGAM B.................... 172HEPARIN (PORCINE) IN NACL.................................. 34heparin (porcine) in nacl..... 34heparin sodium (porcine).... 34heparin sodium (porcine) pf.........................................34HEPATAMINE.................. 129HEPLISAV-B.....................178HEPSERA...........................73HERCEPTIN....................... 57HERCEPTIN HYLECTA..... 57HERZUMA.......................... 57HESPAN............................. 81hetastarch-nacl................... 81HETLIOZ...........................215HEXTEND...........................81HIBERIX........................... 178HIDEX 6-DAY................... 153HIPREX.............................. 27HISTATROL......................188HIZENTRA........................172homatropaire.....................201HONEY BEE VENOM.......188HONEY BEE VENOM PROTEIN..........................188HORIZANT....................... 105HORSE EPITHELIUM...... 188HUMALOG........................122HUMALOG KWIKPEN...... 121HUMALOG MIX 50/50 KWIKPEN......................... 121HUMALOG MIX 50/50 VIAL.................................. 122

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HUMALOG MIX 75/25 KWIKPEN......................... 122HUMALOG MIX 75/25 VIAL.................................. 122HUMALOG U-100 JUNIOR KWIKPEN......................... 122HUMAN ALBUMIN GRIFOLS.......................... 188HUMATE-P......................... 81HUMATROPE...................156HUMIRA............................173HUMIRA PEDIATRIC CROHNS START............. 172HUMIRA PEN................... 173HUMIRA PEN-CD/UC/HS STARTER......................... 173HUMIRA PEN-PS/UV/ADOL HS START. 173HUMULIN 70/30 KWIKPEN......................... 122HUMULIN 70/30 VIAL.......122HUMULIN N KWIKPEN.... 122HUMULIN N VIAL............. 122HUMULIN R U-500 KWIKPEN......................... 122HUMULIN R U-500 VIAL (CONCENTRATED)......... 122HUMULIN R VIAL............. 122HYALGAN.........................188HYALURONIDASE (INTRAOCULAR)..............201HYCAMTIN......................... 57hydralazine hcl....................91HYDREA.............................57hydrochlorothiazide.............91hydrocodone bitartrate er....11hydrocodone polst-cpm polst er.............................. 205hydrocodone-acetaminophen............. 11, 12hydrocodone-homatropine.................................. 205, 206hydrocodone-ibuprofen.......12hydrocortisone.. 112, 153, 180hydrocortisone (perianal).. 180hydrocortisone ace-pramoxine................. 111, 180hydrocortisone acetate..... 180hydrocortisone butyr lipo base.................................. 111hydrocortisone butyrate.................................. 111, 112hydrocortisone valerate.... 112

hydrocortisone-acetic acid 204hydrocortisone-iodoquinol...46hydrocort-pramoxine (perianal)...........................180hydrogen peroxide.............. 27hydromet...........................206hydromorphone hcl............. 12HYDROMORPHONE HCL. 12hydromorphone hcl er.........12hydromorphone hcl pf......... 12HYDROMORPHONE HCL-NACL.................................. 12hydroxocobalamin acetate 129hydroxychloroquine sulfate. 65hydroxyprogesterone caproate............................162hydroxyurea........................ 57hydroxyzine hcl................... 78hydroxyzine pamoate..........78HYLAVITE........................ 129HYLENEX......................... 188HYMOVIS......................... 188hyophen............................ 149hyoscyamine sulfate......... 142hyoscyamine sulfate er..... 142hyoscyamine sulfate sl......142hyosyne............................ 142HYPERHEP B S/D............173HYPERLYTE-CR.............. 130HYPERRAB...................... 173HYPERRAB S/D............... 173HYPERRHO S/D.............. 173HYPERSAL.......................206HYPERTET S/D................173HYSINGLA ER....................12HYZAAR............................. 91ibandronate sodium.......... 182IBRANCE............................57ibu......................................... 7ibuprofen...............................7ibuprofen lysine.....................7ibutilide fumarate................ 91IC GREEN........................ 189ICAR-C PLUS................... 130icatibant acetate................173ICLUSIG............................. 57IDAMYCIN PFS.................. 57idarubicin hcl.......................57IDELVION........................... 81IDHIFA................................ 57iferex 150 forte..................130IFEX....................................57ifosfamide..................... 57, 58

ILARIS.............................. 173ILEVRO.............................197ILUMYA............................ 173ILUVIEN............................197imatinib mesylate................ 58IMBRUVICA........................58imipenem-cilastatin............. 27imipramine hcl.....................41imipramine pamoate........... 41imiquimod......................... 112IMITREX............................. 50IMITREX STATDOSE REFILL................................50IMITREX STATDOSE SYSTEM............................. 50IMLYGIC............................. 58IMOGAM RABIES-HT.......173IMOVAX RABIES..............178IMPAVIDO.......................... 65IMURAN............................173INBRIJA.............................. 67incassia.............................162INCRELEX........................156INCRUSE ELLIPTA.......... 210indapamide......................... 91INDERAL LA.......................91INDERAL XL.......................92INDOCIN...............................7indocyanine green............ 189indomethacin........................ 7indomethacin er.................... 7indomethacin sodium............7INFANRIX......................... 178INFASURF........................206INFED............................... 189INFLECTRA......................173INFUGEM........................... 58INFUMORPH 200............... 12INFUMORPH 500............... 12INFUVITE ADULT.............130INFUVITE PEDIATRIC..... 130INGREZZA........................105INJECTAFER....................130INLYTA............................... 58INNOPRAN XL................... 92INREBIC............................. 58INSPRA.............................. 92INSULIN ASP PROT & ASP FLEXPEN................. 122INSULIN ASPART............ 122INSULIN ASPART FLEXPEN......................... 122

230

INSULIN ASPART PENFILL........................... 122INSULIN ASPART PROT & ASPART........................ 122INSULIN PEN NEEDLES. 123INSULIN SYRINGES........ 123INTEGRA F.......................130INTEGRA PLUS............... 130INTEGRILIN........................68INTELENCE........................73intralipid............................ 130INTRALIPID...................... 130INTRAROSA.....................149INTRON A...........................73introvale............................ 162INTUNIV........................... 101INVEGA.............................. 70INVEGA SUSTENNA..........70INVEGA TRINZA................ 70INVELTYS........................ 197INVIRASE........................... 73INVOKAMET.....................118INVOKAMET XR...............118INVOKANA....................... 118iodine strong..................... 130iodine tincture..................... 27IODOQUIMEZ-HC.............. 46iodoquinol-hc-aloe polysacch............................46iodoquinol-hydrocortisone-aloe..................................... 46IONOSOL-MB IN D5W..... 130IOPIDINE.......................... 199IPOL..................................178ipratropium bromide..206, 210ipratropium-albuterol.........210irbesartan............................92irbesartan-hydrochlorothiazide.............92IRESSA...............................58irinotecan hcl.......................58IROSPAN 24/6..................130IS 24/6.............................. 130ISENTRESS................. 73, 74ISENTRESS HD................. 73isibloom.............................162ISOLYTE-P IN D5W......... 130ISOLYTE-S....................... 130ISOLYTE-S PH 7.4........... 130isoniazid........................51, 52isoproterenol hcl................. 92ISOPTO ATROPINE.........201ISOPTO CARPINE........... 199

ISORDIL TITRADOSE........92isosorbide dinitrate..............92isosorbide mononitrate....... 92isosorbide mononitrate er... 92isosulfan blue....................189isotretinoin........................ 112isoxsuprine hcl.................... 92isradipine............................ 92ISTALOL........................... 199ISTODAX (OVERFILL)....... 58ISUPREL............................ 92itraconazole........................ 46IV STABILIZER FOR LUMOXITI.........................189ivermectin................... 65, 112IXEMPRA KIT..................... 58IXIARO..............................178IXINITY............................... 81JADENU........................... 130JADENU SPRINKLE.........130jaimiess.............................162JAKAFI................................58JALYN...............................151jantoven.............................. 34JANUMET.........................118JANUMET XR...................118JANUVIA...........................118JARDIANCE..................... 118jasmiel...............................162JATENZO......................... 154jencycla.............................162JENTADUETO..................118JENTADUETO XR............118JETREA............................ 202JEVTANA............................58jinteli ..................................162JIVI......................................81JOHNSON GRASS...........189jolessa...............................162JUBLIA................................46juleber............................... 163JULUCA..............................74JUNE GRASS POLLEN STANDARDIZED..............189junel 1.5/30....................... 163junel 1/20.......................... 163junel fe 1.5/30................... 163junel fe 1/20...................... 163junel fe 24......................... 163JUXTAPID.......................... 92JYNARQUE...................... 130KABIVEN.......................... 130KADCYLA........................... 58

KADIAN.............................. 12kaitlib fe.............................163KALBITOR........................ 173KALETRA........................... 74kalliga................................163KALYDECO...................... 212KANJINTI............................58KANUMA.......................... 145KAPOK............................. 189KAPVAY........................... 101KARBINAL ER.................. 206kariva................................ 163KAZANO........................... 118KCENTRA...........................81kcl in dextrose-nacl........... 130kcl-lactated ringers-d5w....130KCL-LIDOCAINE-NACL... 130kedbumin.......................... 189KEDRAB........................... 173KEFLEX.............................. 27kelnor 1/35........................ 163kelnor 1/50........................ 163KENALOG................ 112, 153KENALOG-80................... 153KENGREAL........................ 69KEPIVANCE..................... 106KEPPRA............................. 36KEPPRA XR....................... 36KERALYT......................... 112KERALYT SCALP.............112KERAMATRIX REPLICINE 5CMX5CM........................ 112KERLIX AMD ANTIMICROBIAL..............189KERLIX AMD SUPER SPONGES........................ 189KERYDIN............................46KETALAR......................... 189KETAMINE HCL............... 189ketamine hcl......................189KETAMINE HCL-SODIUM CHLORIDE....................... 189ketoconazole.................46, 47ketodan............................... 47ketoprofen.............................7ketoprofen er.........................7ketorolac tromethamine 7, 197KETOROLAC-BUPIV-KETAMINE........................... 7KETOROLAC-ROPIV-KETAMINE........................... 7KEVEYIS.......................... 199KEVZARA......................... 173

