2020 New Mexico Marketplace Q4 Drug Formulary - Molina Healthcare
Molina, New Mexico, Marketplace, 2020, Q4, Drug Formulary
Molina Healthcare Inc
formulary-2020 2020
Formulary/
Formulario
(List of Covered Drugs) / (Lista de medicinas cubiertas)
New Mexico
The information in this document is effective as of October 1, 2020. The formulary is subject to change and all previous versions of the formulary are no longer in effect. An electronic version of the formulary can be found at MolinaMarketplace.com. Information about prescription drug cost sharing amounts can be found on our Benefits at a Glance brochure or by entering your prescription and pharmacy information into the Check Drug Cost tool.
La información de este documento está vigente a partir del 1 de octubre de 2020. El formulario está sujeto a cambio y todas las versiones anteriores del mismo ya no se encuentran en vigor. Puede encontrar una versión electrónica del formulario en MolinaMarketplace.com. Puede encontrar información sobre los montos de distribución de costos para medicamentos recetados en nuestro folleto Beneficios de un vistazo o ingresando su información de receta y farmacia en la herramienta Verificar Costo de Medicamentos.
MolinaMarketplace.com
10012020
Legend
What are the Requirements and Limits on the drug list?
Requirements and limits may be set up for certain drugs. Drugs may have the following requirements and limitations:
Requirements/Limits Description
AGE
Age limits apply. We only pay for this drug or dosage form for certain age groups based on information about the drug's safety, efficacy, and cost.
MED
Morphine Equivalent Dose limits apply. Quantities of this drug are limited to the equivalent ("EQ") of 90 milligrams of morphine per day of supply filled.
OTC
Over-the-Counter dosage forms are covered on the drug list with a valid prescription from a provider.
PA
Prior Authorization is required. We require advanced approval of coverage on some
drugs before they will be paid for. If Prior Authorization is required for a drug or
dosage form, providers must show you have a medically accepted use for the drug
and other treatments have not worked or are not appropriate. Other requirements
may apply depending on the drug.
QL
Quantity Limits apply. We will pay for a maximum daily amount based on information
about the drug's medically accepted use and cost.
ST
Step Therapy is required. If we have paid for you to have the required Step Therapy
drug(s) in the past, this drug will be paid for at the pharmacy without need for a Prior
Authorization or Step Therapy exception request. The drug list will show you which
drugs are required first and for how long.
Some drugs are designated "Preferred Brand" in the drug class they are listed. If there is a drug in the same class as the drug you are requesting and it is the Preferred Brand drug in the class, we require that the Preferred Brand be used first or instead. Specific drugs that require use of a Preferred Brand drug first may also be indicated "Medical Necessity PA". Medical Necessity Prior Authorization requirements apply to some Tier 4 Specialty Drugs.
The drug list will also indicate if a drug is eligible for Mail Order (MAIL) programs in the Requirements/Limits column. It is your choice if you want to use Mail Order programs. You may have lower cost sharing using Mail Order on some drugs.
What are Drug Tiers and how do they affect my share of the drug's cost?
We put drugs on different levels called tiers based on how well they improve health and how much they cost compared to similar treatments. Your plan has the following tiers. For Tiers 1 through 4, the lower the Drug Tier, the lower your share of the cost will be.
Here are more details about which drugs are on which tiers.
Drug Tier Tier 1 Tier 2 Tier 3 Tier 4
Tier 5 DME
Description
Preferred Generic drugs and low-cost Brand Name drugs; Lowest enrollee cost sharing
Preferred Brand Name drugs; Higher cost sharing than Tier 1
Non-Preferred, Brand Name and Generic drugs; Higher cost sharing than lower tier drugs used to treat the same conditions
Specialty Drugs, both Brand Name and Generic; Higher cost sharing than lower tier drugs used to treat the same conditions if available. Most Specialty Drugs covered in your plan will be available through a Specialty Pharmacy. We may require you to use our exclusive In-Network Specialty Pharmacy
Preventative service drugs
Durable Medical Equipment; Cost sharing may apply for non-drug products on the drug list
In accordance with the Affordable Care Act, your plan covers nationally recognized preventative service drugs and dosage forms (Tier 5) with $0 cost sharing.
How can I find more information about how much my drug will cost?
Information about prescription drug cost sharing amounts can be found on our Benefits at a Glance brochure or by entering your prescription and pharmacy information into the Check Drug Cost tool. This tool will provide you with an estimate of your cost. If you create an account with Caremark.com before using the tool, your plan design information will also be used to more closely estimate actual prices you pay at the pharmacy.
Leyenda
¿Cuáles son los requisitos y límites en la lista de medicamentos?
Se pueden establecer requisitos y límites para ciertos medicamentos. Los medicamentos pueden tener los siguientes requisitos y limitaciones:
Requisitos/límites
Descripción
AGE MED OTC
Se aplican límites de edad. Solo pagamos por este medicamento o forma farmacéutica para ciertos grupos de edad según la información sobre la seguridad, la efectividad y el costo del medicamento.
Se aplican límites de Dosis Equivalente de Morfina. Las cantidades de este medicamento están limitadas al equivalente ("EQ") de 90 miligramos de morfina al día de suministro adquirido.
Las formas farmacéuticas de venta sin receta están cubiertas en la lista de medicamentos con una receta válida de un proveedor.
PA
Se requiere Autorización previa. Requerimos aprobación anticipada de cobertura
para algunos medicamentos antes de que se pague por estos. Si la Autorización
previa es necesaria para un medicamento o forma farmacéutica, los proveedores
deben demostrar que usted tiene un uso aceptado por razones médicas para el
medicamento y otros tratamientos no han funcionado o no son adecuados. Pueden
aplicarse otros requisitos dependiendo del medicamento.
QL
Se aplican límites de cantidad. Pagaremos por un monto máximo diario según la
información acerca del uso y del costo aceptados por razones médicas del
medicamento.
ST
Se requiere Terapia escalonada. Si hemos pagado para que tenga el(los)
medicamento(s) de Terapia escalonada necesario(s) anteriormente, este
medicamento se pagará en la farmacia sin necesidad de una solicitud de excepción
de Terapia escalonada o Autorización previa. La lista de medicamentos le muestra
qué medicamentos se requieren primero y por cuánto tiempo.
!lgunos medicamentos son denominados "de Marca Preferida" en la clase de medicamento en la que aparecen. Si existe un medicamento en la misma clase que el medicamento que está solicitando y es el medicamento de Marca Preferida en la clase, necesitamos que el medicamento de Marca Preferida se utilice primero o en su lugar. Los medicamentos específicos que requieren el uso de un medicamento de Marca Preferida también se pueden indicar primero como "P! de Necesidad Médica". Se aplican requisitos de !utorización previa médicamente necesaria para algunos medicamentos especializados de categoría 4.
La lista de medicamentos además indicará si un medicamento es elegible para programas de pedido por correo
(MAIL) en la columna Requisitos/Límites. Es su decisión si desea usar programas de Pedido por correo. Es posible que tenga una distribución de costos menor cuando use el Pedido por correo en algunos medicamentos.
¿Qué son las categorías de medicamento y cómo afectan mi parte del costo de medicamentos?
Colocamos los medicamentos en distintos niveles llamados "categorías" basándonos en qué tan bien mejoran la salud y cuánto cuestan en comparación con tratamientos similares. Su plan tiene las siguientes categorías. Para las categorías del 1 al 4, mientras más baja es la categoría de medicamento, más baja será su parte del costo.
Estos son más detalles sobre qué medicamentos están en qué categorías.
Categoría de medicamento Tier 1 Tier 2 Tier 3
Tier 4
Tier 5
DME
Descripción
Medicamentos genéricos preferidos; distribución de costos más baja para el afiliado.
Medicamentos de marca preferidos; distribución de costos más alta que la categoría 1.
Medicamentos no preferidos, medicamentos de marca y medicamentos genéricos; distribución de costos más alta que los medicamentos de categoría más baja utilizados para tratar las mismas afecciones.
Medicamentos especializados, tanto de marca como genéricos; distribución de costos más alta que los medicamentos de categoría más baja utilizados para tratar las mismas afecciones, si están disponibles. La mayoría de medicamentos especializados cubiertos en su plan estarán disponibles a través de una farmacia de especialidad. Es posible que necesitemos que use nuestra farmacia de especialidad exclusiva dentro de la red.
Medicamentos de servicio preventivo y medicamentos y dispositivos de planificación familiar (es decir, anticonceptivos) con una distribución de costos de $0.
Equipo médico duradero; la distribución de costos puede aplicar para productos que no sean medicamentos de la lista de medicamentos.
¿Cómo puedo encontrar más información sobre el costo de mi medicamento?
Puede encontrar información sobre los montos de distribución de costos de los medicamentos recetados en nuestro folleto Resumen de los Beneficios (Benefits at a Glance) o ingresando la información de sus medicamentos recetados y la farmacia en la herramienta Verificar Costo de Medicamentos (Check Drug Cost). Si crea una cuenta con Caremark.com antes de usar la herramienta, la información de diseño de su plan también se utilizará para estimar de manera más exacta los precios reales que paga en la farmacia.
Molina Marketplace 2020 Formulary Changes Effective 10/1/2020
Effective Date 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020
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Formulary Change AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG AFINITOR DIS TAB 5MG AFINITOR TAB 10MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG ALECENSA CAP 150MG BRUKINSA CAP 80MG CAPRELSA TAB 100MG CAPRELSA TAB 300MG COMETRIQ 100MG DAILY DOSE KIT COMETRIQ 140MG DAILY DOSE KIT COMETRIQ 60MG DAILY DOSE KIT
Diclofenac gel 1% OTC
DUPIXENT INJ 300/2ML
ERIVEDGE CAP 150MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG FULPHILA INJ 6/0.6ML GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG GLEEVEC TAB 100MG GLEEVEC TAB 400MG IBRANCE CAP 100MG
Change Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL)
Adding Quantity Limit (QL)
Adding Quantity Limit (QL)
Adding Quantity Limit (QL)
Adding Over-the-Counter (OTC) formulation to formulary, Tier 1, Prior Authorization required, Quantity Limit (QL) Adding to formulary, Tier 4, Prior Authorization required Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL)
Notes QL: 60 per 30 days QL: 90 per 30 days QL: 60 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 240 per 30 days QL: 120 per 30 days QL: 60 per 30 days QL: 30 per 30 days QL: 60 per 30 days
QL: 120 per 30 days
QL: 90 per 30 days
QL: 200 per 30 days
QL: 30 per 30 days QL: 6 per 21 days QL: 6 per 21 days QL: 6 per 21 days QL: 0.6 per 14 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 90 per 30 days QL: 60 per 30 days QL: 30 per 30 days
Effective Date 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020
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10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020
Formulary Change IBRANCE CAP 125MG IBRANCE CAP 75MG IBRANCE TAB 100MG IBRANCE TAB 125MG IBRANCE TAB 75MG ICLUSIG TAB 15MG ICLUSIG TAB 45MG IMBRUVICA CAP 140MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG JAKAFI TAB 5MG KISQALI 200 PAK FEMARA KISQALI 400 PAK FEMARA KISQALI 600 PAK FEMARA KISQALI TAB 200 DAILY DOSE KISQALI TAB 400 DAILY DOSE KISQALI TAB 600 DAILY DOSE LENVIMA CAP 10 MG LENVIMA CAP 12 MG (3 x 4 mg) LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG LENVIMA CAP 4 MG LENVIMA CAP 8 MG LONSURF TAB 15-6.14 LONSURF TAB 20-8.19
10/1/2020
MALATHION LOT 0.5%
10/1/2020 10/1/2020 10/1/2020 10/1/2020
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MEKINIST TAB 0.5MG MEKINIST TAB 2MG NEULASTA INJ 6MG/0.6M NEXAVAR TAB 200MG
NEXLIZET TAB 180/10MG
ODOMZO CAP 200MG POLY-VI-SOL SOL 50MG/ML POLY-VI-SOL SOL IRON
Change Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL)
Notes QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 60 per 30 days QL: 30 per 30 days QL: 90 per 30 days QL: 60 per 30 days QL: 60 per 30 days QL: 60 per 30 days QL: 60 per 30 days QL: 60 per 30 days QL: 49 per 28 days QL: 70 per 28 days QL: 91 per 28 days QL: 30 per 30 days QL: 60 per 30 days QL: 90 per 30 days QL: 30 per 30 days
Adding Quantity Limit (QL)
QL: 90 per 30 days
Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Removing Step Therapy Requirement, adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding to formulary, Tier 3, Prior Authorization required Adding Quantity Limit (QL) Adding to formulary, Tier 2 Adding to formulary, Tier 2
QL: 60 per 30 days QL: 90 per 30 days QL: 60 per 30 days QL: 90 per 30 days QL: 30 per 30 days QL: 60 per 30 days QL: 100 per 28 days QL: 100 per 28 days
QL: 59 per 30 days
QL: 90 per 30 days QL: 30 per 30 days QL: 0.6 per 14 days QL: 120 per 30 days
QL: 30 per 30 days
Effective Date 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020
Formulary Change POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 2.5MG REVLIMID CAP 20MG REVLIMID CAP 25MG REVLIMID CAP 5MG
10/1/2020
RIBAVIRIN CAP 200MG
10/1/2020
RIBAVIRIN TAB 200MG
10/1/2020
RUBRACA TAB 200MG
10/1/2020
RUBRACA TAB 250MG
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RUBRACA TAB 300MG
10/1/2020
RYBELSUS TAB 14MG
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RYBELSUS TAB 3MG
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RYBELSUS TAB 7MG
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SPINOSAD SUS 0.9%
SPRYCEL TAB 100MG SPRYCEL TAB 140MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG STIVARGA TAB 40MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG
Change Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Removing Prior Authorization requirement Removing Prior Authorization requirement Adding to formulary, Tier 4, Prior Authorization required Adding to formulary, Tier 4, Prior Authorization required Adding to formulary, Tier 4, Prior Authorization required Adding to formulary, Tier 2, with Step Therapy requirement Adding to formulary, Tier 2, with Step Therapy requirement Adding to formulary, Tier 2, with Step Therapy requirement Removing Step Therapy requirement, adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL)
Notes QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days
QL: 120 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 90 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 90 per 30 days QL: 120 per 30 days QL: 60 per 30 days QL: 30 per 30 days
Effective Date 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020
10/1/2020
10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020 10/1/2020
Formulary Change SUTENT CAP 50MG TAFINLAR CAP 50MG TAFINLAR CAP 75MG TAGRISSO 40MG TAB TAGRISSO TAB 80MG TARCEVA TAB 100MG TARCEVA TAB 150MG TARCEVA TAB 25MG TASIGNA 50MG TASIGNA CAP 150MG TASIGNA CAP 200MG THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG THALOMID CAP 50MG TIVICAY TAB FOR ORAL SUSP 5MG (BASE EQUIV) TYKERB TAB 250MG UDENYCA INJ 6MG/.6ML VOTRIENT TAB 200MG XALKORI CAP 200MG XALKORI CAP 250MG ZEJULA CAP 100MG ZIEXTENZO INJ 6/0.6ML ZOLINZA CAP 100MG ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYTIGA TAB 250MG
Change Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding to formulary, Tier 2, with Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL) Adding Quantity Limit (QL)
Notes QL: 30 per 30 days QL: 120 per 30 days QL: 120 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 30 per 30 days QL: 90 per 30 days QL: 120 per 30 days QL: 120 per 30 days QL: 120 per 30 days QL: 30 per 30 days QL: 60 per 30 days QL: 60 per 30 days QL: 30 per 30 days
QL: 180 per 30 days
QL: 180 per 30 days QL: 0.6 per 14 days QL: 120 per 30 days QL: 60 per 30 days QL: 60 per 30 days QL: 90 per 30 days QL: 0.6 per 14 days QL: 120 per 30 days QL: 60 per 30 days QL: 60 per 30 days QL: 120 per 30 days
Molina New Mexico Marketplace
Effective 10/1/2020
Drug Name
Drug Tier Requirements/Limits
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
AMPHETAMINES
amphetamine-dextroamphetamine cap er 24hr 5 mg
Tier 1
AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years)
amphetamine-dextroamphetamine cap er 24hr 10 mg
Tier 1
AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years)
amphetamine-dextroamphetamine cap er 24hr 15 mg
Tier 1
AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years)
amphetamine-dextroamphetamine cap er 24hr 20 mg
Tier 1
AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years)
amphetamine-dextroamphetamine cap er 24hr 25 mg
Tier 1
AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years)
amphetamine-dextroamphetamine cap er 24hr 30 mg
Tier 1
AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years)
amphetamine-dextroamphetamine tab 5 mg
Tier 1
AGE, QL (90 tabs / 30 days); AGE (Min 3 years, Max 18 years)
amphetamine-dextroamphetamine tab 7.5 mg
Tier 1
AGE, QL (150 tabs / 30 days); AGE (Min 3 years, Max 18 years)
amphetamine-dextroamphetamine tab 10 mg
Tier 1
AGE, QL (90 tabs / 30 days); AGE (Min 3 years, Max 18 years)
amphetamine-dextroamphetamine tab 12.5 mg
Tier 1
AGE, QL (90 tabs / 30 days); AGE (Min 3 years, Max 18 years)
amphetamine-dextroamphetamine tab 15 mg
Tier 1
AGE, QL (90 tabs / 30 days); AGE (Min 3 years, Max 18 years)
amphetamine-dextroamphetamine tab 20 mg
Tier 1
AGE, QL (90 tabs / 30 days); AGE (Min 3 years, Max 18 years)
amphetamine-dextroamphetamine tab 30 mg
Tier 1
AGE, QL (60 tabs / 30 days); AGE (Min 3 years, Max 18 years)
dextroamphetamine sulfate cap er 24hr 5 mg
Tier 3
AGE, QL (120 caps / 30 days), PA; AGE (Min 6 years, Max 18 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
1
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
dextroamphetamine sulfate cap er 24hr 10 mg
Tier 3
AGE, QL (120 caps / 30 days), PA; AGE (Min 6 years, Max 18 years)
dextroamphetamine sulfate cap er 24hr 15 mg
Tier 3
AGE, QL (60 caps / 30 days), PA; AGE (Min 6 years, Max 18 years)
dextroamphetamine sulfate tab 5 mg
Tier 1
AGE, QL (180 tabs / 30 days); AGE (Min 3 years, Max 18 years)
dextroamphetamine sulfate tab 10 mg
methamphetamine hcl tab 5 mg
VYVANSE CAP 10MG (lisdexamfetamine dimesylate)
VYVANSE CAP 20MG (lisdexamfetamine dimesylate)
VYVANSE CAP 30MG (lisdexamfetamine dimesylate)
VYVANSE CAP 40MG (lisdexamfetamine dimesylate)
VYVANSE CAP 50MG (lisdexamfetamine dimesylate)
VYVANSE CAP 60MG (lisdexamfetamine dimesylate)
VYVANSE CAP 70MG (lisdexamfetamine dimesylate)
Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
AGE, QL (180 tabs / 30 days); AGE (Min 3 years, Max 18 years) AGE, PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years)
ANALEPTICS
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)
Tier 1
AGE, QL (120 mL in lifetime); AGE (Max 1 year)
ANOREXIANTS NON-AMPHETAMINE phendimetrazine tartrate tab 35 mg
Tier 1
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS
atomoxetine hcl cap 10 mg (base equiv)
Tier 3
AGE, QL (30 caps / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
2
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name atomoxetine hcl cap 18 mg (base equiv)
atomoxetine hcl cap 25 mg (base equiv)
atomoxetine hcl cap 40 mg (base equiv)
atomoxetine hcl cap 60 mg (base equiv)
atomoxetine hcl cap 80 mg (base equiv)
atomoxetine hcl cap 100 mg (base equiv)
guanfacine hcl tab er 24hr 1 mg (base equiv)
guanfacine hcl tab er 24hr 2 mg (base equiv)
guanfacine hcl tab er 24hr 3 mg (base equiv)
guanfacine hcl tab er 24hr 4 mg (base equiv)
STIMULANTS - MISC. armodafinil tab 50 mg armodafinil tab 150 mg armodafinil tab 200 mg armodafinil tab 250 mg
Drug Tier Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Requirements/Limits
AGE, QL (30 caps / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years)
AGE, QL (30 caps / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years)
AGE, QL (30 caps / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years)
AGE, QL (30 tabs / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years)
AGE, QL (30 tabs / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years)
AGE, QL (30 tabs / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 tabs / 30 days), MAIL, PA; AGE (Min 6 years, Max 18 years)
Tier 1 PA Tier 1 PA Tier 1 PA Tier 1 PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
3
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name dexmethylphenidate hcl tab 2.5 mg dexmethylphenidate hcl tab 5 mg dexmethylphenidate hcl tab 10 mg methylphenidate hcl cap er 10 mg (cd) methylphenidate hcl cap er 20 mg (cd) methylphenidate hcl cap er 24hr 10 mg (la) methylphenidate hcl cap er 24hr 20 mg (la) methylphenidate hcl cap er 24hr 30 mg (la) methylphenidate hcl cap er 24hr 40 mg (la) methylphenidate hcl cap er 30 mg (cd) methylphenidate hcl cap er 40 mg (cd) methylphenidate hcl cap er 50 mg (cd) methylphenidate hcl cap er 60 mg (cd) methylphenidate hcl soln 5 mg/5ml methylphenidate hcl soln 10 mg/5ml
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
AGE, QL (60 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (60 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (60 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days), PA; AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 caps / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (450 mL / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (900 mL / 30 days); AGE (Min 6 years, Max 18 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
4
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name methylphenidate hcl tab 5 mg
methylphenidate hcl tab 10 mg
methylphenidate hcl tab 20 mg
methylphenidate hcl tab er 10 mg
methylphenidate hcl tab er 20 mg
methylphenidate hcl tab er 24hr 18 mg
methylphenidate hcl tab er 24hr 27 mg
methylphenidate hcl tab er 24hr 36 mg
methylphenidate hcl tab er 24hr 54 mg
methylphenidate hcl tab er osmotic release (osm) 18 mg methylphenidate hcl tab er osmotic release (osm) 27 mg methylphenidate hcl tab er osmotic release (osm) 36 mg methylphenidate hcl tab er osmotic release (osm) 54 mg modafinil tab 100 mg modafinil tab 200 mg ALTERNATIVE MEDICINES
ALTERNATIVE MEDICINE - M'S melatonin cap 3 mg
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
Requirements/Limits
AGE, QL (90 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (90 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (90 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (90 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (60 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (60 tabs / 30 days); AGE (Min 6 years, Max 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 6 years, Max 18 years) QL (30 tabs / 30 days), PA QL (60 tabs / 30 days), PA
Tier 1 OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
5
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
melatonin cap 5 mg (Cvs Melatonin)
Tier 1
MELATONIN LIQ 1MG/4ML
Tier 1
melatonin tab 1 mg
Tier 1
melatonin tab 3 mg
Tier 1
melatonin tab 5 mg
Tier 1
melatonin tab 300 mcg
Tier 1
melatonin tab er 10 mg
Tier 1
melatonin tablet disintegrating 5 mg
Tier 1
ALTERNATIVE MEDICINE COMBINATIONS
melatonin-pyridoxine tab 3-1 mg (Melatonin/vitamin B-6 Ext)
Tier 1
melatonin-pyridoxine tab 3-2 mg (Ra Melatonin)
Tier 1
melatonin-pyridoxine tab er 3-10 mg (Melatonin Tr/vitamin B-6)
Tier 1
AMINOGLYCOSIDES
AMINOGLYCOSIDES
neomycin sulfate tab 500 mg
Tier 1
paromomycin sulfate cap 250 mg
Tier 3
tobramycin nebu soln 300 mg/5ml
Tier 4
ANALGESICS - ANTI-INFLAMMATORY
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES
HUMIRA INJ 10/0.1ML (adalimumab)
Tier 4
HUMIRA INJ 10MG/0.2 (adalimumab)
Tier 4
HUMIRA INJ 20/0.2ML (adalimumab)
Tier 4
HUMIRA INJ 40/0.4ML (adalimumab)
Tier 4
HUMIRA KIT 20MG/0.4 (adalimumab)
Tier 4
HUMIRA KIT 40MG/0.8 (adalimumab)
Tier 4
HUMIRA PEDIA INJ CROHNS (adalimumab)
Tier 4
HUMIRA PEDIA INJ CROHNS (adalimumab)
Tier 4
HUMIRA PEN INJ 40/0.4ML (adalimumab)
Tier 4
HUMIRA PEN INJ CD/UC/HS (adalimumab)
Tier 4
HUMIRA PEN KIT CD/UC/HS (adalimumab)
Tier 4
HUMIRA PEN KIT PS/UV (adalimumab)
Tier 4
Requirements/Limits OTC OTC OTC OTC OTC OTC OTC OTC
OTC
OTC OTC
PA
QL (2 mL / 28 days), PA; Preferred Brand QL (2 mL / 28 days), PA; Preferred Brand QL (2 mL / 28 days), PA; Preferred Brand QL (2 mL / 28 days), PA; Preferred Brand QL (2 mL / 28 days), PA; Preferred Brand QL (2 mL / 28 days), PA; Preferred Brand QL (2 ea / year), PA; Preferred Brand QL (3 ea / year), PA; Preferred Brand QL (2 mL / 28 days), PA; Preferred Brand QL (2 mL / 28 days), PA; Preferred Brand QL (3 ea / year), PA; Preferred Brand QL (3 ea / year), PA; Preferred Brand
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
6
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name SIMPONI INJ 50/0.5ML (golimumab)
Drug Tier Tier 4
SIMPONI INJ 100MG/ML (golimumab)
Tier 4
ANTIRHEUMATIC - ENZYME INHIBITORS
RINVOQ TAB 15MG ER (upadacitinib)
Tier 4
XELJANZ TAB 5MG (tofacitinib citrate)
Tier 4
XELJANZ TAB 10MG (tofacitinib citrate)
Tier 4
XELJANZ XR TAB 11MG (tofacitinib citrate)
Tier 4
XELJANZ XR TAB 22MG (tofacitinib citrate)
Tier 4
GOLD COMPOUNDS
RIDAURA CAP 3MG (auranofin)
Tier 3
INTERLEUKIN-1 BLOCKERS
ARCALYST INJ 220MG (rilonacept)
Tier 4
INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)
KINERET INJ (anakinra)
Tier 4
INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA INJ 80MG/4ML (tocilizumab)
Tier 4
ACTEMRA INJ 162/0.9 (tocilizumab)
Tier 4
ACTEMRA INJ 200/10ML (tocilizumab)
Tier 4
ACTEMRA INJ 400/20ML (tocilizumab)
Tier 4
ACTEMRA INJ ACTPEN (tocilizumab)
Tier 4
KEVZARA INJ 150/1.14 (sarilumab)
Tier 4
Requirements/Limits PA; Medical Necessity PA; Prior use of appropriate Preferred Brands PA; Medical Necessity PA; Prior use of appropriate Preferred Brands
PA; Preferred Brand PA; Preferred Brand PA; Preferred Brand PA; Preferred Brand PA; Preferred Brand
MAIL, PA
PA
PA; Medical Necessity PA; Prior use of appropriate Preferred Brands
PA; Medical Necessity PA; Prior use of appropriate Preferred Brands PA; Medical Necessity PA; Prior use of appropriate Preferred Brands PA; Medical Necessity PA; Prior use of appropriate Preferred Brands PA; Medical Necessity PA; Prior use of appropriate Preferred Brands PA; Medical Necessity PA; Prior use of appropriate Preferred Brands PA; Preferred Brand
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
7
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
KEVZARA INJ 200/1.14 (sarilumab)
Tier 4 PA; Preferred Brand
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)
celecoxib cap 50 mg
Tier 1 QL (60 caps / 30 days), MAIL, PA
celecoxib cap 100 mg
Tier 1 QL (60 caps / 30 days), MAIL, PA
celecoxib cap 200 mg
Tier 1 QL (60 caps / 30 days), MAIL, PA
celecoxib cap 400 mg
Tier 1 QL (60 caps / 30 days), MAIL, PA
diclofenac potassium tab 50 mg
Tier 1 QL (120 tabs / 30 days), MAIL
diclofenac sodium tab delayed release 25 mg
Tier 1 QL (90 tabs / 30 days), MAIL
diclofenac sodium tab delayed release 50 mg
Tier 1 QL (90 tabs / 30 days), MAIL
diclofenac sodium tab delayed release 75 mg
Tier 1 QL (60 tabs / 30 days), MAIL
diclofenac sodium tab er 24hr 100 mg
Tier 1 QL (60 tabs / 30 days), MAIL
etodolac tab 400 mg
Tier 1 QL (90 tabs / 30 days), MAIL
etodolac tab 500 mg
Tier 1 QL (90 tabs / 30 days), MAIL
fenoprofen calcium tab 600 mg
Tier 3 QL (120 tabs / 30 days), MAIL
flurbiprofen tab 50 mg
Tier 1 QL (120 tabs / 30 days), MAIL
flurbiprofen tab 100 mg
Tier 1 QL (120 tabs / 30 days), MAIL
ibuprofen cap 200 mg (Medi-profen)
Tier 1 OTC, QL (120 caps / 30 days)
ibuprofen chew tab 100 mg (Sm Ibuprofen Ib)
Tier 1
OTC, AGE, QL (180 tabs / 30 days); AGE (Max 12 years)
ibuprofen susp 40 mg/ml (Cvs Ibuprofen Infants)
Tier 1 OTC, AGE; AGE (Max 12 years)
ibuprofen susp 100 mg/5ml (Ibuprofen Childrens)
Tier 1 OTC, AGE; AGE (Max 12 years)
ibuprofen tab 100 mg (Advil Junior Strength)
Tier 1 OTC, QL (120 tabs / 30 days)
ibuprofen tab 200 mg (Ra Ibuprofen)
Tier 1 OTC, QL (120 tabs / 30 days)
ibuprofen tab 400 mg
Tier 1 QL (120 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
8
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name ibuprofen tab 600 mg ibuprofen tab 800 mg indomethacin cap 25 mg
indomethacin cap 50 mg
ketorolac tromethamine tab 10 mg
meclofenamate sodium cap 50 mg meclofenamate sodium cap 100 mg mefenamic acid cap 250 mg meloxicam tab 7.5 mg meloxicam tab 15 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen sodium tab 220 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg naproxen tab ec 375 mg (Naproxen Dr) naproxen tab ec 500 mg (Naproxen Dr) oxaprozin tab 600 mg piroxicam cap 10 mg piroxicam cap 20 mg sulindac tab 150 mg
Drug Tier Tier 1 Tier 1 Tier 1
Tier 1
Tier 1
Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1
Requirements/Limits
QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL AGE, QL (120 caps / 30 days), MAIL; AGE (Max 64 years) AGE, QL (120 caps / 30 days), MAIL; AGE (Max 64 years) AGE; AGE (Max 64 years), Max 5 day supply per fill MAIL, PA
MAIL, PA
MAIL, PA
QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL OTC, QL (90 tabs / 30 days), MAIL AGE, MAIL; AGE (Max 12 years) QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL, PA QL (120 caps / 30 days), MAIL, PA QL (60 caps / 30 days), MAIL, PA QL (90 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
9
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
sulindac tab 200 mg
Tier 1 QL (90 tabs / 30 days), MAIL
tolmetin sodium cap 400 mg
Tier 3 QL (120 caps / 30 days), MAIL
tolmetin sodium tab 200 mg
Tier 3 QL (90 tabs / 30 days), MAIL
tolmetin sodium tab 600 mg
Tier 3 QL (90 tabs / 30 days), MAIL
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS
OTEZLA TAB 10/20/30 (apremilast)
Tier 4 PA; Preferred Brand
OTEZLA TAB 30MG (apremilast)
Tier 4 PA; Preferred Brand
PYRIMIDINE SYNTHESIS INHIBITORS
leflunomide tab 10 mg
Tier 1 QL (30 tabs / 30 days), MAIL
leflunomide tab 20 mg
Tier 1 QL (30 tabs / 30 days), MAIL
SELECTIVE COSTIMULATION MODULATORS
ORENCIA CLCK INJ 125MG/ML (abatacept)
Tier 4
PA; Medical Necessity PA; Prior use of appropriate Preferred Brands
ORENCIA INJ 50/0.4 (abatacept)
Tier 4
PA; Medical Necessity PA; Prior use of appropriate Preferred Brands
ORENCIA INJ 87.5/0.7 (abatacept)
Tier 4
PA; Medical Necessity PA; Prior use of appropriate Preferred Brands
ORENCIA INJ 125MG/ML (abatacept)
Tier 4
PA; Medical Necessity PA; Prior use of appropriate Preferred Brands
ORENCIA INJ 250MG (abatacept)
Tier 4
PA; Medical Necessity PA; Prior use of appropriate Preferred Brands
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS
ENBREL INJ 25/0.5ML (etanercept)
Tier 4 QL (4 mL / 28 days), PA; Preferred Brand
ENBREL INJ 25MG (etanercept)
Tier 4 QL (4 mL / 28 days), PA; Preferred Brand
ENBREL INJ 50MG/ML (etanercept)
Tier 4 QL (4 mL / 28 days), PA; Preferred Brand
ENBREL MINI INJ 50MG/ML (etanercept)
Tier 4 QL (4 mL / 28 days), PA; Preferred Brand
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
10
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name ENBREL SRCLK INJ 50MG/ML (etanercept)
ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS
butalbital-acetaminophen tab 50-325 mg
Drug Tier Tier 4
Tier 1
butalbital-acetaminophen-caffeine cap 50-30040 mg butalbital-acetaminophen-caffeine cap 50-32540 mg (Esgic) butalbital-acetaminophen-caffeine tab 50-32540 mg butalbital-aspirin-caffeine cap 50-325-40 mg
Tier 1 Tier 1 Tier 1 Tier 1
ANALGESICS OTHER acetaminophen cap 500 mg (Sm Pain Reliever Extra St) acetaminophen chew tab 80 mg (Childrens Pain Reliever) acetaminophen chew tab 160 mg (Non-aspirin Junior Streng) acetaminophen disintegrating tab 80 mg (Ra Acetaminophen Rapid Me) acetaminophen disintegrating tab 160 mg (Ra Acetaminophen Rapid Me) acetaminophen elixir 160 mg/5ml acetaminophen liquid 160 mg/5ml (Mapap) acetaminophen liquid 167 mg/5ml (Eq Pain Relief Adult/rapi) acetaminophen soln 160 mg/5ml (Pain & Fever Childrens) acetaminophen suppos 120 mg acetaminophen suppos 325 mg (Acephen) acetaminophen suppos 650 mg acetaminophen susp 160 mg/5ml (Cvs Pain & Fever Children) acetaminophen tab 325 mg (Mapap) acetaminophen tab 500 mg acetaminophen tab er 650 mg FEVERALL INF SUP 80MG (acetaminophen) FEVERALL SUP 325MG (acetaminophen) NORTEMP SUS INFANTS (acetaminophen)
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1 Tier 1 Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits QL (4 mL / 28 days), PA; Preferred Brand
AGE, QL (300 tabs / 30 days); AGE (Max 64 years) QL (180 caps / 30 days)
QL (180 caps / 30 days)
QL (180 tabs / 30 days)
AGE, QL (180 caps / 30 days); AGE (Max 64 years)
OTC
OTC
OTC
OTC
OTC
OTC OTC OTC
OTC
OTC OTC OTC OTC
OTC OTC OTC OTC OTC OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
11
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name SALICYLATES
aspirin chew tab 81 mg (St Joseph Low Dose Aspiri)
aspirin tab 325 mg (Sm Aspirin) aspirin tab delayed release 81 mg (Aspirin Low Dose)
aspirin tab delayed release 325 mg diflunisal tab 500 mg
salsalate tab 500 mg
salsalate tab 750 mg
ANALGESICS - OPIOID OPIOID AGONISTS
CODEINE SULF TAB 60MG
codeine sulfate tab 30 mg
EMBEDA CAP 20-0.8MG (morphine-naltrexone) EMBEDA CAP 30-1.2MG (morphine-naltrexone) EMBEDA CAP 50-2MG (morphine-naltrexone) EMBEDA CAP 60-2.4MG (morphine-naltrexone) EMBEDA CAP 80-3.2MG (morphine-naltrexone) EMBEDA CAP 100-4MG (morphine-naltrexone) fentanyl td patch 72hr 12 mcg/hr
fentanyl td patch 72hr 25 mcg/hr
fentanyl td patch 72hr 50 mcg/hr
fentanyl td patch 72hr 75 mcg/hr
fentanyl td patch 72hr 100 mcg/hr
hydromorphone hcl tab 2 mg
Drug Tier Requirements/Limits
Tier 5
Tier 1 Tier 5
Tier 1 Tier 1 Tier 1 Tier 1
OTC, MAIL; Tier 5 for ages 50-59 years old, quantity limit 100 per fill otherwise Tier 1 OTC, MAIL
OTC, MAIL; Tier 5 for ages 50-59 years old, quantity limit 100 per fill otherwise Tier 1 OTC, MAIL
QL (90 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL
Tier 1
Tier 1
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (360 tabs / 30 days); Max 7 day supply initial fill, MED PA; MED
PA; MED
PA; MED
PA; MED
PA; MED
PA; MED
QL (10 patches / 30 days), PA; MED QL (10 patches / 30 days), PA; MED QL (10 patches / 30 days), PA; MED QL (10 patches / 30 days), PA; MED QL (10 patches / 30 days), PA; MED QL (360 tabs / 30 days); Max 7 day supply initial fill, MED
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
12
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name hydromorphone hcl tab 4 mg
Drug Tier Tier 1
hydromorphone hcl tab 8 mg
Tier 1
hydromorphone hcl tab er 24hr deter 8 mg hydromorphone hcl tab er 24hr deter 12 mg hydromorphone hcl tab er 24hr deter 16 mg hydromorphone hcl tab er 24hr deter 32 mg HYSINGLA ER TAB 20 MG (hydrocodone bitartrate) HYSINGLA ER TAB 30 MG (hydrocodone bitartrate) HYSINGLA ER TAB 40 MG (hydrocodone bitartrate) HYSINGLA ER TAB 60 MG (hydrocodone bitartrate) HYSINGLA ER TAB 80 MG (hydrocodone bitartrate) HYSINGLA ER TAB 100 MG (hydrocodone bitartrate) HYSINGLA ER TAB 120 MG (hydrocodone bitartrate) meperidine hcl oral soln 50 mg/5ml
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Tier 3
Tier 1
meperidine hcl tab 50 mg
Tier 1
meperidine hcl tab 100 mg
Tier 1
methadone hcl soln 5 mg/5ml methadone hcl soln 10 mg/5ml methadone hcl tab 5 mg
Tier 1 Tier 1 Tier 1
methadone hcl tab 10 mg
Tier 1
morphine sulfate oral soln 10 mg/5ml
Tier 1
morphine sulfate oral soln 20 mg/5ml
Tier 1
Requirements/Limits
QL (360 tabs / 30 days); Max 7 day supply initial fill, MED QL (360 tabs / 30 days); Max 7 day supply initial fill, MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED
PA; MED
AGE; Max 7 day supply initial fill, MED; AGE (Max 64 years) AGE; Max 7 day supply initial fill, MED; AGE (Max 64 years) AGE; Max 7 day supply initial fill, MED; AGE (Max 64 years) Max 7 day supply initial fill, MED Max 7 day supply initial fill, MED QL (360 tabs / 30 days); Max 7 day supply initial fill, MED QL (360 tabs / 30 days); Max 7 day supply initial fill, MED QL (450 mL / 30 days); Max 7 day supply initial fill, MED QL (450 mL / 30 days); Max 7 day supply initial fill, MED
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
13
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name morphine sulfate oral soln 100 mg/5ml (20 mg/ml) morphine sulfate tab 15 mg
morphine sulfate tab 30 mg
morphine sulfate tab er 15 mg morphine sulfate tab er 30 mg morphine sulfate tab er 60 mg morphine sulfate tab er 100 mg morphine sulfate tab er 200 mg NUCYNTA ER TAB 50MG (tapentadol hcl) NUCYNTA ER TAB 100MG (tapentadol hcl) NUCYNTA ER TAB 150MG (tapentadol hcl) NUCYNTA ER TAB 200MG (tapentadol hcl) NUCYNTA ER TAB 250MG (tapentadol hcl) NUCYNTA TAB 50MG (tapentadol hcl) NUCYNTA TAB 75MG (tapentadol hcl) NUCYNTA TAB 100MG (tapentadol hcl) oxycodone hcl soln 5 mg/5ml oxycodone hcl tab 5 mg
oxycodone hcl tab 10 mg
oxycodone hcl tab 15 mg
oxycodone hcl tab 20 mg
oxycodone hcl tab 30 mg
oxycodone hcl tab er 12hr deter 10 mg oxycodone hcl tab er 12hr deter 15 mg
Drug Tier Tier 1
Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3 Tier 3
Requirements/Limits
QL (450 mL / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (90 tabs / 30 days); Step Thru IR, MED QL (90 tabs / 30 days); Step Thru IR, MED QL (90 tabs / 30 days); Step Thru IR, MED QL (90 tabs / 30 days); Step Thru IR, MED QL (90 tabs / 30 days); Step Thru IR, MED PA; MED
PA; MED
PA; MED
PA; MED
PA; MED
PA; MED
PA; MED
PA; MED
Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED PA; MED
PA; MED
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
14
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name oxycodone hcl tab er 12hr deter 20 mg oxycodone hcl tab er 12hr deter 30 mg oxycodone hcl tab er 12hr deter 40 mg oxycodone hcl tab er 12hr deter 60 mg oxycodone hcl tab er 12hr deter 80 mg OXYCONTIN TAB 10MG CR (oxycodone hcl) OXYCONTIN TAB 15MG CR (oxycodone hcl) OXYCONTIN TAB 20MG CR (oxycodone hcl) OXYCONTIN TAB 30MG CR (oxycodone hcl) OXYCONTIN TAB 40MG CR (oxycodone hcl) OXYCONTIN TAB 60MG CR (oxycodone hcl) OXYCONTIN TAB 80MG CR (oxycodone hcl) oxymorphone hcl tab 5 mg oxymorphone hcl tab 10 mg oxymorphone hcl tab er 12hr 5 mg
oxymorphone hcl tab er 12hr 7.5 mg
oxymorphone hcl tab er 12hr 10 mg
oxymorphone hcl tab er 12hr 15 mg
oxymorphone hcl tab er 12hr 20 mg
oxymorphone hcl tab er 12hr 30 mg
oxymorphone hcl tab er 12hr 40 mg
tramadol hcl tab 50 mg
tramadol hcl tab er 24hr 100 mg
tramadol hcl tab er 24hr 200 mg
tramadol hcl tab er 24hr 300 mg
tramadol hcl tab er 24hr biphasic release 100 mg tramadol hcl tab er 24hr biphasic release 200 mg tramadol hcl tab er 24hr biphasic release 300 mg
Drug Tier Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED PA; MED QL (120 tabs / 30 days), PA; MED QL (120 tabs / 30 days), PA; MED QL (120 tabs / 30 days), PA; MED QL (120 tabs / 30 days), PA; MED QL (120 tabs / 30 days), PA; MED QL (120 tabs / 30 days), PA; MED QL (120 tabs / 30 days), PA; MED QL (240 tabs / 30 days); Max 7 day supply initial fill, MED QL (30 tabs / 30 days), PA; MED QL (30 tabs / 30 days), PA; MED QL (30 tabs / 30 days), PA; MED QL (30 tabs / 30 days), PA; MED QL (30 tabs / 30 days), PA; MED QL (30 tabs / 30 days), PA; MED
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
15
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
OPIOID COMBINATIONS
acetaminophen w/ codeine soln 120-12 mg/5ml Tier 1
acetaminophen w/ codeine tab 300-15 mg
Tier 1
acetaminophen w/ codeine tab 300-30 mg
Tier 1
acetaminophen w/ codeine tab 300-60 mg
Tier 1
butalbital-acetaminophen-caff w/ cod cap 50300-40-30 mg
butalbital-acetaminophen-caff w/ cod cap 50325-40-30 mg
hydrocodone-acetaminophen soln 7.5-325 mg/15ml hydrocodone-acetaminophen tab 5-325 mg
Tier 3 Tier 1 Tier 1 Tier 1
hydrocodone-acetaminophen tab 7.5-325 mg
Tier 1
hydrocodone-acetaminophen tab 10-325 mg
Tier 1
hydrocodone-ibuprofen tab 7.5-200 mg
Tier 1
hydrocodone-ibuprofen tab 10-200 mg
Tier 3
oxycodone w/ acetaminophen tab 2.5-325 mg
Tier 1
oxycodone w/ acetaminophen tab 5-325 mg
Tier 1
oxycodone w/ acetaminophen tab 7.5-325 mg
Tier 1
oxycodone w/ acetaminophen tab 10-325 mg
Tier 1
Requirements/Limits
Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (240 caps / 30 days); Max 7 day supply initial fill, MED QL (240 caps / 30 days); Max 7 day supply initial fill, MED Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (240 tabs / 30 days); Max 7 day supply initial fill, MED QL (240 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED QL (180 tabs / 30 days); Max 7 day supply initial fill, MED
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
16
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name oxycodone-ibuprofen tab 5-400 mg
Drug Tier Tier 1
OPIOID PARTIAL AGONISTS buprenorphine hcl sl tab 2 mg (base equiv) buprenorphine hcl sl tab 8 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) buprenorphine td patch weekly 5 mcg/hr buprenorphine td patch weekly 7.5 mcg/hr buprenorphine td patch weekly 10 mcg/hr buprenorphine td patch weekly 15 mcg/hr buprenorphine td patch weekly 20 mcg/hr butorphanol tartrate nasal soln 10 mg/ml
ANDROGENS-ANABOLIC ANABOLIC STEROIDS
ANADROL-50 TAB 50MG (oxymetholone) oxandrolone tab 2.5 mg oxandrolone tab 10 mg
ANDROGENS danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
METHITEST TAB 10MG (methyltestosterone) methyltestosterone cap 10 mg testosterone cypionate im inj in oil 100 mg/ml testosterone cypionate im inj in oil 200 mg/ml testosterone enanthate im inj in oil 200 mg/ml ANORECTAL AGENTS
INTRARECTAL STEROIDS hydrocortisone enema 100 mg/60ml
RECTAL COMBINATIONS pramox-pe-glycerin-petrolatum perianal cream 1-0.25-14.4-15% (Ra Hemorrhoidal)
RECTAL LOCAL ANESTHETICS dibucaine perianal ointment 1%
RECTAL STEROIDS hydrocortisone perianal cream 2.5%
Tier 1 Tier 1 Tier 1
Tier 1
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
Tier 3 Tier 3 Tier 3
Tier 3
Tier 3
Tier 3
Tier 4 Tier 4 Tier 1 Tier 1 Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Requirements/Limits QL (180 tabs / 30 days); Max 7 day supply initial fill, MED
QL (360 tabs / 30 days) QL (90 tabs / 30 days) QL (360 tabs / 30 days)
QL (90 tabs / 30 days)
PA; MED PA; MED PA; MED PA; MED PA; MED QL (150 mL / 30 days), PA; MED
PA PA PA
QL (60 caps / 30 days), MAIL QL (120 caps / 30 days), MAIL QL (120 caps / 30 days), MAIL PA PA QL (10 mL / 30 days) QL (10 mL / 30 days) QL (10 mL / 30 days)
QL (1680 mL / 30 days)
OTC
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
17
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
VASODILATING AGENTS
RECTIV OIN 0.4% (nitroglycerin (intra-anal))
Tier 3
ANTACIDS
ANTACID COMBINATIONS
alum & mag hydroxide-simethicone chew tab 200-200-25 mg (Mintox Plus)
Tier 1
alum & mag hydroxide-simethicone susp 200200-20 mg/5ml (Almacone)
Tier 1
alum & mag hydroxide-simethicone susp 200200-20 mg/5ml (Antacid)
Tier 1
alum & mag hydroxide-simethicone susp 400400-40 mg/5ml (Almacone Double Strength)
Tier 1
aluminum hydroxide-magnesium carbonate chew tab 160-105 mg (Cvs Heartburn Relief)
Tier 1
aluminum hydroxide-magnesium carbonate susp 95-358 mg/15ml (Acid Gone)
Tier 1
aluminum hydroxide-magnesium trisilicate chew tab 80-20 mg (Sm Foaming Antacid)
Tier 1
calcium carbonate-mag hydroxide chew tab 675-135 mg (Tgt Antacid Extra Strengt)
Tier 1
calcium carbonate-mag hydroxide susp 400-135 Tier 1 mg/5ml (Cvs Antacid Supreme)
MI-ACID CHW (calcium carbonate-mag hydrox)
Tier 1
ANTACIDS - BICARBONATE
sodium bicarbonate tab 325 mg
Tier 1
sodium bicarbonate tab 650 mg
Tier 1
ANTACIDS - CALCIUM SALTS
calcium carbonate (antacid) chew tab 400 mg (Childrens Pepto)
Tier 1
calcium carbonate (antacid) chew tab 500 mg (Calcium Antacid)
Tier 1
calcium carbonate (antacid) chew tab 750 mg (Cvs Smooth Antacid Extra)
Tier 1
calcium carbonate (antacid) chew tab 1000 mg (Gnp Antacid Ultra Strengt)
Tier 1
calcium carbonate (antacid) susp 1250 mg/5ml Tier 1
ANTACIDS - MAGNESIUM SALTS
magnesium oxide tab 250 mg (Gnp Magnesium)
Tier 1
magnesium oxide tab 420 mg (Maox)
Tier 1
ANTHELMINTICS
ANTHELMINTICS
BENZNIDAZOLE TAB 12.5MG
Tier 2
BENZNIDAZOLE TAB 100MG
Tier 2
ivermectin tab 3 mg
Tier 1
Requirements/Limits
OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
18
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
praziquantel tab 600 mg
Tier 3
pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv) (Cvs Pinworm Treatment)
Tier 1
ANTI-INFECTIVE AGENTS - MISC.
ANTI-INFECTIVE AGENTS - MISC.
metronidazole tab 250 mg
Tier 1
metronidazole tab 500 mg
Tier 1
NEBUPENT INH 300MG (pentamidine isethionate) Tier 3
pentamidine isethionate for nebulization soln 300 mg
Tier 3
trimethoprim tab 100 mg
Tier 1
XIFAXAN TAB 200MG (rifaximin)
Tier 4
XIFAXAN TAB 550MG (rifaximin)
Tier 4
ANTI-INFECTIVE MISC. - COMBINATIONS
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml
Tier 1
sulfamethoxazole-trimethoprim tab 400-80 mg Tier 1
sulfamethoxazole-trimethoprim tab 800-160 mg Tier 1
ANTIPROTOZOAL AGENTS
ALINIA SUS 100/5ML (nitazoxanide)
Tier 3
ALINIA TAB 500MG (nitazoxanide)
Tier 3
atovaquone susp 750 mg/5ml
Tier 3
GLYCOPEPTIDES
FIRVANQ SOL 25MG/ML (vancomycin hcl)
Tier 2
FIRVANQ SOL 50MG/ML (vancomycin hcl)
Tier 2
LEPROSTATICS
dapsone tab 25 mg
Tier 1
dapsone tab 100 mg
Tier 1
LINCOSAMIDES
clindamycin hcl cap 150 mg
Tier 1
clindamycin hcl cap 300 mg
Tier 1
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
Tier 1
MONOBACTAMS
CAYSTON INH 75MG (aztreonam lysine)
Tier 4
OXAZOLIDINONES
linezolid for susp 100 mg/5ml
Tier 3
linezolid tab 600 mg
Tier 3
Requirements/Limits PA OTC
PA PA AGE; AGE (Max 12 years)
PA PA PA
QL (120 tabs / 30 days) QL (90 tabs / 30 days)
AGE; AGE (Max 12 years) PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
19
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name ANTIANGINAL AGENTS
ANTIANGINALS-OTHER ranolazine tab er 12hr 500 mg
ranolazine tab er 12hr 1000 mg
NITRATES isosorbide dinitrate tab 5 mg isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg isosorbide mononitrate tab 10 mg isosorbide mononitrate tab 20 mg isosorbide mononitrate tab er 24hr 30 mg isosorbide mononitrate tab er 24hr 60 mg isosorbide mononitrate tab er 24hr 120 mg nitroglycerin sl tab 0.3 mg nitroglycerin sl tab 0.4 mg nitroglycerin sl tab 0.6 mg nitroglycerin td patch 24hr 0.1 mg/hr nitroglycerin td patch 24hr 0.2 mg/hr nitroglycerin td patch 24hr 0.4 mg/hr
Drug Tier Requirements/Limits
Tier 3 Tier 3
QL (60 tabs / 30 days), MAIL, ST; Prior use of one agent from each class within the past 90 days: beta blockers, calcium channel blockers, long-acting nitrate
QL (60 tabs / 30 days), MAIL, ST; Prior use of one agent from each class within the past 90 days: beta blockers, calcium channel blockers, long-acting nitrate
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL MAIL
MAIL
MAIL
QL (30 patches / 30 days), MAIL QL (30 patches / 30 days), MAIL QL (30 patches / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
20
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name nitroglycerin td patch 24hr 0.6 mg/hr (Minitran) ANTIANXIETY AGENTS
ANTIANXIETY AGENTS - MISC. buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
hydroxyzine hcl syrup 10 mg/5ml
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
hydroxyzine pamoate cap 25 mg
hydroxyzine pamoate cap 50 mg
hydroxyzine pamoate cap 100 mg
meprobamate tab 200 mg meprobamate tab 400 mg
BENZODIAZEPINES alprazolam tab 0.5 mg
Drug Tier Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1
Requirements/Limits QL (30 patches / 30 days), MAIL
AGE, QL (240 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (240 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (180 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (120 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (1800 mL / 30 days), MAIL; AGE (Max 64 years) AGE, QL (240 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (240 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (240 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (240 caps / 30 days), MAIL; AGE (Max 64 years) AGE, QL (240 caps / 30 days), MAIL; AGE (Max 64 years) AGE, QL (120 caps / 30 days), MAIL; AGE (Max 64 years) QL (90 tabs / 30 days) QL (90 tabs / 30 days)
AGE, QL (90 tabs / 30 days); AGE (Min 18 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
21
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name alprazolam tab 0.25 mg alprazolam tab 1 mg alprazolam tab 2 mg chlordiazepoxide hcl cap 5 mg chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg clorazepate dipotassium tab 3.75 mg clorazepate dipotassium tab 7.5 mg
clorazepate dipotassium tab 15 mg diazepam conc 5 mg/ml (Diazepam Intensol) diazepam oral soln 1 mg/ml diazepam tab 2 mg diazepam tab 5 mg diazepam tab 10 mg lorazepam conc 2 mg/ml
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
AGE, QL (90 tabs / 30 days); AGE (Min 18 years) AGE, QL (90 tabs / 30 days); AGE (Min 18 years) AGE, QL (90 tabs / 30 days); AGE (Min 18 years) AGE, QL (90 caps / 30 days); AGE (Min 6 years, Max 64 years) AGE, QL (90 caps / 30 days); AGE (Min 6 years, Max 64 years) AGE, QL (90 caps / 30 days); AGE (Min 6 years, Max 64 years) AGE, QL (90 tabs / 30 days); AGE (Min 6 years, Max 64 years) QL (120 tabs / 30 days); 50/30 for non-insulin, 200/30 for insulin / pregnant. AGE, QL (90 tabs / 30 days); AGE (Min 6 years, Max 64 years) AGE, QL (30 mL / 30 days); AGE (Max 64 years) AGE, QL (120 mL / 30 days); AGE (Max 64 years) AGE, QL (90 tabs / 30 days); AGE (Max 64 years) AGE, QL (90 tabs / 30 days); AGE (Max 64 years) AGE, QL (90 tabs / 30 days); AGE (Max 64 years) AGE, QL (90 mL / 30 days); AGE (Min 12 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
22
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name lorazepam tab 0.5 mg
Drug Tier Tier 1
lorazepam tab 1 mg
Tier 1
lorazepam tab 2 mg
Tier 1
oxazepam cap 10 mg
Tier 1
oxazepam cap 15 mg
Tier 1
oxazepam cap 30 mg
Tier 1
ANTIARRHYTHMICS
ANTIARRHYTHMICS TYPE I-A
disopyramide phosphate cap 100 mg
Tier 1
disopyramide phosphate cap 150 mg
Tier 1
quinidine sulfate tab 200 mg
Tier 1
quinidine sulfate tab 300 mg
Tier 1
ANTIARRHYTHMICS TYPE I-B
mexiletine hcl cap 150 mg
Tier 1
mexiletine hcl cap 200 mg
Tier 1
mexiletine hcl cap 250 mg
Tier 1
ANTIARRHYTHMICS TYPE I-C flecainide acetate tab 50 mg
Tier 1
flecainide acetate tab 100 mg
Tier 1
flecainide acetate tab 150 mg
Tier 1
propafenone hcl tab 150 mg
Tier 1
propafenone hcl tab 225 mg
Tier 1
propafenone hcl tab 300 mg
Tier 1
ANTIARRHYTHMICS TYPE III
amiodarone hcl tab 200 mg
Tier 1
dofetilide cap 125 mcg (0.125 mg)
Tier 4
dofetilide cap 250 mcg (0.25 mg)
Tier 4
dofetilide cap 500 mcg (0.5 mg)
Tier 4
MULTAQ TAB 400MG (dronedarone hcl)
Tier 3
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
ANTI-INFLAMMATORY AGENTS
cromolyn sodium soln nebu 20 mg/2ml
Tier 3
Requirements/Limits AGE, QL (90 tabs / 30 days); AGE (Min 12 years) AGE, QL (90 tabs / 30 days); AGE (Min 12 years) AGE, QL (90 tabs / 30 days); AGE (Min 12 years) AGE, QL (90 caps / 30 days); AGE (Min 6 years) AGE, QL (90 caps / 30 days); AGE (Min 6 years) AGE, QL (120 caps / 30 days); AGE (Min 6 years)
MAIL MAIL MAIL MAIL
MAIL MAIL MAIL
MAIL MAIL MAIL MAIL MAIL MAIL
MAIL MAIL MAIL MAIL MAIL, PA
MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
23
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
ANTIASTHMATIC - MONOCLONAL ANTIBODIES
XOLAIR INJ 75/0.5 (omalizumab)
Tier 4 QL (2.5 mL / 28 days), PA
XOLAIR INJ 150MG/ML (omalizumab)
Tier 4 QL (5 mL / 28 days), PA
XOLAIR SOL 150MG (omalizumab)
Tier 4 QL (5 mL / 28 days), PA
Antiasthmatic - Monoclonal Antibodies
DUPIXENT INJ 200/1.14 (dupilumab)
Tier 4 PA
NUCALA INJ 100MG (mepolizumab)
Tier 4 PA
BRONCHODILATORS - ANTICHOLINERGICS
ATROVENT HFA AER 17MCG (ipratropium bromide hfa)
Tier 2 QL (12.9 gm / 30 days), MAIL
INCRUSE ELPT INH 62.5MCG (umeclidinium bromide)
Tier 2 QL (30 blisters / 30 days), MAIL
ipratropium bromide inhal soln 0.02%
Tier 1 QL (120 vials / 30 days), MAIL
TUDORZA PRES AER 400/ACT (aclidinium bromide) Tier 2 QL (1 ea / 30 days), MAIL
LEUKOTRIENE MODULATORS
montelukast sodium chew tab 4 mg (base equiv)
Tier 1
AGE, QL (30 tabs / 30 days), MAIL; AGE (Max 9 years)
montelukast sodium chew tab 5 mg (base equiv)
Tier 1
AGE, QL (30 tabs / 30 days), MAIL; AGE (Max 14 years)
montelukast sodium tab 10 mg (base equiv)
Tier 1 QL (30 tabs / 30 days), MAIL
zafirlukast tab 10 mg
Tier 3 QL (60 tabs / 30 days), MAIL
zafirlukast tab 20 mg
Tier 3 QL (60 tabs / 30 days), MAIL
zileuton tab er 12hr 600 mg
Tier 3 MAIL, PA
SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS
DALIRESP TAB 250MCG (roflumilast)
Tier 3 MAIL, PA
DALIRESP TAB 500MCG (roflumilast)
Tier 3 MAIL, PA
STEROID INHALANTS
ASMANEX 7 AER 110MCG (mometasone furoate (inhalation))
Tier 2 QL (1 inhaler / 30 days), MAIL
ASMANEX 14 AER 220MCG (mometasone furoate (inhalation))
Tier 2 QL (1 inhaler / 30 days), MAIL
ASMANEX 30 AER 110MCG (mometasone furoate (inhalation))
Tier 2 QL (1 inhaler / 30 days), MAIL
ASMANEX 30 AER 220MCG (mometasone furoate (inhalation))
Tier 2 QL (1 inhaler / 30 days), MAIL
ASMANEX 60 AER 220MCG (mometasone furoate (inhalation))
Tier 2 QL (1 inhaler / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
24
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
ASMANEX 120 AER 220MCG (mometasone furoate (inhalation))
Tier 2
ASMANEX HFA AER 50MCG (mometasone furoate (inhalation))
Tier 2
ASMANEX HFA AER 100 MCG (mometasone furoate Tier 2 (inhalation))
ASMANEX HFA AER 200 MCG (mometasone furoate Tier 2 (inhalation))
budesonide inhalation susp 0.5 mg/2ml
Tier 3
budesonide inhalation susp 0.25 mg/2ml
Tier 3
FLOVENT HFA AER 44MCG (fluticasone propionate hfa)
Tier 3
FLOVENT HFA AER 110MCG (fluticasone propionate hfa)
Tier 3
PULMICORT INH 90MCG (budesonide (inhalation)) Tier 2
PULMICORT INH 180MCG (budesonide (inhalation)) QVAR REDIHA AER 80MCG (beclomethasone dipropionate hfa) QVAR REDIHAL AER 40MCG (beclomethasone dipropionate hfa)
SYMPATHOMIMETICS albuterol sulfate soln nebu 0.5% (5 mg/ml)
Tier 2 Tier 2 Tier 2
Tier 1
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg ANORO ELLIPT AER 62.5-25 (umeclidiniumvilanterol) ARCAPTA CAP 75MCG (indacaterol maleate)
Tier 1
Tier 1
Tier 1
Tier 1 Tier 3 Tier 3 Tier 2
Tier 3
BEVESPI AER 9-4.8MCG (glycopyrrolateformoterol fumarate)
Tier 2
Requirements/Limits
QL (1 inhaler / 30 days), MAIL QL (1 inhaler / 30 days), MAIL QL (13 gm / 30 days), MAIL QL (13 gm / 30 days), MAIL AGE, QL (120 mL / 30 days), MAIL; AGE (Max 9 years) AGE, QL (120 mL / 30 days), MAIL; AGE (Max 9 years) AGE, QL (1 inhaler / 30 days), MAIL; AGE (Max 11 years) AGE, QL (1 inhaler / 30 days), MAIL; AGE (Max 11 years) QL (1 inhaler / 30 days), MAIL QL (1 inhaler / 30 days), MAIL QL (10.6 gm / 30 days), MAIL QL (10.6 gm / 30 days), MAIL
QL (150 ea / 30 days), MAIL QL (300 mL / 30 days), MAIL QL (225 mL / 30 days), MAIL QL (150 mL / 30 days), MAIL MAIL MAIL MAIL QL (60 blisters / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (10.7 gm / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
25
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name BREO ELLIPTA INH 100-25 (fluticasone furoatevilanterol)
BREO ELLIPTA INH 200-25 (fluticasone furoatevilanterol)
BROVANA NEB 15MCG (arformoterol tartrate) COMBIVENT AER 20-100 (ipratropium-albuterol) DULERA AER 50-5MCG (mometasone furoateformoterol fumarate dihydrate)
DULERA AER 100-5MCG (mometasone furoateformoterol fumarate dihydrate)
Drug Tier Tier 3
Tier 3
Tier 3 Tier 2 Tier 3
Tier 3
Requirements/Limits
QL (60 blisters / 30 days), MAIL, ST; Prior use of (1) Symbicort AND (2) fluticasone/salmerterol inhaler (generic Airduo) or (2) fluticasone/salmeterol diskus (generic Advair Diskus) within the past 90 days QL (60 blisters / 30 days), MAIL, ST; Prior use of (1) Symbicort AND (2) fluticasone/salmerterol inhaler (Airduo AG) or (2) fluticasone/salmeterol diskus (Advair generic) within the past 90 days.
QL (120 mL / 30 days), MAIL
QL (4 gm / 30 days), MAIL
QL (1 inhaler / 30 days), MAIL; Prior use of (1) Symbicort AND (2) fluticasone/salmerterol inhaler (generic Airduo) or (2) fluticasone/salmeterol diskus (generic Advair Diskus) within the past 90 days
QL (13 gm / 30 days), MAIL, ST; Prior use of (1) Symbicort AND (2) fluticasone/salmerterol inhaler (Airduo AG) or (2) fluticasone/salmeterol diskus (Advair generic) within the past 90 days.
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
26
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name DULERA AER 200-5MCG (mometasone furoateformoterol fumarate dihydrate)
fluticasone-salmeterol aer powder ba 55-14 mcg/act fluticasone-salmeterol aer powder ba 100-50 mcg/dose (Wixela Inhub) fluticasone-salmeterol aer powder ba 113-14 mcg/act fluticasone-salmeterol aer powder ba 232-14 mcg/act fluticasone-salmeterol aer powder ba 250-50 mcg/dose (Wixela Inhub) fluticasone-salmeterol aer powder ba 500-50 mcg/dose (Wixela Inhub) ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)
metaproterenol sulfate syrup 10 mg/5ml metaproterenol sulfate tab 10 mg metaproterenol sulfate tab 20 mg PROAIR HFA AER (albuterol sulfate)
Drug Tier Tier 3
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 2
Requirements/Limits
QL (13 gm / 30 days), MAIL, ST; Prior use of (1) Symbicort AND (2) fluticasone/salmerterol inhaler (Airduo AG) or (2) fluticasone/salmeterol diskus (Advair generic) within the past 90 days. QL (1 inhaler / 30 days), MAIL QL (60 inhalations / 30 days), MAIL QL (1 inhaler / 30 days), MAIL QL (1 inhaler / 30 days), MAIL QL (60 inhalations / 30 days), MAIL QL (60 inhalations / 30 days), MAIL QL (360 mL / 30 days), MAIL QL (144 mL / 30 days), MAIL, ST; Prior use of albuterol neb solution within the past 90 days. QL (144 mL / 30 days), MAIL, ST; Prior use of albuterol neb solution within the past 90 days. QL (144 mL / 30 days), MAIL, ST; Prior use of albuterol neb solution within the past 90 days. QL (144 ea / 30 days), MAIL, ST; Prior use of albuterol neb solution within the past 90 days. MAIL
MAIL
MAIL
QL (8.5 gm / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
27
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name PROVENTIL AER HFA (albuterol sulfate)
Drug Tier Tier 3
SEREVENT DIS AER 50MCG (salmeterol xinafoate)
STIOLTO AER 2.5-2.5 (tiotropium bromideolodaterol hcl) STRIVERDI AER 2.5MCG (olodaterol hcl)
SYMBICORT AER 80-4.5 (budesonide-formoterol fumarate dihydrate) SYMBICORT AER 160-4.5 (budesonide-formoterol fumarate dihydrate) terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
VENTOLIN HFA AER (albuterol sulfate)
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3
XANTHINES theophylline soln 80 mg/15ml theophylline tab er 12hr 100 mg theophylline tab er 12hr 200 mg theophylline tab er 12hr 300 mg theophylline tab er 12hr 450 mg theophylline tab er 24hr 400 mg theophylline tab er 24hr 600 mg
ANTICOAGULANTS
COUMARIN ANTICOAGULANTS COUMADIN TAB 1MG (warfarin sodium) COUMADIN TAB 2.5MG (warfarin sodium) COUMADIN TAB 2MG (warfarin sodium) COUMADIN TAB 3MG (warfarin sodium) COUMADIN TAB 4MG (warfarin sodium) COUMADIN TAB 5MG (warfarin sodium) COUMADIN TAB 6MG (warfarin sodium) COUMADIN TAB 7.5MG (warfarin sodium) COUMADIN TAB 10MG (warfarin sodium) warfarin sodium tab 1 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits QL (6.7 gm / 30 days), MAIL, ST; Prior use of Proair HFA within the past 90 days. QL (60 inhalations / 30 days), MAIL QL (4 gm / 30 days), MAIL QL (4 gm / 30 days), MAIL QL (10.2 gm / 30 days), MAIL QL (10.2 gm / 30 days), MAIL QL (240 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL QL (18 gm / 30 days), MAIL, ST; Prior use of Proair HFA within the past 90 days.
MAIL MAIL MAIL MAIL MAIL MAIL MAIL
MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
28
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
warfarin sodium tab 4 mg
Tier 1
warfarin sodium tab 5 mg
Tier 1
warfarin sodium tab 6 mg
Tier 1
warfarin sodium tab 7.5 mg
Tier 1
warfarin sodium tab 10 mg
Tier 1
DIRECT FACTOR XA INHIBITORS
ELIQUIS TAB 2.5MG (apixaban)
Tier 3
ELIQUIS TAB 5MG (apixaban)
Tier 3
XARELTO STAR TAB 15/20MG (rivaroxaban)
Tier 2
XARELTO TAB 2.5MG (rivaroxaban)
Tier 2
XARELTO TAB 10MG (rivaroxaban)
Tier 2
XARELTO TAB 15MG (rivaroxaban)
Tier 2
XARELTO TAB 20MG (rivaroxaban)
Tier 2
HEPARINS AND HEPARINOID-LIKE AGENTS
enoxaparin sodium inj 30 mg/0.3ml
Tier 4
enoxaparin sodium inj 40 mg/0.4ml
Tier 4
enoxaparin sodium inj 60 mg/0.6ml
Tier 4
enoxaparin sodium inj 80 mg/0.8ml
Tier 4
enoxaparin sodium inj 100 mg/ml
Tier 4
enoxaparin sodium inj 120 mg/0.8ml
Tier 4
enoxaparin sodium inj 150 mg/ml
Tier 4
enoxaparin sodium inj 300 mg/3ml
Tier 4
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.4ml fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml fondaparinux sodium subcutaneous inj 10 mg/0.8ml FRAGMIN INJ 2500/0.2 (dalteparin sodium) FRAGMIN INJ 5000/0.2 (dalteparin sodium)
FRAGMIN INJ 7500/0.3 (dalteparin sodium)
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4 Tier 4 Tier 4
Requirements/Limits MAIL MAIL MAIL MAIL MAIL
MAIL, PA MAIL, PA QL (51 tabs / year), PA MAIL, PA MAIL, PA MAIL, PA MAIL, PA
QL (18 mL / 30 days) QL (24 mL / 30 days) QL (36 mL / 30 days), PA; Max 14 day supply then PA QL (48 mL / 30 days), PA; Max 14 day supply then PA QL (60 mL / 30 days), PA; Max 14 day supply then PA QL (48 mL / 30 days), PA; Max 14 day supply then PA QL (60 mL / 30 days), PA; Max 14 day supply then PA QL (30 vials / 30 days), PA; Max 14 day supply then PA PA
PA
PA
PA
PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
29
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
FRAGMIN INJ 10000/ML (dalteparin sodium)
Tier 4
FRAGMIN INJ 12500UNT (dalteparin sodium)
Tier 4
FRAGMIN INJ 15000UNT (dalteparin sodium)
Tier 4
FRAGMIN INJ 18000UNT (dalteparin sodium)
Tier 4
heparin sodium (porcine) inj 1000 unit/ml
Tier 1
heparin sodium (porcine) inj 10000 unit/ml
Tier 1
heparin sodium (porcine) pf inj 5000 unit/0.5ml Tier 1
THROMBIN INHIBITORS
PRADAXA CAP 75MG (dabigatran etexilate mesylate)
Tier 3
PRADAXA CAP 110MG (dabigatran etexilate mesylate)
Tier 3
PRADAXA CAP 150MG (dabigatran etexilate mesylate)
Tier 3
ANTICONVULSANTS
AMPA GLUTAMATE RECEPTOR ANTAGONISTS
FYCOMPA TAB 2MG (perampanel)
Tier 3
FYCOMPA TAB 4MG (perampanel)
Tier 3
FYCOMPA TAB 6MG (perampanel)
Tier 3
FYCOMPA TAB 8MG (perampanel)
Tier 3
FYCOMPA TAB 10MG (perampanel)
Tier 3
FYCOMPA TAB 12MG (perampanel)
Tier 3
ANTICONVULSANTS - BENZODIAZEPINES
clobazam tab 10 mg
Tier 1
clobazam tab 20 mg
Tier 1
clonazepam tab 0.5 mg
Tier 1
clonazepam tab 1 mg
Tier 1
clonazepam tab 2 mg
Tier 1
diazepam rectal gel delivery system 2.5 mg
Tier 1
diazepam rectal gel delivery system 10 mg
Tier 1
diazepam rectal gel delivery system 20 mg
Tier 1
VALTOCO LIQ 15MG (diazepam (anticonvulsant)) Tier 2
VALTOCO LIQ 20MG (diazepam (anticonvulsant)) Tier 2
VALTOCO SPR 5MG (diazepam (anticonvulsant))
Tier 2
VALTOCO SPR 10MG (diazepam (anticonvulsant)) Tier 2
Requirements/Limits PA PA PA PA PA PA PA
MAIL, PA
MAIL, PA
MAIL, PA
QL (300 tabs / 30 days) QL (300 tabs / 30 days) QL (300 tabs / 30 days) QL (2 ea / 30 days) QL (2 ea / 30 days) QL (2 ea / 30 days) AGE, QL (10 ea / 30 days); AGE (Min 6 years) AGE, QL (10 ea / 30 days); AGE (Min 6 years) AGE, QL (10 sprays / 30 days); AGE (Min 6 years) AGE, QL (10 sprays / 30 days); AGE (Min 6 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
30
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
ANTICONVULSANTS - MISC. APTIOM TAB 200MG (eslicarbazepine acetate) APTIOM TAB 400MG (eslicarbazepine acetate) APTIOM TAB 600MG (eslicarbazepine acetate) APTIOM TAB 800MG (eslicarbazepine acetate) BANZEL SUS 40MG/ML (rufinamide) BANZEL TAB 200MG (rufinamide) BANZEL TAB 400MG (rufinamide) carbamazepine cap er 12hr 100 mg carbamazepine cap er 12hr 200 mg carbamazepine cap er 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg (Epitol) carbamazepine tab er 12hr 100 mg carbamazepine tab er 12hr 200 mg carbamazepine tab er 12hr 400 mg DIACOMIT CAP 250MG (stiripentol) DIACOMIT CAP 500MG (stiripentol) DIACOMIT PAK 250MG (stiripentol) DIACOMIT PAK 500MG (stiripentol) gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg lamotrigine tab 25 mg lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab chewable dispersible 25 mg levetiracetam oral soln 100 mg/ml levetiracetam tab 250 mg levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab 1000 mg levetiracetam tab er 24hr 500 mg levetiracetam tab er 24hr 750 mg LYRICA CAP 25MG (pregabalin)
LYRICA CAP 50MG (pregabalin)
Drug Tier Requirements/Limits
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
Tier 3
MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL, PA MAIL, PA MAIL, PA MAIL, PA MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL QL (90 caps / 30 days), PA QL (90 caps / 30 days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
31
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name LYRICA CAP 75MG (pregabalin)
LYRICA CAP 100MG (pregabalin)
LYRICA CAP 150MG (pregabalin)
LYRICA CAP 200MG (pregabalin)
LYRICA CAP 225MG (pregabalin)
LYRICA CAP 300MG (pregabalin)
oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg PREGABALIN CAP 25 MG
PREGABALIN CAP 50 MG
PREGABALIN CAP 75 MG
PREGABALIN CAP 100 MG
PREGABALIN CAP 150 MG
PREGABALIN CAP 200 MG
PREGABALIN CAP 225 MG
PREGABALIN CAP 300 MG
primidone tab 50 mg
primidone tab 250 mg
topiramate sprinkle cap 15 mg topiramate sprinkle cap 25 mg topiramate tab 25 mg topiramate tab 50 mg topiramate tab 100 mg topiramate tab 200 mg VIMPAT SOL 10MG/ML (lacosamide) VIMPAT TAB 50MG (lacosamide) VIMPAT TAB 100MG (lacosamide) VIMPAT TAB 150MG (lacosamide)
Drug Tier Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
Requirements/Limits
QL (90 caps / 30 days), PA QL (90 caps / 30 days), PA QL (90 caps / 30 days), PA QL (90 caps / 30 days), PA QL (60 caps / 30 days), PA QL (60 caps / 30 days), PA MAIL MAIL MAIL
MAIL QL (90 caps / 30 days), PA QL (90 caps / 30 days), PA QL (90 caps / 30 days), PA QL (90 caps / 30 days), PA QL (90 caps / 30 days), PA QL (90 caps / 30 days), PA QL (60 caps / 30 days), PA QL (60 caps / 30 days), PA QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL MAIL MAIL MAIL MAIL MAIL
MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
32
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
VIMPAT TAB 200MG (lacosamide) zonisamide cap 25 mg zonisamide cap 50 mg zonisamide cap 100 mg
CARBAMATES felbamate susp 600 mg/5ml felbamate tab 400 mg felbamate tab 600 mg
GABA MODULATORS tiagabine hcl tab 2 mg tiagabine hcl tab 4 mg tiagabine hcl tab 12 mg tiagabine hcl tab 16 mg vigabatrin powd pack 500 mg (Vigadrone)
Drug Tier Tier 2 Tier 1 Tier 1 Tier 1
Tier 3 Tier 3 Tier 3
Tier 3 Tier 3 Tier 3 Tier 3 Tier 4
vigabatrin tab 500 mg
HYDANTOINS DILANTIN CAP 30MG (phenytoin sodium extended) DILANTIN CAP 100MG (phenytoin sodium extended) PEGANONE TAB 250MG (ethotoin) PHENYTEK CAP 200MG (phenytoin sodium extended) PHENYTEK CAP 300MG (phenytoin sodium extended) phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin susp 125 mg/5ml
SUCCINIMIDES CELONTIN CAP 300MG (methsuximide) ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml
VALPROIC ACID divalproex sodium cap delayed release sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab er 24 hr 250 mg divalproex sodium tab er 24 hr 500 mg
Tier 4
Tier 2
Tier 2
Tier 3 Tier 2
Tier 2
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 3 Tier 1 Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
MAIL MAIL MAIL
MAIL MAIL MAIL
MAIL MAIL MAIL MAIL QL (180 packets / 30 days) QL (180 tabs / 30 days)
MAIL
MAIL
MAIL MAIL
MAIL
MAIL MAIL MAIL MAIL MAIL
MAIL MAIL MAIL
MAIL
MAIL MAIL MAIL MAIL MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
33
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
valproate sodium oral soln 250 mg/5ml (base equiv) valproic acid cap 250 mg
Tier 1 MAIL Tier 1 MAIL
ANTIDEPRESSANTS
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)
mirtazapine tab 15 mg mirtazapine tab 30 mg
Tier 1 Tier 1
QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL
mirtazapine tab 45 mg
Tier 1 QL (30 tabs / 30 days), MAIL
ANTIDEPRESSANTS - MISC.
