2020 PREFERREDRX PDF

HealthPartners® PreferredRx

2020 Formulary

(List of covered drugs)

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

Effective: October 1, 2020

©2020 HealthPartners

What’s the PreferredRx drug list?

This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a

team of experts every three months for new medicines, safety alerts and other updates.

Who decides what’s on the drug list?

The HealthPartners Pharmacy and Therapeutics Committee manage the list. This team of experts focuses on safety,

effectiveness and affordability. Visit healthpartners.com/pharmacy for more information.

How do you use the drug list?

The medicines are listed in alphabetical order by type of medicine starting on page 4.

Generic medicines are in lowercase italics (e.g., cephalexin). These medicines are safe and effective but cost less than brand

medicines.

Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.

The Tier is used to determine how much a medicine will cost you. For exact cost information,

Find the tier status for your medicine.

Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or,

Log on to your myHealthPartners account to check your pharmacy benefits.

Formulary Low Cost Generics - Depending on your plan, these medicines might be covered at the lowest copay or

coinsurance.

Formulary High Cost Generics - Depending on your plan, these medicines may cost more than the Formulary Low Cost

Generics, but less than Formulary Brands.

Formulary Brands - Brand medicines are more expensive than generic medicines. Depending on your plan, these

medicines might be covered at a higher copay or coinsurance than generic medicines.

What’s a Specialty Medicine?

Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases.

These medicines usually require more management, have a high price and aren’t always stocked at retail pharmacies.

Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than

non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan

tab to check your benefits for specialty medicines.

What do the abbreviations under Limits & Restrictions mean?

Special information about the medicine you’re searching for. The abbreviations let you know there might be a special program

or rule for the medicine. Use this key to help you navigate the drug list:

PA - Prior Authorization Required

ST - Step Therapy Required

AL1 - Age Limit

AQ1 – Age Quantity Limit

QL - Quantity Limit

SC - Smoking Cessation Benefit

WL - Weight Loss Benefit

ONC - Oncology Benefit

TD - Trial Drug Program

S – Specialty

Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they need to meet the HealthPartners prior authorization

criteria in order for the medicine to be covered by your pharmacy benefits.

What’s Step Therapy (ST)? Some medicines are on the drug list, but you need to try one or more other medicines first. HealthPartners covers a medicine with step therapy, if you've already tried the other medicine(s). If you haven't, you or your

doctor will need to get approval from HealthPartners before the medicine will be covered by your lowest

brand, generic or specialty copay or coinsurance.

What’s an Age Limit (AL1)? An age edit means some medicines are only covered if

you’re within a specific age range. If you're not in the

approved age range, you or your doctor will need to

request approval from HealthPartners for your

medicine to be covered.

What’s an Age Quantity Limit (AQ1)? An age quantity limit means some medicines have a

quantity limit that only applies to a specific age range. If

you're not in the approved age range, you or your doctor will need to request approval from HealthPartners for your medicine to be covered.

What’s a Quantity Limit (QL)? This means HealthPartners limits the amount of the

medicine you'll get each time you fill your prescription. The quantity limit may be less than the day supply listed

in your contract or Summary Plan Description.

What’s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for certain medicines due to:

Side effects

High cost

High potential for waste Your first 6 fills of a trial drug may be limited to less

than a month supply. If the medicine works well, you’ll

get the rest of your month supply. If a copay applies to

the medicine, you’ll pay no more than one copay for

each one month supply.

What’s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount

you get or may not be covered under all plans. Log on to

your myHealthPartners account and click on My plan

benefits on the Medical Plan tab to check your benefits

for weight loss. Weight Loss medicines are listed on the

drug list under the Weight Loss medicine category.

What’s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you’re only responsible for your regular generic or brand pharmacy copay or coinsurance.

The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or

HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (1/20) ©2020 HealthPartners

LEGEND

TIER DESCRIPTION

1 Formulary Low Cost Generics

2 Formulary High Cost Generics

3 Formulary Brands

4 Covered

5 NOT COVERED

TYPE DESCRIPTION

QL Quantity LimitThere is a limit on the amount of this drug that is covered per

prescription, or within a specific time frame.

PA Prior Authorization

You (or your physician) are required to get prior authorization before

you fill your prescription for this drug. Without prior approval, we may

not cover this drug.

ST Step Therapy

In some cases, you may be required to first try certain drugs to treat

your medical condition before we will cover another drug for that

condition.

AL1 Age LimitThis prescription drug may only be covered if you meet the minimum

or maximum age limit.

S Specialty Drug

Specialty drugs are high-cost drugs used to treat complex or rare

conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis

C, and hemophilia.

AQ1 Age Quantity Limit

There is a limit on the amount of drug covered per prescription, or

within a specific time frame. Must also fall into the specified age

range.

ACA Affordable Care Act This product is covered under the Affordable Care Act.

WL Weight Loss

Medicines marked with this symbol are used for weight loss. Certain

plans dont cover these medicines. Log on to your secure account to

check your benefits for weight loss.

SC Smoking Cessation Medicines marked with this symbol are used for smoking cessation.

PAGE 1 LAST UPDATED 12/2020

ONC Oncology

Oncology (cancer) medicines must be filled at a specialty pharmacy,

but are not subject to the specialty benefit. Your regular generic or

brand pharmacy copay or coinsurance will apply.

DS Diabetic Supply

GH Growth Hormone

INF Infertility

TD Trial Drug

OP Opioid Program

New users will be limited to a 7 days supply for their first fill, and a

total of 14 days supply for each episode within a 60 day period.

Longer therapy requires prior authorization: Provider attestation, that

therapy for this patient is being managed per standard opioid

prescribing guidelines, including assessment and documentation of

risk factors for chronic opioid use.


LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)

NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

ERGOMAR Formulary Brands QL 20 TABS / 30 DAYS

phenoxybenzamine hcl Formulary High Cost Generics PA

SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT

alfuzosin hcl Formulary High Cost Generics

tamsulosin hcl Formulary Low Cost Generics

ANALGESICS AND ANTIPYRETICS

ANALGESICS AND ANTIPYRETICS, MISC.

butalb/acetaminophen/caffeine 50-325-40 capsule

Formulary High Cost Generics QL 6 CAPS / 1 DAY

butalb/acetaminophen/caffeine 50-325-40 tablet

Formulary High Cost Generics QL 6 TABS / 1 DAY

butalbital/acetaminophen 50mg-325mgtablet


TENCON Formulary High Cost Generics QL 6 TABS / 1 DAY

ZEBUTAL Formulary High Cost Generics QL 6 CAPS / 1 DAY

OPIATE AGONISTS

acetaminophen with codeine 120-12mg/5 solution

Formulary Low Cost GenericsAQ1 At least 12 yrs old; 60 /

1 day(s)OP Opioid Program

acetaminophen with codeine300mg/12.5 solution

Formulary High Cost GenericsAQ1 At least 12 yrs old; 60 /

1 DAYOP Opioid Program

acetaminophen with codeine phosphate(300mg-15mg tablet, 300mg-30mgtablet, 300mg-60mg tablet)

Formulary High Cost GenericsAQ1 At least 12 yrs old; 8 /


codeine sulfate Formulary High Cost GenericsAQ1 At least 12 yrs old; 8 /


ENDOCET 10-325 MG TABLET Formulary High Cost GenericsQL 5 TABS / 1 DAY

OP Opioid Program



ENDOCET 5-325 TABLET Formulary High Cost GenericsQL 8 TABS / 1 DAY

OP Opioid Program

ENDOCET 7.5-325 MG TABLET Formulary High Cost GenericsQL 7 TABS / 1 DAY

OP Opioid Program

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

Formulary High Cost GenericsQL 10 PATCHES / 30

DAYSPA

fentanyl (75mcg/hr patch td72, 100mcg/hr patch td72)

Formulary High Cost Generics PA

hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 2.5-108/5solution, hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-325/15solution)

Formulary High Cost GenericsQL 120 ML / 1 DAY

OP Opioid Program

hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 5 mg-325mg tablet,hydrocodone/acetaminophen 7.5-325mg tablet, hydrocodone/acetaminophen10mg-325mg tablet)

Formulary High Cost GenericsQL 8 TABS / 1 DAY

OP Opioid Program

hydrocodone/ibuprofen 7.5-200 mgtablet


OP Opioid Program

hydromorphone hcl 1 mg/ml liquid Formulary High Cost GenericsQL 20 ML / 1 DAY

OP Opioid Program

hydromorphone hcl 2 mg tablet Formulary High Cost GenericsQL 8 TABS / 1 DAY

OP Opioid Program

hydromorphone hcl 3 mg supp.rect Formulary High Cost GenericsQL 8 SUPP / 1 DAY

OP Opioid Program


OP Opioid Program


OP Opioid Program

LORCET Formulary High Cost GenericsQL 8 TABS / 1 DAY

OP Opioid Program



LORCET HD Formulary High Cost GenericsQL 8 TABS / 1 DAY

OP Opioid Program

LORCET PLUS Formulary High Cost GenericsQL 8 TABS / 1 DAY

OP Opioid Program

methadone hcl 10 mg tablet Formulary High Cost GenericsQL 2 TABS / 1 DAY

PA

methadone hcl 10 mg/5 ml solution Formulary High Cost GenericsQL 10 ML / 1 DAY

PA

methadone hcl 10 mg/ml oral conc Formulary High Cost GenericsQL 2 ML / 1 DAY

PA

methadone hcl 40 mg tablet sol Formulary High Cost Generics PA

methadone hcl 5 mg tablet Formulary High Cost GenericsQL 4 TABS / 1 DAY

PA

methadone hcl 5 mg/5 ml solution Formulary High Cost GenericsQL 20 ML / 1 DAY

PA

METHADONE INTENSOL Formulary High Cost GenericsQL 2 ML / 1 DAY

PA

METHADOSE 40 MG TABLET DISPR Formulary High Cost Generics PA

morphine sulfate (5 mg supp.rect, 10 mgsupp.rect, 20 mg supp.rect, 30 mgsupp.rect)

Formulary High Cost GenericsQL 8 SUPP / 1 DAY

OP Opioid Program

morphine sulfate (60 mg tablet er, 100mg tablet er, 200 mg tablet er)


morphine sulfate 10 mg/5 ml solution Formulary High Cost GenericsQL 30 ML / 1 DAY

OP Opioid Program

morphine sulfate 100 mg/5ml solution Formulary High Cost GenericsQL 4 ML / 1 DAY

OP Opioid Program

morphine sulfate 15 mg tablet Formulary BrandsQL 5 TABS / 1 DAY

OP Opioid Program

morphine sulfate 15 mg tablet er Formulary High Cost GenericsQL 4 TABS / 1 DAY

PA



morphine sulfate 20 mg/5 ml solution Formulary High Cost GenericsQL 20 ML / 1 DAY

OP Opioid Program

morphine sulfate 30 mg tablet Formulary BrandsQL 2 TABS / 1 DAY

OP Opioid Program

morphine sulfate 30 mg tablet er Formulary High Cost GenericsQL 2 TABS / 1 DAY

PA

oxycodone hcl (30 mg tab er 12h, 40 mgtab er 12h, 60 mg tab er 12h, 80 mg taber 12h)

Formulary Low Cost Generics PA

oxycodone hcl 10 mg tab er 12h Formulary Low Cost GenericsQL 4 TABS / 1 DAY

PA

oxycodone hcl 10 mg tablet Formulary High Cost GenericsQL 5 TABS / 1 DAY

OP Opioid Program


PA


OP Opioid Program


PA


OP Opioid Program

oxycodone hcl 20 mg/ml oral conc Formulary High Cost GenericsQL 2 ML / 1 DAY

OP Opioid Program

oxycodone hcl 30 mg tablet Formulary High Cost GenericsPA

OP Opioid Program

oxycodone hcl 5 mg capsule Formulary High Cost GenericsQL 8 CAPS / 1 DAY

OP Opioid Program


OP Opioid Program

oxycodone hcl 5 mg/5 ml solution Formulary Low Cost GenericsQL 40 ML / 1 DAY

OP Opioid Program



oxycodone hcl/acetaminophen 10mg-325mg tablet


OP Opioid Program

oxycodone hcl/acetaminophen 5 mg-325mg tablet


OP Opioid Program

oxycodone hcl/acetaminophen 7.5-325mg tablet


OP Opioid Program

oxycodone hcl/aspirin Formulary High Cost GenericsQL 8 TABS / 1 DAY

OP Opioid Program

OXYCONTIN (ER 30 MG TABLET, ER40 MG TABLET, ER 60 MG TABLET,ER 80 MG TABLET)

Formulary Brands PA

OXYCONTIN ER 10 MG TABLET Formulary BrandsQL 4 TABS / 1 DAY

PA


PA


PA

tramadol hcl 50 mg tablet Formulary Low Cost GenericsAQ1 At least 12 yrs old; 8 /


OPIATE PARTIAL AGONISTS

buprenorphine Formulary High Cost GenericsQL 4 PATCHES / 28

DAYSPA

buprenorphine hcl/naloxone hcl 12 mg-3mg film

Formulary High Cost Generics QL 60 FILMS / 30 DAY(S)

buprenorphine hcl/naloxone hcl 2 mg-0.5mg film

Formulary High Cost Generics QL 360 FILMS / 30DAY(S)

buprenorphine hcl/naloxone hcl 2 mg-0.5mg tab subl

Formulary High Cost Generics QL 360 TABS / 30 DAYS

buprenorphine hcl/naloxone hcl 4mg-1mg film

Formulary High Cost Generics QL 180 FILMS / 30DAY(S)

buprenorphine hcl/naloxone hcl 8 mg-2mg film

Formulary High Cost Generics QL 90 FILMS / 30 DAY(S)



buprenorphine hcl/naloxone hcl 8 mg-2mg tab subl


ANOREXIGENIC AGENTS

AMPHETAMINE DERIVATIVES

LOMAIRA Formulary High Cost GenericsQL 3 TABS / 1 DAY

WL Weight Loss

phentermine hcl (30 mg capsule, 37.5mg capsule)

Formulary High Cost GenericsQL 1 CAP / 1 DAY

WL Weight Loss

phentermine hcl 15 mg capsule Formulary High Cost GenericsQL 2 CAPS / 1 DAY

WL Weight Loss

phentermine hcl 37.5 mg tablet Formulary High Cost GenericsQL 1 TAB / 1 DAY

WL Weight Loss

ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS

AMPHETAMINES

ADDERALL XR Formulary High Cost Generics QL 2 CAPS / 1 DAY

dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 15mg tablet,dextroamphetamine/amphetamine 20mg tablet)

Formulary High Cost Generics QL 3 Tabs / 1 day(s)

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


dextroamphetamine sulfate (5 mgcapsule er, 10 mg capsule er, 15 mgcapsule er)


dextroamphetamine sulfate (5 mg tablet,10 mg tablet)


dextroamphetamine/amphetamine 30mg tablet

Formulary High Cost Generics QL 2 Tabs / 1 day(s)



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

Formulary Brands QL 2 CAPS / 1 DAY

VYVANSE (10 MG TABLET, 20 MGTABLET, 30 MG TABLET)

Formulary Brands QL 2 CHEW TABS / 1DAY

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

Formulary Brands QL 1 CAP / 1 DAY

VYVANSE (40 MG TABLET, 50 MGTABLET, 60 MG TABLET)

Formulary Brands QL 1 CHEW TABS / 1DAY

RESPIRATORY AND CNS STIMULANTS

CONCERTA (ER 18 MG TABLET, ER27 MG TABLET, ER 36 MG TABLET)


CONCERTA ER 54 MG TABLET Formulary High Cost Generics QL 1 TAB / 1 DAY

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


dexmethylphenidate hcl (25 mg cpbp 50-50, 30 mg cpbp 50-50, 35 mg cpbp 50-50, 40 mg cpbp 50-50)

