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Atlas $1000 Atlas $3000 Atlas $6400 2021 Formulary (List of covered drugs) For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, 2021 ©2021 HealthPartners

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Page 1: Atlas $1000 Atlas $3000 Atlas $6400

Atlas $1000 Atlas $3000 Atlas $6400

2021 Formulary

(List of covered drugs)

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

Effective: October 1, 2021

©2021 HealthPartners

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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 Low Cost Generics o Tier 2 – Formulary High Cost Generics

o Tier 3 – Formulary Brands

o Tier 4 – Non-Formulary Generics & Brands

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

o Tier 5 – 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

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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. (10/21) ©2021 HealthPartners

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LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

ergoloid mesylates 2 PA

phenoxybenzamine hcl 2 PA

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

tamsulosin hcl 1

ANALGESICS AND ANTIPYRETICSANALGESICS AND ANTIPYRETICS, MISC.

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

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

TENCON 2 QL 6 TABS / 1 DAY

ZEBUTAL 2 QL 6 CAPS / 1 DAY

OPIATE AGONISTS

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

acetaminop-codeine 120-12 mg/5 1 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

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

ENDOCET 10-325 MG TABLET 2 QL 5 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

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

2 QL 8 TABS / 1 DAY

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONShydrocodone-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 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 4 mg tablet 2 QL 5 TABS / 1 DAY

hydromorphone 8 mg tablet 2 QL 2 TABS / 1 DAY

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

LORCET 2 QL 8 TABS / 1 DAY

LORCET HD 2 QL 8 TABS / 1 DAY

LORCET PLUS 2 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 40 MG TABLET DISPR 2 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 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) 3 QL 5 TABS / 1 DAY

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

MORPHINE SULFATE IR 30 MG TAB (BRAND) 3 QL 2 TABS / 1 DAY

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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 15 mg tablet 2 QL 3 TABS / 1 DAY

oxycodone hcl 20 mg tablet 2 QL 2 TABS / 1 DAY

oxycodone hcl 30 mg tablet 2 PA

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

oxycodone hcl 5 mg tablet 2 QL 8 TABS / 1 DAY

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

oxycodone hcl er (er 10 mg tablet, er 15 mg tablet, er 20mg tablet)

2 PA

oxycodone hcl er (er 30 mg tablet, er 40 mg tablet, er 60mg tablet, er 80 mg tablet)

1 PA

oxycodone hcl-aspirin 2 QL 8 TABS / 1 DAY

oxycodone-acetaminophen 10-325 2 QL 5 TABS / 1 DAY

oxycodone-acetaminophen 5-325 2 QL 8 TABS / 1 DAY

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

OXYCONTIN 3 PA

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

tramadol hcl-acetaminophen 2PA

AQ1 At least 12 yrs old; 8/ 1 DAY

OPIATE PARTIAL AGONISTS

buprenorphine 2 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

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANOREXIGENIC AGENTSAMPHETAMINE DERIVATIVES

LOMAIRA 2QL 3 TABS / 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

ANOREXIGENICS;RESPIRATORY,CNS STIMULANTSAMPHETAMINES

ADDERALL XR 2 QL 2 CAPS / 1 DAY

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

dextroamphetamine sulfate er 2 QL 4 CAPS / 1 DAY

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

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

3 QL 2 CAPS / 1 DAY

VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET) 3 QL 2 CHEW TABS / 1DAY

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

3 QL 1 CAP / 1 DAY

VYVANSE (40 MG TABLET, 50 MG TABLET, 60 MG TABLET) 3 QL 1 CHEW TAB / 1 DAY

ZENZEDI (5 MG TABLET, 10 MG TABLET) 2 QL 4 TABS / 1 DAY

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

RESPIRATORY AND CNS STIMULANTSCONCERTA (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

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

METADATE ER 2 QL 3 TABS / 1 DAY

methylphenidate er (la) (10mg cp, 20mg cp, 30mg cp) 2 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(la) 40mg cp 2 QL 1 CAP / 1 DAY

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 3 QL 3 CHEW TABS / 1DAY

QUILLICHEW ER 30 MG CHEW TAB 3 QL 2 CHEW TABS / 1DAY

QUILLICHEW ER 40 MG CHEW TAB 3 QL 1 CHEW TAB / 1 DAY

QUILLIVANT XR 3 QL 6 ML / 1 DAY

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

SUNOSI 3QL 1 TAB / 1 DAY

PA

WAKIX 5PA

S

ANTI-INFECTIVE AGENTSANTHELMINTICS

albendazole 2 PA

ivermectin 3 mg tablet 2

praziquantel 2

URINARY ANTI-INFECTIVES

fosfomycin tromethamine 2 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

trimethoprim 1

ANTI-INFECTIVES (EENT)ANTIBACTERIALS (EENT)

bacitracin 500 unit/gm ophth 2

bacitracin-polymyxin 2

BESIVANCE 3 PA

BLEPHAMIDE S.O.P. 3

CILOXAN 0.3% OINTMENT 3

CIPRO HC 3

ciprofloxacin 0.3% eye drop 1

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ciprofloxacin-dexamethasone 2

doxycycline hyclate 20 mg tab 1

erythromycin 0.5% eye ointment 2

moxifloxacin 0.5% eye drops 1

neomyc-polym-dexamet eye ointm 2

neomycin-bacitracin-polymyxin 2

neomycin-polymyxin-gramicidin 1

neomycin-polymyxin-hc ear susp 2

neomycin-polymyxin-hydrocort 2

ofloxacin (ear drops, eye drops) 2

polymyxin b sul-trimethoprim 2

sulfacetamide sodium (drops, ointment) 2

sulfacetamide-prednisolone 2

TOBRADEX EYE OINTMENT 3

tobramycin 0.3% eye drop 2

tobramycin-dexamethasone 2

TOBREX 0.3% EYE OINTMENT 3

ANTIVIRALS (EENT)trifluridine 2

ZIRGAN 3

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

chlorhexidine gluconate 1

PAROEX 2

PERIOGARD 2

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

CLEOCIN 100 MG VAGINAL OVULE 3

clind ph-benzoyl perox 1.2-5% 2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

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

2

clindamycin-benzoyl peroxide 2

erythromycin 2% gel 2

erythromycin 2% solution 1 QL 60 ML / 30 DAYS

erythromycin-benzoyl peroxide 2

gentamicin 0.1% cream 2 QL 30 GM / 30 DAYS

gentamicin 0.1% ointment 1

metronidazole (cream, lotion, topical gl) 2

metronidazole vaginal 0.75% gl 1

mupirocin 2% cream 2QL 30 GM / 30 DAYS

PA

mupirocin 2% ointment 1 QL 44 GM / RX

ROSADAN 0.75% CREAM 2

LOCAL ANTI-INFECTIVES, MISCELLANEOUSdermazene cream 2

hydrocortisone-iodoquinol 2

selenium sulfide 2.5% lotion 2

silver sulfadiazine 2

sodium sulf-sulfur cleanser 2

SSD 2

sulfacetamide sodium (sod top susp, sodium lotn) 2

SCABICIDES AND PEDICULICIDESmalathion 2

permethrin 2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANTI-INFLAMMATORY AGENTS (EENT)CORTICOSTEROIDS (EENT)

dexamethasone 0.1% eye drop 2

flunisolide 2

fluocinolone acetonide oil 2

fluorometholone 2

fluticasone prop 50 mcg spray 1

FML S.O.P. 3

loteprednol etabonate 0.5% drp 2

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

prednisolone sod 1% eye drop 1

EENT ANTI-INFLAMMATORY AGENTS, MISC.RESTASIS 3

RESTASIS MULTIDOSE 3

EENT NONSTEROIDAL ANTI-INFLAM. AGENTSbromfenac sodium 2

diclofenac 0.1% eye drops 1

flurbiprofen sodium 1

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

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)INTERLEUKIN ANTAGONISTS

DUPIXENT 200 MG/1.14 ML PEN 5

QL 2 PENS / 28 day(s)

PA

S

DUPIXENT 200 MG/1.14 ML SYRING 5

QL 2.28 ML / 28 DAYS

PA

S

FASENRA PEN 5PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

5PA

S

LEUKOTRIENE MODIFIERSmontelukast sod 10 mg tablet 1

montelukast sodium (4 mg granules, 4 mg tab chew, 5 mgtab chew)

2

MAST-CELL STABILIZERS

cromolyn 20 mg/2 ml neb soln 2 PA

cromolyn 4% eye drops 2

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

EUCRISA 3QL 60 GM / 30 DAYS

ST

CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)alclometasone dipropionate 2

anucort-hc 2

betamethasone diprop augmented (gel, lot, oin) 2

betamethasone dipropionate (crm, lot, oint) 2

betamethasone dp aug 0.05% crm 1

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

clobetasol emollient 0.05% crm 2

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

desonide (cream, lotion, ointment) 2

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

2

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

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluocinonide-e 2

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

hydrocortisone (2.5% cream, 2.5% lotion, 100 mg/60 ml) 2

hydrocortisone 2.5% ointment 1

hydrocortisone ac 25 mg supp 2

hydrocortisone butyrate (buty cream, butyr oint) 2

hydrocortisone valerate 2

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

mometasone furoate (cream, oint, soln) 2

PROCTO-MED HC 2

PROCTOSOL-HC 2

PROCTOZONE-HC 2

triamcinolone 0.1% paste 1

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

2

TRIDERM 2

ANTIARRHYTHMIC AGENTSCLASS IA ANTIARRHYTHMICS

disopyramide phosphate 2

NORPACE CR 3

quinidine sulfate 2

CLASS IB ANTIARRHYTHMICSmexiletine hcl 2

CLASS IC ANTIARRHYTHMICSflecainide acetate 2

propafenone hcl 2

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

2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

dofetilide 2

MULTAQ 3 PA

PACERONE (100 MG TABLET, 400 MG TABLET) 2

ANTIBACTERIALSAMINOGLYCOSIDE ANTIBIOTICS

neomycin sulfate 2

tobramycin 300 mg/5 ml ampule 5PA

S

QUINOLONE ANTIBIOTICS

CIPRO (5% SUSPENSION, 10% SUSPENSION) 3 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)

1

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

1

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

moxifloxacin hcl 2

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)sulfamethoxazole-tmp susp 2

sulfamethoxazole-trimethoprim (ds tablet, ss tablet) 1

sulfasalazine 2

sulfasalazine dr 2

SULFATRIM 2

TETRACYCLINE ANTIBIOTICSdemeclocycline hcl 2

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

doxycycline hyclate (50 mg cap, 100 mg cap, 100 mg tab) 1

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

2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSminocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule)

2

MONDOXYNE NL 100 MG CAPSULE 2

ANTIBACTERIALS, MISCELLANEOUSGLYCOPEPTIDE ANTIBIOTICS

vancomycin hcl 125 mg capsule 2

vancomycin hcl 250 mg capsule 1

LINCOMYCIN ANTIBIOTICS

clindamycin (pediatric) 2 AL1 Up to 12 yrs old

clindamycin hcl (150 mg capsule, 300 mg capsule) 1

clindamycin hcl 75 mg capsule 2

OXAZOLIDINONE ANTIBIOTICS

linezolid 100 mg/5 ml susp 2 PA

linezolid 600 mg tablet 2 QL 28 TABS / RX

SIVEXTRO 200 MG TABLET 3 PA

PLEUROMUTILINS

XENLETA 600 MG TABLET 3QL 10 TABS / RX

PA

RIFAMYCIN ANTIBIOTICS

XIFAXAN 3 PA

ANTICHOLINERGIC AGENTSANTIMUSCARINICS/ANTISPASMODICS

ANORO ELLIPTA 3

ATROVENT HFA 3 QL 1 INHALER / 25 DAYS

COMBIVENT RESPIMAT 3 QL 1 INHALER / 30 DAYS

CUVPOSA 3 PA

dicyclomine 10 mg capsule 2

dicyclomine hcl (10 mg/5 ml soln, 20 mg tablet) 1

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ed-spaz 2

glycopyrrolate (1 mg tablet, 2 mg tablet) 2

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 3

ipratropium br 0.02% soln 2

ipratropium-albuterol 2

oscimin 2

oscimin sl 2

oscimin sr 2

propantheline bromide 2

symax-sr 2

ANTICOAGULANTSANTICOAGULANTS, MISCELLANEOUS

fondaparinux sodium 2QL 1 SYRINGE / 1 DAY

PA

COUMARIN DERIVATIVESjantoven 1

warfarin sodium 1

DIRECT FACTOR XA INHIBITORS

ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 3 QL 2 TABS / 1 DAY

ELIQUIS DVT-PE TREAT START 5MG 3 QL 1 RX / 30 DAYS

XARELTO (10 MG TABLET, 20 MG TABLET) 3 QL 1 TAB / 1 DAY

XARELTO (2.5 MG TABLET, 15 MG TABLET) 3 QL 2 TABS / 1 DAY

XARELTO DVT-PE TREAT START 30D 3 QL 51 TABS / 30 DAYS

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DIRECT THROMBIN INHIBITORS

PRADAXA 3 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

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

ANTICONVULSANTSANTICONVULSANTS, MISCELLANEOUS

APTIOM 3 PA

BANZEL 200 MG TABLET 3QL 16 TABS / 1 DAY

PA

BANZEL 400 MG TABLET 3QL 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)

3 PA

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

2

carbamazepine er 2

DIACOMIT 250 MG CAPSULE 5

QL 12 CAPS / 1 DAY

PA

S

DIACOMIT 250 MG POWDER PACKET 5

QL 12 PACKETS / 1 DAY

PA

S

DIACOMIT 500 MG CAPSULE 5

QL 6 CAPS / 1 DAY

PA

S

PAGE 15 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DIACOMIT 500 MG POWDER PACKET 5

QL 6 PACKETS / 1 DAY

PA

S

divalproex sodium (dr 125 mg cap sprnk, dr 125 mgcp(sprnk))

1

divalproex sodium (dr 125 mg tab, dr 250 mg tab, dr 500mg tab)

2

divalproex sodium er 1

EPIDIOLEX 5

QL 20 ML / 1 DAY

PA

S

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

2

FINTEPLA 5PA

S

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

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

lamotrigine 2

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

2

levetiracetam er 1

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

2

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

PAGE 16 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSpregabalin (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

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

SUBVENITE 2

tiagabine hcl 2

topiramate 1

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

2

vigabatrin 5PA

S

VIGADRONE 5PA

S

VIMPAT (150 MG TABLET, 200 MG TABLET) 3 QL 2 TABS / 1 DAY

VIMPAT 10 MG/ML SOLUTION 3 QL 40 ML / 1 DAY

VIMPAT 100 MG TABLET 3 QL 4 TABS / 1 DAY

VIMPAT 50 MG TABLET 3 QL 8 TABS / 1 DAY

zonisamide 1

BARBITURATES (ANTICONVULSANTS)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

PAGE 17 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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)

1 QL 6 TABS / 1 DAY

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

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

NAYZILAM 3QL 2 BOTTLES / RX

PA

HYDANTOINSDILANTIN 30 MG CAPSULE 3

phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4ml susp, 125 mg/5 ml susp)

2

phenytoin sodium extended 2

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

ANTIDEPRESSANTSANTIDEPRESSANTS, MISCELLANEOUS

bupropion hcl 2

bupropion hcl sr 2

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

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

2

MONOAMINE OXIDASE INHIBITORSphenelzine sulfate 2

tranylcypromine sulfate 2

SEL.SEROTONIN,NOREPI REUPTAKE INHIBITORdesvenlafaxine suc er 100 mg tablet (generic for pristiq) 1

desvenlafaxine suc er 25 mg tablet (generic for pristiq) 1

desvenlafaxine suc er 50 mg tablet (generic for pristiq) 1

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

FETZIMA 3 PA

PAGE 18 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

venlafaxine hcl 2

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

2

SELECTIVE-SEROTONIN REUPTAKE INHIBITORScitalopram hbr (10 mg tablet, 20 mg tablet, 40 mg tablet) 1

citalopram hbr (10 mg/5 ml soln, 20 mg/10 ml sol) 2

escitalopram oxalate (5 mg tablet, 10 mg tablet, 20 mgtablet)