bupropion hcl tab 75 mg
Tier 1 QL (120 tabs / 30 days), MAIL
bupropion hcl tab 100 mg bupropion hcl tab er 12hr 100 mg bupropion hcl tab er 12hr 150 mg bupropion hcl tab er 12hr 200 mg
Tier 1 Tier 1 Tier 1 Tier 1
QL (120 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL
bupropion hcl tab er 24hr 150 mg
Tier 1 QL (30 tabs / 30 days), MAIL
bupropion hcl tab er 24hr 300 mg maprotiline hcl tab 25 mg
Tier 1 Tier 1
QL (30 tabs / 30 days), MAIL MAIL
maprotiline hcl tab 50 mg
Tier 1 MAIL
maprotiline hcl tab 75 mg
Tier 1 MAIL
MONOAMINE OXIDASE INHIBITORS (MAOIS)
EMSAM DIS 6MG/24HR (selegiline)
Tier 3 MAIL, PA
EMSAM DIS 9MG/24HR (selegiline) EMSAM DIS 12MG/24H (selegiline)
Tier 3 MAIL, PA Tier 3 MAIL, PA
MARPLAN TAB 10MG (isocarboxazid)
Tier 3 MAIL, PA
phenelzine sulfate tab 15 mg tranylcypromine sulfate tab 10 mg
Tier 1 Tier 3
QL (180 tabs / 30 days), MAIL QL (240 tabs / 30 days), MAIL
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
citalopram hydrobromide oral soln 10 mg/5ml
citalopram hydrobromide tab 10 mg (base equiv)
Tier 1 Tier 1
AGE, QL (600 mL / 30 days), MAIL; AGE (Max 12 years) QL (45 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
34
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) escitalopram oxalate soln 5 mg/5ml (base equiv) escitalopram oxalate tab 5 mg (base equiv)
escitalopram oxalate tab 10 mg (base equiv)
escitalopram oxalate tab 20 mg (base equiv)
fluoxetine hcl cap 10 mg
fluoxetine hcl cap 20 mg
fluoxetine hcl cap 40 mg
fluoxetine hcl solution 20 mg/5ml
fluvoxamine maleate tab 25 mg
fluvoxamine maleate tab 50 mg
fluvoxamine maleate tab 100 mg
paroxetine hcl tab 10 mg
paroxetine hcl tab 20 mg
paroxetine hcl tab 30 mg
paroxetine hcl tab 40 mg
sertraline hcl oral concentrate for solution 20 mg/ml sertraline hcl tab 25 mg
sertraline hcl tab 50 mg
sertraline hcl tab 100 mg
SEROTONIN MODULATORS nefazodone hcl tab 50 mg
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
QL (45 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL AGE, MAIL; AGE (Max 12 years) QL (45 tabs / 30 days), MAIL QL (45 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (90 caps / 30 days), MAIL QL (120 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL AGE, MAIL; AGE (Max 12 years) QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (300 mL / 30 days), MAIL QL (45 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL
Tier 1 QL (60 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
35
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
nefazodone hcl tab 100 mg
Tier 1 QL (60 tabs / 30 days), MAIL
nefazodone hcl tab 150 mg
Tier 1 QL (60 tabs / 30 days), MAIL
nefazodone hcl tab 200 mg
Tier 1 QL (60 tabs / 30 days), MAIL
nefazodone hcl tab 250 mg
Tier 1 QL (60 tabs / 30 days), MAIL
trazodone hcl tab 50 mg
Tier 1 QL (60 tabs / 30 days), MAIL
trazodone hcl tab 100 mg
Tier 1 QL (60 tabs / 30 days), MAIL
trazodone hcl tab 150 mg
Tier 1 QL (60 tabs / 30 days), MAIL
TRINTELLIX TAB 5MG (vortioxetine hbr)
Tier 3 MAIL, PA
TRINTELLIX TAB 10MG (vortioxetine hbr)
Tier 3 MAIL, PA
TRINTELLIX TAB 20MG (vortioxetine hbr)
Tier 3 MAIL, PA
VIIBRYD KIT STARTER (vilazodone hcl)
Tier 3 PA
VIIBRYD TAB 10MG (vilazodone hcl)
Tier 3 MAIL, PA
VIIBRYD TAB 20MG (vilazodone hcl)
Tier 3 MAIL, PA
VIIBRYD TAB 40MG (vilazodone hcl)
Tier 3 MAIL, PA
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
desvenlafaxine succinate tab er 24hr 50 mg (base equiv)
Tier 1 QL (30 tabs / 30 days), MAIL, PA
desvenlafaxine succinate tab er 24hr 100 mg (base equiv)
Tier 1 QL (30 tabs / 30 days), MAIL, PA
duloxetine hcl enteric coated pellets cap 20 mg (base eq)
Tier 1 QL (60 caps / 30 days), MAIL
duloxetine hcl enteric coated pellets cap 30 mg (base eq)
Tier 1 QL (60 caps / 30 days), MAIL
duloxetine hcl enteric coated pellets cap 60 mg (base eq)
Tier 1 QL (60 caps / 30 days), MAIL
FETZIMA CAP 20MG (levomilnacipran hcl)
Tier 3 MAIL, PA
FETZIMA CAP 40MG (levomilnacipran hcl)
Tier 3 MAIL, PA
FETZIMA CAP 80MG (levomilnacipran hcl)
Tier 3 MAIL, PA
FETZIMA CAP 120MG (levomilnacipran hcl)
Tier 3 MAIL, PA
FETZIMA CAP TITRATIO (levomilnacipran hcl)
Tier 3 PA
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)
Tier 1 QL (30 caps / 30 days), MAIL
venlafaxine hcl cap er 24hr 75 mg (base equivalent)
Tier 1 QL (90 caps / 30 days), MAIL
venlafaxine hcl cap er 24hr 150 mg (base equivalent)
Tier 1 QL (30 caps / 30 days), MAIL
venlafaxine hcl tab 25 mg (base equivalent)
Tier 1 QL (90 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
36
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name venlafaxine hcl tab 37.5 mg (base equivalent) venlafaxine hcl tab 50 mg (base equivalent) venlafaxine hcl tab 75 mg (base equivalent) venlafaxine hcl tab 100 mg (base equivalent)
TRICYCLIC AGENTS amitriptyline hcl tab 10 mg
amitriptyline hcl tab 25 mg
amitriptyline hcl tab 50 mg
amitriptyline hcl tab 75 mg
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
amoxapine tab 25 mg amoxapine tab 50 mg amoxapine tab 100 mg amoxapine tab 150 mg clomipramine hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg desipramine hcl tab 10 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1
AGE, QL (180 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (180 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (120 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (120 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (90 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (90 tabs / 30 days), MAIL; AGE (Max 64 years) MAIL
MAIL
MAIL
MAIL
QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (120 caps / 30 days), MAIL QL (180 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
37
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name desipramine hcl tab 100 mg desipramine hcl tab 150 mg doxepin hcl cap 10 mg
doxepin hcl cap 25 mg
doxepin hcl cap 50 mg
doxepin hcl cap 75 mg
doxepin hcl cap 100 mg
doxepin hcl cap 150 mg
doxepin hcl conc 10 mg/ml imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg protriptyline hcl tab 5 mg protriptyline hcl tab 10 mg trimipramine maleate cap 25 mg trimipramine maleate cap 50 mg trimipramine maleate cap 100 mg
Drug Tier Tier 1 Tier 1 Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Requirements/Limits
QL (90 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL AGE, QL (90 caps / 30 days), MAIL; AGE (Max 64 years) AGE, QL (90 caps / 30 days), MAIL; AGE (Max 64 years) AGE, QL (90 caps / 30 days), MAIL; AGE (Max 64 years) AGE, QL (90 caps / 30 days), MAIL; AGE (Max 64 years) AGE, QL (90 caps / 30 days), MAIL; AGE (Max 64 years) AGE, QL (60 caps / 30 days), MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years) QL (180 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (120 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL MAIL
MAIL
MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
38
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name ANTIDIABETICS
ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 mg
Drug Tier Tier 1
acarbose tab 50 mg
Tier 1
acarbose tab 100 mg
Tier 1
miglitol tab 25 mg
Tier 3
miglitol tab 50 mg
Tier 3
miglitol tab 100 mg
Tier 3
ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG (pramlintide acetate) SYMLNPEN 120 INJ 1000MCG (pramlintide acetate)
ANTIDIABETIC COMBINATIONS alogliptin-metformin hcl tab 12.5-500 mg
Tier 3 Tier 3
Tier 3
alogliptin-metformin hcl tab 12.5-1000 mg
Tier 3
alogliptin-pioglitazone tab 12.5-15 mg
Tier 3
alogliptin-pioglitazone tab 12.5-30 mg
Tier 3
alogliptin-pioglitazone tab 12.5-45 mg
Tier 3
alogliptin-pioglitazone tab 25-15 mg
Tier 3
alogliptin-pioglitazone tab 25-30 mg
Tier 3
Requirements/Limits
QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (360 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL
MAIL, PA MAIL, PA
QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
39
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name alogliptin-pioglitazone tab 25-45 mg
Drug Tier Tier 3
glipizide-metformin hcl tab 2.5-250 mg glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl tab 5-500 mg glyburide-metformin tab 1.25-250 mg glyburide-metformin tab 2.5-500 mg glyburide-metformin tab 5-500 mg JANUMET TAB 50-500MG (sitagliptin-metformin hcl)
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
JANUMET TAB 50-1000 (sitagliptin-metformin hcl) Tier 2
JANUMET XR TAB 50-500MG (sitagliptin-metformin Tier 2 hcl)
JANUMET XR TAB 50-1000 (sitagliptin-metformin hcl)
Tier 2
JANUMET XR TAB 100-1000 (sitagliptin-metformin hcl)
Tier 2
JENTADUETO TAB 2.5-500 (linagliptin-metformin hcl)
Tier 2
JENTADUETO TAB 2.5-850 (linagliptin-metformin hcl)
Tier 2
Requirements/Limits
QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
40
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
JENTADUETO TAB 2.5-1000 (linagliptin-metformin hcl)
Tier 2
JENTADUETO TAB XR (linagliptin-metformin hcl)
Tier 2
JENTADUETO TAB XR (linagliptin-metformin hcl)
Tier 2
SYNJARDY TAB (empagliflozin-metformin hcl)
Tier 2
SYNJARDY TAB 5-500MG (empagliflozinmetformin hcl)
Tier 2
SYNJARDY TAB 5-1000MG (empagliflozinmetformin hcl)
Tier 2
SYNJARDY TAB 12.5-500 (empagliflozinmetformin hcl)
Tier 2
SYNJARDY XR TAB (empagliflozin-metformin hcl) Tier 2
Requirements/Limits
QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (60 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
41
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name SYNJARDY XR TAB 5-1000MG (empagliflozinmetformin hcl)
SYNJARDY XR TAB 10-1000 (empagliflozinmetformin hcl)
SYNJARDY XR TAB 25-1000 (empagliflozinmetformin hcl)
XIGDUO XR TAB 2.5-1000 (dapagliflozinmetformin hcl)
XIGDUO XR TAB 5-500MG (dapagliflozinmetformin hcl)
XIGDUO XR TAB 5-1000MG (dapagliflozinmetformin hcl)
XIGDUO XR TAB 10-500MG (dapagliflozinmetformin hcl)
Drug Tier Tier 2 Tier 2 Tier 2 Tier 2
Tier 2
Tier 2
Tier 2
Requirements/Limits
MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
QL (60 tabs / 30 days), MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
QL (30 tabs / 30 days), MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
QL (60 tabs / 30 days), MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
QL (30 tabs / 30 days), MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
42
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
XIGDUO XR TAB 10-1000 (dapagliflozinmetformin hcl)
Drug Tier Tier 2
BIGUANIDES metformin hcl tab 500 mg
Tier 1
metformin hcl tab 850 mg
Tier 1
metformin hcl tab 1000 mg
Tier 1
metformin hcl tab er 24hr 500 mg
Tier 1
metformin hcl tab er 24hr 750 mg
Tier 1
DIABETIC OTHER BAQSIMI ONE POW 3MG/DOSE (glucagon) diazoxide susp 50 mg/ml GLUCAGEN INJ HYPOKIT (glucagon hcl (rdna))
Tier 2 Tier 3 Tier 2
GLUCAGON KIT 1MG (glucagon (rdna))
Tier 2
GNP GLUCOSE CHW ORANGE (dextrose (diabetic use))
Tier 1
PROGLYCEM SUS 50MG/ML (diazoxide)
Tier 3
TGT GLUCOSE CHW GRAPE (glucose-vitamin c)
Tier 1
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
alogliptin benzoate tab 6.25 mg (base equiv)
Tier 3
alogliptin benzoate tab 12.5 mg (base equiv)
Tier 3
alogliptin benzoate tab 25 mg (base equiv)
Tier 3
JANUVIA TAB 25MG (sitagliptin phosphate)
Tier 2
Requirements/Limits QL (30 tabs / 30 days), MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
QL (150 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL
QL (2 ea / 30 days) MAIL QL (2 syringes / 30 days) QL (2 kits / 30 days) OTC
MAIL OTC
QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days QL (30 tabs / 30 days), MAIL, ST; Prior use of metformin in the last 180 days
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
43
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
JANUVIA TAB 50MG (sitagliptin phosphate)
Tier 2 QL (30 tabs / 30 days),
MAIL, ST; Prior use of
metformin in the last
180 days
JANUVIA TAB 100MG (sitagliptin phosphate)
Tier 2 QL (30 tabs / 30 days),
MAIL, ST; Prior use of
metformin in the last 180 days
TRADJENTA TAB 5MG (linagliptin)
Tier 2 QL (30 tabs / 30 days),
MAIL, ST; Prior use of metformin in the last
180 days
DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC
CYCLOSET TAB 0.8MG (bromocriptine mesylate
Tier 2 QL (180 tabs / 30 days),
(diabetes))
MAIL
INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)
OZEMPIC INJ 2/1.5ML (semaglutide)
Tier 2 MAIL, ST; Prior use
within the past 180
days: TWO Formulary
oral diabetes drugs, OR,
ONE Formulary combo
oral diabetes drug
RYBELSUS TAB 3MG (semaglutide)
Tier 2 MAIL, ST; Prior use
within the past 180
days: TWO Formulary
oral diabetes drugs, OR,
ONE Formulary combo oral diabetes drug
RYBELSUS TAB 7MG (semaglutide)
Tier 2 MAIL, ST; Prior use
within the past 180
days: TWO Formulary
oral diabetes drugs, OR,
ONE Formulary combo
oral diabetes drug
RYBELSUS TAB 14MG (semaglutide)
Tier 2 MAIL, ST; Prior use
within the past 180
days: TWO Formulary
oral diabetes drugs, OR,
ONE Formulary combo
oral diabetes drug
TRULICITY INJ 0.75/0.5 (dulaglutide)
Tier 2 MAIL, ST; Prior use
within the past 180
days: TWO Formulary
oral diabetes drugs, OR,
ONE Formulary combo oral diabetes drug
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
44
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name TRULICITY INJ 1.5/0.5 (dulaglutide)
Drug Tier Tier 2
VICTOZA INJ 18MG/3ML (liraglutide)
Tier 2
INSULIN ADMELOG INJ 100U/ML (insulin lispro)
Tier 3
ADMELOG SOLO INJ 100U/ML (insulin lispro)
Tier 3
AFREZZA POW 4-8 UNIT (insulin regular (human)) AFREZZA POW 4-8-12 (insulin regular (human)) AFREZZA POW 4UNIT (insulin regular (human)) AFREZZA POW 8 UNIT (insulin regular (human)) AFREZZA POW 8-12UNIT (insulin regular (human)) AFREZZA POW 12 UNIT (insulin regular (human)) APIDRA INJ SOLOSTAR (insulin glulisine)
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Tier 3 Tier 3
APIDRA INJ U-100 (insulin glulisine)
Tier 3
BASAGLAR INJ 100UNIT (insulin glargine)
FIASP FLEX INJ TOUCH (insulin aspart (with niacinamide)) FIASP INJ 100/ML (insulin aspart (with niacinamide)) FIASP PENFIL INJ U-100 (insulin aspart (with niacinamide))
Tier 2 Tier 2 Tier 2 Tier 2
Requirements/Limits
MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog within the past 90 days. QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog within the past 90 days. MAIL MAIL MAIL MAIL MAIL
MAIL QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog within the past 90 days. QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog within the past 90 days. QL (30 mL / 30 days), MAIL QL (5 pens per 30 days), MAIL QL (3 vials per 30 days), MAIL QL (5 pens per 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
45
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name HUMALOG INJ 100/ML (insulin lispro)
Drug Tier Tier 3
HUMALOG INJ 100/ML (insulin lispro)
Tier 3
HUMALOG JR INJ 100/ML (insulin lispro)
Tier 3
HUMALOG KWIK INJ 100/ML (insulin lispro)
Tier 3
HUMALOG MIX INJ 50/50 (insulin lispro protamine Tier 3 & lispro)
HUMALOG MIX INJ 50/50KWP (insulin lispro protamine & lispro)
Tier 3
HUMALOG MIX INJ 75/25KWP (insulin lispro protamine & lispro)
Tier 3
HUMALOG MIX SUS 75/25 (insulin lispro protamine & lispro)
Tier 3
HUMULIN INJ 70/30 (insulin nph isophane & reg (human))
Tier 3
HUMULIN INJ 70/30KWP (insulin nph isophane & reg (human))
Tier 3
HUMULIN N INJ U-100 (insulin nph (human) (isophane))
Tier 3
Requirements/Limits
QL (30 mL (10 cartridges) / 30 days), MAIL, ST; Prior use of Novolog within the past 90 days.
QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog within the past 90 days.
QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog within the past 90 days.
QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog within the past 90 days. QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog Mix 70/30 within the past 90 days. QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog Mix 70/30 within the past 90 days. QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog Mix 70/30 within the past 90 days.
QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog Mix 70/30 within the past 90 days.
OTC, QL (30 mL / 30 days), MAIL, ST; Prior use of Novolin 70/30 within the past 90 days.
OTC, QL (30 mL / 30 days), MAIL, ST; Prior use of Novolin 70/30 within the past 90 days.
OTC, QL (30 mL / 30 days), MAIL, ST; Prior use of Novolin N within the past 90 days.
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
46
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name HUMULIN N INJ U-100KWP (insulin nph (human) (isophane))
HUMULIN R INJ U-100 (insulin regular (human))
HUMULIN R INJ U-500 (insulin regular (human))
HUMULIN R INJ U-500 (insulin regular (human))
INSULIN LISP INJ 100/ML
LEVEMIR INJ (insulin detemir)
LEVEMIR INJ FLEXTOUC (insulin detemir)
NOVOLIN INJ 70/30 (insulin nph isophane & reg (human)) NOVOLIN INJ 70/30 FP (insulin nph isophane & reg (human)) NOVOLIN N INJ U-100 (insulin nph (human) (isophane)) NOVOLIN R INJ U-100 (insulin regular (human))
NOVOLOG INJ 100/ML (insulin aspart)
NOVOLOG INJ FLEXPEN (insulin aspart)
NOVOLOG INJ PENFILL (insulin aspart)
NOVOLOG MIX INJ 70/30 (insulin aspart protamine & aspart (human)) NOVOLOG MIX INJ FLEXPEN (insulin aspart protamine & aspart (human)) TRESIBA FLEX INJ 100UNIT (insulin degludec)
TRESIBA FLEX INJ 200UNIT (insulin degludec)
TRESIBA INJ 100UNIT (insulin degludec)
INSULIN SENSITIZING AGENTS AVANDIA TAB 2MG (rosiglitazone maleate)
Drug Tier Tier 3
Tier 3
Tier 3 Tier 3 Tier 3
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Tier 3
Requirements/Limits
OTC, QL (30 mL / 30 days), MAIL, ST; Prior use of Novolin N within the past 90 days. OTC, QL (30 mL / 30 days), MAIL, ST; Prior use of Novolin R within the past 90 days. QL (20 mL / 25 days), MAIL QL (6 pens / 30 days), MAIL QL (30 mL / 30 days), MAIL, ST; Prior use of Novolog within the past 90 days. QL (30 mL / 30 days), MAIL QL (30 mL / 30 days), MAIL OTC, QL (30 mL / 30 days), MAIL OTC, QL (30 mL / 30 days), MAIL OTC, QL (30 mL / 30 days), MAIL OTC, QL (30 mL / 30 days), MAIL QL (30 mL / 30 days), MAIL QL (30 mL / 30 days), MAIL QL (30 mL / 30 days), MAIL QL (30 mL / 30 days), MAIL QL (30 mL / 30 days), MAIL QL (30 mL / 30 days), MAIL QL (30 mL / 30 days), MAIL QL (30 mL / 30 days), MAIL
MAIL, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
47
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
AVANDIA TAB 4MG (rosiglitazone maleate)
Tier 3 MAIL, PA
pioglitazone hcl tab 15 mg (base equiv)
Tier 1 QL (30 tabs / 30 days), MAIL
pioglitazone hcl tab 30 mg (base equiv)
Tier 1 QL (30 tabs / 30 days), MAIL
pioglitazone hcl tab 45 mg (base equiv)
Tier 1 QL (30 tabs / 30 days), MAIL
MEGLITINIDE ANALOGUES
nateglinide tab 60 mg
Tier 1 QL (90 tabs / 30 days), MAIL
nateglinide tab 120 mg
Tier 1 QL (90 tabs / 30 days), MAIL
repaglinide tab 0.5 mg
Tier 1 QL (180 tabs / 30 days), MAIL
repaglinide tab 1 mg
Tier 1 QL (180 tabs / 30 days), MAIL
repaglinide tab 2 mg
Tier 1 QL (180 tabs / 30 days), MAIL
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS
FARXIGA TAB 5MG (dapagliflozin propanediol)
Tier 2
QL (30 tabs / 30 days), MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
FARXIGA TAB 10MG (dapagliflozin propanediol)
Tier 2
QL (30 tabs / 30 days), MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
JARDIANCE TAB 10MG (empagliflozin)
Tier 2
QL (30 tabs / 30 days), MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
48
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name JARDIANCE TAB 25MG (empagliflozin)
Drug Tier Tier 2
SULFONYLUREAS chlorpropamide tab 100 mg
Tier 3
chlorpropamide tab 250 mg
Tier 3
glimepiride tab 1 mg
Tier 1
glimepiride tab 2 mg
Tier 1
glimepiride tab 4 mg
Tier 1
glipizide tab 5 mg
Tier 1
glipizide tab 10 mg
Tier 1
glipizide tab er 24hr 2.5 mg
Tier 1
glipizide tab er 24hr 5 mg
Tier 1
glipizide tab er 24hr 10 mg
Tier 1
glyburide micronized tab 1.5 mg
Tier 1
glyburide micronized tab 3 mg
Tier 1
glyburide micronized tab 6 mg
Tier 1
glyburide tab 1.25 mg
Tier 1
glyburide tab 2.5 mg
Tier 1
glyburide tab 5 mg
Tier 1
tolazamide tab 250 mg
Tier 1
tolazamide tab 500 mg
Tier 1
tolbutamide tab 500 mg
Tier 1
ANTIDIARRHEAL/PROBIOTIC AGENTS
ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.
bismuth subsalicylate chew tab 262 mg (Gnp Pink Bismuth)
Tier 1
bismuth subsalicylate susp 262 mg/15ml (Bismatrol)
Tier 1
bismuth subsalicylate susp 525 mg/15ml (Cvs Bismuth Maximum Stren)
Tier 1
bismuth subsalicylate tab 262 mg (Sm Stomach Relief)
Tier 1
ANTIPERISTALTIC AGENTS
diphenoxylate w/ atropine tab 2.5-0.025 mg
Tier 1
loperamide hcl cap 2 mg (Gnp Anti-diarrheal)
Tier 1
Requirements/Limits QL (30 tabs / 30 days), MAIL, ST; Prior use within the past 180 days: TWO Formulary oral diabetes drugs, OR, ONE Formulary combo oral diabetes drug
AGE, QL (90 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (90 tabs / 30 days), MAIL; AGE (Max 64 years) MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL
OTC
OTC
OTC
OTC
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
49
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
loperamide hcl liq 1 mg/5ml (0.2 mg/ml) (Antidiarrheal)
Tier 1
loperamide hcl liq 1 mg/7.5ml
Tier 1
loperamide hcl tab 2 mg (Cvs Anti-diarrheal)
Tier 1
ANTIDOTES AND SPECIFIC ANTAGONISTS
ANTIDOTES - CHELATING AGENTS
CHEMET CAP 100MG (succimer)
Tier 3
deferasirox tab for oral susp 125 mg
Tier 4
deferasirox tab for oral susp 250 mg
Tier 4
deferasirox tab for oral susp 500 mg
Tier 4
FERRIPROX TAB 500MG (deferiprone)
Tier 4
FERRIPROX TAB 1000MG (deferiprone)
Tier 4
OPIOID ANTAGONISTS
naloxone hcl inj 0.4 mg/ml
Tier 1
naloxone hcl soln cartridge 0.4 mg/ml
Tier 1
naloxone hcl soln prefilled syringe 2 mg/2ml
Tier 1
naltrexone hcl tab 50 mg
Tier 1
NARCAN SPR (naloxone hcl)
Tier 2
VIVITROL INJ 380MG (naltrexone)
Tier 2
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS ANZEMET TAB 50MG (dolasetron mesylate) ANZEMET TAB 100MG (dolasetron mesylate) granisetron hcl tab 1 mg ondansetron hcl oral soln 4 mg/5ml
Tier 3 Tier 3 Tier 3 Tier 1
ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg
ANTIEMETICS - ANTICHOLINERGIC dimenhydrinate tab 50 mg (Cvs Motion Sickness) meclizine hcl chew tab 25 mg (Cvs Motion Sickness Relie) meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg scopolamine td patch 72hr 1 mg/3days
trimethobenzamide hcl cap 300 mg ANTIEMETICS - MISCELLANEOUS
AKYNZEO CAP 300-0.5 (netupitant-palonosetron)
Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1
Tier 1 Tier 1 Tier 3
Tier 1
Tier 3
Requirements/Limits OTC
OTC OTC
PA PA PA PA PA PA
QL (60 tabs / 30 days)
QL (1 injection / 30 days)
PA PA QL (60 tabs / 30 days) AGE, QL (50 mL / 30 days); AGE (Max 12 years) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days)
OTC OTC, QL (120 tabs / 30 days) QL (120 tabs / 30 days) QL (120 tabs / 30 days) QL (4 patches / 30 days)
PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
50
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
CESAMET CAP 1MG (nabilone)
Tier 3 PA
dronabinol cap 2.5 mg
Tier 3 PA
dronabinol cap 5 mg
Tier 3 PA
dronabinol cap 10 mg
Tier 3 PA
fructose-dextrose-phosphoric acid oral soln (Cvs Tier 1 OTC Nausea Relief)
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS
aprepitant capsule 40 mg
Tier 3 PA
aprepitant capsule 80 mg
Tier 3 PA
aprepitant capsule 125 mg
Tier 3 PA
aprepitant capsule therapy pack 80 & 125 mg
Tier 3 PA
ANTIFUNGALS
ANTIFUNGALS
flucytosine cap 250 mg
Tier 1 PA
flucytosine cap 500 mg
Tier 1 PA
griseofulvin microsize susp 125 mg/5ml
Tier 1
nystatin tab 500000 unit
Tier 1
terbinafine hcl tab 250 mg
Tier 1 QL (30 tabs / 30 days)
IMIDAZOLE-RELATED ANTIFUNGALS
CRESEMBA CAP 186 MG (isavuconazonium sulfate)
Tier 4 PA
fluconazole for susp 10 mg/ml
Tier 1
AGE, QL (105 mL / 30 days); AGE (Max 12 years)
fluconazole for susp 40 mg/ml
Tier 1
AGE, QL (105 mL / 30 days); AGE (Max 12 years)
fluconazole tab 50 mg
Tier 1 QL (21 tabs / 30 days)
fluconazole tab 100 mg
Tier 1 QL (21 tabs / 30 days)
fluconazole tab 150 mg
Tier 1 QL (2 tabs / 30 days)
fluconazole tab 200 mg
Tier 1 QL (21 tabs / 30 days)
itraconazole cap 100 mg
Tier 1 QL (120 caps / 30 days)
ketoconazole tab 200 mg
Tier 1 QL (60 tabs / 30 days)
voriconazole tab 50 mg
Tier 3 PA
voriconazole tab 200 mg
Tier 3 PA
ANTIHISTAMINES
ANTIHISTAMINES - ALKYLAMINES
chlorpheniramine maleate syrup 2 mg/5ml (Diabetic Tussin Allergy)
Tier 1 OTC
chlorpheniramine maleate tab 4 mg (Eq Chlortabs)
Tier 1 OTC
chlorpheniramine maleate tab er 12 mg (Chlorphen Sr)
Tier 1 OTC, QL (60 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
51
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name dexchlorpheniramine maleate oral soln 2 mg/5ml (Ryclora)
ANTIHISTAMINES - ETHANOLAMINES ALER-DRYL TAB 50MG (diphenhydramine hcl) carbinoxamine maleate soln 4 mg/5ml carbinoxamine maleate tab 4 mg clemastine fumarate tab 1.34 mg (1 mg base equiv) (Gnp Dayhist Allergy) clemastine fumarate tab 2.68 mg diphenhydramine hcl cap 25 mg (Pharbedryl) diphenhydramine hcl cap 50 mg diphenhydramine hcl chew tab 12.5 mg (Gnp Allergy Relief) diphenhydramine hcl elixir 12.5 mg/5ml
diphenhydramine hcl inj 50 mg/ml diphenhydramine hcl liquid 12.5 mg/5ml (Cvs Allergy Relief Childr) diphenhydramine hcl tab 25 mg diphenhydramine hcl tab disint 12.5 mg (Waldryl Allergy Relief C)
ANTIHISTAMINES - NON-SEDATING cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)
cetirizine hcl tab 5 mg
cetirizine hcl tab 10 mg (Ra Cetirizine)
desloratadine tab 5 mg fexofenadine hcl tab 60 mg
fexofenadine hcl tab 180 mg
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)
levocetirizine dihydrochloride tab 5 mg loratadine rapidly-disintegrating tab 10 mg (Wal-itin Aller-melts) loratadine syrup 5 mg/5ml (Gnp Loratadine)
loratadine tab 10 mg (Allergy Relief)
Drug Tier Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1
Tier 1
Requirements/Limits
OTC
OTC
OTC OTC OTC, AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
OTC, AGE; AGE (Max 12 years) OTC OTC
AGE, QL (300 mL / 30 days); AGE (Max 12 years) OTC, QL (30 tabs / 30 days) OTC, QL (30 tabs / 30 days) QL (30 tabs / 30 days) OTC, QL (60 tabs / 30 days) OTC, QL (30 tabs / 30 days) AGE, QL (300 mL / 30 days); AGE (Max 12 years) QL (30 tabs / 30 days) OTC, QL (30 tabs / 30 days) OTC, AGE, QL (300 mL / 30 days); AGE (Max 12 years) OTC, QL (30 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
52
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
ANTIHISTAMINES - PHENOTHIAZINES
promethazine hcl suppos 12.5 mg
Tier 3 AGE; AGE (Min 2 years, Max 64 years)
promethazine hcl suppos 25 mg
Tier 3 AGE; AGE (Min 2 years, Max 64 years)
promethazine hcl syrup 6.25 mg/5ml
Tier 1 AGE; AGE (Min 2 years, Max 64 years)
promethazine hcl tab 12.5 mg
Tier 1 AGE; AGE (Min 2 years, Max 64 years)
promethazine hcl tab 25 mg
Tier 1 AGE; AGE (Min 2 years, Max 64 years)
promethazine hcl tab 50 mg
Tier 1 AGE; AGE (Min 2 years, Max 64 years)
ANTIHISTAMINES - PIPERIDINES
cyproheptadine hcl syrup 2 mg/5ml
Tier 1 AGE; AGE (Max 64 years)
cyproheptadine hcl tab 4 mg
Tier 1 AGE; AGE (Max 64 years)
ANTIHYPERLIPIDEMICS
ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS
NEXLETOL TAB 180MG (bempedoic acid)
Tier 3 MAIL, PA
ANTIHYPERLIPIDEMICS - COMBINATIONS
ezetimibe-simvastatin tab 10-10 mg
Tier 3 MAIL, PA
ezetimibe-simvastatin tab 10-20 mg
Tier 3 MAIL, PA
ezetimibe-simvastatin tab 10-40 mg
Tier 3 MAIL, PA
ezetimibe-simvastatin tab 10-80 mg
Tier 3 MAIL, PA
NEXLIZET TAB 180/10MG (bempedoic acidezetimibe)
Tier 3 MAIL, PA
ANTIHYPERLIPIDEMICS - MISC.
omega-3-acid ethyl esters cap 1 gm
Tier 3 QL (120 caps / 30 days), MAIL
BILE ACID SEQUESTRANTS
cholestyramine light powder 4 gm/dose
Tier 1 QL (240 gm / 30 days), MAIL
cholestyramine powder 4 gm/dose
Tier 1 QL (378 gm / 30 days), MAIL
colesevelam hcl packet for susp 3.75 gm
Tier 3 QL (30 packets / 30 days), MAIL
colesevelam hcl tab 625 mg
Tier 3 QL (180 tabs / 30 days), MAIL
colestipol hcl tab 1 gm
Tier 1 QL (480 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
53
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
FIBRIC ACID DERIVATIVES
choline fenofibrate cap dr 45 mg (fenofibric acid Tier 3 equiv)
choline fenofibrate cap dr 135 mg (fenofibric acid equiv)
Tier 3
fenofibrate micronized cap 43 mg
Tier 3
fenofibrate micronized cap 67 mg
Tier 3
fenofibrate micronized cap 134 mg
Tier 3
fenofibrate micronized cap 200 mg
Tier 3
fenofibrate tab 48 mg
Tier 1
fenofibrate tab 54 mg
Tier 1
fenofibrate tab 145 mg
Tier 1
fenofibrate tab 160 mg
Tier 1
fenofibric acid tab 35 mg
Tier 1
gemfibrozil tab 600 mg
Tier 1
HMG COA REDUCTASE INHIBITORS atorvastatin calcium tab 10 mg (base equivalent)
Tier 5
atorvastatin calcium tab 20 mg (base equivalent)
Tier 5
atorvastatin calcium tab 40 mg (base equivalent) atorvastatin calcium tab 80 mg (base equivalent) fluvastatin sodium cap 20 mg (base equivalent)
Tier 1 Tier 1 Tier 5
Requirements/Limits
QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL
QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1 QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1 QL (45 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 caps / 30 days), MAIL, ST; Tier 5 for ages 40-75, otherwise Tier 3; Prior use in the last 365 days - ONE: Atorvastatin 40 mg OR 80 mg; OR TWO: pravastatin, lovastatin, simvastatin, atorvastatin
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
54
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
fluvastatin sodium cap 40 mg (base equivalent) Tier 5
fluvastatin sodium tab er 24 hr 80 mg (base equivalent)
Tier 5
lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg
Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5
Requirements/Limits
QL (30 caps / 30 days), MAIL, ST; Tier 5 for ages 40-75, otherwise Tier 3; Prior use in the last 365 days - ONE: Atorvastatin 40 mg OR 80 mg; OR TWO: pravastatin, lovastatin, simvastatin, atorvastatin QL (30 tabs / 30 days), MAIL, ST; Tier 5 for ages 40-75, otherwise Tier 3; Prior use in the last 365 days - ONE: Atorvastatin 40 mg OR 80 mg; OR TWO: pravastatin, lovastatin, simvastatin, atorvastatin QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1
QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1 QL (60 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1
QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1 QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1
QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1 QL (30 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
55
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name rosuvastatin calcium tab 5 mg
rosuvastatin calcium tab 10 mg
rosuvastatin calcium tab 20 mg
rosuvastatin calcium tab 40 mg
simvastatin tab 5 mg simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 80 mg
Drug Tier Tier 5
Tier 5
Tier 1
Tier 1
Tier 5 Tier 5 Tier 5 Tier 5 Tier 1
Requirements/Limits
QL (45 tabs / 30 days), MAIL, ST; Tier 5 for ages 40-75, otherwise Tier 1; Prior use in the last 365 days - ONE: Atorvastatin 40 mg OR 80 mg; OR TWO: pravastatin, lovastatin, simvastatin, atorvastatin QL (45 tabs / 30 days), MAIL, ST; Tier 5 for ages 40-75, otherwise Tier 1; Prior use in the last 365 days - ONE: Atorvastatin 40 mg OR 80 mg; OR TWO: pravastatin, lovastatin, simvastatin, atorvastatin QL (45 tabs / 30 days), MAIL, ST; Prior use in the last 365 days - ONE: Atorvastatin 40 mg OR 80 mg; OR TWO: pravastatin, lovastatin, simvastatin, atorvastatin QL (30 tabs / 30 days), MAIL, ST; Prior use in the last 365 days - ONE: Atorvastatin 40 mg OR 80 mg; OR TWO: pravastatin, lovastatin, simvastatin, atorvastatin
QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1
QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1 QL (45 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1
QL (30 tabs / 30 days), MAIL; Tier 5 for ages 40-75, otherwise Tier 1 QL (30 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
56
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS
ezetimibe tab 10 mg
Tier 3
QL (30 tabs / 30 days), MAIL, ST; Prior use in the last 365 days - ONE: Atorvastatin 40 mg OR 80 mg; OR TWO: pravastatin, lovastatin, simvastatin, atorvastatin
NICOTINIC ACID DERIVATIVES
niacin (antihyperlipidemic) tab 500 mg (Niacor)
Tier 3 QL (120 tabs / 30 days), MAIL
niacin tab er 500 mg (antihyperlipidemic)
Tier 3 QL (120 tabs / 30 days), MAIL
PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS
REPATHA INJ 140MG/ML (evolocumab)
Tier 4 PA
REPATHA PUSH INJ 420/3.5 (evolocumab)
Tier 4 PA
REPATHA SURE INJ 140MG/ML (evolocumab)
Tier 4 PA
ANTIHYPERTENSIVES
ACE INHIBITORS
benazepril hcl tab 5 mg
Tier 1 QL (90 tabs / 30 days), MAIL
benazepril hcl tab 10 mg
Tier 1 QL (180 tabs / 30 days), MAIL
benazepril hcl tab 20 mg
Tier 1 QL (180 tabs / 30 days), MAIL
benazepril hcl tab 40 mg
Tier 1 QL (90 tabs / 30 days), MAIL
captopril tab 12.5 mg
Tier 1 QL (180 tabs / 30 days), MAIL
captopril tab 25 mg
Tier 1 QL (180 tabs / 30 days), MAIL
captopril tab 50 mg
Tier 1 QL (180 tabs / 30 days), MAIL
captopril tab 100 mg
Tier 1 QL (120 tabs / 30 days), MAIL
enalapril maleate tab 2.5 mg
Tier 1 QL (60 tabs / 30 days), MAIL
enalapril maleate tab 5 mg
Tier 1 QL (30 tabs / 30 days), MAIL
enalapril maleate tab 10 mg
Tier 1 QL (30 tabs / 30 days), MAIL
enalapril maleate tab 20 mg
Tier 1 QL (60 tabs / 30 days), MAIL
fosinopril sodium tab 10 mg
Tier 1 QL (30 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
57
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg lisinopril tab 2.5 mg lisinopril tab 5 mg lisinopril tab 10 mg lisinopril tab 20 mg lisinopril tab 30 mg lisinopril tab 40 mg moexipril hcl tab 7.5 mg moexipril hcl tab 15 mg perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg perindopril erbumine tab 8 mg quinapril hcl tab 5 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg ramipril cap 1.25 mg ramipril cap 2.5 mg ramipril cap 5 mg ramipril cap 10 mg trandolapril tab 1 mg trandolapril tab 2 mg
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
58
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name trandolapril tab 4 mg
Drug Tier Tier 1
AGENTS FOR PHEOCHROMOCYTOMA phenoxybenzamine hcl cap 10 mg
ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 mg
Tier 4 Tier 3
candesartan cilexetil tab 8 mg
Tier 3
candesartan cilexetil tab 16 mg
Tier 3
candesartan cilexetil tab 32 mg
Tier 3
EDARBI TAB 40MG (azilsartan medoxomil)
Tier 3
EDARBI TAB 80MG (azilsartan medoxomil)
Tier 3
eprosartan mesylate tab 600 mg
Tier 3
Requirements/Limits
QL (30 tabs / 30 days), MAIL
QL (60 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days. QL (60 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days. QL (60 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days. QL (30 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days. QL (30 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days. QL (30 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days. QL (45 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days.
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
59
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name irbesartan tab 75 mg irbesartan tab 150 mg irbesartan tab 300 mg losartan potassium tab 25 mg losartan potassium tab 50 mg losartan potassium tab 100 mg olmesartan medoxomil tab 5 mg olmesartan medoxomil tab 20 mg olmesartan medoxomil tab 40 mg telmisartan tab 20 mg
telmisartan tab 40 mg
telmisartan tab 80 mg
valsartan tab 40 mg valsartan tab 80 mg valsartan tab 160 mg valsartan tab 320 mg
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3
Tier 3
Tier 3
Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days. QL (60 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days. QL (30 tabs / 30 days), MAIL, ST; Prior use of losartan, irbesartan, olmesartan, valsartan, or hctz combo in the past 90 days. QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
60
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name ANTIADRENERGIC ANTIHYPERTENSIVES
clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg clonidine td patch weekly 0.1 mg/24hr
clonidine td patch weekly 0.2 mg/24hr
clonidine td patch weekly 0.3 mg/24hr
doxazosin mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg methyldopa tab 250 mg
methyldopa tab 500 mg
prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg terazosin hcl cap 1 mg (base equivalent) terazosin hcl cap 2 mg (base equivalent) terazosin hcl cap 5 mg (base equivalent)
Drug Tier Requirements/Limits
Tier 1 Tier 1 Tier 1 Tier 3
Tier 3
Tier 3
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
QL (180 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL MAIL, ST; Prior use of clonidine tablets within last 180 days MAIL, ST; Prior use of clonidine tablets within last 180 days MAIL, ST; Prior use of clonidine tablets within last 180 days QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL AGE, QL (120 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (180 tabs / 30 days), MAIL; AGE (Max 64 years) QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
61
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name terazosin hcl cap 10 mg (base equivalent)
Drug Tier Tier 1
ANTIHYPERTENSIVE COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-10 mg amlodipine besylate-benazepril hcl cap 5-10 mg
Tier 1 Tier 1
amlodipine besylate-benazepril hcl cap 5-20 mg Tier 1
amlodipine besylate-benazepril hcl cap 5-40 mg Tier 1
amlodipine besylate-benazepril hcl cap 10-20 mg amlodipine besylate-benazepril hcl cap 10-40 mg amlodipine besylate-olmesartan medoxomil tab 5-20 mg amlodipine besylate-olmesartan medoxomil tab 5-40 mg amlodipine besylate-olmesartan medoxomil tab 10-20 mg amlodipine besylate-olmesartan medoxomil tab 10-40 mg atenolol & chlorthalidone tab 50-25 mg
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
atenolol & chlorthalidone tab 100-25 mg
Tier 1
benazepril & hydrochlorothiazide tab 5-6.25 mg Tier 1
benazepril & hydrochlorothiazide tab 10-12.5 mg benazepril & hydrochlorothiazide tab 20-12.5 mg benazepril & hydrochlorothiazide tab 20-25 mg
Tier 1 Tier 1 Tier 1
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25 mg
Tier 1 Tier 1
bisoprolol & hydrochlorothiazide tab 10-6.25 mg BYVALSON TAB 5-80MG (nebivolol-valsartan) captopril & hydrochlorothiazide tab 25-15 mg
Tier 1
Tier 3 Tier 1
captopril & hydrochlorothiazide tab 25-25 mg
Tier 1
Requirements/Limits
QL (60 caps / 30 days), MAIL
QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL MAIL, PA QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
62
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
captopril & hydrochlorothiazide tab 50-15 mg
Tier 1
captopril & hydrochlorothiazide tab 50-25 mg
Tier 1
enalapril maleate & hydrochlorothiazide tab 512.5 mg enalapril maleate & hydrochlorothiazide tab 1025 mg fosinopril sodium & hydrochlorothiazide tab 1012.5 mg fosinopril sodium & hydrochlorothiazide tab 2012.5 mg irbesartan-hydrochlorothiazide tab 150-12.5 mg
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
irbesartan-hydrochlorothiazide tab 300-12.5 mg Tier 1
lisinopril & hydrochlorothiazide tab 10-12.5 mg Tier 1
lisinopril & hydrochlorothiazide tab 20-12.5 mg Tier 1
lisinopril & hydrochlorothiazide tab 20-25 mg
Tier 1
losartan potassium & hydrochlorothiazide tab 50-12.5 mg losartan potassium & hydrochlorothiazide tab 100-12.5 mg losartan potassium & hydrochlorothiazide tab 100-25 mg metoprolol & hydrochlorothiazide tab 50-25 mg
Tier 1 Tier 1 Tier 1 Tier 1
metoprolol & hydrochlorothiazide tab 100-25 mg metoprolol & hydrochlorothiazide tab 100-50 mg olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg quinapril-hydrochlorothiazide tab 10-12.5 mg
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1
quinapril-hydrochlorothiazide tab 20-12.5 mg
Tier 1
quinapril-hydrochlorothiazide tab 20-25 mg
Tier 1
Requirements/Limits
QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
63
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
valsartan-hydrochlorothiazide tab 80-12.5 mg
Tier 1 QL (30 tabs / 30 days), MAIL
valsartan-hydrochlorothiazide tab 160-12.5 mg
Tier 1 QL (30 tabs / 30 days), MAIL
valsartan-hydrochlorothiazide tab 160-25 mg
Tier 1 QL (30 tabs / 30 days), MAIL
valsartan-hydrochlorothiazide tab 320-12.5 mg
Tier 1 QL (30 tabs / 30 days), MAIL
valsartan-hydrochlorothiazide tab 320-25 mg
Tier 1 QL (30 tabs / 30 days), MAIL
ANTIHYPERTENSIVES - MISC.
VECAMYL TAB 2.5MG (mecamylamine hcl)
Tier 3 MAIL
DIRECT RENIN INHIBITORS
aliskiren fumarate tab 150 mg (base equivalent)
Tier 3 QL (30 tabs / 30 days), MAIL, PA
aliskiren fumarate tab 300 mg (base equivalent)
Tier 3 QL (30 tabs / 30 days), MAIL, PA
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)
eplerenone tab 25 mg
Tier 1 QL (120 tabs / 30 days), MAIL
eplerenone tab 50 mg
Tier 1 QL (60 tabs / 30 days), MAIL
VASODILATORS
hydralazine hcl tab 10 mg
Tier 1 MAIL
hydralazine hcl tab 25 mg
Tier 1 MAIL
hydralazine hcl tab 50 mg
Tier 1 MAIL
hydralazine hcl tab 100 mg
Tier 1 MAIL
minoxidil tab 2.5 mg
Tier 1 MAIL
minoxidil tab 10 mg
Tier 1 MAIL
ANTIMALARIALS
ANTIMALARIAL COMBINATIONS
atovaquone-proguanil hcl tab 62.5-25 mg
Tier 1 QL (30 tabs / 30 days)
atovaquone-proguanil hcl tab 250-100 mg
Tier 1 QL (30 tabs / 30 days)
COARTEM TAB 20-120MG (artemetherlumefantrine)
Tier 3
ANTIMALARIALS
chloroquine phosphate tab 250 mg
Tier 1 QL (20 tabs / 30 days)
chloroquine phosphate tab 500 mg
Tier 1 QL (10 tabs / 30 days)
DARAPRIM TAB 25MG (pyrimethamine)
Tier 4 QL (120 tabs / 30 days), PA
hydroxychloroquine sulfate tab 200 mg
Tier 3 QL (120 tabs / 30 days)
mefloquine hcl tab 250 mg
Tier 1 QL (6 tabs / 30 days)
primaquine phosphate tab 26.3 mg (15 mg base)
Tier 1 QL (21 tabs / 30 days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
64
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
quinine sulfate cap 324 mg
Tier 3
ANTIMYASTHENIC/CHOLINERGIC AGENTS
ANTIMYASTHENIC/CHOLINERGIC AGENTS
GUANIDINE TAB 125MG
Tier 2
pyridostigmine bromide tab 60 mg
Tier 1
ANTIMYCOBACTERIAL AGENTS
ANTI TB COMBINATIONS RIFATER TAB (isoniazid-rifampin w/ pyrazinamide)
Tier 3
ANTIMYCOBACTERIAL AGENTS cycloserine cap 250 mg
Tier 1
ethambutol hcl tab 100 mg
Tier 1
ethambutol hcl tab 400 mg
Tier 1
isoniazid syrup 50 mg/5ml
Tier 1
isoniazid tab 100 mg
Tier 1
isoniazid tab 300 mg PASER GRA 4GM (aminosalicylic acid)
Tier 1 Tier 3
PRIFTIN TAB 150MG (rifapentine)
Tier 2
pyrazinamide tab 500 mg
Tier 3
rifabutin cap 150 mg
Tier 3
rifampin cap 150 mg
Tier 1
rifampin cap 300 mg
Tier 1
SIRTURO TAB 100MG (bedaquiline fumarate)
Tier 3
TRECATOR TAB 250MG (ethionamide)
Tier 3
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
ALKYLATING AGENTS
cyclophosphamide cap 25 mg
Tier 4
cyclophosphamide cap 50 mg
Tier 4
GLEOSTINE CAP 10MG (lomustine)
Tier 4
GLEOSTINE CAP 40MG (lomustine)
Tier 4
GLEOSTINE CAP 100MG (lomustine) LEUKERAN TAB 2MG (chlorambucil)
Tier 4 Tier 3
melphalan tab 2 mg
Tier 1
temozolomide cap 5 mg
Tier 4
temozolomide cap 20 mg
Tier 4
temozolomide cap 100 mg
Tier 4
temozolomide cap 140 mg
Tier 4
temozolomide cap 180 mg
Tier 4
temozolomide cap 250 mg
Tier 4
ANTIMETABOLITES
capecitabine tab 150 mg
Tier 4
capecitabine tab 500 mg
Tier 4
mercaptopurine tab 50 mg
Tier 1
Requirements/Limits QL (30 caps / 30 days)
QL (180 tabs / 30 days)
QL (32 tabs / 30 days)
PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
65
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
methotrexate sodium inj 50 mg/2ml (25 mg/ml)
Tier 1 QL (10 mL / 30 days), MAIL
methotrexate sodium inj 250 mg/10ml (25 mg/ml)
Tier 1 QL (10 mL / 30 days), MAIL
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)
Tier 1 QL (10 mL / 30 days), MAIL
methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)
Tier 1 QL (10 mL / 30 days), MAIL
methotrexate sodium tab 2.5 mg (base equiv)
Tier 1 MAIL
TABLOID TAB 40MG (thioguanine)
Tier 3 PA
ANTINEOPLASTIC - ANTIBODIES
RITUXAN INJ 100MG (rituximab)
Tier 4 PA
RITUXAN INJ 500MG (rituximab)
Tier 4 PA
RUXIENCE INJ 100/10ML (rituximab-pvvr)
Tier 4 PA
RUXIENCE INJ 500/50ML (rituximab-pvvr)
Tier 4 PA
TRUXIMA INJ 100/10ML (rituximab-abbs)
Tier 4 PA
TRUXIMA INJ 500/50ML (rituximab-abbs)
Tier 4 PA
ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS
ERIVEDGE CAP 150MG (vismodegib)
Tier 4 QL (30 per 30 days), PA
ODOMZO CAP 200MG (sonidegib phosphate)
Tier 4 QL (30 per 30 days), PA
ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS
abiraterone acetate tab 250 mg
Tier 4 QL (120 per 30 days), PA
anastrozole tab 1 mg
Tier 1 MAIL
bicalutamide tab 50 mg
Tier 1 QL (90 tabs / 30 days)
ELIGARD INJ 7.5MG (leuprolide acetate)
Tier 4 PA
ELIGARD INJ 22.5MG (leuprolide acetate (3 month))
Tier 4 PA
EMCYT CAP 140MG (estramustine phosphate sodium)
Tier 4 PA
exemestane tab 25 mg
Tier 3 MAIL, PA
FIRMAGON INJ 80MG (degarelix acetate)
Tier 4 PA
flutamide cap 125 mg
Tier 3
hydroxyprogesterone caproate im in oil 1.25 gm/5ml
Tier 3 PA
letrozole tab 2.5 mg
Tier 1 QL (30 tabs / 30 days), MAIL
leuprolide acetate inj kit 5 mg/ml
Tier 4 PA
LUPRON DEPOT INJ 3.75MG (leuprolide acetate)
Tier 4 PA
LUPRON DEPOT INJ 7.5MG (leuprolide acetate)
Tier 4 PA
LUPRON DEPOT INJ 11.25MG (leuprolide acetate (3 month))
Tier 4 PA
LUPRON DEPOT INJ 22.5MG (leuprolide acetate (3 month))
Tier 4 PA
LYSODREN TAB 500MG (mitotane)
Tier 4 PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
66
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
megestrol acetate susp 40 mg/ml megestrol acetate tab 20 mg megestrol acetate tab 40 mg nilutamide tab 150 mg tamoxifen citrate tab 10 mg (base equivalent)
Drug Tier
Tier 1 Tier 1 Tier 1 Tier 4 Tier 5
tamoxifen citrate tab 20 mg (base equivalent)
Tier 5
TRELSTAR MIX INJ 3.75MG (triptorelin pamoate) TRELSTAR MIX INJ 11.25MG (triptorelin pamoate) ZOLADEX IMP 3.6MG (goserelin acetate) ZOLADEX IMP 10.8MG (goserelin acetate)
ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST CAP 1MG (pomalidomide) POMALYST CAP 2MG (pomalidomide) POMALYST CAP 3MG (pomalidomide) POMALYST CAP 4MG (pomalidomide)
ANTINEOPLASTIC COMBINATIONS KISQALI 200 PAK FEMARA (ribociclib succinateletrozole) KISQALI 400 PAK FEMARA (ribociclib succinateletrozole) KISQALI 600 PAK FEMARA (ribociclib succinateletrozole) LONSURF TAB 15-6.14 (trifluridine-tipiracil)
Tier 4 Tier 4 Tier 4 Tier 4
Tier 4 Tier 4 Tier 4 Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
LONSURF TAB 20-8.19 (trifluridine-tipiracil)
Tier 4
ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR DIS TAB 2MG (everolimus) AFINITOR DIS TAB 3MG (everolimus) AFINITOR DIS TAB 5MG (everolimus) AFINITOR TAB 2.5MG (everolimus) AFINITOR TAB 5MG (everolimus) AFINITOR TAB 7.5MG (everolimus) AFINITOR TAB 10MG (everolimus) ALECENSA CAP 150MG (alectinib hcl)
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
BRUKINSA CAP 80MG (zanubrutinib)
Tier 4
CAPRELSA TAB 100MG (vandetanib) CAPRELSA TAB 300MG (vandetanib) COMETRIQ KIT 60MG (cabozantinib s-malate)
Tier 4 Tier 4 Tier 4
Requirements/Limits
PA MAIL; Tier 5 for ages 35 and over, otherwise Tier 1 MAIL; Tier 5 for ages 35 and over, otherwise Tier 1 PA PA PA PA
QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA
QL (49 per 28 days), PA
QL (70 per 28 days), PA
QL (91 per 28 days), PA
QL (100 per 28 days), PA QL (100 per 28 days), PA
QL (60 per 30 days), PA QL (90 per 30 days), PA QL (60 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (240 per 30 days), PA QL (120 per 30 days), MAIL, PA QL (60 per 30 days), PA QL (30 per 30 days), PA QL (90 per 30 days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
67
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name COMETRIQ KIT 100MG (cabozantinib s-malate) COMETRIQ KIT 140MG (cabozantinib s-malate)
Drug Tier Tier 4 Tier 4
erlotinib hcl tab 25 mg (base equivalent) erlotinib hcl tab 100 mg (base equivalent) erlotinib hcl tab 150 mg (base equivalent) everolimus tab 2.5 mg everolimus tab 5 mg everolimus tab 7.5 mg FARYDAK CAP 10MG (panobinostat lactate) FARYDAK CAP 15MG (panobinostat lactate) FARYDAK CAP 20MG (panobinostat lactate) GILOTRIF TAB 20MG (afatinib dimaleate) GILOTRIF TAB 30MG (afatinib dimaleate) GILOTRIF TAB 40MG (afatinib dimaleate) IBRANCE CAP 75MG (palbociclib) IBRANCE CAP 100MG (palbociclib) IBRANCE CAP 125MG (palbociclib) IBRANCE TAB 75MG (palbociclib) IBRANCE TAB 100MG (palbociclib) IBRANCE TAB 125MG (palbociclib) ICLUSIG TAB 15MG (ponatinib hcl) ICLUSIG TAB 45MG (ponatinib hcl) imatinib mesylate tab 100 mg (base equivalent) imatinib mesylate tab 400 mg (base equivalent) IMBRUVICA CAP 140MG (ibrutinib) JAKAFI TAB 5MG (ruxolitinib phosphate) JAKAFI TAB 10MG (ruxolitinib phosphate) JAKAFI TAB 15MG (ruxolitinib phosphate) JAKAFI TAB 20MG (ruxolitinib phosphate) JAKAFI TAB 25MG (ruxolitinib phosphate) KISQALI TAB 200DOSE (ribociclib succinate) KISQALI TAB 400DOSE (ribociclib succinate) KISQALI TAB 600DOSE (ribociclib succinate) LENVIMA CAP 4MG (lenvatinib mesylate) LENVIMA CAP 8 MG (lenvatinib mesylate) LENVIMA CAP 10 MG (lenvatinib mesylate) LENVIMA CAP 12MG (lenvatinib mesylate) LENVIMA CAP 14 MG (lenvatinib mesylate) LENVIMA CAP 18 MG (lenvatinib mesylate) LENVIMA CAP 20 MG (lenvatinib mesylate) LENVIMA CAP 24 MG (lenvatinib mesylate) MEKINIST TAB 0.5MG (trametinib dimethyl sulfoxide)
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
Requirements/Limits
QL (60 per 30 days), PA QL (120 per 30 days), PA QL (90 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (6 per 21 days), PA QL (6 per 21 days), PA QL (6 per 21 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (60 per 30 days), PA QL (30 per 30 days), PA QL (90 per 30 days), PA QL (60 per 30 days), PA QL (90 per 30 days), PA QL (60 per 30 days), PA QL (60 per 30 days), PA QL (60 per 30 days), PA QL (60 per 30 days), PA QL (60 per 30 days), PA QL (30 per 30 days), PA QL (60 per 30 days), PA QL (90 per 30 days), PA QL (30 per 30 days), PA QL (60 per 30 days), PA QL (30 per 30 days), PA QL (90 per 30 days), PA QL (60 per 30 days), PA QL (90 per 30 days), PA QL (60 per 30 days), PA QL (90 per 30 days), PA QL (90 per 30 days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
68
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name MEKINIST TAB 2MG (trametinib dimethyl sulfoxide) NEXAVAR TAB 200MG (sorafenib tosylate)
RUBRACA TAB 200MG (rucaparib camsylate) RUBRACA TAB 250MG (rucaparib camsylate) RUBRACA TAB 300MG (rucaparib camsylate) SPRYCEL TAB 20MG (dasatinib) SPRYCEL TAB 50MG (dasatinib) SPRYCEL TAB 70MG (dasatinib) SPRYCEL TAB 80MG (dasatinib) SPRYCEL TAB 100MG (dasatinib) SPRYCEL TAB 140MG (dasatinib) STIVARGA TAB 40MG (regorafenib) SUTENT CAP 12.5MG (sunitinib malate)
SUTENT CAP 25MG (sunitinib malate) SUTENT CAP 37.5MG (sunitinib malate) SUTENT CAP 50MG (sunitinib malate) TAFINLAR CAP 50MG (dabrafenib mesylate)
TAFINLAR CAP 75MG (dabrafenib mesylate)
TAGRISSO TAB 40MG (osimertinib mesylate) TAGRISSO TAB 80MG (osimertinib mesylate) TARCEVA TAB 25MG (erlotinib hcl) TARCEVA TAB 100MG (erlotinib hcl) TARCEVA TAB 150MG (erlotinib hcl) TASIGNA CAP 50MG (nilotinib hcl)
TASIGNA CAP 150MG (nilotinib hcl)
TASIGNA CAP 200MG (nilotinib hcl)
TYKERB TAB 250MG (lapatinib ditosylate)
VOTRIENT TAB 200MG (pazopanib hcl)
XALKORI CAP 200MG (crizotinib) XALKORI CAP 250MG (crizotinib) ZEJULA CAP 100MG (niraparib tosylate) ZOLINZA CAP 100MG (vorinostat)
ZYDELIG TAB 100MG (idelalisib) ZYDELIG TAB 150MG (idelalisib)
Drug Tier Requirements/Limits Tier 4 QL (30 per 30 days), PA
Tier 4
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
Tier 4 Tier 4 Tier 4 Tier 4
Tier 4
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4 Tier 4 Tier 4 Tier 4
Tier 4 Tier 4
QL (120 per 30 days), PA PA PA PA QL (90 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (90 per 30 days), PA QL (120 per 30 days), PA QL (60 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (120 per 30 days), PA QL (120 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (90 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (120 per 30 days), PA QL (120 per 30 days), PA QL (120 per 30 days), PA QL (180 per 30 days), PA QL (120 per 30 days), PA QL (60 per 30 days), PA QL (60 per 30 days), PA QL (90 per 30 days), PA QL (120 per 30 days), PA QL (60 per 30 days), PA QL (60 per 30 days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
69
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
ZYKADIA CAP 150MG (ceritinib)
Tier 4
ANTINEOPLASTICS MISC. ACTIMMUNE INJ 2MU/0.5 (interferon gamma-1b)
Tier 4
bexarotene cap 75 mg
Tier 4
hydroxyurea cap 500 mg
Tier 1
INTRON A INJ 10MU (interferon alfa-2b)
Tier 4
INTRON A INJ 18MU (interferon alfa-2b)
Tier 4
INTRON A INJ 25MU (interferon alfa-2b)
Tier 4
INTRON A INJ 50MU (interferon alfa-2b)
Tier 4
MATULANE CAP 50MG (procarbazine hcl)
Tier 4
tretinoin cap 10 mg
Tier 4
CHEMOTHERAPY ADJUNCTS
KEPIVANCE INJ 6.25MG (palifermin)
Tier 4
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS
leucovorin calcium tab 5 mg
Tier 1
leucovorin calcium tab 10 mg
Tier 1
leucovorin calcium tab 15 mg
Tier 1
leucovorin calcium tab 25 mg
Tier 1
MITOTIC INHIBITORS etoposide cap 50 mg
Tier 4
ANTIPARKINSON AND RELATED THERAPY AGENTS
ANTIPARKINSON ADJUVANTS
carbidopa tab 25 mg
Tier 3
ANTIPARKINSON ANTICHOLINERGICS
benztropine mesylate tab 0.5 mg
Tier 1
benztropine mesylate tab 1 mg
Tier 1
benztropine mesylate tab 2 mg
Tier 1
trihexyphenidyl hcl oral soln 0.4 mg/ml
Tier 1
trihexyphenidyl hcl tab 2 mg
Tier 1
trihexyphenidyl hcl tab 5 mg
Tier 1
ANTIPARKINSON COMT INHIBITORS entacapone tab 200 mg
Tier 3
tolcapone tab 100 mg
ANTIPARKINSON DOPAMINERGICS amantadine hcl cap 100 mg
Tier 3 Tier 1
Requirements/Limits PA
PA PA
PA PA PA PA PA PA
PA
MAIL MAIL MAIL MAIL
PA
MAIL
AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years)
QL (240 tabs / 30 days), MAIL MAIL
QL (120 caps / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
70
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
amantadine hcl syrup 50 mg/5ml
Tier 1
APOKYN INJ 10MG/ML (apomorphine
Tier 4
hydrochloride)
bromocriptine mesylate cap 5 mg (base
Tier 3
equivalent)
bromocriptine mesylate tab 2.5 mg (base
Tier 3
equivalent)
carbidopa & levodopa orally disintegrating tab 10-100 mg
Tier 1
carbidopa & levodopa orally disintegrating tab
Tier 1
25-100 mg
carbidopa & levodopa orally disintegrating tab
Tier 1
25-250 mg
carbidopa & levodopa tab 10-100 mg
Tier 1
carbidopa & levodopa tab 25-100 mg
Tier 1
carbidopa & levodopa tab 25-250 mg
Tier 1
carbidopa & levodopa tab er 25-100 mg
Tier 1
carbidopa & levodopa tab er 50-200 mg
Tier 1
carbidopa-levodopa-entacapone tabs 12.5-50-
Tier 3
200 mg
carbidopa-levodopa-entacapone tabs 18.75-75200 mg
Tier 3
carbidopa-levodopa-entacapone tabs 25-100200 mg
Tier 3
carbidopa-levodopa-entacapone tabs 31.25-
Tier 3
125-200 mg
carbidopa-levodopa-entacapone tabs 37.5-150- Tier 3
200 mg
carbidopa-levodopa-entacapone tabs 50-200-
Tier 3
200 mg
NEUPRO DIS 1MG/24HR (rotigotine)
Tier 3
NEUPRO DIS 2MG/24HR (rotigotine)
Tier 3
NEUPRO DIS 3MG/24HR (rotigotine)
Tier 3
NEUPRO DIS 4MG/24HR (rotigotine)
Tier 3
NEUPRO DIS 6MG/24HR (rotigotine)
Tier 3
NEUPRO DIS 8MG/24HR (rotigotine)
Tier 3
pramipexole dihydrochloride tab 0.5 mg
Tier 1
pramipexole dihydrochloride tab 0.25 mg
Tier 1
pramipexole dihydrochloride tab 0.75 mg
Tier 1
pramipexole dihydrochloride tab 0.125 mg
Tier 1
pramipexole dihydrochloride tab 1 mg
Tier 1
pramipexole dihydrochloride tab 1.5 mg
Tier 1
ropinirole hydrochloride tab 0.5 mg
Tier 1
ropinirole hydrochloride tab 0.25 mg
Tier 1
ropinirole hydrochloride tab 1 mg
Tier 1
Requirements/Limits MAIL PA
QL (180 caps / 30 days), MAIL QL (180 tabs / 30 days), MAIL MAIL
MAIL
MAIL
MAIL MAIL MAIL MAIL MAIL MAIL
MAIL
QL (240 tabs / 30 days), MAIL QL (240 tabs / 30 days), MAIL QL (240 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL MAIL, PA MAIL, PA MAIL, PA MAIL, PA MAIL, PA MAIL, PA MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
71
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
ropinirole hydrochloride tab 2 mg
Tier 1 MAIL
ropinirole hydrochloride tab 3 mg
Tier 1 MAIL
ropinirole hydrochloride tab 4 mg
Tier 1 MAIL
ropinirole hydrochloride tab 5 mg
Tier 1 MAIL
ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS
rasagiline mesylate tab 0.5 mg (base equiv)
Tier 3 QL (60 tabs / 30 days), MAIL
rasagiline mesylate tab 1 mg (base equiv)
Tier 3 QL (30 tabs / 30 days), MAIL
selegiline hcl cap 5 mg
Tier 1 QL (60 caps / 30 days), MAIL
selegiline hcl tab 5 mg
Tier 1 QL (60 tabs / 30 days), MAIL
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIMANIC AGENTS
lithium carbonate cap 150 mg
Tier 1 AGE, MAIL; AGE (Min 6 years)
lithium carbonate cap 300 mg
Tier 1 AGE, MAIL; AGE (Min 6 years)
lithium carbonate cap 600 mg
Tier 1 AGE, MAIL; AGE (Min 6 years)
lithium carbonate tab 300 mg
Tier 1 AGE, MAIL; AGE (Min 6 years)
lithium carbonate tab er 300 mg
Tier 1 AGE, MAIL; AGE (Min 6 years)
lithium carbonate tab er 450 mg
Tier 1 AGE, MAIL; AGE (Min 6 years)
LITHIUM SOL 8MEQ/5ML
Tier 1 AGE, MAIL; AGE (Min 6 years)
ANTIPSYCHOTICS - MISC.
LATUDA TAB 20MG (lurasidone hcl)
Tier 3 MAIL, PA
LATUDA TAB 40MG (lurasidone hcl)
Tier 3 MAIL, PA
LATUDA TAB 60MG (lurasidone hcl)
Tier 3 MAIL, PA
LATUDA TAB 80MG (lurasidone hcl)
Tier 3 MAIL, PA
LATUDA TAB 120MG (lurasidone hcl)
Tier 3 MAIL, PA
VRAYLAR CAP 1.5MG (cariprazine hcl)
Tier 3 MAIL, PA
VRAYLAR CAP 3MG (cariprazine hcl)
Tier 3 MAIL, PA
VRAYLAR CAP 4.5MG (cariprazine hcl)
Tier 3 MAIL, PA
VRAYLAR CAP 6MG (cariprazine hcl)
Tier 3 MAIL, PA
ziprasidone hcl cap 20 mg
Tier 3
AGE, QL (60 caps / 30 days), MAIL; AGE (Min 6 years)
ziprasidone hcl cap 40 mg
Tier 3
AGE, QL (60 caps / 30 days), MAIL; AGE (Min 6 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
72
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name ziprasidone hcl cap 60 mg
ziprasidone hcl cap 80 mg
BENZISOXAZOLES FANAPT PAK (iloperidone) FANAPT TAB 1MG (iloperidone) FANAPT TAB 2MG (iloperidone) FANAPT TAB 4MG (iloperidone) FANAPT TAB 6MG (iloperidone) FANAPT TAB 8MG (iloperidone) FANAPT TAB 10MG (iloperidone) FANAPT TAB 12MG (iloperidone) INVEGA SUST INJ 39/0.25 (paliperidone palmitate)
INVEGA SUST INJ 78/0.5ML (paliperidone palmitate)
INVEGA SUST INJ 117/0.75 (paliperidone palmitate)
INVEGA SUST INJ 156MG/ML (paliperidone palmitate)
INVEGA SUST INJ 234/1.5 (paliperidone palmitate)
INVEGA TRINZ INJ 273MG (paliperidone palmitate)
INVEGA TRINZ INJ 410MG (paliperidone palmitate)
INVEGA TRINZ INJ 546MG (paliperidone palmitate)
INVEGA TRINZ INJ 819MG (paliperidone palmitate)
paliperidone tab er 24hr 1.5 mg paliperidone tab er 24hr 3 mg paliperidone tab er 24hr 6 mg paliperidone tab er 24hr 9 mg
Drug Tier Tier 3
Tier 3
Requirements/Limits
AGE, QL (60 caps / 30 days), MAIL; AGE (Min 6 years) AGE, QL (60 caps / 30 days), MAIL; AGE (Min 6 years)
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3 Tier 3 Tier 3 Tier 3
MAIL, PA
MAIL, PA
MAIL, PA
MAIL, PA
MAIL, PA
MAIL, PA
MAIL, PA
MAIL, PA
AGE, QL (0.25 mL / 30 days); AGE (Min 6 years) AGE, QL (0.5 mL / 30 days); AGE (Min 6 years) AGE, QL (0.75 mL / 30 days); AGE (Min 6 years) AGE, QL (1 mL / 30 days); AGE (Min 6 years) AGE, QL (1.5 mL / 30 days); AGE (Min 6 years) AGE, QL (0.875 mL / 90 days); AGE (Min 6 years) AGE, QL (1.315 mL / 90 days); AGE (Min 6 years) AGE, QL (1.75 mL / 90 days); AGE (Min 6 years) AGE, QL (2.65 mL / 90 days); AGE (Min 6 years) MAIL, PA
MAIL, PA
MAIL, PA
MAIL, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
73
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
RISPERDAL INJ 12.5MG (risperidone microspheres)
Drug Tier Tier 3
RISPERDAL INJ 25MG (risperidone microspheres) Tier 3
RISPERDAL INJ 37.5MG (risperidone microspheres)
RISPERDAL INJ 50MG (risperidone microspheres)
Tier 3 Tier 3
risperidone orally disintegrating tab 0.5 mg
Tier 3
risperidone orally disintegrating tab 0.25 mg
Tier 3
risperidone orally disintegrating tab 1 mg
Tier 3
risperidone orally disintegrating tab 2 mg
Tier 3
risperidone orally disintegrating tab 3 mg
Tier 3
risperidone orally disintegrating tab 4 mg
Tier 3
risperidone soln 1 mg/ml
Tier 1
risperidone tab 0.5 mg
Tier 1
risperidone tab 0.25 mg
Tier 1
risperidone tab 1 mg
Tier 1
risperidone tab 2 mg
Tier 1
Requirements/Limits
AGE, QL (2 mL / 30 days); AGE (Min 6 years) AGE, QL (2 mL / 30 days); AGE (Min 6 years) AGE, QL (2 mL / 30 days); AGE (Min 6 years) AGE, QL (2 mL / 30 days); AGE (Min 6 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 5 years) AGE, QL (60 ea / 30 days), MAIL; AGE (Min 5 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 5 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 5 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 5 years) AGE, QL (120 tabs / 30 days), MAIL; AGE (Min 5 years) AGE, QL (480 mL / 30 days), MAIL; AGE (Min 5 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 5 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 5 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 5 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 5 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
74
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name risperidone tab 3 mg
risperidone tab 4 mg
BUTYROPHENONES haloperidol decanoate im soln 50 mg/ml haloperidol decanoate im soln 100 mg/ml haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg haloperidol tab 10 mg haloperidol tab 20 mg
DIBENZAPINES clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
clozapine tab 200 mg
loxapine succinate cap 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg
Drug Tier Tier 1
Tier 1
Requirements/Limits
AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 5 years) AGE, QL (120 tabs / 30 days), MAIL; AGE (Min 5 years)
Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
AGE; AGE (Min 6 years)
AGE; AGE (Min 6 years)
AGE; AGE (Min 6 years)
AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years)
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
AGE, QL (60 tabs / 30 days); AGE (Min 6 years) AGE, QL (60 tabs / 30 days); AGE (Min 6 years) AGE, QL (60 tabs / 30 days); AGE (Min 6 years) AGE, QL (120 tabs / 30 days); AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
75
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name olanzapine tab 2.5 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 20 mg quetiapine fumarate tab 25 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab 100 mg quetiapine fumarate tab 200 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 400 mg quetiapine fumarate tab er 24hr 50 mg quetiapine fumarate tab er 24hr 150 mg quetiapine fumarate tab er 24hr 200 mg
Drug Tier Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3
Requirements/Limits
AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (60 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
76
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name quetiapine fumarate tab er 24hr 300 mg
quetiapine fumarate tab er 24hr 400 mg
SAPHRIS SUB 2.5MG (asenapine maleate) SAPHRIS SUB 5MG (asenapine maleate) SAPHRIS SUB 10MG (asenapine maleate) ZYPREXA RELP INJ 210MG (olanzapine pamoate)
ZYPREXA RELP INJ 300MG (olanzapine pamoate)
ZYPREXA RELP INJ 405MG (olanzapine pamoate)
PHENOTHIAZINES chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg fluphenazine decanoate inj 25 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine tab 16 mg
Drug Tier Tier 3
Tier 3
Tier 2 Tier 2 Tier 2 Tier 3
Tier 3
Tier 3
Requirements/Limits
AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) AGE, QL (30 tabs / 30 days), MAIL; AGE (Min 6 years) MAIL, PA
MAIL, PA
MAIL, PA
AGE, QL (2 mL / 30 days); AGE (Min 6 years) AGE, QL (2 mL / 30 days); AGE (Min 6 years) AGE, QL (1 mL / 30 days); AGE (Min 6 years)
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE; AGE (Min 6 years)
AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years, Max 64 years) AGE, MAIL; AGE (Min 6 years, Max 64 years) AGE, MAIL; AGE (Min 6 years, Max 64 years) AGE, MAIL; AGE (Min 6 years, Max 64 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
77
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine suppos 25 mg thioridazine hcl tab 10 mg
Drug Tier Tier 1
Tier 1
Tier 3 Tier 1
thioridazine hcl tab 25 mg
Tier 1
thioridazine hcl tab 50 mg
Tier 1
thioridazine hcl tab 100 mg
Tier 1
trifluoperazine hcl tab 1 mg (base equivalent)
Tier 1
trifluoperazine hcl tab 2 mg (base equivalent)
Tier 1
trifluoperazine hcl tab 5 mg (base equivalent)
Tier 1
trifluoperazine hcl tab 10 mg (base equivalent) Tier 1
QUINOLINONE DERIVATIVES ABILIFY MAIN INJ 300MG (aripiprazole)
Tier 2
ABILIFY MAIN INJ 400MG (aripiprazole)
Tier 2
aripiprazole oral solution 1 mg/ml aripiprazole orally disintegrating tab 10 mg aripiprazole orally disintegrating tab 15 mg aripiprazole tab 2 mg aripiprazole tab 5 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 20 mg aripiprazole tab 30 mg
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Requirements/Limits
AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years, Max 64 years) AGE, MAIL; AGE (Min 6 years, Max 64 years) AGE, MAIL; AGE (Min 6 years, Max 64 years) AGE, MAIL; AGE (Min 6 years, Max 64 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years)
AGE, QL (1 ea / 30 days); AGE (Min 6 years) AGE, QL (1 ea / 30 days); AGE (Min 6 years) MAIL, PA QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
78
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name ARISTADA INJ 441MG/1. (aripiprazole lauroxil)
Drug Tier Tier 2
ARISTADA INJ 662MG/2 (aripiprazole lauroxil)
Tier 2
ARISTADA INJ 882MG/3 (aripiprazole lauroxil)
Tier 2
THIOXANTHENES thiothixene cap 1 mg
Tier 1
thiothixene cap 2 mg
Tier 1
thiothixene cap 5 mg
Tier 1
thiothixene cap 10 mg
Tier 1
ANTISEPTICS & DISINFECTANTS
CHLORINE ANTISEPTICS chlorhexidine gluconate liquid 4%
ANTIVIRALS
ANTIRETROVIRALS abacavir sulfate soln 20 mg/ml (base equiv) abacavir sulfate tab 300 mg (base equiv) abacavir sulfate-lamivudine tab 600-300 mg abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg APTIVUS CAP 250MG (tipranavir) APTIVUS SOL (tipranavir) atazanavir sulfate cap 150 mg (base equiv) atazanavir sulfate cap 200 mg (base equiv) atazanavir sulfate cap 300 mg (base equiv) ATRIPLA TAB (efavirenz-emtricitabine-tenofovir disoproxil fumarate) BIKTARVY TAB (bictegravir-emtricitabinetenofovir alafenamide fumarate) CIMDUO TAB 300-300 (lamivudine-tenofovir disoproxil fumarate) COMPLERA TAB (emtricitabine-rilpivirinetenofovir disoproxil fumarate) CRIXIVAN CAP 200MG (indinavir sulfate) CRIXIVAN CAP 400MG (indinavir sulfate) DELSTRIGO TAB (doravirine-lamivudine-tenofovir disoproxil fumarate)
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1
Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 2
Tier 2
Tier 2
Tier 2
Tier 2 Tier 2 Tier 2
Requirements/Limits AGE, QL (1.6 mL / 30 days); AGE (Min 6 years) AGE, QL (2.4 mL / 30 days); AGE (Min 6 years) AGE, QL (3.2 mL / 30 days); AGE (Min 6 years)
AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years) AGE, MAIL; AGE (Min 6 years)
OTC
QL (900 mL / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days)
QL (120 caps / 30 days) QL (300 mL / 30 days) QL (60 caps / 30 days) QL (60 caps / 30 days) QL (30 caps / 30 days) QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (360 caps / 30 days) QL (180 caps / 30 days) QL (30 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
79
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
DESCOVY TAB 200/25 (emtricitabine-tenofovir
Tier 2
alafenamide fumarate)
didanosine delayed release capsule 200 mg
Tier 1
didanosine delayed release capsule 250 mg
Tier 1
didanosine delayed release capsule 400 mg
Tier 1
DOVATO TAB 50-300MG (dolutegravir sodium-
Tier 2
lamivudine)
EDURANT TAB 25MG (rilpivirine hcl)
Tier 2
efavirenz cap 50 mg
Tier 1
efavirenz cap 200 mg
Tier 1
efavirenz tab 600 mg
Tier 1
EMTRIVA CAP 200MG (emtricitabine)
Tier 2
EMTRIVA SOL 10MG/ML (emtricitabine)
Tier 2
EVOTAZ TAB 300-150 (atazanavir sulfatecobicistat)
Tier 2
fosamprenavir calcium tab 700 mg (base equiv) Tier 1
FUZEON INJ 90MG (enfuvirtide)
Tier 4
GENVOYA TAB (elvitegravir-cobicistat-
Tier 2
emtricitabine-tenofovir alafenamide)
INTELENCE TAB 25MG (etravirine)
Tier 2
INTELENCE TAB 100MG (etravirine)
Tier 2
INTELENCE TAB 200MG (etravirine)
Tier 2
INVIRASE TAB 500MG (saquinavir mesylate)
Tier 2
ISENTRESS CHW 25MG (raltegravir potassium)
Tier 2
ISENTRESS CHW 100MG (raltegravir potassium)
Tier 2
ISENTRESS HD TAB 600MG (raltegravir
Tier 2
potassium)
ISENTRESS POW 100MG (raltegravir potassium)
Tier 2
ISENTRESS TAB 400MG (raltegravir potassium) JULUCA TAB 50-25MG (dolutegravir sodiumrilpivirine hcl) KALETRA TAB 100-25MG (lopinavir-ritonavir) KALETRA TAB 200-50MG (lopinavir-ritonavir) lamivudine oral soln 10 mg/ml lamivudine tab 150 mg lamivudine tab 300 mg lamivudine-zidovudine tab 150-300 mg lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) nevirapine susp 50 mg/5ml nevirapine tab 200 mg nevirapine tab er 24hr 100 mg nevirapine tab er 24hr 400 mg NORVIR SOL 80MG/ML (ritonavir)
Tier 2 Tier 2
Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
Requirements/Limits QL (30 tabs / 30 days)
QL (60 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 tabs / 30 days)
QL (30 tabs / 30 days) QL (360 caps / 30 days) QL (90 caps / 30 days) QL (30 tabs / 30 days) QL (30 caps / 30 days) QL (720 mL / 30 days) QL (30 tabs / 30 days)
QL (120 tabs / 30 days) PA QL (30 tabs / 30 days)
QL (480 tabs / 30 days) QL (120 tabs / 30 days) QL (60 tabs / 30 days) QL (300 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days)
QL (60 packets / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)
QL (360 tabs / 30 days) QL (180 tabs / 30 days) QL (900 mL / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 mL / 30 days)
QL (1200 mL / 30 days) QL (60 tabs / 30 days) QL (120 tabs / 30 days) QL (30 tabs / 30 days) QL (450 mL / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
80
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
ODEFSEY TAB (emtricitabine-rilpivirine-tenofovir Tier 2
alafenamide fumarate)
PIFELTRO TAB 100MG (doravirine)
Tier 2
PREZCOBIX TAB 800-150 (darunavir-cobicistat)
Tier 2
PREZISTA SUS 100MG/ML (darunavir ethanolate) Tier 2
PREZISTA TAB 75MG (darunavir ethanolate)
Tier 2
PREZISTA TAB 150MG (darunavir ethanolate)
Tier 2
PREZISTA TAB 600MG (darunavir ethanolate)
Tier 2
PREZISTA TAB 800MG (darunavir ethanolate)
Tier 2
RESCRIPTOR TAB 200MG (delavirdine mesylate)
Tier 2
ritonavir tab 100 mg
Tier 1
SELZENTRY SOL 20MG/ML (maraviroc)
Tier 2
SELZENTRY TAB 25MG (maraviroc)
Tier 2
SELZENTRY TAB 75MG (maraviroc)
Tier 2
SELZENTRY TAB 150MG (maraviroc)
Tier 2
SELZENTRY TAB 300MG (maraviroc)
Tier 2
stavudine cap 15 mg
Tier 1
stavudine cap 20 mg
Tier 1
stavudine cap 30 mg
Tier 1
stavudine cap 40 mg
Tier 1
STRIBILD TAB (elvitegravir-cobicistat-
Tier 2
emtricitabine-tenofovir df)
SYMFI LO TAB (efavirenz-lamivudine-tenofovir
Tier 2
disoproxil fumarate)
SYMFI TAB (efavirenz-lamivudine-tenofovir disoproxil fumarate)
Tier 2
SYMTUZA TAB (darunavir-cobicistat-
Tier 2
emtricitabine-tenofovir alafenamide)
tenofovir disoproxil fumarate tab 300 mg
Tier 1
TIVICAY PD TAB 5MG (dolutegravir sodium)
Tier 2
TIVICAY TAB 10MG (dolutegravir sodium)
Tier 2
TIVICAY TAB 25MG (dolutegravir sodium)
Tier 2
TIVICAY TAB 50MG (dolutegravir sodium)
Tier 2
TRIUMEQ TAB (abacavir-dolutegravir-
Tier 2
lamivudine)
TRUVADA TAB 100-150 (emtricitabine-tenofovir
Tier 2
disoproxil fumarate)
TRUVADA TAB 133-200 (emtricitabine-tenofovir
Tier 2
disoproxil fumarate)
TRUVADA TAB 167-250 (emtricitabine-tenofovir disoproxil fumarate)
Tier 2
TRUVADA TAB 200-300 (emtricitabine-tenofovir
Tier 2
disoproxil fumarate)
TYBOST TAB 150MG (cobicistat)
Tier 2
VIDEX EC CAP 125MG (didanosine)
Tier 2
Requirements/Limits QL (30 tabs / 30 days)
QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (480 mL / 30 days) QL (480 tabs / 30 days) QL (240 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (180 tabs / 30 days) QL (360 tabs / 30 days) QL (900 mL / 30 days) QL (120 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 caps / 30 days) QL (60 caps / 30 days) QL (60 caps / 30 days) QL (60 caps / 30 days) QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days) QL (180 per 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days) QL (30 caps / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
81
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
VIRACEPT TAB 250MG (nelfinavir mesylate)
Tier 2
VIRACEPT TAB 625MG (nelfinavir mesylate)
Tier 2
VIREAD TAB 150MG (tenofovir disoproxil fumarate)
Tier 2
VIREAD TAB 200MG (tenofovir disoproxil fumarate)
Tier 2
VIREAD TAB 250MG (tenofovir disoproxil fumarate)
Tier 2
zidovudine cap 100 mg
Tier 1
zidovudine syrup 10 mg/ml
Tier 1
zidovudine tab 300 mg
Tier 1
CMV AGENTS
FOSCAVIR INJ 24MG/ML (foscarnet sodium)
Tier 3
valganciclovir hcl for soln 50 mg/ml (base equiv)
Tier 4
valganciclovir hcl tab 450 mg (base equivalent) Tier 4
HEPATITIS AGENTS
adefovir dipivoxil tab 10 mg
Tier 3
BARACLUDE SOL (entecavir)
Tier 3
DAKLINZA TAB 30MG (daclatasvir dihydrochloride)
Tier 4
DAKLINZA TAB 60MG (daclatasvir dihydrochloride)
Tier 4
entecavir tab 0.5 mg
Tier 3
entecavir tab 1 mg
Tier 3
EPIVIR HBV SOL 5MG/ML (lamivudine (hbv))
Tier 3
lamivudine tab 100 mg (hbv)
Tier 1
LEDIP-SOFOSB TAB 90-400MG
Tier 4
PEGASYS INJ (peginterferon alfa-2a) PEGASYS INJ 180MCG/M (peginterferon alfa-2a) ribavirin cap 200 mg (Ribasphere) ribavirin tab 200 mg SOFOS/VELPAT TAB 400-100
Tier 4 Tier 4 Tier 1 Tier 1 Tier 4
SOVALDI TAB 400MG (sofosbuvir)
Tier 4
TECHNIVIE TAB (ombitasvir-paritaprevirritonavir) VOSEVI TAB (sofosbuvir-velpatasvirvoxilaprevir) ZEPATIER TAB 50-100MG (elbasvir-grazoprevir)
Tier 4 Tier 4 Tier 4
HERPES AGENTS acyclovir cap 200 mg
Tier 1
Requirements/Limits QL (300 tabs / 30 days) QL (120 tabs / 30 days) QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (180 caps / 30 days) QL (1800 mL / 30 days) QL (60 tabs / 30 days)
PA PA
PA
QL (30 tabs / 30 days) PA PA
PA
QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (1800 mL / 30 days) QL (90 tabs / 30 days) QL (28 tablets / 28 days), PA; Preferred PA PA
QL (28 tablets / 28 days), PA; Preferred QL (28 tablets / 28 days), PA QL (56 tablets / 28 days), PA QL (28 tablets / 28 days), PA QL (28 tablets / 28 days), PA
QL (150 caps / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
82
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg
INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base equiv) oseltamivir phosphate cap 45 mg (base equiv) oseltamivir phosphate cap 75 mg (base equiv) oseltamivir phosphate for susp 6 mg/ml (base equiv)
RELENZA MIS DISKHALE (zanamivir) rimantadine hydrochloride tab 100 mg XOFLUZA TAB 20MG (baloxavir marboxil) XOFLUZA TAB 40MG (baloxavir marboxil) BETA BLOCKERS
ALPHA-BETA BLOCKERS carvedilol tab 3.125 mg
carvedilol tab 6.25 mg
carvedilol tab 12.5 mg
carvedilol tab 25 mg
labetalol hcl tab 100 mg
labetalol hcl tab 200 mg
labetalol hcl tab 300 mg
BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg atenolol tab 25 mg
atenolol tab 50 mg
atenolol tab 100 mg
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1
Tier 2 Tier 1 Tier 2 Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1 Tier 1 Tier 1
Tier 1
Tier 1
Requirements/Limits QL (750 mL / 30 days) QL (150 tabs / 30 days) QL (150 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (240 tabs / 30 days) QL (240 tabs / 30 days)
QL (20 caps / year) QL (20 caps / year) QL (20 caps / year) AGE, QL (120 mL / year); AGE (Max 12 years) QL (2 inhalers / year) QL (60 tabs / 30 days) QL (2 tabs / 30 days) QL (2 tabs / 30 days)
QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL
MAIL MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
83
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name betaxolol hcl tab 10 mg
betaxolol hcl tab 20 mg
bisoprolol fumarate tab 5 mg
bisoprolol fumarate tab 10 mg
BYSTOLIC TAB 2.5MG (nebivolol hcl) BYSTOLIC TAB 5MG (nebivolol hcl) BYSTOLIC TAB 10MG (nebivolol hcl) BYSTOLIC TAB 20MG (nebivolol hcl) metoprolol succinate tab er 24hr 25 mg (tartrate equiv) metoprolol succinate tab er 24hr 50 mg (tartrate equiv) metoprolol succinate tab er 24hr 100 mg (tartrate equiv) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) metoprolol tartrate tab 25 mg
metoprolol tartrate tab 50 mg
metoprolol tartrate tab 100 mg
BETA BLOCKERS NON-SELECTIVE nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg pindolol tab 5 mg pindolol tab 10 mg propranolol hcl cap er 24hr 60 mg
propranolol hcl cap er 24hr 80 mg
propranolol hcl cap er 24hr 120 mg
propranolol hcl cap er 24hr 160 mg
propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg
Drug Tier Tier 1
Tier 1
Tier 1
Tier 1
Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits
QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL MAIL, PA MAIL, PA MAIL, PA
MAIL, PA QL (90 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
Tier 3
Tier 3
Tier 3
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
MAIL MAIL MAIL MAIL MAIL QL (90 caps / 30 days), MAIL QL (120 caps / 30 days), MAIL QL (90 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL MAIL MAIL MAIL MAIL MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
84
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
propranolol hcl tab 60 mg
Tier 1
propranolol hcl tab 80 mg
Tier 1
sotalol hcl (afib/afl) tab 80 mg
Tier 1
sotalol hcl (afib/afl) tab 120 mg
Tier 1
sotalol hcl (afib/afl) tab 160 mg
Tier 1
sotalol hcl tab 80 mg
Tier 1
sotalol hcl tab 120 mg
Tier 1
sotalol hcl tab 160 mg
Tier 1
sotalol hcl tab 240 mg
Tier 1
timolol maleate tab 5 mg
Tier 1
timolol maleate tab 10 mg
Tier 1
timolol maleate tab 20 mg
Tier 1
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
amlodipine besylate tab 2.5 mg (base equivalent)
Tier 1
amlodipine besylate tab 5 mg (base equivalent) Tier 1
amlodipine besylate tab 10 mg (base equivalent) diltiazem hcl cap er 12hr 120 mg
Tier 1 Tier 1
diltiazem hcl cap er 24hr 120 mg
Tier 1
diltiazem hcl cap er 24hr 180 mg
Tier 1
diltiazem hcl cap er 24hr 240 mg
Tier 1
diltiazem hcl coated beads cap er 24hr 120 mg
Tier 1
diltiazem hcl coated beads cap er 24hr 180 mg
Tier 1
diltiazem hcl coated beads cap er 24hr 240 mg
Tier 1
diltiazem hcl coated beads cap er 24hr 300 mg
Tier 1
diltiazem hcl extended release beads cap er 24hr 120 mg diltiazem hcl extended release beads cap er 24hr 180 mg diltiazem hcl extended release beads cap er 24hr 240 mg diltiazem hcl extended release beads cap er 24hr 300 mg
Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL
QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
85
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name diltiazem hcl extended release beads cap er 24hr 360 mg diltiazem hcl extended release beads cap er 24hr 420 mg diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg diltiazem hcl tab 120 mg felodipine tab er 24hr 2.5 mg felodipine tab er 24hr 5 mg felodipine tab er 24hr 10 mg isradipine cap 2.5 mg isradipine cap 5 mg nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg nifedipine cap 10 mg
nifedipine cap 20 mg
nifedipine tab er 24hr 30 mg nifedipine tab er 24hr 60 mg nifedipine tab er 24hr 90 mg nifedipine tab er 24hr osmotic release 30 mg nifedipine tab er 24hr osmotic release 60 mg nifedipine tab er 24hr osmotic release 90 mg nimodipine cap 30 mg nisoldipine tab er 24hr 8.5 mg
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
Requirements/Limits
QL (60 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (120 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (90 caps / 30 days), MAIL AGE, QL (120 caps / 30 days), MAIL; AGE (Max 64 years) AGE, QL (120 caps / 30 days), MAIL; AGE (Max 64 years) QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL MAIL
MAIL, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
86
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
nisoldipine tab er 24hr 17 mg nisoldipine tab er 24hr 20 mg nisoldipine tab er 24hr 25.5 mg nisoldipine tab er 24hr 30 mg nisoldipine tab er 24hr 34 mg nisoldipine tab er 24hr 40 mg verapamil hcl cap er 24hr 100 mg
Drug Tier
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
verapamil hcl cap er 24hr 120 mg
Tier 1
verapamil hcl cap er 24hr 180 mg
Tier 1
verapamil hcl cap er 24hr 240 mg
Tier 1
verapamil hcl cap er 24hr 300 mg
Tier 1
verapamil hcl cap er 24hr 360 mg
Tier 1
verapamil hcl tab 40 mg
Tier 1
verapamil hcl tab 80 mg
Tier 1
verapamil hcl tab 120 mg
Tier 1
verapamil hcl tab er 120 mg
Tier 1
verapamil hcl tab er 180 mg
Tier 1
verapamil hcl tab er 240 mg
Tier 1
CARDIOTONICS
CARDIAC GLYCOSIDES digoxin oral soln 0.05 mg/ml
Tier 1
digoxin tab 125 mcg (0.125 mg)
Tier 1
digoxin tab 250 mcg (0.25 mg)
Tier 1
LANOXIN TAB 0.25MG (digoxin)
Tier 2
LANOXIN TAB 0.125MG (digoxin)
Tier 2
CARDIOVASCULAR AGENTS - MISC.
