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Express Scripts Medicare (PDP) 2021 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID Number: 21097, Version 4

This formulary was updated on 3/1/2021. For more recent information or other questions, please contact Express Scripts Medicare® (PDP) Customer Service at 1.800.758.4574; New York State residents: 1.800.758.4570 or, for TTY users, 1.800.716.3231, 24 hours a day, 7 days a week, or visit express-scripts.com.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York (for members located in New York State only). When it refers to “plan” or “our plan,” it means Express Scripts Medicare.

This document includes a list of the drugs (formulary) for our plan, which is current as of March 1, 2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.

What is the Express Scripts Medicare Formulary?A formulary is a list of covered drugs selected by Express Scripts Medicare in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Express Scripts Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

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This drug list was updated in March 2021

https://www.express-scripts.com

Can the formulary (drug list) change? Most changes in drug coverage happen on January 1, but Express Scripts Medicare may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the cases below, you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove a brand-name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand-name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Express Scripts Medicare Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand-name drug currently on the formulary; or add new restrictions to the brand-name drug or move it to a different cost-sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Express Scripts Medicare Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.

This drug list was updated in March 2021 i

The enclosed formulary is current as of March 1, 2021. To get updated information about the drugs covered by Express Scripts Medicare, please contact us. Our contact information appears on the front and back cover pages. If there are additional changes made to the formulary that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time from when the changes are made.

How do I use the formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular, Hypertension/Lipids.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 79. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?Express Scripts Medicare covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Express Scripts Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Express Scripts Medicare before you fill your prescriptions. If you don’t get approval, Express Scripts Medicare may not cover the drug.

• Quantity Limits: For certain drugs, Express Scripts Medicare limits the amount of the drug that Express Scripts Medicare will cover. For example, Express Scripts Medicare provides two inhalers (17 grams) for a 1-month supply per prescription for albuterol HFA. This may be in addition to a standard 1-month or 3-month supply.

• Step Therapy: In some cases, Express Scripts Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Express Scripts Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Express Scripts Medicare will then cover Drug B.

This drug list was updated in March 2021 ii

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Express Scripts Medicare to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section “How do I request an exception to the Express Scripts Medicare Formulary?” below for information about how to request an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that Express Scripts Medicare does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Express Scripts Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Express Scripts Medicare.

• You can ask Express Scripts Medicare to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Express Scripts Medicare Formulary? You can ask Express Scripts Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Express Scripts Medicare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously

This drug list was updated in March 2021 iii

harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary, or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

Other times when we will cover a temporary 30-day transition supply (or less, if you have a prescription written for fewer days) include:

• When you leave a long-term care facility • When you are discharged from a hospital • When you leave a skilled nursing facility • When you cancel hospice care • When you are discharged from a psychiatric hospital with a medication regimen that is

highly individualized

If you are entering a long-term care facility, we will cover a 31-day transition supply.

The plan will send you a letter within 3 business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options.

For more information For more detailed information about your Express Scripts Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Express Scripts Medicare, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call 1.877.486.2048. Or, visit http://www.medicare.gov.

This drug list was updated in March 2021 iv

Express Scripts Medicare’s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Express Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 79.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., JANUMET®) and generic drugs are listed in lowercase italics (e.g., omeprazole).

The information in the Requirements/Limits column tells you if Express Scripts Medicare has any special requirements for coverage of your drug.

B/D PA: Part B or Part D Prior Authorization. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

GC: Gap Coverage. We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1.800.758.4574 (New York State residents: 1.800.758.4570), 24 hours a day, 7 days a week. TTY users should call 1.800.716.3231.

MO: Mail-Order Drug. This prescription drug is available through our home delivery pharmacy service, as well as through our retail network pharmacies. Consider using mail order for your long-term medications (the kind you take regularly, such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.

SSM: Senior Savings Model. For this select insulin drug, your copay will be the same in all stages until you reach the Catastrophic Coverage Stage. Please refer to Chapter 4 in our Evidence of Coverage for more information. If you receive Extra Help, you do not qualify for this program, and your Low-Income Subsidy (LIS) benefit will apply.

ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

Your costs The amount you pay for a covered drug will depend on:

• Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage, the amount you pay for a drug may change. However, the Senior Savings Model program provides additional coverage for most insulin drugs on Tier 6. This means your copay for these drugs will be

This drug list was updated in March 2021 v

the same in all stages until you reach the Catastrophic Coverage Stage. If you receive Extra Help, you do not qualify for this program, and your Low-Income Subsidy (LIS) benefit will apply.

• The drug tier for your drug. Each covered drug is in one of six drug tiers. Each tier may have a different copayment or coinsurance amount. The “Drug Tiers” chart below explains what types of drugs are included in each tier and shows how costs may change with each tier.

The Evidence of Coverage has more information about the plan’s coverage stages and lists the copayment and coinsurance amounts for each tier.

If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may be lower. Please refer to the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider)” to find out what your costs are or you may contact Customer Service for more information.

Drug Tiers Tier Description Tier 1: Preferred Generic Drugs

This tier includes commonly prescribed generic drugs. Use Tier 1 drugs for the lowest copayments, unless you have the conditions described in Tier 6.

Tier 2: Generic Drugs

This tier includes generic drugs. Use Tier 2 drugs to keep your copayments low.

Tier 3: Preferred Brand Drugs

This tier includes preferred brand-name drugs as well as generic drugs. Drugs in this tier will generally have lower copayments than non-preferred drugs.

Tier 4: Non-Preferred Drugs

This tier includes non-preferred brand-name drugs as well as generic drugs. There may be lower-cost alternatives for you. Ask your doctor if switching to a lower-cost generic or preferred brand drug may be right for you.

Tier 5: Specialty Tier Drugs

This tier includes very high-cost brand-name and generic drugs. To learn more about medications in this tier, you may contact a pharmacist at the numbers listed on the front and back covers of this document. Drugs in this tier are limited to up to a 30-day supply from either your local retail network pharmacy or from our network home delivery service.

Tier 6: Select Care Tier Drugs

This tier includes most of the plan’s covered insulins, as well as Medicare Part D–covered supplies associated with the delivery of insulin, and select brand-name drugs used to treat diabetes. Use Tier 6 drugs for the lowest copayment if you have these conditions.

Key The abbreviations listed below may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug. You can find information on what the symbols and abbreviations on these tables mean by going to page v.

B/D PA: Part B or Part D Prior Authorization GC: Gap Coverage LA: Limited Availability MO: Mail-Order Drug

PA: Prior Authorization QL: Quantity Limit SSM: Senior Savings Model ST: Step Therapy

This drug list was updated in March 2021 vi

Drug Name Drug Tier

Requirements/Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ABELCET 4 B/D PA; MO

AMBISOME 5 B/D PA; MO

amphotericin b 4 B/D PA; MO

caspofungin 5 B/D PA

clotrimazole mucous membrane

2 MO; GC

CRESEMBA ORAL

4 MO

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml

4 PA; MO

fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml

4 PA

fluconazole oral suspension for reconstitution

3 MO

fluconazole oral tablet

2 MO; GC

flucytosine 5 MO

griseofulvin microsize

4 MO

griseofulvin ultramicrosize

4 MO

itraconazole oral capsule

4 MO; QL (120 per 30 days)

Drug Name Drug Tier

Requirements/Limits

itraconazole oral solution

5 MO

ketoconazole oral 2 MO; GC

nystatin oral suspension

2 MO; GC

nystatin oral tablet 2 MO; GC

posaconazole oral tablet,delayed release (dr/ec)


terbinafine hcl oral 2 MO; GC

voriconazole intravenous

4 PA; MO

voriconazole oral suspension for reconstitution

5 MO

voriconazole oral tablet 200 mg

5 MO

voriconazole oral tablet 50 mg

4 MO

ANTIVIRALS

abacavir oral solution


abacavir oral tablet 4 MO; QL (60 per 30 days)

abacavir-lamivudine 3 MO; QL (30 per 30 days)

abacavir-lamivudine-zidovudine


acyclovir oral capsule

2 MO; GC

acyclovir oral suspension 200 mg/5 ml

4 MO

acyclovir oral tablet 2 MO; GC

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021.

1

Drug Name Drug Tier

Requirements/Limits

acyclovir sodium intravenous solution

4 B/D PA; MO

adefovir 5 MO

amantadine hcl 3 MO

APTIVUS 4 MO; QL (120 per 30 days)

APTIVUS (WITH VITAMIN E)

4 QL (285 per 28 days)

atazanavir oral capsule 150 mg, 300 mg


atazanavir oral capsule 200 mg


ATRIPLA 5 MO; QL (30 per 30 days)

BARACLUDE ORAL SOLUTION


BIKTARVY 5 MO

CIMDUO 4 MO

COMPLERA 4 MO; QL (30 per 30 days)

CRIXIVAN ORAL CAPSULE 200 MG


DELSTRIGO 4 MO

DESCOVY 5 MO; QL (30 per 30 days)

didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg


DOVATO 5 MO

Drug Name Drug Tier

Requirements/Limits

EDURANT 3 MO; QL (30 per 30 days)

efavirenz oral capsule 200 mg


efavirenz oral capsule 50 mg


efavirenz oral tablet 5 MO; QL (30 per 30 days)

efavirenz-emtricitabin-tenofov


efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg


efavirenz-lamivu-tenofov disop oral tablet 600-300-300 mg

4 MO

emtricitabine 3 MO; QL (30 per 30 days)

emtricitabine-tenofovir (tdf)


EMTRIVA ORAL CAPSULE


EMTRIVA ORAL SOLUTION


entecavir 4 MO; QL (30 per 30 days)

EPCLUSA ORAL TABLET 200-50 MG

5 PA; MO; QL (56 per 28 days)


2

Drug Name Drug Tier

Requirements/Limits

EPCLUSA ORAL TABLET 400-100 MG


EPIVIR HBV ORAL SOLUTION

3 MO

EVOTAZ 4 MO; QL (30 per 30 days)

famciclovir 4 MO; QL (60 per 30 days)

fosamprenavir 5 MO; QL (120 per 30 days)

FUZEON SUBCUTANEOUS RECON SOLN


GENVOYA 5 MO; QL (30 per 30 days)

HARVONI ORAL PELLETS IN PACKET 33.75-150 MG


HARVONI ORAL PELLETS IN PACKET 45-200 MG


HARVONI ORAL TABLET 45-200 MG


HARVONI ORAL TABLET 90-400 MG


INTELENCE ORAL TABLET 100 MG, 200 MG


INTELENCE ORAL TABLET 25 MG


Drug Name Drug Tier

Requirements/Limits

INVIRASE ORAL TABLET


ISENTRESS HD 5 MO

ISENTRESS ORAL POWDER IN PACKET


ISENTRESS ORAL TABLET


ISENTRESS ORAL TABLET,CHEWABLE 100 MG


ISENTRESS ORAL TABLET,CHEWABLE 25 MG


JULUCA 5 MO

KALETRA ORAL TABLET 100-25 MG


KALETRA ORAL TABLET 200-50 MG


lamivudine oral solution


lamivudine oral tablet 100 mg, 300 mg


lamivudine oral tablet 150 mg


lamivudine-zidovudine


LEXIVA ORAL SUSPENSION


lopinavir-ritonavir 4 MO


3

Drug Name Drug Tier

Requirements/Limits

MAVYRET 5 PA; MO; QL (84 per 28 days)

nevirapine oral suspension

4 QL (1200 per 30 days)

nevirapine oral tablet


nevirapine oral tablet extended release 24 hr 100 mg


nevirapine oral tablet extended release 24 hr 400 mg


NORVIR ORAL POWDER IN PACKET

4 MO

NORVIR ORAL SOLUTION


ODEFSEY 5 MO; QL (30 per 30 days)

oseltamivir oral capsule 30 mg


oseltamivir oral capsule 45 mg, 75 mg


oseltamivir oral suspension for reconstitution

4 MO; QL (1080 per 365 days)

PIFELTRO 4 MO

PREVYMIS ORAL


PREZCOBIX 4 MO; QL (30 per 30 days)

Drug Name Drug Tier

Requirements/Limits

PREZISTA ORAL SUSPENSION


PREZISTA ORAL TABLET 150 MG








RETROVIR INTRAVENOUS

4 MO

REYATAZ ORAL POWDER IN PACKET


ribavirin oral capsule

3 MO

ribavirin oral tablet200 mg

3 MO

rimantadine 2 MO; GC

ritonavir 3 MO; QL (360 per 30 days)

RUKOBIA 4 MO

SELZENTRY ORAL SOLUTION

5 MO

SELZENTRY ORAL TABLET 150 MG, 75 MG


SELZENTRY ORAL TABLET 25 MG


SELZENTRY ORAL TABLET 300 MG



4

Drug Name Drug Tier

Requirements/Limits

SOVALDI ORAL TABLET 400 MG


stavudine oral capsule


STRIBILD 5 MO; QL (30 per 30 days)

SYMFI 4 MO

SYMFI LO 4 MO; QL (30 per 30 days)

SYMTUZA 4 MO

TEMIXYS 4 MO

tenofovir disoproxil fumarate


TIVICAY ORAL TABLET 10 MG


TIVICAY ORAL TABLET 25 MG, 50 MG


TIVICAY PD 4 MO; QL (180 per 30 days)

TRIUMEQ 5 MO; QL (30 per 30 days)

TROGARZO 5 MO; LA

TRUVADA 5 MO; QL (30 per 30 days)

valacyclovir oral tablet 1 gram


valacyclovir oral tablet 500 mg


Drug Name Drug Tier

Requirements/Limits

valganciclovir 5 MO

VEMLIDY 5 MO

VIRACEPT ORAL TABLET 250 MG


VIRACEPT ORAL TABLET 625 MG


VIREAD ORAL POWDER


VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG


VOSEVI 5 PA; MO; QL (28 per 28 days)

zidovudine oral capsule


zidovudine oral syrup


zidovudine oral tablet

2 MO; GC; QL (60 per 30 days)

CEPHALOSPORINS

cefaclor oral capsule 4 MO

cefaclor oral suspension for reconstitution 125 mg/5 ml

4 MO

cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml

4


5

Drug Name Drug Tier

Requirements/Limits

cefaclor oral tablet extended release 12 hr

4 MO

cefadroxil oral capsule

3 MO

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

3 MO

cefadroxil oral tablet

3 MO

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

4 MO

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML

4

cefazolin injection recon soln 1 gram, 500 mg

4 MO

cefazolin injection recon soln 10 gram, 100 gram, 300 g

4

cefazolin intravenous

4

cefdinir oral capsule 2 MO; GC

cefdinir oral suspension for reconstitution

4 MO

CEFEPIME IN DEXTROSE 5 %

4 MO

Drug Name Drug Tier

Requirements/Limits

cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml

4

cefepime in dextrose,iso-osm intravenous piggyback 2 gram/100 ml

4 MO

cefepime injection 4 MO

CEFEPIME INTRAVENOUS

4

cefixime 4 MO

CEFOTETAN IN DEXTROSE, ISO-OSM

4 PA

cefotetan injection 4 PA

cefoxitin in dextrose, iso-osm

4 PA

cefoxitin intravenous recon soln 1 gram, 2 gram

4 PA; MO

cefoxitin intravenous recon soln 10 gram

4 PA

cefpodoxime 4 MO

cefprozil 3 MO

CEFTAZIDIME IN D5W

4 PA

ceftazidime injection recon soln 1 gram, 2 gram

4 PA; MO

ceftazidime injection recon soln 6 gram

4 PA

ceftriaxone in dextrose,iso-os

4 MO


6

Drug Name Drug Tier

Requirements/Limits

ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg

4 MO

ceftriaxone injection recon soln 10 gram

4

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

4

ceftriaxone intravenous

4 MO

cefuroxime axetil oral tablet

3 MO

cefuroxime sodium injection recon soln750 mg

4 PA; MO

cefuroxime sodium intravenous recon soln 1.5 gram

4 PA; MO

cefuroxime sodium intravenous recon soln 7.5 gram

4 PA

cephalexin oral capsule 250 mg, 500 mg

2 MO; GC

cephalexin oral suspension for reconstitution

2 MO; GC

tazicef injection recon soln 1 gram

4 PA

tazicef injection recon soln 2 gram, 6 gram

4 PA; MO

tazicef intravenous 4 PA

TEFLARO 4 PA; MO

Drug Name Drug Tier

Requirements/Limits

ERYTHROMYCINS / OTHER MACROLIDES

azithromycin intravenous

4 PA; MO

azithromycin oral packet

3 MO

azithromycin oral suspension for reconstitution

4 MO

azithromycin oral tablet

2 MO; GC

clarithromycin oral suspension for reconstitution

4 MO

clarithromycin oral tablet 250 mg

4 MO

clarithromycin oral tablet 500 mg

2 MO; GC

clarithromycin oral tablet extended release 24 hr

4 MO

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

4 MO

erythrocin (as stearate) oral tablet250 mg

4 MO

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4 PA; MO

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

4 MO

erythromycin oral 4 MO


7

Drug Name Drug Tier

Requirements/Limits

MISCELLANEOUS ANTIINFECTIVES

albendazole 5 MO

ALINIA ORAL SUSPENSION FOR RECONSTITUTION


ALINIA ORAL TABLET


amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

4 PA; MO

ARIKAYCE 4 PA; MO; LA

atovaquone 5 MO

atovaquone-proguanil

4 MO

aztreonam 4 PA; MO

bacitracin intramuscular

4 MO

CAPASTAT 4

CAYSTON 5 PA; MO; LA; QL (84 per 28 days)

chloramphenicol sod succinate

4

chloroquine phosphate

2 MO; GC

clindamycin hcl 2 MO; GC

CLINDAMYCIN IN 0.9 % SOD CHLOR

4 PA

clindamycin in 5 % dextrose

4 PA; MO

clindamycin pediatric

4 MO

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate injection

4 PA; MO

clindamycin phosphate intravenous solution600 mg/4 ml

4 PA; MO

COARTEM 4 MO; QL (24 per 30 days)

colistin (colistimethate na)

4 PA; MO

CYCLOSERINE 4 MO

dapsone oral 3 MO

DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG

5 MO

daptomycin intravenous recon soln 500 mg

5 MO

EMVERM 4 MO

ertapenem 4 MO

ethambutol 4 MO

FIRVANQ ORAL RECON SOLN 25 MG/ML


FIRVANQ ORAL RECON SOLN 50 MG/ML


gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50 ml

4 PA; MO

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

4 PA; MO


8

Drug Name Drug Tier

Requirements/Limits

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 120 MG/100 ML

4 PA

gentamicin in nacl (iso-osm) intravenous piggyback 80 mg/100 ml

4 PA

gentamicin injection solution 40 mg/ml

4 PA; MO

gentamicin sulfate (ped) (pf)

4 PA; MO

hydroxychloroquine 2 MO; GC

imipenem-cilastatin 4 MO

isoniazid oral solution

4 MO

isoniazid oral tablet 2 MO; GC

ivermectin oral 3 MO

lincomycin 4 PA

linezolid in dextrose 5%

4 PA

linezolid oral suspension for reconstitution


linezolid oral tablet 3 MO; QL (60 per 30 days)

linezolid-0.9% sodium chloride

4 PA

mefloquine 2 MO; GC

meropenem 4 MO

MEROPENEM-0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM/50 ML

4 MO

Drug Name Drug Tier

Requirements/Limits

MEROPENEM-0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 500 MG/50 ML

4

metro i.v. 4 PA; MO

metronidazole in nacl (iso-os)

4 PA; MO

metronidazole oral tablet

2 MO; GC

neomycin 2 MO; GC

paromomycin 4 MO

PASER 4 MO

PENTAM 4 MO

pentamidine inhalation

3 B/D PA; MO; QL (1 per 28 days)

pentamidine injection

4 MO

praziquantel 4 MO

PRIFTIN 4 MO

PRIMAQUINE 4 MO

pyrazinamide 4 MO

pyrimethamine 5 PA; MO

quinine sulfate 4 PA; MO; QL (42 per 30 days)

rifabutin 4 MO

rifampin 4 MO

SIRTURO ORAL TABLET 100 MG

4 PA; MO; LA

SIRTURO ORAL TABLET 20 MG

4 PA; LA

STREPTOMYCIN 4 PA; MO

SYNERCID 5

tigecycline 5 PA


9

Drug Name Drug Tier

Requirements/Limits

tobramycin in 0.225 % nacl


tobramycin sulfate injection recon soln

4 PA

tobramycin sulfate injection solution

4 PA; MO

TRECATOR 3 MO

VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK

4

VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/200 ML

4 MO

VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML

4

VANCOMYCIN INJECTION

4

vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg

4 MO

VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM

4 MO

VANCOMYCIN INTRAVENOUS RECON SOLN 1.5 GRAM, 250 MG

4

Drug Name Drug Tier

Requirements/Limits

vancomycin oral capsule 125 mg


vancomycin oral capsule 250 mg


vancomycin oral recon soln

2 PA; MO; GC; QL (450 per 10 days)

XIFAXAN ORAL TABLET 550 MG


PENICILLINS

amoxicillin oral capsule

2 MO; GC

amoxicillin oral suspension for reconstitution

2 MO; GC

amoxicillin oral tablet

2 MO; GC

amoxicillin oral tablet,chewable 125 mg, 250 mg

2 MO; GC

amoxicillin-pot clavulanate oral suspension for reconstitution

2 MO; GC

amoxicillin-pot clavulanate oral tablet

2 MO; GC

amoxicillin-pot clavulanate oral tablet extended release 12 hr

4 MO

amoxicillin-pot clavulanate oral tablet,chewable

2 MO; GC

ampicillin oral capsule 500 mg

2 MO; GC


10

Drug Name Drug Tier

Requirements/Limits

ampicillin sodium injection

4 PA; MO

ampicillin sodium intravenous

4 PA

ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram

4 PA; MO

ampicillin-sulbactam injection recon soln 15 gram

4 PA

ampicillin-sulbactam intravenous recon soln 1.5 gram

4 PA

ampicillin-sulbactam intravenous recon soln 3 gram

4 PA; MO

BICILLIN L-A 4 PA; MO

dicloxacillin 2 MO; GC

nafcillin 4 PA; MO

nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml

4 PA

nafcillin in dextrose iso-osm intravenous piggyback 2 gram/100 ml

4 PA; MO

oxacillin injection recon soln 1 gram, 10 gram

4 PA

oxacillin injection recon soln 2 gram

4 PA; MO

penicillin g potassium

4 PA; MO

penicillin v potassium

2 MO; GC

pfizerpen-g 4 PA

Drug Name Drug Tier

Requirements/Limits

PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM

4 MO

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

4 MO

ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML

4

ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 3.375 GRAM/50 ML, 4.5 GRAM/100 ML

