2021 Comprehensive Formulary

Updated 10/01/20

Aetna Medicare(List of Covered Drugs)

Open 2 Plus 4 Tier

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

This formulary was updated on 10/01/2020. For more recent information or other questions, please contact Aetna Medicare Member Services at 1-888-267-2637

or for TTY users: 711, 8 a.m. to 9 p.m., E.S.T., Monday through Friday, or visit AetnaRetireePlans.com choose “Manage your prescription drugs”.

Formulary ID Number: 21115 Version 8

2021 Comprehensive

Formulary

http://AetnaRetireePlans.com

2 Updated 10/01/20

Table of contents

Mail-order Pharmacy 3

What is the Aetna Medicare Comprehensive Formulary? 4

Can the Formulary (drug list) change? 4

How do I use the Formulary? 5

What are generic drugs? 5

Are there any restrictions on my coverage? 5

What if my drug is not on the Formulary? 6

How do I request an exception to the Aetna Medicare Formulary? 6

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? 7

For more information 7

Aetna Medicare Formulary 8

Drug tier copay levels 9

Formulary key 10

Drug list 10

Index of Drugs 154

Enhanced drug list 191

3Updated 10/01/20

Aetna Medicare is a HMO, PPO plan with a Medicare contract. Enrollment in our plans depends on contract renewal. Members who get “Extra Help” are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays.

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

Mail-order PharmacyFor mail order, you can get prescription drugs shipped to your home through the network mail-order delivery program. Typically, mail-order drugs arrive within 10 days. You can call 1-888-267-2637 (TTY: 711) 8 a.m. to 9 p.m., E.S.T., Monday through Friday, if you do not receive your mail-order drugs within this timeframe. Members may have the option to sign up for automated mail-order delivery.

ATTENTION: If you speak Spanish or Chinese, language assistance services, free of charge, are available to you. Call the number on your ID card.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que figura en su tarjeta de identificación.

注意：如果您使用中文，您可以免費獲得語言援

助服務。請撥打您的會員身分卡上的電話號碼。

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

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Aetna Medicare. When it refers to “plan” or “our plan,” it means Aetna.

This document includes a list of the drugs (formulary) for our plan which is current as of 10/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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

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

Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• New generic drugs. When adding a new generic drug, we may move the brand drug to a different cost sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

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

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

• Other changes. We may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost sharing tier or both, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

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

Changes that will not affect you if you are currently taking the drug.

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

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The enclosed formulary is current as of 10/01/2020. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages.

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

Medical ConditionThe formulary begins on page 10. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular”. If you know what your drug is used for, look for the category name in the list that begins on page 10. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 154. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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

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

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

• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for rosuvastatin. This may be in addition to a standard one-month or three-month supply.

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

6 Updated 10/01/20

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 10. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Aetna Medicare formulary?” on page 6 for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

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

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

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

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

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

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

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.

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Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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

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

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 31-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you experience a change in your setting of care (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary coverage (up to a 30-day supply) for the applicable drug(s).

For more informationFor more detailed information about your plan's prescription drug coverage, please review your Evidence of Coverage and other plan materials.

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

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

http://www.medicare.gov

8 Updated 10/01/20

Aetna Medicare Formulary

The comprehensive formulary that begins on page 10 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 154.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine).

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

QL Quantity Limits

PA Prior Authorization

ST Step Therapy

LA Limited Access

MO Mail-order Delivery

B/D Part B vs. D Prior Authorization

QL: Quantity Limits. For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for rosuvastatin.

PA: Prior Authorization. Our plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don't get approval, we may not cover the drug.

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

LA: Limited Access. These prescriptions may be available only at certain pharmacies. For more Information, consult your Pharmacy Directory or call Aetna Member Services at 1-888-267-2637 (TTY: 711), 8 a.m. to 9 p.m., E.S.T., Monday through Friday.

MO: Mail Order. For certain kinds of drugs, you can use CVS Caremark® Mail Service Pharmacy. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan’s mail-order service are marked as “MO” in our Drug List. For more information, consult your Pharmacy Directory or call Aetna Member Services at 1-888-267-2637 (TTY: 711), 8 a.m. to 9 p.m., E.S.T., Monday through Friday.

B/D: Part B versus Part D. This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

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Drug tier copay levels

This 2021 comprehensive formulary is a listing of brand-name and generic drugs. Aetna Medicare’s 2021 formulary covers most drugs identified by Medicare as Part D drugs, and your copay may differ depending upon the tier at which the drug resides.

The copay tiers for covered prescription medications are listed below. Copay amounts and coinsurance percentages for each tier vary by Aetna Medicare plan. Look in the 2021 Prescription Drug Benefits Chart (The Prescription Drug Schedule of Cost Sharing) that was included in your Evidence of Coverage (EOC) packet.

Copay tier Type of drug

Tier 1 Generic Drugs

Tier 2 Preferred Brand Drugs

Tier 3 Non-Preferred Brand Drugs

Tier 4 Specialty Drugs

You may have drug coverage in the Coverage Gap StageThere are four “drug payment stages” of a Medicare Prescription Drug Plan. How much you pay for a Part D drug depends on which drug payment stage you are in. Your plan may include supplemental coverage for some drugs during the Coverage Gap stage of the plan. Look in the 2021 Prescription Drug Benefits Chart (Prescription Drug Schedule of Cost Sharing) that was included in your EOC packet. The Prescription Drug Benefits Chart will tell you if your plan provides coverage in the gap, and how much you will pay for covered drugs. If you need assistance finding this information, call the number on the back of your ID card.

10 Updated 10/01/20

Key*Drug name

UPPERCASE = Brand-name prescription drugs

Lowercase italics = Generic medications

Drug tier

1, 2, 3, 4 = Copay tier level

Requirements/Limits

QL = Quantity Limit PA = Prior Authorization ST = Step Therapy LA = Limited Access MO = Mail-order Delivery B/D = Part B vs. Part D

Drug name Drug tier Requirements/LimitsANALGESICS

GOUT allopurinol sodium inj 1allopurinol tabs 1 MOALOPRIM 3COLCHICINE CAPS 2 QL (60 EA per 30 days) MOcolchicine tabs 1 QL (120 EA per 30 days) MOCOLCRYS 3 QL (120 EA per 30 days) MOfebuxostat 1 ST MOGLOPERBA 3 QL (300 ML per 30 days) PAKRYSTEXXA 4 QL (2 ML per 28 days) PAMITIGARE 2 QL (60 EA per 30 days) MOprobenecid 1 MOprobenecid/colchicine 1 MOULORIC 3 ST MOZYLOPRIM 3 MO

MISCELLANEOUS ALLZITAL 3 QL (180 EA per 30 days) PA MObupap 1 QL (180 EA per 30 days) PAbutalbital/acetaminophen/caffeine 1 QL (180 EA per 30 days) PA MObutalbital/acetaminophen caps 1 QL (180 EA per 30 days) PA MObutalbital/acetaminophen tabs 325mg; 25mg

1 QL (180 EA per 30 days) PA

butalbital/acetaminophen tabs 300mg; 50mg, 325mg; 50mg

1 QL (180 EA per 30 days) PA MO

BUTALBITAL/ASPIRIN/CAFFEINE TABS


butalbital/aspirin/caffeine caps 1 QL (180 EA per 30 days) PA MO

* You can find information on what the symbols and abbreviations on this table mean by going to page 8.

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Drug name Drug tier Requirements/Limitsclonidine hcl inj 100mcg/ml, 500mcg/ml

1

DURACLON 3ESGIC TABS 3 QL (180 EA per 30 days) PA MOesgic caps 1 QL (180 EA per 30 days) PAFIORICET 3 QL (180 EA per 30 days) PA MOFIORINAL 3 QL (180 EA per 30 days) PA MOPRIALT INJ 100MCG 3 B/D MOtencon 1 QL (180 EA per 30 days) PAvanatol lq 4 QL (2700 ML per 30 days) PA MOvanatol s 1 QL (2700 ML per 30 days) PAvtol lq 1 QL (2700 ML per 30 days) PAzebutal 1 QL (180 EA per 30 days) PA MO

NSAIDS ARTHROTEC 50 3 MOARTHROTEC 75 3 MOCALDOLOR 3CELEBREX CAPS 400MG 3 QL (30 EA per 30 days) ST MOCELEBREX CAPS 100MG, 200MG, 50MG

3 QL (60 EA per 30 days) ST MO

celecoxib caps 400mg 1 QL (30 EA per 30 days) MOcelecoxib caps 100mg, 200mg, 50mg 1 QL (60 EA per 30 days) MODAYPRO 3 MOdiclofenac potassium 1 QL (120 EA per 30 days) MOdiclofenac sodium dr 1 MOdiclofenac sodium er 1 MOdiclofenac sodium/misoprostol 1 MOdiflunisal 1 MODUEXIS 4 MOEC-NAPROXEN 3 ST MOetodolac 1 MOetodolac er 1 MOFELDENE 3 MOFENOPROFEN CALCIUM CAPS 400MG

3 MO

fenoprofen calcium tabs 1 MOflurbiprofen tabs 100mg 1 MO

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Drug name Drug tier Requirements/Limitsibu tabs 600mg, 800mg 1ibuprofen 1 MOINDOCIN 3 PA MOindomethacin caps 25mg, 50mg 1 PA MOindomethacin er 1 PA MOketoprofen er 1 MOketoprofen caps 50mg 1ketoprofen caps 25mg 1 MOketorolac tromethamine inj 15mg/ml, 30mg/ml, 60mg/2ml

1 QL (20 ML per 30 days) PA MO

ketorolac tromethamine tabs 10mg 1 QL (20 EA per 30 days) PA MOLODINE 3 ST MOmeclofenamate sodium 1 MOmefenamic acid 1 MOmeloxicam 1 MOMOBIC 3 MOnabumetone 1 MONALFON 3 ST MONAPRELAN 3 ST MOnaproxen 1 MOnaproxen dr 1 MONAPROXEN SODIUM CR TABS 375MG

3 MO

naproxen sodium er tabs 500mg 1 MOnaproxen sodium tabs 275mg, 550mg

1 MO

naproxen/esomeprazole magnesium 4 MOoxaprozin 1 MOpiroxicam 1 MOQMIIZ ODT 3 QL (30 EA per 30 days) ST MORELAFEN DS 3 QL (60 EA per 30 days) ST MOSALSALATE TABS 750MG 3 QL (120 EA per 30 days) MOSALSALATE TABS 500MG 3 QL (180 EA per 30 days) MOSPRIX 3 QL (5 EA per 30 days) PAsulindac 1 MOtolmetin sodium 1 MOVIMOVO 4 MO

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Drug name Drug tier Requirements/LimitsVIVLODEX 3 ST MOZIPSOR 3 ST MOZORVOLEX 3 QL (90 EA per 30 days) MO

OPIOID ANALGESICS, LONG-ACTING ARYMO ER TBEA 15MG 3 QL (240 EA per 30 days) ST MOARYMO ER TBEA 60MG 3 QL (60 EA per 30 days) ST MOARYMO ER TBEA 30MG 3 QL (90 EA per 30 days) ST MOBELBUCA 3 QL (60 EA per 30 days) PA MObuprenorphine transdermal patch 1 QL (4 EA per 28 days) PA MOBUTRANS 3 QL (4 EA per 28 days) PA MOCONZIP 3 QL (30 EA per 30 days) PA MODOLOPHINE 3 QL (90 EA per 30 days) PA MODURAGESIC PT72 12MCG/HR, 25MCG/HR


DURAGESIC PT72 100MCG/HR, 50MCG/HR, 75MCG/HR


EXALGO 3 QL (30 EA per 30 days) PA MOfentanyl transdermal patch 1 QL (10 EA per 30 days) PA MOhydrocodone bitartrate er 1 QL (60 EA per 30 days) PA MOhydromorphone hcl er tabs 24h 12mg, 16mg, 8mg


hydromorphone hcl er tabs 24hr 32mg


HYSINGLA ER 2 QL (30 EA per 30 days) PA MOKADIAN CP24 10MG, 20MG, 40MG 3 QL (60 EA per 30 days) PA MOKADIAN CP24 100MG, 200MG, 30MG, 50MG, 60MG, 80MG


METHADONE HCL INJ 4 PAmethadone hcl oral soln 1 QL (450 ML per 30 days) PA MOmethadone hcl tabs 1 QL (90 EA per 30 days) PA MOmethadone hcl conc 1 QL (90 ML per 30 days) PA MOMETHADOSE 3 QL (90 ML per 30 days) PA MOMETHADOSE SUGAR-FREE 3 QL (90 ML per 30 days) PA MOMORPHABOND ER T12A 30MG 3 QL (60 EA per 30 days) PA MOMORPHABOND ER T12A 15MG 3 QL (90 EA per 30 days) PA MOMORPHABOND ER T12A 100MG, 60MG


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Drug name Drug tier Requirements/Limitsmorphine sulfate er cp24 (generic Avinza) 120mg, 30mg, 45mg, 60mg, 75mg, 90mg


morphine sulfate er cp24 (generic Kadian) 100mg, 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, 80mg


morphine sulfate er tbcr 100mg, 200mg, 30mg, 60mg


morphine sulfate er tbcr 15mg 1 QL (90 EA per 30 days) PA MOMS CONTIN TBCR 30MG 3 QL (60 EA per 30 days) PA MOMS CONTIN TBCR 15MG 3 QL (90 EA per 30 days) PA MOMS CONTIN TBCR 100MG, 200MG, 60MG


NUCYNTA ER 3 QL (60 EA per 30 days) PA MOOXYCODONE HCL ER T12A 15MG, 30MG, 60MG


OXYCODONE HCL ER T12A 10MG, 20MG, 40MG, 80MG


OXYCONTIN 3 QL (60 EA per 30 days) PA MOoxymorphone hydrochloride er 1 QL (60 EA per 30 days) PA MOoxymorphone hydrochloride er tb12 40mg


TRAMADOL HCL ER CP24 3 QL (30 EA per 30 days) PA MOtramadol hcl er tb24 1 QL (30 EA per 30 days) PA MOXTAMPZA ER C12A 36MG 3 QL (240 EA per 30 days) PA MOXTAMPZA ER C12A 13.5MG, 18MG, 27MG, 9MG


ZOHYDRO ER 3 QL (60 EA per 30 days) PA MOOPIOID ANALGESICS, SHORT-ACTING

acetaminophen/caffeine/dihydrocodeine

1 QL (300 EA per 30 days) MO

acetaminophen/caffeine/dihydrocodeine bitartrate

1 QL (300 EA per 30 days)

acetaminophen/codeine tabs 1 QL (180 EA per 30 days) MOacetaminophen/codeine soln 1 QL (2700 ML per 30 days) MOACTIQ 4 QL (120 EA per 30 days) PA MOascomp/codeine 1 QL (180 EA per 30 days) PA MOBUPRENEX 4 MObuprenorphine hcl inj 0.3mg/ml 1 MO

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Drug name Drug tier Requirements/Limitsbutalbital/acetaminophen/caffeine/codeine


butalbital/aspirin/caffeine/codeine 1 QL (180 EA per 30 days) PA MObutorphanol tartrate nasal soln 1 QL (5 ML per 30 days) MObutorphanol tartrate inj 1mg/ml 1butorphanol tartrate inj 2mg/ml 1 MOCODEINE SULFATE TABS 30MG 3 QL (180 EA per 30 days)CODEINE SULFATE TABS 15MG, 60MG


DEMEROL INJ 100MG/2ML, 25MG/0.5ML, 25MG/ML, 75MG/1.5ML, 75MG/ML

3 PA

DEMEROL INJ 100MG/ML, 50MG/ML 3 PA MODILAUDID INJ 3 B/DDILAUDID LIQD 3 QL (600 ML per 30 days) MODILAUDID TABS 2MG, 4MG 3 QL (180 EA per 30 days) MODILAUDID TABS 8MG 4 QL (180 EA per 30 days) MODURAMORPH 3 B/Ddvorah 1 QL (300 EA per 30 days)endocet 1 QL (180 EA per 30 days)fentanyl citrate oral transmucosal lozenge


FENTANYL CITRATE TABS 4 QL (120 EA per 30 days) PA MOFENTANYL CITRATE INJ 1000MCG/20ML, 100MCG/2ML, 2500MCG/50ML, 250MCG/5ML, 500MCG/10ML, 50MCG/ML

3

fentanyl citrate cartridge 100mcg/2ml 1FENTORA 4 QL (120 EA per 30 days) PA MOFIORINAL/CODEINE #3 3 QL (180 EA per 30 days) PA MOhydrocodone bitartrate/acetaminophen tabs


HYDROCODONE BITARTRATE/ACETAMINOPHEN SOLN 325MG/15ML; 10MG/15ML

3 QL (5500 ML per 30 days)

hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 7.5mg/15ml

1 QL (2700 ML per 30 days) MO

hydrocodone/acetaminophen 1 QL (180 EA per 30 days) MO

16 Updated 10/01/20

Drug name Drug tier Requirements/Limitshydrocodone/ibuprofen 1 QL (150 EA per 30 days) MOhydromorphone hcl tabs 1 QL (180 EA per 30 days) MOhydromorphone hcl liqd 1 QL (600 ML per 30 days) MOHYDROMORPHONE HCL INJ 1MG/ML, 4MG/ML

3 B/D MO

hydromorphone hcl inj 10mg/ml 1 B/Dhydromorphone hcl inj 2mg/ml 1 B/D MOHYDROMORPHONE HYDROCHLORIDE PF INJ 1MG/ML

3 B/D

HYDROMORPHONE HYDROCHLORIDE PF INJ 4MG/ML

3 B/D MO

hydromorphone hydrochloride pf inj 2mg/ml, 50mg/5ml

1 B/D

INFUMORPH 200 3 B/DINFUMORPH 500 3 B/DLAZANDA 4 QL (30 EA per 30 days) PA MOlevorphanol tartrate 4 QL (180 EA per 30 days) MOlorcet 1 QL (180 EA per 30 days)lorcet hd 1 QL (180 EA per 30 days)lorcet plus 1 QL (180 EA per 30 days)LORTAB 3 QL (2040 ML per 30 days) MOmeperidine hcl tabs 1 QL (120 EA per 30 days) PA MOmeperidine hcl oral soln 1 QL (3600 ML per 30 days) PA MOmeperidine hcl inj 25mg/ml 1 PAmeperidine hcl inj 100mg/ml, 50mg/ml

1 PA MO

mitigo 1 B/Dmorphine sulfate tabs 1 QL (180 EA per 30 days) MOMORPHINE SULFATE INJ 10MG/ML PF, 25MG/ML PF, 2MG/ML PF, 4MG/ML PF, 50MG/ML, 5MG/ML PF, 8MG/ML PF

3 B/D

morphine sulfate iv inj 0.5mg/ml, 10mg/ml, 1mg/ml, 4mg/ml, 8mg/ml

1 B/D

morphine sulfate pf inj 1mg/ml 1 B/D MOmorphine sulfate oral soln 100mg/5ml


17Updated 10/01/20

Drug name Drug tier Requirements/Limitsmorphine sulfate oral soln 10mg/5ml, 20mg/5ml


MORPHINE SULFATE SUPP 30MG, 5MG


MORPHINE SULFATE SUPP 10MG, 20MG


nalbuphine hcl 1 MOnalocet 4 QL (180 EA per 30 days)NORCO 3 QL (180 EA per 30 days) MONUCYNTA 3 QL (180 EA per 30 days) MOOXAYDO 3 QL (180 EA per 30 days) MOoxycodone hcl 1 QL (180 EA per 30 days) MOoxycodone hydrochloride oral conc 1 QL (180 ML per 30 days) MOoxycodone hydrochloride soln 1 QL (900 ML per 30 days) MOoxycodone hydrochloride tabs 30mg 1 QL (120 EA per 30 days) MOoxycodone hydrochloride tabs 10mg, 15mg, 20mg, 5mg


oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg


oxycodone/acetaminophen tabs 300mg; 2.5mg


oxycodone/aspirin 1 QL (180 EA per 30 days) MOoxymorphone hydrochloride immediate release tabs


pentazocine/naloxone hcl 1 QL (360 EA per 30 days) PA MOPERCOCET TABS 325MG; 2.5MG 3 QL (180 EA per 30 days) MOPERCOCET TABS 325MG; 10MG, 325MG; 5MG, 325MG; 7.5MG


PRIMLEV TABS 300MG; 5MG 3 QL (180 EA per 30 days) MOPRIMLEV TABS 300MG; 10MG, 300MG; 7.5MG


PROLATE TABS 300MG; 5MG 3 QL (180 EA per 30 days) MOPROLATE TABS 300MG; 10MG, 300MG; 7.5MG


ROXICODONE TABS 15MG, 5MG 3 QL (180 EA per 30 days) MOROXICODONE TABS 30MG 4 QL (120 EA per 30 days) MOSUBSYS LIQD 100MCG, 200MCG, 400MCG, 600MCG, 800MCG


18 Updated 10/01/20

Drug name Drug tier Requirements/LimitsSUBSYS LIQD 1200MCG 4 QL (240 EA per 30 days) PASUBSYS LIQD 1600MCG 4 QL (240 EA per 30 days) PA MOtramadol hcl tabs 50mg 1 QL (240 EA per 30 days) MOtramadol hydrochloride tabs 100mg 1 QL (120 EA per 30 days) MOtramadol hydrochloride/acetaminophen


trezix 1 QL (300 EA per 30 days)TYLENOL/CODEINE #3 3 QL (180 EA per 30 days) MOULTRACET 3 QL (240 EA per 30 days) MOULTRAM 3 QL (240 EA per 30 days) MO

ANESTHETICSLOCAL ANESTHETICS

bupivacaine hcl inj 0.25% 1bupivacaine hcl inj 0.5% 1 MObupivacaine hydrochloride 1bupivacaine/epinephrine inj 0.25%; 1:200000, 0.5%; 1:200000 pf

1

bupivacaine/epinephrine inj 0.5%; 1:200000

1 MO

lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%

1

lidocaine hydrochloride pf inj 1%, 2% 1lidocaine/epinephrine 1MARCAINE/EPINEPHRINE INJ 0.25%; 1:200000

3

MARCAINE/EPINEPHRINE INJ 0.5%; 1:200000

3 MO

MARCAINE INJ 0.25%, 0.75% 3MARCAINE INJ 0.5% 3 MONAROPIN 3ropivacaine hydrochloride 1sensorcaine-mpf 1SENSORCAINE-MPF/EPINEPHRINE INJ 0.5%; 1:200000, 0.75%; 1:200000

3

sensorcaine-mpf/epinephrine inj 0.25%; 1:200000

1

sensorcaine/epinephrine 1SENSORCAINE INJ 0.25% 3

19Updated 10/01/20

Drug name Drug tier Requirements/LimitsSENSORCAINE INJ 0.5% 3 MOXYLOCAINE 3xylocaine dental inj 1XYLOCAINE-MPF 3XYLOCAINE-MPF/EPINEPHRINE 3XYLOCAINE/EPINEPHRINE 3

ANTI-INFECTIVESANTI-INFECTIVES - MISCELLANEOUS

AEMCOLO 3 QL (12 EA per 30 days)albendazole 4 MOALBENZA 4 MOALINIA 4 MOamikacin sulfate 1 MOARIKAYCE 4 PA MOatovaquone 1 PA MOAZACTAM 3aztreonam 1 MObacitracin inj 50000unit 1BACTRIM 3 MOBACTRIM DS 3 MOBENZNIDAZOLE 3 PABETHKIS 4 QL (224 ML per 56 days) PA LABILTRICIDE 3 MOCAYSTON 4 PA LAchloramphenicol inj 1gm 1CLEOCIN PEDIATRIC GRANULES 3 MOCLEOCIN PHOSPHATE INJ 300MG/2ML, 600MG/4ML IV, 900MG/6ML IV, 9GM/60ML

3

CLEOCIN PHOSPHATE INJ 600MG/4ML, 900MG/6ML

3 MO

CLEOCIN CAPS 150MG, 300MG, 75MG

3 MO

clindamycin hcl caps 300mg, 75mg 1 MOclindamycin hydrochloride caps 150mg

1 MO

clindamycin palmitate hcl 1 MO

20 Updated 10/01/20

Drug name Drug tier Requirements/Limitsclindamycin phosphate/dextrose 1clindamycin phosphate inj 300mg/2ml, 9000mg/60ml

1

clindamycin phosphate inj 600mg/4ml, 900mg/6ml

1 MO

CLINDAMYCIN/SODIUM CHLORIDE 3colistimethate inj 1 PA MOCOLY-MYCIN M 3 PA MOCUBICIN 4CUBICIN RF 4DALVANCE 4dapsone tabs 100mg, 25mg 1 MODAPTOMYCIN INJ 350MG 4daptomycin inj 500mg 4 MODARAPRIM 4 QL (90 EA per 30 days) PA MOEMVERM 4 QL (12 EA per 365 days) MOertapenem 1 MOFIRVANQ SOLR 25MG/ML 3FIRVANQ SOLR 50MG/ML 3 MOFLAGYL 3 MOgentamicin sulfate pediatric 1 MOgentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%

1

gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9%

1 MO

gentamicin sulfate inj 40mg/ml 1 MOHIPREX 3 MOimipenem/cilastatin 1 MOIMPAVIDO 4 QL (90 EA per 30 days) PA MOINVANZ 3 MOisotonic gentamicin 1 MOivermectin tabs 3mg 1 MOKITABIS PAK 4 QL (280 ML per 56 days) PALINCOCIN 3 MOlincomycin hcl 1linezolid tabs 1 QL (56 EA per 28 days) PA MO

21Updated 10/01/20

Drug name Drug tier Requirements/Limitslinezolid oral susp 4 QL (1800 ML per 28 days) PA MOLINEZOLID INJ 600MG/300ML; 0.9% 3 PAlinezolid inj 600mg/300ml 1 PAMACROBID 3 MOMACRODANTIN 3 MOMEPRON 4 PA MOMEROPENEM/SODIUM CHLORIDE 3meropenem inj 500mg 1meropenem inj 1gm 1 MOMERREM INJ 500MG 3MERREM INJ 1GM 3 MOmethenamine hippurate 1 MOMETHENAMINE MANDELATE 3 MOmetronidazole in nacl 0.79% 1metronidazole caps 375mg 1 MOMETRONIDAZOLE INJ 500MG/100ML; 0.74%

3

metronidazole tabs 250mg, 500mg 1 MOMONUROL 3 MONEBUPENT 3 B/D MOneomycin tabs 1 MOnitrofurantoin macrocrystals 1 MOnitrofurantoin monohydrate 1 MOnitrofurantoin oral suspension 1 MOORBACTIV 4 MOparomomycin caps 1 MOPENTAM 300 3 MOpentamidine isethionate inj 1pentamidine isethionate inhalation solr

1 B/D

PHOSPHASAL 3 MOpolymyxin b sulfate inj 1praziquantel 1 MOPRIMAXIN IV 3 MOpyrimethamine 4 QL (90 EA per 30 days) PA MORECARBRIO 4 PASIVEXTRO INJ 4

22 Updated 10/01/20

Drug name Drug tier Requirements/LimitsSIVEXTRO TABS 4 MOSOLOSEC 3 MOstreptomycin sulfate inj 1 MOSTROMECTOL 3 MOSULFADIAZINE 3 MOsulfamethoxazole/trimethoprim 1 MOsulfamethoxazole/trimethoprim ds 1 MOSYNERCID 4tinidazole 1 MOTOBI 4 QL (280 ML per 56 days) PA LATOBI PODHALER 4 QL (224 EA per 42 days) PAtobramycin nebu 300mg/5ml 1 QL (280 ML per 56 days) PAtobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml

1

tobramycin sulfate inj 1.2gm/30ml, 80mg/2ml

1 MO

trimethoprim tabs 1 MOURIN D/S 3UROGESIC-BLUE 3 MOUTIRA-C 3 MOVABOMERE 4 PAVANCOCIN CAPS 250MG 4 QL (240 EA per 30 days) MOVANCOCIN HCL CAPS 125MG 4 QL (120 EA per 30 days) MOVANCOMYCIN HCL INJ 0.9%; 1GM/200ML

3

vancomycin hcl inj 100gm, 10gm 1VANCOMYCIN HYDROCHLORIDE/DEXTROSE

3

VANCOMYCIN HYDROCHLORIDE ORAL SOLR

3 MO

vancomycin hydrochloride caps 125mg


vancomycin hydrochloride caps 250mg


VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 250MG, 500MG/100ML

3

23Updated 10/01/20

Drug name Drug tier Requirements/Limitsvancomycin hydrochloride inj 1gm, 5gm, 750mg

1

vancomycin hydrochloride inj 500mg 1 MOVANCOMYCIN INJ 500MG/100ML, 750MG/150ML

3

VIBATIV 4 PAXENLETA 4 PAXIFAXAN TABS 200MG 4 QL (9 EA per 30 days) PA MOZEMDRI 4 PAZYVOX INJ 3 PAZYVOX ORAL SUSP 3 QL (1800 ML per 28 days) PA MOZYVOX TABS 4 QL (56 EA per 28 days) PA MO

ANTIFUNGALS ABELCET 3 B/DAMBISOME 4 B/Damphotericin b 1 B/D MOANCOBON CAPS 250MG 4ANCOBON CAPS 500MG 4 MOCANCIDAS INJ 50MG 4CANCIDAS INJ 70MG 4 MOcaspofungin acetate inj 70mg 1caspofungin acetate inj 50mg 4CRESEMBA INJ 4 QL (36 EA per 30 days)CRESEMBA CAPS 4 QL (70 EA per 30 days) MODIFLUCAN ORAL SUSP 3 MODIFLUCAN TABS 100MG, 150MG, 50MG

3 MO

DIFLUCAN TABS 200MG 4 MOERAXIS INJ 100MG 3 PAERAXIS INJ 50MG 4 PAfluconazole 1 MOfluconazole in nacl 200mg; 0.9% 1fluconazole in sodium chloride 400mg; 0.9%

1

flucytosine 4 MOgriseofulvin microsize 1 MOgriseofulvin ultramicrosize 1 MO

24 Updated 10/01/20

Drug name Drug tier Requirements/Limitsitraconazole caps 1 PA MOitraconazole soln 1 QL (600 ML per 30 days) PA MOketoconazole tabs 200mg 1 PA MOmicafungin inj 50mg 1micafungin inj 100mg 4MYCAMINE INJ 50MG 3 MOMYCAMINE INJ 100MG 4NOXAFIL INJ 4NOXAFIL SUSP 4 QL (630 ML per 30 days) MONOXAFIL TBEC 4 QL (93 EA per 30 days) MOnystatin tabs 500000unit 1 MOposaconazole dr 4 QL (93 EA per 30 days) MOSPORANOX PULSEPAK 4 PA MOSPORANOX CAPS 4 PA MOSPORANOX SOLN 4 QL (600 ML per 30 days) PA MOterbinafine hcl tabs 1 QL (90 EA per 365 days) MOTOLSURA 4 PA MOVFEND IV 3 PAVFEND TABS 4 MOVFEND ORAL SUSP 4 PA MOvoriconazole tabs 1 MOvoriconazole inj 1 PAvoriconazole oral susp 1 PA MO

ANTIMALARIALS atovaquone/proguanil hcl 1 MOchloroquine phosphate 1 MOCOARTEM 3 MOKRINTAFEL 3 PAMALARONE 3 MOmefloquine hcl 1 MOprimaquine phosphate 1 MOQUALAQUIN 3 PA MOquinine sulfate 1 PA MO

ANTIRETROVIRAL AGENTS abacavir 1 MOAPTIVUS SOLN 4APTIVUS CAPS 4 MO

25Updated 10/01/20

Drug name Drug tier Requirements/Limitsatazanavir sulfate caps 150mg, 300mg

1 MO

atazanavir sulfate caps 200mg 4 MOCRIXIVAN 3 MOdidanosine caps 200mg, 250mg, 400mg

1 MO

EDURANT 4 MOefavirenz caps 1 MOefavirenz tabs 4 MOEMTRIVA 2 MOEPIVIR 3 MOfosamprenavir calcium 4 MOFUZEON 4INTELENCE TABS 25MG 3INTELENCE TABS 100MG, 200MG 4 MOINVIRASE TABS 4 MOISENTRESS HD 4 MOISENTRESS PACK 2 MOISENTRESS TABS 4 MOISENTRESS CHEW 25MG 2 MOISENTRESS CHEW 100MG 4 MOlamivudine soln 10mg/ml 1 MOlamivudine tabs 150mg, 300mg 1 MOLEXIVA SUSP 3 MOLEXIVA TABS 4 MOnevirapine er tb24 100mg 1nevirapine er tb24 400mg 1 MOnevirapine susp 1nevirapine tabs 1 MONORVIR 3 MOPIFELTRO 4 MOPREZISTA SUSP 4 QL (400 ML per 30 days) MOPREZISTA TABS 75MG 3 QL (480 EA per 30 days) MOPREZISTA TABS 150MG 4 QL (240 EA per 30 days) MOPREZISTA TABS 800MG 4 QL (30 EA per 30 days) MOPREZISTA TABS 600MG 4 QL (60 EA per 30 days) MORESCRIPTOR TABS 200MG 3 MO

26 Updated 10/01/20

Drug name Drug tier Requirements/LimitsRETROVIR CAPS, SYRP 3 MORETROVIR IV INFUSION 3REYATAZ 4 MOritonavir 1 MORUKOBIA 4SELZENTRY SOLN 4SELZENTRY TABS 25MG 2SELZENTRY TABS 75MG 4SELZENTRY TABS 150MG, 300MG 4 MOstavudine 1 MOSUSTIVA TABS 4 MOSUSTIVA CAPS 50MG 3 MOSUSTIVA CAPS 200MG 4 MOtenofovir tabs 1 MOTIVICAY PD 3TIVICAY TABS 10MG 2 MOTIVICAY TABS 25MG, 50MG 4 MOTROGARZO 4 LATYBOST 3 MOVIDEX EC CAPS 125MG, 200MG, 250MG

3 MO

VIDEX PEDIATRIC 3 MOVIRACEPT TABS 4 MOVIRAMUNE XR 3 MOVIRAMUNE SUSP 3 MOVIRAMUNE TABS 4 MOVIREAD 4 MOZIAGEN 3 MOzidovudine 1 MO

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate/lamivudine 1 MOabacavir sulfate/lamivudine/zidovudine

4 MO

ATRIPLA 4 MOBIKTARVY 4 MOCIMDUO 4 MOCOMBIVIR 3 MO

27Updated 10/01/20

Drug name Drug tier Requirements/LimitsCOMPLERA 4 MODELSTRIGO 4 MODESCOVY 4 MODOVATO 4 MOEPZICOM 4 MOEVOTAZ 4 MOGENVOYA 4 MOJULUCA 4 MOKALETRA SOLN 4 MOKALETRA TABS 100MG; 25MG 3 MOKALETRA TABS 200MG; 50MG 4 MOlamivudine/zidovudine 1 MOlopinavir/ritonavir 1 MOODEFSEY 4 MOPREZCOBIX 4 MOSTRIBILD 4 MOSYMFI 4 MOSYMFI LO 4 MOSYMTUZA 4 MOTEMIXYS 4 MOTRIUMEQ 4 MOTRIZIVIR 4 MOTRUVADA 4 QL (30 EA per 30 days) MO

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3cycloserine 4 MOethambutol hydrochloride tabs 400mg

1 MO

isoniazid inj 1isoniazid syrp, tabs 1 MOMYAMBUTOL 3 MOMYCOBUTIN 3 MOPASER 3 MOPRETOMANID 3 QL (30 EA per 30 days) PAPRIFTIN 3 MOpyrazinamide 1 MOrifabutin 1 MO

28 Updated 10/01/20

Drug name Drug tier Requirements/LimitsRIFADIN CAPS 3 MORIFADIN INJ 4RIFAMATE 3 MOrifampin inj 1rifampin caps 1 MORIFATER 3 MOSIRTURO TABS 20MG 4 PASIRTURO TABS 100MG 4 PA LATRECATOR 3 MO

ANTIVIRALS acyclovir sodium inj 50mg/ml 1 B/Dacyclovir caps 200mg 1 MOacyclovir susp 200mg/5ml 1 MOacyclovir tabs 400mg, 800mg 1 MOadefovir dipivoxil 1 QL (30 EA per 30 days) MOBARACLUDE SOLN 3 MOBARACLUDE TABS 4 QL (30 EA per 30 days) MOcidofovir 1CYTOVENE 3 B/D MOentecavir 1 QL (30 EA per 30 days) MOEPCLUSA 4 PAEPIVIR HBV 3 MOfamciclovir tabs 500mg 1 QL (21 EA per 30 days) MOfamciclovir tabs 125mg, 250mg 1 QL (60 EA per 30 days) MOganciclovir inj 500mg/10ml, 500mg 1 B/DHARVONI TABS 4 PAHEPSERA 4 QL (30 EA per 30 days) ST MOlamivudine tabs 100mg 1 MOLEDIPASVIR/SOFOSBUVIR 4 PAMAVYRET 4 PAoseltamivir phosphate caps 30mg 1 QL (168 EA per 365 days) MOoseltamivir phosphate caps 45mg, 75mg


oseltamivir phosphate oral susp 1 QL (1080 ML per 365 days) MOPEGASYS 4 PAPEGINTRON KIT 50MCG 4 PAPREVYMIS INJ 4

29Updated 10/01/20

Drug name Drug tier Requirements/LimitsPREVYMIS TABS 4 QL (28 EA per 28 days) MORELENZA DISKHALER 2 QL (120 EA per 365 days) MOribavirin caps, tabs 1ribavirin inh 4rimantadine hydrochloride 1 MOSITAVIG 3 MOSOFOSBUVIR/VELPATASVIR 4 PASOVALDI TABLETS 4 QL (28 EA per 28 days) PATAMIFLU ORAL SUSP 3 QL (1080 ML per 365 days) MOTAMIFLU CAPS 30MG 3 QL (168 EA per 365 days) MOTAMIFLU CAPS 45MG, 75MG 3 QL (84 EA per 365 days) MOvalacyclovir hcl tabs 1gm 1 MOvalacyclovir hydrochloride tabs 500mg

1 MO

VALCYTE 4 MOvalganciclovir hydrochloride oral soln 4 MOvalganciclovir tabs 4 MOVALTREX 3 MOVEMLIDY 4 MOVIEKIRA PAK 4 QL (112 EA per 28 days) PAVIRAZOLE 4VOSEVI 4 PAXOFLUZA 3 QL (2 EA per 180 days) MOZEPATIER 4 PAZOVIRAX SUSP 200MG/5ML 3 MO

CEPHALOSPORINS AVYCAZ 4 PAcefaclor 1 MOCEFACLOR ER 3 MOcefadroxil 1 MOCEFAZOLIN INJ 2GM/100ML; 4% 2CEFAZOLIN SODIUM/DEXTROSE 3CEFAZOLIN SODIUM INJ 1GM/50ML; 4%

2

CEFAZOLIN SODIUM INJ 100GM, 300GM

3

cefazolin sodium iv inj 1gm 1

30 Updated 10/01/20

Drug name Drug tier Requirements/Limitscefazolin sodium inj 10gm, 1gm, 500mg

1 MO

cefdinir 1 MOCEFEPIME/DEXTROSE 3CEFEPIME INJ 1GM/50ML, 2GM/100ML

3

cefepime inj 1gm, 2gm 1 MOcefixime 1 MOCEFOTAN 3cefotetan 1CEFOTETAN/DEXTROSE 3CEFOXITIN SODIUM INJ 1GM; 4%, 2GM; 2.2%

3

cefoxitin sodium inj 10gm, 1gm, 2gm 1cefpodoxime proxetil 1 MOcefprozil 1 MOCEFTAZIDIME/DEXTROSE 3ceftazidime inj 6gm 1ceftazidime inj 1gm, 2gm 1 MOceftriaxone in iso-osmotic dextrose 1CEFTRIAXONE SODIUM INJ 100GM 3ceftriaxone sodium iv inj 1gm 1ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

1 MO

CEFTRIAXONE/DEXTROSE 3cefuroxime axetil tabs 1 MOcefuroxime sodium inj 1.5gm, 7.5gm 1cefuroxime sodium inj 750mg 1 MOcephalexin 1 MOFETROJA 4SUPRAX CAPS 3 MOSUPRAX CHEW 100MG 3SUPRAX CHEW 200MG 3 MOSUPRAX ORAL SUSP 500MG/5ML 2SUPRAX ORAL SUSP 100MG/5ML, 200MG/5ML

3 MO

tazicef 1

31Updated 10/01/20

Drug name Drug tier Requirements/LimitsTEFLARO 4ZERBAXA 4

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 2 MOazithromycin inj, oral susp, tabs 1 MOclarithromycin er 1 MOclarithromycin oral susp, tabs 1 MODIFICID 4 MOe.e.s. 400 1 MOE.E.S. GRANULES 3 MOery-tab 1ERYPED 200 3 MOERYPED 400 3 MOERYTHROCIN LACTOBIONATE INJ 500MG

3

erythrocin stearate tabs 250mg 1 MOerythromycin base 1 MOerythromycin dr 1 MOerythromycin ethylsuccinate tabs, oral susp

1 MO

erythromycin stearate 1 MOerythromycin cpep 250mg 1 MOZITHROMAX 3 MOZITHROMAX TRI-PAK 3 MOZITHROMAX Z-PAK 3 MO

FLUOROQUINOLONES BAXDELA INJ 4 PABAXDELA TABS 4 PA MOCIPRO TABS, ORAL SUSP 3 MOciprofloxacin hcl tabs 100mg, 750mg 1 MOciprofloxacin hydrochloride tabs 250mg, 500mg

1 MO

ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%

1

ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5%

1 MO

levofloxacin in d5w 1

32 Updated 10/01/20

Drug name Drug tier Requirements/Limitslevofloxacin inj 25mg/ml 1levofloxacin oral soln 25mg/ml 1 MOlevofloxacin tabs 250mg, 500mg, 750mg

1 MO

moxifloxacin hydrochloride/sodium hydrochloride inj

1

moxifloxacin hydrochloride inj 400mg/250ml

1

moxifloxacin hydrochloride tabs 400mg

1 MO

ofloxacin tabs 300mg, 400mg 1 MOPENICILLINS

amoxicillin 1 MOamoxicillin/clavulanate potassium 1 MOamoxicillin/clavulanate potassium er 1 MOampicillin caps 500mg 1 MOampicillin sodium inj 10gm, 125mg, 1gm iv, 250mg, 2gm iv

1

ampicillin sodium inj 1gm, 2gm, 500mg

1 MO

ampicillin-sulbactam 1AUGMENTIN ES-600 3 MOAUGMENTIN TABS 500MG 3 MOBICILLIN C-R INJ 900000UNIT/2ML; 300000UNIT/2ML

3

BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML

4 MO

BICILLIN L-A 3 MOdicloxacillin caps 1 MOnafcillin sodium inj 10gm, 1gm, 2gm iv

1

nafcillin sodium inj 2gm 1 MOnafcillin sodium inj 10gm iv 4NAFCILLIN/DEXTROSE 3OXACILLIN SODIUM INJ 1.5GM/50ML; 1GM/50ML, 300MG/50ML; 2GM/50ML

3

oxacillin sodium inj 10gm, 1gm 1

33Updated 10/01/20

Drug name Drug tier Requirements/Limitsoxacillin sodium inj 2gm 1 MOpenicillin g potassium 1 MOPENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE

3

PENICILLIN G PROCAINE 3 MOpenicillin g sodium 1penicillin v potassium 1 MOpfizerpen inj 20000000unit 1pfizerpen inj 5000000unit 1 MOpiperacillin sodium/tazobactam sodium

1

piperacillin/tazobactam 1UNASYN BULK PACK 3UNASYN INJ 1GM; 0.5GM 3UNASYN INJ 2GM; 1GM 3 MOZOSYN 3

TETRACYCLINES ACTICLATE 3 ST MOdemeclocycline hcl 1 MODORYX MPC 3 ST MODORYX TBEC 50MG 3 ST MODORYX TBEC 200MG 4 ST MOdoxy 100 inj 1 MOdoxycycline hyclate 1 MOdoxycycline hyclate dr 1 MOdoxycycline monohydrate 1 MOdoxycycline oral susp 25mg/5ml 1 MOdoxycycline tabs 50mg 1 MOMINOCIN INJ 3MINOCIN CAPS 50MG 3 ST MOminocycline hcl caps 75mg 1 MOminocycline hcl tabs 1 ST MOminocycline hydrochloride caps 100mg, 50mg

1 MO

minocycline hydrochloride er 1 ST MOMINOLIRA 3 ST MOmondoxyne nl caps 100mg, 75mg 1

34 Updated 10/01/20

Drug name Drug tier Requirements/Limitsmorgidox 1x100mg 1morgidox 2x100mg 1NUZYRA 4 PAokebo 1SEYSARA 4 QL (30 EA per 30 days) PA MOSOLODYN 4 ST MOTARGADOX 3 ST MOtetracycline hydrochloride 1 MOtigecycline 4TYGACIL 4VIBRAMYCIN 3 ST MOXERAVA 3XIMINO 3 ST MO

ANTINEOPLASTIC AGENTSALKYLATING AGENTS

ALKERAN TABS 3 B/D MOALKERAN INJ 4BENDEKA 4BICNU 4busulfan 4BUSULFEX 4carboplatin 1carmustine 4cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml

1

cyclophosphamide inj 1cyclophosphamide caps 1 B/D MOGLEOSTINE CAPS 10MG 3 MOGLEOSTINE CAPS 100MG, 40MG 4 MOIFEX 3IFOSFAMIDE INJ 3GM 3ifosfamide inj 1gm/20ml, 1gm, 3gm/60ml

1

LEUKERAN 4 MOmelphalan hydrochloride inj 4melphalan tabs 1 B/D MOoxaliplatin 1

35Updated 10/01/20

Drug name Drug tier Requirements/Limitsparaplatin 1TEMODAR INJ 4thiotepa 4TREANDA 4YONDELIS 4 PAZANOSAR 3

ANTIBIOTICS adriamycin 1 B/Dbleomycin sulfate 1 B/DCOSMEGEN 4dactinomycin 4DAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML

3

daunorubicin hydrochloride inj 20mg/4ml

1

doxorubicin hcl liposome 2mg/ml 1doxorubicin hydrochloride liposomal 20mg/10ml, 50mg/25ml

1

ELLENCE 4epirubicin hcl 1IDAMYCIN PFS 4idarubicin hcl 1mitomycin inj 20mg, 5mg 1mitomycin inj 40mg 4mutamycin inj 20mg, 5mg 1mutamycin inj 40mg 4VALSTAR 4