CARDIOVASCULAR AGENTS MISC. - COMBINATIONS
ENTRESTO TAB 24-26MG (sacubitril-valsartan)
Tier 2
Requirements/Limits MAIL, PA MAIL, PA MAIL, PA MAIL, PA MAIL, PA MAIL, PA QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (90 tabs / 30 days), MAIL
AGE, MAIL; AGE (Max 12 years) QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL
MAIL, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
87
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
ENTRESTO TAB 49-51MG (sacubitril-valsartan)
Tier 2 MAIL, PA
ENTRESTO TAB 97-103MG (sacubitril-valsartan)
Tier 2 MAIL, PA
PERIPHERAL VASODILATORS
inositol niacinate cap 500 mg (Niacin Flush Free)
Tier 1 OTC, MAIL
PROSTAGLANDIN VASODILATORS
ORENITRAM TAB 0.25MG (treprostinil diolamine)
Tier 4 QL (90 tabs / 30 days), PA
ORENITRAM TAB 0.125MG (treprostinil diolamine)
Tier 4 QL (90 tabs / 30 days), PA
ORENITRAM TAB 1MG (treprostinil diolamine)
Tier 4 QL (90 tabs / 30 days), PA
ORENITRAM TAB 2.5MG (treprostinil diolamine)
Tier 4 QL (90 tabs / 30 days), PA
ORENITRAM TAB 5MG (treprostinil diolamine)
Tier 4 QL (90 tabs / 30 days), PA
REMODULIN INJ 1MG/ML (treprostinil)
Tier 4 PA
REMODULIN INJ 2.5MG/ML (treprostinil)
Tier 4 PA
REMODULIN INJ 5MG/ML (treprostinil)
Tier 4 PA
REMODULIN INJ 10MG/ML (treprostinil)
Tier 4 PA
treprostinil inj soln 20 mg/20ml (1 mg/ml)
Tier 4 PA
treprostinil inj soln 50 mg/20ml (2.5 mg/ml)
Tier 4 PA
treprostinil inj soln 100 mg/20ml (5 mg/ml)
Tier 4 PA
treprostinil inj soln 200 mg/20ml (10 mg/ml)
Tier 4 PA
VENTAVIS SOL 10MCG/ML (iloprost)
Tier 4 PA
VENTAVIS SOL 20MCG/ML (iloprost)
Tier 4 PA
PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS
ambrisentan tab 5 mg
Tier 4 QL (30 tabs / 30 days), PA
ambrisentan tab 10 mg
Tier 4 QL (30 tabs / 30 days), PA
bosentan tab 62.5 mg
Tier 4 QL (60 tabs / 30 days), PA
bosentan tab 125 mg
Tier 4 QL (60 tabs / 30 days), PA
LETAIRIS TAB 5MG (ambrisentan)
Tier 4 QL (30 tabs / 30 days), PA
LETAIRIS TAB 10MG (ambrisentan)
Tier 4 QL (30 tabs / 30 days), PA
OPSUMIT TAB 10MG (macitentan)
Tier 4 QL (30 tabs / 30 days), PA
TRACLEER TAB 32MG (bosentan)
Tier 4 QL (60 tabs / 30 days), PA
TRACLEER TAB 62.5MG (bosentan)
Tier 4 QL (60 tabs / 30 days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
88
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
TRACLEER TAB 125MG (bosentan)
Tier 4 QL (60 tabs / 30 days), PA
PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS
sildenafil citrate tab 20 mg tadalafil tab 20 mg (pah)
Tier 4 Tier 4
QL (90 tabs / 30 days), PA QL (60 tabs / 30 days), PA
PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST
UPTRAVI TAB 200/800 (selexipag) UPTRAVI TAB 200MCG (selexipag) UPTRAVI TAB 400MCG (selexipag) UPTRAVI TAB 600MCG (selexipag) UPTRAVI TAB 800MCG (selexipag)
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
QL (200 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (60 tabs / 30 days), PA
UPTRAVI TAB 1000MCG (selexipag) UPTRAVI TAB 1200MCG (selexipag) UPTRAVI TAB 1400MCG (selexipag) UPTRAVI TAB 1600MCG (selexipag)
Tier 4 Tier 4 Tier 4 Tier 4
QL (60 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (60 tabs / 30 days), PA
PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR
ADEMPAS TAB 0.5MG (riociguat) ADEMPAS TAB 1.5MG (riociguat) ADEMPAS TAB 1MG (riociguat) ADEMPAS TAB 2.5MG (riociguat) ADEMPAS TAB 2MG (riociguat)
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
QL (90 tabs / 30 days), PA QL (90 tabs / 30 days), PA QL (90 tabs / 30 days), PA QL (90 tabs / 30 days), PA QL (90 tabs / 30 days), PA
SINUS NODE INHIBITORS CORLANOR SOL 5MG/5ML (ivabradine hcl)
Tier 2 MAIL, PA
CORLANOR TAB 5MG (ivabradine hcl)
Tier 2 MAIL, PA
CORLANOR TAB 7.5MG (ivabradine hcl)
Tier 2 MAIL, PA
CEPHALOSPORINS
CEPHALOSPORINS - 1ST GENERATION
cefadroxil cap 500 mg
Tier 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
89
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name cefadroxil for susp 250 mg/5ml
Drug Tier Tier 1
cefadroxil for susp 500 mg/5ml
Tier 1
cefadroxil tab 1 gm cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5ml
Tier 1 Tier 1 Tier 1 Tier 1
cephalexin for susp 250 mg/5ml
Tier 1
CEPHALOSPORINS - 2ND GENERATION cefaclor cap 250 mg cefaclor cap 500 mg cefaclor for susp 125 mg/5ml
Tier 1 Tier 1 Tier 1
cefaclor for susp 250 mg/5ml
Tier 1
cefaclor for susp 375 mg/5ml
Tier 1
cefprozil for susp 125 mg/5ml
Tier 1
cefprozil for susp 250 mg/5ml
Tier 1
cefprozil tab 250 mg cefprozil tab 500 mg cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg
CEPHALOSPORINS - 3RD GENERATION cefdinir cap 300 mg cefdinir for susp 125 mg/5ml
Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1
cefdinir for susp 250 mg/5ml
Tier 1
cefditoren pivoxil tab 200 mg (base equivalent) cefditoren pivoxil tab 400 mg (base equivalent) cefixime cap 400 mg cefixime for susp 100 mg/5ml
Tier 1 Tier 1 Tier 3 Tier 3
cefixime for susp 200 mg/5ml
Tier 3
cefpodoxime proxetil for susp 50 mg/5ml
Tier 1
cefpodoxime proxetil for susp 100 mg/5ml
Tier 1
Requirements/Limits AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
QL (20 tabs / 10 days) QL (20 tabs / 10 days)
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) PA PA
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
90
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
cefpodoxime proxetil tab 100 mg
Tier 1
cefpodoxime proxetil tab 200 mg
Tier 1
ceftriaxone sodium for inj 1 gm
Tier 1
SUPRAX CAP 400MG (cefixime)
Tier 3
CONTRACEPTIVES
COMBINATION CONTRACEPTIVES - ORAL
BALCOLTRA TAB 0.1-20 (levonorgestrel-ethinyl estradiol-ferrous bisglycinate)
Tier 5
desogest-eth estrad & eth estrad tab 0.150.02/0.01 mg(21/5)
Tier 5
desogest-ethin est tab 0.1-0.025/0.1250.025/0.15-0.025mg-mg (Velivet)
Tier 5
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
Tier 5
drospirenone-ethinyl estrad-levomefolate tab 3- Tier 5 0.02-0.451 mg
drospirenone-ethinyl estrad-levomefolate tab 3- Tier 5 0.03-0.451 mg (Tydemy)
drospirenone-ethinyl estradiol tab 3-0.02 mg
Tier 5
drospirenone-ethinyl estradiol tab 3-0.03 mg
Tier 5
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg (Kelnor 1/50) FALESSA KIT (levonorgestrel-ethinyl estradiol & folic acid) levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg (Rivelsa) levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg30 mcg levonorgestrel-eth estra tab 0.05-30/0.07540/0.125-30mg-mcg levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg LO LOESTRIN TAB 1-10-10 (norethindrone acetate-ethinyl estradiol-fe fum (biphasic))
Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5
Requirements/Limits
QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (75 tablets / 28 days), MAIL QL (30 tablets / 28 days), MAIL QL (30 tablets / 28 days), MAIL QL (30 tablets / 28 days), MAIL QL (30 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (28 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
91
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name NATAZIA TAB (estradiol valerate-dienogest)
Drug Tier Tier 5
norethindrone & ethinyl estradiol tab 0.4 mg-35 Tier 5
mcg (Briellyn)
norethindrone & ethinyl estradiol tab 0.5 mg-35 Tier 5 mcg (Nortrel 0.5/35 (28))
norethindrone & ethinyl estradiol tab 1 mg-35
Tier 5
mcg (Nortrel 1/35)
norethindrone & ethinyl estradiol-fe chew tab
Tier 5
0.4 mg-35 mcg
norethindrone & ethinyl estradiol-fe chew tab
Tier 5
0.8 mg-25 mcg
norethindrone ac-ethinyl estrad-fe tab 1-20/130/1-35 mg-mcg (Tilia Fe)
Tier 5
norethindrone ace & ethinyl estradiol tab 1 mg- Tier 5
20 mcg
norethindrone ace & ethinyl estradiol tab 1.5
Tier 5
mg-30 mcg (Junel 1.5/30)
norethindrone ace & ethinyl estradiol-fe tab 1
Tier 5
mg-20 mcg
norethindrone ace & ethinyl estradiol-fe tab 1.5 Tier 5
mg-30 mcg (Junel Fe 1.5/30)
norethindrone ace-eth estradiol-fe chew tab 1
Tier 5
mg-20 mcg (24) (Melodetta 24 Fe)
norethindrone ace-ethinyl estradiol-fe tab 1
Tier 5
mg-20 mcg (24) (Larin 24 Fe)
norethindrone-eth estradiol tab 0.5-35/0.75-
Tier 5
35/1-35 mg-mcg (Nortrel 7/7/7)
norethindrone-eth estradiol tab 0.5-35/1-
Tier 5
35/0.5-35 mg-mcg (Leena)
norgestimate & ethinyl estradiol tab 0.25 mg-35 Tier 5
mcg
norgestimate-eth estrad tab 0.18-25/0.21525/0.25-25 mg-mcg
Tier 5
norgestimate-eth estrad tab 0.18-35/0.21535/0.25-35 mg-mcg
Tier 5
norgestrel & ethinyl estradiol tab 0.3 mg-30
Tier 5
mcg (Low-ogestrel)
norgestrel & ethinyl estradiol tab 0.5 mg-50
Tier 5
mcg (Ogestrel)
TAYTULLA CAP 1MG/20MC (norethin acet & estrad- Tier 5
fe)
COMBINATION CONTRACEPTIVES - TRANSDERMAL
norelgestromin-ethinyl estradiol td ptwk 150-35 Tier 5
mcg/24hr (Xulane)
Requirements/Limits
QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (28 tablets / 28 days), MAIL QL (28 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL QL (39 tablets / 28 days), MAIL
QL (4 patches / 28 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
92
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
COMBINATION CONTRACEPTIVES - VAGINAL
etonogestrel-ethinyl estradiol va ring 0.1200.015 mg/24hr
Tier 5
etonogestrel-ethinyl estradiol va ring 0.1200.015 mg/24hr (Eluryng)
Tier 5
NUVARING MIS (etonogestrel-ethinyl estradiol)
Tier 5
COPPER CONTRACEPTIVES - IUD PARAGARD IUD T380A (copper (iud))
EMERGENCY CONTRACEPTIVES ELLA TAB 30MG (ulipristal acetate) levonorgestrel tab 1.5 mg (My Way)
Tier 5
Tier 5 Tier 5
PROGESTIN CONTRACEPTIVES - IMPLANTS
NEXPLANON IMP 68MG (etonogestrel)
Tier 5
PROGESTIN CONTRACEPTIVES - INJECTABLE
DEPO-SQ PROV INJ 104 (medroxyprogesterone acetate (contraceptive))
Tier 5
medroxyprogesterone acetate im susp 150 mg/ml
Tier 5
medroxyprogesterone acetate im susp prefilled syr 150 mg/ml
Tier 5
PROGESTIN CONTRACEPTIVES - IUD
KYLEENA IUD 19.5MG (levonorgestrel (iud))
Tier 5
LILETTA IUD 52MG (levonorgestrel (iud))
Tier 5
MIRENA IUD SYSTEM (levonorgestrel (iud))
Tier 5
SKYLA IUD 13.5MG (levonorgestrel (iud))
Tier 5
PROGESTIN CONTRACEPTIVES - ORAL
norethindrone tab 0.35 mg
Tier 5
CORTICOSTEROIDS
GLUCOCORTICOSTEROIDS budesonide delayed release particles cap 3 mg cortisone acetate tab 25 mg dexamethasone elixir 0.5 mg/5ml dexamethasone sodium phosphate inj 10 mg/ml dexamethasone soln 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg
Tier 3 Tier 3 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
QL (1 ring / 28 days), MAIL QL (1 ring / 28 days), MAIL QL (1 ring / 28 days), MAIL
QL (1 IUD in lifetime)
QL (4 tabs / 90 days) OTC, QL (4 tabs / 90 days)
QL (1 implant in lifetime)
QL (1 injection / 90 days) QL (1 Injection / 75 days) QL (1 injection / 90 days)
QL (1 IUD in lifetime) QL (1 IUD in lifetime) QL (1 IUD in lifetime) QL (1 IUD in lifetime)
QL (39 tablets / 28 days), MAIL
PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
93
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
dexamethasone tab 4 mg
Tier 1
dexamethasone tab 6 mg
Tier 1
hydrocortisone tab 5 mg
Tier 1
hydrocortisone tab 10 mg
Tier 1
hydrocortisone tab 20 mg
Tier 1
methylprednisolone tab 4 mg
Tier 1
methylprednisolone tab 8 mg
Tier 1
methylprednisolone tab 16 mg
Tier 1
methylprednisolone tab 32 mg
Tier 1
methylprednisolone tab therapy pack 4 mg (21) Tier 1
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)
Tier 1
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)
Tier 1
prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)
Tier 1
prednisolone syrup 15 mg/5ml (usp solution equivalent)
Tier 1
prednisone oral soln 5 mg/5ml
Tier 1
prednisone tab 1 mg
Tier 1
prednisone tab 2.5 mg
Tier 1
prednisone tab 5 mg
Tier 1
prednisone tab 10 mg
Tier 1
prednisone tab 20 mg
Tier 1
prednisone tab 50 mg
Tier 1
prednisone tab therapy pack 5 mg (21)
Tier 1
prednisone tab therapy pack 5 mg (48)
Tier 1
prednisone tab therapy pack 10 mg (21)
Tier 1
prednisone tab therapy pack 10 mg (48)
Tier 1
MINERALOCORTICOIDS
fludrocortisone acetate tab 0.1 mg
Tier 1
COUGH/COLD/ALLERGY
ANTITUSSIVES
benzonatate cap 100 mg
Tier 1
benzonatate cap 200 mg
Tier 1
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml
Tier 1
ROBITUSSIN SYP 7.5/5ML (dextromethorphan hbr)
Tier 1
COUGH/COLD/ALLERGY COMBINATIONS
brompheniramine & pseudoephedrine elixir 115 mg/5ml (Wal-tap Cold & Allergy)
Tier 1
BROTAPP DM LIQ 15-1-5/5 (pseudoephedbromphen-dm)
Tier 1
Requirements/Limits
MAIL OTC OTC OTC, QL (240 mL / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
94
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
cetirizine-pseudoephedrine tab er 12hr 5-120
Tier 1
mg (All Day Allergy D)
dextromethorphan-guaifenesin liquid 10-100
Tier 1
mg/5ml (Diabetic Siltussin-dm)
dextromethorphan-guaifenesin liquid 10-200 mg/5ml (Diabetic Tussin Maximum S)
Tier 1
dextromethorphan-guaifenesin syrup 10-100
Tier 1
mg/5ml (Siltussin-dm)
dextromethorphan-guaifenesin tab er 12hr 30- Tier 1
600 mg (Mucus-dm)
diphenhydramine-phenylephrine liq 6.25-2.5
Tier 1
mg/5ml (Cvs Cold & Cough Nighttim)
diphenhydramine-phenylephrine tab 25-10 mg (Wal-dryl Pe Allergy/sinu)
Tier 1
guaifenesin-codeine soln 100-10 mg/5ml
Tier 1
(Guaiatussin Ac)
loratadine & pseudoephedrine tab er 12hr 5-120 Tier 1
mg (Loratadine-d 12hr)
loratadine & pseudoephedrine tab er 24hr 10-
Tier 1
240 mg (Loratadine-d 24hr)
promethazine & phenylephrine syrup 6.25-5
Tier 1
mg/5ml
promethazine w/ codeine syrup 6.25-10
Tier 1
mg/5ml
promethazine-dm syrup 6.25-15 mg/5ml
Tier 1
promethazine-phenylephrine-codeine syrup
Tier 1
6.25-5-10 mg/5ml
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml
Tier 1
pseudoephedrine-guaifenesin tab er 12hr 60-
Tier 1
600 mg (Ra Mucus Relief D)
EXPECTORANTS
guaifenesin liquid 100 mg/5ml
Tier 1
guaifenesin syrup 100 mg/5ml (Robafen)
Tier 1
guaifenesin tab 200 mg
Tier 1
guaifenesin tab 400 mg (Sm Chest Congestion Relie)
Tier 1
guaifenesin tab er 12hr 600 mg (Gnp Mucus Er)
Tier 1
MISC. RESPIRATORY INHALANTS sodium chloride soln nebu 0.9% sodium chloride soln nebu 3% (Nebusal) sodium chloride soln nebu 7%
MUCOLYTICS acetylcysteine inhal soln 10%
Tier 1 Tier 1 Tier 1
Tier 1
Requirements/Limits OTC, QL (60 ea / 30 days) OTC, QL (240 mL / 30 days) OTC, QL (240 mL / 30 days) OTC, QL (240 mL / 30 days) OTC
OTC, QL (240 mL / 30 days) OTC
OTC, QL (240 mL / 30 days) OTC, QL (60 ea / 30 days) OTC, QL (30 tabs / 30 days) QL (240 mL / 30 days)
QL (240 mL / 30 days)
QL (240 mL / 30 days) QL (240 mL / 30 days)
QL (240 mL / 30 days)
OTC
OTC OTC OTC OTC
OTC, QL (60 ea / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
95
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name acetylcysteine inhal soln 20% DERMATOLOGICALS
ACNE PRODUCTS ACNE MEDICAT LOT 5% (benzoyl peroxide) ACNE MEDICAT LOT 10% (benzoyl peroxide) adapalene lotion 0.1%
benzoyl peroxide gel 5% (Bp Gel) benzoyl peroxide gel 10% (Clean & Clear Persagel M) benzoyl peroxide liq 5% (Bp Wash)
benzoyl peroxide liq 10% (Benzoyl Peroxide Wash) benzoyl peroxide-erythromycin gel 5-3% clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% clindamycin phosphate gel 1% clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate-tretinoin gel 1.20.025% DIFFERIN GEL 0.1% (adapalene)
erythromycin soln 2% isotretinoin cap 10 mg (Claravis) isotretinoin cap 20 mg (Amnesteem) isotretinoin cap 30 mg isotretinoin cap 40 mg sulfacetamide sodium lotion 10% (acne) sulfacetamide sodium-sulfur in urea emulsion 10-4% (Bp Cleansing Wash) tretinoin cream 0.1%
Drug Tier Requirements/Limits Tier 1
Tier 1 Tier 1 Tier 1
Tier 1 Tier 1
OTC
OTC
AGE, QL (59 mL / 30 days), ST; AGE (Min 10 years, Max 35 years); Prior use of Differin OTC 0.1% gel within the past 90 days OTC
OTC
Tier 1
Tier 1
Tier 3 Tier 3
OTC, QL (240 gm / 30 days) OTC, QL (240 gm / 30 days) PA
PA
Tier 3 Tier 3 Tier 1 Tier 3
QL (60 gm / 30 days) QL (60 mL / 30 days) QL (60 mL / 30 days) PA
Tier 1
Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
OTC, QL (45 gm / 30 days) QL (60 mL / 30 days) PA PA PA PA
Tier 3
AGE, QL (45 gm / 30 days), ST; AGE (Max 35 years); Prior use of Differin OTC 0.1% gel within the past 90 days
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
96
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
tretinoin cream 0.05%
Tier 3
AGE, QL (45 gm / 30 days), ST; AGE (Max 35 years); Prior use of Differin OTC 0.1% gel within the past 90 days
tretinoin cream 0.025%
Tier 3
AGE, QL (45 gm / 30 days), ST; AGE (Max 35 years); Prior use of Differin OTC 0.1% gel within the past 90 days
tretinoin gel 0.01%
Tier 3
AGE, QL (45 gm / 30 days), ST; AGE (Max 35 years); Prior use of Differin OTC 0.1% gel within the past 90 days
tretinoin gel 0.025% (Avita)
Tier 3
AGE, QL (45 gm / 30 days), ST; AGE (Max 35 years); Prior use of Differin OTC 0.1% gel within the past 90 days
VELTIN GEL (clindamycin phosphate-tretinoin)
Tier 3 PA
AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS
VEREGEN OIN 15% (sinecatechins)
Tier 3 PA
ANTI-INFLAMMATORY AGENTS - TOPICAL
diclofenac sodium gel 1%
Tier 1 QL (200 gm / 30 days), PA
diclofenac sodium gel 1%
Tier 1 OTC, QL (200 gm / 30 days), PA
ANTIBIOTICS - TOPICAL
ALTABAX OIN 1% (retapamulin)
Tier 3 PA
bacitracin oint 500 unit/gm
Tier 1 OTC
bacitracin zinc oint 500 unit/gm
Tier 1 OTC
bacitracin-polymyxin b oint (Double Antibiotic)
Tier 1 OTC
CORTISPORIN OIN 1% (bacitracin-polymyxinneomycin hc)
Tier 3
gentamicin sulfate cream 0.1%
Tier 1
gentamicin sulfate oint 0.1%
Tier 1
mupirocin oint 2%
Tier 1 QL (44 gm / 30 days)
neomycin-bacitracin-polymyxin oint (Cvs Triple Antibiotic)
Tier 1 OTC
neomycin-bacitracin-polymyxin-pramoxine oint 1% (Triple Antibiotic Plus)
Tier 1 OTC
ANTIFUNGALS - TOPICAL
ciclopirox olamine cream 0.77% (base equiv)
Tier 1 QL (90 gm / 30 days)
ciclopirox olamine susp 0.77% (base equiv)
Tier 1 QL (60 mL / 25 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
97
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
ciclopirox solution 8%
Tier 1
clotrimazole cream 1%
Tier 1
clotrimazole soln 1%
Tier 1
clotrimazole w/ betamethasone cream 1-0.05% Tier 1
clotrimazole w/ betamethasone lotion 1-0.05% Tier 1
econazole nitrate cream 1%
Tier 3
ERTACZO CRE 2% (sertaconazole nitrate)
Tier 3
EXELDERM CRE 1% (sulconazole nitrate)
Tier 3
EXELDERM SOL 1% (sulconazole nitrate)
Tier 3
ketoconazole cream 2%
Tier 1
ketoconazole shampoo 2%
Tier 1
luliconazole cream 1%
Tier 3
MENTAX CRE 1% (butenafine hcl)
Tier 2
miconazole nitrate aerosol pow 2% (Lotrimin Af Deodorant Pow)
Tier 1
miconazole nitrate cream 2%
Tier 1
miconazole nitrate ointment 2% (Triple Paste Af) Tier 1
miconazole nitrate powder 2% (Cvs Anti-fungal
Tier 1
Powder)
naftifine hcl cream 1%
Tier 3
naftifine hcl gel 1%
Tier 3
NAFTIN GEL 1% (naftifine hcl)
Tier 3
NAFTIN GEL 2% (naftifine hcl)
Tier 3
nystatin cream 100000 unit/gm
Tier 1
nystatin oint 100000 unit/gm
Tier 1
nystatin topical powder 100000 unit/gm
Tier 1
(Nystop)
nystatin-triamcinolone cream 100000-0.1
Tier 3
unit/gm-%
nystatin-triamcinolone oint 100000-0.1 unit/gm-%
Tier 3
oxiconazole nitrate cream 1%
Tier 3
OXISTAT LOT 1% (oxiconazole nitrate) sulconazole nitrate cream 1% terbinafine hcl cream 1%
Tier 3 Tier 3 Tier 1
tolnaftate aerosol pow 1% (Cvs Af Spray Powder) tolnaftate cream 1% tolnaftate powder 1% (Anti-fungal Powder) tolnaftate soln 1% (Mycocide Clinical Ns Anti)
ANTIHISTAMINES-TOPICAL diphenhydramine-zinc acetate cream 2-0.1% (Sm Anti-itch Extra Streng)
Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
Requirements/Limits QL (6.6 mL / 25 days)
QL (45 gm / 30 days) QL (60 mL / 30 days) PA PA PA PA QL (60 gm / 30 days) QL (120 mL / 30 days) PA
OTC
OTC OTC OTC
PA PA PA PA QL (90 gm / 30 days) QL (90 gm / 30 days) QL (30 gm / 30 days)
QL (60 gm / 30 days)
QL (60 gm / 30 days)
QL (90 gm / 30 days), PA PA PA OTC, QL (30 gm / 30 days) OTC OTC OTC OTC
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
98
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL
fluorouracil cream 5%
Tier 3
PANRETIN GEL 0.1% (alitretinoin)
Tier 4 PA
PICATO GEL 0.05% (ingenol mebutate)
Tier 3 PA
PICATO GEL 0.015% (ingenol mebutate)
Tier 3 PA
TARGRETIN GEL 1% (bexarotene (topical))
Tier 4 PA
ANTIPSORIATICS
acitretin cap 10 mg
Tier 3 PA
acitretin cap 17.5 mg
Tier 3 PA
acitretin cap 25 mg
Tier 3 PA
calcipotriene oint 0.005%
Tier 3 PA
calcipotriene soln 0.005% (50 mcg/ml)
Tier 3 PA
calcitriol oint 3 mcg/gm
Tier 3 QL (100 gm / 30 days)
COSENTYX INJ 150MG/ML (secukinumab)
Tier 4 PA; Preferred Brand
COSENTYX INJ 300DOSE (secukinumab)
Tier 4 PA; Preferred Brand
COSENTYX PEN INJ 150MG/ML (secukinumab)
Tier 4 PA; Preferred Brand
COSENTYX PEN INJ 300DOSE (secukinumab)
Tier 4 PA; Preferred Brand
DRITHO-CREME CRE HP 1% (anthralin)
Tier 2 QL (50 gm / 30 days)
SKYRIZI INJ 150DOSE (risankizumab-rzaa)
Tier 4 PA; Preferred Brand
STELARA INJ 45MG/0.5 (ustekinumab)
Tier 4 PA; Preferred Brand
STELARA INJ 90MG/ML (ustekinumab)
Tier 4 PA; Preferred Brand
tazarotene cream 0.1%
Tier 3 QL (60 gm / 30 days), PA
TAZORAC CRE 0.05% (tazarotene)
Tier 3 QL (60 gm / 30 days), PA
TAZORAC GEL 0.1% (tazarotene)
Tier 3 QL (100 gm / 30 days), PA
TAZORAC GEL 0.05% (tazarotene)
Tier 3 QL (100 gm / 30 days), PA
ANTISEBORRHEIC PRODUCTS
selenium sulfide lotion 1% (Cvs Anti-dandruff)
Tier 1 OTC
selenium sulfide lotion 2.5%
Tier 1
ANTIVIRALS - TOPICAL
ABREVA CRE 10% (docosanol)
Tier 1 OTC, QL (2 gm / 30 days)
acyclovir oint 5%
Tier 3 PA
DENAVIR CRE 1% (penciclovir)
Tier 2 PA
docosanol cream 10%
Tier 1 OTC, QL (2 gm / 30 days)
BURN PRODUCTS
mafenide acetate packet for topical soln 5% (50 Tier 1 gm)
silver sulfadiazine cream 1%
Tier 1 QL (400 gm / 30 days)
SULFAMYLON CRE 85MG/GM (mafenide acetate)
Tier 3 QL (454 gm / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
99
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
CORTICOSTEROIDS - TOPICAL
alclometasone dipropionate cream 0.05%
Tier 1
alclometasone dipropionate oint 0.05%
Tier 1
amcinonide cream 0.1%
Tier 3
amcinonide lotion 0.1%
Tier 3
AMCINONIDE OIN 0.1%
Tier 3
APEXICON E CRE 0.05% (diflorasone diacetate emollient base)
Tier 3
betamethasone dipropionate augmented cream 0.05%
Tier 1
betamethasone dipropionate augmented gel 0.05%
Tier 1
betamethasone dipropionate augmented lotion 0.05%
Tier 1
betamethasone dipropionate augmented oint 0.05%
Tier 1
betamethasone dipropionate cream 0.05%
Tier 1
betamethasone dipropionate lotion 0.05%
Tier 1
betamethasone dipropionate oint 0.05%
Tier 1
betamethasone valerate cream 0.1% (base equivalent)
Tier 1
betamethasone valerate oint 0.1% (base equivalent)
Tier 1
calcipotriene-betamethasone dipropionate oint 0.005-0.064%
Tier 3
calcipotriene-betamethasone dipropionate susp 0.005-0.064%
Tier 3
clobetasol propionate cream 0.05%
Tier 3
clobetasol propionate gel 0.05%
Tier 3
clobetasol propionate oint 0.05%
Tier 3
clobetasol propionate soln 0.05%
Tier 3
CORDRAN 80X3 TAP 4MCG/CM (flurandrenolide)
Tier 3
desonide cream 0.05%
Tier 1
desonide oint 0.05%
Tier 1
desoximetasone cream 0.05%
Tier 3
desoximetasone cream 0.25%
Tier 3
desoximetasone gel 0.05%
Tier 3
desoximetasone oint 0.05%
Tier 3
desoximetasone oint 0.25%
Tier 3
diflorasone diacetate cream 0.05%
Tier 3
diflorasone diacetate oint 0.05%
Tier 3
fluocinolone acetonide cream 0.025%
Tier 1
fluocinolone acetonide oil 0.01% (body oil)
Tier 3
fluocinolone acetonide oil 0.01% (scalp oil)
Tier 3
fluocinolone acetonide oint 0.025%
Tier 1
Requirements/Limits
QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 mL / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days), PA QL (50 gm / 30 days)
QL (50 gm / 30 days)
QL (60 mL / 30 days)
QL (50 gm / 30 days)
QL (60 gm / 30 days) QL (60 mL / 30 days) QL (45 gm / 30 days) QL (454 gm / 30 days)
QL (45 gm / 30 days)
QL (100 gm / 30 days), PA QL (120 gm / 30 days), PA QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (50 mL / 30 days) PA QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (120 mL / 30 days) QL (120 mL / 30 days) QL (60 gm / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
100
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
fluocinonide cream 0.05% fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% flurandrenolide cream 0.05% flurandrenolide lotion 0.05% fluticasone propionate cream 0.05% fluticasone propionate oint 0.005% halcinonide cream 0.1%
Drug Tier
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3
halobetasol propionate cream 0.05% halobetasol propionate oint 0.05% HALOG CRE 0.1% (halcinonide)
Tier 3 Tier 3 Tier 3
HALOG OIN 0.1% (halcinonide)
Tier 3
hydrocortisone acetate cream 1% (Lanacort 10)
Tier 1
hydrocortisone cream 0.5%
Tier 1
hydrocortisone cream 1% (Ra Hydrocortisone Plus 12) hydrocortisone cream 2.5% hydrocortisone gel 1% (Cortizone-10)
Tier 1
Tier 1 Tier 1
hydrocortisone lotion 1% (Cvs Cortisone Maximum Str) hydrocortisone lotion 2.5% hydrocortisone oint 0.5%
Tier 1
Tier 1 Tier 1
hydrocortisone oint 1% (Hydrocortisone 1% In Abso) hydrocortisone oint 2.5% hydrocortisone valerate cream 0.2% hydrocortisone-aloe vera cream 0.5%
Tier 1
Tier 1 Tier 1 Tier 1
hydrocortisone-aloe vera cream 1% (Cortizone10 Plus) mometasone furoate cream 0.1% mometasone furoate oint 0.1% mometasone furoate solution 0.1% (lotion) prednicarbate cream 0.1% prednicarbate oint 0.1%
Tier 1
Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
Requirements/Limits
QL (150 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 mL / 30 days) QL (30 gm / 30 days) QL (120 mL / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days), PA QL (50 gm / 30 days) QL (50 gm / 30 days) QL (60 gm / 30 days), PA QL (60 gm / 30 days), PA OTC, QL (60 gm / 30 days) OTC, QL (60 gm / 30 days) OTC, QL (60 gm / 30 days) QL (60 gm / 30 days) OTC, QL (56 gm / 30 days) OTC, QL (120 gm / 30 days) QL (60 mL / 30 days) OTC, QL (60 gm / 30 days) QL (60 gm / 30 days)
QL (60 gm / 30 days) QL (60 gm / 30 days) OTC, QL (60 gm / 30 days) OTC
QL (60 gm / 30 days) QL (60 gm / 30 days) QL (60 mL / 30 days) QL (60 gm / 30 days) QL (60 gm / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
101
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
TACLONEX SUS (calcipotriene-betamethasone dipropionate) triamcinolone acetonide cream 0.1% triamcinolone acetonide cream 0.5% triamcinolone acetonide cream 0.025% triamcinolone acetonide lotion 0.1% triamcinolone acetonide lotion 0.025% triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5% triamcinolone acetonide oint 0.025%
ECZEMA AGENTS DUPIXENT INJ 300/2ML (dupilumab)
EMOLLIENTS emollient - ointment (Hydrophor) lactic acid (ammonium lactate) cream 12%
Drug Tier Tier 3
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 4
Tier 1 Tier 1
lactic acid (ammonium lactate) lotion 12% (Amlactin)
ENZYMES - TOPICAL SANTYL OIN 250/GM (collagenase)
Tier 1 Tier 3
IMMUNOMODULATING AGENTS - TOPICAL imiquimod cream 5%
IMMUNOSUPPRESSIVE AGENTS - TOPICAL tacrolimus oint 0.1%
Tier 1 Tier 3
tacrolimus oint 0.03%
Tier 3
KERATOLYTIC/ANTIMITOTIC AGENTS podofilox soln 0.5%
LOCAL ANESTHETICS - TOPICAL capsaicin cream 0.1% lidocaine cream 4%
Tier 1
Tier 1 Tier 1
lidocaine hcl gel 2% (Regenecare Ha) lidocaine hcl soln 4% lidocaine hcl urethral/mucosal gel 2% lidocaine hcl urethral/mucosal gel prefilled syringe 2% lidocaine patch 4% (Gnp Lidocaine Pain Relief)
Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
lidocaine patch 5% lidocaine-prilocaine cream 2.5-2.5% SYNERA DIS 70-70MG (lidocaine-tetracaine)
Tier 3 Tier 1 Tier 3
Requirements/Limits QL (120 gm / 30 days), PA QL (454 gm / 30 days) QL (15 gm / 30 days) QL (454 gm / 30 days) QL (60 mL / 30 days) QL (60 mL / 30 days) QL (454 gm / 30 days) QL (15 gm / 30 days) QL (454 gm / 30 days)
PA
OTC OTC, QL (280 gm / 30 days) OTC, QL (225 gm / 30 days)
QL (30 gm / 30 days), PA
QL (24 ea / 30 days), PA
QL (30 gm / 30 days), PA QL (30 gm / 30 days), PA
QL (7 mL / 180 days)
OTC OTC, QL (90 gm / 30 days) OTC
OTC, QL (90 patches / 30 days) QL (90 ea / 30 days), PA QL (60 gm / 30 days) PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
102
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
MISC. TOPICAL DRYSOL SOL 20% (aluminum chloride) menthol-zinc oxide oint 0.44-20% (Zinc-oxyde Plus) skin protectants misc - cream (Dermacerin)
ROSACEA AGENTS metronidazole cream 0.75% metronidazole gel 0.75% metronidazole lotion 0.75% MIRVASO GEL 0.33% (brimonidine tartrate (topical))
SCABICIDES & PEDICULICIDES EURAX CRE 10% (crotamiton)
Drug Tier
Tier 1 Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 3
Tier 2
lindane shampoo 1%
malathion lotion 0.5% permethrin aerosol 0.5% (Sm Bedding Lice Treatment) permethrin cream 5% permethrin creme rinse 1% (Lice Treatment) permethrin lotion 1% (Sm Lice Treatment)
pyreth-piperonyl butox sham-permeth aero-nit remover gel kit (Stop Lice Complete Lice T) pyrethrins-piperonyl butoxide liq 0.3-3% (Sb Lice Treatment) pyrethrins-piperonyl butoxide liq 0.33-4% (Stop Lice Maximum Strengt) pyrethrins-piperonyl butoxide shampoo 0.334% (Lice Killing Maximum Stre) RA LICE KIT SOLUTION (permethrin & pyrethrinspiperonyl butoxide) SKLICE LOT 0.5% (ivermectin (pediculicide))
Tier 1 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
spinosad susp 0.9%
WOUND CARE PRODUCTS REGRANEX GEL 0.01% (becaplermin)
Tier 3 Tier 3
DIAGNOSTIC PRODUCTS
DIAGNOSTIC DRUGS THYROGEN INJ 1.1MG (thyrotropin alfa)
DIAGNOSTIC TESTS RELION KETON TES (acetone (urine) test)
Tier 4 Tier 2
Requirements/Limits
QL (60 mL / 30 days) OTC
OTC
QL (45 gm / 30 days) QL (45 gm / 30 days) QL (59 mL / 30 days) PA
QL (60 gm / 30 days), ST; Prior use of permethrin 5% cream within the past 90 days. QL (60 mL / 30 days) QL (59 mL / 30 days) OTC
QL (120 gm / 30 days) OTC OTC OTC
OTC
OTC
OTC
OTC
QL (117 gm / 30 days), PA QL (120 per 30 days)
QL (15 gm / 30 days), PA
PA
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
103
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name TRUE METRIX TES GLUCOSE (glucose blood)
DIGESTIVE AIDS DIGESTIVE ENZYMES
CREON CAP 3000UNIT (pancrelipase (lipaseprotease-amylase)) CREON CAP 6000UNIT (pancrelipase (lipaseprotease-amylase)) CREON CAP 12000UNT (pancrelipase (lipaseprotease-amylase)) CREON CAP 24000UNT (pancrelipase (lipaseprotease-amylase)) CREON CAP 36000UNT (pancrelipase (lipaseprotease-amylase)) ZENPEP CAP 3000UNIT (pancrelipase (lipaseprotease-amylase)) ZENPEP CAP 5000UNIT (pancrelipase (lipaseprotease-amylase)) ZENPEP CAP 10000UNT (pancrelipase (lipaseprotease-amylase)) ZENPEP CAP 15000UNT (pancrelipase (lipaseprotease-amylase)) ZENPEP CAP 20000UNT (pancrelipase (lipaseprotease-amylase)) ZENPEP CAP 25000 (pancrelipase (lipaseprotease-amylase)) ZENPEP CAP 40000 (pancrelipase (lipaseprotease-amylase)) DIURETICS
CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg
acetazolamide tab 125 mg
acetazolamide tab 250 mg
methazolamide tab 25 mg
methazolamide tab 50 mg
DIURETIC COMBINATIONS ALDACTAZIDE TAB 50/50 (spironolactone & hydrochlorothiazide)
Drug Tier Tier 2
Requirements/Limits
OTC, QL (200 strips / 30 days), ST; 100/month max quantity for noninsulin users
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL QL (180 caps / 30 days), MAIL
Tier 3 Tier 1 Tier 1 Tier 3 Tier 3
QL (120 caps / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL QL (180 tabs / 30 days), MAIL
Tier 2 MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
104
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
amiloride & hydrochlorothiazide tab 5-50 mg
Tier 1
spironolactone & hydrochlorothiazide tab 25-25 Tier 1
mg
triamterene & hydrochlorothiazide cap 37.5-25 Tier 1
mg
triamterene & hydrochlorothiazide tab 37.5-25
Tier 1
mg
triamterene & hydrochlorothiazide tab 75-50 mg
Tier 1
LOOP DIURETICS
bumetanide tab 0.5 mg
Tier 1
bumetanide tab 1 mg
Tier 1
bumetanide tab 2 mg
Tier 1
ethacrynic acid tab 25 mg
Tier 3
furosemide oral soln 8 mg/ml
Tier 1
furosemide oral soln 10 mg/ml
Tier 1
furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg torsemide tab 5 mg torsemide tab 10 mg torsemide tab 20 mg torsemide tab 100 mg
POTASSIUM SPARING DIURETICS amiloride hcl tab 5 mg DYRENIUM CAP 50MG (triamterene) DYRENIUM CAP 100MG (triamterene) spironolactone tab 25 mg spironolactone tab 50 mg spironolactone tab 100 mg triamterene cap 50 mg triamterene cap 100 mg
THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorothiazide tab 250 mg chlorothiazide tab 500 mg chlorthalidone tab 25 mg chlorthalidone tab 50 mg hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits MAIL MAIL
MAIL
MAIL
MAIL
MAIL MAIL MAIL MAIL AGE, MAIL; AGE (Max 12 years) AGE, MAIL; AGE (Max 12 years) MAIL MAIL MAIL MAIL MAIL MAIL MAIL
MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL
MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
105
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
indapamide tab 2.5 mg
Tier 1
methyclothiazide tab 5 mg
Tier 1
metolazone tab 2.5 mg
Tier 1
metolazone tab 5 mg
Tier 1
metolazone tab 10 mg
Tier 1
ENDOCRINE AND METABOLIC AGENTS - MISC.
BONE DENSITY REGULATORS
alendronate sodium tab 5 mg
Tier 1
alendronate sodium tab 10 mg
Tier 1
alendronate sodium tab 35 mg
Tier 1
alendronate sodium tab 40 mg
Tier 1
alendronate sodium tab 70 mg
Tier 1
calcitonin (salmon) nasal soln 200 unit/act
Tier 1
etidronate disodium tab 200 mg etidronate disodium tab 400 mg FORTEO SOL 600/2.4 (teriparatide (recombinant)) ibandronate sodium tab 150 mg (base equivalent) PROLIA SOL 60MG/ML (denosumab) risedronate sodium tab 5 mg
Tier 1 Tier 1 Tier 4
Tier 1
Tier 4 Tier 3
risedronate sodium tab 30 mg
Tier 3
risedronate sodium tab 35 mg
Tier 3
risedronate sodium tab 150 mg
Tier 3
TYMLOS INJ (abaloparatide)
Tier 4
XGEVA INJ (denosumab)
Tier 4
zoledronic acid iv soln 5 mg/100ml
Tier 4
FERTILITY REGULATORS
CHOR GONADOT INJ 10000UNT
Tier 4
GNRH/LHRH ANTAGONISTS
CETROTIDE KIT 0.25MG (cetrorelix acetate)
Tier 4
ganirelix acetate soln prefilled syringe 250 mcg/0.5ml
Tier 4
GROWTH HORMONE RECEPTOR ANTAGONISTS
SOMAVERT INJ 10MG (pegvisomant)
Tier 4
Requirements/Limits MAIL MAIL MAIL MAIL MAIL
QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (4 tablets / 28 days), MAIL QL (30 tabs / 30 days), MAIL QL (4 tablets / 28 days), MAIL QL (30 mL / 30 days), MAIL MAIL MAIL MAIL, PA
QL (1 tablet / 28 days), MAIL PA QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (4 tablets / 28 days), MAIL QL (1 tablet / 28 days), MAIL PA PA PA
PA
PA PA
PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
106
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
SOMAVERT INJ 15MG (pegvisomant)
Tier 4 PA
SOMAVERT INJ 20MG (pegvisomant)
Tier 4 PA
GROWTH HORMONES
OMNITROPE INJ 5.8MG (somatropin)
Tier 4 PA
OMNITROPE INJ 5/1.5ML (somatropin)
Tier 4 PA
OMNITROPE INJ 10/1.5ML (somatropin)
Tier 4 PA
HORMONE RECEPTOR MODULATORS
raloxifene hcl tab 60 mg
Tier 5
QL (30 tabs / 30 days), MAIL; Tier 5 for ages 35 and over, otherwise Tier 1
INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)
INCRELEX INJ 40MG/4ML (mecasermin)
Tier 4 PA
LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS
LUPANETA KIT 3.75-5 (leuprolide acetate & norethindrone acetate)
Tier 4 PA
LUPANETA KIT 11.25-5 (leuprolide acetate & norethindrone acetate)
Tier 4 PA
LUPR DEP-PED INJ 3M 30MG (leuprolide acetate (cpp) (3 month))
Tier 4 PA
LUPR DEP-PED INJ 7.5MG (leuprolide acetate (cpp))
Tier 4 PA
LUPR DEP-PED INJ 11.25MG (leuprolide acetate (cpp))
Tier 4 PA
LUPR DEP-PED INJ 11.25MG (leuprolide acetate (cpp) (3 month))
Tier 4 PA
LUPR DEP-PED INJ 15MG (leuprolide acetate (cpp))
Tier 4 PA
SYNAREL SOL 2MG/ML (nafarelin acetate)
Tier 4 PA
METABOLIC MODIFIERS
calcitriol cap 0.5 mcg
Tier 1 MAIL
calcitriol cap 0.25 mcg
Tier 1 MAIL
cinacalcet hcl tab 30 mg (base equiv)
Tier 4 PA
cinacalcet hcl tab 60 mg (base equiv)
Tier 4 PA
cinacalcet hcl tab 90 mg (base equiv)
Tier 4 PA
CYSTADANE POW (betaine)
Tier 3 MAIL, PA
doxercalciferol cap 0.5 mcg
Tier 3 MAIL, PA
doxercalciferol cap 1 mcg
Tier 3 MAIL, PA
doxercalciferol cap 2.5 mcg
Tier 3 MAIL, PA
ELAPRASE INJ 6MG/3ML (idursulfase)
Tier 4 PA
FABRAZYME INJ 5MG (agalsidase beta)
Tier 4 PA
KUVAN TAB 100MG (sapropterin dihydrochloride) Tier 4 PA
levocarnitine oral soln 1 gm/10ml (10%)
Tier 1 MAIL
levocarnitine tab 330 mg
Tier 1 MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
107
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
nitisinone cap 2 mg nitisinone cap 5 mg nitisinone cap 10 mg ORFADIN CAP 2MG (nitisinone) ORFADIN CAP 5MG (nitisinone) ORFADIN CAP 10MG (nitisinone) ORFADIN CAP 20MG (nitisinone) paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg SENSIPAR TAB 30MG (cinacalcet hcl) SENSIPAR TAB 60MG (cinacalcet hcl) SENSIPAR TAB 90MG (cinacalcet hcl) sodium phenylbutyrate tab 500 mg
POSTERIOR PITUITARY HORMONES desmopressin acetate nasal spray soln 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg
Drug Tier Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4
Tier 3 Tier 3
Tier 1
desmopressin acetate tab 0.2 mg
Tier 1
STIMATE SOL 1.5MG/ML (desmopressin acetate)
PROLACTIN INHIBITORS cabergoline tab 0.5 mg
SOMATOSTATIC AGENTS octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) octreotide acetate inj 1000 mcg/ml (1 mg/ml) SANDOSTATIN KIT LAR 10MG (octreotide acetate) SANDOSTATIN KIT LAR 20MG (octreotide acetate) SANDOSTATIN KIT LAR 30MG (octreotide acetate)
VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG (tolvaptan) SAMSCA TAB 30MG (tolvaptan) tolvaptan tab 30 mg
ESTROGENS
ESTROGEN COMBINATIONS DUAVEE TAB 0.45-20 (conjugated estrogensbazedoxifene)
Tier 4
Tier 1
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
Tier 4 Tier 4 Tier 4
Tier 3
Requirements/Limits PA PA PA PA PA PA PA MAIL, PA MAIL, PA MAIL, PA PA PA PA PA
MAIL, PA MAIL, PA
QL (120 tabs / 30 days), MAIL QL (150 tabs / 30 days), MAIL PA
MAIL
PA PA PA PA PA PA PA PA
PA PA PA
QL (30 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
108
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
estradiol & norethindrone acetate tab 0.5-0.1 mg
Tier 1
estradiol & norethindrone acetate tab 1-0.5 mg (Lopreeza)
Tier 1
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg
Tier 1
norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg (Jinteli)
Tier 1
PREMPHASE TAB (conjugated estrogensmedroxyprogesterone acetate)
Tier 2
PREMPRO TAB (conjugated estrogensmedroxyprogesterone acetate)
Tier 2
PREMPRO TAB 0.3-1.5 (conjugated estrogensmedroxyprogesterone acetate)
Tier 2
PREMPRO TAB 0.45-1.5 (conjugated estrogensmedroxyprogesterone acetate)
Tier 2
PREMPRO TAB 0.625-5 (conjugated estrogensmedroxyprogesterone acetate)
Tier 2
ESTROGENS
estradiol tab 0.5 mg
Tier 1
estradiol tab 1 mg
Tier 1
estradiol tab 2 mg
Tier 1
estropipate tab 0.75 mg
Tier 1
estropipate tab 1.5 mg
Tier 1
estropipate tab 3 mg
Tier 1
MENEST TAB 0.3MG (esterified estrogens)
Tier 2
MENEST TAB 0.625MG (esterified estrogens)
Tier 2
MENEST TAB 1.25MG (esterified estrogens)
Tier 2
PREMARIN TAB 0.3MG (estrogens, conjugated)
Tier 2
PREMARIN TAB 0.9MG (estrogens, conjugated)
Tier 2
PREMARIN TAB 0.45MG (estrogens, conjugated)
Tier 2
PREMARIN TAB 0.625MG (estrogens, conjugated) Tier 2
Requirements/Limits
QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL
QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
109
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
PREMARIN TAB 1.25MG (estrogens, conjugated)
Tier 2 QL (30 tabs / 30 days), MAIL
FLUOROQUINOLONES
FLUOROQUINOLONES
BAXDELA TAB 450MG (delafloxacin meglumine)
Tier 3 PA
ciprofloxacin hcl tab 250 mg (base equiv)
Tier 1
ciprofloxacin hcl tab 500 mg (base equiv)
Tier 1
ciprofloxacin hcl tab 750 mg (base equiv)
Tier 1
levofloxacin oral soln 25 mg/ml
Tier 1 AGE; AGE (Max 12 years)
levofloxacin tab 250 mg
Tier 1
levofloxacin tab 500 mg
Tier 1
levofloxacin tab 750 mg
Tier 1
moxifloxacin hcl tab 400 mg (base equiv)
Tier 3
ofloxacin tab 300 mg
Tier 3
ofloxacin tab 400 mg
Tier 3
GASTROINTESTINAL AGENTS - MISC.
ANTIFLATULENTS
simethicone cap 125 mg (Cvs Gas Relief)
Tier 1 OTC
simethicone cap 180 mg
Tier 1 OTC
simethicone chew tab 80 mg
Tier 1 OTC
simethicone chew tab 125 mg (Cvs Gas Relief Extra Stre)
Tier 1 OTC
simethicone liquid 40 mg/0.6ml (Cvs Gas Relief Drops Extr)
Tier 1 OTC
simethicone susp 40 mg/0.6ml (Gas Relief)
Tier 1 OTC
GALLSTONE SOLUBILIZING AGENTS
ursodiol cap 300 mg
Tier 1 QL (60 caps / 30 days), MAIL
ursodiol tab 250 mg
Tier 1 QL (120 tabs / 30 days), MAIL
ursodiol tab 500 mg
Tier 1 QL (60 tabs / 30 days), MAIL
GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS
AMITIZA CAP 8MCG (lubiprostone)
Tier 3 MAIL, PA
AMITIZA CAP 24MCG (lubiprostone)
Tier 3 MAIL, PA
GASTROINTESTINAL STIMULANTS
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv)
Tier 1
metoclopramide hcl tab 5 mg (base equivalent) Tier 1 QL (180 tabs / 30 days)
metoclopramide hcl tab 10 mg (base equivalent)
Tier 1 QL (180 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
110
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name INFLAMMATORY BOWEL AGENTS
APRISO CAP 0.375GM (mesalamine)
balsalazide disodium cap 750 mg
CIMZIA KIT (certolizumab pegol)
Drug Tier Tier 2 Tier 1 Tier 4
CIMZIA KIT STARTER (certolizumab pegol)
Tier 4
CIMZIA PREFL KIT 200MG/ML (certolizumab pegol) Tier 4
DIPENTUM CAP 250MG (olsalazine sodium) INFLECTRA INJ 100MG (infliximab-dyyb) mesalamine cap er 24hr 0.375 gm
Tier 3 Tier 4 Tier 1
mesalamine enema 4 gm mesalamine tab delayed release 800 mg REMICADE INJ 100MG (infliximab) RENFLEXIS INJ 100MG (infliximab-abda) STELARA INJ 5MG/ML (ustekinumab (iv)) sulfasalazine tab 500 mg
Tier 1 Tier 3 Tier 4 Tier 4 Tier 4 Tier 1
sulfasalazine tab delayed release 500 mg
Tier 1
INTESTINAL ACIDIFIERS
lactulose (encephalopathy) solution 10 gm/15ml
Tier 1
IRRITABLE BOWEL SYNDROME (IBS) AGENTS
alosetron hcl tab 0.5 mg (base equiv)
Tier 3
alosetron hcl tab 1 mg (base equiv)
Tier 3
LINZESS CAP 72MCG (linaclotide)
Tier 3
LINZESS CAP 145MCG (linaclotide)
Tier 3
LINZESS CAP 290MCG (linaclotide)
Tier 3
PERIPHERAL OPIOID RECEPTOR ANTAGONISTS
MOVANTIK TAB 12.5MG (naloxegol oxalate)
Tier 3
MOVANTIK TAB 25MG (naloxegol oxalate)
Tier 3
RELISTOR INJ 12/0.6ML (methylnaltrexone bromide)
Tier 4
Requirements/Limits
QL (120 caps / 30 days), MAIL QL (270 caps / 30 days), MAIL PA; Medical Necessity PA; Prior use of appropriate Preferred Brands PA; Medical Necessity PA; Prior use of appropriate Preferred Brands PA; Medical Necessity PA; Prior use of appropriate Preferred Brands MAIL PA QL (120 caps / 30 days), MAIL MAIL MAIL PA PA PA; Preferred Brand QL (240 tabs / 30 days), MAIL QL (240 tabs / 30 days), MAIL
MAIL
MAIL, PA MAIL, PA MAIL, PA MAIL, PA MAIL, PA
PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
111
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
RELISTOR TAB 150MG (methylnaltrexone bromide)
Tier 4
SYMPROIC TAB 0.2MG (naldemedine tosylate)
Tier 3
PHOSPHATE BINDER AGENTS
calcium acetate (phosphate binder) cap 667 mg (169 mg ca)
Tier 1
lanthanum carbonate chew tab 500 mg (elemental)
Tier 3
lanthanum carbonate chew tab 750 mg (elemental)
Tier 3
lanthanum carbonate chew tab 1000 mg (elemental)
Tier 3
sevelamer carbonate packet 0.8 gm
Tier 3
sevelamer carbonate packet 2.4 gm
Tier 3
sevelamer carbonate tab 800 mg
Tier 3
VELPHORO CHW 500MG (sucroferric oxyhydroxide)
GENITOURINARY AGENTS - MISCELLANEOUS
ALKALINIZERS potassium citrate & citric acid soln 1100-334 mg/5ml potassium citrate tab er 5 meq (540 mg) potassium citrate tab er 10 meq (1080 mg) potassium citrate tab er 15 meq (1620 mg) sodium citrate & citric acid soln 500-334 mg/5ml
CYSTINOSIS AGENTS CYSTAGON CAP 50MG (cysteamine bitartrate) CYSTAGON CAP 150MG (cysteamine bitartrate)
GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% sodium chloride irrigation soln 0.9%
INTERSTITIAL CYSTITIS AGENTS ELMIRON CAP 100MG (pentosan polysulfate sodium)
Tier 3
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 4 Tier 4
Tier 1 Tier 1
Tier 3
Requirements/Limits PA
PA
QL (360 caps / 30 days), MAIL MAIL, ST; Prior use of calcium acetate within the past 90 days. MAIL, ST; Prior use of calcium acetate within the past 90 days. MAIL, ST; Prior use of calcium acetate within the past 90 days. MAIL, ST; Prior use of calcium acetate within the past 90 days. MAIL, ST; Prior use of calcium acetate within the past 90 days. MAIL, ST; Prior use of calcium acetate within the past 90 days. MAIL, PA
QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days)
PA PA
PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
1172
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl tab er 24hr 10 mg
Drug Tier Tier 1
dutasteride cap 0.5 mg
Tier 1
finasteride tab 5 mg
Tier 1
silodosin cap 4 mg
Tier 3
silodosin cap 8 mg
Tier 3
tamsulosin hcl cap 0.4 mg
Tier 1
URINARY ANALGESICS phenazopyridine hcl tab 100 mg phenazopyridine hcl tab 200 mg
GOUT AGENTS
GOUT AGENT COMBINATIONS colchicine w/ probenecid tab 0.5-500 mg
Tier 1 Tier 1
Tier 1
GOUT AGENTS allopurinol tab 100 mg allopurinol tab 300 mg colchicine tab 0.6 mg febuxostat tab 40 mg
Tier 1 Tier 1 Tier 1 Tier 3
febuxostat tab 80 mg
Tier 3
ULORIC TAB 40MG (febuxostat)
Tier 3
ULORIC TAB 80MG (febuxostat)
Tier 3
URICOSURICS probenecid tab 500 mg
Tier 1
HEMATOLOGICAL AGENTS - MISC.