1

escitalopram oxalate 5 mg/5 ml 2

fluoxetine 20 mg/5 ml solution 2

fluoxetine hcl (10 mg capsule, 20 mg capsule, 40 mgcapsule)

1

fluvoxamine maleate 2

paroxetine hcl 1

PAXIL 10 MG/5 ML SUSPENSION 3

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

1

SEROTONIN MODULATORSnefazodone hcl 2

trazodone hcl 1

TRINTELLIX 3 PA

VIIBRYD 3 PA

TRICYCLICS, OTHER NOREPI-RU INHIBITORSamitriptyline hcl 2

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

imipramine hcl 2

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

2

PAGE 19 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANTIDIABETIC AGENTSALPHA-GLUCOSIDASE INHIBITORS

acarbose 1

miglitol 2

BIGUANIDESmetformin hcl 1,000 mg tablet (generic for glucophage) 1

metformin hcl 500 mg tablet (generic for glucophage) 1

metformin hcl 850 mg tablet 1

metformin hcl er 1

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

JENTADUETO 3 QL 2 TABS / 1 DAY

JENTADUETO XR 3 QL 2 TABS / 1 DAY

TRADJENTA 3 QL 1 TAB / 1 DAY

INCRETIN MIMETICS

BYDUREON BCISE 3 QL 3.4 ML / 28 DAYS

BYDUREON PEN 3 QL 4 PEN / 28 DAYS

BYETTA 10 MCG DOSE PEN INJ 3 QL 2.4 ML / 30 DAYS

BYETTA 5 MCG DOSE PEN INJ 3 QL 1.2 ML / 30 DAYS

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

3 QL 3 ML / 28 DAYS

OZEMPIC 0.25-0.5 MG/DOSE PEN 3 QL 1.5 ML / 28 DAYS

RYBELSUS 3 QL 1 TAB / 1 DAY

TRULICITY 3 QL 2 ML / 28 DAYS

VICTOZA 2-PAK 3 QL 9 ML / 30 DAYS

PAGE 20 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VICTOZA 3-PAK 3 QL 9 ML / 30 DAYS

MEGLITINIDESnateglinide 2

repaglinide 2

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

GLYXAMBI 3 QL 1 TAB / 1 DAY

INVOKAMET 3 QL 2 TABS / 1 DAY

INVOKAMET XR 3 QL 2 TABS / 1 DAY

INVOKANA 3 QL 1 TAB / 1 DAY

JARDIANCE 3 QL 1 TAB / 1 DAY

SYNJARDY 3 QL 2 TABS / 1 DAY

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

3 QL 1 TAB / 1 DAY

SYNJARDY XR (5-1,000 MG TABLET, 12.5-1,000 MG TAB) 3 QL 2 TABS / 1 DAY

TRIJARDY XR (10-5-1,000 MG TAB, 25-5-1,000 MG TAB) 3 QL 1 TAB / 1 DAY

TRIJARDY XR (5-2.5-1,000 MG TAB, 12.5-2.5-1,000 MG) 3 QL 2 TABS / 1 DAY

SULFONYLUREASglimepiride 1

glipizide 1

glipizide er 1

glipizide xl 1

glipizide-metformin 1

glyburide 2 PA

glyburide micronized 2 PA

glyburide-metformin hcl 2 PA

PAGE 21 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

THIAZOLIDINEDIONESpioglitazone hcl 1

pioglitazone-glimepiride 2

pioglitazone-metformin 2

ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS

ondansetron 4 mg/5 ml solution 1

ondansetron hcl (4 mg tablet, 8 mg tablet, 24 mg tablet) 2

ondansetron odt 2

ANTIEMETICS, MISCELLANEOUS

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

dronabinol 10 mg capsule 1 QL 4 CAPS / 1 DAY

scopolamine 2

ANTIHISTAMINES (GI DRUGS)prochlorperazine 2

prochlorperazine maleate 1

trimethobenzamide hcl 2

NEUROKININ-1 RECEPTOR ANTAGONISTSaprepitant 2

EMEND 125 MG POWDER PACKET 3

ANTIFUNGAL (SYSTEMIC)ALLYLAMINE ANTIFUNGALS

terbinafine hcl 1

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

griseofulvin ultramicrosize 2

AZOLE ANTIFUNGALS

CRESEMBA 186 MG CAPSULE 3 PA

fluconazole (10 mg/ml susp, 40 mg/ml susp) 2

PAGE 22 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSfluconazole (50 mg tablet, 100 mg tablet, 150 mg tablet,200 mg tablet)

1

itraconazole 100 mg capsule 2

ketoconazole 200 mg tablet 1

posaconazole 2 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 1

ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)AZOLES (SKIN AND MUCOUS MEMBRANE)

clotrimazole 10 mg troche 2

clotrimazole-betamethasone crm 2

econazole nitrate 2 QL 85 GM / 30 DAYS

ketoconazole 2% cream 1 QL 60 GM / 30 DAYS

ketoconazole 2% shampoo 2

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

HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)ciclopirox (0.77% cream, 0.77% gel, 1% shampoo, 8%solution)

2

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

POLYENES (SKIN AND MUCOUS MEMBRANE)nystatin (unit/gm cream, unit/gm oint) 2

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

ANTIGLAUCOMA AGENTSALPHA-ADRENERGIC AGONISTS (EENT)

brimonidine tartrate 2

PAGE 23 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

carteolol hcl 1

levobunolol hcl 1

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

timolol maleate 0.25% eye drop (generic for timoptic) 1

timolol maleate 0.5% eye drops (generic for timoptic) 1

CARBONIC ANHYDRASE INHIBITORS (EENT)acetazolamide 1

acetazolamide er 2

dorzolamide hcl 2

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

methazolamide 2

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

PROSTAGLANDIN ANALOGSbimatoprost 0.03% eye drops 2

latanoprost 2

LUMIGAN 3

travoprost 2

ZIOPTAN 3 PA

RHO KINASE INHIBITORSRHOPRESSA 3

ROCKLATAN 3

ANTIHEMORRHAGIC AGENTSHEMOSTATICS

ADVATE 5PA

S

ADYNOVATE 5PA

S

PAGE 24 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AFSTYLA 5PA

S

ALPHANATE 5PA

S

ALPHANINE SD 5PA

S

ALPROLIX 5PA

S

BENEFIX 5PA

S

COAGADEX 5PA

S

CORIFACT 5PA

S

ELOCTATE 5PA

S

ESPEROCT 5PA

S

FEIBA NF 5PA

S

HELIXATE FS 5PA

S

HEMLIBRA 5PA

S

HEMOFIL M 5PA

S

HUMATE-P 5PA

S

PAGE 25 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

IDELVION 5PA

S

IXINITY 5PA

S

JIVI 5PA

S

KOATE 5PA

S

KOGENATE FS 5PA

S

KOVALTRY 5PA

S

MONONINE 5 S

NOVOEIGHT 5PA

S

NOVOSEVEN RT 5PA

S

NUWIQ 5PA

S

OBIZUR 5PA

S

PROFILNINE 5PA

S

REBINYN 5PA

S

RECOMBINATE 5PA

S

RIXUBIS 5PA

S

PAGE 26 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SEVENFACT 5PA

S

tranexamic acid 650 mg tablet 2 QL 30 TABS / RX

TRETTEN 5PA

S

VONVENDI 5PA

S

WILATE 5PA

S

XYNTHA 5PA

S

XYNTHA SOLOFUSE 5PA

S

ANTIHYPOGLYCEMIC AGENTSGLYCOGENOLYTIC AGENTS

BAQSIMI 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 3

GVOKE HYPOPEN 1-PACK 3

GVOKE HYPOPEN 2-PACK 3

GVOKE PFS 1-PACK SYRINGE 3

GVOKE PFS 2-PACK SYRINGE 3

ZEGALOGUE AUTOINJECTOR 3

ZEGALOGUE SYRINGE 3

PAGE 27 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANTILIPEMIC AGENTSANTILIPEMIC AGENTS, MISCELLANEOUS

icosapent ethyl 2 PA

JUXTAPID 5PA

S

omega-3 acid ethyl esters 1

TRIKLO 1

VASCEPA 3 PA

BILE ACID SEQUESTRANTScholestyramine (packet, powder) 2

cholestyramine light (packet, powder) 2

colestipol hcl 1 gm tablet 2

PREVALITE (PACKET, POWDER) 2

CHOLESTEROL ABSORPTION INHIBITORSezetimibe 1

FIBRIC ACID DERIVATIVESfenofibrate (48 mg tablet, 67 mg capsule, 134 mg capsule,145 mg tablet, 200 mg capsule)

1

fenofibrate (54 mg tablet, 160 mg tablet) 2

gemfibrozil 1

HMG-COA REDUCTASE INHIBITORS

atorvastatin calcium (10 mg tablet, 20 mg tablet) 1 ACA Affordable Care Act

atorvastatin calcium (40 mg tablet, 80 mg tablet) 1

lovastatin (20 mg tablet, 40 mg tablet) 1 ACA Affordable Care Act

lovastatin 10 mg tablet 1

pravastatin sodium 1 ACA Affordable Care Act

rosuvastatin calcium (20 mg tab, 40 mg tab) 1

rosuvastatin calcium (5 mg tab, 10 mg tab) 1 ACA Affordable Care Act

PAGE 28 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 ACA Affordable Care Act

simvastatin (5 mg tablet, 80 mg tablet) 1

PCSK9 INHIBITORS

REPATHA PUSHTRONEX 3QL 1 PEN / 28 DAYS

PA

REPATHA SURECLICK 3QL 2 PENS / 28 DAYS

PA

REPATHA SYRINGE 3QL 2 PENS / 28 DAYS

PA

ANTIMIGRAINE AGENTSCALCITONIN GENE-RELATED PEPTIDE ANTAG.

AJOVY AUTOINJECTOR 5

QL 1.5 ML / 30 DAYS

PA

S

AJOVY SYRINGE 5

QL 1.5 ML / 30 DAYS

PA

S

EMGALITY 120 MG/ML SYRINGE 5

QL 1 ML / 30 DAYS

PA

S

EMGALITY PEN 5

QL 1 ML / 30 DAYS

PA

S

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

5

QL 3 ML / 30 DAYS

PA

S

NURTEC ODT 3QL 8 TABS / 30 DAYS

PA

PAGE 29 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SELECTIVE SEROTONIN AGONISTS

eletriptan hbr 2QL 12 TABS / 28 DAYS

PA

naratriptan hcl 1 QL 12 TABS / 30 DAYS

REYVOW 3QL 8 TABS / 30 DAYS

PA

rizatriptan 2 QL 12 TABS / 28 DAYS

sumatriptan 2 QL 12 ML / 30 DAYS

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

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

zolmitriptan odt 2 QL 12 TABS / 28 DAYS

ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, MISCELLANEOUS

dapsone (25 mg tablet, 100 mg tablet) 2

ANTITUBERCULOSIS AGENTS

cycloserine 2 PA

ethambutol hcl 1

isoniazid (100 mg tablet, 300 mg tablet) 1

isoniazid 50 mg/5 ml solution 2

pretomanid 2 PA

PRIFTIN 3

pyrazinamide 2

rifabutin 2

rifampin (150 mg capsule, 300 mg capsule) 1

SIRTURO 3 PA

PAGE 30 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TRECATOR 3 PA

ANTINEOPLASTIC AGENTS

abiraterone 500 mg tablet 2

QL 2 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

abiraterone acetate 250 mg tab 2

QL 4 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

AFINITOR 10 MG TABLET 3

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

AFINITOR DISPERZ (2 MG TABLET, 5 MG TABLET) 3

QL 2 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

AFINITOR DISPERZ 3 MG TABLET 3

QL 3 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

ALECENSA 3

QL 8 CAPS / 30 DAYS

PA

S

ONC Oncology

PAGE 31 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

anastrozole 1 ACA Affordable Care Act

AYVAKIT 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

BALVERSA 3PA

S

bicalutamide 1

BOSULIF (400 MG TABLET, 500 MG TABLET) 3

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

BOSULIF 100 MG TABLET 3

QL 4 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

BRAFTOVI 50 MG CAPSULE 3

QL 2 CAPS / 1 DAY

PA

S

BRAFTOVI 75 MG CAPSULE 3

QL 6 CAPS / 1 DAY

PA

S

BRUKINSA 5

PA

S

ONC Oncology

CABOMETYX 3

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

PAGE 32 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

capecitabine 2S

ONC Oncology

CAPRELSA 100 MG TABLET 3

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

CAPRELSA 300 MG TABLET 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

COMETRIQ 100 MG DAILY-DOSE PK 3

QL 2 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

COMETRIQ 140 MG DAILY-DOSE PK 3

QL 4 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

COMETRIQ 60 MG DAILY-DOSE PACK 3

QL 3 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

COPIKTRA 3

QL 2 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

COTELLIC 3

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

PAGE 33 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCYCLOPHOSPHAMIDE (25 MG CAPSULE, 25 MG TABLET,50 MG CAPSULE, 50 MG TABLET)

2

DAURISMO 100 MG TABLET 3

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

DAURISMO 25 MG TABLET 3

QL 3 TABS / 1 DAY

PA

S

TD Trial Drug

EMCYT 3

ERIVEDGE 3

QL 1 CAP / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

ERLEADA 3

PA

S

ONC Oncology

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

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

erlotinib hcl 25 mg tablet 2

QL 3 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

etoposide 50 mg capsule 2

PAGE 34 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

exemestane 2 ACA Affordable Care Act

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

flutamide 2

FOTIVDA 3

QL 21 CAPS / 28 DAYS

PA

S

ONC Oncology

GAVRETO 3

PA

S

ONC Oncology

GILOTRIF 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

GLEOSTINE 3

HYCAMTIN 3S

ONC Oncology

hydroxyurea 2

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

3

QL 21 CAPS / 28 DAYS

PA

S

ONC Oncology

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

3

QL 21 TABS / 28 DAYS

PA

S

ONC Oncology

ICLUSIG (10 MG TABLET, 15 MG TABLET) 3

QL 2 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

PAGE 35 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ICLUSIG (30 MG TABLET, 45 MG TABLET) 3

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

IDHIFA 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

imatinib mesylate 2

S

TD Trial Drug

ONC Oncology

IMBRUVICA (420 MG TABLET, 560 MG TABLET) 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

IMBRUVICA 140 MG CAPSULE 3

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

IMBRUVICA 70 MG CAPSULE 3

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

INLYTA 1 MG TABLET 3

QL 6 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

INLYTA 5 MG TABLET 3

QL 4 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

PAGE 36 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

INQOVI 3

QL 5 TABS / 28 DAYS

PA

S

ONC Oncology

INREBIC 3

PA

S

ONC Oncology

IRESSA 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

JAKAFI 3

QL 2 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

KISQALI 200 MG DAILY DOSE 3

QL 21 TABS / 28 DAYS

PA

S

ONC Oncology

KISQALI 400 MG DAILY DOSE 3

QL 42 TABS / 28 DAYS

PA

S

ONC Oncology

KISQALI 600 MG DAILY DOSE 3

QL 63 TABS / 28 DAYS

PA

S

ONC Oncology

KISQALI FEMARA 200 MG CO-PACK 3

QL 49 TABS / 28 DAYS

PA

S

ONC Oncology

PAGE 37 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

KISQALI FEMARA 400 MG CO-PACK 3

QL 70 TABS / 28 DAYS

PA

S

ONC Oncology

KISQALI FEMARA 600 MG CO-PACK 3

QL 91 TABS / 28 DAYS

PA

S

ONC Oncology

KOSELUGO 10 MG CAPSULE 3

QL 8 CAPS / 1 DAY

PA

S

ONC Oncology

KOSELUGO 25 MG CAPSULE 3

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

lapatinib 2

QL 6 TABS / 1 DAY

PA

S

ONC Oncology

letrozole 2 ACA Affordable Care Act

LEUKERAN 3

LONSURF 15 MG-6.14 MG TABLET 3

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

LONSURF 20 MG-8.19 MG TABLET 3

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

LORBRENA 100 MG TABLET 3

QL 1 TAB / 1 DAY

PA

S

TD Trial DrugPAGE 38 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LORBRENA 25 MG TABLET 3

