CHP 2022 Formulary

Mandatory Generic: The Prescription Drug benefit is a “Mandatory Generic” program. Each Prescription will be filled as a Generic when available. If the Physician or the Covered Person requests a Brand Name Medication when there is an FDA “AB” rated Generic available, the Covered Person will be charged the applicable Deductible/Co- insurance/Co-payments plus the difference in the price of the Brand Name Medication and the available Generic. This charge is referred to as a DAW (Dispense as Written). The fee is applicable regardless of prescriber request or member request.

Medication Sourcing Classification Changes: Sourcing classification is dictated solely by the pharmaceutical manufacturer industry. These changes occur when multiple manufactures stop producing a drug leaving only one manufacturer (single source) to produce and sell the drug or new manufacturers enter the market to produce and sell a drug where others are already (multi-source). These changes occur intermittently throughout the year and without notice. The changes often result in a tier change which directly impacts the amount you pay in co-payment or co-insurance. As a result there may be instances where the tier on the formulary may not match the amount you are responsible for. The formulary is constantly updated to account for these types of changes.

lowercase italics = Generic drugsUPPERCASE BOLD = Brand name drugs

Drug TierEX = ExcludedTier 1 = GenericTier 2 = Preferred BrandTier 3 = Non-Preferred Brand/GenericTier 4 = SpecialtyTier 5 = Preventative

NotesFormulary Exclusion = Formulary ExclusionInsufficient Evidence = Insufficient EvidenceMedical Only Exclusion = Medical Only ExclusionNew to Market Exclusion = New to Market ExclusionNon Essential Drug Exclusion = Non Essential Drug ExclusionNon FDA Exclusion = Non FDA ExclusionOpioid Brochure = Opioid BrochurePA = Prior AuthorizationQL = Quantity LimitQL = Quantity LimitQuantity Limit Criteria = Quantity Limit CriteriaSpecialty = SpecialtyST = Step Therapy

Drug Name Drug Tier Notes

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

*Adhd Agent - Selective Alpha Adrenergic Agonists***clonidine hcl er oral tablet extended release 12 hour 0.1 mg

Tier 1

guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg

Tier 1

INTUNIV ORAL TABLET EXTENDED RELEASE 24 HOUR 1 MG, 2 MG, 3 MG, 4 MG

EX Formulary Exclusion

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 MG EX Formulary Exclusion

*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor***atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

Tier 1 QL

QELBREE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 150 MG, 200 MG

EX Formulary Exclusion; QL

STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG EX Formulary Exclusion; QL

1


*Amphetamine Mixtures***ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG EX Formulary Exclusion; QL

ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG


amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

Tier 1 QL

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

Tier 1 QL

MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG


*Amphetamines***ADZENYS ER ORAL SUSPENSION EXTENDED RELEASE 1.25 MG/ML EX Formulary Exclusion; QL

ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG

Benefit Exclusion

amphetamine er oral suspension extended release1.25 mg/ml


amphetamine sulfate oral tablet 10 mg, 5 mg EX Formulary Exclusion; QL

DESOXYN ORAL TABLET 5 MG EX Formulary Exclusion; QL

DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG EX Formulary Exclusion; QL

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

Tier 1 QL

dextroamphetamine sulfate oral solution 5 mg/5ml

Tier 1 QL

dextroamphetamine sulfate oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg

Tier 1 QL

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 2.5 MG/ML EX Formulary Exclusion; QL

EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 20 MG, 5 MG EX Formulary Exclusion; QL

EVEKEO ORAL TABLET 10 MG, 5 MG EX Formulary Exclusion; QL

methamphetamine hcl oral tablet 5 mg Tier 1 QL

PROCENTRA ORAL SOLUTION 5 MG/5ML Tier 1 QL

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG Tier 2 QL

2

Drug Name Drug Tier NotesVYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG Tier 2 QL

ZENZEDI TABLET 10 MG ORAL 10 MG Tier 1 QL

ZENZEDI TABLET 15 MG ORAL 15 MG EX Formulary Exclusion; QL

ZENZEDI TABLET 2.5 MG ORAL 2.5 MG EX Formulary Exclusion; QL



ZENZEDI TABLET 5 MG ORAL 5 MG Tier 1 QL

ZENZEDI TABLET 7.5 MG ORAL 7.5 MG EX Formulary Exclusion; QL

*Analeptics***CAFCIT INTRAVENOUS SOLUTION 60 MG/3ML EX Medical Only Exclusion

caffeine citrate intravenous solution 60 mg/3ml EX Medical Only Exclusion

caffeine citrate oral solution 20 mg/ml, 60 mg/3ml

Tier 1

caffeine-sodium benzoate injection solution 125-125 mg/ml

EX Non FDA Exclusion

DOPRAM INTRAVENOUS SOLUTION 20 MG/ML EX Medical Only Exclusion

*Anorexiant Combinations***PLENITY ORAL CAPSULE Benefit Exclusion

PLENITY WELCOME KIT ORAL CAPSULE Benefit Exclusion

QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG

Benefit Exclusion PA

*Anorexiants Non-Amphetamine***ADIPEX-P ORAL CAPSULE 37.5 MG Benefit Exclusion PA

ADIPEX-P ORAL TABLET 37.5 MG Benefit Exclusion PA

benzphetamine hcl oral tablet 25 mg, 50 mg Benefit Exclusion PA

diethylpropion hcl er oral tablet extended release 24 hour 75 mg


diethylpropion hcl oral tablet 25 mg Benefit Exclusion PA

LOMAIRA ORAL TABLET 8 MG Benefit Exclusion PA

phendimetrazine tartrate er oral capsule extended release 24 hour 105 mg


phendimetrazine tartrate oral tablet 35 mg Benefit Exclusion PA

phentermine hcl oral capsule 15 mg, 30 mg, 37.5 mg


phentermine hcl oral tablet 37.5 mg Benefit Exclusion PA

3


*Anti-Obesity - Glp-1 Receptor Agonists***SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML Benefit Exclusion PA

WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML, 1.7 MG/0.75ML, 2.4 MG/0.75ML


*Anti-Obesity Agent Combinations**CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 8-90 MG Benefit Exclusion PA

*Dopamine And Norepinephrine Reuptake Inhibitors (Dnris)***SUNOSI ORAL TABLET 150 MG, 75 MG Tier 2 PA; QL

*Histamine H3-Receptor Antagonist/Inverse Agonists***

WAKIX ORAL TABLET 17.8 MG, 4.45 MG EX PA; Specialty; Formulary Exclusion; QL

*Lipase Inhibitors***XENICAL ORAL CAPSULE 120 MG Benefit Exclusion PA

*Melanocortin 4 (Mc4) Receptor Agonists***IMCIVREE SUBCUTANEOUS SOLUTION10 MG/ML Tier 4 PA; Specialty

*Stimulant Combinations***AZSTARYS ORAL CAPSULE 26.1-5.2 MG, 39.2-7.8 MG, 52.3-10.4 MG EX Formulary Exclusion; QL

*Stimulants - Misc.***ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 MG, 45 MG, 55 MG, 70 MG, 85 MG


APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

Benefit Exclusion

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

Tier 1 QL

CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 36 MG, 54 MG EX Formulary Exclusion; QL

COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG

Benefit Exclusion

4

Drug Name Drug Tier NotesDAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR


dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

Tier 1 QL

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg

Tier 1 QL

FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG EX Formulary Exclusion; QL

FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG


JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG

Tier 2 QL

METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML EX Formulary Exclusion; QL

methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

Tier 1 QL

methylphenidate hcl er (la) capsule extended release 24 hour 10 mg oral 10 mg



Tier 1 QL


Tier 1 QL


Tier 1 QL



methylphenidate hcl er (osm) tablet extended release 18 mg oral 18 mg

Tier 1 QL


Tier 1 QL


Tier 1 QL


Tier 1 QL



methylphenidate hcl er (xr) oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

Benefit Exclusion

5

Drug Name Drug Tier Notesmethylphenidate hcl er oral tablet extended release 10 mg, 20 mg

Tier 1 QL

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


methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml

Tier 1 QL

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

Tier 1 QL

methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg

Tier 1 QL

modafinil oral tablet 100 mg, 200 mg Tier 1 QL

NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG EX Formulary Exclusion; QL

PROVIGIL ORAL TABLET 100 MG, 200 MG EX Formulary Exclusion; QL

QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG

Tier 2 QL

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 25 MG/5ML Tier 2 QL

RELEXXII ORAL TABLET EXTENDED RELEASE 72 MG EX Formulary Exclusion; QL

RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG


RITALIN ORAL TABLET 10 MG, 20 MG, 5 MG EX Formulary Exclusion; QL

*Allergenic Extracts/Biologicals Misc*

*Allergenic Extracts***acacia subcutaneous solution 1:20 Benefit Exclusion

acremonium subcutaneous solution 20000 pnu/ml Benefit Exclusion

alder subcutaneous solution 1:20 Benefit Exclusion

ALK SQ CAT HAIR INJECTION SOLUTION RECONSTITUTED 5000 BAU/ML

Benefit Exclusion

alternaria subcutaneous solution 20000 pnu/ml Benefit Exclusion

american beech subcutaneous solution 1:20 Benefit Exclusion

american cockroach subcutaneous solution 1:20 Benefit Exclusion

american elm subcutaneous solution 1:20 Benefit Exclusion

american sycamore subcutaneous solution 1:20 Benefit Exclusion

arizona cypress subcutaneous solution 1:20 Benefit Exclusion

6

Drug Name Drug Tier Notesaspergillus fumigatus injection solution 1:10 , 1:20

Benefit Exclusion

aureobasidium pullulans injection solution 1:20 Benefit Exclusion

aureobasidium subcutaneous solution 10000 pnu/ml, 20000 pnu/ml

Benefit Exclusion

australian pine subcutaneous solution 1:20 Benefit Exclusion

bahia subcutaneous solution 1:20 Benefit Exclusion

bald cypress subcutaneous solution 1:20 Benefit Exclusion

bayberry (wax myrtle) subcutaneous solution1:20

Benefit Exclusion

bermuda grass injection solution 10000 bau/ml Benefit Exclusion

bermuda grass subcutaneous solution 10000 bau/ml

Benefit Exclusion

black walnut pollen subcutaneous solution 1:20 Benefit Exclusion

black willow subcutaneous solution 1:20 Benefit Exclusion

botrytis cinerea injection solution 1:20 , 43000 pnu/ml

Benefit Exclusion

botrytis subcutaneous solution 20000 pnu/ml Benefit Exclusion

box elder subcutaneous solution 1:20 Benefit Exclusion

brome subcutaneous solution 1:20 Benefit Exclusion

california pepper tree subcutaneous solution 1:20 Benefit Exclusion

candida albicans extract injection solution1:1000 , 100 mg/ml

Benefit Exclusion

candida albicans extract subcutaneous solution10000 pnu/ml, 20000 pnu/ml

Benefit Exclusion

cat hair extract injection solution 10000 bau/ml, 5000 bau/ml

Benefit Exclusion

cat hair extract subcutaneous solution 10000 bau/ml

Benefit Exclusion

cattle epithelium subcutaneous solution 1:20 Benefit Exclusion

cedar elm subcutaneous solution 1:20 Benefit Exclusion

cladosporium cladosporioides injection solution1:20 , 64000 pnu/ml

Benefit Exclusion

cladosporium cladosporioides intradermal solution 1:20

Benefit Exclusion

cladosporium cladosporioides subcutaneous solution 10000 pnu/ml, 20000 pnu/ml

Benefit Exclusion

cladosporium sphaerospermum subcutaneous solution 20000 pnu/ml

Benefit Exclusion

cocklebur subcutaneous solution 1:20 Benefit Exclusion

corn pollen subcutaneous solution 1:20 Benefit Exclusion

7

Drug Name Drug Tier Notescurvularia subcutaneous solution 20000 pnu/ml Benefit Exclusion

dandelion subcutaneous solution 1:20 Benefit Exclusion

dog epithelium subcutaneous solution 1:10 , 1:20 Benefit Exclusion

dog fennel subcutaneous solution 1:20 Benefit Exclusion

drechslera subcutaneous solution 10000 pnu/ml, 20000 pnu/ml

Benefit Exclusion

eastern cottonwood subcutaneous solution 1:20 Benefit Exclusion

english plantain subcutaneous solution 1:20 Benefit Exclusion

epicoccum nigrum injection solution 1:10 Benefit Exclusion

epicoccum subcutaneous solution 10000 pnu/ml, 20000 pnu/ml

Benefit Exclusion

fire ant subcutaneous solution 1:10 , 1:20 Benefit Exclusion

fusarium subcutaneous solution 10000 pnu/ml, 20000 pnu/ml

Benefit Exclusion

german cockroach subcutaneous solution 1:20 Benefit Exclusion

goldenrod subcutaneous solution 1:20 Benefit Exclusion

grass pollen(k-o-r-t-swt vern) injection solution100000 bau/ml

Benefit Exclusion

GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU Benefit Exclusion

hackberry subcutaneous solution 1:20 Benefit Exclusion

honey bee treatment injection kit 100 mcg Benefit Exclusion

honey bee venom injection solution reconstituted1000 mcg

Benefit Exclusion

HONEY BEE VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED1300 MCG, 550 MCG

Benefit Exclusion

honey bee venom subcutaneous solution reconstituted 1100 mcg, 120 mcg

Benefit Exclusion

horse epithelium subcutaneous solution 1:10 , 1:20

Benefit Exclusion

johnson grass subcutaneous solution 1:20 Benefit Exclusion

june grass pollen standardized subcutaneous solution 100000 bau/ml

Benefit Exclusion

kapok subcutaneous solution 1:20 Benefit Exclusion

kochia subcutaneous solution 1:20 Benefit Exclusion

lambs quarters subcutaneous solution 1:20 Benefit Exclusion

lenscale subcutaneous solution 1:20 Benefit Exclusion

meadow fescue grass pollen subcutaneous solution 100000 bau/ml

Benefit Exclusion

melaleuca subcutaneous solution 1:20 Benefit Exclusion

8

Drug Name Drug Tier Notesmesquite subcutaneous solution 1:20 Benefit Exclusion

mite (d. farinae) injection solution 10000 au/ml, 30000 au/ml, 5000 au/ml

Benefit Exclusion

mite (d. farinae) subcutaneous solution 10000 au/ml

Benefit Exclusion

mite (d. pteronyssinus) injection solution 10000 au/ml, 30000 au/ml, 5000 au/ml

Benefit Exclusion

mite (d. pteronyssinus) subcutaneous solution10000 au/ml

Benefit Exclusion

mixed ragweed subcutaneous solution 1:20 Benefit Exclusion

mixed vespid venom protein injection kit 100-100-100 mcg, 1000-1000-1000 mcg

Benefit Exclusion

mixed vespid venom protein injection solution reconstituted 1300-1300-1300 mcg, 550-550-550 mcg

Benefit Exclusion

mixed vespid venom protein subcutaneous solution reconstituted 1100-1100-1100 mcg, 120-120-120 mcg

Benefit Exclusion

mountain cedar subcutaneous solution 1:20 Benefit Exclusion

mouse epithelium subcutaneous solution 1:20 Benefit Exclusion

mucor injection solution 1:20 Benefit Exclusion

mucor intradermal solution 1:20 Benefit Exclusion

mucor subcutaneous solution 10000 pnu/ml, 20000 pnu/ml

Benefit Exclusion

mugwort subcutaneous solution 1:20 Benefit Exclusion

olive tree subcutaneous solution 1:20 Benefit Exclusion

orchard grass pollen subcutaneous solution100000 bau/ml

Benefit Exclusion

PALFORZIA (12 MG DAILY DOSE) ORAL 2 X 1 MG & 10 MG Benefit Exclusion

PALFORZIA (120 MG DAILY DOSE) ORAL20 MG & 100 MG Benefit Exclusion

PALFORZIA (160 MG DAILY DOSE) ORAL3 X 20 MG & 100 MG Benefit Exclusion

PALFORZIA (20 MG DAILY DOSE) ORAL20 MG Benefit Exclusion

PALFORZIA (200 MG DAILY DOSE) ORAL2 X 100 MG Benefit Exclusion

PALFORZIA (240 MG DAILY DOSE) ORAL2 X 20 MG & 2 X 100 MG Benefit Exclusion

PALFORZIA (3 MG DAILY DOSE) ORAL 3 X 1 MG Benefit Exclusion

9

Drug Name Drug Tier NotesPALFORZIA (300 MG MAINTENANCE) ORAL PACKET 300 MG Benefit Exclusion

PALFORZIA (300 MG TITRATION) ORAL PACKET 300 MG Benefit Exclusion




PALFORZIA INITIAL ESCALATION ORAL0.5 & 1 & 1.5 & 3 & 6 MG Benefit Exclusion

pecan pollen subcutaneous solution 1:20 Benefit Exclusion

penicillium notatum injection solution 1:10 , 1:20 Benefit Exclusion

penicillium notatum subcutaneous solution 10000 pnu/ml, 20000 pnu/ml

Benefit Exclusion

perennial rye grass pollen injection solution100000 bau/ml

Benefit Exclusion

perennial rye grass pollen subcutaneous solution100000 bau/ml

Benefit Exclusion

phoma exigua subcutaneous solution 20000 pnu/ml

Benefit Exclusion

privet subcutaneous solution 1:20 Benefit Exclusion

queen palm subcutaneous solution 1:20 Benefit Exclusion

rabbit epithelium subcutaneous solution 1:10 , 1:20

Benefit Exclusion

RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 1-U Benefit Exclusion

red birch subcutaneous solution 1:20 Benefit Exclusion

red cedar subcutaneous solution 1:20 Benefit Exclusion

red maple subcutaneous solution 1:20 Benefit Exclusion

red mulberry subcutaneous solution 1:20 Benefit Exclusion

red top grass pollen subcutaneous solution100000 bau/ml

Benefit Exclusion

rhizopus subcutaneous solution 20000 pnu/ml Benefit Exclusion

rough marsh elder subcutaneous solution 1:20 Benefit Exclusion

rough pigweed subcutaneous solution 1:20 Benefit Exclusion

russian thistle subcutaneous solution 1:20 Benefit Exclusion

saccharomyces cerevisiae injection solution 1:20 Benefit Exclusion

saccharomyces cerevisiae subcutaneous solution20000 pnu/ml

Benefit Exclusion

sagebrush subcutaneous solution 1:20 Benefit Exclusion

10

Drug Name Drug Tier Notesshagbark hickory subcutaneous solution 1:20 Benefit Exclusion

sheep sorrel subcutaneous solution 1:20 Benefit Exclusion

short ragweed pollen ext subcutaneous solution1:20

Benefit Exclusion

spiny pigweed subcutaneous solution 1:20 Benefit Exclusion

stemphylium subcutaneous solution 20000 pnu/ml Benefit Exclusion

sweet gum subcutaneous solution 1:20 Benefit Exclusion

sweet vernal grass pollen subcutaneous solution100000 bau/ml

Benefit Exclusion

tall ragweed subcutaneous solution 1:20 Benefit Exclusion

timothy grass pollen allergen injection solution10000 bau/ml, 100000 bau/ml

Benefit Exclusion

timothy grass pollen allergen subcutaneous solution 10000 bau/ml, 100000 bau/ml

Benefit Exclusion

trichophyton mentagrophytes subcutaneous solution 1:20

Benefit Exclusion

trichophyton subcutaneous solution 20000 pnu/ml Benefit Exclusion

VENOMIL HONEY BEE VENOM INJECTION KIT 12 MCG, 120 MCG Benefit Exclusion

VENOMIL MIXED VESPID VENOM INJECTION SOLUTION RECONSTITUTED550-550-550 MCG

Benefit Exclusion

VENOMIL WASP VENOM INJECTION KIT12 MCG, 120 MCG Benefit Exclusion

VENOMIL WHITE FACED HORNET INJECTION KIT 12 MCG, 120 MCG Benefit Exclusion

VENOMIL YELLOW HORNET VENOM INJECTION KIT 12 MCG, 120 MCG Benefit Exclusion

VENOMIL YELLOW JACKET VENOM INJECTION KIT 12 MCG, 120 MCG Benefit Exclusion

virginia live oak subcutaneous solution 1:20 Benefit Exclusion

wasp venom protein injection kit 100 mcg Benefit Exclusion

wasp venom protein injection solution reconstituted 1000 mcg, 1300 mcg, 550 mcg

Benefit Exclusion

wasp venom protein subcutaneous solution reconstituted 1100 mcg, 120 mcg

Benefit Exclusion

western juniper subcutaneous solution 1:20 Benefit Exclusion

white ash subcutaneous solution 1:20 Benefit Exclusion

white birch subcutaneous solution 1:20 Benefit Exclusion

white faced hornet venom prot injection kit 100 mcg

Benefit Exclusion

11

Drug Name Drug Tier Noteswhite faced hornet venom prot injection solution reconstituted 1000 mcg

Benefit Exclusion

white faced hornet venom subcutaneous solution reconstituted 1100 mcg, 120 mcg

Benefit Exclusion

white mulberry subcutaneous solution 1:20 Benefit Exclusion

white oak subcutaneous solution 1:20 Benefit Exclusion

white pine subcutaneous solution 1:20 Benefit Exclusion

WHITE-FACED HORNET VENOM INJECTION SOLUTION RECONSTITUTED1300 MCG, 550 MCG

Benefit Exclusion

yellow dock subcutaneous solution 1:20 Benefit Exclusion

yellow hornet venom protein injection kit 100 mcg Benefit Exclusion

yellow hornet venom protein injection solution reconstituted 1000 mcg, 550 mcg

Benefit Exclusion

yellow hornet venom protein subcutaneous solution reconstituted 1100 mcg, 120 mcg

Benefit Exclusion

yellow jacket venom protein injection kit 100 mcg Benefit Exclusion

yellow jacket venom protein injection solution reconstituted 1000 mcg, 1300 mcg, 550 mcg

Benefit Exclusion

yellow jacket venom protein subcutaneous solution reconstituted 120 mcg

Benefit Exclusion

*Mixed Allergenic Extracts***dust mite mixed allergen ext injection solution10000 au/ml, 15000-15000 au/ml

Benefit Exclusion

dust mite mixed allergen ext subcutaneous solution 10000 au/ml

Benefit Exclusion

mixed aspergillus subcutaneous solution 20000 pnu/ml

Benefit Exclusion

mixed feathers subcutaneous solution 1:20 Benefit Exclusion

ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM Benefit Exclusion

ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR Benefit Exclusion

sorrel/dock mix subcutaneous solution 1:20 Benefit Exclusion

*Alternative Medicines*

*Alternative Medicine - Al's***alpha-lipoic acid injection solution 25 mg/ml EX Non FDA Exclusion

NEOKE RA LIPOIC ORAL POWDER 800 MG/GM EX Non FDA Exclusion

12


*Alternative Medicine - Pr's***EC-RX DHEA EXTERNAL CREAM 10 %, 4 % EX Non FDA Exclusion

*Alternative Medicine - Ub***coenzyme q-10 injection solution 20 mg/ml EX Non FDA Exclusion

*Amebicides*

*Amebicides***SOLOSEC ORAL PACKET 2 GM Tier 2

*Aminoglycosides*

*Aminoglycosides***amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml

EX Medical Only Exclusion

ARIKAYCE INHALATION SUSPENSION590 MG/8.4ML Tier 4 PA; Specialty

BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML EX

PA; Specialty; Formulary Exclusion; QL

gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-%


gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml


HUMATIN ORAL CAPSULE 250 MG EX Formulary Exclusion

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML Tier 4 PA; Specialty; QL

neomycin sulfate oral tablet 500 mg Tier 1

paromomycin sulfate oral capsule 250 mg Tier 1

streptomycin sulfate intramuscular solution reconstituted 1 gm


TOBI INHALATION NEBULIZATION SOLUTION 300 MG/5ML EX


TOBI PODHALER INHALATION CAPSULE28 MG Tier 4 PA; Specialty; QL

tobramycin inhalation nebulization solution 300 mg/4ml, 300 mg/5ml

Tier 4 PA; Specialty; QL

tobramycin sulfate injection solution 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml


tobramycin sulfate injection solution reconstituted 1.2 gm


ZEMDRI INTRAVENOUS SOLUTION 500 MG/10ML EX Medical Only Exclusion

13


*Analgesics - Anti-Inflammatory*

*Antirheumatic - Janus Kinase (Jak) Inhibitors***

OLUMIANT TABLET 1 MG ORAL 1 MG EX PA; ST; Specialty; Formulary Exclusion; QL

OLUMIANT TABLET 2 MG ORAL 2 MG EX PA; ST; Specialty; Formulary Exclusion; QL

OLUMIANT TABLET 4 MG ORAL 4 MG EX New to Market Exclusion; Specialty

RINVOQ TABLET EXTENDED RELEASE 24 HOUR 15 MG ORAL 15 MG Tier 4 PA; ST; Specialty; QL

RINVOQ TABLET EXTENDED RELEASE 24 HOUR 30 MG ORAL 30 MG Tier 4 PA; Specialty; QL

RINVOQ TABLET EXTENDED RELEASE 24 HOUR 45 MG ORAL 45 MG Tier 4 PA; Specialty; QL

XELJANZ ORAL SOLUTION 1 MG/ML Tier 4 PA; ST; Specialty; QL

XELJANZ ORAL TABLET 10 MG, 5 MG Tier 4 PA; ST; Specialty; QL

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG, 22 MG Tier 4 PA; ST; Specialty; QL

*Antirheumatic Antimetabolites***OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML

Tier 2 PA

RASUVO SOLUTION AUTO-INJECTOR 10 MG/0.2ML SUBCUTANEOUS 10 MG/0.2ML EX PA; Formulary Exclusion

RASUVO SOLUTION AUTO-INJECTOR 12.5 MG/0.25ML SUBCUTANEOUS 12.5 MG/0.25ML

EX PA; Formulary Exclusion









14

Drug Name Drug Tier NotesRASUVO SOLUTION AUTO-INJECTOR 7.5 MG/0.15ML SUBCUTANEOUS 7.5 MG/0.15ML


REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.4ML, 12.5 MG/0.5ML, 15 MG/0.6ML, 17.5 MG/0.7ML, 20 MG/0.8ML, 22.5 MG/0.9ML, 25 MG/ML, 7.5 MG/0.3ML

Tier 2 PA

*Anti-Tnf-Alpha - Monoclonal Antibodies***HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

Tier 4 PA; ST; Specialty; QL

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML


HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML


HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML


HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML


HUMIRA PREFILLED SYRINGE KIT 10 MG/0.1ML SUBCUTANEOUS 10 MG/0.1ML Tier 4 PA; ST; Specialty; QL


HUMIRA PREFILLED SYRINGE KIT 20 MG/0.4ML SUBCUTANEOUS 20 MG/0.4ML Tier 4 PA; Specialty; QL



SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML Tier 4 PA; Specialty; QL

SIMPONI SOLUTION AUTO-INJECTOR 100 MG/ML SUBCUTANEOUS 100 MG/ML Tier 4 PA; Specialty; QL

SIMPONI SOLUTION AUTO-INJECTOR 50 MG/0.5ML SUBCUTANEOUS 50 MG/0.5ML EX


15

Drug Name Drug Tier NotesSIMPONI SOLUTION PREFILLED SYRINGE 100 MG/ML SUBCUTANEOUS100 MG/ML


SIMPONI SOLUTION PREFILLED SYRINGE 50 MG/0.5ML SUBCUTANEOUS50 MG/0.5ML

EX PA; Specialty; Formulary Exclusion; QL

*Cyclooxygenase 2 (Cox-2) Inhibitors***CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG EX Formulary Exclusion

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

Tier 1

*Gold Compounds***RIDAURA ORAL CAPSULE 3 MG Tier 3

*Interleukin-1 Blockers***ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG Tier 4 PA; Specialty

*Interleukin-1 Receptor Antagonist (Il-1Ra)***KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML EX

PA; ST; Specialty; Formulary Exclusion; QL

*Interleukin-1Beta Blockers***ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML Tier 4 PA; Specialty

*Interleukin-6 Receptor Inhibitors***ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 162 MG/0.9ML


ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, 400 MG/20ML, 80 MG/4ML EX


ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML Tier 4 PA; Specialty; QL

KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML, 200 MG/1.14ML


KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/1.14ML, 200 MG/1.14ML


*Nonsteroidal Anti-Inflammatory Agent Combinations***active injection ket-l injection kit 30 & 1 mg/ml-% EX Non FDA Exclusion

16

Drug Name Drug Tier Notesactive injection ketmarc-l injection kit 30 & 0.25 & 1 mg/ml-%-%


ARTHROTEC ORAL TABLET DELAYED RELEASE 50-0.2 MG, 75-0.2 MG EX Formulary Exclusion

diclofenac-misoprostol oral tablet delayed release50-0.2 mg, 75-0.2 mg

Tier 1

DUEXIS ORAL TABLET 800-26.6 MG Benefit Exclusion Non Essential Drug Exclusion

flexipak combination therapy pack 75 & 0.025 mg-%

Benefit Exclusion

ibuprofen-famotidine oral tablet 800-26.6 mg Benefit Exclusion Non Essential Drug Exclusion

inavix combination therapy pack 75 & 0.025 mg-%


INFLAMMACIN COMBINATION THERAPY PACK 75 & 0.025 MG-% Benefit Exclusion

INFLATHERM COMBINATION THERAPY PACK 75 & 3-3 MG & % EX Non FDA Exclusion

KETOROCAINE-L INJECTION KIT 30 & 1 MG/ML-% EX Non FDA Exclusion

KETOROCAINE-LM INJECTION KIT 30 & 0.25 & 1 MG/ML-%-% EX Non FDA Exclusion

ketorolac-bupiv-ketamine injection solution prefilled syringe 60-150-60 mg/50ml


ketorolac-ropiv-ketamine injection solution prefilled syringe 15-100-30 mg/50ml


naproxen-esomeprazole oral tablet delayed release 375-20 mg, 500-20 mg

Benefit Exclusion

NUDICLO TABPAK COMBINATION THERAPY PACK 75 & 0.025 MG-% EX Non FDA Exclusion

NUDROXIPAK COMBINATION THERAPY PACK 200 MG EX Non FDA Exclusion

PREVIDOLRX ANALGESIC COMBINATION THERAPY PACK 75-20-0.025 MG-MG-%


previdolrx plus analgesic combination therapy pack 75 & 0.025 mg-%


READYSHARP ANESTH + KETOROLAC INJECTION KIT 15 & 0.5 & 1 MG/ML-%-% EX Non FDA Exclusion

TORONOVA II SUIK COMBINATION KIT30 MG/ML EX Non FDA Exclusion

TORONOVA SUIK COMBINATION KIT 30 MG/ML EX Non FDA Exclusion

VIMOVO ORAL TABLET DELAYED RELEASE 375-20 MG, 500-20 MG Benefit Exclusion

17

Drug Name Drug Tier NotesZYNRELEF INJECTION SOLUTION 200-6 MG/7ML, 400-12 MG/14ML EX Medical Only Exclusion

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***ANJESO INTRAVENOUS INJECTABLE 30 MG/ML EX

Medical Only Exclusion; Formulary Exclusion

CALDOLOR INTRAVENOUS SOLUTION800 MG/200ML, 800 MG/8ML EX Medical Only Exclusion

CATAFLAM ORAL TABLET 50 MG Tier 1

DAYPRO ORAL TABLET 600 MG EX Formulary Exclusion

dfs dr/ms/menth/cap pak combination kit 75 mg EX Non FDA Exclusion

diclofenac oral capsule 35 mg Benefit Exclusion

diclofenac potassium oral capsule 25 mg Benefit Exclusion Non Essential Drug Exclusion

diclofenac potassium tablet 25 mg oral 25 mg Benefit Exclusion Non Essential Drug Exclusion

diclofenac potassium tablet 50 mg oral 50 mg Tier 1

diclofenac sodium er oral tablet extended release 24 hour 100 mg

Tier 1

diclofenac sodium tablet delayed release 25 mg oral 25 mg

Tier 1


Tier 1


Benefit Exclusion


Tier 1

EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 500 MG EX Formulary Exclusion

ec-naproxen oral tablet delayed release 375 mg, 500 mg

Tier 1

etodolac er oral tablet extended release 24 hour400 mg, 500 mg, 600 mg

Tier 1

etodolac oral capsule 200 mg, 300 mg Tier 1

etodolac oral tablet 400 mg, 500 mg Tier 1

FELDENE ORAL CAPSULE 10 MG, 20 MG EX Formulary Exclusion

fenoprofen calcium oral capsule 200 mg, 400 mg Benefit Exclusion Non Essential Drug Exclusion

fenoprofen calcium oral tablet 600 mg Tier 1

FENORTHO ORAL CAPSULE 200 MG Benefit Exclusion Non Essential Drug Exclusion

flurbiprofen tablet 100 mg oral 100 mg Tier 1



18

Drug Name Drug Tier NotesIBU ORAL TABLET 400 MG, 600 MG, 800 MG Tier 1

IBUPAK ORAL KIT 600 MG Benefit Exclusion

ibuprofen lysine intravenous solution 10 mg/ml EX Medical Only Exclusion

ibuprofen oral suspension 100 mg/5ml Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1

INDOCIN ORAL SUSPENSION 25 MG/5ML Benefit Exclusion Non Essential Drug Exclusion

INDOCIN RECTAL SUPPOSITORY 50 MG Benefit Exclusion Non Essential Drug Exclusion

indomethacin capsule 20 mg oral 20 mg Benefit Exclusion

indomethacin capsule 25 mg oral 25 mg Tier 1

indomethacin capsule 50 mg oral 50 mg Tier 1

indomethacin er oral capsule extended release 75 mg

Tier 1

indomethacin sodium intravenous solution reconstituted 1 mg


ketoprofen capsule 25 mg oral 25 mg Benefit Exclusion

ketoprofen capsule 25 mg oral 25 mg Tier 1



ketoprofen er oral capsule extended release 24 hour 200 mg

Tier 1

ketorolac tromethamine intramuscular solution60 mg/2ml

Tier 1

ketorolac tromethamine nasal solution 15.75 mg/spray

Benefit Exclusion Non Essential Drug Exclusion

ketorolac tromethamine oral tablet 10 mg Tier 1 QL

ketorolac tromethamine solution 15 mg/ml injection 15 mg/ml

Tier 1




Tier 1

LODINE ORAL TABLET 400 MG EX Formulary Exclusion

LOFENA ORAL TABLET 25 MG Benefit Exclusion Non Essential Drug Exclusion

meclofenamate sodium oral capsule 100 mg, 50 mg

Tier 3

mefenamic acid capsule 250 mg oral 250 mg Benefit Exclusion

mefenamic acid capsule 250 mg oral 250 mg Tier 1

meloxicam oral capsule 10 mg, 5 mg Benefit Exclusion

meloxicam tablet 15 mg oral 15 mg Tier 1

meloxicam tablet 15 mg oral 15 mg Benefit Exclusion

19

Drug Name Drug Tier Notesmeloxicam tablet 7.5 mg oral 7.5 mg Benefit Exclusion

meloxicam tablet 7.5 mg oral 7.5 mg Tier 1

MOBIC ORAL TABLET 15 MG, 7.5 MG EX Formulary Exclusion

nabumetone oral tablet 500 mg, 750 mg Tier 1

NALFON ORAL CAPSULE 400 MG Benefit Exclusion Non Essential Drug Exclusion

NALFON ORAL TABLET 600 MG EX Formulary Exclusion

NAPRELAN TABLET EXTENDED RELEASE 24 HOUR 375 MG ORAL 375 MG Benefit Exclusion

NAPRELAN TABLET EXTENDED RELEASE 24 HOUR 500 MG ORAL 500 MG Benefit Exclusion

NAPRELAN TABLET EXTENDED RELEASE 24 HOUR 750 MG ORAL 750 MG Benefit Exclusion Non Essential Drug Exclusion

NAPROSYN ORAL SUSPENSION 125 MG/5ML EX Formulary Exclusion

NAPROSYN ORAL TABLET 500 MG Tier 3

naproxen oral suspension 125 mg/5ml Tier 1

naproxen oral tablet 250 mg, 375 mg, 500 mg Tier 1

naproxen oral tablet delayed release 375 mg, 500 mg

Tier 1

naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg, 750 mg


naproxen sodium oral tablet 275 mg, 550 mg Tier 1

NEOPROFEN INTRAVENOUS SOLUTION10 MG/ML EX Medical Only Exclusion

NUDROXIPAK DSDR-50 COMBINATION KIT 50 MG EX Non FDA Exclusion

NUDROXIPAK DSDR-75 COMBINATION KIT 75 MG EX Non FDA Exclusion

NUDROXIPAK E-400 COMBINATION KIT400 MG EX Non FDA Exclusion

NUDROXIPAK I-800 COMBINATION KIT800 MG EX Non FDA Exclusion

NUDROXIPAK M-15 COMBINATION KIT15 MG EX Non FDA Exclusion

NUDROXIPAK N-500 COMBINATION KIT500 MG EX Non FDA Exclusion

oxaprozin oral tablet 600 mg Tier 1

piroxicam oral capsule 10 mg, 20 mg Tier 1

QMIIZ ODT ORAL TABLET DISPERSIBLE15 MG, 7.5 MG Benefit Exclusion

RELAFEN DS ORAL TABLET 1000 MG Benefit Exclusion

RELAFEN ORAL TABLET 500 MG, 750 MG Benefit Exclusion Non Essential Drug Exclusion

20

Drug Name Drug Tier NotesSPRIX NASAL SOLUTION 15.75 MG/SPRAY Benefit Exclusion Non Essential Drug Exclusion

sulindac oral tablet 150 mg, 200 mg Tier 1

TIVORBEX ORAL CAPSULE 20 MG Benefit Exclusion

tolmetin sodium oral capsule 400 mg Tier 1

tolmetin sodium oral tablet 600 mg Tier 1

VIVLODEX ORAL CAPSULE 10 MG, 5 MG Benefit Exclusion

ZIPSOR ORAL CAPSULE 25 MG Benefit Exclusion Non Essential Drug Exclusion

ZORVOLEX ORAL CAPSULE 18 MG, 35 MG Benefit Exclusion

*Nsaid-Dietary Management Combinations***PRASTERA ORAL KIT 200 & 400 MG EX Non FDA Exclusion

*Phosphodiesterase 4 (Pde4) Inhibitors***OTEZLA ORAL TABLET 30 MG Tier 4 PA; ST; Specialty; QL

OTEZLA ORAL TABLET THERAPY PACK10 & 20 & 30 MG Tier 4 PA; ST; Specialty; QL

*Pyrimidine Synthesis Inhibitors***ARAVA ORAL TABLET 10 MG, 20 MG EX Formulary Exclusion

leflunomide oral tablet 10 mg, 20 mg Tier 1

*Selective Costimulation Modulators***ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML Tier 4 PA; Specialty; QL

ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG EX


ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML


*Soluble Tumor Necrosis Factor Receptor Agents***ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML Tier 4 PA; ST; Specialty; QL

ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML Tier 4 PA; ST; Specialty; QL

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG Tier 4 PA; ST; Specialty; QL

21

Drug Name Drug Tier NotesENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML Tier 4 PA; ST; Specialty; QL

*Analgesics - Nonnarcotic*

*Analgesics Other***acetaminophen intravenous solution 10 mg/ml, 1000 mg/100ml


acetaminophen intravenous solution prefilled syringe 100 mg/10ml


clonidine hcl (analgesia) epidural solution 100 mcg/ml, 500 mcg/ml


DURACLON EPIDURAL SOLUTION 100 MCG/ML EX Medical Only Exclusion

OFIRMEV INTRAVENOUS SOLUTION 10 MG/ML EX Medical Only Exclusion

*Analgesics-Sedatives***ALLZITAL ORAL TABLET 25-325 MG Benefit Exclusion Non Essential Drug Exclusion

BAC ORAL TABLET 50-325-40 MG Tier 1

BUPAP ORAL TABLET 50-300 MG Benefit Exclusion Non Essential Drug Exclusion

butalbital-acetaminophen capsule 50-300 mg oral50-300 mg

Benefit Exclusion

butalbital-acetaminophen capsule 50-300 mg oral50-300 mg


butalbital-acetaminophen tablet 25-325 mg oral25-325 mg





Tier 1

butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 mg

Tier 1

butalbital-apap-caffeine oral tablet 50-325-40 mg Tier 1

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

Tier 1

butalbital-aspirin-caffeine oral tablet 50-325-40 mg

Tier 3

ESGIC ORAL CAPSULE 50-325-40 MG Tier 1

ESGIC ORAL TABLET 50-325-40 MG EX Formulary Exclusion

FIORICET ORAL CAPSULE 50-300-40 MG EX Formulary Exclusion

FIORINAL ORAL CAPSULE 50-325-40 MG EX Formulary Exclusion

TENCON ORAL TABLET 50-325 MG Tier 1

22

Drug Name Drug Tier NotesVANATOL LQ ORAL SOLUTION 50-325-40 MG/15ML Benefit Exclusion Non Essential Drug Exclusion

VANATOL S ORAL SOLUTION 50-325-40 MG/15ML Benefit Exclusion Non Essential Drug Exclusion

VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML Benefit Exclusion Non Essential Drug Exclusion

ZEBUTAL ORAL CAPSULE 50-325-40 MG Tier 1

*Salicylates***adult aspirin ec low strength oral tablet delayed release 81 mg

Tier 5

adult aspirin regimen oral tablet delayed release81 mg

Tier 5

aspirin 81 oral tablet chewable 81 mg Tier 5

aspirin 81 oral tablet delayed release 81 mg Tier 5

aspirin adult low dose oral tablet delayed release81 mg

Tier 5

aspirin adult low strength oral tablet chewable 81 mg

Tier 5

aspirin adult low strength oral tablet delayed release 81 mg

Tier 5

aspirin childrens oral tablet chewable 81 mg Tier 5

aspirin ec adult low strength oral tablet delayed release 81 mg

Tier 5

aspirin ec low dose oral tablet delayed release 81 mg

Tier 5

aspirin ec low strength oral tablet delayed release81 mg

Tier 5

aspirin ec oral tablet delayed release 81 mg Tier 5

aspirin low dose oral tablet chewable 81 mg Tier 5

aspirin low dose oral tablet delayed release 81 mg

Tier 5

aspirin low strength oral tablet chewable 81 mg Tier 5

aspirin oral tablet chewable 81 mg Tier 5

aspirin oral tablet delayed release 81 mg Tier 5

ASPIR-LOW ORAL TABLET DELAYED RELEASE 81 MG Tier 5

BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG Tier 5

BAYER LOW DOSE ORAL TABLET CHEWABLE 81 MG Tier 5

BAYER LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG Tier 5

23

Drug Name Drug Tier Noteschildrens aspirin low strength oral tablet chewable 81 mg

Tier 5

childrens aspirin oral tablet chewable 81 mg Tier 5

cvs aspirin adult low dose oral tablet chewable81 mg

Tier 5

cvs aspirin adult low strength oral tablet delayed release 81 mg

Tier 5

cvs aspirin ec oral tablet delayed release 81 mg Tier 5

cvs aspirin low dose oral tablet delayed release81 mg

Tier 5

cvs aspirin low strength oral tablet delayed release 81 mg

Tier 5

diflunisal oral tablet 500 mg Tier 1

ECOTRIN LOW STRENGTH ORAL TABLET DELAYED RELEASE 81 MG Tier 5

eq aspirin adult low dose oral tablet delayed release 81 mg

Tier 5

eq aspirin low dose oral tablet chewable 81 mg Tier 5

eql aspirin low dose oral tablet chewable 81 mg Tier 5

eql aspirin low dose oral tablet delayed release81 mg

Tier 5

gnp adult aspirin low strength oral tablet chewable 81 mg

Tier 5

gnp aspirin low dose oral tablet delayed release81 mg

Tier 5

gnp aspirin oral tablet delayed release 81 mg Tier 5

goodsense aspirin adult low st oral tablet chewable 81 mg

Tier 5

goodsense aspirin low dose oral tablet delayed release 81 mg

Tier 5

goodsense aspirin oral tablet chewable 81 mg Tier 5

h-e-b aspirin oral tablet delayed release 81 mg Tier 5

hm aspirin ec low dose oral tablet delayed release81 mg

Tier 5

hm aspirin oral tablet chewable 81 mg Tier 5

kls aspirin low dose oral tablet delayed release 81 mg

Tier 5

kp aspirin oral tablet delayed release 81 mg Tier 5

MINIPRIN LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG Tier 5

px aspirin oral tablet chewable 81 mg Tier 5

24

Drug Name Drug Tier Notespx enteric aspirin oral tablet delayed release 81 mg

Tier 5

qc aspirin low dose oral tablet chewable 81 mg Tier 5

qc aspirin low dose oral tablet delayed release 81 mg

Tier 5

qc childrens aspirin oral tablet chewable 81 mg Tier 5

ra aspirin adult low dose oral tablet chewable 81 mg

Tier 5

ra aspirin adult low strength oral tablet chewable81 mg

Tier 5

ra aspirin childrens oral tablet chewable 81 mg Tier 5

ra aspirin ec adult low st oral tablet delayed release 81 mg

Tier 5

ra aspirin ec oral tablet delayed release 81 mg Tier 5

salsalate tablet 500 mg oral 500 mg EX Formulary Exclusion

salsalate tablet 750 mg oral 750 mg Tier 1

salsalate tablet 750 mg oral 750 mg EX Formulary Exclusion

sb aspirin adult low strength oral tablet delayed release 81 mg

Tier 5

sb aspirin oral tablet delayed release 81 mg Tier 5

sb childrens aspirin oral tablet chewable 81 mg Tier 5

sb low dose asa ec oral tablet delayed release 81 mg

Tier 5

sm aspirin adult low strength oral tablet chewable 81 mg

Tier 5

sm aspirin adult low strength oral tablet delayed release 81 mg

Tier 5

sm aspirin ec low strength oral tablet delayed release 81 mg

Tier 5

sm aspirin low dose oral tablet chewable 81 mg Tier 5

sm aspirin low dose oral tablet delayed release 81 mg

Tier 5

sm childrens aspirin oral tablet chewable 81 mg Tier 5

ST JOSEPH ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG Tier 5

ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE 81 MG Tier 5

ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE 81 MG Tier 5

tgt aspirin low dose oral tablet delayed release 81 mg

Tier 5

tgt aspirin oral tablet chewable 81 mg Tier 5

25

Drug Name Drug Tier Notestgt aspirin oral tablet delayed release 81 mg Tier 5

tgt childrens aspirin oral tablet chewable 81 mg Tier 5

*Selective N-Type Neuronal Calcium Channel Blockers***PRIALT INTRATHECAL SOLUTION 100 MCG/ML, 500 MCG/20ML, 500 MCG/5ML EX Medical Only Exclusion

*Analgesics - Opioid*

*Codeine Combinations***acetaminophen-codeine #2 oral tablet 300-15 mg Tier 1

acetaminophen-codeine #3 oral tablet 300-30 mg Tier 1

acetaminophen-codeine #4 oral tablet 300-60 mg Tier 1

acetaminophen-codeine oral solution 120-12 mg/5ml

Tier 1

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg

Tier 1

ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG Tier 1

butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg

Tier 1

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

Tier 1

FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG EX Formulary Exclusion

FIORINAL/CODEINE #3 ORAL CAPSULE50-325-40-30 MG EX Formulary Exclusion

TYLENOL WITH CODEINE #3 ORAL TABLET 300-30 MG EX Formulary Exclusion

TYLENOL WITH CODEINE #4 ORAL TABLET 300-60 MG EX Formulary Exclusion

*Dihydrocodeine Combinations***apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg

Tier 1

apap-caff-dihydrocodeine oral tablet 325-30-16 mg


DVORAH ORAL TABLET 325-30-16 MG Benefit Exclusion Non Essential Drug Exclusion

TREZIX ORAL CAPSULE 320.5-30-16 MG Tier 3

*Fentanyl Combinations***fentanyl cit-ropivacaine-nacl epidural solution prefilled syringe 0.1-0.125-0.9 mg/50ml-%, 0.1-0.2-0.9 mg/50ml-%

EX Opioid Brochure

26

Drug Name Drug Tier Notesfentanyl cit-ropivacaine-nacl solution 0.2-0.1-0.9 mg/100ml-% epidural 0.2-0.1-0.9 mg/100ml-%


fentanyl cit-ropivacaine-nacl solution 0.2-0.125-0.9 mg/100ml-% epidural 0.2-0.125-0.9 mg/100ml-%



EX Non FDA Exclusion; Medical Only Exclusion









fentanyl-bupivacaine-nacl epidural solution prefilled syringe 0.1-0.125-0.9 mg/50ml-%

EX Opioid Brochure

fentanyl-bupivacaine-nacl injection solution 2-0.125-0.9 mcg/ml-%-%


fentanyl-bupivacaine-nacl solution 0.2-0.1-0.9 mg/100ml-% epidural 0.2-0.1-0.9 mg/100ml-%












*Hydrocodone Combinations***hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

Tier 1

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

Tier 1

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

Tier 1

LORCET HD ORAL TABLET 10-325 MG Tier 1

LORCET ORAL TABLET 5-325 MG Tier 1

27

Drug Name Drug Tier NotesLORCET PLUS ORAL TABLET 7.5-325 MG Tier 1

LORTAB ORAL ELIXIR 10-300 MG/15ML Tier 3

NORCO ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG EX Formulary Exclusion

*Opioid Agonists***ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 400 MCG, 600 MCG, 800 MCG

Tier 3 PA; Opioid Brochure; QL

ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

EX PA; Opioid Brochure; QL

alfentanil hcl intravenous solution 1000 mcg/2ml, 2500 mcg/5ml


ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG, 30 MG, 60 MG

EX Opioid Brochure

codeine sulfate tablet 15 mg oral 15 mg Tier 1 Opioid Brochure

codeine sulfate tablet 30 mg oral 30 mg EX Opioid Brochure



CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

Tier 3 Opioid Brochure

DEMEROL SOLUTION 100 MG/2ML INJECTION 100 MG/2ML Tier 3 Opioid Brochure

DEMEROL SOLUTION 100 MG/ML INJECTION 100 MG/ML EX Medical Only Exclusion

DEMEROL SOLUTION 25 MG/0.5ML INJECTION 25 MG/0.5ML Tier 3 Opioid Brochure



DEMEROL SOLUTION 75 MG/1.5ML INJECTION 75 MG/1.5ML Tier 3 Opioid Brochure


DILAUDID INJECTION SOLUTION 0.2 MG/ML, 1 MG/ML, 2 MG/ML EX


DILAUDID ORAL LIQUID 1 MG/ML EX Opioid Brochure

DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG EX Opioid Brochure

DOLOPHINE ORAL TABLET 10 MG, 5 MG Tier 3 Opioid Brochure

28

Drug Name Drug Tier NotesDSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 MCG EX Opioid Brochure

DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR 100 MCG/HR Tier 3 Opioid Brochure





duramorph injection solution 0.5 mg/ml, 1 mg/ml EX Medical Only Exclusion

EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG


EXALGO ORAL TABLET EXTENDED RELEASE 24 HOUR 12 MG, 16 MG, 32 MG, 8 MG


fentanyl citrate (pf) injection solution cartridge100 mcg/2ml

EX Opioid Brochure

fentanyl citrate (pf) solution 100 mcg/2ml injection 100 mcg/2ml

EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure

fentanyl citrate (pf) solution 50 mcg/ml injection50 mcg/ml

EX Opioid Brochure

fentanyl citrate (pf) solution 50 mcg/ml injection50 mcg/ml



EX Opioid Brochure

fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg


fentanyl citrate buccal tablet 100 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg


fentanyl citrate injection solution 1500 mcg/30ml EX Opioid Brochure

fentanyl citrate pf injection solution prefilled syringe 50 mcg/ml

EX Opioid Brochure

29

Drug Name Drug Tier Notesfentanyl citrate solution 1000 mcg/100ml intravenous 1000 mcg/100ml


fentanyl citrate solution 1000 mcg/50ml intravenous 1000 mcg/50ml



EX Opioid Brochure






EX Opioid Brochure


EX Non FDA Exclusion; Medical Only Exclusion; Opioid Brochure


EX Opioid Brochure

fentanyl citrate solution prefilled syringe 10 mcg/ml intravenous 10 mcg/ml


fentanyl citrate solution prefilled syringe 100 mcg/10ml intravenous 100 mcg/10ml

EX Opioid Brochure

fentanyl citrate solution prefilled syringe 100 mcg/2ml injection 100 mcg/2ml



EX Opioid Brochure




EX Opioid Brochure




EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure




EX Opioid Brochure




EX Opioid Brochure

30

Drug Name Drug Tier Notesfentanyl citrate solution prefilled syringe 50 mcg/5ml injection 50 mcg/5ml

EX Opioid Brochure


EX Opioid Brochure

fentanyl citrate solution prefilled syringe 50 mcg/ml injection 50 mcg/ml

EX Opioid Brochure

fentanyl citrate solution prefilled syringe 50 mcg/ml intravenous 50 mcg/ml



EX Opioid Brochure

fentanyl citrate-nacl epidural solution 1-0.9 mg/250ml-%

EX Opioid Brochure

fentanyl citrate-nacl injection solution 1-0.9 mg/100ml-%, 2.5-0.9 mg/250ml-%

EX Opioid Brochure

fentanyl citrate-nacl solution 1.25-0.9 mg/250ml-% intravenous 1.25-0.9 mg/250ml-%

EX Opioid Brochure

fentanyl citrate-nacl solution 1-0.9 mg/100ml-% intravenous 1-0.9 mg/100ml-%

EX Opioid Brochure


EX Opioid Brochure




EX Opioid Brochure

fentanyl citrate-nacl solution 250-0.9 mcg/50ml-% intravenous 250-0.9 mcg/50ml-%

EX Opioid Brochure


EX Opioid Brochure

fentanyl citrate-nacl solution prefilled syringe 10-0.9 mcg/2ml-% intravenous 10-0.9 mcg/2ml-%

EX Opioid Brochure

fentanyl citrate-nacl solution prefilled syringe 10-0.9 mcg/ml-% intravenous 10-0.9 mcg/ml-%

EX Opioid Brochure




EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure

31

Drug Name Drug Tier Notesfentanyl citrate-nacl solution prefilled syringe 50-0.9 mcg/5ml-% intravenous 50-0.9 mcg/5ml-%

EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure

fentanyl patch 72 hour 100 mcg/hr transdermal100 mcg/hr

Tier 1

fentanyl patch 72 hour 100 mcg/hr transdermal100 mcg/hr


fentanyl patch 72 hour 12 mcg/hr transdermal 12 mcg/hr

Tier 1





fentanyl patch 72 hour 37.5 mcg/hr transdermal37.5 mcg/hr










FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Tier 3 PA; Opioid Brochure; QL

hydrocodone bitartrate er oral capsule extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg


hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg


hydromorphone hcl er oral tablet extended release 24 hour 12 mg, 16 mg, 32 mg, 8 mg


hydromorphone hcl oral liquid 1 mg/ml Tier 1 Opioid Brochure

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg Tier 1 Opioid Brochure

hydromorphone hcl pf solution 1 mg/ml injection1 mg/ml

EX Medical Only Exclusion; Formulary Exclusion



32

Drug Name Drug Tier Noteshydromorphone hcl pf solution 2 mg/ml injection2 mg/ml






hydromorphone hcl pf solution 50 mg/5ml injection 50 mg/5ml


hydromorphone hcl pf solution 500 mg/50ml injection 500 mg/50ml


hydromorphone hcl rectal suppository 3 mg EX Opioid Brochure

hydromorphone hcl solution 0.2 mg/ml injection0.2 mg/ml


hydromorphone hcl solution 0.2 mg/ml intravenous 0.2 mg/ml

EX Opioid Brochure

hydromorphone hcl solution 0.2 mg/ml intravenous 0.2 mg/ml

EX Non FDA Exclusion; Opioid Brochure

hydromorphone hcl solution 0.5 mg/ml injection0.5 mg/ml


hydromorphone hcl solution 1 mg/ml injection 1 mg/ml




hydromorphone hcl solution 1 mg/ml intravenous1 mg/ml










hydromorphone hcl-nacl injection solution 20-0.9 mg/100ml-%

EX Opioid Brochure

hydromorphone hcl-nacl injection solution prefilled syringe 10-0.9 mg/50ml-%, 30-0.9 mg/30ml-%

EX Opioid Brochure

33

Drug Name Drug Tier Noteshydromorphone hcl-nacl intravenous solution prefilled syringe 0.2-0.9 mg/0.2ml-%, 0.4-0.9 mg/2ml-%, 0.5-0.9 mg/0.5ml-%, 0.5-0.9 mg/ml-%, 1-0.9 mg/5ml-%, 1-0.9 mg/ml-%, 10-0.9 mg/25ml-%, 10-0.9 mg/50ml-%, 12-0.9 mg/30ml-%, 12-0.9 mg/60ml-%, 12.5-0.9 mg/25ml-%, 15-0.9 mg/30ml-%, 15-0.9 mg/50ml-%, 2-0.9 mg/10ml-%, 2-0.9 mg/ml-%, 2.5-0.9 mg/25ml-%, 20-0.9 mg/50ml-%, 25-0.9 mg/25ml-%, 25-0.9 mg/50ml-%, 3-0.9 mg/30ml-%, 30-0.9 mg/30ml-%, 5-0.9 mg/25ml-%, 50-0.9 mg/50ml-%, 55-0.9 mg/55ml-%, 6-0.9 mg/30ml-%

EX Opioid Brochure

hydromorphone hcl-nacl solution 10-0.9 mg/100ml-% intravenous 10-0.9 mg/100ml-%

EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure




EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure

34

Drug Name Drug Tier Noteshydromorphone hcl-nacl solution 3-0.9 mg/30ml-% intravenous 3-0.9 mg/30ml-%

EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure

HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

EX Opioid Brochure

INFUMORPH 200 INJECTION SOLUTION200 MG/20ML (10 MG/ML) EX Medical Only Exclusion

INFUMORPH 500 INJECTION SOLUTION500 MG/20ML (25 MG/ML) EX Medical Only Exclusion

IONSYS TRANSDERMAL PATCH 40 MCG/ACT EX Opioid Brochure

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG


LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT Tier 3 PA; Opioid Brochure; QL

levorphanol tartrate tablet 2 mg oral 2 mg Benefit Exclusion

levorphanol tartrate tablet 2 mg oral 2 mg Benefit Exclusion Opioid Brochure

levorphanol tartrate tablet 3 mg oral 3 mg Benefit Exclusion Opioid Brochure

35

Drug Name Drug Tier Notesmeperidine hcl oral solution 50 mg/5ml EX Opioid Brochure

meperidine hcl solution 10 mg/ml injection 10 mg/ml








meperidine hcl tablet 100 mg oral 100 mg Tier 1 Opioid Brochure

meperidine hcl tablet 50 mg oral 50 mg EX Opioid Brochure

meperidine hcl tablet 50 mg oral 50 mg Tier 1 Opioid Brochure

meperidine hcl-sodium chloride intravenous solution 1000-0.9 mg/100ml-%, 300-0.9 mg/30ml-%, 500-0.9 mg/50ml-%

EX Opioid Brochure

methadone hcl concentrate 10 mg/ml oral 10 mg/ml

Tier 1

methadone hcl concentrate 10 mg/ml oral 10 mg/ml


methadone hcl injection solution 10 mg/ml EX Medical Only Exclusion

METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML Tier 1 Opioid Brochure

methadone hcl oral tablet soluble 40 mg Tier 1 Opioid Brochure

methadone hcl solution 10 mg/5ml oral 10 mg/5ml

Tier 1


EX Opioid Brochure



methadone hcl solution 5 mg/5ml oral 5 mg/5ml Tier 1

methadone hcl solution 5 mg/5ml oral 5 mg/5ml EX Opioid Brochure

methadone hcl solution 5 mg/5ml oral 5 mg/5ml Tier 1 Opioid Brochure

methadone hcl tablet 10 mg oral 10 mg Tier 1 Opioid Brochure

methadone hcl tablet 5 mg oral 5 mg Tier 1

methadone hcl tablet 5 mg oral 5 mg Tier 1 Opioid Brochure

methadone hcl-nacl intravenous solution prefilled syringe 1-0.9 mg/ml-%

EX Opioid Brochure

methadone hcl-sodium chloride intravenous solution prefilled syringe 1-0.9 mg/ml-%


METHADOSE ORAL CONCENTRATE 10 MG/ML EX Opioid Brochure

36

Drug Name Drug Tier NotesMETHADOSE ORAL TABLET SOLUBLE40 MG Tier 1 Opioid Brochure

METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 MG/ML EX Opioid Brochure

MITIGO INJECTION SOLUTION 200 MG/20ML (10 MG/ML), 500 MG/20ML (25 MG/ML)


MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 100 MG, 15 MG, 30 MG, 60 MG

EX Opioid Brochure

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml


morphine sulfate (pf) solution 0.5 mg/ml injection0.5 mg/ml


morphine sulfate (pf) solution 1 mg/ml injection 1 mg/ml


morphine sulfate (pf) solution 1 mg/ml intravenous 1 mg/ml


morphine sulfate (pf) solution 10 mg/ml injection10 mg/ml


















morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg


morphine sulfate er capsule extended release 24 hour 10 mg oral 10 mg




37

Drug Name Drug Tier Notesmorphine sulfate er capsule extended release 24 hour 20 mg oral 20 mg












morphine sulfate er oral tablet extended release100 mg, 15 mg, 200 mg, 30 mg, 60 mg


morphine sulfate in dextrose intravenous solution100-5 mg/100ml-%, 250-5 mg/250ml-%

EX Opioid Brochure

morphine sulfate in dextrose intravenous solution prefilled syringe 50-5 mg/25ml-%

EX Opioid Brochure

morphine sulfate intramuscular device 10 mg/0.7ml


morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml


morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg

EX Opioid Brochure

morphine sulfate solution 0.5 mg/ml intravenous0.5 mg/ml

EX Opioid Brochure

morphine sulfate solution 1 mg/ml injection 1 mg/ml

EX Opioid Brochure



morphine sulfate solution 1 mg/ml intravenous 1 mg/ml






morphine sulfate solution 10 mg/ml intravenous10 mg/ml


morphine sulfate solution 150 mg/30ml intravenous 150 mg/30ml






38

Drug Name Drug Tier Notesmorphine sulfate solution 4 mg/ml injection 4 mg/ml







EX Opioid Brochure





morphine sulfate tablet 15 mg oral 15 mg Tier 1 Opioid Brochure



morphine sulfate-nacl injection solution prefilled syringe 5-0.9 mg/5ml-%

EX Opioid Brochure

morphine sulfate-nacl solution 1-0.9 mg/ml-% intravenous 1-0.9 mg/ml-%

EX Opioid Brochure

morphine sulfate-nacl solution 1-0.9 mg/ml-% intravenous 1-0.9 mg/ml-%


morphine sulfate-nacl solution 100-0.9 mg/100ml-% intravenous 100-0.9 mg/100ml-%

EX Opioid Brochure




EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure




EX Opioid Brochure


EX Opioid Brochure

morphine sulfate-nacl solution prefilled syringe 0.5-0.9 mg/ml-% intravenous 0.5-0.9 mg/ml-%

EX Opioid Brochure

morphine sulfate-nacl solution prefilled syringe 1-0.9 mg/ml-% intravenous 1-0.9 mg/ml-%

EX Opioid Brochure

39

Drug Name Drug Tier Notesmorphine sulfate-nacl solution prefilled syringe 150-0.9 mg/30ml-% intravenous 150-0.9 mg/30ml-%

EX Opioid Brochure

morphine sulfate-nacl solution prefilled syringe 2-0.9 mg/2ml-% intravenous 2-0.9 mg/2ml-%

EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure






EX Opioid Brochure


EX Opioid Brochure


EX Opioid Brochure




EX Opioid Brochure


EX Opioid Brochure

MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 15 MG, 200 MG, 30 MG, 60 MG

EX Opioid Brochure

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG


NUCYNTA TABLET 100 MG ORAL 100 MG Tier 3 Opioid Brochure




40

Drug Name Drug Tier NotesNUCYNTA TABLET 75 MG ORAL 75 MG Tier 3 Opioid Brochure


OLINVYK INTRAVENOUS SOLUTION 1 MG/ML, 2 MG/2ML, 30 MG/30ML EX Opioid Brochure

OPANA ORAL TABLET 10 MG, 5 MG Tier 3 Opioid Brochure

OXAYDO ORAL TABLET 5 MG, 7.5 MG Tier 3 Opioid Brochure

oxycodone hcl er tablet er 12 hour abuse-deterrent 10 mg oral 10 mg






















oxycodone hcl oral capsule 5 mg Tier 1 Opioid Brochure

oxycodone hcl oral concentrate 100 mg/5ml Tier 1 Opioid Brochure

oxycodone hcl oral solution 5 mg/5ml Tier 1 Opioid Brochure

oxycodone hcl tablet 10 mg oral 10 mg Tier 1 Opioid Brochure

oxycodone hcl tablet 15 mg oral 15 mg Tier 1



oxycodone hcl tablet 30 mg oral 30 mg Tier 1



OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG


41

Drug Name Drug Tier Notesoxymorphone hcl er tablet extended release 12 hour 10 mg oral 10 mg


oxymorphone hcl er tablet extended release 12 hour 10 mg oral 10 mg

EX Opioid Brochure




EX Opioid Brochure




EX Opioid Brochure




EX Opioid Brochure


EX Opioid Brochure






EX Opioid Brochure

oxymorphone hcl er tablet extended release 12 hour 7.5 mg oral 7.5 mg


oxymorphone hcl er tablet extended release 12 hour 7.5 mg oral 7.5 mg

EX Opioid Brochure

oxymorphone hcl tablet 10 mg oral 10 mg Tier 1

oxymorphone hcl tablet 10 mg oral 10 mg Tier 1 Opioid Brochure

oxymorphone hcl tablet 5 mg oral 5 mg Tier 1

oxymorphone hcl tablet 5 mg oral 5 mg Tier 1 Opioid Brochure

QDOLO ORAL SOLUTION 5 MG/ML Tier 3 Opioid Brochure

remifentanil hcl solution reconstituted 1 mg intravenous 1 mg

EX Opioid Brochure


EX Medical Only Exclusion; Opioid Brochure


EX Opioid Brochure




EX Opioid Brochure

42

Drug Name Drug Tier Notesremifentanil hcl-nacl intravenous solution prefilled syringe 100-0.9 mcg/2ml-%

EX Opioid Brochure

ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG EX Opioid Brochure

ROXYBOND ORAL TABLET ABUSE-DETERRENT 15 MG, 30 MG, 5 MG EX New to Market Exclusion

SUBSYS LIQUID 100 MCG SUBLINGUAL100 MCG Tier 3 PA; Opioid Brochure; QL

SUBSYS LIQUID 1200 (600 X 2) MCG SUBLINGUAL 1200 (600 X 2) MCG Tier 3 PA; Opioid Brochure; QL

SUBSYS LIQUID 1600 (800 X 2) MCG SUBLINGUAL 1600 (800 X 2) MCG Tier 3 PA; Opioid Brochure; QL


SUBSYS LIQUID 400 MCG SUBLINGUAL400 MCG Tier 3 PA; QL


SUBSYS LIQUID 600 MCG SUBLINGUAL600 MCG Tier 3 PA; QL



sufentanil citrate intravenous solution 100 mcg/2ml, 250 mcg/5ml, 50 mcg/ml


SYNAPRYN FUSEPAQ ORAL SUSPENSION RECONSTITUTED 10 MG/ML EX Opioid Brochure

tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg


tramadol hcl er oral capsule extended release 24 hour 100 mg, 150 mg, 200 mg, 300 mg


tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg


tramadol hcl oral tablet 100 mg, 50 mg Tier 1 Opioid Brochure

tramadol hcl solution 5 mg/ml oral 5 mg/ml Benefit Exclusion

tramadol hcl solution 5 mg/ml oral 5 mg/ml Tier 3 Opioid Brochure

ULTIVA INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG EX Opioid Brochure

ULTRAM ORAL TABLET 50 MG EX Opioid Brochure

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG


43

Drug Name Drug Tier NotesZOHYDRO ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG

EX Opioid Brochure

*Opioid Combinations***APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16-325 MG Tier 3 Opioid Brochure

benzhydrocodone-acetaminophen oral tablet4.08-325 mg, 6.12-325 mg, 8.16-325 mg


ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG Tier 1 Opioid Brochure

nalocet oral tablet 2.5-300 mg Tier 1 Opioid Brochure

oxycodone-acetaminophen solution 10-300 mg/5ml oral 10-300 mg/5ml


oxycodone-acetaminophen solution 5-325 mg/5ml oral 5-325 mg/5ml

Tier 3

oxycodone-acetaminophen tablet 10-300 mg oral10-300 mg



Tier 1



oxycodone-acetaminophen tablet 2.5-300 mg oral2.5-300 mg



Tier 1






Tier 1




Tier 3Non Essential Drug Exclusion; Opioid Brochure


Tier 1



oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 Opioid Brochure

oxycodone-ibuprofen oral tablet 5-400 mg Tier 1 Opioid Brochure

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG EX Opioid Brochure

44

Drug Name Drug Tier NotesPRIMLEV TABLET 10-300 MG ORAL 10-300 MG Tier 1 Opioid Brochure

PRIMLEV TABLET 5-300 MG ORAL 5-300 MG Tier 1 Opioid Brochure

PRIMLEV TABLET 7.5-300 MG ORAL 7.5-300 MG Tier 3 Opioid Brochure

PROLATE ORAL SOLUTION 10-300 MG/5ML Tier 3 Opioid Brochure

PROLATE TABLET 10-300 MG ORAL 10-300 MG Tier 1 Opioid Brochure

PROLATE TABLET 5-300 MG ORAL 5-300 MG Tier 1 Opioid Brochure

PROLATE TABLET 7.5-300 MG ORAL 7.5-300 MG Tier 3 Opioid Brochure

*Opioid Partial Agonists***BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG


BUNAVAIL FILM 2.1-0.3 MG BUCCAL 2.1-0.3 MG Tier 3 Opioid Brochure

BUNAVAIL FILM 4.2-0.7 MG BUCCAL 4.2-0.7 MG EX Opioid Brochure; QL

BUNAVAIL FILM 6.3-1 MG BUCCAL 6.3-1 MG Tier 3 Opioid Brochure

BUPRENEX INJECTION SOLUTION 0.3 MG/ML EX Medical Only Exclusion

buprenorphine hcl injection solution 0.3 mg/ml EX Medical Only Exclusion

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg


buprenorphine hcl-naloxone hcl sublingual film12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg

Tier 1 QL

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg

Tier 1 QL

buprenorphine patch weekly 10 mcg/hr transdermal 10 mcg/hr

EX Opioid Brochure


EX Formulary Exclusion; Opioid Brochure


EX Opioid Brochure




EX Opioid Brochure

45

Drug Name Drug Tier Notesbuprenorphine patch weekly 20 mcg/hr transdermal 20 mcg/hr



EX Opioid Brochure



buprenorphine patch weekly 7.5 mcg/hr transdermal 7.5 mcg/hr


buprenorphine patch weekly 7.5 mcg/hr transdermal 7.5 mcg/hr

EX Opioid Brochure

butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml

EX Opioid Brochure

butorphanol tartrate nasal solution 10 mg/ml Tier 1 Opioid Brochure

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR

EX Opioid Brochure

nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml

EX Opioid Brochure

pentazocine-naloxone hcl oral tablet 50-0.5 mg EX Formulary Exclusion

PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 74.2 MG EX Opioid Brochure

SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML


SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG EX Opioid Brochure; QL

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

Tier 3 Opioid Brochure; QL

*Tramadol Combinations***

SEGLENTIS ORAL TABLET 56-44 MG Benefit ExclusionNon Essential Drug Exclusion; Formulary Exclusion

tramadol-acetaminophen oral tablet 37.5-325 mg Tier 1

ULTRACET ORAL TABLET 37.5-325 MG EX Formulary Exclusion

*Androgens-Anabolic*

*Anabolic Steroids***ANADROL-50 ORAL TABLET 50 MG Tier 3

oxandrolone oral tablet 10 mg, 2.5 mg Tier 1

*Androgens***ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR Tier 3 PA; ST

46

Drug Name Drug Tier NotesANDROGEL PUMP TRANSDERMAL GEL20.25 MG/ACT (1.62%) EX PA; ST; Formulary Exclusion

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

EX PA; ST; Formulary Exclusion

AVEED INTRAMUSCULAR SOLUTION 750 MG/3ML Tier 4 PA; ST; Specialty

danazol oral capsule 100 mg, 200 mg, 50 mg Tier 1

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML

EX PA; ST; Formulary Exclusion

ec-rx testosterone transdermal cream 0.2 %, 0.4 %, 10 %, 20 %


FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%) EX PA; ST; Formulary Exclusion

JATENZO ORAL CAPSULE 158 MG, 198 MG, 237 MG Tier 3 PA; ST; QL

methitest oral tablet 10 mg Tier 3

methyltestosterone oral capsule 10 mg Tier 1

NATESTO NASAL GEL 5.5 MG/ACT Tier 3 PA; ST

TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) EX PA; ST; Formulary Exclusion

TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML EX Non FDA Exclusion

TESTOPEL IMPLANT PELLET 75 MG Tier 3 PA; ST

testosterone cypionate injection solution 200 mg/ml


testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

Tier 1 PA

testosterone enanthate intramuscular solution200 mg/ml

Tier 1 PA

testosterone implant pellet 100 mg, 200 mg, 25 mg, 50 mg


testosterone solution 30 mg/act transdermal 30 mg/act

Benefit Exclusion PA; ST

testosterone solution 30 mg/act transdermal 30 mg/act

Tier 1 PA

testosterone transdermal gel 1.62 %, 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

Tier 1 PA

TLANDO ORAL CAPSULE 112.5 MG EX New to Market Exclusion

47

Drug Name Drug Tier NotesVOGELXO PUMP TRANSDERMAL GEL12.5 MG/ACT (1%) Tier 3 PA; ST

VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) Tier 3 PA; ST

XYOSTED SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML

Tier 3 PA; ST

*Anorectal And Related Products*

*Intrarectal Steroids***COLOCORT RECTAL ENEMA 100 MG/60ML Tier 1

CORTENEMA RECTAL ENEMA 100 MG/60ML EX Formulary Exclusion

CORTIFOAM EXTERNAL FOAM 10 % Tier 2

hydrocortisone rectal enema 100 mg/60ml Tier 1

UCERIS RECTAL FOAM 2 MG/ACT Tier 3

*Nitrate Vasodilating Agents***RECTIV RECTAL OINTMENT 0.4 % Tier 3

*Rectal Anesthetic/Steroids***ANA-LEX RECTAL KIT 2-2 % EX Non FDA Exclusion

ANALPRAM HC EXTERNAL CREAM 2.5-1 % EX Formulary Exclusion

ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % EX Formulary Exclusion

ANALPRAM-HC EXTERNAL CREAM 1-1 % EX Formulary Exclusion

ANALPRAM-HC EXTERNAL LOTION 2.5-1 % Tier 3

hydrocortisone ace-pramoxine external cream 1-1 %

Tier 1

hydrocortisone ace-pramoxine rectal suppository25-18 mg


hydrocort-pramoxine (perianal) external cream2.5-1 %


lidocaine-hydrocort (perianal) cream 3-0.5 % external 3-0.5 %

Benefit Exclusion

lidocaine-hydrocort (perianal) cream 3-0.5 % external 3-0.5 %


lidocaine-hydrocortisone ace kit 2-2 % rectal 2-2 %

Benefit Exclusion

lidocaine-hydrocortisone ace kit 3-0.5 % rectal 3-0.5 %

Benefit Exclusion

48

Drug Name Drug Tier Noteslidocaine-hydrocortisone ace kit 3-0.5 % rectal 3-0.5 %


lidocaine-hydrocortisone ace kit 3-1 % rectal 3-1 %

Benefit Exclusion


Benefit Exclusion



lidocaine-hydrocortisone ace rectal gel 2.8-0.55 %

Benefit Exclusion

LIDOCORT EXTERNAL CREAM 3-0.5 % Benefit Exclusion

PROCORT EXTERNAL CREAM 1.85-1.15 % EX Formulary Exclusion

PROCTOFOAM HC EXTERNAL FOAM 1-1 % Tier 3

*Rectal Local Anesthetics***lidocaine (anorectal) rectal suppository 50 mg EX Non FDA Exclusion

*Rectal Steroids***anucort-hc rectal suppository 25 mg Tier 1

ANUSOL-HC EXTERNAL CREAM 2.5 % EX Formulary Exclusion

ANUSOL-HC RECTAL SUPPOSITORY 25 MG Tier 1

HEMMOREX-HC RECTAL SUPPOSITORY25 MG, 30 MG Tier 1

hydrocortisone (perianal) external cream 1 %, 2.5 %

Tier 1

hydrocortisone acetate suppository 25 mg rectal25 mg



Tier 1




Tier 1



PROCTOCORT EXTERNAL CREAM 1 % EX Formulary Exclusion

PROCTOCORT RECTAL SUPPOSITORY30 MG EX Formulary Exclusion

PROCTO-MED HC EXTERNAL CREAM 2.5 % Tier 1

PROCTO-PAK EXTERNAL CREAM 1 % Tier 1

49

Drug Name Drug Tier NotesPROCTOSOL HC EXTERNAL CREAM 2.5 % Tier 1

PROCTOZONE-HC EXTERNAL CREAM2.5 % Tier 1

*Antacids*

*Antacids - Bicarbonate***sodium bicarbonate oral powder EX Formulary Exclusion

*Anthelmintics*

*Anthelmintics***albendazole oral tablet 200 mg Tier 1

ALBENZA ORAL TABLET 200 MG EX Formulary Exclusion

benznidazole oral tablet 100 mg, 12.5 mg Tier 2

BILTRICIDE ORAL TABLET 600 MG EX Formulary Exclusion

EMVERM ORAL TABLET CHEWABLE 100 MG Tier 3

ivermectin oral tablet 3 mg Tier 1 PA; Quantity Limit Criteria; QL

praziquantel oral tablet 600 mg Tier 1

STROMECTOL ORAL TABLET 3 MG EX PA; Formulary Exclusion; Quantity Limit Criteria; QL

*Antianginal Agents*

*Antianginals-Other***RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG EX Formulary Exclusion

ranolazine er oral tablet extended release 12 hour1000 mg, 500 mg

Tier 1

*Nitrates***DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG Tier 3

GONITRO SUBLINGUAL PACKET 400 MCG Tier 3

ISORDIL TITRADOSE TABLET 40 MG ORAL 40 MG Benefit Exclusion

ISORDIL TITRADOSE TABLET 5 MG ORAL 5 MG EX Formulary Exclusion

isosorbide dinitrate tablet 10 mg oral 10 mg Tier 1



isosorbide dinitrate tablet 40 mg oral 40 mg Benefit Exclusion Non Essential Drug Exclusion


50

Drug Name Drug Tier Notesisosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

Tier 1

isosorbide mononitrate oral tablet 10 mg, 20 mg Tier 1

MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

Tier 1

NITRO-BID TRANSDERMAL OINTMENT 2 % Tier 3

NITRO-DUR PATCH 24 HOUR 0.1 MG/HR TRANSDERMAL 0.1 MG/HR EX Formulary Exclusion


NITRO-DUR PATCH 24 HOUR 0.3 MG/HR TRANSDERMAL 0.3 MG/HR Tier 3



NITRO-DUR PATCH 24 HOUR 0.8 MG/HR TRANSDERMAL 0.8 MG/HR Tier 3

nitroglycerin in d5w intravenous solution 100-5 mcg/ml-%, 200-5 mcg/ml-%, 400-5 mcg/ml-%


nitroglycerin intravenous solution 5 mg/ml EX Medical Only Exclusion

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

Tier 1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

Tier 1

nitroglycerin translingual solution 0.4 mg/spray Tier 1

NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 MG/SPRAY EX Formulary Exclusion

NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 MCG/SPRAY Tier 3

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG EX Formulary Exclusion

NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG Tier 1

*Antianxiety Agents*

*Antianxiety Agents - Misc.***buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

Tier 1

droperidol injection solution 2.5 mg/ml EX Medical Only Exclusion

droperidol intravenous solution prefilled syringe0.625 mg/ml


51

Drug Name Drug Tier Noteshydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml


hydroxyzine hcl oral syrup 10 mg/5ml Tier 1

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

Tier 1

meprobamate oral tablet 200 mg, 400 mg EX Formulary Exclusion

VISTARIL ORAL CAPSULE 25 MG, 50 MG EX Formulary Exclusion

*Benzodiazepines***alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg

Tier 1

ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML Tier 3

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 1

alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 1

alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg

Tier 1

ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML EX Medical Only Exclusion

ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG EX Formulary Exclusion

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

Tier 1

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

Tier 1

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML Tier 1

diazepam intramuscular solution auto-injector 10 mg/2ml


diazepam oral concentrate 5 mg/ml Tier 1

diazepam oral tablet 10 mg, 2 mg, 5 mg Tier 1

diazepam solution 5 mg/5ml oral 5 mg/5ml EX Formulary Exclusion

diazepam solution 5 mg/5ml oral 5 mg/5ml Tier 1

diazepam solution 5 mg/ml injection 5 mg/ml Benefit Exclusion

diazepam solution 5 mg/ml injection 5 mg/ml EX Medical Only Exclusion

diazepam solution 5 mg/ml injection 5 mg/ml EX Non FDA Exclusion; Medical Only Exclusion

lorazepam injection solution 2 mg/ml, 4 mg/ml EX Medical Only Exclusion

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML Tier 1

52

Drug Name Drug Tier Noteslorazepam oral concentrate 2 mg/ml Tier 1

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

LOREEV XR ORAL CAPSULE ER 24 HOUR SPRINKLE 1 MG, 1.5 MG, 2 MG, 3 MG EX Formulary Exclusion

oxazepam oral capsule 10 mg, 15 mg, 30 mg Tier 1

TRANXENE-T ORAL TABLET 7.5 MG EX Formulary Exclusion

VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG EX Formulary Exclusion

XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG EX Formulary Exclusion

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 2 MG, 3 MG


*Antiarrhythmics*

*Antiarrhythmics - Misc.***adenosine intravenous solution 12 mg/4ml, 6 mg/2ml


*Antiarrhythmics Type I-A***disopyramide phosphate oral capsule 100 mg, 150 mg

Tier 1

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG

Tier 3

NORPACE ORAL CAPSULE 100 MG, 150 MG Tier 3

procainamide hcl injection solution 100 mg/ml, 500 mg/ml


quinidine gluconate er oral tablet extended release 324 mg

Tier 1

quinidine sulfate oral tablet 200 mg, 300 mg Tier 1

*Antiarrhythmics Type I-B***lidocaine hcl (cardiac) pf intravenous solution100 mg/5ml


lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 100 mg/5ml, 50 mg/5ml


lidocaine hcl (cardiac) solution prefilled syringe 100 mg/10ml intravenous 100 mg/10ml






53

Drug Name Drug Tier Noteslidocaine hcl (cardiac) solution prefilled syringe 200 mg/10ml intravenous 200 mg/10ml






lidocaine in d5w solution 2-5 mg/ml-% intravenous 2-5 mg/ml-%






mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

Tier 1

*Antiarrhythmics Type I-C***flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

Tier 1

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

Tier 1

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

Tier 1

RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 MG, 325 MG, 425 MG


*Antiarrhythmics Type Iii***amiodarone hcl in dextrose intravenous solution450-5 mg/250ml-%, 900-5 mg/500ml-%


amiodarone hcl intravenous solution 150 mg/3ml, 450 mg/9ml, 900 mg/18ml


amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg

Tier 1

bretylium tosylate injection solution 50 mg/ml EX Formulary Exclusion

CORVERT INTRAVENOUS SOLUTION 1 MG/10ML EX Medical Only Exclusion

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

Tier 1

ibutilide fumarate intravenous solution 1 mg/10ml EX Medical Only Exclusion

MULTAQ ORAL TABLET 400 MG Tier 2

NEXTERONE INTRAVENOUS SOLUTION150-4.21 MG/100ML-%, 360-4.14 MG/200ML-%


PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG Tier 1

54

Drug Name Drug Tier NotesTIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG EX Formulary Exclusion

*Antiasthmatic And Bronchodilator Agents*

*5-Lipoxygenase Inhibitors***zileuton er oral tablet extended release 12 hour600 mg

Benefit Exclusion

ZYFLO ORAL TABLET 600 MG Tier 3

*Adrenergic Combinations***ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/ACT, 250-50 MCG/ACT, 500-50 MCG/ACT


ADVAIR HFA INHALATION AEROSOL115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

Tier 2 QL

AIRDUO DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT


AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT






ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

Tier 2 QL

BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT EX Formulary Exclusion; QL

BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH INHALATION 100-25 MCG/INH



Tier 2 QL



55

Drug Name Drug Tier NotesBREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 200-25 MCG/INH INHALATION 200-25 MCG/INH

Tier 2 QL

BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 MCG/ACT Tier 2 QL

budesonide-formoterol fumarate inhalation aerosol 160-4.5 mcg/act, 80-4.5 mcg/act


COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT Tier 2 QL

DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT


DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT Tier 2 QL

fluticasone furoate-vilanterol inhalation aerosol powder breath activated 100-25 mcg/inh, 200-25 mcg/inh

EX New to Market Exclusion; QL

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/act, 113-14 mcg/act, 232-14 mcg/act, 250-50 mcg/act, 500-50 mcg/act, 55-14 mcg/act

Tier 1 QL

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml

Tier 1

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT Tier 2 QL

SYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT, 80-4.5 MCG/ACT Tier 2 QL

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 MCG/INH

Tier 2 QL

UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 MCG EX Formulary Exclusion; QL

WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/ACT, 250-50 MCG/ACT, 500-50 MCG/ACT

Tier 1 QL

*Anti-Ige Monoclonal Antibodies***XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5ML

Tier 4 PA; Specialty

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG Tier 4 PA; Specialty

56


*Anti-Inflammatory Agents***cromolyn sodium inhalation nebulization solution20 mg/2ml

Tier 1

*Beta Adrenergics***albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg

Tier 1

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation 108 (90 base) mcg/act


albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation 108 (90 base) mcg/act

Tier 1 QL

albuterol sulfate nebulization solution (2.5 mg/3ml) 0.083% inhalation (2.5 mg/3ml) 0.083%

Tier 1

albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation (5 mg/ml) 0.5%

Tier 3

albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation (5 mg/ml) 0.5%

Tier 1

albuterol sulfate nebulization solution 0.63 mg/3ml inhalation 0.63 mg/3ml

Tier 1

albuterol sulfate nebulization solution 1.25 mg/3ml inhalation 1.25 mg/3ml

Tier 1

albuterol sulfate nebulization solution 2.5 mg/0.5ml inhalation 2.5 mg/0.5ml

Tier 1

albuterol sulfate oral syrup 2 mg/5ml Tier 1

albuterol sulfate oral tablet 2 mg, 4 mg Tier 1

ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG Tier 3 QL

arformoterol tartrate inhalation nebulization solution 15 mcg/2ml

Tier 1

BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML EX Formulary Exclusion

formoterol fumarate inhalation nebulization solution 20 mcg/2ml


isoproterenol hcl injection solution 0.2 mg/ml EX Medical Only Exclusion

isoproterenol-sodium chloride intravenous solution 200-0.9 mcg/50ml-%


ISUPREL INJECTION SOLUTION 0.2 MG/ML Tier 3

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

Tier 1

levalbuterol tartrate inhalation aerosol 45 mcg/act


57

Drug Name Drug Tier NotesPERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML EX Formulary Exclusion

PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT


PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT EX Formulary Exclusion; QL

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT


PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT


SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE

Tier 2 QL

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT Tier 2 QL

terbutaline sulfate injection solution 1 mg/ml EX Medical Only Exclusion

terbutaline sulfate oral tablet 2.5 mg, 5 mg Tier 1

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT Tier 2 QL

XOPENEX CONCENTRATE INHALATION NEBULIZATION SOLUTION 1.25 MG/0.5ML


XOPENEX HFA INHALATION AEROSOL45 MCG/ACT EX Formulary Exclusion; QL

XOPENEX INHALATION NEBULIZATION SOLUTION 0.31 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML


*Bronchodilators - Anticholinergics***ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT Tier 3 QL

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

Tier 2 QL

ipratropium bromide inhalation solution 0.02 % Tier 1

LONHALA MAGNAIR REFILL KIT INHALATION SOLUTION 25 MCG/ML EX Formulary Exclusion; QL

LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION 25 MCG/ML EX Formulary Exclusion; QL

SEEBRI NEOHALER INHALATION CAPSULE 15.6 MCG EX Formulary Exclusion; QL

58

Drug Name Drug Tier NotesSPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG Tier 2 QL

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

Tier 2 QL

TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT INHALATION 400 MCG/ACT


TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT INHALATION 400 MCG/ACT

Tier 3 QL

YUPELRI INHALATION SOLUTION 175 MCG/3ML EX Formulary Exclusion; QL

*Interleukin-5 Antagonists (Igg1 Kappa)***FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 30 MG/ML Tier 4 PA; Specialty; QL

FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML Tier 4 PA; Specialty; QL

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML Tier 4 PA; Specialty; QL

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 40 MG/0.4ML


NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG Tier 4 PA; Specialty; QL

*Interleukin-5 Antagonists (Igg4 Kappa)***CINQAIR INTRAVENOUS SOLUTION 100 MG/10ML EX


*Leukotriene Receptor Antagonists***ACCOLATE ORAL TABLET 10 MG, 20 MG EX Formulary Exclusion

montelukast sodium oral packet 4 mg Tier 1

montelukast sodium oral tablet 10 mg Tier 1

montelukast sodium oral tablet chewable 4 mg, 5 mg

Tier 1

SINGULAIR ORAL PACKET 4 MG EX Formulary Exclusion

SINGULAIR ORAL TABLET 10 MG EX Formulary Exclusion

SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG EX Formulary Exclusion

zafirlukast oral tablet 10 mg, 20 mg Tier 1

59


*Selective Phosphodiesterase 4 (Pde4) Inhibitors***DALIRESP ORAL TABLET 250 MCG, 500 MCG Tier 3

*Steroid Inhalants***ALVESCO INHALATION AEROSOL SOLUTION 160 MCG/ACT, 80 MCG/ACT EX Formulary Exclusion; QL

ARMONAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113 MCG/ACT, 232 MCG/ACT, 55 MCG/ACT


ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

Tier 2 QL

ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

Tier 2 QL

ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH

Tier 2 QL

ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

Tier 2 QL

ASMANEX HFA INHALATION AEROSOL100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

Tier 2 QL

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

Tier 1 QL

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

Tier 2 QL

FLOVENT HFA INHALATION AEROSOL110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT

Tier 2 QL

fluticasone propionate hfa inhalation aerosol 110 mcg/act, 220 mcg/act, 44 mcg/act

EX New to Market Exclusion; QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT


PULMICORT INHALATION SUSPENSION0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML EX Formulary Exclusion; QL

60

Drug Name Drug Tier NotesQVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT

Tier 2 QL

*Thymic Stromal Lymphopoietin (Tslp) Antagonists***TEZSPIRE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 210 MG/1.91ML EX

New to Market Exclusion; Specialty

*Xanthines***aminophylline intravenous solution 25 mg/ml EX Medical Only Exclusion

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML Tier 3

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG

Tier 3

theophylline er oral tablet extended release 12 hour 300 mg, 450 mg

Tier 1

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

Tier 1

theophylline oral solution 80 mg/15ml Tier 1

*Anticoagulants*

*Anticoagulants - Misc.***sodium citrate in vitro solution prefilled syringe 4 %


sodium citrate lock flush intravenous solution 4 % EX Non FDA Exclusion

sodium citrate lock flush intravenous solution prefilled syringe 120 mg/3ml


*Coumarin Anticoagulants***COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

Tier 3

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

Tier 1

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

Tier 1

*Direct Factor Xa Inhibitors***BEVYXXA ORAL CAPSULE 40 MG, 80 MG Tier 3 PA

ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK 5 MG Tier 2

ELIQUIS ORAL TABLET 2.5 MG, 5 MG Tier 2

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG EX Formulary Exclusion

61

Drug Name Drug Tier NotesXARELTO ORAL SUSPENSION RECONSTITUTED 1 MG/ML Tier 2

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG Tier 2

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG Tier 2

*Heparins And Heparinoid-Like Agents***BD HEPARIN POSIFLUSH INTRAVENOUS SOLUTION 10 UNIT/ML, 100 UNIT/ML EX Formulary Exclusion

heparin (porcine) in nacl intravenous solution prefilled syringe 20-0.9 unt/20ml-%, 50-0.9 unt/50ml-%


heparin (porcine) in nacl solution 1000-0.9 ut/500ml-% intravenous 1000-0.9 ut/500ml-%

Tier 1



heparin (porcine) in nacl solution 2000-0.9 unit/l-% intravenous 2000-0.9 unit/l-%

Tier 1

















heparin lock flush solution 1 unit/ml intravenous1 unit/ml





Tier 1

heparin sod (porcine) in d5w intravenous solution100 unit/ml, 25000-5 ut/500ml-%, 40-5 unit/ml-%


62

Drug Name Drug Tier Notesheparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

Tier 1

heparin sodium (porcine) injection solution prefilled syringe 5000 unit/0.5ml


heparin sodium (porcine) pf solution 5000 unit/0.5ml injection 5000 unit/0.5ml

Tier 1

heparin sodium (porcine) pf solution 5000 unit/ml injection 5000 unit/ml

Tier 3

heparin sodium lock flush solution 100 unit/ml intravenous 100 unit/ml


heparin sodium lock flush solution 100 unit/ml intravenous 100 unit/ml

Tier 1

hepmed combination kit 100&0.9&2.5-2.5 ut/ml&%


*In Vitro/Lock Anticoagulant Combinations***sodium citrate-gentamicin sulf intravenous solution 4-320 %-mcg/ml


*In Vitro/Lock Anticoagulants***acd formula a in vitro solution 0.73-2.45-2.2 gm/100ml


ACD-A NOCLOT-50 IN VITRO SOLUTION0.73-2.45-2.2 GM/100ML EX Medical Only Exclusion

anticoagulant sodium citrate in vitro solution 4 %, 4 gm/100ml


REGIOCIT EXTRACORPOREAL SOLUTION 0.529 % EX

Non FDA Exclusion; Medical Only Exclusion

TRICITRASOL IN VITRO CONCENTRATE46.7 % EX Medical Only Exclusion

*Low Molecular Weight Heparins***enoxaparin sodium injection solution 300 mg/3ml Tier 1

enoxaparin sodium injection solution prefilled syringe 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

Tier 1

FRAGMIN SUBCUTANEOUS SOLUTION95000 UNIT/3.8ML Tier 3

FRAGMIN SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML

Tier 3

63

Drug Name Drug Tier NotesLOVENOX INJECTION SOLUTION 300 MG/3ML EX Formulary Exclusion

LOVENOX INJECTION SOLUTION PREFILLED SYRINGE 100 MG/ML, 120 MG/0.8ML, 150 MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, 60 MG/0.6ML, 80 MG/0.8ML


*Synthetic Heparinoid-Like Agents***ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 2.5 MG/0.5ML, 5 MG/0.4ML, 7.5 MG/0.6ML


fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

Tier 1

*Thrombin Inhibitors - Hirudin Type***ANGIOMAX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG EX Medical Only Exclusion

bivalirudin rtu intravenous solution 250 mg/50ml EX Medical Only Exclusion

bivalirudin trifluoroacetate intravenous solution reconstituted 250 mg


bivalirudin-sodium chloride intravenous solution500-0.9 mg/100ml-%


*Thrombin Inhibitors - Selective Direct & Reversible***argatroban in sodium chloride intravenous solution 50-0.9 mg/50ml-%


argatroban intravenous solution 250 mg/2.5ml, 50 mg/50ml


PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG Tier 3

*Anticonvulsants*

*Ampa Glutamate Receptor Antagonists***FYCOMPA ORAL SUSPENSION 0.5 MG/ML Tier 3 PA

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG Tier 3 PA

*Anticonvulsants - Benzodiazepines***clobazam oral suspension 2.5 mg/ml Tier 1

clobazam oral tablet 10 mg, 20 mg Tier 1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

Tier 1

64

Drug Name Drug Tier NotesDIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG Tier 2

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG Tier 2

diazepam rectal gel 10 mg, 2.5 mg, 20 mg Tier 1

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG EX Formulary Exclusion

NAYZILAM NASAL SOLUTION 5 MG/0.1ML Tier 3 QL

ONFI ORAL SUSPENSION 2.5 MG/ML EX Formulary Exclusion

ONFI ORAL TABLET 10 MG, 20 MG EX Formulary Exclusion

SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG Tier 3

VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML Tier 3

VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PACK 7.5 MG/0.1ML Tier 3

VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PACK 10 MG/0.1ML Tier 3

VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML Tier 3

*Anticonvulsants - Misc.***APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG Tier 2

BANZEL ORAL SUSPENSION 40 MG/ML EX Formulary Exclusion

BANZEL ORAL TABLET 200 MG, 400 MG EX Formulary Exclusion

BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML EX


BRIVIACT ORAL SOLUTION 10 MG/ML Tier 3

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG Tier 3

carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg

Tier 1

carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg

Tier 1

carbamazepine oral suspension 100 mg/5ml Tier 1

carbamazepine oral tablet 200 mg Tier 1

carbamazepine oral tablet chewable 100 mg Tier 1

CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

Tier 3

65

Drug Name Drug Tier NotesDIACOMIT ORAL CAPSULE 250 MG, 500 MG Tier 3 PA

DIACOMIT ORAL PACKET 250 MG, 500 MG Tier 3 PA

ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG, 1500 MG EX Formulary Exclusion

EPIDIOLEX ORAL SOLUTION 100 MG/ML Tier 4 PA; Specialty

EPITOL ORAL TABLET 200 MG Tier 1

EPRONTIA ORAL SOLUTION 25 MG/ML EX Formulary Exclusion

FANATREX FUSEPAQ ORAL SUSPENSION25 MG/ML EX Non FDA Exclusion

FINTEPLA ORAL SOLUTION 2.2 MG/ML Tier 4 PA; Specialty

gabapentin capsule 100 mg oral 100 mg Tier 1 QL


gabapentin capsule 300 mg oral 300 mg Benefit Exclusion QL


gabapentin oral solution 250 mg/5ml, 300 mg/6ml Tier 1 QL

gabapentin oral tablet 600 mg, 800 mg Tier 1 QL

KEPPRA INTRAVENOUS SOLUTION 500 MG/5ML EX Medical Only Exclusion

KEPPRA ORAL SOLUTION 100 MG/ML EX Formulary Exclusion

KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 MG EX Formulary Exclusion

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG EX Formulary Exclusion

lacosamide intravenous solution 200 mg/20ml EX Medical Only Exclusion

lacosamide oral solution 10 mg/ml Tier 1

lacosamide oral tablet 100 mg, 150 mg, 200 mg, 50 mg

Tier 1

LAMICTAL ODT KIT 21 X 25 MG & 7 X 50 MG ORAL 21 X 25 MG & 7 X 50 MG Tier 3

LAMICTAL ODT KIT 25 & 50 & 100 MG ORAL 25 & 50 & 100 MG EX Formulary Exclusion

LAMICTAL ODT KIT 42 X 50 MG & 14X100 MG ORAL 42 X 50 MG & 14X100 MG Tier 3

LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 MG, 25 MG, 50 MG


LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG EX Formulary Exclusion

LAMICTAL ORAL TABLET CHEWABLE25 MG, 5 MG EX Formulary Exclusion

66

Drug Name Drug Tier NotesLAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG


LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 50 & 100 & 200 MG

Tier 3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG


lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

Tier 1

lamotrigine oral kit 25 & 50 & 100 mg Tier 1

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

Tier 1

lamotrigine oral tablet chewable 25 mg, 5 mg Tier 1

lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg

Tier 1

lamotrigine starter kit-blue oral kit 35 x 25 mg Tier 1

lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg

Tier 1

lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg

Tier 1

levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg

Tier 1

levetiracetam in nacl intravenous solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml


levetiracetam intravenous solution 500 mg/5ml EX Medical Only Exclusion

levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg

Tier 1

levetiracetam solution 100 mg/ml oral 100 mg/ml Benefit Exclusion

levetiracetam solution 100 mg/ml oral 100 mg/ml Tier 1

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

Benefit Exclusion

LYRICA ORAL SOLUTION 20 MG/ML Benefit Exclusion

MYSOLINE ORAL TABLET 250 MG, 50 MG Tier 3

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG EX Formulary Exclusion; QL

NEURONTIN ORAL SOLUTION 250 MG/5ML EX Formulary Exclusion; QL

NEURONTIN ORAL TABLET 600 MG, 800 MG EX Formulary Exclusion; QL

67

Drug Name Drug Tier Notesoxcarbazepine oral suspension 300 mg/5ml Tier 1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

Tier 1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG

Tier 3

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

Tier 1 QL

pregabalin oral solution 20 mg/ml Tier 1 QL

primidone oral tablet 250 mg, 50 mg Tier 1

QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

Tier 3

ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG Tier 1

ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG

Tier 1

rufinamide oral suspension 40 mg/ml Tier 1

rufinamide oral tablet 200 mg, 400 mg Tier 1

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG

Tier 3

SUBVENITE ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG Tier 1

SUBVENITE STARTER KIT-BLUE ORAL KIT 35 X 25 MG Tier 1

SUBVENITE STARTER KIT-GREEN ORAL KIT 84 X 25 MG & 14X100 MG Tier 1

SUBVENITE STARTER KIT-ORANGE ORAL KIT 42 X 25 MG & 7 X 100 MG Tier 1

TEGRETOL ORAL SUSPENSION 100 MG/5ML Tier 3

TEGRETOL ORAL TABLET 200 MG Tier 3

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 400 MG

Tier 3

TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG EX Formulary Exclusion

TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 MG EX Formulary Exclusion

topiramate er oral capsule er 24 hour sprinkle100 mg, 150 mg, 200 mg, 25 mg, 50 mg

Tier 1

68

Drug Name Drug Tier Notestopiramate oral capsule sprinkle 15 mg, 25 mg Tier 1

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

Tier 1

TRILEPTAL ORAL SUSPENSION 300 MG/5ML EX Formulary Exclusion

TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG EX Formulary Exclusion

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

Tier 3

VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML EX Medical Only Exclusion

VIMPAT ORAL SOLUTION 10 MG/ML Tier 2

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG Tier 2

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG EX Formulary Exclusion

zonisamide oral capsule 100 mg, 25 mg, 50 mg Tier 1

ZTALMY ORAL SUSPENSION 50 MG/ML EX New to Market Exclusion

*Carbamates***felbamate oral suspension 600 mg/5ml Tier 1

felbamate oral tablet 400 mg, 600 mg Tier 1

FELBATOL ORAL SUSPENSION 600 MG/5ML EX Formulary Exclusion

FELBATOL ORAL TABLET 400 MG, 600 MG EX Formulary Exclusion

XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 100 & 150 MG, 50 & 200 MG

Tier 3 PA

XCOPRI (350 MG DAILY DOSE) ORAL TABLET THERAPY PACK 150 & 200 MG Tier 3 PA

XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG Tier 3 PA

XCOPRI ORAL TABLET THERAPY PACK14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 MG & 14 X100 MG

Tier 3 PA

*Gaba Modulators***GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG EX Formulary Exclusion

SABRIL ORAL PACKET 500 MG EX PA; Specialty; Formulary Exclusion

SABRIL ORAL TABLET 500 MG EX PA; Specialty; Formulary Exclusion

69

Drug Name Drug Tier Notestiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg

Tier 1

vigabatrin oral packet 500 mg Tier 4 PA; Specialty

vigabatrin oral tablet 500 mg Tier 4 PA; Specialty

VIGADRONE ORAL PACKET 500 MG Tier 4 PA; Specialty

*Hydantoins***CEREBYX INJECTION SOLUTION 100 MG PE/2ML, 500 MG PE/10ML EX Medical Only Exclusion

DILANTIN CAPSULE 100 MG ORAL 100 MG Tier 3

DILANTIN CAPSULE 30 MG ORAL 30 MG Tier 2

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG Tier 3

DILANTIN ORAL SUSPENSION 125 MG/5ML Tier 3

fosphenytoin sodium injection solution 100 mg pe/2ml, 500 mg pe/10ml


PEGANONE ORAL TABLET 250 MG Tier 3

PHENYTEK ORAL CAPSULE 200 MG, 300 MG Tier 3

PHENYTOIN INFATABS ORAL TABLET CHEWABLE 50 MG Tier 1

phenytoin oral suspension 100 mg/4ml, 125 mg/5ml

Tier 1

phenytoin oral tablet chewable 50 mg Tier 1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

Tier 1

phenytoin sodium solution 50 mg/ml injection 50 mg/ml


phenytoin sodium solution 50 mg/ml injection 50 mg/ml


*Succinimides***CELONTIN ORAL CAPSULE 300 MG Tier 3

ethosuximide oral capsule 250 mg Tier 1

ethosuximide oral solution 250 mg/5ml Tier 1

ZARONTIN ORAL CAPSULE 250 MG Tier 3

ZARONTIN ORAL SOLUTION 250 MG/5ML Tier 3

70


*Valproic Acid***DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 250 MG, 500 MG


DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 MG, 500 MG EX Formulary Exclusion

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE 125 MG EX Formulary Exclusion

divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg

Tier 1

divalproex sodium oral capsule delayed release sprinkle 125 mg

Tier 1

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

Tier 1

valproate sodium intravenous solution 100 mg/ml EX Medical Only Exclusion

valproic acid oral capsule 250 mg Tier 1

valproic acid oral solution 250 mg/5ml Tier 1

*Antidepressants*

*Alpha-2 Receptor Antagonists (Tetracyclics)***mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

Tier 1

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg

Tier 1

REMERON ORAL TABLET 15 MG, 30 MG EX Formulary Exclusion

REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG, 45 MG EX Formulary Exclusion

*Antidepressants - Misc.***APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG, 348 MG, 522 MG

Benefit Exclusion

bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg

Tier 1

bupropion hcl er (xl) tablet extended release 24 hour 150 mg oral 150 mg

Tier 1


Tier 1



bupropion hcl oral tablet 100 mg, 75 mg Tier 1

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG Benefit Exclusion Non Essential Drug Exclusion

71

Drug Name Drug Tier Notesmaprotiline hcl oral tablet 25 mg, 50 mg, 75 mg Tier 1

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG


WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG


*Gaba Receptor Modulator - Neuroactive Steroid***ZULRESSO INTRAVENOUS SOLUTION100 MG/20ML EX Medical Only Exclusion

*Monoamine Oxidase Inhibitors (Maois)***EMSAM TRANSDERMAL PATCH 24 HOUR12 MG/24HR, 6 MG/24HR, 9 MG/24HR Tier 3

MARPLAN ORAL TABLET 10 MG Tier 3

NARDIL ORAL TABLET 15 MG EX Formulary Exclusion

PARNATE ORAL TABLET 10 MG EX Formulary Exclusion

phenelzine sulfate oral tablet 15 mg Tier 1

tranylcypromine sulfate oral tablet 10 mg Tier 1

*N-Methyl-D-Aspartic Acid (Nmda) Receptor Antagonists***SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PACK 28 MG/DEVICE


SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PACK 28 MG/DEVICE


*Selective Serotonin Reuptake Inhibitors (Ssris)***CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG EX Formulary Exclusion

citalopram hydrobromide oral capsule 30 mg Benefit ExclusionNon Essential Drug Exclusion; Formulary Exclusion

citalopram hydrobromide oral solution 10 mg/5ml

Tier 1

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

Tier 1

escitalopram oxalate oral solution 5 mg/5ml Tier 1

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

Tier 1

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg Tier 1

72

Drug Name Drug Tier Notesfluoxetine hcl oral capsule delayed release 90 mg Tier 1

fluoxetine hcl oral solution 20 mg/5ml Tier 1

fluoxetine hcl tablet 10 mg oral 10 mg Benefit Exclusion Non Essential Drug Exclusion



fluoxetine hcl tablet 60 mg oral 60 mg Benefit Exclusion

fluvoxamine maleate er oral capsule extended release 24 hour 100 mg, 150 mg

Tier 1

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg

Tier 1

LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG EX Formulary Exclusion

paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg

Tier 1

paroxetine hcl oral suspension 10 mg/5ml Tier 1

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

Tier 1

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG


PAXIL ORAL SUSPENSION 10 MG/5ML Tier 3

PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG EX Formulary Exclusion

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG Benefit Exclusion Non Essential Drug Exclusion

PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG EX Formulary Exclusion

sertraline hcl oral capsule 150 mg, 200 mg Benefit Exclusion

sertraline hcl oral concentrate 20 mg/ml Tier 1

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg Tier 1

ZOLOFT ORAL CONCENTRATE 20 MG/ML EX Formulary Exclusion

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG EX Formulary Exclusion

*Serotonin Modulators***nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg


trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

Tier 1

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG Tier 3

73

Drug Name Drug Tier NotesVIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG Tier 3

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG Tier 3

vilazodone hcl oral tablet 10 mg, 20 mg, 40 mg Tier 1

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG, 30 MG, 60 MG


desvenlafaxine er tablet extended release 24 hour 100 mg oral 100 mg

Tier 1


Tier 3


Tier 1

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg

Tier 1

DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG

Benefit Exclusion

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 40 mg, 60 mg

Tier 1 QL

EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 37.5 MG, 75 MG


FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG

Tier 3

FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG Tier 3

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG EX Formulary Exclusion

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

Tier 1

venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 225 mg, 37.5 mg, 75 mg


venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

Tier 1

*Tricyclic Agents***amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 1

74

Drug Name Drug Tier Notesamoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg


ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG EX Formulary Exclusion

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

Tier 1

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 1

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Tier 1

doxepin hcl oral concentrate 10 mg/ml Tier 1

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

Tier 1

NORPRAMIN ORAL TABLET 10 MG, 25 MG EX Formulary Exclusion

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

Tier 1

nortriptyline hcl oral solution 10 mg/5ml Tier 1

PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG EX Formulary Exclusion

protriptyline hcl oral tablet 10 mg, 5 mg Tier 1

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

Tier 1

*Antidiabetics*

*Alpha-Glucosidase Inhibitors***acarbose oral tablet 100 mg, 25 mg, 50 mg Tier 1 QL

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG EX Formulary Exclusion; QL

miglitol oral tablet 100 mg, 25 mg, 50 mg Tier 1 QL

PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG EX Formulary Exclusion; QL

*Antidiabetic - Amylin Analogs***SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML


SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML


*Biguanides***FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG, 500 MG Benefit Exclusion

75

Drug Name Drug Tier NotesGLUMETZA ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG, 500 MG Benefit Exclusion QL

metformin hcl er (mod) tablet extended release 24 hour 1000 mg oral 1000 mg

Benefit Exclusion


Benefit Exclusion QL



metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

Tier 1 QL

metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

Tier 1 QL

metformin hcl solution 500 mg/5ml oral 500 mg/5ml


metformin hcl solution 500 mg/5ml oral 500 mg/5ml

Tier 1 QL

metformin hcl tablet 1000 mg oral 1000 mg Tier 1 QL


metformin hcl tablet 625 mg oral 625 mg EX New to Market Exclusion


RIOMET ER ORAL SUSPENSION RECONSTITUTED ER 500 MG/5ML Tier 3 QL

RIOMET ORAL SOLUTION 500 MG/5ML EX Formulary Exclusion; QL

*Diabetic Other***BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE Tier 2 QL

BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE Tier 2 QL

diazoxide oral suspension 50 mg/ml Tier 1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG Tier 3 QL

glucagon emergency injection solution reconstituted 1 mg/ml

Tier 2 QL

glucagon emergency kit 1 mg injection 1 mg Tier 1 QL

glucagon emergency kit 1 mg injection 1 mg EX Formulary Exclusion; QL

GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML

Tier 2 QL

GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML

Tier 2 QL

76

Drug Name Drug Tier NotesGVOKE KIT SUBCUTANEOUS SOLUTION1 MG/0.2ML Tier 2 QL

GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML

Tier 2 QL

PROGLYCEM ORAL SUSPENSION 50 MG/ML EX Formulary Exclusion

ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.6 MG/0.6ML

Tier 2 QL

ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 0.6 MG/0.6ML

Tier 2 QL

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG Tier 2 QL

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG EX Formulary Exclusion; QL

ONGLYZA ORAL TABLET 2.5 MG, 5 MG EX Formulary Exclusion; QL

TRADJENTA ORAL TABLET 5 MG EX Formulary Exclusion; QL

*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations***alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg


JANUMET ORAL TABLET 50-1000 MG, 50-500 MG Tier 2 QL

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG

Tier 2 QL

JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG EX Formulary Exclusion; QL

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG


KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG EX Formulary Exclusion; QL

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG


77


*Dopamine Receptor Agonists - Ergot Derivatives***CYCLOSET ORAL TABLET 0.8 MG Tier 3 QL

*Dpp-4 Inhibitor-Thiazolidinedione Combinations***alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg


OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


*Human Insulin***ADMELOG INJECTION SOLUTION 100 UNIT/ML EX Formulary Exclusion

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML EX Formulary Exclusion

AFREZZA INHALATION POWDER 12 UNIT, 4 UNIT, 60X4 &60X8 & 60X12 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 UNIT & 90X12 UNIT


APIDRA INJECTION SOLUTION 100 UNIT/ML EX Formulary Exclusion

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML EX Formulary Exclusion

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML EX Formulary Exclusion

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML Tier 2

FIASP INJECTION SOLUTION 100 UNIT/ML Tier 2

FIASP PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML Tier 2

HUMALOG INJECTION SOLUTION 100 UNIT/ML EX Formulary Exclusion

HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML


HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML


78

Drug Name Drug Tier NotesHUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML EX Formulary Exclusion

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML


HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML EX Formulary Exclusion

HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML EX Formulary Exclusion

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML EX Formulary Exclusion

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML


HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML EX Formulary Exclusion

HUMULIN R INJECTION SOLUTION 100 UNIT/ML EX Formulary Exclusion

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML Tier 2

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML

Tier 2

insulin asp prot & asp flexpen subcutaneous suspension pen-injector (70-30) 100 unit/ml


insulin aspart flexpen subcutaneous solution pen-injector 100 unit/ml


insulin aspart injection solution 100 unit/ml EX Formulary Exclusion

insulin aspart penfill subcutaneous solution cartridge 100 unit/ml


insulin aspart prot & aspart subcutaneous suspension (70-30) 100 unit/ml


insulin glargine solostar subcutaneous solution pen-injector 100 unit/ml

EX

insulin glargine subcutaneous solution 100 unit/ml

EX

insulin glargine-yfgn subcutaneous solution 100 unit/ml


insulin glargine-yfgn subcutaneous solution pen-injector 100 unit/ml


79

Drug Name Drug Tier Notesinsulin lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/ml


insulin lispro injection solution 100 unit/ml EX Formulary Exclusion

insulin lispro junior kwikpen subcutaneous solution pen-injector 100 unit/ml


insulin lispro prot & lispro subcutaneous suspension pen-injector (75-25) 100 unit/ml


LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML Tier 2

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML Tier 2

LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML Tier 2

LEVEMIR SUBCUTANEOUS SOLUTION100 UNIT/ML Tier 2

LYUMJEV INJECTION SOLUTION 100 UNIT/ML EX Formulary Exclusion

LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML


MYXREDLIN INTRAVENOUS SOLUTION100-0.9 UT/100ML-% EX Medical Only Exclusion

NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

Tier 2

NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

Tier 2

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML Tier 2

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML Tier 2

NOVOLIN N FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

Tier 2

NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML

Tier 2

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML Tier 2

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML Tier 2

NOVOLIN R FLEXPEN INJECTION SOLUTION PEN-INJECTOR 100 UNIT/ML Tier 2

80

Drug Name Drug Tier NotesNOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN-INJECTOR100 UNIT/ML

Tier 2

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML Tier 2

NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML Tier 2

NOVOLOG 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

Tier 2

NOVOLOG FLEXPEN RELION SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

Tier 2

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML Tier 2

NOVOLOG INJECTION SOLUTION 100 UNIT/ML Tier 2

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

Tier 2

NOVOLOG MIX 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

Tier 2

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML Tier 2

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML Tier 2

NOVOLOG RELION INJECTION SOLUTION 100 UNIT/ML Tier 2

SEMGLEE (YFGN) SUBCUTANEOUS SOLUTION 100 UNIT/ML EX Formulary Exclusion

SEMGLEE (YFGN) SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML EX Formulary Exclusion

SEMGLEE SUBCUTANEOUS SOLUTION100 UNIT/ML EX Formulary Exclusion

SEMGLEE SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML EX Formulary Exclusion

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

Tier 2

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML Tier 2

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

Tier 2

81

Drug Name Drug Tier NotesTRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML Tier 2

*Incretin Mimetic Agents (Gip & Glp-1 Receptor Agonists)***MOUNJARO SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/0.5ML, 12.5 MG/0.5ML, 15 MG/0.5ML, 2.5 MG/0.5ML, 5 MG/0.5ML, 7.5 MG/0.5ML

EX New to Market Exclusion

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)***ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT 10 & 20 MCG/0.2ML


ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 MCG/0.2ML EX Formulary Exclusion; QL

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML Tier 3 ST; QL

BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG Tier 3 QL

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML


BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML EX Formulary Exclusion; QL

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

Tier 2 ST; QL

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML, 4 MG/3ML

Tier 2 ST; QL

RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG Tier 2 ST; QL

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, 4.5 MG/0.5ML

Tier 2 ST; QL

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML Tier 2 ST; QL

*Insulin-Incretin Mimetic Combinations***SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/ML Tier 2 QL

XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML Tier 2 QL

82


*Meglitinide Analogues***nateglinide oral tablet 120 mg, 60 mg Tier 1 QL

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 QL

STARLIX ORAL TABLET 120 MG, 60 MG EX Formulary Exclusion; QL

*Progesterone Receptor Antagonists***KORLYM ORAL TABLET 300 MG Tier 4 PA; Specialty; QL

*Sglt2 Inhibitor - Dpp-4 Inhibitor - Biguanide Comb***TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, 5-2.5-1000 MG

Tier 2 QL

*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG Tier 2 QL

QTERN ORAL TABLET 10-5 MG, 5-5 MG Tier 3 QL

STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG EX Formulary Exclusion; QL

*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors***FARXIGA ORAL TABLET 10 MG, 5 MG Tier 2 QL

INVOKANA ORAL TABLET 100 MG, 300 MG EX Formulary Exclusion; QL

JARDIANCE TABLET 10 MG ORAL 10 MG EX Formulary Exclusion; QL

JARDIANCE TABLET 10 MG ORAL 10 MG Tier 2 QL

JARDIANCE TABLET 25 MG ORAL 25 MG EX Formulary Exclusion; QL

JARDIANCE TABLET 25 MG ORAL 25 MG Tier 2 QL

STEGLATRO ORAL TABLET 15 MG, 5 MG EX Formulary Exclusion; QL

*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG EX QL

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG

EX QL

SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5-1000 MG, 7.5-500 MG EX Formulary Exclusion; QL

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG Tier 2 QL

83

Drug Name Drug Tier NotesSYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG

Tier 2 QL

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, 5-500 MG

Tier 2 QL

*Sulfonylurea-Biguanide Combinations***glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

Tier 1 QL

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

Tier 1 QL

*Sulfonylureas***AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG EX Formulary Exclusion; QL

glimepiride oral tablet 1 mg, 2 mg, 4 mg Tier 1 QL

glipizide er oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg

Tier 1 QL

glipizide oral tablet 10 mg, 5 mg Tier 1 QL

glipizide xl oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg

Tier 1 QL

GLUCOTROL ORAL TABLET 10 MG, 5 MG EX Formulary Exclusion; QL

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 2.5 MG, 5 MG


glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

Tier 1 QL

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg Tier 1 QL

GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG EX Formulary Exclusion; QL

tolbutamide oral tablet 500 mg Tier 3 QL

*Sulfonylurea-Thiazolidinedione Combinations***DUETACT ORAL TABLET 30-2 MG, 30-4 MG EX Formulary Exclusion; QL

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

Tier 1 QL

*Thiazolidinedione-Biguanide Combinations***ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG EX Formulary Exclusion; QL

84

Drug Name Drug Tier Notespioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

Tier 1 QL

*Thiazolidinediones***ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG EX Formulary Exclusion; QL

AVANDIA ORAL TABLET 2 MG, 4 MG Tier 3 QL

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg Tier 1 QL

*Antidiarrheal/Probiotic Agents*

*Antidiarrheal - Chloride Channel Antagonists***MYTESI ORAL TABLET DELAYED RELEASE 125 MG Tier 3 QL

*Antidiarrheal/Probiotic Agents - Misc.***DERMACINRX PROBISOL ORAL CAPSULE Benefit Exclusion

DERMACINRX PROBITRAN ORAL CAPSULE Benefit Exclusion

LACTEROL ORAL CAPSULE Benefit Exclusion

PROBINATE ORAL CAPSULE Benefit Exclusion

prodigen oral capsule Benefit Exclusion

promella in prebiotic oral capsule Benefit Exclusion

provad oral capsule EX Non FDA Exclusion

VISBIOME ORAL PACKET EX Non FDA Exclusion

VSL#3 DS ORAL PACKET EX Non FDA Exclusion

zelac oral capsule Benefit Exclusion

*Antidiarrheal/Probiotic Combinations***probichew oral tablet chewable EX Non FDA Exclusion

RESTORA RX ORAL CAPSULE 60-1.25 MG EX Non FDA Exclusion

*Antiperistaltic Agents***diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

Tier 3

diphenoxylate-atropine oral tablet 2.5-0.025 mg Tier 1

LOMOTIL ORAL TABLET 2.5-0.025 MG EX Formulary Exclusion

loperamide hcl oral capsule 2 mg Tier 1

MOTOFEN ORAL TABLET 1-0.025 MG Tier 3

opium tincture 10 mg/ml (1%) oral 10 mg/ml (1%)


85

Drug Name Drug Tier Notesopium tincture 10 mg/ml (1%) oral 10 mg/ml (1%)

Tier 1

*Antidotes And Specific Antagonists*

*Antidote Combinations***DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR 2.1-600 MG EX Medical Only Exclusion

NITHIODOTE INTRAVENOUS KIT300MG/10ML&12.5 GM/50ML EX Medical Only Exclusion

*Antidotes - Chelating Agents***CHEMET ORAL CAPSULE 100 MG Tier 2

deferasirox granules oral packet 180 mg, 360 mg, 90 mg


deferasirox oral packet 180 mg, 360 mg, 90 mg Tier 4 PA; Specialty

deferasirox oral tablet 180 mg, 360 mg, 90 mg Tier 4 PA; Specialty

deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg


deferiprone oral tablet 1000 mg, 500 mg Tier 4 PA; Specialty

dimercaptopropane-sulfonate injection solution250 mg/5ml


EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG EX

PA; Specialty; Formulary Exclusion

FERRIPROX ORAL SOLUTION 100 MG/ML Tier 4 PA; Specialty

FERRIPROX TABLET 1000 MG ORAL 1000 MG Tier 4 PA; Specialty

FERRIPROX TABLET 500 MG ORAL 500 MG EX


FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG Tier 4 PA; Specialty

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG EX


JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG EX


pentetate calcium trisodium combination solution200 mg/ml


pentetate zinc trisodium combination solution 200 mg/ml


*Antidotes And Specific Antagonists***ACETADOTE INTRAVENOUS SOLUTION200 MG/ML EX Medical Only Exclusion

acetylcysteine intravenous solution 200 mg/ml EX Medical Only Exclusion

86

Drug Name Drug Tier NotesANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 200 MG EX Medical Only Exclusion

bal in oil intramuscular solution 100 mg/ml EX Medical Only Exclusion

BRIDION SOLUTION 200 MG/2ML INTRAVENOUS 200 MG/2ML EX


BRIDION SOLUTION 500 MG/5ML INTRAVENOUS 500 MG/5ML EX


BRIDION SOLUTION 500 MG/5ML INTRAVENOUS 500 MG/5ML EX Medical Only Exclusion

calcium disodium versenate injection solution 1 gm/5ml


CYANOKIT INTRAVENOUS SOLUTION RECONSTITUTED 5 GM EX Medical Only Exclusion

deferoxamine mesylate injection solution reconstituted 2 gm, 500 mg


DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 MG EX Medical Only Exclusion

fomepizole intravenous solution 1.5 gm/1.5ml EX Medical Only Exclusion

methylene blue solution 1 % injection 1 % EX Non FDA Exclusion

methylene blue solution 1 % injection 1 % EX Formulary Exclusion

physostigmine salicylate injection solution 1 mg/ml


PRAXBIND INTRAVENOUS SOLUTION 2.5 GM/50ML EX Medical Only Exclusion

PROTOPAM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM EX Medical Only Exclusion

PROVAYBLUE INTRAVENOUS SOLUTION 50 MG/10ML EX


RADIOGARDASE ORAL CAPSULE 0.5 GM Tier 3

sodium nitrite intravenous solution 30 mg/ml EX Medical Only Exclusion

sodium thiosulfate solution 250 mg/ml intravenous 250 mg/ml


sodium thiosulfate solution 250 mg/ml intravenous 250 mg/ml


VISTOGARD ORAL PACKET 10 GM EX Medical Only Exclusion

*Benzodiazepine Antagonists***flumazenil intravenous solution 0.5 mg/5ml, 1 mg/10ml


*Opioid Antagonist Combinations***naltrexone subcutaneous implant 200-6.5 mg EX Opioid Brochure

87


*Opioid Antagonists***EVZIO INJECTION SOLUTION AUTO-INJECTOR 2 MG/0.4ML EX Opioid Brochure

KLOXXADO NASAL LIQUID 8 MG/0.1ML Tier 2

lifems naloxone injection prefilled syringe kit 2 mg/2ml


nalmefene hcl injection solution 1 mg/ml EX New to Market Exclusion

naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml

Tier 1

naloxone hcl injection solution auto-injector 2 mg/0.4ml

Tier 3

naloxone hcl injection solution prefilled syringe 2 mg/2ml

Tier 1

naloxone hcl nasal liquid 4 mg/0.1ml Tier 1

naloxone hcl solution cartridge 0.4 mg/ml injection 0.4 mg/ml

Tier 1

naloxone hcl solution cartridge 0.4 mg/ml injection 0.4 mg/ml

Tier 3

naltrexone hcl oral tablet 50 mg Tier 1 Opioid Brochure

NARCAN NASAL LIQUID 4 MG/0.1ML Tier 2 Opioid Brochure

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG Tier 4 PA; Specialty; QL

ZIMHI INJECTION SOLUTION PREFILLED SYRINGE 5 MG/0.5ML Tier 3

*Antiemetics*

*5-Ht3 Receptor Antagonists***ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML Tier 3

ANZEMET ORAL TABLET 100 MG, 50 MG Tier 3 QL

granisetron hcl intravenous solution 1 mg/ml, 4 mg/4ml

Tier 1

granisetron hcl oral tablet 1 mg Tier 1 QL

ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml

Tier 1

ondansetron hcl injection solution prefilled syringe 4 mg/2ml

Tier 1

ondansetron hcl oral solution 4 mg/5ml Tier 1 QL

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg Tier 1 QL

ondansetron oral tablet dispersible 4 mg, 8 mg Tier 1 QL

palonosetron hcl intravenous solution prefilled syringe 0.25 mg/5ml

Tier 1

88

Drug Name Drug Tier Notespalonosetron hcl solution 0.25 mg/2ml intravenous 0.25 mg/2ml

Tier 3

palonosetron hcl solution 0.25 mg/5ml intravenous 0.25 mg/5ml

Tier 1

SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR Tier 3

SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 MG/0.4ML EX Formulary Exclusion

ZOFRAN ORAL TABLET 4 MG, 8 MG EX Formulary Exclusion; QL

ZUPLENZ ORAL FILM 4 MG, 8 MG Benefit Exclusion Non Essential Drug Exclusion; QL

*Antiemetic Combinations***AKYNZEO INTRAVENOUS SOLUTION235-0.25 MG/20ML Tier 3 QL

AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 235-0.25 MG Tier 3 QL

AKYNZEO ORAL CAPSULE 300-0.5 MG EX Formulary Exclusion; QL

BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG Tier 3

DICLEGIS ORAL TABLET DELAYED RELEASE 10-10 MG EX Formulary Exclusion

doxylamine-pyridoxine oral tablet delayed release10-10 mg

Tier 1

*Antiemetics - Anticholinergic***ANTIVERT ORAL TABLET 50 MG Benefit Exclusion Non Essential Drug Exclusion

ANTIVERT ORAL TABLET CHEWABLE 25 MG Benefit Exclusion

dimenhydrinate injection solution 50 mg/ml Tier 3

meclizine hcl oral tablet chewable 25 mg Benefit Exclusion Non Essential Drug Exclusion

meclizine hcl tablet 12.5 mg oral (rx) 12.5 mg Tier 1

meclizine hcl tablet 25 mg oral (rx) 25 mg Tier 1

meclizine hcl tablet 50 mg oral 50 mg Benefit Exclusion Non Essential Drug Exclusion

scopolamine transdermal patch 72 hour 1 mg/3days

Tier 1

TIGAN INTRAMUSCULAR SOLUTION 100 MG/ML EX Medical Only Exclusion

TIGAN ORAL CAPSULE 300 MG EX Formulary Exclusion

TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH 72 HOUR 1 MG/3DAYS


TRANSDERM-SCOP TRANSDERMAL PATCH 72 HOUR 1 MG/3DAYS EX Formulary Exclusion

trimethobenzamide hcl oral capsule 300 mg Tier 1

89


*Antiemetics - Antidopaminergic***BARHEMSYS INTRAVENOUS SOLUTION10 MG/4ML, 5 MG/2ML EX Medical Only Exclusion

*Antiemetics - Miscellaneous***dronabinol oral capsule 10 mg, 2.5 mg, 5 mg Tier 1 QL

MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG EX Formulary Exclusion; QL

SYNDROS ORAL SOLUTION 5 MG/ML Tier 3

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists***aprepitant oral 80 & 125 mg Tier 1 QL

aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg

Tier 1 QL

CINVANTI INTRAVENOUS EMULSION 130 MG/18ML EX Formulary Exclusion

EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG Tier 3 QL

EMEND ORAL CAPSULE 40 MG, 80 MG EX Formulary Exclusion; QL

EMEND ORAL SUSPENSION RECONSTITUTED 125 MG/5ML Tier 2 QL

EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG EX Formulary Exclusion; QL

fosaprepitant dimeglumine solution reconstituted 150 mg intravenous 150 mg

Tier 1 QL

fosaprepitant dimeglumine solution reconstituted 150 mg intravenous 150 mg

Tier 2 QL

VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK 2 X 90 MG Tier 2 QL

*Antifungals*

*Antifungal - Glucan Synthesis Inhibitors (Echinocandins)***CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG EX Medical Only Exclusion

caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg


ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG EX Medical Only Exclusion

micafungin sodium intravenous solution reconstituted 100 mg, 50 mg


MYCAMINE SOLUTION RECONSTITUTED 100 MG INTRAVENOUS100 MG


90

Drug Name Drug Tier NotesMYCAMINE SOLUTION RECONSTITUTED 50 MG INTRAVENOUS50 MG

Tier 3

*Antifungal - Glucan Synthesis Inhibitors (Triterpenoids)***BREXAFEMME ORAL TABLET 150 MG EX Formulary Exclusion; QL

*Antifungals***ABELCET INTRAVENOUS SUSPENSION 5 MG/ML EX Medical Only Exclusion

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG EX Medical Only Exclusion

amphotericin b intravenous solution reconstituted50 mg


amphotericin b liposome intravenous suspension reconstituted 50 mg


ANCOBON ORAL CAPSULE 250 MG, 500 MG EX Formulary Exclusion

flucytosine oral capsule 250 mg, 500 mg Tier 1

griseofulvin microsize oral suspension 125 mg/5ml

Tier 1

griseofulvin microsize oral tablet 500 mg Tier 1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

Tier 1

nystatin oral tablet 500000 unit Tier 1

terbinafine hcl oral tablet 250 mg Tier 1 QL

*Imidazoles***ketoconazole oral tablet 200 mg Tier 1

*Triazoles***CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 372 MG EX Medical Only Exclusion

CRESEMBA ORAL CAPSULE 186 MG Tier 3

DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 MG/ML, 40 MG/ML EX Formulary Exclusion

DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG EX Formulary Exclusion

fluconazole in sodium chloride intravenous solution 100-0.9 mg/50ml-%, 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-%


fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

Tier 1

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

Tier 1

91

Drug Name Drug Tier Notesitraconazole oral capsule 100 mg Tier 1 QL

itraconazole solution 10 mg/ml oral 10 mg/ml Benefit Exclusion

itraconazole solution 10 mg/ml oral 10 mg/ml EX Formulary Exclusion

itraconazole solution 10 mg/ml oral 10 mg/ml Tier 1

NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7ML EX Medical Only Exclusion

NOXAFIL ORAL SUSPENSION 40 MG/ML Tier 2

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG EX Formulary Exclusion

posaconazole oral tablet delayed release 100 mg Tier 1

SPORANOX ORAL CAPSULE 100 MG EX Formulary Exclusion; QL

SPORANOX ORAL SOLUTION 10 MG/ML EX Formulary Exclusion

SPORANOX PULSEPAK ORAL CAPSULE100 MG EX Formulary Exclusion; QL

tolsura oral capsule 65 mg Benefit Exclusion Non Essential Drug Exclusion

VFEND IV INTRAVENOUS SOLUTION RECONSTITUTED 200 MG EX Medical Only Exclusion

VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML EX Formulary Exclusion

VFEND ORAL TABLET 200 MG, 50 MG EX Formulary Exclusion

voriconazole intravenous solution reconstituted200 mg


voriconazole oral suspension reconstituted 40 mg/ml

Tier 1

voriconazole oral tablet 200 mg, 50 mg Tier 1

*Antihistamines*

*Antihistamines - Alkylamines***brompheniramine maleate intramuscular solution10 mg/ml


dexchlorpheniramine maleate oral solution 2 mg/5ml

Benefit Exclusion

RYCLORA ORAL SOLUTION 2 MG/5ML Tier 3

*Antihistamines - Ethanolamines***carbinoxamine maleate oral solution 4 mg/5ml Tier 1

carbinoxamine maleate tablet 4 mg oral 4 mg Tier 1

carbinoxamine maleate tablet 6 mg oral 6 mg Benefit Exclusion

clemastine fumarate oral syrup 0.67 mg/5ml Benefit Exclusion Non Essential Drug Exclusion

clemastine fumarate oral tablet 2.68 mg Tier 1

DICOPANOL FUSEPAQ ORAL SUSPENSION RECONSTITUTED 5 MG/ML EX Non FDA Exclusion

92

Drug Name Drug Tier NotesDICOPANOL RAPIDPAQ ORAL SUSPENSION RECONSTITUTED 5 MG/ML EX Non FDA Exclusion

diphen oral elixir 12.5 mg/5ml Benefit Exclusion

di-phen oral elixir 12.5 mg/5ml Benefit Exclusion

diphenhydramine hcl injection solution 50 mg/ml Tier 1

diphenhydramine hcl oral elixir 12.5 mg/5ml Tier 1

KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 MG/5ML Benefit Exclusion Non Essential Drug Exclusion

RYVENT ORAL TABLET 6 MG Tier 3

*Antihistamines - Non-Sedating***cetirizine hcl oral solution 1 mg/ml, 5 mg/5ml Tier 1

CLARINEX ORAL TABLET 5 MG EX Formulary Exclusion

desloratadine oral tablet 5 mg Tier 1

desloratadine tablet dispersible 2.5 mg oral 2.5 mg

Tier 3

desloratadine tablet dispersible 2.5 mg oral 2.5 mg

Tier 1

desloratadine tablet dispersible 5 mg oral 5 mg Tier 3

desloratadine tablet dispersible 5 mg oral 5 mg Tier 1

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

Tier 1

levocetirizine dihydrochloride oral tablet 5 mg Tier 1

QUZYTTIR INTRAVENOUS SOLUTION 10 MG/ML EX Formulary Exclusion

*Antihistamines - Phenothiazines***PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG Tier 1

PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML Tier 3

promethazine hcl injection solution 25 mg/ml, 50 mg/ml

Tier 1

promethazine hcl oral solution 6.25 mg/5ml Tier 1

promethazine hcl oral syrup 6.25 mg/5ml Tier 1

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

Tier 1

promethazine hcl rectal suppository 12.5 mg, 25 mg

Tier 1

PROMETHEGAN RECTAL SUPPOSITORY12.5 MG, 25 MG, 50 MG Tier 1

*Antihistamines - Piperidines***cyproheptadine hcl oral syrup 2 mg/5ml Tier 1

93

Drug Name Drug Tier Notescyproheptadine hcl tablet 4 mg oral 4 mg Tier 1

cyproheptadine hcl tablet 4 mg oral 4 mg Benefit Exclusion

*Antihistamines W/ Corticosteroids***CLOBETEX COMBINATION THERAPY PACK 5 & 0.05 MG & % Benefit Exclusion

*Antihyperlipidemics*

*Acl Inhib-Intestinal Cholesterol Absorption Inhib Comb***NEXLIZET ORAL TABLET 180-10 MG Tier 2 PA

*Adenosine Triphosphate-Citrate Lyase (Acl) Inhibitors***NEXLETOL ORAL TABLET 180 MG Tier 2 PA

*Angiopoietin-Like Protein 3 (Angptl3) Inhibitors***EVKEEZA INTRAVENOUS SOLUTION1200 MG/8ML, 345 MG/2.3ML EX Medical Only Exclusion

*Antihyperlipidemics - Misc.***icosapent ethyl oral capsule 1 gm Tier 1

LOVAZA ORAL CAPSULE 1 GM EX Formulary Exclusion

omega-3-acid ethyl esters oral capsule 1 gm EX Formulary Exclusion

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM Tier 2

*Antihyperlipidemics Misc. Combinations***omega-3 rx complete oral therapy pack 1 gm EX Non FDA Exclusion

sure result o3d3 system oral kit 1 & 1000 gm & unit


*Bile Acid Sequestrants***cholestyramine light oral packet 4 gm Tier 1

cholestyramine light oral powder 4 gm/dose Tier 1

cholestyramine oral packet 4 gm Tier 1

cholestyramine oral powder 4 gm/dose Tier 1

colesevelam hcl oral packet 3.75 gm Tier 1

colesevelam hcl oral tablet 625 mg Tier 1

COLESTID FLAVORED ORAL GRANULES5 GM EX Formulary Exclusion

COLESTID FLAVORED ORAL PACKET 5 GM EX Formulary Exclusion

COLESTID ORAL GRANULES 5 GM EX Formulary Exclusion

COLESTID ORAL PACKET 5 GM EX Formulary Exclusion

94

Drug Name Drug Tier NotesCOLESTID ORAL TABLET 1 GM EX Formulary Exclusion

colestipol hcl oral granules 5 gm Tier 1

colestipol hcl oral packet 5 gm Tier 1

colestipol hcl oral tablet 1 gm Tier 1

PREVALITE ORAL PACKET 4 GM Tier 1

PREVALITE ORAL POWDER 4 GM/DOSE Tier 1

QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE EX Formulary Exclusion

QUESTRAN ORAL PACKET 4 GM EX Formulary Exclusion

QUESTRAN ORAL POWDER 4 GM/DOSE EX Formulary Exclusion

WELCHOL ORAL PACKET 3.75 GM EX Formulary Exclusion

WELCHOL ORAL TABLET 625 MG EX Formulary Exclusion

*Fibric Acid Derivatives***ANTARA ORAL CAPSULE 30 MG, 90 MG Tier 3

fenofibrate capsule 134 mg oral 134 mg Tier 1





fenofibrate micronized capsule 130 mg oral 130 mg

Tier 1


Tier 1


Tier 1

fenofibrate micronized capsule 30 mg oral 30 mg Tier 3




fenofibrate tablet 120 mg oral 120 mg Benefit Exclusion Non Essential Drug Exclusion

fenofibrate tablet 145 mg oral 145 mg Tier 1


fenofibrate tablet 40 mg oral 40 mg Benefit Exclusion Non Essential Drug Exclusion



fenofibric acid oral capsule delayed release 135 mg, 45 mg

Tier 1

fenofibric acid oral tablet 105 mg, 35 mg Tier 3

FENOGLIDE ORAL TABLET 120 MG, 40 MG Benefit Exclusion

95

Drug Name Drug Tier NotesFIBRICOR ORAL TABLET 105 MG, 35 MG Tier 3

gemfibrozil oral tablet 600 mg Tier 1

LIPOFEN ORAL CAPSULE 150 MG, 50 MG Tier 2

LOPID ORAL TABLET 600 MG EX Formulary Exclusion

TRICOR ORAL TABLET 145 MG, 48 MG EX Formulary Exclusion

TRIGLIDE ORAL TABLET 160 MG Tier 3

TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 MG, 45 MG EX Formulary Exclusion

*Hmg Coa Reductase Inhibitors***ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR 20 MG, 40 MG, 60 MG Tier 3

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

Tier 1

CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG EX Formulary Exclusion

EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 20 MG, 40 MG, 5 MG Benefit Exclusion

flolipid oral suspension 20 mg/5ml, 40 mg/5ml Benefit Exclusion Non Essential Drug Exclusion

fluvastatin sodium er oral tablet extended release 24 hour 80 mg

Tier 1

fluvastatin sodium oral capsule 20 mg, 40 mg Tier 1

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 80 MG EX Formulary Exclusion

LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG EX Formulary Exclusion

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG Tier 2

lovastatin tablet 10 mg oral 10 mg Tier 1



PRAVACHOL ORAL TABLET 20 MG, 40 MG EX Formulary Exclusion

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

Tier 1

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Tier 1

simvastatin oral suspension 20 mg/5ml Benefit Exclusion Non Essential Drug Exclusion

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

Tier 1

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG EX Formulary Exclusion

96

Drug Name Drug Tier NotesZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG EX Formulary Exclusion

*Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb***ezetimibe-rosuvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-5 mg

Tier 3

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

Tier 1

ROSZET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-5 MG Tier 3

VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG EX Formulary Exclusion

*Intestinal Cholesterol Absorption Inhibitors***ezetimibe oral tablet 10 mg Tier 1

ZETIA ORAL TABLET 10 MG EX Formulary Exclusion

*Microsomal Triglyceride Transfer Protein Inhibitors***JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG Tier 4 PA; Specialty

*Nicotinic Acid Derivatives***niacin (antihyperlipidemic) tablet 500 mg oral500 mg

Tier 1

niacin (antihyperlipidemic) tablet 500 mg oral500 mg

Tier 3

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

Tier 1

NIACOR ORAL TABLET 500 MG Tier 3

NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 500 MG, 750 MG EX Formulary Exclusion

*Pcsk9 Inhibitors***PRALUENT SOLUTION AUTO-INJECTOR 150 MG/ML SUBCUTANEOUS 150 MG/ML EX PA; ST; Formulary Exclusion; QL

PRALUENT SOLUTION AUTO-INJECTOR 75 MG/ML SUBCUTANEOUS 75 MG/ML EX PA; Formulary Exclusion; QL

PRALUENT SOLUTION AUTO-INJECTOR 75 MG/ML SUBCUTANEOUS 75 MG/ML EX PA; ST; Formulary Exclusion; QL

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE420 MG/3.5ML

Tier 2 PA; QL

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML Tier 2 PA; QL

97

Drug Name Drug Tier NotesREPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML Tier 2 PA; QL

*Small Interfering Rna (Sirna) Pcsk9 Inhibitors***LEQVIO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 284 MG/1.5ML EX New to Market Exclusion

*Antihypertensives*

*Ace Inhibitor & Calcium Channel Blocker Combinations***amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

Tier 1

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG EX Formulary Exclusion

PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG Tier 3

TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2-240 MG, 4-240 MG EX Formulary Exclusion

trandolapril-verapamil hcl er tablet extended release 1-240 mg oral 1-240 mg

Tier 3


Tier 1


Tier 1


Tier 1

*Ace Inhibitors & Thiazide/Thiazide-Like***ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG EX Formulary Exclusion

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

Tier 1

captopril-hydrochlorothiazide tablet 25-15 mg oral 25-15 mg

Tier 3


Tier 1


Tier 3


Tier 1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

Tier 1

98

Drug Name Drug Tier Notesfosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

Tier 1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

Tier 1

LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG EX Formulary Exclusion

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

Tier 1

VASERETIC ORAL TABLET 10-25 MG EX Formulary Exclusion

ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG EX Formulary Exclusion

*Ace Inhibitors***ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG EX Formulary Exclusion

ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG EX Formulary Exclusion

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Tier 1

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

Tier 1

enalapril maleate oral solution 1 mg/ml Tier 1

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

Tier 1

enalaprilat intravenous injectable 1.25 mg/ml EX Medical Only Exclusion

EPANED ORAL SOLUTION 1 MG/ML EX Formulary Exclusion

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg Tier 1

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

Tier 1

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG EX Formulary Exclusion

moexipril hcl oral tablet 15 mg, 7.5 mg Tier 1

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

Tier 1

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG EX Formulary Exclusion

QBRELIS ORAL SOLUTION 1 MG/ML Tier 3

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Tier 1

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

Tier 1

trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1

99

Drug Name Drug Tier NotesVASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG EX Formulary Exclusion

ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG EX Formulary Exclusion

*Adrenolytics-Central & Thiazide/Thiazide-Like Comb***methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

Tier 3

*Agents For Pheochromocytoma***

DEMSER ORAL CAPSULE 250 MG EX PA; Specialty; Formulary Exclusion

DIBENZYLINE ORAL CAPSULE 10 MG EX PA; Specialty; Formulary Exclusion

metyrosine oral capsule 250 mg Tier 4 PA; Specialty

phenoxybenzamine hcl oral capsule 10 mg Tier 4 PA; Specialty

phentolamine mesylate injection solution reconstituted 5 mg


*Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb***amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

Tier 1

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg

Tier 1

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG EX Formulary Exclusion

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 5-320 MG EX Formulary Exclusion

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg

Tier 1

TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80-5 MG EX Formulary Exclusion

*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like***ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32-25 MG EX Formulary Exclusion

AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG EX Formulary Exclusion

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG EX Formulary Exclusion

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

Tier 1

100

Drug Name Drug Tier NotesDIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG


EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG Tier 3

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG EX Formulary Exclusion

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

Tier 1

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

Tier 1

MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80-25 MG EX Formulary Exclusion

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

Tier 1

telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

Tier 1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

Tier 1

*Angiotensin Ii Receptor Antagonists***ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG EX Formulary Exclusion

AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG EX Formulary Exclusion

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG EX Formulary Exclusion

candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

Tier 1

COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG EX Formulary Exclusion

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG EX Formulary Exclusion

EDARBI ORAL TABLET 40 MG, 80 MG Tier 3

irbesartan oral tablet 150 mg, 300 mg, 75 mg Tier 1

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

Tier 1

MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG EX Formulary Exclusion

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

Tier 1

telmisartan oral tablet 20 mg, 40 mg, 80 mg Tier 1

101

Drug Name Drug Tier Notesvalsartan oral solution 4 mg/ml Tier 3

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

Tier 1

*Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides***amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

Tier 1

EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG

Tier 3

olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

Tier 1

TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG


*Antiadrenergics - Centrally Acting***CATAPRES ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG EX Formulary Exclusion

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24HR EX Formulary Exclusion



clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Tier 1

clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr

Tier 1

guanfacine hcl oral tablet 1 mg, 2 mg Tier 1

methyldopa oral tablet 250 mg, 500 mg Tier 1

NEXICLON XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.17 MG EX New to Market Exclusion

*Antiadrenergics - Peripherally Acting***CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG EX Formulary Exclusion

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

Tier 1

MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG EX Formulary Exclusion

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg Tier 1

102

Drug Name Drug Tier Notesterazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

Tier 1

*Antihypertensives - Misc.***VECAMYL ORAL TABLET 2.5 MG Tier 4 PA; Specialty

*Beta Blocker & Diuretic Combinations***atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

Tier 1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

Tier 1

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG


LOPRESSOR HCT ORAL TABLET 50-25 MG EX Formulary Exclusion

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

Tier 1

propranolol-hctz tablet 40-25 mg oral 40-25 mg Tier 3

propranolol-hctz tablet 80-25 mg oral 80-25 mg Tier 1

TENORETIC 100 ORAL TABLET 100-25 MG EX Formulary Exclusion

TENORETIC 50 ORAL TABLET 50-25 MG EX Formulary Exclusion

ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG EX Formulary Exclusion

*Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb***TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG Tier 3

*Direct Renin Inhibitors***aliskiren fumarate oral tablet 150 mg, 300 mg Tier 1

TEKTURNA ORAL TABLET 150 MG, 300 MG EX Formulary Exclusion

*Dopamine D1 Receptor Agonists***CORLOPAM INTRAVENOUS SOLUTION10 MG/ML, 20 MG/2ML EX Medical Only Exclusion

*Selective Aldosterone Receptor Antagonists (Saras)***eplerenone oral tablet 25 mg, 50 mg Tier 1

INSPRA ORAL TABLET 25 MG, 50 MG EX Formulary Exclusion

*Vasodilators***hydralazine hcl injection solution 20 mg/ml EX Medical Only Exclusion

103

Drug Name Drug Tier Noteshydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

Tier 1

minoxidil oral tablet 10 mg, 2.5 mg Tier 1

NIPRIDE RTU INTRAVENOUS SOLUTION20-0.9 MG/100ML-%, 50-0.9 MG/100ML-% EX


nitroprusside sodium intravenous solution 25 mg/ml


sodium nitroprusside intravenous solution 25 mg/ml, 50 mg/2ml


*Anti-Infective Agents - Misc.*

*Anti-Infective Agents - Misc.***AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG Tier 3

bacitracin intramuscular solution reconstituted50000 unit


FIRST-METRONIDAZOLE ORAL SUSPENSION RECONSTITUTED 50 MG/ML

Tier 3

FLAGYL ORAL CAPSULE 375 MG EX Formulary Exclusion

FLAGYL ORAL TABLET 500 MG EX Formulary Exclusion

IMPAVIDO ORAL CAPSULE 50 MG Tier 4 PA; Specialty; QL

METRONIDAZOLE BENZO+SYRSPEND ORAL SUSPENSION RECONSTITUTED 50 MG/ML


metronidazole oral capsule 375 mg Tier 1

metronidazole oral tablet 250 mg, 500 mg Tier 1

metronidazole solution 500 mg/100ml intravenous 500 mg/100ml

Tier 1

metronidazole solution 500 mg/100ml intravenous 500 mg/100ml

Tier 3

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG EX Formulary Exclusion

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG EX Medical Only Exclusion

pentamidine isethionate inhalation solution reconstituted 300 mg

Tier 1

pentamidine isethionate injection solution reconstituted 300 mg


PRIMSOL ORAL SOLUTION 50 MG/5ML Tier 3

tinidazole oral tablet 250 mg, 500 mg Tier 1

trimethoprim oral tablet 100 mg Tier 1

XIFAXAN TABLET 200 MG ORAL 200 MG Tier 3 PA; QL

104

Drug Name Drug Tier NotesXIFAXAN TABLET 550 MG ORAL 550 MG Tier 2 PA; QL

*Anti-Infective Misc. - Combinations***BACTRIM DS ORAL TABLET 800-160 MG EX Formulary Exclusion

BACTRIM ORAL TABLET 400-80 MG EX Formulary Exclusion

sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5ml


sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

Tier 1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

Tier 1

SULFATRIM PEDIATRIC ORAL SUSPENSION 200-40 MG/5ML Tier 1

*Antiprotozoal Agents***ALINIA ORAL TABLET 500 MG EX Insufficient Evidence; QL

ALINIA SUSPENSION RECONSTITUTED 100 MG/5ML ORAL 100 MG/5ML Tier 2 Insufficient Evidence; QL

ALINIA SUSPENSION RECONSTITUTED 100 MG/5ML ORAL 100 MG/5ML Tier 3 Insufficient Evidence; QL

atovaquone oral suspension 750 mg/5ml Tier 1 PA; QL

LAMPIT ORAL TABLET 120 MG, 30 MG Tier 3

MEPRON ORAL SUSPENSION 750 MG/5ML EX PA; Formulary Exclusion; QL

nitazoxanide tablet 500 mg oral 500 mg Tier 1 QL

nitazoxanide tablet 500 mg oral 500 mg Tier 1 Insufficient Evidence; QL

*Carbapenem Combinations***imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg


PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED 500-500 MG EX Medical Only Exclusion

RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM EX Medical Only Exclusion

VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 2 (1-1) GM EX Medical Only Exclusion

*Carbapenems***ertapenem sodium injection solution reconstituted1 gm


INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM EX Medical Only Exclusion

meropenem intravenous solution reconstituted 1 gm, 500 mg


105

Drug Name Drug Tier Notesmeropenem-sodium chloride intravenous solution reconstituted 1 gm/50ml, 500 mg/50ml


*Chloramphenicals***chloramphenicol sod succinate intravenous solution reconstituted 1 gm


*Cyclic Lipopeptides***CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

daptomycin intravenous solution reconstituted350 mg, 500 mg


*Glycopeptides***DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 MG/ML Tier 3

KIMYRSA INTRAVENOUS SOLUTION RECONSTITUTED 1200 MG EX


ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED 400 MG EX Medical Only Exclusion

VANCOCIN ORAL CAPSULE 125 MG, 250 MG EX Formulary Exclusion

vancomycin hcl in dextrose solution 1.25-5 gm/250ml-% intravenous 1.25-5 gm/250ml-%








vancomycin hcl in dextrose solution 1-5 gm/200ml-% intravenous 1-5 gm/200ml-%

Tier 3

vancomycin hcl in dextrose solution 500-5 mg/100ml-% intravenous 500-5 mg/100ml-%

Tier 3

vancomycin hcl in dextrose solution 750-5 mg/150ml-% intravenous 750-5 mg/150ml-%

Tier 3

vancomycin hcl in nacl solution 1.25-0.9 gm/250ml-% intravenous 1.25-0.9 gm/250ml-%






106

Drug Name Drug Tier Notesvancomycin hcl in nacl solution 1.5-0.9 gm/500ml-% intravenous 1.5-0.9 gm/500ml-%




vancomycin hcl in nacl solution 1-0.9 gm/200ml-% intravenous 1-0.9 gm/200ml-%

Tier 3







vancomycin hcl in nacl solution 500-0.9 mg/100ml-% intravenous 500-0.9 mg/100ml-%

Tier 3






Tier 3

vancomycin hcl intravenous solution 1000 mg/200ml, 1250 mg/250ml, 1500 mg/300ml, 1750 mg/350ml, 2000 mg/400ml, 500 mg/100ml, 750 mg/150ml

Tier 3

vancomycin hcl oral capsule 125 mg, 250 mg Tier 1

vancomycin hcl oral solution reconstituted 250 mg/5ml

Tier 3

vancomycin hcl solution reconstituted 1 gm intravenous 1 gm

Tier 1

vancomycin hcl solution reconstituted 1.25 gm intravenous 1.25 gm

Tier 3

vancomycin hcl solution reconstituted 1.5 gm intravenous 1.5 gm

Tier 1


Tier 1


Tier 2

vancomycin hcl solution reconstituted 250 mg intravenous 250 mg

Tier 3


Tier 1


Tier 1

107

Drug Name Drug Tier Notesvancomycin hcl solution reconstituted 750 mg intravenous 750 mg

Tier 1


Tier 2

VANCOMYCIN+SYRSPEND SF ORAL SUSPENSION 50 MG/ML EX Non FDA Exclusion

VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 MG EX Medical Only Exclusion

*Leprostatics***dapsone oral tablet 100 mg, 25 mg Tier 1

*Lincosamides***CLEOCIN ORAL CAPSULE 150 MG, 300 MG, 75 MG EX Formulary Exclusion

CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML EX Formulary Exclusion

CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML, 600 MG/4ML, 9 GM/60ML, 900 MG/6ML


clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

Tier 1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

Tier 1

clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml


clindamycin phosphate in nacl intravenous solution 300-0.9 mg/50ml-%, 600-0.9 mg/50ml-%, 900-0.9 mg/50ml-%


clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml


LINCOCIN INJECTION SOLUTION 300 MG/ML EX Medical Only Exclusion

lincomycin hcl injection solution 300 mg/ml EX Medical Only Exclusion

*Monobactams***AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM EX Medical Only Exclusion

aztreonam injection solution reconstituted 1 gm, 2 gm


CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG Tier 4 PA; Specialty; QL

108


*Oxazolidinones***linezolid in sodium chloride intravenous solution600-0.9 mg/300ml-%


linezolid intravenous solution 600 mg/300ml EX Medical Only Exclusion

linezolid oral suspension reconstituted 100 mg/5ml

Tier 1

linezolid oral tablet 600 mg Tier 1

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG EX Medical Only Exclusion

SIVEXTRO ORAL TABLET 200 MG Tier 3 QL

ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML, 600 MG/300ML EX Medical Only Exclusion

ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML EX Formulary Exclusion

ZYVOX ORAL TABLET 600 MG EX Formulary Exclusion

*Pleuromutilins***XENLETA INTRAVENOUS SOLUTION 150 MG/15ML Tier 3 QL

XENLETA ORAL TABLET 600 MG Tier 3 QL

*Polymyxins***colistimethate sodium (cba) injection solution reconstituted 150 mg


COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 150 MG EX Medical Only Exclusion

polymyxin b sulfate injection solution reconstituted 500000 unit


*Streptogramin Combinations***SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 150-350 MG EX Medical Only Exclusion

*Urinary Anti-Infectives***fosfomycin tromethamine oral packet 3 gm Tier 1

HIPREX ORAL TABLET 1 GM EX Formulary Exclusion

MACROBID ORAL CAPSULE 100 MG EX Formulary Exclusion

MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 MG EX Formulary Exclusion

methenamine hippurate oral tablet 1 gm Tier 1

methenamine mandelate oral tablet 0.5 gm, 1 gm EX Formulary Exclusion

MONUROL ORAL PACKET 3 GM EX Formulary Exclusion

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg

Tier 1

109

Drug Name Drug Tier Notesnitrofurantoin monohyd macro oral capsule 100 mg

Tier 1

nitrofurantoin oral suspension 25 mg/5ml Tier 1

*Urinary Antiseptic-Antispasmodic &/Or Analgesics***HYOPHEN ORAL TABLET 81.6 MG EX Non FDA Exclusion

me/naphos/mb/hyo1 oral tablet 81.6 mg EX Non FDA Exclusion

PHOSPHASAL ORAL TABLET 81.6 MG Tier 1

URELLE ORAL TABLET 81 MG Tier 1

URIBEL ORAL CAPSULE 118 MG EX Non FDA Exclusion

URIMAR-T ORAL TABLET 120 MG EX Non FDA Exclusion

urin ds oral tablet 81.6 mg Tier 1

uro-458 oral tablet 81 mg Tier 1

UROGESIC-BLUE ORAL TABLET 81.6 MG Tier 3

uro-mp oral capsule 118 mg Tier 1

USTELL ORAL CAPSULE 120 MG EX Non FDA Exclusion

UTIRA-C ORAL TABLET 81.6 MG Tier 1

VILAMIT MB ORAL CAPSULE 118 MG EX Non FDA Exclusion

VILEVEV MB ORAL TABLET 81 MG EX Non FDA Exclusion

*Antimalarials*

*Antimalarial Combinations***atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

Tier 1

COARTEM ORAL TABLET 20-120 MG Tier 3

MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG EX Formulary Exclusion

pyrimethamine-leucovorin oral capsule 12.5-2.5 mg, 25-10 mg, 25-5 mg, 50-10 mg, 50-20 mg, 50-25 mg, 75-25 mg


*Antimalarials***ARAKODA ORAL TABLET 100 MG Tier 3

artesunate intravenous solution reconstituted 110 mg


chloroquine phosphate oral tablet 250 mg, 500 mg

Tier 1

DARAPRIM ORAL TABLET 25 MG EX PA; Specialty; Formulary Exclusion

hydroxychloroquine sulfate tablet 100 mg oral100 mg


110

Drug Name Drug Tier Noteshydroxychloroquine sulfate tablet 200 mg oral200 mg

Tier 1





KRINTAFEL ORAL TABLET 150 MG Tier 3

mefloquine hcl oral tablet 250 mg Tier 1

PLAQUENIL ORAL TABLET 200 MG EX Formulary Exclusion

primaquine phosphate tablet 26.3 (15 base) mg oral 26.3 (15 base) mg


primaquine phosphate tablet 26.3 (15 base) mg oral 26.3 (15 base) mg

Tier 1

pyrimethamine oral tablet 25 mg Tier 4 PA; Specialty

QUALAQUIN ORAL CAPSULE 324 MG EX Formulary Exclusion

quinine sulfate oral capsule 324 mg Tier 1

*Antimyasthenic/Cholinergic Agents*

*Antimyasthenic/Cholinergic Agents***BLOXIVERZ INTRAVENOUS SOLUTION10 MG/10ML, 5 MG/10ML EX Medical Only Exclusion

FIRDAPSE ORAL TABLET 10 MG Tier 4 PA; Specialty

guanidine hcl oral tablet 125 mg Tier 3

MESTINON ORAL SOLUTION 60 MG/5ML EX Formulary Exclusion

MESTINON ORAL TABLET 60 MG EX Formulary Exclusion

MESTINON ORAL TABLET EXTENDED RELEASE 180 MG EX Formulary Exclusion

neostigmine methylsulfate solution 10 mg/10ml intravenous 10 mg/10ml








neostigmine methylsulfate solution prefilled syringe 2 mg/2ml intravenous 2 mg/2ml








111

Drug Name Drug Tier Notesneostigmine methylsulfate solution prefilled syringe 5 mg/5ml intravenous 5 mg/5ml


pyridostigmine bromide er oral tablet extended release 180 mg

Tier 1

pyridostigmine bromide oral solution 60 mg/5ml Tier 1

pyridostigmine bromide tablet 30 mg oral 30 mg Tier 3

pyridostigmine bromide tablet 60 mg oral 60 mg Tier 1

REGONOL INTRAVENOUS SOLUTION 10 MG/2ML EX Medical Only Exclusion

RUZURGI ORAL TABLET 10 MG Tier 4 PA; Specialty; QL

*Antimycobacterial Agents*

*Anti Tb Combinations***RIFAMATE ORAL CAPSULE 150-300 MG Tier 3

RIFATER ORAL TABLET 50-120-300 MG Tier 3

*Antimycobacterial Agents***CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM EX Medical Only Exclusion

cycloserine oral capsule 250 mg Tier 1

ethambutol hcl oral tablet 100 mg, 400 mg Tier 1

isoniazid injection solution 100 mg/ml EX Medical Only Exclusion

isoniazid oral syrup 50 mg/5ml Tier 3

isoniazid oral tablet 100 mg, 300 mg Tier 1

MYAMBUTOL ORAL TABLET 400 MG EX Formulary Exclusion

MYCOBUTIN ORAL CAPSULE 150 MG EX Formulary Exclusion

PASER ORAL PACKET 4 GM Tier 3

pretomanid oral tablet 200 mg Tier 3 QL

PRIFTIN ORAL TABLET 150 MG Tier 2

pyrazinamide oral tablet 500 mg Tier 1

rifabutin oral capsule 150 mg Tier 1

RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED 600 MG EX Medical Only Exclusion

RIFADIN ORAL CAPSULE 150 MG, 300 MG EX Formulary Exclusion

rifampin intravenous solution reconstituted 600 mg


rifampin oral capsule 150 mg, 300 mg Tier 1

RIFAMPIN+SYRSPEND SF ORAL SUSPENSION 25 MG/ML EX Non FDA Exclusion

SIRTURO ORAL TABLET 100 MG, 20 MG Tier 4 PA; Specialty

TRECATOR ORAL TABLET 250 MG Tier 3

112


*Antineoplastics And Adjunctive Therapies*

*Alkylating Agents***BELRAPZO INTRAVENOUS SOLUTION100 MG/4ML EX Medical Only Exclusion

BENDEKA INTRAVENOUS SOLUTION 100 MG/4ML EX Medical Only Exclusion

busulfan intravenous solution 6 mg/ml EX Medical Only Exclusion

BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML EX Medical Only Exclusion

carboplatin intravenous solution 150 mg/15ml, 450 mg/45ml, 50 mg/5ml, 600 mg/60ml


cisplatin intravenous solution 100 mg/100ml, 200 mg/200ml, 50 mg/50ml


cisplatin intravenous solution reconstituted 50 mg EX Medical Only Exclusion

MYLERAN ORAL TABLET 2 MG Tier 4 PA; Specialty

oxaliplatin intravenous solution 100 mg/20ml, 200 mg/40ml, 50 mg/10ml


oxaliplatin intravenous solution reconstituted 100 mg, 50 mg


PARAPLATIN INTRAVENOUS SOLUTION1000 MG/100ML, 150 MG/15ML, 450 MG/45ML, 50 MG/5ML, 600 MG/60ML


TEPADINA INJECTION SOLUTION RECONSTITUTED 100 MG, 15 MG EX Medical Only Exclusion

thiotepa injection solution reconstituted 100 mg, 15 mg


TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 25 MG EX Medical Only Exclusion

ZEPZELCA INTRAVENOUS SOLUTION RECONSTITUTED 4 MG EX Medical Only Exclusion

*Androgen Biosynthesis Inhibitors***abiraterone acetate oral tablet 250 mg, 500 mg Tier 4 PA; Specialty; QL

YONSA ORAL TABLET 125 MG Tier 4 PA; Specialty

ZYTIGA ORAL TABLET 250 MG, 500 MG EX PA; Specialty; Formulary Exclusion

*Antiadrenals***LYSODREN ORAL TABLET 500 MG Tier 4 PA; Specialty

*Antiandrogens***bicalutamide oral tablet 50 mg Tier 1 Insufficient Evidence; QL

CASODEX TABLET 50 MG ORAL 50 MG EX Insufficient Evidence; QL

113

Drug Name Drug Tier NotesCASODEX TABLET 50 MG ORAL 50 MG Tier 3 Insufficient Evidence; QL

ERLEADA ORAL TABLET 60 MG Tier 4 PA; Specialty; QL

EULEXIN ORAL CAPSULE 125 MG Tier 3

flutamide oral capsule 125 mg Tier 1 Insufficient Evidence; QL

NILANDRON ORAL TABLET 150 MG EX PA; Specialty; Formulary Exclusion

nilutamide oral tablet 150 mg Tier 4 PA; Specialty; QL

NUBEQA ORAL TABLET 300 MG Tier 4 PA; Specialty

XTANDI ORAL CAPSULE 40 MG Tier 4 PA; Specialty; QL

XTANDI ORAL TABLET 40 MG, 80 MG Tier 4 PA; Specialty

*Antiestrogens***FARESTON ORAL TABLET 60 MG EX Insufficient Evidence; QL

SOLTAMOX ORAL SOLUTION 10 MG/5ML Tier 5

tamoxifen citrate oral tablet 10 mg, 20 mg Tier 5

toremifene citrate oral tablet 60 mg Tier 1 Insufficient Evidence; QL

*Antimetabolites***ADRUCIL INTRAVENOUS SOLUTION 2.5 GM/50ML, 5 GM/100ML, 500 MG/10ML EX Medical Only Exclusion

ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 500 MG EX Medical Only Exclusion

ARRANON INTRAVENOUS SOLUTION 5 MG/ML EX Medical Only Exclusion

azacitidine injection suspension reconstituted 100 mg


capecitabine oral tablet 150 mg, 500 mg Tier 4 PA; Specialty

cladribine intravenous solution 10 mg/10ml EX Medical Only Exclusion

clofarabine intravenous solution 1 mg/ml EX Medical Only Exclusion

CLOLAR INTRAVENOUS SOLUTION 1 MG/ML EX Medical Only Exclusion

cytarabine (pf) injection solution 100 mg/ml, 20 mg/ml


cytarabine injection solution 20 mg/ml EX Medical Only Exclusion

DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG EX Medical Only Exclusion

decitabine intravenous solution reconstituted 50 mg


floxuridine injection solution reconstituted 0.5 gm EX Medical Only Exclusion

fludarabine phosphate intravenous solution 50 mg/2ml


fludarabine phosphate intravenous solution reconstituted 50 mg


114

Drug Name Drug Tier Notesfluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml


FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML, 40 MG/2ML EX Medical Only Exclusion

gemcitabine hcl intravenous solution 1 gm/10ml, 1 gm/26.3ml, 1.5 gm/15ml, 2 gm/20ml, 2 gm/52.6ml, 200 mg/2ml, 200 mg/5.26ml


gemcitabine hcl intravenous solution reconstituted 1 gm, 2 gm, 200 mg


INFUGEM INTRAVENOUS SOLUTION1200-0.9 MG/120ML-%, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 MG/160ML-%, 1700-0.9 MG/170ML-%, 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-%


mercaptopurine oral tablet 50 mg Tier 1

methotrexate oral tablet 2.5 mg Tier 1

methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml

Tier 1

methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml

Tier 1

methotrexate sodium injection solution reconstituted 1 gm

Tier 1

methotrexate sodium oral tablet 2.5 mg Tier 1

nelarabine intravenous solution 5 mg/ml EX Medical Only Exclusion

ONUREG ORAL TABLET 200 MG, 300 MG Tier 4 PA; Specialty

pemetrexed disodium intravenous solution 100 mg/4ml, 500 mg/20ml


pemetrexed disodium intravenous solution reconstituted 100 mg, 1000 mg, 500 mg, 750 mg


pemetrexed solution 1 gm/40ml intravenous 1 gm/40ml


pemetrexed solution 100 mg/4ml intravenous 100 mg/4ml


pemetrexed solution 500 mg/20ml intravenous500 mg/20ml

EX New to Market Exclusion; Medical Only Exclusion

PEMFEXY INTRAVENOUS SOLUTION 500 MG/20ML EX Medical Only Exclusion

PURIXAN ORAL SUSPENSION 2000 MG/100ML Tier 2

TABLOID ORAL TABLET 40 MG Tier 4 PA; Specialty

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG Tier 3

115

Drug Name Drug Tier NotesVIDAZA INJECTION SUSPENSION RECONSTITUTED 100 MG EX Medical Only Exclusion

XATMEP ORAL SOLUTION 2.5 MG/ML Benefit Exclusion Non Essential Drug Exclusion

XELODA ORAL TABLET 150 MG, 500 MG EX PA; Specialty; Formulary Exclusion

*Antineoplastic - Alk Inhibitors***ALECENSA ORAL CAPSULE 150 MG Tier 4 PA; Specialty

ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG Tier 4 PA; Specialty

ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG Tier 4 PA; Specialty

LORBRENA ORAL TABLET 100 MG, 25 MG Tier 4 PA; Specialty

XALKORI ORAL CAPSULE 200 MG, 250 MG Tier 4 PA; Specialty; QL

ZYKADIA ORAL CAPSULE 150 MG Tier 4 PA; Specialty; QL

ZYKADIA ORAL TABLET 150 MG Tier 4 PA; Specialty

*Antineoplastic - Anti-Bcma Antibody-Drug Complex***BLENREP INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX Medical Only Exclusion

*Antineoplastic - Antibody Combinations***OPDUALAG INTRAVENOUS SOLUTION240-80 MG/20ML EX Medical Only Exclusion

*Antineoplastic - Anti-Ccr4 Antibodies***POTELIGEO INTRAVENOUS SOLUTION20 MG/5ML EX Medical Only Exclusion

*Antineoplastic - Anti-Cd19 Antibodies***MONJUVI INTRAVENOUS SOLUTION RECONSTITUTED 200 MG EX Medical Only Exclusion

*Antineoplastic - Anti-Cd19 Antibody-Drug Complex***ZYNLONTA INTRAVENOUS SOLUTION RECONSTITUTED 10 MG EX Medical Only Exclusion

116


*Antineoplastic - Anti-Cd20 Antibodies***ARZERRA INTRAVENOUS CONCENTRATE 100 MG/5ML, 1000 MG/50ML


GAZYVA INTRAVENOUS SOLUTION 1000 MG/40ML EX Medical Only Exclusion

RIABNI INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML Tier 4 PA; Specialty

RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML Tier 4 PA; Specialty; QL

RUXIENCE INTRAVENOUS SOLUTION100 MG/10ML, 500 MG/50ML EX


TRUXIMA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML EX


*Antineoplastic - Anti-Cd22 Antibodies***LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 1 MG EX Medical Only Exclusion

*Antineoplastic - Anti-Cd22 Antibody-Drug Complex***BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED 0.9 MG EX Medical Only Exclusion

*Antineoplastic - Anti-Cd30 Antibody-Drug Complex***ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG EX Medical Only Exclusion

*Antineoplastic - Anti-Cd33 Antibody-Drug Complex***MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG EX Medical Only Exclusion

*Antineoplastic - Anti-Cd38 Antibodies***DARZALEX INTRAVENOUS SOLUTION100 MG/5ML, 400 MG/20ML EX Medical Only Exclusion

SARCLISA INTRAVENOUS SOLUTION 100 MG/5ML, 500 MG/25ML EX Medical Only Exclusion

*Antineoplastic - Anti-Cd79b Antibody-Drug Complex***POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 140 MG, 30 MG EX Medical Only Exclusion

117


*Antineoplastic - Anti-Ctla-4 Antibodies***YERVOY INTRAVENOUS SOLUTION 200 MG/40ML, 50 MG/10ML Tier 4 PA; Specialty

*Antineoplastic - Anti-Gd2 Antibodies***DANYELZA INTRAVENOUS SOLUTION 40 MG/10ML EX Medical Only Exclusion

UNITUXIN INTRAVENOUS SOLUTION17.5 MG/5ML EX Medical Only Exclusion

*Antineoplastic - Anti-Her2 Agents***HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG EX Medical Only Exclusion

HERZUMA INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG EX Medical Only Exclusion

KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG EX Medical Only Exclusion

MARGENZA INTRAVENOUS SOLUTION250 MG/10ML EX Medical Only Exclusion

OGIVRI INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG EX Medical Only Exclusion

ONTRUZANT INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG EX Medical Only Exclusion

PERJETA INTRAVENOUS SOLUTION 420 MG/14ML EX Medical Only Exclusion

TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 420 MG EX Medical Only Exclusion

TUKYSA ORAL TABLET 150 MG, 50 MG Tier 4 PA; Specialty

*Antineoplastic - Anti-Nectin-4 Antibody-Drug Complex***PADCEV INTRAVENOUS SOLUTION RECONSTITUTED 20 MG, 30 MG EX Medical Only Exclusion

*Antineoplastic - Anti-Pd-1 Antibodies***JEMPERLI INTRAVENOUS SOLUTION 500 MG/10ML EX Medical Only Exclusion

KEYTRUDA INTRAVENOUS SOLUTION100 MG/4ML EX Medical Only Exclusion

LIBTAYO INTRAVENOUS SOLUTION 350 MG/7ML EX Medical Only Exclusion

118

Drug Name Drug Tier NotesOPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 120 MG/12ML, 240 MG/24ML, 40 MG/4ML


*Antineoplastic - Anti-Pd-L1 Antibodies***BAVENCIO INTRAVENOUS SOLUTION200 MG/10ML EX Medical Only Exclusion

IMFINZI INTRAVENOUS SOLUTION 120 MG/2.4ML, 500 MG/10ML EX Medical Only Exclusion

TECENTRIQ INTRAVENOUS SOLUTION1200 MG/20ML, 840 MG/14ML EX Medical Only Exclusion

*Antineoplastic - Anti-Slamf7 Antibodies***EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG EX Medical Only Exclusion

*Antineoplastic - Anti-Tf Antibody-Drug Complex***TIVDAK INTRAVENOUS SOLUTION RECONSTITUTED 40 MG EX Medical Only Exclusion

*Antineoplastic - Autologous Cellular Immunotherapy***ABECMA INTRAVENOUS SUSPENSION460000000 CELLS EX Medical Only Exclusion

BREYANZI INTRAVENOUS SUSPENSION70000000 CELLS EX Medical Only Exclusion

CARVYKTI INTRAVENOUS SUSPENSION100000000 CELLS EX Medical Only Exclusion

KYMRIAH INTRAVENOUS SUSPENSION250000000 CELLS, 600000000 CELLS EX Medical Only Exclusion

PROVENGE INTRAVENOUS SUSPENSION50000000 CELLS EX Medical Only Exclusion

TECARTUS INTRAVENOUS SUSPENSION100000000 CELLS, 200000000 CELLS EX Medical Only Exclusion

YESCARTA INTRAVENOUS SUSPENSION200000000 CELLS EX Medical Only Exclusion

*Antineoplastic - Bcl-2 Inhibitors***VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG Tier 4 PA; Specialty

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG


119


*Antineoplastic - Bcr-Abl Kinase Inhibitors***BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG Tier 4 PA; ST; Specialty; QL

GLEEVEC ORAL TABLET 100 MG, 400 MG EX PA; Specialty; Formulary Exclusion

ICLUSIG TABLET 10 MG ORAL 10 MG Tier 4 PA; Specialty

ICLUSIG TABLET 15 MG ORAL 15 MG Tier 4 PA; Specialty; QL

ICLUSIG TABLET 30 MG ORAL 30 MG Tier 4 PA; Specialty

ICLUSIG TABLET 45 MG ORAL 45 MG Tier 4 PA; Specialty; QL

imatinib mesylate tablet 100 mg oral 100 mg Tier 4 PA; Specialty; QL

imatinib mesylate tablet 100 mg oral 100 mg Tier 4 PA; ST; Specialty; QL

imatinib mesylate tablet 400 mg oral 400 mg Tier 4 PA; Specialty; QL

imatinib mesylate tablet 400 mg oral 400 mg Tier 4 PA; ST; Specialty; QL

SCEMBLIX ORAL TABLET 20 MG, 40 MG Tier 4 PA; Specialty

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG Tier 4 PA; ST; Specialty; QL

TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG Tier 4 PA; ST; Specialty; QL

*Antineoplastic - Bispecific T-Cell Engagers***BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 35 MCG EX Medical Only Exclusion

KIMMTRAK INTRAVENOUS SOLUTION100 MCG/0.5ML EX Medical Only Exclusion

*Antineoplastic - Braf Kinase Inhibitors***BRAFTOVI ORAL CAPSULE 50 MG, 75 MG Tier 4 PA; Specialty; QL

TAFINLAR ORAL CAPSULE 50 MG, 75 MG Tier 4 PA; Specialty; QL

ZELBORAF ORAL TABLET 240 MG Tier 4 PA; Specialty; QL

*Antineoplastic - Btk Inhibitors***BRUKINSA ORAL CAPSULE 80 MG Tier 4 PA; Specialty

CALQUENCE ORAL CAPSULE 100 MG Tier 4 PA; Specialty

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG Tier 4 PA; Specialty; QL

IMBRUVICA TABLET 140 MG ORAL 140 MG Tier 4 PA; Specialty; QL

IMBRUVICA TABLET 280 MG ORAL 280 MG Benefit Exclusion

120

Drug Name Drug Tier NotesIMBRUVICA TABLET 420 MG ORAL 420 MG Tier 4 PA; Specialty; QL

IMBRUVICA TABLET 560 MG ORAL 560 MG Tier 4 PA; Specialty; QL

*Antineoplastic - Egfr Inhibitors***ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML, 200 MG/100ML EX Medical Only Exclusion

erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg Tier 4 PA; Specialty; QL

EXKIVITY ORAL CAPSULE 40 MG Tier 4 PA; Specialty

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG Tier 4 PA; Specialty

IRESSA ORAL TABLET 250 MG Tier 4 PA; Specialty

PORTRAZZA INTRAVENOUS SOLUTION800 MG/50ML EX Medical Only Exclusion

TAGRISSO ORAL TABLET 40 MG, 80 MG Tier 4 PA; Specialty; QL

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG EX


VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML EX Medical Only Exclusion

VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG Tier 4 PA; Specialty

*Antineoplastic - Fgfr Kinase Inhibitors***BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG Tier 4 PA; Specialty

PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG Tier 4 PA; Specialty

TRUSELTIQ (100MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 100 MG Tier 4 PA; Specialty

TRUSELTIQ (125MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 100 & 25 MG Tier 4 PA; Specialty



*Antineoplastic - Hedgehog Pathway Inhibitors***DAURISMO ORAL TABLET 100 MG, 25 MG Tier 4 PA; Specialty

ERIVEDGE ORAL CAPSULE 150 MG Tier 4 PA; Specialty

ODOMZO ORAL CAPSULE 200 MG Tier 4 PA; Specialty

121


*Antineoplastic - Hif-2-Alpha Inhibitors***WELIREG ORAL TABLET 40 MG Tier 4 PA; Specialty

*Antineoplastic - Histone Deacetylase Inhibitors***BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG Tier 4 PA; Specialty; QL

ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 10 MG EX Medical Only Exclusion

romidepsin intravenous solution 27.5 mg/5.5ml EX Medical Only Exclusion

romidepsin intravenous solution reconstituted 10 mg


ZOLINZA ORAL CAPSULE 100 MG Tier 4 PA; Specialty; QL

*Antineoplastic - Hormonal And Related Agent Combinations***leuprolide acetate-bupivacaine intramuscular solution 25-5 mg/ml


*Antineoplastic - Immunomodulators***POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG Tier 4 PA; Specialty; QL

*Antineoplastic - Kras Inhibitors***LUMAKRAS ORAL TABLET 120 MG Tier 4 PA; Specialty

*Antineoplastic - Mek Inhibitors***COTELLIC ORAL TABLET 20 MG Tier 4 PA; Specialty; QL

KOSELUGO ORAL CAPSULE 10 MG, 25 MG Tier 4 PA; Specialty

MEKINIST ORAL TABLET 0.5 MG, 2 MG Tier 4 PA; Specialty; QL

MEKTOVI ORAL TABLET 15 MG Tier 4 PA; Specialty; QL

*Antineoplastic - Met Inhibitors***TABRECTA ORAL TABLET 150 MG, 200 MG Tier 4 PA; Specialty

TEPMETKO ORAL TABLET 225 MG Tier 4 PA; Specialty

*Antineoplastic - Methyltransferase Inhibitors***TAZVERIK ORAL TABLET 200 MG Tier 4 PA; Specialty

122


*Antineoplastic - Mtor Kinase Inhibitors***AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG Tier 4 PA; Specialty

AFINITOR TABLET 10 MG ORAL 10 MG Tier 4 PA; Specialty; QL

AFINITOR TABLET 2.5 MG ORAL 2.5 MG EX PA; Specialty; Formulary Exclusion

AFINITOR TABLET 5 MG ORAL 5 MG EX PA; Specialty; Formulary Exclusion

AFINITOR TABLET 7.5 MG ORAL 7.5 MG EX PA; Specialty; Formulary Exclusion

everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg


everolimus oral tablet soluble 2 mg, 3 mg, 5 mg Tier 4 PA; Specialty

FYARRO INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG EX Medical Only Exclusion

temsirolimus intravenous solution 25 mg/ml EX Medical Only Exclusion

TORISEL INTRAVENOUS SOLUTION 25 MG/ML EX Medical Only Exclusion

*Antineoplastic - Multikinase Inhibitors***CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG Tier 4 PA; Specialty

CAPRELSA ORAL TABLET 100 MG, 300 MG Tier 4 PA; Specialty

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 MG Tier 4 PA; Specialty

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 MG & 80 MG Tier 4 PA; Specialty

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG Tier 4 PA; Specialty

FOTIVDA ORAL CAPSULE 0.89 MG, 1.34 MG Tier 4 PA; Specialty

lapatinib ditosylate oral tablet 250 mg Tier 4 PA; Specialty; QL

NERLYNX ORAL TABLET 40 MG Tier 4 PA; Specialty; QL

NEXAVAR ORAL TABLET 200 MG Tier 4 PA; Specialty; QL

QINLOCK ORAL TABLET 50 MG Tier 4 PA; Specialty

RYDAPT ORAL CAPSULE 25 MG Tier 4 PA; Specialty

sorafenib tosylate oral tablet 200 mg Tier 4 PA

STIVARGA ORAL TABLET 40 MG Tier 4 PA; Specialty; QL

sunitinib malate capsule 12.5 mg oral 12.5 mg Tier 4 PA; Specialty; QL

123

Drug Name Drug Tier Notessunitinib malate capsule 25 mg oral 25 mg Tier 4 PA; Specialty; QL

sunitinib malate capsule 37.5 mg oral 37.5 mg Tier 4 PA; QL

sunitinib malate capsule 37.5 mg oral 37.5 mg Tier 4 PA; Specialty; QL

sunitinib malate capsule 50 mg oral 50 mg Tier 4 PA; Specialty; QL

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG EX PA; Specialty; QL

TURALIO ORAL CAPSULE 200 MG Tier 4 PA; Specialty; QL

TYKERB ORAL TABLET 250 MG EX PA; Specialty; Formulary Exclusion

UKONIQ ORAL TABLET 200 MG Tier 4 PA; Specialty

VOTRIENT ORAL TABLET 200 MG Tier 4 PA; Specialty; QL

XOSPATA ORAL TABLET 40 MG Tier 4 PA; Specialty

*Antineoplastic - Multiple Receptor Antibodies***RYBREVANT INTRAVENOUS SOLUTION350 MG/7ML EX Medical Only Exclusion

*Antineoplastic - Pdgfr-Alpha Inhibitors***AYVAKIT ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 50 MG Tier 4 PA; Specialty

*Antineoplastic - Proteasome Inhibitors***bortezomib injection solution reconstituted 1 mg, 2.5 mg, 3.5 mg


bortezomib intravenous solution reconstituted 3.5 mg


KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 10 MG, 30 MG, 60 MG EX Medical Only Exclusion

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG Tier 4 PA; Specialty; QL

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG EX Medical Only Exclusion

*Antineoplastic - Ret Inhibitors***GAVRETO ORAL CAPSULE 100 MG Tier 4 PA; Specialty

RETEVMO ORAL CAPSULE 40 MG, 80 MG Tier 4 PA; Specialty

*Antineoplastic - Tropomyosin Receptor Kinase Inhibitors***ROZLYTREK ORAL CAPSULE 100 MG, 200 MG Tier 4 PA; Specialty

VITRAKVI ORAL CAPSULE 100 MG, 25 MG Tier 4 PA; Specialty

124

Drug Name Drug Tier NotesVITRAKVI ORAL SOLUTION 20 MG/ML Tier 4 PA; Specialty

*Antineoplastic - Xpo1 Inhibitors***XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 20 MG, 50 MG Tier 4 PA; Specialty

XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 20 MG, 40 MG Tier 4 PA; Specialty

XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 20 MG, 40 MG Tier 4 PA; Specialty


XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 20 MG Tier 4 PA; Specialty


XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 20 MG Tier 4 PA; Specialty

*Antineoplastic Antibiotics***ADRIAMYCIN INTRAVENOUS SOLUTION2 MG/ML EX Medical Only Exclusion

adriamycin solution reconstituted 10 mg intravenous 10 mg


ADRIAMYCIN SOLUTION RECONSTITUTED 50 MG INTRAVENOUS50 MG


bleomycin sulfate injection solution reconstituted15 unit, 30 unit


COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG EX Medical Only Exclusion

dactinomycin intravenous solution reconstituted0.5 mg


daunorubicin hcl intravenous solution 20 mg/4ml, 50 mg/10ml


DOXIL INTRAVENOUS INJECTABLE 2 MG/ML EX Medical Only Exclusion

doxorubicin hcl intravenous solution 2 mg/ml EX Medical Only Exclusion

doxorubicin hcl intravenous solution reconstituted 10 mg


doxorubicin hcl liposomal intravenous injectable2 mg/ml


ELLENCE INTRAVENOUS SOLUTION 200 MG/100ML, 50 MG/25ML EX Medical Only Exclusion

epirubicin hcl intravenous solution 200 mg/100ml, 50 mg/25ml


125

Drug Name Drug Tier NotesIDAMYCIN PFS INTRAVENOUS SOLUTION 10 MG/10ML, 20 MG/20ML, 5 MG/5ML


idarubicin hcl intravenous solution 10 mg/10ml, 20 mg/20ml, 5 mg/5ml


JELMYTO SOLUTION RECONSTITUTED80 (2 X 40) MG EX Medical Only Exclusion

mitomycin intravenous solution reconstituted 20 mg, 40 mg, 5 mg


mitomycin intravesical solution prefilled syringe20 mg/40ml


mitoxantrone hcl intravenous concentrate 20 mg/10ml, 25 mg/12.5ml, 30 mg/15ml


MUTAMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 20 MG, 40 MG, 5 MG EX Medical Only Exclusion

valrubicin intravesical solution 40 mg/ml EX Medical Only Exclusion

VALSTAR INTRAVESICAL SOLUTION 40 MG/ML EX Medical Only Exclusion

*Antineoplastic -Antibody For Radiopharmaceutical Therapy***ZEVALIN Y-90 INTRAVENOUS KIT 3.2 MG/2ML EX Medical Only Exclusion

*Antineoplastic Antibody-Drug Complexes***ENHERTU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX Medical Only Exclusion

KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 160 MG EX Medical Only Exclusion

*Antineoplastic Combinations***DARZALEX FASPRO SUBCUTANEOUS SOLUTION 1800-30000 MG-UT/15ML EX Medical Only Exclusion

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600-10000 MG-UNT/5ML EX


INQOVI ORAL TABLET 35-100 MG Tier 4 PA; Specialty

KISQALI FEMARA (400 MG DOSE) ORAL TABLET THERAPY PACK 200 & 2.5 MG Tier 4 PA; ST; Specialty; QL

KISQALI FEMARA (600 MG DOSE) ORAL TABLET THERAPY PACK 200 & 2.5 MG Tier 4 PA; ST; Specialty; QL

KISQALI FEMARA(200 MG DOSE) ORAL TABLET THERAPY PACK 200 & 2.5 MG Tier 4 PA; ST; Specialty; QL

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG Tier 4 PA; Specialty

126

Drug Name Drug Tier NotesPHESGO SUBCUTANEOUS SOLUTION 60-60-2000 MG-MG-U/ML, 80-40-2000 MG-MG-U/ML


RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400-23400 MG -UT/11.7ML, 1600-26800 MG -UT/13.4ML


VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG EX Medical Only Exclusion

*Antineoplastic Enzymes***ASPARLAS INTRAVENOUS SOLUTION3750 UNIT/5ML EX Medical Only Exclusion

ERWINASE INJECTION SOLUTION RECONSTITUTED 10000 UNIT EX Medical Only Exclusion

ERWINAZE INJECTION SOLUTION RECONSTITUTED 10000 UNIT EX Medical Only Exclusion

ONCASPAR INJECTION SOLUTION 750 UNIT/ML EX Medical Only Exclusion

RYLAZE INTRAMUSCULAR SOLUTION10 MG/0.5ML EX Medical Only Exclusion

*Antineoplastic Radiopharmaceuticals***AZEDRA DOSIMETRIC INTRAVENOUS SOLUTION 15 MCI/ML EX Medical Only Exclusion

AZEDRA THERAPEUTIC INTRAVENOUS SOLUTION 15 MCI/ML EX Medical Only Exclusion

LUTATHERA INTRAVENOUS SOLUTION370 MBQ/ML EX Medical Only Exclusion

PLUVICTO INTRAVENOUS SOLUTION1000 MBQ/ML EX Medical Only Exclusion

QUADRAMET INTRAVENOUS SOLUTION1850 MBQ/ML EX Medical Only Exclusion

strontium chloride sr-89 intravenous solution 1 mci/ml


XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML EX Medical Only Exclusion

*Antineoplastics - Interleukins***ELZONRIS INTRAVENOUS SOLUTION1000 MCG/ML EX Medical Only Exclusion

PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 22000000 UNIT EX Medical Only Exclusion

127


*Antineoplastics - Photoactivated Agents***PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED 75 MG EX Medical Only Exclusion

UVADEX EXTRACORPOREAL SOLUTION20 MCG/ML Tier 4 PA; Specialty

*Antineoplastics Misc.***ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML Tier 4 PA; Specialty

ALFERON N INJECTION SOLUTION5000000 UNIT/ML EX Medical Only Exclusion

arsenic trioxide intravenous solution 10 mg/10ml, 12 mg/6ml


BESREMI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 500 MCG/ML Tier 4 PA; Specialty

dacarbazine intravenous solution reconstituted100 mg, 200 mg


HYDREA ORAL CAPSULE 500 MG EX Formulary Exclusion

hydroxyurea oral capsule 500 mg Tier 1

INTRON A INJECTION SOLUTION10000000 UNIT/ML, 6000000 UNIT/ML Tier 4 PA; Specialty

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT


MATULANE ORAL CAPSULE 50 MG Tier 4 PA; Specialty

NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG EX Medical Only Exclusion

SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG Tier 4 PA; Specialty

TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED 50 MG EX Medical Only Exclusion

TRISENOX INTRAVENOUS SOLUTION 12 MG/6ML EX Medical Only Exclusion

*Aromatase Inhibitors***anastrozole oral tablet 1 mg Tier 5

ARIMIDEX ORAL TABLET 1 MG EX Formulary Exclusion

AROMASIN ORAL TABLET 25 MG EX Insufficient Evidence; QL

exemestane oral tablet 25 mg Tier 5 QL

FEMARA ORAL TABLET 2.5 MG EX Formulary Exclusion

letrozole oral tablet 2.5 mg Tier 5

128


*Carboxypeptidase Enzyme Agents***VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT EX Medical Only Exclusion

*Cardiac Protective Agents***dexrazoxane hcl intravenous solution reconstituted 250 mg, 500 mg


TOTECT INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

*Chemotherapy Adjuncts - Hyperuricemia Agents***ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG EX Medical Only Exclusion

*Chemotherapy Adjuncts - Keratinocyte Growth Factors***KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG EX Medical Only Exclusion

*Cyclin-Dependent Kinases (Cdk) Inhibitors***IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG Tier 4 PA; ST; Specialty; QL

IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG Tier 4 PA; ST; Specialty

KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK 200 MG Tier 4 PA; ST; Specialty; QL



VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG Tier 4 PA; ST; Specialty; QL

*Estrogen Receptor Antagonist***FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML Tier 4 PA; Specialty

fulvestrant solution 250 mg/5ml intramuscular250 mg/5ml

Tier 4 PA

fulvestrant solution 250 mg/5ml intramuscular250 mg/5ml


*Estrogens-Antineoplastic***EMCYT ORAL CAPSULE 140 MG Tier 4 PA; Specialty

129


*Folic Acid Antagonists Rescue Agents***KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED 175 MG, 300 MG EX Medical Only Exclusion

leucovorin calcium injection solution 100 mg/10ml, 500 mg/50ml


leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg, 50 mg, 500 mg


leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

Tier 1

levoleucovorin calcium intravenous solution reconstituted 50 mg


levoleucovorin calcium pf intravenous solution175 mg/17.5ml, 250 mg/25ml


*Gonadotropin Releasing Hormone (Gnrh) Antagonists***FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG/VIAL


FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG Tier 4 PA; Specialty

ORGOVYX ORAL TABLET 120 MG Tier 4 PA; Specialty; QL

*Imidazotetrazines***TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX Medical Only Exclusion

TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG EX


temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg


*Isocitrate Dehydrogenase-1 (Idh1) Inhibitors***TIBSOVO ORAL TABLET 250 MG Tier 4 PA; Specialty

*Isocitrate Dehydrogenase-2 (Idh2) Inhibitors***IDHIFA ORAL TABLET 100 MG, 50 MG Tier 4 PA; Specialty; QL

*Janus Associated Kinase (Jak) Inhibitors***INREBIC ORAL CAPSULE 100 MG Tier 4 PA; Specialty

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG Tier 4 PA; Specialty; QL

130

Drug Name Drug Tier NotesVONJO ORAL CAPSULE 100 MG Tier 4 PA; Specialty

*Lhrh Analogs***CAMCEVI SUBCUTANEOUS PREFILLED SYRINGE 42 MG EX


ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG Tier 4 PA; Specialty; QL

leuprolide acetate injection kit 1 mg/0.2ml Tier 4 PA; Specialty; QL

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG Tier 4 PA; Specialty; QL

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG Tier 4 PA; Specialty; QL

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG Tier 4 PA; Specialty; QL

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG Tier 4 PA; Specialty; QL

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG


VANTAS SUBCUTANEOUS KIT 50 MG Tier 4 PA; Specialty

ZOLADEX SUBCUTANEOUS IMPLANT10.8 MG, 3.6 MG Tier 4 PA; Specialty

*Mitotic Inhibitors***ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG EX Medical Only Exclusion

docetaxel concentrate 160 mg/8ml intravenous160 mg/8ml


docetaxel concentrate 20 mg/ml intravenous 20 mg/ml


docetaxel concentrate 200 mg/10ml intravenous200 mg/10ml

Tier 3

docetaxel concentrate 80 mg/4ml intravenous 80 mg/4ml


docetaxel intravenous solution 160 mg/16ml, 20 mg/2ml, 80 mg/8ml


ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX Medical Only Exclusion

etoposide intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml


etoposide oral capsule 50 mg Tier 4 PA; Specialty

HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML EX Medical Only Exclusion

IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 15 MG, 45 MG EX Medical Only Exclusion

131

Drug Name Drug Tier NotesJEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML EX Medical Only Exclusion

MARQIBO INTRAVENOUS SUSPENSION 5 MG/31ML EX Medical Only Exclusion

NAVELBINE INTRAVENOUS SOLUTION10 MG/ML, 50 MG/5ML EX Medical Only Exclusion

paclitaxel intravenous concentrate 100 mg/16.7ml, 150 mg/25ml, 30 mg/5ml, 300 mg/50ml


paclitaxel protein-bound part intravenous suspension reconstituted 100 mg


teniposide intravenous solution 10 mg/ml EX Medical Only Exclusion

TOPOSAR INTRAVENOUS SOLUTION 1 GM/50ML, 100 MG/5ML, 500 MG/25ML EX Medical Only Exclusion

vinblastine sulfate intravenous solution 1 mg/ml EX Medical Only Exclusion

VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML EX Medical Only Exclusion

vincristine sulfate intravenous solution 1 mg/ml EX Medical Only Exclusion

vinorelbine tartrate intravenous solution 10 mg/ml, 50 mg/5ml


*Myeloprotective Agents***COSELA INTRAVENOUS SOLUTION RECONSTITUTED 300 MG EX Medical Only Exclusion

*Nitrogen Mustards And Related Analogues***ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG EX Medical Only Exclusion

ALKERAN ORAL TABLET 2 MG EX PA; Specialty; Formulary Exclusion

cyclophosphamide capsule 25 mg oral 25 mg Tier 1

cyclophosphamide capsule 25 mg oral 25 mg EX Formulary Exclusion

cyclophosphamide capsule 50 mg oral 50 mg Tier 1

cyclophosphamide capsule 50 mg oral 50 mg EX Formulary Exclusion

cyclophosphamide injection solution reconstituted1 gm, 2 gm, 500 mg


cyclophosphamide oral tablet 25 mg, 50 mg Tier 2

cyclophosphamide solution 1 gm/5ml intravenous1 gm/5ml

Tier 4 PA

cyclophosphamide solution 1 gm/5ml intravenous1 gm/5ml


cyclophosphamide solution 2 gm/10ml intravenous 2 gm/10ml

Tier 4 PA

132

Drug Name Drug Tier Notescyclophosphamide solution 500 mg/2.5ml intravenous 500 mg/2.5ml

Tier 4 PA

cyclophosphamide solution 500 mg/2.5ml intravenous 500 mg/2.5ml


EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG EX Medical Only Exclusion

IFEX INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 3 GM EX Medical Only Exclusion

ifosfamide intravenous solution 1 gm/20ml, 3 gm/60ml


ifosfamide intravenous solution reconstituted 1 gm, 3 gm


LEUKERAN ORAL TABLET 2 MG Tier 4 PA; Specialty

melphalan hcl intravenous solution reconstituted50 mg


melphalan oral tablet 2 mg Tier 4 PA; Specialty

PEPAXTO INTRAVENOUS SOLUTION RECONSTITUTED 20 MG EX Medical Only Exclusion

*Nitrosoureas***BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX Medical Only Exclusion

carmustine intravenous solution reconstituted 100 mg


GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG Tier 4 PA; Specialty

GLIADEL WAFER IMPLANT WAFER 7.7 MG EX Medical Only Exclusion

ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM EX Medical Only Exclusion

*Oncolytic Viral Agents - Hsv1***IMLYGIC INTRALESIONAL SUSPENSION1000000 UNIT/ML, 100000000 UNIT/ML EX Medical Only Exclusion

*Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors***ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 MG EX Medical Only Exclusion

COPIKTRA ORAL CAPSULE 15 MG, 25 MG Tier 4 PA; Specialty; QL

PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK 200 MG Tier 4 PA; Specialty

PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 200 & 50 MG Tier 4 PA; Specialty

133

Drug Name Drug Tier NotesPIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK 2 X 150 MG Tier 4 PA; Specialty

ZYDELIG ORAL TABLET 100 MG, 150 MG Tier 4 PA; Specialty; QL

*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors***LYNPARZA ORAL CAPSULE 50 MG Tier 4 PA; Specialty; QL

LYNPARZA ORAL TABLET 100 MG, 150 MG Tier 4 PA; Specialty; QL

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG Tier 4 PA; Specialty; QL

TALZENNA ORAL CAPSULE 0.25 MG, 0.5 MG, 0.75 MG, 1 MG Tier 4 PA; Specialty

ZEJULA ORAL CAPSULE 100 MG Tier 4 PA; Specialty; QL

*Progestins-Antineoplastic***DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML Tier 3

hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml


megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

Tier 1

megestrol acetate oral tablet 20 mg, 40 mg Tier 1

*Retinoids***tretinoin capsule 10 mg oral 10 mg Tier 4 PA

tretinoin capsule 10 mg oral 10 mg Tier 4 PA; Specialty

*Selective Retinoid X Receptor Agonists***bexarotene oral capsule 75 mg Tier 4 PA; Specialty

TARGRETIN ORAL CAPSULE 75 MG EX PA; Specialty; Formulary Exclusion

*Tetrahydroisoquinolines***YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG EX Medical Only Exclusion

*Topoisomerase I Inhibitors - Antibody-Drug Complex***TRODELVY INTRAVENOUS SOLUTION RECONSTITUTED 180 MG EX Medical Only Exclusion

*Topoisomerase I Inhibitors***CAMPTOSAR INTRAVENOUS SOLUTION100 MG/5ML, 300 MG/15ML, 40 MG/2ML EX Medical Only Exclusion

HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED 4 MG EX Medical Only Exclusion

134

Drug Name Drug Tier NotesHYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG Tier 4 PA; Specialty

irinotecan hcl intravenous solution 100 mg/5ml, 300 mg/15ml, 40 mg/2ml, 500 mg/25ml


ONIVYDE INTRAVENOUS INJECTABLE43 MG/10ML EX Medical Only Exclusion

topotecan hcl intravenous solution 4 mg/4ml EX Medical Only Exclusion

topotecan hcl intravenous solution reconstituted 4 mg


*Urinary Tract Protective Agents***ETHYOL INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

mesna intravenous solution 100 mg/ml EX Medical Only Exclusion

MESNEX INTRAVENOUS SOLUTION 100 MG/ML EX Medical Only Exclusion

MESNEX ORAL TABLET 400 MG Tier 4 PA; Specialty

*Vascular Endothelial Growth Factor (Vegf) Inhibitors***ALYMSYS INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML EX Medical Only Exclusion

AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML EX Medical Only Exclusion

CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML EX Medical Only Exclusion

INLYTA ORAL TABLET 1 MG, 5 MG Tier 4 PA; Specialty

LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 MG Tier 4 PA; Specialty; QL

LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 3 X 4 MG Tier 4 PA; Specialty; QL

LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 & 4 MG Tier 4 PA; Specialty; QL

LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 10 MG & 2 X 4 MG



LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 X 10 MG & 4 MG


LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 4 MG Tier 4 PA; Specialty; QL


135

Drug Name Drug Tier NotesMVASI INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML EX Medical Only Exclusion

ZALTRAP INTRAVENOUS SOLUTION 100 MG/4ML, 200 MG/8ML EX Medical Only Exclusion

ZIRABEV INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML EX Medical Only Exclusion

*Antiparkinson And Related Therapy Agents*

*Adenosine Receptor Antagonist***NOURIANZ ORAL TABLET 20 MG, 40 MG Tier 3 QL

*Antiparkinson Anticholinergics***benztropine mesylate injection solution 1 mg/ml EX Medical Only Exclusion

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

Tier 1

COGENTIN INJECTION SOLUTION 1 MG/ML Tier 3

trihexyphenidyl hcl oral solution 0.4 mg/ml Tier 1

trihexyphenidyl hcl oral tablet 2 mg, 5 mg Tier 1

*Antiparkinson Dopaminergics***amantadine hcl oral capsule 100 mg Tier 1

amantadine hcl oral solution 50 mg/5ml Tier 1

amantadine hcl oral tablet 100 mg Tier 1

bromocriptine mesylate oral capsule 5 mg Tier 1

bromocriptine mesylate oral tablet 2.5 mg Tier 1

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MG, 68.5 MG Benefit Exclusion Non Essential Drug Exclusion; QL

INBRIJA INHALATION CAPSULE 42 MG Tier 4 PA; Specialty; QL

OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK 129 & 193 MG Tier 3 QL

OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 129 MG, 193 MG, 258 MG

Tier 3 QL

PARLODEL ORAL CAPSULE 5 MG EX Formulary Exclusion

PARLODEL ORAL TABLET 2.5 MG EX Formulary Exclusion

*Antiparkinson Monoamine Oxidase Inhibitors***AZILECT ORAL TABLET 0.5 MG, 1 MG EX Formulary Exclusion

rasagiline mesylate oral tablet 0.5 mg, 1 mg Tier 1

selegiline hcl oral capsule 5 mg Tier 1

selegiline hcl oral tablet 5 mg Tier 1

136

Drug Name Drug Tier NotesXADAGO ORAL TABLET 100 MG, 50 MG Tier 3

ZELAPAR ORAL TABLET DISPERSIBLE1.25 MG Tier 3

*Central/Peripheral Comt Inhibitors***TASMAR ORAL TABLET 100 MG EX PA; Formulary Exclusion

tolcapone oral tablet 100 mg Tier 4 PA; Specialty

*Decarboxylase Inhibitors***carbidopa oral tablet 25 mg Tier 1

LODOSYN ORAL TABLET 25 MG EX Formulary Exclusion

*Levodopa Combinations***carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

Tier 1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

Tier 1

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg

Tier 1

carbidopa-levodopa-entacapone tablet 12.5-50-200 mg oral 12.5-50-200 mg

Tier 1


Tier 3


Tier 1


Tier 3

carbidopa-levodopa-entacapone tablet 25-100-200 mg oral 25-100-200 mg

Tier 1


Tier 1


Tier 1


Tier 3

carbidopa-levodopa-entacapone tablet 50-200-200 mg oral 50-200-200 mg

Tier 1

DHIVY ORAL TABLET 25-100 MG EX Formulary Exclusion

DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML Tier 4 PA; Specialty

RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

Tier 3

SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG EX Formulary Exclusion

137

Drug Name Drug Tier NotesSINEMET ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG EX Formulary Exclusion

STALEVO 100 ORAL TABLET 25-100-200 MG Tier 3

STALEVO 125 ORAL TABLET 31.25-125-200 MG Tier 3


STALEVO 200 ORAL TABLET 50-200-200 MG Tier 3



*Nonergoline Dopamine Receptor Agonists***APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML Tier 4 PA; Specialty

apomorphine hcl subcutaneous solution cartridge30 mg/3ml


KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 30 MG Tier 2

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG


MIRAPEX ORAL TABLET 0.125 MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG EX Formulary Exclusion

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR

Tier 3

pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

Tier 1

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

Tier 1

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HOUR 12 MG, 6 MG, 8 MG EX Formulary Exclusion

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

Tier 1

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

Tier 1

138


*Peripheral Comt Inhibitors***COMTAN ORAL TABLET 200 MG EX Formulary Exclusion

entacapone oral tablet 200 mg Tier 1

ONGENTYS ORAL CAPSULE 25 MG, 50 MG Tier 3 QL

*Antipsychotics/Antimanic Agents*

*Antimanic Agents***lithium carbonate er oral tablet extended release300 mg, 450 mg

Tier 1

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

Tier 1

lithium carbonate oral tablet 300 mg Tier 1

lithium oral solution 8 meq/5ml Tier 1

LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG Tier 3

*Antipsychotics - Misc.***CAPLYTA ORAL CAPSULE 42 MG EX Formulary Exclusion; QL

EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

Tier 3

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG Tier 3

GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG EX Formulary Exclusion

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG Tier 2

NUPLAZID ORAL CAPSULE 34 MG Tier 4 PA; Specialty

NUPLAZID ORAL TABLET 10 MG Tier 4 PA; Specialty

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG Tier 3

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG Tier 3

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

Tier 1

ziprasidone mesylate intramuscular solution reconstituted 20 mg

Tier 1

*Benzisoxazoles***FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG Tier 3

FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG Tier 3

139

Drug Name Drug Tier NotesINVEGA HAFYERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 1092 MG/3.5ML, 1560 MG/5ML


INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR 1.5 MG, 3 MG, 6 MG, 9 MG


INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML


INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.88ML, 410 MG/1.32ML, 546 MG/1.75ML, 819 MG/2.63ML


paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 6 mg, 9 mg

Tier 1

PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG, 90 MG Tier 2

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, 37.5 MG, 50 MG

Tier 2

RISPERDAL ORAL SOLUTION 1 MG/ML EX Formulary Exclusion

RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG EX Formulary Exclusion

risperidone oral solution 1 mg/ml Tier 1

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Tier 1

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Tier 1

*Butyrophenones***HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML

Tier 3

HALDOL INJECTION SOLUTION 5 MG/ML Tier 3

haloperidol decanoate intramuscular solution100 mg/ml, 50 mg/ml

Tier 1

haloperidol lactate injection solution 5 mg/ml Tier 1

haloperidol lactate oral concentrate 2 mg/ml Tier 1

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

Tier 1

*Dibenzodiazepines***clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

Tier 1

140

Drug Name Drug Tier Notesclozapine tablet dispersible 100 mg oral 100 mg Tier 1

clozapine tablet dispersible 12.5 mg oral 12.5 mg Tier 1

clozapine tablet dispersible 150 mg oral 150 mg Tier 3



CLOZARIL ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG EX Formulary Exclusion

VERSACLOZ ORAL SUSPENSION 50 MG/ML Tier 3

*Dibenzo-Oxepino Pyrroles***asenapine maleate sublingual tablet sublingual10 mg, 2.5 mg, 5 mg

Tier 1

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG EX Formulary Exclusion

SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24HR, 5.7 MG/24HR, 7.6 MG/24HR

Tier 3 QL

*Dibenzothiazepines***quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg

Tier 1

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

Tier 1

SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG EX Formulary Exclusion

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG


*Dibenzoxazepines***ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED 10 MG EX Formulary Exclusion

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

Tier 1

*Dihydroindolones***molindone hcl oral tablet 10 mg, 25 mg, 5 mg Tier 3

*Phenothiazines***chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

Tier 1

chlorpromazine hcl solution 25 mg/ml injection25 mg/ml

Tier 1

chlorpromazine hcl solution 50 mg/2ml injection50 mg/2ml

Tier 2

141

Drug Name Drug Tier NotesCOMPRO RECTAL SUPPOSITORY 25 MG Tier 1

fluphenazine decanoate injection solution 25 mg/ml

Tier 1

fluphenazine hcl injection solution 2.5 mg/ml Tier 2

fluphenazine hcl oral concentrate 5 mg/ml Tier 3

fluphenazine hcl oral elixir 2.5 mg/5ml Tier 3

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

Tier 1

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg Tier 1

prochlorperazine edisylate solution 10 mg/2ml injection 10 mg/2ml

Tier 1

prochlorperazine edisylate solution 50 mg/10ml injection 50 mg/10ml

Tier 2

prochlorperazine maleate oral tablet 10 mg, 5 mg Tier 1

prochlorperazine rectal suppository 25 mg Tier 1

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg


trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

Tier 1

*Quinolinone Derivatives***ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG Tier 2

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG

Tier 2

ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG

EX Insufficient Evidence

ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG EX Insufficient Evidence

ABILIFY MYCITE STARTER KIT ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG

EX Insufficient Evidence

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG EX Formulary Exclusion

aripiprazole oral solution 1 mg/ml Tier 1

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

Tier 1

aripiprazole oral tablet dispersible 10 mg, 15 mg Tier 1

ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 675 MG/2.4ML Tier 2

142

Drug Name Drug Tier NotesARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML

Tier 2

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG Tier 3

*Thienbenzodiazepines***olanzapine intramuscular solution reconstituted10 mg

Tier 1

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

Tier 1

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

Tier 1

ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED 10 MG Tier 3

ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG EX Formulary Exclusion

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 MG

Tier 3

ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 20 MG, 5 MG EX Formulary Exclusion

*Thioxanthenes***thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1

*Antiseptics & Disinfectants*

*Antiseptics & Disinfectants***formaldehyde external solution 10 %, 37 % EX Formulary Exclusion

glutaraldehyde external solution 25 % EX Formulary Exclusion

hydrogen peroxide solution 30 % EX Formulary Exclusion

*Chlorine Antiseptics***benzalkonium chloride external solution , 50 % EX Formulary Exclusion

chlorhexidine gluconate solution 20 % EX Formulary Exclusion

*Iodine Antiseptics***iodine tincture external tincture 2 % EX Formulary Exclusion

IODOFLEX EXTERNAL PAD 0.9 % EX Formulary Exclusion

IODOSORB EXTERNAL GEL 0.9 % EX Formulary Exclusion

lugols strong iodine solution 5-10 % external 5-10 %


lugols strong iodine solution 5-10 % external 5-10 %


143


*Antivirals*

*Antiretroviral Combinations***abacavir sulfate-lamivudine oral tablet 600-300 mg

Tier 1 QL

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

Tier 1 QL

ATRIPLA ORAL TABLET 600-200-300 MG EX Formulary Exclusion; QL

BIKTARVY ORAL TABLET 30-120-15 MG, 50-200-25 MG Tier 2 QL

cabenuva intramuscular suspension extended release 400 & 600 mg/2ml, 600 & 900 mg/3ml

Tier 3 PA; QL

CIMDUO ORAL TABLET 300-300 MG Tier 2 QL

COMBIVIR ORAL TABLET 150-300 MG EX Formulary Exclusion; QL

COMPLERA ORAL TABLET 200-25-300 MG Tier 3 QL

DELSTRIGO ORAL TABLET 100-300-300 MG Tier 2 QL

DESCOVY ORAL TABLET 120-15 MG, 200-25 MG Tier 2 QL

DOVATO ORAL TABLET 50-300 MG Tier 2 QL

efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg

Tier 1 QL

efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600-300-300 mg

Tier 1 QL

emtricitabine-tenofovir df tablet 100-150 mg oral100-150 mg

Tier 1 QL


Tier 1 QL


Tier 1 QL


Tier 5


Tier 5 QL

EPZICOM ORAL TABLET 600-300 MG EX Formulary Exclusion; QL

EVOTAZ ORAL TABLET 300-150 MG Tier 2 QL

GENVOYA ORAL TABLET 150-150-200-10 MG Tier 2 QL

JULUCA ORAL TABLET 50-25 MG Tier 2 QL

KALETRA ORAL SOLUTION 400-100 MG/5ML EX Formulary Exclusion

144

Drug Name Drug Tier NotesKALETRA ORAL TABLET 100-25 MG, 200-50 MG EX Formulary Exclusion; QL

lamivudine-zidovudine oral tablet 150-300 mg Tier 1 QL

lopinavir-ritonavir oral solution 400-100 mg/5ml Tier 1

lopinavir-ritonavir oral tablet 100-25 mg, 200-50 mg

Tier 1 QL

ODEFSEY ORAL TABLET 200-25-25 MG Tier 2 QL

PREZCOBIX ORAL TABLET 800-150 MG Tier 2 QL

STRIBILD ORAL TABLET 150-150-200-300 MG Tier 3 QL

SYMFI LO ORAL TABLET 400-300-300 MG EX Formulary Exclusion; QL

SYMFI ORAL TABLET 600-300-300 MG EX Formulary Exclusion; QL

SYMTUZA ORAL TABLET 800-150-200-10 MG Tier 2 QL

TEMIXYS ORAL TABLET 300-300 MG Tier 2 QL

TRIUMEQ ORAL TABLET 600-50-300 MG Tier 2 QL

TRIUMEQ PD ORAL TABLET SOLUBLE60-5-30 MG Tier 2 QL

TRIZIVIR ORAL TABLET 300-150-300 MG Tier 3 QL

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG EX Formulary Exclusion; QL

*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)***maraviroc oral tablet 150 mg, 300 mg Tier 1 QL

SELZENTRY ORAL SOLUTION 20 MG/ML Tier 3

SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG Tier 3 QL

*Antiretrovirals - Cd4-Directed Post-Attachment Inhibitor***TROGARZO INTRAVENOUS SOLUTION200 MG/1.33ML EX Medical Only Exclusion

*Antiretrovirals - Fusion Inhibitors***FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG Tier 3 QL

*Antiretrovirals - Gp120-Directed Attachment Inhibitor***RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR 600 MG Tier 4 PA; Specialty; QL

145


*Antiretrovirals - Integrase Inhibitors***APRETUDE INTRAMUSCULAR SUSPENSION EXTENDED RELEASE 600 MG/3ML

Tier 3 PA; QL

ISENTRESS HD ORAL TABLET 600 MG Tier 2 QL

ISENTRESS ORAL PACKET 100 MG Tier 2 QL

ISENTRESS ORAL TABLET 400 MG Tier 2 QL

ISENTRESS ORAL TABLET CHEWABLE100 MG, 25 MG Tier 2 QL

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG Tier 2 QL

TIVICAY PD ORAL TABLET SOLUBLE 5 MG Tier 2 QL

*Antiretrovirals - Protease Inhibitors***APTIVUS ORAL CAPSULE 250 MG Tier 3 QL

APTIVUS ORAL SOLUTION 100 MG/ML Tier 3

atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg

Tier 1 QL

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Tier 3 QL

fosamprenavir calcium oral tablet 700 mg Tier 1 QL

INVIRASE ORAL TABLET 500 MG Tier 3 QL

LEXIVA ORAL SUSPENSION 50 MG/ML Tier 3

LEXIVA ORAL TABLET 700 MG EX Formulary Exclusion; QL

NORVIR ORAL PACKET 100 MG Tier 3

NORVIR ORAL SOLUTION 80 MG/ML Tier 2

NORVIR ORAL TABLET 100 MG EX Formulary Exclusion; QL

PREZISTA ORAL SUSPENSION 100 MG/ML Tier 2

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG Tier 2 QL

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG EX Formulary Exclusion; QL

REYATAZ ORAL PACKET 50 MG Tier 3 QL

ritonavir oral tablet 100 mg Tier 1 QL

VIRACEPT ORAL TABLET 250 MG, 625 MG Tier 3 QL

146


*Antiretrovirals - Rti-Non-Nucleoside Analogues***EDURANT ORAL TABLET 25 MG Tier 3 QL

efavirenz oral capsule 200 mg, 50 mg Tier 1 QL

efavirenz oral tablet 600 mg Tier 1 QL

etravirine oral tablet 100 mg, 200 mg Tier 1 QL

INTELENCE TABLET 100 MG ORAL 100 MG EX Formulary Exclusion; QL

INTELENCE TABLET 200 MG ORAL 200 MG EX Formulary Exclusion; QL

INTELENCE TABLET 25 MG ORAL 25 MG Tier 2 QL

nevirapine er oral tablet extended release 24 hour100 mg, 400 mg

Tier 1 QL

nevirapine oral suspension 50 mg/5ml Tier 1

nevirapine oral tablet 200 mg Tier 1 QL

PIFELTRO ORAL TABLET 100 MG Tier 3 QL

RESCRIPTOR ORAL TABLET 200 MG Tier 3 QL

SUSTIVA ORAL CAPSULE 200 MG, 50 MG EX Formulary Exclusion; QL

SUSTIVA ORAL TABLET 600 MG EX Formulary Exclusion; QL

VIRAMUNE ORAL SUSPENSION 50 MG/5ML EX Formulary Exclusion

VIRAMUNE ORAL TABLET 200 MG EX Formulary Exclusion; QL

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 400 MG EX Formulary Exclusion; QL

*Antiretrovirals - Rti-Nucleoside Analogues-Purines***abacavir sulfate oral solution 20 mg/ml Tier 1

abacavir sulfate oral tablet 300 mg Tier 1 QL

didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg

Tier 1 QL

VIDEX EC CAPSULE DELAYED RELEASE 125 MG ORAL 125 MG Tier 3 QL

VIDEX EC CAPSULE DELAYED RELEASE 200 MG ORAL 200 MG EX Formulary Exclusion; QL

VIDEX EC CAPSULE DELAYED RELEASE 250 MG ORAL 250 MG EX Formulary Exclusion; QL

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM Tier 2

ZIAGEN ORAL SOLUTION 20 MG/ML EX Formulary Exclusion

ZIAGEN ORAL TABLET 300 MG EX Formulary Exclusion; QL

147


*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines***emtricitabine oral capsule 200 mg Tier 1 QL

EMTRIVA ORAL CAPSULE 200 MG EX Formulary Exclusion; QL

EMTRIVA ORAL SOLUTION 10 MG/ML Tier 3

EPIVIR ORAL SOLUTION 10 MG/ML EX Formulary Exclusion

EPIVIR ORAL TABLET 150 MG, 300 MG EX Formulary Exclusion; QL

lamivudine oral solution 10 mg/ml Tier 1

lamivudine oral tablet 150 mg, 300 mg Tier 1 QL

*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines***RETROVIR INTRAVENOUS SOLUTION 10 MG/ML EX Medical Only Exclusion

RETROVIR ORAL CAPSULE 100 MG EX Formulary Exclusion; QL

RETROVIR ORAL SYRUP 50 MG/5ML EX Formulary Exclusion

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

Tier 1 QL

zidovudine oral capsule 100 mg Tier 1 QL

zidovudine oral syrup 50 mg/5ml Tier 1

zidovudine oral tablet 300 mg Tier 1 QL

*Antiretrovirals - Rti-Nucleotide Analogues***tenofovir disoproxil fumarate oral tablet 300 mg Tier 1 QL

VIREAD ORAL POWDER 40 MG/GM Tier 2 QL

VIREAD TABLET 150 MG ORAL 150 MG Tier 2 QL



VIREAD TABLET 300 MG ORAL 300 MG EX Formulary Exclusion; QL

*Antiretrovirals Adjuvants***TYBOST ORAL TABLET 150 MG Tier 3 QL

*Antiviral Combinations***acyclovix combination therapy pack 200-10 mg-%


PAXLOVID ORAL TABLET THERAPY PACK 10 X 150 MG & 10 X 100MG, 20 X 150 MG & 10 X 100MG

Tier 3

*Cmv Agents***cidofovir intravenous solution 75 mg/ml EX Medical Only Exclusion

148

Drug Name Drug Tier Notesfoscarnet sodium intravenous solution 6000 mg/250ml


FOSCAVIR INTRAVENOUS SOLUTION6000 MG/250ML EX Medical Only Exclusion

ganciclovir intravenous solution 500 mg/250ml EX Medical Only Exclusion

ganciclovir sodium intravenous solution 500 mg/10ml


ganciclovir sodium intravenous solution reconstituted 500 mg


LIVTENCITY ORAL TABLET 200 MG Tier 4 PA; Specialty

PREVYMIS INTRAVENOUS SOLUTION240 MG/12ML, 480 MG/24ML EX Medical Only Exclusion

PREVYMIS ORAL TABLET 240 MG, 480 MG Tier 3

VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML EX Formulary Exclusion

VALCYTE ORAL TABLET 450 MG EX Formulary Exclusion

valganciclovir hcl oral solution reconstituted 50 mg/ml

Tier 1

valganciclovir hcl oral tablet 450 mg Tier 1

*Hepatitis B Agents***adefovir dipivoxil oral tablet 10 mg Tier 1 QL

BARACLUDE ORAL SOLUTION 0.05 MG/ML Tier 2

BARACLUDE ORAL TABLET 0.5 MG, 1 MG EX Formulary Exclusion; QL

entecavir oral tablet 0.5 mg, 1 mg Tier 1 QL

EPIVIR HBV ORAL SOLUTION 5 MG/ML Tier 3

EPIVIR HBV ORAL TABLET 100 MG EX Formulary Exclusion; QL

HEPSERA ORAL TABLET 10 MG EX Formulary Exclusion; QL

lamivudine oral tablet 100 mg Tier 1 QL

VEMLIDY ORAL TABLET 25 MG Tier 3

*Hepatitis C Agent - Combinations***EPCLUSA ORAL PACKET 150-37.5 MG, 200-50 MG Tier 4 PA; Specialty; QL

EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG Tier 4 PA; Specialty; QL

HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG Tier 4 PA; Specialty; QL

HARVONI ORAL TABLET 45-200 MG, 90-400 MG Tier 4 PA; Specialty; QL

149


ledipasvir-sofosbuvir oral tablet 90-400 mg EX PA; Specialty; Formulary Exclusion; QL

MAVYRET ORAL PACKET 50-20 MG Tier 4 PA; Specialty; QL

MAVYRET ORAL TABLET 100-40 MG Tier 4 PA; Specialty; QL

sofosbuvir-velpatasvir oral tablet 400-100 mg EX PA; Specialty; Formulary Exclusion; QL

VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 &250 MG EX


VOSEVI ORAL TABLET 400-100-100 MG Tier 4 PA; Specialty; QL

ZEPATIER ORAL TABLET 50-100 MG EX PA; Specialty; Formulary Exclusion; QL

*Hepatitis C Agents***PEGASYS PROCLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 180 MCG/0.5ML


PEGASYS SUBCUTANEOUS SOLUTION180 MCG/ML Tier 4 PA; Specialty

PEGASYS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 180 MCG/0.5ML Tier 4 PA; Specialty

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML Tier 4 PA; Specialty

ribavirin oral capsule 200 mg Tier 4 PA; Specialty

ribavirin oral tablet 200 mg Tier 4 PA; Specialty

SOVALDI ORAL PACKET 150 MG, 200 MG Tier 4 PA; Specialty; QL

SOVALDI ORAL TABLET 200 MG, 400 MG Tier 4 PA; Specialty; QL

*Herpes Agents - Purine Analogues***acyclovir oral capsule 200 mg Tier 1

acyclovir oral suspension 200 mg/5ml Tier 1

acyclovir oral tablet 400 mg, 800 mg Tier 1

acyclovir sodium intravenous solution 50 mg/ml EX Medical Only Exclusion

SITAVIG BUCCAL TABLET 50 MG Benefit Exclusion Non Essential Drug Exclusion

valacyclovir hcl oral tablet 1 gm, 500 mg Tier 1

VALTREX ORAL TABLET 1 GM, 500 MG EX Formulary Exclusion

ZOVIRAX ORAL SUSPENSION 200 MG/5ML EX Formulary Exclusion

ZOVIRAX ORAL TABLET 400 MG, 800 MG EX Formulary Exclusion

*Herpes Agents - Thymidine Analogues***famciclovir oral tablet 125 mg, 250 mg, 500 mg Tier 1

150


*Influenza Agents***rimantadine hcl oral tablet 100 mg EX Formulary Exclusion

*Misc. Antivirals***favipiravir oral tablet 200 mg EX New to Market Exclusion

LAGEVRIO ORAL CAPSULE 200 MG Tier 3

remdesivir intravenous solution reconstituted 100 mg, 150 mg


VEKLURY INTRAVENOUS SOLUTION 100 MG/20ML EX Medical Only Exclusion

VEKLURY INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX Medical Only Exclusion

*Neuraminidase Inhibitors***oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg

Tier 1 QL

oseltamivir phosphate oral suspension reconstituted 6 mg/ml

Tier 1

RAPIVAB INTRAVENOUS SOLUTION 200 MG/20ML EX Medical Only Exclusion

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

Tier 3 QL

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG EX Formulary Exclusion; QL

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML EX Formulary Exclusion

*Pa Endonuclease Inhibitors***XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 1 X 40 MG, 2 X 20 MG Tier 3 QL

XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 1 X 80 MG, 2 X 40 MG Tier 3 QL

*Rsv Agents - Nucleoside Analogues***ribavirin inhalation solution reconstituted 6 gm EX Medical Only Exclusion

VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM EX Medical Only Exclusion

*Beta Blockers*

*Alpha-Beta Blockers***carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

Tier 1

carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg

Tier 1

151

Drug Name Drug Tier NotesCOREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 80 MG


COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG EX Formulary Exclusion

labetalol hcl intravenous solution prefilled syringe 20 mg/4ml


labetalol hcl oral tablet 100 mg, 200 mg, 300 mg Tier 1

labetalol hcl solution 5 mg/ml intravenous 5 mg/ml


labetalol hcl solution 5 mg/ml intravenous 5 mg/ml


labetalol hcl-dextrose intravenous solution 200-5 mg/200ml-%


labetalol hcl-sodium chloride intravenous solution 100-0.72 mg/100ml-%, 200-0.72 mg/200ml-%, 300-0.72 mg/300ml-%


*Beta Blockers Cardio-Selective***acebutolol hcl oral capsule 200 mg, 400 mg Tier 1

atenolol oral tablet 100 mg, 25 mg, 50 mg Tier 1

ATENOLOL+SYRSPEND SF ORAL SUSPENSION 1 MG/ML EX Non FDA Exclusion

betaxolol hcl oral tablet 10 mg, 20 mg Tier 1

bisoprolol fumarate oral tablet 10 mg, 5 mg Tier 1

BREVIBLOC IN NACL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML


BREVIBLOC INTRAVENOUS SOLUTION100 MG/10ML EX Medical Only Exclusion

BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION 2000 MG/100ML


BREVIBLOC PREMIXED INTRAVENOUS SOLUTION 2500 MG/250ML EX Medical Only Exclusion

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG EX Formulary Exclusion

esmolol hcl intravenous solution 100 mg/10ml, 2000 mg/100ml, 2500 mg/250ml


esmolol hcl intravenous solution prefilled syringe100 mg/10ml


esmolol hcl-sodium chloride intravenous solution2000 mg/100ml, 2500 mg/250ml


152

Drug Name Drug Tier NotesKAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG


LOPRESSOR ORAL TABLET 100 MG, 50 MG EX Formulary Exclusion

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

Tier 1

metoprolol tartrate intravenous solution 5 mg/5ml EX Medical Only Exclusion

metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

Tier 1

nebivolol hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

Tier 1

TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG EX Formulary Exclusion

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG


*Beta Blockers Non-Selective***BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG EX Formulary Exclusion

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG EX Formulary Exclusion

CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG EX Formulary Exclusion

HEMANGEOL ORAL SOLUTION 4.28 MG/ML Tier 3

INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG


INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG Benefit Exclusion Non Essential Drug Exclusion

INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG


nadolol oral tablet 20 mg, 40 mg, 80 mg Tier 1

pindolol oral tablet 10 mg, 5 mg Tier 1

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

Tier 1

propranolol hcl intravenous solution 1 mg/ml EX Medical Only Exclusion

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

Tier 1

propranolol hcl solution 20 mg/5ml oral 20 mg/5ml

Tier 1

153

Drug Name Drug Tier Notespropranolol hcl solution 20 mg/5ml oral 20 mg/5ml

Tier 2

propranolol hcl solution 40 mg/5ml oral 40 mg/5ml

Tier 2

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG Tier 1

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg Tier 1

sotalol hcl intravenous solution 150 mg/10ml EX Medical Only Exclusion

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg

Tier 1

SOTYLIZE ORAL SOLUTION 5 MG/ML Tier 3

timolol maleate oral tablet 10 mg, 20 mg, 5 mg Tier 1

*Calcium Channel Blockers*

*Calcium Channel Blocker-Nsaid Combinations***CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 MG Benefit Exclusion Non Essential Drug Exclusion

*Calcium Channel Blockers***ADALAT CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG EX Formulary Exclusion

AMLODIPINE BES+SYRSPEND SF ORAL SUSPENSION 1 MG/ML EX Non FDA Exclusion

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg

Tier 1

CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 180 MG, 240 MG EX Formulary Exclusion

CARDENE IV INTRAVENOUS SOLUTION20-0.86 MG/200ML-%, 20-4.8 MG/200ML-%, 40-0.83 MG/200ML-%


CARDIZEM CD CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL 120 MG EX Formulary Exclusion



CARDIZEM CD CAPSULE EXTENDED RELEASE 24 HOUR 300 MG ORAL 300 MG Tier 3


CARDIZEM LA TABLET EXTENDED RELEASE 24 HOUR 120 MG ORAL 120 MG Tier 3

154

Drug Name Drug Tier NotesCARDIZEM LA TABLET EXTENDED RELEASE 24 HOUR 180 MG ORAL 180 MG EX Formulary Exclusion

CARDIZEM LA TABLET EXTENDED RELEASE 24 HOUR 240 MG ORAL 240 MG EX Formulary Exclusion




CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG EX Formulary Exclusion

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG

Tier 1

CLEVIPREX INTRAVENOUS EMULSION25 MG/50ML, 50 MG/100ML EX Medical Only Exclusion

CONJUPRI TABLET 2.5 MG ORAL 2.5 MG Benefit Exclusion

CONJUPRI TABLET 2.5 MG ORAL 2.5 MG Benefit Exclusion Non Essential Drug Exclusion

CONJUPRI TABLET 5 MG ORAL 5 MG Benefit Exclusion Non Essential Drug Exclusion

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

Tier 1

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

Tier 1

diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

Tier 1

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

Tier 1

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Tier 1

diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, 50 mg/10ml


diltiazem hcl intravenous solution reconstituted100 mg


diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

Tier 1

diltiazem hcl-dextrose intravenous solution 125-5 mg/125ml-%


diltiazem hcl-sodium chloride intravenous solution 125-0.7 mg/125ml-%, 125-0.9 mg/125ml-%


155

Drug Name Drug Tier Notesdilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Tier 1

felodipine er oral tablet extended release 24 hour10 mg, 2.5 mg, 5 mg

Tier 1

isradipine oral capsule 2.5 mg, 5 mg Tier 1

KATERZIA ORAL SUSPENSION 1 MG/ML Tier 3

levamlodipine maleate oral tablet 2.5 mg, 5 mg Benefit Exclusion

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

Tier 1

nicardipine hcl in nacl intravenous solution 20-0.9 mg/200ml-%, 40-0.9 mg/200ml-%


nicardipine hcl in nacl intravenous solution prefilled syringe 1-0.9 mg/10ml-%


nicardipine hcl intravenous solution 2.5 mg/ml EX Medical Only Exclusion

nicardipine hcl oral capsule 20 mg, 30 mg Tier 1

nifedipine er oral tablet extended release 24 hour30 mg, 60 mg, 90 mg

Tier 1

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

Tier 1

nifedipine oral capsule 10 mg, 20 mg Tier 1

nimodipine oral capsule 30 mg Tier 1

nisoldipine er tablet extended release 24 hour 17 mg oral 17 mg

Tier 1


Tier 3

nisoldipine er tablet extended release 24 hour 25.5 mg oral 25.5 mg

Tier 1


Tier 3


Tier 1


Tier 1

nisoldipine er tablet extended release 24 hour 8.5 mg oral 8.5 mg

Tier 1

NORLIQVA ORAL SOLUTION 1 MG/ML EX New to Market Exclusion

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG EX Formulary Exclusion

NYMALIZE ORAL SOLUTION 30 MG/10ML, 6 MG/ML, 60 MG/20ML Tier 3

PROCARDIA ORAL CAPSULE 10 MG EX Formulary Exclusion

156

Drug Name Drug Tier NotesPROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG


SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 34 MG, 8.5 MG EX Formulary Exclusion

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

Tier 1

TIADYLT ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

Tier 1

TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG


verapamil hcl er capsule extended release 24 hour 100 mg oral 100 mg

Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 3

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

Tier 1

verapamil hcl intravenous solution 2.5 mg/ml EX Medical Only Exclusion

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg Tier 1

VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG


VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

Tier 3

*Cardiotonics*

*Cardiac Glycosides***DIGITEK ORAL TABLET 125 MCG, 250 MCG Tier 1

DIGOX ORAL TABLET 125 MCG, 250 MCG Tier 1

157

Drug Name Drug Tier Notesdigoxin injection solution 0.25 mg/ml EX Medical Only Exclusion

digoxin oral solution 0.05 mg/ml Tier 1

digoxin oral tablet 125 mcg, 250 mcg, 62.5 mcg Tier 1

LANOXIN INJECTION SOLUTION 0.25 MG/ML EX Medical Only Exclusion

LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML EX Medical Only Exclusion

LANOXIN TABLET 125 MCG ORAL 125 MCG Tier 3



LANOXIN TABLET 62.5 MCG ORAL 62.5 MCG Tier 3

*Inotropes***dobutamine hcl intravenous solution 250 mg/20ml EX Medical Only Exclusion

dobutamine in d5w intravenous solution 1-5 mg/ml-%, 2 mg/ml, 4-5 mg/ml-%


dopamine hcl intravenous solution 40 mg/ml EX Medical Only Exclusion

dopamine in d5w intravenous solution 0.8-5 mg/ml-%, 1.6-5 mg/ml-%, 3.2-5 mg/ml-%


milrinone lactate in dextrose intravenous solution20-5 mg/100ml-%, 40-5 mg/200ml-%


milrinone lactate intravenous solution 10 mg/10ml, 20 mg/20ml, 50 mg/50ml


*Cardiovascular Agents - Misc.*

*Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb***amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

Tier 1

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG


*Cardiac Myosin Inhibitors***CAMZYOS ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 5 MG EX


*Cardioplegic Solutions***ADENOCAINE INTRAVENOUS SOLUTION PREFILLED SYRINGE EX Non FDA Exclusion

158


cardioplegia del nido formula perfusion solution EX Non FDA Exclusion; Medical Only Exclusion

cardioplegia ind plasma high k perfusion solutionEX


cardioplegia ind plasma-tromet perfusion solution


cardioplegia induction high k perfusion solution EX Non FDA Exclusion; Medical Only Exclusion

cardioplegia induction low dex perfusion solutionEX


cardioplegia induction non-enr perfusion solutionEX


cardioplegia main low dextrose perfusion solution


cardioplegia main low trometha perfusion solution


cardioplegia main plasma-trome perfusion solution


cardioplegia maintenance perfusion solution EX Non FDA Exclusion; Medical Only Exclusion

cardioplegia reperfusate 4:1 perfusion solution EX Non FDA Exclusion; Medical Only Exclusion

cardioplegic solution perfusion EX Non FDA Exclusion; Medical Only Exclusion

cardioplegic solution perfusion EX Medical Only Exclusion; Formulary Exclusion

microplegia msa-msg perfusion solution EX Non FDA Exclusion; Medical Only Exclusion

PLEGISOL PERFUSION SOLUTION EX Medical Only Exclusion; Formulary Exclusion

*Impotence Agent Combinations***bi-mix intracavernosal solution reconstituted 150-5 mg


quad-mix intracavernosal solution reconstituted150-10-0.1-1 mg


super bi-mix intracavernosal solution reconstituted 150-10 mg


super quad-mix intracavernosal solution reconstituted 150-20-0.2-2 mg


super tri-mix intracavernosal solution reconstituted 150-10-100 mg-mg-mcg


tri-mix intracavernosal solution reconstituted150-5-50 mg-mg-mcg


159


*Impotence Agents - Other***phenylephrine hcl intracavernosal solution 2 mg/2ml


*Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb***ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG Tier 2 PA; QL

*Nitrate & Vasodilator Combinations***BIDIL ORAL TABLET 20-37.5 MG Tier 3

isosorb dinitrate-hydralazine oral tablet 20-37.5 mg

Tier 1

*Peripheral Vasodilators***isoxsuprine hcl tablet 10 mg oral 10 mg EX Formulary Exclusion

isoxsuprine hcl tablet 20 mg oral 20 mg EX Non FDA Exclusion

isoxsuprine hcl tablet 20 mg oral 20 mg EX Formulary Exclusion

papaverine hcl injection solution 30 mg/ml EX Non FDA Exclusion

*Prostaglandin - Impotence Agents***CAVERJECT IMPULSE INTRACAVERNOSAL KIT 10 MCG, 20 MCG

Tier 3 QL

CAVERJECT INTRACAVERNOSAL SOLUTION RECONSTITUTED 20 MCG, 40 MCG

Tier 3 QL

EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40 MCG Tier 3 QL

MUSE URETHRAL PELLET 1000 MCG, 125 MCG, 250 MCG, 500 MCG Tier 3 QL

*Prostaglandin Vasodilators***epoprostenol sodium intravenous solution reconstituted 0.5 mg, 1.5 mg


FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG Tier 4 PA; Specialty

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG


REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 MG/20ML, 200 MG/20ML, 50 MG/20ML


treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 mg/20ml, 50 mg/20ml


160

Drug Name Drug Tier NotesTYVASO DPI MAINTENANCE KIT INHALATION POWDER 112 X 32MCG & 112 X48MCG, 16 MCG, 32 MCG, 48 MCG, 64 MCG

EX New to Market Exclusion; Specialty

TYVASO DPI TITRATION KIT INHALATION POWDER 112 X 16MCG & 84 X 32MCG, 16 & 32 & 48 MCG


TYVASO INHALATION SOLUTION 0.6 MG/ML Tier 4 PA; Specialty; QL

TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML Tier 4 PA; Specialty; QL

TYVASO STARTER SOLUTION 0.6 MG/ML INHALATION 0.6 MG/ML Tier 4 PA

TYVASO STARTER SOLUTION 0.6 MG/ML INHALATION 0.6 MG/ML Tier 4 PA; Specialty; QL

VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG, 1.5 MG Tier 4 PA; Specialty

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML Tier 4 PA; Specialty; QL

*Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (Sgc)***ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG Tier 4 PA; Specialty; QL

*Pulmonary Hypertension - Endothelin Receptor Antagonists***ambrisentan oral tablet 10 mg, 5 mg Tier 4 PA; Specialty; QL

bosentan oral tablet 125 mg, 62.5 mg Tier 4 PA; Specialty; QL

LETAIRIS ORAL TABLET 10 MG, 5 MG EX PA; Specialty; Formulary Exclusion; QL

OPSUMIT ORAL TABLET 10 MG Tier 4 PA; Specialty; QL

TRACLEER ORAL TABLET SOLUBLE 32 MG Tier 4 PA; Specialty; QL

TRACLEER TABLET 125 MG ORAL 125 MG EX


TRACLEER TABLET 125 MG ORAL 125 MG Tier 4 PA

TRACLEER TABLET 62.5 MG ORAL 62.5 MG EX


TRACLEER TABLET 62.5 MG ORAL 62.5 MG Tier 4 PA

161


*Pulmonary Hypertension - Phosphodiesterase Inhibitors***

ADCIRCA ORAL TABLET 20 MG EX PA; Specialty; Formulary Exclusion; QL

ALYQ ORAL TABLET 20 MG Tier 4 PA; Specialty; QL

REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML EX Medical Only Exclusion

REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML EX


REVATIO ORAL TABLET 20 MG EX PA; Specialty; Formulary Exclusion; QL

sildenafil citrate intravenous solution 10 mg/12.5ml


sildenafil citrate oral suspension reconstituted 10 mg/ml


sildenafil citrate tablet 20 mg oral 20 mg Tier 4 PA

sildenafil citrate tablet 20 mg oral 20 mg Tier 4 PA; Specialty; QL

tadalafil (pah) oral tablet 20 mg Tier 4 PA; Specialty; QL

*Pulmonary Hypertension - Prostacyclin Receptor Agonist***UPTRAVI INTRAVENOUS SOLUTION RECONSTITUTED 1800 MCG EX Medical Only Exclusion

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG


UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG Tier 4 PA; Specialty; QL

*Selective Cgmp Phosphodiesterase Type 5 Inhibitors***CIALIS TABLET 10 MG ORAL 10 MG EX Formulary Exclusion; QL

CIALIS TABLET 2.5 MG ORAL 2.5 MG EX PA; Formulary Exclusion; QL

CIALIS TABLET 20 MG ORAL 20 MG EX Formulary Exclusion; QL

CIALIS TABLET 5 MG ORAL 5 MG EX PA; Formulary Exclusion; QL

LEVITRA ORAL TABLET 10 MG, 20 MG EX Formulary Exclusion; QL

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

Tier 1 QL

STAXYN ORAL TABLET DISPERSIBLE 10 MG EX Formulary Exclusion; QL

STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG Tier 3 QL

tadalafil tablet 10 mg oral 10 mg Tier 1 QL

162

Drug Name Drug Tier Notestadalafil tablet 2.5 mg oral 2.5 mg Tier 1 PA; QL

tadalafil tablet 20 mg oral 20 mg Tier 1 QL

tadalafil tablet 5 mg oral 5 mg Tier 1 PA; QL

vardenafil hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

Tier 1 QL

vardenafil hcl oral tablet dispersible 10 mg Tier 1 QL

VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG EX Formulary Exclusion; QL

*Septal Agents - Ablation**ABLYSINOL INTRA-ARTERIAL SOLUTION EX Medical Only Exclusion

*Sinus Node Inhibitors**CORLANOR ORAL SOLUTION 5 MG/5ML Tier 2 PA; QL

CORLANOR ORAL TABLET 5 MG, 7.5 MG Tier 2 PA; QL

*Transthyretin Stabilizers***VYNDAMAX ORAL CAPSULE 61 MG Tier 4 PA; Specialty; QL

VYNDAQEL ORAL CAPSULE 20 MG Tier 4 PA; Specialty; QL

*Vasoactive Soluble Guanylate Cyclase Stimulator (Sgc)***VERQUVO ORAL TABLET 10 MG, 2.5 MG, 5 MG Tier 2 PA

*Cephalosporins*

*Cephalosporin Combinations***AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED 2.5 (2-0.5) GM EX Medical Only Exclusion

ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM EX Medical Only Exclusion

*Cephalosporins - 1St Generation***cefadroxil oral capsule 500 mg Tier 1

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

Tier 1

cefadroxil oral tablet 1 gm Tier 1

cefazolin in sodium chloride solution 2-0.9 gm/100ml-% intravenous 2-0.9 gm/100ml-%








163

Drug Name Drug Tier Notescefazolin sodium intravenous solution prefilled syringe 1 gm/10ml, 2 gm/20ml


cefazolin sodium intravenous solution reconstituted 1 gm


cefazolin sodium solution reconstituted 1 gm injection 1 gm







Tier 3



cefazolin sodium solution reconstituted 500 mg injection 500 mg


cefazolin sodium-dextrose intravenous solution reconstituted 1-4 gm-%(50ml), 2-3 gm-%(50ml)


cefazolin sodium-dextrose solution 1-4 gm/50ml-% intravenous 1-4 gm/50ml-%






cephalexin oral capsule 250 mg, 500 mg, 750 mg Tier 1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

Tier 1

cephalexin oral tablet 250 mg, 500 mg Tier 3

KEFLEX ORAL CAPSULE 250 MG, 500 MG, 750 MG EX Formulary Exclusion

*Cephalosporins - 2Nd Generation***cefaclor er oral tablet extended release 12 hour500 mg

Tier 3

cefaclor oral capsule 250 mg, 500 mg Tier 1

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

Tier 3

CEFOTAN INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM Tier 3

cefotetan disodium injection solution reconstituted 1 gm, 2 gm


cefotetan disodium-dextrose intravenous solution reconstituted 1-3.58 gm-%(50ml), 2-2.08 gm-%(50ml)

Tier 3

164

Drug Name Drug Tier Notescefoxitin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm


cefoxitin sodium-dextrose intravenous solution reconstituted 1-4 gm-%(50ml), 2-2.2 gm-%(50ml)


cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

Tier 1

cefprozil oral tablet 250 mg, 500 mg Tier 1

cefuroxime axetil oral tablet 250 mg, 500 mg Tier 1

cefuroxime sodium injection solution reconstituted 750 mg


cefuroxime sodium intravenous solution reconstituted 1.5 gm


*Cephalosporins - 3Rd Generation***cefdinir oral capsule 300 mg Tier 1

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

Tier 1

cefditoren pivoxil oral tablet 200 mg, 400 mg Tier 3

cefixime oral capsule 400 mg Tier 1

cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

Tier 1

cefotaxime sodium injection solution reconstituted1 gm, 2 gm


cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

Tier 1

cefpodoxime proxetil oral tablet 100 mg, 200 mg Tier 1

ceftazidime and dextrose intravenous solution reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml)


ceftazidime injection solution reconstituted 1 gm, 6 gm


ceftazidime intravenous solution reconstituted 2 gm


ceftriaxone sodium in dextrose intravenous solution 20 mg/ml, 40 mg/ml


ceftriaxone sodium injection solution reconstituted 1 gm, 100 gm, 2 gm, 250 mg, 500 mg


ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm


ceftriaxone sodium-dextrose intravenous solution reconstituted 1-3.74 gm-%(50ml), 2-2.22 gm-%(50ml)


FORTAZ INJECTION SOLUTION RECONSTITUTED 1 GM, 500 MG Tier 3

165

Drug Name Drug Tier NotesFORTAZ INTRAVENOUS SOLUTION RECONSTITUTED 2 GM Tier 3

SUPRAX ORAL CAPSULE 400 MG EX Formulary Exclusion

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG Tier 2

SUPRAX SUSPENSION RECONSTITUTED 100 MG/5ML ORAL 100 MG/5ML EX Formulary Exclusion

SUPRAX SUSPENSION RECONSTITUTED 200 MG/5ML ORAL 200 MG/5ML EX Formulary Exclusion

SUPRAX SUSPENSION RECONSTITUTED 500 MG/5ML ORAL 500 MG/5ML Tier 2

TAZICEF INJECTION SOLUTION RECONSTITUTED 1 GM EX Medical Only Exclusion

TAZICEF INTRAVENOUS SOLUTION 1 GM/50ML EX Formulary Exclusion

TAZICEF INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 2 GM, 6 GM EX Medical Only Exclusion

*Cephalosporins - 4Th Generation***cefepime hcl injection solution reconstituted 1 gm, 2 gm


cefepime hcl intravenous solution 1 gm/50ml, 2 gm/100ml


cefepime hcl intravenous solution reconstituted100 gm


cefepime-dextrose intravenous solution reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml)


*Cephalosporins - 5Th Generation***TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG EX Medical Only Exclusion

*Cephalosporins - Siderophores***FETROJA INTRAVENOUS SOLUTION RECONSTITUTED 1 GM EX Medical Only Exclusion

*Chemicals*

*Bases***potassium hydroxide external solution 5 % EX Non FDA Exclusion

sodium hydroxide external solution 10 % EX Non FDA Exclusion

*Contraceptives*

*Biphasic Contraceptives - Oral***AZURETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) Tier 5

166

Drug Name Drug Tier NotesBEKYREE ORAL TABLET 0.15-0.02/0.01 MG (21/5) Tier 5

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

Tier 5

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Tier 5

KIMIDESS ORAL TABLET 0.15-0.02/0.01 MG (21/5) Tier 5

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG Tier 2

MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) EX Formulary Exclusion

PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Tier 5

SIMLIYA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Tier 5

viorele oral tablet 0.15-0.02/0.01 mg (21/5) Tier 5

VOLNEA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Tier 5

*Combination Contraceptives - Oral***AFIRMELLE ORAL TABLET 0.1-20 MG-MCG Tier 5

ALTAVERA ORAL TABLET 0.15-30 MG-MCG Tier 5

alyacen 1/35 oral tablet 1-35 mg-mcg Tier 5

APRI ORAL TABLET 0.15-30 MG-MCG Tier 5

AUBRA EQ ORAL TABLET 0.1-20 MG-MCG Tier 5

AUBRA ORAL TABLET 0.1-20 MG-MCG Tier 5

AUROVELA 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

AUROVELA 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

AUROVELA 24 FE ORAL TABLET 1-20 MG-MCG(24) Tier 5

AUROVELA FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

AUROVELA FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

AVIANE ORAL TABLET 0.1-20 MG-MCG Tier 5

AYUNA ORAL TABLET 0.15-30 MG-MCG Tier 5

167

Drug Name Drug Tier NotesBALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) EX Formulary Exclusion

BALZIVA ORAL TABLET 0.4-35 MG-MCG Tier 5

BEYAZ ORAL TABLET 3-0.02-0.451 MG EX Formulary Exclusion

BLISOVI 24 FE ORAL TABLET 1-20 MG-MCG(24) Tier 5

BLISOVI FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

BLISOVI FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

briellyn oral tablet 0.4-35 mg-mcg Tier 5

CHARLOTTE 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24) Tier 5

CHATEAL EQ ORAL TABLET 0.15-30 MG-MCG Tier 5

CHATEAL ORAL TABLET 0.15-30 MG-MCG Tier 5

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG Tier 5

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG Tier 5

CYRED EQ ORAL TABLET 0.15-30 MG-MCG Tier 5

CYRED ORAL TABLET 0.15-30 MG-MCG Tier 5

DASETTA 1/35 ORAL TABLET 1-35 MG-MCG Tier 5

DELYLA ORAL TABLET 0.1-20 MG-MCG Tier 5

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

Tier 5

drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg

Tier 5

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg

Tier 5

ELINEST ORAL TABLET 0.3-30 MG-MCG Tier 5

EMOQUETTE ORAL TABLET 0.15-30 MG-MCG Tier 5

ENSKYCE ORAL TABLET 0.15-30 MG-MCG Tier 5

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG Tier 5

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg

Tier 5

FALESSA ORAL KIT 20-1-0.1 MCG-MG EX Non FDA Exclusion

168

Drug Name Drug Tier NotesFALMINA ORAL TABLET 0.1-20 MG-MCG Tier 5

FEMYNOR ORAL TABLET 0.25-35 MG-MCG Tier 5

GEMMILY ORAL CAPSULE 1-20 MG-MCG(24) Tier 5

GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG EX Formulary Exclusion

GIANVI ORAL TABLET 3-0.02 MG Tier 5

HAILEY 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

HAILEY 24 FE ORAL TABLET 1-20 MG-MCG(24) Tier 5

HAILEY FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

HAILEY FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

ISIBLOOM ORAL TABLET 0.15-30 MG-MCG Tier 5

JASMIEL ORAL TABLET 3-0.02 MG Tier 5

JULEBER ORAL TABLET 0.15-30 MG-MCG Tier 5

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

JUNEL FE 24 ORAL TABLET 1-20 MG-MCG(24) Tier 5

KAITLIB FE ORAL TABLET CHEWABLE0.8-25 MG-MCG Tier 5

KALLIGA ORAL TABLET 0.15-30 MG-MCG Tier 5

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG Tier 5

KELNOR 1/50 ORAL TABLET 1-50 MG-MCG Tier 5

KURVELO ORAL TABLET 0.15-30 MG-MCG Tier 5

LARIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

LARIN 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

169

Drug Name Drug Tier NotesLARIN 24 FE ORAL TABLET 1-20 MG-MCG(24) Tier 5

LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

LARISSIA ORAL TABLET 0.1-20 MG-MCG Tier 5

LAYOLIS FE ORAL TABLET CHEWABLE0.8-25 MG-MCG Tier 5

LESSINA ORAL TABLET 0.1-20 MG-MCG Tier 5

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

Tier 5

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG Tier 5

LILLOW ORAL TABLET 0.15-30 MG-MCG Tier 5

LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG Tier 5

LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG Tier 5

LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

LOESTRIN FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

LORYNA ORAL TABLET 3-0.02 MG Tier 5

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG Tier 5

LO-ZUMANDIMINE ORAL TABLET 3-0.02 MG Tier 5

LUTERA ORAL TABLET 0.1-20 MG-MCG Tier 5

marlissa oral tablet 0.15-30 mg-mcg Tier 5

MELODETTA 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24) Tier 5

MERZEE ORAL CAPSULE 1-20 MG-MCG(24) Tier 5

MIBELAS 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24) Tier 5

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG Tier 5

MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

MICROGESTIN 24 FE ORAL TABLET 1-20 MG-MCG Tier 5

170

Drug Name Drug Tier NotesMICROGESTIN FE 1.5/30 ORAL TABLET1.5-30 MG-MCG Tier 5

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

MILI ORAL TABLET 0.25-35 MG-MCG Tier 5

MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24) EX Formulary Exclusion

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG Tier 5

MONONESSA ORAL TABLET 0.25-35 MG-MCG Tier 5

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG Tier 5

NEXTSTELLIS ORAL TABLET 3-14.2 MG EX Formulary Exclusion

NIKKI ORAL TABLET 3-0.02 MG Tier 5

norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24)

Tier 5

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1-20 mg-mcg(24), 1.5-30 mg-mcg

Tier 5

norethin ace-eth estrad-fe oral tablet chewable 1-20 mg-mcg(24)

Tier 5

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

Tier 5

norethindrone acet-ethinyl est oral tablet chewable 1-20 mg-mcg(24)

Tier 5

norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 0.8-25 mg-mcg

Tier 5

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

Tier 5

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG Tier 5

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG Tier 5

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG Tier 5

NYLIA 1/35 ORAL TABLET 1-35 MG-MCG Tier 5

NYMYO ORAL TABLET 0.25-35 MG-MCG Tier 5

OCELLA ORAL TABLET 3-0.03 MG Tier 5

OGESTREL ORAL TABLET 0.5-50 MG-MCG Tier 1

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG Tier 5

171

Drug Name Drug Tier NotesORTHO-NOVUM 1/35 (28) ORAL TABLET1-35 MG-MCG EX Formulary Exclusion

PHILITH ORAL TABLET 0.4-35 MG-MCG Tier 5

PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG Tier 5

PORTIA-28 ORAL TABLET 0.15-30 MG-MCG Tier 5

PREVIFEM ORAL TABLET 0.25-35 MG-MCG Tier 5

RAJANI ORAL TABLET 3-0.02-0.451 MG Tier 5

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG Tier 5

SAFYRAL ORAL TABLET 3-0.03-0.451 MG EX Formulary Exclusion

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG Tier 5

SRONYX ORAL TABLET 0.1-20 MG-MCG Tier 5

SYEDA ORAL TABLET 3-0.03 MG Tier 5

TARINA 24 FE ORAL TABLET 1-20 MG-MCG(24) Tier 5

TARINA FE 1/20 EQ ORAL TABLET 1-20 MG-MCG Tier 5

TARINA FE 1/20 ORAL TABLET 1-20 MG-MCG Tier 5

TAYSOFY ORAL CAPSULE 1-20 MG-MCG(24) Tier 5

TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) EX Formulary Exclusion

TYBLUME ORAL TABLET CHEWABLE0.1-20 MG-MCG Tier 1

TYDEMY ORAL TABLET 3-0.03-0.451 MG Tier 5

VESTURA ORAL TABLET 3-0.02 MG Tier 5

VIENVA ORAL TABLET 0.1-20 MG-MCG Tier 5

VYFEMLA ORAL TABLET 0.4-35 MG-MCG Tier 5

VYLIBRA ORAL TABLET 0.25-35 MG-MCG Tier 5

WERA ORAL TABLET 0.5-35 MG-MCG Tier 5

WYMZYA FE ORAL TABLET CHEWABLE0.4-35 MG-MCG Tier 5

YASMIN 28 ORAL TABLET 3-0.03 MG EX Formulary Exclusion

YAZ ORAL TABLET 3-0.02 MG EX Formulary Exclusion

ZARAH ORAL TABLET 3-0.03 MG Tier 5

ZENCHENT ORAL TABLET 0.4-35 MG-MCG Tier 5

172

Drug Name Drug Tier NotesZOVIA 1/35 (28) ORAL TABLET 1-35 MG-MCG Tier 5

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG Tier 5

ZUMANDIMINE ORAL TABLET 3-0.03 MG Tier 5

*Combination Contraceptives - Transdermal***TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG/24HR EX Formulary Exclusion

XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR Tier 5

ZAFEMY TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR Tier 5

*Combination Contraceptives - Vaginal***ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR EX Formulary Exclusion; QL

ELURYNG VAGINAL RING 0.12-0.015 MG/24HR Tier 5

etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24hr

Tier 5

NUVARING VAGINAL RING 0.12-0.015 MG/24HR EX Formulary Exclusion

*Continuous Contraceptives - Oral***AMETHYST ORAL TABLET 90-20 MCG Tier 5

DOLISHALE ORAL TABLET 90-20 MCG Tier 5

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

Tier 5

*Copper Contraceptives - Iud***PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE Benefit Exclusion

*Emergency Contraceptives***AFTERA ORAL TABLET 1.5 MG Tier 5

AFTERPILL ORAL TABLET 1.5 MG Tier 5

ECONTRA EZ ORAL TABLET 1.5 MG Tier 5

ECONTRA ONE-STEP ORAL TABLET 1.5 MG Tier 5

ELLA ORAL TABLET 30 MG Tier 2

levonorgestrel oral tablet 1.5 mg Tier 5

MY CHOICE ORAL TABLET 1.5 MG Tier 5

173

Drug Name Drug Tier NotesMY WAY ORAL TABLET 1.5 MG Tier 5

NEW DAY ORAL TABLET 1.5 MG Tier 5

OPCICON ONE-STEP ORAL TABLET 1.5 MG Tier 5

OPTION 2 ORAL TABLET 1.5 MG Tier 5

PLAN B ONE-STEP ORAL TABLET 1.5 MG Tier 5

PREVENTEZA ORAL TABLET 1.5 MG Tier 5

REACT ORAL TABLET 1.5 MG Tier 5

TAKE ACTION ORAL TABLET 1.5 MG Tier 5

*Extended-Cycle Contraceptives - Oral***AMETHIA LO ORAL TABLET 0.1-0.02 & 0.01 MG Tier 5

AMETHIA ORAL TABLET 0.15-0.03 &0.01 MG Tier 5

ASHLYNA ORAL TABLET 0.15-0.03 &0.01 MG Tier 5

CAMRESE LO ORAL TABLET 0.1-0.02 & 0.01 MG Tier 5

CAMRESE ORAL TABLET 0.15-0.03 &0.01 MG Tier 5

DAYSEE ORAL TABLET 0.15-0.03 &0.01 MG Tier 5

FAYOSIM ORAL TABLET 42-21-21-7 DAYS Tier 5

ICLEVIA ORAL TABLET 0.15-0.03 MG Tier 5

INTROVALE ORAL TABLET 0.15-0.03 MG Tier 5

JAIMIESS ORAL TABLET 0.15-0.03 &0.01 MG Tier 5

JOLESSA ORAL TABLET 0.15-0.03 MG Tier 5

levonorgest-eth est & eth est oral tablet 42-21-21-7 days

Tier 5

levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg

Tier 5

LOJAIMIESS ORAL TABLET 0.1-0.02 & 0.01 MG Tier 5

LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG EX Formulary Exclusion

QUARTETTE ORAL TABLET 42-21-21-7 DAYS EX Formulary Exclusion

QUASENSE ORAL TABLET 0.15-0.03 MG Tier 5

RIVELSA ORAL TABLET 42-21-21-7 DAYS Tier 5

174

Drug Name Drug Tier NotesSEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG EX Formulary Exclusion

SETLAKIN ORAL TABLET 0.15-0.03 MG Tier 5

SIMPESSE ORAL TABLET 0.15-0.03 &0.01 MG Tier 5

*Four Phase Contraceptives - Oral***NATAZIA ORAL TABLET 3/2-2/2-3/1 MG Tier 3

*Progestin Contraceptives - Implants***NEXPLANON SUBCUTANEOUS IMPLANT68 MG Benefit Exclusion

*Progestin Contraceptives - Injectable***DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML EX Formulary Exclusion

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML


DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML

Tier 3

medroxyprogesterone acetate intramuscular suspension 150 mg/ml

Tier 5

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml

Tier 5

*Progestin Contraceptives - Iud***KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG Benefit Exclusion

LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 20.1 MCG/DAY Benefit Exclusion

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/DAY Benefit Exclusion

SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG Benefit Exclusion

*Progestin Contraceptives - Oral***CAMILA ORAL TABLET 0.35 MG Tier 5

DEBLITANE ORAL TABLET 0.35 MG Tier 5

ERRIN ORAL TABLET 0.35 MG Tier 5

HEATHER ORAL TABLET 0.35 MG Tier 5

INCASSIA ORAL TABLET 0.35 MG Tier 5

JENCYCLA ORAL TABLET 0.35 MG Tier 5

175

Drug Name Drug Tier NotesJOLIVETTE ORAL TABLET 0.35 MG Tier 5

LYLEQ ORAL TABLET 0.35 MG Tier 5

LYZA ORAL TABLET 0.35 MG Tier 5

NORA-BE ORAL TABLET 0.35 MG Tier 5

norethindrone oral tablet 0.35 mg Tier 5

NORLYDA ORAL TABLET 0.35 MG Tier 5

NORLYROC ORAL TABLET 0.35 MG Tier 5

ORTHO MICRONOR ORAL TABLET 0.35 MG EX Formulary Exclusion

SHAROBEL ORAL TABLET 0.35 MG Tier 5

SLYND ORAL TABLET 4 MG EX Formulary Exclusion

TULANA ORAL TABLET 0.35 MG Tier 5

*Triphasic Contraceptives - Oral***alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg Tier 5