4 MO

QUINOLONES

ciprofloxacin hcl oral tablet 100 mg

4 MO

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

2 MO; GC

ciprofloxacin in 5 % dextrose

4 PA; MO

levofloxacin in d5w intravenous piggyback 250 mg/50 ml

4 PA

levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml

4 PA; MO


11

Drug Name Drug Tier

Requirements/Limits

levofloxacin intravenous

4 PA; MO

levofloxacin oral solution

4 MO

levofloxacin oral tablet

2 MO; GC

moxifloxacin oral 4 MO

MOXIFLOXACIN-SOD.ACE,SUL-WATER

4 PA

moxifloxacin-sod.chloride(iso)

4 PA; MO

SULFA'S / RELATED AGENTS

sulfadiazine 4 MO

sulfamethoxazole-trimethoprim intravenous

4 PA; MO

sulfamethoxazole-trimethoprim oral suspension

4 MO

sulfamethoxazole-trimethoprim oral tablet

2 MO; GC

TETRACYCLINES

doxy-100 4 PA; MO

doxycycline hyclate intravenous

4 PA

doxycycline hyclate oral capsule

3 MO

doxycycline hyclate oral tablet 100 mg

3 MO

doxycycline hyclate oral tablet 20 mg

2 MO; GC

doxycycline monohydrate oral capsule 100 mg

4 MO

Drug Name Drug Tier

Requirements/Limits

doxycycline monohydrate oral capsule 50 mg

3 MO

doxycycline monohydrate oral suspension for reconstitution

4 MO

doxycycline monohydrate oral tablet

3 MO

minocycline oral capsule

2 MO; GC

morgidox oral capsule 100 mg

2 MO; GC

NUZYRA INTRAVENOUS

4 PA; QL (15 per 14 days)

NUZYRA ORAL 4 MO; QL (30 per 14 days)

tetracycline 4 MO

URINARY TRACT AGENTS

methenamine hippurate

2 MO; GC

nitrofurantoin 4 MO

nitrofurantoin macrocrystal oral capsule 100 mg

3 MO


4 MO


2 MO; GC

nitrofurantoin monohyd/m-cryst

4 MO

trimethoprim 2 MO; GC


12

Drug Name Drug Tier

Requirements/Limits

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

leucovorin calcium injection recon soln100 mg, 200 mg, 350 mg, 50 mg

4 B/D PA; MO

leucovorin calcium injection recon soln500 mg

4 B/D PA

leucovorin calcium injection solution

4 B/D PA

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

4 MO

leucovorin calcium oral tablet 5 mg

3 MO

mesna 4 B/D PA; MO

MESNEX ORAL 5 MO

XGEVA 5 B/D PA; MO; QL (1.7 per 28 days)

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

abiraterone oral tablet 250 mg


abiraterone oral tablet 500 mg


Drug Name Drug Tier

Requirements/Limits

ABRAXANE 5 B/D PA; MO

ADCETRIS 4 B/D PA; MO

adriamycin intravenous recon soln 10 mg

4 B/D PA; MO

adriamycin intravenous solution

4 B/D PA

adrucil intravenous solution 2.5 gram/50 ml

4 B/D PA

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG


AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG, 5 MG


AFINITOR ORAL TABLET 10 MG


ALECENSA 5 PA; MO; QL (240 per 30 days)

ALIMTA 5 B/D PA; MO

ALIQOPA 5 B/D PA; MO; LA

ALUNBRIG ORAL TABLET 180 MG, 90 MG


ALUNBRIG ORAL TABLET 30 MG



13

Drug Name Drug Tier

Requirements/Limits

ALUNBRIG ORAL TABLETS,DOSE PACK


anastrozole 2 MO; GC

ARRANON 4 B/D PA

ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML

4 B/D PA

arsenic trioxide intravenous solution2 mg/ml

4 B/D PA; MO

ARZERRA 4 B/D PA; MO

AYVAKIT 5 PA; MO; LA; QL (30 per 30 days)

azacitidine 4 B/D PA; MO

azathioprine 2 B/D PA; MO; GC

azathioprine sodium 4 B/D PA

BALVERSA 5 PA; MO; LA

BAVENCIO 5 B/D PA; MO; LA

BELEODAQ 4 B/D PA; MO

BENDEKA 5 B/D PA; MO

BESPONSA 5 B/D PA; MO; LA

bexarotene 5 PA; MO

bicalutamide 3 MO

BLENREP 4 PA; MO

bleomycin 4 B/D PA; MO

Drug Name Drug Tier

Requirements/Limits

BLINCYTO INTRAVENOUS KIT

4 B/D PA; MO

BORTEZOMIB 5 B/D PA; MO

BOSULIF ORAL TABLET 100 MG


BOSULIF ORAL TABLET 400 MG, 500 MG


BRAFTOVI ORAL CAPSULE 75 MG

5 PA; MO; LA; QL (180 per 30 days)

BRUKINSA 5 PA; MO; LA

busulfan 5 B/D PA

CABOMETYX ORAL TABLET 20 MG, 60 MG


CABOMETYX ORAL TABLET 40 MG


CALQUENCE 5 PA; MO; LA; QL (60 per 30 days)

CAPRELSA ORAL TABLET 100 MG

5 PA; LA; QL (60 per 30 days)

CAPRELSA ORAL TABLET 300 MG

5 PA; LA; QL (30 per 30 days)

carboplatin intravenous solution

4 B/D PA; MO

carmustine 4 B/D PA; MO

cisplatin intravenous solution

4 B/D PA; MO

cladribine 4 B/D PA; MO


14

Drug Name Drug Tier

Requirements/Limits

clofarabine 4 B/D PA

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)


COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)


COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)


COPIKTRA 5 PA; MO; LA; QL (60 per 30 days)

COTELLIC 5 PA; MO; LA; QL (63 per 28 days)

cyclophosphamide intravenous recon soln

5 B/D PA; MO

CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION

3 B/D PA; MO

cyclophosphamide oral capsule

3 B/D PA; MO

cyclosporine intravenous

4 B/D PA

cyclosporine modified

4 B/D PA; MO

cyclosporine oral capsule

4 B/D PA; MO

CYRAMZA 5 B/D PA; MO

cytarabine 4 B/D PA; MO

Drug Name Drug Tier

Requirements/Limits

cytarabine (pf) injection solution100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml)

4 B/D PA; MO

cytarabine (pf) injection solution 20 mg/ml

4 B/D PA

dacarbazine 4 B/D PA; MO

dactinomycin 4 B/D PA

DARZALEX 5 B/D PA; MO; LA

DARZALEX FASPRO

5 B/D PA; MO

daunorubicin intravenous solution

4 B/D PA

DAURISMO ORAL TABLET 100 MG


DAURISMO ORAL TABLET 25 MG


decitabine 4 B/D PA; MO

docetaxel intravenous solution160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml)

4 B/D PA

docetaxel intravenous solution160 mg/8 ml (20 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

4 B/D PA; MO

doxorubicin intravenous recon soln 50 mg

4 B/D PA; MO


15

Drug Name Drug Tier

Requirements/Limits

doxorubicin intravenous solution

4 B/D PA; MO

doxorubicin, peg-liposomal

4 B/D PA; MO

DROXIA 4 MO

ELLENCE 4 B/D PA; MO

ELZONRIS 5 PA; MO; LA

EMCYT 4 MO

EMPLICITI 4 B/D PA; MO

ENHERTU 5 PA; MO

epirubicin intravenous solution

4 B/D PA; MO

ERBITUX 4 B/D PA; MO

ERIVEDGE 5 PA; MO; QL (30 per 30 days)

ERLEADA 4 PA; MO; QL (120 per 30 days)

erlotinib oral tablet100 mg, 150 mg


erlotinib oral tablet25 mg


ERWINAZE 4 B/D PA; MO

ETOPOPHOS 4 B/D PA; MO

etoposide intravenous

3 B/D PA; MO

everolimus (antineoplastic)


Drug Name Drug Tier

Requirements/Limits

everolimus (immunosuppressive) oral tablet 0.25 mg, 0.75 mg


everolimus (immunosuppressive) oral tablet 0.5 mg


EVOMELA 5 B/D PA; MO

exemestane 4 MO

FARYDAK 5 PA; MO; QL (6 per 21 days)

FIRMAGON KIT W DILUENT SYRINGE

4 B/D PA; MO

floxuridine 4 B/D PA

fludarabine intravenous recon soln

4 B/D PA; MO

fludarabine intravenous solution

4 B/D PA

fluorouracil intravenous

4 B/D PA; MO

flutamide 4 MO

FOLOTYN 5 B/D PA; MO

fulvestrant 5 B/D PA; MO

GAVRETO 4 PA; MO; LA; QL (120 per 30 days)

GAZYVA 5 B/D PA; MO

gemcitabine intravenous recon soln 1 gram, 200 mg

4 B/D PA; MO


16

Drug Name Drug Tier

Requirements/Limits

gemcitabine intravenous recon soln 2 gram

4 B/D PA

gemcitabine intravenous solution1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

4 B/D PA; MO

GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML

5 B/D PA

gemcitabine intravenous solution2 gram/52.6 ml (38 mg/ml)

4 B/D PA

gengraf oral capsule100 mg, 25 mg

4 B/D PA; MO

gengraf oral solution

4 B/D PA; MO

GILOTRIF 5 PA; MO; QL (30 per 30 days)

HALAVEN 5 B/D PA; MO

hydroxyurea 2 MO; GC

IBRANCE 5 PA; MO; QL (21 per 28 days)

ICLUSIG ORAL TABLET 10 MG, 30 MG

5 PA; MO

ICLUSIG ORAL TABLET 15 MG


ICLUSIG ORAL TABLET 45 MG


idarubicin 4 B/D PA; MO

Drug Name Drug Tier

Requirements/Limits

IDHIFA 5 PA; MO; LA; QL (30 per 30 days)

ifosfamide intravenous recon soln

4 B/D PA; MO

ifosfamide intravenous solution1 gram/20 ml

4 B/D PA; MO

ifosfamide intravenous solution3 gram/60 ml

4 B/D PA

imatinib oral tablet100 mg


imatinib oral tablet400 mg


IMBRUVICA ORAL CAPSULE 140 MG


IMBRUVICA ORAL CAPSULE 70 MG


IMBRUVICA ORAL TABLET


IMFINZI 5 B/D PA; MO; LA

INFUGEM 5 B/D PA

INLYTA ORAL TABLET 1 MG


INLYTA ORAL TABLET 5 MG


INQOVI 5 PA; MO; QL (5 per 28 days)


17

Drug Name Drug Tier

Requirements/Limits

INREBIC 5 PA; MO; LA; QL (120 per 30 days)

IRESSA 5 PA; MO; QL (30 per 30 days)

irinotecan intravenous solution100 mg/5 ml, 40 mg/2 ml

4 B/D PA; MO

irinotecan intravenous solution300 mg/15 ml, 500 mg/25 ml

4 B/D PA

IXEMPRA 4 B/D PA; MO

JAKAFI 5 PA; MO; QL (60 per 30 days)

JEVTANA 4 B/D PA; MO

KADCYLA 5 PA; MO

KANJINTI 5 B/D PA; MO

KEYTRUDA INTRAVENOUS SOLUTION

5 PA; MO

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG




Drug Name Drug Tier

Requirements/Limits



KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1)






KYPROLIS 5 B/D PA; MO

lapatinib 5 PA; MO; QL (180 per 30 days)

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG


LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1)


LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2)



18

Drug Name Drug Tier

Requirements/Limits

letrozole 2 MO; GC

LEUKERAN 4 MO

leuprolide subcutaneous kit

4 PA; MO

LIBTAYO 5 PA; MO; LA

LONSURF ORAL TABLET 15-6.14 MG


LONSURF ORAL TABLET 20-8.19 MG


LORBRENA ORAL TABLET 100 MG


LORBRENA ORAL TABLET 25 MG


LUMOXITI 5 PA; MO; LA

LUPRON DEPOT 5 PA; MO

LUPRON DEPOT (3 MONTH)

5 PA; MO


5 PA; MO


5 PA; MO

LUPRON DEPOT-PED

5 PA; MO

LUPRON DEPOT-PED (3 MONTH)

5 PA; MO

LYNPARZA ORAL TABLET


LYSODREN 5 MO

MARQIBO 4 B/D PA; MO

MATULANE 5 MO

Drug Name Drug Tier

Requirements/Limits

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 625 mg/5 ml (125 mg/ml)

4 PA; MO

megestrol oral tablet 20 mg

4 PA; MO

megestrol oral tablet 40 mg

3 PA; MO

MEKINIST ORAL TABLET 0.5 MG


MEKINIST ORAL TABLET 2 MG


MEKTOVI 5 PA; MO; LA; QL (180 per 30 days)

melphalan 4 B/D PA; MO

melphalan hcl 5 B/D PA

mercaptopurine 4 MO

methotrexate sodium (pf) injection solution

4 B/D PA; MO

methotrexate sodium injection

4 B/D PA; MO

methotrexate sodium oral

2 B/D PA; MO; GC

mitomycin intravenous

4 B/D PA; MO

mitoxantrone 4 B/D PA; MO

MONJUVI 4 PA; MO; LA

MVASI 5 B/D PA; MO


19

Drug Name Drug Tier

Requirements/Limits

mycophenolate mofetil (hcl)

4 B/D PA

mycophenolate mofetil oral capsule

3 B/D PA; MO

mycophenolate mofetil oral suspension for reconstitution

5 B/D PA; MO

mycophenolate mofetil oral tablet

3 B/D PA; MO

mycophenolate sodium

4 B/D PA; MO

MYLOTARG 5 B/D PA; MO; LA

NERLYNX 5 PA; MO; LA

NEXAVAR 5 PA; MO; LA; QL (120 per 30 days)

nilutamide 5 MO

NINLARO 5 PA; MO; QL (3 per 28 days)

NIPENT 4 B/D PA; MO

NUBEQA 4 PA; MO; LA; QL (120 per 30 days)

NULOJIX 5 B/D PA; MO

octreotide acetate injection solution1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml

4 PA; MO

octreotide acetate injection solution 50 mcg/ml

3 PA; MO

Drug Name Drug Tier

Requirements/Limits

ODOMZO 5 PA; MO; LA; QL (30 per 30 days)

OGIVRI 5 B/D PA; MO

ONCASPAR 4 B/D PA; MO

ONIVYDE 4 B/D PA; MO

ONTRUZANT 5 B/D PA; MO

ONUREG 4 PA; MO; QL (14 per 28 days)

OPDIVO 5 PA; MO

oxaliplatin intravenous recon soln 100 mg

4 B/D PA; MO

oxaliplatin intravenous recon soln 50 mg

4 B/D PA

oxaliplatin intravenous solution100 mg/20 ml, 50 mg/10 ml (5 mg/ml)

4 B/D PA; MO

oxaliplatin intravenous solution200 mg/40 ml

4 B/D PA

paclitaxel 4 B/D PA; MO

PADCEV 4 PA; MO

PEMAZYRE 4 PA; MO; LA; QL (14 per 21 days)

PERJETA 5 B/D PA; MO

PHESGO 5 PA; MO

PIQRAY 5 PA; MO

POLIVY 5 PA; MO


20

Drug Name Drug Tier

Requirements/Limits

POMALYST 5 PA; MO; LA; QL (21 per 28 days)

PORTRAZZA 4 B/D PA; MO

POTELIGEO 5 PA; MO

PROGRAF INTRAVENOUS

4 B/D PA; MO

PROGRAF ORAL GRANULES IN PACKET

4 B/D PA; MO

PURIXAN 5

QINLOCK 5 PA; MO; LA

RETEVMO 5 PA; MO; LA

REVLIMID 5 PA; MO; LA; QL (28 per 28 days)

ROMIDEPSIN INTRAVENOUS SOLUTION

5 B/D PA; MO

ROZLYTREK ORAL CAPSULE 100 MG


ROZLYTREK ORAL CAPSULE 200 MG


RUBRACA 5 PA; MO; LA; QL (120 per 30 days)

RUXIENCE 5 PA; MO

RYDAPT 5 PA; MO; QL (240 per 30 days)

SANDIMMUNE ORAL SOLUTION

4 B/D PA; MO

Drug Name Drug Tier

Requirements/Limits

SARCLISA 4 PA; MO; LA

SIGNIFOR 5 PA; MO

SIMULECT INTRAVENOUS RECON SOLN 10 MG

5 B/D PA

SIMULECT INTRAVENOUS RECON SOLN 20 MG

5 B/D PA; MO

sirolimus oral solution

5 B/D PA; MO

sirolimus oral tablet 4 B/D PA; MO

SOLTAMOX 4 MO

SOMATULINE DEPOT

5 PA; MO

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


SPRYCEL ORAL TABLET 20 MG, 70 MG


STIVARGA 5 PA; MO; QL (84 per 28 days)

SUTENT 5 PA; MO; QL (30 per 30 days)

SYNRIBO 5 B/D PA; MO

TABLOID 4 MO

TABRECTA 5 PA; MO

tacrolimus oral 3 B/D PA; MO

TAFINLAR 5 PA; MO; QL (120 per 30 days)


21

Drug Name Drug Tier

Requirements/Limits

TAGRISSO 5 PA; MO; LA; QL (30 per 30 days)

TALZENNA ORAL CAPSULE 0.25 MG


TALZENNA ORAL CAPSULE 1 MG


tamoxifen 2 MO; GC

TARGRETIN TOPICAL

5 PA; MO

TASIGNA ORAL CAPSULE 150 MG, 200 MG


TASIGNA ORAL CAPSULE 50 MG


TAZVERIK 4 PA; MO; LA

TECENTRIQ 5 B/D PA; MO; LA

TEMODAR INTRAVENOUS

4 B/D PA; MO

temsirolimus 4 B/D PA; MO

THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG


THALOMID ORAL CAPSULE 200 MG


thiotepa injection recon soln 100 mg

4 B/D PA

thiotepa injection recon soln 15 mg

4 B/D PA; MO

TIBSOVO 5 PA; MO

toposar 3 B/D PA; MO

Drug Name Drug Tier

Requirements/Limits

topotecan intravenous recon soln

5 B/D PA

topotecan intravenous solution4 mg/4 ml (1 mg/ml)

4 B/D PA; MO

toremifene 5 MO

TRAZIMERA 5 B/D PA; MO

TREANDA INTRAVENOUS RECON SOLN

5 B/D PA; MO

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

5 B/D PA; MO

tretinoin (antineoplastic)

5 MO

TRIPTODUR 5 PA; MO; QL (1 per 168 days)

TRODELVY 4 PA; MO; LA

TRUXIMA 5 PA; MO

TUKYSA ORAL TABLET 150 MG


TUKYSA ORAL TABLET 50 MG


TURALIO 5 PA; MO; LA; QL (120 per 30 days)


22

Drug Name Drug Tier

Requirements/Limits

TYKERB 5 PA; MO; LA; QL (180 per 30 days)

UNITUXIN 5 B/D PA; MO

valrubicin 4 B/D PA; MO

VECTIBIX 5 B/D PA; MO

VELCADE 5 B/D PA; MO

VENCLEXTA ORAL TABLET 10 MG






VENCLEXTA STARTING PACK


VERZENIO 5 PA; MO; LA; QL (60 per 30 days)

vinblastine intravenous solution

4 B/D PA; MO

vincasar pfs 4 B/D PA; MO

vincristine 4 B/D PA; MO

vinorelbine 4 B/D PA; MO

VITRAKVI ORAL CAPSULE 100 MG


Drug Name Drug Tier

Requirements/Limits

VITRAKVI ORAL CAPSULE 25 MG


VITRAKVI ORAL SOLUTION


VIZIMPRO 5 PA; MO; QL (30 per 30 days)

VOTRIENT 5 PA; MO; QL (120 per 30 days)

VYXEOS 5 B/D PA; MO

XALKORI 5 PA; MO; QL (60 per 30 days)

XATMEP 4 B/D PA; MO

XOSPATA 5 PA; MO; LA

XPOVIO 5 PA; MO; LA

XTANDI 4 PA; MO; QL (120 per 30 days)

YERVOY 5 B/D PA; MO

YONDELIS 5 B/D PA; MO

ZALTRAP 4 B/D PA; MO

ZANOSAR 4 B/D PA; MO

ZEJULA 5 PA; MO; LA; QL (90 per 30 days)


23

Drug Name Drug Tier

Requirements/Limits

ZELBORAF 5 PA; MO; QL (240 per 30 days)

ZEPZELCA 4 PA; MO

ZIRABEV 5 B/D PA; MO

ZOLADEX 4 B/D PA; MO

ZOLINZA 5 PA; MO; QL (120 per 30 days)

ZORTRESS ORAL TABLET 1 MG

5 B/D PA; MO

ZYDELIG 5 PA; MO; QL (60 per 30 days)

ZYKADIA ORAL TABLET


AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

APTIOM ORAL TABLET 200 MG


APTIOM ORAL TABLET 400 MG


APTIOM ORAL TABLET 600 MG, 800 MG


BANZEL 5 PA; MO

BRIVIACT INTRAVENOUS

4

Drug Name Drug Tier

Requirements/Limits

BRIVIACT ORAL SOLUTION


BRIVIACT ORAL TABLET


carbamazepine oral capsule, er multiphase 12 hr

4 MO

carbamazepine oral suspension 100 mg/5 ml

2 MO; GC

carbamazepine oral suspension 200 mg/10 ml

2 GC

carbamazepine oral tablet

2 MO; GC

carbamazepine oral tablet extended release 12 hr

4 MO

carbamazepine oral tablet,chewable

2 MO; GC

CELONTIN ORAL CAPSULE 300 MG

3 MO

clobazam oral suspension


clobazam oral tablet 4 PA; MO; QL (60 per 30 days)

clonazepam oral tablet 0.5 mg, 1 mg


clonazepam oral tablet 2 mg


clonazepam oral tablet,disintegrating0.125 mg, 0.25 mg, 0.5 mg, 1 mg



24

Drug Name Drug Tier

Requirements/Limits

clonazepam oral tablet,disintegrating2 mg


DIACOMIT ORAL CAPSULE 250 MG


DIACOMIT ORAL CAPSULE 500 MG


DIACOMIT ORAL POWDER IN PACKET 250 MG


DIACOMIT ORAL POWDER IN PACKET 500 MG


diazepam rectal 4 MO

DILANTIN 30 MG

4 MO

divalproex oral capsule, delayed rel sprinkle

4 MO

divalproex oral tablet extended release 24 hr

4 MO

divalproex oral tablet,delayed release (dr/ec)