ANTIMETABOLITES adrucil 1 B/DALIMTA 4ARRANON 4azacitidine 4cladribine 1 B/Dclofarabine 4CLOLAR 4cytarabine aqueous 1 B/DDACOGEN 4

36 Updated 10/01/20

Drug name Drug tier Requirements/Limitsdecitabine 1fludarabine phosphate 1fluorouracil inj 1gm/20ml, 2.5gm/50ml, 500mg/10ml, 5gm/100ml

1 B/D

FOLOTYN 4gemcitabine hcl inj 1gm, 200mg, 2gm 1GEMCITABINE HYDROCHLORIDE INJ 1GM/10ML, 2GM/20ML

3

gemcitabine hydrochloride inj 200mg/2ml

1

gemcitabine inj 38mg/ml 1INFUGEM 4mercaptopurine 1 MOmethotrexate sodium inj 1gm/40ml, 1gm

1

methotrexate sodium inj 250mg/10ml, 50mg/2ml

1 MO

methotrexate pf inj 50mg/2ml 1 MOPURIXAN 4TABLOID 3 MOVIDAZA 4

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate 4 PAanastrozole 1 MOARIMIDEX 3 MOAROMASIN 4 MObicalutamide 1 MOCASODEX 3 MODEPO-PROVERA INJ 400MG/ML 3ELIGARD 3 PAEMCYT 3 MOERLEADA 4 PA LAexemestane 1 MOFARESTON 4 PA MOFASLODEX 4FEMARA 3 MOFIRMAGON INJ 80MG 3 PA

37Updated 10/01/20

Drug name Drug tier Requirements/LimitsFIRMAGON INJ 120MG/VIAL 4 PAflutamide 1 MOfulvestrant 4hydroxyprogesterone caproate inj 1.25gm/5ml

4

letrozole 1 MOleuprolide acetate 1 PALUPRON DEPOT (1-MONTH) INJ 3.75MG, 7.5MG

4 PA

LUPRON DEPOT (3-MONTH) INJ 11.25MG, 22.5MG

4 PA

LUPRON DEPOT (4-MONTH) INJ 30MG

4 PA

LUPRON DEPOT (6-MONTH) INJ 45MG

4 PA

LYSODREN 2megestrol acetate tabs 20mg, 40mg 1 MONILANDRON 4 MOnilutamide 4 MONUBEQA 4 PASOLTAMOX 4 MOtamoxifen citrate 1 MOtoremifene citrate 1 PA MOTRELSTAR MIXJECT 4 PAVANTAS 4XTANDI 4 PA LAYONSA 4 PAZOLADEX 3ZYTIGA 4 PA LA

IMMUNOMODULATORS POMALYST CAPS 1MG, 2MG 4 QL (21 EA per 21 days) PA LAPOMALYST CAPS 3MG, 4MG 4 QL (21 EA per 28 days) PA LAREVLIMID 4 QL (28 EA per 28 days) PA LATHALOMID CAPS 100MG, 50MG 4 QL (28 EA per 28 days) PATHALOMID CAPS 150MG, 200MG 4 QL (56 EA per 28 days) PA

MISCELLANEOUS arsenic trioxide 4

38 Updated 10/01/20

Drug name Drug tier Requirements/Limitsbexarotene 4 PACAMPTOSAR 3dacarbazine 1ERWINAZE 4 PAHYCAMTIN INJ 4HYDREA 3 MOhydroxyurea 1 MOIMLYGIC 4 PAINQOVI 4 QL (5 EA per 28 days) PAirinotecan hcl inj 100mg/5ml 1irinotecan hydrochloride inj 300mg/15ml, 40mg/2ml

1

irinotecan inj 500mg/25ml 1KISQALI FEMARA 200MG-2.5MG CO-PACK

4 PA

KISQALI FEMARA 400MG-2.5MG CO-PACK

4 PA

KISQALI FEMARA 600MG-2.5MG CO-PACK

4 PA

LONSURF 4 PAMATULANE 4 LAmitoxantrone hcl 1NIPENT 4ONIVYDE 4 PAPROLEUKIN 4SYLATRON KIT 200MCG, 300MCG 4 PASYLVANT 4 PASYNRIBO 4 PATARGRETIN CAPS 75MG 4 PATICE BCG 3TOPOTECAN HCL INJ 4MG/4ML 4topotecan hcl inj 4mg 4tretinoin caps 10mg 4 MOTRISENOX 4VYXEOS 4 PA

MITOTIC INHIBITORS ABRAXANE 4

39Updated 10/01/20

Drug name Drug tier Requirements/LimitsDOCETAXEL INJ 160MG/16ML 3DOCETAXEL INJ 160MG/8ML, 200MG/10ML, 20MG/2ML, 80MG/8ML

4

docetaxel inj 20mg/ml, 80mg/4ml 1ETOPOPHOS 4etoposide inj 1HALAVEN 4 PAIXEMPRA KIT 4 PAJEVTANA 4 PAMARQIBO 4 PANAVELBINE 3paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml, 30mg/5ml

1

TAXOTERE 4toposar 1vinblastine sulfate 1 B/Dvincristine sulfate 1 B/Dvinorelbine tartrate 1

MOLECULAR TARGET AGENTS AFINITOR 4 QL (30 EA per 30 days) PAAFINITOR DISPERZ TBSO 2MG 4 QL (150 EA per 30 days) PAAFINITOR DISPERZ TBSO 5MG 4 QL (60 EA per 30 days) PAAFINITOR DISPERZ TBSO 3MG 4 QL (90 EA per 30 days) PAALECENSA 4 PA LAALIQOPA 4 QL (3 EA per 28 days) PAALUNBRIG 4 PA LAARZERRA INJ 1000MG/50ML 4 PAARZERRA INJ 100MG/5ML 4 PA LAAVASTIN 4 PA LAAYVAKIT 4 QL (30 EA per 30 days) PA MOBALVERSA TABS 5MG 4 QL (28 EA per 28 days) PA MOBALVERSA TABS 4MG 4 QL (56 EA per 28 days) PA MOBALVERSA TABS 3MG 4 QL (84 EA per 28 days) PA MOBAVENCIO 4 PABELEODAQ 4 PABESPONSA 4 PA

40 Updated 10/01/20

Drug name Drug tier Requirements/LimitsBLINCYTO 4 PA LABORTEZOMIB 4 PABOSULIF 4 PABRAFTOVI 4 PA LA MOBRUKINSA 4 QL (120 EA per 30 days) PA MOCABOMETYX 4 QL (30 EA per 30 days) PA LACALQUENCE 4 PA LA MOCAMPATH 4 QL (36 ML per 365 days) PACAPRELSA 4 PA LA MOCOMETRIQ 4 PA LACOPIKTRA 4 PA LA MOCOTELLIC 4 PA LACYRAMZA 4 PADARZALEX 4 PADAURISMO 4 PA LAEMPLICITI 4 PAENHERTU 4 PAERBITUX 4 PAERIVEDGE 4 PA LAerlotinib hydrochloride tabs 100mg, 150mg


erlotinib hydrochloride tabs 25mg 4 QL (90 EA per 30 days) PAeverolimus tabs 2.5mg, 5mg, 7.5mg 4 QL (30 EA per 30 days) PAFARYDAK CAPS 10MG, 20MG 4 PA LAGAZYVA 4 PA LAGILOTRIF 4 PA LA MOGLEEVEC TABS 400MG 4 QL (60 EA per 30 days) PAGLEEVEC TABS 100MG 4 QL (90 EA per 30 days) PAHERCEPTIN 4 PAHERCEPTIN HYLECTA 4 PAHERZUMA 4 PAIBRANCE TABS 4 QL (21 EA per 28 days) PAIBRANCE CAPS 4 QL (21 EA per 28 days) PA LAICLUSIG 4 PA LA MOIDHIFA 4 QL (30 EA per 30 days) PA LAimatinib mesylate tabs 400mg 4 QL (60 EA per 30 days) PAimatinib mesylate tabs 100mg 4 QL (90 EA per 30 days) PA

41Updated 10/01/20

Drug name Drug tier Requirements/LimitsIMBRUVICA 4 PA LA MOIMFINZI 4 PAINLYTA TABS 5MG 4 QL (120 EA per 30 days) PA LAINLYTA TABS 1MG 4 QL (180 EA per 30 days) PA LAINREBIC 4 QL (120 EA per 30 days) PAIRESSA 4 PA LAISTODAX (OVERFILL) 4JAKAFI 4 QL (60 EA per 30 days) PA LAKADCYLA 4KANJINTI 4 PAKEYTRUDA 4 PAKISQALI 4 PAKYPROLIS 4 PALENVIMA 10 MG DAILY DOSE 4 PA LALENVIMA 12MG DAILY DOSE 4 PA LALENVIMA 14 MG DAILY DOSE 4 PA LALENVIMA 18 MG DAILY DOSE 4 PA LALENVIMA 20 MG DAILY DOSE 4 PA LALENVIMA 24 MG DAILY DOSE 4 PA LALENVIMA 4 MG DAILY DOSE 4 PA LALENVIMA 8 MG DAILY DOSE 4 PA LALIBTAYO 4 PALORBRENA 4 PA LALUMOXITI 4 PALYNPARZA 4 PA LAMEKINIST 4 PA LAMEKTOVI 4 PA LAMVASI 4 PAMYLOTARG 4 PA LANERLYNX 4 PA LANEXAVAR 4 PA LANINLARO 4 PAODOMZO 4 PA LAOGIVRI 4 PAOPDIVO INJ 240MG/24ML 4 PAOPDIVO INJ 100MG/10ML, 40MG/4ML

4 PA LA

42 Updated 10/01/20

Drug name Drug tier Requirements/LimitsPADCEV 4 PAPEMAZYRE 4 QL (14 EA per 21 days) PA MOPERJETA 4 PA LAPIQRAY 200MG DAILY DOSE 4 QL (28 EA per 28 days) PAPIQRAY 250MG DAILY DOSE 4 QL (56 EA per 28 days) PAPIQRAY 300MG DAILY DOSE 4 QL (56 EA per 28 days) PAPOLIVY 4 PAPORTRAZZA 4 PAPOTELIGEO 4 PAQINLOCK 4 QL (90 EA per 30 days) PA MORETEVMO CAPS 80MG 4 QL (120 EA per 30 days) PARETEVMO CAPS 40MG 4 QL (180 EA per 30 days) PARITUXAN 4 PA LARITUXAN HYCELA 4 PA LAROMIDEPSIN 4ROZLYTREK CAPS 100MG 4 QL (150 EA per 30 days) PAROZLYTREK CAPS 200MG 4 QL (90 EA per 30 days) PARUBRACA 4 PA LARUXIENCE 4 PARYDAPT 4 PASARCLISA 4 PASPRYCEL 4 PASTIVARGA 4 PA LASUTENT 4 QL (30 EA per 30 days) PATABRECTA 4 QL (112 EA per 28 days) PATAFINLAR 4 PA LATAGRISSO 4 QL (30 EA per 30 days) PA LATALZENNA 4 PA LATARCEVA TABS 100MG, 150MG 4 QL (30 EA per 30 days) PA LATARCEVA TABS 25MG 4 QL (90 EA per 30 days) PA LATASIGNA 4 PATAZVERIK 4 QL (240 EA per 30 days) PA MOTECENTRIQ INJ 840MG/14ML 4 PATECENTRIQ INJ 1200MG/20ML 4 PA LAtemsirolimus 4TIBSOVO 4 PA LATORISEL 4

43Updated 10/01/20

Drug name Drug tier Requirements/LimitsTRAZIMERA 4 PATRUXIMA 4 PATUKYSA TABS 150MG 4 QL (120 EA per 30 days) PA MOTUKYSA TABS 50MG 4 QL (240 EA per 30 days) PA MOTURALIO 4 QL (120 EA per 30 days) PA MOTYKERB 4 PA LAVECTIBIX 4 PAVELCADE 4 PAVENCLEXTA STARTING PACK 4 PA LA MOVENCLEXTA TABS 10MG 3 PA LA MOVENCLEXTA TABS 100MG, 50MG 4 PA LA MOVERZENIO 4 PA LAVITRAKVI 4 PA LAVIZIMPRO 4 PA LAVOTRIENT 4 PA LAXALKORI 4 PA LAXOSPATA 4 PA LA MOXPOVIO 100 MG ONCE WEEKLY 4 QL (20 EA per 28 days) PA MOXPOVIO 40 MG ONCE WEEKLY 4 QL (8 EA per 28 days) PAXPOVIO 40 MG TWICE WEEKLY 4 QL (16 EA per 28 days) PAXPOVIO 60 MG ONCE WEEKLY 4 QL (12 EA per 28 days) PA MOXPOVIO 60 MG TWICE WEEKLY 4 QL (24 EA per 28 days) PAXPOVIO 80 MG ONCE WEEKLY 4 QL (16 EA per 28 days) PA MOXPOVIO 80 MG TWICE WEEKLY 4 QL (32 EA per 28 days) PA MOYERVOY 4 PAZALTRAP INJ 100MG/4ML 4 PAZALTRAP INJ 200MG/8ML 4 PA LAZEJULA 4 PA LA MOZELBORAF 4 PA LAZIRABEV 4 PAZOLINZA 4 PAZYDELIG 4 PA LAZYKADIA 4 PA

PROTECTIVE AGENTS dexrazoxane 1ELITEK 4KEPIVANCE 4

44 Updated 10/01/20

Drug name Drug tier Requirements/LimitsKHAPZORY 4 B/Dleucovorin calcium inj 1leucovorin calcium tabs 1 MOlevoleucovorin calcium inj 175mg/17.5ml, 250mg/25ml

1

levoleucovorin inj 50mg 4mesna 1MESNEX INJ 4MESNEX TABS 4 MOZINECARD 4

CARDIOVASCULARACE INHIBITOR COMBINATIONS

ACCURETIC 3 MOamlodipine besylate/benazepril hydrochloride


benazepril hcl/hydrochlorothiazide 1 MOcaptopril/hydrochlorothiazide 1 MOenalapril maleate/hydrochlorothiazide

1 MO

fosinopril sodium/hydrochlorothiazide

1 MO

lisinopril/hydrochlorothiazide 1 MOLOTENSIN HCT 3 MOLOTREL 3 QL (30 EA per 30 days) MOquinapril/hydrochlorothiazide 1 MOTARKA 3 MOtrandolapril/verapamil hcl er 1 MOVASERETIC 3 MOZESTORETIC 3 MO

ACE INHIBITORS ACCUPRIL 3 MOALTACE 3 MObenazepril hcl tabs 10mg, 50mg, 5mg 1 MObenazepril hydrochloride tabs 20mg 1 MOcaptopril 1 MOenalapril maleate 1 MOenalaprilat 1

45Updated 10/01/20

Drug name Drug tier Requirements/LimitsEPANED 4 MOfosinopril sodium 1 MOlisinopril 1 MOLOTENSIN 3 MOmoexipril hcl 1 MOperindopril erbumine 1 MOPRINIVIL 3 MOQBRELIS 4 MOquinapril hcl tabs 20mg, 40mg, 5mg 1 MOquinapril hydrochloride tabs 10mg 1 MOramipril 1 MOtrandolapril 1 MOVASOTEC TABS 10MG, 2.5MG, 5MG 3 MOVASOTEC TABS 20MG 4 MOZESTRIL 3 MO

ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE 3 MOCAROSPIR 3 MOeplerenone 1 MOINSPRA 3 MOspironolactone 1 MO

ALPHA BLOCKERS CARDURA 3 MOdoxazosin mesylate 1 MOMINIPRESS 3 MOprazosin hcl caps 1mg, 5mg 1 MOprazosin hydrochloride caps 2mg 1 MOterazosin hcl caps 10mg, 1mg, 5mg 1 MOterazosin hydrochloride caps 2mg 1 MO

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate/valsartan 1 QL (30 EA per 30 days) MOamlodipine/olmesartan medoxomil 1 QL (30 EA per 30 days) MOamlodipine/valsartan/hctz tabs 10mg; 12.5mg; 160mg, 10mg; 25mg; 160mg, 10mg; 25mg; 320mg, 5mg; 25mg; 160mg


46 Updated 10/01/20

Drug name Drug tier Requirements/Limitsamlodipine/valsartan/hydrochlorothiazide tabs 5mg; 12.5mg; 160mg


ATACAND HCT TABS 32MG; 12.5MG, 32MG; 25MG


ATACAND HCT TABS 16MG; 12.5MG 3 QL (60 EA per 30 days) ST MOAVALIDE 3 QL (30 EA per 30 days) ST MOAZOR 3 QL (30 EA per 30 days) ST MOBENICAR HCT 3 QL (30 EA per 30 days) ST MOcandesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg, 32mg; 25mg


candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg


DIOVAN HCT 3 QL (30 EA per 30 days) ST MOEDARBYCLOR 3 QL (30 EA per 30 days) ST MOENTRESTO 2 MOEXFORGE 3 QL (30 EA per 30 days) ST MOEXFORGE HCT 3 QL (30 EA per 30 days) ST MOHYZAAR 3 QL (30 EA per 30 days) ST MOirbesartan/hydrochlorothiazide 1 QL (30 EA per 30 days) MOlosartan potassium/hydrochlorothiazide


MICARDIS HCT TABS 12.5MG; 40MG, 25MG; 80MG


MICARDIS HCT TABS 12.5MG; 80MG 3 QL (60 EA per 30 days) ST MOolmesartan medoxomil/amlodipine/hydrochlorothiazide


olmesartan medoxomil/hydrochlorothiazide


telmisartan/amlodipine 1 QL (30 EA per 30 days) MOtelmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg; 80mg


telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg


TRIBENZOR 3 QL (30 EA per 30 days) ST MOTWYNSTA 3 QL (30 EA per 30 days) ST MOvalsartan/hydrochlorothiazide 1 QL (30 EA per 30 days) MO

47Updated 10/01/20

Drug name Drug tier Requirements/LimitsANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND 3 QL (30 EA per 30 days) ST MOAVAPRO 3 QL (30 EA per 30 days) ST MOBENICAR 3 QL (30 EA per 30 days) ST MOcandesartan cilexetil 1 QL (30 EA per 30 days) MOCOZAAR TABS 100MG 3 QL (30 EA per 30 days) ST MOCOZAAR TABS 25MG, 50MG 3 QL (60 EA per 30 days) ST MODIOVAN TABS 320MG 3 QL (30 EA per 30 days) ST MODIOVAN TABS 160MG, 40MG, 80MG 3 QL (60 EA per 30 days) ST MOEDARBI 3 QL (30 EA per 30 days) ST MOeprosartan mesylate 1 QL (30 EA per 30 days)irbesartan 1 QL (30 EA per 30 days) MOlosartan potassium tabs 100mg 1 QL (30 EA per 30 days) MOlosartan potassium tabs 25mg, 50mg 1 QL (60 EA per 30 days) MOMICARDIS 3 QL (30 EA per 30 days) ST MOolmesartan medoxomil 1 QL (30 EA per 30 days) MOtelmisartan 1 QL (30 EA per 30 days) MOvalsartan tabs 320mg 1 QL (30 EA per 30 days) MOvalsartan tabs 160mg, 40mg, 80mg 1 QL (60 EA per 30 days) MO

ANTIARRHYTHMICS amiodarone hcl inj 50mg/ml 1amiodarone hcl tabs 200mg, 400mg 1 MOamiodarone hydrochloride inj 150mg/3ml, 450mg/9ml, 900mg/18ml

1

amiodarone hydrochloride tabs 100mg

1 MO

BETAPACE AF 3 MOBETAPACE TABS 80MG 3 MOBETAPACE TABS 120MG, 160MG 4 MOdisopyramide phosphate 1 PA MOdofetilide 1flecainide acetate 1 MOLIDOCAINE HCL IN D5W 3LIDOCAINE HCL INJ 100MG/5ML 3lidocaine hcl prefilled syringe inj 100mg/5ml, 50mg/5ml

1

mexiletine hcl 1 MO

48 Updated 10/01/20

Drug name Drug tier Requirements/LimitsMULTAQ 3 MONEXTERONE 3NORPACE 3 PA MONORPACE CR 3 MOpacerone 1procainamide hcl 1propafenone hcl tabs 1 MOpropafenone hydrochloride er 1 MOquinidine gluconate cr 1 MOquinidine gluconate er 1 MOquinidine sulfate 1 MORYTHMOL SR CP12 225MG, 325MG 3 MORYTHMOL SR CP12 425MG 4 MOsorine 1sotalol hcl 1 MOsotalol hcl (af) 1 MOSOTYLIZE 4 MOTIKOSYN 3 ST

ANTILIPEMICS, FIBRATES ANTARA 3 MOfenofibrate 1 MOfenofibrate micronized 1 MOfenofibric acid dr caps 1 MOFENOGLIDE 3 MOgemfibrozil 1 MOLIPOFEN 3 MOLOPID 3 MOTRICOR 3 MOTRIGLIDE 3 MOTRILIPIX 3 MO

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV TB24 40MG, 60MG 3 QL (30 EA per 30 days) ST MOALTOPREV TB24 20MG 3 QL (60 EA per 30 days) ST MOatorvastatin calcium 1 QL (30 EA per 30 days) MOCRESTOR 3 QL (30 EA per 30 days) ST MOEZALLOR SPRINKLE 3 QL (30 EA per 30 days) ST MOFLOLIPID 3 QL (300 ML per 30 days) ST MO

49Updated 10/01/20

Drug name Drug tier Requirements/Limitsfluvastatin caps 1 QL (60 EA per 30 days) MOfluvastatin sodium er tabs 1 QL (30 EA per 30 days) MOLESCOL XL 3 QL (30 EA per 30 days) ST MOLIPITOR 3 QL (30 EA per 30 days) ST MOLIVALO 3 QL (30 EA per 30 days) ST MOlovastatin 1 MOPRAVACHOL 3 QL (30 EA per 30 days) ST MOpravastatin sodium 1 QL (30 EA per 30 days) MOrosuvastatin calcium 1 QL (30 EA per 30 days) MOsimvastatin 1 QL (30 EA per 30 days) MOZOCOR TABS 10MG, 20MG, 40MG, 80MG


ZYPITAMAG 3 QL (30 EA per 30 days) ST MOANTILIPEMICS, MISCELLANEOUS

cholestyramine 1 MOcholestyramine light 1 MOcolesevelam hydrochloride 1 MOCOLESTID 3 MOCOLESTID FLAVORED 3 MOcolestipol hcl 1 MOezetimibe 1 MOezetimibe/simvastatin 1 QL (30 EA per 30 days) MOFENOFIBRIC ACID TABS 2JUXTAPID 4 PA LA MOLOVAZA 3 QL (120 EA per 30 days) MONEXLETOL 3 QL (30 EA per 30 days) PA MONEXLIZET 3 QL (30 EA per 30 days) PAniacin er tbcr 1000mg, 750mg 1 MOniacin er tbcr 500mg 1 QL (60 EA per 30 days) MOniacin tabs 500mg 1 MOniacor 1 MONIASPAN TBCR 500MG 3 QL (60 EA per 30 days) ST MONIASPAN TBCR 1000MG, 750MG 3 ST MOomega-3-acid ethyl esters 1 QL (120 EA per 30 days) MOPRALUENT 2 PA MOprevalite 1 MOQUESTRAN 3 MO

50 Updated 10/01/20

Drug name Drug tier Requirements/LimitsQUESTRAN LIGHT 3 MOREPATHA 2 PA MOREPATHA PUSHTRONEX SYSTEM 2 PA MOREPATHA SURECLICK 2 PA MOVASCEPA 3 MOVYTORIN 3 QL (30 EA per 30 days) ST MOWELCHOL 3 MOZETIA 3 MO

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone 1 MObisoprolol fumarate/hydrochlorothiazide

1 MO

DUTOPROL 3 MOLOPRESSOR HCT TABS 25MG; 50MG 3 MOmetoprolol/hydrochlorothiazide 1 MOpropranolol/hydrochlorothiazide 1 MOTENORETIC 100 3 MOTENORETIC 50 3 MOZIAC 3 MO

BETA-BLOCKERS acebutolol hcl caps 200mg 1 MOacebutolol hydrochloride caps 400mg 1 MOatenolol 1 MObetaxolol hcl tabs 10mg, 20mg 1 MObisoprolol fumarate 1 MOBYSTOLIC TABS 10MG, 2.5MG, 5MG 3 QL (30 EA per 30 days) MOBYSTOLIC TABS 20MG 3 QL (60 EA per 30 days) MOcarvedilol phosphate er caps 1 QL (30 EA per 30 days) MOcarvedilol tabs 1 MOCOREG 3 MOCOREG CR 3 QL (30 EA per 30 days) MOCORGARD 3 MOHEMANGEOL 3INDERAL LA 4 MOINDERAL XL CP24 120MG 3 MOINDERAL XL CP24 80MG 4 MOINNOPRAN XL CP24 120MG 3 MO

51Updated 10/01/20

Drug name Drug tier Requirements/LimitsINNOPRAN XL CP24 80MG 4 MOKAPSPARGO SPRINKLE 3 ST MOlabetalol hydrochloride 1 MOLOPRESSOR 3 MOmetoprolol succinate er 1 MOmetoprolol tartrate tabs 1 MOmetoprolol tartrate cartridge 5mg/5ml

1

metoprolol tartrate vial 5mg/5ml 1 MOnadolol 1 MOpindolol 1 MOpropranolol hcl er caps 120mg, 160mg

1 MO

propranolol hcl inj 1propranolol hcl oral soln, tabs 40mg, 80mg

1 MO

propranolol hydrochloride er caps 60mg, 80mg

1 MO

propranolol hydrochloride tabs 10mg, 20mg, 60mg

1 MO

TENORMIN 3 MOtimolol maleate tabs 10mg, 20mg, 5mg

1 MO

TOPROL XL 3 MOCALCIUM CHANNEL BLOCKERS

afeditab cr tb24 30mg 1amlodipine besylate 1 MOCALAN SR 3 MOCARDENE IV 3CARDIZEM 3 MOCARDIZEM CD CP24 180MG, 300MG 3 MOCARDIZEM CD CP24 120MG, 240MG, 360MG

4 MO

CARDIZEM LA 3 MOcartia xt 1dilt-xr 1 MOdiltiazem hcl cd 1 MOdiltiazem hcl er caps, tabs 1 MO

52 Updated 10/01/20

Drug name Drug tier Requirements/Limitsdiltiazem hcl tabs 1 MODILTIAZEM HCL INJ 100MG 3diltiazem hcl inj 125mg/25ml, 50mg/10ml

1

diltiazem hydrochloride inj 25mg/5ml 1felodipine er 1 MOisradipine 1 MOKATERZIA 3 MOmatzim la 1 MOnicardipine hcl inj 1nicardipine hcl caps 1 MONICARDIPINE HYDROCHLORIDE IV SOL 20MG/200ML

3

NICARDIPINE HYDROCHLORIDE/SODIUM CHLORIDE IV SOL 40MG/200ML

3

nifedical xl 1nifedipine 1 PA MOnifedipine er 1 MOnimodipine 1 MOnisoldipine er 1 MONORVASC 3 MONYMALIZE ORAL SOLN 4PROCARDIA 3 PA MOPROCARDIA XL 3 MOSULAR 3 MOtaztia xt 1tiadylt er cp24 120mg, 180mg, 240mg, 300mg, 360mg

1

tiadylt er cp24 420mg 1 MOTIAZAC 3 MOverapamil hcl 40mg, 80mg 1 MOverapamil hcl er caps, tabs 1 MOVERAPAMIL HCL SR CP24 360MG 2 MOverapamil hcl sr cp24 120mg, 180mg, 240mg

1 MO

verapamil hcl sr tbcr 240mg 1 MOverapamil hydrochloride 1 MO

53Updated 10/01/20

Drug name Drug tier Requirements/Limitsverapamil hydrochloride er caps 200mg

1 MO

VERELAN 3 MOVERELAN PM 3 MO

DIURETICS acetazolamide er caps 1 MOacetazolamide sodium inj 1acetazolamide tabs 1 MOALDACTAZIDE 3 MOamiloride hcl 1 MOamiloride/hydrochlorothiazide 1 MObumetanide 1 MOBUMEX 3 MOchlorothiazide sodium inj 1chlorthalidone 1 MODIURIL 3 MODYAZIDE 3 MODYRENIUM 3 MOEDECRIN 4 MOethacrynate sodium inj 1ethacrynic acid 1 MOfurosemide 1 MOhydrochlorothiazide 1 MOindapamide 1 MOKEVEYIS 4 QL (120 EA per 28 days) PA MOLASIX 3 MOMANNITOL INJ 20% 3mannitol inj 25% 1 MOMAXZIDE 3 MOMAXZIDE-25 3 MOmethazolamide 1 MOmetolazone 1 MOMICROZIDE 3 MOOSMITROL VIAFLEX INJ 3SODIUM DIURIL INJ 3SODIUM EDECRIN INJ 3spironolactone/hydrochlorothiazide 1 MO

54 Updated 10/01/20

Drug name Drug tier Requirements/Limitstorsemide 1 MOtriamterene 1 MOtriamterene/hydrochlorothiazide 1 MO

MISCELLANEOUS ADRENALIN INJ 30MG/30ML 3ADRENALIN INJ 1MG/ML 3 MOaliskiren 1 MOamlodipine besylate/atorvastatin calcium

1 MO

BIDIL 3 MOCADUET 3 MOCATAPRES TABS 3 MOCATAPRES-TTS-1 3 QL (8 EA per 28 days) MOCATAPRES-TTS-2 3 QL (8 EA per 28 days) MOCATAPRES-TTS-3 3 QL (8 EA per 28 days) MOclonidine hcl patch weekly 0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr


clonidine hydrochloride tabs 1 MOCORLANOR SOLN 3CORLANOR TABS 3 MODEMSER 4 PA MODIBENZYLINE 4 MOdigitek 1 QL (30 EA per 30 days)digox 1 QL (30 EA per 30 days)digoxin inj, oral soln 1 MOdigoxin tabs 1 QL (30 EA per 30 days) MOdobutamine hcl 1 B/DDOBUTAMINE HCL/D5W INJ 1MG/ML

3 B/D

DOBUTAMINE HYDROCHLORIDE/DEXTROSE INJ 2ML/ML, 4MG/ML

3 B/D

DOPAMINE HYDROCHLORIDE 3 B/DDOPAMINE HYDROCHLORIDE/DEXTROSE INJ 0.8MG/ML, 1.6MG/ML

3 B/D

DOPAMINE/D5W INJ 3.2MG/ML 3 B/Dguanfacine hcl 1 PA MOhydralazine hcl 1 MO

55Updated 10/01/20

Drug name Drug tier Requirements/Limitshydralazine hydrochloride tabs 1 MOLANOXIN PEDIATRIC 3LANOXIN INJ 3 MOLANOXIN TABS 125MCG, 250MCG 3 QL (30 EA per 30 days) MOLANOXIN TABS 62.5MCG 3 QL (60 EA per 30 days) MOmethyldopa 1 PA MOmethyldopa/hydrochlorothiazide 1 PA MOmidodrine hcl 1 MOmilrinone in dextrose 1 B/Dmilrinone lactate inj 10mg/10ml, 50mg/50ml

1 B/D

milrinone lactate inj 20mg/20ml 4 B/Dminoxidil 1 MONORTHERA CAPS 200MG, 300MG 4 QL (180 EA per 30 days) PA LANORTHERA CAPS 100MG 4 QL (90 EA per 30 days) PA LAphenoxybenzamine hydrochloride 4 MORANEXA 3 MOranolazine er 1 MOTEKTURNA 3 MOTEKTURNA HCT 3 MOVECAMYL 4 QL (300 EA per 30 days) PAVYNDAMAX 4 QL (30 EA per 30 days) PAVYNDAQEL 4 QL (120 EA per 30 days) PA

NITRATES DILATRATE SR 3 MOGONITRO 3 MOISORDIL TITRADOSE 3 MOisosorbide dinitrate immediate release tabs

1 MO

isosorbide mononitrate er tabs 1 MOisosorbide mononitrate immediate release tabs

1 MO

minitran 1NITRO-BID 2 MONITRO-DUR 3 MONITROGLYCERIN IN DEXTROSE 5% 3nitroglycerin lingual spray 0.4mg 1 MO

56 Updated 10/01/20

Drug name Drug tier Requirements/Limitsnitroglycerin patch 1 MONITROGLYCERIN INJ 3nitroglycerin subl 1 MONITROLINGUAL PUMPSPRAY 3 MONITROSTAT 3 MO

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 4 PAADEMPAS 4 QL (90 EA per 30 days) PA LAalyq 4 PAambrisentan 4 QL (30 EA per 30 days) PAbosentan tabs 62.5mg 4 QL (120 EA per 30 days) PAbosentan tabs 125mg 4 QL (60 EA per 30 days) PAepoprostenol sodium 1 B/D LAFLOLAN INJ 0.5MG 3 B/DFLOLAN INJ 1.5MG 4 B/DLETAIRIS 4 QL (30 EA per 30 days) PA LAOPSUMIT 4 QL (30 EA per 30 days) PA LAORENITRAM ER TABS 0.125MG 3 PAORENITRAM ER TABS 0.25MG, 1MG, 2.5MG, 5MG

4 PA

REMODULIN 4 PA LAREVATIO INJ 4 QL (1125 ML per 30 days) PAREVATIO ORAL SUSP 4 QL (224 ML per 30 days) PAREVATIO TABS 4 QL (90 EA per 30 days) PAsildenafil inj 4 QL (1125 ML per 30 days) PAsildenafil citrate tabs 20mg 1 QL (90 EA per 30 days) PAsildenafil citrate oral susp 4 QL (224 ML per 30 days) PAtadalafil (generic adcirca) tabs 20mg 4 PATRACLEER TABS FOR ORAL SUSP 4 QL (120 EA per 30 days) PATRACLEER TABS 62.5MG 4 QL (120 EA per 30 days) PA LATRACLEER TABS 125MG 4 QL (60 EA per 30 days) PA LAtreprostinil 4 PATYVASO 4 B/DTYVASO REFILL 4 B/DTYVASO STARTER 4 B/DUPTRAVI TITRATION PAK 4 PA LAUPTRAVI TABS 800MCG 4 QL (120 EA per 30 days) PA LA

57Updated 10/01/20

Drug name Drug tier Requirements/LimitsUPTRAVI TABS 600MCG 4 QL (150 EA per 30 days) PA LAUPTRAVI TABS 400MCG 4 QL (240 EA per 30 days) PA LAUPTRAVI TABS 200MCG 4 QL (480 EA per 30 days) PA LAUPTRAVI TABS 1200MCG, 1400MCG, 1600MCG

4 QL (60 EA per 30 days) PA LA

UPTRAVI TABS 1000MCG 4 QL (90 EA per 30 days) PA LAVELETRI INJ 0.5MG 3 B/DVELETRI INJ 1.5MG 4 B/DVENTAVIS 4 PA

CENTRAL NERVOUS SYSTEMANTIANXIETY

alprazolam er tb24 0.5mg, 1mg 1 QL (30 EA per 30 days) MOalprazolam er tb24 3mg 1 QL (60 EA per 30 days) MOalprazolam er tb24 2mg 1 QL (90 EA per 30 days) MOALPRAZOLAM INTENSOL 3 QL (300 ML per 30 days) MOalprazolam odt tbdp 0.25mg 1 QL (120 EA per 30 days) MOalprazolam odt tbdp 0.5mg, 1mg, 2mg


ALPRAZOLAM XR TB24 1MG 3 QL (30 EA per 30 days) MOALPRAZOLAM XR TB24 3MG 3 QL (60 EA per 30 days) MOALPRAZOLAM XR TB24 2MG 3 QL (90 EA per 30 days) MOalprazolam tabs 0.25mg, 0.5mg 1 QL (120 EA per 30 days) MOalprazolam tabs 1mg, 2mg 1 QL (150 EA per 30 days) MOATIVAN INJ 4MG/ML 3 QL (150 ML per 30 days)ATIVAN INJ 2MG/ML 3 QL (150 ML per 30 days) MOATIVAN TABS 0.5MG 4 QL (120 EA per 30 days) MOATIVAN TABS 1MG, 2MG 4 QL (150 EA per 30 days) MObuspirone hcl tabs 15mg, 30mg 1 MObuspirone hydrochloride tabs 10mg, 5mg, 7.5mg

1 MO

chlordiazepoxide hcl tabs 10mg, 5mg 1 QL (120 EA per 30 days) MOchlordiazepoxide hydrochloride tabs 25mg


droperidol 1 MOfluvoxamine maleate er 1 QL (60 EA per 30 days) MOfluvoxamine maleate tabs 1 MOlorazepam conc, inj 1 QL (150 ML per 30 days) MO

58 Updated 10/01/20

Drug name Drug tier Requirements/Limitslorazepam tabs 0.5mg 1 QL (120 EA per 30 days) MOlorazepam tabs 1mg, 2mg 1 QL (150 EA per 30 days) MOmeprobamate 1 PA MOoxazepam 1 QL (120 EA per 30 days) MOXANAX XR TB24 0.5MG, 1MG 3 QL (30 EA per 30 days) ST MOXANAX XR TB24 3MG 3 QL (60 EA per 30 days) ST MOXANAX XR TB24 2MG 3 QL (90 EA per 30 days) ST MOXANAX TABS 0.25MG, 0.5MG 3 QL (120 EA per 30 days) ST MOXANAX TABS 1MG 3 QL (150 EA per 30 days) ST MOXANAX TABS 2MG 4 QL (150 EA per 30 days) ST MO

ANTICONVULSANTS APTIOM 4 MOBANZEL 4 PA MOBRIVIACT INJ 4 PABRIVIACT ORAL SOLN, TABS 4 PA MOcarbamazepine chew, susp, tabs 1 MOcarbamazepine er 1 MOCARBATROL 3 MOCELONTIN 3 MOCEREBYX INJ 100MG PE/2ML 3CEREBYX INJ 500MG PE/10ML 3 MOclobazam tabs 1 PA MOclobazam susp 4 PA MOclonazepam odt tbdp 2mg 1 QL (300 EA per 30 days) MOclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg


clonazepam tabs 2mg 1 QL (300 EA per 30 days) MOclonazepam tabs 0.5mg, 1mg 1 QL (90 EA per 30 days) MOclorazepate dipotassium tabs 15mg 1 QL (180 EA per 30 days) PA MOclorazepate dipotassium tabs 3.75mg, 7.5mg


DEPAKOTE 3 MODEPAKOTE ER 3 MODEPAKOTE SPRINKLES 3 MODIASTAT ACUDIAL 3 MODIASTAT PEDIATRIC 3 MODIAZEPAM RECTAL GEL 3 MO

59Updated 10/01/20

Drug name Drug tier Requirements/Limitsdiazepam tabs 1 QL (120 EA per 30 days) PA MOdiazepam oral soln 1 QL (1200 ML per 30 days) PA MOdiazepam oral conc, inj 1 QL (240 ML per 30 days) PA MODILANTIN 3 MODILANTIN INFATABS 3 MODILANTIN-125 3 MOdivalproex sodium dr 1 MOdivalproex sodium er 1 MOdivalproex sodium sprinkle caps 1 MOEPIDIOLEX 4 QL (600 ML per 30 days) PA LAepitol 1ethosuximide 1 MOfelbamate 1 MOFELBATOL 4 MOFINTEPLA 4 QL (360 ML per 30 days) PAfosphenytoin sodium inj 100mg pe/2ml

1

fosphenytoin sodium inj 500mg pe/10ml

1 MO

FYCOMPA SUSP 4 QL (720 ML per 30 days) PA MOFYCOMPA TABS 2MG 3 QL (60 EA per 30 days) PA MOFYCOMPA TABS 10MG, 12MG, 8MG 4 QL (30 EA per 30 days) PA MOFYCOMPA TABS 4MG, 6MG 4 QL (60 EA per 30 days) PA MOgabapentin caps 300mg 1 QL (360 EA per 30 days) MOgabapentin caps 100mg, 400mg 1 QL (90 EA per 30 days) MOgabapentin soln 1 QL (2160 ML per 30 days) MOgabapentin tabs 600mg 1 QL (180 EA per 30 days) MOgabapentin tabs 800mg 1 QL (90 EA per 30 days) MOGABITRIL TABS 2MG, 4MG 3 MOGABITRIL TABS 12MG, 16MG 4 MOKEPPRA XR TB24 500MG 3 MOKEPPRA XR TB24 750MG 4 MOKEPPRA INJ 3KEPPRA ORAL SOLN 4 MOKEPPRA TABS 250MG 3 MOKEPPRA TABS 1000MG, 500MG, 750MG

4 MO

60 Updated 10/01/20

Drug name Drug tier Requirements/LimitsKLONOPIN TABS 2MG 3 QL (300 EA per 30 days) MOKLONOPIN TABS 0.5MG, 1MG 3 QL (90 EA per 30 days) MOLAMICTAL CHEWABLE DISPERSIBLE 4 MOLAMICTAL ODT KIT 3 MOLAMICTAL ODT TBDP 200MG, 50MG 3 MOLAMICTAL ODT TBDP 100MG, 25MG 4 MOLAMICTAL STARTER/NOT TAKING CARBAMAZEPINE

3 MO

LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE

4 MO

LAMICTAL STARTER/TAKING VALPROATE

3 MO

LAMICTAL TABS 4 MOLAMICTAL XR TB24 4 MOLAMICTAL XR STARTER KIT BLUE, ORANGE

3 MO

LAMICTAL XR STARTER KIT GREEN 4 MOlamotrigine chew, tabs 1 MOlamotrigine er 1 MOlamotrigine odt 1 MOlamotrigine starter kit/blue 1 MOlamotrigine starter kit/green 1 MOlamotrigine starter kit/orange 1 MOlevetiracetam er 1 MOlevetiracetam/sodium chloride 1levetiracetam inj 1levetiracetam oral soln, tabs 1 MOLYRICA SOLN 3 QL (900 ML per 30 days) PA MOLYRICA CAPS 100MG, 150MG, 25MG, 50MG, 75MG


LYRICA CAPS 225MG, 300MG 3 QL (60 EA per 30 days) PA MOLYRICA CAPS 200MG 3 QL (90 EA per 30 days) PA MOMYSOLINE 4 MONAYZILAM 3 QL (10 EA per 30 days) PA MONEURONTIN SOLN 3 QL (2160 ML per 30 days) MONEURONTIN CAPS 300MG 3 QL (360 EA per 30 days) MONEURONTIN CAPS 100MG, 400MG 3 QL (90 EA per 30 days) MO

61Updated 10/01/20

Drug name Drug tier Requirements/LimitsNEURONTIN TABS 600MG 4 QL (180 EA per 30 days) MONEURONTIN TABS 800MG 4 QL (90 EA per 30 days) MOONFI 4 PA MOoxcarbazepine 1 MOOXTELLAR XR TB24 150MG, 300MG 3 MOOXTELLAR XR TB24 600MG 4 MOPEGANONE 3 MOPHENOBARBITAL SODIUM INJ 3 PAPHENOBARBITAL TABS 3 QL (120 EA per 30 days) PA MOPHENOBARBITAL ELIX 3 QL (1500 ML per 30 days) PA MOPHENYTEK 3 MOphenytoin chew, susp 1 MOphenytoin sodium er caps 1 MOphenytoin sodium inj 1pregabalin caps 100mg, 150mg, 25mg, 50mg, 75mg


pregabalin caps 225mg, 300mg 1 QL (60 EA per 30 days) PA MOpregabalin caps 200mg 1 QL (90 EA per 30 days) PA MOpregabalin soln 1 QL (900 ML per 30 days) PA MOprimidone 1 MOQUDEXY XR CS24 100MG, 25MG, 50MG

3 MO

QUDEXY XR CS24 150MG, 200MG 4 MOroweepra 1roweepra xr 1SABRIL PACK 4 QL (180 EA per 30 days) PASABRIL TABS 4 QL (180 EA per 30 days) PA LASPRITAM 3 PA MOsubvenite 1subvenite starter kit/blue 1subvenite starter kit/green 1subvenite starter kit/orange 1SYMPAZAN FILM 5MG 3 PA MOSYMPAZAN FILM 10MG, 20MG 4 PA MOTEGRETOL 3 MOTEGRETOL-XR 3 MOtiagabine hydrochloride tabs 1 MO

62 Updated 10/01/20

Drug name Drug tier Requirements/LimitsTOPAMAX SPRINKLE CPSP 15MG 3 MOTOPAMAX SPRINKLE CPSP 25MG 4 MOTOPAMAX TABS 25MG 3 MOTOPAMAX TABS 100MG, 200MG, 50MG

4 MO

TOPIRAMATE ER 3 MOtopiramate sprinkle caps, tabs 1 MOTRANXENE T 3 QL (90 EA per 30 days) PA MOTRILEPTAL SUSP 4 MOTRILEPTAL TABS 150MG 3 MOTRILEPTAL TABS 300MG, 600MG 4 MOTROKENDI XR CP24 100MG, 25MG, 50MG

3 MO

TROKENDI XR CP24 200MG 4 MOVALIUM 3 QL (120 EA per 30 days) PA MOvalproate sodium inj 100mg/ml 1valproic acid caps, soln 1 MOVALTOCO 3 QL (10 EA per 30 days) PAvigabatrin 4 QL (180 EA per 30 days) PAvigadrone 1 QL (180 EA per 30 days) PAVIMPAT INJ 4VIMPAT ORAL SOLN 4 MOVIMPAT TABS 50MG 3 MOVIMPAT TABS 100MG, 150MG, 200MG

4 MO

XCOPRI TABS 150MG 4XCOPRI TABS 100MG, 200MG, 50MG

4 MO

XCOPRI TITRATION PACK 12.5MG-25MG

3 MO

XCOPRI MAINTENACE PACK 4XCOPRI TITRATION PACK 50MG-100MG, 150MG-200MG

4 MO

ZARONTIN 3 MOZONEGRAN CAPS 25MG 3 MOZONEGRAN CAPS 100MG 4 MOzonisamide 1 MO

63Updated 10/01/20

Drug name Drug tier Requirements/LimitsANTIDEMENTIA

ARICEPT TABS 23MG, 5MG 3 QL (30 EA per 30 days) MOARICEPT TABS 10MG 3 QL (60 EA per 30 days) MOdonepezil hcl odt tabs 5mg, 10mg 1 QL (30 EA per 30 days) MOdonepezil hcl tabs 23mg 1 QL (30 EA per 30 days) MOdonepezil hcl tabs 10mg 1 QL (60 EA per 30 days) MOdonepezil hydrochloride tabs 5mg 1 QL (30 EA per 30 days) MOergoloid mesylates 1 PA MOEXELON 3 QL (30 EA per 30 days) MOgalantamine hydrobromide er 1 QL (30 EA per 30 days) MOgalantamine hydrobromide soln 1 QL (200 ML per 30 days) MOgalantamine hydrobromide tabs 1 QL (60 EA per 30 days) MOMEMANTINE HCL TITRATION PAK 2 QL (98 EA per 365 days) PA MOmemantine hydrochloride er 1 PA MOmemantine hydrochloride soln 1 QL (360 ML per 30 days) PA MOmemantine hydrochloride tabs 1 QL (60 EA per 30 days) PA MONAMENDA 3 QL (60 EA per 30 days) PA MONAMENDA TITRATION PAK 3 QL (98 EA per 365 days) PA MONAMENDA XR 3 PA MONAMENDA XR TITRATION PACK 3 PA MONAMZARIC 3 MORAZADYNE ER 3 QL (30 EA per 30 days) MOrivastigmine tartrate caps 1 QL (60 EA per 30 days) MOrivastigmine patch 1 QL (30 EA per 30 days) MO