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG Tier 5

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG Tier 5

CYCLAFEM 7/7/7 ORAL TABLET0.5/0.75/1-35 MG-MCG Tier 5

DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Tier 5

ENPRESSE-28 ORAL TABLET 50-30/75-40/ 125-30 MCG Tier 5

ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG EX Formulary Exclusion

LEENA ORAL TABLET 0.5/1/0.5-35 MG-MCG Tier 5

LEVONEST ORAL TABLET 50-30/75-40/ 125-30 MCG Tier 5

levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 mcg

Tier 5

MYZILRA ORAL TABLET 50-30/75-40/ 125-30 MCG Tier 5

NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Tier 5

norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg

Tier 5

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Tier 5

176

Drug Name Drug Tier NotesNYLIA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Tier 5

ORTHO TRI-CYCLEN LO ORAL TABLET0.18/0.215/0.25 MG-25 MCG EX Formulary Exclusion

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET0.5/0.75/1-35 MG-MCG EX Formulary Exclusion

PIRMELLA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Tier 5

TILIA FE ORAL TABLET 1-20/1-30/1-35 MG-MCG Tier 5

TRI FEMYNOR ORAL TABLET0.18/0.215/0.25 MG-35 MCG Tier 5

TRI-ESTARYLLA ORAL TABLET0.18/0.215/0.25 MG-35 MCG Tier 5

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG Tier 5

TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG Tier 5

TRI-LO-ESTARYLLA ORAL TABLET0.18/0.215/0.25 MG-25 MCG Tier 5

TRI-LO-MARZIA ORAL TABLET0.18/0.215/0.25 MG-25 MCG Tier 5

TRI-LO-MILI ORAL TABLET0.18/0.215/0.25 MG-25 MCG Tier 5

TRI-LO-SPRINTEC ORAL TABLET0.18/0.215/0.25 MG-25 MCG Tier 5

TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-35 MCG Tier 5

TRINESSA (28) ORAL TABLET0.18/0.215/0.25 MG-35 MCG Tier 5

TRINESSA LO ORAL TABLET0.18/0.215/0.25 MG-25 MCG Tier 5

TRI-NYMYO ORAL TABLET 0.18/0.215/0.25 MG-35 MCG Tier 5

TRI-PREVIFEM ORAL TABLET0.18/0.215/0.25 MG-35 MCG Tier 5

TRI-SPRINTEC ORAL TABLET0.18/0.215/0.25 MG-35 MCG Tier 5

TRIVORA (28) ORAL TABLET 50-30/75-40/ 125-30 MCG Tier 5

TRI-VYLIBRA LO ORAL TABLET0.18/0.215/0.25 MG-25 MCG Tier 5

TRI-VYLIBRA ORAL TABLET0.18/0.215/0.25 MG-35 MCG Tier 5

177

Drug Name Drug Tier NotesVELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG Tier 5

*Corticosteroids*

*Glucocorticosteroids***active injection d injection kit 10 mg/ml EX Non FDA Exclusion

ALKINDI SPRINKLE ORAL CAPSULE SPRINKLE 0.5 MG, 1 MG, 2 MG, 5 MG Tier 3 PA

betamethasone sodium phosphate injection solution 12 mg/2ml, 6 mg/ml


budesonide er oral tablet extended release 24 hour 9 mg

Tier 1 PA

budesonide oral capsule delayed release particles3 mg

Tier 1

CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG EX Formulary Exclusion

cortisone acetate oral tablet 25 mg Tier 2

DECADRON ORAL TABLET 0.5 MG, 0.75 MG, 4 MG, 6 MG Tier 1

DEPO-MEDROL INJECTION SUSPENSION20 MG/ML, 40 MG/ML, 80 MG/ML Tier 3

dexabliss oral tablet therapy pack 1.5 mg (39) Benefit Exclusion Non Essential Drug Exclusion

dexamethasone (la) injection suspension 16 mg/ml, 8 mg/ml


DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML Tier 3

dexamethasone oral elixir 0.5 mg/5ml Tier 1

dexamethasone oral solution 0.5 mg/5ml Tier 3

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

Tier 1

dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51)


dexamethasone sod phos-nacl intravenous solution 6-0.9 mg/25ml-%


dexamethasone sod phosphate pf injection solution 10 mg/ml

Tier 1

dexamethasone sod phosphate pf injection solution prefilled syringe 10 mg/ml


dexamethasone sodium phosphate solution 10 mg/ml injection 10 mg/ml



Tier 1

178

Drug Name Drug Tier Notesdexamethasone sodium phosphate solution 100 mg/10ml injection 100 mg/10ml

Tier 1

dexamethasone sodium phosphate solution 120 mg/30ml injection 120 mg/30ml

Tier 1

dexamethasone sodium phosphate solution 20 mg/5ml injection 20 mg/5ml

Tier 1




Tier 1

DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 MG/5ML EX Non FDA Exclusion

DEXPAK 10 DAY ORAL TABLET THERAPY PACK 1.5 MG (35) Benefit Exclusion Non Essential Drug Exclusion



DOUBLEDEX INJECTION KIT 10 MG/ML EX Non FDA Exclusion

DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5 MG Benefit Exclusion Non Essential Drug Exclusion

EMFLAZA ORAL SUSPENSION 22.75 MG/ML Tier 4 PA; Specialty

EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG Tier 4 PA; Specialty

ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES 3 MG EX Formulary Exclusion

HEMADY ORAL TABLET 20 MG Benefit Exclusion Non Essential Drug Exclusion

HEXATRIONE INTRA-ARTICULAR SUSPENSION 20 MG/ML EX Non FDA Exclusion

HIDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21) Benefit Exclusion Non Essential Drug Exclusion

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Tier 1

KENALOG INJECTION SUSPENSION 10 MG/ML, 40 MG/ML Tier 3

KENALOG-80 INJECTION SUSPENSION 80 MG/ML Tier 3

MAS CARE-PAK INJECTION KIT 10 MG/ML EX Non FDA Exclusion

MEDROL ORAL TABLET THERAPY PACK 4 MG EX Formulary Exclusion

MEDROL TABLET 16 MG ORAL 16 MG EX Formulary Exclusion

MEDROL TABLET 2 MG ORAL 2 MG Tier 3

179

Drug Name Drug Tier NotesMEDROL TABLET 32 MG ORAL 32 MG EX Formulary Exclusion



methylprednisolone acetate suspension 40 mg/ml injection 40 mg/ml



Tier 1






Tier 1

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

Tier 1

methylprednisolone oral tablet therapy pack 4 mg Tier 1

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg, 500 mg

Tier 1

MILLIPRED DP 12-DAY ORAL TABLET THERAPY PACK 5 MG (48) Benefit Exclusion Non Essential Drug Exclusion

MILLIPRED DP ORAL TABLET THERAPY PACK 5 MG (21), 5 MG (48) Benefit Exclusion Non Essential Drug Exclusion

MILLIPRED ORAL TABLET 5 MG Benefit Exclusion Non Essential Drug Exclusion

ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 30 MG Tier 3

ORTIKOS CAPSULE EXTENDED RELEASE 24 HOUR 6 MG ORAL 6 MG Benefit Exclusion Non Essential Drug Exclusion

ORTIKOS CAPSULE EXTENDED RELEASE 24 HOUR 9 MG ORAL 9 MG Tier 3

p-care k40 injection kit 40 mg/ml EX Non FDA Exclusion

p-care k80 injection kit 2 x 40 mg/ml EX Non FDA Exclusion

PEDIAPRED ORAL SOLUTION 6.7 (5 BASE) MG/5ML EX Formulary Exclusion

pod-care 100k injection kit 40 mg/ml EX Non FDA Exclusion

prednisolone oral solution 15 mg/5ml Tier 1

prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg

Tier 1

prednisolone sodium phosphate solution 10 mg/5ml oral 10 mg/5ml



Tier 1

180

Drug Name Drug Tier Notesprednisolone sodium phosphate solution 20 mg/5ml oral 20 mg/5ml

Tier 1


Tier 3


Tier 1

prednisolone sodium phosphate solution 6.7 (5 base) mg/5ml oral 6.7 (5 base) mg/5ml

Tier 1

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML Tier 3

prednisone oral solution 5 mg/5ml Tier 1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

Tier 1

prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)

Tier 1

PRO-C-DURE 5 INJECTION KIT 2 X 40 MG/ML EX Non FDA Exclusion

PRO-C-DURE 6 INJECTION KIT 3 X 40 MG/ML EX Non FDA Exclusion

RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2 MG, 5 MG Benefit Exclusion Non Essential Drug Exclusion

READYSHARP DEXAMETHASONE INJECTION KIT 10 MG/ML EX Non FDA Exclusion

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG, 250 MG, 500 MG

Tier 3

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 1000 MG, 125 MG, 2 GM, 40 MG, 500 MG

Tier 3

TAPERDEX 12-DAY ORAL TABLET THERAPY PACK 1.5 MG (49) Benefit Exclusion Non Essential Drug Exclusion

TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG, 1.5 MG (21) Benefit Exclusion Non Essential Drug Exclusion

TAPERDEX 7-DAY ORAL TABLET THERAPY PACK 1.5 MG (27) Benefit Exclusion Non Essential Drug Exclusion

TARPEYO ORAL CAPSULE DELAYED RELEASE 4 MG EX


topidex injection kit 10 mg/ml EX Non FDA Exclusion

triamcinolone acetonide suspension 40 mg/ml injection 40 mg/ml



Tier 1



181

Drug Name Drug Tier Notestriamcinolone diacetate injection suspension 40 mg/ml, 80 mg/ml


UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 MG EX PA; Formulary Exclusion

zcort 7-day oral tablet therapy pack 1.5 mg (25) Benefit Exclusion Non Essential Drug Exclusion

ZILRETTA INTRA-ARTICULAR SUSPENSION RECONSTITUTED ER 32 MG EX Medical Only Exclusion

*Mineralocorticoids***fludrocortisone acetate oral tablet 0.1 mg Tier 1

*Steroid Combinations***active injection blm-1 injection kit 6 & 0.25 & 1 mg/ml-%-%


active injection bm injection kit 6 & 0.25 mg/ml-%


active injection dl injection kit 10 & 1 mg/ml-% EX Non FDA Exclusion

active injection dlm injection kit 10 & 0.25 & 1 mg/ml-%-%


ACTIVE INJECTION KIT L INJECTION KIT 40 & 1 MG/ML-% EX Non FDA Exclusion

active injection kl-3 combination kit 40-1 mg/ml-%


active injection km injection kit 40-0.5 mg/ml-% EX Non FDA Exclusion

active injection lm-dep-2 injection kit 40 & 0.25 & 1 mg/ml-%-%


active injection m-1 injection kit 10 & 0.25 mg/ml-%


beta 1 kit injection kit 30 mg/5ml EX Non FDA Exclusion

BETALIDO INJECTION KIT 6 & 1 MG/ML-% EX Non FDA Exclusion

BETALOAN SUIK COMBINATION KIT 30 MG/5ML EX Non FDA Exclusion

betamethasone combo injection suspension 6 (3-3) mg/ml, 7 (4-3) mg/ml


betamethasone sod phos & acet suspension 6 (3-3) mg/ml injection 6 (3-3) mg/ml



Tier 1



bsp 0820 injection kit 30 mg/5ml EX Non FDA Exclusion

bupivilog injection kit 40 & 0.5 mg/ml-% EX Non FDA Exclusion

182

Drug Name Drug Tier NotesCELESTONE SOLUSPAN SUSPENSION 6 (3-3) MG/ML INJECTION 6 (3-3) MG/ML Tier 3

CELESTONE SOLUSPAN SUSPENSION 6 (3-3) MG/ML INJECTION 6 (3-3) MG/ML EX Formulary Exclusion

CONTRAST ALLERGY PREMED PACK ORAL KIT 3 X 50 MG & 1 X 50 MG EX Non FDA Exclusion

dexameth sod phos-bupiv-epin injection solution prefilled syringe 0.01-0.375 %-1:200000


dexamethasone ace & sod phos injection suspension 8-4 mg/ml


DEXLIDO INJECTION KIT 10 & 1 MG/ML-% EX Non FDA Exclusion

DEXLIDO-M INJECTION KIT 10 & 0.25 & 1 MG/ML-%-% EX Non FDA Exclusion

DMT SUIK COMBINATION KIT 10 MG/ML EX Non FDA Exclusion

DYURAL 80-LM INJECTION KIT 80 & 0.25 & 1 MG/ML-%-% EX Non FDA Exclusion

DYURAL-40 INJECTION KIT 40 & 0.25 & 1 MG/ML-%-% EX Non FDA Exclusion

DYURAL-80 INJECTION KIT 80 & 0.25 & 1 MG/ML-%-% EX Non FDA Exclusion

DYURAL-L INJECTION KIT 40 & 1 MG/ML-% EX Non FDA Exclusion

DYURAL-LM INJECTION KIT 40 & 0.25 & 1 MG/ML-%-% EX Non FDA Exclusion

lidocidex i injection solution 5-10 mg/1.5ml EX Non FDA Exclusion

lidolog injection kit 40 & 2 mg/ml-% EX Non FDA Exclusion

MARBETA-25 INJECTION KIT 6 & 0.25 MG/ML-% EX Non FDA Exclusion

MARBETA-L INJECTION KIT 6 & 0.25 & 1 MG/ML-%-% EX Non FDA Exclusion

MARDEX-25 INJECTION KIT 10 & 0.25 MG/ML-% EX Non FDA Exclusion

MEDROLOAN II SUIK COMBINATION KIT 40 MG/ML EX Non FDA Exclusion

MEDROLOAN SUIK COMBINATION KIT40 MG/ML EX Non FDA Exclusion

methylprednisolone ace-lido injection suspension40-10 mg/ml, 80-10 mg/ml


methylprednisolone-bupivacaine injection suspension 40-5 mg/ml, 80-5 mg/ml


mlk f1 injection kit 40 & 0.5 & 2 mg/ml-%-% EX Non FDA Exclusion

mlk f2 injection kit 40 & 0.5 & 2 mg/ml-%-% EX Non FDA Exclusion

183

Drug Name Drug Tier Notesmlk f3 injection kit 40 & 0.5 & 2 mg/ml-%-% EX Non FDA Exclusion

MLK F4 INJECTION KIT 40 & 0.5 & 2 MG/ML-%-% EX Non FDA Exclusion

multi-specialty injection kit 40 & 1 mg/ml-% EX Non FDA Exclusion

p-care k40g combination kit 40 mg/ml EX Non FDA Exclusion

p-care k40mx injection kit 40 & 0.5 & 1 mg/ml-%-%


p-care k80g combination kit 40 mg/ml EX Non FDA Exclusion

p-care k80mx injection kit 40 & 0.5 & 1 mg/ml-%-%


physicians ez use j/t/t kit ii injection kit 40 & 1 mg/ml-%


physicians ez use joint/tunnel combination kit 40-1 mg/ml-%


physicians ez use m-pred injection kit 40-0.5 mg/ml-%


pod-care 100c injection kit 30 mg/5ml EX Non FDA Exclusion

pod-care 100cg combination kit 30 mg/5ml EX Non FDA Exclusion

pod-care 100cmx injection kit 6 & 0.5 & 1 mg/ml-%-%


pod-care 100kg combination kit 40 mg/ml EX Non FDA Exclusion

pod-care 100kmx injection kit 40 & 0.5 & 1 mg/ml-%-%


POINT OF CARE KM INJECTION KIT 40 & 0.5 MG/ML-% EX Non FDA Exclusion

POINT OF CARE L.2 INJECTION KIT 40 & 1 MG/ML-% EX Non FDA Exclusion

POINT OF CARE L.5 INJECTION KIT 40 & 1 MG/ML-% EX Non FDA Exclusion

POINT OF CARE LM DEP 2 INJECTION KIT 40 & 0.25 & 1 MG/ML-%-% EX Non FDA Exclusion

READYSHARP ANESTH + BETAMETH INJECTION KIT 6 & 0.5 & 1 MG/ML-%-% EX Non FDA Exclusion

READYSHARP ANESTH + DEXAMETH INJECTION KIT 10 & 0.5 & 1 MG/ML-%-% EX Non FDA Exclusion

READYSHARP ANESTH + METHYLPRED INJECTION KIT 80 & 0.5 & 1 MG/ML-%-% EX Non FDA Exclusion

READYSHARP BETAMETHASONE INJECTION KIT 30 MG/5ML EX Non FDA Exclusion

ROPIDEX INJECTION KIT 10-0.5 MG/ML-% EX Non FDA Exclusion

triamcinolone-bupivacaine injection suspension40-5 mg/ml


184

Drug Name Drug Tier NotesTRILOAN II SUIK COMBINATION KIT 40 MG/ML EX Non FDA Exclusion

TRILOAN SUIK COMBINATION KIT 40 MG/ML EX Non FDA Exclusion

*Cough/Cold/Allergy*

*Antitussive - Nonnarcotic***benzonatate capsule 100 mg oral 100 mg Tier 1

benzonatate capsule 150 mg oral 150 mg Benefit Exclusion Non Essential Drug Exclusion

benzonatate capsule 200 mg oral 200 mg Tier 1

TESSALON PERLES ORAL CAPSULE 100 MG EX Formulary Exclusion

*Antitussive - Opioid***HYCODAN ORAL SOLUTION 5-1.5 MG/5ML EX Formulary Exclusion

HYCODAN ORAL TABLET 5-1.5 MG EX Formulary Exclusion

hydrocodone bit-homatrop mbr oral solution 5-1.5 mg/5ml

Tier 1

hydrocodone bit-homatrop mbr oral tablet 5-1.5 mg

Tier 1

hydromet oral solution 5-1.5 mg/5ml Tier 1

*Antitussive-Expectorant***guaifenesin-dm oral liquid 10-100 mg/5ml Tier 1

*Decongestant & Antihistamine***CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR 2.5-120 MG

Tier 3

promethazine vc oral syrup 6.25-5 mg/5ml Tier 1

promethazine-phenylephrine oral syrup 6.25-5 mg/5ml

Tier 1

SEMPREX-D ORAL CAPSULE 8-60 MG Tier 3

*Decongestant W/ Expectorant***GILPHEX TR ORAL TABLET 10-388 MG EX Non FDA Exclusion

*Iodine Expectorants***SSKI ORAL SOLUTION 1 GM/ML Tier 3

*Misc. Respiratory Inhalants***HYPERSAL NEBULIZATION SOLUTION 3.5 % INHALATION 3.5 % Tier 3

HYPERSAL NEBULIZATION SOLUTION 7 % INHALATION 7 % EX Formulary Exclusion

185

Drug Name Drug Tier NotesNEBUSAL INHALATION NEBULIZATION SOLUTION 3 % Tier 1

PULMOSAL INHALATION NEBULIZATION SOLUTION 7 % Tier 1

sodium chloride nebulization solution 0.9 % inhalation (rx) 0.9 %

Tier 1

sodium chloride nebulization solution 10 % inhalation 10 %



Tier 1


Tier 1




Tier 1

*Mucolytics***acetylcysteine inhalation solution 10 %, 20 % Tier 1

*Non-Narc Antitussive-Antihistamine***promethazine-dm oral syrup 6.25-15 mg/5ml Tier 1

*Non-Narc Antitussive-Decongestant-Antihistamine***pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml

Tier 1

*Opioid Antitussive-Antihistamine***hydrocod polst-cpm polst er oral suspension extended release 10-8 mg/5ml


promethazine-codeine oral solution 6.25-10 mg/5ml


promethazine-codeine oral syrup 6.25-10 mg/5ml Tier 1 Opioid Brochure

TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10-8 MG, 5-4 MG Tier 3 Opioid Brochure

TUSSIONEX PENNKINETIC ER ORAL SUSPENSION EXTENDED RELEASE 10-8 MG/5ML


TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 54.3-8 MG Tier 3 Opioid Brochure

TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 14.7-2.8 MG/5ML Tier 3 Opioid Brochure

186


*Opioid Antitussive-Decongestant-Antihistamine***promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml


promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml


pseudoeph-chlorphen-hydrocod oral solution 60-4-5 mg/5ml


*Dermatologicals*

*Acne Antibiotics***ACZONE GEL 5 % EXTERNAL 5 % EX Formulary Exclusion

ACZONE GEL 7.5 % EXTERNAL 7.5 % Tier 3

AMZEEQ EXTERNAL FOAM 4 % Tier 3

CLEOCIN-T EXTERNAL GEL 1 % EX Formulary Exclusion

CLEOCIN-T EXTERNAL LOTION 1 % EX Formulary Exclusion

CLINDACIN ETZ EXTERNAL SWAB 1 % Tier 1

CLINDACIN-P EXTERNAL SWAB 1 % Tier 1

CLINDAGEL EXTERNAL GEL 1 % EX Formulary Exclusion

clindamycin phosphate external foam 1 % Tier 1

clindamycin phosphate external lotion 1 % Tier 1

clindamycin phosphate external solution 1 % Tier 1

clindamycin phosphate external swab 1 % Tier 1

clindamycin phosphate gel 1 % external 1 % EX Formulary Exclusion

clindamycin phosphate gel 1 % external 1 % Tier 1

dapsone external gel 5 %, 7.5 % Tier 1

ery external pad 2 % Tier 1

ERYGEL EXTERNAL GEL 2 % EX Formulary Exclusion

erythromycin external gel 2 % Tier 1

erythromycin external solution 2 % Tier 1

EVOCLIN EXTERNAL FOAM 1 % EX Formulary Exclusion

KLARON EXTERNAL LOTION 10 % EX Formulary Exclusion

sulfacetamide sodium (acne) external lotion 10 % Tier 1

*Acne Combinations***ACANYA EXTERNAL GEL 1.2-2.5 % EX Formulary Exclusion

acioxiay external cream 15-4 % EX Non FDA Exclusion

adainzde external gel 0.3-2.5-1 % EX Non FDA Exclusion

adainzoxia external gel 0.3-2.5-4 % EX Non FDA Exclusion

adapalene-benzoyl peroxide external gel 0.1-2.5 %, 0.3-2.5 %

Tier 1

187

Drug Name Drug Tier Notesadapalene-benzoyl peroxide external pad 0.1-2.5 %


AVAR CLEANSER EXTERNAL LIQUID 10-5 % EX Non FDA Exclusion

AVAR LS CLEANSER EXTERNAL LIQUID10-2 % EX Non FDA Exclusion

AVAR-E EMOLLIENT EXTERNAL CREAM10-5 % EX Non FDA Exclusion

AVAR-E GREEN EXTERNAL CREAM 10-5 % EX Non FDA Exclusion

AVAR-E LS EXTERNAL CREAM 10-2 % EX Non FDA Exclusion

BENZACLIN EXTERNAL GEL 1-5 % EX Formulary Exclusion

BENZACLIN WITH PUMP EXTERNAL GEL 1-5 % EX Formulary Exclusion

BENZAMYCIN EXTERNAL GEL 5-3 % EX Formulary Exclusion

benzoyl perox-hydrocortisone external lotion 5-0.5 %


benzoyl peroxide forte- hc external lotion 7.5-1 % EX Non FDA Exclusion

benzoyl peroxide-erythromycin external gel 5-3 % Tier 1

bp 10-1 external emulsion 10-1 % EX Non FDA Exclusion

bp cleansing wash external emulsion 10-4 % EX Non FDA Exclusion

CLENIA PLUS EXTERNAL SUSPENSION 9-4.25 % EX Non FDA Exclusion

CLINDACIN ETZ EXTERNAL KIT 1 % EX Non FDA Exclusion

CLINDACIN PAC EXTERNAL KIT 1 % EX Non FDA Exclusion

clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, 1.2-5 %

Tier 1

clindamycin-tretinoin gel 1.2-0.025 % external1.2-0.025 %

Benefit Exclusion

clindamycin-tretinoin gel 1.2-0.025 % external1.2-0.025 %


clindavix external kit 1 & 1.8-2 % EX Non FDA Exclusion

CLINOIN EXTERNAL CREAM 1.25-0.025-1 % EX Non FDA Exclusion

deoxia external gel 1-4 % EX Non FDA Exclusion

deoxia external lotion 1-4 % EX Non FDA Exclusion

diadimaxia external gel 6-2-5 % EX Non FDA Exclusion

diaoxia external gel 6-4 % EX Non FDA Exclusion

diasdimaxia external gel 8.5-2-5 % EX Non FDA Exclusion

diasoxia external gel 8.5-4 % EX Non FDA Exclusion

dimoxia external gel 4-5 % EX Non FDA Exclusion

188

Drug Name Drug Tier Notesdraxace external suspension 2-8 % EX Non FDA Exclusion

draxace lotion cleanser external suspension 2-8 %


drixece external suspension 5-10 % EX Non FDA Exclusion

eceoxia external cream 4-10 % EX Non FDA Exclusion

EPIDUO EXTERNAL GEL 0.1-2.5 % EX Formulary Exclusion

EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % Tier 2

ethoxia external cream 4-0.05 % EX Non FDA Exclusion

INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 & 5 % EX Non FDA Exclusion

INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 & 5 % EX Non FDA Exclusion

INOVA EXTERNAL KIT 4 & 5 %, 8 & 5 % EX Non FDA Exclusion

ithoxia external cream 4-0.1 % EX Non FDA Exclusion

NEUAC EXTERNAL GEL 1.2-5 % Tier 1

NEUAC EXTERNAL KIT 1.2-5 % EX Non FDA Exclusion

NUCARACLINPAK EXTERNAL KIT 1 % EX Non FDA Exclusion

NUCARARXPAK EXTERNAL KIT 1-2.5 % EX Non FDA Exclusion

ONEXTON EXTERNAL GEL 1.2-3.75 % Tier 2

onzdeoxia external gel 1-5-4 % EX Non FDA Exclusion

oxiatar external cream 4-0.025 % EX Non FDA Exclusion

oxiavarry external cream 4-0.05 % EX Non FDA Exclusion

oxiazar external cream 4-0.1 % EX Non FDA Exclusion

PLEXION CLEANSER EXTERNAL LIQUID9.8-4.8 % EX Non FDA Exclusion

PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8-4.8 % EX Non FDA Exclusion

PLEXION EXTERNAL CREAM 9.8-4.8 % EX Non FDA Exclusion

PLEXION EXTERNAL LOTION 9.8-4.8 % EX Non FDA Exclusion

resorcinol-sulfur external lotion 2-5 % EX Non FDA Exclusion

saroxia external cream 4-0.05 % EX Non FDA Exclusion

sss 10-5 external cream 10-5 % EX Non FDA Exclusion

sss 10-5 external foam 10-5 % EX Non FDA Exclusion

sulfacetamide sodium-sulfur cream 10-2 % external 10-2 %


sulfacetamide sodium-sulfur cream 10-5 % external 10-5 %


sulfacetamide sodium-sulfur cream 9.8-4.8 % external 9.8-4.8 %

Tier 1

189

Drug Name Drug Tier Notessulfacetamide sodium-sulfur cream 9.8-4.8 % external 9.8-4.8 %


sulfacetamide sodium-sulfur external lotion 10-5 %, 9.8-4.8 %


sulfacetamide sodium-sulfur external pad 10-4 %, 9.8-4.8 %


sulfacetamide sodium-sulfur liquid 10-2 % external 10-2 %



Tier 1




Tier 1

sulfacetamide sodium-sulfur liquid 9.8-4.8 % external 9.8-4.8 %


sulfacetamide sodium-sulfur liquid 9-4 % external9-4 %


sulfacetamide sodium-sulfur liquid 9-4 % external9-4 %

Tier 1

sulfacetamide sodium-sulfur liquid 9-4.5 % external 9-4.5 %


sulfacetamide sodium-sulfur liquid 9-4.5 % external 9-4.5 %

Tier 1

sulfacetamide sodium-sulfur suspension 10-5 % external 10-5 %



Tier 1



sulfacetamide sod-sulfur wash external liquid 9-4 %, 9-4.5 %


sulfacetamide-sulfur in urea external emulsion10-5 %


SULFACLEANSE 8/4 EXTERNAL SUSPENSION 8-4 % EX Non FDA Exclusion

sulfamez wash external emulsion 10-1 % EX Formulary Exclusion

SUMADAN EXTERNAL KIT 9-4.5 % EX Non FDA Exclusion

SUMADAN WASH EXTERNAL LIQUID 9-4.5 % EX Non FDA Exclusion

SUMADAN XLT EXTERNAL KIT 9-4.5 % EX Non FDA Exclusion

SUMAXIN CP EXTERNAL KIT 10-4 % EX Non FDA Exclusion

SUMAXIN EXTERNAL PAD 10-4 % EX Non FDA Exclusion

190

Drug Name Drug Tier Notestardeoxia external cream 1-4-0.025 % EX Non FDA Exclusion

tardimaxia external gel 2-5-0.025 % EX Non FDA Exclusion

taroxia external cream 4-0.025 % EX Non FDA Exclusion

taroxia external gel 4-0.025 % EX Non FDA Exclusion

TWYNEO EXTERNAL CREAM 0.1-3 % EX Formulary Exclusion

VANOXIDE-HC EXTERNAL LOTION 5-0.5 % EX Non FDA Exclusion

vardimaxia external gel 2-5-0.05 % EX Non FDA Exclusion

varoxia external cream 4-0.05 % EX Non FDA Exclusion

varoxia external gel 4-0.05 % EX Non FDA Exclusion

VELTIN EXTERNAL GEL 1.2-0.025 % Benefit Exclusion

ZACARE EXTERNAL KIT 4 & 0.2 %, 8 & 0.2 % EX Non FDA Exclusion

ZIANA EXTERNAL GEL 1.2-0.025 % Benefit Exclusion

*Acne Products***ABSORICA LD ORAL CAPSULE 16 MG, 24 MG, 32 MG, 8 MG Benefit Exclusion Non Essential Drug Exclusion

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG Benefit Exclusion

ACCUTANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG Tier 1

adapalene external cream 0.1 % Tier 1

adapalene external gel 0.1 %, 0.3 % Tier 1

adapalene external pad 0.1 % Benefit Exclusion Non Essential Drug Exclusion

adapalene external solution 0.1 % Tier 3

AKLIEF EXTERNAL CREAM 0.005 % Tier 3

ALTRENO EXTERNAL LOTION 0.05 % Tier 3

AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG Tier 1

ARAZLO EXTERNAL LOTION 0.045 % EX Formulary Exclusion

ATRALIN EXTERNAL GEL 0.05 % EX Formulary Exclusion

AVITA EXTERNAL CREAM 0.025 % Tier 1

AVITA EXTERNAL GEL 0.025 % Tier 1

AZELEX EXTERNAL CREAM 20 % Tier 3

BENZAC AC WASH EXTERNAL LIQUID 5 % EX Formulary Exclusion

BENZEPRO CREAMY WASH EXTERNAL LIQUID 7 % EX Non FDA Exclusion

BENZEPRO EXTERNAL 5.8 % EX Non FDA Exclusion

191

Drug Name Drug Tier NotesBENZEPRO EXTERNAL FOAM 5.2 %, 5.3 %, 9.7 % EX Non FDA Exclusion

BENZEPRO EXTERNAL LIQUID 6.8 % EX Non FDA Exclusion

BENZEPRO FOAMING CLOTHS EXTERNAL 6 % EX Non FDA Exclusion

benzoyl peroxide external foam 9.8 % EX Non FDA Exclusion

benzoyl peroxide external gel 6.5 %, 8 % EX Non FDA Exclusion

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG Tier 1

DIFFERIN EXTERNAL CREAM 0.1 % EX Formulary Exclusion

DIFFERIN EXTERNAL GEL 0.3 % EX Formulary Exclusion

DIFFERIN EXTERNAL LOTION 0.1 % Tier 3

ENZOCLEAR EXTERNAL FOAM 9.8 % EX Non FDA Exclusion

EPSOLAY EXTERNAL CREAM 5 % EX New to Market Exclusion

FABIOR EXTERNAL FOAM 0.1 % EX Formulary Exclusion

isotretinoin capsule 10 mg oral 10 mg Benefit Exclusion Non Essential Drug Exclusion

isotretinoin capsule 10 mg oral 10 mg Tier 1









MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG Tier 1

PR BENZOYL PEROXIDE EXTERNAL LIQUID 6.9 % EX Non FDA Exclusion

PR BENZOYL PEROXIDE WASH LIQUID 7 % EXTERNAL 7 % EX Formulary Exclusion

PR BENZOYL PEROXIDE WASH LIQUID 7 % EXTERNAL 7 % EX Non FDA Exclusion

RETIN-A EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 % EX Formulary Exclusion

RETIN-A EXTERNAL GEL 0.01 %, 0.025 % EX Formulary Exclusion

RETIN-A MICRO EXTERNAL GEL 0.04 %, 0.1 % EX Formulary Exclusion

RETIN-A MICRO PUMP EXTERNAL GEL0.04 %, 0.06 %, 0.08 %, 0.1 % EX Formulary Exclusion

tazarotene external foam 0.1 % EX Formulary Exclusion

192

Drug Name Drug Tier Notestretinoin external cream 0.025 %, 0.05 %, 0.1 % Tier 1

tretinoin external gel 0.01 %, 0.025 %, 0.05 % Tier 1

tretinoin microsphere external gel 0.04 %, 0.1 % Tier 1

tretinoin microsphere pump external gel 0.04 %, 0.1 %

Tier 1

WINLEVI EXTERNAL CREAM 1 % Tier 3

zaclir cleansing external lotion 8 % EX Non FDA Exclusion

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG Tier 1

*Agents For External Genital And Perianal Warts***VEREGEN EXTERNAL OINTMENT 15 % Tier 3

*Agents For Facial Wrinkles - Retinoids***REFISSA EXTERNAL CREAM 0.05 % Benefit Exclusion

RENOVA EXTERNAL CREAM 0.02 % Benefit Exclusion

RENOVA PUMP EXTERNAL CREAM 0.02 % Benefit Exclusion

tretinoin (emollient) external cream 0.05 % Benefit Exclusion

*Analgesic Combinations - Topical***A.A.G.C. KIT IN TERODERM EXTERNAL CREAM 8-4-10-4 % EX Non FDA Exclusion

*Analgesics - Topical***baclofen external cream 2 % EX Non FDA Exclusion

enovarx-baclofen external cream 1 % EX Non FDA Exclusion

enovarx-tramadol external cream 5 % EX Non FDA Exclusion

NEURAPTINE EXTERNAL CREAM 10 % EX Non FDA Exclusion

*Antibiotic Steroid Combinations - Topical***NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % Tier 3

NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % EX Non FDA Exclusion

*Antibiotics - Topical***ALTABAX EXTERNAL OINTMENT 1 % Tier 3

CENTANY AT EXTERNAL KIT 2 % EX Non FDA Exclusion

CENTANY EXTERNAL OINTMENT 2 % Tier 1

gentamicin sulfate external cream 0.1 % Tier 1

gentamicin sulfate external ointment 0.1 % Tier 1

193

Drug Name Drug Tier Notesmupirocin calcium external cream 2 % Tier 1

mupirocin external ointment 2 % Tier 1

XEPI EXTERNAL CREAM 1 % Tier 3

*Antifungals - Topical Combinations***ALA-QUIN EXTERNAL CREAM 3-0.5 % EX Non FDA Exclusion

ALCORTIN A EXTERNAL GEL 1-2-1 % EX Non FDA Exclusion

clotrimazole-betamethasone external cream 1-0.05 %

Tier 1

clotrimazole-betamethasone external lotion 1-0.05 %

Tier 1

corti-sav external cream 1-1 % EX Non FDA Exclusion

DERMACINRX THERAZOLE PAK EXTERNAL THERAPY PACK 1-0.05 & 20 %

Benefit Exclusion

DERMAZENE EXTERNAL CREAM 1-1 % EX Non FDA Exclusion

difmetioxrime external solution 4-2-1-4 % EX Non FDA Exclusion

fungimez external solution EX Non FDA Exclusion

hixdefrima external solution 8-1-1 % EX Non FDA Exclusion

hydrocortisone-iodoquinol external cream 1-1 % EX Non FDA Exclusion

imioxia external cream 1-4 % EX Non FDA Exclusion

iodoquimez-hc external cream 1-1.9 % EX Non FDA Exclusion

iodoquinol-hc-aloe polysacch external gel 1-2-1 %


iodoquinol-hydrocortisone-aloe external cream 1-1.9 %


LOTRISONE EXTERNAL CREAM 1-0.05 % EX Formulary Exclusion

miconazole-zinc oxide-petrolat external ointment0.25-15-81.35 %


nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

Tier 1

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

Tier 1

ONYCHO-MED EXTERNAL KIT 2-250 %-MG EX Non FDA Exclusion

pedizolpak external therapy pack 2 & 2 % EX Non FDA Exclusion

pheodoyo external cream 1-2.5-2 % EX Non FDA Exclusion

pheyo external cream 2.5-2 % EX Non FDA Exclusion

QUINJA EXTERNAL GEL 1.25-1 % EX Non FDA Exclusion

RECURA EXTERNAL CREAM EX Non FDA Exclusion

194

Drug Name Drug Tier NotesVUSION EXTERNAL OINTMENT 0.25-15-81.35 % Benefit Exclusion Non Essential Drug Exclusion

VYTONE EXTERNAL CREAM 1-1.9 % EX Non FDA Exclusion

XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % EX Non FDA Exclusion

XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 % EX Non FDA Exclusion

XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % EX Non FDA Exclusion

ZOLPAK EXTERNAL KIT 1 % Benefit Exclusion

*Antifungals - Topical***CICLODAN EXTERNAL SOLUTION 8 % Tier 1

ciclopirox external gel 0.77 % Tier 1

ciclopirox external shampoo 1 % Tier 1

ciclopirox external solution 8 % Tier 1

ciclopirox olamine external cream 0.77 % Tier 1

ciclopirox olamine external suspension 0.77 % Tier 1

ciclopirox treatment external kit 8 % EX Non FDA Exclusion

LOPROX EXTERNAL CREAM 0.77 % EX Formulary Exclusion

LOPROX EXTERNAL KIT 0.77 %, 0.77 % (SUSP) EX Non FDA Exclusion

LOPROX EXTERNAL SHAMPOO 1 % EX Formulary Exclusion

LOPROX EXTERNAL SUSPENSION 0.77 % EX Formulary Exclusion

MENTAX EXTERNAL CREAM 1 % Tier 3

naftifine hcl external cream 1 %, 2 % Tier 1

naftifine hcl external gel 1 % Tier 1

NAFTIN EXTERNAL CREAM 2 % EX Formulary Exclusion

NAFTIN EXTERNAL GEL 1 %, 2 % Tier 3

NYAMYC EXTERNAL POWDER 100000 UNIT/GM Tier 1

nystatin external cream 100000 unit/gm Tier 1

nystatin external ointment 100000 unit/gm Tier 1

nystatin external powder 100000 unit/gm Tier 1

NYSTOP EXTERNAL POWDER 100000 UNIT/GM Tier 1

*Anti-Inflammatory Agents - Topical***diclofenac epolamine external patch 1.3 % EX Formulary Exclusion

diclofenac sodium external gel 1 % Tier 1 QL

diclofenac sodium solution 1.5 % external 1.5 % Benefit Exclusion Non Essential Drug Exclusion; QL

195

Drug Name Drug Tier Notesdiclofenac sodium solution 2 % external 2 % Benefit Exclusion

DICLOFONO EXTERNAL GEL 1.6 % EX Non FDA Exclusion

enovarx-diclofenac sodium external cream 2.5 % EX Non FDA Exclusion

enovarx-ibuprofen external cream 10 % EX Non FDA Exclusion

enovarx-naproxen external cream 10 % EX Non FDA Exclusion

FLECTOR EXTERNAL PATCH 1.3 % EX Formulary Exclusion

FROTEK EXTERNAL CREAM 10 % EX Non FDA Exclusion

KETOPHENE RAPIDPAQ EXTERNAL CREAM 20 % EX Non FDA Exclusion

ketorolac tromethamine external gel 2 % EX Non FDA Exclusion

LICART EXTERNAL PATCH 24 HOUR 1.3 % Benefit Exclusion

napro external cream 15 % EX Non FDA Exclusion

PENNSAID EXTERNAL SOLUTION 2 % Benefit Exclusion Non Essential Drug Exclusion

VENNGEL ONE EXTERNAL KIT 1 % Benefit Exclusion

VOLTAREN EXTERNAL GEL 1 % EX Formulary Exclusion; QL

*Anti-Inflammatory Combinations - Topical***aif #2 drug preparation kit external cream EX Non FDA Exclusion

aif #3 drug preparation kit external cream EX Non FDA Exclusion

biifenac 1000 external therapy pack 1.5-4 % EX Non FDA Exclusion

biifenac 500 external therapy pack 1.5-4 % EX Non FDA Exclusion

capsfenac pak external therapy pack 1.5 & 0.025 %


capsinac external therapy pack 0.025-1.5 % EX Non FDA Exclusion

DERMACINRX LEXITRAL PHARMAPAK EXTERNAL THERAPY PACK 1.5 & 0.025 % Benefit Exclusion

dfs/ms/menth/cap pak external kit 1.5 % EX Non FDA Exclusion

dicloheal-60 external therapy pack 1.5 & 0.025 % EX Non FDA Exclusion

diclona external gel 1-4.5 % EX Non FDA Exclusion

diclopr external kit 1 & 10-30 % EX Non FDA Exclusion

diclostream external therapy pack 1.5-10 % EX Non FDA Exclusion

DICLOTREX EXTERNAL THERAPY PACK1.5 & 4-10 % Benefit Exclusion

DICLOTREX II EXTERNAL THERAPY PACK 1.5 & 4-10 % Benefit Exclusion

diclovix external kit 1.5 & 2-2.5-4 % EX Non FDA Exclusion

diclovix m external therapy pack 1.5-8 % EX Non FDA Exclusion

diclozor external therapy pack 1 % Benefit Exclusion

dimentho external therapy pack 1.5 & 10 % EX Non FDA Exclusion

196

Drug Name Drug Tier Notesdual complex formula 1 kit external cream EX Non FDA Exclusion

fbl kit external cream 15-4-5 % EX Non FDA Exclusion

FENOVAR EXTERNAL KIT 1.5-10-15 % EX Non FDA Exclusion

gabapentin-naproxen cmpd kit external cream 5-10 %


ICLOFENAC CP EXTERNAL THERAPY PACK 0.025-1.5 % EX Non FDA Exclusion

K.B.G.L IN TERODERM EXTERNAL CREAM 15-4-10-2 % EX Non FDA Exclusion

kapzin dc external therapy pack 0.025-1.5 % EX Non FDA Exclusion

LEXITRAL PHARMAPAK II EXTERNAL THERAPY PACK 1.5 & 0.025 % Benefit Exclusion

np #2 drug preparation kit external cream EX Non FDA Exclusion

NUDICLO SOLUPAK EXTERNAL THERAPY PACK 1.5 & 0.025 % EX Non FDA Exclusion

pennsaicin external therapy pack 1.5 & 0.025 % EX Non FDA Exclusion

PROFINAC EXTERNAL THERAPY PACK1.5 % EX Non FDA Exclusion

sure result dss premium pack external therapy pack 1.5 & 0.025 %


triple complex formula 3 kit external cream 20-2-10 %


VAROPHEN EXTERNAL KIT 1.5-10-15 % EX Non FDA Exclusion

vp fc kit external cream EX Non FDA Exclusion

vp gkl kit external cream 20-2-10 % EX Non FDA Exclusion

XRYLIX EXTERNAL THERAPY PACK 1.5 % Benefit Exclusion

XRYLIX II EXTERNAL THERAPY PACK1.5 % Benefit Exclusion

ZICLOPRO EXTERNAL THERAPY PACK1.5 & 0.025 % EX Non FDA Exclusion

*Antineoplastic Alkylating Agents - Topical***VALCHLOR EXTERNAL GEL 0.016 % Tier 4 PA; Specialty; QL

*Antineoplastic Antimetabolites - Topical***CARAC EXTERNAL CREAM 0.5 % Benefit Exclusion Non Essential Drug Exclusion

EFUDEX EXTERNAL CREAM 5 % EX Formulary Exclusion

FLUOROPLEX EXTERNAL CREAM 1 % EX Formulary Exclusion

fluorouracil cream 0.5 % external 0.5 % Benefit Exclusion

fluorouracil cream 5 % external 5 % Tier 1

197

Drug Name Drug Tier Notesfluorouracil external solution 2 %, 5 % Tier 1

TOLAK EXTERNAL CREAM 4 % EX Formulary Exclusion

*Antineoplastic Or Premalignant Lesion Agent - Comb***ORMECA COMBINATION KIT 3 & 46-0.4-1.1 %-MG EX Non FDA Exclusion

quihoxvar external gel 5-1-0.05 % EX Non FDA Exclusion

roaoxia external gel 3-4 % EX Non FDA Exclusion

solaravix external therapy pack 3 % EX Non FDA Exclusion

*Antineoplastic Or Premalignant Lesions - Topical Misc.***PICATO EXTERNAL GEL 0.015 %, 0.05 % Tier 2

*Antineoplastic Or Premalignant Lesions - Topical Nsaid's***diclofenac sodium gel 3 % external 3 % EX PA; Non FDA Exclusion; QL

diclofenac sodium gel 3 % external 3 % Tier 1 PA; QL

*Antineoplastic Retinoids - Topical***PANRETIN EXTERNAL GEL 0.1 % EX Formulary Exclusion

*Antipruritics - Topical***doxepin hcl external cream 5 % Benefit Exclusion Non Essential Drug Exclusion

PRUDOXIN EXTERNAL CREAM 5 % Benefit Exclusion Non Essential Drug Exclusion

ZONALON EXTERNAL CREAM 5 % Benefit Exclusion Non Essential Drug Exclusion

*Antipsoriatic Combinations***NUDERMRXPAK 120 EXTERNAL THERAPY PACK 0.005-5 % EX Non FDA Exclusion

NUDERMRXPAK 60 EXTERNAL THERAPY PACK 0.005-5 % EX Non FDA Exclusion

*Antipsoriatics - Systemic***acitretin oral capsule 10 mg, 17.5 mg, 25 mg Tier 1 QL

COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML


COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML


COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML


198

Drug Name Drug Tier NotesCOSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5ML


ILUMYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML EX


methoxsalen rapid oral capsule 10 mg Tier 4 PA; Specialty

OXSORALEN ULTRA ORAL CAPSULE 10 MG EX


SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 210 MG/1.5ML EX


SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT 75 MG/0.83ML Tier 4 PA; ST; Specialty; QL

SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML Tier 4 PA; ST; Specialty; QL

SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML Tier 4 PA; ST; Specialty; QL

SORIATANE ORAL CAPSULE 10 MG, 25 MG EX Formulary Exclusion; QL

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML Tier 4 PA; ST; Specialty; QL

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML


TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80 MG/ML EX


TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 80 MG/ML EX


TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 MG/ML Tier 4 PA; ST; Specialty; QL

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML Tier 4 PA; ST; Specialty; QL

*Antipsoriatics***calcipotriene external cream 0.005 % Tier 1

calcipotriene external foam 0.005 % Benefit Exclusion Non Essential Drug Exclusion

calcipotriene external ointment 0.005 % Tier 1

calcipotriene external solution 0.005 % Tier 1

CALCITRENE EXTERNAL OINTMENT0.005 % Tier 1

calcitriol external ointment 3 mcg/gm Tier 1

DOVONEX EXTERNAL CREAM 0.005 % EX Formulary Exclusion

DRITHO-CREME HP EXTERNAL CREAM1 % EX Non FDA Exclusion

199

Drug Name Drug Tier NotesSORILUX EXTERNAL FOAM 0.005 % Benefit Exclusion Non Essential Drug Exclusion

tazarotene external cream 0.1 % Tier 1

TAZORAC CREAM 0.05 % EXTERNAL 0.05 % Tier 2

TAZORAC CREAM 0.1 % EXTERNAL 0.1 % EX Formulary Exclusion

TAZORAC EXTERNAL GEL 0.05 %, 0.1 % Tier 2

VECTICAL EXTERNAL OINTMENT 3 MCG/GM Tier 3

VTAMA EXTERNAL CREAM 1 % EX New to Market Exclusion

ZITHRANOL EXTERNAL SHAMPOO 1 % EX Non FDA Exclusion

*Antiseborrheic Combinations***haxchlo external shampoo 0.77-0.05 % EX Non FDA Exclusion

NUTRASEB EXTERNAL CREAM EX Non FDA Exclusion

PROMISEB EXTERNAL CREAM EX Non FDA Exclusion

sodium sulfacetamide-bakuchiol external liquid10 %


*Antiseborrheic Products***glycolic acid solution 70 % EX Non FDA Exclusion

OVACE PLUS EXTERNAL CREAM 10 % EX Non FDA Exclusion

OVACE PLUS EXTERNAL FOAM 9.8 % EX Non FDA Exclusion

OVACE PLUS EXTERNAL LOTION 9.8 % EX Non FDA Exclusion

OVACE PLUS EXTERNAL SHAMPOO 10 % EX Non FDA Exclusion

OVACE PLUS WASH EXTERNAL GEL 10 % EX Non FDA Exclusion

OVACE PLUS WASH EXTERNAL LIQUID10 % EX Non FDA Exclusion

OVACE WASH EXTERNAL LIQUID 10 % EX Non FDA Exclusion

PLEXION NS EXTERNAL SHAMPOO 9.8 % EX Non FDA Exclusion

selenium sulfide external lotion 2.5 % Tier 1

selenium sulfide external shampoo 2.25 %, 2.3 % EX Non FDA Exclusion

SELRX EXTERNAL SHAMPOO 2.3 % EX Non FDA Exclusion

sodium sulfacetamide external shampoo 10 %, 9.8 %


sodium sulfacetamide wash liquid 10 % external10 %


sodium sulfacetamide wash liquid 10 % external10 %

Tier 1

sulfacetamide sodium (cleans) external gel 10 % EX Non FDA Exclusion

sulfacetamide sodium external liquid 10 % EX Non FDA Exclusion

200


*Antiviral Topical Combinations***XERESE EXTERNAL CREAM 5-1 % Benefit Exclusion Non Essential Drug Exclusion

*Antivirals - Topical***acyclovir external cream 5 % Tier 1

acyclovir external ointment 5 % Tier 1

DENAVIR EXTERNAL CREAM 1 % Tier 3

ZOVIRAX EXTERNAL CREAM 5 % EX Formulary Exclusion

ZOVIRAX EXTERNAL OINTMENT 5 % EX Formulary Exclusion

*Astringents***XERAC AC SOLUTION 6.25 % EXTERNAL6.25 % EX Formulary Exclusion

XERAC AC SOLUTION 6.25 % EXTERNAL6.25 % EX Non FDA Exclusion

*Atopic Dermatitis - Janus Kinase (Jak) Inhibitors***CIBINQO ORAL TABLET 100 MG, 200 MG, 50 MG EX


OPZELURA EXTERNAL CREAM 1.5 % EX PA; Formulary Exclusion; QL

*Atopic Dermatitis - Monoclonal Antibodies***ADBRY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML EX


DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 MG/1.14ML, 300 MG/2ML


DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML, 200 MG/1.14ML, 300 MG/2ML


*Burn Products***mafenide acetate external packet 5 % Tier 1

SILVADENE EXTERNAL CREAM 1 % EX Formulary Exclusion

silver sulfadiazine external cream 1 % Tier 1

SSD EXTERNAL CREAM 1 % Tier 1

SULFAMYLON EXTERNAL CREAM 85 MG/GM Tier 3

SULFAMYLON EXTERNAL PACKET 5 % EX Formulary Exclusion

*Cauterizing Agent Combinations***ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 % EX Non FDA Exclusion

201


*Cauterizing Agents***silver nitrate external solution 0.5 %, 10 %, 25 %, 50 %


TRI-CHLOR EXTERNAL LIQUID 80 % EX Non FDA Exclusion

*Corticosteroids - Topical***ADVANCED ALLERGY COLLECTION EXTERNAL KIT 2.5 % EX Non FDA Exclusion

ALA SCALP EXTERNAL LOTION 2 % Tier 1

ala-cort external cream 1 %, 2.5 % Tier 1

alclometasone dipropionate external cream 0.05 %

Tier 1

alclometasone dipropionate external ointment0.05 %

Tier 1

amcinonide external cream 0.1 % Tier 3

amcinonide external lotion 0.1 % Tier 3

amcinonide external ointment 0.1 % Tier 3

APEXICON E EXTERNAL CREAM 0.05 % Tier 3

BESER EXTERNAL LOTION 0.05 % Tier 1

betamethasone dipropionate aug external cream0.05 %

Tier 1

betamethasone dipropionate aug external gel 0.05 %

Tier 1

betamethasone dipropionate aug external lotion0.05 %

Tier 1

betamethasone dipropionate aug external ointment 0.05 %

Tier 1

betamethasone dipropionate external cream 0.05 %

Tier 1

betamethasone dipropionate external lotion 0.05 %

Tier 1

betamethasone dipropionate external ointment0.05 %

Tier 1

betamethasone valerate external cream 0.1 % Tier 1

betamethasone valerate external foam 0.12 % Benefit Exclusion Non Essential Drug Exclusion

betamethasone valerate external lotion 0.1 % Tier 1

betamethasone valerate external ointment 0.1 % Tier 1

BRYHALI EXTERNAL LOTION 0.01 % Benefit Exclusion Non Essential Drug Exclusion

CAPEX EXTERNAL SHAMPOO 0.01 % Tier 3

clobetasol prop emollient base external cream0.05 %

Tier 1

clobetasol propionate e external cream 0.05 % Tier 1

202

Drug Name Drug Tier Notesclobetasol propionate emulsion external foam0.05 %


clobetasol propionate external cream 0.05 % Tier 1

clobetasol propionate external foam 0.05 % Benefit Exclusion Non Essential Drug Exclusion

clobetasol propionate external gel 0.05 % Tier 1

clobetasol propionate external liquid 0.05 % Tier 1

clobetasol propionate external lotion 0.05 % Tier 1

clobetasol propionate external ointment 0.05 % Tier 1

clobetasol propionate external shampoo 0.05 % Tier 1

clobetasol propionate external solution 0.05 % Tier 1

CLOBEX EXTERNAL LOTION 0.05 % EX Formulary Exclusion

CLOBEX EXTERNAL SHAMPOO 0.05 % EX Formulary Exclusion

CLOBEX SPRAY EXTERNAL LIQUID 0.05 % EX Formulary Exclusion

clocortolone pivalate external cream 0.1 % Tier 1

CLODAN EXTERNAL SHAMPOO 0.05 % Tier 1

CLODERM EXTERNAL CREAM 0.1 % Tier 3

CORDRAN CREAM 0.025 % EXTERNAL0.025 % Tier 3

CORDRAN CREAM 0.05 % EXTERNAL0.05 % EX Formulary Exclusion

CORDRAN EXTERNAL LOTION 0.05 % EX Formulary Exclusion

CORDRAN EXTERNAL OINTMENT 0.05 % EX Formulary Exclusion

CORDRAN EXTERNAL TAPE 4 MCG/SQCM Tier 3

CUTIVATE EXTERNAL LOTION 0.05 % EX Formulary Exclusion

DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 % EX Formulary Exclusion

DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 % EX Formulary Exclusion

DESONATE EXTERNAL GEL 0.05 % EX Formulary Exclusion

desonide external cream 0.05 % Tier 1

desonide external gel 0.05 % Tier 1

desonide external lotion 0.05 % Tier 1

desonide external ointment 0.05 % Tier 1

DESOWEN EXTERNAL CREAM 0.05 % EX Formulary Exclusion

desoximetasone external cream 0.05 %, 0.25 % Tier 1

desoximetasone external gel 0.05 % Tier 1

desoximetasone external liquid 0.25 % Tier 1

desoximetasone external ointment 0.05 %, 0.25 % Tier 1

203

Drug Name Drug Tier NotesDESRX EXTERNAL GEL 0.05 % Tier 1

diflorasone diacetate external cream 0.05 % Benefit Exclusion Non Essential Drug Exclusion

diflorasone diacetate external ointment 0.05 % Tier 1

DIPROLENE AF EXTERNAL CREAM 0.05 % EX Formulary Exclusion

DIPROLENE EXTERNAL OINTMENT 0.05 % EX Formulary Exclusion

fluocinolone acetonide body external oil 0.01 % Tier 1

fluocinolone acetonide external cream 0.01 %, 0.025 %

Tier 1

fluocinolone acetonide external ointment 0.025 % Tier 1

fluocinolone acetonide external solution 0.01 % Tier 1

fluocinolone acetonide scalp external oil 0.01 % Tier 1

fluocinonide cream 0.05 % external 0.05 % Tier 1

fluocinonide cream 0.1 % external 0.1 % Benefit Exclusion Non Essential Drug Exclusion

fluocinonide emulsified base external cream 0.05 %

Tier 1

fluocinonide external gel 0.05 % Tier 1

fluocinonide external ointment 0.05 % Tier 1

fluocinonide external solution 0.05 % Tier 1

flurandrenolide external cream 0.05 % Tier 1

flurandrenolide external lotion 0.05 % Tier 1

flurandrenolide external ointment 0.05 % Tier 1

fluticasone propionate external cream 0.05 % Tier 1

fluticasone propionate external lotion 0.05 % Tier 1

fluticasone propionate external ointment 0.005 % Tier 1

halcinonide external cream 0.1 % Tier 1

halobetasol propionate external cream 0.05 % Tier 1

halobetasol propionate external foam 0.05 % Benefit Exclusion Non Essential Drug Exclusion

halobetasol propionate external ointment 0.05 % Tier 1

HALOG EXTERNAL CREAM 0.1 % EX Formulary Exclusion

HALOG EXTERNAL OINTMENT 0.1 % Tier 3

HALOG EXTERNAL SOLUTION 0.1 % Tier 3

hydrocortisone butyr lipo base external cream 0.1 %

Tier 1

hydrocortisone butyrate external cream 0.1 % Tier 1

hydrocortisone butyrate external lotion 0.1 % Tier 1

hydrocortisone butyrate external ointment 0.1 % Tier 1

hydrocortisone butyrate external solution 0.1 % Tier 1

204

Drug Name Drug Tier Noteshydrocortisone external cream 1 %, 2.5 % Tier 1

hydrocortisone external lotion 2.5 % Tier 1

hydrocortisone external ointment 1 %, 2.5 % Tier 1

HYDROCORTISONE IN ABSORBASE EXTERNAL OINTMENT 1 % Tier 1

hydrocortisone valerate external cream 0.2 % Tier 1

hydrocortisone valerate external ointment 0.2 % Tier 1

IMPEKLO EXTERNAL LOTION 0.15 MG/ACT (0.05%) Benefit Exclusion Non Essential Drug Exclusion

IMPOYZ EXTERNAL CREAM 0.025 % Benefit Exclusion Non Essential Drug Exclusion

KENALOG EXTERNAL AEROSOL SOLUTION 0.147 MG/GM EX Formulary Exclusion

LEXETTE EXTERNAL FOAM 0.05 % Benefit Exclusion Non Essential Drug Exclusion

LOCOID EXTERNAL CREAM 0.1 % EX Formulary Exclusion

LOCOID EXTERNAL LOTION 0.1 % EX Formulary Exclusion

LOCOID EXTERNAL SOLUTION 0.1 % EX Formulary Exclusion

LOCOID LIPOCREAM EXTERNAL CREAM 0.1 % EX Formulary Exclusion

LUXIQ EXTERNAL FOAM 0.12 % Benefit Exclusion

mometasone furoate external cream 0.1 % Tier 1

mometasone furoate external ointment 0.1 % Tier 1

mometasone furoate external solution 0.1 % Tier 1

NOLIX EXTERNAL CREAM 0.05 % Tier 1

NOLIX EXTERNAL LOTION 0.05 % Tier 1

NUCORT EXTERNAL LOTION 2 % EX Non FDA Exclusion

OLUX EXTERNAL FOAM 0.05 % Benefit Exclusion

OLUX-E EXTERNAL FOAM 0.05 % Benefit Exclusion

PANDEL EXTERNAL CREAM 0.1 % Benefit Exclusion Non Essential Drug Exclusion

prednicarbate external cream 0.1 % Tier 1

prednicarbate external ointment 0.1 % Tier 1

PSORCON EXTERNAL CREAM 0.05 % Benefit Exclusion Non Essential Drug Exclusion

SERNIVO EXTERNAL EMULSION 0.05 % Benefit Exclusion Non Essential Drug Exclusion

SYNALAR EXTERNAL CREAM 0.025 % EX Formulary Exclusion

SYNALAR EXTERNAL OINTMENT 0.025 % EX Formulary Exclusion

SYNALAR EXTERNAL SOLUTION 0.01 % EX Formulary Exclusion

TASOPROL EXTERNAL KIT 0.05 % Benefit Exclusion

TEMOVATE EXTERNAL CREAM 0.05 % EX Formulary Exclusion

TEMOVATE EXTERNAL OINTMENT 0.05 % EX Formulary Exclusion

205

Drug Name Drug Tier NotesTEXACORT EXTERNAL SOLUTION 2.5 % Tier 3

TOPICORT EXTERNAL CREAM 0.05 %, 0.25 % EX Formulary Exclusion

TOPICORT EXTERNAL GEL 0.05 % EX Formulary Exclusion

TOPICORT EXTERNAL OINTMENT 0.05 %, 0.25 % EX Formulary Exclusion

TOPICORT SPRAY EXTERNAL LIQUID0.25 % EX Formulary Exclusion

TOVET EXTERNAL FOAM 0.05 % Benefit Exclusion Non Essential Drug Exclusion

TOVET EXTERNAL KIT 0.05 % EX Non FDA Exclusion

triamcinolone acetonide external aerosol solution0.147 mg/gm

Tier 1

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

Tier 1

triamcinolone acetonide external lotion 0.025 %, 0.1 %

Tier 1

triamcinolone acetonide ointment 0.025 % external 0.025 %

Tier 1

triamcinolone acetonide ointment 0.05 % external0.05 %



Tier 1


Tier 1

triamcinolone in absorbase external ointment0.05 %


TRIANEX EXTERNAL OINTMENT 0.05 % Benefit Exclusion Non Essential Drug Exclusion

TRIDERM EXTERNAL CREAM 0.1 %, 0.5 % Tier 1

TRIDESILON EXTERNAL CREAM 0.05 % EX Non FDA Exclusion

TRITOCIN EXTERNAL OINTMENT 0.05 % Benefit Exclusion Non Essential Drug Exclusion

ULTRAVATE EXTERNAL LOTION 0.05 % Benefit Exclusion Non Essential Drug Exclusion

VANOS EXTERNAL CREAM 0.1 % Benefit Exclusion

VERDESO EXTERNAL FOAM 0.05 % Tier 3

*Depigmenting Agents***BLANCHE EXTERNAL CREAM 4 % Benefit Exclusion

hydroquinone external cream 4 % Benefit Exclusion

kaxm external emulsion 4 % Benefit Exclusion

keido external emulsion 6 % Benefit Exclusion

kexm external emulsion 6 % Benefit Exclusion

kutea external emulsion 8 % Benefit Exclusion

206

Drug Name Drug Tier Noteskuxm external emulsion 8 % Benefit Exclusion

*Depigmenting Combinations***katarya external emulsion 4-0.5-0.025 % Benefit Exclusion

kataryaxn external emulsion 4-0.5-0.025 % Benefit Exclusion

ketarya external emulsion 6-0.5-0.025 % Benefit Exclusion

kevarya external emulsion 6-0.5-0.05 % Benefit Exclusion

keya external emulsion 6-0.5 % Benefit Exclusion

kutaryaxm external emulsion 8-0.5-0.025 % Benefit Exclusion

kutaryaxmpa external emulsion 8-0.5-0.025 % Benefit Exclusion

kuvarya external emulsion 8-0.5-0.05 % Benefit Exclusion

kuvarye external emulsion 8-1-0.05 % Benefit Exclusion

TRI-LUMA EXTERNAL CREAM 0.01-4-0.05 % Benefit Exclusion

*Emollient Combinations***lactic acid e external cream 10-3500 %-unt/30gm EX Formulary Exclusion

*Emollient/Keratolytic Agents***CEM-UREA EXTERNAL SOLUTION 45 % EX Formulary Exclusion

CEROVEL EXTERNAL LOTION 40 % EX Formulary Exclusion

DERMACINRX UREA EXTERNAL CREAM41 % EX Non FDA Exclusion

HYDRO 40 EXTERNAL FOAM 40 % EX Formulary Exclusion

KERALAC EXTERNAL CREAM 47 % EX Non FDA Exclusion

protexa external cream 42 % Benefit Exclusion

UMECTA MOUSSE EXTERNAL FOAM 40 % EX Formulary Exclusion

URAMAXIN EXTERNAL GEL 45 % EX Formulary Exclusion

urea cream 39 % external 39 % EX Formulary Exclusion

urea cream 40 % external 40 % EX Non FDA Exclusion






urea external foam 35 % EX Non FDA Exclusion

urea lotion 40 % external 40 % EX Non FDA Exclusion

urea lotion 40 % external 40 % EX Formulary Exclusion

urea nail external gel 45 % EX Formulary Exclusion

UREDEB EXTERNAL CREAM 39 % EX Non FDA Exclusion

uremez-40 external cream 40 % EX Non FDA Exclusion

207

Drug Name Drug Tier NotesURESOL EXTERNAL CREAM 42.5 % EX Non FDA Exclusion

UTOPIC EXTERNAL CREAM 41 % EX Non FDA Exclusion

xurea external cream 39 % EX Non FDA Exclusion

*Emollient/Keratolytic Combinations***urea hydrating external foam 35 % EX Formulary Exclusion

*Emollients***ammonium lactate external cream 12 % Tier 1

ammonium lactate external lotion 12 % Tier 1

lactic acid external lotion 10 % EX Formulary Exclusion

*Enzymes - Topical***SANTYL EXTERNAL OINTMENT 250 UNIT/GM Tier 3 QL

*Eyelid Cleansers & Lubricants***ACUICYN EXTERNAL SOLUTION EX Non FDA Exclusion

AVENOVA EXTERNAL SOLUTION 0.01 % EX Non FDA Exclusion

HYPOCYN EXTERNAL SOLUTION EX Non FDA Exclusion

*Glabellar Lines (Frown Lines) Agents***BOTOX COSMETIC INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 50 UNIT

Benefit Exclusion

*Hair Growth Agent - Combinations***finapod external solution 0.1-7 % EX Non FDA Exclusion

oxopod external solution 0.05-7 % EX Non FDA Exclusion

podprog external solution 0.1-7 % EX Non FDA Exclusion

*Imidazole-Related Antifungals - Topical***clotrimazole external cream 1 % Tier 1

clotrimazole external solution 1 % Tier 1

econazole nitrate external cream 1 % Tier 1

ECOZA EXTERNAL FOAM 1 % Tier 3

ERTACZO EXTERNAL CREAM 2 % Benefit Exclusion Non Essential Drug Exclusion

EXELDERM EXTERNAL CREAM 1 % Tier 3

EXELDERM EXTERNAL SOLUTION 1 % Tier 3

EXTINA EXTERNAL FOAM 2 % Benefit Exclusion

JUBLIA EXTERNAL SOLUTION 10 % Tier 2

ketoconazole external cream 2 % Tier 1

208

Drug Name Drug Tier Notesketoconazole external foam 2 % Benefit Exclusion Non Essential Drug Exclusion

ketoconazole external shampoo 2 % Tier 1

KETODAN EXTERNAL FOAM 2 % Benefit Exclusion Non Essential Drug Exclusion

KETODAN EXTERNAL KIT 2 % EX Non FDA Exclusion

luliconazole external cream 1 % Tier 3

LUZU EXTERNAL CREAM 1 % Tier 3

NIZORAL EXTERNAL SHAMPOO 2 % EX Formulary Exclusion

oxiconazole nitrate external cream 1 % Tier 1

OXISTAT EXTERNAL CREAM 1 % EX Formulary Exclusion

OXISTAT EXTERNAL LOTION 1 % Tier 3

sulconazole nitrate external cream 1 % Tier 3

sulconazole nitrate external solution 1 % Tier 3

XOLEGEL EXTERNAL GEL 2 % Benefit Exclusion Non Essential Drug Exclusion

*Immunomodulators Imidazoquinolinamines - Topical***ALDARA EXTERNAL CREAM 5 % EX Formulary Exclusion

imiquimod external cream 3.75 %, 5 % Tier 1

imiquimod pump external cream 3.75 % Tier 1

ZYCLARA EXTERNAL CREAM 3.75 % EX Formulary Exclusion

ZYCLARA PUMP CREAM 2.5 % EXTERNAL 2.5 % Tier 2

ZYCLARA PUMP CREAM 3.75 % EXTERNAL 3.75 % EX Formulary Exclusion

*Immunosuppressive Agents - Topical Combinations***oxianujo external cream 4-0.1 % EX Non FDA Exclusion

oxianujo external ointment 4-0.1 % EX Non FDA Exclusion

*Keratolytic And/Or Antimitotic Combinations***geametdray external gel 5-2-17 % EX Non FDA Exclusion

GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % EX Non FDA Exclusion

guanendrux external cream 10-5-40 % EX Non FDA Exclusion

guanendrux external gel 10-5-40 % EX Non FDA Exclusion

pyrogallic acid external ointment 25-2 % EX Non FDA Exclusion

SALVAX DUO PLUS EXTERNAL KIT 6 & 35 % EX Non FDA Exclusion

*Keratolytic/Antimitotic Agents***ACNESIC EXTERNAL GEL 0.5 % EX Non FDA Exclusion

209

Drug Name Drug Tier Notesbensal hp external ointment 3 % EX Non FDA Exclusion

cantharidin external solution 0.7 % EX Non FDA Exclusion

CONDYLOX EXTERNAL GEL 0.5 % Tier 3

KERALYT EXTERNAL GEL 6 % EX Non FDA Exclusion

KERALYT EXTERNAL SHAMPOO 6 % EX Non FDA Exclusion

KERALYT SCALP EXTERNAL KIT 6 % EX Non FDA Exclusion

PODOCON-25 EXTERNAL SOLUTION 25 % EX Non FDA Exclusion

podofilox external solution 0.5 % Tier 1

SALEX EXTERNAL SHAMPOO 6 % EX Non FDA Exclusion

salicylic acid er external solution 28.5 % EX Non FDA Exclusion

salicylic acid external foam 6 % EX Non FDA Exclusion

salicylic acid external gel 6 % EX Non FDA Exclusion

salicylic acid external shampoo 6 % EX Non FDA Exclusion

salicylic acid external solution 26 % EX Non FDA Exclusion

salicylic acid wart remover external liquid 27.5 % EX Non FDA Exclusion

salicylic acid-cleanser external kit 6 % cream EX Non FDA Exclusion

salimez external cream 6 % EX Non FDA Exclusion

salimez forte external cream 10 % EX Non FDA Exclusion

SALVAX EXTERNAL FOAM 6 % EX Non FDA Exclusion

ULTRASAL-ER EXTERNAL SOLUTION28.5 % EX Non FDA Exclusion

VIRASAL EXTERNAL LIQUID 27.5 % EX Non FDA Exclusion

XALIX EXTERNAL SOLUTION 28 % EX Non FDA Exclusion

*Liniment Combinations***fordagel external kit 4-10-30 % EX Non FDA Exclusion

*Liniments***methyl salicylate external liquid EX Formulary Exclusion

turpentine external spirit EX Formulary Exclusion

*Local Anesthetics - Topical***7T LIDO EXTERNAL GEL 2 % EX Non FDA Exclusion; QL

ANACAINE EXTERNAL OINTMENT 10 % EX Non FDA Exclusion

ASTERO EXTERNAL GEL 4 % EX Non FDA Exclusion

DERMACINRX LIDOGEL EXTERNAL GEL2.8 % Benefit Exclusion

eha external lotion 4 % EX Non FDA Exclusion; QL

enovarx-lidocaine hcl external cream 10 %, 5 % EX Non FDA Exclusion

gen7t external lotion 3.5 % EX Non FDA Exclusion

gen7t external patch 3.5 % EX Non FDA Exclusion

210

Drug Name Drug Tier NotesGLYDO EXTERNAL PREFILLED SYRINGE 2 % Tier 1 QL

LDO PLUS EXTERNAL GEL 4 % EX Non FDA Exclusion

lidocaine hcl cream 3 % external (rx) 3 % Benefit Exclusion

lidocaine hcl cream 3 % external (rx) 3 % EX Non FDA Exclusion; QL

lidocaine hcl cream 4.12 % external 4.12 % Benefit Exclusion

lidocaine hcl external lotion 3 % EX Non FDA Exclusion

lidocaine hcl external solution 4 % Tier 1 QL

lidocaine hcl urethral/mucosal external gel 2 % Tier 3 QL

lidocaine hcl urethral/mucosal external prefilled syringe 2 %

Tier 1 QL

lidocaine ointment 5 % external 5 % Benefit Exclusion QL

lidocaine ointment 5 % external 5 % EX Non FDA Exclusion; QL

lidocaine ointment 5 % external 5 % Tier 1 QL

lidocaine patch 5 % external 5 % Tier 1 QL

lidocaine patch 5 % external 5 % Benefit Exclusion QL

lidocanna external patch 4 % EX Non FDA Exclusion

LIDODERM EXTERNAL PATCH 5 % EX Formulary Exclusion; QL

lidopin external cream 3 %, 3.25 % EX Non FDA Exclusion; QL

LIDOREX EXTERNAL GEL 2.8 % Benefit Exclusion

lidorx external gel 3 % EX Non FDA Exclusion

LIDO-SORB EXTERNAL LOTION 3 % EX Non FDA Exclusion

LIDOTRAL EXTERNAL CREAM 3.88 % Benefit Exclusion

LIDTOPIC MAX EXTERNAL CREAM 10 % EX Non FDA Exclusion

LYDEXA EXTERNAL CREAM 4.12 % Benefit Exclusion

PRAMOX EXTERNAL GEL 1 % EX Non FDA Exclusion

premium lidocaine external ointment 5 % EX Non FDA Exclusion; QL

PROXIVOL EXTERNAL GEL 2 % EX Non FDA Exclusion; QL

QUTENZA (2 PATCH) EXTERNAL KIT 8 % EX Non FDA Exclusion

QUTENZA (4 PATCH) EXTERNAL KIT 8 % EX Non FDA Exclusion

QUTENZA EXTERNAL KIT 8 % EX Non FDA Exclusion

zionodil 100 external lotion 3 % EX Non FDA Exclusion

zionodil external lotion 3 % EX Non FDA Exclusion

ZTLIDO EXTERNAL PATCH 1.8 % Benefit Exclusion Non Essential Drug Exclusion

ZYLOTROL-L EXTERNAL KIT 4 % EX Non FDA Exclusion

*Macrolide Immunosuppressants - Topical***ELIDEL EXTERNAL CREAM 1 % EX Formulary Exclusion

pimecrolimus external cream 1 % Tier 1

211

Drug Name Drug Tier NotesPROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % EX Formulary Exclusion

tacrolimus external ointment 0.03 %, 0.1 % Tier 1

*Melanocortin Receptor Agonists (Uv Protective)***SCENESSE SUBCUTANEOUS IMPLANT 16 MG EX Medical Only Exclusion

*Microtubule Inhibitors - Topical***KLISYRI EXTERNAL OINTMENT 1 % Tier 3

*Misc. Dermatological Products***ALADERM PLUS EXTERNAL EMULSION EX Non FDA Exclusion

alevamax external cream EX Non FDA Exclusion

ALEVICYN ANTIPRURITIC EXTERNAL GEL EX Non FDA Exclusion

ALEVICYN ANTIPRURITIC SG EXTERNAL GEL EX Non FDA Exclusion

atopaderm external cream EX Non FDA Exclusion

ATOPICLAIR EXTERNAL CREAM EX Non FDA Exclusion

CERACADE EXTERNAL EMULSION EX Non FDA Exclusion

CERAMAX EXTERNAL CREAM EX Non FDA Exclusion

CERAMAX EXTERNAL LOTION EX Non FDA Exclusion

DEXERYL EXTERNAL CREAM EX Non FDA Exclusion

ELETONE EXTERNAL CREAM EX Non FDA Exclusion

EMULSION SB EXTERNAL EMULSION EX Non FDA Exclusion

ENTTY SPRAY EXTERNAL EMULSION EX Non FDA Exclusion

EPICERAM EXTERNAL EMULSION EX Non FDA Exclusion

GENADUR COMBINATION KIT EX Non FDA Exclusion

GENADUR EXTERNAL LIQUID EX Non FDA Exclusion

HALUCORT EXTERNAL GEL EX Non FDA Exclusion

HPR PLUS EXTERNAL CREAM EX Non FDA Exclusion

HPR PLUS EXTERNAL FOAM EX Non FDA Exclusion

HPR PLUS HYDROGEL EXTERNAL KIT EX Non FDA Exclusion

HYLAGUARD EXTERNAL CREAM EX Non FDA Exclusion

HYLATOPIC PLUS EXTERNAL CREAM EX Non FDA Exclusion

HYLATOPIC PLUS EXTERNAL LOTION EX Non FDA Exclusion

iliderm external emulsion EX Non FDA Exclusion

KAMDOY EXTERNAL EMULSION EX Non FDA Exclusion

KIVIK EXTERNAL EMULSION EX Non FDA Exclusion

LEVICYN EXTERNAL GEL EX Non FDA Exclusion

212

Drug Name Drug Tier NotesLOYON EXTERNAL SOLUTION EX Non FDA Exclusion

MIMYX EXTERNAL CREAM EX Non FDA Exclusion

NEOSALUS EXTERNAL CREAM EX Non FDA Exclusion

NEOSALUS EXTERNAL FOAM EX Non FDA Exclusion

NEOSALUS EXTERNAL LOTION EX Non FDA Exclusion

NUVAIL EXTERNAL SOLUTION EX Non FDA Exclusion

PENLEN EXTERNAL EMULSION EX Non FDA Exclusion

PHLAG SPRAY EXTERNAL EMULSION EX Non FDA Exclusion

PR CREAM EXTERNAL KIT EX Non FDA Exclusion

PRESERA EXTERNAL FOAM EX Non FDA Exclusion

PRUCLAIR EXTERNAL CREAM EX Non FDA Exclusion

PRUMYX EXTERNAL CREAM EX Non FDA Exclusion

remigen external cream EX Non FDA Exclusion

SEBUDERM EXTERNAL GEL EX Non FDA Exclusion

STRATA CTX EXTERNAL GEL EX Non FDA Exclusion

STRATA MARK EXTERNAL GEL EX Non FDA Exclusion

STRATA XRT EXTERNAL GEL EX Non FDA Exclusion

suvicort external emulsion Benefit Exclusion

SYNERDERM EXTERNAL EMULSION EX Non FDA Exclusion

TETRIX EXTERNAL CREAM EX Non FDA Exclusion

XERALUX EXTERNAL CREAM EX Non FDA Exclusion

*Misc. Topical Combinations***DERMACINRX CLORHEXACIN EXTERNAL KIT 4 & 2 & 5 % (OINT) Benefit Exclusion

dermacinrx surgical combopak combination kit Benefit Exclusion

NUSURGEPAK SURGICAL PREP/CARE EXTERNAL KIT 4 & 2 & 5 % (OINT) EX Non FDA Exclusion

PRE & POST SX POUCH EXTERNAL THERAPY PACK 4 & 2 & 5 % EX Non FDA Exclusion

*Misc. Topical***arnica flower tincture EX Formulary Exclusion

boric acid external granules EX Formulary Exclusion

DRYSOL EXTERNAL SOLUTION 20 % EX Formulary Exclusion

PROSILK EXTERNAL GEL EX Non FDA Exclusion

QBREXZA EXTERNAL PAD 2.4 % Tier 3

*Ornithine Decarboxylase (Odc) Inhibitors - Topical***VANIQA EXTERNAL CREAM 13.9 % Benefit Exclusion

213


*Oxaborole-Related Antifungals - Topical***KERYDIN EXTERNAL SOLUTION 5 % Benefit Exclusion

tavaborole external solution 5 % Benefit Exclusion

*Phosphodiesterase 4 (Pde4) Inhibitors - Topical***EUCRISA EXTERNAL OINTMENT 2 % Tier 2 PA

*Photodynamic Therapy Agents - Topical***AMELUZ EXTERNAL GEL 10 % EX Formulary Exclusion

LEVULAN KERASTICK EXTERNAL SOLUTION RECONSTITUTED 20 % EX Formulary Exclusion

*Prostaglandins - Topical***bimatoprost external solution 0.03 % Benefit Exclusion

LATISSE EXTERNAL SOLUTION 0.03 % Benefit Exclusion

*Rosacea Agents***azelaic acid external gel 15 % Tier 1

doxycycline oral capsule delayed release 40 mg Benefit Exclusion

FINACEA EXTERNAL FOAM 15 % EX Formulary Exclusion

FINACEA EXTERNAL GEL 15 % EX Formulary Exclusion

ivermectin external cream 1 % Tier 1

METROCREAM EXTERNAL CREAM 0.75 % EX Formulary Exclusion

METROGEL EXTERNAL GEL 1 % EX Formulary Exclusion

METROLOTION EXTERNAL LOTION 0.75 % EX Formulary Exclusion

metronidazole external cream 0.75 % Tier 1

metronidazole external gel 0.75 %, 1 % Tier 1

metronidazole external lotion 0.75 % Tier 1

MIRVASO EXTERNAL GEL 0.33 % Tier 3

NORITATE EXTERNAL CREAM 1 % Benefit Exclusion

ORACEA ORAL CAPSULE DELAYED RELEASE 40 MG Benefit Exclusion Non Essential Drug Exclusion

RHOFADE EXTERNAL CREAM 1 % EX Formulary Exclusion

ROSADAN EXTERNAL CREAM 0.75 % Tier 1

ROSADAN EXTERNAL GEL 0.75 % Tier 1

ROSADAN EXTERNAL KIT 0.75 % (CREAM), 0.75 % (GEL) EX Non FDA Exclusion

SOOLANTRA EXTERNAL CREAM 1 % EX Formulary Exclusion

214

Drug Name Drug Tier NotesZILXI EXTERNAL FOAM 1.5 % Tier 2

*Rosacea Combinations***aveidaoxia external gel 1-1-4 % EX Non FDA Exclusion

*Scabicides & Pediculicides***CROTAN EXTERNAL LOTION 10 % Tier 1

ELIMITE EXTERNAL CREAM 5 % EX Formulary Exclusion

ivermectin external lotion 0.5 % Tier 1

lindane external shampoo 1 % Tier 1

malathion external lotion 0.5 % Tier 1

NATROBA EXTERNAL SUSPENSION 0.9 % Tier 3

OVIDE EXTERNAL LOTION 0.5 % EX Formulary Exclusion

permethrin external cream 5 % Tier 1

SKLICE EXTERNAL LOTION 0.5 % EX Formulary Exclusion

spinosad external suspension 0.9 % Tier 1

sulfurated lime external solution EX Non FDA Exclusion

ULESFIA EXTERNAL LOTION 5 % Tier 3

*Scar Treatment Products - Combinations***silipac external kit Benefit Exclusion

*Scar Treatment Products***beau rx external gel Benefit Exclusion

CELACYN EXTERNAL GEL EX Non FDA Exclusion

COPASIL EXTERNAL GEL EX Non FDA Exclusion

DERMELLE EXTERNAL GEL EX Non FDA Exclusion

JUVAZIN EXTERNAL GEL EX Non FDA Exclusion

KELARX EXTERNAL GEL Benefit Exclusion

RECEDO EXTERNAL GEL EX Non FDA Exclusion

scarcin external gel EX Non FDA Exclusion

scarcin external liquid EX Non FDA Exclusion

scarsilk external gel EX Non FDA Exclusion

STRATA TRIZ EXTERNAL GEL EX Non FDA Exclusion

*Seborrheic Keratosis Products**ESKATA EXTERNAL SOLUTION 40 % EX Medical Only Exclusion

*Skin Cleansers***EPICYN EXTERNAL SOLUTION EX Non FDA Exclusion

HYCLODEX EXTERNAL SOLUTION 0.012 % EX Non FDA Exclusion

HYPOCYN EXTERNAL SOLUTION 0.012 % EX Non FDA Exclusion

215


*Skin Protectants***benzoin compound external tincture EX Formulary Exclusion

benzoin external tincture EX Formulary Exclusion

*Steroid-Local Anesthetic Combinations***CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML EX Formulary Exclusion

EPIFOAM EXTERNAL FOAM 1-1 % EX Formulary Exclusion

hydrocortisone ace-pramoxine cream 2.5-1 % external 2.5-1 %


hydrocortisone ace-pramoxine cream 2.5-1 % external 2.5-1 %


lidocaine-hydrocortisone ace external cream 1-1 %


NOVACORT EXTERNAL GEL 1-2 % EX Non FDA Exclusion

PRAMOSONE EXTERNAL CREAM 1-1 %, 1-2.5 % EX Formulary Exclusion

PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % EX Formulary Exclusion

PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 % EX Formulary Exclusion

pramoxine-hc external cream 1-2.35 % EX Non FDA Exclusion

RADIAURA EXTERNAL CREAM 3-0.5 % Benefit Exclusion

*Tar Products***coal tar external solution 20 % EX Non FDA Exclusion

*Tissue Replacements***AFFINITY EXTERNAL SHEET 1.5 CM X 1.5 CM , 2.5 CM X 2.5 CM EX Non FDA Exclusion

AMNIOCORE HUMAN TISSUE EXTERNAL DISK 16 MM EX Formulary Exclusion

AMNIOCORE HUMAN TISSUE EXTERNAL SHEET 9 CM X 20 CM EX Formulary Exclusion

AMNIOFIX INJECTION SUSPENSION RECONSTITUTED 100 MG, 160 MG, 20 MG, 40 MG


AMNIOTEXT EXTERNAL SHEET 1 CM X 1 CM , 10 CM X 10 CM , 2 CM X 2 CM , 2 CM X 3 CM , 3 CM X 3 CM , 4 CM X 3 CM , 4 CM X 4 CM , 4 CM X 6 CM , 4 CM X 8 CM , 8 CM X 8 CM


amphenol-40 injection suspension reconstituted40 mg


216

Drug Name Drug Tier NotesAPLIGRAF EXTERNAL DISK EX Medical Only Exclusion

BIOVANCE EXTERNAL SHEET 1 CM X 2 CM , 2 CM X 3 CM , 4 CM X 4 CM , 6 CM X 6 CM


CORETEXT INJECTION SUSPENSION 1 ML, 2 ML EX


EPICORD EXTERNAL SHEET 2 CM X 3 CM , 3 CM X 5 CM EX Non FDA Exclusion

EPIFIX EXTERNAL DISK 14 MM , 18 MM , 24 MM EX Non FDA Exclusion

EPIFIX EXTERNAL SHEET 2 CM X 2 CM , 2 CM X 3 CM , 2 CM X 4 CM , 3 CM X 3 CM , 3 CM X 5 CM , 3.5 CM X 3.5 CM , 4 CM X 3 CM , 4 CM X 4 CM , 4 CM X 4.5 CM , 4 CM X 6 CM , 5 CM X 5.5 CM , 5 CM X 6 CM , 7 CM X 7 CM


EPIFIX MICRONIZED INJECTION SUSPENSION RECONSTITUTED 100 MG, 160 MG, 40 MG


GRAFIX CORE 1.5CM X 2CM EXTERNAL EX Non FDA Exclusion

GRAFIX CORE 16MM EXTERNAL EX Non FDA Exclusion

GRAFIX CORE 2CM X 3CM EXTERNAL EX Non FDA Exclusion



GRAFIX PRIME 1.5CM X 2CM EXTERNAL EX Non FDA Exclusion

GRAFIX PRIME 16MM EXTERNAL EX Non FDA Exclusion

GRAFIX PRIME 2CM X 3CM EXTERNAL EX Non FDA Exclusion



GRAFIX XC 7.5CM X 15CM EXTERNAL EX Non FDA Exclusion

KARDIAMEMBRANE EXTERNAL SHEET4 CM X 8 CM , 6 CM X 8 CM , 8 CM X 8 CM EX Non FDA Exclusion

NEOX 100 EXTERNAL SHEET 2 CM X 2 CM , 3 CM X 3 CM , 4 CM X 4 CM , 7 CM X 7 CM


NEOX CORD 1K EXTERNAL SHEET 1 CM X 2 CM , 1.5 CM X 1.5 CM , 2 CM X 2 CM , 2 CM X 3 CM , 2.5 CM X 2.5 CM , 3 CM X 3 CM , 4 CM X 3 CM , 6 CM X 3 CM , 8 CM X 3 CM


NOVACHOR EXTERNAL SHEET 2.5 CM X 2.5 CM EX Non FDA Exclusion

217

Drug Name Drug Tier NotesNUCEL INJECTION INJECTABLE 0.5 ML, 1 ML, 2 ML, 2.5 ML EX


NUSHIELD EXTERNAL DISK 1.6 CM EX Non FDA Exclusion

NUSHIELD EXTERNAL SHEET 2 CM X 3 CM , 2 CM X 4 CM , 4 CM X 3 CM , 4 CM X 4 CM , 4 CM X 6 CM , 6 CM X 6 CM


OSTEOCONDUCTIVE MATRIX PLUS INJECTION INJECTABLE 10 ML, 2 ML, 5 ML


PALINGEN FLOW INJECTION INJECTABLE 0.25 ML, 0.5 ML, 1 ML, 2 ML, 4 ML


PALINGEN HYDROMEMBRANE EXTERNAL SHEET 1 CM X 1 CM , 1 CM X 2 CM , 2 CM X 2 CM , 2 CM X 3 CM , 2 CM X 4 CM , 2 CM X 6 CM , 2 CM X 9 CM , 4 CM X 4 CM , 4 CM X 6 CM , 4 CM X 8 CM , 8 CM X 8 CM


PALINGEN INOVOFLO INJECTION INJECTABLE 0.25 ML, 0.5 ML, 1 ML, 2 ML EX


PALINGEN MEMBRANE EXTERNAL SHEET 1 CM X 1 CM , 1 CM X 2 CM , 2 CM X 2 CM , 2 CM X 3 CM , 2 CM X 4 CM , 2 CM X 6 CM , 2 CM X 9 CM , 4 CM X 4 CM , 4 CM X 6 CM , 4 CM X 8 CM , 8 CM X 8 CM


PALINGEN XPLUS HYDROMEMBRANE EXTERNAL SHEET 1 CM X 1 CM , 1 CM X 2 CM , 2 CM X 2 CM , 2 CM X 3 CM , 2 CM X 4 CM , 2 CM X 6 CM , 2 CM X 9 CM , 4 CM X 4 CM , 4 CM X 6 CM , 4 CM X 8 CM , 8 CM X 8 CM


PALINGEN XPLUS MEMBRANE EXTERNAL SHEET 1 CM X 1 CM , 1 CM X 2 CM , 2 CM X 2 CM , 2 CM X 3 CM , 2 CM X 4 CM , 2 CM X 6 CM , 2 CM X 9 CM , 4 CM X 4 CM , 4 CM X 6 CM , 4 CM X 8 CM , 8 CM X 8 CM


PROTEXT INJECTION SUSPENSION 0.25 ML, 0.5 ML, 1 ML, 2 ML EX


STRATAGRAFT EXTERNAL SHEET EX Medical Only Exclusion

STRAVIX EXTERNAL SHEET 2 CM X 4 CM , 6 CM X 3 CM EX Non FDA Exclusion

TRANSCYTE EXTERNAL SHEET EX Formulary Exclusion

TRUSKIN EXTERNAL SHEET 2 CM X 4 CM , 4 CM X 8 CM EX Non FDA Exclusion

218


*Topical Anesthetic Combinations***1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4-0.0375-5-20 % EX Non FDA Exclusion

ACCUCAINE COMBINATION KIT 1 % EX Medical Only Exclusion

agoneaze external kit 2.5-2.5 % EX Non FDA Exclusion

anodyne lpt external kit 2.5-2.5 % EX Non FDA Exclusion

APRIZIO PAK EXTERNAL KIT 2.5-2.5 % Benefit Exclusion

APRIZIO PAK II EXTERNAL KIT 2.5-2.5 % Benefit Exclusion

CADIRAMD EXTERNAL KIT 2.5-2.5 % EX Non FDA Exclusion

CETACAINE EXTERNAL AEROSOL 2-2-14 % EX Non FDA Exclusion

CETACAINE EXTERNAL GEL 2-2-14 % EX Non FDA Exclusion

CETACAINE EXTERNAL LIQUID 2-2-14 % EX Non FDA Exclusion

DERMACINRX PHN EXTERNAL THERAPY PACK 5 & 5 % Benefit Exclusion

DERMACINRX ZRM EXTERNAL THERAPY PACK 5 % Benefit Exclusion

dermalid external therapy pack 5 % EX Non FDA Exclusion

ELEMAR PATCH EXTERNAL KIT 5-6 % EX Non FDA Exclusion

EMPRICAINE-II EXTERNAL KIT 2.5-2.5 % Benefit Exclusion

enznonuty external ointment 20-10-10 % EX Non FDA Exclusion

gen7t plus external lotion 3.5-7 % EX Non FDA Exclusion

gen7t plus external patch 3.5-7 % EX Non FDA Exclusion

L.E.T. EXTERNAL GEL 4-0.05-0.5 % EX Non FDA Exclusion

l.e.t. external solution 4-0.05-0.5 % EX Non FDA Exclusion

levatio external patch 0.03-5 % EX Non FDA Exclusion

LIDO BDK EXTERNAL KIT 2.5-2.5 % EX Non FDA Exclusion

lidocaine-prilocaine external cream 2.5-2.5 % Tier 1 QL

lidocaine-prilocaine external kit 2.5-2.5 % EX Non FDA Exclusion

lidocaine-tetracaine external cream 7-7 % Benefit Exclusion Non Essential Drug Exclusion; QL

lido-epinephrine-tetracaine external solution 4-0.05-0.5 %


lidopac external kit 5 % Benefit Exclusion

lidopril external kit 2.5-2.5 % Benefit Exclusion

lidopril xr external kit 2.5-2.5 % Benefit Exclusion

LIDO-PRILO CAINE PACK EXTERNAL KIT 2.5-2.5 % EX Non FDA Exclusion

LIDOPURE PATCH EXTERNAL KIT 5 % Benefit Exclusion

lidostream external kit 5 & 10 % EX Non FDA Exclusion

LIDOTHOL EXTERNAL GEL 4.5-5 % EX Non FDA Exclusion

219

Drug Name Drug Tier NotesLIDOTHOL EXTERNAL PATCH 4.5-5 % EX Non FDA Exclusion

LIDOTOR EXTERNAL KIT 2.5-2.5 % Benefit Exclusion

lidovix l external kit 5 % EX Non FDA Exclusion

LIVIXIL PAK EXTERNAL KIT 2.5-2.5 % EX Non FDA Exclusion

LMR PLUS EXTERNAL KIT 5 & 0.5-0.5 % EX Non FDA Exclusion

MOXICAINE EXTERNAL KIT 5 % EX Non FDA Exclusion

nendrux external gel 5-40 % EX Non FDA Exclusion

NUVAKAAN-II EXTERNAL KIT 2.5-2.5 % Benefit Exclusion

paingo kft external kit 2.5-2.5-10-30 % EX Non FDA Exclusion

PLIAGLIS EXTERNAL CREAM 7-7 % Benefit Exclusion Non Essential Drug Exclusion; QL

PLIAGLIS EXTERNAL KIT 7-7 % EX Non FDA Exclusion

premium scar external patch 2-4-30 % EX Non FDA Exclusion

prepiv supply combination kit 2.5-2.5 & 0.9 % EX Non FDA Exclusion

PRILO PATCH EXTERNAL KIT 2.5 % Benefit Exclusion

PRILO PATCH II EXTERNAL KIT 2.5-2.5 & 5 % Benefit Exclusion

priloheal plus 30 external kit 2.5-2.5 % EX Non FDA Exclusion

prilolid external kit 2.5-2.5 % Benefit Exclusion

prilovix external kit 2.5-2.5 % EX Non FDA Exclusion

prilovix lite external kit 2.5-2.5 % EX Non FDA Exclusion

prilovix lite plus external kit 2.5-2.5 % EX Non FDA Exclusion

prilovix plus external kit 2.5-2.5 % EX Non FDA Exclusion

prilovix ultralite external kit 2.5-2.5 % EX Non FDA Exclusion

prilovix ultralite plus external kit 2.5-2.5 % EX Non FDA Exclusion

prilovixil external kit 2.5-2.5 % EX Non FDA Exclusion

PRIZOPAK II EXTERNAL KIT 2.5-2.5 % Benefit Exclusion

PRIZOTRAL-II EXTERNAL KIT 2.5-2.5 & 3.88 % Benefit Exclusion

REAL HEAL-I EXTERNAL KIT 2.5-2.5 % EX Non FDA Exclusion

RELADOR PAK EXTERNAL KIT 2.5-2.5 % EX Non FDA Exclusion

RELADOR PAK PLUS EXTERNAL KIT 2.5-2.5 % EX Non FDA Exclusion

SKYADERM-LP EXTERNAL KIT 2.5-2.5 % EX Non FDA Exclusion

SOOTHEE EXTERNAL PATCH 0.5-0.0375-5-2 % EX Non FDA Exclusion

STERILE TOPICAL L.E.T. GEL EXTERNAL GEL 0.18-4-0.5 % EX Non FDA Exclusion

SX1 MEDICATED POST-OPERATIVE EXTERNAL KIT 2 % EX Non FDA Exclusion

SYNERA EXTERNAL PATCH 70-70 MG Benefit Exclusion Non Essential Drug Exclusion

220

Drug Name Drug Tier Notestopical l.e.t. external gel 4-0.18-0.5 % EX Non FDA Exclusion

valladerm-90 external kit 2.5-2.5 % EX Non FDA Exclusion

VENIPUNCTURE PX1 PHLEBOTOMY EXTERNAL KIT 2 % EX Non FDA Exclusion

vexatrol external kit 2.5-2.5 % Benefit Exclusion

wpr plus wound healing system external therapy pack 4 & 10-30 %


zeruvia external patch 4-1 % EX Non FDA Exclusion

ZILACAINE PATCH EXTERNAL THERAPY PACK 5 % Benefit Exclusion

ziloval external kit 5 % Benefit Exclusion

*Topical Anesthetic Gases***CRYODOSE TA EXTERNAL AEROSOL EX Non FDA Exclusion

ethyl chloride external aerosol EX Non FDA Exclusion

GEBAUERS PAIN EASE EXTERNAL AEROSOL EX Non FDA Exclusion

GEBAUERS SPRAY AND STRETCH EXTERNAL AEROSOL EX Non FDA Exclusion

*Topical Selective Retinoid X Receptor Agonists***bexarotene external gel 1 % Tier 4 PA; Specialty; QL

TARGRETIN EXTERNAL GEL 1 % EX PA; Specialty; Formulary Exclusion; QL

*Topical Steroid Combinations***BESER EXTERNAL KIT 0.05 % EX Non FDA Exclusion

calcipotriene-betameth diprop external ointment0.005-0.064 %

Tier 1

calcipotriene-betameth diprop external suspension 0.005-0.064 %

Tier 1

chlooxia external cream 0.05-4 % EX Non FDA Exclusion

chlooxia external ointment 0.05-4 % EX Non FDA Exclusion

chlooxia external solution 0.05-4 % EX Non FDA Exclusion

clobetavix external kit 0.05 % EX Non FDA Exclusion

CLODAN EXTERNAL KIT 0.05 % EX Non FDA Exclusion

diochloy external solution 0.005-0.05 % EX Non FDA Exclusion

DUOBRII EXTERNAL LOTION 0.01-0.045 % Tier 3

ENSTILAR EXTERNAL FOAM 0.005-0.064 % Tier 2

FLUOPAR EXTERNAL KIT 0.1 & 5 % Benefit Exclusion

221

Drug Name Drug Tier Notesfluovix external therapy pack 0.1 % EX Non FDA Exclusion

fluovix plus external therapy pack 0.1 % EX Non FDA Exclusion

NUTRIARX CREAMPAK EXTERNAL KIT0.1 & 5 % EX Non FDA Exclusion

QUINIXIL EXTERNAL THERAPY PACK0.1 & 5 % EX Non FDA Exclusion

sanadermrx skin repair external kit 0.1 & 5 % EX Non FDA Exclusion

SCALACORT DK EXTERNAL KIT 2 & 2-2 % EX Non FDA Exclusion

SCARZEN SKIN REPAIR EXTERNAL KIT0.1 & 5 % (LOTION) EX Non FDA Exclusion

SILA III EXTERNAL THERAPY PACK 0.1 % Benefit Exclusion

SYNALAR (CREAM) EXTERNAL KIT 0.025 % EX Non FDA Exclusion

SYNALAR (OINTMENT) EXTERNAL KIT0.025 % EX Non FDA Exclusion

SYNALAR TS EXTERNAL KIT 0.01 % EX Non FDA Exclusion

TACLONEX EXTERNAL OINTMENT 0.005-0.064 % EX Formulary Exclusion

TACLONEX EXTERNAL SUSPENSION0.005-0.064 % EX Formulary Exclusion

triadime-80 external kit 5-0.1 % EX Non FDA Exclusion

triheal-80 external kit 0.1 & 5 % EX Non FDA Exclusion

TRILOCICLO EXTERNAL KIT 0.1 & 8 % Benefit Exclusion

TRIVIX EXTERNAL KIT 0.1 & 5 % EX Non FDA Exclusion

WYNZORA EXTERNAL CREAM 0.005-0.064 % EX Formulary Exclusion

*Type Ii 5-Alpha Reductase Inhibitors***finasteride oral tablet 1 mg Benefit Exclusion

PROPECIA ORAL TABLET 1 MG Benefit Exclusion

*Wound Care - Growth Factor Agents***REGRANEX EXTERNAL GEL 0.01 % Tier 3

*Wound Care Combinations***b & c external ointment EX Non FDA Exclusion

balsam peru-castor oil external ointment EX Non FDA Exclusion

bpco external ointment EX Non FDA Exclusion

LIDOTREX (ALOE VERA) EXTERNAL GEL 2 % Benefit Exclusion

222

Drug Name Drug Tier NotesREGENECARE EXTERNAL GEL 2 % EX Non FDA Exclusion

REXASIL PATCH & VITAMIN E LIQ EXTERNAL KIT EX Non FDA Exclusion

SCARCARE GEL-PAD KIT/LARGE EXTERNAL KIT EX Non FDA Exclusion

VENELEX EXTERNAL OINTMENT EX Non FDA Exclusion

XEROFORM OIL EMULSION 2"X2" EXTERNAL PAD EX Non FDA Exclusion

XEROFORM OIL EMULSION GAUZE EXTERNAL PAD EX Non FDA Exclusion

XEROFORM OIL EMULSION STRIP EXTERNAL EX Non FDA Exclusion

XEROFORM OIL ROLL 4"X9' EXTERNAL3 % EX Non FDA Exclusion

XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL EX Non FDA Exclusion

XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL EX Non FDA Exclusion

XEROFORM PETROLAT PATCH 2"X2" EXTERNAL PAD EX Non FDA Exclusion

XEROFORM PETROLAT PATCH 4"X4" EXTERNAL PAD EX Non FDA Exclusion

XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL EX Non FDA Exclusion

*Wound Cleansers/Decubitus Ulcer Therapy***ALEVICYN DERMAL SPRAY EXTERNAL SOLUTION EX Non FDA Exclusion

ATRAPRO DERMAL SPRAY EXTERNAL LIQUID EX Non FDA Exclusion

DELUO EXTERNAL SOLUTION EX Non FDA Exclusion

lavare wound wash external gel EX Non FDA Exclusion

LEVICYN DERMAL SPRAY EXTERNAL SOLUTION EX Non FDA Exclusion

MICROCYN EXTERNAL GEL EX Non FDA Exclusion

MICROCYN EXTERNAL LIQUID 0.023 % EX Non FDA Exclusion

MICROCYN SKIN AND WOUND EXTERNAL GEL EX Non FDA Exclusion

VASHE CLEANSING EXTERNAL SOLUTION EX Non FDA Exclusion

*Wound Dressings***aceso ag external pad 4"x4" EX Non FDA Exclusion

223

Drug Name Drug Tier NotesACTICOAT 7 EXTERNAL PAD 2"X2" , 4"X5" EX Non FDA Exclusion

ACTICOAT 7 EXTERNAL SHEET 6"X6" EX Non FDA Exclusion

ACTICOAT ANTIMICROBIAL EXTERNAL PAD 2"X2" , 4"X4" EX Non FDA Exclusion

ACTICOAT EXTERNAL SHEET 16"X16" , 4"X4" , 4"X48" , 4"X8" , 5"X5" , 8"X16" EX Non FDA Exclusion

ACTICOAT FLEX 3 4"X4" EXTERNAL PAD EX Non FDA Exclusion

ACTICOAT FLEX 3 EXTERNAL SHEET16"X16" , 2"X2" , 4"X48" , 4"X8" , 8"X16" EX Non FDA Exclusion

ACTICOAT FLEX 7 EXTERNAL SHEET1"X24" , 16"X16" , 2"X2" , 4"X5" , 6"X6" , 8"X16"


ACTICOAT SURGICAL EXTERNAL PAD4"X10" , 4"X13-3/4" , 4"X4-3/4" , 4"X8" EX Non FDA Exclusion

ALLEVYN AG ADHESIVE EXTERNAL PAD 12.5X12.5CM , 17.5X17.5CM , 7.5X7.5CM


ALLEVYN AG GENTLE BORDER EXTERNAL PAD 12.5X12.5CM , 17.5X17.5CM , 7.5X7.5CM


ALLEVYN AG GENTLE EXTERNAL PAD2"X2" , 4"X4" , 6"X6" , 8"X8" EX Non FDA Exclusion

ALLEVYN AG NON-ADHESIVE EXTERNAL PAD 2"X2" , 4"X4" , 6"X6" , 8"X8"


ALLEVYN AG SACRUM 6-3/4" EXTERNALEX Non FDA Exclusion

ALLEVYN AG SACRUM 9"X9" EXTERNALEX Non FDA Exclusion

ALLEVYN GENTLE EXTERNAL PAD EX Non FDA Exclusion

AQUACEL AG BURN EXTERNAL PAD4"X5" EX Non FDA Exclusion

ARIDA EXTERNAL GEL EX Non FDA Exclusion

atopavo external emulsion EX Non FDA Exclusion

ATRAPRO CP EXTERNAL KIT EX Non FDA Exclusion

ATRAPRO HYDROGEL EXTERNAL GEL EX Non FDA Exclusion

AVO CREAM EXTERNAL EMULSION EX Non FDA Exclusion

AZADROX EXTERNAL GEL EX Non FDA Exclusion

BASADROX EXTERNAL GEL EX Non FDA Exclusion

BIAFINE EXTERNAL EMULSION EX Non FDA Exclusion

BIONECT EXTERNAL CREAM 0.2 % EX Non FDA Exclusion

224

Drug Name Drug Tier NotesBIONECT EXTERNAL FOAM 0.2 % EX Non FDA Exclusion

BIONECT EXTERNAL GEL 0.2 % EX Non FDA Exclusion

BIOSTEP AG EXTERNAL SHEET 2"X2" , 4"X4" EX Non FDA Exclusion

BIOSTEP EXTERNAL SHEET 2"X2" , 4"X4" EX Non FDA Exclusion

COLLANEX EXTERNAL POWDER EX Non FDA Exclusion

COLLATYL EXTERNAL GEL EX Non FDA Exclusion

CURITY HYPERTONIC NACL STRIP EXTERNAL EX Non FDA Exclusion

CURITY NACL DRESSING 6"X6-3/4" EXTERNAL PAD EX Non FDA Exclusion

DERPIXA EXTERNAL GEL EX Non FDA Exclusion

DURAFIBER AG EXTERNAL PAD 2"X2" , 3/4"X18" , 4"X4" , 4"X4-3/4" , 6"X6" , 8"X11-3/4"


DURAFIBER EXTERNAL PAD 4"X4-3/4" EX Non FDA Exclusion

ENDOFORM DERMAL TEMPLATE EXTERNAL SHEET 10X12.7CM , 5X5CM EX Non FDA Exclusion

ENDOFORM DERMAL/FENESTRATED EXTERNAL SHEET 10X12.7CM , 5X5CM EX Non FDA Exclusion

foraxa external emulsion Benefit Exclusion

haproderm external gel EX Non FDA Exclusion

HYDROFERA BLUE 4"X4" EXTERNAL PAD EX Non FDA Exclusion

HYDROFERA BLUE 6"X6" EXTERNAL PAD EX Non FDA Exclusion

HYDROFERA BLUE FOAM DRESSING EXTERNAL PAD EX Non FDA Exclusion

HYDROFERA BLUE FOAM/TUNNELING EXTERNAL PAD EX Non FDA Exclusion

HYDROFERA BLUE MRF DRESSING EXTERNAL PAD EX Non FDA Exclusion

HYDROFERA BLUE READY FOAM EXTERNAL PAD EX Non FDA Exclusion

hygel external gel 2.5 % EX Non FDA Exclusion

KENDALL ALGINATE 12" ROPE EXTERNAL EX Non FDA Exclusion

KENDALL ALGINATE DRESS 2"X2" EXTERNAL PAD EX Non FDA Exclusion

KENDALL ALGINATE DRESS 4"X8" EXTERNAL PAD EX Non FDA Exclusion

225

Drug Name Drug Tier NotesKENDALL AMORPHOUS WOUND EXTERNAL GEL EX Non FDA Exclusion

KENDALL HYDROGEL GAUZE 2"X2" EXTERNAL PAD EX Non FDA Exclusion



KENDALL HYDROGEL WOUND DRESS EXTERNAL EX Non FDA Exclusion

KENDALL ZINC CA ALGINATE 4"X4" EXTERNAL PAD EX Non FDA Exclusion

KERAGEL EXTERNAL GEL EX Non FDA Exclusion

KERAGELT EXTERNAL GEL EX Non FDA Exclusion

KERAMATRIX REPLICINE 10CMX10CM EXTERNAL SHEET EX Non FDA Exclusion



KERASTAT EXTERNAL CREAM EX Non FDA Exclusion

KERASTAT EXTERNAL GEL 5 % EX Non FDA Exclusion

LUXAMEND EXTERNAL CREAM EX Non FDA Exclusion

MEDIHONEY CA ALGINATE 2"X2" EXTERNAL PAD EX Non FDA Exclusion

MEDIHONEY CA ALGINATE 4"X5" EXTERNAL PAD EX Non FDA Exclusion

MEDIHONEY WOUND/BURN DRESSING EXTERNAL GEL EX Non FDA Exclusion

MEDIHONEY WOUND/BURN DRESSING EXTERNAL PAD EX Non FDA Exclusion

MEDIHONEY WOUND/BURN DRESSING EXTERNAL PASTE EX Non FDA Exclusion

MIRODERM BIOLOGIC MATRIX FENES EXTERNAL SHEET 2X2CM , 2X3CM , 3X3CM , 3X7CM , 4X4CM , 5X5CM , 7X10CM , 8X15CM , 8X8CM


MIRODERM BIOLOGIC WOUND MATRIX EXTERNAL SHEET 3X3CM , 3X7CM , 4X4CM , 5X5CM , 7X10CM , 8X15CM , 8X8CM


NORMLGEL AG EXTERNAL GEL EX Non FDA Exclusion

226

Drug Name Drug Tier NotesOASIS ULTRA MATRIX FENESTRATED EXTERNAL SHEET 3X3.5CM , 3X7CM EX Non FDA Exclusion

OASIS ULTRA TRI-LAYER MATRIX EXTERNAL SHEET 5X7CM , 7X10CM , 7X20CM


OASIS WOUND MATRIX FENESTRATED EXTERNAL SHEET 3X3.5CM , 3X7CM EX Non FDA Exclusion

PROTYL AG EXTERNAL GEL 1 % EX Non FDA Exclusion

PURAPLY 1.6CM EXTERNAL DISK EX Non FDA Exclusion

PURAPLY ANTIMICROBIAL 2X2CM EXTERNAL SHEET EX Non FDA Exclusion







PURAPLY EXTERNAL SHEET 2X4CM , 5X5CM , 6X9CM EX Non FDA Exclusion

PURAPLY XT ANTIMICROBIAL 5X5CM EXTERNAL SHEET 0.1 % EX Non FDA Exclusion

PURAPLY XT ANTIMICROBIAL 6X9CM EXTERNAL SHEET 0.1 % EX Non FDA Exclusion

RADIAPLEXRX EXTERNAL GEL EX Non FDA Exclusion

RESTORE SILVER DRESSING EXTERNAL PAD 2"X2" , 4"X4" , 4"X4.75" , 4"X5" , 6"X8"


RTD WOUND CARE DRESSING EXTERNAL PAD EX Non FDA Exclusion

SILVERSEAL HYDROGEL DRESSING EXTERNAL PAD 2"X3" , 4"X5" EX Non FDA Exclusion

SILVRSTAT WOUND DRESSING EXTERNAL GEL EX Non FDA Exclusion

SOLOX EXTERNAL GEL EX Non FDA Exclusion

SONAFINE EXTERNAL EMULSION EX Non FDA Exclusion

STRATA GRT EXTERNAL GEL EX Non FDA Exclusion

227

Drug Name Drug Tier NotesTEGADERM AG MESH EXTERNAL PAD2"X2" , 4"X5" , 4"X8" , 8"X8" EX Non FDA Exclusion

vexasyn external gel Benefit Exclusion

WOUNDGELHA MATRIX EXTERNAL GEL2.5 % EX Non FDA Exclusion

XCELLISTEM WOUND POWDER EXTERNAL POWDER EX Non FDA Exclusion

zanabin hydrogel external gel EX Non FDA Exclusion

zenphor wound gel external gel EX Non FDA Exclusion

zenphor wound pad external pad EX Non FDA Exclusion

*Diagnostic Products*

*Diagnostic Biologicals***almond (diagnostic) injection solution 1:10 EX Medical Only Exclusion

APLISOL INTRADERMAL SOLUTION 5 UNIT/0.1ML EX


apple (diagnostic) injection solution 1:10 EX Medical Only Exclusion

aspergillus fumigatus intradermal solution 1:20 EX Medical Only Exclusion

aureobasidium pullulans intradermal solution1:20


avocado (diagnostic) injection solution 1:10 EX Medical Only Exclusion

banana (diagnostic) injection solution 1:10 EX Medical Only Exclusion

beef (diagnostic) injection solution 1:10 EX Medical Only Exclusion

botrytis cinerea (diagnostic) intradermal solution1:20


candida albicans skn tst antgn injection solution1:10


candida albicans skn tst antgn intradermal solution


CANDIN INTRADERMAL SOLUTION EX Medical Only Exclusion; Formulary Exclusion

cantaloupe (diagnostic) injection solution 1:10 EX Medical Only Exclusion

casein (diagnostic) injection solution 1:100 EX Medical Only Exclusion

chicken meat (diagnostic) injection solution 1:10 EX Medical Only Exclusion

cocoa bean (diagnostic) injection solution 1:10 EX Medical Only Exclusion

crab (diagnostic) injection solution 1:10 EX Medical Only Exclusion

egg white (diagnostic) injection solution 1:100 EX Medical Only Exclusion

mosquito (diagnostic) intradermal solution 1:100 EX Medical Only Exclusion; Formulary Exclusion

oat grain (diagnostic) injection solution 1:10 EX Medical Only Exclusion

orange (diagnostic) injection solution 1:10 EX Medical Only Exclusion

228

Drug Name Drug Tier Notespeanut (diagnostic) injection solution 1:10 EX Medical Only Exclusion

pecan nut (diagnostic) injection solution 1:10 EX Medical Only Exclusion

penicillium notatum intradermal solution 1:20 EX Medical Only Exclusion

pistachio nut (diagnostic) injection solution 1:10 EX Medical Only Exclusion

pork (diagnostic) injection solution 1:10 EX Medical Only Exclusion

rice (diagnostic) injection solution 1:10 EX Medical Only Exclusion

saccharomyces cerevisiae intradermal solution1:20


sesame seed (diagnostic) injection solution 1:10 EX Medical Only Exclusion

shrimp (diagnostic) injection solution 1:10 EX Medical Only Exclusion

soybean (diagnostic) injection solution 1:10 EX Medical Only Exclusion

SPHERUSOL INTRADERMAL SOLUTION127 MCG/0.1ML EX


strawberry (diagnostic) injection solution 1:10 EX Medical Only Exclusion

sweet corn (diagnostic) injection solution 1:10 EX Medical Only Exclusion

tomato (diagnostic) injection solution 1:10 EX Medical Only Exclusion

trichophyton mentag (diagnost) subcutaneous solution 1:20


TUBERSOL INTRADERMAL SOLUTION 5 UNIT/0.1ML EX


whole egg (diagnostic) injection solution 1:100 EX Medical Only Exclusion

*Diagnostic Drugs***adenosine (diagnostic) intravenous solution 3 mg/ml


adenosine intravenous solution 3 mg/ml EX Medical Only Exclusion

ARIDOL INHALATION KIT 0 & 5 & 10 & 20 & 40 MG EX Formulary Exclusion

CHIRHOSTIM INTRAVENOUS SOLUTION RECONSTITUTED 16 MCG EX Medical Only Exclusion

CORTROSYN INJECTION SOLUTION RECONSTITUTED 0.25 MG EX Medical Only Exclusion

cosyntropin injection solution reconstituted 0.25 mg


CYSVIEW INTRAVESICAL SOLUTION RECONSTITUTED 100 MG EX


dipyridamole intravenous solution 5 mg/ml EX Medical Only Exclusion

d-xylose powder EX Formulary Exclusion

GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 GM EX Medical Only Exclusion

GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED 1 MG EX Medical Only Exclusion

229

Drug Name Drug Tier Notesglucagon hcl (diagnostic) injection solution reconstituted 1 mg


HISTATROL INJECTION SOLUTION 2.75 MG/ML EX Medical Only Exclusion

HISTATROL INTRADERMAL SOLUTION0.275 MG/ML EX


IC GREEN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG EX Medical Only Exclusion

indigo carmine injection solution 8 mg/ml EX Non FDA Exclusion

indocyanine green intravenous solution reconstituted 25 mg


isosulfan blue subcutaneous solution 1 % EX Medical Only Exclusion

KINEVAC INJECTION SOLUTION RECONSTITUTED 5 MCG EX Medical Only Exclusion

LEXISCAN INTRAVENOUS SOLUTION 0.4 MG/5ML EX Medical Only Exclusion

MACRILEN ORAL PACKET 60 MG EX Medical Only Exclusion

methacholine chloride inhalation kit EX Non FDA Exclusion

METOPIRONE ORAL CAPSULE 250 MG EX Formulary Exclusion

PRE-PEN INTRADERMAL SOLUTION 0.25 ML EX


PROVOCHOLINE INHALATION SOLUTION RECONSTITUTED 100 MG EX Formulary Exclusion

R-GENE 10 INTRAVENOUS SOLUTION 10 % EX Medical Only Exclusion

SECREFLO INTRAVENOUS SOLUTION RECONSTITUTED 16 MCG EX Medical Only Exclusion

THYROGEN INTRAMUSCULAR SOLUTION RECONSTITUTED 0.9 MG EX Medical Only Exclusion

*Diagnostic Infection Test Combinations***BD VERITOR SARS-COV-2/FLU A+B IN VITRO KIT EX Non FDA Exclusion

COBAS LIAT SARS-COV-2-AB ASSAY IN VITRO KIT EX Non FDA Exclusion

COBAS LIAT SARS-COV-2-AB CNTRL IN VITRO KIT EX Non FDA Exclusion

SOFIA2 FLU+SARS ANTIGEN FIA IN VITRO KIT EX Non FDA Exclusion

230


*Diagnostic Radiopharmaceuticals - Brain***AMYVID INTRAVENOUS SOLUTION 500-1900 MBQ/ML EX Medical Only Exclusion

DATSCAN INTRAVENOUS SOLUTION 185 MBQ/2.5ML EX Medical Only Exclusion

fluorodopa f 18 intravenous solution 37-1480 mbq/ml


NEURACEQ INTRAVENOUS SOLUTION1.4-135 MCI/ML EX Medical Only Exclusion

VIZAMYL INTRAVENOUS SOLUTION 4.05 MCI/ML EX Medical Only Exclusion

*Diagnostic Radiopharmaceuticals - Cardiac***ammonia n 13 intravenous solution 3.75-37.5 mci/ml


MYOVIEW 30ML INTRAVENOUS KIT EX Medical Only Exclusion

technetium tc 99m sestamibi intravenous kit EX Medical Only Exclusion

thallous chloride tl 201 intravenous solution 2 mci/ml


*Diagnostic Radiopharmaceuticals - Endocrine***ADREVIEW INTRAVENOUS SOLUTION 10 MCI/5ML EX Medical Only Exclusion

DETECTNET INTRAVENOUS SOLUTION 1 MCI/ML EX Medical Only Exclusion

DOTATOC GA 68 INTRAVENOUS SOLUTION 0.5-4 MCI/ML EX Medical Only Exclusion

indium in 111 dtpa intrathecal solution EX Medical Only Exclusion

NETSPOT INTRAVENOUS KIT EX Medical Only Exclusion

*Diagnostic Radiopharmaceuticals - Gases***xenon xe 133 inhalation gas 10 mci, 20 mci EX Medical Only Exclusion

*Diagnostic Radiopharmaceuticals - Hepatobiliary***CHOLETEC INTRAVENOUS KIT EX Medical Only Exclusion

technetium tc 99m mebrofenin intravenous kit EX Medical Only Exclusion

*Diagnostic Radiopharmaceuticals - Miscellaneous***CERIANNA INTRAVENOUS SOLUTION 4-100 MCI/ML EX Medical Only Exclusion

231

Drug Name Drug Tier Notesfludeoxyglucose f 18 intravenous solution 20-300 mci/ml, 20-500 mci/ml


gallium citrate ga 67 intravenous solution 2 mci/ml


LEU TECHNELITE COMBINATION KIT EX Medical Only Exclusion

TECHNELITE COMBINATION KIT EX Medical Only Exclusion

technet tc 99m sulfur colloid combination kit EX Medical Only Exclusion

technetium tc 99m pyrophos intravenous kit EX Medical Only Exclusion

volumex intravenous solution prefilled syringe 25 mcci/ml


*Diagnostic Radiopharmaceuticals - Prostatic***AXUMIN INTRAVENOUS SOLUTION 9-221 MCI/ML EX Medical Only Exclusion

gallium ga 68 psma-11 intravenous solution 0.5-5 mci/ml


ILLUCCIX CONFIGURATION A INTRAVENOUS KIT 25 MCG EX Medical Only Exclusion

ILLUCCIX CONFIGURATION B INTRAVENOUS KIT 25 MCG EX Medical Only Exclusion

LOCAMETZ INTRAVENOUS KIT 25 MCG EX Medical Only Exclusion

PYLARIFY INTRAVENOUS SOLUTION PREFILLED SYRINGE 9 MCI EX Medical Only Exclusion

*Diagnostic Radiopharmaceuticals - Renal***dmsa intravenous kit Tier 3

*Diagnostic Radiopharmaceuticals - Skeletal***technetium tc 99m medronate intravenous kit EX Medical Only Exclusion

*Diagnostic Radiopharmaceuticals-Immune Cell Radiolabeling**CERETEC INTRAVENOUS KIT EX Medical Only Exclusion

indium in 111 oxyquinoline intravenous solution1 mci/ml


*Diagnostic Supplies***cervical specimen collection swab EX Non FDA Exclusion

*Diagnostic Tests***12-PANEL POC TOXICOLOGY SYSTEM IN VITRO KIT EX Medical Only Exclusion

ACCU-CHEK AVIVA PLUS IN VITRO STRIP EX Formulary Exclusion

232

Drug Name Drug Tier NotesACCU-CHEK COMPACT PLUS IN VITRO STRIP EX Formulary Exclusion

ACCU-CHEK GUIDE IN VITRO STRIP EX Formulary Exclusion

ACCU-CHEK SMARTVIEW IN VITRO STRIP EX Formulary Exclusion

ACCUTREND GLUCOSE IN VITRO STRIP EX Formulary Exclusion

ADVANCE INTUITION TEST IN VITRO STRIP EX Formulary Exclusion

ADVANCE MICRO-DRAW TEST IN VITRO STRIP EX Formulary Exclusion

ADVOCATE REDI-CODE IN VITRO STRIP EX Formulary Exclusion

ADVOCATE REDI-CODE+ TEST IN VITRO STRIP EX Formulary Exclusion

ADVOCATE TEST IN VITRO STRIP EX Formulary Exclusion

AGAMATRIX AMP TEST IN VITRO STRIP EX Formulary Exclusion

AGAMATRIX JAZZ TEST IN VITRO STRIPEX Formulary Exclusion

AGAMATRIX KEYNOTE TEST IN VITRO STRIP EX Formulary Exclusion

AGAMATRIX PRESTO TEST IN VITRO STRIP EX Formulary Exclusion

ASSURE 3 TEST IN VITRO STRIP EX Formulary Exclusion

ASSURE 4 TEST IN VITRO STRIP EX Formulary Exclusion

ASSURE II CHECK IN VITRO STRIP EX Formulary Exclusion

ASSURE II IN VITRO STRIP EX Formulary Exclusion

ASSURE PLATINUM IN VITRO STRIP EX Formulary Exclusion

ASSURE PRISM MULTI TEST IN VITRO STRIP EX Formulary Exclusion

ASSURE PRO TEST IN VITRO STRIP EX Formulary Exclusion

AT LAST TEST IN VITRO STRIP EX

BIOSCANNER GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

blood glucose test in vitro strip EX Formulary Exclusion

BLULINK GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

CAREONE BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

CARESENS N GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

CARETOUCH TEST IN VITRO STRIP EX Formulary Exclusion

CHEMSTRIP K IN VITRO STRIP Benefit Exclusion

233

Drug Name Drug Tier Notescholesterol and lipid test in vitro diagnostic test EX Non FDA Exclusion

CLEVER CHEK AUTO-CODE TEST IN VITRO STRIP EX Formulary Exclusion

CLEVER CHEK AUTO-CODE VOICE IN VITRO STRIP EX Formulary Exclusion

CLEVER CHEK TEST IN VITRO STRIP EX Formulary Exclusion

CLEVER CHOICE AUTO-CODE TEST IN VITRO STRIP EX Formulary Exclusion

CLEVER CHOICE MICRO TEST IN VITRO STRIP EX Formulary Exclusion

CLEVER CHOICE NO CODING IN VITRO STRIP EX Formulary Exclusion

CLEVER CHOICE TALK SYSTEM IN VITRO STRIP EX Formulary Exclusion

CONTOUR NEXT TEST IN VITRO STRIP EX Formulary Exclusion

CONTOUR TEST IN VITRO STRIP EX Formulary Exclusion

COOL BLOOD GLUCOSE TEST STRIPS IN VITRO STRIP EX Formulary Exclusion

CVS ADVANCED GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

cvs glucose meter test strips in vitro strip EX Formulary Exclusion

D-CARE BLOOD GLUCOSE IN VITRO STRIP EX Formulary Exclusion

DIATHRIVE BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

DIATHRIVE GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

DIATHRIVE+ GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

diatrue plus test in vitro strip EX Formulary Exclusion

DUO-CARE TEST IN VITRO STRIP EX Formulary Exclusion

DX1 ORAGENOMIC DNA SCREEN COMBINATION KIT EX


DX2 ORAGENOMIC DNA SCREEN COMBINATION KIT EX


easy plus ii glucose test in vitro strip EX Formulary Exclusion

EASY STEP TEST IN VITRO STRIP EX Formulary Exclusion

easy talk blood glucose test in vitro strip EX Formulary Exclusion

easy talk plus ii test strips in vitro strip EX Formulary Exclusion

EASY TOUCH HEALTHPRO GLUCOSE IN VITRO STRIP EX Formulary Exclusion

EASY TOUCH TEST IN VITRO STRIP EX Formulary Exclusion

234

Drug Name Drug Tier Noteseasy trak blood glucose test in vitro strip EX Formulary Exclusion

easy trak ii glucose test in vitro strip EX Formulary Exclusion

EASYGLUCO IN VITRO STRIP EX Formulary Exclusion

EASYGLUCO PLUS IN VITRO STRIP EX Formulary Exclusion

EASYMAX 15 TEST IN VITRO STRIP EX Formulary Exclusion

EASYMAX TEST IN VITRO STRIP EX Formulary Exclusion

EASYPRO BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

EASYPRO PLUS IN VITRO STRIP EX Formulary Exclusion

element compact test in vitro strip EX Formulary Exclusion

ELEMENT TEST IN VITRO STRIP EX Formulary Exclusion

EMBRACE BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

EMBRACE EVO BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

EMBRACE PRO GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

EMBRACE TALK GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

eq blood glucose test in vitro strip EX Formulary Exclusion

EVENCARE + BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

EVENCARE BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

EVENCARE G2 TEST IN VITRO STRIP EX Formulary Exclusion

EVENCARE G3 TEST IN VITRO STRIP EX Formulary Exclusion

EVENCARE MINI GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

EVENCARE PROVIEW GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

EVOLUTION AUTOCODE IN VITRO STRIP EX Formulary Exclusion

EXACTECH R-S-G TEST IN VITRO STRIP EX Formulary Exclusion

EXACTECH TEST IN VITRO STRIP EX Formulary Exclusion

FIFTY50 GLUCOSE TEST 2.0 IN VITRO STRIP EX Formulary Exclusion

FORA 6 CONNECT IN VITRO STRIP EX Formulary Exclusion

FORA BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

FORA D15G BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

235

Drug Name Drug Tier NotesFORA D20 BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

FORA D40/G31 BLOOD GLUCOSE IN VITRO STRIP EX Formulary Exclusion

FORA G20 BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

FORA G30/PREM V10 GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

FORA GD20 TEST IN VITRO STRIP EX Formulary Exclusion

FORA GD50 BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

FORA GTEL BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

FORA TN'G ADVANCE PRO IN VITRO STRIP EX Formulary Exclusion

FORA TN'G/TN'G VOICE IN VITRO STRIP EX Formulary Exclusion

FORA V10 BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion



FORA V30A BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

FORACARE GD40 TEST IN VITRO STRIP EX Formulary Exclusion

FORACARE PREMIUM V10 TEST IN VITRO STRIP EX Formulary Exclusion

FORACARE TEST N GO TEST IN VITRO STRIP EX Formulary Exclusion

FORTISCARE G1 TEST STRIP IN VITRO STRIP EX Formulary Exclusion

FORTISCARE TEST IN VITRO STRIP EX Formulary Exclusion

FREESTYLE INSULINX TEST IN VITRO STRIP EX Formulary Exclusion

FREESTYLE LITE TEST IN VITRO STRIP EX Formulary Exclusion

FREESTYLE PRECISION NEO TEST IN VITRO STRIP EX Formulary Exclusion

FREESTYLE TEST IN VITRO STRIP EX Formulary Exclusion

ge100 blood glucose test in vitro strip EX Formulary Exclusion

GENULTIMATE TEST IN VITRO STRIP EX Formulary Exclusion

ght test in vitro strip EX Formulary Exclusion

236

Drug Name Drug Tier NotesGLUCO PERFECT 3 TEST IN VITRO STRIP EX Formulary Exclusion

GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP EX Formulary Exclusion

GLUCOCARD EXPRESSION TEST IN VITRO STRIP EX Formulary Exclusion

GLUCOCARD SHINE TEST IN VITRO STRIP EX Formulary Exclusion

GLUCOCARD VITAL TEST IN VITRO STRIP EX Formulary Exclusion

GLUCOCARD X-SENSOR IN VITRO STRIPEX Formulary Exclusion

GLUCOCOM TEST IN VITRO STRIP EX Formulary Exclusion

GLUCONAVII BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

glucose meter test in vitro strip EX Formulary Exclusion

gnp easy touch glucose test in vitro strip EX Formulary Exclusion

GNP TRUE METRIX GLUCOSE STRIPS IN VITRO STRIP EX Formulary Exclusion

GNP TRUETRACK SMART SYSTEM IN VITRO STRIP EX Formulary Exclusion

GNP TRUETRACK TEST STRIPS IN VITRO STRIP EX Formulary Exclusion

GOJJI BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

GOJJI BLOOD TEST STRIP/LANCETS IN VITRO STRIP EX Formulary Exclusion

goodsense blood glucose in vitro strip EX Formulary Exclusion

HARMONY BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

home pap kit in vitro kit 2.5 % EX Medical Only Exclusion

HW EMBRACE PRO GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

HW EMBRACE TALK GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

IGLUCOSE TEST STRIPS IN VITRO STRIPEX Formulary Exclusion

IN TOUCH BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

INFINITY BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

INFINITY VOICE IN VITRO STRIP EX Formulary Exclusion

ketone test in vitro strip Benefit Exclusion

237

Drug Name Drug Tier NotesKETOSTIX IN VITRO STRIP Benefit Exclusion

kroger blood glucose test in vitro strip EX Formulary Exclusion

KROGER HEALTHPRO GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

kroger premium glucose test in vitro strip EX Formulary Exclusion

kroger test in vitro strip EX Formulary Exclusion

LIBERTY NEXT GENERATION TEST IN VITRO STRIP EX Formulary Exclusion

liberty test in vitro strip EX Formulary Exclusion

medicated dna collection 2 combination kit EX Non FDA Exclusion; Medical Only Exclusion

medicated dna collection kit combination EX Non FDA Exclusion; Medical Only Exclusion

medicated dna collection kit combination EX Medical Only Exclusion; Formulary Exclusion

meijer blood glucose test in vitro strip EX Formulary Exclusion

meijer essential glucose test in vitro strip EX Formulary Exclusion

meijer premium glucose test in vitro strip EX Formulary Exclusion

MEIJER TRUETEST TEST IN VITRO STRIP EX Formulary Exclusion

MEIJER TRUETRACK TEST IN VITRO STRIP EX Formulary Exclusion

MICRODOT TEST IN VITRO STRIP EX Formulary Exclusion

MM EASY TOUCH GLUCOSE IN VITRO STRIP EX Formulary Exclusion

MYGLUCOHEALTH TEST IN VITRO STRIP EX Formulary Exclusion

NEUTEK 2TEK TEST IN VITRO STRIP EX Formulary Exclusion

NOVA MAX GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

ON CALL EXPRESS BLOOD GLUCOSE IN VITRO STRIP EX Formulary Exclusion

ON CALL PLUS BLOOD GLUCOSE IN VITRO STRIP EX Formulary Exclusion

ON CALL VIVID BLOOD GLUCOSE IN VITRO STRIP EX Formulary Exclusion

one drop test in vitro strip EX Formulary Exclusion

ONETOUCH ULTRA IN VITRO STRIP Tier 2

ONETOUCH VERIO IN VITRO STRIP Tier 2

OPTIUM TEST IN VITRO STRIP EX Formulary Exclusion

OPTIUMEZ TEST IN VITRO STRIP EX Formulary Exclusion

238

Drug Name Drug Tier NotesOPTUMRX BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

ph strips in vitro diagnostic test Tier 3

PHARMACIST CHOICE AUTOCODE IN VITRO STRIP EX Formulary Exclusion

pharmacist choice no coding in vitro strip EX Formulary Exclusion

POCKETCHEM EZ TEST IN VITRO STRIP EX Formulary Exclusion

POGO AUTOMATIC TEST CARTRIDGES IN VITRO DIAGNOSTIC TEST EX Formulary Exclusion

PRECISION PCX IN VITRO STRIP EX Formulary Exclusion

PRECISION PCX PLUS TEST IN VITRO STRIP EX Formulary Exclusion

PRECISION POINT OF CARE TEST IN VITRO STRIP EX Formulary Exclusion

PRECISION QID TEST IN VITRO STRIP EX Formulary Exclusion

PRECISION SOF-TACT TEST IN VITRO STRIP EX Formulary Exclusion

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP EX Formulary Exclusion

premium blood glucose test in vitro strip EX Formulary Exclusion

PRO DNA COLLECTION COMBINATION KIT 2 % EX


pro voice v8/v9 glucose in vitro strip EX Formulary Exclusion

PRODIGY NO CODING BLOOD GLUC IN VITRO STRIP EX Formulary Exclusion

professional dna collection kit combination Benefit Exclusion

professional dna collection kit combination EX Medical Only Exclusion

PTS PANELS GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

QUICKTEK TEST IN VITRO STRIP EX Formulary Exclusion

QUINTET AC BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

QUINTET BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

REFUAH PLUS BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

RELION BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

RELION CONFIRM/MICRO TEST IN VITRO STRIP EX Formulary Exclusion

RELION KETONE TEST IN VITRO STRIP Benefit Exclusion

RELION PREMIER TEST IN VITRO STRIP EX Formulary Exclusion

239

Drug Name Drug Tier NotesRELION PRIME TEST IN VITRO STRIP EX Formulary Exclusion

RELION TRUE METRIX TEST STRIPS IN VITRO STRIP EX Formulary Exclusion

RELION ULTIMA TEST IN VITRO STRIP EX Formulary Exclusion

REVEAL BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

REXALL BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

RIGHTEST GS100 BLOOD GLUCOSE IN VITRO STRIP EX Formulary Exclusion



RIGHTEST GT333 BLOOD GLUCOSE IN VITRO STRIP EX Formulary Exclusion

SMART SENSE PREMIUM TEST IN VITRO STRIP EX Formulary Exclusion

SMART SENSE VALUE TEST IN VITRO STRIP EX Formulary Exclusion

SMARTEST BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

SOLUS V2 TEST IN VITRO STRIP EX Formulary Exclusion

SUPREME TEST IN VITRO STRIP EX Formulary Exclusion

SURE EDGE TEST IN VITRO STRIP EX Formulary Exclusion

SURECHEK BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

SURE-TEST EASYPLUS MINI TEST IN VITRO STRIP EX Formulary Exclusion

TELCARE BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

tgt blood glucose test in vitro strip EX Formulary Exclusion

TOXICOLOGY MED COLLECTION SYS IN VITRO KIT EX Medical Only Exclusion

true focus blood glucose strip in vitro strip EX Formulary Exclusion

TRUE METRIX BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

TRUETEST TEST IN VITRO STRIP EX Formulary Exclusion

TRUETRACK TEST IN VITRO STRIP EX Formulary Exclusion

ULTRATRAK PRO TEST IN VITRO STRIP EX Formulary Exclusion

ULTRATRAK ULTIMATE TEST IN VITRO STRIP EX Formulary Exclusion

240

Drug Name Drug Tier NotesUNISTRIP1 GENERIC IN VITRO STRIP EX Formulary Exclusion

verasens blood glucose test in vitro strip EX Formulary Exclusion

VIVAGUARD INO TEST STRIPS IN VITRO STRIP EX Formulary Exclusion

VOCAL POINT BLOOD GLUCOSE TEST IN VITRO STRIP EX Formulary Exclusion

*Digital Diagnostic Aids***CANVAS DX EX Non FDA Exclusion

*Infection Tests***ACCULA SARS-COV-2 IN VITRO KIT EX New to Market Exclusion

BD VERITOR HOME COVID-19 TEST IN VITRO KIT Tier 3

BD VERITOR SYSTEM GROUP A STRP IN VITRO KIT EX Non FDA Exclusion

BD VERITOR SYSTEM SARS-COV-2 IN VITRO KIT EX New to Market Exclusion

BINAXNOW COVID-19 AG CARD IN VITRO KIT EX New to Market Exclusion

BINAXNOW COVID-19 AG HOME TEST IN VITRO KIT Tier 3

CARESTART COVID-19 HOME TEST IN VITRO KIT Tier 3

CLEARDETECT COVID-19 AG HOME IN VITRO KIT Tier 3

CLINITEST RAPID COVID-19 TEST IN VITRO KIT Tier 3

COBAS LIAT SARS-COV-2 ASSAY IN VITRO KIT EX Non FDA Exclusion

COBAS LIAT SARS-COV-2 CONTROL IN VITRO KIT EX Non FDA Exclusion

covid-19 at-home test in vitro kit Tier 3

covid-19 otc antigen 1-pack in vitro kit EX New to Market Exclusion

covid-19 otc antigen 2-pack in vitro kit EX New to Market Exclusion

covid-19 specimen collection kit EX New to Market Exclusion

covid-19 testing by pharmacist kit Tier 3

CUE COVID-19 TEST IN VITRO CARTRIDGE EX Non FDA Exclusion

CUE HEALTH MONITORING SYSTEM IN VITRO EX Non FDA Exclusion

DIATRUST COVID-19 HOME TEST IN VITRO KIT Tier 3

241

Drug Name Drug Tier NotesDXTERITY COVID-19 HOME TEST IN VITRO KIT EX New to Market Exclusion

ECOTEST COVID-19 RAPID TEST IN VITRO KIT EX Non FDA Exclusion

ellume covid-19 home test in vitro kit Tier 3

EVERLYWELL COVID-19 HOME TEST IN VITRO KIT EX New to Market Exclusion

FASTEP COVID-19 RAPID TEST IN VITRO KIT EX Non FDA Exclusion

FLOWFLEX COVID-19 AG HOME TEST IN VITRO KIT Tier 3

ID NOW COVID-19 CONTROL IN VITRO KIT EX New to Market Exclusion

ID NOW COVID-19 IN VITRO KIT EX New to Market Exclusion

ID NOW INFLUENZA A & B 2 CONTR IN VITRO KIT EX Non FDA Exclusion

ID NOW INFLUENZA A & B 2 IN VITRO KIT EX Non FDA Exclusion

ID NOW RSV CONTROL SWAB IN VITRO KIT EX Non FDA Exclusion

ID NOW RSV IN VITRO KIT EX Non FDA Exclusion

ID NOW STREP A2 CONTROL SWAB IN VITRO KIT EX Non FDA Exclusion

ID NOW STREP A2 IN VITRO KIT EX Non FDA Exclusion

IHEALTH COVID-19 RAPID TEST IN VITRO KIT Tier 3

INDICAID COVID-19 RAPID TEST IN VITRO KIT Tier 3

INTELISWAB COVID-19 RAPID TEST IN VITRO KIT Tier 3

LUCIRA CHECK IT COVID-19 TEST IN VITRO KIT EX Non FDA Exclusion

LUCIRA COVID-19 ALL-IN-ONE IN VITRO KIT EX Non FDA Exclusion

LYRA DIRECT SARS-COV-2 ASSAY IN VITRO KIT EX New to Market Exclusion

LYRA SARS-COV-2 ASSAY IN VITRO KIT EX New to Market Exclusion

MYLAB BOX COVID-19 TESTING IN VITRO KIT EX New to Market Exclusion

ON/GO COVID-19 ANTIGEN TEST IN VITRO KIT Tier 3

ON/GO ONE COVID-19 HOME TEST IN VITRO KIT Tier 3

242

Drug Name Drug Tier NotesPIXEL COVID-19 PCR HOME TEST IN VITRO KIT EX New to Market Exclusion

QUICKVUE + STREP A TEST IN VITRO KIT EX Non FDA Exclusion

QUICKVUE AT-HOME COVID-19 TEST IN VITRO KIT Tier 3

QUICKVUE DIPSTICK STREP A TEST IN VITRO KIT EX Non FDA Exclusion

QUICKVUE INFLUENZA A+B TEST IN VITRO KIT EX Non FDA Exclusion

QUICKVUE IN-LINE STREP A TEST IN VITRO KIT EX Non FDA Exclusion

QUICKVUE SARS ANTIGEN TEST IN VITRO KIT EX New to Market Exclusion

SIMPLICITY COVID-19 AT-HOME IN VITRO KIT EX New to Market Exclusion

SOFIA INFLUENZA A+B FIA IN VITRO KIT EX Non FDA Exclusion

SOFIA SARS ANTIGEN FIA IN VITRO KIT EX New to Market Exclusion

SOFIA STREP A FIA IN VITRO KIT EX Non FDA Exclusion

SOFIA STREP A+ FIA IN VITRO KIT EX Non FDA Exclusion

SOFIA2 SARS ANTIGEN FIA IN VITRO KIT EX New to Market Exclusion

XPERT XPRESS SARS-COV-2 IN VITRO KIT EX New to Market Exclusion

*Miscellaneous Contrast Media***CLARISCAN INTRAVENOUS SOLUTION10 MMOL/20ML, 2.5 MMOL/5ML, 5 MMOL/10ML, 50 MMOL/100ML, 7.5 MMOL/15ML


CLARISCAN INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MMOL/20ML, 5 MMOL/10ML, 7.5 MMOL/15ML


DEFINITY INTRAVENOUS SUSPENSION6.52 MG/ML EX Medical Only Exclusion

DEFINITY RT INTRAVENOUS SUSPENSION 6.52 MG/ML EX Medical Only Exclusion

DOTAREM INTRAVENOUS SOLUTION 10 MMOL/20ML, 2.5 MMOL/5ML, 5 MMOL/10ML, 50 MMOL/100ML, 7.5 MMOL/15ML


DOTAREM INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MMOL/20ML, 5 MMOL/10ML, 7.5 MMOL/15ML


243

Drug Name Drug Tier NotesEOVIST INTRAVENOUS SOLUTION 0.25 MOL/L EX Medical Only Exclusion

EXEM INTRAUTERINE FOAM 10 ML EX Medical Only Exclusion

GADAVIST INTRAVENOUS SOLUTION 1 MMOL/ML EX Medical Only Exclusion

GADAVIST INTRAVENOUS SOLUTION PREFILLED SYRINGE 10 MMOL/10ML, 15 MMOL/15ML, 7.5 MMOL/7.5ML


LUMASON INJECTION SUSPENSION RECONSTITUTED 60.7-25 MG EX Medical Only Exclusion

MULTIHANCE INTRAVENOUS SOLUTION 529 MG/ML EX Medical Only Exclusion

OMNISCAN INJECTION INJECTABLE 287 MG/ML EX Medical Only Exclusion

OMNISCAN INTRAVENOUS SOLUTION287 MG/ML EX Medical Only Exclusion

OPTISON INTRAVENOUS SUSPENSION EX Medical Only Exclusion

PROHANCE INTRAVENOUS SOLUTION279.3 MG/ML EX Medical Only Exclusion

*Multiple Skin Tests***T.R.U.E. TEST EXTERNAL DIAGNOSTIC TEST EX Formulary Exclusion

*Multiple Urine Tests***KETO-DIASTIX IN VITRO STRIP Benefit Exclusion

*Radiographic Contrast Media - Barium***barium sulfate powder EX Formulary Exclusion

ENTERO VU ORAL SUSPENSION 24 % EX Formulary Exclusion

E-Z-HD ORAL SUSPENSION RECONSTITUTED 98 % EX Formulary Exclusion

LIQUID E-Z-PAQUE ORAL SUSPENSION60 % EX Formulary Exclusion

NEULUMEX SUSPENSION 0.1 % ORAL 0.1 % EX Formulary Exclusion

NEULUMEX SUSPENSION 0.1 % ORAL 0.1 % EX Non FDA Exclusion

READI-CAT 2 ORAL SUSPENSION 2 % EX Formulary Exclusion

SITZMARKS COMBO PACKAGE ORAL CAPSULE THERAPY PACK EX Non FDA Exclusion

SITZMARKS ORAL CAPSULE EX Non FDA Exclusion

TAGITOL V ORAL SUSPENSION 40 % EX Formulary Exclusion

244

Drug Name Drug Tier NotesVARIBAR NECTAR ORAL SUSPENSION 40 % EX Formulary Exclusion

VARIBAR THIN LIQUID ORAL SUSPENSION RECONSTITUTED 40 % EX Formulary Exclusion

*Radiographic Contrast Media - Iodinated***CONRAY INJECTION SOLUTION 60 % EX Medical Only Exclusion

CYSTO-CONRAY II URETHRAL SOLUTION 17.2 % EX


CYSTOGRAFIN URETHRAL SOLUTION 30 % EX


CYSTOGRAFIN-DILUTE URETHRAL SOLUTION 18 % EX


GASTROGRAFIN ORAL SOLUTION 66-10 % EX Formulary Exclusion

iohexol epidural solution 240 mg/ml, 300 mg/ml EX Non FDA Exclusion

ISOVUE-200 INTRAVENOUS SOLUTION 41 % EX Medical Only Exclusion




ISOVUE-M 200 INJECTION SOLUTION 41 % EX Medical Only Exclusion

ISOVUE-M 300 INJECTION SOLUTION 61 % EX Medical Only Exclusion

LIPIODOL INJECTION OIL 480 MG/ML EX Medical Only Exclusion

OMNIPAQUE COMBINATION SOLUTION300 MG/ML, 350 MG/ML EX Medical Only Exclusion

OMNIPAQUE INJECTION SOLUTION 180 MG/ML, 240 MG/ML, 300 MG/ML EX Medical Only Exclusion

OMNIPAQUE INTRAVENOUS SOLUTION140 MG/ML, 350 MG/ML EX Medical Only Exclusion

OMNIPAQUE ORAL SOLUTION 12 MG/ML, 9 MG/ML EX Formulary Exclusion

ULTRAVIST INJECTION SOLUTION 62 %, 77 % EX Medical Only Exclusion

VISIPAQUE INTRAVENOUS SOLUTION270 MG/ML, 320 MG/ML EX Medical Only Exclusion

245


*Dietary Products/Dietary Management Products*

*Dietary Management Product Combinations***algesis oral tablet Benefit Exclusion

APPTRIM ORAL CAPSULE Benefit Exclusion

APPTRIM-D ORAL CAPSULE Benefit Exclusion

ASTAMED MYO ORAL CAPSULE Benefit Exclusion

AXONA ORAL PACKET Benefit Exclusion

CARDIOTEK RX ORAL TABLET Benefit Exclusion

CEREFOLIN NAC ORAL TABLET 6-90.314-2-600 MG Benefit Exclusion

CEREFOLIN ORAL TABLET 6-1-50-5 MG Benefit Exclusion

DEPLIN 15 ORAL CAPSULE 15-90.314 MG Benefit Exclusion

DEPLIN 7.5 ORAL CAPSULE 7.5-90.314 MG Benefit Exclusion

ELFOLATE PLUS ORAL TABLET 3-35-2 MG Benefit Exclusion

ELIGEN B12 ORAL TABLET 1000-100 MCG-MG Benefit Exclusion

ENLYTE ORAL CAPSULE Benefit Exclusion

FOLBIC ORAL TABLET 2.5-25-2 MG Benefit Exclusion

FOLBIC RF ORAL TABLET 1.13-25-2 MG Benefit Exclusion

FOLTANX ORAL TABLET 3-35-2 MG Benefit Exclusion

FOLTANX RF ORAL CAPSULE 3-90.314-2-35 MG Benefit Exclusion

FOLTX ORAL TABLET 1.13-25-2 MG Benefit Exclusion

FOSTEUM ORAL CAPSULE 27-20-200 MG-MG-UNIT Benefit Exclusion

FOSTEUM PLUS ORAL CAPSULE Benefit Exclusion

FOVEX ORAL CAPSULE Benefit Exclusion

GABADONE ORAL CAPSULE Benefit Exclusion

GLYGEST ORAL PACKET Benefit Exclusion

HYPERTENSA ORAL CAPSULE Benefit Exclusion

hypnosom oral tablet Benefit Exclusion

LDL CARE ORAL POWDER Benefit Exclusion

lexazin oral capsule Benefit Exclusion

LIMBREL250 ORAL CAPSULE 250-50 MG Benefit Exclusion

LIMBREL500 ORAL CAPSULE 500-50 MG Benefit Exclusion

LIPICHOL 540 ORAL CAPSULE Benefit Exclusion

246

Drug Name Drug Tier NotesLISTER-V ORAL CAPSULE Benefit Exclusion

l-methylfolate ca me-cbl nac oral tablet 6-90.314-2-600 mg

Benefit Exclusion

l-methylfolate forte oral capsule 15-90.314 mg, 7.5-90.314 mg

Benefit Exclusion

l-methylfolate-algae oral capsule 15-90.314 mg, 7.5-90.314 mg

Benefit Exclusion

l-methylfolate-algae-b12-b6 oral capsule 3-90.314-2-35 mg

Benefit Exclusion

l-methylfolate-b6-b12 oral tablet 3-35-2 mg Benefit Exclusion

l-methyl-mc nac oral tablet 6-2-600 mg Benefit Exclusion

l-methyl-mc oral tablet 6-1-50-5 mg Benefit Exclusion

lormate oral capsule Benefit Exclusion

MACUTEK ORAL TABLET DISPERSIBLE Benefit Exclusion

macuzin oral capsule Benefit Exclusion

mebolic oral tablet Benefit Exclusion

medactiv oral tablet Benefit Exclusion

METAFOLBIC ORAL TABLET 6-1-50-5 MG Benefit Exclusion

METAFOLBIC PLUS ORAL TABLET 6-2-600 MG Benefit Exclusion

METAFOLBIC PLUS RF ORAL TABLET 6-90.314-2-600 MG Benefit Exclusion

METANX ORAL CAPSULE 3-90.314-2-35 MG Benefit Exclusion

methaver oral capsule Benefit Exclusion

methazel oral capsule Benefit Exclusion

methylfol-algae-b12-acetylcyst oral tablet 6-90.314-2-600 mg

Benefit Exclusion

neoke bhb oral powder Benefit Exclusion

NEUREPA ORAL CAPSULE Benefit Exclusion

NICAPRIN ORAL TABLET Benefit Exclusion

nicazyme oral tablet Benefit Exclusion

NIVA-FOL ORAL TABLET 2.5-25-2 MG Benefit Exclusion

omniquin oral capsule Benefit Exclusion

omnivex oral tablet Benefit Exclusion

PERCURA ORAL CAPSULE Benefit Exclusion

PODIAPN ORAL CAPSULE Benefit Exclusion

pro-critic oral packet Benefit Exclusion

PROLEEVA ORAL CAPSULE Benefit Exclusion

proleva oral tablet Benefit Exclusion

247

Drug Name Drug Tier NotesPROTEOLIN DS ORAL TABLET Benefit Exclusion

PROTEOLIN ORAL TABLET Benefit Exclusion

PULMONA ORAL CAPSULE Benefit Exclusion

RHEUMATE ORAL CAPSULE Benefit Exclusion

ribozel oral capsule Benefit Exclusion

SENTRA AM ORAL CAPSULE Benefit Exclusion

SENTRA PM ORAL CAPSULE Benefit Exclusion

SULFZIX ORAL CAPSULE Benefit Exclusion

THERAMINE ORAL CAPSULE Benefit Exclusion

THERAMINE PLUS ORAL PACKET Benefit Exclusion

tl-icare oral capsule Benefit Exclusion

TOBAKIENT ORAL CAPSULE Benefit Exclusion

TREPADONE ORAL CAPSULE Benefit Exclusion

t-support max oral capsule Benefit Exclusion

VASCULERA ORAL TABLET Benefit Exclusion

VAYACOG ORAL CAPSULE 100-19.5-6.5 MG Benefit Exclusion

VAYARIN ORAL CAPSULE 75-21.5-8.5 MG Benefit Exclusion

VAYARIN PLUS ORAL CAPSULE Benefit Exclusion

VAYAROL ORAL CAPSULE 630-232.5-92.5 MG Benefit Exclusion

vb6 p5p oral powder Benefit Exclusion

vp-gstn oral capsule 27-20-200 mg-mg-unit Benefit Exclusion

vp-precip oral capsule 250-125-10 mg Benefit Exclusion

westab max oral tablet 2.5-25-2 mg Benefit Exclusion

xyzbac oral tablet Benefit Exclusion

ZAVITROL ORAL CAPSULE Benefit Exclusion

zyvexol oral tablet Benefit Exclusion

zyvit oral tablet Benefit Exclusion

*Dietary Management Products***AVAILNEX ORAL TABLET CHEWABLE750 MG Benefit Exclusion

ELFOLATE ORAL TABLET 15 MG, 7.5 MG Benefit Exclusion

ENTERAGAM ORAL PACKET 5 GM Benefit Exclusion

GALAXTRA ORAL POWDER Benefit Exclusion

LIMBREL ORAL CAPSULE 250 MG, 500 MG Benefit Exclusion

l-methylfolate calcium oral tablet 15 mg, 7.5 mg Benefit Exclusion

l-methylfolate oral tablet 15 mg, 7.5 mg Benefit Exclusion

248

Drug Name Drug Tier Notesluvira oral capsule 1.22 gm Benefit Exclusion

VASCAZEN ORAL CAPSULE 1 GM Benefit Exclusion

XAQUIL XR ORAL TABLET EXTENDED RELEASE 30 MG Benefit Exclusion

*Nutritional Supplements - Diet Aids***APP SLIM RMS ORAL CAPSULE Benefit Exclusion

*Nutritional Supplements***AMINOPMRMS ORAL CAPSULE Benefit Exclusion

ASILNASALRMS ORAL CAPSULE Benefit Exclusion

CAMINO PRO 15PE ORAL LIQUID Benefit Exclusion

CAMINO PRO COMPLETE/GLYTACTIN ORAL BAR Benefit Exclusion

CAMINO PRO PKU ORAL LIQUID Benefit Exclusion

ENU NUTRITIONAL SHAKE ORAL LIQUID Benefit Exclusion

ENU PRO3 PLUS ORAL POWDER Benefit Exclusion

equacare jr oral powder Benefit Exclusion

ESSENTIAL CARE JR ORAL POWDER Benefit Exclusion

FIBERSOURCE HN ORAL LIQUID Benefit Exclusion

GLYTACTIN BETTERMILK 15 ORAL PACKET Benefit Exclusion

GLYTACTIN BETTERMILK DE-LITE ORAL PACKET Benefit Exclusion

GLYTACTIN BUILD 10PE ORAL PACKET Benefit Exclusion

GLYTACTIN BUILD 20/20 ORAL PACKET Benefit Exclusion

GLYTACTIN BUILD 20/20 PKU ORAL PACKET Benefit Exclusion

GLYTACTIN BURST ORAL PACKET Benefit Exclusion

GLYTACTIN COMPLETE 10PE ORAL BARBenefit Exclusion

GLYTACTIN RESTORE 10 ORAL LIQUID Benefit Exclusion

GLYTACTIN RESTORE 5 ORAL PACKET Benefit Exclusion

GLYTACTIN RESTORE LITE 10 ORAL LIQUID Benefit Exclusion

GLYTACTIN RESTORE LITE 10PE ORAL PACKET Benefit Exclusion

GLYTACTIN RTD 10 ORAL LIQUID Benefit Exclusion

GLYTACTIN RTD 15 ORAL LIQUID Benefit Exclusion

GLYTACTIN RTD LITE 15 ORAL LIQUID Benefit Exclusion

249

Drug Name Drug Tier NotesGLYTACTIN SWIRL 15PE ORAL PACKET Benefit Exclusion

HCU EASY ORAL TABLET Benefit Exclusion

HCU EXPRESS 15 PLUS+ ORAL PACKET Benefit Exclusion

HCU EXPRESS 20 PLUS+ ORAL PACKET Benefit Exclusion

HOMACTIN AA PLUS ORAL LIQUID Benefit Exclusion

HOMACTIN AA PLUS ORAL PACKET Benefit Exclusion

ISOVACTIN AA PLUS ORAL LIQUID Benefit Exclusion

ISOVACTIN AA PLUS ORAL PACKET Benefit Exclusion

KATE FARMS PEPTIDE 1.5 ENTERAL LIQUID Benefit Exclusion

KATE FARMS STANDARD 1.4 ENTERAL LIQUID Benefit Exclusion

KETOVIE 4:1 ORAL LIQUID Benefit Exclusion

KETOVIE ORAL LIQUID Benefit Exclusion

KETOVIE PEPTIDE ORAL LIQUID Benefit Exclusion

MSUD EASY ORAL TABLET Benefit Exclusion

NOURISH ORAL LIQUID Benefit Exclusion

PHENACTIN AA PLUS ORAL LIQUID Benefit Exclusion

PHENYLADE GMP MIX DHA/FIBER ORAL POWDER Benefit Exclusion Non FDA Exclusion

PKU EASY MICROTABS ORAL TABLET DELAYED RELEASE Benefit Exclusion

PKU EASY ORAL TABLET Benefit Exclusion

PKU EXPRESS 15 PLUS+ ORAL PACKET Benefit Exclusion

PKU EXPRESS 20 PLUS+ ORAL PACKET Benefit Exclusion

PKU GO ORAL PACKET Benefit Exclusion

PROMACTIN AA PLUS 20PE ORAL SUSPENSION Benefit Exclusion

thrivacin 30 oral liquid Benefit Exclusion

thrivacin detox oral liquid Benefit Exclusion

TYLACTIN BUILD 20PE TYR ORAL PACKET Benefit Exclusion

TYLACTIN COMPLETE 15 PE ORAL BAR Benefit Exclusion

TYLACTIN RESTORE 10 ORAL LIQUID Benefit Exclusion

TYLACTIN RESTORE 5PE ORAL PACKET Benefit Exclusion

TYLACTIN RTD 15 ORAL LIQUID Benefit Exclusion

TYR EASY ORAL TABLET Benefit Exclusion

TYR EXPRESS 15 PLUS+ ORAL PACKET Benefit Exclusion

TYR EXPRESS 20 PLUS+ ORAL PACKET Benefit Exclusion

VILACTIN AA PLUS ORAL LIQUID Benefit Exclusion

250

Drug Name Drug Tier NotesVILACTIN AA PLUS ORAL PACKET Benefit Exclusion

*Sweeteners***sodium saccharin granules Benefit Exclusion

sodium saccharin powder Benefit Exclusion

*Digestive Aids*

*Digestive Enzyme Combinations***enzadyne oral capsule Benefit Exclusion

*Digestive Enzymes***CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000-114000 UNIT, 6000-19000 UNIT

Tier 2

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200-14200 UNIT


PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 UNIT, 8000-28750 UNIT


SUCRAID ORAL SOLUTION 8500 UNIT/ML Tier 4 PA; Specialty

VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 UNIT EX Formulary Exclusion

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT

Tier 2

*Diuretics*

*Carbonic Anhydrase Inhibitors***acetazolamide er oral capsule extended release 12 hour 500 mg

Tier 1

acetazolamide oral tablet 125 mg, 250 mg Tier 1

acetazolamide sodium injection solution reconstituted 500 mg


KEVEYIS ORAL TABLET 50 MG Tier 4 PA; Specialty

methazolamide oral tablet 25 mg, 50 mg Tier 1

*Diuretic Combinations***ALDACTAZIDE TABLET 25-25 MG ORAL25-25 MG EX Formulary Exclusion

251

Drug Name Drug Tier NotesALDACTAZIDE TABLET 50-50 MG ORAL50-50 MG Tier 3

amiloride-hydrochlorothiazide oral tablet 5-50 mg

Tier 1

DYAZIDE ORAL CAPSULE 37.5-25 MG EX Formulary Exclusion

MAXZIDE ORAL TABLET 75-50 MG EX Formulary Exclusion

MAXZIDE-25 ORAL TABLET 37.5-25 MG EX Formulary Exclusion

spironolactone-hctz oral tablet 25-25 mg Tier 1

triamterene-hctz oral capsule 37.5-25 mg Tier 1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg Tier 1

*Loop Diuretics***bumetanide injection solution 0.25 mg/ml EX Medical Only Exclusion

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

BUMEX ORAL TABLET 0.5 MG, 1 MG, 2 MG EX Formulary Exclusion

EDECRIN ORAL TABLET 25 MG EX Formulary Exclusion

ethacrynate sodium intravenous solution reconstituted 50 mg


ethacrynic acid oral tablet 25 mg Tier 1

furosemide in sodium chloride intravenous solution 100-0.9 mg/100ml-%


furosemide injection solution 10 mg/ml EX Medical Only Exclusion

furosemide oral tablet 20 mg, 40 mg, 80 mg Tier 1

furosemide solution 10 mg/ml oral 10 mg/ml Tier 1

furosemide solution 8 mg/ml oral 8 mg/ml Tier 3

LASIX ORAL TABLET 20 MG, 40 MG, 80 MG EX Formulary Exclusion

SOAANZ ORAL TABLET 20 MG, 40 MG, 60 MG Benefit Exclusion

Non Essential Drug Exclusion; Formulary Exclusion

SODIUM EDECRIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG EX Medical Only Exclusion

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg Tier 1

*Osmotic Diuretics***mannitol intravenous solution 20 %, 25 % EX Medical Only Exclusion

OSMITROL INTRAVENOUS SOLUTION 10 %, 15 %, 20 % EX Medical Only Exclusion

*Potassium Sparing Diuretics***ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG EX Formulary Exclusion

amiloride hcl oral tablet 5 mg Tier 1

252

Drug Name Drug Tier NotesCAROSPIR ORAL SUSPENSION 25 MG/5ML Benefit Exclusion Non Essential Drug Exclusion

DYRENIUM ORAL CAPSULE 100 MG, 50 MG EX Formulary Exclusion

spironolactone oral tablet 100 mg, 25 mg, 50 mg Tier 1

triamterene oral capsule 100 mg, 50 mg Tier 1

*Thiazides And Thiazide-Like Diuretics***chlorothiazide sodium intravenous solution reconstituted 500 mg


chlorthalidone oral tablet 25 mg, 50 mg Tier 1

DIURIL ORAL SUSPENSION 250 MG/5ML Tier 3

hydrochlorothiazide oral capsule 12.5 mg Tier 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

Tier 1

indapamide oral tablet 1.25 mg, 2.5 mg Tier 1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg Tier 1

SODIUM DIURIL INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

THALITONE ORAL TABLET 15 MG Tier 3

*Endocrine And Metabolic Agents - Misc.*

*Abortifacient - Progesterone Receptor Antagonists***MIFEPREX ORAL TABLET 200 MG Benefit Exclusion

mifepristone oral tablet 200 mg Benefit Exclusion

*Adenosine Deaminase Scid Treatment - Agents***REVCOVI SOLUTION 2.4 MG/1.5ML INTRAMUSCULAR 2.4 MG/1.5ML Tier 4 PA

REVCOVI SOLUTION 2.4 MG/1.5ML INTRAMUSCULAR 2.4 MG/1.5ML Tier 4 PA; Specialty

*Bisphosphonates***ACTONEL ORAL TABLET 150 MG, 35 MG EX Formulary Exclusion; QL

alendronate sodium oral solution 70 mg/75ml Tier 1 QL

alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg

Tier 1 QL

ATELVIA ORAL TABLET DELAYED RELEASE 35 MG EX Formulary Exclusion; QL

253

Drug Name Drug Tier NotesBINOSTO ORAL TABLET EFFERVESCENT 70 MG Benefit Exclusion Non Essential Drug Exclusion; QL

BONIVA ORAL TABLET 150 MG EX Formulary Exclusion; QL

FOSAMAX ORAL TABLET 70 MG EX Formulary Exclusion; QL

FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70-5600 MG-UNIT Benefit Exclusion Non Essential Drug Exclusion; QL

ibandronate sodium intravenous solution 3 mg/3ml

Tier 1

ibandronate sodium oral tablet 150 mg Tier 1 QL

pamidronate disodium intravenous solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml


RECLAST INTRAVENOUS SOLUTION 5 MG/100ML Tier 4 PA; Specialty; QL

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg

Tier 1 QL

risedronate sodium oral tablet delayed release 35 mg

Tier 1 QL

zoledronic acid intravenous concentrate 4 mg/5ml Tier 4 PA; Specialty

zoledronic acid solution 4 mg/100ml intravenous4 mg/100ml


zoledronic acid solution 5 mg/100ml intravenous5 mg/100ml


*Calcimimetic Agents***cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg Tier 1 QL

PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5 MG/0.5ML, 5 MG/ML EX Medical Only Exclusion

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG EX Formulary Exclusion; QL

*Calcitonins***calcitonin (salmon) injection solution 200 unit/ml Tier 1 QL

calcitonin (salmon) nasal solution 200 unit/act Tier 1 QL

MIACALCIN INJECTION SOLUTION 200 UNIT/ML EX Formulary Exclusion; QL

*Carnitine Replenisher - Agents***CARNITOR INTRAVENOUS SOLUTION200 MG/ML Tier 3

CARNITOR ORAL SOLUTION 1 GM/10ML EX Formulary Exclusion

CARNITOR ORAL TABLET 330 MG EX Formulary Exclusion

CARNITOR SF ORAL SOLUTION 1 GM/10ML EX Formulary Exclusion

levocarnitine injection solution 500 mg/ml EX Non FDA Exclusion

254

Drug Name Drug Tier Noteslevocarnitine oral solution 1 gm/10ml Tier 1

levocarnitine oral tablet 330 mg Tier 1

levocarnitine sf oral solution 1 gm/10ml Tier 1

*Corticotropin***ACTHAR INJECTION GEL 80 UNIT/ML Tier 4 PA; Specialty

CORTROPHIN INJECTION GEL 80 UNIT/ML EX Insufficient Evidence

*Cortisol Synthesis Inhibitors***ISTURISA ORAL TABLET 1 MG, 10 MG, 5 MG Tier 4 PA; Specialty; QL

RECORLEV ORAL TABLET 150 MG EX New to Market Exclusion; Specialty

*Dopamine Receptor Agonists***cabergoline oral tablet 0.5 mg Tier 1

*Fabry Disease - Agents***FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG, 5 MG Tier 4 PA; Specialty; QL

GALAFOLD ORAL CAPSULE 123 MG Tier 4 PA; Specialty; QL

*Gaa Deficiency Treatment - Agents***LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG Tier 4 PA; Specialty

NEXVIAZYME INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX


*Gnrh/Lhrh Antagonists***CETROTIDE SUBCUTANEOUS KIT 0.25 MG EX


FYREMADEL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 250 MCG/0.5ML


ganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous 250 mcg/0.5ml

EX PA; Specialty; Formulary Exclusion


Tier 4 PA



ORILISSA ORAL TABLET 150 MG, 200 MG Tier 2 PA; QL

*Growth Hormone Receptor Antagonists***SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG


255


*Growth Hormone Releasing Hormones (Ghrh)***EGRIFTA SV SUBCUTANEOUS SOLUTION RECONSTITUTED 2 MG Tier 3 QL

*Growth Hormones***GENOTROPIN MINIQUICK SUBCUTANEOUS PREFILLED SYRINGE0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG

EX PA; ST; Specialty; Formulary Exclusion

GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG, 5 MG EX

PA; ST; Specialty; Formulary Exclusion

HUMATROPE INJECTION CARTRIDGE 12 MG, 24 MG, 6 MG EX


HUMATROPE INJECTION SOLUTION RECONSTITUTED 5 MG EX


NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

Tier 4 PA; ST; Specialty

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/2ML






OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE 10 MG/1.5ML, 5 MG/1.5ML


OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED 5.8 MG EX


SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 MG EX


SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 MG EX


SEROSTIM SOLUTION RECONSTITUTED 4 MG SUBCUTANEOUS 4 MG EX Formulary Exclusion



256

Drug Name Drug Tier NotesSEROSTIM SOLUTION RECONSTITUTED 6 MG SUBCUTANEOUS 6 MG EX ST; Formulary Exclusion

SKYTROFA SUBCUTANEOUS CARTRIDGE 11 MG, 13.3 MG, 3 MG, 3.6 MG, 4.3 MG, 5.2 MG, 6.3 MG, 7.6 MG, 9.1 MG

Tier 4 PA; ST; Specialty

ZOMACTON (FOR ZOMA-JET 10) SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG


ZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 5 MG EX


ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 8.8 MG EX


*Hereditary Orotic Aciduria Treatment - Agents**XURIDEN ORAL PACKET 2 GM Tier 4 PA; Specialty

*Hereditary Tyrosinemia Type 1 (Ht-1) Treatment - Agents***nitisinone oral capsule 10 mg, 2 mg, 5 mg Tier 4 PA; Specialty

NITYR ORAL TABLET 10 MG, 2 MG, 5 MG Tier 4 PA; Specialty

ORFADIN CAPSULE 10 MG ORAL 10 MG EX PA; Specialty; Formulary Exclusion


ORFADIN CAPSULE 20 MG ORAL 20 MG Tier 4 PA; Specialty


ORFADIN ORAL SUSPENSION 4 MG/ML Tier 4 PA; Specialty

*Homocystinuria Treatment - Agents***betaine powder oral EX PA; Non FDA Exclusion

betaine powder oral Tier 1 PA

CYSTADANE ORAL POWDER Tier 2 PA

*Hyperammonemia Treatment - Agents***CARBAGLU ORAL TABLET SOLUBLE 200 MG Tier 4 PA; Specialty

carglumic acid oral tablet soluble 200 mg Tier 4 PA; Specialty

*Hyperparathyroid Treatment - Vitamin D Analogs***calcitriol intravenous solution 1 mcg/ml EX Medical Only Exclusion

257

Drug Name Drug Tier Notescalcitriol oral capsule 0.25 mcg, 0.5 mcg Tier 1

calcitriol oral solution 1 mcg/ml Tier 1

doxercalciferol intravenous solution 4 mcg/2ml EX Medical Only Exclusion

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

Tier 1

HECTOROL INTRAVENOUS SOLUTION 4 MCG/2ML EX Medical Only Exclusion

paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml


paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg Tier 1

RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 MCG Tier 3

ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG EX Formulary Exclusion

ROCALTROL ORAL SOLUTION 1 MCG/ML EX Formulary Exclusion

ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML EX Medical Only Exclusion

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG EX Formulary Exclusion

*Hypophosphatasia (Hpp) Agents***STRENSIQ SUBCUTANEOUS SOLUTION18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML


*Insulin-Like Growth Factor-1 Receptor Inhibitors(Igf-1R)***TEPEZZA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

*Insulin-Like Growth Factors (Somatomedins)***INCRELEX SUBCUTANEOUS SOLUTION40 MG/4ML Tier 4 PA; ST; Specialty; QL

*Leptin Analogues***MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 11.3 MG Tier 4 PA; Specialty

*Lhrh/Gnrh Agonist Analog Combinations***LUPANETA PACK COMBINATION KIT11.25 & 5 MG, 3.75 & 5 MG Tier 4 PA; Specialty; QL

258


*Lhrh/Gnrh Agonist Analog Pituitary Suppressants***FENSOLVI (6 MONTH) SUBCUTANEOUS KIT 45 MG EX


LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG


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


SUPPRELIN LA SUBCUTANEOUS KIT 50 MG Tier 4 PA; Specialty; QL

SYNAREL NASAL SOLUTION 2 MG/ML Tier 4 PA; Specialty

TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 22.5 MG


*Lysosomal Acid Lipase (Lal) Deficiency - Agents***KANUMA INTRAVENOUS SOLUTION 20 MG/10ML EX Medical Only Exclusion

*Molybdenum Cofactor Deficiency (Mocd) - Agents***NULIBRY INTRAVENOUS SOLUTION RECONSTITUTED 9.5 MG Tier 4 PA; Specialty

*Mucopolysaccharidosis I (Mps I) - Agents***ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML EX Medical Only Exclusion

*Mucopolysaccharidosis Ii (Mps Ii) - Agents***ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML Tier 4 PA; Specialty; QL

*Mucopolysaccharidosis Iv (Mps Iv) - Agents***VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML EX Medical Only Exclusion

*Mucopolysaccharidosis Vi (Mps Vi) - Agents***NAGLAZYME INTRAVENOUS SOLUTION1 MG/ML EX Medical Only Exclusion

259


*Mucopolysaccharidosis Vii (Mps Vii) - Agents***MEPSEVII INTRAVENOUS SOLUTION 10 MG/5ML EX Medical Only Exclusion

*Natriuretic Peptides***VOXZOGO SUBCUTANEOUS SOLUTION RECONSTITUTED 0.4 MG, 0.56 MG, 1.2 MG Tier 4 PA; Specialty

*Non-Steroidal Mineralocorticoid Receptor Antagonists***KERENDIA ORAL TABLET 10 MG, 20 MG EX PA; Formulary Exclusion; QL

*Ovulation Stimulants-Gonadotropins***chorionic gonadotropin intramuscular solution reconstituted 10000 unit


FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300 UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML


GONAL-F INJECTION SOLUTION RECONSTITUTED 1050 UNIT, 450 UNIT EX


GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 UNIT/1.5ML


GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT EX


MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 75 UNIT Tier 4 PA; Specialty

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 10000 UNIT, 5000 UNIT Tier 4 PA; Specialty

OVIDREL SUBCUTANEOUS INJECTABLE250 MCG/0.5ML EX


PREGNYL INTRAMUSCULAR SOLUTION RECONSTITUTED 10000 UNIT Tier 4 PA; Specialty

*Ovulation Stimulants-Synthetic***clomiphene citrate oral tablet 50 mg Benefit Exclusion

clomiphene citrate powder Benefit Exclusion

*Parathyroid Hormone And Derivatives***FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 600 MCG/2.4ML Tier 4 PA; ST; Specialty; QL

NATPARA SUBCUTANEOUS CARTRIDGE100 MCG, 25 MCG, 50 MCG, 75 MCG Tier 4 PA; Specialty; QL

260

Drug Name Drug Tier Notesteriparatide (recombinant) subcutaneous solution pen-injector 620 mcg/2.48ml

EX PA; ST; Specialty; Formulary Exclusion; QL

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML Tier 4 PA; ST; Specialty; QL

*Phenylketonuria Treatment - Agents***

KUVAN ORAL PACKET 100 MG, 500 MG EX PA; Specialty; Formulary Exclusion

KUVAN ORAL TABLET 100 MG EX PA; Specialty; Formulary Exclusion

PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML


sapropterin dihydrochloride oral packet 100 mg, 500 mg


sapropterin dihydrochloride oral tablet 100 mg Tier 4 PA; Specialty

*Rank Ligand (Rankl) Inhibitors***PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 60 MG/ML Tier 4 PA; Specialty; QL

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML Tier 4 PA; Specialty; QL

*Sclerostin Inhibitors***EVENITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 105 MG/1.17ML EX


*Selective Estrogen Receptor Modulators (Serms)***EVISTA ORAL TABLET 60 MG EX Formulary Exclusion

OSPHENA ORAL TABLET 60 MG Tier 3

raloxifene hcl oral tablet 60 mg Tier 5

*Selective Vasopressin V2-Receptor Antagonists***JYNARQUE ORAL TABLET 15 MG, 30 MG Tier 4 PA; Specialty; QL

JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 30 & 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG


SAMSCA TABLET 15 MG ORAL 15 MG Tier 4 PA; Specialty; QL

SAMSCA TABLET 30 MG ORAL 30 MG EX PA; Specialty; Formulary Exclusion; QL

tolvaptan tablet 15 mg oral 15 mg Tier 4 PA; Specialty; QL

tolvaptan tablet 30 mg oral 30 mg Tier 4 PA; QL

tolvaptan tablet 30 mg oral 30 mg Tier 4 PA; Specialty; QL

261


*Somatostatic Agents***BYNFEZIA PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 2500 MCG/ML (2.8 ML)


lanreotide acetate subcutaneous solution 120 mg/0.5ml


MYCAPSSA ORAL CAPSULE DELAYED RELEASE 20 MG Tier 4 PA; Specialty; QL

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml


octreotide acetate subcutaneous solution prefilled syringe 100 mcg/ml, 50 mcg/ml, 500 mcg/ml


SANDOSTATIN INJECTION SOLUTION100 MCG/ML, 50 MCG/ML, 500 MCG/ML EX


SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG


SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 20 MG, 30 MG, 40 MG, 60 MG


SIGNIFOR SUBCUTANEOUS SOLUTION0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML Tier 4 PA; Specialty; QL

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML


*Tripeptidyl Peptidase 1 Deficiency Treatment - Agents***BRINEURA KIT 2 X 150 MG/5ML EX Medical Only Exclusion

*Urea Cycle Disorder - Agents***AMMONUL INTRAVENOUS SOLUTION10-10 % EX Medical Only Exclusion

BUPHENYL ORAL POWDER 3 GM/TSP EX PA; Specialty; Formulary Exclusion

BUPHENYL ORAL TABLET 500 MG EX PA; Specialty; Formulary Exclusion

citrulline easy oral tablet extended release 1 gm EX Non FDA Exclusion

RAVICTI ORAL LIQUID 1.1 GM/ML Tier 4 PA; Specialty

sod benz-sod phenylacet intravenous solution 10-10 %


sodium phenylbutyrate oral powder 3 gm/tsp Tier 4 PA; Specialty

sodium phenylbutyrate oral tablet 500 mg Tier 4 PA; Specialty

262


*V1a/V2-Arginine Vasopressin (Avp) Receptor Antagonists***VAPRISOL INTRAVENOUS SOLUTION 20-5 MG/100ML-% Tier 3

*Vasopressin***DDAVP INJECTION SOLUTION 4 MCG/ML EX Formulary Exclusion

DDAVP NASAL SOLUTION 0.01 % EX Formulary Exclusion

DDAVP ORAL TABLET 0.1 MG, 0.2 MG EX Formulary Exclusion

DDAVP PF INJECTION SOLUTION 4 MCG/ML EX Formulary Exclusion

DDAVP RHINAL TUBE NASAL SOLUTION0.01 % Tier 3

desmopressin ace spray refrig nasal solution 0.01 %

Tier 1

desmopressin acetate injection solution 4 mcg/ml Tier 1

desmopressin acetate nasal solution 1.5 mg/ml EX PA; Non FDA Exclusion

desmopressin acetate oral tablet 0.1 mg, 0.2 mg Tier 1

desmopressin acetate pf injection solution 4 mcg/ml

Tier 1

desmopressin acetate spray nasal solution 0.01 % Tier 1

NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 55.3 MCG Tier 3

NOCTIVA NASAL EMULSION 1.66 MCG/0.1ML Tier 3

STIMATE NASAL SOLUTION 1.5 MG/ML Tier 4 PA; Specialty

vasopressin intravenous solution 20 unit/ml Tier 1

vasopressin-dextrose intravenous solution 20-5 ut/100ml-%, 50-5 ut/50ml-%


vasopressin-dextrose intravenous solution prefilled syringe 5-5 unit/5ml-%


VASOSTRICT INTRAVENOUS SOLUTION0.2 UNIT/ML, 0.4 UNIT/ML, 20 UNIT/ML Tier 3

*X-Linked Hypophosphatemia (Xlh) Treatment - Agents***CRYSVITA SUBCUTANEOUS SOLUTION10 MG/ML, 20 MG/ML, 30 MG/ML Tier 4 PA; Specialty; QL

*Estrogens*

*Estrogen & Androgen***COVARYX HS ORAL TABLET 0.625-1.25 MG EX Formulary Exclusion

263

Drug Name Drug Tier NotesCOVARYX ORAL TABLET 1.25-2.5 MG EX Formulary Exclusion

EEMT HS ORAL TABLET 0.625-1.25 MG EX Formulary Exclusion

EEMT ORAL TABLET 1.25-2.5 MG EX Formulary Exclusion

est estrogens-methyltest ds oral tablet 1.25-2.5 mg


est estrogens-methyltest hs oral tablet 0.625-1.25 mg


est estrogens-methyltest oral tablet 0.625-1.25 mg, 1.25-2.5 mg


*Estrogen & Progestin***ACTIVELLA ORAL TABLET 1-0.5 MG EX Formulary Exclusion

AMABELZ ORAL TABLET 0.5-0.1 MG, 1-0.5 MG Tier 1

ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG Tier 3

BIJUVA ORAL CAPSULE 1-100 MG EX Formulary Exclusion

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/DAY Tier 2

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

Tier 3

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

Tier 1

FEMHRT ORAL TABLET 0.5-2.5 MG-MCG EX Formulary Exclusion

FYAVOLV ORAL TABLET 0.5-2.5 MG-MCG, 1-5 MG-MCG Tier 1

JINTELI ORAL TABLET 1-5 MG-MCG Tier 1

LOPREEZA ORAL TABLET 1-0.5 MG Tier 1

MIMVEY ORAL TABLET 1-0.5 MG Tier 1

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

Tier 1

PREFEST ORAL TABLET 1/1-0.09 MG (15/15) Tier 3

PREMPHASE ORAL TABLET 0.625-5 MG Tier 2

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG Tier 2

*Estrogen-Progestin-Gnrh Antagonist***MYFEMBREE ORAL TABLET 40-1-0.5 MG Tier 2 PA

ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 MG Tier 2 PA

264


*Estrogens***ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

Tier 3

CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR


DELESTROGEN OIL 10 MG/ML INTRAMUSCULAR 10 MG/ML Tier 3

DELESTROGEN OIL 20 MG/ML INTRAMUSCULAR 20 MG/ML EX Formulary Exclusion

DELESTROGEN OIL 40 MG/ML INTRAMUSCULAR 40 MG/ML EX Formulary Exclusion

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML Tier 3

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM

Tier 2

DOTTI TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

Tier 1

ec-rx estradiol transdermal cream 0.4 %, 0.6 % EX Non FDA Exclusion

ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) Tier 3

ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG EX Formulary Exclusion

estradiol implant pellet 6 mg EX Non FDA Exclusion

estradiol oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Tier 1

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Tier 1

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

Tier 1

ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) Tier 2

EVAMIST TRANSDERMAL SOLUTION1.53 MG/SPRAY Tier 3

265

Drug Name Drug Tier NotesLYLLANA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

Tier 1

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG Tier 3

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24HR Tier 3

MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR


PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG EX Medical Only Exclusion

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG Tier 2

VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR


*Estrogen-Selective Estrogen Receptor Modulator Comb***DUAVEE ORAL TABLET 0.45-20 MG Tier 2

*Fluoroquinolones*

*Fluoroquinolones***BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED 300 MG EX Medical Only Exclusion

BAXDELA ORAL TABLET 450 MG Tier 3 QL

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (10%)

Tier 3

CIPRO ORAL TABLET 250 MG, 500 MG EX Formulary Exclusion

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

Tier 1

ciprofloxacin in d5w intravenous solution 200 mg/100ml, 400 mg/200ml


LEVAQUIN ORAL TABLET 500 MG, 750 MG EX Formulary Exclusion

levofloxacin in d5w intravenous solution 250 mg/50ml, 500 mg/100ml, 750 mg/150ml


levofloxacin intravenous solution 25 mg/ml EX Medical Only Exclusion

levofloxacin oral solution 25 mg/ml Tier 1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg Tier 1

266

Drug Name Drug Tier Notesmoxifloxacin hcl in nacl intravenous solution 400 mg/250ml


moxifloxacin hcl intravenous solution 400 mg/250ml


moxifloxacin hcl oral tablet 400 mg Tier 1

ofloxacin oral tablet 300 mg, 400 mg Tier 1

*Gastrointestinal Agents - Misc.*

*5-Ht4 Receptor Agonists***MOTEGRITY TABLET 1 MG ORAL 1 MG EX Formulary Exclusion; QL

MOTEGRITY TABLET 2 MG ORAL 2 MG EX Formulary Exclusion

*Bile Acid Synthesis Disorder Agents***CHOLBAM ORAL CAPSULE 250 MG, 50 MG Tier 4 PA; Specialty

*Cic Agents - Guanylate Cyclase-C (Gc-C) Agonists***TRULANCE ORAL TABLET 3 MG Tier 2

*Farnesoid X Receptor (Fxr) Agonists***OCALIVA ORAL TABLET 10 MG, 5 MG Tier 4 PA; Specialty

*Gallstone Solubilizing Agents***ACTIGALL ORAL CAPSULE 300 MG EX Formulary Exclusion

CHENODAL ORAL TABLET 250 MG Tier 4 PA; Specialty

RELTONE ORAL CAPSULE 200 MG, 400 MG Benefit Exclusion Non Essential Drug Exclusion

URSO 250 ORAL TABLET 250 MG EX Formulary Exclusion

URSO FORTE ORAL TABLET 500 MG EX Formulary Exclusion

ursodiol capsule 200 mg oral 200 mg Benefit Exclusion Non Essential Drug Exclusion

ursodiol capsule 300 mg oral 300 mg EX Formulary Exclusion

ursodiol capsule 300 mg oral 300 mg Tier 1

ursodiol capsule 400 mg oral 400 mg Benefit Exclusion Non Essential Drug Exclusion

ursodiol oral tablet 250 mg, 500 mg Tier 1

URSODIOL+SYRSPEND SF ORAL SUSPENSION 30 MG/ML EX Non FDA Exclusion

*Gastrointestinal Antiallergy Agents***cromolyn sodium oral concentrate 100 mg/5ml Tier 1

GASTROCROM ORAL CONCENTRATE100 MG/5ML EX Formulary Exclusion

267


*Gastrointestinal Chloride Channel Activators***AMITIZA ORAL CAPSULE 24 MCG, 8 MCG EX Formulary Exclusion; QL

lubiprostone oral capsule 24 mcg, 8 mcg EX Formulary Exclusion; QL

*Gastrointestinal Stimulants***dexpanthenol injection solution 250 mg/ml EX Non FDA Exclusion

GIMOTI NASAL SOLUTION 15 MG/ACT Benefit Exclusion Non Essential Drug Exclusion

metoclopramide hcl injection solution 5 mg/ml EX Medical Only Exclusion

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

Tier 1

metoclopramide hcl oral tablet 10 mg, 5 mg Tier 1

metoclopramide hcl oral tablet dispersible 10 mg, 5 mg

Tier 3

REGLAN ORAL TABLET 10 MG, 5 MG EX Formulary Exclusion

*Glucagon-Like Peptide-2 (Glp-2) Analogs***GATTEX SUBCUTANEOUS KIT 5 MG Tier 4 PA; Specialty; QL

*Ibs Agent - 5-Ht4 Receptor Partial Agonists***ZELNORM ORAL TABLET 6 MG EX PA; Formulary Exclusion

*Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists***LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG Tier 2 QL

*Ibs Agent - Mu-Opioid Receptor Agonists***VIBERZI ORAL TABLET 100 MG, 75 MG Tier 2 PA; QL

*Ibs Agent - Selective 5-Ht3 Receptor Antagonists***alosetron hcl oral tablet 0.5 mg, 1 mg Tier 1

LOTRONEX ORAL TABLET 0.5 MG, 1 MG EX Formulary Exclusion

*Ibs Agent - Sodium/Hydrogen Exchanger 3 (Nhe3) Inhibitor***IBSRELA ORAL TABLET 50 MG EX New to Market Exclusion

*Ileal Bile Acid Transporter (Ibat) Inhibitors***BYLVAY (PELLETS) ORAL CAPSULE SPRINKLE 200 MCG, 600 MCG Tier 4 PA; Specialty; QL

268

Drug Name Drug Tier NotesBYLVAY ORAL CAPSULE 1200 MCG, 400 MCG Tier 4 PA; Specialty; QL

LIVMARLI ORAL SOLUTION 9.5 MG/ML Tier 4 PA; Specialty

*Inflammatory Bowel Agents***APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM EX Formulary Exclusion

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG EX Formulary Exclusion

AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 500 MG EX Formulary Exclusion

AZULFIDINE ORAL TABLET 500 MG EX Formulary Exclusion

balsalazide disodium oral capsule 750 mg Tier 1

CANASA RECTAL SUPPOSITORY 1000 MG EX Formulary Exclusion

COLAZAL ORAL CAPSULE 750 MG EX Formulary Exclusion

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG EX Formulary Exclusion

DIPENTUM ORAL CAPSULE 250 MG Tier 3

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM EX Formulary Exclusion

mesalamine er oral capsule extended release 24 hour 0.375 gm

Tier 1

mesalamine er oral capsule extended release 500 mg

Tier 1

mesalamine oral capsule delayed release 400 mg Tier 1

mesalamine oral tablet delayed release 1.2 gm, 800 mg

Tier 1

mesalamine rectal enema 4 gm Tier 1

mesalamine rectal suppository 1000 mg Tier 1

mesalamine-cleanser rectal kit 4 gm Tier 1

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG Tier 3

ROWASA RECTAL KIT 4 GM Tier 3

SFROWASA RECTAL ENEMA 4 GM/60ML Tier 3

sulfasalazine oral tablet 500 mg Tier 1

sulfasalazine oral tablet delayed release 500 mg Tier 1

*Integrin Receptor Antagonists***ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 300 MG EX


269


*Interleukin Antagonists***STELARA INTRAVENOUS SOLUTION 130 MG/26ML Tier 4

PA; ST; Specialty; Quantity Limit Criteria; QL

*Intestinal Acidifiers***enulose oral solution 10 gm/15ml Tier 1

generlac oral solution 10 gm/15ml Tier 1

lactulose encephalopathy oral solution 10 gm/15ml

Tier 1

*Peripheral Opioid Receptor Antagonists***MOVANTIK ORAL TABLET 12.5 MG, 25 MG Tier 2

RELISTOR ORAL TABLET 150 MG EX PA; Formulary Exclusion

RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML EX PA; Formulary Exclusion

SYMPROIC ORAL TABLET 0.2 MG Tier 2

*Phosphate Binder Agents***AURYXIA ORAL TABLET 1 GM 210 MG(FE) Tier 3

calcium acetate (phos binder) oral capsule 667 mg

Tier 1

calcium acetate (phos binder) oral tablet 667 mg Tier 1

calcium acetate oral tablet 667 mg Tier 1

FOSRENOL ORAL PACKET 1000 MG, 750 MG Tier 3

FOSRENOL ORAL TABLET CHEWABLE1000 MG, 500 MG, 750 MG EX Formulary Exclusion

lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg

Tier 1

PHOSLYRA ORAL SOLUTION 667 MG/5ML Tier 3

RENAGEL ORAL TABLET 800 MG EX Formulary Exclusion

RENVELA ORAL PACKET 0.8 GM, 2.4 GM EX Formulary Exclusion

RENVELA ORAL TABLET 800 MG EX Formulary Exclusion

sevelamer carbonate oral packet 0.8 gm, 2.4 gm Tier 1

sevelamer carbonate oral tablet 800 mg Tier 1

sevelamer hcl oral tablet 400 mg, 800 mg Tier 1

VELPHORO ORAL TABLET CHEWABLE500 MG Tier 2

270


*Tryptophan Hydroxylase Inhibitors***XERMELO ORAL TABLET 250 MG Tier 4 PA; Specialty

*Tumor Necrosis Factor Alpha Blockers***AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG Tier 4 PA; Specialty; QL

CIMZIA PREFILLED SUBCUTANEOUS PREFILLED SYRINGE KIT 2 X 200 MG/ML Tier 4 PA; ST; Specialty; QL

CIMZIA STARTER KIT SUBCUTANEOUS PREFILLED SYRINGE KIT 6 X 200 MG/ML Tier 4 PA; ST; Specialty; QL

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG EX PA; ST; Specialty; Formulary Exclusion; QL

INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX


infliximab intravenous solution reconstituted 100 mg


REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX


RENFLEXIS SOLUTION RECONSTITUTED 100 MG INTRAVENOUS100 MG

Tier 4 PA

RENFLEXIS SOLUTION RECONSTITUTED 100 MG INTRAVENOUS100 MG


*General Anesthetics*

*Anesthetics - Misc.***AMIDATE INTRAVENOUS SOLUTION 2 MG/ML EX Medical Only Exclusion

anesthesia s/i-40a intravenous kit 200 mg/20ml EX Non FDA Exclusion; Medical Only Exclusion

anesthesia s/i-40h intravenous kit 200 mg/20ml EX Non FDA Exclusion; Medical Only Exclusion

anesthesia s/i-40s intravenous kit 200 mg/20ml EX Non FDA Exclusion; Medical Only Exclusion

DIPRIVAN INTRAVENOUS EMULSION 100 MG/10ML, 1000 MG/100ML, 200 MG/20ML, 500 MG/50ML


etomidate intravenous solution 2 mg/ml EX Medical Only Exclusion

fresenius propoven intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 2000 mg/100ml, 500 mg/50ml


271

Drug Name Drug Tier NotesKETALAR INJECTION SOLUTION 10 MG/ML, 100 MG/ML, 50 MG/ML EX Medical Only Exclusion

ketamine hcl intravenous solution 100 mg/100ml EX Non FDA Exclusion

ketamine hcl solution 0.6 mg/ml injection 0.6 mg/ml


ketamine hcl solution 1 mg/ml injection 1 mg/ml EX Non FDA Exclusion

ketamine hcl solution 10 mg/ml injection 10 mg/ml








ketamine hcl solution prefilled syringe 100 mg/2ml injection 100 mg/2ml


ketamine hcl solution prefilled syringe 100 mg/2ml intravenous 100 mg/2ml












ketamine hcl solution prefilled syringe 50 mg/ml injection 50 mg/ml


ketamine hcl solution prefilled syringe 50 mg/ml intravenous 50 mg/ml


ketamine hcl sublingual troche 100 mg EX Non FDA Exclusion

ketamine hcl-sodium chloride injection solution prefilled syringe 50-0.9 mg/5ml-%


ketamine hcl-sodium chloride solution prefilled syringe 10-0.9 mg/ml-% intravenous 10-0.9 mg/ml-%


ketamine hcl-sodium chloride solution prefilled syringe 100-0.9 mg/10ml-% intravenous 100-0.9 mg/10ml-%


ketamine hcl-sodium chloride solution prefilled syringe 20-0.9 mg/2ml-% intravenous 20-0.9 mg/2ml-%


272

Drug Name Drug Tier Notesketamine hcl-sodium chloride solution prefilled syringe 50-0.9 mg/5ml-% intravenous 50-0.9 mg/5ml-%


propofol intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 mg/50ml


propofol-lipuro intravenous emulsion 1000 mg/100ml


*Barbiturate Anesthetics***BREVITAL SODIUM INJECTION SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

methohexital sodium intravenous solution prefilled syringe 100 mg/10ml


*Volatile Anesthetics***desflurane inhalation solution EX Formulary Exclusion

FORANE INHALATION SOLUTION EX Formulary Exclusion

isoflurane inhalation solution EX Formulary Exclusion

sevoflurane inhalation solution EX Formulary Exclusion

SUPRANE INHALATION SOLUTION EX Formulary Exclusion

TERRELL INHALATION SOLUTION EX Formulary Exclusion

ULTANE INHALATION SOLUTION EX Formulary Exclusion

*Genitourinary Agents - Miscellaneous*

*5-Alpha Reductase Inhibitors***AVODART ORAL CAPSULE 0.5 MG EX Formulary Exclusion

dutasteride oral capsule 0.5 mg Tier 1

finasteride oral tablet 5 mg Tier 1

PROSCAR ORAL TABLET 5 MG EX Formulary Exclusion

*Alpha 1-Adrenoceptor Antagonists***alfuzosin hcl er oral tablet extended release 24 hour 10 mg

Tier 1

CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG Tier 3

FLOMAX ORAL CAPSULE 0.4 MG EX Formulary Exclusion

RAPAFLO ORAL CAPSULE 4 MG, 8 MG EX Formulary Exclusion

silodosin oral capsule 4 mg, 8 mg Tier 1

tamsulosin hcl oral capsule 0.4 mg Tier 1

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG EX Formulary Exclusion

273


*Anti-Infective Genitourinary Irrigants***neomycin-polymyxin b gu irrigation solution 40-200000


*Citrates***cytra k crystals oral packet 3300-1002 mg EX Formulary Exclusion

cytra-2 oral solution 500-334 mg/5ml Tier 1

ORACIT ORAL SOLUTION 490-640 MG/5ML EX Formulary Exclusion

pot & sod cit-cit ac solution 550-500-334 mg/5ml oral 550-500-334 mg/5ml

Tier 1

pot & sod cit-cit ac solution 550-500-334 mg/5ml oral 550-500-334 mg/5ml


potassium citrate er oral tablet extended release10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)

Tier 1

potassium citrate-citric acid solution 1100-334 mg/5ml oral 1100-334 mg/5ml


potassium citrate-citric acid solution 1100-334 mg/5ml oral 1100-334 mg/5ml


sod citrate-citric acid oral solution 500-334 mg/5ml

Tier 1

tricitrates oral solution 550-500-334 mg/5ml EX Formulary Exclusion

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ (1080 MG) EX Formulary Exclusion



*Cystinosis Agents***CYSTAGON ORAL CAPSULE 150 MG, 50 MG Tier 4 PA; Specialty

PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 MG Tier 4 PA; Specialty

PROCYSBI ORAL PACKET 300 MG, 75 MG Tier 4 PA; Specialty

*Genitourinary Irrigants***acetic acid irrigation solution 0.25 % EX Formulary Exclusion

ARGYLE STERILE SALINE IRRIGATION SOLUTION 0.9 % EX Non FDA Exclusion

CURITY STERILE SALINE IRRIGATION SOLUTION 0.9 % EX Non FDA Exclusion

glycine irrigation solution 1.5 % EX Formulary Exclusion

274

Drug Name Drug Tier Notesglycine urologic irrigation solution 1.5 % EX Formulary Exclusion

RENACIDIN IRRIGATION SOLUTION EX Formulary Exclusion

sodium chloride solution 0.9 % irrigation 0.9 % EX Non FDA Exclusion

sodium chloride solution 0.9 % irrigation 0.9 % EX Formulary Exclusion

sorbitol irrigation solution 3 % EX Formulary Exclusion

sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml


*Interstitial Cystitis Agents***ELMIRON ORAL CAPSULE 100 MG Tier 3

pentosan polysulfate sodium oral capsule delayed release 150 mg, 200 mg


RIMSO-50 INTRAVESICAL SOLUTION 50 % EX Formulary Exclusion

*Phosphates***K-PHOS NO 2 ORAL TABLET 305-700 MG Tier 2

*Prostatic Hypertrophy Agent Combinations***dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg

Tier 1

JALYN ORAL CAPSULE 0.5-0.4 MG EX Formulary Exclusion

*Small Interfering Ribonucleic Acid Agents (Sirna)***OXLUMO SUBCUTANEOUS SOLUTION94.5 MG/0.5ML EX Medical Only Exclusion

*Urinary Analgesics***PHENAZO ORAL TABLET 200 MG Tier 1

phenazopyridine hcl oral tablet 100 mg, 200 mg Tier 1

PYRIDIUM ORAL TABLET 100 MG, 200 MG Tier 3

*Urinary Stone Agents***LITHOSTAT ORAL TABLET 250 MG Tier 3

THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG, 300 MG Tier 4 PA; Specialty

THIOLA ORAL TABLET 100 MG EX PA; Formulary Exclusion

tiopronin oral tablet 100 mg Tier 4 PA; Specialty

*Vesicoureteral Reflux (Vur) Agent Combinations***DEFLUX INJECTION PREFILLED SYRINGE 50-15 MG/ML EX Medical Only Exclusion

275


*Gout Agents*

*Gout Agent Combinations***colchicine-probenecid oral tablet 0.5-500 mg Tier 1

*Gout Agents***allopurinol oral tablet 100 mg, 300 mg Tier 1

allopurinol sodium intravenous solution reconstituted 500 mg


ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

colchicine capsule 0.6 mg oral 0.6 mg Tier 3

colchicine capsule 0.6 mg oral 0.6 mg Tier 1

colchicine oral tablet 0.6 mg Tier 1

COLCRYS ORAL TABLET 0.6 MG EX Formulary Exclusion

febuxostat oral tablet 40 mg, 80 mg Tier 1

GLOPERBA ORAL SOLUTION 0.6 MG/5ML Benefit Exclusion

KRYSTEXXA INTRAVENOUS SOLUTION8 MG/ML EX Medical Only Exclusion; QL

MITIGARE ORAL CAPSULE 0.6 MG Tier 3

ULORIC ORAL TABLET 40 MG, 80 MG EX Formulary Exclusion

ZYLOPRIM ORAL TABLET 100 MG, 300 MG EX Formulary Exclusion

*Uricosurics***probenecid oral tablet 500 mg Tier 1

*Hematological Agents - Misc.*

*Aminolevulinate Synthase 1-Directed Sirna***GIVLAARI SUBCUTANEOUS SOLUTION189 MG/ML EX Medical Only Exclusion

*Antihemophilic Products - Monoclonal Antibodies***HEMLIBRA SUBCUTANEOUS SOLUTION105 MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML


*Antihemophilic Products***ADVATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Benefit Exclusion

ADVATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Tier 4 PA; Specialty; QL

ADVATE SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS 1500 UNIT Benefit Exclusion

276

Drug Name Drug Tier NotesADVATE SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS 1500 UNIT Tier 4 PA; Specialty; QL











adynovate intravenous solution reconstituted1000 unit, 1500 unit, 2000 unit, 250 unit, 3000 unit, 500 unit, 750 unit


AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT


ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT


ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT


ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT


ALPROLIX SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Tier 4 PA; Specialty; QL

ALPROLIX SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Benefit Exclusion


277

Drug Name Drug Tier NotesALPROLIX SOLUTION RECONSTITUTED 2000 UNIT INTRAVENOUS 2000 UNIT Benefit Exclusion









BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT Tier 4 PA; Specialty; QL

COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT Tier 4 PA; Specialty; QL

CORIFACT INTRAVENOUS KIT 1000-1600 UNIT Tier 4 PA; Specialty; QL

ELOCTATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Tier 4 PA; Specialty; QL

ELOCTATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Benefit Exclusion









278

Drug Name Drug Tier NotesELOCTATE SOLUTION RECONSTITUTED 4000 UNIT INTRAVENOUS 4000 UNIT Tier 4 PA; Specialty; QL









ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT


FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT


FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED Benefit Exclusion

HELIXATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

Benefit Exclusion

HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT


HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT


IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3500 UNIT, 500 UNIT


IXINITY SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Tier 4 PA; Specialty

IXINITY SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Benefit Exclusion

IXINITY SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Tier 4 PA; Specialty; QL

279

Drug Name Drug Tier NotesIXINITY SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS 1500 UNIT Tier 4 PA; Specialty

IXINITY SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS 1500 UNIT Benefit Exclusion










JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT


KCENTRA INTRAVENOUS KIT 1000 UNIT, 500 UNIT Benefit Exclusion

KOATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Benefit Exclusion

PA; Non FDA Exclusion; Specialty; QL

KOATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Tier 4 PA; Specialty; QL







KOATE-DVI SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT


280

Drug Name Drug Tier NotesKOATE-DVI SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS 250 UNIT

Benefit Exclusion

KOATE-DVI SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS 500 UNIT


KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT


KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT


MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT Tier 4 PA; Specialty; QL

NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT


NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG


NUWIQ KIT 1000 UNIT INTRAVENOUS1000 UNIT Tier 4 PA; Specialty; QL

NUWIQ KIT 1500 UNIT INTRAVENOUS1500 UNIT Tier 4 PA; Specialty


NUWIQ KIT 250 UNIT INTRAVENOUS 250 UNIT Tier 4 PA; Specialty; QL




NUWIQ KIT 500 UNIT INTRAVENOUS 500 UNIT Tier 4 PA; Specialty; QL

NUWIQ SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT Tier 4 PA; Specialty; QL

NUWIQ SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS 1500 UNIT Tier 4 PA; Specialty



281

Drug Name Drug Tier NotesNUWIQ SOLUTION RECONSTITUTED 2500 UNIT INTRAVENOUS 2500 UNIT Tier 4 PA; Specialty; QL




obizur solution reconstituted 500 unit intravenous500 unit

Benefit Exclusion

obizur solution reconstituted 500 unit intravenous500 unit


PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT


REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT


RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT


RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED Benefit Exclusion

rixubis intravenous solution reconstituted 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit


SEVENFACT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 5 MG Tier 4 PA; Specialty; QL

TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 2000-3125 UNIT Tier 4 PA; Specialty; QL

VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT Tier 4 PA; Specialty; QL

WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT Tier 4 PA; Specialty; QL

XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT Tier 4 PA; Specialty; QL

XYNTHA SOLOFUSE INTRAVENOUS KIT1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT


*Anti-Von Willebrand Factor Agents***CABLIVI INJECTION KIT 11 MG Tier 4 PA; Specialty

282


*Bradykinin B2 Receptor Antagonists***FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML Benefit Exclusion

PA; Specialty; Quantity Limit Criteria

icatibant acetate subcutaneous solution 30 mg/3ml

Benefit Exclusion PA; Specialty

SAJAZIR SUBCUTANEOUS SOLUTION 30 MG/3ML Benefit Exclusion PA; Specialty

*C1 Inhibitors***BERINERT INTRAVENOUS KIT 500 UNIT Benefit Exclusion Specialty

CINRYZE SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS 500 UNIT Benefit Exclusion

CINRYZE SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS 500 UNIT Benefit Exclusion Specialty

HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT Tier 4 PA; Specialty

RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT Benefit Exclusion Specialty

*Complement Inhibitors***EMPAVELI SUBCUTANEOUS SOLUTION1080 MG/20ML Tier 4 PA; Specialty; QL

ENJAYMO INTRAVENOUS SOLUTION1100 MG/22ML EX Medical Only Exclusion

SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML EX Medical Only Exclusion

TAVNEOS ORAL CAPSULE 10 MG Tier 4 PA; Specialty

ULTOMIRIS INTRAVENOUS SOLUTION1100 MG/11ML, 300 MG/3ML EX Medical Only Exclusion

*Direct-Acting P2y12 Inhibitors***BRILINTA ORAL TABLET 60 MG, 90 MG Tier 2

KENGREAL SOLUTION RECONSTITUTED 50 MG INTRAVENOUS50 MG


KENGREAL SOLUTION RECONSTITUTED 50 MG INTRAVENOUS50 MG


*Glycoprotein Iib/Iiia Receptor Inhibitors***AGGRASTAT INTRAVENOUS CONCENTRATE 3.75 MG/15ML Benefit Exclusion

AGGRASTAT INTRAVENOUS SOLUTION12.5-0.9 MG/250ML-%, 5-0.9 MG/100ML-% Benefit Exclusion

283

Drug Name Drug Tier Noteseptifibatide intravenous solution 20 mg/10ml, 200 mg/100ml, 75 mg/100ml

Benefit Exclusion

INTEGRILIN INTRAVENOUS SOLUTION20 MG/10ML, 200 MG/100ML, 75 MG/100ML Benefit Exclusion

REOPRO INTRAVENOUS SOLUTION 2 MG/ML Benefit Exclusion

*Hematorheologic Agents***pentoxifylline er oral tablet extended release 400 mg

Tier 1

*Hemin***PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG Benefit Exclusion

*Human Protein C***CEPROTIN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT EX Medical Only Exclusion

*Phosphodiesterase Iii Inhibitors***cilostazol oral tablet 100 mg, 50 mg Tier 1

*Plasma Expanders***HESPAN INTRAVENOUS SOLUTION 6-0.9 % Benefit Exclusion

hetastarch-nacl intravenous solution 6-0.9 % Benefit Exclusion

HEXTEND INTRAVENOUS SOLUTION 6 % Benefit Exclusion

LMD IN D5W INTRAVENOUS SOLUTION10-5 % EX Medical Only Exclusion

LMD IN NACL INTRAVENOUS SOLUTION10-0.9 % EX Medical Only Exclusion

VOLUVEN INTRAVENOUS SOLUTION 6-0.9 % Benefit Exclusion

*Plasma Kallikrein Inhibitors - Monoclonal Antibodies***TAKHZYRO SUBCUTANEOUS SOLUTION300 MG/2ML Benefit Exclusion PA; Specialty

TAKHZYRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML Benefit Exclusion PA; Specialty

*Plasma Kallikrein Inhibitors***KALBITOR SUBCUTANEOUS SOLUTION10 MG/ML Tier 4 PA; Specialty

ORLADEYO ORAL CAPSULE 110 MG, 150 MG EX


284


*Plasma Proteins***ALBUKED 25 INTRAVENOUS SOLUTION25 % Benefit Exclusion

ALBUKED 5 INTRAVENOUS SOLUTION 5 % Benefit Exclusion

albumin human intravenous solution 25 %, 5 % Benefit Exclusion

ALBUMINAR-25 INTRAVENOUS SOLUTION 25 % Benefit Exclusion

ALBUMINAR-5 INTRAVENOUS SOLUTION 5 % Benefit Exclusion

ALBUMINEX INTRAVENOUS SOLUTION25 %, 5 % Benefit Exclusion

albumin-zlb intravenous solution 25 %, 5 % Benefit Exclusion

alburx intravenous solution 5 % Benefit Exclusion

ALBUTEIN SOLUTION 25 % INTRAVENOUS 25 % Benefit Exclusion Medical Only Exclusion

ALBUTEIN SOLUTION 25 % INTRAVENOUS 25 % Benefit Exclusion

ALBUTEIN SOLUTION 5 % INTRAVENOUS 5 % Benefit Exclusion

BUMINATE INTRAVENOUS SOLUTION 25 %, 5 % Benefit Exclusion

FLEXBUMIN INTRAVENOUS SOLUTION25 %, 5 % Benefit Exclusion

HUMAN ALBUMIN GRIFOLS INTRAVENOUS SOLUTION 25 % Benefit Exclusion

kedbumin intravenous solution 25 % Benefit Exclusion

OCTAPLAS BLOOD GROUP A INTRAVENOUS SOLUTION Benefit Exclusion

OCTAPLAS BLOOD GROUP AB INTRAVENOUS SOLUTION Benefit Exclusion

OCTAPLAS BLOOD GROUP B INTRAVENOUS SOLUTION Benefit Exclusion

OCTAPLAS BLOOD GROUP O INTRAVENOUS SOLUTION Benefit Exclusion

PLASBUMIN-25 INTRAVENOUS SOLUTION 25 % Benefit Exclusion

PLASBUMIN-5 INTRAVENOUS SOLUTION5 % Benefit Exclusion

PLASMANATE INTRAVENOUS SOLUTION 5 % Benefit Exclusion

RYPLAZIM INTRAVENOUS SOLUTION RECONSTITUTED 68.8 MG Benefit Exclusion PA

285

Drug Name Drug Tier NotesTHROMBATE III INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT

Benefit Exclusion

*Platelet Aggregation Inhibitor Combinations***AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG EX Formulary Exclusion

aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg

Tier 1

aspirin-omeprazole oral tablet delayed release325-40 mg, 81-40 mg

Benefit Exclusion

YOSPRALA ORAL TABLET DELAYED RELEASE 325-40 MG, 81-40 MG Benefit Exclusion

*Platelet Aggregation Inhibitors***dipyridamole oral tablet 25 mg, 50 mg, 75 mg Tier 1

DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 162.5 MG Benefit Exclusion

*Protamine***protamine sulfate intravenous solution 10 mg/ml Benefit Exclusion

*Protease-Activated Receptor-1 (Par-1) Antagonists***ZONTIVITY ORAL TABLET 2.08 MG Tier 3

*Pyruvate Kinase Activators***PYRUKYND ORAL TABLET 20 MG, 5 MG, 50 MG Tier 4 PA; Specialty; QL

PYRUKYND TAPER PACK ORAL TABLET THERAPY PACK 5 MG, 7 X 20 MG & 7 X 5 MG, 7 X 50 MG & 7 X 20 MG


*Quinazoline Agents***AGRYLIN ORAL CAPSULE 0.5 MG EX Formulary Exclusion

anagrelide hcl oral capsule 0.5 mg, 1 mg Tier 1

*Spleen Tyrosine Kinase (Syk) Inhibitors***TAVALISSE ORAL TABLET 100 MG, 150 MG Tier 4 PA; Specialty; QL

*Thienopyridine Derivatives***clopidogrel bisulfate oral tablet 300 mg, 75 mg Tier 1

EFFIENT ORAL TABLET 10 MG, 5 MG EX Formulary Exclusion

PLAVIX ORAL TABLET 75 MG EX Formulary Exclusion

prasugrel hcl oral tablet 10 mg, 5 mg Tier 1

286


*Thrombolytic Agent - Misc***DEFITELIO INTRAVENOUS SOLUTION200 MG/2.5ML EX Medical Only Exclusion

*Tissue Plasminogen Activators***ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG EX Medical Only Exclusion

CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 2 MG Benefit Exclusion

RETAVASE HALF-KIT INTRAVENOUS KIT 1 X 10 UNIT Benefit Exclusion

RETAVASE INTRAVENOUS KIT 2 X 10 UNIT Benefit Exclusion

TNKASE INTRAVENOUS KIT 50 MG Benefit Exclusion

*Hematopoietic Agents*

*Agents For Gaucher Disease***CERDELGA ORAL CAPSULE 84 MG Tier 4 PA; Specialty; QL

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT EX Medical Only Exclusion

ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT EX


miglustat oral capsule 100 mg Tier 4 PA; Specialty

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT EX Medical Only Exclusion

ZAVESCA ORAL CAPSULE 100 MG EX PA; Specialty; Formulary Exclusion

*Amino Acids***ENDARI ORAL PACKET 5 GM Tier 4 PA; Specialty; QL

*Cobalamin Combinations***ABANEU-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 MCG Benefit Exclusion

BIOPAR DELTA-FORTE ORAL CAPSULE Benefit Exclusion

FOLTRATE ORAL TABLET 500-1 MCG-MG Benefit Exclusion

lipo-b intramuscular solution Benefit Exclusion

neurin-sl sublingual tablet sublingual 600-600 mcg

Benefit Exclusion

vit b12-methionine-inos-chol intramuscular solution

Benefit Exclusion

*Cobalamins***cyanocobalamin injection solution 1000 mcg/ml, 2000 mcg/ml

Benefit Exclusion

287

Drug Name Drug Tier NotesDODEX INJECTION SOLUTION 1000 MCG/ML EX

hydroxocobalamin acetate intramuscular solution1000 mcg/ml

Tier 3

methylcobalamin injection solution 150 mg/30ml, 30 mg/30ml, 300 mg/30ml

Benefit Exclusion

methylcobalamin injection solution reconstituted10000 mcg, 50000 mcg

Benefit Exclusion

NASCOBAL NASAL SOLUTION 500 MCG/0.1ML Benefit Exclusion

physicians ez use b-12 injection kit 1000 mcg/ml EX Non FDA Exclusion; Medical Only Exclusion

vitamin deficiency system-b12 injection kit 1000 mcg/ml


*Cxcr4 Receptor Antagonist***MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML Tier 4 PA; Specialty; QL

*Cytotoxic Agents***DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG Tier 3

SIKLOS ORAL TABLET 100 MG, 1000 MG Tier 3

*Erythroid Maturation Agents***REBLOZYL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG, 75 MG EX


*Erythropoiesis-Stimulating Agents (Esas)***ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML


ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML


EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML


MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML


288

Drug Name Drug Tier NotesPROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML


RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML


*Folic Acid/Folate Combinations***ABATREX ORAL TABLET 8-200-4-100-600 MG Benefit Exclusion

AIRAVITE ORAL TABLET 2.5-25-1 MG Benefit Exclusion

ANIMI-3 ORAL CAPSULE 1 MG Benefit Exclusion

ANIMI-3/VITAMIN D ORAL CAPSULE 1 MG Benefit Exclusion

av-vite fb oral tablet 2.5-25-1 mg Benefit Exclusion

axifol oral capsule 1-3760 mg-unit Benefit Exclusion

b-6 folic acid oral capsule 8.333-100-1 mg EX Formulary Exclusion

bp vit 3 oral capsule 1 mg Benefit Exclusion

CENFOL ORAL TABLET 2.3-24.5-2 MG Benefit Exclusion

cholecal df oral tablet 1-3800 mg-unit Benefit Exclusion

CIFEREX ORAL CAPSULE 1-3775 MG-UNIT Benefit Exclusion

cifrazol oral capsule 1-3775 mg-unit Benefit Exclusion

D 1000 PLUS ALOE ORAL TABLET Benefit Exclusion

DERMACINRX DOTREMIN ORAL TABLET 1-10000 MG-UNIT Benefit Exclusion

DERMACINRX FOLTAMIN ORAL TABLET 125-1 MCG-MG Benefit Exclusion

DERMACINRX PUREFOLIX ORAL TABLET 1-5000 MG-UNIT Benefit Exclusion

DIVISTA ORAL CAPSULE 1 MG Benefit Exclusion

durachol oral capsule 1-3775 mg-unit Benefit Exclusion

fabb oral tablet 2.2-25-1 mg Benefit Exclusion

fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg

Benefit Exclusion

folbee oral tablet 2.5-25-1 mg Benefit Exclusion

FOLDITAM ORAL TABLET 1-10000 MG-UNIT Benefit Exclusion

FOLGARD ORAL TABLET Benefit Exclusion

FOLGARD RX ORAL TABLET 2.2-25-1 MG Benefit Exclusion

289

Drug Name Drug Tier Notesfolic d3 oral capsule 1-3775 mg-unit Benefit Exclusion

FOLI-D ORAL TABLET 1-2000 MG-UNIT Benefit Exclusion

folika-d oral tablet 1-5000 mg-unit Benefit Exclusion

folinic-plus oral tablet 4-50-2 mg Benefit Exclusion

folite oral tablet Benefit Exclusion

FOLIXAPURE ORAL TABLET 1-5000 MG-UNIT Benefit Exclusion

folplex 2.2 oral tablet 2.2-25-0.5 mg Benefit Exclusion

FOLTABS 800 ORAL TABLET 800-10-115 MCG-MG-MCG Benefit Exclusion

FOLTREXYL ORAL TABLET 1-5000 MG-UNIT Benefit Exclusion

folvik-d oral tablet 1-3775 mg-unit Benefit Exclusion

FOLVITE-D ORAL TABLET 1-3775 MG-UNIT Benefit Exclusion

GENICIN VITA-D ORAL TABLET 1-3775 MG-UNIT Benefit Exclusion

homocysteine formula oral tablet 800-50-100 mcg-mg-mcg

Benefit Exclusion

INTRINSI B12-FOLATE ORAL TABLET800-500-20 MCG-MCG-MG Benefit Exclusion

MILLGUARD ORAL TABLET 800-10-115 MCG-MG-MCG Benefit Exclusion

noxifol-d oral tablet 1-2500 mg-unit Benefit Exclusion

NUFOL ORAL TABLET 2.5-25-1 MG Benefit Exclusion

ortho d oral capsule 1-3775 mg-unit Benefit Exclusion

ortho df oral capsule 1-3775 mg-unit Benefit Exclusion

ostachol oral tablet 1-3800 mg-unit EX Non FDA Exclusion

OVEEZA ORAL CAPSULE 0.5 MG Benefit Exclusion

revesta oral capsule 1-5750 mg-unit Benefit Exclusion

roxifol-d oral tablet 1-500 mg-unit Benefit Exclusion

RX SUPPORT HB/REFLUX/ALOE ORAL TABLET Benefit Exclusion

TALIVA ORAL CAPSULE 1 MG Benefit Exclusion

tl gard rx oral tablet 2.2-25-1 mg Benefit Exclusion

VIRT-GARD ORAL TABLET 2.2-25-1 MG Benefit Exclusion

VITAMEZ ORAL CAPSULE 1 MG Benefit Exclusion

westab mini oral tablet 2.2-25-1 mg Benefit Exclusion

westab one oral tablet 2.5-25-1 mg Benefit Exclusion

zavara oral capsule 1-5750 mg-unit Benefit Exclusion

290

Drug Name Drug Tier NotesZOLATE ORAL CAPSULE 1-3775 MG-UNIT Benefit Exclusion

*Folic Acid/Folates***cvs folic acid oral tablet 800 mcg Tier 1

FA-8 ORAL CAPSULE 0.8 MG Tier 1

folate oral tablet 400 mcg Tier 1

folic acid injection solution 5 mg/ml EX Medical Only Exclusion

folic acid oral capsule 0.8 mg Tier 1

folic acid oral tablet 1 mg, 400 mcg, 800 mcg Tier 1

gnp folic acid oral tablet 400 mcg Tier 1

hm folic acid oral tablet 400 mcg Tier 1

kp folic acid oral tablet 800 mcg Tier 1

px folic acid oral tablet 400 mcg Tier 1

qc folic acid oral tablet 800 mcg Tier 1

ra folic acid oral tablet 400 mcg, 800 mcg Tier 1

sm folic acid oral tablet 400 mcg Tier 1

yl folic acid oral tablet 400 mcg Tier 1

*Granulocyte Colony-Stimulating Factors (G-Csf)***FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML EX


GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6ML EX


GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML


NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 6 MG/0.6ML EX


NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML EX


NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML EX


NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML


NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML Tier 4 PA; Specialty

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML


NYVEPRIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML Tier 4 PA; Specialty

291

Drug Name Drug Tier NotesRELEUKO SOLUTION 300 MCG/ML INJECTION 300 MCG/ML EX


releuko solution 480 mcg/1.6ml injection 480 mcg/1.6ml


releuko subcutaneous solution prefilled syringe300 mcg/0.5ml, 480 mcg/0.8ml


UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML EX


ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML


ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML Tier 4 PA; Specialty

*Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)***LEUKINE INJECTION SOLUTION RECONSTITUTED 250 MCG Tier 4 PA; Specialty

*Hemoglobin S (Hbs) Polymerization Inhibitors***OXBRYTA ORAL TABLET 500 MG Tier 4 PA; Specialty; QL

OXBRYTA ORAL TABLET SOLUBLE 300 MG Tier 4 PA; Specialty

*Iron Combinations***active fe oral tablet 75-1.25 mg Benefit Exclusion

CENTRATEX ORAL CAPSULE 106-1 MG Benefit Exclusion

CHROMAGEN ORAL CAPSULE Benefit Exclusion

CORVITA 150 ORAL TABLET 150-1.25 MG Benefit Exclusion

CORVITE 150 ORAL TABLET , 150-1.25 MG Benefit Exclusion

corvite fe oral tablet Benefit Exclusion

feonyx oral tablet Benefit Exclusion

FERIVAFA ORAL CAPSULE 110-1 MG Benefit Exclusion

ferocon oral capsule Benefit Exclusion

ferotrinsic oral capsule Benefit Exclusion

FERROCITE PLUS ORAL TABLET 106-1 MG Benefit Exclusion

FERRO-PLEX HEMATINIC ORAL TABLET 115-1 MG Benefit Exclusion

FERRO-PLEX ORAL TABLET 115-1 MG EX Non FDA Exclusion

FOLIVANE-PLUS ORAL CAPSULE Benefit Exclusion

foltrin oral capsule Benefit Exclusion

292

Drug Name Drug Tier NotesFOLVITE-FE ORAL TABLET 90-120-0.012-1 MG Benefit Exclusion

FUSION PLUS ORAL CAPSULE Benefit Exclusion

hematinic plus vit/minerals oral tablet 106-1 mg Benefit Exclusion

HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG EX Formulary Exclusion

HEMATOGEN FORTE ORAL CAPSULE460-60-0.01-1 MG Benefit Exclusion

HEMATOGEN ORAL CAPSULE Benefit Exclusion

HEMATRON-AF ORAL TABLET 150-1 MG Benefit Exclusion

HEMOCYTE PLUS ORAL CAPSULE 106-1 MG Benefit Exclusion

hemocyte-plus oral tablet 106-1 mg Benefit Exclusion

ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG EX Formulary Exclusion

IFEREX 150 FORTE ORAL CAPSULE 150-25-1 MG-MCG-MG Benefit Exclusion

INTEGRA PLUS ORAL CAPSULE Benefit Exclusion

IROSPAN 24/6 ORAL Benefit Exclusion

IS 24/6 ORAL Benefit Exclusion

K-TAN PLUS ORAL CAPSULE 162-115.2-1 MG Benefit Exclusion

MAXFE ORAL TABLET 160-1 MG Benefit Exclusion

MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG Benefit Exclusion

MULTIGEN ORAL TABLET 70 MG Benefit Exclusion

MULTIGEN PLUS ORAL TABLET 50-101-1 MG Benefit Exclusion

myferon 150 forte oral capsule 150-25-1 mg-mcg-mg

Benefit Exclusion

NEPHRON FA ORAL TABLET Benefit Exclusion

NIFEREX ORAL TABLET Benefit Exclusion

NUFERA ORAL TABLET Benefit Exclusion

poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg

Benefit Exclusion

polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg

Benefit Exclusion

PROTECTIRON ORAL TABLET 60-1 MG Benefit Exclusion

purefe plus oral capsule 106-1 mg Benefit Exclusion

purevit dualfe plus oral capsule 162-115.2-1 mg Benefit Exclusion

se-tan plus oral capsule 162-115.2-1 mg Benefit Exclusion

293

Drug Name Drug Tier NotesTANDEM PLUS ORAL CAPSULE 162-115.2-1 MG Benefit Exclusion

taron forte oral capsule Benefit Exclusion

tl icon oral capsule Benefit Exclusion

tl-hem 150 oral tablet 150-1 mg Benefit Exclusion

TRICON ORAL CAPSULE Benefit Exclusion

trigels-f forte oral capsule 460-60-0.01-1 mg Benefit Exclusion

virt-fefa plus oral capsule Benefit Exclusion

*Iron W/ Folic Acid***BENTIVITE ORAL TABLET 35-1 MG EX Non FDA Exclusion

FOLIVANE-F ORAL CAPSULE 125-1 MG Benefit Exclusion

FUSION SPRINKLES ORAL PACKET 7-0.25-50-5 MG Benefit Exclusion

hematinic/folic acid oral tablet 324-1 mg Tier 1

HEMOCYTE-F ORAL TABLET 324-1 MG Tier 1

INTEGRA F ORAL CAPSULE 125-1 MG Benefit Exclusion

PROFERRIN-FORTE ORAL TABLET 12-1 MG Benefit Exclusion

TANDEM F ORAL CAPSULE 162-115.2-1 MG Benefit Exclusion

*Iron***ACCRUFER ORAL CAPSULE 30 MG Benefit Exclusion

BPROTECTED PEDIA IRON ORAL SOLUTION 75 (15 FE) MG/ML Tier 1

FERAHEME INTRAVENOUS SOLUTION510 MG/17ML EX Medical Only Exclusion

FERRLECIT INTRAVENOUS SOLUTION12.5 MG/ML EX Medical Only Exclusion

ferrous sulfate oral elixir 220 (44 fe) mg/5ml Tier 1

ferrous sulfate oral solution 75 (15 fe) mg/ml Tier 1

ferrous sulfate oral syrup 300 (60 fe) mg/5ml Tier 1

ferumoxytol intravenous solution 510 mg/17ml EX Medical Only Exclusion

fe-vite iron oral solution 75 (15 fe) mg/ml Tier 1

INFED INJECTION SOLUTION 50 MG/ML EX Medical Only Exclusion

INJECTAFER INTRAVENOUS SOLUTION750 MG/15ML EX Medical Only Exclusion

iron supplement childrens oral solution 75 (15 fe) mg/ml

Tier 1

iron supplement oral elixir 220 (44 fe) mg/5ml Tier 1

294

Drug Name Drug Tier NotesMONOFERRIC INTRAVENOUS SOLUTION 1000 MG/10ML Benefit Exclusion

na ferric gluc cplx in sucrose intravenous solution12.5 mg/ml


pc pediatric iron drops oral solution 15 mg/ml Tier 1

TRIFERIC AVNU INTRAVENOUS SOLUTION 6.75 MG/4.5ML EX Medical Only Exclusion

TRIFERIC HEMODIALYSIS PACKET 272 MG Benefit Exclusion

TRIFERIC HEMODIALYSIS SOLUTION27.2 MG/5ML Benefit Exclusion

VENOFER INTRAVENOUS SOLUTION 20 MG/ML EX Medical Only Exclusion

*Iron-B12-Folate***BIFERARX ORAL TABLET 22-6-1-0.025 MG Benefit Exclusion

FERIVA 21/7 ORAL TABLET 75-1 MG Benefit Exclusion

FERRALET 90 ORAL TABLET 90-1 MG Benefit Exclusion

ferraplus 90 oral tablet 90-1 mg Benefit Exclusion

FERREX 150 FORTE ORAL CAPSULE 150-1-25 MG-MG-MCG Benefit Exclusion

FERREX 28 ORAL Benefit Exclusion

hemetab oral tablet 22-6-1-0.025 mg Benefit Exclusion

*Selectin Blockers***ADAKVEO INTRAVENOUS SOLUTION 100 MG/10ML Benefit Exclusion

*Thrombopoietin (Tpo) Receptor Agonists***DOPTELET ORAL TABLET 20 MG Tier 4 PA; Specialty; QL

MULPLETA ORAL TABLET 3 MG Tier 4 PA; Specialty; QL

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG, 250 MCG, 500 MCG


PROMACTA ORAL PACKET 12.5 MG, 25 MG Tier 4 PA; Specialty; QL

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG Tier 4 PA; Specialty; QL

*Hemostatics*

*Hemostatic Combinations - Topical***ARTISS EXTERNAL SOLUTION EX Medical Only Exclusion

GEL-FLOW EXTERNAL KIT Benefit Exclusion

295

Drug Name Drug Tier NotesGELFOAM-JMI POWDER EXTERNAL KIT

Benefit Exclusion

GELFOAM-JMI SPONGE EXTERNAL KIT Benefit Exclusion

TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML EX Medical Only Exclusion

TISSEEL EXTERNAL SOLUTION EX Medical Only Exclusion

*Hemostatics - Systemic***AMICAR ORAL SOLUTION 0.25 GM/ML EX Formulary Exclusion

AMICAR ORAL TABLET 1000 MG, 500 MG EX Formulary Exclusion

aminocaproic acid intravenous solution 250 mg/ml


aminocaproic acid oral solution 0.25 gm/ml Tier 1

aminocaproic acid oral tablet 1000 mg, 500 mg Tier 1

CYKLOKAPRON INTRAVENOUS SOLUTION 1000 MG/10ML Benefit Exclusion

LYSTEDA ORAL TABLET 650 MG EX Formulary Exclusion

tranexamic acid oral tablet 650 mg Tier 1

tranexamic acid solution 1000 mg/10ml intravenous 1000 mg/10ml

Benefit Exclusion Medical Only Exclusion

tranexamic acid solution 1000 mg/10ml intravenous 1000 mg/10ml

Benefit Exclusion

tranexamic acid-nacl intravenous solution 1000-0.7 mg/100ml-%

Benefit Exclusion

*Hemostatics - Topical***ASTRINGYN EXTERNAL SOLUTION 259 MG/GM Benefit Exclusion

GELFILM EXTERNAL FILM Benefit Exclusion

GELFOAM COMPRESSED SIZE 100 EXTERNAL Benefit Exclusion

GELFOAM DENTAL PACK SIZE 4 EXTERNAL Benefit Exclusion

GELFOAM MOUTH/THROAT POWDER Benefit Exclusion

GELFOAM SPONGE EXTERNAL 12-7 MM Benefit Exclusion

GELFOAM SPONGE SIZE 100 EXTERNAL Benefit Exclusion



monsels ferric subsulfate external solution Benefit Exclusion

RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT EX Medical Only Exclusion

RECOTHROM SPRAY KIT EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT EX Medical Only Exclusion

296

Drug Name Drug Tier NotesSURGICEL SNOW 1"X2" EXTERNAL PAD EX Formulary Exclusion

SURGICEL SNOW 2"X4" EXTERNAL PAD EX Formulary Exclusion

SURGICEL SNOW 4"X4" EXTERNAL PAD EX Formulary Exclusion

THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 UNIT Tier 3

THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 UNIT Tier 3

THROMBIN-JMI EXTERNAL SOLUTION RECONSTITUTED 20000 UNIT, 5000 UNIT Tier 3

THROMBOGEN EXTERNAL KIT 10000 UNIT EX Non FDA Exclusion

THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 1000 UNIT, 10000 UNIT EX Non FDA Exclusion

*Hypnotics/Sedatives/Sleep Disorder Agents*

*Barbiturate Hypnotics***AMYTAL SODIUM INJECTION SOLUTION RECONSTITUTED 500 MG EX Non FDA Exclusion

NEMBUTAL INJECTION SOLUTION 50 MG/ML EX Medical Only Exclusion

pentobarbital sodium injection solution 50 mg/ml EX Medical Only Exclusion

phenobarbital oral elixir 20 mg/5ml Tier 1

phenobarbital oral solution 20 mg/5ml Tier 1

phenobarbital sodium injection solution 130 mg/ml, 65 mg/ml


phenobarbital tablet 100 mg oral 100 mg Tier 1


phenobarbital tablet 16.2 mg oral 16.2 mg Benefit Exclusion

phenobarbital tablet 16.2 mg oral 16.2 mg Tier 1









*Benzodiazepine Hypnotics***BYFAVO INTRAVENOUS SOLUTION RECONSTITUTED 20 MG EX Medical Only Exclusion

297

Drug Name Drug Tier NotesDORAL ORAL TABLET 15 MG Tier 3

estazolam oral tablet 1 mg, 2 mg Tier 1

flurazepam hcl oral capsule 15 mg, 30 mg Tier 1 QL

HALCION ORAL TABLET 0.25 MG EX Formulary Exclusion

midazolam hcl (pf) solution 10 mg/2ml injection10 mg/2ml

Tier 1

midazolam hcl (pf) solution 2 mg/2ml injection 2 mg/2ml

Tier 1

midazolam hcl (pf) solution 5 mg/5ml injection 5 mg/5ml

Tier 2

midazolam hcl (pf) solution 5 mg/ml injection 5 mg/ml

Tier 1

midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml

Tier 1

midazolam hcl intravenous solution 150 mg/30ml EX Non FDA Exclusion

midazolam hcl oral syrup 2 mg/ml EX Formulary Exclusion

midazolam hcl-sodium chloride intravenous solution 100-0.8 mg/100ml-%, 100-0.9 mg/100ml-%, 50-0.8 mg/50ml-%, 50-0.9 mg/50ml-%


midazolam hcl-sodium chloride intravenous solution prefilled syringe 2-0.9 mg/2ml-%, 5-0.9 mg/5ml-%, 55-0.9 mg/55ml-%


midazolam injection solution prefilled syringe 2 mg/2ml, 3 mg/3ml, 5 mg/5ml


midazolam intravenous solution 100 mg/100ml, 50 mg/50ml


midazolam intravenous solution prefilled syringe2 mg/2ml, 25 mg/25ml, 30 mg/30ml, 50 mg/50ml


MIDAZOLAM+SYRSPEND SF ORAL SUSPENSION 1 MG/ML EX Non FDA Exclusion

midazolam-sodium chloride intravenous solution prefilled syringe 30-0.9 mg/30ml-%, 50-0.9 mg/50ml-%, 55-0.9 mg/55ml-%, 60-0.9 mg/30ml-%


midazolam-sodium chloride solution 100-0.9 mg/100ml-% intravenous 100-0.9 mg/100ml-%



Tier 3




Tier 3

298

Drug Name Drug Tier Notesquazepam tablet 15 mg oral 15 mg Tier 1

quazepam tablet 15 mg oral 15 mg Tier 3

RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG EX Formulary Exclusion; QL

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

Tier 1 QL

triazolam oral tablet 0.125 mg, 0.25 mg EX Formulary Exclusion

*Hypnotic Combinations***

mko melt dose pack sublingual troche 3-25-2 mg EX Non FDA Exclusion; Medical Only Exclusion

*Hypnotics - Tricyclic Agents***doxepin hcl tablet 3 mg oral 3 mg Benefit Exclusion

doxepin hcl tablet 3 mg oral 3 mg Benefit ExclusionNon Essential Drug Exclusion; Formulary Exclusion; QL

doxepin hcl tablet 6 mg oral 6 mg Benefit Exclusion

SILENOR ORAL TABLET 3 MG, 6 MG Benefit Exclusion

*Non-Benzodiazepine - Gaba-Receptor Modulators***AMBIEN CR ORAL TABLET EXTENDED RELEASE 12.5 MG, 6.25 MG EX Formulary Exclusion; QL

AMBIEN ORAL TABLET 10 MG, 5 MG EX Formulary Exclusion; QL

EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG Tier 3 QL

eszopiclone oral tablet 1 mg, 2 mg, 3 mg Tier 1 QL

INTERMEZZO SUBLINGUAL TABLET SUBLINGUAL 1.75 MG EX Formulary Exclusion; QL

LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG EX Formulary Exclusion; QL

zaleplon oral capsule 10 mg, 5 mg Tier 1 QL

zolpidem tartrate er oral tablet extended release12.5 mg, 6.25 mg

Tier 1 QL

zolpidem tartrate oral tablet 10 mg, 5 mg Tier 1 QL

zolpidem tartrate sublingual tablet sublingual1.75 mg, 3.5 mg

Tier 1 QL

ZOLPIMIST ORAL SOLUTION 5 MG/ACT Tier 3 QL

*Orexin Receptor Antagonists***BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG Tier 2 QL

DAYVIGO ORAL TABLET 10 MG, 5 MG EX Formulary Exclusion; QL

QUVIVIQ ORAL TABLET 25 MG, 50 MG EX New to Market Exclusion

299


*Selective Alpha2-Adrenoreceptor Agonist Sedatives***dexmedetomidine hcl in nacl intravenous solution prefilled syringe 20-0.9 mcg/5ml-%


dexmedetomidine hcl in nacl solution 200 mcg/50ml intravenous 200 mcg/50ml


dexmedetomidine hcl in nacl solution 200-0.9 mcg/50ml-% intravenous 200-0.9 mcg/50ml-%


dexmedetomidine hcl in nacl solution 200-0.9 mcg/50ml-% intravenous 200-0.9 mcg/50ml-%








dexmedetomidine hcl intravenous solution 1000 mcg/10ml, 200 mcg/2ml, 400 mcg/4ml


dexmedetomidine hcl-dextrose intravenous solution 200mcg/50ml -5%, 400mcg/100ml -5%


IGALMI SUBLINGUAL FILM 120 MCG, 180 MCG EX Medical Only Exclusion

PRECEDEX INTRAVENOUS SOLUTION1000 MCG/250ML, 200 MCG/2ML, 200 MCG/50ML, 400 MCG/100ML, 80 MCG/20ML


*Selective Melatonin Receptor Agonists***HETLIOZ LQ ORAL SUSPENSION 4 MG/ML Tier 4 PA; Specialty; QL

HETLIOZ ORAL CAPSULE 20 MG Tier 4 PA; Specialty; QL

ramelteon oral tablet 8 mg EX Formulary Exclusion

ROZEREM ORAL TABLET 8 MG EX Formulary Exclusion

*Laxatives*

*Bowel Evacuant Combinations***CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML EX Formulary Exclusion

COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 240 GM EX Formulary Exclusion

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM Tier 5

300

Drug Name Drug Tier NotesGAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM Tier 5

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

Tier 5

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM EX Formulary Exclusion

MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM EX Formulary Exclusion

NULYTELY LEMON-LIME ORAL SOLUTION RECONSTITUTED 420 GM EX Formulary Exclusion

NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 420 GM EX Formulary Exclusion

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

Tier 5

peg-3350/electrolytes oral solution reconstituted236 gm

Tier 5

peg-3350/electrolytes/ascorbat oral solution reconstituted 100 gm


peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm


PEG-PREP ORAL KIT 5-210 MG-GM Tier 5

PLENVU ORAL SOLUTION RECONSTITUTED 140 GM EX Formulary Exclusion

PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM EX Formulary Exclusion

SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 GM/177ML Tier 5

SUTAB ORAL TABLET 1479-225-188 MG EX Formulary Exclusion

TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM Tier 5

*Laxatives - Miscellaneous***constulose oral solution 10 gm/15ml Tier 1

GIALAX ORAL KIT EX Non FDA Exclusion

KRISTALOSE ORAL PACKET 10 GM, 20 GM Tier 3

lactulose oral packet 10 gm Benefit Exclusion

lactulose oral solution 10 gm/15ml, 20 gm/30ml Tier 1

*Lubricant Laxatives***mineral oil heavy oral oil EX Formulary Exclusion

301


*Saline Laxative Mixtures***OSMOPREP ORAL TABLET 1.102-0.398 GM EX Formulary Exclusion

*Stimulant Laxatives***cascara sagrada oral fluid extract 1 gm/ml EX Non FDA Exclusion

*Local Anesthetics-Parenteral*

*Local Anesthetic & Sympathomimetic***ARTICADENT DENTAL INJECTION SOLUTION CARTRIDGE 4 %-1:100000 EX Medical Only Exclusion

bupivacaine-epinephrine (pf) injection solution0.25% -1:200000, 0.5% -1:200000


bupivacaine-epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000


lets kit EX Non FDA Exclusion

lidocaine-epinephrine (3 ml) injection solution prefilled syringe 0.5 %-1:100000


lidocaine-epinephrine solution 0.5 %-1:200000 injection 0.5 %-1:200000


lidocaine-epinephrine solution 1 %-1:100000 injection 1 %-1:100000


lidocaine-epinephrine solution 1.5 %-1:200000 injection 1.5 %-1:200000










MARCAINE/EPINEPHRINE INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000 EX Medical Only Exclusion

MARCAINE/EPINEPHRINE PF INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000 EX Medical Only Exclusion

ORABLOC INJECTION SOLUTION CARTRIDGE 4 %-1:100000, 4 %-1:200000 EX Medical Only Exclusion

reck solution prefilled syringe 123-0.25-0.04- 15 mg/50ml


ropiv-clonidine-ketorolac solution prefilled syringe 123-0.04-15 mg/50ml


302

Drug Name Drug Tier NotesSENSORCAINE/EPINEPHRINE INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000


SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.25% -1:200000, 0.5% -1:200000, 0.75-1:200000 %


XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 0.5 %-1:200000, 1 %-1:100000, 2 %-1:100000


XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 1 %-1:200000, 1.5 %-1:200000, 2 %-1:200000


*Local Anesthetic Combinations***active injection lm-2 injection kit 1 & 0.25 % EX Non FDA Exclusion

lidocaine hcl-tetracaine hcl injection solution 0.4-0.2 %


lidocaine-sodium bicarbonate injection solution prefilled syringe 1-8.4 %


LIDOMAR INJECTION SOLUTION 50-18.75 MG/5ML EX Non FDA Exclusion

marlido injection kit 2 & 0.5 % EX Non FDA Exclusion

MARLIDO-25 INJECTION KIT 1 & 0.25 % EX Non FDA Exclusion; Medical Only Exclusion

MARVONA SUIK COMBINATION KIT 0.5 % EX Non FDA Exclusion

POINT OF CARE LM-2.2 INJECTION KIT 1 & 0.25 % EX


POINT OF CARE LM-2.5 INJECTION KIT 1 & 0.25 % EX


READYSHARP-A INJECTION KIT 1 & 0.5 % EX


*Local Anesthetics - Amides***bupivacaine fisiopharma injection solution 2.5 mg/ml, 5 mg/ml


bupivacaine hcl (pf) solution 0.25 % injection0.25 %




bupivacaine hcl (pf) solution 0.5 % injection 0.5 %




303

Drug Name Drug Tier Notesbupivacaine hcl injection solution prefilled syringe 0.125 % (50 ml), 0.25 % (10 ml)


bupivacaine hcl solution 0.125 % injection 0.125 %


bupivacaine hcl solution 0.25 % injection 0.25 % EX Medical Only Exclusion

bupivacaine hcl solution 0.5 % injection 0.5 % EX Non FDA Exclusion; Medical Only Exclusion

bupivacaine hcl solution 0.5 % injection 0.5 % EX Medical Only Exclusion

bupivacaine hcl-nacl epidural solution 0.125-0.9 %


bupivacaine hcl-nacl epidural solution prefilled syringe 0.25-0.9 %


bupivacaine in dextrose intrathecal solution 0.75-8.25 %


bupivacaine spinal intrathecal solution 0.75-8.25 %


CARBOCAINE INJECTION SOLUTION 1 % Tier 3

CARBOCAINE PRESERVATIVE-FREE INJECTION SOLUTION 1 %, 1.5 %, 2 % Tier 3

EXPAREL INJECTION SUSPENSION 1.3 % EX Medical Only Exclusion

lidocaine hcl (buffered) injection solution prefilled syringe 100 mg/10ml


lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %, 4 %


lidocaine hcl injection solution 0.5 %, 1 %, 2 % EX Medical Only Exclusion

lidocaine hcl injection solution prefilled syringe10 mg/ml, 100 mg/10ml, 100 mg/5ml, 200 mg/10ml, 60 mg/3ml, 9 mg/ml


lidocaine hcl intradermal jet-injector 0.5 mg EX Formulary Exclusion

lidocaine in dextrose solution 5-7.5 % EX Formulary Exclusion

lidomark 1/5 injection kit 1 % EX Non FDA Exclusion; Medical Only Exclusion

lidomark 2/5 injection kit 2 % EX Non FDA Exclusion

MARCAINE INJECTION SOLUTION 0.25 %, 0.5 %, 0.75 % EX Medical Only Exclusion

MARCAINE PRESERVATIVE FREE INJECTION SOLUTION 0.25 %, 0.5 % EX Medical Only Exclusion

MARCAINE SPINAL INTRATHECAL SOLUTION 0.75-8.25 % EX Medical Only Exclusion

MONOJECT BONE MARROW BIOPSY INJECTION KIT 1 % EX


304

Drug Name Drug Tier NotesNAROPIN SOLUTION 10 MG/ML INJECTION 10 MG/ML EX Medical Only Exclusion

NAROPIN SOLUTION 2 MG/ML INJECTION 2 MG/ML EX Medical Only Exclusion

NAROPIN SOLUTION 2 MG/ML INJECTION 2 MG/ML EX


NAROPIN SOLUTION 5 MG/ML INJECTION 5 MG/ML EX Medical Only Exclusion

NAROPIN SOLUTION 7.5 MG/ML INJECTION 7.5 MG/ML EX Medical Only Exclusion

POLOCAINE INJECTION SOLUTION 1 %, 2 % EX Medical Only Exclusion

POLOCAINE-MPF INJECTION SOLUTION1 %, 1.5 %, 2 % EX Medical Only Exclusion

POSIMIR INJECTION SOLUTION 660 MG/5ML EX Medical Only Exclusion

READYSHARP LIDOCAINE INJECTION KIT 1 % EX


ropivacaine hcl epidural solution 0.2 % EX Non FDA Exclusion

ropivacaine hcl injection solution prefilled syringe 0.2 %, 0.5 %


ropivacaine hcl solution 10 mg/ml injection 10 mg/ml








ropivacaine hcl solution 7.5 mg/ml injection 7.5 mg/ml


ropivacaine hcl-nacl epidural solution 0.15-0.9 %, 0.2-0.9 %


ropivacaine hcl-nacl injection solution 0.2-0.9 % EX Non FDA Exclusion; Medical Only Exclusion

SENSORCAINE INJECTION SOLUTION0.25 %, 0.5 % EX Medical Only Exclusion

SENSORCAINE-MPF INJECTION SOLUTION 0.25 %, 0.5 %, 0.75 % EX Medical Only Exclusion

XARACOLL IMPLANT IMPLANT 3 X 100 MG EX Medical Only Exclusion

XYLOCAINE INJECTION SOLUTION 0.5 %, 1 %, 2 % EX Medical Only Exclusion

305

Drug Name Drug Tier NotesXYLOCAINE-MPF INJECTION SOLUTION0.5 %, 1 %, 1.5 %, 2 % EX Medical Only Exclusion

ZINGO INTRADERMAL JET-INJECTOR0.5 MG EX


*Local Anesthetics - Esters***chloroprocaine hcl (pf) injection solution 2 %, 3 %


CLOROTEKAL INTRATHECAL SOLUTION 50 MG/5ML EX Medical Only Exclusion

NESACAINE INJECTION SOLUTION 1 %, 2 % EX Medical Only Exclusion

NESACAINE-MPF INJECTION SOLUTION2 %, 3 % EX Medical Only Exclusion

tetracaine hcl injection solution 1 % EX Non FDA Exclusion

*Macrolides*

*Azithromycin***azithromycin intravenous solution reconstituted500 mg


azithromycin oral packet 1 gm Tier 2

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

Tier 1

azithromycin oral tablet 250 mg, 500 mg, 600 mg Tier 1

ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED 500 MG EX Medical Only Exclusion

ZITHROMAX ORAL PACKET 1 GM Tier 3

ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML


ZITHROMAX ORAL TABLET 250 MG, 500 MG, 600 MG EX Formulary Exclusion

ZITHROMAX TRI-PAK ORAL TABLET 500 MG EX Formulary Exclusion

ZITHROMAX Z-PAK ORAL TABLET 250 MG EX Formulary Exclusion

*Clarithromycin***clarithromycin er oral tablet extended release 24 hour 500 mg

Tier 1

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

Tier 1

clarithromycin oral tablet 250 mg, 500 mg Tier 1

306


*Erythromycins***E.E.S. 400 ORAL TABLET 400 MG Tier 3

E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML EX Formulary Exclusion

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML EX Formulary Exclusion

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML EX Formulary Exclusion

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG Tier 1

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG


ERYTHROCIN STEARATE ORAL TABLET250 MG Tier 2

erythromycin base oral capsule delayed release particles 250 mg

Tier 1

erythromycin base oral tablet 250 mg, 500 mg Tier 1

erythromycin base oral tablet delayed release 250 mg, 333 mg, 500 mg

Tier 1

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml, 400 mg/5ml

Tier 1

erythromycin ethylsuccinate oral tablet 400 mg Tier 3

erythromycin lactobionate intravenous solution reconstituted 500 mg


erythromycin oral tablet delayed release 250 mg, 333 mg, 500 mg

Tier 1

*Fidaxomicin***DIFICID ORAL SUSPENSION RECONSTITUTED 40 MG/ML Tier 2

DIFICID ORAL TABLET 200 MG Tier 2

*Medical Devices And Supplies*

*Adhesive Bandages***CURITY WOUND CLOSURE 1/2"X4" EX Non FDA Exclusion

CURITY WOUND CLOSURE 1/4"X1.5" EX Non FDA Exclusion

CURITY WOUND CLOSURE 1/4"X3" EX Non FDA Exclusion



*Applicators,Cotton Balls,Etc***ALCOH-GLOVE CONTOURED WIPE PAD Benefit Exclusion

alcoh-wipe sheet Benefit Exclusion

307


*Cervical Caps***FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM Tier 5

*Conception Assistance Supplies***CLEARBLUE FERTILITY DEVICE Benefit Exclusion

*Condoms - Female***FC FEMALE CONDOM Tier 5

FC2 FEMALE CONDOM Benefit Exclusion

*Diaphragms***CAYA VAGINAL DIAPHRAGM Tier 5

OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM Tier 2

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % Tier 2








*Foot Care Products***BIOFREQUENCY INSOLES EX Non FDA Exclusion

*Gauze Pads & Dressings***AMD FOAM DRESSING PAD 3-1/2"X3" , 4"X4" , 6"X6" EX Non FDA Exclusion

AMD FOAM DRESSING TOPSHEET PAD4"X4" EX Non FDA Exclusion

BIOGUARD GAUZE SPONGES PAD 2"X2" , 4"X4" EX Non FDA Exclusion

BIOGUARD ISLAND DRESSINGS PAD4"X10" , 4"X14" , 4"X5" Benefit Exclusion

BIOGUARD NON-ADHERENT DRESSING PAD 3"X4" , 3"X8" Benefit Exclusion

308

Drug Name Drug Tier NotesCURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4" EX Non FDA Exclusion

CURITY AMD ANTIMICROBIAL STRIP EX Non FDA Exclusion

CURITY IODOFORM PACKING STRIP EX Non FDA Exclusion

EXCILON AMD DRAIN SPONGES PAD4"X4" EX Non FDA Exclusion

KERLIX AMD ANTIMICROBIAL EX Non FDA Exclusion

KERLIX AMD SUPER SPONGES PAD6"X6-3/4" EX Non FDA Exclusion

TELFA AMD ISLAND DRESSING PAD 4"X5" 4"X5" Benefit Exclusion

TELFA AMD ISLAND DRESSING PAD 4"X8" 4"X8" Benefit Exclusion

TELFA AMD ISLAND DRESSING PAD 4"X8" 4"X8" EX Non FDA Exclusion

TELFA AMD NON-ADHERENT PAD 3"X8" Benefit Exclusion

*Glucose Monitor & Blood Pressure Monitor Combinations***ADVOCATE DUO DEVICE Tier 3

CLEVER CHEK AUTO-CODE DEVICE Tier 3

DUO-CARE DEVICE Tier 3

FORA D10 2-IN-1 MONITOR DEVICE Tier 3

FORA D15G 2-IN-1 MONITOR DEVICE Tier 3

FORA D20 2-IN-1 MONITOR DEVICE Tier 3

FORA D40 GLUCOSE/PRESSURE DEVICE EX Formulary Exclusion

FORA D40G GLUCOSE/PRESSURE DEVICE EX Formulary Exclusion

*Glucose Monitor & Cholesterol Monitor Combinations***ACCUTREND PLUS DEVICE Tier 3

*Glucose Monitoring Test Supplies***1st tier unilet comfortouch Tier 2

ACCU-CHEK AVIVA PLUS KIT W/DEVICE EX Formulary Exclusion

ACCU-CHEK FASTCLIX LANCET KIT Tier 2

ACCU-CHEK FASTCLIX LANCETS Tier 2

ACCU-CHEK GUIDE KIT W/DEVICE EX Formulary Exclusion

ACCU-CHEK GUIDE ME KIT W/DEVICE EX Formulary Exclusion

ACCU-CHEK MULTICLIX LANCETS Tier 2

ACCU-CHEK SAFE-T PRO LANCETS Tier 2

309

Drug Name Drug Tier NotesACCU-CHEK SOFTCLIX LANCET DEV KIT Tier 2

ACCU-CHEK SOFTCLIX LANCETS Tier 2

acti-lance 28g Tier 2

acti-lance lite lancets 28g Tier 2

acti-lance special lancets 17g Tier 2

acti-lance universal 23g Tier 2

adjustable lancing device Tier 2

ADVANCE INTUITION METER DEVICE EX Formulary Exclusion

ADVANCE INTUITION MONITOR KIT EX Formulary Exclusion

ADVANCE MICRO-DRAW METER DEVICE EX Formulary Exclusion

advanced mobile lancet Tier 2

ADVOCATE BLOOD GLUCOSE MONITOR DEVICE EX Formulary Exclusion

ADVOCATE BLOOD GLUCOSE SYSTEM KIT W/DEVICE EX Formulary Exclusion

ADVOCATE LANCETS Tier 2

ADVOCATE LANCETS 30G Tier 2

ADVOCATE REDI-CODE DEVICE EX Formulary Exclusion

ADVOCATE REDI-CODE KIT W/DEVICE EX Formulary Exclusion

ADVOCATE REDI-CODE+ DEVICE EX Formulary Exclusion

ADVOCATE SAFETY LANCETS Tier 2

ADVOCATE SAFETY LANCETS 26G Tier 2

AGAMATRIX AMP DEVICE EX Formulary Exclusion

AGAMATRIX JAZZ WIRELESS 2 KITW/DEVICE EX Formulary Exclusion

AGAMATRIX PRESTO KIT W/DEVICE EX Formulary Exclusion

AGAMATRIX PRESTO PRO METER DEVICE EX Formulary Exclusion

AGAMATRIX ULTRA-THIN LANCETS Tier 2

aimsco twist lancets 32g Tier 2

AIMSCO TWIST LANCETS 33G Tier 2

AQUALANCE LANCETS 30G Tier 2

ASSURE 3 METER KIT EX Formulary Exclusion

ASSURE 4 METER DEVICE EX Formulary Exclusion

assure comfort lancets 28g Tier 2

ASSURE HAEMOLANCE PLUS HIGH Tier 2

ASSURE HAEMOLANCE PLUS LOW Tier 2

ASSURE HAEMOLANCE PLUS MICRO Tier 2

310

Drug Name Drug Tier NotesASSURE HAEMOLANCE PLUS NORMAL Tier 2

ASSURE HAEMOLANCE PLUS PED Tier 2

ASSURE LANCE LANCETS Tier 2

ASSURE LANCE LANCETS 21G Tier 2

ASSURE LANCE PLUS SAFETY 25G Tier 2

ASSURE LANCE PLUS SAFETY 30G Tier 2

ASSURE LANCE SAFETY LANCET 28G Tier 2

ASSURE LANCETS Tier 2

ASSURE PLATINUM METER DEVICE EX Formulary Exclusion

ASSURE PRISM MULTI METER DEVICE Tier 3

ASSURE PRO BLOOD GLUCOSE METER DEVICE EX Formulary Exclusion

aurora lancet super thin 30g Tier 2

aurora lancet thin 23g Tier 2

AUTOLET II CLINISAFE KIT Tier 2

AUTOLET LANCING DEVICE Tier 2

AUTOLET LITE CLINISAFE KIT Tier 2

AUTOLET LITE STARTER PACK KIT Tier 2

AUTOLET MINI Tier 2

AUTOLET PLATFORMS Tier 2

AUTOLET PLUS Tier 2

BD LANCET ULTRAFINE 30G Tier 2

BD LANCET ULTRAFINE 33G Tier 2

BD LATITUDE DIABETES KIT EX Formulary Exclusion

BD LATITUDE DIABETES SYSTEM KIT EX Formulary Exclusion

BD LOGIC BLOOD GLUCOSE MONITOR KIT W/DEVICE EX Formulary Exclusion

BD MAGNI-GUIDE MAGNIFIER Tier 3

BD MICROTAINER LANCETS Tier 2

BIOTEL CARE BLOOD GLUCOSE KITW/DEVICE Tier 3

BIOTEL CARE BLOOD GLUCOSE SYST KIT W/DEVICE EX Formulary Exclusion

blood glucose monitor system kit w/device EX Formulary Exclusion

blood glucose system pak kit EX Formulary Exclusion

BLUESTAR DEVICE (OTC) Tier 3

BLUESTAR DEVICE (RX) EX Non FDA Exclusion

BLULINK GLUCOSE MONITORING SYS DEVICE Tier 3

311

Drug Name Drug Tier Notesbullseye mini safety lancets Tier 2

BULLSEYE SAFETY LANCETS Tier 2

CARDIOCOM LANCING DEVICE Tier 2

careone advanced lancing dev Tier 2

CAREONE BLOOD GLUCOSE SYSTEM KIT W/DEVICE EX Formulary Exclusion

CAREONE LANCET SUPER THIN 30G Tier 2

careone lancet thin 23g Tier 2

CARESENS LANCETS Tier 2

CARESENS N GLUCOSE SYSTEM DEVICETier 3

CARESENS N VOICE SYSTEM DEVICE Tier 3

CARETOUCH LANCING/EJECTOR Tier 2

CARETOUCH MONITOR SYSTEM KITW/DEVICE Tier 3

CARETOUCH SAFETY LANCETS Tier 2

CARETOUCH SAFETY LANCETS 26G Tier 2

CARETOUCH TWIST LANCETS 28G Tier 2



CHEMSTRIP BG LOG BOOK Tier 3

CLEANLET LANCETS 28G Tier 2

CLEVER CHEK AUTO-CODE SYSTEM DEVICE EX Formulary Exclusion

CLEVER CHEK AUTO-CODE VOICE DEVICE EX Formulary Exclusion

CLEVER CHEK LANCETS Tier 2

CLEVER CHEK SYSTEM KIT W/DEVICE EX Formulary Exclusion

CLEVER CHOICE AUTO-CODE SYSTEM DEVICE EX Formulary Exclusion

CLEVER CHOICE LANCETS 21G Tier 2



CLEVER CHOICE MICRO SYSTEM KITW/DEVICE EX Formulary Exclusion

CLEVER CHOICE MINI SYSTEM DEVICE EX Formulary Exclusion

CLEVER CHOICE TALK SYSTEM DEVICEEX Formulary Exclusion

COAGUCHEK LANCETS Tier 2

comfort assured lancets 28g Tier 2

312

Drug Name Drug Tier Notescomfort assured lancets 33g Tier 2

comfort lancets Tier 2

COMFORT TOUCH LANCETS 31G Tier 2

COMFORT TOUCH PLUS LANCETS 30G Tier 2

CONTOUR CONTROL IN VITRO LIQUIDHIGH , LOW , NORMAL EX Formulary Exclusion

CONTOUR MONITOR DEVICE EX Formulary Exclusion

CONTOUR NEXT CONTROL IN VITRO SOLUTION LOW , NORMAL EX Formulary Exclusion

CONTOUR NEXT EZ KIT W/DEVICE EX Formulary Exclusion

CONTOUR NEXT LINK KIT W/DEVICE EX Formulary Exclusion

CONTOUR NEXT MONITOR KITW/DEVICE EX Formulary Exclusion

CONTOUR NEXT ONE KIT EX Formulary Exclusion

COOL MONITOR DEVICE EX Formulary Exclusion

COOL MONITOR KIT KIT W/DEVICE EX Formulary Exclusion

CVS BLOOD GLUCOSE METER KITW/DEVICE EX Formulary Exclusion

cvs lancets 21g Tier 2

cvs lancets micro thin 33g Tier 2

cvs lancets original Tier 2

cvs lancets thin 26g Tier 2

cvs lancets ultra thin 30g Tier 2

cvs lancets ultra-thin 30g Tier 2

cvs lancing device Tier 2

cvs ultra thin lancets Tier 2

D-CARE GLUCOMETER KIT W/DEVICE EX Formulary Exclusion

DEXCOM G4 PLAT PED RCV/SHARE DEVICE EX Formulary Exclusion; QL

DEXCOM G4 PLAT PED RECEIVER DEVICE EX Formulary Exclusion; QL

DEXCOM G4 PLATINUM RCV/SHARE DEVICE EX Formulary Exclusion; QL

DEXCOM G4 PLATINUM RECEIVER DEVICE EX Formulary Exclusion; QL

DEXCOM G4 PLATINUM TRANSMITTER EX Formulary Exclusion; QL

DEXCOM G4 SENSOR EX Formulary Exclusion; QL

DEXCOM G5 MOB/G4 PLAT SENSOR Tier 2 QL

DEXCOM G5 MOBILE RECEIVER DEVICETier 2 QL

313

Drug Name Drug Tier NotesDEXCOM G5 MOBILE TRANSMITTER Tier 2 QL

DEXCOM G5 RECEIVER KIT DEVICE Tier 2 QL

DEXCOM G6 RECEIVER DEVICE Tier 2 QL

DEXCOM G6 SENSOR Tier 2 QL

DEXCOM G6 TRANSMITTER Tier 2 QL

DIATHRIVE BLOOD GLUCOSE METER DEVICE EX Formulary Exclusion

DIATHRIVE LANCET ULTRA THIN 30 Tier 2

DIATHRIVE LANCETS Tier 2

DIATHRIVE+ GLUCOSE MONITOR DEVICE Tier 3

diatrue plus blood glucose device EX Formulary Exclusion

DROPLET GENTEEL LANCING DEVICE Tier 2

DROPLET LANCETS ULTRA THIN 30G Tier 2

DROPLET LANCING DEVICE Tier 2

DROPLET PERSONAL LANCETS 30G Tier 2

drug mart lancets thin 26g Tier 2

DRUG MART LANCING DEVICE Tier 2

DRUG MART ON-THE-GO LANCET 30G Tier 2

DRUG MART UNILET LANCETS 28G Tier 2



easy comfort lancets Tier 2

easy comfort lancets twist top Tier 2

easy plus ii glucose system device EX Formulary Exclusion

EASY STEP GLUCOSE MONITOR DEVICEEX Formulary Exclusion

easy talk blood glucose system device EX Formulary Exclusion

EASY TOUCH GLUCOSE SYSTEM KITW/DEVICE EX Formulary Exclusion

EASY TOUCH LANCETS 21G Tier 2




EASY TOUCH LANCETS 28G/TWIST Tier 2





314

Drug Name Drug Tier NotesEASY TOUCH LANCETS 33G/TWIST Tier 2

EASY TOUCH LANCING DEVICE Tier 2

EASY TOUCH SAFETY LANCETS 21G Tier 2




easy trak blood glucose system device EX Formulary Exclusion

easy trak ii blood glucose sys device EX Formulary Exclusion

EASY TWIST & CAP LANCETS Tier 2

EASYGLUCO KIT EX Formulary Exclusion

EASYMAX NG BLOOD GLUCOSE DEVICEEX Formulary Exclusion

EASYMAX NG BLOOD GLUCOSE KITW/DEVICE EX Formulary Exclusion

EASYMAX V BLOOD GLUCOSE DEVICE EX Formulary Exclusion

EASYPRO BLOOD GLUCOSE MONITOR KIT W/DEVICE EX Formulary Exclusion

EASYPRO PLUS KIT W/DEVICE EX Formulary Exclusion

ELEMENT AUTOCODE SYSTEM KITW/DEVICE EX Formulary Exclusion

element compact glucose system device EX Formulary Exclusion

element compact v glucose sys device EX Formulary Exclusion

ELEMENT PLUS DEVICE EX Formulary Exclusion

EMBRACE BLOOD GLUCOSE MONITOR DEVICE EX Formulary Exclusion

EMBRACE EVO GLUCOSE MONITOR DEVICE Tier 3

EMBRACE EVO GLUCOSE MONITORING KIT W/DEVICE EX Formulary Exclusion

EMBRACE LANCETS ULTRA THIN 30G Tier 2

EMBRACE PRESSURE ACTIVATED 21G Tier 2

EMBRACE PRESSURE ACTIVATED 28G Tier 2

EMBRACE PRO GLUCOSE METER DEVICE Tier 3

EMBRACE PRO GLUCOSE METER DEVICE EX Formulary Exclusion

EMBRACE TALK BLOOD GLUCOSE DEVICE EX Formulary Exclusion

EMBRACE TALK MONITORING SYSTEM KIT W/DEVICE EX Formulary Exclusion

ENLITE GLUCOSE SENSOR EX Formulary Exclusion

315

Drug Name Drug Tier Noteseql color lancets 21g Tier 2

eql color lancets micro 33g Tier 2

eql super thin lancets 30g Tier 2

eql thin lancets 26g Tier 2

EVERSENSE SENSOR/HOLDER EX Formulary Exclusion

EVERSENSE SMART TRANSMITTER EX Formulary Exclusion

EVOLUTION AUTOCODE DEVICE EX Formulary Exclusion

E-Z JECT LANCET MICRO-THIN 33G Tier 2

E-Z JECT LANCET SUPER THIN 30G Tier 2

E-Z JECT LANCETS Tier 2

E-Z JECT LANCETS 21G Tier 2

E-Z JECT LANCETS THIN 26G Tier 2

EZ-LETS LANCETS 21G Tier 2




FIFTY50 GLUCOSE METER 2.0 KITW/DEVICE EX Formulary Exclusion

FIFTY50 SAFETY SEAL LANCETS Tier 2

FIFTY50 UNILET LANCETS 33G Tier 2

FINE 30 Tier 2

FINGERSTIX LANCETS Tier 2

FORA G20 BLOOD GLUCOSE SYSTEM KIT W/DEVICE EX Formulary Exclusion

FORA G30A BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

FORA GD20 BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

FORA GD50 BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

FORA GTEL BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

FORA LANCETS Tier 2

FORA PREMIUM V10 BLE SYSTEM DEVICE EX Formulary Exclusion

FORA TEST N' GO MONITOR DEVICE EX Formulary Exclusion

FORA TN'G VOICE KIT W/DEVICE EX Formulary Exclusion

FORA V10 BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

FORA V10/V12/D10/D20 TEST KIT EX Formulary Exclusion

316

Drug Name Drug Tier NotesFORA V12 BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