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KEYTRUDA........................ 58KHAPZORY........................ 58KINERET.......................... 174KINEVAC.......................... 189KINRIX..............................178kionex............................... 130KISQALI (200 MG DOSE).. 58KISQALI (400 MG DOSE).. 58KISQALI (600 MG DOSE).. 59KITABIS PAK....................212KLARITY-A....................... 197KLONOPIN......................... 78klor-con............................. 131klor-con 10........................ 130klor-con m10..................... 130KLOR-CON M15...............131klor-con m20..................... 131klor-con sprinkle................131klor-con/ef......................... 131KOATE................................81KOATE-DVI........................ 81KOCHIA............................ 189KOGENATE FS.................. 81KOMBIGLYZE XR............ 118KORLYM...........................159KOVALTRY.........................81K-PHOS............................ 131K-PHOS NO 2...................131K-PHOS-NEUTRAL.......... 131k-prime..............................131KRINTAFEL........................ 65KRISTALOSE................... 142KRYSTEXXA...................... 49K-TAB............................... 131k-tan plus.......................... 131kurvelo.............................. 163KUVAN............................. 145KYLEENA......................... 163KYMRIAH......................... 174KYPROLIS..........................59LABETALOL HCL............... 92labetalol hcl.........................92LACRISERT......................202lactated ringers................. 131lactic acid.......................... 112lactic acid e....................... 112lactulose............................143lactulose encephalopathy. 142LAMBS QUARTERS.........189LAMICTAL.......................... 36LAMICTAL ODT..................36LAMICTAL STARTER........ 37LAMICTAL XR.................... 37

lamivudine...........................74lamivudine-zidovudine........ 74lamotrigine.......................... 37lamotrigine er...................... 37lamotrigine starter kit-blue.. 37lamotrigine starter kit-green...................................37lamotrigine starter kit-orange.................................37LANOXIN............................ 92LANOXIN PEDIATRIC........92lansoprazole..................... 139lanthanum carbonate........ 149LANTUS SOLOSTAR....... 123LANTUS U-100 VIAL........ 123larin 1.5/30........................ 163larin 1/20........................... 163larin 24 fe.......................... 163larin fe 1.5/30.................... 163larin fe 1/20....................... 163larissia...............................163LARTRUVO........................ 59LASIX..................................92LASTACAFT..................... 202latanoprost........................ 199LATANOPROST-TIMOLOL MALEATE........ 199LATRIX XM.......................112LATUDA..............................70layolis fe............................163LAZANDA........................... 12LEDIPASVIR-SOFOSBUVIR.................... 74leena................................. 163leflunomide....................... 174LEMTRADA...................... 103LENSCALE....................... 189LENVIMA (10 MG DAILY DOSE)................................ 59LENVIMA (12 MG DAILY DOSE)................................ 59LENVIMA (14 MG DAILY DOSE)................................ 59LENVIMA (18 MG DAILY DOSE)................................ 59LENVIMA (20 MG DAILY DOSE)................................ 59LENVIMA (24 MG DAILY DOSE)................................ 59LENVIMA (4 MG DAILY DOSE)................................ 59LENVIMA (8 MG DAILY DOSE)................................ 59

LESCOL XL........................ 92lessina...............................163LETAIRIS..........................213letrozole.............................. 59LETS...................................17leucovorin calcium.............. 59LEUKERAN........................ 59LEUKINE............................ 81leuprolide acetate............. 156LEUPROLIDE ACETATE-BUPIVACAINE..................156levalbuterol hcl..................210LEVAQUIN..........................27LEVATIO.............................17LEVBID............................. 143LEVEMIR U-100 FLEXTOUCH.................... 123LEVEMIR U-100 VIAL...... 123levetiracetam...................... 37levetiracetam er.................. 37levetiracetam in nacl........... 37LEVITRA...........................149levobunolol hcl.................. 199LEVOCARNITINE.............131levocarnitine......................131levocarnitine sf..................131levocetirizine dihydrochloride................. 206levofloxacin................. 27, 197levofloxacin in d5w..............27levoleucovorin calcium........59levoleucovorin calcium pf....59levonest............................ 163levonorgest-eth est & eth est..................................... 163levonorgest-eth estrad 91-day.................................... 163levonorgestrel................... 163levonorgestrel-ethinyl estrad................................163levonorg-eth estrad triphasic............................ 163LEVOPHED........................ 92levora 0.15/30 (28)............163levorphanol tartrate.............12levo-t................................. 168levothyroxine sodium 168, 169levoxyl...............................169LEVSIN............................. 143LEVSIN/SL........................143LEVULAN KERASTICK.... 112LEXAPRO...........................41LEXISCAN........................ 189

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LEXIVA............................... 74LIALDA............................. 180LIBRAX............................. 143LIBTAYO.............................59LIDO BDK........................... 17lidocaine..............................17lidocaine hcl........................ 17LIDOCAINE HCL................ 17lidocaine hcl (cardiac)......... 17lidocaine hcl (cardiac) pf..... 17lidocaine hcl (pf)..................17lidocaine hcl urethral/mucosal................. 17LIDOCAINE IN D5W...........17lidocaine in d5w.................. 17LIDOCAINE IN DEXTROSE........................ 18lidocaine viscous hcl......... 106lidocaine-epinephrine..........18LIDOCAINE-EPINEPHRINE................. 202lidocaine-hydrocort (perianal)...........................180lidocaine-hydrocortisone ace.................................... 180LIDOCAINE-HYDROCORTISONE ACE.......................................... 180LIDOCAINE-PHENYLEPHRINE........... 202LIDOCAINE-PHENYLEPHRINE-BSS... 202lidocaine-prilocaine............. 18LIDOCAINE-SODIUM BICARBONATE.................. 18LIDOCAINE-TETRACAINE 18LIDOCIDEX I.................... 153LIDODERM.........................18LIDO-EPINEPHRINE-TETRACAINE..................... 18lidopin................................. 18LIDOPRIL........................... 18LIDOPRIL XR..................... 18LIDO-PRILO CAINE PACK.18LIDOPROFEN...................... 7LIDO-SORB........................ 18LIDOZION...........................18LILETTA (52 MG)............. 163lillow.................................. 163LINCOCIN...........................27lincomycin hcl..................... 27lindane................................ 65linezolid...............................27

linezolid in sodium chloride.27LINZESS...........................143LIORESAL........................ 214liothyronine sodium...........169LIPITOR..............................92LIPO..................................131LIPO-C..............................131LIPOFEN............................ 92LIQUIVIDA HYDRATION..131lisinopril ...............................93lisinopril-hydrochlorothiazide.............93lithium................................. 79lithium carbonate................ 79lithium carbonate er............ 79LITHOBID........................... 79LITHOSTAT...................... 149LIVALO............................... 93LIVIXIL PAK........................18LMD IN D5W.......................81LMD IN NACL..................... 81LO LOESTRIN FE............ 163LOCOID............................ 112LOCOID LIPOCREAM......112LODINE................................ 7LODOSYN.......................... 67LOESTRIN 1.5/30 (21)..... 163LOESTRIN 1/20 (21)........ 163LOESTRIN FE 1.5/30....... 164LOESTRIN FE 1/20.......... 164lojaimiess.......................... 164LOMOTIL.......................... 143LONSURF...........................59loperamide hcl.................. 143LOPID................................. 93lopinavir-ritonavir................ 74lopreeza............................ 164LOPRESSOR..................... 93LOPRESSOR HCT............. 93LOPROX.............................47lorazepam........................... 78lorazepam intensol..............78LORBRENA........................ 59lorcet................................... 13lorcet hd.............................. 12lorcet plus........................... 13LORID...............................131LORTAB............................. 13loryna................................ 164LORZONE........................ 214losartan potassium..............93losartan potassium-hctz......93LOSEASONIQUE............. 164

LOTEMAX.........................197LOTEMAX SM.................. 197LOTENSIN..........................93LOTENSIN HCT................. 93loteprednol etabonate....... 197LOTREL..............................93LOTRONEX...................... 143lovastatin.............................93LOVAZA..............................93LOVENOX.......................... 34low-ogestrel...................... 164loxapine succinate.............. 70LOYON............................. 112lo-zumandimine................ 164LUCEMYRA........................20LUCENTIS........................ 202ludent................................ 131LULICONAZOLE................ 47LUMIGAN......................... 199LUMIZYME....................... 146LUMOXITI...........................59LUNESTA......................... 215LUPANETA PACK............ 156LUPRON DEPOT (1-MONTH)........................... 157LUPRON DEPOT (3-MONTH)........................... 157LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG................................ 157LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG................................ 157LUPRON DEPOT-PED (1-MONTH)........................... 157LUPRON DEPOT-PED (3-MONTH)........................... 157lutera.................................164LUXTURNA...................... 202LUZU.................................. 47LYNPARZA.........................59LYRICA.............................105LYRICA CR.......................105LYSINE HCL.....................131lysiplex plus...................... 131LYSODREN........................ 59LYSTEDA........................... 81lyza................................... 164M.V.I. ADULT....................131M.V.I. PEDIATRIC............ 131MACI.................................189

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MACRILEN....................... 189MACROBID........................ 27MACRODANTIN........... 27, 28MACUGEN....................... 202mafenide acetate................ 28MAGNEBIND 400............. 131MAGNESIUM SULFATE.. 131magnesium sulfate............131magnesium sulfate in d5w 131MAGNESIUM SULFATE-NACL................................ 132MAKENA...........................164MALARONE........................65malathion............................ 65MANGANESE CHLORIDE132mannitol.............................. 93maprotiline hcl.....................41MARCAINE.........................18MARCAINE PRESERVATIVE FREE......18MARCAINE SPINAL........... 18MARCAINE/EPINEPHRINE......................................... 18MARCAINE/EPINEPHRINE PF....................................18marlissa............................ 164MARPLAN.......................... 41MARQIBO...........................60MATULANE........................ 60matzim la............................ 93MAVENCLAD (10 TABS)..103MAVENCLAD (4 TABS)....103MAVENCLAD (5 TABS)....103MAVENCLAD (6 TABS)....103MAVENCLAD (7 TABS)....103MAVENCLAD (8 TABS)....103MAVENCLAD (9 TABS)....103MAVYRET.......................... 74MAXALT............................. 50MAXALT-MLT..................... 50MAXICOMFORT SYR 27G X 1/2"................................ 123MAXIDEX..........................197MAXITROL....................... 202MAXZIDE............................93MAXZIDE-25.......................93MAYZENT.........................103MAYZENT STARTER PACK................................ 103me/naphos/mb/hyo1......... 149MEADOW FESCUE GRASS POLLEN.............. 189meclizine hcl....................... 44

meclofenamate sodium.........7MEDI-DERM/L-RX..............18MEDI-DERM-RX.................13MEDI-PATCH RX............... 18MEDROL.......................... 153MEDROX-RX......................13medroxyprogesterone acetate.............................. 164mefenamic acid.....................7mefloquine hcl.....................66MEGACE ES.................... 164megestrol acetate............. 164MEKINIST...........................60MEKTOVI............................60MELALEUCA.................... 189melodetta 24 fe................. 164meloxicam.............................8melphalan........................... 60melphalan hcl......................60memantine hcl.................... 40memantine hcl er................ 40MEMBRANEBLUE............202MENACTRA......................178MENEST...........................164MENOPUR....................... 157MENOSTAR..................... 164MENTAX.............................47MENVEO.......................... 178meperidine hcl.................... 13MEPHYTON..................... 132meprobamate......................78MEPRON............................ 66MEPSEVII.........................146mercaptopurine...................60meropenem.........................28MEROPENEM-SODIUM CHLORIDE......................... 28MERREM............................28mesalamine.............. 180, 181mesalamine er.................. 180mesalamine-cleanser........181mesna................................. 60MESNEX.............................60MESQUITE....................... 190MESTINON.........................51metadate er.......................101metaproterenol sulfate...... 210metaxalone....................... 214METFORMIN HCL............118metformin hcl.................... 118metformin hcl er................ 118methadone hcl.................... 13methadone hcl intensol.......13

METHADOSE..................... 13methadose.......................... 13METHADOSE SUGAR-FREE.................................. 13methamphetamine hcl...... 101methazolamide................. 199methenamine hippurate...... 28methenamine mandelate.... 28methergine........................190methimazole..................... 169METHITEST..................... 154methocarbamol................. 214methotrexate.....................174methotrexate sodium........ 174methotrexate sodium (pf)..174methoxsalen rapid............ 112methscopolamine bromide143methyl salicylate............... 112METHYLCOBALAMIN...... 132methyldopa......................... 93methyldopa-hydrochlorothiazide.............93methylergonovine maleate190METHYLIN........................101methylphenidate hcl..........102methylphenidate hcl er......102methylphenidate hcl er (cd).......................................... 101methylphenidate hcl er (la)101methylprednisolone...........153METHYLPREDNISOLONE ACETATE......................... 153methylprednisolone acetate.............................. 153methylprednisolone sodium succ......................153METHYLPREDNISOLONE-BUPIVACAINE................ 153methyltestosterone........... 154metoclopramide hcl.............44metolazone......................... 93metoprolol succinate er.......93metoprolol tartrate...............93metoprolol-hydrochlorothiazide.............93metronidazole............. 28, 112metronidazole in nacl..........28mexiletine hcl...................... 93MI PASTE......................... 106MI PASTE PLUS...............106MIACALCIN...................... 182mibelas 24 fe.................... 164MICARDIS.......................... 93