ANTIDEPRESSANTS amitriptyline hcl tabs 100mg, 10mg, 150mg, 25mg, 75mg

1 PA MO

amitriptyline hydrochloride tabs 50mg

1 PA MO

amoxapine 1 MOANAFRANIL 4 PA MOAPLENZIN TB24 348MG, 522MG 4 QL (30 EA per 30 days) ST MOAPLENZIN TB24 174MG 4 QL (60 EA per 30 days) ST MObupropion hcl tabs 100mg 1 QL (180 EA per 30 days) MObupropion hydrochloride er (sr) tb12 100mg, 150mg, 200mg


64 Updated 10/01/20

Drug name Drug tier Requirements/LimitsBUPROPION HYDROCHLORIDE ER (XL) TB24 450MG


bupropion hydrochloride er (xl) tb24 150mg, 300mg


bupropion hydrochloride tabs 75mg 1 QL (180 EA per 30 days) MOCELEXA TABS 10MG 3 QL (120 EA per 30 days) ST MOCELEXA TABS 40MG 3 QL (30 EA per 30 days) ST MOCELEXA TABS 20MG 3 QL (60 EA per 30 days) ST MOcitalopram hydrobromide soln 1 QL (600 ML per 30 days) MOcitalopram hydrobromide tabs 10mg 1 QL (120 EA per 30 days) MOcitalopram hydrobromide tabs 40mg 1 QL (30 EA per 30 days) MOcitalopram hydrobromide tabs 20mg 1 QL (60 EA per 30 days) MOclomipramine hcl caps 1 PA MOCYMBALTA 3 QL (60 EA per 30 days) MOdesipramine hcl tabs 1 MODESVENLAFAXINE ER (GENERIC KHEDEZLA) TB24 100MG, 50MG


desvenlafaxine er (generic Pristiq) tb24 100mg, 25mg, 50mg


doxepin hcl caps 10mg, 50mg, 75mg, 100mg, 150mg, oral conc 10mg/ml

1 PA MO

doxepin hydrochloride caps 25mg 1 PA MODRIZALMA SPRINKLE CSDR 20MG, 30MG, 60MG


DRIZALMA SPRINKLE CSDR 40MG 3 QL (90 EA per 30 days) PA MOduloxetine hcl caps 40mg 1 QL (60 EA per 30 days) MOduloxetine hydrochloride caps 20mg, 30mg, 60mg


EFFEXOR XR CP24 37.5MG, 75MG 3 QL (30 EA per 30 days) ST MOEFFEXOR XR CP24 150MG 3 QL (60 EA per 30 days) ST MOEMSAM 4 QL (30 EA per 30 days) PA MOescitalopram oxalate soln 1 QL (600 ML per 30 days) MOescitalopram oxalate tabs 20mg 1 QL (30 EA per 30 days) MOescitalopram oxalate tabs 10mg, 5mg 1 QL (45 EA per 30 days) MOFETZIMA TITRATION PACK 3 PA MOFETZIMA CP24 120MG, 80MG 3 QL (30 EA per 30 days) PA MOFETZIMA CP24 20MG, 40MG 3 QL (60 EA per 30 days) PA MOfluoxetine dr caps 90mg 1 QL (4 EA per 28 days) MO

65Updated 10/01/20

Drug name Drug tier Requirements/Limitsfluoxetine hcl caps 20mg 1 QL (120 EA per 30 days) MOfluoxetine hydrochloride caps 10mg 1 QL (30 EA per 30 days) MOfluoxetine hydrochloride caps 40mg 1 QL (60 EA per 30 days) MOfluoxetine hydrochloride soln 1 MOfluoxetine hydrochloride (generic Prozac) tabs 10mg, 20mg, 60mg

1 MO

fluoxetine hydrochloride (generic Sarafem) tabs 20mg


fluoxetine hydrochloride (generic Sarafem) tabs 10mg


FORFIVO XL 3 QL (30 EA per 30 days) ST MOimipramine hcl tabs 25mg, 50mg 1 PA MOimipramine hydrochloride tabs 10mg 1 PA MOimipramine pamoate 1 PA MOLEXAPRO TABS 20MG 3 QL (30 EA per 30 days) MOLEXAPRO TABS 10MG, 5MG 3 QL (45 EA per 30 days) MOmaprotiline hcl 1 MOMARPLAN 3 QL (180 EA per 30 days) MOmirtazapine odt 1 QL (30 EA per 30 days) MOmirtazapine tabs 1 QL (30 EA per 30 days) MONARDIL 3 MOnefazodone hcl tabs 100mg, 150mg 1 MOnefazodone hydrochloride tabs 200mg, 250mg, 50mg

1 MO

NORPRAMIN 3 MOnortriptyline hcl caps 25mg, 75mg, soln 10mg/5ml

1 MO

nortriptyline hydrochloride caps 10mg, 50mg

1 MO

olanzapine/fluoxetine 1 QL (30 EA per 30 days) MOPAMELOR 4 MOPARNATE 4 MOparoxetine hcl tabs 30mg, 40mg 1 QL (60 EA per 30 days) MOparoxetine hcl er tb24 37.5mg 1 QL (60 EA per 30 days) MOparoxetine hcl er tb24 12.5mg, 25mg 1 QL (90 EA per 30 days) MOparoxetine hydrochloride tabs 10mg, 20mg


PAXIL CR TB24 37.5MG 3 QL (60 EA per 30 days) ST MO

66 Updated 10/01/20

Drug name Drug tier Requirements/LimitsPAXIL CR TB24 12.5MG, 25MG 3 QL (90 EA per 30 days) ST MOPAXIL ORAL SUSP 3 QL (900 ML per 30 days) MOPAXIL TABS 10MG, 20MG 3 QL (30 EA per 30 days) ST MOPAXIL TABS 30MG, 40MG 3 QL (60 EA per 30 days) ST MOperphenazine/amitriptyline 1 PA MOPEXEVA TABS 10MG, 20MG, 40MG 3 QL (30 EA per 30 days) ST MOPEXEVA TABS 30MG 3 QL (60 EA per 30 days) ST MOphenelzine sulfate 1 MOPRISTIQ 3 QL (30 EA per 30 days) ST MOprotriptyline hcl 1 MOPROZAC CAPS 20MG 3 QL (120 EA per 30 days) ST MOPROZAC CAPS 10MG 3 QL (30 EA per 30 days) ST MOPROZAC CAPS 40MG 4 QL (60 EA per 30 days) ST MOREMERON 3 QL (30 EA per 30 days) MOREMERON SOLTAB 3 QL (30 EA per 30 days) MOSARAFEM TABS 20MG 3 QL (120 EA per 30 days) MOSARAFEM TABS 10MG 3 QL (30 EA per 30 days) MOsertraline hcl oral conc 1 QL (300 ML per 30 days) MOsertraline hcl tabs 25mg 1 QL (30 EA per 30 days) MOsertraline hcl tabs 50mg 1 QL (60 EA per 30 days) MOsertraline hydrochloride tabs 100mg 1 QL (60 EA per 30 days) MOSYMBYAX 3 QL (30 EA per 30 days) MOtranylcypromine sulfate 1 MOtrazodone hydrochloride tabs 1 MOtrimipramine maleate caps 50mg 1 QL (120 EA per 30 days) PA MOtrimipramine maleate caps 25mg 1 QL (240 EA per 30 days) PA MOtrimipramine maleate caps 100mg 1 QL (60 EA per 30 days) PA MOTRINTELLIX TABS 5MG 3 QL (120 EA per 30 days) MOTRINTELLIX TABS 20MG 3 QL (30 EA per 30 days) MOTRINTELLIX TABS 10MG 3 QL (60 EA per 30 days) MOvenlafaxine hcl er cp24 37.5mg 1 QL (30 EA per 30 days) MOvenlafaxine hcl er cp24 150mg 1 QL (60 EA per 30 days) MOvenlafaxine hcl er tb24 37.5mg 1 QL (30 EA per 30 days) MOvenlafaxine hcl tabs 25mg, 37.5mg, 50mg, 75mg, 100mg

1 MO

venlafaxine hydrochloride er cp24 75mg


67Updated 10/01/20

Drug name Drug tier Requirements/Limitsvenlafaxine hydrochloride er tb24 225mg, 75mg


venlafaxine hydrochloride er tb24 150mg


VIIBRYD 3 QL (30 EA per 30 days) MOVIIBRYD STARTER PACK 3 MOWELLBUTRIN SR 3 QL (60 EA per 30 days) ST MOWELLBUTRIN XL 4 QL (30 EA per 30 days) ST MOZOLOFT ORAL CONC 3 QL (300 ML per 30 days) MOZOLOFT TABS 25MG 3 QL (30 EA per 30 days) ST MOZOLOFT TABS 100MG, 50MG 3 QL (60 EA per 30 days) ST MO

ANTIPARKINSONIAN AGENTS amantadine hcl syrp, tabs 1 MOamantadine hcl caps 1 QL (120 EA per 30 days) MOAPOKYN 4 QL (60 ML per 30 days) PA LAAZILECT 3 MObenztropine mesylate inj 1 MObenztropine mesylate tabs 1 PA MObromocriptine mesylate tabs, caps 1 MOcarbidopa tabs 4 MOcarbidopa/levodopa 1 MOcarbidopa/levodopa er 1 MOcarbidopa/levodopa odt 1 MOCARBIDOPA/LEVODOPA/ENTACAPONE

3 MO

COGENTIN 3COMTAN 4 MODUOPA 4 B/D MOentacapone 1 MOGOCOVRI 4 QL (60 EA per 30 days)INBRIJA 3 QL (300 EA per 30 days) PAKYNMOBI 4 QL (150 EA per 30 days) PALODOSYN 4 MOMIRAPEX 3 ST MOMIRAPEX ER 3 QL (30 EA per 30 days) ST MONEUPRO 3 MONOURIANZ 4 QL (30 EA per 30 days) PA

68 Updated 10/01/20

Drug name Drug tier Requirements/LimitsOSMOLEX ER TABS 129MG, 193MG, 258MG

3 QL (30 EA per 30 days) ST

OSMOLEX ER DOSING KIT 3 QL (60 EA per 30 days) STPARLODEL 3 MOpramipexole dihydrochloride er 1 QL (30 EA per 30 days) MOpramipexole dihydrochloride immediate release tabs

1 MO

rasagiline mesylate 1 MOropinirole er tb24 6mg 1 QL (120 EA per 30 days) MOropinirole er tb24 4mg 1 QL (150 EA per 30 days) MOropinirole er tb24 2mg 1 QL (30 EA per 30 days) MOropinirole er tb24 12mg 1 QL (60 EA per 30 days) MOropinirole er tb24 8mg 1 QL (90 EA per 30 days) MOropinirole hcl immediate release tabs 0.5mg, 1mg, 2mg, 4mg, 5mg

1 MO

ropinirole hydrochloride immediate release tabs 0.25mg, 3mg

1 MO

RYTARY 3 ST MOselegiline hcl tabs, caps 1 MOSINEMET 3 MOSINEMET CR 3 MOSTALEVO 100 4 ST MOSTALEVO 125 4 ST MOSTALEVO 150 4 ST MOSTALEVO 200 4 ST MOSTALEVO 50 3 ST MOSTALEVO 75 4 ST MOTASMAR 4 MOtolcapone 4 MOtrihexyphenidyl hcl oral soln 1 PA MOtrihexyphenidyl hydrochloride tabs 1 PA MOXADAGO 3 QL (30 EA per 30 days) ST MOZELAPAR 4 QL (60 EA per 30 days) MO

ANTIPSYCHOTICS ABILIFY 4 QL (30 EA per 30 days) MOABILIFY MAINTENA 4 QL (1 EA per 28 days) MOABILIFY MYCITE 4 QL (30 EA per 30 days) PA

69Updated 10/01/20

Drug name Drug tier Requirements/Limitsaripiprazole odt 4 QL (60 EA per 30 days) MOaripiprazole tabs 1 QL (30 EA per 30 days) MOaripiprazole soln 1 QL (900 ML per 30 days) MOARISTADA INITIO 4ARISTADA INJ 441MG/1.6ML 4 QL (1.6 ML per 28 days)ARISTADA INJ 662MG/2.4ML 4 QL (2.4 ML per 28 days)ARISTADA INJ 882MG/3.2ML 4 QL (3.2 ML per 28 days)ARISTADA INJ 1064MG/3.9ML 4 QL (3.9 ML per 56 days)CAPLYTA 4 QL (30 EA per 30 days) PA MOchlorpromazine hcl tabs 1 MOCHLORPROMAZINE HCL INJ 50MG/2ML

3

CHLORPROMAZINE HCL INJ 25MG/ML

3 MO

CLOZAPINE ODT TBDP 200MG 3 QL (135 EA per 30 days) PACLOZAPINE ODT TBDP 150MG 3 QL (180 EA per 30 days) PAclozapine odt tbdp 12.5mg, 25mg 1 PAclozapine odt tbdp 100mg 1 QL (270 EA per 30 days) PAclozapine tabs 1CLOZARIL TABS 25MG, 50MG 3CLOZARIL TABS 100MG, 200MG 4FANAPT TITRATION PACK 3 PA MOFANAPT TABS 1MG 3 QL (60 EA per 30 days) PA MOFANAPT TABS 10MG, 12MG, 2MG, 4MG, 6MG, 8MG


fluphenazine decanoate inj 1 MOfluphenazine hcl 1 MOfluphenazine hydrochloride oral elixir 1 MOGEODON INJ 3 QL (6 EA per 3 days) MOGEODON CAPS 20MG 3 QL (60 EA per 30 days) MOGEODON CAPS 40MG, 60MG, 80MG 4 QL (60 EA per 30 days) MOHALDOL DECANOATE 100 3 MOHALDOL DECANOATE 50 3 MOHALDOL INJ 3 MOhaloperidol 1 MOhaloperidol decanoate inj 1 MOhaloperidol lactate inj 1 MO

70 Updated 10/01/20

Drug name Drug tier Requirements/LimitsINVEGA SUSTENNA INJ 39MG/0.25ML

3 QL (0.25 ML per 28 days) MO

INVEGA SUSTENNA INJ 78MG/0.5ML 4 QL (0.5 ML per 28 days) MOINVEGA SUSTENNA INJ 117MG/0.75ML


INVEGA SUSTENNA INJ 156MG/ML 4 QL (1 ML per 28 days) MOINVEGA SUSTENNA INJ 234MG/1.5ML


INVEGA TRINZA INJ 273MG/0.875ML 4 QL (0.88 ML per 90 days)INVEGA TRINZA INJ 410MG/1.315ML 4 QL (1.32 ML per 90 days)INVEGA TRINZA INJ 546MG/1.75ML 4 QL (1.75 ML per 90 days)INVEGA TRINZA INJ 819MG/2.625ML 4 QL (2.63 ML per 90 days)INVEGA TB24 1.5MG, 3MG, 9MG 4 QL (30 EA per 30 days) MOINVEGA TB24 6MG 4 QL (60 EA per 30 days) MOLATUDA TABS 120MG, 20MG, 40MG, 60MG


LATUDA TABS 80MG 4 QL (60 EA per 30 days) MOloxapine caps 10mg 1 MOloxapine succinate caps 25mg, 50mg, 5mg

1 MO

molindone hydrochloride 1NUPLAZID 4 QL (30 EA per 30 days) PA LAolanzapine odt 1 QL (30 EA per 30 days) MOolanzapine inj 1 QL (3 EA per 1 days) MOolanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg


olanzapine tabs 2.5mg 1 QL (60 EA per 30 days) MOpaliperidone er tb24 1.5mg, 3mg 1 QL (30 EA per 30 days) MOpaliperidone er tb24 6mg 1 QL (60 EA per 30 days) MOpaliperidone er tb24 9mg 4 QL (30 EA per 30 days) MOperphenazine 1 MOPERSERIS 4 QL (1 EA per 30 days)pimozide 1 MOquetiapine fumarate er tb24 150mg, 200mg


quetiapine fumarate er tb24 300mg, 400mg, 50mg


quetiapine fumarate tabs 200mg 1 QL (120 EA per 30 days) MO

71Updated 10/01/20

Drug name Drug tier Requirements/Limitsquetiapine fumarate tabs 25mg 1 QL (180 EA per 30 days) MOquetiapine fumarate tabs 300mg, 400mg


quetiapine fumarate tabs 100mg, 50mg


REXULTI TABS 3MG, 4MG 4 QL (30 EA per 30 days) MOREXULTI TABS 0.25MG, 0.5MG, 1MG, 2MG


RISPERDAL CONSTA INJ 12.5MG, 25MG


RISPERDAL CONSTA INJ 37.5MG, 50MG


RISPERDAL SOLN 4 MORISPERDAL TABS 1MG, 2MG 3 QL (60 EA per 30 days) MORISPERDAL TABS 0.5MG 3 QL (90 EA per 30 days) MORISPERDAL TABS 4MG 4 QL (120 EA per 30 days) MORISPERDAL TABS 3MG 4 QL (90 EA per 30 days) MOrisperidone odt tbdp 1mg, 2mg, 3mg, 4mg


risperidone odt tbdp 0.25mg, 0.5mg 1 QL (90 EA per 30 days) MOrisperidone soln 1 MOrisperidone tabs 4mg 1 QL (120 EA per 30 days) MOrisperidone tabs 1mg, 2mg 1 QL (60 EA per 30 days) MOrisperidone tabs 0.25mg, 0.5mg, 3mg 1 QL (90 EA per 30 days) MOSAPHRIS 4 QL (60 EA per 30 days) MOSECUADO 4 QL (30 EA per 30 days)SEROQUEL XR TB24 150MG, 200MG 3 QL (30 EA per 30 days) PA MOSEROQUEL XR TB24 300MG, 50MG 3 QL (60 EA per 30 days) PA MOSEROQUEL XR TB24 400MG 4 QL (60 EA per 30 days) PA MOSEROQUEL TABS 200MG 3 QL (120 EA per 30 days) MOSEROQUEL TABS 25MG 3 QL (180 EA per 30 days) MOSEROQUEL TABS 300MG 3 QL (60 EA per 30 days) MOSEROQUEL TABS 100MG, 50MG 3 QL (90 EA per 30 days) MOSEROQUEL TABS 400MG 4 QL (60 EA per 30 days) MOthioridazine hcl tabs 1 PA MOthiothixene 1 MOtrifluoperazine hcl 1 MOVERSACLOZ 4 QL (600 ML per 30 days) PA

72 Updated 10/01/20

Drug name Drug tier Requirements/LimitsVRAYLAR CAP THERAPY PACK 3 PA MOVRAYLAR CAPS 3MG, 4.5MG, 6MG 4 QL (30 EA per 30 days) PA MOVRAYLAR CAPS 1.5MG 4 QL (60 EA per 30 days) PA MOziprasidone hcl caps 1 QL (60 EA per 30 days) MOziprasidone mesylate inj 1 QL (6 EA per 3 days)ZYPREXA RELPREVV INJ 210MG 3 QL (2 EA per 28 days) PAZYPREXA RELPREVV INJ 405MG 4 QL (1 EA per 28 days) PAZYPREXA RELPREVV INJ 300MG 4 QL (2 EA per 28 days) PAZYPREXA ZYDIS TBDP 10MG, 5MG 3 QL (30 EA per 30 days) MOZYPREXA ZYDIS TBDP 15MG, 20MG 4 QL (30 EA per 30 days) MOZYPREXA INJ 3 QL (3 EA per 1 days) MOZYPREXA TABS 10MG, 5MG, 7.5MG 3 QL (30 EA per 30 days) MOZYPREXA TABS 2.5MG 3 QL (60 EA per 30 days) MOZYPREXA TABS 15MG, 20MG 4 QL (30 EA per 30 days) MO

ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL XR 3 QL (30 EA per 30 days) MOADDERALL TABS 5MG, 7.5MG, 10MG, 12.5MG, 15MG, 30MG


ADDERALL TABS 20MG 3 QL (90 EA per 30 days) MOADZENYS ER ORAL SUSP 3 QL (450 ML per 30 days) MOADZENYS XR-ODT 3 QL (30 EA per 30 days) MOAMPHETAMINE ER ORAL SUSP 3 QL (450 ML per 30 days) MOamphetamine sulfate tabs 1 QL (180 EA per 30 days) MOamphetamine/dextroamphetamine er cp24


amphetamine/dextroamphetamine tabs 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 30mg


amphetamine/dextroamphetamine tabs 20mg


APTENSIO XR 3 QL (30 EA per 30 days) MOatomoxetine caps 10mg, 18mg, 25mg 1 QL (120 EA per 30 days) MOatomoxetine caps 100mg, 60mg, 80mg


atomoxetine caps 40mg 1 QL (60 EA per 30 days) MOclonidine hcl er tabs 0.1mg 1 MOCONCERTA 3 QL (30 EA per 30 days) MOCOTEMPLA XR-ODT 3 QL (30 EA per 30 days) MO

73Updated 10/01/20

Drug name Drug tier Requirements/LimitsDAYTRANA 3 QL (30 EA per 30 days) MODESOXYN 4 QL (150 EA per 30 days) MODEXEDRINE CP24 5MG 3 QL (120 EA per 30 days) MODEXEDRINE CP24 10MG, 15MG 4 QL (120 EA per 30 days) MOdexmethylphenidate hcl er caps 1 QL (30 EA per 30 days) MOdexmethylphenidate hcl tabs 5mg, 10mg


dexmethylphenidate hydrochloride tabs 2.5mg


dextroamphetamine sulfate er 1 QL (120 EA per 30 days) MOdextroamphetamine sulfate tabs 1 QL (180 EA per 30 days) MOdextroamphetamine sulfate soln 1 QL (1800 ML per 30 days) MODYANAVEL XR ORAL SUSP 3 QL (240 ML per 30 days) MOEVEKEO 3 QL (180 EA per 30 days) MOEVEKEO ODT TBDP 15MG, 5MG 3 QL (60 EA per 30 days)EVEKEO ODT TBDP 10MG, 20MG 3 QL (60 EA per 30 days) MOFOCALIN 3 QL (60 EA per 30 days) MOFOCALIN XR 3 QL (30 EA per 30 days) MOguanfacine er 1 QL (30 EA per 30 days) PA MOINTUNIV 3 QL (30 EA per 30 days) PA MOJORNAY PM 3 QL (30 EA per 30 days) MOKAPVAY 3 MOmetadate er 1 QL (90 EA per 30 days)methamphetamine hcl 1 QL (150 EA per 30 days) MOMETHYLIN SOLN 5MG/5ML 3 QL (1800 ML per 30 days) MOMETHYLIN SOLN 10MG/5ML 3 QL (900 ML per 30 days) MOmethylphenidate hydrochloride cd er caps 10mg, 20mg, 50mg, 60mg


methylphenidate hydrochloride er cp24 (generic ritalin la) 60mg


methylphenidate hydrochloride er cp24 10mg, 15mg, 50mg, 60mg


methylphenidate hydrochloride er cp24 (generic Ritalin LA) 10mg, 20mg, 40mg


methylphenidate hydrochloride er cp24 (generic Ritalin LA) 30mg


74 Updated 10/01/20

Drug name Drug tier Requirements/Limitsmethylphenidate hydrochloride er tb24 18mg, 27mg, 36mg, 54mg


methylphenidate hydrochloride cd er caps 30mg, 40mg


METHYLPHENIDATE HYDROCHLORIDE ER TBCR 72MG


methylphenidate hydrochloride er tbcr (generic Concerta) 18mg, 27mg, 36mg, 54mg


methylphenidate hydrochloride er tbcr 10mg, 20mg


methylphenidate hydrochloride chewable tablet


methylphenidate hydrochloride tabs 5mg, 10mg, 20mg


methylphenidate hydrochloride oral soln 5mg/5ml


methylphenidate hydrochloride oral soln 10mg/5ml


MYDAYIS 3 QL (30 EA per 30 days) MOprocentra oral soln 1 QL (1800 ML per 30 days)QUILLICHEW ER 40MG 3 QL (30 EA per 30 days) MOQUILLICHEW ER 30MG 3 QL (60 EA per 30 days) MOQUILLICHEW ER 20MG 3 QL (90 EA per 30 days) MOQUILLIVANT XR ORAL SUSP 3 MORELEXXII 3 QL (30 EA per 30 days) MORITALIN 3 QL (90 EA per 30 days) MORITALIN LA CP24 10MG, 20MG, 40MG


RITALIN LA CP24 30MG 3 QL (60 EA per 30 days) MOSTRATTERA CAPS 10MG, 18MG, 25MG


STRATTERA CAPS 100MG, 60MG, 80MG


STRATTERA CAPS 40MG 3 QL (60 EA per 30 days) MOVYVANSE 3 QL (30 EA per 30 days) MOzenzedi tabs 15mg 1 QL (120 EA per 30 days) MOzenzedi tabs 10mg, 5mg 1 QL (180 EA per 30 days)zenzedi tabs 2.5mg 1 QL (180 EA per 30 days) MO

75Updated 10/01/20

Drug name Drug tier Requirements/Limitszenzedi tabs 7.5mg 1 QL (240 EA per 30 days) MOzenzedi tabs 30mg 1 QL (60 EA per 30 days) MOzenzedi tabs 20mg 1 QL (90 EA per 30 days) MO

HYPNOTICS AMBIEN 3 QL (30 EA per 30 days) PA MOAMBIEN CR 3 QL (30 EA per 30 days) PA MOBELSOMRA 3 QL (30 EA per 30 days) MODAYVIGO 3 QL (30 EA per 30 days) PA MOdoxepin hydrochloride tabs 3mg, 6mg 1 QL (30 EA per 30 days) MOEDLUAR SUBL 10MG 3 QL (30 EA per 30 days) PA MOEDLUAR SUBL 5MG 3 QL (60 EA per 30 days) PA MOestazolam 1 QL (30 EA per 30 days) MOeszopiclone 1 QL (30 EA per 30 days) PA MOflurazepam hcl 1 QL (30 EA per 30 days) MOHALCION 3 QL (60 EA per 30 days) MOHETLIOZ 4 PA LA MOLUNESTA 3 QL (30 EA per 30 days) PA MOmidazolam hcl inj 10mg/10ml, 10mg/2ml, 25mg/5ml, 2mg/2ml pf, 5mg/5ml pf, 5mg/ml

1

midazolam hcl syrp 1 QL (300 ML per 30 days)midazolam hydrochloride inj 10mg/2ml pf, 25mg/5ml, 50mg/10ml, 5mg/ml

1

NEMBUTAL SODIUM INJ 3pentobarbital sodium inj 1ramelteon 1 QL (30 EA per 30 days) MORESTORIL CAPS 22.5MG 3 QL (30 EA per 30 days) PA MORESTORIL CAPS 15MG, 30MG, 7.5MG


ROZEREM 3 QL (30 EA per 30 days) MOSECONAL SODIUM 3 QL (30 EA per 30 days) PA MOSILENOR 3 QL (30 EA per 30 days) MOtemazepam 1 QL (30 EA per 30 days) PA MOtriazolam 1 QL (60 EA per 30 days) MOzaleplon caps 5mg 1 QL (30 EA per 30 days) PA MOzaleplon caps 10mg 1 QL (60 EA per 30 days) PA MO

76 Updated 10/01/20

Drug name Drug tier Requirements/Limitszolpidem tartrate immediate release tabs, subl


zolpidem tartrate er 1 QL (30 EA per 30 days) PA MOZOLPIMIST 3 QL (15.4 ML per 30 days) MO

MIGRAINE AIMOVIG 2 QL (1 ML per 30 days) PAAJOVY INJ 225MG/1.5ML AUTO-INJECTOR

3 QL (1.5 ML per 28 days) PA

AJOVY INJ 225MG/1.5ML PREFILLED SYRINGE


almotriptan malate 1 QL (8 EA per 30 days) MOAMERGE 3 QL (9 EA per 30 days) ST MOCAFERGOT 3 MOCAMBIA 3 PA MOD.H.E. 45 3 PA MOdihydroergotamine mesylate inj 1 PA MOdihydroergotamine mesylate nasal soln


eletriptan hydrobromide 1 QL (12 EA per 30 days) MOEMGALITY INJ 120MG/ML 2 QL (2 ML per 30 days) PAEMGALITY INJ 100MG/ML 2 QL (3 ML per 30 days) PAERGOMAR 3ergotamine tartrate/caffeine 1 MOFROVA 4 QL (12 EA per 30 days) ST MOfrovatriptan succinate 1 QL (12 EA per 30 days) MOIMITREX STATDOSE REFILL INJ 4MG/0.5ML

3 QL (4 ML per 30 days) ST MO

IMITREX STATDOSE REFILL INJ 6MG/0.5ML


IMITREX STATDOSE SYSTEM INJ 4MG/0.5ML


IMITREX STATDOSE SYSTEM INJ 6MG/0.5ML


IMITREX NASAL SOLN 3 QL (12 EA per 30 days) ST MOIMITREX INJ 4 QL (4 ML per 30 days) ST MOIMITREX TABS 25MG, 50MG 3 QL (9 EA per 30 days) ST MOIMITREX TABS 100MG 4 QL (9 EA per 30 days) ST MOMAXALT 3 QL (12 EA per 30 days) ST MO

77Updated 10/01/20

Drug name Drug tier Requirements/LimitsMAXALT-MLT 3 QL (12 EA per 30 days) ST MOmigergot 1 QL (20 EA per 28 days) MOMIGRANAL 4 QL (8 ML per 30 days) PA MOnaratriptan hcl 1 QL (9 EA per 30 days) MOONZETRA XSAIL 3 QL (16 EA per 30 days) ST MORELPAX 3 QL (12 EA per 30 days) MOREYVOW 3 QL (8 EA per 30 days) ST MOrizatriptan benzoate odt 1 QL (12 EA per 30 days) MOrizatriptan benzoate tabs 1 QL (12 EA per 30 days) MOsumatriptan nasal spray 1 QL (12 EA per 30 days) MOsumatriptan succinate refill 1 QL (4 ML per 30 days) MOsumatriptan succinate tabs 1 QL (9 EA per 30 days) MOsumatriptan succinate prefilled syringe 6mg/0.5ml


sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml


sumatriptan/naproxen sodium 1 QL (9 EA per 30 days) MOTOSYMRA 3 QL (12 EA per 30 days) ST MOTREXIMET 4 QL (9 EA per 30 days) ST MOUBRELVY 3 QL (16 EA per 30 days) PA MOVYEPTI 3 QL (1 ML per 90 days) PAZEMBRACE SYMTOUCH 4 QL (8 ML per 30 days) ST MOzolmitriptan odt 1 QL (6 EA per 30 days) MOzolmitriptan tabs 1 QL (6 EA per 30 days) MOZOMIG ZMT TBDP 5MG 3 QL (6 EA per 30 days) ST MOZOMIG ZMT TBDP 2.5MG 4 QL (6 EA per 30 days) ST MOZOMIG NASAL SPRAY 3 QL (12 EA per 30 days) ST MOZOMIG TABS 4 QL (6 EA per 30 days) ST MO

MISCELLANEOUS AUSTEDO TABS 12MG, 9MG 4 QL (120 EA per 30 days) PA LAAUSTEDO TABS 6MG 4 QL (60 EA per 30 days) PA LABRISDELLE 3 PA MOEQUETRO 3 MOEXONDYS 51 4 PA MOFIRDAPSE 4 PA MOflumazenil 1GRALISE 3 MO

78 Updated 10/01/20

Drug name Drug tier Requirements/LimitsGRALISE STARTER 3 QL (156 EA per 365 days) MOGUANIDINE HCL 3HORIZANT TBCR 300MG 3 QL (30 EA per 30 days) MOHORIZANT TBCR 600MG 3 QL (60 EA per 30 days) MOINGREZZA CAP INITIATION PACK 4 QL (28 EA per 28 days) PA MOINGREZZA CAPS 4 QL (30 EA per 30 days) PA MOlithium carbonate caps, tabs 1 MOlithium carbonate er 1 MOLITHIUM ORAL SOLN 3 MOLITHOBID 3 MOLYRICA CR 2 QL (60 EA per 30 days) PA MOMESTINON 4 MOMESTINON TIMESPAN 4 MONUEDEXTA 4 QL (60 EA per 30 days) PA MOparoxetine caps 7.5mg 1 PA MOpyridostigmine bromide er 1 MOpyridostigmine bromide tabs 60mg, 30mg

1 MO

pyridostigmine bromide soln 4 MORADICAVA 4 QL (2800 ML per 28 days) PAREGONOL 4RILUTEK 4 MOriluzole 1 MORUZURGI 4 PA MOSAVELLA 3 QL (60 EA per 30 days) PA MOSAVELLA TITRATION PACK 3 QL (110 EA per 365 days) PA MOTEGSEDI 4 QL (6 ML per 28 days) PA MOtetrabenazine tabs 25mg 4 QL (120 EA per 30 days) PAtetrabenazine tabs 12.5mg 4 QL (90 EA per 30 days) PATIGLUTIK ORAL SUSP 4VYONDYS 53 4 PA MOXENAZINE TABS 25MG 4 QL (120 EA per 30 days) PA LAXENAZINE TABS 12.5MG 4 QL (90 EA per 30 days) PA LA

MULTIPLE SCLEROSIS AGENTS AMPYRA 4 PA LAAUBAGIO 4 QL (30 EA per 30 days) PAAVONEX 4 QL (1 EA per 28 days) PA

79Updated 10/01/20

Drug name Drug tier Requirements/LimitsAVONEX PEN 4 QL (1 EA per 28 days) PABETASERON 4 QL (14 EA per 28 days) PACOPAXONE INJ 40MG/ML 4 QL (12 ML per 28 days) PACOPAXONE INJ 20MG/ML 4 QL (30 ML per 30 days) PAdalfampridine er 4 PAEXTAVIA 4 QL (15 EA per 30 days) PAGILENYA CAPS 0.5MG 4 QL (28 EA per 28 days) PAglatiramer acetate inj 40mg/ml 4 QL (12 ML per 28 days) PAglatiramer acetate inj 20mg/ml 4 QL (30 ML per 30 days) PAglatopa inj 40mg/ml 4 QL (12 ML per 28 days) PAglatopa inj 20mg/ml 4 QL (30 ML per 30 days) PAKESIMPTA 4 QL (6.4 ML per 365 days) PALEMTRADA 4 QL (6 ML per 365 days) PAMAVENCLAD TBPK (4 TAB PACK) 10MG


MAVENCLAD TBPK (5 TAB PACK) 10MG












MAYZENT TABS 0.25MG 4 QL (112 EA per 28 days) PAMAYZENT TABS 2MG 4 QL (30 EA per 30 days) PAOCREVUS 4 QL (20 ML per 166 days) PAPLEGRIDY 4 QL (1 ML per 28 days) PAPLEGRIDY STARTER PACK 4 QL (2 ML per 365 days) PAREBIF 4 QL (6 ML per 28 days) PAREBIF REBIDOSE 4 QL (6 ML per 28 days) PAREBIF REBIDOSE TITRATION PACK 4 QL (8.4 ML per 365 days) PAREBIF TITRATION PACK 4 QL (8.4 ML per 365 days) PATECFIDERA STARTER PACK 4 QL (60 EA per 365 days) PATECFIDERA CPDR 120MG 4 QL (14 EA per 7 days) PA

80 Updated 10/01/20

Drug name Drug tier Requirements/LimitsTECFIDERA CPDR 240MG 4 QL (60 EA per 30 days) PATYSABRI 4 PAVUMERITY 4 QL (120 EA per 30 days) PAZEPOSIA 4 QL (30 EA per 30 days) PAZEPOSIA 7-DAY STARTER PACK 4 QL (14 EA per 365 days) PAZEPOSIA STARTER KIT 4 QL (74 EA per 365 days) PA

MUSCULOSKELETAL THERAPY AGENTS AMRIX 4 QL (30 EA per 30 days) PA MObaclofen tabs 1 MObaclofen inj 20000mcg/20ml, 500mcg/ml

1 B/D

baclofen inj 40mg/20ml 4 B/DBOTOX INJ 200UNIT 3 QL (2 EA per 70 days) PABOTOX INJ 100UNIT 3 QL (4 EA per 70 days) PAcarisoprodol tabs 1 QL (120 EA per 30 days) PA MOcarisoprodol/aspirin 1 QL (240 EA per 30 days) PA MOcarisoprodol/aspirin/codeine 1 QL (240 EA per 30 days) PA MOCHLORZOXAZONE TABS 250MG 2 QL (180 EA per 30 days) PAchlorzoxazone tabs 375mg, 750mg 1 QL (120 EA per 30 days) PA MOchlorzoxazone tabs 500mg 1 QL (180 EA per 30 days) PA MOcyclobenzaprine hydrochloride tabs 1 QL (90 EA per 30 days) PA MOcyclobenzaprine hydrochloride er 1 QL (30 EA per 30 days) PA MODANTRIUM CAPS 25MG, 50MG 3 MOdantrolene sodium caps 25mg, 50mg, 100mg

1 MO

DYSPORT 3 PAFEXMID 3 QL (90 EA per 30 days) PAGABLOFEN INJ 10000MCG/20ML, 20000MCG/20ML, 50MCG/ML

3 B/D

GABLOFEN INJ 40000MCG/20ML 4 B/DLIORESAL INTRATHECAL INJ 0.05MG/ML, 10MG/20ML, 10MG/5ML

3 B/D

LIORESAL INTRATHECAL INJ 40MG/20ML

4 B/D

LORZONE TABS 375MG 3 QL (120 EA per 30 days) PAlorzone tabs 750mg 1 QL (120 EA per 30 days) PAmetaxalone 1 QL (120 EA per 30 days) PA MO

81Updated 10/01/20

Drug name Drug tier Requirements/Limitsmethocarbamol inj 1 PAmethocarbamol tabs 750mg 1 QL (240 EA per 30 days) PA MOmethocarbamol tabs 500mg 1 QL (360 EA per 30 days) PA MOMYOBLOC 3 PANORGESIC FORTE 3 QL (120 EA per 30 days) PAorphenadrine citrate er 1 QL (60 EA per 30 days) PA MOorphenadrine citrate inj 1 PAorphenadrine citrate/aspirin/caffeine 1 QL (120 EA per 30 days) PAorphengesic forte 1 QL (120 EA per 30 days) PAROBAXIN INJ 3 PA MOROBAXIN-750 TABS 3 QL (240 EA per 30 days) PA MOSKELAXIN 3 QL (120 EA per 30 days) PA MOSOMA TABS 250MG 3 QL (120 EA per 30 days) PA MOSOMA TABS 350MG 4 QL (120 EA per 30 days) PA MOtizanidine hcl 1 MOtizanidine hydrochloride tabs 4mg 1 MOXEOMIN 3 PAZANAFLEX 3 MO

NARCOLEPSY/CATAPLEXY armodafinil 1 QL (30 EA per 30 days) PA MOmodafinil tabs 100mg 1 QL (30 EA per 30 days) PA MOmodafinil tabs 200mg 1 QL (60 EA per 30 days) PA MONUVIGIL 3 QL (30 EA per 30 days) PA MOPROVIGIL TABS 100MG 4 QL (30 EA per 30 days) PA MOPROVIGIL TABS 200MG 4 QL (60 EA per 30 days) PA MOSUNOSI 3 QL (30 EA per 30 days) PA MOWAKIX 4 QL (60 EA per 30 days) PAXYREM 4 QL (540 ML per 30 days) PA LA

MOPSYCHOTHERAPEUTIC-MISC

acamprosate calcium dr 1 MOANTABUSE 3 MOBUNAVAIL FILM 2.1MG; 0.3MG, 4.2MG; 0.7MG


BUNAVAIL FILM 6.3MG; 1MG 3 QL (30 EA per 30 days) MObuprenorphine hcl/naloxone hcl subl tabs


82 Updated 10/01/20

Drug name Drug tier Requirements/Limitsbuprenorphine hcl subl 2mg, 8mg 1 QL (90 EA per 30 days) PA MObuprenorphine hydrochloride/naloxone hydrochloride film 12mg; 3mg


buprenorphine hydrochloride/naloxone hydrochloride film 2mg; 0.5mg, 4mg; 1mg, 8mg; 2mg


bupropion hydrochloride er (sr) tb12 150mg


CHANTIX 3 PA MOCHANTIX CONTINUING MONTH PAK 3 PA MOCHANTIX STARTING MONTH PAK 3 PA MOdisulfiram tabs 1 MOEVZIO 4 PA MOLUCEMYRA 3 PA MOnaloxone hcl inj 0.4mg/ml cartridge, 2mg/2ml

1

naloxone hcl inj 4mg/10ml 1 MOnaloxone hydrochloride vial 0.4mg/ml

1 MO

naltrexone hcl tabs 1 MONARCAN 2 MONICOTROL INHALER 3 MONICOTROL NASAL SPRAY 3 MOSUBLOCADE INJ 100MG/0.5ML 4 QL (1 ML per 30 days) PASUBLOCADE INJ 300MG/1.5ML 4 QL (1.5 ML per 30 days) PASUBOXONE FILM 12MG; 3MG 3 QL (60 EA per 30 days) MOSUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG


VIVITROL 4ZUBSOLV SUBL 11.4MG; 2.9MG 3 QL (30 EA per 30 days) MOZUBSOLV SUBL 1.4MG; 0.36MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG


ZUBSOLV SUBL 0.7MG; 0.18MG 3 QL (90 EA per 30 days) MOENDOCRINE AND METABOLIC

ANDROGENS ANADROL-50 4 PA MO

83Updated 10/01/20

Drug name Drug tier Requirements/LimitsANDRODERM 3 QL (30 EA per 30 days) PA MOANDROGEL PUMP 3 QL (150 GM per 30 days) PA MOANDROGEL GEL 1.62% (20.25MG/1.25GM, 40.5MG/2.5GM)

3 QL (150 GM per 30 days) PA MO

ANDROGEL GEL 1% (25MG/2.5GM, 50MG/5GM)


AVEED 4 QL (6 ML per 70 days)DEPO-TESTOSTERONE 3 PA MOFORTESTA 3 QL (120 GM per 30 days) PA MOMETHITEST 3 PAmethyltestosterone caps 4 PA MONATESTO 3 QL (24 GM per 30 days) PA MOoxandrolone tabs 2.5mg 1 QL (120 EA per 30 days) PA MOoxandrolone tabs 10mg 4 QL (60 EA per 30 days) PA MOTESTIM 3 QL (300 GM per 30 days) PA MOTESTOPEL 3 PAtestosterone cypionate inj 1 PA MOtestosterone enanthate inj 1 PA MOtestosterone pump gel 1% (12.5mg/act


testosterone pump gel 2% (10mg/act) 1 QL (120 GM per 30 days) PA MOtestosterone gel 1.62% (20.25mg/act, 20.25mg/1.25gm, 40.5mg/2.5gm)


testosterone gel 1% (25mg/2.5gm, 50mg/5gm)


testosterone topical soln 30mg/act 1 QL (180 ML per 30 days) PA MOVOGELXO 3 QL (300 GM per 30 days) PA MOVOGELXO PUMP 3 QL (300 GM per 30 days) PA MOXYOSTED 3 PA MO

ANTIDIABETICS, INSULINS ADMELOG 3 ST MOADMELOG SOLOSTAR 3 ST MOAFREZZA POWD 4-8UNIT TITRATION PACK, 12UNIT, 4UNIT, 8UNIT

3 MO

AFREZZA POWD 4-8-12UNIT TITRATION PACK, 8-12UNIT PACK

4 MO

BD ALCOHOL SWABS 2 MOAPIDRA 3 ST MO

84 Updated 10/01/20

Drug name Drug tier Requirements/LimitsAPIDRA SOLOSTAR 3 ST MOBD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X 5/16”

2 MO

BASAGLAR KWIKPEN 2 MOBD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE SAFETYGLIDE/1ML/ 29G X 1/2”

2 MO

BD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 1/2”

2 MO

BD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE ULTRA-FINE/1ML/31G X 5/16”

2 MO

NOVO/BD/ULTIMED/OWEN/TRIVIDIA PEN NEEDLE/ORIGINAL/ULTRA-FINE

2 MO

BD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE ULTRA-AFINE/0.3ML/31G X 6MM

2 MO

CURITY GAUZE PADS 2”X2” 2 MOFIASP 2 MOFIASP FLEXTOUCH 2 MOFIASP PENFILL 2 MOHUMALOG 3 ST MOHUMALOG JUNIOR KWIKPEN 3 ST MOHUMALOG KWIKPEN INJ 100UNIT/ML

3 ST MO

HUMALOG KWIKPEN INJ 200UNIT/ML

4 ST MO

HUMALOG MIX 50/50 4 ST MOHUMALOG MIX 50/50 KWIKPEN 3 ST MOHUMALOG MIX 75/25 3 ST MOHUMALOG MIX 75/25 KWIKPEN 3 ST MOHUMULIN 70/30 3 ST MOHUMULIN 70/30 KWIKPEN 3 ST MOHUMULIN N 3 ST MOHUMULIN N KWIKPEN 3 ST MO

85Updated 10/01/20

Drug name Drug tier Requirements/LimitsHUMULIN R 3 ST MOHUMULIN R U-500 (CONCENTRATED)

4 B/D MO

HUMULIN R U-500 KWIKPEN 4 MOINSULIN ASPART 3 ST MOINSULIN ASPART FLEXPEN 3 ST MOINSULIN ASPART PENFILL 3 ST MOINSULIN ASPART PROTAMINE/INSULIN ASPART

3 ST MO

INSULIN ASPART PROTAMINE/INSULIN ASPART FLEXPEN

3 ST MO

INSULIN LISPRO 3 ST MOINSULIN LISPRO JUNIOR KWIKPEN 3 ST MOINSULIN LISPRO KWIKPEN 3 ST MOINSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN

3 ST MO

LANTUS 3 ST MOLANTUS SOLOSTAR 3 ST MOLEVEMIR 2 MOLEVEMIR FLEXTOUCH 2 MOLYUMJEV 3 STLYUMJEV KWIKPEN INJ 100UNIT/ML 3 STLYUMJEV KWIKPEN INJ 200UNIT/ML 4 STMYXREDLIN 3 STNOVOLIN 70/30 2 MONOVOLIN 70/30 FLEXPEN 2 MONOVOLIN 70/30 FLEXPEN RELION 3 ST MONOVOLIN 70/30 RELION 3 ST MONOVOLIN N 2 MONOVOLIN N FLEXPEN 2 MONOVOLIN N FLEXPEN RELION 3 ST MONOVOLIN N RELION 3 ST MONOVOLIN R 2 MONOVOLIN R FLEXPEN 2 MONOVOLIN R FLEXPEN RELION 3 ST MONOVOLIN R RELION 3 ST MONOVOLOG 2 MO

86 Updated 10/01/20

Drug name Drug tier Requirements/LimitsNOVOLOG FLEXPEN 2 MONOVOLOG MIX 70/30 2 MONOVOLOG MIX 70/30 PREFILLED FLEXPEN

2 MO

NOVOLOG PENFILL 2 MOOMNIPOD 5 PACK 3 MOOMNIPOD STARTER KIT 3 MOSOLIQUA 100/33 2 QL (30 ML per 30 days) MOTOUJEO MAX SOLOSTAR 3 ST MOTOUJEO SOLOSTAR 3 ST MOTRESIBA 2 MOTRESIBA FLEXTOUCH 2 MOV-GO 20 3 MOV-GO 30 3 MOV-GO 40 3 MOXULTOPHY 100/3.6 2 QL (15 ML per 30 days) MO

ANTIDIABETICS acarbose tabs 1 QL (90 EA per 30 days) MOACTOPLUS MET 3 QL (90 EA per 30 days) MOACTOS 3 QL (30 EA per 30 days) MOADLYXIN 3 QL (6 ML per 28 days) ST MOADLYXIN STARTER PACK 3 QL (6 ML per 28 days) ST MOALOGLIPTIN 3 QL (30 EA per 30 days) ST MOALOGLIPTIN/METFORMIN HCL 3 QL (60 EA per 30 days) ST MOALOGLIPTIN/PIOGLITAZONE 3 QL (30 EA per 30 days) ST MOAMARYL TABS 4MG 3 QL (60 EA per 30 days) MOAMARYL TABS 1MG, 2MG 3 QL (90 EA per 30 days) MOAVANDIA 3 QL (60 EA per 30 days) MOBYDUREON BCISE 2 QL (3.4 ML per 28 days) MOBYDUREON PEN 2 QL (4 EA per 28 days) MOBYETTA INJ 5MCG/0.02ML 3 QL (1.2 ML per 30 days) MOBYETTA INJ 10MCG/0.04ML 3 QL (2.4 ML per 30 days) MOCYCLOSET 3 QL (180 EA per 30 days) PA MODUETACT 3 QL (30 EA per 30 days) MOFARXIGA 2 QL (30 EA per 30 days) MOFORTAMET TB24 500MG 4 QL (120 EA per 30 days) PA MOFORTAMET TB24 1000MG 4 QL (60 EA per 30 days) PA MO

87Updated 10/01/20

Drug name Drug tier Requirements/Limitsglimepiride tabs 4mg 1 QL (60 EA per 30 days) MOglimepiride tabs 1mg, 2mg 1 QL (90 EA per 30 days) MOglipizide er tb24 10mg 1 QL (60 EA per 30 days) MOglipizide er tb24 2.5mg, 5mg 1 QL (90 EA per 30 days) MOglipizide xl tb24 10mg 1 QL (60 EA per 30 days) MOglipizide xl tb24 2.5mg, 5mg 1 QL (90 EA per 30 days) MOglipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg; 500mg


glipizide/metformin hydrochloride tabs 2.5mg; 250mg


glipizide tabs 10mg 1 QL (120 EA per 30 days) MOglipizide tabs 5mg 1 QL (240 EA per 30 days) MOGLUCOTROL XL TB24 10MG 3 QL (60 EA per 30 days) MOGLUCOTROL XL TB24 2.5MG, 5MG 3 QL (90 EA per 30 days) MOGLUCOTROL TABS 10MG 3 QL (120 EA per 30 days) MOGLUCOTROL TABS 5MG 3 QL (240 EA per 30 days) MOGLUMETZA TB24 500MG 4 QL (120 EA per 30 days) PA MOGLUMETZA TB24 1000MG 4 QL (60 EA per 30 days) PA MOglyburide micronized tabs 1 PA MOglyburide tabs 1 PA MOglyburide/metformin hydrochloride 1 PA MOGLYNASE 3 PA MOGLYSET 3 QL (90 EA per 30 days) MOGLYXAMBI 2 QL (30 EA per 30 days) MOINVOKAMET XR TB24 50MG; 500MG 3 QL (120 EA per 30 days) ST MOINVOKAMET XR TB24 150MG; 1000MG, 150MG; 500MG, 50MG; 1000MG


INVOKAMET TABS 50MG; 500MG 3 QL (120 EA per 30 days) ST MOINVOKAMET TABS 150MG; 1000MG, 150MG; 500MG, 50MG; 1000MG


INVOKANA TABS 300MG 3 QL (30 EA per 30 days) ST MOINVOKANA TABS 100MG 3 QL (60 EA per 30 days) ST MOJANUMET 2 QL (60 EA per 30 days) MOJANUMET XR TB24 1000MG; 100MG 2 QL (30 EA per 30 days) MOJANUMET XR TB24 1000MG; 50MG, 500MG; 50MG


JANUVIA 2 QL (30 EA per 30 days) MO

88 Updated 10/01/20

Drug name Drug tier Requirements/LimitsJARDIANCE TABS 25MG 2 QL (30 EA per 30 days) MOJARDIANCE TABS 10MG 2 QL (60 EA per 30 days) MOJENTADUETO 2 QL (60 EA per 30 days) MOJENTADUETO XR TB24 5MG; 1000MG


JENTADUETO XR TB24 2.5MG; 1000MG


KAZANO 3 QL (60 EA per 30 days) ST MOKOMBIGLYZE XR TB24 1000MG; 5MG, 500MG; 5MG


KOMBIGLYZE XR TB24 1000MG; 2.5MG


metformin hydrochloride er tb24 (generic Glucophage XR) 500mg


metformin hydrochloride er tb24 (generic Glumetza and Fortamet) 500mg


metformin hydrochloride er tb24 (generic Glucophage XR) 750mg


metformin hydrochloride er tb24 (generic Fortamet) 1000mg


metformin hydrochloride er tb24 (generic Glumetza) 1000mg


metformin hydrochloride tabs 500mg 1 QL (150 EA per 30 days) MOmetformin hydrochloride tabs 1000mg


metformin hydrochloride tabs 850mg 1 QL (90 EA per 30 days) MOmiglitol 1 QL (90 EA per 30 days) MOnateglinide 1 QL (90 EA per 30 days) MONESINA 3 QL (30 EA per 30 days) ST MOONGLYZA 3 QL (30 EA per 30 days) ST MOOSENI 3 QL (30 EA per 30 days) ST MOOZEMPIC INJ 2MG/1.5ML (0.25MG AND 0.5MG DOSE)


OZEMPIC INJ 2MG/1.5ML (1MG DOSE)


pioglitazone hcl tabs 45mg 1 QL (30 EA per 30 days) MOpioglitazone hcl-glimepiride 1 QL (30 EA per 30 days) MOpioglitazone hcl/metformin hcl 1 QL (90 EA per 30 days) MO

89Updated 10/01/20

Drug name Drug tier Requirements/Limitspioglitazone hydrochloride tabs 15mg, 30mg


PRECOSE 3 QL (90 EA per 30 days) MOQTERN 3 QL (30 EA per 30 days) MOrepaglinide tabs 0.5mg, 1mg 1 QL (120 EA per 30 days) MOrepaglinide tabs 2mg 1 QL (240 EA per 30 days) MORIOMET 3 MORIOMET ER 3 MORYBELSUS 3 QL (30 EA per 30 days) ST MOSEGLUROMET TABS 2.5MG; 500MG 3 QL (120 EA per 30 days) ST MOSEGLUROMET TABS 2.5MG; 1000MG, 7.5MG; 1000MG, 7.5MG; 500MG


STARLIX 3 QL (90 EA per 30 days) MOSTEGLATRO TABS 15MG 3 QL (30 EA per 30 days) ST MOSTEGLATRO TABS 5MG 3 QL (60 EA per 30 days) ST MOSTEGLUJAN 3 QL (30 EA per 30 days) MOSYMLINPEN 120 4 QL (10.8 ML per 30 days) PA MOSYMLINPEN 60 4 QL (12 ML per 30 days) PA MOSYNJARDY XR TB24 25MG; 1000MG 2 QL (30 EA per 30 days) MOSYNJARDY XR TB24 10MG; 1000MG, 12.5MG; 1000MG, 5MG; 1000MG


SYNJARDY TABS 5MG; 500MG 2 QL (120 EA per 30 days) MOSYNJARDY TABS 12.5MG; 1000MG, 12.5MG; 500MG, 5MG; 1000MG


TRADJENTA 2 QL (30 EA per 30 days) MOTRULICITY 2 QL (2 ML per 28 days) MOVICTOZA 2 QL (9 ML per 30 days) MOXIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG


XIGDUO XR TB24 2.5MG; 1000MG, 5MG; 1000MG, 5MG; 500MG


CALCIUM REGULATORS ACTONEL TABS 150MG 3 QL (1 EA per 28 days) ST MOACTONEL TABS 35MG 3 QL (12 EA per 84 days) ST MOACTONEL TABS 5MG 3 QL (30 EA per 30 days) ST MOalendronate sodium oral soln 1 MOalendronate sodium tabs 10mg 1 QL (30 EA per 30 days) MO

90 Updated 10/01/20

Drug name Drug tier Requirements/Limitsalendronate sodium tabs 35mg, 70mg


ATELVIA 3 QL (4 EA per 28 days) ST MOBINOSTO 3 QL (4 EA per 28 days) ST MOBONIVA TABS 3 QL (1 EA per 30 days) MOBONIVA INJ 3 QL (3 ML per 90 days) MOcalcitonin-salmon 1 MOEVENITY 4 QL (2.34 ML per 28 days) PAFORTEO 4 PAFOSAMAX 3 QL (4 EA per 28 days) ST MOFOSAMAX PLUS D 3 QL (4 EA per 28 days) ST MOibandronate sodium tabs 1 QL (1 EA per 30 days) MOibandronate sodium inj 1 QL (3 ML per 90 days) MOMIACALCIN 4 PA MONATPARA 4 PAPAMIDRONATE DISODIUM INJ 6MG/ML

3

pamidronate disodium inj 30mg/10ml, 30mg, 90mg/10ml, 90mg

1

PROLIA 3 QL (1 ML per 180 days)RECLAST 3risedronate sodium dr tab 35mg 1 QL (4 EA per 28 days) MOrisedronate sodium tabs 150mg 1 QL (1 EA per 28 days) MOrisedronate sodium tabs 35mg 1 QL (12 EA per 84 days) MOrisedronate sodium tabs 30mg, 5mg 1 QL (30 EA per 30 days) MOTERIPARATIDE 4 PATYMLOS 4 PAXGEVA 4 PAZOLEDRONIC ACID INJ 4MG/100ML 3zoledronic acid inj 4mg/5ml, 5mg/100ml

1

CHELATING AGENTS CHEMET 4 MOclovique 4 PACUPRIMINE 4 MOdeferasirox 4 PAdeferoxamine mesylate 1 B/D

91Updated 10/01/20

Drug name Drug tier Requirements/LimitsDEPEN TITRATABS 4 MODESFERAL 4 B/DEXJADE 4 PAFERRIPROX 4 PA MOJADENU SPRINKLE PACK 90MG 3 PA LAJADENU SPRINKLE PACK 180MG, 360MG

4 PA LA

JADENU TABS 4 PA LAkionex 1LOKELMA 2 MOpenicillamine caps, tabs 4 MOsodium polystyrene sulfonate rectal susp

1

sodium polystyrene sulfonate powd, oral susp

1 MO

sps oral susp 15gm/60ml 1 MOSYPRINE 4 PA MOtrientine hydrochloride 4 PA MOVELTASSA PACK 16.8GM, 25.2GM 3 QL (30 EA per 30 days) PA MOVELTASSA PACK 8.4GM 3 QL (90 EA per 30 days) PA MO

CONTRACEPTIVES afirmelle 1altavera 1alyacen 1/35 1alyacen 7/7/7 1amethia 1AMETHIA LO 2amethyst 1ANNOVERA 3 QL (1 EA per 365 days) MOapri 1aranelle 1ashlyna 1aubra 1aubra eq 1aurovela 1.5/30 1aurovela 24 fe 1aurovela fe 1.5/30 1

92 Updated 10/01/20

Drug name Drug tier Requirements/Limitsaurovela fe 1/20 1aviane 1ayuna 1azurette 1BALCOLTRA 3 MObalziva 1bekyree 1BEYAZ 3 MOblisovi 24 fe 1 MOblisovi fe 1.5/30 1blisovi fe 1/20 1briellyn 1camila 1 MOCAMRESE 2CAMRESE LO 2caziant 1chateal 1chateal eq 1cryselle-28 1 MOcyclafem 1/35 1cyclafem 7/7/7 1cyred 1cyred eq 1dasetta 1/35 1dasetta 7/7/7 1daysee 1 MOdeblitane 1DEPO-PROVERA CONTRACEPTIVE 150MG/ML

3 MO

DEPO-SUBQ PROVERA 104 3 MOdesogestrel/ethinyl estradiol 1 MOdrospirenone/ethinyl estradiol 1 MOdrospirenone/ethinyl estradiol/levomefolate calcium

1 MO

elinest 1ELLA 2eluryng 1

93Updated 10/01/20

Drug name Drug tier Requirements/Limitsemoquette 1enpresse-28 1enskyce 1 MOerrin 1 MOestarylla 1ESTROSTEP FE 3 MOethynodiol diacetate/ethinyl estradiol 1 MOETONOGESTREL/ETHINYL ESTRADIOL

3 MO

falmina 1fayosim 1femynor 1GENERESS FE 3 MOGIANVI 2 MOhailey 1.5/30 1 MOhailey 24 fe 1heather 1incassia 1introvale 1isibloom 1jaimiess 1jasmiel 1jencycla 1JOLESSA 2JOLIVETTE 2juleber 1junel 1.5/30 1junel 1/20 1junel fe 1.5/30 1 MOjunel fe 1/20 1 MOjunel fe 24 1kaitlib fe 1 MOkalliga 1kariva 1kelnor 1/35 1 MOkelnor 1/50 1 MOkurvelo 1

94 Updated 10/01/20

Drug name Drug tier Requirements/LimitsKYLEENA 3larin 1.5/30 1larin 1/20 1larin 24 fe 1larin fe 1.5/30 1larin fe 1/20 1larissia 1LAYOLIS FE 3LEENA 2 MOlessina 1levonest 1levonorgestrel/ethinyl estradiol 1 MOlevora 0.15/30-28 1lillow 1LO LOESTRIN FE 3 MOlo-zumandimine 1LOESTRIN 1.5/30-21 3 MOLOESTRIN 1/20-21 3 MOLOESTRIN FE 1.5/30 3 MOLOESTRIN FE 1/20 3 MOlojaimiess 1loryna 1LOSEASONIQUE 3 MOlow-ogestrel 1lutera 1lyza 1marlissa 1 MOmedroxyprogesterone acetate inj 150mg/ml

1 MO

melodetta 24 fe 1mibelas 24 fe 1 MOMICROGESTIN 1.5/30 2MICROGESTIN 1/20 2MICROGESTIN FE 1.5/30 2MICROGESTIN FE 1/20 2mili 1MINASTRIN 24 FE 3 MO

95Updated 10/01/20

Drug name Drug tier Requirements/LimitsMIRCETTE 3 MOMIRENA 3mono-linyah 1NATAZIA 3 MOnecon 0.5/35-28 1NEXPLANON 3nikki 1NORA-BE 2norethindrone acetate/ethinyl estradiol/ferrous fumarate

1 MO

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg, 30mcg; 1.5mg

1 MO

norethindrone tabs 0.35mg 1 MOnorethindrone/ethinyl estradiol/ferrous fumarate

1 MO

norgestimate/ethinyl estradiol 1 MOnorlyda 1nortrel 0.5/35 (28) 1 MOnortrel 1/35 1nortrel 7/7/7 1NUVARING 3 MOOCELLA 2ogestrel 1orsythia 1ORTHO-NOVUM 1/35 3 MOORTHO-NOVUM 7/7/7 3 MOPARAGARD INTRAUTERINE COPPER CONTRACEPTIVE T380A

3

philith 1pimtrea 1pirmella 1/35 1 MOpirmella 7/7/7 1 MOportia-28 1previfem 1 MOQUARTETTE 3 MOreclipsen 1

96 Updated 10/01/20

Drug name Drug tier Requirements/LimitsRIVELSA 2SAFYRAL 3 MOSEASONIQUE 3 MOsetlakin 1sharobel 1simliya 1simpesse 1SKYLA 3SLYND 2 MOsprintec 28 1sronyx 1 MOsyeda 1tarina 24 fe 1tarina fe 1/20 1tarina fe 1/20 eq 1TAYTULLA 3 MOTILIA FE 2tri femynor 1tri-estarylla 1 MOtri-legest fe 1 MOtri-linyah 1tri-lo-estarylla 1tri-lo-marzia 1tri-lo-mili 1tri-lo-sprintec 1 MOtri-mili 1tri-previfem 1tri-sprintec 1tri-vylibra 1tri-vylibra lo 1trivora-28 1tulana 1tydemy 1velivet 1 MOvienva 1viorele 1 MOvolnea 1

97Updated 10/01/20

Drug name Drug tier Requirements/Limitsvyfemla 1 MOvylibra 1wera 1wymzya fe 1xulane 1 MOYASMIN 28 3 MOYAZ 3 MOzarah 1zovia 1/35e 1zumandimine 1

ENDOMETRIOSIS danazol caps 1 MOLUPANETA PACK 4 PAORILISSA TABS 150MG 4 QL (28 EA per 28 days) PA MOORILISSA TABS 200MG 4 QL (56 EA per 28 days) PA MOSYNAREL 4 MO

ESTROGENS ACTIVELLA 3 MOALORA 3 QL (8 EA per 28 days) MOamabelz 1 MOANGELIQ 3 MOBIJUVA 3 QL (30 EA per 30 days) MOCLIMARA 3 QL (4 EA per 28 days) MOCLIMARA PRO 3 QL (4 EA per 28 days) MOCOMBIPATCH 3 QL (8 EA per 28 days) MODELESTROGEN INJ 10MG/ML 3 MODEPO-ESTRADIOL 3 MODIVIGEL GEL 0.25MG/0.25GM, 0.5MG/0.5GM, 0.75MG/0.75GM


DIVIGEL GEL 1.25MG/1.25GM, 1MG/GM

3 QL (30 GM per 30 days) MO

dotti 1 QL (8 EA per 28 days)DUAVEE 3 MOELESTRIN 3 QL (70 GM per 30 days) MOESTRACE 3 MOestradiol valerate inj 1 MO

98 Updated 10/01/20

Drug name Drug tier Requirements/Limitsestradiol/norethindrone acetate tabs 1mg/0.5mg, 0.5mg/0.1mg

1 MO

estradiol vaginal crea, oral tabs, vaginal tabs

1 MO

estradiol patch weekly 1 QL (4 EA per 28 days) MOestradiol patch twice weekly 1 QL (8 EA per 28 days) MOESTRING 3 QL (1 EA per 90 days) MOESTROGEL 3 QL (50 GM per 30 days) MOEVAMIST 3 QL (16.2 ML per 30 days) MOFEMHRT LOW DOSE 3 MOFEMRING 3 QL (1 EA per 90 days) MOfyavolv 1 MOIMVEXXY MAINTENANCE PACK 3 PA MOIMVEXXY STARTER PACK 3 PA MOjinteli 1LOPREEZA 2MENEST 3 MOMENOSTAR 3 QL (4 EA per 28 days) MOmimvey 1MINIVELLE 3 QL (8 EA per 28 days) MOnorethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg

1 MO

PREFEST 3 MOPREMARIN 3 MOPREMPHASE 3 MOPREMPRO 3 MOVAGIFEM 3 MOVIVELLE-DOT 3 QL (8 EA per 28 days) MOyuvafem 1

GLUCOCORTICOIDS betamethasone sodium phosphate/betamethasone acetate inj

1 MO

CELESTONE-SOLUSPAN 3 MOCORTEF 3 MOcortisone acetate tabs 1 MOdecadron 1

99Updated 10/01/20

Drug name Drug tier Requirements/LimitsDEPO-MEDROL 3 B/D MODEXABLISS 3 STdexamethasone 10-day dose pack 1 MOdexamethasone 13-day dose pack 1 MOdexamethasone 6-day dose pack 1 MODEXAMETHASONE INTENSOL 3 MOdexamethasone sodium phosphate inj 10mg/ml

1

dexamethasone sodium phosphate inj 100mg/10ml, 120mg/30ml, 20mg/5ml, 4mg/ml

1 MO

dexamethasone tabs, oral soln, oral elixir

1 MO

dexpak 10 day 1 ST MOdexpak 13 day 1 STdexpak 6 day 1 STDXEVO 11-DAY 3 STEMFLAZA 4 PA MOfludrocortisone acetate tabs 1 MOhidex 6-day 1hydrocortisone tabs 10mg, 20mg, 5mg

1 MO

KENALOG-10 3 MOKENALOG-40 3 MOKENALOG-80 3 MOMEDROL 3 B/D MOMEDROL DOSEPAK 3 MOmethylprednisolone acetate inj 1 B/D MOmethylprednisolone dose pack 1 MOmethylprednisolone sodium succinate inj 125mg, 1000mg, 40mg

1 B/D MO

methylprednisolone sodium succinate inj 500mg

1 B/D

methylprednisolone tabs 1 B/D MOMILLIPRED 3 B/D MOORAPRED ODT 3 B/D MOPEDIAPRED 3 B/D MOprednisolone oral soln 15mg/5ml 1 B/D MO

100 Updated 10/01/20

Drug name Drug tier Requirements/Limitsprednisolone sodium phosphate odt 1 B/D MOprednisolone sodium phosphate oral soln 10mg/5ml, 15mg/5ml, 20mg/5ml, 25mg/5ml, 5mg/5ml

1 B/D MO

PREDNISONE INTENSOL 3 B/D MOprednisone soln, tabs 1 B/D MOprednisone tab therapy pack 1 MORAYOS 4 B/D MOSOLU-CORTEF INJ 1000MG 3SOLU-CORTEF INJ 100MG, 250MG, 500MG

3 MO

SOLU-MEDROL INJ 2GM 3 B/DSOLU-MEDROL INJ 1000MG, 125MG, 40MG, 500MG

3 B/D MO

taperdex 12-day 1 STtaperdex 6-day 1 ST MOtaperdex 7-day 1 STtriamcinolone acetonide inj 40mg/ml 1 MOZILRETTA 3

GLUCOSE ELEVATING AGENTS BAQSIMI ONE PACK 3 MOBAQSIMI TWO PACK 3 MOdiazoxide oral susp 1 MOGLUCAGEN HYPOKIT 3 MOGLUCAGON EMERGENCY KIT 3 MOGLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR

3 MO

GVOKE HYPOPEN 1-PACK 2 MOGVOKE HYPOPEN 2-PACK 2 MOGVOKE PFS 2 MOPROGLYCEM 3 MO

MISCELLANEOUS ACETADOTE 3acetylcysteine inj 200mg/ml 1ACTHAR 4 PAALDURAZYME 4 PA LABUPHENYL POWD 4 PA

101Updated 10/01/20

Drug name Drug tier Requirements/LimitsBUPHENYL TABS 4 PA LABYNFEZIA PEN 4 PAcabergoline 1 MOCARBAGLU 4 PA LA MOCARNITOR 3 MOCARNITOR SF 3 MOCERDELGA 4 PACEREZYME 4 PA LACHORIONIC GONADOTROPIN INJ 3 PAcinacalcet hydrochloride tabs 30mg 1 QL (120 EA per 30 days)cinacalcet hydrochloride tabs 90mg 4 QL (120 EA per 30 days)cinacalcet hydrochloride tabs 60mg 4 QL (60 EA per 30 days)CRYSVITA 4 PACYSTADANE 4 LA MOCYSTAGON 3 PA LADDAVP INJ, TABS 3 MODDAVP NASAL SOLN 0.01% (REFRIGERATED)

3 MO

DDAVP NASAL SPRAY 0.01% 4 MOdesmopressin acetate 1 MODOJOLVI 4 PAEGRIFTA 4 QL (60 EA per 30 days) PAEGRIFTA SV 4 QL (30 EA per 30 days) PAELAPRASE 4 PAELELYSO 4 PAEVISTA 3 MOFABRAZYME 4 PA LAfomepizole 4GALAFOLD 4 QL (14 EA per 28 days) PAGENOTROPIN 4 PAGENOTROPIN MINIQUICK INJ 0.2MG

2 PA

GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

4 PA

HUMATROPE 4 PAHUMATROPE COMBO PACK 4 PA

102 Updated 10/01/20

Drug name Drug tier Requirements/LimitsINCRELEX 4 PA LAISTURISA TABS 10MG 4 QL (180 EA per 30 days) PA MOISTURISA TABS 1MG 4 QL (1800 EA per 30 days) PA MOISTURISA TABS 5MG 4 QL (360 EA per 30 days) PA MOJYNARQUE TABS 4 PA MOJYNARQUE TBPK 45MG;15MG, 60MG;30MG, 90MG;30MG

4 PA

JYNARQUE TBPK 30MG;15MG, 15MG

4 PA MO

KANUMA 4 PAKORLYM 4 PA LA MOKUVAN 4 PA LALEVOCARNITINE TABS 3 MOlevocarnitine soln 1 MOLUMIZYME 4 PA LALUPRON DEPOT-PED (1-MONTH) INJ 11.25MG, 15MG, 7.5MG

4 PA

LUPRON DEPOT-PED (3-MONTH) INJ 11.25MG, 30MG

4 PA

MEPSEVII 4 PA MOmethergine 1methylergonovine maleate tabs 1 MOmifepristone 1miglustat 4 PAMYALEPT 4 QL (30 EA per 30 days) PA MOMYCAPSSA 4 QL (112 EA per 28 days) PANAGLAZYME 4 PA LAnitisinone 4 PA MONITYR 4 PA LA MONOCDURNA 3 QL (30 EA per 30 days) PA MONORDITROPIN FLEXPRO 4 PANOVAREL 3 PANUTROPIN AQ NUSPIN 10 4 PANUTROPIN AQ NUSPIN 20 4 PANUTROPIN AQ NUSPIN 5 4 PAoctreotide acetate 1 PAOMNITROPE 4 PA

103Updated 10/01/20

Drug name Drug tier Requirements/LimitsORFADIN 4 PA LA MOORIAHNN 4 QL (56 EA per 28 days) PAOSPHENA 3 QL (30 EA per 30 days) PA MOPALYNZIQ 4 PAPREGNYL INJ 3 PAPROCYSBI CPDR 25MG 4 QL (120 EA per 30 days) PA MOPROCYSBI CPDR 75MG 4 QL (810 EA per 30 days) PA MOraloxifene hydrochloride 1 MORAVICTI 4 PAREVCOVI 4 PA MOSAIZEN 4 PASAIZENPREP RECONSTITUTIONKIT 4 PASAMSCA TABS 15MG 4 QL (30 EA per 30 days) PASAMSCA TABS 30MG 4 QL (60 EA per 30 days) PASANDOSTATIN LAR DEPOT 4 PASANDOSTATIN INJ 50MCG/ML 3 PASANDOSTATIN INJ 100MCG/ML, 500MCG/ML

4 PA

SENSIPAR TABS 30MG, 90MG 4 QL (120 EA per 30 days)SENSIPAR TABS 60MG 4 QL (60 EA per 30 days)SEROSTIM 4 PASIGNIFOR INJ 4 PA LA MOSIGNIFOR LAR INJ 4 QL (1 EA per 28 days) PA MOsodium phenylbutyrate tabs, oral powder

4 PA

SOMATULINE DEPOT 4 PASOMAVERT INJ 4 PA LASTIMATE 4STRENSIQ 4 PA MOTEPEZZA 4 QL (8 EA per 365 days) PAtolvaptan 4 QL (60 EA per 30 days) PATRIPTODUR 4 PA MOVASOSTRICT 3VIMIZIM 4 PAVISTOGARD 4 QL (20 EA per 166 days) MOVPRIV 4 PAXIAFLEX 4 PA MO

104 Updated 10/01/20

Drug name Drug tier Requirements/LimitsXURIDEN 4 QL (120 EA per 30 days) PA MOZAVESCA 4 PA LA MOZOMACTON INJ 10MG 3 PAZOMACTON INJ 5MG 4 PAZORBTIVE 4 PA

PHOSPHATE BINDER AGENTS AURYXIA 4 QL (360 EA per 30 days) PA MOcalcium acetate caps, tabs 667mg 1 QL (360 EA per 30 days) MOFOSRENOL 4 MOlanthanum carbonate 4 MOPHOSLYRA 3 MORENAGEL 4 ST MORENVELA TABS 4 QL (540 EA per 30 days) ST MORENVELA PACK 2.4GM 4 QL (180 EA per 30 days) ST MORENVELA PACK 0.8GM 4 QL (540 EA per 30 days) ST MOsevelamer carbonate tabs 1 QL (540 EA per 30 days) MOsevelamer carbonate pack 2.4gm 1 QL (180 EA per 30 days) MOsevelamer carbonate pack 0.8gm 1 QL (540 EA per 30 days) MOsevelamer hydrochloride tabs 400mg 1 MOVELPHORO 4 MO

PROGESTINS AYGESTIN 3 MOCRINONE GEL 8% 3 QL (16.88 GM per 30 days) PA

MOCRINONE GEL 4% 3 QL (6.75 GM per 30 days) PA MOhydroxyprogesterone caproate inj 250mg/ml

4

MAKENA 4medroxyprogesterone acetate tabs 10mg, 2.5mg, 5mg

1 MO

megestrol acetate susp 40mg/ml, 625mg/5ml

1 MO

norethindrone acetate tabs 5mg 1 MOprogesterone caps, inj 1 MOPROMETRIUM 3 MOPROVERA 3 MO

105Updated 10/01/20

Drug name Drug tier Requirements/LimitsTHYROID AGENTS

ARMOUR THYROID 3 MOCYTOMEL 3 MOeuthyrox 1 MOLEVO-T 3levothyroxine sodium tabs 1 MOLEVOTHYROXINE SODIUM INJ SOLN 100MCG/5ML, 200MCG/5ML, 500MCG/5ML

3

levothyroxine sodium inj powder 100mcg, 200mcg, 500mcg

1 MO

LEVOTHYROXINE/LIOTHYRONINE 3 MOLEVOXYL 2 MOliothyronine sodium tabs 1 MOliothyronine sodium inj 4methimazole tabs 1 MONP THYROID 120 3 MONP THYROID 15 3 MONP THYROID 30 3 MONP THYROID 60 3 MONP THYROID 90 3 MOpropylthiouracil tabs 1 MOSYNTHROID 3 MOTAPAZOLE 3 MOTIROSINT 3 MOTIROSINT-SOL 3 MOTRIOSTAT 4UNITHROID 2

VITAMIN D ANALOGS calcitriol caps 0.25mcg, 0.5mcg 1 MOcalcitriol inj 1mcg/ml 1calcitriol oral soln 1mcg/ml 1 MOdoxercalciferol inj 1doxercalciferol caps 1 MOHECTOROL 3paricalcitol 1 MORAYALDEE 4 MO

106 Updated 10/01/20

Drug name Drug tier Requirements/LimitsROCALTROL 3 MOZEMPLAR CAPS 3 MOZEMPLAR INJ 2MCG/ML 3 MOZEMPLAR INJ 5MCG/ML 4 MO

GASTROINTESTINALANTIEMETICS

AKYNZEO INJ 3AKYNZEO CAPS 4 QL (4 EA per 30 days) B/D MOALOXI 3aprepitant 1 B/D MOBONJESTA 3 QL (60 EA per 30 days) MOCINVANTI 3compro 1 MODICLEGIS 3 QL (120 EA per 30 days) MODIMENHYDRINATE INJ 3doxylamine succinate/pyridoxine hydrochloride


dronabinol 1 QL (60 EA per 30 days) PA MOEMEND TRIPACK 4 B/D MOEMEND CAPS, ORAL SUSP 3 B/D MOEMEND INJ 3 MOfosaprepitant dimeglumine 1 MOgranisetron hcl inj 1 MOgranisetron hcl tabs 1 QL (60 EA per 30 days) B/D MOmeclizine hcl tabs 1 MOmetoclopramide hcl tabs 5mg 1 MOmetoclopramide hydrochloride tabs 10mg

1 MO

METOCLOPRAMIDE ODT TBDP 10MG

2 MO

metoclopramide odt tbdp 5mg 1 MOondansetron hcl tabs 24mg 1 B/Dondansetron hcl oral soln 1 QL (900 ML per 30 days) B/D MOondansetron hydrochloride tabs 4mg, 8mg

1 B/D MO

ondansetron hydrochloride inj 1 MOondansetron odt 1 B/D MO

107Updated 10/01/20

Drug name Drug tier Requirements/LimitsPALONOSETRON HYDROCHLORIDE INJ 0.25MG/2ML

3

palonosetron hydrochloride inj 0.25mg/5ml

1

phenadoz supp 25mg 1 PAphenadoz supp 12.5mg 1 PA MOPHENERGAN 3 PA MOprochlorperazine edisylate inj 50mg/10ml

1

prochlorperazine edisylate inj 10mg/2ml

1 MO

prochlorperazine maleate tabs 1 MOprochlorperazine supp 1 MOpromethazine hcl inj, supp 1 PA MOpromethazine hcl plain syrp 6.25mg/5ml

1 PA MO

promethazine hydrochloride tabs 1 PA MOpromethegan supp 12.5mg, 25mg 1 PApromethegan supp 50mg 1 PA MOREGLAN 3 MOSANCUSO 4 QL (4 EA per 28 days) MOscopolamine patch 1 QL (10 EA per 30 days) PA MOSUSTOL 3SYNDROS 4 PA MOTIGAN 3 PA MOTRANSDERM-SCOP 3 QL (10 EA per 30 days) PA MOtrimethobenzamide hydrochloride caps

1 PA MO

VARUBI 3 QL (4 EA per 30 days) B/DZOFRAN 4 B/D MOZUPLENZ FILM 4MG 3 QL (180 EA per 30 days) B/D MOZUPLENZ FILM 8MG 4 QL (90 EA per 30 days) B/D MO

ANTISPASMODICS ANASPAZ 3 MOATROPINE SULFATE INJ 0.25MG/5ML, 0.5MG/5ML, 8MG/20ML

3

108 Updated 10/01/20

Drug name Drug tier Requirements/LimitsATROPINE SULFATE INJ 0.4MG/ML, 1MG/10ML, 1MG/ML

3 MO

BELLADONNA/OPIUM 3 MOBENTYL 4 MOCHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE


CUVPOSA 3 QL (1350 ML per 30 days) MOdicyclomine hcl oral soln 1 MOdicyclomine hydrochloride 1 MOED-SPAZ 3GLYCATE 3 MOglycopyrrolate inj 0.2mg/ml, 0.4mg/2ml

1

glycopyrrolate inj 1mg/5ml, 4mg/20ml

1 MO

GLYCOPYRROLATE TABS 1.5MG 3 MOglycopyrrolate tabs 1mg, 2mg 1 MOHYOSCYAMINE SULFATE ELIX, SUBL 3 MOhyoscyamine sulfate immediate release tabs

1 MO

LEVSIN/SL 3 MOLEVSIN INJ 3LEVSIN TABS 3 MOLIBRAX 4 QL (240 EA per 30 days) ST MOmethscopolamine bromide tabs 1 PA MONULEV 3 MOOSCIMIN 3OSCIMIN SR 3propantheline bromide tabs 1 MO

H2-RECEPTOR ANTAGONISTS cimetidine hcl oral soln 1 MOcimetidine tabs 1 MOfamotidine premixed inj 20mg/50ml 1famotidine inj 1famotidine oral susp, tabs 1 MOnizatidine 1 MOPEPCID 3 MO

109Updated 10/01/20

Drug name Drug tier Requirements/LimitsINFLAMMATORY BOWEL DISEASE

APRISO 3 QL (120 EA per 30 days) MOASACOL HD 3 MOAZULFIDINE 3 MOAZULFIDINE EN-TABS 3 MObalsalazide disodium 1 MObudesonide er tab 9mg 4 MObudesonide cpep 3mg 1 MOCANASA 3 MOCOLAZAL 4 MOcolocort 1CORTENEMA 3 MODELZICOL 3 MODIPENTUM 4 MOENTOCORT EC 4 MOhydrocortisone enem 100mg/60ml 1 MOLIALDA 3 MOmesalamine dr 1 MOmesalamine er 1 QL (120 EA per 30 days) MOmesalamine kit, supp 1 MOmesalamine enem 1 QL (1680 ML per 28 days) MOORTIKOS 4PENTASA CPCR 250MG 3 MOPENTASA CPCR 500MG 4 MOROWASA 3 MOSFROWASA 4 QL (1680 ML per 28 days) MOSULFASALAZINE DELAYED RELEASE TABS

2 MO

sulfasalazine tabs 1 MOUCERIS FOAM 3 QL (33.4 GM per 30 days) MOUCERIS TB24 4 MO

LAXATIVES CLENPIQ 3 MOCOLYTE-FLAVOR PACKS 3 MOconstulose 1enulose 1 MOgavilyte-c 1 MO

110 Updated 10/01/20

Drug name Drug tier Requirements/Limitsgavilyte-g 1 MOgavilyte-n/flavor pack 1 MOgenerlac 1GOLYTELY 2 MOKRISTALOSE 3 MOLACTULOSE PACK 3 MOlactulose oral soln 1 MOMOVIPREP 3 MONULYTELY/FLAVOR PACKS 2 MOOSMOPREP 3 MOpeg-3350/electrolytes 1 MOpeg-3350/nacl/na bicarbonate/kcl 1 MOPLENVU 3 MOSUPREP BOWEL PREP KIT 3 MOtrilyte 1

MISCELLANEOUS ACTIGALL 3 MOalosetron hydrochloride 4 QL (60 EA per 30 days) PA MOAMITIZA CAPS 8MCG 3 QL (180 EA per 30 days) PA MOAMITIZA CAPS 24MCG 3 QL (60 EA per 30 days) PA MOCARAFATE 3 MOCHENODAL 4 PACHOLBAM 4 PA MOcromolyn sodium oral conc 100mg/5ml

1 MO

CYTOTEC 3 MOdiphenoxylate/atropine 1 MOGASTROCROM 4 MOGATTEX 4 PA LAlansoprazole/amoxicillin/clarithromycin


LINZESS 3 QL (30 EA per 30 days) MOLOMOTIL 3 MOloperamide hcl caps 1 MOLOTRONEX 4 QL (60 EA per 30 days) PA MOmisoprostol tabs 1 MOMOTEGRITY 3 QL (30 EA per 30 days) PA MO

111Updated 10/01/20

Drug name Drug tier Requirements/LimitsMOTOFEN 3 QL (240 EA per 30 days) ST MOMOVANTIK TABS 25MG 2 QL (30 EA per 30 days) MOMOVANTIK TABS 12.5MG 2 QL (60 EA per 30 days) MOMYTESI 3 PA MOOCALIVA 4 QL (30 EA per 30 days) PAOMECLAMOX-PAK 3 QL (160 EA per 365 days) MOOPIUM TINCTURE 3 MOPAREGORIC 3 MOPYLERA 3 MORELISTOR INJ 4 PA MORELISTOR TABS 4 QL (90 EA per 30 days) PA MOSUCRAID 4SUCRALFATE SUSP 3 MOsucralfate tabs 1 MOSYMPROIC 3 MOTALICIA 4 QL (336 EA per 365 days) MOTRULANCE 3 MOURSO 250 3 MOURSO FORTE 3 MOursodiol caps, tabs 1 MOVIBERZI 4 QL (60 EA per 30 days) PA MOXERMELO 4 QL (84 EA per 28 days) PA MOXIFAXAN TABS 550MG 4 PA MOZELNORM 3 QL (60 EA per 30 days) PA MO

PANCREATIC ENZYMES CREON 2 MOPANCREAZE CPEP 2600UNIT, 4200UNIT, 10500UNIT

3 MO

PANCREAZE CPEP 21000UNIT, 16800UNIT

4 MO

PERTZYE CPEP 4000UNIT, 8000UNIT 3 MOPERTZYE CPEP 16000UNIT, 24000UNIT

4 MO

VIOKACE TABS 10440UNIT 3 MOVIOKACE TABS 20880UNIT 4 MOZENPEP 3 MO

112 Updated 10/01/20

Drug name Drug tier Requirements/LimitsPROTON PUMP INHIBITORS

ACIPHEX DR TABS 20MG 3 QL (30 EA per 30 days) MODEXILANT 3 QL (30 EA per 30 days) MOesomeprazole magnesium caps 1 QL (30 EA per 30 days) MOesomeprazole sodium inj 1lansoprazole dr caps, odt 1 QL (30 EA per 30 days) MONEXIUM CAPS, PACKET 3 QL (30 EA per 30 days) MONEXIUM I.V. INJ 3 PAomeprazole caps 1 QL (30 EA per 30 days) MOomeprazole/sodium bicarbonate 1 QL (30 EA per 30 days) MOpantoprazole sodium dr tabs 20mg 1 QL (30 EA per 30 days) MOpantoprazole sodium inj 1pantoprazole sodium pack 1 QL (30 EA per 30 days)pantoprazole sodium tbec 20mg 1 QL (30 EA per 30 days) MOpantoprazole sodium tbec 40mg 1 QL (60 EA per 30 days) MOPREVACID 3 QL (30 EA per 30 days) MOPREVACID SOLUTAB 3 QL (30 EA per 30 days) MOPRILOSEC PACK 10MG 3 QL (120 EA per 30 days) MOPRILOSEC PACK 2.5MG 3 QL (90 EA per 30 days) MOPROTONIX INJ 3PROTONIX PACK 3 QL (30 EA per 30 days) MOPROTONIX TBEC 20MG 3 QL (30 EA per 30 days) MOPROTONIX TBEC 40MG 3 QL (60 EA per 30 days) MOrabeprazole sodium dr tabs 20mg 1 QL (30 EA per 30 days) MOZEGERID 4 QL (30 EA per 30 days) PA MO

GENITOURINARYBENIGN PROSTATIC HYPERPLASIA

alfuzosin hcl er 1 QL (30 EA per 30 days) MOAVODART 3 QL (30 EA per 30 days) MOCARDURA XL 3 QL (60 EA per 30 days) MOdutasteride 1 QL (30 EA per 30 days) MOdutasteride/tamsulosin hcl 1 QL (30 EA per 30 days) MOfinasteride tabs 5mg 1 QL (30 EA per 30 days) MOFLOMAX 3 QL (60 EA per 30 days) MOJALYN 3 QL (30 EA per 30 days) MOPROSCAR 3 QL (30 EA per 30 days) MORAPAFLO 3 QL (30 EA per 30 days) MO

113Updated 10/01/20

Drug name Drug tier Requirements/Limitssilodosin 1 QL (30 EA per 30 days) MOtamsulosin hydrochloride 1 QL (60 EA per 30 days) MOUROXATRAL 3 QL (30 EA per 30 days) MO

MISCELLANEOUS ACETIC ACID 0.25% IRRIGATION SOLN

2 MO

bethanechol chloride 1 MOCYTRA K CRYSTALS 3 MOELMIRON 3 MOflavoxate hcl 1 MOINTRAROSA 3 QL (28 EA per 28 days) PA MOLITHOSTAT 3 MOneomycin/polymyxin b sulfates irrigation soln

1 MO

ORACIT 3 MOpotassium citrate er 1 MOPOTASSIUM CITRATE/CITRIC ACID SOLN

3 MO

RENACIDIN 3 MORIMSO-50 4 MOSODIUM CITRATE/CITRIC ACID 3 MOSORBITOL IRRIGATION SOLN 3SORBITOL-MANNITOL IRRIGATION SOLN

3

THIOLA 4THIOLA EC 4TRICITRATES 3UROCIT-K 10 3 MOUROCIT-K 15 3 MOUROCIT-K 5 3 MO

URINARY ANTISPASMODICS darifenacin hydrobromide er 1 QL (30 EA per 30 days) MODETROL 3 QL (60 EA per 30 days) MODETROL LA 3 QL (30 EA per 30 days) MODITROPAN XL TB24 5MG 3 QL (30 EA per 30 days) MODITROPAN XL TB24 10MG 3 QL (60 EA per 30 days) MOENABLEX 3 QL (30 EA per 30 days) MO

114 Updated 10/01/20

Drug name Drug tier Requirements/LimitsGELNIQUE 10% 3 QL (30 GM per 30 days) MOMYRBETRIQ 3 QL (30 EA per 30 days) MOoxybutynin chloride er tb24 5mg 1 QL (30 EA per 30 days) MOoxybutynin chloride er tb24 10mg, 15mg


oxybutynin chloride tabs 1 QL (120 EA per 30 days) MOoxybutynin chloride syrp 1 QL (600 ML per 30 days) MOOXYTROL 3 QL (8 EA per 28 days) MOsolifenacin succinate 1 QL (30 EA per 30 days) ST MOtolterodine tartrate 1 QL (60 EA per 30 days) ST MOtolterodine tartrate er 1 QL (30 EA per 30 days) ST MOTOVIAZ 3 QL (30 EA per 30 days) MOtrospium chloride 1 QL (60 EA per 30 days) MOtrospium chloride er 1 QL (30 EA per 30 days) MOVESICARE 3 QL (30 EA per 30 days) ST MO

VAGINAL ANTI-INFECTIVES CLEOCIN CREA 2% 3 MOCLEOCIN SUPP 100MG 3 MOclindamycin phosphate crea 2% 1 MOCLINDESSE 3 QL (5 GM per 30 days) MOGYNAZOLE-1 3 QL (5 GM per 30 days) MOmetronidazole vaginal 1 MOmiconazole 3 1 MONUVESSA 3 MOterconazole 1 MOVANDAZOLE 3 MO