Formulary High Cost Generics QL 1 CAP / 1 DAY

dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 20 mg cpbp 50-50)


METADATE ER Formulary High Cost Generics QL 3 TABS / 1 DAY

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


methylphenidate hcl (40 mg cpbp 30-70,40 mg cpbp 50-50, 50 mg cpbp 30-70,60 mg cpbp 30-70, 60 mg cpbp 50-50)


methylphenidate hcl (5 mg tablet, 10 mgtablet, 20 mg tablet, 20 mg tablet er)


methylphenidate hcl 10 mg tablet er Formulary High Cost Generics QL 4 TABS / 1 DAY

QUILLICHEW ER 20 MG CHEW TAB Formulary Brands QL 3 CHEW TABS / 1DAY





QUILLIVANT XR Formulary Brands QL 180 ML / 30 day(s)

WAKEFULNESS-PROMOTING AGENTS

armodafinil (150 mg tablet, 200 mgtablet, 250 mg tablet)

Formulary High Cost Generics QL 1 TAB / 1 DAY

armodafinil 50 mg tablet Formulary High Cost Generics QL 2 TABS / 1 DAY

modafinil Formulary High Cost Generics QL 2 TABS / 1 DAY

SUNOSI Formulary BrandsQL 1 TAB / 1 DAY

PA

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

albendazole Formulary High Cost Generics PA

ivermectin 3 mg tablet Formulary High Cost Generics

praziquantel Formulary High Cost Generics

URINARY ANTI-INFECTIVES

fosfomycin tromethamine Formulary High Cost Generics QL 1 packet / rx

nitrofurantoin Formulary High Cost Generics AL1 Up to 12 yrs old

nitrofurantoin macrocrystal (50 mgcapsule, 100 mg capsule)

Formulary High Cost Generics

nitrofurantoin macrocrystal 25 mgcapsule

Formulary High Cost Generics AL1 Up to 12 yrs old

nitrofurantoinmonohydrate/macrocrystals


trimethoprim Formulary Low Cost Generics

ANTI-INFECTIVES (EENT)

ANTIBACTERIALS (EENT)

bacitracin 500 unit/g oint. (g) Formulary High Cost Generics

bacitracin/polymyxin b sulfate Formulary High Cost Generics

BESIVANCE Formulary Brands PA

BLEPHAMIDE S.O.P. Formulary Brands

CILOXAN 0.3% OINTMENT Formulary Brands



CIPRO HC Formulary Brands

CIPRODEX Formulary Brands

ciprofloxacin hcl 0.3 % drops Formulary Low Cost Generics

ciprofloxacin hcl/dexamethasone Formulary High Cost Generics

doxycycline hyclate 20 mg tablet Formulary Low Cost Generics

erythromycin base 5 mg/gram oint. (g) Formulary High Cost Generics

gatifloxacin Formulary High Cost Generics

moxifloxacin hcl 0.5 % drops Formulary Low Cost Generics

neomycin sulfate/bacitracin/polymyxin b Formulary High Cost Generics

neomycin sulfate/polymyxin bsulfate/gramicidin d

Formulary Low Cost Generics

neomycin sulfate/polymyxin bsulfate/hydrocortisone(neomycin/polymyxin b/hydrocort dropssusp, neomycin/polymyxin b/hydrocortsolution)


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


ofloxacin 0.3 % drops Formulary High Cost Generics

polymyxin b sulfate/trimethoprim Formulary High Cost Generics

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


sulfacetamide sodium/prednisolonesodium phosphate


TOBRADEX EYE OINTMENT Formulary Brands

tobramycin 0.3 % drops Formulary High Cost Generics

tobramycin/dexamethasone Formulary High Cost Generics

TOBREX 0.3% EYE OINTMENT Formulary Brands

ANTIVIRALS (EENT)

trifluridine Formulary High Cost Generics

ZIRGAN Formulary Brands



EENT ANTI-INFECTIVES, MISCELLANEOUS

acetic acid 2 % solution Formulary High Cost Generics

chlorhexidine gluconate Formulary Low Cost Generics

PAROEX Formulary High Cost Generics

PERIOGARD Formulary High Cost Generics

ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

ALTABAX Formulary Brands ST

CLEOCIN 100 MG VAGINAL OVULE Formulary Brands

CLEOCIN T 1% SOLUTION Formulary Brands QL 60 ML / 30 day(s)

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


clindamycin phosphate 1 % solution Formulary High Cost Generics QL 60 ML / 30 day(s)

clindamycin phosphate/benzoyl peroxide(phos/benzoyl 1 %-5 % gel (gram),phos/benzoyl 1.2(1)%-5% gel (gram))


erythromycin base in ethanol 2 % gel(gram)


erythromycin base in ethanol 2 %solution

Formulary Low Cost Generics QL 60 ML / 30 day(s)

gentamicin sulfate 0.1 % cream (g) Formulary High Cost Generics QL 30 GM / 30 day(s)

gentamicin sulfate 0.1 % oint. (g) Formulary Low Cost Generics

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


metronidazole 0.75 % gel w/appl Formulary Low Cost Generics

mupirocin Formulary Low Cost Generics QL 44 grams / rx

mupirocin calcium Formulary High Cost GenericsQL 30 GM / 30 day(s)

PA

ROSADAN 0.75% CREAM Formulary High Cost Generics



LOCAL ANTI-INFECTIVES, MISCELLANEOUS

hydrocortisone/iodoquinol Formulary High Cost Generics

selenium sulfide 2.5 % lotion Formulary High Cost Generics

silver sulfadiazine Formulary High Cost Generics

SSD Formulary High Cost Generics

sulfacetamide sod/sulfur/urea 10%-5%-10% cleanser


sulfacetamide sodium 10 % suspension Formulary High Cost Generics

SCABICIDES AND PEDICULICIDES

EURAX 10% CREAM Formulary Brands

malathion Formulary High Cost Generics

permethrin Formulary High Cost Generics

ANTI-INFLAMMATORY AGENTS (EENT)

CORTICOSTEROIDS (EENT)

dexamethasone sodium phosphate 0.1% drops


flunisolide Formulary High Cost Generics

fluocinolone acetonide oil Formulary High Cost Generics

fluorometholone Formulary High Cost Generics

fluticasone propionate 50 mcg spraysusp


FML S.O.P. Formulary Brands

LOTEMAX (EYE OINTMENT,OPHTHALMIC GEL)

Formulary Brands

LOTEMAX SM Formulary Brands

loteprednol etabonate Formulary High Cost Generics

prednisolone acetate Formulary High Cost Generics

prednisolone sodium phosphate 1 %drops


QNASL Formulary Brands

QNASL CHILDREN Formulary Brands



EENT ANTI-INFLAMMATORY AGENTS, MISC.

RESTASIS Formulary Brands

RESTASIS MULTIDOSE Formulary Brands

EENT NONSTEROIDAL ANTI-INFLAM. AGENTS

ACUVAIL Formulary Brands PA

bromfenac sodium Formulary High Cost Generics

diclofenac sodium 0.1 % drops Formulary Low Cost Generics

flurbiprofen sodium Formulary Low Cost Generics

ketorolac tromethamine (0.4 % drops,0.5 % drops)


ANTI-INFLAMMATORY AGENTS (RESPIRATORY)

INTERLEUKIN ANTAGONISTS

DUPIXENT 200 MG/1.14 ML SYRING Formulary Brands

QL 2.28 ML / 28 DAY(S)

PA

S

FASENRA PEN Formulary BrandsPA

S

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

Formulary BrandsPA

S

LEUKOTRIENE MODIFIERS

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


montelukast sodium 10 mg tablet Formulary Low Cost Generics

MAST-CELL STABILIZERS

cromolyn sodium 4 % drops Formulary High Cost Generics

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

ANTI-INFLAMMATORY AGENTS, MISC (SKIN)

EUCRISA Formulary BrandsQL 60 GM / 30 DAYS

ST



CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)

alclometasone dipropionate Formulary High Cost Generics

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


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


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


betamethasone/propylene glyc 0.05 %cream (g)


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


clobetasol propionate/emoll 0.05 %cream (g)


CORDRAN 4 MCG/SQ CM TAPELARGE

Formulary Brands PA

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


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


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


fluocinolone acetonide/shower cap Formulary High Cost Generics

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


fluocinonide/emollient base Formulary High Cost Generics

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


hydrocortisone (2.5 % cream (g), 2.5 %crm/pe app, 2.5 % lotion, 100mg/60mlenema)


hydrocortisone 2.5 % oint. (g) Formulary Low Cost Generics



hydrocortisone acetate 25 mg supp.rect Formulary High Cost Generics

hydrocortisone acetate/pramoxine hcl(hydrocortisone/pramoxine 1 %cream/appl, hydrocortisone/pramoxine2.5 % cream (g),hydrocortisone/pramoxine 2.5 %cream/appl)


hydrocortisone valerate Formulary High Cost Generics

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


PROCTO-MED HC Formulary High Cost Generics

PROCTOFOAM-HC Formulary Brands

PROCTOSOL-HC Formulary High Cost Generics

PROCTOZONE-HC Formulary High Cost Generics

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


triamcinolone acetonide 0.1 % paste (g) Formulary Low Cost Generics

TRIDERM Formulary High Cost Generics

ANTIARRHYTHMIC AGENTS

CLASS IA ANTIARRHYTHMICS

disopyramide phosphate Formulary High Cost Generics

NORPACE CR Formulary Brands

quinidine sulfate Formulary High Cost Generics

CLASS IB ANTIARRHYTHMICS

mexiletine hcl Formulary High Cost Generics

CLASS IC ANTIARRHYTHMICS

flecainide acetate Formulary High Cost Generics

propafenone hcl (150 mg tablet, 225 mgtablet, 300 mg tablet)


CLASS III ANTIARRHYTHMICS

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




dofetilide Formulary High Cost Generics

MULTAQ Formulary Brands PA

PACERONE (100 MG TABLET, 400 MGTABLET)


ANTIBACTERIALS

AMINOGLYCOSIDE ANTIBIOTICS

neomycin sulfate Formulary High Cost Generics

tobramycin in 0.225 % sodium chloride Formulary High Cost GenericsPA

S

QUINOLONE ANTIBIOTICS

CIPRO (5% SUSPENSION, 10%SUSPENSION)

Formulary Brands AL1 Up to 12 yrs old

ciprofloxacin Formulary High Cost Generics AL1 Up to 12 yrs old

ciprofloxacin hcl (100 mg tablet, 250 mgtablet, 500 mg tablet, 750 mg tablet)


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


levofloxacin 250mg/10ml solution Formulary High Cost Generics AL1 Up to 12 yrs old

moxifloxacin hcl 400 mg tablet Formulary High Cost Generics

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)

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


sulfamethoxazole/trimethoprim(sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160mg tablet)


sulfasalazine (500 mg tablet, 500 mgtablet dr)


SULFATRIM Formulary High Cost Generics



TETRACYCLINE ANTIBIOTICS

demeclocycline hcl Formulary High Cost Generics

doxycycline hyclate (50 mg capsule, 100mg capsule, 100 mg tablet)


doxycycline monohydrate (50 mgcapsule, 50 mg tablet, 100 mg capsule,100 mg tablet)


doxycycline monohydrate 25 mg/5 mlsusp recon


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


MONDOXYNE NL 100 MG CAPSULE Formulary High Cost Generics

ANTIBACTERIALS, MISCELLANEOUS

GLYCOPEPTIDE ANTIBIOTICS

vancomycin hcl 125 mg capsule Formulary High Cost Generics

vancomycin hcl 250 mg capsule Formulary Low Cost Generics

LINCOMYCIN ANTIBIOTICS

clindamycin hcl (150 mg capsule, 300mg capsule)


clindamycin hcl 75 mg capsule Formulary High Cost Generics

clindamycin palmitate hcl Formulary High Cost Generics AL1 Up to 12 yrs old

OXAZOLIDINONE ANTIBIOTICS

linezolid 100 mg/5ml susp recon Formulary High Cost Generics PA

linezolid 600 mg tablet Formulary High Cost Generics QL 28 tablets / rx

SIVEXTRO 200 MG TABLET Formulary Brands PA

PLEUROMUTILINS

XENLETA 600 MG TABLET Formulary BrandsQL 10 TABS / rx

PA

RIFAMYCIN ANTIBIOTICS

XIFAXAN Formulary Brands PA



ANTICHOLINERGIC AGENTS

ANTIMUSCARINICS/ANTISPASMODICS

ANORO ELLIPTA Formulary Brands

ATROVENT HFA Formulary Brands QL 1 INHALER / 25 day(s)

COMBIVENT RESPIMAT Formulary Brands QL 1 INHALER / 30 day(s)

CUVPOSA Formulary Brands PA

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


dicyclomine hcl 10 mg capsule Formulary High Cost Generics

glycopyrrolate (1 mg tablet, 2 mg tablet) Formulary High Cost Generics

hyoscyamine sulfate (0.125 mg tabrapdis, 0.125 mg tab subl, 0.125 mgtablet, 0.125mg/ml drops, 0.375 mg taber 12h, 125mcg/5ml elixir)


INCRUSE ELLIPTA Formulary Brands

ipratropium bromide 0.2 mg/ml solution Formulary High Cost Generics

ipratropium bromide/albuterol sulfate Formulary High Cost Generics

propantheline bromide Formulary High Cost Generics

ANTICOAGULANTS

ANTICOAGULANTS, MISCELLANEOUS

fondaparinux sodium (2.5 mg/0.5syringe, 5mg/0.4ml syringe, 10mg/0.8mlsyringe)

Formulary High Cost GenericsQL 1 syringe / 1 day(s)

PA

fondaparinux sodium 7.5mg/0.6 syringe Formulary High Cost GenericsQL 1 syringe / 1 day(s)

PA

COUMARIN DERIVATIVES

warfarin sodium Formulary Low Cost Generics

DIRECT FACTOR XA INHIBITORS

ELIQUIS (2.5 MG TABLET, 5 MGTABLET)

Formulary Brands QL 60 TABS / 30 DAY(S)

ELIQUIS DVT-PE TREAT START 5MG Formulary Brands QL 1 RX / 30 day(s)

XARELTO (10 MG TABLET, 20 MGTABLET)




XARELTO (2.5 MG TABLET, 15 MGTABLET)


XARELTO DVT-PE TREAT START 30D Formulary Brands QL 51 TABS / 30 DAY(S)

DIRECT THROMBIN INHIBITORS

PRADAXA Formulary Brands PA

HEPARINS

enoxaparin sodium (30mg/0.3ml syringe,40mg/0.4ml syringe, 60mg/0.6mlsyringe, 80mg/0.8ml syringe, 100 mg/mlsyringe, 120mg/.8ml syringe, 150 mg/mlsyringe)

Formulary High Cost Generics QL 2 syringes / 1 day(s)

enoxaparin sodium 300mg/3ml vial Formulary High Cost Generics QL 2 vials / 1 day(s)

heparin sodium,porcine (1000/ml vial,5000/ml syringe, 5000/ml vial,5000/ml(1) cartridge, 10000/ml vial,20000/ml vial)


heparin sodium,porcine/pf 5000/0.5mlcartridge


ANTICONVULSANTS

ANTICONVULSANTS, MISCELLANEOUS

APTIOM Formulary Brands PA

BANZEL 200 MG TABLET Formulary BrandsQL 16 TABS / 1 DAY

PA

BANZEL 400 MG TABLET Formulary BrandsQL 8 TABS / 1 DAY

PA

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

Formulary Brands PA

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


DIACOMIT 250 MG CAPSULE Formulary Brands

QL 360 CAPS / 30 day(s)

