$3000 hsa silver $6750 hsa bronze $8550 catastrophic

$3000 HSA Silver $7000 HSA Bronze $8700 Catastrophic

2022 Formulary

(List of covered drugs)

For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy.

Effective: January 1, 2022

©2022 HealthPartners

What’s the GenericsAdvantageRx drug list?

This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a

team of experts every three months for new medicines, safety alerts and other updates.

Who decides what’s on the drug list?

The HealthPartners Pharmacy and Therapeutics Committee manage the list. This team of experts focuses on safety,

effectiveness and affordability. Visit healthpartners.com/pharmacy for more information.

How do you use the drug list?

The medicines are listed in alphabetical order by type of medicine starting on page 4.

Generic medicines are in lowercase italics (e.g., cephalexin). These medicines are safe and effective but cost less than brand

medicines.

Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.

The Tier is used to determine how much a medicine will cost you. For exact cost information,

• Find the tier status for your medicine.

• Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or,

• Log on to your myHealthPartners account to check your pharmacy benefits.

o Tier 1 – Formulary Generics

o Tier 2 – Formulary Brands

o Tier 3 – Non-Formulary Generics &Brands

(Non-Formulary medicines are not listed in this document)

o Tier 4 – Specialty Generics & Brands

What’s a Specialty Medicine?

Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases.

These medicines usually require more management, have a high price and aren’t always stocked at retail pharmacies.

Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than

non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan

tab to check your benefits for specialty medicines.

What do the abbreviations under Limits & Restrictions mean?

Special information about the medicine you’re searching for. The abbreviations let you know there might be a special program

or rule for the medicine. Use this key to help you navigate the drug list:

• PA - Prior Authorization Required

• ST - Step Therapy Required

• AL1 - Age Limit

• AQ1 – Age Quantity Limit

• QL - Quantity Limit

• SC - Smoking Cessation Benefit

• WL - Weight Loss Benefit

• ONC - Oncology Benefit

• TD - Trial Drug Program

• S – Specialty

Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they

need to meet the HealthPartners prior authorization

criteria in order for the medicine to be covered by your

pharmacy benefits.

What’s Step Therapy (ST)? Some medicines are on the drug list, but you need to try

one or more other medicines first. HealthPartners

covers a medicine with step therapy, if you've already

tried the other medicine(s). If you haven't, you or your

doctor will need to get approval from HealthPartners

before the medicine will be covered by your lowest

brand, generic or specialty copay or coinsurance.

What’s an Age Limit (AL1)? An age edit means some medicines are only covered if

you’re within a specific age range. If you're not in the

approved age range, you or your doctor will need to

request approval from HealthPartners for your

medicine to be covered.

What’s an Age Quantity Limit (AQ1)?

An age quantity limit means some medicines have a

quantity limit that only applies to a specific age range. If

you're not in the approved age range, you or your

doctor will need to request approval from

HealthPartners for your medicine to be covered.

What’s a Quantity Limit (QL)? This means HealthPartners limits the amount of the

medicine you'll get each time you fill your prescription.

The quantity limit may be less than the day supply listed

in your contract or Summary Plan Description.

What’s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for

certain medicines that may not be well tolerated due

to:

• Side effects

• High cost

• High potential for waste

Your first 6 fills of a trial drug may be limited to less

than a month supply. If the medicine works well, you’ll

get the rest of your month supply. If a copay applies to

the medicine, you’ll pay no more than one copay for

each one month supply.

What’s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount

you get or may not be covered under all plans. Log on to

your myHealthPartners account and click on My plan

benefits on the Medical Plan tab to check your benefits

for weight loss. Weight Loss medicines are listed on the

drug list under the Weight Loss medicine category.

What’s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you’re only responsible for your regular generic or brand pharmacy copay or coinsurance.

The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (1/22) ©2022 HealthPartners

LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

CAFERGOT 3 QL 40 TABS / 30 DAYS

D.H.E.45 3QL 24 MG (AMPS) / 28

DAYSPA

DIBENZYLINE 3 PA

dihydroergotamine 1 mg/ml amp 2QL 24 MG (AMPS) / 28

DAYSPA

dihydroergotamine 4 mg/ml spry 2QL 8 VIALS / 28 DAYS

PA

ergoloid mesylates 2 PA

ERGOMAR 3 QL 20 TABS / 30 DAYS

ergotamine-caffeine 2QL 40 TABS / 30 DAYS

PA

MIGERGOT 3QL 24 SUPP / 30 DAYS

PA

MIGRANAL 3QL 8 VIALS / 28 DAYS

PA

phenoxybenzamine hcl 2 PA

TRUDHESA 3QL 1 PKG / 28 DAYS

PA

SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENTalfuzosin hcl er 2

FLOMAX 3

RAPAFLO 3

silodosin 2 PA

PAGE 1 LAST UPDATED 01/2022

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tamsulosin hcl 2

UROXATRAL 3 PA

ANALGESICS AND ANTIPYRETICSANALGESICS AND ANTIPYRETICS, MISC.

ALLZITAL 3QL 8 TABS / 1 DAY

PA

BUPAP 3 PA

butalb-acetamin-caff 50-300-40 3 QL 6 CAPS / 1 DAY

butalb-acetamin-caff 50-325-40 2 QL 6 TABS / 1 DAY

butalbital-acetaminophn 25-325 3QL 8 TABS / 1 DAY

PA

butalbital-acetaminophn 50-300 3 PA

butalbital-acetaminophn 50-325 2 QL 6 TABS / 1 DAY

ESGIC 50-325-40 MG TABLET 3 QL 6 TABS / 1 DAY

ESGIC CAPSULE 3 QL 6 CAPS / 1 DAY

FIORICET 3 QL 6 CAPS / 1 DAY

GRALISE 30-DAY STARTER PACK 3QL 78 TABS / RX

PA

GRALISE ER 300 MG TABLET 3QL 1 TAB / 1 DAY

PA

GRALISE ER 600 MG TABLET 3QL 3 TABS / 1 DAY

PA

LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET) 3QL 1 TAB / 1 DAY

PA

LYRICA CR 330 MG TABLET 3QL 2 TABS / 1 DAY

PA

pregabalin er (er 82.5 mg tablet, er 165 mg tablet) 3QL 1 TAB / 1 DAY

PA



pregabalin er 330 mg tablet 3QL 2 TABS / 1 DAY

PA

TENCON 2 QL 6 TABS / 1 DAY

VANATOL LQ 3 PA

VANATOL S 3 PA

VTOL LQ 3 PA

ZEBUTAL 2 QL 6 CAPS / 1 DAY

OPIATE AGONISTS

ABSTRAL 3 PA

acetamin-caf-dihydrocodein 325 2 PA

acetamin-codein 300-30 mg/12.5 2 AQ1 At least 12 yrs old;60 / 1 DAY

acetaminop-codeine 120-12 mg/5 2 AQ1 At least 12 yrs old;60 / 1 day(s)

acetaminophen-codeine (#2 tablet, #3 tablet, #4 tablet) 2 AQ1 At least 12 yrs old; 8/ 1 DAY

acetamn-caf-dihydrcodein 320.5 2PA

AQ1 At least 12 yrs old; 8/ 1 DAY(s)

ACTIQ 3 PA

ASCOMP WITH CODEINE 3QL 6 CAPS / 1 DAY

AL1 At least 12 yrs old

belladonna-opium 3 QL 4 SUPP / 1 DAY

benzhydrocodone-acetaminophen 2 PA

butalb-acetamin-caf-cod 50-300 2

QL 6 TABS / 1 DAY

PA

AQ1 At least 12 yrs old; 6/ 1 DAY

butalb-acetamin-caf-cod 50-325 2PA




butalbital compound-codeine 3QL 6 CAPS / 1 DAY


codeine sulfate 2 AQ1 At least 12 yrs old; 8/ 1 DAY

CONZIP (200 MG CAPSULE, 300 MG CAPSULE) 3PA


CONZIP 100 MG CAPSULE 3PA


DILAUDID 2 MG TABLET 3 QL 8 TABS / 1 DAY


DILAUDID 5 MG/5 ML ORAL LIQUID 3 QL 20 ML / 1 DAY


DISKETS 3 PA

DOLOPHINE HCL 3 PA

DURAGESIC 3 PA

DVORAH 3 PA

EMBEDA (ER 50-2 MG CAPSULE, ER 60-2.4 MG CAPSULE,ER 80-3.2 MG CAPSULE)

3QL 1 CAP / 1 DAY

PA

EMBEDA ER 100-4 MG CAPSULE 3 PA

EMBEDA ER 20-0.8 MG CAPSULE 3QL 4 CAPS / 1 DAY

PA

EMBEDA ER 30-1.2 MG CAPSULE 3QL 2 CAPS / 1 DAY

PA

ENDOCET 10-325 MG TABLET 2 QL 5 TABS / 1 DAY

ENDOCET 2.5-325 MG TABLET 3 QL 8 TABS / 1 DAY



ENDOCET 5-325 TABLET 2 QL 8 TABS / 1 DAY

ENDOCET 7.5-325 MG TABLET 2 QL 7 TABS / 1 DAY

fentanyl (12 mcg/hr patch, 25 mcg/hr patch, 50 mcg/hrpatch, 75 mcg/hr patch, 100 mcg/hr patch)

2 PA

fentanyl (37.5 mcg/hr patch, 62.5 mcg/hr patch, 87.5mcg/hr patch)

3 PA

fentanyl citrate (cit 100 mcg buccal tb, cit 200 mcg buccaltb, cit 400 mcg buccal tb, cit 600 mcg buccal tb, cit 800mcg buccal tb, cit otfc 1,200 mcg, cit otfc 1,600 mcg,citrate otfc 200 mcg, citrate otfc 400 mcg, citrate otfc 600mcg, citrate otfc 800 mcg)

3 PA

FENTORA 3 PA

FIORICET WITH CODEINE 3QL 6 TABS / 1 DAY


FIORINAL WITH CODEINE #3 3QL 6 CAPS / 1 DAY


hydrocodone bitartrate er (er 10 mg capsule, er 15 mgcapsule, er 20 mg capsule, er 30 mg capsule, er 40 mgcapsule, er 50 mg capsule)

2 PA

hydrocodone bitartrate er (er 20 mg tablet, er 30 mgtablet, er 40 mg tablet, er 60 mg tablet, er 80 mg tablet,er 100 mg tablet, er 120 mg tablet)

3 PA

hydrocodone-acetamin 10-325/15 3 PA

hydrocodone-acetaminophen (2.5-325, 5-300 mg, 7.5-300, 10-300 mg)

3 QL 8 TABS / 1 DAY

hydrocodone-acetaminophen (5-325 mg, 7.5-325, 10-325mg)

2 QL 8 TABS / 1 DAY

hydrocodone-acetaminophen (hydrocodone-acetamin2.5-108/5, hydrocodone-acetamin 5-217/10,hydrocodone-acetamn 7.5-325/15)

2 QL 120 ML / 1 DAY

hydrocodone-ibuprofen (5-200 mg, 10-200) 3 QL 8 TABS / 1 DAY

hydrocodone-ibuprofen 7.5-200 2 QL 8 TABS / 1 DAY

hydromorphone 2 mg tablet 2 QL 8 TABS / 1 DAY



hydromorphone 3 mg suppos 2 QL 8 SUPP / 1 DAY



hydromorphone er 2 PA

hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 2 QL 20 ML / 1 DAY

HYSINGLA ER 3 PA

KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE, ER60 MG CAPSULE, ER 80 MG CAPSULE, ER 100 MGCAPSULE, ER 200 MG CAPSULE)

3 PA

LAZANDA 3 PA

levorphanol tartrate 2 PA

LORCET 2 QL 8 TABS / 1 DAY

LORCET HD 2 QL 8 TABS / 1 DAY

LORCET PLUS 2 QL 8 TABS / 1 DAY

LORTAB 3 QL 120 ML / 1 DAY

meperidine 50 mg/5 ml solution 3 QL 60 ML / 1 DAY

meperidine hcl (50 mg tablet, 100 mg tablet) 3 QL 8 TABS / 1 DAY

methadone hcl (5 mg/5 ml solution, hcl 5 mg tablet, 10mg/5 ml solution, 10 mg/ml oral conc, hcl 10 mg tablet,40 mg tablet dispr)

2 PA

METHADONE INTENSOL 2 PA

METHADOSE 10 MG/ML ORAL CONC 3 PA

METHADOSE 40 MG TABLET DISPR 2 PA

MORPHABOND ER (ER 60 MG TABLET, ER 100 MGTABLET)

3 PA

MORPHABOND ER 15 MG TABLET 3QL 5 TABS / 1 DAY

PA



MORPHABOND ER 30 MG TABLET 3QL 2 TABS / 1 DAY

PA

morphine sulf 10 mg/5 ml soln 2 QL 30 ML / 1 DAY

morphine sulf 100 mg/5 ml conc 2 QL 4 ML / 1 DAY

morphine sulf 20 mg/5 ml soln 2 QL 20 ML / 1 DAY

morphine sulfate (5 mg suppos, 10 mg suppos, 20 mgsuppos, 30 mg suppos)

2 QL 8 SUPP / 1 DAY

morphine sulfate er (er 10 mg cap, er 20 mg cap, er 30 mgcap, er 40 mg cap, er 45 mg cap, er 50 mg cap, er 60 mgcap, er 75 mg cap, er 80 mg cap, er 90 mg cap, er 100 mgcap, er 120 mg cap)

3 PA

morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er60 mg tablet, er 100 mg tablet, er 200 mg tablet)

2 PA

morphine sulfate ir 15 mg tab 2 QL 5 TABS / 1 DAY

MORPHINE SULFATE IR 15 MG TAB (BRAND) 1 QL 5 TABS / 1 DAY

morphine sulfate ir 30 mg tab 2 QL 2 TABS / 1 DAY

MORPHINE SULFATE IR 30 MG TAB (BRAND) 1 QL 2 TABS / 1 DAY

MS CONTIN 3 PA

NALOCET 3 PA

NORCO 3 QL 8 TABS / 1 DAY

NUCYNTA 100 MG TABLET 1QL 2 TABS / 1 DAY

PA


PA


PA

NUCYNTA ER (ER 150 MG TABLET, ER 200 MG TABLET, ER250 MG TABLET)

3 PA

NUCYNTA ER 100 MG TABLET 3QL 2 TABS / 1 DAY

PA



NUCYNTA ER 50 MG TABLET 3QL 4 TABS / 1 DAY

PA

OPANA 10 MG TABLET 3 QL 2 TABS / 1 DAY

OPANA 5 MG TABLET 3 QL 5 TABS / 1 DAY

OXAYDO 3 PA

oxycodone hcl 10 mg tablet 2 QL 5 TABS / 1 DAY

oxycodone hcl 100 mg/5 ml conc 2 QL 2 ML / 1 DAY



oxycodone hcl 30 mg tablet 2 PA

oxycodone hcl 5 mg capsule 2 QL 8 CAPS / 1 DAY


oxycodone hcl 5 mg/5 ml soln 2 QL 40 ML / 1 DAY

oxycodone hcl er 2 PA

oxycodone hcl-aspirin 2 QL 8 TABS / 1 DAY

oxycodone hcl-ibuprofen 3 QL 4 TABS / 1 DAY

oxycodone-acetaminophen (oxycodone-acetaminophen 5-300, oxycodone-acetaminophn 2.5-325)

3 QL 8 TABS / 1 DAY

oxycodone-acetaminophen 10-300 3 QL 5 TABS / 1 DAY



oxycodone-acetaminophn 7.5-325 2 QL 7 TABS / 1 DAY

OXYCONTIN 1 PA

oxymorphone hcl 10 mg tablet 2QL 2 TABS / 1 DAY

PA



oxymorphone hcl 5 mg tablet 2QL 5 TABS / 1 DAY

PA

oxymorphone hcl er 2 PA

PERCOCET (2.5-325 MG TABLET, 5-325 MG TABLET) 3 QL 8 TABS / 1 DAY

PERCOCET 10-325 MG TABLET 3 QL 5 TABS / 1 DAY

PERCOCET 7.5-325 MG TABLET 3 QL 7 TABS / 1 DAY

PRIMLEV 10-300 MG TABLET 3 QL 5 TABS / 1 DAY

PRIMLEV 5-300 MG TABLET 3 QL 8 TABS / 1 DAY

PRIMLEV 7.5-300 MG TABLET 3 QL 7 TABS / 1 DAY

PROLATE 10 MG-300 MG/5 ML SOLN 3QL 20 ML / 1 DAY

PA

PROLATE 10-300 MG TABLET 3 QL 5 TABS / 1 DAY

PROLATE 5-300 MG TABLET 3 QL 8 TABS / 1 DAY

PROLATE 7.5-300 MG TABLET 3 QL 7 TABS / 1 DAY

QDOLO 3

QL 80 ML / 1 DAY

PA


ROXICODONE 15 MG TABLET 3 QL 3 TABS / 1 DAY

ROXICODONE 30 MG TABLET 3 PA

ROXICODONE 5 MG TABLET 3 QL 8 TABS / 1 DAY

SUBSYS 3 PA

tramadol er 100 mg tablet (generic for ryzolt) 2

QL 3 TABS / 1 DAY

PA



QL 1 TAB / 1 DAY

PA





QL 1 TAB / 1 DAY

PA


tramadol hcl 100 mg tablet 3PA

AQ1 At least 4 yrs old; 4 /1 day(s)

tramadol hcl 50 mg tablet 2 AQ1 At least 12 yrs old; 8/ 1 DAY

tramadol hcl er 100 mg capsule (generic for conzip) 2PA


tramadol hcl er 100 mg tablet (generic for ultram er) 2PA


tramadol hcl er 150 mg capsule 2PA

AQ1 At least 12 yrs old; 1/ 1 day(s)









tramadol hcl-acetaminophen 2PA


TREZIX 3 AQ1 At least 12 yrs old; 8/ 1 DAY



TYLENOL-CODEINE NO.3 3 AQ1 At least 12 yrs old; 8/ 1 DAY

TYLENOL-CODEINE NO.4 3 AQ1 At least 12 yrs old; 8/ 1 DAY

ULTRACET 3 AQ1 At least 12 yrs old; 8/ 1 DAY

ULTRAM 3 AQ1 At least 12 yrs old; 8/ 1 DAY

VICODIN HP 3 QL 8 TABS / 1 DAY

XTAMPZA ER 3 PA

ZOHYDRO ER 3 PA

OPIATE PARTIAL AGONISTS

BELBUCA (75 MCG FILM, 150 MCG FILM, 300 MCG FILM,450 MCG FILM)

3QL 4 FILMS / 1 DAY

PA

BELBUCA (750 MCG FILM, 900 MCG FILM) 3QL 2 FILMS / 1 DAY

PA

BELBUCA 600 MCG FILM 3QL 3 FILMS / 1 DAY

PA

BUNAVAIL 2.1-0.3 MG FILM 3 QL 6 FILMS / 1 DAY

BUNAVAIL 4.2-0.7 MG FILM 3 QL 3 FILMS / 1 DAY

BUNAVAIL 6.3-1 MG FILM 3 QL 2 FILMS / 1 DAY

buprenorphine 2 PA

buprenorphine 2 mg tablet sl 2QL 12 TABS / 1 DAY

PA

buprenorphine 600 mcg film 3QL 3 FILMS / 1 DAY

PA

buprenorphine 8 mg tablet sl 2QL 3 TABS / 1 DAY

PA



buprenorphine hcl (75 mcg film, 150 mcg film, 300 mcgfilm, 450 mcg film)

3QL 4 FILMS / 1 DAY

PA

buprenorphine hcl (750 mcg film, 900 mcg film) 3QL 2 FILMS / 1 DAY

PA

buprenorphine-nalox 12-3mg flm 2 QL 2 FILMS / 1 DAY

buprenorphine-naloxone (2-0.5mg fm, 4-1mg film, 8-2mgfilm)

2 QL 3 FILMS / 1 DAY

buprenorphine-naloxone (2-0.5mg tb, 8-2 mg tab) 2 QL 3 TABS / 1 DAY

butorphanol 10 mg/ml spray 3 QL 5 ML / 30 DAYS

BUTRANS 3 PA

pentazocine-naloxone hcl 2QL 8 TABS / 1 DAY

PA

SUBOXONE (2 MG-0.5 MG FILM, 4 MG-1 MG FILM, 8 MG-2 MG FILM)

3 QL 3 FILMS / 1 DAY

SUBOXONE 12 MG-3 MG SL FILM 3 QL 2 FILMS / 1 DAY

ZUBSOLV (0.7-0.18 MG TABLET, 1.4-0.36 MG TABLET) 3QL 12 TABS / 1 DAY

PA

ZUBSOLV 11.4-2.9 MG TABLET SL 3QL 1 TAB / 1 DAY

PA

ZUBSOLV 2.9-0.71 MG TABLET SL 3QL 4 TABS / 1 DAY

PA


PA


PA

ANOREXIGENIC AGENTSAMPHETAMINE DERIVATIVES

ADIPEX-P 37.5 MG CAPSULE 3QL 1 CAP / 1 DAY

WL Weight Loss



ADIPEX-P 37.5 MG TABLET 3QL 1 TAB / 1 DAY

WL Weight Loss

diethylpropion hcl 3QL 3 TABS / 1 DAY

WL Weight Loss

diethylpropion hcl er 3QL 1 TAB / 1 DAY

WL Weight Loss

LOMAIRA 2QL 3 TABS / 1 DAY

WL Weight Loss

phendimetrazine tartrate 3QL 3 TABS / 1 DAY

WL Weight Loss

phendimetrazine tartrate er 3QL 1 CAP / 1 DAY

WL Weight Loss

phentermine 15 mg capsule 2QL 2 CAPS / 1 DAY

WL Weight Loss

phentermine 37.5 mg tablet 2QL 1 TAB / 1 DAY

WL Weight Loss

phentermine hcl (30 mg capsule, 37.5 mg capsule) 2QL 1 CAP / 1 DAY

WL Weight Loss

ANOREXIGENIC AGENTS, MISCELLANEOUS

CONTRAVE 1PA

WL Weight Loss

IMCIVREE 4

QL 9 ML / 30 DAYS

PA

S

WL Weight Loss

QSYMIA (7.5 MG-46 MG CAPSULE, 11.25 MG-69 MGCAPSULE, 15 MG-92 MG CAPSULE)

1

QL 2 CAPS / 1 DAY

PA

WL Weight Loss

QSYMIA 3.75 MG-23 MG CAPSULE 1

QL 4 CAPS / 1 DAY

PA

WL Weight Loss



SELECTIVE SEROTONIN RECEPTOR AGONISTS

BELVIQ 3QL 2 TABS / 1 DAY

WL Weight Loss

BELVIQ XR 3QL 1 TAB / 1 DAY

WL Weight Loss

ANOREXIGENICS;RESPIRATORY,CNS STIMULANTSAMPHETAMINES

ADDERALL (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET,12.5 MG TABLET, 15 MG TABLET, 20 MG TABLET)

3 QL 3 TABS / 1 DAY

ADDERALL 30 MG TABLET 3 QL 2 TABS / 1 DAY

ADDERALL XR 2 QL 2 CAPS / 1 DAY

ADZENYS ER 3QL 15 ML / 1 DAY

PA

ADZENYS XR-ODT (12.5 MG TABLET, 15.7 MG TABLET,18.8 MG TABLET)

3QL 1 TAB / 1 DAY

PA

ADZENYS XR-ODT (3.1 MG TABLET, 6.3 MG TABLET, 9.4MG TABLET)

3QL 2 TABS / 1 DAY

PA

amphetamine 3QL 15 ML / 1 DAY

PA

amphetamine sulfate 2QL 4 TABS / 1 DAY

PA

benzphetamine hcl 3QL 3 TABS / 1 DAY

WL Weight Loss

DESOXYN 3 QL 5 TABS / 1 DAY

DEXEDRINE 3QL 4 CAPS / 1 DAY

PA

dextroamp-amphetamin 15 mg tab (generic adderall) 2 QL 3 TABS / 1 DAY

dextroamp-amphetamin 20 mg tab (generic adderall) 2 QL 3 TABS / 1 DAY



dextroamp-amphetamin 30 mg tab 2 QL 2 TABS / 1 DAY

dextroamphetamine 5 mg/5 ml 3 QL 60 ML / 1 DAY

dextroamphetamine sulfate (5 mg tab, 10 mg tab) 2 QL 4 TABS / 1 DAY

dextroamphetamine sulfate er 2 QL 4 CAPS / 1 DAY

dextroamphetamine-amphet er 3QL 2 CAPS / 1 DAY

PA

dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroamp-amphetam 12.5 mgtab, dextroamp-amphetamin 10 mg tab, dextroamp-amphetamine 5 mg tab)

2 QL 3 TABS / 1 DAY

DYANAVEL XR 3 QL 8 ML / 1 DAY

EVEKEO 3 QL 4 TABS / 1 DAY

EVEKEO ODT (ODT 15 MG, ODT 20 MG) 3 QL 2 TABS / 1 DAY

EVEKEO ODT (ODT 5 MG, ODT 10 MG) 3 QL 3 TABS / 1 DAY

methamphetamine hcl 3 QL 5 TABS / 1 DAY

MYDAYIS 3 QL 1 CAP / 1 DAY

PROCENTRA 3 QL 4 TABS / 1 DAY

VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)

1 QL 2 CAPS / 1 DAY

VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET) 1 QL 2 CHEW TABS / 1DAY

VYVANSE (40 MG CAPSULE, 50 MG CAPSULE, 60 MGCAPSULE, 70 MG CAPSULE)

1 QL 1 CAP / 1 DAY

VYVANSE (40 MG TABLET, 50 MG TABLET, 60 MG TABLET) 1 QL 1 CHEW TAB / 1 DAY

ZENZEDI (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET,10 MG TABLET, 15 MG TABLET, 20 MG TABLET)

3 QL 4 TABS / 1 DAY

ZENZEDI 30 MG TABLET 3 QL 2 TABS / 1 DAY

RESPIRATORY AND CNS STIMULANTS

ADHANSIA XR 3QL 1 CAP / 1 DAY

PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSAPTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MGCAPSULE, 30 MG CAPSULE)

3 QL 2 CAPS / 1 DAY

APTENSIO XR (40 MG CAPSULE, 50 MG CAPSULE, 60 MGCAPSULE)

3 QL 1 CAP / 1 DAY

AZSTARYS 3QL 1 CAP / 1 DAY

PA

CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36MG TABLET)

2 QL 2 TABS / 1 DAY

CONCERTA ER 54 MG TABLET 2 QL 1 TAB / 1 DAY

COTEMPLA XR-ODT 3 QL 2 TABS / 1 DAY

DAYTRANA 3 QL 1 PATCH / 1 DAY

dexmethylphenidate hcl 2 QL 2 TABS / 1 DAY

dexmethylphenidate hcl er (er 25 mg cp, er 30 mg cp, er35 mg cp, er 40 mg cp)

2 QL 1 CAP / 1 DAY

dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er15 mg cp, er 20 mg cp)

2 QL 2 CAPS / 1 DAY

FOCALIN 3 QL 2 TABS / 1 DAY

FOCALIN XR (25 MG CAPSULE, 30 MG CAPSULE, 35 MGCAPSULE, 40 MG CAPSULE)

3 QL 1 CAP / 1 DAY

FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MGCAPSULE, 20 MG CAPSULE)

3 QL 2 CAPS / 1 DAY

JORNAY PM 3QL 1 CAP / 1 DAY

PA

METADATE ER 2 QL 3 TABS / 1 DAY

METHYLIN 10 MG/5 ML SOLUTION 3 QL 30 ML / 1 DAY

METHYLIN 5 MG/5 ML SOLUTION 3 QL 60 ML / 1 DAY

methylphenidate 10 mg/5 ml sol 3 QL 30 ML / 1 DAY

methylphenidate 5 mg/5 ml soln 3 QL 60 ML / 1 DAY

methylphenidate er (er 10 mg cap, er 15 mg cap, er 20 mgcap, er 30 mg cap)

3 QL 2 CAPS / 1 DAY



methylphenidate er (er 18 mg tab, er 27 mg tab, er 36 mgtab)

3QL 2 TABS / 1 DAY

PA

methylphenidate er (er 40 mg cap, er 50 mg cap, er 60 mgcap)

3 QL 1 CAP / 1 DAY

methylphenidate er (la) (10mg cp, 20mg cp, 30mg cp) 2 QL 2 CAPS / 1 DAY

methylphenidate er 10 mg cap (authorized generic) 3 QL 2 CAPS / 1 DAY

methylphenidate er 10 mg tab 2 QL 4 TABS / 1 DAY



methylphenidate er 20 mg tab 2 QL 3 TABS / 1 DAY


methylphenidate er 40 mg cap (authorized generic) 3 QL 1 CAP / 1 DAY


methylphenidate er 54 mg tab 3QL 1 TAB / 1 DAY

PA


methylphenidate er(la) 40mg cp 2 QL 1 CAP / 1 DAY

methylphenidate hcl (2.5 mg chew tb, 5 mg chew tab, 10mg chew tab)

3 QL 4 CHEW TABS / 1DAY

methylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mgtablet)

2 QL 3 TABS / 1 DAY

methylphenidate hcl cd (10 mg cap, 20 mg cap, 30 mgcap)

2 QL 2 CAPS / 1 DAY

methylphenidate hcl cd (40 mg cap, 50 mg cap, 60 mgcap)

2 QL 1 CAP / 1 DAY

methylphenidate hcl er (cd) (10mg cp, 20mg cp, 30mg cp) 2 QL 2 CAPS / 1 DAY

methylphenidate hcl er (cd) (40mg cp, 50mg cp, 60mg cp) 2 QL 1 CAP / 1 DAY

methylphenidate la (10 mg cap, 20 mg cap, 30 mg cap) 2 QL 2 CAPS / 1 DAY



methylphenidate la (40 mg cap, 60 mg cap) 2 QL 1 CAP / 1 DAY

QUILLICHEW ER 20 MG CHEW TAB 1 QL 3 CHEW TABS / 1DAY

QUILLICHEW ER 30 MG CHEW TAB 1 QL 2 CHEW TABS / 1DAY

QUILLICHEW ER 40 MG CHEW TAB 1 QL 1 CHEW TAB / 1 DAY

QUILLIVANT XR 1 QL 6 ML / 1 DAY

RITALIN 3 QL 3 TABS / 1 DAY

RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)

3 QL 2 CAPS / 1 DAY

RITALIN LA 40 MG CAPSULE 3 QL 1 CAP / 1 DAY

WAKEFULNESS-PROMOTING AGENTS

armodafinil (150 mg tablet, 200 mg tablet, 250 mg tablet) 2 QL 1 TAB / 1 DAY

armodafinil 50 mg tablet 2 QL 2 TABS / 1 DAY

modafinil 2 QL 2 TABS / 1 DAY

NUVIGIL (150 MG TABLET, 200 MG TABLET, 250 MGTABLET)

3QL 1 TAB / 1 DAY

PA

NUVIGIL 50 MG TABLET 3QL 2 TABS / 1 DAY

PA

PROVIGIL 3QL 2 TABS / 1 DAY

PA

SUNOSI 1QL 1 TAB / 1 DAY

PA

WAKIX 4PA

S



ANTI-INFECTIVE AGENTSANTHELMINTICS

albendazole 2 PA

ALBENZA 3 PA

BILTRICIDE 3

EMVERM 3 PA

ivermectin 3 mg tablet 2

praziquantel 2

STROMECTOL 3

URINARY ANTI-INFECTIVES

fosfomycin tromethamine 2 QL 1 PACKET / RX

FURADANTIN 3 AL1 Up to 12 yrs old

HIPREX 3

MACROBID 3

MACRODANTIN (50 MG CAPSULE, 100 MG CAPSULE) 3

MACRODANTIN 25 MG CAPSULE 3 AL1 Up to 12 yrs old

methenamine hippurate 2 PA

methenamine mandelate 3

MONUROL 3 QL 1 PACKET / RX

nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap) 2 AL1 Up to 12 yrs old

nitrofurantoin (50 mg cap, 100 mg cap) 2

nitrofurantoin mono-macro 2

phosphasal 3

PRIMSOL 3

trimethoprim 2

TRIMPEX 3

URELLE 3



URETRON D-S 3

URIBEL 3

uro-mp 3

UROQID-ACID NO.2 3

utira-c 3

ANTI-INFECTIVES (EENT)ANTIBACTERIALS (EENT)

AZASITE 1 PA

bacitracin 500 unit/gm ophth 2

bacitracin-polymyxin 2

BESIVANCE 1 PA

BLEPHAMIDE 3

BLEPHAMIDE S.O.P. 1

CETRAXAL 3

CILOXAN 0.3% EYE DROPS 3

CILOXAN 0.3% OINTMENT 1

CIPRO HC 1

CIPRODEX 3

ciprofloxacin 0.2% otic soln 2 PA

ciprofloxacin 0.3% eye drop 2

ciprofloxacin hcl-fluocinolone 2 PA

ciprofloxacin-dexamethasone 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

doxycycline hyclate 20 mg tab 2

erythromycin 0.5% eye ointment 2

gatifloxacin 2

GENTAK 1 PA



gentamicin 0.3% eye drop 2 PA

levofloxacin 0.5% eye drops 2 PA

MAXITROL (DROPS, OINTMENT) 3

MOXEZA 3

moxifloxacin 0.5% eye drops 2

moxifloxacin 0.5% eye drops (generic for moxeza) 3

neomyc-polym-dexamet eye ointm 2

neomyc-polym-dexameth eye drop 3

neomycin-bacitracin-poly-hc 3

neomycin-bacitracin-polymyxin 2

neomycin-polymyxin-gramicidin 2

neomycin-polymyxin-hc ear susp 2

neomycin-polymyxin-hydrocort 2

OCUFLOX 3

ofloxacin (ear drops, eye drops) 2

OTIPRIO 3 PA

OTOVEL 3

polymyxin b sul-trimethoprim 2

POLYTRIM 3

PRED-G (1% DROPS, S.O.P. OINTMENT) 1 PA

sulfacetamide sodium (drops, ointment) 2

sulfacetamide-prednisolone 2

TOBRADEX EYE DROPS 3

TOBRADEX EYE OINTMENT 1

TOBRADEX ST 3

tobramycin 0.3% eye drop 2

tobramycin-dexamethasone 2



TOBREX 0.3% EYE DROP 3

TOBREX 0.3% EYE OINTMENT 1

VIGAMOX 3

ZYLET 1 PA

ZYMAXID 3

ANTIFUNGALS (EENT)

NATACYN 1 PA

ANTIVIRALS (EENT)trifluridine 2

ZIRGAN 1

EENT ANTI-INFECTIVES, MISCELLANEOUSacetic acid 2% ear solution 2

chlorhexidine gluconate 2

hydrocortisone-acetic acid 2 PA

PAROEX 2

PERIDEX 3

PERIOGARD 2

ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

ACANYA 3 PA

ALTABAX 1 ST

AMZEEQ 3 PA

BENZACLIN 3 PA

BENZAMYCIN 3

CENTANY 3 QL 44 GM / RX

CENTANY AT 3

CLEOCIN 100 MG VAGINAL OVULE 1



CLEOCIN 2% VAGINAL CREAM 3

CLEOCIN T (GEL, LOION) 3

CLEOCIN T 1% SOLUTION 3 QL 60 ML / 30 DAYS

clind ph-benzoyl pero 1.2-2.5% 3 PA

clind ph-benzoyl perox 1.2-5% 2

CLINDACIN ETZ (1% PLEDGET, KIT) 3 PA

CLINDACIN P 3 PA

CLINDACIN PAC 3 PA

CLINDAGEL 3 PA

clindamycin ph 1% gel (generic for cleocin t) 2

clindamycin ph 1% solution 2 QL 60 ML / 30 DAYS

clindamycin phos-tretinoin 3

clindamycin phosphate (phos 1% pledget, phosp 1%lotion, 2% vaginal cream)

2

clindamycin phosphate 1% foam 3

clindamycin phosphate 1% gel (generic for clindagel) 3 PA

clindamycin-benzoyl peroxide 2

CLINDESSE 3

CORTISPORIN (CREAM, OINTMENT) 3

DUAC 3

ERY 3

ERYGEL 3

erythromycin 2% gel 2

erythromycin 2% solution 2 QL 60 ML / 30 DAYS

erythromycin-benzoyl peroxide 2

EVOCLIN 3

gentamicin 0.1% cream 2 QL 30 GM / 30 DAYS



gentamicin 0.1% ointment 2

METROCREAM 3

METROGEL TOPICAL 1% GEL 3

METROGEL-VAGINAL 3

METROLOTION 3

metronidazole (0.75% cream, 0.75% lotion, topical 0.75%gl, topical 1% gel, vaginal 0.75% gl)

2

mupirocin 2% cream 2QL 30 GM / 30 DAYS

PA

mupirocin 2% ointment 2 QL 44 GM / RX

NEO-SYNALAR (0.5%-0.025% CREAM, 0.5-0.025% CRMKIT)

3 PA

NEUAC (1.2-5% KIT, GEL) 3

NORITATE 3 PA

NUVESSA 3

ONEXTON GEL PUMP 3 PA

ROSADAN 0.75% CREAM 2

ROSADAN 0.75% CREAM KIT 3

VANDAZOLE 3

VELTIN 3 PA

XEPI 3

ZIANA 3 PA

ZILXI 3 PA

ANTIVIRALS (SKIN AND MUCOUS MEMBRANE)

acyclovir 5% cream 2QL 5 GM / RX

PA

acyclovir 5% ointment 2QL 15 GM / 1 FILL

PA



DENAVIR 1 PA

XERESE 3 PA

ZOVIRAX 5% CREAM 3QL 5 GM / RX

PA

ZOVIRAX 5% OINTMENT 3QL 15 GM / 1 FILL

PA

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

ALCORTIN A 3 PA

AVC 3

cleansing wash 3

dermazene cream 2

FEM PH 3

hydrocortisone-iodoquinol 2

hydrocortisone-iodoquinol-aloe 3 PA

iodoquinol-hydrocortisone-aloe 3 PA

KLARON 3

mafenide acetate 2 PA

OVACE 3

OVACE PLUS (9.8% FOAM, 9.8% LOTION, 10% SHAMPOO,10% WASH)

3

ovace plus wash 3

QUINJA 3

selenium sulfide (2.25% shampoo, 2.3% shampoo) 3

selenium sulfide 2.5% lotion 2

SELRX 3

SILVADENE 3

silver sulfadiazine 2

sod sulface-sulfur 9-4.5% wash 3



sodium sulf-sulfur cleanser 2

sodium sulfacetamide (sod sulfacetam clnsng gel, sodiumsulfacetamide wash)

3

SSD 2

sulfacetamide sodium (sod top susp, sodium lotn) 2

SULFAMYLON 8.5% CREAM 3

SUMADAN XLT 3 PA

VYTONE 3 PA

SCABICIDES AND PEDICULICIDESCROTAN 3

ELIMITE 3

EURAX 10% CREAM 1 PA

EURAX 10% LOTION 3

ivermectin 0.5% lotion 2 PA

lindane 2 PA

malathion 2

NATROBA 3

OVIDE 3

permethrin 2

SKLICE 3 PA

spinosad 2 PA

ULESFIA 1 PA

ANTI-INFLAMMATORY AGENTS (EENT)CORTICOSTEROIDS (EENT)

ALREX 1 PA

BECONASE AQ 3

DERMOTIC 3



dexamethasone 0.1% eye drop 2

difluprednate 3

DUREZOL 3 PA

EYSUVIS 3 PA

FLAC OTIC OIL 3

FLAREX 3

flunisolide 2

fluocinolone acetonide oil 2

fluorometholone 2

fluticasone prop 50 mcg spray 2

FML 3

FML FORTE 3

FML S.O.P. 1

INVELTYS 3

LOTEMAX (EYE DROPS, OPHTHALMIC GEL) 3

LOTEMAX 0.5% EYE OINTMENT 1

LOTEMAX SM 1

loteprednol etabonate (etabonate drp, ophthalmc gel) 2

MAXIDEX 3

mometasone furoate 50 mcg spry 3

NASONEX 3

OMNARIS 3

PRED FORTE 3

PRED MILD 3

prednisolone ac 1% eye drop (generic pred forte) 2

prednisolone sod 1% eye drop 2

prednisolone-nepafenac 3

QNASL 3



QNASL CHILDREN 3

XHANCE 3 PA

ZETONNA 3

EENT ANTI-INFLAMMATORY AGENTS, MISC.