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MICARDIS HCT..................93MIC-L-CARNITINE........... 132miconazole 3.......................47MICONAZOLE-ZINC OXIDE-PETROLAT............ 47MICRHOGAM ULTRA-FILTERED PLUS.............. 174MICROCYN...................... 112MICRODOT PEN NEEDLE.......................................... 123microgestin 1.5/30............ 164microgestin 1/20............... 164microgestin fe 1.5/30........ 164microgestin fe 1/20........... 164MICROPLEGIA MSA-MSG.......................................... 132midazolam hcl.....................78MIDAZOLAM HCL.............. 78midazolam hcl (pf).............. 78MIDAZOLAM HCL-SODIUM CHLORIDE..........78MIDAZOLAM-SODIUM CHLORIDE......................... 78midodrine hcl...................... 93MIFEPREX....................... 132mifepristone...................... 132MIGERGOT........................ 50miglitol...............................118miglustat........................... 146MIGRANAL......................... 50mili .................................... 164MILLIPRED.......................153MILLIPRED DP.................153MILLIPRED DP 12-DAY... 153milrinone lactate..................94milrinone lactate in dextrose.............................. 94mimvey............................. 164MINASTRIN 24 FE........... 164mineral oil heavy...............143MINIPRESS........................ 94minitran............................... 94MINIVELLE............... 164, 165MINOCIN............................ 28minocycline hcl................... 28minoxidil ..............................94MIOCHOL-E..................... 202MIOSTAT..........................202MIRAPEX............................67MIRAPEX ER......................67MIRCERA........................... 82MIRCETTE....................... 165MIRENA (52 MG)..............165

mirtazapine......................... 42MIRVASO......................... 112misoprostol....................... 139MITE (D. FARINAE)..........190MITE (D. PTERONYSSINUS)..........190MITIGARE.......................... 49mitigo.................................. 13mitomycin............................60MITOMYCIN....................... 60MITOSOL..........................197mitoxantrone hcl................. 60MIXED ASPERGILLUS.... 190MIXED FEATHERS.......... 190MIXED RAGWEED...........190MIXED VESPID VENOM PROTEIN..........................190mixed vespid venom protein...............................190M-M-R II............................178M-NATAL PLUS................132MOBIC.................................. 8modafinil ........................... 215moexipril hcl........................94molindone hcl......................70mometasone furoate.112, 206mondoxyne nl..................... 28mono-linyah...................... 165MONONINE........................ 82MONOVISC...................... 190MONSELS FERRIC SUBSULFATE.................... 82montelukast sodium..........210MONUROL......................... 28morgidox............................. 28MORPHINE SULFATE. 13, 14morphine sulfate........... 13, 14morphine sulfate (concentrate).......................13morphine sulfate (pf)...........13morphine sulfate er............. 13morphine sulfate er beads.. 13MORPHINE SULFATE-NACL.................................. 14MOTEGRITY.................... 143MOTOFEN........................143MOUNTAIN CEDAR......... 190MOUSE EPITHELIUM...... 190MOVANTIK....................... 143MOVIPREP.......................143MOXEZA...........................197MOXIFLOXACIN HCL 28, 197moxifloxacin hcl.......... 28, 197

moxifloxacin hcl (2x day).. 197moxifloxacin hcl in nacl....... 28MOXIFLOXACIN HCL-BSS...................................202MOZOBIL............................82MS CONTIN........................14MUCOR............................ 190MUCOSITISRX.................106MUGWORT...................... 190MULPLETA.........................82MULTAQ.............................94MULTIGEN....................... 132MULTIGEN FOLIC............132MULTIGEN PLUS.............132multi-vit/iron/fluoride..........132multivitamin/fluoride.......... 132multi-vitamin/fluoride.........132multivitamin/fluoride/iron... 132multi-vitamin/fluoride/iron..132mupirocin............................ 28MUSE............................... 149mutamycin.......................... 60MVASI.................................60mvc-fluoride...................... 132MYALEPT......................... 146MYAMBUTOL..................... 52MYCAMINE........................ 47MYCOBUTIN...................... 52mycophenolate mofetil ......174mycophenolate mofetil hcl 174mycophenolate sodium.....174myferon 150 forte..............132MYFORTIC....................... 174MYLERAN.......................... 60MYLOTARG........................60mynephrocaps.................. 132mynephron........................132MYOBLOC........................190myorisan........................... 112MYRBETRIQ.................... 149MYSOLINE......................... 37MYTESI............................ 143MYXREDLIN.....................123na ferric gluc cplx in sucrose............................. 132NABI-HB........................... 174nabumetone..........................8n-acetyl-l-cysteine.............132nadolol................................ 94nafcillin sodium................... 28NAFCILLIN SODIUM IN DEXTROSE........................ 28nafrinse............................. 132

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NAFRINSE DAILY ACIDULATED................... 106NAFRINSE DAILY/NEUTRAL..............106nafrinse drops................... 132NAFRINSE WEEKLY........106naftifine hcl..........................47NAFTIN...............................47NAGLAZYME....................146nalbuphine hcl.....................14NALFON............................... 8NALOCET...........................14naloxone hcl........................21NALTREXONE................... 21naltrexone hcl..................... 21NAMENDA..........................40NAMENDA TITRATION PAK.....................................40NAMENDA XR....................40NAMENDA XR TITRATION PACK.............. 40NAMZARIC......................... 40NAPRELAN.......................... 8NAPRO................................. 8NAPROSYN..........................8naproxen...............................8naproxen dr...........................8naproxen sodium.................. 8naproxen sodium er.............. 8naratriptan hcl..................... 50NARCAN.............................21NARDIL...............................42NAROPIN........................... 18NASCOBAL...................... 132NASONEX........................ 206NATACYN.........................197NATAZIA...........................165nateglinide........................ 119NATESTO.........................154NATPARA.........................182NATROBA.......................... 66NATURE-THROID............ 169NAVELBINE........................60NAYZILAM..........................37NEBUPENT........................ 66nebusal............................. 206NEBUSAL......................... 206necon 0.5/35 (28)..............165nefazodone hcl................... 42NEMBUTAL........................ 37neomycin sulfate.................28neomycin-bacitracin zn-polymyx.............................202

neomycin-polymyxin b gu... 28neomycin-polymyxin-dexameth.......................... 202neomycin-polymyxin-gramicidin......................... 202neomycin-polymyxin-hc.................................. 202, 204NEONATAL COMPLETE..132NEONATAL PLUS............ 132neo-polycin....................... 203neo-polycin hc...................203NEOPROFEN....................... 8NEORAL........................... 174neostigmine methylsulfate.. 51NEOSTIGMINE METHYLSULFATE............. 51NEO-SYNALAR................ 112NEOTUSS PLUS.............. 206NEOVITE.......................... 133NEPHPLEX RX.................133NEPHRAMINE..................133NEPHRON FA.................. 133nephronex.........................133NEPHRO-VITE RX........... 133NERLYNX...........................60NESACAINE....................... 18NESACAINE-MPF.............. 18NESINA............................ 119NESTABS......................... 133NEULASTA.........................82NEULASTA ONPRO...........82NEUPOGEN....................... 82NEUPRO............................ 67NEURIN-SL...................... 133NEURONTIN...................... 37neutral sodium fluoride..... 106NEUTRASAL.................... 106NEVANAC........................ 197nevirapine........................... 74nevirapine er....................... 74NEXAVAR...........................60NEXIUM 24HR..................139NEXIUM I.V...................... 140NEXPLANON....................165NEXTERONE..................... 94niacin (antihyperlipidemic).. 94niacin er (antihyperlipidemic).............94niacor.................................. 94NIASPAN............................ 94NICADAN..........................133nicardipine hcl.....................94NICAZEL...........................133

NICAZEL FORTE............. 133NICOMIDE........................133NICORETTE....................... 21nicotine polacrilex............... 21nicotine step 1.....................21nicotine step 2.....................21nicotine step 3.....................21NICOTROL......................... 21NICOTROL NS................... 21nifedipine............................ 94nifedipine er........................ 94nifedipine er osmotic release................................ 94NIFEREX.......................... 133nikki...................................165NILANDRON.......................60nilutamide........................... 60NIMBEX............................ 105nimodipine.......................... 94NINLARO............................60NIPENT...............................60NIPRIDE RTU.....................94nisoldipine er.......................94NITHIODOTE....................190nitisinone...........................146NITRO-BID......................... 94NITRO-DUR........................94nitrofurantoin.......................29nitrofurantoin macrocrystal. 28nitrofurantoin monohydrate macrocrystals......................29nitroglycerin........................ 95nitroglycerin in d5w............. 94NITROLINGUAL................. 95NITROMIST........................ 95NITROPRESS.................... 95nitroprusside sodium...........95NITROSTAT....................... 95nitro-time.............................95NITYR............................... 146NIVESTYM......................... 82nizatidine...........................140NIZORAL............................ 47nolix.................................. 112nora-be............................. 165NORCO.............................. 14NORDITROPIN FLEXPRO.......................................... 157norepinephrine bitartrate.....95NOREPINEPHRINE-DEXTROSE........................ 95NOREPINEPHRINE-SODIUM CHLORIDE..........95

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norethin ace-eth estrad-fe.165norethindrone....................165norethindrone acetate.......165norethindrone acet-ethinyl est..................................... 165norethindrone-eth estradiol.......................................... 165norethin-eth estradiol-fe....165NORGESIC FORTE......... 214norgestimate-eth estradiol 166norgestimate-ethinyl estradiol triphasic..............166norlyda.............................. 166norlyroc............................. 166NORMOSOL-M IN D5W... 133NORMOSOL-R................. 133NORMOSOL-R IN D5W... 133NORMOSOL-R PH 7.4..... 133NORPACE.......................... 95NORPACE CR....................95NORPRAMIN......................42NORTHERA........................95nortrel 0.5/35 (28)............. 166nortrel 1/35 (21)................ 166nortrel 1/35 (28)................ 166nortrel 7/7/7.......................166nortriptyline hcl....................42NORVASC.......................... 95NORVIR..............................74NOURIANZ......................... 67novarel.............................. 157NOVAREL.........................157NOVOEIGHT...................... 82NOVOFINE AUTOCOVER PEN NEEDLE................... 123NOVOFINE PEN NEEDLE123NOVOFINE PLUS PEN NEEDLE........................... 123NOVOLIN 70/30 FLEXPEN.......................................... 123NOVOLIN 70/30 FLEXPEN RELION............................ 123NOVOLIN 70/30 RELION. 123NOVOLIN 70/30 VIAL.......123NOVOLIN N RELION........123NOVOLIN N VIAL............. 123NOVOLIN R RELION........124NOVOLIN R VIAL............. 124NOVOLOG FLEXPEN...... 124NOVOLOG MIX 70/30 FLEXPEN......................... 124NOVOLOG MIX 70/30 VIAL.................................. 124

