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INDIVIDUAL & FAMILY METAL PLANS, BASE AND ESSENTIAL PLANS FORMULARY GUIDEIncludes generic and brand-name medications

A nonprofit independent licensee of the Blue Cross Blue Shield Association

January 2019

Dear Member,

The prescription drug benefit is one of the most important and frequently

utilized elements of health plan coverage. To help you identify which

medications are covered under your plan, we are pleased to provide the

3-Tier Formulary Guide. This booklet provides you with easy to understand

information about your prescription drug coverage including descriptions of

prescription drug safety and cost-saving programs.

The 3-Tier Formulary Guide lists commonly prescribed medications and their

tier classifications. The medications listed have been approved by the Food

and Drug Administration (FDA) as safe and effective and were selected in

consultation with a team of health care professionals because they meet our

criteria for safety, quality and value. We continually review and update

our formulary.

The drugs listed in the formulary and program descriptions may not apply to all plans.

This booklet includes the Formulary Guide and prescription drug benefit information. Please refer to this booklet when you see your healthcare practioner or are prescribed a medication.

The drugs listed in the formulary and program descriptions may not apply to all plans. Please see your plan documents for a complete description of your pharmacy benefit.

If you have questions or need additional information, please visit our website, ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.

What is a Formulary?A formulary is a list of brand-name and generic drugs that are covered under your prescription drug benefit.

How is the Formulary Developed?Drugs listed on the formulary were selected by our independent Pharmacy and Therapeutics (P&T) Committee, which is made up of practicing health care providers and clinical pharmacists. The P&T Committee reviews each drug based upon scientific evidence, findings by federal government agencies, professional medical associations and journals to help ensure that the medications covered meet criteria for safety, effectiveness and value.

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

Medical ConditionDrugs are listed in alphabetical order according to drug categories. For example, drugs used to treat heart conditions are listed under the category “Cardiovascular.” Drugs are listed in alphabetical order by condition.

Alphabetical ListingIf you are not sure what category to look under, look for your drug in the Index that follows the formulary. The Index provides an alphabetical listing of all of the drugs included in the formulary and the page where they can be found in the formulary.

3-Tier Drug BenefitYour 3-tier prescription drug benefit allows you to make informed choices and encourages value when choosing your prescription medications. Your copayment will vary depending on the tier in which your prescription drug is placed.

• Tier One drugs are typically generics and have the lowest copayment amount.

• Tier Two drugs are brand drugs that have unique, significant clinical advantages and offer overall greater value over the other products in the same drug class.

• Tier Three drugs are all other brand drugs, including new brand drugs and drugs that have generic equivalents. Tier Three drugs have the highest copayment amount.

The 3-Tier Formulary Guide lists commonly used medications and their tier designations. Because there are thousands of medications included in your pharmacy benefit, we list only the most commonly prescribed.

Your plan may not cover all medications listed in this booklet. Please see your plan documents for a complete description of your pharmacy benefit, or call the Pharmacy Help Desk at 1-800-499-1275.

Can the Formulary Change?Our P&T Committee regularly reviews the drugs on our formulary to be sure they meet the criteria for safety, effectiveness and value. The list is subject to change. Drugs may be added, removed, or change tier designation at any time.

Generics Are Real MedicineGeneric drugs: safe, effective, affordable! To help keep your prescription drug costs down, choose a generic drug over a brand. Generics are as safe and effective as their brand-name counterparts – they just cost a lot less.

In fact, you’ll save money when you choose a generic because generics have the lowest copay. That means you’ll always pay the lowest out-of-pocket amount for a generic.

Generic drugs treat your illness or condition with the same effectiveness and safety as their brand-name equivalents because they have to meet the same rigorous FDA requirements as brand-name drugs.

Experience has shown that more than 90 percent of members who start on a generic will stay on a generic. So the next time you need your brand prescription filled, ask your doctor or pharmacist if a generic is right for you.

Where Can I Purchase My Prescription Medications?You have access to more than 65,000 participating pharmacies in our nationwide Pharmacy Network, including national chains and most independents. Just show your Member Card at any participating pharmacy; it identifies you as having prescription drug coverage. A list of participating pharmacies in your area is available on our website, ExcellusBCBS.com

Mail Service PharmacyGet your prescriptions delivered right to your door!

When you use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, you get the convenience of home delivery and the ease of ordering new prescriptions and refills either by phone or via our website, ExcellusBCBS.com. Some benefits offer

copay savings for ordering prescriptions through Express Scripts Home Delivery PharmacySM

or Wegmans® Home Delivery Pharmacy.

Using a home delivery pharmacy is ideal for those who take prescription medication on a continuing basis. For more information on how to use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, please visit our website at ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.

Specialty PharmacySpecialty pharmacies focus on you and your individual health care needs. Because they work exclusively with specialty medications, they are experts in handling and administering these complex medications. Nationally recognized specialty pharmacy Accredo Health participates in our network. Accredo Health offers outstanding customer service and is dedicated to providing quality care to our members. With a single, toll-free phone call they take care of all the details – they will contact your doctor for your prescription and arrange delivery to your home. There are several local/regional specialty pharmacies also participating in our specialty pharmacy network. A complete listing of participating specialty pharmacies is available on our website, ExcellusBCBS.com

Are There Any Restrictions On Coverage?Some covered drugs may have additional requirements or limits for coverage. If a drug has requirements or limits, it will be noted in the formulary.

If your health-care practitioner determines that you need a medication that has a requirement or limit, we have an exception process in place. Your health-care practitioner must submit a request to the Health Plan supporting your need.

Coverage requirements or limits may include:

Prior Authorization Prior authorization helps ensure that a prescribed drug is safe and appropriate for your medical condition. Certain medications require that your doctor gets approval before the medication is covered. Our clinical pharmacists and physicians review medication requests to make sure that the choice of drug or dose is appropriately prescribed based

on FDA and manufacturer guidelines, medical literature, safety, use and benefit design.

Step Therapy In some cases you may be required to first try one or more drugs to treat your medical condition before another drug for that condition will be covered. The medication treatment moves along a series of “steps.” 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, we will then cover Drug B.

Specialty Drug Benefit Specialty medications are designed for conditions like multiple sclerosis, rheumatoid arthritis, hepatitis C, and others that are difficult to treat with traditional medications. These medications are self-administered, either taken orally or by injection.

Your prescription drug benefit may require that you purchase certain specialty medications at a specialty pharmacy that participates in the Specialty Pharmacy Network in order to receive coverage. If a participating specialty pharmacy is not used, you may be responsible for the full cost of the prescription. A complete listing of participating specialty pharmacies can be found on our website, ExcellusBCBS.com

Quantity Limits For certain drugs, we limit the amount of the drug that we will cover. The amount of drug we cover is based on FDA approved dosing and usage guidelines.

Generic Advantage Program The Generic Advantage program promotes the use of generic medications. If you fill your prescription with a brand-name medication when there is a generic equivalent available, you will pay the difference between the pharmacy’s charge for the more costly brand-name medication and our price for the less expensive generic. Check your benefits summary to find out if the Generic Advantage program applies to your plan.

Key:

UPPERCASE – Brand name medicationlowercase – generic medication

PA = Prior Authorization required

QL = Quantity Limit applies

ST = Step Therapy required

MS = Drug must be purchased at a participating network specialty pharmacy for coverage

LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

butalbital/aspirin/caffeine 50-325-40 capsule 1 QL

butalbital/aspirin/caffeine 50-325-40 tablet 1

CAMBIA 3

QL

ST

celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule, 400 mg capsule) 1 QL

choline salicylate/magnesium salicylate 1

diclofenac potassium 1

diclofenac sodium (1.5 % drops, 25 mg tablet dr, 50 mg tablet dr, 75 mg tabletdr, 100 mg tab er 24h)

1

diclofenac sodium/misoprostol 1 QL

DICLOPR 3

QL

PA

diflunisal 1

DITHOL 3

QL

PA

DUEXIS 3

QL

PA

etodolac 1

fenoprofen calcium (200 mg capsule, 400 mg capsule) 3 PA

fenoprofen calcium 600 mg tablet 1 PA

FENORTHO 3 PA

FLECTOR 3

QL

PA

flurbiprofen 1

IBU 1

ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) 1

indomethacin 1

ketoprofen 1

PAGE 5 LAST UPDATED 01/2019


ketorolac tromethamine 10 mg tablet 1 QL

MECLOFENAMATE SODIUM 3

mefenamic acid 1

meloxicam (7.5 mg tablet, 15 mg tablet) 1

MELOXICAM 7.5 MG/5 ML ORAL SUSP 3

nabumetone (500 mg tablet, 750 mg tablet) 1 QL

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

1

NAPROXEN 125 MG/5 ML ORAL SUSP 3

naproxen sodium (275 mg tablet, 375 mg tbmp 24hr, 500 mg tbmp 24hr, 550mg tablet)

1

oxaprozin 600 mg tablet 1 QL

PENNSAID 2% PUMP 3

QL

PA

piroxicam 1

PROFENO 1 PA

salsalate 1

SPRIX 3

QL

PA

sulindac 1

TIVORBEX 3

QL

PA

tolmetin sodium 1

VIMOVO 3

QL

PA

VIVLODEX 3 PA

ZIPSOR 3

QL

PA

ZORVOLEX 3

QL

PA

OPIOID ANALGESICS, LONG-ACTING

ARYMO ER (ER 15 MG TABLET, ER 30 MG TABLET, ER 60 MG TABLET) 3 PA



BELBUCA (75 MCG FILM, 150 MCG FILM, 300 MCG FILM, 450 MCG FILM,600 MCG FILM, 750 MCG FILM, 900 MCG FILM)

3 PA

BUPRENORPHINE PATCH 3

QL

PA

BUTRANS (5 MCG/HR PATCH, 7.5 MCG/HR PATCH, 10 MCG/HR PATCH, 15MCG/HR PATCH, 20 MCG/HR PATCH)

3 PA

EMBEDA 3 PA

EXALGO 3 PA

fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72,75mcg/hr patch td72, 100 mcg/hr patch td72)

1 PA

FENTANYL (37.5MCG/HR PATCH TD72, 62.5MCG/HR PATCH TD72,87.5MCG/HR PATCH TD72)

1 PA

hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32mg tab er 24h)

1

QL

PA

HYSINGLA ER 3 PA

levorphanol tartrate 1 PA

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

1 PA

METHADONE INTENSOL 1 PA

METHADOSE 40 MG TABLET DISPR 1 PA

MORPHABOND ER 3 PA

morphine sulfate (10 mg cap er pel, 15 mg tablet er, 20 mg cap er pel, 30 mgcap er pel, 30 mg tablet er, 50 mg cap er pel, 60 mg cap er pel, 80 mg cap erpel, 100 mg cap er pel, 100 mg tablet er, 200 mg tablet er)

1 PA

morphine sulfate (30 mg cpmp 24hr, 45 mg cpmp 24hr, 60 mg cpmp 24hr, 75mg cpmp 24hr, 90 mg cpmp 24hr, 120 mg cpmp 24hr)

2 PA

morphine sulfate 60 mg tablet er 1

QL

PA

NUCYNTA ER (ER 50 MG TABLET, ER 100 MG TABLET, ER 150 MGTABLET, ER 200 MG TABLET, ER 250 MG TABLET)

2 PA

OXYCODONE HCL ER 3 PA

OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MGTABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET)

3 PA

oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg tab er 12h, 15 mgtab er 12h, 20 mg tab er 12h, 30 mg tab er 12h, 40 mg tab er 12h)

1 PA

TRAMADOL ER CAPS 3

QL

PA

tramadol hcl (100 mg tab er 24h, 200 mg tab er 24h, 300 mg tbmp 24hr) 1 PA

tramadol hcl (100 mg tbmp 24hr, 200 mg tbmp 24hr, 300 mg tab er 24h) 1

QL

PA



XTAMPZA ER 3 PA

ZOHYDRO ER 3

QL

PA

OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL 3

QL

PA

acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg-15mgtablet, 300mg-30mg tablet, 300mg-60mg tablet, 300mg/12.5 solution)

1

acetaminophen/caff/dihydrocod 320.5-30mg capsule 1

ACTIQ 3

QL

PA

ASCOMP WITH CODEINE 1

aspirin/caffeine/dihydrocodeine bitartrate 1

butalbital/acetaminophen/caffeine/codeine phosphate 1 QL

butorphanol tartrate 10 mg/ml spray 1 QL

carisoprodol/aspirin/codeine 200-325-16 tablet 1

codeine phosphate/butalbital/aspirin/caffeine 1

codeine sulfate 1

ENDOCET 1

fentanyl citrate 1

QL

PA

FENTORA 3

QL

PA



hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 2.5-108/5solution, hydrocodone/acetaminophen 2.5-325 mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet, hydrocodone/acetaminophen5 mg-325mg tablet, hydrocodone/acetaminophen 5-163/7.5 solution,hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-300 mg tablet, hydrocodone/acetaminophen7.5-325 mg tablet, hydrocodone/acetaminophen 7.5-325/15 solution,hydrocodone/acetaminophen 10-325/15 solution, hydrocodone/acetaminophen10mg-300mg tablet, hydrocodone/acetaminophen 10mg-325mg tablet)

1

hydrocodone/ibuprofen 1

hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect, 4 mg tablet, 8mg tablet)

1

ibuprofen/oxycodone hcl 1

LAZANDA 3

QL

PA

LORCET 1

LORCET HD 1

LORCET PLUS 1

LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MG TABLET) 1

meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100 mg tablet) 1

MORPHINE SULFATE (15 MG TABLET, 30 MG TABLET) 2

morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10 mg/5 ml solution, 20 mgsupp.rect, 20 mg/5 ml solution, 30 mg supp.rect, 100 mg/5ml solution)

1

NUCYNTA 2 QL

opium/belladonna alkaloids 1

oxycodone hcl (5 mg capsule, 5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 15mg tablet, 20 mg tablet, 20 mg/ml oral conc, 30 mg tablet)

1

oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mg tablet,hcl/acetaminophen 5 mg-325mg tablet, hcl/acetaminophen 5-325/5 ml solution,hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen 10mg-325mg tablet)

1

oxycodone hcl/aspirin 1

oxymorphone hcl (5 mg tablet, 10 mg tablet) 1

pentazocine hcl/naloxone hcl 1

REPREXAIN 1

SUBSYS (100 MCG SPRAY, 200 MCG SPRAY, 400 MCG SPRAY, 600 MCGSPRAY, 800 MCG SPRAY, 1,200 MCG SPRAY, 1,600 MCG SPRAY)

3

QL

PA

tramadol hcl 50 mg tablet 1

tramadol hcl/acetaminophen 1

VERDROCET 1

VICODIN 1

VICODIN ES 1



VICODIN HP 1

XARTEMIS XR 3 PA

XYLON 10 1

ANESTHETICS

LOCAL ANESTHETICS

ANODYNE LPT 3

QL

PA

DERMACINRX EMPRICAINE 3 PA

DERMACINRX PRIZOPAK 1

QL

PA

DOLOTRANZ 3

QL

PA

GLYDO 1

LIDO-K 1

LIDO-PRILO CAINE PACK 3

QL

PA

lidocaine (5 % adh. patch, 5 % oint. (g)) 1

lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 3 % cream (g), 3 %lotion, 4 % solution, 40 mg/ml solution)

1

lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5kit)

1

LIDOPAC 3

QL

PA

LIDOPIN 3% CREAM 1

LIDOPRIL 3

QL

PA

LIDOPRIL XR 3

QL

PA

LIDOTRANS 5 PAK 3

QL

PA

LIPROZONEPAK 3 PA

MEDOLOR PAK 3 PA

NEURCAINE 3

QL

PA



PAINGO KFT 3

QL

PA

PRILOLID 3 PA

RELADOR PAK 3

QL

PA

SOLUPAK 3

QL

PA

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium 1 QL

disulfiram 1

naltrexone hcl 1

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1

buprenorphine hcl/naloxone hcl 1

SUBOXONE 2

ZUBSOLV 2

OPIOID REVERSAL AGENTS

naloxone hcl (0.4 mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml syringe) 1

NARCAN 4 MG NASAL SPRAY 2

SMOKING CESSATION AGENTS

BUPROBAN 1

bupropion hcl 150 mg tab er 12h 1

CHANTIX 3 QL

NICOTROL 3 QL

NICOTROL NS 3 QL

ZYBAN 3

ANTIBACTERIALS

AMINOGLYCOSIDES

GENTAK 1

gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 % drops, 0.3 % oint.(g))

1



neomycin sulfate 1

paromomycin sulfate 1

tobramycin 1

ANTIBACTERIALS, OTHER

ALTABAX 3

bacitracin 500 unit/g oint. (g) 1

CENTANY AT 3

QL

PA

CLINDACIN ETZ 1% PLEDGET 1

CLINDACIN ETZ KIT 3

QL

PA

CLINDACIN P 1

CLINDACIN PAC 3

QL

PA

clindamycin hcl 1

clindamycin palmitate hcl 75 mg/5 ml soln recon 1

clindamycin phosphate (1 % gel (gram), 1 % lotion, 1 % med. swab, 1 %solution, 2 % cream/appl)

1

erythromycin base/benzoyl peroxide 1

FIRVANQ 2

HYOLEV MB 1

HYOPHEN 1

linezolid 100 mg/5ml susp recon 1

linezolid 600 mg tablet 1 QL

methenamine hippurate 1

methenamine mandelate 1

methenamine/sod phosph,monobasic/methylene blue/hyoscyamine 1

metronidazole (0.75 % gel w/appl, 250 mg tablet, 375 mg capsule, 500 mgtablet)

1

MONUROL 3

mupirocin 1

mupirocin calcium 1

nitrofurantoin 1

nitrofurantoin macrocrystal 1



nitrofurantoin monohydrate/macrocrystals 1

PHOSPHASAL 1

SIVEXTRO 200 MG TABLET 3 PA

SULFAMYLON 8.5% CREAM 3

tinidazole 1

trimethoprim 1

UR N-C 1

URAMIT MB 1

URETRON D-S 1

URIMAR-T 1

URIN D.S. 1

URO-458 1

URO-MP 1

UROGESIC-BLUE 1

UROLET MB 1

UROPHEN MB 1

URYL 1

UTIRA-C 1

vancomycin hcl (125 mg capsule, 250 mg capsule) 1

VANDAZOLE 1

ZYVOX 100 MG/5 ML SUSPENSION 3

ZYVOX 600 MG TABLET 3 QL

BETA-LACTAM, CEPHALOSPORINS

cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375mg/5ml susp recon, 500 mg capsule, 500 mg tab er 12h)

1

cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5mlsusp recon)

1

cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) 1

cefditoren pivoxil 1

cefixime 1

cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susprecon, 200 mg tablet)

1

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

1

CEFTIBUTEN 3

cefuroxime axetil 1



cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 750 mg capsule)

1

BETA-LACTAM, PENICILLINS

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

1

AMOXICILLIN ER 775 MG 3

amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon,amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mgtablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab chew, amoxicillin/potassium 400-57mg/5 susp recon,amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susprecon, amoxicillin/potassium 875-125 mg tablet, amoxicillin/potassium 1000-62.5 tab er 12h)

1

ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susprecon, 500 mg capsule)

1

dicloxacillin sodium 1

MOXATAG 3 PA

penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml solnrecon, 500 mg tablet)

1

MACROLIDES

AZASITE 3

azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250mg tablet, 500 mg tablet, 600 mg tablet)

1

clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon,500 mg tab er 24h, 500 mg tablet)

1

DIFICID 3 ST

E.E.S. 200 3

E.E.S. 400 3

ERY 1

ERY-TAB 1

ERYPED 200 3

ERYPED 400 3

ERYTHROCIN STEARATE 1

erythromycin base (5 mg/gram oint. (g), 250 mg capsule dr, 250 mg tablet, 500mg tablet)

1

erythromycin base in ethanol (erythromyc2 % gel (gram), erythromyc2 % med.swab, erythromyc2 % solution)

1

erythromycin ethylsuccinate (200 mg/5ml susp recon, 400 mg tablet) 1

QUINOLONES

BAXDELA 450 MG TABLET 3 QL

BESIVANCE 3

CILOXAN 0.3% OINTMENT 3



ciprofloxacin 1

ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750mg tablet)

1

ciprofloxacin hcl 0.2 % droperette 1 QL

ciprofloxacin/ciprofloxacin hcl 1

FACTIVE 3

gatifloxacin 1

levofloxacin (0.5 % drops, 250 mg tablet, 250mg/10ml solution, 500 mg tablet,500mg/20ml solution, 750 mg tablet)

1

MOXEZA 2

moxifloxacin hcl (0.5 % drops, 400 mg tablet) 1

ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet) 1

VIGAMOX 3

ZYMAXID 3

SULFONAMIDES

silver sulfadiazine 1

SSD 1

sulfacetamide sodium (10 % drops, 10 % oint. (g), 10 % suspension) 1

sulfadiazine 1

sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 200-40mg/5 oralsusp, sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160 mg tablet,sulfamethoxazole/trimethoprim 800-160/20 oral susp)