CEQUA 3 PA

RESTASIS 1

RESTASIS MULTIDOSE 1

XIIDRA 3 PA

EENT NONSTEROIDAL ANTI-INFLAM. AGENTSACULAR 3

ACULAR LS 3

ACUVAIL 3

bromfenac sodium 2

BROMSITE 3

diclofenac 0.1% eye drops 2

flurbiprofen sodium 2

ILEVRO 1 PA

ketorolac tromethamine (0.4% solution, 0.5% solution) 2

NEVANAC 3

PROLENSA 3

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)INTERLEUKIN ANTAGONISTS

DUPIXENT 200 MG/1.14 ML PEN 4

QL 2 PENS / 28 DAYS

PA

S

DUPIXENT 200 MG/1.14 ML SYRING 4

QL 2.28 ML / 28 DAYS

PA

S



FASENRA PEN 4PA

S

NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/MLSYRINGE)

4PA

S

LEUKOTRIENE MODIFIERSACCOLATE 3

montelukast sodium 2

SINGULAIR 3

zafirlukast 2 PA

zileuton er 2QL 4 TABS / 1 DAY

PA

MAST-CELL STABILIZERS

ALOCRIL 1 PA

cromolyn 100 mg/5 ml oral conc 3 PA

cromolyn 20 mg/2 ml neb soln 2 PA

cromolyn 4% eye drops 2

GASTROCROM 3 PA

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)ANTI-INFLAMMATORY AGENTS, MISC (SKIN)

EUCRISA 1QL 60 GM / 30 DAYS

ST

CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)

ADV ALLERGY COLLECTION KIT 3 PA

ALA-CORT 1% CREAM 3

alclometasone dipropionate 2

amcinonide 0.1% cream 2 PA

amcinonide 0.1% lotion 3

ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1%LOTION)

3



anucort-hc 2

ANUSOL-HC (2.5% CREAM, 25 MG SUPPOSITORY) 3

APEXICON E 3 PA

betamethasone diprop augmented (crm, gel, lot, oin) 2

betamethasone dipropionate (crm, lot, oint) 2

betamethasone valer 0.12% foam 3 PA

betamethasone valerate (va cream, va lotion, valer ointm) 2

BRYHALI 3

CAPEX SHAMPOO 3 PA

clobetasol emollient 0.05% crm 2

clobetasol emollnt 0.05% foam 3 PA

clobetasol emulsion 3 PA

clobetasol propionate (cream, gel, ointment, solution) 2

clobetasol propionate (foam, spray) 3 PA

clobetasol propionate (shampoo, topical lotn) 3

CLOBEX 3 PA

clocortolone pivalate 3

CLODAN (KIT, SHAMPOO) 3

CLODERM 3

COLOCORT 3

CORDRAN (0.025% CREAM, 0.05% CREAM, 0.05% LOTION,0.05% OINTMENT)

3 PA

CORDRAN 4 MCG/SQ CM TAPE LARGE 1 PA

CORTENEMA 3

CORTIFOAM 3 PA

CUTIVATE 0.05% LOTION 3

DERMA-SMOOTHE-FS BODY OIL 3



DERMATOP 3

DESONATE 3 PA

desonide (cream, lotion, ointment) 2

desonide 0.05% gel 3 PA

DESOWEN 0.05% LOTION 3

desoximetasone (0.05% cream, 0.05% gel, 0.25% cream,0.25% ointment)

2

desoximetasone 0.05% ointment 3

desoximetasone 0.25% spray 3 PA

diflorasone diacetate 2 PA

DIPROLENE 3

ELOCON 3

EPIFOAM 3

fluocinolone 0.01% solution 2 QL 60 ML / 30 DAYS

fluocinolone acetonide (0.01% body oil, 0.01% cream,0.01% scalp oil, 0.025% cream, 0.025% ointment)

2

fluocinonide (0.05% cream, 0.05% gel, 0.05% ointment,0.05% solution, 0.1% cream)

2

fluocinonide-e 2

flurandrenolide (cream, lotion, ointment) 3 PA

fluticasone prop 0.05% lotion 3

fluticasone propionate (0.005% oint, 0.05% cream) 2

halcinonide 3 PA

halobetasol propionate (cream, foam, ointmnt) 2 PA

HALOG (CREAM, OINTMENT, SOLUTION) 3 PA

hemmorex-hc 3

hydrocortisone (2.5% cream, 2.5% lotion, 2.5% ointment,100 mg/60 ml)

2

hydrocortisone 1% cream 3



hydrocortisone ac 25 mg supp 2

hydrocortisone butyrate (buty cream, butyr oint) 2

hydrocortisone butyrate (lipid crm, lipo cream) 3

hydrocortisone butyrate (lotn, soln) 3 PA

hydrocortisone valerate 2

hydrocortisone-1% ointment 3

hydrocortisone-pramoxine (1%-1% crm, 2.5-1% crm) 2

IMPEKLO 3 PA

IMPOYZ 3 PA

KENALOG 3 PA

lidocaine-hc 3-0.5% cream 3

LOCOID (CREAM, LOTION, SOLUTION) 3 PA

LOCOID LIPOCREAM 3 PA

LUXIQ 3 PA

MICORT-HC 3

mometasone furoate (cream, oint, soln) 2

NOLIX (CREAM, LOTION) 3 PA

NOVACORT 3 PA

NOXIPAK 3 PA

NUTRIARX 3 PA

OLUX 3 PA

OLUX-E 3 PA

PANDEL 3

PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1%OINTMENT, 2.5%-1% CREAM, 2.5%-1% LOTION, 2.5%-1%OINTMENT)

3

prednicarbate 3



PROCTO-MED HC 2

PROCTO-PAK 3

PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3

PROCTOFOAM-HC 3

PROCTOSOL-HC 2

PROCTOZONE-HC 2

PSORCON 3 PA

SERNIVO 3 PA

SYNALAR (CREAM, CREAM KIT, OINTMENT, OINTMENTKIT)

3

SYNALAR 0.01% SOLUTION 3 QL 60 ML / 30 DAYS

SYNALAR TS 3

TEMOVATE 3

TEXACORT 3

TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT,0.25% CREAM, 0.25% OINTMENT)

3

TOPICORT 0.25% SPRAY 3 PA

TOVET EMOLLIENT 3 PA

triamcinolone 0.05% ointment 3

triamcinolone 0.147 mg/g spray 3 PA

triamcinolone acetonide (0.025% cream, 0.025% lotion,0.025% oint, 0.1% cream, 0.1% lotion, 0.1% ointment,0.1% paste, 0.5% cream, 0.5% ointment)

2

TRIDERM 2

VANOS 3

VANOXIDE-HC 3

VERDESO 3 PA

WHYTEDERM TDPAK 3 PA

WHYTEDERM TRILASIL PAK 3 PA



XILAPAK 3 PA

NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN)FROTEK 10% CREAM PACKET 3

ANTIANEMIA DRUGSIRON PREPARATIONS

ABATRON 3 PA

ACCRUFER 3 PA

folitab 500 3 PA

SIDEROL 3 PA

ANTIARRHYTHMIC AGENTSCLASS IA ANTIARRHYTHMICS

disopyramide phosphate 2

NORPACE 3

NORPACE CR 1

quinidine gluconate 3

quinidine sulfate 2

CLASS IB ANTIARRHYTHMICSmexiletine hcl 2

CLASS IC ANTIARRHYTHMICSflecainide acetate 2

propafenone hcl 2

propafenone hcl er 3 PA

RYTHMOL SR 3

CLASS III ANTIARRHYTHMICSamiodarone hcl (100 mg tablet, 200 mg tablet, 400 mgtablet)

2

dofetilide 2

MULTAQ 1 PA



PACERONE (100 MG TABLET, 400 MG TABLET) 2

TIKOSYN 3

ANTIBACTERIALSAMINOGLYCOSIDE ANTIBIOTICS

ARIKAYCE 4

QL 8.4 ML / 1 DAY

PA

S

BETHKIS 4PA

S

KITABIS PAK 4PA

S

neomycin sulfate 2

TOBI 4PA

S

TOBI PODHALER 4PA

S

tobramycin (300 mg/4 ml ampule, 300 mg/5 ml ampule,pak 300 mg/5 ml)

4PA

S

QUINOLONE ANTIBIOTICS

BAXDELA 450 MG TABLET 1 PA

CIPRO (250 MG TABLET, 500 MG TABLET) 3

CIPRO (5% SUSPENSION, 10% SUSPENSION) 1 AL1 Up to 12 yrs old

ciprofloxacin 2 AL1 Up to 12 yrs old

ciprofloxacin hcl (100 mg tab, 250 mg tab, 500 mg tab,750 mg tab)

2

FACTIVE 1 PA

LEVAQUIN 3

levofloxacin (250 mg tablet, 500 mg tablet, 750 mgtablet)

2



levofloxacin 25 mg/ml solution 2 AL1 Up to 12 yrs old

moxifloxacin hcl 2

ofloxacin 400 mg tablet 3

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)AZULFIDINE 3

BACTRIM 3

BACTRIM DS 3

sulfadiazine 2 PA

sulfamethoxazole-trimethoprim (ds tablet, ss tablet, susp) 2

sulfasalazine 2

sulfasalazine dr 2

SULFATRIM 2

TETRACYCLINE ANTIBIOTICS

ACTICLATE 3 PA

AVIDOXY 3 PA

COREMINO 3 PA

demeclocycline hcl 2

DORYX 3 PA

DORYX MPC 3 PA

doxycycline 25 mg/5 ml susp 2 AL1 Up to 12 yrs old

doxycycline hyclate (50 mg cap, 100 mg cap, 100 mg tab) 2

doxycycline hyclate (50 mg tablet, hyc dr 50 mg tab, hycdr 75 mg tab, hyc dr 80 mg tab, hyc dr 100 mg tab, hyc dr150 mg tab, hyc dr 200 mg tab, hyclate 75 mg tab,hyclate 150 mg tab)

3 PA

doxycycline ir-dr 3 PA

doxycycline monohydrate (50 mg cap, 50 mg tablet, 100mg cap, 100 mg tablet)

2



doxycycline monohydrate (75 mg capsule, 150 mg cap) 3 PA

doxycycline monohydrate (75 mg tablet, 150 mg tablet) 3

MINOCIN 50 MG PELLETIZED CAP 3

minocycline er 3 PA

minocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule)

2

minocycline hcl (50 mg tablet, 75 mg tablet, 100 mgtablet)

3

minocycline hcl er 3 PA

MINOLIRA ER 3 PA

MONDOXYNE NL 3 PA

MONODOX 3 PA

MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 3 PA

OKEBO 3

ORACEA 3 PA

SOLODYN 3 PA

TARGADOX 3 PA

tetracycline hcl 2 PA

VIBRAMYCIN 100 MG CAPSULE 3 PA

VIBRAMYCIN 25 MG/5 ML SUSP 3PA

AL1 Up to 12 yrs old

VIBRAMYCIN 50 MG/5 ML SYRUP 3

XIMINO 3 PA

ANTIBACTERIALS, MISCELLANEOUSGLYCOPEPTIDE ANTIBIOTICS

FIRVANQ 3

VANCOCIN HCL 3



vancomycin 250 mg/5 ml soln 3

vancomycin hcl (125 mg capsule, 250 mg capsule) 2

LINCOMYCIN ANTIBIOTICSCLEOCIN HCL 3

CLEOCIN PEDIATRIC 3 AL1 Up to 12 yrs old

clindamycin (pediatric) 2 AL1 Up to 12 yrs old

clindamycin hcl 2

OTHER MISC. ANTIBACTERIAL AGENTS

HELIDAC 3 PA

PYLERA 3

OXAZOLIDINONE ANTIBIOTICS

linezolid 100 mg/5 ml susp 2 PA

linezolid 600 mg tablet 2 QL 28 TABS / RX

SIVEXTRO 200 MG TABLET 1 PA

ZYVOX 100 MG/5 ML SUSPENSION 3 PA

ZYVOX 600 MG TABLET 3QL 28 TABS / RX

PA

PLEUROMUTILINS

XENLETA 600 MG TABLET 1QL 10 TABS / RX

PA

RIFAMYCIN ANTIBIOTICS

AEMCOLO 3 PA

XIFAXAN 1 PA

ANTICHOLINERGIC AGENTSANTIMUSCARINICS/ANTISPASMODICS

ANASPAZ 3

ANORO ELLIPTA 1



ATROVENT HFA 1 QL 1 INHALER / 25 DAYS

belladonna-phenobarbital 3

BEVESPI AEROSPHERE 3 PA

chlordiazepoxide-clidinium 3

COMBIVENT RESPIMAT 1 QL 1 INHALER / 30 DAYS

CUVPOSA 1 PA

dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mgtablet)

2

DUAKLIR PRESSAIR 3 PA

ed-spaz 2

glycopyrrolate (1 mg tablet, 2 mg tablet) 2

glycopyrrolate 1.5 mg tablet 3 PA

hyoscyamine sulfate (0.125 mg odt, 0.125 mg tab sl,0.125 mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab)

2

hyoscyamine sulfate er 2

hyoscyamine sulfate sr 2

hyosyne 2

INCRUSE ELLIPTA 1

ipratropium br 0.02% soln 2

ipratropium-albuterol 2

LEVBID 3

LEVSIN 0.125 MG TABLET 3

LEVSIN-SL 3

LIBRAX 3

LONHALA MAGNAIR REFILL 3 PA

LONHALA MAGNAIR STARTER 3 PA

methscopolamine bromide 2 PA

nulev 3



oscimin 2

oscimin sl 2

oscimin sr 2

phenobarb-hyosc-atrop-scop tab 3

phenohytro tablet 3

propantheline bromide 2

QBREXZA 4

QL 1 TOWELETTE / 1DAY

PA

S

SEEBRI NEOHALER 3 PA

SPIRIVA 3 PA

SPIRIVA RESPIMAT 3 PA

STIOLTO RESPIMAT 3 PA

symax 3

SYMAX DUOTAB 3

symax-sl 3

symax-sr 2

TUDORZA PRESSAIR 3 PA

YUPELRI 3 PA

ANTICOAGULANTSANTICOAGULANTS, MISCELLANEOUS

ARIXTRA 3QL 1 SYRINGE / 1 DAY

PA

fondaparinux sodium 2QL 1 SYRINGE / 1 DAY

PA

COUMARIN DERIVATIVEScoumadin 3



jantoven 2

warfarin sodium 2

DIRECT FACTOR XA INHIBITORS

BEVYXXA 3 PA

ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 1 QL 2 TABS / 1 DAY

ELIQUIS DVT-PE TREAT START 5MG 1 QL 1 RX / 30 DAYS

SAVAYSA 3 PA

XARELTO (10 MG TABLET, 20 MG TABLET) 1 QL 1 TAB / 1 DAY

XARELTO (2.5 MG TABLET, 15 MG TABLET) 1 QL 2 TABS / 1 DAY

XARELTO DVT-PE TREAT START 30D 1 QL 51 TABS / 30 DAYS

DIRECT THROMBIN INHIBITORS

PRADAXA 1 PA

HEPARINS

enoxaparin 300 mg/3 ml vial 2 QL 2 VIALS / 1 DAY

enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr,60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe,120 mg/0.8 ml syr, 150 mg/ml syringe)

2 QL 2 SYRINGES / 1 DAY

FRAGMIN (2,500 UNIT/0.2 ML SYR, 5,000 UNIT/0.2 MLSYR, 7,500 UNIT/0.3 ML SYR, 10,000 UNIT/ML SYRINGE,12,500 UNIT/0.5 ML SYR, 15,000 UNIT/0.6 ML SYR, 18,000UNIT/0.72 ML)

3 QL 1 SYRINGE / 1 DAY

FRAGMIN 95,000 UNIT/3.8 ML VL 3 QL 1 VIAL / 1 DAY

heparin sodium (sod 1,000 unit/ml vial, 5,000 unit/mlcarpujct, sod 5,000 unit/0.5 ml, sod 5,000 unit/ml syrg,sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod 10,000unit/ml vl, sod 20,000 unit/ml vl, 30,000 unit/30 ml vial,40,000 unit/4 ml vial, 50,000 unit/10 ml vial, 50,000unit/5 ml vial)

2

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

3 QL 2 SYRINGES / 1 DAY



LOVENOX 300 MG/3 ML VIAL 3 QL 2 VIALS / 1 DAY

ANTICONVULSANTSANTICONVULSANTS, MISCELLANEOUS

ACTIVE-PAC 3 PA

APTIOM 1 PA

BANZEL 200 MG TABLET 1QL 16 TABS / 1 DAY

PA

BANZEL 40 MG/ML SUSPENSION 3QL 80 ML / 1 DAY

PA

BANZEL 400 MG TABLET 1QL 8 TABS / 1 DAY

PA

BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MGTABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET)

1 PA

carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200mg tablet)

2

carbamazepine er 2

CARBATROL 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLE 3

DIACOMIT 250 MG CAPSULE 4

QL 12 CAPS / 1 DAY

PA

S

DIACOMIT 250 MG POWDER PACKET 4

QL 12 PACKETS / 1 DAY

PA

S

DIACOMIT 500 MG CAPSULE 4

QL 6 CAPS / 1 DAY

PA

S



DIACOMIT 500 MG POWDER PACKET 4


PA

S

divalproex sodium 2

divalproex sodium er 2

ELEPSIA XR 3 PA

EPIDIOLEX 4

QL 20 ML / 1 DAYS

PA

S

EPITOL 3

EQUETRO 3

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 mlsusp)

2

FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5ML SUSP)

3

FINTEPLA 4PA

S

FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MGTABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12MG TABLET)

1 PA

GABACAINE 3 PA

gabapentin (100 mg capsule, 300 mg capsule) 2 QL 12 CAPS / 1 DAY

gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) 2 QL 72 ML / 1 DAY

gabapentin 400 mg capsule 2 QL 9 CAPS / 1 DAY

gabapentin 600 mg tablet 2 QL 6 TABS / 1 DAY

gabapentin 800 mg tablet 2 QL 4 TABS / 1 DAY

GABITRIL 3

HORIZANT ER 300 MG TABLET 3QL 1 TAB / 1 DAY

PA



HORIZANT ER 600 MG TABLET 3QL 2 TABS / 1 DAY

PA

KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500MG TABLET, 750 MG TABLET, 1,000 MG TABLET)

3 PA

KEPPRA XR 3 PA

LAMICTAL (25 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

3 PA

LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET) 3

LAMICTAL (BLUE) 3 PA

LAMICTAL (GREEN) 3 PA

LAMICTAL (ORANGE) 3 PA

LAMICTAL ODT 3 PA

LAMICTAL ODT (BLUE) 3 PA

LAMICTAL ODT (GREEN) 3 PA

LAMICTAL ODT (ORANGE) 3 PA

LAMICTAL XR 3 PA

LAMICTAL XR (BLUE) 3 PA

LAMICTAL XR (GREEN) 3 PA

LAMICTAL XR (ORANGE) 3 PA

lamotrigine 2

lamotrigine (blue) 3 PA

lamotrigine (green) 3 PA

lamotrigine (orange) 3 PA

lamotrigine er 3

lamotrigine odt 3 PA

lamotrigine odt (blue) 3 PA



lamotrigine odt (green) 3 PA

lamotrigine odt (orange) 3 PA

levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mgtablet, 750 mg tablet, 1,000 mg tablet, 1000 mg/10 ml)

2

levetiracetam er 2

LYRICA (225 MG CAPSULE, 300 MG CAPSULE) 3QL 2 CAPS / 1 DAY

PA

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MGCAPSULE)

3QL 3 CAPS / 1 DAY

PA

LYRICA 20 MG/ML ORAL SOLUTION 3QL 30 ML / 1 DAY

PA

NEURONTIN (100 MG CAPSULE, 300 MG CAPSULE) 3QL 12 CAPS / 1 DAY

PA

NEURONTIN (250 MG/5 ML SOLN, 250 MG/5 MLSOLUTION)

3QL 72 ML / 1 DAY

PA

NEURONTIN 400 MG CAPSULE 3QL 9 CAPS / 1 DAY

PA

NEURONTIN 600 MG TABLET 3QL 6 TABS / 1 DAY

PA

NEURONTIN 800 MG TABLET 3QL 4 TABS / 1 DAY

PA

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml susp, 600 mg tablet)

2

OXTELLAR XR 3 PA

pregabalin (225 mg capsule, 300 mg capsule) 2 QL 2 CAPS / 1 DAY

pregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule,100 mg capsule, 150 mg capsule, 200 mg capsule)

2 QL 3 CAPS / 1 DAY

pregabalin 20 mg/ml solution 2 QL 30 ML / 1 DAY

QUDEXY XR 3 PA



ROWEEPRA 3 PA

ROWEEPRA XR 3 PA

rufinamide 200 mg tablet 2QL 16 TABS / 1 DAY

PA

rufinamide 40 mg/ml suspension 2QL 80 ML / 1 DAY

PA

rufinamide 400 mg tablet 2QL 8 TABS / 1 DAY

PA

SABRIL 4PA

S

SPRITAM 3 PA

SUBVENITE 2

SUBVENITE (BLUE) 3 PA

SUBVENITE (GREEN) 3 PA

SUBVENITE (ORANGE) 3 PA

TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3

TEGRETOL XR 3

tiagabine hcl 2

TOPAMAX 3 PA

topiramate 2

topiramate er 3 PA

TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5ML SUSP, 600 MG TABLET)

3 PA

TROKENDI XR 3 PA

valproic acid (250 mg capsule, 250 mg/5 ml soln, 500mg/10 ml sol)

2

vigabatrin 4PA

S



VIGADRONE 4PA

S

VIMPAT (150 MG TABLET, 200 MG TABLET) 1 QL 2 TABS / 1 DAY

VIMPAT 10 MG/ML SOLUTION 1 QL 40 ML / 1 DAY

VIMPAT 100 MG TABLET 1 QL 4 TABS / 1 DAY

VIMPAT 50 MG TABLET 1 QL 8 TABS / 1 DAY

XCOPRI 3 QL 1 TAB / 1 DAY

ZONEGRAN 3 PA

zonisamide 2

BARBITURATES (ANTICONVULSANTS)

MYSOLINE 3 PA

primidone 2

BENZODIAZEPINES (ANTICONVULSANTS)

clobazam 10 mg tablet 2 QL 4 TABS / 1 DAY

clobazam 2.5 mg/ml suspension 2 QL 16 ML / 1 DAY

clobazam 20 mg tablet 2 QL 2 TABS / 1 DAY

clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mgodt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet)

2 QL 6 TABS / 1 DAY

clonazepam (1 mg dis tablet, 1 mg odt, 1 mg tablet) 2 QL 4 TABS / 1 DAY

clonazepam (2 mg odt, 2 mg tablet) 2 QL 2 TABS / 1 DAY

KLONOPIN 0.5 MG TABLET 3 QL 6 TABS / 1 DAY

KLONOPIN 1 MG TABLET 3 QL 4 TABS / 1 DAY

KLONOPIN 2 MG TABLET 3 QL 2 TABS / 1 DAY

NAYZILAM 1QL 2 BOTTLES / RX

PA

ONFI 10 MG TABLET 3QL 4 TABS / 1 DAY

PA



ONFI 2.5 MG/ML SUSPENSION 3QL 16 ML / 1 DAY

PA

ONFI 20 MG TABLET 3QL 2 TABS / 1 DAY

PA

SYMPAZAN 3

HYDANTOINSDILANTIN (50 MG INFATAB, 100 MG CAPSULE) 3

DILANTIN 30 MG CAPSULE 1

DILANTIN-125 3

PEGANONE 3

PHENYTEK 3

phenytoin (50 mg infatab, 50 mg tablet chew, 125 mg/5ml susp)

2

phenytoin sodium extended 2

SUCCINIMIDESCELONTIN 1

ethosuximide (250 mg capsule, 250 mg/5 ml soln) 2

ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3

ANTIDEPRESSANTSANTIDEPRESSANTS, MISCELLANEOUS

APLENZIN 3 PA

bupropion hcl 2

bupropion hcl sr 2

bupropion hcl xl 450 mg tablet 3 PA

bupropion xl (150 mg tablet, 300 mg tablet) 2

FORFIVO XL 3 PA

mirtazapine (15 mg odt, 30 mg odt, 45 mg odt) 3

mirtazapine (7.5 mg tablet, 15 mg tablet, 30 mg tablet, 45mg tablet)

2



REMERON 3

SPRAVATO 3 PA

WELLBUTRIN SR 3

WELLBUTRIN XL 3 PA

MONOAMINE OXIDASE INHIBITORSMARPLAN 3

NARDIL 3

PARNATE 3

phenelzine sulfate 2

tranylcypromine sulfate 2

SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR

CYMBALTA 3 PA

desvenlafaxine er 3

desvenlafaxine suc er 100 mg tablet (generic for pristiq) 2



DRIZALMA SPRINKLE 3 PA

duloxetine hcl (dr 20 mg cap, dr 30 mg cap, dr 60 mg cap) 2

duloxetine hcl dr 40 mg cap 3 PA

EFFEXOR XR 3 PA

FETZIMA 1 PA

PRISTIQ 3 PA

venlafaxine hcl 2

venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er 150mg cap)

2

venlafaxine hcl er (er 37.5 mg tab, er 75 mg tab, er 150mg tab, er 225 mg tab)

3



SELECTIVE-SEROTONIN REUPTAKE INHIBITORSBRISDELLE 3

CELEXA 3 PA

citalopram hbr (10 mg tablet, 10 mg/5 ml soln, 20 mgtablet, 20 mg/10 ml sol, 40 mg tablet)

2

escitalopram oxalate (5 mg tablet, oxalate 5 mg/5 ml, 10mg tablet, 20 mg tablet)

2

fluoxetine dr 3

fluoxetine hcl (10 mg tablet, 20 mg tablet, 60 mg tablet) 3

fluoxetine hcl (hcl 10 mg capsule, 20 mg/5 ml solution, hcl20 mg capsule, hcl 40 mg capsule)

2

fluvoxamine maleate 2

fluvoxamine maleate er 3

LEXAPRO 3 PA

olanzapine-fluoxetine hcl 3 AL1 At least 13 yrs old

paroxetine cr 3

paroxetine er 3

paroxetine hcl (10 mg tablet, 10 mg/5 ml susp, 20 mgtablet, 30 mg tablet, 40 mg tablet)

2

paroxetine mesylate 3

PAXIL (10 MG TABLET, 10 MG/5 ML SUSPENSION, 20 MGTABLET, 30 MG TABLET, 40 MG TABLET)

3

PAXIL CR 3

PEXEVA 3

PROZAC 3 PA

SARAFEM 3

sertraline hcl (150 mg capsule, 200 mg capsule) 3 PA

sertraline hcl (20 mg/ml oral conc, hcl 25 mg tablet, hcl 50mg tablet, hcl 100 mg tablet)

2

SYMBYAX 3 AL1 At least 13 yrs old


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSZOLOFT (20 MG/ML ORAL CONC, 25 MG TABLET, 50 MGTABLET, 100 MG TABLET)

3 PA

SEROTONIN MODULATORSnefazodone hcl 2

trazodone hcl 2

TRINTELLIX 1 PA

VIIBRYD 1 PA

TRICYCLICS, OTHER NOREPI-RU INHIBITORSamitriptyline hcl 2

amoxapine 2 PA

ANAFRANIL 3

chlordiazepoxide-amitriptyline 2PA

AQ1 Up to 64 yrs old; 4 /1 DAY

clomipramine hcl 2

desipramine hcl 2

doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mgcapsule, 50 mg capsule, 75 mg capsule, 100 mg capsule,150 mg capsule)

2

doxepin hcl (3 mg tablet, 6 mg tablet) 2 PA

imipramine hcl 2

imipramine pamoate 3

maprotiline hcl 2 PA

NORPRAMIN 3

nortriptyline hcl (10 mg/5 ml soln, hcl 10 mg cap, hcl 25mg cap, hcl 50 mg cap, hcl 75 mg cap)

2

PAMELOR 3

perphenazine-amitriptyline 2PA


protriptyline hcl 2 PA



SILENOR 3 PA

TOFRANIL 3 PA

trimipramine maleate 2 PA

ANTIDIABETIC AGENTSALPHA-GLUCOSIDASE INHIBITORS

acarbose 2

GLYSET 3

miglitol 2

AMYLINOMIMETICSSYMLINPEN 60 3

ANTIDIABETIC AGENTS, MISCELLANEOUS

KORLYM 4PA

S

BIGUANIDES

FORTAMET 3 PA

GLUMETZA 3 PA

metformin er 1,000 mg gastr-tb (generic for glumetza er) 3 PA

metformin er 1,000 mg osm-tab (generic for fortamet er) 3 PA

metformin er 500 mg gastrc-tb (generic for glumetza er) 3 PA

metformin er 500 mg osmotic tb (generic for fortamet er) 3 PA

metformin hcl 1,000 mg tablet (generic for glucophage) 2

metformin hcl 500 mg tablet (generic for glucophage) 2

metformin hcl 500 mg/5 ml soln 3

metformin hcl 850 mg tablet 2

metformin hcl er 2

RIOMET 3

RIOMET ER 3 PA



DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

alogliptin 2 QL 1 TAB / 1 DAY

alogliptin-metformin 2 QL 2 TABS / 1 DAY

alogliptin-pioglitazone 2 QL 1 TAB / 1 DAY

JANUMET 3QL 2 TABS / 1 DAY

PA

JANUMET XR 3QL 2 TABS / 1 DAY

PA

JANUVIA 3QL 1 TAB / 1 DAY

PA

JENTADUETO 1 QL 2 TABS / 1 DAY

JENTADUETO XR 1 QL 2 TABS / 1 DAY

KAZANO 3QL 2 TABS / 1 DAY

PA

KOMBIGLYZE XR 3QL 2 TABS / 1 DAY

PA

NESINA 3QL 1 TAB / 1 DAY

PA

ONGLYZA 3QL 1 TAB / 1 DAY

PA

OSENI 3QL 1 TAB / 1 DAY

PA

TRADJENTA 1 QL 1 TAB / 1 DAY

INCRETIN MIMETICS

ADLYXIN 3QL 6 PENS / 28 DAYS

PA

BYDUREON BCISE 1 QL 3.4 ML / 28 DAYS



BYDUREON PEN 1 QL 4 PEN / 28 DAYS

BYETTA 10 MCG DOSE PEN INJ 1 QL 2.4 ML / 30 DAYS

BYETTA 5 MCG DOSE PEN INJ 1 QL 1.2 ML / 30 DAYS

OZEMPIC (1 MG/DOSE (2 MG/1.5ML), 1 MG/DOSE (4MG/3 ML))

1 QL 3 ML / 28 DAYS

OZEMPIC 0.25-0.5 MG/DOSE PEN 1 QL 1.5 ML / 28 DAYS

RYBELSUS 1 QL 1 TAB / 1 DAY

SAXENDA 3PA

WL Weight Loss

TRULICITY 1 QL 2 ML / 28 DAYS

VICTOZA 2-PAK 1 QL 9 ML / 30 DAYS

VICTOZA 3-PAK 1 QL 9 ML / 30 DAYS

WEGOVY 3PA

WL Weight Loss

MEGLITINIDESnateglinide 2

repaglinide 2

repaglinide-metformin hcl 3

STARLIX 3

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

FARXIGA 3QL 1 TAB / 1 DAY

PA

GLYXAMBI 1 QL 1 TAB / 1 DAY

INVOKAMET 3QL 2 TABS / 1 DAY

PA

INVOKAMET XR 3QL 2 TABS / 1 DAY

PA



INVOKANA 3QL 1 TAB / 1 DAY

PA

JARDIANCE 1 QL 1 TAB / 1 DAY

QTERN 3QL 1 TAB / 1 DAY

PA

SEGLUROMET 3QL 2 TABS / 1 DAY

PA

STEGLATRO 3QL 1 TAB / 1 DAY

PA

STEGLUJAN 3QL 1 TAB / 1 DAY

PA

SYNJARDY 1 QL 2 TABS / 1 DAY

SYNJARDY XR (10-1,000 MG TABLET, 25-1,000 MGTABLET)

1 QL 1 TAB / 1 DAY

SYNJARDY XR (5-1,000 MG TABLET, 12.5-1,000 MG TAB) 1 QL 2 TABS / 1 DAY

TRIJARDY XR (10-5-1,000 MG TAB, 25-5-1,000 MG TAB) 1 QL 1 TAB / 1 DAY

TRIJARDY XR (5-2.5-1,000 MG TAB, 12.5-2.5-1,000 MG) 1 QL 2 TABS / 1 DAY

XIGDUO XR 3QL 1 TAB / 1 DAY

PA

SULFONYLUREASAMARYL 3

glimepiride 2

glipizide 2

glipizide er 2

glipizide xl 2

glipizide-metformin 2

GLUCOTROL 3

GLUCOTROL XL 3



glyburide 2 PA

glyburide micronized 2 PA

glyburide-metformin hcl 2 PA

GLYNASE 3 PA

THIAZOLIDINEDIONESACTOPLUS MET 3

ACTOPLUS MET XR 3

ACTOS 3

AVANDIA 3 PA

DUETACT 3

pioglitazone hcl 2

pioglitazone-glimepiride 2

pioglitazone-metformin 2

ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS

granisetron hcl 1 mg tablet 2 PA

ondansetron hcl (4 mg/5 ml solution, hcl 4 mg tablet, hcl 8mg tablet, hcl 24 mg tablet)

2

ondansetron odt 2

SANCUSO 3 PA

ZOFRAN 3 PA

ZUPLENZ 3 PA

ANTIEMETICS, MISCELLANEOUS

dronabinol (2.5 mg capsule, 5 mg capsule) 2 QL 6 CAPS / 1 DAY

dronabinol 10 mg capsule 2 QL 4 CAPS / 1 DAY

MARINOL (2.5 MG CAPSULE, 5 MG CAPSULE) 3 QL 6 CAPS / 1 DAY

MARINOL 10 MG CAPSULE 3 QL 4 CAPS / 1 DAY



scopolamine 2

SYNDROS 3

TRANSDERM-SCOP 3

ANTIHISTAMINES (GI DRUGS)

ANTIVERT 3 PA

BONJESTA 3 PA

DICLEGIS 3 PA

doxylamine succ-pyridoxine hcl 3 PA

meclizine 12.5 mg tablet 3

meclizine 25 mg tablet 2 PA

prochlorperazine 2

prochlorperazine maleate 2

TIGAN 300 MG CAPSULE 3

trimethobenzamide hcl 2

NEUROKININ-1 RECEPTOR ANTAGONISTSAKYNZEO 300-0.5 MG CAPSULE 3

aprepitant 2

EMEND (40 MG CAPSULE, 80 MG CAPSULE, 125 MGCAPSULE, TRIPACK)

3

EMEND 125 MG POWDER PACKET 1

VARUBI (90 MG TABLET, 180 MG DOSE(2X 90MG TB)) 3

ANTIFUNGAL (SYSTEMIC)ALLYLAMINE ANTIFUNGALS

terbinafine hcl 2

ANTIFUNGALS, MISCELLANEOUS

BREXAFEMME 3 PA

griseofulvin (125 mg/5 ml susp, micro 500 mg tab) 2

griseofulvin ultramicrosize 2



AZOLE ANTIFUNGALS

CRESEMBA 186 MG CAPSULE 1 PA

DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/MLSUSPENSION, 50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

3

fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet,100 mg tablet, 150 mg tablet, 200 mg tablet)

2

itraconazole 10 mg/ml solution 3 PA

itraconazole 100 mg capsule 2

ketoconazole 200 mg tablet 2

NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) 3 PA

ONMEL 3 PA

posaconazole 2 PA

SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) 3 PA

TOLSURA 3 PA

VFEND (40 MG/ML SUSPENSION, 50 MG TABLET, 200 MGTABLET)

3 PA

voriconazole (40 mg/ml susp, 50 mg tablet, 200 mgtablet)

2 PA

POLYENE ANTIFUNGALS

nystatin (100,000 unit/ml susp, 500,000 unit/5 ml sus) 2 QL 480 ML / RX

nystatin 500,000 unit oral tab 2

PYRIMIDINE ANTIFUNGALS

ANCOBON 3 PA

flucytosine 2 PA

ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)ALLYLAMINES (SKIN AND MUCOUS MEMBRANE)

naftifine hcl (cream, gel) 2 PA

naftifine hcl 2% cream 2QL 60 GM / 30 DAYS

PA



NAFTIN (1% GEL, 2% GEL) 3 PA

NAFTIN 2% CREAM 3 QL 60 GM / 30 DAYS

AZOLES (SKIN AND MUCOUS MEMBRANE)clotrimazole 1% solution 3

clotrimazole 10 mg troche 2

clotrimazole-1% solution 3

clotrimazole-betamethasone crm 2

DERMACINRX THERAZOLE PAK 3 PA

econazole nitrate 2 QL 85 GM / 30 DAYS

ECOZA 3

ERTACZO 1 PA

EXELDERM (CREAM, SOLUTION) 3 PA

EXTINA 3

GYNAZOLE 1 3

JUBLIA 3 PA

ketoconazole 2% cream 2 QL 60 GM / 30 DAYS

ketoconazole 2% foam 3

ketoconazole 2% shampoo 2

KETODAN 2% FOAM 3

LOTRISONE 3

luliconazole 2 PA

LUZU 3 PA

miconazole 3 200 mg vag supp 3

miconazole-zinc oxide-petroltm 3 PA

NIZORAL 3

ORAVIG 3



oxiconazole nitrate 2QL 60 GM / 30 DAYS

PA

OXISTAT 1% CREAM 3 QL 60 GM / 30 DAYS

OXISTAT 1% LOTION 1 PA

sulconazole nitrate (cream, soln) 2 PA

terconazole (0.4% cream, 0.8% cream, 80 mg suppository) 2

VUSION 3 PA

BENZYLAMINES (SKIN AND MUCOUS MEMBRANE)MENTAX 3

HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)CICLODAN (0.77% CREAM, 0.77% CREAM KIT, 8%SOLUTION)

3

ciclopirox (0.77% cream, 0.77% gel, 1% shampoo, 8%solution)

2

ciclopirox 0.77% topical susp 2 QL 60 ML / 30 DAYS

ciclopirox 8% treatment kit 3

LOPROX (0.77% CREAM, 0.77% SUSPENSION KIT, 1%SHAMPOO)

3

PENLAC 3

OXABOROLES

KERYDIN 3 PA

tavaborole 3 PA

POLYENES (SKIN AND MUCOUS MEMBRANE)