QL 3 TABS / 1 DAY

PA

S

TD Trial Drug

LUMAKRAS 3

PA

S

ONC Oncology

LYNPARZA 3

QL 4 TABS / 1 DAY

PA

S

TD Trial Drug

LYSODREN 3PA

S

MATULANE 3

QL 2 CAPS / 1 DAY

PA

S

ONC Oncology

MEKINIST 0.5 MG TABLET 3

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

MEKINIST 2 MG TABLET 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

MEKTOVI 3

QL 6 TABS / 1 DAY

PA

S

melphalan 2

mercaptopurine 2

PAGE 39 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSmethotrexate (2.5 mg tablet, 50 mg/2 ml vial, 250 mg/10ml vial)

2

methotrexate sodium 2

MYLERAN 3

NERLYNX 3

QL 6 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

NEXAVAR 3

QL 4 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

NINLARO 3

QL 3 CAPS / 28 DAYS

PA

S

ONC Oncology

NUBEQA 3PA

S

ODOMZO 3

QL 1 CAP / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

ONUREG 3

QL 14 TABS / 28 DAYS

PA

S

ONC Oncology

PEMAZYRE 3

QL 14 TABS / 21 DAYS

PA

S

ONC Oncology

PAGE 40 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PICATO 3 PA

POMALYST 3

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

QINLOCK 3

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

RASUVO 3 PA

RETEVMO 40 MG CAPSULE 3

QL 6 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

RETEVMO 80 MG CAPSULE 3

QL 4 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

REVLIMID 3

QL 1 CAP / 1 DAY

S

ONC Oncology

ROZLYTREK 3

PA

S

ONC Oncology

RYDAPT 3

PA

S

ONC Oncology

SPRYCEL 3

PA

S

TD Trial Drug

ONC Oncology

PAGE 41 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

STIVARGA 3

PA

S

ONC Oncology

sunitinib malate 2

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

TABLOID 3

TABRECTA 3

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TAFINLAR 3

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

TAGRISSO 3

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

TASIGNA 3

PA

S

TD Trial Drug

ONC Oncology

TAZVERIK 3

QL 8 TABS / 1 DAY

PA

S

ONC Oncology

temozolomide 2S

ONC Oncology

PAGE 42 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TEPMETKO 3

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TIBSOVO 3

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

tretinoin 10 mg capsule 2S

ONC Oncology

TRUSELTIQ 3

PA

S

ONC Oncology

TURALIO 3PA

S

UKONIQ 3

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

VALCHLOR 3

QL 120 GM / 30 DAYS

PA

S

ONC Oncology

VERZENIO 3

QL 56 TABS / 28 DAYS

PA

S

ONC Oncology

VITRAKVI 100 MG CAPSULE 3

QL 2 CAPS / 1 DAY

PA

S

TD Trial Drug

PAGE 43 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VITRAKVI 20 MG/ML SOLUTION 3

QL 300 ML / 30 DAYS

PA

S

TD Trial Drug

VITRAKVI 25 MG CAPSULE 3

QL 6 CAPS / 1 DAY

PA

S

TD Trial Drug

VIZIMPRO 3

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

VOTRIENT 3

QL 4 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

WELIREG 3

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

XALKORI 3

QL 2 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

XOSPATA 3

QL 3 TABS / 1 DAY

PA

S

XPOVIO 3

PA

S

ONC Oncology

PAGE 44 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

XTANDI 3

PA

S

TD Trial Drug

ONC Oncology

ZEJULA 3

QL 3 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

ZELBORAF 3

QL 8 TABS / 30 DAYS

PA

S

ONC Oncology

ZOLINZA 3

QL 4 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

ZYKADIA 150 MG CAPSULE 3

QL 3 CAPS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

ZYKADIA 150 MG TABLET 3

QL 3 TABS / 1 DAY

PA

S

TD Trial Drug

ONC Oncology

PAGE 45 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANTIPARKINSONIAN AGENTS (CNS)ADAMANTANES (CNS)

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

2

amantadine 100 mg capsule 1

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

2

trihexyphenidyl 2 mg/5 ml soln 2

trihexyphenidyl hcl (2 mg tablet, 5 mg tablet) 1

CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.entacapone 2

DOPAMINE PRECURSORScarbidopa-levodopa 2

carbidopa-levodopa er 2

carbidopa-levodopa-entacapone 2

INBRIJA 5PA

S

RYTARY 3 ST

MONOAMINE OXIDASE B INHIBITORS

rasagiline mesylate 2 PA

selegiline hcl 2

ANTIPROTOZOALSANTIMALARIALS

atovaquone-proguanil hcl 2

chloroquine phosphate 2

hydroxychloroquine 200 mg tab 2

mefloquine hcl 1

ANTIPROTOZOALS, MISCELLANEOUS

ALINIA 100 MG/5 ML SUSPENSION 3 PA

PAGE 46 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

atovaquone 2

benznidazole 2 PA

LAMPIT 3 PA

metronidazole (250 mg tablet, 500 mg tablet) 2

nitazoxanide 2 PA

ANTIPSYCHOTIC AGENTSANTIPSYCHOTICS, MISCELLANEOUS

loxapine 2 AL1 At least 13 yrs old

ATYPICAL ANTIPSYCHOTICSaripiprazole (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

AL1 At least 13 yrs old

asenapine maleate 2 PA

CAPLYTA 3QL 1 CAP / 1 DAY

PA

clozapine 2 AL1 At least 13 yrs old

clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet, odt100 mg tablet, odt 150 mg tablet)

2PA

AL1 At least 13 yrs old

clozapine odt 200 mg tablet 1PA

AL1 At least 13 yrs old

FANAPT 3 PA

LATUDA 3QL 1 TAB / 1 DAY

PA

NUPLAZID 5

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)

2 AL1 At least 13 yrs old

PAGE 47 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

olanzapine odt 2PA

AL1 At least 13 yrs old

paliperidone er 1 PA

quetiapine fumarate 2 AL1 At least 13 yrs old

quetiapine fumarate er 2 AL1 At least 13 yrs old

REXULTI 3 PA

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

1 AL1 At least 13 yrs old

risperidone 1 mg/ml solution 2 AL1 At least 13 yrs old

risperidone odt 2PA

AL1 At least 13 yrs old

SECUADO 3 PA

VERSACLOZ 3PA

AL1 At least 13 yrs old

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

PA

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

3QL 1 CAP / 1 DAY

PA

ziprasidone hcl 2 AL1 At least 13 yrs old

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, 5 mg tablet,10 mg tablet)

2 AL1 At least 13 yrs old

fluphenazine hcl (2.5 mg/5 ml elix, 5 mg/ml conc) 1 AL1 At least 13 yrs old

PAGE 48 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

perphenazine 1

thioridazine hcl 1 AL1 At least 13 yrs old

trifluoperazine hcl 2 AL1 At least 13 yrs old

THIOXANTHENES

thiothixene 1 AL1 At least 13 yrs old

ANTIRETROVIRALSHIV ENTRY AND FUSION INHIBITORS

FUZEON 5 S

RUKOBIA 3 PA

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

3

HIV INTEGRASE INHIBITOR ANTIRETROVIRALSISENTRESS 3

ISENTRESS HD 3

JULUCA 3

TIVICAY 3

TIVICAY PD 3

VOCABRIA 3

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.EDURANT 3

efavirenz (50 mg capsule, 600 mg tablet) 2

efavirenz 200 mg capsule 1

etravirine 2

INTELENCE 25 MG TABLET 3

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

nevirapine er 2

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

abacavir-lamivudine 1

PAGE 49 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

abacavir-lamivudine-zidovudine 2

BIKTARVY 3

COMPLERA 3

DESCOVY 3 ACA Affordable Care Act

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

EPIVIR HBV 25 MG/5 ML SOLN 3

GENVOYA 3

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

2

lamivudine hbv 2

lamivudine-zidovudine 2

ODEFSEY 3

STRIBILD 3

tenofovir disoproxil fumarate 1

TRIUMEQ 3

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

3

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

3

zidovudine (50 mg/5 ml syrup, 300 mg tablet) 2

zidovudine 100 mg capsule 1

HIV PROTEASE INHIBITOR ANTIRETROVIRALSAPTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3

atazanavir sulfate 2

EVOTAZ 3

fosamprenavir calcium 2

PAGE 50 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

INVIRASE 3

KALETRA (100-25 MG TABLET, 200-50 MG TABLET) 3

LEXIVA 50 MG/ML SUSPENSION 3

lopinavir-ritonavir (lopinavir-ritonavir 80-20mg/ml,lopinavir-ritonavr 100-25mg tb, lopinavir-ritonavr 200-50mg tb)

2

NORVIR 80 MG/ML SOLUTION 3

PREZCOBIX 3

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

3

REYATAZ 50 MG POWDER PACKET 3

ritonavir 2

SYMTUZA 3

ANTITHROMBOTIC AGENTSANTITHROMBOTIC AGENTS, MISCELLANEOUS

CABLIVI 11 MG KIT 5PA

S

PLATELET-AGGREGATION INHIBITORSBRILINTA 3

cilostazol 2

clopidogrel 75 mg tablet 1

prasugrel hcl 2

ZONTIVITY 3 PA

PLATELET-REDUCING AGENTSanagrelide hcl 2

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

GRASTEK 3 PA

ODACTRA 3 PA

PALFORZIA 5PA

S

PAGE 51 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

RAGWITEK 3 PA

TOXOIDSADACEL TDAP 3

BOOSTRIX TDAP 3

DAPTACEL DTAP 3

diphtheria-tetanus toxoids-ped 3

INFANRIX DTAP 3

tdvax 3

TENIVAC SYRINGE 3

VAXELIS 3

VACCINESACTHIB 3

adenovirus type 4 3

adenovirus type 4 and type 7 3

adenovirus type 7 3

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

AFLURIA QUAD 2019-20 (6-35MO) 3 ACA Affordable Care Act

AFLURIA QUAD 2019-2020 3 ACA Affordable Care Act

AFLURIA QUAD 2020-2021 3 ACA Affordable Care Act

AFLURIA QUAD 2020-21 (3YR UP) 3 ACA Affordable Care Act

AFLURIA QUAD 2020-21 (6-35MO) 3 ACA Affordable Care Act

AFLURIA QUAD 2021-2022 3 ACA Affordable Care Act

AFLURIA QUAD 2021-22 (3YR UP) 3 ACA Affordable Care Act

AFLURIA QUAD 2021-22 (6-35MO) 3 ACA Affordable Care Act

ASTRAZENECA COVID19 VAC(UNAPP) 3

BEXSERO 3

COMIRNATY 3

PAGE 52 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ENGERIX-B ADULT 3

ENGERIX-B PEDIATRIC-ADOLESCENT 3

FLUAD 2019-2020 3 ACA Affordable Care Act

FLUAD 2020-2021 3 ACA Affordable Care Act

FLUAD QUAD 2020-2021 3 ACA Affordable Care Act

FLUAD QUAD 2021-2022 3 ACA Affordable Care Act

FLUARIX QUAD 2019-2020 3 ACA Affordable Care Act

FLUARIX QUAD 2020-2021 3 ACA Affordable Care Act

FLUARIX QUAD 2021-2022 3 ACA Affordable Care Act

FLUBLOK QUAD 2019-2020 3 ACA Affordable Care Act

FLUBLOK QUAD 2020-2021 3 ACA Affordable Care Act

FLUBLOK QUAD 2021-2022 3 ACA Affordable Care Act

FLUCELVAX QUAD 2019-2020 (SYR, VIAL) 3 ACA Affordable Care Act

FLUCELVAX QUAD 2020-2021 (SYR, VIAL) 3 ACA Affordable Care Act

FLUCELVAX QUAD 2021-2022 (SYR, VIAL) 3 ACA Affordable Care Act

FLULAVAL QUAD 2019-2020 (SYR, VIAL) 3 ACA Affordable Care Act

FLULAVAL QUAD 2020-2021 3 ACA Affordable Care Act

FLULAVAL QUAD 2021-2022 3 ACA Affordable Care Act

FLUMIST QUAD 2019-2020 3 ACA Affordable Care Act

FLUMIST QUAD 2020-2021 3 ACA Affordable Care Act

FLUMIST QUAD 2021-2022 3 ACA Affordable Care Act

FLUZONE HIGH-DOSE 2019-2020 3 ACA Affordable Care Act

FLUZONE HIGH-DOSE QUAD 2020-21 3 ACA Affordable Care Act

FLUZONE HIGH-DOSE QUAD 2021-22 3 ACA Affordable Care Act

PAGE 53 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FLUZONE QUAD 2019-2020 3 ACA Affordable Care Act

FLUZONE QUAD 2020-2021 3 ACA Affordable Care Act

FLUZONE QUAD 2021-2022 3 ACA Affordable Care Act

FLUZONE QUAD PEDI 2019-2020 3 ACA Affordable Care Act

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

3 ACA Affordable Care Act

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

3 ACA Affordable Care Act

GARDASIL 9 3

HAVRIX 3

HEPLISAV-B 3

HIBERIX 3

IPOL 3 ACA Affordable Care Act

JANSSEN COVID-19 VACCINE (EUA) 3

KINRIX 3

M-M-R II VACCINE 3 ACA Affordable Care Act

MENACTRA 3

MENQUADFI 3 ACA Affordable Care Act

MENVEO A-C-Y-W-135-DIP 3

MENVEO MENA COMPONENT 3 ACA Affordable Care Act

MENVEO MENCYW-135 COMPONENT 3 ACA Affordable Care Act

MODERNA COVID-19 VACCINE (EUA) 3

NOVAVAX COVID19 VAC,ADJ(UNAPP) 3

PEDIARIX 3

PEDVAXHIB 3

PENTACEL 3

PENTACEL ACTHIB COMPONENT 3

PENTACEL DTAP-IPV COMPONENT 3

PAGE 54 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PFIZER COVID-19 VACCINE (EUA) 3

PNEUMOVAX 23 3

PREVNAR 13 3

PREVNAR 20 3

PROQUAD 3

QUADRACEL DTAP-IPV 3 ACA Affordable Care Act

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

3

RECOMBIVAX HB (5 MCG/0.5 ML VL, 10 MCG/ML VIAL) 3 ACA Affordable Care Act

ROTARIX 3

ROTATEQ 3

SHINGRIX 3 QL 1 KIT / RX

SHINGRIX GE ANTIGEN COMPONENT 3 QL 1 KIT / RX

TRUMENBA 3

TWINRIX 3

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

3

VAQTA 25 UNITS/0.5 ML VIAL 3 ACA Affordable Care Act

VARIVAX VACCINE 3

VAXCHORA ACTIVE COMPONENT 3

VAXCHORA VACCINE 3

VAXNEUVANCE 3

VIVOTIF 3

ZOSTAVAX 3

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

TALICIA 3 PA

PAGE 55 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HISTAMINE H2-ANTAGONISTScimetidine (300 mg tablet, 300 mg/5 ml soln, 400 mgtablet, 400 mg/6.67 ml soln, 800 mg tablet)

2

famotidine (20 mg tablet, 40 mg tablet) 1

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

PROSTAGLANDINSmisoprostol 2

PROTECTANTSsucralfate 1 gm tablet 2

sucralfate 1 gm/10 ml susp 2 PA

PROTON-PUMP INHIBITORSesomeprazole 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