NOVOLOG PENFILL........ 124NOVOLOG U-100 VIAL.... 124NOVOSEVEN RT............... 82NOVOTWIST PEN NEEDLE........................... 124NOXAFIL............................ 47np thyroid.......................... 169NPLATE..............................82NUBEQA.............................60NUCALA........................... 206NUCORT.......................... 113NUCYNTA.......................... 14NUCYNTA ER.................... 14NUFERA........................... 133nulev................................. 143NULOJIX...........................174NULYTELY WITH FLAVOR PACKS.............. 143NUMBRINO........................ 18NUMOISYN...................... 106NUPLAZID.......................... 70NUTRICAP....................... 133NUTRIDOX......................... 29nutrifac zx......................... 133nutrilipid............................ 133NUTRIVIT......................... 133NUTROPIN AQ NUSPIN 10......................................157NUTROPIN AQ NUSPIN 20......................................157NUTROPIN AQ NUSPIN 5157NUVAIL.............................113NUVAKAAN........................ 18NUVARING.......................166NUVIGIL........................... 215NUWIQ............................... 82NUZYRA............................. 29NYMALIZE..........................95nystatin............................... 47nystatin-triamcinolone.........47nystop................................. 47OBIZUR.............................. 82OCALIVA.......................... 146ocella................................ 166OCREVUS........................ 103OCTAGAM........................174OCTAPLAS BLOOD GROUP A......................... 190OCTAPLAS BLOOD GROUP AB.......................190OCTAPLAS BLOOD GROUP B......................... 191

OCTAPLAS BLOOD GROUP O.........................191octreotide acetate............. 157OCUFLOX........................ 197ODACTRA........................ 191ODEFSEY...........................74ODOMZO............................60OFEV................................ 210ofloxacin..............29, 197, 204ogestrel............................. 166OGIVRI............................... 60okebo.................................. 29olanzapine.......................... 70olanzapine-fluoxetine hcl.... 42OLIVE TREE.....................191olmesartan medoxomil........95olmesartan medoxomil-hctz..................................... 95olmesartan-amlodipine-hctz..................................... 95olopatadine hcl..........197, 206OLUMIANT....................... 174OLUX................................ 113OLUX-E............................ 113OMECLAMOX-PAK.......... 143omega-3-acid ethyl esters.. 95OMEGAVEN..................... 133omeprazole....................... 140OMEPRAZOLE+SYRSPEND SF ALKA.....................140OMIDRIA.......................... 203OMNARIS......................... 206OMNITROPE.................... 157ONCASPAR........................60ondansetron hcl.................. 44ONDANSETRON HCL........44ondansetron odt..................44ONEVITE.......................... 133ONFI................................... 37ONGLYZA.........................119ONIVYDE............................60ONPATTRO......................105OPANA............................... 14OPDIVO..............................61opium................................ 143OPSUMIT......................... 213OPTIONS CONCEPTROL191ORABLOC.......................... 19ORACIT............................ 133ORAFATE.........................191ORALAIR.......................... 191ORALAIR ADULT SAMPLE KIT.....................191

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ORALAIR ADULT STARTER PACK.............. 191ORALAIR CHILDRENS SAMPLE KIT.....................191ORALAIR CHILDRENS STARTER PACK.............. 191oralone..............................106ORAPRED ODT............... 153ORAVIG..............................47ORBACTIV......................... 29ORCHARD GRASS POLLEN............................191ORENCIA......................... 174ORENCIA CLICKJECT.....174ORENITRAM.................... 213ORFADIN..........................146ORILISSA......................... 157ORKAMBI......................... 212orphenadrine citrate..........214orphenadrine citrate er......214orphenadrine-aspirin-caffeine............................. 214ORPHENGESIC FORTE.. 215orsythia............................. 166ORTHO MICRONOR........166ORTHO TRI-CYCLEN LO 166ORTHO-NOVUM 7/7/7 (28)................................... 166ORTHOVISC.................... 191oscimin..............................143oscimin sr..........................143oseltamivir phosphate.........74OSENI...............................119OSMITROL......................... 95osmitrol............................... 95OSMOPREP..................... 143OSPHENA........................ 155OTEZLA............................175OTICIN HC NR................. 204OTIPRIO........................... 204OTOVEL........................... 205OVACE PLUS...................113OVACE PLUS WASH....... 113OVACE WASH................. 113OVIDE.................................66OVIDREL.......................... 157oxacillin sodium.................. 29OXACILLIN SODIUM IN DEXTROSE........................ 29oxaliplatin............................61oxandrolone...................... 155oxaprozin.............................. 8OXAYDO............................ 14

oxazepam........................... 78OXBRYTA.........................191oxcarbazepine.................... 37OXERVATE...................... 203oxiconazole nitrate..............47OXISTAT...................... 47, 48OXSORALEN ULTRA.......113OXTELLAR XR................... 37oxybutynin chloride........... 149oxybutynin chloride er.......149oxycodone hcl.....................14OXYCODONE HCL ER...... 14oxycodone-acetaminophen.14oxycodone-aspirin...............14oxycodone-ibuprofen.......... 14OXYCONTIN...................... 15oxymorphone hcl................ 15oxymorphone hcl er............ 15oxytocin.............................157OXYTOCIN-LACTATED RINGERS......................... 157OXYTOCIN-SODIUM CHLORIDE....................... 158OZEMPIC......................... 119OZURDEX........................ 197PACERONE........................95pacerone.............................96paclitaxel.............................61PADCEV............................. 61PAINGO KFT...................... 19paliperidone er.................... 70palonosetron hcl................. 44PALYNZIQ........................ 146PAMELOR.......................... 42pamidronate disodium...... 182PANCREAZE....................146pancuronium bromide....... 105PANDEL........................... 113PANHEMATIN.................... 82PANRETIN..........................61pantoprazole sodium........ 140PANZYGA.........................175PARAGARD INTRAUTERINE COPPER.......................................... 166paraplatin............................ 61paricalcitol.................182, 183PARLODEL.........................67PARNATE...........................42paroex...............................106paromomycin sulfate...........29paroxetine hcl..................... 42paroxetine hcl er................. 42

PARSABIV........................183PASER................................52PATANASE.......................206PAXIL..................................42PAXIL CR........................... 42PAZEO..............................197pb-hyoscy-atropine-scopolamine......................143PECAN POLLEN.............. 191PEDIAPRED..................... 153PEDIARIX......................... 178PEDVAX HIB.................... 178peg 3350...........................143peg 3350-kcl-na bicarb-nacl................................... 144peg-3350/electrolytes....... 144PEGANONE....................... 37PEGASYS...........................74PEGASYS PROCLICK....... 74PEGINTRON...................... 74peg-prep........................... 144penicillamine..................... 149PENICILLIN G POT IN DEXTROSE........................ 29penicillin g potassium..........29penicillin g procaine............ 29penicillin g sodium.............. 29penicillin v potassium..........29PENICILLIUM NOTATUM 191PENTACEL.......................178PENTAM.............................66pentamidine isethionate......66PENTASA......................... 181pentazocine-naloxone hcl... 15pentobarbital sodium.......... 37pentoxifylline er...................96PEPCID............................ 140PERCOCET........................15PERENNIAL RYE GRASS POLLEN............................191PERFOROMIST............... 210PERIDEX.......................... 107PERIKABIVEN..................133perindopril erbumine........... 96periogard...........................107PERJETA............................61permethrin...........................66perphenazine...................... 44perphenazine-amitriptyline..42PERSERIS..........................70PERTZYE......................... 146PFIZERPEN........................29phenadoz.......................... 206

238

phenazo............................ 149phenazopyridine hcl..........149phenelzine sulfate...............42phenobarbital................ 37, 38phenobarbital sodium......... 38phenobarbital-belladonna alk..................................... 144phenohytro........................144PHENOL........................... 191phenoxybenzamine hcl....... 96phentolamine mesylate.......96phenylephrine hcl........96, 203PHENYLEPHRINE HCL.................................... 96, 149PHENYLEPHRINE HCL (PRESSORS)..................... 96PHENYLEPHRINE HCL-NACL.................................. 96PHENYTEK........................ 38phenytoin............................ 38phenytoin infatabs...............38phenytoin sodium................38phenytoin sodium extended............................. 38philith................................ 166PHOMA EXIGUA.............. 191PHOSLYRA...................... 149phospha 250 neutral......... 133phosphasal....................... 149PHOSPHOLINE IODIDE.. 199phosphorous..................... 133phospho-trin 250 neutral...133PHOTOFRIN.......................61PHOTREXA VISCOUS.....191PHYSIOLYTE................... 133PHYSIOSOL IRRIGATION.......................................... 133phytonadione.................... 133PICATO............................ 113PIFELTRO.......................... 74pilocarpine hcl...........107, 199pimecrolimus.....................113pimozide............................. 70pimtrea..............................166pindolol............................... 96pioglitazone hcl................. 119pioglitazone hcl-glimepiride.......................................... 119pioglitazone hcl-metformin hcl..................................... 119piperacillin sod-tazobactam so........................................ 29

PIQRAY (200 MG DAILY DOSE)................................ 61PIQRAY (250 MG DAILY DOSE)................................ 61PIQRAY (300 MG DAILY DOSE)................................ 61pirmella 1/35..................... 166pirmella 7/7/7.................... 166piroxicam.............................. 8PITOCIN........................... 158PLAN B ONE-STEP..........166PLAQUENIL........................66PLASBUMIN-25................191PLASBUMIN-5..................191PLASMA-LYTE 148.......... 133PLASMA-LYTE A..............133PLASMANATE..................191PLAVIX............................... 69PLEGISOL........................ 134PLEGRIDY........................104PLEGRIDY STARTER PACK................................ 104PLENAMINE..................... 134PLIAGLIS............................19PNEUMOVAX 23..............178pnv prenatal plus multivit+dha.......................134podocon............................ 113podofilox........................... 113POLIDOCANOL..................96POLIVY...............................61polocaine............................ 19polocaine-mpf..................... 19polycin...............................203polyethylene glycol 3350.. 144poly-iron 150 forte.............134polymyxin b sulfate............. 29polymyxin b-trimethoprim..203polysaccharide iron forte...134POLYTRIM....................... 203POLY-VI-FLOR.................134POLY-VI-FLOR FS........... 134POLY-VI-FLOR/IRON.......134POMALYST........................ 61portia-28............................166PORTRAZZA...................... 61posaconazole......................48pot bicarb-pot chloride...... 134POTABA........................... 134potassium acetate.............134potassium bicarbonate......134potassium chloride............134POTASSIUM CHLORIDE. 134

potassium chloride crys er 134potassium chloride er........134potassium chloride in dextrose............................ 134potassium chloride in nacl 134potassium citrate er.......... 134potassium citrate-citric acid.......................................... 134potassium phosphates(71 meq k)...............................134POTELIGEO....................... 61POVIDONE-IODINE......... 197PRADAXA...........................34pralidoxime chloride..........192PRALUENT.........................96pramipexole dihydrochloride................... 67pramipexole dihydrochloride er............... 67PRAMOSONE.................. 113PRAMOTIC.......................205pramox..............................113prasugrel hcl....................... 69PRAVACHOL......................96pravastatin sodium..............96PRAXBIND....................... 192praziquantel........................ 66prazosin hcl.........................96PRE & POST SX POUCH 113PRECEDEX...................... 192PRECISION PCX PLUS TEST.................................120PRECISION QID TEST.... 120PRECISION SOF-TACT TEST.................................120PRECISION XTRA BLOOD GLUCOSE...........120PRECISION XTRA KETONE........................... 120PRECOSE........................ 119PRED FORTE...................198PRED MILD...................... 198PRED-G............................203PRED-G S.O.P................. 203prednicarbate....................113PREDNISOL ACE-MOXIFLOX-BROMFEN.... 198prednisolone..................... 153prednisolone acetate........ 198prednisolone acetate p-f... 198prednisolone sodium phosphate......... 153, 154, 198