1

SULFATRIM 1

THERMAZENE 1

TETRACYCLINES

ACTICLATE 3 PA

AVIDOXY 1

demeclocycline hcl 1

DORYX 3 ST

doxycycline hyclate (20 mg tablet, 50 mg capsule, 50 mg tablet dr, 75 mg tabletdr, 100 mg capsule, 100 mg tablet, 100 mg tablet dr, 150 mg tablet dr, 200 mgtablet dr)

1

doxycycline hyclate (75 mg tablet, 150 mg tablet) 1

QL

PA



doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mgtablet, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet, 150 mgcapsule, 150 mg tablet)

1

DOXYCYCLINE MONOHYDRATE 40 MG CAP IR DR 3

QL

ST

minocycline hcl (45 mg tab er 24h, 65 mg tab er 24h, 90 mg tab er 24h, 115mgtab er 24h, 135 mg tab er 24h)

1

QL

PA

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

1

MONDOXYNE NL 1

MORGIDOX (1X100 MG KIT, 1X50 MG KIT, 2X100 MG KIT) 3

QL

PA

MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1

ORACEA 3

QL

ST

SOLODYN 3

QL

PA

tetracycline hcl 1

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

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

3

QL

PA

levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mg tablet)

1

levetiracetam (500 mg tab er 24h, 750 mg tab er 24h) 1 QL

ROWEEPRA 1

ROWEEPRA XR 500 MG TABLET 1

ROWEEPRA XR 750 MG TABLET 1 QL

SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MGTABLET)

3

QL

PA

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 3

ethosuximide (250 mg capsule, 250 mg/5ml solution) 1

zonisamide 1



GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1

divalproex sodium 1

gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet)

1

GRALISE (ER 300 MG TABLET, ER 600 MG TABLET) 3

QL

PA

GRALISE 30-DAY STARTER PACK 3 PA

ONFI (10 MG TABLET, 20 MG TABLET) 3 QL

ONFI 2.5 MG/ML SUSPENSION 3

phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet,32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)

1

primidone 1

SABRIL 3

QL

PA

MS

tiagabine hcl 1

valproic acid 1

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

1

vigabatrin 1

QL

PA

MS

GLUTAMATE REDUCING AGENTS

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) 1

lamotrigine (25 mg tab rapdis, 25(42)-100 tab ds pk, 25(84)-100 tab ds pk, 50mg tab rapdis, 100 mg tab rapdis, 200 mg tab rapdis)

1 QL

lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tablet, 25 mg tb chw dsp,25(21)-50 tb rd dspk, 25-50-100 tb rd dspk, 25mg (35) tab ds pk, 50 mg tab er24, 50(42)-100 tb rd dspk, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200mg tab er 24, 200 mg tablet, 250 mg tab er 24, 300 mg tab er 24)

1

QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 150MG CAPSULE, 200 MG CAPSULE)

3

QL

PA

topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet)

1

topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mgcap spr 24, 200 mg cap spr 24)

3

QL

PA



TROKENDI XR 3

QL

PA

SODIUM CHANNEL AGENTS

APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MGTABLET)

3

QL

PA

BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) 3

carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300mg cpmp 12hr, 400 mg tab er 12h)

1

EPITOL 1

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

1

OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG TABLET) 3

QL

PA

PEGANONE 3

phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) 1

phenytoin sodium extended 1

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

2

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates 1

CHOLINESTERASE INHIBITORS

donepezil hcl 1

galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet,12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)

1

NAMZARIC 3

QL

PA

rivastigmine 1

rivastigmine tartrate 1

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl (2 mg/ml solution, 5 mg tablet, 5 mg-10 mg tab ds pk, 10 mgtablet)

1

memantine hcl (7 mg cap spr 24, 14 mg cap spr 24, 21 mg cap spr 24, 28 mgcap spr 24)

1 QL

NAMENDA (2 MG/ML SOLUTION, 5-10 MG TITRATION PK) 3

NAMENDA XR 3

QL

ST



ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

amitriptyline hcl/chlordiazepoxide 1

bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) 1 QL

bupropion hcl (75 mg tablet, 100 mg tab sr 12h, 100 mg tablet, 150 mg tab sr12h, 200 mg tab sr 12h)

1

mirtazapine 1

perphenazine/amitriptyline hcl 1

MONOAMINE OXIDASE INHIBITORS

EMSAM 3

QL

ST

MARPLAN 3

phenelzine sulfate 1

tranylcypromine sulfate 1

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS)

BRISDELLE 3

QL

PA

citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL

citalopram hydrobromide 10 mg/5 ml solution 1

DESVENLAFAXINE ER 3

QL

ST

DESVENLAFAXINE FUMARATE 3

QL

ST

desvenlafaxine succinate 1 QL

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

1

FETZIMA 3 QL

fluoxetine hcl (10 mg capsule, 10 mg tablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule, 60 mg tablet)

1

fluoxetine hcl 90 mg capsule dr 1 QL

fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h) 1 QL

fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1

KHEDEZLA 3

QL

ST



maprotiline hcl 1

nefazodone hcl (150 mg tablet, 200 mg tablet, 250 mg tablet) 1

nefazodone hcl (50 mg tablet, 100 mg tablet) 1 QL

OLEPTRO ER (ER 150 MG TABLET, ER 300 MG TABLET) 3

QL

ST

paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) 1

paroxetine hcl (12.5 mg tab er 24h, 25 mg tab er 24h, 37.5 mg tab er 24h) 1 QL

paroxetine mesylate 1

QL

PA

sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1

trazodone hcl 1

TRINTELLIX 3 QL

VENLAFAXINE ER TAB (TIER DEPENDENT ON MANUFACTURER. UCB T3,OTHERS T1)

3

QL

ST

venlafaxine hcl (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100mg tablet)

1

venlafaxine hcl (37.5 mg cap er 24h, 75 mg cap er 24h, 150 mg cap er 24h) 1 QL

VIIBRYD (10 MG TABLET, 10-20-40 MG STARTER PK, 20 MG TABLET, 40MG TABLET)

3 QL

VIIBRYD 10-20 MG STARTER PACK 3

TRICYCLICS

amitriptyline hcl 1

amoxapine 1

clomipramine hcl 1

desipramine hcl 1

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

1

imipramine hcl 1

imipramine pamoate 1

nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) 1

nortriptyline hcl (10 mg/5 ml solution, 20 mg/10ml solution) 3

QL

PA

protriptyline hcl 1

trimipramine maleate 1



ANTIEMETICS

ANTIEMETICS, OTHER

BONJESTA 3

QL

PA

COMPAZINE 25 MG SUPPOSITORY 1

COMPRO 1

DICLEGIS 3

QL

PA

metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10mlsolution)

1

perphenazine 1

PHENADOZ 1

PHENERGAN (12.5 MG, 25 MG, 50 MG) 1

prochlorperazine 1

prochlorperazine maleate 1

promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mg supp.rect, 50 mgtablet)

1

PROMETHEGAN 1

scopolamine 1

TRANSDERM-SCOP 3

trimethobenzamide hcl 1

EMETOGENIC THERAPY ADJUNCTS

AKYNZEO 300-0.5 MG CAPSULE 3 QL

aprepitant (40 mg capsule, 80 mg capsule, 125 mg capsule, 125mg-80mg capds pk)

1 QL

CESAMET 3

dronabinol 1

granisetron hcl 1 mg tablet 1 QL

ondansetron 1

ondansetron hcl (4 mg tablet, 4 mg/5 ml solution, 8 mg tablet, 24 mg tablet) 1

SANCUSO 3

QL

ST

SYNDROS 3 PA

VARUBI 90 MG TABLET 3



ANTIFUNGALS

CICLODAN 0.77% CREAM 1

CICLODAN 8% SOLUTION 1 QL

ciclopirox (0.77 % gel (gram), 1 % shampoo) 1

ciclopirox 8 % solution 1 QL

ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) 1

clotrimazole 10 mg troche 1

CRESEMBA 186 MG CAPSULE 3

econazole nitrate 1

ERTACZO 3 ST

EXELDERM (CREAM, SOLUTION) 3

EXTINA 3 ST

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

1

flucytosine 1

griseofulvin ultramicrosize 1

griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) 1

itraconazole (10 mg/ml solution, 100 mg capsule) 1

JUBLIA 3

QL

PA

KERYDIN 3 PA

ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo, 200 mg tablet) 1

KETODAN 2% FOAM 1

LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK) 3

QL

PA

LOPROX (CREAM KIT, SUSPENSION KIT) 3

QL

PA

luliconazole 3 QL

miconazole nitrate 200 mg supp.vag 1

naftifine hcl 1 % cream (g) 1

naftifine hcl 2 % cream (g) 1 QL

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



NAFTIN 2% CREAM 3 QL

NATACYN 3

NOXAFIL 40 MG/ML SUSPENSION 3

NYAMYC 1

NYATA 100,000 UNIT/GM POWDER 3

nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500k unit tablet,500mm unit powder(ea), 100000/g cream (g), 100000/g oint. (g), 100000/gpowder, 100000/ml oral susp)

1

nystatin/triamcinolone acetonide 1

NYSTOP 1

ORAVIG 3 PA

oxiconazole nitrate 1

OXISTAT 1% CREAM 3

OXISTAT 1% LOTION 3 ST

terbinafine hcl 250 mg tablet 1

terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) 1

voriconazole (50 mg tablet, 200 mg/5ml susp recon) 1

voriconazole 200 mg tablet 1 QL

ANTIGOUT AGENTS

allopurinol 1

COLCHICINE 3 QL

COLCRYS 2 QL

DUZALLO 3

QL

PA

probenecid 1

probenecid/colchicine 1

ULORIC 2

QL

ST

ZURAMPIC 3

QL

PA



ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS, OTHER

AIMOVIG AUTOINJECTOR 2

QL

PA

AIMOVIG AUTOINJECTOR (2 PACK) 2

QL

PA

ERGOT ALKALOIDS

D.H.E.45 3

dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) 1

DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP 3 QL

ERGOMAR 3

ergotamine tartrate/caffeine 1

MIGRANAL 3 QL

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate 1 QL

eletriptan hydrobromide 1 QL

frovatriptan succinate 1 QL

naratriptan hcl (1 mg tablet, 2.5 mg tablet) 1 QL

rizatriptan benzoate 1 QL

sumatriptan (5 mg spray, 20 mg spray) 1 QL

sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5mlcartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml vial, 25 mgtablet, 50 mg tablet, 100 mg tablet)

1 QL

sumatriptan succinate/naproxen sodium 1 QL

SUMAVEL DOSEPRO (4 MG/0.5 ML, 6 MG/0.5 ML) 3

QL

ST

TREXIMET 3 QL

zolmitriptan 1 QL

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 3

QL

ST



ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

GUANIDINE HCL 3

MESTINON 60 MG/5 ML SYRUP 3

pyridostigmine bromide 1

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone (25 mg tablet, 100 mg tablet) 1

MYCOBUTIN 3

rifabutin 1

ANTITUBERCULARS

cycloserine 1

ethambutol hcl 1

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1

PASER 3

PRIFTIN 3

pyrazinamide 1

rifampin (150 mg capsule, 300 mg capsule) 1

RIFATER 3

SIRTURO 3

TRECATOR 3

ANTINEOPLASTICS

ALKYLATING AGENTS

ALKERAN 2 MG TABLET 2

CYCLOPHOSPHAMIDE (25 MG CAPSULE, 50 MG CAPSULE) 1

GLEOSTINE 3

HEXALEN 3

LEUKERAN 2

lomustine 1

MATULANE 2

melphalan 1

MYLERAN 2



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

3 MS

temozolomide 1 MS

VALCHLOR 3

QL

PA

MS

ANTIANDROGENS

bicalutamide 1

ERLEADA 3

QL

PA

MS

flutamide 1

NILANDRON 3

nilutamide 1

XTANDI 2

QL

PA

MS

YONSA 3

QL

PA

MS

ZYTIGA (250 MG TABLET, 500 MG TABLET) 2

QL

PA

MS

ANTIANGIOGENIC AGENTS

POMALYST 3

QL

PA

MS

REVLIMID 2

QL

PA

MS

THALOMID 3

QL

MS



ANTIESTROGENS/MODIFIERS

EMCYT 3

FARESTON 2

SOLTAMOX 3

QL

PA

tamoxifen citrate 1

ANTIMETABOLITES

capecitabine 1 MS

DROXIA 3

fluorouracil (2 % solution, 5 % cream (g), 5 % solution) 1

hydroxyurea 1

mercaptopurine 1

PURIXAN 3

QL

PA

TABLOID 2

ANTINEOPLASTICS, OTHER

ALUNBRIG (30 MG TABLET, 90 MG TABLET, 90 MG-180 MG TAB PACK, 180MG TABLET)

3

QL

PA

MS

IDHIFA (50 MG TABLET, 100 MG TABLET) 3

QL

PA

MS

leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) 1

LONSURF 3

PA

MS

LYSODREN 2

NINLARO 3

PA

MS

RUBRACA 250 MG TABLET 3

QL

PA

RYDAPT 3

QL

PA

MS



SYLATRON 3

PA

MS

ZOLINZA 3

QL

PA

MS

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole 1

exemestane 1

letrozole 1

ENZYME INHIBITORS

etoposide 50 mg capsule 1

HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 2

QL

PA

MS

MOLECULAR TARGET INHIBITORS

AFINITOR 2

QL

PA

MS

ALECENSA 3

PA

MS

BOSULIF (100 MG TABLET, 400 MG TABLET, 500 MG TABLET) 3

QL

PA

MS

BRAFTOVI (50 MG CAPSULE, 75 MG CAPSULE) 3

QL

PA

CABOMETYX 3

QL

PA

MS

CALQUENCE 3

QL

PA

CAPRELSA (100 MG TABLET, 300 MG TABLET) 2

QL

PA



COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK) 2

QL

PA

COTELLIC 3

PA

MS

ERIVEDGE 3

QL

PA

MS

FARYDAK 3

QL

PA

MS

GILOTRIF 3

QL

PA

MS

IBRANCE 2

QL

PA

MS

ICLUSIG (15 MG TABLET, 45 MG TABLET) 3

QL

PA

imatinib mesylate (100 mg tablet, 400 mg tablet) 1

QL

MS

IMBRUVICA (70 MG CAPSULE, 140 MG CAPSULE, 140 MG TABLET, 280MG TABLET, 420 MG TABLET, 560 MG TABLET)

3

QL

PA

INLYTA (1 MG TABLET, 5 MG TABLET) 3

QL

PA

MS

IRESSA 3

QL

PA

MS

JAKAFI 2

QL

PA

MS



KISQALI (200 MG DAILY, 400 MG DAILY, 600 MG DAILY) 3

QL

PA

MS

KISQALI FEMARA CO-PACK (200 MG, 400 MG, 600 MG) 3

QL

PA

MS

LENVIMA (4 MG CAPSULE, 8 MG DAILY DOSE, 10 MG DAILY DOSE, 12 MGDAILY DOSE, 14 MG DAILY DOSE, 18 MG DAILY DOSE, 20 MG DAILYDOSE, 24 MG DAILY DOSE)

3

QL

PA

MS

LYNPARZA (100 MG TABLET, 150 MG TABLET) 3

QL

PA

MS

LYNPARZA 50 MG CAPSULE 3

PA

MS

MEKINIST (0.5 MG TABLET, 2 MG TABLET) 3

QL

PA

MS

MEKTOVI 3

QL

PA

MS

NERLYNX 3

QL

PA

MS

NEXAVAR 2

QL

PA

MS

ODOMZO 3

PA

MS

SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MGTABLET, 100 MG TABLET, 140 MG TABLET)

2

QL

PA

MS



STIVARGA 2

QL

PA

MS

SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MGCAPSULE)

2

QL

PA

MS

TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) 3

QL

PA

MS

TAGRISSO 3

PA

MS

TARCEVA 3

QL

PA

MS

TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) 3

QL

PA

MS

TYKERB 2

QL

PA

MS

VENCLEXTA 3

QL

PA

VERZENIO 2

QL

PA

MS

VOTRIENT 2

QL

PA

MS

XALKORI 3

QL

PA

MS

ZEJULA 3

QL

PA



ZELBORAF 2

QL

PA

MS

ZYDELIG 3

QL

PA

MS

ZYKADIA 3

QL

PA

MS

RETINOIDS

bexarotene 1

QL

PA

MS

PANRETIN 3

TARGRETIN 1% GEL 3

PA

MS

TARGRETIN 75 MG CAPSULE 2

QL

PA

MS

tretinoin 10 mg capsule 1

TREATMENT ADJUNCTS

MESNEX 400 MG TABLET 3

ANTIPARASITICS

ANTIHELMINTHICS

ALBENZA 3

benznidazole (12.5 mg tablet, 100 mg tablet) 3 QL

BILTRICIDE 3

ivermectin 1

praziquantel 1

STROMECTOL 3

ANTIPROTOZOALS

ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3



atovaquone 1

atovaquone/proguanil hcl 1

chloroquine phosphate 1

COARTEM 3

DARAPRIM 3

hydroxychloroquine sulfate 1

IMPAVIDO 3

QL

PA

mefloquine hcl 1

MEPRON 3

NEBUPENT 3

quinine sulfate 1 PA

PEDICULICIDES/SCABICIDES

EURAX 3 QL

lindane 1 QL

malathion 1

permethrin 5 % cream (g) 1

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) 1

ANTIPARKINSON AGENTS, OTHER

amantadine hcl (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet) 1

carbidopa/levodopa/entacapone 1

entacapone 1

GOCOVRI 3

QL

PA

OSMOLEX ER (ER 129 MG TABLET, ER 193 MG TABLET, ER 258 MGTABLET)

3

QL

PA

TASMAR 3

tolcapone 1



DOPAMINE AGONISTS

APOKYN 3 MS

bromocriptine mesylate 1

NEUPRO 3

QL

PA

pramipexole di-hcl 1

ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mgtablet, 4 mg tablet, 5 mg tablet)

1

ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er 24h, 8 mg tab er24h, 12 mg tab er 24h)

1 QL

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa 1

carbidopa/levodopa 1

LODOSYN 3

RYTARY (ER 23.75 MG-95 MG CAP, ER 36.25 MG-145 MG CAP, ER 48.75MG-195 MG CAP, ER 61.25 MG-245 MG CAP)

3

QL

PA

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

rasagiline mesylate 1 QL

selegiline hcl 1

ZELAPAR 3

QL

PA

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet,200 mg tablet)

1

fluphenazine decanoate 1

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

1

haloperidol 1

haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial) 1

loxapine succinate 1

molindone hcl 1

ORAP 3

pimozide 1

thioridazine hcl 1



thiothixene 1

trifluoperazine hcl 1

2ND GENERATION/ATYPICAL

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

1 QL

FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MGTABLET, 10 MG TABLET, 12 MG TABLET)

3

QL

ST

FANAPT TITRATION PACK 3 ST

LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET,120 MG TABLET)

3

QL

ST

NUPLAZID 17 MG TABLET 3

QL

PA

MS

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

1

paliperidone 1 QL

quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet,300 mg tablet)

1

quetiapine fumarate (50 mg tab er 24h, 150 mg tab er 24h, 200 mg tab er 24h,300 mg tab er 24h, 400 mg tab er 24h, 400 mg tablet)

1 QL

REXULTI 3

QL

ST

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

1

SAPHRIS 3

QL

ST

VRAYLAR 3

QL

ST

ziprasidone hcl 1

TREATMENT-RESISTANT

clozapine 1

ANTISPASTICITY AGENTS

baclofen (10 mg tablet, 20 mg tablet) 1

baclofen 5 mg tablet 1

dantrolene sodium 1



tizanidine hcl 1

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

PREVYMIS (240 MG TABLET, 480 MG TABLET) 3

VALCYTE 450 MG TABLET 3

valganciclovir hcl (50 mg/ml soln recon, 450 mg tablet) 1

ZIRGAN 3

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil 1

BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG TABLET, 1 MG TABLET) 3 QL

entecavir 1 QL

EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 3

HEPSERA 3

lamivudine 100 mg tablet 1

TYZEKA 3 QL

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

DAKLINZA (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) 3

QL

PA

ST

MS

EPCLUSA 3

QL

PA

MS

HARVONI 3

QL

PA

MS

MAVYRET 3

QL

PA

MS

OLYSIO 3

QL

PA

ST

MS



SOVALDI 3

QL

PA

MS

TECHNIVIE 3

QL

PA

ST

MS

VIEKIRA PAK 3

QL

PA

ST

MS

VIEKIRA XR 3

QL

PA

ST

MS

VOSEVI 3

QL

PA

MS

ZEPATIER 3

QL

PA

ST

MS

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

COPEGUS 3

PA

MS

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

3 MS

MODERIBA 1

PA

MS

PEGASYS 3

QL

PA

MS

PEGASYS PROCLICK 3

QL

PA

MS



PEGINTRON 3

QL

PA

MS

PEGINTRON REDIPEN 3

QL

PA

MS

REBETOL (40 MG/ML SOLUTION, 200 MG CAPSULE) 3

PA

MS

RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 1

PA

MS

RIBASPHERE (400 MG TABLET, 600 MG TABLET) 3

PA

MS

RIBASPHERE RIBAPAK 3

PA

MS

RIBATAB 3

PA

MS

ribavirin (200 mg capsule, 200 mg tablet) 1

PA

MS

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

BIKTARVY 2

GENVOYA 2

ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400 MGTABLET)