2 MO; GC

EPIDIOLEX 5 PA; MO; LA

epitol 2 MO; GC

ethosuximide 4 MO

felbamate 4 MO

FINTEPLA 4 PA; MO; LA

fosphenytoin 3 MO

Drug Name Drug Tier

Requirements/Limits

FYCOMPA ORAL SUSPENSION


FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG


FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG


gabapentin oral capsule 100 mg, 400 mg


gabapentin oral capsule 300 mg


gabapentin oral solution 250 mg/5 ml


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

4 QL (2160 per 30 days)

gabapentin oral tablet 600 mg


gabapentin oral tablet 800 mg


lamotrigine oral tablet

2 MO; GC

lamotrigine oral tablet extended release 24hr

4 MO

lamotrigine oral tablet, chewable dispersible

2 MO; GC

lamotrigine oral tablet,disintegrating

4 MO


25

Drug Name Drug Tier

Requirements/Limits

levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml

4

levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml

4 MO

levetiracetam intravenous

3 MO

levetiracetam oral solution 100 mg/ml

2 MO; GC

levetiracetam oral solution 500 mg/5 ml (5 ml)

2 GC

levetiracetam oral tablet

2 MO; GC

levetiracetam oral tablet extended release 24 hr

4 MO

NAYZILAM 4 PA; MO; QL (10 per 30 days)

oxcarbazepine 3 MO

phenobarbital oral elixir


phenobarbital oral tablet


phenobarbital sodium injection solution 130 mg/ml

3 MO

phenobarbital sodium injection solution 65 mg/ml

3

Drug Name Drug Tier

Requirements/Limits

phenytoin oral suspension 100 mg/4 ml

2 GC

phenytoin oral suspension 125 mg/5 ml

2 MO; GC

phenytoin oral tablet,chewable

2 MO; GC

phenytoin sodium extended

2 MO; GC

phenytoin sodium intravenous solution

3 MO

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg


pregabalin oral capsule 225 mg, 300 mg


pregabalin oral solution


primidone 2 MO; GC

roweepra 2 MO; GC

rufinamide 5 PA; MO

SPRITAM 4 MO

subvenite 3 MO

subvenite starter (blue) kit

3 MO

subvenite starter (green) kit

3 MO

subvenite starter (orange) kit

3 MO

SYMPAZAN 5 PA; MO; QL (60 per 30 days)

tiagabine 4 MO

topiramate oral capsule, sprinkle

3 PA; MO


26

Drug Name Drug Tier

Requirements/Limits

topiramate oral tablet

2 PA; MO; GC

valproate sodium 3 MO

valproic acid 2 MO; GC

valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml)

2 GC

valproic acid (as sodium salt) oral solution 250 mg/5 ml, 500 mg/10 ml (10 ml)

2 MO; GC

VALTOCO 4 PA; MO; QL (10 per 30 days)

vigabatrin 5 PA; MO; LA; QL (180 per 30 days)

vigadrone 5 PA; MO; LA; QL (180 per 30 days)

VIMPAT INTRAVENOUS

4 MO

VIMPAT ORAL SOLUTION


VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG


VIMPAT ORAL TABLET 50 MG


XCOPRI 4 PA; MO

XCOPRI MAINTENANCE PACK

4 PA; MO

Drug Name Drug Tier

Requirements/Limits

XCOPRI TITRATION PACK

4 PA; MO

zonisamide 3 PA; MO

ANTIPARKINSONISM AGENTS

APOKYN 5 PA; MO; LA; QL (60 per 30 days)

benztropine injection

4 MO

benztropine oral 2 PA; MO; GC

bromocriptine 4 MO

carbidopa 5 MO

carbidopa-levodopa oral tablet

2 MO; GC

carbidopa-levodopa oral tablet extended release

3 MO

carbidopa-levodopa oral tablet,disintegrating

2 MO; GC

carbidopa-levodopa-entacapone

4 MO

entacapone 2 MO; GC

NEUPRO 4 MO

pramipexole oral tablet

2 MO; GC

rasagiline oral tablet 0.5 mg

4 MO

rasagiline oral tablet 1 mg

2 MO; GC

ropinirole oral tablet

2 MO; GC

ropinirole oral tablet extended release 24 hr

4 MO


27

Drug Name Drug Tier

Requirements/Limits

RYTARY 4 ST; MO

selegiline hcl 3 MO

MIGRAINE / CLUSTER HEADACHE THERAPY

AIMOVIG AUTOINJECTOR


dihydroergotamine nasal


ergotamine-caffeine 3 MO

naratriptan 4 MO; QL (18 per 28 days)

rizatriptan oral tablet


rizatriptan oral tablet,disintegrating


sumatriptan nasal spray,non-aerosol20 mg/actuation


sumatriptan nasal spray,non-aerosol 5 mg/actuation


sumatriptan succinate oral


sumatriptan succinate subcutaneous cartridge


sumatriptan succinate subcutaneous pen injector


Drug Name Drug Tier

Requirements/Limits

sumatriptan succinate subcutaneous solution


sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml


MISCELLANEOUS NEUROLOGICAL THERAPY

AUSTEDO ORAL TABLET 12 MG, 9 MG


AUSTEDO ORAL TABLET 6 MG


COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML


COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML


dalfampridine 3 PA; MO; QL (60 per 30 days)

dimethyl fumarate oral capsule,delayed release(dr/ec) 120 mg


dimethyl fumarate oral capsule,delayed release(dr/ec) 120 mg (14)- 240 mg (46)



28

Drug Name Drug Tier

Requirements/Limits

dimethyl fumarate oral capsule,delayed release(dr/ec) 240 mg


donepezil oral tablet10 mg


donepezil oral tablet5 mg


donepezil oral tablet,disintegrating10 mg


donepezil oral tablet,disintegrating5 mg


galantamine oral capsule,ext rel. pellets 24 hr


galantamine oral solution


galantamine oral tablet


glatiramer subcutaneous syringe 20 mg/ml


glatiramer subcutaneous syringe 40 mg/ml


glatopa subcutaneous syringe 20 mg/ml


glatopa subcutaneous syringe 40 mg/ml


memantine oral capsule,sprinkle,er 24hr

4 PA; MO

Drug Name Drug Tier

Requirements/Limits

memantine oral solution


memantine oral tablet 10 mg


memantine oral tablet 5 mg


MEMANTINE ORAL TABLETS,DOSE PACK


NAMZARIC 3 PA; MO

NUEDEXTA 4 PA; MO

OCREVUS 5 PA; MO; LA

rivastigmine 4 MO

rivastigmine tartrate 4 MO; QL (60 per 30 days)

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG


TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46)


TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 240 MG



29

Drug Name Drug Tier

Requirements/Limits

tetrabenazine oral tablet 12.5 mg


tetrabenazine oral tablet 25 mg


TYSABRI 5 PA; MO; LA

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

baclofen oral 2 MO; GC

cyclobenzaprine oral tablet 10 mg, 5 mg

3 PA; MO

dantrolene oral 4 MO

pyridostigmine bromide oral syrup

4 MO

pyridostigmine bromide oral tablet60 mg

3 MO

pyridostigmine bromide oral tablet extended release

3 MO

regonol 4

tizanidine oral tablet

2 MO; GC

NARCOTIC ANALGESICS

acetaminophen-codeine oral solution120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml

2 GC; QL (4500 per 30 days); NDS

acetaminophen-codeine oral solution120-12 mg/5 ml

2 MO; GC; QL (4500 per 30 days); NDS

Drug Name Drug Tier

Requirements/Limits

acetaminophen-codeine oral tablet300-15 mg, 300-30 mg


acetaminophen-codeine oral tablet300-60 mg


buprenorphine hcl injection solution

4 MO; NDS

buprenorphine hcl injection syringe

4 NDS

buprenorphine hcl sublingual

3 PA; MO

endocet oral tablet10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

4 MO; QL (360 per 30 days); NDS

fentanyl citrate buccal lozenge on a handle

5 PA; MO; QL (120 per 30 days); NDS

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


hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml)

4 QL (5550 per 30 days); NDS

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml


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



30

Drug Name Drug Tier

Requirements/Limits

hydrocodone-ibuprofen oral tablet7.5-200 mg


hydromorphone oral liquid


hydromorphone oral tablet


INFUMORPH P/F INJECTION SOLUTION 10 MG/ML

4 B/D PA; MO; QL (200 per 30 days); NDS

INFUMORPH P/F INJECTION SOLUTION 25 MG/ML

4 B/D PA; MO; QL (80 per 30 days); NDS

methadone injection solution


methadone intensol 4 PA; MO; QL (90 per 30 days); NDS

methadone oral concentrate


methadone oral solution 10 mg/5 ml


methadone oral solution 5 mg/5 ml


methadone oral tablet 10 mg

2 PA; MO; GC; QL (120 per 30 days); NDS

Drug Name Drug Tier

Requirements/Limits

methadone oral tablet 5 mg

2 PA; MO; GC; QL (240 per 30 days); NDS

morphine (pf) injection solution0.5 mg/ml


morphine (pf) injection solution 1 mg/ml


morphine concentrate oral solution


MORPHINE INJECTION SOLUTION 10 MG/ML








morphine injection solution 8 mg/ml


morphine injection syringe 2 mg/ml





31

Drug Name Drug Tier

Requirements/Limits



morphine intravenous solution10 mg/ml


MORPHINE INTRAVENOUS SOLUTION 4 MG/ML


MORPHINE INTRAVENOUS SOLUTION 8 MG/ML


morphine intravenous syringe2 mg/ml


morphine intravenous syringe4 mg/ml


MORPHINE INTRAVENOUS SYRINGE 8 MG/ML


morphine oral solution


morphine oral tablet 3 MO; QL (180 per 30 days); NDS

morphine oral tablet extended release


oxycodone oral concentrate


oxycodone oral solution


Drug Name Drug Tier

Requirements/Limits

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


oxycodone oral tablet 5 mg


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


oxycodone-aspirin 4 MO; QL (360 per 30 days); NDS

oxymorphone oral tablet extended release 12 hr


NON-NARCOTIC ANALGESICS

buprenorphine-naloxone sublingual film 12-3 mg


buprenorphine-naloxone sublingual film 2-0.5 mg


buprenorphine-naloxone sublingual film 4-1 mg, 8-2 mg


buprenorphine-naloxone sublingual tablet 2-0.5 mg


buprenorphine-naloxone sublingual tablet 8-2 mg


butorphanol nasal 4 MO; QL (10 per 28 days); NDS


32

Drug Name Drug Tier

Requirements/Limits

celecoxib 3 MO; QL (60 per 30 days)

diclofenac potassium

2 MO; GC

diclofenac sodium oral

2 MO; GC

diclofenac sodium topical gel 1 %


diflunisal 2 MO; GC

ec-naproxen 2 MO; GC

etodolac 4 MO

flurbiprofen oral tablet 100 mg

2 MO; GC

ibu 1 MO; GC

ibuprofen oral suspension

2 MO; GC

ibuprofen oral tablet400 mg, 600 mg, 800 mg

1 MO; GC

meloxicam oral tablet


nabumetone 2 MO; GC

naloxone injection solution

2 MO; GC

naloxone injection syringe 1 mg/ml

2 MO; GC

naltrexone 2 MO; GC

naproxen oral suspension

4 MO

naproxen oral tablet 1 MO; GC

naproxen oral tablet,delayed release (dr/ec)

2 MO; GC

naproxen sodium oral tablet 275 mg, 550 mg

4 MO

Drug Name Drug Tier

Requirements/Limits

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

3 MO

oxaprozin 4 MO

SUBOXONE SUBLINGUAL FILM 12-3 MG


SUBOXONE SUBLINGUAL FILM 2-0.5 MG


SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG


sulindac 2 MO; GC

tramadol oral tablet50 mg


tramadol-acetaminophen


VIVITROL 5 MO

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


ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG


PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA


ADASUVE 4 LA


33

Drug Name Drug Tier

Requirements/Limits

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg


alprazolam oral tablet 2 mg


amitriptyline 2 MO; GC

amoxapine 4 MO

aripiprazole oral solution

4 MO

aripiprazole oral tablet


aripiprazole oral tablet,disintegrating


asenapine maleate 4 MO; QL (60 per 30 days)

atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg


atomoxetine oral capsule 100 mg, 60 mg, 80 mg


bupropion hcl oral tablet 100 mg


bupropion hcl oral tablet 75 mg


bupropion hcl oral tablet extended release 24 hr 150 mg


bupropion hcl oral tablet extended release 24 hr 300 mg


bupropion hcl oral tablet sustained-release 12 hr


buspirone 2 MO; GC

Drug Name Drug Tier

Requirements/Limits

CAPLYTA 4 PA; MO; QL (30 per 30 days)

chlorpromazine 4 MO

citalopram oral solution


citalopram oral tablet


clomipramine 4 MO

clorazepate dipotassium oral tablet 15 mg


clorazepate dipotassium oral tablet 3.75 mg


clorazepate dipotassium oral tablet 7.5 mg


clozapine oral tablet100 mg, 200 mg

4 MO

clozapine oral tablet25 mg, 50 mg

3 MO

clozapine oral tablet,disintegrating

4 MO

desipramine 4 MO

desvenlafaxine succinate


dexmethylphenidate oral tablet

3 MO

dextroamphetamine oral capsule, extended release

4 MO

dextroamphetamine oral tablet

4 MO


34

Drug Name Drug Tier

Requirements/Limits

dextroamphetamine-amphetamine oral capsule,extended release 24hr


dextroamphetamine-amphetamine oral tablet 10 mg, 15 mg, 20 mg, 5 mg

2 MO; GC

dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg


diazepam injection solution

2 PA; GC

diazepam injection syringe

2 PA; MO; GC

diazepam intensol 2 PA; MO; GC; QL (240 per 30 days)

diazepam oral concentrate


diazepam oral solution 5 mg/5 ml (1 mg/ml)


diazepam oral tablet 2 PA; MO; GC; QL (120 per 30 days)

doxepin oral capsule 3 MO

doxepin oral concentrate

3 MO

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 60 MG


Drug Name Drug Tier

Requirements/Limits

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 40 MG


duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg


EMSAM 4 MO; QL (30 per 30 days)

escitalopram oxalate oral solution


escitalopram oxalate oral tablet


FANAPT ORAL TABLET


FANAPT ORAL TABLETS,DOSE PACK


FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

4 ST; MO; QL (28 per 28 days)

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR


fluoxetine oral capsule 10 mg



2 MO; GC




35

Drug Name Drug Tier

Requirements/Limits

fluoxetine oral solution

2 MO; GC

fluphenazine decanoate

4 MO

fluphenazine hcl injection

4 MO

fluphenazine hcl oral concentrate

4 MO

fluphenazine hcl oral elixir

4 MO

fluphenazine hcl oral tablet

2 MO; GC

fluvoxamine oral tablet 100 mg






haloperidol 2 MO; GC

haloperidol decanoate

4 MO

haloperidol lactate injection

4 MO

haloperidol lactate oral

2 MO; GC

HETLIOZ 5 PA; MO; QL (30 per 30 days)

imipramine hcl 3 MO

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML

4 MO; QL (0.75 per 28 days)

Drug Name Drug Tier

Requirements/Limits

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML








INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML









36

Drug Name Drug Tier

Requirements/Limits

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


LATUDA ORAL TABLET 80 MG


lithium carbonate 2 MO; GC

lorazepam injection solution

4 PA; MO

lorazepam injection syringe 2 mg/ml

4 PA; MO

lorazepam injection syringe 4 mg/ml

4 PA

lorazepam intensol 3 PA; MO; QL (150 per 30 days)

lorazepam oral concentrate


lorazepam oral tablet 0.5 mg, 1 mg


lorazepam oral tablet 2 mg


loxapine succinate 4 MO

maprotiline 4 MO

MARPLAN 4 MO; QL (180 per 30 days)

methylphenidate hcl oral tablet


methylphenidate hcl oral tablet extended release

4 MO

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl oral tablet extended release 24hr 18 mg (bx rating), 27 mg (bx rating), 36 mg (bx rating), 54 mg (bx rating)

4

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

4 MO

mirtazapine oral tablet


mirtazapine oral tablet,disintegrating


modafinil oral tablet100 mg


modafinil oral tablet200 mg


molindone 2 MO; GC

nefazodone 4 MO

nortriptyline 2 MO; GC

NUPLAZID ORAL CAPSULE


NUPLAZID ORAL TABLET 10 MG


olanzapine intramuscular


olanzapine oral tablet



37

Drug Name Drug Tier

Requirements/Limits

olanzapine oral tablet,disintegrating


olanzapine-fluoxetine

4 MO

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg


paliperidone oral tablet extended release 24hr 6 mg


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


paroxetine hcl oral tablet 30 mg


PAXIL ORAL SUSPENSION


perphenazine 4 MO

perphenazine-amitriptyline

4 MO

PERSERIS 4 MO; QL (1 per 30 days)

phenelzine 3 MO

pimozide 4 MO

protriptyline 4 MO

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


quetiapine oral tablet 300 mg, 400 mg


quetiapine oral tablet extended release 24 hr 150 mg, 200 mg


Drug Name Drug Tier

Requirements/Limits

quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg


ramelteon 3 MO; QL (30 per 30 days)

REXULTI 4 MO; QL (30 per 30 days)

RISPERDAL CONSTA


risperidone oral solution

4 MO

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


risperidone oral tablet 4 mg


risperidone oral tablet,disintegrating0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet,disintegrating4 mg


SAPHRIS 4 MO; QL (60 per 30 days)

SECUADO 4 MO; QL (30 per 30 days)

sertraline oral concentrate

4 MO

sertraline oral tablet100 mg, 50 mg



38

Drug Name Drug Tier

Requirements/Limits

sertraline oral tablet25 mg


temazepam oral capsule 22.5 mg, 7.5 mg

4 MO

thioridazine 4 MO

thiothixene 4 MO

tranylcypromine 4 MO

trazodone oral tablet 100 mg, 150 mg, 50 mg

1 MO; GC

trazodone oral tablet 300 mg

2 MO; GC

trifluoperazine oral tablet 1 mg

3 MO

trifluoperazine oral tablet 10 mg, 2 mg, 5 mg

4 MO

trimipramine 4 MO

TRINTELLIX 4 ST; MO; QL (30 per 30 days)

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg


venlafaxine oral capsule,extended release 24hr 75 mg


venlafaxine oral tablet


VERSACLOZ 4

VIIBRYD ORAL TABLET


Drug Name Drug Tier

Requirements/Limits

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)


VRAYLAR ORAL CAPSULE


VRAYLAR ORAL CAPSULE,DOSE PACK


XYREM 5 PA; MO; LA; QL (540 per 30 days)

zaleplon oral capsule 10 mg


zaleplon oral capsule 5 mg


ziprasidone hcl 4 MO; QL (60 per 30 days)

ziprasidone mesylate

4 QL (6 per 30 days)

zolpidem oral tablet 2 MO; GC; QL (30 per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG



39

Drug Name Drug Tier

Requirements/Limits

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG


CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone intravenous solution

4 B/D PA; MO

amiodarone oral tablet 100 mg, 200 mg

2 MO; GC

amiodarone oral tablet 400 mg

4 MO

dofetilide 4 MO

flecainide 4 MO

lidocaine (pf) intravenous solution

4 MO

lidocaine (pf) intravenous syringe

4

mexiletine 4 MO

pacerone oral tablet100 mg, 200 mg

2 MO; GC

pacerone oral tablet400 mg

4 MO

propafenone 4 MO

quinidine sulfate oral tablet

2 MO; GC

sorine oral tablet120 mg, 160 mg, 80 mg

2 MO; GC

sorine oral tablet240 mg

2 GC

Drug Name Drug Tier

Requirements/Limits

sotalol af 2 MO; GC

sotalol oral 2 MO; GC

SOTYLIZE 4 MO

ANTIHYPERTENSIVE THERAPY

acebutolol 2 MO; GC

aliskiren 4 MO

amiloride 2 MO; GC

amiloride-hydrochlorothiazide

2 MO; GC

amlodipine 1 MO; GC

amlodipine-benazepril

2 MO; GC

amlodipine-valsartan

2 MO; GC

amlodipine-valsartan-hcthiazid

2 MO; GC

atenolol 1 MO; GC

atenolol-chlorthalidone

2 MO; GC

benazepril 1 MO; GC

benazepril-hydrochlorothiazide

2 MO; GC

betaxolol oral 3 MO

BIDIL 3 MO

bisoprolol fumarate 2 MO; GC

bisoprolol-hydrochlorothiazide

1 MO; GC

bumetanide injection

4 MO

bumetanide oral 2 MO; GC

BYSTOLIC 4 MO

candesartan oral tablet 16 mg, 4 mg, 8 mg



40

Drug Name Drug Tier

Requirements/Limits

candesartan oral tablet 32 mg


candesartan-hydrochlorothiazid

2 MO; GC

captopril 4 MO

captopril-hydrochlorothiazide

4 MO

cartia xt 2 MO; GC

carvedilol 1 MO; GC

carvedilol phosphate 4 MO

chlorothiazide sodium

4 MO

chlorthalidone oral tablet 25 mg, 50 mg

2 MO; GC

clonidine 3 MO; QL (4 per 28 days)

clonidine hcl oral tablet 0.1 mg, 0.2 mg

1 MO; GC

clonidine hcl oral tablet 0.3 mg

2 MO; GC

DEMSER 4 PA; MO

diltiazem hcl intravenous recon soln

4

diltiazem hcl intravenous solution

4 MO

diltiazem hcl oral capsule,ext.rel 24h degradable

2 MO; GC

diltiazem hcl oral capsule,extended release 12 hr

2 MO; GC

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg

2 MO; GC

Drug Name Drug Tier

Requirements/Limits

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

2 MO; GC

diltiazem hcl oral tablet

2 MO; GC

diltiazem hcl oral tablet extended release 24 hr

2 MO; GC

dilt-xr 2 MO; GC

doxazosin oral tablet 1 mg, 2 mg, 4 mg


doxazosin oral tablet 8 mg


enalapril maleate 1 MO; GC

enalapril-hydrochlorothiazide

1 MO; GC

ethacrynate sodium 4 MO

felodipine 2 MO; GC

fosinopril 2 MO; GC

fosinopril-hydrochlorothiazide

2 MO; GC

furosemide injection 4 MO

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

2 MO; GC

furosemide oral tablet

1 MO; GC

hydralazine injection

4 MO

hydralazine oral 2 MO; GC

hydrochlorothiazide 1 MO; GC

indapamide 1 MO; GC

irbesartan 1 MO; GC; QL (30 per 30 days)