FORA V20 BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

FORA V30A BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

FORA V30A BLOOD GLUCOSE SYSTEM KIT W/DEVICE EX Formulary Exclusion

FORACARE GD40 MONITOR DEVICE EX Formulary Exclusion

FORACARE PREMIUM V10 DEVICE EX Formulary Exclusion

FORACARE TEST N GO MONITOR DEVICE EX Formulary Exclusion

FORTISCARE T1 GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

freds pharmacy autolet lancing Tier 2

freds pharmacy unilet lanc 28g Tier 2

freds pharmacy unilet lanc 30g Tier 2

FREESTYLE FREEDOM LITE KITW/DEVICE EX Formulary Exclusion

FREESTYLE LANCETS Tier 2

FREESTYLE LIBRE 14 DAY READER DEVICE Tier 2 QL

FREESTYLE LIBRE 14 DAY SENSOR Tier 2 QL

FREESTYLE LIBRE 2 READER DEVICE Tier 2 QL

FREESTYLE LIBRE 2 SENSOR Tier 2 QL

FREESTYLE LIBRE READER DEVICE Tier 2 QL

FREESTYLE LIBRE SENSOR SYSTEM Tier 2 QL

FREESTYLE LITE DEVICE EX Formulary Exclusion

FREESTYLE LITE KIT W/DEVICE EX Formulary Exclusion

FREESTYLE PRECISION NEO SYSTEM KIT W/DEVICE EX Formulary Exclusion

FREESTYLE UNISTICK II LANCETS Tier 2

ge100 blood glucose system device EX Formulary Exclusion

ge100 blood glucose system kit w/device EX Formulary Exclusion

GENTEEL BUTTERFLY TOUCH LANCET Tier 2

GENTLE-LET GP LANCETS Tier 2

GENTLE-LET LANCETS Tier 2

GENTLE-LET PLATFORMS Tier 2

ght blood glucose monitor kit w/device EX Formulary Exclusion

global inject ease lancets 28g Tier 2

317

Drug Name Drug Tier Notesglobal inject ease lancets 30g Tier 2

GLUCO PERFECT 3 METER DEVICE EX Formulary Exclusion

GLUCOCARD 01 BLOOD GLUCOSE DEVICE EX Formulary Exclusion

GLUCOCARD 01 BLOOD GLUCOSE KITW/DEVICE EX Formulary Exclusion

GLUCOCARD 01-MINI GLUCOSE KITW/DEVICE EX Formulary Exclusion

GLUCOCARD EXPRESSION MONITOR KIT W/DEVICE EX Formulary Exclusion

GLUCOCARD SHINE CONNEX KITW/DEVICE EX Formulary Exclusion

GLUCOCARD SHINE DEVICE Tier 3

GLUCOCARD SHINE EXPRESS KITW/DEVICE EX Formulary Exclusion

GLUCOCARD SHINE KIT W/DEVICE Tier 3

GLUCOCARD SHINE XL DEVICE EX Formulary Exclusion

GLUCOCARD VITAL MONITOR KITW/DEVICE EX Formulary Exclusion

GLUCOCARD X-METER KIT W/DEVICE EX Formulary Exclusion

GLUCOCOM AUTOLINK TELEMONITOR Tier 3

GLUCOCOM BLOOD GLUCOSE MONITOR DEVICE EX Formulary Exclusion

GLUCOCOM LANCETS 28G Tier 2



GLUCOCOM MONITOR KIT W/DEVICE EX Formulary Exclusion

GLUCONAVII BLOOD GLUCOSE SYS KITW/DEVICE EX Formulary Exclusion

GNP EASY TOUCH GLUCOSE METER DEVICE Tier 3

GNP EASY TOUCH GLUCOSE METER DEVICE EX Formulary Exclusion

gnp lancets 21g Tier 2

gnp lancets micro thin 33g Tier 2

gnp lancets super thin 30g Tier 2

gnp lancets thin Tier 2

gnp lancets thin 26g Tier 2

gnp sterile lancets 28g Tier 2



318

Drug Name Drug Tier NotesGNP TRUE METRIX AIR METER KITW/DEVICE Tier 3

GNP TRUE METRIX GLUCOSE METER KIT W/DEVICE Tier 3

GOJJI STERILE LANCETS Tier 2

goodsense blood glucose kit w/device EX Formulary Exclusion

goodsense color lancets 33g Tier 2

goodsense lancets 26g univ Tier 2

goodsense lancets 30g Tier 2


goodsense lancets 33g Tier 2


GUARDIAN CONNECT TRANSMITTER EX Formulary Exclusion

GUARDIAN LINK 3 TRANSMITTER EX Formulary Exclusion

GUARDIAN REAL-TIME CHARGER EX Formulary Exclusion

GUARDIAN REAL-TIME REPLACE PED DEVICE EX Formulary Exclusion

GUARDIAN REAL-TIME TEST PLUG EX Formulary Exclusion

GUARDIAN SENSOR (3) EX Formulary Exclusion

guardian sensor 3 EX Formulary Exclusion

HAEMOLANCE PLUS Tier 2

HAEMOLANCE PLUS HIGH FLOW Tier 2

HAEMOLANCE PLUS LOW FLOW Tier 2

HAEMOLANCE PLUS MAX FLOW Tier 2

HAEMOLANCE PLUS PEDIATRIC FLOW Tier 2

HEALTH CARE LANCING DEVICE Tier 2

healthy accents lancing device Tier 2

healthy accents unilet lancets Tier 2

h-e-b incontrol adv lancing Tier 2

h-e-b incontrol lancets 28g Tier 2



HM EMBRACE TALK SYSTEM KITW/DEVICE EX Formulary Exclusion

HW EMBRACE PRO GLUCOSE METER DEVICE EX Formulary Exclusion

HW EMBRACE TALK BLOOD GLUCOSE DEVICE EX Formulary Exclusion

HYPOLANCE AST LANCING KIT Tier 2

HY-VEE LANCETS Tier 2

319

Drug Name Drug Tier Noteshy-vee thin lancets Tier 2

IGLUCOSE MONITORING SYSTEM KITW/DEVICE EX Formulary Exclusion

IN TOUCH Tier 3

IN TOUCH DEVICE EX Formulary Exclusion

IN TOUCH STERILE LANCETS 30G Tier 2

INFINITY BLOOD GLUCOSE SYSTEM KITW/DEVICE EX Formulary Exclusion

INFINITY VOICE KIT W/DEVICE EX Formulary Exclusion

INSUL-TOTE Tier 3

INSUL-TOTE JR Tier 3

kinney lancets Tier 2

kinney thin lancets Tier 2

KROGER AUTOLET LANCING DEVICE Tier 2

kroger blood glucose kit w/device EX Formulary Exclusion

KROGER HEALTHPRO GLUC MON SYS KIT W/DEVICE EX Formulary Exclusion

KROGER HEALTHPRO LANCET 26G Tier 2

kroger lancets Tier 2

kroger lancets 21g Tier 2

kroger lancets micro thin 33g Tier 2

kroger lancets super thin Tier 2

kroger lancets thin Tier 2

kroger lancets thin 26g Tier 2

kroger lancets ultrathin 30g Tier 2

kroger lancing device Tier 2

kroger premium blood glucose kit w/device EX Formulary Exclusion

lancet device with ejector Tier 2

lancet transporter case Tier 2

lancets Tier 2

lancets 28g Tier 2

lancets 30g Tier 2

lancets 33g Tier 2

lancets micro thin 33g Tier 2

lancets super thin 28g Tier 2

lancets thin Tier 2

LANCETS ULTRA FINE Tier 2

LANCETS ULTRA THIN Tier 2

lancets ultra thin 30g Tier 2

320

Drug Name Drug Tier Noteslancing device Tier 2

LANZO Tier 2

ldr blood glucose truetest kit w/device EX Formulary Exclusion

leader advanced lancing device Tier 2

liberty blood glucose meter device EX Formulary Exclusion

LIBERTY MEDICAL LANCETS Tier 2

LIBERTY MINI LANCING DEVICE Tier 2

LIBERTY NXT GENERATION MONITOR DEVICE EX Formulary Exclusion

LIFESCAN UNISTIK 2 Tier 2

LIFESCAN UNISTIK II LANCETS Tier 2

lite touch lancets Tier 2

LITETOUCH LANCETS Tier 2

live better adv lancing device Tier 2

live better lancet super thin Tier 2

live better lancet ultra thin Tier 2

longs lancets standard Tier 2

longs lancets thin Tier 2

longs lancets ultra thin Tier 2

medichoice safety lancet Tier 2

medichoice safety lancet extra Tier 2

medichoice safety lancet norm Tier 2

MEDISENSE THIN LANCETS Tier 2

MEDLANCE EXTRA 21G Tier 2

MEDLANCE LITE 25G Tier 2

MEDLANCE PLUS EXTRA 21G Tier 2

MEDLANCE PLUS LANCETS Tier 2

MEDLANCE PLUS LITE 25G Tier 2

MEDLANCE PLUS SPECIAL 0.8MM Tier 2

MEDLANCE PLUS SUPERLITE 30G Tier 2

MEDLANCE PLUS UNIVERSAL 21G Tier 2

MEDLANCE UNIVERSAL 21G Tier 2

meijer blood glucose kit w/device EX Formulary Exclusion

meijer essential blood glucose kit w/device EX Formulary Exclusion

MEIJER LANCETS Tier 2

MEIJER LANCETS THIN Tier 2

MEIJER LANCETS UNIVERSAL 21G Tier 2

MEIJER LANCETS UNIVERSAL 30G Tier 2

321

Drug Name Drug Tier NotesMEIJER LANCETS UNIVERSAL 33G Tier 2

meijer premium blood glucose kit w/device EX Formulary Exclusion

MEIJER SUPER THIN LANCETS Tier 2

MEIJER TRUE2GO BLOOD GLUCOSE KITW/DEVICE EX Formulary Exclusion

MEIJER TRUERESULT GLUCOSE SYS KIT W/DEVICE EX Formulary Exclusion

MEIJER TRUETRACK GLUCOSE SYS KITW/DEVICE EX Formulary Exclusion

MICRODOT BLOOD GLUCOSE SYSTEM KIT W/DEVICE EX Formulary Exclusion

MICROLET LANCETS Tier 2

MICROLET NEXT LANCING DEVICE Tier 2

mini lancing device Tier 2

MINILINK REAL-TIME TRANSMITTER EX Formulary Exclusion

MINIMED 630G GUARDIAN PRESS EX Formulary Exclusion

MM EASY TOUCH GLUCOSE METER KITW/DEVICE EX Formulary Exclusion

MM TWIST LANCETS Tier 2

MONOLET LANCETS Tier 2

MONOLET OPD LANCETS Tier 2

MONOLETTOR SAFETY LANCETS Tier 2

mpd safety lancet 21g Tier 2




multi-lancet device Tier 2

MULTI-LANCET DEVICE 2 KIT Tier 2

MYGLUCOHEALTH BLOOD GLUCOSE KIT W/DEVICE EX Formulary Exclusion

MYGLUCOHEALTH LANCETS 30G Tier 2

NOVA MAX BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

NOVA MAX BLOOD GLUCOSE SYSTEM KIT W/DEVICE EX Formulary Exclusion

NOVA SAFETY LANCETS 23G Tier 2

NOVA SAFETY LANCETS 28G Tier 2

NOVA SUREFLEX LANCETS Tier 2

NOVA SUREFLEX LANCING DEVICE Tier 2

ON CALL LANCETS Tier 2

322

Drug Name Drug Tier NotesON CALL LANCING DEVICE Tier 2

ON CALL PLUS LANCETS Tier 2

ON CALL PLUS LANCING DEVICE Tier 2

one drop blood glucose monitor kit w/device EX Formulary Exclusion

ONETOUCH CLUB LANCETS FINE PT Tier 2

ONETOUCH DELICA LANCETS 30G Tier 2

ONETOUCH DELICA LANCETS 33G Tier 2

ONETOUCH DELICA PLUS LANCET30G Tier 2

ONETOUCH DELICA PLUS LANCET33G Tier 2

ONETOUCH DELICA PLUS LANCING Tier 2

ONETOUCH FINEPOINT LANCETS Tier 2

ONETOUCH ULTRA 2 KIT W/DEVICE Tier 3

ONETOUCH ULTRA MINI KIT W/DEVICE Tier 3

ONETOUCH ULTRALINK KIT W/DEVICE Tier 3

ONETOUCH ULTRASOFT LANCETS Tier 2

ONETOUCH VERIO FLEX SYSTEM KITW/DEVICE Tier 3

ONETOUCH VERIO IQ SYSTEM KITW/DEVICE Tier 3

ONETOUCH VERIO KIT W/DEVICE Tier 3

ONETOUCH VERIO REFLECT KITW/DEVICE Tier 3

ONETOUCH VERIO SYNC SYSTEM KITW/DEVICE Tier 3

oval tape Tier 3

PARADIGM REAL-TIME TRANSMITTER EX Formulary Exclusion

pc lancets super thin 30g Tier 2

PENLET II BLOOD SAMPLER KIT Tier 2

PENLET II REPLACEMENT CAP Tier 2

PEN-TOTE Tier 3

PERFECT LANCETS 28G Tier 2

PERFECT LANCETS 30G Tier 2

PHARMACIST CHOICE AUTOCODE SYS KIT W/DEVICE EX Formulary Exclusion

PHARMACIST CHOICE LANCETS Tier 2

PHARMACIST CHOICE MINI SYSTEM DEVICE EX Formulary Exclusion

PHARMACY COUNTER LANCETS Tier 2

pip lancets 28g Tier 2

pip lancets 30g Tier 2

323

Drug Name Drug Tier NotesPOCKETCHEM EZ SYSTEM KITW/DEVICE EX Formulary Exclusion

POGO AUTOMATIC BLOOD GLUCOSE DEVICE Tier 3

PRECISION THINS GP LANCETS Tier 2

PRECISION XTRA KIT W/DEVICE Tier 3

preferred plus lancets colored Tier 2

preferred plus lancets thin Tier 2

pressure activat safety lancet Tier 2

pro comfort lancets 30g Tier 2

pro comfort lancets 31g Tier 2

pro voice v8 glucose system device EX Formulary Exclusion

pro voice v9 glucose system device EX Formulary Exclusion

PRODIGY AUTOCODE BLOOD GLUCOSE DEVICE EX Formulary Exclusion

PRODIGY AUTOCODE BLOOD GLUCOSE KIT W/DEVICE EX Formulary Exclusion

PRODIGY LANCETS 28G Tier 2

PRODIGY LANCING DEVICE Tier 2

PRODIGY NO CODING BLOOD GLUC KITW/DEVICE EX Formulary Exclusion

PRODIGY POCKET BLOOD GLUCOSE KIT W/DEVICE EX Formulary Exclusion

PRODIGY SAFETY LANCETS 26G Tier 2

PRODIGY TWIST TOP LANCETS 28G Tier 2

PRODIGY VOICE BLOOD GLUCOSE KITW/DEVICE EX Formulary Exclusion

PSS SELECT GP LANCETS Tier 2

PSS SELECT PLATFORMS Tier 2

PSS SELECT SAFETY LANCETS Tier 2

pure comfort lancets 30g Tier 2

push button safety lancets Tier 2

push button safety lancets 28g Tier 2

px advanced lancing device Tier 2

px lancets microthin 33g Tier 2

px lancets ultra thin Tier 2

px lancets ultra thin 28g Tier 2

qc advanced lancing device Tier 2

qc lancets super thin 30g Tier 2

qc lancets ultra thin Tier 2

324

Drug Name Drug Tier Notesqc unilet lancets 28g Tier 2

qc unilet lancets micro thin Tier 2

QUICKTEK KIT EX Formulary Exclusion

QUICKTEK/METER KIT EX Formulary Exclusion

RA E-ZJECT LANCETS 28G Tier 2

RA E-ZJECT LANCETS THIN 26G Tier 2

RA E-ZJECT LANCETS THIN 28G Tier 2

RA E-ZJECT LANCETS ULTRA THIN Tier 2

READYLANCE SAFETY LANCETS Tier 2

reality lancets Tier 2

reality trigger lancets Tier 2

REFUAH PLUS MONITORING SYSTEM KIT W/DEVICE EX Formulary Exclusion

RELION ALL-IN-ONE DEVICE EX Formulary Exclusion

RELION CONFIRM GLUCOSE MONITOR KIT W/DEVICE EX Formulary Exclusion

RELION LANCETS MICRO-THIN 33G Tier 2

RELION LANCETS THIN 26G Tier 2

RELION LANCETS ULTRA-THIN 30G Tier 2

RELION LANCING DEVICE Tier 2

RELION LANCING DEVICE KIT Tier 2

RELION MICRO KIT W/DEVICE EX Formulary Exclusion

RELION PREMIER BLU MONITOR DEVICE EX Formulary Exclusion

RELION PREMIER CLASSIC DEVICE EX Formulary Exclusion

RELION PREMIER COMPACT SYSTEM KIT W/DEVICE EX Formulary Exclusion

RELION PREMIER VOICE MONITOR DEVICE EX Formulary Exclusion

RELION PRIME MONITOR DEVICE EX Formulary Exclusion

RELION TRUE MET AIR GLUC METER KIT W/DEVICE Tier 3

RELION ULTIMA GLUCOSE SYSTEM KITW/DEVICE EX Formulary Exclusion

RELION ULTRA THIN LANCETS 30G Tier 2

RELION ULTRA THIN PLUS LANCETS Tier 2

REXALL BLOOD GLUCOSE SYSTEM KITW/DEVICE EX Formulary Exclusion

REXALL LANCETS ULTRA THIN 30G Tier 2

RIGHTEST ALTERNATE SITE ADAPT Tier 2

325

Drug Name Drug Tier NotesRIGHTEST GD500 LANCING DEVICE Tier 2

RIGHTEST GL300 LANCETS Tier 2

RIGHTEST GM100 BLOOD GLUCOSE KITW/DEVICE EX Formulary Exclusion



RIGHTEST GT333 BLOOD GLUCOSE DEVICE Tier 3

SAFE-T-LANCE Tier 2

SAFE-T-LANCE PLUS Tier 2

safety lancet 21g/pressure act Tier 2




SAFETY LANCETS Tier 2

SAFETY LANCETS 21G Tier 2

safety lancets 28g Tier 2

SAFETY LET LANCETS Tier 2

SAFETY SEAL LANCETS Tier 2

saps health twist top lancets Tier 2

saps twist top lancets Tier 2

sapscare twist top lancets Tier 2

sb lancets thin Tier 2

sb lancets ultra thin Tier 2

SHOPKO AUTOLET LANCING DEVICE Tier 2

SHOPKO ON-THE-GO LANCETS 30G Tier 2

SHOPKO UNILET LANCETS 28G Tier 2

SHOPKO UNILET LANCETS 30G Tier 2

side button safety lancet Tier 2

SINGLE-LET Tier 2

sm lancets 33g Tier 2

SMART DIABETES VANTAGE LANCING Tier 2

SMART SENSE COLOR LANCETS 33G Tier 2

SMART SENSE PREMIUM SYSTEM KITW/DEVICE EX Formulary Exclusion

SMART SENSE STANDARD LANCETS Tier 2

SMART SENSE SUPER THIN LANCETS Tier 2

326

Drug Name Drug Tier NotesSMART SENSE THIN LANCETS 26G Tier 2

SMART SENSE VALUE GLUCOSE SYS KITW/DEVICE EX Formulary Exclusion

SMARTEST EJECT DEVICE EX Formulary Exclusion

SMARTEST EJECT STARTER KITW/DEVICE EX Formulary Exclusion

SMARTEST LANCETS 28G Tier 2

SMARTEST PERSONA STARTER KITW/DEVICE EX Formulary Exclusion

SMARTEST PRONTO STARTER KITW/DEVICE EX Formulary Exclusion

SMARTEST PROTEGE DEVICE EX Formulary Exclusion

SMARTEST PROTEGE STARTER KITW/DEVICE EX Formulary Exclusion

SOLUS V2 BLOOD GLUCOSE SYSTEM DEVICE EX Formulary Exclusion

SOLUS V2 BLOOD GLUCOSE SYSTEM KIT W/DEVICE EX Formulary Exclusion

SOLUS V2 LANCETS 28G Tier 2

SOLUS V2 LANCING DEVICE Tier 2

SOLUS V2 TWIST LANCETS 30G Tier 2

STERILANCE PA Tier 2

STERILANCE TL Tier 2

super thin lancets Tier 2

sure comfort lancets 18g Tier 2





SURE-LANCE FLAT LANCETS Tier 2

SURE-LANCE LANCETS 26G Tier 2

SURE-LANCE THIN LANCETS 28G Tier 2

SURE-LANCE ULTRA THIN LANCETS Tier 2

SURELITE LANCETS Tier 2

SURESTEP PRO LINEARITY KIT Tier 3

SURE-TEST EASYPLUS MINI METER DEVICE EX Formulary Exclusion

SURE-TOUCH LANCETS UNIVERSAL Tier 2

TECHLITE AST LANCETS Tier 2

TECHLITE LANCETS Tier 2

327

Drug Name Drug Tier NotesTECHLITE LANCETS 30G Tier 2

tgt blood glucose monitoring kit w/device EX Formulary Exclusion

tgt lancet micro thin 33g Tier 2

tgt lancet thin 26g Tier 2

tgt lancet ultra thin 30g Tier 2

tgt lancing device Tier 2

THINLETS GP LANCETS Tier 2

todays health lancing device Tier 2

todays health thin lancets 28g Tier 2

todays health thin lancets 30g Tier 2

topcare lancets micro-thin 33g Tier 2

TRACER II 3 VOLT BATTERY Tier 3

travel lancets Tier 2

TRAVEL LANCETS ADVANCED 28G Tier 2

true comfort twist top lancets Tier 2

TRUE FOCUS BLOOD GLUCOSE METER DEVICE EX Formulary Exclusion

TRUE METRIX AIR GLUCOSE METER DEVICE EX Formulary Exclusion

TRUE METRIX AIR GLUCOSE METER KIT W/DEVICE EX Formulary Exclusion

TRUE METRIX GO GLUCOSE METER KITW/DEVICE EX Formulary Exclusion

TRUE METRIX METER DEVICE EX Formulary Exclusion

TRUE METRIX METER KIT W/DEVICEW/DEVICE Tier 3

TRUE METRIX METER KIT W/DEVICEW/DEVICE EX Formulary Exclusion

TRUEDRAW LANCING DEVICE Tier 2

TRUEPLUS LANCETS 26G Tier 2




TRUEPLUS SAFETY LANCETS 28G Tier 2

TRUERESULT BLOOD GLUCOSE KITW/DEVICE EX Formulary Exclusion

TRUETRACK BLOOD GLUCOSE DEVICE EX Formulary Exclusion

TRUETRACK BLOOD GLUCOSE KITW/DEVICE EX Formulary Exclusion

TRUETRACK SMART SYSTEM KIT EX Formulary Exclusion

328

Drug Name Drug Tier NotesULTILET CLASSIC LANCETS Tier 2

ULTILET LANCETS Tier 2

ULTILET SAFETY LANCETS Tier 2

ULTILET SAFETY LANCETS 23G Tier 2

ultra thin lancets 31g Tier 2

ultra-care lancets 30g Tier 2

ULTRALANCE Tier 2

ULTRA-THIN II AUTO LANCET Tier 2

UNILET COMFORTOUCH LANCET Tier 2

UNILET EXCELITE Tier 2

UNILET EXCELITE II Tier 2

UNILET G.P. LANCET Tier 2

UNILET G.P. SUPERLITE LANCET Tier 2

UNILET GP 28 ULTRA THIN Tier 2

UNILET LANCET Tier 2

UNILET MICRO-THIN 33G Tier 2

UNILET SUPERLITE LANCET Tier 2

UNILET SUPER-THIN 30G Tier 2

UNILET ULTRA-THIN 28G Tier 2

UNISTIK 1 Tier 2

UNISTIK 2 Tier 2

UNISTIK 2 COMFORT Tier 2

UNISTIK 2 EXTRA Tier 2

UNISTIK 2 NEONATAL Tier 2

UNISTIK 2 NORMAL Tier 2

UNISTIK 2 SUPER Tier 2

UNISTIK 3 Tier 2

UNISTIK 3 COMFORT Tier 2

UNISTIK 3 EXTRA Tier 2

UNISTIK 3 GENTLE Tier 2

UNISTIK 3 NEONATAL Tier 2

UNISTIK 3 NORMAL Tier 2

UNISTIK CZT COMFORT Tier 2

UNISTIK CZT NORMAL Tier 2

UNISTIK NORMAL Tier 2

UNISTIK PRO SAFETY LANCET Tier 2

UNISTIK SAFETY LANCETS 28G Tier 2

UNISTIK SAFETY LANCETS 30G Tier 2

329

Drug Name Drug Tier NotesUNISTIK TOUCH SAFETY LANC 21G Tier 2

UNISTIK TOUCH SAFETY LANC 23G Tier 2



UNIVERSAL 1 LANCETS THIN 26G Tier 2

UNIVERSAL 1 LANCETS THIN 33G Tier 2

UNIVERSAL 1 LANCETS ULTRA THIN Tier 2

value plus lancet standard 21g Tier 2

value plus lancets super thin Tier 2

value plus lancets thin 26g Tier 2

valumark lancet super thin 30g Tier 2

valumark lancet ultra thin 28g Tier 2

verasens blood glucose meter device EX Formulary Exclusion

verasens blood glucose system kit w/device EX Formulary Exclusion

VIDA MIA AUTOLET LANCING DEV Tier 2

VIDA MIA UNILET LANCETS 28G Tier 2

VIDA MIA UNILET LANCETS 30G Tier 2

VITALET PRO LANCETS Tier 2

VITALET PRO PLUS LANCETS Tier 2

VIVAGUARD INO GLUCOSE METER DEVICE EX Formulary Exclusion

VIVAGUARD INO SMART GLUC METER DEVICE EX Formulary Exclusion

VIVAGUARD LANCETS Tier 2

walgreens adv travel lancets Tier 2

WALGREENS LANCETS Tier 2

walgreens lancets micro thin Tier 2

walgreens lancets super thin Tier 2

WALGREENS THIN LANCETS Tier 2

WALGREENS ULTRA THIN LANCETS Tier 2

WAVESENSE AMP KIT W/DEVICE EX Formulary Exclusion

zevrx twist top lancets 30g Tier 2

*Glucose/Ketone Monitoring Test Supplies***CARDIO CHEK Tier 3

CARDIO CHEK PA Tier 3

FORA TN'G ADVANCE PRO DEVICE Benefit Exclusion

GOJJI MULTI-FUNCTIONAL SYSTEM DEVICE Benefit Exclusion

330

Drug Name Drug Tier NotesGOJJI MULTI-FUNCTIONAL SYSTEM KITW/DEVICE Benefit Exclusion

*Incontinence Supplies***URESTA STARTER KIT EX Non FDA Exclusion

*Insulin Administration Supplies***ACCU-CHEK LINKASSIST EX Formulary Exclusion

MINIMED 770G INSULIN PUMP SYS KIT EX Formulary Exclusion

MINIMED MIO ADVANCE INFUSE SET EX Formulary Exclusion

MINIMED QUICK SET INF SET 18" EX Formulary Exclusion




OMNIPOD 5 G6 INTRO (GEN 5) KIT Tier 2

OMNIPOD 5 G6 POD (GEN 5) Tier 2

OMNIPOD CLASSIC PDM (GEN 3) KIT EX Formulary Exclusion

OMNIPOD CLASSIC PODS (GEN 3) Tier 2

OMNIPOD DASH INTRO (GEN 4) KIT Tier 2

OMNIPOD DASH PODS (GEN 4) Tier 2

SURE T INFUSION SET 18"/6MM Tier 3

SURE T INFUSION SET 32"/10MM EX Formulary Exclusion

T: SLIM X2 INS PMP/CONTROL 7.4 DEVICE EX Formulary Exclusion

T:SLIM X2 3ML CARTRIDGE EX Formulary Exclusion

T:SLIM X2 INSULIN PMP BASAL6.4 DEVICE EX Formulary Exclusion

V-GO 20 KIT Tier 2

V-GO 30 KIT Tier 2

V-GO 40 KIT Tier 2

*Ketone Monitoring Test Supplies***GOJJI CONTROL LEVEL 1 IN VITRO SOLUTION Benefit Exclusion

*Masks***SAFE-SENSE EARLOOP FACE MASK EX Non FDA Exclusion

*Misc. Devices***CLEVER CHOICE PULSE OXIMETER Benefit Exclusion

face shield full length EX Non FDA Exclusion

face shield full length/clear EX Non FDA Exclusion

MAD NASAL ATOMIZATION DEVICE Benefit Exclusion

331


*Nebulizers***CLEVER CHOICE WHIS AIR PED NEB Benefit Exclusion

CLEVER CHOICE WHISPER AIRE NEB Benefit Exclusion

COMP A-I-R NEBULIZER Benefit Exclusion

MICROAIR VIBRATING MESH NEBUL Benefit Exclusion

MICRONEB Benefit Exclusion

neb-rite4 Benefit Exclusion

nebulizer ped frog Benefit Exclusion

nebulizer ped frog kit Benefit Exclusion

PULMONEB LT EX Formulary Exclusion

*Needles & Syringes***1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 6 mm , 33g x 4 mm

Tier 2

1st tier unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 33g x 4 mm

Tier 2

ABOUTTIME PEN NEEDLE 30G X 8 MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM Tier 2

ADVOCATE INSULIN PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 33G X 4 MM

Tier 2

ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 31G X 15/64" 1 ML

Tier 2

ASSURE ID SAFETY PEN NEEDLES 30G X 5 MM , 30G X 8 MM , 31G X 5 MM Tier 2

aum mini insulin pen needle 32g x 4 mm , 32g x 5 mm , 32g x 6 mm , 32g x 8 mm , 33g x 4 mm , 33g x 5 mm , 33g x 6 mm

Tier 2

AUM READYGARD DUO PEN NEEDLE32G X 4 MM Tier 2

AUM SAFETY PEN NEEDLE 31G X 4 MM , 31G X 5 MM Tier 2

aurora pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm

Tier 2

aurora unifine pentips 31g x 5 mm , 32g x 4 mm Tier 2

autopen device Tier 2

332

Drug Name Drug Tier NotesBD ALLERGIST TRAY KIT 27G X 1/2" 1 ML Tier 2

BD ALLERGY SYRINGE 28G X 1/2" 1 ML Tier 2

BD AUTOSHIELD 29G X 5MM , 29G X 8MM Tier 2

BD AUTOSHIELD DUO 30G X 5 MM Tier 2

BD DISP NEEDLE 27G X 1-1/4" Tier 2

BD ECLIPSE NEEDLE 25G X 1-1/2" , 25G X 5/8" Tier 2

BD ECLIPSE SHIELDED NEEDLE 18G X 1-1/2" Tier 2

BD ECLIPSE SYRINGE 22G X 1-1/2" 3 ML, 27G X 1/2" 1 ML, 30G X 1/2" 1 ML Tier 2

BD ECLIPSE SYRINGE/NEEDLE 22G X 1" 3 ML, 25G X 5/8" 3 ML Tier 2

BD HYPODERMIC NEEDLE 23G X 1" Tier 2

BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML Tier 2

BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, U-100 1 ML

Tier 2

BD INSULIN SYRINGE HALF-UNIT 31G X 5/16" 0.3 ML Tier 2

BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML

Tier 2

BD INSULIN SYRINGE U/F 1/2UNIT 31G X 5/16" 0.3 ML Tier 2

BD INSULIN SYRINGE U/F 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML Tier 2

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 31G X 5/16" 0.5 ML

Tier 2

BD INTEGRA SYRINGE 21G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML Tier 2

BD LUER-LOK SYRINGE 10 ML , 23G X 1" 3 ML Tier 2

BD PEN Tier 2

333

Drug Name Drug Tier NotesBD PEN MINI Tier 2

BD PEN NEEDLE MICRO U/F 32G X 6 MM Tier 2

BD PEN NEEDLE MINI U/F 31G X 5 MM Tier 2

BD PEN NEEDLE NANO 2ND GEN 32G X 4 MM Tier 2

BD PEN NEEDLE NANO U/F 32G X 4 MM Tier 2

BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM Tier 2

BD PEN NEEDLE SHORT U/F 31G X 8 MM Tier 2

BD SAFETYGLIDE ALLERGY SYRINGE27G X 1/2" 1 ML Tier 2

BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML

Tier 2

BD SAFETYGLIDE NEEDLE 21G X 1" , 25G X 1" , 27G X 5/8" Tier 2

BD SAFETYGLIDE SHIELDED NEEDLE22G X 1-1/2" Tier 2

BD SAFETY-LOK INSULIN SYRINGE 29G X 1/2" 1 ML Tier 2

BD SYRINGE LUER SLIP TIP 5 ML Tier 2

BD SYRINGE LUER-LOK 3 ML , 30 ML , 5 ML Tier 2

BD SYRINGE SLIP TIP 1 ML , 26G X 5/8" 1 ML, 3 ML Tier 2

BD SYRINGE/NEEDLE 25G X 5/8" 1 ML, 25G X 5/8" 3 ML Tier 2

BD TB SYRINGE 21G X 1" 1 ML Tier 2

BD VEO INSULIN SYR U/F 1/2UNIT 31G X 15/64" 0.3 ML Tier 2

BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML

Tier 2

CAREFINE PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM

Tier 2

careone insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

careone unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm

Tier 2

334

Drug Name Drug Tier Notescareone unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 33g x 4 mm

Tier 2

CAREPOINT SAFETY1ST SYR/NEEDLE23G X 1" 1 ML, 23G X 1" 3 ML, 25G X 1" 1 ML, 25G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2

CARETOUCH INSULIN SYRINGE 28G X 5/16" 1 ML, 29G X 5/16" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

CARETOUCH LUER SLIP 3 ML Tier 2

CARETOUCH PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM

Tier 2

CEQUR SIMPLICITY 2U DEVICE Tier 2

CEQUR SIMPLICITY INSERTER Tier 2

CEQUR SIMPLICITY INSERTER Tier 3

CLEVER CHOICE COMFORT EZ 29G X 12MM , 33G X 4 MM Tier 2

CLICKFINE PEN NEEDLES 31G X 5 MM31G X 5 MM Tier 2

clickfine pen needles 31g x 6 mm 31g x 6 mm Tier 2



COMFORT ASSIST INSULIN SYRINGE31G X 5/16" 0.3 ML Tier 2

COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

COMFORT EZ MICRO PEN NEEDLES 32G X 4 MM Tier 2

COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM , 33G X 8 MM

Tier 2

COMFORT EZ SHORT PEN NEEDLES 31G X 8 MM Tier 2

335

Drug Name Drug Tier NotesCOMFORT TOUCH INSULIN PEN NEED31G X 4 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM

Tier 2

DIATHRIVE PEN NEEDLE 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM Tier 2

DROPLET INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 15/64" 0.3 ML, 30G X 15/64" 0.5 ML, 30G X 15/64" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

DROPLET MICRON 34G X 3.5 MM Tier 2

DROPLET PEN NEEDLES 29G X 10MM , 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 32G X 8 MM

Tier 2

dropsafe safety pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm

Tier 2

drug mart unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm

Tier 2

drug mart unifine pentips plus 32g x 4 mm Tier 2

easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml, 32g x 5/16" 0.5 ml, 32g x 5/16" 1 ml

Tier 2

easy comfort pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 33g x 4 mm , 33g x 5 mm , 33g x 6 mm

Tier 2

easy glide pen needles 33g x 4 mm Tier 2

EASY TOUCH FLIPLOCK INSULIN SY 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML

Tier 2

EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML

Tier 2

336

Drug Name Drug Tier NotesEASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

EASY TOUCH PEN NEEDLES 29G X 12MM , 30G X 5 MM , 30G X 6 MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM

Tier 2

EASY TOUCH SAFETY PEN NEEDLES 29G X 5MM , 29G X 8MM , 30G X 8 MM Tier 2

EASY TOUCH SHEATHLOCK SYRINGE29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML

Tier 2

EASY TOUCH SYRINGE BARREL 10ML Tier 2




EASYPOINT NEEDLE 23G X 1" , 25G X 1" , 25G X 5/8" Tier 2

EASYPOINT NEEDLE/SYRINGE 18G X 1" 3 ML, 18G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2

elite-thin insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 28g x 5/16" 0.5 ml, 28g x 5/16" 1 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 29g x 5/16" 0.5 ml, 29g x 5/16" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

eql insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

EXEL COMFORT POINT INSULIN SYR28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 2

EXEL COMFORT POINT PEN NEEDLE29G X 12MM , 31G X 4 MM , 31G X 6 MM , 31G X 8 MM

Tier 2

FIFTY50 PEN NEEDLES 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM Tier 2

337

Drug Name Drug Tier NotesFIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

freds pharmacy unifine pentip+ 31g x 5 mm , 31g x 8 mm

Tier 2

freds pharmacy unifine pentips 32g x 4 mm Tier 2

FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

global ease inject pen needles 29g x 12mm , 31g x 5 mm , 31g x 8 mm , 32g x 4 mm

Tier 2

global easy glide insulin syr 31g x 15/64" 0.3 ml, 31g x 15/64" 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml

Tier 2

global easy glide pen needles 32g x 4 mm Tier 2

global inject ease insulin syr 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

global insulin syringes 30g x 1/2" 0.3 ml, 30g x 5/16" 0.3 ml

Tier 2

GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

gnp clickfine pen needles 31g x 6 mm , 31g x 8 mm

Tier 2

gnp insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

gnp insulin syringes 28gx1/2" 28g x 1/2" 1 ml Tier 2

gnp insulin syringes 29gx1/2" 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

Tier 2

gnp insulin syringes 30g x 5/16" 1 ml Tier 2

gnp insulin syringes 30gx5/16" 30g x 5/16" 0.3 ml Tier 2

gnp insulin syringes 31gx5/16" 31g x 5/16" 0.3 ml Tier 2

gnp ulticare pen needles 31g x 5 mm , 31g x 8 mm , 32g x 4 mm , 32g x 6 mm

Tier 2

338

Drug Name Drug Tier NotesGNP ULTIGUARD SAFEPACK NEEDLE31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

Tier 2

gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml

Tier 2

goodsense clickfine pen needle 31g x 5 mm Tier 2

GOODSENSE PEN NEEDLE PENFINE 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

Tier 2

healthwise insulin syr/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

healthwise micron pen needles 32g x 4 mm Tier 2

healthwise mini pen needles 31g x 6 mm Tier 2

healthwise pen needles 29g x 12mm Tier 2

healthwise short pen needles 31g x 5 mm , 31g x 8 mm

Tier 2

healthwise unifine pentips 32g x 4 mm Tier 2

healthy accents unifine pentip 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm

Tier 2

h-e-b incontrol pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm

Tier 2

H-E-B INCONTROL UNIFINE PENTIP 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 33G X 4 MM

Tier 2

HM ULTICARE INSULIN SYRINGE 30G X 1/2" 1 ML, 31G X 5/16" 0.3 ML Tier 2

HM ULTICARE MINI PEN NEEDLES 31G X 5 MM Tier 2

HM ULTICARE SHORT PEN NEEDLES31G X 8 MM Tier 2

INPEN 100-BLUE-LILLY-HUMALOG DEVICE Tier 2

INPEN 100-BLUE-NOVOLOG-FIASP DEVICE Tier 2

INPEN 100-GREY-LILLY-HUMALOG DEVICE Tier 2

INPEN 100-GREY-NOVOLOG-FIASP DEVICE Tier 2

INPEN 100-PINK-LILLY-HUMALOG DEVICE Tier 2

INPEN 100-PINK-NOVOLOG-FIASP DEVICE Tier 2

339

Drug Name Drug Tier Notesinsulin syringe 27g x 1/2" 0.5 ml, 27g x 1/2" 1 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml

Tier 2

insulin syringe-needle u-100 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

insupen pen needles 29g x 12mm , 31g x 5 mm , 31g x 8 mm , 32g x 4 mm , 33g x 4 mm

Tier 2

INSUPEN SENSITIVE 32G X 6 MM , 32G X 8 MM Tier 2

INSUPEN ULTRAFIN 29G X 12MM , 30G X 8 MM , 31G X 6 MM , 31G X 8 MM Tier 2

kinray insulin syringe 29g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

kmart valu insulin syringe 29g u-100 0.5 ml, u-100 1 ml

Tier 2

kmart valu insulin syringe 30g u-100 0.3 ml, u-100 0.5 ml, u-100 1 ml

Tier 2

kroger insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

kroger pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 33g x 4 mm

Tier 2

leader insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

LEADER UNIFINE PENTIPS 31G X 5 MM , 32G X 4 MM Tier 2

LEADER UNIFINE PENTIPS PLUS 31G X 5 MM , 31G X 8 MM , 32G X 4 MM Tier 2

340

Drug Name Drug Tier NotesLITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

LITETOUCH PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

longs insulin syringe 31g x 5/16" 0.5 ml Tier 2

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 2

MAGELLAN SYRINGE-SAFETY NEEDLE23G X 1" 1 ML Tier 2

MAGELLAN TUBERCULIN SYRINGE 27G X 1/2" 1 ML, 28G X 1/2" 1 ML Tier 2

MARATHON MEDICAL PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

MAXICOMFORT II PEN NEEDLE 31G X 6 MM Tier 2

MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 ML Tier 2

MAXI-COMFORT SAFETY PEN NEEDLE29G X 5MM , 29G X 8MM Tier 2

MAXICOMFORT SYR 27G X 1/2" 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML Tier 2

medic insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml

Tier 2

medicine shoppe pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm

Tier 2

meijer pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm

Tier 2

MICRODOT PEN NEEDLE 31G X 6 MM , 32G X 4 MM , 33G X 4 MM Tier 2

mm insulin syringe/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

MM PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM Tier 2

MONOJECT ALLERGIST TRAY KIT 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML

Tier 2

341

Drug Name Drug Tier NotesMONOJECT BLUNTIP CANNULA 20G X 1-1/2" , 21G X 1" Tier 2

MONOJECT BLUNTIP SYR/CANNULA 3 ML , 6 ML Tier 2

MONOJECT CONTROL SYRINGE 12 ML , 20 ML Tier 2

MONOJECT FILTER ASPIRATOR Tier 2

MONOJECT FILTER NEEDLE 18G X 1-1/2" , 20G X 1-1/2" Tier 2

MONOJECT HYPODERMIC NEEDLE 14G X 1" , 14G X 1-1/2" , 14G X 2" , 16G X 1" , 16G X 1-1/2" , 16G X 3/4" , 16G X 5/8" , 18G X 1" , 18G X 1-1/2" , 19G X 1" , 19G X 1-1/2" , 20G X 1" , 20G X 1-1/2" , 21G X 1" , 21G X 1-1/2" , 21G X 2" , 22G X 1" , 22G X 1-1/2" , 23G X 1" , 23G X 3/4" , 25G X 1" , 25G X 1-1/2" , 25G X 1-1/4" , 25G X 2" , 25G X 5/8" , 26G X 1-1/2" , 26G X 1/2" , 27G X 1-1/2" , 27G X 1-1/4" , 27G X 1/2" , 30G X 3/4"

Tier 2

MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML, U-100 1 ML

Tier 2

MONOJECT INTRODUCER NEEDLE 18G X 1-1/4" Tier 2

MONOJECT LIFESHIELD SYRINGE 18G X 1" 12 ML, 18G X 1" 3 ML Tier 2

MONOJECT MAGELLAN SAFETY NDL18G X 1" , 18G X 1-1/2" , 19G X 1" , 19G X 1-1/2" , 20G X 1" , 20G X 1-1/2" , 21G X 1" , 21G X 1-1/2" , 21G X 5/8" , 22G X 1" , 22G X 1-1/2" , 23G X 1" , 23G X 5/8" , 25G X 1" , 25G X 5/8"

Tier 2

MONOJECT MAGELLAN SYRINGE 18G X 1" 12 ML, 18G X 1" 6 ML, 20G X 1-1/2" 12 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 6 ML, 21G X 1" 12 ML, 21G X 1" 3 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 3 ML, 21G X 1-1/2" 6 ML, 22G X 1-1/2" 12 ML, 22G X 1-1/2" 3 ML, 22G X 1-1/2" 6 ML, 23G X 1" 1 ML, 23G X 1" 3 ML, 25G X 1" 1 ML, 25G X 1" 3 ML, 25G X 5/8" 1 ML, 25G X 5/8" 3 ML

Tier 2

MONOJECT PHARMACY TRAY 12 ML , 20 ML , 3 ML , 35 ML , 6 ML , 60 ML Tier 2

MONOJECT PISTON SYRINGE 140 ML Tier 2

342

Drug Name Drug Tier NotesMONOJECT SYRINGE 12 ML , 18G X 1" 12 ML, 20G X 1" 3 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 6 ML, 20G X 3/4" 3 ML, 21G X 1" 3 ML, 21G X 1" 6 ML, 21G X 1-1/2" 3 ML, 21G X 1-1/2" 6 ML, 22G X 1-1/2" 3 ML, 22G X 1-1/2" 6 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 1-1/4" 3 ML, 25G X 5/8" 3 ML, 27G X 1-1/4" 3 ML, 3 ML , 6 ML

Tier 2

MONOJECT SYRINGE CATH TIP 35 ML , 60 ML Tier 2

MONOJECT SYRINGE ECC LUER 20 ML , 35 ML Tier 2

MONOJECT SYRINGE ECCENTRIC TIP 60 ML Tier 2

MONOJECT SYRINGE LUER LOCK 20 ML , 35 ML , 6 ML , 60 ML Tier 2

MONOJECT SYRINGE LUER-LOCK TIP140 ML , 60 ML Tier 2

MONOJECT SYRINGE PHARMACY TRAY1 ML Tier 2

MONOJECT SYRINGE REG LUER 20 ML , 3 ML , 35 ML , 6 ML Tier 2

MONOJECT SYRINGE REGULAR TIP 20 ML , 3 ML , 6 ML , 60 ML Tier 2

MONOJECT SYRINGE TOOMEY TYPE 60 ML Tier 2

MONOJECT TB SAFETY SYRINGE 25G X 5/8" 1 ML, 28G X 1/2" 1 ML Tier 2

MONOJECT TB SYRINGE 1 ML , 25G X 5/8" 1 ML, 26G X 3/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML

Tier 2

MONOJECT ULTRA COMFORT SYRINGE28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML

Tier 2

ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

multi-draw needle 20g x 1" , 21g x 1" , 22g x 1" Tier 2

NORDIPEN 5 INJECTION DEVICE Tier 2

NORDIPEN DELIVERY SYSTEM Tier 2

NORM-JECT LUER SLIP SYRINGE 1 ML Tier 2

NOVOFINE AUTOCOVER PEN NEEDLE30G X 8 MM Tier 2

343

Drug Name Drug Tier NotesNOVOFINE PEN NEEDLE 32G X 6 MM Tier 2

NOVOFINE PLUS PEN NEEDLE 32G X 4 MM Tier 2

NOVOPEN ECHO DEVICE Tier 2

NOVOTWIST PEN NEEDLE 32G X 5 MM Tier 2

OMNITROPE PEN 5 INJ DEVICE Tier 2

pc unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm

Tier 2

pen needles 1/2" 29g x 12mm Tier 2

pen needles 29g x 12mm , 30g x 5 mm , 30g x 8 mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g x 6 mm , 33g x 4 mm

Tier 2

pen needles 3/16" 31g x 5 mm Tier 2

pen needles 5/16" 30g x 8 mm , 31g x 8 mm Tier 2

PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM

Tier 2

PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Tier 2

PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X 3/8" 0.5 ML, 30G X 5/16" 0.3 ML

Tier 2

preferred plus insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml

Tier 2

preferred plus unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm

Tier 2

PREVENT DROPSAFE PEN NEEDLES 31G X 6 MM , 31G X 8 MM Tier 2

PREVENT SAFETY PEN NEEDLES 31G X 6 MM , 31G X 8 MM Tier 2

PRO COMFORT INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

pro comfort pen needles 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g x 6 mm

Tier 2

PRODIGY INSULIN SYRINGE 28G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML Tier 2

pure comfort pen needle 32g x 4 mm , 32g x 5 mm , 32g x 6 mm , 32g x 8 mm

Tier 2

px extra short pen needles 31g x 6 mm Tier 2

344

Drug Name Drug Tier Notespx insulin syringe 30g x 1/2" 0.5 ml Tier 2

px mini pen needles 31g x 5 mm Tier 2

px pen needle 29g x 12mm , 31g x 8 mm Tier 2

px shortlength pen needles 31g x 8 mm Tier 2

qc pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm

Tier 2

qc unifine pentips 32g x 4 mm Tier 2

ra insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml

Tier 2

ra pen needles 31g x 5 mm , 31g x 8 mm Tier 2

reality insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

Tier 2

RELION INSULIN SYRINGE 29G X 1/2" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

RELION MINI PEN NEEDLES 31G X 6 MM Tier 2

RELION PEN NEEDLES 29G X 12MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM Tier 2

RELION SHORT PEN NEEDLES 31G X 8 MM Tier 2

SAFESNAP INSULIN SYRINGE 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML

Tier 2

safety insulin syringes 27g x 1/2" 1 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml

Tier 2

sb insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 1 ml

Tier 2

SECURESAFE INSULIN SYRINGE 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML Tier 2

SECURESAFE SAFETY PEN NEEDLES 30G X 8 MM Tier 2

SHOPKO UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM Tier 2

SHOPKO UNIFINE PENTIPS PLUS 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

345

Drug Name Drug Tier Notessure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

sure comfort pen needles 29g x 12.7mm , 30g x 8 mm , 31g x 5 mm , 31g x 8 mm , 32g x 4 mm , 32g x 6 mm

Tier 2

SURE-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM Tier 2

SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

syringe luer lock 30 ml Tier 2

syringe luer slip 1 ml Tier 2

tb syringe 1 ml Tier 2

techlite insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 15/64" 0.3 ml, 31g x 15/64" 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

TECHLITE PEN NEEDLES 29G X 10MM , 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM , 32G X 8 MM

Tier 2

todays health mini pen needles 31g x 6 mm Tier 2

todays health pen needles 29g x 12mm Tier 2

todays health short pen needle 31g x 8 mm Tier 2

toomey syringe 70 ml Tier 2

topcare clickfine pen needles 31g x 6 mm , 31g x 8 mm

Tier 2

topcare ultra comfort ins syr 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

true comfort insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

346

Drug Name Drug Tier Notestrue comfort pen needles 31g x 5 mm , 31g x 6 mm , 32g x 4 mm

Tier 2

true comfort pro insulin syr 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml, 32g x 5/16" 0.5 ml, 32g x 5/16" 1 ml

Tier 2

true comfort pro pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g x 6 mm , 33g x 4 mm , 33g x 5 mm , 33g x 6 mm

Tier 2

TRUEPLUS 5-BEVEL PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

TRUEPLUS PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML Tier 2

ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 0.5 ML, 31G X 1/4" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

ULTICARE MICRO PEN NEEDLES 31G X 6 MM , 31G X 8 MM , 32G X 4 MM Tier 2

ULTICARE MINI PEN NEEDLES 30G X 5 MM , 31G X 6 MM , 32G X 6 MM Tier 2

ULTICARE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM Tier 2

ULTICARE SHORT PEN NEEDLES 30G X 8 MM , 31G X 8 MM Tier 2

ultiguard safepack pen needle 29g x 12.7mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 6 mm

Tier 2

347

Drug Name Drug Tier NotesULTIGUARD SAFEPACK SYR/NEEDLE30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML

Tier 2

ULTILET INSULIN SYRINGE SHORT 30G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

ULTILET PEN NEEDLE 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM Tier 2

ultra comfort insulin syringe 30g x 5/16" 0.3 ml Tier 2

ULTRA FLO INSULIN PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 33G X 4 MM

Tier 2

ULTRA FLO INSULIN SYR 1/2 UNIT 30G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML, 31G X 5/16" 0.3 ML

Tier 2

ULTRA FLO INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

ULTRA THIN PEN NEEDLES 32G X 4 MM Tier 2

ultracare insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 2

ultracare pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g x 6 mm , 33g x 4 mm

Tier 2

ULTRA-THIN II INS SYR SHORT 31G X 5/16" 1 ML Tier 2

UNIFINE PEN NEEDLES 32G X 4 MM Tier 2

UNIFINE PENTIPS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM , 33G X 4 MM

Tier 2

348

Drug Name Drug Tier NotesUNIFINE PENTIPS PLUS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 33G X 4 MM

Tier 2

UNIFINE SAFECONTROL PEN NEEDLE30G X 5 MM , 30G X 8 MM , 32G X 4 MM Tier 2

UNIFINE ULTRA PEN NEEDLE 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

value health insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

Tier 2

valumark pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm

Tier 2

VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 30G X 1/2" 0.5 ML, 30G X 3/16" 0.5 ML, 30G X 3/16" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 2

VANISHPOINT SAFETY SYRINGE 21G X 1" 5 ML, 22G X 1-1/2" 5 ML Tier 2

VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM Tier 2

vp insulin syringe 29g x 1/2" 0.3 ml Tier 2

wegmans unifine pentips plus 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm

Tier 2

zevrx insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml

Tier 2

zevrx pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm

Tier 2

*Nerve Stimulators***GAMMACORE DEVICE EX Non FDA Exclusion

GAMMACORE SAPPHIRE 31-DAY DEVICE EX Non FDA Exclusion

GAMMACORE SAPPHIRE D DEVICE EX Non FDA Exclusion

GAMMACORE SAPPHIRE DEVICE EX Non FDA Exclusion

GAMMACORE SAPPHIRE REFILL KIT EX Non FDA Exclusion

*Ocular Implants***SUSVIMO OCULAR IMPLANT INTRAVITREAL IMPLANT EX Medical Only Exclusion

*Respiratory Therapy Supplies***ACE AEROSOL CLOUD ENHANCER EX Formulary Exclusion

adult mask device Tier 2

AEROBIKA DEVICE Tier 2

ALL FLOW 1000 PFT FILTER DEVICE Tier 2

349

Drug Name Drug Tier NotesALL FLOW 2000 PFT FILTER DEVICE Tier 2






BREATHERITE VALVED MDI CHAMBER DEVICE Tier 2

co monitor device Tier 2

IN-CHECK DIAL FLOW TRAINER DEVICE Tier 2

IN-CHECK INSPIRATORY FLOW MTR DEVICE Tier 2

MISTASSIST DEVICE Benefit Exclusion

nebulizer mask adult EX Formulary Exclusion

nebulizer mask child EX Formulary Exclusion

OMBRA TABLE TOP COMPRESSOR DEVICE Tier 2

ONE FLOW SPIROMETER DEVICE Tier 2

PARI MANUAL INTERRUPTER DEVICE Tier 2

PARI TREK S COMBO PACK DEVICE Tier 2

PRIMEAIRE HOLDING CHAMBER DEVICE Tier 2

QUAKE DEVICE Tier 2

silicone mask/adult EX Formulary Exclusion

silicone mask/infant EX Formulary Exclusion

silicone mask/pediatric EX Formulary Exclusion

spiro pd device Tier 2

THRESHOLD PEP DEVICE Tier 2

VORTEX HOLD CHMBR/MASK/CHILD DEVICE Tier 2

VORTEX HOLD CHMBR/MASK/TODDLER DEVICE Tier 2

VORTEX HOLDING CHAMBER/MASK DEVICE Tier 2

*Scar Treatments***cellpad sheet EX Non FDA Exclusion

CICASIL SHEET EX Non FDA Exclusion

cicatrace pad sheet EX Non FDA Exclusion

coatamax patch sheet EX Non FDA Exclusion

350

Drug Name Drug Tier NotesKELOTOP SHEET Benefit Exclusion

NUVA III SHEET Benefit Exclusion

NUVAGEL SHEET Benefit Exclusion

NUVAZIL II SHEET Benefit Exclusion

NUVAZIL SHEET EX Non FDA Exclusion

polytoza patch sheet Benefit Exclusion

PROSILK SHEET EX Non FDA Exclusion

scarcin pad plus sheet EX Non FDA Exclusion

scarcinpad sheet EX Non FDA Exclusion

scarsilk sheet EX Non FDA Exclusion

SILADERM SHEET EX Non FDA Exclusion

siladone scar patch sheet EX Non FDA Exclusion

silivex sheet Benefit Exclusion

SILTREX SHEET EX Non FDA Exclusion

skarlite sheet EX Non FDA Exclusion

SZOSIL 15 DAY SUPPLY SHEET EX Non FDA Exclusion

SZOSIL 8 DAY SUPPLY SHEET EX Non FDA Exclusion

*Skin Adhesives***SURGISEAL EXTERNAL LIQUID Benefit Exclusion

SURGISEAL STYLUS EXTERNAL LIQUID Benefit Exclusion

SURGISEAL TWIST EXTERNAL LIQUID Benefit Exclusion

*Spacer/Aerosol-Holding Chambers & Supplies***AEROCHAMBER MINI CHAMBER DEVICE Tier 2

AEROCHAMBER MV Tier 2

AEROCHAMBER PLUS FLO-VU Tier 2

AEROCHAMBER PLUS FLO-VU LARGE Tier 2

AEROCHAMBER PLUS FLO-VU SMALL Tier 2

AEROCHAMBER PLUS FLO-VU W/MASK Tier 2

AEROCHAMBER Z-STAT PLUS Tier 2

AEROCHAMBER Z-STAT PLUS CHAMBR Tier 2

AEROCHAMBER Z-STAT PLUS/LARGE Tier 2

AEROCHAMBER Z-STAT PLUS/MEDIUM Tier 2

AEROCHAMBER Z-STAT PLUS/SMALL Tier 2

AEROVENT PLUS DEVICE Tier 2

ARIAL CHAMBER DEVICE Tier 2

breathe comfort chamber/adult device Tier 2

351

Drug Name Drug Tier Notesbreathe comfort chamber/child device Tier 2

breathe ease large device Tier 2

breathe ease medium device Tier 2

breathe ease small device Tier 2

BREATHERITE Tier 2

BREATHERITE COLL SPACER ADULT Tier 2

BREATHERITE COLL SPACER CHILD Tier 2

BREATHERITE COLL SPACER INFANT Tier 2

BREATHERITE RIGID SPACER/MASK Tier 2

BREATHERITE SPACER NEONATE Tier 2

BREATHERITE SPACER SMALL CHILD Tier 2

BREATHERITE/LARGE MASK Tier 2

BREATHERITE/MEDIUM MASK Tier 2

BREATHERITE/SMALL MASK Tier 2

CLEVER CHOICE HOLDING CHAMBER DEVICE Tier 2

COMPACT SPACE CHAMBER DEVICE Tier 2

COMPACT SPACE CHAMBER/LG MASK DEVICE Tier 2

COMPACT SPACE CHAMBER/MED MASK DEVICE Tier 2

COMPACT SPACE CHAMBER/SM MASK DEVICE Tier 2

EASIVENT Tier 2

EASIVENT MASK LARGE Tier 2

EASIVENT MASK MEDIUM Tier 2

EASIVENT MASK SMALL Tier 2

eq space chamber anti-static device Tier 2

eq space chamber anti-static l device Tier 2

eq space chamber anti-static m device Tier 2

eq space chamber anti-static s device Tier 2

FLEXICHAMBER ADULT MASK/SMALL Tier 2

FLEXICHAMBER CHILD MASK/LARGE Tier 2

FLEXICHAMBER CHILD MASK/SMALL Tier 2

FLEXICHAMBER DEVICE Tier 2

INSPIRACHAMBER/LARGE DEVICE Tier 2

INSPIRACHAMBER/MEDIUM DEVICE Tier 2

INSPIRACHAMBER/MOUTHPIECE DEVICE Tier 2

352

Drug Name Drug Tier NotesINSPIRACHAMBER/SMALL DEVICE Tier 2

INSPIREASE Tier 2

INSPIREASE RESERVOIR BAGS Tier 2

LITEAIRE DEVICE Tier 2

MASK VORTEX Tier 2

MASK VORTEX/CHILD/FROG Tier 2

MASK VORTEX/TODDLER/LADYBUG Tier 2

MICROCHAMBER Tier 2

MICROCHAMBER DEVICE Tier 2

MICROSPACER Tier 2

OPTICHAMBER ADVANTAGE Tier 2

OPTICHAMBER ADVANTAGE-LG MASK Tier 2

OPTICHAMBER ADVANTAGE-MED MASK Tier 2

OPTICHAMBER ADVANTAGE-SM MASK Tier 2

OPTICHAMBER DIAMOND Tier 2

OPTICHAMBER DIAMOND DEVICE Tier 2

OPTICHAMBER DIAMOND-LG MASK DEVICE Tier 2

OPTICHAMBER DIAMOND-MD MASK Tier 2

OPTICHAMBER DIAMOND-SM MASK Tier 2

OPTICHAMBER FACE MASK-LARGE Tier 2

OPTICHAMBER FACE MASK-MEDIUM Tier 2

OPTICHAMBER FACE MASK-SMALL Tier 2

OPTIHALER Tier 2

OPTIHALER DEVICE Tier 2

PANDA MASK LARGE Tier 2

PANDA MASK MEDIUM Tier 2

PANDA MASK SMALL Tier 2

PEDIATRIC PANDA MASK Tier 2

POCKET CHAMBER DEVICE Tier 2

POCKET SPACER DEVICE Tier 2

pro comfort spacer adult Tier 2

pro comfort spacer child Tier 2

pro comfort spacer infant device Tier 2

procare spacer/adult mask device Tier 2

procare spacer/child mask device Tier 2

RITEFLO DEVICE Tier 2

valved holding chamber device Tier 2

353

Drug Name Drug Tier NotesVORTEX VALVED HOLDING CHAMBER DEVICE Tier 2

WATCHHALER DEVICE Tier 2

*Tumor Treating Fields Products (Ttfields)***OPTUNE DEVICE EX Non FDA Exclusion

OPTUNE LUA DEVICE EX Non FDA Exclusion

*Migraine Products*

*Calcitonin Gene-Related Peptide Receptor Antag (Cgrp)***NURTEC ORAL TABLET DISPERSIBLE 75 MG Tier 2 PA; QL

QULIPTA ORAL TABLET 10 MG, 30 MG, 60 MG EX PA; Formulary Exclusion; QL

UBRELVY ORAL TABLET 100 MG, 50 MG Tier 2 PA; QL

*Cgrp Receptor Antagonists - Monocolonal Antibodies***AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML Tier 2 PA; QL

AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 225 MG/1.5ML Tier 2 PA; QL

AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 225 MG/1.5ML Tier 2 PA; QL

EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

Tier 2 PA; QL

EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120 MG/ML Tier 2 PA; QL

EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 120 MG/ML Tier 2 PA; QL

VYEPTI INTRAVENOUS SOLUTION 100 MG/ML EX Medical Only Exclusion

*Ergot Combinations***CAFERGOT ORAL TABLET 1-100 MG EX Formulary Exclusion

ergotamine-caffeine oral tablet 1-100 mg Tier 1

MIGERGOT SUPPOSITORY 2-100 MG RECTAL 2-100 MG EX PA; QL

MIGERGOT SUPPOSITORY 2-100 MG RECTAL 2-100 MG Tier 3 PA; Insufficient Evidence; QL

354


*Migraine Combinations***MIGRAINE PACK COMBINATION THERAPY PACK 50 MG EX Non FDA Exclusion

MIGRANOW COMBINATION THERAPY PACK 50 & 4-10 MG & % Benefit Exclusion

SUMANSETRON ORAL TABLET THERAPY PACK 50 & 4 MG Benefit Exclusion

*Migraine Products - Cyclooxygenase 2 (Cox-2) Inhibitors***ELYXYB ORAL SOLUTION 120 MG/4.8ML Benefit Exclusion Non Essential Drug Exclusion

*Migraine Products - Nsaids***CAMBIA ORAL PACKET 50 MG Benefit Exclusion Non Essential Drug Exclusion

*Migraine Products***D.H.E. 45 INJECTION SOLUTION 1 MG/ML EX Formulary Exclusion

dihydroergotamine mesylate injection solution 1 mg/ml

Tier 1

dihydroergotamine mesylate nasal solution 4 mg/ml

Tier 1 PA

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG Tier 3 PA

MIGRANAL NASAL SOLUTION 4 MG/ML EX PA; Formulary Exclusion

TRUDHESA NASAL AEROSOL SOLUTION0.725 MG/ACT EX PA; Formulary Exclusion

*Selective Serotonin Agonist-Nsaid Combinations***sumatriptan-naproxen sodium oral tablet 85-500 mg

Benefit Exclusion Non Essential Drug Exclusion; QL

TREXIMET ORAL TABLET 85-500 MG Benefit Exclusion

*Selective Serotonin Agonists 5-Ht(1)***almotriptan malate oral tablet 12.5 mg, 6.25 mg Tier 1 QL

AMERGE ORAL TABLET 1 MG, 2.5 MG EX Formulary Exclusion; QL

eletriptan hydrobromide oral tablet 20 mg, 40 mg Tier 1 QL

FROVA ORAL TABLET 2.5 MG EX Formulary Exclusion; QL

frovatriptan succinate oral tablet 2.5 mg Tier 1 QL

IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT EX Formulary Exclusion; QL

IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG EX Formulary Exclusion; QL

355

Drug Name Drug Tier NotesIMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE4 MG/0.5ML, 6 MG/0.5ML


IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 MG/0.5ML, 6 MG/0.5ML


IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5ML EX Formulary Exclusion; QL

MAXALT ORAL TABLET 10 MG EX Formulary Exclusion; QL

MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG EX Formulary Exclusion; QL

naratriptan hcl oral tablet 1 mg, 2.5 mg Tier 1 QL

ONZETRA XSAIL NASAL EXHALER POWDER 11 MG/NOSEPC Tier 3 QL

RELPAX ORAL TABLET 20 MG, 40 MG EX Formulary Exclusion; QL

rizatriptan benzoate oral tablet 10 mg, 5 mg Tier 1 QL

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

Tier 1 QL

sumatriptan nasal solution 20 mg/act, 5 mg/act Tier 1 QL

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

Tier 1 QL

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml

Tier 1 QL

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

Tier 1 QL

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml

Tier 1 QL

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml

Tier 2 QL

TOSYMRA NASAL SOLUTION 10 MG/ACT Tier 3

ZEMBRACE SYMTOUCH SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 MG/0.5ML

Tier 3 PA; QL

zolmitriptan oral tablet 2.5 mg, 5 mg Tier 1 QL

zolmitriptan oral tablet dispersible 2.5 mg, 5 mg Tier 1 QL

zolmitriptan solution 2.5 mg nasal 2.5 mg Tier 3 QL

zolmitriptan solution 5 mg nasal 5 mg Tier 1 QL

ZOMIG ORAL TABLET 2.5 MG, 5 MG EX Formulary Exclusion; QL

ZOMIG SOLUTION 2.5 MG NASAL 2.5 MG Tier 3 QL

ZOMIG SOLUTION 5 MG NASAL 5 MG EX Formulary Exclusion; QL

ZOMIG ZMT ORAL TABLET DISPERSIBLE 2.5 MG, 5 MG EX Formulary Exclusion; QL

356


*Selective Serotonin Agonists 5-Ht(1F)***REYVOW ORAL TABLET 100 MG, 50 MG Tier 2 PA; QL

*Minerals & Electrolytes*

*Bicarbonates***sodium acetate solution 2 meq/ml intravenous 2 meq/ml


sodium acetate solution 4 meq/ml intravenous 4 meq/ml


sodium acetate solution 4 meq/ml intravenous 4 meq/ml


sodium bicarbonate solution 4.2 % intravenous4.2 %












sodium bicarbonate-dextrose intravenous solution150-5 meq/l-%


THAM INTRAVENOUS SOLUTION 30 MEQ/100ML EX Medical Only Exclusion

*Calcium Combinations***CALCIFOL ORAL WAFER 1342-1.6 MG EX Formulary Exclusion

calcium gluconate-nacl solution 1-0.675 gm/50ml-% intravenous 1-0.675 gm/50ml-%










calcium-folic acid plus d oral wafer 1342-1 mg Benefit Exclusion

*Calcium***calcium chloride solution 10 % intravenous 10 % EX Medical Only Exclusion

357


calcium chloride solution 10 % intravenous 10 % EX Medical Only Exclusion; Formulary Exclusion

calcium gluconate solution 10 % intravenous 10 %


calcium gluconate solution 10 % intravenous 10 %


*Electrolytes & Dextrose***dextrose 5%/electrolyte #48 intravenous solution Tier 3

dextrose in lactated ringers intravenous solution5 %

Tier 1

dextrose-nacl solution 10-0.2 % intravenous 10-0.2 %

Tier 3


Tier 2

dextrose-nacl solution 2.5-0.45 % intravenous2.5-0.45 %

Tier 1


Tier 1


Tier 1


Tier 1


Tier 1

dextrose-sodium chloride solution 2.5-0.45 % intravenous 2.5-0.45 %

Tier 1

dextrose-sodium chloride solution 5-0.225 % intravenous 5-0.225 %

Tier 1


Tier 1


Tier 3


Tier 1


Tier 1

ELLIOTTS B INTRATHECAL SOLUTION EX Medical Only Exclusion

IONOSOL-MB IN D5W INTRAVENOUS SOLUTION Tier 3

ISOLYTE-P IN D5W INTRAVENOUS SOLUTION Tier 3

kcl in dextrose-nacl solution 10-5-0.45 meq/l-%-% intravenous 10-5-0.45 meq/l-%-%

Tier 1

358

Drug Name Drug Tier Noteskcl in dextrose-nacl solution 20-5-0.2 meq/l-%-% intravenous 20-5-0.2 meq/l-%-%

Tier 1


Tier 3


Tier 1


Tier 1


Tier 1


Tier 1


Tier 3

kcl-lactated ringers-d5w intravenous solution 20 meq/l

Tier 3

NORMOSOL-M IN D5W INTRAVENOUS SOLUTION Tier 3

NORMOSOL-R IN D5W INTRAVENOUS SOLUTION Tier 3

potassium chloride in dextrose intravenous solution 20-5 meq/l-%


*Electrolytes Parenteral***HYPERLYTE-CR INTRAVENOUS CONCENTRATE EX


ISOLYTE-S INTRAVENOUS SOLUTION EX Medical Only Exclusion

ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION EX Medical Only Exclusion

kcl (in nacl 0.9%) intravenous solution 40 meq/500ml


kcl-lidocaine-nacl solution 10-10 meq-mg /100ml intravenous 10-10 meq-mg /100ml


kcl-lidocaine-nacl solution 10-10 meq-mg /100ml intravenous 10-10 meq-mg /100ml


lactated ringers intravenous solution EX Medical Only Exclusion

NORMOSOL-R INTRAVENOUS SOLUTION EX Medical Only Exclusion

NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION EX Medical Only Exclusion

PLASMA-LYTE 148 INTRAVENOUS SOLUTION EX Medical Only Exclusion

PLASMA-LYTE A INTRAVENOUS SOLUTION EX Medical Only Exclusion

359

Drug Name Drug Tier Notespotassium chloride in nacl intravenous solution20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%


ringers intravenous solution EX Medical Only Exclusion

TPN ELECTROLYTES INTRAVENOUS CONCENTRATE EX Medical Only Exclusion

*Fluoride Combinations***FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML Tier 3

*Fluoride***FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML Tier 5

fluoritab oral solution 0.275 (0.125 f) mg/drop Tier 5

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

Tier 5

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP Tier 5

LUDENT ORAL TABLET CHEWABLE 0.55 (0.25 F) MG, 1.1 (0.5 F) MG, 2.2 (1 F) MG Tier 5

NAFRINSE DROPS ORAL SOLUTION 0.275 (0.125 F) MG/DROP Tier 5

NAFRINSE ORAL TABLET CHEWABLE2.2 (1 F) MG Tier 5

sodium fluoride oral solution 0.5 mg/ml, 1.1 (0.5 f) mg/ml

Tier 5

sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg

Tier 5

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg

Tier 5

*Iodine Products***iodine strong oral solution 5 % EX Formulary Exclusion

*Magnesium***magnesium chloride injection solution 200 mg/ml EX Formulary Exclusion

magnesium sulfate in d5w intravenous solution 1-5 gm/100ml-%


magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml


magnesium sulfate solution 50 % injection 50 % EX Non FDA Exclusion; Medical Only Exclusion

magnesium sulfate solution 50 % injection 50 % EX Medical Only Exclusion

magnesium sulfate-nacl intravenous solution 2-0.9 gm/50ml-%


360


*Manganese***manganese chloride intravenous solution 0.1 mg/ml


*Phosphate***GLYCOPHOS INTRAVENOUS SOLUTION1 MMOLE/ML EX Formulary Exclusion

K-PHOS ORAL TABLET 500 MG Tier 2

K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG EX Formulary Exclusion

PHOSPHA 250 NEUTRAL ORAL TABLET155-852-130 MG Tier 1

phosphorous oral tablet 155-852-130 mg Tier 1

PHOSPHO-TRIN 250 NEUTRAL ORAL TABLET 155-852-130 MG Tier 1

PHOSPHO-TRIN K500 ORAL TABLET 500 MG Tier 1

potassium phosphates solution 15 mmole/5ml intravenous 15 mmole/5ml








potassium phosphates(66 meq k) intravenous solution 45 mmole/15ml


potassium phosphates(71 meq k) intravenous solution 45 mmole/15ml


sodium phosphates solution 15 mmole/5ml intravenous 15 mmole/5ml






virt-phos 250 neutral oral tablet 155-852-130 mg Tier 1

*Potassium Combinations***EFFER-K TABLET EFFERVESCENT 10 MEQ ORAL 10 MEQ EX Formulary Exclusion

EFFER-K TABLET EFFERVESCENT 20 MEQ ORAL 20 MEQ EX

Non FDA Exclusion; Formulary Exclusion

EFFER-K TABLET EFFERVESCENT 20 MEQ ORAL 20 MEQ EX Formulary Exclusion

361


*Potassium***EFFER-K ORAL TABLET EFFERVESCENT25 MEQ EX Formulary Exclusion

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ Tier 1

KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ Tier 1



KLOR-CON ORAL PACKET 20 MEQ Tier 1

KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ Tier 1

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ Tier 1

KLOR-CON/EF ORAL TABLET EFFERVESCENT 25 MEQ EX Formulary Exclusion

K-PRIME ORAL TABLET EFFERVESCENT25 MEQ EX Formulary Exclusion

K-TAB TABLET EXTENDED RELEASE 10 MEQ ORAL 10 MEQ EX Formulary Exclusion

K-TAB TABLET EXTENDED RELEASE 20 MEQ ORAL 20 MEQ EX Formulary Exclusion

K-TAB TABLET EXTENDED RELEASE 8 MEQ ORAL 8 MEQ Tier 3

potassium acetate solution 2 meq/ml intravenous2 meq/ml


potassium acetate solution 2 meq/ml intravenous2 meq/ml


potassium chloride crys er tablet extended release 10 meq oral 10 meq

Tier 1


Tier 1




Tier 1

potassium chloride er oral capsule extended release 10 meq, 8 meq

Tier 1

potassium chloride er oral tablet extended release10 meq, 20 meq, 8 meq

Tier 1

potassium chloride oral packet 20 meq Tier 1

362

Drug Name Drug Tier Notespotassium chloride oral solution 10 %, 20 meq/15ml (10%), 40 meq/15ml (20%)

Tier 1

potassium chloride solution 10 meq/100ml intravenous 10 meq/100ml








potassium chloride solution 2 meq/ml intravenous2 meq/ml


potassium chloride solution 2 meq/ml intravenous2 meq/ml
















*Sodium***AQUASTAT INTRAVENOUS SOLUTION0.9 % Tier 1

BD POSIFLUSH INTRAVENOUS SOLUTION 0.9 % EX Formulary Exclusion

MONOJECT FLUSH SYRINGE INTRAVENOUS SOLUTION 0.9 % EX Formulary Exclusion

MONOJECT SODIUM CHLORIDE FLUSH INTRAVENOUS SOLUTION 0.9 % EX Formulary Exclusion

normal saline flush intravenous solution 0.9 % EX Formulary Exclusion

sodium chloride (pf) solution 0.9 % injection 0.9 %


sodium chloride (pf) solution 0.9 % injection 0.9 %

Tier 1

363

Drug Name Drug Tier Notessodium chloride flush solution 0.9 % intravenous0.9 %

Tier 1

sodium chloride flush solution 0.9 % intravenous0.9 %


sodium chloride injection solution 2.5 meq/ml Tier 1

sodium chloride solution 0.45 % intravenous 0.45 %

Tier 1

sodium chloride solution 0.9 % intravenous 0.9 % EX Formulary Exclusion

sodium chloride solution 0.9 % intravenous 0.9 % Tier 1

sodium chloride solution 3 % intravenous 3 % Tier 1

sodium chloride solution 4 meq/ml intravenous 4 meq/ml


sodium chloride solution 4 meq/ml intravenous 4 meq/ml

Tier 1

sodium chloride solution 5 % intravenous 5 % Tier 1

*Trace Mineral Combinations***MULTITRACE-4 NEONATAL INTRAVENOUS SOLUTION 100-25-1500 MCG/ML


MULTITRACE-4 PEDIATRIC INTRAVENOUS SOLUTION 1-100-25-1000 MCG/ML


MULTRYS INTRAVENOUS SOLUTION 60-3-6-1000 MCG/ML EX Medical Only Exclusion

THE LIQUILIFT TRACE INTRAVENOUS KIT 10-1000-500-60 MCG/ML EX Non FDA Exclusion

TRACE ELEMENTS 4/PEDIATRIC INTRAVENOUS SOLUTION 1-100-30-500 MCG/ML


TRALEMENT INTRAVENOUS SOLUTION300-55-60-3000 MCG/ML EX


*Trace Minerals***chromic chloride intravenous solution 40 mcg/10ml


cupric chloride intravenous solution 0.4 mg/ml EX Medical Only Exclusion

selenious acid solution 12 mcg/2ml intravenous12 mcg/2ml


selenious acid solution 60 mcg/ml intravenous 60 mcg/ml


selenious acid solution 60 mcg/ml intravenous 60 mcg/ml


364


*Zinc***GALZIN ORAL CAPSULE 25 MG, 50 MG Tier 3

WILZIN ORAL CAPSULE 25 MG EX Non FDA Exclusion

zinc chloride intravenous solution 1 mg/ml EX Medical Only Exclusion

zinc sulfate intravenous solution 1 mg/ml, 3 mg/ml, 5 mg/ml


*Miscellaneous Therapeutic Classes*

*Allogeneic Thymus Tissue***RETHYMIC INTRAMUSCULAR IMPLANT EX Medical Only Exclusion

*Antileprotics***THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG Tier 4 PA; Specialty

*B-Lymphocyte Stimulator (Blys)-Specific Inhibitors***BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG Tier 4 PA; Specialty

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML Tier 4 PA; Specialty; QL

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML Tier 4 PA; Specialty; QL

*Chelating Agents***CLOVIQUE ORAL CAPSULE 250 MG Tier 4 PA; Specialty

CUPRIMINE ORAL CAPSULE 250 MG EX PA; Specialty; Formulary Exclusion

DEPEN TITRATABS ORAL TABLET 250 MG EX


edetate disodium intravenous solution 150 mg/ml EX Non FDA Exclusion

penicillamine oral capsule 250 mg Tier 4 PA; Specialty

penicillamine oral tablet 250 mg Tier 4 PA; Specialty

SYPRINE ORAL CAPSULE 250 MG EX PA; Specialty; Formulary Exclusion

trientine hcl capsule 250 mg oral 250 mg Tier 4 PA

trientine hcl capsule 250 mg oral 250 mg Tier 4 PA; Specialty

*Continuous Renal Replacement Therapy (Crrt) Solutions***phoxillum b22k4/0 extracorporeal solution 22-4-1 meq-mmol/l

Tier 3

PRISMASOL BGK 4/0/1.2 EXTRACORPOREAL SOLUTION 32-4-1.2 MEQ/L


365

Drug Name Drug Tier Notestrisodium citrate/crrt extracorporeal solution EX Non FDA Exclusion

*Cyclosporine Analogs***cyclosporine intravenous solution 50 mg/ml EX Medical Only Exclusion

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

Tier 1

cyclosporine modified oral solution 100 mg/ml Tier 1

cyclosporine oral capsule 100 mg, 25 mg Tier 1

GENGRAF ORAL CAPSULE 100 MG, 25 MG Tier 1

GENGRAF ORAL SOLUTION 100 MG/ML Tier 1

LUPKYNIS ORAL CAPSULE 7.9 MG Tier 4 PA; Specialty; QL

NEORAL ORAL CAPSULE 100 MG, 25 MG Tier 3

NEORAL ORAL SOLUTION 100 MG/ML Tier 3

SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML EX Medical Only Exclusion

SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG Tier 3

SANDIMMUNE ORAL SOLUTION 100 MG/ML Tier 3

*Digital Therapy***ENDEAVORRX EX Non FDA Exclusion

LEVA PELVIC HEALTH SYSTEM KIT EX Non FDA Exclusion

MAHANA IBS EX Non FDA Exclusion

RESET EX Non FDA Exclusion

RESET FOR IOS OR ANDROID APP EX Non FDA Exclusion

RESET NON-MONETARY CM EX Non FDA Exclusion

RESET-O EX Non FDA Exclusion

RESET-O FOR IOS OR ANDROID APP EX Non FDA Exclusion

RESET-O NON-MONETARY CM EX Non FDA Exclusion

SOMRYST EX Non FDA Exclusion

*Enzymes***AMPHADASE INJECTION SOLUTION 150 UNIT/ML EX Medical Only Exclusion

HYLENEX INJECTION SOLUTION 150 UNIT/ML EX Medical Only Exclusion

VITRASE INJECTION SOLUTION 200 UNIT/ML EX Medical Only Exclusion

XIAFLEX INJECTION SOLUTION RECONSTITUTED 0.9 MG Tier 4 PA; Specialty

366


*Farnesyltransferase Inhibitors***ZOKINVY ORAL CAPSULE 50 MG, 75 MG Tier 4 PA; Specialty

*Fecal Incontinence Bulking Agent - Combinations***SOLESTA INJECTION GEL 50-15 MG/ML EX Medical Only Exclusion

*Homeopathic Products***ACUNOL ORAL TABLET EX Non FDA Exclusion

bhi uri-control oral tablet EX Non FDA Exclusion

COLCIGEL EXTERNAL GEL EX Non FDA Exclusion

ECZEMOL ORAL TABLET EX Non FDA Exclusion

ENGYSTOL INJECTION INJECTABLE EX Non FDA Exclusion

HYLAFEM VAGINAL SUPPOSITORY EX Non FDA Exclusion

LYMPHOMYOSOT X INJECTION INJECTABLE EX Non FDA Exclusion

morcin external cream EX Non FDA Exclusion

NEURALGO-RHEUM INJECTION INJECTABLE EX Non FDA Exclusion

PSORIZIDE FORTE ORAL TABLET 30-1-15 MG EX Non FDA Exclusion

PSORIZIDE ULTRA ORAL TABLET EX Non FDA Exclusion

rapid gel rx external gel EX Non FDA Exclusion

SPASCUPREEL INJECTION INJECTABLE EX Non FDA Exclusion

SPEEDGEL RX EXTERNAL GEL EX Non FDA Exclusion

streptococcinum 30c sublingual pellet EX Non FDA Exclusion

TRANZGEL EXTERNAL GEL EX Non FDA Exclusion

TRAUMEEL EXTERNAL OINTMENT EX Non FDA Exclusion

TRAUMEEL INJECTION INJECTABLE EX Non FDA Exclusion

TRAUMEEL ORAL TABLET EX Non FDA Exclusion

WELLMIND VERTIGO ORAL TABLET EX Non FDA Exclusion

ZEEL INJECTION INJECTABLE EX Non FDA Exclusion

*Immune Globulin Immunosuppressants***ATGAM INTRAVENOUS INJECTABLE 50 MG/ML EX Medical Only Exclusion

THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG EX Medical Only Exclusion

367


*Immunomodulators For Myelodysplastic Syndromes***lenalidomide oral capsule 10 mg, 15 mg, 25 mg, 5 mg

Tier 4

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG Tier 4 PA; Specialty

*Inosine Monophosphate Dehydrogenase Inhibitors***CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED 500 MG


CELLCEPT ORAL CAPSULE 250 MG Tier 3

CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML Tier 3

CELLCEPT ORAL TABLET 500 MG Tier 3

mycophenolate mofetil hcl intravenous solution reconstituted 500 mg


mycophenolate mofetil intravenous solution reconstituted 500 mg


mycophenolate mofetil oral capsule 250 mg Tier 1

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

Tier 1

mycophenolate mofetil oral tablet 500 mg Tier 1

mycophenolate sodium oral tablet delayed release180 mg, 360 mg

Tier 1

MYFORTIC ORAL TABLET DELAYED RELEASE 180 MG, 360 MG Tier 3

*Interleukin-6 (Il-6) Antagonists***SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 400 MG EX Medical Only Exclusion

*Irrigation Solutions***PHYSIOLYTE IRRIGATION SOLUTION EX Medical Only Exclusion

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION EX Medical Only Exclusion

*Macrolide Immunosuppressants***ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 5 MG

Tier 3

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, 1 MG, 4 MG

Tier 3

368

Drug Name Drug Tier Noteseverolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg

Tier 1

PROGRAF INTRAVENOUS SOLUTION 5 MG/ML EX Medical Only Exclusion

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG Tier 3

PROGRAF ORAL PACKET 0.2 MG, 1 MG Tier 3

RAPAMUNE ORAL SOLUTION 1 MG/ML Tier 3

RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG Tier 3

sirolimus oral solution 1 mg/ml Tier 1

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Tier 1

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG Tier 3

*Misc Natural Products***azalgia oral capsule EX Non FDA Exclusion

ultra hers rx oral capsule EX Non FDA Exclusion

ultra his oral capsule EX Non FDA Exclusion

ultra pcos oral capsule EX Non FDA Exclusion

xyzmune oral capsule EX Non FDA Exclusion

*Miscellaneous Therapeutic Classes***NEXAVIR INJECTION SOLUTION 25.5 MG/ML EX Medical Only Exclusion

phenol injection solution 6 % EX Non FDA Exclusion

*Monoclonal Antibodies***ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 120 MG/ML Tier 4 PA; Specialty; QL

GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML, 100 MG/20ML, 50 MG/10ML EX Medical Only Exclusion

SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG, 20 MG EX Medical Only Exclusion

UPLIZNA INTRAVENOUS SOLUTION 100 MG/10ML EX Medical Only Exclusion

*Neonatal Fc Receptor (Fcrn) Antagonists***VYVGART INTRAVENOUS SOLUTION 400 MG/20ML EX Medical Only Exclusion

369


*Peritoneal Dialysis Solutions***DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L


DELFLEX-LC/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 394 MOSM/L


DELFLEX-LC/4.25% DEXTROSE INTRAPERITONEAL SOLUTION 483 MOSM/L


DELFLEX-SM/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 347 MOSM/L


DELFLEX-SM/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 398 MOSM/L


DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION 344 MOSM/L






DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 346 MOSM/L






EXTRANEAL INTRAPERITONEAL SOLUTION 7.5 % EX Medical Only Exclusion

ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL SOLUTION 346 MOSM/L


ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL SOLUTION 396 MOSM/L


ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL SOLUTION 485 MOSM/L


370

Drug Name Drug Tier NotesULTRABAG/DIANEAL/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 344 MOSM/L


ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 395 MOSM/L


ULTRABAG/DIANEAL/4.25% DEX INTRAPERITONEAL SOLUTION 483 MOSM/L


*Pik3ca-Related Overgrowth Spectrum Agents - Pi3k Inhib***VIJOICE ORAL TABLET THERAPY PACK125 MG, 200 & 50 MG, 50 MG EX


*Potassium Removing Agents***KIONEX ORAL SUSPENSION 15 GM/60ML Tier 1

LOKELMA ORAL PACKET 10 GM, 5 GM Tier 2

sodium polystyrene sulfonate oral powder Tier 1

sodium polystyrene sulfonate oral suspension 15 gm/60ml

Tier 1

SPS ORAL SUSPENSION 15 GM/60ML Tier 1

VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM Tier 2

*Prostaglandins***alprostadil injection solution 500 mcg/ml Tier 1

PROSTIN VR INJECTION SOLUTION 500 MCG/ML Tier 3

*Purine Analogs***AZASAN ORAL TABLET 100 MG, 75 MG Tier 1

azathioprine oral tablet 100 mg, 50 mg, 75 mg Tier 1

azathioprine sodium injection solution reconstituted 100 mg


IMURAN ORAL TABLET 50 MG Tier 3

*Rock Inhibitors***REZUROCK ORAL TABLET 200 MG Tier 4 PA; Specialty

*Sclerosing Agents***ASCLERA INTRAVENOUS SOLUTION 0.5 %, 1 % EX Medical Only Exclusion

ETHAMOLIN INTRAVENOUS SOLUTION5 % EX Medical Only Exclusion

polidocanol intravenous solution 5 % EX Non FDA Exclusion

371

Drug Name Drug Tier Notessodium tetradecyl sulfate intravenous solution 3 %


SOTRADECOL INTRAVENOUS SOLUTION 1 %, 3 % EX Medical Only Exclusion

VARITHENA INTRAVENOUS FOAM 180 MG/18ML EX Medical Only Exclusion

*Selective T-Cell Costimulation Blockers***NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG EX Medical Only Exclusion

*Type I Interferon (Ifn) Receptor Antagonists***SAPHNELO INTRAVENOUS SOLUTION300 MG/2ML EX


*Uremic Pruritus Agents***KORSUVA INTRAVENOUS SOLUTION 65 MCG/1.3ML EX Medical Only Exclusion

*Mouth/Throat/Dental Agents*

*Anesthetics Topical Oral - Combinations***FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION Tier 3

*Anesthetics Topical Oral***lidocaine hcl mouth/throat solution 4 % EX Formulary Exclusion

lidocaine viscous hcl mouth/throat solution 2 % Tier 1

*Anti-Infectives - Throat***clotrimazole mouth/throat troche 10 mg Tier 1

nystatin mouth/throat suspension 100000 unit/ml Tier 1

ORAVIG BUCCAL TABLET 50 MG Tier 3

*Antiseptic Combinations - Mouth/Throat***DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % EX Non FDA Exclusion

*Antiseptics - Mouth/Throat***chlorhexidine gluconate solution 0.12 % mouth/throat 0.12 %

Benefit Exclusion

chlorhexidine gluconate solution 0.12 % mouth/throat 0.12 %

Tier 1

PAROEX MOUTH/THROAT SOLUTION0.12 % Tier 1

372

Drug Name Drug Tier NotesPERIDEX MOUTH/THROAT SOLUTION0.12 % EX Formulary Exclusion

PERIOGARD MOUTH/THROAT SOLUTION 0.12 % Tier 1

*Dental Products - Combinations***FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE 1.1-5 % Benefit Exclusion

FLUORIMAX 5000 SENSITIVE DENTAL PASTE 1.1-5 % Tier 3

NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML

Tier 3

PREVIDENT 5000 ENAMEL PROTECT DENTAL GEL 1.1-5 % EX Formulary Exclusion

PREVIDENT 5000 SENSITIVE DENTAL GEL 1.1-5 % EX Formulary Exclusion

sodium fluoride 5000 enamel dental gel 1.1-5 % Benefit Exclusion

sodium fluoride 5000 sensitive dental gel 1.1-5 % Benefit Exclusion

*Dry Mouth Agents And Artificial Saliva***AQUORAL MOUTH/THROAT SOLUTION EX Non FDA Exclusion

BOCASAL MOUTH/THROAT PACKET EX Non FDA Exclusion

MUCOSITISRX MOUTH/THROAT PACKET EX Non FDA Exclusion

NEUTRASAL MOUTH/THROAT PACKET EX Non FDA Exclusion

NUMOISYN MOUTH/THROAT LIQUID EX Formulary Exclusion

NUMOISYN MOUTH/THROAT LOZENGE EX Formulary Exclusion

SALIVAMAX MOUTH/THROAT PACKET EX Non FDA Exclusion

XEROSTOMIA RELIEF SPRAY MOUTH/THROAT SOLUTION EX Non FDA Exclusion

*Fluoride Dental Products***CAVAREST DENTAL GEL 1.1 % Tier 1

CLINPRO 5000 DENTAL PASTE 1.1 % Tier 1

DENTA 5000 PLUS DENTAL CREAM 1.1 % Tier 1

DENTAGEL DENTAL GEL 1.1 % Tier 1

EASYGEL DENTAL GEL 0.4 % Tier 1

FLUORIDEX DAILY RENEWAL MOUTH/THROAT CONCENTRATE 0.63 % Benefit Exclusion

FLUORIDEX DENTAL PASTE 1.1 % Benefit Exclusion

FLUORIDEX ENHANCED WHITENING DENTAL PASTE 1.1 % Benefit Exclusion

373

Drug Name Drug Tier NotesFLUORIMAX 5000 DENTAL PASTE 1.1 % Benefit Exclusion

JUST FOR KIDS DENTAL GEL 0.4 % Tier 1

JUST RIGHT 5000 DENTAL PASTE 1.1 % Benefit Exclusion

NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION RECONSTITUTED 0.05 %

Tier 3

NAFRINSE WEEKLY MOUTH/THROAT SOLUTION RECONSTITUTED 0.2 % Tier 3

neutral sodium fluoride mouth/throat solution 0.2 %

Benefit Exclusion

PERIOMED MOUTH/THROAT CONCENTRATE 0.63 % Benefit Exclusion

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 % EX Formulary Exclusion

PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % EX Formulary Exclusion

PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE 1.1 % EX Formulary Exclusion

PREVIDENT 5000 PLUS DENTAL CREAM1.1 % EX Formulary Exclusion

PREVIDENT DENTAL GEL 1.1 % EX Formulary Exclusion

PREVIDENT MOUTH/THROAT SOLUTION 0.2 % EX Formulary Exclusion

sf 5000 plus dental cream 1.1 % Tier 1

sf dental gel 1.1 % Tier 1

sodium fluoride 5000 plus cream 1.1 % dental 1.1 %

Benefit Exclusion

sodium fluoride 5000 plus cream 1.1 % dental 1.1 %

Tier 1

sodium fluoride 5000 ppm dental cream 1.1 % Tier 1

sodium fluoride 5000 ppm dental gel 1.1 % Benefit Exclusion

sodium fluoride 5000 ppm dental paste 1.1 % Benefit Exclusion

sodium fluoride dental cream 1.1 % Tier 1

sodium fluoride gel 1.1 % dental 1.1 % Benefit Exclusion

sodium fluoride gel 1.1 % dental 1.1 % Tier 1

sodium fluoride mouth/throat solution 0.2 % Benefit Exclusion

*Periodontal Anti-Infectives***ARESTIN DENTAL 1 MG EX Medical Only Exclusion

*Protectants - Mouth/Throat***EPISIL MOUTH/THROAT LIQUID EX Formulary Exclusion

GELCLAIR MOUTH/THROAT GEL EX Non FDA Exclusion

374

Drug Name Drug Tier NotesGELX MOUTH/THROAT GEL EX Non FDA Exclusion

MUCOTROL MOUTH/THROAT WAFER EX Formulary Exclusion

MUGARD MOUTH/THROAT LIQUID EX Formulary Exclusion

ORAFATE MOUTH/THROAT PASTE 10 % EX Non FDA Exclusion

ORAMAGICRX MOUTH/THROAT SUSPENSION RECONSTITUTED EX Formulary Exclusion

ORAPEUTIC MOUTH/THROAT GEL EX Non FDA Exclusion

PROTHELIAL MOUTH/THROAT PASTE 10 % EX Non FDA Exclusion

silatrix mouth/throat gel 10 % EX Non FDA Exclusion

*Saliva Stimulants***cevimeline hcl oral capsule 30 mg Tier 1

EVOXAC ORAL CAPSULE 30 MG EX Formulary Exclusion

pilocarpine hcl oral tablet 5 mg, 7.5 mg Tier 1

SALAGEN ORAL TABLET 5 MG, 7.5 MG EX Formulary Exclusion

*Steroids - Mouth/Throat/Dental***ORALONE MOUTH/THROAT PASTE 0.1 % Tier 1

triamcinolone acetonide mouth/throat paste 0.1 % Tier 1

*Multivitamins*

*B-Complex Vitamins***b-complex injection injectable Benefit Exclusion

vitamin b complex 100 injection injectable EX Formulary Exclusion

vitamin b complex-hydroxocobal injection injectable

Benefit Exclusion

vitamin b-complex 100 injection injectable EX Formulary Exclusion

*B-Complex W/ C & Folic Acid***activite oral tablet 1 mg Benefit Exclusion

b complex-c-folic acid oral tablet Tier 5

b-complex/vitamin c oral tablet Tier 5

b-plex oral tablet EX Formulary Exclusion

davite oral tablet 1 mg Benefit Exclusion

DEXIFOL ORAL TABLET 5 MG Benefit Exclusion

DIALYVITE 800 ORAL TABLET 0.8 MG Tier 5

DIALYVITE ORAL TABLET EX Formulary Exclusion

folbee plus oral tablet Tier 5

folika-t oral tablet 1 mg Benefit Exclusion

full spectrum b/vitamin c oral tablet 0.8 mg Benefit Exclusion

GENICIN VITA-S ORAL TABLET 1 MG Benefit Exclusion

375

Drug Name Drug Tier Noteshylavite oral tablet Benefit Exclusion

lorid oral tablet 1 mg Benefit Exclusion

mynephrocaps oral capsule 1 mg Benefit Exclusion

MYNEPHRON ORAL CAPSULE 1 MG Benefit Exclusion

NEPHRONEX ORAL TABLET Benefit Exclusion

NEPHRO-VITE ORAL TABLET 0.8 MG Benefit Exclusion

NEPHRO-VITE RX ORAL TABLET 1 MG Benefit Exclusion

RENAL MULTIVITAMIN FORMULA ORAL TABLET Benefit Exclusion

RENAL ORAL CAPSULE 1 MG Benefit Exclusion

renal vitamin oral tablet 0.8 mg Benefit Exclusion

renal-vite oral tablet 0.8 mg Benefit Exclusion

rena-vite oral tablet Benefit Exclusion

rena-vite rx oral tablet 1 mg Benefit Exclusion

reno caps capsule 1 mg oral (otc) 1 mg Benefit Exclusion

reno caps capsule 1 mg oral (rx) 1 mg Tier 5

triphrocaps oral capsule 1 mg Benefit Exclusion

tronvite oral tablet 1 mg Benefit Exclusion

virt-caps oral capsule 1 mg Tier 5

VITALINE BIOTIN FORTE ORAL TABLET0.8 MG Benefit Exclusion

vitasure oral tablet 1 mg Benefit Exclusion

vp-vite rx oral tablet 1 mg EX Formulary Exclusion

wescaps oral capsule 1 mg Benefit Exclusion

xvite oral tablet 1 mg Benefit Exclusion

*B-Complex W/ C-Biotin-D-Zinc & Folic Acid***VITAL-D RX ORAL TABLET 1 MG Benefit Exclusion

*B-Complex W/ C-Biotin-E & Folic Acid***RENATABS ORAL TABLET 1 MG Benefit Exclusion

*B-Complex W/ C-Biotin-E-Folic Acid & Iron***RENATABS WITH IRON ORAL 1 & 100 MG Benefit Exclusion

*B-Complex W/ C-Biotin-E-Minerals & Folic Acid***DIALYVITE 3000 ORAL TABLET 3 MG Tier 5

DIALYVITE 5000 ORAL TABLET 5 MG EX Formulary Exclusion

376


*B-Complex W/ C-Biotin-Minerals & Folic Acid***FOLBEE PLUS CZ ORAL TABLET 5 MG Benefit Exclusion

*B-Complex W/ C-Zn & Folic Acid***DIALYVITE/ZINC ORAL TABLET EX Formulary Exclusion

NEPHPLEX RX ORAL TABLET Benefit Exclusion

VITALINE BIOTIN FORTE/ZINC ORAL TABLET 0.8 MG Benefit Exclusion

*B-Complex W/ E & Folic Acid***folica-v oral capsule 1 mg Benefit Exclusion

folic-k oral capsule 1 mg Benefit Exclusion

*B-Complex W/ Lysine-Min-Fe & Folic Acid***NUTRIVIT ORAL LIQUID EX Formulary Exclusion

*B-Complex W/ Lysine-Zn & Folic Acid***SUPERVITE ORAL LIQUID EX Formulary Exclusion

*Bioflavonoid Products***ADRENAL C FORMULA ORAL TABLET EX Formulary Exclusion

daflonex-xl oral capsule Benefit Exclusion

*Iron W/ Vitamins***VITAFOL ORAL TABLET Benefit Exclusion

*Multiple Vitamins & Fluoride-Folic Acid***multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg


*Multiple Vitamins W/ Calcium***advanced am/pm oral Benefit Exclusion

*Multiple Vitamins W/ Minerals & Calcium-Folic Acid***FOLGARD OS ORAL TABLET 500-1.1 MG Benefit Exclusion

TL G-FOL OS ORAL TABLET 500-1.1 MG Benefit Exclusion

*Multiple Vitamins W/ Minerals & Fluoride-Iron-Folic Acid***QUFLORA FE ORAL TABLET CHEWABLE0.25 MG Benefit Exclusion

377


*Multiple Vitamins W/ Minerals & Folic Acid***CORVITA ORAL TABLET Benefit Exclusion

CORVITE ORAL TABLET Benefit Exclusion

DERMACINRX MULTITAM ORAL TABLET Benefit Exclusion

DIALYVITE SUPREME D ORAL TABLET Benefit Exclusion

folamed dha oral capsule Benefit Exclusion

OCUVEL ORAL CAPSULE Benefit Exclusion

onevite oral tablet Benefit Exclusion

REMEDIENT ORAL CAPSULE Benefit Exclusion

SYNAGEX ORAL CAPSULE Benefit Exclusion

SYNATEK ORAL CAPSULE Benefit Exclusion

thrivite 19 oral tablet EX Formulary Exclusion

UDAMIN SP ORAL TABLET Benefit Exclusion

VENTRIXYL ORAL TABLET Benefit Exclusion

*Multiple Vitamins W/ Minerals***BACMIN ORAL TABLET Benefit Exclusion

biocel oral tablet Benefit Exclusion

b-plex plus oral tablet Benefit Exclusion

CORVITE FREE ORAL TABLET Benefit Exclusion

dayavite oral tablet Benefit Exclusion

DERMACINRX RIBOTIN-E ORAL TABLETBenefit Exclusion

DERMACINRX ZINTREXYL-C ORAL TABLET Benefit Exclusion

folamax oral tablet Benefit Exclusion

FOLIFLEX ORAL TABLET Benefit Exclusion

FOLITIN-Z ORAL TABLET Benefit Exclusion

FORTAVIT ORAL CAPSULE Benefit Exclusion

hylazinc oral tablet Benefit Exclusion

LYSIPLEX PLUS ORAL TABLET Benefit Exclusion

multipro oral capsule Benefit Exclusion

neovite oral tablet Benefit Exclusion

NICADAN ORAL TABLET Benefit Exclusion

NICAZEL FORTE ORAL TABLET Benefit Exclusion

NICAZEL ORAL TABLET Benefit Exclusion

NUTRICAP ORAL TABLET Benefit Exclusion

NUTRIFAC ZX ORAL TABLET Benefit Exclusion

378

Drug Name Drug Tier Notesprofola oral tablet Benefit Exclusion

PROTECT PLUS ORAL CAPSULE Benefit Exclusion

REQ 49+ ORAL TABLET Benefit Exclusion

SIDEROL ORAL TABLET Benefit Exclusion

STROVITE FORTE ORAL SYRUP Benefit Exclusion

STROVITE FORTE ORAL TABLET Benefit Exclusion

STROVITE ONE ORAL TABLET Benefit Exclusion

support oral liquid Benefit Exclusion

v-c forte oral capsule Benefit Exclusion

VENEXA FE ORAL TABLET Benefit Exclusion

VENEXA ORAL TABLET Benefit Exclusion

VENTRIXYL FE ORAL TABLET Benefit Exclusion

VIC-FORTE ORAL CAPSULE Benefit Exclusion

VITA S FORTE ORAL TABLET Benefit Exclusion

VITACEL ORAL TABLET Benefit Exclusion

vita-min oral capsule Benefit Exclusion

VITAROCA PLUS ORAL TABLET Benefit Exclusion

VITRAMYN ORAL TABLET Benefit Exclusion

VITRANOL FE ORAL TABLET Benefit Exclusion

VITRANOL ORAL TABLET Benefit Exclusion

VITREXATE FE ORAL TABLET Benefit Exclusion

VITREXATE ORAL TABLET Benefit Exclusion

VITREXYL + IRON ORAL TABLET Benefit Exclusion

VITREXYL ORAL TABLET Benefit Exclusion

vp-zel oral tablet Benefit Exclusion

zyvana oral capsule Benefit Exclusion

*Multiple Vitamins With Folic Acid***folika-v oral tablet Benefit Exclusion

GENICIN VITA-Q ORAL TABLET Benefit Exclusion

vitaxyme oral tablet Benefit Exclusion

*Multivitamins***AMLADEX ORAL TABLET EX Non FDA Exclusion

INFUVITE ADULT INTRAVENOUS INJECTABLE EX Medical Only Exclusion

*Niacinamide W/ Zinc-Copper & Folic Acid***NICOMIDE ORAL TABLET 750-27-2-0.5 MG Benefit Exclusion

379

Drug Name Drug Tier Notesnicotinamide oral tablet 750-27-2-0.5 mg Benefit Exclusion

*Ped Multi Vitamins W/Fl & Fe***ESCAVITE D ORAL TABLET CHEWABLE0.25-6 MG Benefit Exclusion

ESCAVITE ORAL TABLET CHEWABLE0.25-7.5 MG Benefit Exclusion

multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml

Benefit Exclusion

POLY-VI-FLOR/IRON ORAL SUSPENSION0.25-7 MG/ML Benefit Exclusion

POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG Benefit Exclusion

QUFLORA FE PEDIATRIC ORAL LIQUID0.25-9.5 MG/ML Benefit Exclusion

tl-fluorivite oral tablet chewable 0.25-7.5 mg Benefit Exclusion

*Ped Multiple Vitamins W/ Minerals & C***VITAMAX PEDIATRIC ORAL SOLUTION Benefit Exclusion

*Ped Mv W/ Fluoride***FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML Benefit Exclusion

multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

Benefit Exclusion

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg

Benefit Exclusion

MULTI-VIT-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG Benefit Exclusion

POLY-VI-FLOR FS ORAL STRIP 0.25 MG, 0.5 MG, 1 MG Benefit Exclusion

POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML Benefit Exclusion

POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG Benefit Exclusion

QUFLORA GUMMIES ORAL TABLET CHEWABLE 0.125 MG Benefit Exclusion

QUFLORA PEDIATRIC ORAL SOLUTION0.25 MG/ML, 0.5 MG/ML Benefit Exclusion

QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG Benefit Exclusion

380


*Ped Vitamins Acd & Fa W/ Fluoride***TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML Benefit Exclusion

tri-vi-floro oral suspension 0.25 mg/ml, 0.5 mg/ml Benefit Exclusion

*Ped Vitamins Acd W/ Fluoride***adc/f (0.5mg/ml) oral solution 0.5 mg/ml Benefit Exclusion

tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml

Benefit Exclusion

vitamins acd-fluoride oral solution 0.25 mg/ml Benefit Exclusion

*Pediatric Multiple Vitamins & Minerals W/ Fluoride***FLORIVA ORAL TABLET CHEWABLE0.25 MG, 0.5 MG, 1 MG Benefit Exclusion

*Pediatric Multiple Vitamins***INFUVITE PEDIATRIC SOLUTION INTRAVENOUS Benefit Exclusion

INFUVITE PEDIATRIC SOLUTION INTRAVENOUS EX Medical Only Exclusion

M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED Benefit Exclusion

*Prenatal Mv & Min W/Fe-Fa***ATABEX EC ORAL TABLET DELAYED RELEASE 29-1 MG Tier 3

ATABEX OB ORAL TABLET 29-1 MG Tier 3

azeschew prenatal/postnatal oral tablet chewable13-1 mg

Benefit Exclusion

azesco oral tablet 13-1 mg Benefit Exclusion

BAL-CARE DHA ORAL 27-1 & 430 MG Tier 3

CITRANATAL B-CALM ORAL 20-1 MG & 2 X 25 MG Tier 3

CITRANATAL BLOOM ORAL TABLET 90-1 MG Tier 3

CITRANATAL RX ORAL TABLET 27-1 MG Tier 3

classic prenatal oral tablet 28-0.8 mg Tier 5

c-nate dha oral capsule 28-1-200 mg Tier 3

completenate oral tablet chewable 29-1 mg Tier 3

CO-NATAL FA ORAL TABLET Tier 3

CONCEPT DHA ORAL CAPSULE 53.5-38-1 MG Tier 5

381

Drug Name Drug Tier NotesCONCEPT OB ORAL CAPSULE 130-92.4-1 MG Tier 3

DERMACINRX PRETRATE ORAL TABLET 1 MG Benefit Exclusion

DUET DHA 400 ORAL 25-1 & 400 MG Benefit Exclusion

DUET DHA BALANCED ORAL 25-1 & 267 MG Benefit Exclusion

ELITE-OB ORAL TABLET 50-1.25 MG Tier 3

ENBRACE HR ORAL CAPSULE Benefit Exclusion

FOLIVANE-OB ORAL CAPSULE 85-1 MG Tier 3

gnp prenatal oral tablet 28-0.8 mg Tier 5

INATAL GT ORAL TABLET Tier 3

jenliva prenatal/postnatal oral capsule 1 mg EX Non FDA Exclusion

kosher prenatal plus iron oral tablet 30-1 mg Benefit Exclusion

MARNATAL-F ORAL CAPSULE 60-1 MG Tier 3

m-natal plus oral tablet 27-1 mg Benefit Exclusion

multi-mac oral tablet 15-0.75-1 mg EX Non FDA Exclusion

MYNATAL ADVANCE ORAL TABLET Tier 3

MYNATAL ORAL TABLET 90-1 MG Tier 3

mynatal plus oral tablet Benefit Exclusion

mynatal-z oral tablet Benefit Exclusion

mynate 90 plus oral tablet extended release Tier 3

NATACHEW ORAL TABLET CHEWABLE28-1 MG Tier 3

NATALVIT ORAL TABLET Tier 3

NATELLE ONE ORAL CAPSULE 28-1-250 MG Benefit Exclusion

NEEVO DHA ORAL CAPSULE 27-1.13 MG Benefit Exclusion

neonatal complete oral tablet 27-1 mg, 29-1 mg Tier 3

neonatal fe oral tablet 90-1 mg Tier 3

NEONATAL PLUS TABLET 27-1 MG ORAL27-1 MG Benefit Exclusion

NEONATAL PLUS TABLET 27-1 MG ORAL27-1 MG Tier 3

NEONATAL VITAMIN ORAL TABLET 27-0.8 MG Tier 5

NESTABS DHA ORAL 32-1 MG Benefit Exclusion

NESTABS ORAL TABLET 32-1 MG Benefit Exclusion

NIVA-PLUS ORAL TABLET 27-1 MG Tier 3

382

Drug Name Drug Tier NotesOB COMPLETE ONE ORAL CAPSULE 50-1-476 MG Benefit Exclusion

OB COMPLETE ORAL TABLET 50-1.25 MG Benefit Exclusion

OB COMPLETE PETITE ORAL CAPSULE35-5-1-200 MG Benefit Exclusion

OB COMPLETE PREMIER ORAL TABLET30-20-1 MG Benefit Exclusion

OB COMPLETE/DHA ORAL CAPSULE 30-10-1-200 MG Benefit Exclusion

OBSTETRIX DHA ORAL 29-1 & 387 MG Tier 3

OBSTETRIX EC ORAL TABLET 29-1 MG Tier 3

O-CAL FA ORAL TABLET 27-1 MG Benefit Exclusion

O-CAL PRENATAL ORAL TABLET Tier 3

one vite womens plus oral tablet 27-1 mg Tier 3

pnv tabs 20-1 oral tablet 20-1 mg Benefit Exclusion

pnv tabs 29-1 oral tablet 29-1 mg Tier 5

pnv-omega oral capsule 28-0.6-0.4-340 mg Tier 3

pnv-select oral tablet 27-0.6-0.4 mg Tier 3

PREFERA OB ORAL TABLET 34-1 MG Benefit Exclusion

pregenna oral tablet 20-1 mg Benefit Exclusion

prena1 pearl oral capsule extended release 30-1.4-200 mg

Tier 3

prenara oral capsule 15-1 mg Benefit Exclusion

PRENATABS RX ORAL TABLET 29-1 MG Tier 5

prenatal 19 oral tablet 29-1 mg Tier 5

prenatal 19 oral tablet chewable , 29-1 mg Tier 5

prenatal multi +dha oral capsule 27-0.8-228 mg Tier 5

prenatal plus iron oral tablet 29-1 mg Tier 5

prenatal plus oral tablet 27-1 mg Tier 5

prenatal plus vitamin/mineral oral tablet 27-1 mg Tier 5

prenatal tablet 27-0.8 mg oral (otc) 27-0.8 mg Tier 5

prenatal tablet 27-1 mg oral 27-1 mg Tier 3

prenatal tablet 27-1 mg oral 27-1 mg Tier 5

prenatal vitamin plus low iron oral tablet 27-1 mg

Tier 5

prenatal vitamins oral tablet 28-0.8 mg Tier 5

PRENATAL-U ORAL CAPSULE 106.5-1 MG Tier 2

PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG Benefit Exclusion

383

Drug Name Drug Tier NotesPRENATRIX ORAL TABLET 27-1 MG Benefit Exclusion

PRENATRYL ORAL TABLET 27-1 MG Benefit Exclusion

prenatvite complete oral tablet 1 mg Tier 3

prenatvite plus oral tablet 1 mg Tier 3

prenatvite rx oral tablet 0.8 mg Tier 3

preplus oral tablet 27-1 mg Tier 5

pretab oral tablet 29-1 mg Tier 5

PRIMACARE ORAL CAPSULE 30-1-470 MG Benefit Exclusion

PROVIDA OB ORAL CAPSULE 20-20-1.25 MG Tier 3

purefe ob plus oral capsule 162-115.2-1 mg Benefit Exclusion

relnate dha oral capsule 28-1-200 mg Tier 3

SELECT-OB ORAL TABLET CHEWABLE29-0.6-0.4 MG, 29-1 MG Benefit Exclusion

se-natal 19 oral tablet 29-1 mg Tier 5

se-natal 19 oral tablet chewable 29-1 mg Tier 5

TARON-C DHA ORAL CAPSULE 35-1 MG Tier 5

thrivite rx oral tablet 29-1 mg Tier 5

TRICARE ORAL TABLET Tier 3

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG Tier 3

trinatal rx 1 oral tablet 60-1 mg Tier 3

TRINATE ORAL TABLET Tier 5

trinaz oral tablet 12-1 mg Benefit Exclusion

tri-tabs dha oral 32-1 mg Benefit Exclusion

VINATE DHA RF ORAL CAPSULE 27-1.13 MG Tier 3

VINATE II ORAL TABLET 29-1 MG Tier 2

VINATE ONE ORAL TABLET 60-1 MG Tier 2

virt-c dha oral capsule 53.5-38-1 mg Tier 3

virt-nate dha oral capsule 28-1-200 mg Tier 3

virt-pn plus oral capsule 28-0.6-0.4-340 mg Tier 3

VITAFOL GUMMIES ORAL TABLET CHEWABLE 3.33-0.333-34.8 MG Benefit Exclusion

VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG Benefit Exclusion

VITAFOL-OB ORAL TABLET Benefit Exclusion

VITAPEARL ORAL CAPSULE EXTENDED RELEASE 30-1.4-200 MG Tier 3

384

Drug Name Drug Tier NotesVITATHELY WITH GINGER ORAL TABLET 27-1 MG Benefit Exclusion

VIVA DHA ORAL CAPSULE 28-1-200 MG Tier 3

vol-plus oral tablet 27-1 mg Benefit Exclusion

vol-tab rx oral tablet 29-1 mg Tier 5

vp-pnv-dha oral capsule 28-1-215.8 mg Tier 5

wescap-c dha oral capsule 53.5-38-1 mg Tier 5

wesnate dha oral capsule 28-1-200 mg Tier 3

westab plus oral tablet 27-1 mg Tier 5

zalvit oral tablet 13-1 mg Benefit Exclusion

ZATEAN-PN PLUS ORAL CAPSULE 28-0.6-0.4-340 MG Tier 3

*Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil***complete natal dha oral 29-1-200 & 200 mg Tier 3

NESTABS ABC ORAL 32-1-200 MG Benefit Exclusion

PR NATAL 400 EC ORAL 29-1-200 & 400 MG (DR) Tier 3

PR NATAL 400 ORAL 29-1-200 & 400 MG Tier 3

PR NATAL 430 EC ORAL 29-1-200 & 430 MG (DR) Tier 3

PR NATAL 430 ORAL 29-1-200 & 430 MG Tier 3

TRIVEEN-DUO DHA ORAL 29-1-200 & 300 MG Tier 3

*Prenatal Mv & Min W/Fe-Fa-Dha***CITRANATAL 90 DHA ORAL 90-1 & 300 MG Tier 3

CITRANATAL ASSURE ORAL 35-1 & 300 MG Tier 3

CITRANATAL BLOOM DHA ORAL 90-1 & 300 MG Tier 3

CITRANATAL DHA ORAL 27-1 & 250 MG Tier 3

CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 MG Tier 3

CITRANATAL HARMONY ORAL CAPSULE 27-1-260 MG Tier 3

CITRANATAL MEDLEY ORAL CAPSULE27-1-200 MG Tier 3

FOLET DHA ORAL THERAPY PACK 38-1 & 350 MG Tier 3

FOLET ONE ORAL CAPSULE 38-1-225 MG Tier 3

385

Drug Name Drug Tier Notesneonatal + dha oral 29-1 & 200 mg Tier 3

NESTABS ONE ORAL CAPSULE 38-1-225 MG Benefit Exclusion

NEXA PLUS ORAL CAPSULE 29-1.25-350 MG Benefit Exclusion

OBSTETRIX ONE ORAL CAPSULE 38-1-225 MG Tier 3

pnv ob+dha oral 27-1 & 250 mg Benefit Exclusion

pnv-dha oral capsule 27-0.6-0.4-300 mg Tier 3

pnv-dha+docusate oral capsule 27-1.25-300 mg Tier 3

PREFERAOB +DHA ORAL 28-6-1 & 200 MG Benefit Exclusion

PREFERAOB ONE ORAL CAPSULE 22-6-1-200 MG Benefit Exclusion

pregen dha oral capsule 28-1-35 mg EX Non FDA Exclusion

prena 1 true oral 30-1.4 & 300 mg Tier 3

prenaissance oral capsule 29-1.25-325 mg Tier 3

prenaissance plus oral capsule 28-1-250 mg Tier 3

PRENATAL + DHA ORAL THERAPY PACK27-1 & 250 MG Benefit Exclusion

PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG Benefit Exclusion

PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG Benefit Exclusion

PRENATE ESSENTIAL ORAL CAPSULE18-0.6-0.4-300 MG Benefit Exclusion

PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG Benefit Exclusion

PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG Benefit Exclusion

PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG Benefit Exclusion

R-NATAL OB ORAL CAPSULE 20-1-320 MG Tier 3

SELECT-OB+DHA ORAL 29-1 & 250 MG Benefit Exclusion

TARON-PREX ORAL CAPSULE 30-1.2-265 MG Tier 5

tristart dha oral capsule 31-0.6-0.4-200 mg Benefit Exclusion

TRISTART FREE ORAL CAPSULE 33-1 MG EX Non FDA Exclusion

TRISTART ONE ORAL CAPSULE 35-1-215 MG Benefit Exclusion

virt-pn dha oral capsule 27-0.6-0.4-300 mg Tier 5

386

Drug Name Drug Tier NotesVITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG Tier 3

VITAFOL FE+ ORAL CAPSULE THERAPY PACK 90-1-200 & 50 MG Benefit Exclusion

VITAFOL ULTRA ORAL CAPSULE 29-0.6-0.4-200 MG Benefit Exclusion

VITAFOL-OB+DHA ORAL 65-1 & 250 MG Benefit Exclusion

VITAFOL-ONE ORAL CAPSULE 29-1-200 MG Benefit Exclusion

VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG Tier 3

VITATRUE ORAL 30-1.4 & 300 MG Tier 3

wescap-pn dha oral capsule 27-0.6-0.4-300 mg Tier 5

westgel dha oral capsule 31-0.6-0.4-200 mg Tier 3

ZATEAN-PN DHA ORAL CAPSULE 27-0.6-0.4-300 MG Tier 5

*Prenatal Mv & Minerals W/Fa Without Iron***PRENATE ORAL TABLET CHEWABLE0.6-0.4 MG Benefit Exclusion

*Prenatal Vitamins***neonatal 19 oral tablet 1 mg Tier 3

PREMESISRX ORAL TABLET 1 MG Benefit Exclusion

prena1 oral tablet chewable 1.4 mg Tier 3

PRENATE AM ORAL TABLET 1 MG Benefit Exclusion

VITAFOL STRIPS ORAL FILM 1 MG Benefit Exclusion

VITAMEDMD REDICHEW RX ORAL TABLET CHEWABLE 1.4 MG Tier 3

*Specialty Vitamins Products***pro hers rx oral capsule Benefit Exclusion

pro his rx oral capsule Benefit Exclusion

pro pcos rx oral capsule Benefit Exclusion

SUPPORT-500 ORAL CAPSULE Benefit Exclusion

urosex oral tablet Benefit Exclusion

vita-rx diabetic vitamin oral capsule Benefit Exclusion

*Vitamins A & D***cod liver oil oral oil Benefit Exclusion

387


*Musculoskeletal Therapy Agents*

*Articular Cartilage Repair Therapy***CARTICEL INTRA-ARTICULAR IMPLANT


MACI INTRA-ARTICULAR SHEET EX Medical Only Exclusion

*Central Muscle Relaxants***AMRIX ORAL CAPSULE EXTENDED RELEASE 24 HOUR 15 MG, 30 MG Benefit Exclusion

baclofen intrathecal solution 10 mg/20ml, 20000 mcg/20ml, 40 mg/20ml


baclofen intrathecal solution prefilled syringe 50 mcg/ml


baclofen oral solution 5 mg/5ml Tier 3

baclofen oral tablet 10 mg, 20 mg, 5 mg Tier 1

carisoprodol oral tablet 250 mg, 350 mg EX Formulary Exclusion

chlorzoxazone tablet 250 mg oral 250 mg Benefit Exclusion Non Essential Drug Exclusion


chlorzoxazone tablet 500 mg oral 500 mg Tier 1


cyclobenzaprine hcl er oral capsule extended release 24 hour 15 mg, 30 mg


cyclobenzaprine hcl tablet 10 mg oral 10 mg Tier 1

cyclobenzaprine hcl tablet 10 mg oral 10 mg Benefit Exclusion

cyclobenzaprine hcl tablet 5 mg oral 5 mg Tier 1

cyclobenzaprine hcl tablet 5 mg oral 5 mg Benefit Exclusion

cyclobenzaprine hcl tablet 7.5 mg oral 7.5 mg Tier 1

CYCLOPHENE RAPIDPAQ TRANSDERMAL CREAM 5 % EX Non FDA Exclusion

enovarx-cyclobenzaprine hcl transdermal cream20 mg/gm


FEXMID ORAL TABLET 7.5 MG EX Formulary Exclusion

FIRST-BACLOFEN ORAL SUSPENSION 1 MG/ML, 5 MG/ML Tier 3

FLEQSUVY ORAL SUSPENSION 25 MG/5ML Benefit Exclusion


GABLOFEN INTRATHECAL SOLUTION10000 MCG/20ML, 20000 MCG/20ML, 40000 MCG/20ML


388

Drug Name Drug Tier NotesGABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 10000 MCG/20ML, 20000 MCG/20ML, 40000 MCG/20ML, 50 MCG/ML


LIORESAL INTRATHECAL SOLUTION0.05 MG/ML, 10 MG/20ML, 10 MG/5ML, 40 MG/20ML


LORZONE ORAL TABLET 375 MG, 750 MG Benefit Exclusion Non Essential Drug Exclusion

LYVISPAH ORAL PACKET 10 MG, 20 MG, 5 MG EX New to Market Exclusion

metaxalone tablet 400 mg oral 400 mg Benefit Exclusion

metaxalone tablet 400 mg oral 400 mg Tier 1

metaxalone tablet 800 mg oral 800 mg Tier 1

methocarbamol injection solution 1000 mg/10ml EX Medical Only Exclusion

methocarbamol oral tablet 500 mg, 750 mg Tier 1

orphenadrine citrate er oral tablet extended release 12 hour 100 mg

Tier 1

orphenadrine citrate injection solution 30 mg/ml EX Medical Only Exclusion

OZOBAX ORAL SOLUTION 5 MG/5ML Tier 3

ROBAXIN INJECTION SOLUTION 1000 MG/10ML EX Medical Only Exclusion

ROBAXIN-750 ORAL TABLET 750 MG EX Formulary Exclusion

SKELAXIN ORAL TABLET 800 MG EX Formulary Exclusion

SOMA ORAL TABLET 250 MG, 350 MG EX Formulary Exclusion

TABRADOL FUSEPAQ ORAL SUSPENSION 1 MG/ML EX Non FDA Exclusion

TABRADOL RAPIDPAQ ORAL SUSPENSION 1 MG/ML EX Non FDA Exclusion

tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg Benefit Exclusion

tizanidine hcl oral tablet 2 mg, 4 mg Tier 1

VANADOM ORAL TABLET 350 MG EX Formulary Exclusion

ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG Benefit Exclusion

ZANAFLEX ORAL TABLET 4 MG Benefit Exclusion

*Direct Muscle Relaxants***DANTRIUM INTRAVENOUS SOLUTION RECONSTITUTED 20 MG EX Medical Only Exclusion