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

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

2

pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 1

rabeprazole sod dr 20 mg tab 2

ANTIVIRALS (SYSTEMIC)ADAMANTANE ANTIVIRALS

rimantadine hcl 2

ANTIVIRALS, MISCELLANEOUSPREVYMIS (240 MG TABLET, 480 MG TABLET) 3

TPOXX (NATIONAL STOCKPILE) 3 PA

INTERFERON ANTIVIRALS

ALFERON N 5 S

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

5 S

PAGE 56 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PEGASYS 5PA

S

PEGASYS PROCLICK 5PA

S

PEGINTRON 5PA

S

SYLATRON 3S

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 3 QL 20 CAPS / 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 0.05 MG/ML SOLUTION 3

entecavir 1

famciclovir 2

ribavirin (200 mg capsule, 200 mg tablet) 5 S

valacyclovir 2

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

VEMLIDY 3

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

buspirone hcl 2

eszopiclone 2

PAGE 57 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydroxyzine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1

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

2

hydroxyzine pamoate 2

ramelteon 2 QL 1 TAB / 1 DAY

zaleplon 2

zolpidem tartrate (5 mg tablet, 10 mg tablet) 1

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

BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

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

alprazolam 2 mg tablet 1 QL 3 TABS / 1 DAY

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

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

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

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

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

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

chlordiazepoxide 10 mg capsule 1 QL 6 CAPS / 1 DAY

chlordiazepoxide 25 mg capsule 1 QL 4 CAPS / 1 DAY

chlordiazepoxide 5 mg capsule 2 QL 6 CAPS / 1 DAY

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

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

2 QL 4 KIT / 30 DAYS

diazepam 10 mg tablet 1 QL 4 TABS / 1 DAY

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

PAGE 58 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

lorazepam 2 mg tablet 1 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

temazepam 15 mg capsule 1 QL 2 CAPS / 1 DAY

temazepam 30 mg capsule 1 QL 1 CAP / 1 DAY

VALTOCO 3QL 1 CARTON / RX

PA

AUTONOMIC DRUGSAUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX 3QL 2 TABS / 1 DAY

SC Smoking Cessation

nicotine gum 2 SC Smoking Cessation

nicotine 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

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnicotine 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 3 SC Smoking Cessation

NICOTROL NS 3 SC Smoking Cessation

varenicline tartrate 2

QL 2 TABS / 1 DAY

ACA Affordable Care Act

SC Smoking Cessation

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)bethanechol chloride 2

cevimeline hcl 2

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

donepezil hcl odt 2

galantamine er 2

galantamine hbr 2

galantamine hydrobromide 2

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

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

pyridostigmine br 60 mg tablet 2

pyridostigmine bromide er 2 PA

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

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET) 3

BETA-ADRENERGIC AGONISTSSELECTIVE BETA-2-ADRENERGIC AGONISTS

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

levalbuterol tartrate hfa 2

SEREVENT DISKUS 3

STRIVERDI RESPIMAT 3

VENTOLIN HFA 2

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

OXBRYTA 5

QL 3 TABS / 1 DAY

PA

S

HEMATOPOIETIC AGENTS

ARANESP 5 S

FULPHILA 3

GRANIX 3 S

NYVEPRIA 3

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

5PA

S

PROMACTA 12.5 MG SUSPEN PACKET 5

QL 1 PACKET / 1 DAY

PA

S

PROMACTA 25 MG SUSPENSION PCKT 5

QL 3 PACKETS / 1 DAY

PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSRETACRIT (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)

5 S

UDENYCA 3

ZIEXTENZO 3

HEMORRHEOLOGIC AGENTSpentoxifylline 2

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

CARTIA XT 2

DILT-XR 1

diltiazem 24hr er (24hr er 120 mg cap, 24hr er 180 mgcap, 24hr er 240 mg cap, 24hr er 300 mg cap, 24hr er 420mg cap)

2

diltiazem 24hr er (cd) (24h 120 mg cp, 24h 180 mg cp, 24h240 mg cp, 24h 300 mg cp)

2

diltiazem 24hr er (xr) 1

diltiazem 24hr er 360 mg cap 1

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

2

MATZIM LA 240 MG TABLET 1

TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE, 240 MGCAPSULE, 300 MG CAPSULE)

2

TAZTIA XT 360 MG CAPSULE 1

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

verapamil 360 mg cap pellet 2

verapamil er (er 120 mg capsule, er 180 mg capsule, er240 mg capsule)

1

verapamil er (er 120 mg tablet, er 180 mg tablet, er 240mg tablet)

2

verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet) 1

verapamil sr 1

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DIHYDROPYRIDINESamlodipine besylate 1

amlodipine besylate-benazepril 2

amlodipine-olmesartan 2

amlodipine-valsartan 1

amlodipine-valsartan-hctz 2

felodipine er 2

nifedipine 2 AL1 Up to 45 yrs old

nifedipine er 2

nimodipine 2

CARDIAC DRUGSCARDIAC DRUGS, MISCELLANEOUS

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

3 PA

VYNDAMAX 5PA

S

VYNDAQEL 5PA

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 3

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CARDIOVASCULAR DRUGSALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate 2

prazosin hcl 2

terazosin hcl 1

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl 2

atenolol 1

atenolol-chlorthalidone 2

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

bisoprolol fumarate 2

bisoprolol-hydrochlorothiazide 1

carvedilol 1

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

2

metoprolol succinate 2

metoprolol tartrate (25 mg tab, 50 mg tab, 100 mg tab) 1

metoprolol-hydrochlorothiazide 2

nadolol 1

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 1

propranolol-hydrochlorothiazid 2

sotalol 2

SOTALOL AF 2

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

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CENTRAL NERVOUS SYSTEM AGENTSANTIMANIC AGENTS

lithium 2

lithium carbonate 2

lithium carbonate er 2

CENTRAL NERVOUS SYSTEM AGENTS, MISC.acamprosate calcium 2

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

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

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

2

NOURIANZ 5PA

S

riluzole 2

XYREM 5

QL 18 ML / 1 DAY

PA

S

XYWAV 5

QL 18 ML / 1 DAY

PA

S

OPIATE ANTAGONISTSKLOXXADO 3

naloxone 2 mg/2 ml syringe 2

naltrexone hcl 2

NARCAN 3

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

AUSTEDO 5PA

S

INGREZZA 5PA

S

INGREZZA INITIATION PACK 5PA

S

tetrabenazine 5PA

S

CEPHALOSPORIN ANTIBIOTICS1ST GENERATION CEPHALOSPORIN ANTIBIOTICS

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

1

cefadroxil 500 mg capsule 2

cephalexin (125 mg/5 ml susp, 250 mg/5 ml susp) 2

cephalexin (250 mg capsule, 500 mg capsule) 1

2ND GENERATION CEPHALOSPORIN ANTIBIOTICScefprozil (125 mg/5 ml susp, 250 mg/5 ml susp) 1

cefprozil (250 mg tablet, 500 mg tablet) 2

cefuroxime 2

3RD GENERATION CEPHALOSPORIN ANTIBIOTICScefdinir (125 mg/5 ml susp, 250 mg/5 ml susp) 2

cefdinir 300 mg capsule 1

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

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CORTICOSTEROIDS (RESPIRATORY TRACT)ORALLY INHALED PREPARATIONS (STEROIDS)

ADVAIR DISKUS 2

ADVAIR HFA 3

ARNUITY ELLIPTA 3

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

3

ASMANEX HFA 3

BREO ELLIPTA 3

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 3

FLOVENT HFA 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 FLEXHALER 3

QVAR REDIHALER 3

TRELEGY ELLIPTA 3

CYSTIC FIBROSIS (CFTR) MODULATORSCYSTIC FIBROSIS (CFTR) CORRECTORS

SYMDEKO 5PA

S

TRIKAFTA 5PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CYSTIC FIBROSIS (CFTR) POTENTIATORS

KALYDECO 5PA

S

ORKAMBI 5PA

S

DIAGNOSTIC AGENTSADRENOCORTICAL INSUFFICIENCY

ACTHAR 5PA

S

DIURETICSLOOP DIURETICS

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

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

1

torsemide 2

POTASSIUM-SPARING DIURETICSamiloride hcl 2

amiloride-hydrochlorothiazide 2

triamterene-hydrochlorothiazid 1

THIAZIDE DIURETICShydrochlorothiazide 1

THIAZIDE-LIKE DIURETICSchlorthalidone 2

indapamide 2

metolazone 2

DOPAMINE RECEPTOR AGONISTSERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

bromocriptine mesylate 2

cabergoline 2

CYCLOSET 3 PA

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

NEUPRO 3 PA

pramipexole dihydrochloride 2

ropinirole hcl 2

ELECTROLYTIC, CALORIC, AND WATER BALANCEALKALINIZING AGENTS

potassium citrate er 2

AMMONIA DETOXICANTS

CARBAGLU 5PA

S

ENULOSE 2

GENERLAC 2

lactulose 10 gm/15 ml solution 2

sodium phenylbutyrate powder 2 PA

CALORIC AGENTS

DOJOLVI 5PA

S

levocarnitine 330 mg tablet 1

REPLACEMENT PREPARATIONSKLOR-CON M10 2

KLOR-CON M15 2

KLOR-CON M20 2

potassium 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 AGENTSprobenecid 2

probenecid-colchicine 2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

EMOLLIENTS, DEMULCENTS, AND PROTECTANTSBASIC LOTIONS AND LINIMENTS

ammonium lactate 12% lotion 2

BASIC OINTMENTS AND PROTECTANTSammonium lactate 12% cream 2

ENZYMES

REVCOVI 5PA

S

STRENSIQ 5PA

S

SUCRAID 5PA

S

ESTROGENS AND ANTIESTROGENSESTROGEN AGONIST-ANTAGONISTS

raloxifene hcl 2 ACA Affordable Care Act

SOLTAMOX 3

tamoxifen citrate 2 ACA Affordable Care Act

ESTROGENSAMABELZ 0.5 MG-0.1 MG TABLET 2

DOTTI 2

estradiol (0.01% cream, 10 mcg vaginal insrt) 2

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

estradiol (once weekly) 2

estradiol (twice weekly) 2

estradiol-noreth 0.5-0.1 mg tb 2

FYAVOLV 1 MG-5 MCG TABLET 2

JINTELI 2

LOPREEZA 0.5 MG-0.1 MG TABLET 2

MIMVEY LO 2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

norethin-eth estrad 1 mg-5 mcg 2

PREMARIN VAGINAL CREAM-APPL 3

PREMPRO 3

YUVAFEM 2

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

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

epinastine hcl 2

olopatadine hcl 0.1% eye drops 2

EENT DRUGS, MISCELLANEOUS

CYSTADROPS 5

QL 5 ML / RX

PA

S

CYSTARAN 5

QL 15 ML / RX

PA

S

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

OXERVATE 5

QL 1 ML / 1 DAY

PA

S

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

2

lidocaine hcl viscous 2

MYDRIATICSatropine sulfate (drops, ointment) 2

cyclopentolate hcl (drop, drops) 2

homatropaire 2

homatropine hydrobromide 2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

FIRST GENERATION ANTIHISTAMINESFIRST 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) 1 AQ1 Up to 64 yrs old; 300/ 1 FILL

promethazine vc 1

promethazine-phenylephrine 1

PROMETHEGAN 2

GASTROINTESTINAL DRUGSANTI-INFLAMMATORY AGENTS (GI DRUGS)

alosetron hcl 2 PA

balsalazide disodium 2

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

2

mesalamine dr 2

mesalamine er 2

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

paregoric 2 QL 40 ML / 1 DAY

XERMELO 5PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CATHARTICS AND LAXATIVESGAVILYTE-C 2

GAVILYTE-G 2 ACA Affordable Care Act

GAVILYTE-N 2

lubiprostone 2 QL 2 CAPS / 1 DAY

peg 3350-electrolyte (3350 electrolyte soln, 3350-electrolyte solution)

2

SUPREP 3 ACA Affordable Care Act

TRILYTE WITH FLAVOR PACKETS 2

CHOLELITHOLYTIC AGENTSursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 2

DIGESTANTSCREON 3

GI DRUGS, MISCELLANEOUS

ALLI 3PA

WL Weight Loss

CHOLBAM 5PA

S

ENDARI 5PA

S

HUMIRA(CF) PEDI CROHN 80-40 MG 5

QL 2 SYRINGES / 28DAYS

PA

S

LINZESS 3 QL 1 CAP / 1 DAY

MOVANTIK 3QL 1 TAB / 1 DAY

PA

SYMPROIC 3 PA

XENICAL 3PA

WL Weight Loss

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PROKINETIC AGENTS

GIMOTI 3 PA

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

1

metoclopramide hcl odt 2 PA

GENITOURINARY SMOOTH MUSCLE RELAXANTSANTIMUSCARINICS

oxybutynin 5 mg tablet 1

oxybutynin 5 mg/5 ml syrup 2

oxybutynin chloride er 2

solifenacin succinate 2

tolterodine tartrate 2

tolterodine tartrate er 2

trospium chloride 1

GOLD COMPOUNDSRIDAURA 3

GONADOTROPINS AND ANTIGONADOTROPINSANTIGONADTROPINS

MYFEMBREE 5

QL 28 TABS / 28 DAYS

PA

S

ORGOVYX 3PA

S

ORIAHNN 5

QL 2 CAPS / 1 DAY

PA

S

ORILISSA 150 MG TABLET 5

QL 1 TAB / 1 DAY

PA

S

ORILISSA 200 MG TABLET 5

QL 56 TABS / 28 DAYS

PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HCV ANTIVIRALSHCV POLYMERASE INHIBITOR ANTIVIRALS

EPCLUSA 200 MG-50 MG TABLET 5PA

S

HARVONI (33.75-150 MG PELLET PK, 45-200 MG PELLETPACKT, 45-200 MG TABLET)

5PA

S

ledipasvir-sofosbuvir 5PA

S

sofosbuvir-velpatasvir 5PA

S

SOVALDI (150 MG PELLET PACKET, 200 MG PELLETPACKET, 200 MG TABLET)

5PA

S

VOSEVI 5PA

S

HCV PROTEASE INHIBITOR ANTIVIRALS

MAVYRET 5PA

S

HEAVY METAL ANTAGONISTSCHEMET 3

D-PENAMINE 2 PA

deferasirox (90 mg tablet, 125 mg tb for susp, 180 mgtablet, 250 mg tb for susp, 500 mg tb for susp)

5

PA

S

TD Trial Drug

deferiprone 5PA

S

FERRIPROX (100 MG/ML SOLUTION, 1,000 MG TABLET) 5PA

S

FERRIPROX (2 TIMES A DAY) 5PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FERRIPROX (3 TIMES A DAY) 5PA

S

penicillamine 250 mg tablet 5PA

S

HORMONES AND SYNTHETIC SUBSTITUTESADRENALS

budesonide ec 2

dexamethasone (0.5 mg tablet, 0.75 mg tablet, 1 mgtablet, 1.5 mg tablet, 4 mg tablet, 6 mg tablet)

1

dexamethasone (0.5 mg/5 ml elx, 0.5 mg/5 ml liq, 2 mgtablet)

2

DEXAMETHASONE INTENSOL 3

dexamethasone sodium phosphate (10 mg/ml syring, 10mg/ml vial, 100 mg/10 ml vl)

2

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

1

fludrocortisone acetate 2

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

MEDROL 2 MG TABLET 3

methylprednisolone 2

MILLIPRED 3

prednisolone 1

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

1

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dosepack, 5 mg tablet, 10 mg tab dose pack, 10 mg tablet, 20mg tablet, 50 mg tablet)