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PREDNISOLONE-BROMFENAC...................203PREDNISOLONE-GATIFLOXACIN............... 203PREDNISOLON-GATIFLOX-BROMFENAC 203PREDNISOLON-MOXIFLOX-BROMFENAC.......................................... 203prednisone........................ 154prednisone intensol...........154PREFEST......................... 166pregabalin......................... 105pregnyl.............................. 158PREMARIN.......................166PREMASOL......................135PREMESISRX.................. 135PREMIUM CONDOMS LUBRICATED................... 192premium lidocaine...............19PREMPHASE................... 166PREMPRO........................166PRENAISSANCE..............135PRENATA.........................135prenatal.............................135prenatal plus iron.............. 135PRENATE.........................135PRENATE DHA................ 135PRENATE ELITE..............135PRENATE ENHANCE...... 135PRENATE ESSENTIAL.... 135PRENATE MINI................ 135PRENATE PIXIE...............135PRENATE RESTORE...... 135PRENATVITE COMPLETE.......................................... 135PRENATVITE PLUS.........135PRENATVITE RX............. 135PREPIDIL......................... 149PREPOPIK....................... 144PRESTALIA........................ 96PRETOMANID....................52PREVACID....................... 140PREVACID SOLUTAB......140prevalite.............................. 96preventeza........................ 166PREVIDENT..................... 107prevident........................... 107PREVIDENT 5000 BOOSTER PLUS..............107PREVIDENT 5000 DRY MOUTH.............................107

PREVIDENT 5000 ENAMEL PROTECT.........107PREVIDENT 5000 ORTHO DEFENSE.........................107PREVIDENT 5000 PLUS..107PREVIDENT 5000 SENSITIVE....................... 107previfem............................ 166PREVNAR 13................... 178PREVYMIS......................... 74PREZCOBIX....................... 74PREZISTA.................... 74, 75PRIALT............................... 15PRIFTIN..............................52PRILOLID........................... 19PRILOSEC........................140PRILOVIX........................... 19PRILOVIX LITE...................19PRILOVIX LITE PLUS........ 19PRILOVIX PLUS.................19prilovix ultralite.................... 19prilovix ultralite plus............ 19primaquine phosphate........ 66PRIMAXIN IV...................... 30primidone............................ 38PRIMLEV............................ 15PRIMSOL............................30PRINIVIL.............................96PRISMASOL B22GK 4/0.. 135PRISMASOL BGK 0/2.5... 135PRISMASOL BGK 2/0...... 135PRISMASOL BGK 2/3.5... 135PRISMASOL BGK 4/2.5... 135PRISMASOL BK 0/0/1.2... 135PRISTIQ............................. 42PRIVET.............................192PRIVIGEN.........................175PROAIR HFA....................210PROAIR RESPICLICK......210probenecid.......................... 49PROBUPHINE IMPLANT KIT...................................... 15procainamide hcl.................96PROCALAMINE................135PROCARDIA...................... 96PROCARDIA XL................. 96PROCENTRA................... 102prochlorperazine................. 44prochlorperazine edisylate..44prochlorperazine maleate... 44PROCORT........................181PROCRIT............................83PROCTOCORT................ 181

PROCTOFOAM HC..........181procto-med hc...................181procto-pak.........................181proctosol hc...................... 181proctozone-hc................... 181PROCYSBI....................... 146PROFILNINE...................... 83PROFILNINE SD................ 83progesterone.....................167progesterone micronized.. 167PROGLYCEM...................121PROGRAF........................ 175PROLASTIN-C..................210PROLATE........................... 15PROLENSA...................... 198PROLEUKIN....................... 61PROLIA.............................182PROMACTA....................... 83promethazine hcl.............. 206promethazine-codeine...... 206promethazine-dm..............206promethazine-phenyleph-codeine............................. 207promethazine-phenylephrine................... 207promethegan.....................207PROMETRIUM................. 167propafenone hcl.................. 96propafenone hcl er..............96propantheline bromide...... 144proparacaine hcl............... 203propofol.............................192propranolol hcl.................... 97propranolol hcl er................ 97propranolol-hctz.................. 97propylthiouracil ..................169PROQUAD........................179PROSCAR........................ 151PROSOL...........................135PROSTIN E2.................... 149PROSTIN VR......................97protamine sulfate................ 83PROTHELIAL................... 192PROTONIX....................... 140PROTOPAM CHLORIDE..192protriptyline hcl....................42PROVAYBLUE................. 192PROVENGE..................... 175PROVERA........................ 167PROVIGIL.........................215PROVISC..........................203PROZAC.............................42PRUDOXIN.......................113

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pseudoephedrine-bromphen-dm................... 207PSORCON........................113PULMICORT FLEXHALER.......................................... 210PULMICORT SUSPENSION.................. 211pulmosal........................... 207PULMOZYME................... 212PURAPLY......................... 113PURE COMFORT PEN NEEDLE........................... 124purevit dualfe plus.............135PURIXAN............................61PYLERA............................144pyrazinamide...................... 52PYRIDIUM........................ 149pyridostigmine bromide.......51pyridostigmine bromide er.. 51PYRIDOXAL-5 PHOSPHATE....................135PYRIDOXINE HCL........... 135pyridoxine hcl....................136pyrimethamine.................... 66PYRIMETHAMINE-LEUCOVORIN.................... 66PYROGALLIC ACID......... 113QBRELIS............................ 97QBREXZA.........................113qc aspirin low dose............... 8QNASL..............................207QNASL CHILDRENS........207QTERN............................. 119QUAD-MIX........................149QUADRACEL................... 179QUADRAMET.....................61QUALAQUIN.......................66QUARTETTE.................... 167quazepam........................... 78QUDEXY XR.......................38QUEEN PALM.................. 192QUELICIN.........................105QUESTRAN........................97QUESTRAN LIGHT............ 97quetiapine fumarate............ 71quetiapine fumarate er........71QUFLORA PEDIATRIC.... 136QUILLICHEW ER............. 102QUILLIVANT XR...............102quinapril hcl.........................97quinapril-hydrochlorothiazide.............97quinidine gluconate er.........97

quinidine sulfate..................97quinine sulfate.....................66QUINJA...............................48QUTENZA.........................113QUTENZA (2 PATCH)...... 113QUZYTTIR........................207QVAR REDIHALER.......... 211RABAVERT...................... 179RABBIT EPITHELIUM...... 192RABEPRAZOLE SODIUM 140rabeprazole sodium.......... 140RADICAVA....................... 105RADIOGARDASE.............192RAGWITEK.......................192raloxifene hcl.....................155ramelteon..........................215ramipril ................................ 97RANEXA............................. 97ranitidine hcl......................140ranolazine er....................... 97RAPAFLO......................... 151RAPAMUNE..................... 175RAPIVAB............................ 75RAPPORT RLS................ 192RAPPORT VTD................ 192rasagiline mesylate............. 67RAVICTI............................146RAYALDEE.......................182RAZADYNE........................ 40RAZADYNE ER.................. 40REBIF............................... 104REBIF REBIDOSE............104REBIF REBIDOSE TITRATION PACK............ 104REBIF TITRATION PACK 104REBINYN............................83REBLOZYL......................... 83RECARBRIO...................... 30RECK..................................19RECLAST......................... 182reclipsen........................... 167RECOMBINATE................. 83RECOMBIVAX HB............179RECOTHROM.................... 83RECOTHROM SPRAY KIT 83RECTIV...............................97RECURA.............................48RED BIRCH...................... 192RED CEDAR.....................192RED MAPLE..................... 192RED MULBERRY............. 192RED TOP GRASS POLLEN............................192

REGLAN............................. 44REGONOL..........................51REGRANEX......................113RELADOR PAK.................. 19RELADOR PAK PLUS........19RELENZA DISKHALER......75relexxii ...............................102RELISTOR........................144RELNATE DHA.................136RELPAX..............................50REMEDIENT.....................136REMERON......................... 42REMERON SOLTAB.......... 42REMESENSE................... 107REMICADE.......................175remifentanil hcl....................15REMODULIN.................... 213RENACIDIN...................... 149RENAGEL.........................149renal..................................136RENATABS...................... 136RENATABS WITH IRON.. 136RENFLEXIS......................175RENOVO............................ 19RENVELA................. 149, 150repaglinide........................ 119REPATHA...........................97REPATHA PUSHTRONEX SYSTEM............................. 97REPATHA SURECLICK..... 97REQ 49+...........................136REQUIP XL.........................67RESORCINOL-SULFUR.. 113RESTASIS........................ 203RESTASIS MULTIDOSE.. 203RESTORIL........................215RETACRIT..........................83RETIN-A........................... 113RETIN-A MICRO.............. 113RETIN-A MICRO PUMP... 114RETROVIR......................... 75REVATIO.......................... 213REVCOVI..........................146REVLIMID...........................61revonto..............................215REXULTI.............................71REYATAZ........................... 75R-GENE 10.......................192RHIZOPUS....................... 192RHOFADE........................ 114RHOGAM ULTRA-FILTERED PLUS.............. 175RHOPHYLAC................... 175

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RHOPRESSA................... 199RIASTAP............................ 83ribavirin............................... 75RIDAURA..........................175rifabutin............................... 52RIFADIN............................. 52RIFAMATE..........................52rifampin............................... 52RIFATER............................ 52RILUTEK...........................105riluzole.............................. 105rimantadine hcl................... 75RIMSO-50.........................150ringers...............................136ringers irrigation................ 136RINVOQ............................175RIOMET............................119risedronate sodium........... 182RISPERDAL....................... 71RISPERDAL CONSTA....... 71risperidone.......................... 71RITALIN............................ 102RITALIN LA.......................102ritonavir............................... 75RITUXAN............................ 61RITUXAN HYCELA.............61rivastigmine.........................40rivastigmine tartrate............ 40rivelsa............................... 167RIXUBIS............................. 83rizatriptan benzoate............ 50ROBAXIN..........................215ROBAXIN-750.................. 215ROCALTROL....................183ROCKLATAN....................199rocuronium bromide..........105ROCURONIUM BROMIDE.......................................... 105ROMIDEPSIN..................... 62ropinirole hcl....................... 67ropinirole hcl er................... 67ropivacaine hcl....................19ROPIVACAINE HCL........... 19ROPIVACAINE HCL-NACL 19ROPIV-CLONIDINE-KETOROLAC......................19rosadan.............................114rosuvastatin calcium........... 97ROTARIX..........................179ROTATEQ........................ 179ROUGH MARSH ELDER. 192ROUGH PIGWEED.......... 192ROWASA..........................181

roweepra.............................38roweepra xr.........................38ROXICODONE................... 15ROZEREM........................215ROZLYTREK...................... 62RUBRACA.......................... 62RUCONEST......................175RUSSIAN THISTLE.......... 192RUXIENCE......................... 62RUZURGI......................... 192RYANODEX......................215RYCLORA........................ 207RYDAPT............................. 62RYTARY............................. 67RYTHMOL SR.................... 97SABRIL............................... 38SACCHAROMYCES CEREVISIAE.................... 193SAFYRAL......................... 167SAGEBRUSH................... 193SAIZEN.............................158SAIZENPREP................... 158SALAGEN.........................107SALEX.............................. 114salicylic acid......................114salicylic acid wart remover 114salicylic acid-cleanser....... 114salimez..............................114SALIMEZ FORTE............. 114saline bacteriostatic.......... 136SALINE-PHENOL............. 136SALIVAMAX..................... 107salsalate................................8SALVAX............................114SALVAX DUO PLUS........ 114SAMSCA...........................136SANCUSO.......................... 44SANDIMMUNE................. 175SANDOSTATIN................ 158SANDOSTATIN LAR DEPOT............................. 158SANTYL............................114SAPHRIS............................ 71SARCLISA.......................... 62SAVAYSA........................... 34SAVELLA..........................105SAVELLA TITRATION PACK................................ 105SCALACORT DK..............114SCENESSE...................... 114SCLEROSOL INTRAPLEURAL...............211scopolamine........................44