2 QL

ISENTRESS 100 MG POWDER PACKET 2

ISENTRESS HD 2 QL

STRIBILD 3 QL

TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG TABLET) 3 QL

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA 3 QL

COMPLERA 3

DELSTRIGO 3 QL

EDURANT 3



efavirenz 1

INTELENCE 2

nevirapine (100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) 1

NEVIRAPINE 50 MG/5 ML ORAL SUSP 1

ODEFSEY 3

PIFELTRO 3 QL

RESCRIPTOR 2

SUSTIVA 3

SYMFI LO 2 QL

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

VIRAMUNE XR 3

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate (20 mg/ml solution, 300 mg tablet) 1

abacavir sulfate/lamivudine 1

abacavir sulfate/lamivudine/zidovudine 1

didanosine 1

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

EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 3

lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet) 1

lamivudine/zidovudine 1

stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule,40 mg capsule)

1

tenofovir disoproxil fumarate 1

TRIZIVIR 3

TRUVADA 2

VIDEX 2

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MGTABLET, POWDER)

3

ZIAGEN 20 MG/ML SOLUTION 3

zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 1

ANTI-HIV AGENTS, OTHER

DESCOVY 2

JULUCA 3 QL

SELZENTRY (25 MG TABLET, 75 MG TABLET, 150 MG TABLET, 300 MGTABLET)

2 QL



SELZENTRY 20 MG/ML ORAL SOLN 2

TRIUMEQ 3

TYBOST 2 QL

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3

atazanavir sulfate 1

CRIXIVAN 3

INVIRASE 3

KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50 MGTABLET)

3

LEXIVA 50 MG/ML SUSPENSION 3

lopinavir/ritonavir 1

NORVIR (80 MG/ML SOLUTION, 100 MG POWDER PACKET, 100 MGSOFTGEL CAP, 100 MG TABLET)

3

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET,400 MG TABLET, 600 MG TABLET, 800 MG TABLET)

3

REYATAZ 3

ritonavir 1

VIRACEPT 3

ANTI-INFLUENZA AGENTS

oseltamivir phosphate (6 mg/ml susp recon, 30 mg capsule, 45 mg capsule, 75mg capsule)

1 QL

RELENZA 3 QL

rimantadine hcl 1

ANTIHERPETIC AGENTS

acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) 1

acyclovir 5 % oint. (g) 1 QL

ALFERON N 3

DENAVIR 3 QL

famciclovir (125 mg tablet, 250 mg tablet) 1

famciclovir 500 mg tablet 1 QL

SITAVIG 3 PA

trifluridine 1

valacyclovir hcl 1

XERESE 3 PA



ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl 1

meprobamate 1

midazolam hcl 2 mg/ml syrup 1

BENZODIAZEPINES

alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tabrapdis, 0.5 mg tablet, 1 mg tab er 24h, 1 mg tab rapdis, 1 mg tablet, 2 mg tab er24h, 2 mg tab rapdis, 2 mg tablet, 3 mg tab er 24h)

1

ALPRAZOLAM INTENSOL 1

chlordiazepoxide hcl 1

clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5mg tablet, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet)

1

clorazepate dipotassium 1

diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg/ml oral conc, 10mg tablet)

1

lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc) 1

LORAZEPAM INTENSOL 1

oxazepam 1

BIPOLAR AGENTS

MOOD STABILIZERS

lithium carbonate 1

lithium citrate 1

BLOOD GLUCOSE REGULATORS

DIABETIC BENEFIT and/or DME BENEFIT APPLIES. Please refer to member contract for copayment amount. If Diabetic BenefitDOES NOT apply please refer to the following tier classifications:

ANTIDIABETIC AGENTS

acarbose 1

ACTOPLUS MET 3

ACTOPLUS MET XR (15-1,000 MG TB, 30-1,000 MG TB) 3 QL

ACTOS 3

ADLYXIN 3 QL

ALOGLIPTIN BENZOATE 3

QL

ST

ALOGLIPTIN BENZOATE/METFORMIN HCL 3

QL

ST



ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 3

QL

ST

AVANDIA 3

BYDUREON 2 QL

BYDUREON BCISE 2 QL

BYDUREON PEN 2 QL

BYETTA (5 MCG PEN INJ, 10 MCG PEN INJ) 2 QL

CYCLOSET 3 QL

DUETACT 3 QL

FARXIGA 2

glimepiride 1

glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 mg tab er 24, 10 mgtablet)

1

glipizide/metformin hcl 1

GLUMETZA 3 ST

glyburide 1

glyburide,micronized 1

glyburide/metformin hcl 1

GLYXAMBI 3 QL

INVOKAMET (50-1,000 MG TABLET, 150-1,000 MG TABLET, 150-500 MGTABLET)

2

INVOKAMET 50-500 MG TABLET 2 QL

INVOKAMET XR 2

INVOKANA (100 MG TABLET, 300 MG TABLET) 2 QL

JANUMET 2 QL

JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET, 100-1,000 MGTABLET)

2 QL

JANUVIA 2 QL

JARDIANCE 10 MG TABLET 3 QL

JARDIANCE 25 MG TABLET 3

JENTADUETO 2 QL

JENTADUETO XR (2.5 MG, 5 MG TB) 2 QL



KAZANO 3

QL

ST

KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG TAB, 5-500 MG TABLET) 3

QL

ST

metformin er 500mg & 1000mg tab (generic version of glumetza and fortamet) 1 ST

metformin hcl (500 mg tab er 24, 500 mg tab er 24h, 500 mg tablet, 750 mg taber 24h, 850 mg tablet, 1000 mg tablet)

1

metformin hcl 1000 mg tab er 24 1 ST

miglitol 1

nateglinide 1

NESINA 3

QL

ST

ONGLYZA 3

QL

ST

OSENI 3

QL

ST

OZEMPIC (0.25-0.5 MG PEN, 1 MG PEN) 2 QL

pioglitazone hcl 1

pioglitazone hcl/glimepiride 1 QL

pioglitazone hcl/metformin hcl 1

PRANDIN 3

QTERN 3 QL

repaglinide 1

REPAGLINIDE/METFORMIN 3

SEGLUROMET 2 QL

STEGLATRO 2 QL

STEGLUJAN 3 QL

SYMLINPEN 120 3

SYMLINPEN 60 3

SYNJARDY 3



SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5-1,000 MGTAB, 25-1,000 MG TABLET)

3 QL

TANZEUM 30 MG PEN INJECT 3 QL

TANZEUM 50 MG PEN INJECT 3

tolazamide 1

tolbutamide 1

TRADJENTA 2 QL

TRULICITY 2 QL

VICTOZA 2-PAK 2 QL

VICTOZA 3-PAK 2 QL

XIGDUO XR (2.5 MG-1,000 MG TAB, 5 MG-1,000 MG TABLET, 5 MG-500 MGTABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET)

2 QL

BLOOD GLUCOSE SUPPLIES

Lifescan and Abbott are preferred test meters/strips and Step Therapy applies prior to all other meters and strips.

FREESTYLE FREEDOM LITE METER 2

FREESTYLE INSULINX GLUCOSE SYS 2

FREESTYLE INSULINX TEST STRIPS 2 QL

FREESTYLE LITE METER 2

FREESTYLE LITE TEST STRIPS 2 QL

FREESTYLE PREC NEO TEST STRIPS 2 QL

FREESTYLE PRECISION NEO METER 2

FREESTYLE TEST STRIPS 2 QL

ONETOUCH ULTRA TEST STRIP 2 QL

ONETOUCH ULTRA2 GLUCOSE SYST 2

ONETOUCH ULTRAMINI METER 2

ONETOUCH VERIO FLEX SYSTEM KIT 2

ONETOUCH VERIO IQ SYSTEM KIT 2

ONETOUCH VERIO METER SYSTEM 2

ONETOUCH VERIO SYNC SYST KIT 2

ONETOUCH VERIO TEST STRIP 2 QL

PRECISION XTRA MONITOR 2

PRECISION XTRA TEST STRIPS 2 QL



GLYCEMIC AGENTS

GLUCAGEN 1 MG HYPOKIT 2

GLUCAGON EMERGENCY KIT 2 QL

PROGLYCEM 3

INSULINS

ADMELOG 3 ST

ADMELOG SOLOSTAR 3 ST

AFREZZA 3

APIDRA 3 ST

APIDRA SOLOSTAR 3 ST

BASAGLAR KWIKPEN U-100 3

FIASP 3 ST

FIASP FLEXTOUCH 3 ST

HUMALOG 2

HUMALOG JUNIOR KWIKPEN 2

HUMALOG KWIKPEN U-100 2


HUMALOG MIX 50-50 2

HUMALOG MIX 50-50 KWIKPEN 2

HUMALOG MIX 75-25 2


HUMULIN 70-30 2

HUMULIN 70/30 KWIKPEN 2

HUMULIN N 2

HUMULIN N KWIKPEN 2

HUMULIN R 2

HUMULIN R U-500 2

HUMULIN R U-500 KWIKPEN 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2



LEVEMIR FLEXTOUCH 2

NOVOLIN 70-30 2

NOVOLIN N 2

NOVOLIN R 2

NOVOLOG 3 ST

NOVOLOG FLEXPEN 3 ST

NOVOLOG MIX 70-30 3 ST

NOVOLOG MIX 70-30 FLEXPEN 3 ST

SOLIQUA 100-33 3 QL

TOUJEO SOLOSTAR 2

TRESIBA FLEXTOUCH U-100 2


XULTOPHY 100-3.6 3 QL

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

COUMADIN 2

ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2 QL

ELIQUIS 5 MG STARTER PACK 2 QL

enoxaparin sodium 1

fondaparinux sodium 1

FRAGMIN 3

JANTOVEN 1

PRADAXA (75 MG CAPSULE, 150 MG CAPSULE) 2 QL

PRADAXA 110 MG CAPSULE 2

SAVAYSA 3 QL

warfarin sodium 1

XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG TABLET) 2 QL

XARELTO STARTER PACK 2

ZONTIVITY 3

QL

PA



BLOOD FORMATION MODIFIERS

anagrelide hcl 1

ARANESP 2 MS

DOPTELET 3

QL

PA

MS

EPOGEN 2 MS

FULPHILA 3

QL

MS

GRANIX 3

QL

PA

MS

LEUKINE 3

QL

MS

MOZOBIL 3

QL

PA

MS

MULPLETA 3

QL

PA

MS

NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 MLSYR, 480 MCG/1.6 ML VIAL)

3

QL

PA

MS

NIVESTYM 3

PA

MS

PROCRIT 2 MS

PROMACTA 3

QL

PA

MS

TAVALISSE (100 MG TABLET, 150 MG TABLET) 3

QL

PA

ZARXIO 2 MS



HEMOSTASIS AGENTS

AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, 1,000 MG TABLET) 3

aminocaproic acid (250 mg/ml solution, 500 mg tablet) 1

aminocaproic acid 1000 mg tablet 3

phytonadione (vit k1) 5 mg tablet 1

tranexamic acid 650 mg tablet 1 QL

PLATELET MODIFYING AGENTS

ASPIRIN/DIPYRIDAMOLE 1

BRILINTA 60 MG TABLET 2

BRILINTA 90 MG TABLET 2 QL

cilostazol 1

clopidogrel bisulfate 300 mg tablet 1

clopidogrel bisulfate 75 mg tablet 1 QL

dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1

EFFIENT (5 MG TABLET, 10 MG TABLET) 3 QL

prasugrel hcl (5 mg tablet, 10 mg tablet) 1 QL

ticlopidine hcl 1

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine (0.1mg/24hr patch tdwk, 0.2mg/24hr patch tdwk, 0.3mg/24hr patchtdwk)

1 QL

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

guanfacine hcl (1 mg tablet, 2 mg tablet) 1

methyldopa 1

midodrine hcl 1

NORTHERA 3

QL

PA

MS

ALPHA-ADRENERGIC BLOCKING AGENTS

DIBENZYLINE 3

doxazosin mesylate 1

phenoxybenzamine hcl 1



prazosin hcl 1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 1

EDARBI 3 ST

eprosartan mesylate 1

irbesartan 1

losartan potassium 1

olmesartan medoxomil 1

telmisartan 1

valsartan 1

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl 1

captopril 1

enalapril maleate 1

EPANDED SOLUTION 3 PA

fosinopril sodium 1

lisinopril 1

moexipril hcl 1

perindopril erbumine 1

QBRELIS 3

QL

PA

quinapril hcl 1

ramipril 1

trandolapril 1

ANTIARRHYTHMICS

amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1

disopyramide phosphate 1

dofetilide 1

flecainide acetate 1

mexiletine hcl 1

MULTAQ 2 QL



PACERONE 1

propafenone hcl 1

quinidine gluconate 324 mg tablet er 1

quinidine sulfate 1

SORINE 1

sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) 1

SOTYLIZE 3 PA

TIKOSYN 3

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl 1

atenolol 1

betaxolol hcl (10 mg tablet, 20 mg tablet) 1

bisoprolol fumarate 1

BYSTOLIC 3

carvedilol 1

carvedilol phosphate 1 QL

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1

metoprolol succinate 1

metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet,100 mg tablet)

1

nadolol 1

pindolol 1

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet,40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mgtablet, 120 mg cap sa 24h, 160 mg cap sa 24h)

1

timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

CALCIUM CHANNEL BLOCKING AGENTS

AFEDITAB CR 1

amlodipine besylate 1

CARTIA XT 1

DILT-XR 1



diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h,90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120mg cap sa 24h, 120 mg tablet, 180 mg cap er 24h, 180 mg cap er deg, 180 mgcap sa 24h, 180 mg tab er 24h, 240 mg cap er 24h, 240 mg cap er deg, 240 mgcap sa 24h, 240 mg tab er 24h, 300 mg cap er 24h, 300 mg cap sa 24h, 300mg tab er 24h, 360 mg cap er 24h, 360 mg cap sa 24h, 360 mg tab er 24h, 420mg cap sa 24h, 420 mg tab er 24h)

1

felodipine 1

isradipine 1

MATZIM LA 1

nicardipine hcl (20 mg capsule, 30 mg capsule) 1

NIFEDICAL XL 1

nifedipine 1

nimodipine 1

nisoldipine 1 QL

TAZTIA XT 1

verapamil hcl 1

CARDIOVASCULAR AGENTS, OTHER

amiloride hcl/hydrochlorothiazide 1

amlodipine besylate/atorvastatin calcium 1 QL

amlodipine besylate/benazepril hcl 1

amlodipine besylate/olmesartan medoxomil 1 QL

amlodipine besylate/valsartan 1

QL

PA

amlodipine besylate/valsartan/hydrochlorothiazide 1

QL

PA

atenolol/chlorthalidone 1

benazepril hcl/hydrochlorothiazide 1

bisoprolol fumarate/hydrochlorothiazide 1

BYVALSON 3 QL

candesartan cilexetil/hydrochlorothiazide 1

captopril/hydrochlorothiazide 1

CLORPRES (0.1-15 TABLET, 0.2-15 TABLET) 1

CORLANOR 3 QL

DIGITEK 1



DIGOX 1

digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) 1

enalapril maleate/hydrochlorothiazide 1

ENTRESTO 3

QL

ST

EXFORGE 3 QL

EXFORGE HCT 3 QL

fosinopril sodium/hydrochlorothiazide 1

irbesartan/hydrochlorothiazide 1

isoxsuprine hcl 1

lisinopril/hydrochlorothiazide 1

losartan potassium/hydrochlorothiazide 1

methyldopa/hydrochlorothiazide 1

metoprolol tartrate/hydrochlorothiazide 1

moexipril hcl/hydrochlorothiazide 1

nadolol/bendroflumethiazide 1

olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide 1 QL

olmesartan medoxomil/hydrochlorothiazide 1

pentoxifylline 1

propranolol hcl/hydrochlorothiazide 1

quinapril hcl/hydrochlorothiazide 1

RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET) 3 QL

RESERPINE 3

spironolactone/hydrochlorothiazide 1

TEKTURNA 3 QL

telmisartan/hydrochlorothiazide 1

trandolapril/verapamil hcl 1 QL

triamterene/hydrochlorothiazide 1

valsartan/hydrochlorothiazide 1

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide 1



KEVEYIS 3 PA

DIURETICS, LOOP

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

EDECRIN 3

ethacrynic acid 1

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

1

torsemide 1

DIURETICS, POTASSIUM-SPARING

amiloride hcl 1

DYRENIUM 3

eplerenone 1

spironolactone 1

DIURETICS, THIAZIDE

chlorothiazide 1

chlorthalidone 1

hydrochlorothiazide 1

indapamide 1

methyclothiazide 1

metolazone 1

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate (40 mg tablet, 120 mg tablet, 160 mg tablet) 1 QL

fenofibrate (50 mg capsule, 54 mg tablet, 150 mg capsule) 1

fenofibrate nanocrystallized (48 mg tablet, 145mg tablet) 1 QL

fenofibrate,micronized 1

fenofibric acid 1

fenofibric acid (choline) 1 QL

gemfibrozil 1

TRILIPIX 3 QL

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin calcium 1

fluvastatin sodium (20 mg capsule, 40 mg capsule) 1 QL



LIVALO 3

QL

ST

lovastatin (10 mg tablet, 20 mg tablet) 1

lovastatin 40 mg tablet 1 QL

pravastatin sodium 1

rosuvastatin calcium (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL

simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) 1 QL

DYSLIPIDEMICS, OTHER

cholestyramine (with sugar) (4 g powd pack, 4 g powder) 1

cholestyramine/aspartame (cholestyramine/aspartame 4 g powd pack,cholestyramine/aspartame 4 g powder)

1

colesevelam hcl 1

colestipol hcl 1

ezetimibe 1

ezetimibe/simvastatin 1

JUXTAPID 3

QL

PA

KYNAMRO 3

PA

MS

niacin (500 mg tab er 24h, 750 mg tab er 24h, 1000 mg tab er 24h) 1 QL

omega-3 acid ethyl esters 1 QL

PRALUENT 2

QL

PA

MS

PREVALITE (PACKET, POWDER) 1

REPATHA 2

QL

PA

MS

VYTORIN 3

WELCHOL 3

ZETIA 3



VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1

minoxidil (2.5 mg tablet, 10 mg tablet) 1

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

GONITRO 3 PA

isosorbide dinitrate 1

isosorbide mononitrate (10 mg tablet, 20 mg tablet) 1

isosorbide mononitrate (30 mg tab er 24h, 60 mg tab er 24h, 120 mg tab er24h)

1

MINITRAN 1

NITRO-TIME 1

nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24,0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er)

1

nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1

nitroglycerin 400mcg/spr spray 1

QL

PA

NITROLINGUAL 3 QL

NITROMIST 3

QL

PA

NITROSTAT 3

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

ADZENYS ER 3

QL

PA

ADZENYS XR-ODT (3.1 MG TABLET, 6.3 MG TABLET, 9.4 MG TABLET, 12.5MG TABLET, 15.7 MG TABLET, 18.8 MG TABLET)

3

QL

PA

DEXEDRINE 10 MG TABLET 1



dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg cap er 24h,dextroamphetamine/amphetamine 10 mg cap er 24h,dextroamphetamine/amphetamine 15 mg cap er 24h,dextroamphetamine/amphetamine 20 mg cap er 24h,dextroamphetamine/amphetamine 25 mg cap er 24h,dextroamphetamine/amphetamine 30 mg cap er 24h)

1 QL

dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg tablet,dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 30 mg tablet)

1

dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet, 5 mg/5 ml solution,10 mg capsule er, 10 mg tablet, 15 mg capsule er)

1

DYANAVEL XR 3

QL

PA

VYVANSE 2 QL

ZENZEDI (5 MG TABLET, 10 MG TABLET) 1

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

atomoxetine hcl 1

clonidine hcl 0.1 mg tab er 12h 1 QL

CONCERTA 3 QL

COTEMPLA XR-ODT 3

QL

PA

dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1

dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 20 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35 mg cpbp 50-50, 40 mg cpbp 50-50)

1 QL

guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er24h)

1 QL

METADATE ER 1

methylphenidate hcl (10 mg cpbp 30-70, 10 mg cpbp 50-50, 20 mg cpbp 30-70,20 mg cpbp 50-50, 30 mg cpbp 30-70, 30 mg cpbp 50-50, 40 mg cpbp 30-70,40 mg cpbp 50-50)

1 QL

methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mg tab er 24, 50 mgcpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70, 60 mg cpbp 50-50)