PA

S



DIACOMIT 250 MG POWDER PACKET Formulary Brands

QL 360 PACKETS / 30day(s)

PA

S

DIACOMIT 500 MG CAPSULE Formulary BrandsPA

S

DIACOMIT 500 MG POWDER PACKET Formulary Brands

QL 180 PACKETS / 30day(s)

PA

S

divalproex sodium (125 mg cap dr spr,250 mg tab er 24h, 500 mg tab er 24h)


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


EPIDIOLEX Formulary Brands

QL 20 ML / 1 DAY

PA

S

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


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

Formulary Brands PA

gabapentin (100 mg capsule, 300 mgcapsule)


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

Formulary High Cost Generics QL 72 ML / 1 DAY

gabapentin 400 mg capsule Formulary High Cost Generics QL 9 CAPS / 1 DAY

gabapentin 600 mg tablet Formulary High Cost Generics QL 6 TABS / 1 DAY

gabapentin 800 mg tablet Formulary High Cost Generics QL 4 TABS / 1 DAY

lamotrigine (5 mg tb chw dsp, 25 mgtablet, 25 mg tb chw dsp, 100 mg tablet,150 mg tablet, 200 mg tablet)


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




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


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


pregabalin (225 mg capsule, 300 mgcapsule)


pregabalin (25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mgcapsule, 150 mg capsule, 200 mgcapsule)


pregabalin 20 mg/ml solution Formulary High Cost Generics QL 30 ML / 1 DAY

rufinamide Formulary High Cost GenericsQL 80 ML / 1 day(s)

PA

SUBVENITE Formulary High Cost Generics

tiagabine hcl Formulary High Cost Generics

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


valproic acid Formulary High Cost Generics

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


vigabatrin Formulary High Cost GenericsPA

S

VIGADRONE Formulary High Cost GenericsPA

S

VIMPAT (150 MG TABLET, 200 MGTABLET)

Formulary Brands QL 2 TABS / 1 DAY

VIMPAT 10 MG/ML SOLUTION Formulary Brands QL 40 ML / 1 DAY

VIMPAT 100 MG TABLET Formulary Brands QL 4 TABS / 1 DAY

VIMPAT 50 MG TABLET Formulary Brands QL 8 TABS / 1 DAY

zonisamide Formulary Low Cost Generics



BARBITURATES (ANTICONVULSANTS)

primidone Formulary High Cost Generics

BENZODIAZEPINES (ANTICONVULSANTS)

clobazam 10 mg tablet Formulary High Cost Generics QL 4 TABS / 1 DAY

clobazam 2.5 mg/ml oral susp Formulary High Cost Generics QL 16 ML / 1 DAY

clobazam 20 mg tablet Formulary High Cost Generics QL 2 TABS / 1 DAY

clonazepam (0.125 mg tab rapdis, 0.25mg tab rapdis, 0.5 mg tab rapdis, 0.5 mgtablet)

Formulary Low Cost Generics QL 6 TABS / 1 DAY

clonazepam (1 mg tab rapdis, 1 mgtablet)


clonazepam (2 mg tab rapdis, 2 mgtablet)


NAYZILAM Formulary BrandsQL 2 bottles / rx

PA

HYDANTOINS

DILANTIN 30 MG CAPSULE Formulary Brands

phenytoin (50 mg tab chew, 125 mg/5mloral susp)


phenytoin sodium extended Formulary High Cost Generics

SUCCINIMIDES

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


ANTIDEPRESSANTS

ANTIDEPRESSANTS, MISCELLANEOUS

bupropion hcl (75 mg tablet, 100 mg tabsr 12h, 100 mg tablet, 150 mg tab er12h, 150 mg tab er 24h, 150 mg tab sr12h, 200 mg tab sr 12h, 300 mg tab er24h)


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




MONOAMINE OXIDASE INHIBITORS

phenelzine sulfate Formulary High Cost Generics

tranylcypromine sulfate Formulary High Cost Generics

SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR

desvenlafaxine succinate Formulary Low Cost Generics

duloxetine hcl (20 mg capsule dr, 30 mgcapsule dr, 60 mg capsule dr)


FETZIMA Formulary Brands PA

venlafaxine hcl (25 mg tablet, 37.5 mgcap er 24h, 37.5 mg tablet, 50 mg tablet,75 mg cap er 24h, 75 mg tablet, 100 mgtablet, 150 mg cap er 24h)


SELECTIVE-SEROTONIN REUPTAKE INHIBITORS

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


citalopram hydrobromide (10 mg/5 mlsolution, 20 mg/10ml solution)


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


escitalopram oxalate 5 mg/5 ml solution Formulary High Cost Generics

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


fluoxetine hcl 20 mg/5 ml solution Formulary High Cost Generics

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


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


PAXIL 10 MG/5 ML SUSPENSION Formulary Brands

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


SEROTONIN MODULATORS

nefazodone hcl Formulary High Cost Generics

trazodone hcl Formulary Low Cost Generics

TRINTELLIX Formulary Brands PA



VIIBRYD Formulary Brands PA

TRICYCLICS, OTHER NOREPI-RU INHIBITORS

amitriptyline hcl Formulary High Cost Generics

clomipramine hcl Formulary High Cost Generics AL1 Up to 64 yrs old

desipramine hcl Formulary High Cost Generics

doxepin hcl (10 mg capsule, 25 mgcapsule, 50 mg capsule, 75 mg capsule,100 mg capsule, 150 mg capsule)


doxepin hcl 10 mg/ml oral conc Formulary High Cost Generics AL1 Up to 64 yrs old

imipramine hcl Formulary High Cost Generics

nortriptyline hcl (10 mg capsule, 10 mg/5ml solution, 25 mg capsule, 50 mgcapsule, 75 mg capsule)


ANTIDIABETIC AGENTS

ALPHA-GLUCOSIDASE INHIBITORS

acarbose Formulary Low Cost Generics

miglitol Formulary High Cost Generics

BIGUANIDES

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


DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

JENTADUETO Formulary Brands QL 60 TABS / 30 DAY(S)

JENTADUETO XR Formulary Brands QL 60 TABS / 30 DAY(S)

TRADJENTA Formulary Brands QL 30 TABS / 30 DAY(S)

INCRETIN MIMETICS

BYDUREON Formulary Brands QL 4 ML / 28 DAYS

BYDUREON BCISE Formulary Brands QL 3.4 ML / 28 day(s)

BYDUREON PEN Formulary Brands QL 4 PEN / 28 DAYS

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



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

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

OZEMPIC 1 MG DOSE PEN Formulary Brands QL 3 ML / 28 DAYSS

RYBELSUS Formulary Brands QL 1 tab / 1 day(s)

TRULICITY (0.75 MG/0.5 ML PEN, 1.5MG/0.5 ML PEN)

Formulary Brands QL 2 ML / 28 DAYS

TRULICITY (3 MG/0.5 ML PEN, 4.5MG/0.5 ML PEN)

Formulary Brands QL 2 ML / 28 DAY(S)

VICTOZA 2-PAK Formulary Brands QL 9 ML / 30 DAYS

VICTOZA 3-PAK Formulary Brands QL 9 ML / 30 DAYS

MEGLITINIDES

nateglinide Formulary High Cost Generics

repaglinide Formulary High Cost Generics

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

INVOKAMET Formulary Brands QL 60 TABS / 30 DAY(S)

INVOKAMET XR Formulary Brands QL 60 TABS / 30 DAY(S)

INVOKANA Formulary Brands QL 30 TABS / 30 DAY(S)

JARDIANCE Formulary Brands QL 30 TABS / 30 DAY(S)

SYNJARDY Formulary Brands QL 60 TABS / 30 DAY(S)

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

Formulary Brands QL 1 TABS / 1 DAY

SYNJARDY XR (5-1,000 MG TABLET,12.5-1,000 MG TAB)


TRIJARDY XR (10-5-1,000 MG TAB,25-5-1,000 MG TAB)

Formulary Brands QL 1 TABLET / 1 day(s)

TRIJARDY XR (5-2.5-1,000 MG TAB,12.5-2.5-1,000 MG)

Formulary Brands QL 2 TABLETS / 1 day(s)

SULFONYLUREAS

glimepiride Formulary Low Cost Generics

glipizide (2.5 mg tab er 24, 5 mg tab er24, 5 mg tablet, 10 mg tab er 24, 10 mgtablet)




glipizide/metformin hcl Formulary Low Cost Generics

glyburide Formulary High Cost Generics PA

glyburide,micronized Formulary High Cost Generics PA

THIAZOLIDINEDIONES

pioglitazone hcl Formulary Low Cost Generics

pioglitazone hcl/glimepiride Formulary High Cost Generics

pioglitazone hcl/metformin hcl Formulary High Cost Generics

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

ondansetron Formulary High Cost Generics

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


ondansetron hcl 4 mg/5 ml solution Formulary Low Cost Generics

ANTIEMETICS, MISCELLANEOUS

dronabinol (2.5 mg capsule, 5 mgcapsule)


dronabinol 10 mg capsule Formulary Low Cost Generics QL 4 CAPS / 1 DAY

scopolamine Formulary High Cost Generics

ANTIHISTAMINES (GI DRUGS)

prochlorperazine Formulary High Cost Generics

prochlorperazine maleate Formulary Low Cost Generics

trimethobenzamide hcl Formulary High Cost Generics

NEUROKININ-1 RECEPTOR ANTAGONISTS

aprepitant Formulary High Cost Generics

EMEND 125 MG POWDER PACKET Formulary Brands

ANTIFUNGAL (SYSTEMIC)

ALLYLAMINE ANTIFUNGALS

terbinafine hcl Formulary Low Cost Generics



ANTIFUNGALS, MISCELLANEOUS

griseofulvin ultramicrosize Formulary High Cost Generics

griseofulvin, microsize (125 mg/5ml oralsusp, 500 mg tablet)


AZOLE ANTIFUNGALS

CRESEMBA 186 MG CAPSULE Formulary Brands PA

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


fluconazole (50 mg tablet, 100 mg tablet,150 mg tablet, 200 mg tablet)


itraconazole 100 mg capsule Formulary High Cost Generics ST

ketoconazole 200 mg tablet Formulary Low Cost Generics

posaconazole (100 mg tablet dr, 200mg/5ml oral susp)


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


POLYENE ANTIFUNGALS

nystatin 100000/ml oral susp Formulary High Cost Generics QL 480 ml / rx

nystatin 500k unit tablet Formulary Low Cost Generics

ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)

AZOLES (SKIN AND MUCOUS MEMBRANE)

clotrimazole 10 mg troche Formulary High Cost Generics

econazole nitrate Formulary High Cost Generics QL 85 GM / 30 day(s)

ketoconazole 2 % cream (g) Formulary Low Cost Generics QL 60 GM / 30 day(s)

ketoconazole 2 % shampoo Formulary High Cost Generics

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


HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)

ciclopirox (0.77 % gel (gram), 8 %solution)


ciclopirox olamine 0.77 % cream (g) Formulary High Cost Generics

ciclopirox olamine 0.77 % suspension Formulary High Cost Generics QL 60 ML / 30 day(s)



POLYENES (SKIN AND MUCOUS MEMBRANE)

nystatin (100000/g cream (g), 100000/goint. (g))


nystatin 100000/g powder Formulary High Cost Generics QL 240 grams / rx

ANTIGLAUCOMA AGENTS

ALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P 0.1% DROPS Formulary Brands

brimonidine tartrate Formulary High Cost Generics

COMBIGAN Formulary Brands

BETA-ADRENERGIC BLOCKING AGENTS (EENT)

betaxolol hcl 0.5 % drops Formulary High Cost Generics

carteolol hcl Formulary Low Cost Generics

levobunolol hcl Formulary Low Cost Generics

timolol maleate (0.25 % drops, 0.5 %drops)


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


CARBONIC ANHYDRASE INHIBITORS (EENT)

acetazolamide (125 mg tablet, 250 mgtablet)


acetazolamide 500 mg capsule er Formulary High Cost Generics

AZOPT Formulary Brands

dorzolamide hcl Formulary High Cost Generics

dorzolamide hcl/timolol maleate Formulary High Cost Generics

dorzolamide/timolol/pf 2 %-0.5 %droperette


methazolamide Formulary High Cost Generics

SIMBRINZA Formulary Brands

MIOTICS

PHOSPHOLINE IODIDE Formulary Brands

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




PROSTAGLANDIN ANALOGS

bimatoprost 0.03 % drops Formulary High Cost Generics

latanoprost Formulary High Cost Generics

LUMIGAN Formulary Brands

travoprost Formulary High Cost Generics

ZIOPTAN Formulary Brands PA

RHO KINASE INHIBITORS

RHOPRESSA Formulary Brands

ROCKLATAN Formulary Brands

ANTIHEMORRHAGIC AGENTS

HEMOSTATICS

ADVATE Formulary BrandsPA

S

ADYNOVATE Formulary BrandsPA

S

AFSTYLA Formulary BrandsPA

S

ALPHANATE Formulary BrandsPA

S

ALPHANINE SD Formulary BrandsPA

S

ALPROLIX Formulary BrandsPA

S

BENEFIX Formulary BrandsPA

S

COAGADEX Formulary BrandsPA

S

CORIFACT Formulary BrandsPA

S



ELOCTATE Formulary BrandsPA

S

ESPEROCT (500 UNIT VIAL, 1,000UNIT VIAL, 1,500 UNIT VIAL, 2,000UNIT VIAL, 3,000 UNIT VIAL)

Formulary BrandsPA

S

FEIBA NF Formulary BrandsPA

S

HELIXATE FS Formulary BrandsPA

S

HEMLIBRA Formulary BrandsPA

S

HEMOFIL M Formulary BrandsPA

S

HUMATE-P Formulary BrandsPA

S

IDELVION Formulary BrandsPA

S

IXINITY Formulary BrandsPA

S

JIVI Formulary BrandsPA

S

KOATE Formulary BrandsPA

S

KOGENATE FS Formulary BrandsPA

S

KOVALTRY Formulary BrandsPA

S

MONONINE Formulary Brands S

NOVOEIGHT Formulary BrandsPA

S



NOVOSEVEN RT Formulary BrandsPA

S

NUWIQ Formulary BrandsPA

S

OBIZUR Formulary BrandsPA

S

PROFILNINE Formulary BrandsPA

S

REBINYN Formulary BrandsPA

S

RECOMBINATE Formulary BrandsPA

S

RIXUBIS Formulary BrandsPA

S

SEVENFACT Formulary BrandsPA

S

tranexamic acid 650 mg tablet Formulary High Cost Generics QL 30 TABS / RX

TRETTEN Formulary BrandsPA

S

VONVENDI Formulary BrandsPA

S

WILATE Formulary BrandsPA

S

XYNTHA Formulary BrandsPA

S

XYNTHA SOLOFUSE Formulary BrandsPA

S



ANTIHYPOGLYCEMIC AGENTS

GLYCOGENOLYTIC AGENTS

BAQSIMI Formulary Brands

GLUCAGEN 1 MG HYPOKIT Formulary Brands

GLUCAGON EMERGENCY KIT Formulary Brands

GVOKE HYPOPEN 1-PACK Formulary Brands

GVOKE HYPOPEN 2-PACK Formulary Brands

GVOKE PFS 1-PACK SYRINGE Formulary Brands

GVOKE PFS 2-PACK SYRINGE Formulary Brands

ANTILIPEMIC AGENTS

ANTILIPEMIC AGENTS, MISCELLANEOUS

icosapent ethyl Formulary High Cost Generics PA

JUXTAPID Formulary BrandsPA

S

omega-3 acid ethyl esters Formulary Low Cost Generics

TRIKLO Formulary Low Cost Generics

VASCEPA 0.5 GM CAPSULE Formulary Brands PA

BILE ACID SEQUESTRANTS

cholestyramine (with sugar) (4 g powdpack, 4 g powder)


cholestyramine/aspartame(cholestyramine/aspartame 4 g powdpack, cholestyramine/aspartame 4 gpowder)


colestipol hcl 1 g tablet Formulary High Cost Generics

PREVALITE (PACKET, POWDER) Formulary High Cost Generics

CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe Formulary Low Cost Generics

FIBRIC ACID DERIVATIVES

fenofibrate (54 mg tablet, 160 mg tablet) Formulary High Cost Generics

fenofibrate nanocrystallized (48 mgtablet, 145 mg tablet)




fenofibrate,micronized (67 mg capsule,134 mg capsule, 200 mg capsule)


gemfibrozil Formulary Low Cost Generics

HMG-COA REDUCTASE INHIBITORS

atorvastatin calcium (10 mg tablet, 20mg tablet)

Formulary Low Cost Generics ACA

atorvastatin calcium (40 mg tablet, 80mg tablet)


lovastatin (20 mg tablet, 40 mg tablet) Formulary Low Cost Generics ACA

lovastatin 10 mg tablet Formulary Low Cost Generics

pravastatin sodium Formulary Low Cost Generics ACA

rosuvastatin calcium (20 mg tablet, 40mg tablet)


rosuvastatin calcium (5 mg tablet, 10 mgtablet)


simvastatin (10 mg tablet, 20 mg tablet,40 mg tablet)


simvastatin (5 mg tablet, 80 mg tablet) Formulary Low Cost Generics

PCSK9 INHIBITORS

REPATHA PUSHTRONEX Formulary BrandsQL 1 pen / 28 day(s)

PA

REPATHA SURECLICK Formulary BrandsQL 2 pens / 28 day(s)

PA

REPATHA SYRINGE Formulary BrandsQL 2 pens / 28 day(s)

PA

ANTIMIGRAINE AGENTS

CALCITONIN GENE-RELATED PEPTIDE ANTAG.