HEMATOLOGICANTICOAGULANTS

ARGATROBAN 3ARIXTRA INJ 2.5MG/0.5ML 3 MOARIXTRA INJ 10MG/0.8ML, 5MG/0.4ML, 7.5MG/0.6ML

4 MO

BEVYXXA CAPS 40MG 3 QL (30 EA per 30 days) PABEVYXXA CAPS 80MG 3 QL (30 EA per 30 days) PA MOELIQUIS STARTER PACK 2 QL (74 EA per 30 days) MOELIQUIS TABS 2.5MG 2 QL (60 EA per 30 days) MOELIQUIS TABS 5MG 2 QL (74 EA per 30 days) MO

115Updated 10/01/20

Drug name Drug tier Requirements/Limitsenoxaparin sodium 1 MOfondaparinux sodium 1 MOFRAGMIN 3 MOHEPARIN SODIUM/D5W INJ 20000UNIT/500ML, 25000UNIT/500ML

3

HEPARIN SODIUM/DEXTROSE 100UNIT/ML

3

HEPARIN SODIUM/NACL 0.45% INJ 25000UNIT/250ML, 25000UNIT/500ML

2

HEPARIN SODIUM/SODIUM CHLORIDE 25000UNIT/250ML; 0.45%

2

HEPARIN SODIUM INJ 5000UNIT/0.5ML, 5000UNIT/ML

2

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

1 MO

jantoven 1 MOLOVENOX INJ 300MG/3ML, 40MG/0.4ML

3 MO

LOVENOX INJ 100MG/ML, 120MG/0.8ML, 150MG/ML, 30MG/0.3ML, 60MG/0.6ML, 80MG/0.8ML

4 MO

PRADAXA 3 QL (60 EA per 30 days) MOSAVAYSA 3 QL (30 EA per 30 days) ST MOwarfarin sodium 1 MOXARELTO STARTER PACK 2 QL (51 EA per 30 days) MOXARELTO TABS 10MG, 15MG, 20MG 2 QL (30 EA per 30 days) MOXARELTO TABS 2.5MG 2 QL (60 EA per 30 days) MO

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE INJ 60MCG/0.3ML


ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML


ARANESP ALBUMIN FREE INJ 25MCG/0.42ML


116 Updated 10/01/20

Drug name Drug tier Requirements/LimitsARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML, 60MCG/ML

3 QL (4 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 500MCG/ML










ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML


EPOGEN INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML


EPOGEN INJ 20000UNIT/ML 4 QL (12 ML per 28 days) PAFULPHILA 4 PAGRANIX 4 PALEUKINE 4 PAMOZOBIL 4 PANEULASTA 4 PANEULASTA ONPRO KIT 4 PANEUPOGEN 4 PANIVESTYM 4 PANPLATE 4 PAPROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

2 PA

PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML

4 PA

RETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 PA

RETACRIT INJ 40000UNIT/ML 4 PAUDENYCA 4 PAZARXIO 4 PA

117Updated 10/01/20

Drug name Drug tier Requirements/LimitsZIEXTENZO 4 PA

MISCELLANEOUS ADAKVEO 4 PAAGRYLIN 3 MOAMICAR SOLN 4 MOAMICAR TABS 1000MG 4AMICAR TABS 500MG 4 MOaminocaproic acid inj 1aminocaproic acid oral soln, tabs 1 MOanagrelide hydrochloride 1 MOBERINERT 4 QL (24 EA per 30 days) PA LACABLIVI 4 PA MOcilostazol 1 MOCINRYZE 4 QL (20 EA per 30 days) PACYKLOKAPRON 3DOPTELET 4 QL (30 EA per 30 days)DROXIA 2 MOENDARI 4 PA LA MOFIRAZYR 4 QL (27 ML per 30 days) PAGIVLAARI 4 PA MOHAEGARDA INJ 3000UNIT 4 QL (20 EA per 30 days) PA LAHAEGARDA INJ 2000UNIT 4 QL (30 EA per 30 days) PA LAicatibant acetate 4 QL (27 ML per 30 days) PAKALBITOR 4 QL (12 ML per 30 days) PALYSTEDA 3 QL (30 EA per 30 days) MOMULPLETA 4 QL (14 EA per 365 days) PAOXBRYTA 4 QL (90 EA per 30 days) PApentoxifylline er 1 MOPROMACTA POWDER PACK 25MG 4 QL (180 EA per 30 days) PAPROMACTA POWDER PACK 12.5MG 4 QL (360 EA per 30 days) PA LAPROMACTA TABS 12.5MG, 25MG 4 QL (30 EA per 30 days) PA LAPROMACTA TABS 50MG, 75MG 4 QL (60 EA per 30 days) PA LAREBLOZYL 4 PARUCONEST 4 QL (12 EA per 30 days) PASIKLOS TABS 100MG 3 PA MOSIKLOS TABS 1000MG 4 PA MOSOLIRIS 4 PA

118 Updated 10/01/20

Drug name Drug tier Requirements/LimitsTAKHZYRO 4 QL (4 ML per 28 days) PATAVALISSE 4 QL (60 EA per 30 days) PAtranexamic acid inj 1tranexamic acid tabs 1 QL (30 EA per 30 days) MOULTOMIRIS 4 PA

PLATELET AGGREGATION INHIBITORS AGGRENOX 3 QL (60 EA per 30 days) ST MOaspirin/dipyridamole 1 QL (60 EA per 30 days) MOBRILINTA 3 MOclopidogrel tabs 300mg 1 QL (2 EA per 365 days) MOclopidogrel tabs 75mg 1 QL (30 EA per 30 days) MOdipyridamole 1 PA MOEFFIENT 3 ST MOPLAVIX 3 QL (30 EA per 30 days) ST MOprasugrel 1 MOZONTIVITY 3 MO

IMMUNOLOGIC AGENTSAUTOIMMUNE AGENTS

ACTEMRA ACTPEN 4 QL (3.6 ML per 28 days) PAACTEMRA INJ 162MG/0.9ML 4 QL (3.6 ML per 28 days) PAACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML


CIMZIA 4 QL (2 EA per 28 days) PACIMZIA STARTER KIT 4 QL (6 EA per 365 days) PACOSENTYX 4 QL (32 ML per 365 days) PACOSENTYX SENSOREADY PEN 4 QL (32 ML per 365 days) PADUPIXENT INJ 200MG/1.14ML 4 QL (4.56 ML per 28 days) PADUPIXENT INJ 300MG/2ML 4 QL (8 ML per 28 days) PAENBREL MINI 4 QL (8 ML per 28 days) PAENBREL SURECLICK 4 QL (8 ML per 28 days) PAENBREL INJ 25MG/VIAL 4 QL (8 EA per 28 days) PAENBREL INJ 25MG/0.5ML VIAL, 50MG/ML


ENBREL INJ 25MG/0.5ML PREFILLED SYRINGE


ENTYVIO 4 QL (10 EA per 365 days) PA

119Updated 10/01/20

Drug name Drug tier Requirements/LimitsHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

4 PA

HUMIRA PEN 4 QL (6 EA per 28 days) PAHUMIRA PEN-CD/UC/HS STARTER 4 PAHUMIRA PEN-PS/UV STARTER 4 PAHUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML


HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML


ILUMYA 4 PAINFLECTRA 4 PAKEVZARA 4 QL (2.28 ML per 28 days) PAKINERET 4 QL (18.76 ML per 28 days) PA

MOOLUMIANT 4 QL (30 EA per 30 days) PAORENCIA CLICKJECT 4 QL (4 ML per 28 days) PAORENCIA INJ 250MG 4 PAORENCIA INJ 50MG/0.4ML 4 QL (1.6 ML per 28 days) PAORENCIA INJ 87.5MG/0.7ML 4 QL (2.8 ML per 28 days) PAORENCIA INJ 125MG/ML 4 QL (4 ML per 28 days) PAOTEZLA STARTER PACK 4 QL (55 EA per 365 days) PAOTEZLA TABS 4 QL (60 EA per 30 days) PAREMICADE 4 PARENFLEXIS 4 PARINVOQ 4 QL (30 EA per 30 days) PASILIQ 4 QL (6 ML per 28 days) PASIMPONI ARIA 4 PASIMPONI INJ 50MG/0.5ML 4 QL (0.5 ML per 30 days) PASIMPONI INJ 100MG/ML 4 QL (3 ML per 30 days) PASKYRIZI 4 QL (7 EA per 365 days) PASTELARA INJ 45MG/0.5ML 4 QL (0.5 ML per 28 days) PASTELARA INJ 90MG/ML 4 QL (1 ML per 28 days) PASTELARA INJ 130MG/26ML 4 QL (104 ML per 365 days) PATALTZ 4 QL (3 ML per 28 days) PATREMFYA 4 QL (1 ML per 28 days) PAXELJANZ 4 QL (60 EA per 30 days) PA

120 Updated 10/01/20

Drug name Drug tier Requirements/LimitsXELJANZ XR 4 QL (30 EA per 30 days) PA

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ARAVA TABS 10MG 3 QL (30 EA per 30 days) MOARAVA TABS 20MG 4 QL (30 EA per 30 days) MOhydroxychloroquine sulfate 1 MOleflunomide 1 QL (30 EA per 30 days) MOmethotrexate tabs 2.5mg 1 MOOTREXUP 3PLAQUENIL 3 MORASUVO 3RIDAURA 4 MOTREXALL 3 MOXATMEP 3 MO

IMMUNOGLOBULINS ASCENIV 4 PABIVIGAM 4 PACUTAQUIG 4 PA MOCUVITRU INJ 1GM/5ML 3 PACUVITRU INJ 10GM/50ML, 2GM/10ML, 4GM/20ML, 8GM/40ML

4 PA

CYTOGAM 4FLEBOGAMMA DIF INJ 5GM/100ML 3 PAFLEBOGAMMA DIF INJ 0.5GM/10ML, 10GM/100ML, 10GM/200ML, 2.5GM/50ML, 20GM/200ML, 20GM/400ML, 5GM/50ML

4 PA

GAMASTAN 2 B/DGAMMAGARD LIQUID 4 PAGAMMAGARD S/D INJ 5GM, 10GM 4 PAGAMMAKED 4 PAGAMMAPLEX 4 PAGAMUNEX-C 4 PAHEPAGAM B 3HIZENTRA 4 PAHYPERHEP B S/D 3HYPERRAB S/D 3HYPERRAB INJ 300UNIT/ML 3

121Updated 10/01/20

Drug name Drug tier Requirements/LimitsHYPERRAB INJ 1500UNIT/5ML, 900UNIT/3ML

4

HYPERRHO S/D 3HYPERRHO S/D MINI-DOSE 3HYPERTET S/D 3HYQVIA 4 PAIMOGAM RABIES-HT 3KEDRAB 3MICRHOGAM ULTRA-FILTERED PLUS

3

NABI-HB 3OCTAGAM 4 PAPANZYGA 4 PAPRIVIGEN 4 PARHOGAM ULTRA-FILTERED PLUS 3RHOPHYLAC 3VARIZIG 4WINRHO SDF 3XEMBIFY 4 PA

IMMUNOMODULATORS ACTIMMUNE 4 PA LAARCALYST 4 PAGRASTEK 3 QL (30 EA per 30 days) PA MOILARIS 4 QL (2 ML per 28 days) PAINTRON A INJ 10MU 3INTRON A INJ 10MU/ML, 18MU, 50MU, 6000000UNIT/ML

4

ODACTRA 3 QL (30 EA per 30 days) PA MOORALAIR 300 IR 3 QL (30 EA per 30 days) PARAGWITEK 3 QL (30 EA per 30 days) PA MOSYNAGIS 4ZINPLAVA 4 PA

IMMUNOSUPPRESSANTS ASTAGRAF XL CP24 0.5MG, 1MG 3 B/D MOASTAGRAF XL CP24 5MG 4 B/D MOATGAM 4 B/DAZASAN 3 B/D MO

122 Updated 10/01/20

Drug name Drug tier Requirements/LimitsAZATHIOPRINE INJ 3 B/Dazathioprine tabs 1 B/D MOBENLYSTA 4 PACELLCEPT 4 B/D MOCELLCEPT INJ 3 B/Dcyclosporine 1 B/D MOcyclosporine modified caps, soln 1 B/D MOENVARSUS XR TB24 0.75MG, 1MG 3 B/D MOENVARSUS XR TB24 4MG 4 B/D MOeverolimus tabs 0.25mg, 0.5mg, 0.75mg

4 B/D MO

gengraf caps 1 B/Dgengraf soln 1 B/D MOIMURAN 3 B/D MOmycophenolate mofetil inj 1 B/Dmycophenolate mofetil caps, tabs 1 B/D MOmycophenolate mofetil oral susp 4 B/D MOmycophenolic acid dr 1 B/D MOMYFORTIC 3 B/D MONEORAL 3 B/D MONULOJIX 4 B/DPROGRAF INJ 3 B/DPROGRAF GRANULES 3 B/D MOPROGRAF CAPS 0.5MG, 1MG 3 B/D MOPROGRAF CAPS 5MG 4 B/D MORAPAMUNE TABS 3 B/D MORAPAMUNE SOLN 4 B/D MOSANDIMMUNE ORAL SOLN 2 B/D MOSANDIMMUNE INJ 3 B/DSANDIMMUNE CAPS 3 B/D MOSIMULECT 4 B/Dsirolimus tabs 1 B/D MOsirolimus soln 4 B/D MOtacrolimus caps 0.5mg, 1mg, 5mg 1 B/D MOTHYMOGLOBULIN 4 B/DZORTRESS 4 B/D MO

123Updated 10/01/20

Drug name Drug tier Requirements/LimitsVACCINES

ACTHIB 2ADACEL 2BCG VACCINE 2BEXSERO 2BOOSTRIX 2DAPTACEL 2DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

2 B/D

ENGERIX-B 2 B/DGARDASIL 9 2HAVRIX 2HIBERIX 2IMOVAX RABIES (H.D.C.V.) 2 B/DINFANRIX 2IPOL INACTIVATED IPV 2IXIARO 2KINRIX 2M-M-R II 2MENACTRA 2MENVEO 2PEDIARIX 2PEDVAX HIB 2PENTACEL 2PROQUAD 2QUADRACEL 2RABAVERT 2 B/DRECOMBIVAX HB 2 B/DROTARIX 2ROTATEQ 2SHINGRIX 2 QL (2 EA per 999 days)STAMARIL 3TDVAX 2 B/DTENIVAC 2 B/DTRUMENBA 2TWINRIX 2TYPHIM VI 2

124 Updated 10/01/20

Drug name Drug tier Requirements/LimitsVAQTA 2VARIVAX 2YF-VAX 2ZOSTAVAX 2 QL (1 EA per 999 days)

NUTRITIONAL/SUPPLEMENTSELECTROLYTES/MINERALS, INJECTABLE

CALCIUM GLUCONATE 3 MODEXTROSE 10%/NACL 0.45% 3DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX

2

DEXTROSE 10%/NACL 0.2% 3DEXTROSE 2.5%/NACL 0.45% 3DEXTROSE 5%/LACTATED RINGERS 3DEXTROSE 5%/NACL 0.2% 3DEXTROSE 5%/NACL 0.225% 3DEXTROSE 5%/NACL 0.3% 3DEXTROSE 5%/NACL 0.33% 3DEXTROSE 5%/NACL 0.45% 3DEXTROSE 5%/NACL 0.9% 3 MOHYPERLYTE-CR 3 B/DIONOSOL-MB/DEXTROSE 5% 3ISOLYTE-P/DEXTROSE 5% 3ISOLYTE-S 3ISOLYTE-S PH 7.4 3 B/DKCL 0.075%/D5W/NACL 0.45% 3KCL 0.15%/D5W/NACL 0.2% 3KCL 0.15%/D5W/NACL 0.225% 3KCL 0.15%/D5W/NACL 0.45% 3KCL 0.15%/D5W/NACL 0.9% 3KCL 0.3%/D5W/NACL 0.45% 3KCL 0.3%/D5W/NACL 0.9% 3lactated ringers viaflex inj 1magnesium sulfate in d5w 1MAGNESIUM SULFATE INJ 20GM/500ML, 40GM/1000ML, 4GM/50ML

3

125Updated 10/01/20

Drug name Drug tier Requirements/Limitsmagnesium sulfate inj 2gm/50ml, 4gm/100ml, 50%

1

NORMOSOL -R 3NORMOSOL-M IN D5W 3NORMOSOL-R INJ PH 7.4 3PLASMA-LYTE A 3PLASMA-LYTE-148 3POTASSIUM ACETATE 3POTASSIUM CHLORIDE/DEXTROSE 3POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS

3

POTASSIUM CHLORIDE/DEXTROSE/SODIUM CHLORIDE

3

POTASSIUM CHLORIDE/SODIUM CHLORIDE INJ 40MEQ/L; 0.9%

3

potassium chloride/sodium chloride inj 20meq/l; 0.45%

1

potassium chloride/sodium chloride inj 20meq/l; 0.9%

1 MO

POTASSIUM CHLORIDE INJ 0.4MEQ/ML, 10MEQ/100ML, 10MEQ/50ML, 20MEQ/100ML, 40MEQ/100ML

3

potassium chloride inj 2meq/ml 1 MOPOTASSIUM PHOSPHATES INJ 236MG/ML; 224MG/ML

3

potassium phosphates pf inj 236mg/ml; 224mg/ml

1

RINGERS INJECTION 2SODIUM ACETATE INJ 2MEQ/ML 3sodium acetate inj 4meq/ml 1SODIUM BICARBONATE INJ 7.5% 3 MOsodium bicarbonate inj 4.2% 1sodium bicarbonate inj 8.4% 1 MOSODIUM CHLORIDE INJ 2.5MEQ/ML, 4MEQ/ML, 5%

3 MO

sodium chloride inj 0.45% 1sodium chloride inj 0.9%, 3% 1 MOSODIUM PHOSPHATE 3

126 Updated 10/01/20

Drug name Drug tier Requirements/LimitsTPN ELECTROLYTES 3 B/D

ELECTROLYTES/MINERALS/VITAMINS, ORAL ADC/FLUORIDE 3 MOBAL-CARE DHA 2 MOC-NATE DHA 2 MOCITRANATAL 90 DHA 2 MOCITRANATAL B-CALM 2 MOCITRANATAL BLOOM 2 MOCITRANATAL HARMONY 2 MOCITRANATAL MEDLEY 2CITRANATAL RX 2 MOCOMPLETENATE 2 MOCONCEPT DHA 2 MOCONCEPT OB 2 MODUET DHA 400 2 MODUET DHA BALANCED 2 MOEFFER-K TAB 25MEQ 2 MOEFFER-K TAB 10MEQ, 20MEQ 3 MOEFFERVESCENT POTASSIUM 2 MOELITE-OB 2 MOENBRACE HR 2 MOFLORIVA 3 MOFLUORIDE 3 MOFLUORITAB 3FLURA-DROPS 3 MOFOLIVANE-OB 2 MOK-TAB 3 MOKLOR-CON 10 2KLOR-CON 8 2 MOklor-con m10 1 MOklor-con m15 1 MOklor-con m20 1 MOklor-con pow 20meq 1KLOR-CON/EF 2 MOLUDENT 3 MOM-NATAL PLUS 2 MOMARNATAL-F 2 MO

127Updated 10/01/20

Drug name Drug tier Requirements/LimitsMULTI VITAMIN/FLUORIDE 3 MOMULTI-VITAMIN/FLUORIDE DROPS 3 MOMULTI-VITAMIN/FLUORIDE/IRON DROPS

3 MO

MULTIVITAMIN/FLUORIDE CHEW 0.5MG

3

MULTIVITAMIN/FLUORIDE CHEW 0.25MG, 0.5MG

3 MO

NATACHEW 2 MONEONATAL PLUS 2 MONESTABS 2 MONESTABS ONE 2 MONIVA-PLUS 2 MOO-CAL PRENATAL 2 MOOB COMPLETE 2 MOOB COMPLETE ONE 2 MOOB COMPLETE PETITE 2 MOOB COMPLETE PREMIER 2 MOOB COMPLETE/DHA 2 MOPNV FOLIC ACID + IRON MULTIVITAMIN

2 MO

PNV PRENATAL PLUS MULTIVITAMIN

2 MO

PNV TABS 29-1 2 MOPNV-DHA 2 MOPNV-OMEGA 2 MOPNV-SELECT 2 MOPOLY-VI-FLOR 3 MOPOLY-VI-FLOR/IRON 3 MOPOLY-VITAMIN/FLUORIDE 3potassium chloride cr 1 MOpotassium chloride er 1 MOpotassium chloride sr 1 MOpotassium chloride pack 20meq 1 MOpotassium chloride oral soln 10%, 20%

1 MO

PRENAISSANCE 2 MOPRENAISSANCE PLUS 2 MO

128 Updated 10/01/20

Drug name Drug tier Requirements/LimitsPRENATA 2 MOPRENATAL 2 MOPRENATAL 19 2 MOPRENATAL PLUS 2 MOPRENATAL PLUS IRON 2 MOPRENATAL VITAMINS PLUS LOW IRON

2 MO

PRENATE 2 MOPRENATE AM 2 MOPRENATE DHA 2 MOPRENATE ELITE 2 MOPRENATE ENHANCE 2 MOPRENATE ESSENTIAL 2 MOPRENATE MINI 2 MOPRENATE PIXIE 2 MOPRENATE RESTORE 2 MOPREPLUS 2 MOPRETAB 2 MOPRIMACARE 2 MOPROVIDA OB 2 MOQUFLORA FE 3QUFLORA FE PEDIATRIC 3QUFLORA GUMMIES 3 MOQUFLORA PEDIATRIC CHEW 3 MOQUFLORA PEDIATRIC SOLN 0.5MG/ML

3

QUFLORA PEDIATRIC SOLN 0.25 MG/ML

3 MO

SE-NATAL 19 2 MOSELECT-OB CHW 29-1 MG 2SELECT-OB CHW 29-0.6-0.4 MG 2 MOSODIUM FLUORIDE CHEW 0.25MG, 0.5MG, 1MG

3 MO

SODIUM FLUORIDE SOLN 0.5MG/ML

3 MO

TARON-C DHA 2 MOTARON-PREX 2 MO

129Updated 10/01/20

Drug name Drug tier Requirements/LimitsTHRIVITE RX 2 MOTRI-VI-FLOR 3 MOTRI-VITE/FLUORIDE 3 MOTRICARE PRENATAL DHA ONE 2TRICARE PRENATAL TABS 2 MOTRINATAL RX 1 2 MOTRISTART DHA 2 MOTRISTART ONE 2VIRT-C DHA 2 MOVIRT-NATE DHA 2 MOVIRT-PN DHA 2 MOVIRT-PN PLUS 2 MOVITAFOL FE+ 2VITAFOL GUMMIES 2 MOVITAFOL STRIPS 2VITAFOL ULTRA 2 MOVITAFOL-NANO 2 MOVITAFOL-OB 2 MOVITAFOL-ONE 2 MOVITAMEDMD ONE RX/QUATREFOLIC 2 MOVOL-PLUS 2 MOVP-PNV-DHA 2 MOZATEAN-PN DHA 2 MOZATEAN-PN PLUS 2 MO

IV NUTRITION AMINOSYN II INJ 10% 3 B/DAMINOSYN-PF 10% 3 B/DAMINOSYN-PF 7% 3 B/DCLINIMIX 4.25%/DEXTROSE 10% 3 B/DCLINIMIX 4.25%/DEXTROSE 5% 3 B/DCLINIMIX 5%/DEXTROSE 15% 3 B/DCLINIMIX 5%/DEXTROSE 20% 3 B/DCLINIMIX E 2.75%/DEXTROSE 5% 3 B/DCLINIMIX E 4.25%/DEXTROSE 10% 3 B/DCLINIMIX E 4.25%/DEXTROSE 5% 3 B/DCLINIMIX E 5%/DEXTROSE 15% 3 B/DCLINIMIX E 5%/DEXTROSE 20% 3 B/D

130 Updated 10/01/20

Drug name Drug tier Requirements/Limitsclinisol sf 15% 1 B/D MOCLINOLIPID 2 B/Ddextrose 10% 1DEXTROSE 20% 3 B/DDEXTROSE 25% 3 B/DDEXTROSE 30% 3 B/DDEXTROSE 40% 3 B/Ddextrose 5% 1 MODEXTROSE 50% 2 B/DDEXTROSE 70% 2 B/DFREAMINE HBC 6.9% 3 B/DFREAMINE III 3 B/DHEPATAMINE 3 B/DINTRALIPID INJ 20GM/100ML 2 B/DINTRALIPID INJ 30GM/100ML 3 B/DKABIVEN 3 B/DNEPHRAMINE 3 B/DNUTRILIPID 2 B/DOMEGAVEN 4 B/DPERIKABIVEN 3 B/Dplenamine 1 B/DPOTASSIUM PHOSPHATES INJ 3MM/ML

3

PREMASOL 10% 3 B/DPROCALAMINE 3 B/DPROSOL 3 B/DSMOFLIPID 3 B/DTRAVASOL 3 B/DTROPHAMINE 3 B/D

OPHTHALMICANTI-INFECTIVE/ANTI-INFLAMMATORY

BLEPHAMIDE 3 MOBLEPHAMIDE S.O.P. OINT 3 MOMAXITROL 3 MOneomycin/polymyxin/bacitracin/hydrocortisone ophthalmic oint

1 MO

neomycin/polymyxin/dexamethasone 1 MO

131Updated 10/01/20

Drug name Drug tier Requirements/Limitsneomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml; 10000unit/ml

1 MO

PRED-G 3 MOPRED-G S.O.P. OINT 3 MOsulfacetamide sodium/prednisolone sodium phosphate

1 MO

TOBRADEX ST 2 MOTOBRADEX OINT 2 MOTOBRADEX SUSP 3 MOtobramycin/dexamethasone ophthalmic susp

1 MO

ZYLET 2 MOANTI-INFECTIVES

AZASITE 3 MObacitracin/polymyxin ophthalmic oint 1 MObacitracin oint 500unit/gm 1 MOBESIVANCE 2 MOBETADINE OPHTHALMIC PREP 3 MOBLEPH-10 3 QL (90 ML per 30 days) MOCILOXAN OINT 2 QL (42 GM per 30 days) MOCILOXAN SOLN 3 QL (30 ML per 30 days) MOciprofloxacin hydrochloride ophthalmic soln 0.3%


erythromycin oint 5mg/gm 1 QL (42 GM per 30 days) MOgatifloxacin soln 1 QL (20 ML per 30 days) MOgentak 1 QL (42 GM per 30 days) MOgentamicin sulfate ophthalmic soln 0.3%


levofloxacin ophthalmic soln 0.5% 1 QL (30 ML per 30 days) MOMOXEZA 3 QL (12 ML per 30 days) MOmoxifloxacin hydrochloride ophthalmic soln 0.5%


NATACYN 3 MOneo-polycin 1neomycin/bacitracin/polymyxin topical ointment

1 MO

neomycin/polymyxin/gramicidin 1 MO

132 Updated 10/01/20

Drug name Drug tier Requirements/LimitsOCUFLOX 3 QL (60 ML per 30 days) MOofloxacin ophthalmic soln 0.3% 1 QL (60 ML per 30 days) MOpolycin 1polymyxin b sulfate/trimethoprim sulfate

1 MO

POLYTRIM 3 MOsodium sulfacetamide ophthalmic soln


sulfacetamide sodium oint 10% 1 QL (42 GM per 30 days) MOsulfacetamide sodium soln 10% 1 QL (90 ML per 30 days) MOtobramycin sulfate ophthalmic soln 0.3%


TOBREX OINT 3 MOTOBREX SOLN 3 QL (30 ML per 30 days) MOtrifluridine 1 MOtrimethoprim sulfate/polymyxin b sulfate

1 MO

VIGAMOX 3 QL (12 ML per 30 days) MOZIRGAN 3 MOZYMAXID 3 QL (20 ML per 30 days) MO

ANTI-INFLAMMATORIES ACULAR 3 MOACULAR LS 3 MOACUVAIL 3 MOALREX 2 MObromfenac 1 MOBROMSITE 3 MOdexamethasone sodium phosphate ophthalmic soln 0.1%

1 MO

diclofenac sodium ophthalmic soln 0.1%


DUREZOL 2 MOFLAREX 3 MOFLUOROMETHOLONE 2 MOflurbiprofen sodium ophthalmic soln 0.03%

1 MO

FML 3 MOFML FORTE 3 MO

133Updated 10/01/20

Drug name Drug tier Requirements/LimitsFML LIQUIFILM 3 MOILEVRO 2 MOINVELTYS 3 MOketorolac tromethamine ophthalmic soln 0.4%, 0.5%

1 MO

LOTEMAX SM 2 MOLOTEMAX GEL, OINT 2 MOLOTEMAX SUSP 3 MOloteprednol etabonate 1 MOMAXIDEX 3 MONEVANAC 3 MOOZURDEX 4PRED FORTE 3 MOPRED MILD 3 MOprednisolone acetate ophthalmic soln 1 MOPREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC SOLN 1%

2 MO

PROLENSA 2 MOTRIESENCE 3 MO

ANTIALLERGICS ALOCRIL 3 MOALOMIDE 3 MOazelastine hcl nasal soln 0.15% (137mcg/spray) ophthalmic soln 0.05%

1 MO

BEPREVE 2 MOcromolyn sodium ophthalmic soln 4% 1 MOepinastine hcl 1 MOLASTACAFT 3 MOolopatadine hcl ophthalmic soln 0.2% 1 MOolopatadine hcl ophthalmic soln 0.1% 1 MOPATADAY 3 MOPATANOL 3 MOPAZEO 2 MOZERVIATE 3 MO

134 Updated 10/01/20

Drug name Drug tier Requirements/LimitsANTIGLAUCOMA

ALPHAGAN P SOLN 0.1% 2 MOALPHAGAN P SOLN 0.15% 3 MOapraclonidine 1 MOAZOPT 2 MObetaxolol hcl soln 0.5% 1 MOBETIMOL 3 MOBETOPTIC-S 2 MObimatoprost 1 MOBRIMONIDINE TARTRATE SOLN 0.15%

2 MO

brimonidine tartrate soln 0.2% 1 MOcarteolol hcl 1 MOCOMBIGAN 2 MOCOSOPT 3 MOCOSOPT PF 3 MOdorzolamide hcl 1 MOdorzolamide hcl/timolol maleate 1 MOdorzolamide hydrochloride/timolol maleate pf

1 MO

IOPIDINE 3 MOISOPTO CARPINE 3 MOISTALOL 3 MOlatanoprost 1 MOlevobunolol hcl 1 MOLUMIGAN 2 MOPHOSPHOLINE IODIDE 3pilocarpine hcl ophthalmic soln 1 MORHOPRESSA 2 MOROCKLATAN 3 MOSIMBRINZA 2 MOTIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLN

3 MO

timolol maleate soln 0.25%, 0.5% 1 MOTIMOPTIC 3 MOTIMOPTIC OCUDOSE 3 MOTIMOPTIC-XE 3 MO

135Updated 10/01/20

Drug name Drug tier Requirements/LimitsTRAVATAN Z 3 MOtravoprost 1 MOTRUSOPT 3 MOVYZULTA 3 ST MOXALATAN 3 MOXELPROS 3 STZIOPTAN 3 ST MO

MISCELLANEOUS ATROPINE SULFATE OINT 1% 3 MOATROPINE SULFATE OPHTHALMIC SOLN 1%

2 MO

BEOVU 4 PACEQUA 3 QL (60 EA per 30 days) PA MOCYCLOGYL 3 MOcyclopentolate hcl 1 MOCYSTARAN 4 PA LA MOEYLEA 4 PAISOPTO ATROPINE 3 MOLACRISERT 3 MOLUCENTIS 4 PAOXERVATE 4 QL (28 ML per 28 days) PA MOPHENYLEPHRINE HCL OPHTHALMIC SOLN 10%

3

PHENYLEPHRINE HCL OPHTHALMIC SOLN 2.5%

3 MO

proparacaine hcl 1 MORESTASIS 2 QL (60 EA per 30 days) MORESTASIS MULTIDOSE 2 QL (5.5 ML per 30 days) MOTETRACAINE HYDROCHLORIDE 3 MOXIIDRA 3 QL (60 EA per 30 days) PA MO

RESPIRATORYANTICHOLINERGIC/BETA AGONIST COMBINATIONS

ANORO ELLIPTA 2 QL (60 EA per 30 days) MOBEVESPI AEROSPHERE 2 QL (10.7 GM per 30 days) MOCOMBIVENT RESPIMAT 3 QL (8 GM per 30 days) MODUAKLIR PRESSAIR 3 QL (1 EA per 30 days) ST MO

136 Updated 10/01/20

Drug name Drug tier Requirements/Limitsipratropium bromide/albuterol sulfate neb

1 B/D MO

STIOLTO RESPIMAT 3 QL (4 GM per 30 days) ST MOTRELEGY ELLIPTA 2 QL (60 EA per 30 days) MOUTIBRON NEOHALER 3 QL (60 EA per 30 days) ST MO

ANTICHOLINERGICS ATROVENT HFA 3 QL (25.8 GM per 30 days) MOINCRUSE ELLIPTA 2 QL (30 EA per 30 days) MOipratropium bromide inhalation soln 1 B/D MOipratropium bromide nasal soln 0.03%


ipratropium bromide nasal soln 0.06%


LONHALA MAGNAIR REFILL KIT 3 QL (60 ML per 30 days) ST MOSEEBRI NEOHALER 3 QL (60 EA per 30 days) ST MOSPIRIVA HANDIHALER 3 QL (30 EA per 30 days) ST MOSPIRIVA RESPIMAT 3 QL (4 GM per 30 days) ST MOTUDORZA PRESSAIR 3 QL (1 EA per 30 days) ST MOYUPELRI 4 QL (90 ML per 30 days) PA MO

ANTIHISTAMINE COMBINATIONS azelastine hydrochloride/fluticasone propionate


CLARINEX-D 12 HOUR 3 MODYMISTA 3 QL (23 GM per 30 days) MOpromethazine/phenylephrine syrp 1 PA MOSEMPREX-D 3 QL (56 EA per 28 days) MO

ANTIHISTAMINES azelastine hcl nasal soln 0.15% (137mcg/spray) nasal soln 0.15%


azelastine hydrochloride nasal spray 0.15% (205.5mcg/spray)


carbinoxamine maleate soln 1 PA MOCARBINOXAMINE MALEATE TABS 6MG

4 PA MO

carbinoxamine maleate tabs 4mg 1 PA MOcetirizine hydrochloride oral soln 1mg/ml


CLARINEX 3 QL (30 EA per 30 days) MO

137Updated 10/01/20

Drug name Drug tier Requirements/Limitsclemastine fumarate tab 2.68mg 1 PA MOcyproheptadine hcl syrp 2mg/5ml 1 PA MOcyproheptadine hydrochloride tab 4mg

1 PA MO

desloratadine 1 QL (30 EA per 30 days) MOdesloratadine odt 1 QL (30 EA per 30 days) MOdexchlorpheniramine maleate 1 PAdiphen elixir 1 PAdiphenhydramine hcl elix 1 PAdiphenhydramine hcl inj 1 PA MOhydroxyzine hcl inj, syrp 1 PA MOhydroxyzine hydrochloride tabs 1 PA MOhydroxyzine pamoate 1 PA MOlevocetirizine dihydrochloride soln 1 MOlevocetirizine dihydrochloride tabs 1 QL (30 EA per 30 days) MOolopatadine hcl nasal soln 0.6% 1 QL (30.5 GM per 30 days) MOPATANASE 3 QL (30.5 GM per 30 days) MOQUZYTTIR 3 PAryclora 1 PARYVENT 3 PA MOVISTARIL 3 PA MO

BETA AGONISTS albuterol sulfate er tabs 1 MOalbuterol sulfate hfa (generic Proventil HFA) aers 108mcg/act

1 QL (13.4 GM per 30 days) MO

albuterol sulfate hfa (generic Proair HFA) aers 108mcg/act


albuterol sulfate hfa (generic Ventolin HFA) aers 108mcg/act


albuterol sulfate nebu 1 B/D MOalbuterol sulfate syrp, tabs 1 MOARCAPTA NEOHALER 3 QL (30 EA per 30 days) ST MOBROVANA 3 QL (120 ML per 30 days) PA MOlevalbuterol hcl neb 1.25mg/0.5ml 1 B/D MOlevalbuterol hydrochloride nebu 0.31mg/3ml, 0.63mg/3ml, 1.25mg/3ml

1 B/D MO

LEVALBUTEROL TARTRATE HFA 2 QL (30 GM per 30 days) MO

138 Updated 10/01/20

Drug name Drug tier Requirements/Limitsmetaproterenol sulfate 1PERFOROMIST 3 QL (120 ML per 30 days) PA MOPROAIR DIGIHALER 3 QL (2 EA per 30 days) PAPROAIR HFA 3 QL (17 GM per 30 days) MOPROAIR RESPICLICK 3 QL (2 EA per 30 days) MOPROVENTIL HFA 3 QL (13.4 GM per 30 days) MOSEREVENT DISKUS 2 QL (60 EA per 30 days) MOSTRIVERDI RESPIMAT 3 QL (4 GM per 30 days) ST MOterbutaline sulfate 1 MOVENTOLIN HFA 2 QL (36 GM per 30 days) MOXOPENEX CONCENTRATE NEB 3 B/D MOXOPENEX HFA 3 QL (30 GM per 30 days) MOXOPENEX NEBU 0.31MG/3ML, 0.63MG/3ML

3 B/D MO

XOPENEX NEBU 1.25MG/3ML 4 B/D MOLEUKOTRIENE MODULATORS

ACCOLATE 3 QL (60 EA per 30 days) MOmontelukast sodium 1 QL (30 EA per 30 days) MOSINGULAIR 3 QL (30 EA per 30 days) ST MOzafirlukast 1 QL (60 EA per 30 days) MOzileuton er 4 QL (120 EA per 30 days) MOZYFLO 4 QL (120 EA per 30 days) MO

MISCELLANEOUS acetylcysteine inhalation soln 10%, 20%

1 B/D MO

aminophylline 1ARALAST NP 4 PA LAAUVI-Q INJ 0.15MG/0.15ML 3 QL (2 EA per 30 days) ST MOAUVI-Q INJ 0.1MG/0.1ML 4 QL (2 EA per 30 days) STAUVI-Q INJ 0.3MG/0.3ML 4 QL (2 EA per 30 days) ST MOCINQAIR 4 PACOCAINE HYDROCHLORIDE NASAL SOLN

3 PA

cromolyn sodium nebu 20mg/2ml 1 B/D MODALIRESP 3 MOELIXOPHYLLIN 3 MOepinephrine hcl inj soln 1 QL (2 EA per 30 days) MO

139Updated 10/01/20

Drug name Drug tier Requirements/LimitsEPIPEN 2-PAK 3 QL (2 EA per 30 days) MOEPIPEN-JR 2-PAK 3 QL (2 EA per 30 days) MOESBRIET 4 PAFASENRA 4 QL (1 ML per 28 days) PAFASENRA PEN 4 QL (1 ML per 28 days) PAGLASSIA 4 PAGOPRELTO 3 PAKALYDECO 4 PA MONUCALA INJ 100MG/VIAL 4 QL (3 EA per 28 days) PANUCALA INJ 100MG/ML 4 QL (3 ML per 28 days) PANUMBRINO 3 PAOFEV 4 PAORKAMBI 4 PA MOPROLASTIN-C 4 PA LA MOPULMOZYME 4 PASYMDEKO TBPK 75MG; 50MG 4 PASYMDEKO TBPK 150MG; 100MG 4 PA LASYMJEPI INJ 0.15MG/0.3ML 3 QL (2 EA per 30 days)SYMJEPI INJ 0.3MG/0.3ML 3 QL (2 EA per 30 days) MOTHEO-24 3 MOtheophylline er 1 MOtheophylline soln 80 mg/15ml 1 MOTHEOPHYLLINE/D5W 3TRIKAFTA 4 QL (84 EA per 28 days) PA MOXOLAIR 4 PA LAZEMAIRA 4 PA LA

NASAL STEROIDS BECONASE AQ 3 QL (50 GM per 30 days) MOflunisolide 1 QL (75 ML per 30 days) MOfluticasone propionate susp 50mcg/act


mometasone furoate susp 50mcg/act 1 QL (34 GM per 30 days) MONASONEX 3 QL (34 GM per 30 days) ST MOOMNARIS 3 QL (12.5 GM per 30 days) MOQNASL 3 QL (10.6 GM per 30 days) MOQNASL CHILDRENS 3 QL (4.9 GM per 30 days) MOXHANCE 3 QL (32 ML per 30 days) MO

140 Updated 10/01/20

Drug name Drug tier Requirements/LimitsZETONNA 3 QL (6.1 GM per 30 days) MO

STEROID INHALANTS ALVESCO 3 QL (12.2 GM per 30 days) ST MOARNUITY ELLIPTA 2 QL (30 EA per 30 days) MOASMANEX HFA 3 QL (13 GM per 30 days) ST MOASMANEX TWISTHALER 120 METERED DOSES


ASMANEX TWISTHALER 14 METERED DOSES






budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml

1 B/D MO

FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST


FLOVENT DISKUS AEPB 250MCG/BLIST


FLOVENT HFA AERO 44MCG/ACT 2 QL (21.2 GM per 30 days) MOFLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT


PULMICORT FLEXHALER 3 QL (2 EA per 30 days) MOPULMICORT SUSP 0.25MG/2ML, 0.5MG/2ML

3 B/D MO

PULMICORT SUSP 1MG/2ML 4 B/D MOQVAR REDIHALER 3 QL (21.2 GM per 30 days) ST MO

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 2 QL (60 EA per 30 days) MOADVAIR HFA 2 QL (12 GM per 30 days) MOAIRDUO RESPICLICK 113/14 3 QL (1 EA per 30 days) ST MOAIRDUO RESPICLICK 232/14 3 QL (1 EA per 30 days) ST MOAIRDUO RESPICLICK 55/14 3 QL (1 EA per 30 days) ST MOBREO ELLIPTA 2 QL (60 EA per 30 days) MOBUDESONIDE/FORMOTEROL FUMARATE DIHYDRATE

2 QL (10.2 GM per 30 days) MO

DULERA 3 QL (13 GM per 30 days) ST MO

141Updated 10/01/20

Drug name Drug tier Requirements/LimitsFLUTICASONE PROPIONATE/SALMETEROL


FLUTICASONE PROPIONATE/SALMETEROL DISKUS


SYMBICORT 2 QL (10.2 GM per 30 days) MOwixela inhub 1 QL (60 EA per 30 days) MO

TOPICALDERMATOLOGY, ACNE

ABSORICA 4 PAABSORICA LD 4ACANYA 3 MOACZONE 3 QL (90 GM per 30 days) MOadapalene/benzoyl peroxide 1 QL (45 GM per 30 days) PA MOADAPALENE SOLN 3 QL (60 ML per 30 days) PAadapalene pads 1 QL (30 EA per 30 days) PAadapalene crea, gel 1 QL (45 GM per 30 days) PA MOAKLIEF 3 QL (45 GM per 30 days) PA MOALTRENO 3 QL (45 GM per 30 days) PA MOamnesteem 1 PAAMZEEQ 3 QL (30 GM per 30 days) MOARAZLO 3ATRALIN 3 QL (45 GM per 30 days) PA MOAVITA CREA 3 QL (45 GM per 30 days) PAAVITA GEL 3 QL (45 GM per 30 days) PA MOAZELEX 3 QL (50 GM per 30 days) MOBENZACLIN 3 MOBENZACLIN WITH PUMP 3 MOBENZAMYCIN 3 MOclaravis 1 PACLEOCIN-T LOTN 3 QL (60 ML per 30 days) MOCLEOCIN-T GEL 4 QL (75 GM per 30 days) MOclindacin etz pledgets 1 MOclindacin-p pad 1% 1 MOCLINDAGEL 4 QL (75 ML per 30 days) MOclindamycin phosphate/benzoyl peroxide

1 MO

clindamycin phosphate/tretinoin 1 QL (60 GM per 30 days) PA MO

142 Updated 10/01/20

Drug name Drug tier Requirements/Limitsclindamycin phosphate foam 1% 1 QL (100 GM per 30 days) MOclindamycin phosphate gel 1% 1 QL (75 GM per 30 days) MOCLINDAMYCIN PHOSPHATE LOTN 1%


clindamycin phosphate external soln 1%


clindamycin phosphate swab 1% 1 MOclindamycin/benzoyl peroxide gel 5%;1%

1 MO

dapsone gel 5%, 7.5% 1 QL (90 GM per 30 days) MODIFFERIN CREA, GEL 3 QL (45 GM per 30 days) PA MODIFFERIN LOTN 3 QL (59 ML per 30 days) PA MOEPIDUO 3 QL (45 GM per 30 days) PA MOEPIDUO FORTE 3 QL (70 GM per 30 days) PA MOery pad 2% 1 MOERYGEL 3 QL (60 GM per 30 days) MOerythromycin/benzoyl peroxide gel 5%; 3%

1 MO

erythromycin gel 2% 1 QL (60 GM per 30 days) MOerythromycin soln 2% 1 QL (60 ML per 30 days) MOEVOCLIN 3 QL (100 GM per 30 days) MOFABIOR 3 QL (100 GM per 30 days) MOisotretinoin 1 PAKLARON 3 MOmyorisan 1 PAneuac gel 1 MOONEXTON 3 MORETIN-A 3 QL (45 GM per 30 days) PA MORETIN-A MICRO PUMP GEL 0.04%, 0.1%


RETIN-A MICRO PUMP GEL 0.08% 4 QL (50 GM per 30 days) PA MORETIN-A MICRO GEL 0.04%, 0.1% 3 QL (50 GM per 30 days) PA MORETIN-A MICRO GEL 0.06% 4 QL (50 GM per 30 days) PA MOSODIUM SULFACETAMIDE/SULFUR 3 QL (473 ML per 30 days) MOSODIUM SULFACETAMIDE/SULFUR CLEANSER IN UREA


sulfacetamide sodium lotn 10% 1 MOSULFACLEANSE 8/4 3 QL (473 ML per 30 days) MO

143Updated 10/01/20

Drug name Drug tier Requirements/LimitsTRETINOIN MICROSPHERE GEL 3 QL (50 GM per 30 days) PA MOTRETINOIN MICROSPHERE PUMP GEL


tretinoin crea 0.025%, 0.05%, 0.1% 1 QL (45 GM per 30 days) PA MOtretinoin gel 0.01%, 0.025%, 0.05% 1 QL (45 GM per 30 days) PA MOVELTIN 3 QL (60 GM per 30 days) PA MOzenatane 1 PAZIANA 3 QL (60 GM per 30 days) PA MO