SEASONIQUE.................. 167SECONAL.........................215SECUADO.......................... 71SEGLUROMET.................119SELECT-OB..................... 136selegiline hcl....................... 68SELENIOUS ACID............136selenium sulfide................ 114SELRX.............................. 114SELZENTRY.......................75SENSIPAR........................183sensorcaine........................ 19sensorcaine/epinephrine.....19sensorcaine-mpf................. 19sensorcaine-mpf/epinephrine.................. 19SENSORCAINE-MPF/EPINEPHRINE...........20SEREVENT DISKUS........ 211SEROQUEL........................71SEROQUEL XR..................71SEROSTIM....................... 144sertraline hcl....................... 42se-tan plus........................ 136setlakin..............................167sevelamer carbonate........ 150sevelamer hcl....................150sf....................................... 107sf 5000 plus...................... 107SFROWASA..................... 181SHAGBARK HICKORY.... 193sharobel............................ 167SHEEP SORREL..............193SHINGRIX........................ 179SHORT RAGWEED POLLEN EXT....................193SIDEROL.......................... 136SIGNIFOR........................ 158SIGNIFOR LAR................ 158sildenafil citrate......... 150, 213SILENOR.......................... 215SILIQ.................................175silodosin............................151SILVADENE........................30silver nitrate........................ 30silver sulfadiazine............... 30SIMBRINZA...................... 199simliya...............................167simpesse...........................167SIMPONI...........................175SIMPONI ARIA................. 175SIMULECT........................176simvastatin..........................97

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SINEMET............................68SINGULAIR...................... 211SINUVA............................ 207sirolimus............................176SIRTURO............................52SIVEXTRO..........................30SKELAXIN........................ 215SKLICE............................... 66SKYLA.............................. 167SKYRIZI (150 MG DOSE) 176SLYND..............................167SMOFLIPID...................... 136sod benz-sod phenylacet..146sod citrate-citric acid......... 136sodium acetate................. 136SODIUM BICARBONATE.136sodium bicarbonate.. 136, 144sodium chloride.........136, 207sodium chloride (pf).......... 136sodium chloride bacteriostatic.....................136SODIUM CITRATE............. 34SODIUM CITRATE LOCK FLUSH................................ 34SODIUM CITRATE-GENTAMICIN SULF........... 34SODIUM DIURIL.................97SODIUM EDECRIN............ 98sodium fluoride......... 107, 136sodium fluoride 5000 plus.107sodium fluoride 5000 ppm 107SODIUM HYALURONATE193sodium nitrite.................... 193sodium phenylbutyrate......146sodium polystyrene sulfonate................... 136, 137sodium saccharin..............193sodium sulfacetamide....... 114sodium sulfacetamide wash................................. 114SODIUM SULFACETAMIDE WASH 114sodium tetradecyl sulfate.... 98sodium thiosulfate.............193SOFOSBUVIR-VELPATASVIR................... 75SOLESTA......................... 193solifenacin succinate.........150SOLIQUA..........................119SOLIRIS..............................83SOLOSEC.......................... 30SOLU-CORTEF................ 154SOLU-MEDROL............... 154

SOMA............................... 215SOMATULINE DEPOT..... 158SOMAVERT......................158SOOLANTRA....................114SORBITOL........................193sorbitol.............................. 193sorbitol-mannitol............... 193SORIATANE..................... 114sorine.................................. 98SORREL/DOCK MIX........ 193SOTALOL HCL................... 98sotalol hcl............................98sotalol hcl (af)..................... 98SOTRADECOL................... 98SOTYLIZE.......................... 98SOVALDI............................ 75SPECTRACEF....................30spinosad............................. 66SPINRAZA........................193SPINY PIGWEED............. 193SPIRIVA HANDIHALER... 211SPIRIVA RESPIMAT........ 211spironolactone.................... 98spironolactone-hctz.............98SPORANOX....................... 48SPORANOX PULSEPAK... 48SPRAVATO (56 MG DOSE)................................ 42SPRAVATO (84 MG DOSE)................................ 42sprintec 28........................ 167SPRITAM............................38SPRYCEL........................... 62sps.................................... 137sronyx............................... 167ssd...................................... 30SSKI..................................207sss 10-5............................ 114ST JOSEPH LOW DOSE..... 8STALEVO 100.................... 68STALEVO 125.................... 68STALEVO 150.................... 68STALEVO 200.................... 68STALEVO 50...................... 68STALEVO 75...................... 68STAMARIL........................179STARLIX...........................119stavudine............................ 75STAXYN........................... 150STEGLATRO.................... 119STEGLUJAN.....................119STELARA......................... 176STEMPHYLIUM................193

STENDRA.........................150STERILE DILUENT FLOLAN PH 12.................193sterile diluent/epoprostenol.......................................... 193STERILE TALC POWDER211sterile water for injection... 193sterile water for irrigation.. 137STIMATE.......................... 158STIOLTO RESPIMAT....... 211STIVARGA..........................62STRATTERA.................... 102STRENSIQ....................... 146streptomycin sulfate............30STRIANT.......................... 155STRIBILD............................75STRIVERDI RESPIMAT... 211STROMECTOL...................66STRONTIUM CHLORIDE SR-89..................................62STROVITE FORTE...........137STROVITE ONE............... 137SUBLOCADE......................21SUBOXONE....................... 21SUBSYS............................. 15subvenite............................ 38subvenite starter kit-blue.....38subvenite starter kit-green.. 38subvenite starter kit-orange 38succinylcholine chloride.... 105SUCCINYLCHOLINE CHLORIDE....................... 105SUCRAID..........................146sucralfate.......................... 140sufentanil citrate..................15SULAR................................98SULCONAZOLE NITRATE.48sulfacetamide sodium.................................. 114, 198sulfacetamide sodium (acne)................................114sulfacetamide sodium-sulfur......................... 114, 115sulfacetamide-prednisolone..................... 203sulfacetamide-sulfur in urea...................................115sulfacleanse 8/4................115sulfadiazine.........................30sulfamethoxazole-trimethoprim........................30sulfamez wash.................. 115SULFAMYLON................... 30

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sulfasalazine..................... 181sulfatrim pediatric................30sulfurated lime.................... 66sulindac.................................8sumatriptan......................... 50sumatriptan succinate...50, 51sumatriptan succinate refill . 50SUNOSI............................ 215SUPARTZ FX................... 193SUPER BI-MIX................. 150SUPER QUAD-MIX.......... 150SUPER TRI-MIX............... 150SUPERVITE..................... 137SUPPORT........................ 137SUPPORT-500................. 137SUPPRELIN LA................ 158SUPRAX............................. 30SUPREP BOWEL PREP KIT.................................... 144SURVANTA...................... 207SUSTIVA............................ 75SUSTOL............................. 44SUTENT............................. 62SWEET GUM....................193SWEET VERNAL GRASS POLLEN............................193syeda................................ 167SYLATRON........................ 75SYLVANT........................... 62SYMAX DUOTAB............. 144symax-sl............................144symax-sr........................... 144SYMBICORT.................... 211SYMBYAX.......................... 43SYMDEKO........................212SYMFI.................................75SYMFI LO........................... 75SYMLINPEN 120.............. 119SYMLINPEN 60................ 119SYMPAZAN........................ 38SYMPROIC.......................144SYMTUZA...........................75SYNAGEX........................ 137SYNAGIS..........................176SYNALAR......................... 115SYNAREL......................... 158SYNATEK......................... 137SYNDROS.......................... 44SYNERA............................. 20SYNERCID......................... 30SYNJARDY.......................119SYNJARDY XR.................119SYNRIBO............................62

SYNTHAMIN 17................137SYNTHROID.....................169SYNVEXIA TC.................... 20SYNVISC.......................... 193SYNVISC ONE................. 193SYPRINE.......................... 137TABLOID............................ 62tacrolimus................. 115, 176tadalafil ............................. 150tadalafil (pah).................... 213TAFINLAR.......................... 62TAGRISSO......................... 62TAKHZYRO...................... 176TALIVA............................. 137TALL RAGWEED..............194TALTZ...............................176TALZENNA......................... 62TAMIFLU...................... 75, 76tamoxifen citrate................. 62tamsulosin hcl................... 151TAPAZOLE....................... 169TAPERDEX 6-DAY...........154TARCEVA...........................62TARGRETIN....................... 62tarina 24 fe........................167tarina fe 1/20.....................167tarina fe 1/20 eq................167TARKA................................98TARON FORTE................ 137taron-crystals.................... 137TASIGNA............................ 62TASMAR.............................68TAURINE.......................... 137TAVALISSE........................ 83TAXOTERE........................ 62TAYTULLA........................167tazarotene.........................115tazicef........................... 30, 31TAZICEF.......................30, 31TAZORAC.........................115taztia xt............................... 98TAZVERIK.......................... 62TDVAX..............................179TECENTRIQ....................... 62TECFIDERA..................... 104TEFLARO........................... 31TEGRETOL........................ 38TEGRETOL-XR.................. 38TEGSEDI.......................... 105TEKTURNA........................ 98TEKTURNA HCT................ 98TELFA AMD ISLAND DRESSING....................... 194

TELFA AMD NON-ADHERENT...................... 194telmisartan.......................... 98telmisartan-amlodipine........98telmisartan-hctz.................. 98temazepam....................... 216TEMIXYS............................ 76TEMODAR..........................62TEMOVATE...................... 115temozolomide..................... 63temsirolimus......................176tencon................................. 15teniposide........................... 63TENIVAC.......................... 179tenofovir disoproxil fumarate..............................76TENORETIC 100................ 98TENORETIC 50.................. 98TENORMIN.........................98TEPADINA..........................63TEPEZZA..........................158terazosin hcl......................151terbinafine hcl..................... 48terbutaline sulfate............. 211terconazole......................... 48TERIPARATIDE (RECOMBINANT).............182TESSALON PERLES....... 207TESTIM.............................155TESTONE CIK..................155TESTOPEL....................... 155testosterone...................... 155TESTOSTERONE CYPIONATE..................... 155testosterone cypionate......155testosterone enanthate..... 155tetrabenazine.................... 105tetracaine hcl.................... 203tetracycline hcl.................... 31TEXACORT...................... 115THALOMID......................... 63THEO-24...........................211theophylline.......................211theophylline er.................. 211theophylline in d5w........... 211THERAHONEY.................115thiamine hcl.......................137THIOLA.............................150THIOLA EC.......................150thioridazine hcl....................71thiotepa............................... 63thiothixene.......................... 71THROMBATE III ................. 34