AJOVY AUTOINJECTOR Formulary Brands

QL 1.5 ML / 30 day(s)

PA

S

AJOVY SYRINGE Formulary Brands

QL 1.5 ML / 30 DAY(S)

PA

S



EMGALITY 120 MG/ML SYRINGE Formulary Brands

QL 1 ML / 30 DAY(S)

PA

S

EMGALITY PEN Formulary Brands

QL 1 ML / 30 DAYS

PA

S

EMGALITY SYRINGE (100 MG/MLSYR(1 OF 3), 300 MG (100 MGX3SYR))

Formulary Brands

QL 3 ML / 30 day(s)

PA

S

NURTEC ODT Formulary BrandsQL 8 TABS / 30 day(s)

PA

SELECTIVE SEROTONIN AGONISTS

naratriptan hcl Formulary Low Cost Generics QL 12 TABS / 30 DAYS

REYVOW Formulary BrandsQL 8 tabs / 30 day(s)

PA

rizatriptan benzoate Formulary High Cost Generics QL 12 TABS / 28 DAYS

sumatriptan Formulary High Cost Generics QL 12 ML / 30 DAYS

sumatriptan succinate (25 mg tablet, 50mg tablet, 100 mg tablet)


sumatriptan succinate (4 mg/0.5mlcartridge, 4 mg/0.5ml pen injctr, 6mg/0.5ml cartridge, 6 mg/0.5ml peninjctr, 6 mg/0.5ml vial)

Formulary High Cost Generics QL 5 ML / 30 DAYS

sumatriptan succinate 6 mg/0.5mlsyringe

Formulary High Cost Generics QL 5 ML / 30 DAYSS

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, MISCELLANEOUS

dapsone (25 mg tablet, 100 mg tablet) Formulary High Cost Generics

ANTITUBERCULOSIS AGENTS

cycloserine Formulary High Cost Generics PA

ethambutol hcl Formulary Low Cost Generics



isoniazid (100 mg tablet, 300 mg tablet) Formulary Low Cost Generics

isoniazid 50 mg/5 ml solution Formulary High Cost Generics

pretomanid Formulary High Cost Generics PA

PRIFTIN Formulary Brands

pyrazinamide Formulary High Cost Generics

rifabutin Formulary High Cost Generics

rifampin (150 mg capsule, 300 mgcapsule)


SIRTURO Formulary Brands PA

TRECATOR Formulary Brands PA

ANTINEOPLASTIC AGENTS

abiraterone acetate Formulary High Cost Generics

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

AFINITOR 10 MG TABLET Formulary Brands

QL 30 TABS / 30 DAY(S)

PA

S

ONC Oncology

TD Trial Drug

AFINITOR DISPERZ (2 MG TABLET, 5MG TABLET)

Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

AFINITOR DISPERZ 3 MG TABLET Formulary Brands

QL 90 TABS / 30 day(s)

PA

S

ONC Oncology

TD Trial Drug



ALECENSA Formulary Brands


PA

S

ONC Oncology

anastrozole Formulary Low Cost Generics ACA

AYVAKIT Formulary Brands

QL 1 tab / 1 day(s)

PA

S

ONC Oncology

BALVERSA Formulary Brands

PA

S

ONC Oncology

bicalutamide Formulary Low Cost Generics

BOSULIF (400 MG TABLET, 500 MGTABLET)

Formulary Brands

QL 1 tab / 1 day(s)

PA

S

ONC Oncology

TD Trial Drug

BOSULIF 100 MG TABLET Formulary Brands

QL 4 tabs / 1 day(s)

PA

S

ONC Oncology

TD Trial Drug

BRAFTOVI 50 MG CAPSULE Formulary Brands

QL 60 CAPS / 30 DAY(S)

PA

S

ONC Oncology

BRAFTOVI 75 MG CAPSULE Formulary Brands


PA

S

ONC Oncology



BRUKINSA Formulary Brands

PA

S

ONC Oncology

CABOMETYX Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

capecitabine Formulary High Cost GenericsS

ONC Oncology

CAPRELSA 100 MG TABLET Formulary Brands


PA

S

ONC Oncology

CAPRELSA 300 MG TABLET Formulary Brands


PA

S

ONC Oncology

COMETRIQ 100 MG DAILY-DOSE PK Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

COMETRIQ 140 MG DAILY-DOSE PK Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

COMETRIQ 60 MG DAILY-DOSE PACK Formulary Brands


PA

S

ONC Oncology

TD Trial Drug



COPIKTRA Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

COTELLIC Formulary Brands


PA

S

ONC Oncology

cyclophosphamide (25 mg capsule, 50mg capsule)


DAURISMO 100 MG TABLET Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

DAURISMO 25 MG TABLET Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

EMCYT Formulary Brands

ERIVEDGE Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

ERLEADA Formulary Brands

PA

S

ONC Oncology



erlotinib hcl 25 mg tablet Formulary High Cost Generics


PA

S

ONC Oncology

TD Trial Drug

etoposide 50 mg capsule Formulary High Cost Generics

everolimus (5 mg tablet, 7.5 mg tablet) Formulary High Cost Generics


PA

S

ONC Oncology

TD Trial Drug

everolimus 2.5 mg tablet Formulary High Cost Generics

QL 1 TAB / 1 day(s)

PA

S

ONC Oncology

TD Trial Drug

exemestane Formulary High Cost Generics ACA

FLUOROPLEX Formulary Brands

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


flutamide Formulary High Cost Generics

GILOTRIF Formulary Brands


PA

S

ONC Oncology

GLEOSTINE Formulary Brands

HYCAMTIN Formulary BrandsS

ONC Oncology

hydroxyurea Formulary High Cost Generics

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

Formulary Brands

QL 21 CAPS / 28 DAYS

PA

S

ONC Oncology



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

Formulary Brands

QL 21 TABS / 28 DAYS

PA

S

ONC Oncology

ICLUSIG 15 MG TABLET Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

ICLUSIG 45 MG TABLET Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

IDHIFA Formulary Brands


PA

S

ONC Oncology

imatinib mesylate Formulary High Cost Generics

S

ONC Oncology

TD Trial Drug

IMBRUVICA (420 MG TABLET, 560 MGTABLET)

Formulary Brands

QL 1 tablet / 1 day(s)

PA

S

ONC Oncology

IMBRUVICA 140 MG CAPSULE Formulary Brands


PA

S

ONC Oncology

IMBRUVICA 70 MG CAPSULE Formulary Brands

QL 1 CAPSULE / 1 day(s)

PA

S

ONC Oncology



INLYTA 1 MG TABLET Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

INLYTA 5 MG TABLET Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

INREBIC Formulary Brands

PA

S

ONC Oncology

IRESSA Formulary Brands


PA

S

ONC Oncology

JAKAFI Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

KISQALI 200 MG DAILY DOSE Formulary Brands


PA

S

ONC Oncology



PA

S

ONC Oncology



PA

S

ONC Oncology



KISQALI FEMARA 200 MG CO-PACK Formulary Brands


PA

S

ONC Oncology



PA

S

ONC Oncology



PA

S

ONC Oncology

KOSELUGO 10 MG CAPSULE Formulary Brands

QL 8 capsules / 1 day(s)

PA

S

ONC Oncology

KOSELUGO 25 MG CAPSULE Formulary Brands


PA

S

ONC Oncology

lapatinib ditosylate Formulary High Cost Generics

QL 6 TABS / DAY

PA

S

ONC Oncology

LENVIMA 10 MG DAILY DOSE Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

letrozole Formulary High Cost Generics ACA

LEUKERAN Formulary Brands



LONSURF 15 MG-6.14 MG TABLET Formulary Brands


PA

S

ONC Oncology

LONSURF 20 MG-8.19 MG TABLET Formulary Brands


PA

S

ONC Oncology

LORBRENA 100 MG TABLET Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

LORBRENA 25 MG TABLET Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

LYNPARZA Formulary Brands

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

MATULANE Formulary Brands


PA

S

ONC Oncology

MEKINIST 0.5 MG TABLET Formulary Brands


PA

S

ONC Oncology



MEKINIST 2 MG TABLET Formulary Brands


PA

S

ONC Oncology

MEKTOVI Formulary Brands


PA

S

ONC Oncology

melphalan Formulary High Cost Generics

mercaptopurine Formulary High Cost Generics

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


methotrexate sodium/pf 25 mg/ml vial Formulary High Cost Generics

MYLERAN Formulary Brands

NERLYNX Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

NEXAVAR Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

NINLARO Formulary Brands


PA

S

ONC Oncology

NUBEQA Formulary Brands

PA

S

ONC Oncology



PEMAZYRE (9 MG TABLET, 13.5 MGTABLET)

Formulary Brands

QL 14 tablets / 21 day(s)

PA

S

ONC Oncology

PEMAZYRE 4.5 MG TABLET Formulary Brands


S

ONC Oncology

PICATO Formulary Brands PA

POMALYST Formulary Brands


PA

S

ONC Oncology

QINLOCK Formulary Brands


PA

S

ONC Oncology

RASUVO Formulary Brands PA

RETEVMO 40 MG CAPSULE Formulary Brands


PA

S

ONC Oncology

RETEVMO 80 MG CAPSULE Formulary Brands


PA

S

ONC Oncology

REVLIMID Formulary Brands


S

ONC Oncology

ROZLYTREK Formulary Brands

PA

S

ONC Oncology



RYDAPT Formulary Brands

PA

S

ONC Oncology

SPRYCEL Formulary Brands

PA

S

ONC Oncology

TD Trial Drug

STIVARGA Formulary Brands

PA

S

ONC Oncology

SUTENT Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

TABLOID Formulary Brands

TABRECTA Formulary Brands


PA

S

ONC Oncology

TAFINLAR Formulary Brands


PA

S

ONC Oncology

TAGRISSO Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

TASIGNA Formulary Brands

PA

S

ONC Oncology

TD Trial Drug



TAZVERIK Formulary Brands

QL 8 tabs / 1 day(s)

PA

S

ONC Oncology

temozolomide Formulary High Cost GenericsS

ONC Oncology

TIBSOVO Formulary Brands


PA

S

ONC Oncology

tretinoin 10 mg capsule Formulary High Cost GenericsS

ONC Oncology

TURALIO Formulary Brands

PA

S

ONC Oncology

TYKERB Formulary Brands

QL 6 TABS / DAY

PA

S

ONC Oncology

VALCHLOR Formulary Brands

QL 120 GM / 30 DAYS

PA

S

ONC Oncology

VERZENIO Formulary Brands


PA

S

ONC Oncology

VITRAKVI 100 MG CAPSULE Formulary Brands


PA

S

ONC Oncology

TD Trial Drug



VITRAKVI 20 MG/ML SOLUTION Formulary Brands

QL 300 ML / 30 DAY(S)

PA

S

ONC Oncology

TD Trial Drug

VITRAKVI 25 MG CAPSULE Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

VIZIMPRO Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

VOTRIENT Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

XALKORI Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

XOSPATA Formulary Brands


PA

S

ONC Oncology

XPOVIO Formulary Brands

PA

S

ONC Oncology



XTANDI Formulary Brands

PA

S

ONC Oncology

TD Trial Drug

ZEJULA Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

ZELBORAF Formulary Brands


PA

S

ONC Oncology

ZOLINZA Formulary Brands


PA

S

ONC Oncology

TD Trial Drug

ZYKADIA 150 MG CAPSULE Formulary Brands

QL 90 caps / 30 day(s)

PA

S

ONC Oncology

TD Trial Drug

ZYKADIA 150 MG TABLET Formulary Brands

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



ANTIPARKINSONIAN AGENTS (CNS)

ADAMANTANES (CNS)

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


amantadine hcl 100 mg capsule Formulary Low Cost Generics

ANTICHOLINERGIC AGENTS (CNS)

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


trihexyphenidyl hcl (2 mg tablet, 5 mgtablet)


trihexyphenidyl hcl 2 mg/5 ml elixir Formulary High Cost Generics

CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.

entacapone Formulary High Cost Generics

DOPAMINE PRECURSORS

carbidopa/levodopa (carbidopa/levodopa10mg-100mg tab rapdis,carbidopa/levodopa 10mg-100mg tablet,carbidopa/levodopa 25mg-100mg tabrapdis, carbidopa/levodopa 25mg-100mg tablet, carbidopa/levodopa25mg-100mg tablet er,carbidopa/levodopa 25mg-250mg tabrapdis, carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa50mg-200mg tablet er)


carbidopa/levodopa/entacapone Formulary High Cost Generics

INBRIJA Formulary BrandsPA

S

RYTARY Formulary Brands ST

MONOAMINE OXIDASE B INHIBITORS

EMSAM Formulary Brands PA

rasagiline mesylate Formulary High Cost Generics PA

selegiline hcl Formulary High Cost Generics



ANTIPROTOZOALS

ANTIMALARIALS

atovaquone/proguanil hcl Formulary High Cost Generics

chloroquine phosphate Formulary High Cost Generics

hydroxychloroquine sulfate Formulary High Cost Generics

mefloquine hcl Formulary Low Cost Generics

ANTIPROTOZOALS, MISCELLANEOUS

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

Formulary Brands PA

atovaquone Formulary High Cost Generics

metronidazole (250 mg tablet, 500 mgtablet)


ANTIPSYCHOTIC AGENTS

ANTIPSYCHOTICS, MISCELLANEOUS

loxapine succinate Formulary High Cost Generics AL1 At least 13 yrs old

ATYPICAL ANTIPSYCHOTICS

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

Formulary High Cost Generics AL1 At least 13 yrs old

aripiprazole (10 mg tab rapdis, 15 mgtab rapdis)

Formulary High Cost GenericsPA

AL1 At least 13 yrs old

CAPLYTA Formulary BrandsQL 1 cap / 1 day(s)