DERMATOLOGY, ANTIBIOTICS ALTABAX 3 QL (30 GM per 30 days) MOCENTANY GEL 3 QL (30 GM per 30 days) MOCORTISPORIN OINT 3 QL (15 GM per 30 days) MOCORTISPORIN CREA 3 QL (7.5 GM per 30 days) MOgentamicin sulfate crea 0.1% 1 QL (60 GM per 30 days) MOgentamicin sulfate oint 0.1% 1 QL (60 GM per 30 days) MOmafenide acetate 1 MOmupirocin 1 QL (30 GM per 30 days) MONEO-SYNALAR CREA 3 QL (60 GM per 30 days) MOSILVADENE 3 MOSILVER SULFADIAZINE 2 MOSSD 2SULFAMYLON CREA 3 MOSULFAMYLON PACK 4 MOXEPI 3 QL (30 GM per 30 days)

DERMATOLOGY, ANTIFUNGALS ciclodan 1ciclopirox nail lacquer 1 MOciclopirox olamine cream 1 QL (90 GM per 30 days) MOciclopirox gel 1 QL (100 GM per 30 days) MOciclopirox sham 1 QL (120 ML per 30 days) MOciclopirox susp 1 QL (60 ML per 30 days) MOclotrimazole/betamethasone dipropionate lotn


clotrimazole/betamethasone dipropionate crea


clotrimazole crea 1% 1 QL (45 GM per 30 days) MOclotrimazole soln 1% 1 QL (30 ML per 30 days) MO

144 Updated 10/01/20

Drug name Drug tier Requirements/Limitseconazole nitrate 1 QL (85 GM per 30 days) MOERTACZO 4 QL (60 GM per 30 days) MOEXELDERM SOLN 3 QL (30 ML per 30 days) MOEXELDERM CREA 3 QL (60 GM per 30 days) MOEXTINA 4 QL (100 GM per 30 days) MOJUBLIA 3 QL (8 ML per 30 days) PA MOKERYDIN 4 QL (10 ML per 30 days) PA MOketoconazole crea 2% 1 QL (60 GM per 30 days) MOketoconazole foam 2% 1 QL (100 GM per 30 days) MOLOPROX SHAMPOO 3 QL (120 ML per 30 days) MOLOPROX SUSP 3 QL (60 ML per 30 days) MOLOPROX CREA 3 QL (90 GM per 30 days) MOLOTRISONE 3 QL (45 GM per 30 days) MOLULICONAZOLE 3 QL (60 GM per 30 days) ST MOLUZU 3 QL (60 GM per 30 days) ST MOMENTAX 3 QL (30 GM per 30 days) MOMICONAZOLE NITRATE/ZINC OXIDE/WHITE PETROLATUM


naftifine hcl crea 1% 1 QL (90 GM per 30 days) MOnaftifine hydrochloride crea 2% 1 QL (60 GM per 30 days) MOnaftifine hydrochloride gel 1 QL (90 GM per 30 days) MONAFTIN CREA 3 QL (60 GM per 30 days) MONAFTIN GEL 2% 3 QL (60 GM per 30 days) MONAFTIN GEL 1% 3 QL (90 GM per 30 days) MOnyamyc 1 QL (60 GM per 30 days)nystatin/triamcinolone 1 QL (60 GM per 30 days) MOnystatin crea 100000unit/gm 1 QL (30 GM per 30 days) MOnystatin oint 100000unit/gm 1 QL (30 GM per 30 days) MOnystatin powd 100000unit/gm 1 QL (60 GM per 30 days) MOnystop 1 QL (60 GM per 30 days) MOoxiconazole nitrate 1 QL (90 GM per 30 days) MOOXISTAT LOTN 3 QL (60 ML per 30 days) MOOXISTAT CREA 4 QL (90 GM per 30 days) MOPENLAC NAIL LACQUER 3 MOVUSION 3 QL (50 GM per 30 days) PA MO

DERMATOLOGY, ANTIPSORIATICS acitretin 1 PA MO

145Updated 10/01/20

Drug name Drug tier Requirements/Limitscalcipotriene crea, oint 1 QL (120 GM per 30 days) PA MOcalcipotriene soln 1 QL (60 ML per 30 days) PA MOCALCITRIOL OINT 3MCG/GM 3 QL (100 GM per 30 days) MODOVONEX 3 QL (120 GM per 30 days) PA MOmethoxsalen 4 MOOXSORALEN ULTRA 4 MOSORIATANE 4 PA MOSORILUX 3 QL (120 GM per 30 days) PA MOtazarotene crea 0.1% 1 QL (60 GM per 30 days) PA MOTAZORAC GEL 3 QL (100 GM per 30 days) PA MOTAZORAC CREA 3 QL (60 GM per 30 days) PA MOVECTICAL 4 QL (100 GM per 30 days) MO

DERMATOLOGY, ANTISEBORRHEICS ketoconazole sham 2% 1 QL (120 ML per 30 days) MONIZORAL 3 QL (120 ML per 30 days) MOSELENIUM SULFIDE SHAM 3 QL (180 ML per 30 days) MOselenium sulfide lotn 1 MOXOLEGEL 4 QL (45 GM per 30 days) MO

DERMATOLOGY, CORTICOSTEROIDS ALA SCALP 3 MOala-cort crea 1% 1ala-cort crea 2.5% 1 QL (30 GM per 30 days)alclometasone dipropionate 1 MOAMCINONIDE OINT 3 QL (60 GM per 30 days) MOamcinonide crea 1 QL (60 GM per 30 days) MOamcinonide lotn 1 QL (60 ML per 30 days) MOAPEXICON E 4 QL (60 GM per 30 days) MOaugmented betamethasone dipropionate

1 MO

beser lotn 0.05% 1 QL (120 ML per 30 days)betamethasone dipropionate 1 MObetamethasone valerate 1 MOBRYHALI 3 QL (100 GM per 30 days) MOCALCIPOTRIENE/BETAMETHASONE DIPROPIONATE SUSP


calcipotriene/betamethasone dipropionate oint


146 Updated 10/01/20

Drug name Drug tier Requirements/LimitsCAPEX 3 QL (120 ML per 30 days) MOclobetasol propionate emollient foam 1 QL (100 GM per 30 days) MOclobetasol propionate emollient crea 1 QL (60 GM per 30 days) MOclobetasol propionate foam 1 QL (100 GM per 30 days) MOclobetasol propionate lotn, sham 1 QL (118 ML per 30 days) MOclobetasol propionate spray 1 QL (125 ML per 30 days) MOclobetasol propionate soln 1 QL (50 ML per 30 days) MOclobetasol propionate crea, gel, oint 1 QL (60 GM per 30 days) MOCLOBEX LOTN, SHAM 3 QL (118 ML per 30 days) MOCLOBEX SPRAY 3 QL (125 ML per 30 days) MOCLOCORTOLONE PIVALATE 3 QL (90 GM per 30 days) MOclodan shampoo 1 QL (118 ML per 30 days)CLODERM 3 QL (90 GM per 30 days) MOCORDRAN TAPE 3 MOCORDRAN CREA 3 QL (120 GM per 30 days) MOCORDRAN LOTN 3 QL (120 ML per 30 days) MOCORDRAN OINT 3 QL (60 GM per 30 days) MOCUTIVATE 3 QL (120 ML per 30 days) MODERMA-SMOOTHE/FS BODY 3 QL (118.28 ML per 30 days) MODERMA-SMOOTHE/FS SCALP 3 QL (118.28 ML per 30 days) MODESONATE 3 QL (60 GM per 30 days) MOdesonide lotn 1 QL (118 ML per 30 days) MOdesonide crea, oint 1 QL (60 GM per 30 days) MODESOWEN 3 QL (60 GM per 30 days) MOdesoximetasone crea, oint 1 QL (100 GM per 30 days) MOdesoximetasone spray 1 QL (100 ML per 30 days) MOdesoximetasone gel 1 QL (60 GM per 30 days) MOdiflorasone diacetate 1 QL (60 GM per 30 days) MODIPROLENE 3 MODIPROLENE AF 3 MODUOBRII 3 QL (100 GM per 30 days) PA MOELOCON CREA 3 MOENSTILAR 3 QL (120 GM per 30 days) PA MOEPIFOAM 3 QL (10 GM per 30 days) MOfluocinolone acetonide body oil 1 QL (118.28 ML per 30 days) MOfluocinolone acetonide scalp oil 1 QL (118.28 ML per 30 days) MOfluocinolone acetonide crea 0.025% 1 QL (120 GM per 30 days) MO

147Updated 10/01/20

Drug name Drug tier Requirements/Limitsfluocinolone acetonide crea 0.01% 1 QL (60 GM per 30 days) MOfluocinolone acetonide oint 0.025% 1 QL (120 GM per 30 days) MOfluocinolone acetonide topical soln 0.01%


fluocinonide emulsified cream 1 QL (120 GM per 30 days) MOfluocinonide crea 0.05% 1 QL (120 GM per 30 days) MOfluocinonide crea 0.1% 4 QL (120 GM per 30 days) MOfluocinonide gel, oint 1 QL (60 GM per 30 days) MOfluocinonide soln 1 QL (60 ML per 30 days) MOflurandrenolide crea 1 QL (120 GM per 30 days) MOflurandrenolide lotn 1 QL (120 ML per 30 days) MOflurandrenolide oint 1 QL (60 GM per 30 days) MOfluticasone propionate crea 0.05% 1 MOfluticasone propionate lotn 0.05% 1 QL (120 ML per 30 days) MOfluticasone propionate oint 0.005% 1 MOhalcinonide 1 QL (60 GM per 30 days) MOHALOBETASOL PROPIONATE FOAM 3 QL (100 GM per 30 days) MOhalobetasol propionate crea, oint 1 QL (50 GM per 30 days) MOHALOG CREA, OINT 3 QL (60 GM per 30 days) MOHALOG SOLN 4 QL (120 ML per 30 days)hydrocortisone butyrate (lipophilic) crea


hydrocortisone butyrate lotn 1 QL (118 ML per 30 days) MOhydrocortisone butyrate crea, oint 1 QL (45 GM per 30 days) MOhydrocortisone butyrate soln 1 QL (60 ML per 30 days) MOhydrocortisone valerate crea, oint 1 QL (60 GM per 30 days) MOhydrocortisone (generic Ala-Cort) crea 2.5%


hydrocortisone crea 1% 1 QL (90 GM per 30 days) MOhydrocortisone lotn 2.5% 1 MOhydrocortisone oint 1%, 2.5% 1 QL (30 GM per 30 days) MOIMPOYZ 3 QL (60 GM per 30 days) MOKENALOG AER SPRAY 3 MOLEXETTE 3 QL (100 GM per 30 days) MOLOCOID LIPOCREAM 4 QL (60 GM per 30 days) MOLOCOID LOTN 3 QL (118 ML per 30 days) MOLOCOID CREA 3 QL (45 GM per 30 days) MO

148 Updated 10/01/20

Drug name Drug tier Requirements/LimitsLOCOID SOLN 3 QL (60 ML per 30 days) MOLUXIQ 3 MOmometasone furoate crea 0.1% 1 MOmometasone furoate oint 0.1% 1 MOmometasone furoate soln 0.1% 1 MOnolix crea 1 QL (120 GM per 30 days) MOnolix lotn 1 QL (120 ML per 30 days)OLUX 3 QL (100 GM per 30 days) MOOLUX-E 3 QL (100 GM per 30 days) MOPANDEL 4 QL (80 GM per 30 days) MOPREDNICARBATE CREA 3 QL (60 GM per 30 days) MOprednicarbate oint 1 QL (60 GM per 30 days) MOPSORCON 3 QL (60 GM per 30 days) MOSERNIVO 3 QL (120 ML per 30 days) MOSYNALAR CREA, OINT 3 QL (120 GM per 30 days) MOSYNALAR SOLN 3 QL (90 ML per 30 days) MOTACLONEX OINT 4 QL (100 GM per 30 days) PA MOTACLONEX SUSP 4 QL (120 GM per 30 days) PA MOTEMOVATE 3 QL (60 GM per 30 days) MOTEXACORT 3 MOTOPICORT CREA, OINT 3 QL (100 GM per 30 days) MOTOPICORT SPRAY 3 QL (100 ML per 30 days) MOTOPICORT GEL 4 QL (60 GM per 30 days) MOtovet foam 1 QL (100 GM per 30 days)triamcinolone acetonide aers spray 1 MOtriamcinolone acetonide crea 0.025%, 0.5%

1 MO

triamcinolone acetonide crea 0.1% 1 QL (454 GM per 30 days) MOtriamcinolone acetonide lotn 0.025%, 0.1%

1 MO

triamcinolone acetonide oint 0.025%, 0.1%, 0.5%

1 MO

triamcinolone acetonide oint 0.05% 1 QL (430 GM per 30 days) MOtrianex 1 QL (430 GM per 30 days)triderm crea 0.5% 1triderm crea 0.1% 1 QL (454 GM per 30 days)TRIDESILON 3 QL (60 GM per 30 days) MO

149Updated 10/01/20

Drug name Drug tier Requirements/LimitsULTRAVATE 4 QL (60 ML per 30 days) MOVANOS 4 QL (120 GM per 30 days) MOVERDESO 4 QL (100 GM per 30 days) MO

DERMATOLOGY, LOCAL ANESTHETICS glydo 1 QL (30 ML per 30 days) PA MOlidocaine hcl jelly 1 QL (30 ML per 30 days) PA MOlidocaine hcl prsy 2% 1 QL (30 ML per 30 days) PA MOlidocaine hcl external soln 4% 1 QL (50 ML per 30 days) PA MOlidocaine/prilocaine 1 QL (30 GM per 30 days) PA MOlidocaine ptch 1 QL (3 EA per 1 days) PA MOlidocaine oint 1 QL (35.44 GM per 30 days) PA

MOLIDODERM 3 QL (3 EA per 1 days) PA MOPLIAGLIS 3 QL (30 GM per 30 days) PASYNERA 3 QL (10 EA per 30 days) PA MOZTLIDO 3 QL (3 EA per 1 days) PA MO

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ACYCLOVIR CREA 5% 3 QL (5 GM per 30 days) MOacyclovir oint 5% 1 QL (30 GM per 30 days) MOALDARA 3 QL (24 EA per 30 days) MOammonium lactate 1 MOANUSOL-HC CREA 3 MOazelaic acid 1 QL (50 GM per 30 days) MOBENSAL HP 4 QL (30 GM per 30 days) MOCARAC 4 QL (30 GM per 30 days) PA MOCONDYLOX 3 QL (7 GM per 30 days) MOCORTIFOAM 3 QL (15 GM per 30 days) MODENAVIR 3 QL (5 GM per 30 days) MOdiclofenac sodium gel 3% 1 QL (100 GM per 30 days) PA MOdiclofenac sodium gel 1% 1 QL (1000 GM per 30 days) PA

MOdiclofenac sodium transdermal soln 1.5%


DICLOFENACE EPOLAMINE PATCH 3 QL (60 EA per 30 days) PA MODOXEPIN HYDROCHLORIDE CREA 5%


DOXYCYCLINE CPDR 40MG 3 QL (30 EA per 30 days) PA MO

150 Updated 10/01/20

Drug name Drug tier Requirements/LimitsEFUDEX 3 QL (40 GM per 30 days) PA MOELIDEL 3 QL (100 GM per 30 days) ST MOEUCRISA 3 QL (60 GM per 30 days) ST MOFINACEA 3 QL (50 GM per 30 days) MOFLECTOR 3 QL (60 EA per 30 days) PA MOFLUOROURACIL CREA 0.5% 3 QL (30 GM per 30 days) PA MOfluorouracil crea 5% 1 QL (40 GM per 30 days) PA MOfluorouracil external soln 2%, 5% 1 QL (10 ML per 30 days) MOhydrocortisone acetate/pramoxine 1 QL (30 GM per 30 days) MOhydrocortisone (generic Proctosol HC) crea 2.5%

1 MO

imiquimod 1 QL (24 EA per 30 days) MOIMIQUIMOD PUMP 4 QL (7.5 GM per 30 days) MOivermectin crea 1% 1 QL (45 GM per 30 days)LEVULAN KERASTICK 3 QL (6 EA per 30 days)METROCREAM 3 QL (45 GM per 30 days) MOMETROGEL 3 MOMETROLOTION 3 MOmetronidazole crea 0.75% 1 QL (45 GM per 30 days) MOmetronidazole gel 0.75%, 1% 1 MOmetronidazole lotn 0.75% 1 MOMIRVASO 3 MONORITATE 4 QL (60 GM per 30 days) MOORACEA 3 QL (30 EA per 30 days) PA MOPANRETIN 4 QL (60 GM per 30 days)PENNSAID 4 QL (224 GM per 28 days) PA MOPICATO GEL 0.05% 4 QL (2 EA per 30 days) MOPICATO GEL 0.015% 4 QL (3 EA per 30 days) MOpimecrolimus 1 QL (100 GM per 30 days) ST MOPODOCON 25 IN BENZOIN TINCTURE


podofilox 1 MOprocto-med hc 1procto-pak 1 MOPROCTOCORT CREA 3 MOPROCTOFOAM HC 3 QL (10 GM per 30 days) MOproctosol hc 1 MO

151Updated 10/01/20

Drug name Drug tier Requirements/Limitsproctozone-hc 1PROTOPIC OINT 0.03% 3 QL (60 GM per 30 days) ST MOPROTOPIC OINT 0.1% 4 QL (60 GM per 30 days) ST MOPRUDOXIN 4 QL (45 GM per 30 days) PA MOQBREXZA 3 QL (30 EA per 30 days) PA MORECTIV 3 QL (30 GM per 30 days) MORHOFADE 3 QL (60 GM per 30 days) PA MOrosadan gel 1rosadan crea 1 QL (45 GM per 30 days)SALEX 3 QL (177 ML per 30 days) MOSALICYLIC ACID WART REMOVER 3 QL (10 ML per 30 days) MOSALICYLIC ACID SHAM 6% 3 QL (177 ML per 30 days) MOSALICYLIC ACID CREA 6% 3 QL (454 GM per 30 days)SALICYLIC ACID LOTN 6% 3 QL (473 ML per 30 days) MOSILVER NITRATE 3 QL (960 ML per 30 days) MOSOOLANTRA 3 QL (45 GM per 30 days) MOtacrolimus oint 0.03%, 0.1% 1 QL (60 GM per 30 days) MOTARGRETIN GEL 1% 4 QL (60 GM per 30 days) PATOLAK 3 QL (40 GM per 30 days) PA MOVALCHLOR 4 QL (60 GM per 30 days) PA LA

MOVEREGEN 4 QL (30 GM per 30 days) MOVIRASAL 3 QL (10 ML per 30 days) MOVOLTAREN 3 QL (1000 GM per 30 days) PA

MOXERESE 4 QL (5 GM per 30 days) MOZONALON 3 QL (45 GM per 30 days) PA MOZOVIRAX CREA 5% 4 QL (5 GM per 30 days) MOZOVIRAX OINT 5% 4 QL (30 GM per 30 days) MOZYCLARA CREA 3.75% 4 QL (28 EA per 28 days) MOZYCLARA PUMP 4 QL (15 GM per 30 days) MO

DERMATOLOGY, SCABICIDES AND PEDICULIDES crotan 4 QL (237 GM per 30 days)ELIMITE 3 MOlindane 1 MOmalathion 1 MONATROBA 3 QL (120 ML per 30 days) MO

152 Updated 10/01/20

Drug name Drug tier Requirements/LimitsOVIDE 3 MOpermethrin 1 MOSKLICE 3 QL (117 GM per 30 days) MO

DERMATOLOGY, WOUND CARE AGENTS LACTATED RINGERS IRRIGATION 3PHYSIOLYTE 3PHYSIOSOL IRRIGATION 3REGRANEX 4 QL (30 GM per 30 days) PA MORINGERS IRRIGATION 3SANTYL 3 MOSODIUM CHLORIDE 0.9% IRRIGATION SOLN

2 MO

STERILE WATER IRRIGATION PLASTIC BOTTLE

2 MO

TIS-U-SOL 3MOUTH/THROAT/DENTAL AGENTS

ARESTIN 4 PAcevimeline hydrochloride 1 MOchlorhexidine gluconate oral soln 1 MOCLINPRO 5000 3 MOclotrimazole troc 10mg 1 MODENTA 5000 PLUS CREA 1.1% 3 QL (51 GM per 30 days)DENTA 5000 PLUS CREA 1.1% (2 PACK)


DENTAGEL 3 QL (56 GM per 30 days) MOEVOXAC 3 MOFLUORIDEX 3FLUORIDEX SENSITIVITY RELIEF/SLS FREE

3

lidocaine hcl mouth/throat soln 4% 1lidocaine viscous 1 MOnystatin susp 100000unit/ml 1 MOoralone dental paste 1ORAVIG 4 MOparoex oral soln 1periogard oral soln 1pilocarpine hydrochloride tabs 1 MO

153Updated 10/01/20

Drug name Drug tier Requirements/LimitsPREVIDENT 5000 BOOSTER PLUS 3 MOPREVIDENT 5000 DRY MOUTH 3 QL (56 ML per 30 days) MOPREVIDENT 5000 ENAMEL PROTECT 3 MOPREVIDENT 5000 PLUS 3 QL (51 GM per 30 days) MOPREVIDENT FLUORIDE 3 QL (56 GM per 30 days) MOPREVIDENT RINSE 3 MOSALAGEN 3 MOSF 5000 PLUS 3 QL (51 GM per 30 days) MOSF GEL 3 QL (56 GM per 30 days) MOSODIUM FLUORIDE 5000 PLUS 3 QL (51 GM per 30 days)SODIUM FLUORIDE 5000 PPM 3 QL (51 GM per 30 days)SODIUM FLUORIDE GEL 1.1% 3 QL (56 GM per 30 days) MOtriamcinolone acetonide dental paste 1 MO

OTIC acetic acid otic soln 1 MOCETRAXAL 3 MOCIPRO HC OTIC SUSP 3 MOCIPRODEX 2 MOCIPROFLOXACIN OTIC SOLN 0.2% 2 MOCIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF

3 MO

CORTISPORIN-TC 3 MODERMOTIC 3 QL (20 ML per 30 days) MOflac otic oil 1 QL (20 ML per 30 days)fluocinolone acetonide otic oil 0.01% 1 QL (20 ML per 30 days) MOhydrocortisone/acetic acid otic soln 1 MOneomycin/polymyxin/hydrocortisone otic soln

1 MO

neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 10000unit/ml

1 MO

ofloxacin otic soln 0.3% 1 MOOTOVEL 3 MO

154 Updated 10/01/20

Drug name PageDrug name Page

Index of Drugs

Drug name Page

abacavir sulfate/lamivudine

26

abacavir sulfate/lamivudine/zidovudine

26

ABELCET 23ABILIFY 68

ABILIFY MAINTENA 68ABILIFY MYCITE 68

abiraterone acetate 36ABRAXANE 38ABSORICA 141

ABSORICA LD 141acamprosate calcium dr 81

ACANYA 141acarbose 86

ACCOLATE 138ACCUPRIL 44

ACCURETIC 44acebutolol hcl 50

acebutolol hydrochloride

50

ACETADOTE 100acetaminophen/

caffeine/dihydrocodeine14

acetaminophen/caffeine/dihydrocodeine

bitartrate

14

acetaminophen/codeine soln

14

acetaminophen/codeine tabs

14

acetazolamide 53acetazolamide er 53

acetazolamide sodium 53acetic acid 153

ACETIC ACID 0.25% 113

acetylcysteine 100, 138

ACIPHEX 112acitretin 144

ACTEMRA 118ACTEMRA ACTPEN 118

ACTHAR 100ACTHIB 123

ACTICLATE 33ACTIGALL 110

ACTIMMUNE 121ACTIQ 14

ACTIVELLA 97ACTONEL 89

ACTOPLUS MET 86ACTOS 86

ACULAR 132ACULAR LS 132

ACUVAIL 132acyclovir 28,

149ACYCLOVIR 149

acyclovir sodium 28ACZONE 141ADACEL 123

ADAKVEO 117adapalene 141

ADAPALENE 141adapalene/benzoyl

peroxide141

ADC/FLUORIDE 126ADCIRCA 56

ADDERALL 72ADDERALL XR 72

adefovir dipivoxil 28ADEMPAS 56

ADLYXIN 86ADLYXIN STARTER

PACK86

ADMELOG 83ADMELOG SOLOSTAR 83

ADRENALIN 54adriamycin 35

adrucil 35ADVAIR DISKUS 140

ADVAIR HFA 140ADZENYS ER 72

ADZENYS XR-ODT 72AEMCOLO 19afeditab cr 51AFINITOR 39

AFINITOR DISPERZ 39afirmelle 91

AFREZZA 83AGGRENOX 118

AGRYLIN 117AIMOVIG 76

AIRDUO RESPICLICK 140AJOVY 76AKLIEF 141

AKYNZEO 106ala-cort 145

ALA SCALP 145albendazole 19

ALBENZA 19albuterol sulfate 137

albuterol sulfate er 137albuterol sulfate hfa 137

alclometasone dipropionate

145

ALDACTAZIDE 53ALDACTONE 45

155Updated 10/01/20

Drug name Page Drug name Page Drug name Page

ALDARA 149ALDURAZYME 100

ALECENSA 39alendronate sodium 89,

90alfuzosin hcl er 112

ALIMTA 35ALINIA 19

ALIQOPA 39aliskiren 54

ALKERAN 34allopurinol 10

allopurinol sodium 10ALLZITAL 10

almotriptan malate 76ALOCRIL 133

ALOGLIPTIN 86ALOGLIPTIN/

METFORMIN HCL86

ALOGLIPTIN/PIOGLITAZONE

86

ALOMIDE 133ALOPRIM 10

ALORA 97alosetron hydrochloride 110

ALOXI 106ALPHAGAN P 134

alprazolam 57alprazolam er 57

ALPRAZOLAM INTENSOL

57

alprazolam odt 57ALPRAZOLAM XR 57

ALREX 132ALTABAX 143

ALTACE 44altavera 91

ALTOPREV 48ALTRENO 141

ALUNBRIG 39ALVESCO 140

alyacen 1/35 91alyacen 7/7/7 91

alyq 56amabelz 97

amantadine hcl 67AMARYL 86AMBIEN 75

AMBIEN CR 75AMBISOME 23

ambrisentan 56amcinonide 145

AMCINONIDE 145AMERGE 76amethia 91

AMETHIA LO 91amethyst 91AMICAR 117

amikacin sulfate 19amiloride hcl 53

amiloride/hydrochlorothiazide

53

aminocaproic acid 117aminophylline 138AMINOSYN II 129

AMINOSYN-PF 129amiodarone hcl 47

amiodarone hydrochloride

47

AMITIZA 110amitriptyline hcl 63

amitriptyline hydrochloride

63

amlodipine besylate 44, 45, 51, 54

amlodipine besylate/atorvastatin calcium

54

amlodipine besylate/benazepril

hydrochloride

44

amlodipine besylate/valsartan

45

amlodipine/olmesartan medoxomil

45

amlodipine/valsartan/hctz

45

amlodipine/valsartan/hydrochlorothiazide

46

ammonium lactate 149amnesteem 141amoxapine 63amoxicillin 32

amoxicillin/clavulanate potassium

32

amoxicillin/clavulanate potassium er

32

amphetamine/dextroamphetamine

72

amphetamine/dextroamphetamine er

72

AMPHETAMINE ER 72amphetamine sulfate 72

amphotericin b 23ampicillin 32

ampicillin sodium 32ampicillin-sulbactam 32

AMPYRA 78AMRIX 80

AMZEEQ 141ANADROL-50 82

ANAFRANIL 63anagrelide

hydrochloride117

ANASPAZ 107anastrozole 36ANCOBON 23

ANDRODERM 83ANDROGEL 83

ANDROGEL PUMP 83ANGELIQ 97

ANNOVERA 91

156 Updated 10/01/20


ANORO ELLIPTA 135ANTABUSE 81

ANTARA 48ANUSOL-HC 149APEXICON E 145

APIDRA 83, 84

APIDRA SOLOSTAR 84APLENZIN 63

APOKYN 67apraclonidine 134

aprepitant 106apri 91

APRISO 109APTENSIO XR 72

APTIOM 58APTIVUS 24

ARALAST NP 138aranelle 91

ARANESP ALBUMIN FREE

115, 116

ARAVA 120ARAZLO 141

ARCALYST 121ARCAPTA NEOHALER 137

ARESTIN 152ARGATROBAN 114

ARICEPT 63ARIKAYCE 19ARIMIDEX 36

aripiprazole odt 69aripiprazole soln 69aripiprazole tabs 69

ARISTADA 69ARISTADA INITIO 69

ARIXTRA 114armodafinil 81

ARMOUR THYROID 105ARNUITY ELLIPTA 140

AROMASIN 36

ARRANON 35arsenic trioxide 37

ARTHROTEC 50 11ARTHROTEC 75 11

ARYMO ER 13ARZERRA 39

ASACOL HD 109ASCENIV 120

ascomp/codeine 14ashlyna 91

ASMANEX HFA 140ASMANEX

TWISTHALER140

aspirin/dipyridamole 118ASTAGRAF XL 121

ATACAND 46, 47

ATACAND HCT 46atazanavir sulfate 25

ATELVIA 90atenolol 50

atenolol/chlorthalidone 50ATGAM 121ATIVAN 57

atomoxetine 72atorvastatin calcium 48

atovaquone 19, 24

atovaquone/proguanil hcl

24

ATRALIN 141ATRIPLA 26

ATROPINE SULFATE 107, 108, 135

ATROVENT HFA 136AUBAGIO 78

aubra 91aubra eq 91

augmented betamethasone

dipropionate

145

AUGMENTIN 32AUGMENTIN ES-600 32

aurovela 1.5/30 91aurovela 24 fe 91

aurovela fe 1.5/30 91aurovela fe 1/20 92

AURYXIA 104AUSTEDO 77

AUVI-Q 138AVALIDE 46

AVANDIA 86AVAPRO 47AVASTIN 39

AVEED 83aviane 92AVITA 141

AVODART 112AVONEX 78,

79AVONEX PEN 79

AVYCAZ 29AYGESTIN 104

ayuna 92AYVAKIT 39

azacitidine 35AZACTAM 19

AZASAN 121AZASITE 131

azathioprine 122azelaic acid 149

azelastine hcl 133, 136

azelastine hydrochloride 136azelastine

hydrochloride/fluticasone propionate

136

AZELEX 141AZILECT 67

157Updated 10/01/20


azithromycin 31AZITHROMYCIN PACK 31

AZOPT 134AZOR 46

aztreonam 19AZULFIDINE 109

AZULFIDINE EN-TABS 109azurette 92

bacitracin 19, 131

bacitracin/polymyxin 131baclofen 80

baclofen inj 80BACTRIM 19

BACTRIM DS 19BAL-CARE DHA 126

BALCOLTRA 92balsalazide disodium 109

BALVERSA 39balziva 92

BANZEL 58BAQSIMI ONE PACK 100BAQSIMI TWO PACK 100

BARACLUDE 28BASAGLAR KWIKPEN 84

BAVENCIO 39BAXDELA 31

BCG 123BD ALCOHOL SWABS 83

BD/ULTIMED/ALLISON/TRIVIDIA/

MHC INSULIN SYRINGE SAFETYGLIDE/1ML/

29G X 1/2

84


MHC INSULIN SYRINGE ULTRA-

AFINE/0.3ML/31G X 6MM

84



FINE/0.5ML/30G X 1/2

84



FINE/1ML/31G X 5/16

84


MHC INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X 5/16

84

BECONASE AQ 139bekyree 92

BELBUCA 13BELEODAQ 39

BELLADONNA/OPIUM 108BELSOMRA 75

benazepril hcl 44benazepril hcl/

hydrochlorothiazide44

benazepril hydrochloride

44

BENDEKA 34BENICAR 46,

47BENICAR HCT 46

BENLYSTA 122BENSAL HP 149

BENTYL 108BENZACLIN 141

BENZACLIN WITH PUMP

141

BENZAMYCIN 141BENZNIDAZOLE 19

benztropine mesylate 67BEOVU 135

BEPREVE 133BERINERT 117

beser 145BESIVANCE 131BESPONSA 39BETADINE

OPHTHALMIC PREP131

betamethasone dipropionate

145

betamethasone sodium phosphate/

betamethasone acetate

98

betamethasone valerate 145BETAPACE 47

BETAPACE AF 47BETASERON 79betaxolol hcl 50,

134bethanechol chloride 113

BETHKIS 19BETIMOL 134

BETOPTIC-S 134BEVESPI AEROSPHERE 135

BEVYXXA 114bexarotene 38

BEXSERO 123BEYAZ 92

bicalutamide 36BICILLIN C-R 32BICILLIN L-A 32

BICNU 34BIDIL 54

BIJUVA 97BIKTARVY 26

BILTRICIDE 19bimatoprost 134

BINOSTO 90bisoprolol fumarate 50

bisoprolol fumarate/hydrochlorothiazide

50

BIVIGAM 120bleomycin sulfate 35

BLEPH-10 131

158 Updated 10/01/20


BLEPHAMIDE 130BLEPHAMIDE S.O.P. 130

BLINCYTO 40blisovi 24 fe 92

blisovi fe 1.5/30 92blisovi fe 1/20 92

BONIVA 90BONJESTA 106BOOSTRIX 123

BORTEZOMIB 40bosentan 56BOSULIF 40

BOTOX 80BRAFTOVI 40

BREO ELLIPTA 140briellyn 92

BRILINTA 118brimonidine tartrate 134

BRIMONIDINE TARTRATE

134

BRISDELLE 77BRIVIACT 58

bromfenac 132bromocriptine mesylate 67

BROMSITE 132BROVANA 137BRUKINSA 40

BRYHALI 145budesonide 109,

140budesonide er 109

BUDESONIDE/FORMOTEROL

FUMARATE DIHYDRATE

140

bumetanide 53BUMEX 53

BUNAVAIL 81bupap 10

BUPHENYL 100, 101

bupivacaine/epinephrine

18

bupivacaine hcl 18bupivacaine

hydrochloride18

BUPRENEX 14buprenorphine 13

buprenorphine hcl 14, 82

buprenorphine hcl/naloxone hcl

81

buprenorphine hydrochloride/naloxone

hydrochloride

82

bupropion hcl 63bupropion

hydrochloride64

bupropion hydrochloride er (sr)

63, 82

bupropion hydrochloride er (xl)

64

BUPROPION HYDROCHLORIDE ER

(XL)