1 QL

methylphenidate hcl (2.5 mg tab chew, 5 mg tab chew, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab chew, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 20mg tablet, 20 mg tablet er)

1

methylphenidate hcl 72 mg tab er 24 3 QL

QUILLICHEW ER (ER 20 MG CHEW TAB, ER 30 MG CHEW TAB, ER 40 MGCHEW TAB)

3

QL

PA

QUILLIVANT XR 3

QL

PA



RELEXXII 3 QL

CENTRAL NERVOUS SYSTEM, OTHER

AUSTEDO (6 MG TABLET, 9 MG TABLET, 12 MG TABLET) 3

QL

PA

MS

BELVIQ 3

QL

PA

BELVIQ XR 3

QL

PA

benzphetamine hcl 1

butalbital/acetaminophen 50mg-325mg tablet 1

butalbital/acetaminophen/caffeine 1

CAPACET 1

CONTRAVE 3

QL

PA

diethylpropion hcl 1

ESGIC CAPSULE 1

HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET) 3

QL

PA

INGREZZA 3

QL

PA

MARGESIC 1

MARTEN-TAB 1

NUEDEXTA 3

QL

PA

phendimetrazine tartrate 1

phentermine hcl 1

QSYMIA (3.75 MG-23 MG CAPSULE, 7.5 MG-46 MG CAPSULE, 11.25 MG-69MG CAPSULE, 15 MG-92 MG CAPSULE)

3

QL

PA

riluzole 1

SUPRENZA ODT 3

QL

PA



tetrabenazine (12.5 mg tablet, 25 mg tablet) 1

QL

PA

MS

ZEBUTAL 1

FIBROMYALGIA AGENTS

duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) 1 QL

duloxetine hcl 40 mg capsule dr 1

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MGCAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300MG CAPSULE)

2

LYRICA 20 MG/ML ORAL SOLUTION 2 QL

LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET, CR 330 MGTABLET)

3

QL

PA

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

3

QL

ST

MULTIPLE SCLEROSIS AGENTS

AMPYRA 3

QL

PA

MS

AUBAGIO 3

QL

ST

MS

AVONEX 2

QL

MS

BETASERON 3

QL

ST

MS

COPAXONE (20 MG/ML SYRINGE, 40 MG/ML SYRINGE) 2

QL

MS

dalfampridine 1

QL

PA

MS

EXTAVIA 3

PA

MS



GILENYA 0.5 MG CAPSULE 2

QL

MS

glatiramer acetate 20 mg/ml syringe 1

QL

ST

MS

glatiramer acetate 40 mg/ml syringe 1

QL

MS

GLATOPA 20 MG/ML SYRINGE 1

QL

ST

MS

GLATOPA 40 MG/ML SYRINGE 1

QL

MS

PLEGRIDY 2

QL

MS

PLEGRIDY PEN 2

QL

MS

REBIF 2

QL

MS

TECFIDERA 2

QL

MS

ZINBRYTA 3

QL

ST

DENTAL AND ORAL AGENTS

cevimeline hcl 1

chlorhexidine gluconate 0.12 % mouthwash 1

EVOXAC 3

ORALONE 1

PAROEX 1

PERIOGARD 1

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1

triamcinolone acetonide 0.1 % paste (g) 1



DERMATOLOGICAL AGENTS

ABSORICA 3 PA

acitretin 1 QL

ACZONE 5% GEL 3

QL

ST

adapalene 0.3 % gel w/pump 1

adapalene/benzoyl peroxide 1 QL

AMNESTEEM 1

AVAR CLEANSER 1

AVITA 1

AZELEX 3

BENZEPRO 6% FOAMING CLOTHS 1 QL

BENZEPRO 7% CREAMY WASH 1

benzoyl peroxide 7 % cleanser 1

BPO (4% GEL, 8% GEL) 1

calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution) 1

calcipotriene/betamethasone dipropionate 1

CALCITRENE 1

CALCITRIOL 3 MCG/G OINTMENT 3

CARAC 3 PA

CLARAVIS 1

clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 1

QL

PA

clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 % gel (gram),phos/benzoyl 1 % gel w/pump)

1 QL

clindamycin phosphate/tretinoin 1 PA

clotrimazole/betamethasone dipropionate (clotrimazole/betamethasone 1 %cream (g), clotrimazole/betamethasone 1 % lotion)

1

CORTISPORIN OINTMENT 3

COSENTYX 2

QL

PA

ST

MS



dapsone 5 % gel (gram) 1 QL

DERMACINRX CLORHEXACIN 3

QL

PA

DERMACINRX SURGICAL PHARMAPAK 3

QL

PA

DERMACINRX THERAZOLE PAK 3

QL

PA

DICLO GEL 3

QL

PA

DICLO GEL-XRYLIX SHEET 3

QL

PA

diclofenac sodium 1 % gel (gram) 1 QL

diclofenac sodium 3 % gel (gram) 1 PA

DICLOZOR 3

QL

PA

DRYSOL 3

ELIDEL 3 QL

ENSTILAR 3

QL

PA

EPIDUO FORTE 3 QL

FABIOR 3

QL

PA

FLUOROURACIL 0.5% CREAM 3 PA

hydrocortisone acetate/iodoquinol/aloe vera 1

hydrocortisone acetate/lidocaine hcl/aloe vera (hydrocortisone/lidocaine/aloe0.55%-2.8% gel w/appl, hydrocortisone/lidocaine/aloe 2 %-2 % kit,hydrocortisone/lidocaine/aloe 2.5-3%(7g) kit)

1

hydrocortisone acetate/pramoxine hcl 1

hydroquinone microspheres 1

imiquimod 5 % cream pack 1

lactic acid 10 % lotion 1



LEXIXRYL 3

QL

PA

lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone 3 %-0.5 % cream(g), lidocaine/hydrocortisone 3 %-0.5 % cream/appl, lidocaine/hydrocortisone 3%-0.5 % kit, lidocaine/hydrocortisone 3%-1%(7 g) cream/appl,lidocaine/hydrocortisone 3%-1%(7 g) kit, lidocaine/hydrocortisone 3-2.5%(7g)gel w/appl)

1

methoxsalen 10 mg cap lq rap 1

metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % lotion, 1 % gel(gram), 1 % gel w/pump)

1

MYORISAN 1

NEUAC GEL 1

NUDICLO SOLUPAK 3

QL

PA

ONEXTON GEL PUMP 3

QL

PA

PICATO (0.015% GEL, 0.05% GEL) 2 QL

podofilox 1

PR BENZOYL PEROXIDE 1

PRAMCORT 1

PROTOPIC 3 QL

REA LO 39 1

REA LO 40 (40 CM, 40 TION) 1

RECTIV 3 QL

REGRANEX 3 QL

ROSADAN (CREAM KIT, GEL KIT) 3

QL

PA

ROSADAN (CREAM, GEL) 1

SANTYL 3

SEB-PREV 1

selenium sulfide (2.25 % shampoo, 2.5 % lotion) 1

SOLARAZE 3 PA

SORIATANE 3 QL



SORILUX 3

QL

PA

spinosad 3

STELARA (45 MG/0.5 ML SYRINGE, 90 MG/ML SYRINGE) 2

QL

PA

MS

STELARA 45 MG/0.5 ML VIAL 2

PA

MS

sulfacetamide sodium (10 % cleanser, 10 % clnsr gel, 10 % shampoo) 1

sulfacetamide sodium/sulfur (sodium/sulfur 9.8%-4.8% cream (g), sodium/sulfur9.8%-4.8% lotion, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur 10-5%(w/w)cleanser, sodium/sulfur 10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion,sodium/sulfur 10-5%(w/w) suspension)

1

TACLONEX 0.005%-0.064% SUSPENS 3

QL

PA

tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 QL

tazarotene 1

TAZORAC 3

TOLAK 2

TREMFYA 3

QL

PA

ST

MS

TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3

QL

PA

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

1

tretinoin microspheres 1

tretinoin/emollient base 1 PA

TRI-CHLOR 1

ULESFIA 3

VELTIN 3 PA

VEREGEN 3

XELITRAL 3

QL

PA



XRYLIX 3

QL

PA

ZENATANE 1

ZEYOCAINE 3

QL

PA

ZIANA 3 PA

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

CARBAGLU 3

PA

MS

CYTRA-K CRYSTALS PACKET 1

DENTA 5000 PLUS 1

DENTAGEL 1

EFFER-K 25 MEQ TABLET EFF 1

ENDARI 3

QL

PA

FLUORIDEX DAILY DEFENSE 1

FLUORIDEX SENSITIVITY RELIEF 1

K EFFERVESCENT 1

K-SOL 1

K-TAB ER 3

KLOR-CON 10 1

KLOR-CON 20 MEQ PACKET 1

KLOR-CON 8 1

KLOR-CON M10 1

KLOR-CON M15 1

KLOR-CON M20 1

KLOR-CON SPRINKLE 1

KLOR-CON-EF 1

levocarnitine (with sugar) 1

levocarnitine 330 mg tablet 1

NUTRESTORE 3



potassium bicarbonate/citric acid 1

potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20 meq packet, 20 meq tab er prt, 20 meqtablet er, 20meq/15ml liquid, 40meq/15ml liquid)

1

potassium chloride/potassium bicarbonate/citric acid 1

potassium citrate 1

potassium citrate/citric acid 3300-1002 packet 1

PREVIDENT (0.2%, DENTAL) 1

SF 1

SF 5000 PLUS 1

TL G-FOL OS 1

UROCIT-K 3

ELECTROLYTE/MINERAL/METAL MODIFIERS

CHEMET 3

CUPRIMINE 3 PA

EXJADE 3 MS

FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 3

JADENU 3 MS

KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1

SAMSCA 3

QL

MS

sodium polystyrene sulfonate 1

SPS 1

SYPRINE 3 PA

trientine hcl 1 PA

DEPEN 2

PHOSPHATE BINDERS

calcium acetate 1

ELIPHOS 1

FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MGTABLET CHEW)

3 QL

lanthanum carbonate (500 mg tab chew, 750 mg tab chew, 1000 mg tab chew) 1 QL

PHOSLO 3



PHOSLYRA 3

RENAGEL 3

sevelamer carbonate (2.4 g powd pack, 800 mg tablet) 1

sevelamer carbonate 0.8 g powd pack 1 QL

VELPHORO 3 QL

VELTASSA 3

VITAMINS

cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1

ENTERAL FORMULA REQUIRES PRIOR AUTHORIZATION. BRANDS ARETIER 3 & GENERICS ARE TIER 1.

3 PA

XURIDEN 3

QL

PA

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

chlordiazepoxide/clidinium bromide 1

CUVPOSA 3

QL

PA

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

ED-SPAZ 1

GLYCATE 3

QL

PA

glycopyrrolate (1 mg tablet, 2 mg tablet) 1

glycopyrrolate 1.5 mg tablet 1

QL

PA

hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl, 0.125 mg tablet,0.125mg/ml drops, 0.375 mg tab er 12h, 125mcg/5ml elixir)

1

HYOSYNE 1

methscopolamine bromide 1

NULEV 1

OSCIMIN 1

OSCIMIN SL 1

OSCIMIN SR 1

propantheline bromide 1



SYMAX 1

SYMAX-SL 1

SYMAX-SR 1

GASTROINTESTINAL AGENTS, OTHER

cromolyn sodium 20 mg/ml oral conc 1

diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine2.5-.025mg tablet)

1

GATTEX 3

QL

PA

MS

lansoprazole/amoxicillin trihydrate/clarithromycin 1

MOTOFEN 3

MOVANTIK 2 QL

MYALEPT 3

PA

MS

MYTESI 3

QL

PA

OMECLAMOX-PAK 3

QL

PA

opium tincture 1

paregoric 1

ursodiol 1

XENICAL 3 PA

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine 1

cimetidine hcl 1

famotidine (40 mg tablet, 40mg/5ml oral susp) 1

nizatidine (150 mg capsule, 150mg/10ml solution, 300 mg capsule) 1

ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 300 mg capsule, 300 mg tablet) 1

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl 1 QL

AMITIZA 3

QL

ST



LINZESS 2 QL

LOTRONEX 3 QL

LAXATIVES

CLENPIQ 3

CONSTULOSE 1

ENULOSE 1

GAVILYTE-C 1

GAVILYTE-G 1

GAVILYTE-H AND BISACODYL 1

GAVILYTE-N 1

GENERLAC 1

GOLYTELY PACKET 3

lactulose (10 g/15 ml solution, 20 g/30 ml solution) 1

MOVIPREP 3 QL

peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride 1

PEG-PREP 1

polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder) 1

PREPOPIK 2

sodium chloride/sodium bicarbonate/potassium chloride/peg 1

SUPREP 2

TRILYTE WITH FLAVOR PACKETS 1

PROTECTANTS

CARAFATE (1 GM TABLET, 1 GM/10 ML SUSP) 3

misoprostol 1

sucralfate 1

PROTON PUMP INHIBITORS

ACIPHEX SPRINKLE 3

QL

PA

DEXILANT 3

QL

ST

esomeprazole magnesium 1 QL

ESOMEPRAZOLE STRONTIUM 3 PA



lansoprazole (15 mg tab rap dr, 30 mg tab rap dr) 1

QL

ST

lansoprazole 30 mg capsule dr 1 QL

NEXIUM 3

QL

ST

omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr) 1 QL

pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1 QL

rabeprazole sodium 1 QL

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

BUPHENYL (500 MG TABLET, POWDER) 3

CERDELGA 3

PA

MS

CHOLBAM 3 PA

CREON 2

CYSTADANE 3

CYSTAGON 2

GALAFOLD 3

QL

PA

MS

KUVAN 3

PA

MS

miglustat 1

QL

PA

MS

NITYR (2 MG TABLET, 5 MG TABLET, 10 MG TABLET) 3 PA

OCALIVA 3

QL

PA

MS

ORFADIN (2 MG CAPSULE, 5 MG CAPSULE, 10 MG CAPSULE, 20 MGCAPSULE)

3 PA

PALYNZIQ (2.5 MG/0.5 ML SYRINGE, 10 MG/0.5 ML SYRINGE, 20 MG/MLSYRINGE)

3

PA

MS



PANCREAZE 3

PANCRELIPASE 5,000 1

PROCYSBI (DR 25 MG CAPSULE, DR 75 MG CAPSULE) 3

QL

PA

MS

RAVICTI 3

QL

PA

MS

sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 1

STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL, 80MG/0.8 ML VIAL)

3

QL

PA

ZAVESCA 3

QL

PA

MS

ZENPEP 2

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide 1 QL

flavoxate hcl 1

GELNIQUE (3% GEL, 10% GEL PUMP, 10% GEL SACHET, 10% GELSACHETS)

3

QL

ST

MYRBETRIQ 2 QL

oxybutynin chloride (5 mg tab er 24, 5 mg tablet, 5 mg/5 ml syrup, 10 mg tab er24, 15 mg tab er 24)

1

OXYTROL 3 ST

tolterodine tartrate (1 mg tablet, 2 mg cap er 24h, 2 mg tablet, 4 mg cap er 24h) 1 QL

TOVIAZ 2 QL

trospium chloride (20 mg tablet, 60 mg cap er 24h) 1 QL

VESICARE 2 QL

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl 1 QL

CIALIS (2.5 MG TABLET, 5 MG TABLET) 3

QL

ST



dutasteride 1 QL

finasteride 5 mg tablet 1

RAPAFLO 3

QL

ST

tamsulosin hcl 1 QL

GENITOURINARY AGENTS, OTHER

ADDYI 3 PA

bethanechol chloride 1

CIALIS (10 MG TABLET, 20 MG TABLET) 3

QL

ST

CONCEPTROL 3 C zero copay

ELMIRON 3

GYNOL II 3 C zero copay

LEVITRA 3

QL

ST

phenazopyridine hcl 1

sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1 QL

STAXYN 3

QL

ST

STENDRA 3

QL

ST

TODAY CONTRACEPTIVE SPONGE 3 C zero copay

VCF (FILM, FOAM, GEL) 3 C zero copay

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ALA-CORT 1

alclometasone dipropionate 1

amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) 1

ANUCORT-HC 1

betamethasone dipropionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 %lotion, 0.05 % oint. (g))

1



betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05% cream (g), betamethasone/propylene 0.05 % lotion,betamethasone/propylene 0.05 % oint. (g))

1

betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.12 %foam)

1

clobetasol propionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 % lotion, 0.05% oint. (g), 0.05 % shampoo, 0.05 % solution, 0.05 % spray)

1

CLOCORTOLONE PIVALATE 0.1 % CREAM(G) 3 ST

CLODAN 0.05% KIT 3

QL

PA

CLODAN 0.05% SHAMPOO 1

CLODERM 3 ST

CORDRAN (4 MCG/SQ CM TAPE LARGE, 4 MCG/SQ CM TAPE SMALL) 3 QL

CORMAX 1

cortisone acetate 1

DECADRON 0.5 MG/5 ML ELIXIR 1

DELTASONE 1

DERMACINRX CINLONE-I CPI 3

QL

PA

DERMACINRX SILAPAK 3

QL

PA

DERMACINRX SILAZONE 3

QL

PA

DERMAZONE 3

QL

PA

DESONATE 3 ST

desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1

desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.25 %cream (g), 0.25 % oint. (g))

1

dexamethasone ((21) tab ds pk, (35) tab ds pk, (51) tab ds pk) 1

QL

PA

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

1

DIFLORASONE DIACETATE 3

ELLZIA PAK 3

QL

PA



EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL SUSP, 36MG TABLET)

3

QL

PA

EMFLAZA 30 MG TABLET 3 QL

fludrocortisone acetate 1

fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 %cream (g), 0.025 % oint. (g))

1

fluocinolone acetonide/shower cap 1

fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 %solution, 0.1 % cream (g))

1

fluocinonide/emollient base 1

flurandrenolide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1

fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g), 0.05 % lotion) 1

H.P. ACTHAR 3

QL

PA

MS

halobetasol propionate 1

HALOG 3 ST

HEMMOREX-HC 1

hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g), 2.5 % cream (g),2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint. (g), 5 mg tablet, 10 mg tablet, 20 mgtablet)

1

hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect) 1

hydrocortisone butyrate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1

hydrocortisone butyrate/emoll 0.1 % cream (g) 1

hydrocortisone valerate 1

hydrocortisone/mineral oil/petrolatum,white 1

methylprednisolone 1

mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1

NOLIX 0.05% CREAM 1

NUTRIARX 3

QL

PA

PEDIADERM HC 3

QL

PA

prednicarbate 1

prednisolone 15 mg/5 ml solution 1



prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 10 mg/5 mlsolution, 15 mg tab rapdis, 15 mg/5 ml solution, 20 mg/5 ml solution, 25 mg/5ml solution, 30 mg tab rapdis)

1

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab ds pk, 10 mg tablet, 20 mg tablet, 50 mg tablet)

1

PREDNISONE INTENSOL 1

PROCTO-MED HC 1

PROCTO-PAK 1

PROCTOSOL-HC 1

PROCTOZONE-HC 1

RAYOS 3 PA

SANADERMRX 3

QL

PA

SCALACORT 1

SILALITE PAK 3

QL

PA

SILAZONE-II 3

QL

PA

SYNALAR TS 3

QL

PA

TAPERDEX 3

QL

PA

TRI-SILA 3

QL

PA

triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g),0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.147mg/g aerosol, 0.5 % cream(g), 0.5 % oint. (g))

1

TRIANEX 3 ST

TRIDERM 1

ULTRAVATE X 3

QL

PA

WHYTEDERM TRILASIL PAK 3

QL

PA

ZODEX 12 DAY 1.5 MG TABLET 3 QL

ZODEX 6 DAY 1.5 MG TABLET 3

QL

PA



HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

BRAVELLE 3

QL

PA

MS

chorionic gonadotropin, human 1

QL

PA

MS

desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet,10/spray spray/pump)

1

desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial) 1 MS

desmopressin acetate (non-refrigerated) 1

EGRIFTA (1 MG VIAL, 2 MG VIAL) 3

QL

PA

FOLLISTIM AQ (75 VIAL, 300 CARTRIDG, 600 CARTRIDG, 900 CARTRIDG) 3

QL

PA

ST

MS

GENOTROPIN 3

PA

ST

MS

GONAL-F 2

QL

PA

MS

HUMATROPE 3

PA

ST

MS

INCRELEX 3

PA

MS

MENOPUR 3

PA

MS

NORDITROPIN FLEXPRO 3

PA

ST

MS



NOVAREL 10,000 UNITS VIAL 1

QL

PA

MS

NUTROPIN AQ 3

PA

ST

MS

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG) 2

PA

MS

OVIDREL 3

PA

MS

PREGNYL 1

QL

PA

MS

SAIZEN 3

QL

PA

ST

MS

SEROSTIM 3

QL

PA

MS

ZOMACTON 3

QL

PA

MS

ZORBTIVE 3

QL

PA

MS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 3

oxandrolone 1

ANDROGENS

ANDRODERM 2 PA



ANDROGEL 2 PA

ANDROID 3 PA

ANDROXY 1 PA

AXIRON 3 PA

danazol 1

DEPO-TESTOSTERONE 3

FORTESTA 3 PA

METHITEST 1 PA

methyltestosterone 1 PA

NATESTO 3

QL

PA

STRIANT 3 PA

TESTIM 3 PA

TESTOSTERONE (10 MG (2%) GEL MD PMP, 12.5/1.25G GEL MD PMP, 50MG (1%) GEL (GRAM)