PA

clozapine (12.5 mg tab rapdis, 25 mgtab rapdis, 100 mg tab rapdis, 150 mgtab rapdis)



clozapine (25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet)


clozapine 200 mg tab rapdis Formulary Low Cost GenericsPA


FANAPT Formulary Brands PA

LATUDA Formulary BrandsQL 1 TAB / 1 DAY

PA



NUPLAZID Formulary Brands

PA

S

TD Trial Drug

olanzapine (2.5 mg tablet, 5 mg tablet,7.5 mg tablet, 10 mg tablet, 15 mgtablet, 20 mg tablet)


olanzapine (5 mg tab rapdis, 10 mg tabrapdis, 15 mg tab rapdis, 20 mg tabrapdis)



paliperidone Formulary Low Cost Generics PA

quetiapine fumarate (25 mg tablet, 50mg tab er 24h, 50 mg tablet, 100 mgtablet, 150 mg tab er 24h, 200 mg tab er24h, 200 mg tablet, 300 mg tab er 24h,300 mg tablet, 400 mg tab er 24h, 400mg tablet)


REXULTI Formulary Brands PA

risperidone (0.25 mg tab rapdis, 0.5 mgtab rapdis, 1 mg tab rapdis, 2 mg tabrapdis, 3 mg tab rapdis, 4 mg tab rapdis)



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

Formulary Low Cost Generics AL1 At least 13 yrs old

risperidone 1 mg/ml solution Formulary High Cost Generics AL1 At least 13 yrs old

SAPHRIS Formulary Brands PA

SECUADO Formulary Brands PA

VERSACLOZ Formulary BrandsPA


VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK)

Formulary BrandsQL 2 CAPSULES / 1

day(s)PA

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

Formulary BrandsQL 1 CAPSULE / 1 day(s)

PA

ziprasidone hcl Formulary High Cost Generics AL1 At least 13 yrs old



BUTYROPHENONES

haloperidol Formulary High Cost Generics AL1 At least 13 yrs old

haloperidol lactate 2 mg/ml oral conc Formulary High Cost Generics AL1 At least 13 yrs old

PHENOTHIAZINES

fluphenazine hcl (1 mg tablet, 2.5 mgtablet, 5 mg tablet, 10 mg tablet)


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

Formulary Low Cost Generics AL1 At least 13 yrs old

perphenazine Formulary Low Cost Generics AL1 At least 13 yrs old

thioridazine hcl Formulary Low Cost Generics AL1 At least 13 yrs old

trifluoperazine hcl Formulary High Cost Generics AL1 At least 13 yrs old

THIOXANTHENES

thiothixene Formulary Low Cost Generics AL1 At least 13 yrs old

ANTIRETROVIRALS

HIV ENTRY AND FUSION INHIBITORS

FUZEON Formulary Brands S

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

Formulary Brands

HIV INTEGRASE INHIBITOR ANTIRETROVIRALS

ISENTRESS Formulary Brands

ISENTRESS HD Formulary Brands

JULUCA Formulary Brands

TIVICAY Formulary Brands

TIVICAY PD Formulary Brands

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.

EDURANT Formulary Brands

efavirenz (50 mg capsule, 600 mgtablet)


efavirenz 200 mg capsule Formulary Low Cost Generics



INTELENCE Formulary Brands

nevirapine (50 mg/5 ml oral susp, 100mg tab er 24h, 200 mg tablet, 400 mgtab er 24h)


HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS

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


abacavir sulfate/lamivudine Formulary Low Cost Generics

abacavir sulfate/lamivudine/zidovudine Formulary High Cost Generics

BIKTARVY Formulary Brands

COMPLERA Formulary Brands

DESCOVY Formulary Brands ACA

efavirenz/emtricitabine/tenofovirdisoproxil fumarate


emtricitabine Formulary High Cost Generics ACA

emtricitabine/tenofovir disoproxilfumarate

Formulary High Cost Generics ACA

EMTRIVA 10 MG/ML SOLUTION Formulary Brands ACA

EPIVIR HBV 25 MG/5 ML SOLN Formulary Brands

GENVOYA Formulary Brands

lamivudine (10 mg/ml solution, 100 mgtablet, 150 mg tablet, 300 mg tablet)


lamivudine/zidovudine Formulary High Cost Generics

ODEFSEY Formulary Brands

STRIBILD Formulary Brands

tenofovir disoproxil fumarate Formulary Low Cost Generics ACA

TRIUMEQ Formulary Brands

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

Formulary Brands ACA

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

Formulary Brands

zidovudine (10 mg/ml syrup, 300 mgtablet)




zidovudine 100 mg capsule Formulary Low Cost Generics

HIV PROTEASE INHIBITOR ANTIRETROVIRALS

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

Formulary Brands

atazanavir sulfate Formulary High Cost Generics

EVOTAZ Formulary Brands

fosamprenavir calcium Formulary High Cost Generics

INVIRASE Formulary Brands

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

Formulary Brands

LEXIVA 50 MG/ML SUSPENSION Formulary Brands

lopinavir/ritonavir Formulary High Cost Generics

NORVIR 80 MG/ML SOLUTION Formulary Brands

PREZCOBIX Formulary Brands

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

Formulary Brands

REYATAZ 50 MG POWDER PACKET Formulary Brands

ritonavir Formulary High Cost Generics

SYMTUZA Formulary Brands

ANTITHROMBOTIC AGENTS

ANTITHROMBOTIC AGENTS, MISCELLANEOUS

CABLIVI 11 MG KIT Formulary BrandsPA

S

PLATELET-AGGREGATION INHIBITORS

BRILINTA Formulary Brands

cilostazol Formulary High Cost Generics

clopidogrel bisulfate 75 mg tablet Formulary Low Cost Generics

prasugrel hcl Formulary High Cost Generics

ZONTIVITY Formulary Brands PA



PLATELET-REDUCING AGENTS

anagrelide hcl Formulary High Cost Generics

ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES

ALLERGENIC EXTRACTS (THERAPEUTIC)

GRASTEK Formulary Brands PA

ODACTRA Formulary Brands PA

PALFORZIA Formulary BrandsPA

S

RAGWITEK Formulary Brands PA

ANTITOXINS AND IMMUNE GLOBULINS

PANZYGA Formulary BrandsPA

S

TOXOIDS

ADACEL TDAP Formulary Brands

BOOSTRIX TDAP Formulary Brands

DAPTACEL DTAP Formulary Brands

INFANRIX DTAP Formulary Brands

TENIVAC SYRINGE Formulary Brands

tetanus and diphtheria toxoids, adult Formulary Brands

tetanus,diphtheria toxoid ped/pf Formulary Brands

VACCINES

ACTHIB Formulary Brands

adenovirus live type-4 and adenoviruslive type-7 vaccine

Formulary Brands

adenovirus vaccine live type-4 Formulary Brands

adenovirus vaccine live type-7 Formulary Brands

AFLURIA 2018-2019 (SYRINGE, VIAL) Formulary Brands

AFLURIA QUAD 2018-2019 (SYRINGE,VIAL)

Formulary Brands

AFLURIA QUAD 2019-20 (3YR UP) Formulary Brands



AFLURIA QUAD 2019-20 (6-35MO) Formulary Brands

AFLURIA QUAD 2019-2020 Formulary Brands

AFLURIA QUAD 2020-2021 Formulary Brands

AFLURIA QUAD 2020-21 (3YR UP) Formulary Brands

AFLURIA QUAD 2020-21 (6-35MO) Formulary Brands

BEXSERO Formulary Brands

ENGERIX-B ADULT Formulary Brands

ENGERIX-B PEDIATRIC-ADOLESCENT

Formulary Brands

EZ FLU 2018-2019 (FLUCELVAX) Formulary Brands

FLUAD 2018-2019 Formulary Brands



FLUAD QUAD 2020-2021 Formulary Brands

FLUARIX QUAD 2018-2019 Formulary Brands



FLUBLOK QUAD 2018-2019 Formulary Brands



FLUCELVAX QUAD 2018-2019 (SYR,VIAL)

Formulary Brands


Formulary Brands


Formulary Brands

FLULAVAL QUAD 2018-2019 (SYR,VIAL)

Formulary Brands

FLULAVAL QUAD 2019-2020 (SYR,VIAL)

Formulary Brands

FLULAVAL QUAD 2020-2021 Formulary Brands

FLUMIST QUAD 2018-2019 Formulary Brands





FLUZONE HIGH-DOSE 2018-2019 Formulary Brands

FLUZONE HIGH-DOSE 2019-2020 Formulary Brands

FLUZONE HIGH-DOSE QUAD 2020-21 Formulary Brands

FLUZONE QUAD 2018-2019 Formulary Brands



FLUZONE QUAD PEDI 2018-2019 Formulary Brands

FLUZONE QUAD PEDI 2019-2020 Formulary Brands

GARDASIL 9 Formulary Brands

HAVRIX Formulary Brands

HEPLISAV-B 20 MCG/0.5 ML SYRNG Formulary Brands

HIBERIX Formulary Brands

KINRIX Formulary Brands

MENACTRA Formulary Brands

MENQUADFI Formulary Brands

MENVEO A-C-Y-W-135-DIP Formulary Brands

MODERNA COVID19VACC(UNAPPROV)

Formulary Brands

PEDIARIX Formulary Brands

PEDVAXHIB Formulary Brands

PENTACEL Formulary Brands

PENTACEL ACTHIB COMPONENT Formulary Brands

PENTACEL DTAP-IPV COMPONENT Formulary Brands

PFIZER COVID19 VACC (UNAPPROV) Formulary Brands

PNEUMOVAX 23 Formulary Brands

PREVNAR 13 Formulary Brands

PROQUAD Formulary Brands

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

Formulary Brands

SHINGRIX Formulary Brands QL 1 KIT / rx



SHINGRIX GE ANTIGEN COMPONENT Formulary Brands QL 1 KIT / rx

TRUMENBA Formulary Brands

TWINRIX Formulary Brands

VAQTA (25 UNITS/0.5 ML SYRINGE,50 UNITS/ML SYRINGE, 50 UNITS/MLVIAL)

Formulary Brands

VARIVAX VACCINE Formulary Brands

VAXCHORA ACTIVE COMPONENT Formulary Brands

VAXCHORA VACCINE Formulary Brands

VIVOTIF Formulary Brands

ZOSTAVAX Formulary Brands

ANTIULCER AGENTS AND ACID SUPPRESSANTS

ANTIULCER AGENTS AND ACID SUPPRESS.,MISC

TALICIA Formulary Brands PA

HISTAMINE H2-ANTAGONISTS

cimetidine (300 mg tablet, 400 mg tablet,800 mg tablet)


cimetidine hcl Formulary High Cost Generics

famotidine (20 mg tablet, 40 mg tablet) Formulary Low Cost Generics

PROSTAGLANDINS

misoprostol Formulary High Cost Generics

PROTECTANTS

sucralfate 1 g tablet Formulary High Cost Generics

PROTON-PUMP INHIBITORS

esomeprazole magnesium (20 mgcapsule dr, 40 mg capsule dr)


lansoprazole (15 mg capsule dr, 30 mgcapsule dr)


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


omeprazole Formulary High Cost Generics

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




rabeprazole sodium 20 mg tablet dr Formulary High Cost Generics

ANTIVIRALS (SYSTEMIC)

ADAMANTANE ANTIVIRALS

rimantadine hcl Formulary High Cost Generics

ANTIVIRALS, MISCELLANEOUS

PREVYMIS (240 MG TABLET, 480 MGTABLET)

Formulary Brands

INTERFERON ANTIVIRALS

ALFERON N Formulary Brands S

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

Formulary Brands S

PEGASYS Formulary BrandsPA

S

PEGASYS PROCLICK Formulary BrandsPA

S

PEGINTRON Formulary BrandsPA

S

SYLATRON Formulary BrandsS

ONC Oncology

NEURAMINIDASE INHIBITOR ANTIVIRALS

oseltamivir phosphate (45 mg capsule,75 mg capsule)

Formulary High Cost Generics QL 10 CAPS / 1 FILL

oseltamivir phosphate 30 mg capsule Formulary High Cost Generics QL 20 CAPS / 1 FILL

oseltamivir phosphate 6 mg/ml susprecon

Formulary High Cost Generics QL 180 ML / 1 FILL

RELENZA Formulary Brands QL 20 CAPS / 1 FILL

NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS

acyclovir (200 mg capsule, 400 mgtablet, 800 mg tablet)


acyclovir 200 mg/5ml oral susp Formulary High Cost Generics AL1 Up to 12 yrs old



adefovir dipivoxil Formulary High Cost Generics

BARACLUDE 0.05 MG/ML SOLUTION Formulary Brands

entecavir Formulary Low Cost Generics

famciclovir Formulary High Cost Generics

REBETOL Formulary Brands S

ribavirin (200 mg capsule, 200 mgtablet)

Formulary High Cost Generics S

valacyclovir hcl Formulary High Cost Generics

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


VEMLIDY Formulary Brands

ANXIOLYTICS, SEDATIVES AND HYPNOTICS

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

buspirone hcl Formulary High Cost Generics

eszopiclone Formulary High Cost Generics

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


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


hydroxyzine pamoate Formulary High Cost Generics

zaleplon Formulary High Cost Generics

zolpidem tartrate (5 mg tablet, 10 mgtablet)


zolpidem tartrate (6.25 mg tab mphase,12.5 mg tab mphase)

Formulary High Cost Generics ST

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)

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


BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

alprazolam (0.25 mg tablet, 0.5 mg taber 24h, 0.5 mg tablet, 1 mg tab er 24h, 1mg tablet)


alprazolam (2 mg tab er 24h, 2 mgtablet)




alprazolam 3 mg tab er 24h Formulary Low Cost Generics QL 2 TABS / 1 DAY

chlordiazepoxide hcl 10 mg capsule Formulary Low Cost Generics QL 6 CAPS / 1 DAY

chlordiazepoxide hcl 25 mg capsule Formulary Low Cost Generics QL 4 CAPS / 1 DAY

chlordiazepoxide hcl 5 mg capsule Formulary High Cost Generics QL 6 CAPS / 1 DAY

diazepam (2 mg tablet, 5 mg tablet) Formulary Low Cost Generics QL 6 TABS / 1 DAY

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

Formulary High Cost Generics QL 4 KIT / 30 DAYS

diazepam 10 mg tablet Formulary Low Cost Generics QL 4 TABS / 1 DAY

diazepam 5 mg/5 ml solution Formulary High Cost Generics QL 40 ML / 1 DAY

diazepam 5 mg/ml oral conc Formulary High Cost Generics QL 8 ML / 1 DAY

lorazepam (0.5 mg tablet, 1 mg tablet) Formulary Low Cost Generics QL 6 TABS / 1 DAY

lorazepam 2 mg tablet Formulary Low Cost Generics QL 5 TABS / 1 DAY

lorazepam 2 mg/ml oral conc Formulary High Cost Generics QL 5 ML / 1 DAY

LORAZEPAM INTENSOL Formulary High Cost Generics QL 5 ML / 1 DAY

temazepam 15 mg capsule Formulary Low Cost Generics QL 2 CAPS / 1 DAY

temazepam 30 mg capsule Formulary Low Cost Generics QL 1 CAP / 1 DAY

VALTOCO Formulary BrandsQL 1 carton / rx

PA

AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX Formulary BrandsQL 2 TABS / 1 DAY

SC Smoking Cessation

NICOTROL Formulary Brands SC Smoking Cessation

NICOTROL NS Formulary Brands SC Smoking Cessation

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

bethanechol chloride Formulary High Cost Generics

cevimeline hcl Formulary High Cost Generics



donepezil hcl (5 mg tab rapdis, 5 mgtablet, 10 mg tab rapdis, 10 mg tablet)


galantamine hbr (4 mg tablet, 4 mg/mlsolution, 8 mg cap24h pel, 8 mg tablet,12 mg tablet, 16 mg cap24h pel, 24 mgcap24h pel)


pilocarpine hcl (5 mg tablet, 7.5 mgtablet)


pyridostigmine bromide 180 mg tablet er Formulary High Cost Generics PA

pyridostigmine bromide 30 mg tablet Formulary High Cost Generics QL 30 TABS / 30 DAY(S)

pyridostigmine bromide 60 mg tablet Formulary High Cost Generics

rivastigmine Formulary High Cost Generics

rivastigmine tartrate Formulary High Cost Generics

BETA-3-ADRENERGIC AGONISTS

SELECTIVE BETA-3-ADRENERGIC AGONISTS

MYRBETRIQ Formulary Brands

BETA-ADRENERGIC AGONISTS

SELECTIVE BETA-2-ADRENERGIC AGONISTS

albuterol sulfate (0.63mg/3ml vial-neb,1.25mg/3ml vial-neb, 2 mg/5 ml syrup,2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb,5 mg/ml solution)


levalbuterol tartrate Formulary High Cost Generics

SEREVENT DISKUS Formulary Brands

STRIVERDI RESPIMAT Formulary Brands

VENTOLIN HFA Formulary High Cost Generics

BLOOD FORMATION, COAGULATION, THROMBOSIS

BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.