64

buspirone hcl 57buspirone

hydrochloride57

busulfan 34BUSULFEX 34butalbital/

acetaminophen10

butalbital/acetaminophen/caffeine

10, 15

butalbital/acetaminophen/caffeine/codeine

15

butalbital/aspirin/caffeine

10

BUTALBITAL/ASPIRIN/CAFFEINE

10

butalbital/aspirin/caffeine/codeine

15

butorphanol tartrate 15BUTRANS 13

BYDUREON BCISE 86BYDUREON PEN 86

BYETTA 86BYNFEZIA PEN 101

BYSTOLIC 50cabergoline 101

CABLIVI 117CABOMETYX 40

CADUET 54CAFERGOT 76CALAN SR 51

calcipotriene 145calcipotriene/


145

CALCIPOTRIENE/BETAMETHASONE

DIPROPIONATE

145

calcitonin-salmon 90calcitriol 105

CALCITRIOL 145calcium acetate 104

CALCIUM GLUCONATE 124CALDOLOR 11

CALQUENCE 40CAMBIA 76

camila 92CAMPATH 40

CAMPTOSAR 38CAMRESE 92

CAMRESE LO 92CANASA 109

CANCIDAS 23candesartan cilexetil 46,

47candesartan cilexetil/


CAPASTAT SULFATE 27CAPEX 146

159Updated 10/01/20


CAPLYTA 69CAPRELSA 40

captopril 44captopril/


CARAC 149CARAFATE 110

CARBAGLU 101carbamazepine 58

carbamazepine er 58CARBATROL 58

carbidopa 67carbidopa/levodopa 67

CARBIDOPA/LEVODOPA/

ENTACAPONE

67

carbidopa/levodopa er 67carbidopa/levodopa odt 67carbinoxamine maleate 136

CARBINOXAMINE MALEATE

136

carboplatin 34CARDENE IV 51

CARDIZEM 51CARDIZEM CD 51CARDIZEM LA 51

CARDURA 45, 112

CARDURA XL 112carisoprodol 80

carisoprodol/aspirin 80carisoprodol/aspirin/

codeine80

carmustine 34CARNITOR 101

CARNITOR SF 101CAROSPIR 45

carteolol hcl 134cartia xt 51

carvedilol 50carvedilol phosphate er 50

CASODEX 36caspofungin acetate 23

CATAPRES 54CATAPRES-TTS-1 54CATAPRES-TTS-2 54CATAPRES-TTS-3 54

CAYSTON 19caziant 92

cefaclor 29CEFACLOR ER 29

cefadroxil 29CEFAZOLIN 29

cefazolin sodium 29, 30

CEFAZOLIN SODIUM 29CEFAZOLIN SODIUM/

DEXTROSE29

cefdinir 30cefepime 30

CEFEPIME 30CEFEPIME/DEXTROSE 30

cefixime 30CEFOTAN 30cefotetan 30

CEFOTETAN/DEXTROSE

30

cefoxitin sodium 30CEFOXITIN SODIUM 30cefpodoxime proxetil 30

cefprozil 30ceftazidime 30

CEFTAZIDIME/DEXTROSE

30

CEFTRIAXONE/DEXTROSE

30

ceftriaxone in iso-osmotic dextrose

30

ceftriaxone sodium 30CEFTRIAXONE

SODIUM30

cefuroxime axetil 30

cefuroxime sodium 30CELEBREX 11

celecoxib 11CELESTONE-

SOLUSPAN98

CELEXA 64CELLCEPT 122

CELONTIN 58CENTANY 143

cephalexin 30CEQUA 135

CERDELGA 101CEREBYX 58

CEREZYME 101cetirizine hydrochloride 136

CETRAXAL 153cevimeline

hydrochloride152

CHANTIX 82CHANTIX CONTINUING

MONTH PAK82

CHANTIX STARTING MONTH PAK

82

chateal 92chateal eq 92

CHEMET 90CHENODAL 110

chloramphenicol 19chlordiazepoxide hcl 57

CHLORDIAZEPOXIDE HCL/CLIDINIUM

BROMIDE

108

chlordiazepoxide hydrochloride

57

chlorhexidine gluconate 152chloroquine phosphate 24chlorothiazide sodium 53

chlorpromazine 69CHLORPROMAZINE

HCL INJ69

chlorthalidone 53

160 Updated 10/01/20


chlorzoxazone 80CHLORZOXAZONE 80

CHOLBAM 110cholestyramine 49

cholestyramine light 49CHORIONIC

GONADOTROPIN101

ciclodan 143ciclopirox 143

ciclopirox gel 143ciclopirox nail lacquer 143

ciclopirox olamine 143cidofovir 28cilostazol 117CILOXAN 131CIMDUO 26

cimetidine 108cimetidine hcl 108

CIMZIA 118CIMZIA STARTER KIT 118

cinacalcet hydrochloride 101CINQAIR 138CINRYZE 117

CINVANTI 106CIPRO 31

CIPRODEX 153CIPROFLOXACIN 153

CIPROFLOXACIN/FLUOCINOLONE

ACETONIDE PF

153

ciprofloxacin hcl 31ciprofloxacin

hydrochloride31, 131

ciprofloxacin i.v.-in d5w 31CIPRO HC 153

cisplatin 34citalopram

hydrobromide64

CITRANATAL 90 DHA 126CITRANATAL B-CALM 126CITRANATAL BLOOM 126

CITRANATAL HARMONY

126

CITRANATAL MEDLEY 126CITRANATAL RX 126

cladribine 35claravis 141

CLARINEX 136CLARINEX-D 136

clarithromycin 31clarithromycin er 31

clemastine fumarate 137CLENPIQ 109CLEOCIN 19,

114CLEOCIN PEDIATRIC 19

CLEOCIN PHOSPHATE 19CLEOCIN-T 141

CLIMARA 97CLIMARA PRO 97

clindacin etz pledgets 141clindacin-p 141

CLINDAGEL 141clindamycin/benzoyl

peroxide142

clindamycin hcl 19clindamycin

hydrochloride19

clindamycin palmitate hcl

19

clindamycin phosphat 20clindamycin phosphate 20,

114, 142

CLINDAMYCIN PHOSPHATE

142

clindamycin phosphate/benzoyl peroxide

141

clindamycin phosphate/dextrose

20

clindamycin phosphate/tretinoin

141

CLINDAMYCIN/SODIUM CHLORIDE

20

CLINDESSE 114CLINIMIX 4.25%/

DEXTROSE 5%129

CLINIMIX 4.25%/DEXTROSE 10%

129

CLINIMIX 5%/DEXTROSE 15%

129

CLINIMIX 5%/DEXTROSE 20%

129

CLINIMIX E 2.75%/DEXTROSE 5%

129


129


129

CLINIMIX E 5%/DEXTROSE 15%

129

CLINIMIX E 5%/DEXTROSE 20%

129

clinisol sf 130CLINOLIPID 130

CLINPRO 5000 152clobazam 58

clobetasol propionate 146CLOBEX 146

CLOCORTOLONE PIVALATE

146

clodan shampoo 146CLODERM 146

clofarabine 35CLOLAR 35

clomipramine hcl 64clonazepam 58

clonazepam odt 58clonidine hcl 11,

54clonidine hcl er 72

clonidine hydrochloride 54clopidogrel 118

161Updated 10/01/20


clorazepate dipotassium

58

clotrimazole 143clotrimazole/


143

clotrimazole troc 152clovique 90

clozapine 69clozapine odt 69

CLOZAPINE ODT 69CLOZARIL 69

C-NATE DHA 126COARTEM 24COCAINE

HYDROCHLORIDE NASAL

138

CODEINE SULFATE 15COGENTIN 67

COLAZAL 109colchicine 10

COLCHICINE 10COLCRYS 10

colesevelam hydrochloride

49

COLESTID 49COLESTID FLAVORED 49

colestipol hcl 49colistimethate 20

colocort 109COLY-MYCIN M 20

COLYTE-FLAVOR PACKS

109

COMBIGAN 134COMBIPATCH 97

COMBIVENT RESPIMAT 135COMBIVIR 26

COMETRIQ 40COMPLERA 27

COMPLETENATE 126compro 106

COMTAN 67CONCEPT DHA 126

CONCEPT OB 126CONCERTA 72CONDYLOX 149

constulose 109CONZIP 13

COPAXONE 79COPIKTRA 40CORDRAN 146

COREG 50COREG CR 50CORGARD 50

CORLANOR 54CORTEF 98

CORTENEMA 109CORTIFOAM 149

cortisone acetate 98CORTISPORIN 143

CORTISPORIN-TC 153COSENTYX 118COSENTYX

SENSOREADY PEN118

COSMEGEN 35COSOPT 134

COSOPT PF 134COTELLIC 40

COTEMPLA XR-ODT 72COZAAR 47

CREON 111CRESEMBA 23

CRESTOR 48CRINONE 104CRIXIVAN 25

cromolyn sodium 110, 133, 138

crotan 151cryselle-28 92CRYSVITA 101

CUBICIN 20CUBICIN RF 20CUPRIMINE 90CUTAQUIG 120CUTIVATE 146CUVITRU 120

CUVPOSA 108cyclafem 1/35 92

cyclafem 7/7/7 92cyclobenzaprine

hydrochloride80

cyclobenzaprine hydrochloride er

80

CYCLOGYL 135cyclopentolate hcl 135

cyclophosphamide 34cycloserine 27CYCLOSET 86

cyclosporine 122cyclosporine modified 122

CYKLOKAPRON 117CYMBALTA 64

cyproheptadine hcl 137cyproheptadine

hydrochloride137

CYRAMZA 40cyred 92

cyred eq 92CYSTADANE 101CYSTAGON 101CYSTARAN 135

cytarabine aqueous 35CYTOGAM 120CYTOMEL 105CYTOTEC 110

CYTOVENE 28CYTRA K CRYSTALS 113

dacarbazine 38DACOGEN 35

dactinomycin 35

162 Updated 10/01/20


dalfampridine er 79DALIRESP 138

DALVANCE 20danazol 97

DANTRIUM 80dantrolene sodium 80

dapsone 20, 142

DAPTACEL 123daptomycin 20

DAPTOMYCIN 20DARAPRIM 20darifenacin

hydrobromide er113

DARZALEX 40dasetta 1/35 92

dasetta 7/7/7 92daunorubicin hydrochloride

35

DAUNORUBICIN HYDROCHLORIDE

35

DAURISMO 40DAYPRO 11

daysee 92DAYTRANA 73

DAYVIGO 75DDAVP 101

DDAVP NASAL 101deblitane 92decadron 98

decitabine 36deferasirox 90

deferoxamine mesylate 90DELESTROGEN 97

DELSTRIGO 27DELZICOL 109

demeclocycline hcl 33DEMEROL 15

DEMSER 54DENAVIR 149

DENTA 5000 PLUS 152

DENTAGEL 152DEPAKOTE 58

DEPAKOTE ER 58DEPAKOTE SPRINKLES 58

DEPEN TITRATABS 91DEPO-ESTRADIOL 97

DEPO-MEDROL 99DEPO-PROVERA 36DEPO-PROVERA

CONTRACEPTIVE92

DEPO-SUBQ PROVERA 92DEPO-TESTOSTERONE 83DERMA-SMOOTHE/FS

BODY146

DERMA-SMOOTHE/FS SCALP

146

DERMOTIC 153DESCOVY 27

DESFERAL 91desipramine hcl 64

desloratadine 137desloratadine odt 137

desmopressin acetate 101desogestrel/ethinyl

estradiol92

DESONATE 146desonide 146

DESOWEN 146desoximetasone 146

DESOXYN 73desvenlafaxine er 64

DESVENLAFAXINE ER 64DETROL 113

DETROL LA 113DEXABLISS 99

dexamethasone 99dexamethasone 6-day

dose pack99

dexamethasone 10-day dose pack

99

dexamethasone 13-day dose pack

99

DEXAMETHASONE INTENSOL

99

dexamethasone sodium phosphate

99, 132

dexchlorpheniramine maleate

137

DEXEDRINE 73DEXILANT 112

dexmethylphenidate hcl 73dexmethylphenidate

hcl er73

dexmethylphenidate hydrochloride

73

dexpak 6 day 99dexpak 10 day 99dexpak 13 day 99

dexrazoxane 43dextroamphetamine

sulfate73

dextroamphetamine sulfate er

73

DEXTROSE 2.5%/NACL 0.45%

124

dextrose 5% 124, 130

DEXTROSE 5% /ELECTROLYTE #48

VIAFLEX

124

DEXTROSE 5%/LACTATED RINGERS

124

DEXTROSE 5%/NACL 0.2%

124


124


124


124


124

163Updated 10/01/20



124

dextrose 10% 124, 130


124


124

DEXTROSE 20% 130DEXTROSE 25% 130DEXTROSE 30% 130DEXTROSE 40% 130DEXTROSE 50% 130DEXTROSE 70% 130

D.H.E. 45 76DIASTAT ACUDIAL 58

DIASTAT PEDIATRIC 58diazepam 59

DIAZEPAM RECTAL GEL

58

diazoxide 100DIBENZYLINE 54

DICLEGIS 106DICLOFENACE

EPOLAMINE149

diclofenac potassium 11diclofenac sodium 132,

149diclofenac sodium dr 11diclofenac sodium er 11

diclofenac sodium/misoprostol

11

diclofenac sodium transdermal

149

dicloxacillin 32dicyclomine hcl 108

dicyclomine hydrochloride

108

didanosine 25DIFFERIN 142

DIFICID 31

diflorasone diacetate 146DIFLUCAN 23

diflunisal 11digitek 54

digox 54digoxin 54

dihydroergotamine mesylate

76

DILANTIN 59DILANTIN-125 59

DILANTIN INFATABS 59DILATRATE SR 55

DILAUDID 15diltiazem hcl 52

DILTIAZEM HCL 52diltiazem hcl cd 51diltiazem hcl er 51diltiazem hcl inj 52

diltiazem hydrochloride 52dilt-xr 51

DIMENHYDRINATE 106DIOVAN 47

DIOVAN HCT 46DIPENTUM 109

diphen 137diphenhydramine hcl 137

diphenoxylate/atropine 110DIPHTHERIA/TETANUS

TOXOIDS ADSORBED PEDIATRIC

123

DIPROLENE 146DIPROLENE AF 146

dipyridamole 118disopyramide

phosphate47

disulfiram 82DITROPAN XL 113

DIURIL 53divalproex sodium 59

divalproex sodium dr 59divalproex sodium er 59

DIVIGEL 97dobutamine hcl 54

DOBUTAMINE HCL/D5W

54

DOBUTAMINE HYDROCHLORIDE/

DEXTROSE

54

docetaxel 39DOCETAXEL 39

dofetilide 47DOJOLVI 101

DOLOPHINE 13donepezil hc 63donepezil hcl 63

donepezil hydrochloride 63DOPAMINE/D5W 54

DOPAMINE HYDROCHLORIDE

54

DOPAMINE HYDROCHLORIDE/

DEXTROSE

54

DOPTELET 117DORYX 33

DORYX MPC 33dorzolamide hcl 134

dorzolamide hcl/timolol maleate

134

dorzolamide hydrochloride/timolol

maleate pf

134

dotti 97DOVATO 27

DOVONEX 145doxazosin mesylate 45

DOXEPINE HYDROCHLORIDE

149

doxepin hcl 64doxepin hydrochloride 64,

75doxercalciferol 105

doxorubicin hcl liposome

35

164 Updated 10/01/20


doxorubicin hydrochloride liposomal

35

doxy 100 33doxycycline 33

DOXYCYCLINE 149doxycycline hyclate 33

doxycycline hyclate dr 33doxycycline

monohydrate33

doxylamine succinate/pyridoxine

hydrochloride

106

DRIZALMA 64dronabinol 106droperidol 57

drospirenone/ethinyl estradiol

92

drospirenone/ethinyl estradiol/levomefolate

calcium

92

DROXIA 117DUAKLIR PRESSAIR 135

DUAVEE 97DUETACT 86

DUET DHA 400 126DUET DHA BALANCED 126

DUEXIS 11DULERA 140

duloxetine hcl 64duloxetine

hydrochloride64

DUOBRII 146DUOPA 67

DUPIXENT 118DURACLON 11DURAGESIC 13

DURAMORPH 15DUREZOL 132

dutasteride 112dutasteride/tamsulosin

hcl112

DUTOPROL 50dvorah 15

DXEVO 11-DAY 99DYANAVEL XR 73

DYAZIDE 53DYMISTA 136

DYRENIUM 53DYSPORT 80

EC-NAPROXEN 11econazole nitrate 144

EDARBI 47EDARBYCLOR 46

EDECRIN 53EDLUAR 75ED-SPAZ 108

EDURANT 25e.e.s. 400 31

E.E.S. GRANULES 31efavirenz 25EFFER-K 126

EFFERVESCENT POTASSIUM

126

EFFEXOR XR 64EFFIENT 118EFUDEX 150EGRIFTA 101

EGRIFTA SV 101ELAPRASE 101

ELELYSO 101ELESTRIN 97eletriptan

hydrobromide76

ELIDEL 150ELIGARD 36ELIMITE 151

elinest 92ELIQUIS 114

ELIQUIS STARTER PACK 114ELITEK 43

ELITE-OB 126

ELIXOPHYLLIN 138ELLA 92

ELLENCE 35ELMIRON 113ELOCON 146

eluryng 92EMBRE; 118EMCYT 36EMEND 106

EMEND TRIPACK 106EMFLAZA 99

EMGALITY 76emoquette 93EMPLICITI 40

EMSAM 64EMTRIVA 25EMVERM 20ENABLEX 113

enalaprilat 44enalapril maleate 44

enalapril maleate/hydrochlorothiazide

44

ENBRACE HR 126ENBREL 118

ENBREL MINI 118ENBREL SURECLICK 118

ENDARI 117endocet 15

ENGERIX-B 123ENHERTU 40

enoxaparin sodium 115enpresse-28 93

enskyce 93ENSTILAR 146

entacapone 67entecavir 28

ENTOCORT EC 109ENTRESTO 46

ENTYVIO 118enulose 109

165Updated 10/01/20


ENVARSUS XR 122EPANED 45

EPCLUSA 28EPIDIOLEX 59

EPIDUO 142EPIDUO FORTE 142

EPIFOAM 146epinastine hcl 133

epinephrine hcl 138EPIPEN 139

EPIPEN-JR 139epirubicin hcl 35

epitol 59EPIVIR 25,

28EPIVIR HBV 28eplerenone 45

EPOGEN 116epoprostenol sodium 56eprosartan mesylate 47

EPZICOM 27EQUETRO 77

ERAXIS 23ERBITUX 40

ergoloid mesylates 63ERGOMAR 76

ergotamine tartrate/caffeine

76

ERIVEDGE 40ERLEADA 36

erlotinib hydrochloride 40errin 93

ERTACZO 144ertapenem 20ERWINAZE 38

ERYGEL 142ery pad 142

ERYPED 200 31ERYPED 400 31

ery-tab 31

ERYTHROCIN LACTOBIONATE

31

erythrocin stearate 31erythromycin 31,

131, 142

erythromycin base 31erythromycin/benzoyl

peroxide142

erythromycin dr 31erythromycin

ethylsuccinate31

erythromycin stearate 31ESBRIET 139

escitalopram oxalate 64esgic 11

ESGIC 11esomeprazole

magnesium112

esomeprazole sodium 112estarylla 93

estazolam 75ESTRACE 97estradiol 98

estradiol/norethindrone acetatemg

98

estradiol valerate 97ESTRING 98

ESTROGEL 98ESTROSTEP FE 93

eszopiclone 75ethacrynate sodium 53

ethacrynic acid 53ethambutol

hydrochloride27

ethosuximide 59ethynodiol diacetate/

ethinyl estradiol93

etodolac 11etodolac er 11

ETONOGESTREL/ETHINYL ESTRADIOL

93

ETOPOPHOS 39etoposide 39EUCRISA 150euthyrox 105EVAMIST 98EVEKEO 73

EVEKEO ODT 73EVENITY 90

everolimus 40, 122

EVISTA 101EVOCLIN 142EVOTAZ 27EVOXAC 152

EVZIO 82EXALGO 13

EXELDERM 144exelon 63

exemestane 36EXFORGE 46

EXFORGE HCT 46EXJADE 91

EXONDYS 51 77EXTAVIA 79EXTINA 144

EYLEA 135EZALLOR SPRINKLE 48

ezetimibe 49ezetimibe/simvastatin 49

FABIOR 142FABRAZYME 101

falmina 93famciclovir 28famotidine 108

famotidine premixedl 108FANAPT 69

FANAPT TITRATION PACK

69

166 Updated 10/01/20


FARESTON 36FARXIGA 86FARYDAK 40FASENRA 139

FASENRA PEN 139FASLODEX 36

fayosim 93febuxostat 10felbamate 59FELBATOL 59FELDENE 11

felodipine er 52FEMARA 36

FEMHRT LOW DOSE 98FEMRING 98

femynor 93fenofibrate 48

fenofibrate micronized 48FENOFIBRIC ACID 49

fenofibric acid dr 48FENOGLIDE 48

fenoprofen calcium 11FENOPROFEN

CALCIUM11

fentanyl 13fentanyl citrate 15

FENTANYL CITRATE 15fentanyl citrate oral

transmucosal15

FENTORA 15FERRIPROX 91

FETROJA 30FETZIMA 64

FETZIMA TITRATION PACK

64

FEXMID 80FIASP 84

FIASP FLEXTOUCH 84FIASP PENFILL 84

FINACEA 150

finasteride 112FINTEPLA 59FIORICET 11FIORINAL 11,

15FIORINAL/CODEINE #3 15

FIRAZYR 117FIRDAPSE 77

FIRMAGON 36, 37

FIRVANQ 20flac 153

FLAGYL 20FLAREX 132

flavoxate hcl 113FLEBOGAMMA DIF 120

flecainide acetate 47FLECTOR 150FLOLAN 56

FLOLIPID 48FLOMAX 112FLORIVA 126

FLOVENT DISKUS 140FLOVENT HFA 140

fluconazole 23fluconazole in nacl 23

fluconazole in sodium chloride

23

flucytosine 23fludarabine phosphate 36fludrocortisone acetate 99

flumazenil 77flunisolide 139

fluocinolone acetonide 146, 147, 153

fluocinolone acetonide body oil

146

fluocinolone acetonide scalp oil

146

fluocinonide 147

fluocinonide emulsified 147FLUORIDE 126

FLUORIDEX 152FLUORIDEX

SENSITIVITY RELIEF/SLS FREE

152

FLUORITAB 126FLUOROMETHOLONE 132

fluorouracil 36, 150

FLUOROURACIL CREA 0.5%

150

fluoxetine dr 64fluoxetine hcl 65

fluoxetine hydrochloride 65fluphenazine decanoate 69

fluphenazine hcl 69fluphenazine

hydrochloride69

FLURA-DROPS 126flurandrenolide 147flurazepam hcl 75

flurbiprofen 11flurbiprofen sodium 132

flutamide 37fluticasone propionate 139,

147FLUTICASONE PROPIONATE/SALMETEROL

141

FLUTICASONE PROPIONATE/

SALMETEROL DISKUS

141

fluvastatin 49fluvastatin sodium er 49fluvoxamine maleate 57

fluvoxamine maleate er 57FML 132,

133FML FORTE 132

FML LIQUIFILM 133

167Updated 10/01/20


FOCALIN 73FOCALIN XR 73

FOLIVANE-OB 126FOLOTYN 36fomepizole 101

fondaparinux sodium 115FORFIVO XL 65FORTAMET 86

FORTEO 90FORTESTA 83FOSAMAX 90

FOSAMAX PLUS D 90fosamprenavir calcium 25

fosaprepitant dimeglumine

106

fosinopril sodium 44, 45

fosinopril sodium/hydrochlorothiazide

44

fosphenytoin sodium 59FOSRENOL 104

FRAGMIN 115FREAMINE HBC 130

FREAMINE III 130FROVA 76

frovatriptan succinate 76FULPHILA 116fulvestrant 37furosemide 53

FUZEON 25fyavolv 98

FYCOMPA 59gabapentin 59

GABITRIL 59GABLOFEN 80GALAFOLD 101

galantamine hydrobromide

63

galantamine hydrobromide er

63

GAMASTAN 120

GAMMAGARD 120GAMMAKED 120

GAMMAPLEX 120GAMUNEX-C 120

ganciclovir 28GARDASIL 9 123

GASTROCROM 110gatifloxacin 131

GATTEX 110GAUZE PADS 84

gavilyte-c 109gavilyte-g 110

gavilyte-n/flavor pack 110GAZYVA 40

GELNIQUE 114gemcitabine 36

gemcitabine hcl 36gemcitabine

hydrochloride36

GEMCITABINE HYDROCHLORIDE

36

gemfibrozil 48GENERESS FE 93

generlac 110gengraf 122

GENOTROPIN 101GENOTROPIN

MINIQUICK101

gentak 131gentamicin sulfate 20,

131, 143

gentamicin sulfate pediatric

20

gentamicin sulfate/sodium chloride

20

GENVOYA 27GEODON 69

GIANVI 93GILENYA 79

GILOTRIF 40

GIVLAARI 117GLASSIA 139

glatiramer acetate 79glatopa 79

GLEEVEC 40GLEOSTINE 34glimepiride 87

glipizide 87glipizide er 87

glipizide/metformin hydrochloride

87

glipizide xl 87GLOPERBA 10

GLUCAGEN HYPOKIT 100GLUCAGON

EMERGENCY KIT100

GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR

100

GLUCOTROL 87GLUCOTROL XL 87

GLUMETZA 87glyburide 87

glyburide/metformin hydrochloride

87

glyburide micronized 87GLYCATE 108

glycopyrrolate 108GLYCOPYRROLATE 108

glydo 149GLYNASE 87

GLYSET 87GLYXAMBI 87

GOCOVRI 67GOLYTELY 110GONITRO 55

GOPRELTO 139GRALISE 77,

78GRALISE STARTER 78

granisetron hcl 106

168 Updated 10/01/20


GRANIX 116GRASTEK 121

griseofulvin microsize 23griseofulvin

ultramicrosize23

guanfacine er 73guanfacine hcl 54

GUANIDINE HCL 78GVOKE HYPOPEN 100

GVOKE PFS 100GYNAZOLE-1 114

HAEGARDA 117hailey 1.5/30 93

hailey 24 fe 93HALAVEN 39

halcinonide 147HALCION 75HALDOL 69

HALDOL DECANOATE 50

69

HALDOL DECANOATE 100

69

halobetasol propionate 147HALOBETASOL

PROPIONATE147

HALOG 147haloperidol 69

haloperidol decanoate 69haloperidol lactate 69

HARVONI 28HAVRIX 123heather 93

HECTOROL 105HEMANGEOL 50HEPAGAM B 120

heparin sodium 115HEPARIN SODIUM 115

HEPARIN SODIUM/D5W

115

HEPARIN SODIUM/DEXTROSE

115

HEPARIN SODIUM/NACL 0.45%

115

HEPARIN SODIUM/SODIUM CHLORIDE

115

HEPATAMINE 130HEPSERA 28

HERCEPTIN 40HERCEPTIN HYLECTA 40

HERZUMA 40HETLIOZ 75HIBERIX 123

hidex 6-day 99HIPREX 20

HIZENTRA 120HORIZANT 78HUMALOG 84

HUMALOG JUNIOR KWIKPEN

84

HUMALOG KWIKPEN 84HUMALOG MIX 50/50 84HUMALOG MIX 50/50

KWIKPEN84

HUMALOG MIX 75/25 84HUMALOG MIX 75/25

KWIKPEN84

HUMATROPE 101HUMATROPE COMBO

PACK101

HUMIRA 119HUMIRA PEDIATRIC

CROHNS DISEASE STARTER PACK

119

HUMIRA PEN 119HUMIRA PEN-CD/UC/

HS STARTER119

HUMIRA PEN-PS/UV STARTER

119

HUMULIN 70/30 84HUMULIN 70/30

KWIKPEN84

HUMULIN N 84

HUMULIN N KWIKPEN 84HUMULIN R 85

HUMULIN R U-500 85HYCAMTIN 38

hydralazine hcl 54hydralazine

hydrochloride55

HYDREA 38hydrochlorothiazide 53

hydrocodone/acetaminophen

15

hydrocodone bitartrate/acetaminophen

15

HYDROCODONE BITARTRATE/

ACETAMINOPHEN

15

hydrocodone bitartrate er

13

hydrocodone/ibuprofen 16hydrocortisone 99,

109, 147, 150

hydrocortisone acetate/pramoxine

150

hydrocortisone/acetic acid

153

hydrocortisone butyrate 147hydrocortisone butyrate

(lipophilic)147

hydrocortisone valerate 147hydromorphone hcl 16

HYDROMORPHONE HCL

16

hydromorphone hcl er 13hydromorphone

hydrochloride16

HYDROMORPHONE HYDROCHLORIDE

16

hydroxychloroquine sulfate

120

169Updated 10/01/20


hydroxyprogesterone caproate

37, 104

hydroxyurea 38hydroxyzine hcl 137

hydroxyzine hydrochloride

137

hydroxyzine pamoate 137hyoscyamine sulfate 108

HYOSCYAMINE SULFATE

108

HYPERHEP B S/D 120HYPERLYTE-CR 124

HYPERRAB 120, 121

HYPERRAB S/D 120HYPERRHO S/D 121

HYPERRHO S/D MINI-DOSE

121

HYPERTET S/D 121HYQVIA 121

HYSINGLA ER 13HYZAAR 46

ibandronate sodium 90IBRANCE 40

ibu 12ibuprofen 12

icatibant acetate 117ICLUSIG 40

IDAMYCIN PFS 35idarubicin hcl 35

IDHIFA 40IFEX 34

ifosfamide 34IFOSFAMIDE 34

ILARIS 121ILEVRO 133ILUMYA 119

imatinib mesylate 40IMBRUVICA 41

IMFINZI 41imipenem/cilastatin 20

imipramine hcl 65imipramine

hydrochloride65

imipramine pamoate 65imiquimod 150

IMIQUIMOD PUMP 150IMITREX 76

IMITREX STATDOSE REFILL

76

IMITREX STATDOSE SYSTEM

76

IMLYGIC 38IMOGAM RABIES-HT 121

IMOVAX RABIES (H.D.C.V.)

123

IMPAVIDO 20IMPOYZ 147

IMURAN 122IMVEXXY

MAINTENANCE PACK98

IMVEXXY STARTER PACK

98

INBRIJA 67incassia 93

INCRELEX 102INCRUSE ELLIPTA 136

indapamide 53INDERAL LA 50INDERAL XL 50

INDOCIN 12indomethacin 12

indomethacin er 12INFANRIX 123

INFLECTRA 119INFUGEM 36

INFUMORPH 200 16INFUMORPH 500 16

INGREZZA 78INLYTA 41

INNOPRAN XL 50, 51

INQOVI 38INREBIC 41INSPRA 45

INSULIN ASPART 85INSULIN ASPART

FLEXPEN85

INSULIN ASPART PENFILL

85

INSULIN ASPART PROTAMINE/INSULIN

ASPART

85

INSULIN ASPART PROTAMINE/INSULIN

ASPART FLEXPEN

85

INSULIN LISPRO 85INSULIN LISPRO

JUNIOR KWIKPEN85

INSULIN LISPRO KWIKPEN

85

INSULIN LISPRO PROTAMINE/INSULIN

LISPRO KWIKPEN

85

INTELENCE 25INTRALIPID 130INTRAROSA 113

INTRON A 121introvale 93INTUNIV 73INVANZ 20INVEGA 70

INVEGA SUSTENNA 70INVEGA TRINZA 70

INVELTYS 133INVIRASE 25

INVOKAMET 87INVOKAMET XR 87

INVOKANA 87IONOSOL-MB/DEXTROSE 5%

124

IOPIDINE 134IPOL INACTIVATED IPV 123

170 Updated 10/01/20


ipratropium bromide 136ipratropium bromide/

albuterol sulfate136

irbesartan 46, 47

irbesartan/hydrochlorothiazide

46

IRESSA 41irinotecan 38

irinotecan hcl 38irinotecan

hydrochloride38

ISENTRESS 25ISENTRESS HD 25

isibloom 93ISOLYTE-P/DEXTROSE

5%124

ISOLYTE-S 124ISOLYTE-S PH 7.4 124

isoniazid 27ISOPTO ATROPINE 135

ISOPTO CARPINE 134ISORDIL TITRADOSE 55

isosorbide dinitrate immediate release

55

isosorbide mononitrate 55isosorbide mononitrate

er55

isotonic gentamicin 20isotretinoin 142

isradipine 52ISTALOL 134

ISTODAX (OVERFILL) 41ISTURISA 102

itraconazole 24ivermectin 20,

150IXEMPRA KIT 39

IXIARO 123JADENU 91

JADENU SPRINKLE 91

jaimiess 93JAKAFI 41JALYN 112

jantoven 115JANUMET 87

JANUMET XR 87JANUVIA 87

JARDIANCE 88jasmiel 93

jencycla 93JENTADUETO 88

JENTADUETO XR 88JEVTANA 39

jinteli 98JOLESSA 93

JOLIVETTE 93JORNAY PM 73

JUBLIA 144juleber 93

JULUCA 27junel 1.5/30 93

junel 1/20 93junel fe 1.5/30 93

junel fe 1/20 93junel fe 24 93JUXTAPID 49

JYNARQUE 102KABIVEN 130

KADCYLA 41KADIAN 13kaitlib fe 93

KALBITOR 117KALETRA 27

kalliga 93KALTETRA 27KALYDECO 139

KANJINTI 41KANUMA 102

KAPSPARGO SPRINKLE 51KAPVAY 73

kariva 93KATERZIA 52KAZANO 88

KCL 0.3%/D5W/NACL 0.9%

124

KCL 0.3%/D5W/NACL 0.45%

124

KCL 0.15%/D5W/NACL 0.2%

124

KCL 0.15%/D5W/NACL 0.9%

124

KCL 0.15%/D5W/NACL 0.45%

124

KCL 0.15%/D5W/NACL 0.225%

124

KCL 0.075%/D5W/NACL 0.45%

124

KEDRAB 121kelnor 1/35 93kelnor 1/50 93

KENALOG-10 99KENALOG-40 99KENALOG-80 99

KENALOG AER SPRAY 147KEPIVANCE 43

KEPPRA 59KEPPRA XR 59

KERYDIN 144KESIMPTA 79

ketoconazole 24, 144, 145

ketoprofen 12ketoprofen er 12

ketorolac tromethamine 12, 133

KEVEYIS 53KEVZARA 119

KEYTRUDA 41KHAPZORY 44

KINERET 119

171Updated 10/01/20


KINRIX 123kionex 91

KISQALI 38, 41

KISQALI FEMARA CO-PACK

38

KITABIS PAK 20KLARON 142

KLONOPIN 60klor-con 126

KLOR-CON 8 126KLOR-CON 10 126KLOR-CON/EF 126

klor-con m10 126klor-con m15 126klor-con m20 126

KOMBIGLYZE XR 88KORLYM 102

KRINTAFEL 24KRISTALOSE 110KRYSTEXXA 10

K-TAB 126kurvelo 93KUVAN 102

KYLEENA 94KYNMOBI 67KYPROLIS 41

labetalol hydrochloride 51LACRISERT 135

LACTATED RINGERS IRRIGATION

152

lactated ringers viaflex 124lactulose 110

LACTULOSE 110LAMICTAL 60

LAMICTAL ODT 60LAMICTAL STARTER/

NOT TAKING CARBAMAZEPINE

60

LAMICTAL STARTER/TAKING

CARBAMAZEPINE/NOT TAKING VALPROATE

60

LAMICTAL STARTER/TAKING VALPROATE

60

LAMICTAL XR 60LAMICTAL XR STARTER

KIT BLUE, ORANGE60

LAMICTAL XR STARTER KIT GREEN

60

lamivudine 25, 28

lamivudine/zidovudine 27lamotrigine 60

lamotrigine er 60lamotrigine odt 60

lamotrigine starter kit/blue

60

lamotrigine starter kit/green

60

lamotrigine starter kit/orange

60

LANOXIN 55LANOXIN PEDIATRIC 55

lansoprazole/amoxicillin/

clarithromycin

110

lansoprazole dr 112lanthanum carbonate 104

LANTUS 85LANTUS SOLOSTAR 85

larin 1.5/30 94larin 1/20 94larin 24 fe 94

larin fe 1.5/30 94larin fe 1/20 94

larissia 94LASIX 53

LASTACAFT 133latanoprost 134

LATUDA 70

LAYOLIS FE 94LAZANDA 16

LEDIPASVIR/SOFOSBUVIR

28

LEENA 94leflunomide 120LEMTRADA 79

LENVIMA 4 MG DAILY DOSE

41


41


41

LENVIMA 12MG DAILY DOSE

41


41


41


41


41

LESCOL XL 49lessina 94

LETAIRIS 56letrozole 37

leucovorin calcium 44LEUKERAN 34

LEUKINE 116leuprolide acetate 37

levalbuterol hcl 137levalbuterol

hydrochloride137

LEVALBUTEROL TARTRATE HFA

137

LEVEMIR 85LEVEMIR FLEXTOUCH 85

levetiracetam 60levetiracetam er 60

levetiracetam/sodium chloride

60

172 Updated 10/01/20


levobunolol hcl 134levocarnitine 102

LEVOCARNITINE 102levocetirizine

dihydrochloride137

levofloxacin 32, 131

levofloxacin in d5w 31levoleucovorin 44

levoleucovorin calcium 44levonest 94

levonorgestrel/ethinyl estradiol

94

levora 0.15/30-28 94levorphanol tartrate 16

LEVO-T 105LEVOTHYROXINE/

LIOTHYRONINE105

levothyroxine sodium 105LEVOTHYROXINE

SODIUM105

LEVOXYL 105LEVSIN 108

LEVSIN/SL 108LEVULAN KERASTICK 150

LEXAPRO 65LEXETTE 147

LEXIVA 25LIALDA 109LIBRAX 108

LIBTAYO 41lidocaine 149

lidocaine/epinephrine 18lidocaine hcl 18,

149LIDOCAINE HCL 47

LIDOCAINE HCL IN D5W

47

lidocaine hcl jelly 149lidocaine hcl mouth/

throat152

lidocaine hcl prefilled syringe

47

lidocaine hydrochloride pf

18

lidocaine/prilocaine 149lidocaine viscous 152

LIDODERM 149lillow 94

LINCOCIN 20lincomycin hcl 20

lindane 151linezolid 20,

21LINEZOLID 21

LINZESS 110LIORESAL

INTRATHECAL80

liothyronine sodium 105LIPITOR 49

LIPOFEN 48lisinopril 44,

45lisinopril/


LITHIUM 78lithium carbonate 78

lithium carbonate er 78LITHOBID 78

LITHOSTAT 113LIVALO 49

LOCOID 147, 148

LOCOID LIPOCREAM 147LODINE 12

LODOSYN 67LOESTRIN 1.5/30-21 94

LOESTRIN 1/20-21 94LOESTRIN FE 1.5/30 94

LOESTRIN FE 1/20 94lojaimiess 94LOKELMA 91

LO LOESTRIN FE 94LOMOTIL 110

LONHALA MAGNAIR REFILL KIT

136

LONSURF 38loperamide hcl 110

LOPID 48lopinavir/ritonavir 27

LOPREEZA 98LOPRESSOR 50,

51LOPRESSOR HCT 50

LOPROX 144lorazepam 57,

58LORBRENA 41

lorcet 16lorcet hd 16

lorcet plus 16LORTAB 16

loryna 94lorzone 80

LORZONE 80losartan potassium 47

losartan potassium/hydrochlorothiazide

46

LOSEASONIQUE 94LOTEMAX 133

LOTEMAX SM 133LOTENSIN 44,

45LOTENSIN HCT 44

loteprednol etabonate 133LOTREL 44

LOTRISONE 144LOTRONEX 110

lovastatin 49LOVAZA 49

LOVENOX 115low-ogestrel 94

loxapine 70

173Updated 10/01/20


loxapine succinate 70lo-zumandimine 94

LUCEMYRA 82LUCENTIS 135

LUDENT 126LULICONAZOLE 144

LUMIGAN 134LUMIZYME 102LUMOXITI 41LUNESTA 75

LUPANETA PACK 97LUPRON DEPOT

(1-MONTH)37

LUPRON DEPOT (3-MONTH)

37


37


37

LUPRON DEPOT-PED (1-MONTH)

102

LUPRON DEPOT-PED (3-MONTH)