ANTIHEMOPHILIC PRODUCTS ADVATE INJ 250UNIT (antihemophilic factor rahfpfm) ADVATE INJ 500UNIT (antihemophilic factor rahfpfm) ADVATE INJ 1000UNIT (antihemophilic factor rahf-pfm) ADVATE INJ 1500UNIT (antihemophilic factor rahf-pfm)
Tier 4 Tier 4 Tier 4 Tier 4
Requirements/Limits
QL (30 tabs / 30 days), MAIL QL (30 caps / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 caps / 30 days), MAIL, PA QL (30 caps / 30 days), MAIL, PA QL (60 caps / 30 days), MAIL
QL (90 tabs / 30 days) QL (90 tabs / 30 days)
QL (90 tabs / 30 days), MAIL
MAIL MAIL QL (30 tabs / 90 days) QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA QL (30 tabs / 30 days), MAIL, PA
QL (90 tabs / 30 days), MAIL
PA
PA
PA
PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
113
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
ADVATE INJ 2000UNIT (antihemophilic factor
Tier 4
rahf-pfm)
ADVATE INJ 3000UNIT (antihemophilic factor
Tier 4
rahf-pfm)
ADVATE INJ 4000UNIT (antihemophilic factor rahf-pfm)
Tier 4
ALPHANINE SD INJ 500UNIT (coagulation factor
Tier 4
ix)
ALPHANINE SD INJ 1500UNIT (coagulation factor
Tier 4
ix)
ALPROLIX INJ 250UNIT (coagulation factor ix
Tier 4
(recomb) fc fusion protein (rfixfc))
ALPROLIX INJ 500UNIT (coagulation factor ix (recomb) fc fusion protein (rfixfc))
Tier 4
ALPROLIX INJ 1000UNIT (coagulation factor ix
Tier 4
(recomb) fc fusion protein (rfixfc))
ALPROLIX INJ 2000UNIT (coagulation factor ix
Tier 4
(recomb) fc fusion protein (rfixfc))
ALPROLIX INJ 3000UNIT (coagulation factor ix
Tier 4
(recomb) fc fusion protein (rfixfc))
ALPROLIX INJ 4000UNIT (coagulation factor ix
Tier 4
(recomb) fc fusion protein (rfixfc))
BENEFIX INJ 250UNIT (coagulation factor ix
Tier 4
(recombinant))
BENEFIX INJ 500UNIT (coagulation factor ix
Tier 4
(recombinant))
BENEFIX INJ 1000UNIT (coagulation factor ix
Tier 4
(recombinant))
BENEFIX INJ 2000UNIT (coagulation factor ix
Tier 4
(recombinant))
BENEFIX INJ 3000UNIT (coagulation factor ix
Tier 4
(recombinant))
FEIBA INJ (antiinhibitor coagulant complex)
Tier 4
HELIXATE FS INJ 500UNIT (antihemophilic factor
Tier 4
(recombinant))
HELIXATE FS INJ 2000UNIT (antihemophilic factor Tier 4
(recombinant))
HELIXATE FS INJ 3000UNIT (antihemophilic factor (recombinant))
Tier 4
HEMLIBRA INJ 30MG/ML (emicizumab-kxwh)
Tier 4
HEMLIBRA INJ 60/0.4 (emicizumab-kxwh)
Tier 4
HEMLIBRA INJ 105/0.7 (emicizumab-kxwh)
Tier 4
HEMLIBRA INJ 150/ML (emicizumab-kxwh)
Tier 4
HEMOFIL M INJ 1700UNIT (antihemophilic factor
Tier 4
(human))
Requirements/Limits PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
114
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
HUMATE-P SOL 500-1200 (antihemophilic
Tier 4
factor/von willebrand factor complex (human))
HUMATE-P SOL 2400UNIT (antihemophilic
Tier 4
factor/von willebrand factor complex (human))
KOATE-DVI INJ 250UNIT (antihemophilic factor (human))
Tier 4
KOATE-DVI INJ 500UNIT (antihemophilic factor
Tier 4
(human))
KOATE-DVI INJ 1000UNIT (antihemophilic factor
Tier 4
(human))
KOGENATE FS INJ 250UNIT (antihemophilic factor Tier 4
(recombinant))
KOGENATE FS INJ 1000UNIT (antihemophilic factor (recombinant))
Tier 4
KOGENATE FS INJ 2000UNIT (antihemophilic
Tier 4
factor (recombinant))
KOGENATE FS INJ 3000UNIT (antihemophilic
Tier 4
factor (recombinant))
KOVALTRY INJ 250UNIT (antihemophilic factor
Tier 4
rahf-pfm)
KOVALTRY INJ 500UNIT (antihemophilic factor
Tier 4
rahf-pfm)
KOVALTRY INJ 1000UNIT (antihemophilic factor
Tier 4
rahf-pfm)
KOVALTRY INJ 2000UNIT (antihemophilic factor
Tier 4
rahf-pfm)
KOVALTRY INJ 3000UNIT (antihemophilic factor
Tier 4
rahf-pfm)
MONOCLATE-P INJ 1000UNIT (antihemophilic
Tier 4
factor (human))
NOVOEIGHT INJ 1500UNIT (antihemophilic factor Tier 4
(rcmb) bd truncated (bd trunc-rfviii))
NOVOSEVEN RT INJ 1MG (coagulation factor viia (recombinant))
Tier 4
NOVOSEVEN RT INJ 2MG (coagulation factor viia (recombinant))
Tier 4
NOVOSEVEN RT INJ 5MG (coagulation factor viia
Tier 4
(recombinant))
NOVOSEVEN RT INJ 8MG (coagulation factor viia
Tier 4
(recombinant))
NUWIQ INJ 250UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
NUWIQ INJ 500UNIT (antihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim))
Tier 4
NUWIQ INJ 1000UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
Requirements/Limits PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA MAIL, PA PA PA PA PA PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
115
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
NUWIQ INJ 2000UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
NUWIQ INJ 2500UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
NUWIQ INJ 3000UNIT (antihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim))
Tier 4
NUWIQ INJ 4000UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
NUWIQ KIT 250UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
NUWIQ KIT 500UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
NUWIQ KIT 1000UNIT (antihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim))
Tier 4
NUWIQ KIT 2000UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
NUWIQ KIT 2500UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
NUWIQ KIT 3000UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
NUWIQ KIT 4000UNIT (antihemophilic factor
Tier 4
(rcmb) simoctocog alfa(bdd-rfviii,sim))
PROFILNINE INJ 1500UNIT (factor ix complex)
Tier 4
RECOMBINATE INJ (antihemophilic factor
Tier 4
(recombinant))
RECOMBINATE INJ 220-400 (antihemophilic factor Tier 4
(recombinant))
RECOMBINATE INJ 401-800 (antihemophilic factor (recombinant))
Tier 4
RECOMBINATE INJ 801-1240 (antihemophilic
Tier 4
factor (recombinant))
RIXUBIS INJ 250 UNIT (coagulation factor ix
Tier 4
(recombinant))
RIXUBIS INJ 500UNIT (coagulation factor ix
Tier 4
(recombinant))
RIXUBIS INJ 1000UNIT (coagulation factor ix
Tier 4
(recombinant))
RIXUBIS INJ 2000UNIT (coagulation factor ix (recombinant))
Tier 4
RIXUBIS INJ 3000UNIT (coagulation factor ix
Tier 4
(recombinant))
XYNTHA SOLOF INJ 500UNIT (antihemophilic
Tier 4
factor (recombinant) plasma/albumin free)
XYNTHA SOLOF INJ 1000UNIT (antihemophilic
Tier 4
factor (recombinant) plasma/albumin free)
Requirements/Limits PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
116
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
XYNTHA SOLOF INJ 2000UNIT (antihemophilic factor (recombinant) plasma/albumin free)
Tier 4
XYNTHA SOLOF INJ 3000UNIT (antihemophilic factor (recombinant) plasma/albumin free)
Tier 4
XYNTHA SOLOF KIT 250UNIT (antihemophilic factor (recombinant) plasma/albumin free)
Tier 4
BRADYKININ B2 RECEPTOR ANTAGONISTS
FIRAZYR INJ 30MG/3ML (icatibant acetate)
Tier 4
icatibant acetate inj 30 mg/3ml (base equivalent)
Tier 4
COMPLEMENT INHIBITORS
BERINERT INJ 500UNIT (c1 esterase inhibitor (human))
Tier 4
HEMATORHEOLOGIC AGENTS
pentoxifylline tab er 400 mg
Tier 1
PLASMA KALLIKREIN INHIBITORS TAKHZYRO INJ 300/2ML (lanadelumab-flyo)
PLATELET AGGREGATION INHIBITORS anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg aspirin-dipyridamole cap er 12hr 25-200 mg BRILINTA TAB 60MG (ticagrelor)
Tier 4
Tier 1 Tier 1 Tier 3 Tier 3
BRILINTA TAB 90MG (ticagrelor)
Tier 3
cilostazol tab 50 mg cilostazol tab 100 mg clopidogrel bisulfate tab 75 mg (base equiv)
Tier 1 Tier 1 Tier 1
dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg prasugrel hcl tab 5 mg (base equiv)
Tier 1 Tier 1 Tier 1 Tier 3
prasugrel hcl tab 10 mg (base equiv)
Tier 3
ZONTIVITY TAB 2.08MG (vorapaxar sulfate)
Tier 3
HEMATOPOIETIC AGENTS
AGENTS FOR GAUCHER DISEASE CERDELGA CAP 84MG (eliglustat tartrate) miglustat cap 100 mg
Tier 4 Tier 4
Requirements/Limits PA
PA
PA
PA PA
PA
QL (120 tabs / 30 days), MAIL
PA
MAIL MAIL MAIL, PA QL (60 tabs / 30 days), MAIL, PA QL (60 tabs / 30 days), MAIL, PA MAIL MAIL QL (30 tabs / 30 days), MAIL MAIL MAIL MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL, PA
PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
117
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
COBALAMINS
cyanocobalamin inj 1000 mcg/ml
Tier 1
cyanocobalamin sl tab 500 mcg (Cvs B-12)
Tier 1
cyanocobalamin sl tab 1000 mcg
Tier 1
cyanocobalamin sl tab 2500 mcg
Tier 1
cyanocobalamin tab 100 mcg
Tier 1
cyanocobalamin tab 250 mcg
Tier 1
cyanocobalamin tab 500 mcg
Tier 1
cyanocobalamin tab 1000 mcg
Tier 1
cyanocobalamin tab er 1000 mcg (Cvs Vitamin B12 Tr)
Tier 1
FOLIC ACID/FOLATES
folic acid cap 0.8 mg (Fa-8)
Tier 5
folic acid tab 1 mg folic acid tab 400 mcg
Tier 1 Tier 5
folic acid tab 800 mcg
Tier 5
HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG (darbepoetin alfa) ARANESP INJ 25MCG (darbepoetin alfa) ARANESP INJ 40MCG (darbepoetin alfa) ARANESP INJ 60MCG (darbepoetin alfa) ARANESP INJ 100MCG (darbepoetin alfa) ARANESP INJ 150MCG (darbepoetin alfa) ARANESP INJ 200MCG (darbepoetin alfa) ARANESP INJ 300MCG (darbepoetin alfa) ARANESP INJ 500MCG (darbepoetin alfa) EPOGEN INJ 3000/ML (epoetin alfa) EPOGEN INJ 4000/ML (epoetin alfa) EPOGEN INJ 10000/ML (epoetin alfa) EPOGEN INJ 20000/ML (epoetin alfa) FULPHILA INJ 6/0.6ML (pegfilgrastim-jmdb) LEUKINE INJ 250MCG (sargramostim) NEULASTA INJ 6MG/0.6M (pegfilgrastim) NEUPOGEN INJ 300/0.5 (filgrastim) NEUPOGEN INJ 300MCG (filgrastim)
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
Requirements/Limits
QL (10 vials per 30 day) OTC OTC OTC OTC OTC OTC OTC OTC
OTC, QL (30 caps / 30 days), MAIL; Tier 5 for ages 55 and under, otherwise Tier 1 MAIL OTC, QL (30 tabs / 30 days), MAIL; Tier 5 for ages 55 and under, otherwise Tier 1 OTC, QL (30 tabs / 30 days), MAIL; Tier 5 for ages 55 and under, otherwise Tier 1
PA PA PA PA PA PA PA PA PA PA PA PA PA QL (0.6 per 14 days), PA PA QL (0.6 per 14 days), PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
118
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
NEUPOGEN INJ 480/0.8 (filgrastim)
Tier 4
NEUPOGEN INJ 480MCG (filgrastim)
Tier 4
NIVESTYM INJ 300/0.5 (filgrastim-aafi)
Tier 4
NIVESTYM INJ 300MCG (filgrastim-aafi)
Tier 4
NIVESTYM INJ 480/0.8 (filgrastim-aafi)
Tier 4
NIVESTYM INJ 480MCG (filgrastim-aafi)
Tier 4
PROCRIT INJ 2000/ML (epoetin alfa)
Tier 4
PROCRIT INJ 3000/ML (epoetin alfa)
Tier 4
PROCRIT INJ 40000/ML (epoetin alfa)
Tier 4
PROMACTA TAB 12.5MG (eltrombopag olamine)
Tier 4
PROMACTA TAB 25MG (eltrombopag olamine)
Tier 4
PROMACTA TAB 50MG (eltrombopag olamine)
Tier 4
PROMACTA TAB 75MG (eltrombopag olamine)
Tier 4
RETACRIT INJ 2000UNIT (epoetin alfa-epbx)
Tier 4
RETACRIT INJ 3000UNIT (epoetin alfa-epbx)
Tier 4
RETACRIT INJ 4000UNIT (epoetin alfa-epbx)
Tier 4
RETACRIT INJ 10000UNT (epoetin alfa-epbx)
Tier 4
RETACRIT INJ 40000UNT (epoetin alfa-epbx)
Tier 4
UDENYCA INJ 6MG/.6ML (pegfilgrastim-cbqv)
Tier 4
ZARXIO INJ 300/0.5 (filgrastim-sndz)
Tier 4
ZARXIO INJ 480/0.8 (filgrastim-sndz)
Tier 4
ZIEXTENZO INJ 6/0.6ML (pegfilgrastim-bmez)
Tier 4
HEMATOPOIETIC MIXTURES
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.01575-0.5-240 mg (Tricon)
Tier 1
FERREX 150 CAP FORTE (polysaccharide iron-folic acid-vit b12)
Tier 1
iron combination cap (Chromagen)
Tier 1
iron polysacch complex-vit b12-fa cap 1500.025-1 mg (Poly-iron 150 Forte)
Tier 1
IRON
carbonyl iron susp 15 mg/1.25ml (elemental iron) (Wee Care)
Tier 1
FE GLUCONATE TAB 239MG
Tier 1
FERRETTS TAB 325MG (ferrous fumarate)
Tier 1
ferrous fumarate tab 324 mg (106 mg elemental fe)
Tier 1
FERROUS GLUC TAB 324MG
Tier 1
ferrous gluconate tab 240 mg (27 mg elemental fe) (Ferate)
Tier 1
ferrous gluconate tab 324 mg (37.5 mg elemental iron)
Tier 1
FERROUS SUL LIQ 220/5ML
Tier 1
FERROUS SULF TAB 324MG EC
Tier 1
Requirements/Limits PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA QL (0.6 per 14 days), PA PA PA QL (0.6 per 14 days), PA
QL (60 caps / 30 days)
OTC
QL (60 caps / 30 days) QL (60 caps / 30 days)
OTC
OTC, MAIL OTC, MAIL OTC, MAIL
OTC, MAIL OTC, MAIL
OTC, MAIL
OTC, MAIL OTC, MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
119
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
ferrous sulfate dried tab 200 mg (65 mg elemental fe) (Px Iron)
Tier 1
ferrous sulfate dried tab er 45 mg (fe equivalent) (Slow-release Iron)
Tier 1
ferrous sulfate dried tab er 160 mg (50 mg fe equivalent) (Slow Iron)
Tier 1
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
Tier 1
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)
Tier 1
ferrous sulfate tab 325 mg (65 mg elemental fe) Tier 1
ferrous sulfate tab ec 325 mg (65 mg fe equivalent)
Tier 1
ferrous sulfate tab er 47.5 mg (elemental fe) (Ra Slow Release Iron)
Tier 1
ferrous sulfate tab er 50 mg (elemental fe) (Slow Release Iron)
Tier 1
ferrous sulfate tab er 142 mg (45 mg fe equivalent)
Tier 1
IRON CHW PEDIATRI (carbonyl iron)
Tier 1
polysaccharide iron complex cap 150 mg (iron equivalent) (Poly-iron 150)
Tier 1
SLOW FE TAB 45MG (ferrous sulfate)
Tier 1
HEMOSTATICS
HEMOSTATICS - SYSTEMIC
aminocaproic acid tab 500 mg
Tier 1
aminocaproic acid tab 1000 mg
Tier 1
tranexamic acid tab 650 mg
Tier 1
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS
ANTIHISTAMINE HYPNOTICS
diphenhydramine hcl (sleep) tab 25 mg (Cvs Sleep Aid Nighttime)
Tier 1
diphenhydramine hcl (sleep) tab 50 mg
Tier 1
doxylamine succinate (sleep) tab 25 mg (Sleep Aid)
Tier 1
BARBITURATE HYPNOTICS
phenobarbital elixir 20 mg/5ml
Tier 1
phenobarbital tab 15 mg phenobarbital tab 16.2 mg phenobarbital tab 30 mg phenobarbital tab 32.4 mg phenobarbital tab 60 mg phenobarbital tab 64.8 mg
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC OTC
OTC, MAIL
PA PA
OTC, MAIL
OTC, MAIL OTC, MAIL
AGE, QL (1500 mL / 30 days); AGE (Max 12 years) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (90 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
120
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name phenobarbital tab 97.2 mg phenobarbital tab 100 mg
HYPNOTICS - TRICYCLIC AGENTS doxepin hcl (sleep) tab 3 mg (base equiv) doxepin hcl (sleep) tab 6 mg (base equiv) SILENOR TAB 3MG (doxepin hcl (sleep)) SILENOR TAB 6MG (doxepin hcl (sleep))
NON-BARBITURATE HYPNOTICS estazolam tab 1 mg
estazolam tab 2 mg
eszopiclone tab 1 mg
eszopiclone tab 2 mg
eszopiclone tab 3 mg
flurazepam hcl cap 15 mg
flurazepam hcl cap 30 mg
temazepam cap 15 mg
temazepam cap 30 mg
triazolam tab 0.25 mg
triazolam tab 0.125 mg
zaleplon cap 5 mg
Drug Tier Requirements/Limits Tier 1 QL (60 tabs / 30 days) Tier 1 QL (60 tabs / 30 days)
Tier 3 Tier 3 Tier 3 Tier 3
MAIL, PA MAIL, PA MAIL, PA MAIL, PA
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
AGE, QL (30 tabs / 30 days); AGE (Min 18 years)
AGE, QL (30 tabs / 30 days); AGE (Min 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 18 years) AGE, QL (30 caps / 30 days); AGE (Min 15 years, Max 64 years) AGE, QL (30 caps / 30 days); AGE (Min 15 years, Max 64 years) AGE, QL (30 caps / 30 days); AGE (Min 18 years) AGE, QL (30 caps / 30 days); AGE (Min 18 years) AGE, QL (60 tabs / 30 days); AGE (Min 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 18 years) AGE, QL (30 caps / 30 days); AGE (Min 18 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
121
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name zaleplon cap 10 mg
Drug Tier Tier 1
zolpidem tartrate tab 5 mg
Tier 1
zolpidem tartrate tab 10 mg
Tier 1
OREXIN RECEPTOR ANTAGONISTS
BELSOMRA TAB 5MG (suvorexant)
Tier 3
BELSOMRA TAB 10MG (suvorexant)
Tier 3
BELSOMRA TAB 15MG (suvorexant)
Tier 3
BELSOMRA TAB 20MG (suvorexant)
Tier 3
SELECTIVE MELATONIN RECEPTOR AGONISTS
HETLIOZ CAP 20MG (tasimelteon)
Tier 4
ramelteon tab 8 mg
Tier 3
ROZEREM TAB 8MG (ramelteon)
Tier 3
LAXATIVES
BULK LAXATIVES
calcium polycarbophil tab 625 mg corn dextrin oral powder (Cvs Easy Fiber)
Tier 1 Tier 1
KONSYL DAILY POW 28.3% (psyllium)
Tier 1
KONSYL DAILY POW 100% (psyllium)
Tier 1
KONSYL-D POW 52.3% (psyllium)
Tier 1
METAMUCIL POW 28%ORG (psyllium)
Tier 1
METAMUCIL POW 58.12% (psyllium) METAMUCIL WAF (psyllium)
Tier 1 Tier 1
methylcellulose tab 500 mg (Gnp Fiber Therapy)
Tier 1
NAT FIBER POW 58.6% (psyllium)
Tier 1
psyllium cap 0.52 gm (Fiber Laxative)
Tier 1
psyllium cap 400 mg (Reguloid)
Tier 1
psyllium powder 28.3% (Gnp Natural Fiber)
Tier 1
psyllium powder 30.9% (Konsyl)
Tier 1
psyllium powder 33% (Sb Fib Lax Orange)
Tier 1
psyllium powder 48.57% (Cvs Natural Daily Fiber) Tier 1
psyllium powder 58.6% (Cvs Natural Daily Fiber)
Tier 1
psyllium powder 95% (Qc Natural Vegetable) psyllium powder 100%
Tier 1 Tier 1
UNIFIBER POW (cellulose)
Tier 1
wheat dextrin oral powder (Clear Soluble Fiber)
Tier 1
LAXATIVE COMBINATIONS
CLENPIQ SOL (sodium picosulfate-magnesium oxide-anhydrous citric acid)
Tier 5
Requirements/Limits AGE, QL (30 caps / 30 days); AGE (Min 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 18 years) AGE, QL (30 tabs / 30 days); AGE (Min 18 years)
PA PA PA PA
PA MAIL, PA MAIL, PA
OTC OTC OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC OTC
Tier 5 for ages 50-74, otherwise Tier 3
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
122
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
GOLYTELY SOL (peg 3350-kcl-sod bicarb-sod chloride-sod sulfate)
Tier 5
MEDI-LAXX CAP 8.6-50MG (sennosides-docusate sodium)
Tier 1
MOVIPREP SOL (peg 3350-kcl-nacl-na sulfate-na ascorbate-ascorbic acid)
Tier 5
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
Tier 5
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
Tier 5
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
Tier 5
PLENVU SOL (peg 3350-kcl-nacl-na sulfate-na ascorbate-ascorbic acid) PREPOPIK PAK (sodium picosulfate-magnesium oxide-anhydrous citric acid) sennosides-docusate sodium tab 8.6-50 mg SUPREP BOWEL SOL PREP KIT (sodium sulfatepotassium sulfate-magnesium sulfate)
LAXATIVES - MISCELLANEOUS glycerin suppos 1.2 gm (Gnp Glycerin Child) glycerin suppos 2 gm (Cvs Glycerin Adult) glycerin suppos 2.1 gm (Gnp Glycerin Adult) glycerin suppos 80.7% (Ra Glycerin Child) lactulose solution 10 gm/15ml polyethylene glycol 3350 oral packet 17 gm (Ra Laxative) polyethylene glycol 3350 oral powder 17 gm/scoop (Ra Laxative)
LUBRICANT LAXATIVES mineral oil mineral oil enema
SALINE LAXATIVES magnesium citrate soln (Gnp Magnesium Citrate) magnesium hydroxide susp 400 mg/5ml (Milk Of Magnesia) magnesium hydroxide susp concentrate 2400 mg/10ml (Milk Of Magnesia Concentr) OSMOPREP TAB 1.5GM (sodium phosphate monobasic-sodium phosphate dibasic) sodium phosphates - enema
STIMULANT LAXATIVES bisacodyl suppos 10 mg (Cvs Gentle Laxative) bisacodyl tab delayed release 5 mg (Stimulant Laxative)
Tier 5
Tier 5
Tier 1 Tier 5
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
Tier 1 Tier 1
Tier 1 Tier 1
Tier 1
Tier 3
Tier 1
Tier 1 Tier 1
Requirements/Limits Tier 5 for ages 50-74, otherwise Tier 3 OTC, MAIL
Tier 5 for ages 50-74, otherwise Tier 3 Tier 5 for ages 50-74, otherwise Tier 1 Tier 5 for ages 50-74, otherwise Tier 1 Tier 5 for ages 50-74, otherwise Tier 1 Tier 5 for ages 50-74, otherwise Tier 3 Tier 5 for ages 50-74, otherwise Tier 3 OTC, MAIL Tier 5 for ages 50-74, otherwise Tier 3
OTC OTC OTC OTC MAIL OTC, QL (60 packets / 30 days) OTC, QL (527 gm / 30 days)
OTC OTC
OTC OTC
OTC
PA
OTC
OTC OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
123
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
sennosides chew tab 15 mg (Cvs Chocolate Laxative Pi)
Tier 1
sennosides syrup 8.8 mg/5ml
Tier 1
sennosides tab 8.6 mg (Eq Natural Vegetable Laxa) Tier 1
sennosides tab 25 mg (Ra Laxative Maximum Stren)
Tier 1
SURFACTANT LAXATIVES
docusate calcium cap 240 mg (Stool Softener)
Tier 1
docusate sodium cap 50 mg (Ra Col-rite)
Tier 1
docusate sodium cap 100 mg (Stool Softener)
Tier 1
docusate sodium cap 250 mg
Tier 1
docusate sodium liquid 150 mg/15ml (Silace)
Tier 1
docusate sodium syrup 60 mg/15ml (Silace)
Tier 1
docusate sodium tab 100 mg (Dok)
Tier 1
DOCUSOL PLUS ENE 20-283 (benzocaine-docusate Tier 1 sodium)
PEDIA-LAX LIQ 50MG (docusate sodium)
Tier 1
MACROLIDES
AZITHROMYCIN
azithromycin for susp 100 mg/5ml
Tier 1
azithromycin for susp 200 mg/5ml
Tier 1
azithromycin powd pack for susp 1 gm azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg
CLARITHROMYCIN clarithromycin for susp 125 mg/5ml
Tier 1 Tier 1 Tier 1 Tier 1
Tier 1
clarithromycin for susp 250 mg/5ml
Tier 1
clarithromycin tab 250 mg clarithromycin tab 500 mg
ERYTHROMYCINS erythromycin ethylsuccinate for susp 200 mg/5ml erythromycin ethylsuccinate for susp 400 mg/5ml erythromycin ethylsuccinate tab 400 mg erythromycin stearate tab 250 mg (Erythrocin Stearate) erythromycin tab 250 mg erythromycin tab 500 mg
Tier 1 Tier 1
Tier 3
Tier 3
Tier 3 Tier 3
Tier 3 Tier 3
Requirements/Limits OTC, MAIL
OTC, MAIL OTC, MAIL OTC, MAIL
OTC OTC OTC OTC OTC OTC OTC OTC
OTC
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) QL (2 packets / 30 days) QL (12 tabs / 30 days) QL (6 tabs / 30 days) QL (60 tabs / 30 days)
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
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mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
erythromycin tab delayed release 250 mg (Erytab)
Tier 3
erythromycin tab delayed release 333 mg (Erytab)
Tier 3
erythromycin tab delayed release 500 mg (Erytab)
Tier 3
FIDAXOMICIN
DIFICID TAB 200MG (fidaxomicin)
Tier 3
MEDICAL DEVICES
Parenteral Therapy Supplies
BD U-500 MIS 31GX6MM (insulin syringe/needle u-500)
DME
MEDICAL DEVICES AND SUPPLIES
CONTRACEPTIVES
CAYA DPR (diaphragm arc-spring)
Tier 5
CONDOMS MIS
Tier 5
CONDOMS MIS LUBRICAT (condoms latex lubricated - male)
Tier 5
DUREX MIS REALFEEL (condoms non-latex lubricated - male)
Tier 5
FC2 FEMALE MIS CONDOM (condoms - female)
Tier 5
FEMCAP MIS 22MM (cervical caps)
Tier 5
FEMCAP MIS 26MM (cervical caps)
Tier 5
FEMCAP MIS 30MM (cervical caps)
Tier 5
OMNIFLEX DPR (diaphragms)
Tier 5
TROJAN MIS (condoms latex non-lubricated male)
Tier 5
TROJAN MIS NATULAMB (condoms non-latex nonlubricated - male)
Tier 5
WIDE-SEAL DPR KIT 60 (diaphragm wide seal)
Tier 5
WIDE-SEAL DPR KIT 65 (diaphragm wide seal)
Tier 5
WIDE-SEAL DPR KIT 70 (diaphragm wide seal)
Tier 5
WIDE-SEAL DPR KIT 75 (diaphragm wide seal)
Tier 5
WIDE-SEAL DPR KIT 80 (diaphragm wide seal)
Tier 5
WIDE-SEAL DPR KIT 85 (diaphragm wide seal)
Tier 5
WIDE-SEAL DPR KIT 90 (diaphragm wide seal)
Tier 5
WIDE-SEAL DPR KIT 95 (diaphragm wide seal)
Tier 5
DIABETIC SUPPLIES
DEXCOM G5 MIS RECEIVER (continuous blood glucose system receiver)
Tier 2
DEXCOM G5 MIS TRANSMIT (continuous blood glucose system transmitter)
Tier 2
DEXCOM G6 MIS RECEIVER (continuous blood glucose system receiver)
Tier 2
Requirements/Limits
PA QL (150 ea / 30 days)
OTC OTC OTC OTC
OTC OTC
QL (1 each / year), PA QL (1 box / 90 days), PA QL (1 each / year), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
125
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
DEXCOM G6 MIS SENSOR (continuous blood glucose system sensor) DEXCOM G6 MIS TRANSMIT (continuous blood glucose system transmitter) FREESTYLE KIT SENSOR (continuous blood glucose system sensor) FREESTYLE KIT SENSOR (continuous blood glucose system sensor) FREESTYLE MIS READER (continuous blood glucose system receiver) G5/G4 MIS SENSOR (continuous blood glucose system sensor) LANCETS MIS 30G TRUE METRIX KIT AIR (blood glucose monitoring supplies)
MISC. DEVICES ALCOHOL PREP PAD MED 70% (alcohol swabs)
PARENTERAL THERAPY SUPPLIES INSULIN SYRG MIS 0.3/29G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.3/29G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.3/30G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.3/30G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.3/31G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.3/31G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.5/28G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.5/29G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.5/29G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.5/30G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.5/30G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.5/31G (insulin syringe/needle u-100) INSULIN SYRG MIS 0.5/31G (insulin syringe/needle u-100)
Drug Tier Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 DME DME
Tier 1
DME DME DME DME DME DME DME DME DME DME DME DME DME
Requirements/Limits QL (3 boxes / 30 days), PA QL (1 box / 90 days), PA
QL (2 boxes / 30 days), PA QL (3 boxes / 30 days), PA QL (1 each / year), PA
QL (4 boxes / 30 days), PA OTC OTC, QL (1 box / year)
OTC, QL (200 ea / 30 days)
OTC, QL (150 ea / 30 days); TECHLITE OTC, QL (150 ea / 30 days); TRUEPLUS OTC, QL (150 ea / 30 days); TECHLITE OTC, QL (150 ea / 30 days); TRUEPLUS OTC, QL (150 ea / 30 days); TECHLITE OTC, QL (150 ea / 30 days); TRUEPLUS OTC, QL (150 ea / 30 days); TRUEPLUS OTC, QL (150 ea / 30 days); TECHLITE OTC, QL (150 ea / 30 days); TRUEPLUS OTC, QL (150 ea / 30 days); TECHLITE OTC, QL (150 ea / 30 days); TRUEPLUS OTC, QL (150 ea / 30 days); TECHLITE OTC, QL (150 ea / 30 days); TRUEPLUS
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
126
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
INSULIN SYRG MIS 1ML/28G (insulin syringe/needle u-100)
DME
INSULIN SYRG MIS 1ML/29G (insulin syringe/needle u-100)
DME
INSULIN SYRG MIS 1ML/29G (insulin syringe/needle u-100)
DME
INSULIN SYRG MIS 1ML/30G (insulin syringe/needle u-100)
DME
INSULIN SYRG MIS 1ML/30G (insulin syringe/needle u-100)
DME
INSULIN SYRG MIS 1ML/31G (insulin syringe/needle u-100)
DME
INSULIN SYRG MIS 1ML/31G (insulin syringe/needle u-100)
DME
NEEDLES MIS 18GX1.5" (needle (disp) 18 g)
DME
PEN NEEDLES MIS 29GX10MM (insulin pen needle) DME
PEN NEEDLES MIS 29GX12.7 (insulin pen needle)
DME
PEN NEEDLES MIS 29GX12MM (insulin pen needle) DME
PEN NEEDLES MIS 31GX5MM (insulin pen needle)
DME
PEN NEEDLES MIS 31GX5MM (insulin pen needle)
DME
PEN NEEDLES MIS 31GX6MM (insulin pen needle)
DME
PEN NEEDLES MIS 31GX6MM (insulin pen needle)
DME
PEN NEEDLES MIS 31GX8MM (insulin pen needle)
DME
PEN NEEDLES MIS 31GX8MM (insulin pen needle)
DME
PEN NEEDLES MIS 32GX4MM (insulin pen needle)
DME
PEN NEEDLES MIS 32GX4MM (insulin pen needle)
DME
PEN NEEDLES MIS 32GX6MM (insulin pen needle)
DME
PEN NEEDLES MIS 32GX8MM (insulin pen needle)
DME
3ML SYRINGE MIS REG TIP (syringe (disposable))
RESPIRATORY THERAPY SUPPLIES ADULT MASK MIS LARGE EASY NEB MIS (nebulizers)
DME
Tier 2 Tier 2
Requirements/Limits
OTC, QL (150 ea / 30 days); TRUEPLUS QL (150 ea / 30 days); TECHLITE OTC, QL (150 ea / 30 days); TRUEPLUS OTC, QL (150 ea / 30 days); TECHLITE OTC, QL (150 ea / 30 days); TRUEPLUS OTC, QL (150 ea / 30 days); TECHLITE OTC, QL (150 ea / 30 days); TRUEPLUS OTC OTC, QL (150 / 30 days); TECHLITE QL (150 / 30 days); TRUEPLUS OTC, QL (150 / 30 days); TECHLITE QL (150 / 30 days); TRUEPLUS OTC, QL (150 / 30 days); TECHLITE QL (150 / 30 days); TRUEPLUS OTC, QL (150 / 30 days); TECHLITE QL (150 / 30 days); TRUEPLUS OTC, QL (150 / 30 days); TECHLITE QL (150 / 30 days); TRUEPLUS OTC, QL (150 / 30 days); TECHLITE OTC, QL (150 / 30 days); TECHLITE OTC, QL (150 / 30 days); TECHLITE
QL (1 box / year) OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
127
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
INSPIRACHAMB MIS LARGE (spacer/aerosolholding chambers)
Tier 2
PEAK AIR FLO MIS ADLT/PED (peak flow meter)
DME
PULMONEB LT MIS NEBULIZE (respiratory therapy supplies)
Tier 2
MIGRAINE PRODUCTS
MIGRAINE COMBINATIONS
ergotamine w/ caffeine tab 1-100 mg
Tier 3
MIGRAINE PRODUCTS
dihydroergotamine mesylate inj 1 mg/ml
Tier 3
ERGOMAR SUB 2MG (ergotamine tartrate)
Tier 3
SEROTONIN AGONISTS
almotriptan malate tab 6.25 mg
Tier 3
almotriptan malate tab 12.5 mg
Tier 3
eletriptan hydrobromide tab 20 mg (base equivalent)
Tier 3
eletriptan hydrobromide tab 40 mg (base equivalent)
Tier 3
frovatriptan succinate tab 2.5 mg (base equivalent)
Tier 3
naratriptan hcl tab 1 mg (base equiv) naratriptan hcl tab 2.5 mg (base equiv) rizatriptan benzoate oral disintegrating tab 5 mg (base eq)
Tier 1 Tier 1 Tier 1
Requirements/Limits QL (1 each / year)
OTC, QL (1 each / year) QL (1 each / 30 days)
PA
PA
QL (9 tabs / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (9 tabs / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (9 tabs / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (9 tabs / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (9 tabs / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (9 tabs / 30 days) QL (9 tabs / 30 days) QL (12 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
128
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
rizatriptan benzoate oral disintegrating tab 10 mg (base eq)
Tier 1
rizatriptan benzoate tab 5 mg (base equivalent) Tier 1
rizatriptan benzoate tab 10 mg (base equivalent)
Tier 1
sumatriptan succinate inj 6 mg/0.5ml
Tier 3
sumatriptan succinate tab 25 mg sumatriptan succinate tab 50 mg sumatriptan succinate tab 100 mg zolmitriptan orally disintegrating tab 2.5 mg
Tier 1 Tier 1 Tier 1 Tier 1
zolmitriptan orally disintegrating tab 5 mg
Tier 1
zolmitriptan tab 2.5 mg
Tier 1
zolmitriptan tab 5 mg
Tier 1
ZOMIG SPR 2.5MG (zolmitriptan)
Tier 3
ZOMIG SPR 5MG (zolmitriptan)
Tier 3
Requirements/Limits
QL (12 tabs / 30 days)
QL (12 tabs / 30 days) QL (12 tabs / 30 days)
QL (2 mL / 30 days); Vials QL (9 tabs / 30 days) QL (9 tabs / 30 days) QL (9 tabs / 30 days) QL (6 tabs / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (6 tabs / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (6 tabs / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (6 tabs / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (2 mL / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan QL (2 mL / 30 days), ST; Prior use of TWO of the following within the past 90 days: naratriptan, rizatriptan, sumatriptan
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
129
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
MINERALS & ELECTROLYTES
CALCIUM
calcium carb-vit d w/ minerals chew tab 600 mg-400 unit (Ra Calcium 600 Plus Vitam)
Tier 1
calcium carb-vit d w/ minerals chew tab 600 mg-800 unit (Sm Calcium 600 + D Plus M)
Tier 1
calcium carbonate tab 600 mg (Calcium 600)
Tier 1
calcium carbonate tab 1250 mg (500 mg elemental ca)
Tier 1
calcium carbonate tab 1500 mg (600 mg elemental ca)
Tier 1
calcium carbonate-cholecalciferol cap 600 mg500 unit (Calcium Plus Vitamin D3)
Tier 1
calcium carbonate-cholecalciferol chew tab 500 mg-100 unit
Tier 1
calcium carbonate-cholecalciferol chew tab 500 mg-400 unit (Calcium 500/d)
Tier 1
calcium carbonate-cholecalciferol chew tab 500 mg-600 unit (Oysco 500+d)
Tier 1
calcium carbonate-cholecalciferol tab 250 mg125 unit
Tier 1
calcium carbonate-cholecalciferol tab 500 mg125 unit (Cvs Oyster Shell Calcium)
Tier 1
calcium carbonate-cholecalciferol tab 500 mg200 unit (Oyster Shell Calcium Plus)
Tier 1
calcium carbonate-cholecalciferol tab 500 mg400 unit (Oystercal-d)
Tier 1
calcium carbonate-cholecalciferol tab 500 mg600 unit (Gnp Calcium 500 +d3)
Tier 1
calcium carbonate-cholecalciferol tab 600 mg200 unit
Tier 1
calcium carbonate-cholecalciferol tab 600 mg400 unit
Tier 1
calcium carbonate-cholecalciferol tab 600 mg800 unit (Calcium 600/vitamin D3)
Tier 1
calcium carbonate-vitamin d cap 600 mg-200 unit (Liquid Calcium/vitamin D)
Tier 1
calcium carbonate-vitamin d chew tab 600 mg400 unit (Calcium 600 With Vitamin)
Tier 1
calcium carbonate-vitamin d tab 250 mg-125 unit (Ra Oyster Shell Calcium/v)
Tier 1
calcium carbonate-vitamin d tab 500 mg-125 unit (Calcium 500 + D)
Tier 1
calcium carbonate-vitamin d tab 500 mg-200 unit (Gnp Calcium 500/d)
Tier 1
Requirements/Limits
OTC OTC OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL OTC, MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
130
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
calcium carbonate-vitamin d tab 500 mg-400 unit
Tier 1
calcium carbonate-vitamin d tab 600 mg-125 unit
Tier 1
calcium carbonate-vitamin d tab 600 mg-200 unit
Tier 1
calcium carbonate-vitamin d tab 600 mg-400 unit
Tier 1
CALCIUM CITR TAB 200MG
Tier 1
calcium citrate tab 950 mg (200 mg elemental ca) (Calcitrate)
Tier 1
calcium citrate-vitamin d tab 200 mg-250 unit (elemental ca)
Tier 1
calcium citrate-vitamin d tab 250 mg-200 unit (elemental ca) (Calcium Citrate + D3)
Tier 1
calcium citrate-vitamin d tab 315 mg-200 unit (elemental ca)
Tier 1
calcium citrate-vitamin d tab 315 mg-250 unit (elemental ca) (Cvs Calcium Citrate + D)
Tier 1
CALCIUM TAB 600MG
Tier 1
calcium-magnesium-zinc tab 333-133-5 mg
Tier 1
CALTRATE 600 CHW 600-800 (calcium carbonatecholecalciferol)
Tier 1
oyster shell calcium tab 500 mg
Tier 1
RA OYS SHL/D TAB 500MG (calcium carbonateergocalciferol)
Tier 1
RISACAL-D TAB (calcium & phosphorus w/ vitamin d)
Tier 1
ELECTROLYTE MIXTURES
oral electrolyte solution
Tier 1
FLUORIDE
FLUORABON DRO (sodium fluoride)
Tier 5
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
Tier 5
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
Tier 5
Requirements/Limits OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL OTC, MAIL OTC, MAIL
OTC, MAIL OTC, MAIL
OTC
OTC
QL (60 mL / 30 days), MAIL; Tier 5 for ages 6 and under, otherwise Tier 2 QL (30 tabs / 30 days), MAIL; Tier 5 for less than 6 years old, otherwise Tier 1 QL (30 tabs / 30 days), MAIL; Tier 5 for less than 6 years old, otherwise Tier 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
131
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
Drug Tier Tier 5
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
Tier 5
sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) (Flura-drops)
Tier 5
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) (Fluoritab)
Tier 5
sodium fluoride tab 0.5 mg f (from 1.1 mg naf) Tier 5
MAGNESIUM MAG64 TAB 64MG (magnesium chloride) MAGDELAY TAB 70MG (magnesium chloride) magnesium chloride tab dr 64 mg (elemental mg) (Magdelay) magnesium gluconate tab 27.5 mg (elemental mg) magnesium gluconate tab 500 mg (27 mg elemental mg) (Mag-g) magnesium oxide cap 500 mg (elemental mg) magnesium oxide tab 250 mg (mg supplement) magnesium oxide tab 400 mg (240 mg elemental mg) magnesium oxide tab 400 mg (241.3 mg elemental mg) (Magnesium-oxide) magnesium oxide tab 500 mg (mg supplement) magnesium tab 250 mg
PHOSPHATE pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (Virt-phos 250 Neutral)
POTASSIUM potassium bicarbonate effer tab 25 meq (Klorcon/ef) potassium chloride cap er 8 meq
Tier 1 Tier 1 Tier 1
Tier 1
Tier 1
Tier 1 Tier 1 Tier 1
Tier 1
Tier 1 Tier 1
Tier 1
Tier 1
Tier 1
Requirements/Limits QL (30 tabs / 30 days), MAIL; Tier 5 for less than 6 years old, otherwise Tier 1 QL (50 mL / 30 days), MAIL; Tier 5 for less than 6 years old, otherwise Tier 1 QL (24 mL / 30 days), MAIL; Tier 5 for less than 6 years old, otherwise Tier 1 QL (30 mL / 30 days), MAIL; Tier 5 for less than 6 years old, otherwise Tier 1 QL (30 tabs / 30 days), MAIL; Tier 5 for less than 6 years old, otherwise Tier 1
OTC OTC OTC
OTC
OTC
OTC, MAIL OTC, MAIL OTC, MAIL
OTC, MAIL
OTC, MAIL OTC, MAIL
QL (120 tabs / 30 days), MAIL
QL (60 ea / 30 days), MAIL QL (120 caps / 30 days), MAIL
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132
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name potassium chloride cap er 10 meq
potassium chloride microencapsulated crys er tab 10 meq potassium chloride microencapsulated crys er tab 20 meq potassium chloride oral soln 10% (20 meq/15ml) potassium chloride oral soln 20% (40 meq/15ml) potassium chloride tab er 8 meq (600 mg)
potassium chloride tab er 10 meq
potassium chloride tab er 20 meq (1500 mg)
SODIUM sodium chloride tab 1 gm
ZINC zinc sulfate cap 220 mg (50 mg elemental zn) (Zinc-220) MISCELLANEOUS THERAPEUTIC CLASSES
CHELATING AGENTS D-PENAMINE TAB 125MG (penicillamine) DEPEN TITRA TAB 250MG (penicillamine) penicillamine tab 250 mg
IMMUNOMODULATORS REVLIMID CAP 2.5MG (lenalidomide) REVLIMID CAP 5MG (lenalidomide) REVLIMID CAP 10MG (lenalidomide) REVLIMID CAP 15MG (lenalidomide) REVLIMID CAP 20MG (lenalidomide) REVLIMID CAP 25MG (lenalidomide) THALOMID CAP 50MG (thalidomide) THALOMID CAP 100MG (thalidomide) THALOMID CAP 150MG (thalidomide) THALOMID CAP 200MG (thalidomide)
IMMUNOSUPPRESSIVE AGENTS azathioprine tab 50 mg
cyclosporine cap 25 mg cyclosporine cap 100 mg cyclosporine modified cap 25 mg cyclosporine modified cap 50 mg
Drug Tier Tier 1 Tier 1 Tier 1 Tier 3
Requirements/Limits
QL (120 caps / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (150 tabs / 30 days), MAIL MAIL
Tier 3 MAIL
Tier 1 Tier 1 Tier 1
QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (150 tabs / 30 days), MAIL
Tier 1 OTC
Tier 1 OTC, MAIL
Tier 2 Tier 2 Tier 1
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (30 per 30 days), PA QL (60 per 30 days), PA QL (60 per 30 days), PA
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1
QL (240 tabs / 30 days), MAIL MAIL MAIL MAIL MAIL
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133
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
cyclosporine modified cap 100 mg cyclosporine modified oral soln 100 mg/ml everolimus tab 0.5 mg everolimus tab 0.25 mg everolimus tab 0.75 mg mycophenolate mofetil cap 250 mg mycophenolate mofetil tab 500 mg mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) NEORAL CAP 25MG (cyclosporine modified (for microemulsion)) NEORAL CAP 100MG (cyclosporine modified (for microemulsion)) NULOJIX INJ 250MG (belatacept) RAPAMUNE SOL 1MG/ML (sirolimus) SANDIMMUNE CAP 25MG (cyclosporine) SANDIMMUNE CAP 100MG (cyclosporine) sirolimus oral soln 1 mg/ml sirolimus tab 0.5 mg sirolimus tab 1 mg sirolimus tab 2 mg tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg ZORTRESS TAB 0.5MG (everolimus (immunosuppressant)) ZORTRESS TAB 0.25MG (everolimus (immunosuppressant)) ZORTRESS TAB 0.75MG (everolimus (immunosuppressant)) ZORTRESS TAB 1MG (everolimus (immunosuppressant))
IRRIGATION SOLUTIONS irrigation solution, physiological (Physiolyte) water for irrigation, sterile irrigation soln
POTASSIUM REMOVING AGENTS sodium polystyrene sulfonate oral susp 15 gm/60ml sodium polystyrene sulfonate powder
MOUTH/THROAT/DENTAL AGENTS
ANESTHETICS TOPICAL ORAL lidocaine hcl viscous soln 2%
Drug Tier
Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 3
Requirements/Limits
MAIL MAIL PA PA PA MAIL MAIL MAIL
Tier 3 MAIL
Tier 2 MAIL
Tier 2 MAIL
Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 4
PA MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL PA
Tier 4 PA
Tier 4 PA
Tier 4 PA
Tier 1 Tier 1
Tier 1 Tier 1
Tier 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
134
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
ANTI-INFECTIVES - THROAT
clotrimazole troche 10 mg
Tier 1
nystatin susp 100000 unit/ml
Tier 1
ORAVIG TAB 50MG (miconazole (mouth-throat)) Tier 3
ANTISEPTICS - MOUTH/THROAT
chlorhexidine gluconate soln 0.12%
Tier 1
DENTAL PRODUCTS
sodium fluoride cream 1.1% (Sf 5000 Plus)
Tier 1
sodium fluoride gel 1.1% (0.5% f) (Sf)
Tier 1
STEROIDS - MOUTH/THROAT/DENTAL
triamcinolone acetonide dental paste 0.1%
Tier 1
THROAT PRODUCTS - MISC. cevimeline hcl cap 30 mg
Tier 3
pilocarpine hcl tab 5 mg
Tier 1
pilocarpine hcl tab 7.5 mg
Tier 1
MULTIVITAMINS
B-COMPLEX W/ FOLIC ACID
b-complex w/ c & folic acid cap 1 mg (Virt-caps) Tier 1
b-complex w/ c & folic acid tab (Vita-bee/c)
b-complex w/ c & folic acid tab 0.8 mg (Renavite) b-complex w/ c & folic acid tab 5 mg (Folbee Plus)
Tier 1 Tier 1
Tier 1
MULTIPLE VITAMINS W/ IRON multiple vitamins w/ iron tab (Stress Formula W/iron)
Tier 1
MULTIPLE VITAMINS W/ MINERALS multiple vitamins w/ minerals cap (V-c Forte)
Tier 1
multiple vitamins w/ minerals liquid (Multivitamin & Mineral) multiple vitamins w/ minerals tab (Ocuvite/lutein)
Tier 1 Tier 1
MULTIVITAMINS
MULTI VITAMI TAB D-3
Tier 1
multiple vitamin cap (Mv-one)
Tier 1
multiple vitamin tab (Daily Vite)
Tier 1
PED MULTI VITAMINS W/FL & FE pediatric multiple vitamins w/ fl-fe drops 0.2510 mg/ml (Multi-vit/iron/fluoride)
Tier 1
PED MULTIPLE VITAMINS W/ MINERALS pediatric multiple vitamin w/ minerals & c chew tab (Mvw Complete Formulation)
Tier 1
Requirements/Limits QL (70 ea / 10 days) PA
MAIL MAIL
MAIL, PA MAIL MAIL
OTC OTC
OTC
OTC OTC
OTC OTC OTC QL (50 mL / 30 days)
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
135
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
pediatric multiple vitamin w/ minerals & c chew Tier 1 tab (Polyvitamin/iron)
pediatric multiple vitamin w/ minerals & c drops 45 mg/ml (Aquadeks)
Tier 1
PED MV W/ FLUORIDE
pediatric multiple vitamins w/ fluoride chew tab Tier 1 0.5 mg (Multivitamin/fluoride)
pediatric multiple vitamins w/ fluoride chew tab Tier 1 0.25 mg (Multivitamin/fluoride)
pediatric multiple vitamins w/ fluoride chew tab Tier 1 1 mg (Multivitamin/fluoride)
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml (Multivitamin With Fluorid)
Tier 1
pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml (Multivitamin With Fluorid)
Tier 1
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml (Tri-vitamin/fluoride)
Tier 1
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml (Tri-vitamin/fluoride)
Tier 1
PED MV W/ IRON
ANIMAL SHAPE CHW IRON (pediatric multiple vitamins w/ iron)
Tier 1
MULTIVITAMIN DRO /IRON (pediatric multiple vitamins w/ iron)
Tier 2
pediatric multiple vitamins w/ iron chew tab 15 mg (Chewable Vite With Iron/c)
Tier 1
pediatric multiple vitamins w/ iron drops 10 mg/ml (Bprotected Pedia Poly-vit)
Tier 1
PEDIATRIC MULTIPLE VITAMINS
MULT VITAM DRO (pediatric multiple vitamins)
Tier 2
pediatric multiple vitamin liq (Multi-delyn)
Tier 1
pediatric multiple vitamin w/ c & fa chew tab (Chewable Vite Childrens)
Tier 1
pediatric multiple vitamin w/ c soln 35 mg/ml (Bprotected Pedia Poly-vit)
Tier 1
pediatric multiple vitamin w/ extra c & fa chew tab (Land Before Time Multivit)
Tier 1
POLY-VI-SOL SOL 50MG/ML (pediatric multiple vitamin w/ c)
Tier 2
PEDIATRIC VITAMINS
pediatric vitamins adc drops 750 unit-400 unit35 mg/ml (Bprotected Pedia Tri-vite)
Tier 1
TRI-VI-SOL SOL A/C/D (pediatric vitamins adc)
Tier 2
Requirements/Limits OTC OTC
QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (50 mL / 30 days) QL (50 mL / 30 days) QL (50 mL / 30 days) QL (50 mL / 30 days)
OTC OTC OTC OTC
OTC, QL (50 / 30 days) OTC OTC OTC OTC OTC
OTC, QL (50 / 30 days) OTC, QL (50 / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
136
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
PRENATAL VITAMINS
BE WELL PAK ROUNDED (prenatal vit w/ fe bisglycinate-folic acid-omega 3 fatty acd)
Tier 1
BRAINSTRONG MIS PRENATAL (prenatal mv & min w/fe carbonyl-fa-dha)
Tier 1
CALNA TAB (prenatal vitamin)
Tier 1
CENTRUM SPEC PAK PRENATAL (prenatal mv & min w/fe fumarate-fa-dha) CO-NATAL FA TAB 29-1MG (prenatal vit w/ ferrous fumarate-folic acid) CVS PRENATAL CHW GUMMY (prenatal multivitamins & minerals w/ folic acid-fish oil) ENFAMIL MIS EXPECTA (prenatal mv & min w/fe fumarate-fa-dha) EZFE FORTE CAP (prenatal without vit a w/ iron polysaccharide complex-fa) KPN PRENATAL TAB (prenatal multivit-min w/fefa) MYNATAL CAP (prenatal multivit-min w/fe-fa)
MYNATAL TAB (prenatal vit w/ docusate-iron carbonyl-folic acid) MYNATE 90 TAB PLUS (prenatal vit w/ docusatefe fumarate-folic acid) NATALVIT TAB 75-1MG (prenatal vit w/ ferrous fumarate-folic acid) NESTABS TAB (prenatal vit without vit a w/ fe bisglycinate-folic acid) NUTRIENTS TAB PRENATAL (prenatal vitamins w/ ferrous succinate-folic acid) O-CAL TAB PRENATAL (prenatal vit w/ ferrous fumarate-folic acid) ONE A DAY MIS PRENATAL (prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids) PERRY PRENAT CAP (prenatal vit w/ ferrous fumarate-folic acid) PRENAT MULTI CAP +DHA (prenatal mv & min w/fe fumarate-fa-dha) PRENATAL 19 TAB 29-1MG (prenatal vit w/ docusate-fe fumarate-folic acid) PRENATAL CAP FORMULA (prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids) PRENATAL CAP OMEGA-3 (prenatal vit w/ ferrous fumarate-fa-fish oil) PRENATAL DHA PAK MULTI (prenatal mv & min w/ methylfolate-choline-fish oil)
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits
OTC
OTC, QL (30 tabs / 30 days) OTC, QL (30 tabs / 30 days) OTC, QL (30 tabs / 30 days) QL (30 tabs / 30 days)
OTC, QL (30 tabs / 30 days) OTC, QL (60 tabs / 30 days) OTC, QL (30 caps / 30 days) OTC, QL (30 tabs / 30 days) QL (30 caps / 30 days) QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
OTC, QL (30 tabs / 30 days) QL (30 tabs / 30 days)
OTC, QL (30 caps / 30 days) OTC, QL (30 caps / 30 days) OTC, QL (30 caps / 30 days) QL (30 tabs / 30 days)
OTC, QL (30 caps / 30 days) OTC, QL (30 caps / 30 days) OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
137
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
PRENATAL FRM TAB A-FREE (prenatal without a vit Tier 1
w/ fe fumarate-folic acid)
PRENATAL MUL CAP +DHA (prenatal vit w/ ferrous Tier 1
fumarate-fa-omega 3 fatty acids)
PRENATAL TAB (prenatal vit w/ ferrous fumarate-folic acid)
Tier 1
PRENATAL TAB COMPLETE (prenatal vit w/ ferrous Tier 1
fumarate-folic acid)
PRENATAL TAB FORMULA (prenatal vit w/
Tier 1
selenium-fe fumarate-folic acid)
prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg Tier 1
(Prenatal 19)
prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg (Inatal Gt)
Tier 1
prenatal vit w/ fe fumarate-fa chew tab 29-1
Tier 1
mg (Prenatal 19)
prenatal vit w/ fe fumarate-fa tab 28-1 mg
Tier 1
(Trinate)
prenatal vit w/ iron carbonyl-fa tab 29-1 mg
Tier 1
(Prenatabs Rx)
PRENATAL+DHA MIS (prenatal mv & min w/fe
Tier 1
fumarate-fa-dha)
PRENATAL/FE TAB (prenatal multivit-min w/fe-
Tier 1
fa)
RA PRENATAL TAB FORMULA (prenatal vit w/
Tier 1
ferrous fumarate-folic acid)
SE-NATAL 19 CHW (prenatal vit w/ ferrous
Tier 1
fumarate-folic acid)
SM ONE DAILY MIS PRENATAL (prenatal vit w/
Tier 1
ferrous fumarate-fa-omega 3 fatty acids)
THERANATAL MIS COMPLETE (prenatal mv & min
Tier 1
w/fe fumarate-fa-dha)
TL FOLATE TAB (prenatal vit w/ ferrous fumarate-l methylfolate-folic acid)
Tier 1
TRINATAL RX TAB 1 (prenatal vit w/ ferrous fumarate-folic acid)
Tier 1
VINATE II TAB (prenatal vit w/ fe bisglycinate
Tier 1
chelate-folic acid)
VINATE M TAB (prenatal vit w/ selenium-fe
Tier 1
fumarate-folic acid)
VITAFOL-OB TAB 65-1MG (prenatal vit w/ ferrous Tier 1
fumarate-folic acid)
VOL-PLUS TAB (prenatal vit w/ ferrous fumarate- Tier 1 folic acid)
VOL-TAB RX TAB (prenatal vit w/ iron carbonyl-
Tier 1
folic acid)
Requirements/Limits OTC, QL (30 tabs / 30 days) OTC, QL (30 caps / 30 days) OTC, QL (30 tabs / 30 days) OTC, QL (30 tabs / 30 days) OTC, QL (30 tabs / 30 days) QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
OTC, QL (30 tabs / 30 days) OTC, QL (30 tabs / 30 days) OTC, QL (30 tabs / 30 days) QL (30 tabs / 30 days)
OTC, QL (30 tabs / 30 days) OTC, QL (30 tabs / 30 days) QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
138
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name MUSCULOSKELETAL THERAPY AGENTS
CENTRAL MUSCLE RELAXANTS baclofen tab 10 mg
baclofen tab 20 mg
carisoprodol tab 350 mg chlorzoxazone tab 500 mg cyclobenzaprine hcl tab 5 mg cyclobenzaprine hcl tab 10 mg metaxalone tab 800 mg methocarbamol tab 500 mg
Drug Tier
Tier 1
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1
methocarbamol tab 750 mg
Tier 1
orphenadrine citrate tab er 12hr 100 mg tizanidine hcl tab 2 mg (base equivalent)
Tier 1 Tier 1
tizanidine hcl tab 4 mg (base equivalent)
Tier 1
DIRECT MUSCLE RELAXANTS dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dantrolene sodium cap 100 mg
VISCOSUPPLEMENTS EUFLEXXA INJ 10MG/ML (sodium hyaluronate (viscosupplement)) VISCO-3 INJ 25/2.5ML (sodium hyaluronate (viscosupplement))
NASAL AGENTS - SYSTEMIC AND TOPICAL
NASAL AGENTS - MISC. saline nasal spray 0.65% (Cvs Saline Nasal Spray)
NASAL ANTIALLERGY azelastine hcl nasal spray 0.1% (137 mcg/spray)
Tier 1 Tier 1 Tier 1 Tier 4 Tier 4
Tier 1 Tier 1
Requirements/Limits
QL (90 tabs / 30 days), MAIL QL (120 tabs / 30 days), MAIL QL (120 tabs / 30 days) QL (180 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) PA AGE, QL (180 tabs / 30 days); AGE (Max 64 years) AGE, QL (300 tabs / 30 days); AGE (Max 64 years) QL (60 tabs / 30 days) AGE, QL (240 tabs / 30 days), MAIL; AGE (Max 64 years) AGE, QL (270 tabs / 30 days), MAIL; AGE (Max 64 years)
QL (3 syringes / 180 days), PA PA
OTC
QL (30 mL / 30 days), MAIL, ST; Prior use of TWO of the following within the past 90 days: fluticasone spray, triamcinolone spray, ipratropium spray, cromolyn spray
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
139
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%)
Tier 1
olopatadine hcl nasal soln 0.6%
Tier 3
NASAL ANTICHOLINERGICS ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray)
NASAL STEROIDS budesonide nasal susp 32 mcg/act (Ra Budesonide Nasal Spray) flunisolide nasal soln 25 mcg/act (0.025%)
Tier 1 Tier 1
Tier 1 Tier 1
fluticasone propionate nasal susp 50 mcg/act
Tier 1
OMNARIS SPR (ciclesonide (nasal))
triamcinolone acetonide nasal aerosol suspension 55 mcg/act (Goodsense Nasal Allergy S)
SYMPATHOMIMETIC DECONGESTANTS NASAL DECON SYP 30MG/5ML (pseudoephedrine hcl) NASAL DECONG LIQ 30MG/5ML (pseudoephedrine hcl) oxymetazoline hcl nasal soln 0.05% (Cvs Nasal Spray) phenylephrine hcl tab 10 mg (Cvs Nasal Decongestant Pe) pseudoephedrine hcl liq 15 mg/5ml (Childrens Silfedrine) pseudoephedrine hcl tab 30 mg (Cvs Nasal Decongestant)
Tier 3 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Requirements/Limits OTC, QL (52 mL / 30 days), MAIL QL (30.5 gm / 30 days), MAIL, ST; Prior use of TWO of the following within the past 90 days: fluticasone spray, triamcinolone spray, ipratropium spray, cromolyn spray
QL (30 mL / 30 days), MAIL QL (15 mL / 30 days), MAIL
OTC, QL (1 bottle / 30 days), MAIL QL (25 mL / 30 days), MAIL, ST; Prior use of TWO of the following within the past 90 days: fluticasone spray, triamcinolone spray, ipratropium spray, cromolyn spray AGE, QL (16 gm / 30 days), MAIL; AGE (Min 4 years) MAIL, PA OTC, QL (16.9 mL / 30 days), MAIL
OTC
OTC
OTC
OTC
OTC
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
140
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
pseudoephedrine hcl tab 60 mg
Tier 1 OTC
pseudoephedrine hcl tab er 12hr 120 mg (12 Hour Decongestant)
Tier 1 OTC
SUDAFED PE SOL CHILDREN (phenylephrine hcl (oral))
Tier 1 OTC
NEUROMUSCULAR AGENTS
ALS AGENTS
riluzole tab 50 mg
Tier 3 QL (60 tabs / 30 days), MAIL, PA
NEUROMUSCULAR BLOCKING AGENT - NEUROTOXINS
BOTOX INJ 100UNIT (onabotulinumtoxina)
Tier 4 PA
BOTOX INJ 200UNIT (onabotulinumtoxina)
Tier 4 PA
NUTRIENTS
MISC. NUTRITIONAL SUBSTANCES
docosahexaenoic acid cap 200 mg (Prenatal Dha)
Tier 1 OTC, QL (30 caps / 30 days)
omega-3 fatty acids cap 300 mg
Tier 1 OTC
omega-3 fatty acids cap 500 mg
Tier 1 OTC
omega-3 fatty acids cap 1000 mg
Tier 1 OTC
omega-3 fatty acids cap 1200 mg
Tier 1 OTC
omega-3 fatty acids cap delayed release 1000 mg (Hm Fish Oil)
Tier 1 OTC
omega-3 fatty acids cap delayed release 1200 mg (Cvs Fish Oil)
Tier 1 OTC
OPHTHALMIC AGENTS
ARTIFICIAL TEARS AND LUBRICANTS
artificial tear ophth ointment (Akwa Tears)
Tier 1 OTC, MAIL
artificial tear ophth solution (Sm Artificial Tears)
Tier 1 OTC, MAIL
carboxymethylcellulose sodium (pf) ophth soln 0.5% (Hm Lubricating Plus)
Tier 1 OTC, MAIL
carboxymethylcellulose sodium ophth soln 0.5% (Cvs Lubricant Eye Drops)
Tier 1 OTC, MAIL
dextran 70-hypromellose (pf) ophth soln 0.10.3% (Cvs Natural Tears)
Tier 1 OTC, MAIL
dextran 70-hypromellose ophth soln 0.1-0.3% (Artificial Tears)
Tier 1 OTC, MAIL
glycerin-hypromellose-peg 400 ophth soln 0.20.2-1% (Cvs Dry Eye Relief)
Tier 1 OTC, MAIL
hypromellose ophth soln 0.3% (Pure & Gentle Lubricant)
Tier 1 OTC, MAIL
LACRISERT MIS 5MG OP (artificial tear insert)
Tier 3 MAIL, PA
polyethylene glycol-propylene glycol ophth soln 0.4-0.3% (Lubricant Eye Drops)
Tier 1 OTC, MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
141
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
polyvinyl alcohol ophth soln 1.4% (Artificial Tears)
Tier 1
polyvinyl alcohol-povidone ophth soln 5-6 mg/ml (0.5-0.6%) (Gnp Artificial Tears)
Tier 1
propylene glycol-glycerin ophth soln 1-0.3% (Ra Tier 1 Lubricant Eye Drops)
white petrolatum-mineral oil ophth ointment (Genteal Tears Night-time)
Tier 1
BETA-BLOCKERS - OPHTHALMIC
betaxolol hcl ophth soln 0.5%
Tier 1
carteolol hcl ophth soln 1%
Tier 1
COMBIGAN SOL 0.2/0.5% (brimonidine tartratetimolol maleate) dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml levobunolol hcl ophth soln 0.5%
Tier 2 Tier 1 Tier 1
timolol maleate ophth gel forming soln 0.5%
Tier 3
timolol maleate ophth gel forming soln 0.25%
Tier 3
timolol maleate ophth soln 0.5%
Tier 1
timolol maleate ophth soln 0.25%
Tier 1
CYCLOPLEGIC MYDRIATICS ATROPINE SUL SOL 1% OP
Tier 2
cyclopentolate hcl ophth soln 1% tropicamide ophth soln 0.5% tropicamide ophth soln 1%
MIOTICS PHOSPHOLINE SOL 0.125%OP (echothiophate iodide) pilocarpine hcl ophth soln 1% pilocarpine hcl ophth soln 2% pilocarpine hcl ophth soln 4%
OPHTHALMIC ADRENERGIC AGENTS apraclonidine hcl ophth soln 0.5% (base equivalent) brimonidine tartrate ophth soln 0.2%
Tier 1 Tier 1 Tier 1
Tier 2
Tier 1 Tier 1 Tier 1
Tier 1
Tier 1
brimonidine tartrate ophth soln 0.15%
Tier 3
Requirements/Limits OTC, MAIL
OTC, MAIL
OTC, MAIL
OTC, MAIL
MAIL QL (15 mL / 30 days), MAIL QL (10 mL / 30 days), MAIL QL (10 mL / 30 days), MAIL QL (15 mL / 30 days), MAIL QL (5 mL / 30 days), MAIL QL (5 mL / 30 days), MAIL QL (10 mL / 30 days), MAIL QL (10 mL / 30 days), MAIL
QL (15 mL / 30 days), MAIL QL (15 / 30 days), MAIL MAIL MAIL
MAIL
MAIL MAIL MAIL
QL (15 mL / 30 days), MAIL QL (15 mL / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
142
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
SIMBRINZA SUS 1-0.2% (brinzolamidebrimonidine tartrate)
OPHTHALMIC ANTI-INFECTIVES AZASITE SOL 1% (azithromycin (ophth)) bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint (Polycin) BESIVANCE SUS 0.6% (besifloxacin hcl) ciprofloxacin hcl ophth soln 0.3% (base equivalent) erythromycin ophth oint 5 mg/gm gatifloxacin ophth soln 0.5% gentamicin sulfate ophth oint 0.3% (Gentak) gentamicin sulfate ophth soln 0.3% levofloxacin ophth soln 0.5% moxifloxacin hcl ophth soln 0.5% (base equiv) NATACYN SUS 5% OP (natamycin) neomycin-bacitrac zn-polymyx 5(3.5)mg400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.75-100000.025mg-unt-mg/ml ofloxacin ophth soln 0.3% polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% sulfacetamide sodium ophth soln 10% tobramycin ophth soln 0.3% trifluridine ophth soln 1% ZIRGAN GEL 0.15% (ganciclovir ophthalmic)
OPHTHALMIC IMMUNOMODULATORS RESTASIS EMU 0.05% (cyclosporine (ophth))
OPHTHALMIC LOCAL ANESTHETICS proparacaine hcl ophth soln 0.5%
OPHTHALMIC STEROIDS ALREX SUS 0.2% (loteprednol etabonate) bacitracin-polymyxin-neomycin-hc ophth oint 1% dexamethasone sodium phosphate ophth soln 0.1% DUREZOL EMU 0.05% (difluprednate) fluorometholone ophth susp 0.1% LOTEMAX GEL 0.5% (loteprednol etabonate) LOTEMAX OIN 0.5% (loteprednol etabonate) LOTEMAX SUS 0.5% (loteprednol etabonate) loteprednol etabonate ophth susp 0.5%
Drug Tier Tier 3
Tier 3 Tier 1 Tier 1 Tier 3 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1
Tier 1
Tier 1 Tier 1
Tier 1 Tier 1 Tier 1 Tier 3
Tier 3
Tier 1
Tier 3 Tier 1
Tier 1
Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3
Requirements/Limits QL (8 mL / 30 days), MAIL PA
PA
PA QL (5 mL / 30 days) QL (3 mL / 30 days) PA
QL (5 mL / 30 days) QL (10 mL / 30 days) QL (15 mL / 30 days) QL (5 mL / 30 days) QL (7.5 mL / 30 days) PA
MAIL, PA
PA
QL (5 mL / 30 days) PA QL (15 mL / 30 days) PA PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
143
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
neomycin-polymyxin-dexamethasone ophth oint Tier 1
0.1%
neomycin-polymyxin-dexamethasone ophth
Tier 1
susp 0.1%
prednisolone acetate ophth susp 1%
Tier 1
sulfacetamide sodium-prednisolone ophth soln
Tier 1
10-0.23(0.25)%
TOBRADEX OIN 0.3-0.1% (tobramycindexamethasone)
Tier 2
tobramycin-dexamethasone ophth susp 0.3-
Tier 1
0.1%
OPHTHALMICS - MISC.
ALOCRIL SOL 2% (nedocromil sodium (ophth))
Tier 3
ALOMIDE SOL 0.1% OP (lodoxamide
Tier 3
tromethamine)
azelastine hcl ophth soln 0.05%
Tier 1
AZOPT SUS 1% OP (brinzolamide)
Tier 2
BEPREVE DRO 1.5% (bepotastine besilate) bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) cromolyn sodium ophth soln 4%
Tier 3 Tier 3
Tier 1
CYSTARAN SOL 0.44% (cysteamine hcl) diclofenac sodium ophth soln 0.1% dorzolamide hcl ophth soln 2%
Tier 3 Tier 1 Tier 1
EMADINE SOL 0.05% OP (emedastine difumarate) epinastine hcl ophth soln 0.05%
Tier 3 Tier 1
flurbiprofen sodium ophth soln 0.03% ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% ketotifen fumarate ophth soln 0.025% (base equiv) LASTACAFT SOL 0.25% (alcaftadine) NEVANAC SUS 0.1% (nepafenac) olopatadine hcl ophth soln 0.1% (base equivalent) olopatadine hcl ophth soln 0.2% (base equivalent) sodium chloride hypertonic ophth oint 5% (Cvs Sodium Chloride) sodium chloride hypertonic ophth soln 5% (Cvs Sodium Chloride)
Tier 1 Tier 1 Tier 1 Tier 1
Tier 3 Tier 3 Tier 3
Tier 3
Tier 1
Tier 1
Requirements/Limits
QL (3.5 gm / 30 days)
QL (10 mL / 30 days)
MAIL, PA MAIL, PA
QL (6 mL / 30 days), MAIL QL (10 mL / 30 days), MAIL MAIL, PA
QL (10 mL / 30 days), MAIL MAIL, PA
QL (10 mL / 30 days), MAIL MAIL, PA QL (5 mL / 30 days), MAIL
QL (10 mL / 30 days) QL (10 mL / 30 days) OTC, QL (5 mL / 30 days), MAIL MAIL, PA PA QL (5 mL / 30 days), MAIL, PA QL (2.5 mL / 30 days), MAIL, PA OTC
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
144
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
PROSTAGLANDINS - OPHTHALMIC bimatoprost ophth soln 0.03%
Drug Tier Tier 1
latanoprost ophth soln 0.005% LUMIGAN SOL 0.01% (bimatoprost)
Tier 1 Tier 3
TRAVATAN Z DRO 0.004% (travoprost)
Tier 2
travoprost ophth soln 0.004% (benzalkonium free) (bak free)
ZIOPTAN DRO 0.0015% (tafluprost)
Tier 1 Tier 2
OTIC AGENTS
OTIC AGENTS - MISCELLANEOUS acetic acid otic soln 2% carbamide peroxide 6.5% otic soln (Ear Drops Earwax Removal) isopropyl alcohol-glycerin otic liquid 95-5% (Ra Ear Drying Agent)
OTIC ANTI-INFECTIVES ciprofloxacin hcl otic soln 0.2% (base equivalent) ofloxacin otic soln 0.3%
OTIC COMBINATIONS CIPRO HC SUS OTIC (ciprofloxacinhydrocortisone) CIPRODEX SUS 0.3-0.1% (ciprofloxacindexamethasone) COLY-MYCIN S SUS OTIC (neomycin-colistin-hcthonzonium) neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 mg/ml10000 unit/ml-1%
Tier 1 Tier 1 Tier 1
Tier 1 Tier 1
Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
Requirements/Limits
QL (5 mL / 30 days), MAIL, ST; Prior use of latanoprost within the past 90 days. QL (5 mL / 30 days), MAIL QL (5 mL / 30 days), MAIL, ST; Prior use of latanoprost within the past 90 days. QL (5 mL / 30 days), MAIL, ST; Prior use of latanoprost within the past 90 days. QL (5 mL / 30 days), MAIL, ST; Prior use of latanoprost within the past 90 days. QL (30 ea / 30 days), MAIL, ST; Prior use of latanoprost within the past 90 days.
OTC
OTC
QL (14 ea / 30 days)
QL (5 mL / 30 days)
PA
PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
145
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
OTIC STEROIDS
fluocinolone acetonide (otic) oil 0.01%
Tier 1
hydrocortisone w/ acetic acid otic soln 1-2%
Tier 1
OXYTOCICS
OXYTOCICS
methylergonovine maleate tab 0.2 mg
Tier 3
PASSIVE IMMUNIZING AND TREATMENT AGENTS
IMMUNE SERUMS
CARIMUNE NF INJ 12GM (immune globulin (human) iv)
Tier 4
CUVITRU INJ 4GM/20ML (immune globulin (human) subcutaneous)
Tier 4
CUVITRU SOL 1GM/5ML (immune globulin (human) subcutaneous)
Tier 4
CUVITRU SOL 10GM/50M (immune globulin (human) subcutaneous)
Tier 4
FLEBOGAMMA INJ DIF 5% (immune globulin (human) iv)
Tier 4
GAMASTAN INJ (immune globulin (human) im)
Tier 4
GAMMAGARD INJ 1GM/10ML (immune globulin (human) iv or subcutaneous)
Tier 4
GAMMAGARD SD INJ 10GM HU (immune globulin (human) iv)
Tier 4
HIZENTRA INJ 1GM/5ML (immune globulin (human) subcutaneous)
Tier 4
HIZENTRA INJ 2GM/10ML (immune globulin (human) subcutaneous)
Tier 4
HIZENTRA INJ 4GM/20ML (immune globulin (human) subcutaneous)
Tier 4
HIZENTRA INJ 10/50ML (immune globulin (human) subcutaneous)
Tier 4
HIZENTRA SOL 20% (immune globulin (human) subcutaneous)
Tier 4
OCTAGAM INJ 5GM (immune globulin (human) iv) Tier 4
PRIVIGEN INJ 20GRAMS (immune globulin (human) iv)
Tier 4
RHOGAM PLUS INJ 300MCG (rho d immune globulin (human))
Tier 2
MONOCLONAL ANTIBODIES
SYNAGIS INJ 50MG (palivizumab)
Tier 4
SYNAGIS INJ 100MG/ML (palivizumab)
Tier 4
PASSIVE IMMUNIZING AGENTS - COMBINATIONS
HYQVIA INJ 2.5-200 (immune globulin (human)hyaluronidase (human recombinant))
Tier 4
Requirements/Limits
PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA
PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
146
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
HYQVIA INJ 5-400 (immune globulin (human)hyaluronidase (human recombinant))
Tier 4
HYQVIA INJ 10-800 (immune globulin (human)hyaluronidase (human recombinant))
Tier 4
HYQVIA INJ 20-1600 (immune globulin (human)hyaluronidase (human recombinant))
Tier 4
HYQVIA INJ 30-2400 (immune globulin (human)hyaluronidase (human recombinant))
Tier 4
PENICILLINS
AMINOPENICILLINS
amoxicillin (trihydrate) cap 250 mg
Tier 1
amoxicillin (trihydrate) cap 500 mg
Tier 1
amoxicillin (trihydrate) chew tab 125 mg
Tier 1
amoxicillin (trihydrate) chew tab 250 mg
Tier 1
amoxicillin (trihydrate) for susp 125 mg/5ml
Tier 1
amoxicillin (trihydrate) for susp 200 mg/5ml
Tier 1
amoxicillin (trihydrate) for susp 250 mg/5ml
Tier 1
amoxicillin (trihydrate) for susp 400 mg/5ml
Tier 1
amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg ampicillin cap 500 mg
NATURAL PENICILLINS penicillin v potassium for soln 125 mg/5ml
Tier 3 Tier 1 Tier 1
Tier 1
penicillin v potassium for soln 250 mg/5ml
Tier 1
penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg
PENICILLIN COMBINATIONS amoxicillin & k clavulanate chew tab 200-28.5 mg amoxicillin & k clavulanate chew tab 400-57 mg
Tier 1 Tier 1
Tier 3 Tier 3
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 400-57 mg/5ml
Tier 1 Tier 3 Tier 1
Requirements/Limits PA
PA
PA
PA
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years) AGE; AGE (Max 12 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
147
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
Tier 1 AGE; AGE (Max 12 years)
amoxicillin & k clavulanate tab 250-125 mg
Tier 1 QL (20 tabs / 10 days)
amoxicillin & k clavulanate tab 500-125 mg
Tier 1 QL (20 tabs / 10 days)
amoxicillin & k clavulanate tab 875-125 mg
Tier 1 QL (20 tabs / 10 days)
AUGMENTIN SUS 125/5ML (amoxicillin & pot clavulanate)
Tier 3 AGE; AGE (Max 12 years)
PENICILLINASE-RESISTANT PENICILLINS
dicloxacillin sodium cap 250 mg
Tier 1
dicloxacillin sodium cap 500 mg
Tier 1
PROGESTINS
PROGESTINS
hydroxyprogesterone caproate im in oil 250 mg/ml
Tier 4 PA
medroxyprogesterone acetate tab 2.5 mg
Tier 1 QL (60 tabs / 30 days), MAIL
medroxyprogesterone acetate tab 5 mg
Tier 1 QL (60 tabs / 30 days), MAIL
medroxyprogesterone acetate tab 10 mg
Tier 1 QL (60 tabs / 30 days), MAIL
norethindrone acetate tab 5 mg
Tier 1 QL (30 tabs / 30 days), MAIL
progesterone micronized cap 100 mg
Tier 1 QL (30 caps / 30 days), MAIL
progesterone micronized cap 200 mg
Tier 1 QL (60 caps / 30 days), MAIL
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
AGENTS FOR CHEMICAL DEPENDENCY
acamprosate calcium tab delayed release 333 mg
Tier 1 MAIL
disulfiram tab 250 mg
Tier 1 QL (30 tabs / 30 days), MAIL
disulfiram tab 500 mg
Tier 1 QL (30 tabs / 30 days), MAIL
ANTI-CATAPLECTIC AGENTS
XYREM SOL 500MG/ML (sodium oxybate)
Tier 4 PA
ANTIDEMENTIA AGENTS
donepezil hydrochloride orally disintegrating tab 5 mg
Tier 1 QL (60 tabs / 30 days), MAIL
donepezil hydrochloride orally disintegrating tab 10 mg
Tier 1 QL (30 tabs / 30 days), MAIL
donepezil hydrochloride tab 5 mg
Tier 1 QL (30 tabs / 30 days), MAIL
donepezil hydrochloride tab 10 mg
Tier 1 QL (30 tabs / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
148
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name galantamine hydrobromide cap er 24hr 8 mg galantamine hydrobromide cap er 24hr 16 mg galantamine hydrobromide cap er 24hr 24 mg galantamine hydrobromide tab 4 mg galantamine hydrobromide tab 8 mg galantamine hydrobromide tab 12 mg memantine hcl cap er 24hr 7 mg memantine hcl cap er 24hr 14 mg memantine hcl cap er 24hr 21 mg memantine hcl cap er 24hr 28 mg memantine hcl oral solution 2 mg/ml memantine hcl tab 5 mg
memantine hcl tab 10 mg
memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack rivastigmine tartrate cap 1.5 mg (base equivalent) rivastigmine tartrate cap 3 mg (base equivalent) rivastigmine tartrate cap 4.5 mg (base equivalent) rivastigmine tartrate cap 6 mg (base equivalent) rivastigmine td patch 24hr 4.6 mg/24hr rivastigmine td patch 24hr 9.5 mg/24hr rivastigmine td patch 24hr 13.3 mg/24hr
FIBROMYALGIA AGENTS SAVELLA MIS TITR PAK (milnacipran hcl) SAVELLA TAB 12.5MG (milnacipran hcl) SAVELLA TAB 25MG (milnacipran hcl) SAVELLA TAB 50MG (milnacipran hcl) SAVELLA TAB 100MG (milnacipran hcl)
MOVEMENT DISORDER DRUG THERAPY tetrabenazine tab 12.5 mg tetrabenazine tab 25 mg
MULTIPLE SCLEROSIS AGENTS AUBAGIO TAB 7MG (teriflunomide) AUBAGIO TAB 14MG (teriflunomide) AVONEX KIT 30MCG (interferon beta-1a) AVONEX PEN KIT 30MCG (interferon beta-1a) AVONEX PREFL KIT 30MCG (interferon beta-1a) dalfampridine tab er 12hr 10 mg
Drug Tier Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
Tier 1
Tier 1
Requirements/Limits
MAIL MAIL MAIL MAIL MAIL MAIL MAIL, PA MAIL, PA MAIL, PA MAIL, PA MAIL QL (60 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (49 tabs / year)
Tier 3 MAIL
Tier 3 MAIL
Tier 3 MAIL
Tier 3 MAIL
Tier 3 Tier 3 Tier 3
MAIL, PA MAIL, PA MAIL, PA
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
MAIL, PA MAIL, PA MAIL, PA MAIL, PA MAIL, PA
Tier 4 PA Tier 4 PA
Tier 4 PA Tier 4 PA Tier 4 PA Tier 4 PA Tier 4 PA Tier 4 PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
149
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
EXTAVIA INJ 0.3MG (interferon beta-1b)
Tier 4 PA
GILENYA CAP 0.5MG (fingolimod hcl)
Tier 4 PA
glatiramer acetate soln prefilled syringe 20 mg/ml (Glatopa)
Tier 4 PA
glatiramer acetate soln prefilled syringe 40 mg/ml
Tier 4 PA
MAYZENT TAB 0.25MG (siponimod fumarate)
Tier 4 PA
PLEGRIDY INJ (peginterferon beta-1a)
Tier 4 PA
PLEGRIDY INJ PEN (peginterferon beta-1a)
Tier 4 PA
PLEGRIDY INJ STARTER (peginterferon beta-1a)
Tier 4 PA
PLEGRIDY PEN INJ STARTER (peginterferon beta1a)
Tier 4 PA
TECFIDERA CAP 120MG (dimethyl fumarate)
Tier 4 PA
TECFIDERA CAP 240MG (dimethyl fumarate)
Tier 4 PA
TECFIDERA MIS STARTER (dimethyl fumarate)
Tier 4 PA
TYSABRI INJ 300/15ML (natalizumab)
Tier 4 PA
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
ergoloid mesylates tab 1 mg
Tier 3 MAIL, PA
pimozide tab 1 mg
Tier 1 QL (300 tabs / 30 days), MAIL
pimozide tab 2 mg
Tier 1 QL (150 tabs / 30 days), MAIL
SMOKING DETERRENTS
bupropion hcl (smoking deterrent) tab er 12hr 150 mg
Tier 5 QL (60 tabs / 30 days), MAIL
CHANTIX PAK 0.5& 1MG (varenicline tartrate)
Tier 5 QL (53 tabs / year), MAIL
CHANTIX TAB 0.5MG (varenicline tartrate)
Tier 5 QL (60 tabs / 30 days), MAIL
CHANTIX TAB 1MG (varenicline tartrate)
Tier 5 QL (60 tabs / 30 days), MAIL
nicotine polacrilex gum 2 mg
Tier 5 OTC, QL (240 pieces / 30 days), MAIL
nicotine polacrilex gum 4 mg (Cvs Nicotine Polacrilex)
Tier 5 OTC, QL (240 pieces / 30 days), MAIL
nicotine polacrilex lozenge 2 mg (Cvs Nicotine Lozenge)
Tier 5 OTC, QL (240 lozgs / 30 days), MAIL
nicotine polacrilex lozenge 4 mg (Eq Nicotine Polacrilex)
Tier 5 OTC, QL (240 lozgs / 30 days), MAIL
NICOTINE SYS KIT TRANSDER
Tier 5 OTC, QL (56 patches / 30 days), MAIL
nicotine td patch 24hr 7 mg/24hr (Nicotine Transdermal Syst)
Tier 5 OTC, QL (30 patches / 30 days), MAIL
nicotine td patch 24hr 14 mg/24hr (Hm Nicotine Transdermal S)
Tier 5 OTC, QL (30 patches / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
150
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
nicotine td patch 24hr 21 mg/24hr (Cvs Nicotine Transdermal)
Tier 5
NICOTROL INH (nicotine)
Tier 5
NICOTROL NS SPR 10MG/ML (nicotine)
Tier 5
RESPIRATORY AGENTS - MISC.