OXBRYTA Formulary Brands


PA

S



HEMATOPOIETIC AGENTS

ARANESP Formulary Brands S

FULPHILA Formulary Brands

GRANIX Formulary Brands S

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

Formulary BrandsPA

S

PROMACTA 12.5 MG SUSPENPACKET

Formulary Brands

QL 1 PACKETS / 1 day(s)

PA

S

PROMACTA 25 MG SUSPENSIONPCKT

Formulary Brands

QL 3 PACKETS / 1 day(s)

PA

S

RETACRIT (2,000 UNIT/ML VIAL, 3,000UNIT/ML VIAL, 4,000 UNIT/ML VIAL,10,000 UNIT/ML VIAL, 20,000 UNIT/2ML VIAL, 40,000 UNIT/ML VIAL)

Formulary Brands S

UDENYCA Formulary Brands

ZIEXTENZO Formulary Brands

HEMORRHEOLOGIC AGENTS

pentoxifylline Formulary High Cost Generics

CALCIUM-CHANNEL BLOCKING AGENTS

CALCIUM-CHANNEL BLOCKING AGENTS, MISC.

CARTIA XT Formulary High Cost Generics

DILT-XR Formulary Low Cost Generics

diltiazem hcl (120 mg cap er deg, 180mg cap er deg, 240 mg cap er deg, 360mg cap sa 24h)


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




MATZIM LA 240 MG TABLET Formulary Low Cost Generics

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


TAZTIA XT 360 MG CAPSULE Formulary Low Cost Generics

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


verapamil hcl (120 mg tablet er, 180 mgtablet er, 240 mg tablet er, 360 mgcap24h pel)


verapamil hcl (40 mg tablet, 80 mgtablet, 120 mg cap24h pel, 120 mgtablet, 180 mg cap24h pel, 240 mgcap24h pel)


DIHYDROPYRIDINES

AFEDITAB CR Formulary High Cost Generics

amlodipine besylate Formulary Low Cost Generics

amlodipine besylate/benazepril hcl Formulary High Cost Generics

amlodipine besylate/valsartan Formulary Low Cost Generics

amlodipinebesylate/valsartan/hydrochlorothiazide


felodipine Formulary High Cost Generics

nifedipine (10 mg capsule, 20 mgcapsule)


nifedipine (30 mg tab er 24, 30 mg tableter, 60 mg tab er 24, 60 mg tablet er, 90mg tab er 24, 90 mg tablet er)


nimodipine Formulary High Cost Generics

CARDIAC DRUGS

CARDIAC DRUGS, MISCELLANEOUS

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

Formulary Brands PA

VYNDAMAX Formulary BrandsPA

S

VYNDAQEL Formulary BrandsPA

S



CARDIOTONIC AGENTS

DIGITEK 125 MCG TABLET Formulary High Cost Generics

DIGITEK 250 MCG TABLET Formulary High Cost Generics AL1 Up to 64 yrs old

DIGOX 125 MCG TABLET Formulary High Cost Generics

DIGOX 250 MCG TABLET Formulary High Cost Generics AL1 Up to 64 yrs old

digoxin 125 mcg tablet Formulary High Cost Generics

digoxin 250 mcg tablet Formulary High Cost Generics AL1 Up to 64 yrs old

digoxin 50 mcg/ml solution Formulary Brands

CARDIOVASCULAR DRUGS

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate Formulary High Cost Generics

prazosin hcl Formulary High Cost Generics

terazosin hcl Formulary Low Cost Generics

BETA-ADRENERGIC BLOCKING AGENTS

atenolol Formulary Low Cost Generics

atenolol/chlorthalidone Formulary High Cost Generics

bisoprolol fumarate Formulary High Cost Generics

bisoprolol fumarate/hydrochlorothiazide Formulary Low Cost Generics

carvedilol Formulary Low Cost Generics

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


metoprolol succinate Formulary High Cost Generics

metoprolol tartrate (25 mg tablet, 50 mgtablet, 100 mg tablet)


metoprolol tartrate/hydrochlorothiazide Formulary High Cost Generics

nadolol Formulary Low Cost Generics

propranolol hcl (10 mg tablet, 20 mgtablet, 20 mg/5 ml solution, 40 mg tablet,40mg/5ml solution, 60 mg tablet, 80 mgtablet)


propranolol hcl (60 mg cap sa 24h, 80mg cap sa 24h, 120 mg cap sa 24h, 160mg cap sa 24h)




propranolol hcl/hydrochlorothiazide Formulary High Cost Generics

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


CENTRAL NERVOUS SYSTEM AGENTS

ANTIMANIC AGENTS

lithium carbonate (150 mg capsule, 300mg capsule, 300 mg tablet, 300 mgtablet er, 450 mg tablet er, 600 mgcapsule)


lithium citrate Formulary High Cost Generics

CENTRAL NERVOUS SYSTEM AGENTS, MISC.

acamprosate calcium Formulary High Cost Generics

atomoxetine hcl (10 mg capsule, 18 mgcapsule, 25 mg capsule, 40 mg capsule)


atomoxetine hcl (60 mg capsule, 80 mgcapsule, 100 mg capsule)


carbidopa Formulary Low Cost Generics

guanfacine hcl (3 mg tab er 24h, 4 mgtab er 24h)

Formulary High Cost Generics QL 1 TAB / 1 DAY

guanfacine hcl 1 mg tab er 24h Formulary High Cost Generics QL 3 TABS / 1 DAY

guanfacine hcl 2 mg tab er 24h Formulary High Cost Generics QL 2 TABS / 1 DAY

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


NOURIANZ Formulary BrandsPA

S

riluzole Formulary High Cost Generics

XYREM Formulary Brands

QL 18 ML / 1 DAY

PA

S

XYWAV Formulary Brands

QL 18 ML / DAY

PA

S



FIBROMYALGIA AGENTS

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

Formulary BrandsQL 2 tabs / 1 day(s)

PA

SAVELLA TITRATION PACK Formulary BrandsQL 55 tabs / 28 day(s)

PA

OPIATE ANTAGONISTS

naloxone hcl 1 mg/ml syringe Formulary High Cost Generics

naltrexone hcl Formulary High Cost Generics

NARCAN Formulary Brands

VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

AUSTEDO Formulary BrandsPA

S

INGREZZA Formulary BrandsPA

S

INGREZZA INITIATION PACK Formulary BrandsPA

S

tetrabenazine Formulary High Cost GenericsPA

S

CEPHALOSPORIN ANTIBIOTICS

1ST GENERATION CEPHALOSPORIN ANTIBIOTICS

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


cefadroxil 500 mg capsule Formulary High Cost Generics

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


cephalexin (250 mg capsule, 500 mgcapsule)


2ND GENERATION CEPHALOSPORIN ANTIBIOTICS

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


cefprozil (250 mg tablet, 500 mg tablet) Formulary High Cost Generics



cefuroxime axetil Formulary High Cost Generics

3RD GENERATION CEPHALOSPORIN ANTIBIOTICS

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


cefdinir 300 mg capsule Formulary Low Cost Generics

cefixime 400 mg capsule Formulary High Cost Generics QL 1 CAP / 30 DAY(S)

CORTICOSTEROIDS (RESPIRATORY TRACT)

ORALLY INHALED PREPARATIONS (STEROIDS)

ADVAIR DISKUS Formulary High Cost Generics

ADVAIR HFA Formulary Brands

ARNUITY ELLIPTA Formulary Brands

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

Formulary Brands

ASMANEX HFA Formulary Brands

BREO ELLIPTA Formulary Brands

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


budesonide/formoterol fumarate Formulary High Cost Generics PA

DULERA Formulary Brands PA

FLOVENT DISKUS Formulary Brands

FLOVENT HFA Formulary Brands

fluticasone propionate/salmeterolxinafoate (propion/salmeterol 55-14 mcgaer pow ba, propion/salmeterol 113-14mcg aer pow ba, propion/salmeterol232-14 mcg aer pow ba)


PULMICORT FLEXHALER Formulary Brands

QVAR REDIHALER Formulary Brands

TRELEGY ELLIPTA Formulary Brands



CYSTIC FIBROSIS (CFTR) MODULATORS

CYSTIC FIBROSIS (CFTR) CORRECTORS

SYMDEKO Formulary BrandsPA

S

TRIKAFTA Formulary BrandsPA

S

CYSTIC FIBROSIS (CFTR) POTENTIATORS

KALYDECO Formulary BrandsPA

S

ORKAMBI Formulary BrandsPA

S

DEVICES

ACE AEROSOL CLOUD ENHANCER Covered

AEROCHAMBER MINI Covered

AEROCHAMBER MV Covered

AEROCHAMBER PLUS FLOW-VU (,LARGE, MED, SMALL)

Covered

AEROCHAMBER WITH FLOWSIGNAL Covered

AEROCHAMBER Z-STAT PLUS (PLUSLARGE, PLUS W-FLOW, PLUS-MED,PLUS-SMALL)

Covered

AEROTRACH PLUS Covered

BREATHERITE Covered

BREATHRITE Covered

DEXCOM Covered

QL 1 receiver / 365 day(s)

PA

DS Diabetic Supply

DEXCOM G4 ((PED) RECEIVER KIT,RECEIVER KIT, RECEIVER-SHARE(PED), RECEIVER-SHARE KIT)

Covered


PA

DS Diabetic Supply

DEXCOM G4 TRANSMITTER KIT Covered

QL 1 transmitter / 180day(s)

PA

DS Diabetic Supply



DEXCOM G5 RECEIVER KIT Covered


PA

DS Diabetic Supply

DEXCOM G5 TRANSMITTER KIT Covered


PA

DS Diabetic Supply

DEXCOM G5-G4 SENSOR Covered

QL 1 kit (a 4 pack) / 28day(s)

PA

DS Diabetic Supply

DEXCOM G6 RECEIVER Covered


PA

DS Diabetic Supply

DEXCOM G6 SENSOR Covered

QL 3 sensors / 30 day(s)

PA

DS Diabetic Supply

DEXCOM G6 TRANSMITTER Covered


PA

DS Diabetic Supply

EASIVENT (HOLDING CHAMBER,MASK-LARGE, MASK-MEDIUM, MASK-SMALL)

Covered

FREESTYLE LIBRE 10 DAY READER Covered

QL 1 reader / 365 day(s)

PA

DS Diabetic Supply

FREESTYLE LIBRE 10 DAY SENSOR Covered


PA

DS Diabetic Supply

FREESTYLE LIBRE 14 DAY READER Covered


PA

DS Diabetic Supply



FREESTYLE LIBRE 14 DAY SENSOR Covered


PA

DS Diabetic Supply

FREESTYLE LIBRE 2 READER Covered


PA

DS Diabetic Supply

FREESTYLE LIBRE 2 SENSOR Covered


PA

DS Diabetic Supply

INPEN (FOR HUMALOG) Covered

INPEN (FOR NOVOLOG OR FIASP) Covered

LITETOUCH Covered

MICROCHAMBER Covered

MICROSPACER Covered

NOVOPEN ECHO Covered

OMNIPOD (5 PACK POD, STARTERKIT)

Covered

OMNIPOD DASH 5 PACK POD Covered

OMNIPOD DASH PDM KIT Covered

OPTICHAMBER Covered

OPTICHAMBER DIAMOND (VHC, W-LRG MASK)

Covered

POCKET CHAMBER Covered

PROCHAMBER Covered

SILICONE MASK-INFANT Covered

V-GO 20 Covered

V-GO 30 Covered

V-GO 40 Covered

VGO 20 Covered

VGO 30 Covered

VGO 40 Covered



VORTEX Covered

DIAGNOSTIC AGENTS

ADRENOCORTICAL INSUFFICIENCY

ACTHAR Formulary BrandsPA

S

DIURETICS

LOOP DIURETICS

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


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


torsemide Formulary High Cost Generics

POTASSIUM-SPARING DIURETICS

amiloride hcl Formulary High Cost Generics

amiloride hcl/hydrochlorothiazide Formulary High Cost Generics

triamterene/hydrochlorothiazide Formulary Low Cost Generics

THIAZIDE DIURETICS

chlorothiazide Formulary High Cost Generics

DIURIL Formulary Brands

hydrochlorothiazide Formulary Low Cost Generics

THIAZIDE-LIKE DIURETICS

chlorthalidone Formulary High Cost Generics

indapamide Formulary High Cost Generics

metolazone Formulary High Cost Generics

DOPAMINE RECEPTOR AGONISTS

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

bromocriptine mesylate Formulary High Cost Generics

cabergoline Formulary High Cost Generics

CYCLOSET Formulary Brands PA



NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

NEUPRO Formulary Brands PA

pramipexole di-hcl (0.125 mg tablet,0.25 mg tablet, 0.5 mg tablet, 0.75 mgtablet, 1 mg tablet, 1.5 mg tablet)


pramipexole di-hcl (0.375 mg tab er 24h,0.75 mg tab er 24h, 1.5 mg tab er 24h,2.25 mg tab er 24h, 3 mg tab er 24h,3.75 mg tab er 24h, 4.5 mg tab er 24h)


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


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


ELECTROLYTIC, CALORIC, AND WATER BALANCE

ALKALINIZING AGENTS

potassium citrate Formulary High Cost Generics

AMMONIA DETOXICANTS

CARBAGLU Formulary BrandsPA

S

ENULOSE Formulary High Cost Generics

GENERLAC Formulary High Cost Generics

lactulose 10 g/15 ml solution Formulary High Cost Generics

sodium phenylbutyrate 0.94 g/g powder Formulary High Cost Generics PA

CALORIC AGENTS

DOJOLVI Formulary BrandsPA

S

REPLACEMENT PREPARATIONS

KLOR-CON M10 Formulary High Cost Generics





potassium chloride (8 meq capsule er, 8meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20 meqpacket, 20 meq tab er prt, 20 meq tableter, 20meq/15ml liquid, 40meq/15mlliquid)