3 PA

testosterone (25mg(1%) gel packet, 30mg/1.5ml sol md pmp) 1 PA

TESTOSTERONE (50 MG (1%) GEL PACKET). SOME MANUFACTURERSARE T3 AND OTHERS T1

3 PA

testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1

testosterone enanthate 200 mg/ml vial 1

TESTRED 3 PA

VOGELXO 3 PA

ESTROGENS

ALORA 3 QL

ALTAVERA 1 C zero copay

ALYACEN 1 C zero copay

AMABELZ 1

AMETHIA 1 C zero copay

AMETHIA LO 1 C zero copay

AMETHYST 1 C zero copay



APRI 1 C zero copay

ARANELLE 1 C zero copay

ASHLYNA 1 C zero copay

AUBRA 1 C zero copay

AVIANE 1 C zero copay

AZURETTE 1 C zero copay

BALZIVA 1 C zero copay

BEKYREE 1 C zero copay

BLISOVI 24 FE 1 C zero copay

BLISOVI FE 1 C zero copay

BRIELLYN 1 C zero copay

CAMRESE 1 C zero copay

CAMRESE LO 1 C zero copay

CAZIANT 1 C zero copay

CHATEAL 1 C zero copay

CLIMARA PRO 2

COMBIPATCH 3

COVARYX 1

COVARYX H.S. 1

CRYSELLE 1 C zero copay

CYCLAFEM 1 C zero copay

CYRED 1 C zero copay

DASETTA 1 C zero copay

DAYSEE 1 C zero copay

DELYLA 1 C zero copay

desogestrel-ethinyl estradiol 1 C zero copay

desogestrel-ethinyl estradiol/ethinyl estradiol 1 C zero copay

drospirenone/ethinyl estradiol/levomefolate calcium 1 C zero copay



ECONTRA ONE-STEP 3 C zero copay

EEMT 1

EEMT H.S. 1

ELINEST 1 C zero copay

EMOQUETTE 1 C zero copay

ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET)

3 QL

ENPRESSE 1 C zero copay

ENSKYCE 1 C zero copay

ESTARYLLA 1 C zero copay

ESTRACE 0.01% CREAM 2

estradiol (.025mg/24h patch tdsw, .025mg/24h patch tdwk, .0375mg/24 patchtdsw, .0375mg/24 patch tdwk, 0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk,0.06mg/24h patch tdwk, .075mg/24h patch tdsw, .075mg/24h patch tdwk,0.1mg/24hr patch tdsw, 0.1mg/24hr patch tdwk)

1 QL

estradiol (0.01 % cream/appl, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 10 mcgtablet)

1

estradiol valerate 1

estradiol/norethindrone acetate 1

ESTRING 3

estrogens,esterified/methyltestosterone 1

estropipate 1

ethinyl estradiol/drospirenone 1 C zero copay

ethynodiol d-ethinyl estradiol 1 mg-35mcg tablet 1 C zero copay

ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet 1 C zero copay

FALMINA 1 C zero copay

FAYOSIM 1 C zero copay

FEMYNOR 1 C zero copay

FYAVOLV 1

GENERESS FE 3

GIANVI 1 C zero copay

GILDAGIA 1 C zero copay

GILDESS 24 FE 1 C zero copay



INTROVALE 1 C zero copay

JEVANTIQUE LO 1

JINTELI 1

JOLESSA 1 C zero copay

JULEBER 1 C zero copay

JUNEL 1 C zero copay

JUNEL FE 1 C zero copay

JUNEL FE 24 1 C zero copay

KAITLIB FE 1 C zero copay

KARIVA 1 C zero copay

KELNOR 1-35 1 C zero copay

KIMIDESS 1 C zero copay

KURVELO 1 C zero copay

l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo 1 C zero copay

LARIN 1 C zero copay

LARIN 24 FE 1 C zero copay

LARIN FE 1 C zero copay

LARISSIA 1 C zero copay

LAYOLIS FE 1 C zero copay

LEENA 1 C zero copay

LESSINA 1 C zero copay

LEVONEST 1 C zero copay

levonorgestrel-ethinyl estradiol 1 C zero copay

levonorgestrel/ethinyl estradiol and ethinyl estradiol (l-norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo, l-norgest/e.estradiol-e.estrad 150-30(84)tbdspk 3mo)

1 C zero copay

LEVORA-28 1 C zero copay

LO LOESTRIN FE 2 C zero copay

LOMEDIA 24 FE 1 C zero copay



LOPREEZA 1

LORYNA 1 C zero copay

LOW-OGESTREL 1 C zero copay

LUTERA 1 C zero copay

MARLISSA 1 C zero copay

MENEST 3

MIBELAS 24 FE 1 C zero copay

MICROGESTIN 1 C zero copay

MICROGESTIN 24 FE 1 C zero copay

MICROGESTIN FE 1 C zero copay

MIMVEY 1

MIMVEY LO 1

MONO-LINYAH 1 C zero copay

MONONESSA 1 C zero copay

MY CHOICE 3 C zero copay

MY WAY 3 C zero copay

MYZILRA 1 C zero copay

NATAZIA 3 C zero copay

NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 1-50-28 TABLET, 7-7-7-28TABLET, 10-11-28 TABLET)

1 C zero copay

NEW DAY 3 C zero copay

NIKKI 1 C zero copay

norethindrone ac-eth estradiol 1mg-20mcg tablet 1 C zero copay

norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg-5mcg tablet) 1

norethindrone acetate-ethinyl estradiol/ferrous fumarate 1 C zero copay

norethindrone-ethinyl estradiol/ferrous fumarate 1 C zero copay

norgestimate-ethinyl estradiol 1 C zero copay

NORTREL 1 C zero copay

OCELLA 1 C zero copay



OGESTREL 1 C zero copay

ORSYTHIA 1 C zero copay

ORTHO TRI-CYCLEN LO 3

PHILITH 1 C zero copay

PIMTREA 1 C zero copay

PIRMELLA 1 C zero copay

PORTIA 1 C zero copay

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

2

PREMPHASE 2

PREMPRO 2

PREVIFEM 1 C zero copay

QUASENSE 1 C zero copay

RAJANI 1 C zero copay

RECLIPSEN 1 C zero copay

SETLAKIN 1 C zero copay

SPRINTEC 1 C zero copay

SRONYX 1 C zero copay

SYEDA 1 C zero copay

TARINA FE 1 C zero copay

TILIA FE 1 C zero copay

TRI-ESTARYLLA 1 C zero copay

TRI-LEGEST FE 1 C zero copay

TRI-LINYAH 1 C zero copay

TRI-LO-ESTARYLLA 1 C zero copay

TRI-LO-MARZIA 1 C zero copay

TRI-LO-SPRINTEC 1 C zero copay

TRI-PREVIFEM 1 C zero copay

TRI-SPRINTEC 1 C zero copay



TRINESSA 1 C zero copay

TRINESSA LO 1 C zero copay

TRIVORA-28 1 C zero copay

TYDEMY 1 C zero copay

VAGIFEM 3

VELIVET 1 C zero copay

VESTURA 1 C zero copay

VIENVA 1 C zero copay

VIORELE 1 C zero copay

VIVELLE-DOT 3 QL

VYFEMLA 1 C zero copay

WERA 1 C zero copay

WYMZYA FE 1 C zero copay

XULANE 3 C zero copay

YUVAFEM 1

ZARAH 1 C zero copay

ZENCHENT 1 C zero copay

ZENCHENT FE 1 C zero copay

ZOVIA 1-35E 1 C zero copay

ZOVIA 1-50E 1 C zero copay

PROGESTERONE AGONISTS/ANTAGONISTS

ELLA 3 C zero copay

PROGESTINS

AFTERA 3 C zero copay

CAMILA 1 C zero copay

CRINONE 3

DEBLITANE 1 C zero copay

DEPO-SUBQ PROVERA 104 3 C zero copay



ECONTRA EZ 3 C zero copay

ENDOMETRIN 3 PA

ERRIN 1 C zero copay

FALLBACK SOLO 3 C zero copay

HEATHER 1 C zero copay

JENCYCLA 1 C zero copay

JOLIVETTE 1 C zero copay

levonorgestrel 3 C zero copay

LYZA 1 C zero copay

medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/ml vial) 1 C zero copay

medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1

megestrol acetate (20 mg tablet, 40 mg tablet) 1

megestrol acetate (400mg/10ml oral susp, 625mg/5ml oral susp) 1

NEXT CHOICE ONE DOSE 3 C zero copay

NORA-BE 1 C zero copay

norethindrone 1 C zero copay

norethindrone acetate 5 mg tablet 1

NORLYROC 1 C zero copay

OPCICON ONE-STEP 3 C zero copay

OPTION 2 3 C zero copay

PLAN B ONE-STEP 3 C zero copay

progesterone 1 MS

progesterone, micronized 1

SHAROBEL 1 C zero copay

TAKE ACTION 3 C zero copay

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

clomiphene citrate 1

DUAVEE 2

raloxifene hcl 1



SEROPHENE 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID 3

LEVO-T 1

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

1

LEVOXYL 1

liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) 1

NATURE-THROID 3

NP THYROID 1

SYNTHROID 3

THYROLAR-1 3

THYROLAR-1/2 3

THYROLAR-1/4 3

THYROLAR-2 3

THYROLAR-3 3

TIROSINT 3

UNITHROID 1

WESTHROID 3

WP THYROID 3

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline 1

CETROTIDE 3

PA

MS

GANIRELIX ACETATE 3

PA

MS

leuprolide acetate 1 PA

octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 50 mcg/ml vial, 100mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 200 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial, 1000mcg/ml vial)

1 MS

SIGNIFOR 3

PA

MS

SOMAVERT 3

PA

MS



HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole 1

propylthiouracil 1

SSKI 3

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT 500 UNIT KIT 3

QL

PA

MS

CINRYZE 3

QL

PA

MS

FIRAZYR 3

QL

PA

MS

HAEGARDA (2,000 VIAL, 3,000 VIAL) 3

QL

PA

MS

RUCONEST 3

QL

PA

MS

TAKHZYRO 3

QL

PA

MS

IMMUNE SUPPRESSANTS

ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3

QL

PA

azathioprine 1

CELLCEPT 200 MG/ML ORAL SUSP 3

cyclosporine (25 mg capsule, 100 mg capsule) 1

cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100mg/ml solution)

1



ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE) 2

QL

PA

MS

ENBREL MINI 2

QL

PA

MS

ENBREL SURECLICK 2

QL

PA

MS

ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4 MG TABLET) 3

QL

PA

GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION)

1

HUMIRA 2

QL

PA

MS

KINERET 3

QL

PA

ST

methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) 1

methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial) 1

mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) 1

mycophenolate sodium 1

OLUMIANT 3

QL

PA

MS

ORENCIA 3

QL

PA

ST

MS

OTREXUP 3 PA

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MGTABLET)

3

RASUVO 3 PA



sirolimus 1

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

TREXALL 3

XATMEP 3 PA

XELJANZ 10 MG TABLET 2

QL

PA

MS

XELJANZ 5 MG TABLET 2

PA

MS

XELJANZ XR 2

QL

PA

MS

ZORTRESS 3

IMMUNOMODULATORS

ACTEMRA 162 MG/0.9 ML SYRINGE 2

QL

PA

MS

ACTIMMUNE 3

PA

MS

ARCALYST 3

PA

MS

BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 3

QL

PA

MS

DUPIXENT 3

QL

PA

GRASTEK 3 QL

leflunomide 1

ORALAIR 3 QL

OTEZLA 2

QL

PA

MS



RAGWITEK 3 QL

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO 3 QL

ASACOL HD 3

balsalazide disodium 1

CANASA 3

DELZICOL 2

DIPENTUM 3

GIAZO 3

QL

PA

mesalamine (1.2 g tablet dr, 4 g/60 ml enema) 1

MESALAMINE 800 MG TABLET DR 1

mesalamine with cleansing wipes 1

QL

PA

PENTASA 2

ROWASA 4 GM/60 ML ENEMA KIT 3

QL

PA

GLUCOCORTICOIDS

budesonide 3 mg capdr - er 1

budesonide 9 mg tabdr - er 1

QL

PA

COLOCORT 1

hydrocortisone 100mg/60ml enema 1

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

QL

PA

SULFONAMIDES

sulfasalazine 1

METABOLIC BONE DISEASE AGENTS

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

1 QL

alendronate sodium 70 mg/75ml solution 1



calcitonin,salmon,synthetic 1

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1

doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) 1

ergocalciferol (vitamin d2) 50000 unit capsule 1

etidronate disodium 1

FORTEO 3

PA

MS

ibandronate sodium 150 mg tablet 1 QL

NATPARA 3

QL

PA

MS

paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 1

risedronate sodium (5 mg tablet, 30 mg tablet, 35 mg tablet, 35 mg tablet dr,150 mg tablet)

1 QL

SENSIPAR 3

TRIXYLITRAL 3

QL

PA

TYMLOS 3

QL

PA

MS

MISCELLANEOUS THERAPEUTIC AGENTS

BD PEN NEEDLES T2. ALL OTHER MANUFACTURERS T3. 2

cervical cap 3 C zero copay

COMFORT PAC-MELOXICAM 3

QL

PA

COMFORT PAC-NAPROXEN 3

QL

PA

condoms, female 3 C zero copay

diaphragms, contoured 3 C zero copay

diaphragms, wide seal 3 C zero copay



FLEXIPAK 3

QL

PA

foam/gauze bandage/lidocaine/chlorhexidine/isopropyl alcohol 3

QL

PA

INFLAMMACIN 3

QL

PA

isometheptene mucate/dichloralphenazone/acetaminophen 1

MD-GASTROVIEW 1

METHERGINE 1 QL

methylergonovine maleate 0.2 mg tablet 1 QL

NODOLOR 1

NUDICLO TABPAK 3

QL

PA

ODACTRA 3 QL

potassium iodide/iodine 1

PREVIDOLRX PLUS ANALGESIC PAK 3

QL

PA

SAXENDA 3

QL

PA

silver/bandage/foam/gauze/lidocaine/chlorhexidin/isopropanol 3

QL

PA

XENAFLAMM 3

QL

PA

XERMELO 3

QL

PA

MODIFIED SOLID FOODS

All modified solid foods are covered as brands with Prior Authorization

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

atropine sulfate (1 % drops, 1 % oint. (g)) 1

bacitracin/polymyxin b sulfate 500-10k/g oint. (g) 1



BLEPHAMIDE S.O.P. 3

cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1

CYSTARAN 3 PA

NAPHAZOLINE 0.1% 3

NEO-POLYCIN 1

NEO-POLYCIN HC 1

neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 1

neomycin sulfate/bacitracin/polymyxin b 1

neomycin sulfate/polymyxin b sulfate/gramicidin d 1

neomycin/polymyxin b sulfate/dexamethasone (neomycin/polymyxinb/dexametha 0.1 % drops susp, neomycin/polymyxin b/dexametha 3.5-10k-.1oint. (g))

1

neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1

phenylephrine hcl (2.5 % drops, 10 % drops) 1

POLYCIN 1

polymyxin b sulfate/trimethoprim 1

proparacaine hcl 1

RESTASIS 2 QL

RESTASIS MULTIDOSE 2 QL

sulfacetamide sodium/prednisolone sodium phosphate 1

TOBRADEX EYE OINTMENT 3

tobramycin/dexamethasone 1

tropicamide (0.5 % drops, 1 % drops) 1

XIIDRA 2 QL

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL 3

ALOMIDE 3

azelastine hcl 0.05 % drops 1

BEPREVE 3

cromolyn sodium 4 % drops 1

ELESTAT 3

EMADINE 3

epinastine hcl 1



LASTACAFT 3

olopatadine hcl 0.1 % drops 1

OPHTHALMIC ANTI-INFLAMMATORIES

bromfenac sodium 1

dexamethasone sodium phosphate 0.1 % drops 1

diclofenac sodium 0.1 % drops 1

DUREZOL 3

fluorometholone 1

flurbiprofen sodium 1

ILEVRO 3

ketorolac tromethamine (0.4 % drops, 0.5 % drops) 1

LOTEMAX (EYE DROPS, EYE OINTMENT, OPHTHALMIC GEL) 2

MAXIDEX 3

NEVANAC 3

prednisolone acetate 1

prednisolone sod phosphate 1 % drops 1

VEXOL 3

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 2

apraclonidine hcl 1

AZOPT 3

betaxolol hcl 0.5 % drops 1

brimonidine tartrate 1

carteolol hcl 1

COMBIGAN 2 QL

dorzolamide hcl 1

dorzolamide hcl/timolol maleate 1

dorzolamide/timolol/pf 2 %-0.5 % droperette 1 QL

levobunolol hcl 1

methazolamide 1

metipranolol 1

PHOSPHOLINE IODIDE 3



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

SIMBRINZA 3 QL

timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drops, 0.5 % sol-gel) 1

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

BIMATOPROST 0.03 % DROPS (INTO THE EYE FOR GLAUCOMA) 2

latanoprost 1 QL

LUMIGAN 2

TRAVATAN Z 2

ZIOPTAN 3

QL

ST

OTIC AGENTS

ACETASOL HC 1

acetic acid 2 % solution 1

acetic acid/aluminum acetate 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

fluocinolone acetonide oil 1

hydrocortisone/acetic acid 1

neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxinb/hydrocort drops susp, neomycin/polymyxin b/hydrocort solution)

1

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ARMONAIR RESPICLICK 2 QL

ARNUITY ELLIPTA 2 QL

ASMANEX 2 QL

ASMANEX HFA 2 QL

BECONASE AQ 3 QL

budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb)

1 QL

FLOVENT DISKUS 2 QL



FLOVENT HFA (HFA 44 MCG INHALER, HFA 110 MCG INHALER, HFA 220MCG INHALER)

2 QL

flunisolide 1 QL

mometasone furoate 50 mcg spray/pump 1

NASONEX 3

OMNARIS 3 QL

PULMICORT 3 QL

PULMICORT FLEXHALER (90 MCG, 180 MCG) 3

QL

ST

QNASL 2 QL

QNASL CHILDREN 2 QL

QVAR 2 QL

QVAR REDIHALER 2 QL

TICANASE 3

QL

PA

TICASPRAY 3

QL

PA

triamcinolone acetonide 55 mcg spray 1

VERAMYST 3 QL

XHANCE 3

QL

PA

ZETONNA 3 QL

ANTIHISTAMINES

ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1

azelastine hcl 137 mcg spray/pump 1

azelastine hcl 205.5 mcg spray/pump 1 QL

carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) 1

clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) 1

cyproheptadine hcl (2 mg/5 ml syrup, 4 mg/10 ml syrup) 1

QL

PA

cyproheptadine hcl 4 mg tablet 1



desloratadine 5 mg tablet 1

diphenhydramine hcl 12.5mg/5ml elixir 1

hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet,50 mg/25ml solution)

1

hydroxyzine pamoate 1

levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tablet) 1 QL

olopatadine hcl 0.6 % spray/pump 1 QL

promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 25 mg tablet) 1

ANTILEUKOTRIENES

montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mgtablet)

1 QL

zafirlukast 1

zileuton 1 QL

ZYFLO CR 3 QL

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA 2

INCRUSE ELLIPTA 3 QL

ipratropium bromide 1

SPIRIVA 2

SPIRIVA RESPIMAT 2

TUDORZA PRESSAIR 3 QL

BRONCHODILATORS, SYMPATHOMIMETIC

albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg tablet, 2 mg/5ml syrup, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 4 mg tab er 12h, 4 mgtablet, 5 mg/ml solution, 8 mg tab er 12h)

1

AUVI-Q (0.15 MG, 0.3 MG) 3

QL

PA

BROVANA 3

epinephrine (0.1 mg/ml syringe, 1 mg/ml vial, 1 mg/ml(1) ampul) 1

epinephrine (0.15/0.15 auto injct, 0.15mg/0.3 auto injct, 0.3mg/0.3 auto injct) 1 QL

EPIPEN 2 QL

EPIPEN 2-PAK 2 QL

EPIPEN JR 2-PAK 2 QL

FORADIL 2 QL



levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb, 1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb)