1

prednisone 5 mg/5 ml solution 2

PREDNISONE INTENSOL 3

SOLU-CORTEF 100 MG ACT-O-VIAL 3

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANDROGENSdanazol 2

methyltestosterone 2QL 5 CAPS / 1 DAY

PA

oxandrolone 10 mg tablet 2QL 2 TABS / 1 DAY

PA

oxandrolone 2.5 mg tablet 2QL 4 TABS / 1 DAY

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 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

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

APRI 2 ACA Affordable Care Act

ARANELLE 2 ACA Affordable Care Act

ASHLYNA 2 ACA Affordable Care Act

AUBRA 2 ACA Affordable Care Act

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

BALZIVA 2 ACA Affordable Care Act

BEKYREE 2 ACA Affordable Care Act

BLISOVI 24 FE 3 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

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

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DEBLITANE 2 ACA Affordable Care Act

desogestr-eth estrad eth estra 2 ACA Affordable Care Act

desogestrel-ethinyl estradiol 2 ACA Affordable Care Act

drospirenone-ethinyl estradiol 2 ACA Affordable Care Act

ELINEST 2 ACA Affordable Care Act

ELLA 3 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

ethynodiol-ethinyl estradiol 2 ACA Affordable Care Act

etonogestrel-ethinyl estradiol 2 ACA Affordable Care Act

FALMINA 2 ACA Affordable Care Act

FEMYNOR 2 ACA Affordable Care Act

GIANVI 2 ACA Affordable Care Act

HAILEY 2 ACA Affordable Care Act

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

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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 FE 2 ACA Affordable Care Act

LARISSIA 2 ACA Affordable Care Act

LEENA 2 ACA Affordable Care Act

LESSINA 2 ACA Affordable Care Act

LEVONEST 2 ACA Affordable Care Act

levonorg-eth estrad eth estrad (levono-e 0.15-0.03-0.01,levonor-e 0.1-0.02-0.01)

2 ACA Affordable Care Act

levonorgestrel 2 ACA Affordable Care Act

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

2 ACA Affordable Care Act

LEVORA-28 2 ACA Affordable Care Act

LILLOW 2 ACA Affordable Care Act

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LO-ZUMANDIMINE 2 ACA Affordable Care Act

LOJAIMIESS 2 ACA Affordable Care Act

LORYNA 2 ACA Affordable Care Act

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

MICROGESTIN 2 ACA Affordable Care Act

MICROGESTIN FE 2 ACA Affordable Care Act

MILI 2 ACA Affordable Care Act

MONO-LINYAH 2 ACA Affordable Care Act

MY WAY 2 ACA Affordable Care Act

NECON 2 ACA Affordable Care Act

NIKKI 2 ACA Affordable Care Act

NORA-BE 2 ACA Affordable Care Act

norethindron-ethinyl estradiol (norethin-ee 1.5-0.03mg(21) tb, norethind-eth estrad 1-0.02 mg)

2 ACA Affordable Care Act

norethindrone 2 ACA Affordable Care Act

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

2 ACA Affordable Care Act

norgestimate-ethinyl estradiol 2 ACA Affordable Care Act

NORLYDA 2 ACA Affordable Care Act

NORTREL 2 ACA Affordable Care Act

NYMYO 2 ACA Affordable Care Act

OCELLA 2 ACA Affordable Care Act

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

OGESTREL 2 ACA Affordable Care Act

ORSYTHIA 2 ACA Affordable Care Act

PHILITH 2 ACA Affordable Care Act

PIMTREA 2 ACA Affordable Care Act

PIRMELLA 2 ACA Affordable Care Act

PORTIA 2 ACA Affordable Care Act

PREVIFEM 2 ACA Affordable Care Act

RECLIPSEN 2 ACA Affordable Care Act

SETLAKIN 2 ACA Affordable Care Act

SHAROBEL 2 ACA Affordable Care Act

SIMLIYA 2 ACA Affordable Care Act

SIMPESSE 2 ACA Affordable Care Act

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

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

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

TYBLUME 2 ACA Affordable Care Act

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

XULANE 2 ACA Affordable Care Act

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

PAGE 83 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PITUITARY

desmopressin acetate (0.01% solution, 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

STIMATE 3 PA

PROGESTINS

hydroxyprogest 250 mg/ml vial 5QL 2 ML / 1 FILL

S

MAKENA 250 MG/ML VIAL 5QL 2 ML / 1 FILL

S

MAKENA 275 MG/1.1 ML AUTOINJCT 5QL 2.2 ML / 1 FILL

S

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

1

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

HYPOTENSIVE AGENTSCENTRAL ALPHA-AGONISTS

clonidine 2

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1

guanfacine hcl 1

methyldopa 2

DIRECT VASODILATORShydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet)

2

minoxidil 2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

INSULINSINTERMEDIATE-ACTING INSULINS

HUMULIN 70-30 3

HUMULIN 70/30 KWIKPEN 3

HUMULIN N 3

HUMULIN N KWIKPEN 3

relion novolin 70-30 flexpen 3

relion novolin 70-30 vial 3

relion novolin n 100 unit/ml 3

relion novolin n u-100 flexpen 3

LONG-ACTING INSULINSLANTUS 3

LANTUS SOLOSTAR 3

LEVEMIR 3 PA

LEVEMIR FLEXTOUCH 3 PA

SOLIQUA 100-33 3

TOUJEO MAX SOLOSTAR 3

TOUJEO SOLOSTAR 3

XULTOPHY 100-3.6 3

RAPID-ACTING INSULINSHUMALOG 3

HUMALOG JUNIOR KWIKPEN 3

HUMALOG KWIKPEN U-100 3

HUMALOG KWIKPEN U-200 3

HUMALOG MIX 50-50 3

HUMALOG MIX 50-50 KWIKPEN 3

HUMALOG MIX 75-25 3

HUMALOG MIX 75-25 KWIKPEN 3

PAGE 85 LAST UPDATED 10/2021

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

insulin lispro 2

insulin lispro junior kwikpen 2

insulin lispro kwikpen u-100 2

insulin lispro protamine mix 2

SHORT-ACTING INSULINSHUMULIN R 3

HUMULIN R U-500 3

HUMULIN R U-500 KWIKPEN 3

relion novolin r 100 unit/ml 3

relion novolin r u-100 flexpen 3

ION-REMOVING AGENTSPHOSPHATE-REMOVING AGENTS

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

PHOSLYRA 3

sevelamer carbonate 2

POTASSIUM-REMOVING AGENTSsodium polystyrene sulfonate (sod polystyren 15 g/60 ml,sodium polystyrene powder)

2

MACROLIDE ANTIBIOTICSOTHER MACROLIDE ANTIBIOTICS

azithromycin (100 mg/5 ml susp, 200 mg/5 ml susp) 2

azithromycin (250 mg tablet, 500 mg tablet, 600 mgtablet)

1

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

DIFICID (40 MG/ML SUSPENSION, 200 MG TABLET) 3 PA

MISC. BETA-LACTAM ANTIBIOTICSMONOBACTAM ANTIBIOTICS

CAYSTON 5PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MISCELLANEOUS THERAPEUTIC AGENTS5-ALPHA-REDUCTASE INHIBITORS

dutasteride 2

finasteride 5 mg tablet 1

ALCOHOL DETERRENTSdisulfiram 2

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

2

VISTOGARD 5PA

S

ANTIGOUT AGENTSallopurinol 1

colchicine 2

febuxostat 2 ST

BONE RESORPTION INHIBITORS

alendronate sod 70 mg/75 ml 2 PA

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

1

alendronate sodium 40 mg tab 2

etidronate disodium 2

ibandronate sodium 150 mg tab 2

CARIOSTATIC AGENTSdenta 5000 plus 1

dentagel 1

fluoride 1AL1 Up to 5 yrs old

ACA Affordable Care Act

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

ACA Affordable Care Act

flura-drops 1AL1 Up to 5 yrs old

ACA Affordable Care Act

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ludent fluoride 1AL1 Up to 5 yrs old

ACA Affordable Care Act

sf 1

sf 5000 plus 1

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

1AL1 Up to 5 yrs old

ACA Affordable Care Act

COMPLEMENT INHIBITORS

BERINERT 5PA

S

CINRYZE 5PA

S

FIRAZYR 5

QL 9 ML / 1 FILL

PA

S

HAEGARDA 5PA

S

KALBITOR 5PA

S

ORLADEYO 5

QL 1 CAP / 1 DAY

PA

S

RUCONEST 5PA

S

TAKHZYRO 5

QL 4 ML / 28 DAYS

PA

S

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

ACTEMRA 162 MG/0.9 ML SYRINGE 5

QL 4 SYRINGES / 28DAYS

PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ACTEMRA ACTPEN 5PA

S

CIMZIA (MG/ML SYRINGE KIT, MG/ML(X3)START KT) 5

QL 2 SYRINGES / 28DAYS

PA

S

ENBREL (25 MG/0.5 ML SYRINGE, 25 MG/0.5 ML VIAL) 5

QL 4 ML (8 DOSES) / 28DAYS

PA

S

ENBREL 25 MG KIT 5

QL 8 VIALS (8 ML) / 28DAYS

PA

S

ENBREL 50 MG/ML SYRINGE 5

QL 4 ML (4 DOSES) / 28DAYS

PA

S

ENBREL MINI 5

QL 4 ML (4 DOSES) / 28DAYS

PA

S

ENBREL SURECLICK 5

QL 4 ML (4 DOSES) / 28DAYS

PA

S

HUMIRA 5

QL 2 SYRINGES / 28DAYS

PA

S

HUMIRA PEN 5

QL 2 PENS / 28 DAYS

PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HUMIRA PEN CROHN'S-UC-HS 5

QL 2 PENS / 28 DAYS

PA

S

HUMIRA PEN PSOR-UVEITS-ADOL HS 5

QL 2 PENS / 28 DAYS

PA

S

HUMIRA(CF) 5

QL 2 SYRINGES / 28DAYS

PA

S

HUMIRA(CF) PEDI CROHN 80MG/0.8 5

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN 40 MG/0.4 ML 5

QL 2 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN 80 MG/0.8 ML 5

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN CROHN'S-UC-HS 5

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN PEDIATRIC UC 5

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN PSOR-UV-ADOL HS 5

QL 2 PENS / 28 DAYS

PA

S

KINERET 5

QL 28 SYRINGES / 28DAYS

PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

leflunomide 2

OLUMIANT 5

QL 1 TAB / 1 DAY

PA

S

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

5

QL 4 SYRINGES / 28DAYS

PA

S

ORENCIA CLICKJECT 5

QL 4 ML / 28 DAYS

PA

S

OTEZLA 28 DAY STARTER PACK 5

QL 55 TABS / 28 DAYS

PA

S

OTEZLA 30 MG TABLET 5

QL 2 TABS / 1 DAY

PA

S

OTEZLA STARTER PACK 5

QL 2 PACKS / 28 DAYS

PA

S

RINVOQ 5

QL 1 TAB / 1 DAY

PA

S

IMMUNOMODULATORY AGENTS

AUBAGIO 5QL 1 TAB / 1 DAY

S

AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT) 5QL 1 KIT / 28 DAYS

S

AVONEX 30 MCG/0.5 ML SYRINGE 5QL 4 SYRINGES / 28

DAYSS

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AVONEX PEN 5QL 1 KIT / 28 DAYS

S

BAFIERTAM 5QL 4 CAPS / 1 DAY

S

BETASERON 0.3 MG KIT 5QL 15 ML / 28 DAYS

S

BETASERON 0.3 MG VIAL 5QL 15 ML / 30 DAYS

S

dimethyl fumarate 5QL 2 CAPS / 1 DAY

S

ENSPRYNG 5PA

S

GILENYA 5QL 1 CAP / 1 DAY

S

glatiramer 20 mg/ml syringe 5QL 30 ML / 30 DAYS

S

glatiramer 40 mg/ml syringe 5QL 12 ML / 28 DAYS

S

GLATOPA 20 MG/ML SYRINGE 5QL 30 ML / 30 DAYS

S

GLATOPA 40 MG/ML SYRINGE 5QL 12 ML / 28 DAYS

S

KESIMPTA PEN 5QL 1 PEN / 28 DAYS

S

MAYZENT 0.25 MG STARTER PACK 5QL 12 TABS / 4 DAYS

S

MAYZENT 0.25 MG TABLET 5QL 4 TABS / 1 DAY

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MAYZENT 2 MG TABLET 5QL 1 TAB / 1 DAY

S

PLEGRIDY 5QL 1 ML / 28 DAYS

S

PLEGRIDY PEN 5QL 1 ML / 28 DAYS

S

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

5QL 6 ML / 28 DAYS

S

REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 5QL 6 ML / 28 DAYS

S

REBIF REBIDOSE TITRATION PACK 5QL 4.2 ML / 28 DAYS

S

REBIF TITRATION PACK 5QL 4.2 ML / 28 DAYS

S

REDITREX 3 PA

THALOMID 3S

ONC Oncology

VUMERITY 5QL 4 CAPS / 1 DAY

S

ZEPOSIA 0.23-0.46 MG START PCK 5QL 7 CAPS / 180 DAYS

S

ZEPOSIA 0.23-0.46-0.92 MG KIT 5QL 37 CAPS / 180 DAYS

S

ZEPOSIA 0.92 MG CAPSULE 5QL 1 CAP / 1 DAY

S

IMMUNOSUPPRESSIVE AGENTSazathioprine 2

cyclosporine (25 mg capsule, 100 mg capsule) 2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

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

2

MAVENCLAD 5PA

S

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

2

mycophenolic acid 2

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

OTHER MISCELLANEOUS THERAPEUTIC AGENTS

ARCALYST 5PA

S

CERDELGA 5PA

S

CYSTAGON 3

dalfampridine er 5

QL 2 TABS / 1 DAY

PA

S

EVRYSDI 5PA

S

GALAFOLD 5

QL 14 CAPS / 28 DAYS

PA

S

ILARIS 5

QL 2 ML / 28 DAYS

PA

S

ISTURISA 5PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

levocarnitine 1 g/10 ml soln 2

levocarnitine sf 2

miglustat 5PA

S

REZUROCK 3

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

RUZURGI 5

QL 10 TABS / 1 DAY

PA

S

sapropterin dihydrochloride 5PA

S

THIOLA 5PA

S

THIOLA EC 5PA

S

tiopronin 5PA

S

TYBOST 3

ZOKINVY 5PA

S

PROTECTIVE AGENTSELMIRON 3

NONHORMONAL CONTRACEPTIVES

TODAY CONTRACEPTIVE SPONGE 3 ACA Affordable Care Act

vcf 1 ACA Affordable Care Act

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

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

celecoxib 2

OTHER NONSTEROIDAL ANTI-INFLAM. AGENTSdiclofenac potassium 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

etodolac (200 mg capsule, 300 mg capsule) 1

etodolac (400 mg tablet, 500 mg tablet) 2

etodolac er 2

flurbiprofen 2

ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1

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

ketorolac 10 mg tablet 2 QL 20 TABS / RX

meloxicam (7.5 mg tablet, 15 mg tablet) 1

nabumetone 2

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

1

naproxen (dr 375 mg tablet, dr 500 mg tablet) 2

piroxicam 1

sulindac 2

tolmetin sodium 2 PA

SALICYLATES

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

salsalate 2

OXYTOCICSmethylergonovine 0.2 mg tablet 2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PARATHYROID AND ANTIPARATHYROID AGENTSANTIPARATHYROID AGENTS

calcitonin-salmon 200 units sp 2

cinacalcet hcl 2

SENSIPAR 3

PARATHYROID AGENTS

FORTEO 5PA

S

teriparatide 5PA

S

TYMLOS 5PA

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)

1

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 1

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

2

penicillin v potassium (250 mg tablet, 500 mg tablet) 1

PENICILLINASE-RESISTANT PENICILLINSdicloxacillin sodium 2

PHARMACEUTICAL AIDS

SHINGRIX ADJUVANT COMPONENT 3 QL 1 KIT / RX

VAXCHORA BUFFER COMPONENT 3

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIBANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 2