URICOSURIC AGENTS

probenecid Formulary High Cost Generics

probenecid/colchicine Formulary High Cost Generics

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

BASIC LOTIONS AND LINIMENTS

ammonium lactate 12 % lotion Formulary High Cost Generics

BASIC OINTMENTS AND PROTECTANTS

ammonium lactate 12 % cream (g) Formulary High Cost Generics

ENZYMES

REVCOVI Formulary BrandsPA

S

STRENSIQ Formulary BrandsPA

S

SUCRAID Formulary BrandsPA

S

ESTROGENS AND ANTIESTROGENS

ESTROGEN AGONIST-ANTAGONISTS

clomiphene citrate Covered INF Infertility

raloxifene hcl Formulary High Cost Generics ACA

SEROPHENE Covered INF Infertility

SOLTAMOX Formulary Brands

tamoxifen citrate Formulary High Cost Generics ACA

ESTROGENS

AMABELZ 0.5 MG-0.1 MG TABLET Formulary High Cost Generics

CLIMARA PRO Formulary Brands



COMBIPATCH Formulary Brands

DOTTI Formulary High Cost Generics

estradiol (0.01 % cream/appl,.025mg/24h patch tdsw, .025mg/24hpatch tdwk, .0375mg/24 patch tdsw,.0375mg/24 patch tdwk, 0.05mg/24hpatch tdsw, 0.05mg/24h patch tdwk,0.06mg/24h patch tdwk, .075mg/24hpatch tdsw, .075mg/24h patch tdwk,0.1mg/24hr patch tdsw, 0.1mg/24hrpatch tdwk, 10 mcg tablet)


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


estradiol/norethindrone acet 0.5-0.1 mgtablet


ESTRING Formulary Brands

FYAVOLV 1 MG-5 MCG TABLET Formulary High Cost Generics

JINTELI Formulary High Cost Generics

LOPREEZA 0.5 MG-0.1 MG TABLET Formulary High Cost Generics

MIMVEY LO Formulary High Cost Generics

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


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

Formulary Brands

PREMPHASE Formulary Brands

PREMPRO Formulary Brands

YUVAFEM Formulary High Cost Generics

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

ANTIALLERGIC AGENTS

azelastine hcl (0.05 % drops, 137 mcgspray/pump)


epinastine hcl Formulary High Cost Generics

olopatadine hcl 0.1 % drops Formulary High Cost Generics



EENT DRUGS, MISCELLANEOUS

CYSTADROPS Formulary BrandsPA

S

CYSTARAN Formulary BrandsPA

S

ipratropium bromide (21 mcg spray, 42mcg spray)


LACRISERT Formulary Brands PA

OXERVATE Formulary Brands

QL 1 ML / 1 DAY

PA

S

LOCAL ANESTHETICS (EENT)

lidocaine hcl (2 % jel/pf app, 2 %jelly(ml), 2 % solution, 40 mg/mlsolution)


MYDRIATICS

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


cyclopentolate hcl Formulary High Cost Generics

homatropine hbr Formulary High Cost Generics

VASOCONSTRICTORS

phenylephrine hcl (2.5 % drops, 10 %drops)


FIRST GENERATION ANTIHISTAMINES

FIRST GEN. ANTIHIST. DERIVATIVES, MISC.

cyproheptadine hcl Formulary High Cost Generics

PHENOTHIAZINE DERIVATIVES

PHENADOZ Formulary High Cost Generics

phenylephrine hcl/promethazine hcl Formulary Low Cost Generics

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


promethazine hcl (12.5 mg tablet, 25 mgtablet, 50 mg tablet)

Formulary High Cost Generics AQ1 Up to 64 yrs old; 30 / 1FILL



promethazine hcl 6.25mg/5ml syrup Formulary Low Cost Generics AQ1 Up to 64 yrs old; 300 /1 FILL

PROMETHEGAN Formulary High Cost Generics

GASTROINTESTINAL DRUGS

ANTI-INFLAMMATORY AGENTS (GI DRUGS)

alosetron hcl Formulary High Cost Generics PA

balsalazide disodium Formulary High Cost Generics

mesalamine (0.375g cap er 24h, 1.2 gtablet dr, 4 g/60 ml enema, 400 mgcap(drtab), 800 mg tablet dr, 1000 mgsupp.rect)


ANTIDIARRHEA AGENTS

diphenoxylate hcl/atropine 2.5-.025/5liquid

Formulary High Cost Generics QL 40 ML / 1 DAY

diphenoxylate hcl/atropine 2.5-.025mgtablet


paregoric Formulary High Cost Generics QL 40 ML / 1 DAY

XERMELO Formulary BrandsPA

S

CATHARTICS AND LAXATIVES

AMITIZA Formulary Brands QL 2 CAPS / 1 DAY

GAVILYTE-C Formulary High Cost Generics

GAVILYTE-G Formulary High Cost Generics ACA

GAVILYTE-N Formulary High Cost Generics

sodium chloride/sodiumbicarbonate/potassium chloride/peg


SUPREP Formulary Brands ACA

TRILYTE WITH FLAVOR PACKETS Formulary High Cost Generics

CHOLELITHOLYTIC AGENTS

ursodiol Formulary High Cost Generics



DIGESTANTS

CREON Formulary Brands

GI DRUGS, MISCELLANEOUS

CHOLBAM Formulary BrandsPA

S

ENDARI Formulary BrandsPA

S

HUMIRA(CF) PEDI CROHN 80-40 MG Formulary Brands

QL 2 ML / 28 day(s)

PA

S

LINZESS Formulary Brands QL 1 CAP / 1 DAY

MOVANTIK Formulary BrandsQL 1 TAB / 1 DAY

PA

SYMPROIC Formulary Brands PA

XENICAL Formulary BrandsPA

WL Weight Loss

PROKINETIC AGENTS

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


GENITOURINARY SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

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


oxybutynin chloride 5 mg tablet Formulary Low Cost Generics

solifenacin succinate Formulary High Cost Generics

tolterodine tartrate (1 mg tablet, 2 mgcap er 24h, 2 mg tablet, 4 mg cap er24h)


trospium chloride 20 mg tablet Formulary Low Cost Generics



GOLD COMPOUNDS

RIDAURA Formulary Brands

GONADOTROPINS AND ANTIGONADOTROPINS

ANTIGONADTROPINS

CETROTIDE Covered INF Infertility

ganirelix acetate Covered INF Infertility

ORILISSA 150 MG TABLET Formulary Brands


PA

S

ORILISSA 200 MG TABLET Formulary Brands


PA

S

GONADOTROPINS

chorionic gonadotropin, human (6000unit vial, 10000 unit vial, 12000 unit vial)

Covered INF Infertility

FOLLISTIM AQ Covered INF Infertility

leuprolide acetate Covered INF Infertility

MENOPUR Covered INF Infertility

NOVAREL Covered INF Infertility

OVIDREL Covered INF Infertility

PREGNYL Covered INF Infertility

HCV ANTIVIRALS

HCV POLYMERASE INHIBITOR ANTIVIRALS

EPCLUSA 200 MG-50 MG TABLET Formulary BrandsPA

S

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

Formulary BrandsPA

S

ledipasvir/sofosbuvir Formulary High Cost GenericsPA

S



sofosbuvir/velpatasvir Formulary High Cost GenericsPA

S

SOVALDI (150 MG PELLET PACKET,200 MG PELLET PACKET, 200 MGTABLET)

Formulary BrandsPA

S

VOSEVI Formulary BrandsPA

S

HCV PROTEASE INHIBITOR ANTIVIRALS

MAVYRET Formulary BrandsPA

S

HEAVY METAL ANTAGONISTS

CHEMET Formulary Brands

D-PENAMINE Formulary High Cost Generics PA

deferasirox (90 mg tablet, 125 mg tabdisper, 180 mg tablet, 250 mg tabdisper, 360 mg tablet, 500 mg tabdisper)


PA

S

TD Trial Drug

deferiprone Formulary High Cost GenericsPA

S

FERRIPROX (100 MG/ML SOLUTION,500 MG TABLET, 1,000 MG TABLET)

Formulary BrandsPA

S

penicillamine 250 mg tablet Formulary High Cost GenericsPA

S

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

budesonide 3 mg capdr - er Formulary High Cost Generics

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


dexamethasone (0.5 mg/5ml elixir, 0.5mg/5ml solution, 2 mg tablet)


DEXAMETHASONE INTENSOL Formulary Brands



dexamethasone sodium phosphate 10mg/ml vial


dexamethasone sodium phosphate 4mg/ml vial


dexamethasone sodium phosphate/pf Formulary High Cost Generics

fludrocortisone acetate Formulary High Cost Generics

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


MEDROL 2 MG TABLET Formulary Brands

methylprednisolone Formulary High Cost Generics

MILLIPRED Formulary Brands

prednisolone Formulary Low Cost Generics

prednisolone sodium phosphate (5 mg/5ml solution, 15 mg/5 ml solution, 25mg/5 ml solution)


prednisone (1 mg tablet, 2.5 mg tablet, 5mg tab ds pk, 5 mg tablet, 10 mg tab dspk, 10 mg tablet, 20 mg tablet, 50 mgtablet)


prednisone 5 mg/5 ml solution Formulary High Cost Generics

PREDNISONE INTENSOL Formulary Brands

SOLU-CORTEF 100 MG ACT-O-VIAL Formulary Brands

ANDROGENS

danazol Formulary High Cost Generics

testosterone (1.25g-1.62 gel packet,2.5g-1.62% gel packet, 10 mg (2%) gelmd pmp, 12.5/1.25g gel md pmp,20.25/1.25 gel md pmp, 25mg(1%) gelpacket, 50 mg (1%) gel (gram), 50 mg(1%) gel packet)


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


testosterone enanthate 200 mg/ml vial Formulary High Cost Generics PA

testosterone propionate Formulary High Cost Generics PA



CONTRACEPTIVES

ALTAVERA Formulary High Cost Generics

ALYACEN Formulary High Cost Generics

AMETHIA Formulary High Cost Generics

AMETHIA LO Formulary High Cost Generics

APRI Formulary High Cost Generics

ARANELLE Formulary High Cost Generics

ASHLYNA Formulary High Cost Generics

AUBRA Formulary High Cost Generics

AUBRA EQ Formulary High Cost Generics

AVIANE Formulary High Cost Generics

AZURETTE Formulary High Cost Generics

BALZIVA Formulary High Cost Generics

BEKYREE Formulary High Cost Generics

BLISOVI 24 FE Formulary Brands

BLISOVI FE Formulary High Cost Generics

BRIELLYN Formulary High Cost Generics

CAMILA Formulary High Cost Generics

CAMRESE Formulary High Cost Generics

CAMRESE LO Formulary High Cost Generics

CAZIANT Formulary High Cost Generics

CHATEAL Formulary High Cost Generics

CHATEAL EQ Formulary High Cost Generics

CRYSELLE Formulary High Cost Generics

CYCLAFEM Formulary High Cost Generics

CYRED Formulary High Cost Generics

CYRED EQ Formulary High Cost Generics

DASETTA Formulary High Cost Generics

DAYSEE Formulary High Cost Generics

DEBLITANE Formulary High Cost Generics



DELYLA Formulary High Cost Generics

desogestrel-ethinyl estradiol Formulary High Cost Generics

desogestrel-ethinyl estradiol/ethinylestradiol


ELINEST Formulary High Cost Generics

ELLA Formulary Brands

ELURYNG Formulary High Cost Generics

EMOQUETTE Formulary High Cost Generics

ENPRESSE Formulary High Cost Generics

ENSKYCE Formulary High Cost Generics

ERRIN Formulary High Cost Generics

ESTARYLLA Formulary High Cost Generics

ethinyl estradiol/drospirenone Formulary High Cost Generics

ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet


etonogestrel/ethinyl estradiol Formulary High Cost Generics

FALMINA Formulary High Cost Generics

FEMYNOR Formulary High Cost Generics

GIANVI Formulary High Cost Generics

HEATHER Formulary High Cost Generics

INCASSIA Formulary High Cost Generics

INTROVALE Formulary High Cost Generics

ISIBLOOM Formulary High Cost Generics

JASMIEL Formulary High Cost Generics

JENCYCLA Formulary High Cost Generics

JOLESSA Formulary High Cost Generics

JOLIVETTE Formulary High Cost Generics

JULEBER Formulary High Cost Generics

JUNEL Formulary High Cost Generics

JUNEL FE Formulary High Cost Generics

KARIVA Formulary High Cost Generics



KELNOR 1-35 Formulary High Cost Generics

KELNOR 1-50 Formulary High Cost Generics

KURVELO Formulary High Cost Generics

LARIN Formulary High Cost Generics

LARIN FE Formulary High Cost Generics

LARISSIA Formulary High Cost Generics

LEENA Formulary High Cost Generics

LESSINA Formulary High Cost Generics

LEVONEST Formulary High Cost Generics

levonorgestrel/ethinyl estradiol(levonorgestrel/ethin.estradiol 0.1-0.02mg tablet,levonorgestrel/ethin.estradiol 0.15-0.03tablet, levonorgestrel/ethin.estradiol0.15-0.03 tbdspk 3mo)


levonorgestrel/ethinyl estradiol andethinyl estradiol


LEVORA-28 Formulary High Cost Generics

LILLOW Formulary High Cost Generics

LORYNA Formulary High Cost Generics

LOW-OGESTREL Formulary High Cost Generics

LUTERA Formulary High Cost Generics

LYZA Formulary High Cost Generics

MARLISSA Formulary High Cost Generics

MICROGESTIN Formulary High Cost Generics

MICROGESTIN FE Formulary High Cost Generics

MILI Formulary High Cost Generics

MONO-LINYAH Formulary High Cost Generics

MONONESSA Formulary High Cost Generics

MYZILRA Formulary High Cost Generics

NECON Formulary High Cost Generics

NIKKI Formulary High Cost Generics

NORA-BE Formulary High Cost Generics



norethindrone Formulary High Cost Generics

norethindrone ac-eth estradiol 1mg-20mcg tablet


norethindrone acetate-ethinylestradiol/ferrous fumarate (1mg-20(21)tablet, 1.5-30(21) tablet)


norgestimate-ethinyl estradiol (0.25-0.035 tablet, 7daysx3 28 tablet, 7daysx3lo tablet)


NORLYDA Formulary High Cost Generics

NORLYROC Formulary High Cost Generics

NORTREL Formulary High Cost Generics

OCELLA Formulary High Cost Generics

OGESTREL Formulary High Cost Generics

ORSYTHIA Formulary High Cost Generics

PHILITH Formulary High Cost Generics

PIMTREA Formulary High Cost Generics

PIRMELLA Formulary High Cost Generics

PORTIA Formulary High Cost Generics

PREVIFEM Formulary High Cost Generics

QUASENSE Formulary High Cost Generics

RECLIPSEN Formulary High Cost Generics

SETLAKIN Formulary High Cost Generics

SHAROBEL Formulary High Cost Generics

SIMPESSE Formulary High Cost Generics

SPRINTEC Formulary High Cost Generics

SRONYX Formulary High Cost Generics

SYEDA Formulary High Cost Generics

TARINA FE Formulary High Cost Generics

TARINA FE 1-20 EQ Formulary High Cost Generics

TILIA FE Formulary High Cost Generics

TRI FEMYNOR Formulary High Cost Generics



TRI-ESTARYLLA Formulary High Cost Generics

TRI-LEGEST FE Formulary High Cost Generics

TRI-LINYAH Formulary High Cost Generics

TRI-LO-ESTARYLLA Formulary High Cost Generics

TRI-LO-MARZIA Formulary High Cost Generics

TRI-LO-SPRINTEC Formulary High Cost Generics

TRI-MILI Formulary High Cost Generics

TRI-PREVIFEM Formulary High Cost Generics

TRI-SPRINTEC Formulary High Cost Generics

TRI-VYLIBRA Formulary High Cost Generics

TRI-VYLIBRA LO Formulary High Cost Generics

TRIVORA-28 Formulary High Cost Generics

TULANA Formulary High Cost Generics

VELIVET Formulary High Cost Generics

VIENVA Formulary High Cost Generics

VIORELE Formulary High Cost Generics

VYFEMLA Formulary High Cost Generics

VYLIBRA Formulary High Cost Generics

WERA Formulary High Cost Generics

XULANE Formulary High Cost Generics

ZARAH Formulary High Cost Generics

ZOVIA 1-35E Formulary High Cost Generics

PITUITARY

desmopressin acetate (0.1 mg tablet,0.2 mg tablet)


desmopressin acetate (non-refrigerated) Formulary High Cost Generics PA

desmopressin acetate 10/sprayspray/pump


NORDITROPIN FLEXPRO CoveredPA

GH Growth Hormone

STIMATE Formulary Brands PA



PROGESTINS

hydroxyprogesterone caproate/pf Formulary High Cost GenericsQL 2 ML / 1 FILL

S

MAKENA 250 MG/ML VIAL Formulary BrandsQL 2 ML / 1 FILL

S

MAKENA 275 MG/1.1 ML AUTOINJCT Formulary BrandsQL 2.2 ML / FILL(S)