1

levalbuterol tartrate 1

metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) 1

PERFOROMIST 3 QL

PROAIR HFA 2 QL

PROAIR RESPICLICK 2 QL

PROVENTIL HFA 3 QL

SEREVENT DISKUS 2

STRIVERDI RESPIMAT 2 QL

terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 1

VENTOLIN HFA 2 QL

CYSTIC FIBROSIS AGENTS

BETHKIS 3

QL

MS

CAYSTON 3 MS

KALYDECO 3

QL

PA

MS

KITABIS PAK 3 MS

ORKAMBI (100 MG-125 MG TABLET, 100-125 MG GRANULE PKT, 150-188MG GRANULE PKT, 200 MG-125 MG TABLET)

3

QL

PA

MS

SYMDEKO 3

QL

PA

MS

TOBI PODHALER 3 QL

tobramycin/nebulizer 1 MS

MAST CELL STABILIZERS

cromolyn sodium 20 mg/2 ml ampul-neb 1



PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine citrate 60 mg/3 ml solution 1

THEOCHRON 1

theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er12h, 600 mg tab er 24h)

1

PULMONARY ANTIHYPERTENSIVES

ADCIRCA 3

QL

PA

MS

ADEMPAS 3

QL

PA

MS

LETAIRIS 3

QL

PA

MS

OPSUMIT 3

QL

PA

MS

ORENITRAM ER 3

PA

MS

REVATIO (10 MG/ML ORAL SUSP, 20 MG TABLET) 3

QL

PA

MS

sildenafil citrate 20 mg tablet 1

QL

PA

MS

tadalafil 20 mg tablet 1

QL

PA

MS

TRACLEER (62.5 MG TABLET, 125 MG TABLET) 3

PA

MS

TRACLEER 32 MG TABLET FOR SUSP 3

QL

PA

MS



TYVASO 3

QL

PA

MS

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

3

QL

PA

PULMONARY FIBROSIS AGENTS

ESBRIET (267 MG CAPSULE, 267 MG TABLET, 801 MG TABLET) 2

QL

PA

MS

OFEV 2

QL

PA

MS

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1

ADVAIR DISKUS 2 QL

ADVAIR HFA 2 QL

ANORO ELLIPTA 2 QL

benzonatate 1

BEVESPI AEROSPHERE 2 QL

BREO ELLIPTA 100-25 MCG INH 2 QL

BREO ELLIPTA 200-25 MCG INH 2

BROMFED DM 1

brompheniramine/pseudoephed/dm 2-30-10/5 syrup 1

CENTERGY DM 1

COMBIVENT RESPIMAT 2 QL

DYMISTA 3

QL

PA

FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 2 QL

hydrocodone bitart/chlorpheniramine maleate/pseudoephedrine 1

hydrocodone bitartrate/homatropine methylbromide (bit/homatrop 5 mg-1.5mgtablet, bit/homatrop 5-1.5 mg/5 syrup)

1

hydrocodone polistirex/chlorpheniramine polistirex 1 QL



HYDROMET 1

ipratropium bromide/albuterol sulfate 1

phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup 1

promethazine hcl/codeine 1

promethazine/dextromethorphan 6.25-15/5 syrup 1

promethazine/phenyleph/codeine 6.25-5-10 syrup 1

ribavirin 6 g vial-neb 1 MS

sodium chloride for inhalation 1

STIOLTO RESPIMAT 2 QL

SYMBICORT 2 QL

TICALAST 3

QL

PA

TOBI 3

tobramycin in 0.225 % sodium chloride 1

TUSSIGON 1

TYZINE 3

UTIBRON NEOHALER 2

SKELETAL MUSCLE RELAXANTS

AMRIX 3

QL

PA

carisoprodol 250 mg tablet 1

QL

PA

carisoprodol 350 mg tablet 1

carisoprodol/aspirin 200-325 mg tablet 1

chlorzoxazone 250 mg tablet 1

QL

PA

chlorzoxazone 500 mg tablet 1 QL

COMFORT PAC-CYCLOBENZAPRINE 3

QL

PA

COMFORT PAC-TIZANIDINE 3

QL

PA



cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 1

cyclobenzaprine hcl 7.5 mg tablet 1

QL

PA

FEXMID 3

QL

PA

LORZONE 3

QL

PA

METAXALL 1 QL

metaxalone 400 mg tablet 1

metaxalone 800 mg tablet 1 QL

methocarbamol (500 mg tablet, 750 mg tablet) 1

orphenadrine citrate 100 mg tablet er 1

SOMA 250 MG TABLET 3

QL

PA

SOMA 350 MG TABLET 3

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

EDLUAR 3

QL

ST

estazolam 1

eszopiclone 1 QL

flurazepam hcl 1

INTERMEZZO 3

QL

ST

quazepam 1

temazepam 1

triazolam 1

zaleplon (5 mg capsule, 10 mg capsule) 1 QL

zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mg tablet, 6.25 mg tabmphase, 10 mg tablet, 12.5 mg tab mphase)

1 QL

ZOLPIMIST 3

QL

ST



SLEEP DISORDERS, OTHER

armodafinil (50 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet) 1 QL

HETLIOZ 3

QL

PA

MS

modafinil 1 QL

ROZEREM 3

QL

ST

SILENOR 3

QL

ST

XYREM 3

QL

PA

Uncategorized

Unclassified

CIMDUO 2 QL

ESOMEP-EZS 3

QL

PA

JYNARQUE 3

QL

PA

KAPSPARGO SPRINKLE 3

NUDROXIPAK 3

QL

PA

NUDROXIPAK DSDR-50 3

QL

PA


QL

PA

NUDROXIPAK E-400 3

QL

PA

NUDROXIPAK I-800 3

QL

PA

NUDROXIPAK N-500 3

QL

PA



NUPLAZID (10 MG TABLET, 34 MG CAPSULE) 3

QL

PA

MS

ORILISSA (150 MG TABLET, 200 MG TABLET) 3

QL

PA

SYMFI 2 QL

SYMTUZA 3 QL

TASIGNA 50 MG CAPSULE 3

QL

PA

MS

TIBSOVO 3

QL

PA

TOUJEO MAX SOLOSTAR 2

XIMINO 3

QL

PA


Index of covered drugs

Aabacavir sulfate 39

abacavir sulfate/lamivudine 39

abacavir sulfate/lamivudine/zidovudine 39

ABSORICA 60

ABSTRAL 8

acamprosate calcium 11

acarbose 41

acebutolol hcl 50

acetaminophen with codeine phosphate 8

acetaminophen/caffeine/dihydrocodeine

bitartrate 8

ACETASOL HC 94

acetazolamide 52

acetic acid 94

acetic acid/aluminum acetate 94

acetylcysteine 99

ACIPHEX SPRINKLE 68

acitretin 60

ACTEMRA 88

ACTICLATE 15

ACTIMMUNE 88

ACTIQ 8

ACTOPLUS MET 41

ACTOPLUS MET XR 41

ACTOS 41

acyclovir 40

ACZONE 60

adapalene 60

adapalene/benzoyl peroxide 60

ADCIRCA 98

ADDYI 71

adefovir dipivoxil 36

ADEMPAS 98

ADLYXIN 41

ADMELOG 45

ADMELOG SOLOSTAR 45

ADVAIR DISKUS 99

ADVAIR HFA 99

ADZENYS ER 55

ADZENYS XR-ODT 55

AFEDITAB CR 50

AFINITOR 28

AFREZZA 45

AFTERA 83

AIMOVIG AUTOINJECTOR 24

AIMOVIG AUTOINJECTOR (2 PACK) 24

AKYNZEO 21

ALA-CORT 71

ALBENZA 32

albuterol sulfate 96

alclometasone dipropionate 71

ALECENSA 28

alendronate sodium 89

ALFERON N 40

alfuzosin hcl 70

ALINIA 32

ALKERAN 25

allopurinol 23

almotriptan malate 24

ALOCRIL 92

ALOGLIPTIN BENZOATE 41

alogliptin benzoate/metformin hcl 41

alogliptin benzoate/pioglitazone hcl 42

ALOMIDE 92

ALORA 77

alosetron hcl 67

ALPHAGAN P 93

alprazolam 41

ALPRAZOLAM INTENSOL 41

ALTABAX 12

ALTAVERA 77

ALUNBRIG 27

ALYACEN 77

AMABELZ 77

amantadine hcl 33

amcinonide 71

AMETHIA 77

AMETHIA LO 77

AMETHYST 77

AMICAR 48

amiloride hcl 53

amiloride hcl/hydrochlorothiazide 51

aminocaproic acid 48

amiodarone hcl 49

AMITIZA 67

amitriptyline hcl 20

amitriptyline hcl/chlordiazepoxide 19

amlodipine besylate 50

amlodipine besylate/atorvastatin calcium 51

amlodipine besylate/benazepril hcl 51

amlodipine besylate/olmesartan medoxomil 51

amlodipine besylate/valsartan 51

amlodipine

besylate/valsartan/hydrochlorothiazide 51

AMNESTEEM 60

amoxapine 20

amoxicillin 14

AMOXICILLIN ER 775 MG 14

amoxicillin/potassium clavulanate 14

ampicillin trihydrate 14

AMPYRA 58

AMRIX 100

ANADROL-50 76

anagrelide hcl 47

anastrozole 28

ANDRODERM 76

ANDROGEL 77

ANDROID 77

ANDROXY 77

ANODYNE LPT 10

ANORO ELLIPTA 99

ANUCORT-HC 71

APIDRA 45

APIDRA SOLOSTAR 45

APOKYN 34

apraclonidine hcl 93

aprepitant 21

APRI 78

APRISO 89

APTIOM 18

APTIVUS 40


ARANELLE 78

ARANESP 47

ARBINOXA 95

ARCALYST 88

aripiprazole 35

102

94

85

94

6

89

8

78

94

94

8

48

86

40

50

51

56

53

33

33

38

91

96

58

78

57

96

42

60

78

15

60

58

77

armodafinil

ARMONAIR RESPICLICK

ARMOUR THYROID

ARNUITY ELLIPTA

ARYMO ER

ASACOL HD

ASCOMP WITH CODEINE

ASHLYNA

ASMANEX

ASMANEX HFA

aspirin/caffeine/dihydrocodeine bitartrate

ASPIRIN/DIPYRIDAMOLE

ASTAGRAF XL

atazanavir sulfate

atenolol

atenolol/chlorthalidone

atomoxetine hcl

atorvastatin calcium

atovaquone

atovaquone/proguanil hcl

ATRIPLA

atropine sulfate

ATROVENT HFA

AUBAGIO

AUBRA

AUSTEDO

AUVI-Q

AVANDIA

AVAR

AVIANE

AVIDOXY

AVITA

Avonex

AXIRON

AZASITE 14

azathioprine 86

azelastine hcl 92,95

AZELEX 60

azithromycin 14

AZOPT 93

AZURETTE 78

Bbacitracin 12

bacitracin/polymyxin b sulfate 91

baclofen 35

balsalazide disodium 89

BALZIVA 78

BANZEL 18

BARACLUDE 36

BASAGLAR KWIKPEN U-100 45

BAXDELA 14

BD Pen Needles T2. All other manufacturers

T3. 90

BECONASE AQ 94

BEKYREE 78

BELBUCA 7

BELVIQ 57

BELVIQ XR 57

benazepril hcl 49

benazepril hcl/hydrochlorothiazide 51

BENLYSTA 88

BENZEPRO 60

benznidazole 32

benzonatate 99

benzoyl peroxide 60

benzphetamine hcl 57

benztropine mesylate 33

BEPREVE 92

BERINERT 86

BESIVANCE 14

betamethasone dipropionate 71

betamethasone dipropionate/propylene

glycol 72

betamethasone valerate 72

BETASERON 58

betaxolol hcl 50,93

bethanechol chloride 71

BETHKIS 97

BEVESPI AEROSPHERE 99

bexarotene 32

bicalutamide 26

BIKTARVY 38

BILTRICIDE 32

bimatoprost 0.03 % drops (into the eye for

glaucoma) 94

bisoprolol fumarate 50

bisoprolol fumarate/hydrochlorothiazide 51

BLEPHAMIDE S.O.P. 92

BLISOVI 24 FE 78

BLISOVI FE 78

BONJESTA 21

BOSULIF 28

BPO 60

BRAFTOVI 28

BRAVELLE 75

BREO ELLIPTA 99

BRIELLYN 78

BRILINTA 48

brimonidine tartrate 93

BRISDELLE 19

BRIVIACT 16

BROMFED DM 99

bromfenac sodium 93

bromocriptine mesylate 34

brompheniramine maleate/pseudoephedrine

hcl/dextromethorphan 99

BROVANA 96

budesonide 89,94

bumetanide 53

BUPHENYL 69

buprenorphine hcl 11

buprenorphine hcl/naloxone hcl 11

BUPRENORPHINE PATCH 7

BUPROBAN 11

bupropion hcl 11,19

buspirone hcl 41


butalbital/acetaminophen 57

butalbital/acetaminophen/caffeine 57

butalbital/acetaminophen/caffeine/codeine

phosphate 8

butalbital/aspirin/caffeine 5

butorphanol tartrate 8

BUTRANS 7

BYDUREON 42

BYDUREON BCISE 42

BYDUREON PEN 42

BYETTA 42

BYSTOLIC 50

BYVALSON 51

Ccabergoline 85

CABOMETYX 28

caffeine citrate 98

calcipotriene 60

calcipotriene/betamethasone dipropionate 60

calcitonin,salmon,synthetic 90

CALCITRENE 60

calcitriol 90

CALCITRIOL 3 MCG/G OINTMENT 60

calcium acetate 65

CALQUENCE 28

CAMBIA 5

CAMILA 83

CAMRESE 78

CAMRESE LO 78

CANASA 89

candesartan cilexetil 49

candesartan cilexetil/hydrochlorothiazide 51

CAPACET 57

capecitabine 27

CAPRELSA 28

captopril 49

captopril/hydrochlorothiazide 51

CARAC 60

CARAFATE 68

CARBAGLU 64

carbamazepine 18

carbidopa 34

carbidopa/levodopa 34

carbidopa/levodopa/entacapone 33

carbinoxamine maleate 95

carisoprodol 100

carisoprodol/aspirin 100

carisoprodol/aspirin/codeine phosphate 8

carteolol hcl 93

CARTIA XT 50

carvedilol 50

carvedilol phosphate 50

CAYSTON 97

CAZIANT 78

cefaclor 13

cefadroxil 13

cefdinir 13

cefditoren pivoxil 13

cefixime 13

cefpodoxime proxetil 13

cefprozil 13

CEFTIBUTEN 13

cefuroxime axetil 13

celecoxib 5

CELLCEPT 86

CELONTIN 16

CENTANY AT 12

CENTERGY DM 99

cephalexin 14

CERDELGA 69

cervical cap 90

CESAMET 21

CETROTIDE 85

cevimeline hcl 59

CHANTIX 11

CHATEAL 78

CHEMET 65

chlordiazepoxide hcl 41

chlordiazepoxide/clidinium bromide 66

chlorhexidine gluconate 59

chloroquine phosphate 33

chlorothiazide 53

chlorpromazine hcl 34

chlorthalidone 53

chlorzoxazone 100

CHOLBAM 69

cholestyramine (with sugar) 54

cholestyramine/aspartame 54

choline salicylate/magnesium salicylate 5

chorionic gonadotropin, human 75

CIALIS 70,71

CICLODAN 22

ciclopirox 22

ciclopirox olamine 22

cilostazol 48

CILOXAN 14

CIMDUO 102

cimetidine 67

cimetidine hcl 67

CINRYZE 86

CIPRO HC 94

CIPRODEX 94

ciprofloxacin 15

ciprofloxacin hcl 15

ciprofloxacin/ciprofloxacin hcl 15

citalopram hydrobromide 19

CLARAVIS 60

clarithromycin 14

clemastine fumarate 95

CLENPIQ 68

CLIMARA PRO 78

CLINDACIN ETZ 12

CLINDACIN P 12

CLINDACIN PAC 12

clindamycin hcl 12

clindamycin palmitate hcl 12

clindamycin phosphate 12

clindamycin phosphate/benzoyl peroxide 60

clindamycin phosphate/tretinoin 60

clobetasol propionate 72

CLOCORTOLONE PIVALATE 0.1 %

CREAM(G) 72


CLODAN 72

CLODERM 72

clomiphene citrate 84

clomipramine hcl 20

clonazepam 41

clonidine 48

clonidine hcl 48,56

clopidogrel bisulfate 48

clorazepate dipotassium 41

CLORPRES 51

clotrimazole 22

clotrimazole/betamethasone dipropionate 60

clozapine 35

COARTEM 33

codeine phosphate/butalbital/aspirin/caffeine 8

codeine sulfate 8

COLCHICINE 23

COLCRYS 23

colesevelam hcl 54

colestipol hcl 54

COLOCORT 89

COLY-MYCIN S 94

COMBIGAN 93

COMBIPATCH 78

COMBIVENT RESPIMAT 99

COMETRIQ 29

COMFORT PAC-CYCLOBENZAPRINE 100

COMFORT PAC-MELOXICAM 90

COMFORT PAC-NAPROXEN 90

COMFORT PAC-TIZANIDINE 100

COMPAZINE 21

COMPLERA 38

COMPRO 21

CONCEPTROL 71

CONCERTA 56

condoms, female 90

CONSTULOSE 68

CONTRAVE 57

COPAXONE 58

COPEGUS 37

CORDRAN 72

CORLANOR 51

CORMAX 72

cortisone acetate 72

CORTISPORIN 60

CORTISPORIN-TC 94

COSENTYX 60

COTELLIC 29

COTEMPLA XR-ODT 56

COUMADIN 46

COVARYX 78

COVARYX H.S. 78

CREON 69

CRESEMBA 22

CRINONE 83

CRIXIVAN 40

cromolyn sodium 67,92,97

CRYSELLE 78

CUPRIMINE 65

CUVPOSA 66

cyanocobalamin (vitamin b-12) 66

CYCLAFEM 78

cyclobenzaprine hcl 101

cyclopentolate hcl 92

CYCLOPHOSPHAMIDE (25 mg CAPSULE, 50

mg CAPSULE) 25

cycloserine 25

CYCLOSET 42

cyclosporine 86

cyclosporine, modified 86

cyproheptadine hcl 95

CYRED 78

CYSTADANE 69

CYSTAGON 69

CYSTARAN 92

CYTRA-K 64

DD.H.E.45 24

DAKLINZA 36

dalfampridine 58

danazol 77

dantrolene sodium 35

dapsone 25,61

DARAPRIM 33

darifenacin hydrobromide 70

DASETTA 78

DAYSEE 78

DEBLITANE 83

DECADRON 72

DELSTRIGO 38

DELTASONE 72

DELYLA 78

DELZICOL 89

demeclocycline hcl 15

DENAVIR 40

DENTA 5000 PLUS 64

DENTAGEL 64

DEPEN 65

DEPO-SUBQ PROVERA 104 83

DEPO-TESTOSTERONE 77

DERMACINRX CINLONE-I CPI 72

DERMACINRX CLORHEXACIN 61

DERMACINRX EMPRICAINE 10

DERMACINRX PRIZOPAK 10

DERMACINRX SILAPAK 72

DERMACINRX SILAZONE 72

DERMACINRX SURGICAL PHARMAPAK 61

DERMACINRX THERAZOLE PAK 61

DERMAZONE 72

DESCOVY 39

desipramine hcl 20

desloratadine 96

desmopressin acetate 75

desmopressin acetate (non-refrigerated) 75

desogestrel-ethinyl estradiol 78

desogestrel-ethinyl estradiol/ethinyl estradiol 78

DESONATE 72

desonide 72

desoximetasone 72

DESVENLAFAXINE ER 19

DESVENLAFAXINE FUMARATE 19

desvenlafaxine succinate 19


dexamethasone 72

dexamethasone sodium phosphate 93

DEXEDRINE 55

DEXILANT 68

dexmethylphenidate hcl 56

dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate 56

dextroamphetamine sulfate 56

diaphragms, contoured 90

diaphragms, wide seal 90

diazepam 17,41

DIBENZYLINE 48

DICLEGIS 21

DICLO GEL 61

DICLO GEL-XRYLIX SHEET 61

diclofenac potassium 5

diclofenac sodium 5,61,93

diclofenac sodium/misoprostol 5

DICLOPR 5

dicloxacillin sodium 14

DICLOZOR 61

dicyclomine hcl 66

didanosine 39

diethylpropion hcl 57

DIFICID 14

diflorasone diacetate 72

diflunisal 5

DIGITEK 51

DIGOX 52

digoxin 52

dihydroergotamine mesylate 24

dihydroergotamine mesylate 0.5mg/spry

spray/pump 24

DILT-XR 50

diltiazem hcl 51

DIPENTUM 89

diphenhydramine hcl 96

diphenoxylate hcl/atropine sulfate 67

dipyridamole 48

disopyramide phosphate 49

disulfiram 11

DITHOL 5

divalproex sodium 17

dofetilide 49

DOLOTRANZ 10

donepezil hcl 18

DOPTELET 47

DORYX 15

dorzolamide hcl 93

dorzolamide hcl/timolol maleate 93

dorzolamide hcl/timolol maleate/pf 93

doxazosin mesylate 48

doxepin hcl 20

doxercalciferol 90

doxycycline hyclate 15

doxycycline monohydrate 16

DOXYCYCLINE MONOHYDRATE 40 mg CAP

IR DR 16

dronabinol 21

drospirenone/ethinyl estradiol/levomefolate

calcium 78

DROXIA 27

DRYSOL 61

DUAVEE 84

DUETACT 42

DUEXIS 5

duloxetine hcl 58

DUPIXENT 88

DUREZOL 93

dutasteride 71

DUZALLO 23

DYANAVEL XR 56

DYMISTA 99

DYRENIUM 53

EE.E.S. 200 14

E.E.S. 400 14

econazole nitrate 22

ECONTRA EZ 84

ECONTRA ONE-STEP 79

ED-SPAZ 66

EDARBI 49

EDECRIN 53

EDLUAR 101

EDURANT 38

EEMT 79

EEMT H.S. 79

efavirenz 39

EFFER-K 64

EFFIENT 48

EGRIFTA 75

ELESTAT 92

eletriptan hydrobromide 24

ELIDEL 61

ELINEST 79

ELIPHOS 65

ELIQUIS 46

ELLA 83

ELLZIA PAK 72

ELMIRON 71

EMADINE 92

EMBEDA 7

EMCYT 27

EMFLAZA 73

EMOQUETTE 79

EMSAM 19

EMTRIVA 39

enalapril maleate 49

enalapril maleate/hydrochlorothiazide 52

ENBREL 87

ENBREL MINI 87

ENBREL SURECLICK 87

ENDARI 64

ENDOCET 8

ENDOMETRIN 84

ENJUVIA 79

enoxaparin sodium 46

ENPRESSE 79

ENSKYCE 79

ENSTILAR 61

entacapone 33

entecavir 36


66

52

68

87

49

36

61

92

96

96

96

96

18

39

36

53

47

49

90

18

24

24

29

26

84

22

14

14

14

14

14

14

14

12

14

99

19

57

Enteral Formula Requires Prior Authorization.