41

Drug Name Drug Tier

Requirements/Limits

irbesartan-hydrochlorothiazide


isradipine 4 MO

labetalol oral 2 MO; GC

lisinopril 1 MO; GC

lisinopril-hydrochlorothiazide

1 MO; GC

losartan 1 MO; GC; QL (60 per 30 days)

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg


losartan-hydrochlorothiazide oral tablet 50-12.5 mg


matzim la 2 MO; GC

methyldopa 4 MO

metolazone 3 MO

metoprolol succinate

1 MO; GC

metoprolol ta-hydrochlorothiaz

2 MO; GC

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

1 MO; GC

metyrosine 5 PA; MO

minoxidil oral 2 MO; GC

moexipril 2 MO; GC

nadolol oral tablet20 mg, 40 mg

2 MO; GC

nadolol oral tablet80 mg

4 MO

nadolol-bendroflumethiazide oral tablet 80-5 mg

4 MO

Drug Name Drug Tier

Requirements/Limits

nicardipine intravenous solution

4 MO

nicardipine oral 4 MO

nifedipine oral tablet extended release

2 MO; GC

nifedipine oral tablet extended release 24hr

2 MO; GC

nimodipine 4 MO

nisoldipine 4 MO

olmesartan 2 MO; GC

olmesartan-hydrochlorothiazide

2 MO; GC

perindopril erbumine

2 MO; GC

phenoxybenzamine 5 MO

pindolol 2 MO; GC

prazosin 4 MO

propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 80 mg

4 MO

propranolol oral capsule,extended release 24 hr 60 mg

2 MO; GC

propranolol oral solution

4 MO

propranolol oral tablet

2 MO; GC

propranolol-hydrochlorothiazid

3 MO

quinapril 1 MO; GC

quinapril-hydrochlorothiazide

2 MO; GC

ramipril 1 MO; GC

spironolactone 2 MO; GC

spironolacton-hydrochlorothiaz

2 MO; GC


42

Drug Name Drug Tier

Requirements/Limits

taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg

2 MO; GC

TEKTURNA HCT 4 MO

telmisartan 2 MO; GC

telmisartan-amlodipine

2 MO; GC

telmisartan-hydrochlorothiazid

2 MO; GC

terazosin oral capsule 1 mg, 2 mg, 5 mg


terazosin oral capsule 10 mg


tiadylt er 3 MO

timolol maleate oral 2 MO; GC

torsemide oral 2 MO; GC

trandolapril 2 MO; GC

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1 MO; GC

triamterene-hydrochlorothiazid oral tablet

1 MO; GC

UPTRAVI 5 PA; MO; LA

valsartan oral tablet160 mg, 40 mg, 80 mg


valsartan oral tablet320 mg


valsartan-hydrochlorothiazide


Drug Name Drug Tier

Requirements/Limits

verapamil intravenous solution

4 MO

verapamil oral capsule, 24 hr er pellet ct

2 MO; GC

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg

2 MO; GC

verapamil oral capsule,ext rel. pellets 24 hr 360 mg

3 MO

verapamil oral tablet

1 MO; GC

verapamil oral tablet extended release

2 MO; GC

COAGULATION THERAPY

aspirin-dipyridamole

4 MO

BRILINTA 3 MO; QL (60 per 30 days)

cilostazol 2 MO; GC

clopidogrel oral tablet 300 mg

4 MO

clopidogrel oral tablet 75 mg


dipyridamole oral 2 MO; GC

ELIQUIS 3 MO

ELIQUIS DVT-PE TREAT 30D START

3 MO

enoxaparin subcutaneous solution

4 MO


43

Drug Name Drug Tier

Requirements/Limits

enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml


enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml


enoxaparin subcutaneous syringe 30 mg/0.3 ml, 60 mg/0.6 ml


enoxaparin subcutaneous syringe 40 mg/0.4 ml


fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5 MO

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

4 MO

heparin (porcine) in 5 % dex intravenous parenteral solution20,000 unit/500 ml (40 unit/ml)

4

heparin (porcine) in 5 % dex intravenous parenteral solution25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

4 MO

heparin (porcine) in nacl (pf)

4

heparin (porcine) injection solution

3 MO

Drug Name Drug Tier

Requirements/Limits

heparin(porcine) in 0.45% nacl intravenous parenteral solution25,000 unit/250 ml, 25,000 unit/500 ml

4 MO

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

4 MO

HEPARIN, PORCINE (PF) SUBCUTANEOUS

4

jantoven 1 MO; GC

pentoxifylline 2 MO; GC

prasugrel 4 MO

PROMACTA ORAL POWDER IN PACKET 12.5 MG


PROMACTA ORAL POWDER IN PACKET 25 MG


PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG


PROMACTA ORAL TABLET 75 MG


warfarin 1 MO; GC

XARELTO 3 MO

XARELTO DVT-PE TREAT 30D START

3 MO


44

Drug Name Drug Tier

Requirements/Limits

LIPID/CHOLESTEROL LOWERING AGENTS

atorvastatin 1 MO; GC; QL (30 per 30 days)

cholestyramine (with sugar)

3 MO

cholestyramine light 3 MO

colesevelam 3 MO

colestipol oral granules

4 MO

colestipol oral packet

4 MO

colestipol oral tablet 3 MO

ezetimibe 3 MO; QL (30 per 30 days)

ezetimibe-simvastatin


fenofibrate micronized oral capsule 134 mg, 200 mg


fenofibrate micronized oral capsule 67 mg


fenofibrate nanocrystallized oral tablet 145 mg


fenofibrate nanocrystallized oral tablet 48 mg


fenofibrate oral tablet 160 mg


Drug Name Drug Tier

Requirements/Limits

fenofibrate oral tablet 54 mg


fenofibric acid (choline)

4 MO

fluvastatin oral capsule 20 mg


fluvastatin oral capsule 40 mg


gemfibrozil 1 MO; GC; QL (60 per 30 days)

lovastatin oral tablet 10 mg


lovastatin oral tablet 20 mg, 40 mg


niacin oral tablet extended release 24 hr

4 MO

pravastatin 1 MO; GC; QL (30 per 30 days)

prevalite 3 MO

REPATHA 3 PA; QL (3 per 28 days)

REPATHA PUSHTRONEX

3 PA; QL (3.5 per 28 days)

REPATHA SURECLICK

3 PA; QL (3 per 28 days)

rosuvastatin 2 MO; GC; QL (30 per 30 days)

simvastatin oral tablet


VASCEPA 3 MO


45

Drug Name Drug Tier

Requirements/Limits

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR ORAL TABLET


digitek oral tablet125 mcg (0.125 mg)


digitek oral tablet250 mcg (0.25 mg)

3 MO

digox oral tablet125 mcg (0.125 mg)


digox oral tablet250 mcg (0.25 mg)

3 MO

digoxin injection solution

4 MO

digoxin oral solution50 mcg/ml (0.05 mg/ml)

3 MO

digoxin oral tablet125 mcg (0.125 mg)


digoxin oral tablet250 mcg (0.25 mg)

3 MO

ENTRESTO 3 MO; QL (60 per 30 days)

LANOXIN ORAL TABLET 62.5 MCG (0.0625 MG)

4 MO

LANOXIN PEDIATRIC

4

ranolazine 3 MO; QL (60 per 30 days)

VYNDAQEL 4 PA; MO

Drug Name Drug Tier

Requirements/Limits

NITRATES

isosorbide dinitrate oral tablet

4 MO

isosorbide mononitrate

2 MO; GC

MINITRAN 3 MO

nitroglycerin intravenous

4 B/D PA

nitroglycerin sublingual

2 MO; GC

nitroglycerin transdermal patch 24 hour

2 MO; GC

nitroglycerin translingual spray,non-aerosol

4 MO

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin 4 MO

calcipotriene scalp 3 MO; QL (120 per 30 days)

calcipotriene topical cream


calcipotriene topical ointment


selenium sulfide topical lotion

2 MO; GC

SKYRIZI SUBCUTANEOUS SYRINGE KIT



46

Drug Name Drug Tier

Requirements/Limits

STELARA SUBCUTANEOUS SOLUTION

5 PA; MO; QL (0.5 per 28 days)

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML


STELARA SUBCUTANEOUS SYRINGE 90 MG/ML


TALTZ SYRINGE 5 PA; MO; QL (4 per 28 days)

MISCELLANEOUS DERMATOLOGICALS

ammonium lactate 2 MO; GC

DUPIXENT PEN 5 PA; MO; QL (8 per 28 days)

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG/1.14 ML


DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG/2 ML


fluorouracil topical cream 5 %

3 MO

fluorouracil topical solution

3 MO

glydo 3 MO; QL (60 per 30 days)

imiquimod topical cream in packet 5 %

3 MO

Drug Name Drug Tier

Requirements/Limits

lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)

4 MO

lidocaine (pf) injection solution 15 mg/ml (1.5 %)

4

lidocaine hcl injection solution

4 MO

lidocaine hcl laryngotracheal

3 MO

lidocaine hcl mucous membrane jelly


lidocaine hcl mucous membrane jelly in applicator


lidocaine hcl mucous membrane solution4 % (40 mg/ml)

3 MO

lidocaine topical adhesive patch,medicated 5 %


lidocaine topical ointment


lidocaine viscous 2 MO; GC

lidocaine-prilocaine topical cream


methoxsalen 4 MO

PANRETIN 5 MO

PICATO 4 MO

podofilox 4 MO

REGRANEX 5 PA; MO

SANTYL 4 MO

silver sulfadiazine 2 MO; GC


47

Drug Name Drug Tier

Requirements/Limits

ssd 4 MO

tacrolimus topical 4 PA; MO; QL (100 per 30 days)

VALCHLOR 5 PA; MO

ZTLIDO 3 PA; MO; QL (90 per 30 days)

THERAPY FOR ACNE

avita topical cream 4 PA; MO

claravis 4 MO

clindamycin phosphate topical gel


CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY


clindamycin phosphate topical lotion


clindamycin phosphate topical solution


clindamycin phosphate topical swab


ery pads 4 MO

erythromycin with ethanol topical gel

4 MO

erythromycin with ethanol topical solution

2 MO; GC

erythromycin-benzoyl peroxide

4 MO

isotretinoin 4 MO

metronidazole topical

3 MO

Drug Name Drug Tier

Requirements/Limits

rosadan topical cream

3 MO

rosadan topical gel 3 MO

tazarotene 4 PA; MO

TAZORAC TOPICAL CREAM 0.05 %

4 PA; MO

tretinoin microspheres topical gel 0.1 %

4 PA; MO

tretinoin microspheres topical gel with pump 0.1 %

4 PA; MO

tretinoin topical cream 0.025 %, 0.05 %, 0.1 %

4 PA; MO

tretinoin topical topical gel 0.01 %

3 PA; MO

tretinoin topical topical gel 0.025 %, 0.05 %

4 PA; MO

TOPICAL ANTIBACTERIALS

gentamicin topical cream

4 MO

gentamicin topical ointment

3 MO

mupirocin 2 MO; GC; QL (30 per 30 days)

mupirocin calcium 4 MO; QL (30 per 30 days)

sulfacetamide sodium (acne)

4 MO


48

Drug Name Drug Tier

Requirements/Limits

TOPICAL ANTIFUNGALS

ciclodan topical solution

4 MO

ciclopirox topical cream


ciclopirox topical shampoo


ciclopirox topical solution

2 MO; GC

ciclopirox topical suspension


clotrimazole topical cream


clotrimazole topical solution


clotrimazole-betamethasone topical cream


clotrimazole-betamethasone topical lotion


econazole 4 MO; QL (85 per 28 days)

ketoconazole topical cream


ketoconazole topical shampoo


nyamyc 2 MO; GC

nystatin topical cream


Drug Name Drug Tier

Requirements/Limits

nystatin topical ointment


nystatin topical powder

3 MO

nystatin-triamcinolone


nystop 4 MO

TOPICAL ANTIVIRALS

acyclovir topical ointment


DENAVIR 4 MO

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 1 %

2 MO; GC

alclometasone topical cream

3 MO

alclometasone topical ointment

2 MO; GC

betamethasone dipropionate

4 MO

betamethasone valerate topical cream

2 MO; GC

betamethasone valerate topical lotion

4 MO

betamethasone valerate topical ointment

2 MO; GC

betamethasone, augmented topical cream

2 MO; GC


49

Drug Name Drug Tier

Requirements/Limits

betamethasone, augmented topical gel

4 MO

betamethasone, augmented topical lotion

4 MO

betamethasone, augmented topical ointment

4 MO

clobetasol scalp 2 MO; GC; QL (100 per 28 days)

clobetasol topical cream


clobetasol topical foam


clobetasol topical gel


clobetasol topical lotion


clobetasol topical ointment


clobetasol topical shampoo


clobetasol topical spray,non-aerosol


clobetasol-emollient topical cream


clodan 4 MO; QL (236 per 28 days)

DESONATE 4 MO

desonide 4 MO

Drug Name Drug Tier

Requirements/Limits

desoximetasone topical cream

4 MO

desoximetasone topical gel

4 MO

desoximetasone topical ointment

4 MO

fluocinolone 4 MO

fluocinolone and shower cap

4 MO

fluocinonide topical cream 0.05 %


fluocinonide topical gel


fluocinonide topical ointment


fluocinonide topical solution


fluticasone propionate topical cream

2 MO; GC

fluticasone propionate topical ointment

3 MO

halobetasol propionate topical cream

4 MO

halobetasol propionate topical ointment

4 MO

hydrocortisone butyrate topical cream


hydrocortisone butyrate topical ointment

4 MO


50

Drug Name Drug Tier

Requirements/Limits

hydrocortisone butyr-emollient


hydrocortisone topical cream 1 %, 2.5 %

2 MO; GC

hydrocortisone topical lotion 2.5 %

2 MO; GC

hydrocortisone topical ointment 1 %, 2.5 %

2 MO; GC

hydrocortisone valerate

4 MO

IMPOYZ 4 MO; QL (120 per 28 days)

mometasone topical 2 MO; GC

prednicarbate topical ointment

2 MO; GC

triamcinolone acetonide topical cream

2 MO; GC

triamcinolone acetonide topical lotion

3 MO

triamcinolone acetonide topical ointment

2 MO; GC

triderm topical cream 0.1 %

2 MO; GC

TOPICAL SCABICIDES / PEDICULICIDES

lindane topical shampoo

4 MO

malathion 4 MO

permethrin topical cream

3 MO

Drug Name Drug Tier

Requirements/Limits

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

lactated ringers irrigation

4 MO

neomycin-polymyxin b gu

4 MO

ringer's irrigation 4 MO

tis-u-sol pentalyte 4 MO

MISCELLANEOUS AGENTS

acamprosate 4 MO

anagrelide 3 MO

AURYXIA 4 PA; MO; QL (360 per 30 days)

CARBAGLU 5 PA; MO; LA

CHEMET 4 PA; MO

CLINIMIX 4.25%/D5W SULFIT FREE

4 B/D PA

d10 %-0.45 % sodium chloride

4

d2.5 %-0.45 % sodium chloride

4

d5 % and 0.9 % sodium chloride

4 MO

d5 %-0.45 % sodium chloride

4 MO

deferasirox oral tablet, dispersible

5 PA; MO

dextrose 10 % and 0.2 % nacl

4


51

Drug Name Drug Tier

Requirements/Limits

dextrose 10 % in water (d10w)

4 MO


4


4


4


4 MO

dextrose 5 %-lactated ringers

4 MO

dextrose 5%-0.2 % sod chloride

4


4 MO


4 MO

disulfiram 4 MO

INCRELEX 4 PA; MO; LA

kionex (with sorbitol)

3 MO

levocarnitine (with sugar)

2 MO; GC

levocarnitine oral solution 100 mg/ml

2 MO; GC

levocarnitine oral tablet

2 MO; GC

midodrine 3 MO

nitisinone 5 MO

NORTHERA ORAL CAPSULE 100 MG


NORTHERA ORAL CAPSULE 200 MG, 300 MG


pilocarpine hcl oral tablet 5 mg

2 MO; GC

Drug Name Drug Tier

Requirements/Limits

pilocarpine hcl oral tablet 7.5 mg

4 MO

PROLASTIN-C INTRAVENOUS RECON SOLN

5 PA; LA

PROLASTIN-C INTRAVENOUS SOLUTION

5 PA; MO; LA

riluzole 3 MO

sevelamer carbonate oral powder in packet

5 MO

sevelamer carbonate oral tablet


sodium chloride 0.9 % intravenous

4 MO

sodium chloride irrigation

4 MO

sodium phenylbutyrate

5 PA; MO

sodium polystyrene (sorb free)

3 MO

sodium polystyrene sulfonate oral powder

3 MO

sps (with sorbitol) oral

3 MO

sps (with sorbitol) rectal

3

trientine 5 PA; MO; QL (240 per 30 days)

VELPHORO 4 MO

VELTASSA 3 MO

water for irrigation, sterile

4 MO


52

Drug Name Drug Tier

Requirements/Limits

zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml

4 PA; MO

SMOKING DETERRENTS

bupropion hcl (smoking deter)


CHANTIX 4 MO

CHANTIX CONTINUING MONTH BOX

4 MO

CHANTIX STARTING MONTH BOX

4 MO

NICOTROL 4 MO

NICOTROL NS 4 MO

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal 3 MO; QL (60 per 30 days)

chlorhexidine gluconate mucous membrane

2 MO; GC

ipratropium bromide nasal


oralone 4 MO

paroex oral rinse 2 MO; GC

triamcinolone acetonide dental

4 MO

Drug Name Drug Tier

Requirements/Limits

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear)

2 MO; GC

flac otic oil 4

fluocinolone acetonide oil

4 MO

hydrocortisone-acetic acid

4 MO

OTIC STEROID / ANTIBIOTIC

CIPRO HC 4 MO

CIPRODEX 3 MO

ciprofloxacin-dexamethasone

3 MO

neomycin-polymyxin-hc otic (ear)

3 MO

ENDOCRINE/DIABETES

ADRENAL HORMONES

DEPO-MEDROL 4 MO

dexamethasone intensol

4 MO

dexamethasone oral elixir

2 MO; GC

dexamethasone oral solution

2 MO; GC

dexamethasone oral tablet 0.5 mg, 0.75 mg

1 MO; GC

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

2 MO; GC


53

Drug Name Drug Tier

Requirements/Limits

dexamethasone sodium phos (pf) injection solution

4 MO

dexamethasone sodium phosphate injection solution

4 MO

fludrocortisone 2 MO; GC

hydrocortisone oral 3 MO

MEDROL ORAL TABLET 2 MG

3 MO

methylprednisolone acetate

4 MO

methylprednisolone oral tablet

2 B/D PA; MO; GC

methylprednisolone oral tablets,dose pack

2 MO; GC

methylprednisolone sodium succ injection recon soln125 mg, 40 mg

4 MO

prednisolone oral solution 15 mg/5 ml

4 MO

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

4 MO

prednisolone sodium phosphate oral solution 15 mg/5 ml (5 ml)

4

prednisone intensol 4 B/D PA; MO

prednisone oral solution

2 MO; GC

prednisone oral tablet

2 B/D PA; MO; GC

Drug Name Drug Tier

Requirements/Limits

prednisone oral tablets,dose pack

1 MO; GC

SOLU-CORTEF 3 MO

SOLU-CORTEF ACT-O-VIAL (PF)

4 MO

triamcinolone acetonide injection suspension 40 mg/ml

4 MO

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg

2 MO; GC

propylthiouracil 3 MO

DIABETES THERAPY

acarbose oral tablet100 mg






alcohol pads 6 MO

BAQSIMI 3 MO

BYDUREON BCISE


BYDUREON SUBCUTANEOUS PEN INJECTOR


diazoxide 4 MO

GAUZE PADS 2 X 2

6 MO

glimepiride oral tablet 1 mg



54

Drug Name Drug Tier

Requirements/Limits





glipizide oral tablet10 mg


glipizide oral tablet5 mg


glipizide oral tablet extended release 24hr 10 mg


glipizide oral tablet extended release 24hr 2.5 mg


glipizide oral tablet extended release 24hr 5 mg


glipizide-metformin oral tablet 2.5-250 mg


glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg


GLUCAGEN HYPOKIT

3 MO

GLUCAGON (HCL) EMERGENCY KIT

3

GLUCAGON EMERGENCY KIT (HUMAN)

3 MO

GLYXAMBI 4 MO; QL (30 per 30 days)

Drug Name Drug Tier

Requirements/Limits

GVOKE HYPOPEN 1-PACK

3 MO

GVOKE HYPOPEN 2-PACK

3 MO

GVOKE PFS 1-PACK SYRINGE

3 MO

GVOKE PFS 2-PACK SYRINGE

3 MO

HUMALOG JUNIOR KWIKPEN U-100

6 MO; SSM

HUMALOG KWIKPEN INSULIN

6 MO; SSM

HUMALOG MIX 50-50 INSULN U-100

6 MO; SSM

HUMALOG MIX 50-50 KWIKPEN

6 MO; SSM

HUMALOG MIX 75-25 KWIKPEN

6 MO; SSM

HUMALOG MIX 75-25(U-100)INSULN

6 MO; SSM

HUMALOG U-100 INSULIN

6 MO; SSM

HUMULIN 70/30 U-100 INSULIN

6 MO; SSM

HUMULIN 70/30 U-100 KWIKPEN

6 MO; SSM

HUMULIN N NPH INSULIN KWIKPEN

6 MO; SSM

HUMULIN N NPH U-100 INSULIN

6 MO; SSM

HUMULIN R REGULAR U-100 INSULN

6 MO; SSM


55

Drug Name Drug Tier

Requirements/Limits

HUMULIN R U-500 (CONC) INSULIN

5 MO

HUMULIN R U-500 (CONC) KWIKPEN

5 MO

INSULIN PEN NEEDLE

6 MO

INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML

6 MO

INVOKAMET 6 MO; QL (60 per 30 days)