NYAMYC 3 QL 240 GM / RX

nystatin (unit/gm cream, unit/gm oint) 2

nystatin 100,000 unit/gm powd 2 QL 240 GM / RX

nystatin-triamcinolone 2 PA

NYSTOP 3 QL 240 GM / RX



ANTIGLAUCOMA AGENTSALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P 0.1% DROPS 1

brimonidine tartrate 2

COMBIGAN 1

BETA-ADRENERGIC BLOCKING AGENTS (EENT)betaxolol hcl 0.5% eye drop 2

BETIMOL 3

BETOPTIC S 3

carteolol hcl 2

ISTALOL 3

levobunolol hcl 2

metipranolol 2 PA

timolol 0.5% eye drop (generic for istalol) 3

timolol maleate (0.25%, 0.25% gfs, 0.5%, 0.5% gfs) 2

timolol maleate 0.25% eye drop (generic for timoptic) 2

timolol maleate 0.5% eye drops (generic for timoptic) 2

timolol maleate/pf 0.5% eye drop (generic for ocudose) 3 PA

TIMOPTIC 3

TIMOPTIC OCUDOSE (0.25% DROP, 0.5% DROP) 3 PA

TIMOPTIC-XE 3

CARBONIC ANHYDRASE INHIBITORS (EENT)acetazolamide 2

acetazolamide er 2

AZOPT 3

brinzolamide 2

COSOPT 3

COSOPT PF 3



dorzolamide hcl 2

dorzolamide-timolol (2%-0.5%, eye drops) 2

methazolamide 2

SIMBRINZA 1

TRUSOPT 3

MIOTICSISOPTO CARPINE 3

PHOSPHOLINE IODIDE 1

pilocarpine hcl (1% drops, 2% drops, 4% drops) 2

PROSTAGLANDIN ANALOGSbimatoprost 0.03% eye drops 2

latanoprost 2

LUMIGAN 1

TRAVATAN Z 3

travoprost 2

VYZULTA 3 PA

XALATAN 3

XELPROS 3

ZIOPTAN 1 PA

RHO KINASE INHIBITORSRHOPRESSA 1

ROCKLATAN 1

ANTIHEMORRHAGIC AGENTSHEMOSTATICS

ADVATE 4PA

S

ADYNOVATE 4PA

S



AFSTYLA 4PA

S

ALPHANATE 4PA

S

ALPHANINE SD 4PA

S

ALPROLIX 4PA

S

AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET,1,000 MG TABLET)

3 PA

aminocaproic acid (0.25 gram/ml, 500 mg tab, 1,000 mgtab)

3 PA

BENEFIX 4PA

S

COAGADEX 4PA

S

CORIFACT 4PA

S

ELOCTATE 4PA

S

ESPEROCT 4PA

S

FEIBA NF 4PA

S

HEMLIBRA 4PA

S

HEMOFIL M 4PA

S

HUMATE-P 4PA

S



IDELVION 4PA

S

IXINITY 4PA

S

JIVI 4PA

S

KOATE 4PA

S

KOGENATE FS 4PA

S

KOVALTRY 4PA

S

LYSTEDA 3 QL 30 TABS / RX

MONONINE 4 S

NOVOEIGHT 4PA

S

NOVOSEVEN RT 4PA

S

NUWIQ 4PA

S

OBIZUR 4PA

S

PROFILNINE 4PA

S

REBINYN 4PA

S

RECOMBINATE 4PA

S



RIXUBIS 4PA

S

SEVENFACT 4PA

S

tranexamic acid 650 mg tablet 2 QL 30 TABS / RX

TRETTEN 4PA

S

VONVENDI 4PA

S

WILATE 4PA

S

XYNTHA 4PA

S

XYNTHA SOLOFUSE 4PA

S

ANTIHISTAMINE DRUGSSECOND GENERATION ANTIHISTAMINES

cetirizine hcl (1 mg/ml soln, 1 mg/ml syrup, 5 mg/5 mlsoln)

3

CLARINEX 3 PA

CLARINEX-D 12 HOUR 3 PA

desloratadine (2.5 mg odt, 5 mg odt) 3

desloratadine 5 mg tablet 2 PA

levocetirizine 2.5 mg/5 ml sol 3

levocetirizine 5 mg tablet 2 PA

SEMPREX-D 3

XYZAL 5 MG TABLET 3



ANTIHYPOGLYCEMIC AGENTSANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS

diazoxide 3

PROGLYCEM 3

GLYCOGENOLYTIC AGENTSBAQSIMI 1

GLUCAGEN 1 MG HYPOKIT (NOVO) 3

GLUCAGEN DIAGNOSTIC 1 MG VIAL 3

glucagon 1 mg emergency kit 2

glucagon 1 mg emergency kit (generic glucagen) 2

GLUCAGON 1 MG EMERGENCY KIT (LILLY) 3

GLUCAGON 1 MG VIAL 1

GVOKE HYPOPEN 1-PACK 1

GVOKE HYPOPEN 2-PACK 1

GVOKE PFS 1-PACK SYRINGE 1

GVOKE PFS 2-PACK SYRINGE 1

ZEGALOGUE AUTOINJECTOR 1

ZEGALOGUE SYRINGE 1

ANTILIPEMIC AGENTSANTILIPEMIC AGENTS, MISCELLANEOUS

icosapent ethyl 2 PA

JUXTAPID 4PA

S

LOVAZA 3

NEXLETOL 3 PA

NEXLIZET 3 PA

niacin er 3

NIACOR 3



NIASPAN 3

omega-3 acid ethyl esters 2

TRIKLO 2

VASCEPA 1 PA

BILE ACID SEQUESTRANTScholestyramine (packet, powder) 2

cholestyramine light (packet, powder) 2

colesevelam hcl 3 PA

COLESTID (1 GM TABLET, FLAVORED GRANULES,GRANULES, GRANULES PACKET)

3

colestipol hcl (granules, granules packet) 3

colestipol hcl 1 gm tablet 2

PREVALITE (PACKET, POWDER) 2

QUESTRAN (PACKET, POWDER) 3

QUESTRAN LIGHT 3

WELCHOL 3 PA

CHOLESTEROL ABSORPTION INHIBITORSezetimibe 2

ezetimibe-simvastatin 2 PA

rosuvastatin-ezetimibe 3 PA

ROSZET 3 PA

VYTORIN 3

ZETIA 3

FIBRIC ACID DERIVATIVES

ANTARA 3 PA

fenofibrate (40 mg tablet, 120 mg tablet) 3 PA

fenofibrate (43 mg capsule, 50 mg capsule, 130 mgcapsule, 150 mg capsule)

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSfenofibrate (48 mg tablet, 54 mg tablet, 67 mg capsule,134 mg capsule, 145 mg tablet, 160 mg tablet, 200 mgcapsule)

2

fenofibric acid (35 mg tablet, dr 45 mg cap, 105 mgtablet, dr 135 mg cap)

3

FENOGLIDE 3 PA

FIBRICOR 3

gemfibrozil 2

LIPOFEN 3

LOPID 3

TRICOR 3

TRIGLIDE 3

TRILIPIX 3

HMG-COA REDUCTASE INHIBITORSamlodipine-atorvastatin 3

atorvastatin calcium (10 mg tablet, 20 mg tablet) 2 ACA Affordable Care Act

atorvastatin calcium (40 mg tablet, 80 mg tablet) 2

CADUET 3

CRESTOR 3 PA

EZALLOR SPRINKLE 3 PA

FLOLIPID 20 MG/5 ML ORAL SUSP 3 PA

FLOLIPID 40 MG/5 ML ORAL SUSP 3

fluvastatin er 2 PA

fluvastatin sodium 2 PA

LESCOL 3

LESCOL XL 3

LIPITOR 3 PA

LIVALO 3



lovastatin (20 mg tablet, 40 mg tablet) 2 ACA Affordable Care Act

lovastatin 10 mg tablet 2

PRAVACHOL 3

pravastatin sodium 2 ACA Affordable Care Act

rosuvastatin calcium (20 mg tab, 40 mg tab) 2

rosuvastatin calcium (5 mg tab, 10 mg tab) 2 ACA Affordable Care Act

simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 2 ACA Affordable Care Act

simvastatin (5 mg tablet, 80 mg tablet) 2

simvastatin 20 mg/5 ml susp 3 PA

ZOCOR 3

ZYPITAMAG 3 PA

PCSK9 INHIBITORS

PRALUENT PEN 3QL 2 PENS / 28 DAYS

PA

REPATHA PUSHTRONEX 1QL 1 PEN / 28 DAYS

PA

REPATHA SURECLICK 1QL 2 PENS / 28 DAYS

PA

REPATHA SYRINGE 1QL 2 PENS / 28 DAYS

PA

ANTIMIGRAINE AGENTSCALCITONIN GENE-RELATED PEPTIDE ANTAG.

AIMOVIG AUTOINJECTOR 4

QL 1 ML / 30 DAYS

PA

S

AJOVY AUTOINJECTOR 4

QL 1.5 ML / 30 DAYS

PA

S



AJOVY SYRINGE 4

QL 1.5 ML / 30 DAYS

PA

S

EMGALITY 120 MG/ML SYRINGE 4

QL 1 ML / 30 DAYS

PA

S

EMGALITY PEN 4

QL 1 ML / 30 DAYS

PA

S

EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 300 MG(100 MG X3SYR))

4

QL 3 ML / 30 DAYS

PA

S

NURTEC ODT 1QL 8 TABS / 30 DAYS

PA

QULIPTA 4

QL 1 TAB / DAY

PA

S

UBRELVY 3QL 10 TABS / 30 DAYS

PA

SELECTIVE SEROTONIN AGONISTS

almotriptan malate 2QL 12 TABS / 28 DAYS

PA

AMERGE 3QL 12 TABS / 30 DAYS

PA

eletriptan hbr 2QL 12 TABS / 28 DAYS

PA

FROVA 3QL 12 TABS / 28 DAYS

PA

frovatriptan succinate 2QL 12 TABS / 28 DAYS

PA



IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 3QL 12 TABS / 28 DAYS

PA

IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PENINJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PENINJECT, 6 MG/0.5 ML VIAL)

3QL 5 ML / 30 DAYS

PA

IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 3QL 12 ML / 30 DAYS

PA

MAXALT 3QL 12 TABS / 28 DAYS

PA

MAXALT MLT 3QL 12 TABS / 28 DAYS

PA

MIGRANOW 3 PA

naratriptan hcl 2 QL 12 TABS / 30 DAYS

ONZETRA XSAIL 3QL 16 CAPS / 30 DAYS

PA

RELPAX 3QL 12 TABS / 28 DAYS

PA

REYVOW 1QL 8 TABS / 30 DAYS

PA

rizatriptan 2 QL 12 TABS / 28 DAYS

sumatriptan 2 QL 12 ML / 30 DAYS

sumatriptan succ-naproxen sod 2QL 12 TABS / 28 DAYS

PA

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100mg tablet)

2 QL 12 TABS / 28 DAYS

sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 mlinject, 6 mg/0.5 ml cart, 6 mg/0.5 ml inject, 6 mg/0.5 mlsyrng, 6 mg/0.5 ml vial)

2 QL 5 ML / 30 DAYS

TOSYMRA 3QL 6 DOSES / 30 DAYS

PA



TREXIMET 3QL 12 TABS / 28 DAYS

PA

ZEMBRACE SYMTOUCH 3QL 4 ML / 30 DAYS

PA

zolmitriptan (2.5 mg nasal spry, 5 mg nasal spray) 3 QL 12 ML / 30 DAYS

zolmitriptan (2.5 mg tablet, 5 mg tablet) 2 QL 12 TABS / 28 DAYS

zolmitriptan odt 2 QL 12 TABS / 28 DAYS

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 3QL 12 ML / 30 DAYS

PA

ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3QL 12 TABS / 28 DAYS

PA

ZOMIG ZMT 3QL 12 TABS / 28 DAYS

PA

ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, MISCELLANEOUS

dapsone (25 mg tablet, 100 mg tablet) 2

ANTITUBERCULOSIS AGENTS

cycloserine 2 PA

ethambutol hcl 2

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mgtablet)

2

MYAMBUTOL 3

MYCOBUTIN 3

PASER 3

pretomanid 2 PA

PRIFTIN 1

pyrazinamide 2

rifabutin 2



RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3

RIFAMATE 3

rifampin (150 mg capsule, 300 mg capsule) 2

RIFATER 3

SIRTURO 1 PA

TRECATOR 1 PA

ANTINEOPLASTIC AGENTS

abiraterone 500 mg tablet 2

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

abiraterone acetate 250 mg tab 2

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

AFINITOR (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET) 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

AFINITOR 10 MG TABLET 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

AFINITOR DISPERZ (2 MG TABLET, 5 MG TABLET) 1

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



AFINITOR DISPERZ 3 MG TABLET 1

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ALECENSA 1

QL 8 CAPS / 30 DAYS

PA

S

ONC Oncology

ALKERAN 2 MG TABLET 3 PA

ALUNBRIG (90 MG-180 MG TAB PACK, 180 MG TABLET) 3

QL 1 TAB / 1 DAY

PA

S

ALUNBRIG 30 MG TABLET 3

QL 4 TABS / 1 DAY

PA

S

ALUNBRIG 90 MG TABLET 3

QL 2 TABS / 1 DAY

PA

S

anastrozole 2 ACA Affordable Care Act

ARIMIDEX 3 PA

AROMASIN 3 PA

AYVAKIT 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

BALVERSA 1PA

S

bexarotene 2

QL 10 CAPS / 1 DAY

PA

S

TD Trial Drug



bicalutamide 2

BOSULIF (400 MG TABLET, 500 MG TABLET) 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

BOSULIF 100 MG TABLET 1

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

BRAFTOVI 50 MG CAPSULE 1

QL 2 CAPS / 1 DAY

PA

S

BRAFTOVI 75 MG CAPSULE 1

QL 6 CAPS / 1 DAY

PA

S

BRUKINSA 4

PA

S

ONC Oncology

CABOMETYX 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

CALQUENCE 3

QL 2 CAPS / 1 DAY

PA

S

capecitabine 2S

ONC Oncology

CAPRELSA 100 MG TABLET 1

QL 2 TABS / 1 DAY

PA

S

ONC OncologyPAGE 75 LAST UPDATED 01/2022


CAPRELSA 300 MG TABLET 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

CARAC 3 PA

CASODEX 3 PA

COMETRIQ 100 MG DAILY-DOSE PK 1

QL 2 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

COMETRIQ 140 MG DAILY-DOSE PK 1

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

COMETRIQ 60 MG DAILY-DOSE PACK 1

QL 3 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

COPIKTRA 1

QL 2 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

COTELLIC 1

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

cyclophosphamide (25 mg capsule, 25 mg tablet, 50 mgcapsule, 50 mg tablet)

2



DAURISMO 100 MG TABLET 1

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

DAURISMO 25 MG TABLET 1

QL 3 TABS / 1 DAY

PA

S

TD Trial Drug

diclofenac sodium 3% gel 3

DROXIA 3

EFUDEX 3 PA

EMCYT 1

ERIVEDGE 1

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ERLEADA 1

PA

S

ONC Oncology

erlotinib hcl (100 mg tablet, 150 mg tablet) 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

erlotinib hcl 25 mg tablet 2

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

etoposide 50 mg capsule 2



everolimus (2 mg tab susp, 5 mg tab susp) 2

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

everolimus (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10mg tablet)

2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

everolimus 3 mg tab for susp 2

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

exemestane 2 ACA Affordable Care Act

EXKIVITY 1

QL 4 CAPS / DAY

PA

S

ONC Oncology

FARYDAK 3

QL 1 CAP / 1 DAY

PA

S

FEMARA 3 PA

FLUOROPLEX 3

fluorouracil (2% topical soln, 5% cream, 5% topical soln) 2

fluorouracil 0.5% cream 3 PA

flutamide 2

FOTIVDA 1

QL 21 CAPS / 28 DAYS

PA

S

ONC Oncology



GAVRETO 1

PA

S

ONC Oncology

GILOTRIF 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

GLEEVEC 3

PA

S

TD Trial Drug

GLEOSTINE 1

HYCAMTIN 1S

ONC Oncology

HYDREA 3 PA

hydroxyurea 2

IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125 MGCAPSULE)

1


PA

S

ONC Oncology

IBRANCE (75 MG TABLET, 100 MG TABLET, 125 MGTABLET)

1

QL 21 TABS / 28 DAYS

PA

S

ONC Oncology

ICLUSIG (10 MG TABLET, 15 MG TABLET) 1

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ICLUSIG (30 MG TABLET, 45 MG TABLET) 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



IDHIFA 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

imatinib mesylate 2

S

ONC Oncology

TD Trial Drug

IMBRUVICA (420 MG TABLET, 560 MG TABLET) 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

IMBRUVICA 140 MG CAPSULE 1

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

IMBRUVICA 140 MG TABLET 3

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

IMBRUVICA 280 MG TABLET 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

IMBRUVICA 70 MG CAPSULE 1

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

INLYTA 1 MG TABLET 1

QL 6 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



INLYTA 5 MG TABLET 1

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

INQOVI 1

QL 5 TABS / 28 DAYS

PA

S

ONC Oncology

INREBIC 1

PA

S

ONC Oncology

IRESSA 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

JAKAFI 1

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

KISQALI 200 MG DAILY DOSE 1


PA

S

ONC Oncology



PA

S

ONC Oncology



PA

S

ONC Oncology



KISQALI FEMARA 200 MG CO-PACK 1


PA

S

ONC Oncology



PA

S

ONC Oncology



PA

S

ONC Oncology

KOSELUGO 10 MG CAPSULE 1

QL 8 CAPS / 1 DAY

PA

S

ONC Oncology

KOSELUGO 25 MG CAPSULE 1

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

lapatinib 2

QL 6 TABS / 1 DAY

PA

S

ONC Oncology

LENVIMA (12 MG DAILY, 18 MG DAILY, 24 MG DAILY) 3

QL 3 CAPS / 1 DAY

PA

S

TD Trial Drug

LENVIMA (8 MG DAILY, 14 MG DAILY, 20 MG DAILY) 3

QL 2 CAPS / 1 DAY

PA

S

TD Trial Drug



LENVIMA 10 MG DAILY DOSE 3

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

LENVIMA 4 MG CAPSULE 3

QL 1 CAP / 1 DAY

PA

S

TD Trial Drug

letrozole 2 ACA Affordable Care Act

LEUKERAN 1

LONSURF 15 MG-6.14 MG TABLET 1

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

LONSURF 20 MG-8.19 MG TABLET 1

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

LORBRENA 100 MG TABLET 1

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

LORBRENA 25 MG TABLET 1

QL 3 TABS / 1 DAY

PA

S

TD Trial Drug

LUMAKRAS 1

PA

S

ONC Oncology

LYNPARZA 1

QL 4 TABS / 1 DAY

PA

S

TD Trial Drug



LYSODREN 1PA

S

MATULANE 1

QL 2 CAPS / 1 DAY

PA

S

ONC Oncology

MEKINIST 0.5 MG TABLET 1

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

MEKINIST 2 MG TABLET 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

MEKTOVI 1

QL 6 TABS / 1 DAY

PA

S

melphalan 2

mercaptopurine 2

methotrexate (2.5 mg tablet, 50 mg/2 ml vial, 250 mg/10ml vial)

2

methotrexate sodium 2

MYLERAN 1

NERLYNX 1

QL 6 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

NEXAVAR 1

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



NILANDRON 3 PA

nilutamide 2 PA

NINLARO 1

QL 3 CAPS / 28 DAYS

PA

S

ONC Oncology

NUBEQA 1PA

S

ODOMZO 1

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ONUREG 1


PA

S

ONC Oncology

OTREXUP 3 PA

PANRETIN 3 PA

PEMAZYRE 1


PA

S

ONC Oncology

PICATO 1 PA

PIQRAY (250 MG DAILY, 300 MG DAILY) 3

QL 2 CAPS / 1 DAY

PA

S

PIQRAY 200 MG DAILY DOSE 3

QL 1 CAP / 1 DAY

PA

S



POMALYST 1

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

PURIXAN 3PA

S

QINLOCK 1

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

RASUVO 1 PA

RETEVMO 40 MG CAPSULE 1

QL 6 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

RETEVMO 80 MG CAPSULE 1

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

REVLIMID 1

QL 1 CAP / 1 DAY

S

ONC Oncology

ROZLYTREK 1

PA

S

ONC Oncology

RUBRACA 3

QL 4 TABS / 1 DAY

PA

S

TD Trial Drug



RYDAPT 1

PA

S

ONC Oncology

SIKLOS 1,000 MG TABLET 3

SIKLOS 100 MG TABLET 3QL 2 TABS / 1 DAY

PA

SOLARAZE 3 PA

SPRYCEL 1

PA

S

ONC Oncology

TD Trial Drug

STIVARGA 1

PA

S

ONC Oncology

sunitinib malate 2

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

SUTENT 3

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

SYNRIBO 3

QL 30 ML / 30 DAYS

PA

S

ONC Oncology

TABLOID 1

TABRECTA 1

QL 4 TABS / 1 DAY

PA

S

ONC Oncology



TAFINLAR 1

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

TAGRISSO 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

TALZENNA 0.25 MG CAPSULE 3

QL 3 CAPS / 1 DAY

PA

S

TD Trial Drug

TALZENNA 1 MG CAPSULE 3

QL 1 CAP / 1 DAY

PA

S

TD Trial Drug

TARCEVA (100 MG TABLET, 150 MG TABLET) 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

TARCEVA 25 MG TABLET 3

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

TARGRETIN 1% GEL 4PA

S

TARGRETIN 75 MG CAPSULE 3

QL 10 CAPS / 1 DAY

PA

S

TD Trial Drug



TASIGNA 1

PA

S

ONC Oncology

TD Trial Drug

TAZVERIK 1

QL 8 TABS / 1 DAY

PA

S

ONC Oncology

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MGCAPSULE, 140 MG CAPSULE, 180 MG CAPSULE, 250 MGCAPSULE)

3PA

S

temozolomide 2S

ONC Oncology

TEPMETKO 1

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TIBSOVO 1

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TOLAK 3

tretinoin 10 mg capsule 2S

ONC Oncology

TREXALL 3 PA

TRUSELTIQ 1

PA

S

ONC Oncology

TUKYSA 150 MG TABLET 3

QL 4 TABS / 1 DAY

PA

S

ONC Oncology



TUKYSA 50 MG TABLET 3

QL 10 TABS / 1 DAY

PA

S

ONC Oncology

TURALIO 1PA

S

TYKERB 3

QL 6 TABS / 1 DAY

PA

S

ONC Oncology

UKONIQ 1

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

VALCHLOR 1

QL 120 GM / 30 DAYS

PA

S

ONC Oncology

VENCLEXTA (10 MG TAB (10MG X 2), 10 MG TABLET) 3

QL 2 TABS / 1 DAY

PA

S

VENCLEXTA 100 MG TABLET 3

QL 3 TABS / 1 DAY

PA

S

VENCLEXTA 50 MG TABLET 3

QL 1 TAB / 1 DAY

PA

S

VENCLEXTA STARTING PACK 3


PA

S



VERZENIO 1


PA

S

ONC Oncology

VITRAKVI 100 MG CAPSULE 1

QL 2 CAPS / 1 DAY

PA

S

TD Trial Drug

VITRAKVI 20 MG/ML SOLUTION 1

QL 300 ML / 30 DAYS

PA

S

TD Trial Drug

VITRAKVI 25 MG CAPSULE 1

QL 6 CAPS / 1 DAY

PA

S

TD Trial Drug

VIZIMPRO 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

VOTRIENT 1

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

WELIREG 1

QL 3 TABS / 1 DAY

PA

S

ONC Oncology



XATMEP 3 PA

XELODA 3PA

S

XOSPATA 1

QL 3 TABS / 1 DAY

PA

S

XPOVIO 1

PA

S

ONC Oncology

XTANDI 1

PA

S

ONC Oncology

TD Trial Drug

YONSA 3

PA

S

TD Trial Drug

ZEJULA 1

QL 3 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ZELBORAF 1

QL 8 TABS / 30 DAYS

PA

S

ONC Oncology

ZOLINZA 1

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



ZYDELIG 3

QL 2 TABS / 1 DAY

PA

S

ZYKADIA 1

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ZYTIGA 3

QL 2 TABS / 1 DAY

PA

S

TD Trial Drug

ANTIPARKINSONIAN AGENTS (CNS)ADAMANTANES (CNS)

amantadine (50 mg/5 ml solution, 100 mg capsule, 100mg tablet, 100 mg/10 ml soln)

2

GOCOVRI 3 PA

OSMOLEX ER 3 PA

ANTICHOLINERGIC AGENTS (CNS)benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mgtablet)

2

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml soln, 5 mgtablet)

2

CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.COMTAN 3

entacapone 2

ONGENTYS 3 PA

TASMAR 3

tolcapone 3



DOPAMINE PRECURSORScarbidopa-levodopa 2

carbidopa-levodopa er 2

carbidopa-levodopa-entacapone 2

INBRIJA 4PA

S

RYTARY 1 ST

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

MONOAMINE OXIDASE B INHIBITORS

AZILECT 3 PA

EMSAM 1 PA

rasagiline mesylate 2 PA

selegiline hcl 2

XADAGO 3 PA

ZELAPAR 3

ANTIPROTOZOALSAMEBICIDES

paromomycin sulfate 3

ANTIMALARIALSARAKODA 3

atovaquone-proguanil hcl 2

chloroquine phosphate 2

COARTEM 3



DARAPRIM 3 PA

hydroxychloroquine 200 mg tab 2

hydroxychloroquine sulfate (100 mg tab, 300 mg tab, 400mg tab)

3 PA

KRINTAFEL 3

MALARONE 62.5-25 MG PED TAB 3

mefloquine hcl 2

PLAQUENIL 3

primaquine 3

pyrimethamine 3 PA

QUALAQUIN 3

quinine sulfate 2 PA

ANTIPROTOZOALS, MISCELLANEOUS

ALINIA 100 MG/5 ML SUSPENSION 1 PA

ALINIA 500 MG TABLET 3 PA

atovaquone 2

benznidazole 2 PA

FLAGYL 3

IMPAVIDO 1 PA

LAMPIT 1 PA

MEPRON 3

metronidazole (250 mg tablet, 500 mg tablet) 2

metronidazole 375 mg capsule 3

NEBUPENT 3

nitazoxanide 2 PA

pentamidine 300 mg inhal powdr 3

SOLOSEC 3 PA



tinidazole 2 PA

ANTIPSYCHOTIC AGENTSANTIPSYCHOTICS, MISCELLANEOUS

ADASUVE 3 PA

loxapine 2 AL1 At least 13 yrs old

molindone hcl 3 AL1 At least 13 yrs old

pimozide 2PA


ATYPICAL ANTIPSYCHOTICS

ABILIFY 3PA


ABILIFY MYCITE 3PA


aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet,10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)

2 AL1 At least 13 yrs old

aripiprazole odt 2PA


asenapine maleate 2 PA

CAPLYTA 1QL 1 CAP / 1 DAY

PA

clozapine 2 AL1 At least 13 yrs old

clozapine odt 2PA


CLOZARIL 3PA


FANAPT 1 PA

FAZACLO 3PA




GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MGCAPSULE, 80 MG CAPSULE)

3PA


INVEGA 3 PA

LATUDA 1QL 1 TAB / 1 DAY

PA

LYBALVI 1QL 1 TAB / DAY

PA

NUPLAZID 4

PA

S

TD Trial Drug

olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10mg tablet, 15 mg tablet, 20 mg tablet)


olanzapine odt 2PA


paliperidone er 2 PA

quetiapine fumarate 2 AL1 At least 13 yrs old

quetiapine fumarate er 2 AL1 At least 13 yrs old

REXULTI 1 PA

RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MGTABLET, 1 MG/ML SOLUTION, 2 MG TABLET, 3 MGTABLET, 4 MG TABLET)

3PA


risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 1mg/ml solution, 2 mg tablet, 3 mg tablet, 4 mg tablet)


risperidone odt 2PA


SAPHRIS 3 PA

SECUADO 1 PA

SEROQUEL 3PA




SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200 MGTABLET, 300 MG TABLET, 400 MG TABLET, SAMPLE KIT)

3PA


VERSACLOZ 1PA


VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK) 1QL 2 CAPS / 1 DAY

PA

VRAYLAR (3 MG CAPSULE, 4.5 MG CAPSULE, 6 MGCAPSULE)

1QL 1 CAP / 1 DAY

PA

ziprasidone hcl 2 AL1 At least 13 yrs old

ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET,10 MG TABLET, 15 MG TABLET, 20 MG TABLET)

3PA


ZYPREXA ZYDIS 3PA


BUTYROPHENONES

haloperidol 2 AL1 At least 13 yrs old

haloperidol lactate (2 mg/ml conc, 10 mg/5 ml cup) 2 AL1 At least 13 yrs old

PHENOTHIAZINESchlorpromazine hcl (10 mg tablet, 25 mg tablet, 30 mg/mlconc, 50 mg tablet, 100 mg tablet, 100 mg/ml conc, 200mg tablet)

2 PA

fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5 mlelix, 5 mg tablet, 5 mg/ml conc, 10 mg tablet)


perphenazine 2

thioridazine hcl 2 AL1 At least 13 yrs old

trifluoperazine hcl 2 AL1 At least 13 yrs old

THIOXANTHENES

thiothixene 2 AL1 At least 13 yrs old



ANTIRETROVIRALSHIV ENTRY AND FUSION INHIBITORS

FUZEON 4 S

RUKOBIA 1 PA

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75MG TABLET, 150 MG TABLET, 300 MG TABLET)

1

HIV INTEGRASE INHIBITOR ANTIRETROVIRALSDOVATO 3

ISENTRESS 1

ISENTRESS HD 1

JULUCA 1

TIVICAY 1

TIVICAY PD 1

VOCABRIA 1

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.DELSTRIGO 3

EDURANT 1

efavirenz 2

efavirenz-lamivu-tenofov disop 3

etravirine 2

INTELENCE (100 MG TABLET, 200 MG TABLET) 3

INTELENCE 25 MG TABLET 1

nevirapine (50 mg/5 ml susp, 200 mg tablet) 2

nevirapine er 2

PIFELTRO 3

RESCRIPTOR 3

SUSTIVA 3

SYMFI 3

SYMFI LO 3



VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 3

VIRAMUNE XR 3

HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORSabacavir (20 mg/ml solution, 300 mg tablet) 2

abacavir-lamivudine 2

abacavir-lamivudine-zidovudine 2

ATRIPLA 3

BIKTARVY 1

CIMDUO 3

COMBIVIR 3

COMPLERA 1

DESCOVY 1PA

ACA Affordable Care Act

didanosine 3

efavirenz-emtric-tenofov disop 2

emtricitabine 2

emtricitabine-tenofovir disop (100-150mg, 133-200mg,167-250mg)

2

emtricitabine-tenofv 200-300mg 2 ACA Affordable Care Act

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 3

EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MGTABLET)

3

EPIVIR HBV 100 MG TABLET 3

EPIVIR HBV 25 MG/5 ML SOLN 1

EPZICOM 3

GENVOYA 1

lamivudine (10 mg/ml oral soln, 150 mg tablet, 300 mgtablet)

2

lamivudine hbv 2

lamivudine-zidovudine 2



ODEFSEY 1

RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 3

stavudine 3

STRIBILD 1

TEMIXYS 3

tenofovir disoproxil fumarate 2

TRIUMEQ 1

TRIZIVIR 3

TRUVADA (100 MG-150 MG TABLET, 133 MG-200 MGTABLET, 167 MG-250 MG TABLET)

1

TRUVADA 200 MG-300 MG TABLET 3 PA

VIDEX 3

VIDEX EC 3

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, POWDER)

1

VIREAD 300 MG TABLET 3

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 3

zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mgtablet)

2

HIV PROTEASE INHIBITOR ANTIRETROVIRALSAPTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 1

atazanavir sulfate 2

CRIXIVAN 3

EVOTAZ 1

fosamprenavir calcium 2

INVIRASE 1

KALETRA (100-25 MG TABLET, 200-50 MG TABLET) 1

KALETRA 80 MG-20 MG/ML SOLN 3

LEXIVA 50 MG/ML SUSPENSION 1

LEXIVA 700 MG TABLET 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSlopinavir-ritonavir (lopinavir-ritonavir 80-20mg/ml,lopinavir-ritonavr 100-25mg tb, lopinavir-ritonavr 200-50mg tb)

2

NORVIR (100 MG POWDER PACKET, 100 MG TABLET) 3

NORVIR 80 MG/ML SOLUTION 1

PREZCOBIX 1

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150MG TABLET, 600 MG TABLET, 800 MG TABLET)

1

REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE)

3

REYATAZ 50 MG POWDER PACKET 1

ritonavir 2

SYMTUZA 1

VIRACEPT 3

ANTITHROMBOTIC AGENTSANTITHROMBOTIC AGENTS, MISCELLANEOUS

CABLIVI 11 MG KIT 4PA

S

PLATELET-AGGREGATION INHIBITORSBRILINTA 1

cilostazol 2

clopidogrel 300 mg tablet 3

clopidogrel 75 mg tablet 2

EFFIENT 3

PLAVIX 3

prasugrel hcl 2

ZONTIVITY 1 PA

PLATELET-REDUCING AGENTSanagrelide hcl 2



ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINESALLERGENIC EXTRACTS (THERAPEUTIC)

GRASTEK 1 PA

ODACTRA 1 PA

ORALAIR 3 PA

PALFORZIA 4PA

S

RAGWITEK 1 PA

TOXOIDSADACEL TDAP 1

BOOSTRIX TDAP 1

DAPTACEL DTAP 1

diphtheria-tetanus toxoids-ped 1

INFANRIX DTAP 1

tdvax 1

TENIVAC SYRINGE 1

VAXELIS 1

VACCINESACTHIB 1

adenovirus type 4 1

adenovirus type 4 and type 7 1

adenovirus type 7 1

AFLURIA QUAD 2019-20 (3YR UP) 1 ACA Affordable Care Act

AFLURIA QUAD 2019-20 (6-35MO) 1 ACA Affordable Care Act

AFLURIA QUAD 2019-2020 1 ACA Affordable Care Act









ASTRAZENECA COVID19 VAC(UNAPP) 1

BEXSERO 1

COMIRNATY 1

DENGVAXIA 1

ENGERIX-B ADULT 1

ENGERIX-B PEDIATRIC-ADOLESCENT 1

FLUAD 2019-2020 1 ACA Affordable Care Act

FLUAD 2020-2021 1 ACA Affordable Care Act

FLUAD QUAD 2020-2021 1 ACA Affordable Care Act

FLUAD QUAD 2021-2022 1 ACA Affordable Care Act

FLUARIX QUAD 2019-2020 1 ACA Affordable Care Act



FLUBLOK QUAD 2019-2020 1 ACA Affordable Care Act



FLUCELVAX QUAD 2019-2020 (SYR, VIAL) 1 ACA Affordable Care Act



FLULAVAL QUAD 2019-2020 (SYR, VIAL) 1 ACA Affordable Care Act

FLULAVAL QUAD 2020-2021 1 ACA Affordable Care Act



FLULAVAL QUAD 2021-2022 1 ACA Affordable Care Act

FLUMIST QUAD 2019-2020 1 ACA Affordable Care Act



FLUZONE HIGH-DOSE 2019-2020 1 ACA Affordable Care Act

FLUZONE HIGH-DOSE QUAD 2020-21 1 ACA Affordable Care Act

FLUZONE HIGH-DOSE QUAD 2021-22 1 ACA Affordable Care Act

FLUZONE QUAD 2019-2020 1 ACA Affordable Care Act



FLUZONE QUAD PEDI 2019-2020 1 ACA Affordable Care Act

FLUZONE QUAD SOUTHERN HEM 2020 (HEM2020 SYR,HEM 2020 VL)

1 ACA Affordable Care Act

FLUZONE QUAD SOUTHERN HEM 2021 (HEM2021 SYR,HEM 2021 VL)


GARDASIL 9 1

HAVRIX 1

HEPLISAV-B 1

HIBERIX 1

IPOL 1 ACA Affordable Care Act

JANSSEN COVID-19 VACCINE (EUA) 1

KINRIX 1

M-M-R II VACCINE 1 ACA Affordable Care Act

MENACTRA 1

MENQUADFI 1 ACA Affordable Care Act

MENVEO A-C-Y-W-135-DIP 1

MENVEO MENA COMPONENT 1 ACA Affordable Care Act



MENVEO MENCYW-135 COMPONENT 1 ACA Affordable Care Act

MODERNA COVID-19 VACCINE (EUA) 1

NOVAVAX COVID19 VAC,ADJ(UNAPP) 1

PEDIARIX 1

PEDVAXHIB 1

PENTACEL 1

PENTACEL ACTHIB COMPONENT 1

PENTACEL DTAP-IPV COMPONENT 1

PFIZER COVID(12Y UP) VAC(UNAP) 1

PFIZER COVID(5-11Y) VAC(UNAPP) 1

PFIZER COVID-19 VACCINE (EUA) 1

PNEUMOVAX 23 1

PREVNAR 13 1

PREVNAR 20 1

PROQUAD 1

QUADRACEL DTAP-IPV 1 ACA Affordable Care Act

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 10 MCG/ML SYR,40 MCG/ML VIAL)

1

RECOMBIVAX HB (5 MCG/0.5 ML VL, 10 MCG/ML VIAL) 1 ACA Affordable Care Act

ROTARIX 1

ROTATEQ 1

SHINGRIX 1 QL 1 KIT / RX

SHINGRIX GE ANTIGEN COMPONENT 1 QL 1 KIT / RX

TRUMENBA 1

TWINRIX 1

VAQTA (25 UNITS/0.5 ML SYRINGE, 50 UNITS/MLSYRINGE, 50 UNITS/ML VIAL)

1

VAQTA 25 UNITS/0.5 ML VIAL 1 ACA Affordable Care Act



VARIVAX VACCINE 1

VAXCHORA ACTIVE COMPONENT 1

VAXCHORA VACCINE 1

VAXNEUVANCE 1

VIVOTIF 1

ZOSTAVAX 1

ANTIULCER AGENTS AND ACID SUPPRESSANTSANTIULCER AGENTS AND ACID SUPPRESS.,MISC

TALICIA 1 PA

HISTAMINE H2-ANTAGONISTScimetidine (200 mg tablet, cvs 200 mg tablet, gnp 200 mgtablet)

3

cimetidine (300 mg tablet, 300 mg/5 ml soln, 400 mgtablet, 400 mg/6.67 ml soln, 800 mg tablet)

2

cimetidine 200 mg tablet (prescription only) 3

famotidine (20 mg tablet, 40 mg tablet) 2

famotidine 40 mg/5 ml susp 2 AL1 Up to 12 yrs old

nizatidine (15 mg/ml solution, 150 mg capsule, 300 mgcapsule)

2 PA

PEPCID 3

ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mgtablet, 150 mg/10 ml syrup, 300 mg capsule, 300 mgtablet)

3

PROSTAGLANDINSCYTOTEC 3

misoprostol 2

PROTECTANTSCARAFATE 1 GM TABLET 3

CARAFATE 1 GM/10 ML SUSP 3 PA

sucralfate 1 gm tablet 2

sucralfate 1 gm/10 ml susp 2 PA



PROTON-PUMP INHIBITORS

ACIPHEX 3 PA

ACIPHEX SPRINKLE (DR 5 MG CAP, DR 10 MG CAP) 3 PA

DEXILANT 3 PA

esomeprazole magnesium (cvs 20 mg cap, dr 20 mg cap,dr 40 mg cap, gnp dr 20 mg, gs dr 20 mg, hm dr 20 mg, qcdr 20 mg, ra dr 20 mg, sm dr 20 mg)

2

esomeprazole magnesium (dr 10 mg packet, dr 20 mgpacket, dr 40 mg packet, mag dr 20 mg tab)