Brands are Tier 3 & generics are Tier 1.

ENTRESTO

ENULOSE

ENVARSUS XR

EPANDED SOLUTION

EPCLUSA

EPIDUO FORTE

epinastine hcl

epinephrine

EPIPEN

EPIPEN 2-PAK

EPIPEN JR 2-PAK

EPITOL

EPIVIR

EPIVIR HBV

eplerenone

EPOGEN

eprosartan mesylate

ergocalciferol (vitamin d2)

ergoloid mesylates

ERGOMAR

ergotamine tartrate/caffeine

ERIVEDGE

ERLEADA

ERRIN

ERTACZO

ERY

ERY-TAB

ERYPED 200

ERYPED 400

ERYTHROCIN STEARATE

erythromycin base

erythromycin base in ethanol

erythromycin base/benzoyl peroxide

erythromycin ethylsuccinate

ESBRIET

escitalopram oxalate

ESGIC

ESOMEP-EZS 102

esomeprazole magnesium 68

esomeprazole strontium 68

ESTARYLLA 79

estazolam 101

ESTRACE 79

estradiol 79

estradiol valerate 79

estradiol/norethindrone acetate 79

ESTRING 79

estrogens,esterified/methyltestosterone 79

estropipate 79

eszopiclone 101

ethacrynic acid 53

ethambutol hcl 25

ethinyl estradiol/drospirenone 79

ethosuximide 16

ethynodiol diacetate-ethinyl estradiol 79

etidronate disodium 90

etodolac 5

etoposide 28

EURAX 33

EVOXAC 59

EXALGO 7

EXELDERM 22

exemestane 28

EXFORGE 52

EXFORGE HCT 52

EXJADE 65

EXTAVIA 58

EXTINA 22

ezetimibe 54

ezetimibe/simvastatin 54

FFABIOR 61

FACTIVE 15

FALLBACK SOLO 84

FALMINA 79

famciclovir 40

famotidine 67

FANAPT 35

FARESTON 27

FARXIGA 42

FARYDAK 29

FAYOSIM 79

felbamate 17

felodipine 51

FEMYNOR 79

fenofibrate 53

fenofibrate nanocrystallized 53

fenofibrate,micronized 53

fenofibric acid 53

fenofibric acid (choline) 53

fenoprofen calcium 5

FENORTHO 5

fentanyl 7

FENTANYL (37.5mcg/hr patch td72,

62.5mcg/hr patch td72, 87.5mcg/hr patch

td72) 7

fentanyl citrate 8

FENTORA 8

FERRIPROX 65

FETZIMA 19

FEXMID 101

FIASP 45

FIASP FLEXTOUCH 45

finasteride 71

FIRAZYR 86

FIRVANQ 12

flavoxate hcl 70

flecainide acetate 49

FLECTOR 5

FLEXIPAK 91

FLOVENT DISKUS 94

FLOVENT HFA 95

fluconazole 22

flucytosine 22

fludrocortisone acetate 73

flunisolide 95

fluocinolone acetonide 73

fluocinolone acetonide oil 94

fluocinolone acetonide/shower cap 73


fluocinonide 73

fluocinonide/emollient base 73

FLUORIDEX DAILY DEFENSE 64

FLUORIDEX SENSITIVITY RELIEF 64

fluorometholone 93

fluorouracil 27

FLUOROURACIL 0.5% CREAM 61

fluoxetine hcl 19

fluphenazine decanoate 34

fluphenazine hcl 34

flurandrenolide 73

flurazepam hcl 101

flurbiprofen 5

flurbiprofen sodium 93

flutamide 26

fluticasone propionate 73

fluticasone propionate/salmeterol xinafoate 99

fluvastatin sodium 53

fluvoxamine maleate 19

foam/gauze

bandage/lidocaine/chlorhexidine/isopropyl

alcohol 91

FOLLISTIM AQ 75

fondaparinux sodium 46

FORADIL 96

FORTEO 90

FORTESTA 77

FOSAMAX PLUS D 90

fosinopril sodium 49

fosinopril sodium/hydrochlorothiazide 52

FOSRENOL 65

FRAGMIN 46

FREESTYLE FREEDOM LITE METER 44

FREESTYLE INSULINX GLUCOSE SYS 44

FREESTYLE INSULINX TEST STRIPS 44

FREESTYLE LITE METER 44

FREESTYLE LITE TEST STRIPS 44

FREESTYLE PREC NEO TEST STRIPS 44

FREESTYLE PRECISION NEO METER 44

FREESTYLE TEST STRIPS 44

frovatriptan succinate 24

FULPHILA 47

furosemide 53

FYAVOLV 79

Ggabapentin 17

GALAFOLD 69

galantamine hbr 18

GANIRELIX ACETATE 85

gatifloxacin 15

GATTEX 67

GAVILYTE-C 68

GAVILYTE-G 68

GAVILYTE-H AND BISACODYL 68

GAVILYTE-N 68

GELNIQUE 70

gemfibrozil 53

GENERESS FE 79

GENERLAC 68

GENGRAF 87

GENOTROPIN 75

GENTAK 11

gentamicin sulfate 11

GENVOYA 38

GIANVI 79

GIAZO 89

GILDAGIA 79

GILDESS 24 FE 79

GILENYA 59

GILOTRIF 29

glatiramer acetate 59

GLATOPA 59

GLEOSTINE 25

glimepiride 42

glipizide 42

glipizide/metformin hcl 42

GLUCAGEN 45

GLUCAGON EMERGENCY KIT 45

GLUMETZA 42

glyburide 42

glyburide,micronized 42

glyburide/metformin hcl 42

GLYCATE 66

glycopyrrolate 66

GLYDO 10

GLYXAMBI 42

GOCOVRI 33

GOLYTELY 68

Gonal-f 75

GONITRO 55

GRALISE 17

granisetron hcl 21

GRANIX 47

GRASTEK 88

griseofulvin ultramicrosize 22

griseofulvin, microsize 22

guanfacine hcl 48,56

GUANIDINE HCL 25

GYNOL II 71

HH.P. ACTHAR 73

HAEGARDA 86

halobetasol propionate 73

HALOG 73

haloperidol 34

haloperidol lactate 34

HARVONI 36

HEATHER 84

HEMMOREX-HC 73

HEPSERA 36

HETLIOZ 102

HEXALEN 25

HORIZANT 57

HUMALOG 45

HUMALOG JUNIOR KWIKPEN 45



HUMALOG MIX 50-50 45


HUMALOG MIX 75-25 45



HUMATROPE 75

Humira 87

HUMULIN 70-30 45

HUMULIN 70/30 KWIKPEN 45

HUMULIN N 45

HUMULIN N KWIKPEN 45

HUMULIN R 45

HUMULIN R U-500 45

HUMULIN R U-500 KWIKPEN 45

HYCAMTIN 28

hydralazine hcl 55

hydrochlorothiazide 53

hydrocodone bitart/chlorpheniramine

maleate/pseudoephedrine 99

hydrocodone bitartrate/acetaminophen 9

hydrocodone bitartrate/homatropine

methylbromide 99

hydrocodone polistirex/chlorpheniramine

polistirex 99

hydrocodone/ibuprofen 9

hydrocortisone 73,89

hydrocortisone acetate 73

hydrocortisone acetate/iodoquinol/aloe vera 61

hydrocortisone acetate/lidocaine hcl/aloe

vera 61

hydrocortisone acetate/pramoxine hcl 61

hydrocortisone butyrate 73

hydrocortisone butyrate/emollient base 73

hydrocortisone valerate 73

hydrocortisone/acetic acid 94

hydrocortisone/mineral oil/petrolatum,white 73

HYDROMET 100

hydromorphone hcl 7,9

hydroquinone microspheres 61

hydroxychloroquine sulfate 33

hydroxyurea 27

hydroxyzine hcl 96

hydroxyzine pamoate 96

HYOLEV MB 12

HYOPHEN 12

hyoscyamine sulfate 66

HYOSYNE 66

HYSINGLA ER 7

Iibandronate sodium 90

IBRANCE 29

IBU 5

ibuprofen 5

ibuprofen/oxycodone hcl 9

ICLUSIG 29

IDHIFA 27

ILEVRO 93

imatinib mesylate 29

IMBRUVICA 29

imipramine hcl 20

imipramine pamoate 20

imiquimod 61

IMPAVIDO 33

INCRELEX 75

INCRUSE ELLIPTA 96

indapamide 53

indomethacin 5

INFLAMMACIN 91

INGREZZA 57

INLYTA 29

INTELENCE 39

INTERMEZZO 101

INTRON A 37

INTROVALE 80

INVIRASE 40

INVOKAMET 42

INVOKAMET XR 42

INVOKANA 42

ipratropium bromide 96

ipratropium bromide/albuterol sulfate 100

irbesartan 49

irbesartan/hydrochlorothiazide 52

IRESSA 29

ISENTRESS 38

ISENTRESS HD 38

isometheptene

mucate/dichloralphenazone/acetaminophen 91

isoniazid 25

isosorbide dinitrate 55

isosorbide mononitrate 55

isoxsuprine hcl 52

isradipine 51

itraconazole 22

ivermectin 32

JJadenu 65

JAKAFI 29

JANTOVEN 46

JANUMET 42

JANUMET XR 42

JANUVIA 42

JARDIANCE 42

JENCYCLA 84

JENTADUETO 42

JENTADUETO XR 42

JEVANTIQUE LO 80

JINTELI 80

JOLESSA 80

JOLIVETTE 84

JUBLIA 22

JULEBER 80

JULUCA 39

JUNEL 80

JUNEL FE 80

JUNEL FE 24 80

JUXTAPID 54

JYNARQUE 102

KK EFFERVESCENT 64

K-SOL 64

K-TAB ER 64

KAITLIB FE 80

KALETRA 40

KALYDECO 97


KAPSPARGO SPRINKLE 102

KARIVA 80

KAZANO 43

KELNOR 1-35 80

KERYDIN 22

ketoconazole 22

KETODAN 22

ketoprofen 5

ketorolac tromethamine 6,93

KEVEYIS 53

KHEDEZLA 19

KIMIDESS 80

KINERET 87

KIONEX 65

KISQALI 30

KISQALI FEMARA CO-PACK 30

KITABIS PAK 97

KLOR-CON 64

KLOR-CON 10 64

KLOR-CON 8 64

KLOR-CON M10 64

KLOR-CON M15 64

KLOR-CON M20 64

KLOR-CON SPRINKLE 64

KLOR-CON-EF 64

KOMBIGLYZE XR 43

KURVELO 80

KUVAN 69

KYNAMRO 54

Llabetalol hcl 50

lactic acid 61

lactulose 68

LAMISIL 22

lamivudine 36,39

lamivudine/zidovudine 39

lamotrigine 17

lansoprazole 69

lansoprazole/amoxicillin

trihydrate/clarithromycin 67

lanthanum carbonate 65

LANTUS 45

LANTUS SOLOSTAR 45

LARIN 80

LARIN 24 FE 80

LARIN FE 80

LARISSIA 80

LASTACAFT 93

latanoprost 94

LATUDA 35

LAYOLIS FE 80

LAZANDA 9

LEENA 80

leflunomide 88

LENVIMA 30

LESSINA 80

LETAIRIS 98

letrozole 28

leucovorin calcium 27

LEUKERAN 25

LEUKINE 47

leuprolide acetate 85

levalbuterol hcl 97

levalbuterol tartrate 97

LEVEMIR 45

LEVEMIR FLEXTOUCH 46

levetiracetam 16

LEVITRA 71

LEVO-T 85

levobunolol hcl 93

levocarnitine 64

levocarnitine (with sugar) 64

levocetirizine dihydrochloride 96

levofloxacin 15

LEVONEST 80

levonorgestrel 84

levonorgestrel-ethinyl estradiol 80

levonorgestrel/ethinyl estradiol and ethinyl

estradiol 80

LEVORA-28 80

levorphanol tartrate 7

levothyroxine sodium 85

LEVOXYL 85

LEXIVA 40

LEXIXRYL 62

LIDO-K 10

LIDO-PRILO CAINE PACK 10

lidocaine 10

lidocaine hcl 10

lidocaine hcl/hydrocortisone acetate 62

lidocaine/prilocaine 10

LIDOPAC 10

LIDOPIN 10

LIDOPRIL 10

LIDOPRIL XR 10

LIDOTRANS 5 PAK 10

lindane 33

linezolid 12

LINZESS 68

liothyronine sodium 85

LIPROZONEPAK 10

lisinopril 49

lisinopril/hydrochlorothiazide 52

lithium carbonate 41

lithium citrate 41

LIVALO 54

LO LOESTRIN FE 80

LODOSYN 34

LOMEDIA 24 FE 80

lomustine 25

LONSURF 27

lopinavir/ritonavir 40

LOPREEZA 81

LOPROX 22

lorazepam 41

LORAZEPAM INTENSOL 41

LORCET 9

LORCET HD 9

LORCET PLUS 9

LORTAB 9

LORYNA 81

LORZONE 101


losartan potassium 49

losartan potassium/hydrochlorothiazide 52

LOTEMAX 93

LOTRONEX 68

lovastatin 54

LOW-OGESTREL 81

loxapine succinate 34

luliconazole 22

LUMIGAN 94

LUTERA 81

LYNPARZA 30

LYRICA 58

LYRICA CR 58

LYSODREN 27

LYZA 84

Mmalathion 33

maprotiline hcl 20

MARGESIC 57

MARLISSA 81

MARPLAN 19

MARTEN-TAB 57

MATULANE 25

MATZIM LA 51

MAVYRET 36

MAXIDEX 93

MD-GASTROVIEW 91

MECLOFENAMATE SODIUM 6

MEDOLOR PAK 10

medroxyprogesterone acetate 84

mefenamic acid 6

mefloquine hcl 33

megestrol acetate 84

MEKINIST 30

MEKTOVI 30

meloxicam 6

MELOXICAM 7.5 MG/5 ML ORAL SUSP 6

melphalan 25

memantine hcl 18

MENEST 81

75

9

41

33

27

89

89

89

32

25

56

97

101

101

43

43

7

7

7

93

12

12

12

91

86

77

101

87

87

62

66

53

48

52

91

56

73

MENOPUR

meperidine hcl

meprobamate

MEPRON

mercaptopurine

mesalamine

MESALAMINE 800 MG TABLET DR

mesalamine with cleansing wipes

MESNEX

MESTINON

METADATE ER

metaproterenol sulfate

METAXALL

metaxalone

metformin er 500mg & 1000mg tab (generic

version of glumetza and fortamet)