INVOKAMET XR 6 MO; QL (60 per 30 days)

INVOKANA 6 MO; QL (30 per 30 days)

JANUMET 6 MO; QL (60 per 30 days)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG


JANUVIA 6 MO; QL (30 per 30 days)

JARDIANCE 6 MO; QL (30 per 30 days)

Drug Name Drug Tier

Requirements/Limits

JENTADUETO 6 MO; QL (60 per 30 days)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG


JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG


LANTUS SOLOSTAR U-100 INSULIN

6 MO; SSM

LANTUS U-100 INSULIN

6 MO; SSM

LYUMJEV KWIKPEN U-100 INSULIN

6 MO; SSM

LYUMJEV KWIKPEN U-200 INSULIN

6 MO; SSM

LYUMJEV U-100 INSULIN

6 MO; SSM

metformin oral solution


metformin oral tablet 1,000 mg


metformin oral tablet 500 mg


metformin oral tablet 850 mg


metformin oral tablet extended release 24 hr 500 mg



56

Drug Name Drug Tier

Requirements/Limits

metformin oral tablet extended release 24 hr 750 mg


nateglinide oral tablet 120 mg


nateglinide oral tablet 60 mg


NEEDLES, INSULIN DISP.,SAFETY

6 MO

OMNIPOD DASH 5 PACK POD


OMNIPOD INSULIN MANAGEMENT


OMNIPOD INSULIN REFILL


OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML)


OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML)


pioglitazone 2 MO; GC; QL (30 per 30 days)

pioglitazone-metformin


PROGLYCEM 4 MO

repaglinide oral tablet 0.5 mg


Drug Name Drug Tier

Requirements/Limits

repaglinide oral tablet 1 mg


repaglinide oral tablet 2 mg


RYBELSUS 6 MO; QL (30 per 30 days)

SYNJARDY 6 MO; QL (60 per 30 days)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG


TOUJEO MAX U-300 SOLOSTAR

6 MO; SSM

TOUJEO SOLOSTAR U-300 INSULIN

6 MO; SSM

TRADJENTA 6 MO; QL (30 per 30 days)

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-5-1,000 MG, 25-5-1,000 MG



57

Drug Name Drug Tier

Requirements/Limits

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-2.5-1,000 MG, 5-2.5-1,000 MG


TRULICITY 6 MO; QL (2 per 28 days)

V-GO 20 3 MO

V-GO 30 3 MO

V-GO 40 3 MO

VICTOZA 2-PAK 6 MO; QL (9 per 30 days)

VICTOZA 3-PAK 6 MO; QL (9 per 30 days)

MISCELLANEOUS HORMONES

ALDURAZYME 5 PA; MO

ANADROL-50 4 PA; MO

cabergoline 4 MO

calcitonin (salmon) 3 MO

calcitriol intravenous solution1 mcg/ml

4 MO

calcitriol oral 2 MO; GC

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 PA; MO

CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR

4 PA; MO

cinacalcet oral tablet 30 mg, 60 mg


cinacalcet oral tablet 90 mg


Drug Name Drug Tier

Requirements/Limits

danazol 4 MO

desmopressin injection

4 MO

desmopressin nasal spray with pump

4 MO

desmopressin nasal spray,non-aerosol

4 MO

desmopressin oral 3 MO

doxercalciferol intravenous

4

doxercalciferol oral 4 MO

ELAPRASE 5 PA; MO

FABRAZYME 5 MO

KORLYM 5 PA; MO; QL (120 per 30 days)

KUVAN 5 PA; MO

LUMIZYME 5 PA; MO

miglustat 5 MO; LA

NAGLAZYME 5 PA; MO; LA

NATPARA 5 PA; MO; LA; QL (2 per 28 days)

oxandrolone oral tablet 10 mg


oxandrolone oral tablet 2.5 mg


pamidronate 4 MO

paricalcitol oral 4 MO

SAMSCA ORAL TABLET 15 MG


SAMSCA ORAL TABLET 30 MG


sapropterin 5 PA; MO


58

Drug Name Drug Tier

Requirements/Limits

SOMAVERT 5 PA; MO; QL (30 per 30 days)

SYNAREL 4 MO

testosterone cypionate intramuscular oil100 mg/ml, 200 mg/ml

3 PA; MO

testosterone cypionate intramuscular oil200 mg/ml (1 ml)

3 PA

testosterone enanthate

4 PA; MO

testosterone transdermal gel


TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 12.5 MG/ 1.25 GRAM (1 %)


testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)


tolvaptan oral tablet30 mg


zoledronic acid intravenous solution

4 B/D PA; MO

zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml

4 B/D PA; MO

ZOLEDRONIC AC-MANNITOL-0.9NACL

4 B/D PA; MO

Drug Name Drug Tier

Requirements/Limits

THYROID HORMONES

euthyrox 3 MO

levo-t 3

levothyroxine oral tablet

2 MO; GC

levoxyl oral tablet100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

3 MO

liothyronine oral 2 MO; GC

unithroid 3 MO

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICS

dicyclomine oral capsule

2 MO; GC

dicyclomine oral solution

4 MO

dicyclomine oral tablet

2 MO; GC

diphenoxylate-atropine

4 MO

GLYCOPYRROLATE (PF) IN WATER INJECTION

4

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml)

4

glycopyrrolate oral tablet 1 mg, 2 mg

4 MO


59

Drug Name Drug Tier

Requirements/Limits

glycopyrrolate oral tablet 1.5 mg

4

loperamide oral capsule

2 MO; GC

MISCELLANEOUS GASTROINTESTINAL AGENTS

alosetron 5 PA; MO

aprepitant 4 B/D PA; MO

balsalazide 4 MO

budesonide oral 4 MO

compro 4 MO

constulose 2 MO; GC

CREON 3 MO

cromolyn oral 3 MO

CYSTADANE 5 MO

dronabinol 4 B/D PA; MO; QL (60 per 30 days)

EMEND ORAL SUSPENSION FOR RECONSTITUTION

4 B/D PA; MO

enulose 2 MO; GC

GATTEX 30-VIAL 5 PA; MO

GATTEX ONE-VIAL

5 PA; MO

gavilyte-c 2 MO; GC

gavilyte-n 2 MO; GC

generlac 2 MO; GC

granisetron hcl oral 4 B/D PA; MO; QL (60 per 30 days)

Drug Name Drug Tier

Requirements/Limits

hydrocortisone rectal

3 MO

hydrocortisone topical cream with perineal applicator

2 MO; GC

lactulose oral solution

2 MO; GC

LINZESS 3 MO; QL (30 per 30 days)

meclizine oral tablet12.5 mg, 25 mg

2 MO; GC

mesalamine oral capsule,extended release 24hr

3 MO

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

4 MO

mesalamine rectal enema

4 MO

mesalamine with cleansing wipe

4 MO

metoclopramide hcl oral solution

2 MO; GC

metoclopramide hcl oral tablet

2 MO; GC

MOVANTIK 4 MO; QL (30 per 30 days)

OCALIVA 4 PA; MO; LA; QL (30 per 30 days)

ondansetron 2 B/D PA; MO; GC

ondansetron hcl (pf)

4 MO

ondansetron hcl intravenous

4 MO


60

Drug Name Drug Tier

Requirements/Limits

ondansetron hcl oral solution


ondansetron hcl oral tablet 24 mg

2 B/D PA; GC

ondansetron hcl oral tablet 4 mg, 8 mg

2 B/D PA; MO; GC

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

2 MO; GC

peg-electrolyte 2 GC

PENTASA 4 MO

PLENVU 4 MO

prochlorperazine 4 MO

prochlorperazine edisylate

4 MO

prochlorperazine maleate oral

2 MO; GC

procto-med hc 2 MO; GC

procto-pak 2 MO; GC

proctosol hc topical 2 MO; GC

proctozone-hc 2 MO; GC

RECTIV 4 MO

RELISTOR SUBCUTANEOUS SOLUTION

5 PA; MO

RELISTOR SUBCUTANEOUS SYRINGE

5 PA; MO

REMICADE 5 PA; MO

scopolamine base 4 MO; QL (10 per 30 days)

sulfasalazine 2 MO; GC

SUPREP BOWEL PREP KIT

4 MO

Drug Name Drug Tier

Requirements/Limits

trilyte with flavor packets

2 MO; GC

ursodiol 3 MO

VIOKACE 4 MO

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

3 MO

ULCER THERAPY

DEXILANT 4 MO; QL (30 per 30 days)

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg


esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg

3 MO

famotidine oral suspension

4 MO

famotidine oral tablet 20 mg, 40 mg

2 MO; GC


61

Drug Name Drug Tier

Requirements/Limits

lansoprazole oral capsule,delayed release(dr/ec) 15 mg


lansoprazole oral capsule,delayed release(dr/ec) 30 mg

3 MO

misoprostol 3 MO

omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg


omeprazole oral capsule,delayed release(dr/ec) 40 mg


pantoprazole oral tablet,delayed release (dr/ec) 20 mg


pantoprazole oral tablet,delayed release (dr/ec) 40 mg


sucralfate oral suspension

4 MO

sucralfate oral tablet

2 MO; GC

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ACTIMMUNE 5 B/D PA; MO

ARCALYST 5 PA; MO

Drug Name Drug Tier

Requirements/Limits

BETASERON SUBCUTANEOUS KIT


GENOTROPIN 5 PA; MO

GENOTROPIN MINIQUICK

5 PA; MO

INTRON A INJECTION RECON SOLN

5 B/D PA; MO

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

5 B/D PA; MO

INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML

4 B/D PA; MO

MOZOBIL 5 B/D PA; MO

NIVESTYM 5 PA; MO

PROCRIT 4 PA; MO

PROLEUKIN 4 B/D PA; MO

ZIEXTENZO 4 PA; MO

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

ACTHIB (PF) 3 MO

ADACEL(TDAP ADOLESN/ADULT)(PF)

3 MO

ATGAM 4 B/D PA

BCG VACCINE, LIVE (PF)

3 MO

BEXSERO 3 MO


62

Drug Name Drug Tier

Requirements/Limits

BOOSTRIX TDAP 3 MO

DAPTACEL (DTAP PEDIATRIC) (PF)

3 MO

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; MO

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; MO

fomepizole 5

GAMUNEX-C 5 PA; MO

GARDASIL 9 (PF) 4 MO

HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML

3 MO

HAVRIX (PF) INTRAMUSCULAR SYRINGE

3 MO

HIBERIX (PF) 3 MO

HIZENTRA 4 B/D PA; MO

IMOVAX RABIES VACCINE (PF)

4 MO

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3 MO

IPOL 3 MO

IXIARO (PF) 4 MO

KINRIX (PF) INTRAMUSCULAR SUSPENSION

3

KINRIX (PF) INTRAMUSCULAR SYRINGE

3 MO

Drug Name Drug Tier

Requirements/Limits

MENACTRA (PF) INTRAMUSCULAR SOLUTION

3 MO

MENQUADFI (PF)

3

MENVEO A-C-Y-W-135-DIP (PF)

3 MO

M-M-R II (PF) 3 MO

PEDIARIX (PF) 3 MO

PEDVAX HIB (PF)

3 MO

PROQUAD (PF) 3 MO

QUADRACEL (PF)

3 MO

RABAVERT (PF) 3 MO

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

3 B/D PA; MO

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML

3 B/D PA; MO

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML

3 B/D PA

ROTARIX 3

ROTATEQ VACCINE

3 MO

SHINGRIX (PF) 3 MO; QL (2 per 999 days)

STAMARIL (PF) 4

TDVAX 3 MO

TENIVAC (PF) INTRAMUSCULAR SYRINGE

3 MO


63

Drug Name Drug Tier

Requirements/Limits

TETANUS,DIPHTHERIA TOX PED(PF)

3 MO

TRUMENBA 3 MO

TWINRIX (PF) INTRAMUSCULAR SYRINGE

3 MO

TYPHIM VI INTRAMUSCULAR SOLUTION

3

TYPHIM VI INTRAMUSCULAR SYRINGE

3 MO

VAQTA (PF) 3 MO

VARIVAX (PF) 3 MO

VARIZIG INTRAMUSCULAR SOLUTION

4 MO

YF-VAX (PF) 3 MO

ZOSTAVAX (PF) 4 MO

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

allopurinol 1 MO; GC

colchicine oral tablet


febuxostat 4 ST; MO

MITIGARE 3 MO

probenecid 3 MO

probenecid-colchicine

3 MO

Drug Name Drug Tier

Requirements/Limits

OSTEOPOROSIS THERAPY

alendronate oral tablet 10 mg, 5 mg


alendronate oral tablet 35 mg, 70 mg


BINOSTO 4 MO; QL (4 per 28 days)

ibandronate oral 3 MO; QL (1 per 30 days)

PROLIA 4 PA; MO; QL (1 per 180 days)

raloxifene 2 MO; GC; QL (30 per 30 days)

TERIPARATIDE 5 PA; MO; QL (2.48 per 28 days)

TYMLOS 5 PA; MO; QL (1.56 per 30 days)

OTHER RHEUMATOLOGICALS

BENLYSTA 5 PA; MO

DEPEN TITRATABS

5 MO

ENBREL MINI 5 PA; MO; QL (8 per 28 days)

ENBREL SUBCUTANEOUS RECON SOLN


ENBREL SUBCUTANEOUS SOLUTION



64

Drug Name Drug Tier

Requirements/Limits

ENBREL SUBCUTANEOUS SYRINGE


ENBREL SURECLICK


HUMIRA PEN 5 PA; MO; QL (4 per 28 days)

HUMIRA PEN CROHNS-UC-HS START


HUMIRA PEN PSOR-UVEITS-ADOL HS


HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML


HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML


HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN CROHNS-UC-HS


HUMIRA(CF) PEN PSOR-UV-ADOL HS


Drug Name Drug Tier

Requirements/Limits

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML


HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML


leflunomide 3 MO; QL (30 per 30 days)

ORENCIA CLICKJECT


ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML


ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML


ORENCIA SUBCUTANEOUS SYRINGE 87.5 MG/0.7 ML


penicillamine 5 MO


65

Drug Name Drug Tier

Requirements/Limits

RINVOQ 5 PA; MO; QL (30 per 30 days)

XELJANZ ORAL TABLET


XELJANZ XR 5 PA; MO; QL (30 per 30 days)

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINS

ALORA 4 MO; QL (8 per 28 days)

camila 3 MO

deblitane 3 MO

dotti 4 MO; QL (8 per 28 days)

errin 3 MO

estradiol oral 3 MO

estradiol transdermal patch semiweekly


estradiol transdermal patch weekly


estradiol vaginal cream

2 MO; GC

estradiol vaginal tablet

4 MO

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

4 MO

heather 2 MO; GC

Drug Name Drug Tier

Requirements/Limits

hydroxyprogesterone caproate

5 MO

incassia 3 MO

jencycla 2 MO; GC

lyza 2 MO; GC

medroxyprogesterone

2 MO; GC

nora-be 3 MO

norethindrone (contraceptive)

3 MO

norethindrone acetate

2 MO; GC

PREMARIN INJECTION

4 MO

PREMARIN ORAL

3 MO

PREMARIN VAGINAL

4 MO

PREMPRO 3 MO

progesterone micronized

2 MO; GC

sharobel 3 MO

yuvafem 4 MO

MISCELLANEOUS OB/GYN

clindamycin phosphate vaginal

4 MO

metronidazole vaginal

4 MO

terconazole 4 MO

tranexamic acid oral

3 MO

vandazole 4 MO

ORAL CONTRACEPTIVES / RELATED AGENTS

afirmelle 2 MO; GC


66

Drug Name Drug Tier

Requirements/Limits

altavera (28) 2 MO; GC

alyacen 1/35 (28) 2 MO; GC

alyacen 7/7/7 (28) 2 MO; GC

amethia 2 MO; GC

amethyst (28) 2 MO; GC

apri 2 MO; GC

aranelle (28) 2 MO; GC

ashlyna 2 MO; GC

aubra 2 MO; GC

aubra eq 2 MO; GC

aurovela 1.5/30 (21)

2 MO; GC

aurovela 1/20 (21) 2 MO; GC

aurovela 24 fe 2 MO; GC

aurovela fe 1.5/30 (28)

2 MO; GC

aurovela fe 1-20 (28)

2 MO; GC

aviane 2 MO; GC

ayuna 2 GC

azurette (28) 2 MO; GC

balziva (28) 2 MO; GC

bekyree (28) 2 MO; GC

blisovi 24 fe 2 MO; GC

blisovi fe 1.5/30 (28)

2 MO; GC

blisovi fe 1/20 (28) 2 MO; GC

briellyn 2 MO; GC

camrese lo 2 MO; GC

caziant (28) 2 MO; GC

chateal (28) 2 GC

chateal eq (28) 2 MO; GC

cryselle (28) 2 MO; GC

cyclafem 1/35 (28) 2 MO; GC

cyclafem 7/7/7 (28) 2 MO; GC

cyred 3 MO

Drug Name Drug Tier

Requirements/Limits

cyred eq 3 MO

dasetta 1/35 (28) 2 MO; GC

dasetta 7/7/7 (28) 2 MO; GC

desog-e.estradiol/e.estradiol

2 MO; GC

drospirenone-e.estradiol-lm.fa

2 MO; GC

drospirenone-ethinyl estradiol

2 MO; GC

elinest 2 MO; GC

emoquette 2 MO; GC

enpresse 2 MO; GC

enskyce 2 MO; GC

estarylla 2 MO; GC

ethynodiol diac-eth estradiol oral tablet1-35 mg-mcg

2 MO; GC

ethynodiol diac-eth estradiol oral tablet1-50 mg-mcg

2 GC

falmina (28) 2 MO; GC

fayosim 2 MO; GC

femynor 2 MO; GC

gianvi (28) 2 MO; GC

hailey 2 MO; GC

hailey 24 fe 3 MO

iclevia 2 GC

introvale 2 MO; GC

isibloom 2 MO; GC

jasmiel (28) 2 MO; GC

juleber 2 MO; GC

junel 1.5/30 (21) 2 MO; GC

junel 1/20 (21) 2 MO; GC

junel fe 1.5/30 (28) 2 MO; GC

junel fe 1/20 (28) 2 MO; GC

junel fe 24 2 MO; GC


67

Drug Name Drug Tier

Requirements/Limits

kaitlib fe 2 MO; GC

kalliga 2 GC

kariva (28) 2 MO; GC

kelnor 1/35 (28) 2 MO; GC

kelnor 1-50 (28) 2 MO; GC

kurvelo (28) 2 MO; GC

l norgest/e.estradiol-e.estrad

2 MO; GC

larin 1.5/30 (21) 2 MO; GC

larin 1/20 (21) 2 MO; GC

larin 24 fe 2 MO; GC

larin fe 1.5/30 (28) 2 MO; GC

larin fe 1/20 (28) 2 MO; GC

larissia 2 MO; GC

layolis fe 2 MO; GC

leena 28 2 MO; GC

lessina 2 MO; GC

levonest (28) 2 MO; GC

levonorgestrel-ethinyl estrad

2 MO; GC

levonorg-eth estrad triphasic

2 MO; GC

levora-28 2 MO; GC

lillow (28) 2 MO; GC

loryna (28) 2 MO; GC

low-ogestrel (28) 2 MO; GC

lo-zumandimine (28)

2 MO; GC

lutera (28) 2 MO; GC

marlissa (28) 2 MO; GC

melodetta 24 fe 2 MO; GC

mibelas 24 fe 2 MO; GC

microgestin 1.5/30 (21)

2 MO; GC

microgestin 1/20 (21)

2 MO; GC

Drug Name Drug Tier

Requirements/Limits

microgestin fe 1.5/30 (28)

2 MO; GC

microgestin fe 1/20 (28)

2 MO; GC

mili 2 MO; GC

mono-linyah 2 MO; GC

necon 0.5/35 (28) 2 MO; GC

nikki (28) 2 MO; GC

noreth-ethinyl estradiol-iron

2 MO; GC

norethindrone ac-eth estradiol oral tablet 1.5-30 mg-mcg

2 GC

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

2 MO; GC

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7)

2 MO; GC

norethindrone-e.estradiol-iron oral tablet 1.5 mg-30 mcg (21)/75 mg (7)

2 GC

norethindrone-e.estradiol-iron oral tablet,chewable

2 MO; GC

norgestimate-ethinyl estradiol

2 MO; GC

nortrel 0.5/35 (28) 2 MO; GC

nortrel 1/35 (21) 2 MO; GC

nortrel 1/35 (28) 2 MO; GC

nortrel 7/7/7 (28) 2 MO; GC

ocella 2 MO; GC

orsythia 2 MO; GC

philith 2 MO; GC

pimtrea (28) 2 MO; GC

pirmella 2 MO; GC


68

Drug Name Drug Tier

Requirements/Limits

portia 28 2 MO; GC

previfem 2 MO; GC

reclipsen (28) 2 MO; GC

rivelsa 2 MO; GC

setlakin 2 MO; GC

simliya (28) 2 MO; GC

sprintec (28) 2 MO; GC

sronyx 2 MO; GC

syeda 2 MO; GC

tarina 24 fe 2 MO; GC

tarina fe 1/20 (28) 2 MO; GC

tarina fe 1-20 eq (28)

2 MO; GC

tilia fe 2 MO; GC

tri femynor 2 MO; GC

tri-estarylla 2 MO; GC

tri-legest fe 2 MO; GC

tri-linyah 2 MO; GC

tri-lo-estarylla 2 MO; GC

tri-lo-marzia 2 MO; GC

tri-lo-mili 2 MO; GC

tri-lo-sprintec 2 MO; GC

tri-mili 2 MO; GC

tri-previfem (28) 2 MO; GC

tri-sprintec (28) 2 MO; GC

trivora (28) 2 MO; GC

tri-vylibra 2 MO; GC

tri-vylibra lo 2 MO; GC

tydemy 2 MO; GC

velivet triphasic regimen (28)

2 MO; GC

vienva 2 MO; GC

viorele (28) 2 MO; GC

volnea (28) 2 MO; GC

vyfemla (28) 2 MO; GC

vylibra 2 MO; GC

Drug Name Drug Tier

Requirements/Limits

wera (28) 2 MO; GC

wymzya fe 2 MO; GC

zarah 2 MO; GC

zovia 1/35e (28) 2 MO; GC

zovia 1-35 (28) 2 GC

zumandimine (28) 2 MO; GC

OPHTHALMOLOGY

ANTIBIOTICS

ak-poly-bac 2 MO; GC

AZASITE 4 MO

bacitracin ophthalmic (eye)

4 MO

bacitracin-polymyxin b ophthalmic (eye)

2 MO; GC

BESIVANCE 4 MO

CILOXAN OPHTHALMIC (EYE) OINTMENT

3 MO

ciprofloxacin hcl ophthalmic (eye)

2 MO; GC

erythromycin ophthalmic (eye)

2 MO; GC

gentak ophthalmic (eye) ointment

2 MO; GC

gentamicin ophthalmic (eye) drops

3 MO

moxifloxacin ophthalmic (eye)

3 MO

NATACYN 4 MO

neomycin-bacitracin-polymyxin

2 MO; GC


69

Drug Name Drug Tier

Requirements/Limits

neomycin-polymyxin-gramicidin

3 MO

neo-polycin 2 MO; GC

ofloxacin ophthalmic (eye)

2 MO; GC

polycin 2 MO; GC

polymyxin b sulf-trimethoprim

2 MO; GC

tobramycin ophthalmic (eye)

2 MO; GC

ANTIVIRALS

trifluridine 2 MO; GC

ZIRGAN 4 MO

BETA-BLOCKERS

carteolol 2 MO; GC

levobunolol ophthalmic (eye) drops 0.5 %

2 MO; GC

timolol maleate ophthalmic (eye) drops

1 MO; GC

timolol maleate ophthalmic (eye) gel forming solution

4 MO

MISCELLANEOUS OPHTHALMOLOGICS

atropine ophthalmic (eye) drops

3 MO

azelastine ophthalmic (eye)

4 MO

BLEPHAMIDE 4 MO

BLEPHAMIDE S.O.P.