3

esomeprazole strontium 3 PA

lansoprazol-amoxicil-clarithro 2 PA

lansoprazole (dr 15 mg capsule, dr 30 mg capsule) 2

lansoprazole (odt 15 mg tablet, odt 30 mg tablet) 2 AL1 Up to 9 yrs old

NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10MG PACKET, DR 20 MG PACKET, DR 40 MG PACKET)

3

NEXIUM (DR 20 MG CAPSULE, DR 40 MG CAPSULE) 3 PA

NEXIUM 24HR 3

OMECLAMOX-PAK 3

OMEPPI 3 PA

omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40mg capsule)

2

omeprazole-sodium bicarbonate (20-1,100 cap, 20-1,680pkt, cvs 20-1,100, 40-1,100 cap, 40-1,680 pkt)

3 PA

pantoprazole 40 mg suspension 3

pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 2

PREVACID (15 MG, 30 MG) 3 AL1 Up to 9 yrs old

PREVACID (DR 15 MG CAPSULE, DR 30 MG CAPSULE) 3 PA

PREVACID 24HR DR 15 MG CAPSULE (OTC) 3 PA

PRILOSEC 3



PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET) 3 PA

PROTONIX 40 MG SUSPENSION 3

rabeprazole dr 10 mg sprnkl cp 3 PA

rabeprazole sod dr 20 mg tab 2

ZEGERID 3 PA

ANTIVIRALS (SYSTEMIC)ADAMANTANE ANTIVIRALS

FLUMADINE 3

rimantadine hcl 2

ANTIVIRALS, MISCELLANEOUSPREVYMIS (240 MG TABLET, 480 MG TABLET) 1

TPOXX (NATIONAL STOCKPILE) 1 PA

XOFLUZA 3

INTERFERON ANTIVIRALS

ALFERON N 4 S

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML,18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50MILLION UNITS VIL)

4 S

PEGASYS 4PA

S

PEGASYS PROCLICK 4PA

S

PEGINTRON 4PA

S

SYLATRON 1S

ONC Oncology

NEURAMINIDASE INHIBITOR ANTIVIRALS

oseltamivir 6 mg/ml suspension 2 QL 180 ML / 1 FILL

oseltamivir phos 30 mg capsule 2 QL 20 CAPS / 1 FILL



oseltamivir phosphate (45 mg capsule, 75 mg capsule) 2 QL 10 CAPS / 1 FILL

RELENZA 1 QL 20 CAPS / 1 FILL

TAMIFLU (45 MG CAPSULE, 75 MG CAPSULE) 3 QL 10 CAPS / 1 FILL

TAMIFLU 30 MG CAPSULE 3 QL 20 CAPS / 1 FILL

TAMIFLU 6 MG/ML SUSPENSION 3 QL 180 ML / 1 FILL

NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSacyclovir (200 mg capsule, 400 mg tablet, 800 mg tablet) 2

acyclovir 200 mg/5 ml susp 2 AL1 Up to 12 yrs old

adefovir dipivoxil 2

BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 3

BARACLUDE 0.05 MG/ML SOLUTION 1

entecavir 2

famciclovir 2

HEPSERA 3

RIBASPHERE 4PA

S

RIBASPHERE RIBAPAK 4PA

S

ribavirin (200 mg capsule, 200 mg tablet) 4 S

ribavirin 6 gm inhalation vial 4PA

S

SITAVIG 3

valacyclovir 2

VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET) 3

valganciclovir hcl (hcl 50 mg/ml, 450 mg tablet) 2

VALTREX 3 PA

VEMLIDY 1



VIRAZOLE 4PA

S

ZOVIRAX 200 MG/5 ML SUSP 3PA

AL1 Up to 12 yrs old

ANXIOLYTICS, SEDATIVES AND HYPNOTICSANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

AMBIEN 3 PA

AMBIEN CR 3 PA

BELSOMRA (15 MG TABLET, 20 MG TABLET) 3QL 1 TAB / 1 DAY

PA

BELSOMRA (5 MG TABLET, 10 MG TABLET) 3QL 2 TABS / 1 DAY

PA

buspirone hcl 2

DAYVIGO 3QL 1 TAB / 1 DAY

PA

EDLUAR 3PA

AQ1 Up to 64 yrs old; 20 /1 FILL

eszopiclone 2

HETLIOZ 4PA

S

HETLIOZ LQ 4PA

S

hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, hcl10 mg tablet, hcl 25 mg tablet, 50 mg/25 ml syrup, hcl 50mg tablet)

2

hydroxyzine pamoate 2

INTERMEZZO 3 PA

LUNESTA 3



meprobamate 2QL 6 TABS / 1 DAY

PA

ramelteon 2 QL 1 TAB / 1 DAY

ROZEREM 3 QL 1 TAB / 1 DAY

VISTARIL 3

zaleplon 2

zolpidem tartrate (1.75 mg tab, 3.5 mg tablet) 3 PA

zolpidem tartrate (5 mg tablet, 10 mg tablet) 2

zolpidem tartrate er 2 ST

ZOLPIMIST 3 AQ1 Up to 64 yrs old; 7.7/ 1 FILL

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 mlelix, 20 mg/5 ml soln, 30 mg tablet, 60 mg tablet, 100 mgtablet)

2

SECONAL SODIUM 3 QL 1 CAP / 1 DAY

BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 2 QL 6 TABS / 1 DAY

alprazolam 2 mg tablet 2 QL 3 TABS / 1 DAY

alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 2 QL 6 TABS / 1 DAY

alprazolam er 2 mg tablet 2 QL 3 TABS / 1 DAY

alprazolam er 3 mg tablet 2 QL 2 TABS / 1 DAY

ALPRAZOLAM INTENSOL 3 QL 6 ML / 1 DAY

alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1mg tab)

3 QL 6 TABS / 1 DAY

alprazolam odt 2 mg tab 3 QL 3 TABS / 1 DAY

alprazolam xr (0.5 mg tablet, 1 mg tablet) 2 QL 6 TABS / 1 DAY

alprazolam xr 2 mg tablet 2 QL 3 TABS / 1 DAY



alprazolam xr 3 mg tablet 2 QL 2 TABS / 1 DAY

ATIVAN (0.5 MG TABLET, 1 MG TABLET) 3QL 6 TABS / 1 DAY

PA

ATIVAN 2 MG TABLET 3QL 5 TABS / 1 DAY

PA

chlordiazepoxide 25 mg capsule 2 QL 4 CAPS / 1 DAY

chlordiazepoxide hcl (5 mg capsule, 10 mg capsule) 2 QL 6 CAPS / 1 DAY

clorazepate 15 mg tablet 2QL 4 TABS / 1 DAY

PA

clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet) 2QL 6 TABS / 1 DAY

PA

DIASTAT 3QL 4 KITS / 30 DAYS

PA

DIASTAT ACUDIAL 3QL 4 KITS / 30 DAYS

PA

diazepam (2 mg tablet, 5 mg tablet) 2 QL 6 TABS / 1 DAY

diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20mg rectal gel syst)

2 QL 4 KITS / 30 DAYS

diazepam 10 mg tablet 2 QL 4 TABS / 1 DAY

diazepam 5 mg/5 ml solution 2 QL 40 ML / 1 DAY

diazepam 5 mg/ml oral conc 2 QL 8 ML / 1 DAY

DORAL 3 QL 2 TABS / 1 DAY

estazolam 1 mg tablet 2QL 2 TABS / 1 DAY

PA

estazolam 2 mg tablet 2QL 1 TAB / 1 DAY

PA

flurazepam 15 mg capsule 2QL 2 CAPS / 1 DAY

PA



flurazepam 30 mg capsule 2QL 1 CAP / 1 DAY

PA

HALCION 3 QL 2 TABS / 1 DAY

lorazepam (0.5 mg tablet, 1 mg tablet) 2 QL 6 TABS / 1 DAY

lorazepam 2 mg tablet 2 QL 5 TABS / 1 DAY

lorazepam 2 mg/ml oral concent 2 QL 5 ML / 1 DAY

LORAZEPAM INTENSOL 2 QL 5 ML / 1 DAY

LOREEV XR 3 PA

midazolam hcl 2 mg/ml syrup 3 QL 4 ML / 1 DAY

oxazepam (10 mg capsule, 15 mg capsule) 2QL 6 CAPS / 1 DAY

PA

oxazepam 30 mg capsule 2QL 4 CAPS / 1 DAY

PA

quazepam 2QL 2 TABS / 1 DAY

PA

RESTORIL (22.5 MG CAPSULE, 30 MG CAPSULE) 3QL 1 CAP / 1 DAY

PA

RESTORIL (7.5 MG CAPSULE, 15 MG CAPSULE) 3QL 2 CAPS / 1 DAY

PA

temazepam 15 mg capsule 2 QL 2 CAPS / 1 DAY

temazepam 22.5 mg capsule 3 QL 1 CAP / 1 DAY

temazepam 30 mg capsule 2 QL 1 CAP / 1 DAY

temazepam 7.5 mg capsule 3 QL 2 CAPS / 1 DAY

TRANXENE T-TAB 3QL 6 TABS / 1 DAY

PA

triazolam 0.125 mg tablet 2QL 4 TABS / 1 DAY

PA



triazolam 0.25 mg tablet 2QL 2 TABS / 1 DAY

PA

VALIUM (2 MG TABLET, 5 MG TABLET) 3 QL 6 TABS / 1 DAY

VALIUM 10 MG TABLET 3 QL 4 TABS / 1 DAY

VALTOCO 1QL 1 CARTON / RX

PA

XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) 3 QL 6 TABS / 1 DAY

XANAX 2 MG TABLET 3 QL 3 TABS / 1 DAY

XANAX XR (0.5 MG TABLET, 1 MG TABLET) 3 QL 6 TABS / 1 DAY

XANAX XR 2 MG TABLET 3 QL 3 TABS / 1 DAY

XANAX XR 3 MG TABLET 3 QL 2 TABS / 1 DAY

AUTONOMIC DRUGSAUTONOMIC DRUGS, MISCELLANEOUS

apo-varenicline 0.5 mg tablet (apotex) 2

QL 2 TABS / 1 DAY


SC Smoking Cessation

apo-varenicline 1 mg tablet (apotex) 2

QL 2 TABS / 1 DAY



CHANTIX 3 QL 2 TABS / 1 DAY

nicotine gum 2 SC Smoking Cessation


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnicotine lozenge (2 mg lozenge, 2 mg mini lozenge, cvs 2mg lozenge, eq 2 mg lozenge, eql 2 mg lozenge, gnp 2 mglozenge, hm 2 mg lozenge, kro 2 mg lozenge, ra 2 mglozenge, sm 2 mg lozenge, sw 2 mg lozenge, 4 mglozenge, 4 mg mini lozenge, cvs 4 mg lozenge, eq 4 mglozenge, eql 4 mg lozenge, gnp 4 mg lozenge, gs 4 mglozenge, hm 4 mg lozenge, kro 4 mg lozenge, ra 4 mglozenge, sm 4 mg lozenge, sw 4 mg lozenge)

2 SC Smoking Cessation

nicotine patch (7 mg/24hr patch, cvs 7 mg/24hr patch, eq7 mg/24hr patch, hm 7 mg/24hr patch, kro 7 mg/24hrpatch, ra 7 mg/24hr patch, sm 7 mg/24hr patch, 14mg/24hr patch, cvs 14 mg/24hr patch, gnp 7 mg/24hrpatch, hm 14 mg/24hr patch, qc 14 mg/24hr patch, ra 14mg/24hr patch, 21 mg/24hr patch, cvs 21 mg/24hr patch,eq 14 mg/24hr patch, eq 21 mg/24hr patch, gnp 14mg/24hr patch, gnp 21 mg/24hr patch, hm 21 mg/24hrpatch, kro 14 mg/24hr patch, kro 21 mg/24hr patch, qc 21mg/24hr patch, ra 21 mg/24hr patch, sm 14 mg/24hrpatch, sm 21 mg/24hr patch)

2 SC Smoking Cessation

NICOTROL 1 SC Smoking Cessation

NICOTROL NS 1 SC Smoking Cessation

varenicline tartrate (0.5 mg tablet, 1 mg tablet) 2

QL 2 TABS / 1 DAY



PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

ARICEPT 3 PA

bethanechol chloride 2

cevimeline hcl 2

donepezil hcl (5 mg tablet, 10 mg tablet) 2

donepezil hcl 23 mg tablet 3

donepezil hcl odt 2

EVOXAC 3

EXELON 3

galantamine er 2



galantamine hbr 2

galantamine hydrobromide 2

guanidine hcl 1 PA

MESTINON (60 MG TABLET, 60 MG/5 ML SOLUTION, 180MG TIMESPAN)

3 PA

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 2

pyridostigmine 60 mg/5 ml soln 3 PA

pyridostigmine br 30 mg tablet 2 QL 1 TAB / 1 DAY

pyridostigmine br 60 mg tablet 2

pyridostigmine bromide er 2 PA

RAZADYNE 3

RAZADYNE ER 3

rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mgcapsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hrpatch, 13.3 mg/24hr ptch)

2

SALAGEN 3

BETA-3-ADRENERGIC AGONISTSSELECTIVE BETA-3-ADRENERGIC AGONISTS

GEMTESA 3 PA

MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET) 1

MYRBETRIQ ER 8 MG/ML SUSP 3 PA

BETA-ADRENERGIC AGONISTSSELECTIVE BETA-2-ADRENERGIC AGONISTS

albuterol sulfate (2 mg tab, 4 mg tab, er 4 mg tab, er 8mg tab)

3

albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 mlsol, 2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, sulf 2 mg/5ml syrup, 5 mg/ml solution, 100 mg/20 ml soln)

2

albuterol sulfate 90 mcg hfa aer ad (generic proair) 3 PA

albuterol sulfate 90 mcg hfa aer ad (generic proventil) 3 PA



albuterol sulfate 90 mcg hfa aer ad (generic ventolin) 3 PA

albuterol sulfate hfa 3 PA

ARCAPTA NEOHALER 3

arformoterol tartrate 3 PA

BROVANA 1 PA

formoterol fumarate 3 PA

levalbuterol concentrate 3

levalbuterol hcl 3

levalbuterol tartrate hfa 2

metaproterenol sulfate 3

PERFOROMIST 1 PA

PROAIR DIGIHALER 3 PA

PROAIR HFA 3 PA

PROAIR RESPICLICK 3 PA

PROVENTIL HFA 3 PA

SEREVENT DISKUS 1 PA

STRIVERDI RESPIMAT 1

terbutaline sulfate (2.5 mg tab, 5 mg tab) 2 PA

UTIBRON NEOHALER 3 PA

VENTOLIN HFA 2

XOPENEX 3

XOPENEX HFA 3

BLOOD FORMATION, COAGULATION, THROMBOSISBLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.

OXBRYTA 4

QL 3 TABS / 1 DAY

PA

S



TAVALISSE 4PA

S

HEMATOPOIETIC AGENTS

ARANESP 4 S

DOPTELET 4PA

S

EPOGEN 4PA

S

FULPHILA 1 PA

GRANIX 1 S

LEUKINE 4PA

S

MIRCERA (30 MCG/0.3 ML SYRINGE, 50 MCG/0.3 MLSYRINGE, 75 MCG/0.3 ML SYRINGE, 100 MCG/0.3 MLSYRINGE, 150 MCG/0.3 ML SYRINGE, 200 MCG/0.3 MLSYRINGE)

4PA

S

MULPLETA 4PA

S

NEULASTA 4PA

S

NEULASTA ONPRO 4PA

S

NEUPOGEN 4PA

S

NIVESTYM 4PA

S

NYVEPRIA 1 PA

PROCRIT 4PA

S



PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET)

4PA

S

PROMACTA 12.5 MG SUSPEN PACKET 4

QL 1 PACKET / 1 DAY

PA

S

PROMACTA 25 MG SUSPENSION PCKT 4


PA

S

RETACRIT (2,000 UNIT/ML VIAL, 3,000 UNIT/ML VIAL,4,000 UNIT/ML VIAL, 10,000 UNIT/ML VIAL, 20,000UNIT/ML VIAL, 40,000 UNIT/ML VIAL)

4 S

UDENYCA 1 PA

ZARXIO 4PA

S

ZIEXTENZO 1 PA

HEMORRHEOLOGIC AGENTSpentoxifylline 2

CALCIUM-CHANNEL BLOCKING AGENTSCALCIUM-CHANNEL BLOCKING AGENTS, MISC.

CALAN 3

CALAN SR 3

CARDIZEM 3

CARDIZEM CD 3 PA

CARDIZEM LA 3 PA

CARTIA XT 2

DILT-XR 2

diltiazem 12hr er 3

diltiazem 24h er(la) 360 mg tb (generic for cardizem la) 3

diltiazem 24hr er 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSdiltiazem 24hr er (cd) (24h 120 mg cp, 24h 180 mg cp, 24h240 mg cp, 24h 300 mg cp)

2

diltiazem 24hr er (la) (24h 180 mg tb, 24h 240 mg tb, 24h300 mg tb, 24h 420 mg tb)

3

diltiazem 24hr er (xr) 2

diltiazem 24hr er 360 mg cap (generic for cardizem cd) 3

diltiazem hcl (30 mg tablet, 60 mg tablet, 90 mg tablet,120 mg tablet)

2

MATZIM LA (180 MG TABLET, 300 MG TABLET, 420 MGTABLET)

3

MATZIM LA 240 MG TABLET 2

MATZIM LA 360 MG TABLET (GENERIC FOR CARDIZEM LA) 3

TAZTIA XT 2

TIADYLT ER (ER 180 MG CAPSULE, ER 420 MG CAPSULE) 2

TIAZAC 3 PA

verapamil er 2

verapamil er pm 3

verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet,360 mg cap pellet)

2

verapamil sr 2

VERELAN 3

VERELAN PM 3

DIHYDROPYRIDINESADALAT CC 3

amlodipine besylate 2

amlodipine besylate-benazepril 2

amlodipine-olmesartan 2

amlodipine-valsartan 2

amlodipine-valsartan-hctz 2

AZOR 3 PA



CONJUPRI 3 PA

EXFORGE 3

EXFORGE HCT 3

felodipine er 2

isradipine 3

KATERZIA 3

LOTREL 3

nicardipine hcl (20 mg capsule, 30 mg capsule) 3

nifedipine 2 AL1 Up to 45 yrs old

nifedipine er 2

nimodipine 2

nisoldipine 3

NORVASC 3 PA

NYMALIZE 3 PA

PROCARDIA 3 AL1 Up to 45 yrs old

PROCARDIA XL 3

SULAR 3

CARDIAC DRUGSCARDIAC DRUGS, MISCELLANEOUS

CORLANOR (5 MG TABLET, 5 MG/5 ML ORAL SOLN, 7.5MG TABLET)

1 PA

RANEXA 3

ranolazine er 3

VYNDAMAX 4PA

S

VYNDAQEL 4PA

S



CARDIOTONIC AGENTSDIGITEK 125 MCG TABLET 2

DIGITEK 250 MCG TABLET 2 AL1 Up to 64 yrs old

DIGOX 125 MCG TABLET 2

DIGOX 250 MCG TABLET 2 AL1 Up to 64 yrs old

digoxin (0.125 mg tablet, 125 mcg tablet) 2

digoxin (0.25 mg tablet, 250 mcg tablet) 2 AL1 Up to 64 yrs old

digoxin 0.05 mg/ml solution 1

LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5MCG TABLET)

3

LANOXIN 250 MCG TABLET 3 AL1 Up to 64 yrs old

CARDIOVASCULAR DRUGSALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA 3

CARDURA XL 3

doxazosin mesylate 2

MINIPRESS 3

prazosin hcl 2

terazosin hcl 2

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl 2

atenolol 2

atenolol-chlorthalidone 2

BETAPACE 3

BETAPACE AF 3

betaxolol hcl (10 mg tablet, 20 mg tablet) 2

bisoprolol fumarate 2

bisoprolol-hydrochlorothiazide 2



BYSTOLIC 3 PA

carvedilol 2

carvedilol er 3

COREG CR 3 PA

CORGARD 3

DUTOPROL 3 PA

HEMANGEOL 3 PA

INDERAL LA 3 PA

INDERAL XL 3 PA

INNOPRAN XL 3 PA

KAPSPARGO SPRINKLE 3

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet)

2

LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3

LOPRESSOR HCT 3

metoprolol succinate 2

metoprolol succinate er-hctz 3 PA

metoprolol tartrate (25 mg tab, 50 mg tab, 100 mg tab) 2

metoprolol tartrate (37.5 mg tb, 75 mg tab) 3

metoprolol-hydrochlorothiazide 2

nadolol 2

nadolol-bendroflumethiazide 3

nebivolol hcl 3 PA

pindolol 3

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsoln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mgtablet)

2

propranolol hcl er 2



propranolol-hydrochlorothiazid 2

SORINE 3

sotalol 2

SOTALOL AF 2

SOTYLIZE 3

TENORMIN 3

timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 2

TOPROL XL 3

CENTRAL NERVOUS SYSTEM AGENTSANTIMANIC AGENTS

lithium 2

lithium carbonate 2

lithium carbonate er 2

LITHOBID 3

CENTRAL NERVOUS SYSTEM AGENTS, MISC.acamprosate calcium 2

ADDYI 3 PA

atomoxetine hcl (10 mg capsule, 18 mg capsule, 25 mgcapsule, 40 mg capsule)

2 QL 2 CAPS / 1 DAY

atomoxetine hcl (60 mg capsule, 80 mg capsule, 100 mgcapsule)

2 QL 1 CAP / 1 DAY

carbidopa 3

guanfacine hcl er (er 3 mg tablet, er 4 mg tablet) 2 QL 1 TAB / 1 DAY

guanfacine hcl er 1 mg tablet 2 QL 3 TABS / 1 DAY

guanfacine hcl er 2 mg tablet 2 QL 2 TABS / 1 DAY

INTUNIV (ER 3 MG TABLET, ER 4 MG TABLET) 3 QL 1 TAB / 1 DAY

INTUNIV ER 1 MG TABLET 3 QL 3 TABS / 1 DAY

INTUNIV ER 2 MG TABLET 3 QL 2 TABS / 1 DAY



LODOSYN 3

memantine hcl (hcl 2 mg/ml solution, 5-10 mg titrationpk, hcl 5 mg tablet, hcl 10 mg tablet)

2

memantine hcl er 3 PA

NAMENDA 3 PA

NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MGCAPSULE, 28 MG CAPSULE, TITRATION PACK)

3 PA

NAMZARIC 3

NOURIANZ 4PA

S

NUEDEXTA 3

QELBREE 3 PA

RILUTEK 3

riluzole 2

STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MGCAPSULE, 40 MG CAPSULE)

3 QL 2 CAPS / 1 DAY

STRATTERA (60 MG CAPSULE, 80 MG CAPSULE, 100 MGCAPSULE)

3 QL 1 CAP / 1 DAY

TIGLUTIK 3 PA

VYLEESI 3 PA

XYREM 4

QL 18 ML / 1 DAY

PA

S

XYWAV 4

QL 18 ML / 1 DAY

PA

S

FIBROMYALGIA AGENTS

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 100 MG TABLET)

1QL 2 TABS / 1 DAY

PA

SAVELLA TITRATION PACK 1QL 55 TABS / 28 DAYS

PA



OPIATE ANTAGONISTS

EVZIO 3 PA

KLOXXADO 1

LIFEMS NALOXONE 3 PA

naloxone 2 mg auto-injector 3

naloxone 2 mg/2 ml syringe 2

naltrexone hcl 2

NARCAN 1

VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

AUSTEDO 4PA

S

INGREZZA 4PA

S

INGREZZA INITIATION PACK 4PA

S

tetrabenazine 4PA

S

XENAZINE 4PA

S

CEPHALOSPORIN ANTIBIOTICS1ST GENERATION CEPHALOSPORIN ANTIBIOTICS

cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mgcapsule, 500 mg/5 ml susp)

2

cephalexin (125 mg/5 ml susp, 250 mg capsule, 250 mg/5ml susp, 500 mg capsule)

2

cephalexin (250 mg tablet, 500 mg tablet, 750 mgcapsule)

3

KEFLEX 3



2ND GENERATION CEPHALOSPORIN ANTIBIOTICScefaclor (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 mlsusp, 375 mg/5 ml suspen)

3

cefaclor 500 mg capsule 2 PA

cefaclor er 3

cefprozil (125 mg/5 ml susp, 250 mg tablet, 250 mg/5 mlsusp, 500 mg tablet)

2

cefuroxime 2

3RD GENERATION CEPHALOSPORIN ANTIBIOTICScefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mgcapsule)

2

cefixime (100 mg/5 ml susp, 200 mg/5 ml susp) 3

cefixime 400 mg capsule 2 QL 1 CAP / 30 DAYS

cefpodoxime proxetil (100 mg tablet, 200 mg tablet) 2QL 14 TABS / RX

PA

cefpodoxime proxetil (50 mg/5 ml susp, 100 mg/5 mlsusp)

2QL 100 ML / RX

PA

SUPRAX (100 MG TABLET CHEWABLE, 100 MG/5 MLSUSPENSION, 200 MG TABLET CHEWABLE, 200 MG/5 MLSUSPENSION, 500 MG/5 ML SUSPENSION)

3

SUPRAX 400 MG CAPSULE 3QL 1 CAP / 30 DAYS

PA

CORTICOSTEROIDS (RESPIRATORY TRACT)ORALLY INHALED PREPARATIONS (STEROIDS)

ADVAIR DISKUS 2

ADVAIR HFA 1

AIRDUO DIGIHALER 3 PA

AIRDUO RESPICLICK 3 PA

ALVESCO 3

ARMONAIR DIGIHALER 3 PA



ARNUITY ELLIPTA 1

ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220MCG #30, TWISTHALER 220 MCG #60, TWISTHALR 220MCG #120)

1

ASMANEX HFA 1

BREO ELLIPTA 1

BREZTRI AEROSPHERE 3 PA

budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1 mg/2ml inh susp)

2

budesonide-formoterol fumarate 2

DULERA 3 PA

FLOVENT DISKUS 1

FLOVENT HFA 1

fluticasone-salmeterol (100-50, 250-50, 500-50) 3

fluticasone-salmeterol 113-14 (generic for airduorespiclick)

2

fluticasone-salmeterol 232-14 (generic for airduorespiclick)

2

fluticasone-salmeterol 55-14 (generic for airduo respiclick) 2

PULMICORT 3 PA

PULMICORT FLEXHALER 1

QVAR REDIHALER 1

SYMBICORT 3 PA

TRELEGY ELLIPTA 1

WIXELA INHUB 3

CYSTIC FIBROSIS (CFTR) MODULATORSCYSTIC FIBROSIS (CFTR) CORRECTORS

SYMDEKO 4PA

S

TRIKAFTA 4PA

S



CYSTIC FIBROSIS (CFTR) POTENTIATORS

KALYDECO 4PA

S

ORKAMBI 4PA

S

DEPIGMENTING AND PIGMENTING AGENTSPIGMENTING AGENTS

methoxsalen 3 PA

OXSORALEN-ULTRA 3 PA

DEVICES

astero 3 PA

ATOPICLAIR 3

CAPHOSOL 3

CERAMAX SKIN BARRIER CREAM 3 PA

ELETONE 3

emulsion sb 3

ENTTY 3 PA

EPICYN 3

EPISIL 3

HYLATOPICPLUS (EMOLLIENT FOAM, LOTION) 3

ldo plus 3 PA

LEVICYN (ANTIPRURITIC GEL, DERMAL SPRAY) 3

LIDOTREX 2%-1.2%-1% WOUND GEL 3 PA

LOUTREX 3

mb hydrogel 3 PA

MICROCYN HYDROGEL 3 PA

NEOSALUS FOAM 3 PA



SALIVAMAX 3 PA

SCARCARE 3 PA

SILIPAC 3 PA

SILVRSTAT 3 PA

SYNERDERM 3

VASHE WOUND 3

VASHE WOUND THERAPY 3

VEXASYN 3

DIAGNOSTIC AGENTSADRENOCORTICAL INSUFFICIENCY

ACTHAR 4PA

S

PITUITARY FUNCTION

MACRILEN 4PA

S

METOPIRONE 3 PA

RESPIRATORY FUNCTION

methacholine chloride 3 PA

ROENTGENOGRAPHY AND OTHER IMAGING AGENTSOMNIPAQUE 12 MG/ML ORAL SOLN 3

DIURETICSLOOP DIURETICS

bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 2

EDECRIN 3 PA

ethacrynic acid 2 PA

furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40 mg/5 ml soln, 80 mg tablet)

2

LASIX 3



torsemide 2

POTASSIUM-SPARING DIURETICSamiloride hcl 2

amiloride-hydrochlorothiazide 2

DYAZIDE 3

DYRENIUM 3

MAXZIDE 3

MAXZIDE-25 MG 3

triamterene 3

triamterene-hydrochlorothiazid 2

THIAZIDE DIURETICSDIURIL 1

hydrochlorothiazide 2

MICROZIDE 3

THIAZIDE-LIKE DIURETICSchlorthalidone 2

indapamide 2

metolazone 2

THALITONE 3

VASOPRESSIN ANTAGONISTS

JYNARQUE 4PA

S

SAMSCA 4PA

S

tolvaptan 4PA

S



DOPAMINE RECEPTOR AGONISTSERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

bromocriptine mesylate 2

cabergoline 2

CYCLOSET 1 PA

PARLODEL 2.5 MG TABLET 3

NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

APOKYN 4PA

S

KYNMOBI 4PA

S

MIRAPEX 3 PA

MIRAPEX ER 3 PA

NEUPRO 1 PA

pramipexole dihydrochloride 2

pramipexole er 3

REQUIP XL 3 PA

ropinirole er 2 PA

ropinirole hcl 2

ELECTROLYTIC, CALORIC, AND WATER BALANCEACIDIFYING AGENTS

K-PHOS NO.2 3

K-PHOS ORIGINAL 3

ALKALINIZING AGENTSpotassium citrate er 2

UROCIT-K 3

AMMONIA DETOXICANTS

BUPHENYL (500 MG TABLET, POWDER) 4PA

S



CARBAGLU 4PA

S

ENULOSE 2

GENERLAC 2

KRISTALOSE (10 GM PACKET, 20 GM PACKET) 3 PA

lactulose 10 gm packet 3 PA

lactulose 10 gm/15 ml solution 2

LITHOSTAT 3

RAVICTI 4PA

S

sodium phenylbutyrate 500mg tb 4PA

S

sodium phenylbutyrate powder 2 PA

CALORIC AGENTS

DOJOLVI 4PA

S

levocarnitine 330 mg tablet 2

REPLACEMENT PREPARATIONS

CALTRATE 600-D3 PLUS MINERALS 3 PA

EFFER-K (10 TABLET EFF, 20 TABLET EFF, 25 TABLET EFF) 3

k-tab er 3

KLOR-CON 3

KLOR-CON 10 3

KLOR-CON 8 3

KLOR-CON M10 2

KLOR-CON M15 2

KLOR-CON M20 2

klor-con-ef 3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSpotassium chloride (er 8 meq capsule, er 8 meq tablet,10% (20 meq/15ml), 10% (40 meq/30ml), er 10 meqcapsule, er 10 meq tablet, 20 meq packet, 20% (40meq/15ml), er 20 meq tablet)

2

URICOSURIC AGENTS

DUZALLO 3 PA

probenecid 2

probenecid-colchicine 2

EMOLLIENTS, DEMULCENTS, AND PROTECTANTSBASIC LOTIONS AND LINIMENTS

ammonium lactate 12% lotion 2

BASIC OILS AND OTHER SOLVENTS

CERACADE 3 PA

BASIC OINTMENTS AND PROTECTANTSammonium lactate 12% cream 2

DEXERYL 3 PA

NUTRASEB 3 PA

TETRIX 3 PA

ENZYMES

PALYNZIQ 4PA

S

REVCOVI 4PA

S

STRENSIQ 4PA

S

SUCRAID 4PA

S



ESTROGENS AND ANTIESTROGENSESTROGEN AGONIST-ANTAGONISTS

EVISTA 3

FARESTON 3 PA

OSPHENA 3

raloxifene hcl 2 ACA Affordable Care Act

SOLTAMOX 1

tamoxifen citrate 2 ACA Affordable Care Act

toremifene citrate 2 PA

ESTROGENSACTIVELLA 3

ALORA 3

AMABELZ 0.5 MG-0.1 MG TABLET 2

AMABELZ 1 MG-0.5 MG TABLET 3

ANGELIQ 3

CLIMARA 3

CLIMARA PRO 1

COMBIPATCH 1

DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 0.75MG GEL PACKET, 1 MG GEL PACKET, 1.25 MG GELPACKET)

3

DOTTI 2

DUAVEE 3

ELESTRIN 3

ESTRACE (0.01% CREAM, 0.5 MG TABLET, 1 MG TABLET, 2MG TABLET)

3

estradiol (0.01% cream, 0.5 mg tablet, 1 mg tablet, 2 mgtablet, 10 mcg vaginal insrt)

2

estradiol (once weekly) 2

estradiol (twice weekly) 2



estradiol-noreth 0.5-0.1 mg tb 2

estradiol-noreth 1-0.5 mg tab 3

ESTRING 1

ESTROGEL 3

EVAMIST 3

FEMHRT 3

FEMRING 3

FYAVOLV 2

IMVEXXY (4 MCG PACK, 10 MCG PACK) 3 QL 18 TABS / 28 DAYS

IMVEXXY (4 MCG PACK, 10 MCG PAK) 3 QL 8 TABS / 28 DAYS

JINTELI 2

LOPREEZA 0.5 MG-0.1 MG TABLET 2

LOPREEZA 1 MG-0.5 MG TABLET 3

MENEST (0.3 MG TABLET, 0.625 MG TABLET, 1.25 MGTABLET)

3

MENOSTAR 3

MIMVEY 3

MIMVEY LO 2

MINIVELLE 3

norethindron-ethinyl estradiol (norethin-eth 1 mg-5 mcg,norethind-eth 0.5-2.5)

2

PREFEST 3

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MGTABLET, 0.9 MG TABLET, 1.25 MG TABLET, VAGINALCREAM-APPL)

1

PREMPHASE 1

PREMPRO 1

VAGIFEM 3

VIVELLE-DOT 3

YUVAFEM 2



EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIALLERGIC AGENTS

ALOMIDE 1 PA

azelastine 0.15% nasal spray 3

azelastine hcl (hcl 0.05% drops, 0.1% (137 mcg) spry) 2

azelastine-fluticasone 3

bepotastine besilate 3 PA

BEPREVE 3 PA

DYMISTA 3

epinastine hcl 2

LASTACAFT 1 PA

olopatadine 665 mcg nasal spry 2 PA

olopatadine hcl 0.1% eye drops 2

olopatadine hcl 0.2% eye drop 3

PATADAY 3

PATANASE 3

PATANOL 3

PAZEO 3 PA

TICALAST 3 PA

ZERVIATE 1 PA

EENT DRUGS, MISCELLANEOUS

apraclonidine hcl 2 PA

CYSTADROPS 4

QL 5 ML / RX

PA

S

CYSTARAN 4

QL 15 ML / RX

PA

S



IOPIDINE 3

ipratropium bromide (0.03% spray, 0.06% spray) 2

LACRISERT 3 PA

OXERVATE 4

QL 1 ML / 1 DAY

PA

S

PHOTREXA 3

PHOTREXA VISCOUS 3

LOCAL ANESTHETICS (EENT)

ADVANCED DNA MEDICATED COLLECT 3 PA

fluorescein-benoxinate 3

lidocaine hcl (2% jel urojet ac, 2% jelly, 2% jelly uro-jet, 4%solution)

2

lidocaine hcl viscous 2

pro dna collection 3 PA

PRO DNA MEDICATED COLLECTION 3 PA

proparacaine hcl 3

MYDRIATICSatropine sulfate (drops, ointment) 2

CYCLOGYL 3

CYCLOMYDRIL 3

cyclopentolate hcl (0.5% eye drops, hcl 2% drops) 3

cyclopentolate hcl (drop, drops) 2

homatropaire 2

homatropine hydrobromide 2

MYDRIACYL 3

tropicamide 3



VASOCONSTRICTORSADRENALIN CHLORIDE 3

phenylephrine hcl (2.5% drop, 10% drops) 2

UPNEEQ 3 PA

FIRST GENERATION ANTIHISTAMINESETHANOLAMINE DERIVATIVES

carbinoxamine maleate 4 mg tab 2 PA

carbinoxamine maleate 6 mg tab 3 PA

clemastine 0.5 mg/5 ml syrup 3 PA

clemastine fum 2.68 mg tab 3

diphenhydramine hcl (12.5 mg/5 ml, 25 mg capsule, 25mg/10 ml, 50 mg capsule)

3

KARBINAL ER 3

RYVENT 3

FIRST GEN. ANTIHIST. DERIVATIVES, MISC.cyproheptadine hcl (2 mg/5 ml soln, 2 mg/5 ml syrup, 4mg tablet, 4 mg/10 ml syrp)

2

PHENOTHIAZINE DERIVATIVESPHENADOZ 2

promethazine hcl (12.5 mg suppos, 25 mg suppository, 50mg suppository)

2

promethazine hcl (12.5 mg tablet, 25 mg tablet, 50 mgtablet)

2 AQ1 Up to 64 yrs old; 30 /1 FILL

promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 ml syrp) 2 AQ1 Up to 64 yrs old; 300/ 1 FILL

promethazine vc 2

promethazine-phenylephrine 2

PROMETHEGAN 2

PROPYLAMINE DERIVATIVESdexchlorpheniramine maleate 3



RYCLORA 3

GASTROINTESTINAL DRUGSANTI-INFLAMMATORY AGENTS (GI DRUGS)

alosetron hcl 2 PA

APRISO 3

ASACOL HD 3

balsalazide disodium 2

CANASA 3

COLAZAL 3 PA

DELZICOL 3

DIPENTUM 1 PA

LIALDA 3

LOTRONEX 3 PA

mesalamine (dr 1.2 gm tablet, 4 gm/60 ml enema, 800mg dr tablet, 1,000 mg supp)

2

mesalamine 4 gm/60 ml kit 3 QL 4 KITS / 28 DAYS

mesalamine dr 2

mesalamine er 2

PENTASA 3

ROWASA 4 GM/60 ML ENEMA KIT 3 QL 4 KITS / 28 DAYS

ANTIDIARRHEA AGENTS

diphenoxylat-atrop 2.5-0.025/5 2 QL 40 ML / 1 DAY

diphenoxylate-atrop 2.5-0.025 2 QL 8 TABS / 1 DAY

LOMOTIL 3QL 8 TABS / 1 DAY

PA

loperamide (2 mg capsule, hm 2 mg softgel) 3

MOTOFEN 3 PA



opium tincture 3 QL 2.4 ML / 1 DAY

paregoric 2 QL 40 ML / 1 DAY

XERMELO 4PA

S

CATHARTICS AND LAXATIVES

AMITIZA 3QL 2 CAPS / 1 DAY

PA

CLENPIQ 3

COLYTE WITH FLAVOR PACKETS 3

GAVILYTE-C 2 ACA Affordable Care Act

GAVILYTE-G 2 ACA Affordable Care Act

GAVILYTE-N 2

GIALAX 3

GOLYTELY (PACKET, SOLUTION) 3

lubiprostone 2 QL 2 CAPS / 1 DAY

MOVIPREP 3

NULYTELY WITH FLAVOR PACKS 3

OSMOPREP 3

peg 3350 electrolyte soln 2 ACA Affordable Care Act

peg 3350-electrolyte solution 2

peg-3350 and electrolytes 2 ACA Affordable Care Act

PEG-PREP 3

peg3350-sod sul-nacl-kcl-asb-c 3

PLENVU 3

polyethylene glycol 3350 3

PREPOPIK 3

SUPREP 1 ACA Affordable Care Act



SUTAB 3 PA

TRILYTE WITH FLAVOR PACKETS 3

CHOLELITHOLYTIC AGENTS

ACTIGALL 3 PA

CHENODAL 4PA

S

RELTONE 3 PA

URSO 3

URSO FORTE 3

ursodiol (200 mg capsule, 400 mg capsule) 3 PA

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 2

DIGESTANTSCREON 1

PANCREAZE 3 PA

PERTZYE 3 PA

VIOKACE 3 PA

ZENPEP 3 PA

GI DRUGS, MISCELLANEOUS

ALLI 3 WL Weight Loss

alvimopan 3

BYLVAY 4PA

S

CHOLBAM 4PA

S

ENDARI 4PA

S

ENTEREG 3



GATTEX 4PA

S

HUMIRA(CF) PEDI CROHN 80-40 MG 4

QL 2 SYRINGES / 28DAYS

PA

S

LINZESS 1 QL 1 CAP / 1 DAY

LIVMARLI 4PA

S

MOVANTIK 1QL 1 TAB / 1 DAY

PA

OCALIVA 4PA

S

RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 MLSYRINGE, 12 MG/0.6 ML VIAL, 150 MG TABLET)