ALPHA-PROTEINASE INHIBITOR (HUMAN) GLASSIA INJ (alpha1-proteinase inhibitor (human)) PROLASTIN-C INJ 1000MG (alpha1-proteinase inhibitor (human))
CYSTIC FIBROSIS AGENTS KALYDECO PAK 25MG (ivacaftor) KALYDECO PAK 50MG (ivacaftor) KALYDECO PAK 75MG (ivacaftor) KALYDECO TAB 150MG (ivacaftor) PULMOZYME SOL 1MG/ML (dornase alfa)
PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG (pirfenidone) ESBRIET TAB 267MG (pirfenidone) ESBRIET TAB 801MG (pirfenidone)
SULFONAMIDES
SULFONAMIDES SULFADIAZINE TAB 500MG
TETRACYCLINES
TETRACYCLINES demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate tab 20 mg doxycycline hyclate tab 100 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 100 mg doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 100 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl cap 100 mg tetracycline hcl cap 250 mg tetracycline hcl cap 500 mg
Tier 4
Tier 4
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
Tier 4 Tier 4 Tier 4
Tier 3
Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
Requirements/Limits OTC, QL (30 patches / 30 days), MAIL QL (480 cartridges / 30 days), MAIL QL (40 mL / 30 days), MAIL
PA
PA
PA PA PA PA PA
PA PA PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
151
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
THYROID AGENTS
ANTITHYROID AGENTS methimazole tab 5 mg methimazole tab 10 mg propylthiouracil tab 50 mg
THYROID HORMONES ARMOUR THYRO TAB 15MG (thyroid) ARMOUR THYRO TAB 30MG (thyroid) ARMOUR THYRO TAB 60MG (thyroid) ARMOUR THYRO TAB 90MG (thyroid) ARMOUR THYRO TAB 120MG (thyroid) ARMOUR THYRO TAB 180MG (thyroid) ARMOUR THYRO TAB 240MG (thyroid) ARMOUR THYRO TAB 300MG (thyroid) levothyroxine sodium tab 25 mcg (Levoxyl) levothyroxine sodium tab 50 mcg (Levoxyl) levothyroxine sodium tab 75 mcg (Levoxyl) levothyroxine sodium tab 88 mcg (Levoxyl) levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg (Levoxyl) levothyroxine sodium tab 125 mcg (Levoxyl) levothyroxine sodium tab 137 mcg (Levoxyl) levothyroxine sodium tab 150 mcg (Levoxyl) levothyroxine sodium tab 175 mcg (Levoxyl) levothyroxine sodium tab 200 mcg levothyroxine sodium tab 300 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 25 mcg liothyronine sodium tab 50 mcg NATURE THROI TAB 162.5MG (thyroid) NATURE-THROI TAB 16.25MG (thyroid) NATURE-THROI TAB 32.5MG (thyroid) NATURE-THROI TAB 48.75MG (thyroid) NATURE-THROI TAB 65MG (thyroid) NATURE-THROI TAB 97.5MG (thyroid) NATURE-THROI TAB 113.75MG (thyroid) NATURE-THROI TAB 130MG (thyroid) NATURE-THROI TAB 146.25MG (thyroid) NATURE-THROI TAB 195MG (thyroid) NATURE-THROI TAB 260MG (thyroid) NATURE-THROI TAB 325MG (thyroid) SYNTHROID TAB 25MCG (levothyroxine sodium) SYNTHROID TAB 50MCG (levothyroxine sodium)
Drug Tier Requirements/Limits
Tier 1 Tier 1 Tier 1
MAIL MAIL MAIL
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
152
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
SYNTHROID TAB 75MCG (levothyroxine sodium)
Tier 2 MAIL
SYNTHROID TAB 88MCG (levothyroxine sodium)
Tier 2 MAIL
SYNTHROID TAB 100MCG (levothyroxine sodium) Tier 2 MAIL
SYNTHROID TAB 112MCG (levothyroxine sodium) Tier 2 MAIL
SYNTHROID TAB 125MCG (levothyroxine sodium) Tier 2 MAIL
SYNTHROID TAB 137MCG (levothyroxine sodium) Tier 2 MAIL
SYNTHROID TAB 150MCG (levothyroxine sodium) Tier 2 MAIL
SYNTHROID TAB 175MCG (levothyroxine sodium) Tier 2 MAIL
SYNTHROID TAB 200MCG (levothyroxine sodium) Tier 2 MAIL
SYNTHROID TAB 300MCG (levothyroxine sodium) Tier 2 MAIL
thyroid tab 15 mg (1/4 grain) (Np Thyroid 15)
Tier 1 MAIL
thyroid tab 30 mg (1/2 grain) (Np Thyroid 30)
Tier 1 MAIL
thyroid tab 60 mg (1 grain) (Np Thyroid 60)
Tier 1 MAIL
thyroid tab 90 mg (1 1/2 grain) (Np Thyroid 90)
Tier 1 MAIL
thyroid tab 120 mg (2 grain) (Np Thyroid 120)
Tier 1 MAIL
THYROLAR-1 TAB 60MG (liotrix (t3-t4))
Tier 2 MAIL
THYROLAR-1/2 TAB 30MG (liotrix (t3-t4))
Tier 2 MAIL
THYROLAR-1/4 TAB 15MG (liotrix (t3-t4))
Tier 2 MAIL
THYROLAR-2 TAB 120MG (liotrix (t3-t4))
Tier 2 MAIL
THYROLAR-3 TAB 180MG (liotrix (t3-t4))
Tier 2 MAIL
WP THYROID TAB 81.25MG (thyroid)
Tier 2 MAIL
TOXOIDS
TOXOID COMBINATIONS
ADACEL INJ (tetanus toxoid-diphtheria-acellular pertussis adsorb (tdap))
Tier 5
Prior history of prenatal vitamins in past 90 days required
BOOSTRIX INJ (tetanus toxoid-diphtheriaacellular pertussis adsorb (tdap))
Tier 5
Members who are not pregnant must go through provider office
TDVAX INJ 2-2 LF (tetanus-diphtheria toxoids (td))
Tier 5
AGE, QL (Max 1 injection / 10 years); AGE (Min 7 years)
TENIVAC INJ 5-2LF (tetanus-diphtheria toxoids (td))
Tier 5
AGE, QL (Max 1 injection / 10 years); AGE (Min 7 years)
ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS
ANTISPASMODICS
dicyclomine hcl cap 10 mg
Tier 1 AGE; AGE (Max 64 years)
dicyclomine hcl oral soln 10 mg/5ml
Tier 1 AGE; AGE (Max 64 years)
dicyclomine hcl tab 20 mg
Tier 1 AGE; AGE (Max 64 years)
glycopyrrolate tab 1 mg
Tier 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
153
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name glycopyrrolate tab 2 mg hyoscyamine sulfate elixir 0.125 mg/5ml (Hyosyne) hyoscyamine sulfate sl tab 0.125 mg
hyoscyamine sulfate soln 0.125 mg/ml
hyoscyamine sulfate tab 0.125 mg
hyoscyamine sulfate tab disint 0.125 mg
hyoscyamine sulfate tab er 12hr 0.375 mg
methscopolamine bromide tab 2.5 mg methscopolamine bromide tab 5 mg
H-2 ANTAGONISTS cimetidine tab 200 mg cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg famotidine for susp 40 mg/5ml
famotidine tab 10 mg famotidine tab 20 mg famotidine tab 40 mg nizatidine cap 150 mg nizatidine cap 300 mg nizatidine oral soln 15 mg/ml
ranitidine hcl tab 75 mg (Sm Acid Reducer) ranitidine hcl tab 150 mg ranitidine hcl tab 300 mg
MISC. ANTI-ULCER sucralfate tab 1 gm
PROTON PUMP INHIBITORS DEXILANT CAP 30MG DR (dexlansoprazole)
Drug Tier Tier 1 Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3 Tier 3
Requirements/Limits
AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years) AGE, MAIL; AGE (Max 64 years)
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1
MAIL MAIL MAIL MAIL AGE, QL (150 mL / 30 days), MAIL; AGE (Max 12 years) OTC, MAIL MAIL MAIL MAIL MAIL AGE, MAIL; AGE (Max 12 years) OTC, MAIL MAIL MAIL
Tier 1 QL (120 tabs / 30 days), MAIL
Tier 3
QL (30 caps / 30 days), MAIL, ST; Prior use of TWO of the following within the past 90 days: esomeprazole, omeprazole, pantoprazole
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
154
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name DEXILANT CAP 60MG DR (dexlansoprazole)
Drug Tier Tier 3
esomeprazole magnesium cap delayed release 20 mg (base eq) (Sm Esomeprazole Magnesium) FIRST-OMEPRA SUS 2MG/ML (omeprazole)
Tier 1 Tier 1
lansoprazole cap delayed release 15 mg
Tier 3
lansoprazole cap delayed release 30 mg
Tier 3
omeprazole cap delayed release 10 mg
omeprazole cap delayed release 20 mg
omeprazole cap delayed release 40 mg
omeprazole magnesium cap dr 20.6 mg (20 mg base equiv) (Cvs Omeprazole Magnesium) pantoprazole sodium ec tab 20 mg (base equiv)
pantoprazole sodium ec tab 40 mg (base equiv)
PRILOSEC OTC TAB 20MG (omeprazole magnesium) rabeprazole sodium ec tab 20 mg
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
Requirements/Limits
QL (30 caps / 30 days), MAIL, ST; Prior use of TWO of the following within the past 90 days: esomeprazole, omeprazole, pantoprazole OTC, QL (60 caps / 30 days), MAIL AGE, QL (150 mL / 30 days), MAIL; AGE (Max 12 years) QL (60 caps / 30 days), MAIL, ST; Prior use of TWO of the following within the past 90 days: esomeprazole, omeprazole, pantoprazole QL (30 caps / 30 days), MAIL, ST; Prior use of TWO of the following within the past 90 days: esomeprazole, omeprazole, pantoprazole QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL QL (60 caps / 30 days), MAIL OTC, QL (60 caps / 30 days) QL (30 tabs / 30 days), MAIL QL (60 tabs / 30 days), MAIL OTC, QL (60 tabs / 30 days), MAIL QL (30 tabs / 30 days), MAIL, ST; Prior use of TWO of the following within the past 90 days: esomeprazole, omeprazole, pantoprazole
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
155
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
ULCER DRUGS - PROSTAGLANDINS
misoprostol tab 100 mcg
Tier 1 QL (120 tabs / 30 days), MAIL
misoprostol tab 200 mcg
Tier 1 QL (120 tabs / 30 days), MAIL
URINARY ANTI-INFECTIVES
URINARY ANTI-INFECTIVES
methenamine hippurate tab 1 gm
Tier 1
MONUROL PAK GRANULES (fosfomycin tromethamine)
Tier 3
nitrofurantoin macrocrystalline cap 50 mg
Tier 1
AGE, QL (60 caps / 30 days); AGE (Max 64 years)
nitrofurantoin macrocrystalline cap 100 mg
Tier 1
AGE, QL (120 caps / 30 days); AGE (Max 64 years)
nitrofurantoin monohydrate macrocrystalline cap 100 mg
Tier 1
AGE, QL (60 caps / 30 days); AGE (Max 64 years)
nitrofurantoin susp 25 mg/5ml
Tier 3 AGE; AGE (Max 12 years)
URINARY ANTISPASMODICS
URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)
darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)
Tier 3
QL (60 tabs / 30 days), MAIL, ST; Prior use of oxybutynin in the last 90 days
darifenacin hydrobromide tab er 24hr 15 mg (base equiv)
Tier 3
QL (30 tabs / 30 days), MAIL, ST; Prior use of oxybutynin in the last 90 days
oxybutynin chloride syrup 5 mg/5ml
Tier 1 QL (600 mL / 30 days), MAIL
oxybutynin chloride tab 5 mg
Tier 1 QL (90 tabs / 30 days), MAIL
oxybutynin chloride tab er 24hr 5 mg
Tier 1 QL (30 tabs / 30 days), MAIL
oxybutynin chloride tab er 24hr 10 mg
Tier 1 QL (30 tabs / 30 days), MAIL
oxybutynin chloride tab er 24hr 15 mg
Tier 1 QL (30 tabs / 30 days), MAIL
OXYTROL/WOMN DIS 3.9MG/24 (oxybutynin)
Tier 2 OTC, QL (8 ea / 30 days), MAIL
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
156
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
solifenacin succinate tab 5 mg
Tier 3 QL (60 tabs / 30 days),
MAIL, ST; Prior use of
oxybutynin in the last 90
days
solifenacin succinate tab 10 mg
Tier 3 QL (30 tabs / 30 days),
MAIL, ST; Prior use of
oxybutynin in the last 90 days
tolterodine tartrate tab 1 mg
Tier 1 QL (60 tabs / 30 days),
MAIL, ST; Prior use of oxybutynin within the
past 90 days.
tolterodine tartrate tab 2 mg
Tier 1 QL (60 tabs / 30 days),
MAIL, ST; Prior use of
oxybutynin within the
past 90 days.
TOVIAZ TAB 4MG (fesoterodine fumarate)
Tier 3 QL (30 tabs / 30 days),
MAIL, PA
TOVIAZ TAB 8MG (fesoterodine fumarate)
Tier 3 QL (30 tabs / 30 days),
MAIL, PA
trospium chloride cap er 24hr 60 mg
Tier 3 QL (30 caps / 30 days),
MAIL, ST; Prior use of oxybutynin in the last 90
days
trospium chloride tab 20 mg
Tier 1 QL (60 tabs / 30 days), MAIL, ST; Prior use of
oxybutynin within the
past 90 days.
VESICARE TAB 5MG (solifenacin succinate)
Tier 3 QL (60 tabs / 30 days),
MAIL, ST; Prior use of
oxybutynin in the last 90
days
VESICARE TAB 10MG (solifenacin succinate)
Tier 3 QL (30 tabs / 30 days),
MAIL, ST; Prior use of
oxybutynin in the last 90 days
URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS
MYRBETRIQ TAB 25MG (mirabegron)
Tier 3 QL (30 tabs / 30 days),
MAIL, PA
MYRBETRIQ TAB 50MG (mirabegron)
Tier 3 QL (30 tabs / 30 days),
MAIL, PA
URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS
bethanechol chloride tab 5 mg
Tier 1 QL (120 tabs / 30 days)
bethanechol chloride tab 10 mg
Tier 1 QL (120 tabs / 30 days)
bethanechol chloride tab 25 mg
Tier 1 QL (120 tabs / 30 days)
bethanechol chloride tab 50 mg
Tier 1 QL (120 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
157
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS
flavoxate hcl tab 100 mg
Tier 1 QL (120 tabs / 30 days), MAIL
VACCINES
BACTERIAL VACCINES
PNEUMOVAX 23 INJ 25/0.5 (pneumococcal vac polyvalent)
Tier 5 QL (Max 2 injections per lifetime)
PREVNAR 13 INJ (pneumococcal 13-valent conjugate vaccine)
Tier 5 QL (Max 4 injections per lifetime)
VIRAL VACCINES
AFLURIA QUAD INJ 2019-20 (influenza virus vaccine split quadrivalent)
Tier 5 QL (Max 1 Injection per year)
ENGERIX-B INJ 10/0.5ML (hepatitis b vaccine (recomb))
Tier 5 QL (Maximum 3 injections per lifetime)
ENGERIX-B INJ 20MCG/ML (hepatitis b vaccine (recomb))
Tier 5 QL (Maximum 3 injections per lifetime)
FLUARIX QUAD INJ 2019-20 (influenza virus vaccine split quadrivalent)
Tier 5 QL (Max 1 Injection per year)
FLUBLOK QUAD INJ 2019-20 (influenza virus vac recomb hemagglutinin (ha) quadrivalent)
Tier 5 QL (Max 1 Injection per year)
FLUCLVX QUAD INJ 2019-20 (influenza virus vaccine tissue-cultured subunit quadrivalent)
Tier 5 QL (Max 1 Injection per year)
FLULAVAL QUA INJ 2019-20 (influenza virus vaccine split quadrivalent)
Tier 5 QL (Max 1 Injection per year)
FLUMIST QUAD SUS 2019-20 (influenza virus vaccine live quadrivalent)
Tier 5
AGE, QL (Max 1 Injection per year); AGE (Max 49 years)
FLUZONE QUAD INJ 2019-20 (influenza virus vaccine split quadrivalent)
Tier 5 QL (Max 1 Injection per year)
HAVRIX INJ 720UNIT (hepatitis a vaccine)
Tier 5 QL (Max 2 injections per lifetime)
HAVRIX INJ 1440UNIT (hepatitis a vaccine)
Tier 5 QL (Max 2 injections per lifetime)
HEPLISAV-B INJ 20/0.5ML (hepatitis b vaccine recombinant adjuvanted)
Tier 5 QL (Maximum 3 injections per lifetime)
HEPLISAV-B INJ 20MCG (hepatitis b vaccine recombinant adjuvanted)
Tier 5 QL (Maximum 3 injections per lifetime)
RECOMBIVA HB INJ 5MCG/0.5 (hepatitis b vaccine (recomb))
Tier 5 QL (Maximum 3 injections per lifetime)
RECOMBIVA HB INJ 10MCG/ML (hepatitis b vaccine Tier 5 QL (Maximum 3
(recomb))
injections per lifetime)
SHINGRIX INJ 50/0.5ML (zoster vaccine recombinant adjuvanted)
Tier 5
AGE, QL (Max 2 injections per lifetime); AGE (Min 50 years)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
158
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier
TWINRIX INJ (hepatitis a (inactivated)-hepatitis b (recombinant) vaccines)
Tier 5
VAQTA INJ 25/0.5ML (hepatitis a vaccine)
Tier 5
VAQTA INJ 50UNT/ML (hepatitis a vaccine)
Tier 5
ZOSTAVAX INJ (zoster vaccine live)
Tier 5
VAGINAL PRODUCTS
SPERMICIDES CONCEPTROL GEL 4% (nonoxynol-9) ENCARE SUP 100MG (nonoxynol-9) GYNOL II GEL 3% (nonoxynol-9) nonoxynol-9 gel 4% (Vcf Vaginal Contraceptive) SHUR-SEAL GEL 2% (nonoxynol-9) TODAY SPONGE MIS (nonoxynol-9) VCF VAGINAL AER CONTRACP (nonoxynol-9) VCF VAGINAL MIS CONTRACP (nonoxynol-9)
VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2% clotrimazole vaginal cream 1% clotrimazole vaginal cream 2% (Gnp Clotrimazole 3) GYNAZOLE-1 CRE 2% (butoconazole nitrate (one dose)) metronidazole vaginal gel 0.75% miconazole nitrate vaginal app 200 mg & 2% cream 9 gm kit (Sm Miconazole 3) miconazole nitrate vaginal cream 2% (Miconazole 7) miconazole nitrate vaginal cream 4% (200 mg/5gm) (Qc 3 Day Vaginal Cream) miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit (Gnp Miconazole 3) miconazole nitrate vaginal suppos 100 mg (Miconazole 7) MONISTAT 7 KIT COMBO PK (miconazole nitrate vaginal) terconazole vaginal cream 0.4% terconazole vaginal cream 0.8% terconazole vaginal suppos 80 mg tioconazole vaginal oint 6.5% (Ra Tioconazole 1)
Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5 Tier 5
Tier 1 Tier 1 Tier 1
Tier 2
Tier 1 Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1 Tier 1 Tier 3 Tier 1
Requirements/Limits AGE, QL (Max 3 injections per lifetime); AGE (Min 18 years) QL (Max 2 injections per lifetime) QL (Max 2 injections per lifetime) AGE, QL (Max 1 injection per lifetime); AGE (Min 50 years)
OTC OTC OTC OTC OTC OTC OTC OTC
QL (40 gm / 30 days) OTC OTC
QL (70 gm / 30 days) OTC
OTC
OTC
OTC
OTC
OTC
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
159
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
Drug Tier Requirements/Limits
VAGINAL ESTROGENS
estradiol vaginal cream 0.1 mg/gm
estradiol vaginal tab 10 mcg
PREMARIN VAG CRE 0.625MG (estrogens, conjugated vaginal)
Tier 1 Tier 3 Tier 2
QL (42.5 gm / 30 days), MAIL QL (60 tabs / 30 days), MAIL QL (30 gm / 30 days), MAIL
VAGINAL PROGESTINS PROGESTERONE SUP VGS 100 (progesterone (vaginal)) PROGESTERONE SUP VGS 200 (progesterone (vaginal))
Tier 3 PA Tier 3 PA
VASOPRESSORS
ANAPHYLAXIS THERAPY AGENTS
EPIPEN 2-PAK INJ 0.3MG (epinephrine (anaphylaxis)) EPIPEN-JR INJ 0.15MG (epinephrine (anaphylaxis)) SYMJEPI INJ 0.3MG (epinephrine (anaphylaxis))
Tier 2 QL (2 ea / 30 days)
Tier 2 QL (2 ea / 30 days)
Tier 2 QL (2 syringes / 30 days)
SYMJEPI INJ 0.15MG (epinephrine (anaphylaxis))
Tier 2 QL (2 syringes / 30 days)
NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS
NORTHERA CAP 100MG (droxidopa)
Tier 4 PA
NORTHERA CAP 200MG (droxidopa)
Tier 4 PA
NORTHERA CAP 300MG (droxidopa)
Tier 4 PA
VASOPRESSORS
midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg
Tier 1 Tier 1
midodrine hcl tab 10 mg
Tier 1
VITAMINS
OIL SOLUBLE VITAMINS cholecalciferol cap 1.25 mg (50000 unit)
Tier 1 OTC
cholecalciferol cap 25 mcg (1000 unit) (D 1000) Tier 1 OTC
cholecalciferol cap 50 mcg (2000 unit) (D2000 Ultra Strength) cholecalciferol cap 125 mcg (5000 unit) (D 5000) cholecalciferol cap 250 mcg (10000 unit)
Tier 1 OTC Tier 1 OTC Tier 1 OTC
cholecalciferol chew tab 10 mcg (400 unit) (Kp Vitamin D) cholecalciferol chew tab 25 mcg (1000 unit) (Cvs D3)
Tier 1 OTC Tier 1 OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
160
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Drug Name
cholecalciferol drops 125 mcg/ml (5000 unit/ml) (D3 Maximum Strength) cholecalciferol oral liquid 10 mcg/ml (400 unit/ml) (Aqueous Vitamin D Infants) cholecalciferol tab 10 mcg (400 unit) cholecalciferol tab 25 mcg (1000 unit) cholecalciferol tab 50 mcg (2000 unit) cholecalciferol tab 125 mcg (5000 unit) ergocalciferol cap 1.25 mg (50000 unit) phytonadione tab 5 mg
WATER SOLUBLE VITAMINS ascorbic acid tab 500 mg (Hm Vitamin C/rose Hips) niacin cap er 250 mg niacin cap er 500 mg niacin tab 50 mg niacin tab 100 mg niacin tab 250 mg niacin tab 500 mg niacin tab er 250 mg niacin tab er 500 mg niacin tab er 750 mg niacinamide tab 500 mg pyridoxine hcl tab 25 mg pyridoxine hcl tab 50 mg pyridoxine hcl tab 100 mg pyridoxine hcl tab er 200 mg riboflavin tab 100 mg (Cvs Vitamin B-2) thiamine hcl tab 50 mg thiamine hcl tab 100 mg thiamine hcl tab 250 mg
Drug Tier Requirements/Limits Tier 1 OTC
Tier 1 OTC
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
OTC OTC OTC OTC
QL (150 tabs / 30 days)
Tier 1 OTC
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MAIL - Available at
161
mail-order OTC - Over the counter AGE - Age Limit MED - Max 90 mg Morphine EQ
Dose per day
Index
1
12 Hour Decongestant see pseudoephedrine hcl tab er 12hr 120 mg ........................ 141
3
3ML SYRINGE MIS REG TIP............127 A
abacavir sulfate soln 20 mg/ml (base equiv) .............................79
abacavir sulfate tab 300 mg (base equiv) .......................................79
abacavir sulfate-lamivudine tab 600-300 mg ..............................79
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg ................................................. 79
abacavir-dolutegravir-lamivudine see TRIUMEQ TAB .......................81
abaloparatide see TYMLOS INJ ........................ 106
abatacept see ORENCIA CLCK INJ 125MG/ML 10 see ORENCIA INJ 125MG/ML.........10 see ORENCIA INJ 250MG ..............10 see ORENCIA INJ 50/0.4 ..............10 see ORENCIA INJ 87.5/0.7............10
ABILIFY MAIN INJ 300MG ................78 ABILIFY MAIN INJ 400MG ................78 abiraterone acetate tab 250 mg ..66 ABREVA CRE 10% ..........................99 acamprosate calcium tab delayed
release 333 mg ....................... 148 acarbose tab 100 mg ...................39 acarbose tab 25 mg .....................39 acarbose tab 50 mg .....................39 acebutolol hcl cap 200 mg ...........83 acebutolol hcl cap 400 mg ...........83 Acephen
see acetaminophen suppos 325 mg .........................................11
acetaminophen see FEVERALL INF SUP 80MG........11 see FEVERALL SUP 325MG ............11 see NORTEMP SUS INFANTS .........11
acetaminophen cap 500 mg.........11
acetaminophen chew tab 160 mg 11 acetaminophen chew tab 80 mg..11 acetaminophen disintegrating tab
160 mg .....................................11 acetaminophen disintegrating tab
80 mg .......................................11 acetaminophen elixir 160 mg/5ml
................................................. 11 acetaminophen liquid 160 mg/5ml
................................................. 11 acetaminophen liquid 167 mg/5ml
................................................. 11 acetaminophen soln 160 mg/5ml 11 acetaminophen suppos 120 mg ...11 acetaminophen suppos 325 mg ...11 acetaminophen suppos 650 mg ...11 acetaminophen susp 160 mg/5ml
................................................. 11 acetaminophen tab 325 mg .........11 acetaminophen tab 500 mg .........11 acetaminophen tab er 650 mg.....11 acetaminophen w/ codeine soln
120-12 mg/5ml ........................16 acetaminophen w/ codeine tab
300-15 mg................................16 acetaminophen w/ codeine tab
300-30 mg................................16 acetaminophen w/ codeine tab
300-60 mg................................16 acetazolamide cap er 12hr 500 mg
............................................... 104 acetazolamide tab 125 mg ........ 104 acetazolamide tab 250 mg ........ 104 acetic acid irrigation soln 0.25%
............................................... 112 acetic acid otic soln 2% ............ 145 acetone (urine) test
see RELION KETON TES ............. 103 acetylcysteine inhal soln 10%.....95 acetylcysteine inhal soln 20%.....96 Acid Gone
see aluminum hydroxidemagnesium carbonate susp 95358 mg/15ml ........................18
acitretin cap 10 mg .....................99
162
acitretin cap 17.5 mg ..................99 acitretin cap 25 mg .....................99 aclidinium bromide
see TUDORZA PRES AER 400/ACT .24 ACNE MEDICAT LOT 10% ................96 ACNE MEDICAT LOT 5% ..................96 ACTEMRA INJ 162/0.9...................... 7 ACTEMRA INJ 200/10ML................... 7 ACTEMRA INJ 400/20ML................... 7 ACTEMRA INJ 80MG/4ML .................. 7 ACTEMRA INJ ACTPEN...................... 7 ACTIMMUNE INJ 2MU/0.5 ................70 acyclovir cap 200 mg...................82 acyclovir oint 5% ........................99 acyclovir susp 200 mg/5ml .........83 acyclovir tab 400 mg ...................83 acyclovir tab 800 mg ...................83 ADACEL INJ ................................. 153 adalimumab
see HUMIRA INJ 10/0.1ML ............. 6 see HUMIRA INJ 10MG/0.2 ............ 6 see HUMIRA INJ 20/0.2ML ............. 6 see HUMIRA INJ 40/0.4ML ............. 6 see HUMIRA KIT 20MG/0.4 ............ 6 see HUMIRA KIT 40MG/0.8 ............ 6 see HUMIRA PEDIA INJ CROHNS .... 6 see HUMIRA PEN INJ 40/0.4ML ...... 6 see HUMIRA PEN INJ CD/UC/HS ..... 6 see HUMIRA PEN KIT CD/UC/HS ..... 6 see HUMIRA PEN KIT PS/UV........... 6 adapalene see DIFFERIN GEL 0.1%...............96 adapalene lotion 0.1% ................96 adefovir dipivoxil tab 10 mg ........82 ADEMPAS TAB 0.5MG .....................89 ADEMPAS TAB 1.5MG .....................89 ADEMPAS TAB 1MG ........................89 ADEMPAS TAB 2.5MG .....................89 ADEMPAS TAB 2MG ........................89 ADMELOG INJ 100U/ML...................45 ADMELOG SOLO INJ 100U/ML ..........45 ADULT MASK MIS LARGE...............127 ADVATE INJ 1000UNIT .................. 113 ADVATE INJ 1500UNIT .................. 113 ADVATE INJ 2000UNIT .................. 114 ADVATE INJ 250UNIT....................113 ADVATE INJ 3000UNIT .................. 114
ADVATE INJ 4000UNIT.................. 114 ADVATE INJ 500UNIT ................... 113 Advil Junior Strength
see ibuprofen tab 100 mg .......... 8 afatinib dimaleate
see GILOTRIF TAB 20MG ..............68 see GILOTRIF TAB 30MG ..............68 see GILOTRIF TAB 40MG ..............68 AFINITOR DIS TAB 2MG ..................67 AFINITOR DIS TAB 3MG ..................67 AFINITOR DIS TAB 5MG ..................67 AFINITOR TAB 10MG ......................67 AFINITOR TAB 2.5MG .....................67 AFINITOR TAB 5MG ........................67 AFINITOR TAB 7.5MG .....................67 AFLURIA QUAD INJ 2019-20 .......... 158 AFREZZA POW 12 UNIT...................45 AFREZZA POW 4-8 UNIT .................45 AFREZZA POW 4-8-12 ....................45 AFREZZA POW 4UNIT .....................45 AFREZZA POW 8 UNIT ....................45 AFREZZA POW 8-12UNIT.................45 agalsidase beta see FABRAZYME INJ 5MG ........... 107 Akwa Tears see artificial tear ophth ointment
............................................ 141 AKYNZEO CAP 300-0.5 ...................50 albuterol sulfate
see PROAIR HFA AER ...................27 see PROVENTIL AER HFA ..............28 see VENTOLIN HFA AER ...............28 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) ...........................25 albuterol sulfate soln nebu 0.5% (5 mg/ml) ..................................... 25 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) ...............25 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) ...............25 albuterol sulfate syrup 2 mg/5ml25 albuterol sulfate tab 2 mg ...........25 albuterol sulfate tab 4 mg ...........25 alcaftadine see LASTACAFT SOL 0.25% ........ 144 alclometasone dipropionate cream 0.05% .................................... 100
163
alclometasone dipropionate oint 0.05% .................................... 100
ALCOHOL PREP PAD MED 70% ....... 126 alcohol swabs
see ALCOHOL PREP PAD MED 70% ............................................ 126
ALDACTAZIDE TAB 50/50 .............. 104 ALECENSA CAP 150MG....................67 alectinib hcl
see ALECENSA CAP 150MG ...........67 alendronate sodium tab 10 mg .. 106 alendronate sodium tab 35 mg .. 106 alendronate sodium tab 40 mg .. 106 alendronate sodium tab 5 mg .... 106 alendronate sodium tab 70 mg .. 106 ALER-DRYL TAB 50MG ....................52 alfuzosin hcl tab er 24hr 10 mg . 113 ALINIA SUS 100/5ML ......................19 ALINIA TAB 500MG.........................19 aliskiren fumarate tab 150 mg
(base equivalent) .....................64 aliskiren fumarate tab 300 mg
(base equivalent) .....................64 alitretinoin
see PANRETIN GEL 0.1% ..............99 All Day Allergy D
see cetirizine-pseudoephedrine tab er 12hr 5-120 mg.............95
Allergy Relief see loratadine tab 10 mg ..........52
allopurinol tab 100 mg .............. 113 allopurinol tab 300 mg .............. 113 Almacone
see alum & mag hydroxidesimethicone susp 200-200-20 mg/5ml .................................18
Almacone Double Strength see alum & mag hydroxidesimethicone susp 400-400-40 mg/5ml .................................18
almotriptan malate tab 12.5 mg 128 almotriptan malate tab 6.25 mg 128 ALOCRIL SOL 2% ......................... 144 alogliptin benzoate tab 12.5 mg
(base equiv) .............................43 alogliptin benzoate tab 25 mg
(base equiv) .............................43
alogliptin benzoate tab 6.25 mg (base equiv) .............................43
alogliptin-metformin hcl tab 12.51000 mg ...................................39
alogliptin-metformin hcl tab 12.5500 mg .....................................39
alogliptin-pioglitazone tab 12.5-15 mg ............................................39
alogliptin-pioglitazone tab 12.5-30 mg ............................................39
alogliptin-pioglitazone tab 12.5-45 mg ............................................39
alogliptin-pioglitazone tab 25-15 mg ............................................39
alogliptin-pioglitazone tab 25-30 mg ............................................39
alogliptin-pioglitazone tab 25-45 mg ............................................40
ALOMIDE SOL 0.1% OP................. 144 alosetron hcl tab 0.5 mg (base
equiv) ..................................... 111 alosetron hcl tab 1 mg (base equiv)
............................................... 111 alpha1-proteinase inhibitor
(human) see GLASSIA INJ ....................... 151 see PROLASTIN-C INJ 1000MG.... 151 ALPHANINE SD INJ 1500UNIT ........ 114 ALPHANINE SD INJ 500UNIT.......... 114 alprazolam tab 0.25 mg...............22 alprazolam tab 0.5 mg ................21 alprazolam tab 1 mg ...................22 alprazolam tab 2 mg ...................22 ALPROLIX INJ 1000UNIT ............... 114 ALPROLIX INJ 2000UNIT ............... 114 ALPROLIX INJ 250UNIT ................. 114 ALPROLIX INJ 3000UNIT ............... 114 ALPROLIX INJ 4000UNIT ............... 114 ALPROLIX INJ 500UNIT ................. 114 ALREX SUS 0.2% ......................... 143 ALTABAX OIN 1%...........................97 alum & mag hydroxide-simethicone chew tab 200-200-25 mg .........18 alum & mag hydroxide-simethicone susp 200-200-20 mg/5ml ........18 alum & mag hydroxide-simethicone susp 400-400-40 mg/5ml ........18
164
aluminum chloride see DRYSOL SOL 20%................103
aluminum hydroxide-magnesium carbonate chew tab 160-105 mg ................................................. 18
aluminum hydroxide-magnesium carbonate susp 95-358 mg/15ml ................................................. 18
aluminum hydroxide-magnesium trisilicate chew tab 80-20 mg ...18
amantadine hcl cap 100 mg.........70 amantadine hcl syrup 50 mg/5ml71 ambrisentan
see LETAIRIS TAB 10MG...............88 see LETAIRIS TAB 5MG ................88 ambrisentan tab 10 mg ...............88 ambrisentan tab 5 mg .................88 amcinonide cream 0.1%............100 amcinonide lotion 0.1% ............ 100 AMCINONIDE OIN 0.1% ................ 100 amiloride & hydrochlorothiazide tab 5-50 mg ............................ 105 amiloride hcl tab 5 mg...............105 aminocaproic acid tab 1000 mg.120 aminocaproic acid tab 500 mg...120 aminosalicylic acid see PASER GRA 4GM....................65 amiodarone hcl tab 200 mg .........23 AMITIZA CAP 24MCG .................... 110 AMITIZA CAP 8MCG ...................... 110 amitriptyline hcl tab 10 mg .........37 amitriptyline hcl tab 100 mg .......37 amitriptyline hcl tab 150 mg .......37 amitriptyline hcl tab 25 mg .........37 amitriptyline hcl tab 50 mg .........37 amitriptyline hcl tab 75 mg .........37 Amlactin see lactic acid (ammonium
lactate) lotion 12%..............102 amlodipine besylate tab 10 mg
(base equivalent) .....................85 amlodipine besylate tab 2.5 mg
(base equivalent) .....................85 amlodipine besylate tab 5 mg
(base equivalent) .....................85 amlodipine besylate-benazepril hcl
cap 10-20 mg ...........................62
amlodipine besylate-benazepril hcl cap 10-40 mg ...........................62
amlodipine besylate-benazepril hcl cap 2.5-10 mg ..........................62
amlodipine besylate-benazepril hcl cap 5-10 mg .............................62
amlodipine besylate-benazepril hcl cap 5-20 mg .............................62
amlodipine besylate-benazepril hcl cap 5-40 mg .............................62
amlodipine besylate-olmesartan medoxomil tab 10-20 mg .........62
amlodipine besylate-olmesartan medoxomil tab 10-40 mg .........62
amlodipine besylate-olmesartan medoxomil tab 5-20 mg ...........62
amlodipine besylate-olmesartan medoxomil tab 5-40 mg ...........62
Amnesteem see isotretinoin cap 20 mg ........96
amoxapine tab 100 mg................37 amoxapine tab 150 mg................37 amoxapine tab 25 mg..................37 amoxapine tab 50 mg..................37 amoxicillin & k clavulanate chew
tab 200-28.5 mg..................... 147 amoxicillin & k clavulanate chew
tab 400-57 mg........................ 147 amoxicillin & k clavulanate for susp
200-28.5 mg/5ml ................... 147 amoxicillin & k clavulanate for susp
250-62.5 mg/5ml ................... 147 amoxicillin & k clavulanate for susp
400-57 mg/5ml ...................... 147 amoxicillin & k clavulanate for susp
600-42.9 mg/5ml ................... 148 amoxicillin & k clavulanate tab
250-125 mg ............................ 148 amoxicillin & k clavulanate tab
500-125 mg ............................ 148 amoxicillin & k clavulanate tab
875-125 mg ............................ 148 amoxicillin & pot clavulanate
see AUGMENTIN SUS 125/5ML .... 148 amoxicillin (trihydrate) cap 250 mg
............................................... 147
165
amoxicillin (trihydrate) cap 500 mg ............................................... 147
amoxicillin (trihydrate) chew tab 125 mg ................................... 147
amoxicillin (trihydrate) chew tab 250 mg ................................... 147
amoxicillin (trihydrate) for susp 125 mg/5ml ........................... 147
amoxicillin (trihydrate) for susp 200 mg/5ml ........................... 147
amoxicillin (trihydrate) for susp 250 mg/5ml ........................... 147
amoxicillin (trihydrate) for susp 400 mg/5ml ........................... 147
amoxicillin (trihydrate) tab 500 mg ............................................... 147
amoxicillin (trihydrate) tab 875 mg ............................................... 147
amphetamine-dextroamphetamine cap er 24hr 10 mg ..................... 1
amphetamine-dextroamphetamine cap er 24hr 15 mg ..................... 1
amphetamine-dextroamphetamine cap er 24hr 20 mg ..................... 1
amphetamine-dextroamphetamine cap er 24hr 25 mg ..................... 1
amphetamine-dextroamphetamine cap er 24hr 30 mg ..................... 1
amphetamine-dextroamphetamine cap er 24hr 5 mg ....................... 1
amphetamine-dextroamphetamine tab 10 mg .................................. 1
amphetamine-dextroamphetamine tab 12.5 mg ............................... 1
amphetamine-dextroamphetamine tab 15 mg .................................. 1
amphetamine-dextroamphetamine tab 20 mg .................................. 1
amphetamine-dextroamphetamine tab 30 mg .................................. 1
amphetamine-dextroamphetamine tab 5 mg .................................... 1
amphetamine-dextroamphetamine tab 7.5 mg ................................. 1
ampicillin cap 500 mg ............... 147 ANADROL-50 TAB 50MG..................17 anagrelide hcl cap 0.5 mg ......... 117
anagrelide hcl cap 1 mg ............ 117 anakinra
see KINERET INJ .......................... 7 anastrozole tab 1 mg ..................66 ANIMAL SHAPE CHW IRON ............ 136 ANORO ELLIPT AER 62.5-25 ............25 Antacid
see alum & mag hydroxidesimethicone susp 200-200-20 mg/5ml .................................18
anthralin see DRITHO-CREME CRE HP 1%....99
Anti-diarrheal see loperamide hcl liq 1 mg/5ml (0.2 mg/ml) ..........................50
Anti-fungal Powder see tolnaftate powder 1%.........98
antihemophilic factor (human) see HEMOFIL M INJ 1700UNIT .... 114 see KOATE-DVI INJ 1000UNIT..... 115 see KOATE-DVI INJ 250UNIT ...... 115 see KOATE-DVI INJ 500UNIT ...... 115 see MONOCLATE-P INJ 1000UNIT 115
antihemophilic factor (rcmb) bd truncated (bd trunc-rfviii) see NOVOEIGHT INJ 1500UNIT ... 115
antihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim) see NUWIQ INJ 1000UNIT .......... 115 see NUWIQ INJ 2000UNIT .......... 116 see NUWIQ INJ 2500UNIT .......... 116 see NUWIQ INJ 250UNIT ............ 115 see NUWIQ INJ 3000UNIT .......... 116 see NUWIQ INJ 4000UNIT .......... 116 see NUWIQ INJ 500UNIT ............ 115 see NUWIQ KIT 1000UNIT .......... 116 see NUWIQ KIT 2000UNIT .......... 116 see NUWIQ KIT 2500UNIT .......... 116 see NUWIQ KIT 250UNIT ............ 116 see NUWIQ KIT 3000UNIT .......... 116 see NUWIQ KIT 4000UNIT .......... 116 see NUWIQ KIT 500UNIT ............ 116
antihemophilic factor (recombinant) see HELIXATE FS INJ 2000UNIT .. 114 see HELIXATE FS INJ 3000UNIT .. 114 see HELIXATE FS INJ 500UNIT .... 114
166
see KOGENATE FS INJ 1000UNIT.115 see KOGENATE FS INJ 2000UNIT.115 see KOGENATE FS INJ 250UNIT .. 115 see KOGENATE FS INJ 3000UNIT.115 see RECOMBINATE INJ ............... 116 see RECOMBINATE INJ 220-400 .. 116 see RECOMBINATE INJ 401-800 .. 116 see RECOMBINATE INJ 801-1240 116 antihemophilic factor (recombinant) plasma/albumin free see XYNTHA SOLOF INJ 1000UNIT
............................................ 116 see XYNTHA SOLOF INJ 2000UNIT
............................................ 117 see XYNTHA SOLOF INJ 3000UNIT
............................................ 117 see XYNTHA SOLOF INJ 500UNIT.116 see XYNTHA SOLOF KIT 250UNIT 117 antihemophilic factor rahf-pfm see ADVATE INJ 1000UNIT ......... 113 see ADVATE INJ 1500UNIT ......... 113 see ADVATE INJ 2000UNIT ......... 114 see ADVATE INJ 250UNIT ........... 113 see ADVATE INJ 3000UNIT ......... 114 see ADVATE INJ 4000UNIT ......... 114 see ADVATE INJ 500UNIT ........... 113 see KOVALTRY INJ 1000UNIT ...... 115 see KOVALTRY INJ 2000UNIT ...... 115 see KOVALTRY INJ 250UNIT........115 see KOVALTRY INJ 3000UNIT ...... 115 see KOVALTRY INJ 500UNIT........115 antihemophilic factor/von willebrand factor complex (human) see HUMATE-P SOL 2400UNIT.....115 see HUMATE-P SOL 500-1200 ..... 115 antiinhibitor coagulant complex see FEIBA INJ ........................... 114 ANZEMET TAB 100MG .....................50 ANZEMET TAB 50MG.......................50 APEXICON E CRE 0.05% ............... 100 APIDRA INJ SOLOSTAR ...................45 APIDRA INJ U-100 ..........................45 apixaban see ELIQUIS TAB 2.5MG ...............29 see ELIQUIS TAB 5MG..................29
APOKYN INJ 10MG/ML ....................71 apomorphine hydrochloride
see APOKYN INJ 10MG/ML ............71 apraclonidine hcl ophth soln 0.5%
(base equivalent) ................... 142 apremilast
see OTEZLA TAB 10/20/30 ...........10 see OTEZLA TAB 30MG ................10 aprepitant capsule 125 mg..........51 aprepitant capsule 40 mg............51 aprepitant capsule 80 mg............51 aprepitant capsule therapy pack 80 & 125 mg..................................51 APRISO CAP 0.375GM................... 111 APTIOM TAB 200MG .......................31 APTIOM TAB 400MG .......................31 APTIOM TAB 600MG .......................31 APTIOM TAB 800MG .......................31 APTIVUS CAP 250MG ......................79 APTIVUS SOL.................................79 Aquadeks see pediatric multiple vitamin w/
minerals & c drops 45 mg/ml ............................................ 136 Aqueous Vitamin D Infants see cholecalciferol oral liquid 10 mcg/ml (400 unit/ml) ......... 161 ARANESP INJ 100MCG .................. 118 ARANESP INJ 10MCG .................... 118 ARANESP INJ 150MCG .................. 118 ARANESP INJ 200MCG .................. 118 ARANESP INJ 25MCG .................... 118 ARANESP INJ 300MCG .................. 118 ARANESP INJ 40MCG .................... 118 ARANESP INJ 500MCG .................. 118 ARANESP INJ 60MCG .................... 118 ARCALYST INJ 220MG...................... 7 ARCAPTA CAP 75MCG .....................25 arformoterol tartrate see BROVANA NEB 15MCG............26 aripiprazole see ABILIFY MAIN INJ 300MG .......78 see ABILIFY MAIN INJ 400MG .......78 aripiprazole lauroxil see ARISTADA INJ 441MG/1. ........79 see ARISTADA INJ 662MG/2 .........79 see ARISTADA INJ 882MG/3 .........79
167
aripiprazole oral solution 1 mg/ml ................................................. 78
aripiprazole orally disintegrating tab 10 mg .................................78
aripiprazole orally disintegrating tab 15 mg .................................78
aripiprazole tab 10 mg ................78 aripiprazole tab 15 mg ................78 aripiprazole tab 2 mg ..................78 aripiprazole tab 20 mg ................78 aripiprazole tab 30 mg ................78 aripiprazole tab 5 mg ..................78 ARISTADA INJ 441MG/1..................79 ARISTADA INJ 662MG/2 ..................79 ARISTADA INJ 882MG/3 ..................79 armodafinil tab 150 mg ................ 3 armodafinil tab 200 mg ................ 3 armodafinil tab 250 mg ................ 3 armodafinil tab 50 mg .................. 3 ARMOUR THYRO TAB 120MG ......... 152 ARMOUR THYRO TAB 15MG ........... 152 ARMOUR THYRO TAB 180MG ......... 152 ARMOUR THYRO TAB 240MG ......... 152 ARMOUR THYRO TAB 300MG ......... 152 ARMOUR THYRO TAB 30MG ........... 152 ARMOUR THYRO TAB 60MG ........... 152 ARMOUR THYRO TAB 90MG ........... 152 artemether-lumefantrine
see COARTEM TAB 20-120MG .......64 artificial tear insert
see LACRISERT MIS 5MG OP ....... 141 artificial tear ophth ointment .... 141 artificial tear ophth solution ...... 141 Artificial Tears
see dextran 70-hypromellose ophth soln 0.1-0.3% ............ 141
see polyvinyl alcohol ophth soln 1.4%.................................... 142
ascorbic acid tab 500 mg...........161 asenapine maleate
see SAPHRIS SUB 10MG...............77 see SAPHRIS SUB 2.5MG..............77 see SAPHRIS SUB 5MG ................77 ASMANEX 120 AER 220MCG ............25 ASMANEX 14 AER 220MCG ..............24 ASMANEX 30 AER 110MCG ..............24 ASMANEX 30 AER 220MCG ..............24
ASMANEX 60 AER 220MCG ..............24 ASMANEX 7 AER 110MCG................24 ASMANEX HFA AER 100 MCG ...........25 ASMANEX HFA AER 200 MCG ...........25 ASMANEX HFA AER 50MCG..............25 aspirin chew tab 81 mg ...............12 Aspirin Low Dose
see aspirin tab delayed release 81 mg .........................................12
aspirin tab 325 mg ......................12 aspirin tab delayed release 325 mg
................................................. 12 aspirin tab delayed release 81 mg
................................................. 12 aspirin-dipyridamole cap er 12hr
25-200 mg.............................. 117 atazanavir sulfate cap 150 mg
(base equiv) .............................79 atazanavir sulfate cap 200 mg
(base equiv) .............................79 atazanavir sulfate cap 300 mg
(base equiv) .............................79 atazanavir sulfate-cobicistat
see EVOTAZ TAB 300-150 ............80 atenolol & chlorthalidone tab 100-
25 mg .......................................62 atenolol & chlorthalidone tab 50-25
mg ............................................62 atenolol tab 100 mg ....................83 atenolol tab 25 mg ......................83 atenolol tab 50 mg ......................83 atomoxetine hcl cap 10 mg (base
equiv) ........................................ 2 atomoxetine hcl cap 100 mg (base
equiv) ........................................ 3 atomoxetine hcl cap 18 mg (base
equiv) ........................................ 3 atomoxetine hcl cap 25 mg (base
equiv) ........................................ 3 atomoxetine hcl cap 40 mg (base
equiv) ........................................ 3 atomoxetine hcl cap 60 mg (base
equiv) ........................................ 3 atomoxetine hcl cap 80 mg (base
equiv) ........................................ 3 atorvastatin calcium tab 10 mg
(base equivalent) .....................54
168
atorvastatin calcium tab 20 mg (base equivalent) .....................54
atorvastatin calcium tab 40 mg (base equivalent) .....................54
atorvastatin calcium tab 80 mg (base equivalent) .....................54
atovaquone susp 750 mg/5ml.....19 atovaquone-proguanil hcl tab 250-
100 mg .....................................64 atovaquone-proguanil hcl tab 62.5-
25 mg .......................................64 ATRIPLA TAB .................................79 ATROPINE SUL SOL 1% OP............142 ATROVENT HFA AER 17MCG ............24 AUBAGIO TAB 14MG ..................... 149 AUBAGIO TAB 7MG.......................149 AUGMENTIN SUS 125/5ML ............ 148 auranofin
see RIDAURA CAP 3MG ................. 7 AVANDIA TAB 2MG .........................47 AVANDIA TAB 4MG .........................48 Avita
see tretinoin gel 0.025%...........97 AVONEX KIT 30MCG ..................... 149 AVONEX PEN KIT 30MCG...............149 AVONEX PREFL KIT 30MCG............149 AZASITE SOL 1% ......................... 143 azathioprine tab 50 mg ............. 133 azelastine hcl nasal spray 0.1%
(137 mcg/spray) .................... 139 azelastine hcl ophth soln 0.05%144 azilsartan medoxomil
see EDARBI TAB 40MG .................59 see EDARBI TAB 80MG .................59 azithromycin (ophth) see AZASITE SOL 1%................. 143 azithromycin for susp 100 mg/5ml ............................................... 124 azithromycin for susp 200 mg/5ml ............................................... 124 azithromycin powd pack for susp 1 gm .......................................... 124 azithromycin tab 250 mg...........124 azithromycin tab 500 mg...........124 azithromycin tab 600 mg...........124 AZOPT SUS 1% OP ....................... 144 aztreonam lysine
see CAYSTON INH 75MG ..............19 B
bacitracin oint 500 unit/gm ........97 bacitracin ophth oint 500 unit/gm
............................................... 143 bacitracin zinc oint 500 unit/gm .97 bacitracin-polymyxin b oint.........97 bacitracin-polymyxin b ophth oint
............................................... 143 bacitracin-polymyxin-neomycin hc
see CORTISPORIN OIN 1% ...........97 bacitracin-polymyxin-neomycin-hc
ophth oint 1% ........................ 143 baclofen tab 10 mg ................... 139 baclofen tab 20 mg ................... 139 BALCOLTRA TAB 0.1-20 ..................91 baloxavir marboxil
see XOFLUZA TAB 20MG ..............83 see XOFLUZA TAB 40MG ..............83 balsalazide disodium cap 750 mg ............................................... 111 BANZEL SUS 40MG/ML ...................31 BANZEL TAB 200MG .......................31 BANZEL TAB 400MG .......................31 BAQSIMI ONE POW 3MG/DOSE ........43 BARACLUDE SOL ............................82 BASAGLAR INJ 100UNIT..................45 BAXDELA TAB 450MG ................... 110 b-complex w/ c & folic acid cap 1 mg .......................................... 135 b-complex w/ c & folic acid tab . 135 b-complex w/ c & folic acid tab 0.8 mg .......................................... 135 b-complex w/ c & folic acid tab 5 mg .......................................... 135 BD U-500 MIS 31GX6MM .............. 125 BE WELL PAK ROUNDED................ 137 becaplermin see REGRANEX GEL 0.01% ......... 103 beclomethasone dipropionate hfa see QVAR REDIHA AER 80MCG......25 see QVAR REDIHAL AER 40MCG ....25 bedaquiline fumarate see SIRTURO TAB 100MG .............65 belatacept see NULOJIX INJ 250MG............. 134 BELSOMRA TAB 10MG................... 122
169
BELSOMRA TAB 15MG...................122 BELSOMRA TAB 20MG...................122 BELSOMRA TAB 5MG .................... 122 bempedoic acid
see NEXLETOL TAB 180MG ...........53 bempedoic acid-ezetimibe
see NEXLIZET TAB 180/10MG .......53 benazepril & hydrochlorothiazide
tab 10-12.5 mg .........................62 benazepril & hydrochlorothiazide
tab 20-12.5 mg .........................62 benazepril & hydrochlorothiazide
tab 20-25 mg............................62 benazepril & hydrochlorothiazide
tab 5-6.25 mg...........................62 benazepril hcl tab 10 mg .............57 benazepril hcl tab 20 mg .............57 benazepril hcl tab 40 mg .............57 benazepril hcl tab 5 mg ...............57 BENEFIX INJ 1000UNIT ................. 114 BENEFIX INJ 2000UNIT ................. 114 BENEFIX INJ 250UNIT...................114 BENEFIX INJ 3000UNIT ................. 114 BENEFIX INJ 500UNIT...................114 BENZNIDAZOLE TAB 100MG ............18 BENZNIDAZOLE TAB 12.5MG ...........18 benzocaine-docusate sodium
see DOCUSOL PLUS ENE 20-283 . 124 benzonatate cap 100 mg .............94 benzonatate cap 200 mg .............94 benzoyl peroxide
see ACNE MEDICAT LOT 10%........96 see ACNE MEDICAT LOT 5% .........96 benzoyl peroxide gel 10% ...........96 benzoyl peroxide gel 5% .............96 benzoyl peroxide liq 10%............96 benzoyl peroxide liq 5%..............96 Benzoyl Peroxide Wash see benzoyl peroxide liq 10% ...96 benzoyl peroxide-erythromycin gel 5-3% ........................................96 benztropine mesylate tab 0.5 mg 70 benztropine mesylate tab 1 mg ...70 benztropine mesylate tab 2 mg ...70 bepotastine besilate see BEPREVE DRO 1.5%.............144 BEPREVE DRO 1.5% ..................... 144
BERINERT INJ 500UNIT................. 117 besifloxacin hcl
see BESIVANCE SUS 0.6% ......... 143 BESIVANCE SUS 0.6% .................. 143 betaine
see CYSTADANE POW ................ 107 betamethasone dipropionate
augmented cream 0.05% ....... 100 betamethasone dipropionate
augmented gel 0.05% ............ 100 betamethasone dipropionate
augmented lotion 0.05% ........ 100 betamethasone dipropionate
augmented oint 0.05%........... 100 betamethasone dipropionate cream
0.05% .................................... 100 betamethasone dipropionate lotion
0.05% .................................... 100 betamethasone dipropionate oint
0.05% .................................... 100 betamethasone valerate cream
0.1% (base equivalent).......... 100 betamethasone valerate oint 0.1%
(base equivalent) ................... 100 betaxolol hcl ophth soln 0.5%... 142 betaxolol hcl tab 10 mg ...............84 betaxolol hcl tab 20 mg ...............84 bethanechol chloride tab 10 mg 157 bethanechol chloride tab 25 mg 157 bethanechol chloride tab 5 mg .. 157 bethanechol chloride tab 50 mg 157 BEVESPI AER 9-4.8MCG ..................25 bexarotene (topical)
see TARGRETIN GEL 1% ..............99 bexarotene cap 75 mg.................70 bicalutamide tab 50 mg...............66 bictegravir-emtricitabine-tenofovir
alafenamide fumarate see BIKTARVY TAB ......................79 BIKTARVY TAB ...............................79 bimatoprost see LUMIGAN SOL 0.01% ........... 145 bimatoprost ophth soln 0.03%.. 145 bisacodyl suppos 10 mg ............ 123 bisacodyl tab delayed release 5 mg ............................................... 123 Bismatrol
170
see bismuth subsalicylate susp 262 mg/15ml.........................49
bismuth subsalicylate chew tab 262 mg .....................................49
bismuth subsalicylate susp 262 mg/15ml ..................................49
bismuth subsalicylate susp 525 mg/15ml ..................................49
bismuth subsalicylate tab 262 mg ................................................. 49
bisoprolol & hydrochlorothiazide tab 10-6.25 mg .........................62
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg ........................62
bisoprolol & hydrochlorothiazide tab 5-6.25 mg...........................62
bisoprolol fumarate tab 10 mg ....84 bisoprolol fumarate tab 5 mg ......84 blood glucose monitoring supplies
see TRUE METRIX KIT AIR .......... 126 BOOSTRIX INJ ............................. 153 bosentan
see TRACLEER TAB 125MG ...........89 see TRACLEER TAB 32MG .............88 see TRACLEER TAB 62.5MG ..........88 bosentan tab 125 mg ..................88 bosentan tab 62.5 mg .................88 BOTOX INJ 100UNIT ..................... 141 BOTOX INJ 200UNIT ..................... 141 Bp Cleansing Wash see sulfacetamide sodium-sulfur
in urea emulsion 10-4% ........96 Bp Gel
see benzoyl peroxide gel 5% ....96 Bp Wash
see benzoyl peroxide liq 5% .....96 Bprotected Pedia Poly-vit
see pediatric multiple vitamin w/ c soln 35 mg/ml .................. 136
see pediatric multiple vitamins w/ iron drops 10 mg/ml ...... 136
Bprotected Pedia Tri-vite see pediatric vitamins adc drops 750 unit-400 unit-35 mg/ml 136
BRAINSTRONG MIS PRENATAL ....... 137 BREO ELLIPTA INH 100-25 ..............26 BREO ELLIPTA INH 200-25 ..............26
Briellyn see norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg..92
BRILINTA TAB 60MG..................... 117 BRILINTA TAB 90MG..................... 117 brimonidine tartrate (topical)
see MIRVASO GEL 0.33% ........... 103 brimonidine tartrate ophth soln
0.15% .................................... 142 brimonidine tartrate ophth soln
0.2% ...................................... 142 brimonidine tartrate-timolol
maleate see COMBIGAN SOL 0.2/0.5% .... 142 brinzolamide see AZOPT SUS 1% OP .............. 144 brinzolamide-brimonidine tartrate see SIMBRINZA SUS 1-0.2% ...... 143 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) ............................................... 144 bromocriptine mesylate (diabetes) see CYCLOSET TAB 0.8MG ............44 bromocriptine mesylate cap 5 mg (base equivalent) .....................71 bromocriptine mesylate tab 2.5 mg (base equivalent) .....................71 brompheniramine & pseudoephedrine elixir 1-15 mg/5ml ....................................94 BROTAPP DM LIQ 15-1-5/5..............94 BROVANA NEB 15MCG ....................26 BRUKINSA CAP 80MG .....................67 budesonide (inhalation) see PULMICORT INH 180MCG .......25 see PULMICORT INH 90MCG .........25 budesonide delayed release particles cap 3 mg ....................93 budesonide inhalation susp 0.25 mg/2ml ....................................25 budesonide inhalation susp 0.5 mg/2ml ....................................25 budesonide nasal susp 32 mcg/act ............................................... 140 budesonide-formoterol fumarate dihydrate see SYMBICORT AER 160-4.5........28
171
see SYMBICORT AER 80-4.5 .........28 bumetanide tab 0.5 mg ............. 105 bumetanide tab 1 mg ................ 105 bumetanide tab 2 mg ................ 105 buprenorphine hcl sl tab 2 mg
(base equiv) .............................17 buprenorphine hcl sl tab 8 mg
(base equiv) .............................17 buprenorphine hcl-naloxone hcl sl
tab 2-0.5 mg (base equiv) ........17 buprenorphine hcl-naloxone hcl sl
tab 8-2 mg (base equiv) ...........17 buprenorphine td patch weekly 10
mcg/hr .....................................17 buprenorphine td patch weekly 15
mcg/hr .....................................17 buprenorphine td patch weekly 20
mcg/hr .....................................17 buprenorphine td patch weekly 5
mcg/hr .....................................17 buprenorphine td patch weekly 7.5
mcg/hr .....................................17 bupropion hcl (smoking deterrent)
tab er 12hr 150 mg.................150 bupropion hcl tab 100 mg ...........34 bupropion hcl tab 75 mg .............34 bupropion hcl tab er 12hr 100 mg
................................................. 34 bupropion hcl tab er 12hr 150 mg
................................................. 34 bupropion hcl tab er 12hr 200 mg
................................................. 34 bupropion hcl tab er 24hr 150 mg
................................................. 34 bupropion hcl tab er 24hr 300 mg
................................................. 34 buspirone hcl tab 10 mg ..............21 buspirone hcl tab 15 mg ..............21 buspirone hcl tab 30 mg ..............21 buspirone hcl tab 5 mg................21 buspirone hcl tab 7.5 mg .............21 butalbital-acetaminophen tab 50-
325 mg .....................................11 butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg ........16 butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg ........16
butalbital-acetaminophen-caffeine cap 50-300-40 mg ....................11
butalbital-acetaminophen-caffeine cap 50-325-40 mg ....................11
butalbital-acetaminophen-caffeine tab 50-325-40 mg ....................11
butalbital-aspirin-caffeine cap 50325-40 mg................................11
butenafine hcl see MENTAX CRE 1% ...................98
butoconazole nitrate (one dose) see GYNAZOLE-1 CRE 2% .......... 159
butorphanol tartrate nasal soln 10 mg/ml ......................................17
BYSTOLIC TAB 10MG ......................84 BYSTOLIC TAB 2.5MG .....................84 BYSTOLIC TAB 20MG ......................84 BYSTOLIC TAB 5MG........................84 BYVALSON TAB 5-80MG ..................62 C
c1 esterase inhibitor (human) see BERINERT INJ 500UNIT ........ 117
cabergoline tab 0.5 mg.............. 108 cabozantinib s-malate
see COMETRIQ KIT 100MG ...........68 see COMETRIQ KIT 140MG ...........68 see COMETRIQ KIT 60MG .............67 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) 2 calcipotriene oint 0.005% ...........99 calcipotriene soln 0.005% (50 mcg/ml) ...................................99 calcipotriene-betamethasone dipropionate see TACLONEX SUS ................... 102 calcipotriene-betamethasone dipropionate oint 0.005-0.064% ............................................... 100 calcipotriene-betamethasone dipropionate susp 0.005-0.064% ............................................... 100 calcitonin (salmon) nasal soln 200 unit/act .................................. 106 Calcitrate see calcium citrate tab 950 mg
(200 mg elemental ca) ........ 131 calcitriol cap 0.25 mcg .............. 107
172
calcitriol cap 0.5 mcg ................ 107 calcitriol oint 3 mcg/gm ..............99 calcium & phosphorus w/ vitamin d
see RISACAL-D TAB ................... 131 Calcium 500 + D
see calcium carbonate-vitamin d tab 500 mg-125 unit ............ 130
Calcium 500/d see calcium carbonatecholecalciferol chew tab 500 mg-400 unit ......................... 130
Calcium 600 see calcium carbonate tab 600 mg ............................................ 130
Calcium 600 With Vitamin see calcium carbonate-vitamin d chew tab 600 mg-400 unit ... 130
Calcium 600/vitamin D3 see calcium carbonatecholecalciferol tab 600 mg-800 unit ...................................... 130
calcium acetate (phosphate binder) cap 667 mg (169 mg ca).........112
Calcium Antacid see calcium carbonate (antacid) chew tab 500 mg ...................18
calcium carbonate (antacid) chew tab 1000 mg .............................18
calcium carbonate (antacid) chew tab 400 mg ...............................18
calcium carbonate (antacid) chew tab 500 mg ...............................18
calcium carbonate (antacid) chew tab 750 mg ...............................18
calcium carbonate (antacid) susp 1250 mg/5ml ...........................18
calcium carbonate tab 1250 mg (500 mg elemental ca) ........... 130
calcium carbonate tab 1500 mg (600 mg elemental ca) ........... 130
calcium carbonate tab 600 mg .. 130 calcium carbonate-cholecalciferol
see CALTRATE 600 CHW 600-800 131 calcium carbonate-cholecalciferol
cap 600 mg-500 unit .............. 130 calcium carbonate-cholecalciferol
chew tab 500 mg-100 unit......130
calcium carbonate-cholecalciferol chew tab 500 mg-400 unit ..... 130
calcium carbonate-cholecalciferol chew tab 500 mg-600 unit ..... 130
calcium carbonate-cholecalciferol tab 250 mg-125 unit............... 130
calcium carbonate-cholecalciferol tab 500 mg-125 unit............... 130
calcium carbonate-cholecalciferol tab 500 mg-200 unit............... 130
calcium carbonate-cholecalciferol tab 500 mg-400 unit............... 130
calcium carbonate-cholecalciferol tab 500 mg-600 unit............... 130
calcium carbonate-cholecalciferol tab 600 mg-200 unit............... 130
calcium carbonate-cholecalciferol tab 600 mg-400 unit............... 130
calcium carbonate-cholecalciferol tab 600 mg-800 unit............... 130
calcium carbonate-ergocalciferol see RA OYS SHL/D TAB 500MG ... 131
calcium carbonate-mag hydrox see MI-ACID CHW .......................18
calcium carbonate-mag hydroxide chew tab 675-135 mg...............18
calcium carbonate-mag hydroxide susp 400-135 mg/5ml..............18
calcium carbonate-vitamin d cap 600 mg-200 unit..................... 130
calcium carbonate-vitamin d chew tab 600 mg-400 unit............... 130
calcium carbonate-vitamin d tab 250 mg-125 unit..................... 130
calcium carbonate-vitamin d tab 500 mg-125 unit..................... 130
calcium carbonate-vitamin d tab 500 mg-200 unit..................... 130
calcium carbonate-vitamin d tab 500 mg-400 unit..................... 131
calcium carbonate-vitamin d tab 600 mg-125 unit..................... 131
calcium carbonate-vitamin d tab 600 mg-200 unit..................... 131
calcium carbonate-vitamin d tab 600 mg-400 unit..................... 131
173
calcium carb-vit d w/ minerals chew tab 600 mg-400 unit......130
calcium carb-vit d w/ minerals chew tab 600 mg-800 unit......130
CALCIUM CITR TAB 200MG ............ 131 Calcium Citrate + D3
see calcium citrate-vitamin d tab 250 mg-200 unit (elemental ca) ............................................ 131
calcium citrate tab 950 mg (200 mg elemental ca)....................131
calcium citrate-vitamin d tab 200 mg-250 unit (elemental ca)....131
calcium citrate-vitamin d tab 250 mg-200 unit (elemental ca)....131
calcium citrate-vitamin d tab 315 mg-200 unit (elemental ca)....131
calcium citrate-vitamin d tab 315 mg-250 unit (elemental ca)....131
Calcium Plus Vitamin D3 see calcium carbonatecholecalciferol cap 600 mg-500 unit ...................................... 130
calcium polycarbophil tab 625 mg ............................................... 122
CALCIUM TAB 600MG ................... 131 calcium-magnesium-zinc tab 333-
133-5 mg ................................ 131 CALNA TAB .................................. 137 CALTRATE 600 CHW 600-800 ........ 131 candesartan cilexetil tab 16 mg ..59 candesartan cilexetil tab 32 mg ..59 candesartan cilexetil tab 4 mg ....59 candesartan cilexetil tab 8 mg ....59 capecitabine tab 150 mg .............65 capecitabine tab 500 mg .............65 CAPRELSA TAB 100MG ....................67 CAPRELSA TAB 300MG ....................67 capsaicin cream 0.1% ............... 102 captopril & hydrochlorothiazide tab
25-15 mg ..................................62 captopril & hydrochlorothiazide tab
25-25 mg ..................................62 captopril & hydrochlorothiazide tab
50-15 mg ..................................63 captopril & hydrochlorothiazide tab
50-25 mg ..................................63
captopril tab 100 mg ...................57 captopril tab 12.5 mg ..................57 captopril tab 25 mg .....................57 captopril tab 50 mg .....................57 carbamazepine cap er 12hr 100 mg
................................................. 31 carbamazepine cap er 12hr 200 mg
................................................. 31 carbamazepine cap er 12hr 300 mg
................................................. 31 carbamazepine chew tab 100 mg 31 carbamazepine susp 100 mg/5ml
................................................. 31 carbamazepine tab 200 mg .........31 carbamazepine tab er 12hr 100 mg
................................................. 31 carbamazepine tab er 12hr 200 mg
................................................. 31 carbamazepine tab er 12hr 400 mg
................................................. 31 carbamide peroxide 6.5% otic soln
............................................... 145 carbidopa & levodopa orally
disintegrating tab 10-100 mg ...71 carbidopa & levodopa orally
disintegrating tab 25-100 mg ...71 carbidopa & levodopa orally
disintegrating tab 25-250 mg ...71 carbidopa & levodopa tab 10-100
mg ............................................71 carbidopa & levodopa tab 25-100
mg ............................................71 carbidopa & levodopa tab 25-250
mg ............................................71 carbidopa & levodopa tab er 25-
100 mg .....................................71 carbidopa & levodopa tab er 50-
200 mg .....................................71 carbidopa tab 25 mg ...................70 carbidopa-levodopa-entacapone
tabs 12.5-50-200 mg................71 carbidopa-levodopa-entacapone
tabs 18.75-75-200 mg ..............71 carbidopa-levodopa-entacapone
tabs 25-100-200 mg.................71 carbidopa-levodopa-entacapone
tabs 31.25-125-200 mg ............71
174
carbidopa-levodopa-entacapone tabs 37.5-150-200 mg ..............71
carbidopa-levodopa-entacapone tabs 50-200-200 mg .................71
carbinoxamine maleate soln 4 mg/5ml ....................................52
carbinoxamine maleate tab 4 mg 52 carbonyl iron
see IRON CHW PEDIATRI............120 carbonyl iron susp 15 mg/1.25ml
(elemental iron) ..................... 119 carboxymethylcellulose sodium
(pf) ophth soln 0.5% .............. 141 carboxymethylcellulose sodium
ophth soln 0.5% ..................... 141 CARIMUNE NF INJ 12GM ............... 146 cariprazine hcl
see VRAYLAR CAP 1.5MG ..............72 see VRAYLAR CAP 3MG.................72 see VRAYLAR CAP 4.5MG ..............72 see VRAYLAR CAP 6MG.................72 carisoprodol tab 350 mg............ 139 carteolol hcl ophth soln 1%....... 142 carvedilol tab 12.5 mg.................83 carvedilol tab 25 mg....................83 carvedilol tab 3.125 mg...............83 carvedilol tab 6.25 mg.................83 CAYA DPR ................................... 125 CAYSTON INH 75MG .......................19 cefaclor cap 250 mg ....................90 cefaclor cap 500 mg ....................90 cefaclor for susp 125 mg/5ml .....90 cefaclor for susp 250 mg/5ml .....90 cefaclor for susp 375 mg/5ml .....90 cefadroxil cap 500 mg .................89 cefadroxil for susp 250 mg/5ml ..90 cefadroxil for susp 500 mg/5ml ..90 cefadroxil tab 1 gm .....................90 cefdinir cap 300 mg.....................90 cefdinir for susp 125 mg/5ml......90 cefdinir for susp 250 mg/5ml......90 cefditoren pivoxil tab 200 mg (base equivalent) ...............................90 cefditoren pivoxil tab 400 mg (base equivalent) ...............................90 cefixime see SUPRAX CAP 400MG...............91
cefixime cap 400 mg ...................90 cefixime for susp 100 mg/5ml ....90 cefixime for susp 200 mg/5ml ....90 cefpodoxime proxetil for susp 100
mg/5ml ....................................90 cefpodoxime proxetil for susp 50
mg/5ml ....................................90 cefpodoxime proxetil tab 100 mg 91 cefpodoxime proxetil tab 200 mg 91 cefprozil for susp 125 mg/5ml ....90 cefprozil for susp 250 mg/5ml ....90 cefprozil tab 250 mg ...................90 cefprozil tab 500 mg ...................90 ceftriaxone sodium for inj 1 gm ..91 cefuroxime axetil tab 250 mg......90 cefuroxime axetil tab 500 mg......90 celecoxib cap 100 mg ................... 8 celecoxib cap 200 mg ................... 8 celecoxib cap 400 mg ................... 8 celecoxib cap 50 mg ..................... 8 cellulose
see UNIFIBER POW .................... 122 CELONTIN CAP 300MG ....................33 CENTRUM SPEC PAK PRENATAL...... 137 cephalexin cap 250 mg................90 cephalexin cap 500 mg................90 cephalexin for susp 125 mg/5ml.90 cephalexin for susp 250 mg/5ml.90 CERDELGA CAP 84MG ................... 117 ceritinib
see ZYKADIA CAP 150MG .............70 certolizumab pegol
see CIMZIA KIT ......................... 111 see CIMZIA KIT STARTER ........... 111 see CIMZIA PREFL KIT 200MG/ML 111 cervical caps see FEMCAP MIS 22MM .............. 125 see FEMCAP MIS 26MM .............. 125 see FEMCAP MIS 30MM .............. 125 CESAMET CAP 1MG ........................51 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) ................................... 52 cetirizine hcl tab 10 mg ...............52 cetirizine hcl tab 5 mg.................52 cetirizine-pseudoephedrine tab er 12hr 5-120 mg .........................95 cetrorelix acetate
175
see CETROTIDE KIT 0.25MG ....... 106 CETROTIDE KIT 0.25MG ................ 106 cevimeline hcl cap 30 mg .......... 135 CHANTIX PAK 0.5& 1MG................150 CHANTIX TAB 0.5MG .................... 150 CHANTIX TAB 1MG ....................... 150 CHEMET CAP 100MG.......................50 Chewable Vite Childrens
see pediatric multiple vitamin w/ c & fa chew tab .................... 136
Chewable Vite With Iron/c see pediatric multiple vitamins w/ iron chew tab 15 mg ...... 136
Childrens Pain Reliever see acetaminophen chew tab 80 mg .........................................11
Childrens Pepto see calcium carbonate (antacid) chew tab 400 mg ...................18
Childrens Silfedrine see pseudoephedrine hcl liq 15 mg/5ml ............................... 140
chlorambucil see LEUKERAN TAB 2MG ..............65
chlordiazepoxide hcl cap 10 mg ..22 chlordiazepoxide hcl cap 25 mg ..22 chlordiazepoxide hcl cap 5 mg ....22 chlorhexidine gluconate liquid 4%
................................................. 79 chlorhexidine gluconate soln
0.12% .................................... 135 chloroquine phosphate tab 250 mg
................................................. 64 chloroquine phosphate tab 500 mg
................................................. 64 chlorothiazide tab 250 mg.........105 chlorothiazide tab 500 mg.........105 Chlorphen Sr
see chlorpheniramine maleate tab er 12 mg ................................51
chlorpheniramine maleate syrup 2 mg/5ml ....................................51
chlorpheniramine maleate tab 4 mg ................................................. 51
chlorpheniramine maleate tab er 12 mg .......................................51
chlorpromazine hcl tab 10 mg .....77
chlorpromazine hcl tab 100 mg ...77 chlorpromazine hcl tab 200 mg ...77 chlorpromazine hcl tab 25 mg .....77 chlorpromazine hcl tab 50 mg .....77 chlorpropamide tab 100 mg ........49 chlorpropamide tab 250 mg ........49 chlorthalidone tab 25 mg .......... 105 chlorthalidone tab 50 mg .......... 105 chlorzoxazone tab 500 mg ........ 139 cholecalciferol cap 1.25 mg (50000
unit) ....................................... 160 cholecalciferol cap 125 mcg (5000
unit) ....................................... 160 cholecalciferol cap 25 mcg (1000
unit) ....................................... 160 cholecalciferol cap 250 mcg (10000
unit) ....................................... 160 cholecalciferol cap 50 mcg (2000
unit) ....................................... 160 cholecalciferol chew tab 10 mcg
(400 unit)............................... 160 cholecalciferol chew tab 25 mcg
(1000 unit)............................. 160 cholecalciferol drops 125 mcg/ml
(5000 unit/ml) ....................... 161 cholecalciferol oral liquid 10
mcg/ml (400 unit/ml)............ 161 cholecalciferol tab 10 mcg (400
unit) ....................................... 161 cholecalciferol tab 125 mcg (5000
unit) ....................................... 161 cholecalciferol tab 25 mcg (1000
unit) ....................................... 161 cholecalciferol tab 50 mcg (2000
unit) ....................................... 161 cholestyramine light powder 4
gm/dose ................................... 53 cholestyramine powder 4 gm/dose
................................................. 53 choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) ..............54 choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) ..............54 CHOR GONADOT INJ 10000UNT ..... 106 Chromagen
see iron combination cap ........ 119 ciclesonide (nasal)
176
see OMNARIS SPR ..................... 140 ciclopirox olamine cream 0.77%
(base equiv) .............................97 ciclopirox olamine susp 0.77%
(base equiv) .............................97 ciclopirox solution 8%.................98 cilostazol tab 100 mg ................ 117 cilostazol tab 50 mg .................. 117 CIMDUO TAB 300-300 ....................79 cimetidine tab 200 mg...............154 cimetidine tab 300 mg...............154 cimetidine tab 400 mg...............154 cimetidine tab 800 mg...............154 CIMZIA KIT ................................. 111 CIMZIA KIT STARTER....................111 CIMZIA PREFL KIT 200MG/ML ........ 111 cinacalcet hcl
see SENSIPAR TAB 30MG ........... 108 see SENSIPAR TAB 60MG ........... 108 see SENSIPAR TAB 90MG ........... 108 cinacalcet hcl tab 30 mg (base equiv) ..................................... 107 cinacalcet hcl tab 60 mg (base equiv) ..................................... 107 cinacalcet hcl tab 90 mg (base equiv) ..................................... 107 CIPRO HC SUS OTIC ..................... 145 CIPRODEX SUS 0.3-0.1% .............. 145 ciprofloxacin hcl ophth soln 0.3% (base equivalent) ................... 143 ciprofloxacin hcl otic soln 0.2% (base equivalent) ................... 145 ciprofloxacin hcl tab 250 mg (base equiv) ..................................... 110 ciprofloxacin hcl tab 500 mg (base equiv) ..................................... 110 ciprofloxacin hcl tab 750 mg (base equiv) ..................................... 110 ciprofloxacin-dexamethasone see CIPRODEX SUS 0.3-0.1% ..... 145 ciprofloxacin-hydrocortisone see CIPRO HC SUS OTIC ............ 145 citalopram hydrobromide oral soln 10 mg/5ml ...............................34 citalopram hydrobromide tab 10 mg (base equiv) .......................34
citalopram hydrobromide tab 20 mg (base equiv) .......................35
citalopram hydrobromide tab 40 mg (base equiv) .......................35
Claravis see isotretinoin cap 10 mg ........96
clarithromycin for susp 125 mg/5ml .................................. 124
clarithromycin for susp 250 mg/5ml .................................. 124
clarithromycin tab 250 mg ........ 124 clarithromycin tab 500 mg ........ 124 Clean & Clear Persa-gel M
see benzoyl peroxide gel 10% ..96 Clear Soluble Fiber
see wheat dextrin oral powder 122 clemastine fumarate tab 1.34 mg
(1 mg base equiv) ....................52 clemastine fumarate tab 2.68 mg 52 CLENPIQ SOL............................... 122 clindamycin hcl cap 150 mg ........19 clindamycin hcl cap 300 mg ........19 clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) ..........19 clindamycin phosphate gel 1% ...96 clindamycin phosphate lotion 1%
................................................. 96 clindamycin phosphate soln 1%..96 clindamycin phosphate vaginal
cream 2%............................... 159 clindamycin phosphate-tretinoin
see VELTIN GEL ..........................97 clindamycin phosphate-tretinoin
gel 1.2-0.025% ........................96 clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5% ................................................. 96 clobazam tab 10 mg ....................30 clobazam tab 20 mg ....................30 clobetasol propionate cream 0.05% .................................... 100 clobetasol propionate gel 0.05% ............................................... 100 clobetasol propionate oint 0.05% ............................................... 100 clobetasol propionate soln 0.05% ............................................... 100
177
clomipramine hcl cap 25 mg........37 clomipramine hcl cap 50 mg........37 clomipramine hcl cap 75 mg........37 clonazepam tab 0.5 mg ...............30 clonazepam tab 1 mg ..................30 clonazepam tab 2 mg ..................30 clonidine hcl tab 0.1 mg ..............61 clonidine hcl tab 0.2 mg ..............61 clonidine hcl tab 0.3 mg ..............61 clonidine td patch weekly 0.1
mg/24hr ...................................61 clonidine td patch weekly 0.2
mg/24hr ...................................61 clonidine td patch weekly 0.3
mg/24hr ...................................61 clopidogrel bisulfate tab 75 mg
(base equiv) ........................... 117 clorazepate dipotassium tab 15 mg
................................................. 22 clorazepate dipotassium tab 3.75
mg ............................................22 clorazepate dipotassium tab 7.5
mg ............................................22 clotrimazole cream 1% ...............98 clotrimazole soln 1%...................98 clotrimazole troche 10 mg.........135 clotrimazole vaginal cream 1% . 159 clotrimazole vaginal cream 2% . 159 clotrimazole w/ betamethasone
cream 1-0.05% ........................98 clotrimazole w/ betamethasone
lotion 1-0.05% .........................98 clozapine tab 100 mg ..................75 clozapine tab 200 mg ..................75 clozapine tab 25 mg ....................75 clozapine tab 50 mg ....................75 coagulation factor ix
see ALPHANINE SD INJ 1500UNIT114 see ALPHANINE SD INJ 500UNIT . 114 coagulation factor ix (recomb) fc fusion protein (rfixfc) see ALPROLIX INJ 1000UNIT.......114 see ALPROLIX INJ 2000UNIT.......114 see ALPROLIX INJ 250UNIT ........ 114 see ALPROLIX INJ 3000UNIT.......114 see ALPROLIX INJ 4000UNIT.......114 see ALPROLIX INJ 500UNIT ........ 114
coagulation factor ix (recombinant) see BENEFIX INJ 1000UNIT ........ 114 see BENEFIX INJ 2000UNIT ........ 114 see BENEFIX INJ 250UNIT .......... 114 see BENEFIX INJ 3000UNIT ........ 114 see BENEFIX INJ 500UNIT .......... 114 see RIXUBIS INJ 1000UNIT ........ 116 see RIXUBIS INJ 2000UNIT ........ 116 see RIXUBIS INJ 250 UNIT ......... 116 see RIXUBIS INJ 3000UNIT ........ 116 see RIXUBIS INJ 500UNIT .......... 116
coagulation factor viia (recombinant) see NOVOSEVEN RT INJ 1MG ...... 115 see NOVOSEVEN RT INJ 2MG ...... 115 see NOVOSEVEN RT INJ 5MG ...... 115 see NOVOSEVEN RT INJ 8MG ...... 115
COARTEM TAB 20-120MG................64 cobicistat
see TYBOST TAB 150MG...............81 CODEINE SULF TAB 60MG ...............12 codeine sulfate tab 30 mg ...........12 colchicine tab 0.6 mg ................ 113 colchicine w/ probenecid tab 0.5-