ENTRESTO 3

irbesartan 1

irbesartan-hydrochlorothiazide 2

losartan potassium 1

losartan-hydrochlorothiazide 1

olmesartan medoxomil 2

olmesartan-hydrochlorothiazide 2

telmisartan 2

telmisartan-hydrochlorothiazid 2

valsartan 2

valsartan-hydrochlorothiazide 2

ANGIOTENSIN-CONVERTING ENZYME INHIBITORSbenazepril hcl 1

benazepril-hydrochlorothiazide 2

captopril 2

captopril-hydrochlorothiazide 2

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

2

enalapril-hydrochlorothiazide 1

fosinopril sodium 1

fosinopril-hydrochlorothiazide 2

lisinopril 1

lisinopril-hydrochlorothiazide 1

moexipril hcl 2

perindopril erbumine 2

quinapril hcl 1

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

quinapril-hydrochlorothiazide 2

ramipril 1

trandolapril 2

MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSeplerenone 2

spironolactone 2

spironolactone-hctz 2

RESPIRATORY TRACT AGENTSANTIFIBROTIC AGENTS

ESBRIET 5PA

S

OFEV 5PA

S

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

2

codeine-guaifenesin 2

QL 60 ML / 1 DAY

AL1 At least 18 yrs old

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

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

promethazine-dm 1

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

PULMOZYME 5

QL 150 ML / 30 DAYS

PA

S

PHOSPHODIESTERASE TYPE 4 INHIBITORS

DALIRESP 3 PA

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VASODILATING AGENTS (RESPIRATORY TRACT)

ADEMPAS 5PA

S

ambrisentan 5PA

S

bosentan 5PA

S

epoprostenol sodium 5PA

S

FLOLAN 1.5 MG VIAL 5PA

S

OPSUMIT 5PA

S

TRACLEER 32 MG TABLET FOR SUSP 5PA

S

treprostinil 5PA

S

TYVASO 5PA

S

TYVASO REFILL KIT 5PA

S

TYVASO STARTER KIT 5PA

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)

5PA

S

VENTAVIS 5PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SKELETAL MUSCLE RELAXANTSCENTRALLY ACTING SKELETAL MUSCLE RELAXNT

chlorzoxazone 500 mg tablet 2

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

methocarbamol (500 mg tablet, 750 mg tablet) 2

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

DIRECT-ACTING SKELETAL MUSCLE RELAXANTSdantrolene 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

SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS

lidocaine-prilocaine 2 QL 60 GM / 1 FILL

phenazopyridine hcl 1

ASTRINGENTSDRYSOL 3

CELL STIMULANTS AND PROLIFERANTSAVITA 2

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

2

KERATOLYTIC AGENTS

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

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

sss 10-5 cream 2

urea (cream, lotion) 2

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.acitretin 2

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

adapalene 0.1% gel 2

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AMNESTEEM 2

azelaic acid 2

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

CLARAVIS 2

COSENTYX (2 SYRINGES) 5PA

S

COSENTYX PEN 5PA

S

COSENTYX PEN (2 PENS) 5PA

S

COSENTYX SYRINGE 5PA

S

DIFFERIN 0.1% GEL 3

DUPIXENT 300 MG/2 ML PEN 5

QL 2 PENS / 28 DAYS

PA

S

DUPIXENT 300 MG/2 ML SYRINGE 5

QL 4 ML / 28 DAYS

PA

S

imiquimod 5% cream packet 2

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

2

MYORISAN 2

pimecrolimus 2

podofilox 2

SKYRIZI 5PA

S

SKYRIZI (2 SYRINGES) KIT 5PA

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SKYRIZI PEN 5PA

S

tacrolimus (0.03% ointment, 0.1% ointment) 2

tazarotene 0.1% cream 2 QL 30 GM / 30 DAYS

ZENATANE 2

SMOOTH MUSCLE RELAXANTSRESPIRATORY SMOOTH MUSCLE RELAXANTS

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

theophylline anhydrous 2

SOMATOSTATIN AGONISTS AND ANTAGONISTSSOMATOSTATIN AGONISTS

BYNFEZIA 5PA

S

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

5QL 3 ML / 1 DAY

S

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

5QL 9 VIALS / 30 DAYS

S

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

S

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

5 S

octreotide acetate (500 mcg/ml amp, 500 mcg/ml vl) 5QL 7 ML / DAY

S

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

5QL 7.5 ML / 1 DAY

S

SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL) 5QL 1 KIT / 28 DAYS

S

SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 5QL 2 KITS / 28 DAYS

S

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SANDOSTATIN LAR DEPOT (30 MG KT, 30 MG VL) 5QL 3 KITS / 28 DAYS

S

SIGNIFOR 5PA

S

SYMPATHOMIMETIC (ADRENERGIC) AGENTSALPHA- AND BETA-ADRENERGIC AGONISTS

epinephrine 0.15 mg auto-injct (teva) 2

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

SYMJEPI 3

ALPHA-ADRENERGIC AGONISTSmidodrine hcl 2

TETRACYCLINE ANTIBIOTICSAMINOMETHYLCYCLINES

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

3 PA

THYROID AND ANTITHYROID AGENTSANTITHYROID AGENTS

methimazole 1

propylthiouracil 2

THYROID AGENTSeuthyrox 2

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

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

SYNTHROID 3

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VASODILATING AGENTSNITRATES AND NITRITES

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

2

isosorbide mononitrate 2

isosorbide mononitrate er 2

NITRO-BID 3

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

nitroglycerin patch 2

PHOSPHODIESTERASE TYPE 5 INHIBITORS

sildenafil 20 mg tablet (generic for revatio) 2 QL 1 TAB / 1 DAY

tadalafil (2.5 mg tablet, 5 mg tablet) 2QL 1 TAB / 1 DAY

PA

tadalafil 20 mg tablet (generic for adcirca) 2QL 2 TABS / 1 DAY

PA

VASODILATING AGENTS, MISCELLANEOUSaspirin-dipyridamole er 2

dipyridamole 2

VERQUVO 3 PA

VITAMINSMULTIVITAMIN PREPARATIONS

completenate 2

m-natal plus 1

mynatal plus 1

mynatal-z 1

O-CAL PRENATAL 1

pnv 29-1 2

PRENATA 3

PRENATABS FA 1

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PRENATABS RX 2

prenatal plus (iron tablet, pnv multivit tab) 1

prenatal vitamin plus low iron 1

prenatal-u 2 PA

PRENATE ELITE 3 PA

preplus 1

PUREFE OB PLUS 1

se-natal 19 1

TRINATE 2

VINATE CARE 1

vinate one 1

vinate-m 1

VITAMIN B COMPLEXcyanocobalamin injection 1

folic acid 1 mg tablet 1

VITAMIN Dcalcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlsolution)

2

vitamin d2 1.25mg(50,000 unit) 1

VITAMIN K ACTIVITY

phytonadione 5 mg tablet 2 QL 3 TABS / 1 FILL

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Index of Covered Drugs

Aabacavir 49abacavir-lamivudine 49abacavir-lamivudine-zidovudine 50abiraterone acetate 31acamprosate calcium 65acarbose 20acebutolol hcl 64acetaminophen-codeine 1acetazolamide 24acetazolamide er 24acetic acid 7acetylcysteine 99acitretin 101ACTEMRA 88ACTEMRA ACTPEN 89ACTHAR 68ACTHIB 52acyclovir 57ADACEL TDAP 52adapalene 101ADDERALL XR 4adefovir dipivoxil 57ADEMPAS 100adenovirus type 4 52adenovirus type 4 and type 7 52adenovirus type 7 52ADVAIR DISKUS 67ADVAIR HFA 67ADVATE 24ADYNOVATE 24AFINITOR 31AFINITOR DISPERZ 31AFIRMELLE 77AFLURIA QUAD 2019-20 (3YR UP) 52AFLURIA QUAD 2019-20 (6-35MO) 52AFLURIA QUAD 2019-2020 52AFLURIA QUAD 2020-2021 52AFLURIA QUAD 2020-21 (3YR UP) 52AFLURIA QUAD 2020-21 (6-35MO) 52

AFLURIA QUAD 2021-2022 52AFLURIA QUAD 2021-22 (3YR UP) 52AFLURIA QUAD 2021-22 (6-35MO) 52AFSTYLA 25AJOVY AUTOINJECTOR 29AJOVY SYRINGE 29albendazole 6albuterol sulfate 61alclometasone dipropionate 10ALECENSA 31alendronate sodium 87ALFERON N 56alfuzosin hcl er 1ALINIA 46ALLI 73allopurinol 87alogliptin 20alogliptin-metformin 20alogliptin-pioglitazone 20alosetron hcl 72ALPHANATE 25ALPHANINE SD 25alprazolam 58alprazolam er 58alprazolam xr 58ALPROLIX 25ALTAVERA 77ALYACEN 77AMABELZ 70amantadine 46ambrisentan 100AMETHIA 77AMETHIA LO 77amiloride hcl 68amiloride-hydrochlorothiazide 68amiodarone hcl 11amitriptyline hcl 19amlodipine besylate 63amlodipine besylate-benazepril 63amlodipine-olmesartan 63amlodipine-valsartan 63

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amlodipine-valsartan-hctz 63ammonium lactate 70AMNESTEEM 102amoxicillin 97amoxicillin-clavulanate potass 97ampicillin trihydrate 97anagrelide hcl 51anastrozole 32ANORO ELLIPTA 13anucort-hc 10aprepitant 22APRI 77APTIOM 15APTIVUS 50ARANELLE 77ARANESP 61ARCALYST 94aripiprazole 47aripiprazole odt 47armodafinil 6ARNUITY ELLIPTA 67asenapine maleate 47ASHLYNA 77ASMANEX 67ASMANEX HFA 67aspirin-dipyridamole er 105ASTRAZENECA COVID19 VAC(UNAPP) 52atazanavir sulfate 50atenolol 64atenolol-chlorthalidone 64atomoxetine hcl 65atorvastatin calcium 28atovaquone 47atovaquone-proguanil hcl 46atropine sulfate 71ATROVENT HFA 13AUBAGIO 91AUBRA 77AUBRA EQ 78AUROVELA 78AUROVELA 24 FE 78

AUROVELA FE 78AUSTEDO 66AVIANE 78AVITA 101AVONEX 91AVONEX PEN 92AYUNA 78AYVAKIT 32azathioprine 93azelaic acid 102azelastine hcl 71azithromycin 86AZURETTE 78

Bbacitracin 6bacitracin-polymyxin 6baclofen 101BAFIERTAM 92balsalazide disodium 72BALVERSA 32BALZIVA 78BANZEL 15BAQSIMI 27BARACLUDE 57BEKYREE 78benazepril hcl 98benazepril-hydrochlorothiazide 98BENEFIX 25benznidazole 47benzonatate 99benztropine mesylate 46BERINERT 88BESIVANCE 6betamethasone diprop augmented 10betamethasone dipropionate 10betamethasone valerate 10BETASERON 92betaxolol hcl 24,64bethanechol chloride 60BEXSERO 52

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bicalutamide 32BIKTARVY 50bimatoprost 24bisoprolol fumarate 64bisoprolol-hydrochlorothiazide 64BLEPHAMIDE S.O.P. 6BLISOVI 24 FE 78BLISOVI FE 78BOOSTRIX TDAP 52bosentan 100BOSULIF 32BRAFTOVI 32BREO ELLIPTA 67BRIELLYN 78BRILINTA 51brimonidine tartrate 23BRIVIACT 15bromfenac sodium 9bromocriptine mesylate 68BRUKINSA 32budesonide 67budesonide ec 76budesonide-formoterol fumarate 67bumetanide 68buprenorphine 3buprenorphine-naloxone 3bupropion hcl 18bupropion hcl sr 18bupropion xl 18buspirone hcl 57butalbital-acetaminophen 1butalbital-acetaminophen-caffe 1butalbital-aspirin-caffeine 96BYDUREON BCISE 20BYDUREON PEN 20BYETTA 20BYNFEZIA 103

Ccabergoline 68CABLIVI 51

CABOMETYX 32calcipotriene 102calcitonin-salmon 97calcitriol 106calcium acetate 86CAMILA 78CAMRESE 78CAMRESE LO 78candesartan cilexetil 98capecitabine 33CAPLYTA 47CAPRELSA 33captopril 98captopril-hydrochlorothiazide 98CARBAGLU 69carbamazepine 15carbamazepine er 15carbidopa-levodopa 46carbidopa-levodopa er 46carbidopa-levodopa-entacapone 46carteolol hcl 24CARTIA XT 62carvedilol 64CAYSTON 86CAZIANT 78cefadroxil 66cefdinir 66cefixime 66cefpodoxime proxetil 66cefprozil 66cefuroxime 66celecoxib 96cephalexin 66CERDELGA 94cevimeline hcl 60CHANTIX 59CHATEAL 78CHATEAL EQ 78CHEMET 75chlordiazepoxide hcl 58chlorhexidine gluconate 7

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chloroquine phosphate 46chlorpromazine hcl 48chlorthalidone 68chlorzoxazone 101CHOLBAM 73cholestyramine 28cholestyramine light 28ciclopirox 23cilostazol 51CILOXAN 6cimetidine 56CIMZIA 89cinacalcet hcl 97CINRYZE 88CIPRO 12CIPRO HC 6ciprofloxacin 12ciprofloxacin hcl 6,12ciprofloxacin-dexamethasone 7citalopram hbr 19CLARAVIS 102clarithromycin 86CLEOCIN 7clindamycin (pediatric) 13clindamycin hcl 13clindamycin ph 1% gel (generic for cleocin t) 8clindamycin phos-benzoyl perox 7clindamycin phosphate 8clindamycin-benzoyl peroxide 8clobazam 17,18clobetasol emollient 10clobetasol propionate 10clomipramine hcl 19clonazepam 18clonidine 84clonidine hcl 84clopidogrel 51clotrimazole 23clotrimazole-betamethasone 23clozapine 47clozapine odt 47

COAGADEX 25codeine sulfate 1codeine-guaifenesin 99colchicine 87colestipol hcl 28COMBIVENT RESPIMAT 13COMETRIQ 33COMIRNATY 52COMPLERA 50completenate 105CONCERTA 5COPIKTRA 33CORIFACT 25CORLANOR 63COSENTYX (2 SYRINGES) 102COSENTYX PEN 102COSENTYX PEN (2 PENS) 102COSENTYX SYRINGE 102COTELLIC 33CREON 73CRESEMBA 22cromolyn sodium 10CRYSELLE 78CUVPOSA 13cyanocobalamin injection 106CYCLAFEM 78cyclobenzaprine hcl 101cyclopentolate hcl 71CYCLOPHOSPHAMIDE 34cycloserine 30CYCLOSET 68cyclosporine 93cyclosporine modified 94cyproheptadine hcl 72CYRED 78CYRED EQ 78CYSTADROPS 71CYSTAGON 94CYSTARAN 71