3 PA

SYMPROIC 1 PA

TRULANCE 3 PA

VIBERZI 3 PA

XENICAL 3 WL Weight Loss

PROKINETIC AGENTS

GIMOTI 1 PA

metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mgtablet, 10 mg/10 ml sol)

2

metoclopramide hcl odt 2 PA

MOTEGRITY 3 PA

REGLAN 3

ZELNORM 3 PA



GENITOURINARY SMOOTH MUSCLE RELAXANTSANTIMUSCARINICS

darifenacin er 2 PA

DETROL 3

DETROL LA 3

DITROPAN XL 3

ENABLEX 1 PA

flavoxate hcl 2 PA

GELNIQUE 10% GEL PUMP 3 PA

GELNIQUE 10% GEL SACHET 3

oxybutynin chloride (5 mg tablet, 5 mg/5 ml syrup) 2

oxybutynin chloride er 2

OXYTROL 3 PA

solifenacin succinate 2

tolterodine tartrate 2

tolterodine tartrate er 2

TOVIAZ 3

trospium chloride 2

trospium chloride er 3

VESICARE 3

VESICARE LS 3 PA

GOLD COMPOUNDSRIDAURA 1

GONADOTROPINS AND ANTIGONADOTROPINSANTIGONADTROPINS

MYFEMBREE 4


PA

S



ORGOVYX 1PA

S

ORIAHNN 4

QL 2 CAPS / 1 DAY

PA

S

ORILISSA 150 MG TABLET 4

QL 1 TAB / 1 DAY

PA

S

ORILISSA 200 MG TABLET 4


PA

S

GONADOTROPINS

LUPANETA PACK 3 PA

SYNAREL 3

HCV ANTIVIRALSHCV POLYMERASE INHIBITOR ANTIVIRALS

EPCLUSA 4PA

S

HARVONI 4PA

S

ledipasvir-sofosbuvir 4PA

S

sofosbuvir-velpatasvir 4PA

S

SOVALDI 4PA

S

VOSEVI 4PA

S



HCV PROTEASE INHIBITOR ANTIVIRALS

MAVYRET 4PA

S

HCV REPLICATION COMPLEX INHIBITORS

VIEKIRA PAK 4PA

S

ZEPATIER 4PA

S

HEAVY METAL ANTAGONISTSCHEMET 1

CUPRIMINE 4PA

S

D-PENAMINE 2 PA

deferasirox (90 mg granule pkt, 90 mg tablet, 125 mg tbfor susp, 180 mg granule pkt, 180 mg tablet, 250 mg tbfor susp, 360 mg granule pkt, 360 mg tablet, 500 mg tbfor susp)

4

PA

S

TD Trial Drug

deferiprone 4PA

S

DEPEN 4PA

S

EXJADE 4

PA

S

TD Trial Drug

FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET,1,000 MG TABLET)

4PA

S

FERRIPROX (2 TIMES A DAY) 4PA

S

FERRIPROX (3 TIMES A DAY) 4PA

S



JADENU 4

PA

S

TD Trial Drug

JADENU SPRINKLE 4

PA

S

TD Trial Drug

penicillamine (250 mg capsule, 250 mg tablet) 4PA

S

SYPRINE 3PA

S

trientine hcl 4PA

S

HORMONES AND SYNTHETIC SUBSTITUTESADRENALS

ALKINDI SPRINKLE 3 PA

BETALOAN SUIK 3 PA

budesonide ec 2

budesonide er 3

CORTEF 3

cortisone acetate 2 PA

dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5 mg/5ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mgtablet, 4 mg tablet, 6 mg tablet)

2

dexamethasone 6 day 1.5 mg tab 3 PA

DEXAMETHASONE INTENSOL 1

dexamethasone sodium phosphate (4 mg/ml vial, 10mg/ml syring, 10 mg/ml vial, 20 mg/5 ml vial, 100 mg/10ml vl, 120 mg/30 ml vl)

2

DEXPAK 3 PA

DMT SUIK 3 PA



EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/MLORAL SUSP, 30 MG TABLET, 36 MG TABLET)

4PA

S

ENTOCORT EC 3

fludrocortisone acetate 2

HEMADY 3 PA

hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 2

INTRAROSA 3

MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET,16 MG TABLET, 32 MG TABLET)

3

MEDROL 2 MG TABLET 1

MEDROLOAN II SUIK 3 PA

MEDROLOAN SUIK 3 PA

methylprednisolone 2

MILLIPRED 1

ORAPRED ODT 3

ORTIKOS 3 PA

prednisolone 2

prednisolone sodium phos odt 3

prednisolone sodium phosphate (10 mg/5 ml soln, 20mg/5 ml soln)

3

prednisolone sodium phosphate (5 mg/5 ml soln, 15 mg/5ml soln, sod ph 25 mg/5 ml)

2

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dosepack, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab dosepack, 10 mg tablet, 20 mg tablet, 50 mg tablet)

2

PREDNISONE INTENSOL 1

SOLU-CORTEF (100 MG ACT-O-VIAL, 100 MG VIAL, 250MG ACT-O-VIAL, 500 MG ACT-O-VIAL)

1

TAPERDEX (6 1.5 MG TABLET, 12 1.5 MG TABLET) 3 PA

TRILOAN SUIK 3 PA



UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) 3

ZCORT 3 PA

ANDROGENS

ANADROL-50 1 PA

ANDRODERM 3 PA

ANDROGEL 3 PA

ANDROID 3QL 5 CAPS / 1 DAY

PA

covaryx 3 QL 1 TAB / 1 DAY

covaryx h.s. 3 QL 1 TAB / 1 DAY

danazol 2

DEPO-TESTOSTERONE 3 PA

eemt 3 QL 1 TAB / 1 DAY

eemt h.s. 3 QL 1 TAB / 1 DAY

estrogen-methyltestosterone 3 QL 1 TAB / 1 DAY

FORTESTA 3 PA

JATENZO 3 PA

METHITEST 3QL 5 TABS / 1 DAY

PA

methyltestosterone 2QL 5 CAPS / 1 DAY

PA

NATESTO 3 PA

OXANDRIN 10 MG TABLET 3QL 2 TABS / 1 DAY

PA

OXANDRIN 2.5 MG TABLET 3QL 4 TABS / 1 DAY

PA



oxandrolone 10 mg tablet 2QL 2 TABS / 1 DAY

PA

oxandrolone 2.5 mg tablet 2QL 4 TABS / 1 DAY

PA

STRIANT 3 PA

TESTIM 3 PA

testosterone (1% (25mg/2.5g) pk, 1% (50 mg/5 g) pk,1.62% (2.5 g) pkt, 1.62% gel pump, 1.62%(1.25 g) pkt, 10mg gel pump, 12.5 mg/1.25 gram, 50 mg/5 gram gel, 50mg/5 gram pkt)

2 PA

testosterone 30 mg/1.5 ml pump 3 PA

testosterone cypionate (testosteron 1,000 mg/10 ml,testosteron 2,000 mg/10 ml, testosterone 100 mg/ml,testosterone 200 mg/ml, testosterone 500 mg/2.5 ml,testosterone 500 mg/5 ml, testosterone 1,000 mg/5 ml,testosterone 6,000 mg/30ml)

2 PA

testosterone enanthate 2 PA

testosterone propionate 2 PA

TESTRED 3QL 5 CAPS / 1 DAY

PA

VOGELXO 3 PA

XYOSTED 3 PA

CONTRACEPTIVES

AFIRMELLE 2 ACA Affordable Care Act

ALTAVERA 2 ACA Affordable Care Act

ALYACEN 2 ACA Affordable Care Act

AMETHIA 2 ACA Affordable Care Act

AMETHIA LO 2 ACA Affordable Care Act

AMETHYST 3 PA



ANNOVERA 3QL 1 RING / 365 DAYS

PA

APRI 2 ACA Affordable Care Act

ARANELLE 2 ACA Affordable Care Act

ASHLYNA 2 ACA Affordable Care Act

AUBRA 2 ACA Affordable Care Act

AUBRA EQ 2 ACA Affordable Care Act

AUROVELA 2 ACA Affordable Care Act

AUROVELA 24 FE 2 ACA Affordable Care Act

AUROVELA FE 2 ACA Affordable Care Act

AVIANE 2 ACA Affordable Care Act

AYUNA 2 ACA Affordable Care Act

AZURETTE 2 ACA Affordable Care Act

BALCOLTRA 3 PA

BALZIVA 2 ACA Affordable Care Act

BEKYREE 2 ACA Affordable Care Act

BEYAZ 3 PA

BLISOVI 24 FE 1 ACA Affordable Care Act

BLISOVI FE 2 ACA Affordable Care Act

BRIELLYN 2 ACA Affordable Care Act

CAMILA 2 ACA Affordable Care Act

CAMRESE 2 ACA Affordable Care Act

CAMRESE LO 2 ACA Affordable Care Act

CAZIANT 2 ACA Affordable Care Act



CHARLOTTE 24 FE 3 PA

CHATEAL 2 ACA Affordable Care Act

CHATEAL EQ 2 ACA Affordable Care Act

CRYSELLE 2 ACA Affordable Care Act

CYCLAFEM 2 ACA Affordable Care Act

CYRED 2 ACA Affordable Care Act

CYRED EQ 2 ACA Affordable Care Act

DASETTA 2 ACA Affordable Care Act

DAYSEE 2 ACA Affordable Care Act

DEBLITANE 2 ACA Affordable Care Act

desogestr-eth estrad eth estra 2 ACA Affordable Care Act

desogestrel-ethinyl estradiol 2 ACA Affordable Care Act

DOLISHALE 3 PA

drospirenone-eth estra-levomef 3 PA

drospirenone-ethinyl estradiol 2 ACA Affordable Care Act

ELINEST 2 ACA Affordable Care Act

ELLA 1 ACA Affordable Care Act

ELURYNG 2 ACA Affordable Care Act

EMOQUETTE 2 ACA Affordable Care Act

ENPRESSE 2 ACA Affordable Care Act

ENSKYCE 2 ACA Affordable Care Act

ERRIN 2 ACA Affordable Care Act

ESTARYLLA 2 ACA Affordable Care Act

ESTROSTEP FE 3 PA



ethynodiol-ethinyl estradiol 2 ACA Affordable Care Act

etonogestrel-ethinyl estradiol 2 ACA Affordable Care Act

FALMINA 2 ACA Affordable Care Act

FAYOSIM 3 PA

FEMYNOR 2 ACA Affordable Care Act

GEMMILY 3 PA

GENERESS FE 3 PA

GIANVI 2 ACA Affordable Care Act

HAILEY 2 ACA Affordable Care Act

HAILEY 24 FE 3 PA

HAILEY FE 2 ACA Affordable Care Act

HEATHER 2 ACA Affordable Care Act

ICLEVIA 2 ACA Affordable Care Act

INCASSIA 2 ACA Affordable Care Act

INTROVALE 2 ACA Affordable Care Act

ISIBLOOM 2 ACA Affordable Care Act

JAIMIESS 2 ACA Affordable Care Act

JASMIEL 2 ACA Affordable Care Act

JENCYCLA 2 ACA Affordable Care Act

JOLESSA 2 ACA Affordable Care Act

JULEBER 2 ACA Affordable Care Act

JUNEL 2 ACA Affordable Care Act

JUNEL FE 2 ACA Affordable Care Act

JUNEL FE 24 3 PA



KAITLIB FE 3 PA

KALLIGA 2 ACA Affordable Care Act

KARIVA 2 ACA Affordable Care Act

KELNOR 1-35 2 ACA Affordable Care Act

KELNOR 1-50 2 ACA Affordable Care Act

KURVELO 2 ACA Affordable Care Act

LARIN 2 ACA Affordable Care Act

LARIN 24 FE 3 PA

LARIN FE 2 ACA Affordable Care Act

LARISSIA 2 ACA Affordable Care Act

LAYOLIS FE 3 PA

LEENA 2 ACA Affordable Care Act

LESSINA 2 ACA Affordable Care Act

LEVONEST 2 ACA Affordable Care Act

levonor-eth estra 0.09-0.02 mg 3 PA

levonorg-eth estrad eth estrad 2 ACA Affordable Care Act

levonorgestrel 2 ACA Affordable Care Act

levonorgestrel-eth estradiol (0.1-0.02 mg, 0.15-0.03,triphasic)


LEVORA-28 2 ACA Affordable Care Act

LILLOW 2 ACA Affordable Care Act

LO LOESTRIN FE 3 PA

LO-ZUMANDIMINE 2 ACA Affordable Care Act

LOESTRIN 3 PA

LOESTRIN FE 3 PA



LOJAIMIESS 2 ACA Affordable Care Act

LORYNA 2 ACA Affordable Care Act

LOSEASONIQUE 3 PA

LOW-OGESTREL 2 ACA Affordable Care Act

LUTERA 2 ACA Affordable Care Act

LYZA 2 ACA Affordable Care Act

MARLISSA 2 ACA Affordable Care Act

MELODETTA 24 FE 3 PA

MERZEE 3 PA

MIBELAS 24 FE 3 PA

MICROGESTIN 2 ACA Affordable Care Act

MICROGESTIN 24 FE 3 PA

MICROGESTIN FE 2 ACA Affordable Care Act

MILI 2 ACA Affordable Care Act

MINASTRIN 24 FE 3 PA

MIRCETTE 3 PA

MONO-LINYAH 2 ACA Affordable Care Act

MY WAY 2 ACA Affordable Care Act

NATAZIA 3 PA

NECON 2 ACA Affordable Care Act

NEXTSTELLIS 3 PA

NIKKI 2 ACA Affordable Care Act

NORA-BE 2 ACA Affordable Care Act

norethin-eth estra-ferrous fum 3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnorethindron-ethinyl estradiol (norethin-ee 1.5-0.03mg(21) tb, norethind-eth estrad 1-0.02 mg)


norethindrone 2 ACA Affordable Care Act

norethindrone-e.estradiol-iron (1-0.02(21)-75 tab, 1.5-0.03mg(21)-75)


norethindrone-e.estradiol-iron (cap, chw) 3 PA

norgestimate-ethinyl estradiol 2 ACA Affordable Care Act

NORLYDA 2 ACA Affordable Care Act

NORTREL 2 ACA Affordable Care Act

NUVARING 3

NYMYO 2 ACA Affordable Care Act

OCELLA 2 ACA Affordable Care Act

OGESTREL 2 ACA Affordable Care Act

ORSYTHIA 2 ACA Affordable Care Act

ORTHO MICRONOR 3 PA

ORTHO TRI-CYCLEN 3 PA

ORTHO-NOVUM 3 PA

PHILITH 2 ACA Affordable Care Act

PIMTREA 2 ACA Affordable Care Act

PIRMELLA 2 ACA Affordable Care Act

PLAN B ONE-STEP 3 PA

PORTIA 2 ACA Affordable Care Act

PREVIFEM 2 ACA Affordable Care Act

QUARTETTE 3 PA

RECLIPSEN 2 ACA Affordable Care Act

RIVELSA 3 PA



SAFYRAL 3 PA

SEASONIQUE 3 PA

SETLAKIN 2 ACA Affordable Care Act

SHAROBEL 2 ACA Affordable Care Act

SIMLIYA 2 ACA Affordable Care Act

SIMPESSE 2 ACA Affordable Care Act

SLYND 3 PA

SPRINTEC 2 ACA Affordable Care Act

SRONYX 2 ACA Affordable Care Act

SYEDA 2 ACA Affordable Care Act

TARINA 24 FE 2 ACA Affordable Care Act

TARINA FE 2 ACA Affordable Care Act

TARINA FE 1-20 EQ 2 ACA Affordable Care Act

TAYTULLA 3 PA

TILIA FE 2 ACA Affordable Care Act

TRI FEMYNOR 2 ACA Affordable Care Act

TRI-ESTARYLLA 2 ACA Affordable Care Act

TRI-LEGEST FE 2 ACA Affordable Care Act

TRI-LINYAH 2 ACA Affordable Care Act

TRI-LO-ESTARYLLA 2 ACA Affordable Care Act

TRI-LO-MARZIA 2 ACA Affordable Care Act

TRI-LO-MILI 2 ACA Affordable Care Act

TRI-LO-SPRINTEC 2 ACA Affordable Care Act

TRI-MILI 2 ACA Affordable Care Act



TRI-PREVIFEM 2 ACA Affordable Care Act

TRI-SPRINTEC 2 ACA Affordable Care Act

TRI-VYLIBRA 2 ACA Affordable Care Act

TRI-VYLIBRA LO 2 ACA Affordable Care Act

TRIVORA-28 2 ACA Affordable Care Act

TULANA 2 ACA Affordable Care Act

TWIRLA 3 PA

TYBLUME 2 ACA Affordable Care Act

TYDEMY 3 PA

VELIVET 2 ACA Affordable Care Act

VESTURA 2

VIENVA 2 ACA Affordable Care Act

VIORELE 2 ACA Affordable Care Act

VOLNEA 2 ACA Affordable Care Act

VYFEMLA 2 ACA Affordable Care Act

VYLIBRA 2 ACA Affordable Care Act

WERA 2 ACA Affordable Care Act

WYMZYA FE 3 PA

XULANE 2 ACA Affordable Care Act

YASMIN 28 3 PA

YAZ 3 PA

ZARAH 2 ACA Affordable Care Act

ZOVIA 1-35 2 ACA Affordable Care Act

ZOVIA 1-35E 2 ACA Affordable Care Act



ZUMANDIMINE 2 ACA Affordable Care Act

LEPTINS

MYALEPT 4PA

S

PITUITARY

DDAVP (0.01% NASAL SPRAY, 10 MCG/0.1 ML SOLUTION) 3 PA

DDAVP (0.1 MG TABLET, 0.2 MG TABLET) 3 AL1 At least 8 yrs old

desmopressin acetate (0.01% solution, 1.5 mg/ml spray,10 mcg/0.1 ml spr)

2 PA

desmopressin acetate (0.1 mg tb, 0.2 mg tb) 2 AL1 At least 8 yrs old

NOCDURNA 3

NOCTIVA 3

SEROSTIM 4PA

S

STIMATE 3 PA

PROGESTINSAYGESTIN 3

CRINONE 4% GEL 3

hydroxyprogest 250 mg/ml vial 4QL 2 ML / 1 FILL

S

medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10mg tab)

2

MEGACE ES 3

megestrol 625 mg/5 ml susp 3

megestrol acetate (20 mg tablet, 40 mg tablet, acet 40mg/ml susp)

2

norethindrone ac (lupaneta) 2

norethindrone acetate 2

progesterone (100 mg capsule, 200 mg capsule) 2



progesterone 500 mg/10 ml vial 3

PROMETRIUM 3

PROVERA 3

HYPOTENSIVE AGENTSCENTRAL ALPHA-AGONISTS

CATAPRES 3

CATAPRES-TTS 1 3

CATAPRES-TTS 2 3

CATAPRES-TTS 3 3

clonidine 2

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 2

clonidine hcl er 2QL 4 TABS / 1 DAY

PA

guanfacine hcl 2

KAPVAY 3QL 4 TABS / 1 DAY

PA

methyldopa 2

methyldopa-hydrochlorothiazide 3

DIRECT VASODILATORSBIDIL 3

hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet)

2

minoxidil 2

INSULINSINTERMEDIATE-ACTING INSULINS

HUMULIN 70-30 1

HUMULIN 70/30 KWIKPEN 1

HUMULIN N 1

HUMULIN N KWIKPEN 1



NOVOLIN 70-30 100 UNIT/ML VIAL 3 PA

NOVOLIN 70-30 FLEXPEN 3 PA

NOVOLIN N 100 UNIT/ML FLEXPEN 3 PA

NOVOLIN N 100 UNIT/ML VIAL 3 PA

relion novolin 70-30 flexpen 1

relion novolin 70-30 vial 1

relion novolin n 100 unit/ml 1

relion novolin n u-100 flexpen 1

LONG-ACTING INSULINS

BASAGLAR KWIKPEN U-100 3 PA

insulin glargine-yfgn 3 PA

LANTUS 1

LANTUS SOLOSTAR 1

LEVEMIR 1 PA

LEVEMIR FLEXTOUCH 1 PA

SEMGLEE 3 PA

SEMGLEE (YFGN) 3 PA

SEMGLEE (YFGN) PEN 3 PA

SEMGLEE PEN 3 PA

SOLIQUA 100-33 1

TOUJEO MAX SOLOSTAR 1

TOUJEO SOLOSTAR 1

TRESIBA 3 PA

TRESIBA FLEXTOUCH U-100 3 PA

TRESIBA FLEXTOUCH U-200 3 PA

XULTOPHY 100-3.6 1



RAPID-ACTING INSULINS

ADMELOG 3 PA

ADMELOG SOLOSTAR 3 PA

AFREZZA 3 PA

APIDRA 3 PA

APIDRA SOLOSTAR 3 PA

FIASP 3 PA

FIASP FLEXTOUCH 3 PA

FIASP PENFILL 3 PA

HUMALOG 1

HUMALOG JUNIOR KWIKPEN 1

HUMALOG KWIKPEN U-100 1

HUMALOG KWIKPEN U-200 1

HUMALOG MIX 50-50 1

HUMALOG MIX 50-50 KWIKPEN 1

HUMALOG MIX 75-25 1

HUMALOG MIX 75-25 KWIKPEN 1

insulin aspart 2 PA

insulin aspart flexpen 2 PA

insulin aspart penfill 2 PA

insulin aspart prot mix 70-30 3 PA

insulin lispro 2

insulin lispro junior kwikpen 2

insulin lispro kwikpen u-100 2

insulin lispro protamine mix 2

LYUMJEV 3 PA



LYUMJEV KWIKPEN U-100 3 PA

LYUMJEV KWIKPEN U-200 3 PA

NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML VIAL,RELION 100 UNIT/ML VL)

3 PA

novolog flexpen (100 unit/ml, relion u-100) 3 PA

NOVOLOG MIX 70-30 (RELION VIAL, VIAL) 3 PA

NOVOLOG MIX 70-30 FLEXPEN (FLEXPEN, RELION FLXPN) 3 PA

SHORT-ACTING INSULINSHUMULIN R 1

HUMULIN R U-500 1

HUMULIN R U-500 KWIKPEN 1

NOVOLIN R 100 UNIT/ML FLEXPEN 3 PA

NOVOLIN R 100 UNIT/ML VIAL 3 PA

relion novolin r 100 unit/ml 1

relion novolin r u-100 flexpen 1

ION-REMOVING AGENTSPHOSPHATE-REMOVING AGENTS

AURYXIA 3

calcium acetate (667 mg capsule, 667 mg gelcap) 2

calcium acetate 667 mg tablet 3

FOSRENOL 3

lanthanum carbonate 2 PA

PHOSLYRA 1

RENAGEL 3

RENVELA 3

sevelamer carbonate 2

sevelamer hcl 3

VELPHORO 3



POTASSIUM-REMOVING AGENTSLOKELMA 1

sodium polystyrene sulfonate (sod polystyren 15 g/60 ml,sodium polystyrene powder)

2

VELTASSA 3

LOCAL ANESTHETICS (PARENTERAL)

ACCUCAINE 3 PA

MARVONA SUIK 3 PA

MACROLIDE ANTIBIOTICSERYTHROMYCIN ANTIBIOTICS

E.E.S. 200 3

E.E.S. 400 3

ERY-TAB 3

ERYPED 200 3

ERYPED 400 3

ERYTHROCIN STEARATE 3

erythromycin (250 mg filmtab, dr 250 mg cap, dr 333 mgtablet)

3

erythromycin 500 mg filmtab 1 PA

erythromycin ethylsuccinate (200 mg/5 ml susp, es 400mg tab)

3

OTHER MACROLIDE ANTIBIOTICSazithromycin (100 mg/5 ml susp, 200 mg/5 ml susp, 250mg tablet, 500 mg tablet, 600 mg tablet)

2

clarithromycin (125 mg/5 ml sus, 250 mg/5 ml sus) 2 AL1 Up to 12 yrs old

clarithromycin (250 mg tablet, 500 mg tablet) 2

clarithromycin er 3

DIFICID (40 MG/ML SUSPENSION, 200 MG TABLET) 1 PA

ZITHROMAX (250 MG TABLET, 250 MG Z-PAK TABLET) 3 PA



MISC. BETA-LACTAM ANTIBIOTICSMONOBACTAM ANTIBIOTICS

CAYSTON 4PA

S

MISCELLANEOUS THERAPEUTIC AGENTS5-ALPHA-REDUCTASE INHIBITORS

AVODART 3 PA

dutasteride 2

dutasteride-tamsulosin 2 PA

finasteride 5 mg tablet 2

JALYN 3

PROSCAR 3

ALCOHOL DETERRENTSANTABUSE 3

disulfiram 2

ANTIDOTESleucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25mg tab)

2

VISTOGARD 4PA

S

ANTIGOUT AGENTSallopurinol 2

colchicine 2

COLCRYS 3

febuxostat 2 ST

GLOPERBA 3 PA

MITIGARE 3 PA

ULORIC 3 PA



ANTISENSE OLIGONUCLEOTIDES

TEGSEDI 4PA

S

BONE RESORPTION INHIBITORS

ACTONEL 3 PA

alendronate sod 70 mg/75 ml 2 PA

alendronate sodium (5 mg tablet, 10 mg tab, 35 mg tab,40 mg tab, 70 mg tab)

2

ATELVIA 3

BINOSTO 3 PA

BONIVA 3

etidronate disodium 2

FOSAMAX PLUS D 3

ibandronate sodium 150 mg tab 2

risedronate sodium 2

risedronate sodium dr 3

CARBONIC ANHYDRASE INHIBITORS (MISC.)

KEVEYIS 4PA

S

CARIOSTATIC AGENTSCLINPRO 5000 3

denta 5000 plus 2

dentagel 2

fluoride 2AL1 Up to 5 yrs old


fluoridex 3

FLUORIDEX SENSITIVITY RELIEF 3

fluoritab (0.5 mg tablet chew, 1 mg tablet chew) 2AL1 Up to 5 yrs old




flura-drops 2AL1 Up to 5 yrs old


GEL-KAM 3 PA

ludent fluoride 2AL1 Up to 5 yrs old


PERIOMED 3

PREVIDENT (0.2% RINSE, 1.1% GEL, 5000 BOOSTER PLUS,DENTAL RINSE)

3

PREVIDENT 5000 3

PREVIDENT 5000 ENAMEL PROTECT 3

PREVIDENT 5000 PLUS 3

PREVIDENT 5000 SENSITIVE 3

sf 2

sf 5000 plus 2

sodium fluoride (0.25 (0.55) mg, 0.5 mg(1.1 mg), 0.5mg/ml drop, 1 mg (2.2 mg))

2AL1 Up to 5 yrs old


sodium fluoride 5000 dry mouth 3

sodium fluoride 5000 ppm paste 3

sodium fluoride enamel protect 3

sodium fluoride sensitive 3

COMPLEMENT INHIBITORS

BERINERT 4PA

S

CINRYZE 4PA

S

FIRAZYR 4

QL 9 ML / 1 FILL

PA

S

HAEGARDA 4PA

S



icatibant 4

QL 9 ML / 1 FILL

PA

S

KALBITOR 4PA

S

ORLADEYO 4

QL 1 CAP / 1 DAY

PA

S

RUCONEST 4PA

S

SAJAZIR 4

QL 9 ML / 1 FILL

PA

S

TAKHZYRO 4

QL 4 ML / 28 DAYS

PA

S

TAVNEOS 4

QL 6 CAPS / 1 DAY

PA

S

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

ACTEMRA 162 MG/0.9 ML SYRINGE 4


PA

S

ACTEMRA ACTPEN 4PA

S

ARAVA 3

CIMZIA (MG/ML SYRINGE KIT, MG/ML(X3)START KT) 4


PA

S



ENBREL (25 MG/0.5 ML SYRINGE, 25 MG/0.5 ML VIAL) 4

QL 4 ML (8 DOSES) / 28DAYS

PA

S

ENBREL 25 MG KIT 4

QL 8 VIALS (8 ML) / 28DAYS

PA

S

ENBREL 50 MG/ML SYRINGE 4


PA

S

ENBREL MINI 4


PA

S

ENBREL SURECLICK 4


PA

S

HUMIRA 4


PA

S

HUMIRA PEN 4

QL 2 PENS / 28 DAYS

PA

S

HUMIRA PEN CROHN'S-UC-HS 4

QL 2 PENS / 28 DAYS

PA

S

HUMIRA PEN PSOR-UVEITS-ADOL HS 4

QL 2 PENS / 28 DAYS

PA

S



HUMIRA(CF) 4


PA

S

HUMIRA(CF) PEDI CROHN 80MG/0.8 4

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN 40 MG/0.4 ML 4

QL 2 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN 80 MG/0.8 ML 4

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN CROHN'S-UC-HS 4

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN PEDIATRIC UC 4

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN PSOR-UV-ADOL HS 4

QL 2 PENS / 28 DAYS

PA

S

KEVZARA (150 MG/1.14 ML PEN INJ, 200 MG/1.14 MLPEN INJ)

4

QL 2 PENS / 28 DAYS

PA

S

KEVZARA (150 MG/1.14 ML SYRINGE, 200 MG/1.14 MLSYRINGE)

4


PA

S

KINERET 4


PA

S



leflunomide 2

OLUMIANT 4

QL 1 TAB / 1 DAY

PA

S

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/ML SYRINGE)

4


PA

S

ORENCIA CLICKJECT 4

QL 4 ML / 28 DAYS

PA

S

OTEZLA 28 DAY STARTER PACK 4


PA

S

OTEZLA 30 MG TABLET 4

QL 2 TABS / 1 DAY

PA

S

OTEZLA STARTER PACK 4

QL 2 PACKS / 28 DAYS

PA

S

RINVOQ 4

QL 1 TAB / 1 DAY

PA

S

SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 MLSYRINGE, 100 MG/ML PEN INJECTOR)

4

QL 1 SYRINGE / 28 DAYS

PA

S

SIMPONI 100 MG/ML SYRINGE 4

QL 1 ML / 28 DAYS

PA

S

SIMPONI ARIA 4

QL 4 INJECTIONS / 56DAYS

PA

S



XELJANZ (5 MG TABLET, 10 MG TABLET) 4

QL 2 TABS / 1 DAY

PA

S

XELJANZ 1 MG/ML SOLUTION 4

QL 10 ML / 1 DAY

PA

S

XELJANZ XR 4

QL 1 TAB / 1 DAY

PA

S

IMMUNOMODULATORY AGENTS

ACTIMMUNE 4PA

S

AUBAGIO 4QL 1 TAB / 1 DAY

S

AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT) 4QL 1 KIT / 28 DAYS

S

AVONEX 30 MCG/0.5 ML SYRINGE 4QL 4 SYRINGES / 28

DAYSS

AVONEX PEN 4QL 1 KIT / 28 DAYS

S

BAFIERTAM 4

QL 4 CAPS / 1 DAY

PA

S

BETASERON 0.3 MG KIT 4QL 15 ML / 28 DAYS

S

BETASERON 0.3 MG VIAL 4QL 15 ML / 30 DAYS

S

COPAXONE 20 MG/ML SYRINGE 4

QL 30 ML / 30 DAYS

PA

S



COPAXONE 40 MG/ML SYRINGE 4

QL 12 ML / 28 DAYS

PA

S

dimethyl fumarate 4QL 2 CAPS / 1 DAY

S

ENSPRYNG 4PA

S

EXTAVIA 0.3 MG KIT 4

QL 15 ML / 28 DAYS

PA

S

EXTAVIA 0.3 MG VIAL 4

QL 15 ML / 30 DAYS

PA

S

GILENYA 4QL 1 CAP / 1 DAY

S

glatiramer 20 mg/ml syringe 4QL 30 ML / 30 DAYS

S

glatiramer 40 mg/ml syringe 4QL 12 ML / 28 DAYS

S

GLATOPA 20 MG/ML SYRINGE 4QL 30 ML / 30 DAYS

S

GLATOPA 40 MG/ML SYRINGE 4QL 12 ML / 28 DAYS

S

KESIMPTA PEN 4QL 1 PEN / 28 DAYS

S

MAYZENT 0.25 MG STARTER PACK 4QL 12 TABS / 4 DAYS

S

MAYZENT 0.25 MG TABLET 4QL 4 TABS / 1 DAY

S



MAYZENT 2 MG TABLET 4QL 1 TAB / 1 DAY

S

PLEGRIDY 4QL 1 ML / 28 DAYS

S

PLEGRIDY PEN 4QL 1 ML / 28 DAYS

S

PONVORY 14-DAY STARTER PACK 4


PA

S

PONVORY 20 MG TABLET 4

QL 1 TAB / 1 DAY

PA

S

REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 MLSYRINGE)

4

QL 6 ML / 28 DAYS

PA

S

REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 4

QL 6 ML / 28 DAYS

PA

S

REBIF REBIDOSE TITRATION PACK 4

QL 4.2 ML / 28 DAYS

PA

S

REBIF TITRATION PACK 4

QL 4.2 ML / 28 DAYS

PA

S

REDITREX 1 PA

TECFIDERA 4

QL 2 CAPS / 1 DAY

PA

S

THALOMID 1S

ONC Oncology



VUMERITY 4QL 4 CAPS / 1 DAY

S

ZEPOSIA 0.23-0.46 MG START PCK 4


PA

S

ZEPOSIA 0.23-0.46-0.92 MG KIT 4


PA

S

ZEPOSIA 0.92 MG CAPSULE 4

QL 1 CAP / DAY

PA

S

IMMUNOSUPPRESSIVE AGENTS

ASTAGRAF XL 3 PA

AZASAN 3

azathioprine (75 mg tablet, 100 mg tablet) 3

azathioprine 50 mg tablet 2

BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/MLSYRINGE)

4PA

S

CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500MG TABLET)

3 PA

cyclosporine (25 mg capsule, 100 mg capsule) 2

cyclosporine modified (25 mg, 50 mg, 100 mg, 100mg/ml) 2

ENVARSUS XR 3 PA

everolimus (0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet) 2 PA

GENGRAF (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION)

2

LUPKYNIS 4

QL 6 CAPS / 30 DAYS

PA

S



MAVENCLAD 4PA

S

mycophenolate mofetil (200 mg/ml susp, 250 mg capsule,500 mg tablet)

2

mycophenolic acid 2

MYFORTIC 3 PA

NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATINCAPSULE, 100 MG/ML SOLUTION)

3

PROGRAF (0.2 MG GRANULE PACKET, 1 MG GRANULEPACKET)

3 PA

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MGCAPSULE)

3

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/MLORAL SOLN, 2 MG TABLET)

3

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLN)

3

sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet)

2

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 2

ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MGTABLET)

3

ZORTRESS 1 MG TABLET 1 PA

OTHER MISCELLANEOUS THERAPEUTIC AGENTS

AMPYRA 4

QL 2 TABS / 1 DAY

PA

S

ARCALYST 4PA

S

CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3

CARNITOR SF 3

CERDELGA 4PA

S



CYSTADANE 3

CYSTAGON 1

dalfampridine er 4

QL 2 TABS / 1 DAY

PA

S

DEMSER 3 PA

EVRYSDI 4PA

S

FIRDAPSE 4

QL 8 TABS / 30 DAYS

PA

S

GALAFOLD 4


PA

S

ILARIS 4

QL 2 ML / 28 DAYS

PA

S

ISTURISA 4PA

S

KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500MG POWDER PACKET)

4PA

S

levocarnitine 1 g/10 ml soln 2

levocarnitine sf 2

metyrosine 3 PA

miglustat 4PA

S

nitisinone 4PA

S

NITYR 4PA

S



ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MGCAPSULE, 10 MG CAPSULE, 20 MG CAPSULE)

4PA

S

POTABA 3 PA

PROCYSBI 4PA

S

RETAINE OM3 3 PA

RETAINE VISION 3 PA

REZUROCK 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

RUZURGI 4

QL 10 TABS / 1 DAY

PA

S

sapropterin dihydrochloride 4PA

S

THIOLA 4PA

S

THIOLA EC 4PA

S

tiopronin 4PA

S

TYBOST 1

wrestone 3 PA

XURIDEN 4PA

S

ZAVESCA 4PA

S



ZOKINVY 4PA

S

PROTECTIVE AGENTSELMIRON 1

MESNEX 400 MG TABLET 3

NONHORMONAL CONTRACEPTIVES

PHEXXI 3 PA

TODAY CONTRACEPTIVE SPONGE 1 ACA Affordable Care Act

vcf 2 ACA Affordable Care Act

NONSTEROIDAL ANTI-INFLAMMATORY AGENTSCYCLOOXYGENASE-2 (COX-2) INHIBITORS

CELEBREX 3 PA

celecoxib 2

NUDROXIPAK 3 PA

OTHER NONSTEROIDAL ANTI-INFLAM. AGENTSANAPROX DS 3

ARTHROTEC 50 3

ARTHROTEC 75 3

CAMBIA 3 PA

DAYPRO 3

DERMACINRX LEXITRAL 3 PA

diclo gel 3 PA

DICLO GEL-XRYLIX SHEET 3 PA

diclofenac 3 PA

diclofenac 1.5% topical soln 3 PA

diclofenac epolamine 3 PA

diclofenac pot 25 mg tablet 3 PA



diclofenac pot 50 mg tablet 2

diclofenac sodium (sod dr 25 mg tab, sod dr 50 mg tab,sod dr 75 mg tab, sod ec 25 mg tab, sod ec 50 mg tab, sodec 75 mg tab, sodium 1% gel)

2

diclofenac sodium er 2

diclofenac sodium-misoprostol 2 PA

DICLOFONO 3

DICLOPR 3 PA

DICLOZOR 3 PA

diflunisal 2 PA

DITHOL 3 PA

DUEXIS 1 PA

EC-NAPROSYN 3

ec-naproxen 3

etodolac 2

etodolac er 2

FELDENE 3

fenoprofen calcium 2 PA

FLECTOR 3 PA

flurbiprofen 2

ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 2

ibuprofen-famotidine 3 PA

INDOCIN 25 MG/5 ML SUSPENSION 3PA

AQ1 Up to 64 yrs old; 150/ 1 FILL

INDOCIN 50 MG SUPPOSITORY 3 PA

indomethacin (25 mg capsule, 50 mg capsule) 2 AQ1 Up to 64 yrs old; 20 /1 FILL



indomethacin 20 mg capsule 3PA

AQ1 Up to 64 yrs old; 20 /fill(s)

indomethacin er 3 AQ1 Up to 64 yrs old; 20 /1 FILL

INFLAMMA-K 3 PA

ketoprofen (25 mg capsule, 50 mg capsule, 75 mgcapsule)