metformin hcl

methadone hcl

METHADONE INTENSOL

METHADOSE

methazolamide

methenamine hippurate

methenamine mandelate

methenamine/sod

phosph,monobasic/methylene

blue/hyoscyamine

METHERGINE

methimazole

METHITEST

methocarbamol

methotrexate sodium

methotrexate sodium/pf

methoxsalen

methscopolamine bromide

methyclothiazide

methyldopa

methyldopa/hydrochlorothiazide

methylergonovine maleate

methylphenidate hcl

methylprednisolone

methyltestosterone 77

metipranolol 93

metoclopramide hcl 21

metolazone 53

metoprolol succinate 50

metoprolol tartrate 50

metoprolol tartrate/hydrochlorothiazide 52

metronidazole 12,62

mexiletine hcl 49

MIBELAS 24 FE 81

miconazole nitrate 22

MICROGESTIN 81

MICROGESTIN 24 FE 81

MICROGESTIN FE 81

midazolam hcl 41

midodrine hcl 48

miglitol 43

miglustat 69

MIGRANAL 24

MIMVEY 81

MIMVEY LO 81

MINITRAN 55

minocycline hcl 16

minoxidil 55

mirtazapine 19

misoprostol 68

modafinil 102

MODERIBA 37

moexipril hcl 49

moexipril hcl/hydrochlorothiazide 52

molindone hcl 34

mometasone furoate 73,95

MONDOXYNE NL 16

MONO-LINYAH 81

MONONESSA 81

montelukast sodium 96

MONUROL 12

MORGIDOX 16

MORPHABOND ER 7

morphine sulfate 7,9

morphine sulfate (15 mg tablet, 30 mg tablet) 9

MOTOFEN 67


MOVANTIK 67

MOVIPREP 68

MOXATAG 14

MOXEZA 15

moxifloxacin hcl 15

MOZOBIL 47

MULPLETA 47

MULTAQ 49

mupirocin 12

mupirocin calcium 12

MY CHOICE 81

MY WAY 81

MYALEPT 67

MYCOBUTIN 25

mycophenolate mofetil 87

mycophenolate sodium 87

MYLERAN 25

MYORISAN 62

MYRBETRIQ 70

MYTESI 67

MYZILRA 81

Nnabumetone 6

nadolol 50

nadolol/bendroflumethiazide 52

naftifine hcl 22

NAFTIN 22,23

naloxone hcl 11

naltrexone hcl 11

NAMENDA 18

NAMENDA XR 18

NAMZARIC 18

NAPHAZOLINE 0.1% 92

naproxen 6

NAPROXEN 125 MG/5 ML ORAL SUSP 6

naproxen sodium 6

naratriptan hcl 24

NARCAN 11

NASONEX 95

NATACYN 23

NATAZIA 81

nateglinide 43

NATESTO 77

NATPARA 90

NATURE-THROID 85

NEBUPENT 33

NECON 81

nefazodone hcl 20

NEO-POLYCIN 92

NEO-POLYCIN HC 92

neomycin sulfate 12

neomycin sulfate/bacitracin zinc/polymyxin

b/hydrocortisone 92

neomycin sulfate/bacitracin/polymyxin b 92

neomycin sulfate/polymyxin b sulfate/gramicidin

d 92

neomycin sulfate/polymyxin b

sulfate/hydrocortisone 92,94

neomycin/polymyxin b

sulfate/dexamethasone 92

NERLYNX 30

NESINA 43

NEUAC 62

NEUPOGEN 47

NEUPRO 34

NEURCAINE 10

NEVANAC 93

nevirapine 39

NEVIRAPINE 50 MG/5 ML ORAL SUSP 39

NEW DAY 81

NEXAVAR 30

NEXIUM 69

NEXT CHOICE ONE DOSE 84

niacin 54

nicardipine hcl 51

NICOTROL 11

NICOTROL NS 11

NIFEDICAL XL 51

nifedipine 51

NIKKI 81

NILANDRON 26

nilutamide 26

nimodipine 51

NINLARO 27

nisoldipine 51

NITRO-TIME 55

nitrofurantoin 12

nitrofurantoin macrocrystal 12

nitrofurantoin monohydrate/macrocrystals 13

nitroglycerin 55

NITROLINGUAL 55

NITROMIST 55

NITROSTAT 55

NITYR 69

NIVESTYM 47

nizatidine 67

NODOLOR 91

NOLIX 73

NORA-BE 84

NORDITROPIN FLEXPRO 75

norethindrone 84

norethindrone acetate 84

norethindrone acetate-ethinyl estradiol 81

norethindrone acetate-ethinyl estradiol/ferrous

fumarate 81

norethindrone-ethinyl estradiol/ferrous

fumarate 81

norgestimate-ethinyl estradiol 81

NORLYROC 84

NORTHERA 48

NORTREL 81

nortriptyline hcl 20

NORVIR 40

NOVAREL 76

NOVOLIN 70-30 46

NOVOLIN N 46

NOVOLIN R 46

NOVOLOG 46

NOVOLOG FLEXPEN 46

NOVOLOG MIX 70-30 46

NOVOLOG MIX 70-30 FLEXPEN 46

NOXAFIL 23


NP THYROID 85

NUCYNTA 9

NUCYNTA ER 7

NUDICLO 62,91

NUDROXIPAK 102



NUDROXIPAK E-400 102

NUDROXIPAK I-800 102

NUDROXIPAK N-500 102

NUEDEXTA 57

NULEV 66

NUPLAZID 35,103

NUTRESTORE 64

NUTRIARX 73

NUTROPIN AQ 76

NYAMYC 23

NYATA 23

nystatin 23

nystatin/triamcinolone acetonide 23

NYSTOP 23

OOCALIVA 69

OCELLA 81

octreotide acetate 85

ODACTRA 91

ODEFSEY 39

ODOMZO 30

OFEV 99

ofloxacin 15

OGESTREL 82

olanzapine 35

OLEPTRO ER 20

olmesartan medoxomil 49

olmesartan medoxomil/amlodipine

besylate/hydrochlorothiazide 52

olmesartan medoxomil/hydrochlorothiazide 52

olopatadine hcl 93,96

OLUMIANT 87

OLYSIO 36

OMECLAMOX-PAK 67

omega-3 acid ethyl esters 54

omeprazole 69

OMNARIS 95

OMNITROPE 76

ondansetron 21

ondansetron hcl 21

ONETOUCH ULTRA TEST STRIP 44

ONETOUCH ULTRA2 GLUCOSE SYST 44

ONETOUCH ULTRAMINI METER 44

ONETOUCH VERIO FLEX SYSTEM KIT 44

ONETOUCH VERIO IQ SYSTEM KIT 44

ONETOUCH VERIO METER SYSTEM 44

ONETOUCH VERIO SYNC SYST KIT 44

ONETOUCH VERIO TEST STRIP 44

ONEXTON 62

ONFI 17

ONGLYZA 43

OPCICON ONE-STEP 84

opium tincture 67

opium/belladonna alkaloids 9

OPSUMIT 98

OPTION 2 84

ORACEA 16

Oralair 88

ORALONE 59

ORAP 34

ORAVIG 23

ORENCIA 87

ORENITRAM ER 98

ORFADIN 69

ORILISSA 103

ORKAMBI 97

orphenadrine citrate 101

ORSYTHIA 82

ORTHO TRI-CYCLEN LO 82

OSCIMIN 66

OSCIMIN SL 66

OSCIMIN SR 66

oseltamivir phosphate 40

OSENI 43

OSMOLEX ER 33

OTEZLA 88

OTREXUP 87

OVIDREL 76

oxandrolone 76

oxaprozin 6

oxazepam 41

oxcarbazepine 18

oxiconazole nitrate 23

OXISTAT 23

OXTELLAR XR 18

oxybutynin chloride 70

oxycodone hcl 9

OXYCODONE HCL ER 7

oxycodone hcl/acetaminophen 9

oxycodone hcl/aspirin 9

OXYCONTIN 7

oxymorphone hcl 7,9

OXYTROL 70

OZEMPIC 43

PPACERONE 50

PAINGO KFT 11

paliperidone 35

PALYNZIQ 69

PANCREAZE 70

PANCRELIPASE 5,000 70

PANRETIN 32

pantoprazole sodium 69

paregoric 67

paricalcitol 90

PAROEX 59

paromomycin sulfate 12

paroxetine hcl 20

paroxetine mesylate 20

PASER 25

PEDIADERM HC 73

peg 3350/sod sulf/sod bicarb/sod

chloride/potassium chloride 68

PEG-PREP 68


PEGANONE 18

PEGASYS 37

PEGASYS PROCLICK 37

PEGINTRON 38

PEGINTRON REDIPEN 38

penicillin v potassium 14

PENNSAID 6

PENTASA 89

pentazocine hcl/naloxone hcl 9

pentoxifylline 52

PERFOROMIST 97

perindopril erbumine 49

PERIOGARD 59

permethrin 33

perphenazine 21

perphenazine/amitriptyline hcl 19

PHENADOZ 21

phenazopyridine hcl 71

phendimetrazine tartrate 57

phenelzine sulfate 19

PHENERGAN 21

phenobarbital 17

phenoxybenzamine hcl 48

phentermine hcl 57

phenylephrine hcl 92

phenylephrine hcl/promethazine hcl 100

phenytoin 18

phenytoin sodium extended 18

PHILITH 82

PHOSLO 65

PHOSLYRA 66

PHOSPHASAL 13

PHOSPHOLINE IODIDE 93

phytonadione (vit k1) 48

PICATO 62

PIFELTRO 39

pilocarpine hcl 59,94

pimozide 34

PIMTREA 82

pindolol 50

pioglitazone hcl 43

pioglitazone hcl/glimepiride 43

pioglitazone hcl/metformin hcl 43

PIRMELLA 82

piroxicam 6

PLAN B ONE-STEP 84

PLEGRIDY 59

PLEGRIDY PEN 59

podofilox 62

POLYCIN 92

polyethylene glycol 3350 68

polymyxin b sulfate/trimethoprim 92

POMALYST 26

PORTIA 82

potassium bicarbonate/citric acid 65

potassium chloride 65

potassium chloride/potassium bicarbonate/citric

acid 65

potassium citrate 65

potassium citrate/citric acid 65

potassium iodide/iodine 91

PR BENZOYL PEROXIDE 62

PRADAXA 46

PRALUENT 54

PRAMCORT 62

pramipexole di-hcl 34

PRANDIN 43

prasugrel hcl 48

pravastatin sodium 54

praziquantel 32

prazosin hcl 49

PRECISION XTRA MONITOR 44

PRECISION XTRA TEST STRIPS 44

prednicarbate 73

prednisolone 73

prednisolone acetate 93

prednisolone sod phosphate 74,93

prednisone 74

PREDNISONE INTENSOL 74

PREGNYL 76

PREMARIN 82

PREMPHASE 82

PREMPRO 82

PREPOPIK 68

PREVALITE 54

PREVIDENT 65

PREVIDOLRX PLUS ANALGESIC PAK 91

PREVIFEM 82

PREVYMIS 36

PREZISTA 40

PRIFTIN 25

PRILOLID 11

primidone 17

PROAIR HFA 97

PROAIR RESPICLICK 97

probenecid 23

probenecid/colchicine 23

prochlorperazine 21

prochlorperazine maleate 21

PROCRIT 47

PROCTO-MED HC 74

PROCTO-PAK 74

PROCTOSOL-HC 74

PROCTOZONE-HC 74

PROCYSBI 70

PROFENO 6

progesterone 84

progesterone, micronized 84

PROGLYCEM 45

PROMACTA 47

promethazine hcl 21,96

promethazine hcl/codeine 100

promethazine hcl/dextromethorphan hbr 100

promethazine/phenylephrine hcl/codeine 100

PROMETHEGAN 21

propafenone hcl 50

propantheline bromide 66

proparacaine hcl 92

propranolol hcl 50

propranolol hcl/hydrochlorothiazide 52

propylthiouracil 86

PROTOPIC 62

protriptyline hcl 20


PROVENTIL HFA 97

PULMICORT 95

PULMICORT FLEXHALER 95

PURIXAN 27

pyrazinamide 25

pyridostigmine bromide 25

QQBRELIS 49

QNASL 95

QNASL CHILDREN 95

QSYMIA 57

QTERN 43

QUASENSE 82

quazepam 101

QUDEXY XR 17

quetiapine fumarate 35

QUILLICHEW ER 56

QUILLIVANT XR 56

quinapril hcl 49

quinapril hcl/hydrochlorothiazide 52

quinidine gluconate 50

quinidine sulfate 50

quinine sulfate 33

QVAR 95

QVAR REDIHALER 95

Rrabeprazole sodium 69

RAGWITEK 89

RAJANI 82

raloxifene hcl 84

ramipril 49

RANEXA 52

ranitidine hcl 67

RAPAFLO 71

RAPAMUNE 87

rasagiline mesylate 34

RASUVO 87

RAVICTI 70

RAYOS 74

REA LO 39 62

REA LO 40 62

REBETOL 38

Rebif 59

RECLIPSEN 82

RECTIV 62

REGRANEX 62

RELADOR PAK 11

RELENZA 40

RELEXXII 57

RENAGEL 66

repaglinide 43

REPAGLINIDE/METFORMIN 43

REPATHA 54

REPREXAIN 9

RESCRIPTOR 39

RESERPINE 52

RESTASIS 92

RESTASIS MULTIDOSE 92

REVATIO 98

REVLIMID 26

REXULTI 35

REYATAZ 40

RIBASPHERE 38

RIBASPHERE RIBAPAK 38

RIBATAB 38

ribavirin 38,100

rifabutin 25

rifampin 25

RIFATER 25

riluzole 57

rimantadine hcl 40

risedronate sodium 90

risperidone 35

ritonavir 40

rivastigmine 18

rivastigmine tartrate 18

rizatriptan benzoate 24

ropinirole hcl 34

ROSADAN 62

rosuvastatin calcium 54

ROWASA 89

ROWEEPRA 16

ROWEEPRA XR 16

ROZEREM 102

RUBRACA 27

RUCONEST 86

RYDAPT 27

RYTARY 34

SSABRIL 17

SAIZEN 76

salsalate 6

SAMSCA 65

SANADERMRX 74

SANCUSO 21

SANTYL 62

SAPHRIS 35

SAVAYSA 46

SAVELLA 58

SAXENDA 91

SCALACORT 74

scopolamine 21

SEB-PREV 62

SEGLUROMET 43

selegiline hcl 34

selenium sulfide 62

SELZENTRY 39,40

SENSIPAR 90

SEREVENT DISKUS 97

SEROPHENE 85

SEROSTIM 76

sertraline hcl 20

SETLAKIN 82

sevelamer carbonate 66

SF 65

SF 5000 PLUS 65

SHAROBEL 84

SIGNIFOR 85

SILALITE PAK 74

SILAZONE-II 74


sildenafil citrate 71,98

SILENOR 102

silver sulfadiazine 15

silver/bandage/foam/gauze/lidocaine/chlorhexid

in/isopropanol 91

SIMBRINZA 94

simvastatin 54

sirolimus 88

SIRTURO 25

SITAVIG 40

SIVEXTRO 13

sodium chloride for inhalation 100

sodium chloride/sodium bicarbonate/potassium

chloride/peg 68

sodium phenylbutyrate 70

sodium polystyrene sulfonate 65

SOLARAZE 62

SOLIQUA 100-33 46

SOLODYN 16

SOLTAMOX 27

SOLUPAK 11

SOMA 101

SOMAVERT 85

SORIATANE 62

SORILUX 63

SORINE 50

sotalol hcl 50

SOTYLIZE 50

SOVALDI 37

spinosad 63

SPIRIVA 96

SPIRIVA RESPIMAT 96

spironolactone 53

spironolactone/hydrochlorothiazide 52

SPRINTEC 82

SPRITAM 16

SPRIX 6

SPRYCEL 30

SPS 65

SRONYX 82

SSD 15

SSKI 86

stavudine 39

STAXYN 71

STEGLATRO 43

STEGLUJAN 43

STELARA 63

STENDRA 71

STIOLTO RESPIMAT 100

STIVARGA 31

STRENSIQ 70

STRIANT 77

STRIBILD 38

STRIVERDI RESPIMAT 97

STROMECTOL 32

SUBOXONE 11

SUBSYS 9

sucralfate 68

sulfacetamide sodium 15,63

sulfacetamide sodium/prednisolone sodium

phosphate 92

sulfacetamide sodium/sulfur 63

sulfadiazine 15

sulfamethoxazole/trimethoprim 15

SULFAMYLON 13

sulfasalazine 89

SULFATRIM 15

sulindac 6

sumatriptan 24

sumatriptan succinate 24

sumatriptan succinate/naproxen sodium 24

SUMAVEL DOSEPRO 24

SUPRENZA ODT 57

SUPREP 68

SUSTIVA 39

SUTENT 31

SYEDA 82

SYLATRON 28

SYMAX 67

SYMAX-SL 67

SYMAX-SR 67

SYMBICORT 100

SYMDEKO 97

SYMFI 103

SYMFI LO 39

SYMLINPEN 120 43

SYMLINPEN 60 43

SYMTUZA 103

SYNALAR TS 74

SYNDROS 21

SYNJARDY 43

SYNJARDY XR 44

SYNTHROID 85

SYPRINE 65

TTABLOID 27

TACLONEX 63

tacrolimus 63,88

tadalafil 98

TAFINLAR 31

TAGRISSO 31

TAKE ACTION 84

TAKHZYRO 86

tamoxifen citrate 27

tamsulosin hcl 71

TANZEUM 44

TAPERDEX 74

TARCEVA 31

TARGRETIN 32

TARINA FE 82

TASIGNA 31,103

TASMAR 33

TAVALISSE 47

tazarotene 63

TAZORAC 63

TAZTIA XT 51

TECFIDERA 59

TECHNIVIE 37

TEKTURNA 52

telmisartan 49

telmisartan/hydrochlorothiazide 52

temazepam 101


TEMODAR 26

temozolomide 26

tenofovir disoproxil fumarate 39

terazosin hcl 49

terbinafine hcl 23

terbutaline sulfate 97

terconazole 23

TESTIM 77

testosterone 77

TESTOSTERONE (10 mg (2%) gel md pmp,

12.5/1.25g gel md pmp, 50 mg (1%) gel

(gram) 77

TESTOSTERONE (50 mg (1%) gel packet).

SOME MANUFACTURERS ARE T3 AND

OTHERS T1 77

testosterone cypionate 77

testosterone enanthate 77

TESTRED 77

tetrabenazine 58

tetracycline hcl 16

THALOMID 26

THEOCHRON 98

theophylline anhydrous 98

THERMAZENE 15

thioridazine hcl 34

thiothixene 35

THYROLAR-1 85

THYROLAR-1/2 85

THYROLAR-1/4 85

THYROLAR-2 85

THYROLAR-3 85

tiagabine hcl 17

TIBSOVO 103

TICALAST 100

TICANASE 95

TICASPRAY 95

ticlopidine hcl 48

TIKOSYN 50

TILIA FE 82

timolol maleate 50,94

tinidazole 13

TIROSINT 85

TIVICAY 38

TIVORBEX 6

tizanidine hcl 36

TL G-FOL OS 65

TOBI 100

TOBI PODHALER 97

TOBRADEX 92

tobramycin 12

tobramycin in 0.225 % sodium chloride 100

tobramycin/dexamethasone 92

tobramycin/nebulizer 97

TODAY CONTRACEPTIVE SPONGE 71

TOLAK 63

tolazamide 44

tolbutamide 44

tolcapone 33

tolmetin sodium 6

tolterodine tartrate 70

topiramate 17

torsemide 53

TOUJEO MAX SOLOSTAR 103

TOUJEO SOLOSTAR 46

TOVIAZ 70

TRACLEER 98

TRADJENTA 44

TRAMADOL ER CAPS 7

tramadol hcl 7,9

tramadol hcl/acetaminophen 9

trandolapril 49

trandolapril/verapamil hcl 52

tranexamic acid 48

TRANSDERM-SCOP 21

tranylcypromine sulfate 19

TRAVATAN Z 94

trazodone hcl 20

TRECATOR 25

TREMFYA 63



TRETIN-X 63

tretinoin 32,63

tretinoin microspheres 63

tretinoin/emollient base 63

TREXALL 88

TREXIMET 24

TRI-CHLOR 63

TRI-ESTARYLLA 82

TRI-LEGEST FE 82

TRI-LINYAH 82

TRI-LO-ESTARYLLA 82

TRI-LO-MARZIA 82

TRI-LO-SPRINTEC 82

TRI-PREVIFEM 82

TRI-SILA 74

TRI-SPRINTEC 82

triamcinolone acetonide 59,74,95

triamterene/hydrochlorothiazide 52

TRIANEX 74

triazolam 101

TRIDERM 74

trientine hcl 65

trifluoperazine hcl 35

trifluridine 40

trihexyphenidyl hcl 33

TRILIPIX 53

TRILYTE WITH FLAVOR PACKETS 68

trimethobenzamide hcl 21

trimethoprim 13

trimipramine maleate 20

TRINESSA 83

TRINESSA LO 83

TRINTELLIX 20

TRIUMEQ 40

TRIVORA-28 83

TRIXYLITRAL 90

TRIZIVIR 39

TROKENDI XR 18

tropicamide 92

trospium chloride 70

TRULICITY 44

TRUVADA 39


TUDORZA PRESSAIR 96

TUSSIGON 100

TYBOST 40

TYDEMY 83

TYKERB 31

TYMLOS 90

Tyvaso 99

TYZEKA 36

TYZINE 100

UUCERIS 89

ULESFIA 63

ULORIC 23

ULTRAVATE X 74

UNITHROID 85

UPTRAVI 99

UR N-C 13

URAMIT MB 13

URETRON D-S 13

URIMAR-T 13

URIN D.S. 13

URO-458 13

URO-MP 13

UROCIT-K 65

UROGESIC-BLUE 13

UROLET MB 13

UROPHEN MB 13

ursodiol 67

URYL 13

UTIBRON NEOHALER 100

UTIRA-C 13

VVAGIFEM 83

valacyclovir hcl 40

VALCHLOR 26

VALCYTE 36

valganciclovir hcl 36

valproic acid 17

valproic acid (as sodium salt) (valproate

sodium) 17

valsartan 49

valsartan/hydrochlorothiazide 52

vancomycin hcl 13

VANDAZOLE 13

VARUBI 21

VCF 71

VELIVET 83

VELPHORO 66

VELTASSA 66

VELTIN 63

VENCLEXTA 31

VENLAFAXINE ER TAB (TIER DEPENDENT

ON MANUFACTURER. UCB T3, OTHERS

T1) 20

venlafaxine hcl 20

VENTOLIN HFA 97

VERAMYST 95

verapamil hcl 51

VERDROCET 9

VEREGEN 63

VERZENIO 31

VESICARE 70

VESTURA 83

VEXOL 93

VICODIN 9

VICODIN ES 9

VICODIN HP 10

VICTOZA 2-PAK 44

VICTOZA 3-PAK 44

VIDEX 39

VIEKIRA PAK 37

VIEKIRA XR 37

VIENVA 83

vigabatrin 17

VIGAMOX 15

VIIBRYD 20

VIMOVO 6

VIMPAT 18

VIORELE 83

VIRACEPT 40

VIRAMUNE 39

VIRAMUNE XR 39

VIREAD 39

VIVELLE-DOT 83

VIVLODEX 6

VOGELXO 77

voriconazole 23

VOSEVI 37

VOTRIENT 31

VRAYLAR 35

VYFEMLA 83

VYTORIN 54

VYVANSE 56

Wwarfarin sodium 46

WELCHOL 54

WERA 83

WESTHROID 85

WHYTEDERM TRILASIL PAK 74

WP THYROID 85

WYMZYA FE 83

XXALKORI 31

XARELTO 46

XARTEMIS XR 10

XATMEP 88

XELITRAL 63

XELJANZ 88

XELJANZ XR 88

XENAFLAMM 91

XENICAL 67

XERESE 40

XERMELO 91

XHANCE 95

XIGDUO XR 44

XIIDRA 92

XIMINO 103

XRYLIX 64


XTAMPZA ER 8

XTANDI 26

XULANE 83

XULTOPHY 100-3.6 46

XURIDEN 66

XYLON 10 10

XYREM 102

YYONSA 26

YUVAFEM 83

Zzafirlukast 96

zaleplon 101

ZARAH 83

ZARXIO 47

ZAVESCA 70

ZEBUTAL 58

ZEJULA 31

ZELAPAR 34

ZELBORAF 32

ZENATANE 64

ZENCHENT 83

ZENCHENT FE 83

ZENPEP 70

ZENZEDI 56

ZEPATIER 37

ZETIA 54

ZETONNA 95

ZEYOCAINE 64

ZIAGEN 39

ZIANA 64

zidovudine 39

zileuton 96

ZINBRYTA 59

ZIOPTAN 94

ziprasidone hcl 35

ZIPSOR 6

ZIRGAN 36

ZODEX 74

ZOHYDRO ER 8

ZOLINZA 28

zolmitriptan 24

zolpidem tartrate 101

ZOLPIMIST 101

ZOMACTON 76

ZOMIG 24

zonisamide 16

ZONTIVITY 46

ZORBTIVE 76

ZORTRESS 88

ZORVOLEX 6

ZOVIA 1-35E 83

ZOVIA 1-50E 83

ZUBSOLV 11

ZURAMPIC 23

ZYBAN 11

ZYDELIG 32

ZYFLO CR 96

ZYKADIA 32

ZYMAXID 15

ZYTIGA 26

ZYVOX 13


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