4 MO

Drug Name Drug Tier

Requirements/Limits

cromolyn ophthalmic (eye)

2 MO; GC

CYSTARAN 5 PA; MO

epinastine 4 MO

EYLEA 4 PA; MO

olopatadine ophthalmic (eye)

4 MO

OXERVATE 4 PA; MO; QL (112 per 999 days)

PHOSPHOLINE IODIDE

4 MO

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

3 MO

RESTASIS 3 MO; QL (60 per 30 days)

RESTASIS MULTIDOSE


sulfacetamide sodium ophthalmic (eye) drops

2 MO; GC

sulfacetamide-prednisolone

2 MO; GC

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

diclofenac sodium ophthalmic (eye)

2 MO; GC

flurbiprofen sodium 2 MO; GC

ketorolac ophthalmic (eye)

2 MO; GC

PROLENSA 3 MO


70

Drug Name Drug Tier

Requirements/Limits

ORAL DRUGS FOR GLAUCOMA

acetazolamide 3 MO

acetazolamide sodium

4 MO

methazolamide 4 MO

OTHER GLAUCOMA DRUGS

AZOPT 4 MO

COMBIGAN 3 MO

dorzolamide 2 MO; GC

dorzolamide-timolol 2 MO; GC

latanoprost 1 MO; GC

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

3 MO

RHOPRESSA 4 ST; MO

ROCKLATAN 4 ST; MO

SIMBRINZA 4 MO

travoprost 3 MO

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc

4 MO

neomycin-polymyxin b-dexameth

2 MO; GC

neomycin-polymyxin-hc ophthalmic (eye)

4 MO

neo-polycin hc 4 MO

tobramycin-dexamethasone

3 MO

Drug Name Drug Tier

Requirements/Limits

STEROIDS

dexamethasone sodium phosphate ophthalmic (eye)

2 MO; GC

fluorometholone 3 MO

INVELTYS 4 MO

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL

4 MO

LOTEMAX OPHTHALMIC (EYE) OINTMENT

4 MO

LOTEMAX SM 4 MO

prednisolone acetate 3 MO

prednisolone sodium phosphate ophthalmic (eye)

2 MO; GC

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

3 MO

apraclonidine 4 MO

brimonidine ophthalmic (eye) drops 0.15 %

3 MO

brimonidine ophthalmic (eye) drops 0.2 %

2 MO; GC


71

Drug Name Drug Tier

Requirements/Limits

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTS

adrenalin injection solution 1 mg/ml

4 MO

desloratadine oral tablet


diphenhydramine hcl injection solution50 mg/ml

4 MO

EPINEPHRINE INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML


epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml


epinephrine injection solution 1 mg/ml

4

hydroxyzine hcl oral tablet

2 PA; MO; GC

levocetirizine oral solution

4 MO

levocetirizine oral tablet


promethazine oral 2 PA; MO; GC

Drug Name Drug Tier

Requirements/Limits

PULMONARY AGENTS

acetylcysteine 4 B/D PA; MO

ADEMPAS 5 PA; MO; LA; QL (90 per 30 days)

ADVAIR DISKUS 3 MO; QL (60 per 30 days)

ADVAIR HFA 3 MO; QL (12 per 30 days)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation


albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (nda020503)


albuterol sulfate inhalation solution for nebulization

2 B/D PA; MO; GC

albuterol sulfate oral syrup

2 MO; GC

albuterol sulfate oral tablet

4 MO

albuterol sulfate oral tablet extended release 12 hr

4 MO

alyq 5 PA; MO; QL (60 per 30 days)

ambrisentan 5 PA; MO; LA; QL (30 per 30 days)

ANORO ELLIPTA



72

Drug Name Drug Tier

Requirements/Limits

ARNUITY ELLIPTA


ATROVENT HFA 4 MO; QL (25.8 per 30 days)

BREO ELLIPTA 3 MO; QL (60 per 30 days)

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml


budesonide inhalation suspension for nebulization 1 mg/2 ml


CINRYZE 5 PA; MO

COMBIVENT RESPIMAT


cromolyn inhalation 2 B/D PA; MO; GC

DALIRESP 4 PA; MO; QL (30 per 30 days)

ESBRIET ORAL CAPSULE


ESBRIET ORAL TABLET 267 MG


ESBRIET ORAL TABLET 801 MG


Drug Name Drug Tier

Requirements/Limits

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION


FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION






flunisolide nasal spray,non-aerosol25 mcg (0.025 %)


fluticasone propionate nasal


icatibant 5 PA; MO; QL (18 per 30 days)


73

Drug Name Drug Tier

Requirements/Limits

INCRUSE ELLIPTA


ipratropium bromide inhalation

2 B/D PA; MO; GC

ipratropium-albuterol

2 B/D PA; MO; GC

KALYDECO ORAL GRANULES IN PACKET


KALYDECO ORAL TABLET


metaproterenol oral syrup

4 MO

montelukast oral granules in packet


montelukast oral tablet


montelukast oral tablet,chewable


OFEV 5 PA; MO; QL (60 per 30 days)

ORKAMBI ORAL GRANULES IN PACKET


ORKAMBI ORAL TABLET


PERFOROMIST 4 B/D PA; MO; QL (120 per 30 days)

Drug Name Drug Tier

Requirements/Limits

PULMOZYME 5 B/D PA; MO; QL (150 per 30 days)

SEREVENT DISKUS


sildenafil (pulmonary arterial hypertension) oral tablet


SYMDEKO 5 PA; MO; QL (56 per 28 days)

tadalafil (pulm. hypertension)


terbutaline 4 MO

THEO-24 4 MO

theophylline oral tablet extended release 12 hr 300 mg, 450 mg

2 MO; GC

theophylline oral tablet extended release 24 hr

2 MO; GC

TRELEGY ELLIPTA


TRIKAFTA 5 PA; MO

VENTAVIS 4 B/D PA; MO

VENTOLIN HFA 3 MO; QL (36 per 30 days)

XOLAIR SUBCUTANEOUS RECON SOLN



74

Drug Name Drug Tier

Requirements/Limits

XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML


XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML


zafirlukast 4 MO; QL (60 per 30 days)

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICS

MYRBETRIQ 4 MO

oxybutynin chloride oral syrup

2 MO; GC

oxybutynin chloride oral tablet

2 MO; GC

oxybutynin chloride oral tablet extended release 24hr


solifenacin 3 MO

tolterodine oral capsule,extended release 24hr

2 MO; GC

tolterodine oral tablet

4 MO

TOVIAZ 4 MO; QL (30 per 30 days)

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

alfuzosin 2 MO; GC

Drug Name Drug Tier

Requirements/Limits

dutasteride 3 MO

finasteride oral tablet 5 mg


tamsulosin 2 MO; GC; QL (60 per 30 days)

MISCELLANEOUS UROLOGICALS

bethanechol chloride 3 MO

CYSTAGON 4 MO; LA

ELMIRON 4 MO

potassium citrate oral tablet extended release 10 meq (1,080 mg)

2 MO; GC

potassium citrate oral tablet extended release 15 meq, 5 meq (540 mg)

4 MO

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

calcium acetate(phosphat bind)

2 MO; GC

klor-con 2 MO; GC

klor-con 10 3 MO

klor-con 8 3 MO

klor-con m10 1 MO; GC




75

Drug Name Drug Tier

Requirements/Limits

lactated ringers intravenous

4 MO

MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML

4

magnesium sulfate in water intravenous parenteral solution

4

magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %)

4

magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %)

4 MO

magnesium sulfate injection solution

4 MO

magnesium sulfate injection syringe

4

NORMOSOL-R 4 MO

PHOSLYRA 4 MO

potassium chlorid-d5-0.45%nacl intravenous parenteral solution10 meq/l, 30 meq/l, 40 meq/l

4

potassium chlorid-d5-0.45%nacl intravenous parenteral solution20 meq/l

4 MO

potassium chloride in 0.9%nacl intravenous parenteral solution20 meq/l, 40 meq/l

4

Drug Name Drug Tier

Requirements/Limits

potassium chloride in 5 % dex intravenous parenteral solution20 meq/l, 30 meq/l, 40 meq/l

4

potassium chloride in lr-d5 intravenous parenteral solution20 meq/l

4 MO

potassium chloride in water intravenous piggyback 10 meq/100 ml

4 MO

potassium chloride in water intravenous piggyback 10 meq/50 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml

4

potassium chloride intravenous

4 MO

potassium chloride oral capsule, extended release

1 MO; GC

potassium chloride oral liquid

4 MO

potassium chloride oral packet

2 MO; GC

potassium chloride oral tablet extended release

1 MO; GC

potassium chloride oral tablet,er particles/crystals

1 MO; GC

potassium chloride-0.45 % nacl

4


76

Drug Name Drug Tier

Requirements/Limits

potassium chloride-d5-0.2%nacl intravenous parenteral solution20 meq/l

4 MO

potassium chloride-d5-0.2%nacl intravenous parenteral solution30 meq/l, 40 meq/l

4

potassium chloride-d5-0.9%nacl

4

ringer's intravenous 4

sodium bicarbonate intravenous syringe10 meq/10 ml (8.4 %), 7.5 % (0.9 meq/ml)

4 MO

sodium bicarbonate intravenous syringe8.4 % (1 meq/ml)

4

sodium chloride 0.45 % intravenous parenteral solution

4 MO

sodium chloride 3 % 4 MO

sodium chloride 5 % 4 MO

sodium chloride intravenous

4 MO

MISCELLANEOUS NUTRITION PRODUCTS

AMINOSYN II 15 %

4 B/D PA

AMINOSYN-PF 7 % (SULFITE-FREE)

4 B/D PA

CLINIMIX 5%/D15W SULFITE FREE

4 B/D PA

Drug Name Drug Tier

Requirements/Limits

CLINIMIX 4.25%/D10W SULF FREE

4 B/D PA

CLINIMIX 5%-D20W(SULFITE-FREE)

4 B/D PA

CLINIMIX E 4.25%/D10W SUL FREE

4 B/D PA

CLINISOL SF 15 %

4 B/D PA; MO

electrolyte-48 in d5w

4

freamine iii 10 % 4 B/D PA

HEPATAMINE 8%

4 B/D PA

intralipid intravenous emulsion 20 %

4 B/D PA

INTRALIPID INTRAVENOUS EMULSION 30 %

4 B/D PA

KABIVEN 4 B/D PA

NEPHRAMINE 5.4 %

4 B/D PA

NORMOSOL-M IN 5 % DEXTROSE

4

NORMOSOL-R PH 7.4

4

PERIKABIVEN 4 B/D PA

plenamine 4 B/D PA

premasol 10 % 4 B/D PA; MO

PROCALAMINE 3%

4 B/D PA

PROSOL 20 % 4 B/D PA; MO

travasol 10 % 4 B/D PA; MO


77

Drug Name Drug Tier

Requirements/Limits

TROPHAMINE 10 %

4 B/D PA; MO

VITAMINS / HEMATINICS

fluoride (sodium) oral tablet

1 MO; GC

fluoride (sodium) oral tablet,chewable1 mg (2.2 mg sod. fluoride)

1 MO; GC

prenatal vitamin oral tablet

3 MO


78

Indexabacavir ................................... 1abacavir-lamivudine ................. 1abacavir-lamivudine-zidovudine ................................ 1ABELCET.............................. 1ABILIFY MAINTENA........33abiraterone .............................13ABRAXANE........................ 13acamprosate ........................... 51acarbose .................................54acebutolol ...............................40acetaminophen-codeine ...........30acetazolamide .........................71acetazolamide sodium .............71acetic acid .............................. 53acetylcysteine ......................... 72acitretin ..................................46ACTHIB (PF)....................... 62ACTIMMUNE..................... 62acyclovir .............................1, 49acyclovir sodium .......................2ADACEL(TDAP ADOLESN/ADULT)(PF).... 62ADASUVE........................... 33ADCETRIS...........................13adefovir ....................................2ADEMPAS........................... 72adrenalin ................................ 72adriamycin ............................. 13adrucil ....................................13ADVAIR DISKUS............... 72ADVAIR HFA..................... 72AFINITOR........................... 13AFINITOR DISPERZ..........13afirmelle .................................66AIMOVIG AUTOINJECTOR................28ak-poly-bac ............................ 69ala-cort .................................. 49albendazole .............................. 8albuterol sulfate ......................72alclometasone .........................49alcohol pads ........................... 54ALDURAZYME..................58ALECENSA..........................13alendronate ............................ 64alfuzosin .................................75

ALIMTA...............................13ALINIA.................................. 8ALIQOPA.............................13aliskiren ................................. 40allopurinol ..............................64ALORA.................................66alosetron ................................ 60ALPHAGAN P.....................71alprazolam ............................. 34altavera (28) ..........................67ALUNBRIG....................13, 14alyacen 1/35 (28) ................... 67alyacen 7/7/7 (28) ..................67alyq ........................................72amantadine hcl ......................... 2AMBISOME...........................1ambrisentan ............................72amethia .................................. 67amethyst (28) ........................ 67amikacin .................................. 8amiloride ................................ 40amiloride-hydrochlorothiazide 40AMINOSYN II 15 %............ 77AMINOSYN-PF 7 % (SULFITE-FREE)................ 77amiodarone ............................ 40amitriptyline ...........................34amlodipine ..............................40amlodipine-benazepril .............40amlodipine-valsartan .............. 40amlodipine-valsartan-hcthiazid .................................40ammonium lactate .................. 47amoxapine ..............................34amoxicillin ............................. 10amoxicillin-pot clavulanate ..... 10amphotericin b ......................... 1ampicillin ............................... 10ampicillin sodium ....................11ampicillin-sulbactam ...............11ANADROL-50......................58anagrelide .............................. 51anastrozole .............................14ANORO ELLIPTA...............72APOKYN..............................27apraclonidine ..........................71aprepitant ...............................60

apri ........................................ 67APTIOM...............................24APTIVUS................................2APTIVUS (WITH VITAMIN E).......................... 2aranelle (28) ..........................67ARCALYST......................... 62ARIKAYCE........................... 8aripiprazole ............................ 34ARNUITY ELLIPTA...........73ARRANON.......................... 14ARSENIC TRIOXIDE.........14arsenic trioxide .......................14ARZERRA........................... 14asenapine maleate ...................34ashlyna ...................................67aspirin-dipyridamole ...............43atazanavir ................................ 2atenolol .................................. 40atenolol-chlorthalidone ........... 40ATGAM................................62atomoxetine ........................... 34atorvastatin ............................ 45atovaquone ...............................8atovaquone-proguanil ............... 8ATRIPLA............................... 2atropine ..................................70ATROVENT HFA............... 73aubra ......................................67aubra eq ................................. 67aurovela 1.5/30 (21) ...............67aurovela 1/20 (21) ..................67aurovela 24 fe ......................... 67aurovela fe 1.5/30 (28) ...........67aurovela fe 1-20 (28) ..............67AURYXIA............................51AUSTEDO............................28aviane .....................................67avita .......................................48ayuna ..................................... 67AYVAKIT............................ 14azacitidine ..............................14AZASITE..............................69azathioprine ........................... 14azathioprine sodium ................14azelastine ..........................53, 70azithromycin ............................ 7


79

AZOPT..................................71aztreonam ................................ 8azurette (28) ..........................67bacitracin ........................... 8, 69bacitracin-polymyxin b ........... 69baclofen ..................................30balsalazide ............................. 60BALVERSA..........................14balziva (28) ........................... 67BANZEL...............................24BAQSIMI..............................54BARACLUDE........................2BAVENCIO.......................... 14BCG VACCINE, LIVE (PF).62bekyree (28) .......................... 67BELEODAQ......................... 14benazepril ...............................40benazepril-hydrochlorothiazide ................ 40BENDEKA........................... 14BENLYSTA..........................64benztropine .............................27BESIVANCE........................ 69BESPONSA.......................... 14betamethasone dipropionate ....49betamethasone valerate ...........49betamethasone, augmented49, 50BETASERON.......................62betaxolol ................................ 40bethanechol chloride ............... 75bexarotene ............................. 14BEXSERO............................ 62bicalutamide ...........................14BICILLIN L-A......................11BIDIL....................................40BIKTARVY............................2BINOSTO............................. 64bisoprolol fumarate ................ 40bisoprolol-hydrochlorothiazide ................ 40BLENREP............................ 14bleomycin ...............................14BLEPHAMIDE.................... 70BLEPHAMIDE S.O.P.......... 70BLINCYTO.......................... 14blisovi 24 fe ............................ 67blisovi fe 1.5/30 (28) .............. 67blisovi fe 1/20 (28) ................. 67

BOOSTRIX TDAP............... 63BORTEZOMIB.................... 14BOSULIF..............................14BRAFTOVI.......................... 14BREO ELLIPTA.................. 73briellyn ...................................67BRILINTA........................... 43brimonidine ............................ 71BRIVIACT............................24bromocriptine ......................... 27BRUKINSA..........................14budesonide ........................ 60, 73bumetanide .............................40buprenorphine hcl ................... 30buprenorphine-naloxone ......... 32bupropion hcl ..........................34bupropion hcl (smoking deter) .....................................53buspirone ................................34busulfan ................................. 14butorphanol ............................ 32BYDUREON........................54BYDUREON BCISE............54BYSTOLIC........................... 40cabergoline .............................58CABOMETYX..................... 14calcipotriene ...........................46calcitonin (salmon) ................ 58calcitriol .................................58calcium acetate(phosphat bind) ...................................... 75CALQUENCE......................14camila .................................... 66camrese lo .............................. 67candesartan ...................... 40, 41candesartan-hydrochlorothiazid ..................41CAPASTAT............................8CAPLYTA............................ 34CAPRELSA.......................... 14captopril .................................41captopril-hydrochlorothiazide . 41CARBAGLU........................ 51carbamazepine ........................24carbidopa ............................... 27carbidopa-levodopa .................27carbidopa-levodopa-entacapone ............................. 27

carboplatin ............................. 14carmustine ..............................14carteolol ................................. 70cartia xt ................................. 41carvedilol ................................41carvedilol phosphate ............... 41caspofungin .............................. 1CAYSTON............................. 8caziant (28) ........................... 67cefaclor ................................ 5, 6cefadroxil .................................6cefazolin ...................................6cefazolin in dextrose (iso-os) ... 6CEFAZOLIN IN DEXTROSE (ISO-OS)........... 6cefdinir .....................................6cefepime ...................................6CEFEPIME............................ 6CEFEPIME IN DEXTROSE 5 %.................... 6cefepime in dextrose,iso-osm .... 6cefixime ................................... 6cefotetan .................................. 6CEFOTETAN IN DEXTROSE, ISO-OSM......... 6cefoxitin ...................................6cefoxitin in dextrose, iso-osm ....6cefpodoxime .............................6cefprozil ................................... 6ceftazidime ...............................6CEFTAZIDIME IN D5W...... 6ceftriaxone ...............................7CEFTRIAXONE....................7ceftriaxone in dextrose,iso-os ... 6cefuroxime axetil ..................... 7cefuroxime sodium ................... 7celecoxib ................................ 33CELONTIN.......................... 24cephalexin ................................ 7CEREZYME.........................58CHANTIX............................ 53CHANTIX CONTINUING MONTH BOX...................... 53CHANTIX STARTING MONTH BOX...................... 53chateal (28) ........................... 67chateal eq (28) .......................67CHEMET..............................51