2 PA

ketoprofen er 200 mg capsule 3

ketorolac 10 mg tablet 2 QL 20 TABS / RX

ketorolac 15.75 mg nasal spray 3 PA

ketorolac tromethamine (15 mg/ml carpuject, 15 mg/mlisecure syr, 15 mg/ml vial, 30 mg/ml carpuject, 30 mg/mlvial, 60 mg/2 ml vial)

3 QL 20 ML / 30 DAYS

LICART 3 PA

meclofenamate sodium 2 PA

mefenamic acid 2 PA

meloxicam (5 mg capsule, 10 mg capsule) 3 PA

meloxicam (7.5 mg tablet, 15 mg tablet) 2

MOBIC 3

nabumetone 2

NALFON 400 MG CAPSULE 3

NAPRELAN 3 PA

NAPROSYN 500 MG TABLET 3

naproxen (250 mg tablet, 375 mg tablet, dr 375 mgtablet, 500 mg kit, 500 mg tablet, dr 500 mg tablet)

2

naproxen sodium (275 mg tab, 550 mg tab) 3

naproxen sodium cr 3 PA

naproxen sodium er 3 PA



naproxen-esomeprazole mag 2 PA

NUDROXIPAK DSDR-50 3 PA

NUDROXIPAK DSDR-75 3 PA

NUDROXIPAK E-400 3 PA

NUDROXIPAK I-800 3 PA

NUDROXIPAK N-500 3 PA

oxaprozin 2 PA

piroxicam 2

RELAFEN DS 3 PA

SPRIX 3 PA

sulindac 2

tolmetin sodium 2 PA

TORONOVA II SUIK 3 PA

TORONOVA SUIK 3 PA

TRIXYLITRAL 3 PA

VENNGEL ONE 3 PA

VIMOVO 3 PA

VIVLODEX 3 PA

VOLTAREN 3

VOLTAREN-XR 3

XRYLIX 3 PA

ZIPSOR 3 PA

ZORVOLEX (18 MG CAPSULE, 35 MG CAPSULE) 3 PA



SALICYLATES

aspirin-omeprazole 2 PA

butalbital-asa-caffeine cap 2 QL 6 CAPS / 1 DAY

choline mag trisalicylate 3

DURLAZA 3 PA

FIORINAL 3 QL 6 CAPS / 1 DAY

salsalate 2

tru-micin 3

YOSPRALA 3 PA

OXYTOCICSMETHERGINE 3

methylergonovine 0.2 mg tablet 2

MIFEPREX 3

PARATHYROID AND ANTIPARATHYROID AGENTSANTIPARATHYROID AGENTS

calcitonin-salmon 200 units sp 2

cinacalcet hcl 2

SENSIPAR 1

PARATHYROID AGENTS

FORTEO 4PA

S

NATPARA 4PA

S

teriparatide 4PA

S

TYMLOS 4PA

S



PENICILLIN ANTIBIOTICSAMINOPENICILLIN ANTIBIOTICS

amoxicillin (125 mg tab chew, 125 mg/5 ml susp, 200mg/5 ml susp, 250 mg capsule, 250 mg tab chew, 250mg/5 ml susp, 400 mg/5 ml susp, 500 mg capsule, 500 mgtablet, 875 mg tablet)

2

amoxicillin-clavulanate pot er 3

amoxicillin-clavulanate potass (200-28.5 mg tab chew,200-28.5 mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5ml sus, 400-57 mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 600-42.9 mg/5 ml sus, 875-125 mg tablet)

2

ampicillin trihydrate 2

AUGMENTIN 125-31.25 MG/5 ML 3

AUGMENTIN XR 3

MOXATAG 3

NATURAL PENICILLIN ANTIBIOTICSpenicillin v potassium (125 mg/5 ml soln, 250 mg tablet,250 mg/5 ml soln, 500 mg tablet)

2

PENICILLINASE-RESISTANT PENICILLINSdicloxacillin sodium 2

PHARMACEUTICAL AIDS

SHINGRIX ADJUVANT COMPONENT 1 QL 1 KIT / RX

VAXCHORA BUFFER COMPONENT 1

RADIOACTIVE AGENTS

HICON 3 PA

sodium iodide i-123 3PA

S

sodium iodide i-131 3PA

S



RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIBANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND 3

ATACAND HCT 3

AVALIDE 3

AVAPRO 3

BENICAR 3 PA

BENICAR HCT 3 PA

candesartan cilexetil 2

candesartan-hydrochlorothiazid 3

COZAAR 3

DIOVAN 3

DIOVAN HCT 3

EDARBI 3 PA

EDARBYCLOR 3 PA

ENTRESTO 1

eprosartan mesylate 3

HYZAAR 3

irbesartan 2

irbesartan-hydrochlorothiazide 2

losartan potassium 2

losartan-hydrochlorothiazide 2

MICARDIS 3

MICARDIS HCT 3

olmesartan medoxomil 2

olmesartan-amlodipine-hctz 3

olmesartan-hydrochlorothiazide 2

telmisartan 2



telmisartan-amlodipine 3

telmisartan-hydrochlorothiazid 2

TRIBENZOR 3 PA

TWYNSTA 3

valsartan 2

valsartan-hydrochlorothiazide 2

ANGIOTENSIN-CONVERTING ENZYME INHIBITORSACCUPRIL 3

ACCURETIC 3

ALTACE 3

benazepril hcl 2

benazepril-hydrochlorothiazide 2

captopril 2

captopril-hydrochlorothiazide 2

enalapril 1 mg/ml oral soln 3

enalapril maleate (2.5 mg tab, 5 mg tablet, 10 mg tab, 20mg tab)

2

enalapril-hydrochlorothiazide 2

EPANED 3

fosinopril sodium 2

fosinopril-hydrochlorothiazide 2

lisinopril 2

lisinopril-hydrochlorothiazide 2

LOTENSIN 10 MG TABLET 3

moexipril hcl 2

perindopril erbumine 2

PRESTALIA 3

PRINIVIL 3

QBRELIS 3



quinapril hcl 2

quinapril-hydrochlorothiazide 2

ramipril 2

TARKA 3

trandolapril 2

trandolapril-verapamil er 3

VASERETIC 3

VASOTEC 3 PA

ZESTORETIC 3

ZESTRIL 3

MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSALDACTAZIDE 3

ALDACTONE 3

CAROSPIR 3 PA

eplerenone 2

INSPRA 3 PA

KERENDIA 3QL 1 TAB / 1 DAY

PA

spironolactone 2

spironolactone-hctz 2

RENIN INHIBITORSaliskiren 150 mg tablet 3

TEKTURNA 3

TEKTURNA HCT 3

RESPIRATORY TRACT AGENTSANTIFIBROTIC AGENTS

ESBRIET 4PA

S



OFEV 4PA

S

ANTITUSSIVESbenzonatate (100 mg capsule, perle 100 mg cap, 200 mgcapsule)

2

benzonatate 150 mg capsule 3

CAPCOF 3 AQ1 At least 6 yrs old; 60/ 1 DAY

codeine-guaifenesin 2

QL 60 ML / 1 DAY


AQ1 At least 18 yrs old;60 / 1 day(s)

guaifenesin dac 3 AQ1 At least 6 yrs old; 40/ 1 DAY

guaifenesin-codeine 2 AQ1 At least 18 yrs old;60 / 1 day(s)

HISTEX-AC 3 AQ1 At least 6 yrs old; 20/ 1 DAY

hydrocodone-chlorpheniramne er 2PA

AQ1 At least 18 yrs old;10 / 1 DAY

hydrocodone-homatropine mbr 3 AQ1 At least 18 yrs old;30 / 1 DAY

ninjacof-xg 3 AQ1 At least 6 yrs old; 60/ 1 DAY

OBREDON 3 QL 60 ML / 1 DAY

promethazine vc-codeine 3 AQ1 At least 6 yrs old; 30/ 1 DAY

promethazine-codeine 3PA

AQ1 At least 18 yrs old;30 / 1 DAY

promethazine-dm 2

promethazine-phenyleph-codeine 3 AQ1 At least 6 yrs old; 30/ 1 DAY(s)



rydex 3 AQ1 At least 6 yrs old; 60/ 1 DAY

TUSNEL PEDIATRIC LIQUID 3

TUSSICAPS 3 QL 2 CAPS / 1 DAY

TUZISTRA XR 3 AQ1 At least 18 yrs old;20 / 1 DAY

MUCOLYTIC AGENTSacetylcysteine (10% vial, 20% vial) 2

PULMOZYME 4

QL 150 ML / 30 DAYS

PA

S

PHOSPHODIESTERASE TYPE 4 INHIBITORS

DALIRESP 1 PA

RESPIRATORY TRACT AGENTS, MISCELLANEOUS

BRONCHITOL 4


PA

S

XOLAIR (75 MG/0.5 ML SYRINGE, 150 MG/ML SYRINGE) 4PA

S

VASODILATING AGENTS (RESPIRATORY TRACT)

ADEMPAS 4PA

S

ambrisentan 4PA

S

bosentan 4PA

S

epoprostenol sodium 4PA

S

FLOLAN 1.5 MG VIAL 4PA

S



LETAIRIS 4PA

S

OPSUMIT 4PA

S

ORENITRAM ER 4PA

S

REMODULIN 4PA

S

TRACLEER 4PA

S

treprostinil 4PA

S

TYVASO 4PA

S

TYVASO REFILL KIT 4PA

S

TYVASO STARTER KIT 4PA

S

UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK,400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET,1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCGTABLET, 1,600 MCG TABLET)

4PA

S

VELETRI 4PA

S

VENTAVIS 4PA

S

SKELETAL MUSCLE RELAXANTSCENTRALLY ACTING SKELETAL MUSCLE RELAXNT

AMRIX 3 PA



carisoprodol 2QL 4 TABS / 1 DAY

PA

carisoprodol-aspirin 3 QL 8 TABS / 1 DAY

carisoprodol-aspirin-codeine 2QL 8 TABS / 1 DAY

PA

chlorzoxazone (375 mg tablet, 750 mg tablet) 3

chlorzoxazone 250 mg tablet 3 PA

chlorzoxazone 500 mg tablet 2

cyclobenzaprine 7.5 mg tablet 3 PA

cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 2

cyclobenzaprine hcl er (er 15 mg cap, er 30 mg cap) 3 PA

CYCLOTENS (REFILL, STARTER) 3 PA

FEXMID 3 PA

LORZONE 3 PA

METAXALL 3

metaxalone 400 mg tablet 3

metaxalone 800 mg tablet 2 PA

methocarbamol (500 mg tablet, 750 mg tablet) 2

ROBAXIN-750 3

SKELAXIN 3

SOMA 3 QL 4 TABS / 1 DAY

tizanidine hcl (2 mg capsule, 4 mg capsule, 6 mg capsule) 3

tizanidine hcl (2 mg tablet, 4 mg tablet) 2

ZANAFLEX 3

DIRECT-ACTING SKELETAL MUSCLE RELAXANTSDANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3

dantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 2



GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTbaclofen (5 mg tablet, 10 mg tablet, 20 mg tablet) 2

OZOBAX 3 PA

SKELETAL MUSCLE RELAXANTS, MISCELLANEOUSorphenadrine citrate er 3

SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS

ADAZIN 3

agoneaze 3 PA

ANACAINE 3

ANASTIA 3

anodyne lpt 3 PA

CETACAINE 3

dermacinrx empricaine 3 PA

DERMACINRX PHN PAK 3 PA

dermacinrx prizopak 3 PA

DERMACINRX ZRM PAK 3 PA

DOLOTRANZ 3 PA

doxepin 5% cream 2QL 45 GM / 1 FILL

PA

leva set 3 PA

lido-k 3 PA

lido-prilo caine pack 3 PA

lidocaine 3% cream 3

lidocaine 5% ointment 3

lidocaine 5% patch 2QL 1 PATCH / 1 DAY

PA



lidocaine hcl 3% lotion 3 PA

lidocaine-hydrocortisone (2.8-0.55% gel, 3-0.5% cream kit,3-1% cream kit, 3-2.5% gel kit)

3

lidocaine-prilocaine 3

lidocaine-tetracaine 2 PA

LIDODERM 3QL 1 PATCH / 1 DAY

PA

LIDOPAC 3 PA

lidopin (3% cream, 3.25% cream) 3

lidopril 3 PA

lidopril xr 3 PA

LIDOTRAL 3 PA

LIDOTRANS 5 PAK 3 PA

LIDOVEX 3 PA

LIPROZONEPAK 3 PA

livixil pak 3 PA

MEDOLOR PAK 3 PA

MENTHO-CAINE 3 PA

NEURCAINE 3 PA

NUMBONEX 3

PAINGO KFT 3 PA

phenazopyridine hcl 2

PONTOCAINE 3

prikaan 3 PA

prikaan lite 3 PA

prilolid 3 PA



prilovix 3 PA

prilovix plus 3 PA

PRUDOXIN 3 QL 45 GM / 1 FILL

RELADOR PAK 3 PA

RELADOR PAK PLUS 3 PA

SOLUPAK 3 PA

SYNERA 3

SYNVEXIA TC 3 PA

TRANZAREL 3 PA

WPR PLUS 3 PA

XRYLIDERM 3 PA

ZONALON 3 QL 45 GM / 1 FILL

ASTRINGENTSDRYSOL 1

CELL STIMULANTS AND PROLIFERANTSATRALIN 3

AVITA 2

REGRANEX 3

RETIN-A 3

RETIN-A MICRO 3 PA

RETIN-A MICRO PUMP (PUMP 0.04% GEL, PUMP 0.06%GEL, PUMP 0.08% GEL, PUMP 0.1% GEL)

3 PA

TRETIN-X 0.075% CREAM 3

tretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05%cream, 0.1% cream)

2

tretinoin 0.05% gel 3

tretinoin microsphere 3 PA



EMOLLIENTS, DEMULCENTS, AND PROTECTANTSLEVICYN ANTIPRURITIC SG 3

KERATOLYTIC AGENTS

AVAR 9.5-5% CLEANSING PADS 3 PA

avar cleanser 3QL 12 ML / 1 DAY

PA

AVAR LS (10%-2% FOAM, 10-2% CLEANSING PADS,CLEANSER)

3 PA

avar-e 3 PA

avar-e green 3 PA

AVAR-E LS 3 PA

bensal hp 3

benzepro (5.3% emollient foam, 6% foaming cloths, 9.8%foam)

3 PA

bp 10-1 3 PA

bpo (4% gel, 6% foaming cloths, 8% gel) 3 PA

HYDRO 35 3

HYDRO 40 3

KERAFOAM 30% FOAM 3

KERALAC 3

PACNEX 3 PA

RIAX 3

rosanil 3QL 12 ML / 1 DAY

PA

ROSULA 10%-4.5% WASH 3

SALEX 6% SHAMPOO 3

salicylic acid (3% ointment, 6% cream, 6% lotion, 6%shampoo)

3

sod sulfacet-sulfur 10-5% clsr 2 QL 12 ML / 1 DAY



sodium sulfacetamide-sulfur (10-5% crm, sod lotn) 2

sodium sulfacetamide-sulfur (sod sulfac-sulfur 9.8-4.8%crm, sod sulfac-sulfur 9.8-4.8% lot, sod sulface-sulf 9.8-4.8% clsr, sod sulfacet-sulfur 10-2% clsr, sod sulfacet-sulfur 10-4% pad, sod sulfacetamide-sulfur susp, sodiumsulfacet-sulfur wash)

3

sss 10-5 cream 2

sulfacetamide-sulfur 8-4% susp 3 PA

sulfacleanse 8-4 3 PA

SUMADAN 9%-4.5% WASH 3 PA

SUMAXIN 9%-4% WASH 3

SUMAXIN CLEANSING PADS 3 PA

SUMAXIN TS 3 PA

ULTRASAL-ER 3

URAMAXIN 45% UREA CREAM 3

urea (41% cream, 45% cream, 45% nail gel, 47% cream,50% nail stick)

3

urea (cream, lotion) 2

UREVAZ 3

XALIX 3

KERATOPLASTIC AGENTSDRITHOCREME HP 3

ZITHRANOL 3

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

ABSORICA 3 PA

ABSORICA LD 3 PA

acitretin 2

ACZONE 3 PA

adapalene (0.1% cream, 0.3% gel, 0.3% gel pump) 2 PA



adapalene (gel, solution, swab) 3 PA

adapalene 0.1% gel (rx only) 3 PA

adapalene 0.1% lotion 3

adapalene-benzoyl peroxide 3

AKLIEF 3 PA

ALDARA 3 PA

AMELUZ 3

AMNESTEEM 2

azelaic acid 2

AZELEX 3 PA

calcipotriene (cream, ointment, solution) 2 QL 120 GM / 30 DAYS

calcipotriene 0.005% foam 3 PA

calcipotriene-betamethasone 3 PA

calcipotriene-betamethasone dp 3

CALCITRENE 3 QL 120 GM / 30 DAYS

calcitriol 3 mcg/g ointment 2 PA

CLARAVIS 2

CONDYLOX 3 PA

COSENTYX (2 SYRINGES) 4PA

S

COSENTYX PEN 4PA

S

COSENTYX PEN (2 PENS) 4PA

S

COSENTYX SYRINGE 4PA

S



dapsone 5% gel 2 PA

dapsone 7.5% gel pump 3 PA

DERMACINRX SURGICAL PHARMAPAK 3 PA

DIFFERIN (0.1% CREAM, 0.1% LOTION, 0.3% GEL, 0.3%GEL PUMP)

3 PA

DIFFERIN 0.1% GEL 1

DOVONEX 3 QL 120 GM / 30 DAYS

DUPIXENT 300 MG/2 ML PEN 4

QL 2 PENS / 28 DAYS

PA

S

DUPIXENT 300 MG/2 ML SYRINGE 4

QL 4 ML / 28 DAYS

PA

S

ELIDEL 3 QL 100 GM / 30 DAYS

ENSTILAR 3 PA

EPIDUO 3

EPIDUO FORTE 3 PA

FABIOR 3QL 50 GM / 30 DAYS

PA

FINACEA 15% FOAM 3 PA

FINACEA 15% GEL 3

imiquimod (cream, cream pump) 3 PA

imiquimod 5% cream packet 2

isotretinoin (10 mg capsule, 20 mg capsule, 30 mgcapsule, 40 mg capsule)

2

isotretinoin (25 mg capsule, 35 mg capsule) 3 PA

ivermectin 1% cream 3 PA

KLISYRI 3 PA



MYORISAN 2

NEURAPTINE 10% CREAM PACKET 3

NUSURGEPAK 3

OPZELURA 3QL 60 GM / 30 DAYS

PA

pimecrolimus 2 QL 100 GM / 30 DAYS

podofilox 2

PROTOPIC 3QL 100 GM / 30 DAYS

PA

RECTIV 3

SANTYL 3

SILIQ 4


PA

S

SKYRIZI (2 SYRINGES) KIT 4PA

S

SKYRIZI 75 MG/0.83 ML SYRINGE 4PA

S

SOOLANTRA 3 PA

SORIATANE 3

SORILUX 3 PA

STELARA 4PA

S

TACLONEX 3 PA

tacrolimus (0.03% ointment, 0.1% ointment) 2 QL 100 GM / 30 DAYS

TALTZ AUTOINJECTOR 4

QL 1 PACKAGE / 28DAYS

PA

S



TALTZ AUTOINJECTOR (2 PACK) 4


PA

S

TALTZ AUTOINJECTOR (3 PACK) 4


PA

S

TALTZ SYRINGE 4


PA

S

tazarotene 0.1% cream 2 QL 30 GM / 30 DAYS

tazarotene 0.1% foam 3QL 50 GM / 30 DAYS

PA

TAZORAC (0.05% CREAM, 0.05% GEL, 0.1% GEL) 1 QL 30 GM / 30 DAYS

TAZORAC 0.1% CREAM 3 QL 30 GM / 30 DAYS

TREMFYA 100 MG/ML INJECTOR 4

QL 1 ML / 28 DAYS

PA

S

TREMFYA 100 MG/ML SYRINGE 4


PA

S

VECTICAL 3 PA

WHYTEDERM SURGIPAK 3 PA

WINLEVI 3 PA

WYNZORA 3 PA

ZENATANE 2

ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM, 3.75%CREAM PUMP)

3 PA



SMOOTH MUSCLE RELAXANTSRESPIRATORY SMOOTH MUSCLE RELAXANTS

ELIXOPHYLLIN 3

THEO-24 3

theophylline (er 400 mg tablet, er 600 mg tablet) 2

theophylline 80 mg/15 ml soln 3

theophylline anhydrous 2

SOMATOSTATIN AGONISTS AND ANTAGONISTSSOMATOSTATIN AGONISTS

BYNFEZIA 4PA

S

MYCAPSSA 4PA

S

octreotide acetate (0.05 mg/ml vl, 50 mcg/ml amp, 50mcg/ml vial)

4QL 3 ML / 1 DAY

S

octreotide acetate (1,000 mcg/ml vial, 5,000 mcg/5 mlvial)

4QL 9 VIALS / 30 DAYS

S

octreotide acetate (100 mcg/ml amp, 100 mcg/ml vl) 4QL 5 ML / 1 DAY

S

octreotide acetate (50 mcg/ml syr, 100 mcg/ml syr, 500mcg/ml syr)

4 S

octreotide acetate (500 mcg/ml amp, 500 mcg/ml vl) 4QL 7 ML / DAY

S

octreotide acetate (acet 200 mcg/ml vl, 1,000 mcg/5 mlvial)

4QL 7.5 ML / 1 DAY

S

SANDOSTATIN 0.05 MG/ML AMPUL 4

QL 3 ML / 1 DAY

PA

S


QL 5 ML / 1 DAY

PA

S




QL 7 ML / DAY

PA

S

SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL) 4QL 1 KIT / 28 DAYS

S

SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 4QL 2 KITS / 28 DAYS

S

SANDOSTATIN LAR DEPOT (30 MG KT, 30 MG VL) 4QL 3 KITS / 28 DAYS

S

SIGNIFOR 4PA

S

SIGNIFOR LAR 4PA

S

SOMATULINE DEPOT 4PA

S

SOMATOTROPIN AGONISTS AND ANTAGONISTSSOMATOTROPIN AGONISTS

EGRIFTA 4PA

S

EGRIFTA SV 4PA

S

SOMATOTROPIN ANTAGONISTS

SOMAVERT 4PA

S

SYMPATHOMIMETIC (ADRENERGIC) AGENTSALPHA- AND BETA-ADRENERGIC AGONISTS

AUVI-Q (0.1 MG, 0.15 MG, 0.3 MG) 3 PA

droxidopa (100 mg capsule, 200 mg capsule) 4

QL 3 CAPS / 1 DAY

PA

S



droxidopa 300 mg capsule 4

QL 6 CAPS / 1 DAY

PA

S

epinephrine 0.15 mg auto-injct (teva) 2

epinephrine 0.15 mg auto-inject (generic for adrenaclick) 3 PA

epinephrine 0.15 mg auto-inject (generic for epi-pen jr /mylan)

2

epinephrine 0.3 mg auto-inject (generic for adrenaclick) 2

epinephrine 0.3 mg auto-inject (generic for epi-pen /mylan)

2

epinephrine 0.3 mg auto-inject (teva) 2

EPIPEN 3

EPIPEN 2-PAK 3

EPIPEN JR 3

EPIPEN JR 2-PAK 3

NORTHERA (100 MG CAPSULE, 200 MG CAPSULE) 4

QL 3 CAPS / 1 DAY

PA

S

NORTHERA 300 MG CAPSULE 4

QL 6 CAPS / 1 DAY

PA

S

SYMJEPI 1

ALPHA-ADRENERGIC AGONISTSmidodrine hcl 2

TETRACYCLINE ANTIBIOTICSAMINOMETHYLCYCLINES

NUZYRA (150 MG TABLET, 150 MG TABLET-7 DAY, 150MG-7 DAY WITH LOAD)

1 PA

SEYSARA 3 PA



THYROID AND ANTITHYROID AGENTSANTITHYROID AGENTS

methimazole 2

propylthiouracil 2

SSKI 3

TAPAZOLE 3

THYROID AGENTSARMOUR THYROID 3

CYTOMEL 3

euthyrox 2

LEVO-T 3

levothyroxine 3

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcgtablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet,175 mcg tablet, 200 mcg tablet, 300 mcg tablet)

2

LEVOXYL 3

liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 2

NATURE-THROID 3

np thyroid 3

SYNTHROID 1

THYQUIDITY 3 PA

thyroid (15 mg tablet, 30 mg tablet, 60 mg tablet, 90 mgtablet, 120 mg tablet)

3

TIROSINT 3

TIROSINT-SOL 3

UNITHROID 3

WESTHROID 3

WP THYROID 3



UncategorizedUnclassified

amcinonide 0.1% ointment 2 PA

VASODILATING AGENTSNITRATES AND NITRITES

DILATRATE-SR 3

GONITRO 3

ISORDIL 3

ISORDIL TITRADOSE 3

isosorbide dinitrate (5 mg tab, 10 mg tab, 20 mg tab, 30mg tab)

2

isosorbide dinitrate 40 mg tab 3

isosorbide mononitrate 2

isosorbide mononitrate er 2

MINITRAN 3

NITRO-BID 1

NITRO-DUR 3

NITRO-TIME ER 9 MG CAPSULE 3

nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 2

nitroglycerin (er 2.5 mg cap, er 6.5 mg cap, er 9 mgcapsule, 400 mcg spray)

3

nitroglycerin patch 2

NITROLINGUAL 3

NITROMIST 3

NITROSTAT 3

PHOSPHODIESTERASE TYPE 5 INHIBITORS

ADCIRCA 4

QL 2 TABS / 1 DAY

PA

S

ALYQ 4

QL 2 TABS / 1 DAY

PA

S



CIALIS (10 MG TABLET, 20 MG TABLET) 3 PA

CIALIS (2.5 MG TABLET, 5 MG TABLET) 3QL 1 TAB / 1 DAY

PA

LEVITRA 3 PA

REVATIO 10 MG/ML ORAL SUSP 4PA

S

REVATIO 20 MG TABLET 4

QL 1 TAB / 1 DAY

PA

S

sildenafil 10 mg/ml oral susp 4PA

S

sildenafil 20 mg tablet (generic for revatio) 2 QL 1 TAB / 1 DAY

sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mgtablet)

2

STAXYN 3

STENDRA 3

tadalafil (10 mg tablet, 20 mg tablet) 2

tadalafil (2.5 mg tablet, 5 mg tablet) 2 QL 1 TAB / 1 DAY

tadalafil 20 mg tablet (generic for adcirca) 2QL 2 TABS / 1 DAY

PA

vardenafil hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet,20 mg tablet)

3 PA

vardenafil hcl 10 mg odt 3

VIAGRA 3 PA

VASODILATING AGENTS, MISCELLANEOUSAGGRENOX 3

aspirin-dipyridamole er 2

CAVERJECT 3

dipyridamole 2



EDEX 3

isoxsuprine hcl 3

MUSE 3

papaverine-phentolamine 3

VERQUVO 1 PA

VITAMINSMULTIVITAMIN PREPARATIONS

bal-care dha 3 PA

BAL-CARE DHA ESSENTIAL 3 PA

c-nate dha 3 PA

CADEAU DHA 3 PA

complete natal dha 3 PA

completenate 2

CONCEPT DHA 3 PA

CONCEPT OB 3 PA

DUET DHA 400 3 PA

DUET DHA BALANCED 3 PA

ENBRACE HR 3 PA

folivane-ob 3 PA

KOSHER PRENATAL PLUS IRON 3 PA

m-natal plus 2

M.V.I. ADULT 3 PA

M.V.I.-12 3 PA

MARNATAL-F 3 PA

multi-vitamin daily 3 PA



MVW COMPLETE FORMLTN PEDIATRIC 3 PA

MVW COMPLETE FORMULATION D3000 3 PA

MYNATAL 3 PA

mynatal plus 2

mynatal-z 2

NATACHEW 3 PA

NEEVODHA 3 PA

NESTABS 3 PA

NESTABS ABC 3 PA

NESTABS DHA 3 PA

NESTABS ONE 3 PA

O-CAL PRENATAL 2

OB COMPLETE 3 PA

OB COMPLETE ONE 3 PA

OB COMPLETE PETITE 3 PA

OB COMPLETE PREMIER 3 PA

OB COMPLETE WITH DHA 3 PA

OCUVEL 3 PA

pnv 29-1 2

pnv-dha 3 PA

pnv-omega 3 PA

pnv-select 3 PA

pr natal 400 3 PA

pr natal 400 ec 3 PA

pr natal 430 3 PA



pr natal 430 ec 3 PA

PRENA1 CHEW 3 PA

prena1 pearl 3 PA

prena1 true 3 PA

PRENATA 1

PRENATABS FA 2

PRENATABS RX 2

prenatal 19 3 PA

prenatal plus (iron tablet, pnv multivit tab) 2

prenatal plus-dha 3 PA

prenatal vitamin plus low iron 2

prenatal-u 2 PA

PRENATE AM 3 PA

PRENATE CHEWABLE 3 PA

PRENATE DHA 3 PA

PRENATE ELITE 1 PA

PRENATE ENHANCE 3 PA

PRENATE ESSENTIAL 3 PA

PRENATE MINI 3 PA

PRENATE PIXIE 3 PA

PRENATE RESTORE 3 PA

PRENATE STAR 3 PA

preplus 2

PRIMACARE 3 PA

PROVIDA OB 3 PA



PUREFE OB PLUS 2

r-natal ob 3 PA

se-natal 19 2

SELECT-OB 3 PA

SELECT-OB + DHA 3 PA

taron-c dha 3 PA

thrivite rx 3 PA

TRICARE 3 PA

trinatal rx 1 3 PA

TRINATE 2

triveen-duo dha 3 PA

trust natal dha 3 PA

VINATE CARE 2

vinate one 2

vinate-m 2

virt-c dha 3 PA

virt-nate dha 3

virt-pn dha 3 PA

virt-pn plus 3 PA

VITAFOL GUMMIES 3 PA

VITAFOL NANO 3 PA

VITAFOL ULTRA 3 PA

VITAFOL-OB 3 PA

VITAFOL-OB+DHA 3 PA

VITAFOL-ONE 3 PA



VITAMEDMD ONE RX 3 PA

VITAMEDMD REDICHEW RX 3 PA

VITAPEARL 3 PA

VP-PNV-DHA 3 PA

zatean-pn dha 3 PA

zatean-pn plus 3 PA

zingiber 3 PA

VITAMIN A

AQUASOL A 3 PA

VITAMIN B COMPLEXcyanocobalamin injection 2

ELIGEN B12 3 PA

folic acid (0.4 mg tablet, 0.8 mg tablet, 400 mcg tablet,800 mcg tablet, cvs 800 mcg tablet, gnp 400 mcg tablet,hm 400 mcg tablet, ra 0.4 mg tablet, ra 800 mcg tablet,sm 0.4 mg tablet, sm 400 mcg tablet, sv 800 mcg tablet)


folic acid (1 mg tablet, 1,000 mcg tablet) 2

hydroxocobalamin 3 PA

NEPHRONEX-SL 3 PA

SUPPORT-500 3 PA

vitamin b-12 5,000 mcg tab sl 3 PA

VITAMIN C

ascorbic acid 3 PA

VITAMIN Dcalcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlsolution)

2

doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcg cap) 3

DRISDOL 3 PA



paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 3

RAYALDEE 3 PA

ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1MCG/ML ORAL SOLN)

3 PA

vitamin d2 1.25mg(50,000 unit) 2

ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 3

VITAMIN K ACTIVITY

MEPHYTON 3QL 3 TABS / 1 FILL

PA

phytonadione 5 mg tablet 2 QL 3 TABS / 1 FILL


Index of Covered Drugs

Aabacavir 100abacavir-lamivudine 100abacavir-lamivudine-zidovudine 100ABATRON 34ABILIFY 96ABILIFY MYCITE 96abiraterone acetate 73ABSORICA 197ABSORICA LD 197ABSTRAL 3acamprosate calcium 125ACANYA 22acarbose 52ACCOLATE 29ACCRUFER 34ACCUCAINE 165ACCUPRIL 187ACCURETIC 187acebutolol hcl 123acetamin-caff-dihydrocodeine 3acetaminophen-codeine 3acetazolamide 61acetazolamide er 61acetic acid 22acetylcysteine 190ACIPHEX 108ACIPHEX SPRINKLE 108acitretin 197ACTEMRA 169ACTEMRA ACTPEN 169ACTHAR 131ACTHIB 103ACTICLATE 36ACTIGALL 143ACTIMMUNE 173ACTIQ 3ACTIVE-PAC 42ACTIVELLA 136ACTONEL 167

ACTOPLUS MET 56ACTOPLUS MET XR 56ACTOS 56ACULAR 28ACULAR LS 28ACUVAIL 28acyclovir 24,110ACZONE 197ADACEL TDAP 103ADALAT CC 121adapalene 197,198adapalene 0.1% gel (rx only) 198adapalene-benzoyl peroxide 198ADASUVE 96ADAZIN 193ADCIRCA 206ADDERALL 14ADDERALL XR 14ADDYI 125adefovir dipivoxil 110ADEMPAS 190adenovirus type 4 103adenovirus type 4 and type 7 103adenovirus type 7 103ADHANSIA XR 15ADIPEX-P 12,13ADLYXIN 53ADMELOG 163ADMELOG SOLOSTAR 163ADRENALIN CHLORIDE 140ADV ALLERGY COLLECTION KIT 29ADVAIR DISKUS 128ADVAIR HFA 128ADVANCED DNA MEDICATED COLLECT 139ADVATE 62ADYNOVATE 62ADZENYS ER 14ADZENYS XR-ODT 14AEMCOLO 38AFINITOR 73AFINITOR DISPERZ 73,74

AFIRMELLE 151AFLURIA QUAD 2019-20 (3YR UP) 103AFLURIA QUAD 2019-20 (6-35MO) 103AFLURIA QUAD 2019-2020 103AFLURIA QUAD 2020-2021 103AFLURIA QUAD 2020-21 (3YR UP) 103AFLURIA QUAD 2020-21 (6-35MO) 104AFLURIA QUAD 2021-2022 104AFLURIA QUAD 2021-22 (3YR UP) 104AFLURIA QUAD 2021-22 (6-35MO) 104AFREZZA 163AFSTYLA 63AGGRENOX 207agoneaze 193AIMOVIG AUTOINJECTOR 69AIRDUO DIGIHALER 128AIRDUO RESPICLICK 128AJOVY AUTOINJECTOR 69AJOVY SYRINGE 70AKLIEF 198AKYNZEO 57ALA-CORT 29albendazole 19ALBENZA 19albuterol sulfate 117albuterol sulfate 90 mcg hfa aer ad (genericproair) 117albuterol sulfate 90 mcg hfa aer ad (genericproventil) 117albuterol sulfate 90 mcg hfa aer ad (genericventolin) 118albuterol sulfate hfa 118alclometasone dipropionate 29ALCORTIN A 25ALDACTAZIDE 188ALDACTONE 188ALDARA 198ALECENSA 74alendronate sodium 167ALFERON N 109alfuzosin hcl er 1

ALINIA 95aliskiren 188ALKERAN 74ALKINDI SPRINKLE 148ALLI 143allopurinol 166ALLZITAL 2almotriptan malate 70ALOCRIL 29alogliptin 53alogliptin-metformin 53alogliptin-pioglitazone 53ALOMIDE 138ALORA 136alosetron hcl 141ALPHAGAN P 61ALPHANATE 63ALPHANINE SD 63alprazolam 112alprazolam er 112ALPRAZOLAM INTENSOL 112alprazolam odt 112alprazolam xr 112,113ALPROLIX 63ALREX 26ALTABAX 22ALTACE 187ALTAVERA 151ALUNBRIG 74ALVESCO 128alvimopan 143ALYACEN 151ALYQ 206AMABELZ 136amantadine 93AMARYL 55AMBIEN 111AMBIEN CR 111ambrisentan 190amcinonide 29,206AMELUZ 198

AMERGE 70AMETHIA 151AMETHIA LO 151AMETHYST 151AMICAR 63amiloride hcl 132amiloride-hydrochlorothiazide 132aminocaproic acid 63amiodarone hcl 34AMITIZA 142amitriptyline hcl 51amlodipine besylate 121amlodipine besylate-benazepril 121amlodipine-atorvastatin 68amlodipine-olmesartan 121amlodipine-valsartan 121amlodipine-valsartan-hctz 121ammonium lactate 135AMNESTEEM 198amoxapine 51amoxicillin 185amoxicillin-clavulanate pot er 185amoxicillin-clavulanate potass 185amphetamine 14amphetamine sulfate 14ampicillin trihydrate 185AMPYRA 177AMRIX 191AMZEEQ 22ANACAINE 193ANADROL-50 150ANAFRANIL 51anagrelide hcl 102ANALPRAM HC 29ANAPROX DS 180ANASPAZ 38ANASTIA 193anastrozole 74ANCOBON 58ANDRODERM 150ANDROGEL 150

ANDROID 150ANGELIQ 136ANNOVERA 152anodyne lpt 193ANORO ELLIPTA 38ANTABUSE 166ANTARA 67ANTIVERT 57anucort-hc 30ANUSOL-HC 30APEXICON E 30APIDRA 163APIDRA SOLOSTAR 163APLENZIN 48apo-varenicline 0.5 mg tablet (apotex) 115apo-varenicline 1 mg tablet (apotex) 115APOKYN 133apraclonidine hcl 138aprepitant 57APRI 152APRISO 141APTENSIO XR 16APTIOM 42APTIVUS 101AQUASOL A 212ARAKODA 94ARANELLE 152ARANESP 119ARAVA 169ARCALYST 177ARCAPTA NEOHALER 118arformoterol tartrate 118ARICEPT 116ARIKAYCE 35ARIMIDEX 74aripiprazole 96aripiprazole odt 96ARIXTRA 40armodafinil 18ARMONAIR DIGIHALER 128ARMOUR THYROID 205

ARNUITY ELLIPTA 129AROMASIN 74ARTHROTEC 50 180ARTHROTEC 75 180ASACOL HD 141ASCOMP WITH CODEINE 3ascorbic acid 212asenapine maleate 96ASHLYNA 152ASMANEX 129ASMANEX HFA 129aspirin-dipyridamole er 207aspirin-omeprazole 184ASTAGRAF XL 176astero 130ASTRAZENECA COVID19 VAC(UNAPP) 104ATACAND 186ATACAND HCT 186atazanavir sulfate 101ATELVIA 167atenolol 123atenolol-chlorthalidone 123ATIVAN 113atomoxetine hcl 125ATOPICLAIR 130atorvastatin calcium 68atovaquone 95atovaquone-proguanil hcl 94ATRALIN 195ATRIPLA 100atropine sulfate 139ATROVENT HFA 39AUBAGIO 173AUBRA 152AUBRA EQ 152AUGMENTIN 185AUGMENTIN XR 185AUROVELA 152AUROVELA 24 FE 152AUROVELA FE 152AURYXIA 164

AUSTEDO 127AUVI-Q 203AVALIDE 186AVANDIA 56AVAPRO 186AVAR 196avar 196AVAR LS 196avar-e 196avar-e green 196AVAR-E LS 196AVC 25AVIANE 152AVIDOXY 36AVITA 195AVODART 166AVONEX 173AVONEX PEN 173AYGESTIN 160AYUNA 152AYVAKIT 74AZASAN 176AZASITE 20azathioprine 176azelaic acid 198azelastine hcl 138azelastine-fluticasone 138AZELEX 198AZILECT 94azithromycin 165AZOPT 61AZOR 121AZSTARYS 16AZULFIDINE 36AZURETTE 152