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THROMBIN-JMI..................83THROMBIN-JMI EPISTAXIS......................... 83THROMBOGEN..................84THYMOGLOBULIN...........176THYROGEN..................... 194thyroid............................... 169tiadylt er.............................. 98tiagabine hcl........................38TIAZAC............................... 98TIBSOVO............................63TICE BCG.........................176TIGAN.................................44tigecycline........................... 31TIGLUTIK..........................105TIKOSYN............................ 98tilia fe................................ 167timolol maleate............98, 199TIMOLOL-BRIMON-DORZOL-LATANOPR...... 200TIMOLOL-BRIMONIDINE-DORZOLAMID..................200TIMOLOL-DORZOLAMID-LATANOPROST............... 200TIMOPTIC.........................200TIMOPTIC OCUDOSE..... 200TIMOPTIC-XE...................200TIMOTHY GRASS POLLEN ALLERGEN....... 194tinidazole.............................31TIROSINT......................... 169TISSEEL........................... 194tis-u-sol............................. 137TIVICAY..............................76tizanidine hcl..................... 215tl-hem 150.........................137TNKASE............................. 35TOBI NEBULIZER............ 212TOBI PODHALER.............212TOBRADEX...................... 203TOBRADEX ST................ 204tobramycin................ 198, 212TOBRAMYCIN..................213tobramycin sulfate...............31tobramycin-dexamethasone................ 204TOBREX........................... 198TODAY SPONGE............. 194tolbutamide....................... 119tolcapone............................ 68tolmetin sodium.....................8tolterodine tartrate.............150tolterodine tartrate er........ 150

TOPAMAX.......................... 38TOPAMAX SPRINKLE....... 38TOPEX TOPICAL ANESTHETIC................... 107TOPICORT....................... 115TOPICORT SPRAY.......... 115topiramate.....................38, 39topiramate er.......................38toposar................................63topotecan hcl...................... 63TOPROL XL........................98toremifene citrate................ 63TORISEL.......................... 176torsemide............................ 99TOTECT............................. 63TOUJEO MAX SOLOSTAR...................... 124TOUJEO SOLOSTAR.......124tovet.................................. 115TOVIAZ.............................150tpn electrolytes..................137TRACLEER.......................213TRADJENTA.....................119tramadol hcl........................ 15tramadol hcl er.................... 15tramadol hcl er (biphasic)... 15tramadol-acetaminophen.... 15trandolapril .......................... 99trandolapril-verapamil hcl er.........................................99tranexamic acid...................84TRANEXAMIC ACID-NACL.................................. 84TRANSDERM SCOP (1.5 MG).....................................45TRANSDERM-SCOP (1.5 MG).....................................45TRANXENE-T.....................78tranylcypromine sulfate.......43TRAVASOL.......................137TRAVATAN Z................... 200travoprost (bak free)......... 200TRAZIMERA....................... 63trazodone hcl...................... 43TREANDA...........................63TRECATOR........................ 52TRELEGY ELLIPTA..........211TRELSTAR MIXJECT.......158TREMFYA.........................176treprostinil ......................... 213TRESIBA.......................... 124TRESIBA FLEXTOUCH....124tretinoin....................... 63, 115

tretinoin microsphere........ 115tretinoin microsphere pump.......................................... 115TRETTEN........................... 84TREXALL..........................176TREZIX............................... 15tri femynor.........................167triamcinolone acetonide.................. 107, 115, 116, 154TRIAMCINOLONE ACETONIDE.....................154TRIAMCINOLONE-BUPIVACAINE..................154TRIAMCINOLONE-MOXIFLOXACIN...............204triamterene..........................99triamterene-hctz..................99trianex............................... 116triazolam............................. 78TRIBENZOR....................... 99TRICARE PRENATAL DHA ONE......................... 137TRI-CHLOR...................... 116TRICHOPHYTON............. 194TRICITRASOL.................... 35tricitrates........................... 137tricon................................. 137TRICOR.............................. 99triderm...............................116TRIDESILON.................... 116trientine hcl....................... 137TRIESENCE..................... 198tri-estarylla........................ 167trifluoperazine hcl................71trifluridine.......................... 198trigels-f forte......................137TRIGLIDE........................... 99trihexyphenidyl hcl.............. 68TRIKAFTA........................ 213tri-legest fe........................ 167TRILEPTAL.........................39tri-linyah............................ 167TRILIPIX............................. 99tri-lo-estarylla.................... 167tri-lo-marzia.......................167tri-lo-mili ............................ 167tri-lo-sprintec..................... 167TRILURON....................... 194trilyte................................. 144trimethobenzamide hcl........45trimethoprim........................31tri-mili ................................ 167trimipramine maleate.......... 43

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trinate................................137TRINTELLIX....................... 43TRIOSTAT........................ 169triphrocaps........................ 137TRIPLE PMB.................... 198TRIPLE PMK.................... 198tri-previfem........................168TRIPTODUR.....................158tri-sprintec......................... 168TRIUMEQ........................... 76TRI-VI-FLOR.....................137TRI-VI-FLORO..................137TRIVISC............................194tri-vitamin/fluoride............. 137tri-vite/fluoride................... 137trivora (28)........................ 168tri-vylibra........................... 168tri-vylibra lo....................... 168TRIZIVIR.............................76TROGARZO....................... 76TROKENDI XR................... 39TRONVITE........................137TROPHAMINE..................137TROPICAMIDE-CYCLOPENTOLATE-PE.. 204TROPICAMIDE-PHENYLEPHRINE........... 204TROPIC-PROPARACA-PE-KETOROLAC..............204trospium chloride.............. 150trospium chloride er.......... 150TRULANCE...................... 144TRULICITY....................... 120TRUMENBA......................179TRUSOPT.........................200TRUVADA...........................76TRUXIMA............................63tryptophan.........................137TUDORZA PRESSAIR..... 211tulana................................ 168TURALIO............................ 63turpentine..........................116TUSSICAPS..................... 207TUXARIN ER.................... 207TUZISTRA XR.................. 207TWINRIX...........................179TWYNSTA.......................... 99TYBOST............................. 76tydemy.............................. 168TYGACIL............................ 31TYKERB............................. 63TYLENOL WITH CODEINE #3...................... 15

TYMLOS........................... 182TYPHIM VI........................179TYSABRI.......................... 104TYVASO........................... 213TYVASO REFILL.............. 213TYVASO STARTER......... 213UCERIS............................ 181UDAMIN SP......................137UDENYCA.......................... 84ULORIC.............................. 49ULTIGUARD SAFEPACK PEN NEEDLE................... 124ULTIVA............................... 15ULTOMIRIS........................ 84ULTRA FLO INSULIN PEN NEEDLES......................... 124ULTRA FLO INSULIN SYRINGE..........................124ULTRABAG/DIANEAL PD-2/1.5% DEX...................... 138ULTRABAG/DIANEAL PD-2/2.5% DEX...................... 138ULTRABAG/DIANEAL PD-2/4.25%DEX..................... 138ULTRABAG/DIANEAL/1.5% DEXTROSE..................138ULTRABAG/DIANEAL/2.5% DEXTROSE..................138ULTRABAG/DIANEAL/4.25% DEX............................ 138ULTRACET.........................15ULTRAM............................. 15UNASYN.............................31UNIFINE SAFECONTROL PEN NEEDLE................... 124unithroid............................ 169UNITUXIN...........................63UPTRAVI.......................... 214urea...................................116urea hydrating...................116urea nail ............................ 116urea-c40............................116URECHOLINE.................. 150uredeb...............................116URELLE............................150uremez-40.........................116uretron d/s.........................150uribel................................. 150URIMAR-T........................ 151urin ds............................... 151URO-458...........................151UROCIT-K 10................... 138UROCIT-K 15................... 138

UROCIT-K 5..................... 138UROGESIC-BLUE............ 151uro-mp.............................. 151urosex............................... 138UROXATRAL....................152URSO 250........................ 144URSO FORTE.................. 144ursodiol............................. 144URYL................................ 151ustell ................................. 151UTIBRON NEOHALER.....212uticap................................ 151utira-c................................151utrona-c.............................151VABOMERE....................... 31VAGIFEM..........................168valacyclovir hcl....................76VALCHLOR........................ 63VALCYTE........................... 76valganciclovir hcl.................76VALIUM.............................. 78valproate sodium................ 39valproic acid........................39valrubicin.............................63valsartan............................. 99valsartan-hydrochlorothiazide.............99VALSTAR........................... 63VALTOCO 10 MG DOSE....39VALTOCO 15 MG DOSE....39VALTOCO 20 MG DOSE....39VALTOCO 5 MG DOSE......39VALTREX........................... 76VANATOL LQ..................... 15VANATOL S........................16VANCOCIN.........................31VANCOCIN HCL.................31VANCOMYCIN HCL........... 32vancomycin hcl................... 32VANCOMYCIN HCL IN DEXTROSE........................ 31vancomycin hcl in dextrose.31vancomycin hcl in nacl..31, 32VANCOMYCIN HCL IN NACL.................................. 31vandazole........................... 32VANTAS........................... 158VAPRISOL........................158VAQTA..............................179vardenafil hcl.....................151VARITHENA....................... 99VARIVAX.......................... 179VARUBI.............................. 45

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VARUBI (180 MG DOSE)... 45VASCEPA...........................99VASERETIC....................... 99VASOSTRICT...................158VASOTEC...........................99VAZCULEP.........................99v-c forte.............................138VCF VAGINAL CONTRACEPTIVE........... 194vcf vaginal contraceptive.. 194VECAMYL...........................99VECTIBIX........................... 63VECTICAL........................ 116vecuronium bromide......... 105VELCADE........................... 63VELETRI...........................214velivet................................168VELPHORO......................151VELTASSA....................... 138VEMLIDY............................ 76VENCLEXTA...................... 63VENCLEXTA STARTING PACK.................................. 63VENELEX......................... 116venlafaxine hcl.................... 43venlafaxine hcl er................43VENOFER........................ 138VENOMIL MIXED VESPID VENOM.............................194VENTAVIS........................ 214VENTOLIN HFA................212verapamil hcl.......................99verapamil hcl er.................. 99VERDESO........................ 116VEREGEN........................ 116VERELAN........................... 99VERELAN PM.....................99VERSACLOZ...................... 71VERZENIO......................... 64VESICARE........................151VEXATROL.........................20VFEND................................48VFEND IV........................... 48VIAGRA............................ 151VIBATIV.............................. 32VIBERZI............................145VIBRAMYCIN..................... 32vic-forte............................. 138VICTOZA.......................... 120VIDAZA...............................64VIEKIRA PAK..................... 76vienva............................... 168vigabatrin............................ 39

vigadrone............................ 39VIGAMOX......................... 198VIIBRYD............................. 43VIIBRYD STARTER PACK.43vilamit mb..........................151VILEVEV MB.................... 151VIMIZIM............................ 146VIMPAT.............................. 39vinblastine sulfate............... 64vincristine sulfate................ 64vinorelbine tartrate.............. 64VIOKACE..........................146viorele............................... 168VIRACEPT..........................76VIRAMUNE.........................76VIRAMUNE XR...................76VIRASAL...........................116VIRAZOLE.......................... 76VIREAD.............................. 76VIRGINIA LIVE OAK.........194virt-caps............................ 138VIRT-FEFA PLUS.............138virt-gard.............................138virt-phos 250 neutral......... 138virtussin ac w/alc...............207VISCO-3........................... 194VISIONBLUE.................... 204VISTARIL............................78VISTOGARD.....................194VISUDYNE....................... 204vita s forte......................... 138vitacel................................138VITAFOL...........................138VITAFOL-OB+DHA...........138VITAL-D RX...................... 138VITAMAX PEDIATRIC......138VITAMEZ.......................... 138vita-min............................. 138vitamin d (cholecalciferol). 138vitamin d (ergocalciferol)...138vitamin d3......................... 138vitamin k1..........................138vitamins acd-fluoride.........138VITAROCA PLUS............. 138VITA-RX DIABETIC VITAMIN........................... 139VITASURE........................139VITATHELY WITH GINGER............................139VITRAKVI........................... 64VITRASE.......................... 194VIVELLE-DOT.................. 168VIVITROL........................... 21