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DD-PENAMINE 75dalfampridine er 94DALIRESP 99danazol 77dantrolene sodium 101dapsone 30DAPTACEL DTAP 52DASETTA 78DAURISMO 34DAYSEE 78DEBLITANE 79deferasirox 75deferiprone 75demeclocycline hcl 12denta 5000 plus 87dentagel 87dermazene 8DESCOVY 50desipramine hcl 19desmopressin acetate 84desogestr-eth estrad eth estra 79desogestrel-ethinyl estradiol 79desonide 10desoximetasone 10desvenlafaxine suc er 100 mg tablet (generic forpristiq) 18desvenlafaxine suc er 25 mg tablet (generic forpristiq) 18desvenlafaxine suc er 50 mg tablet (generic forpristiq) 18dexamethasone 76DEXAMETHASONE INTENSOL 76dexamethasone sodium phosphate 9,76dexmethylphenidate hcl 5dexmethylphenidate hcl er 5dextroamp-amphetamin 15 mg tab (genericadderall) 4dextroamp-amphetamin 20 mg tab (genericadderall) 4

dextroamphetamine sulfate 4dextroamphetamine sulfate er 4dextroamphetamine-amphetamine 4DIACOMIT 15,16diazepam 58,59diclofenac potassium 96diclofenac sodium 9,96diclofenac sodium er 96dicloxacillin sodium 97dicyclomine hcl 13DIFFERIN 102DIFICID 86DIGITEK 63DIGOX 63digoxin 63DILANTIN 18DILT-XR 62diltiazem 24hr er 62diltiazem 24hr er (cd) 62diltiazem 24hr er (xr) 62diltiazem hcl 62dimethyl fumarate 92diphenoxylate-atropine 72diphtheria-tetanus toxoids-ped 52dipyridamole 105disopyramide phosphate 11disulfiram 87divalproex sodium 16divalproex sodium er 16dofetilide 12DOJOLVI 69donepezil hcl 60donepezil hcl odt 60dorzolamide hcl 24dorzolamide-timolol 24DOTTI 70doxazosin mesylate 64doxepin hcl 19doxycycline hyclate 7,12doxycycline monohydrate 12dronabinol 22

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drospirenone-ethinyl estradiol 79DRYSOL 101DULERA 67duloxetine hcl 18DUPIXENT PEN 9,102DUPIXENT SYRINGE 9,102dutasteride 87

Eeconazole nitrate 23ed-spaz 14EDURANT 49efavirenz 49efavirenz-emtric-tenofov disop 50eletriptan hbr 30ELINEST 79ELIQUIS 14ELLA 79ELMIRON 95ELOCTATE 25ELURYNG 79EMCYT 34EMEND 22EMGALITY PEN 29EMGALITY SYRINGE 29EMOQUETTE 79emtricitabine 50emtricitabine-tenofovir disop 50enalapril maleate 98enalapril-hydrochlorothiazide 98ENBREL 89ENBREL MINI 89ENBREL SURECLICK 89ENDARI 73ENDOCET 1ENGERIX-B ADULT 53ENGERIX-B PEDIATRIC-ADOLESCENT 53enoxaparin sodium 15ENPRESSE 79ENSKYCE 79ENSPRYNG 92

entacapone 46entecavir 57ENTRESTO 98ENULOSE 69EPCLUSA 75EPIDIOLEX 16epinastine hcl 71epinephrine 0.15 mg auto-injct (teva) 104epinephrine 0.15 mg auto-inject (generic for epi-pen jr / mylan) 104epinephrine 0.3 mg auto-inject (generic foradrenaclick) 104epinephrine 0.3 mg auto-inject (generic for epi-pen / mylan) 104epinephrine 0.3 mg auto-inject (teva) 104EPIVIR HBV 50eplerenone 99epoprostenol sodium 100ergoloid mesylates 1ERIVEDGE 34ERLEADA 34erlotinib hcl 34ERRIN 79erythromycin 7,8erythromycin-benzoyl peroxide 8ESBRIET 99escitalopram oxalate 19esomeprazole magnesium 56ESPEROCT 25ESTARYLLA 79estradiol 70estradiol (once weekly) 70estradiol (twice weekly) 70estradiol-norethindrone acetat 70eszopiclone 57ethambutol hcl 30ethosuximide 18ethynodiol-ethinyl estradiol 79etidronate disodium 87etodolac 96etodolac er 96

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etonogestrel-ethinyl estradiol 79etoposide 34etravirine 49EUCRISA 10euthyrox 104everolimus 35EVOTAZ 50EVRYSDI 94exemestane 35ezetimibe 28

FFALMINA 79famciclovir 57famotidine 56FANAPT 47FASENRA PEN 9febuxostat 87FEIBA NF 25felbamate 16felodipine er 63FEMYNOR 79fenofibrate 28fentanyl 1FERRIPROX 75FERRIPROX (2 TIMES A DAY) 75FERRIPROX (3 TIMES A DAY) 76FETZIMA 18finasteride 87FINTEPLA 16FIRAZYR 88flecainide acetate 11FLOLAN 100FLOVENT DISKUS 67FLOVENT HFA 67FLUAD 2019-2020 53FLUAD 2020-2021 53FLUAD QUAD 2020-2021 53FLUAD QUAD 2021-2022 53FLUARIX QUAD 2019-2020 53FLUARIX QUAD 2020-2021 53

FLUARIX QUAD 2021-2022 53FLUBLOK QUAD 2019-2020 53FLUBLOK QUAD 2020-2021 53FLUBLOK QUAD 2021-2022 53FLUCELVAX QUAD 2019-2020 53FLUCELVAX QUAD 2020-2021 53FLUCELVAX QUAD 2021-2022 53fluconazole 22,23fludrocortisone acetate 76FLULAVAL QUAD 2019-2020 53FLULAVAL QUAD 2020-2021 53FLULAVAL QUAD 2021-2022 53FLUMIST QUAD 2019-2020 53FLUMIST QUAD 2020-2021 53FLUMIST QUAD 2021-2022 53flunisolide 9fluocinolone acetonide 10fluocinolone acetonide oil 9fluocinonide 10fluocinonide-e 11fluoride 87fluoritab 87fluorometholone 9fluorouracil 35fluoxetine hcl 19fluphenazine hcl 48flura-drops 87flurbiprofen 96flurbiprofen sodium 9flutamide 35fluticasone propionate 9,11fluticasone-salmeterol 113-14 (generic for airduorespiclick) 67fluticasone-salmeterol 232-14 (generic for airduorespiclick) 67fluticasone-salmeterol 55-14 (generic for airduorespiclick) 67fluvoxamine maleate 19FLUZONE HIGH-DOSE 2019-2020 53FLUZONE HIGH-DOSE QUAD 2020-21 53FLUZONE HIGH-DOSE QUAD 2021-22 53

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FLUZONE QUAD 2019-2020 54FLUZONE QUAD 2020-2021 54FLUZONE QUAD 2021-2022 54FLUZONE QUAD PEDI 2019-2020 54FLUZONE QUAD SOUTHERN HEM 2020 54FLUZONE QUAD SOUTHERN HEM 2021 54FML S.O.P. 9folic acid 106fondaparinux sodium 14FORTEO 97fosamprenavir calcium 50fosfomycin tromethamine 6fosinopril sodium 98fosinopril-hydrochlorothiazide 98FOTIVDA 35FULPHILA 61furosemide 68FUZEON 49FYAVOLV 70FYCOMPA 16

Ggabapentin 16GALAFOLD 94galantamine er 60galantamine hbr 60galantamine hydrobromide 60GARDASIL 9 54GAVILYTE-C 73GAVILYTE-G 73GAVILYTE-N 73GAVRETO 35gemfibrozil 28GENERLAC 69GENGRAF 94gentamicin sulfate 8GENVOYA 50GIANVI 79GILENYA 92GILOTRIF 35GIMOTI 74

glatiramer acetate 92GLATOPA 92GLEOSTINE 35glimepiride 21glipizide 21glipizide er 21glipizide xl 21glipizide-metformin 21glucagon 1 mg emergency kit 27glucagon 1 mg emergency kit (genericglucagen) 27glucagon 1 mg emergency kit (Lilly) 27GLUCAGON 1 MG VIAL 27glyburide 21glyburide micronized 21glyburide-metformin hcl 21glycopyrrolate 14GLYXAMBI 21GRANIX 61GRASTEK 51griseofulvin 22griseofulvin ultramicrosize 22guaifenesin-codeine 99guanfacine hcl 84guanfacine hcl er 65GVOKE HYPOPEN 1-PACK 27GVOKE HYPOPEN 2-PACK 27GVOKE PFS 1-PACK SYRINGE 27GVOKE PFS 2-PACK SYRINGE 27

HHAEGARDA 88HAILEY 79HAILEY FE 79haloperidol 48haloperidol lactate 48HARVONI 75HAVRIX 54HEATHER 79HELIXATE FS 25HEMLIBRA 25

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HEMOFIL M 25heparin sodium 15HEPLISAV-B 54HIBERIX 54homatropaire 71homatropine hydrobromide 71HUMALOG 85HUMALOG JUNIOR KWIKPEN 85HUMALOG KWIKPEN U-100 85HUMALOG KWIKPEN U-200 85HUMALOG MIX 50-50 85HUMALOG MIX 50-50 KWIKPEN 85HUMALOG MIX 75-25 85HUMALOG MIX 75-25 KWIKPEN 85HUMATE-P 25HUMIRA 89HUMIRA PEN 89HUMIRA PEN CROHN'S-UC-HS 90HUMIRA PEN PSOR-UVEITS-ADOL HS 90HUMIRA(CF) 90HUMIRA(CF) PEDIATRIC CROHN'S 73,90HUMIRA(CF) PEN 90HUMIRA(CF) PEN CROHN'S-UC-HS 90HUMIRA(CF) PEN PEDIATRIC UC 90HUMIRA(CF) PEN PSOR-UV-ADOL HS 90HUMULIN 70-30 85HUMULIN 70/30 KWIKPEN 85HUMULIN N 85HUMULIN N KWIKPEN 85HUMULIN R 86HUMULIN R U-500 86HUMULIN R U-500 KWIKPEN 86HYCAMTIN 35hydralazine hcl 84hydrochlorothiazide 68hydrocodone-acetaminophen 1,2hydrocodone-ibuprofen 2hydrocortisone 11,76hydrocortisone acetate 11hydrocortisone butyrate 11hydrocortisone valerate 11

hydrocortisone-iodoquinol 8hydrocortisone-pramoxine 11hydromorphone hcl 2hydroxychloroquine sulfate 46hydroxyprogesterone caproate 84hydroxyurea 35hydroxyzine hcl 58hydroxyzine pamoate 58hyoscyamine sulfate 14hyoscyamine sulfate er 14hyoscyamine sulfate sr 14hyosyne 14

Iibandronate sodium 87IBRANCE 35ibuprofen 96ICLEVIA 79ICLUSIG 35,36icosapent ethyl 28IDELVION 26IDHIFA 36ILARIS 94imatinib mesylate 36IMBRUVICA 36imipramine hcl 19imiquimod 102INBRIJA 46INCASSIA 79INCRUSE ELLIPTA 14indapamide 68indomethacin 96INFANRIX DTAP 52INGREZZA 66INGREZZA INITIATION PACK 66INLYTA 36INQOVI 37INREBIC 37insulin lispro 86insulin lispro junior kwikpen 86insulin lispro kwikpen u-100 86

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insulin lispro protamine mix 86INTELENCE 49INTRON A 56INTROVALE 79INVIRASE 51INVOKAMET 21INVOKAMET XR 21INVOKANA 21IPOL 54ipratropium bromide 14,71ipratropium-albuterol 14irbesartan 98irbesartan-hydrochlorothiazide 98IRESSA 37ISENTRESS 49ISENTRESS HD 49ISIBLOOM 79isoniazid 30isosorbide dinitrate 105isosorbide mononitrate 105isosorbide mononitrate er 105isotretinoin 102ISTURISA 94itraconazole 23ivermectin 6IXINITY 26

JJAIMIESS 80JAKAFI 37JANSSEN COVID-19 VACCINE (EUA) 54jantoven 14JARDIANCE 21JASMIEL 80JENCYCLA 80JENTADUETO 20JENTADUETO XR 20JINTELI 70JIVI 26JOLESSA 80JULEBER 80

JULUCA 49JUNEL 80JUNEL FE 80JUXTAPID 28

KKALBITOR 88KALETRA 51KALLIGA 80KALYDECO 68KARIVA 80KELNOR 1-35 80KELNOR 1-50 80KESIMPTA PEN 92ketoconazole 23ketorolac tromethamine 9,96KINERET 90KINRIX 54KISQALI 37KISQALI FEMARA CO-PACK 37,38KLOR-CON M10 69KLOR-CON M15 69KLOR-CON M20 69KLOXXADO 65KOATE 26KOGENATE FS 26KOSELUGO 38KOVALTRY 26KURVELO 80

Llabetalol hcl 64lactulose 69lamivudine 50lamivudine hbv 50lamivudine-zidovudine 50lamotrigine 16LAMPIT 47lansoprazole 56LANTUS 85LANTUS SOLOSTAR 85

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lapatinib 38LARIN 80LARIN FE 80LARISSIA 80latanoprost 24LATUDA 47ledipasvir-sofosbuvir 75LEENA 80leflunomide 91LESSINA 80letrozole 38leucovorin calcium 87LEUKERAN 38levalbuterol tartrate hfa 61LEVEMIR 85LEVEMIR FLEXTOUCH 85levetiracetam 16levetiracetam er 16levobunolol hcl 24levocarnitine 69,95levocarnitine sf 95levofloxacin 12LEVONEST 80levonorg-eth estrad eth estrad 80levonorgestrel 80levonorgestrel-eth estradiol 80LEVORA-28 80levothyroxine sodium 104LEXIVA 51lidocaine hcl 71lidocaine hcl viscous 71lidocaine-prilocaine 101LILLOW 80linezolid 13LINZESS 73liothyronine sodium 104lisinopril 98lisinopril-hydrochlorothiazide 98lithium 65lithium carbonate 65lithium carbonate er 65

LO-ZUMANDIMINE 81LOJAIMIESS 81LOMAIRA 4LONSURF 38lopinavir-ritonavir 51LOPREEZA 70lorazepam 59LORAZEPAM INTENSOL 59LORBRENA 38,39LORCET 2LORCET HD 2LORCET PLUS 2LORYNA 81losartan potassium 98losartan-hydrochlorothiazide 98loteprednol etabonate 9lovastatin 28LOW-OGESTREL 81loxapine 47lubiprostone 73ludent fluoride 88LUMAKRAS 39LUMIGAN 24LUTERA 81LYNPARZA 39LYSODREN 39LYZA 81

MM-M-R II VACCINE 54m-natal plus 105MAKENA 84malathion 8MARLISSA 81MATULANE 39MATZIM LA 62MAVENCLAD 94MAVYRET 75MAYZENT 92,93MEDROL 76medroxyprogesterone acetate 84

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mefloquine hcl 46megestrol acetate 84MEKINIST 39MEKTOVI 39meloxicam 96melphalan 39memantine hcl 65MENACTRA 54MENQUADFI 54MENVEO A-C-Y-W-135-DIP 54MENVEO MENA COMPONENT 54MENVEO MENCYW-135 COMPONENT 54mercaptopurine 39mesalamine 72mesalamine dr 72mesalamine er 72METADATE ER 5metformin hcl 20metformin hcl 1,000 mg tablet (generic forglucophage) 20metformin hcl 500 mg tablet (generic forglucophage) 20metformin hcl er 20methadone hcl 2METHADONE INTENSOL 2METHADOSE 2methazolamide 24methimazole 104methocarbamol 101methotrexate 40methotrexate sodium 40methyldopa 84methylergonovine maleate 96methylphenidate er 5methylphenidate er (la) 5methylphenidate hcl 5methylphenidate hcl cd 5methylphenidate hcl er (cd) 5methylphenidate la 5methylprednisolone 76methyltestosterone 77

metoclopramide hcl 74metoclopramide hcl odt 74metolazone 68metoprolol succinate 64metoprolol tartrate 64metoprolol-hydrochlorothiazide 64metronidazole 8,47mexiletine hcl 11MICROGESTIN 81MICROGESTIN FE 81midodrine hcl 104miglitol 20miglustat 95MILI 81MILLIPRED 76MIMVEY LO 70minocycline hcl 13minoxidil 84mirtazapine 18misoprostol 56modafinil 6MODERNA COVID-19 VACCINE (EUA) 54moexipril hcl 98mometasone furoate 11MONDOXYNE NL 13MONO-LINYAH 81MONONINE 26montelukast sodium 10morphine sulfate 2morphine sulfate er 2MORPHINE SULFATE IR 15 MG TAB (BRAND) 2MORPHINE SULFATE IR 30 MG TAB (BRAND) 2MOVANTIK 73moxifloxacin 7moxifloxacin hcl 12MULTAQ 12mupirocin 8MY WAY 81mycophenolate mofetil 94mycophenolic acid 94MYFEMBREE 74