Bbacitracin 20bacitracin-polymyxin 20baclofen 193BACTRIM 36

BACTRIM DS 36BAFIERTAM 173bal-care dha 208BAL-CARE DHA ESSENTIAL 208BALCOLTRA 152balsalazide disodium 141BALVERSA 74BALZIVA 152BANZEL 42BAQSIMI 66BARACLUDE 110BASAGLAR KWIKPEN U-100 162BAXDELA 35BECONASE AQ 26BEKYREE 152BELBUCA 11belladonna-opium 3belladonna-phenobarbital 39BELSOMRA 111BELVIQ 14BELVIQ XR 14benazepril hcl 187benazepril-hydrochlorothiazide 187BENEFIX 63BENICAR 186BENICAR HCT 186BENLYSTA 176bensal hp 196BENZACLIN 22BENZAMYCIN 22benzepro 196benzhydrocodone-acetaminophen 3benznidazole 95benzonatate 189benzphetamine hcl 14benztropine mesylate 93bepotastine besilate 138BEPREVE 138BERINERT 168BESIVANCE 20BETALOAN SUIK 148

betamethasone diprop augmented 30betamethasone dipropionate 30betamethasone valerate 30BETAPACE 123BETAPACE AF 123BETASERON 173betaxolol hcl 61,123bethanechol chloride 116BETHKIS 35BETIMOL 61BETOPTIC S 61BEVESPI AEROSPHERE 39BEVYXXA 41bexarotene 74BEXSERO 104BEYAZ 152bicalutamide 75BIDIL 161BIKTARVY 100BILTRICIDE 19bimatoprost 62BINOSTO 167bisoprolol fumarate 123bisoprolol-hydrochlorothiazide 123BLEPHAMIDE 20BLEPHAMIDE S.O.P. 20BLISOVI 24 FE 152BLISOVI FE 152BONIVA 167BONJESTA 57BOOSTRIX TDAP 103bosentan 190BOSULIF 75bp 10-1 196bpo 196BRAFTOVI 75BREO ELLIPTA 129BREXAFEMME 57BREZTRI AEROSPHERE 129BRIELLYN 152BRILINTA 102

brimonidine tartrate 61brinzolamide 61BRISDELLE 50BRIVIACT 42bromfenac sodium 28bromocriptine mesylate 133BROMSITE 28BRONCHITOL 190BROVANA 118BRUKINSA 75BRYHALI 30budesonide 129budesonide ec 148budesonide er 148budesonide-formoterol fumarate 129bumetanide 131BUNAVAIL 11BUPAP 2BUPHENYL 133buprenorphine 11buprenorphine hcl 11,12buprenorphine-naloxone 12bupropion hcl 48bupropion hcl sr 48bupropion xl 48buspirone hcl 111butalb-acetaminoph-caff-codein 3butalbital compound-codeine 4butalbital-acetaminophen 2butalbital-acetaminophen-caffe 2butalbital-aspirin-caffeine 184butorphanol tartrate 12BUTRANS 12BYDUREON BCISE 53BYDUREON PEN 54BYETTA 54BYLVAY 143BYNFEZIA 202BYSTOLIC 124

Cc-nate dha 208cabergoline 133CABLIVI 102CABOMETYX 75CADEAU DHA 208CADUET 68CAFERGOT 1CALAN 120CALAN SR 120calcipotriene 198calcipotriene-betamethasone 198calcipotriene-betamethasone dp 198calcitonin-salmon 184CALCITRENE 198calcitriol 198,212calcium acetate 164CALQUENCE 75CALTRATE 600-D3 PLUS MINERALS 134CAMBIA 180CAMILA 152CAMRESE 152CAMRESE LO 152CANASA 141candesartan cilexetil 186candesartan-hydrochlorothiazid 186CAPCOF 189capecitabine 75CAPEX SHAMPOO 30CAPHOSOL 130CAPLYTA 96CAPRELSA 75,76captopril 187captopril-hydrochlorothiazide 187CARAC 76CARAFATE 107CARBAGLU 134carbamazepine 42carbamazepine er 42CARBATROL 42

carbidopa 125carbidopa-levodopa 94carbidopa-levodopa er 94carbidopa-levodopa-entacapone 94carbinoxamine maleate 140CARDIZEM 120CARDIZEM CD 120CARDIZEM LA 120CARDURA 123CARDURA XL 123carisoprodol 192carisoprodol-aspirin 192carisoprodol-aspirin-codeine 192CARNITOR 177CARNITOR SF 177CAROSPIR 188carteolol hcl 61CARTIA XT 120carvedilol 124carvedilol er 124CASODEX 76CATAPRES 161CATAPRES-TTS 1 161CATAPRES-TTS 2 161CATAPRES-TTS 3 161CAVERJECT 207CAYSTON 166CAZIANT 152cefaclor 128cefaclor er 128cefadroxil 127cefdinir 128cefixime 128cefpodoxime proxetil 128cefprozil 128cefuroxime 128CELEBREX 180celecoxib 180CELEXA 50CELLCEPT 176CELONTIN 48

CENTANY 22CENTANY AT 22cephalexin 127CEQUA 28CERACADE 135CERAMAX 130CERDELGA 177CETACAINE 193cetirizine hcl 65CETRAXAL 20cevimeline hcl 116CHANTIX 115CHARLOTTE 24 FE 153CHATEAL 153CHATEAL EQ 153CHEMET 147CHENODAL 143chlordiazepoxide hcl 113chlordiazepoxide-amitriptyline 51chlordiazepoxide-clidinium 39chlorhexidine gluconate 22chloroquine phosphate 94chlorpromazine hcl 98chlorthalidone 132chlorzoxazone 192CHOLBAM 143cholestyramine 67cholestyramine light 67choline mag trisalicylate 184CIALIS 207CICLODAN 60ciclopirox 60cilostazol 102CILOXAN 20CIMDUO 100cimetidine 107cimetidine 200 mg tablet (prescription only) 107CIMZIA 169cinacalcet hcl 184CINRYZE 168CIPRO 35

CIPRO HC 20CIPRODEX 20ciprofloxacin 35ciprofloxacin hcl 20,35ciprofloxacin hcl-fluocinolone 20ciprofloxacin-dexamethasone 20citalopram hbr 50CLARAVIS 198CLARINEX 65CLARINEX-D 12 HOUR 65clarithromycin 165clarithromycin er 165cleansing wash 25clemastine fumarate 140CLENPIQ 142CLEOCIN 22,23CLEOCIN HCL 38CLEOCIN PEDIATRIC 38CLEOCIN T 23CLIMARA 136CLIMARA PRO 136CLINDACIN ETZ 23CLINDACIN P 23CLINDACIN PAC 23CLINDAGEL 23clindamycin (pediatric) 38clindamycin hcl 38clindamycin ph 1% gel (generic for cleocin t) 23clindamycin phos-benzoyl perox 23clindamycin phos-tretinoin 23clindamycin phosphate 23clindamycin phosphate 1% gel (generic forclindagel) 23clindamycin-benzoyl peroxide 23CLINDESSE 23CLINPRO 5000 167clobazam 47clobetasol emollient 30clobetasol emulsion 30clobetasol propionate 30CLOBEX 30

clocortolone pivalate 30CLODAN 30CLODERM 30clomipramine hcl 51clonazepam 47clonidine 161clonidine hcl 161clonidine hcl er 161clopidogrel 102clorazepate dipotassium 113clotrimazole 59clotrimazole-1% solution 59clotrimazole-betamethasone 59clozapine 96clozapine odt 96CLOZARIL 96COAGADEX 63COARTEM 94codeine sulfate 4codeine-guaifenesin 189COLAZAL 141colchicine 166COLCRYS 166colesevelam hcl 67COLESTID 67colestipol hcl 67COLOCORT 30COLY-MYCIN S 20COLYTE WITH FLAVOR PACKETS 142COMBIGAN 61COMBIPATCH 136COMBIVENT RESPIMAT 39COMBIVIR 100COMETRIQ 76COMIRNATY 104COMPLERA 100complete natal dha 208completenate 208COMTAN 93CONCEPT DHA 208CONCEPT OB 208

CONCERTA 16CONDYLOX 198CONJUPRI 122CONTRAVE 13CONZIP 4COPAXONE 173,174COPIKTRA 76CORDRAN 30COREG CR 124COREMINO 36CORGARD 124CORIFACT 63CORLANOR 122CORTEF 148CORTENEMA 30CORTIFOAM 30cortisone acetate 148CORTISPORIN 23CORTISPORIN-TC 20COSENTYX (2 SYRINGES) 198COSENTYX PEN 198COSENTYX PEN (2 PENS) 198COSENTYX SYRINGE 198COSOPT 61COSOPT PF 61COTELLIC 76COTEMPLA XR-ODT 16coumadin 40covaryx 150covaryx h.s. 150COZAAR 186CREON 143CRESEMBA 58CRESTOR 68CRINONE 160CRIXIVAN 101cromolyn sodium 29CROTAN 26CRYSELLE 153CUPRIMINE 147CUTIVATE 30

CUVPOSA 39cyanocobalamin injection 212CYCLAFEM 153cyclobenzaprine hcl 192cyclobenzaprine hcl er 192CYCLOGYL 139CYCLOMYDRIL 139cyclopentolate hcl 139cyclophosphamide 76cycloserine 72CYCLOSET 133cyclosporine 176cyclosporine modified 176CYCLOTENS 192CYMBALTA 49cyproheptadine hcl 140CYRED 153CYRED EQ 153CYSTADANE 178CYSTADROPS 138CYSTAGON 178CYSTARAN 138CYTOMEL 205CYTOTEC 107

DD-PENAMINE 147D.H.E.45 1dalfampridine er 178DALIRESP 190danazol 150DANTRIUM 192dantrolene sodium 192dapsone 72,199DAPTACEL DTAP 103DARAPRIM 95darifenacin er 145DASETTA 153DAURISMO 77DAYPRO 180DAYSEE 153

DAYTRANA 16DAYVIGO 111DDAVP 160DEBLITANE 153deferasirox 147deferiprone 147DELSTRIGO 99DELZICOL 141demeclocycline hcl 36DEMSER 178DENAVIR 25DENGVAXIA 104denta 5000 plus 167dentagel 167DEPAKOTE 42DEPAKOTE ER 42DEPAKOTE SPRINKLE 42DEPEN 147DEPO-TESTOSTERONE 150DERMA-SMOOTHE-FS 30dermacinrx empricaine 193DERMACINRX LEXITRAL 180DERMACINRX PHN PAK 193dermacinrx prizopak 193DERMACINRX SURGICAL PHARMAPAK 199DERMACINRX THERAZOLE PAK 59DERMACINRX ZRM PAK 193DERMATOP 31dermazene 25DERMOTIC 26DESCOVY 100desipramine hcl 51desloratadine 65desmopressin acetate 160desogestr-eth estrad eth estra 153desogestrel-ethinyl estradiol 153DESONATE 31desonide 31DESOWEN 31desoximetasone 31DESOXYN 14

desvenlafaxine er 49desvenlafaxine suc er 100 mg tablet (generic forpristiq) 49desvenlafaxine suc er 25 mg tablet (generic forpristiq) 49desvenlafaxine suc er 50 mg tablet (generic forpristiq) 49DETROL 145DETROL LA 145dexamethasone 148DEXAMETHASONE INTENSOL 148dexamethasone sodium phosphate 27,148dexchlorpheniramine maleate 140DEXEDRINE 14DEXERYL 135DEXILANT 108dexmethylphenidate hcl 16dexmethylphenidate hcl er 16DEXPAK 148dextroamp-amphetamin 15 mg tab (genericadderall) 14dextroamp-amphetamin 20 mg tab (genericadderall) 14dextroamphetamine sulfate 15dextroamphetamine sulfate er 15dextroamphetamine-amphet er 15dextroamphetamine-amphetamine 15DIACOMIT 42,43DIASTAT 113DIASTAT ACUDIAL 113diazepam 113diazoxide 66DIBENZYLINE 1DICLEGIS 57diclo gel 180DICLO GEL-XRYLIX SHEET 180diclofenac 180diclofenac epolamine 180diclofenac potassium 180,181diclofenac sodium 28,77,180,181diclofenac sodium er 181

diclofenac sodium-misoprostol 181DICLOFONO 181DICLOPR 181dicloxacillin sodium 185DICLOZOR 181dicyclomine hcl 39didanosine 100diethylpropion hcl 13diethylpropion hcl er 13DIFFERIN 199DIFICID 165diflorasone diacetate 31DIFLUCAN 58diflunisal 181difluprednate 27DIGITEK 123DIGOX 123digoxin 123dihydroergotamine mesylate 1DILANTIN 48DILANTIN-125 48DILATRATE-SR 206DILAUDID 4DILT-XR 120diltiazem 12hr er 120diltiazem 24h er(la) 360 mg tb (generic forcardizem la) 120diltiazem 24hr er 120diltiazem 24hr er (cd) 121diltiazem 24hr er (la) 121diltiazem 24hr er (xr) 121diltiazem 24hr er 360 mg cap (generic forcardizem cd) 121diltiazem hcl 121dimethyl fumarate 174DIOVAN 186DIOVAN HCT 186DIPENTUM 141diphenhydramine hcl 140diphenoxylate-atropine 141diphtheria-tetanus toxoids-ped 103

DIPROLENE 31dipyridamole 207DISKETS 4disopyramide phosphate 34disulfiram 166DITHOL 181DITROPAN XL 145DIURIL 132divalproex sodium 43divalproex sodium er 43DIVIGEL 136DMT SUIK 148dofetilide 34DOJOLVI 134DOLISHALE 153DOLOPHINE HCL 4DOLOTRANZ 193donepezil hcl 116donepezil hcl odt 116DOPTELET 119DORAL 113DORYX 36DORYX MPC 36dorzolamide hcl 62dorzolamide-timolol 62DOTTI 136DOVATO 99DOVONEX 199doxazosin mesylate 123doxepin hcl 51,193doxercalciferol 212doxycycline hyclate 20,36doxycycline ir-dr 36doxycycline monohydrate 36,37doxylamine succ-pyridoxine hcl 57DRISDOL 212DRITHOCREME HP 197DRIZALMA SPRINKLE 49dronabinol 56drospirenone-eth estra-levomef 153drospirenone-ethinyl estradiol 153

DROXIA 77droxidopa 203,204DRYSOL 195DUAC 23DUAKLIR PRESSAIR 39DUAVEE 136DUET DHA 400 208DUET DHA BALANCED 208DUETACT 56DUEXIS 181DULERA 129duloxetine hcl 49DUPIXENT PEN 28,199DUPIXENT SYRINGE 28,199DURAGESIC 4DUREZOL 27DURLAZA 184dutasteride 166dutasteride-tamsulosin 166DUTOPROL 124DUZALLO 135DVORAH 4DYANAVEL XR 15DYAZIDE 132DYMISTA 138DYRENIUM 132

EE.E.S. 200 165E.E.S. 400 165EC-NAPROSYN 181ec-naproxen 181econazole nitrate 59ECOZA 59ed-spaz 39EDARBI 186EDARBYCLOR 186EDECRIN 131EDEX 208EDLUAR 111EDURANT 99

eemt 150eemt h.s. 150efavirenz 99efavirenz-emtric-tenofov disop 100efavirenz-lamivu-tenofov disop 99EFFER-K 134EFFEXOR XR 49EFFIENT 102EFUDEX 77EGRIFTA 203EGRIFTA SV 203ELEPSIA XR 43ELESTRIN 136ELETONE 130eletriptan hbr 70ELIDEL 199ELIGEN B12 212ELIMITE 26ELINEST 153ELIQUIS 41ELIXOPHYLLIN 202ELLA 153ELMIRON 180ELOCON 31ELOCTATE 63ELURYNG 153EMBEDA 4EMCYT 77EMEND 57EMFLAZA 149EMGALITY PEN 70EMGALITY SYRINGE 70EMOQUETTE 153EMSAM 94emtricitabine 100emtricitabine-tenofovir disop 100EMTRIVA 100emulsion sb 130EMVERM 19ENABLEX 145enalapril maleate 187

enalapril-hydrochlorothiazide 187ENBRACE HR 208ENBREL 170ENBREL MINI 170ENBREL SURECLICK 170ENDARI 143ENDOCET 4,5ENGERIX-B ADULT 104ENGERIX-B PEDIATRIC-ADOLESCENT 104enoxaparin sodium 41ENPRESSE 153ENSKYCE 153ENSPRYNG 174ENSTILAR 199entacapone 93entecavir 110ENTEREG 143ENTOCORT EC 149ENTRESTO 186ENTTY 130ENULOSE 134ENVARSUS XR 176EPANED 187EPCLUSA 146EPICYN 130EPIDIOLEX 43EPIDUO 199EPIDUO FORTE 199EPIFOAM 31epinastine hcl 138epinephrine 0.15 mg auto-injct (teva) 204epinephrine 0.15 mg auto-inject (generic foradrenaclick) 204epinephrine 0.15 mg auto-inject (generic for epi-pen jr / mylan) 204epinephrine 0.3 mg auto-inject (generic foradrenaclick) 204epinephrine 0.3 mg auto-inject (generic for epi-pen / mylan) 204epinephrine 0.3 mg auto-inject (teva) 204EPIPEN 204

EPIPEN 2-PAK 204EPIPEN JR 204EPIPEN JR 2-PAK 204EPISIL 130EPITOL 43EPIVIR 100EPIVIR HBV 100eplerenone 188EPOGEN 119epoprostenol sodium 190eprosartan mesylate 186EPZICOM 100EQUETRO 43ergoloid mesylates 1ERGOMAR 1ergotamine-caffeine 1ERIVEDGE 77ERLEADA 77erlotinib hcl 77ERRIN 153ERTACZO 59ERY 23ERY-TAB 165ERYGEL 23ERYPED 200 165ERYPED 400 165ERYTHROCIN STEARATE 165erythromycin 20,23,165erythromycin ethylsuccinate 165erythromycin-benzoyl peroxide 23ESBRIET 188escitalopram oxalate 50ESGIC 2esomeprazole magnesium 108esomeprazole strontium 108ESPEROCT 63ESTARYLLA 153estazolam 113ESTRACE 136estradiol 136estradiol (once weekly) 136

estradiol (twice weekly) 136estradiol-norethindrone acetat 137ESTRING 137ESTROGEL 137estrogen-methyltestosterone 150ESTROSTEP FE 153eszopiclone 111ethacrynic acid 131ethambutol hcl 72ethosuximide 48ethynodiol-ethinyl estradiol 154etidronate disodium 167etodolac 181etodolac er 181etonogestrel-ethinyl estradiol 154etoposide 77etravirine 99EUCRISA 29EURAX 26euthyrox 205EVAMIST 137EVEKEO 15EVEKEO ODT 15everolimus 78,176EVISTA 136EVOCLIN 23EVOTAZ 101EVOXAC 116EVRYSDI 178EVZIO 127EXELDERM 59EXELON 116exemestane 78EXFORGE 122EXFORGE HCT 122EXJADE 147EXKIVITY 78EXTAVIA 174EXTINA 59EYSUVIS 27EZALLOR SPRINKLE 68

ezetimibe 67ezetimibe-simvastatin 67

FFABIOR 199FACTIVE 35FALMINA 154famciclovir 110famotidine 107FANAPT 96FARESTON 136FARXIGA 54FARYDAK 78FASENRA PEN 29FAYOSIM 154FAZACLO 96febuxostat 166FEIBA NF 63felbamate 43FELBATOL 43FELDENE 181felodipine er 122FEM PH 25FEMARA 78FEMHRT 137FEMRING 137FEMYNOR 154fenofibrate 67,68fenofibric acid 68FENOGLIDE 68fenoprofen calcium 181fentanyl 5fentanyl citrate 5FENTORA 5FERRIPROX 147FERRIPROX (2 TIMES A DAY) 147FERRIPROX (3 TIMES A DAY) 147FETZIMA 49FEXMID 192FIASP 163FIASP FLEXTOUCH 163

FIASP PENFILL 163FIBRICOR 68FINACEA 199finasteride 166FINTEPLA 43FIORICET 2FIORICET WITH CODEINE 5FIORINAL 184FIORINAL WITH CODEINE #3 5FIRAZYR 168FIRDAPSE 178FIRVANQ 37FLAC OTIC OIL 27FLAGYL 95FLAREX 27flavoxate hcl 145flecainide acetate 34FLECTOR 181FLOLAN 190FLOLIPID 68FLOMAX 1FLOVENT DISKUS 129FLOVENT HFA 129FLUAD 2019-2020 104FLUAD 2020-2021 104FLUAD QUAD 2020-2021 104FLUAD QUAD 2021-2022 104FLUARIX QUAD 2019-2020 104FLUARIX QUAD 2020-2021 104FLUARIX QUAD 2021-2022 104FLUBLOK QUAD 2019-2020 104FLUBLOK QUAD 2020-2021 104FLUBLOK QUAD 2021-2022 104FLUCELVAX QUAD 2019-2020 104FLUCELVAX QUAD 2020-2021 104FLUCELVAX QUAD 2021-2022 104fluconazole 58flucytosine 58fludrocortisone acetate 149FLULAVAL QUAD 2019-2020 104FLULAVAL QUAD 2020-2021 104

FLULAVAL QUAD 2021-2022 105FLUMADINE 109FLUMIST QUAD 2019-2020 105FLUMIST QUAD 2020-2021 105FLUMIST QUAD 2021-2022 105flunisolide 27fluocinolone acetonide 31fluocinolone acetonide oil 27fluocinonide 31fluocinonide-e 31fluorescein-benoxinate 139fluoride 167fluoridex 167FLUORIDEX SENSITIVITY RELIEF 167fluoritab 167fluorometholone 27FLUOROPLEX 78fluorouracil 78fluoxetine dr 50fluoxetine hcl 50fluphenazine hcl 98flura-drops 168flurandrenolide 31flurazepam hcl 113,114flurbiprofen 181flurbiprofen sodium 28flutamide 78fluticasone propionate 27,31fluticasone-salmeterol 129fluticasone-salmeterol 113-14 (generic for airduorespiclick) 129fluticasone-salmeterol 232-14 (generic for airduorespiclick) 129fluticasone-salmeterol 55-14 (generic for airduorespiclick) 129fluvastatin er 68fluvastatin sodium 68fluvoxamine maleate 50fluvoxamine maleate er 50FLUZONE HIGH-DOSE 2019-2020 105FLUZONE HIGH-DOSE QUAD 2020-21 105

FLUZONE HIGH-DOSE QUAD 2021-22 105FLUZONE QUAD 2019-2020 105FLUZONE QUAD 2020-2021 105FLUZONE QUAD 2021-2022 105FLUZONE QUAD PEDI 2019-2020 105FLUZONE QUAD SOUTHERN HEM 2020 105FLUZONE QUAD SOUTHERN HEM 2021 105FML 27FML FORTE 27FML S.O.P. 27FOCALIN 16FOCALIN XR 16folic acid 212folitab 500 34folivane-ob 208fondaparinux sodium 40FORFIVO XL 48formoterol fumarate 118FORTAMET 52FORTEO 184FORTESTA 150FOSAMAX PLUS D 167fosamprenavir calcium 101fosfomycin tromethamine 19fosinopril sodium 187fosinopril-hydrochlorothiazide 187FOSRENOL 164FOTIVDA 78FRAGMIN 41FROTEK 34FROVA 70frovatriptan succinate 70FULPHILA 119FURADANTIN 19furosemide 131FUZEON 99FYAVOLV 137FYCOMPA 43

GGABACAINE 43

gabapentin 43GABITRIL 43GALAFOLD 178galantamine er 116galantamine hbr 117galantamine hydrobromide 117GARDASIL 9 105GASTROCROM 29gatifloxacin 20GATTEX 144GAVILYTE-C 142GAVILYTE-G 142GAVILYTE-N 142GAVRETO 79GEL-KAM 168GELNIQUE 145gemfibrozil 68GEMMILY 154GEMTESA 117GENERESS FE 154GENERLAC 134GENGRAF 176GENTAK 20gentamicin sulfate 21,23,24GENVOYA 100GEODON 97GIALAX 142GIANVI 154GILENYA 174GILOTRIF 79GIMOTI 144glatiramer acetate 174GLATOPA 174GLEEVEC 79GLEOSTINE 79glimepiride 55glipizide 55glipizide er 55glipizide xl 55glipizide-metformin 55GLOPERBA 166

GLUCAGEN 66GLUCAGEN 1 MG HYPOKIT (NOVO) 66glucagon 1 mg emergency kit 66glucagon 1 mg emergency kit (genericglucagen) 66glucagon 1 mg emergency kit (Lilly) 66GLUCAGON 1 MG VIAL 66GLUCOTROL 55GLUCOTROL XL 55GLUMETZA 52glyburide 56glyburide micronized 56glyburide-metformin hcl 56glycopyrrolate 39GLYNASE 56GLYSET 52GLYXAMBI 54GOCOVRI 93GOLYTELY 142GONITRO 206GRALISE 2granisetron hcl 56GRANIX 119GRASTEK 103griseofulvin 57griseofulvin ultramicrosize 57guaifenesin dac 189guaifenesin-codeine 189guanfacine hcl 161guanfacine hcl er 125guanidine hcl 117GVOKE HYPOPEN 1-PACK 66GVOKE HYPOPEN 2-PACK 66GVOKE PFS 1-PACK SYRINGE 66GVOKE PFS 2-PACK SYRINGE 66GYNAZOLE 1 59

HHAEGARDA 168HAILEY 154HAILEY 24 FE 154

HAILEY FE 154halcinonide 31HALCION 114halobetasol propionate 31HALOG 31haloperidol 98haloperidol lactate 98HARVONI 146HAVRIX 105HEATHER 154HELIDAC 38HEMADY 149HEMANGEOL 124HEMLIBRA 63hemmorex-hc 31HEMOFIL M 63heparin sodium 41HEPLISAV-B 105HEPSERA 110HETLIOZ 111HETLIOZ LQ 111HIBERIX 105HICON 185HIPREX 19HISTEX-AC 189homatropaire 139homatropine hydrobromide 139HORIZANT 43,44HUMALOG 163HUMALOG JUNIOR KWIKPEN 163HUMALOG KWIKPEN U-100 163HUMALOG KWIKPEN U-200 163HUMALOG MIX 50-50 163HUMALOG MIX 50-50 KWIKPEN 163HUMALOG MIX 75-25 163HUMALOG MIX 75-25 KWIKPEN 163HUMATE-P 63HUMIRA 170HUMIRA PEN 170HUMIRA PEN CROHN'S-UC-HS 170HUMIRA PEN PSOR-UVEITS-ADOL HS 170

HUMIRA(CF) 171HUMIRA(CF) PEDIATRIC CROHN'S 144,171HUMIRA(CF) PEN 171HUMIRA(CF) PEN CROHN'S-UC-HS 171HUMIRA(CF) PEN PEDIATRIC UC 171HUMIRA(CF) PEN PSOR-UV-ADOL HS 171HUMULIN 70-30 161HUMULIN 70/30 KWIKPEN 161HUMULIN N 161HUMULIN N KWIKPEN 161HUMULIN R 164HUMULIN R U-500 164HUMULIN R U-500 KWIKPEN 164HYCAMTIN 79hydralazine hcl 161HYDREA 79HYDRO 35 196HYDRO 40 196hydrochlorothiazide 132hydrocodone bitartrate er 5hydrocodone-acetaminophen 5hydrocodone-chlorpheniramne er 189hydrocodone-homatropine mbr 189hydrocodone-ibuprofen 5hydrocortisone 31,149hydrocortisone acetate 32hydrocortisone butyrate 32hydrocortisone valerate 32hydrocortisone-1% ointment 32hydrocortisone-acetic acid 22hydrocortisone-iodoquinol 25hydrocortisone-iodoquinol-aloe 25hydrocortisone-pramoxine 32hydromorphone er 6hydromorphone hcl 5,6hydroxocobalamin 212hydroxychloroquine sulfate 95hydroxyprogesterone caproate 160hydroxyurea 79hydroxyzine hcl 111hydroxyzine pamoate 111

HYLATOPICPLUS 130hyoscyamine sulfate 39hyoscyamine sulfate er 39hyoscyamine sulfate sr 39hyosyne 39HYSINGLA ER 6HYZAAR 186

Iibandronate sodium 167IBRANCE 79ibuprofen 181ibuprofen-famotidine 181icatibant 169ICLEVIA 154ICLUSIG 79icosapent ethyl 66IDELVION 64IDHIFA 80ILARIS 178ILEVRO 28imatinib mesylate 80IMBRUVICA 80IMCIVREE 13imipramine hcl 51imipramine pamoate 51imiquimod 199IMITREX 71IMPAVIDO 95IMPEKLO 32IMPOYZ 32IMVEXXY 137INBRIJA 94INCASSIA 154INCRUSE ELLIPTA 39indapamide 132INDERAL LA 124INDERAL XL 124INDOCIN 181indomethacin 181,182indomethacin er 182

INFANRIX DTAP 103INFLAMMA-K 182INGREZZA 127INGREZZA INITIATION PACK 127INLYTA 80,81INNOPRAN XL 124INQOVI 81INREBIC 81INSPRA 188insulin aspart 163insulin aspart flexpen 163insulin aspart penfill 163insulin aspart prot mix 70-30 163insulin glargine-yfgn 162insulin lispro 163insulin lispro junior kwikpen 163insulin lispro kwikpen u-100 163insulin lispro protamine mix 163INTELENCE 99INTERMEZZO 111INTRAROSA 149INTRON A 109INTROVALE 154INTUNIV 125INVEGA 97INVELTYS 27INVIRASE 101INVOKAMET 54INVOKAMET XR 54INVOKANA 55iodoquinol-hydrocortisone-aloe 25IOPIDINE 139IPOL 105ipratropium bromide 39,139ipratropium-albuterol 39irbesartan 186irbesartan-hydrochlorothiazide 186IRESSA 81ISENTRESS 99ISENTRESS HD 99ISIBLOOM 154

isoniazid 72ISOPTO CARPINE 62ISORDIL 206ISORDIL TITRADOSE 206isosorbide dinitrate 206isosorbide mononitrate 206isosorbide mononitrate er 206isotretinoin 199isoxsuprine hcl 208isradipine 122ISTALOL 61ISTURISA 178itraconazole 58ivermectin 19,26,199IXINITY 64

JJADENU 148JADENU SPRINKLE 148JAIMIESS 154JAKAFI 81JALYN 166JANSSEN COVID-19 VACCINE (EUA) 105jantoven 41JANUMET 53JANUMET XR 53JANUVIA 53JARDIANCE 55JASMIEL 154JATENZO 150JENCYCLA 154JENTADUETO 53JENTADUETO XR 53JINTELI 137JIVI 64JOLESSA 154JORNAY PM 16JUBLIA 59JULEBER 154JULUCA 99JUNEL 154

JUNEL FE 154JUNEL FE 24 154JUXTAPID 66JYNARQUE 132

KK-PHOS NO.2 133K-PHOS ORIGINAL 133k-tab er 134KADIAN 6KAITLIB FE 155KALBITOR 169KALETRA 101KALLIGA 155KALYDECO 130KAPSPARGO SPRINKLE 124KAPVAY 161KARBINAL ER 140KARIVA 155KATERZIA 122KAZANO 53KEFLEX 127KELNOR 1-35 155KELNOR 1-50 155KENALOG 32KEPPRA 44KEPPRA XR 44KERAFOAM 196KERALAC 196KERENDIA 188KERYDIN 60KESIMPTA PEN 174ketoconazole 58,59KETODAN 59ketoprofen 182ketorolac tromethamine 28,182KEVEYIS 167KEVZARA 171KINERET 171KINRIX 105KISQALI 81

KISQALI FEMARA CO-PACK 82KITABIS PAK 35KLARON 25KLISYRI 199KLONOPIN 47KLOR-CON 134KLOR-CON 10 134KLOR-CON 8 134KLOR-CON M10 134KLOR-CON M15 134KLOR-CON M20 134klor-con-ef 134KLOXXADO 127KOATE 64KOGENATE FS 64KOMBIGLYZE XR 53KORLYM 52KOSELUGO 82KOSHER PRENATAL PLUS IRON 208KOVALTRY 64KRINTAFEL 95KRISTALOSE 134KURVELO 155KUVAN 178KYNMOBI 133

Llabetalol hcl 124LACRISERT 139lactulose 134LAMICTAL 44LAMICTAL (BLUE) 44LAMICTAL (GREEN) 44LAMICTAL (ORANGE) 44LAMICTAL ODT 44LAMICTAL ODT (BLUE) 44LAMICTAL ODT (GREEN) 44LAMICTAL ODT (ORANGE) 44LAMICTAL XR 44LAMICTAL XR (BLUE) 44LAMICTAL XR (GREEN) 44

LAMICTAL XR (ORANGE) 44lamivudine 100lamivudine hbv 100lamivudine-zidovudine 100lamotrigine 44lamotrigine (blue) 44lamotrigine (green) 44lamotrigine (orange) 44lamotrigine er 44lamotrigine odt 44lamotrigine odt (blue) 44lamotrigine odt (green) 45lamotrigine odt (orange) 45LAMPIT 95LANOXIN 123lansoprazol-amoxicil-clarithro 108lansoprazole 108lanthanum carbonate 164LANTUS 162LANTUS SOLOSTAR 162lapatinib 82LARIN 155LARIN 24 FE 155LARIN FE 155LARISSIA 155LASIX 131LASTACAFT 138latanoprost 62LATUDA 97LAYOLIS FE 155LAZANDA 6ldo plus 130ledipasvir-sofosbuvir 146LEENA 155leflunomide 172LENVIMA 82,83LESCOL 68LESCOL XL 68LESSINA 155LETAIRIS 191letrozole 83

leucovorin calcium 166LEUKERAN 83LEUKINE 119leva set 193levalbuterol concentrate 118levalbuterol hcl 118levalbuterol tartrate hfa 118LEVAQUIN 35LEVBID 39LEVEMIR 162LEVEMIR FLEXTOUCH 162levetiracetam 45levetiracetam er 45LEVICYN 130LEVICYN ANTIPRURITIC SG 196LEVITRA 207LEVO-T 205levobunolol hcl 61levocarnitine 134,178levocarnitine sf 178levocetirizine dihydrochloride 65levofloxacin 21,35,36LEVONEST 155levonorg-eth estrad eth estrad 155levonorgestrel 155levonorgestrel-eth estradiol 155LEVORA-28 155levorphanol tartrate 6levothyroxine 205levothyroxine sodium 205LEVOXYL 205LEVSIN 39LEVSIN-SL 39LEXAPRO 50LEXIVA 101LIALDA 141LIBRAX 39LICART 182lido-k 193lido-prilo caine pack 193lidocaine 193

lidocaine hcl 139,193,194lidocaine hcl viscous 139lidocaine-hydrocortisone 32,194lidocaine-prilocaine 194lidocaine-tetracaine 194LIDODERM 194LIDOPAC 194lidopin 194lidopril 194lidopril xr 194LIDOTRAL 194LIDOTRANS 5 PAK 194LIDOTREX 130LIDOVEX 194LIFEMS NALOXONE 127LILLOW 155lindane 26linezolid 38LINZESS 144liothyronine sodium 205LIPITOR 68LIPOFEN 68LIPROZONEPAK 194lisinopril 187lisinopril-hydrochlorothiazide 187lithium 125lithium carbonate 125lithium carbonate er 125LITHOBID 125LITHOSTAT 134LIVALO 68livixil pak 194LIVMARLI 144LO LOESTRIN FE 155LO-ZUMANDIMINE 155LOCOID 32LOCOID LIPOCREAM 32LODOSYN 126LOESTRIN 155LOESTRIN FE 155LOJAIMIESS 156

LOKELMA 165LOMAIRA 13LOMOTIL 141LONHALA MAGNAIR REFILL 39LONHALA MAGNAIR STARTER 39LONSURF 83loperamide 141LOPID 68lopinavir-ritonavir 102LOPREEZA 137LOPRESSOR 124LOPRESSOR HCT 124LOPROX 60lorazepam 114LORAZEPAM INTENSOL 114LORBRENA 83LORCET 6LORCET HD 6LORCET PLUS 6LOREEV XR 114LORTAB 6LORYNA 156LORZONE 192losartan potassium 186losartan-hydrochlorothiazide 186LOSEASONIQUE 156LOTEMAX 27LOTEMAX SM 27LOTENSIN 187loteprednol etabonate 27LOTREL 122LOTRISONE 59LOTRONEX 141LOUTREX 130lovastatin 69LOVAZA 66LOVENOX 41,42LOW-OGESTREL 156loxapine 96lubiprostone 142ludent fluoride 168

luliconazole 59LUMAKRAS 83LUMIGAN 62LUNESTA 111LUPANETA PACK 146LUPKYNIS 176LUTERA 156LUXIQ 32LUZU 59LYBALVI 97LYNPARZA 83LYRICA 45LYRICA CR 2LYSODREN 84LYSTEDA 64LYUMJEV 163LYUMJEV KWIKPEN U-100 164LYUMJEV KWIKPEN U-200 164LYZA 156

MM-M-R II VACCINE 105m-natal plus 208M.V.I. ADULT 208M.V.I.-12 208MACRILEN 131MACROBID 19MACRODANTIN 19mafenide acetate 25MALARONE 95malathion 26maprotiline hcl 51MARINOL 56MARLISSA 156MARNATAL-F 208MARPLAN 49MARVONA SUIK 165MATULANE 84MATZIM LA 121MATZIM LA 360 MG TABLET (generic forCARDIZEM LA) 121