80

chloramphenicol sod succinate .. 8chlorhexidine gluconate .......... 53chloroquine phosphate .............. 8chlorothiazide sodium ............. 41chlorpromazine .......................34chlorthalidone .........................41cholestyramine (with sugar) ...45cholestyramine light ................45CHORIONIC GONADOTROPIN, HUMAN...............................58ciclodan ..................................49ciclopirox ............................... 49cilostazol ................................ 43CILOXAN............................ 69CIMDUO................................2cinacalcet ............................... 58CINRYZE.............................73CIPRO HC............................53CIPRODEX.......................... 53ciprofloxacin hcl ............... 11, 69ciprofloxacin in 5 % dextrose ..11ciprofloxacin-dexamethasone ..53cisplatin ..................................14citalopram ..............................34cladribine ............................... 14claravis ...................................48clarithromycin ..........................7clindamycin hcl .........................8CLINDAMYCIN IN 0.9 % SOD CHLOR..........................8clindamycin in 5 % dextrose ..... 8clindamycin pediatric ................8clindamycin phosphate .. 8, 48, 66CLINDAMYCIN PHOSPHATE....................... 48CLINIMIX 5%/D15W SULFITE FREE...................77CLINIMIX 4.25%/D10W SULF FREE......................... 77CLINIMIX 4.25%/D5W SULFIT FREE..................... 51CLINIMIX 5%-D20W(SULFITE-FREE)......77CLINIMIX E 4.25%/D10W SUL FREE............................77CLINISOL SF 15 %.............. 77clobazam ................................24

clobetasol ............................... 50clobetasol-emollient ................50clodan .................................... 50clofarabine ............................. 15clomipramine ..........................34clonazepam .......................24, 25clonidine .................................41clonidine hcl ........................... 41clopidogrel ............................. 43clorazepate dipotassium ..........34clotrimazole ........................1, 49clotrimazole-betamethasone ....49clozapine ................................ 34COARTEM............................ 8colchicine ............................... 64colesevelam ............................ 45colestipol ................................ 45colistin (colistimethate na) .......8COMBIGAN........................ 71COMBIVENT RESPIMAT..73COMETRIQ......................... 15COMPLERA.......................... 2compro ................................... 60constulose ...............................60COPAXONE.........................28COPIKTRA.......................... 15CORLANOR........................ 46COTELLIC........................... 15CREON.................................60CRESEMBA...........................1CRIXIVAN............................ 2cromolyn .....................60, 70, 73cryselle (28) ...........................67cyclafem 1/35 (28) ................. 67cyclafem 7/7/7 (28) ................67cyclobenzaprine ...................... 30cyclophosphamide ...................15CYCLOPHOSPHAMIDE.... 15CYCLOSERINE.................... 8cyclosporine ........................... 15cyclosporine modified ............. 15CYRAMZA.......................... 15cyred ...................................... 67cyred eq ..................................67CYSTADANE...................... 60CYSTAGON.........................75CYSTARAN.........................70cytarabine .............................. 15

cytarabine (pf) .......................15d10 %-0.45 % sodium chloride 51d2.5 %-0.45 % sodium chloride .................................. 51d5 % and 0.9 % sodium chloride .................................. 51d5 %-0.45 % sodium chloride .. 51dacarbazine ............................ 15dactinomycin .......................... 15dalfampridine ......................... 28DALIRESP........................... 73danazol ...................................58dantrolene .............................. 30dapsone .................................... 8DAPTACEL (DTAP PEDIATRIC) (PF)................63DAPTOMYCIN..................... 8daptomycin .............................. 8DARZALEX.........................15DARZALEX FASPRO........ 15dasetta 1/35 (28) ....................67dasetta 7/7/7 (28) .................. 67daunorubicin ...........................15DAURISMO.........................15deblitane .................................66decitabine ...............................15deferasirox ............................. 51DELSTRIGO..........................2DEMSER..............................41DENAVIR............................ 49DEPEN TITRATABS.......... 64DEPO-MEDROL................. 53DESCOVY..............................2desipramine ............................ 34desloratadine .......................... 72desmopressin .......................... 58desog-e.estradiol/e.estradiol ....67DESONATE......................... 50desonide ................................. 50desoximetasone ...................... 50desvenlafaxine succinate ......... 34dexamethasone .......................53dexamethasone intensol .......... 53dexamethasone sodium phos (pf) ........................................54dexamethasone sodium phosphate ......................... 54, 71DEXILANT..........................61


81

dexmethylphenidate ................34dextroamphetamine ................ 34dextroamphetamine-amphetamine .......................... 35dextrose 10 % and 0.2 % nacl . 51dextrose 10 % in water (d10w) ...................................52dextrose 25 % in water (d25w) ...................................52dextrose 30 % in water (d30w) ...................................52dextrose 40 % in water (d40w) ...................................52dextrose 5 % in water (d5w) ...52dextrose 5 %-lactated ringers ..52dextrose 5%-0.2 % sod chloride .................................. 52dextrose 50 % in water (d50w) ...................................52dextrose 70 % in water (d70w) ...................................52DIACOMIT.......................... 25diazepam .......................... 25, 35diazepam intensol ................... 35diazoxide ................................54diclofenac potassium ...............33diclofenac sodium ..............33, 70dicloxacillin ............................11dicyclomine ............................ 59didanosine ................................ 2diflunisal ................................ 33digitek ....................................46digox ......................................46digoxin ................................... 46dihydroergotamine ..................28DILANTIN 30 MG.............. 25diltiazem hcl ........................... 41dilt-xr .....................................41dimethyl fumarate .............28, 29diphenhydramine hcl ...............72diphenoxylate-atropine ........... 59dipyridamole .......................... 43disulfiram ...............................52divalproex .............................. 25docetaxel ................................15dofetilide ................................ 40donepezil ................................ 29dorzolamide ............................71

dorzolamide-timolol ................71dotti ....................................... 66DOVATO................................2doxazosin ............................... 41doxepin .................................. 35doxercalciferol ....................... 58doxorubicin .......................15, 16doxorubicin, peg-liposomal ..... 16doxy-100 ................................ 12doxycycline hyclate ................ 12doxycycline monohydrate ....... 12DRIZALMA SPRINKLE.... 35dronabinol .............................. 60drospirenone-e.estradiol-lm.fa .67drospirenone-ethinyl estradiol . 67DROXIA...............................16duloxetine .............................. 35DUPIXENT PEN................. 47DUPIXENT SYRINGE....... 47dutasteride ............................. 75ec-naproxen ............................33econazole ................................49EDURANT............................ 2efavirenz .................................. 2efavirenz-emtricitabin-tenofov .. 2efavirenz-lamivu-tenofov disop ........................................ 2ELAPRASE.......................... 58electrolyte-48 in d5w ...............77elinest .....................................67ELIQUIS...............................43ELIQUIS DVT-PE TREAT 30D START.......................... 43ELLENCE............................ 16ELMIRON............................75ELZONRIS...........................16EMCYT................................ 16EMEND................................60emoquette ...............................67EMPLICITI.......................... 16EMSAM................................35emtricitabine ............................ 2emtricitabine-tenofovir (tdf) .... 2EMTRIVA..............................2EMVERM.............................. 8enalapril maleate .................... 41enalapril-hydrochlorothiazide . 41ENBREL......................... 64, 65

ENBREL MINI.................... 64ENBREL SURECLICK....... 65endocet ...................................30ENGERIX-B (PF)................ 63ENGERIX-B PEDIATRIC (PF)....................................... 63ENHERTU........................... 16enoxaparin ........................43, 44enpresse ..................................67enskyce .................................. 67entacapone ............................. 27entecavir .................................. 2ENTRESTO..........................46enulose ................................... 60EPCLUSA...........................2, 3EPIDIOLEX......................... 25epinastine ............................... 70EPINEPHRINE....................72epinephrine .............................72epirubicin ............................... 16epitol ......................................25EPIVIR HBV.......................... 3ERBITUX.............................16ergotamine-caffeine ................ 28ERIVEDGE.......................... 16ERLEADA........................... 16erlotinib ..................................16errin ....................................... 66ertapenem ................................ 8ERWINAZE......................... 16ery pads ..................................48ery-tab ..................................... 7ERYTHROCIN......................7erythrocin (as stearate) ........... 7erythromycin ...................... 7, 69erythromycin ethylsuccinate ..... 7erythromycin with ethanol ...... 48erythromycin-benzoyl peroxide ................................. 48ESBRIET.............................. 73escitalopram oxalate .............. 35esomeprazole magnesium ........61estarylla ................................. 67estradiol ................................. 66estradiol valerate .................... 66ethacrynate sodium .................41ethambutol ............................... 8ethosuximide .......................... 25


82

ethynodiol diac-eth estradiol ... 67etodolac ..................................33ETOPOPHOS....................... 16etoposide ................................ 16euthyrox .................................59everolimus (antineoplastic) .... 16everolimus (immunosuppressive) ............. 16EVOMELA........................... 16EVOTAZ................................ 3exemestane .............................16EYLEA................................. 70ezetimibe ................................ 45ezetimibe-simvastatin ............. 45FABRAZYME..................... 58falmina (28) .......................... 67famciclovir ............................... 3famotidine .............................. 61FANAPT.............................. 35FARYDAK.......................... 16fayosim .................................. 67febuxostat .............................. 64felbamate ............................... 25felodipine ................................41femynor ..................................67fenofibrate ..............................45fenofibrate micronized ............ 45fenofibrate nanocrystallized ....45fenofibric acid (choline) ......... 45fentanyl ..................................30fentanyl citrate ....................... 30FETZIMA.............................35finasteride .............................. 75FINTEPLA........................... 25FIRMAGON KIT W DILUENT SYRINGE..........16FIRVANQ.............................. 8flac otic oil ............................. 53flecainide ................................40FLOVENT DISKUS............ 73FLOVENT HFA...................73floxuridine ..............................16fluconazole ...............................1fluconazole in nacl (iso-osm) ....1flucytosine ................................1fludarabine ............................. 16fludrocortisone ....................... 54flunisolide ...............................73

fluocinolone ............................50fluocinolone acetonide oil ........53fluocinolone and shower cap ....50fluocinonide ............................50fluoride (sodium) ................... 78fluorometholone ..................... 71fluorouracil .......................16, 47fluoxetine ......................... 35, 36fluphenazine decanoate ........... 36fluphenazine hcl ......................36flurbiprofen ............................ 33flurbiprofen sodium ................ 70flutamide ................................16fluticasone propionate ....... 50, 73fluvastatin .............................. 45fluvoxamine ............................36FOLOTYN........................... 16fomepizole ..............................63fondaparinux ..........................44fosamprenavir .......................... 3fosinopril ................................41fosinopril-hydrochlorothiazide 41fosphenytoin ........................... 25freamine iii 10 % .................... 77fulvestrant .............................. 16furosemide ..............................41FUZEON................................3FYCOMPA...........................25gabapentin ..............................25galantamine ............................29GAMUNEX-C......................63GARDASIL 9 (PF)............... 63GATTEX 30-VIAL............... 60GATTEX ONE-VIAL.......... 60GAUZE PAD....................... 54gavilyte-c ................................60gavilyte-n ............................... 60GAVRETO........................... 16GAZYVA..............................16gemcitabine ...................... 16, 17GEMCITABINE.................. 17gemfibrozil ............................. 45generlac ..................................60gengraf ...................................17GENOTROPIN.................... 62GENOTROPIN MINIQUICK........................62gentak .................................... 69

gentamicin .................... 9, 48, 69gentamicin in nacl (iso-osm) .8, 9GENTAMICIN IN NACL (ISO-OSM)..........................8, 9gentamicin sulfate (ped) (pf) ...9GENVOYA............................ 3gianvi (28) .............................67GILOTRIF........................... 17glatiramer .............................. 29glatopa ...................................29glimepiride ........................54, 55glipizide ..................................55glipizide-metformin ................ 55GLUCAGEN HYPOKIT..... 55GLUCAGON (HCL) EMERGENCY KIT............. 55GLUCAGON EMERGENCY KIT (HUMAN)............................ 55glycopyrrolate ...................59, 60GLYCOPYRROLATE (PF) IN WATER...........................59glycopyrrolate (pf) in water ... 59glydo ...................................... 47GLYXAMBI.........................55granisetron hcl ........................60griseofulvin microsize ............... 1griseofulvin ultramicrosize ........1GVOKE HYPOPEN 1-PACK....................................55GVOKE HYPOPEN 2-PACK....................................55GVOKE PFS 1-PACK SYRINGE.............................55GVOKE PFS 2-PACK SYRINGE.............................55hailey ..................................... 67hailey 24 fe .............................67HALAVEN........................... 17halobetasol propionate ............50haloperidol ............................. 36haloperidol decanoate ............. 36haloperidol lactate .................. 36HARVONI..............................3HAVRIX (PF).......................63heather ................................... 66heparin (porcine) ................... 44heparin (porcine) in 5 % dex .. 44


83

heparin (porcine) in nacl (pf) 44heparin(porcine) in 0.45% nacl ........................................ 44heparin, porcine (pf) .............. 44HEPARIN, PORCINE (PF). 44HEPATAMINE 8%.............. 77HETLIOZ............................. 36HIBERIX (PF)......................63HIZENTRA..........................63HUMALOG JUNIOR KWIKPEN U-100.................55HUMALOG KWIKPEN INSULIN..............................55HUMALOG MIX 50-50 INSULN U-100.....................55HUMALOG MIX 50-50 KWIKPEN........................... 55HUMALOG MIX 75-25 KWIKPEN........................... 55HUMALOG MIX 75-25(U-100)INSULN.........................55HUMALOG U-100 INSULIN..............................55HUMIRA..............................65HUMIRA PEN.....................65HUMIRA PEN CROHNS-UC-HS START.....................65HUMIRA PEN PSOR-UVEITS-ADOL HS..............65HUMIRA(CF)...................... 65HUMIRA(CF) PEDI CROHNS STARTER........... 65HUMIRA(CF) PEN............. 65HUMIRA(CF) PEN CROHNS-UC-HS.................65HUMIRA(CF) PEN PSOR-UV-ADOL HS...................... 65HUMULIN 70/30 U-100 INSULIN..............................55HUMULIN 70/30 U-100 KWIKPEN........................... 55HUMULIN N NPH INSULIN KWIKPEN.......... 55HUMULIN N NPH U-100 INSULIN..............................55HUMULIN R REGULAR U-100 INSULN.....................55

HUMULIN R U-500 (CONC) INSULIN............... 56HUMULIN R U-500 (CONC) KWIKPEN.............56hydralazine .............................41hydrochlorothiazide ................ 41hydrocodone-acetaminophen ...30hydrocodone-ibuprofen ........... 31hydrocortisone ............ 51, 54, 60hydrocortisone butyrate ..........50hydrocortisone butyr-emollient ................................ 51hydrocortisone valerate ...........51hydrocortisone-acetic acid ...... 53hydromorphone ...................... 31hydroxychloroquine ..................9hydroxyprogesterone caproate ................................. 66hydroxyurea ........................... 17hydroxyzine hcl ...................... 72ibandronate ............................ 64IBRANCE.............................17ibu ..........................................33ibuprofen ................................33icatibant .................................73iclevia .....................................67ICLUSIG.............................. 17idarubicin ............................... 17IDHIFA................................ 17ifosfamide .............................. 17imatinib ..................................17IMBRUVICA....................... 17IMFINZI.............................. 17imipenem-cilastatin .................. 9imipramine hcl ........................36imiquimod .............................. 47IMOVAX RABIES VACCINE (PF).....................63IMPOYZ...............................51incassia .................................. 66INCRELEX.......................... 52INCRUSE ELLIPTA............74indapamide .............................41INFANRIX (DTAP) (PF).... 63INFUGEM........................... 17INFUMORPH P/F............... 31INLYTA............................... 17INQOVI................................ 17

INREBIC.............................. 18INSULIN PEN NEEDLE.... 56INSULIN SYRINGE (DISP) U-100........................ 56INTELENCE..........................3intralipid ................................ 77INTRALIPID....................... 77INTRON A........................... 62introvale ................................. 67INVEGA SUSTENNA......... 36INVEGA TRINZA...............36INVELTYS........................... 71INVIRASE............................. 3INVOKAMET...................... 56INVOKAMET XR............... 56INVOKANA.........................56IPOL..................................... 63ipratropium bromide ......... 53, 74ipratropium-albuterol ............. 74irbesartan ...............................41irbesartan-hydrochlorothiazide ................ 42IRESSA.................................18irinotecan ............................... 18ISENTRESS........................... 3ISENTRESS HD.................... 3isibloom ..................................67isoniazid ...................................9isosorbide dinitrate ................. 46isosorbide mononitrate ............46isotretinoin ............................. 48isradipine ................................42itraconazole ............................. 1ivermectin ................................ 9IXEMPRA............................ 18IXIARO (PF)........................ 63JAKAFI................................ 18jantoven ..................................44JANUMET........................... 56JANUMET XR.....................56JANUVIA.............................56JARDIANCE........................56jasmiel (28) ........................... 67jencycla .................................. 66JENTADUETO.................... 56JENTADUETO XR............. 56JEVTANA............................ 18juleber .................................... 67


84

JULUCA.................................3junel 1.5/30 (21) .................... 67junel 1/20 (21) ....................... 67junel fe 1.5/30 (28) .................67junel fe 1/20 (28) ................... 67junel fe 24 ...............................67KABIVEN............................ 77KADCYLA...........................18kaitlib fe .................................68KALETRA............................. 3kalliga ....................................68KALYDECO........................ 74KANJINTI........................... 18kariva (28) ............................ 68kelnor 1/35 (28) .....................68kelnor 1-50 (28) .....................68ketoconazole .......................1, 49ketorolac ................................ 70KEYTRUDA........................18KINRIX (PF)........................63kionex (with sorbitol) ............ 52KISQALI.............................. 18KISQALI FEMARA CO-PACK....................................18klor-con ..................................75klor-con 10 ............................. 75klor-con 8 ...............................75klor-con m10 .......................... 75klor-con m15 .......................... 75klor-con m20 .......................... 75KORLYM.............................58kurvelo (28) ...........................68KUVAN................................58KYPROLIS...........................18l norgest/e.estradiol-e.estrad ... 68labetalol ................................. 42lactated ringers ................. 51, 76lactulose ................................. 60lamivudine ................................3lamivudine-zidovudine .............. 3lamotrigine .............................25LANOXIN............................46LANOXIN PEDIATRIC......46lansoprazole ........................... 62LANTUS SOLOSTAR U-100 INSULIN....................... 56LANTUS U-100 INSULIN.. 56lapatinib .................................18

larin 1.5/30 (21) .....................68larin 1/20 (21) ....................... 68larin 24 fe ...............................68larin fe 1.5/30 (28) .................68larin fe 1/20 (28) ....................68larissia ................................... 68latanoprost ............................. 71LATUDA..............................37layolis fe .................................68leena 28 ..................................68leflunomide .............................65LENVIMA............................18lessina .................................... 68letrozole ................................. 19leucovorin calcium .................. 13LEUKERAN........................ 19leuprolide ............................... 19levetiracetam ..........................26levetiracetam in nacl (iso-os) . 26levobunolol ............................. 70levocarnitine ...........................52levocarnitine (with sugar) ...... 52levocetirizine .......................... 72levofloxacin ............................12levofloxacin in d5w ................. 11levonest (28) ..........................68levonorgestrel-ethinyl estrad ... 68levonorg-eth estrad triphasic ... 68levora-28 ................................ 68levo-t ......................................59levothyroxine ..........................59levoxyl ................................... 59LEXIVA..................................3LIBTAYO............................. 19lidocaine .................................47lidocaine (pf) ................... 40, 47lidocaine hcl ........................... 47lidocaine viscous ..................... 47lidocaine-prilocaine ................ 47lillow (28) ..............................68lincomycin ................................9lindane ................................... 51linezolid ................................... 9linezolid in dextrose 5% ............9linezolid-0.9% sodium chloride .................................... 9LINZESS.............................. 60liothyronine ............................ 59

lisinopril ................................. 42lisinopril-hydrochlorothiazide . 42lithium carbonate ....................37LONSURF............................19loperamide ............................. 60lopinavir-ritonavir .................... 3lorazepam .............................. 37lorazepam intensol ..................37LORBRENA.........................19loryna (28) ............................ 68losartan ..................................42losartan-hydrochlorothiazide .. 42LOTEMAX...........................71LOTEMAX SM.................... 71lovastatin ............................... 45low-ogestrel (28) ....................68loxapine succinate .................. 37lo-zumandimine (28) ..............68LUMIGAN...........................71LUMIZYME........................ 58LUMOXITI.......................... 19LUPRON DEPOT................ 19LUPRON DEPOT (3 MONTH).............................. 19LUPRON DEPOT (4 MONTH).............................. 19LUPRON DEPOT (6 MONTH).............................. 19LUPRON DEPOT-PED....... 19LUPRON DEPOT-PED (3 MONTH).............................. 19lutera (28) ............................. 68LYNPARZA.........................19LYSODREN.........................19LYUMJEV KWIKPEN U-100 INSULIN....................... 56LYUMJEV KWIKPEN U-200 INSULIN....................... 56LYUMJEV U-100 INSULIN..............................56lyza ........................................ 66magnesium sulfate .................. 76MAGNESIUM SULFATE IN D5W................................ 76magnesium sulfate in water .....76malathion ............................... 51maprotiline .............................37marlissa (28) ......................... 68


85

MARPLAN.......................... 37MARQIBO........................... 19MATULANE........................19matzim la ............................... 42MAVYRET............................ 4meclizine ................................ 60MEDROL............................. 54medroxyprogesterone ............. 66mefloquine ................................9megestrol ................................19MEKINIST...........................19MEKTOVI............................19melodetta 24 fe .......................68meloxicam ..............................33melphalan ...............................19melphalan hcl ......................... 19memantine ..............................29MEMANTINE..................... 29MENACTRA (PF)............... 63MENQUADFI (PF)............. 63MENVEO A-C-Y-W-135-DIP (PF)................................63mercaptopurine .......................19meropenem ...............................9MEROPENEM-0.9% SODIUM CHLORIDE.......... 9mesalamine ............................ 60mesalamine with cleansing wipe ....................................... 60mesna .....................................13MESNEX..............................13metaproterenol ....................... 74metformin .........................56, 57methadone ..............................31methadone intensol ................. 31methazolamide ....................... 71methenamine hippurate ...........12methimazole ........................... 54methotrexate sodium .............. 19methotrexate sodium (pf) .......19methoxsalen ........................... 47methyldopa .............................42methylphenidate hcl ................37methylprednisolone .................54methylprednisolone acetate .....54methylprednisolone sodium succ ........................................54metoclopramide hcl .................60

metolazone ............................. 42metoprolol succinate ...............42metoprolol ta-hydrochlorothiaz .................... 42metoprolol tartrate ................. 42metro i.v. ..................................9metronidazole ............... 9, 48, 66metronidazole in nacl (iso-os) .. 9metyrosine ..............................42mexiletine ...............................40mibelas 24 fe .......................... 68microgestin 1.5/30 (21) .......... 68microgestin 1/20 (21) .............68microgestin fe 1.5/30 (28) ...... 68microgestin fe 1/20 (28) ......... 68midodrine ............................... 52miglustat ................................ 58mili .........................................68MINITRAN..........................46minocycline ............................ 12minoxidil ................................ 42mirtazapine ............................ 37misoprostol .............................62MITIGARE.......................... 64mitomycin .............................. 19mitoxantrone ..........................19M-M-R II (PF)......................63modafinil ................................37moexipril ................................42molindone ...............................37mometasone ........................... 51MONJUVI............................ 19mono-linyah ........................... 68montelukast ............................74morgidox ................................12MORPHINE................... 31, 32morphine .......................... 31, 32morphine (pf) ........................ 31morphine concentrate ............. 31MOVANTIK........................ 60moxifloxacin .....................12, 69MOXIFLOXACIN-SOD.ACE,SUL-WATER..... 12moxifloxacin-sod.chloride(iso) .................... 12MOZOBIL............................ 62mupirocin ............................... 48mupirocin calcium .................. 48