500 mg ................................... 113 colesevelam hcl packet for susp
3.75 gm ....................................53 colesevelam hcl tab 625 mg ........53 colestipol hcl tab 1 gm ................53 collagenase
see SANTYL OIN 250/GM............ 102 COLY-MYCIN S SUS OTIC .............. 145 COMBIGAN SOL 0.2/0.5% ............. 142 COMBIVENT AER 20-100 .................26 COMETRIQ KIT 100MG....................68 COMETRIQ KIT 140MG....................68 COMETRIQ KIT 60MG .....................67 COMPLERA TAB..............................79 CO-NATAL FA TAB 29-1MG ............ 137 CONCEPTROL GEL 4% .................. 159 condoms - female
see FC2 FEMALE MIS CONDOM.... 125 condoms latex lubricated - male
see CONDOMS MIS LUBRICAT..... 125 condoms latex non-lubricated -
male see TROJAN MIS........................ 125
178
CONDOMS MIS ............................ 125 CONDOMS MIS LUBRICAT ............. 125 condoms non-latex lubricated -
male see DUREX MIS REALFEEL .......... 125 condoms non-latex non-lubricated - male see TROJAN MIS NATULAMB ....... 125 conjugated estrogensbazedoxifene see DUAVEE TAB 0.45-20 ........... 108 conjugated estrogensmedroxyprogesterone acetate see PREMPHASE TAB..................109 see PREMPRO TAB ..................... 109 see PREMPRO TAB 0.3-1.5 .......... 109 see PREMPRO TAB 0.45-1.5 ........ 109 see PREMPRO TAB 0.625-5 ......... 109 continuous blood glucose system receiver see DEXCOM G5 MIS RECEIVER .. 125 see DEXCOM G6 MIS RECEIVER .. 125 see FREESTYLE MIS READER.......126 continuous blood glucose system sensor see DEXCOM G6 MIS SENSOR ..... 126 see FREESTYLE KIT SENSOR ....... 126 see G5/G4 MIS SENSOR ............. 126 continuous blood glucose system transmitter see DEXCOM G5 MIS TRANSMIT .. 125 see DEXCOM G6 MIS TRANSMIT .. 126 copper (iud) see PARAGARD IUD T380A ...........93 CORDRAN 80X3 TAP 4MCG/CM ...... 100 CORLANOR SOL 5MG/5ML ...............89 CORLANOR TAB 5MG ......................89 CORLANOR TAB 7.5MG ...................89 corn dextrin oral powder ........... 122 cortisone acetate tab 25 mg ........93 CORTISPORIN OIN 1%....................97 Cortizone-10 see hydrocortisone gel 1% ..... 101 Cortizone-10 Plus see hydrocortisone-aloe vera
cream 1% ............................ 101 COSENTYX INJ 150MG/ML ...............99
COSENTYX INJ 300DOSE.................99 COSENTYX PEN INJ 150MG/ML ........99 COSENTYX PEN INJ 300DOSE ..........99 COUMADIN TAB 10MG ....................28 COUMADIN TAB 1MG ......................28 COUMADIN TAB 2.5MG ...................28 COUMADIN TAB 2MG ......................28 COUMADIN TAB 3MG ......................28 COUMADIN TAB 4MG ......................28 COUMADIN TAB 5MG ......................28 COUMADIN TAB 6MG ......................28 COUMADIN TAB 7.5MG ...................28 CREON CAP 12000UNT.................. 104 CREON CAP 24000UNT.................. 104 CREON CAP 3000UNIT .................. 104 CREON CAP 36000UNT.................. 104 CREON CAP 6000UNIT .................. 104 CRESEMBA CAP 186 MG ..................51 CRIXIVAN CAP 200MG ....................79 CRIXIVAN CAP 400MG ....................79 crizotinib
see XALKORI CAP 200MG .............69 see XALKORI CAP 250MG .............69 cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) ............ 140 cromolyn sodium ophth soln 4% ............................................... 144 cromolyn sodium soln nebu 20 mg/2ml ....................................23 crotamiton see EURAX CRE 10% ................. 103 CUVITRU INJ 4GM/20ML ............... 146 CUVITRU SOL 10GM/50M .............. 146 CUVITRU SOL 1GM/5ML ................ 146 Cvs Af Spray Powder see tolnaftate aerosol pow 1% .98 Cvs Allergy Relief Childr see diphenhydramine hcl liquid
12.5 mg/5ml .........................52 Cvs Antacid Supreme
see calcium carbonate-mag hydroxide susp 400-135 mg/5ml .................................18
Cvs Anti-dandruff see selenium sulfide lotion 1% .99
Cvs Anti-diarrheal see loperamide hcl tab 2 mg .....50
179
Cvs Anti-fungal Powder see miconazole nitrate powder 2% ......................................... 98
Cvs B-12 see cyanocobalamin sl tab 500 mcg...................................... 118
Cvs Bismuth Maximum Stren see bismuth subsalicylate susp 525 mg/15ml.........................49
Cvs Calcium Citrate + D see calcium citrate-vitamin d tab 315 mg-250 unit (elemental ca) ............................................ 131
Cvs Chocolate Laxative Pi see sennosides chew tab 15 mg ............................................ 124
Cvs Cold & Cough Nighttim see diphenhydraminephenylephrine liq 6.25-2.5 mg/5ml .................................95
Cvs Cortisone Maximum Str see hydrocortisone lotion 1% . 101
Cvs D3 see cholecalciferol chew tab 25 mcg (1000 unit)...................160
Cvs Dry Eye Relief see glycerin-hypromellose-peg 400 ophth soln 0.2-0.2-1%..141
Cvs Easy Fiber see corn dextrin oral powder .. 122
Cvs Fish Oil see omega-3 fatty acids cap delayed release 1200 mg ..... 141
Cvs Gas Relief see simethicone cap 125 mg ... 110
Cvs Gas Relief Drops Extr see simethicone liquid 40 mg/0.6ml ............................ 110
Cvs Gas Relief Extra Stre see simethicone chew tab 125 mg ............................................ 110
Cvs Gentle Laxative see bisacodyl suppos 10 mg .... 123
Cvs Glycerin Adult see glycerin suppos 2 gm ........ 123
Cvs Heartburn Relief
see aluminum hydroxidemagnesium carbonate chew tab 160-105 mg ...........................18
Cvs Ibuprofen Infants see ibuprofen susp 40 mg/ml .... 8
Cvs Lubricant Eye Drops see carboxymethylcellulose sodium ophth soln 0.5% ...... 141
Cvs Melatonin see melatonin cap 5 mg ............. 6
Cvs Motion Sickness see dimenhydrinate tab 50 mg..50
Cvs Motion Sickness Relie see meclizine hcl chew tab 25 mg .............................................. 50
Cvs Nasal Decongestant see pseudoephedrine hcl tab 30 mg ....................................... 140
Cvs Nasal Decongestant Pe see phenylephrine hcl tab 10 mg ............................................ 140
Cvs Nasal Spray see oxymetazoline hcl nasal soln 0.05% ................................. 140
Cvs Natural Daily Fiber see psyllium powder 48.57% .. 122 see psyllium powder 58.6% .... 122
Cvs Natural Tears see dextran 70-hypromellose (pf) ophth soln 0.1-0.3%............ 141
Cvs Nausea Relief see fructose-dextrose-phosphoric acid oral soln .........................51
Cvs Nicotine Lozenge see nicotine polacrilex lozenge 2 mg ....................................... 150
Cvs Nicotine Polacrilex see nicotine polacrilex gum 4 mg ............................................ 150
Cvs Nicotine Transdermal see nicotine td patch 24hr 21 mg/24hr .............................. 151
Cvs Omeprazole Magnesium see omeprazole magnesium cap dr 20.6 mg (20 mg base equiv) ............................................ 155
Cvs Oyster Shell Calcium
180
see calcium carbonatecholecalciferol tab 500 mg-125 unit ...................................... 130
Cvs Pain & Fever Children see acetaminophen susp 160 mg/5ml .................................11
Cvs Pinworm Treatment see pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv) .............................................. 19
CVS PRENATAL CHW GUMMY ......... 137 Cvs Saline Nasal Spray
see saline nasal spray 0.65%..139 Cvs Sleep Aid Nighttime
see diphenhydramine hcl (sleep) tab 25 mg ............................ 120
Cvs Smooth Antacid Extra see calcium carbonate (antacid) chew tab 750 mg ...................18
Cvs Sodium Chloride see sodium chloride hypertonic ophth oint 5% ..................... 144 see sodium chloride hypertonic ophth soln 5% ..................... 144
Cvs Triple Antibiotic see neomycin-bacitracinpolymyxin oint .......................97
Cvs Vitamin B-12 Tr see cyanocobalamin tab er 1000 mcg...................................... 118
Cvs Vitamin B-2 see riboflavin tab 100 mg........ 161
cyanocobalamin inj 1000 mcg/ml ............................................... 118
cyanocobalamin sl tab 1000 mcg ............................................... 118
cyanocobalamin sl tab 2500 mcg ............................................... 118
cyanocobalamin sl tab 500 mcg.118 cyanocobalamin tab 100 mcg .... 118 cyanocobalamin tab 1000 mcg .. 118 cyanocobalamin tab 250 mcg .... 118 cyanocobalamin tab 500 mcg .... 118 cyanocobalamin tab er 1000 mcg
............................................... 118 cyclobenzaprine hcl tab 10 mg .. 139 cyclobenzaprine hcl tab 5 mg .... 139
cyclopentolate hcl ophth soln 1% ............................................... 142
cyclophosphamide cap 25 mg......65 cyclophosphamide cap 50 mg......65 cycloserine cap 250 mg ...............65 CYCLOSET TAB 0.8MG ....................44 cyclosporine
see SANDIMMUNE CAP 100MG .... 134 see SANDIMMUNE CAP 25MG ...... 134 cyclosporine (ophth) see RESTASIS EMU 0.05% ......... 143 cyclosporine cap 100 mg ........... 133 cyclosporine cap 25 mg ............. 133 cyclosporine modified (for microemulsion) see NEORAL CAP 100MG ............ 134 see NEORAL CAP 25MG .............. 134 cyclosporine modified cap 100 mg ............................................... 134 cyclosporine modified cap 25 mg ............................................... 133 cyclosporine modified cap 50 mg ............................................... 133 cyclosporine modified oral soln 100 mg/ml .................................... 134 cyproheptadine hcl syrup 2 mg/5ml ....................................53 cyproheptadine hcl tab 4 mg .......53 CYSTADANE POW ......................... 107 CYSTAGON CAP 150MG................. 112 CYSTAGON CAP 50MG .................. 112 CYSTARAN SOL 0.44%.................. 144 cysteamine bitartrate see CYSTAGON CAP 150MG ........ 112 see CYSTAGON CAP 50MG .......... 112 cysteamine hcl see CYSTARAN SOL 0.44% ......... 144 D
D 1000 see cholecalciferol cap 25 mcg (1000 unit) .......................... 160
D 5000 see cholecalciferol cap 125 mcg (5000 unit) .......................... 160
D2000 Ultra Strength see cholecalciferol cap 50 mcg (2000 unit) .......................... 160
181
D3 Maximum Strength see cholecalciferol drops 125 mcg/ml (5000 unit/ml) ....... 161
dabigatran etexilate mesylate see PRADAXA CAP 110MG.............30 see PRADAXA CAP 150MG.............30 see PRADAXA CAP 75MG ..............30
dabrafenib mesylate see TAFINLAR CAP 50MG..............69 see TAFINLAR CAP 75MG..............69
daclatasvir dihydrochloride see DAKLINZA TAB 30MG .............82 see DAKLINZA TAB 60MG .............82
Daily Vite see multiple vitamin tab..........135
DAKLINZA TAB 30MG......................82 DAKLINZA TAB 60MG......................82 dalfampridine tab er 12hr 10 mg
............................................... 149 DALIRESP TAB 250MCG ..................24 DALIRESP TAB 500MCG ..................24 dalteparin sodium
see FRAGMIN INJ 10000/ML .........30 see FRAGMIN INJ 12500UNT .........30 see FRAGMIN INJ 15000UNT .........30 see FRAGMIN INJ 18000UNT .........30 see FRAGMIN INJ 2500/0.2...........29 see FRAGMIN INJ 5000/0.2...........29 see FRAGMIN INJ 7500/0.3...........29 danazol cap 100 mg ....................17 danazol cap 200 mg ....................17 danazol cap 50 mg ......................17 dantrolene sodium cap 100 mg . 139 dantrolene sodium cap 25 mg ... 139 dantrolene sodium cap 50 mg ... 139 dapagliflozin propanediol see FARXIGA TAB 10MG ...............48 see FARXIGA TAB 5MG .................48 dapagliflozin-metformin hcl see XIGDUO XR TAB 10-1000 .......43 see XIGDUO XR TAB 10-500MG.....42 see XIGDUO XR TAB 2.5-1000 ......42 see XIGDUO XR TAB 5-1000MG.....42 see XIGDUO XR TAB 5-500MG ......42 dapsone tab 100 mg ....................19 dapsone tab 25 mg......................19 DARAPRIM TAB 25MG .....................64
darbepoetin alfa see ARANESP INJ 100MCG.......... 118 see ARANESP INJ 10MCG ........... 118 see ARANESP INJ 150MCG.......... 118 see ARANESP INJ 200MCG.......... 118 see ARANESP INJ 25MCG ........... 118 see ARANESP INJ 300MCG.......... 118 see ARANESP INJ 40MCG ........... 118 see ARANESP INJ 500MCG.......... 118 see ARANESP INJ 60MCG ........... 118
darifenacin hydrobromide tab er 24hr 15 mg (base equiv) ........ 156
darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv) ....... 156
darunavir ethanolate see PREZISTA SUS 100MG/ML ......81 see PREZISTA TAB 150MG............81 see PREZISTA TAB 600MG............81 see PREZISTA TAB 75MG..............81 see PREZISTA TAB 800MG............81
darunavir-cobicistat see PREZCOBIX TAB 800-150 .......81
darunavir-cobicistat-emtricitabinetenofovir alafenamide see SYMTUZA TAB .......................81
dasatinib see SPRYCEL TAB 100MG .............69 see SPRYCEL TAB 140MG .............69 see SPRYCEL TAB 20MG ...............69 see SPRYCEL TAB 50MG ...............69 see SPRYCEL TAB 70MG ...............69 see SPRYCEL TAB 80MG ...............69
deferasirox tab for oral susp 125 mg ............................................50
deferasirox tab for oral susp 250 mg ............................................50
deferasirox tab for oral susp 500 mg ............................................50
deferiprone see FERRIPROX TAB 1000MG ........50 see FERRIPROX TAB 500MG..........50
degarelix acetate see FIRMAGON INJ 80MG .............66
delafloxacin meglumine see BAXDELA TAB 450MG........... 110
delavirdine mesylate see RESCRIPTOR TAB 200MG........81
182
DELSTRIGO TAB.............................79 demeclocycline hcl tab 150 mg..151 demeclocycline hcl tab 300 mg..151 DENAVIR CRE 1% ..........................99 denosumab
see PROLIA SOL 60MG/ML .......... 106 see XGEVA INJ .......................... 106 DEPEN TITRA TAB 250MG..............133 DEPO-SQ PROV INJ 104 ..................93 Dermacerin see skin protectants misc - cream
............................................ 103 DESCOVY TAB 200/25.....................80 desipramine hcl tab 10 mg ..........37 desipramine hcl tab 100 mg ........38 desipramine hcl tab 150 mg ........38 desipramine hcl tab 25 mg ..........37 desipramine hcl tab 50 mg ..........37 desipramine hcl tab 75 mg ..........37 desloratadine tab 5 mg ...............52 desmopressin acetate
see STIMATE SOL 1.5MG/ML ....... 108 desmopressin acetate nasal spray
soln 0.01% ............................. 108 desmopressin acetate nasal spray
soln 0.01% (refrigerated) ...... 108 desmopressin acetate tab 0.1 mg
............................................... 108 desmopressin acetate tab 0.2 mg
............................................... 108 desogest-eth estrad & eth estrad
tab 0.15-0.02/0.01 mg(21/5) ..91 desogest-ethin est tab 0.1-
0.025/0.125-0.025/0.150.025mg-mg .............................91 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg .......................91 desonide cream 0.05%..............100 desonide oint 0.05% ................. 100 desoximetasone cream 0.05% .. 100 desoximetasone cream 0.25% .. 100 desoximetasone gel 0.05% ....... 100 desoximetasone oint 0.05% ...... 100 desoximetasone oint 0.25% ...... 100 desvenlafaxine succinate tab er 24hr 100 mg (base equiv) ........36
desvenlafaxine succinate tab er 24hr 50 mg (base equiv) ..........36
dexamethasone elixir 0.5 mg/5ml ................................................. 93
dexamethasone sodium phosphate inj 10 mg/ml ............................93
dexamethasone sodium phosphate ophth soln 0.1% ..................... 143
dexamethasone soln 0.5 mg/5ml 93 dexamethasone tab 0.5 mg .........93 dexamethasone tab 0.75 mg .......93 dexamethasone tab 1 mg ............93 dexamethasone tab 1.5 mg .........93 dexamethasone tab 2 mg ............93 dexamethasone tab 4 mg ............94 dexamethasone tab 6 mg ............94 dexchlorpheniramine maleate oral
soln 2 mg/5ml..........................52 DEXCOM G5 MIS RECEIVER ........... 125 DEXCOM G5 MIS TRANSMIT .......... 125 DEXCOM G6 MIS RECEIVER ........... 125 DEXCOM G6 MIS SENSOR ............. 126 DEXCOM G6 MIS TRANSMIT .......... 126 DEXILANT CAP 30MG DR ............... 154 DEXILANT CAP 60MG DR ............... 155 dexlansoprazole
see DEXILANT CAP 30MG DR ...... 154 see DEXILANT CAP 60MG DR ...... 155 dexmethylphenidate hcl tab 10 mg .................................................. 4 dexmethylphenidate hcl tab 2.5 mg .................................................. 4 dexmethylphenidate hcl tab 5 mg 4 dextran 70-hypromellose (pf) ophth soln 0.1-0.3%............... 141 dextran 70-hypromellose ophth soln 0.1-0.3%......................... 141 dextroamphetamine sulfate cap er 24hr 10 mg................................ 2 dextroamphetamine sulfate cap er 24hr 15 mg................................ 2 dextroamphetamine sulfate cap er 24hr 5 mg.................................. 1 dextroamphetamine sulfate tab 10 mg ............................................. 2 dextroamphetamine sulfate tab 5 mg ............................................. 2
183
dextromethorphan hbr see ROBITUSSIN SYP 7.5/5ML ......94
dextromethorphan-guaifenesin liquid 10-100 mg/5ml ..............95
dextromethorphan-guaifenesin liquid 10-200 mg/5ml ..............95
dextromethorphan-guaifenesin syrup 10-100 mg/5ml ..............95
dextromethorphan-guaifenesin tab er 12hr 30-600 mg ...................95
dextrose (diabetic use) see GNP GLUCOSE CHW ORANGE ..43
Diabetic Siltussin-dm see dextromethorphanguaifenesin liquid 10-100 mg/5ml .................................95
Diabetic Tussin Allergy see chlorpheniramine maleate syrup 2 mg/5ml.....................51
Diabetic Tussin Maximum S see dextromethorphanguaifenesin liquid 10-200 mg/5ml .................................95
DIACOMIT CAP 250MG ....................31 DIACOMIT CAP 500MG ....................31 DIACOMIT PAK 250MG ....................31 DIACOMIT PAK 500MG ....................31 diaphragm arc-spring
see CAYA DPR ........................... 125 diaphragm wide seal
see WIDE-SEAL DPR KIT 60 ........ 125 see WIDE-SEAL DPR KIT 65 ........ 125 see WIDE-SEAL DPR KIT 70 ........ 125 see WIDE-SEAL DPR KIT 75 ........ 125 see WIDE-SEAL DPR KIT 80 ........ 125 see WIDE-SEAL DPR KIT 85 ........ 125 see WIDE-SEAL DPR KIT 90 ........ 125 see WIDE-SEAL DPR KIT 95 ........ 125 diaphragms see OMNIFLEX DPR .................... 125 diazepam (anticonvulsant) see VALTOCO LIQ 15MG ...............30 see VALTOCO LIQ 20MG ...............30 see VALTOCO SPR 10MG ..............30 see VALTOCO SPR 5MG ................30 diazepam conc 5 mg/ml ..............22 Diazepam Intensol
see diazepam conc 5 mg/ml .....22 diazepam oral soln 1 mg/ml........22 diazepam rectal gel delivery
system 10 mg ...........................30 diazepam rectal gel delivery
system 2.5 mg ..........................30 diazepam rectal gel delivery
system 20 mg ...........................30 diazepam tab 10 mg....................22 diazepam tab 2 mg......................22 diazepam tab 5 mg......................22 diazoxide
see PROGLYCEM SUS 50MG/ML .....43 diazoxide susp 50 mg/ml ............43 dibucaine perianal ointment 1% .17 diclofenac potassium tab 50 mg ... 8 diclofenac sodium gel 1% ...........97 diclofenac sodium ophth soln 0.1%
............................................... 144 diclofenac sodium tab delayed
release 25 mg............................ 8 diclofenac sodium tab delayed
release 50 mg............................ 8 diclofenac sodium tab delayed
release 75 mg............................ 8 diclofenac sodium tab er 24hr 100
mg ............................................. 8 dicloxacillin sodium cap 250 mg 148 dicloxacillin sodium cap 500 mg 148 dicyclomine hcl cap 10 mg ........ 153 dicyclomine hcl oral soln 10
mg/5ml .................................. 153 dicyclomine hcl tab 20 mg ......... 153 didanosine
see VIDEX EC CAP 125MG ............81 didanosine delayed release capsule
200 mg .....................................80 didanosine delayed release capsule
250 mg .....................................80 didanosine delayed release capsule
400 mg .....................................80 DIFFERIN GEL 0.1% .......................96 DIFICID TAB 200MG ..................... 125 diflorasone diacetate cream 0.05%
............................................... 100 diflorasone diacetate emollient
base
184
see APEXICON E CRE 0.05% ....... 100 diflorasone diacetate oint 0.05%
............................................... 100 diflunisal tab 500 mg...................12 difluprednate
see DUREZOL EMU 0.05% .......... 143 digoxin
see LANOXIN TAB 0.125MG ..........87 see LANOXIN TAB 0.25MG ............87 digoxin oral soln 0.05 mg/ml ......87 digoxin tab 125 mcg (0.125 mg) .87 digoxin tab 250 mcg (0.25 mg) ...87 dihydroergotamine mesylate inj 1 mg/ml .................................... 128 DILANTIN CAP 100MG.....................33 DILANTIN CAP 30MG ......................33 diltiazem hcl cap er 12hr 120 mg 85 diltiazem hcl cap er 24hr 120 mg 85 diltiazem hcl cap er 24hr 180 mg 85 diltiazem hcl cap er 24hr 240 mg 85 diltiazem hcl coated beads cap er 24hr 120 mg .............................85 diltiazem hcl coated beads cap er 24hr 180 mg .............................85 diltiazem hcl coated beads cap er 24hr 240 mg .............................85 diltiazem hcl coated beads cap er 24hr 300 mg .............................85 diltiazem hcl extended release beads cap er 24hr 120 mg ........85 diltiazem hcl extended release beads cap er 24hr 180 mg ........85 diltiazem hcl extended release beads cap er 24hr 240 mg ........85 diltiazem hcl extended release beads cap er 24hr 300 mg ........85 diltiazem hcl extended release beads cap er 24hr 360 mg ........86 diltiazem hcl extended release beads cap er 24hr 420 mg ........86 diltiazem hcl tab 120 mg .............86 diltiazem hcl tab 30 mg ...............86 diltiazem hcl tab 60 mg ...............86 diltiazem hcl tab 90 mg ...............86 dimenhydrinate tab 50 mg ..........50 dimethyl fumarate see TECFIDERA CAP 120MG ........ 150
see TECFIDERA CAP 240MG ........ 150 see TECFIDERA MIS STARTER ..... 150 DIPENTUM CAP 250MG ................. 111 diphenhydramine hcl see ALER-DRYL TAB 50MG............52 diphenhydramine hcl (sleep) tab 25 mg ..................................... 120 diphenhydramine hcl (sleep) tab 50 mg ..................................... 120 diphenhydramine hcl cap 25 mg..52 diphenhydramine hcl cap 50 mg..52 diphenhydramine hcl chew tab 12.5 mg ....................................52 diphenhydramine hcl elixir 12.5 mg/5ml ....................................52 diphenhydramine hcl inj 50 mg/ml ................................................. 52 diphenhydramine hcl liquid 12.5 mg/5ml ....................................52 diphenhydramine hcl tab 25 mg ..52 diphenhydramine hcl tab disint 12.5 mg ....................................52 diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml .................95 diphenhydramine-phenylephrine tab 25-10 mg............................95 diphenhydramine-zinc acetate cream 2-0.1% ..........................98 diphenoxylate w/ atropine tab 2.50.025 mg ..................................49 dipyridamole tab 25 mg ............ 117 dipyridamole tab 50 mg ............ 117 dipyridamole tab 75 mg ............ 117 disopyramide phosphate cap 100 mg ............................................23 disopyramide phosphate cap 150 mg ............................................23 disulfiram tab 250 mg ............... 148 disulfiram tab 500 mg ............... 148 divalproex sodium cap delayed release sprinkle 125 mg ...........33 divalproex sodium tab delayed release 125 mg.........................33 divalproex sodium tab delayed release 250 mg.........................33 divalproex sodium tab delayed release 500 mg.........................33
185
divalproex sodium tab er 24 hr 250 mg ............................................33
divalproex sodium tab er 24 hr 500 mg ............................................33
docosahexaenoic acid cap 200 mg ............................................... 141
docosanol see ABREVA CRE 10%..................99
docosanol cream 10% .................99 docusate calcium cap 240 mg....124 docusate sodium
see PEDIA-LAX LIQ 50MG ........... 124 docusate sodium cap 100 mg .... 124 docusate sodium cap 250 mg .... 124 docusate sodium cap 50 mg ...... 124 docusate sodium liquid 150
mg/15ml ................................ 124 docusate sodium syrup 60
mg/15ml ................................ 124 docusate sodium tab 100 mg..... 124 DOCUSOL PLUS ENE 20-283 .......... 124 dofetilide cap 125 mcg (0.125 mg)
................................................. 23 dofetilide cap 250 mcg (0.25 mg)23 dofetilide cap 500 mcg (0.5 mg) .23 Dok
see docusate sodium tab 100 mg ............................................ 124
dolasetron mesylate see ANZEMET TAB 100MG ............50 see ANZEMET TAB 50MG ..............50
dolutegravir sodium see TIVICAY PD TAB 5MG .............81 see TIVICAY TAB 10MG ................81 see TIVICAY TAB 25MG ................81 see TIVICAY TAB 50MG ................81
dolutegravir sodium-lamivudine see DOVATO TAB 50-300MG .........80
dolutegravir sodium-rilpivirine hcl see JULUCA TAB 50-25MG ............80
donepezil hydrochloride orally disintegrating tab 10 mg ........ 148
donepezil hydrochloride orally disintegrating tab 5 mg .......... 148
donepezil hydrochloride tab 10 mg ............................................... 148
donepezil hydrochloride tab 5 mg ............................................... 148
doravirine see PIFELTRO TAB 100MG ............81
doravirine-lamivudine-tenofovir disoproxil fumarate see DELSTRIGO TAB ....................79
dornase alfa see PULMOZYME SOL 1MG/ML..... 151
dorzolamide hcl ophth soln 2% . 144 dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml .... 142 Double Antibiotic
see bacitracin-polymyxin b oint 97 DOVATO TAB 50-300MG .................80 doxazosin mesylate tab 1 mg ......61 doxazosin mesylate tab 2 mg ......61 doxazosin mesylate tab 4 mg ......61 doxazosin mesylate tab 8 mg ......61 doxepin hcl (sleep)
see SILENOR TAB 3MG ............... 121 see SILENOR TAB 6MG ............... 121 doxepin hcl (sleep) tab 3 mg (base equiv) ..................................... 121 doxepin hcl (sleep) tab 6 mg (base equiv) ..................................... 121 doxepin hcl cap 10 mg ................38 doxepin hcl cap 100 mg ..............38 doxepin hcl cap 150 mg ..............38 doxepin hcl cap 25 mg ................38 doxepin hcl cap 50 mg ................38 doxepin hcl cap 75 mg ................38 doxepin hcl conc 10 mg/ml .........38 doxercalciferol cap 0.5 mcg....... 107 doxercalciferol cap 1 mcg.......... 107 doxercalciferol cap 2.5 mcg....... 107 doxycycline hyclate cap 100 mg 151 doxycycline hyclate cap 50 mg .. 151 doxycycline hyclate tab 100 mg 151 doxycycline hyclate tab 20 mg .. 151 doxycycline monohydrate cap 100 mg .......................................... 151 doxycycline monohydrate cap 50 mg .......................................... 151 doxycycline monohydrate tab 100 mg .......................................... 151
186
doxycycline monohydrate tab 50 mg .......................................... 151
doxylamine succinate (sleep) tab 25 mg ..................................... 120
D-PENAMINE TAB 125MG .............. 133 DRITHO-CREME CRE HP 1% ............99 dronabinol cap 10 mg..................51 dronabinol cap 2.5 mg.................51 dronabinol cap 5 mg....................51 dronedarone hcl
see MULTAQ TAB 400MG ..............23 drospirenone-ethinyl estradiol tab
3-0.02 mg .................................91 drospirenone-ethinyl estradiol tab
3-0.03 mg .................................91 drospirenone-ethinyl estrad-
levomefolate tab 3-0.02-0.451 mg ............................................91 drospirenone-ethinyl estradlevomefolate tab 3-0.03-0.451 mg ............................................91 droxidopa see NORTHERA CAP 100MG ........ 160 see NORTHERA CAP 200MG ........ 160 see NORTHERA CAP 300MG ........ 160 DRYSOL SOL 20% ........................ 103 DUAVEE TAB 0.45-20....................108 dulaglutide see TRULICITY INJ 0.75/0.5..........44 see TRULICITY INJ 1.5/0.5 ...........45 DULERA AER 100-5MCG ..................26 DULERA AER 200-5MCG ..................27 DULERA AER 50-5MCG....................26 duloxetine hcl enteric coated pellets cap 20 mg (base eq) .....36 duloxetine hcl enteric coated pellets cap 30 mg (base eq) .....36 duloxetine hcl enteric coated pellets cap 60 mg (base eq) .....36 dupilumab see DUPIXENT INJ 200/1.14 .........24 see DUPIXENT INJ 300/2ML ........ 102 DUPIXENT INJ 200/1.14 ..................24 DUPIXENT INJ 300/2ML ................ 102 DUREX MIS REALFEEL...................125 DUREZOL EMU 0.05% ................... 143 dutasteride cap 0.5 mg..............113
DYRENIUM CAP 100MG ................. 105 DYRENIUM CAP 50MG ................... 105 E
Ear Drops Earwax Removal see carbamide peroxide 6.5% otic soln ..................................... 145
EASY NEB MIS ............................. 127 echothiophate iodide
see PHOSPHOLINE SOL 0.125%OP ............................................ 142
econazole nitrate cream 1% .......98 EDARBI TAB 40MG .........................59 EDARBI TAB 80MG .........................59 EDURANT TAB 25MG ......................80 efavirenz cap 200 mg ..................80 efavirenz cap 50 mg ....................80 efavirenz tab 600 mg ..................80 efavirenz-emtricitabine-tenofovir
disoproxil fumarate see ATRIPLA TAB.........................79 efavirenz-lamivudine-tenofovir disoproxil fumarate see SYMFI LO TAB .......................81 see SYMFI TAB............................81 ELAPRASE INJ 6MG/3ML ............... 107 elbasvir-grazoprevir see ZEPATIER TAB 50-100MG .......82 eletriptan hydrobromide tab 20 mg (base equivalent) ................... 128 eletriptan hydrobromide tab 40 mg (base equivalent) ................... 128 ELIGARD INJ 22.5MG......................66 ELIGARD INJ 7.5MG .......................66 eliglustat tartrate see CERDELGA CAP 84MG .......... 117 ELIQUIS TAB 2.5MG .......................29 ELIQUIS TAB 5MG ..........................29 ELLA TAB 30MG .............................93 ELMIRON CAP 100MG ................... 112 eltrombopag olamine see PROMACTA TAB 12.5MG ....... 119 see PROMACTA TAB 25MG .......... 119 see PROMACTA TAB 50MG .......... 119 see PROMACTA TAB 75MG .......... 119 Eluryng see etonogestrel-ethinyl estradiol
va ring 0.120-0.015 mg/24hr 93
187
elvitegravir-cobicistatemtricitabine-tenofovir alafenamide see GENVOYA TAB .......................80
elvitegravir-cobicistatemtricitabine-tenofovir df see STRIBILD TAB .......................81
EMADINE SOL 0.05% OP ............... 144 EMBEDA CAP 100-4MG....................12 EMBEDA CAP 20-0.8MG...................12 EMBEDA CAP 30-1.2MG...................12 EMBEDA CAP 50-2MG .....................12 EMBEDA CAP 60-2.4MG...................12 EMBEDA CAP 80-3.2MG...................12 EMCYT CAP 140MG .........................66 emedastine difumarate
see EMADINE SOL 0.05% OP ...... 144 emicizumab-kxwh
see HEMLIBRA INJ 105/0.7 ......... 114 see HEMLIBRA INJ 150/ML..........114 see HEMLIBRA INJ 30MG/ML ....... 114 see HEMLIBRA INJ 60/0.4...........114 emollient - ointment..................102 empagliflozin see JARDIANCE TAB 10MG............48 see JARDIANCE TAB 25MG............49 empagliflozin-metformin hcl see SYNJARDY TAB ......................41 see SYNJARDY TAB 12.5-500 ........41 see SYNJARDY TAB 5-1000MG ......41 see SYNJARDY TAB 5-500MG ........41 see SYNJARDY XR TAB .................41 see SYNJARDY XR TAB 10-1000 ....42 see SYNJARDY XR TAB 25-1000 ....42 see SYNJARDY XR TAB 5-1000MG..42 EMSAM DIS 12MG/24H ...................34 EMSAM DIS 6MG/24HR ...................34 EMSAM DIS 9MG/24HR ...................34 emtricitabine see EMTRIVA CAP 200MG .............80 see EMTRIVA SOL 10MG/ML..........80 emtricitabine-rilpivirine-tenofovir alafenamide fumarate see ODEFSEY TAB........................81 emtricitabine-rilpivirine-tenofovir disoproxil fumarate see COMPLERA TAB .....................79
emtricitabine-tenofovir alafenamide fumarate see DESCOVY TAB 200/25 ............80
emtricitabine-tenofovir disoproxil fumarate see TRUVADA TAB 100-150 ..........81 see TRUVADA TAB 133-200 ..........81 see TRUVADA TAB 167-250 ..........81 see TRUVADA TAB 200-300 ..........81
EMTRIVA CAP 200MG......................80 EMTRIVA SOL 10MG/ML ..................80 enalapril maleate &
hydrochlorothiazide tab 10-25 mg ............................................63 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ............................................63 enalapril maleate tab 10 mg........57 enalapril maleate tab 2.5 mg.......57 enalapril maleate tab 20 mg........57 enalapril maleate tab 5 mg..........57 ENBREL INJ 25/0.5ML .....................10 ENBREL INJ 25MG ..........................10 ENBREL INJ 50MG/ML .....................10 ENBREL MINI INJ 50MG/ML .............10 ENBREL SRCLK INJ 50MG/ML...........11 ENCARE SUP 100MG ..................... 159 ENFAMIL MIS EXPECTA ................. 137 enfuvirtide see FUZEON INJ 90MG .................80 ENGERIX-B INJ 10/0.5ML .............. 158 ENGERIX-B INJ 20MCG/ML ............ 158 enoxaparin sodium inj 100 mg/ml ................................................. 29 enoxaparin sodium inj 120 mg/0.8ml .................................29 enoxaparin sodium inj 150 mg/ml ................................................. 29 enoxaparin sodium inj 30 mg/0.3ml .................................29 enoxaparin sodium inj 300 mg/3ml ................................................. 29 enoxaparin sodium inj 40 mg/0.4ml .................................29 enoxaparin sodium inj 60 mg/0.6ml .................................29
188
enoxaparin sodium inj 80 mg/0.8ml .................................29
entacapone tab 200 mg ...............70 entecavir
see BARACLUDE SOL ...................82 entecavir tab 0.5 mg ...................82 entecavir tab 1 mg ......................82 ENTRESTO TAB 24-26MG ................87 ENTRESTO TAB 49-51MG ................88 ENTRESTO TAB 97-103MG...............88 epinastine hcl ophth soln 0.05%
............................................... 144 epinephrine (anaphylaxis)
see EPIPEN 2-PAK INJ 0.3MG ...... 160 see EPIPEN-JR INJ 0.15MG ......... 160 see SYMJEPI INJ 0.15MG ............ 160 see SYMJEPI INJ 0.3MG .............. 160 EPIPEN 2-PAK INJ 0.3MG............... 160 EPIPEN-JR INJ 0.15MG .................. 160 Epitol see carbamazepine tab 200 mg.31 EPIVIR HBV SOL 5MG/ML ................82 eplerenone tab 25 mg .................64 eplerenone tab 50 mg .................64 epoetin alfa see EPOGEN INJ 10000/ML ......... 118 see EPOGEN INJ 20000/ML ......... 118 see EPOGEN INJ 3000/ML ........... 118 see EPOGEN INJ 4000/ML ........... 118 see PROCRIT INJ 2000/ML .......... 119 see PROCRIT INJ 3000/ML .......... 119 see PROCRIT INJ 40000/ML ........ 119 epoetin alfa-epbx see RETACRIT INJ 10000UNT ...... 119 see RETACRIT INJ 2000UNIT.......119 see RETACRIT INJ 3000UNIT.......119 see RETACRIT INJ 40000UNT ...... 119 see RETACRIT INJ 4000UNIT.......119 EPOGEN INJ 10000/ML..................118 EPOGEN INJ 20000/ML..................118 EPOGEN INJ 3000/ML ................... 118 EPOGEN INJ 4000/ML ................... 118 eprosartan mesylate tab 600 mg.59 Eq Chlortabs see chlorpheniramine maleate tab
4 mg ......................................51 Eq Natural Vegetable Laxa
see sennosides tab 8.6 mg ...... 124 Eq Nicotine Polacrilex
see nicotine polacrilex lozenge 4 mg ....................................... 150
Eq Pain Relief Adult/rapi see acetaminophen liquid 167 mg/5ml .................................11
ergocalciferol cap 1.25 mg (50000 unit) ....................................... 161
ergoloid mesylates tab 1 mg ..... 150 ERGOMAR SUB 2MG ..................... 128 ergotamine tartrate
see ERGOMAR SUB 2MG ............. 128 ergotamine w/ caffeine tab 1-100
mg .......................................... 128 ERIVEDGE CAP 150MG....................66 erlotinib hcl
see TARCEVA TAB 100MG.............69 see TARCEVA TAB 150MG.............69 see TARCEVA TAB 25MG ..............69 erlotinib hcl tab 100 mg (base equivalent) ...............................68 erlotinib hcl tab 150 mg (base equivalent) ...............................68 erlotinib hcl tab 25 mg (base equivalent) ...............................68 ERTACZO CRE 2% ..........................98 Ery-tab see erythromycin tab delayed
release 250 mg .................... 125 see erythromycin tab delayed
release 333 mg .................... 125 see erythromycin tab delayed
release 500 mg .................... 125 Erythrocin Stearate
see erythromycin stearate tab 250 mg ................................ 124
erythromycin ethylsuccinate for susp 200 mg/5ml ................... 124
erythromycin ethylsuccinate for susp 400 mg/5ml ................... 124
erythromycin ethylsuccinate tab 400 mg ................................... 124
erythromycin ophth oint 5 mg/gm ............................................... 143
erythromycin soln 2%.................96
189
erythromycin stearate tab 250 mg ............................................... 124
erythromycin tab 250 mg .......... 124 erythromycin tab 500 mg .......... 124 erythromycin tab delayed release
250 mg ................................... 125 erythromycin tab delayed release
333 mg ................................... 125 erythromycin tab delayed release
500 mg ................................... 125 ESBRIET CAP 267MG .................... 151 ESBRIET TAB 267MG .................... 151 ESBRIET TAB 801MG .................... 151 escitalopram oxalate soln 5
mg/5ml (base equiv) ...............35 escitalopram oxalate tab 10 mg
(base equiv) .............................35 escitalopram oxalate tab 20 mg
(base equiv) .............................35 escitalopram oxalate tab 5 mg
(base equiv) .............................35 Esgic
see butalbital-acetaminophencaffeine cap 50-325-40 mg ....11
eslicarbazepine acetate see APTIOM TAB 200MG ...............31 see APTIOM TAB 400MG ...............31 see APTIOM TAB 600MG ...............31 see APTIOM TAB 800MG ...............31
esomeprazole magnesium cap delayed release 20 mg (base eq) ............................................... 155
estazolam tab 1 mg ................... 121 estazolam tab 2 mg ................... 121 esterified estrogens
see MENEST TAB 0.3MG ............. 109 see MENEST TAB 0.625MG.......... 109 see MENEST TAB 1.25MG ........... 109 estradiol & norethindrone acetate tab 0.5-0.1 mg ........................ 109 estradiol & norethindrone acetate tab 1-0.5 mg ........................... 109 estradiol tab 0.5 mg .................. 109 estradiol tab 1 mg ..................... 109 estradiol tab 2 mg ..................... 109 estradiol vaginal cream 0.1 mg/gm ............................................... 160
estradiol vaginal tab 10 mcg ..... 160 estradiol valerate-dienogest
see NATAZIA TAB ........................92 estramustine phosphate sodium
see EMCYT CAP 140MG ................66 estrogens, conjugated
see PREMARIN TAB 0.3MG .......... 109 see PREMARIN TAB 0.45MG ........ 109 see PREMARIN TAB 0.625MG ...... 109 see PREMARIN TAB 0.9MG.......... 109 see PREMARIN TAB 1.25MG ........ 110 estrogens, conjugated vaginal see PREMARIN VAG CRE 0.625MG160 estropipate tab 0.75 mg ............ 109 estropipate tab 1.5 mg .............. 109 estropipate tab 3 mg ................. 109 eszopiclone tab 1 mg ................ 121 eszopiclone tab 2 mg ................ 121 eszopiclone tab 3 mg ................ 121 etanercept see ENBREL INJ 25/0.5ML ............10 see ENBREL INJ 25MG..................10 see ENBREL INJ 50MG/ML ............10 see ENBREL MINI INJ 50MG/ML.....10 see ENBREL SRCLK INJ 50MG/ML ..11 ethacrynic acid tab 25 mg ......... 105 ethambutol hcl tab 100 mg .........65 ethambutol hcl tab 400 mg .........65 ethionamide see TRECATOR TAB 250MG...........65 ethosuximide cap 250 mg ...........33 ethosuximide soln 250 mg/5ml ..33 ethotoin see PEGANONE TAB 250MG ..........33 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg .......91 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg .......91 etidronate disodium tab 200 mg 106 etidronate disodium tab 400 mg 106 etodolac tab 400 mg .................... 8 etodolac tab 500 mg .................... 8 etonogestrel see NEXPLANON IMP 68MG...........93 etonogestrel-ethinyl estradiol see NUVARING MIS .....................93
190
etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr .......93
etoposide cap 50 mg ...................70 etravirine
see INTELENCE TAB 100MG ..........80 see INTELENCE TAB 200MG ..........80 see INTELENCE TAB 25MG ............80 EUFLEXXA INJ 10MG/ML................139 EURAX CRE 10% .......................... 103 everolimus see AFINITOR DIS TAB 2MG .........67 see AFINITOR DIS TAB 3MG .........67 see AFINITOR DIS TAB 5MG .........67 see AFINITOR TAB 10MG ..............67 see AFINITOR TAB 2.5MG .............67 see AFINITOR TAB 5MG................67 see AFINITOR TAB 7.5MG .............67 everolimus (immunosuppressant) see ZORTRESS TAB 0.25MG........134 see ZORTRESS TAB 0.5MG ......... 134 see ZORTRESS TAB 0.75MG........134 see ZORTRESS TAB 1MG ............ 134 everolimus tab 0.25 mg.............134 everolimus tab 0.5 mg...............134 everolimus tab 0.75 mg.............134 everolimus tab 2.5 mg.................68 everolimus tab 5 mg....................68 everolimus tab 7.5 mg.................68 evolocumab see REPATHA INJ 140MG/ML.........57 see REPATHA PUSH INJ 420/3.5 ....57 see REPATHA SURE INJ 140MG/ML 57 EVOTAZ TAB 300-150 .....................80 EXELDERM CRE 1% ........................98 EXELDERM SOL 1% ........................98 exemestane tab 25 mg ................66 EXTAVIA INJ 0.3MG ...................... 150 ezetimibe tab 10 mg....................57 ezetimibe-simvastatin tab 10-10 mg ............................................53 ezetimibe-simvastatin tab 10-20 mg ............................................53 ezetimibe-simvastatin tab 10-40 mg ............................................53 ezetimibe-simvastatin tab 10-80 mg ............................................53 EZFE FORTE CAP .......................... 137
F Fa-8
see folic acid cap 0.8 mg ......... 118 FABRAZYME INJ 5MG .................... 107 factor ix complex
see PROFILNINE INJ 1500UNIT ... 116 FALESSA KIT .................................91 famciclovir tab 125 mg................83 famciclovir tab 250 mg................83 famciclovir tab 500 mg................83 famotidine for susp 40 mg/5ml. 154 famotidine tab 10 mg ................ 154 famotidine tab 20 mg ................ 154 famotidine tab 40 mg ................ 154 FANAPT PAK ..................................73 FANAPT TAB 10MG .........................73 FANAPT TAB 12MG .........................73 FANAPT TAB 1MG ...........................73 FANAPT TAB 2MG ...........................73 FANAPT TAB 4MG ...........................73 FANAPT TAB 6MG ...........................73 FANAPT TAB 8MG ...........................73 FARXIGA TAB 10MG .......................48 FARXIGA TAB 5MG .........................48 FARYDAK CAP 10MG .......................68 FARYDAK CAP 15MG .......................68 FARYDAK CAP 20MG .......................68 FC2 FEMALE MIS CONDOM ............ 125 fe fumarate w/ b12-vit c-fa-ifc cap
110-0.015-75-0.5-240 mg ...... 119 FE GLUCONATE TAB 239MG........... 119 febuxostat
see ULORIC TAB 40MG ............... 113 see ULORIC TAB 80MG ............... 113 febuxostat tab 40 mg ................ 113 febuxostat tab 80 mg ................ 113 FEIBA INJ.................................... 114 felbamate susp 600 mg/5ml .......33 felbamate tab 400 mg .................33 felbamate tab 600 mg .................33 felodipine tab er 24hr 10 mg .......86 felodipine tab er 24hr 2.5 mg ......86 felodipine tab er 24hr 5 mg .........86 FEMCAP MIS 22MM ....................... 125 FEMCAP MIS 26MM ....................... 125 FEMCAP MIS 30MM ....................... 125
191
fenofibrate micronized cap 134 mg ................................................. 54
fenofibrate micronized cap 200 mg ................................................. 54
fenofibrate micronized cap 43 mg ................................................. 54
fenofibrate micronized cap 67 mg ................................................. 54
fenofibrate tab 145 mg................54 fenofibrate tab 160 mg................54 fenofibrate tab 48 mg..................54 fenofibrate tab 54 mg..................54 fenofibric acid tab 35 mg.............54 fenoprofen calcium tab 600 mg .... 8 fentanyl td patch 72hr 100 mcg/hr
................................................. 12 fentanyl td patch 72hr 12 mcg/hr
................................................. 12 fentanyl td patch 72hr 25 mcg/hr
................................................. 12 fentanyl td patch 72hr 50 mcg/hr
................................................. 12 fentanyl td patch 72hr 75 mcg/hr
................................................. 12 Ferate
see ferrous gluconate tab 240 mg (27 mg elemental fe) ........... 119
FERRETTS TAB 325MG .................. 119 FERREX 150 CAP FORTE ................ 119 FERRIPROX TAB 1000MG.................50 FERRIPROX TAB 500MG ..................50 ferrous fumarate
see FERRETTS TAB 325MG..........119 ferrous fumarate tab 324 mg (106
mg elemental fe) .................... 119 FERROUS GLUC TAB 324MG .......... 119 ferrous gluconate tab 240 mg (27
mg elemental fe) .................... 119 ferrous gluconate tab 324 mg (37.5
mg elemental iron) ................. 119 FERROUS SUL LIQ 220/5ML ........... 119 FERROUS SULF TAB 324MG EC ...... 119 ferrous sulfate
see SLOW FE TAB 45MG ............. 120 ferrous sulfate dried tab 200 mg
(65 mg elemental fe)..............120
ferrous sulfate dried tab er 160 mg (50 mg fe equivalent)............. 120
ferrous sulfate dried tab er 45 mg (fe equivalent) ....................... 120
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ...... 120
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) .............. 120
ferrous sulfate tab 325 mg (65 mg elemental fe) .......................... 120
ferrous sulfate tab ec 325 mg (65 mg fe equivalent) ................... 120
ferrous sulfate tab er 142 mg (45 mg fe equivalent) ................... 120
ferrous sulfate tab er 47.5 mg (elemental fe) ........................ 120
ferrous sulfate tab er 50 mg (elemental fe) ........................ 120
fesoterodine fumarate see TOVIAZ TAB 4MG ................ 157 see TOVIAZ TAB 8MG ................ 157
FETZIMA CAP 120MG ......................36 FETZIMA CAP 20MG........................36 FETZIMA CAP 40MG........................36 FETZIMA CAP 80MG........................36 FETZIMA CAP TITRATIO ..................36 FEVERALL INF SUP 80MG ................11 FEVERALL SUP 325MG ....................11 fexofenadine hcl tab 180 mg .......52 fexofenadine hcl tab 60 mg .........52 FIASP FLEX INJ TOUCH ...................45 FIASP INJ 100/ML ..........................45 FIASP PENFIL INJ U-100 .................45 Fiber Laxative
see psyllium cap 0.52 gm ........ 122 fidaxomicin
see DIFICID TAB 200MG ............ 125 filgrastim
see NEUPOGEN INJ 300/0.5........ 118 see NEUPOGEN INJ 300MCG ....... 118 see NEUPOGEN INJ 480/0.8........ 119 see NEUPOGEN INJ 480MCG ....... 119 filgrastim-aafi see NIVESTYM INJ 300/0.5 ......... 119 see NIVESTYM INJ 300MCG ........ 119 see NIVESTYM INJ 480/0.8 ......... 119 see NIVESTYM INJ 480MCG ........ 119
192
filgrastim-sndz see ZARXIO INJ 300/0.5.............119 see ZARXIO INJ 480/0.8.............119
finasteride tab 5 mg .................. 113 fingolimod hcl
see GILENYA CAP 0.5MG ............ 150 FIRAZYR INJ 30MG/3ML ................ 117 FIRMAGON INJ 80MG......................66 FIRST-OMEPRA SUS 2MG/ML ......... 155 FIRVANQ SOL 25MG/ML ..................19 FIRVANQ SOL 50MG/ML ..................19 flavoxate hcl tab 100 mg ........... 158 FLEBOGAMMA INJ DIF 5% ............. 146 flecainide acetate tab 100 mg .....23 flecainide acetate tab 150 mg .....23 flecainide acetate tab 50 mg .......23 FLOVENT HFA AER 110MCG .............25 FLOVENT HFA AER 44MCG...............25 FLUARIX QUAD INJ 2019-20 .......... 158 FLUBLOK QUAD INJ 2019-20 ......... 158 FLUCLVX QUAD INJ 2019-20..........158 fluconazole for susp 10 mg/ml....51 fluconazole for susp 40 mg/ml....51 fluconazole tab 100 mg ...............51 fluconazole tab 150 mg ...............51 fluconazole tab 200 mg ...............51 fluconazole tab 50 mg .................51 flucytosine cap 250 mg ...............51 flucytosine cap 500 mg ...............51 fludrocortisone acetate tab 0.1 mg
................................................. 94 FLULAVAL QUA INJ 2019-20 .......... 158 FLUMIST QUAD SUS 2019-20 ........ 158 flunisolide nasal soln 25 mcg/act
(0.025%) ............................... 140 fluocinolone acetonide (otic) oil
0.01% .................................... 146 fluocinolone acetonide cream
0.025% .................................. 100 fluocinolone acetonide oil 0.01%
(body oil) ............................... 100 fluocinolone acetonide oil 0.01%
(scalp oil) ............................... 100 fluocinolone acetonide oint 0.025%
............................................... 100 fluocinonide cream 0.05% ........ 101
fluocinonide emulsified base cream 0.05% .................................... 101
fluocinonide gel 0.05% ............. 101 fluocinonide oint 0.05% ............ 101 fluocinonide soln 0.05% ........... 101 FLUORABON DRO ......................... 131 Fluoritab
see sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) ............................................ 132
fluorometholone ophth susp 0.1% ............................................... 143
fluorouracil cream 5% ................99 fluoxetine hcl cap 10 mg .............35 fluoxetine hcl cap 20 mg .............35 fluoxetine hcl cap 40 mg .............35 fluoxetine hcl solution 20 mg/5ml
................................................. 35 fluphenazine decanoate inj 25
mg/ml ......................................77 fluphenazine hcl tab 1 mg ...........77 fluphenazine hcl tab 10 mg .........77 fluphenazine hcl tab 2.5 mg ........77 fluphenazine hcl tab 5 mg ...........77 Flura-drops
see sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) ..................................... 132
flurandrenolide see CORDRAN 80X3 TAP 4MCG/CM ............................................ 100
flurandrenolide cream 0.05% ... 101 flurandrenolide lotion 0.05% .... 101 flurazepam hcl cap 15 mg ......... 121 flurazepam hcl cap 30 mg ......... 121 flurbiprofen sodium ophth soln
0.03% .................................... 144 flurbiprofen tab 100 mg ............... 8 flurbiprofen tab 50 mg ................. 8 flutamide cap 125 mg..................66 fluticasone furoate-vilanterol
see BREO ELLIPTA INH 100-25......26 see BREO ELLIPTA INH 200-25......26 fluticasone propionate cream 0.05% .................................... 101 fluticasone propionate hfa see FLOVENT HFA AER 110MCG ....25
193
see FLOVENT HFA AER 44MCG ......25 fluticasone propionate nasal susp
50 mcg/act ............................. 140 fluticasone propionate oint 0.005%
............................................... 101 fluticasone-salmeterol aer powder
ba 100-50 mcg/dose ................27 fluticasone-salmeterol aer powder
ba 113-14 mcg/act...................27 fluticasone-salmeterol aer powder
ba 232-14 mcg/act...................27 fluticasone-salmeterol aer powder
ba 250-50 mcg/dose ................27 fluticasone-salmeterol aer powder
ba 500-50 mcg/dose ................27 fluticasone-salmeterol aer powder
ba 55-14 mcg/act.....................27 fluvastatin sodium cap 20 mg
(base equivalent) .....................54 fluvastatin sodium cap 40 mg
(base equivalent) .....................55 fluvastatin sodium tab er 24 hr 80
mg (base equivalent) ...............55 fluvoxamine maleate tab 100 mg 35 fluvoxamine maleate tab 25 mg ..35 fluvoxamine maleate tab 50 mg ..35 FLUZONE QUAD INJ 2019-20 ......... 158 Folbee Plus
see b-complex w/ c & folic acid tab 5 mg .............................. 135
folic acid cap 0.8 mg..................118 folic acid tab 1 mg ..................... 118 folic acid tab 400 mcg ............... 118 folic acid tab 800 mcg ............... 118 fondaparinux sodium subcutaneous
inj 10 mg/0.8ml .......................29 fondaparinux sodium subcutaneous
inj 2.5 mg/0.5ml ......................29 fondaparinux sodium subcutaneous
inj 5 mg/0.4ml .........................29 fondaparinux sodium subcutaneous
inj 7.5 mg/0.6ml ......................29 FORTEO SOL 600/2.4....................106 fosamprenavir calcium tab 700 mg
(base equiv) .............................80 foscarnet sodium
see FOSCAVIR INJ 24MG/ML .........82
FOSCAVIR INJ 24MG/ML .................82 fosfomycin tromethamine
see MONUROL PAK GRANULES .... 156 fosinopril sodium &
hydrochlorothiazide tab 10-12.5 mg ............................................63 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg ............................................63 fosinopril sodium tab 10 mg........57 fosinopril sodium tab 20 mg........58 fosinopril sodium tab 40 mg........58 FRAGMIN INJ 10000/ML ..................30 FRAGMIN INJ 12500UNT .................30 FRAGMIN INJ 15000UNT .................30 FRAGMIN INJ 18000UNT .................30 FRAGMIN INJ 2500/0.2 ...................29 FRAGMIN INJ 5000/0.2 ...................29 FRAGMIN INJ 7500/0.3 ...................29 FREESTYLE KIT SENSOR ............... 126 FREESTYLE MIS READER ............... 126 frovatriptan succinate tab 2.5 mg (base equivalent) ................... 128 fructose-dextrose-phosphoric acid oral soln ...................................51 FULPHILA INJ 6/0.6ML .................. 118 furosemide oral soln 10 mg/ml . 105 furosemide oral soln 8 mg/ml ... 105 furosemide tab 20 mg ............... 105 furosemide tab 40 mg ............... 105 furosemide tab 80 mg ............... 105 FUZEON INJ 90MG .........................80 FYCOMPA TAB 10MG.......................30 FYCOMPA TAB 12MG.......................30 FYCOMPA TAB 2MG ........................30 FYCOMPA TAB 4MG ........................30 FYCOMPA TAB 6MG ........................30 FYCOMPA TAB 8MG ........................30 G
G5/G4 MIS SENSOR ..................... 126 gabapentin cap 100 mg ...............31 gabapentin cap 300 mg ...............31 gabapentin cap 400 mg ...............31 gabapentin oral soln 250 mg/5ml
................................................. 31 gabapentin tab 600 mg ...............31 gabapentin tab 800 mg ...............31
194
galantamine hydrobromide cap er 24hr 16 mg ............................. 149
galantamine hydrobromide cap er 24hr 24 mg ............................. 149
galantamine hydrobromide cap er 24hr 8 mg ............................... 149
galantamine hydrobromide tab 12 mg .......................................... 149
galantamine hydrobromide tab 4 mg .......................................... 149
galantamine hydrobromide tab 8 mg .......................................... 149
GAMASTAN INJ ............................ 146 GAMMAGARD INJ 1GM/10ML ......... 146 GAMMAGARD SD INJ 10GM HU ...... 146 ganciclovir ophthalmic
see ZIRGAN GEL 0.15% ............. 143 ganirelix acetate soln prefilled
syringe 250 mcg/0.5ml .......... 106 Gas Relief
see simethicone susp 40 mg/0.6ml ............................ 110
gatifloxacin ophth soln 0.5% .... 143 gemfibrozil tab 600 mg ...............54 Gentak
see gentamicin sulfate ophth oint 0.3%.................................... 143
gentamicin sulfate cream 0.1%...97 gentamicin sulfate oint 0.1% ......97 gentamicin sulfate ophth oint 0.3%
............................................... 143 gentamicin sulfate ophth soln
0.3% ...................................... 143 Genteal Tears Night-time
see white petrolatum-mineral oil ophth ointment .................... 142
GENVOYA TAB ...............................80 GILENYA CAP 0.5MG ..................... 150 GILOTRIF TAB 20MG.......................68 GILOTRIF TAB 30MG.......................68 GILOTRIF TAB 40MG.......................68 GLASSIA INJ................................151 glatiramer acetate soln prefilled
syringe 20 mg/ml ................... 150 glatiramer acetate soln prefilled
syringe 40 mg/ml ................... 150 Glatopa
see glatiramer acetate soln prefilled syringe 20 mg/ml .. 150
GLEOSTINE CAP 100MG ..................65 GLEOSTINE CAP 10MG....................65 GLEOSTINE CAP 40MG....................65 glimepiride tab 1 mg ...................49 glimepiride tab 2 mg ...................49 glimepiride tab 4 mg ...................49 glipizide tab 10 mg......................49 glipizide tab 5 mg........................49 glipizide tab er 24hr 10 mg .........49 glipizide tab er 24hr 2.5 mg ........49 glipizide tab er 24hr 5 mg ...........49 glipizide-metformin hcl tab 2.5-250
mg ............................................40 glipizide-metformin hcl tab 2.5-500
mg ............................................40 glipizide-metformin hcl tab 5-500
mg ............................................40 GLUCAGEN INJ HYPOKIT .................43 glucagon
see BAQSIMI ONE POW 3MG/DOSE43 glucagon (rdna)
see GLUCAGON KIT 1MG ..............43 glucagon hcl (rdna)
see GLUCAGEN INJ HYPOKIT.........43 GLUCAGON KIT 1MG ......................43 glucose blood
see TRUE METRIX TES GLUCOSE . 104 glucose-vitamin c
see TGT GLUCOSE CHW GRAPE.....43 glyburide micronized tab 1.5 mg .49 glyburide micronized tab 3 mg ....49 glyburide micronized tab 6 mg ....49 glyburide tab 1.25 mg .................49 glyburide tab 2.5 mg ...................49 glyburide tab 5 mg ......................49 glyburide-metformin tab 1.25-250
mg ............................................40 glyburide-metformin tab 2.5-500
mg ............................................40 glyburide-metformin tab 5-500 mg
................................................. 40 glycerin suppos 1.2 gm ............. 123 glycerin suppos 2 gm ................ 123 glycerin suppos 2.1 gm ............. 123 glycerin suppos 80.7%.............. 123
195
glycerin-hypromellose-peg 400 ophth soln 0.2-0.2-1% ........... 141
glycopyrrolate tab 1 mg ............ 153 glycopyrrolate tab 2 mg ............ 154 glycopyrrolate-formoterol fumarate
see BEVESPI AER 9-4.8MCG..........25 Gnp Allergy Relief
see diphenhydramine hcl chew tab 12.5 mg ...........................52
Gnp Antacid Ultra Strengt see calcium carbonate (antacid) chew tab 1000 mg .................18
Gnp Anti-diarrheal see loperamide hcl cap 2 mg .....49
Gnp Artificial Tears see polyvinyl alcohol-povidone ophth soln 5-6 mg/ml (0.50.6%) .................................. 142
Gnp Calcium 500 +d3 see calcium carbonatecholecalciferol tab 500 mg-600 unit ...................................... 130
Gnp Calcium 500/d see calcium carbonate-vitamin d tab 500 mg-200 unit ............ 130
Gnp Clotrimazole 3 see clotrimazole vaginal cream 2%....................................... 159
Gnp Dayhist Allergy see clemastine fumarate tab 1.34 mg (1 mg base equiv)............52
Gnp Fiber Therapy see methylcellulose tab 500 mg ............................................ 122
GNP GLUCOSE CHW ORANGE...........43 Gnp Glycerin Adult
see glycerin suppos 2.1 gm ..... 123 Gnp Glycerin Child
see glycerin suppos 1.2 gm ..... 123 Gnp Lidocaine Pain Relief
see lidocaine patch 4% ........... 102 Gnp Loratadine
see loratadine syrup 5 mg/5ml .52 Gnp Magnesium
see magnesium oxide tab 250 mg .............................................. 18
Gnp Magnesium Citrate
see magnesium citrate soln .... 123 Gnp Miconazole 3
see miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit ........................................ 159
Gnp Mucus Er see guaifenesin tab er 12hr 600 mg .........................................95
Gnp Natural Fiber see psyllium powder 28.3% .... 122
Gnp Pink Bismuth see bismuth subsalicylate chew tab 262 mg ............................49
golimumab see SIMPONI INJ 100MG/ML .......... 7 see SIMPONI INJ 50/0.5ML ............ 7
GOLYTELY SOL............................. 123 Goodsense Nasal Allergy S
see triamcinolone acetonide nasal aerosol suspension 55 mcg/act ............................................ 140
goserelin acetate see ZOLADEX IMP 10.8MG............67 see ZOLADEX IMP 3.6MG .............67
granisetron hcl tab 1 mg .............50 griseofulvin microsize susp 125
mg/5ml ....................................51 Guaiatussin Ac
see guaifenesin-codeine soln 10010 mg/5ml ............................95
guaifenesin liquid 100 mg/5ml ...95 guaifenesin syrup 100 mg/5ml ...95 guaifenesin tab 200 mg...............95 guaifenesin tab 400 mg...............95 guaifenesin tab er 12hr 600 mg ..95 guaifenesin-codeine soln 100-10
mg/5ml ....................................95 guanfacine hcl tab 1 mg ..............61 guanfacine hcl tab 2 mg ..............61 guanfacine hcl tab er 24hr 1 mg
(base equiv) .............................. 3 guanfacine hcl tab er 24hr 2 mg
(base equiv) .............................. 3 guanfacine hcl tab er 24hr 3 mg
(base equiv) .............................. 3 guanfacine hcl tab er 24hr 4 mg
(base equiv) .............................. 3
196
GUANIDINE TAB 125MG ..................65 GYNAZOLE-1 CRE 2% ................... 159 GYNOL II GEL 3% ........................ 159 H
halcinonide see HALOG CRE 0.1% ................ 101 see HALOG OIN 0.1% ................ 101
halcinonide cream 0.1%............101 halobetasol propionate cream
0.05% .................................... 101 halobetasol propionate oint 0.05%
............................................... 101 HALOG CRE 0.1%.........................101 HALOG OIN 0.1% ......................... 101 haloperidol decanoate im soln 100
mg/ml ......................................75 haloperidol decanoate im soln 50
mg/ml ......................................75 haloperidol lactate inj 5 mg/ml ...75 haloperidol lactate oral conc 2
mg/ml ......................................75 haloperidol tab 0.5 mg ................75 haloperidol tab 1 mg ...................75 haloperidol tab 10 mg .................75 haloperidol tab 2 mg ...................75 haloperidol tab 20 mg .................75 haloperidol tab 5 mg ...................75 HAVRIX INJ 1440UNIT .................. 158 HAVRIX INJ 720UNIT .................... 158 HELIXATE FS INJ 2000UNIT ........... 114 HELIXATE FS INJ 3000UNIT ........... 114 HELIXATE FS INJ 500UNIT.............114 HEMLIBRA INJ 105/0.7 ................. 114 HEMLIBRA INJ 150/ML .................. 114 HEMLIBRA INJ 30MG/ML ............... 114 HEMLIBRA INJ 60/0.4 ................... 114 HEMOFIL M INJ 1700UNIT ............. 114 heparin sodium (porcine) inj 1000
unit/ml .....................................30 heparin sodium (porcine) inj 10000
unit/ml .....................................30 heparin sodium (porcine) pf inj
5000 unit/0.5ml .......................30 hepatitis a (inactivated)-hepatitis b
(recombinant) vaccines see TWINRIX INJ ....................... 159 hepatitis a vaccine
see HAVRIX INJ 1440UNIT.......... 158 see HAVRIX INJ 720UNIT ........... 158 see VAQTA INJ 25/0.5ML............ 159 see VAQTA INJ 50UNT/ML .......... 159 hepatitis b vaccine (recomb) see ENGERIX-B INJ 10/0.5ML ..... 158 see ENGERIX-B INJ 20MCG/ML.... 158 see RECOMBIVA HB INJ 10MCG/ML
............................................ 158 see RECOMBIVA HB INJ 5MCG/0.5
............................................ 158 hepatitis b vaccine recombinant
adjuvanted see HEPLISAV-B INJ 20/0.5ML .... 158 see HEPLISAV-B INJ 20MCG ....... 158 HEPLISAV-B INJ 20/0.5ML............. 158 HEPLISAV-B INJ 20MCG ................ 158 HETLIOZ CAP 20MG...................... 122 HIZENTRA INJ 10/50ML ................ 146 HIZENTRA INJ 1GM/5ML ............... 146 HIZENTRA INJ 2GM/10ML.............. 146 HIZENTRA INJ 4GM/20ML.............. 146 HIZENTRA SOL 20% ..................... 146 Hm Fish Oil see omega-3 fatty acids cap
delayed release 1000 mg ..... 141 Hm Lubricating Plus
see carboxymethylcellulose sodium (pf) ophth soln 0.5% ............................................ 141
Hm Nicotine Transdermal S see nicotine td patch 24hr 14 mg/24hr .............................. 150
Hm Vitamin C/rose Hips see ascorbic acid tab 500 mg .. 161
HUMALOG INJ 100/ML ....................46 HUMALOG JR INJ 100/ML ................46 HUMALOG KWIK INJ 100/ML............46 HUMALOG MIX INJ 50/50 ................46 HUMALOG MIX INJ 50/50KWP..........46 HUMALOG MIX INJ 75/25KWP..........46 HUMALOG MIX SUS 75/25...............46 HUMATE-P SOL 2400UNIT ............. 115 HUMATE-P SOL 500-1200.............. 115 HUMIRA INJ 10/0.1ML ..................... 6 HUMIRA INJ 10MG/0.2 ..................... 6 HUMIRA INJ 20/0.2ML ..................... 6
197
HUMIRA INJ 40/0.4ML ..................... 6 HUMIRA KIT 20MG/0.4..................... 6 HUMIRA KIT 40MG/0.8..................... 6 HUMIRA PEDIA INJ CROHNS ............. 6 HUMIRA PEN INJ 40/0.4ML ............... 6 HUMIRA PEN INJ CD/UC/HS.............. 6 HUMIRA PEN KIT CD/UC/HS ............. 6 HUMIRA PEN KIT PS/UV ................... 6 HUMULIN INJ 70/30........................46 HUMULIN INJ 70/30KWP .................46 HUMULIN N INJ U-100 ....................46 HUMULIN N INJ U-100KWP ..............47 HUMULIN R INJ U-100 ....................47 HUMULIN R INJ U-500 ....................47 hydralazine hcl tab 10 mg ...........64 hydralazine hcl tab 100 mg .........64 hydralazine hcl tab 25 mg ...........64 hydralazine hcl tab 50 mg ...........64 hydrochlorothiazide cap 12.5 mg
............................................... 105 hydrochlorothiazide tab 12.5 mg
............................................... 105 hydrochlorothiazide tab 25 mg..105 hydrochlorothiazide tab 50 mg..105 hydrocodone bitartrate
see HYSINGLA ER TAB 100 MG......13 see HYSINGLA ER TAB 120 MG......13 see HYSINGLA ER TAB 20 MG .......13 see HYSINGLA ER TAB 30 MG .......13 see HYSINGLA ER TAB 40 MG .......13 see HYSINGLA ER TAB 60 MG .......13 see HYSINGLA ER TAB 80 MG .......13 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml .................94 hydrocodone-acetaminophen soln 7.5-325 mg/15ml .....................16 hydrocodone-acetaminophen tab 10-325 mg ................................16 hydrocodone-acetaminophen tab 5325 mg .....................................16 hydrocodone-acetaminophen tab 7.5-325 mg ...............................16 hydrocodone-ibuprofen tab 10-200 mg ............................................16 hydrocodone-ibuprofen tab 7.5200 mg .....................................16 Hydrocortisone 1% In Abso
see hydrocortisone oint 1% .... 101 hydrocortisone acetate cream 1%
............................................... 101 hydrocortisone cream 0.5% ...... 101 hydrocortisone cream 1% ......... 101 hydrocortisone cream 2.5% ...... 101 hydrocortisone enema 100
mg/60ml ..................................17 hydrocortisone gel 1% .............. 101 hydrocortisone lotion 1%.......... 101 hydrocortisone lotion 2.5%....... 101 hydrocortisone oint 0.5% ......... 101 hydrocortisone oint 1% ............ 101 hydrocortisone oint 2.5% ......... 101 hydrocortisone perianal cream
2.5% ........................................17 hydrocortisone tab 10 mg ...........94 hydrocortisone tab 20 mg ...........94 hydrocortisone tab 5 mg .............94 hydrocortisone valerate cream
0.2% ...................................... 101 hydrocortisone w/ acetic acid otic
soln 1-2% .............................. 146 hydrocortisone-aloe vera cream
0.5% ...................................... 101 hydrocortisone-aloe vera cream
1% ......................................... 101 hydromorphone hcl tab 2 mg ......12 hydromorphone hcl tab 4 mg ......13 hydromorphone hcl tab 8 mg ......13 hydromorphone hcl tab er 24hr
deter 12 mg..............................13 hydromorphone hcl tab er 24hr
deter 16 mg..............................13 hydromorphone hcl tab er 24hr
deter 32 mg..............................13 hydromorphone hcl tab er 24hr
deter 8 mg................................13 Hydrophor
see emollient - ointment ......... 102 hydroxychloroquine sulfate tab 200
mg ............................................64 hydroxyprogesterone caproate im
in oil 1.25 gm/5ml....................66 hydroxyprogesterone caproate im
in oil 250 mg/ml..................... 148 hydroxyurea cap 500 mg.............70
198
hydroxyzine hcl syrup 10 mg/5ml ................................................. 21
hydroxyzine hcl tab 10 mg ..........21 hydroxyzine hcl tab 25 mg ..........21 hydroxyzine hcl tab 50 mg ..........21 hydroxyzine pamoate cap 100 mg
................................................. 21 hydroxyzine pamoate cap 25 mg .21 hydroxyzine pamoate cap 50 mg .21 hyoscyamine sulfate elixir 0.125
mg/5ml .................................. 154 hyoscyamine sulfate sl tab 0.125
mg .......................................... 154 hyoscyamine sulfate soln 0.125
mg/ml .................................... 154 hyoscyamine sulfate tab 0.125 mg
............................................... 154 hyoscyamine sulfate tab disint
0.125 mg ................................ 154 hyoscyamine sulfate tab er 12hr
0.375 mg ................................ 154 Hyosyne
see hyoscyamine sulfate elixir 0.125 mg/5ml......................154
hypromellose ophth soln 0.3%..141 HYQVIA INJ 10-800 ...................... 147 HYQVIA INJ 2.5-200 ..................... 146 HYQVIA INJ 20-1600 .................... 147 HYQVIA INJ 30-2400 .................... 147 HYQVIA INJ 5-400 ........................ 147 HYSINGLA ER TAB 100 MG ..............13 HYSINGLA ER TAB 120 MG ..............13 HYSINGLA ER TAB 20 MG ................13 HYSINGLA ER TAB 30 MG ................13 HYSINGLA ER TAB 40 MG ................13 HYSINGLA ER TAB 60 MG ................13 HYSINGLA ER TAB 80 MG ................13 I
ibandronate sodium tab 150 mg (base equivalent) ................... 106
IBRANCE CAP 100MG......................68 IBRANCE CAP 125MG......................68 IBRANCE CAP 75MG .......................68 IBRANCE TAB 100MG......................68 IBRANCE TAB 125MG......................68 IBRANCE TAB 75MG .......................68 ibrutinib
see IMBRUVICA CAP 140MG .........68 ibuprofen cap 200 mg .................. 8 ibuprofen chew tab 100 mg.......... 8 Ibuprofen Childrens
see ibuprofen susp 100 mg/5ml 8 ibuprofen susp 100 mg/5ml ......... 8 ibuprofen susp 40 mg/ml............. 8 ibuprofen tab 100 mg................... 8 ibuprofen tab 200 mg................... 8 ibuprofen tab 400 mg................... 8 ibuprofen tab 600 mg................... 9 ibuprofen tab 800 mg................... 9 icatibant acetate
see FIRAZYR INJ 30MG/3ML ....... 117 icatibant acetate inj 30 mg/3ml
(base equivalent) ................... 117 ICLUSIG TAB 15MG ........................68 ICLUSIG TAB 45MG ........................68 idelalisib
see ZYDELIG TAB 100MG .............69 see ZYDELIG TAB 150MG .............69 idursulfase see ELAPRASE INJ 6MG/3ML ....... 107 iloperidone see FANAPT PAK..........................73 see FANAPT TAB 10MG.................73 see FANAPT TAB 12MG.................73 see FANAPT TAB 1MG ..................73 see FANAPT TAB 2MG ..................73 see FANAPT TAB 4MG ..................73 see FANAPT TAB 6MG ..................73 see FANAPT TAB 8MG ..................73 iloprost see VENTAVIS SOL 10MCG/ML ......88 see VENTAVIS SOL 20MCG/ML ......88 imatinib mesylate tab 100 mg (base equivalent) .....................68 imatinib mesylate tab 400 mg (base equivalent) .....................68 IMBRUVICA CAP 140MG ..................68 imipramine hcl tab 10 mg............38 imipramine hcl tab 25 mg............38 imipramine hcl tab 50 mg............38 imiquimod cream 5% ................ 102 immune globulin (human) im see GAMASTAN INJ.................... 146 immune globulin (human) iv
199
see CARIMUNE NF INJ 12GM ....... 146 see FLEBOGAMMA INJ DIF 5% .... 146 see GAMMAGARD SD INJ 10GM HU
............................................ 146 see OCTAGAM INJ 5GM .............. 146 see PRIVIGEN INJ 20GRAMS ....... 146 immune globulin (human) iv or subcutaneous see GAMMAGARD INJ 1GM/10ML . 146 immune globulin (human) subcutaneous see CUVITRU INJ 4GM/20ML ....... 146 see CUVITRU SOL 10GM/50M......146 see CUVITRU SOL 1GM/5ML........146 see HIZENTRA INJ 10/50ML ........ 146 see HIZENTRA INJ 1GM/5ML ....... 146 see HIZENTRA INJ 2GM/10ML ..... 146 see HIZENTRA INJ 4GM/20ML ..... 146 see HIZENTRA SOL 20% ............ 146 immune globulin (human)hyaluronidase (human recombinant) see HYQVIA INJ 10-800..............147 see HYQVIA INJ 2.5-200.............146 see HYQVIA INJ 20-1600 ............ 147 see HYQVIA INJ 30-2400 ............ 147 see HYQVIA INJ 5-400 ............... 147 Inatal Gt see prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg ...... 138 INCRELEX INJ 40MG/4ML .............. 107 INCRUSE ELPT INH 62.5MCG ...........24 indacaterol maleate
see ARCAPTA CAP 75MCG.............25 indapamide tab 1.25 mg............105 indapamide tab 2.5 mg..............106 indinavir sulfate
see CRIXIVAN CAP 200MG ............79 see CRIXIVAN CAP 400MG ............79 indomethacin cap 25 mg .............. 9 indomethacin cap 50 mg .............. 9 INFLECTRA INJ 100MG .................. 111 infliximab see REMICADE INJ 100MG .......... 111 infliximab-abda see RENFLEXIS INJ 100MG ......... 111 infliximab-dyyb
see INFLECTRA INJ 100MG ......... 111 influenza virus vac recomb
hemagglutinin (ha) quadrivalent see FLUBLOK QUAD INJ 2019-20. 158 influenza virus vaccine live quadrivalent see FLUMIST QUAD SUS 2019-20 158 influenza virus vaccine split quadrivalent see AFLURIA QUAD INJ 2019-20 . 158 see FLUARIX QUAD INJ 2019-20 . 158 see FLULAVAL QUA INJ 2019-20.. 158 see FLUZONE QUAD INJ 2019-20 158 influenza virus vaccine tissuecultured subunit quadrivalent see FLUCLVX QUAD INJ 2019-20 . 158 ingenol mebutate see PICATO GEL 0.015% ..............99 see PICATO GEL 0.05%................99 inositol niacinate cap 500 mg......88 INSPIRACHAMB MIS LARGE ........... 128 insulin aspart see NOVOLOG INJ 100/ML ............47 see NOVOLOG INJ FLEXPEN ..........47 see NOVOLOG INJ PENFILL ...........47 insulin aspart (with niacinamide) see FIASP FLEX INJ TOUCH...........45 see FIASP INJ 100/ML ..................45 see FIASP PENFIL INJ U-100 .........45 insulin aspart protamine & aspart (human) see NOVOLOG MIX INJ 70/30........47 see NOVOLOG MIX INJ FLEXPEN....47 insulin degludec see TRESIBA FLEX INJ 100UNIT ....47 see TRESIBA FLEX INJ 200UNIT ....47 see TRESIBA INJ 100UNIT ............47 insulin detemir see LEVEMIR INJ .........................47 see LEVEMIR INJ FLEXTOUC .........47 insulin glargine see BASAGLAR INJ 100UNIT .........45 insulin glulisine see APIDRA INJ SOLOSTAR...........45 see APIDRA INJ U-100 .................45 INSULIN LISP INJ 100/ML ...............47 insulin lispro
200
see ADMELOG INJ 100U/ML ..........45 see ADMELOG SOLO INJ 100U/ML .45 see HUMALOG INJ 100/ML ............46 see HUMALOG JR INJ 100/ML........46 see HUMALOG KWIK INJ 100/ML ...46 insulin lispro protamine & lispro see HUMALOG MIX INJ 50/50........46 see HUMALOG MIX INJ 50/50KWP .46 see HUMALOG MIX INJ 75/25KWP .46 see HUMALOG MIX SUS 75/25 ......46 insulin nph (human) (isophane) see HUMULIN N INJ U-100............46 see HUMULIN N INJ U-100KWP .....47 see NOVOLIN N INJ U-100 ............47 insulin nph isophane & reg (human) see HUMULIN INJ 70/30 ...............46 see HUMULIN INJ 70/30KWP.........46 see NOVOLIN INJ 70/30 ...............47 see NOVOLIN INJ 70/30 FP ...........47 insulin pen needle see PEN NEEDLES MIS 29GX10MM
............................................ 127 see PEN NEEDLES MIS 29GX12.7 127 see PEN NEEDLES MIS 29GX12MM
............................................ 127 see PEN NEEDLES MIS 31GX5MM 127 see PEN NEEDLES MIS 31GX6MM 127 see PEN NEEDLES MIS 31GX8MM 127 see PEN NEEDLES MIS 32GX4MM 127 see PEN NEEDLES MIS 32GX6MM 127 see PEN NEEDLES MIS 32GX8MM 127 insulin regular (human) see AFREZZA POW 12 UNIT ..........45 see AFREZZA POW 4-8 UNIT .........45 see AFREZZA POW 4-8-12 ............45 see AFREZZA POW 4UNIT .............45 see AFREZZA POW 8 UNIT ............45 see AFREZZA POW 8-12UNIT ........45 see HUMULIN R INJ U-100 ............47 see HUMULIN R INJ U-500 ............47 see NOVOLIN R INJ U-100 ............47 INSULIN SYRG MIS 0.3/29G .......... 126 INSULIN SYRG MIS 0.3/30G .......... 126 INSULIN SYRG MIS 0.3/31G .......... 126 INSULIN SYRG MIS 0.5/28G .......... 126 INSULIN SYRG MIS 0.5/29G .......... 126