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MYLERAN 40mynatal plus 105mynatal-z 105MYORISAN 102MYRBETRIQ 61

Nnabumetone 96nadolol 64naloxone hcl 65naltrexone hcl 65naproxen 96naratriptan hcl 30NARCAN 65nateglinide 21NAYZILAM 18NECON 81nefazodone hcl 19neomycin sulfate 12neomycin-bacitracin-polymyxin 7neomycin-polymyxin-dexameth 7neomycin-polymyxin-gramicidin 7neomycin-polymyxin-hc 7neomycin-polymyxin-hydrocort 7NERLYNX 40NEUPRO 69nevirapine 49nevirapine er 49NEXAVAR 40nicotine gum 59nicotine lozenge 59nicotine patch 60NICOTROL 60NICOTROL NS 60nifedipine 63nifedipine er 63NIKKI 81nimodipine 63NINLARO 40nitazoxanide 47NITRO-BID 105

nitrofurantoin 6nitrofurantoin mono-macro 6nitroglycerin 105nitroglycerin patch 105NORA-BE 81norethindron-ethinyl estradiol 71,81norethindrone 81norethindrone ac (lupaneta) 84norethindrone acetate 84norethindrone-e.estradiol-iron 81norgestimate-ethinyl estradiol 81NORLYDA 81NORPACE CR 11NORTREL 81nortriptyline hcl 19NORVIR 51NOURIANZ 65NOVAVAX COVID19 VAC,ADJ(UNAPP) 54NOVOEIGHT 26novolin 70-30 flexpen 85NOVOSEVEN RT 26NUBEQA 40NUCALA 10NUPLAZID 47NURTEC ODT 29NUWIQ 26NUZYRA 104NYMYO 81nystatin 23NYVEPRIA 61

OO-CAL PRENATAL 105OBIZUR 26OCELLA 81octreotide acetate 103ODACTRA 51ODEFSEY 50ODOMZO 40OFEV 99ofloxacin 7

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OGESTREL 82olanzapine 47olanzapine odt 48olmesartan medoxomil 98olmesartan-hydrochlorothiazide 98olopatadine hcl 71OLUMIANT 91omega-3 acid ethyl esters 28omeprazole 56ondansetron hcl 22ondansetron odt 22ONUREG 40OPSUMIT 100ORENCIA 91ORENCIA CLICKJECT 91ORGOVYX 74ORIAHNN 74ORILISSA 74ORKAMBI 68ORLADEYO 88ORSYTHIA 82oscimin 14oscimin sl 14oscimin sr 14oseltamivir phosphate 57OTEZLA 91oxandrolone 77OXBRYTA 61oxcarbazepine 16OXERVATE 71oxybutynin chloride 74oxybutynin chloride er 74oxycodone hcl 3oxycodone hcl er 3oxycodone hcl-aspirin 3oxycodone-acetaminophen 3OXYCONTIN 3OZEMPIC 20

PPACERONE 12

PALFORZIA 51paliperidone er 48pantoprazole sodium 56paregoric 72PAROEX 7paroxetine hcl 19PAXIL 19PEDIARIX 54PEDVAXHIB 54peg 3350-electrolyte 73PEGASYS 57PEGASYS PROCLICK 57PEGINTRON 57PEMAZYRE 40penicillamine 76penicillin v potassium 97PENTACEL 54PENTACEL ACTHIB COMPONENT 54PENTACEL DTAP-IPV COMPONENT 54pentoxifylline 62perindopril erbumine 98PERIOGARD 7permethrin 8perphenazine 49PFIZER COVID-19 VACCINE (EUA) 55PHENADOZ 72phenazopyridine hcl 101phenelzine sulfate 18phenobarbital 58phenoxybenzamine hcl 1phentermine hcl 4phenylephrine hcl 72phenytoin 18phenytoin sodium extended 18PHILITH 82PHOSLYRA 86phytonadione 106PICATO 41pilocarpine hcl 24,60pimecrolimus 102PIMTREA 82

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pioglitazone hcl 22pioglitazone-glimepiride 22pioglitazone-metformin 22PIRMELLA 82piroxicam 96PLEGRIDY 93PLEGRIDY PEN 93PNEUMOVAX 23 55pnv 29-1 105podofilox 102polymyxin b sul-trimethoprim 7POMALYST 41PORTIA 82posaconazole 23potassium chloride 69potassium citrate er 69PRADAXA 15pramipexole dihydrochloride 69prasugrel hcl 51pravastatin sodium 28praziquantel 6prazosin hcl 64prednisolone 76prednisolone ac 1% eye drop (generic predforte) 9prednisolone sodium phosphate 9,76prednisone 76PREDNISONE INTENSOL 76pregabalin 16,17PREMARIN 71PREMPRO 71PRENATA 105PRENATABS FA 105PRENATABS RX 106prenatal plus 106prenatal vitamin plus low iron 106prenatal-u 106PRENATE ELITE 106preplus 106pretomanid 30PREVALITE 28

PREVIFEM 82PREVNAR 13 55PREVNAR 20 55PREVYMIS 56PREZCOBIX 51PREZISTA 51PRIFTIN 30primidone 17probenecid 69probenecid-colchicine 69prochlorperazine 22prochlorperazine maleate 22PROCTO-MED HC 11PROCTOSOL-HC 11PROCTOZONE-HC 11PROFILNINE 26progesterone 84PROMACTA 61promethazine hcl 72promethazine vc 72promethazine-dm 99promethazine-phenylephrine 72PROMETHEGAN 72propafenone hcl 11propantheline bromide 14propranolol hcl 64propranolol hcl er 64propranolol-hydrochlorothiazid 64propylthiouracil 104PROQUAD 55PULMICORT FLEXHALER 67PULMOZYME 99PUREFE OB PLUS 106pyrazinamide 30pyridostigmine bromide 60pyridostigmine bromide er 60

QQINLOCK 41QUADRACEL DTAP-IPV 55quetiapine fumarate 48

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quetiapine fumarate er 48QUILLICHEW ER 5QUILLIVANT XR 5quinapril hcl 98quinapril-hydrochlorothiazide 99quinidine sulfate 11QVAR REDIHALER 67

Rrabeprazole sodium 56RAGWITEK 52raloxifene hcl 70ramelteon 58ramipril 99rasagiline mesylate 46RASUVO 41REBIF 93REBIF REBIDOSE 93REBINYN 26RECLIPSEN 82RECOMBINATE 26RECOMBIVAX HB 55REDITREX 93RELENZA 57relion novolin 70-30 vial 85relion novolin n 100 unit/ml 85relion novolin n u-100 flexpen 85relion novolin r 100 unit/ml 86relion novolin r u-100 flexpen 86repaglinide 21REPATHA PUSHTRONEX 29REPATHA SURECLICK 29REPATHA SYRINGE 29RESTASIS 9RESTASIS MULTIDOSE 9RETACRIT 62RETEVMO 41REVCOVI 70REVLIMID 41REXULTI 48REYATAZ 51

REYVOW 30REZUROCK 95RHOPRESSA 24ribavirin 57RIDAURA 74rifabutin 30rifampin 30riluzole 65rimantadine hcl 56RINVOQ 91risperidone 48risperidone odt 48ritonavir 51rivastigmine 60RIXUBIS 26rizatriptan 30ROCKLATAN 24ropinirole hcl 69ROSADAN 8rosuvastatin calcium 28ROTARIX 55ROTATEQ 55ROZLYTREK 41RUCONEST 88rufinamide 17RUKOBIA 49RUZURGI 95RYBELSUS 20RYDAPT 41RYTARY 46

Ssalsalate 96SANDOSTATIN LAR DEPOT 103,104sapropterin dihydrochloride 95scopolamine 22se-natal 19 106SECUADO 48selegiline hcl 46selenium sulfide 8SELZENTRY 49

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SENSIPAR 97SEREVENT DISKUS 61sertraline hcl 19SETLAKIN 82sevelamer carbonate 86SEVENFACT 27sf 88sf 5000 plus 88SHAROBEL 82SHINGRIX 55SHINGRIX ADJUVANT COMPONENT 97SHINGRIX GE ANTIGEN COMPONENT 55SIGNIFOR 104sildenafil 20 mg tablet (generic for revatio) 105silver sulfadiazine 8SIMLIYA 82SIMPESSE 82simvastatin 29sirolimus 94SIRTURO 30SIVEXTRO 13SKYRIZI 102SKYRIZI (2 SYRINGES) KIT 102SKYRIZI PEN 103sodium fluoride 88sodium phenylbutyrate 69sodium polystyrene sulfonate 86sodium sulfacetamide-sulfur 8,101sofosbuvir-velpatasvir 75solifenacin succinate 74SOLIQUA 100-33 85SOLTAMOX 70SOLU-CORTEF 76sotalol 64SOTALOL AF 64SOVALDI 75spironolactone 99spironolactone-hctz 99SPRINTEC 82SPRYCEL 41SRONYX 82

SSD 8sss 10-5 101STIMATE 84STIVARGA 42STRENSIQ 70STRIBILD 50STRIVERDI RESPIMAT 61SUBVENITE 17SUCRAID 70sucralfate 56sulfacetamide sodium 7,8sulfacetamide-prednisolone 7sulfamethoxazole-trimethoprim 12sulfasalazine 12sulfasalazine dr 12SULFATRIM 12sulindac 96sumatriptan 30sumatriptan succinate 30sunitinib malate 42SUNOSI 6SUPREP 73SYEDA 82SYLATRON 57symax-sr 14SYMDEKO 67SYMJEPI 104SYMPROIC 73SYMTUZA 51SYNJARDY 21SYNJARDY XR 21SYNTHROID 104

TTABLOID 42TABRECTA 42tacrolimus 94,103tadalafil 105tadalafil 20 mg tablet (generic for adcirca) 105TAFINLAR 42TAGRISSO 42

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TAKHZYRO 88TALICIA 55tamoxifen citrate 70tamsulosin hcl 1TARINA 24 FE 82TARINA FE 82TARINA FE 1-20 EQ 82TASIGNA 42tazarotene 103TAZTIA XT 62TAZVERIK 42tdvax 52telmisartan 98telmisartan-hydrochlorothiazid 98temazepam 59temozolomide 42TENCON 1TENIVAC 52tenofovir disoproxil fumarate 50TEPMETKO 43terazosin hcl 64terbinafine hcl 22terconazole 23teriparatide 97testosterone 77testosterone cypionate 77testosterone enanthate 77testosterone propionate 77tetrabenazine 66THALOMID 93theophylline 103theophylline anhydrous 103THIOLA 95THIOLA EC 95thioridazine hcl 49thiothixene 49TIADYLT ER 62tiagabine hcl 17TIBSOVO 43TILIA FE 82timolol maleate 24,64

timolol maleate 0.25% eye drop (generic fortimoptic) 24timolol maleate 0.5% eye drops (generic fortimoptic) 24tiopronin 95TIVICAY 49TIVICAY PD 49tizanidine hcl 101TOBRADEX 7tobramycin 7,12tobramycin-dexamethasone 7TOBREX 7TODAY CONTRACEPTIVE SPONGE 95tolmetin sodium 96tolterodine tartrate 74tolterodine tartrate er 74topiramate 17torsemide 68TOUJEO MAX SOLOSTAR 85TOUJEO SOLOSTAR 85TPOXX (NATIONAL STOCKPILE) 56TRACLEER 100TRADJENTA 20tramadol hcl 3tramadol hcl-acetaminophen 3trandolapril 99tranexamic acid 27tranylcypromine sulfate 18travoprost 24trazodone hcl 19TRECATOR 31TRELEGY ELLIPTA 67treprostinil 100tretinoin 43,101TRETTEN 27TRI FEMYNOR 82TRI-ESTARYLLA 82TRI-LEGEST FE 82TRI-LINYAH 82TRI-LO-ESTARYLLA 82TRI-LO-MARZIA 83

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TRI-LO-MILI 83TRI-LO-SPRINTEC 83TRI-MILI 83TRI-PREVIFEM 83TRI-SPRINTEC 83TRI-VYLIBRA 83TRI-VYLIBRA LO 83triamcinolone acetonide 11triamterene-hydrochlorothiazid 68TRIDERM 11trifluoperazine hcl 49trifluridine 7trihexyphenidyl hcl 46TRIJARDY XR 21TRIKAFTA 67TRIKLO 28TRILYTE WITH FLAVOR PACKETS 73trimethobenzamide hcl 22trimethoprim 6TRINATE 106TRINTELLIX 19TRIUMEQ 50TRIVORA-28 83trospium chloride 74TRULICITY 20TRUMENBA 55TRUSELTIQ 43TRUVADA 50TULANA 83TURALIO 43TWINRIX 55TYBLUME 83TYBOST 95TYMLOS 97TYVASO 100TYVASO REFILL KIT 100TYVASO STARTER KIT 100

UUDENYCA 62UKONIQ 43

UPTRAVI 100urea 101ursodiol 73

Vvalacyclovir 57VALCHLOR 43valganciclovir hcl 57valproic acid 17valsartan 98valsartan-hydrochlorothiazide 98VALTOCO 59vancomycin hcl 13VAQTA 55varenicline tartrate 60VARIVAX VACCINE 55VASCEPA 28VAXCHORA ACTIVE COMPONENT 55VAXCHORA BUFFER COMPONENT 97VAXCHORA VACCINE 55VAXELIS 52VAXNEUVANCE 55vcf 95VELIVET 83VEMLIDY 57venlafaxine hcl 19venlafaxine hcl er 19VENTAVIS 100VENTOLIN HFA 61verapamil er 62verapamil hcl 62verapamil sr 62VERQUVO 105VERSACLOZ 48VERZENIO 43VESTURA 83VICTOZA 2-PAK 20VICTOZA 3-PAK 21VIENVA 83vigabatrin 17VIGADRONE 17

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VIIBRYD 19VIMPAT 17VINATE CARE 106vinate one 106vinate-m 106VIORELE 83VIREAD 50VISTOGARD 87vitamin d2 106VITRAKVI 43,44VIVOTIF 55VIZIMPRO 44VOCABRIA 49VOLNEA 83VONVENDI 27voriconazole 23VOSEVI 75VOTRIENT 44VRAYLAR 48VUMERITY 93VYFEMLA 83VYLIBRA 83VYNDAMAX 63VYNDAQEL 63VYVANSE 4

WWAKIX 6warfarin sodium 14WELIREG 44WERA 83WILATE 27

XXALKORI 44XARELTO 14XENICAL 73XENLETA 13XERMELO 72XIFAXAN 13XOSPATA 44

XPOVIO 44XTANDI 45XULANE 83XULTOPHY 100-3.6 85XYNTHA 27XYNTHA SOLOFUSE 27XYREM 65XYWAV 65

YYUVAFEM 71

Zzaleplon 58ZARAH 83ZEBUTAL 1ZEGALOGUE AUTOINJECTOR 27ZEGALOGUE SYRINGE 27ZEJULA 45ZELBORAF 45ZENATANE 103ZENZEDI 4ZEPOSIA 93zidovudine 50ZIEXTENZO 62ZIOPTAN 24ziprasidone hcl 48ZIRGAN 7ZOKINVY 95ZOLINZA 45zolmitriptan 30zolmitriptan odt 30zolpidem tartrate 58zonisamide 17ZONTIVITY 51ZOSTAVAX 55ZOVIA 1-35 83ZOVIA 1-35E 83ZUMANDIMINE 83ZYKADIA 45