DANTRIUM ORAL CAPSULE 25 MG, 50 MG EX Formulary Exclusion

dantrolene sodium intravenous solution reconstituted 20 mg


389

Drug Name Drug Tier Notesdantrolene sodium oral capsule 100 mg, 25 mg, 50 mg

Tier 1

REVONTO INTRAVENOUS SOLUTION RECONSTITUTED 20 MG EX Medical Only Exclusion

RYANODEX INTRAVENOUS SUSPENSION RECONSTITUTED 250 MG EX Medical Only Exclusion

*Muscle Relaxant Combinations***carisoprodol-aspirin-codeine oral tablet 200-325-16 mg


cyclo/gaba 10/300 oral therapy pack 10-300 mg EX Non FDA Exclusion

CYCLOPAK COMBINATION THERAPY PACK 5 & 2.5-2.5 MG & % Benefit Exclusion

METAXALL CP COMBINATION KIT 800 & 0.025 MG & % EX Non FDA Exclusion

norgesic forte oral tablet 50-770-60 mg Benefit Exclusion

NORGESIC ORAL TABLET 25-385-30 MG Benefit Exclusion Non Essential Drug Exclusion

orphenadrine-asa-caffeine oral tablet 50-770-60 mg

Benefit Exclusion

orphenadrine-aspirin-caffeine oral tablet 25-385-30 mg, 50-770-60 mg


ORPHENGESIC FORTE TABLET 50-770-60 MG ORAL 50-770-60 MG Benefit Exclusion

ORPHENGESIC FORTE TABLET 770-60-50 MG ORAL 770-60-50 MG Benefit Exclusion Non Essential Drug Exclusion

*Muscle Relaxant-Liniments Combinations***NOPIOID-LMC KIT COMBINATION THERAPY PACK 7.5 & 4-4 MG & % EX Non FDA Exclusion

*Viscosupplement Combinations***HYRONAN INJECTION KIT 1 & 2 % EX Non FDA Exclusion

*Viscosupplements***DUROLANE INTRA-ARTICULAR PREFILLED SYRINGE 60 MG/3ML Tier 4 PA; Specialty; QL

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML


GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE 30 MG/3ML EX PA; Formulary Exclusion; QL

GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16.8 MG/2ML


390

Drug Name Drug Tier NotesGENVISC 850 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML

EX PA; Formulary Exclusion; QL

HYALGAN INTRA-ARTICULAR SOLUTION 20 MG/2ML EX PA; Formulary Exclusion; QL

HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML


HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 24 MG/3ML


MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 88 MG/4ML


ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 30 MG/2ML


SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML


SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16 MG/2ML EX PA; Formulary Exclusion; QL

SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 48 MG/6ML


TRILURON INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML


TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML EX PA; Formulary Exclusion; QL

VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML EX PA; Formulary Exclusion; QL

*Nasal Agents - Systemic And Topical*

*Antihistamine-Steroid***azelastine-fluticasone nasal suspension 137-50 mcg/act

Tier 1

DERMACINRX AZENASE PAK NASAL THERAPY PACK 137 & 50 MCG/ACT Benefit Exclusion

DYMISTA NASAL SUSPENSION 137-50 MCG/ACT EX Formulary Exclusion

*Nasal Anesthetics***cocaine hcl nasal solution 40 mg/ml EX Medical Only Exclusion

goprelto nasal solution 40 mg/ml EX Medical Only Exclusion

391

Drug Name Drug Tier NotesNUMBRINO NASAL SOLUTION 40 MG/ML EX Medical Only Exclusion

*Nasal Anticholinergics***ipratropium bromide nasal solution 0.03 %, 0.06 %

Tier 1

*Nasal Antihistamines***azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray

Tier 1

olopatadine hcl nasal solution 0.6 % Benefit Exclusion

PATANASE SOLUTION 0.6 % NASAL 0.6 % EX Formulary Exclusion

PATANASE SOLUTION 0.6 % NASAL 0.6 % Benefit Exclusion

*Nasal Steroids***BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY Benefit Exclusion

flunisolide nasal solution 25 mcg/act (0.025%) Tier 1

fluticasone propionate nasal suspension 50 mcg/act

Tier 1

mometasone furoate nasal suspension 50 mcg/act Tier 1

NASONEX NASAL SUSPENSION 50 MCG/ACT Benefit Exclusion

OMNARIS NASAL SUSPENSION 50 MCG/ACT Benefit Exclusion

PROPEL MINI NASAL IMPLANT 370 MCG EX Medical Only Exclusion

PROPEL MINI SDS NASAL IMPLANT 370 MCG EX


PROPEL NASAL IMPLANT 370 MCG EX Medical Only Exclusion

QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 MCG/ACT Tier 3

QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT Tier 3

SINUVA NASAL IMPLANT 1350 MCG EX Medical Only Exclusion

XHANCE NASAL EXHALER SUSPENSION93 MCG/ACT Benefit Exclusion PA

ZETONNA NASAL AEROSOL SOLUTION37 MCG/ACT Benefit Exclusion

*Topical Decongestants***ADRENALIN NASAL SOLUTION 0.1 % EX Non FDA Exclusion

*Neuromuscular Agents*

*Als Agents - Miscellaneous***RADICAVA INTRAVENOUS SOLUTION 30 MG/100ML Tier 4 PA; Specialty

392

Drug Name Drug Tier NotesRADICAVA ORS ORAL SUSPENSION 105 MG/5ML EX


RADICAVA ORS STARTER KIT ORAL SUSPENSION 105 MG/5ML EX


*Benzathiazoles***EXSERVAN ORAL FILM 50 MG Tier 4 PA; Specialty

RILUTEK ORAL TABLET 50 MG EX PA; Specialty; Formulary Exclusion

riluzole oral tablet 50 mg Tier 4 PA; Specialty

TIGLUTIK ORAL SUSPENSION 50 MG/10ML Tier 4 PA; Specialty

*Depolarizing Muscle Relaxants***ANECTINE INJECTION SOLUTION 20 MG/ML EX Medical Only Exclusion

QUELICIN INJECTION SOLUTION 20 MG/ML EX Medical Only Exclusion

succinylcholine chloride injection solution prefilled syringe 100 mg/5ml, 140 mg/7ml, 200 mg/10ml


succinylcholine chloride intravenous solution prefilled syringe 100 mg/5ml, 140 mg/7ml, 200 mg/10ml


succinylcholine chloride solution 20 mg/ml injection 20 mg/ml


succinylcholine chloride solution 20 mg/ml injection 20 mg/ml


*Muscular Dystrophy Agents***amondys 45 intravenous solution 100 mg/2ml EX Insufficient Evidence

EXONDYS 51 INTRAVENOUS SOLUTION100 MG/2ML, 500 MG/10ML EX Insufficient Evidence

VILTEPSO INTRAVENOUS SOLUTION 250 MG/5ML EX Insufficient Evidence

VYONDYS 53 INTRAVENOUS SOLUTION100 MG/2ML EX Insufficient Evidence

*Neuromuscular Blocking Agent - Neurotoxins***BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT Tier 4 PA; Specialty

DYSPORT SOLUTION RECONSTITUTED 300 UNIT INTRAMUSCULAR 300 UNIT Tier 4 PA

DYSPORT SOLUTION RECONSTITUTED 300 UNIT INTRAMUSCULAR 300 UNIT Tier 4 PA; Specialty

393

Drug Name Drug Tier NotesDYSPORT SOLUTION RECONSTITUTED 500 UNIT INTRAMUSCULAR 500 UNIT Tier 4 PA; Specialty

MYOBLOC INTRAMUSCULAR SOLUTION10000 UNIT/2ML, 2500 UNIT/0.5ML, 5000 UNIT/ML


XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT


*Nondepolarizing Muscle Relaxants***atracurium besylate intravenous solution 100 mg/10ml, 50 mg/5ml


cisatracurium besylate (pf) intravenous solution10 mg/5ml, 200 mg/20ml


cisatracurium besylate intravenous solution 20 mg/10ml


NIMBEX INTRAVENOUS SOLUTION 10 MG/5ML, 20 MG/10ML, 200 MG/20ML EX Medical Only Exclusion

pancuronium bromide intravenous solution 1 mg/ml


rocuronium bromide intravenous solution 100 mg/10ml, 50 mg/5ml


rocuronium bromide intravenous solution prefilled syringe 100 mg/10ml, 50 mg/5ml, 75 mg/7.5ml


vecuronium bromide intravenous solution prefilled syringe 10 mg/10ml


vecuronium bromide intravenous solution reconstituted 10 mg, 20 mg


*Spinal Muscular Atrophy-Antisense Oligonucleotides***SPINRAZA INTRATHECAL SOLUTION 12 MG/5ML EX Medical Only Exclusion

*Spinal Muscular Atrophy-Gene Therapy Agents***ZOLGENSMA 10.1-10.5 KG INTRAVENOUS KIT 7X8.3 ML EX Medical Only Exclusion

ZOLGENSMA 10.6-11.0 KG INTRAVENOUS KIT 2X5.5ML & 6X8.3ML EX Medical Only Exclusion


ZOLGENSMA 11.6-12.0 KG INTRAVENOUS KIT 8X8.3 ML EX Medical Only Exclusion

394

Drug Name Drug Tier NotesZOLGENSMA 12.1-12.5 KG INTRAVENOUS KIT 2X5.5ML & 7X8.3ML EX Medical Only Exclusion


















*Spinal Muscular Atrophy-Smn2 Splicing Modifiers***EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 MG/ML Tier 4 PA; Specialty

*Nutrients*

*Amino Acid Mixtures***amino acid intravenous solution 5 % Benefit Exclusion

395

Drug Name Drug Tier NotesAMINOAMRMS ORAL CAPSULE Benefit Exclusion

AMINOPROTECT INTRAVENOUS SOLUTION 5 % Benefit Exclusion

AMINORELIEFRMS ORAL CAPSULE Benefit Exclusion

AMINOSYN II SOLUTION 10 % INTRAVENOUS 10 % Benefit Exclusion

AMINOSYN II SOLUTION 10 % INTRAVENOUS 10 % EX Medical Only Exclusion

AMINOSYN II SOLUTION 10 % INTRAVENOUS 10 % EX


AMINOSYN II SOLUTION 15 % INTRAVENOUS 15 % Benefit Exclusion

AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 % Benefit Exclusion

AMINOSYN-PF 7% INTRAVENOUS SOLUTION 7 % Benefit Exclusion

AMINOSYN-PF SOLUTION 10 % INTRAVENOUS 10 % Benefit Exclusion

AMINOSYN-PF SOLUTION 10 % INTRAVENOUS 10 % EX


AMINOSYN-PF SOLUTION 7 % INTRAVENOUS 7 % Benefit Exclusion

bcaa injection solution 15-10-40 mg/ml Benefit Exclusion

bcaa intravenous solution 15-10-40 mg/ml Benefit Exclusion

CLINIMIX E/DEXTROSE (2.75/5) SOLUTION 2.75 % INTRAVENOUS 2.75 % Benefit Exclusion

CLINIMIX E/DEXTROSE (2.75/5) SOLUTION 2.75 % INTRAVENOUS 2.75 % EX


CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 % Benefit Exclusion

CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % Benefit Exclusion

CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % Benefit Exclusion

CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % Benefit Exclusion

clinimix e/dextrose (8/10) intravenous solution 8 %

Benefit Exclusion

clinimix e/dextrose (8/14) intravenous solution 8 %

Benefit Exclusion

CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 % Benefit Exclusion

396

Drug Name Drug Tier NotesCLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % Benefit Exclusion

CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % Benefit Exclusion

CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % Benefit Exclusion

clinimix/dextrose (6/5) intravenous solution 6 % Benefit Exclusion



CLINISOL SF INTRAVENOUS SOLUTION15 % Benefit Exclusion

FREAMINE III INTRAVENOUS SOLUTION10 % Benefit Exclusion

PHLEXY-10 ORAL CAPSULE Benefit Exclusion

PLENAMINE SOLUTION 15 % INTRAVENOUS 15 % Benefit Exclusion

PLENAMINE SOLUTION 15 % INTRAVENOUS 15 % EX Medical Only Exclusion

PREMASOL INTRAVENOUS SOLUTION 10 % Benefit Exclusion

PROCALAMINE INTRAVENOUS SOLUTION 3 % Benefit Exclusion

PROSOL INTRAVENOUS SOLUTION 20 % Benefit Exclusion

SYNTHAMIN 17 INTRAVENOUS SOLUTION 10 % Benefit Exclusion

TRAVASOL INTRAVENOUS SOLUTION 10 % Benefit Exclusion

TROPHAMINE INTRAVENOUS SOLUTION 10 % Benefit Exclusion

*Amino Acids-Single***arginine hcl injection solution 6 gm/30ml Benefit Exclusion

ELCYS INTRAVENOUS SOLUTION 50 MG/ML Benefit Exclusion

gaba injection solution 1000 mg/10ml Benefit Exclusion

glutathione injection solution 200 mg/ml, 6 gm/30ml

Benefit Exclusion

glutathione intravenous solution 6 gm/30ml Benefit Exclusion

glycine injection solution 50 mg/ml Benefit Exclusion

l-cysteine hcl intravenous solution 50 mg/ml Benefit Exclusion

lysine hcl injection solution 100 mg/ml Benefit Exclusion

nac oral capsule 600 mg Benefit Exclusion

397

Drug Name Drug Tier Notesn-acetyl cysteine oral tablet 600 mg Benefit Exclusion

n-acetyl-l-cysteine oral capsule 600 mg Benefit Exclusion

NEOKE ALCAR ORAL POWDER Benefit Exclusion

taurine injection solution 50 mg/ml Benefit Exclusion

tryptophan oral capsule 500 mg Benefit Exclusion

*Carbohydrates***alcohol injection solution 98 % Benefit Exclusion

dehydrated alcohol injection solution 98 % Benefit Exclusion

dextrose intravenous solution 10 %, 20 %, 250 mg/ml, 30 %, 40 %, 5 %, 50 %, 70 %

Benefit Exclusion

*Lipids***CLINOLIPID INTRAVENOUS EMULSION20 % Benefit Exclusion

DOJOLVI ORAL LIQUID 100 % Tier 4 PA; Specialty; QL

INTRALIPID INTRAVENOUS EMULSION20 %, 30 % Benefit Exclusion

NEOKE MCT70 ORAL POWDER 70 GM/100GM Benefit Exclusion

NUTRILIPID INTRAVENOUS EMULSION20 % Benefit Exclusion

OMEGAVEN INTRAVENOUS EMULSION10 GM/100ML, 5 GM/50ML Benefit Exclusion

SMOFLIPID INTRAVENOUS EMULSION20 % Benefit Exclusion

*Lipotropic Combinations***lecithin oral granules Benefit Exclusion

lipo intramuscular solution 50-50-25 mg/ml Benefit Exclusion

lipo-c intramuscular solution Benefit Exclusion

mic-l-carnitine injection solution 25-50-50-50 mg/ml

Benefit Exclusion

*Misc. Nutritional Substances***CYTOTINE ORAL POWDER Benefit Exclusion

*Protein Combinations***calm injection solution Benefit Exclusion

tri-amino injection solution 100-100-100 mg/ml Benefit Exclusion

*Protein-Carbohydrate-Lipid With Electrolyte Combinations***KABIVEN INTRAVENOUS EMULSION 3.3-9.8-3.9-0.7 % Benefit Exclusion

398

Drug Name Drug Tier NotesPERIKABIVEN INTRAVENOUS EMULSION 2.4-6.8-3.5-0.5 % Benefit Exclusion

*Ophthalmic Agents*

*Alpha Adrenergic Agonist & Carbonic Anhydrase Inhib Comb***brimonidine-dorzolamide ophthalmic solution0.15-2 %


SIMBRINZA OPHTHALMIC SUSPENSION1-0.2 % Tier 2

*Artificial Tear Inserts***LACRISERT OPHTHALMIC INSERT 5 MG EX Formulary Exclusion

*Artificial Tears And Lubricants***polyvinyl alcohol ophthalmic solution 1.4 % Benefit Exclusion

*Beta-Blockers - Ophthalmic Combinations***brimonidine tartrate-timolol ophthalmic solution0.2-0.5 %

Tier 1

COMBIGAN OPHTHALMIC SOLUTION0.2-0.5 % Tier 3

COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML EX Formulary Exclusion

COSOPT PF OPHTHALMIC SOLUTION 2-0.5 % EX Formulary Exclusion

dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 %

Tier 1

dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml ophthalmic 22.3-6.8 mg/ml


dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml ophthalmic 22.3-6.8 mg/ml

Tier 1

latanoprost-timolol maleate ophthalmic solution0.005-0.5 %


timolol-brimon-dorzol-latanopr ophthalmic solution 0.5-0.15-2 -0.005%


timolol-brimonidine-dorzolamid ophthalmic solution 0.5-0.15-2 %


timolol-dorzolamid-latanoprost ophthalmic solution 0.5-0.15-0.005 %


*Beta-Blockers - Ophthalmic***betaxolol hcl ophthalmic solution 0.5 % Tier 1

BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % Tier 3

399

Drug Name Drug Tier NotesBETOPTIC-S OPHTHALMIC SUSPENSION0.25 % Tier 3

carteolol hcl ophthalmic solution 1 % Tier 1

ISTALOL OPHTHALMIC SOLUTION 0.5 % EX Formulary Exclusion

levobunolol hcl ophthalmic solution 0.5 % Tier 1

timolol maleate (once-daily) ophthalmic solution0.5 %

Tier 1

timolol maleate gel forming solution 0.25 % ophthalmic 0.25 %

Tier 3


Tier 1


Tier 1

timolol maleate ocudose ophthalmic solution 0.5 %

Tier 1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

Tier 1

timolol maleate pf ophthalmic solution 0.5 % Tier 1

TIMOPTIC OCUDOSE SOLUTION 0.25 % OPHTHALMIC 0.25 % Tier 3

TIMOPTIC OCUDOSE SOLUTION 0.5 % OPHTHALMIC 0.5 % EX Formulary Exclusion

TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 % EX Formulary Exclusion

TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 %, 0.5 % EX Formulary Exclusion

*Cholinergic Agonists***TYRVAYA NASAL SOLUTION 0.03 MG/ACT EX Formulary Exclusion

*Cycloplegic Mydriatic Combinations***CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % Tier 3

tropicamide-cyclopentolate-pe ophthalmic solution 1-1-2.5 %


tropicamide-phenylephrine ophthalmic solution1-2.5 %


tropic-cyclopent-pe-ketorolac ophthalmic solution1-1-10-0.5 %, 1-1-2.5-0.5 %


tropic-cyclopent-pe-ketorolac ophthalmic solution prefilled syringe 1-1-10-0.5 %, 1-1-2.5-0.5 %


400

Drug Name Drug Tier Notestropic-cyclop-pe-keto-propar ophthalmic solution prefilled syringe


tropic-proparaca-pe-ketorolac ophthalmic solution 1-0.5-2.5-0.5 %


*Cycloplegic Mydriatics***ALTAFRIN OPHTHALMIC SOLUTION 10 %, 2.5 % Tier 1

atropine sulfate ophthalmic ointment 1 % EX Formulary Exclusion

atropine sulfate solution 0.01 % ophthalmic 0.01 %


atropine sulfate solution 1 % ophthalmic 1 % Tier 1

atropine sulfate solution 1 % ophthalmic 1 % Tier 3

CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 1 %, 2 % EX Formulary Exclusion

cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 %

Tier 1

HOMATROPAIRE OPHTHALMIC SOLUTION 5 % EX Formulary Exclusion

ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % Tier 3

MYDRIACYL OPHTHALMIC SOLUTION 1 % EX Formulary Exclusion

phenylephrine hcl intraocular solution prefilled syringe 1.5 %


phenylephrine hcl ophthalmic solution 10 %, 2.5 %

Tier 1

tropicamide ophthalmic solution 0.5 %, 1 % EX Formulary Exclusion

*Lymphocyte Function-Associated Antigen-1 (Lfa-1) Antag***XIIDRA OPHTHALMIC SOLUTION 5 % Tier 2

*Miotics - Direct Acting***ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 %, 4 % EX Formulary Exclusion

MIOCHOL-E INTRAOCULAR SOLUTION RECONSTITUTED 20 MG EX


MIOSTAT INTRAOCULAR SOLUTION 0.01 % EX


pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

Tier 1

VUITY OPHTHALMIC SOLUTION 1.25 % Benefit Exclusion

401


*Ophthalmic - Multiple Receptor Angiogenesis Inhibitors***VABYSMO INTRAVITREAL SOLUTION 6 MG/0.05ML EX Medical Only Exclusion

*Ophthalmic Adrenergic Agents***epinephrine hcl intraocular solution prefilled syringe 1 mg/ml


*Ophthalmic Antiallergic***ALOCRIL OPHTHALMIC SOLUTION 2 % Tier 3

ALOMIDE OPHTHALMIC SOLUTION 0.1 % Tier 3

azelastine hcl ophthalmic solution 0.05 % Tier 1

bepotastine besilate ophthalmic solution 1.5 % Tier 1

BEPREVE OPHTHALMIC SOLUTION 1.5 % EX Formulary Exclusion

cromolyn sodium ophthalmic solution 4 % Tier 1

epinastine hcl ophthalmic solution 0.05 % Tier 1

LASTACAFT OPHTHALMIC SOLUTION0.25 % Tier 3

olopatadine hcl ophthalmic solution 0.1 %, 0.2 % Tier 1

PATADAY OPHTHALMIC SOLUTION 0.2 % EX Formulary Exclusion

PATANOL OPHTHALMIC SOLUTION 0.1 % EX Formulary Exclusion

PAZEO OPHTHALMIC SOLUTION 0.7 % Tier 2

ZERVIATE OPHTHALMIC SOLUTION 0.24 % Tier 3

*Ophthalmic Antibiotics***AZASITE OPHTHALMIC SOLUTION 1 % EX Formulary Exclusion

bacitracin ophthalmic ointment 500 unit/gm Tier 2

BESIVANCE OPHTHALMIC SUSPENSION0.6 % Tier 2

CILOXAN OPHTHALMIC OINTMENT 0.3 % EX Formulary Exclusion

CILOXAN OPHTHALMIC SOLUTION 0.3 % EX Formulary Exclusion

ciprofloxacin hcl ophthalmic solution 0.3 % Tier 1

erythromycin ophthalmic ointment 5 mg/gm Tier 1

gatifloxacin ophthalmic solution 0.5 % Tier 1

GENTAK OPHTHALMIC OINTMENT 0.3 % Tier 1

402

Drug Name Drug Tier Notesgentamicin sulfate ophthalmic solution 0.3 % Tier 1

KLARITY-A OPHTHALMIC SOLUTION 1 % EX Non FDA Exclusion

levofloxacin ophthalmic solution 0.5 % Tier 1

mitomycin intraocular solution prefilled syringe0.02 %, 0.03 %, 0.04 %


MITOSOL OPHTHALMIC KIT 0.2 MG EX Formulary Exclusion

MOXEZA OPHTHALMIC SOLUTION 0.5 % EX Formulary Exclusion

moxifloxacin hcl (2x day) ophthalmic solution 0.5 %

Tier 1

moxifloxacin hcl intraocular solution 1 mg/ml, 5 mg/ml


moxifloxacin hcl intraocular solution prefilled syringe 0.16 %, 0.3 mg/0.3ml


moxifloxacin hcl ophthalmic solution 0.5 % Tier 1

moxifloxacin hcl ophthalmic solution prefilled syringe 0.5 %


OCUFLOX OPHTHALMIC SOLUTION 0.3 % EX Formulary Exclusion

ofloxacin ophthalmic solution 0.3 % Tier 1

tobramycin ophthalmic solution 0.3 % Tier 1

TOBREX OPHTHALMIC OINTMENT 0.3 % EX Formulary Exclusion

TOBREX OPHTHALMIC SOLUTION 0.3 % EX Formulary Exclusion

vancomycin hcl ophthalmic solution prefilled syringe 10 mg/ml


VIGAMOX OPHTHALMIC SOLUTION 0.5 % EX Formulary Exclusion

ZYMAXID OPHTHALMIC SOLUTION 0.5 % EX Formulary Exclusion

*Ophthalmic Antifungal***NATACYN OPHTHALMIC SUSPENSION 5 % Tier 2

*Ophthalmic Anti-Infective Combinations***ak-poly-bac ophthalmic ointment 500-10000 unit/gm

Tier 1

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

Tier 1

moxifloxacin hcl-bss intravitreal solution 1 mg/ml EX Non FDA Exclusion

neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400-10000 , 5-400-10000

Tier 1

403

Drug Name Drug Tier Notesneomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Tier 1

NEO-POLYCIN OPHTHALMIC OINTMENT 3.5-400-10000 Tier 1

POLYCIN OPHTHALMIC OINTMENT 500-10000 UNIT/GM Tier 1

polymyxin b-trimethoprim ophthalmic solution10000-0.1 unit/ml-%

Tier 1

POLYTRIM OPHTHALMIC SOLUTION10000-0.1 UNIT/ML-% EX Formulary Exclusion

*Ophthalmic Antiseptics***BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 % EX Formulary Exclusion

povidone-iodine ophthalmic solution 5 % EX Non FDA Exclusion

*Ophthalmic Antivirals***trifluridine ophthalmic solution 1 % Tier 1

ZIRGAN OPHTHALMIC GEL 0.15 % EX Formulary Exclusion

*Ophthalmic Carbonic Anhydrase Inhibitors***AZOPT OPHTHALMIC SUSPENSION 1 % EX Formulary Exclusion

brinzolamide ophthalmic suspension 1 % Tier 1

dorzolamide hcl solution 2 % ophthalmic 2 % EX Non FDA Exclusion

dorzolamide hcl solution 2 % ophthalmic 2 % Tier 1

TRUSOPT OPHTHALMIC SOLUTION 2 % EX Formulary Exclusion

*Ophthalmic Diagnostic Products***ak-fluor intravenous solution 10 %, 25 % EX Medical Only Exclusion

altafluor benox ophthalmic solution 0.25-0.4 % EX Formulary Exclusion

BIO GLO OPHTHALMIC STRIP 1 MG EX Non FDA Exclusion

FLUCAINE OPHTHALMIC SOLUTION0.25-0.5 % EX Non FDA Exclusion

fluorescein sodium/benoxinate ophthalmic solution 0.3-0.4 %


fluorescein-benoxinate ophthalmic solution 0.25-0.4 %

Tier 1

FLUORESCITE INTRAVENOUS SOLUTION 10 % EX Medical Only Exclusion

FLUOR-I-STRIPS A.T. OPHTHALMIC STRIP 1 MG EX Non FDA Exclusion

FLURA-SAFE OPHTHALMIC SOLUTION0.35-0.4 % EX Non FDA Exclusion

404

Drug Name Drug Tier NotesFUL-GLO OPHTHALMIC STRIP 0.6 MG, 1 MG EX Non FDA Exclusion

GREEN GLO LISSAMINE GREEN OPHTHALMIC STRIP 1.5 MG EX Non FDA Exclusion

PAREMYD OPHTHALMIC SOLUTION 1-0.25 % EX Formulary Exclusion

proparacaine-fluorescein ophthalmic solution0.5-0.25 %


*Ophthalmic Gene Therapy***LUXTURNA INTRAOCULAR SUSPENSION5000000000000 VG/ML EX Medical Only Exclusion

*Ophthalmic Immunomodulators***CEQUA OPHTHALMIC SOLUTION 0.09 % EX Formulary Exclusion

CYCLOSPORINE IN KLARITY OPHTHALMIC EMULSION 0.1 % EX Non FDA Exclusion

cyclosporine ophthalmic emulsion 0.05 % Tier 1

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 % Tier 2

RESTASIS OPHTHALMIC EMULSION 0.05 % Tier 2

VERKAZIA OPHTHALMIC EMULSION 0.1 % EX New to Market Exclusion

*Ophthalmic Irrigation Solutions***balanced salt intraocular solution EX Formulary Exclusion

BSS PLUS INTRAOCULAR SOLUTION EX Medical Only Exclusion; Formulary Exclusion

BSS SOLUTION INTRAOCULAR EX Medical Only Exclusion

BSS SOLUTION INTRAOCULAR EX Medical Only Exclusion; Formulary Exclusion

*Ophthalmic Kinase Inhibitors - Combinations***ROCKLATAN OPHTHALMIC SOLUTION0.02-0.005 % Tier 3

*Ophthalmic Local Anesthetic - Combinations***lidocaine-epinephrine intraocular solution 7.5-0.25 mg/ml


lidocaine-phenylephrine intraocular solution 1-1.5 %


lidocaine-phenylephrine-bss intraocular solution prefilled syringe 1-1.5 % (1ml)


405


*Ophthalmic Local Anesthetics***AKTEN OPHTHALMIC GEL 3.5 % Tier 3

ALCAINE OPHTHALMIC SOLUTION 0.5 % Tier 3

ALTACAINE OPHTHALMIC SOLUTION0.5 % Tier 1

proparacaine hcl ophthalmic solution 0.5 % Tier 1

tetracaine hcl ophthalmic solution 0.5 % Tier 1

*Ophthalmic Nerve Growth Factors***OXERVATE OPHTHALMIC SOLUTION0.002 % Tier 4 PA; Specialty; QL

*Ophthalmic Nonsteroidal Anti-Inflammatory Agents***ACULAR LS OPHTHALMIC SOLUTION 0.4 % EX Formulary Exclusion

ACULAR OPHTHALMIC SOLUTION 0.5 % EX Formulary Exclusion

ACUVAIL OPHTHALMIC SOLUTION 0.45 % EX Formulary Exclusion

bromfenac sodium (once-daily) ophthalmic solution 0.09 %

Tier 1

BROMSITE OPHTHALMIC SOLUTION0.075 % Tier 3

diclofenac sodium ophthalmic solution 0.1 % Tier 1

flurbiprofen sodium ophthalmic solution 0.03 % Tier 1

ILEVRO OPHTHALMIC SUSPENSION 0.3 % Tier 3

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

Tier 1

NEVANAC OPHTHALMIC SUSPENSION0.1 % EX Formulary Exclusion

PROLENSA OPHTHALMIC SOLUTION0.07 % EX Formulary Exclusion

*Ophthalmic Photodynamic Therapy Agents***VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 15 MG EX Medical Only Exclusion

*Ophthalmic Photoenhancer Combinations***PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146-20 %


406

Drug Name Drug Tier NotesPHOTREXA-PHOTREXA VISCOUS KIT OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146 &0.146-20 %


*Ophthalmic Rho Kinase Inhibitors***RHOPRESSA OPHTHALMIC SOLUTION0.02 % Tier 3

*Ophthalmic Selective Alpha Adrenergic Agonists***ALPHAGAN P OPHTHALMIC SOLUTION0.1 %, 0.15 % EX Formulary Exclusion

apraclonidine hcl ophthalmic solution 0.5 % Tier 1

brimonidine tartrate ophthalmic solution 0.15 %, 0.2 %

Tier 1

IOPIDINE OPHTHALMIC SOLUTION 1 % EX Formulary Exclusion

*Ophthalmic Steroid Combinations***bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

Tier 1

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % Tier 3

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % Tier 3

dexamethasone-moxifloxacin intraocular solution1-5 mg/ml


dexameth-moxiflox-ketorolac intraocular solution1-0.5-0.4 mg/ml


double pm ophthalmic solution reconstituted 1-0.5 %


MAXITROL OPHTHALMIC OINTMENT3.5-10000-0.1 EX Formulary Exclusion

MAXITROL OPHTHALMIC SUSPENSION3.5-10000-0.1 EX Formulary Exclusion

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

Tier 1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

Tier 1

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

Tier 3

NEO-POLYCIN HC OPHTHALMIC OINTMENT 1 % Tier 1

PRED-G OPHTHALMIC SUSPENSION 0.3-1 % Tier 3

PRED-G S.O.P. OPHTHALMIC OINTMENT0.3-0.6 % Tier 3

407

Drug Name Drug Tier Notesprednisol ace-moxiflox-bromfen ophthalmic suspension 1-0.5-0.075 %


prednisolone acetate-nepafenac ophthalmic suspension 1-0.1 %


prednisolone acet-moxifloxacin ophthalmic suspension 1-0.5 %


prednisolone-bromfenac ophthalmic solution 1-0.075 %


prednisolone-bromfenac ophthalmic suspension1-0.075 %


prednisolone-gatifloxacin ophthalmic suspension1-0.5 %


prednisolone-moxifloxacin ophthalmic solution 1-0.5 %


prednisolon-gatiflox-bromfenac ophthalmic solution 1-0.5-0.075 %


prednisolon-gatiflox-bromfenac ophthalmic suspension 1-0.5-0.075 %


prednisolon-moxiflox-bromfenac ophthalmic solution 1-0.5-0.075 %


prednisolon-moxiflox-nepafenac ophthalmic suspension 1-0.5-0.1 %


sulfacetamide-prednisolone ophthalmic solution10-0.23 %

Tier 1

TOBRADEX OPHTHALMIC OINTMENT0.3-0.1 % EX Formulary Exclusion

TOBRADEX OPHTHALMIC SUSPENSION0.3-0.1 % EX Formulary Exclusion

TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % Tier 3

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

Tier 1

triamcinolone-moxifloxacin intraocular suspension 15-1 mg/ml


TRIMOXI+ INTRAOCULAR SUSPENSION15-1 MG/ML EX Non FDA Exclusion

triple pmb ophthalmic solution reconstituted 1-0.5-0.09 %


triple pmk ophthalmic solution reconstituted 1-0.5-0.5 %


ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % Tier 3

408


*Ophthalmic Steroids***ALREX OPHTHALMIC SUSPENSION 0.2 % Tier 3

dexamethasone sodium phosphate ophthalmic solution 0.1 %

Tier 1

DEXTENZA OPHTHALMIC INSERT 0.4 MG EX Medical Only Exclusion

DEXYCU INTRAOCULAR SUSPENSION 9 % EX Medical Only Exclusion

difluprednate ophthalmic emulsion 0.05 % Tier 1

DUREZOL OPHTHALMIC EMULSION 0.05 % EX Formulary Exclusion

EYSUVIS OPHTHALMIC SUSPENSION0.25 % EX Formulary Exclusion; QL

FLAREX OPHTHALMIC SUSPENSION 0.1 % Tier 3

fluorometholone ophthalmic suspension 0.1 % Tier 1

FML FORTE OPHTHALMIC SUSPENSION0.25 % EX Formulary Exclusion

FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 % EX Formulary Exclusion

FML OPHTHALMIC OINTMENT 0.1 % EX Formulary Exclusion

ILUVIEN INTRAVITREAL IMPLANT 0.19 MG EX Medical Only Exclusion

INVELTYS OPHTHALMIC SUSPENSION 1 % EX Formulary Exclusion

KLARITY-L OPHTHALMIC EMULSION0.2 %, 0.5 % EX Non FDA Exclusion

LOTEMAX OPHTHALMIC GEL 0.5 % EX Formulary Exclusion

LOTEMAX OPHTHALMIC OINTMENT 0.5 % Tier 2

LOTEMAX OPHTHALMIC SUSPENSION0.5 % EX Formulary Exclusion

LOTEMAX SM OPHTHALMIC GEL 0.38 % Tier 2

loteprednol etabonate ophthalmic gel 0.5 % Tier 1

loteprednol etabonate ophthalmic suspension 0.5 %

Tier 1

MAXIDEX OPHTHALMIC SUSPENSION0.1 % Tier 3

OZURDEX INTRAVITREAL IMPLANT 0.7 MG EX


PRED FORTE OPHTHALMIC SUSPENSION 1 % EX Formulary Exclusion

409

Drug Name Drug Tier NotesPRED MILD OPHTHALMIC SUSPENSION0.12 % EX Formulary Exclusion

prednisolone acetate ophthalmic suspension 1 % Tier 1

prednisolone acetate p-f ophthalmic suspension 1 %


prednisolone sodium phosphate ophthalmic solution 1 %

Tier 3

RETISERT INTRAVITREAL IMPLANT 0.59 MG EX Medical Only Exclusion

TRIESENCE INTRAOCULAR SUSPENSION40 MG/ML EX


XIPERE INTRAOCULAR SUSPENSION 40 MG/ML EX Medical Only Exclusion

YUTIQ INTRAVITREAL IMPLANT 0.18 MG EX Medical Only Exclusion

*Ophthalmic Sulfonamides***BLEPH-10 OPHTHALMIC SOLUTION 10 % EX Formulary Exclusion

sulfacetamide sodium ophthalmic ointment 10 % Tier 1

sulfacetamide sodium ophthalmic solution 10 % Tier 1

*Ophthalmic Surgical Aids - Combinations***DISCOVISC INTRAOCULAR SOLUTION40-17 MG/ML EX


DUOVISC KIT 0.4-0.35 ML INTRAOCULAR0.4-0.35 ML EX






OMIDRIA INTRAOCULAR SOLUTION 1-0.3 % EX Medical Only Exclusion

VISCOAT INTRAOCULAR SOLUTION PREFILLED SYRINGE 20-15 MG/0.5ML, 30-22.5 MG/0.75ML


*Ophthalmic Surgical Aids***AMVISC INTRAOCULAR SOLUTION PREFILLED SYRINGE 9.6 MG/0.8ML EX Medical Only Exclusion

AMVISC PLUS INTRAOCULAR SOLUTION PREFILLED SYRINGE 12.8 MG/0.8ML


CELLUGEL INTRAOCULAR SOLUTION 2 % EX


410

Drug Name Drug Tier NotesGELFILM OPHTHALMIC FILM EX Non FDA Exclusion

HEALON DUET PRO INTRAOCULAR SOLUTION PREFILLED SYRINGE 1 & 3 % EX Medical Only Exclusion

HEALON GV INTRAOCULAR SOLUTION PREFILLED SYRINGE 11.9 MG/0.85ML EX Medical Only Exclusion

HEALON GV PRO INTRAOCULAR SOLUTION PREFILLED SYRINGE 15.3 MG/0.85ML


HEALON INTRAOCULAR SOLUTION PREFILLED SYRINGE 5.5 MG/0.55ML, 8.5 MG/0.85ML


HEALON PRO INTRAOCULAR SOLUTION PREFILLED SYRINGE 5.5 MG/0.55ML, 8.5 MG/0.85ML


HEALON5 INTRAOCULAR SOLUTION PREFILLED SYRINGE 13.8 MG/0.6ML EX Medical Only Exclusion

HEALON5 PRO INTRAOCULAR SOLUTION PREFILLED SYRINGE 13.8 MG/0.6ML


MEMBRANEBLUE OPHTHALMIC SOLUTION 0.15 % EX Formulary Exclusion

OCUCOAT VISCOADHERENT INTRAOCULAR SOLUTION 2 % EX


PROVISC INTRAOCULAR SOLUTION PREFILLED SYRINGE 4 MG/0.4ML, 5.5 MG/0.55ML, 8.5 MG/0.85ML


TISSUEBLUE INTRAOCULAR SOLUTION PREFILLED SYRINGE 0.025 % EX Medical Only Exclusion

VISIONBLUE OPHTHALMIC SOLUTION0.06 % EX Formulary Exclusion

*Ophthalmics - Blepharoptosis Agents**UPNEEQ OPHTHALMIC SOLUTION 0.1 % Tier 3

*Ophthalmics - Cystinosis Agents**CYSTADROPS OPHTHALMIC SOLUTION0.37 % Tier 4 PA; Specialty

CYSTARAN OPHTHALMIC SOLUTION0.44 % Tier 4 PA; Specialty

*Ophthalmics Misc. - Other***chondroitin sulfate ophthalmic solution 0.25 % EX Non FDA Exclusion

*Prostaglandins - Ophthalmic***bimatoprost ophthalmic solution 0.03 % EX Formulary Exclusion

411

Drug Name Drug Tier NotesDURYSTA INTRAOCULAR IMPLANT 10 MCG EX Medical Only Exclusion

latanoprost solution 0.005 % ophthalmic 0.005 % EX Non FDA Exclusion

latanoprost solution 0.005 % ophthalmic 0.005 % Tier 1

LUMIGAN OPHTHALMIC SOLUTION 0.01 % Tier 2

TRAVATAN Z OPHTHALMIC SOLUTION0.004 % EX Formulary Exclusion

travoprost (bak free) ophthalmic solution 0.004 % Tier 1

VYZULTA OPHTHALMIC SOLUTION0.024 % Tier 3

XALATAN OPHTHALMIC SOLUTION0.005 % EX Formulary Exclusion

XELPROS OPHTHALMIC EMULSION0.005 % EX Formulary Exclusion

ZIOPTAN OPHTHALMIC SOLUTION0.0015 % EX Formulary Exclusion

*Vascular Endothelial Growth Factor (Vegf) Antagonists***BEOVU INTRAVITREAL SOLUTION 6 MG/0.05ML EX Medical Only Exclusion

BEOVU INTRAVITREAL SOLUTION PREFILLED SYRINGE 6 MG/0.05ML EX Medical Only Exclusion

bevacizumab intraocular solution prefilled syringe 2.75 mg/0.11ml, 3.75 mg/0.15ml


bevacizumab solution prefilled syringe 2.5 mg/0.1ml intravitreal 2.5 mg/0.1ml


bevacizumab solution prefilled syringe 3 mg/0.12ml intravitreal 3 mg/0.12ml






BYOOVIZ INTRAVITREAL SOLUTION 0.5 MG/0.05ML EX Medical Only Exclusion

EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML EX Medical Only Exclusion

EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE 2 MG/0.05ML EX Medical Only Exclusion

LUCENTIS INTRAVITREAL SOLUTION0.3 MG/0.05ML, 0.5 MG/0.05ML EX Medical Only Exclusion

412

Drug Name Drug Tier NotesLUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 0.3 MG/0.05ML, 0.5 MG/0.05ML


SUSVIMO (IMPLANT 1ST FILL) INTRAVITREAL SOLUTION 10 MG/0.1ML EX Medical Only Exclusion

SUSVIMO (IMPLANT REFILL) INTRAVITREAL SOLUTION 10 MG/0.1ML EX Medical Only Exclusion

*Otic Agents*

*Otic Agents - Miscellaneous***acetic acid otic solution 2 % Tier 1

*Otic Analgesic Combinations***CORTIC-ND OTIC SOLUTION 10-10-1 MG/ML EX Non FDA Exclusion

PRAMOTIC OTIC LIQUID 1-0.1 % EX Non FDA Exclusion

*Otic Anti-Infectives***CETRAXAL OTIC SOLUTION 0.2 % Tier 3

ciprofloxacin hcl otic solution 0.2 % Tier 3

ofloxacin otic solution 0.3 % Tier 1

OTIPRIO INTRATYMPANIC SUSPENSION6 % EX


*Otic Steroid-Anti-Infective Combinations***CIPRO HC OTIC SUSPENSION 0.2-1 % Tier 3

CIPRODEX OTIC SUSPENSION 0.3-0.1 % EX Formulary Exclusion

ciprofloxacin-dexamethasone otic suspension 0.3-0.1 %

Tier 1

ciprofloxacin-fluocinolone pf otic solution 0.3-0.025 %

Tier 3

COLY-MYCIN S OTIC SUSPENSION 3.3-3-10-0.5 MG/ML Tier 3

CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML Tier 3

neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1

Tier 1

neomycin-polymyxin-hc otic suspension 3.5-10000-1

Tier 1

OTOVEL OTIC SOLUTION 0.3-0.025 % Tier 3

*Otic Steroids***DERMOTIC OTIC OIL 0.01 % EX Formulary Exclusion

FLAC OTIC OIL 0.01 % Tier 1

413

Drug Name Drug Tier Notesfluocinolone acetonide otic oil 0.01 % Tier 1

hydrocortisone-acetic acid otic solution 1-2 % Tier 1

*Oxytocics*

*Abortifacients/Cervical Ripening - Prostaglandins***carboprost tromethamine intramuscular solution250 mcg/ml

Benefit Exclusion

CERVIDIL VAGINAL INSERT 10 MG Tier 3

HEMABATE INTRAMUSCULAR SOLUTION 250 MCG/ML Benefit Exclusion

PREPIDIL VAGINAL GEL 0.5 MG/3GM EX Formulary Exclusion

PROSTIN E2 VAGINAL SUPPOSITORY 20 MG EX Formulary Exclusion

*Oxytocics***METHERGINE ORAL TABLET 0.2 MG Tier 1

methylergonovine maleate injection solution 0.2 mg/ml


methylergonovine maleate oral tablet 0.2 mg Tier 1

oxytocin injection solution 10 unit/ml EX Medical Only Exclusion

oxytocin-lactated ringers intravenous solution 20 unit/l, 30 unit/500ml


oxytocin-sodium chloride solution 15-0.9 ut/250ml-% intravenous 15-0.9 ut/250ml-%


oxytocin-sodium chloride solution 20-0.9 unit/l-% intravenous 20-0.9 unit/l-%


oxytocin-sodium chloride solution 30-0.9 ut/500ml-% intravenous 30-0.9 ut/500ml-%


PITOCIN INJECTION SOLUTION 10 UNIT/ML EX Medical Only Exclusion

*Passive Immunizing And Treatment Agents*

*Antitoxins-Antivenins***ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED EX Medical Only Exclusion

ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED EX Medical Only Exclusion

antivenin latrodectus mactans injection kit EX Medical Only Exclusion

antivenin micrurus fulvius intravenous solution reconstituted


CROFAB INTRAVENOUS SOLUTION RECONSTITUTED EX Medical Only Exclusion

414


*Antiviral Monoclonal Antibodies***bamlanivimab intravenous solution 700 mg/20ml EX Medical Only Exclusion

bebtelovimab intravenous solution 175 mg/2ml EX Medical Only Exclusion

casirivimab injection solution 1332 mg/11.1ml, 300 mg/2.5ml


etesevimab intravenous solution 700 mg/20ml EX Medical Only Exclusion

imdevimab injection solution 1332 mg/11.1ml, 300 mg/2.5ml


sotrovimab intravenous solution 500 mg/8ml EX Medical Only Exclusion

SYNAGIS SOLUTION 100 MG/ML INTRAMUSCULAR 100 MG/ML Tier 4 PA; Specialty

SYNAGIS SOLUTION 100 MG/ML INTRAMUSCULAR 100 MG/ML Tier 4 PA; Specialty; QL

SYNAGIS SOLUTION 50 MG/0.5ML INTRAMUSCULAR 50 MG/0.5ML Tier 4 PA; Specialty

SYNAGIS SOLUTION 50 MG/0.5ML INTRAMUSCULAR 50 MG/0.5ML Tier 4 PA; Specialty; QL

*Bacterial Monoclonal Antibodies***ZINPLAVA INTRAVENOUS SOLUTION1000 MG/40ML EX Medical Only Exclusion; QL

*Immune Serums***ASCENIV INTRAVENOUS SOLUTION 5 GM/50ML EX


BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML, 5 GM/50ML Tier 4 PA; Specialty

CUTAQUIG SUBCUTANEOUS SOLUTION1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 GM/48ML


CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML


CYTOGAM INTRAVENOUS INJECTABLE50 MG/ML EX Medical Only Exclusion

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML


GAMASTAN INTRAMUSCULAR INJECTABLE Tier 4 PA; Specialty

GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML


415

Drug Name Drug Tier NotesGAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM


GAMMAKED SOLUTION 1 GM/10ML INJECTION 1 GM/10ML EX


GAMMAKED SOLUTION 10 GM/100ML INJECTION 10 GM/100ML Tier 4 PA; Specialty



GAMMAPLEX INTRAVENOUS SOLUTION10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML


GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML


HEPAGAM B INJECTION SOLUTION 312 UNIT/ML EX Medical Only Exclusion

HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML


HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML


HYPERHEP B INTRAMUSCULAR SOLUTION 220 UNIT/ML EX Medical Only Exclusion

HYPERHEP B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 110 UNIT/0.5ML, 220 UNIT/ML


HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML, 900 UNIT/3ML EX Medical Only Exclusion

HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT, 250 UNIT

Tier 3

HYPERTET INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT/ML


IMOGAM RABIES-HT INJECTION SOLUTION 300 UNIT/2ML EX Medical Only Exclusion

kedrab injection solution 1500 unit/10ml, 300 unit/2ml


416

Drug Name Drug Tier NotesMICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT

Tier 3

NABI-HB INTRAMUSCULAR SOLUTION312 UNIT/ML EX Medical Only Exclusion

OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 GM/500ML, 30 GM/300ML, 5 GM/100ML, 5 GM/50ML


PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML


PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML


RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT

Tier 3

RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 1500 UNIT/2ML Tier 3

VARIZIG INTRAMUSCULAR SOLUTION125 UNIT/1.2ML EX Medical Only Exclusion

WINRHO SDF INJECTION SOLUTION 1500 UNIT/1.3ML, 15000 UNIT/13ML, 2500 UNIT/2.2ML, 5000 UNIT/4.4ML

Tier 3

XEMBIFY SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML


*Monoclonal Antibody - Combinations***EVUSHELD INTRAMUSCULAR SOLUTION 150 & 150 MG/1.5ML EX Medical Only Exclusion

REGEN-COV INJECTION SOLUTION(4)300 & (4)300 MG/2.5ML, (4)300MG &1332/ 2.5&11.1ML, 1332 & 1332 MG/11.1ML, 1332 &(4)300MG/ 11.1&2.5ML, 300 & 300 MG/2.5ML, 600-600 MG/10ML


*Passive Immunizing Agents - Combinations***HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML


417


*Penicillins*

*Aminopenicillins***amoxicillin oral capsule 250 mg, 500 mg Tier 1

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

Tier 1

amoxicillin oral tablet 500 mg, 875 mg Tier 1

amoxicillin tablet chewable 125 mg oral 125 mg Tier 3

amoxicillin tablet chewable 250 mg oral 250 mg Tier 1

ampicillin oral capsule 500 mg Tier 1

ampicillin sodium injection solution reconstituted1 gm, 125 mg, 2 gm, 250 mg, 500 mg


ampicillin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm


*Natural Penicillins***BICILLIN L-A INTRAMUSCULAR SUSPENSION 2400000 UNIT/4ML EX Medical Only Exclusion

BICILLIN L-A INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE1200000 UNIT/2ML, 600000 UNIT/ML

Tier 3

penicillin g pot in dextrose intravenous solution20000 unit/ml, 40000 unit/ml, 60000 unit/ml


penicillin g potassium injection solution reconstituted 20000000 unit, 5000000 unit


penicillin g procaine intramuscular suspension600000 unit/ml


penicillin g sodium injection solution reconstituted 5000000 unit


penicillin v potassium oral solution reconstituted125 mg/5ml, 250 mg/5ml

Tier 1

penicillin v potassium oral tablet 250 mg, 500 mg Tier 1

PFIZERPEN INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT


*Penicillin Combinations***amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1000-62.5 mg

Tier 1

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

Tier 1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

Tier 1

418

Drug Name Drug Tier Notesamoxicillin-pot clavulanate oral tablet chewable200-28.5 mg, 400-57 mg

Tier 1

ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm


ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm


AUGMENTIN ES-600 ORAL SUSPENSION RECONSTITUTED 600-42.9 MG/5ML EX Formulary Exclusion

AUGMENTIN ORAL TABLET 500-125 MG EX Formulary Exclusion

AUGMENTIN SUSPENSION RECONSTITUTED 125-31.25 MG/5ML ORAL 125-31.25 MG/5ML

Tier 3

AUGMENTIN SUSPENSION RECONSTITUTED 250-62.5 MG/5ML ORAL250-62.5 MG/5ML


BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION 900000-300000 UNIT/2ML EX Medical Only Exclusion

BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML EX Medical Only Exclusion

piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (12-1.5) gm, 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4-0.5 gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm


UNASYN INJECTION SOLUTION RECONSTITUTED 1.5 (1-0.5) GM, 3 (2-1) GM


UNASYN INTRAVENOUS SOLUTION RECONSTITUTED 15 (10-5) GM EX Medical Only Exclusion

ZOSYN INTRAVENOUS SOLUTION 2-0.25 GM/50ML, 3-0.375 GM/50ML, 4-0.5 GM/100ML


*Penicillinase-Resistant Penicillins***dicloxacillin sodium oral capsule 250 mg, 500 mg Tier 1

nafcillin sodium in dextrose intravenous solution1 gm/50ml, 2 gm/100ml


nafcillin sodium injection solution reconstituted 1 gm, 2 gm


nafcillin sodium solution reconstituted 1 gm intravenous 1 gm






419

Drug Name Drug Tier Notesnafcillin sodium solution reconstituted 2 gm intravenous 2 gm


oxacillin sodium in dextrose intravenous solution1 gm/50ml, 2 gm/50ml


oxacillin sodium injection solution reconstituted 1 gm, 2 gm


oxacillin sodium intravenous solution reconstituted 10 gm


*Pharmaceutical Adjuvants*

*External Vehicles***FOAMIL EXTERNAL LIQUID EX Non FDA Exclusion

RHEOSPRAY EXTERNAL LIQUID EX Non FDA Exclusion

*Parenteral Vehicles***diluent for treprostinil intravenous solution EX Medical Only Exclusion

saline bacteriostatic injection solution 0.9 % Tier 1

saline-phenol injection solution 0.4-0.9 % Tier 3

sodium chloride bacteriostatic injection solution0.9 %

Tier 1

STERILE DILUENT FLOLAN PH 12 INTRAVENOUS SOLUTION EX Medical Only Exclusion

sterile diluent/epoprostenol intravenous solution EX Medical Only Exclusion

sterile water for injection intravenous solution Tier 1

sterile water for injection solution injection EX Non FDA Exclusion

sterile water for injection solution injection Tier 1

*Semi Solid Vehicles***AUXIPRO VANISHING EXTERNAL CREAM EX Non FDA Exclusion

cream base niosomes external cream EX Non FDA Exclusion

cream-heavy base niosomes external cream EX Non FDA Exclusion

freedom adaptaderm external cream EX Non FDA Exclusion

freedom derma serum external cream EX Non FDA Exclusion

FREEDOM DERMA-D EXTERNAL CREAMEX Non FDA Exclusion

FREEDOM DERMA-N EXTERNAL CREAMEX Non FDA Exclusion

hormone cr heavy base niosomes external cream EX Non FDA Exclusion

hormone cream base niosomes external cream EX Non FDA Exclusion

LIOPEN ABSORPTION ENHANCING EXTERNAL CREAM EX Non FDA Exclusion

pensomal external cream EX Non FDA Exclusion

420

Drug Name Drug Tier Notessa3 derm external cream EX Non FDA Exclusion

salt durable cream external cream EX Non FDA Exclusion

SALTSTABLE LO EXTERNAL CREAM EX Non FDA Exclusion

TDC MAX EXTERNAL CREAM EX Formulary Exclusion

teroderm-plus external cream EX Non FDA Exclusion

VERSAPRO EXTERNAL CREAM EX Non FDA Exclusion

*Progestins*

*Progestins***AYGESTIN ORAL TABLET 5 MG EX Formulary Exclusion

ec-rx progesterone transdermal cream 10 %, 20 %


hydroxyprogesterone caproate intramuscular oil250 mg/ml

Tier 1 PA

MAKENA INTRAMUSCULAR OIL 250 MG/ML Tier 3 PA

MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/1.1ML Tier 3 PA

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

Tier 1

MEGACE ES ORAL SUSPENSION 625 MG/5ML EX Formulary Exclusion

megestrol acetate oral suspension 625 mg/5ml Tier 1

norethindrone acetate oral tablet 5 mg Tier 1

progesterone intramuscular oil 50 mg/ml Tier 1

progesterone micronized transdermal cream 10 %


progesterone oral capsule 100 mg, 200 mg Tier 1

PROMETRIUM ORAL CAPSULE 100 MG, 200 MG EX Formulary Exclusion

PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG EX Formulary Exclusion

*Psychotherapeutic And Neurological Agents - Misc.*

*Agents For Opioid Withdrawal***LUCEMYRA ORAL TABLET 0.18 MG Tier 3 QL

*Alcohol Deterrents***acamprosate calcium oral tablet delayed release333 mg

Tier 1

ANTABUSE ORAL TABLET 250 MG, 500 MG EX Formulary Exclusion

421

Drug Name Drug Tier Notesdisulfiram oral tablet 250 mg, 500 mg Tier 1

*Alzheimer's Treatment - Anti-Amyloid Antibodies***ADUHELM INTRAVENOUS SOLUTION 170 MG/1.7ML, 300 MG/3ML EX Insufficient Evidence

*Anti-Cataplectic Agents***XYREM ORAL SOLUTION 500 MG/ML Tier 4 PA; Specialty; QL

*Anti-Cataplectic Combinations***XYWAV ORAL SOLUTION 500 MG/ML Tier 4 PA; Specialty; QL

*Antidementia Agent Combinations***NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28 -10 MG Tier 3

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

Tier 3

*Antisense Oligonucleotide (Aso) Inhibitor Agents***TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 284 MG/1.5ML Tier 4 PA; Specialty; QL

*Benzodiazepines & Tricyclic Agents***chlordiazepoxide-amitriptyline tablet 10-25 mg oral 10-25 mg

Tier 1

chlordiazepoxide-amitriptyline tablet 5-12.5 mg oral 5-12.5 mg

Tier 3

*Cholinomimetics - Ache Inhibitors***ADLARITY TRANSDERMAL PATCH WEEKLY 10 MG/DAY, 5 MG/DAY EX New to Market Exclusion

ARICEPT ORAL TABLET 10 MG, 23 MG, 5 MG EX Formulary Exclusion

donepezil hcl oral tablet 10 mg, 23 mg, 5 mg Tier 1

donepezil hcl oral tablet dispersible 10 mg, 5 mg Tier 1

EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR


galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg

Tier 1

galantamine hydrobromide oral solution 4 mg/ml Tier 1

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

Tier 1

422

Drug Name Drug Tier NotesRAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 MG, 24 MG, 8 MG


RAZADYNE ORAL TABLET 12 MG, 4 MG, 8 MG EX Formulary Exclusion

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

Tier 1

rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr

Tier 1

*Fibromyalgia Agent - Snris***SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG Tier 3

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG Tier 3

*Melanocortin Receptor Agonists***VYLEESI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 1.75 MG/0.3ML Tier 3 PA; QL

*Movement Disorder Drug Therapy***AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Tier 4 PA; Specialty; QL

INGREZZA ORAL CAPSULE 40 MG, 60 MG, 80 MG Tier 4 PA; Specialty; QL

INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 MG Tier 4 PA; Specialty; QL

tetrabenazine oral tablet 12.5 mg, 25 mg Tier 4 PA; Specialty; QL

XENAZINE ORAL TABLET 12.5 MG, 25 MG EX


*Ms Agents - Pyrimidine Synthesis Inhibitors***AUBAGIO ORAL TABLET 14 MG, 7 MG Tier 4 PA; ST; Specialty; QL

*Multiple Sclerosis Agents - Antimetabolites***MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK 10 MG Benefit Exclusion

MAVENCLAD (4 TABS) ORAL TABLET THERAPY PACK 10 MG Benefit Exclusion




423

Drug Name Drug Tier NotesMAVENCLAD (8 TABS) ORAL TABLET THERAPY PACK 10 MG Benefit Exclusion


*Multiple Sclerosis Agents - Interferons***AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML Tier 4 PA; ST; Specialty; QL

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML Tier 4 PA; ST; Specialty; QL

BETASERON SUBCUTANEOUS KIT 0.3 MG Tier 4 PA; ST; Specialty; QL

EXTAVIA SUBCUTANEOUS KIT 0.3 MG EX PA; ST; Specialty; Formulary Exclusion; QL

PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML Tier 4 PA; ST; Specialty; QL

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML


PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML


PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 125 MCG/0.5ML Tier 4 PA; ST; Specialty; QL

PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML Tier 4 PA; ST; Specialty; QL

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML


REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG


REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML


REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG


*Multiple Sclerosis Agents - Monoclonal Antibodies***KESIMPTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML Tier 4 PA; Specialty; QL

LEMTRADA INTRAVENOUS SOLUTION12 MG/1.2ML Tier 4 PA; Specialty; QL

424

Drug Name Drug Tier NotesOCREVUS INTRAVENOUS SOLUTION 300 MG/10ML Tier 4

PA; Specialty; Quantity Limit Criteria; QL

TYSABRI INTRAVENOUS CONCENTRATE300 MG/15ML Tier 4 PA; Specialty; QL

*Multiple Sclerosis Agents - Nrf2 Pathway Activators***BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95 MG EX


dimethyl fumarate oral capsule delayed release120 mg, 240 mg


dimethyl fumarate starter pack oral 120 & 240 mg


TECFIDERA ORAL 120 & 240 MG EX PA; ST; Specialty; Formulary Exclusion; QL

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG EX


VUMERITY (STARTER) ORAL CAPSULE DELAYED RELEASE 231 MG EX


VUMERITY ORAL CAPSULE DELAYED RELEASE 231 MG Tier 4 PA; Specialty; QL

*Multiple Sclerosis Agents - Potassium Channel Blockers***AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG EX


dalfampridine er tablet extended release 12 hour 10 mg oral 10 mg

Tier 4 PA; QL

dalfampridine er tablet extended release 12 hour 10 mg oral 10 mg


*Multiple Sclerosis Agents***COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML


glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml


GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML


*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists***memantine hcl er oral capsule extended release 24 hour 14 mg, 21 mg, 28 mg, 7 mg

Tier 1

memantine hcl oral solution 10 mg/5ml, 2 mg/ml Tier 1

425

Drug Name Drug Tier Notesmemantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg

Tier 1

NAMENDA ORAL TABLET 10 MG, 5 MG EX Formulary Exclusion

NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 10 MG EX Formulary Exclusion

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG


NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR7 & 14 & 21 &28 MG

Tier 3

*Phenothiazines & Tricyclic Agents***perphenazine-amitriptyline tablet 2-10 mg oral 2-10 mg

Tier 3

perphenazine-amitriptyline tablet 2-25 mg oral 2-25 mg

Tier 1


Tier 3


Tier 3


Tier 3

*Postherpetic Neuralgia (Phn)/Neuropathic Pain Agents***GRALISE ORAL TABLET 300 MG, 600 MG Benefit Exclusion Non Essential Drug Exclusion; QL

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 165 MG, 330 MG, 82.5 MG


pregabalin er oral tablet extended release 24 hour 165 mg, 330 mg, 82.5 mg


*Postherpetic Neuralgia(Phn)/Neuropathic Pain Comb Agents***CONVENIENCE PAK COMBINATION THERAPY PACK 600 & 5 MG & % EX Non FDA Exclusion

*Premenstrual Dysphoric Disorder (Pmdd) Agents - Ssris***fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg Benefit Exclusion Non Essential Drug Exclusion

SARAFEM ORAL TABLET 10 MG, 20 MG Benefit Exclusion

*Pseudobulbar Affect Agent Combinations***NUEDEXTA ORAL CAPSULE 20-10 MG Tier 2 PA; QL

426


*Psychotherapeutic And Neurological Agents - Misc.***ergoloid mesylates oral tablet 1 mg EX Formulary Exclusion

pimozide oral tablet 1 mg, 2 mg Tier 1

*Restless Leg Syndrome (Rls) Agents***HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG Benefit Exclusion Non Essential Drug Exclusion; QL

*Serotonin 1A Recept Agonist/Serotonin 2A Recept Antag***ADDYI ORAL TABLET 100 MG Benefit Exclusion PA

*Small Interfering Ribonucleic Acid (Sirna) Agents***ONPATTRO INTRAVENOUS SOLUTION 10 MG/5ML EX Medical Only Exclusion

*Smoking Deterrents***apo-varenicline oral tablet 0.5 mg, 1 mg Tier 5

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg

Tier 5

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG Tier 5

CHANTIX ORAL TABLET 0.5 MG, 1 MG Tier 5

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 Tier 5

cvs nicotine mouth/throat gum 2 mg, 4 mg Tier 5

cvs nicotine mouth/throat lozenge 2 mg Tier 5

cvs nicotine polacrilex mouth/throat gum 2 mg, 4 mg

Tier 5

cvs nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

Tier 5

cvs nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr

Tier 5

eq nicotine mouth/throat gum 4 mg Tier 5

eq nicotine mouth/throat lozenge 4 mg Tier 5

eq nicotine polacrilex mouth/throat gum 2 mg, 4 mg

Tier 5

eq nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

Tier 5

eq nicotine step 3 transdermal patch 24 hour 7 mg/24hr

Tier 5

427

Drug Name Drug Tier Noteseq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

Tier 5

eql nicotine polacrilex mouth/throat gum 2 mg Tier 5

eql nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

Tier 5

gnp nicotine mini mouth/throat lozenge 2 mg, 4 mg

Tier 5

gnp nicotine mouth/throat gum 2 mg, 4 mg Tier 5

gnp nicotine polacrilex mouth/throat gum 2 mg, 4 mg

Tier 5

gnp nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

Tier 5

gnp nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr

Tier 5

goodsense nicotine mouth/throat gum 2 mg, 4 mg Tier 5

goodsense nicotine mouth/throat lozenge 2 mg, 4 mg

Tier 5

HABITROL TRANSDERMAL PATCH 24 HOUR 21 MG/24HR Tier 5

hm nicotine polacrilex mouth/throat gum 2 mg, 4 mg

Tier 5

hm nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

Tier 5

hm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr

Tier 5

KLS QUIT2 MOUTH/THROAT GUM 2 MG Tier 5

KLS QUIT2 MOUTH/THROAT LOZENGE 2 MG Tier 5

KLS QUIT4 MOUTH/THROAT GUM 4 MG Tier 5

KLS QUIT4 MOUTH/THROAT LOZENGE 4 MG Tier 5

nicotine mini mouth/throat lozenge 2 mg, 4 mg Tier 5

nicotine polacrilex mini mouth/throat lozenge 2 mg

Tier 5

nicotine polacrilex mouth/throat gum 2 mg, 4 mg Tier 5

nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

Tier 5

nicotine step 1 transdermal patch 24 hour 21 mg/24hr

Tier 5


Tier 5


Tier 5

428

Drug Name Drug Tier Notesnicotine transdermal kit 21-14-7 mg/24hr Tier 5

nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr

Tier 5

NICOTROL INHALATION INHALER 10 MG Tier 5

NICOTROL NS NASAL SOLUTION 10 MG/ML Tier 5

px stop smoking aid mouth/throat gum 2 mg, 4 mg Tier 5

px stop smoking aid mouth/throat lozenge 2 mg, 4 mg

Tier 5

qc nicotine transdermal system transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

Tier 5

ra mini nicotine mouth/throat lozenge 2 mg, 4 mg Tier 5

ra nicotine gum mouth/throat gum 2 mg, 4 mg Tier 5

ra nicotine mouth/throat gum 2 mg, 4 mg Tier 5

ra nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

Tier 5

ra nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

Tier 5

sm nicotine mouth/throat gum 4 mg Tier 5

sm nicotine mouth/throat lozenge 2 mg Tier 5

sm nicotine polacrilex mouth/throat gum 2 mg, 4 mg

Tier 5

sm nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

Tier 5

sm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr

Tier 5

tgt nicotine mouth/throat gum 2 mg, 4 mg Tier 5

tgt nicotine polacrilex mouth/throat gum 2 mg, 4 mg

Tier 5

tgt nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg

Tier 5

tgt nicotine step one transdermal patch 24 hour21 mg/24hr

Tier 5

tgt nicotine step three transdermal patch 24 hour7 mg/24hr

Tier 5

tgt nicotine step two transdermal patch 24 hour14 mg/24hr

Tier 5

THRIVE MOUTH/THROAT GUM 2 MG Tier 5

varenicline tartrate oral 0.5 mg x 11 & 1 mg x 42 Tier 5

varenicline tartrate oral tablet 0.5 mg, 1 mg Tier 5

429


*Sphingosine 1-Phosphate (S1p) Receptor Modulators***GILENYA ORAL CAPSULE 0.5 MG Tier 4 PA; ST; Specialty; QL

MAYZENT ORAL TABLET 0.25 MG, 1 MG, 2 MG Tier 4 PA; Specialty; QL

MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 0.25 MG, 12 X 0.25 MG


PONVORY ORAL TABLET 20 MG EX PA; Specialty; Formulary Exclusion; QL

PONVORY STARTER PACK ORAL TABLET THERAPY PACK 2-3-4-5-6-7-8-9 & 10 MG


ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 X 0.23MG & 3 X 0.46MG


ZEPOSIA ORAL CAPSULE 0.92 MG Tier 4 PA; ST; Specialty; QL

ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK 0.23MG & 0.46MG & 0.92MG


*Thienbenzodiazepines & Opioid Antagonists***LYBALVI ORAL TABLET 10-10 MG, 15-10 MG, 20-10 MG, 5-10 MG EX Formulary Exclusion

*Thienbenzodiazepines & Ssris***olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

Tier 1

SYMBYAX ORAL CAPSULE 12-50 MG, 3-25 MG, 6-25 MG, 6-50 MG EX Formulary Exclusion

*Vasomotor Symptom Agents - Ssris***BRISDELLE ORAL CAPSULE 7.5 MG EX Formulary Exclusion

paroxetine mesylate oral capsule 7.5 mg Tier 1

*Respiratory Agents - Misc.*

*Alpha-Proteinase Inhibitor (Human)***ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG EX


GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML Tier 4 PA; Specialty; QL

PROLASTIN-C INTRAVENOUS SOLUTION1000 MG/20ML Tier 4 PA; Specialty; QL

430

Drug Name Drug Tier NotesPROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG Tier 4 PA; Specialty; QL

ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG EX


*Cftr Potentiators***KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG Tier 4 PA; Specialty

KALYDECO ORAL TABLET 150 MG Tier 4 PA; Specialty

*Cystic Fibrosis Agent - Combinations***ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG Tier 4 PA; Specialty

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG Tier 4 PA; Specialty

SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG, 50-75 & 75 MG Tier 4 PA; Specialty

TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 MG, 50-25-37.5 & 75 MG


*Cystic Fibrosis Agents - Miscellaneous***BRONCHITOL INHALATION CAPSULE 40 MG Tier 4 PA; Specialty; QL

BRONCHITOL TOLERANCE TEST INHALATION CAPSULE 40 MG Tier 4 PA; Specialty; QL

*Hydrolytic Enzymes***PULMOZYME INHALATION SOLUTION2.5 MG/2.5ML Tier 4 PA; Specialty; QL

*Pleural Sclerosing Agents***SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL POWDER 4 GM


STERILE TALC POWDER INTRAPLEURAL SUSPENSION RECONSTITUTED 5 GM


STERITALC INTRAPLEURAL POWDER 2 GM, 3 GM, 4 GM EX Medical Only Exclusion

*Pulmonary Fibrosis Agents - Kinase Inhibitors***OFEV ORAL CAPSULE 100 MG, 150 MG Tier 4 PA; Specialty; QL

*Pulmonary Fibrosis Agents***ESBRIET ORAL CAPSULE 267 MG Tier 4 PA; Specialty; QL

431

Drug Name Drug Tier NotesESBRIET ORAL TABLET 267 MG, 801 MG Tier 4 PA; Specialty; QL

pirfenidone oral tablet 267 mg, 801 mg Tier 4 PA; QL

*Respiratory Agents - Misc.***CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML, 240 MG/3ML EX Medical Only Exclusion

INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-% EX Medical Only Exclusion

SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 MG/ML-% EX Medical Only Exclusion

*Sulfonamides*

*Sulfonamides***sulfadiazine oral tablet 500 mg Tier 1

*Tetracyclines*

*Aminomethylcyclines***NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX Medical Only Exclusion; QL

NUZYRA ORAL TABLET 150 MG Tier 3 QL

*Fluorocyclines***XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG EX Medical Only Exclusion

*Glycylcyclines***tigecycline solution reconstituted 50 mg intravenous 50 mg


tigecycline solution reconstituted 50 mg intravenous 50 mg


TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG EX


*Tetracycline Combinations***AVIDOXY DK COMBINATION KIT 100 MG EX Non FDA Exclusion

BENZODOX COMBINATION THERAPY PACK 30 X 100 MG & 4.4%, 60 X 100 MG & 4.4%


*Tetracyclines***ACTICLATE ORAL TABLET 150 MG, 75 MG Benefit Exclusion

avidoxy oral tablet 100 mg Benefit Exclusion Non Essential Drug Exclusion

COREMINO ORAL TABLET EXTENDED RELEASE 24 HOUR 135 MG, 45 MG, 90 MG EX Non FDA Exclusion

demeclocycline hcl oral tablet 150 mg, 300 mg Tier 1

432

Drug Name Drug Tier NotesDORYX MPC ORAL TABLET DELAYED RELEASE 120 MG Benefit Exclusion

DORYX ORAL TABLET DELAYED RELEASE 200 MG, 50 MG, 80 MG Benefit Exclusion

DOXY 100 INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX Medical Only Exclusion

doxycycline hyclate intravenous solution reconstituted 100 mg


doxycycline hyclate oral capsule 100 mg, 50 mg Tier 1

doxycycline hyclate tablet 100 mg oral 100 mg Tier 1

doxycycline hyclate tablet 150 mg oral 150 mg Benefit Exclusion Non Essential Drug Exclusion

doxycycline hyclate tablet 20 mg oral 20 mg Tier 1

doxycycline hyclate tablet 50 mg oral 50 mg EX Formulary Exclusion

doxycycline hyclate tablet 75 mg oral 75 mg Benefit Exclusion Non Essential Drug Exclusion

doxycycline hyclate tablet delayed release 100 mg oral 100 mg

Tier 1


Tier 1






Tier 1



doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg

Tier 1

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

Tier 1

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

Tier 1

LYMEPAK ORAL TABLET 100 MG EX New to Market Exclusion

MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED 100 MG EX Medical Only Exclusion

MINOCIN ORAL CAPSULE 50 MG EX Formulary Exclusion

minocycline hcl er oral capsule extended release 24 hour 135 mg, 45 mg, 90 mg

Benefit Exclusion

minocycline hcl er oral tablet extended release 24 hour 105 mg, 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg

Tier 1

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

Tier 1

433

Drug Name Drug Tier Notesminocycline hcl oral tablet 100 mg, 50 mg, 75 mg Tier 1

MINOLIRA ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG, 135 MG Benefit Exclusion

MONDOXYNE NL ORAL CAPSULE 100 MG, 75 MG Tier 1

MORGIDOX COMBINATION KIT 1 X 100 MG, 2 X 100 MG EX Non FDA Exclusion

MORGIDOX ORAL CAPSULE 100 MG Benefit Exclusion Non Essential Drug Exclusion

NUTRIDOX ORAL KIT 75 MG EX Non FDA Exclusion

OKEBO ORAL CAPSULE 75 MG Tier 1

SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG EX Formulary Exclusion; QL

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG


TARGADOX ORAL TABLET 50 MG EX Formulary Exclusion

tetracycline hcl oral capsule 250 mg, 500 mg Tier 1

VIBRAMYCIN ORAL CAPSULE 100 MG EX Formulary Exclusion

VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 MG/5ML EX Formulary Exclusion

VIBRAMYCIN ORAL SYRUP 50 MG/5ML EX Formulary Exclusion

XIMINO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 135 MG, 45 MG, 90 MG Benefit Exclusion

*Thyroid Agents*

*Antithyroid Agents - Radiopharmaceuticals***sodium iodide i-131 oral solution 1000 mci/ml EX Formulary Exclusion

*Antithyroid Agents***methimazole oral tablet 10 mg, 5 mg Tier 1

propylthiouracil oral tablet 50 mg Tier 1

TAPAZOLE ORAL TABLET 10 MG, 5 MG EX Formulary Exclusion

*Thyroid Hormones***ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

Tier 3

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG EX Formulary Exclusion

EUTHYROX ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 1

434

Drug Name Drug Tier NotesLEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 1

levothyroxine sodium intravenous solution 100 mcg/5ml, 200 mcg/5ml, 500 mcg/5ml


levothyroxine sodium intravenous solution reconstituted 100 mcg, 200 mcg, 500 mcg


levothyroxine sodium oral capsule 100 mcg, 112 mcg, 125 mcg, 13 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg


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

Tier 1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 1

liothyronine sodium intravenous solution 10 mcg/ml


liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

Tier 1

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

Tier 3

NP THYROID ORAL TABLET 120 MG, 15 MG, 30 MG, 60 MG, 90 MG Tier 1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 2

THYQUIDITY ORAL SOLUTION 100 MCG/5ML Benefit Exclusion Non Essential Drug Exclusion

thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

Tier 1

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG


TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 37.5 MCG/ML, 44 MCG/ML, 50 MCG/ML, 62.5 MCG/ML, 75 MCG/ML, 88 MCG/ML

Tier 3

435

Drug Name Drug Tier NotesTRIOSTAT INTRAVENOUS SOLUTION 10 MCG/ML EX Medical Only Exclusion

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 1

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG Tier 3

WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

Tier 3

*Toxoids*

*Toxoid Combinations***ADACEL INTRAMUSCULAR SUSPENSION5-2-15.5 LF-MCG/0.5 Tier 2

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF-MCG/0.5 Tier 2

BOOSTRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 5-2.5-18.5 LF-MCG/0.5

Tier 2

DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5 Tier 2

diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml

Tier 2

INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10 Tier 2

KINRIX INTRAMUSCULAR SUSPENSION Tier 2

KINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML Tier 2

PEDIARIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE Tier 2

PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED Tier 2

QUADRACEL INTRAMUSCULAR SUSPENSION Tier 2

QUADRACEL INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 2

TDVAX INTRAMUSCULAR SUSPENSION2-2 LF/0.5ML Tier 2

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU Tier 2

VAXELIS INTRAMUSCULAR SUSPENSION Tier 5

436

Drug Name Drug Tier NotesVAXELIS INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE Tier 5

*Ulcer Drugs/Antispasmodics/Anticholinergics*

*Anticholinergic Combinations***belladonna alkaloids-opium suppository 16.2-30 mg rectal 16.2-30 mg

EX Non FDA Exclusion; Formulary Exclusion

belladonna alkaloids-opium suppository 16.2-30 mg rectal 16.2-30 mg

Tier 3


EX Non FDA Exclusion; Formulary Exclusion


Tier 3

chlordiazepoxide-clidinium capsule 5-2.5 mg oral5-2.5 mg


chlordiazepoxide-clidinium capsule 5-2.5 mg oral5-2.5 mg


DONNATAL ELIXIR 16.2 MG/5ML ORAL16.2 MG/5ML EX Formulary Exclusion

DONNATAL ELIXIR 16.2 MG/5ML ORAL16.2 MG/5ML Tier 3

DONNATAL ORAL TABLET 16.2 MG Tier 3

LIBRAX ORAL CAPSULE 5-2.5 MG Benefit Exclusion

pb-hyoscy-atropine-scopolamine oral elixir 16.2 mg/5ml


pb-hyoscy-atropine-scopolamine oral tablet 16.2 mg


phenobarbital-belladonna alk oral elixir 16.2 mg/5ml

Tier 1

phenobarbital-belladonna alk oral tablet 16.2 mg Tier 1

PHENOHYTRO ORAL ELIXIR 16.2 MG/5ML Tier 1

PHENOHYTRO ORAL TABLET 16.2 MG Tier 1

*Antispasmodics***BENTYL INTRAMUSCULAR SOLUTION 10 MG/ML EX Medical Only Exclusion

dicyclomine hcl intramuscular solution 10 mg/ml EX Medical Only Exclusion

dicyclomine hcl oral capsule 10 mg Tier 1

dicyclomine hcl oral solution 10 mg/5ml Tier 1

dicyclomine hcl oral tablet 20 mg Tier 1

437


*Belladonna Alkaloids***ANASPAZ ORAL TABLET DISPERSIBLE0.125 MG Tier 3

ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR 0.25 MG/0.3ML, 0.5 MG/0.7ML, 1 MG/0.7ML, 2 MG/0.7ML


atropine sulfate intravenous solution 0.4 mg/ml, 1 mg/ml


atropine sulfate intravenous solution prefilled syringe 0.8 mg/2ml, 1 mg/2.5ml, 1.2 mg/3ml


atropine sulfate solution 0.4 mg/ml injection 0.4 mg/ml


atropine sulfate solution 1 mg/ml injection 1 mg/ml


atropine sulfate solution 8 mg/20ml injection 8 mg/20ml


atropine sulfate solution 8 mg/20ml injection 8 mg/20ml


atropine sulfate solution prefilled syringe 0.25 mg/5ml injection 0.25 mg/5ml








atropine sulfate solution prefilled syringe 1 mg/10ml injection 1 mg/10ml


atropine sulfate solution prefilled syringe 1 mg/10ml injection 1 mg/10ml


ed-spaz oral tablet dispersible 0.125 mg Tier 1

hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg

Tier 1

hyoscyamine sulfate injection solution 0.5 mg/ml Tier 1

hyoscyamine sulfate oral elixir 0.125 mg/5ml Tier 1

hyoscyamine sulfate oral solution 0.125 mg/ml Tier 1

hyoscyamine sulfate oral tablet 0.125 mg Tier 1

hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg

Tier 1

hyoscyamine sulfate sublingual tablet sublingual0.125 mg

Tier 1

hyoscyamine sulfate tablet dispersible 0.125 mg oral 0.125 mg


438

Drug Name Drug Tier Noteshyoscyamine sulfate tablet dispersible 0.125 mg oral 0.125 mg

Tier 1

hyosyne oral elixir 0.125 mg/5ml Tier 1

hyosyne oral solution 0.125 mg/ml Tier 1

LEVBID ORAL TABLET EXTENDED RELEASE 12 HOUR 0.375 MG Tier 3

LEVSIN INJECTION SOLUTION 0.5 MG/ML Tier 3

LEVSIN ORAL TABLET 0.125 MG Tier 3

LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG Tier 3

NULEV ORAL TABLET DISPERSIBLE0.125 MG Tier 1

oscimin oral tablet 0.125 mg Tier 1

oscimin sr oral tablet extended release 12 hour0.375 mg

Tier 1

oscimin sublingual tablet sublingual 0.125 mg Tier 1

SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 MG EX Formulary Exclusion

SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG EX Formulary Exclusion

SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HOUR 0.375 MG EX Formulary Exclusion

*H-2 Antagonists***cimetidine hcl oral solution 300 mg/5ml, 400 mg/6.67ml

Tier 1

cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg

Tier 1

famotidine (pf) intravenous solution 20 mg/2ml Tier 1

famotidine intravenous solution 200 mg/20ml, 40 mg/4ml


famotidine oral suspension reconstituted 40 mg/5ml

Tier 1

famotidine oral tablet 20 mg, 40 mg Tier 1

famotidine premixed intravenous solution 20-0.9 mg/50ml-%


nizatidine capsule 150 mg oral 150 mg Tier 1



nizatidine oral solution 15 mg/ml Tier 1

PEPCID ORAL TABLET 20 MG, 40 MG EX Formulary Exclusion

439


*Misc. Anti-Ulcer***CARAFATE ORAL SUSPENSION 1 GM/10ML EX Formulary Exclusion

CARAFATE ORAL TABLET 1 GM EX Formulary Exclusion

sucralfate oral suspension 1 gm/10ml Tier 1

sucralfate oral tablet 1 gm Tier 1

*Proton Pump Inhibitor-Antacid Combinations***omeprazole-sodium bicarbonate capsule 20-1100 mg oral (rx) 20-1100 mg

Tier 1 QL

omeprazole-sodium bicarbonate capsule 20-1100 mg oral (rx) 20-1100 mg


omeprazole-sodium bicarbonate capsule 40-1100 mg oral 40-1100 mg

Tier 1 QL

omeprazole-sodium bicarbonate capsule 40-1100 mg oral 40-1100 mg


omeprazole-sodium bicarbonate oral packet 20-1680 mg, 40-1680 mg


ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG Benefit Exclusion

ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG Benefit Exclusion

*Proton Pump Inhibitors***ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG EX Formulary Exclusion; QL

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 5 MG Tier 3 QL

DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG Tier 3 QL

dexlansoprazole oral capsule delayed release 30 mg, 60 mg


esomeprazole magnesium oral capsule delayed release 20 mg, 40 mg

Tier 1 QL

esomeprazole magnesium oral packet 10 mg, 20 mg, 40 mg

Tier 1 QL

esomeprazole sodium intravenous solution reconstituted 40 mg


esomeprazole strontium oral capsule delayed release 49.3 mg

Benefit Exclusion

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML Tier 3

440

Drug Name Drug Tier NotesFIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML Tier 3

lansoprazole capsule delayed release 15 mg oral (rx) 15 mg

Tier 1 QL

lansoprazole capsule delayed release 30 mg oral30 mg


lansoprazole capsule delayed release 30 mg oral30 mg

Tier 1 QL

lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg

Tier 1 QL

NEXIUM I.V. INTRAVENOUS SOLUTION RECONSTITUTED 40 MG EX Medical Only Exclusion

NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG, 40 MG EX Formulary Exclusion; QL

NEXIUM PACKET 10 MG ORAL 10 MG EX Formulary Exclusion; QL

NEXIUM PACKET 2.5 MG ORAL 2.5 MG Tier 2 QL



NEXIUM PACKET 5 MG ORAL 5 MG Tier 2 QL

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

Tier 1 QL

OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 MG/ML EX Non FDA Exclusion

pantoprazole sodium intravenous solution reconstituted 40 mg


pantoprazole sodium oral packet 40 mg Tier 1

pantoprazole sodium oral tablet delayed release20 mg, 40 mg

Tier 1 QL

PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG, 30 MG EX Formulary Exclusion; QL

PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE DISPERSIBLE 15 MG, 30 MG


PRILOSEC PACKET 10 MG ORAL 10 MG Tier 3

PRILOSEC PACKET 2.5 MG ORAL 2.5 MG Tier 1

PROTONIX INTRAVENOUS SOLUTION RECONSTITUTED 40 MG EX Medical Only Exclusion

PROTONIX ORAL PACKET 40 MG EX Formulary Exclusion

PROTONIX ORAL TABLET DELAYED RELEASE 20 MG, 40 MG EX Formulary Exclusion; QL

rabeprazole sodium oral capsule sprinkle 10 mg Tier 3 QL

441

Drug Name Drug Tier Notesrabeprazole sodium oral tablet delayed release 20 mg

Tier 1 QL

*Quaternary Anticholinergics***CUVPOSA ORAL SOLUTION 1 MG/5ML Tier 3

DARTISLA ODT ORAL TABLET DISPERSIBLE 1.7 MG Benefit Exclusion


GLYCATE ORAL TABLET 1.5 MG Tier 3

glycopyrrolate injection solution 0.2 mg/ml, 0.4 mg/2ml, 1 mg/5ml, 4 mg/20ml


glycopyrrolate injection solution prefilled syringe0.6 mg/3ml, 1 mg/5ml


glycopyrrolate intravenous solution prefilled syringe 0.6 mg/3ml, 1 mg/5ml


glycopyrrolate oral solution 1 mg/5ml Tier 1

glycopyrrolate pf solution prefilled syringe 0.2 mg/ml injection 0.2 mg/ml


glycopyrrolate pf solution prefilled syringe 0.2 mg/ml injection 0.2 mg/ml


glycopyrrolate pf solution prefilled syringe 0.4 mg/2ml injection 0.4 mg/2ml


glycopyrrolate tablet 1 mg oral 1 mg Tier 1

glycopyrrolate tablet 1.5 mg oral 1.5 mg Benefit Exclusion

glycopyrrolate tablet 1.5 mg oral 1.5 mg Tier 3

glycopyrrolate tablet 2 mg oral 2 mg Tier 1

GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 MG/2ML EX


GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE 0.6 MG/3ML, 1 MG/5ML


methscopolamine bromide oral tablet 2.5 mg, 5 mg

Tier 1

propantheline bromide oral tablet 15 mg Tier 1

ROBINUL ORAL TABLET 1 MG EX Formulary Exclusion

ROBINUL-FORTE ORAL TABLET 2 MG EX Formulary Exclusion

*Ulcer Anti-Infective W/ Bismuth Combinations***HELIDAC THERAPY ORAL EX Formulary Exclusion

PYLERA ORAL CAPSULE 140-125-125 MG EX Formulary Exclusion

*Ulcer Anti-Infective W/ Proton Pump Inhibitors***amoxicill-clarithro-lansopraz oral Tier 1

442

Drug Name Drug Tier NotesOMECLAMOX-PAK ORAL 500-500-20 MG EX Formulary Exclusion

TALICIA ORAL CAPSULE DELAYED RELEASE 250-12.5-10 MG Tier 2 QL

*Ulcer Anti-Infective-Pcab Combinations***VOQUEZNA DUAL PAK ORAL THERAPY PACK 500-20 MG EX New to Market Exclusion

VOQUEZNA TRIPLE PAK ORAL THERAPY PACK 500-500-20 MG EX New to Market Exclusion

*Ulcer Drugs - Prostaglandins***CYTOTEC ORAL TABLET 100 MCG, 200 MCG EX Formulary Exclusion

misoprostol oral tablet 100 mcg, 200 mcg Tier 1

*Urinary Antispasmodics*

*Urinary Antispasmodic - Antimuscarinic (Anticholinergic)***darifenacin hydrobromide er oral tablet extended release 24 hour 15 mg, 7.5 mg


DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 MG, 4 MG EX Formulary Exclusion

DETROL ORAL TABLET 1 MG, 2 MG EX Formulary Exclusion

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG, 5 MG


ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG, 7.5 MG EX Formulary Exclusion

GELNIQUE TRANSDERMAL GEL 10 % Benefit Exclusion

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

Tier 1

oxybutynin chloride oral syrup 5 mg/5ml Tier 1

oxybutynin chloride oral tablet 5 mg Tier 1

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY 3.9 MG/24HR Tier 3

solifenacin succinate oral tablet 10 mg, 5 mg Tier 1

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

Tier 1

tolterodine tartrate oral tablet 1 mg, 2 mg Tier 1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG EX Formulary Exclusion

trospium chloride er oral capsule extended release 24 hour 60 mg

Tier 1

443

Drug Name Drug Tier Notestrospium chloride oral tablet 20 mg Tier 1

VESICARE LS ORAL SUSPENSION 5 MG/5ML EX Formulary Exclusion

VESICARE ORAL TABLET 10 MG, 5 MG EX Formulary Exclusion

*Urinary Antispasmodics - Beta-3 Adrenergic Agonists***GEMTESA ORAL TABLET 75 MG EX Formulary Exclusion

MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER 8 MG/ML Tier 2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG Tier 2

*Urinary Antispasmodics - Cholinergic Agonists***bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

Tier 1

URECHOLINE ORAL TABLET 25 MG, 50 MG EX Formulary Exclusion

*Urinary Antispasmodics - Direct Muscle Relaxants***flavoxate hcl oral tablet 100 mg EX Formulary Exclusion

*Vaccines*

*Bacterial Vaccines***ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED Benefit Exclusion

bcg vaccine injection solution reconstituted 50 mg Benefit Exclusion

BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE Tier 5

BIOTHRAX INTRAMUSCULAR SUSPENSION Benefit Exclusion

HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG Benefit Exclusion

MENACTRA INTRAMUSCULAR SOLUTION Tier 5

MENQUADFI INTRAMUSCULAR SOLUTION Tier 5

MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED Tier 5

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML Benefit Exclusion

PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML Tier 5

444

Drug Name Drug Tier NotesPREVNAR 13 INTRAMUSCULAR SUSPENSION Tier 5

PREVNAR 20 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 5

TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE Tier 5

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML Benefit Exclusion

TYPHIM VI INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 25 MCG/0.5ML

Benefit Exclusion

VAXCHORA ORAL SUSPENSION RECONSTITUTED Benefit Exclusion

VAXNEUVANCE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 5

VIVOTIF ORAL CAPSULE DELAYED RELEASE Benefit Exclusion

*Viral Vaccine Combinations***M-M-R II INJECTION SOLUTION RECONSTITUTED Benefit Exclusion

PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED Benefit Exclusion

TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 720-20 ELU-MCG/ML

Benefit Exclusion

*Viral Vaccines***AFLURIA INTRAMUSCULAR SUSPENSION Tier 5

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 5

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION Tier 5

AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML

Tier 5

astrazeneca covid-19 vaccine intramuscular suspension 0.5 ml

Benefit Exclusion

COMIRNATY INTRAMUSCULAR SUSPENSION 30 MCG/0.3ML Tier 2

DENGVAXIA SUBCUTANEOUS SUSPENSION RECONSTITUTED Tier 3

445

Drug Name Drug Tier NotesENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML Benefit Exclusion

ENGERIX-B INTRAMUSCULAR INJECTABLE 10 MCG/0.5ML, 20 MCG/ML Benefit Exclusion

EZ FLU SHOT-FLUCELVAX QUAD INTRAMUSCULAR PREFILLED SYRINGE KIT 0.5 ML

Tier 5

FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML Tier 5

FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE0.5 ML

Tier 5

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 5

FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 0.5 ML

Tier 5

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION Tier 5

FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 5

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION Tier 5

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 5

FLUMIST QUADRIVALENT NASAL SUSPENSION Tier 5

FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 5

FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.7 ML

Tier 5

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION , 0.5 ML Tier 5

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML

Tier 5

GARDASIL 9 INTRAMUSCULAR SUSPENSION Tier 5

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE Tier 5

446

Drug Name Drug Tier NotesHAVRIX INTRAMUSCULAR SUSPENSION1440 EL U/ML, 720 EL U/0.5ML Benefit Exclusion

HEPLISAV-B INTRAMUSCULAR SOLUTION 20 MCG/0.5ML Benefit Exclusion

HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 20 MCG/0.5ML

Benefit Exclusion

IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML Benefit Exclusion

IPOL INJECTION INJECTABLE Benefit Exclusion

IXIARO INTRAMUSCULAR SUSPENSION Benefit Exclusion

janssen covid-19 vaccine intramuscular suspension 0.5 ml

Benefit Exclusion

moderna covid-19 vac (booster) intramuscular suspension 50 mcg/0.5ml

Tier 2

moderna covid-19 vacc 6-11y intramuscular suspension 50 mcg/0.5ml


moderna covid-19 vacc 6m-5y intramuscular suspension 25 mcg/0.25ml

Tier 2

moderna covid-19 vaccine intramuscular suspension 100 mcg/0.5ml

Tier 2

novavax covid-19 vaccine intramuscular suspension 5 mcg/0.5ml

Benefit Exclusion

pfizer covid-19 vac-tris 5-11y intramuscular suspension 10 mcg/0.2ml

Tier 2

pfizer covid-19 vac-tris 6m-4y intramuscular suspension 3 mcg/0.2ml

Tier 2

pfizer-biont covid-19 vac-tris intramuscular suspension 30 mcg/0.3ml

Tier 2

pfizer-biontech covid-19 vacc intramuscular suspension 30 mcg/0.3ml

Tier 2

prehevbrio intramuscular suspension 10 mcg/ml Tier 2

RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED Benefit Exclusion

RECOMBIVAX HB SUSPENSION 10 MCG/ML INJECTION 10 MCG/ML Tier 2

RECOMBIVAX HB SUSPENSION 10 MCG/ML INJECTION 10 MCG/ML Benefit Exclusion

RECOMBIVAX HB SUSPENSION 40 MCG/ML INJECTION 40 MCG/ML Benefit Exclusion

RECOMBIVAX HB SUSPENSION 5 MCG/0.5ML INJECTION 5 MCG/0.5ML Benefit Exclusion

447

Drug Name Drug Tier NotesRECOMBIVAX HB SUSPENSION 5 MCG/0.5ML INJECTION 5 MCG/0.5ML Tier 2

ROTARIX ORAL SUSPENSION RECONSTITUTED Benefit Exclusion

ROTATEQ ORAL SOLUTION Benefit Exclusion

sanofi covid-19 vac (booster) intramuscular emulsion 5 mcg/0.5ml


SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

Tier 5

SPIKEVAX COVID-19 VACCINE INTRAMUSCULAR SUSPENSION 100 MCG/0.5ML

Tier 2

stamaril injection suspension reconstituted Benefit Exclusion

TICOVAC INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2.4 MCG/0.5ML

Tier 3

VAQTA INTRAMUSCULAR SUSPENSION25 UNIT/0.5ML, 50 UNIT/ML Benefit Exclusion

VARIVAX SUBCUTANEOUS INJECTABLE1350 PFU/0.5ML Benefit Exclusion

YF-VAX SUBCUTANEOUS INJECTABLE Benefit Exclusion

ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 19400 UNT/0.65ML

Tier 5

*Vaginal And Related Products*

*Fertility Enhancers***PRO-CEPTION VAGINAL KIT Benefit Exclusion

*Imidazole-Related Antifungals***GYNAZOLE-1 VAGINAL CREAM 2 % Tier 3

miconazole 3 vaginal suppository 200 mg Tier 3

terconazole vaginal cream 0.4 %, 0.8 % Tier 1

terconazole vaginal suppository 80 mg Tier 1

*Miscellaneous Vaginal Combinations***FEM PH VAGINAL GEL 0.9-0.025 % EX Non FDA Exclusion

TRIMO-SAN VAGINAL GEL 0.025-0.01 % EX Non FDA Exclusion

*Miscellaneous Vaginal Products***INTRAROSA VAGINAL INSERT 6.5 MG Tier 3

448


*Spermicides***ENCARE VAGINAL SUPPOSITORY 100 MG Tier 2

OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL 3 % Tier 2

SHUR-SEAL CONTRACEPTIVE VAGINAL GEL 2 % Tier 2

TODAY SPONGE VAGINAL 1000 MG Tier 5

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 % Tier 2

VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 % Tier 5

VCF VAGINAL CONTRACEPTIVE VAGINAL GEL 4 % Tier 3

*Vaginal Anti-Infectives***AVC VAGINAL VAGINAL CREAM 15 % Tier 3

CLEOCIN VAGINAL CREAM 2 % EX Formulary Exclusion

CLEOCIN VAGINAL SUPPOSITORY 100 MG EX Formulary Exclusion

clindamycin phosphate vaginal cream 2 % Tier 1

CLINDESSE VAGINAL CREAM 2 % Tier 3

metronidazole vaginal gel 0.75 % Tier 1

NUVESSA VAGINAL GEL 1.3 % Tier 3

VANDAZOLE VAGINAL GEL 0.75 % Tier 1

*Vaginal Contraceptive Ph Modulator - Combinations***PHEXXI VAGINAL GEL 1.8-1-0.4 % EX Formulary Exclusion

*Vaginal Estrogens***ESTRACE VAGINAL CREAM 0.1 MG/GM EX Formulary Exclusion

estradiol vaginal cream 0.1 mg/gm Tier 1

estradiol vaginal tablet 10 mcg Tier 1

ESTRING VAGINAL RING 2 MG Tier 2

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR EX Formulary Exclusion

IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG, 4 MCG EX Formulary Exclusion

IMVEXXY STARTER PACK VAGINAL INSERT 10 MCG, 4 MCG EX Formulary Exclusion

PREMARIN VAGINAL CREAM 0.625 MG/GM Tier 2

449

Drug Name Drug Tier NotesVAGIFEM VAGINAL TABLET 10 MCG EX Formulary Exclusion

YUVAFEM VAGINAL TABLET 10 MCG Tier 1

*Vaginal Progestins***CRINONE GEL 4 % VAGINAL 4 % EX Formulary Exclusion

CRINONE GEL 8 % VAGINAL 8 % EX PA; Formulary Exclusion

ENDOMETRIN VAGINAL INSERT 100 MG Benefit Exclusion PA

FIRST-PROGESTERONE VGS VAGINAL SUPPOSITORY 100 MG, 200 MG Tier 3

*Vasopressors*

*Anaphylaxis Therapy Agents***ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 MG/30ML Tier 3

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML


epinephrine (anaphylaxis) injection solution 30 mg/30ml

Tier 1

epinephrine professional injection kit 1 mg/ml EX Non FDA Exclusion

epinephrine solution auto-injector 0.15 mg/0.15ml injection 0.15 mg/0.15ml

EX QL


Tier 1 QL


EX QL


Tier 1 QL

EPINEPHRINESNAP-EMS INJECTION KIT1 MG/ML EX Non FDA Exclusion

EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML EX Non FDA Exclusion

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML EX QL

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML EX QL

EPISNAP INJECTION KIT 1 MG/ML EX Non FDA Exclusion

SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML


*Neurogenic Orthostatic Hypotension (Noh) - Agents***droxidopa oral capsule 100 mg, 200 mg, 300 mg Tier 4 PA; Specialty

450

Drug Name Drug Tier NotesNORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG EX


*Vasopressors***AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML EX Medical Only Exclusion

AKOVAZ INTRAVENOUS SOLUTION PREFILLED SYRINGE 25 MG/5ML EX Medical Only Exclusion

BIORPHEN INTRAVENOUS SOLUTION 0.5 MG/5ML EX Medical Only Exclusion

EMERPHED INTRAVENOUS SOLUTION 5 MG/ML EX Medical Only Exclusion

ephedrine sulfate (pressors) injection solution prefilled syringe 25 mg/5ml, 50 mg/10ml, 50 mg/5ml


ephedrine sulfate injection solution 50 mg/ml EX Medical Only Exclusion

ephedrine sulfate intravenous solution 5 mg/ml, 50 mg/ml


ephedrine sulfate intravenous solution prefilled syringe 25 mg/5ml


ephedrine sulfate-nacl solution prefilled syringe 10-0.9 mg/ml-% intravenous 10-0.9 mg/ml-%


ephedrine sulfate-nacl solution prefilled syringe 100-0.9 mg/10ml-% intravenous 100-0.9 mg/10ml-%










epinephrine hcl-dextrose intravenous solution 4-5 mg/250ml-%


epinephrine hcl-nacl intravenous solution 8-0.9 mg/250ml-%


epinephrine injection solution 10 mg/10ml Tier 3

epinephrine intravenous solution 1 mg/10ml EX Non FDA Exclusion

epinephrine pf injection solution 1 mg/ml Tier 3

epinephrine solution prefilled syringe 0.1 mg/10ml intravenous 0.1 mg/10ml


451

Drug Name Drug Tier Notesepinephrine solution prefilled syringe 0.2 mg/0.2ml injection 0.2 mg/0.2ml


epinephrine solution prefilled syringe 1 mg/10ml injection 1 mg/10ml


epinephrine solution prefilled syringe 1 mg/10ml injection 1 mg/10ml


epinephrine solution prefilled syringe 1 mg/10ml intravenous 1 mg/10ml


epinephrine-dextrose intravenous solution 2-5 mg/250ml-%, 5-5 mg/250ml-%


epinephrine-dextrose intravenous solution prefilled syringe 100-5 mcg/10ml-%


epinephrine-nacl intravenous solution prefilled syringe 1-0.9 mg/10ml-%


epinephrine-nacl solution 2-0.9 mg/250ml-% intravenous 2-0.9 mg/250ml-%


epinephrine-nacl solution 5-0.9 mg/250ml-% intravenous 5-0.9 mg/250ml-%


GIAPREZA INTRAVENOUS SOLUTION 2.5 MG/ML EX Medical Only Exclusion

LEVOPHED INTRAVENOUS SOLUTION 1 MG/ML EX Medical Only Exclusion

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg Tier 1

norepinephrine bitartrate intravenous solution 1 mg/ml


norepinephrine-dextrose solution 16-5 mg/250ml-% intravenous 16-5 mg/250ml-%












norepinephrine-sodium chloride solution 16-0.9 mg/250ml-% intravenous 16-0.9 mg/250ml-%






452

Drug Name Drug Tier Notesnorepinephrine-sodium chloride solution 4-0.9 mg/250ml-% intravenous 4-0.9 mg/250ml-%








phenylephrine hcl (pressors) intravenous solution0.4 mg/10ml, 0.8 mg/10ml


phenylephrine hcl (pressors) intravenous solution prefilled syringe 0.5 mg/5ml, 1 mg/10ml


phenylephrine hcl intravenous solution prefilled syringe 0.4 mg/10ml, 0.8 mg/10ml, 1 mg/10ml


phenylephrine hcl solution 1 mg/10ml intravenous1 mg/10ml


phenylephrine hcl solution 10 mg/ml intravenous10 mg/ml

Tier 1

phenylephrine hcl solution 10 mg/ml intravenous10 mg/ml

Tier 3

phenylephrine hcl-nacl intravenous solution 10-0.9 mg/250ml-%, 100-0.9 mg/250ml-%, 20-0.9 mg/250ml-%, 25-0.9 mg/250ml-%, 40-0.9 mg/250ml-%, 50-0.9 mg/250ml-%, 80-0.9 mg/250ml-%


phenylephrine hcl-nacl intravenous solution prefilled syringe 0.4-0.9 mg/10ml-%, 0.5-0.9 mg/5ml-%, 0.8-0.9 mg/10ml-%, 1-0.9 mg/10ml-%, 100-0.9 mcg/10ml-%, 20-0.9 mg/50ml-%, 5-0.9 mg/50ml-%


REZIPRES INTRAVENOUS SOLUTION23.5 MG/5ML EX Medical Only Exclusion

VAZCULEP INTRAVENOUS SOLUTION 10 MG/ML Tier 3

*Vitamins*

*Paba***POTABA ORAL CAPSULE 500 MG EX Formulary Exclusion

*Vitamin A***AQUASOL A INTRAMUSCULAR SOLUTION 15 MG/ML, 50000 UNIT/ML Benefit Exclusion

*Vitamin B-1***thiamine hcl injection solution 100 mg/ml EX Medical Only Exclusion

453


*Vitamin B-3***niacin (antihyperlipidemic) oral tablet 500 mg Tier 1

*Vitamin B-6***pyridoxal-5 phosphate injection solution 100 mg/ml

Benefit Exclusion

pyridoxine hcl solution 100 mg/ml injection 100 mg/ml

Benefit Exclusion

pyridoxine hcl solution 100 mg/ml injection 100 mg/ml


*Vitamin C***ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML EX Medical Only Exclusion

ascorbic acid intravenous solution 15000 mg/30ml

Benefit Exclusion

ascorbic acid solution 500 mg/ml injection 500 mg/ml

Benefit Exclusion

ascorbic acid solution 500 mg/ml injection 500 mg/ml


*Vitamin D***DRISDOL ORAL CAPSULE 1.25 MG (50000 UT) Benefit Exclusion

ergocal oral capsule 62.5 mcg (2500 ut) Benefit Exclusion

ergocalciferol oral capsule 1.25 mg (50000 ut) Benefit Exclusion

vitamin d (ergocalciferol) capsule 1.25 mg (50000 ut) oral 1.25 mg (50000 ut)

Benefit Exclusion

vitamin d (ergocalciferol) capsule 50000 unit oral50000 unit

EX

*Vitamin E***wheat germ oil oral oil EX Formulary Exclusion

*Vitamin K***MEPHYTON ORAL TABLET 5 MG EX Formulary Exclusion

phytonadione injection solution 1 mg/0.5ml, 10 mg/ml

Benefit Exclusion

phytonadione oral tablet 5 mg Tier 1

vitamin k (phytonadione) oral tablet 100 mcg Benefit Exclusion

vitamin k1 solution 1 mg/0.5ml injection 1 mg/0.5ml

Benefit Exclusion

vitamin k1 solution 1 mg/0.5ml injection 1 mg/0.5ml


vitamin k1 solution 10 mg/ml injection 10 mg/ml EX Medical Only Exclusion

vitamin k1 solution 10 mg/ml injection 10 mg/ml Benefit Exclusion

454

Index12-PANEL POC TOXICOLOGY SYSTEM .....2321ST MEDX-PATCH/ LIDOCAINE ........................... 2191st tier unifine pentips .............. 3321st tier unifine pentips plus .......3321st tier unilet comfortouch ........3097T LIDO .................................. 210A.A.G.C. KIT IN TERODERM ...........................193abacavir sulfate ........................ 147abacavir sulfate-lamivudine ..... 144abacavir-lamivudine-zidovudine...................................................144ABANEU-SL ........................... 287ABATREX ...............................289ABECMA .................................119ABELCET ................................. 91ABILIFY ..................................142ABILIFY MAINTENA .......... 142ABILIFY MYCITE ................ 142ABILIFY MYCITE MAINTENANCE KIT ........... 142ABILIFY MYCITE STARTER KIT ....................... 142abiraterone acetate ...................113ABLYSINOL ...........................163ABOUTTIME PEN NEEDLE...................................................332ABRAXANE ............................131ABSORICA ............................. 191ABSORICA LD .......................191ABSTRAL ................................. 28acacia ............................................6acamprosate calcium ................ 421ACANYA ................................. 187acarbose ......................................75ACCOLATE ..............................59ACCRUFER ............................294ACCUCAINE ..........................219ACCU-CHEK AVIVA PLUS...........................................232, 309ACCU-CHEK COMPACT PLUS ........................................ 233ACCU-CHEK FASTCLIX LANCET ..................................309ACCU-CHEK FASTCLIX LANCETS ............................... 309ACCU-CHEK GUIDE ....233, 309ACCU-CHEK GUIDE ME .... 309ACCU-CHEK LINKASSIST .331

ACCU-CHEK MULTICLIX LANCETS ............................... 309ACCU-CHEK SAFE-T PRO LANCETS ............................... 309ACCU-CHEK SMARTVIEW233ACCU-CHEK SOFTCLIX LANCET DEV ........................ 310ACCU-CHEK SOFTCLIX LANCETS ............................... 310ACCULA SARS-COV-2 .........241ACCUPRIL ............................... 99ACCURETIC ............................ 98ACCUTANE ............................191ACCUTREND GLUCOSE .... 233ACCUTREND PLUS ..............309acd formula a ..............................63ACD-A NOCLOT-50 ................63ACE AEROSOL CLOUD ENHANCER ........................... 349acebutolol hcl ............................152aceso ag .................................... 223ACETADOTE ........................... 86acetaminophen ............................22acetaminophen-codeine .............. 26acetaminophen-codeine #2 ......... 26acetaminophen-codeine #3 ......... 26acetaminophen-codeine #4 ......... 26acetazolamide ........................... 251acetazolamide er .......................251acetazolamide sodium ...............251acetic acid .........................274, 413acetylcysteine ...................... 86, 186acioxiay .....................................187ACIPHEX ................................440ACIPHEX SPRINKLE .......... 440acitretin .....................................198ACNESIC ................................ 209acremonium .................................. 6ACTEMRA ................................16ACTEMRA ACTPEN .............. 16ACTHAR ................................. 255ACTHIB ...................................444ACTICLATE ...........................432ACTICOAT .............................224ACTICOAT 7 ..........................224ACTICOAT ANTIMICROBIAL ................ 224ACTICOAT FLEX 3 .............. 224ACTICOAT FLEX 3 4"X4" ..224ACTICOAT FLEX 7 .............. 224ACTICOAT SURGICAL .......224

ACTIGALL ............................. 267acti-lance 28g ........................... 310acti-lance lite lancets 28g .........310acti-lance special lancets 17g ...310acti-lance universal 23g ............310ACTIMMUNE ........................ 128ACTIQ ....................................... 28ACTIVASE ..............................287active fe .....................................292active injection blm-1 ................182active injection bm ....................182active injection d .......................178active injection dl ......................182active injection dlm ...................182active injection ket-l ....................16active injection ketmarc-l ............17ACTIVE INJECTION KIT L182active injection kl-3 ...................182active injection km .................... 182active injection lm-2 ..................303active injection lm-dep-2 .......... 182active injection m-1 ...................182ACTIVELLA ...........................264activite .......................................375ACTONEL ...............................253ACTOPLUS MET .................... 84ACTOS .......................................85ACUICYN ................................208ACULAR ................................. 406ACULAR LS ........................... 406ACUNOL ................................. 367ACUVAIL ................................406acyclovir ............................150, 201acyclovir sodium .......................150acyclovix ................................... 148ACZONE ................................. 187ADACEL ................................. 436adainzde ....................................187adainzoxia .................................187ADAKVEO ..............................295ADALAT CC ...........................154adapalene ..................................191adapalene-benzoyl peroxide...........................................187, 188ADASUVE ............................... 141ADBRY .................................... 201adc/f (0.5mg/ml) ........................381ADCETRIS ..............................117ADCIRCA ................................162ADDERALL ................................2ADDERALL XR ......................... 2

455

ADDYI ..................................... 427adefovir dipivoxil ...................... 149ADEMPAS ...............................161ADENOCAINE ....................... 158adenosine ............................ 53, 229adenosine (diagnostic) ..............229ADHANSIA XR .......................... 4ADIPEX-P ................................... 3adjustable lancing device ..........310ADLARITY ............................. 422ADLYXIN ..................................82ADLYXIN STARTER PACK . 82ADMELOG ............................... 78ADMELOG SOLOSTAR ........ 78ADRENAL C FORMULA ..... 377ADRENALIN .................. 392, 450ADREVIEW ............................231ADRIAMYCIN ....................... 125adriamycin ................................ 125ADRUCIL ................................114ADUHELM ............................. 422adult aspirin ec low strength ...... 23adult aspirin regimen ..................23adult mask .................................349ADVAIR DISKUS .................... 55ADVAIR HFA ...........................55ADVANCE INTUITION METER ....................................310ADVANCE INTUITION MONITOR .............................. 310ADVANCE INTUITION TEST ........................................ 233ADVANCE MICRO-DRAW METER ....................................310ADVANCE MICRO-DRAW TEST ........................................ 233ADVANCED ALLERGY COLLECTION ....................... 202advanced am/pm ....................... 377advanced mobile lancet ............ 310ADVATE ......................... 276, 277ADVOCATE BLOOD GLUCOSE MONITOR ..........310ADVOCATE BLOOD GLUCOSE SYSTEM ............. 310ADVOCATE DUO ..................309ADVOCATE INSULIN PEN NEEDLES ................................332ADVOCATE INSULIN SYRINGE ................................ 332ADVOCATE LANCETS ........310ADVOCATE LANCETS 30G310

ADVOCATE REDI-CODE...........................................233, 310ADVOCATE REDI-CODE+ . 310ADVOCATE REDI-CODE+ TEST ........................................ 233ADVOCATE SAFETY LANCETS ............................... 310ADVOCATE SAFETY LANCETS 26G ....................... 310ADVOCATE TEST ................ 233adynovate ..................................277ADZENYS ER .............................2ADZENYS XR-ODT .................. 2AEMCOLO ............................. 104AEROBIKA .............................349AEROCHAMBER MINI CHAMBER ............................. 351AEROCHAMBER MV .......... 351AEROCHAMBER PLUS FLO-VU ................................... 351AEROCHAMBER PLUS FLO-VU LARGE ....................351AEROCHAMBER PLUS FLO-VU SMALL ....................351AEROCHAMBER PLUS FLO-VU W/MASK .................351AEROCHAMBER Z-STAT PLUS ........................................ 351AEROCHAMBER Z-STAT PLUS CHAMBR .....................351AEROCHAMBER Z-STAT PLUS/LARGE .........................351AEROCHAMBER Z-STAT PLUS/MEDIUM ..................... 351AEROCHAMBER Z-STAT PLUS/SMALL .........................351AEROVENT PLUS ................ 351AFFINITY ............................... 216AFINITOR .............................. 123AFINITOR DISPERZ ............ 123AFIRMELLE .......................... 167AFLURIA ................................ 445AFLURIA PRESERVATIVE FREE ........................................445AFLURIA QUADRIVALENT...................................................445AFREZZA ................................. 78AFSTYLA ................................277AFTERA ..................................173AFTERPILL ........................... 173AGAMATRIX AMP ...............310AGAMATRIX AMP TEST ... 233

AGAMATRIX JAZZ TEST .. 233AGAMATRIX JAZZ WIRELESS 2 .......................... 310AGAMATRIX KEYNOTE TEST ........................................ 233AGAMATRIX PRESTO ........310AGAMATRIX PRESTO PRO METER ....................................310AGAMATRIX PRESTO TEST ........................................ 233AGAMATRIX ULTRA-THIN LANCETS ............................... 310AGGRASTAT ......................... 283AGGRENOX ...........................286agoneaze ................................... 219AGRYLIN ............................... 286aif #2 drug preparation kit ....... 196aif #3 drug preparation kit ....... 196AIMOVIG ............................... 354aimsco twist lancets 32g ........... 310AIMSCO TWIST LANCETS 33G ........................................... 310AIRAVITE .............................. 289AIRDUO DIGIHALER ............55AIRDUO RESPICLICK 113/14 ......................................... 55AIRDUO RESPICLICK 232/14 ......................................... 55AIRDUO RESPICLICK 55/14 ........................................... 55AJOVY .....................................354ak-fluor ..................................... 404AKLIEF ................................... 191AKOVAZ .................................451ak-poly-bac ............................... 403AKTEN .................................... 406AKYNZEO ................................ 89ALA SCALP ............................202ala-cort ..................................... 202ALADERM PLUS .................. 212ALA-QUIN .............................. 194albendazole ................................. 50ALBENZA ................................. 50ALBUKED 25 ..........................285ALBUKED 5 ............................285albumin human ......................... 285ALBUMINAR-25 ....................285ALBUMINAR-5 ......................285ALBUMINEX ......................... 285albumin-zlb ............................... 285alburx ........................................285ALBUTEIN ............................. 285

456

albuterol sulfate .......................... 57albuterol sulfate er ......................57albuterol sulfate hfa ....................57ALCAINE ................................406alclometasone dipropionate ......202ALCOH-GLOVE CONTOURED WIPE .............307alcohol ...................................... 398alcoh-wipe .................................307ALCORTIN A .........................194ALDACTAZIDE .............251, 252ALDACTONE .........................252ALDARA ................................. 209alder ..............................................6ALDURAZYME ..................... 259ALECENSA .............................116alendronate sodium .................. 253alevamax ................................... 212ALEVICYN ANTIPRURITIC...................................................212ALEVICYN ANTIPRURITIC SG ............................................. 212ALEVICYN DERMAL SPRAY ..................................... 223alfentanil hcl ............................... 28ALFERON N ...........................128alfuzosin hcl er ..........................273algesis ....................................... 246ALIMTA ..................................114ALINIA ....................................105ALIQOPA ................................133aliskiren fumarate .....................103ALK SQ CAT HAIR .................. 6ALKERAN .............................. 132ALKINDI SPRINKLE ........... 178ALL FLOW 1000 PFT FILTER ................................... 349ALL FLOW 2000 PFT FILTER ................................... 350ALL FLOW 3000 PFT FILTER ................................... 350ALL FLOW 4000 PFT FILTER ................................... 350ALL FLOW 5000 PFT FILTER ................................... 350ALL FLOW 6000 PFT FILTER ................................... 350ALL FLOW 7000 PFT FILTER ................................... 350ALLEVYN AG ADHESIVE ..224ALLEVYN AG GENTLE ...... 224

ALLEVYN AG GENTLE BORDER ................................. 224ALLEVYN AG NON-ADHESIVE ............................. 224ALLEVYN AG SACRUM 6-3/4" ........................................... 224ALLEVYN AG SACRUM 9"X9" ....................................... 224ALLEVYN GENTLE ............. 224allopurinol ................................ 276allopurinol sodium ....................276ALLZITAL ................................22almond (diagnostic) .................. 228almotriptan malate ....................355ALOCRIL ................................402alogliptin benzoate ......................77alogliptin-metformin hcl ............. 77alogliptin-pioglitazone ................78ALOMIDE ...............................402ALOPRIM ............................... 276ALORA ....................................265alosetron hcl ............................. 268ALOXI ....................................... 88ALPHAGAN P ........................ 407alpha-lipoic acid .........................12ALPHANATE ......................... 277ALPHANATE/VWF COMPLEX/HUMAN ............. 277ALPHANINE SD .................... 277alprazolam .................................. 52alprazolam er ..............................52ALPRAZOLAM INTENSOL ..52alprazolam xr ..............................52ALPROLIX ..................... 277, 278alprostadil .................................371ALREX .................................... 409ALTABAX ...............................193ALTACAINE .......................... 406ALTACE ....................................99altafluor benox ..........................404ALTAFRIN ............................. 401ALTAVERA ............................167alternaria ...................................... 6ALTOPREV .............................. 96ALTRENO ...............................191ALUNBRIG .............................116ALVESCO ................................. 60alyacen 1/35 ..............................167alyacen 7/7/7 .............................176ALYMSYS ...............................135ALYQ .......................................162AMABELZ .............................. 264

amantadine hcl ..........................136AMARYL .................................. 84AMBIEN ..................................299AMBIEN CR ........................... 299AMBISOME ..............................91ambrisentan .............................. 161amcinonide ................................202AMD FOAM DRESSING ...... 308AMD FOAM DRESSING TOPSHEET .............................308AMELUZ .................................214AMERGE ................................ 355american beech .............................6american cockroach ......................6american elm .................................6american sycamore .......................6AMETHIA ...............................174AMETHIA LO ........................ 174AMETHYST ........................... 173AMICAR ..................................296AMIDATE ............................... 271amikacin sulfate .......................... 13amiloride hcl .............................252amiloride-hydrochlorothiazide . 252amino acid ................................ 395AMINOAMRMS .....................396aminocaproic acid .................... 296aminophylline ............................. 61AMINOPMRMS ..................... 249AMINOPROTECT .................396AMINORELIEFRMS ............ 396AMINOSYN II ........................ 396AMINOSYN/ELECTROLYTES ............................................. 396AMINOSYN-PF ......................396AMINOSYN-PF 7% ...............396amiodarone hcl ........................... 54amiodarone hcl in dextrose .........54AMITIZA ................................ 268amitriptyline hcl ..........................74AMLADEX ..............................379AMLODIPINE BES+SYRSPEND SF ..............154amlodipine besy-benazepril hcl .. 98amlodipine besylate .................. 154amlodipine besylate-valsartan ..100amlodipine-atorvastatin ............158amlodipine-olmesartan ............. 100amlodipine-valsartan-hctz ........ 102ammonia n 13 ........................... 231ammonium lactate .....................208AMMONUL ............................ 262

457

AMNESTEEM ........................ 191AMNIOCORE HUMAN TISSUE .................................... 216AMNIOFIX ............................. 216AMNIOTEXT ......................... 216amondys 45 ............................... 393amoxapine ...................................75amoxicill-clarithro-lansopraz ...442amoxicillin ................................ 418amoxicillin-pot clavulanate...........................................418, 419amoxicillin-pot clavulanate er ..418AMPHADASE .........................366amphenol-40 ............................. 216amphetamine er .............................2amphetamine sulfate ..................... 2amphetamine-dextroamphet er ..... 2amphetamine-dextroamphetamine .......................2amphotericin b ............................ 91amphotericin b liposome .............91ampicillin .................................. 418ampicillin sodium ......................418ampicillin-sulbactam sodium ....419AMPYRA .................................425AMRIX .................................... 388AMVISC .................................. 410AMVISC PLUS .......................410AMYTAL SODIUM ............... 297AMYVID ..................................231AMZEEQ .................................187ANACAINE .............................210ANADROL-50 ...........................46ANAFRANIL ............................ 75anagrelide hcl ........................... 286ANA-LEX .................................. 48ANALPRAM HC ...................... 48ANALPRAM HC SINGLES ....48ANALPRAM-HC ......................48ANASCORP ............................ 414ANASPAZ ............................... 438anastrozole ................................128ANAVIP ...................................414ANCOBON ................................91ANDEXXA ................................ 87ANDRODERM ..........................46ANDROGEL ............................. 47ANDROGEL PUMP .................47ANECTINE ............................. 393anesthesia s/i-40a ..................... 271anesthesia s/i-40h ..................... 271anesthesia s/i-40s ......................271

ANGELIQ ............................... 264ANGIOMAX ............................. 64ANIMI-3 .................................. 289ANIMI-3/VITAMIN D ........... 289ANJESO .....................................18ANNOVERA ........................... 173anodyne lpt ................................219ANORO ELLIPTA ...................55ANTABUSE .............................421ANTARA ................................... 95anticoagulant sodium citrate ...... 63antivenin latrodectus mactans .. 414antivenin micrurus fulvius ........ 414ANTIVERT ............................... 89anucort-hc ...................................49ANUSOL-HC ............................ 49ANZEMET ................................ 88APADAZ ....................................44apap-caff-dihydrocodeine ...........26APEXICON E ......................... 202APIDRA .....................................78APIDRA SOLOSTAR .............. 78APLENZIN ................................71APLIGRAF ............................. 217APLISOL .................................228APOKYN ................................. 138apomorphine hcl ....................... 138apo-varenicline ......................... 427APP SLIM RMS ..................... 249apple (diagnostic) ..................... 228APPTRIM ................................246APPTRIM-D ............................246apraclonidine hcl ...................... 407aprepitant ....................................90APRETUDE ............................ 146APRI .........................................167APRISO ................................... 269APRIZIO PAK ........................219APRIZIO PAK II ....................219APTENSIO XR ........................... 4APTIOM ....................................65APTIVUS .................................146AQUACEL AG BURN ........... 224AQUALANCE LANCETS 30G ........................................... 310AQUASOL A ...........................453AQUASTAT ............................ 363AQUORAL ..............................373ARAKODA ..............................110ARALAST NP .........................430ARANELLE ............................ 176

ARANESP (ALBUMIN FREE) ...................................... 288ARAVA ......................................21ARAZLO ................................. 191ARCALYST .............................. 16ARCAPTA NEOHALER .........57ARESTIN .................................374arformoterol tartrate .................. 57argatroban .................................. 64argatroban in sodium chloride ... 64arginine hcl ...............................397ARGYLE STERILE SALINE...................................................274ARIAL CHAMBER ................351ARICEPT ................................ 422ARIDA ..................................... 224ARIDOL .................................. 229ARIKAYCE ...............................13ARIMIDEX ............................. 128aripiprazole ...............................142ARISTADA ............................. 143ARISTADA INITIO ............... 142ARIXTRA ..................................64arizona cypress ............................. 6armodafinil ................................... 4ARMONAIR DIGIHALER ..... 60ARMOUR THYROID ............434arnica flower .............................213ARNUITY ELLIPTA ............... 60AROMASIN ............................ 128ARRANON ..............................114arsenic trioxide ......................... 128artesunate ................................. 110ARTHROTEC ...........................17ARTICADENT DENTAL ......302ARTISS ....................................295ARYMO ER .............................. 28ARZERRA ...............................117ARZOL SILVER NIT APPLICATORS ......................201ASACOL HD ...........................269ASCENIV ................................ 415ASCLERA ............................... 371ASCOMP-CODEINE ............... 26ASCOR .................................... 454ascorbic acid .............................454asenapine maleate .....................141ASHLYNA ...............................174ASILNASALRMS ...................249ASMANEX (120 METERED DOSES) ......................................60

458

ASMANEX (30 METERED DOSES) ......................................60ASMANEX (60 METERED DOSES) ......................................60ASMANEX HFA .......................60ASPARLAS ............................. 127aspergillus fumigatus ............7, 228aspirin ......................................... 23aspirin 81 .................................... 23aspirin adult low dose .................23aspirin adult low strength ...........23aspirin childrens ......................... 23aspirin ec .................................... 23aspirin ec adult low strength ...... 23aspirin ec low dose ..................... 23aspirin ec low strength ................23aspirin low dose ..........................23aspirin low strength .................... 23aspirin-dipyridamole er ............ 286aspirin-omeprazole ................... 286ASPIR-LOW ............................. 23ASSURE 3 METER ................310ASSURE 3 TEST .................... 233ASSURE 4 METER ................310ASSURE 4 TEST .................... 233assure comfort lancets 28g ....... 310ASSURE HAEMOLANCE PLUS HIGH ............................ 310ASSURE HAEMOLANCE PLUS LOW ............................. 310ASSURE HAEMOLANCE PLUS MICRO .........................310ASSURE HAEMOLANCE PLUS NORMAL .....................311ASSURE HAEMOLANCE PLUS PED ............................... 311ASSURE ID INSULIN SAFETY SYR ..........................332ASSURE ID SAFETY PEN NEEDLES ................................332ASSURE II .............................. 233ASSURE II CHECK ...............233ASSURE LANCE LANCETS 311ASSURE LANCE LANCETS 21G ........................................... 311ASSURE LANCE PLUS SAFETY 25G .......................... 311ASSURE LANCE PLUS SAFETY 30G .......................... 311ASSURE LANCE SAFETY LANCET 28G ..........................311ASSURE LANCETS ...............311

ASSURE PLATINUM ............233ASSURE PLATINUM METER ....................................311ASSURE PRISM MULTI METER ....................................311ASSURE PRISM MULTI TEST ........................................ 233ASSURE PRO BLOOD GLUCOSE METER ............... 311ASSURE PRO TEST ..............233ASTAGRAF XL ......................368ASTAMED MYO ....................246ASTERO ..................................210astrazeneca covid-19 vaccine ... 445ASTRINGYN .......................... 296AT LAST TEST ...................... 233ATABEX EC ........................... 381ATABEX OB ...........................381ATACAND .............................. 101ATACAND HCT .....................100atazanavir sulfate ......................146ATELVIA ................................ 253atenolol ..................................... 152ATENOLOL+SYRSPEND SF...................................................152atenolol-chlorthalidone ............ 103ATGAM ................................... 367ATIVAN .....................................52atomoxetine hcl .............................1atopaderm ................................. 212atopavo ..................................... 224ATOPICLAIR .........................212atorvastatin calcium ................... 96atovaquone ................................105atovaquone-proguanil hcl .........110atracurium besylate .................. 394ATRALIN ................................191ATRAPRO CP ........................ 224ATRAPRO DERMAL SPRAY ..................................... 223ATRAPRO HYDROGEL ...... 224ATRIPLA ................................ 144ATROPEN ...............................438atropine sulfate ................. 401, 438ATROVENT HFA .................... 58AUBAGIO ............................... 423AUBRA .................................... 167AUBRA EQ ............................. 167AUGMENTIN ......................... 419AUGMENTIN ES-600 ............419aum mini insulin pen needle ..... 332

AUM READYGARD DUO PEN NEEDLE .........................332AUM SAFETY PEN NEEDLE ..................................332aureobasidium .............................. 7aureobasidium pullulans ...... 7, 228aurora lancet super thin 30g .... 311aurora lancet thin 23g .............. 311aurora pen needles ....................332aurora unifine pentips ...............332AUROVELA 1.5/30 ................ 167AUROVELA 1/20 ................... 167AUROVELA 24 FE ................ 167AUROVELA FE 1.5/30 .......... 167AUROVELA FE 1/20 ............. 167AURYXIA ................................270AUSTEDO ............................... 423australian pine .............................. 7AUTOLET II CLINISAFE ....311AUTOLET LANCING DEVICE ...................................311AUTOLET LITE CLINISAFE .............................311AUTOLET LITE STARTER PACK ....................................... 311AUTOLET MINI .................... 311AUTOLET PLATFORMS .....311AUTOLET PLUS ....................311autopen ..................................... 332AUVI-Q ....................................450AUXIPRO VANISHING ........420AVAILNEX ............................. 248AVALIDE ................................100AVANDIA ..................................85AVAPRO ................................. 101AVAR CLEANSER ................ 188AVAR LS CLEANSER .......... 188AVAR-E EMOLLIENT ......... 188AVAR-E GREEN ....................188AVAR-E LS .............................188AVASTIN ................................ 135AVC VAGINAL ......................449AVEED ...................................... 47aveidaoxia .................................215AVENOVA .............................. 208AVIANE ...................................167avidoxy ......................................432AVIDOXY DK ........................ 432AVITA ..................................... 191AVO CREAM ......................... 224avocado (diagnostic) .................228AVODART .............................. 273

459

AVONEX PEN ........................ 424AVONEX PREFILLED ......... 424AVSOLA ..................................271av-vite fb ................................... 289AVYCAZ ................................. 163axifol ......................................... 289AXONA ....................................246AXUMIN ..................................232AYGESTIN ............................. 421AYUNA ....................................167AYVAKIT ............................... 124azacitidine .................................114AZACTAM ..............................108AZADROX .............................. 224azalgia .......................................369AZASAN ..................................371AZASITE .................................402azathioprine .............................. 371azathioprine sodium ..................371AZEDRA DOSIMETRIC ...... 127AZEDRA THERAPEUTIC ... 127azelaic acid ............................... 214azelastine hcl .................... 392, 402azelastine-fluticasone ............... 391AZELEX ..................................191azeschew prenatal/postnatal .....381azesco ........................................381AZILECT ................................ 136azithromycin ............................. 306AZOPT .....................................404AZOR .......................................100AZSTARYS ................................. 4aztreonam ................................. 108AZULFIDINE ......................... 269AZULFIDINE EN-TABS .......269AZURETTE ............................ 166b & c ......................................... 222b complex-c-folic acid ...............375b-6 folic acid ............................. 289BAC ............................................22bacitracin ..........................104, 402bacitracin-polymyxin b ............. 403bacitra-neomycin-polymyxin-hc407baclofen .............................193, 388BACMIN ..................................378BACTRIM ............................... 105BACTRIM DS .........................105BAFIERTAM ..........................425bahia ............................................. 7bal in oil ......................................87balanced salt .............................405BAL-CARE DHA ....................381