VIVOTIF............................179VIZIMPRO.......................... 64VOGELXO........................ 155VOGELXO PUMP.............155volnea............................... 168VOLTAREN.......................... 8VONVENDI......................... 84VOPAC KT............................8VORAXAZE........................ 64voriconazole........................48VOSEVI.............................. 76VOTRIENT..........................64vp-pnv-dha........................139VPRIV............................... 146vp-vite rx........................... 139VRAYLAR........................... 71VTOL LQ.............................16VUMERITY....................... 104VUMERITY (STARTER)... 104VUSION.............................. 48VYEPTI............................... 51vyfemla............................. 168vylibra............................... 168VYNDAMAX........................99VYNDAQEL........................ 99VYTONE............................. 48VYTORIN..........................100VYVANSE.................102, 103VYXEOS............................. 64VYZULTA..........................200WAKIX.............................. 216warfarin sodium.................. 35WASP VENOM PROTEIN 194water for irrigation, sterile. 139weekly-d............................139WELCHOL........................ 100WELLBUTRIN SR...............43WELLBUTRIN XL............... 43wera.................................. 168WESTERN JUNIPER....... 194WESTHROID....................169wheat germ oil .................. 139WHITE ASH......................194WHITE BIRCH.................. 194WHITE FACED HORNET VENOM.............................194WHITE MULBERRY......... 195WHITE OAK......................195WHITE PINE.....................195WHITE-FACED HORNET VENOM.............................195WIDE-SEAL DIAPHRAGM 60......................................195

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WIDE-SEAL DIAPHRAGM 65......................................195WIDE-SEAL DIAPHRAGM 70......................................195WIDE-SEAL DIAPHRAGM 75......................................195WIDE-SEAL DIAPHRAGM 80......................................195WIDE-SEAL DIAPHRAGM 85......................................195WIDE-SEAL DIAPHRAGM 90......................................195WIDE-SEAL DIAPHRAGM 95......................................195WILATE.............................. 84WINRHO SDF...................176wixela inhub...................... 212WP THYROID...................169wymzya fe.........................168XADAGO............................ 68XALATAN......................... 200XALKORI............................ 64XANAX................................78XANAX XR..........................78XARELTO........................... 35XARELTO STARTER PACK.................................. 35XELJANZ.......................... 176XELJANZ XR.................... 176XELODA............................. 64XEMBIFY.......................... 176XENAZINE........................106XENLETA........................... 32XEOMIN............................195XEPI....................................32XERAC AC....................... 116XERAVA............................. 32XERMELO........................ 145XEROFORM OIL EMULSION 2"X2"............. 116XEROFORM OIL EMULSION GAUZE..........116XEROFORM OIL EMULSION STRIP........... 116XEROFORM OIL ROLL 4"X9'................................. 116XEROFORM PETROLAT GAUZE 1"X8"................... 116XEROFORM PETROLAT GAUZE 5"X9"................... 116XEROFORM PETROLAT PATCH 2"X2"....................116

XEROFORM PETROLAT PATCH 4"X4"....................116XEROFORM PETROLATUM ROLL 4"X9'................................. 116XEROSTOMIA RELIEF SPRAY..............................107XGEVA............................. 182XHANCE...........................207XIAFLEX........................... 195XIFAXAN............................ 32XIGDUO XR......................120XIIDRA..............................204XOFIGO..............................64XOFLUZA (40 MG DOSE)..76XOFLUZA (80 MG DOSE)..76XOLAIR.............................207XOLEGEL........................... 48XOLEGEL COREPAK........ 48XOLEGEL DUO/HEAD & SHOULDERS..................... 48XOLEGEL DUO/XOLEX..... 48XOPENEX........................ 212XOPENEX CONCENTRATE.............. 212XOSPATA...........................64XPOVIO (100 MG ONCE WEEKLY)............................64XPOVIO (60 MG ONCE WEEKLY)............................64XPOVIO (80 MG ONCE WEEKLY)............................64XPOVIO (80 MG TWICE WEEKLY)............................64XTAMPZA ER.....................16XTANDI...............................64xulane............................... 168XULTOPHY...................... 120xurea.................................116XURIDEN..........................147XVITE............................... 139XYLOCAINE....................... 20xylocaine dental.................. 20XYLOCAINE/EPINEPHRINE......................................... 20XYLOCAINE-MPF.............. 20XYLOCAINE-MPF/EPINEPHRINE...........20XYNTHA............................. 84XYNTHA SOLOFUSE.........84XYREM............................. 216YASMIN 28....................... 168YAZ...................................168

YELLOW DOCK............... 195YELLOW HORNET VENOM PROTEIN............195YELLOW JACKET VENOM PROTEIN............195YERVOY.............................64YESCARTA........................ 64YF-VAX.............................179YONDELIS..........................64YONSA............................... 64YUPELRI.......................... 212yuvafem............................ 168zafirlukast..........................212zaleplon............................ 216ZALTRAP............................64ZANAFLEX....................... 215ZANOSAR.......................... 65zarah.................................168ZARONTIN......................... 39ZARXIO.............................. 84ZAVESCA......................... 147ZEBUTAL............................16ZEJULA.............................. 65ZELAPAR........................... 68ZELBORAF.........................65ZEMAIRA..........................212ZEMDRI.............................. 32ZEMPLAR.........................183zenatane........................... 116ZENPEP........................... 147ZENZEDI.......................... 103ZEPATIER.......................... 76ZERBAXA........................... 32ZERUVIA............................ 20ZERVIATE........................ 198ZESTORETIC................... 100ZESTRIL........................... 100ZETIA................................100ZETONNA.........................207ZEVALIN Y-90.................... 65ZIAC..................................100ZIAGEN.............................. 77zidovudine...........................77ZIEXTENZO........................84zileuton er......................... 212ZILRETTA.........................154ZINC CHLORIDE..............139ZINC SULFATE................ 139ZINECARD......................... 65ZINGO................................ 20ZINPLAVA........................ 177ZIONODIL...........................20ZIONODIL 100....................20

248

ZIOPTAN.......................... 200ziprasidone hcl....................71ziprasidone mesylate.......... 71ZIRABEV............................ 65ZIRGAN............................ 198ZITHRANOL..................... 116ZITHROMAX.......................32ZITHROMAX TRI-PAK....... 32ZITHROMAX Z-PAK........... 32ZOCOR.............................100ZOFRAN............................. 45ZOHYDRO ER....................16ZOLADEX......................... 158zoledronic acid..................182ZOLGENSMA 10.1-10.5 KG.....................................147ZOLGENSMA 10.6-11.0 KG.....................................147ZOLGENSMA 11.1-11.5 KG.....................................147ZOLGENSMA 11.6-12.0 KG.....................................147ZOLGENSMA 12.1-12.5 KG.....................................147ZOLGENSMA 12.6-13.0 KG.....................................147ZOLGENSMA 13.1-13.5 KG.....................................147ZOLGENSMA 2.6-3.0 KG.147ZOLGENSMA 3.1-3.5 KG.147ZOLGENSMA 3.6-4.0 KG.147ZOLGENSMA 4.1-4.5 KG.147ZOLGENSMA 4.6-5.0 KG.147ZOLGENSMA 5.1-5.5 KG.147ZOLGENSMA 5.6-6.0 KG.147ZOLGENSMA 6.1-6.5 KG.147ZOLGENSMA 6.6-7.0 KG.147ZOLGENSMA 7.1-7.5 KG.147ZOLGENSMA 7.6-8.0 KG.147ZOLGENSMA 8.1-8.5 KG.147ZOLGENSMA 8.6-9.0 KG.147ZOLGENSMA 9.1-9.5 KG.147ZOLGENSMA 9.6-10.0 KG.......................................... 147ZOLINZA.............................65zolmitriptan......................... 51ZOLOFT..............................43zolpidem tartrate............... 216zolpidem tartrate er...........216ZOMACTON..................... 159ZOMIG................................ 51ZOMIG ZMT........................51ZONALON........................ 116

ZONEGRAN....................... 39zonisamide..........................39ZONTIVITY......................... 69ZORBTIVE........................145ZORTRESS...................... 177ZOSYN............................... 33zovia 1/35e (28)................ 168ZOVIRAX............................ 77ZUBSOLV........................... 21zumandimine.................... 168ZUPLENZ........................... 45ZYDELIG............................ 65ZYFLO.............................. 212ZYKADIA............................ 65ZYLET...............................204ZYLOPRIM......................... 49ZYMAXID..........................198ZYPITAMAG..................... 100ZYPREXA........................... 71ZYPREXA RELPREVV.......72ZYPREXA ZYDIS............... 72ZYTIGA...............................65ZYVOX................................33

249

DISCRIMINATION IS AGAINST THE LAW

Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Health Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats,

other formats)

• Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact customer service. If you believe that Health Alliance has failed to provide these services or discriminated in another way on thebasis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Alliance Medical Plans, Customer Service, 3310 Fields South Drive, Champaign, IL 61822, telephone: 1-800-851-3379, TTY: 711, fax: 217-902-9705, [email protected]. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Customer Service is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

cmp-nondiscrim15MWCM-0318

DISCRIMINATION IS AGAINST THE LAW

Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Health Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other

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

o Qualified interpreters o Information written in other languages

If you need these services, contact customer service. If you believe that Health Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Alliance Medical Plans, Customer Service, 3310 Fields South Drive, Champaign, IL 61822, telephone: 1-800-851-3379, TTY: 711, fax: 217-902-9705, [email protected]. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Customer Service is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: Si habla Español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-851-3379 (TTY: 711). 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫1-800-851-3379（TTY: 711）。 Polish: UWAGA: Je li mówi Polskie, usługi pomocy j zyka, bezpłatnie, s dost pne dla Ciebie. Zadzwo 1-800-851-3379 (TTY: 711). Chú ý: Nếu bạn nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, có sẵn cho bạn. Gọi 1-800-851-3379 (TTY: 711). 주의 : 당신이한국어, 무료 언어 지원 서비스를 말하는 경우 사용할 수 있습니다. 1-800-851-3379 전화 (TTY: 711). ВНИМАНИЕ: Если вы говорите русский, вставки услуги языковой помощи, бесплатно, доступны для вас. Вызов 1-800-851-3379 (TTY: 711). Pansin: Kung magsalita ka Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tumawag 1-800-851-3379 (TTY: 711). .(TTY: 711) 3379-851-800-1 تنبيه: إذا كنت تتحدث اللغة العربية ، خدمات المساعدة اللغوية ، مجانا ، تتوفر لك . ستدعاء Wenn Sie Deutsch sprechen, Sprachassistenzdienste sind kostenlos, zur Verfügung. Anruf 1-800-851-3379 (TTY: 711). ATTENTION: Si vous parlez français, les services d'assistance linguistique, gratuitement, sont à votre disposition. Appelez 1-800-851-3379 (TTY: 711).

�યા�: તમે વાત તો �જુરાતી, ભાષા સહાય સેવાઓ, મફત, તમારા માટ� ��લ�� છે. કૉલ 1-800-851-3379 (TTY: 711).

注意：あなたは、日本語、無料で言語支援サービスを、話す場合は、あなたに利用可能です。 1-800-851-3379コール

（TTY: 711）。 LET OP: Als je spreekt pennsylvania nederlandse, taalkundige bijstand diensten, gratis voor u beschikbaar zijn. Bel 1-800-851-3379 (TTY: 711). УВАГА: Якщо ви говорите український, вставки послуги мовної допомоги, безкоштовно, доступні для вас. Виклик 1-800-851-3379 (TTY: 711). ATTENZIONE: Se si parla italiano, servizi di assistenza linguistica, a titolo gratuito, sono a vostra disposizione. Chiamare 1-800-851-3379 (TTY: 711).

updated may 1, 2020 - health alliance · by your plan for their safety, cost and effectiveness....

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