MAVENCLAD 177MAVYRET 147MAXALT 71MAXALT MLT 71MAXIDEX 27MAXITROL 21MAXZIDE 132MAXZIDE-25 MG 132MAYZENT 174,175mb hydrogel 130meclizine hcl 57meclofenamate sodium 182MEDOLOR PAK 194MEDROL 149MEDROLOAN II SUIK 149MEDROLOAN SUIK 149medroxyprogesterone acetate 160mefenamic acid 182mefloquine hcl 95MEGACE ES 160megestrol acetate 160MEKINIST 84MEKTOVI 84MELODETTA 24 FE 156meloxicam 182melphalan 84memantine hcl 126memantine hcl er 126MENACTRA 105MENEST 137MENOSTAR 137MENQUADFI 105MENTAX 60MENTHO-CAINE 194MENVEO A-C-Y-W-135-DIP 105MENVEO MENA COMPONENT 105MENVEO MENCYW-135 COMPONENT 106meperidine hcl 6MEPHYTON 213meprobamate 112MEPRON 95

mercaptopurine 84MERZEE 156mesalamine 141mesalamine dr 141mesalamine er 141MESNEX 180MESTINON 117METADATE ER 16metaproterenol sulfate 118METAXALL 192metaxalone 192metformin er 1,000 mg gastr-tb (generic forglumetza er) 52metformin er 1,000 mg osm-tab (generic forfortamet er) 52metformin er 500 mg gastrc-tb (generic forglumetza er) 52metformin er 500 mg osmotic tb (generic forfortamet er) 52metformin hcl 52metformin hcl 1,000 mg tablet (generic forglucophage) 52metformin hcl 500 mg tablet (generic forglucophage) 52metformin hcl er 52methacholine chloride 131methadone hcl 6METHADONE INTENSOL 6METHADOSE 6methamphetamine hcl 15methazolamide 62methenamine hippurate 19methenamine mandelate 19METHERGINE 184methimazole 205METHITEST 150methocarbamol 192methotrexate 84methotrexate sodium 84methoxsalen 130methscopolamine bromide 39

methyldopa 161methyldopa-hydrochlorothiazide 161methylergonovine maleate 184METHYLIN 16methylphenidate er 16,17methylphenidate er (la) 17methylphenidate er 10 mg cap (authorizedgeneric) 17methylphenidate er 15 mg cap (authorizedgeneric) 17methylphenidate er 20 mg cap (authorizedgeneric) 17methylphenidate er 30 mg cap (authorizedgeneric) 17methylphenidate er 40 mg cap (authorizedgeneric) 17methylphenidate er 50 mg cap (authorizedgeneric) 17methylphenidate er 60 mg cap (authorizedgeneric) 17methylphenidate hcl 16,17methylphenidate hcl cd 17methylphenidate hcl er (cd) 17methylphenidate la 17,18methylprednisolone 149methyltestosterone 150metipranolol 61metoclopramide hcl 144metoclopramide hcl odt 144metolazone 132METOPIRONE 131metoprolol succinate 124metoprolol succinate er-hctz 124metoprolol tartrate 124metoprolol-hydrochlorothiazide 124METROCREAM 24METROGEL 24METROGEL-VAGINAL 24METROLOTION 24metronidazole 24,95metyrosine 178

mexiletine hcl 34MIBELAS 24 FE 156MICARDIS 186MICARDIS HCT 186miconazole 3 59miconazole-zinc oxide-petroltm 59MICORT-HC 32MICROCYN HYDROGEL 130MICROGESTIN 156MICROGESTIN 24 FE 156MICROGESTIN FE 156MICROZIDE 132midazolam hcl 114midodrine hcl 204MIFEPREX 184MIGERGOT 1miglitol 52miglustat 178MIGRANAL 1MIGRANOW 71MILI 156MILLIPRED 149MIMVEY 137MIMVEY LO 137MINASTRIN 24 FE 156MINIPRESS 123MINITRAN 206MINIVELLE 137MINOCIN 37minocycline er 37minocycline hcl 37minocycline hcl er 37MINOLIRA ER 37minoxidil 161MIRAPEX 133MIRAPEX ER 133MIRCERA 119MIRCETTE 156mirtazapine 48misoprostol 107MITIGARE 166

MOBIC 182modafinil 18MODERNA COVID-19 VACCINE (EUA) 106moexipril hcl 187molindone hcl 96mometasone furoate 27,32MONDOXYNE NL 37MONO-LINYAH 156MONODOX 37MONONINE 64montelukast sodium 29MONUROL 19MORGIDOX 37MORPHABOND ER 6,7morphine sulfate 7morphine sulfate er 7MORPHINE SULFATE IR 15 MG TAB (BRAND) 7MORPHINE SULFATE IR 30 MG TAB (BRAND) 7MOTEGRITY 144MOTOFEN 141MOVANTIK 144MOVIPREP 142MOXATAG 185MOXEZA 21moxifloxacin 21moxifloxacin 0.5% eye drops (generic formoxeza) 21moxifloxacin hcl 36MS CONTIN 7MULPLETA 119MULTAQ 34multi-vitamin daily 208mupirocin 24MUSE 208MVW COMPLETE FORMLTN PEDIATRIC 209MVW COMPLETE FORMULATION D3000 209MY WAY 156MYALEPT 160MYAMBUTOL 72MYCAPSSA 202MYCOBUTIN 72

mycophenolate mofetil 177mycophenolic acid 177MYDAYIS 15MYDRIACYL 139MYFEMBREE 145MYFORTIC 177MYLERAN 84MYNATAL 209mynatal plus 209mynatal-z 209MYORISAN 200MYRBETRIQ 117MYSOLINE 47

Nnabumetone 182nadolol 124nadolol-bendroflumethiazide 124naftifine hcl 58NAFTIN 59NALFON 182NALOCET 7naloxone hcl 127naltrexone hcl 127NAMENDA 126NAMENDA XR 126NAMZARIC 126NAPRELAN 182NAPROSYN 182naproxen 182naproxen sodium 182naproxen sodium cr 182naproxen sodium er 182naproxen-esomeprazole mag 183naratriptan hcl 71NARCAN 127NARDIL 49NASONEX 27NATACHEW 209NATACYN 22NATAZIA 156

nateglinide 54NATESTO 150NATPARA 184NATROBA 26NATURE-THROID 205NAYZILAM 47nebivolol hcl 124NEBUPENT 95NECON 156NEEVODHA 209nefazodone hcl 51NEO-SYNALAR 24neomycin sulfate 35neomycin-bacitracin-poly-hc 21neomycin-bacitracin-polymyxin 21neomycin-polymyxin-dexameth 21neomycin-polymyxin-gramicidin 21neomycin-polymyxin-hc 21neomycin-polymyxin-hydrocort 21NEORAL 177NEOSALUS 130NEPHRONEX-SL 212NERLYNX 84NESINA 53NESTABS 209NESTABS ABC 209NESTABS DHA 209NESTABS ONE 209NEUAC 24NEULASTA 119NEULASTA ONPRO 119NEUPOGEN 119NEUPRO 133NEURAPTINE 200NEURCAINE 194NEURONTIN 45NEVANAC 28nevirapine 99nevirapine er 99NEXAVAR 84NEXIUM 108

NEXIUM 24HR 108NEXLETOL 66NEXLIZET 66NEXTSTELLIS 156niacin er 66NIACOR 66NIASPAN 67nicardipine hcl 122nicotine gum 115nicotine lozenge 116nicotine patch 116NICOTROL 116NICOTROL NS 116nifedipine 122nifedipine er 122NIKKI 156NILANDRON 85nilutamide 85nimodipine 122ninjacof-xg 189NINLARO 85nisoldipine 122nitazoxanide 95nitisinone 178NITRO-BID 206NITRO-DUR 206NITRO-TIME 206nitrofurantoin 19nitrofurantoin mono-macro 19nitroglycerin 206nitroglycerin patch 206NITROLINGUAL 206NITROMIST 206NITROSTAT 206NITYR 178NIVESTYM 119nizatidine 107NIZORAL 59NOCDURNA 160NOCTIVA 160NOLIX 32

NORA-BE 156NORCO 7norethin-eth estra-ferrous fum 156norethindron-ethinyl estradiol 137,157norethindrone 157norethindrone ac (lupaneta) 160norethindrone acetate 160norethindrone-e.estradiol-iron 157norgestimate-ethinyl estradiol 157NORITATE 24NORLYDA 157NORPACE 34NORPACE CR 34NORPRAMIN 51NORTHERA 204NORTREL 157nortriptyline hcl 51NORVASC 122NORVIR 102NOURIANZ 126NOVACORT 32NOVAVAX COVID19 VAC,ADJ(UNAPP) 106NOVOEIGHT 64NOVOLIN 70-30 162NOVOLIN 70-30 FLEXPEN 162novolin 70-30 flexpen 162NOVOLIN N 162NOVOLIN N FLEXPEN 162NOVOLIN R 164NOVOLIN R FLEXPEN 164NOVOLOG 164novolog flexpen 164NOVOLOG MIX 70-30 164NOVOLOG MIX 70-30 FLEXPEN 164NOVOSEVEN RT 64NOXAFIL 58NOXIPAK 32np thyroid 205NUBEQA 85NUCALA 29NUCYNTA 7

NUCYNTA ER 7,8NUDROXIPAK 180NUDROXIPAK DSDR-50 183NUDROXIPAK DSDR-75 183NUDROXIPAK E-400 183NUDROXIPAK I-800 183NUDROXIPAK N-500 183NUEDEXTA 126nulev 39NULYTELY WITH FLAVOR PACKS 142NUMBONEX 194NUPLAZID 97NURTEC ODT 70NUSURGEPAK 200NUTRASEB 135NUTRIARX 32NUVARING 157NUVESSA 24NUVIGIL 18NUWIQ 64NUZYRA 204NYAMYC 60NYMALIZE 122NYMYO 157nystatin 58,60nystatin-triamcinolone 60NYSTOP 60NYVEPRIA 119

OO-CAL PRENATAL 209OB COMPLETE 209OB COMPLETE ONE 209OB COMPLETE PETITE 209OB COMPLETE PREMIER 209OB COMPLETE WITH DHA 209OBIZUR 64OBREDON 189OCALIVA 144OCELLA 157octreotide acetate 202

OCUFLOX 21OCUVEL 209ODACTRA 103ODEFSEY 101ODOMZO 85OFEV 189ofloxacin 21,36OGESTREL 157OKEBO 37olanzapine 97olanzapine odt 97olanzapine-fluoxetine hcl 50olmesartan medoxomil 186olmesartan-amlodipine-hctz 186olmesartan-hydrochlorothiazide 186olopatadine hcl 138OLUMIANT 172OLUX 32OLUX-E 32OMECLAMOX-PAK 108omega-3 acid ethyl esters 67OMEPPI 108omeprazole 108omeprazole-sodium bicarbonate 108OMNARIS 27OMNIPAQUE 131ondansetron hcl 56ondansetron odt 56ONEXTON 24ONFI 47,48ONGENTYS 93ONGLYZA 53ONMEL 58ONUREG 85ONZETRA XSAIL 71OPANA 8opium tincture 142OPSUMIT 191OPZELURA 200ORACEA 37ORALAIR 103

ORAPRED ODT 149ORAVIG 59ORENCIA 172ORENCIA CLICKJECT 172ORENITRAM ER 191ORFADIN 179ORGOVYX 146ORIAHNN 146ORILISSA 146ORKAMBI 130ORLADEYO 169orphenadrine citrate er 193ORSYTHIA 157ORTHO MICRONOR 157ORTHO TRI-CYCLEN 157ORTHO-NOVUM 157ORTIKOS 149oscimin 40oscimin sl 40oscimin sr 40oseltamivir phosphate 109,110OSENI 53OSMOLEX ER 93OSMOPREP 142OSPHENA 136OTEZLA 172OTIPRIO 21OTOVEL 21OTREXUP 85OVACE 25OVACE PLUS 25ovace plus wash 25OVIDE 26OXANDRIN 150oxandrolone 151oxaprozin 183OXAYDO 8oxazepam 114OXBRYTA 118oxcarbazepine 45OXERVATE 139

oxiconazole nitrate 60OXISTAT 60OXSORALEN-ULTRA 130OXTELLAR XR 45oxybutynin chloride 145oxybutynin chloride er 145oxycodone hcl 8oxycodone hcl er 8oxycodone hcl-aspirin 8oxycodone hcl-ibuprofen 8oxycodone-acetaminophen 8OXYCONTIN 8oxymorphone hcl 8,9oxymorphone hcl er 9OXYTROL 145OZEMPIC 54OZOBAX 193

PPACERONE 35PACNEX 196PAINGO KFT 194PALFORZIA 103paliperidone er 97PALYNZIQ 135PAMELOR 51PANCREAZE 143PANDEL 32PANRETIN 85pantoprazole sodium 108papaverine-phentolamine 208paregoric 142paricalcitol 213PARLODEL 133PARNATE 49PAROEX 22paromomycin sulfate 94paroxetine cr 50paroxetine er 50paroxetine hcl 50paroxetine mesylate 50

PASER 72PATADAY 138PATANASE 138PATANOL 138PAXIL 50PAXIL CR 50PAZEO 138PEDIARIX 106PEDVAXHIB 106peg 3350-electrolyte 142peg-3350 and electrolytes 142PEG-PREP 142peg3350-sod sul-nacl-kcl-asb-c 142PEGANONE 48PEGASYS 109PEGASYS PROCLICK 109PEGINTRON 109PEMAZYRE 85penicillamine 148penicillin v potassium 185PENLAC 60PENTACEL 106PENTACEL ACTHIB COMPONENT 106PENTACEL DTAP-IPV COMPONENT 106pentamidine isethionate 95PENTASA 141pentazocine-naloxone hcl 12pentoxifylline 120PEPCID 107PERCOCET 9PERFOROMIST 118PERIDEX 22perindopril erbumine 187PERIOGARD 22PERIOMED 168permethrin 26perphenazine 98perphenazine-amitriptyline 51PERTZYE 143PEXEVA 50PFIZER COVID(12Y UP) VAC(UNAP) 106

PFIZER COVID(5-11Y) VAC(UNAPP) 106PFIZER COVID-19 VACCINE (EUA) 106PHENADOZ 140phenazopyridine hcl 194phendimetrazine tartrate 13phendimetrazine tartrate er 13phenelzine sulfate 49phenobarbital 112phenobarbital-hyosc-atrop-scop 40phenohytro 40phenoxybenzamine hcl 1phentermine hcl 13phenylephrine hcl 140PHENYTEK 48phenytoin 48phenytoin sodium extended 48PHEXXI 180PHILITH 157PHOSLYRA 164phosphasal 19PHOSPHOLINE IODIDE 62PHOTREXA 139PHOTREXA VISCOUS 139phytonadione 213PICATO 85PIFELTRO 99pilocarpine hcl 62,117pimecrolimus 200pimozide 96PIMTREA 157pindolol 124pioglitazone hcl 56pioglitazone-glimepiride 56pioglitazone-metformin 56PIQRAY 85PIRMELLA 157piroxicam 183PLAN B ONE-STEP 157PLAQUENIL 95PLAVIX 102PLEGRIDY 175

PLEGRIDY PEN 175PLENVU 142PNEUMOVAX 23 106pnv 29-1 209pnv-dha 209pnv-omega 209pnv-select 209podofilox 200polyethylene glycol 3350 142polymyxin b sul-trimethoprim 21POLYTRIM 21POMALYST 86PONTOCAINE 194PONVORY 175PORTIA 157posaconazole 58POTABA 179potassium chloride 135potassium citrate er 133pr natal 400 209pr natal 400 ec 209pr natal 430 209pr natal 430 ec 210PRADAXA 41PRALUENT PEN 69pramipexole dihydrochloride 133pramipexole er 133PRAMOSONE 32prasugrel hcl 102PRAVACHOL 69pravastatin sodium 69praziquantel 19prazosin hcl 123PRED FORTE 27PRED MILD 27PRED-G 21prednicarbate 32prednisolone 149prednisolone ac 1% eye drop (generic predforte) 27prednisolone sodium phos odt 149

prednisolone sodium phosphate 27,149prednisolone-nepafenac 27prednisone 149PREDNISONE INTENSOL 149PREFEST 137pregabalin 45pregabalin er 2,3PREMARIN 137PREMPHASE 137PREMPRO 137PRENA1 CHEW 210prena1 pearl 210prena1 true 210PRENATA 210PRENATABS FA 210PRENATABS RX 210prenatal 19 210prenatal plus 210prenatal plus-dha 210prenatal vitamin plus low iron 210prenatal-u 210PRENATE AM 210PRENATE CHEWABLE 210PRENATE DHA 210PRENATE ELITE 210PRENATE ENHANCE 210PRENATE ESSENTIAL 210PRENATE MINI 210PRENATE PIXIE 210PRENATE RESTORE 210PRENATE STAR 210preplus 210PREPOPIK 142PRESTALIA 187pretomanid 72PREVACID 108PREVACID 24HR DR 15 MG CAPSULE (OTC) 108PREVALITE 67PREVIDENT 168PREVIDENT 5000 168PREVIDENT 5000 ENAMEL PROTECT 168

PREVIDENT 5000 PLUS 168PREVIDENT 5000 SENSITIVE 168PREVIFEM 157PREVNAR 13 106PREVNAR 20 106PREVYMIS 109PREZCOBIX 102PREZISTA 102PRIFTIN 72prikaan 194prikaan lite 194prilolid 194PRILOSEC 108prilovix 195prilovix plus 195PRIMACARE 210primaquine 95primidone 47PRIMLEV 9PRIMSOL 19PRINIVIL 187PRISTIQ 49pro dna collection 139PRO DNA MEDICATED COLLECTION 139PROAIR DIGIHALER 118PROAIR HFA 118PROAIR RESPICLICK 118probenecid 135probenecid-colchicine 135PROCARDIA 122PROCARDIA XL 122PROCENTRA 15prochlorperazine 57prochlorperazine maleate 57PROCRIT 119PROCTO-MED HC 33PROCTO-PAK 33PROCTOCORT 33PROCTOFOAM-HC 33PROCTOSOL-HC 33PROCTOZONE-HC 33

PROCYSBI 179PROFILNINE 64progesterone 160,161PROGLYCEM 66PROGRAF 177PROLATE 9PROLENSA 28PROMACTA 120promethazine hcl 140promethazine vc 140promethazine vc-codeine 189promethazine-codeine 189promethazine-dm 189promethazine-phenyleph-codeine 189promethazine-phenylephrine 140PROMETHEGAN 140PROMETRIUM 161propafenone hcl 34propafenone hcl er 34propantheline bromide 40proparacaine hcl 139propranolol hcl 124propranolol hcl er 124propranolol-hydrochlorothiazid 125propylthiouracil 205PROQUAD 106PROSCAR 166PROTONIX 109PROTOPIC 200protriptyline hcl 51PROVENTIL HFA 118PROVERA 161PROVIDA OB 210PROVIGIL 18PROZAC 50PRUDOXIN 195PSORCON 33PULMICORT 129PULMICORT FLEXHALER 129PULMOZYME 190PUREFE OB PLUS 211

PURIXAN 86PYLERA 38pyrazinamide 72pyridostigmine bromide 117pyridostigmine bromide er 117pyrimethamine 95

QQBRELIS 187QBREXZA 40QDOLO 9QELBREE 126QINLOCK 86QNASL 27QNASL CHILDREN 28QSYMIA 13QTERN 55QUADRACEL DTAP-IPV 106QUALAQUIN 95QUARTETTE 157quazepam 114QUDEXY XR 45QUESTRAN 67QUESTRAN LIGHT 67quetiapine fumarate 97quetiapine fumarate er 97QUILLICHEW ER 18QUILLIVANT XR 18quinapril hcl 188quinapril-hydrochlorothiazide 188quinidine gluconate 34quinidine sulfate 34quinine sulfate 95QUINJA 25QULIPTA 70QVAR REDIHALER 129

Rr-natal ob 211rabeprazole sodium 109RAGWITEK 103

raloxifene hcl 136ramelteon 112ramipril 188RANEXA 122ranitidine hcl 107ranolazine er 122RAPAFLO 1RAPAMUNE 177rasagiline mesylate 94RASUVO 86RAVICTI 134RAYALDEE 213RAZADYNE 117RAZADYNE ER 117REBIF 175REBIF REBIDOSE 175REBINYN 64RECLIPSEN 157RECOMBINATE 64RECOMBIVAX HB 106RECTIV 200REDITREX 175REGLAN 144REGRANEX 195RELADOR PAK 195RELADOR PAK PLUS 195RELAFEN DS 183RELENZA 110relion novolin 70-30 vial 162relion novolin n 100 unit/ml 162relion novolin n u-100 flexpen 162relion novolin r 100 unit/ml 164relion novolin r u-100 flexpen 164RELISTOR 144RELPAX 71RELTONE 143REMERON 49REMODULIN 191RENAGEL 164RENVELA 164repaglinide 54

repaglinide-metformin hcl 54REPATHA PUSHTRONEX 69REPATHA SURECLICK 69REPATHA SYRINGE 69REQUIP XL 133RESCRIPTOR 99RESTASIS 28RESTASIS MULTIDOSE 28RESTORIL 114RETACRIT 120RETAINE OM3 179RETAINE VISION 179RETEVMO 86RETIN-A 195RETIN-A MICRO 195RETIN-A MICRO PUMP 195RETROVIR 101REVATIO 207REVCOVI 135REVLIMID 86REXULTI 97REYATAZ 102REYVOW 71REZUROCK 179RHOPRESSA 62RIAX 196RIBASPHERE 110RIBASPHERE RIBAPAK 110ribavirin 110RIDAURA 145rifabutin 72RIFADIN 73RIFAMATE 73rifampin 73RIFATER 73RILUTEK 126riluzole 126rimantadine hcl 109RINVOQ 172RIOMET 52RIOMET ER 52

risedronate sodium 167risedronate sodium dr 167RISPERDAL 97risperidone 97risperidone odt 97RITALIN 18RITALIN LA 18ritonavir 102rivastigmine 117RIVELSA 157RIXUBIS 65rizatriptan 71ROBAXIN-750 192ROCALTROL 213ROCKLATAN 62ropinirole er 133ropinirole hcl 133ROSADAN 24rosanil 196ROSULA 196rosuvastatin calcium 69rosuvastatin-ezetimibe 67ROSZET 67ROTARIX 106ROTATEQ 106ROWASA 141ROWEEPRA 46ROWEEPRA XR 46ROXICODONE 9ROZEREM 112ROZLYTREK 86RUBRACA 86RUCONEST 169rufinamide 46RUKOBIA 99RUZURGI 179RYBELSUS 54RYCLORA 141RYDAPT 87rydex 190RYTARY 94

RYTHMOL SR 34RYVENT 140

SSABRIL 46SAFYRAL 158SAJAZIR 169SALAGEN 117SALEX 196salicylic acid 196SALIVAMAX 131salsalate 184SAMSCA 132SANCUSO 56SANDIMMUNE 177SANDOSTATIN 202,203SANDOSTATIN LAR DEPOT 203SANTYL 200SAPHRIS 97sapropterin dihydrochloride 179SARAFEM 50SAVAYSA 41SAVELLA 126SAXENDA 54SCARCARE 131scopolamine 57se-natal 19 211SEASONIQUE 158SECONAL SODIUM 112SECUADO 97SEEBRI NEOHALER 40SEGLUROMET 55SELECT-OB 211SELECT-OB + DHA 211selegiline hcl 94selenium sulfide 25SELRX 25SELZENTRY 99SEMGLEE 162SEMGLEE (YFGN) 162SEMGLEE (YFGN) PEN 162

SEMGLEE PEN 162SEMPREX-D 65SENSIPAR 184SEREVENT DISKUS 118SERNIVO 33SEROQUEL 97SEROQUEL XR 98SEROSTIM 160sertraline hcl 50SETLAKIN 158sevelamer carbonate 164sevelamer hcl 164SEVENFACT 65SEYSARA 204sf 168sf 5000 plus 168SHAROBEL 158SHINGRIX 106SHINGRIX ADJUVANT COMPONENT 185SHINGRIX GE ANTIGEN COMPONENT 106SIDEROL 34SIGNIFOR 203SIGNIFOR LAR 203SIKLOS 87sildenafil 20 mg tablet (generic for revatio) 207sildenafil citrate 207SILENOR 52SILIPAC 131SILIQ 200silodosin 1SILVADENE 25silver sulfadiazine 25SILVRSTAT 131SIMBRINZA 62SIMLIYA 158SIMPESSE 158SIMPONI 172SIMPONI ARIA 172simvastatin 69SINGULAIR 29sirolimus 177

SIRTURO 73SITAVIG 110SIVEXTRO 38SKELAXIN 192SKLICE 26SKYRIZI 200SKYRIZI (2 SYRINGES) KIT 200SLYND 158sodium fluoride 168sodium fluoride 5000 dry mouth 168sodium fluoride enamel protect 168sodium fluoride sensitive 168sodium iodide i-123 185sodium iodide i-131 185sodium phenylbutyrate 134sodium polystyrene sulfonate 165sodium sulfacetamide 26sodium sulfacetamide-sulfur 25,26,196,197sofosbuvir-velpatasvir 146SOLARAZE 87solifenacin succinate 145SOLIQUA 100-33 162SOLODYN 37SOLOSEC 95SOLTAMOX 136SOLU-CORTEF 149SOLUPAK 195SOMA 192SOMATULINE DEPOT 203SOMAVERT 203SOOLANTRA 200SORIATANE 200SORILUX 200SORINE 125sotalol 125SOTALOL AF 125SOTYLIZE 125SOVALDI 146spinosad 26SPIRIVA 40SPIRIVA RESPIMAT 40

spironolactone 188spironolactone-hctz 188SPORANOX 58SPRAVATO 49SPRINTEC 158SPRITAM 46SPRIX 183SPRYCEL 87SRONYX 158SSD 26SSKI 205sss 10-5 197STALEVO 100 94STALEVO 125 94STALEVO 150 94STALEVO 200 94STALEVO 50 94STALEVO 75 94STARLIX 54stavudine 101STAXYN 207STEGLATRO 55STEGLUJAN 55STELARA 200STENDRA 207STIMATE 160STIOLTO RESPIMAT 40STIVARGA 87STRATTERA 126STRENSIQ 135STRIANT 151STRIBILD 101STRIVERDI RESPIMAT 118STROMECTOL 19SUBOXONE 12SUBSYS 9SUBVENITE 46SUBVENITE (BLUE) 46SUBVENITE (GREEN) 46SUBVENITE (ORANGE) 46SUCRAID 135

sucralfate 107SULAR 122sulconazole nitrate 60sulfacetamide sodium 21,26sulfacetamide-prednisolone 21sulfacleanse 8-4 197sulfadiazine 36sulfamethoxazole-trimethoprim 36SULFAMYLON 26sulfasalazine 36sulfasalazine dr 36SULFATRIM 36sulindac 183SUMADAN 197SUMADAN XLT 26sumatriptan 71sumatriptan succ-naproxen sod 71sumatriptan succinate 71SUMAXIN 197SUMAXIN TS 197sunitinib malate 87SUNOSI 18SUPPORT-500 212SUPRAX 128SUPREP 142SUSTIVA 99SUTAB 143SUTENT 87SYEDA 158SYLATRON 109symax 40SYMAX DUOTAB 40symax-sl 40symax-sr 40SYMBICORT 129SYMBYAX 50SYMDEKO 129SYMFI 99SYMFI LO 99SYMJEPI 204SYMLINPEN 60 52

SYMPAZAN 48SYMPROIC 144SYMTUZA 102SYNALAR 33SYNALAR TS 33SYNAREL 146SYNDROS 57SYNERA 195SYNERDERM 131SYNJARDY 55SYNJARDY XR 55SYNRIBO 87SYNTHROID 205SYNVEXIA TC 195SYPRINE 148

TTABLOID 87TABRECTA 87TACLONEX 200tacrolimus 177,200tadalafil 207tadalafil 20 mg tablet (generic for adcirca) 207TAFINLAR 88TAGRISSO 88TAKHZYRO 169TALICIA 107TALTZ AUTOINJECTOR 200TALTZ AUTOINJECTOR (2 PACK) 201TALTZ AUTOINJECTOR (3 PACK) 201TALTZ SYRINGE 201TALZENNA 88TAMIFLU 110tamoxifen citrate 136tamsulosin hcl 2TAPAZOLE 205TAPERDEX 149TARCEVA 88TARGADOX 37TARGRETIN 88TARINA 24 FE 158

TARINA FE 158TARINA FE 1-20 EQ 158TARKA 188taron-c dha 211TASIGNA 89TASMAR 93tavaborole 60TAVALISSE 119TAVNEOS 169TAYTULLA 158tazarotene 201TAZORAC 201TAZTIA XT 121TAZVERIK 89tdvax 103TECFIDERA 175TEGRETOL 46TEGRETOL XR 46TEGSEDI 167TEKTURNA 188TEKTURNA HCT 188telmisartan 186telmisartan-amlodipine 187telmisartan-hydrochlorothiazid 187temazepam 114TEMIXYS 101TEMODAR 89TEMOVATE 33temozolomide 89TENCON 3TENIVAC 103tenofovir disoproxil fumarate 101TENORMIN 125TEPMETKO 89terazosin hcl 123terbinafine hcl 57terbutaline sulfate 118terconazole 60teriparatide 184TESTIM 151testosterone 151

testosterone cypionate 151testosterone enanthate 151testosterone propionate 151TESTRED 151tetrabenazine 127tetracycline hcl 37TETRIX 135TEXACORT 33THALITONE 132THALOMID 175THEO-24 202theophylline 202theophylline anhydrous 202THIOLA 179THIOLA EC 179thioridazine hcl 98thiothixene 98thrivite rx 211THYQUIDITY 205thyroid 205TIADYLT ER 121tiagabine hcl 46TIAZAC 121TIBSOVO 89TICALAST 138TIGAN 57TIGLUTIK 126TIKOSYN 35TILIA FE 158timolol 0.5% eye drop (generic for istalol) 61timolol maleate 61,125timolol maleate 0.25% eye drop (generic fortimoptic) 61timolol maleate 0.5% eye drops (generic fortimoptic) 61timolol maleate/pf 0.5% eye drop (generic forocudose) 61TIMOPTIC 61TIMOPTIC OCUDOSE 61TIMOPTIC-XE 61tinidazole 96

tiopronin 179TIROSINT 205TIROSINT-SOL 205TIVICAY 99TIVICAY PD 99tizanidine hcl 192TOBI 35TOBI PODHALER 35TOBRADEX 21TOBRADEX ST 21tobramycin 21,35tobramycin-dexamethasone 21TOBREX 22TODAY CONTRACEPTIVE SPONGE 180TOFRANIL 52TOLAK 89tolcapone 93tolmetin sodium 183TOLSURA 58tolterodine tartrate 145tolterodine tartrate er 145tolvaptan 132TOPAMAX 46TOPICORT 33topiramate 46topiramate er 46TOPROL XL 125toremifene citrate 136TORONOVA II SUIK 183TORONOVA SUIK 183torsemide 132TOSYMRA 71TOUJEO MAX SOLOSTAR 162TOUJEO SOLOSTAR 162TOVET EMOLLIENT 33TOVIAZ 145TPOXX (NATIONAL STOCKPILE) 109TRACLEER 191TRADJENTA 53tramadol er 100 mg tablet (generic for ryzolt) 9tramadol er 200 mg tablet (generic for ryzolt) 9

tramadol er 300 mg tablet (generic for ryzolt) 10tramadol hcl 10tramadol hcl er 10tramadol hcl er 100 mg capsule (generic forconzip) 10tramadol hcl er 100 mg tablet (generic for ultramer) 10tramadol hcl er 200 mg capsule (generic forconzip) 10tramadol hcl er 200 mg tablet (generic for ultramer) 10tramadol hcl er 300 mg capsule (generic forconzip) 10tramadol hcl er 300 mg tablet (generic for ultramer) 10tramadol hcl-acetaminophen 10trandolapril 188trandolapril-verapamil er 188tranexamic acid 65TRANSDERM-SCOP 57TRANXENE T-TAB 114tranylcypromine sulfate 49TRANZAREL 195TRAVATAN Z 62travoprost 62trazodone hcl 51TRECATOR 73TRELEGY ELLIPTA 129TREMFYA 201treprostinil 191TRESIBA 162TRESIBA FLEXTOUCH U-100 162TRESIBA FLEXTOUCH U-200 162TRETIN-X 195tretinoin 89,195tretinoin microsphere 195TRETTEN 65TREXALL 89TREXIMET 72TREZIX 10TRI FEMYNOR 158

TRI-ESTARYLLA 158TRI-LEGEST FE 158TRI-LINYAH 158TRI-LO-ESTARYLLA 158TRI-LO-MARZIA 158TRI-LO-MILI 158TRI-LO-SPRINTEC 158TRI-MILI 158TRI-PREVIFEM 159TRI-SPRINTEC 159TRI-VYLIBRA 159TRI-VYLIBRA LO 159triamcinolone acetonide 33triamterene 132triamterene-hydrochlorothiazid 132triazolam 114,115TRIBENZOR 187TRICARE 211TRICOR 68TRIDERM 33trientine hcl 148trifluoperazine hcl 98trifluridine 22TRIGLIDE 68trihexyphenidyl hcl 93TRIJARDY XR 55TRIKAFTA 129TRIKLO 67TRILEPTAL 46TRILIPIX 68TRILOAN SUIK 149TRILYTE WITH FLAVOR PACKETS 143trimethobenzamide hcl 57trimethoprim 19trimipramine maleate 52TRIMPEX 19trinatal rx 1 211TRINATE 211TRINTELLIX 51TRIUMEQ 101triveen-duo dha 211

TRIVORA-28 159TRIXYLITRAL 183TRIZIVIR 101TROKENDI XR 46tropicamide 139trospium chloride 145trospium chloride er 145tru-micin 184TRUDHESA 1TRULANCE 144TRULICITY 54TRUMENBA 106TRUSELTIQ 89TRUSOPT 62trust natal dha 211TRUVADA 101TUDORZA PRESSAIR 40TUKYSA 89,90TULANA 159TURALIO 90TUSNEL PEDIATRIC 190TUSSICAPS 190TUZISTRA XR 190TWINRIX 106TWIRLA 159TWYNSTA 187TYBLUME 159TYBOST 179TYDEMY 159TYKERB 90TYLENOL-CODEINE NO.3 11TYLENOL-CODEINE NO.4 11TYMLOS 184TYVASO 191TYVASO REFILL KIT 191TYVASO STARTER KIT 191

UUBRELVY 70UCERIS 150UDENYCA 120

UKONIQ 90ULESFIA 26ULORIC 166ULTRACET 11ULTRAM 11ULTRASAL-ER 197UNITHROID 205UPNEEQ 140UPTRAVI 191URAMAXIN 197urea 197URELLE 19URETRON D-S 20UREVAZ 197URIBEL 20uro-mp 20UROCIT-K 133UROQID-ACID NO.2 20UROXATRAL 2URSO 143URSO FORTE 143ursodiol 143UTIBRON NEOHALER 118utira-c 20

VVAGIFEM 137valacyclovir 110VALCHLOR 90VALCYTE 110valganciclovir hcl 110VALIUM 115valproic acid 46valsartan 187valsartan-hydrochlorothiazide 187VALTOCO 115VALTREX 110VANATOL LQ 3VANATOL S 3VANCOCIN HCL 37vancomycin hcl 38

VANDAZOLE 24VANOS 33VANOXIDE-HC 33VAQTA 106vardenafil hcl 207varenicline tartrate 116VARIVAX VACCINE 107VARUBI 57VASCEPA 67VASERETIC 188VASHE WOUND 131VASHE WOUND THERAPY 131VASOTEC 188VAXCHORA ACTIVE COMPONENT 107VAXCHORA BUFFER COMPONENT 185VAXCHORA VACCINE 107VAXELIS 103VAXNEUVANCE 107vcf 180VECTICAL 201VELETRI 191VELIVET 159VELPHORO 164VELTASSA 165VELTIN 24VEMLIDY 110VENCLEXTA 90VENCLEXTA STARTING PACK 90venlafaxine hcl 49venlafaxine hcl er 49VENNGEL ONE 183VENTAVIS 191VENTOLIN HFA 118verapamil er 121verapamil er pm 121verapamil hcl 121verapamil sr 121VERDESO 33VERELAN 121VERELAN PM 121VERQUVO 208

VERSACLOZ 98VERZENIO 91VESICARE 145VESICARE LS 145VESTURA 159VEXASYN 131VFEND 58VIAGRA 207VIBERZI 144VIBRAMYCIN 37VICODIN HP 11VICTOZA 2-PAK 54VICTOZA 3-PAK 54VIDEX 101VIDEX EC 101VIEKIRA PAK 147VIENVA 159vigabatrin 46VIGADRONE 47VIGAMOX 22VIIBRYD 51VIMOVO 183VIMPAT 47VINATE CARE 211vinate one 211vinate-m 211VIOKACE 143VIORELE 159VIRACEPT 102VIRAMUNE 100VIRAMUNE XR 100VIRAZOLE 111VIREAD 101virt-c dha 211virt-nate dha 211virt-pn dha 211virt-pn plus 211VISTARIL 112VISTOGARD 166VITAFOL GUMMIES 211VITAFOL NANO 211

VITAFOL ULTRA 211VITAFOL-OB 211VITAFOL-OB+DHA 211VITAFOL-ONE 211VITAMEDMD ONE RX 212VITAMEDMD REDICHEW RX 212vitamin b-12 212vitamin d2 213VITAPEARL 212VITRAKVI 91VIVELLE-DOT 137VIVLODEX 183VIVOTIF 107VIZIMPRO 91VOCABRIA 99VOGELXO 151VOLNEA 159VOLTAREN 183VOLTAREN-XR 183VONVENDI 65voriconazole 58VOSEVI 146VOTRIENT 91VP-PNV-DHA 212VRAYLAR 98VTOL LQ 3VUMERITY 176VUSION 60VYFEMLA 159VYLEESI 126VYLIBRA 159VYNDAMAX 122VYNDAQEL 122VYTONE 26VYTORIN 67VYVANSE 15VYZULTA 62

WWAKIX 18warfarin sodium 41

WEGOVY 54WELCHOL 67WELIREG 91WELLBUTRIN SR 49WELLBUTRIN XL 49WERA 159WESTHROID 205WHYTEDERM SURGIPAK 201WHYTEDERM TDPAK 33WHYTEDERM TRILASIL PAK 33WILATE 65WINLEVI 201WIXELA INHUB 129WP THYROID 205WPR PLUS 195wrestone 179WYMZYA FE 159WYNZORA 201

XXADAGO 94XALATAN 62XALIX 197XALKORI 92XANAX 115XANAX XR 115XARELTO 41XATMEP 92XCOPRI 47XELJANZ 173XELJANZ XR 173XELODA 92XELPROS 62XENAZINE 127XENICAL 144XENLETA 38XEPI 24XERESE 25XERMELO 142XHANCE 28XIFAXAN 38

XIGDUO XR 55XIIDRA 28XILAPAK 34XIMINO 37XOFLUZA 109XOLAIR 190XOPENEX 118XOPENEX HFA 118XOSPATA 92XPOVIO 92XRYLIDERM 195XRYLIX 183XTAMPZA ER 11XTANDI 92XULANE 159XULTOPHY 100-3.6 162XURIDEN 179XYNTHA 65XYNTHA SOLOFUSE 65XYOSTED 151XYREM 126XYWAV 126XYZAL 65

YYASMIN 28 159YAZ 159YONSA 92YOSPRALA 184YUPELRI 40YUVAFEM 137

Zzafirlukast 29zaleplon 112ZANAFLEX 192ZARAH 159ZARONTIN 48ZARXIO 120zatean-pn dha 212zatean-pn plus 212

ZAVESCA 179ZCORT 150ZEBUTAL 3ZEGALOGUE AUTOINJECTOR 66ZEGALOGUE SYRINGE 66ZEGERID 109ZEJULA 92ZELAPAR 94ZELBORAF 92ZELNORM 144ZEMBRACE SYMTOUCH 72ZEMPLAR 213ZENATANE 201ZENPEP 143ZENZEDI 15ZEPATIER 147ZEPOSIA 176ZERVIATE 138ZESTORETIC 188ZESTRIL 188ZETIA 67ZETONNA 28ZIAGEN 101ZIANA 24zidovudine 101ZIEXTENZO 120zileuton er 29ZILXI 24zingiber 212ZIOPTAN 62ziprasidone hcl 98ZIPSOR 183ZIRGAN 22ZITHRANOL 197ZITHROMAX 165ZOCOR 69ZOFRAN 56ZOHYDRO ER 11ZOKINVY 180ZOLINZA 92zolmitriptan 72

zolmitriptan odt 72ZOLOFT 51zolpidem tartrate 112zolpidem tartrate er 112ZOLPIMIST 112ZOMIG 72ZOMIG ZMT 72ZONALON 195ZONEGRAN 47zonisamide 47ZONTIVITY 102ZORTRESS 177ZORVOLEX 183ZOSTAVAX 107ZOVIA 1-35 159ZOVIA 1-35E 159ZOVIRAX 25,111ZUBSOLV 12ZUMANDIMINE 160ZUPLENZ 56ZYCLARA 201ZYDELIG 93ZYKADIA 93ZYLET 22ZYMAXID 22ZYPITAMAG 69ZYPREXA 98ZYPREXA ZYDIS 98ZYTIGA 93ZYVOX 38

$3000 hsa silver $6750 hsa bronze $8550 catastrophic

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