BALCOLTRA ......................... 168bald cypress .................................. 7balsalazide disodium ................ 269balsam peru-castor oil ..............222BALVERSA .............................121BALZIVA ................................ 168bamlanivimab ........................... 415banana (diagnostic) .................. 228BANZEL ....................................65BAQSIMI ONE PACK .............76BAQSIMI TWO PACK ........... 76BARACLUDE ......................... 149BARHEMSYS ........................... 90barium sulfate ........................... 244BASADROX ............................224BASAGLAR KWIKPEN ......... 78BAVENCIO .............................119BAXDELA ...............................266bayberry (wax myrtle) ...................7BAYER ASPIRIN EC LOW DOSE ......................................... 23BAYER LOW DOSE ................23bcaa ...........................................396bcg vaccine ............................... 444b-complex ..................................375b-complex/vitamin c ..................375BD ALLERGIST TRAY ........ 333BD ALLERGY SYRINGE .....333BD AUTOSHIELD ................. 333BD AUTOSHIELD DUO ....... 333BD DISP NEEDLE ................. 333BD ECLIPSE NEEDLE ......... 333BD ECLIPSE SHIELDED NEEDLE ..................................333BD ECLIPSE SYRINGE ....... 333BD ECLIPSE SYRINGE/NEEDLE ...............333BD HEPARIN POSIFLUSH ....62BD HYPODERMIC NEEDLE ..................................333BD INSULIN SYR ULTRAFINE II .......................333BD INSULIN SYRINGE ........333BD INSULIN SYRINGE HALF-UNIT ............................333BD INSULIN SYRINGE MICROFINE ...........................333BD INSULIN SYRINGE U/F 333BD INSULIN SYRINGE U/F 1/2UNIT ................................... 333BD INSULIN SYRINGE U-500 ............................................ 333

BD INSULIN SYRINGE ULTRAFINE ...........................333BD INTEGRA SYRINGE ......333BD LANCET ULTRAFINE 30G ........................................... 311BD LANCET ULTRAFINE 33G ........................................... 311BD LATITUDE DIABETES ..311BD LATITUDE DIABETES SYSTEM ..................................311BD LOGIC BLOOD GLUCOSE MONITOR ..........311BD LUER-LOK SYRINGE ... 333BD MAGNI-GUIDE MAGNIFIER ...........................311BD MICROTAINER LANCETS ............................... 311BD PEN ....................................333BD PEN MINI ......................... 334BD PEN NEEDLE MICRO U/F ............................................334BD PEN NEEDLE MINI U/F 334BD PEN NEEDLE NANO 2ND GEN .................................334BD PEN NEEDLE NANO U/F ............................................334BD PEN NEEDLE ORIGINAL U/F ...................... 334BD PEN NEEDLE SHORT U/F ............................................334BD POSIFLUSH ..................... 363BD SAFETYGLIDE ALLERGY SYRINGE ........... 334BD SAFETYGLIDE INSULIN SYRINGE .............. 334BD SAFETYGLIDE NEEDLE ..................................334BD SAFETYGLIDE SHIELDED NEEDLE ............ 334BD SAFETY-LOK INSULIN SYRINGE ................................ 334BD SYRINGE LUER SLIP TIP ............................................334BD SYRINGE LUER-LOK ... 334BD SYRINGE SLIP TIP ........ 334BD SYRINGE/NEEDLE ........ 334BD TB SYRINGE ................... 334BD VEO INSULIN SYR U/F 1/2UNIT ................................... 334BD VEO INSULIN SYRINGE U/F ............................................334

460

BD VERITOR HOME COVID-19 TEST .................... 241BD VERITOR SARS-COV-2/FLU A+B .............................. 230BD VERITOR SYSTEM GROUP A STRP .....................241BD VERITOR SYSTEM SARS-COV-2 ...........................241beau rx ...................................... 215bebtelovimab .............................415BECONASE AQ ..................... 392beef (diagnostic) ....................... 228BEKYREE ...............................167BELBUCA ................................. 45BELEODAQ ............................122belladonna alkaloids-opium ..... 437BELRAPZO ............................ 113BELSOMRA ........................... 299benazepril hcl ..............................99benazepril-hydrochlorothiazide ..98BENDEKA ...............................113BENEFIX .................................278BENICAR ................................101BENICAR HCT ...................... 100BENLYSTA .............................365bensal hp ...................................210BENTIVITE ............................ 294BENTYL ..................................437BENZAC AC WASH ..............191BENZACLIN ...........................188BENZACLIN WITH PUMP ..188benzalkonium chloride ..............143BENZAMYCIN .......................188BENZEPRO .................... 191, 192BENZEPRO CREAMY WASH ...................................... 191BENZEPRO FOAMING CLOTHS ..................................192benzhydrocodone-acetaminophen ............................44benznidazole ............................... 50BENZODOX ........................... 432benzoin ......................................216benzoin compound .................... 216benzonatate ............................... 185benzoyl perox-hydrocortisone ...188benzoyl peroxide ....................... 192benzoyl peroxide forte- hc .........188benzoyl peroxide-erythromycin .188benzphetamine hcl .........................3benztropine mesylate .................136BEOVU .................................... 412

bepotastine besilate .................. 402BEPREVE ............................... 402BERINERT ............................. 283bermuda grass .............................. 7BESER ............................. 202, 221BESIVANCE ........................... 402BESPONSA ............................. 117BESREMI ................................128beta 1 kit ................................... 182BETADINE OPHTHALMIC PREP ........................................404betaine .......................................257BETALIDO ............................. 182BETALOAN SUIK ................. 182betamethasone combo ...............182betamethasone dipropionate .....202betamethasone dipropionate aug ............................................ 202betamethasone sod phos & acet182betamethasone sodium phosphate ..................................178betamethasone valerate ............ 202BETAPACE .............................153BETAPACE AF ...................... 153BETASERON ..........................424betaxolol hcl ......................152, 399bethanechol chloride .................444BETHKIS .................................. 13BETIMOL ............................... 399BETOPTIC-S .......................... 400bevacizumab ..............................412BEVESPI AEROSPHERE .......55BEVYXXA .................................61bexarotene .........................134, 221BEXSERO ............................... 444BEYAZ .....................................168bhi uri-control ...........................367BIAFINE ..................................224bicalutamide ............................. 113BICILLIN C-R ........................419BICILLIN C-R 900/300 ..........419BICILLIN L-A ........................ 418BICNU ..................................... 133BIDIL ....................................... 160BIFERARX ............................. 295biifenac 1000 ............................ 196biifenac 500 .............................. 196BIJUVA ................................... 264BIKTARVY .............................144BILTRICIDE ............................ 50bimatoprost ....................... 214, 411bi-mix ........................................ 159

BINAXNOW COVID-19 AG CARD .......................................241BINAXNOW COVID-19 AG HOME TEST .......................... 241BINOSTO ................................ 254BIO GLO ................................. 404biocel .........................................378BIOFREQUENCY INSOLES308BIOGUARD GAUZE SPONGES ................................308BIOGUARD ISLAND DRESSINGS ............................308BIOGUARD NON-ADHERENT DRESSING ...... 308BIONECT ........................224, 225BIOPAR DELTA-FORTE .....287BIORPHEN ............................. 451BIOSCANNER GLUCOSE TEST ........................................ 233BIOSTEP ................................. 225BIOSTEP AG .......................... 225BIOTEL CARE BLOOD GLUCOSE ...............................311BIOTEL CARE BLOOD GLUCOSE SYST ....................311BIOTHRAX .............................444BIOVANCE .............................217bisoprolol fumarate .................. 152bisoprolol-hydrochlorothiazide 103bivalirudin rtu .............................64bivalirudin trifluoroacetate ........ 64bivalirudin-sodium chloride ....... 64BIVIGAM ................................415black walnut pollen .......................7black willow .................................. 7BLANCHE ...............................206BLENREP ............................... 116bleomycin sulfate ...................... 125BLEPH-10 ............................... 410BLEPHAMIDE ....................... 407BLEPHAMIDE S.O.P. ........... 407BLINCYTO ............................. 120BLISOVI 24 FE .......................168BLISOVI FE 1.5/30 ................ 168BLISOVI FE 1/20 ................... 168blood glucose monitor system ...311blood glucose system pak ..........311blood glucose test ..................... 233BLOXIVERZ .......................... 111BLUESTAR .............................311BLULINK GLUCOSE MONITORING SYS .............. 311

461

BLULINK GLUCOSE TEST 233BOCASAL ............................... 373BONIVA .................................. 254BONJESTA ............................... 89BOOSTRIX ............................. 436boric acid .................................. 213bortezomib ................................ 124bosentan ....................................161BOSULIF .................................120BOTOX ....................................393BOTOX COSMETIC ............. 208botrytis .......................................... 7botrytis cinerea ............................. 7botrytis cinerea (diagnostic) .....228box elder ....................................... 7bp 10-1 ...................................... 188bp cleansing wash .....................188bp vit 3 ...................................... 289bpco ...........................................222b-plex ........................................ 375b-plex plus .................................378BPROTECTED PEDIA IRON ........................................294BRAFTOVI ............................. 120breathe comfort chamber/adult 351breathe comfort chamber/child .352breathe ease large .....................352breathe ease medium ................ 352breathe ease small .................... 352BREATHERITE ..................... 352BREATHERITE COLL SPACER ADULT ................... 352BREATHERITE COLL SPACER CHILD .................... 352BREATHERITE COLL SPACER INFANT .................. 352BREATHERITE RIGID SPACER/MASK ..................... 352BREATHERITE SPACER NEONATE ...............................352BREATHERITE SPACER SMALL CHILD ...................... 352BREATHERITE VALVED MDI CHAMBER .................... 350BREATHERITE/LARGE MASK ...................................... 352BREATHERITE/MEDIUM MASK ...................................... 352BREATHERITE/SMALL MASK ...................................... 352BREO ELLIPTA ................ 55, 56bretylium tosylate ........................54

BREVIBLOC .......................... 152BREVIBLOC IN NACL .........152BREVIBLOC PREMIXED ....152BREVIBLOC PREMIXED DS ............................................. 152BREVITAL SODIUM ............ 273BREXAFEMME ....................... 91BREYANZI ............................. 119BREZTRI AEROSPHERE ......56BRIDION ...................................87briellyn ......................................168BRILINTA ...............................283brimonidine tartrate ..................407brimonidine tartrate-timolol .....399brimonidine-dorzolamide ......... 399BRINEURA ............................. 262brinzolamide ............................. 404BRISDELLE ........................... 430BRIVIACT ................................ 65brome ............................................ 7bromfenac sodium (once-daily) 406bromocriptine mesylate .............136brompheniramine maleate .......... 92BROMSITE .............................406BRONCHITOL .......................431BRONCHITOL TOLERANCE TEST ..............431BROVANA ................................ 57BRUKINSA ............................. 120BRYHALI ................................202bsp 0820 ....................................182BSS ........................................... 405BSS PLUS ................................ 405budesonide .......................... 60, 178budesonide er ............................178budesonide-formoterol fumarate 56bullseye mini safety lancets .......312BULLSEYE SAFETY LANCETS ............................... 312bumetanide ................................252BUMEX ................................... 252BUMINATE ............................ 285BUNAVAIL ............................... 45BUPAP ....................................... 22BUPHENYL ............................ 262bupivacaine fisiopharma .......... 303bupivacaine hcl .........................304bupivacaine hcl (pf) .................. 303bupivacaine hcl-nacl .................304bupivacaine in dextrose ............ 304bupivacaine spinal .................... 304bupivacaine-epinephrine .......... 302

bupivacaine-epinephrine (pf) ....302bupivilog ................................... 182BUPRENEX .............................. 45buprenorphine .......................45, 46buprenorphine hcl .......................45buprenorphine hcl-naloxone hcl .45bupropion hcl ..............................71bupropion hcl er (smoking det) .427bupropion hcl er (sr) ...................71bupropion hcl er (xl) ...................71buspirone hcl .............................. 51busulfan .....................................113BUSULFEX ............................. 113butalbital-acetaminophen ........... 22butalbital-apap-caff-cod ............. 26butalbital-apap-caffeine ............. 22butalbital-asa-caff-codeine .........26butalbital-aspirin-caffeine .......... 22butorphanol tartrate ................... 46BUTRANS ................................. 46BYDUREON ............................. 82BYDUREON BCISE ................ 82BYETTA 10 MCG PEN ........... 82BYETTA 5 MCG PEN ............. 82BYFAVO ................................. 297BYLVAY ................................. 269BYLVAY (PELLETS) ............268BYNFEZIA PEN .....................262BYOOVIZ ............................... 412BYSTOLIC ..............................152cabenuva ................................... 144cabergoline ............................... 255CABLIVI ................................. 282CABOMETYX ........................123CADIRAMD ............................219CADUET ................................. 158CAFCIT ....................................... 3CAFERGOT ............................354caffeine citrate .............................. 3caffeine-sodium benzoate ..............3CALAN SR .............................. 154CALCIFOL ............................. 357calcipotriene ............................. 199calcipotriene-betameth diprop ..221calcitonin (salmon) ................... 254CALCITRENE ........................199calcitriol ....................199, 257, 258calcium acetate ......................... 270calcium acetate (phos binder) ...270calcium chloride ............... 357, 358calcium disodium versenate ........87calcium gluconate .....................358

462

calcium gluconate-nacl .............357calcium-folic acid plus d ...........357CALDOLOR ............................. 18california pepper tree ................... 7calm ...........................................398CALQUENCE .........................120CAMBIA ..................................355CAMCEVI ...............................131CAMILA ..................................175CAMINO PRO 15PE ..............249CAMINO PRO COMPLETE/GLYTACTIN .. 249CAMINO PRO PKU .............. 249CAMPTOSAR .........................134CAMRESE .............................. 174CAMRESE LO ........................174CAMZYOS ..............................158CANASA ..................................269CANCIDAS ............................... 90candesartan cilexetil .................101candesartan cilexetil-hctz ......... 100candida albicans extract ...............7candida albicans skn tst antgn ..228CANDIN .................................. 228cantaloupe (diagnostic) ............ 228cantharidin ................................210CANVAS DX ...........................241CAPASTAT SULFATE ......... 112capecitabine ..............................114CAPEX .....................................202CAPLYTA ............................... 139CAPRELSA .............................123capsfenac pak ............................196capsinac .................................... 196captopril ......................................99captopril-hydrochlorothiazide ....98CARAC ....................................197CARAFATE ............................ 440CARBAGLU ........................... 257carbamazepine ............................65carbamazepine er ........................65CARBATROL ...........................65carbidopa ..................................137carbidopa-levodopa ..................137carbidopa-levodopa er ..............137carbidopa-levodopa-entacapone...................................................137carbinoxamine maleate ...............92CARBOCAINE ....................... 304CARBOCAINE PRESERVATIVE-FREE ....... 304carboplatin ................................113

carboprost tromethamine ..........414CARDENE IV ......................... 154CARDIO CHEK ..................... 330CARDIO CHEK PA ............... 330CARDIOCOM LANCING DEVICE ...................................312cardioplegia del nido formula .. 159cardioplegia ind plasma high k 159cardioplegia ind plasma-tromet159cardioplegia induction high k ...159cardioplegia induction low dex 159cardioplegia induction non-enr 159cardioplegia main low dextrose159cardioplegia main low trometha...................................................159cardioplegia main plasma-trome ......................................... 159cardioplegia maintenance .........159cardioplegia reperfusate 4:1 .... 159cardioplegic .............................. 159CARDIOTEK RX ...................246CARDIZEM ............................ 155CARDIZEM CD ..................... 154CARDIZEM LA ..............154, 155CARDURA .............................. 102CARDURA XL ........................273CAREFINE PEN NEEDLES .334careone advanced lancing dev ..312CAREONE BLOOD GLUCOSE SYSTEM ............. 312CAREONE BLOOD GLUCOSE TEST ....................233careone insulin syringe .............334CAREONE LANCET SUPER THIN 30G ................................ 312careone lancet thin 23g .............312careone unifine pentips .............334careone unifine pentips plus ..... 335CAREPOINT SAFETY1ST SYR/NEEDLE .........................335CARESENS LANCETS ......... 312CARESENS N GLUCOSE SYSTEM ..................................312CARESENS N GLUCOSE TEST ........................................ 233CARESENS N VOICE SYSTEM ..................................312CARESTART COVID-19 HOME TEST .......................... 241CARETOUCH INSULIN SYRINGE ................................ 335

CARETOUCH LANCING/EJECTOR ........... 312CARETOUCH LUER SLIP .. 335CARETOUCH MONITOR SYSTEM ..................................312CARETOUCH PEN NEEDLES ................................335CARETOUCH SAFETY LANCETS ............................... 312CARETOUCH SAFETY LANCETS 26G ....................... 312CARETOUCH TEST ............. 233CARETOUCH TWIST LANCETS 28G ....................... 312CARETOUCH TWIST LANCETS 30G ....................... 312CARETOUCH TWIST LANCETS 33G ....................... 312carglumic acid .......................... 257carisoprodol ..............................388carisoprodol-aspirin-codeine ... 390carmustine .................................133CARNITOR .............................254CARNITOR SF .......................254CAROSPIR ............................. 253carteolol hcl .............................. 400CARTIA XT ............................ 155CARTICEL ............................. 388carvedilol .................................. 151carvedilol phosphate er ............ 151CARVYKTI .............................119cascara sagrada ........................302casein (diagnostic) ....................228casirivimab ............................... 415CASODEX .......................113, 114caspofungin acetate .................... 90cat hair extract ..............................7CATAFLAM ............................. 18CATAPRES .............................102CATAPRES-TTS-1 .................102CATAPRES-TTS-2 .................102CATAPRES-TTS-3 .................102CATHFLO ACTIVASE .........287cattle epithelium ............................7CAVAREST ............................ 373CAVERJECT ..........................160CAVERJECT IMPULSE .......160CAYA .......................................308CAYSTON ...............................108CAZIANT ................................176cedar elm .......................................7cefaclor ..................................... 164

463

cefaclor er .................................164cefadroxil .................................. 163cefazolin in sodium chloride .....163cefazolin sodium ....................... 164cefazolin sodium-dextrose .........164cefdinir ......................................165cefditoren pivoxil ...................... 165cefepime hcl .............................. 166cefepime-dextrose ..................... 166cefixime ..................................... 165CEFOTAN ...............................164cefotaxime sodium .....................165cefotetan disodium .................... 164cefotetan disodium-dextrose ..... 164cefoxitin sodium ........................ 165cefoxitin sodium-dextrose ......... 165cefpodoxime proxetil .................165cefprozil .................................... 165ceftazidime ................................ 165ceftazidime and dextrose ...........165ceftriaxone sodium ....................165ceftriaxone sodium in dextrose . 165ceftriaxone sodium-dextrose ..... 165cefuroxime axetil .......................165cefuroxime sodium .................... 165CELACYN ...............................215CELEBREX .............................. 16celecoxib ..................................... 16CELESTONE SOLUSPAN ....183CELEXA ....................................72CELLCEPT .............................368CELLCEPT INTRAVENOUS...................................................368cellpad .......................................350CELLUGEL ............................ 410CELONTIN ............................... 70CEM-UREA ............................ 207CENFOL ..................................289CENTANY ...............................193CENTANY AT ........................ 193CENTRATEX ......................... 292cephalexin ................................. 164CEPROTIN ............................. 284CEQUA ....................................405CEQUR SIMPLICITY 2U .....335CEQUR SIMPLICITY INSERTER ..............................335CERACADE ............................212CERAMAX ..............................212CERDELGA ............................287CEREBYX .................................70CEREFOLIN ...........................246

CEREFOLIN NAC .................246CERETEC ............................... 232CEREZYME ........................... 287CERIANNA .............................231CEROVEL ...............................207cervical specimen collection .....232CERVIDIL .............................. 414CETACAINE .......................... 219cetirizine hcl ................................93CETRAXAL ............................413CETROTIDE .......................... 255cevimeline hcl ........................... 375CHANTIX ............................... 427CHANTIX CONTINUING MONTH PAK ......................... 427CHANTIX STARTING MONTH PAK ......................... 427CHARLOTTE 24 FE ..............168CHATEAL ...............................168CHATEAL EQ ........................168CHEMET ...................................86CHEMSTRIP BG LOG BOOK ...................................... 312CHEMSTRIP K ...................... 233CHENODAL ........................... 267chicken meat (diagnostic) ......... 228childrens aspirin ......................... 24childrens aspirin low strength .... 24CHIRHOSTIM ....................... 229chlooxia .....................................221chloramphenicol sod succinate .106chlordiazepoxide hcl ...................52chlordiazepoxide-amitriptyline .422chlordiazepoxide-clidinium ...... 437chlorhexidine gluconate ....143, 372chloroprocaine hcl (pf) ............. 306chloroquine phosphate ..............110chlorothiazide sodium ...............253chlorpromazine hcl ................... 141chlorthalidone ...........................253chlorzoxazone ........................... 388CHOLBAM ............................. 267cholecal df .................................289cholesterol and lipid test ...........234cholestyramine ............................94cholestyramine light ....................94CHOLETEC ............................231chondroitin sulfate .................... 411chorionic gonadotropin ............ 260CHROMAGEN ....................... 292chromic chloride .......................364CIALIS .....................................162

CIBINQO .................................201CICASIL ..................................350cicatrace pad .............................350CICLODAN .............................195ciclopirox .................................. 195ciclopirox olamine .................... 195ciclopirox treatment ..................195cidofovir ....................................148CIFEREX ................................ 289cifrazol ...................................... 289cilostazol ................................... 284CILOXAN ............................... 402CIMDUO ................................. 144cimetidine ..................................439cimetidine hcl ............................439CIMZIA ................................... 271CIMZIA PREFILLED ........... 271CIMZIA STARTER KIT .......271cinacalcet hcl ............................ 254CINQAIR ...................................59CINRYZE ................................283CINVANTI ................................ 90CIPRO ..................................... 266CIPRO HC .............................. 413CIPRODEX ............................. 413ciprofloxacin hcl ....... 266, 402, 413ciprofloxacin in d5w ................. 266ciprofloxacin-dexamethasone ... 413ciprofloxacin-fluocinolone pf ....413cisatracurium besylate ..............394cisatracurium besylate (pf) ....... 394cisplatin .....................................113citalopram hydrobromide ........... 72CITRANATAL 90 DHA .........385CITRANATAL ASSURE .......385CITRANATAL B-CALM ...... 381CITRANATAL BLOOM ....... 381CITRANATAL BLOOM DHA ......................................... 385CITRANATAL DHA ..............385CITRANATAL ESSENCE .... 385CITRANATAL HARMONY .385CITRANATAL MEDLEY .....385CITRANATAL RX .................381citrulline easy ............................262cladosporium cladosporioides ......7cladosporium sphaerospermum ....7cladribine ..................................114CLARAVIS ............................. 192CLARINEX ............................... 93CLARINEX-D 12 HOUR .......185CLARISCAN ...........................243

464

clarithromycin ...........................306clarithromycin er ...................... 306classic prenatal .........................381CLEANLET LANCETS 28G 312CLEARBLUE FERTILITY .. 308CLEARDETECT COVID-19 AG HOME ...............................241clemastine fumarate ....................92CLENIA PLUS ........................188CLENPIQ ................................ 300CLEOCIN ........................108, 449CLEOCIN PHOSPHATE ...... 108CLEOCIN-T ............................187CLEVER CHEK AUTO-CODE .......................................309CLEVER CHEK AUTO-CODE SYSTEM ..................... 312CLEVER CHEK AUTO-CODE TEST ............................234CLEVER CHEK AUTO-CODE VOICE .................234, 312CLEVER CHEK LANCETS . 312CLEVER CHEK SYSTEM ... 312CLEVER CHEK TEST ..........234CLEVER CHOICE AUTO-CODE SYSTEM ..................... 312CLEVER CHOICE AUTO-CODE TEST ............................234CLEVER CHOICE COMFORT EZ ....................... 335CLEVER CHOICE HOLDING CHAMBER ......... 352CLEVER CHOICE LANCETS 21G ....................... 312CLEVER CHOICE LANCETS 23G ....................... 312CLEVER CHOICE LANCETS 28G ....................... 312CLEVER CHOICE MICRO SYSTEM ..................................312CLEVER CHOICE MICRO TEST ........................................ 234CLEVER CHOICE MINI SYSTEM ..................................312CLEVER CHOICE NO CODING ..................................234CLEVER CHOICE PULSE OXIMETER ............................ 331CLEVER CHOICE TALK SYSTEM ..........................234, 312CLEVER CHOICE WHIS AIR PED NEB .........................332

CLEVER CHOICE WHISPER AIRE NEB ........... 332CLEVIPREX ...........................155CLICKFINE PEN NEEDLES...................................................335clickfine pen needles ................. 335CLIMARA ...............................265CLIMARA PRO ..................... 264CLINDACIN ETZ .......... 187, 188CLINDACIN PAC .................. 188CLINDACIN-P ........................187CLINDAGEL .......................... 187clindamycin hcl .........................108clindamycin palmitate hcl .........108clindamycin phos-benzoyl perox...................................................188clindamycin phosphate...................................108, 187, 449clindamycin phosphate in d5w ..108clindamycin phosphate in nacl . 108clindamycin-tretinoin ................188clindavix ....................................188CLINDESSE ............................449CLINIMIX E/DEXTROSE (2.75/5) ......................................396CLINIMIX E/DEXTROSE (4.25/10) ....................................396CLINIMIX E/DEXTROSE (4.25/5) ......................................396CLINIMIX E/DEXTROSE (5/15) .........................................396CLINIMIX E/DEXTROSE (5/20) .........................................396clinimix e/dextrose (8/10) ......... 396clinimix e/dextrose (8/14) ......... 396CLINIMIX/DEXTROSE (4.25/10) ....................................396CLINIMIX/DEXTROSE (4.25/5) ......................................397CLINIMIX/DEXTROSE (5/15) .........................................397CLINIMIX/DEXTROSE (5/20) .........................................397clinimix/dextrose (6/5) .............. 397clinimix/dextrose (8/10) ............ 397clinimix/dextrose (8/14) ............ 397CLINISOL SF ......................... 397CLINITEST RAPID COVID-19 TEST ................................... 241CLINOIN .................................188CLINOLIPID .......................... 398CLINPRO 5000 .......................373

clobazam ..................................... 64clobetasol prop emollient base . 202clobetasol propionate ............... 203clobetasol propionate e .............202clobetasol propionate emulsion 203clobetavix ..................................221CLOBETEX .............................. 94CLOBEX ................................. 203CLOBEX SPRAY ................... 203clocortolone pivalate ................ 203CLODAN ......................... 203, 221CLODERM ............................. 203clofarabine ................................114CLOLAR ................................. 114clomiphene citrate .....................260clomipramine hcl ........................ 75clonazepam ................................. 64clonidine ................................... 102clonidine hcl ..............................102clonidine hcl (analgesia) ............ 22clonidine hcl er ............................. 1clopidogrel bisulfate ................. 286clorazepate dipotassium ............. 52CLOROTEKAL ......................306clotrimazole ...................... 208, 372clotrimazole-betamethasone ..... 194CLOVIQUE .............................365clozapine ........................... 140, 141CLOZARIL ............................. 141c-nate dha ................................. 381co monitor .................................350COAGADEX ........................... 278COAGUCHEK LANCETS ....312coal tar ......................................216COARTEM ............................. 110coatamax patch .........................350COBAS LIAT SARS-COV-2 ASSAY ..................................... 241COBAS LIAT SARS-COV-2 CONTROL .............................. 241COBAS LIAT SARS-COV-2-AB ASSAY ...............................230COBAS LIAT SARS-COV-2-AB CNTRL ..............................230cocaine hcl ................................ 391cocklebur .......................................7cocoa bean (diagnostic) ............228cod liver oil ............................... 387codeine sulfate ............................ 28coenzyme q-10 .............................13COGENTIN .............................136COLAZAL ...............................269

465

colchicine ..................................276colchicine-probenecid ...............276COLCIGEL .............................367COLCRYS ...............................276colesevelam hcl ........................... 94COLESTID ..........................94, 95COLESTID FLAVORED ........ 94colestipol hcl ...............................95colistimethate sodium (cba) ......109COLLANEX ............................225COLLATYL ............................225COLOCORT ............................. 48COLY-MYCIN M ...................109COLY-MYCIN S .................... 413COLYTE WITH FLAVOR PACKS .....................................300COMBIGAN ........................... 399COMBIPATCH ...................... 264COMBIVENT RESPIMAT ..... 56COMBIVIR ............................. 144COMETRIQ (100 MG DAILY DOSE) ........................ 123COMETRIQ (140 MG DAILY DOSE) ........................ 123COMETRIQ (60 MG DAILY DOSE) ...................................... 123COMFORT ASSIST INSULIN SYRINGE .............. 335comfort assured lancets 28g ..... 312comfort assured lancets 33g ..... 313COMFORT EZ INSULIN SYRINGE ................................ 335COMFORT EZ MICRO PEN NEEDLES ................................335COMFORT EZ PEN NEEDLES ................................335COMFORT EZ SHORT PEN NEEDLES ................................335comfort lancets ..........................313COMFORT TOUCH INSULIN PEN NEED .............336COMFORT TOUCH LANCETS 31G ....................... 313COMFORT TOUCH PLUS LANCETS 30G ....................... 313COMIRNATY .........................445COMP A-I-R NEBULIZER ...332COMPACT SPACE CHAMBER ............................. 352COMPACT SPACE CHAMBER/LG MASK ..........352

COMPACT SPACE CHAMBER/MED MASK ...... 352COMPACT SPACE CHAMBER/SM MASK ......... 352COMPLERA ........................... 144complete natal dha ....................385completenate ............................. 381COMPRO ................................ 142COMTAN ................................ 139CO-NATAL FA .......................381CONCEPT DHA .....................381CONCEPT OB ........................ 382CONCERTA ............................... 4CONDYLOX ........................... 210CONJUPRI ..............................155CONRAY .................................245CONSENSI ..............................154constulose ................................. 301CONTOUR CONTROL .........313CONTOUR MONITOR .........313CONTOUR NEXT CONTROL .............................. 313CONTOUR NEXT EZ ........... 313CONTOUR NEXT LINK .......313CONTOUR NEXT MONITOR .............................. 313CONTOUR NEXT ONE ........ 313CONTOUR NEXT TEST .......234CONTOUR TEST ...................234CONTRAST ALLERGY PREMED PACK .....................183CONTRAVE ............................... 4CONVENIENCE PAK ...........426CONZIP .....................................28COOL BLOOD GLUCOSE TEST STRIPS ......................... 234COOL MONITOR ..................313COOL MONITOR KIT ......... 313COPASIL .................................215COPAXONE ........................... 425COPIKTRA .............................133CORDRAN ..............................203COREG ....................................152COREG CR .............................152COREMINO ........................... 432CORETEXT ............................217CORGARD ..............................153CORIFACT ............................. 278CORLANOR ........................... 163CORLOPAM ...........................103corn pollen .................................... 7CORTANE-B .......................... 216

CORTEF ..................................178CORTENEMA ..........................48CORTIC-ND ........................... 413CORTIFOAM ........................... 48corti-sav .................................... 194cortisone acetate .......................178CORTISPORIN-TC ............... 413CORTROPHIN .......................255CORTROSYN .........................229CORVERT ................................ 54CORVITA ............................... 378CORVITA 150 ........................ 292CORVITE ................................378CORVITE 150 .........................292corvite fe ................................... 292CORVITE FREE .................... 378COSELA ..................................132COSENTYX ............................ 199COSENTYX (300 MG DOSE)...................................................198COSENTYX SENSOREADY (300 MG) ..................................198COSENTYX SENSOREADY PEN .......................................... 198COSMEGEN ........................... 125COSOPT ..................................399COSOPT PF ............................ 399cosyntropin ............................... 229COTELLIC ............................. 122COTEMPLA XR-ODT .............. 4COUMADIN ..............................61COVARYX ..............................264COVARYX HS ........................263covid-19 at-home test ................241covid-19 otc antigen 1-pack ......241covid-19 otc antigen 2-pack ......241covid-19 specimen collection ....241covid-19 testing by pharmacist .241COZAAR ................................. 101crab (diagnostic) .......................228cream base niosomes ................ 420cream-heavy base niosomes ......420CREON ....................................251CRESEMBA ..............................91CRESTOR ................................. 96CRINONE ............................... 450CRIXIVAN ..............................146CROFAB ................................. 414cromolyn sodium .........57, 267, 402CROTAN ................................. 215CRYODOSE TA ..................... 221CRYSELLE-28 ....................... 168

466

CRYSVITA ............................. 263CUBICIN ................................. 106CUBICIN RF ...........................106CUE COVID-19 TEST ........... 241CUE HEALTH MONITORING SYSTEM ..... 241cupric chloride ..........................364CUPRIMINE ...........................365CURITY AMD ANTIMICROBIAL SPNGE .. 309CURITY AMD ANTIMICROBIAL STRIP ....309CURITY HYPERTONIC NACL STRIP .......................... 225CURITY IODOFORM PACKING STRIP ...................309CURITY NACL DRESSING 6"X6-3/4" .................................225CURITY STERILE SALINE 274CURITY WOUND CLOSURE 1/2"X4" ................307CURITY WOUND CLOSURE 1/4"X1.5" .............307CURITY WOUND CLOSURE 1/4"X3" ................307CURITY WOUND CLOSURE 1/4"X4" ................307CURITY WOUND CLOSURE 1/8"X3" ................307CUROSURF ............................ 432curvularia ..................................... 8CUTAQUIG ............................ 415CUTIVATE ............................. 203CUVITRU ................................415CUVPOSA ............................... 442CVS ADVANCED GLUCOSE TEST ....................234cvs aspirin adult low dose ...........24cvs aspirin adult low strength .....24cvs aspirin ec .............................. 24cvs aspirin low dose ....................24cvs aspirin low strength .............. 24CVS BLOOD GLUCOSE METER ....................................313cvs folic acid ............................. 291cvs glucose meter test strips ......234cvs lancets 21g ..........................313cvs lancets micro thin 33g ........ 313cvs lancets original ................... 313cvs lancets thin 26g ...................313cvs lancets ultra thin 30g ..........313cvs lancets ultra-thin 30g ..........313

cvs lancing device ..................... 313cvs nicotine ............................... 427cvs nicotine polacrilex .............. 427cvs ultra thin lancets .................313cyanocobalamin ........................287CYANOKIT .............................. 87CYCLAFEM 1/35 ................... 168CYCLAFEM 7/7/7 .................. 176cyclo/gaba 10/300 .....................390cyclobenzaprine hcl .................. 388cyclobenzaprine hcl er .............. 388CYCLOGYL ........................... 401CYCLOMYDRIL ................... 400CYCLOPAK ........................... 390cyclopentolate hcl ..................... 401CYCLOPHENE RAPIDPAQ 388cyclophosphamide .............132, 133cycloserine ................................ 112CYCLOSET .............................. 78cyclosporine ......................366, 405CYCLOSPORINE IN KLARITY ................................405cyclosporine modified ...............366CYKLOKAPRON .................. 296CYMBALTA ............................. 74cyproheptadine hcl ................93, 94CYRAMZA ..............................135CYRED .................................... 168CYRED EQ ............................. 168CYSTADANE ......................... 257CYSTADROPS ....................... 411CYSTAGON ............................274CYSTARAN ............................ 411CYSTO-CONRAY II ..............245CYSTOGRAFIN .....................245CYSTOGRAFIN-DILUTE .... 245CYSVIEW ............................... 229cytarabine ................................. 114cytarabine (pf) ...........................114CYTOGAM ............................. 415CYTOMEL ..............................434CYTOTEC ...............................443CYTOTINE ............................. 398cytra k crystals ..........................274cytra-2 .......................................274D 1000 PLUS ALOE ...............289D.H.E. 45 ..................................355dacarbazine ...............................128DACOGEN ..............................114dactinomycin .............................125daflonex-xl ................................ 377dalfampridine er ....................... 425

DALIRESP ................................ 60DALVANCE ............................106danazol ........................................47dandelion ...................................... 8DANTRIUM ............................389dantrolene sodium ............ 389, 390DANYELZA ............................118dapsone ............................. 108, 187DAPTACEL ............................ 436daptomycin ................................106DARAPRIM ............................ 110darifenacin hydrobromide er ....443DARTISLA ODT .................... 442DARZALEX ............................117DARZALEX FASPRO ...........126DASETTA 1/35 ....................... 168DASETTA 7/7/7 ...................... 176DATSCAN ............................... 231daunorubicin hcl .......................125DAURISMO ............................ 121davite .........................................375dayavite .....................................378DAYPRO ................................... 18DAYSEE .................................. 174DAYTRANA ................................5DAYVIGO ............................... 299D-CARE BLOOD GLUCOSE...................................................234D-CARE GLUCOMETER .... 313DDAVP .................................... 263DDAVP PF ...............................263DDAVP RHINAL TUBE ....... 263DEBACTEROL ...................... 372DEBLITANE ...........................175DECADRON ........................... 178decitabine ..................................114deferasirox .................................. 86deferasirox granules ................... 86deferiprone ..................................86deferoxamine mesylate ................87DEFINITY ...............................243DEFINITY RT ........................ 243DEFITELIO ............................ 287DEFLUX ..................................275dehydrated alcohol ................... 398DELESTROGEN ....................265DELFLEX-LC/1.5% DEXTROSE ............................ 370DELFLEX-LC/2.5% DEXTROSE ............................ 370DELFLEX-LC/4.25% DEXTROSE ............................ 370

467

DELFLEX-SM/1.5% DEXTROSE ............................ 370DELFLEX-SM/2.5% DEXTROSE ............................ 370DELSTRIGO ...........................144DELUO .................................... 223DELYLA ..................................168DELZICOL ............................. 269demeclocycline hcl ....................432DEMEROL ................................28DEMSER ................................. 100DENAVIR ................................201DENGVAXIA ..........................445DENTA 5000 PLUS ................ 373DENTAGEL ............................373deoxia ........................................188DEPAKOTE ..............................71DEPAKOTE ER ....................... 71DEPAKOTE SPRINKLES ...... 71DEPEN TITRATABS .............365DEPLIN 15 .............................. 246DEPLIN 7.5 ............................. 246DEPO-ESTRADIOL .............. 265DEPO-MEDROL ....................178DEPO-PROVERA .......... 134, 175DEPO-SUBQ PROVERA 104175DEPO-TESTOSTERONE ....... 47DERMACINRX AZENASE PAK ..........................................391DERMACINRX CLORHEXACIN ....................213DERMACINRX DOTREMIN...................................................289DERMACINRX FOLTAMIN289DERMACINRX LEXITRAL PHARMAPAK ........................196DERMACINRX LIDOGEL .. 210DERMACINRX MULTITAM...................................................378DERMACINRX PHN .............219DERMACINRX PRETRATE382DERMACINRX PROBISOL .. 85DERMACINRX PROBITRAN ............................ 85DERMACINRX PUREFOLIX ...........................289DERMACINRX RIBOTIN-E 378dermacinrx surgical combopak 213DERMACINRX THERAZOLE PAK ................194DERMACINRX UREA ..........207

DERMACINRX ZINTREXYL-C ...................... 378DERMACINRX ZRM ............219dermalid ....................................219DERMA-SMOOTHE/FS BODY .......................................203DERMA-SMOOTHE/FS SCALP ..................................... 203DERMAZENE ........................ 194DERMELLE ........................... 215DERMOTIC ............................413DERPIXA ................................ 225DESCOVY ...............................144DESFERAL ............................... 87desflurane ................................. 273desipramine hcl ...........................75desloratadine .............................. 93desmopressin ace spray refrig .. 263desmopressin acetate ................ 263desmopressin acetate pf ............263desmopressin acetate spray ...... 263desogestrel-ethinyl estradiol...........................................167, 168DESONATE ............................ 203desonide .................................... 203DESOWEN ..............................203desoximetasone ......................... 203DESOXYN ...................................2DESRX .....................................204desvenlafaxine er ........................ 74desvenlafaxine succinate er ........ 74DETECTNET ..........................231DETROL ................................. 443DETROL LA ...........................443dexabliss ................................... 178dexameth sod phos-bupiv-epin ..183dexamethasone ..........................178dexamethasone (la) ................... 178dexamethasone ace & sod phos 183DEXAMETHASONE INTENSOL ..............................178dexamethasone sod phos-nacl .. 178dexamethasone sod phosphate pf ............................................... 178dexamethasone sodium phosphate ..................178, 179, 409dexamethasone-moxifloxacin ....407dexameth-moxiflox-ketorolac ....407dexchlorpheniramine maleate .....92DEXCOM G4 PLAT PED RCV/SHARE ...........................313

DEXCOM G4 PLAT PED RECEIVER ............................. 313DEXCOM G4 PLATINUM RCV/SHARE ...........................313DEXCOM G4 PLATINUM RECEIVER ............................. 313DEXCOM G4 PLATINUM TRANSMITTER .....................313DEXCOM G4 SENSOR ......... 313DEXCOM G5 MOB/G4 PLAT SENSOR .......................313DEXCOM G5 MOBILE RECEIVER ............................. 313DEXCOM G5 MOBILE TRANSMITTER .....................314DEXCOM G5 RECEIVER KIT ........................................... 314DEXCOM G6 RECEIVER ....314DEXCOM G6 SENSOR ......... 314DEXCOM G6 TRANSMITTER .....................314DEXEDRINE .............................. 2DEXERYL ...............................212DEXIFOL ................................ 375DEXILANT ............................. 440dexlansoprazole ........................ 440DEXLIDO ................................183DEXLIDO-M ...........................183dexmedetomidine hcl .................300dexmedetomidine hcl in nacl .....300dexmedetomidine hcl-dextrose ..300dexmethylphenidate hcl .................5dexmethylphenidate hcl er ............ 5DEXONTO 0.4% .................... 179DEXPAK 10 DAY ...................179DEXPAK 13 DAY ...................179DEXPAK 6 DAY .....................179dexpanthenol .............................268dexrazoxane hcl ........................ 129DEXTENZA ............................ 409dextroamphetamine sulfate ...........2dextroamphetamine sulfate er .......2dextrose .....................................398dextrose 5%/electrolyte #48 ......358dextrose in lactated ringers ...... 358dextrose-nacl .............................358dextrose-sodium chloride ..........358DEXYCU ................................. 409dfs dr/ms/menth/cap pak ............. 18dfs/ms/menth/cap pak ................196DHIVY ..................................... 137DIACOMIT ............................... 66

468

diadimaxia ................................ 188DIALYVITE ............................375DIALYVITE 3000 ...................376DIALYVITE 5000 ...................376DIALYVITE 800 .....................375DIALYVITE SUPREME D ... 378DIALYVITE/ZINC .................377DIANEAL LOW CALCIUM/1.5% DEX ........... 370DIANEAL LOW CALCIUM/2.5% DEX ........... 370DIANEAL LOW CALCIUM/4.25% DEX ......... 370DIANEAL PD-2/1.5% DEXTROSE ............................ 370DIANEAL PD-2/2.5% DEXTROSE ............................ 370DIANEAL PD-2/4.25% DEXTROSE ............................ 370diaoxia ...................................... 188diasdimaxia ...............................188diasoxia .....................................188DIASTAT ACUDIAL ...............65DIASTAT PEDIATRIC ........... 65DIATHRIVE BLOOD GLUCOSE METER ............... 314DIATHRIVE BLOOD GLUCOSE TEST ....................234DIATHRIVE GLUCOSE TEST ........................................ 234DIATHRIVE LANCET ULTRA THIN 30 .................... 314DIATHRIVE LANCETS ....... 314DIATHRIVE PEN NEEDLE .336DIATHRIVE+ GLUCOSE MONITOR .............................. 314DIATHRIVE+ GLUCOSE TEST ........................................ 234diatrue plus blood glucose ........314diatrue plus test .........................234DIATRUST COVID-19 HOME TEST .......................... 241diazepam ............................... 52, 65DIAZEPAM INTENSOL .........52diazoxide ..................................... 76DIBENZYLINE ...................... 100DICLEGIS .................................89diclofenac ....................................18diclofenac epolamine ................ 195diclofenac potassium .................. 18

diclofenac sodium.....................18, 195, 196, 198, 406diclofenac sodium er ...................18diclofenac-misoprostol ............... 17DICLOFONO ..........................196dicloheal-60 .............................. 196diclona ...................................... 196diclopr .......................................196diclostream ............................... 196DICLOTREX .......................... 196DICLOTREX II ...................... 196diclovix ......................................196diclovix m ..................................196dicloxacillin sodium ..................419diclozor ..................................... 196DICOPANOL FUSEPAQ ........ 92DICOPANOL RAPIDPAQ ......93dicyclomine hcl ......................... 437didanosine .................................147diethylpropion hcl .........................3diethylpropion hcl er .....................3DIFFERIN ............................... 192DIFICID ...................................307diflorasone diacetate ................ 204DIFLUCAN ............................... 91diflunisal ..................................... 24difluprednate .............................409difmetioxrime ............................ 194DIGIFAB ................................... 87DIGITEK .................................157DIGOX .....................................157digoxin ...................................... 158dihydroergotamine mesylate .....355DILANTIN ................................ 70DILANTIN INFATABS ........... 70DILATRATE-SR ...................... 50DILAUDID ................................ 28diltiazem hcl ..............................155diltiazem hcl er ......................... 155diltiazem hcl er beads ............... 155diltiazem hcl er coated beads ....155diltiazem hcl-dextrose ...............155diltiazem hcl-sodium chloride ...155dilt-xr ........................................ 156diluent for treprostinil ...............420dimenhydrinate ........................... 89dimentho ................................... 196dimercaptopropane-sulfonate .....86dimethyl fumarate ..................... 425dimethyl fumarate starter pack .425dimoxia ..................................... 188diochloy .....................................221

DIOVAN .................................. 101DIOVAN HCT ........................ 101DIPENTUM .............................269diphen ......................................... 93di-phen ........................................ 93diphenhydramine hcl ...................93diphenoxylate-atropine ............... 85diphtheria-tetanus toxoids dt .... 436DIPRIVAN .............................. 271DIPROLENE ...........................204DIPROLENE AF .................... 204dipyridamole ..................... 229, 286DISCOVISC ............................ 410disopyramide phosphate ............. 53disulfiram ..................................422DITROPAN XL ...................... 443DIURIL ....................................253divalproex sodium .......................71divalproex sodium er .................. 71DIVIGEL ................................. 265DIVISTA ..................................289dmsa ..........................................232DMT SUIK .............................. 183dobutamine hcl ..........................158dobutamine in d5w ....................158docetaxel ................................... 131DODEX ....................................288dofetilide ..................................... 54dog epithelium .............................. 8dog fennel ......................................8DOJOLVI ................................ 398DOLISHALE ...........................173DOLOPHINE ............................28donepezil hcl ............................. 422DONNATAL ........................... 437dopamine hcl .............................158dopamine in d5w .......................158DOPRAM .................................... 3DOPTELET .............................295DORAL ....................................298DORYX ....................................433DORYX MPC ..........................433dorzolamide hcl ........................ 404dorzolamide hcl-timolol mal .....399dorzolamide hcl-timolol mal pf .399DOTAREM ............................. 243DOTATOC GA 68 .................. 231DOTTI ..................................... 265double pm ..................................407DOUBLEDEX ......................... 179DOVATO .................................144DOVONEX ..............................199

469

doxazosin mesylate ................... 102doxepin hcl ..................75, 198, 299doxercalciferol ..........................258DOXIL ..................................... 125doxorubicin hcl ......................... 125doxorubicin hcl liposomal ........ 125DOXY 100 ................................433doxycycline ................................214doxycycline hyclate ................... 433doxycycline monohydrate ......... 433doxylamine-pyridoxine ................89draxace ......................................189draxace lotion cleanser .............189drechslera ..................................... 8DRISDOL ................................ 454DRITHO-CREME HP ........... 199drixece .......................................189DRIZALMA SPRINKLE .........74dronabinol ...................................90droperidol ................................... 51DROPLET GENTEEL LANCING DEVICE ...............314DROPLET INSULIN SYRINGE ................................ 336DROPLET LANCETS ULTRA THIN 30G ................. 314DROPLET LANCING DEVICE ...................................314DROPLET MICRON .............336DROPLET PEN NEEDLES .. 336DROPLET PERSONAL LANCETS 30G ....................... 314dropsafe safety pen needles ...... 336drospiren-eth estrad-levomefol .168drospirenone-ethinyl estradiol ..168DROXIA .................................. 288droxidopa ..................................450drug mart lancets thin 26g ........314DRUG MART LANCING DEVICE ...................................314DRUG MART ON-THE-GO LANCET 30G ..........................314drug mart unifine pentips ..........336drug mart unifine pentips plus ..336DRUG MART UNILET LANCETS 28G ....................... 314DRUG MART UNILET LANCETS 30G ....................... 314DRUG MART UNILET LANCETS 33G ....................... 314DRYSOL ..................................213DSUVIA ..................................... 29

DUAKLIR PRESSAIR .............56dual complex formula 1 kit ....... 197DUAVEE ................................. 266DUET DHA 400 ...................... 382DUET DHA BALANCED ......382DUETACT .................................84DUEXIS ..................................... 17DULERA ................................... 56duloxetine hcl ..............................74DUOBRII .................................221DUO-CARE .............................309DUO-CARE TEST ..................234DUODOTE ................................ 86DUOPA .................................... 137DUOVISC ................................410DUPIXENT ............................. 201durachol ....................................289DURACLON ............................. 22DURAFIBER ...........................225DURAFIBER AG ....................225DURAGESIC-100 ..................... 29DURAGESIC-12 ....................... 29DURAGESIC-25 ....................... 29DURAGESIC-50 ....................... 29DURAGESIC-75 ....................... 29duramorph .................................. 29DUREZOL ...............................409DURLAZA ...............................286DUROLANE ........................... 390DURYSTA ............................... 412dust mite mixed allergen ext ....... 12dutasteride ................................ 273dutasteride-tamsulosin hcl ........275DUTOPROL ............................103DVORAH ...................................26DX1 ORAGENOMIC DNA SCREEN .................................. 234DX2 ORAGENOMIC DNA SCREEN .................................. 234DXEVO 11-DAY .....................179DXTERITY COVID-19 HOME TEST .......................... 242d-xylose ..................................... 229DYANAVEL XR .........................2DYAZIDE ................................252DYMISTA ............................... 391DYRENIUM ............................253DYSPORT ....................... 393, 394DYURAL 80-LM .....................183DYURAL-40 ............................183DYURAL-80 ............................183DYURAL-L ............................. 183

DYURAL-LM ..........................183E.E.S. 400 .................................307E.E.S. GRANULES .................307EASIVENT ..............................352EASIVENT MASK LARGE ..352EASIVENT MASK MEDIUM...................................................352EASIVENT MASK SMALL ..352eastern cottonwood .......................8easy comfort insulin syringe ..... 336easy comfort lancets ..................314easy comfort lancets twist top ...314easy comfort pen needles .......... 336easy glide pen needles ...............336easy plus ii glucose system ........314easy plus ii glucose test .............234EASY STEP GLUCOSE MONITOR .............................. 314EASY STEP TEST ................. 234easy talk blood glucose system . 314easy talk blood glucose test ...... 234easy talk plus ii test strips .........234EASY TOUCH FLIPLOCK INSULIN SY ............................336EASY TOUCH GLUCOSE SYSTEM ..................................314EASY TOUCH HEALTHPRO GLUCOSE .... 234EASY TOUCH INSULIN SAFETY SYR ..........................336EASY TOUCH INSULIN SYRINGE ................................ 337EASY TOUCH LANCETS 21G ........................................... 314EASY TOUCH LANCETS 23G ........................................... 314EASY TOUCH LANCETS 26G ........................................... 314EASY TOUCH LANCETS 28G ........................................... 314EASY TOUCH LANCETS 28G/TWIST ............................. 314EASY TOUCH LANCETS 30G ........................................... 314EASY TOUCH LANCETS 30G/TWIST ............................. 314EASY TOUCH LANCETS 32G ........................................... 314EASY TOUCH LANCETS 32G/TWIST ............................. 314EASY TOUCH LANCETS 33G/TWIST ............................. 315

470

EASY TOUCH LANCING DEVICE ...................................315EASY TOUCH PEN NEEDLES ................................337EASY TOUCH SAFETY LANCETS 21G ....................... 315EASY TOUCH SAFETY LANCETS 23G ....................... 315EASY TOUCH SAFETY LANCETS 26G ....................... 315EASY TOUCH SAFETY LANCETS 28G ....................... 315EASY TOUCH SAFETY PEN NEEDLES ................................337EASY TOUCH SHEATHLOCK SYRINGE ...337EASY TOUCH SYRINGE BARREL 10ML ...................... 337EASY TOUCH SYRINGE BARREL 1ML ........................ 337EASY TOUCH SYRINGE BARREL 3ML ........................ 337EASY TOUCH SYRINGE BARREL 5ML ........................ 337EASY TOUCH TEST .............234easy trak blood glucose system .315easy trak blood glucose test ......235easy trak ii blood glucose sys ... 315easy trak ii glucose test .............235EASY TWIST & CAP LANCETS ............................... 315EASYGEL ............................... 373EASYGLUCO ................. 235, 315EASYGLUCO PLUS ..............235EASYMAX 15 TEST ..............235EASYMAX NG BLOOD GLUCOSE ...............................315EASYMAX TEST ...................235EASYMAX V BLOOD GLUCOSE ...............................315EASYPOINT NEEDLE ..........337EASYPOINT NEEDLE/SYRINGE ...............337EASYPRO BLOOD GLUCOSE MONITOR ..........315EASYPRO BLOOD GLUCOSE TEST ....................235EASYPRO PLUS ............ 235, 315eceoxia ...................................... 189EC-NAPROSYN ....................... 18ec-naproxen ................................ 18econazole nitrate .......................208

ECONTRA EZ ........................ 173ECONTRA ONE-STEP ......... 173ECOTEST COVID-19 RAPID TEST .......................... 242ECOTRIN LOW STRENGTH .............................. 24ECOZA .................................... 208EC-RX DHEA ........................... 13ec-rx estradiol ...........................265ec-rx progesterone .................... 421ec-rx testosterone ........................47ECZEMOL ..............................367EDARBI ...................................101EDARBYCLOR ......................101EDECRIN ................................252edetate disodium ....................... 365EDEX ....................................... 160EDLUAR ................................. 299ed-spaz ...................................... 438EDURANT ...............................147EEMT .......................................264EEMT HS ................................ 264efavirenz ....................................147efavirenz-emtricitab-tenofovir .. 144efavirenz-lamivudine-tenofovir .144EFFER-K .........................361, 362EFFEXOR XR .......................... 74EFFIENT ................................. 286EFUDEX ..................................197egg white (diagnostic) ...............228EGRIFTA SV .......................... 256eha .............................................210ELAPRASE ............................. 259ELCYS ..................................... 397ELELYSO ............................... 287ELEMAR PATCH ..................219ELEMENT AUTOCODE SYSTEM ..................................315element compact glucose system...................................................315element compact test .................235element compact v glucose sys ..315ELEMENT PLUS ................... 315ELEMENT TEST ................... 235ELEPSIA XR ............................ 66ELESTRIN .............................. 265ELETONE ............................... 212eletriptan hydrobromide ........... 355ELFOLATE .............................248ELFOLATE PLUS ................. 246ELIDEL ................................... 211ELIGARD ................................131

ELIGEN B12 ........................... 246ELIMITE .................................215ELINEST ................................. 168ELIQUIS ....................................61ELIQUIS DVT/PE STARTER PACK ..................... 61ELITEK ................................... 129ELITE-OB ............................... 382elite-thin insulin syringe ........... 337ELIXOPHYLLIN ..................... 61ELLA ....................................... 173ELLENCE ............................... 125ELLIOTTS B .......................... 358ellume covid-19 home test .........242ELMIRON ...............................275ELOCTATE .................... 278, 279ELURYNG .............................. 173ELYXYB ..................................355ELZONRIS ..............................127EMBEDA ...................................29EMBRACE BLOOD GLUCOSE MONITOR ..........315EMBRACE BLOOD GLUCOSE TEST ....................235EMBRACE EVO BLOOD GLUCOSE TEST ....................235EMBRACE EVO GLUCOSE MONITOR .............................. 315EMBRACE EVO GLUCOSE MONITORING .......................315EMBRACE LANCETS ULTRA THIN 30G ................. 315EMBRACE PRESSURE ACTIVATED 21G .................. 315EMBRACE PRESSURE ACTIVATED 28G .................. 315EMBRACE PRO GLUCOSE METER ....................................315EMBRACE PRO GLUCOSE TEST ........................................ 235EMBRACE TALK BLOOD GLUCOSE ...............................315EMBRACE TALK GLUCOSE TEST ....................235EMBRACE TALK MONITORING SYSTEM ..... 315EMCYT ................................... 129EMEND ..................................... 90EMEND TRI-PACK .................90EMERPHED ........................... 451EMFLAZA .............................. 179EMGALITY ............................ 354

471

EMGALITY (300 MG DOSE)...................................................354EMOQUETTE ........................ 168EMPAVELI .............................283EMPLICITI .............................119EMPRICAINE-II ....................219EMSAM ..................................... 72emtricitabine ............................. 148emtricitabine-tenofovir df ......... 144EMTRIVA ............................... 148EMULSION SB .......................212EMVERM ..................................50ENABLEX ............................... 443enalapril maleate ........................ 99enalaprilat ...................................99enalapril-hydrochlorothiazide ....98ENBRACE HR ........................382ENBREL ....................................21ENBREL MINI ......................... 21ENBREL SURECLICK ........... 22ENCARE ................................. 449ENDARI ...................................287ENDEAVORRX ......................366ENDOCET .................................44ENDOFORM DERMAL TEMPLATE ............................225ENDOFORM DERMAL/FENESTRATED ..225ENDOMETRIN ...................... 450ENGERIX-B ............................446english plantain ............................ 8ENGYSTOL ............................ 367ENHERTU ...............................126ENJAYMO .............................. 283ENLITE GLUCOSE SENSOR .................................. 315ENLYTE ..................................246enovarx-baclofen ...................... 193enovarx-cyclobenzaprine hcl .... 388enovarx-diclofenac sodium ....... 196enovarx-ibuprofen .....................196enovarx-lidocaine hcl ............... 210enovarx-naproxen ..................... 196enovarx-tramadol ......................193enoxaparin sodium ......................63ENPRESSE-28 ........................ 176ENSKYCE ............................... 168ENSPRYNG ............................ 369ENSTILAR ..............................221entacapone ................................139entecavir ....................................149ENTERAGAM ........................248

ENTERO VU ...........................244ENTOCORT EC .....................179ENTRESTO .............................160ENTTY SPRAY ...................... 212ENTYVIO ................................269ENU NUTRITIONAL SHAKE .................................... 249ENU PRO3 PLUS ................... 249enulose ...................................... 270ENVARSUS XR ...................... 368enzadyne ....................................251enznonuty .................................. 219ENZOCLEAR ......................... 192EOVIST ................................... 244EPANED ....................................99EPCLUSA ................................149ephedrine sulfate .......................451ephedrine sulfate (pressors) ......451ephedrine sulfate-nacl ...............451EPICERAM .............................212epicoccum ..................................... 8epicoccum nigrum .........................8EPICORD ................................217EPICYN ................................... 215EPIDIOLEX ..............................66EPIDUO ...................................189EPIDUO FORTE .................... 189EPIFIX .....................................217EPIFIX MICRONIZED .........217EPIFOAM ............................... 216epinastine hcl ............................ 402epinephrine ............... 450, 451, 452epinephrine (anaphylaxis) ........ 450epinephrine hcl ......................... 402epinephrine hcl-dextrose ...........451epinephrine hcl-nacl ................. 451epinephrine pf ........................... 451epinephrine professional .......... 450epinephrine-dextrose ................ 452epinephrine-nacl ....................... 452EPINEPHRINESNAP-EMS .. 450EPINEPHRINESNAP-V ........450EPIPEN 2-PAK .......................450EPIPEN JR 2-PAK ................. 450epirubicin hcl ............................ 125EPISIL ..................................... 374EPISNAP ................................. 450EPITOL ..................................... 66EPIVIR .................................... 148EPIVIR HBV ...........................149eplerenone .................................103EPOGEN ................................. 288

epoprostenol sodium .................160EPRONTIA ............................... 66EPSOLAY ............................... 192eptifibatide ................................ 284EPZICOM ............................... 144eq aspirin adult low dose ............24eq aspirin low dose ..................... 24eq blood glucose test .................235eq nicotine .........................427, 428eq nicotine polacrilex ................427eq nicotine step 3 ...................... 427eq space chamber anti-static .... 352eq space chamber anti-static l .. 352eq space chamber anti-static m 352eq space chamber anti-static s ..352eql aspirin low dose .................... 24eql color lancets 21g .................316eql color lancets micro 33g ...... 316eql insulin syringe .....................337eql nicotine polacrilex .............. 428eql super thin lancets 30g ......... 316eql thin lancets 26g ...................316equacare jr ................................249EQUETRO .............................. 139ERAXIS ..................................... 90ERBITUX ................................ 121ergocal ...................................... 454ergocalciferol ............................454ergoloid mesylates .................... 427ERGOMAR ............................. 355ergotamine-caffeine .................. 354ERIVEDGE ............................. 121ERLEADA ...............................114erlotinib hcl ...............................121ERRIN ..................................... 175ERTACZO ...............................208ertapenem sodium .....................105ERWINASE .............................127ERWINAZE ............................ 127ery ............................................. 187ERYGEL ................................. 187ERYPED 200 ...........................307ERYPED 400 ...........................307ERY-TAB ................................ 307ERYTHROCIN LACTOBIONATE ..................307ERYTHROCIN STEARATE 307erythromycin ............. 187, 307, 402erythromycin base .....................307erythromycin ethylsuccinate ..... 307erythromycin lactobionate ........ 307ESBRIET ......................... 431, 432

472

ESCAVITE ..............................380ESCAVITE D .......................... 380escitalopram oxalate ...................72ESGIC ........................................22ESKATA ..................................215esmolol hcl ................................ 152esmolol hcl-sodium chloride .....152esomeprazole magnesium ......... 440esomeprazole sodium ................440esomeprazole strontium ............ 440ESPEROCT .............................279ESSENTIAL CARE JR ..........249est estrogens-methyltest ............ 264est estrogens-methyltest ds ........264est estrogens-methyltest hs ........264ESTARYLLA ..........................168estazolam .................................. 298ESTRACE ....................... 265, 449estradiol ............................ 265, 449estradiol valerate ...................... 265estradiol-norethindrone acet .... 264ESTRING ................................ 449ESTROGEL ............................ 265ESTROSTEP FE .....................176eszopiclone ................................299etesevimab .................................415ethacrynate sodium ...................252ethacrynic acid ..........................252ethambutol hcl .......................... 112ETHAMOLIN ......................... 371ethosuximide ............................... 70ethoxia .......................................189ethyl chloride ............................ 221ethynodiol diac-eth estradiol .... 168ETHYOL ................................. 135etodolac .......................................18etodolac er .................................. 18etomidate ...................................271etonogestrel-ethinyl estradiol ... 173ETOPOPHOS ......................... 131etoposide ................................... 131etravirine ...................................147EUCRISA ................................ 214EUFLEXXA ............................ 390EULEXIN ................................ 114EUTHYROX ........................... 434EVAMIST ................................265EVEKEO ..................................... 2EVEKEO ODT ............................2EVENCARE + BLOOD GLUCOSE TEST ....................235

EVENCARE BLOOD GLUCOSE TEST ....................235EVENCARE G2 TEST ...........235EVENCARE G3 TEST ...........235EVENCARE MINI GLUCOSE TEST ....................235EVENCARE PROVIEW GLUCOSE TEST ....................235EVENITY ................................ 261EVERLYWELL COVID-19 HOME TEST .......................... 242everolimus .........................123, 369EVERSENSE SENSOR/HOLDER ................316EVERSENSE SMART TRANSMITTER .....................316EVISTA ................................... 261EVKEEZA .................................94EVOCLIN ................................187EVOLUTION AUTOCODE...........................................235, 316EVOMELA ..............................133EVOTAZ ................................. 144EVOXAC ................................. 375EVRYSDI ................................ 395EVUSHELD ............................ 417EVZIO ....................................... 88EXACTECH R-S-G TEST .....235EXACTECH TEST ................ 235EXALGO ................................... 29EXCILON AMD DRAIN SPONGES ................................309EXEL COMFORT POINT INSULIN SYR .........................337EXEL COMFORT POINT PEN NEEDLE .........................337EXELDERM ........................... 208EXELON ................................. 422EXEM ...................................... 244exemestane ................................ 128EXFORGE ...............................100EXFORGE HCT .....................102EXJADE .................................... 86EXKIVITY .............................. 121EXONDYS 51 ..........................393EXPAREL ............................... 304EXSERVAN ............................ 393EXTAVIA ................................424EXTINA ...................................208EXTRANEAL ......................... 370EYLEA .....................................412EYSUVIS ................................. 409

EZ FLU SHOT-FLUCELVAX QUAD .............446E-Z JECT LANCET MICRO-THIN 33G ................................ 316E-Z JECT LANCET SUPER THIN 30G ................................ 316E-Z JECT LANCETS .............316E-Z JECT LANCETS 21G .... 316E-Z JECT LANCETS THIN 26G ........................................... 316EZALLOR SPRINKLE ........... 96ezetimibe ..................................... 97ezetimibe-rosuvastatin ................ 97ezetimibe-simvastatin ..................97E-Z-HD .................................... 244EZ-LETS LANCETS 21G ..... 316EZ-LETS LANCETS 26G ..... 316EZ-LETS LANCETS 28G ..... 316EZ-LETS LANCETS 30G ..... 316FA-8 ..........................................291fabb ........................................... 289FABIOR ...................................192FABRAZYME .........................255face shield full length ................331face shield full length/clear ...... 331FALESSA ................................ 168FALMINA ............................... 169famciclovir ................................ 150famotidine ................................. 439famotidine (pf) .......................... 439famotidine premixed ................. 439FANAPT .................................. 139FANAPT TITRATION PACK ....................................... 139FANATREX FUSEPAQ .......... 66FARESTON .............................114FARXIGA ..................................83FARYDAK .............................. 122FASENRA ................................. 59FASENRA PEN ........................ 59FASLODEX .............................129FASTEP COVID-19 RAPID TEST ........................................ 242favipiravir ................................. 151fa-vitamin b-6-vitamin b-12 ......289FAYOSIM ............................... 174fbl kit ......................................... 197FC FEMALE CONDOM ....... 308FC2 FEMALE CONDOM ..... 308febuxostat ..................................276FEIBA ...................................... 279felbamate .....................................69

473

FELBATOL ...............................69FELDENE ................................. 18felodipine er .............................. 156FEM PH ...................................448FEMARA .................................128FEMCAP ................................. 308FEMHRT .................................264FEMRING ............................... 449FEMYNOR ..............................169fenofibrate ...................................95fenofibrate micronized ................ 95fenofibric acid .............................95FENOGLIDE ............................ 95fenoprofen calcium ..................... 18FENORTHO ............................. 18FENOVAR ...............................197FENSOLVI (6 MONTH) ........259fentanyl ....................................... 32fentanyl citrate ................ 29, 30, 31fentanyl citrate (pf) ..................... 29fentanyl citrate pf ........................29fentanyl citrate-nacl ..............31, 32fentanyl cit-ropivacaine-nacl 26, 27fentanyl-bupivacaine-nacl .......... 27FENTORA .................................32feonyx ........................................292FERAHEME ........................... 294FERIVA 21/7 ...........................295FERIVAFA ..............................292ferocon ...................................... 292ferotrinsic ..................................292FERRALET 90 ........................295ferraplus 90 ...............................295FERREX 150 FORTE ............ 295FERREX 28 .............................295FERRIPROX .............................86FERRIPROX TWICE-A-DAY ............................................86FERRLECIT ........................... 294FERROCITE PLUS ............... 292FERRO-PLEX ........................ 292FERRO-PLEX HEMATINIC292ferrous sulfate ........................... 294ferumoxytol ............................... 294FETROJA ................................166FETZIMA ..................................74FETZIMA TITRATION ..........74fe-vite iron .................................294FEXMID .................................. 388FIASP .........................................78FIASP FLEXTOUCH .............. 78FIASP PENFILL ...................... 78

FIBERSOURCE HN .............. 249FIBRICOR ................................ 96FIBRYGA ................................279FIFTY50 GLUCOSE METER 2.0 ..............................316FIFTY50 GLUCOSE TEST 2.0 ............................................. 235FIFTY50 PEN NEEDLES ......337FIFTY50 SAFETY SEAL LANCETS ............................... 316FIFTY50 SUPERIOR COMFORT SYR .................... 338FIFTY50 UNILET LANCETS 33G ....................... 316FINACEA ................................ 214finapod ...................................... 208finasteride ......................... 222, 273FINE 30 ....................................316FINGERSTIX LANCETS ......316FINTEPLA ................................ 66FIORICET .................................22FIORICET/CODEINE .............26FIORINAL ................................ 22FIORINAL/CODEINE #3 ........26FIRAZYR ................................ 283FIRDAPSE .............................. 111fire ant ...........................................8FIRMAGON ............................130FIRMAGON (240 MG DOSE)...................................................130FIRST-BACLOFEN ............... 388FIRST-LANSOPRAZOLE .... 440FIRST-METRONIDAZOLE .104FIRST-MOUTHWASH BLM372FIRST-OMEPRAZOLE ........ 441FIRST-PROGESTERONE VGS .......................................... 450FIRVANQ ................................106FLAC ....................................... 413FLAGYL ..................................104FLAREX ..................................409flavoxate hcl ..............................444FLEBOGAMMA DIF ............ 415flecainide acetate ........................ 54FLECTOR ............................... 196FLEQSUVY .............................388FLEXBUMIN ..........................285FLEXICHAMBER ................. 352FLEXICHAMBER ADULT MASK/SMALL ....................... 352FLEXICHAMBER CHILD MASK/LARGE ....................... 352

FLEXICHAMBER CHILD MASK/SMALL ....................... 352flexipak ........................................17FLOLAN ..................................160flolipid .........................................96FLOMAX .................................273FLORIVA ........................360, 381FLORIVA PLUS .....................380FLOVENT DISKUS ................. 60FLOVENT HFA ........................60FLOWFLEX COVID-19 AG HOME TEST .......................... 242floxuridine .................................114FLUAD .....................................446FLUAD QUADRIVALENT ...446FLUARIX QUADRIVALENT...................................................446FLUBLOK QUADRIVALENT ................. 446FLUCAINE ............................. 404FLUCELVAX QUADRIVALENT ................. 446fluconazole ..................................91fluconazole in sodium chloride ...91flucytosine ................................... 91fludarabine phosphate .............. 114fludeoxyglucose f 18 ..................232fludrocortisone acetate ............. 182FLULAVAL QUADRIVALENT ................. 446flumazenil ....................................87FLUMIST QUADRIVALENT...................................................446flunisolide ................................. 392fluocinolone acetonide ......204, 414fluocinolone acetonide body ..... 204fluocinolone acetonide scalp .... 204fluocinonide .............................. 204fluocinonide emulsified base .....204FLUOPAR ............................... 221FLUORABON .........................360fluorescein sodium/benoxinate . 404fluorescein-benoxinate ..............404FLUORESCITE ......................404FLUORIDEX .......................... 373FLUORIDEX DAILY RENEWAL ..............................373FLUORIDEX ENHANCED WHITENING ..........................373FLUORIDEX SENSITIVITY RELIEF ................................... 373FLUORIMAX 5000 ................ 374

474

FLUORIMAX 5000 SENSITIVE ............................. 373FLUOR-I-STRIPS A.T. ..........404fluoritab .................................... 360fluorodopa f 18 ......................... 231fluorometholone ........................409FLUOROPLEX .......................197fluorouracil ............... 115, 197, 198fluovix ....................................... 222fluovix plus ................................222fluoxetine hcl .........................72, 73fluoxetine hcl (pmdd) ................ 426fluphenazine decanoate .............142fluphenazine hcl ........................ 142FLURA-DROPS ......................360flurandrenolide ......................... 204FLURA-SAFE ......................... 404flurazepam hcl .......................... 298flurbiprofen ................................. 18flurbiprofen sodium .................. 406flutamide ................................... 114fluticasone furoate-vilanterol ..... 56fluticasone propionate ...... 204, 392fluticasone propionate hfa .......... 60fluticasone-salmeterol .................56fluvastatin sodium .......................96fluvastatin sodium er ...................96fluvoxamine maleate ................... 73fluvoxamine maleate er ...............73FLUZONE HIGH-DOSE .......446FLUZONE HIGH-DOSE QUADRIVALENT ................. 446FLUZONE QUADRIVALENT ................. 446FML ......................................... 409FML FORTE ...........................409FML LIQUIFILM .................. 409FOAMIL ..................................420FOCALIN ....................................5FOCALIN XR ............................. 5folamax ..................................... 378folamed dha .............................. 378folate ......................................... 291folbee .........................................289folbee plus .................................375FOLBEE PLUS CZ ................ 377FOLBIC ................................... 246FOLBIC RF .............................246FOLDITAM ............................ 289FOLET DHA ...........................385FOLET ONE ........................... 385FOLGARD .............................. 289

FOLGARD OS ........................ 377FOLGARD RX ........................289folic acid ................................... 291folic d3 ...................................... 290folica-v ...................................... 377folic-k ........................................ 377FOLI-D .................................... 290FOLIFLEX ..............................378folika-d ......................................290folika-t .......................................375folika-v ...................................... 379folinic-plus ................................ 290folite .......................................... 290FOLITIN-Z ............................. 378FOLIVANE-F ......................... 294FOLIVANE-OB ...................... 382FOLIVANE-PLUS ..................292FOLIXAPURE ........................290FOLLISTIM AQ .....................260FOLOTYN ...............................115folplex 2.2 ................................. 290FOLTABS 800 .........................290FOLTANX ...............................246FOLTANX RF ........................ 246FOLTRATE ............................ 287FOLTREXYL ......................... 290foltrin ........................................ 292FOLTX .....................................246folvik-d ...................................... 290FOLVITE-D ............................ 290FOLVITE-FE ..........................293fomepizole ................................... 87fondaparinux sodium .................. 64FORA 6 CONNECT ............... 235FORA BLOOD GLUCOSE TEST ........................................ 235FORA D10 2-IN-1 MONITOR .............................. 309FORA D15G 2-IN-1 MONITOR .............................. 309FORA D15G BLOOD GLUCOSE TEST ....................235FORA D20 2-IN-1 MONITOR .............................. 309FORA D20 BLOOD GLUCOSE TEST ....................236FORA D40 GLUCOSE/PRESSURE .........309FORA D40/G31 BLOOD GLUCOSE ...............................236FORA D40G GLUCOSE/PRESSURE .........309

FORA G20 BLOOD GLUCOSE SYSTEM ............. 316FORA G20 BLOOD GLUCOSE TEST ....................236FORA G30/PREM V10 GLUCOSE TEST ....................236FORA G30A BLOOD GLUCOSE SYSTEM ............. 316FORA GD20 BLOOD GLUCOSE SYSTEM ............. 316FORA GD20 TEST .................236FORA GD50 BLOOD GLUCOSE SYSTEM ............. 316FORA GD50 BLOOD GLUCOSE TEST ....................236FORA GTEL BLOOD GLUCOSE SYSTEM ............. 316FORA GTEL BLOOD GLUCOSE TEST ....................236FORA LANCETS ................... 316FORA PREMIUM V10 BLE SYSTEM ..................................316FORA TEST N' GO MONITOR .............................. 316FORA TN'G ADVANCE PRO ..................................236, 330FORA TN'G VOICE .............. 316FORA TN'G/TN'G VOICE ... 236FORA V10 BLOOD GLUCOSE SYSTEM ............. 316FORA V10 BLOOD GLUCOSE TEST ....................236FORA V10/V12/D10/D20 TEST ........................................ 316FORA V12 BLOOD GLUCOSE SYSTEM ............. 317FORA V12 BLOOD GLUCOSE TEST ....................236FORA V20 BLOOD GLUCOSE SYSTEM ............. 317FORA V20 BLOOD GLUCOSE TEST ....................236FORA V30A BLOOD GLUCOSE SYSTEM ............. 317FORA V30A BLOOD GLUCOSE TEST ....................236FORACARE GD40 MONITOR .............................. 317FORACARE GD40 TEST ..... 236FORACARE PREMIUM V10...................................................317

475

FORACARE PREMIUM V10 TEST ........................................ 236FORACARE TEST N GO MONITOR .............................. 317FORACARE TEST N GO TEST ........................................ 236FORANE ................................. 273foraxa ........................................225fordagel .....................................210FORFIVO XL ........................... 71formaldehyde ............................ 143formoterol fumarate ....................57FORTAMET ............................. 75FORTAVIT ............................. 378FORTAZ ..........................165, 166FORTEO ................................. 260FORTESTA ...............................47FORTISCARE G1 TEST STRIP .......................................236FORTISCARE T1 GLUCOSE SYSTEM ............. 317FORTISCARE TEST .............236FOSAMAX .............................. 254FOSAMAX PLUS D ............... 254fosamprenavir calcium ............. 146fosaprepitant dimeglumine ......... 90foscarnet sodium .......................149FOSCAVIR ............................. 149fosfomycin tromethamine ..........109fosinopril sodium ........................ 99fosinopril sodium-hctz ................ 99fosphenytoin sodium ................... 70FOSRENOL ............................ 270FOSTEUM ...............................246FOSTEUM PLUS ................... 246FOTIVDA ................................123FOVEX .................................... 246FRAGMIN .................................63FREAMINE III .......................397freds pharmacy autolet lancing 317freds pharmacy unifine pentip+338freds pharmacy unifine pentips .338freds pharmacy unilet lanc 28g 317freds pharmacy unilet lanc 30g 317freedom adaptaderm .................420freedom derma serum ............... 420FREEDOM DERMA-D ..........420FREEDOM DERMA-N ..........420FREESTYLE FREEDOM LITE .........................................317FREESTYLE INSULINX TEST ........................................ 236

FREESTYLE LANCETS .......317FREESTYLE LIBRE 14 DAY READER ................................. 317FREESTYLE LIBRE 14 DAY SENSOR .................................. 317FREESTYLE LIBRE 2 READER ................................. 317FREESTYLE LIBRE 2 SENSOR .................................. 317FREESTYLE LIBRE READER ................................. 317FREESTYLE LIBRE SENSOR SYSTEM .................317FREESTYLE LITE ................ 317FREESTYLE LITE TEST .....236FREESTYLE PRECISION INS SYR ...................................338FREESTYLE PRECISION NEO SYSTEM ........................ 317FREESTYLE PRECISION NEO TEST .............................. 236FREESTYLE TEST ............... 236FREESTYLE UNISTICK II LANCETS ............................... 317fresenius propoven ....................271FROTEK ................................. 196FROVA .................................... 355frovatriptan succinate ...............355FUL-GLO ................................ 405full spectrum b/vitamin c .......... 375FULPHILA ..............................291fulvestrant ................................. 129fungimez ....................................194furosemide .................................252furosemide in sodium chloride ..252fusarium ........................................ 8FUSION PLUS ........................ 293FUSION SPRINKLES ............294FUZEON ..................................145FYARRO ................................. 123FYAVOLV ...............................264FYCOMPA ................................64FYREMADEL .........................255gaba .......................................... 397GABADONE ........................... 246gabapentin .................................. 66gabapentin-naproxen cmpd kit . 197GABITRIL ................................ 69GABLOFEN ....................388, 389GADAVIST ............................. 244GALAFOLD ............................255galantamine hydrobromide .......422

galantamine hydrobromide er .. 422GALAXTRA ........................... 248gallium citrate ga 67 .................232gallium ga 68 psma-11 ............. 232GALZIN ...................................365GAMASTAN ........................... 415GAMIFANT ............................ 369GAMMACORE ...................... 349GAMMACORE SAPPHIRE . 349GAMMACORE SAPPHIRE 31-DAY .................................... 349GAMMACORE SAPPHIRE D ............................................... 349GAMMACORE SAPPHIRE REFILL KIT ........................... 349GAMMAGARD ...................... 415GAMMAGARD S/D LESS IGA ...........................................416GAMMAKED ......................... 416GAMMAPLEX ....................... 416GAMUNEX-C ......................... 416ganciclovir ................................ 149ganciclovir sodium ....................149ganirelix acetate ....................... 255GARDASIL 9 .......................... 446GASTROCROM .....................267GASTROGRAFIN ..................245gatifloxacin ............................... 402GATTEX ................................. 268GAVILYTE-C .........................300GAVILYTE-G .........................301GAVILYTE-N WITH FLAVOR PACK ..................... 301GAVRETO .............................. 124GAZYVA ................................. 117ge100 blood glucose system ......317ge100 blood glucose test ...........236geametdray ................................209GEBAUERS PAIN EASE ...... 221GEBAUERS SPRAY AND STRETCH ............................... 221GELCLAIR ............................. 374GELFILM ....................... 296, 411GEL-FLOW ............................ 295GELFOAM ..............................296GELFOAM COMPRESSED SIZE 100 .................................. 296GELFOAM DENTAL PACK SIZE 4 ...................................... 296GELFOAM SPONGE ............ 296GELFOAM SPONGE SIZE 100 ............................................ 296

476

GELFOAM SPONGE SIZE 200 ............................................ 296GELFOAM SPONGE SIZE 50 .............................................. 296GELFOAM-JMI POWDER .. 296GELFOAM-JMI SPONGE ....296GELNIQUE .............................443GEL-ONE ................................390GELSYN-3 ...............................390GELX ....................................... 375gemcitabine hcl .........................115gemfibrozil .................................. 96GEMMILY ..............................169GEMTESA .............................. 444gen7t ......................................... 210gen7t plus ..................................219GENADUR .............................. 212GENERESS FE .......................169generlac .................................... 270GENGRAF .............................. 366GENICIN VITA-D ..................290GENICIN VITA-Q ................. 379GENICIN VITA-S .................. 375GENOTROPIN ....................... 256GENOTROPIN MINIQUICK...................................................256GENTAK ................................. 402gentamicin in saline ....................13gentamicin sulfate .......13, 193, 403GENTEEL BUTTERFLY TOUCH LANCET .................. 317GENTLE-LET GP LANCETS ............................... 317GENTLE-LET LANCETS .... 317GENTLE-LET PLATFORMS...................................................317GENULTIMATE TEST .........236GENVISC 850 ......................... 391GENVOYA ..............................144GEODON .................................139german cockroach .........................8ght blood glucose monitor ........ 317ght test .......................................236GIALAX .................................. 301GIANVI ................................... 169GIAPREZA ............................. 452GILENYA ................................430GILOTRIF .............................. 121GILPHEX TR ......................... 185GIMOTI ...................................268GIVLAARI ..............................276GLASSIA .................................430

glatiramer acetate .....................425GLATOPA ...............................425GLEEVEC ...............................120GLEOLAN .............................. 229GLEOSTINE ...........................133GLIADEL WAFER ................ 133glimepiride ..................................84glipizide .......................................84glipizide er .................................. 84glipizide xl ...................................84glipizide-metformin hcl ...............84global ease inject pen needles .. 338global easy glide insulin syr ..... 338global easy glide pen needles ... 338global inject ease insulin syr .... 338global inject ease lancets 28g ...317global inject ease lancets 30g ...318global insulin syringes ..............338GLOPERBA ............................276GLUCAGEN DIAGNOSTIC 229GLUCAGEN HYPOKIT ......... 76glucagon emergency ................... 76glucagon hcl (diagnostic) ......... 230GLUCO PERFECT 3 METER ....................................318GLUCO PERFECT 3 TEST ..237GLUCOCARD 01 BLOOD GLUCOSE ...............................318GLUCOCARD 01 SENSOR PLUS ........................................ 237GLUCOCARD 01-MINI GLUCOSE ...............................318GLUCOCARD EXPRESSION MONITOR ....318GLUCOCARD EXPRESSION TEST ..............237GLUCOCARD SHINE ...........318GLUCOCARD SHINE CONNEX ................................. 318GLUCOCARD SHINE EXPRESS ................................ 318GLUCOCARD SHINE TEST237GLUCOCARD SHINE XL .... 318GLUCOCARD VITAL MONITOR .............................. 318GLUCOCARD VITAL TEST237GLUCOCARD X-METER .... 318GLUCOCARD X-SENSOR ...237GLUCOCOM AUTOLINK TELEMONITOR ....................318GLUCOCOM BLOOD GLUCOSE MONITOR ..........318

GLUCOCOM LANCETS 28G ........................................... 318GLUCOCOM LANCETS 30G ........................................... 318GLUCOCOM LANCETS 33G ........................................... 318GLUCOCOM MONITOR .....318GLUCOCOM TEST ...............237GLUCONAVII BLOOD GLUCOSE SYS ...................... 318GLUCONAVII BLOOD GLUCOSE TEST ....................237GLUCOPRO INSULIN SYRINGE ................................ 338glucose meter test ......................237GLUCOTROL .......................... 84GLUCOTROL XL ....................84GLUMETZA ............................. 76glutaraldehyde .......................... 143glutathione ................................ 397glyburide ..................................... 84glyburide micronized .................. 84glyburide-metformin ................... 84GLYCATE ...............................442glycine ...............................274, 397glycine urologic ........................ 275glycolic acid ..............................200GLYCOPHOS .........................361glycopyrrolate ...........................442glycopyrrolate pf .......................442GLYDO ....................................211GLYGEST ............................... 246GLYNASE ................................. 84GLYRX-PF ..............................442GLYSET .................................... 75GLYTACTIN BETTERMILK 15 .................. 249GLYTACTIN BETTERMILK DE-LITE ......249GLYTACTIN BUILD 10PE .. 249GLYTACTIN BUILD 20/20 .. 249GLYTACTIN BUILD 20/20 PKU ..........................................249GLYTACTIN BURST ............249GLYTACTIN COMPLETE 10PE ......................................... 249GLYTACTIN RESTORE 10 . 249GLYTACTIN RESTORE 5 ... 249GLYTACTIN RESTORE LITE 10 ....................................249GLYTACTIN RESTORE LITE 10PE ...............................249

477

GLYTACTIN RTD 10 ............249GLYTACTIN RTD 15 ............249GLYTACTIN RTD LITE 15 . 249GLYTACTIN SWIRL 15PE ..250GLYXAMBI ..............................83gnp adult aspirin low strength ....24gnp aspirin .................................. 24gnp aspirin low dose ...................24gnp clickfine pen needles .......... 338GNP EASY TOUCH GLUCOSE METER ............... 318gnp easy touch glucose test .......237gnp folic acid ............................ 291gnp insulin syringe ....................338gnp insulin syringes .................. 338gnp insulin syringes 28gx1/2" ...338gnp insulin syringes 29gx1/2" ...338gnp insulin syringes 30gx5/16" .338gnp insulin syringes 31gx5/16" .338gnp lancets 21g ......................... 318gnp lancets micro thin 33g ....... 318gnp lancets super thin 30g ........318gnp lancets thin .........................318gnp lancets thin 26g ..................318gnp nicotine .............................. 428gnp nicotine mini ...................... 428gnp nicotine polacrilex ............. 428gnp prenatal ..............................382gnp sterile lancets 28g .............. 318gnp sterile lancets 30g .............. 318gnp sterile lancets 33g .............. 318GNP TRUE METRIX AIR METER ....................................319GNP TRUE METRIX GLUCOSE METER ............... 319GNP TRUE METRIX GLUCOSE STRIPS ................237GNP TRUETRACK SMART SYSTEM ..................................237GNP TRUETRACK TEST STRIPS .................................... 237gnp ulticare pen needles ........... 338GNP ULTIGUARD SAFEPACK NEEDLE ........... 339gnp ultra com insulin syringe ... 339GOCOVRI ...............................136GOJJI BLOOD GLUCOSE TEST ........................................ 237GOJJI BLOOD TEST STRIP/LANCETS ...................237GOJJI CONTROL LEVEL 1 331

GOJJI MULTI-FUNCTIONAL SYSTEM...........................................330, 331GOJJI STERILE LANCETS 319goldenrod ......................................8GOLYTELY ............................301GONAL-F ................................260GONAL-F RFF ....................... 260GONAL-F RFF REDIJECT ..260GONITRO ................................. 50goodsense aspirin ....................... 24goodsense aspirin adult low st ....24goodsense aspirin low dose ........ 24goodsense blood glucose .. 237, 319goodsense clickfine pen needle . 339goodsense color lancets 33g .....319goodsense lancets 26g univ .......319goodsense lancets 30g .............. 319goodsense lancets 30g univ .......319goodsense lancets 33g .............. 319goodsense lancets 33g univ .......319goodsense nicotine ....................428GOODSENSE PEN NEEDLE PENFINE .................................339goprelto .....................................391GORDOFILM .........................209GRAFIX CORE 1.5CM X 2CM ..........................................217GRAFIX CORE 16MM ..........217GRAFIX CORE 2CM X 3CM...................................................217GRAFIX CORE 3CM X 4CM...................................................217GRAFIX CORE 5CM X 5CM...................................................217GRAFIX PRIME 1.5CM X 2CM ..........................................217GRAFIX PRIME 16MM ........217GRAFIX PRIME 2CM X 3CM ..........................................217GRAFIX PRIME 3CM X 4CM ..........................................217GRAFIX PRIME 5CM X 5CM ..........................................217GRAFIX XC 7.5CM X 15CM217GRALISE ................................ 426granisetron hcl ............................88GRANIX .................................. 291grass pollen(k-o-r-t-swt vern) .......8GRASTEK ...................................8GREEN GLO LISSAMINE GREEN .................................... 405

griseofulvin microsize .................91griseofulvin ultramicrosize ......... 91guaifenesin-dm ..........................185guanendrux ............................... 209guanfacine hcl ...........................102guanfacine hcl er .......................... 1guanidine hcl ............................ 111GUARDIAN CONNECT TRANSMITTER .....................319GUARDIAN LINK 3 TRANSMITTER .....................319GUARDIAN REAL-TIME CHARGER ..............................319GUARDIAN REAL-TIME REPLACE PED ...................... 319GUARDIAN REAL-TIME TEST PLUG ............................ 319GUARDIAN SENSOR (3) ......319guardian sensor 3 ..................... 319GVOKE HYPOPEN 1-PACK . 76GVOKE HYPOPEN 2-PACK . 76GVOKE KIT ............................. 77GVOKE PFS ............................. 77GYNAZOLE-1 ........................ 448HABITROL .............................428hackberry ...................................... 8HAEGARDA ........................... 283HAEMOLANCE PLUS ..........319HAEMOLANCE PLUS HIGH FLOW .......................... 319HAEMOLANCE PLUS LOW FLOW ...................................... 319HAEMOLANCE PLUS MAX FLOW ...................................... 319HAEMOLANCE PLUS PEDIATRIC FLOW ...............319HAILEY 1.5/30 ....................... 169HAILEY 24 FE ....................... 169HAILEY FE 1.5/30 ................. 169HAILEY FE 1/20 .................... 169HALAVEN .............................. 131halcinonide ............................... 204HALCION ............................... 298HALDOL ................................. 140HALDOL DECANOATE ...... 140halobetasol propionate ............. 204HALOG ................................... 204haloperidol ................................140haloperidol decanoate .............. 140haloperidol lactate ....................140HALUCORT ........................... 212haproderm .................................225

478

HARMONY BLOOD GLUCOSE TEST ....................237HARVONI ............................... 149HAVRIX .................................. 447haxchlo ......................................200HCU EASY ..............................250HCU EXPRESS 15 PLUS+ .... 250HCU EXPRESS 20 PLUS+ .... 250HEALON ................................. 411HEALON DUET PRO ........... 411HEALON GV .......................... 411HEALON GV PRO .................411HEALON PRO ........................411HEALON5 ............................... 411HEALON5 PRO ......................411HEALTH CARE LANCING DEVICE ...................................319healthwise insulin syr/needle ....339healthwise micron pen needles . 339healthwise mini pen needles ..... 339healthwise pen needles ..............339healthwise short pen needles .... 339healthwise unifine pentips .........339healthy accents lancing device . 319healthy accents unifine pentip ...339healthy accents unilet lancets ... 319HEATHER .............................. 175h-e-b aspirin ................................24h-e-b incontrol adv lancing .......319h-e-b incontrol lancets 28g .......319h-e-b incontrol lancets 30g .......319h-e-b incontrol lancets 33g .......319h-e-b incontrol pen needles .......339H-E-B INCONTROL UNIFINE PENTIP ..................339HECTOROL ........................... 258HELIDAC THERAPY ........... 442HELIXATE FS ........................279HEMABATE ........................... 414HEMADY ................................ 179HEMANGEOL ....................... 153hematinic plus vit/minerals .......293hematinic/folic acid .................. 294HEMATOGEN ....................... 293HEMATOGEN FA ................. 293HEMATOGEN FORTE .........293HEMATRON-AF ....................293hemetab .....................................295HEMLIBRA ............................ 276HEMMOREX-HC .................... 49HEMOCYTE PLUS ............... 293HEMOCYTE-F .......................294

hemocyte-plus ........................... 293HEMOFIL M .......................... 279HEPAGAM B ..........................416heparin (porcine) in nacl ............ 62heparin lock flush ....................... 62heparin sod (porcine) in d5w ......62heparin sodium (porcine) ............63heparin sodium (porcine) pf ....... 63heparin sodium lock flush ...........63HEPLISAV-B ..........................447hepmed ........................................63HEPSERA ............................... 149HERCEPTIN ...........................118HERCEPTIN HYLECTA ......126HERZUMA ............................. 118HESPAN .................................. 284hetastarch-nacl ......................... 284HETLIOZ ................................300HETLIOZ LQ ......................... 300HEXATRIONE ....................... 179HEXTEND ...............................284HIBERIX ................................. 444HIDEX 6-DAY ........................ 179HIPREX ...................................109HISTATROL ...........................230hixdefrima ................................. 194HIZENTRA ............................. 416hm aspirin ................................... 24hm aspirin ec low dose ............... 24HM EMBRACE TALK SYSTEM ..................................319hm folic acid ............................. 291hm nicotine ................................428hm nicotine polacrilex .............. 428HM ULTICARE INSULIN SYRINGE ................................ 339HM ULTICARE MINI PEN NEEDLES ................................339HM ULTICARE SHORT PEN NEEDLES .......................339HOMACTIN AA PLUS ......... 250HOMATROPAIRE ................ 401home pap kit ..............................237homocysteine formula ...............290honey bee treatment ...................... 8honey bee venom ...........................8HONEY BEE VENOM PROTEIN .................................... 8HORIZANT .............................427hormone cr heavy base niosomes ................................... 420hormone cream base niosomes . 420

horse epithelium ............................8HPR PLUS ...............................212HPR PLUS HYDROGEL ...... 212HUMALOG .........................78, 79HUMALOG JUNIOR KWIKPEN .................................78HUMALOG KWIKPEN .......... 78HUMALOG MIX 50/50 ........... 79HUMALOG MIX 50/50 KWIKPEN .................................78HUMALOG MIX 75/25 ........... 79HUMALOG MIX 75/25 KWIKPEN .................................79HUMAN ALBUMIN GRIFOLS ................................ 285HUMATE-P .............................279HUMATIN .................................13HUMATROPE ........................256HUMIRA ................................... 15HUMIRA PEDIATRIC CROHNS START .....................15HUMIRA PEN .......................... 15HUMIRA PEN-CD/UC/HS STARTER ................................. 15HUMIRA PEN-PEDIATRIC UC START ................................ 15HUMIRA PEN-PS/UV/ADOL HS START .................................15HUMIRA PEN-PSOR/UVEIT STARTER ................................. 15HUMULIN 70/30 ...................... 79HUMULIN 70/30 KWIKPEN ..79HUMULIN N .............................79HUMULIN N KWIKPEN ........79HUMULIN R .............................79HUMULIN R U-500 (CONCENTRATED) ................79HUMULIN R U-500 KWIKPEN .................................79HW EMBRACE PRO GLUCOSE METER ............... 319HW EMBRACE PRO GLUCOSE TEST ....................237HW EMBRACE TALK BLOOD GLUCOSE ............... 319HW EMBRACE TALK GLUCOSE TEST ....................237HYALGAN ..............................391HYCAMTIN ....................134, 135HYCLODEX ........................... 215HYCODAN ..............................185hydralazine hcl ..................103, 104

479

HYDREA ................................. 128HYDRO 40 .............................. 207hydrochlorothiazide ..................253hydrocod polst-cpm polst er ..... 186hydrocodone bitartrate er ...........32hydrocodone bit-homatrop mbr 185hydrocodone-acetaminophen ......27hydrocodone-ibuprofen ...............27hydrocortisone ............ 48, 179, 205hydrocortisone (perianal) ...........49hydrocortisone ace-pramoxine.............................................48, 216hydrocortisone acetate ................49hydrocortisone butyr lipo base . 204hydrocortisone butyrate ............204HYDROCORTISONE IN ABSORBASE .......................... 205hydrocortisone valerate ............ 205hydrocortisone-acetic acid ....... 414hydrocortisone-iodoquinol ....... 194hydrocort-pramoxine (perianal) . 48HYDROFERA BLUE 4"X4" 225HYDROFERA BLUE 6"X6" 225HYDROFERA BLUE FOAM DRESSING ..............................225HYDROFERA BLUE FOAM/TUNNELING .............225HYDROFERA BLUE MRF DRESSING ..............................225HYDROFERA BLUE READY FOAM .......................225hydrogen peroxide .................... 143hydromet ................................... 185hydromorphone hcl ...............32, 33hydromorphone hcl er .................32hydromorphone hcl pf ...........32, 33hydromorphone hcl-nacl .33, 34, 35hydroquinone ............................ 206hydroxocobalamin acetate ........288hydroxychloroquine sulfate...........................................110, 111hydroxyprogesterone caproate...........................................134, 421hydroxyurea .............................. 128hydroxyzine hcl ........................... 52hydroxyzine pamoate .................. 52hygel ..........................................225HYLAFEM ..............................367HYLAGUARD ........................ 212HYLATOPIC PLUS ...............212hylavite ......................................376hylazinc ..................................... 378

HYLENEX ...............................366HYMOVIS ...............................391HYOPHEN .............................. 110hyoscyamine sulfate .......... 438, 439hyoscyamine sulfate er ..............438hyoscyamine sulfate sl .............. 438hyosyne ......................................439HYPERHEP B ........................ 416HYPERLYTE-CR .................. 359HYPERRAB ............................416HYPERRHO S/D .................... 416HYPERSAL .............................185HYPERTENSA ....................... 246HYPERTET ............................ 416hypnosom .................................. 246HYPOCYN ...................... 208, 215HYPOLANCE AST LANCING ............................... 319HYQVIA ..................................417HYRONAN ..............................390HYSINGLA ER ........................ 35HY-VEE LANCETS ...............319hy-vee thin lancets .................... 320HYZAAR ................................. 101ibandronate sodium .................. 254IBRANCE ................................129IBSRELA .................................268IBU ............................................. 19IBUPAK .....................................19ibuprofen .....................................19ibuprofen lysine .......................... 19ibuprofen-famotidine .................. 17ibutilide fumarate ........................54IC GREEN ...............................230ICAR-C PLUS .........................293icatibant acetate ........................283ICLEVIA ................................. 174ICLOFENAC CP .................... 197ICLUSIG ................................. 120icosapent ethyl ............................ 94ID NOW COVID-19 ............... 242ID NOW COVID-19 CONTROL .............................. 242ID NOW INFLUENZA A & B 2 ................................................ 242ID NOW INFLUENZA A & B 2 CONTR .................................242ID NOW RSV ..........................242ID NOW RSV CONTROL SWAB .......................................242ID NOW STREP A2 ............... 242

ID NOW STREP A2 CONTROL SWAB ................. 242IDAMYCIN PFS .....................126idarubicin hcl ............................126IDELVION .............................. 279IDHIFA ....................................130IFEREX 150 FORTE ............. 293IFEX .........................................133ifosfamide ..................................133IGALMI ...................................300IGLUCOSE MONITORING SYSTEM ..................................320IGLUCOSE TEST STRIPS ... 237IHEALTH COVID-19 RAPID TEST ........................................ 242ILARIS .......................................16ILEVRO ...................................406iliderm .......................................212ILLUCCIX CONFIGURATION A ............232ILLUCCIX CONFIGURATION B ............232ILUMYA ..................................199ILUVIEN ................................. 409imatinib mesylate ...................... 120IMBRUVICA .................. 120, 121IMCIVREE ................................. 4imdevimab .................................415IMFINZI ..................................119imioxia ...................................... 194imipenem-cilastatin ...................105imipramine hcl ............................ 75imipramine pamoate ................... 75imiquimod ................................. 209imiquimod pump ....................... 209IMITREX ........................ 355, 356IMITREX STATDOSE REFILL ................................... 356IMITREX STATDOSE SYSTEM ..................................356IMLYGIC ................................133IMOGAM RABIES-HT ......... 416IMOVAX RABIES ................. 447IMPAVIDO ............................. 104IMPEKLO ............................... 205IMPOYZ ..................................205IMURAN ..................................371IMVEXXY MAINTENANCE PACK ....................................... 449IMVEXXY STARTER PACK...................................................449IN TOUCH .............................. 320

480

IN TOUCH BLOOD GLUCOSE TEST ....................237IN TOUCH STERILE LANCETS 30G ....................... 320INATAL GT ............................ 382inavix ...........................................17INBRIJA ..................................136INCASSIA ............................... 175IN-CHECK DIAL FLOW TRAINER ................................350IN-CHECK INSPIRATORY FLOW MTR ............................350INCRELEX ............................. 258INCRUSE ELLIPTA ................58indapamide ............................... 253INDERAL LA ......................... 153INDERAL XL ......................... 153INDICAID COVID-19 RAPID TEST .......................... 242indigo carmine .......................... 230indium in 111 dtpa .................... 231indium in 111 oxyquinoline ...... 232INDOCIN ...................................19indocyanine green .....................230indomethacin ...............................19indomethacin er .......................... 19indomethacin sodium .................. 19INFANRIX .............................. 436INFASURF .............................. 432INFED ......................................294INFINITY BLOOD GLUCOSE SYSTEM ............. 320INFINITY BLOOD GLUCOSE TEST ....................237INFINITY VOICE ..........237, 320INFLAMMACIN ...................... 17INFLATHERM .........................17INFLECTRA ...........................271infliximab .................................. 271INFUGEM ............................... 115INFUMORPH 200 .................... 35INFUMORPH 500 .................... 35INFUVITE ADULT ................379INFUVITE PEDIATRIC ....... 381INGREZZA ............................. 423INJECTAFER .........................294INLYTA ...................................135INNOPRAN XL ...................... 153INOVA ..................................... 189INOVA 4/1 ACNE CONTROL THERAPY ..........189

INOVA 8/2 ACNE CONTROL THERAPY ..........189INPEN 100-BLUE-LILLY-HUMALOG .............................339INPEN 100-BLUE-NOVOLOG-FIASP .................339INPEN 100-GREY-LILLY-HUMALOG .............................339INPEN 100-GREY-NOVOLOG-FIASP .................339INPEN 100-PINK-LILLY-HUMALOG .............................339INPEN 100-PINK-NOVOLOG-FIASP .................339INQOVI ................................... 126INREBIC ................................. 130INSPIRACHAMBER/LARGE ................................................352INSPIRACHAMBER/MEDIUM ...............................................352INSPIRACHAMBER/MOUTHPIECE ................................... 352INSPIRACHAMBER/SMALL ................................................353INSPIREASE .......................... 353INSPIREASE RESERVOIR BAGS ....................................... 353INSPRA ................................... 103insulin asp prot & asp flexpen .... 79insulin aspart .............................. 79insulin aspart flexpen ..................79insulin aspart penfill ................... 79insulin aspart prot & aspart ....... 79insulin glargine ...........................79insulin glargine solostar ............. 79insulin glargine-yfgn ...................79insulin lispro ............................... 80insulin lispro (1 unit dial) ........... 80insulin lispro junior kwikpen ...... 80insulin lispro prot & lispro ......... 80insulin syringe ...........................340insulin syringe/needle ............... 340insulin syringe-needle u-100 .....340INSUL-TOTE ..........................320INSUL-TOTE JR ....................320insupen pen needles .................. 340INSUPEN SENSITIVE .......... 340INSUPEN ULTRAFIN ...........340INTEGRA F ............................ 294INTEGRA PLUS .................... 293INTEGRILIN ..........................284INTELENCE ...........................147

INTELISWAB COVID-19 RAPID TEST .......................... 242INTERMEZZO .......................299INTRALIPID .......................... 398INTRAROSA .......................... 448INTRINSI B12-FOLATE .......290INTRON A .............................. 128INTROVALE .......................... 174INTUNIV ..................................... 1INVANZ ...................................105INVEGA .................................. 140INVEGA HAFYERA ..............140INVEGA SUSTENNA ............ 140INVEGA TRINZA ..................140INVELTYS ..............................409INVIRASE ...............................146INVOKAMET ...........................83INVOKAMET XR .................... 83INVOKANA .............................. 83iodine strong ............................. 360iodine tincture ...........................143IODOFLEX ............................. 143iodoquimez-hc ...........................194iodoquinol-hc-aloe polysacch ...194iodoquinol-hydrocortisone-aloe194IODOSORB .............................143iohexol .......................................245IONOSOL-MB IN D5W .........358IONSYS ..................................... 35IOPIDINE ................................407IPOL .........................................447ipratropium bromide ...........58, 392ipratropium-albuterol ................. 56irbesartan ..................................101irbesartan-hydrochlorothiazide 101IRESSA ....................................121irinotecan hcl ............................ 135iron supplement ........................ 294iron supplement childrens .........294IROSPAN 24/6 ........................ 293IS 24/6 ...................................... 293ISENTRESS ............................ 146ISENTRESS HD ..................... 146ISIBLOOM ..............................169isoflurane .................................. 273ISOLYTE-P IN D5W ............. 358ISOLYTE-S ............................. 359ISOLYTE-S PH 7.4 ................ 359isoniazid ....................................112isoproterenol hcl .........................57isoproterenol-sodium chloride ....57ISOPTO ATROPINE ............. 401

481

ISOPTO CARPINE ................ 401ISORDIL TITRADOSE ...........50isosorb dinitrate-hydralazine ....160isosorbide dinitrate .....................50isosorbide mononitrate ............... 51isosorbide mononitrate er ...........51isosulfan blue ............................ 230isotretinoin ................................192ISOVACTIN AA PLUS ..........250ISOVUE-200 ............................245ISOVUE-250 ............................245ISOVUE-300 ............................245ISOVUE-370 ............................245ISOVUE-M 200 .......................245ISOVUE-M 300 .......................245isoxsuprine hcl .......................... 160isradipine .................................. 156ISTALOL .................................400ISTODAX (OVERFILL) ........122ISTURISA ............................... 255ISUPREL ................................... 57ithoxia ....................................... 189itraconazole ................................ 92ivermectin ....................50, 214, 215IXEMPRA KIT .......................131IXIARO ................................... 447IXINITY .......................... 279, 280JADENU .................................... 86JADENU SPRINKLE ...............86JAIMIESS ............................... 174JAKAFI ................................... 130JALYN ..................................... 275janssen covid-19 vaccine .......... 447JANTOVEN .............................. 61JANUMET .................................77JANUMET XR ..........................77JANUVIA .................................. 77JARDIANCE .............................83JASMIEL .................................169JATENZO ................................. 47JELMYTO ...............................126JEMPERLI ..............................118JENCYCLA .............................175jenliva prenatal/postnatal .........382JENTADUETO ......................... 77JENTADUETO XR .................. 77JEVTANA ............................... 132JINTELI .................................. 264JIVI .......................................... 280johnson grass ................................ 8JOLESSA .................................174JOLIVETTE ........................... 176

JORNAY PM ...............................5JUBLIA ....................................208JULEBER ................................169JULUCA .................................. 144june grass pollen standardized ..... 8JUNEL 1.5/30 .......................... 169JUNEL 1/20 ............................. 169JUNEL FE 1.5/30 .................... 169JUNEL FE 1/20 ....................... 169JUNEL FE 24 .......................... 169JUST FOR KIDS .................... 374JUST RIGHT 5000 ................. 374JUVAZIN .................................215JUXTAPID ................................ 97JYNARQUE ............................ 261K.B.G.L IN TERODERM ......197KABIVEN ................................398KADCYLA .............................. 126KADIAN .................................... 35KAITLIB FE ........................... 169KALBITOR .............................284KALETRA .......................144, 145KALLIGA ............................... 169KALYDECO ........................... 431KAMDOY ................................212KANJINTI ...............................118KANUMA ................................259kapok .............................................8KAPSPARGO SPRINKLE ....153KAPVAY ..................................... 1kapzin dc ................................... 197KARBINAL ER ........................ 93KARDIAMEMBRANE ..........217KARIVA .................................. 167katarya ...................................... 207kataryaxn .................................. 207KATE FARMS PEPTIDE 1.5250KATE FARMS STANDARD 1.4 ............................................. 250KATERZIA ............................. 156kaxm ..........................................206KAZANO ...................................77KCENTRA .............................. 280kcl (in nacl 0.9%) ......................359kcl in dextrose-nacl ...........358, 359kcl-lactated ringers-d5w ...........359kcl-lidocaine-nacl ..................... 359kedbumin ...................................285kedrab ....................................... 416KEFLEX ..................................164keido ..........................................206KELARX ................................. 215

KELNOR 1/35 .........................169KELNOR 1/50 .........................169KELOTOP ...............................351KENALOG ......................179, 205KENALOG-80 .........................179KENDALL ALGINATE 12" ROPE ....................................... 225KENDALL ALGINATE DRESS 2"X2" ......................... 225KENDALL ALGINATE DRESS 4"X8" ......................... 225KENDALL AMORPHOUS WOUND ...................................226KENDALL HYDROGEL GAUZE 2"X2" ........................226KENDALL HYDROGEL GAUZE 4"X4" ........................226KENDALL HYDROGEL GAUZE 4"X8" ........................226KENDALL HYDROGEL WOUND DRESS .....................226KENDALL ZINC CA ALGINATE 4"X4" .................226KENGREAL ........................... 283KEPIVANCE .......................... 129KEPPRA ....................................66KEPPRA XR ............................. 66KERAGEL .............................. 226KERAGELT ............................226KERALAC .............................. 207KERALYT ...............................210KERALYT SCALP ................ 210KERAMATRIX REPLICINE 10CMX10CM .......................... 226KERAMATRIX REPLICINE 2CMX3CM .............................. 226KERAMATRIX REPLICINE 5CMX5CM .............................. 226KERASTAT ............................ 226KERENDIA .............................260KERLIX AMD ANTIMICROBIAL ................ 309KERLIX AMD SUPER SPONGES ................................309KERYDIN ............................... 214KESIMPTA ............................. 424KETALAR ...............................272ketamine hcl .............................. 272ketamine hcl-sodium chloride...........................................272, 273ketarya ...................................... 207ketoconazole ................91, 208, 209

482

KETODAN .............................. 209KETO-DIASTIX .....................244ketone test ................................. 237KETOPHENE RAPIDPAQ ...196ketoprofen ................................... 19ketoprofen er ...............................19KETOROCAINE-L ..................17KETOROCAINE-LM .............. 17ketorolac tromethamine.....................................19, 196, 406ketorolac-bupiv-ketamine ........... 17ketorolac-ropiv-ketamine ............17KETOSTIX ............................. 238KETOVIE ................................250KETOVIE 4:1 ......................... 250KETOVIE PEPTIDE ............. 250kevarya ......................................207KEVEYIS ................................ 251KEVZARA ................................ 16kexm .......................................... 206keya ........................................... 207KEYTRUDA ........................... 118KHAPZORY ........................... 130KIMIDESS .............................. 167KIMMTRAK ...........................120KIMYRSA ............................... 106KINERET ..................................16KINEVAC ............................... 230kinney lancets ............................320kinney thin lancets .................... 320kinray insulin syringe ............... 340KINRIX ................................... 436KIONEX .................................. 371KISQALI (200 MG DOSE) ....129KISQALI (400 MG DOSE) ....129KISQALI (600 MG DOSE) ....129KISQALI FEMARA (400 MG DOSE) ...................................... 126KISQALI FEMARA (600 MG DOSE) ...................................... 126KISQALI FEMARA(200 MG DOSE) ...................................... 126KITABIS PAK .......................... 13KIVIK ...................................... 212KLARITY-A ........................... 403KLARITY-L ............................409KLARON .................................187KLISYRI ................................. 212KLONOPIN ...............................65KLOR-CON ............................ 362KLOR-CON 10 ....................... 362KLOR-CON M10 ....................362

KLOR-CON M15 ....................362KLOR-CON M20 ....................362KLOR-CON SPRINKLE .......362KLOR-CON/EF ...................... 362KLOXXADO .............................88kls aspirin low dose .................... 24KLS QUIT2 ............................. 428KLS QUIT4 ............................. 428kmart valu insulin syringe 29g . 340kmart valu insulin syringe 30g . 340KOATE ....................................280KOATE-DVI ................... 280, 281kochia ............................................8KOGENATE FS ......................281KOMBIGLYZE XR ................. 77KORLYM ..................................83KORSUVA .............................. 372KOSELUGO ........................... 122kosher prenatal plus iron ..........382KOVALTRY ........................... 281kp aspirin .................................... 24kp folic acid ...............................291K-PHOS ................................... 361K-PHOS NO 2 ......................... 275K-PHOS-NEUTRAL .............. 361K-PRIME .................................362KRINTAFEL ...........................111KRISTALOSE ........................ 301KROGER AUTOLET LANCING DEVICE ...............320kroger blood glucose ................ 320kroger blood glucose test ..........238KROGER HEALTHPRO GLUC MON SYS ....................320KROGER HEALTHPRO GLUCOSE TEST ....................238KROGER HEALTHPRO LANCET 26G ..........................320kroger insulin syringe ............... 340kroger lancets ........................... 320kroger lancets 21g .................... 320kroger lancets micro thin 33g ...320kroger lancets super thin .......... 320kroger lancets thin .................... 320kroger lancets thin 26g ............. 320kroger lancets ultrathin 30g ..... 320kroger lancing device ................320kroger pen needles .................... 340kroger premium blood glucose . 320kroger premium glucose test .....238kroger test ................................. 238KRYSTEXXA ......................... 276

K-TAB ......................................362K-TAN PLUS .......................... 293KURVELO .............................. 169kutaryaxm ..................................207kutaryaxmpa ..............................207kutea ..........................................206KUVAN ....................................261kuvarya ......................................207kuvarye ......................................207kuxm ..........................................207KYLEENA ...............................175KYMRIAH .............................. 119KYNMOBI .............................. 138KYPROLIS ............................. 124L.E.T. ....................................... 219l.e.t. ........................................... 219labetalol hcl .............................. 152labetalol hcl-dextrose ............... 152labetalol hcl-sodium chloride ... 152lacosamide .................................. 66LACRISERT ........................... 399lactated ringers .........................359LACTEROL ..............................85lactic acid ..................................208lactic acid e ...............................207lactulose ....................................301lactulose encephalopathy ..........270LAGEVRIO .............................151lambs quarters .............................. 8LAMICTAL .............................. 66LAMICTAL ODT .....................66LAMICTAL STARTER .......... 67LAMICTAL XR ........................67lamivudine .........................148, 149lamivudine-zidovudine ..............145lamotrigine ..................................67lamotrigine er ............................. 67lamotrigine starter kit-blue .........67lamotrigine starter kit-green .......67lamotrigine starter kit-orange .... 67LAMPIT .................................. 105lancet device with ejector ......... 320lancet transporter case ............. 320lancets ....................................... 320lancets 28g ................................ 320lancets 30g ................................ 320lancets 33g ................................ 320lancets micro thin 33g .............. 320lancets super thin 28g ...............320lancets thin ................................320LANCETS ULTRA FINE ......320LANCETS ULTRA THIN ..... 320

483

lancets ultra thin 30g ................ 320lancing device ........................... 321LANOXIN ............................... 158LANOXIN PEDIATRIC ........ 158lanreotide acetate ..................... 262lansoprazole ..............................441lanthanum carbonate ................ 270LANTUS .................................... 80LANTUS SOLOSTAR ............. 80LANZO .................................... 321lapatinib ditosylate ................... 123LARIN 1.5/30 .......................... 169LARIN 1/20 ............................. 169LARIN 24 FE .......................... 170LARIN FE 1.5/30 .................... 170LARIN FE 1/20 ....................... 170LARISSIA ............................... 170LASIX ...................................... 252LASTACAFT .......................... 402latanoprost ................................412latanoprost-timolol maleate ......399LATISSE ................................. 214LATUDA ................................. 139lavare wound wash ................... 223LAYOLIS FE .......................... 170LAZANDA .................................35l-cysteine hcl ............................. 397LDL CARE ..............................246LDO PLUS .............................. 211ldr blood glucose truetest ......... 321leader advanced lancing device321leader insulin syringe ............... 340LEADER UNIFINE PENTIPS ................................. 340LEADER UNIFINE PENTIPS PLUS ...................... 340lecithin ...................................... 398ledipasvir-sofosbuvir ................ 150LEENA .....................................176leflunomide ................................. 21LEMTRADA ........................... 424lenalidomide ............................. 368lenscale ......................................... 8LENVIMA (10 MG DAILY DOSE) ...................................... 135LENVIMA (12 MG DAILY DOSE) ...................................... 135LENVIMA (14 MG DAILY DOSE) ...................................... 135LENVIMA (18 MG DAILY DOSE) ...................................... 135

LENVIMA (20 MG DAILY DOSE) ...................................... 135LENVIMA (24 MG DAILY DOSE) ...................................... 135LENVIMA (4 MG DAILY DOSE) ...................................... 135LENVIMA (8 MG DAILY DOSE) ...................................... 135LEQVIO .................................... 98LESCOL XL ..............................96LESSINA ................................. 170LETAIRIS ............................... 161letrozole .................................... 128lets .............................................302LEU TECHNELITE ...............232leucovorin calcium ....................130LEUKERAN ............................133LEUKINE ................................292leuprolide acetate ..................... 131leuprolide acetate-bupivacaine .122LEVA PELVIC HEALTH SYSTEM ..................................366levalbuterol hcl ........................... 57levalbuterol tartrate ....................57levamlodipine maleate .............. 156LEVAQUIN .............................266levatio ....................................... 219LEVBID ................................... 439LEVEMIR ................................. 80LEVEMIR FLEXTOUCH .......80levetiracetam ...............................67levetiracetam er .......................... 67levetiracetam in nacl ...................67LEVICYN ................................212LEVICYN DERMAL SPRAY...................................................223LEVITRA ................................ 162levobunolol hcl ..........................400levocarnitine ..................... 254, 255levocarnitine sf ..........................255levocetirizine dihydrochloride .... 93levofloxacin .......................266, 403levofloxacin in d5w ................... 266levoleucovorin calcium ............. 130levoleucovorin calcium pf .........130LEVONEST .............................176levonorgest-eth est & eth est .....174levonorgest-eth estrad 91-day .. 174levonorgestrel ........................... 173levonorgestrel-ethinyl estrad...........................................170, 173levonorg-eth estrad triphasic ....176

LEVOPHED ............................452LEVORA 0.15/30 (28) ............ 170levorphanol tartrate ....................35LEVO-T ................................... 435levothyroxine sodium ................ 435LEVOXYL ...............................435LEVSIN ................................... 439LEVSIN/SL ............................. 439LEVULAN KERASTICK ......214LEXAPRO .................................73lexazin ....................................... 246LEXETTE ............................... 205LEXISCAN ..............................230LEXITRAL PHARMAPAK II ............................................... 197LEXIVA ...................................146LIALDA ...................................269liberty blood glucose meter .......321LIBERTY MEDICAL LANCETS ............................... 321LIBERTY MINI LANCING DEVICE ...................................321LIBERTY NEXT GENERATION TEST ............238LIBERTY NXT GENERATION MONITOR .. 321liberty test ................................. 238LIBRAX ...................................437LIBTAYO ................................118LICART ...................................196LIDO BDK .............................. 219lidocaine ................................... 211lidocaine (anorectal) ...................49lidocaine hcl ..............211, 304, 372lidocaine hcl (buffered) .............304lidocaine hcl (cardiac) ..........53, 54lidocaine hcl (cardiac) pf ............53lidocaine hcl (pf) .......................304lidocaine hcl urethral/mucosal . 211lidocaine hcl-tetracaine hcl ...... 303lidocaine in d5w ..........................54lidocaine in dextrose .................304lidocaine viscous hcl .................372lidocaine-epinephrine ....... 302, 405lidocaine-epinephrine (3 ml) .... 302lidocaine-hydrocort (perianal) ... 48lidocaine-hydrocortisone ace.......................................48, 49, 216lidocaine-phenylephrine ........... 405lidocaine-phenylephrine-bss .....405lidocaine-prilocaine ..................219lidocaine-sodium bicarbonate .. 303

484

lidocaine-tetracaine ..................219lidocanna .................................. 211lidocidex i ..................................183LIDOCORT ...............................49LIDODERM ............................211lido-epinephrine-tetracaine ...... 219lidolog ....................................... 183LIDOMAR ...............................303lidomark 1/5 ..............................304lidomark 2/5 ..............................304lidopac ...................................... 219lidopin ....................................... 211lidopril ...................................... 219lidopril xr .................................. 219LIDO-PRILO CAINE PACK 219LIDOPURE PATCH .............. 219LIDOREX ................................211lidorx .........................................211LIDO-SORB ............................211lidostream ................................. 219LIDOTHOL .....................219, 220LIDOTOR ............................... 220LIDOTRAL ............................. 211LIDOTREX (ALOE VERA) ..222lidovix l ..................................... 220LIDTOPIC MAX .................... 211lifems naloxone ........................... 88LIFESCAN UNISTIK 2 ......... 321LIFESCAN UNISTIK II LANCETS ............................... 321LILETTA (52 MG) ................. 175LILLOW ..................................170LIMBREL ............................... 248LIMBREL250 ......................... 246LIMBREL500 ......................... 246LINCOCIN ..............................108lincomycin hcl ...........................108lindane ...................................... 215linezolid .....................................109linezolid in sodium chloride ......109LINZESS ................................. 268LIOPEN ABSORPTION ENHANCING ......................... 420LIORESAL ..............................389liothyronine sodium .................. 435LIPICHOL 540 ....................... 246LIPIODOL .............................. 245LIPITOR ................................... 96lipo ............................................ 398lipo-b .........................................287lipo-c ......................................... 398LIPOFEN ...................................96

LIQUID E-Z-PAQUE .............244lisinopril ......................................99lisinopril-hydrochlorothiazide ....99LISTER-V ............................... 247lite touch lancets ....................... 321LITEAIRE ...............................353LITETOUCH INSULIN SYRINGE ................................ 341LITETOUCH LANCETS ...... 321LITETOUCH PEN NEEDLES ................................341lithium ....................................... 139lithium carbonate ......................139lithium carbonate er ................. 139LITHOBID .............................. 139LITHOSTAT ...........................275LIVALO .....................................96live better adv lancing device ... 321live better lancet super thin ...... 321live better lancet ultra thin ....... 321LIVIXIL PAK ......................... 220LIVMARLI ............................. 269LIVTENCITY ......................... 149LMD IN D5W ..........................284LMD IN NACL ....................... 284l-methylfolate ............................ 248l-methylfolate ca me-cbl nac .....247l-methylfolate calcium ...............248l-methylfolate forte ....................247l-methylfolate-algae ..................247l-methylfolate-algae-b12-b6 ..... 247l-methylfolate-b6-b12 ................247l-methyl-mc ............................... 247l-methyl-mc nac .........................247LMR PLUS ..............................220LO LOESTRIN FE .................167LOCAMETZ ........................... 232LOCOID .................................. 205LOCOID LIPOCREAM ........ 205LODINE .....................................19LODOSYN ...............................137LOESTRIN 1.5/30 (21) ...........170LOESTRIN 1/20 (21) ..............170LOESTRIN FE 1.5/30 ............ 170LOESTRIN FE 1/20 ............... 170LOFENA ....................................19LOJAIMIESS ..........................174LOKELMA ............................. 371LOMAIRA ...................................3LOMOTIL .................................85longs insulin syringe ................. 341longs lancets standard .............. 321

longs lancets thin ...................... 321longs lancets ultra thin ............. 321LONHALA MAGNAIR REFILL KIT ............................. 58LONHALA MAGNAIR STARTER KIT ......................... 58LONSURF ............................... 126loperamide hcl ............................ 85LOPID ........................................96lopinavir-ritonavir .................... 145LOPREEZA ............................ 264LOPRESSOR .......................... 153LOPRESSOR HCT ................ 103LOPROX ................................. 195lorazepam ............................. 52, 53LORAZEPAM INTENSOL .....52LORBRENA ............................116LORCET ................................... 27LORCET HD ............................ 27LORCET PLUS ........................ 28LOREEV XR .............................53lorid ...........................................376lormate ......................................247LORTAB ................................... 28LORYNA ................................. 170LORZONE .............................. 389losartan potassium ....................101losartan potassium-hctz ............ 101LOSEASONIQUE .................. 174LOTEMAX ..............................409LOTEMAX SM .......................409LOTENSIN ................................99LOTENSIN HCT ...................... 99loteprednol etabonate ............... 409LOTREL ....................................98LOTRISONE ...........................194LOTRONEX ........................... 268lovastatin .....................................96LOVAZA ................................... 94LOVENOX ................................ 64LOW-OGESTREL ................. 170loxapine succinate .....................141LOYON ....................................213LO-ZUMANDIMINE .............170lubiprostone .............................. 268LUCEMYRA ...........................421LUCENTIS ......................412, 413LUCIRA CHECK IT COVID-19 TEST .................... 242LUCIRA COVID-19 ALL-IN-ONE ..........................................242LUDENT ..................................360

485

lugols strong iodine .................. 143luliconazole ...............................209LUMAKRAS ........................... 122LUMASON ..............................244LUMIGAN ...............................412LUMIZYME ........................... 255LUMOXITI ............................. 117LUNESTA ............................... 299LUPANETA PACK ................ 258LUPKYNIS ..............................366LUPRON DEPOT (1-MONTH) ................................. 131LUPRON DEPOT (3-MONTH) ................................. 131LUPRON DEPOT (4-MONTH) ................................. 131LUPRON DEPOT (6-MONTH) ................................. 131LUPRON DEPOT-PED (1-MONTH) ................................. 259LUPRON DEPOT-PED (3-MONTH) ................................. 259LUTATHERA ......................... 127LUTERA ..................................170luvira .........................................249LUXAMEND ...........................226LUXIQ ..................................... 205LUXTURNA ............................405LUZU ....................................... 209LYBALVI ................................ 430LYDEXA ................................. 211LYLEQ .................................... 176LYLLANA ...............................266LYMEPAK ..............................433LYMPHOMYOSOT X ...........367LYNPARZA ............................ 134LYRA DIRECT SARS-COV-2 ASSAY .................................. 242LYRA SARS-COV-2 ASSAY 242LYRICA .....................................67LYRICA CR ............................426lysine hcl ................................... 397LYSIPLEX PLUS ................... 378LYSODREN ............................ 113LYSTEDA ............................... 296LYUMJEV .................................80LYUMJEV KWIKPEN ............80LYVISPAH ..............................389LYZA ....................................... 176M.V.I. PEDIATRIC ................381MACI ....................................... 388MACRILEN ............................ 230

MACROBID ............................109MACRODANTIN ................... 109MACUTEK ............................. 247macuzin ..................................... 247MAD NASAL ATOMIZATION DEVICE .... 331mafenide acetate ....................... 201MAGELLAN INSULIN SAFETY SYR ..........................341MAGELLAN SYRINGE-SAFETY NEEDLE ................. 341MAGELLAN TUBERCULIN SYRINGE ................................ 341magnesium chloride ..................360magnesium sulfate .................... 360magnesium sulfate in d5w .........360magnesium sulfate-nacl ............ 360MAHANA IBS ........................ 366MAKENA ................................ 421MALARONE ...........................110malathion .................................. 215manganese chloride .................. 361mannitol .................................... 252maprotiline hcl ............................72MARATHON MEDICAL PENTIPS ................................. 341maraviroc ..................................145MARBETA-25 .........................183MARBETA-L ..........................183MARCAINE ............................304MARCAINE PRESERVATIVE FREE ....... 304MARCAINE SPINAL ............ 304MARCAINE/EPINEPHRINE...................................................302MARCAINE/EPINEPHRINE PF ............................................. 302MARDEX-25 ........................... 183MARGENZA ...........................118MARINOL .................................90marlido ......................................303MARLIDO-25 ......................... 303marlissa .....................................170MARNATAL-F ....................... 382MARPLAN ................................72MARQIBO .............................. 132MARVONA SUIK .................. 303MAS CARE-PAK ................... 179MASK VORTEX .................... 353MASK VORTEX/CHILD/FROG ...... 353

MASK VORTEX/TODDLER/LADYBUG ..........................................353MATULANE ........................... 128MATZIM LA .......................... 156MAVENCLAD (10 TABS) .....423MAVENCLAD (4 TABS) .......423MAVENCLAD (5 TABS) .......423MAVENCLAD (6 TABS) .......423MAVENCLAD (7 TABS) .......423MAVENCLAD (8 TABS) .......424MAVENCLAD (9 TABS) .......424MAVYRET ..............................150MAXALT .................................356MAXALT-MLT ...................... 356MAXFE ....................................293MAXICOMFORT II PEN NEEDLE ..................................341MAXI-COMFORT INSULIN SYRINGE ................................ 341MAXI-COMFORT SAFETY PEN NEEDLE .........................341MAXICOMFORT SYR 27G X 1/2" ....................................... 341MAXIDEX ...............................409MAXITROL ............................407MAXZIDE ............................... 252MAXZIDE-25 ..........................252MAYZENT ..............................430MAYZENT STARTER PACK ....................................... 430me/naphos/mb/hyo1 .................. 110meadow fescue grass pollen ......... 8mebolic ......................................247meclizine hcl ............................... 89meclofenamate sodium ................19medactiv ....................................247medic insulin syringe ................ 341medicated dna collection .......... 238medicated dna collection 2 ....... 238medichoice safety lancet ........... 321medichoice safety lancet extra ..321medichoice safety lancet norm ..321medicine shoppe pen needles ....341MEDIHONEY CA ALGINATE 2"X2" .................226MEDIHONEY CA ALGINATE 4"X5" .................226MEDIHONEY WOUND/BURN DRESSING .226MEDISENSE THIN LANCETS ............................... 321

486

MEDLANCE EXTRA 21G ....321MEDLANCE LITE 25G ........ 321MEDLANCE PLUS EXTRA 21G ........................................... 321MEDLANCE PLUS LANCETS ............................... 321MEDLANCE PLUS LITE 25G ........................................... 321MEDLANCE PLUS SPECIAL 0.8MM ................... 321MEDLANCE PLUS SUPERLITE 30G ....................321MEDLANCE PLUS UNIVERSAL 21G ...................321MEDLANCE UNIVERSAL 21G ........................................... 321MEDROL ........................ 179, 180MEDROLOAN II SUIK .........183MEDROLOAN SUIK .............183medroxyprogesterone acetate...........................................175, 421mefenamic acid ........................... 19mefloquine hcl ...........................111MEGACE ES .......................... 421megestrol acetate .............. 134, 421meijer blood glucose .................321meijer blood glucose test .......... 238meijer essential blood glucose ..321meijer essential glucose test ..... 238MEIJER LANCETS ...............321MEIJER LANCETS THIN ....321MEIJER LANCETS UNIVERSAL 21G ...................321MEIJER LANCETS UNIVERSAL 30G ...................321MEIJER LANCETS UNIVERSAL 33G ...................322meijer pen needles .................... 341meijer premium blood glucose ..322meijer premium glucose test ..... 238MEIJER SUPER THIN LANCETS ............................... 322MEIJER TRUE2GO BLOOD GLUCOSE ...............................322MEIJER TRUERESULT GLUCOSE SYS ...................... 322MEIJER TRUETEST TEST . 238MEIJER TRUETRACK GLUCOSE SYS ...................... 322MEIJER TRUETRACK TEST ........................................ 238MEKINIST ..............................122