MVASI..................................19mycophenolate mofetil ............20mycophenolate mofetil (hcl) ...20mycophenolate sodium ............20MYLOTARG....................... 20MYRBETRIQ.......................75nabumetone ............................ 33nadolol ................................... 42nadolol-bendroflumethiazide ... 42nafcillin .................................. 11nafcillin in dextrose iso-osm ....11NAGLAZYME.....................58naloxone ................................ 33naltrexone .............................. 33NAMZARIC.........................29naproxen ................................ 33naproxen sodium .................... 33naratriptan ............................. 28NARCAN............................. 33NATACYN...........................69nateglinide ..............................57NATPARA........................... 58NAYZILAM.........................26necon 0.5/35 (28) ................... 68NEEDLES, INSULIN DISP.,SAFETY.....................57nefazodone ............................. 37neomycin ..................................9neomycin-bacitracin-poly-hc ... 71neomycin-bacitracin-polymyxin .............................. 69neomycin-polymyxin b gu ....... 51neomycin-polymyxin b-dexameth ............................... 71neomycin-polymyxin-gramicidin .............................. 70neomycin-polymyxin-hc .... 53, 71neo-polycin .............................70neo-polycin hc ........................ 71NEPHRAMINE 5.4 %..........77NERLYNX...........................20NEUPRO..............................27nevirapine .................................4NEXAVAR...........................20niacin ..................................... 45nicardipine ............................. 42NICOTROL..........................53NICOTROL NS....................53


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nifedipine ................................42nikki (28) .............................. 68nilutamide .............................. 20nimodipine ..............................42NINLARO............................20NIPENT................................20nisoldipine .............................. 42nitisinone ................................52nitrofurantoin .........................12nitrofurantoin macrocrystal .... 12nitrofurantoin monohyd/m-cryst .......................................12nitroglycerin ...........................46NIVESTYM..........................62nora-be ...................................66noreth-ethinyl estradiol-iron ... 68norethindrone (contraceptive) 66norethindrone acetate ............. 66norethindrone ac-eth estradiol .68norethindrone-e.estradiol-iron .68norgestimate-ethinyl estradiol .68NORMOSOL-M IN 5 % DEXTROSE......................... 77NORMOSOL-R....................76NORMOSOL-R PH 7.4........77NORTHERA........................ 52nortrel 0.5/35 (28) ................. 68nortrel 1/35 (21) .................... 68nortrel 1/35 (28) .................... 68nortrel 7/7/7 (28) ................... 68nortriptyline ........................... 37NORVIR.................................4NUBEQA..............................20NUEDEXTA........................ 29NULOJIX............................. 20NUPLAZID..........................37NUZYRA............................. 12nyamyc ...................................49nystatin .............................. 1, 49nystatin-triamcinolone ............49nystop .................................... 49OCALIVA.............................60ocella ..................................... 68OCREVUS............................29octreotide acetate ................... 20ODEFSEY.............................. 4ODOMZO.............................20OFEV.................................... 74

ofloxacin ................................ 70OGIVRI................................ 20olanzapine ........................ 37, 38olanzapine-fluoxetine ..............38olmesartan ............................. 42olmesartan-hydrochlorothiazide ................ 42olopatadine .............................70omeprazole .............................62OMNIPOD DASH 5 PACK POD...................................... 57OMNIPOD INSULIN MANAGEMENT.................57OMNIPOD INSULIN REFILL................................ 57ONCASPAR......................... 20ondansetron ............................60ondansetron hcl .................60, 61ondansetron hcl (pf) ...............60ONIVYDE............................ 20ONTRUZANT..................... 20ONUREG............................. 20OPDIVO............................... 20oralone ................................... 53ORENCIA............................ 65ORENCIA CLICKJECT......65ORKAMBI........................... 74orsythia ..................................68oseltamivir ............................... 4oxacillin ................................. 11oxaliplatin ..............................20oxandrolone ........................... 58oxaprozin ............................... 33oxcarbazepine ........................ 26OXERVATE......................... 70oxybutynin chloride ................ 75oxycodone .............................. 32oxycodone-acetaminophen ...... 32oxycodone-aspirin .................. 32oxymorphone ..........................32OZEMPIC.............................57pacerone .................................40paclitaxel ............................... 20PADCEV.............................. 20paliperidone ............................38pamidronate ........................... 58PANRETIN.......................... 47pantoprazole ...........................62

paricalcitol ............................. 58paroex oral rinse .................... 53paromomycin ........................... 9paroxetine hcl .........................38PASER....................................9PAXIL...................................38PEDIARIX (PF)................... 63PEDVAX HIB (PF).............. 63peg 3350-electrolytes .............. 61peg-electrolyte ........................61PEMAZYRE.........................20penicillamine .......................... 65penicillin g potassium ..............11penicillin v potassium ..............11PENTAM................................9pentamidine ..............................9PENTASA............................ 61pentoxifylline ......................... 44PERFOROMIST.................. 74PERIKABIVEN................... 77perindopril erbumine ...............42PERJETA............................. 20permethrin ..............................51perphenazine .......................... 38perphenazine-amitriptyline ..... 38PERSERIS............................ 38pfizerpen-g ............................. 11phenelzine ...............................38phenobarbital ......................... 26phenobarbital sodium ..............26phenoxybenzamine ................. 42phenytoin ............................... 26phenytoin sodium ....................26phenytoin sodium extended ..... 26PHESGO...............................20philith .....................................68PHOSLYRA......................... 76PHOSPHOLINE IODIDE....70PICATO................................47PIFELTRO............................. 4pilocarpine hcl .................. 52, 70pimozide .................................38pimtrea (28) .......................... 68pindolol .................................. 42pioglitazone ............................57pioglitazone-metformin ...........57PIPERACILLIN-TAZOBACTAM...................11


87

piperacillin-tazobactam .......... 11PIQRAY............................... 20pirmella ..................................68plenamine ...............................77PLENVU.............................. 61podofilox ................................47POLIVY................................20polycin ................................... 70polymyxin b sulf-trimethoprim .......................... 70POMALYST......................... 21portia 28 .................................69PORTRAZZA.......................21posaconazole ............................ 1potassium chlorid-d5-0.45%nacl .............................. 76potassium chloride .................. 76potassium chloride in 0.9%nacl ................................ 76potassium chloride in 5 % dex . 76potassium chloride in lr-d5 ......76potassium chloride in water .....76potassium chloride-0.45 % nacl ........................................ 76potassium chloride-d5-0.2%nacl ................................ 77potassium chloride-d5-0.9%nacl ................................ 77potassium citrate .................... 75POTELIGEO........................ 21pramipexole ........................... 27prasugrel ................................ 44pravastatin ............................. 45praziquantel ............................. 9prazosin ..................................42prednicarbate ......................... 51prednisolone ........................... 54prednisolone acetate ............... 71prednisolone sodium phosphate ......................... 54, 71prednisone .............................. 54prednisone intensol ................. 54pregabalin .............................. 26PREMARIN......................... 66premasol 10 % ........................ 77PREMPRO........................... 66prenatal vitamin oral tablet .....78prevalite ................................. 45

previfem ................................. 69PREVYMIS............................ 4PREZCOBIX.......................... 4PREZISTA............................. 4PRIFTIN................................ 9PRIMAQUINE...................... 9primidone ............................... 26probenecid ..............................64probenecid-colchicine ..............64PROCALAMINE 3%........... 77prochlorperazine .....................61prochlorperazine edisylate ...... 61prochlorperazine maleate oral .61PROCRIT............................. 62procto-med hc .........................61procto-pak ..............................61proctosol hc ............................61proctozone-hc ......................... 61progesterone micronized ......... 66PROGLYCEM..................... 57PROGRAF........................... 21PROLASTIN-C.................... 52PROLENSA..........................70PROLEUKIN....................... 62PROLIA................................64PROMACTA........................ 44promethazine ..........................72propafenone ............................40propranolol .............................42propranolol-hydrochlorothiazid ..................42propylthiouracil ......................54PROQUAD (PF)...................63PROSOL 20 %.......................77protriptyline ........................... 38PULMOZYME.....................74PURIXAN............................ 21pyrazinamide ............................9pyridostigmine bromide .......... 30pyrimethamine ......................... 9QINLOCK............................ 21QUADRACEL (PF)............. 63quetiapine ...............................38quinapril .................................42quinapril-hydrochlorothiazide . 42quinidine sulfate ..................... 40quinine sulfate .......................... 9RABAVERT (PF).................63

raloxifene ...............................64ramelteon ............................... 38ramipril .................................. 42ranolazine .............................. 46rasagiline ................................27reclipsen (28) .........................69RECOMBIVAX HB (PF)..... 63RECTIV................................61regonol ................................... 30REGRANEX........................ 47RELISTOR........................... 61REMICADE......................... 61repaglinide ............................. 57REPATHA............................45REPATHA PUSHTRONEX....................45REPATHA SURECLICK.... 45RESTASIS............................ 70RESTASIS MULTIDOSE....70RETEVMO........................... 21RETROVIR............................4REVLIMID.......................... 21REXULTI.............................38REYATAZ............................. 4RHOPRESSA....................... 71ribavirin ................................... 4rifabutin ................................... 9rifampin ................................... 9riluzole ................................... 52rimantadine ..............................4ringer's ..............................51, 77RINVOQ...............................66RISPERDAL CONSTA....... 38risperidone ............................. 38ritonavir ................................... 4rivastigmine ............................29rivastigmine tartrate ...............29rivelsa .................................... 69rizatriptan .............................. 28ROCKLATAN..................... 71ROMIDEPSIN..................... 21ropinirole ................................27rosadan .................................. 48rosuvastatin ............................45ROTARIX............................ 63ROTATEQ VACCINE......... 63roweepra ................................ 26ROZLYTREK...................... 21


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RUBRACA...........................21rufinamide ..............................26RUKOBIA..............................4RUXIENCE..........................21RYBELSUS.......................... 57RYDAPT.............................. 21RYTARY..............................28SAMSCA.............................. 58SANDIMMUNE.................. 21SANTYL...............................47SAPHRIS..............................38sapropterin ............................. 58SARCLISA........................... 21scopolamine base .................... 61SECUADO........................... 38selegiline hcl ........................... 28selenium sulfide ...................... 46SELZENTRY......................... 4SEREVENT DISKUS.......... 74sertraline .......................... 38, 39setlakin .................................. 69sevelamer carbonate ............... 52sharobel ..................................66SHINGRIX (PF)...................63SIGNIFOR........................... 21sildenafil (pulmonary arterial hypertension) ......................... 74silver sulfadiazine ................... 47SIMBRINZA........................ 71simliya (28) ........................... 69SIMULECT.......................... 21simvastatin ............................. 45sirolimus .................................21SIRTURO...............................9SKYRIZI.............................. 46sodium bicarbonate .................77sodium chloride .................52, 77sodium chloride 0.45 % ........... 77sodium chloride 0.9 % .............52sodium chloride 3 % ................77sodium chloride 5 % ................77sodium phenylbutyrate ............52sodium polystyrene (sorb free) .......................................52sodium polystyrene sulfonate .. 52solifenacin .............................. 75SOLTAMOX........................ 21SOLU-CORTEF................... 54

SOLU-CORTEF ACT-O-VIAL (PF).............................54SOMATULINE DEPOT...... 21SOMAVERT.........................59sorine ..................................... 40sotalol .................................... 40sotalol af ................................ 40SOTYLIZE........................... 40SOVALDI...............................5spironolactone ........................ 42spironolacton-hydrochlorothiaz .................... 42sprintec (28) .......................... 69SPRITAM.............................26SPRYCEL.............................21sps (with sorbitol) .................. 52sronyx .................................... 69ssd ..........................................48STAMARIL (PF)..................63stavudine .................................. 5STELARA............................ 47STIVARGA.......................... 21STREPTOMYCIN................. 9STRIBILD.............................. 5SUBOXONE.........................33subvenite ................................ 26subvenite starter (blue) kit ..... 26subvenite starter (green) kit ... 26subvenite starter (orange) kit . 26sucralfate ............................... 62sulfacetamide sodium ..............70sulfacetamide sodium (acne) .. 48sulfacetamide-prednisolone ..... 70sulfadiazine ............................ 12sulfamethoxazole-trimethoprim .......................... 12sulfasalazine ...........................61sulindac .................................. 33sumatriptan ............................ 28sumatriptan succinate ............. 28SUPREP BOWEL PREP KIT....................................... 61SUTENT...............................21syeda ......................................69SYMDEKO.......................... 74SYMFI....................................5SYMFI LO..............................5SYMPAZAN........................ 26

SYMTUZA.............................5SYNAREL............................59SYNERCID............................9SYNJARDY......................... 57SYNJARDY XR...................57SYNRIBO.............................21TABLOID.............................21TABRECTA......................... 21tacrolimus .........................21, 48tadalafil (pulm. hypertension) 74TAFINLAR.......................... 21TAGRISSO...........................22TALTZ SYRINGE............... 47TALZENNA.........................22tamoxifen ...............................22tamsulosin .............................. 75TARGRETIN....................... 22tarina 24 fe .............................69tarina fe 1/20 (28) ..................69tarina fe 1-20 eq (28) ............. 69TASIGNA.............................22tazarotene .............................. 48tazicef ...................................... 7TAZORAC........................... 48taztia xt ................................. 43TAZVERIK.......................... 22TDVAX.................................63TECENTRIQ........................22TECFIDERA........................29TEFLARO..............................7TEKTURNA HCT............... 43telmisartan ............................. 43telmisartan-amlodipine ........... 43telmisartan-hydrochlorothiazid ..................43temazepam ............................. 39TEMIXYS.............................. 5TEMODAR.......................... 22temsirolimus ...........................22TENIVAC (PF).....................63tenofovir disoproxil fumarate ....5terazosin .................................43terbinafine hcl .......................... 1terbutaline ..............................74terconazole .............................66TERIPARATIDE................. 64testosterone ............................ 59TESTOSTERONE................ 59


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testosterone cypionate ............ 59testosterone enanthate ............ 59TETANUS,DIPHTHERIA TOX PED(PF)...................... 64tetrabenazine ..........................30tetracycline ............................ 12THALOMID.........................22THEO-24...............................74theophylline ............................74thioridazine ............................ 39thiotepa ..................................22thiothixene ............................. 39tiadylt er ................................ 43tiagabine ................................ 26TIBSOVO..............................22tigecycline ................................ 9tilia fe .....................................69timolol maleate ................. 43, 70tis-u-sol pentalyte ................... 51TIVICAY................................5TIVICAY PD..........................5tizanidine ................................30tobramycin ............................. 70tobramycin in 0.225 % nacl .....10tobramycin sulfate ..................10tobramycin-dexamethasone .... 71tolterodine ..............................75tolvaptan ................................ 59topiramate ........................ 26, 27toposar ...................................22topotecan ............................... 22toremifene .............................. 22torsemide ................................43TOUJEO MAX U-300 SOLOSTAR.......................... 57TOUJEO SOLOSTAR U-300 INSULIN....................... 57TOVIAZ................................75TRADJENTA.......................57tramadol ................................ 33tramadol-acetaminophen ........ 33trandolapril ............................ 43tranexamic acid ......................66tranylcypromine ..................... 39travasol 10 % ..........................77travoprost ...............................71TRAZIMERA.......................22trazodone ............................... 39

TREANDA...........................22TRECATOR......................... 10TRELEGY ELLIPTA...........74TRELSTAR.......................... 22tretinoin (antineoplastic) ........22tretinoin microspheres ............ 48tretinoin topical ...................... 48tri femynor ............................. 69triamcinolone acetonide................................... 51, 53, 54triamterene-hydrochlorothiazid ..................43triderm ................................... 51trientine ..................................52tri-estarylla ............................ 69trifluoperazine ........................ 39trifluridine ..............................70TRIJARDY XR.............. 57, 58TRIKAFTA.......................... 74tri-legest fe ............................. 69tri-linyah ................................ 69tri-lo-estarylla ........................ 69tri-lo-marzia ...........................69tri-lo-mili ................................69tri-lo-sprintec ......................... 69trilyte with flavor packets ....... 61trimethoprim .......................... 12tri-mili ....................................69trimipramine .......................... 39TRINTELLIX...................... 39tri-previfem (28) .................... 69TRIPTODUR....................... 22tri-sprintec (28) ..................... 69TRIUMEQ............................. 5trivora (28) ............................69tri-vylibra ...............................69tri-vylibra lo ........................... 69TRODELVY.........................22TROGARZO.......................... 5TROPHAMINE 10 %........... 78TRULICITY.........................58TRUMENBA........................64TRUVADA............................ 5TRUXIMA........................... 22TUKYSA.............................. 22TURALIO............................ 22TWINRIX (PF).....................64tydemy ................................... 69

TYKERB.............................. 23TYMLOS.............................. 64TYPHIM VI..........................64TYSABRI............................. 30unithroid ................................ 59UNITUXIN.......................... 23UPTRAVI.............................43ursodiol .................................. 61valacyclovir .............................. 5VALCHLOR.........................48valganciclovir ........................... 5valproate sodium .................... 27valproic acid ........................... 27valproic acid (as sodium salt) .27valrubicin ............................... 23valsartan ................................ 43valsartan-hydrochlorothiazide .43VALTOCO............................27VANCOMYCIN...................10vancomycin ............................ 10VANCOMYCIN IN 0.9 % SODIUM CHL..................... 10VANCOMYCIN IN DEXTROSE 5 %...................10vandazole ............................... 66VAQTA (PF).........................64VARIVAX (PF).................... 64VARIZIG..............................64VASCEPA.............................45VECTIBIX............................ 23VELCADE............................23velivet triphasic regimen (28) . 69VELPHORO......................... 52VELTASSA...........................52VEMLIDY..............................5VENCLEXTA...................... 23VENCLEXTA STARTING PACK....................................23venlafaxine .............................39VENTAVIS...........................74VENTOLIN HFA.................74verapamil ............................... 43VERSACLOZ....................... 39VERZENIO.......................... 23V-GO 20................................ 58V-GO 30................................ 58V-GO 40................................ 58VICTOZA 2-PAK.................58


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VICTOZA 3-PAK.................58vienva .....................................69vigabatrin ...............................27vigadrone ............................... 27VIIBRYD..............................39VIMPAT............................... 27vinblastine .............................. 23vincasar pfs ............................ 23vincristine ...............................23vinorelbine ..............................23VIOKACE............................ 61viorele (28) ............................ 69VIRACEPT.............................5VIREAD................................. 5VITRAKVI........................... 23VIVITROL............................33VIZIMPRO...........................23volnea (28) ............................ 69voriconazole ............................. 1VOSEVI.................................. 5VOTRIENT.......................... 23VRAYLAR........................... 39vyfemla (28) .......................... 69vylibra ....................................69VYNDAQEL........................ 46VYXEOS...............................23warfarin ................................. 44water for irrigation, sterile ......52wera (28) ...............................69wymzya fe .............................. 69XALKORI............................ 23XARELTO............................44XARELTO DVT-PE TREAT 30D START............ 44XATMEP..............................23XCOPRI................................27XCOPRI MAINTENANCE PACK....................................27XCOPRI TITRATION PACK....................................27XELJANZ.............................66XELJANZ XR...................... 66XGEVA.................................13XIFAXAN............................ 10XOLAIR......................... 74, 75XOSPATA............................ 23XPOVIO................................23XTANDI...............................23

XYREM................................39YERVOY..............................23YF-VAX (PF)....................... 64YONDELIS.......................... 23yuvafem ..................................66zafirlukast .............................. 75zaleplon ..................................39ZALTRAP............................ 23ZANOSAR........................... 23zarah ......................................69ZEJULA............................... 23ZELBORAF..........................24ZENPEP............................... 61ZEPZELCA.......................... 24zidovudine ................................ 5ZIEXTENZO........................62ziprasidone hcl ........................39ziprasidone mesylate ...............39ZIRABEV............................. 24ZIRGAN...............................70ZOLADEX........................... 24zoledronic acid ....................... 59zoledronic acid-mannitol-water ................................ 53, 59ZOLEDRONIC AC-MANNITOL-0.9NACL........59ZOLINZA.............................24zolpidem .................................39zonisamide ............................. 27ZORTRESS.......................... 24ZOSTAVAX (PF)................. 64ZOSYN IN DEXTROSE (ISO-OSM)............................11zovia 1/35e (28) ..................... 69zovia 1-35 (28) ...................... 69ZTLIDO................................48ZUBSOLV............................ 33zumandimine (28) ..................69ZYDELIG.............................24ZYKADIA............................24ZYPREXA RELPREVV.39, 40


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This formulary was updated on 3/1/2021. For more recent information or other questions, please contact Express Scripts Medicare Customer Service at 1.800.758.4574; New York State residents: 1.800.758.4570 or, for TTY users, 1.800.716.3231, 24 hours a day, 7 days a week, or visit express-scripts.com.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1.800.758.4574; para residentes del estado de New York: 1.800.758.4570 (TTY: 1.800.716.3231).

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This drug list was updated in March 2021

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