INSULIN SYRG MIS 0.5/30G .......... 126 INSULIN SYRG MIS 0.5/31G .......... 126 INSULIN SYRG MIS 1ML/28G ......... 127 INSULIN SYRG MIS 1ML/29G ......... 127 INSULIN SYRG MIS 1ML/30G ......... 127 INSULIN SYRG MIS 1ML/31G ......... 127 insulin syringe/needle u-100
see INSULIN SYRG MIS 0.3/29G . 126 see INSULIN SYRG MIS 0.3/30G . 126 see INSULIN SYRG MIS 0.3/31G . 126 see INSULIN SYRG MIS 0.5/28G . 126 see INSULIN SYRG MIS 0.5/29G . 126 see INSULIN SYRG MIS 0.5/30G . 126 see INSULIN SYRG MIS 0.5/31G . 126 see INSULIN SYRG MIS 1ML/28G 127 see INSULIN SYRG MIS 1ML/29G 127 see INSULIN SYRG MIS 1ML/30G 127 see INSULIN SYRG MIS 1ML/31G 127 insulin syringe/needle u-500 see BD U-500 MIS 31GX6MM ...... 125 INTELENCE TAB 100MG ..................80 INTELENCE TAB 200MG ..................80 INTELENCE TAB 25MG ....................80 interferon alfa-2b see INTRON A INJ 10MU...............70 see INTRON A INJ 18MU...............70 see INTRON A INJ 25MU...............70 see INTRON A INJ 50MU...............70 interferon beta-1a see AVONEX KIT 30MCG............. 149 see AVONEX PEN KIT 30MCG ...... 149 see AVONEX PREFL KIT 30MCG ... 149 interferon beta-1b see EXTAVIA INJ 0.3MG ............. 150 interferon gamma-1b see ACTIMMUNE INJ 2MU/0.5 .......70 INTRON A INJ 10MU .......................70 INTRON A INJ 18MU .......................70 INTRON A INJ 25MU .......................70 INTRON A INJ 50MU .......................70 INVEGA SUST INJ 117/0.75.............73 INVEGA SUST INJ 156MG/ML...........73 INVEGA SUST INJ 234/1.5 ..............73 INVEGA SUST INJ 39/0.25 ..............73 INVEGA SUST INJ 78/0.5ML ............73 INVEGA TRINZ INJ 273MG...............73 INVEGA TRINZ INJ 410MG...............73
201
INVEGA TRINZ INJ 546MG...............73 INVEGA TRINZ INJ 819MG...............73 INVIRASE TAB 500MG.....................80 ipratropium bromide hfa
see ATROVENT HFA AER 17MCG ....24 ipratropium bromide inhal soln
0.02% ......................................24 ipratropium bromide nasal soln
0.03% (21 mcg/spray) .......... 140 ipratropium bromide nasal soln
0.06% (42 mcg/spray) .......... 140 ipratropium-albuterol
see COMBIVENT AER 20-100 ........26 ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml ...................27 irbesartan tab 150 mg .................60 irbesartan tab 300 mg .................60 irbesartan tab 75 mg...................60 irbesartan-hydrochlorothiazide tab
150-12.5 mg .............................63 irbesartan-hydrochlorothiazide tab
300-12.5 mg .............................63 IRON CHW PEDIATRI .................... 120 iron combination cap ................. 119 iron polysacch complex-vit b12-fa
cap 150-0.025-1 mg ............... 119 irrigation solution, physiological134 isavuconazonium sulfate
see CRESEMBA CAP 186 MG .........51 ISENTRESS CHW 100MG .................80 ISENTRESS CHW 25MG...................80 ISENTRESS HD TAB 600MG .............80 ISENTRESS POW 100MG .................80 ISENTRESS TAB 400MG ..................80 isocarboxazid
see MARPLAN TAB 10MG ..............34 isoniazid syrup 50 mg/5ml..........65 isoniazid tab 100 mg ...................65 isoniazid tab 300 mg ...................65 isoniazid-rifampin w/
pyrazinamide see RIFATER TAB.........................65 isopropyl alcohol-glycerin otic liquid 95-5% .......................... 145 isosorbide dinitrate tab 10 mg ....20 isosorbide dinitrate tab 20 mg ....20 isosorbide dinitrate tab 30 mg ....20
isosorbide dinitrate tab 5 mg ......20 isosorbide mononitrate tab 10 mg
................................................. 20 isosorbide mononitrate tab 20 mg
................................................. 20 isosorbide mononitrate tab er 24hr
120 mg .....................................20 isosorbide mononitrate tab er 24hr
30 mg .......................................20 isosorbide mononitrate tab er 24hr
60 mg .......................................20 isotretinoin cap 10 mg ................96 isotretinoin cap 20 mg ................96 isotretinoin cap 30 mg ................96 isotretinoin cap 40 mg ................96 isradipine cap 2.5 mg ..................86 isradipine cap 5 mg .....................86 itraconazole cap 100 mg .............51 ivabradine hcl
see CORLANOR SOL 5MG/5ML.......89 see CORLANOR TAB 5MG..............89 see CORLANOR TAB 7.5MG ...........89 ivacaftor see KALYDECO PAK 25MG .......... 151 see KALYDECO PAK 50MG .......... 151 see KALYDECO PAK 75MG .......... 151 see KALYDECO TAB 150MG......... 151 ivermectin (pediculicide) see SKLICE LOT 0.5% ................ 103 ivermectin tab 3 mg ....................18 J
JAKAFI TAB 10MG ..........................68 JAKAFI TAB 15MG ..........................68 JAKAFI TAB 20MG ..........................68 JAKAFI TAB 25MG ..........................68 JAKAFI TAB 5MG ............................68 JANUMET TAB 50-1000 ...................40 JANUMET TAB 50-500MG ................40 JANUMET XR TAB 100-1000.............40 JANUMET XR TAB 50-1000 ..............40 JANUMET XR TAB 50-500MG............40 JANUVIA TAB 100MG ......................44 JANUVIA TAB 25MG........................43 JANUVIA TAB 50MG........................44 JARDIANCE TAB 10MG ....................48 JARDIANCE TAB 25MG ....................49 JENTADUETO TAB 2.5-1000.............41
202
JENTADUETO TAB 2.5-500...............40 JENTADUETO TAB 2.5-850...............40 JENTADUETO TAB XR......................41 Jinteli
see norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg ..... 109
JULUCA TAB 50-25MG.....................80 Junel 1.5/30
see norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg ..92
Junel Fe 1.5/30 see norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg .............................................. 92
K
KALETRA TAB 100-25MG .................80 KALETRA TAB 200-50MG .................80 KALYDECO PAK 25MG ................... 151 KALYDECO PAK 50MG ................... 151 KALYDECO PAK 75MG ................... 151 KALYDECO TAB 150MG ................. 151 Kelnor 1/50
see ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg .....91
KEPIVANCE INJ 6.25MG ..................70 ketoconazole cream 2% ..............98 ketoconazole shampoo 2% .........98 ketoconazole tab 200 mg ............51 ketorolac tromethamine ophth soln
0.4% ...................................... 144 ketorolac tromethamine ophth soln
0.5% ...................................... 144 ketorolac tromethamine tab 10 mg
.................................................. 9 ketotifen fumarate ophth soln
0.025% (base equiv)..............144 KEVZARA INJ 150/1.14 .................... 7 KEVZARA INJ 200/1.14 .................... 8 KINERET INJ ................................... 7 KISQALI 200 PAK FEMARA...............67 KISQALI 400 PAK FEMARA...............67 KISQALI 600 PAK FEMARA...............67 KISQALI TAB 200DOSE ...................68 KISQALI TAB 400DOSE ...................68 KISQALI TAB 600DOSE ...................68 Klor-con/ef
see potassium bicarbonate effer tab 25 meq .......................... 132
KOATE-DVI INJ 1000UNIT ............. 115 KOATE-DVI INJ 250UNIT ............... 115 KOATE-DVI INJ 500UNIT ............... 115 KOGENATE FS INJ 1000UNIT ......... 115 KOGENATE FS INJ 2000UNIT ......... 115 KOGENATE FS INJ 250UNIT ........... 115 KOGENATE FS INJ 3000UNIT ......... 115 Konsyl
see psyllium powder 30.9% .... 122 KONSYL DAILY POW 100% ............ 122 KONSYL DAILY POW 28.3% ........... 122 KONSYL-D POW 52.3% ................. 122 KOVALTRY INJ 1000UNIT .............. 115 KOVALTRY INJ 2000UNIT .............. 115 KOVALTRY INJ 250UNIT ................ 115 KOVALTRY INJ 3000UNIT .............. 115 KOVALTRY INJ 500UNIT ................ 115 Kp Vitamin D
see cholecalciferol chew tab 10 mcg (400 unit) .................... 160
KPN PRENATAL TAB ...................... 137 KUVAN TAB 100MG ...................... 107 KYLEENA IUD 19.5MG.....................93 L
labetalol hcl tab 100 mg..............83 labetalol hcl tab 200 mg..............83 labetalol hcl tab 300 mg..............83 lacosamide
see VIMPAT SOL 10MG/ML............32 see VIMPAT TAB 100MG ...............32 see VIMPAT TAB 150MG ...............32 see VIMPAT TAB 200MG ...............33 see VIMPAT TAB 50MG .................32 LACRISERT MIS 5MG OP ............... 141 lactic acid (ammonium lactate) cream 12%............................. 102 lactic acid (ammonium lactate) lotion 12% ............................. 102 lactulose (encephalopathy) solution 10 gm/15ml.............. 111 lactulose solution 10 gm/15ml . 123 lamivudine (hbv) see EPIVIR HBV SOL 5MG/ML........82 lamivudine oral soln 10 mg/ml ...80 lamivudine tab 100 mg (hbv) ......82
203
lamivudine tab 150 mg................80 lamivudine tab 300 mg................80 lamivudine-tenofovir disoproxil
fumarate see CIMDUO TAB 300-300 ............79 lamivudine-zidovudine tab 150-300 mg ............................................80 lamotrigine tab 100 mg ...............31 lamotrigine tab 150 mg ...............31 lamotrigine tab 200 mg ...............31 lamotrigine tab 25 mg .................31 lamotrigine tab chewable dispersible 25 mg .....................31 lamotrigine tab chewable dispersible 5 mg .......................31 Lanacort 10 see hydrocortisone acetate cream
1%....................................... 101 lanadelumab-flyo
see TAKHZYRO INJ 300/2ML ....... 117 LANCETS MIS 30G ........................ 126 Land Before Time Multivit
see pediatric multiple vitamin w/ extra c & fa chew tab ........... 136
LANOXIN TAB 0.125MG...................87 LANOXIN TAB 0.25MG ....................87 lansoprazole cap delayed release
15 mg ..................................... 155 lansoprazole cap delayed release
30 mg ..................................... 155 lanthanum carbonate chew tab
1000 mg (elemental)..............112 lanthanum carbonate chew tab 500
mg (elemental)....................... 112 lanthanum carbonate chew tab 750
mg (elemental)....................... 112 lapatinib ditosylate
see TYKERB TAB 250MG ...............69 Larin 24 Fe
see norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) .......................................92
LASTACAFT SOL 0.25%.................144 latanoprost ophth soln 0.005% . 145 LATUDA TAB 120MG .......................72 LATUDA TAB 20MG .........................72 LATUDA TAB 40MG .........................72
LATUDA TAB 60MG.........................72 LATUDA TAB 80MG.........................72 LEDIP-SOFOSB TAB 90-400MG ........82 Leena
see norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg .......................................92
leflunomide tab 10 mg ................10 leflunomide tab 20 mg ................10 lenalidomide
see REVLIMID CAP 10MG............ 133 see REVLIMID CAP 15MG............ 133 see REVLIMID CAP 2.5MG........... 133 see REVLIMID CAP 20MG............ 133 see REVLIMID CAP 25MG............ 133 see REVLIMID CAP 5MG ............. 133 lenvatinib mesylate see LENVIMA CAP 10 MG ..............68 see LENVIMA CAP 12MG ...............68 see LENVIMA CAP 14 MG ..............68 see LENVIMA CAP 18 MG ..............68 see LENVIMA CAP 20 MG ..............68 see LENVIMA CAP 24 MG ..............68 see LENVIMA CAP 4MG.................68 see LENVIMA CAP 8 MG................68 LENVIMA CAP 10 MG ......................68 LENVIMA CAP 12MG .......................68 LENVIMA CAP 14 MG ......................68 LENVIMA CAP 18 MG ......................68 LENVIMA CAP 20 MG ......................68 LENVIMA CAP 24 MG ......................68 LENVIMA CAP 4MG .........................68 LENVIMA CAP 8 MG ........................68 LETAIRIS TAB 10MG .......................88 LETAIRIS TAB 5MG.........................88 letrozole tab 2.5 mg ....................66 leucovorin calcium tab 10 mg......70 leucovorin calcium tab 15 mg......70 leucovorin calcium tab 25 mg......70 leucovorin calcium tab 5 mg........70 LEUKERAN TAB 2MG .......................65 LEUKINE INJ 250MCG ................... 118 leuprolide acetate see ELIGARD INJ 7.5MG ...............66 see LUPRON DEPOT INJ 3.75MG ....66 see LUPRON DEPOT INJ 7.5MG......66
204
leuprolide acetate & norethindrone acetate see LUPANETA KIT 11.25-5.........107 see LUPANETA KIT 3.75-5 .......... 107
leuprolide acetate (3 month) see ELIGARD INJ 22.5MG .............66 see LUPRON DEPOT INJ 11.25MG ..66 see LUPRON DEPOT INJ 22.5MG ....66
leuprolide acetate (cpp) see LUPR DEP-PED INJ 11.25MG.. 107 see LUPR DEP-PED INJ 15MG ...... 107 see LUPR DEP-PED INJ 7.5MG ..... 107
leuprolide acetate (cpp) (3 month) see LUPR DEP-PED INJ 11.25MG.. 107 see LUPR DEP-PED INJ 3M 30MG . 107
leuprolide acetate inj kit 5 mg/ml ................................................. 66
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) ...............27
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) ...............27
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) ...............27
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv).....27
LEVEMIR INJ..................................47 LEVEMIR INJ FLEXTOUC ..................47 levetiracetam oral soln 100 mg/ml
................................................. 31 levetiracetam tab 1000 mg..........31 levetiracetam tab 250 mg ...........31 levetiracetam tab 500 mg ...........31 levetiracetam tab 750 mg ...........31 levetiracetam tab er 24hr 500 mg
................................................. 31 levetiracetam tab er 24hr 750 mg
................................................. 31 levobunolol hcl ophth soln 0.5%
............................................... 142 levocarnitine oral soln 1 gm/10ml
(10%) .................................... 107 levocarnitine tab 330 mg...........107 levocetirizine dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml)..........52 levocetirizine dihydrochloride tab 5
mg ............................................52 levofloxacin ophth soln 0.5% .... 143
levofloxacin oral soln 25 mg/ml 110 levofloxacin tab 250 mg ............ 110 levofloxacin tab 500 mg ............ 110 levofloxacin tab 750 mg ............ 110 levomilnacipran hcl
see FETZIMA CAP 120MG .............36 see FETZIMA CAP 20MG ...............36 see FETZIMA CAP 40MG ...............36 see FETZIMA CAP 80MG ...............36 see FETZIMA CAP TITRATIO..........36 levonor-eth est tab 0.150.02/0.025/0.03 mg ð est 0.01 mg ....................................91 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg .......91 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ...................91 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg .................91 levonorgestrel (iud) see KYLEENA IUD 19.5MG ............93 see LILETTA IUD 52MG ................93 see MIRENA IUD SYSTEM .............93 see SKYLA IUD 13.5MG ................93 levonorgestrel tab 1.5 mg ...........93 levonorgestrel-eth estra tab 0.0530/0.075-40/0.125-30mg-mcg 91 levonorgestrel-ethinyl estradiol & folic acid see FALESSA KIT.........................91 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg .....91 levonorgestrel-ethinyl estradiolferrous bisglycinate see BALCOLTRA TAB 0.1-20..........91 levonorg-eth est tab 0.10.02mg(84) & eth est tab 0.01mg(7) ................................91 levonorg-eth est tab 0.150.03mg(84) & eth est tab 0.01mg(7) ................................91 levothyroxine sodium see SYNTHROID TAB 100MCG ..... 153 see SYNTHROID TAB 112MCG ..... 153 see SYNTHROID TAB 125MCG ..... 153 see SYNTHROID TAB 137MCG ..... 153 see SYNTHROID TAB 150MCG ..... 153
205
see SYNTHROID TAB 175MCG ..... 153 see SYNTHROID TAB 200MCG ..... 153 see SYNTHROID TAB 25MCG ....... 152 see SYNTHROID TAB 300MCG ..... 153 see SYNTHROID TAB 50MCG ....... 152 see SYNTHROID TAB 75MCG ....... 153 see SYNTHROID TAB 88MCG ....... 153 levothyroxine sodium tab 100 mcg ............................................... 152 levothyroxine sodium tab 112 mcg ............................................... 152 levothyroxine sodium tab 125 mcg ............................................... 152 levothyroxine sodium tab 137 mcg ............................................... 152 levothyroxine sodium tab 150 mcg ............................................... 152 levothyroxine sodium tab 175 mcg ............................................... 152 levothyroxine sodium tab 200 mcg ............................................... 152 levothyroxine sodium tab 25 mcg ............................................... 152 levothyroxine sodium tab 300 mcg ............................................... 152 levothyroxine sodium tab 50 mcg ............................................... 152 levothyroxine sodium tab 75 mcg ............................................... 152 levothyroxine sodium tab 88 mcg ............................................... 152 Levoxyl see levothyroxine sodium tab 112
mcg...................................... 152 see levothyroxine sodium tab 125
mcg...................................... 152 see levothyroxine sodium tab 137
mcg...................................... 152 see levothyroxine sodium tab 150
mcg...................................... 152 see levothyroxine sodium tab 175
mcg...................................... 152 see levothyroxine sodium tab 25
mcg...................................... 152 see levothyroxine sodium tab 50
mcg...................................... 152
see levothyroxine sodium tab 75 mcg ..................................... 152
see levothyroxine sodium tab 88 mcg ..................................... 152
Lice Killing Maximum Stre see pyrethrins-piperonyl butoxide shampoo 0.33-4% ............... 103
Lice Treatment see permethrin creme rinse 1% ............................................ 103
lidocaine cream 4% .................. 102 lidocaine hcl gel 2% .................. 102 lidocaine hcl soln 4% ................ 102 lidocaine hcl urethral/mucosal gel
2% ......................................... 102 lidocaine hcl urethral/mucosal gel
prefilled syringe 2% ............... 102 lidocaine hcl viscous soln 2%.... 134 lidocaine patch 4% ................... 102 lidocaine patch 5% ................... 102 lidocaine-prilocaine cream 2.5-
2.5% ...................................... 102 lidocaine-tetracaine
see SYNERA DIS 70-70MG .......... 102 LILETTA IUD 52MG .........................93 linaclotide
see LINZESS CAP 145MCG.......... 111 see LINZESS CAP 290MCG.......... 111 see LINZESS CAP 72MCG ........... 111 linagliptin see TRADJENTA TAB 5MG .............44 linagliptin-metformin hcl see JENTADUETO TAB 2.5-1000 ....41 see JENTADUETO TAB 2.5-500 ......40 see JENTADUETO TAB 2.5-850 ......40 see JENTADUETO TAB XR .............41 lindane shampoo 1% ................ 103 linezolid for susp 100 mg/5ml ....19 linezolid tab 600 mg....................19 LINZESS CAP 145MCG .................. 111 LINZESS CAP 290MCG .................. 111 LINZESS CAP 72MCG .................... 111 liothyronine sodium tab 25 mcg 152 liothyronine sodium tab 5 mcg .. 152 liothyronine sodium tab 50 mcg 152 liotrix (t3-t4) see THYROLAR-1 TAB 60MG ....... 153
206
see THYROLAR-1/2 TAB 30MG.....153 see THYROLAR-1/4 TAB 15MG.....153 see THYROLAR-2 TAB 120MG ...... 153 see THYROLAR-3 TAB 180MG ...... 153 Liquid Calcium/vitamin D see calcium carbonate-vitamin d
cap 600 mg-200 unit............130 liraglutide
see VICTOZA INJ 18MG/3ML .........45 lisdexamfetamine dimesylate
see VYVANSE CAP 10MG ............... 2 see VYVANSE CAP 20MG ............... 2 see VYVANSE CAP 30MG ............... 2 see VYVANSE CAP 40MG ............... 2 see VYVANSE CAP 50MG ............... 2 see VYVANSE CAP 60MG ............... 2 see VYVANSE CAP 70MG ............... 2 lisinopril & hydrochlorothiazide tab 10-12.5 mg ...............................63 lisinopril & hydrochlorothiazide tab 20-12.5 mg ...............................63 lisinopril & hydrochlorothiazide tab 20-25 mg ..................................63 lisinopril tab 10 mg .....................58 lisinopril tab 2.5 mg ....................58 lisinopril tab 20 mg .....................58 lisinopril tab 30 mg .....................58 lisinopril tab 40 mg .....................58 lisinopril tab 5 mg .......................58 lithium carbonate cap 150 mg .....72 lithium carbonate cap 300 mg .....72 lithium carbonate cap 600 mg .....72 lithium carbonate tab 300 mg .....72 lithium carbonate tab er 300 mg .72 lithium carbonate tab er 450 mg .72 LITHIUM SOL 8MEQ/5ML .................72 LO LOESTRIN TAB 1-10-10 ..............91 lodoxamide tromethamine see ALOMIDE SOL 0.1% OP ........ 144 lomustine see GLEOSTINE CAP 100MG..........65 see GLEOSTINE CAP 10MG ...........65 see GLEOSTINE CAP 40MG ...........65 LONSURF TAB 15-6.14....................67 LONSURF TAB 20-8.19....................67 loperamide hcl cap 2 mg .............49
loperamide hcl liq 1 mg/5ml (0.2 mg/ml) ..................................... 50
loperamide hcl liq 1 mg/7.5ml ....50 loperamide hcl tab 2 mg..............50 lopinavir-ritonavir
see KALETRA TAB 100-25MG ........80 see KALETRA TAB 200-50MG ........80 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) ...........80 Lopreeza see estradiol & norethindrone
acetate tab 1-0.5 mg ........... 109 loratadine & pseudoephedrine tab
er 12hr 5-120 mg .....................95 loratadine & pseudoephedrine tab
er 24hr 10-240 mg ...................95 loratadine rapidly-disintegrating
tab 10 mg .................................52 loratadine syrup 5 mg/5ml .........52 loratadine tab 10 mg ...................52 Loratadine-d 12hr
see loratadine & pseudoephedrine tab er 12hr 5-120 mg ............95
Loratadine-d 24hr see loratadine & pseudoephedrine tab er 24hr 10-240 mg ..........95
lorazepam conc 2 mg/ml.............22 lorazepam tab 0.5 mg .................23 lorazepam tab 1 mg ....................23 lorazepam tab 2 mg ....................23 losartan potassium &
hydrochlorothiazide tab 100-12.5 mg ............................................63 losartan potassium & hydrochlorothiazide tab 100-25 mg ............................................63 losartan potassium & hydrochlorothiazide tab 50-12.5 mg ............................................63 losartan potassium tab 100 mg ...60 losartan potassium tab 25 mg .....60 losartan potassium tab 50 mg .....60 LOTEMAX GEL 0.5% ..................... 143 LOTEMAX OIN 0.5% ..................... 143 LOTEMAX SUS 0.5% ..................... 143 loteprednol etabonate see ALREX SUS 0.2%................. 143
207
see LOTEMAX GEL 0.5% ............. 143 see LOTEMAX OIN 0.5% ............. 143 see LOTEMAX SUS 0.5% ............ 143 loteprednol etabonate ophth susp 0.5% ...................................... 143 Lotrimin Af Deodorant Pow see miconazole nitrate aerosol
pow 2% .................................98 lovastatin tab 10 mg ...................55 lovastatin tab 20 mg ...................55 lovastatin tab 40 mg ...................55 Low-ogestrel
see norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.................92
loxapine succinate cap 10 mg......75 loxapine succinate cap 25 mg......75 loxapine succinate cap 5 mg .......75 loxapine succinate cap 50 mg......75 lubiprostone
see AMITIZA CAP 24MCG............110 see AMITIZA CAP 8MCG ............. 110 Lubricant Eye Drops see polyethylene glycol-propylene
glycol ophth soln 0.4-0.3% .. 141 luliconazole cream 1% ................98 LUMIGAN SOL 0.01%.................... 145 LUPANETA KIT 11.25-5 ................. 107 LUPANETA KIT 3.75-5 ................... 107 LUPR DEP-PED INJ 11.25MG .......... 107 LUPR DEP-PED INJ 15MG...............107 LUPR DEP-PED INJ 3M 30MG ......... 107 LUPR DEP-PED INJ 7.5MG..............107 LUPRON DEPOT INJ 11.25MG...........66 LUPRON DEPOT INJ 22.5MG ............66 LUPRON DEPOT INJ 3.75MG ............66 LUPRON DEPOT INJ 7.5MG ..............66 lurasidone hcl
see LATUDA TAB 120MG...............72 see LATUDA TAB 20MG ................72 see LATUDA TAB 40MG ................72 see LATUDA TAB 60MG ................72 see LATUDA TAB 80MG ................72 LYRICA CAP 100MG ........................32 LYRICA CAP 150MG ........................32 LYRICA CAP 200MG ........................32 LYRICA CAP 225MG ........................32 LYRICA CAP 25MG ..........................31
LYRICA CAP 300MG ........................32 LYRICA CAP 50MG ..........................31 LYRICA CAP 75MG ..........................32 LYSODREN TAB 500MG ...................66 M
macitentan see OPSUMIT TAB 10MG...............88
mafenide acetate see SULFAMYLON CRE 85MG/GM...99
mafenide acetate packet for topical soln 5% (50 gm) ......................99
MAG64 TAB 64MG ........................ 132 Magdelay
see magnesium chloride tab dr 64 mg (elemental mg) .............. 132
MAGDELAY TAB 70MG................... 132 Mag-g
see magnesium gluconate tab 500 mg (27 mg elemental mg) ... 132
magnesium chloride see MAG64 TAB 64MG................ 132 see MAGDELAY TAB 70MG .......... 132
magnesium chloride tab dr 64 mg (elemental mg) ...................... 132
magnesium citrate soln ............. 123 magnesium gluconate tab 27.5 mg
(elemental mg) ...................... 132 magnesium gluconate tab 500 mg
(27 mg elemental mg)............ 132 magnesium hydroxide susp 400
mg/5ml .................................. 123 magnesium hydroxide susp
concentrate 2400 mg/10ml.... 123 magnesium oxide cap 500 mg
(elemental mg) ...................... 132 magnesium oxide tab 250 mg .....18 magnesium oxide tab 250 mg (mg
supplement) ........................... 132 magnesium oxide tab 400 mg (240
mg elemental mg) .................. 132 magnesium oxide tab 400 mg
(241.3 mg elemental mg) ....... 132 magnesium oxide tab 420 mg .....18 magnesium oxide tab 500 mg (mg
supplement) ........................... 132 magnesium tab 250 mg............. 132 Magnesium-oxide
208
see magnesium oxide tab 400 mg (241.3 mg elemental mg) .... 132
malathion lotion 0.5%...............103 Maox
see magnesium oxide tab 420 mg .............................................. 18
Mapap see acetaminophen liquid 160 mg/5ml .................................11 see acetaminophen tab 325 mg 11
maprotiline hcl tab 25 mg ...........34 maprotiline hcl tab 50 mg ...........34 maprotiline hcl tab 75 mg ...........34 maraviroc
see SELZENTRY SOL 20MG/ML ......81 see SELZENTRY TAB 150MG..........81 see SELZENTRY TAB 25MG ...........81 see SELZENTRY TAB 300MG..........81 see SELZENTRY TAB 75MG ...........81 MARPLAN TAB 10MG.......................34 MATULANE CAP 50MG .....................70 MAYZENT TAB 0.25MG .................. 150 mecamylamine hcl see VECAMYL TAB 2.5MG..............64 mecasermin see INCRELEX INJ 40MG/4ML......107 meclizine hcl chew tab 25 mg .....50 meclizine hcl tab 12.5 mg............50 meclizine hcl tab 25 mg...............50 meclofenamate sodium cap 100 mg .................................................. 9 meclofenamate sodium cap 50 mg 9 MEDI-LAXX CAP 8.6-50MG ............ 123 Medi-profen see ibuprofen cap 200 mg .......... 8 medroxyprogesterone acetate (contraceptive) see DEPO-SQ PROV INJ 104..........93 medroxyprogesterone acetate im susp 150 mg/ml .......................93 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml ...93 medroxyprogesterone acetate tab 10 mg ..................................... 148 medroxyprogesterone acetate tab 2.5 mg .................................... 148
medroxyprogesterone acetate tab 5 mg ....................................... 148
mefenamic acid cap 250 mg ......... 9 mefloquine hcl tab 250 mg ..........64 megestrol acetate susp 40 mg/ml
................................................. 67 megestrol acetate tab 20 mg.......67 megestrol acetate tab 40 mg.......67 MEKINIST TAB 0.5MG .....................68 MEKINIST TAB 2MG........................69 melatonin cap 3 mg...................... 5 melatonin cap 5 mg...................... 6 MELATONIN LIQ 1MG/4ML................ 6 melatonin tab 1 mg ...................... 6 melatonin tab 3 mg ...................... 6 melatonin tab 300 mcg ................ 6 melatonin tab 5 mg ...................... 6 melatonin tab er 10 mg ................ 6 melatonin tablet disintegrating 5
mg ............................................. 6 Melatonin Tr/vitamin B-6
see melatonin-pyridoxine tab er 3-10 mg .................................. 6
Melatonin/vitamin B-6 Ext see melatonin-pyridoxine tab 3-1 mg .......................................... 6
melatonin-pyridoxine tab 3-1 mg . 6 melatonin-pyridoxine tab 3-2 mg . 6 melatonin-pyridoxine tab er 3-10
mg ............................................. 6 Melodetta 24 Fe
see norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)................................92
meloxicam tab 15 mg ................... 9 meloxicam tab 7.5 mg .................. 9 melphalan tab 2 mg ....................65 memantine hcl cap er 24hr 14 mg
............................................... 149 memantine hcl cap er 24hr 21 mg
............................................... 149 memantine hcl cap er 24hr 28 mg
............................................... 149 memantine hcl cap er 24hr 7 mg
............................................... 149 memantine hcl oral solution 2
mg/ml .................................... 149
209
memantine hcl tab 10 mg .......... 149 memantine hcl tab 28 x 5 mg & 21
x 10 mg titration pack ............ 149 memantine hcl tab 5 mg ............ 149 MENEST TAB 0.3MG......................109 MENEST TAB 0.625MG .................. 109 MENEST TAB 1.25MG .................... 109 MENTAX CRE 1%............................98 menthol-zinc oxide oint 0.44-20%
............................................... 103 meperidine hcl oral soln 50
mg/5ml ....................................13 meperidine hcl tab 100 mg ..........13 meperidine hcl tab 50 mg............13 mepolizumab
see NUCALA INJ 100MG ...............24 meprobamate tab 200 mg ...........21 meprobamate tab 400 mg ...........21 mercaptopurine tab 50 mg ..........65 mesalamine
see APRISO CAP 0.375GM .......... 111 mesalamine cap er 24hr 0.375 gm
............................................... 111 mesalamine enema 4 gm...........111 mesalamine tab delayed release
800 mg ................................... 111 METAMUCIL POW 28%ORG............122 METAMUCIL POW 58.12% ............. 122 METAMUCIL WAF..........................122 metaproterenol sulfate syrup 10
mg/5ml ....................................27 metaproterenol sulfate tab 10 mg
................................................. 27 metaproterenol sulfate tab 20 mg
................................................. 27 metaxalone tab 800 mg.............139 metformin hcl tab 1000 mg .........43 metformin hcl tab 500 mg ...........43 metformin hcl tab 850 mg ...........43 metformin hcl tab er 24hr 500 mg
................................................. 43 metformin hcl tab er 24hr 750 mg
................................................. 43 methadone hcl soln 10 mg/5ml...13 methadone hcl soln 5 mg/5ml.....13 methadone hcl tab 10 mg ............13 methadone hcl tab 5 mg ..............13
methamphetamine hcl tab 5 mg ... 2 methazolamide tab 25 mg ......... 104 methazolamide tab 50 mg ......... 104 methenamine hippurate tab 1 gm
............................................... 156 methimazole tab 10 mg............. 152 methimazole tab 5 mg............... 152 METHITEST TAB 10MG ....................17 methocarbamol tab 500 mg ...... 139 methocarbamol tab 750 mg ...... 139 methotrexate sodium inj 250
mg/10ml (25 mg/ml)...............66 methotrexate sodium inj 50
mg/2ml (25 mg/ml).................66 methotrexate sodium inj pf 250
mg/10ml (25 mg/ml)...............66 methotrexate sodium inj pf 50
mg/2ml (25 mg/ml).................66 methotrexate sodium tab 2.5 mg
(base equiv) .............................66 methscopolamine bromide tab 2.5
mg .......................................... 154 methscopolamine bromide tab 5
mg .......................................... 154 methsuximide
see CELONTIN CAP 300MG ...........33 methyclothiazide tab 5 mg ........ 106 methylcellulose tab 500 mg ...... 122 methyldopa tab 250 mg ..............61 methyldopa tab 500 mg ..............61 methylergonovine maleate tab 0.2
mg .......................................... 146 methylnaltrexone bromide
see RELISTOR INJ 12/0.6ML ....... 111 see RELISTOR TAB 150MG.......... 112 methylphenidate hcl cap er 10 mg (cd) ........................................... 4 methylphenidate hcl cap er 20 mg (cd) ........................................... 4 methylphenidate hcl cap er 24hr 10 mg (la) ...................................... 4 methylphenidate hcl cap er 24hr 20 mg (la) ...................................... 4 methylphenidate hcl cap er 24hr 30 mg (la) ...................................... 4 methylphenidate hcl cap er 24hr 40 mg (la) ...................................... 4
210
methylphenidate hcl cap er 30 mg (cd) ........................................... 4
methylphenidate hcl cap er 40 mg (cd) ........................................... 4
methylphenidate hcl cap er 50 mg (cd) ........................................... 4
methylphenidate hcl cap er 60 mg (cd) ........................................... 4
methylphenidate hcl soln 10 mg/5ml ..................................... 4
methylphenidate hcl soln 5 mg/5ml ..................................... 4
methylphenidate hcl tab 10 mg .... 5 methylphenidate hcl tab 20 mg .... 5 methylphenidate hcl tab 5 mg ...... 5 methylphenidate hcl tab er 10 mg 5 methylphenidate hcl tab er 20 mg 5 methylphenidate hcl tab er 24hr 18
mg ............................................. 5 methylphenidate hcl tab er 24hr 27
mg ............................................. 5 methylphenidate hcl tab er 24hr 36
mg ............................................. 5 methylphenidate hcl tab er 24hr 54
mg ............................................. 5 methylphenidate hcl tab er osmotic
release (osm) 18 mg ................. 5 methylphenidate hcl tab er osmotic
release (osm) 27 mg ................. 5 methylphenidate hcl tab er osmotic
release (osm) 36 mg ................. 5 methylphenidate hcl tab er osmotic
release (osm) 54 mg ................. 5 methylprednisolone tab 16 mg ....94 methylprednisolone tab 32 mg ....94 methylprednisolone tab 4 mg ......94 methylprednisolone tab 8 mg ......94 methylprednisolone tab therapy
pack 4 mg (21) .........................94 methyltestosterone
see METHITEST TAB 10MG ...........17 methyltestosterone cap 10 mg ....17 metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml) (base equiv)....110 metoclopramide hcl tab 10 mg
(base equivalent) ................... 110
metoclopramide hcl tab 5 mg (base equivalent) ............................. 110
metolazone tab 10 mg............... 106 metolazone tab 2.5 mg.............. 106 metolazone tab 5 mg................. 106 metoprolol & hydrochlorothiazide
tab 100-25 mg..........................63 metoprolol & hydrochlorothiazide
tab 100-50 mg..........................63 metoprolol & hydrochlorothiazide
tab 50-25 mg............................63 metoprolol succinate tab er 24hr
100 mg (tartrate equiv) ...........84 metoprolol succinate tab er 24hr
200 mg (tartrate equiv) ...........84 metoprolol succinate tab er 24hr
25 mg (tartrate equiv) .............84 metoprolol succinate tab er 24hr
50 mg (tartrate equiv) .............84 metoprolol tartrate tab 100 mg...84 metoprolol tartrate tab 25 mg.....84 metoprolol tartrate tab 50 mg.....84 metronidazole cream 0.75% ..... 103 metronidazole gel 0.75% .......... 103 metronidazole lotion 0.75% ...... 103 metronidazole tab 250 mg ..........19 metronidazole tab 500 mg ..........19 metronidazole vaginal gel 0.75%
............................................... 159 mexiletine hcl cap 150 mg ..........23 mexiletine hcl cap 200 mg ..........23 mexiletine hcl cap 250 mg ..........23 MI-ACID CHW ................................18 miconazole (mouth-throat)
see ORAVIG TAB 50MG .............. 135 Miconazole 7
see miconazole nitrate vaginal cream 2% ............................ 159
see miconazole nitrate vaginal suppos 100 mg .................... 159
miconazole nitrate aerosol pow 2% ................................................. 98
miconazole nitrate cream 2% .....98 miconazole nitrate ointment 2% .98 miconazole nitrate powder 2% ...98 miconazole nitrate vaginal
see MONISTAT 7 KIT COMBO PK . 159
211
miconazole nitrate vaginal app 200 mg & 2% cream 9 gm kit ........ 159
miconazole nitrate vaginal cream 2% ......................................... 159
miconazole nitrate vaginal cream 4% (200 mg/5gm) ................. 159
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit . 159
miconazole nitrate vaginal suppos 100 mg ................................... 159
midodrine hcl tab 10 mg............160 midodrine hcl tab 2.5 mg...........160 midodrine hcl tab 5 mg.............. 160 miglitol tab 100 mg .....................39 miglitol tab 25 mg .......................39 miglitol tab 50 mg .......................39 miglustat cap 100 mg ................ 117 Milk Of Magnesia
see magnesium hydroxide susp 400 mg/5ml.........................123
Milk Of Magnesia Concentr see magnesium hydroxide susp concentrate 2400 mg/10ml . 123
milnacipran hcl see SAVELLA MIS TITR PAK ........ 149 see SAVELLA TAB 100MG ........... 149 see SAVELLA TAB 12.5MG .......... 149 see SAVELLA TAB 25MG ............. 149 see SAVELLA TAB 50MG ............. 149
mineral oil ................................. 123 mineral oil enema......................123 Minitran
see nitroglycerin td patch 24hr 0.6 mg/hr ..............................21
minocycline hcl cap 100 mg ...... 151 minocycline hcl cap 50 mg ........ 151 minocycline hcl cap 75 mg ........ 151 minoxidil tab 10 mg ....................64 minoxidil tab 2.5 mg ...................64 Mintox Plus
see alum & mag hydroxidesimethicone chew tab 200-20025 mg ....................................18
mirabegron see MYRBETRIQ TAB 25MG ......... 157 see MYRBETRIQ TAB 50MG ......... 157
MIRENA IUD SYSTEM ......................93
mirtazapine tab 15 mg ................34 mirtazapine tab 30 mg ................34 mirtazapine tab 45 mg ................34 MIRVASO GEL 0.33% ................... 103 misoprostol tab 100 mcg ........... 156 misoprostol tab 200 mcg ........... 156 mitotane
see LYSODREN TAB 500MG ..........66 modafinil tab 100 mg ................... 5 modafinil tab 200 mg ................... 5 moexipril hcl tab 15 mg...............58 moexipril hcl tab 7.5 mg..............58 mometasone furoate (inhalation)
see ASMANEX 120 AER 220MCG....25 see ASMANEX 14 AER 220MCG .....24 see ASMANEX 30 AER 110MCG .....24 see ASMANEX 30 AER 220MCG .....24 see ASMANEX 60 AER 220MCG .....24 see ASMANEX 7 AER 110MCG .......24 see ASMANEX HFA AER 100 MCG ..25 see ASMANEX HFA AER 200 MCG ..25 see ASMANEX HFA AER 50MCG .....25 mometasone furoate cream 0.1% ............................................... 101 mometasone furoate oint 0.1%. 101 mometasone furoate solution 0.1% (lotion) ................................... 101 mometasone furoate-formoterol fumarate dihydrate see DULERA AER 100-5MCG .........26 see DULERA AER 200-5MCG .........27 see DULERA AER 50-5MCG ...........26 MONISTAT 7 KIT COMBO PK .......... 159 MONOCLATE-P INJ 1000UNIT ........ 115 montelukast sodium chew tab 4 mg (base equiv) .............................24 montelukast sodium chew tab 5 mg (base equiv) .............................24 montelukast sodium tab 10 mg (base equiv) .............................24 MONUROL PAK GRANULES ............ 156 morphine sulfate oral soln 10 mg/5ml ....................................13 morphine sulfate oral soln 100 mg/5ml (20 mg/ml).................14 morphine sulfate oral soln 20 mg/5ml ....................................13
212
morphine sulfate tab 15 mg ........14 morphine sulfate tab 30 mg ........14 morphine sulfate tab er 100 mg ..14 morphine sulfate tab er 15 mg ....14 morphine sulfate tab er 200 mg ..14 morphine sulfate tab er 30 mg ....14 morphine sulfate tab er 60 mg ....14 morphine-naltrexone
see EMBEDA CAP 100-4MG ...........12 see EMBEDA CAP 20-0.8MG ..........12 see EMBEDA CAP 30-1.2MG ..........12 see EMBEDA CAP 50-2MG.............12 see EMBEDA CAP 60-2.4MG ..........12 see EMBEDA CAP 80-3.2MG ..........12 MOVANTIK TAB 12.5MG ................ 111 MOVANTIK TAB 25MG ................... 111 MOVIPREP SOL ............................ 123 moxifloxacin hcl ophth soln 0.5% (base equiv) ........................... 143 moxifloxacin hcl tab 400 mg (base equiv) ..................................... 110 Mucus-dm see dextromethorphan-
guaifenesin tab er 12hr 30-600 mg .........................................95 MULT VITAM DRO ......................... 136 MULTAQ TAB 400MG.......................23 MULTI VITAMI TAB D-3 ................. 135 Multi-delyn see pediatric multiple vitamin liq ............................................ 136 multiple vitamin cap .................. 135 multiple vitamin tab .................. 135 multiple vitamins w/ iron tab....135 multiple vitamins w/ minerals cap ............................................... 135 multiple vitamins w/ minerals liquid ...................................... 135 multiple vitamins w/ minerals tab ............................................... 135 Multi-vit/iron/fluoride see pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml ............................................ 135 Multivitamin & Mineral see multiple vitamins w/ minerals liquid ................................... 135
MULTIVITAMIN DRO /IRON............ 136 Multivitamin With Fluorid
see pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml136
see pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml . 136
Multivitamin/fluoride see pediatric multiple vitamins w/ fluoride chew tab 0.25 mg ............................................ 136 see pediatric multiple vitamins w/ fluoride chew tab 0.5 mg 136 see pediatric multiple vitamins w/ fluoride chew tab 1 mg .. 136
mupirocin oint 2% ......................97 Mv-one
see multiple vitamin cap ......... 135 Mvw Complete Formulation
see pediatric multiple vitamin w/ minerals & c chew tab ......... 135
My Way see levonorgestrel tab 1.5 mg...93
Mycocide Clinical Ns Anti see tolnaftate soln 1%..............98
mycophenolate mofetil cap 250 mg ............................................... 134
mycophenolate mofetil tab 500 mg ............................................... 134
mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) 134
mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) 134
MYNATAL CAP .............................. 137 MYNATAL TAB .............................. 137 MYNATE 90 TAB PLUS ................... 137 MYRBETRIQ TAB 25MG ................. 157 MYRBETRIQ TAB 50MG ................. 157 N
nabilone see CESAMET CAP 1MG ................51
nabumetone tab 500 mg .............. 9 nabumetone tab 750 mg .............. 9 nadolol tab 20 mg .......................84 nadolol tab 40 mg .......................84 nadolol tab 80 mg .......................84 nafarelin acetate
see SYNAREL SOL 2MG/ML ......... 107
213
naftifine hcl see NAFTIN GEL 1% ....................98 see NAFTIN GEL 2% ....................98
naftifine hcl cream 1% ................98 naftifine hcl gel 1%.....................98 NAFTIN GEL 1% .............................98 NAFTIN GEL 2% .............................98 naldemedine tosylate
see SYMPROIC TAB 0.2MG .......... 112 naloxegol oxalate
see MOVANTIK TAB 12.5MG........111 see MOVANTIK TAB 25MG .......... 111 naloxone hcl see NARCAN SPR .........................50 naloxone hcl inj 0.4 mg/ml .........50 naloxone hcl soln cartridge 0.4 mg/ml ......................................50 naloxone hcl soln prefilled syringe 2 mg/2ml .................................50 naltrexone see VIVITROL INJ 380MG .............50 naltrexone hcl tab 50 mg.............50 Naproxen Dr see naproxen tab ec 375 mg ...... 9 see naproxen tab ec 500 mg ...... 9 naproxen sodium tab 220 mg ....... 9 naproxen susp 125 mg/5ml ......... 9 naproxen tab 250 mg ................... 9 naproxen tab 375 mg ................... 9 naproxen tab 500 mg ................... 9 naproxen tab ec 375 mg ............... 9 naproxen tab ec 500 mg ............... 9 naratriptan hcl tab 1 mg (base equiv) ..................................... 128 naratriptan hcl tab 2.5 mg (base equiv) ..................................... 128 NARCAN SPR .................................50 NASAL DECON SYP 30MG/5ML ....... 140 NASAL DECONG LIQ 30MG/5ML ..... 140 NAT FIBER POW 58.6%.................122 NATACYN SUS 5% OP ................... 143 natalizumab see TYSABRI INJ 300/15ML ........ 150 NATALVIT TAB 75-1MG ................. 137 natamycin see NATACYN SUS 5% OP .......... 143 NATAZIA TAB.................................92
nateglinide tab 120 mg ...............48 nateglinide tab 60 mg .................48 NATURE THROI TAB 162.5MG ........ 152 NATURE-THROI TAB 113.75MG ...... 152 NATURE-THROI TAB 130MG .......... 152 NATURE-THROI TAB 146.25MG ...... 152 NATURE-THROI TAB 16.25MG........ 152 NATURE-THROI TAB 195MG .......... 152 NATURE-THROI TAB 260MG .......... 152 NATURE-THROI TAB 32.5MG ......... 152 NATURE-THROI TAB 325MG .......... 152 NATURE-THROI TAB 48.75MG........ 152 NATURE-THROI TAB 65MG ............ 152 NATURE-THROI TAB 97.5MG ......... 152 nebivolol hcl
see BYSTOLIC TAB 10MG .............84 see BYSTOLIC TAB 2.5MG ............84 see BYSTOLIC TAB 20MG .............84 see BYSTOLIC TAB 5MG ...............84 nebivolol-valsartan see BYVALSON TAB 5-80MG .........62 nebulizers see EASY NEB MIS..................... 127 NEBUPENT INH 300MG ...................19 Nebusal see sodium chloride soln nebu
3% ........................................95 nedocromil sodium (ophth)
see ALOCRIL SOL 2% ................ 144 needle (disp) 18 g
see NEEDLES MIS 18GX1.5......... 127 NEEDLES MIS 18GX1.5 ................. 127 nefazodone hcl tab 100 mg .........36 nefazodone hcl tab 150 mg .........36 nefazodone hcl tab 200 mg .........36 nefazodone hcl tab 250 mg .........36 nefazodone hcl tab 50 mg ...........35 nelfinavir mesylate
see VIRACEPT TAB 250MG............82 see VIRACEPT TAB 625MG............82 neomycin sulfate tab 500 mg ....... 6 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin .......................................... 143 neomycin-bacitracin-polymyxin oint ........................................... 97
214
neomycin-bacitracin-polymyxinpramoxine oint 1%...................97
neomycin-colistin-hc-thonzonium see COLY-MYCIN S SUS OTIC......145
neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ............................................... 143
neomycin-polymyxindexamethasone ophth oint 0.1% ............................................... 144
neomycin-polymyxindexamethasone ophth susp 0.1% ............................................... 144
neomycin-polymyxin-hc otic soln 1% ......................................... 145
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%145
NEORAL CAP 100MG ..................... 134 NEORAL CAP 25MG.......................134 nepafenac
see NEVANAC SUS 0.1% ............ 144 NESTABS TAB .............................. 137 netupitant-palonosetron
see AKYNZEO CAP 300-0.5 ...........50 NEULASTA INJ 6MG/0.6M .............. 118 NEUPOGEN INJ 300/0.5 ................ 118 NEUPOGEN INJ 300MCG................118 NEUPOGEN INJ 480/0.8 ................ 119 NEUPOGEN INJ 480MCG................119 NEUPRO DIS 1MG/24HR..................71 NEUPRO DIS 2MG/24HR..................71 NEUPRO DIS 3MG/24HR..................71 NEUPRO DIS 4MG/24HR..................71 NEUPRO DIS 6MG/24HR..................71 NEUPRO DIS 8MG/24HR..................71 NEVANAC SUS 0.1%.....................144 nevirapine susp 50 mg/5ml ........80 nevirapine tab 200 mg ................80 nevirapine tab er 24hr 100 mg ....80 nevirapine tab er 24hr 400 mg ....80 NEXAVAR TAB 200MG .....................69 NEXLETOL TAB 180MG ....................53 NEXLIZET TAB 180/10MG................53 NEXPLANON IMP 68MG ...................93 niacin (antihyperlipidemic) tab 500
mg ............................................57 niacin cap er 250 mg ................. 161
niacin cap er 500 mg ................. 161 Niacin Flush Free
see inositol niacinate cap 500 mg .............................................. 88
niacin tab 100 mg ..................... 161 niacin tab 250 mg ..................... 161 niacin tab 50 mg ....................... 161 niacin tab 500 mg ..................... 161 niacin tab er 250 mg ................. 161 niacin tab er 500 mg ................. 161 niacin tab er 500 mg
(antihyperlipidemic) ................. 57 niacin tab er 750 mg ................. 161 niacinamide tab 500 mg ............ 161 Niacor
see niacin (antihyperlipidemic) tab 500 mg ............................57
nicardipine hcl cap 20 mg ...........86 nicardipine hcl cap 30 mg ...........86 nicotine
see NICOTROL INH .................... 151 see NICOTROL NS SPR 10MG/ML. 151 nicotine polacrilex gum 2 mg .... 150 nicotine polacrilex gum 4 mg .... 150 nicotine polacrilex lozenge 2 mg ............................................... 150 nicotine polacrilex lozenge 4 mg ............................................... 150 NICOTINE SYS KIT TRANSDER ....... 150 nicotine td patch 24hr 14 mg/24hr ............................................... 150 nicotine td patch 24hr 21 mg/24hr ............................................... 151 nicotine td patch 24hr 7 mg/24hr ............................................... 150 Nicotine Transdermal Syst see nicotine td patch 24hr 7
mg/24hr .............................. 150 NICOTROL INH ............................ 151 NICOTROL NS SPR 10MG/ML ......... 151 nifedipine cap 10 mg ...................86 nifedipine cap 20 mg ...................86 nifedipine tab er 24hr 30 mg .......86 nifedipine tab er 24hr 60 mg .......86 nifedipine tab er 24hr 90 mg .......86 nifedipine tab er 24hr osmotic
release 30 mg...........................86
215
nifedipine tab er 24hr osmotic release 60 mg...........................86
nifedipine tab er 24hr osmotic release 90 mg...........................86
nilotinib hcl see TASIGNA CAP 150MG .............69 see TASIGNA CAP 200MG .............69 see TASIGNA CAP 50MG ...............69
nilutamide tab 150 mg ................67 nimodipine cap 30 mg .................86 niraparib tosylate
see ZEJULA CAP 100MG ...............69 nisoldipine tab er 24hr 17 mg .....87 nisoldipine tab er 24hr 20 mg .....87 nisoldipine tab er 24hr 25.5 mg ..87 nisoldipine tab er 24hr 30 mg .....87 nisoldipine tab er 24hr 34 mg .....87 nisoldipine tab er 24hr 40 mg .....87 nisoldipine tab er 24hr 8.5 mg ....86 nitazoxanide
see ALINIA SUS 100/5ML .............19 see ALINIA TAB 500MG ................19 nitisinone see ORFADIN CAP 10MG.............108 see ORFADIN CAP 20MG.............108 see ORFADIN CAP 2MG .............. 108 see ORFADIN CAP 5MG .............. 108 nitisinone cap 10 mg ................. 108 nitisinone cap 2 mg ................... 108 nitisinone cap 5 mg ................... 108 nitrofurantoin macrocrystalline cap 100 mg ................................... 156 nitrofurantoin macrocrystalline cap 50 mg ..................................... 156 nitrofurantoin monohydrate macrocrystalline cap 100 mg .. 156 nitrofurantoin susp 25 mg/5ml . 156 nitroglycerin (intra-anal) see RECTIV OIN 0.4%..................18 nitroglycerin sl tab 0.3 mg ..........20 nitroglycerin sl tab 0.4 mg ..........20 nitroglycerin sl tab 0.6 mg ..........20 nitroglycerin td patch 24hr 0.1 mg/hr ....................................... 20 nitroglycerin td patch 24hr 0.2 mg/hr ....................................... 20
nitroglycerin td patch 24hr 0.4 mg/hr ....................................... 20
nitroglycerin td patch 24hr 0.6 mg/hr ....................................... 21
NIVESTYM INJ 300/0.5 ................. 119 NIVESTYM INJ 300MCG ................. 119 NIVESTYM INJ 480/0.8 ................. 119 NIVESTYM INJ 480MCG ................. 119 nizatidine cap 150 mg ............... 154 nizatidine cap 300 mg ............... 154 nizatidine oral soln 15 mg/ml ... 154 Non-aspirin Junior Streng
see acetaminophen chew tab 160 mg .........................................11
nonoxynol-9 see CONCEPTROL GEL 4% .......... 159 see ENCARE SUP 100MG ............ 159 see GYNOL II GEL 3% ................ 159 see SHUR-SEAL GEL 2%............. 159 see TODAY SPONGE MIS ............ 159 see VCF VAGINAL AER CONTRACP159 see VCF VAGINAL MIS CONTRACP159
nonoxynol-9 gel 4% .................. 159 norelgestromin-ethinyl estradiol td
ptwk 150-35 mcg/24hr ............92 norethin acet & estrad-fe
see TAYTULLA CAP 1MG/20MC ......92 norethindrone & ethinyl estradiol
tab 0.4 mg-35 mcg ...................92 norethindrone & ethinyl estradiol
tab 0.5 mg-35 mcg ...................92 norethindrone & ethinyl estradiol
tab 1 mg-35 mcg ......................92 norethindrone & ethinyl estradiol-
fe chew tab 0.4 mg-35 mcg ......92 norethindrone & ethinyl estradiol-
fe chew tab 0.8 mg-25 mcg ......92 norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg .......92 norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg ....92 norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg ...92 norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg 92 norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24) .....92
216
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) ..........................................92
norethindrone acetate tab 5 mg 148 norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg..109 norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg........109 norethindrone acetate-ethinyl
estradiol-fe fum (biphasic) see LO LOESTRIN TAB 1-10-10 .....91 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg....92 norethindrone tab 0.35 mg..........93 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg..92 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg....92 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg .................92 norgestimate-eth estrad tab 0.1825/0.215-25/0.25-25 mg-mcg .92 norgestimate-eth estrad tab 0.1835/0.215-35/0.25-35 mg-mcg .92 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg .........................92 norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg .........................92 NORTEMP SUS INFANTS..................11 NORTHERA CAP 100MG ................. 160 NORTHERA CAP 200MG ................. 160 NORTHERA CAP 300MG ................. 160 Nortrel 0.5/35 (28) see norethindrone & ethinyl
estradiol tab 0.5 mg-35 mcg ..92 Nortrel 1/35
see norethindrone & ethinyl estradiol tab 1 mg-35 mcg .....92
Nortrel 7/7/7 see norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg ........................................ 92
nortriptyline hcl cap 10 mg .........38 nortriptyline hcl cap 25 mg .........38 nortriptyline hcl cap 50 mg .........38 nortriptyline hcl cap 75 mg .........38 NORVIR SOL 80MG/ML....................80
NOVOEIGHT INJ 1500UNIT ............ 115 NOVOLIN INJ 70/30........................47 NOVOLIN INJ 70/30 FP ...................47 NOVOLIN N INJ U-100 ....................47 NOVOLIN R INJ U-100 ....................47 NOVOLOG INJ 100/ML ....................47 NOVOLOG INJ FLEXPEN...................47 NOVOLOG INJ PENFILL ...................47 NOVOLOG MIX INJ 70/30 ................47 NOVOLOG MIX INJ FLEXPEN ............47 NOVOSEVEN RT INJ 1MG .............. 115 NOVOSEVEN RT INJ 2MG .............. 115 NOVOSEVEN RT INJ 5MG .............. 115 NOVOSEVEN RT INJ 8MG .............. 115 Np Thyroid 120
see thyroid tab 120 mg (2 grain) ............................................ 153
Np Thyroid 15 see thyroid tab 15 mg (1/4 grain) ............................................ 153
Np Thyroid 30 see thyroid tab 30 mg (1/2 grain) ............................................ 153
Np Thyroid 60 see thyroid tab 60 mg (1 grain) ............................................ 153
Np Thyroid 90 see thyroid tab 90 mg (1 1/2 grain) .................................. 153
NUCALA INJ 100MG ........................24 NUCYNTA ER TAB 100MG ................14 NUCYNTA ER TAB 150MG ................14 NUCYNTA ER TAB 200MG ................14 NUCYNTA ER TAB 250MG ................14 NUCYNTA ER TAB 50MG ..................14 NUCYNTA TAB 100MG .....................14 NUCYNTA TAB 50MG.......................14 NUCYNTA TAB 75MG.......................14 NULOJIX INJ 250MG ..................... 134 NUTRIENTS TAB PRENATAL ........... 137 NUVARING MIS ..............................93 NUWIQ INJ 1000UNIT ................... 115 NUWIQ INJ 2000UNIT ................... 116 NUWIQ INJ 2500UNIT ................... 116 NUWIQ INJ 250UNIT..................... 115 NUWIQ INJ 3000UNIT ................... 116 NUWIQ INJ 4000UNIT ................... 116
217
NUWIQ INJ 500UNIT.....................115 NUWIQ KIT 1000UNIT...................116 NUWIQ KIT 2000UNIT...................116 NUWIQ KIT 2500UNIT...................116 NUWIQ KIT 250UNIT .................... 116 NUWIQ KIT 3000UNIT...................116 NUWIQ KIT 4000UNIT...................116 NUWIQ KIT 500UNIT .................... 116 nystatin cream 100000 unit/gm..98 nystatin oint 100000 unit/gm .....98 nystatin susp 100000 unit/ml ... 135 nystatin tab 500000 unit .............51 nystatin topical powder 100000
unit/gm ....................................98 nystatin-triamcinolone cream
100000-0.1 unit/gm-% ............98 nystatin-triamcinolone oint
100000-0.1 unit/gm-% ............98 Nystop
see nystatin topical powder 100000 unit/gm ....................98
O
O-CAL TAB PRENATAL ................... 137 OCTAGAM INJ 5GM ....................... 146 octreotide acetate
see SANDOSTATIN KIT LAR 10MG108 see SANDOSTATIN KIT LAR 20MG108 see SANDOSTATIN KIT LAR 30MG108 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ........................... 108 octreotide acetate inj 1000 mcg/ml (1 mg/ml) .............................. 108 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) ........................... 108 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ......................... 108 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ........................... 108 Ocuvite/lutein see multiple vitamins w/ minerals
tab ....................................... 135 ODEFSEY TAB ................................81 ODOMZO CAP 200MG .....................66 ofloxacin ophth soln 0.3%......... 143 ofloxacin otic soln 0.3% ............ 145 ofloxacin tab 300 mg.................110 ofloxacin tab 400 mg.................110
Ogestrel see norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg ................92
olanzapine pamoate see ZYPREXA RELP INJ 210MG ......77 see ZYPREXA RELP INJ 300MG ......77 see ZYPREXA RELP INJ 405MG ......77
olanzapine tab 10 mg ..................76 olanzapine tab 15 mg ..................76 olanzapine tab 2.5 mg .................76 olanzapine tab 20 mg ..................76 olanzapine tab 5 mg ....................76 olanzapine tab 7.5 mg .................76 olmesartan medoxomil tab 20 mg
................................................. 60 olmesartan medoxomil tab 40 mg
................................................. 60 olmesartan medoxomil tab 5 mg .60 olmesartan medoxomil-
hydrochlorothiazide tab 20-12.5 mg ............................................63 olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg ............................................63 olmesartan medoxomilhydrochlorothiazide tab 40-25 mg ............................................63 olodaterol hcl see STRIVERDI AER 2.5MCG .........28 olopatadine hcl nasal soln 0.6% 140 olopatadine hcl ophth soln 0.1% (base equivalent) ................... 144 olopatadine hcl ophth soln 0.2% (base equivalent) ................... 144 olsalazine sodium see DIPENTUM CAP 250MG ......... 111 omalizumab see XOLAIR INJ 150MG/ML ...........24 see XOLAIR INJ 75/0.5.................24 see XOLAIR SOL 150MG ...............24 ombitasvir-paritaprevir-ritonavir see TECHNIVIE TAB .....................82 omega-3 fatty acids cap 1000 mg ............................................... 141 omega-3 fatty acids cap 1200 mg ............................................... 141 omega-3 fatty acids cap 300 mg 141
218
omega-3 fatty acids cap 500 mg 141 omega-3 fatty acids cap delayed
release 1000 mg ..................... 141 omega-3 fatty acids cap delayed
release 1200 mg ..................... 141 omega-3-acid ethyl esters cap 1
gm ............................................53 omeprazole
see FIRST-OMEPRA SUS 2MG/ML.155 omeprazole cap delayed release 10
mg .......................................... 155 omeprazole cap delayed release 20
mg .......................................... 155 omeprazole cap delayed release 40
mg .......................................... 155 omeprazole magnesium
see PRILOSEC OTC TAB 20MG.....155 omeprazole magnesium cap dr 20.6
mg (20 mg base equiv) .......... 155 OMNARIS SPR..............................140 OMNIFLEX DPR ............................ 125 OMNITROPE INJ 10/1.5ML ............. 107 OMNITROPE INJ 5.8MG ................. 107 OMNITROPE INJ 5/1.5ML...............107 onabotulinumtoxina
see BOTOX INJ 100UNIT ............ 141 see BOTOX INJ 200UNIT ............ 141 ondansetron hcl oral soln 4 mg/5ml ....................................50 ondansetron hcl tab 4 mg............50 ondansetron hcl tab 8 mg............50 ondansetron orally disintegrating tab 4 mg ...................................50 ondansetron orally disintegrating tab 8 mg ...................................50 ONE A DAY MIS PRENATAL ............ 137 OPSUMIT TAB 10MG .......................88 oral electrolyte solution ............ 131 ORAVIG TAB 50MG ....................... 135 ORENCIA CLCK INJ 125MG/ML .........10 ORENCIA INJ 125MG/ML .................10 ORENCIA INJ 250MG ......................10 ORENCIA INJ 50/0.4 .......................10 ORENCIA INJ 87.5/0.7 ....................10 ORENITRAM TAB 0.125MG...............88 ORENITRAM TAB 0.25MG ................88 ORENITRAM TAB 1MG .....................88
ORENITRAM TAB 2.5MG ..................88 ORENITRAM TAB 5MG.....................88 ORFADIN CAP 10MG ..................... 108 ORFADIN CAP 20MG ..................... 108 ORFADIN CAP 2MG ....................... 108 ORFADIN CAP 5MG ....................... 108 orphenadrine citrate tab er 12hr
100 mg ................................... 139 oseltamivir phosphate cap 30 mg
(base equiv) .............................83 oseltamivir phosphate cap 45 mg
(base equiv) .............................83 oseltamivir phosphate cap 75 mg
(base equiv) .............................83 oseltamivir phosphate for susp 6
mg/ml (base equiv) .................83 osimertinib mesylate
see TAGRISSO TAB 40MG.............69 see TAGRISSO TAB 80MG.............69 OSMOPREP TAB 1.5GM ................. 123 OTEZLA TAB 10/20/30 ....................10 OTEZLA TAB 30MG .........................10 oxandrolone tab 10 mg ...............17 oxandrolone tab 2.5 mg ..............17 oxaprozin tab 600 mg .................. 9 oxazepam cap 10 mg...................23 oxazepam cap 15 mg...................23 oxazepam cap 30 mg...................23 oxcarbazepine susp 300 mg/5ml (60 mg/ml) ..............................32 oxcarbazepine tab 150 mg ..........32 oxcarbazepine tab 300 mg ..........32 oxcarbazepine tab 600 mg ..........32 oxiconazole nitrate see OXISTAT LOT 1% ..................98 oxiconazole nitrate cream 1%.....98 OXISTAT LOT 1% ...........................98 oxybutynin see OXYTROL/WOMN DIS 3.9MG/24
............................................ 156 oxybutynin chloride syrup 5
mg/5ml .................................. 156 oxybutynin chloride tab 5 mg .... 156 oxybutynin chloride tab er 24hr 10
mg .......................................... 156 oxybutynin chloride tab er 24hr 15
mg .......................................... 156
219
oxybutynin chloride tab er 24hr 5 mg .......................................... 156
oxycodone hcl see OXYCONTIN TAB 10MG CR ......15 see OXYCONTIN TAB 15MG CR ......15 see OXYCONTIN TAB 20MG CR ......15 see OXYCONTIN TAB 30MG CR ......15 see OXYCONTIN TAB 40MG CR ......15 see OXYCONTIN TAB 60MG CR ......15 see OXYCONTIN TAB 80MG CR ......15
oxycodone hcl soln 5 mg/5ml .....14 oxycodone hcl tab 10 mg.............14 oxycodone hcl tab 15 mg.............14 oxycodone hcl tab 20 mg.............14 oxycodone hcl tab 30 mg.............14 oxycodone hcl tab 5 mg...............14 oxycodone hcl tab er 12hr deter 10
mg ............................................14 oxycodone hcl tab er 12hr deter 15
mg ............................................14 oxycodone hcl tab er 12hr deter 20
mg ............................................15 oxycodone hcl tab er 12hr deter 30
mg ............................................15 oxycodone hcl tab er 12hr deter 40
mg ............................................15 oxycodone hcl tab er 12hr deter 60
mg ............................................15 oxycodone hcl tab er 12hr deter 80
mg ............................................15 oxycodone w/ acetaminophen tab
10-325 mg ................................16 oxycodone w/ acetaminophen tab
2.5-325 mg ...............................16 oxycodone w/ acetaminophen tab
5-325 mg ..................................16 oxycodone w/ acetaminophen tab
7.5-325 mg ...............................16 oxycodone-ibuprofen tab 5-400 mg
................................................. 17 OXYCONTIN TAB 10MG CR ..............15 OXYCONTIN TAB 15MG CR ..............15 OXYCONTIN TAB 20MG CR ..............15 OXYCONTIN TAB 30MG CR ..............15 OXYCONTIN TAB 40MG CR ..............15 OXYCONTIN TAB 60MG CR ..............15 OXYCONTIN TAB 80MG CR ..............15
oxymetazoline hcl nasal soln 0.05% .................................... 140
oxymetholone see ANADROL-50 TAB 50MG .........17
oxymorphone hcl tab 10 mg ........15 oxymorphone hcl tab 5 mg..........15 oxymorphone hcl tab er 12hr 10
mg ............................................15 oxymorphone hcl tab er 12hr 15
mg ............................................15 oxymorphone hcl tab er 12hr 20
mg ............................................15 oxymorphone hcl tab er 12hr 30
mg ............................................15 oxymorphone hcl tab er 12hr 40
mg ............................................15 oxymorphone hcl tab er 12hr 5 mg
................................................. 15 oxymorphone hcl tab er 12hr 7.5
mg ............................................15 OXYTROL/WOMN DIS 3.9MG/24..... 156 Oysco 500+d
see calcium carbonatecholecalciferol chew tab 500 mg-600 unit ......................... 130
Oyster Shell Calcium Plus see calcium carbonatecholecalciferol tab 500 mg-200 unit ...................................... 130
oyster shell calcium tab 500 mg 131 Oystercal-d
see calcium carbonatecholecalciferol tab 500 mg-400 unit ...................................... 130
OZEMPIC INJ 2/1.5ML.....................44 P
Pain & Fever Childrens see acetaminophen soln 160 mg/5ml .................................11
palbociclib see IBRANCE CAP 100MG .............68 see IBRANCE CAP 125MG .............68 see IBRANCE CAP 75MG ...............68 see IBRANCE TAB 100MG .............68 see IBRANCE TAB 125MG .............68 see IBRANCE TAB 75MG ...............68
palifermin
220
see KEPIVANCE INJ 6.25MG..........70 paliperidone palmitate
see INVEGA SUST INJ 117/0.75 ....73 see INVEGA SUST INJ 156MG/ML ..73 see INVEGA SUST INJ 234/1.5 ......73 see INVEGA SUST INJ 39/0.25 ......73 see INVEGA SUST INJ 78/0.5ML ....73 see INVEGA TRINZ INJ 273MG ......73 see INVEGA TRINZ INJ 410MG ......73 see INVEGA TRINZ INJ 546MG ......73 see INVEGA TRINZ INJ 819MG ......73 paliperidone tab er 24hr 1.5 mg ..73 paliperidone tab er 24hr 3 mg .....73 paliperidone tab er 24hr 6 mg .....73 paliperidone tab er 24hr 9 mg .....73 palivizumab see SYNAGIS INJ 100MG/ML ....... 146 see SYNAGIS INJ 50MG .............. 146 pancrelipase (lipase-proteaseamylase) see CREON CAP 12000UNT ......... 104 see CREON CAP 24000UNT ......... 104 see CREON CAP 3000UNIT..........104 see CREON CAP 36000UNT ......... 104 see CREON CAP 6000UNIT..........104 see ZENPEP CAP 10000UNT ........ 104 see ZENPEP CAP 15000UNT ........ 104 see ZENPEP CAP 20000UNT ........ 104 see ZENPEP CAP 25000 .............. 104 see ZENPEP CAP 3000UNIT.........104 see ZENPEP CAP 40000 .............. 104 see ZENPEP CAP 5000UNIT.........104 panobinostat lactate see FARYDAK CAP 10MG...............68 see FARYDAK CAP 15MG...............68 see FARYDAK CAP 20MG...............68 PANRETIN GEL 0.1% ......................99 pantoprazole sodium ec tab 20 mg (base equiv) ........................... 155 pantoprazole sodium ec tab 40 mg (base equiv) ........................... 155 PARAGARD IUD T380A ....................93 paricalcitol cap 1 mcg................108 paricalcitol cap 2 mcg................108 paricalcitol cap 4 mcg................108 paromomycin sulfate cap 250 mg. 6 paroxetine hcl tab 10 mg.............35
paroxetine hcl tab 20 mg ............35 paroxetine hcl tab 30 mg ............35 paroxetine hcl tab 40 mg ............35 PASER GRA 4GM ............................65 pazopanib hcl
see VOTRIENT TAB 200MG ...........69 PEAK AIR FLO MIS ADLT/PED ........ 128 peak flow meter
see PEAK AIR FLO MIS ADLT/PED 128 PEDIA-LAX LIQ 50MG ................... 124 pediatric multiple vitamin liq..... 136 pediatric multiple vitamin w/ c
see POLY-VI-SOL SOL 50MG/ML .. 136 pediatric multiple vitamin w/ c & fa
chew tab................................. 136 pediatric multiple vitamin w/ c
soln 35 mg/ml ........................ 136 pediatric multiple vitamin w/ extra
c & fa chew tab....................... 136 pediatric multiple vitamin w/
minerals & c chew tab .....135, 136 pediatric multiple vitamin w/
minerals & c drops 45 mg/ml . 136 pediatric multiple vitamins
see MULT VITAM DRO ................ 136 pediatric multiple vitamins w/ fl-fe
drops 0.25-10 mg/ml ............. 135 pediatric multiple vitamins w/
fluoride chew tab 0.25 mg ...... 136 pediatric multiple vitamins w/
fluoride chew tab 0.5 mg ........ 136 pediatric multiple vitamins w/
fluoride chew tab 1 mg........... 136 pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml........ 136 pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml.......... 136 pediatric multiple vitamins w/ iron
see ANIMAL SHAPE CHW IRON.... 136 see MULTIVITAMIN DRO /IRON ... 136 pediatric multiple vitamins w/ iron chew tab 15 mg ...................... 136 pediatric multiple vitamins w/ iron drops 10 mg/ml ..................... 136 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml ..................... 136
221
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ....................... 136
pediatric vitamins adc see TRI-VI-SOL SOL A/C/D ......... 136
pediatric vitamins adc drops 750 unit-400 unit-35 mg/ml ......... 136
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm...........123
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm...........123
peg 3350-kcl-nacl-na sulfate-na ascorbate-ascorbic acid see MOVIPREP SOL .................... 123 see PLENVU SOL........................ 123
peg 3350-kcl-sod bicarb-nacl for soln 420 gm............................123
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate see GOLYTELY SOL .................... 123
PEGANONE TAB 250MG...................33 PEGASYS INJ .................................82 PEGASYS INJ 180MCG/M .................82 pegfilgrastim
see NEULASTA INJ 6MG/0.6M ..... 118 pegfilgrastim-bmez
see ZIEXTENZO INJ 6/0.6ML ....... 119 pegfilgrastim-cbqv
see UDENYCA INJ 6MG/.6ML ....... 119 pegfilgrastim-jmdb
see FULPHILA INJ 6/0.6ML..........118 peginterferon alfa-2a
see PEGASYS INJ.........................82 see PEGASYS INJ 180MCG/M ........82 peginterferon beta-1a see PLEGRIDY INJ......................150 see PLEGRIDY INJ PEN ............... 150 see PLEGRIDY INJ STARTER........150 see PLEGRIDY PEN INJ STARTER . 150 pegvisomant see SOMAVERT INJ 10MG ........... 106 see SOMAVERT INJ 15MG ........... 107 see SOMAVERT INJ 20MG ........... 107 PEN NEEDLES MIS 29GX10MM ....... 127 PEN NEEDLES MIS 29GX12.7 ......... 127 PEN NEEDLES MIS 29GX12MM ....... 127 PEN NEEDLES MIS 31GX5MM ......... 127 PEN NEEDLES MIS 31GX6MM ......... 127
PEN NEEDLES MIS 31GX8MM......... 127 PEN NEEDLES MIS 32GX4MM......... 127 PEN NEEDLES MIS 32GX6MM......... 127 PEN NEEDLES MIS 32GX8MM......... 127 penciclovir
see DENAVIR CRE 1% ..................99 penicillamine
see DEPEN TITRA TAB 250MG ..... 133 see D-PENAMINE TAB 125MG...... 133 penicillamine tab 250 mg .......... 133 penicillin v potassium for soln 125 mg/5ml .................................. 147 penicillin v potassium for soln 250 mg/5ml .................................. 147 penicillin v potassium tab 250 mg ............................................... 147 penicillin v potassium tab 500 mg ............................................... 147 pentamidine isethionate see NEBUPENT INH 300MG ...........19 pentamidine isethionate for nebulization soln 300 mg .........19 pentosan polysulfate sodium see ELMIRON CAP 100MG ........... 112 pentoxifylline tab er 400 mg ..... 117 perampanel see FYCOMPA TAB 10MG ..............30 see FYCOMPA TAB 12MG ..............30 see FYCOMPA TAB 2MG ................30 see FYCOMPA TAB 4MG ................30 see FYCOMPA TAB 6MG ................30 see FYCOMPA TAB 8MG ................30 perindopril erbumine tab 2 mg ....58 perindopril erbumine tab 4 mg ....58 perindopril erbumine tab 8 mg ....58 permethrin & pyrethrins-piperonyl butoxide see RA LICE KIT SOLUTION ........ 103 permethrin aerosol 0.5% .......... 103 permethrin cream 5% ............... 103 permethrin creme rinse 1% ...... 103 permethrin lotion 1%................ 103 perphenazine tab 16 mg..............77 perphenazine tab 2 mg................77 perphenazine tab 4 mg................77 perphenazine tab 8 mg................77 PERRY PRENAT CAP ...................... 137
222
Pharbedryl see diphenhydramine hcl cap 25 mg .........................................52
phenazopyridine hcl tab 100 mg113 phenazopyridine hcl tab 200 mg113 phendimetrazine tartrate tab 35
mg ............................................. 2 phenelzine sulfate tab 15 mg ......34 phenobarbital elixir 20 mg/5ml 120 phenobarbital tab 100 mg ......... 121 phenobarbital tab 15 mg ........... 120 phenobarbital tab 16.2 mg ........ 120 phenobarbital tab 30 mg ........... 120 phenobarbital tab 32.4 mg ........ 120 phenobarbital tab 60 mg ........... 120 phenobarbital tab 64.8 mg ........ 120 phenobarbital tab 97.2 mg ........ 121 phenoxybenzamine hcl cap 10 mg
................................................. 59 phenylephrine hcl (oral)
see SUDAFED PE SOL CHILDREN . 141 phenylephrine hcl tab 10 mg ..... 140 PHENYTEK CAP 200MG....................33 PHENYTEK CAP 300MG....................33 phenytoin chew tab 50 mg ..........33 phenytoin sodium extended
see DILANTIN CAP 100MG ............33 see DILANTIN CAP 30MG ..............33 see PHENYTEK CAP 200MG ...........33 see PHENYTEK CAP 300MG ...........33 phenytoin sodium extended cap 100 mg .....................................33 phenytoin sodium extended cap 200 mg .....................................33 phenytoin sodium extended cap 300 mg .....................................33 phenytoin susp 125 mg/5ml .......33 PHOSPHOLINE SOL 0.125%OP ....... 142 Physiolyte see irrigation solution,
physiological........................ 134 phytonadione tab 5 mg.............. 161 PICATO GEL 0.015%.......................99 PICATO GEL 0.05% ........................99 PIFELTRO TAB 100MG .....................81 pilocarpine hcl ophth soln 1% ... 142 pilocarpine hcl ophth soln 2% ... 142
pilocarpine hcl ophth soln 4% ... 142 pilocarpine hcl tab 5 mg ............ 135 pilocarpine hcl tab 7.5 mg ......... 135 pimozide tab 1 mg..................... 150 pimozide tab 2 mg..................... 150 pindolol tab 10 mg ......................84 pindolol tab 5 mg ........................84 pioglitazone hcl tab 15 mg (base