MEKTOVI ...............................122melaleuca ......................................8MELODETTA 24 FE ............. 170meloxicam ............................. 19, 20melphalan ................................. 133melphalan hcl ............................133memantine hcl ...................425, 426memantine hcl er .......................425MEMBRANEBLUE ............... 411MENACTRA ...........................444MENEST ................................. 266MENOPUR ..............................260MENOSTAR ........................... 266MENQUADFI ......................... 444MENTAX .................................195MENVEO ................................ 444meperidine hcl .............................36meperidine hcl-sodium chloride . 36MEPHYTON ...........................454meprobamate .............................. 52MEPRON .................................105MEPSEVII ...............................260mercaptopurine .........................115meropenem ................................105meropenem-sodium chloride .....106MERZEE ................................. 170mesalamine ............................... 269mesalamine er ...........................269mesalamine-cleanser ................ 269mesna ........................................ 135MESNEX ................................. 135mesquite ........................................ 9MESTINON .............................111METAFOLBIC ....................... 247METAFOLBIC PLUS ............247METAFOLBIC PLUS RF ..... 247METANX .................................247METAXALL CP .....................390metaxalone ................................389metformin hcl .............................. 76metformin hcl er ..........................76metformin hcl er (mod) ............... 76metformin hcl er (osm) ................76methacholine chloride ...............230methadone hcl .............................36METHADONE HCL INTENSOL ................................36methadone hcl-nacl .....................36methadone hcl-sodium chloride ..36METHADOSE .................... 36, 37METHADOSE SUGAR-FREE ..........................................37

methamphetamine hcl ................... 2methaver ....................................247methazel .................................... 247methazolamide .......................... 251methenamine hippurate .............109methenamine mandelate ........... 109METHERGINE ...................... 414methimazole .............................. 434methitest ......................................47methocarbamol ......................... 389methohexital sodium ................. 273methotrexate ..............................115methotrexate sodium .................115methotrexate sodium (pf) .......... 115methoxsalen rapid .....................199methscopolamine bromide ........ 442methyl salicylate ....................... 210methylcobalamin .......................288methyldopa ................................102methyldopa-hydrochlorothiazide ..................100methylene blue ............................ 87methylergonovine maleate ........ 414methylfol-algae-b12-acetylcyst .247METHYLIN ................................ 5methylphenidate hcl ...................... 6methylphenidate hcl er ..................6methylphenidate hcl er (cd) .......... 5methylphenidate hcl er (la) ...........5methylphenidate hcl er (osm) ........5methylphenidate hcl er (xr) ...........5methylprednisolone ...................180methylprednisolone ace-lido .....183methylprednisolone acetate ...... 180methylprednisolone sodium succ...................................................180methylprednisolone-bupivacaine ...............................183methyltestosterone ...................... 47metoclopramide hcl ...................268metolazone ................................ 253METOPIRONE .......................230metoprolol succinate er ............ 153metoprolol tartrate ....................153metoprolol-hydrochlorothiazide...................................................103METROCREAM .................... 214METROGEL ...........................214METROLOTION ................... 214metronidazole ........... 104, 214, 449METRONIDAZOLE BENZO+SYRSPEND ............. 104

487

metyrosine .................................100mexiletine hcl .............................. 54MIACALCIN .......................... 254MIBELAS 24 FE .....................170micafungin sodium ......................90MICARDIS ..............................101MICARDIS HCT .................... 101mic-l-carnitine .......................... 398miconazole 3 ............................. 448miconazole-zinc oxide-petrolat .194MICRHOGAM ULTRA-FILTERED PLUS ...................417MICROAIR VIBRATING MESH NEBUL ........................332MICROCHAMBER ............... 353MICROCYN ............................223MICROCYN SKIN AND WOUND ...................................223MICRODOT BLOOD GLUCOSE SYSTEM ............. 322MICRODOT PEN NEEDLE . 341MICRODOT TEST ................ 238MICROGESTIN 1.5/30 ..........170MICROGESTIN 1/20 .............170MICROGESTIN 24 FE ..........170MICROGESTIN FE 1.5/30 ....171MICROGESTIN FE 1/20 .......171MICROLET LANCETS ........ 322MICROLET NEXT LANCING DEVICE ...............322MICRONEB ............................332microplegia msa-msg ................159MICROSPACER .................... 353midazolam .................................298midazolam hcl ...........................298midazolam hcl (pf) .................... 298midazolam hcl-sodium chloride 298MIDAZOLAM+SYRSPEND SF ..............................................298midazolam-sodium chloride ......298midodrine hcl ............................ 452MIFEPREX ............................. 253mifepristone .............................. 253MIGERGOT ........................... 354miglitol ........................................75miglustat ................................... 287MIGRAINE PACK .................355MIGRANAL ............................355MIGRANOW .......................... 355MILI .........................................171MILLGUARD ......................... 290MILLIPRED ........................... 180

MILLIPRED DP .....................180MILLIPRED DP 12-DAY ......180milrinone lactate .......................158milrinone lactate in dextrose .... 158MIMVEY .................................264MIMYX ....................................213MINASTRIN 24 FE ................171mineral oil heavy ...................... 301mini lancing device ................... 322MINILINK REAL-TIME TRANSMITTER .....................322MINIMED 630G GUARDIAN PRESS ......................................322MINIMED 770G INSULIN PUMP SYS .............................. 331MINIMED MIO ADVANCE INFUSE SET ........................... 331MINIMED QUICK SET INF SET 18" ....................................331MINIMED QUICK SET INF SET 23" ....................................331MINIMED QUICK SET INF SET 32" ....................................331MINIMED QUICK SET INF SET 43" ....................................331MINIPRESS ............................ 102MINIPRIN LOW DOSE .......... 24MINITRAN ............................... 51MINIVELLE ........................... 266MINOCIN ................................433minocycline hcl ................. 433, 434minocycline hcl er .....................433MINOLIRA ............................. 434minoxidil ................................... 104MIOCHOL-E .......................... 401MIOSTAT ............................... 401MIRAPEX ............................... 138MIRAPEX ER .........................138MIRCERA ...............................288MIRCETTE .............................167MIRENA (52 MG) .................. 175MIRODERM BIOLOGIC MATRIX FENES ....................226MIRODERM BIOLOGIC WOUND MATRIX .................226mirtazapine ................................. 71MIRVASO ............................... 214misoprostol ............................... 443MISTASSIST .......................... 350mite (d. farinae) ............................ 9mite (d. pteronyssinus) ..................9MITIGARE ............................. 276

MITIGO .....................................37mitomycin ..........................126, 403MITOSOL ............................... 403mitoxantrone hcl ....................... 126mixed aspergillus ........................ 12mixed feathers .............................12mixed ragweed .............................. 9mixed vespid venom protein ..........9mko melt dose pack ...................299mlk f1 ........................................ 183mlk f2 ........................................ 183mlk f3 ........................................ 184MLK F4 ................................... 184MM EASY TOUCH GLUCOSE ...............................238MM EASY TOUCH GLUCOSE METER ............... 322mm insulin syringe/needle ........ 341MM PEN NEEDLES .............. 341MM TWIST LANCETS .........322M-M-R II ................................. 445m-natal plus .............................. 382MOBIC ...................................... 20modafinil ....................................... 6moderna covid-19 vac (booster)...................................................447moderna covid-19 vacc 6-11y ...447moderna covid-19 vacc 6m-5y ..447moderna covid-19 vaccine ........ 447moexipril hcl ............................... 99molindone hcl ............................141mometasone furoate ..........205, 392MONDOXYNE NL .................434MONJUVI ............................... 116MONOFERRIC ...................... 295MONOJECT ALLERGIST TRAY ....................................... 341MONOJECT BLUNTIP CANNULA .............................. 342MONOJECT BLUNTIP SYR/CANNULA ..................... 342MONOJECT BONE MARROW BIOPSY ...............304MONOJECT CONTROL SYRINGE ................................ 342MONOJECT FILTER ASPIRATOR ...........................342MONOJECT FILTER NEEDLE ..................................342MONOJECT FLUSH SYRINGE ................................ 363

488

MONOJECT HYPODERMIC NEEDLE .....342MONOJECT INSULIN SYRINGE ................................ 342MONOJECT INTRODUCER NEEDLE ..................................342MONOJECT LIFESHIELD SYRINGE ................................ 342MONOJECT MAGELLAN SAFETY NDL ......................... 342MONOJECT MAGELLAN SYRINGE ................................ 342MONOJECT PHARMACY TRAY ....................................... 342MONOJECT PISTON SYRINGE ................................ 342MONOJECT SODIUM CHLORIDE FLUSH .............. 363MONOJECT SYRINGE ........ 343MONOJECT SYRINGE CATH TIP ............................... 343MONOJECT SYRINGE ECC LUER ....................................... 343MONOJECT SYRINGE ECCENTRIC TIP ...................343MONOJECT SYRINGE LUER LOCK .......................... 343MONOJECT SYRINGE LUER-LOCK TIP .................. 343MONOJECT SYRINGE PHARMACY TRAY .............. 343MONOJECT SYRINGE REG LUER ....................................... 343MONOJECT SYRINGE REGULAR TIP .......................343MONOJECT SYRINGE TOOMEY TYPE .................... 343MONOJECT TB SAFETY SYRINGE ................................ 343MONOJECT TB SYRINGE ..343MONOJECT ULTRA COMFORT SYRINGE .......... 343MONOLET LANCETS ..........322MONOLET OPD LANCETS 322MONOLETTOR SAFETY LANCETS ............................... 322MONO-LINYAH .................... 171MONONESSA .........................171MONONINE ........................... 281MONOVISC ............................391monsels ferric subsulfate .......... 296montelukast sodium .................... 59

MONUROL ............................. 109morcin ....................................... 367MORGIDOX ........................... 434MORPHABOND ER ................ 37morphine sulfate ................... 38, 39morphine sulfate (concentrate) ...37morphine sulfate (pf) ...................37morphine sulfate er ............... 37, 38morphine sulfate er beads ...........37morphine sulfate in dextrose .......38morphine sulfate-nacl ........... 39, 40mosquito (diagnostic) ............... 228MOTEGRITY ......................... 267MOTOFEN ................................85MOUNJARO .............................82mountain cedar ............................. 9mouse epithelium .......................... 9MOVANTIK ........................... 270MOVIPREP .............................301MOXEZA ................................ 403MOXICAINE .......................... 220moxifloxacin hcl ................267, 403moxifloxacin hcl (2x day) ..........403moxifloxacin hcl in nacl ............267moxifloxacin hcl-bss ................. 403MOZOBIL ...............................288mpd safety lancet 21g ............... 322mpd safety lancet 23g ............... 322mpd safety lancet 28g ............... 322mpd safety lancet 30g ............... 322MS CONTIN ............................. 40ms insulin syringe ..................... 343MSUD EASY ...........................250mucor ............................................ 9MUCOSITISRX ......................373MUCOTROL .......................... 375MUGARD ................................375mugwort ........................................ 9MULPLETA ............................295MULTAQ .................................. 54multi-draw needle ..................... 343MULTIGEN ............................ 293MULTIGEN FOLIC .............. 293MULTIGEN PLUS .................293MULTIHANCE ...................... 244multi-lancet device ....................322MULTI-LANCET DEVICE 2322multi-mac .................................. 382multipro .....................................378multi-specialty ...........................184MULTITRACE-4 NEONATAL ............................364

MULTITRACE-4 PEDIATRIC ............................364multivitamin/fluoride ........ 377, 380multi-vitamin/fluoride ............... 380multi-vitamin/fluoride/iron ....... 380MULTI-VIT-FLOR ................380MULTRYS .............................. 364mupirocin ..................................194mupirocin calcium .................... 194MUSE .......................................160MUTAMYCIN ........................ 126MVASI ..................................... 136MY CHOICE .......................... 173MY WAY .................................174MYALEPT .............................. 258MYAMBUTOL ....................... 112MYCAMINE ....................... 90, 91MYCAPSSA ............................ 262MYCOBUTIN ......................... 112mycophenolate mofetil .............. 368mycophenolate mofetil hcl ........ 368mycophenolate sodium ..............368MYDAYIS ................................... 2MYDRIACYL ......................... 401MYFEMBREE ........................264myferon 150 forte ......................293MYFORTIC ............................ 368MYGLUCOHEALTH BLOOD GLUCOSE ............... 322MYGLUCOHEALTH LANCETS 30G ....................... 322MYGLUCOHEALTH TEST .238MYLAB BOX COVID-19 TESTING .................................242MYLERAN ..............................113MYLOTARG .......................... 117MYNATAL ..............................382MYNATAL ADVANCE .........382mynatal plus ..............................382mynatal-z ...................................382mynate 90 plus .......................... 382mynephrocaps ........................... 376MYNEPHRON ........................376MYOBLOC ............................. 394MYORISAN ............................ 192MYOVIEW 30ML .................. 231MYRBETRIQ ......................... 444MYSOLINE ...............................67MYTESI .....................................85MYXREDLIN ........................... 80MYZILRA ............................... 176na ferric gluc cplx in sucrose ....295

489

NABI-HB ................................. 417nabumetone .................................20nac .............................................397n-acetyl cysteine ........................398n-acetyl-l-cysteine .....................398nadolol ...................................... 153nafcillin sodium ................ 419, 420nafcillin sodium in dextrose ......419NAFRINSE ..............................360NAFRINSE DAILY ACIDULATED ....................... 373NAFRINSE DAILY/NEUTRAL .................374NAFRINSE DROPS ............... 360NAFRINSE WEEKLY ...........374naftifine hcl ............................... 195NAFTIN ................................... 195NAGLAZYME ........................259nalbuphine hcl ............................ 46NALFON ................................... 20nalmefene hcl .............................. 88nalocet .........................................44naloxone hcl ................................88naltrexone ................................... 87naltrexone hcl ............................. 88NAMENDA ..............................426NAMENDA TITRATION PAK ..........................................426NAMENDA XR .......................426NAMENDA XR TITRATION PACK ....................................... 426NAMZARIC ............................422NAPRELAN .............................. 20napro .........................................196NAPROSYN .............................. 20naproxen ..................................... 20naproxen sodium .........................20naproxen sodium er .................... 20naproxen-esomeprazole .............. 17naratriptan hcl .......................... 356NARCAN ................................... 88NARDIL .....................................72NAROPIN ................................305NASCOBAL ............................ 288NASONEX ...............................392NATACHEW .......................... 382NATACYN .............................. 403NATALVIT ............................. 382NATAZIA ................................175nateglinide .................................. 83NATELLE ONE ......................382NATESTO ................................. 47

NATPARA ...............................260NATROBA .............................. 215NATURE-THROID ................435NAVELBINE ...........................132NAYZILAM .............................. 65nebivolol hcl ..............................153neb-rite4 ....................................332nebulizer mask adult ................. 350nebulizer mask child ................. 350nebulizer ped frog ..................... 332nebulizer ped frog kit ................ 332NEBUPENT .............................104NEBUSAL ............................... 186NECON 0.5/35 (28) ................. 171NECON 7/7/7 ...........................176NEEVO DHA .......................... 382nefazodone hcl ............................ 73nelarabine ................................. 115NEMBUTAL ........................... 297nendrux ..................................... 220NEOKE ALCAR .....................398neoke bhb .................................. 247NEOKE MCT70 ......................398NEOKE RA LIPOIC ................12neomycin sulfate ......................... 13neomycin-bacitracin zn-polymyx ..................................... 403neomycin-polymyxin b gu ......... 274neomycin-polymyxin-dexameth .407neomycin-polymyxin-gramicidin...................................................404neomycin-polymyxin-hc .... 407, 413neonatal + dha ..........................386neonatal 19 ............................... 387neonatal complete .....................382neonatal fe ................................ 382NEONATAL PLUS ................ 382NEONATAL VITAMIN ........ 382NEO-POLYCIN ......................404NEO-POLYCIN HC ...............407NEOPROFEN ........................... 20NEORAL ................................. 366NEOSALUS .............................213neostigmine methylsulfate .111, 112NEO-SYNALAR ..................... 193neovite .......................................378NEOX 100 ................................217NEOX CORD 1K ....................217NEPHPLEX RX ......................377NEPHRON FA ........................ 293NEPHRONEX .........................376NEPHRO-VITE ...................... 376

NEPHRO-VITE RX ............... 376NERLYNX ...............................123NESACAINE ...........................306NESACAINE-MPF .................306NESINA ..................................... 77NESTABS ................................ 382NESTABS ABC .......................385NESTABS DHA ...................... 382NESTABS ONE ...................... 386NETSPOT ................................231NEUAC .................................... 189NEULASTA .............................291NEULASTA ONPRO ............. 291NEULUMEX ........................... 244NEUPOGEN ............................291NEUPRO ................................. 138NEURACEQ ........................... 231NEURALGO-RHEUM ...........367NEURAPTINE ........................193NEUREPA ............................... 247neurin-sl ....................................287NEURONTIN ............................67NEUTEK 2TEK TEST ...........238neutral sodium fluoride .............374NEUTRASAL ..........................373NEVANAC .............................. 406nevirapine ................................. 147nevirapine er .............................147NEW DAY ............................... 174NEXA PLUS ............................386NEXAVAR .............................. 123NEXAVIR ................................369NEXICLON XR ...................... 102NEXIUM ..................................441NEXIUM I.V. .......................... 441NEXLETOL .............................. 94NEXLIZET ................................94NEXPLANON ......................... 175NEXTERONE ........................... 54NEXTSTELLIS .......................171NEXVIAZYME .......................255niacin (antihyperlipidemic) .97, 454niacin er (antihyperlipidemic) .... 97NIACOR .................................... 97NIASPAN ...................................97NICADAN ................................378NICAPRIN .............................. 247nicardipine hcl .......................... 156nicardipine hcl in nacl .............. 156NICAZEL ................................ 378NICAZEL FORTE ................. 378nicazyme ....................................247

490

NICOMIDE ............................. 379nicotinamide ............................. 380nicotine ..................................... 429nicotine mini ............................. 428nicotine polacrilex .................... 428nicotine polacrilex mini ............ 428nicotine step 1 ........................... 428nicotine step 2 ........................... 428nicotine step 3 ........................... 428NICOTROL .............................429NICOTROL NS ...................... 429nifedipine .................................. 156nifedipine er .............................. 156nifedipine er osmotic release .... 156NIFEREX ................................ 293NIKKI ...................................... 171NILANDRON ..........................114nilutamide ................................. 114NIMBEX ..................................394nimodipine ................................ 156NINLARO ............................... 124NIPENT ................................... 128NIPRIDE RTU ........................ 104nisoldipine er ............................ 156nitazoxanide ..............................105NITHIODOTE .......................... 86nitisinone ...................................257NITRO-BID ...............................51NITRO-DUR ............................. 51nitrofurantoin ............................110nitrofurantoin macrocrystal ......109nitrofurantoin monohyd macro .110nitroglycerin ............................... 51nitroglycerin in d5w ....................51NITROLINGUAL .....................51NITROMIST ............................. 51nitroprusside sodium ................ 104NITROSTAT .............................51NITRO-TIME ........................... 51NITYR ..................................... 257NIVA-FOL ...............................247NIVA-PLUS .............................382NIVESTYM .............................291nizatidine ...................................439NIZORAL ................................209NOCDURNA ........................... 263NOCTIVA ............................... 263NOLIX ..................................... 205NOPIOID-LMC KIT ..............390NORA-BE ................................176NORCO ..................................... 28

NORDIPEN 5 INJECTION DEVICE ...................................343NORDIPEN DELIVERY SYSTEM ..................................343NORDITROPIN FLEXPRO . 256norepinephrine bitartrate ......... 452norepinephrine-dextrose ...........452norepinephrine-sodium chloride...........................................452, 453norethin ace-eth estrad-fe .........171norethindrone ........................... 176norethindrone acetate ...............421norethindrone acet-ethinyl est .. 171norethindrone-eth estradiol ...... 264norethin-eth estradiol-fe ........... 171NORGESIC ............................. 390norgesic forte ............................ 390norgestimate-eth estradiol ........ 171norgestim-eth estrad triphasic ..176NORITATE ............................. 214NORLIQVA ............................ 156NORLYDA .............................. 176NORLYROC ........................... 176normal saline flush ................... 363NORM-JECT LUER SLIP SYRINGE ................................ 343NORMLGEL AG ....................226NORMOSOL-M IN D5W ...... 359NORMOSOL-R ...................... 359NORMOSOL-R IN D5W ....... 359NORMOSOL-R PH 7.4 ..........359NORPACE .................................53NORPACE CR ..........................53NORPRAMIN ........................... 75NORTHERA ........................... 451NORTREL 0.5/35 (28) ............171NORTREL 1/35 (21) ...............171NORTREL 1/35 (28) ...............171NORTREL 7/7/7 ..................... 176nortriptyline hcl .......................... 75NORVASC ...............................156NORVIR .................................. 146NOURIANZ .............................136NOURISH ................................250NOVA MAX BLOOD GLUCOSE SYSTEM ............. 322NOVA MAX GLUCOSE TEST ........................................ 238NOVA SAFETY LANCETS 23G ........................................... 322NOVA SAFETY LANCETS 28G ........................................... 322

NOVA SUREFLEX LANCETS ............................... 322NOVA SUREFLEX LANCING DEVICE ...............322NOVACHOR ...........................217NOVACORT ........................... 216NOVAREL .............................. 260novavax covid-19 vaccine .........447NOVOEIGHT ......................... 281NOVOFINE AUTOCOVER PEN NEEDLE .........................343NOVOFINE PEN NEEDLE .. 344NOVOFINE PLUS PEN NEEDLE ..................................344NOVOLIN 70/30 ....................... 80NOVOLIN 70/30 FLEXPEN ... 80NOVOLIN 70/30 FLEXPEN RELION .....................................80NOVOLIN 70/30 RELION ...... 80NOVOLIN N ............................. 80NOVOLIN N FLEXPEN ..........80NOVOLIN N FLEXPEN RELION .....................................80NOVOLIN N RELION .............80NOVOLIN R ............................. 81NOVOLIN R FLEXPEN ..........80NOVOLIN R FLEXPEN RELION .....................................81NOVOLIN R RELION .............81NOVOLOG ............................... 81NOVOLOG 70/30 FLEXPEN RELION .....................................81NOVOLOG FLEXPEN ............81NOVOLOG FLEXPEN RELION .....................................81NOVOLOG MIX 70/30 ............ 81NOVOLOG MIX 70/30 FLEXPEN ..................................81NOVOLOG MIX 70/30 RELION .....................................81NOVOLOG PENFILL ............. 81NOVOLOG RELION ...............81NOVOPEN ECHO ..................344NOVOSEVEN RT .................. 281NOVOTWIST PEN NEEDLE...................................................344NOXAFIL ..................................92noxifol-d ....................................290np #2 drug preparation kit ........197NP THYROID .........................435NPLATE .................................. 295NUBEQA ................................. 114

491

NUCALA ................................... 59NUCARACLINPAK ...............189NUCARARXPAK ...................189NUCEL .................................... 218NUCORT ................................. 205NUCYNTA .......................... 40, 41NUCYNTA ER ..........................40NUDERMRXPAK 120 ........... 198NUDERMRXPAK 60 ............. 198NUDICLO SOLUPAK ........... 197NUDICLO TABPAK ................17NUDROXIPAK .........................17NUDROXIPAK DSDR-50 ........20NUDROXIPAK DSDR-75 ........20NUDROXIPAK E-400 ..............20NUDROXIPAK I-800 ...............20NUDROXIPAK M-15 ...............20NUDROXIPAK N-500 ..............20NUEDEXTA ............................426NUFERA ..................................293NUFOL .................................... 290NULEV .................................... 439NULIBRY ................................259NULOJIX ................................ 372NULYTELY LEMON-LIME 301NULYTELY WITH FLAVOR PACKS ...................301NUMBRINO ............................392NUMOISYN ............................ 373NUPLAZID ............................. 139NURTEC ................................. 354NUSHIELD ............................. 218NUSURGEPAK SURGICAL PREP/CARE ........................... 213NUTRASEB .............................200NUTRIARX CREAMPAK .... 222NUTRICAP ............................. 378NUTRIDOX .............................434NUTRIFAC ZX .......................378NUTRILIPID .......................... 398NUTRIVIT .............................. 377NUTROPIN AQ NUSPIN 10 . 256NUTROPIN AQ NUSPIN 20 . 256NUTROPIN AQ NUSPIN 5 ... 256NUVA III ................................. 351NUVAGEL .............................. 351NUVAIL ...................................213NUVAKAAN-II .......................220NUVARING ............................ 173NUVAZIL ................................351NUVAZIL II ............................351NUVESSA ................................449

NUVIGIL .....................................6NUWIQ ............................281, 282NUZYRA ................................. 432NYAMYC ................................ 195NYLIA 1/35 ............................. 171NYLIA 7/7/7 ............................ 177NYMALIZE ............................ 156NYMYO ...................................171nystatin ........................91, 195, 372nystatin-triamcinolone ..............194NYSTOP .................................. 195NYVEPRIA ............................. 291OASIS ULTRA MATRIX FENESTRATED .....................227OASIS ULTRA TRI-LAYER MATRIX ..................................227OASIS WOUND MATRIX FENESTRATED .....................227oat grain (diagnostic) ............... 228OB COMPLETE .....................383OB COMPLETE ONE ........... 383OB COMPLETE PETITE ..... 383OB COMPLETE PREMIER .383OB COMPLETE/DHA ...........383obizur ........................................ 282OBSTETRIX DHA ................. 383OBSTETRIX EC .................... 383OBSTETRIX ONE ................. 386O-CAL FA ............................... 383O-CAL PRENATAL .............. 383OCALIVA ............................... 267OCELLA ................................. 171OCREVUS ...............................425OCTAGAM ............................. 417OCTAPLAS BLOOD GROUP A ................................ 285OCTAPLAS BLOOD GROUP AB ............................. 285OCTAPLAS BLOOD GROUP B ................................ 285OCTAPLAS BLOOD GROUP O ................................285octreotide acetate ......................262OCUCOAT VISCOADHERENT ............... 411OCUFLOX .............................. 403OCUVEL ................................. 378ODACTRA ................................ 12ODEFSEY ............................... 145ODOMZO ................................121OFEV ....................................... 431OFIRMEV ................................. 22

ofloxacin ................... 267, 403, 413OGESTREL ............................ 171OGIVRI ................................... 118OKEBO ....................................434olanzapine .................................143olanzapine-fluoxetine hcl ..........430OLINVYK ................................. 41olive tree ....................................... 9olmesartan medoxomil ..............101olmesartan medoxomil-hctz ...... 101olmesartan-amlodipine-hctz ..... 102olopatadine hcl ................. 392, 402OLUMIANT ..............................14OLUX .......................................205OLUX-E ...................................205OMBRA TABLE TOP COMPRESSOR ...................... 350OMECLAMOX-PAK .............443omega-3 rx complete ...................94omega-3-acid ethyl esters ........... 94OMEGAVEN .......................... 398omeprazole ................................441OMEPRAZOLE+SYRSPEND SF ALKA ............................. 441omeprazole-sodium bicarbonate...................................................440OMIDRIA ................................410OMNARIS ............................... 392OMNIFLEX DIAPHRAGM ..308OMNIPAQUE ......................... 245OMNIPOD 5 G6 INTRO (GEN 5) .................................... 331OMNIPOD 5 G6 POD (GEN 5) ............................................... 331OMNIPOD CLASSIC PDM (GEN 3) .................................... 331OMNIPOD CLASSIC PODS (GEN 3) .................................... 331OMNIPOD DASH INTRO (GEN 4) .................................... 331OMNIPOD DASH PODS (GEN 4) .................................... 331omniquin ................................... 247OMNISCAN ............................ 244OMNITROPE ......................... 256OMNITROPE PEN 5 INJ DEVICE ...................................344omnivex ..................................... 247ON CALL EXPRESS BLOOD GLUCOSE ............... 238ON CALL LANCETS ............ 322

492

ON CALL LANCING DEVICE ...................................323ON CALL PLUS BLOOD GLUCOSE ...............................238ON CALL PLUS LANCETS . 323ON CALL PLUS LANCING DEVICE ...................................323ON CALL VIVID BLOOD GLUCOSE ...............................238ON/GO COVID-19 ANTIGEN TEST .................... 242ON/GO ONE COVID-19 HOME TEST .......................... 242ONCASPAR ............................ 127ondansetron ................................ 88ondansetron hcl .......................... 88one drop blood glucose monitor...................................................323one drop test ............................. 238ONE FLOW SPIROMETER .350one vite womens plus ................ 383ONETOUCH CLUB LANCETS FINE PT ...............323ONETOUCH DELICA LANCETS 30G ....................... 323ONETOUCH DELICA LANCETS 33G ....................... 323ONETOUCH DELICA PLUS LANCET30G ...........................323ONETOUCH DELICA PLUS LANCET33G ...........................323ONETOUCH DELICA PLUS LANCING ............................... 323ONETOUCH FINEPOINT LANCETS ............................... 323ONETOUCH ULTRA ............ 238ONETOUCH ULTRA 2 ......... 323ONETOUCH ULTRA MINI . 323ONETOUCH ULTRALINK ..323ONETOUCH ULTRASOFT LANCETS ............................... 323ONETOUCH VERIO .....238, 323ONETOUCH VERIO FLEX SYSTEM ..................................323ONETOUCH VERIO IQ SYSTEM ..................................323ONETOUCH VERIO REFLECT ............................... 323ONETOUCH VERIO SYNC SYSTEM ..................................323onevite .......................................378ONEXTON .............................. 189

ONFI .......................................... 65ONGENTYS ............................139ONGLYZA ................................ 77ONIVYDE ............................... 135ONPATTRO ............................427ONTRUZANT .........................118ONUREG .................................115ONYCHO-MED ......................194onzdeoxia .................................. 189ONZETRA XSAIL ................. 356OPANA ...................................... 41OPCICON ONE-STEP .......... 174OPDIVO .................................. 119OPDUALAG ........................... 116opium .................................... 85, 86OPSUMIT ................................161OPTICHAMBER ADVANTAGE .........................353OPTICHAMBER ADVANTAGE-LG MASK .... 353OPTICHAMBER ADVANTAGE-MED MASK .353OPTICHAMBER ADVANTAGE-SM MASK .... 353OPTICHAMBER DIAMOND...................................................353OPTICHAMBER DIAMOND-LG MASK .......... 353OPTICHAMBER DIAMOND-MD MASK ......... 353OPTICHAMBER DIAMOND-SM MASK .......... 353OPTICHAMBER FACE MASK-LARGE .......................353OPTICHAMBER FACE MASK-MEDIUM ....................353OPTICHAMBER FACE MASK-SMALL .......................353OPTIHALER .......................... 353OPTION 2 ................................174OPTIONS GYNOL II CONTRACEPTIVE ............... 449OPTISON ................................ 244OPTIUM TEST .......................238OPTIUMEZ TEST ................. 238OPTUMRX BLOOD GLUCOSE TEST ....................239OPTUNE ..................................354OPTUNE LUA ........................ 354OPZELURA ............................ 201ORABLOC .............................. 302ORACEA ................................. 214

ORACIT .................................. 274ORAFATE ...............................375ORALAIR ................................. 12ORALONE .............................. 375ORAMAGICRX ......................375orange (diagnostic) ...................228ORAPEUTIC .......................... 375ORAPRED ODT .....................180ORAVIG ..................................372ORBACTIV .............................106orchard grass pollen .....................9ORENCIA ................................. 21ORENCIA CLICKJECT ......... 21ORENITRAM ......................... 160ORFADIN ................................257ORGOVYX ............................. 130ORIAHNN ............................... 264ORILISSA ............................... 255ORKAMBI .............................. 431ORLADEYO ........................... 284ORMECA ................................ 198orphenadrine citrate ................. 389orphenadrine citrate er .............389orphenadrine-asa-caffeine ........390orphenadrine-aspirin-caffeine ..390ORPHENGESIC FORTE ...... 390ORSYTHIA ............................. 171ortho d .......................................290ortho df ......................................290ORTHO MICRONOR ........... 176ORTHO TRI-CYCLEN LO .. 177ORTHO-NOVUM 1/35 (28) ...172ORTHO-NOVUM 7/7/7 (28) ..177ORTHOVISC ..........................391ORTIKOS ................................180oscimin ......................................439oscimin sr ..................................439oseltamivir phosphate ...............151OSENI ........................................78OSMITROL ............................ 252OSMOLEX ER ....................... 136OSMOPREP ............................302OSPHENA ............................... 261ostachol .....................................290OSTEOCONDUCTIVE MATRIX PLUS ...................... 218OTEZLA ....................................21OTIPRIO ................................. 413OTOVEL ................................. 413OTREXUP .................................14OVACE PLUS .........................200OVACE PLUS WASH ........... 200

493

OVACE WASH .......................200oval tape ....................................323OVEEZA ................................. 290OVIDE ..................................... 215OVIDREL ................................260oxacillin sodium ........................420oxacillin sodium in dextrose ..... 420oxaliplatin ................................. 113oxandrolone ................................ 46oxaprozin .................................... 20OXAYDO ...................................41oxazepam .................................... 53OXBRYTA .............................. 292oxcarbazepine ............................. 68OXERVATE ............................406oxianujo .................................... 209oxiatar .......................................189oxiavarry ...................................189oxiazar ...................................... 189oxiconazole nitrate ....................209OXISTAT ................................ 209OXLUMO ................................275oxopod .......................................208OXSORALEN ULTRA .......... 199OXTELLAR XR ....................... 68oxybutynin chloride ...................443oxybutynin chloride er .............. 443oxycodone hcl ............................. 41oxycodone hcl er ......................... 41oxycodone-acetaminophen ..........44oxycodone-aspirin .......................44oxycodone-ibuprofen .................. 44OXYCONTIN ........................... 41oxymorphone hcl .........................42oxymorphone hcl er .................... 42oxytocin .....................................414oxytocin-lactated ringers .......... 414oxytocin-sodium chloride ..........414OXYTROL .............................. 443OZEMPIC (0.25 OR 0.5 MG/DOSE) ................................ 82OZEMPIC (1 MG/DOSE) ........82OZOBAX ................................. 389OZURDEX .............................. 409PACERONE ..............................54paclitaxel ...................................132paclitaxel protein-bound part ... 132PADCEV ..................................118paingo kft .................................. 220PALFORZIA (12 MG DAILY DOSE) .......................................... 9

PALFORZIA (120 MG DAILY DOSE) ............................ 9PALFORZIA (160 MG DAILY DOSE) ............................ 9PALFORZIA (20 MG DAILY DOSE) .......................................... 9PALFORZIA (200 MG DAILY DOSE) ............................ 9PALFORZIA (240 MG DAILY DOSE) ............................ 9PALFORZIA (3 MG DAILY DOSE) .......................................... 9PALFORZIA (300 MG MAINTENANCE) .................... 10PALFORZIA (300 MG TITRATION) ............................ 10PALFORZIA (40 MG DAILY DOSE) ........................................ 10PALFORZIA (6 MG DAILY DOSE) ........................................ 10PALFORZIA (80 MG DAILY DOSE) ........................................ 10PALFORZIA INITIAL ESCALATION ..........................10PALINGEN FLOW ................ 218PALINGEN HYDROMEMBRANE ........... 218PALINGEN INOVOFLO ...... 218PALINGEN MEMBRANE .... 218PALINGEN XPLUS HYDROMEMBRANE ........... 218PALINGEN XPLUS MEMBRANE .......................... 218paliperidone er ..........................140palonosetron hcl ................... 88, 89PALYNZIQ ............................. 261PAMELOR ................................75pamidronate disodium .............. 254PANCREAZE ......................... 251pancuronium bromide ...............394PANDA MASK LARGE ........ 353PANDA MASK MEDIUM .....353PANDA MASK SMALL ........ 353PANDEL ..................................205PANHEMATIN .......................284PANRETIN ............................. 198pantoprazole sodium .................441PANZYGA ...............................417papaverine hcl ...........................160PARADIGM REAL-TIME TRANSMITTER .....................323

PARAGARD INTRAUTERINE COPPER ..173PARAPLATIN ........................ 113PAREMYD ..............................405PARI MANUAL INTERRUPTER ..................... 350PARI TREK S COMBO PACK ....................................... 350paricalcitol ................................258PARLODEL ............................ 136PARNATE ................................. 72PAROEX ................................. 372paromomycin sulfate ...................13paroxetine hcl ............................. 73paroxetine hcl er ......................... 73paroxetine mesylate .................. 430PARSABIV ..............................254PASER ..................................... 112PATADAY ...............................402PATANASE .............................392PATANOL ...............................402PAXIL ........................................73PAXIL CR ................................. 73PAXLOVID ............................. 148PAZEO .....................................402pb-hyoscy-atropine-scopolamine .............................. 437pc lancets super thin 30g .......... 323pc pediatric iron drops ............. 295pc unifine pentips ......................344p-care k40 ................................. 180p-care k40g ............................... 184p-care k40mx .............................184p-care k80 ................................. 180p-care k80g ............................... 184p-care k80mx .............................184peanut (diagnostic) ................... 229pecan nut (diagnostic) .............. 229pecan pollen ................................10PEDIAPRED ........................... 180PEDIARIX ...............................436PEDIATRIC PANDA MASK 353pedizolpak ................................. 194PEDVAX HIB ......................... 444peg 3350-kcl-na bicarb-nacl .....301peg-3350/electrolytes ................301peg-3350/electrolytes/ascorbat .301PEGANONE ..............................70PEGASYS ................................150PEGASYS PROCLICK ......... 150PEGINTRON .......................... 150peg-kcl-nacl-nasulf-na asc-c .....301

494

PEG-PREP .............................. 301PEMAZYRE ........................... 121pemetrexed ................................ 115pemetrexed disodium ................ 115PEMFEXY ...............................115pen needles ................................344pen needles 1/2" ........................344pen needles 3/16" ......................344pen needles 5/16" ......................344penicillamine .............................365penicillin g pot in dextrose ....... 418penicillin g potassium ............... 418penicillin g procaine ................. 418penicillin g sodium ....................418penicillin v potassium ............... 418penicillium notatum ............ 10, 229PENLEN .................................. 213PENLET II BLOOD SAMPLER ...............................323PENLET II REPLACEMENT CAP .......... 323pennsaicin ................................. 197PENNSAID ..............................196pensomal ................................... 420PENTACEL .............................436PENTAM ................................. 104pentamidine isethionate ............ 104PENTASA ................................269pentazocine-naloxone hcl ........... 46pentetate calcium trisodium ........86pentetate zinc trisodium ..............86PENTIPS ................................. 344pentobarbital sodium ................ 297pentosan polysulfate sodium .....275PEN-TOTE ..............................323pentoxifylline er ........................ 284PEPAXTO ............................... 133PEPCID ................................... 439PERCOCET .............................. 44PERCURA ...............................247perennial rye grass pollen .......... 10PERFECT LANCETS 28G ....323PERFECT LANCETS 30G ....323PERFOROMIST .......................58PERIDEX ................................ 373PERIKABIVEN ...................... 399perindopril erbumine .................. 99PERIOGARD ..........................373PERIOMED ............................ 374PERJETA ................................ 118permethrin .................................215perphenazine .............................142

perphenazine-amitriptyline .......426PERSERIS ...............................140PERTZYE ............................... 251PEXEVA ....................................73pfizer covid-19 vac-tris 5-11y ... 447pfizer covid-19 vac-tris 6m-4y .. 447pfizer-biont covid-19 vac-tris ....447pfizer-biontech covid-19 vacc ...447PFIZERPEN ............................418ph strips .................................... 239PHARMACIST CHOICE AUTOCODE ........................... 239PHARMACIST CHOICE AUTOCODE SYS ...................323PHARMACIST CHOICE LANCETS ............................... 323PHARMACIST CHOICE MINI SYSTEM ....................... 323pharmacist choice no coding .... 239PHARMACY COUNTER LANCETS ............................... 323PHENACTIN AA PLUS ........ 250PHENADOZ ..............................93PHENAZO ...............................275phenazopyridine hcl ..................275phendimetrazine tartrate .............. 3phendimetrazine tartrate er .......... 3phenelzine sulfate ........................72PHENERGAN ...........................93phenobarbital ............................297phenobarbital sodium ............... 297phenobarbital-belladonna alk .. 437PHENOHYTRO ..................... 437phenol ....................................... 369phenoxybenzamine hcl .............. 100phentermine hcl .............................3phentolamine mesylate ..............100PHENYLADE GMP MIX DHA/FIBER ............................ 250phenylephrine hcl ......160, 401, 453phenylephrine hcl (pressors) .... 453phenylephrine hcl-nacl ............. 453PHENYTEK ..............................70phenytoin .....................................70PHENYTOIN INFATABS .......70phenytoin sodium ........................ 70phenytoin sodium extended .........70pheodoyo ...................................194PHESGO ..................................127PHEXXI ...................................449pheyo .........................................194PHILITH ................................. 172

PHLAG SPRAY ......................213PHLEXY-10 ............................ 397phoma exigua ..............................10PHOSLYRA ............................ 270PHOSPHA 250 NEUTRAL ... 361PHOSPHASAL ....................... 110phosphorous ..............................361PHOSPHO-TRIN 250 NEUTRAL ...............................361PHOSPHO-TRIN K500 ......... 361PHOTOFRIN .......................... 128PHOTREXA VISCOUS .........406PHOTREXA-PHOTREXA VISCOUS KIT ........................ 407phoxillum b22k4/0 .................... 365physicians ez use b-12 ...............288physicians ez use j/t/t kit ii ........ 184physicians ez use joint/tunnel ... 184physicians ez use m-pred .......... 184PHYSIOLYTE ........................ 368PHYSIOSOL IRRIGATION .368physostigmine salicylate ............. 87phytonadione .............................454PICATO ...................................198PIFELTRO ..............................147pilocarpine hcl .................. 375, 401pimecrolimus .............................211pimozide ....................................427PIMTREA ............................... 167pindolol ..................................... 153pioglitazone hcl ...........................85pioglitazone hcl-glimepiride .......84pioglitazone hcl-metformin hcl ... 85pip lancets 28g ..........................323pip lancets 30g ..........................323piperacillin sod-tazobactam so .419PIQRAY (200 MG DAILY DOSE) ...................................... 133PIQRAY (250 MG DAILY DOSE) ...................................... 133PIQRAY (300 MG DAILY DOSE) ...................................... 134pirfenidone ................................432PIRMELLA 1/35 .....................172PIRMELLA 7/7/7 ....................177piroxicam .................................... 20pistachio nut (diagnostic) ......... 229PITOCIN ................................. 414PIXEL COVID-19 PCR HOME TEST .......................... 243PKU EASY .............................. 250PKU EASY MICROTABS .....250

495

PKU EXPRESS 15 PLUS+ .... 250PKU EXPRESS 20 PLUS+ .... 250PKU GO ...................................250PLAN B ONE-STEP ...............174PLAQUENIL ...........................111PLASBUMIN-25 ..................... 285PLASBUMIN-5 ....................... 285PLASMA-LYTE 148 .............. 359PLASMA-LYTE A ................. 359PLASMANATE ...................... 285PLAVIX ................................... 286PLEGISOL ..............................159PLEGRIDY ............................. 424PLEGRIDY STARTER PACK ....................................... 424PLENAMINE ..........................397PLENITY .....................................3PLENITY WELCOME KIT ..... 3PLENVU ..................................301PLEXION ................................ 189PLEXION CLEANSER ......... 189PLEXION CLEANSING CLOTH ....................................189PLEXION NS .......................... 200PLIAGLIS ............................... 220PLUVICTO ............................. 127PNEUMOVAX 23 ...................444pnv ob+dha ...............................386pnv tabs 20-1 .............................383pnv tabs 29-1 .............................383pnv-dha ..................................... 386pnv-dha+docusate .................... 386pnv-omega .................................383pnv-select .................................. 383POCKET CHAMBER ............353POCKET SPACER ................ 353POCKETCHEM EZ SYSTEM ..................................324POCKETCHEM EZ TEST ... 239pod-care 100c ........................... 184pod-care 100cg ......................... 184pod-care 100cmx .......................184pod-care 100k ........................... 180pod-care 100kg ......................... 184pod-care 100kmx .......................184PODIAPN ................................ 247PODOCON-25 .........................210podofilox ................................... 210podprog .....................................208POGO AUTOMATIC BLOOD GLUCOSE ............... 324

POGO AUTOMATIC TEST CARTRIDGES ........................239POINT OF CARE KM ...........184POINT OF CARE L.2 ............ 184POINT OF CARE L.5 ............ 184POINT OF CARE LM DEP 2184POINT OF CARE LM-2.2 ..... 303POINT OF CARE LM-2.5 ..... 303polidocanol ............................... 371POLIVY ...................................117POLOCAINE .......................... 305POLOCAINE-MPF ................ 305POLYCIN ................................404poly-iron 150 forte ....................293polymyxin b sulfate ................... 109polymyxin b-trimethoprim .........404polysaccharide iron forte ..........293polytoza patch ...........................351POLYTRIM ............................ 404POLY-VI-FLOR ..................... 380POLY-VI-FLOR FS ............... 380POLY-VI-FLOR/IRON ......... 380polyvinyl alcohol .......................399POMALYST ............................122PONVORY .............................. 430PONVORY STARTER PACK ....................................... 430pork (diagnostic) .......................229PORTIA-28 ............................. 172PORTRAZZA ......................... 121posaconazole ...............................92POSIMIR .................................305pot & sod cit-cit ac ................... 274POTABA ..................................453potassium acetate ......................362potassium chloride ............362, 363potassium chloride crys er ........362potassium chloride er ............... 362potassium chloride in dextrose . 359potassium chloride in nacl ........360potassium citrate er .................. 274potassium citrate-citric acid ..... 274potassium hydroxide ................. 166potassium phosphates ............... 361potassium phosphates(66 meq k) ............................................... 361potassium phosphates(71 meq k) ............................................... 361POTELIGEO .......................... 116povidone-iodine ........................ 404PR BENZOYL PEROXIDE .. 192

PR BENZOYL PEROXIDE WASH ...................................... 192PR CREAM .............................213PR NATAL 400 ....................... 385PR NATAL 400 EC ................ 385PR NATAL 430 ....................... 385PR NATAL 430 EC ................ 385PRADAXA .................................64PRALUENT .............................. 97pramipexole dihydrochloride ....138pramipexole dihydrochloride er138PRAMOSONE ........................ 216PRAMOTIC ............................ 413PRAMOX ................................ 211pramoxine-hc ............................ 216PRASTERA ...............................21prasugrel hcl .............................286PRAVACHOL ...........................96pravastatin sodium ......................96PRAXBIND ............................... 87praziquantel ................................ 50prazosin hcl ...............................102PRE & POST SX POUCH ..... 213PRECEDEX ............................ 300PRECISION PCX ...................239PRECISION PCX PLUS TEST ........................................ 239PRECISION POINT OF CARE TEST ............................239PRECISION QID TEST ........ 239PRECISION SOF-TACT TEST ........................................ 239PRECISION SUREDOSE PLUS SYR ............................... 344PRECISION SURE-DOSE SYRINGE ................................ 344PRECISION THINS GP LANCETS ............................... 324PRECISION XTRA ................324PRECISION XTRA BLOOD GLUCOSE ...............................239PRECOSE ................................. 75PRED FORTE .........................409PRED MILD ............................410PRED-G ................................... 407PRED-G S.O.P. ....................... 407prednicarbate ............................205prednisol ace-moxiflox-bromfen...................................................408prednisolone ............................. 180prednisolone acetate .................410prednisolone acetate p-f ............410

496

prednisolone acetate-nepafenac408prednisolone acet-moxifloxacin 408prednisolone sodium phosphate...................................180, 181, 410prednisolone-bromfenac ........... 408prednisolone-gatifloxacin ......... 408prednisolone-moxifloxacin ........408prednisolon-gatiflox-bromfenac408prednisolon-moxiflox-bromfenac ................................. 408prednisolon-moxiflox-nepafenac...................................................408prednisone .................................181PREDNISONE INTENSOL .. 181PREFERA OB .........................383PREFERAOB +DHA ..............386PREFERAOB ONE ................ 386preferred plus insulin syringe ...344preferred plus lancets colored .. 324preferred plus lancets thin ........ 324preferred plus unifine pentips ...344PREFEST ................................ 264pregabalin ...................................68pregabalin er ............................ 426pregen dha ................................ 386pregenna ................................... 383PREGNYL ...............................260prehevbrio .................................447PREMARIN .................... 266, 449PREMASOL ............................397PREMESISRX ........................ 387premium blood glucose test ...... 239premium lidocaine .................... 211premium scar ............................ 220PREMPHASE ......................... 264PREMPRO .............................. 264prena 1 true ...............................386prena1 ....................................... 387prena1 pearl ..............................383prenaissance ............................. 386prenaissance plus ......................386prenara ..................................... 383PRENATABS RX ................... 383prenatal .....................................383PRENATAL + DHA ............... 386prenatal 19 ................................383prenatal multi +dha ..................383prenatal plus ............................. 383prenatal plus iron ..................... 383prenatal plus vitamin/mineral ...383prenatal vitamin plus low iron ..383prenatal vitamins ...................... 383

PRENATAL-U ........................ 383PRENATE ............................... 387PRENATE AM ........................387PRENATE DHA ..................... 386PRENATE ELITE .................. 383PRENATE ENHANCE .......... 386PRENATE ESSENTIAL ........386PRENATE MINI .................... 386PRENATE PIXIE ................... 386PRENATE RESTORE ........... 386PRENATRIX ...........................384PRENATRYL ......................... 384prenatvite complete ...................384prenatvite plus .......................... 384prenatvite rx ..............................384PRE-PEN ................................. 230PREPIDIL ............................... 414prepiv supply .............................220preplus ...................................... 384PREPOPIK ..............................301PRESERA ................................213pressure activat safety lancet ....324PRESTALIA ............................. 98pretab ........................................384pretomanid ................................112PREVACID ............................. 441PREVACID SOLUTAB ......... 441PREVALITE ............................. 95PREVENT DROPSAFE PEN NEEDLES ................................344PREVENT SAFETY PEN NEEDLES ................................344PREVENTEZA ....................... 174PREVIDENT ...........................374PREVIDENT 5000 BOOSTER PLUS ....................374PREVIDENT 5000 DRY MOUTH ...................................374PREVIDENT 5000 ENAMEL PROTECT ............................... 373PREVIDENT 5000 ORTHO DEFENSE ................................374PREVIDENT 5000 PLUS .......374PREVIDENT 5000 SENSITIVE ............................. 373PREVIDOLRX ANALGESIC .17previdolrx plus analgesic ............17PREVIFEM ............................. 172PREVNAR 13 ..........................445PREVNAR 20 ..........................445PREVYMIS ............................. 149PREZCOBIX ...........................145

PREZISTA .............................. 146PRIALT ..................................... 26PRIFTIN ..................................112PRILO PATCH .......................220PRILO PATCH II ...................220priloheal plus 30 ....................... 220prilolid ...................................... 220PRILOSEC ..............................441prilovix ......................................220prilovix lite ................................220prilovix lite plus ........................ 220prilovix plus .............................. 220prilovix ultralite ........................ 220prilovix ultralite plus ................ 220prilovixil ....................................220PRIMACARE ..........................384primaquine phosphate .............. 111PRIMAXIN IV ........................ 105PRIMEAIRE HOLDING CHAMBER ............................. 350primidone ....................................68PRIMLEV ................................. 45PRIMSOL ................................104PRINIVIL ..................................99PRISMASOL BGK 4/0/1.2 .... 365PRISTIQ ....................................74privet ........................................... 10PRIVIGEN .............................. 417PRIZOPAK II ......................... 220PRIZOTRAL-II ...................... 220PRO COMFORT INSULIN SYRINGE ................................ 344pro comfort lancets 30g ............ 324pro comfort lancets 31g ............ 324pro comfort pen needles ............344pro comfort spacer adult .......... 353pro comfort spacer child ...........353pro comfort spacer infant ......... 353PRO DNA COLLECTION .... 239pro hers rx .................................387pro his rx ...................................387pro pcos rx ................................ 387pro voice v8 glucose system ......324pro voice v8/v9 glucose .............239pro voice v9 glucose system ......324PROAIR DIGIHALER ............ 58PROAIR HFA ........................... 58PROAIR RESPICLICK ...........58probenecid ................................ 276probichew ................................... 85PROBINATE .............................85

497

PROBUPHINE IMPLANT KIT ............................................. 46procainamide hcl ........................ 53PROCALAMINE ....................397PROCARDIA ..........................156PROCARDIA XL ................... 157procare spacer/adult mask ........353procare spacer/child mask ........353PRO-C-DURE 5 ...................... 181PRO-C-DURE 6 ...................... 181PROCENTRA ............................. 2PRO-CEPTION ...................... 448prochlorperazine .......................142prochlorperazine edisylate ....... 142prochlorperazine maleate .........142PROCORT ................................ 49PROCRIT ................................289pro-critic ................................... 247PROCTOCORT ........................49PROCTOFOAM HC ................ 49PROCTO-MED HC ..................49PROCTO-PAK ......................... 49PROCTOSOL HC .................... 50PROCTOZONE-HC .................50PROCYSBI ..............................274prodigen ......................................85PRODIGY AUTOCODE BLOOD GLUCOSE ............... 324PRODIGY INSULIN SYRINGE ................................ 344PRODIGY LANCETS 28G ... 324PRODIGY LANCING DEVICE ...................................324PRODIGY NO CODING BLOOD GLUC ............... 239, 324PRODIGY POCKET BLOOD GLUCOSE ............... 324PRODIGY SAFETY LANCETS 26G ....................... 324PRODIGY TWIST TOP LANCETS 28G ....................... 324PRODIGY VOICE BLOOD GLUCOSE ...............................324PROFERRIN-FORTE ........... 294professional dna collection .......239PROFILNINE ......................... 282PROFINAC ............................. 197profola .......................................379progesterone ............................. 421progesterone micronized ...........421PROGLYCEM ..........................77PROGRAF ...............................369

PROHANCE ........................... 244PROLASTIN-C ...............430, 431PROLATE ................................. 45PROLEEVA ............................ 247PROLENSA .............................406PROLEUKIN .......................... 127proleva ...................................... 247PROLIA ...................................261PROMACTA ...........................295PROMACTIN AA PLUS 20PE ......................................... 250promella in prebiotic .................. 85promethazine hcl .........................93promethazine vc ........................ 185promethazine vc/codeine ...........187promethazine-codeine ...............186promethazine-dm ...................... 186promethazine-phenyleph-codeine ......................................187promethazine-phenylephrine .... 185PROMETHEGAN .................... 93PROMETRIUM ......................421PROMISEB ............................. 200propafenone hcl .......................... 54propafenone hcl er ......................54propantheline bromide ..............442proparacaine hcl .......................406proparacaine-fluorescein ..........405PROPECIA ............................. 222PROPEL .................................. 392PROPEL MINI ....................... 392PROPEL MINI SDS ............... 392propofol .....................................273propofol-lipuro ......................... 273propranolol hcl ................. 153, 154propranolol hcl er .....................153propranolol-hctz ....................... 103propylthiouracil ........................ 434PROQUAD .............................. 445PROSCAR ............................... 273PROSILK ........................ 213, 351PROSOL ..................................397PROSTIN E2 ...........................414PROSTIN VR ..........................371protamine sulfate ...................... 286PROTECT PLUS ....................379PROTECTIRON .....................293PROTEOLIN .......................... 248PROTEOLIN DS .................... 248protexa ...................................... 207PROTEXT ............................... 218PROTHELIAL ........................375

PROTONIX .............................441PROTOPAM CHLORIDE ...... 87PROTOPIC ............................. 212protriptyline hcl .......................... 75PROTYL AG ...........................227provad ......................................... 85PROVAYBLUE ........................ 87PROVENGE ............................119PROVENTIL HFA ................... 58PROVERA ...............................421PROVIDA OB .........................384PROVIGIL .................................. 6PROVISC ................................ 411PROVOCHOLINE ................. 230PROXIVOL .............................211PROZAC ................................... 73PRUCLAIR ............................. 213PRUDOXIN .............................198PRUMYX .................................213pseudoeph-bromphen-dm ..........186pseudoeph-chlorphen-hydrocod187PSORCON ...............................205PSORIZIDE FORTE ..............367PSORIZIDE ULTRA ............. 367PSS SELECT GP LANCETS 324PSS SELECT PLATFORMS .324PSS SELECT SAFETY LANCETS ............................... 324PTS PANELS GLUCOSE TEST ........................................ 239PULMICORT ........................... 60PULMICORT FLEXHALER ..60PULMONA ..............................248PULMONEB LT .....................332PULMOSAL ............................186PULMOZYME ....................... 431PURAPLY ............................... 227PURAPLY 1.6CM ...................227PURAPLY ANTIMICROBIAL 2X2CM ..227PURAPLY ANTIMICROBIAL 2X4CM ..227PURAPLY ANTIMICROBIAL 3X4CM ..227PURAPLY ANTIMICROBIAL 4X4CM ..227PURAPLY ANTIMICROBIAL 5X5CM ..227PURAPLY ANTIMICROBIAL 6X9CM ..227PURAPLY ANTIMICROBIAL 8X16CM 227

498

PURAPLY XT ANTIMICROBIAL 5X5CM ..227PURAPLY XT ANTIMICROBIAL 6X9CM ..227pure comfort lancets 30g .......... 324pure comfort pen needle ........... 344purefe ob plus ........................... 384purefe plus ................................ 293purevit dualfe plus .................... 293PURIXAN ................................115push button safety lancets .........324push button safety lancets 28g ..324px advanced lancing device ...... 324px aspirin .................................... 24px enteric aspirin ........................ 25px extra short pen needles ........ 344px folic acid ...............................291px insulin syringe ......................345px lancets microthin 33g ...........324px lancets ultra thin .................. 324px lancets ultra thin 28g ........... 324px mini pen needles ...................345px pen needle ............................ 345px shortlength pen needles ........345px stop smoking aid .................. 429PYLARIFY ..............................232PYLERA ..................................442pyrazinamide .............................112PYRIDIUM ..............................275pyridostigmine bromide ............ 112pyridostigmine bromide er ........112pyridoxal-5 phosphate .............. 454pyridoxine hcl ........................... 454pyrimethamine .......................... 111pyrimethamine-leucovorin ........ 110pyrogallic acid .......................... 209PYRUKYND ............................286PYRUKYND TAPER PACK .286QBRELIS ...................................99QBREXZA ...............................213qc advanced lancing device ...... 324qc aspirin low dose ..................... 25qc childrens aspirin .................... 25qc folic acid ...............................291qc lancets super thin 30g .......... 324qc lancets ultra thin .................. 324qc nicotine transdermal system .429qc pen needles ...........................345qc unifine pentips ......................345qc unilet lancets 28g ................. 325qc unilet lancets micro thin .......325QDOLO ..................................... 42

QELBREE ................................... 1QINLOCK ............................... 123QMIIZ ODT .............................. 20QNASL .....................................392QNASL CHILDRENS ............392QSYMIA ......................................3QTERN ...................................... 83quad-mix ................................... 159QUADRACEL .........................436QUADRAMET ........................127QUAKE ....................................350QUALAQUIN ......................... 111QUARTETTE ......................... 174QUASENSE .............................174quazepam .................................. 299QUDEXY XR ............................ 68queen palm ..................................10QUELICIN .............................. 393QUESTRAN .............................. 95QUESTRAN LIGHT ................ 95quetiapine fumarate .................. 141quetiapine fumarate er ..............141QUFLORA FE ........................ 377QUFLORA FE PEDIATRIC .380QUFLORA GUMMIES ......... 380QUFLORA PEDIATRIC .......380QUICKTEK ............................ 325QUICKTEK TEST ................. 239QUICKTEK/METER .............325QUICKVUE + STREP A TEST ........................................ 243QUICKVUE AT-HOME COVID-19 TEST .................... 243QUICKVUE DIPSTICK STREP A TEST ...................... 243QUICKVUE INFLUENZA A+B TEST ............................... 243QUICKVUE IN-LINE STREP A TEST ...................... 243QUICKVUE SARS ANTIGEN TEST .................... 243quihoxvar .................................. 198QUILLICHEW ER .....................6QUILLIVANT XR ......................6quinapril hcl ................................99quinapril-hydrochlorothiazide ....99quinidine gluconate er ................ 53quinidine sulfate ..........................53quinine sulfate ...........................111QUINIXIL ............................... 222QUINJA ................................... 194

QUINTET AC BLOOD GLUCOSE TEST ....................239QUINTET BLOOD GLUCOSE TEST ....................239QULIPTA ................................ 354QUTENZA ...............................211QUTENZA (2 PATCH) ..........211QUTENZA (4 PATCH) ..........211QUVIVIQ ................................ 299QUZYTTIR ............................... 93QVAR REDIHALER ............... 61ra aspirin adult low dose ............ 25ra aspirin adult low strength ...... 25ra aspirin childrens .....................25ra aspirin ec ................................25ra aspirin ec adult low st ............ 25RA E-ZJECT LANCETS 28G...................................................325RA E-ZJECT LANCETS THIN 26G ................................ 325RA E-ZJECT LANCETS THIN 28G ................................ 325RA E-ZJECT LANCETS ULTRA THIN ......................... 325ra folic acid ...............................291ra insulin syringe ...................... 345ra mini nicotine .........................429ra nicotine .................................429ra nicotine gum ......................... 429ra nicotine polacrilex ................429ra pen needles ........................... 345RABAVERT ............................447rabbit epithelium .........................10rabeprazole sodium .......... 441, 442RADIAPLEXRX .....................227RADIAURA .............................216RADICAVA .............................392RADICAVA ORS ................... 393RADICAVA ORS STARTER KIT ........................................... 393RADIOGARDASE ................... 87RAGWITEK ............................. 10RAJANI ................................... 172raloxifene hcl ............................ 261ramelteon .................................. 300ramipril ....................................... 99RANEXA ................................... 50ranolazine er ...............................50RAPAFLO ............................... 273RAPAMUNE ........................... 369rapid gel rx ............................... 367RAPIVAB ................................ 151

499

rasagiline mesylate ................... 136RASUVO ............................. 14, 15RAVICTI ................................. 262RAYALDEE ............................258RAYOS .................................... 181RAZADYNE ............................423RAZADYNE ER ..................... 423REACT .................................... 174READI-CAT 2 .........................244READYLANCE SAFETY LANCETS ............................... 325READYSHARP ANESTH + BETAMETH ........................... 184READYSHARP ANESTH + DEXAMETH ...........................184READYSHARP ANESTH + KETOROLAC .......................... 17READYSHARP ANESTH + METHYLPRED ......................184READYSHARP BETAMETHASONE ............. 184READYSHARP DEXAMETHASONE ............. 181READYSHARP LIDOCAINE...................................................305READYSHARP-A .................. 303REAL HEAL-I ........................ 220reality insulin syringe ............... 345reality lancets ............................325reality trigger lancets ............... 325REBIF ...................................... 424REBIF REBIDOSE ................ 424REBIF REBIDOSE TITRATION PACK ............... 424REBIF TITRATION PACK ..424REBINYN ................................282REBLOZYL ............................ 288RECARBRIO ..........................105RECEDO ................................. 215reck ............................................302RECLAST ............................... 254RECLIPSEN ........................... 172RECOMBINATE ....................282RECOMBIVAX HB ....... 447, 448RECORLEV ............................255RECOTHROM ....................... 296RECOTHROM SPRAY KIT .296RECTIV .....................................48RECURA ................................. 194red birch ......................................10red cedar .....................................10red maple .................................... 10

red mulberry ............................... 10red top grass pollen .................... 10REDITREX ............................... 15REFISSA ................................. 193REFUAH PLUS BLOOD GLUCOSE TEST ....................239REFUAH PLUS MONITORING SYSTEM ..... 325REGEN-COV ..........................417REGENECARE ...................... 223REGIOCIT ................................63REGLAN ................................. 268REGONOL ..............................112REGRANEX ........................... 222RELADOR PAK .....................220RELADOR PAK PLUS ..........220RELAFEN ................................. 20RELAFEN DS ........................... 20RELENZA DISKHALER ...... 151RELEUKO .............................. 292releuko ...................................... 292RELEXXII ...................................6RELION ALL-IN-ONE ..........325RELION BLOOD GLUCOSE TEST ........................................ 239RELION CONFIRM GLUCOSE MONITOR ..........325RELION CONFIRM/MICRO TEST ........................................ 239RELION INSULIN SYRINGE ................................ 345RELION KETONE TEST ..... 239RELION LANCETS MICRO-THIN 33G ................ 325RELION LANCETS THIN 26G ........................................... 325RELION LANCETS ULTRA-THIN 30G ................................ 325RELION LANCING DEVICE ...................................325RELION MICRO ................... 325RELION MINI PEN NEEDLES ................................345RELION PEN NEEDLES ......345RELION PREMIER BLU MONITOR .............................. 325RELION PREMIER CLASSIC ................................. 325RELION PREMIER COMPACT SYSTEM ............ 325RELION PREMIER TEST ... 239

RELION PREMIER VOICE MONITOR .............................. 325RELION PRIME MONITOR325RELION PRIME TEST ......... 240RELION SHORT PEN NEEDLES ................................345RELION TRUE MET AIR GLUC METER ....................... 325RELION TRUE METRIX TEST STRIPS ......................... 240RELION ULTIMA GLUCOSE SYSTEM ............. 325RELION ULTIMA TEST ......240RELION ULTRA THIN LANCETS 30G ....................... 325RELION ULTRA THIN PLUS LANCETS .................... 325RELISTOR ..............................270relnate dha ................................ 384RELPAX ..................................356RELTONE ...............................267remdesivir ................................. 151REMEDIENT ..........................378REMERON ............................... 71REMERON SOLTAB .............. 71REMICADE ............................ 271remifentanil hcl ...........................42remifentanil hcl-nacl ...................43remigen ..................................... 213REMODULIN ......................... 160RENACIDIN ........................... 275RENAGEL ...............................270RENAL .................................... 376RENAL MULTIVITAMIN FORMULA ..............................376renal vitamin .............................376renal-vite ...................................376RENATABS .............................376RENATABS WITH IRON .....376rena-vite ....................................376rena-vite rx ................................376RENFLEXIS ........................... 271reno caps ...................................376RENOVA ................................. 193RENOVA PUMP .....................193RENVELA ...............................270REOPRO ................................. 284repaglinide ..................................83REPATHA .................................97REPATHA PUSHTRONEX SYSTEM ....................................97REPATHA SURECLICK ........ 98

500

REQ 49+ .................................. 379REQUIP XL ............................ 138RESCRIPTOR ........................ 147RESET ..................................... 366RESET FOR IOS OR ANDROID APP .......................366RESET NON-MONETARY CM ............................................366RESET-O .................................366RESET-O FOR IOS OR ANDROID APP .......................366RESET-O NON-MONETARY CM ...................366resorcinol-sulfur ....................... 189RESTASIS ............................... 405RESTASIS MULTIDOSE ......405RESTORA RX .......................... 85RESTORE SILVER DRESSING ..............................227RESTORIL ..............................299RETACRIT ............................. 289RETAVASE .............................287RETAVASE HALF-KIT ........287RETEVMO ..............................124RETHYMIC ............................365RETIN-A ................................. 192RETIN-A MICRO .................. 192RETIN-A MICRO PUMP ......192RETISERT .............................. 410RETROVIR .............................148REVATIO ................................162REVCOVI ............................... 253REVEAL BLOOD GLUCOSE TEST ....................240revesta .......................................290REVLIMID ............................. 368REVONTO .............................. 390REXALL BLOOD GLUCOSE SYSTEM ............. 325REXALL BLOOD GLUCOSE TEST ....................240REXALL LANCETS ULTRA THIN 30G ................................ 325REXASIL PATCH & VITAMIN E LIQ .................... 223REXULTI ................................ 143REYATAZ ...............................146REYVOW ................................357REZIPRES .............................. 453REZUROCK ........................... 371R-GENE 10 ..............................230RHEOSPRAY ......................... 420

RHEUMATE ...........................248rhizopus .......................................10RHOFADE .............................. 214RHOGAM ULTRA-FILTERED PLUS ...................417RHOPHYLAC ........................ 417RHOPRESSA ..........................407RIABNI ....................................117RIASTAP .................................282ribavirin ............................ 150, 151ribozel ....................................... 248rice (diagnostic) ........................229RIDAURA ..................................16rifabutin .................................... 112RIFADIN ................................. 112RIFAMATE .............................112rifampin .....................................112RIFAMPIN+SYRSPEND SF .112RIFATER ................................ 112RIGHTEST ALTERNATE SITE ADAPT .......................... 325RIGHTEST GD500 LANCING DEVICE ...............326RIGHTEST GL300 LANCETS ............................... 326RIGHTEST GM100 BLOOD GLUCOSE ...............................326RIGHTEST GM300 BLOOD GLUCOSE ...............................326RIGHTEST GM550 BLOOD GLUCOSE ...............................326RIGHTEST GS100 BLOOD GLUCOSE ...............................240RIGHTEST GS300 BLOOD GLUCOSE ...............................240RIGHTEST GS550 BLOOD GLUCOSE ...............................240RIGHTEST GT333 BLOOD GLUCOSE .......................240, 326RILUTEK ................................393riluzole ...................................... 393rimantadine hcl .........................151RIMSO-50 ............................... 275ringers .......................................360RINVOQ ....................................14RIOMET ....................................76RIOMET ER ............................. 76risedronate sodium ................... 254RISPERDAL ........................... 140RISPERDAL CONSTA ..........140risperidone ................................140RITALIN ..................................... 6

RITALIN LA ...............................6RITEFLO ................................ 353ritonavir .................................... 146RITUXAN ................................117RITUXAN HYCELA ..............127rivastigmine .............................. 423rivastigmine tartrate ................. 423RIVELSA .................................174rixubis ....................................... 282rizatriptan benzoate .................. 356R-NATAL OB ......................... 386roaoxia ......................................198ROBAXIN ............................... 389ROBAXIN-750 ........................ 389ROBINUL ................................442ROBINUL-FORTE .................442ROCALTROL .........................258ROCKLATAN ........................ 405rocuronium bromide ................. 394romidepsin ................................ 122ROPIDEX ................................184ropinirole hcl ............................ 138ropinirole hcl er ........................138ropivacaine hcl ......................... 305ropivacaine hcl-nacl ................. 305ropiv-clonidine-ketorolac ......... 302ROSADAN ...............................214rosuvastatin calcium ...................96ROSZET .................................... 97ROTARIX ............................... 448ROTATEQ .............................. 448rough marsh elder .......................10rough pigweed ............................ 10ROWASA ................................ 269ROWEEPRA .............................68ROWEEPRA XR ...................... 68ROXICODONE ........................ 43roxifol-d .................................... 290ROXYBOND ............................. 43ROZEREM ..............................300ROZLYTREK .........................124RTD WOUND CARE DRESSING ..............................227RUBRACA .............................. 134RUCONEST ............................ 283rufinamide ...................................68RUKOBIA ............................... 145russian thistle ..............................10RUXIENCE ............................. 117RUZURGI ............................... 112RX SUPPORT HB/REFLUX/ALOE ...............290

501

RYANODEX ........................... 390RYBELSUS ............................... 82RYBREVANT ......................... 124RYCLORA ................................ 92RYDAPT ..................................123RYLAZE ..................................127RYPLAZIM .............................285RYTARY ................................. 137RYTHMOL SR ......................... 54RYVENT ................................... 93sa3 derm ....................................421SABRIL ..................................... 69saccharomyces cerevisiae ...10, 229SAFE-SENSE EARLOOP FACE MASK .......................... 331SAFESNAP INSULIN SYRINGE ................................ 345SAFE-T-LANCE .....................326SAFE-T-LANCE PLUS ..........326safety insulin syringes ...............345safety lancet 21g/pressure act ...326safety lancet 23g/pressure act ...326safety lancet 28g/pressure act ...326safety lancet 30g/pressure act ...326SAFETY LANCETS ...............326SAFETY LANCETS 21G .......326safety lancets 28g ......................326SAFETY LET LANCETS ......326SAFETY SEAL LANCETS ... 326SAFYRAL ............................... 172sagebrush ....................................10SAIZEN ................................... 256SAIZENPREP ......................... 256SAJAZIR ................................. 283SALAGEN ............................... 375SALEX ..................................... 210salicylic acid ............................. 210salicylic acid er .........................210salicylic acid wart remover .......210salicylic acid-cleanser .............. 210salimez ...................................... 210salimez forte ..............................210saline bacteriostatic ..................420saline-phenol .............................420SALIVAMAX ..........................373salsalate ...................................... 25salt durable cream .................... 421SALTSTABLE LO ................. 421SALVAX ..................................210SALVAX DUO PLUS .............209SAMSCA ................................. 261sanadermrx skin repair .............222

SANCUSO ................................. 89SANDIMMUNE ......................366SANDOSTATIN ..................... 262SANDOSTATIN LAR DEPOT .....................................262sanofi covid-19 vac (booster) ... 448SANTYL .................................. 208SAPHNELO ............................ 372SAPHRIS ................................. 141sapropterin dihydrochloride .....261saps health twist top lancets ..... 326saps twist top lancets ................ 326sapscare twist top lancets ......... 326SARAFEM ...............................426SARCLISA .............................. 117saroxia ...................................... 189SAVAYSA ................................. 61SAVELLA ............................... 423SAVELLA TITRATION PACK ....................................... 423SAXENDA ................................... 4sb aspirin .................................... 25sb aspirin adult low strength ...... 25sb childrens aspirin .....................25sb insulin syringe ...................... 345sb lancets thin ........................... 326sb lancets ultra thin .................. 326sb low dose asa ec .......................25SCALACORT DK .................. 222SCARCARE GEL-PAD KIT/LARGE ............................223scarcin .......................................215scarcin pad plus ........................351scarcinpad .................................351scarsilk ..............................215, 351SCARZEN SKIN REPAIR .... 222SCEMBLIX ............................. 120SCENESSE ..............................212SCLEROSOL INTRAPLEURAL .................. 431scopolamine ................................ 89SEASONIQUE ........................ 175SEBUDERM ............................213SECREFLO .............................230SECUADO ...............................141SECURESAFE INSULIN SYRINGE ................................ 345SECURESAFE SAFETY PEN NEEDLES .......................345SEEBRI NEOHALER ..............58SEGLENTIS ..............................46SEGLUROMET ........................83

SELECT-OB ........................... 384SELECT-OB+DHA ................ 386selegiline hcl ............................. 136selenious acid ............................364selenium sulfide ........................ 200SELRX ..................................... 200SELZENTRY .......................... 145SEMGLEE .................................81SEMGLEE (YFGN) ..................81SEMPREX-D ...........................185se-natal 19 ................................ 384SENSIPAR ...............................254SENSORCAINE ..................... 305SENSORCAINE/EPINEPHRINE ........................................... 303SENSORCAINE-MPF ........... 305SENSORCAINE-MPF/EPINEPHRINE .............303SENTRA AM .......................... 248SENTRA PM ...........................248SEREVENT DISKUS ...............58SERNIVO ................................ 205SEROQUEL ............................ 141SEROQUEL XR ..................... 141SEROSTIM ..................... 256, 257sertraline hcl ...............................73sesame seed (diagnostic) .......... 229se-tan plus .................................293SETLAKIN ..............................175sevelamer carbonate .................270sevelamer hcl ............................ 270SEVENFACT .......................... 282sevoflurane ................................273SEYSARA ................................434sf ................................................374sf 5000 plus ............................... 374SFROWASA ............................269shagbark hickory .........................11SHAROBEL ............................ 176sheep sorrel .................................11SHINGRIX .............................. 448SHOPKO AUTOLET LANCING DEVICE ...............326SHOPKO ON-THE-GO LANCETS 30G ....................... 326SHOPKO UNIFINE PENTIPS ................................. 345SHOPKO UNIFINE PENTIPS PLUS ...................... 345SHOPKO UNILET LANCETS 28G ....................... 326

502

SHOPKO UNILET LANCETS 30G ....................... 326short ragweed pollen ext .............11shrimp (diagnostic) ...................229SHUR-SEAL CONTRACEPTIVE ............... 449side button safety lancet ............326SIDEROL ................................ 379SIGNIFOR ...............................262SIGNIFOR LAR ..................... 262SIKLOS ................................... 288SILA III ................................... 222SILADERM .............................351siladone scar patch ................... 351silatrix ....................................... 375sildenafil citrate ........................ 162SILENOR ................................ 299silicone mask/adult ................... 350silicone mask/infant .................. 350silicone mask/pediatric ............. 350silipac ........................................215SILIQ ....................................... 199silivex ........................................ 351silodosin ....................................273SILTREX .................................351SILVADENE ........................... 201silver nitrate ..............................202silver sulfadiazine ..................... 201SILVERSEAL HYDROGEL DRESSING ..............................227SILVRSTAT WOUND DRESSING ..............................227SIMBRINZA ........................... 399SIMLIYA .................................167SIMPESSE ...............................175SIMPLICITY COVID-19 AT-HOME ......................................243SIMPONI .............................15, 16SIMPONI ARIA ........................15SIMULECT ............................. 369simvastatin .................................. 96SINEMET ................................138SINEMET CR ......................... 137SINGLE-LET ..........................326SINGULAIR ..............................59SINUVA ................................... 392sirolimus ................................... 369SIRTURO ................................ 112SITAVIG ................................. 150SITZMARKS .......................... 244SITZMARKS COMBO PACKAGE .............................. 244

SIVEXTRO ............................. 109skarlite ...................................... 351SKELAXIN ............................. 389SKLICE ................................... 215SKYADERM-LP .....................220SKYLA .....................................175SKYRIZI ................................. 199SKYRIZI (150 MG DOSE) .... 199SKYRIZI PEN ........................ 199SKYTROFA ............................ 257SLYND .....................................176sm aspirin adult low strength ..... 25sm aspirin ec low strength .......... 25sm aspirin low dose .................... 25sm childrens aspirin ....................25sm folic acid ..............................291sm lancets 33g ...........................326sm nicotine ................................ 429sm nicotine polacrilex ...............429SMART DIABETES VANTAGE LANCING .......... 326SMART SENSE COLOR LANCETS 33G ....................... 326SMART SENSE PREMIUM SYSTEM ..................................326SMART SENSE PREMIUM TEST ........................................ 240SMART SENSE STANDARD LANCETS ............................... 326SMART SENSE SUPER THIN LANCETS .................... 326SMART SENSE THIN LANCETS 26G ....................... 327SMART SENSE VALUE GLUCOSE SYS ...................... 327SMART SENSE VALUE TEST ........................................ 240SMARTEST BLOOD GLUCOSE TEST ....................240SMARTEST EJECT .............. 327SMARTEST EJECT STARTER ............................... 327SMARTEST LANCETS 28G 327SMARTEST PERSONA STARTER ............................... 327SMARTEST PRONTO STARTER ............................... 327SMARTEST PROTEGE ........327SMARTEST PROTEGE STARTER ............................... 327SMOFLIPID ............................398SOAANZ ..................................252

sod benz-sod phenylacet ........... 262sod citrate-citric acid ................274sodium acetate .......................... 357sodium bicarbonate ............ 50, 357sodium bicarbonate-dextrose ....357sodium chloride ........ 186, 275, 364sodium chloride (pf) ..................363sodium chloride bacteriostatic . 420sodium chloride flush ................364sodium citrate ............................. 61sodium citrate lock flush .............61sodium citrate-gentamicin sulf ... 63SODIUM DIURIL .................. 253SODIUM EDECRIN .............. 252sodium fluoride ................. 360, 374sodium fluoride 5000 enamel ....373sodium fluoride 5000 plus ........ 374sodium fluoride 5000 ppm ........ 374sodium fluoride 5000 sensitive . 373sodium hydroxide ......................166sodium iodide i-131 .................. 434sodium nitrite .............................. 87sodium nitroprusside ................ 104sodium phenylbutyrate ..............262sodium phosphates ....................361sodium polystyrene sulfonate ....371sodium saccharin ...................... 251sodium sulfacetamide ................200sodium sulfacetamide wash ...... 200sodium sulfacetamide-bakuchiol...................................................200sodium tetradecyl sulfate .......... 372sodium thiosulfate .......................87SOFIA INFLUENZA A+B FIA ........................................... 243SOFIA SARS ANTIGEN FIA243SOFIA STREP A FIA ............ 243SOFIA STREP A+ FIA .......... 243SOFIA2 FLU+SARS ANTIGEN FIA ........................230SOFIA2 SARS ANTIGEN FIA ........................................... 243sofosbuvir-velpatasvir ...............150solaravix ................................... 198SOLESTA ................................367solifenacin succinate .................443SOLIQUA ..................................82SOLIRIS .................................. 283SOLODYN ...............................434SOLOSEC ................................. 13SOLOX .................................... 227SOLTAMOX ........................... 114

503

SOLU-CORTEF ..................... 181SOLU-MEDROL .................... 181SOLUS V2 BLOOD GLUCOSE SYSTEM ............. 327SOLUS V2 LANCETS 28G ... 327SOLUS V2 LANCING DEVICE ...................................327SOLUS V2 TEST .................... 240SOLUS V2 TWIST LANCETS 30G ....................... 327SOMA ...................................... 389SOMATULINE DEPOT ........ 262SOMAVERT ........................... 255SOMRYST ...............................366SONAFINE ..............................227SOOLANTRA ......................... 214SOOTHEE ...............................220sorafenib tosylate ......................123sorbitol ......................................275sorbitol-mannitol ...................... 275SORIATANE ...........................199SORILUX ................................ 200SORINE ................................... 154sorrel/dock mix ........................... 12sotalol hcl ..................................154sotalol hcl (af) ...........................154SOTRADECOL ...................... 372sotrovimab ................................ 415SOTYLIZE ..............................154SOVALDI ................................ 150soybean (diagnostic) .................229SPASCUPREEL ..................... 367SPEEDGEL RX ...................... 367SPHERUSOL .......................... 229SPIKEVAX COVID-19 VACCINE ................................448spinosad .................................... 215SPINRAZA ..............................394spiny pigweed ..............................11SPIRIVA HANDIHALER ....... 59SPIRIVA RESPIMAT ..............59spiro pd ..................................... 350spironolactone .......................... 253spironolactone-hctz ...................252SPORANOX ..............................92SPORANOX PULSEPAK ........92SPRAVATO (56 MG DOSE) ...72SPRAVATO (84 MG DOSE) ...72SPRINTEC 28 ......................... 172SPRITAM ..................................68SPRIX ........................................ 21SPRYCEL ................................120

SPS ........................................... 371SRONYX ................................. 172SSD ........................................... 201SSKI ......................................... 185sss 10-5 ..................................... 189ST JOSEPH ASPIRIN ............. 25ST JOSEPH LOW DOSE ........ 25STALEVO 100 ........................ 138STALEVO 125 ........................ 138STALEVO 150 ........................ 138STALEVO 200 ........................ 138STALEVO 50 .......................... 138STALEVO 75 .......................... 138stamaril ..................................... 448STARLIX ...................................83stavudine ................................... 148STAXYN ..................................162STEGLATRO ........................... 83STEGLUJAN ............................ 83STELARA ....................... 199, 270stemphylium ................................ 11STENDRA ............................... 162STERILANCE PA .................. 327STERILANCE TL .................. 327STERILE DILUENT FLOLAN PH 12 ...................... 420sterile diluent/epoprostenol ...... 420STERILE TALC POWDER ..431STERILE TOPICAL L.E.T. GEL ..........................................220sterile water for injection ..........420STERITALC ........................... 431STIMATE ................................263STIOLTO RESPIMAT ............ 56STIVARGA ............................. 123STRATA CTX .........................213STRATA GRT ........................ 227STRATA MARK .................... 213STRATA TRIZ ....................... 215STRATA XRT .........................213STRATAGRAFT .................... 218STRATTERA ..............................1STRAVIX ................................ 218strawberry (diagnostic) ............ 229STRENSIQ .............................. 258streptococcinum 30c ................. 367streptomycin sulfate .................... 13STRIBILD ............................... 145STRIVERDI RESPIMAT ........ 58STROMECTOL ........................50strontium chloride sr-89 ........... 127STROVITE FORTE ...............379

STROVITE ONE .................... 379SUBLOCADE ........................... 46SUBOXONE ..............................46SUBSYS ..................................... 43SUBVENITE ............................. 68SUBVENITE STARTER KIT-BLUE .................................68SUBVENITE STARTER KIT-GREEN ............................. 68SUBVENITE STARTER KIT-ORANGE .......................... 68succinylcholine chloride ........... 393SUCRAID ................................ 251sucralfate .................................. 440sufentanil citrate ......................... 43SULAR .....................................157sulconazole nitrate ....................209sulfacetamide sodium ........200, 410sulfacetamide sodium (acne) .... 187sulfacetamide sodium (cleans) ..200sulfacetamide sodium-sulfur...........................................189, 190sulfacetamide sod-sulfur wash ..190sulfacetamide-prednisolone ......408sulfacetamide-sulfur in urea ..... 190SULFACLEANSE 8/4 ............ 190sulfadiazine ............................... 432sulfamethoxazole-trimethoprim 105sulfamez wash ........................... 190SULFAMYLON ......................201sulfasalazine ............................. 269SULFATRIM PEDIATRIC ...105sulfurated lime .......................... 215SULFZIX ................................. 248sulindac .......................................21SUMADAN ..............................190SUMADAN WASH .................190SUMADAN XLT .....................190SUMANSETRON ................... 355sumatriptan ............................... 356sumatriptan succinate ...............356sumatriptan succinate refill ...... 356sumatriptan-naproxen sodium .. 355SUMAXIN ............................... 190SUMAXIN CP .........................190sunitinib malate ................ 123, 124SUNOSI ....................................... 4SUPARTZ FX ......................... 391super bi-mix .............................. 159super quad-mix ......................... 159super thin lancets ......................327super tri-mix ..............................159

504

SUPERVITE ........................... 377support ...................................... 379SUPPORT-500 ........................ 387SUPPRELIN LA ..................... 259SUPRANE ............................... 273SUPRAX .................................. 166SUPREME TEST ....................240SUPREP BOWEL PREP KIT...................................................301sure comfort insulin syringe ..... 346sure comfort lancets 18g ...........327sure comfort lancets 21g ...........327sure comfort lancets 23g ...........327sure comfort lancets 28g ...........327sure comfort lancets 30g ...........327sure comfort pen needles .......... 346SURE EDGE TEST ................ 240sure result dss premium pack ....197sure result o3d3 system ...............94SURE T INFUSION SET 18"/6MM ..................................331SURE T INFUSION SET 32"/10MM ................................331SURECHEK BLOOD GLUCOSE TEST ....................240SURE-FINE PEN NEEDLES 346SURE-JECT INSULIN SYRINGE ................................ 346SURE-LANCE FLAT LANCETS ............................... 327SURE-LANCE LANCETS 26G ........................................... 327SURE-LANCE THIN LANCETS 28G ....................... 327SURE-LANCE ULTRA THIN LANCETS .................... 327SURELITE LANCETS .......... 327SURESTEP PRO LINEARITY ............................327SURE-TEST EASYPLUS MINI METER .........................327SURE-TEST EASYPLUS MINI TEST ............................. 240SURE-TOUCH LANCETS UNIVERSAL ...........................327SURGICEL SNOW 1"X2" ....297SURGICEL SNOW 2"X4" ....297SURGICEL SNOW 4"X4" ....297SURGISEAL ........................... 351SURGISEAL STYLUS ...........351SURGISEAL TWIST ............. 351SURVANTA ............................ 432

SUSTIVA ................................. 147SUSTOL .....................................89SUSVIMO (IMPLANT 1ST FILL) ........................................413SUSVIMO (IMPLANT REFILL) .................................. 413SUSVIMO OCULAR IMPLANT ............................... 349SUTAB ..................................... 301SUTENT .................................. 124suvicort ..................................... 213sweet corn (diagnostic) .............229sweet gum ....................................11sweet vernal grass pollen ............11SX1 MEDICATED POST-OPERATIVE ...........................220SYEDA .....................................172SYLVANT ............................... 368SYMAX DUOTAB ..................439SYMAX-SL ............................. 439SYMAX-SR ............................. 439SYMBICORT ............................56SYMBYAX .............................. 430SYMDEKO ..............................431SYMFI ..................................... 145SYMFI LO ...............................145SYMJEPI .................................450SYMLINPEN 120 ..................... 75SYMLINPEN 60 ....................... 75SYMPAZAN ..............................65SYMPROIC .............................270SYMTUZA .............................. 145SYNAGEX ...............................378SYNAGIS .................................415SYNALAR ............................... 205SYNALAR (CREAM) ............ 222SYNALAR (OINTMENT) ..... 222SYNALAR TS ......................... 222SYNAPRYN FUSEPAQ ...........43SYNAREL ............................... 259SYNATEK ............................... 378SYNDROS ................................. 90SYNERA ..................................220SYNERCID ............................. 109SYNERDERM .........................213SYNJARDY ...............................83SYNJARDY XR ........................ 84SYNRIBO ................................ 128SYNTHAMIN 17 .................... 397SYNTHROID .......................... 435SYNVISC .................................391SYNVISC ONE ....................... 391

SYPRINE .................................365syringe luer lock ........................346syringe luer slip ........................ 346SZOSIL 15 DAY SUPPLY .....351SZOSIL 8 DAY SUPPLY .......351T.R.U.E. TEST ........................ 244T: SLIM X2 INS PMP/CONTROL 7.4 .............. 331T:SLIM X2 3ML CARTRIDGE ..........................331T:SLIM X2 INSULIN PMP BASAL6.4 ................................ 331TABLOID ................................115TABRADOL FUSEPAQ ........ 389TABRADOL RAPIDPAQ ......389TABRECTA ............................ 122TACLONEX ............................222tacrolimus ......................... 212, 369tadalafil .............................162, 163tadalafil (pah) ........................... 162TAFINLAR ............................. 120TAGITOL V ............................244TAGRISSO ..............................121TAKE ACTION ...................... 174TAKHZYRO ........................... 284TALICIA ................................. 443TALIVA ...................................290tall ragweed ................................ 11TALTZ .....................................199TALZENNA ............................ 134TAMIFLU ............................... 151tamoxifen citrate ....................... 114tamsulosin hcl ........................... 273TANDEM F ............................. 294TANDEM PLUS ..................... 294TAPAZOLE ............................ 434TAPERDEX 12-DAY ............. 181TAPERDEX 6-DAY ............... 181TAPERDEX 7-DAY ............... 181TARCEVA ...............................121tardeoxia ................................... 191tardimaxia .................................191TARGADOX ........................... 434TARGRETIN .................. 134, 221TARINA 24 FE ....................... 172TARINA FE 1/20 .................... 172TARINA FE 1/20 EQ ..............172TARKA ......................................98taron forte ................................. 294TARON-C DHA ......................384TARON-PREX ........................386taroxia .......................................191

505

TARPEYO ...............................181TASIGNA ................................ 120TASMAR ................................. 137TASOPROL ............................ 205taurine .......................................398tavaborole ................................. 214TAVALISSE ............................286TAVNEOS ............................... 283TAYSOFY ............................... 172TAYTULLA ............................ 172tazarotene ......................... 192, 200TAZICEF .................................166TAZORAC .............................. 200TAZTIA XT ............................ 157TAZVERIK ............................. 122tb syringe 1 ml .......................... 346TDC MAX ............................... 421TDVAX .................................... 436TECARTUS .............................119TECENTRIQ .......................... 119TECFIDERA ...........................425TECHLITE AST LANCETS .327techlite insulin syringe ..............346TECHLITE LANCETS ..........327TECHLITE LANCETS 30G . 328TECHLITE PEN NEEDLES .346TECHNELITE ........................232technet tc 99m sulfur colloid .....232technetium tc 99m mebrofenin ..231technetium tc 99m medronate ... 232technetium tc 99m pyrophos ..... 232technetium tc 99m sestamibi .....231TEFLARO ............................... 166TEGADERM AG MESH ....... 228TEGRETOL ..............................68TEGRETOL-XR .......................68TEGSEDI .................................422TEKTURNA ............................103TEKTURNA HCT .................. 103TELCARE BLOOD GLUCOSE TEST ....................240TELFA AMD ISLAND DRESSING ..............................309TELFA AMD NON-ADHERENT ............................309telmisartan ................................ 101telmisartan-amlodipine .............100telmisartan-hctz ........................ 101temazepam ................................ 299TEMIXYS ................................145TEMODAR ............................. 130TEMOVATE ........................... 205

temozolomide ............................ 130temsirolimus ..............................123TENCON ................................... 22teniposide ..................................132TENIVAC ................................436tenofovir disoproxil fumarate ... 148TENORETIC 100 ................... 103TENORETIC 50 ..................... 103TENORMIN ............................153TEPADINA ............................. 113TEPEZZA ................................258TEPMETKO ........................... 122terazosin hcl ..............................103terbinafine hcl .............................91terbutaline sulfate ....................... 58terconazole ................................448teriparatide (recombinant) ....... 261teroderm-plus ............................421TERRELL ............................... 273TESSALON PERLES ............ 185TESTIM .....................................47TESTONE CIK .........................47TESTOPEL ............................... 47testosterone ................................. 47testosterone cypionate .................47testosterone enanthate ................ 47tetrabenazine .............................423tetracaine hcl .................... 306, 406tetracycline hcl ..........................434TETRIX ................................... 213TEXACORT ............................206TEZSPIRE .................................61tgt aspirin ..............................25, 26tgt aspirin low dose .....................25tgt blood glucose monitoring .... 328tgt blood glucose test ................ 240tgt childrens aspirin ....................26tgt lancet micro thin 33g ...........328tgt lancet thin 26g ..................... 328tgt lancet ultra thin 30g ............ 328tgt lancing device ......................328tgt nicotine ................................ 429tgt nicotine polacrilex ............... 429tgt nicotine step one .................. 429tgt nicotine step three ................429tgt nicotine step two .................. 429THALITONE .......................... 253thallous chloride tl 201 .............231THALOMID ............................365THAM ......................................357THE LIQUILIFT TRACE .....364THEO-24 ................................... 61

theophylline .................................61theophylline er ............................ 61THERAMINE ......................... 248THERAMINE PLUS .............. 248thiamine hcl .............................. 453THINLETS GP LANCETS ... 328THIOLA .................................. 275THIOLA EC ............................275thioridazine hcl ......................... 142thiotepa ..................................... 113thiothixene .................................143THRESHOLD PEP ................ 350thrivacin 30 ...............................250thrivacin detox .......................... 250THRIVE ...................................429thrivite 19 ..................................378thrivite rx .................................. 384THROMBATE III .................. 286THROMBIN-JMI ................... 297THROMBIN-JMI EPISTAXIS ............................. 297THROMBOGEN .................... 297THYMOGLOBULIN ............. 367THYQUIDITY ........................ 435THYROGEN ........................... 230thyroid .......................................435TIADYLT ER ..........................157tiagabine hcl ............................... 70TIAZAC ...................................157TIBSOVO ................................ 130TICE BCG ...............................128TICOVAC ............................... 448TIGAN ....................................... 89tigecycline ................................. 432TIGLUTIK .............................. 393TIKOSYN ..................................55TILIA FE .................................177timolol maleate ................. 154, 400timolol maleate (once-daily) .....400timolol maleate ocudose ........... 400timolol maleate pf ..................... 400timolol-brimon-dorzol-latanopr399timolol-brimonidine-dorzolamid...................................................399timolol-dorzolamid-latanoprost 399TIMOPTIC ..............................400TIMOPTIC OCUDOSE .........400TIMOPTIC-XE .......................400timothy grass pollen allergen ..... 11tinidazole ...................................104tiopronin ................................... 275TIROSINT ...............................435

506

TIROSINT-SOL ..................... 435TISSEEL ..................................296TISSUEBLUE ......................... 411TIVDAK .................................. 119TIVICAY ................................. 146TIVICAY PD ...........................146TIVORBEX ............................... 21tizanidine hcl .............................389tl gard rx ................................... 290TL G-FOL OS ......................... 377tl icon ........................................ 294TLANDO ................................... 47tl-fluorivite ................................ 380tl-hem 150 ................................. 294tl-icare .......................................248TNKASE ..................................287TOBAKIENT .......................... 248TOBI .......................................... 13TOBI PODHALER ...................13TOBRADEX ............................408TOBRADEX ST ......................408tobramycin .......................... 13, 403tobramycin sulfate ...................... 13tobramycin-dexamethasone ...... 408TOBREX ................................. 403TODAY SPONGE .................. 449todays health lancing device .....328todays health mini pen needles . 346todays health pen needles ......... 346todays health short pen needle ..346todays health thin lancets 28g .. 328todays health thin lancets 30g .. 328TOLAK ....................................198tolbutamide ................................. 84tolcapone ...................................137tolmetin sodium ...........................21tolsura ......................................... 92tolterodine tartrate ....................443tolterodine tartrate er ............... 443tolvaptan ................................... 261tomato (diagnostic) ...................229toomey syringe .......................... 346TOPAMAX ................................68TOPAMAX SPRINKLE .......... 68topcare clickfine pen needles ....346topcare lancets micro-thin 33g .328topcare ultra comfort ins syr .... 346topical l.e.t. ............................... 221TOPICORT ............................. 206TOPICORT SPRAY ...............206topidex .......................................181topiramate ...................................69

topiramate er .............................. 68TOPOSAR ............................... 132topotecan hcl .............................135TOPROL XL ...........................153toremifene citrate ......................114TORISEL .................................123TORONOVA II SUIK ..............17TORONOVA SUIK .................. 17torsemide ...................................252TOSYMRA ..............................356TOTECT ..................................129TOUJEO MAX SOLOSTAR ...81TOUJEO SOLOSTAR ............. 81TOVET .................................... 206TOVIAZ ...................................443TOXICOLOGY MED COLLECTION SYS ...............240TPN ELECTROLYTES .........360TRACE ELEMENTS 4/PEDIATRIC .........................364TRACER II 3 VOLT BATTERY ............................... 328TRACLEER ............................ 161TRADJENTA ............................77TRALEMENT .........................364tramadol hcl ................................43tramadol hcl er ........................... 43tramadol hcl er (biphasic) .......... 43tramadol-acetaminophen ............46trandolapril .................................99trandolapril-verapamil hcl er ..... 98tranexamic acid .........................296tranexamic acid-nacl ................ 296TRANSCYTE ..........................218TRANSDERM SCOP (1.5 MG) ............................................ 89TRANSDERM-SCOP ...............89TRANXENE-T ..........................53tranylcypromine sulfate .............. 72TRANZGEL ............................367TRAUMEEL ........................... 367TRAVASOL ............................ 397TRAVATAN Z ........................ 412travel lancets .............................328TRAVEL LANCETS ADVANCED 28G ................... 328travoprost (bak free) ................. 412TRAZIMERA ......................... 118trazodone hcl .............................. 73TREANDA ...............................113TRECATOR ............................112TRELEGY ELLIPTA .............. 56

TRELSTAR MIXJECT ......... 131TREMFYA .............................. 199TREPADONE ......................... 248treprostinil ................................ 160TRESIBA ...................................82TRESIBA FLEXTOUCH ........ 81tretinoin .............................134, 193tretinoin (emollient) .................. 193tretinoin microsphere ................193tretinoin microsphere pump ......193TRETTEN ............................... 282TREXALL ............................... 115TREXIMET .............................355TREZIX ..................................... 26TRI FEMYNOR ......................177triadime-80 ............................... 222triamcinolone acetonide...................................181, 206, 375triamcinolone diacetate ............ 182triamcinolone in absorbase ...... 206triamcinolone-bupivacaine ....... 184triamcinolone-moxifloxacin ......408tri-amino ................................... 398triamterene ................................253triamterene-hctz ........................252TRIANEX ................................206triazolam ................................... 299TRIBENZOR .......................... 102TRICARE ................................384TRICARE PRENATAL DHA ONE ..........................................384TRI-CHLOR ........................... 202trichophyton ................................11trichophyton mentag (diagnost) 229trichophyton mentagrophytes ..... 11TRICITRASOL ........................ 63tricitrates ...................................274TRICON .................................. 294TRICOR .................................... 96TRIDERM ............................... 206TRIDESILON ......................... 206trientine hcl ...............................365TRIESENCE ........................... 410TRI-ESTARYLLA ................. 177TRIFERIC ...............................295TRIFERIC AVNU .................. 295trifluoperazine hcl .....................142trifluridine .................................404trigels-f forte ............................. 294TRIGLIDE ................................ 96triheal-80 .................................. 222trihexyphenidyl hcl ....................136

507

TRIJARDY XR .........................83TRIKAFTA ............................. 431TRI-LEGEST FE ....................177TRILEPTAL ............................. 69TRI-LINYAH ..........................177TRILIPIX .................................. 96TRILOAN II SUIK .................185TRILOAN SUIK .....................185TRILOCICLO ........................ 222TRI-LO-ESTARYLLA .......... 177TRI-LO-MARZIA .................. 177TRI-LO-MILI ......................... 177TRI-LO-SPRINTEC ...............177TRI-LUMA ..............................207TRILURON .............................391TRILYTE ................................ 301trimethobenzamide hcl ................89trimethoprim ............................. 104TRI-MILI ................................ 177trimipramine maleate ..................75tri-mix ....................................... 159TRIMO-SAN ........................... 448TRIMOXI+ ..............................408trinatal rx 1 ............................... 384TRINATE ................................ 384trinaz ......................................... 384TRINESSA (28) .......................177TRINESSA LO ........................177TRINTELLIX ........................... 73TRI-NYMYO .......................... 177TRIOSTAT ..............................436triphrocaps ................................376triple complex formula 3 kit ......197triple pmb ..................................408triple pmk .................................. 408TRI-PREVIFEM .....................177TRIPTODUR .......................... 259TRISENOX ............................. 128trisodium citrate/crrt ................ 366TRI-SPRINTEC ......................177tristart dha ................................ 386TRISTART FREE .................. 386TRISTART ONE .................... 386tri-tabs dha ................................384TRITOCIN .............................. 206TRIUMEQ ...............................145TRIUMEQ PD ........................ 145TRIVEEN-DUO DHA ............ 385TRI-VI-FLOR ......................... 381tri-vi-floro ................................. 381TRIVISC ..................................391tri-vite/fluoride ..........................381

TRIVIX ....................................222TRIVORA (28) ........................177TRI-VYLIBRA ....................... 177TRI-VYLIBRA LO .................177TRIZIVIR ................................145TRODELVY ............................134TROGARZO ........................... 145TROKENDI XR ........................69tronvite ......................................376TROPHAMINE ...................... 397tropicamide ............................... 401tropicamide-cyclopentolate-pe . 400tropicamide-phenylephrine .......400tropic-cyclopent-pe-ketorolac ...400tropic-cyclop-pe-keto-propar ....401tropic-proparaca-pe-ketorolac . 401trospium chloride ......................444trospium chloride er ................. 443TRUDHESA ............................ 355true comfort insulin syringe ......346true comfort pen needles ...........347true comfort pro insulin syr ...... 347true comfort pro pen needles .... 347true comfort twist top lancets ... 328TRUE FOCUS BLOOD GLUCOSE METER ............... 328true focus blood glucose strip ...240TRUE METRIX AIR GLUCOSE METER ............... 328TRUE METRIX BLOOD GLUCOSE TEST ....................240TRUE METRIX GO GLUCOSE METER ............... 328TRUE METRIX METER ...... 328TRUEDRAW LANCING DEVICE ...................................328TRUEPLUS 5-BEVEL PEN NEEDLES ................................347TRUEPLUS INSULIN SYRINGE ................................ 347TRUEPLUS LANCETS 26G . 328TRUEPLUS LANCETS 28G . 328TRUEPLUS LANCETS 30G . 328TRUEPLUS LANCETS 33G . 328TRUEPLUS PEN NEEDLES 347TRUEPLUS SAFETY LANCETS 28G ....................... 328TRUERESULT BLOOD GLUCOSE ...............................328TRUETEST TEST ..................240TRUETRACK BLOOD GLUCOSE ...............................328

TRUETRACK SMART SYSTEM ..................................328TRUETRACK TEST ..............240TRULANCE ............................267TRULICITY ..............................82TRUMENBA ........................... 445TRUSELTIQ (100MG DAILY DOSE) ........................ 121TRUSELTIQ (125MG DAILY DOSE) ........................ 121TRUSELTIQ (50MG DAILY DOSE) ...................................... 121TRUSELTIQ (75MG DAILY DOSE) ...................................... 121TRUSKIN ................................ 218TRUSOPT ............................... 404TRUVADA .............................. 145TRUXIMA ...............................117tryptophan .................................398t-support max ............................ 248TUBERSOL .............................229TUDORZA PRESSAIR ............59TUKYSA ..................................118TULANA ................................. 176TURALIO ................................124turpentine ..................................210TUSSICAPS ............................ 186TUSSIONEX PENNKINETIC ER ................186TUXARIN ER ......................... 186TUZISTRA XR ....................... 186TWINRIX ................................445TWIRLA ..................................173TWYNEO ................................ 191TWYNSTA .............................. 100TYBLUME .............................. 172TYBOST .................................. 148TYDEMY .................................172TYGACIL ................................432TYKERB ................................. 124TYLACTIN BUILD 20PE TYR ..........................................250TYLACTIN COMPLETE 15 PE ............................................. 250TYLACTIN RESTORE 10 .... 250TYLACTIN RESTORE 5PE . 250TYLACTIN RTD 15 ...............250TYLENOL WITH CODEINE #3 ................................................ 26TYLENOL WITH CODEINE #4 ................................................ 26TYMLOS ................................. 261

508

TYPHIM VI ............................ 445TYR EASY .............................. 250TYR EXPRESS 15 PLUS+ .... 250TYR EXPRESS 20 PLUS+ .... 250TYRVAYA .............................. 400TYSABRI .................................425TYVASO ..................................161TYVASO DPI MAINTENANCE KIT ........... 161TYVASO DPI TITRATION KIT ........................................... 161TYVASO REFILL ..................161TYVASO STARTER ..............161UBRELVY ...............................354UCERIS ............................. 48, 182UDAMIN SP ............................378UDENYCA .............................. 292UKONIQ ..................................124ULESFIA ................................. 215ULORIC .................................. 276ULTANE ..................................273ULTICARE INSULIN SAFETY SYR ..........................347ULTICARE INSULIN SYRINGE ................................ 347ULTICARE MICRO PEN NEEDLES ................................347ULTICARE MINI PEN NEEDLES ................................347ULTICARE PEN NEEDLES .347ULTICARE SHORT PEN NEEDLES ................................347ultiguard safepack pen needle .. 347ULTIGUARD SAFEPACK SYR/NEEDLE .........................348ULTILET CLASSIC LANCETS ............................... 329ULTILET INSULIN SYRINGE ................................ 348ULTILET INSULIN SYRINGE SHORT ................. 348ULTILET LANCETS .............329ULTILET PEN NEEDLE ...... 348ULTILET SAFETY LANCETS ............................... 329ULTILET SAFETY LANCETS 23G ....................... 329ULTIVA .....................................43ULTOMIRIS ........................... 283ultra comfort insulin syringe .... 348ULTRA FLO INSULIN PEN NEEDLES ................................348

ULTRA FLO INSULIN SYR 1/2 UNIT .................................. 348ULTRA FLO INSULIN SYRINGE ................................ 348ultra hers rx .............................. 369ultra his .....................................369ultra pcos .................................. 369ultra thin lancets 31g ................ 329ULTRA THIN PEN NEEDLES ................................348ULTRABAG/DIANEAL PD-2/1.5% DEX .............................370ULTRABAG/DIANEAL PD-2/2.5% DEX .............................370ULTRABAG/DIANEAL PD-2/4.25%DEX ............................370ULTRABAG/DIANEAL/1.5% DEXTROSE ....................... 371ULTRABAG/DIANEAL/2.5% DEXTROSE ....................... 371ULTRABAG/DIANEAL/4.25% DEX .....................................371ultracare insulin syringe ...........348ultra-care lancets 30g ...............329ultracare pen needles ................348ULTRACET .............................. 46ULTRALANCE ...................... 329ULTRAM ...................................43ULTRASAL-ER ......................210ULTRA-THIN II AUTO LANCET ..................................329ULTRA-THIN II INS SYR SHORT .................................... 348ULTRATRAK PRO TEST .... 240ULTRATRAK ULTIMATE TEST ........................................ 240ULTRAVATE ......................... 206ULTRAVIST ........................... 245UMECTA MOUSSE ...............207UNASYN ..................................419UNIFINE PEN NEEDLES .....348UNIFINE PENTIPS ................348UNIFINE PENTIPS PLUS .... 349UNIFINE SAFECONTROL PEN NEEDLE .........................349UNIFINE ULTRA PEN NEEDLE ..................................349UNILET COMFORTOUCH LANCET ..................................329UNILET EXCELITE ............. 329UNILET EXCELITE II ......... 329UNILET G.P. LANCET .........329

UNILET G.P. SUPERLITE LANCET ..................................329UNILET GP 28 ULTRA THIN ........................................ 329UNILET LANCET ................. 329UNILET MICRO-THIN 33G 329UNILET SUPERLITE LANCET ..................................329UNILET SUPER-THIN 30G . 329UNILET ULTRA-THIN 28G 329UNISTIK 1 .............................. 329UNISTIK 2 .............................. 329UNISTIK 2 COMFORT .........329UNISTIK 2 EXTRA ............... 329UNISTIK 2 NEONATAL .......329UNISTIK 2 NORMAL ........... 329UNISTIK 2 SUPER ................ 329UNISTIK 3 .............................. 329UNISTIK 3 COMFORT .........329UNISTIK 3 EXTRA ............... 329UNISTIK 3 GENTLE .............329UNISTIK 3 NEONATAL .......329UNISTIK 3 NORMAL ........... 329UNISTIK CZT COMFORT .. 329UNISTIK CZT NORMAL ..... 329UNISTIK NORMAL .............. 329UNISTIK PRO SAFETY LANCET ..................................329UNISTIK SAFETY LANCETS 28G ....................... 329UNISTIK SAFETY LANCETS 30G ....................... 329UNISTIK TOUCH SAFETY LANC 21G ...............................330UNISTIK TOUCH SAFETY LANC 23G ...............................330UNISTIK TOUCH SAFETY LANC 28G ...............................330UNISTIK TOUCH SAFETY LANC 30G ...............................330UNISTRIP1 GENERIC ..........241UNITHROID ...........................436UNITUXIN .............................. 118UNIVERSAL 1 LANCETS THIN 26G ................................ 330UNIVERSAL 1 LANCETS THIN 33G ................................ 330UNIVERSAL 1 LANCETS ULTRA THIN ......................... 330UPLIZNA ................................ 369UPNEEQ ..................................411UPTRAVI ................................ 162

509

URAMAXIN ............................207urea ........................................... 207urea hydrating .......................... 208urea nail ....................................207URECHOLINE ....................... 444UREDEB ..................................207URELLE ..................................110uremez-40 ..................................207URESOL ..................................208URESTA STARTER KIT ......331URIBEL ................................... 110URIMAR-T ..............................110urin ds ....................................... 110uro-458 ..................................... 110UROCIT-K 10 .........................274UROCIT-K 15 .........................274UROCIT-K 5 ...........................274UROGESIC-BLUE .................110uro-mp .......................................110urosex ........................................387UROXATRAL .........................273URSO 250 ................................ 267URSO FORTE ........................ 267ursodiol ..................................... 267URSODIOL+SYRSPEND SF 267USTELL ...................................110UTIBRON NEOHALER ..........56UTIRA-C ................................. 110UTOPIC ...................................208UVADEX ................................. 128VABOMERE ...........................105VABYSMO ..............................402VAGIFEM ............................... 450valacyclovir hcl .........................150VALCHLOR ........................... 197VALCYTE ...............................149valganciclovir hcl ..................... 149VALIUM ....................................53valladerm-90 .............................221valproate sodium ........................ 71valproic acid ............................... 71valrubicin ..................................126valsartan ................................... 102valsartan-hydrochlorothiazide . 101VALSTAR ............................... 126VALTOCO 10 MG DOSE ....... 65VALTOCO 15 MG DOSE ....... 65VALTOCO 20 MG DOSE ....... 65VALTOCO 5 MG DOSE ......... 65VALTREX ...............................150value health insulin syringe ...... 349value plus lancet standard 21g . 330

value plus lancets super thin .....330value plus lancets thin 26g ....... 330valumark lancet super thin 30g 330valumark lancet ultra thin 28g . 330valumark pen needles ................349valved holding chamber ............353VANADOM ............................. 389VANATOL LQ ..........................23VANATOL S ............................. 23VANCOCIN ............................ 106vancomycin hcl ......... 107, 108, 403vancomycin hcl in dextrose .......106vancomycin hcl in nacl ..... 106, 107VANCOMYCIN+SYRSPEND SF ..............................................108VANDAZOLE .........................449VANIQA .................................. 213VANISHPOINT INSULIN SYRINGE ................................ 349VANISHPOINT SAFETY SYRINGE ................................ 349VANOS .................................... 206VANOXIDE-HC ..................... 191VANTAS ..................................131VAPRISOL ..............................263VAQTA ....................................448vardenafil hcl ............................ 163vardimaxia ................................ 191varenicline tartrate ................... 429VARIBAR NECTAR ..............245VARIBAR THIN LIQUID .....245VARITHENA ..........................372VARIVAX ................................448VARIZIG .................................417VAROPHEN ........................... 197varoxia ...................................... 191VARUBI (180 MG DOSE) ....... 90VASCAZEN ............................ 249VASCEPA ................................. 94VASCULERA ......................... 248VASERETIC ............................. 99VASHE CLEANSING ............223vasopressin ............................... 263vasopressin-dextrose .................263VASOSTRICT ........................ 263VASOTEC ............................... 100VAXCHORA ...........................445VAXELIS .........................436, 437VAXNEUVANCE ................... 445VAYACOG ..............................248VAYARIN ................................248VAYARIN PLUS .................... 248

VAYAROL .............................. 248VAZCULEP ............................ 453vb6 p5p ......................................248v-c forte .....................................379VCF VAGINAL CONTRACEPTIVE ............... 449VECAMYL ..............................103VECTIBIX ...............................121VECTICAL ............................. 200vecuronium bromide ................. 394VEKLURY .............................. 151VELCADE ...............................124VELETRI ................................ 161VELIVET ................................ 178VELPHORO ........................... 270VELTASSA ............................. 371VELTIN ................................... 191VEMLIDY ............................... 149VENCLEXTA ......................... 119VENCLEXTA STARTING PACK ....................................... 119VENELEX ............................... 223VENEXA ................................. 379VENEXA FE ........................... 379VENIPUNCTURE PX1 PHLEBOTOMY ..................... 221venlafaxine hcl ............................ 74venlafaxine hcl er ........................74VENNGEL ONE .....................196VENOFER ...............................295VENOMIL HONEY BEE VENOM ..................................... 11VENOMIL MIXED VESPID VENOM ..................................... 11VENOMIL WASP VENOM ....11VENOMIL WHITE FACED HORNET ................................... 11VENOMIL YELLOW HORNET VENOM ...................11VENOMIL YELLOW JACKET VENOM ....................11VENTAVIS ..............................161VENTOLIN HFA ......................58VENTRIXYL .......................... 378VENTRIXYL FE .................... 379verapamil hcl ............................ 157verapamil hcl er ........................157verasens blood glucose meter ...330verasens blood glucose system . 330verasens blood glucose test .......241VERDESO ............................... 206VEREGEN ...............................193

510

VERELAN ...............................157VERELAN PM ........................157VERKAZIA .............................405VERQUVO ..............................163VERSACLOZ ......................... 141VERSAPRO ............................ 421VERZENIO ............................. 129VESICARE ..............................444VESICARE LS ........................444VESTURA ............................... 172vexasyn ......................................228vexatrol ..................................... 221VFEND .......................................92VFEND IV ................................. 92V-GO 20 ...................................331V-GO 30 ...................................331V-GO 40 ...................................331VIAGRA .................................. 163VIBATIV ................................. 108VIBERZI ................................. 268VIBRAMYCIN ........................434VIC-FORTE ............................379VICTOZA ..................................82VIDA MIA AUTOLET LANCING DEV ...................... 330VIDA MIA UNIFINE PENTIPS ................................. 349VIDA MIA UNILET LANCETS 28G ....................... 330VIDA MIA UNILET LANCETS 30G ....................... 330VIDAZA ...................................116VIDEX ..................................... 147VIDEX EC ...............................147VIEKIRA PAK ....................... 150VIENVA ...................................172vigabatrin ....................................70VIGADRONE ........................... 70VIGAMOX .............................. 403VIIBRYD ................................... 74VIIBRYD STARTER PACK ...74VIJOICE ..................................371VILACTIN AA PLUS .... 250, 251VILAMIT MB .........................110vilazodone hcl ............................. 74VILEVEV MB .........................110VILTEPSO .............................. 393VIMIZIM .................................259VIMOVO ................................... 17VIMPAT .................................... 69VINATE DHA RF ...................384VINATE II ...............................384

VINATE ONE ......................... 384vinblastine sulfate ..................... 132VINCASAR PFS ..................... 132vincristine sulfate ......................132vinorelbine tartrate ...................132VIOKACE ............................... 251viorele ....................................... 167VIRACEPT ............................. 146VIRAMUNE ............................147VIRAMUNE XR ..................... 147VIRASAL ................................ 210VIRAZOLE ............................. 151VIREAD ...................................148virginia live oak .......................... 11virt-c dha ...................................384virt-caps .................................... 376virt-fefa plus ..............................294VIRT-GARD ........................... 290virt-nate dha ..............................384virt-phos 250 neutral ................ 361virt-pn dha ................................ 386virt-pn plus ................................384VISBIOME ................................85VISCO-3 .................................. 391VISCOAT ................................ 410VISIONBLUE ......................... 411VISIPAQUE ............................ 245VISTARIL ................................. 52VISTOGARD ............................ 87VISUDYNE ............................. 406vit b12-methionine-inos-chol .... 287VITA S FORTE ...................... 379VITACEL ................................ 379VITAFOL ................................ 377VITAFOL FE+ ........................387VITAFOL GUMMIES ........... 384VITAFOL STRIPS ................. 387VITAFOL ULTRA ................. 387VITAFOL-NANO ................... 384VITAFOL-OB ......................... 384VITAFOL-OB+DHA ..............387VITAFOL-ONE ...................... 387VITAL-D RX ...........................376VITALET PRO LANCETS ... 330VITALET PRO PLUS LANCETS ............................... 330VITALINE BIOTIN FORTE 376VITALINE BIOTIN FORTE/ZINC ......................... 377VITAMAX PEDIATRIC ....... 380VITAMEDMD ONE RX/QUATREFOLIC ..............387

VITAMEDMD REDICHEW RX .............................................387VITAMEZ ............................... 290vita-min ..................................... 379vitamin b complex 100 .............. 375vitamin b complex-hydroxocobal ............................ 375vitamin b-complex 100 ..............375vitamin d (ergocalciferol) ......... 454vitamin deficiency system-b12 .. 288vitamin k (phytonadione) .......... 454vitamin k1 ..................................454vitamins acd-fluoride ................ 381VITAPEARL ...........................384VITAROCA PLUS ................. 379vita-rx diabetic vitamin .............387vitasure ..................................... 376VITATHELY WITH GINGER .................................. 385VITATRUE ............................. 387vitaxyme .................................... 379VITRAKVI ......................124, 125VITRAMYN ............................379VITRANOL .............................379VITRANOL FE .......................379VITRASE .................................366VITREXATE ...........................379VITREXATE FE .................... 379VITREXYL ............................. 379VITREXYL + IRON ...............379VIVA DHA .............................. 385VIVAGUARD INO GLUCOSE METER ............... 330VIVAGUARD INO SMART GLUC METER ....................... 330VIVAGUARD INO TEST STRIPS .................................... 241VIVAGUARD LANCETS ......330VIVELLE-DOT ...................... 266VIVITROL ................................ 88VIVLODEX ...............................21VIVOTIF ................................. 445VIZAMYL ............................... 231VIZIMPRO ............................. 121VOCAL POINT BLOOD GLUCOSE TEST ....................241VOGELXO ................................48VOGELXO PUMP ................... 48VOLNEA ................................. 167vol-plus ..................................... 385vol-tab rx ...................................385VOLTAREN ............................196

511

volumex ..................................... 232VOLUVEN .............................. 284VONJO .................................... 131VONVENDI .............................282VOQUEZNA DUAL PAK ..... 443VOQUEZNA TRIPLE PAK ..443VORAXAZE ........................... 129voriconazole ................................92VORTEX HOLD CHMBR/MASK/CHILD ........350VORTEX HOLD CHMBR/MASK/TODDLER . 350VORTEX HOLDING CHAMBER/MASK ................ 350VORTEX VALVED HOLDING CHAMBER ......... 354VOSEVI ................................... 150VOTRIENT ............................. 124VOXZOGO ............................. 260vp fc kit ......................................197vp gkl kit ....................................197vp insulin syringe ......................349vp-gstn .......................................248vp-pnv-dha ................................ 385vp-precip ................................... 248VPRIV ......................................287vp-vite rx ................................... 376vp-zel .........................................379VRAYLAR .............................. 139VSL#3 DS .................................. 85VTAMA ................................... 200VTOL LQ .................................. 23VUITY ..................................... 401VUMERITY ............................ 425VUMERITY (STARTER) ......425VUSION ...................................195VYEPTI ................................... 354VYFEMLA .............................. 172VYLEESI .................................423VYLIBRA ................................172VYNDAMAX .......................... 163VYNDAQEL ........................... 163VYONDYS 53 ..........................393VYTONE ................................. 195VYTORIN ................................. 97VYVANSE ............................... 2, 3VYVGART .............................. 369VYXEOS ..................................127VYZULTA ...............................412WAKIX ........................................4walgreens adv travel lancets .....330WALGREENS LANCETS .... 330

walgreens lancets micro thin .... 330walgreens lancets super thin .... 330WALGREENS THIN LANCETS ............................... 330WALGREENS ULTRA THIN LANCETS .................... 330warfarin sodium ..........................61wasp venom protein .................... 11WATCHHALER .....................354WAVESENSE AMP ............... 330wegmans unifine pentips plus ... 349WEGOVY ....................................4WELCHOL ............................... 95WELIREG ...............................122WELLBUTRIN SR ...................72WELLBUTRIN XL .................. 72WELLMIND VERTIGO ....... 367WERA ......................................172wescap-c dha .............................385wescap-pn dha .......................... 387wescaps ..................................... 376wesnate dha .............................. 385westab max ................................248westab mini ............................... 290westab one ................................ 290westab plus ................................385western juniper ........................... 11westgel dha ............................... 387WESTHROID ......................... 436wheat germ oil .......................... 454white ash ..................................... 11white birch .................................. 11white faced hornet venom ........... 12white faced hornet venom prot...............................................11, 12white mulberry ............................ 12white oak .....................................12white pine ....................................12WHITE-FACED HORNET VENOM ..................................... 12whole egg (diagnostic) ..............229WIDE-SEAL DIAPHRAGM 60 .............................................. 308WIDE-SEAL DIAPHRAGM 65 .............................................. 308WIDE-SEAL DIAPHRAGM 70 .............................................. 308WIDE-SEAL DIAPHRAGM 75 .............................................. 308WIDE-SEAL DIAPHRAGM 80 .............................................. 308

WIDE-SEAL DIAPHRAGM 85 .............................................. 308WIDE-SEAL DIAPHRAGM 90 .............................................. 308WIDE-SEAL DIAPHRAGM 95 .............................................. 308WILATE ..................................282WILZIN ................................... 365WINLEVI ................................ 193WINRHO SDF ........................ 417WIXELA INHUB ......................56WOUNDGELHA MATRIX .. 228WP THYROID ........................436wpr plus wound healing system 221WYMZYA FE ......................... 172WYNZORA ............................. 222XADAGO .................................137XALATAN ...............................412XALIX ..................................... 210XALKORI ............................... 116XANAX ......................................53XANAX XR ............................... 53XAQUIL XR ............................249XARACOLL ........................... 305XARELTO .................................62XARELTO STARTER PACK 62XATMEP ................................. 116XCELLISTEM WOUND POWDER ................................ 228XCOPRI .....................................69XCOPRI (250 MG DAILY DOSE) ........................................ 69XCOPRI (350 MG DAILY DOSE) ........................................ 69XELJANZ ..................................14XELJANZ XR ...........................14XELODA ................................. 116XELPROS ............................... 412XEMBIFY ............................... 417XENAZINE ............................. 423XENICAL ....................................4XENLETA ............................... 109xenon xe 133 ............................. 231XEOMIN ................................. 394XEPI .........................................194XERAC AC ............................. 201XERALUX ...............................213XERAVA ................................. 432XERESE .................................. 201XERMELO ..............................271XEROFORM OIL EMULSION 2"X2" ................ 223

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XEROFORM OIL EMULSION GAUZE ............. 223XEROFORM OIL EMULSION STRIP ................223XEROFORM OIL ROLL 4"X9' ........................................ 223XEROFORM PETROLAT GAUZE 1"X8" ........................223XEROFORM PETROLAT GAUZE 5"X9" ........................223XEROFORM PETROLAT PATCH 2"X2" ........................ 223XEROFORM PETROLAT PATCH 4"X4" ........................ 223XEROFORM PETROLATUM ROLL 4"X9' ........................................ 223XEROSTOMIA RELIEF SPRAY ..................................... 373XGEVA ....................................261XHANCE ................................. 392XIAFLEX ................................ 366XIFAXAN ........................104, 105XIGDUO XR ............................. 84XIIDRA ....................................401XIMINO ...................................434XIPERE ................................... 410XOFIGO .................................. 127XOFLUZA (40 MG DOSE) ... 151XOFLUZA (80 MG DOSE) ... 151XOLAIR .................................... 56XOLEGEL ...............................209XOLEGEL COREPAK ..........195XOLEGEL DUO/HEAD & SHOULDERS ..........................195XOLEGEL DUO/XOLEX ..... 195XOPENEX .................................58XOPENEX CONCENTRATE .58XOPENEX HFA ....................... 58XOSPATA ............................... 124XPERT XPRESS SARS-COV-2 ...................................... 243XPOVIO (100 MG ONCE WEEKLY) ............................... 125XPOVIO (40 MG ONCE WEEKLY) ............................... 125XPOVIO (40 MG TWICE WEEKLY) ............................... 125XPOVIO (60 MG ONCE WEEKLY) ............................... 125XPOVIO (60 MG TWICE WEEKLY) ............................... 125

XPOVIO (80 MG ONCE WEEKLY) ............................... 125XPOVIO (80 MG TWICE WEEKLY) ............................... 125XRYLIX ...................................197XRYLIX II .............................. 197XTAMPZA ER ..........................43XTANDI ...................................114XULANE ................................. 173XULTOPHY ..............................82xurea ......................................... 208XURIDEN ................................257xvite ...........................................376XYLOCAINE ..........................305XYLOCAINE/EPINEPHRINE ................................................303XYLOCAINE-MPF ................306XYLOCAINE-MPF/EPINEPHRINE .............303XYNTHA ................................. 282XYNTHA SOLOFUSE ...........282XYOSTED ................................. 48XYREM ................................... 422XYWAV ...................................422xyzbac ........................................248xyzmune .....................................369YASMIN 28 ............................. 172YAZ ..........................................172yellow dock ................................. 12yellow hornet venom protein .......12yellow jacket venom protein ....... 12YERVOY ................................. 118YESCARTA ............................ 119YF-VAX ................................... 448yl folic acid ............................... 291YONDELIS ............................. 134YONSA .................................... 113YOSPRALA ............................ 286YUPELRI .................................. 59YUTIQ ..................................... 410YUVAFEM ..............................450ZACARE ................................. 191zaclir cleansing .........................193ZAFEMY ................................. 173zafirlukast ................................... 59zaleplon .....................................299ZALTRAP ............................... 136zalvit ..........................................385zanabin hydrogel ...................... 228ZANAFLEX ............................ 389ZANOSAR ...............................133ZARAH ....................................172

ZARONTIN ...............................70ZARXIO .................................. 292ZATEAN-PN DHA ................. 387ZATEAN-PN PLUS ................385zavara ....................................... 290ZAVESCA ............................... 287ZAVITROL ............................. 248zcort 7-day ................................ 182ZEBUTAL ................................. 23ZEEL ........................................367ZEGALOGUE ...........................77ZEGERID ................................440ZEJULA ...................................134zelac ............................................ 85ZELAPAR ............................... 137ZELBORAF ............................ 120ZELNORM ..............................268ZEMAIRA ............................... 431ZEMBRACE SYMTOUCH ...356ZEMDRI ....................................13ZEMPLAR .............................. 258ZENATANE ............................ 193ZENCHENT ............................172ZENPEP ...................................251zenphor wound gel ....................228zenphor wound pad ...................228ZENZEDI .................................... 3ZEPATIER ..............................150ZEPOSIA .................................430ZEPOSIA 7-DAY STARTER PACK ....................................... 430ZEPOSIA STARTER KIT .....430ZEPZELCA .............................113ZERBAXA ...............................163zeruvia .......................................221ZERVIATE ............................. 402ZESTORETIC .......................... 99ZESTRIL ................................. 100ZETIA ........................................97ZETONNA ...............................392ZEVALIN Y-90 .......................126zevrx insulin syringe ................. 349zevrx pen needles ...................... 349zevrx twist top lancets 30g ........330ZIAC ........................................ 103ZIAGEN ...................................147ZIANA ..................................... 191ZICLOPRO ............................. 197zidovudine ................................. 148ZIEXTENZO ...........................292ZILACAINE PATCH .............221zileuton er ................................... 55

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ziloval ........................................221ZILRETTA ..............................182ZILXI ....................................... 215ZIMHI ........................................88zinc chloride ..............................365zinc sulfate ................................ 365ZINGO ..................................... 306ZINPLAVA ............................. 415zionodil ..................................... 211zionodil 100 .............................. 211ZIOPTAN ................................ 412ziprasidone hcl ..........................139ziprasidone mesylate .................139ZIPSOR ..................................... 21ZIRABEV ................................ 136ZIRGAN .................................. 404ZITHRANOL ..........................200ZITHROMAX .........................306ZITHROMAX TRI-PAK .......306ZITHROMAX Z-PAK ........... 306ZOCOR ......................................96ZOFRAN ................................... 89ZOHYDRO ER ......................... 44ZOKINVY ............................... 367ZOLADEX ...............................131ZOLATE ..................................291zoledronic acid ..........................254ZOLGENSMA 10.1-10.5 KG .394ZOLGENSMA 10.6-11.0 KG .394ZOLGENSMA 11.1-11.5 KG .394ZOLGENSMA 11.6-12.0 KG .394ZOLGENSMA 12.1-12.5 KG .395ZOLGENSMA 12.6-13.0 KG .395ZOLGENSMA 13.1-13.5 KG .395ZOLGENSMA 2.6-3.0 KG .....395ZOLGENSMA 3.1-3.5 KG .....395ZOLGENSMA 3.6-4.0 KG .....395ZOLGENSMA 4.1-4.5 KG .....395ZOLGENSMA 4.6-5.0 KG .....395ZOLGENSMA 5.1-5.5 KG .....395ZOLGENSMA 5.6-6.0 KG .....395ZOLGENSMA 6.1-6.5 KG .....395ZOLGENSMA 6.6-7.0 KG .....395ZOLGENSMA 7.1-7.5 KG .....395ZOLGENSMA 7.6-8.0 KG .....395ZOLGENSMA 8.1-8.5 KG .....395ZOLGENSMA 8.6-9.0 KG .....395ZOLGENSMA 9.1-9.5 KG .....395ZOLGENSMA 9.6-10.0 KG ...395ZOLINZA ................................122zolmitriptan ...............................356ZOLOFT ....................................73

ZOLPAK ................................. 195zolpidem tartrate .......................299zolpidem tartrate er .................. 299ZOLPIMIST ............................299ZOMACTON .......................... 257ZOMACTON (FOR ZOMA-JET 10) .....................................257ZOMIG .................................... 356ZOMIG ZMT .......................... 356ZONALON .............................. 198ZONEGRAN ............................. 69zonisamide .................................. 69ZONTIVITY ........................... 286ZORBTIVE ............................. 257ZORTRESS ............................. 369ZORVOLEX ............................. 21ZOSTAVAX ............................ 448ZOSYN .....................................419ZOVIA 1/35 (28) ..................... 173ZOVIA 1/35E (28) ...................173ZOVIRAX ....................... 150, 201ZTALMY ...................................69ZTLIDO ...................................211ZUBSOLV ................................. 46ZULRESSO ............................... 72ZUMANDIMINE ....................173ZUPLENZ ................................. 89ZYCLARA ...............................209ZYCLARA PUMP .................. 209ZYDELIG ................................134ZYFLO .......................................55ZYKADIA ............................... 116ZYLET .....................................408ZYLOPRIM ............................ 276ZYLOTROL-L ........................211ZYMAXID ...............................403ZYNLONTA ............................116ZYNRELEF ...............................18ZYPITAMAG ........................... 97ZYPREXA ............................... 143ZYPREXA RELPREVV ........ 143ZYPREXA ZYDIS ..................143ZYTIGA ...................................113zyvana ....................................... 379zyvexol .......................................248zyvit ........................................... 248ZYVOX ....................................109

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CHP 2022 Formulary

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