102

lutera 94LUXIQ 148LUZU 144

LYNPARZA 41LYRICA 60

LYRICA CR 78LYSODREN 37

LYSTEDA 117LYUMJEV 85

LYUMJEV KWIKPEN 85lyza 94

MACROBID 21MACRODANTIN 21

mafenide acetate 143magnesium sulfate 125

MAGNESIUM SULFATE 124magnesium sulfate in

d5w124

MAKENA 104MALARONE 24

malathion 151mannitol 53

MANNITOL 53maprotiline hcl 65

MARCAINE 18MARCAINE/

EPINEPHRINE18

marlissa 94MARNATAL-F 126

MARPLAN 65MARQIBO 39

MATULANE 38matzim la 52

MAVENCLAD 79MAVYRET 28

MAXALT 76, 77

MAXALT-MLT 77MAXIDEX 133

MAXITROL 130MAXZIDE 53

MAXZIDE-25 53MAYZENT 79

meclizine hcl 106meclofenamate sodium 12

MEDROL 99MEDROL DOSEPAK 99

medroxyprogesterone acetate

94, 104

mefenamic acid 12mefloquine hcl 24

megestrol acetate 37, 104

MEKINIST 41MEKTOVI 41

melodetta 24 fe 94meloxicam 12melphalan 34

melphalan hydrochloride

34

MEMANTINE HCL TITRATION PAK

63

memantine hydrochloride

63

memantine hydrochloride er

63

MENACTRA 123MENEST 98

MENOSTAR 98MENTAX 144MENVEO 123

meperidine hcl 16meprobamate 58

MEPRON 21MEPSEVII 102

mercaptopurine 36meropenem 21

MEROPENEM/SODIUM CHLORIDE

21

MERREM 21mesalamine 109

mesalamine dr 109mesalamine er 109

mesna 44MESNEX 44

MESTINON 78MESTINON TIMESPAN 78

metadate er 73metaproterenol sulfate 138

metaxalone 80metformin

hydrochloride88

metformin hydrochloride er

88

methadone hcl 13METHADONE HCL INJ 13

METHADOSE 13METHADOSE SUGAR-

FREE13

174 Updated 10/01/20


methamphetamine hcl 73methazolamide 53

methenamine hippurate 21METHENAMINE

MANDELATE21

methergine 102methimazole 105METHITEST 83

methocarbamol 81methotrexate 36,

120methotrexate sodium 36

methoxsalen 145methscopolamine

bromide108

methyldopa 55methyldopa/


methylergonovine maleate

102

METHYLIN 73methylphenidate

hydrochloride74

methylphenidate hydrochloride/5ml

74

methylphenidate hydrochloride cd er

73, 74

methylphenidate hydrochloride er

73, 74

METHYLPHENIDATE HYDROCHLORIDE ER

74

methylprednisolone 99methylprednisolone

acetate99

methylprednisolone sodium succinate

99

methyltestosterone 83metoclopramide hcl 106

metoclopramide hydrochloride

106

metoclopramide odt 106

METOCLOPRAMIDE ODT

106

metolazone 53metoprolol/


metoprolol succinate er 51metoprolol tartrate 51

METROCREAM 150METROGEL 150

METROLOTION 150metronidazole 21,

114, 150

METRONIDAZOLE INJ 21metronidazole in nacl 21

mexiletine hcl 47MIACALCIN 90

mibelas 24 fe 94micafungin 24MICARDIS 46,

47MICARDIS HCT 46

miconazole 3 114MICONAZOLE

NITRATE/ZINC OXIDE/WHITE PETROLATUM

144

MICRHOGAM ULTRA-FILTERED PLUS

121

MICROGESTIN 1.5/30 94MICROGESTIN 1/20 94

MICROGESTIN FE 1.5/30

94

MICROGESTIN FE 1/20 94MICROZIDE 53

midazolam hcl 75midazolam

hydrochloride75

midodrine hcl 55mifepristone 102

migergot 77miglitol 88

miglustat 102MIGRANAL 77

mili 94MILLIPRED 99

milrinone in dextrose 55milrinone lactate 55

mimvey 98MINASTRIN 24 FE 94

MINIPRESS 45minitran 55

MINIVELLE 98MINOCIN 33

minocycline hcl 33minocycline

hydrochloride33

minocycline hydrochloride er

33

MINOLIRA 33minoxidil 55MIRAPEX 67

MIRAPEX ER 67MIRCETTE 95

MIRENA 95mirtazapine 65

MIRVASO 150misoprostol 110

MITIGARE 10mitigo 16

mitomycin 35mitoxantrone hcl 38

M-M-R II 123M-NATAL PLUS 126

MOBIC 12modafinil 81

moexipril hcl 45molindone

hydrochloride70

mometasone furoate 139, 148

mondoxyne nl 33mono-linyah 95

175Updated 10/01/20


montelukast sodium 138MONUROL 21

morgidox 1x100mg 34morgidox 2x100mg 34MORPHABOND ER 13

morphine sulfate 16, 17

MORPHINE SULFATE 16, 17

morphine sulfate er 14MOTEGRITY 110

MOTOFEN 111MOVANTIK 111MOVIPREP 110

MOXEZA 131moxifloxacin

hydrochloride32, 131

moxifloxacin hydrochloride/sodium

hydrochloride

32

MOZOBIL 116MS CONTIN 14MULPLETA 117

MULTAQ 48MULTI VITAMIN/

FLUORIDE127

MULTIVITAMIN/FLUORIDE

127

MULTI-VITAMIN/FLUORIDE DROPS

127

MULTI-VITAMIN/FLUORIDE/IRON

127

mupirocin 143mutamycin 35

MVASI 41MYALEPT 102

MYAMBUTOL 27MYCAMINE 24MYCAPSSA 102

MYCOBUTIN 27mycophenolate mofetil 122

mycophenolic acid dr 122MYDAYIS 74

MYFORTIC 122MYLOTARG 41MYOBLOC 81

myorisan 142MYRBETRIQ 114

MYSOLINE 60MYTESI 111

MYXREDLIN 85NABI-HB 121

nabumetone 12nadolol 51

NAFCILLIN/DEXTROSE 32nafcillin sodium 32

naftifine hcl 144naftifine hydrochloride 144

NAFTIN 144NAGLAZYME 102

nalbuphine hcl 17NALFON 12

nalocet 17naloxone hcl 82

naloxone hydrochloride 82naltrexone hcl 82

NAMENDA 63NAMENDA TITRATION

PAK63

NAMENDA XR 63NAMENDA XR

TITRATION PACK63

NAMZARIC 63NAPRELAN 12

naproxen 12naproxen dr 12

naproxen/esomeprazole magnesium

12

naproxen sodium 12NAPROXEN SODIUM

CR12

naproxen sodium er 12

naratriptan hcl 77NARCAN 82

NARDIL 65NAROPIN 18NASONEX 139

NATACHEW 127NATACYN 131NATAZIA 95

nateglinide 88NATESTO 83NATPARA 90NATROBA 151

NAVELBINE 39NAYZILAM 60NEBUPENT 21

necon 0.5/35-28 95nefazodone hcl 65

nefazodone hydrochloride

65

NEMBUTAL SODIUM 75neomycin 21

neomycin/bacitracin/polymyxin

131

neomycin/polymyxin/bacitracin/

hydrocortisone

130

neomycin/polymyxin b sulfates irrigation

113

neomycin/polymyxin/dexamethasone

130

neomycin/polymyxin/gramicidin

131

neomycin/polymyxin/hydrocortisone

131, 153

NEONATAL PLUS 127neo-polycin 131

NEORAL 122NEO-SYNALAR 143NEPHRAMINE 130

NERLYNX 41NESINA 88

176 Updated 10/01/20


NESTABS 127NESTABS ONE 127

neuac 142NEULASTA 116

NEULASTA ONPRO KIT 116NEUPOGEN 116

NEUPRO 67NEURONTIN 60,

61NEVANAC 133nevirapine 25

nevirapine er 25NEXAVAR 41

NEXIUM 112NEXIUM I.V. 112

NEXLETOL 49NEXLIZET 49

NEXPLANON 95NEXTERONE 48

niacin 49niacin er 49

niacor 49NIASPAN 49

nicardipine hcl 52NICARDIPINE

HYDROCHLORIDE IV52

NICARDIPINE HYDROCHLORIDE/

SODIUM CHLORIDE IV

52

NICOTROL 82NICOTROL INHALER 82

nifedical xl 52nifedipine 52

nifedipine er 52nikki 95

NILANDRON 37nilutamide 37nimodipine 52

NINLARO 41NIPENT 38

nisoldipine er 52

nitisinone 102NITRO-BID 55

NITRO-DUR 55nitrofurantoin 21nitrofurantoin macrocrystals

21

nitrofurantoin monohydrate

21

nitroglycerin 56NITROGLYCERIN IN

DEXTROSE 5%55

NITROGLYCERIN INJ 56nitroglycerin lingual 55

nitroglycerin subl 56NITROLINGUAL

PUMPSPRAY56

NITROSTAT 56NITYR 102

NIVA-PLUS 127NIVESTYM 116

nizatidine 108NIZORAL 145

NOCDURNA 102nolix 148

NORA-BE 95NORCO 17

NORDITROPIN FLEXPRO

102

norethindrone 95norethindrone acetate 104

norethindrone acetate/ethinyl estradiol

95, 98

norethindrone acetate/ethinyl estradiol/ferrous

fumarate

95

norethindrone/ethinyl estradiol/ferrous

fumarate

95

NORGESIC FORTE 81norgestimate/ethinyl

estradiol95

NORITATE 150norlyda 95

NORMOSOL-M IN D5W 125NORMOSOL -R 125

NORMOSOL-R PH 7.4 125NORPACE 48

NORPACE CR 48NORPRAMIN 65

NORTHERA 55nortrel 0.5/35 (28) 95

nortrel 1/35 95nortrel 7/7/7 95

nortriptyline hcl 65nortriptyline

hydrochloride65

NORVASC 52NORVIR 25

NOURIANZ 67NOVAREL 102

NOVO/BD/ULTIMED/OWEN/TRIVIDIA PEN

NEEDLE/ORIGINAL/ULTRA-FINE

84

NOVOLIN 70/30 85NOVOLIN 70/30

FLEXPEN85

NOVOLIN 70/30 FLEXPEN RELION

85

NOVOLIN 70/30 RELION

85

NOVOLIN N 85NOVOLIN N FLEXPEN 85NOVOLIN N FLEXPEN

RELION85

NOVOLIN N RELION 85NOVOLIN R 85

NOVOLIN R FLEXPEN 85NOVOLIN R FLEXPEN

RELION85

NOVOLIN R RELION 85

177Updated 10/01/20


NOVOLOG 85, 86

NOVOLOG FLEXPEN 86NOVOLOG MIX 70/30 86NOVOLOG MIX 70/30

PREFILLED FLEXPEN86

NOVOLOG PENFILL 86NOXAFIL 24NPLATE 116

NP THYROID 105NUBEQA 37NUCALA 139

NUCYNTA 14, 17

NUCYNTA ER 14NUEDEXTA 78

NULEV 108NULOJIX 122

NULYTELY/FLAVOR PACKS

110

NUMBRINO 139NUPLAZID 70

NUTRILIPID 130NUTROPIN AQ NUSPIN 102

NUVARING 95NUVESSA 114NUVIGIL 81NUZYRA 34

nyamyc 144NYMALIZE 52

nystatin 24, 144, 152

nystatin/triamcinolone 144nystop 144

OB COMPLETE 127OB COMPLETE/DHA 127OB COMPLETE ONE 127

OB COMPLETE PETITE 127OB COMPLETE

PREMIER127

OCALIVA 111O-CAL PRENATAL 127

OCELLA 95OCREVUS 79

OCTAGAM 121octreotide acetate 102

OCUFLOX 132ODACTRA 121ODEFSEY 27ODOMZO 41

OFEV 139ofloxacin 32,

132, 153

ogestrel 95OGIVRI 41

okebo 34olanzapine 70

olanzapine/fluoxetine 65olanzapine odt 70

olmesartan medoxomil 46, 47

olmesartan medoxomil/amlodipine/

hydrochlorothiazide

46

olmesartan medoxomil/hydrochlorothiazide

46

olopatadine hcl 133, 137

OLUMIANT 119OLUX 148

OLUX-E 148OMECLAMOX-PAK 111omega-3-acid ethyl

esters49

OMEGAVEN 130omeprazole 112

omeprazole/sodium bicarbonate

112

OMNARIS 139OMNIPOD 5 PACK 86

OMNIPOD STARTER KIT

86

OMNITROPE 102ondansetron hcl 106

ondansetron hydrochloride

106

ondansetron odt 106ONEXTON 142

ONFI 61ONGLYZA 88ONIVYDE 38

ONZETRA XSAIL 77OPDIVO 41

OPIUM TINCTURE 111OPSUMIT 56ORACEA 150ORACIT 113

ORALAIR 121oralone dental paste 152

ORAPRED ODT 99ORAVIG 152

ORBACTIV 21ORENCIA 119

ORENCIA CLICKJECT 119ORENITRAM ER 56

ORFADIN 103ORIAHNN 103ORILISSA 97

ORKAMBI 139orphenadrine citrate 81

orphenadrine citrate/aspirin/caffeine

81

orphenadrine citrate er 81orphengesic forte 81

orsythia 95ORTHO-NOVUM 1/35 95

ORTHO-NOVUM 7/7/7 95ORTIKOS 109OSCIMIN 108

OSCIMIN SR 108

178 Updated 10/01/20


oseltamivir phosphate 28OSENI 88

OSMITROL VIAFLEX 53OSMOLEX ER 68

OSMOLEX ER DOSING KIT

68

OSMOPREP 110OSPHENA 103

OTEZLA 119OTEZLA STARTER PACK 119

OTOVEL 153OTREXUP 120

OVIDE 152oxacillin sodium 32,

33OXACILLIN SODIUM 32

oxaliplatin 34oxandrolone 83

oxaprozin 12OXAYDO 17

oxazepam 58OXBRYTA 117

oxcarbazepine 61OXERVATE 135

oxiconazole nitrate 144OXISTAT 144

OXSORALEN ULTRA 145OXTELLAR XR 61

oxybutynin chloride 114oxybutynin chloride er 114

oxycodone/acetaminophen

17

oxycodone/aspirin 17oxycodone hcl 14,

17OXYCODONE HCL ER 14

oxycodone hydrochloride

17

OXYCONTIN 14oxymorphone hydrochloride

17

oxymorphone hydrochloride er

14

OXYTROL 114OZEMPIC 88

OZURDEX 133pacerone 48paclitaxel 39PADCEV 42

paliperidone er 70palonosetron hydrochloride

107

PALONOSETRON HYDROCHLORIDE

107

PALYNZIQ 103PAMELOR 65

pamidronate disodium 90PAMIDRONATE

DISODIUM90

PANCREAZE 111PANDEL 148

PANRETIN 150pantoprazole sodium 112

pantoprazole sodium dr 112PANZYGA 121

PARAGARD INTRAUTERINE

COPPER CONTRACEPTIVE

95

paraplatin 35PAREGORIC 111

paricalcitol 105PARLODEL 68

PARNATE 65paroex 152

paromomycin 21paroxetine 78

paroxetine hcl 65paroxetine hcl er 65

paroxetine hydrochloride

65

PASER 27

PATADAY 133PATANASE 137PATANOL 133

PAXIL 66PAXIL CR 65,

66PAZEO 133

PEDIAPRED 99PEDIARIX 123

PEDVAX HIB 123peg-3350/electrolytes 110

peg-3350/nacl/na bicarbonate/kcl

110

PEGANONE 61PEGASYS 28

PEGINTRON KIT 50MCG

28

PEMAZYRE 42penicillamine 91

penicillin g potassium 33PENICILLIN G

POTASSIUM IN ISO-OSMOTIC DEXTROSE

33

PENICILLIN G PROCAINE

33

penicillin g sodium 33penicillin v potassium 33

PENLAC NAIL LACQUER

144

PENNSAID 150PENTACEL 123

PENTAM 300 21pentamidine isethionate 21

PENTASA 109pentazocine/naloxone

hcl17

pentobarbital sodium 75pentoxifylline er 117

PEPCID 108PERCOCET 17

PERFOROMIST 138

179Updated 10/01/20


PERIKABIVEN 130perindopril erbumine 45

periogard 152PERJETA 42

permethrin 152perphenazine 66,

70perphenazine/

amitriptyline66

PERSERIS 70PERTZYE 111

PEXEVA 66pfizerpen 33

phenadoz 107phenelzine sulfate 66

PHENERGAN 107PHENOBARBITAL ELIX 61

PHENOBARBITAL SODIUM

61

PHENOBARBITAL TABS 61phenoxybenzamine

hydrochloride55

PHENYLEPHRINE HCL 135PHENYTEK 61

phenytoin 61phenytoin sodium 61

phenytoin sodium er 61philith 95

PHOSLYRA 104PHOSPHASAL 21

PHOSPHOLINE IODIDE 134PHYSIOLYTE 152PHYSIOSOL IRRIGATION

152

PICATO 150PIFELTRO 25

pilocarpine hcl 134pilocarpine

hydrochloride152

pimecrolimus 150pimozide 70

pimtrea 95pindolol 51

pioglitazone hcl 88pioglitazone hcl-

glimepiride88

pioglitazone hcl/metformin hcl

88

pioglitazone hydrochloride

89

piperacillin sodium/tazobactam sodium

33

piperacillin/tazobactam 33PIQRAY 200MG DAILY

DOSE42

PIQRAY 250MG DAILY DOSE

42

PIQRAY 300MG DAILY DOSE

42

pirmella 1/35 95pirmella 7/7/7 95

piroxicam 12PLAQUENIL 120

PLASMA-LYTE-148 125PLASMA-LYTE A 125

PLAVIX 118PLEGRIDY 79

PLEGRIDY STARTER PACK

79

plenamine 130PLENVU 110

PLIAGLIS 149PNV 127

PNV-DHA 127PNV FOLIC ACID +

IRON MULTIVITAMIN127

PNV-OMEGA 127PNV PRENATAL PLUS

MULTIVITAMIN127

PNV-SELECT 127PODOCON 25 IN

BENZOIN TINCTURE150

podofilox 150POLIVY 42polycin 132

polymyxin b sulfate 21polymyxin b sulfate/trimethoprim sulfate

132

POLYTRIM 132POLY-VI-FLOR 127

POLY-VI-FLOR/IRON 127POLY-VITAMIN/

FLUORIDE127

POMALYST 37portia-28 95

PORTRAZZA 42posaconazole dr 24

POTASSIUM ACETATE 125potassium chloride 125,

127POTASSIUM CHLORIDE 125

potassium chloride cr 127POTASSIUM

CHLORIDE/DEXTROSE125

POTASSIUM CHLORIDE/DEXTROSE/

LACTATED RINGERS

125

POTASSIUM CHLORIDE/DEXTROSE/

SODIUM CHLORIDE

125

potassium chloride er 127potassium chloride/

sodium chloride125

POTASSIUM CHLORIDE/SODIUM

CHLORIDE

125

potassium chloride sr 127POTASSIUM CITRATE/

CITRIC ACID113

potassium citrate er 113POTASSIUM

PHOSPHATES125, 130

potassium phosphates pf

125

180 Updated 10/01/20


POTELIGEO 42PRADAXA 115

PRALUENT 49pramipexole

dihydrochloride68

pramipexole dihydrochloride er

68

prasugrel 118PRAVACHOL 49

pravastatin sodium 49praziquantel 21prazosin hcl 45

prazosin hydrochloride 45PRECOSE 89

PRED FORTE 133PRED-G 131

PRED-G S.O.P. 131PRED MILD 133

prednicarbate 148PREDNICARBATE 148

prednisolone 99prednisolone acetate 133prednisolone sodium

phosphate100

prednisolone sodium phosphate odt

100

PREDNISOLONE SODIUM PHOSPHATE

OPHTHALMIC SOLN 1%

133

prednisone 100PREDNISONE

INTENSOL100

PREFEST 98pregabalin 61PREGNYL 103

PREMARIN 98PREMASOL 130

PREMPHASE 98PREMPRO 98

PRENAISSANCE 127

PRENAISSANCE PLUS 127PRENATA 128

PRENATAL 128PRENATAL 19 128

PRENATAL PLUS 128PRENATAL PLUS IRON 128

PRENATAL VITAMINS PLUS LOW IRON

128

PRENATE 128PRENATE AM 128

PRENATE DHA 128PRENATE ELITE 128

PRENATE ENHANCE 128PRENATE ESSENTIAL 128

PRENATE MINI 128PRENATE PIXIE 128

PRENATE RESTORE 128PREPLUS 128

PRETAB 128PRETOMANID 27

PREVACID 112PREVACID SOLUTAB 112

prevalite 49PREVIDENT 5000

BOOSTER PLUS153

PREVIDENT 5000 DRY MOUTH

153

PREVIDENT 5000 ENAMEL PROTECT

153

PREVIDENT 5000 PLUS 153PREVIDENT FLUORIDE 153

PREVIDENT RINSE 153previfem 95

PREVYMIS 28, 29

PREZCOBIX 27PREZISTA 25

PRIALT 11PRIFTIN 27

PRILOSEC 112PRIMACARE 128

primaquine phosphate 24PRIMAXIN IV 21

primidone 61PRIMLEV 17PRINIVIL 45PRISTIQ 66

PRIVIGEN 121PROAIR DIGIHALER 138

PROAIR HFA 138PROAIR RESPICLICK 138

probenecid 10probenecid/colchicine 10

procainamide hcl 48PROCALAMINE 130

PROCARDIA 52PROCARDIA XL 52

procentra oral 74prochlorperazine 107prochlorperazine

edisylate107

prochlorperazine maleate

107

PROCRIT 116PROCTOCORT 150

PROCTOFOAM HC 150procto-med hc 150

procto-pak 150proctosol hc 150

proctozone-hc 151PROCYSBI 103

progesterone 104PROGLYCEM 100

PROGRAF 122PROLASTIN-C 139

PROLATE 17PROLENSA 133

PROLEUKIN 38PROLIA 90

PROMACTA 117promethazine hcl 107

181Updated 10/01/20


promethazine hcl plain 107promethazine hydrochloride

107

promethazine/phenylephrine

136

promethegan 107PROMETRIUM 104

propafenone hcl 48propafenone

hydrochloride er48

propantheline bromide 108proparacaine hcl 135

propranolol hcl 51propranolol hcl er 51

propranolol hydrochloride

51

propranolol hydrochloride er

51

propranolol/hydrochlorothiazide

50

propylthiouracil 105PROQUAD 123PROSCAR 112

PROSOL 130PROTONIX 112

PROTONIX PACK 112PROTOPIC 151

protriptyline hcl 66PROVENTIL HFA 138

PROVERA 104PROVIDA OB 128

PROVIGIL 81PROZAC 66

PRUDOXIN 151PSORCON 148

PULMICORT 140PULMICORT FLEXHALER

140

PULMOZYME 139PURIXAN 36

PYLERA 111

pyrazinamide 27pyridostigmine bromide 78pyridostigmine bromide

er78

pyrimethamine 21QBRELIS 45

QBREXZA 151QINLOCK 42

QMIIZ ODT 12QNASL 139

QNASL CHILDRENS 139QTERN 89

QUADRACEL 123QUALAQUIN 24QUARTETTE 95QUDEXY XR 61QUESTRAN 49,

50QUESTRAN LIGHT 50

quetiapine fumarate 70, 71

quetiapine fumarate er 70QUFLORA 128

QUFLORA FE 128QUFLORA FE

PEDIATRIC128

QUFLORA PEDIATRIC 128QUILLICHEW ER 74QUILLIVANT XR 74

quinapril hcl 45quinapril hydrochloride 45

quinapril/hydrochlorothiazide

44

quinidine gluconate cr 48quinidine gluconate er 48

quinidine sulfate 48quinine sulfate 24

QUZYTTIR 137QVAR REDIHALER 140

QXTELLA XR 61RABAVERT 123

rabeprazole sodium dr 112RADICAVA 78RAGWITEK 121

raloxifene hydrochloride 103ramelteon 75

ramipril 45RANEXA 55

ranolazine er 55RAPAFLO 112

RAPAMUNE 122rasagiline mesylate 68

RASUVO 120RAVICTI 103

RAYALDEE 105RAYOS 100

RAZADYNE ER 63REBIF 79

REBIF REBIDOSE 79REBIF REBIDOSE TITRATION PACK

79

REBIF TITRATION PACK 79REBLOZYL 117

RECARBRIO 21RECLAST 90reclipsen 95

RECOMBIVAX HB 123RECTIV 151

REGLAN 107REGONOL 78

REGRANEX 152RELAFEN DS 12

RELENZA DISKHALER 29RELEXXII 74

RELISTOR 111RELPAX 77

REMERON 66REMERON SOLTAB 66

REMICADE 119REMODULIN 56

RENACIDIN 113

182 Updated 10/01/20


RENAGEL 104RENFLEXIS 119

RENVELA 104RENVELA PACK 104

repaglinide 89REPATHA 50REPATHA

PUSHTRONEX SYSTEM50

REPATHA SURECLICK 50RESCRIPTOR 25

RESTASIS 135RESTASIS MULTIDOSE 135

RESTORIL 75RETACRIT 116RETEVMO 42

RETIN-A 142RETIN-A MICRO 142

RETIN-A MICRO PUMP 142RETROVIR 26

RETROVIR IV 26REVATIO 56REVCOVI 103

REVLIMID 37REXULTI 71REYATAZ 26REYVOW 77

RHOFADE 151RHOGAM ULTRA-

FILTERED PLUS121

RHOPHYLAC 121RHOPRESSA 134

ribavirin 29RIDAURA 120rifabutin 27RIFADIN 28

RIFAMATE 28rifampin 28RIFATER 28RILUTEK 78

riluzole 78

rimantadine hydrochloride

29

RIMSO-50 113RINGERS INJECTION 125

RINGERS IRRIGATION 152RINVOQ 119RIOMET 89

RIOMET ER 89risedronate sodium 90

risedronate sodium dr 90RISPERDAL 71

RISPERDAL CONSTA 71risperidone 71

risperidone odt 71RITALIN 74

RITALIN LA 74ritonavir 26

RITUXAN 42RITUXAN HYCELA 42

rivastigmine 63rivastigmine tartrate 63

RIVELSA 96rizatriptan benzoate 77

rizatriptan benzoate odt 77ROBAXIN 81

ROBAXIN-750 81ROCALTROL 106ROCKLATAN 134

ROMIDEPSIN 42ropinirole er 68

ropinirole hcl 68ropinirole hydrochloride 68

ropivacaine hydrochloride

18

rosadan 151rosuvastatin calcium 49

ROTARIX 123ROTATEQ 123ROWASA 109roweepra 61

roweepra xr 61ROXICODONE 17

ROZEREM 75ROZYLTREK 42

RUBRACA 42RUCONEST 117

RUKOBIA 26RUXIENCE 42RUZURGI 78

RYBELSUS 89ryclora 137

RYDAPT 42RYTARY 68

RYTHMOL SR 48RYVENT 137SABRIL 61

SAFYRAL 96SAIZEN 103

SAIZENPREP RECONSTITUTIONKIT

103

SALAGEN 153SALEX 151

SALICYLIC ACID 151SALICYLIC ACID WART

REMOVER151

SALSALATE 12SAMSCA 103

SANCUSO 107SANDIMMUNE 122SANDOSTATIN 103

SANDOSTATIN LAR DEPOT

103

SANTYL 152SAPHRIS 71

SARAFEM 66SARCLISA 42SAVAYSA 115SAVELLA 78

SAVELLA TITRATION PACK

78

scopolamine 107

183Updated 10/01/20


SEASONIQUE 96SECONAL SODIUM 75

SECUADO 71SEEBRI NEOHALER 136

SEGLUROMET 89SELECT-OB 128

selegiline hcl 68selenium sulfide 145

SELENIUM SULFIDE 145SELZENTRY 26SEMPREX-D 136

SE-NATAL 19 128SENSIPAR 103

SENSORCAINE 18, 19

sensorcaine/epinephrine

18

sensorcaine-mpf 18sensorcaine-mpf/

epinephrine18

SENSORCAINE-MPF/EPINEPHRINE

18

SEREVENT DISKUS 138SERNIVO 148

SEROQUEL 71SEROQUEL XR 71

SEROSTIM 103sertraline hcl 66

sertraline hydrochloride 66setlakin 96

sevelamer carbonate 104sevelamer

hydrochloride104

SEYSARA 34SF 153

SF 5000 PLUS 153SFROWASA 109

sharobel 96SHINGRIX 123SIGNIFOR 103

SIGNIFOR LAR 103

SIKLOS 117SIKLOS 100MG 117

sildenafil 56sildenafil citrate 56

SILENOR 75SILIQ 119

silodosin 113SILVADENE 143

SILVER NITRATE 151SILVER SULFADIAZINE 143

SIMBRINZA 134simliya 96

simpesse 96SIMPONI 119

SIMPONI ARIA 119SIMULECT 122

simvastatin 49SINEMET 68

SINEMET CR 68SINGULAIR 138

sirolimus 122SIRTURO 28

SITAVIG 29SIVEXTRO 21

SIVEXTRO TABS 22SKELAXIN 81

SKLICE 152SKYLA 96

SKYRIZI 119SLYND 96

SMOFLIPID 130sodium acetate 125

SODIUM ACETATE 2MEQ/ML

125

sodium bicarbonate 125SODIUM

BICARBONATE125

SODIUM CHLORIDE 0.9% IRRIGATION

SOLN

152

sodium chloride inj 125

SODIUM CHLORIDE INJ 125SODIUM CITRATE/

CITRIC ACID113

SODIUM DIURIL 53SODIUM EDECRIN 53

SODIUM FLUORIDE 128, 153

SODIUM FLUORIDE 5000 PLUS

153

SODIUM FLUORIDE 5000 PPM

153

sodium phenylbutyrate 103SODIUM PHOSPHATE 125

sodium polystyrene sulfonate

91

sodium sulfacetamide 132SODIUM

SULFACETAMIDE/SULFUR

142

SODIUM SULFACETAMIDE/

SULFUR CLEANSER IN UREA

142

SOFOSBUVIR/VELPATASVIR

29

solifenacin succinate 114SOLIQUA 100/33 86

SOLIRIS 117SOLODYN 34SOLOSEC 22

SOLTAMOX 37SOLU-CORTEF INJ 100

SOLU-MEDROL 100SOMA 81

SOMATULINE DEPOT 103SOMAVERT 103

SOOLANTRA 151SORBITOL IRRIGATION 113SORBITOL-MANNITOL

IRRIGATION113

SORIATANE 145SORILUX 145

184 Updated 10/01/20


sorine 48sotalol hcl 48

sotalol hcl (af) 48SOTYLIZE 48SOVALDI 29

SPIRIVA HANDIHALER 136SPIRIVA RESPIMAT 136

spironolactone 45, 53

spironolactone/hydrochlorothiazide

53

SPORANOX 24sprintec 28 96

SPRITAM 61SPRIX 12

SPRYCEL 42sps 91

sronyx 96SSD 143

STALEVO 50 68STALEVO 75 68

STALEVO 100 68STALEVO 125 68STALEVO 150 68STALEVO 200 68

STAMARIL 123STARLIX 89

stavudine 26STEGLATRO 89STEGLUJAN 89

STELARA 119STERILE WATER

IRRIGATION PLASTIC BOTTLE

152

STIMATE 103STIOLTO RESPIMAT 136

STIVARGA 42STRATTERA 74

STRENSIQ 103streptomycin sulfate 22

STRIBILD 27

STRIVERDI RESPIMAT 138STROMECTOL 22

SUBLOCADE 82SUBOXONE 82

SUBOXONEMG 82SUBSYS 17,

18subvenite 61

subvenite starter kit/blue

61

subvenite starter kit/green

61

subvenite starter kit/orange

61

SUCRAID 111SUCRALFATE SUSP 111

sucralfate tabs 111SULAR 52

sulfacetamide sodium 132, 142

sulfacetamide sodium/prednisolone sodium

phosphate

131

SULFACLEANSE 142SULFADIAZINE 22

sulfamethoxazole/trimethoprim

22

sulfamethoxazole/trimethoprim ds

22

SULFAMYLON 143sulfasalazine 109

SULFASALAZINE 109sulindac 12

sumatriptan 77sumatriptan/naproxen

sodium77

sumatriptan succinate 77SUNOSI 81SUPRAX 30

SUPREP BOWEL PREP KIT

110

SUSTIVA 26SUSTOL 107SUTENT 42

syeda 96SYLATRON 38

SYLVANT 38SYMBICORT 141

SYMBYAX 66SYMDEKO 139

SYMFI 27SYMFI LO 27

SYMJEPI 139SYMLINPEN 60 89

SYMLINPEN 120 89SYMPAZAN 61SYMPROIC 111SYMTUZA 27SYNAGIS 121

SYNALAR 148SYNAREL 97

SYNDROS 107SYNERA 149

SYNERCID 22SYNJARDY 89

SYNJARDY XR 89SYNRIBO 38

SYNTHROID 105SYPRINE 91TABLOID 36

TABRECTA 42TACLONEX 148tacrolimus 122,

151tadalafil 56

TAFINLAR 42TAGRISSO 42

TAKHZYRO 118TALICIA 111

TALTZ 119TALZENNA 42

185Updated 10/01/20


TAMIFLU 29tamoxifen citrate 37

tamsulosin hydrochloride

113

TAPAZOLE 105taperdex 6-day 100taperdex 7-day 100

taperdex 12-day 100TARCEVA 42

TARGADOX 34TARGRETIN 38,

151tarina 24 fe 96

tarina fe 1/20 96tarina fe 1/20 eq 96

TARKA 44TARON-C DHA 128

TARON-PREX 128TASIGNA 42TASMAR 68

TAVALISSE 118TAXOTERE 39TAYTULLA 96tazarotene 145

tazicef 30TAZORAC 145

taztia xt 52TAZVERIK 42

TDVAX 123TECENTRIQ 42TECFIDERA 79,

80TECFIDERA STARTER

PACK79

TEFLARO 31TEGRETOL 61

TEGRETOL-XR 61TEGSEDI 78

TEKTURNA 55TEKTURNA HCT 55

telmisartan 46, 47

telmisartan/amlodipine 46telmisartan/


temazepam 75TEMIXYS 27

TEMODAR 35TEMOVATE 148

temsirolimus 42tencon 11

TENIVAC 123tenofovir 26

TENORETIC 50 50TENORETIC 100 50

TENORMIN 51TEPEZZA 103

terazosin hcl 45terazosin hydrochloride 45

terbinafine hcl 24terbutaline sulfate 138

terconazole 114TERIPARATIDE 90

TESTIM 83TESTOPEL 83

testosterone 83testosterone cypionate 83testosterone enanthate 83

testosterone gel 83testosterone pum 83

testosterone pump gel 83testosterone topical 83

tetrabenazine 78TETRACAINE

HYDROCHLORIDE135

tetracycline hydrochloride

34

TEXACORT 148THALOMID 37

THEO-24 139theophylline 139

THEOPHYLLINE/D5W 139theophylline er 139

THIOLA 113THIOLA EC 113

thioridazine hcl 71thiotepa 35

thiothixene 71THRIVITE RX 129

THYMOGLOBULIN 122tiadylt er 52

tiagabine hydrochloride 61TIAZAC 52

TIBSOVO 42TICE BCG 38

TIGAN 107tigecycline 34TIGLUTIK 78TIKOSYN 48TILIA FE 96

TIMOLOL MALEATE OPHTHALMIC

134

timolol maleate soln 134timolol maleate tabs 51

TIMOPTIC 134TIMOPTIC OCUDOSE 134

TIMOPTIC-XE 134tinidazole 22TIROSINT 105

TIROSINT-SOL 105TIS-U-SOL 152

TIVICAY 26TIVICAY PD 26

tizanidine hcl 81tizanidine hydrochloride 81

TOBI 22TOBI PODHALER 22

TOBRADEX 131TOBRADEX ST 131

tobramycin 22

186 Updated 10/01/20


tobramycin/dexamethasone

131

tobramycin sulfate 22, 132

TOBREX 132TOLAK 151

tolcapone 68tolmetin sodium 12

TOLSURA 24tolterodine tartrate 114

tolterodine tartrate er 114tolvaptan 103

TOPAMAX 62TOPAMAX SPRINKLE 62

TOPICORT 148topiramate 62

TOPIRAMATE ER 62toposar 39

topotecan 38TOPOTECAN 38

TOPROL XL 51toremifene citrate 37

TORISEL 42torsemide 54

TOSYMRA 77TOUJEO MAX

SOLOSTAR86

TOUJEO SOLOSTAR 86tovet foam 148

TOVIAZ 114TPN ELECTROLYTES 126

TRACLEER 56TRADJENTA 89

tramadol hcl 18TRAMADOL HCL ER 14tramadol hcl er tabs 14

tramadol hydrochloride 18tramadol

hydrochloride/acetaminophen

18

trandolapril 44, 45

trandolapril/verapamil hcl er

44

tranexamic acid 118TRANSDERM-SCOP 107

TRANXENE T 62tranylcypromine sulfate 66

TRAVASOL 130TRAVATAN Z 135

travoprost 135TRAZIMERA 43

trazodone hydrochloride

66

TREANDA 35TRECATOR 28

TRELEGY ELLIPTA 136TRELSTAR MIXJECT 37

TREMFYA 119treprostinil 56

TRESIBA 86TRESIBA FLEXTOUCH 86

tretinoin 38, 143

TRETINOIN MICROSPHERE

143

TREXALL 120TREXIMET 77

trezix 18triamcinolone acetonide 148triamcinolone acetonide

dental paste153

triamcinolone acetonide inj

100

triamterene 54triamterene/


trianex 148triazolam 75

TRIBENZOR 46TRICARE PRENATAL 129

TRICARE PRENATAL DHA ONE

129

TRICITRATES 113TRICOR 48triderm 148

TRIDESILON 148trientine hydrochloride 91

TRIESENCE 133tri-estarylla 96tri femynor 96

trifluoperazine hcl 71trifluridine 132TRIGLIDE 48

trihexyphenidyl hcl 68trihexyphenidyl

hydrochloride68

TRIKAFTA 139tri-legest fe 96TRILEPTAL 62

tri-linyah 96TRILIPIX 48

tri-lo-estarylla 96tri-lo-marzia 96

tri-lo-mili 96tri-lo-sprintec 96

trilyte 110trimethobenzamide

hydrochloride107

trimethoprim 22trimethoprim sulfate/

polymyxin b sulfate132

tri-mili 96trimipramine maleate 66

TRINATAL RX 1 129TRINTELLIX 66

TRIOSTAT 105tri-previfem 96

TRIPTODUR 103TRISENOX 38tri-sprintec 96

TRISTART DHA 129

187Updated 10/01/20


TRISTART ONE 129TRIUMEQ 27

TRI-VI-FLOR 129TRI-VITE/FLUORIDE 129

trivora-28 96tri-vylibra 96

tri-vylibra lo 96TRIZIVIR 27

TROGARZO 26TROKENDI XR 62TROPHAMINE 130

trospium chloride 114trospium chloride er 114

TRULANCE 111TRULICITY 89

TRUMENBA 123TRUSOPT 135TRUVADA 27TRUXIMA 43

TUDORZA PRESSAIR 136TUKYSA 43

tulana 96TURALIO 43TWINRIX 123

TWYNSTA 46TYBOST 26

tydemy 96TYGACIL 34TYKERB 43

TYLENOL/CODEINE #3 18TYMLOS 90

TYPHIM VI 123TYSABRI 80TYVASO 56

TYVASO REFILL 56TYVASO STARTER 56

UBRELVY 77UCERIS 109

UCERIS FOAM 109UDENYCA 116

ULORIC 10ULTOMIRIS 118ULTRACET 18

ULTRAM 18ULTRAVATE 149

UNASYN 33UNASYN BULK PACK 33

UNITHROID 105UPTRAVI 56,

57UPTRAVI TITRATION

PAK56

URIN D/S 22UROCIT-K 113

UROGESIC-BLUE 22UROXATRAL 113

URSO 250 111ursodiol 111

URSO FORTE 111UTIBRON NEOHALER 136

UTIRA-C 22VABOMERE 22

VAGIFEM 98valacyclovir hcl 29

valacyclovir hydrochloride

29

VALCHLOR 151VALCYTE 29

valganciclovir 29valganciclovir hydrochloride

29

VALIUM 62valproate sodium 62

valproic acid 62valsartan 47

valsartan/hydrochlorothiazide

46

VALSTAR 35VALTOCO 62VALTREX 29

vanatol lq 11

vanatol s 11VANCOCIN 22

VANCOCIN HCL 22VANCOMYCIN 23

vancomycin hcl 22VANCOMYCIN HLC 22

vancomycin hydrochloride

22, 23

VANCOMYCIN HYDROCHLORIDE

22

VANCOMYCIN HYDROCHLORIDE/

DEXTROSE

22

VANDAZOLE 114VANOS 149

VANTAS 37VAQTA 124

VARIVAX 124VARIZIG 121VARUBI 107

VASCEPA 50VASERETIC 44

VASOSTRICT 103VASOTEC 45VECAMYL 55VECTIBIX 43

VECTICAL 145VELCADE 43

VELETRI 57velivet 96

VELPHORO 104VELTASSA PACK 91

VELTIN 143VEMLIDY 29

VENCLEXTA 43VENCLEXTA STARTING

PACK43

venlafaxine hcl 66venlafaxine hcl er 66

venlafaxine hydrochloride er

66, 67

188 Updated 10/01/20


VENTAVIS 57VENTOLIN HFA 138

verapamil hcl 52verapamil hcl er 52verapamil hcl sr 52

VERAPAMIL HCL SR CP24 360MG

52

verapamil hydrochloride

52, 53

verapamil hydrochloride er

53

VERDESO 149VEREGEN 151VERELAN 53

VERELAN PM 53VERSACLOZ 71

VERZENIO 43VESICARE 114

VFEND 24VFEND IV 24V-GO 20 86V-GO 30 86V-GO 40 86VIBATIV 23VIBERZI 111

VIBRAMYCIN 34VICTOZA 89

VIDAZA 36VIDEX EC 26

VIDEX PEDIATRIC 26VIEKIRA PAK 29

vienva 96vigabatrin 62vigadrone 62VIGAMOX 132

VIIBRYD 67VIIBRYD STARTER

PACK67

VIMIZIM 103VIMOVO 12VIMPAT 62

vinblastine sulfate 39vincristine sulfate 39

vinorelbine tartrate 39VIOKACE 111

viorele 96VIRACEP 26

VIRAMUNE 26VIRAMUNE XR 26

VIRASAL 151VIRAZOLE 29

VIREAD 26VIRT-C DHA 129

VIRT-NATE DHA 129VIRT-PN DHA 129VIRT-PN PLUS 129

VISTARIL 137VISTOGARD 103VITAFOL FE+ 129

VITAFOL GUMMIES 129VITAFOL-NANO 129

VITAFOL-OB 129VITAFOL-ONE 129

VITAFOL STRIPS 129VITAFOL ULTRA 129

VITAMEDMD ONE RX/QUATREFOLIC

129

VITRAKVI 43VIVELLE-DOT 98

VIVITROL 82VIVLODEX 13VIZIMPRO 43VOGELXO 83

VOGELXO PUMP 83volnea 96

VOL-PLUS 129VOLTAREN 151

voriconazole 24VOSEVI 29

VOTRIENT 43VP-PNV-DHA 129

VPRIV 103VRAYLAR 72

VRAYLAR CAP THERAPY PACK

72

vtol lq 11VUMERITY 80

VUSION 144VYEPTI 77vyfemla 97vylibra 97

VYNDAMAX 55VYNDAQEL 55

VYONDYS 53 78VYTORIN 50VYVANSE 74

VYXEOS 38VYZULTA 135

WAKIX 81warfarin sodium 115

WELCHOL 50WELLBUTRIN SR 67WELLBUTRIN XL 67

wera 97WINRHO SDF 121

wixela inhub 141wymzya fe 97XADAGO 68XALATAN 135XALKORI 43

XANAX 58XANAX XR 58

XARELTO 115XARELTO STARTER

PACK115

XATMEP 120XCOPRI 62

XCOPRI MAINTENACE PACK

62

XCOPRI TITRATION PACK

62

189Updated 10/01/20


XELJANZ 119, 120

XELJANZ XR 120XELPROS 135XEMBIFY 121

XENAZINE 78XENLETA 23XEOMIN 81

XEPI 143XERAVA 34XERESE 151

XERMELO 111XGEVA 90

XHANCE 139XIAFLEX 103

XIFAXAN 23, 111

XIGDUO XR 89XIIDRA 135

XIMINO 34XOFLUZA 29

XOLAIR 139XOLEGEL 145XOPENEX 138XOPENEX

CONCENTRATE138

XOPENEX HFA 138XOSPATA 43XPOVIO 43

XPOVIO 60 MG ONCE WEEKLY

43


43

XPOVIO 80 MG TWICE WEEKLY

43


43

XTAMPZA ER 14XTANDI 37

xulane 97XULTOPHY 86

XURIDEN 104XYLOCAINE 19

xylocaine dental 19XYLOCAINE/

EPINEPHRINE19

XYLOCAINE-MPF 19XYLOCAINE-MPF/

EPINEPHRINE19

XYOSTED 83XYREM 81

YASMIN 28 97YAZ 97

YERVOY 43YF-VAX 124

YONDELIS 35YONSA 37

YUPELRI 136yuvafem 98

zafirlukast 138zaleplon 75

ZALTRAP 43ZANAFLEX 81ZANOSAR 35

zarah 97ZARONTIN 62

ZARXIO 116ZATEAN-PN DHA 129ZATEAN-PN PLUS 129

ZAVESCA 104zebutal 11

ZEGERID 112ZEJULA 43

ZELAPAR 68ZELBORAF 43ZELNORM 111ZEMAIRA 139

ZEMBRACE SYMTOUCH

77

ZEMDRI 23ZEMPLAR 106

zenatane 143ZENPEP 111zenzedi 74,

75ZEPATIER 29ZEPOSIA 80

ZEPOSIA 7-DAY STARTER PACK

80

ZEPOSIA STARTER KIT 80ZERBAXA 31ZERVIATE 133

ZESTORETIC 44ZESTRIL 45

ZETIA 50ZETONNA 140

ZIAC 50ZIAGEN 26

ZIANA 143zidovudine 26

ZIEXTENZO 117zileuton er 138ZILRETTA 100

ZINECARD 44ZINPLAVA 121ZIOPTAN 135

ziprasidone hcl 72ziprasidone mesylate 72

ZIPSOR 13ZIRABEV 43ZIRGAN 132

ZITHROMAX 31ZITHROMAX TRI-PAK 31

ZITHROMAX Z-PAK 31ZOCOR 49

ZOFRAN 107ZOHYDRO ER 14

ZOLADEX 37zoledronic acid 90

ZOLEDRONIC ACID 90ZOLINZA 43

190 Updated 10/01/20

Drug name Page

zolmitriptan 77zolmitriptan odt 77

ZOLOFT 67zolpidem tartrate 76

zolpidem tartrate er 76ZOLPIMIST 76

ZOMACTON 104ZOMIG 77

ZOMIG ZMT 77ZONALON 151

ZONEGRAN 62zonisamide 62ZONTIVITY 118ZORBTIVE 104ZORTRESS 122ZORVOLEX 13ZOSTAVAX 124

ZOSYN 33zovia 1/35e 97

ZOVIRAX 29, 151

ZTLIDO 149ZUBSOLV 82

zumandimine 97ZUPLENZ 107ZYCLARA 151

ZYCLARA PUMP 151ZYDELIG 43

ZYFLO 138ZYKADIA 43

ZYLET 131ZYLOPRIM 10ZYMAXID 132

ZYPITAMAG 49ZYPREXA 72

ZYPREXA RELPREVV 72ZYPREXA ZYDIS 72

ZYTIGA 37ZYVOX 23

191Updated 10/01/20

Enhanced Drug Benefit List*Please check your Prescription Drug Schedule of Cost Sharing to find out if your plan includes an “Enhanced Drug Benefit.” The enhanced drugs are listed in this guide by Enhanced Drug Benefit Categories. If your plan includes enhanced drug benefits, look for the Enhanced Drug Benefit Category in the following pages to determine which drugs are covered. For example, if your Prescription Drug Schedule of Cost Sharing says that your plan includes coverage for “Vitamins and Minerals” and “Erectile Dysfunction”, find the lists titled “Vitamins and Minerals” and “Erectile Dysfunction” to find which drugs are covered. For more information, call the toll-free telephone number on your Aetna identification card or our member service center at 1-888-267-2637. Representatives are available to assist you 8 a.m. to 9 p.m., E.S.T., Monday through Friday. For TTY assistance please dial 711.

Key**Drug name

UPPERCASE = Brand-name prescription drugs

Lowercase italics = Generic medications

Drug tier

1, 2, 3, 4 = Copay tier level

Requirements/Limits

QL = Quantity Limit PA = Prior Authorization

Drug name Drug tier Requirements/LimitsCOSMETIC

ACUICYN ANTIMICROBIAL EY ELID & EYELASH HYGIENE

2

alphaquin hp 1ARNICA FLOWER 2AVENOVA 2BENZOIN TINCTURE 2BETAMETHASONE DIPROPIONATE/MINOXIDIL

2

bimatoprost 1blanche 1BORIC ACID 2BOTOX COSMETIC 2DRYSOL 2EPICYN 2

* These prescription drugs are not normally covered in a Medicare Prescription Drug Plan. Check your Prescription Drug Schedule of Cost Sharing to find out if you have coverage for these drugs. The amount you pay when you fill a prescription for these drugs does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.

** You can find information on what the symbols and abbreviations on this table mean by going to page 8.

192 Updated 10/01/20

Drug name Drug tier Requirements/LimitsEPIQUIN MICRO 2finasteride 1FINASTERIDE/MINOXIDIL 2HYALURONIC ACID SODIUM/HYDROQUINONE

2

HYCLODEX 2HYDROCORTISONE/HYDROQUINONE

2

HYDROCORTISONE/HYDROQUINONE/TRETINOIN

2

hydroquinone time release 1HYDROQUINONE EMUL 2hydroquinone crea 1HYPOCYN 2KYBELLA 2LACTIC ACID/NIACINAMIDE 2LATISSE 2LUSTRA 2LUSTRA-AF 2LUSTRA-ULTRA 2melpaque hp 1melquin hp 1MINOXIDIL/PROGESTERONE 2MINOXIDIL/PROGESTERONE/TRETINOIN

2

nuquin hp 1PROPECIA 2REFISSA 2remergent hq 1RENOVA 2RENOVA PUMP 2skin bleaching 1

193Updated 10/01/20

Drug name Drug tier Requirements/Limitsskin bleaching/sunscreen 1tl hydroquinone 1tretinoin emollient 1TRI-LUMA 2VANIQA 2XERAC AC 2

COUGH AND COLDbenzonatate 1biotuss 1biotuss pediatric 1bromfed dm 1CARBAPHEN 12 2CARBAPHEN 12 PED 2centergy dm 1CODAR AR 2CPB WC 2DECON-G 2dextromethorphan hbr/phenylephrine hcl/chlorpheniramine

1

EXACTUSS 2exefen-ir 1FLOWTUSS 2GILPHEX TR 2GILTUSS 2giltuss pediatric 1GILTUSS TR 2guaifenesin/dextromethorphan sr 1HDC DM 2HYCOFENIX 2hydrocodone bitartrate/chlorpheniramine maleate/pse

1

194 Updated 10/01/20

Drug name Drug tier Requirements/Limitshydrocodone bitartrate/homatropine methylbromide

1

hydrocodone polistirex/chlorpheniramine polistirex

1

hydromet 1lexuss 210 1MUCINEX DM 2NARIZ 2NASOTUSS 2NEOTUSS PLUS 2nohist-dm 1nortuss-de 1NORTUSS-EX 2OBREDON 2phenylephrine/guaifenesin 1PROHIST CD 2PROHIST CF 2PROMETHAZINE VC/CODEINE 2promethazine/codeine 1promethazine/dextromethorphan 1RELHIST 2RHINOLAR 2TESSALON PERLES 2TGQ 15DM/5PEH/2CPM 2TGQ 30PSE/150GFN/15DM 2TGQ 30PSE/3BRM/15DM 2TUSNEL PED-C 2TUSSICAPS 2tussigon 1TUSSIONEX PENNKINETIC EXTENDED RELEASE

2

TUXARIN ER 2

195Updated 10/01/20

Drug name Drug tier Requirements/LimitsTUZISTRA XR 2VAZOTAN 2VIRAVAN-DM 2VITUZ 2ZONATUSS 2zotex-12d 1ZOTEX-C 2ZUTRIPRO 2

ERECTILE DYSFUNCTIONBI-MIX 2 QL (6 EA per 30 days)CAVERJECT 2 QL (6 EA per 30 days)CAVERJECT IMPULSE 2 QL (6 EA per 30 days)CIALIS 2 QL (6 EA per 30 days)EDEX 2 QL (6 EA per 30 days)LEVITRA 2 QL (6 EA per 30 days)MUSE 2 QL (6 EA per 30 days)papaverine-phentolamine mesylate 1 QL (5 ML per 30 days)QUAD-MIX 2 QL (6 EA per 30 days)STAXYN 2 QL (6 EA per 30 days)STENDRA 2 QL (6 EA per 30 days)SUPER BI-MIX 2 QL (6 EA per 30 days)SUPER QUAD-MIX 2 QL (6 EA per 30 days)SUPER TRI-MIX 2 QL (6 EA per 30 days)tadalafil 1 QL (6 EA per 30 days)TRI-MIX 2 QL (6 EA per 30 days)vardenafil hydrochloride 1 QL (6 EA per 30 days)VIAGRA 2 QL (6 EA per 30 days)

FERTILITYCETROTIDE 2clomiphene citrate 1ENDOMETRIN 2

196 Updated 10/01/20

Drug name Drug tier Requirements/LimitsFIRST-PROGESTERONE VGS 100 COMPOUNDING KIT

2

FIRST-PROGESTERONE VGS 200 COMPOUNDING KIT

2

FOLLISTIM AQ 2ganirelix acetate 1GONAL-F 2GONAL-F RFF 2GONAL-F RFF REDIJECT 2MENOPUR 2OVIDREL 2

MISCELLANEOUSaero otic hc 1ALA-QUIN 2ALCORTIN A 2ALOQUIN 2aminobenzoate potassium 1ANALPRAM-HC 2ANALPRAM-HC SINGLES 2anucort-hc 1ANUSOL-HC 2arzol silver nitrate app licators 1ASCOR 2ascorbic acid 1benzoyl peroxide 8% 1bpm/pse/dm 1bromfed dm 1CETACAINE 2CORTANE-B 2CORTANE-B-OTIC 2cortic-nd 1covaryx 1

197Updated 10/01/20

Drug name Drug tier Requirements/Limitscovaryx hs 1cyotic 1dermazene 1DONNATAL 2DRYSOL 2eemt 1eemt hs 1esterified estrogens/methyltestosterone

1

exactacain 1exotic-hc 1FIRST-MOUTHWASH BLM 2GILPHEX TR 2GILTUSS TR 2grx hicort 25 1hemorrhoidal-hc 1hydrocodone polistirex/chlorpheniramine polistirex

1

hydrocortisone acetate 1hydrocortisone acetate/pramoxine 1hydrocortisone/iodoquinol 1HYOPHEN 2hyoscyamine sulfate er 1hyosyne 1iodoquinol/hydrocortisone acetate/aloe polysaccharides

1

IODOSORB 2isoxsuprine hcl 1K-PHOS 2K-PHOS NEUTRAL 2LEVBID 2lidocaine hcl/hydrocortisone acetate 1

198 Updated 10/01/20

Drug name Drug tier Requirements/Limitsme/naphos/mb/hyo 1 1MEZPAROX-HC FORTE 2NATURE-THROID 2NEOTUSS PLUS 2NITRO-TIME 2nohist-dm 1NOVACORT 2OTICIN HC NR 2oto-end 10 1otomax-hc 1phenazopyridine hcl 1phenazopyridine hydrochloride 1phospha 250 neutral 1POTABA 2PRAMOSONE 2PROCORT 2PROCTOCORT 2promethazine hydrochloride/dextromethorphan hydrobromide

1

promethazine vc/codeine 1promethazine/codeine 1promethazine/dextromethorphan 1promethazine/phenylephrine/codeine 1pyridoxine hcl 1QUINJA 2rectacort-hc 1RHINOLAR 2sodium chloride 1sodium sulfacetamide/sulfur 1thiamine hcl 1TUSSICAPS 2

199Updated 10/01/20

Drug name Drug tier Requirements/LimitsTUXARIN ER 2TUZISTRA XR 2urea 1uribel 1uro-458 1uro-mp 1ustell 1vilamit mb 1vilevev mb 1VIRATAN-DM 2VYTONE 2WP THYROID 2

VITAMINS AND MINERALSACTIVE FE 2ADRENAL C FORMULA 2airavite 1ALBAFORT 2aminobenzoate potassium 1ANIMI-3 2ANIMI-3/VITAMIN D 2AP-ZEL 2AQUASOL A PARENTERAL 2ASCOR 2ASCORBIC ACID INJ 15000MG/30ML 2ascorbic acid inj 500mg/ml 1ASTAMED MYO 2AVAILNEX 2AXONA 2b-6 folic acid 1b-complex 100 1b-plex 1

200 Updated 10/01/20

Drug name Drug tier Requirements/Limitsb-plex plus 1BACMIN 2biocel 1BP VIT 3 2CENFOL 2CENTRATEX 2CEREFOLIN 2CEREFOLIN NAC 2CHOLECAL DF 2CIFEREX 2cod liver oil 1corvita 1corvita 150 1CORVITE 2CORVITE 150 2CORVITE FE 2corvite free 1CYANOCOBALAMIN INJ 2000MCG/ML

2

cyanocobalamin inj 1000mcg/ml 1DEPLIN 15 2DEPLIN 7.5 2dialyvite 1DIALYVITE 3000 2DIALYVITE 5000 2DIALYVITE SUPREME D 2DIALYVITE/ZINC 2DRISDOL 2DURACHOL 2ELFOLATE PLUS 2ENLYTE 2

201Updated 10/01/20

Drug name Drug tier Requirements/LimitsENTERAGAM 2ERGOCAL 2ergocalciferol 1fabb 1FE 90 PLUS 2FERAHEME 2FERIVA 21/7 2FERIVAFA 2ferocon 1ferotrinsic 1FERRALET 90 2FERRAPLUS 90 2FERRO-PLEX HEMATINIC 2ferrocite plus 1ferrogels forte 1FERROTRIN 2FIBRIK 2folbee 1folbee plus 1folbee plus cz 1folbic 1FOLBIC RF 2FOLGARD RX 2FOLI-D 2folic acid 1folic acid/cyanocobalamin/pyridoxine hydrochloride

1

folic acid/vitamin b-6/vitamin b-12 1FOLIKA-V 2FOLITE 2FOLIVANE-F 2

202 Updated 10/01/20

Drug name Drug tier Requirements/LimitsFOLIVANE-PLUS 2FOLIXAPURE 2folplex 2.2 1FOLTANX 2FOLTANX RF 2FOLTRATE 2foltrin 1FOLTX 2FOLVITE FE 2FORTAVIT 2FOSTEUM 2FOSTEUM PLUS 2FOVEX 2FUSION PLUS 2FUSION SPRINKLES 2GABADONE 2GENICIN VITA-D 2hematinic plus complex 1hematinic plus vitamins/minerals 1hematinic/folic acid 1hematogen 1HEMATOGEN FA 2hematogen forte 1HEMATRON-AF 2HEMENATAL OB + DHA 2HEMOCYTE PLUS 2hemocyte-f 1hemocyte-plus 1hydroxocobalamin 1HYPERTENSA 2ICAR-C PLUS 2

203Updated 10/01/20

Drug name Drug tier Requirements/Limitsiferex 150 forte 1infed 1infuvite adult 1infuvite pediatric 1INJECTAFER 2INTEGRA F 2INTEGRA PLUS 2IROSPAN 24/6 2l-methyl-b6-b12 1L-METHYL-MC 2L-METHYL-MC NAC 2l-methylfolate 1L-METHYLFOLATE CA ME-CBL NAC 2l-methylfolate ca/p-5-p/me-cbl 1l-methylfolate calcium 1L-METHYLFOLATE FORMULA 15 2L-METHYLFOLATE FORMULA 7.5 2L-METHYLFOLATE FORTE 2LIMBREL 2LIPICHOL 540 2LISTER-V 2lmthf/pyridoxine hcl/cyanocobalamin 1lysiplex plus 1M.V.I. ADULT 2M.V.I. PEDIATRIC 2M.V.I.-12 WITHOUT VITAMIN K 2MEPHYTON 2METAFOLBIC 2METAFOLBIC PLUS 2METAFOLBIC PLUS RF 2METANX 2

204 Updated 10/01/20

Drug name Drug tier Requirements/Limitsmethionine/inositol/choline/cyanocobalamin

1

METHYLCOBALAMIN 2multi-b-plus 1MULTIGEN 2MULTIGEN FOLIC 2MULTIGEN PLUS 2myferon 150 forte 1mynephrocaps 1NASCOBAL 2NATALVIRT FLT 2NEPHPLEX RX 2NEPHRO-VITE RX 2NEPHROCAPS 2NEPHRON FA 2nephronex 1NEUREPA 2NEURIN-SL 2niacin 1NICADAN 2NICAZEL 2NICAZEL FORTE 2NICOMIDE 2nufol 1NUTRICAP 2nutrifac zx 1NUTRIVIT 2OCUVEL 2ORTHO-FOLIC 2PERCURA 2PHYSICIANS EZ USE B-12 COMPLIANCE KIT

2

205Updated 10/01/20

Drug name Drug tier Requirements/LimitsPHYTONADIONE 1PNV-VP-U 2PODIAPN 2poly-iron 150 forte 1polysaccharide iron forte 1POTABA 2PROTECT PLUS 2PROTECTIRON 2PROTEOLIN 2PULMONA 2PUREFE PLUS 2purevit dualfe plus 1PYRIDOXAL-5-PHOSPHATE 2pyridoxine hcl 1renal caps 1RENATABS 2RENATABS WITH IRON 2reno caps 1REQ 49+ 2REVESTA 2RHEUMATE 2se-tan plus 1SENTRA AM 2SENTRA PM 2SIDEROL 2sodium ferric gluconate complex/sucrose

1

STROVITE FORTE 2STROVITE ONE 2SUPERVITE 2SUPPORT 2

206 Updated 10/01/20

Drug name Drug tier Requirements/LimitsSUPPORT-500 2SYNAGEX 2SYNATEK 2TANDEM PLUS 2TARON FORTE 2THERAMINE 2thiamine hcl 1tl gard rx 1tl icon 1tl-hem 150 1TL-ICARE 2TOZAL 2TREPADONE 2tricon 1TRIFERIC 2trigels-f forte 1triphrocaps 1UDAMIN SP 2v-c forte 1VASCAZEN 2VASCULERA 2VENOFER 2vic-forte 1vicap forte 1virt-caps 1virt-vite 1virt-vite forte 1virt-vite plus 1vita s forte 1vita-min 1vitacel 1

207Updated 10/01/20

Drug name Drug tier Requirements/LimitsVITAL-D RX 2vitamax pediatric 1vitamin b-complex 100 1vitamin d 1VITAMIN K1 1VITAROCA PLUS 2vol-care rx 1VP-GSTN 2VP-ZEL 2wheat germ 1XAQUIL XR 2xyzbac 1

WEIGHT LOSSADIPEX-P 2 PAAPPTRIM 2 PAAPPTRIM-D 2 PAbenzphetamine hcl 1 PACONTRAVE 2 PAdiethylpropion hcl 1 PAdiethylpropion hcl er 1 PALOMAIRA 2 PAMEDACTIV 2 PAphendimetrazine tartrate 1 PAphendimetrazine tartrate er 1 PAphentermine hcl 1 PAphentermine hydrochloride 1 PAQSYMIA 2 PASAXENDA 2 PAXENICAL 2 PA

This formulary was updated on 10/01/2020. For more recent information or other questions, please contact Aetna Medicare Member Services at 1-888-267-2637 or for TTY users: 711, 8 a.m. to 9 p.m., E.S.T., Monday through Friday, or visit AetnaRetireePlans.com choose “Manage your prescription drugs”.

AetnaRetireePlans.com

©2020 Aetna Inc. 2021OPEN2PLUS4.1 B (10/20) Y0001_GRP_1085_2989_2021_C_Final_13 08/20202021OPEN2PLUS4Updated 10/01/20



2021 Comprehensive Formulary

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