equiv) ....................................... 48 pioglitazone hcl tab 30 mg (base
equiv) ....................................... 48 pioglitazone hcl tab 45 mg (base
equiv) ....................................... 48 pirfenidone
see ESBRIET CAP 267MG............ 151 see ESBRIET TAB 267MG............ 151 see ESBRIET TAB 801MG............ 151 piroxicam cap 10 mg .................... 9 piroxicam cap 20 mg .................... 9 PLEGRIDY INJ .............................. 150 PLEGRIDY INJ PEN ....................... 150 PLEGRIDY INJ STARTER ................ 150 PLEGRIDY PEN INJ STARTER.......... 150 PLENVU SOL ................................ 123 pneumococcal 13-valent conjugate vaccine see PREVNAR 13 INJ .................. 158 pneumococcal vac polyvalent see PNEUMOVAX 23 INJ 25/0.5 ... 158 PNEUMOVAX 23 INJ 25/0.5 ........... 158 podofilox soln 0.5% .................. 102 Polycin see bacitracin-polymyxin b ophth
oint ...................................... 143 polyethylene glycol 3350 oral
packet 17 gm.......................... 123 polyethylene glycol 3350 oral
powder 17 gm/scoop ............. 123 polyethylene glycol-propylene
glycol ophth soln 0.4-0.3% .... 141 Poly-iron 150
see polysaccharide iron complex cap 150 mg (iron equivalent) ............................................ 120
Poly-iron 150 Forte see iron polysacch complex-vit b12-fa cap 150-0.025-1 mg . 119
223
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% ....... 143
polysaccharide iron complex cap 150 mg (iron equivalent)........120
polysaccharide iron-folic acid-vit b12 see FERREX 150 CAP FORTE ....... 119
polyvinyl alcohol ophth soln 1.4% ............................................... 142
polyvinyl alcohol-povidone ophth soln 5-6 mg/ml (0.5-0.6%) .... 142
POLY-VI-SOL SOL 50MG/ML........... 136 Polyvitamin/iron
see pediatric multiple vitamin w/ minerals & c chew tab ......... 136
pomalidomide see POMALYST CAP 1MG ..............67 see POMALYST CAP 2MG ..............67 see POMALYST CAP 3MG ..............67 see POMALYST CAP 4MG ..............67
POMALYST CAP 1MG .......................67 POMALYST CAP 2MG .......................67 POMALYST CAP 3MG .......................67 POMALYST CAP 4MG .......................67 ponatinib hcl
see ICLUSIG TAB 15MG................68 see ICLUSIG TAB 45MG................68 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg ............................................... 132 potassium bicarbonate effer tab 25 meq ........................................ 132 potassium chloride cap er 10 meq ............................................... 133 potassium chloride cap er 8 meq ............................................... 132 potassium chloride microencapsulated crys er tab 10 meq ........................................ 133 potassium chloride microencapsulated crys er tab 20 meq ........................................ 133 potassium chloride oral soln 10% (20 meq/15ml) ...................... 133 potassium chloride oral soln 20% (40 meq/15ml) ...................... 133
potassium chloride tab er 10 meq ............................................... 133
potassium chloride tab er 20 meq (1500 mg) .............................. 133
potassium chloride tab er 8 meq (600 mg) ................................ 133
potassium citrate & citric acid soln 1100-334 mg/5ml .................. 112
potassium citrate tab er 10 meq (1080 mg) .............................. 112
potassium citrate tab er 15 meq (1620 mg) .............................. 112
potassium citrate tab er 5 meq (540 mg) ................................ 112
PRADAXA CAP 110MG .....................30 PRADAXA CAP 150MG .....................30 PRADAXA CAP 75MG.......................30 pramipexole dihydrochloride tab
0.125 mg ..................................71 pramipexole dihydrochloride tab
0.25 mg ....................................71 pramipexole dihydrochloride tab
0.5 mg ......................................71 pramipexole dihydrochloride tab
0.75 mg ....................................71 pramipexole dihydrochloride tab 1
mg ............................................71 pramipexole dihydrochloride tab
1.5 mg ......................................71 pramlintide acetate
see SYMLINPEN 60 INJ 1000MCG ..39 see SYMLNPEN 120 INJ 1000MCG..39 pramox-pe-glycerin-petrolatum perianal cream 1-0.25-14.4-15% ................................................. 17 prasugrel hcl tab 10 mg (base equiv) ..................................... 117 prasugrel hcl tab 5 mg (base equiv) ..................................... 117 pravastatin sodium tab 10 mg.....55 pravastatin sodium tab 20 mg.....55 pravastatin sodium tab 40 mg.....55 pravastatin sodium tab 80 mg.....55 praziquantel tab 600 mg .............19 prazosin hcl cap 1 mg..................61 prazosin hcl cap 2 mg..................61 prazosin hcl cap 5 mg..................61
224
prednicarbate cream 0.1% ........ 101 prednicarbate oint 0.1% ........... 101 prednisolone acetate ophth susp
1% ......................................... 144 prednisolone sod phosph oral soln
6.7 mg/5ml (5 mg/5ml base) ..94 prednisolone sod phosphate oral
soln 15 mg/5ml (base equiv) ...94 prednisolone sodium phosphate
oral soln 25 mg/5ml (base eq) .94 prednisolone syrup 15 mg/5ml
(usp solution equivalent) .........94 prednisone oral soln 5 mg/5ml ...94 prednisone tab 1 mg ...................94 prednisone tab 10 mg .................94 prednisone tab 2.5 mg ................94 prednisone tab 20 mg .................94 prednisone tab 5 mg ...................94 prednisone tab 50 mg .................94 prednisone tab therapy pack 10 mg
(21) ..........................................94 prednisone tab therapy pack 10 mg
(48) ..........................................94 prednisone tab therapy pack 5 mg
(21) ..........................................94 prednisone tab therapy pack 5 mg
(48) ..........................................94 pregabalin
see LYRICA CAP 100MG................32 see LYRICA CAP 150MG................32 see LYRICA CAP 200MG................32 see LYRICA CAP 225MG................32 see LYRICA CAP 25MG .................31 see LYRICA CAP 300MG................32 see LYRICA CAP 50MG .................31 see LYRICA CAP 75MG .................32 PREGABALIN CAP 100 MG ...............32 PREGABALIN CAP 150 MG ...............32 PREGABALIN CAP 200 MG ...............32 PREGABALIN CAP 225 MG ...............32 PREGABALIN CAP 25 MG .................32 PREGABALIN CAP 300 MG ...............32 PREGABALIN CAP 50 MG .................32 PREGABALIN CAP 75 MG .................32 PREMARIN TAB 0.3MG .................. 109 PREMARIN TAB 0.45MG.................109 PREMARIN TAB 0.625MG ............... 109
PREMARIN TAB 0.9MG .................. 109 PREMARIN TAB 1.25MG ................ 110 PREMARIN VAG CRE 0.625MG........ 160 PREMPHASE TAB .......................... 109 PREMPRO TAB.............................. 109 PREMPRO TAB 0.3-1.5 .................. 109 PREMPRO TAB 0.45-1.5 ................ 109 PREMPRO TAB 0.625-5 ................. 109 PRENAT MULTI CAP +DHA ............. 137 Prenatabs Rx
see prenatal vit w/ iron carbonylfa tab 29-1 mg ..................... 138
Prenatal 19 see prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg ..... 138 see prenatal vit w/ fe fumarate-fa chew tab 29-1 mg ................ 138
PRENATAL 19 TAB 29-1MG ............ 137 PRENATAL CAP FORMULA .............. 137 PRENATAL CAP OMEGA-3 .............. 137 Prenatal Dha
see docosahexaenoic acid cap 200 mg ................................ 141
PRENATAL DHA PAK MULTI............ 137 PRENATAL FRM TAB A-FREE........... 138 PRENATAL MUL CAP +DHA ............ 138 prenatal multivitamins & minerals
w/ folic acid-fish oil see CVS PRENATAL CHW GUMMY 137 prenatal multivit-min w/fe-fa see KPN PRENATAL TAB ............. 137 see MYNATAL CAP ..................... 137 see PRENATAL/FE TAB ............... 138 prenatal mv & min w/ methylfolate-choline-fish oil see PRENATAL DHA PAK MULTI ... 137 prenatal mv & min w/fe carbonylfa-dha see BRAINSTRONG MIS PRENATAL
............................................ 137 prenatal mv & min w/fe fumarate-
fa-dha see CENTRUM SPEC PAK PRENATAL
............................................ 137 see ENFAMIL MIS EXPECTA......... 137 see PRENAT MULTI CAP +DHA .... 137 see PRENATAL+DHA MIS ............ 138
225
see THERANATAL MIS COMPLETE 138 PRENATAL TAB.............................138 PRENATAL TAB COMPLETE ............. 138 PRENATAL TAB FORMULA .............. 138 prenatal vit w/ docusate-fe
fumarate-folic acid see MYNATE 90 TAB PLUS .......... 137 see PRENATAL 19 TAB 29-1MG....137 prenatal vit w/ docusate-iron carbonyl-folic acid see MYNATAL TAB ..................... 137 prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg ............................ 138 prenatal vit w/ dss-iron carbonylfa tab 90-1 mg ........................ 138 prenatal vit w/ fe bisglycinate chelate-folic acid see VINATE II TAB ..................... 138 prenatal vit w/ fe bisglycinate-folic acid-omega 3 fatty acd see BE WELL PAK ROUNDED ....... 137 prenatal vit w/ fe fumarate-fa chew tab 29-1 mg...................138 prenatal vit w/ fe fumarate-fa tab 28-1 mg .................................. 138 prenatal vit w/ ferrous fumaratefa-fish oil see PRENATAL CAP OMEGA-3 ...... 137 prenatal vit w/ ferrous fumaratefa-omega 3 fatty acids see ONE A DAY MIS PRENATAL....137 see PRENATAL CAP FORMULA......137 see PRENATAL MUL CAP +DHA .... 138 see SM ONE DAILY MIS PRENATAL
............................................ 138 prenatal vit w/ ferrous fumarate-
folic acid see CO-NATAL FA TAB 29-1MG....137 see NATALVIT TAB 75-1MG.........137 see O-CAL TAB PRENATAL .......... 137 see PERRY PRENAT CAP..............137 see PRENATAL TAB .................... 138 see PRENATAL TAB COMPLETE .... 138 see RA PRENATAL TAB FORMULA . 138 see SE-NATAL 19 CHW ............... 138 see TRINATAL RX TAB 1 ............. 138 see VITAFOL-OB TAB 65-1MG ..... 138
see VOL-PLUS TAB .................... 138 prenatal vit w/ ferrous fumarate-l
methylfolate-folic acid see TL FOLATE TAB.................... 138 prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................. 138 prenatal vit w/ iron carbonyl-folic acid see VOL-TAB RX TAB ................. 138 prenatal vit w/ selenium-fe fumarate-folic acid see PRENATAL TAB FORMULA...... 138 see VINATE M TAB..................... 138 prenatal vit without vit a w/ fe bisglycinate-folic acid see NESTABS TAB ..................... 137 prenatal vitamin see CALNA TAB ......................... 137 prenatal vitamins w/ ferrous succinate-folic acid see NUTRIENTS TAB PRENATAL... 137 prenatal without a vit w/ fe fumarate-folic acid see PRENATAL FRM TAB A-FREE .. 138 prenatal without vit a w/ iron polysaccharide complex-fa see EZFE FORTE CAP ................. 137 PRENATAL/FE TAB ........................ 138 PRENATAL+DHA MIS .................... 138 PREPOPIK PAK ............................. 123 PREVNAR 13 INJ .......................... 158 PREZCOBIX TAB 800-150 ................81 PREZISTA SUS 100MG/ML ...............81 PREZISTA TAB 150MG ....................81 PREZISTA TAB 600MG ....................81 PREZISTA TAB 75MG ......................81 PREZISTA TAB 800MG ....................81 PRIFTIN TAB 150MG .......................65 PRILOSEC OTC TAB 20MG ............. 155 primaquine phosphate tab 26.3 mg (15 mg base)............................64 primidone tab 250 mg .................32 primidone tab 50 mg ...................32 PRIVIGEN INJ 20GRAMS ............... 146 PROAIR HFA AER............................27 probenecid tab 500 mg ............. 113 procarbazine hcl
226
see MATULANE CAP 50MG ............70 prochlorperazine maleate tab 10
mg (base equivalent) ...............78 prochlorperazine maleate tab 5 mg
(base equivalent) .....................78 prochlorperazine suppos 25 mg ..78 PROCRIT INJ 2000/ML .................. 119 PROCRIT INJ 3000/ML .................. 119 PROCRIT INJ 40000/ML.................119 PROFILNINE INJ 1500UNIT ............ 116 progesterone (vaginal)
see PROGESTERONE SUP VGS 100 ............................................ 160
see PROGESTERONE SUP VGS 200 ............................................ 160
progesterone micronized cap 100 mg .......................................... 148
progesterone micronized cap 200 mg .......................................... 148
PROGESTERONE SUP VGS 100 ....... 160 PROGESTERONE SUP VGS 200 ....... 160 PROGLYCEM SUS 50MG/ML .............43 PROLASTIN-C INJ 1000MG ............ 151 PROLIA SOL 60MG/ML .................. 106 PROMACTA TAB 12.5MG ................ 119 PROMACTA TAB 25MG...................119 PROMACTA TAB 50MG...................119 PROMACTA TAB 75MG...................119 promethazine & phenylephrine
syrup 6.25-5 mg/5ml ...............95 promethazine hcl suppos 12.5 mg
................................................. 53 promethazine hcl suppos 25 mg ..53 promethazine hcl syrup 6.25
mg/5ml ....................................53 promethazine hcl tab 12.5 mg .....53 promethazine hcl tab 25 mg ........53 promethazine hcl tab 50 mg ........53 promethazine w/ codeine syrup
6.25-10 mg/5ml .......................95 promethazine-dm syrup 6.25-15
mg/5ml ....................................95 promethazine-phenylephrine-
codeine syrup 6.25-5-10 mg/5ml ................................................. 95 propafenone hcl tab 150 mg........23 propafenone hcl tab 225 mg........23
propafenone hcl tab 300 mg........23 proparacaine hcl ophth soln 0.5%
............................................... 143 propranolol hcl cap er 24hr 120 mg
................................................. 84 propranolol hcl cap er 24hr 160 mg
................................................. 84 propranolol hcl cap er 24hr 60 mg
................................................. 84 propranolol hcl cap er 24hr 80 mg
................................................. 84 propranolol hcl oral soln 20
mg/5ml ....................................84 propranolol hcl oral soln 40
mg/5ml ....................................84 propranolol hcl tab 10 mg ...........84 propranolol hcl tab 20 mg ...........84 propranolol hcl tab 40 mg ...........84 propranolol hcl tab 60 mg ...........85 propranolol hcl tab 80 mg ...........85 propylene glycol-glycerin ophth
soln 1-0.3%............................ 142 propylthiouracil tab 50 mg ........ 152 protriptyline hcl tab 10 mg..........38 protriptyline hcl tab 5 mg............38 PROVENTIL AER HFA ......................28 pseudoephed-bromphen-dm
see BROTAPP DM LIQ 15-1-5/5 .....94 pseudoephed-bromphen-dm syrup
30-2-10 mg/5ml.......................95 pseudoephedrine hcl
see NASAL DECON SYP 30MG/5ML ............................................ 140
see NASAL DECONG LIQ 30MG/5ML ............................................ 140
pseudoephedrine hcl liq 15 mg/5ml ............................................... 140
pseudoephedrine hcl tab 30 mg 140 pseudoephedrine hcl tab 60 mg 141 pseudoephedrine hcl tab er 12hr
120 mg ................................... 141 pseudoephedrine-guaifenesin tab
er 12hr 60-600 mg ...................95 psyllium
see KONSYL DAILY POW 100% ... 122 see KONSYL DAILY POW 28.3% .. 122 see KONSYL-D POW 52.3% ........ 122
227
see METAMUCIL POW 28%ORG ... 122 see METAMUCIL POW 58.12% ..... 122 see METAMUCIL WAF ................. 122 see NAT FIBER POW 58.6% ........ 122 psyllium cap 0.52 gm ................ 122 psyllium cap 400 mg ................. 122 psyllium powder 100% ............. 122 psyllium powder 28.3% ............ 122 psyllium powder 30.9% ............ 122 psyllium powder 33% ............... 122 psyllium powder 48.57% .......... 122 psyllium powder 58.6% ............ 122 psyllium powder 95% ............... 122 PULMICORT INH 180MCG ................25 PULMICORT INH 90MCG ..................25 PULMONEB LT MIS NEBULIZE ........ 128 PULMOZYME SOL 1MG/ML ............. 151 Pure & Gentle Lubricant see hypromellose ophth soln
0.3%.................................... 141 Px Iron
see ferrous sulfate dried tab 200 mg (65 mg elemental fe) ..... 120
pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv).............19
pyrazinamide tab 500 mg ............65 pyreth-piperonyl butox sham-
permeth aero-nit remover gel kit ............................................... 103 pyrethrins-piperonyl butoxide liq 0.3-3% ................................... 103 pyrethrins-piperonyl butoxide liq 0.33-4% ................................. 103 pyrethrins-piperonyl butoxide shampoo 0.33-4% .................. 103 pyridostigmine bromide tab 60 mg ................................................. 65 pyridoxine hcl tab 100 mg ......... 161 pyridoxine hcl tab 25 mg ........... 161 pyridoxine hcl tab 50 mg ........... 161 pyridoxine hcl tab er 200 mg.....161 pyrimethamine see DARAPRIM TAB 25MG.............64 Q
Qc 3 Day Vaginal Cream see miconazole nitrate vaginal cream 4% (200 mg/5gm) ... 159
Qc Natural Vegetable see psyllium powder 95% ....... 122
quetiapine fumarate tab 100 mg .76 quetiapine fumarate tab 200 mg .76 quetiapine fumarate tab 25 mg ...76 quetiapine fumarate tab 300 mg .76 quetiapine fumarate tab 400 mg .76 quetiapine fumarate tab 50 mg ...76 quetiapine fumarate tab er 24hr
150 mg .....................................76 quetiapine fumarate tab er 24hr
200 mg .....................................76 quetiapine fumarate tab er 24hr
300 mg .....................................77 quetiapine fumarate tab er 24hr
400 mg .....................................77 quetiapine fumarate tab er 24hr 50
mg ............................................76 quinapril hcl tab 10 mg ...............58 quinapril hcl tab 20 mg ...............58 quinapril hcl tab 40 mg ...............58 quinapril hcl tab 5 mg .................58 quinapril-hydrochlorothiazide tab
10-12.5 mg...............................63 quinapril-hydrochlorothiazide tab
20-12.5 mg...............................63 quinapril-hydrochlorothiazide tab
20-25 mg..................................63 quinidine sulfate tab 200 mg.......23 quinidine sulfate tab 300 mg.......23 quinine sulfate cap 324 mg .........65 QVAR REDIHA AER 80MCG ..............25 QVAR REDIHAL AER 40MCG.............25 R
Ra Acetaminophen Rapid Me see acetaminophen disintegrating tab 160 mg ............................11 see acetaminophen disintegrating tab 80 mg ..............................11
Ra Budesonide Nasal Spray see budesonide nasal susp 32 mcg/act ............................... 140
Ra Calcium 600 Plus Vitam see calcium carb-vit d w/ minerals chew tab 600 mg-400 unit ...................................... 130
Ra Cetirizine
228
see cetirizine hcl tab 10 mg ......52 Ra Col-rite
see docusate sodium cap 50 mg ............................................ 124
Ra Ear Drying Agent see isopropyl alcohol-glycerin otic liquid 95-5%........................145
Ra Glycerin Child see glycerin suppos 80.7% ..... 123
Ra Hemorrhoidal see pramox-pe-glycerinpetrolatum perianal cream 10.25-14.4-15% ......................17
Ra Hydrocortisone Plus 12 see hydrocortisone cream 1%. 101
Ra Ibuprofen see ibuprofen tab 200 mg .......... 8
Ra Laxative see polyethylene glycol 3350 oral packet 17 gm ....................... 123 see polyethylene glycol 3350 oral powder 17 gm/scoop...........123
Ra Laxative Maximum Stren see sennosides tab 25 mg ....... 124
RA LICE KIT SOLUTION ................. 103 Ra Lubricant Eye Drops
see propylene glycol-glycerin ophth soln 1-0.3% ............... 142
Ra Melatonin see melatonin-pyridoxine tab 3-2 mg .......................................... 6
Ra Mucus Relief D see pseudoephedrine-guaifenesin tab er 12hr 60-600 mg...........95
RA OYS SHL/D TAB 500MG ............ 131 Ra Oyster Shell Calcium/v
see calcium carbonate-vitamin d tab 250 mg-125 unit ............ 130
RA PRENATAL TAB FORMULA ......... 138 Ra Slow Release Iron
see ferrous sulfate tab er 47.5 mg (elemental fe)......................120
Ra Tioconazole 1 see tioconazole vaginal oint 6.5% ............................................ 159
rabeprazole sodium ec tab 20 mg ............................................... 155
raloxifene hcl tab 60 mg............ 107 raltegravir potassium
see ISENTRESS CHW 100MG ........80 see ISENTRESS CHW 25MG ..........80 see ISENTRESS HD TAB 600MG ....80 see ISENTRESS POW 100MG.........80 see ISENTRESS TAB 400MG..........80 ramelteon see ROZEREM TAB 8MG ............. 122 ramelteon tab 8 mg ................... 122 ramipril cap 1.25 mg ...................58 ramipril cap 10 mg ......................58 ramipril cap 2.5 mg .....................58 ramipril cap 5 mg ........................58 ranitidine hcl tab 150 mg .......... 154 ranitidine hcl tab 300 mg .......... 154 ranitidine hcl tab 75 mg ............ 154 ranolazine tab er 12hr 1000 mg ..20 ranolazine tab er 12hr 500 mg ....20 RAPAMUNE SOL 1MG/ML ............... 134 rasagiline mesylate tab 0.5 mg (base equiv) .............................72 rasagiline mesylate tab 1 mg (base equiv) ....................................... 72 RECOMBINATE INJ ....................... 116 RECOMBINATE INJ 220-400........... 116 RECOMBINATE INJ 401-800........... 116 RECOMBINATE INJ 801-1240 ......... 116 RECOMBIVA HB INJ 10MCG/ML ...... 158 RECOMBIVA HB INJ 5MCG/0.5 ....... 158 RECTIV OIN 0.4% ..........................18 Regenecare Ha see lidocaine hcl gel 2% ......... 102 regorafenib see STIVARGA TAB 40MG .............69 REGRANEX GEL 0.01% ................. 103 Reguloid see psyllium cap 400 mg ......... 122 RELENZA MIS DISKHALE .................83 RELION KETON TES ...................... 103 RELISTOR INJ 12/0.6ML................ 111 RELISTOR TAB 150MG .................. 112 REMICADE INJ 100MG .................. 111 REMODULIN INJ 10MG/ML...............88 REMODULIN INJ 1MG/ML ................88 REMODULIN INJ 2.5MG/ML..............88 REMODULIN INJ 5MG/ML ................88
229
Rena-vite see b-complex w/ c & folic acid tab 0.8 mg ........................... 135
RENFLEXIS INJ 100MG .................. 111 repaglinide tab 0.5 mg ................48 repaglinide tab 1 mg ...................48 repaglinide tab 2 mg ...................48 REPATHA INJ 140MG/ML .................57 REPATHA PUSH INJ 420/3.5 ............57 REPATHA SURE INJ 140MG/ML.........57 RESCRIPTOR TAB 200MG ................81 respiratory therapy supplies
see PULMONEB LT MIS NEBULIZE 128 RESTASIS EMU 0.05% .................. 143 RETACRIT INJ 10000UNT .............. 119 RETACRIT INJ 2000UNIT ............... 119 RETACRIT INJ 3000UNIT ............... 119 RETACRIT INJ 40000UNT .............. 119 RETACRIT INJ 4000UNIT ............... 119 retapamulin
see ALTABAX OIN 1% ..................97 REVLIMID CAP 10MG .................... 133 REVLIMID CAP 15MG .................... 133 REVLIMID CAP 2.5MG ................... 133 REVLIMID CAP 20MG .................... 133 REVLIMID CAP 25MG .................... 133 REVLIMID CAP 5MG ...................... 133 rho d immune globulin (human)
see RHOGAM PLUS INJ 300MCG .. 146 RHOGAM PLUS INJ 300MCG...........146 Ribasphere
see ribavirin cap 200 mg ...........82 ribavirin cap 200 mg ...................82 ribavirin tab 200 mg....................82 ribociclib succinate
see KISQALI TAB 200DOSE...........68 see KISQALI TAB 400DOSE...........68 see KISQALI TAB 600DOSE...........68 ribociclib succinate-letrozole see KISQALI 200 PAK FEMARA ......67 see KISQALI 400 PAK FEMARA ......67 see KISQALI 600 PAK FEMARA ......67 riboflavin tab 100 mg ................ 161 RIDAURA CAP 3MG .......................... 7 rifabutin cap 150 mg ...................65 rifampin cap 150 mg ...................65 rifampin cap 300 mg ...................65
rifapentine see PRIFTIN TAB 150MG ..............65
RIFATER TAB .................................65 rifaximin
see XIFAXAN TAB 200MG .............19 see XIFAXAN TAB 550MG .............19 rilonacept see ARCALYST INJ 220MG ............. 7 rilpivirine hcl see EDURANT TAB 25MG ..............80 riluzole tab 50 mg ..................... 141 rimantadine hydrochloride tab 100 mg ............................................83 RINVOQ TAB 15MG ER ..................... 7 riociguat see ADEMPAS TAB 0.5MG .............89 see ADEMPAS TAB 1.5MG .............89 see ADEMPAS TAB 1MG................89 see ADEMPAS TAB 2.5MG .............89 see ADEMPAS TAB 2MG................89 RISACAL-D TAB ........................... 131 risankizumab-rzaa see SKYRIZI INJ 150DOSE............99 risedronate sodium tab 150 mg 106 risedronate sodium tab 30 mg .. 106 risedronate sodium tab 35 mg .. 106 risedronate sodium tab 5 mg .... 106 RISPERDAL INJ 12.5MG ..................74 RISPERDAL INJ 25MG .....................74 RISPERDAL INJ 37.5MG ..................74 RISPERDAL INJ 50MG .....................74 risperidone microspheres see RISPERDAL INJ 12.5MG..........74 see RISPERDAL INJ 25MG.............74 see RISPERDAL INJ 37.5MG..........74 see RISPERDAL INJ 50MG.............74 risperidone orally disintegrating tab 0.25 mg ..............................74 risperidone orally disintegrating tab 0.5 mg ................................74 risperidone orally disintegrating tab 1 mg ...................................74 risperidone orally disintegrating tab 2 mg ...................................74 risperidone orally disintegrating tab 3 mg ...................................74
230
risperidone orally disintegrating tab 4 mg ...................................74
risperidone soln 1 mg/ml ............74 risperidone tab 0.25 mg ..............74 risperidone tab 0.5 mg ................74 risperidone tab 1 mg ...................74 risperidone tab 2 mg ...................74 risperidone tab 3 mg ...................75 risperidone tab 4 mg ...................75 ritonavir
see NORVIR SOL 80MG/ML ...........80 ritonavir tab 100 mg ...................81 RITUXAN INJ 100MG.......................66 RITUXAN INJ 500MG.......................66 rituximab
see RITUXAN INJ 100MG ..............66 see RITUXAN INJ 500MG ..............66 rituximab-abbs see TRUXIMA INJ 100/10ML..........66 see TRUXIMA INJ 500/50ML..........66 rituximab-pvvr see RUXIENCE INJ 100/10ML ........66 see RUXIENCE INJ 500/50ML ........66 rivaroxaban see XARELTO STAR TAB 15/20MG .29 see XARELTO TAB 10MG...............29 see XARELTO TAB 15MG...............29 see XARELTO TAB 2.5MG..............29 see XARELTO TAB 20MG...............29 rivastigmine tartrate cap 1.5 mg (base equivalent) ................... 149 rivastigmine tartrate cap 3 mg (base equivalent) ................... 149 rivastigmine tartrate cap 4.5 mg (base equivalent) ................... 149 rivastigmine tartrate cap 6 mg (base equivalent) ................... 149 rivastigmine td patch 24hr 13.3 mg/24hr ................................. 149 rivastigmine td patch 24hr 4.6 mg/24hr ................................. 149 rivastigmine td patch 24hr 9.5 mg/24hr ................................. 149 Rivelsa see levonor-eth est tab 0.15-
0.02/0.025/0.03 mg ð est 0.01 mg .................................91
RIXUBIS INJ 1000UNIT ................. 116 RIXUBIS INJ 2000UNIT ................. 116 RIXUBIS INJ 250 UNIT .................. 116 RIXUBIS INJ 3000UNIT ................. 116 RIXUBIS INJ 500UNIT ................... 116 rizatriptan benzoate oral
disintegrating tab 10 mg (base eq) ......................................... 129 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) ............................................... 128 rizatriptan benzoate tab 10 mg (base equivalent) ................... 129 rizatriptan benzoate tab 5 mg (base equivalent) ................... 129 Robafen see guaifenesin syrup 100
mg/5ml .................................95 ROBITUSSIN SYP 7.5/5ML ...............94 roflumilast
see DALIRESP TAB 250MCG..........24 see DALIRESP TAB 500MCG..........24 ropinirole hydrochloride tab 0.25 mg ............................................71 ropinirole hydrochloride tab 0.5 mg ................................................. 71 ropinirole hydrochloride tab 1 mg ................................................. 71 ropinirole hydrochloride tab 2 mg ................................................. 72 ropinirole hydrochloride tab 3 mg ................................................. 72 ropinirole hydrochloride tab 4 mg ................................................. 72 ropinirole hydrochloride tab 5 mg ................................................. 72 rosiglitazone maleate see AVANDIA TAB 2MG ................47 see AVANDIA TAB 4MG ................48 rosuvastatin calcium tab 10 mg ..56 rosuvastatin calcium tab 20 mg ..56 rosuvastatin calcium tab 40 mg ..56 rosuvastatin calcium tab 5 mg ....56 rotigotine see NEUPRO DIS 1MG/24HR .........71 see NEUPRO DIS 2MG/24HR .........71 see NEUPRO DIS 3MG/24HR .........71
231
see NEUPRO DIS 4MG/24HR .........71 see NEUPRO DIS 6MG/24HR .........71 see NEUPRO DIS 8MG/24HR .........71 ROZEREM TAB 8MG ...................... 122 RUBRACA TAB 200MG .....................69 RUBRACA TAB 250MG .....................69 RUBRACA TAB 300MG .....................69 rucaparib camsylate see RUBRACA TAB 200MG ............69 see RUBRACA TAB 250MG ............69 see RUBRACA TAB 300MG ............69 rufinamide see BANZEL SUS 40MG/ML ...........31 see BANZEL TAB 200MG...............31 see BANZEL TAB 400MG...............31 RUXIENCE INJ 100/10ML.................66 RUXIENCE INJ 500/50ML.................66 ruxolitinib phosphate see JAKAFI TAB 10MG ..................68 see JAKAFI TAB 15MG ..................68 see JAKAFI TAB 20MG ..................68 see JAKAFI TAB 25MG ..................68 see JAKAFI TAB 5MG....................68 RYBELSUS TAB 14MG .....................44 RYBELSUS TAB 3MG .......................44 RYBELSUS TAB 7MG .......................44 Ryclora see dexchlorpheniramine maleate
oral soln 2 mg/5ml ................52 S
sacubitril-valsartan see ENTRESTO TAB 24-26MG........87 see ENTRESTO TAB 49-51MG........88 see ENTRESTO TAB 97-103MG ......88
saline nasal spray 0.65% .......... 139 salmeterol xinafoate
see SEREVENT DIS AER 50MCG.....28 salsalate tab 500 mg ...................12 salsalate tab 750 mg ...................12 SAMSCA TAB 15MG ...................... 108 SAMSCA TAB 30MG ...................... 108 SANDIMMUNE CAP 100MG.............134 SANDIMMUNE CAP 25MG .............. 134 SANDOSTATIN KIT LAR 10MG ........ 108 SANDOSTATIN KIT LAR 20MG ........ 108 SANDOSTATIN KIT LAR 30MG ........ 108 SANTYL OIN 250/GM .................... 102
SAPHRIS SUB 10MG .......................77 SAPHRIS SUB 2.5MG ......................77 SAPHRIS SUB 5MG .........................77 sapropterin dihydrochloride
see KUVAN TAB 100MG .............. 107 saquinavir mesylate
see INVIRASE TAB 500MG ............80 sargramostim
see LEUKINE INJ 250MCG........... 118 sarilumab
see KEVZARA INJ 150/1.14 ........... 7 see KEVZARA INJ 200/1.14 ........... 8 SAVELLA MIS TITR PAK................. 149 SAVELLA TAB 100MG .................... 149 SAVELLA TAB 12.5MG ................... 149 SAVELLA TAB 25MG...................... 149 SAVELLA TAB 50MG...................... 149 Sb Fib Lax Orange see psyllium powder 33% ....... 122 Sb Lice Treatment see pyrethrins-piperonyl butoxide
liq 0.3-3% ........................... 103 scopolamine td patch 72hr 1
mg/3days ................................. 50 secukinumab
see COSENTYX INJ 150MG/ML ......99 see COSENTYX INJ 300DOSE ........99 see COSENTYX PEN INJ 150MG/ML 99 see COSENTYX PEN INJ 300DOSE..99 selegiline see EMSAM DIS 12MG/24H...........34 see EMSAM DIS 6MG/24HR...........34 see EMSAM DIS 9MG/24HR...........34 selegiline hcl cap 5 mg ................72 selegiline hcl tab 5 mg ................72 selenium sulfide lotion 1%..........99 selenium sulfide lotion 2.5%.......99 selexipag see UPTRAVI TAB 1000MCG..........89 see UPTRAVI TAB 1200MCG..........89 see UPTRAVI TAB 1400MCG..........89 see UPTRAVI TAB 1600MCG..........89 see UPTRAVI TAB 200/800 ...........89 see UPTRAVI TAB 200MCG ...........89 see UPTRAVI TAB 400MCG ...........89 see UPTRAVI TAB 600MCG ...........89 see UPTRAVI TAB 800MCG ...........89
232
SELZENTRY SOL 20MG/ML...............81 SELZENTRY TAB 150MG ..................81 SELZENTRY TAB 25MG ....................81 SELZENTRY TAB 300MG ..................81 SELZENTRY TAB 75MG ....................81 semaglutide
see OZEMPIC INJ 2/1.5ML ............44 see RYBELSUS TAB 14MG .............44 see RYBELSUS TAB 3MG...............44 see RYBELSUS TAB 7MG...............44 SE-NATAL 19 CHW ....................... 138 sennosides chew tab 15 mg ...... 124 sennosides syrup 8.8 mg/5ml ... 124 sennosides tab 25 mg ............... 124 sennosides tab 8.6 mg .............. 124 sennosides-docusate sodium see MEDI-LAXX CAP 8.6-50MG .... 123 sennosides-docusate sodium tab 8.6-50 mg ............................... 123 SENSIPAR TAB 30MG .................... 108 SENSIPAR TAB 60MG .................... 108 SENSIPAR TAB 90MG .................... 108 SEREVENT DIS AER 50MCG .............28 sertaconazole nitrate see ERTACZO CRE 2% .................98 sertraline hcl oral concentrate for solution 20 mg/ml....................35 sertraline hcl tab 100 mg ............35 sertraline hcl tab 25 mg ..............35 sertraline hcl tab 50 mg ..............35 sevelamer carbonate packet 0.8 gm .......................................... 112 sevelamer carbonate packet 2.4 gm .......................................... 112 sevelamer carbonate tab 800 mg ............................................... 112 Sf see sodium fluoride gel 1.1%
(0.5% f) .............................. 135 Sf 5000 Plus
see sodium fluoride cream 1.1% ............................................ 135
SHINGRIX INJ 50/0.5ML................158 SHUR-SEAL GEL 2% ..................... 159 Silace
see docusate sodium liquid 150 mg/15ml ............................. 124
see docusate sodium syrup 60 mg/15ml ............................. 124
sildenafil citrate tab 20 mg .........89 SILENOR TAB 3MG ....................... 121 SILENOR TAB 6MG ....................... 121 silodosin cap 4 mg .................... 113 silodosin cap 8 mg .................... 113 Siltussin-dm
see dextromethorphanguaifenesin syrup 10-100 mg/5ml .................................95
silver sulfadiazine cream 1% ......99 SIMBRINZA SUS 1-0.2% ............... 143 simethicone cap 125 mg ........... 110 simethicone cap 180 mg ........... 110 simethicone chew tab 125 mg ... 110 simethicone chew tab 80 mg..... 110 simethicone liquid 40 mg/0.6ml 110 simethicone susp 40 mg/0.6ml . 110 SIMPONI INJ 100MG/ML................... 7 SIMPONI INJ 50/0.5ML .................... 7 simvastatin tab 10 mg.................56 simvastatin tab 20 mg.................56 simvastatin tab 40 mg.................56 simvastatin tab 5 mg...................56 simvastatin tab 80 mg.................56 sinecatechins
see VEREGEN OIN 15%................97 siponimod fumarate
see MAYZENT TAB 0.25MG ......... 150 sirolimus
see RAPAMUNE SOL 1MG/ML ...... 134 sirolimus oral soln 1 mg/ml ...... 134 sirolimus tab 0.5 mg ................. 134 sirolimus tab 1 mg .................... 134 sirolimus tab 2 mg .................... 134 SIRTURO TAB 100MG .....................65 sitagliptin phosphate
see JANUVIA TAB 100MG .............44 see JANUVIA TAB 25MG ...............43 see JANUVIA TAB 50MG ...............44 sitagliptin-metformin hcl see JANUMET TAB 50-1000...........40 see JANUMET TAB 50-500MG ........40 see JANUMET XR TAB 100-1000 ....40 see JANUMET XR TAB 50-1000......40 see JANUMET XR TAB 50-500MG ...40
233
skin protectants misc - cream ... 103 SKLICE LOT 0.5% ........................ 103 SKYLA IUD 13.5MG.........................93 SKYRIZI INJ 150DOSE ....................99 Sleep Aid
see doxylamine succinate (sleep) tab 25 mg ............................ 120
SLOW FE TAB 45MG ..................... 120 Slow Iron
see ferrous sulfate dried tab er 160 mg (50 mg fe equivalent) ............................................ 120
Slow Release Iron see ferrous sulfate tab er 50 mg (elemental fe)......................120
Slow-release Iron see ferrous sulfate dried tab er 45 mg (fe equivalent) ............... 120
Sm Acid Reducer see ranitidine hcl tab 75 mg .... 154
Sm Anti-itch Extra Streng see diphenhydramine-zinc acetate cream 2-0.1% ...........98
Sm Artificial Tears see artificial tear ophth solution ............................................ 141
Sm Aspirin see aspirin tab 325 mg..............12
Sm Bedding Lice Treatment see permethrin aerosol 0.5% .. 103
Sm Calcium 600 + D Plus M see calcium carb-vit d w/ minerals chew tab 600 mg-800 unit ...................................... 130
Sm Chest Congestion Relie see guaifenesin tab 400 mg ......95
Sm Esomeprazole Magnesium see esomeprazole magnesium cap delayed release 20 mg (base eq) ....................................... 155
Sm Foaming Antacid see aluminum hydroxidemagnesium trisilicate chew tab 80-20 mg ...............................18
Sm Ibuprofen Ib see ibuprofen chew tab 100 mg . 8
Sm Lice Treatment
see permethrin lotion 1% ....... 103 Sm Miconazole 3
see miconazole nitrate vaginal app 200 mg & 2% cream 9 gm kit ........................................ 159
SM ONE DAILY MIS PRENATAL ....... 138 Sm Pain Reliever Extra St
see acetaminophen cap 500 mg 11 Sm Stomach Relief
see bismuth subsalicylate tab 262 mg .........................................49
sodium bicarbonate tab 325 mg ..18 sodium bicarbonate tab 650 mg ..18 sodium chloride hypertonic ophth
oint 5% .................................. 144 sodium chloride hypertonic ophth
soln 5% .................................. 144 sodium chloride irrigation soln
0.9% ...................................... 112 sodium chloride soln nebu 0.9% .95 sodium chloride soln nebu 3% ....95 sodium chloride soln nebu 7% ....95 sodium chloride tab 1 gm .......... 133 sodium citrate & citric acid soln
500-334 mg/5ml .................... 112 sodium fluoride
see FLUORABON DRO ................ 131 sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf)................. 131 sodium fluoride chew tab 0.5 mg f
(from 1.1 mg naf)................... 131 sodium fluoride chew tab 1 mg f
(from 2.2 mg naf)................... 132 sodium fluoride cream 1.1% ..... 135 sodium fluoride gel 1.1% (0.5% f)
............................................... 135 sodium fluoride soln 0.125
mg/drop f (0.275 mg/drop naf) ............................................... 132 sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) ..... 132 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) ............. 132 sodium fluoride tab 0.5 mg f (from 1.1 mg naf) ............................ 132 sodium hyaluronate (viscosupplement)
234
see EUFLEXXA INJ 10MG/ML ....... 139 see VISCO-3 INJ 25/2.5ML ......... 139 sodium oxybate see XYREM SOL 500MG/ML ......... 148 sodium phenylbutyrate tab 500 mg ............................................... 108 sodium phosphate monobasicsodium phosphate dibasic see OSMOPREP TAB 1.5GM ......... 123 sodium phosphates - enema......123 sodium picosulfate-magnesium oxide-anhydrous citric acid see CLENPIQ SOL ...................... 122 see PREPOPIK PAK.....................123 sodium polystyrene sulfonate oral susp 15 gm/60ml ................... 134 sodium polystyrene sulfonate powder ................................... 134 sodium sulfate-potassium sulfatemagnesium sulfate see SUPREP BOWEL SOL PREP KIT
............................................ 123 SOFOS/VELPAT TAB 400-100...........82 sofosbuvir
see SOVALDI TAB 400MG .............82 sofosbuvir-velpatasvir-voxilaprevir
see VOSEVI TAB ..........................82 solifenacin succinate
see VESICARE TAB 10MG ........... 157 see VESICARE TAB 5MG ............. 157 solifenacin succinate tab 10 mg 157 solifenacin succinate tab 5 mg .. 157 somatropin see OMNITROPE INJ 10/1.5ML .... 107 see OMNITROPE INJ 5.8MG.........107 see OMNITROPE INJ 5/1.5ML ...... 107 SOMAVERT INJ 10MG ................... 106 SOMAVERT INJ 15MG ................... 107 SOMAVERT INJ 20MG ................... 107 sonidegib phosphate see ODOMZO CAP 200MG .............66 sorafenib tosylate see NEXAVAR TAB 200MG ............69 sotalol hcl (afib/afl) tab 120 mg .85 sotalol hcl (afib/afl) tab 160 mg .85 sotalol hcl (afib/afl) tab 80 mg ...85 sotalol hcl tab 120 mg .................85
sotalol hcl tab 160 mg .................85 sotalol hcl tab 240 mg .................85 sotalol hcl tab 80 mg...................85 SOVALDI TAB 400MG .....................82 spacer/aerosol-holding chambers
see INSPIRACHAMB MIS LARGE .. 128 spinosad susp 0.9% .................. 103 spironolactone &
hydrochlorothiazide see ALDACTAZIDE TAB 50/50 ..... 104 spironolactone & hydrochlorothiazide tab 25-25 mg .......................................... 105 spironolactone tab 100 mg........ 105 spironolactone tab 25 mg.......... 105 spironolactone tab 50 mg.......... 105 SPRYCEL TAB 100MG ......................69 SPRYCEL TAB 140MG ......................69 SPRYCEL TAB 20MG........................69 SPRYCEL TAB 50MG........................69 SPRYCEL TAB 70MG........................69 SPRYCEL TAB 80MG........................69 St Joseph Low Dose Aspiri see aspirin chew tab 81 mg ......12 stavudine cap 15 mg ...................81 stavudine cap 20 mg ...................81 stavudine cap 30 mg ...................81 stavudine cap 40 mg ...................81 STELARA INJ 45MG/0.5...................99 STELARA INJ 5MG/ML ................... 111 STELARA INJ 90MG/ML ...................99 STIMATE SOL 1.5MG/ML ............... 108 Stimulant Laxative see bisacodyl tab delayed release
5 mg .................................... 123 STIOLTO AER 2.5-2.5 .....................28 stiripentol
see DIACOMIT CAP 250MG ...........31 see DIACOMIT CAP 500MG ...........31 see DIACOMIT PAK 250MG ...........31 see DIACOMIT PAK 500MG ...........31 STIVARGA TAB 40MG .....................69 Stool Softener see docusate calcium cap 240 mg
............................................ 124 see docusate sodium cap 100 mg
............................................ 124
235
Stop Lice Complete Lice T see pyreth-piperonyl butox shampermeth aero-nit remover gel kit ........................................ 103
Stop Lice Maximum Strengt see pyrethrins-piperonyl butoxide liq 0.33-4%.......................... 103
Stress Formula W/iron see multiple vitamins w/ iron tab ............................................ 135
STRIBILD TAB................................81 STRIVERDI AER 2.5MCG .................28 succimer
see CHEMET CAP 100MG ..............50 sucralfate tab 1 gm ................... 154 sucroferric oxyhydroxide
see VELPHORO CHW 500MG ....... 112 SUDAFED PE SOL CHILDREN.......... 141 sulconazole nitrate
see EXELDERM CRE 1%................98 see EXELDERM SOL 1%................98 sulconazole nitrate cream 1%.....98 sulfacetamide sodium lotion 10% (acne)....................................... 96 sulfacetamide sodium ophth soln 10% ....................................... 143 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%....144 sulfacetamide sodium-sulfur in urea emulsion 10-4% ...............96 SULFADIAZINE TAB 500MG ........... 151 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml ................19 sulfamethoxazole-trimethoprim tab 400-80 mg ................................19 sulfamethoxazole-trimethoprim tab 800-160 mg ..............................19 SULFAMYLON CRE 85MG/GM ...........99 sulfasalazine tab 500 mg...........111 sulfasalazine tab delayed release 500 mg ................................... 111 sulindac tab 150 mg ..................... 9 sulindac tab 200 mg ....................10 sumatriptan succinate inj 6 mg/0.5ml ............................... 129 sumatriptan succinate tab 100 mg ............................................... 129
sumatriptan succinate tab 25 mg ............................................... 129
sumatriptan succinate tab 50 mg ............................................... 129
sunitinib malate see SUTENT CAP 12.5MG..............69 see SUTENT CAP 25MG ................69 see SUTENT CAP 37.5MG..............69 see SUTENT CAP 50MG ................69
SUPRAX CAP 400MG .......................91 SUPREP BOWEL SOL PREP KIT ....... 123 SUTENT CAP 12.5MG ......................69 SUTENT CAP 25MG .........................69 SUTENT CAP 37.5MG ......................69 SUTENT CAP 50MG .........................69 suvorexant
see BELSOMRA TAB 10MG .......... 122 see BELSOMRA TAB 15MG .......... 122 see BELSOMRA TAB 20MG .......... 122 see BELSOMRA TAB 5MG ............ 122 SYMBICORT AER 160-4.5 ................28 SYMBICORT AER 80-4.5 ..................28 SYMFI LO TAB................................81 SYMFI TAB ....................................81 SYMJEPI INJ 0.15MG .................... 160 SYMJEPI INJ 0.3MG ...................... 160 SYMLINPEN 60 INJ 1000MCG...........39 SYMLNPEN 120 INJ 1000MCG ..........39 SYMPROIC TAB 0.2MG .................. 112 SYMTUZA TAB................................81 SYNAGIS INJ 100MG/ML ............... 146 SYNAGIS INJ 50MG ...................... 146 SYNAREL SOL 2MG/ML.................. 107 SYNERA DIS 70-70MG .................. 102 SYNJARDY TAB ..............................41 SYNJARDY TAB 12.5-500.................41 SYNJARDY TAB 5-1000MG ...............41 SYNJARDY TAB 5-500MG.................41 SYNJARDY XR TAB..........................41 SYNJARDY XR TAB 10-1000.............42 SYNJARDY XR TAB 25-1000.............42 SYNJARDY XR TAB 5-1000MG ..........42 SYNTHROID TAB 100MCG ............. 153 SYNTHROID TAB 112MCG ............. 153 SYNTHROID TAB 125MCG ............. 153 SYNTHROID TAB 137MCG ............. 153 SYNTHROID TAB 150MCG ............. 153
236
SYNTHROID TAB 175MCG.............. 153 SYNTHROID TAB 200MCG.............. 153 SYNTHROID TAB 25MCG ............... 152 SYNTHROID TAB 300MCG.............. 153 SYNTHROID TAB 50MCG ............... 152 SYNTHROID TAB 75MCG ............... 153 SYNTHROID TAB 88MCG ............... 153 syringe (disposable)
see 3ML SYRINGE MIS REG TIP ... 127 T
TABLOID TAB 40MG........................66 TACLONEX SUS ............................ 102 tacrolimus cap 0.5 mg ............... 134 tacrolimus cap 1 mg .................. 134 tacrolimus cap 5 mg .................. 134 tacrolimus oint 0.03%...............102 tacrolimus oint 0.1%.................102 tadalafil tab 20 mg (pah) ............89 TAFINLAR CAP 50MG ......................69 TAFINLAR CAP 75MG ......................69 tafluprost
see ZIOPTAN DRO 0.0015% ....... 145 TAGRISSO TAB 40MG .....................69 TAGRISSO TAB 80MG .....................69 TAKHZYRO INJ 300/2ML................117 tamoxifen citrate tab 10 mg (base
equivalent) ...............................67 tamoxifen citrate tab 20 mg (base
equivalent) ...............................67 tamsulosin hcl cap 0.4 mg ......... 113 tapentadol hcl
see NUCYNTA ER TAB 100MG........14 see NUCYNTA ER TAB 150MG........14 see NUCYNTA ER TAB 200MG........14 see NUCYNTA ER TAB 250MG........14 see NUCYNTA ER TAB 50MG..........14 see NUCYNTA TAB 100MG ............14 see NUCYNTA TAB 50MG ..............14 see NUCYNTA TAB 75MG ..............14 TARCEVA TAB 100MG .....................69 TARCEVA TAB 150MG .....................69 TARCEVA TAB 25MG .......................69 TARGRETIN GEL 1% .......................99 TASIGNA CAP 150MG......................69 TASIGNA CAP 200MG......................69 TASIGNA CAP 50MG .......................69 tasimelteon
see HETLIOZ CAP 20MG ............. 122 TAYTULLA CAP 1MG/20MC...............92 tazarotene
see TAZORAC CRE 0.05%.............99 see TAZORAC GEL 0.05% .............99 see TAZORAC GEL 0.1%...............99 tazarotene cream 0.1%...............99 TAZORAC CRE 0.05% .....................99 TAZORAC GEL 0.05% .....................99 TAZORAC GEL 0.1% .......................99 TDVAX INJ 2-2 LF......................... 153 TECFIDERA CAP 120MG ................ 150 TECFIDERA CAP 240MG ................ 150 TECFIDERA MIS STARTER ............. 150 TECHNIVIE TAB .............................82 telmisartan tab 20 mg .................60 telmisartan tab 40 mg .................60 telmisartan tab 80 mg .................60 temazepam cap 15 mg .............. 121 temazepam cap 30 mg .............. 121 temozolomide cap 100 mg ..........65 temozolomide cap 140 mg ..........65 temozolomide cap 180 mg ..........65 temozolomide cap 20 mg ............65 temozolomide cap 250 mg ..........65 temozolomide cap 5 mg ..............65 TENIVAC INJ 5-2LF....................... 153 tenofovir disoproxil fumarate see VIREAD TAB 150MG ...............82 see VIREAD TAB 200MG ...............82 see VIREAD TAB 250MG ...............82 tenofovir disoproxil fumarate tab 300 mg .....................................81 terazosin hcl cap 1 mg (base equivalent) ...............................61 terazosin hcl cap 10 mg (base equivalent) ...............................62 terazosin hcl cap 2 mg (base equivalent) ...............................61 terazosin hcl cap 5 mg (base equivalent) ...............................61 terbinafine hcl cream 1%............98 terbinafine hcl tab 250 mg ..........51 terbutaline sulfate tab 2.5 mg .....28 terbutaline sulfate tab 5 mg ........28 terconazole vaginal cream 0.4% ............................................... 159
237
terconazole vaginal cream 0.8% ............................................... 159
terconazole vaginal suppos 80 mg ............................................... 159
teriflunomide see AUBAGIO TAB 14MG ............ 149 see AUBAGIO TAB 7MG .............. 149
teriparatide (recombinant) see FORTEO SOL 600/2.4 ........... 106
testosterone cypionate im inj in oil 100 mg/ml ...............................17
testosterone cypionate im inj in oil 200 mg/ml ...............................17
testosterone enanthate im inj in oil 200 mg/ml ...............................17
tetanus toxoid-diphtheria-acellular pertussis adsorb (tdap) see ADACEL INJ ........................ 153 see BOOSTRIX INJ.....................153
tetanus-diphtheria toxoids (td) see TDVAX INJ 2-2 LF ................ 153 see TENIVAC INJ 5-2LF .............. 153
tetrabenazine tab 12.5 mg ........ 149 tetrabenazine tab 25 mg ........... 149 tetracycline hcl cap 250 mg.......151 tetracycline hcl cap 500 mg.......151 Tgt Antacid Extra Strengt
see calcium carbonate-mag hydroxide chew tab 675-135 mg .........................................18
TGT GLUCOSE CHW GRAPE .............43 thalidomide
see THALOMID CAP 100MG ......... 133 see THALOMID CAP 150MG ......... 133 see THALOMID CAP 200MG ......... 133 see THALOMID CAP 50MG...........133 THALOMID CAP 100MG ................. 133 THALOMID CAP 150MG ................. 133 THALOMID CAP 200MG ................. 133 THALOMID CAP 50MG ................... 133 theophylline soln 80 mg/15ml ....28 theophylline tab er 12hr 100 mg .28 theophylline tab er 12hr 200 mg .28 theophylline tab er 12hr 300 mg .28 theophylline tab er 12hr 450 mg .28 theophylline tab er 24hr 400 mg .28 theophylline tab er 24hr 600 mg .28
THERANATAL MIS COMPLETE......... 138 thiamine hcl tab 100 mg............ 161 thiamine hcl tab 250 mg............ 161 thiamine hcl tab 50 mg ............. 161 thioguanine
see TABLOID TAB 40MG ...............66 thioridazine hcl tab 10 mg...........78 thioridazine hcl tab 100 mg.........78 thioridazine hcl tab 25 mg...........78 thioridazine hcl tab 50 mg...........78 thiothixene cap 1 mg...................79 thiothixene cap 10 mg.................79 thiothixene cap 2 mg...................79 thiothixene cap 5 mg...................79 THYROGEN INJ 1.1MG .................. 103 thyroid
see ARMOUR THYRO TAB 120MG . 152 see ARMOUR THYRO TAB 15MG... 152 see ARMOUR THYRO TAB 180MG . 152 see ARMOUR THYRO TAB 240MG . 152 see ARMOUR THYRO TAB 300MG . 152 see ARMOUR THYRO TAB 30MG... 152 see ARMOUR THYRO TAB 60MG... 152 see ARMOUR THYRO TAB 90MG... 152 see NATURE THROI TAB 162.5MG 152 see NATURE-THROI TAB 113.75MG
............................................ 152 see NATURE-THROI TAB 130MG .. 152 see NATURE-THROI TAB 146.25MG
............................................ 152 see NATURE-THROI TAB 16.25MG152 see NATURE-THROI TAB 195MG .. 152 see NATURE-THROI TAB 260MG .. 152 see NATURE-THROI TAB 32.5MG . 152 see NATURE-THROI TAB 325MG .. 152 see NATURE-THROI TAB 48.75MG152 see NATURE-THROI TAB 65MG.... 152 see NATURE-THROI TAB 97.5MG . 152 see WP THYROID TAB 81.25MG... 153 thyroid tab 120 mg (2 grain)..... 153 thyroid tab 15 mg (1/4 grain)... 153 thyroid tab 30 mg (1/2 grain)... 153 thyroid tab 60 mg (1 grain)....... 153 thyroid tab 90 mg (1 1/2 grain) 153 THYROLAR-1 TAB 60MG ................ 153 THYROLAR-1/2 TAB 30MG ............. 153 THYROLAR-1/4 TAB 15MG ............. 153
238
THYROLAR-2 TAB 120MG .............. 153 THYROLAR-3 TAB 180MG .............. 153 thyrotropin alfa
see THYROGEN INJ 1.1MG .......... 103 tiagabine hcl tab 12 mg ...............33 tiagabine hcl tab 16 mg ...............33 tiagabine hcl tab 2 mg.................33 tiagabine hcl tab 4 mg.................33 ticagrelor
see BRILINTA TAB 60MG ............ 117 see BRILINTA TAB 90MG ............ 117 Tilia Fe see norethindrone ac-ethinyl
estrad-fe tab 1-20/1-30/1-35 mg-mcg .................................92 timolol maleate ophth gel forming soln 0.25% ............................. 142 timolol maleate ophth gel forming soln 0.5% ............................... 142 timolol maleate ophth soln 0.25% ............................................... 142 timolol maleate ophth soln 0.5% ............................................... 142 timolol maleate tab 10 mg...........85 timolol maleate tab 20 mg...........85 timolol maleate tab 5 mg ............85 tioconazole vaginal oint 6.5% ... 159 tiotropium bromide-olodaterol hcl see STIOLTO AER 2.5-2.5 .............28 tipranavir see APTIVUS CAP 250MG..............79 see APTIVUS SOL ........................79 TIVICAY PD TAB 5MG......................81 TIVICAY TAB 10MG.........................81 TIVICAY TAB 25MG.........................81 TIVICAY TAB 50MG.........................81 tizanidine hcl tab 2 mg (base equivalent) ............................. 139 tizanidine hcl tab 4 mg (base equivalent) ............................. 139 TL FOLATE TAB ............................ 138 TOBRADEX OIN 0.3-0.1% ............. 144 tobramycin nebu soln 300 mg/5ml .................................................. 6 tobramycin ophth soln 0.3% ..... 143 tobramycin-dexamethasone see TOBRADEX OIN 0.3-0.1% ..... 144
tobramycin-dexamethasone ophth susp 0.3-0.1% ........................ 144
tocilizumab see ACTEMRA INJ 162/0.9 ............. 7 see ACTEMRA INJ 200/10ML .......... 7 see ACTEMRA INJ 400/20ML .......... 7 see ACTEMRA INJ 80MG/4ML ......... 7 see ACTEMRA INJ ACTPEN ............. 7
TODAY SPONGE MIS ..................... 159 tofacitinib citrate
see XELJANZ TAB 10MG ................ 7 see XELJANZ TAB 5MG .................. 7 see XELJANZ XR TAB 11MG ........... 7 see XELJANZ XR TAB 22MG ........... 7 tolazamide tab 250 mg................49 tolazamide tab 500 mg................49 tolbutamide tab 500 mg ..............49 tolcapone tab 100 mg..................70 tolmetin sodium cap 400 mg .......10 tolmetin sodium tab 200 mg .......10 tolmetin sodium tab 600 mg .......10 tolnaftate aerosol pow 1%..........98 tolnaftate cream 1% ...................98 tolnaftate powder 1% .................98 tolnaftate soln 1% ......................98 tolterodine tartrate tab 1 mg .... 157 tolterodine tartrate tab 2 mg .... 157 tolvaptan see SAMSCA TAB 15MG.............. 108 see SAMSCA TAB 30MG.............. 108 tolvaptan tab 30 mg .................. 108 topiramate sprinkle cap 15 mg....32 topiramate sprinkle cap 25 mg....32 topiramate tab 100 mg................32 topiramate tab 200 mg................32 topiramate tab 25 mg..................32 topiramate tab 50 mg..................32 torsemide tab 10 mg ................. 105 torsemide tab 100 mg ............... 105 torsemide tab 20 mg ................. 105 torsemide tab 5 mg ................... 105 TOVIAZ TAB 4MG ......................... 157 TOVIAZ TAB 8MG ......................... 157 TRACLEER TAB 125MG....................89 TRACLEER TAB 32MG......................88 TRACLEER TAB 62.5MG...................88 TRADJENTA TAB 5MG .....................44
239
tramadol hcl tab 50 mg ...............15 tramadol hcl tab er 24hr 100 mg .15 tramadol hcl tab er 24hr 200 mg .15 tramadol hcl tab er 24hr 300 mg .15 tramadol hcl tab er 24hr biphasic
release 100 mg .........................15 tramadol hcl tab er 24hr biphasic
release 200 mg .........................15 tramadol hcl tab er 24hr biphasic
release 300 mg .........................15 trametinib dimethyl sulfoxide
see MEKINIST TAB 0.5MG.............68 see MEKINIST TAB 2MG ...............69 trandolapril tab 1 mg ..................58 trandolapril tab 2 mg ..................58 trandolapril tab 4 mg ..................59 tranexamic acid tab 650 mg ...... 120 tranylcypromine sulfate tab 10 mg ................................................. 34 TRAVATAN Z DRO 0.004% ............ 145 travoprost see TRAVATAN Z DRO 0.004% .... 145 travoprost ophth soln 0.004% (benzalkonium free) (bak free) ............................................... 145 trazodone hcl tab 100 mg............36 trazodone hcl tab 150 mg............36 trazodone hcl tab 50 mg..............36 TRECATOR TAB 250MG ...................65 TRELSTAR MIX INJ 11.25MG............67 TRELSTAR MIX INJ 3.75MG..............67 treprostinil see REMODULIN INJ 10MG/ML ......88 see REMODULIN INJ 1MG/ML ........88 see REMODULIN INJ 2.5MG/ML .....88 see REMODULIN INJ 5MG/ML ........88 treprostinil diolamine see ORENITRAM TAB 0.125MG ......88 see ORENITRAM TAB 0.25MG ........88 see ORENITRAM TAB 1MG ............88 see ORENITRAM TAB 2.5MG..........88 see ORENITRAM TAB 5MG ............88 treprostinil inj soln 100 mg/20ml (5 mg/ml) ................................88 treprostinil inj soln 20 mg/20ml (1 mg/ml) ..................................... 88
treprostinil inj soln 200 mg/20ml (10 mg/ml) ..............................88
treprostinil inj soln 50 mg/20ml (2.5 mg/ml) .............................88
TRESIBA FLEX INJ 100UNIT.............47 TRESIBA FLEX INJ 200UNIT.............47 TRESIBA INJ 100UNIT ....................47 tretinoin cap 10 mg .....................70 tretinoin cream 0.025% ..............97 tretinoin cream 0.05% ................97 tretinoin cream 0.1% ..................96 tretinoin gel 0.01% .....................97 tretinoin gel 0.025% ...................97 triamcinolone acetonide cream
0.025% .................................. 102 triamcinolone acetonide cream
0.1% ...................................... 102 triamcinolone acetonide cream
0.5% ...................................... 102 triamcinolone acetonide dental
paste 0.1% ............................. 135 triamcinolone acetonide lotion
0.025% .................................. 102 triamcinolone acetonide lotion
0.1% ...................................... 102 triamcinolone acetonide nasal
aerosol suspension 55 mcg/act ............................................... 140 triamcinolone acetonide oint 0.025% .................................. 102 triamcinolone acetonide oint 0.1% ............................................... 102 triamcinolone acetonide oint 0.5% ............................................... 102 triamterene see DYRENIUM CAP 100MG......... 105 see DYRENIUM CAP 50MG .......... 105 triamterene & hydrochlorothiazide cap 37.5-25 mg ...................... 105 triamterene & hydrochlorothiazide tab 37.5-25 mg....................... 105 triamterene & hydrochlorothiazide tab 75-50 mg.......................... 105 triamterene cap 100 mg ............ 105 triamterene cap 50 mg .............. 105 triazolam tab 0.125 mg ............. 121 triazolam tab 0.25 mg ............... 121
240
Tricon see fe fumarate w/ b12-vit c-faifc cap 110-0.015-75-0.5-240 mg ....................................... 119
trifluoperazine hcl tab 1 mg (base equivalent) ...............................78
trifluoperazine hcl tab 10 mg (base equivalent) ...............................78
trifluoperazine hcl tab 2 mg (base equivalent) ...............................78
trifluoperazine hcl tab 5 mg (base equivalent) ...............................78
trifluridine ophth soln 1% ......... 143 trifluridine-tipiracil
see LONSURF TAB 15-6.14 ...........67 see LONSURF TAB 20-8.19 ...........67 trihexyphenidyl hcl oral soln 0.4 mg/ml ......................................70 trihexyphenidyl hcl tab 2 mg .......70 trihexyphenidyl hcl tab 5 mg .......70 trimethobenzamide hcl cap 300 mg ................................................. 50 trimethoprim tab 100 mg ............19 trimipramine maleate cap 100 mg ................................................. 38 trimipramine maleate cap 25 mg.38 trimipramine maleate cap 50 mg.38 TRINATAL RX TAB 1......................138 Trinate see prenatal vit w/ fe fumarate-fa
tab 28-1 mg ......................... 138 TRINTELLIX TAB 10MG....................36 TRINTELLIX TAB 20MG....................36 TRINTELLIX TAB 5MG .....................36 Triple Antibiotic Plus
see neomycin-bacitracinpolymyxin-pramoxine oint 1% .............................................. 97
Triple Paste Af see miconazole nitrate ointment 2% ......................................... 98
triptorelin pamoate see TRELSTAR MIX INJ 11.25MG ...67 see TRELSTAR MIX INJ 3.75MG .....67
TRIUMEQ TAB ................................81 TRI-VI-SOL SOL A/C/D.................. 136 Tri-vitamin/fluoride
see pediatric vitamins acd w/ fluoride soln 0.25 mg/ml ..... 136
see pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ....... 136
TROJAN MIS ................................ 125 TROJAN MIS NATULAMB................ 125 tropicamide ophth soln 0.5% .... 142 tropicamide ophth soln 1% ....... 142 trospium chloride cap er 24hr 60
mg .......................................... 157 trospium chloride tab 20 mg ..... 157 TRUE METRIX KIT AIR................... 126 TRUE METRIX TES GLUCOSE ......... 104 TRULICITY INJ 0.75/0.5 ..................44 TRULICITY INJ 1.5/0.5....................45 TRUVADA TAB 100-150...................81 TRUVADA TAB 133-200...................81 TRUVADA TAB 167-250...................81 TRUVADA TAB 200-300...................81 TRUXIMA INJ 100/10ML ..................66 TRUXIMA INJ 500/50ML ..................66 TUDORZA PRES AER 400/ACT ..........24 TWINRIX INJ ............................... 159 TYBOST TAB 150MG .......................81 Tydemy
see drospirenone-ethinyl estradlevomefolate tab 3-0.03-0.451 mg .........................................91
TYKERB TAB 250MG .......................69 TYMLOS INJ................................. 106 TYSABRI INJ 300/15ML ................. 150 U
UDENYCA INJ 6MG/.6ML ............... 119 ulipristal acetate
see ELLA TAB 30MG.....................93 ULORIC TAB 40MG ....................... 113 ULORIC TAB 80MG ....................... 113 umeclidinium bromide
see INCRUSE ELPT INH 62.5MCG ..24 umeclidinium-vilanterol
see ANORO ELLIPT AER 62.5-25....25 UNIFIBER POW ............................ 122 upadacitinib
see RINVOQ TAB 15MG ER ............ 7 UPTRAVI TAB 1000MCG ..................89 UPTRAVI TAB 1200MCG ..................89 UPTRAVI TAB 1400MCG ..................89
241
UPTRAVI TAB 1600MCG ..................89 UPTRAVI TAB 200/800 ....................89 UPTRAVI TAB 200MCG ....................89 UPTRAVI TAB 400MCG ....................89 UPTRAVI TAB 600MCG ....................89 UPTRAVI TAB 800MCG ....................89 ursodiol cap 300 mg .................. 110 ursodiol tab 250 mg .................. 110 ursodiol tab 500 mg .................. 110 ustekinumab
see STELARA INJ 45MG/0.5 ..........99 see STELARA INJ 90MG/ML ...........99 ustekinumab (iv) see STELARA INJ 5MG/ML...........111 V
valacyclovir hcl tab 1 gm .............83 valacyclovir hcl tab 500 mg .........83 valganciclovir hcl for soln 50
mg/ml (base equiv) .................82 valganciclovir hcl tab 450 mg (base
equivalent) ...............................82 valproate sodium oral soln 250
mg/5ml (base equiv) ...............34 valproic acid cap 250 mg .............34 valsartan tab 160 mg ..................60 valsartan tab 320 mg ..................60 valsartan tab 40 mg ....................60 valsartan tab 80 mg ....................60 valsartan-hydrochlorothiazide tab
160-12.5 mg .............................64 valsartan-hydrochlorothiazide tab
160-25 mg ................................64 valsartan-hydrochlorothiazide tab
320-12.5 mg .............................64 valsartan-hydrochlorothiazide tab
320-25 mg ................................64 valsartan-hydrochlorothiazide tab
80-12.5 mg ...............................64 VALTOCO LIQ 15MG .......................30 VALTOCO LIQ 20MG .......................30 VALTOCO SPR 10MG.......................30 VALTOCO SPR 5MG.........................30 vancomycin hcl
see FIRVANQ SOL 25MG/ML..........19 see FIRVANQ SOL 50MG/ML..........19 vandetanib see CAPRELSA TAB 100MG ...........67
see CAPRELSA TAB 300MG ...........67 VAQTA INJ 25/0.5ML .................... 159 VAQTA INJ 50UNT/ML ................... 159 varenicline tartrate
see CHANTIX PAK 0.5& 1MG ....... 150 see CHANTIX TAB 0.5MG ............ 150 see CHANTIX TAB 1MG .............. 150 V-c Forte see multiple vitamins w/ minerals
cap....................................... 135 VCF VAGINAL AER CONTRACP........ 159 Vcf Vaginal Contraceptive
see nonoxynol-9 gel 4% ......... 159 VCF VAGINAL MIS CONTRACP........ 159 VECAMYL TAB 2.5MG ......................64 Velivet
see desogest-ethin est tab 0.10.025/0.125-0.025/0.150.025mg-mg ..........................91
VELPHORO CHW 500MG ................ 112 VELTIN GEL ...................................97 venlafaxine hcl cap er 24hr 150 mg
(base equivalent) .....................36 venlafaxine hcl cap er 24hr 37.5
mg (base equivalent) ...............36 venlafaxine hcl cap er 24hr 75 mg
(base equivalent) .....................36 venlafaxine hcl tab 100 mg (base
equivalent) ...............................37 venlafaxine hcl tab 25 mg (base
equivalent) ...............................36 venlafaxine hcl tab 37.5 mg (base
equivalent) ...............................37 venlafaxine hcl tab 50 mg (base
equivalent) ...............................37 venlafaxine hcl tab 75 mg (base
equivalent) ...............................37 VENTAVIS SOL 10MCG/ML ..............88 VENTAVIS SOL 20MCG/ML ..............88 VENTOLIN HFA AER ........................28 verapamil hcl cap er 24hr 100 mg
................................................. 87 verapamil hcl cap er 24hr 120 mg
................................................. 87 verapamil hcl cap er 24hr 180 mg
................................................. 87
242
verapamil hcl cap er 24hr 240 mg ................................................. 87
verapamil hcl cap er 24hr 300 mg ................................................. 87
verapamil hcl cap er 24hr 360 mg ................................................. 87
verapamil hcl tab 120 mg ............87 verapamil hcl tab 40 mg ..............87 verapamil hcl tab 80 mg ..............87 verapamil hcl tab er 120 mg........87 verapamil hcl tab er 180 mg........87 verapamil hcl tab er 240 mg........87 VEREGEN OIN 15% ........................97 VESICARE TAB 10MG .................... 157 VESICARE TAB 5MG......................157 VICTOZA INJ 18MG/3ML..................45 VIDEX EC CAP 125MG .....................81 vigabatrin powd pack 500 mg .....33 vigabatrin tab 500 mg .................33 Vigadrone
see vigabatrin powd pack 500 mg .............................................. 33
VIIBRYD KIT STARTER ....................36 VIIBRYD TAB 10MG ........................36 VIIBRYD TAB 20MG ........................36 VIIBRYD TAB 40MG ........................36 vilazodone hcl
see VIIBRYD KIT STARTER............36 see VIIBRYD TAB 10MG................36 see VIIBRYD TAB 20MG................36 see VIIBRYD TAB 40MG................36 VIMPAT SOL 10MG/ML ....................32 VIMPAT TAB 100MG........................32 VIMPAT TAB 150MG........................32 VIMPAT TAB 200MG........................33 VIMPAT TAB 50MG .........................32 VINATE II TAB ............................. 138 VINATE M TAB ............................. 138 VIRACEPT TAB 250MG ....................82 VIRACEPT TAB 625MG ....................82 VIREAD TAB 150MG........................82 VIREAD TAB 200MG........................82 VIREAD TAB 250MG........................82 Virt-caps see b-complex w/ c & folic acid
cap 1 mg .............................. 135 Virt-phos 250 Neutral
see pot phos monobasic w/sod phos di & monobas tab 155852-130mg .......................... 132
VISCO-3 INJ 25/2.5ML.................. 139 vismodegib
see ERIVEDGE CAP 150MG ...........66 Vita-bee/c
see b-complex w/ c & folic acid tab ....................................... 135
VITAFOL-OB TAB 65-1MG.............. 138 VIVITROL INJ 380MG......................50 VOL-PLUS TAB ............................. 138 VOL-TAB RX TAB .......................... 138 vorapaxar sulfate
see ZONTIVITY TAB 2.08MG ....... 117 voriconazole tab 200 mg .............51 voriconazole tab 50 mg ...............51 vorinostat
see ZOLINZA CAP 100MG .............69 vortioxetine hbr
see TRINTELLIX TAB 10MG ...........36 see TRINTELLIX TAB 20MG ...........36 see TRINTELLIX TAB 5MG.............36 VOSEVI TAB ..................................82 VOTRIENT TAB 200MG ....................69 VRAYLAR CAP 1.5MG ......................72 VRAYLAR CAP 3MG .........................72 VRAYLAR CAP 4.5MG ......................72 VRAYLAR CAP 6MG .........................72 VYVANSE CAP 10MG ........................ 2 VYVANSE CAP 20MG ........................ 2 VYVANSE CAP 30MG ........................ 2 VYVANSE CAP 40MG ........................ 2 VYVANSE CAP 50MG ........................ 2 VYVANSE CAP 60MG ........................ 2 VYVANSE CAP 70MG ........................ 2 W
Wal-dryl Allergy Relief C see diphenhydramine hcl tab disint 12.5 mg........................52
Wal-dryl Pe Allergy/sinu see diphenhydraminephenylephrine tab 25-10 mg..95
Wal-itin Aller-melts see loratadine rapidlydisintegrating tab 10 mg .......52
Wal-tap Cold & Allergy
243
see brompheniramine & pseudoephedrine elixir 1-15 mg/5ml .................................94
warfarin sodium see COUMADIN TAB 10MG ............28 see COUMADIN TAB 1MG..............28 see COUMADIN TAB 2.5MG ...........28 see COUMADIN TAB 2MG..............28 see COUMADIN TAB 3MG..............28 see COUMADIN TAB 4MG..............28 see COUMADIN TAB 5MG..............28 see COUMADIN TAB 6MG..............28 see COUMADIN TAB 7.5MG ...........28
warfarin sodium tab 1 mg ...........28 warfarin sodium tab 10 mg .........29 warfarin sodium tab 2 mg ...........28 warfarin sodium tab 2.5 mg ........28 warfarin sodium tab 3 mg ...........28 warfarin sodium tab 4 mg ...........29 warfarin sodium tab 5 mg ...........29 warfarin sodium tab 6 mg ...........29 warfarin sodium tab 7.5 mg ........29 water for irrigation, sterile
irrigation soln ......................... 134 Wee Care
see carbonyl iron susp 15 mg/1.25ml (elemental iron) 119
wheat dextrin oral powder ........ 122 white petrolatum-mineral oil ophth
ointment ................................. 142 WIDE-SEAL DPR KIT 60 ................ 125 WIDE-SEAL DPR KIT 65 ................ 125 WIDE-SEAL DPR KIT 70 ................ 125 WIDE-SEAL DPR KIT 75 ................ 125 WIDE-SEAL DPR KIT 80 ................ 125 WIDE-SEAL DPR KIT 85 ................ 125 WIDE-SEAL DPR KIT 90 ................ 125 WIDE-SEAL DPR KIT 95 ................ 125 Wixela Inhub
see fluticasone-salmeterol aer powder ba 100-50 mcg/dose.27
see fluticasone-salmeterol aer powder ba 250-50 mcg/dose.27
see fluticasone-salmeterol aer powder ba 500-50 mcg/dose.27
WP THYROID TAB 81.25MG ........... 153
X
XALKORI CAP 200MG......................69 XALKORI CAP 250MG......................69 XARELTO STAR TAB 15/20MG ..........29 XARELTO TAB 10MG .......................29 XARELTO TAB 15MG .......................29 XARELTO TAB 2.5MG ......................29 XARELTO TAB 20MG .......................29 XELJANZ TAB 10MG......................... 7 XELJANZ TAB 5MG .......................... 7 XELJANZ XR TAB 11MG .................... 7 XELJANZ XR TAB 22MG .................... 7 XGEVA INJ .................................. 106 XIFAXAN TAB 200MG ......................19 XIFAXAN TAB 550MG ......................19 XIGDUO XR TAB 10-1000................43 XIGDUO XR TAB 10-500MG .............42 XIGDUO XR TAB 2.5-1000...............42 XIGDUO XR TAB 5-1000MG .............42 XIGDUO XR TAB 5-500MG ...............42 XOFLUZA TAB 20MG .......................83 XOFLUZA TAB 40MG .......................83 XOLAIR INJ 150MG/ML ...................24 XOLAIR INJ 75/0.5 .........................24 XOLAIR SOL 150MG .......................24 Xulane
see norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr ..............................92
XYNTHA SOLOF INJ 1000UNIT ....... 116 XYNTHA SOLOF INJ 2000UNIT ....... 117 XYNTHA SOLOF INJ 3000UNIT ....... 117 XYNTHA SOLOF INJ 500UNIT ......... 116 XYNTHA SOLOF KIT 250UNIT......... 117 XYREM SOL 500MG/ML ................. 148 Z
zafirlukast tab 10 mg ..................24 zafirlukast tab 20 mg ..................24 zaleplon cap 10 mg ................... 122 zaleplon cap 5 mg ..................... 121 zanamivir
see RELENZA MIS DISKHALE ........83 zanubrutinib
see BRUKINSA CAP 80MG.............67 ZARXIO INJ 300/0.5 ..................... 119 ZARXIO INJ 480/0.8 ..................... 119 ZEJULA CAP 100MG ........................69
244
ZENPEP CAP 10000UNT.................104 ZENPEP CAP 15000UNT.................104 ZENPEP CAP 20000UNT.................104 ZENPEP CAP 25000 ...................... 104 ZENPEP CAP 3000UNIT ................. 104 ZENPEP CAP 40000 ...................... 104 ZENPEP CAP 5000UNIT ................. 104 ZEPATIER TAB 50-100MG................82 zidovudine cap 100 mg................82 zidovudine syrup 10 mg/ml ........82 zidovudine tab 300 mg ................82 ZIEXTENZO INJ 6/0.6ML ............... 119 zileuton tab er 12hr 600 mg ........24 zinc sulfate cap 220 mg (50 mg
elemental zn) ......................... 133 Zinc-220
see zinc sulfate cap 220 mg (50 mg elemental zn).................133
Zinc-oxyde Plus see menthol-zinc oxide oint 0.4420%..................................... 103
ZIOPTAN DRO 0.0015% ................ 145 ziprasidone hcl cap 20 mg ...........72 ziprasidone hcl cap 40 mg ...........72 ziprasidone hcl cap 60 mg ...........73 ziprasidone hcl cap 80 mg ...........73 ZIRGAN GEL 0.15% ...................... 143 ZOLADEX IMP 10.8MG ....................67 ZOLADEX IMP 3.6MG ......................67 zoledronic acid iv soln 5 mg/100ml
............................................... 106 ZOLINZA CAP 100MG......................69 zolmitriptan
see ZOMIG SPR 2.5MG ............... 129 see ZOMIG SPR 5MG.................. 129 zolmitriptan orally disintegrating tab 2.5 mg .............................. 129 zolmitriptan orally disintegrating tab 5 mg ................................. 129 zolmitriptan tab 2.5 mg ............. 129 zolmitriptan tab 5 mg................ 129 zolpidem tartrate tab 10 mg...... 122 zolpidem tartrate tab 5 mg........ 122 ZOMIG SPR 2.5MG ....................... 129 ZOMIG SPR 5MG .......................... 129 zonisamide cap 100 mg...............33 zonisamide cap 25 mg.................33 zonisamide cap 50 mg.................33 ZONTIVITY TAB 2.08MG................ 117 ZORTRESS TAB 0.25MG ................ 134 ZORTRESS TAB 0.5MG .................. 134 ZORTRESS TAB 0.75MG ................ 134 ZORTRESS TAB 1MG..................... 134 ZOSTAVAX INJ............................. 159 zoster vaccine live see ZOSTAVAX INJ .................... 159 zoster vaccine recombinant adjuvanted see SHINGRIX INJ 50/0.5ML ....... 158 ZYDELIG TAB 100MG ......................69 ZYDELIG TAB 150MG ......................69 ZYKADIA CAP 150MG......................70 ZYPREXA RELP INJ 210MG...............77 ZYPREXA RELP INJ 300MG...............77 ZYPREXA RELP INJ 405MG...............77
245
PO Box 3887, Albuquerque, NM 87190
Product offered by Molina Healthcare of New Mexico, Inc. , a wholly owned subsidiary of Molina Healthcare, Inc.
Producto ofrecido por Molina Healthcare of New Mexico, Inc.
una filial de completa propiedad de Molina Healthcare, Inc.
5066735CORP1016