S

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


megestrol acetate (20 mg tablet, 40 mgtablet, 400mg/10ml oral susp)


norethindrone acetate Formulary High Cost Generics

progesterone, micronized Formulary High Cost Generics

HYPOTENSIVE AGENTS

CENTRAL ALPHA-AGONISTS

clonidine Formulary High Cost Generics

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


clonidine hcl 0.1 mg tab er 12h Formulary High Cost GenericsQL 4 TABS / 1 DAY

PA

guanfacine hcl (1 mg tablet, 2 mg tablet) Formulary Low Cost Generics

methyldopa Formulary High Cost Generics

DIRECT VASODILATORS

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


minoxidil Formulary High Cost Generics

INSULINS

LONG-ACTING INSULINS

LANTUS Formulary Brands

LANTUS SOLOSTAR Formulary Brands

LEVEMIR Formulary Brands PA



LEVEMIR FLEXTOUCH Formulary Brands PA

SOLIQUA 100-33 Formulary Brands QL 18 ml / 30 day(s)

TOUJEO MAX SOLOSTAR Formulary Brands

TOUJEO SOLOSTAR Formulary Brands

XULTOPHY 100-3.6 Formulary Brands QL 15 ml / 30 day(s)

RAPID-ACTING INSULINS

HUMALOG Formulary Brands

HUMALOG JUNIOR KWIKPEN Formulary Brands

HUMALOG KWIKPEN U-100 Formulary Brands

HUMALOG KWIKPEN U-200 Formulary Brands

HUMALOG MIX 50-50 Formulary Brands

HUMALOG MIX 50-50 KWIKPEN Formulary Brands

HUMALOG MIX 75-25 Formulary Brands

HUMALOG MIX 75-25 KWIKPEN Formulary Brands

insulin lispro (100/ml ins pen hf, 100/mlinsuln pen, 100/ml vial)


insulin lispro protamine and insulin lispro Formulary High Cost Generics

SHORT-ACTING INSULINS

HUMULIN R U-500 Formulary Brands

HUMULIN R U-500 KWIKPEN Formulary Brands

ION-REMOVING AGENTS

PHOSPHATE-REMOVING AGENTS

calcium acetate Formulary High Cost Generics

PHOSLYRA Formulary Brands

sevelamer carbonate Formulary High Cost Generics

POTASSIUM-REMOVING AGENTS

sodium polystyrene sulfonate (15 g/60ml oral susp, powder)




MACROLIDE ANTIBIOTICS

OTHER MACROLIDE ANTIBIOTICS

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


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


clarithromycin (125 mg/5ml susp recon,250 mg/5ml susp recon)


clarithromycin (250 mg tablet, 500 mgtablet)


DIFICID 200 MG TABLET Formulary Brands PA

MISC. BETA-LACTAM ANTIBIOTICS

MONOBACTAM ANTIBIOTICS

CAYSTON Formulary BrandsPA

S

MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

dutasteride Formulary High Cost Generics

dutasteride/tamsulosin hcl Formulary High Cost Generics

finasteride 5 mg tablet Formulary Low Cost Generics

ALCOHOL DETERRENTS

disulfiram Formulary High Cost Generics

ANTIDOTES

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


VISTOGARD Formulary BrandsPA

S

ANTIGOUT AGENTS

allopurinol Formulary Low Cost Generics

colchicine Formulary High Cost Generics

febuxostat Formulary High Cost Generics ST



BONE RESORPTION INHIBITORS

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


alendronate sodium 40 mg tablet Formulary High Cost Generics

alendronate sodium 70 mg/75ml solution Formulary High Cost Generics PA

etidronate disodium Formulary High Cost Generics

ibandronate sodium 150 mg tablet Formulary High Cost Generics

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


CARIOSTATIC AGENTS

FLUORABON Formulary Low Cost GenericsAL1 Up to 5 yrs old

ACA

fluoride (sodium) (0.25(0.55) tab chew,0.25mg/drp drops, 0.5 mg/ml drops,0.5(1.1)mg tab chew, 1mg(2.2mg) tabchew)

Formulary Low Cost GenericsAL1 Up to 5 yrs old

ACA

fluoride (sodium) (1.1 % cream (g), 1.1% gel (gram))


FLUORITAB Formulary Low Cost GenericsAL1 Up to 5 yrs old

ACA

COMPLEMENT INHIBITORS

BERINERT Formulary BrandsPA

S

CINRYZE Formulary BrandsPA

S

FIRAZYR Formulary Brands

QL 9 ML / fill(s)

PA

S

HAEGARDA Formulary BrandsPA

S

KALBITOR Formulary BrandsPA

S



RUCONEST Formulary BrandsPA

S

TAKHZYRO Formulary Brands

QL 4 ML / 28 DAY(S)

PA

S

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

ACTEMRA 162 MG/0.9 ML SYRINGE Formulary Brands

QL 4 SYRINGES / 28DAYS

PA

S

ACTEMRA ACTPEN Formulary BrandsPA

S

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

Formulary Brands

QL 2 SYRINGES / 28day(s)

PA

S

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

Formulary Brands

QL 4 ML / 28 DAY(S)

PA

S

ENBREL 25 MG KIT Formulary Brands

QL 4 Vials / 28 day(s)

PA

S

ENBREL 25 MG/0.5 ML VIAL Formulary Brands

QL 8 VIALS / 28 DAYS

PA

S

ENBREL MINI Formulary Brands

QL 4 Cartridges / 28day(s)

PA

S

ENBREL SURECLICK Formulary Brands

QL 4 ml / 28 day(s)

PA

S



HUMIRA 10 MG/0.2 ML SYRINGE Formulary Brands

QL 2 ML / 28 day(s)

PA

S


QL 2 sryinges / 28 day(s)

PA

S



PA

S

HUMIRA PEDIATRIC CROHN'S Formulary Brands


PA

S

HUMIRA PEN Formulary Brands

QL 2 PENS / 28 day(s)

PA

S

HUMIRA PEN CROHN'S-UC-HS Formulary Brands


PA

S

HUMIRA PEN PSOR-UVEITS-ADOL HS Formulary Brands


PA

S

HUMIRA(CF) (10 MG/0.1 ML SYRING,20 MG/0.2 ML SYRING)

Formulary Brands


PA

S

HUMIRA(CF) 40 MG/0.4 ML SYRING Formulary Brands

QL 2 syringes / 28 day(s)

PA

S

HUMIRA(CF) PEDI CROHN 80MG/0.8 Formulary Brands

QL 3 ML / 28 DAY(S)

PA

S



HUMIRA(CF) PEN 40 MG/0.4 ML Formulary Brands

QL 2 pens / 28 day(s)

PA

S

HUMIRA(CF) PEN 80 MG/0.8 ML Formulary Brands

QL 3 ML / 28 DAY(S)

PA

S

HUMIRA(CF) PEN CROHN'S-UC-HS Formulary Brands

QL 3 ML / 28 DAY(S)

PA

S

HUMIRA(CF) PEN PSOR-UV-ADOL HS Formulary Brands

QL 2 ML / 28 day(s)

PA

S

KINERET Formulary Brands


PA

S

leflunomide Formulary High Cost Generics

OLUMIANT 1 MG TABLET Formulary Brands

QL 1 TAB / 1 day(s)

PA

S

OLUMIANT 2 MG TABLET Formulary Brands

QL 1 TAB / 1 DAY

PA

S

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

Formulary Brands


PA

S

ORENCIA CLICKJECT Formulary Brands

QL 4 ML / 28 DAY(S)

PA

S

OTEZLA 28 DAY STARTER PACK Formulary Brands


PA

S



OTEZLA 30 MG TABLET Formulary Brands

QL 2 TABS / 1 DAY

PA

S

OTEZLA STARTER PACK Formulary Brands

QL 2 PACKS / 28 DAYS

PA

S

RINVOQ Formulary Brands

QL 1 TAB / 1 day(s)

PA

S

IMMUNOMODULATORY AGENTS

AUBAGIO Formulary BrandsQL 1 TAB / 1 DAY

S

AVONEX (30 MCG VIAL KIT,PREFILLED SYR 30 MCG KT)

Formulary BrandsQL 1 KIT / 28 DAYS

S

AVONEX PEN Formulary BrandsQL 1 KIT / 28 DAYS

S

BETASERON 0.3 MG KIT Formulary BrandsQL 15 ML / 28 DAYS

S

BETASERON 0.3 MG VIAL Formulary BrandsQL 15 ML / 30 day(s)

S

dimethyl fumarate (120 mg capsule dr,240 mg capsule dr)

Formulary High Cost GenericsQL 2 caps / 1 day(s)

S

dimethyl fumarate 120-240 mg capsuledr

Formulary High Cost GenericsQL 2 CAPS / DAY

S

GILENYA Formulary BrandsQL 1 CAP / 1 DAY

S

glatiramer acetate 20 mg/ml syringe Formulary High Cost GenericsQL 30 ML / 30 DAYS

S

glatiramer acetate 40 mg/ml syringe Formulary High Cost GenericsQL 12 ML / 28 DAYS

S



GLATOPA 20 MG/ML SYRINGE Formulary High Cost GenericsQL 30 ML / 30 DAYS

S

GLATOPA 40 MG/ML SYRINGE Formulary High Cost GenericsQL 12 ML / 28 DAYS

S

MAYZENT 0.25 MG STARTER PACK Formulary BrandsQL 12 TABS / 4 day(s)

S

MAYZENT 0.25 MG TABLET Formulary BrandsQL 120 TABS / 30 day(s)

S

MAYZENT 2 MG TABLET Formulary BrandsQL 30 TABS / 30 DAY(S)

S

PLEGRIDY Formulary BrandsQL 1 ML / 28 DAYS

S

PLEGRIDY PEN Formulary BrandsQL 1 ML / 28 DAYS

S

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

Formulary BrandsQL 6 ML / 28 DAYS

S

REBIF REBIDOSE (22 MCG/0.5 ML, 44MCG/0.5 ML)

Formulary BrandsQL 6 ML / 28 DAYS

S

REBIF REBIDOSE TITRATION PACK Formulary BrandsQL 4.2 ML / 28 DAYS

S

REBIF TITRATION PACK Formulary BrandsQL 4.2 ML / 28 DAYS

S

THALOMID Formulary BrandsS

ONC Oncology

VUMERITY Formulary BrandsQL 4 CAPS / 1 day(s)

S

IMMUNOSUPPRESSIVE AGENTS

azathioprine Formulary High Cost Generics

cyclosporine (25 mg capsule, 100 mgcapsule)




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


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


MAVENCLAD Formulary BrandsPA

S

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


sirolimus (0.5 mg tablet, 1 mg tablet, 1mg/ml solution, 2 mg tablet)


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


OTHER MISCELLANEOUS THERAPEUTIC AGENTS

ARCALYST Formulary BrandsPA

S

CERDELGA Formulary BrandsPA

S

CYSTAGON Formulary Brands

dalfampridine Formulary High Cost Generics


PA

S

GALAFOLD Formulary Brands

QL 14 CAPS / 28 DAYS

PA

S

ILARIS Formulary Brands

QL 2 ML / 28 day(s)

PA

S

ISTURISA Formulary BrandsPA

S

levocarnitine (with sugar) Formulary High Cost Generics

levocarnitine 100 mg/ml solution Formulary High Cost Generics



levocarnitine 330 mg tablet Formulary Low Cost Generics

miglustat Formulary High Cost GenericsPA

S

RUZURGI Formulary Brands


PA

S

sapropterin dihydrochloride Formulary High Cost GenericsPA

S

THIOLA Formulary BrandsPA

S

THIOLA EC Formulary BrandsPA

S

TYBOST Formulary Brands

PROTECTIVE AGENTS

ELMIRON Formulary Brands

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

celecoxib Formulary High Cost Generics

OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS

diclofenac potassium Formulary High Cost Generics

diclofenac sodium (1 % gel (gram), 25mg tablet dr, 50 mg tablet dr, 75 mgtablet dr, 100 mg tab er 24h)


etodolac (200 mg capsule, 300 mgcapsule)


etodolac (400 mg tab er 24h, 400 mgtablet, 500 mg tab er 24h, 500 mg tablet,600 mg tab er 24h)


flurbiprofen Formulary High Cost Generics

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


indomethacin (25 mg capsule, 50 mgcapsule)

Formulary Low Cost Generics AQ1 Up to 64 yrs old; 20 / 1FILL



ketorolac tromethamine 10 mg tablet Formulary Low Cost Generics QL 20 TABS / 30 DAYS

meloxicam Formulary Low Cost Generics

nabumetone Formulary High Cost Generics

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


naproxen (375 mg tablet dr, 500 mgtablet dr)


piroxicam Formulary Low Cost Generics

sulindac Formulary High Cost Generics

SALICYLATES

butalbital/aspirin/caffeine 50-325-40capsule

Formulary Low Cost Generics QL 6 CAPS / 1 DAY

salsalate Formulary High Cost Generics

OXYTOCICS

methylergonovine maleate 0.2 mg tablet Formulary High Cost Generics

PARATHYROID AND ANTIPARATHYROID AGENTS

ANTIPARATHYROID AGENTS

calcitonin,salmon,synthetic Formulary High Cost Generics

cinacalcet hcl Formulary High Cost Generics

SENSIPAR Formulary Brands

PARATHYROID AGENTS

FORTEO Formulary BrandsPA

S

TYMLOS Formulary BrandsPA

S



PENICILLIN ANTIBIOTICS

AMINOPENICILLIN ANTIBIOTICS

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


amoxicillin/potassium clavulanate(amoxicillin/potassium 200-28.5/5 susprecon, amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium250-125 mg tablet, amoxicillin/potassium250-62.5/5 susp recon,amoxicillin/potassium 400-57mg tabchew, amoxicillin/potassium 400-57mg/5susp recon, amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium600-42.9/5 susp recon,amoxicillin/potassium 875-125 mgtablet)


ampicillin trihydrate Formulary Low Cost Generics

NATURAL PENICILLIN ANTIBIOTICS

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


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


PENICILLINASE-RESISTANT PENICILLINS

dicloxacillin sodium Formulary High Cost Generics

PHARMACEUTICAL AIDS

SHINGRIX ADJUVANT COMPONENT Formulary Brands QL 1 KIT / rx

VAXCHORA BUFFER COMPONENT Formulary Brands

RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ENTRESTO Formulary Brands

irbesartan Formulary Low Cost Generics

irbesartan/hydrochlorothiazide Formulary High Cost Generics



losartan potassium Formulary Low Cost Generics

losartan potassium/hydrochlorothiazide Formulary Low Cost Generics

olmesartan medoxomil Formulary High Cost Generics

olmesartanmedoxomil/hydrochlorothiazide


telmisartan Formulary High Cost Generics

valsartan Formulary High Cost Generics

valsartan/hydrochlorothiazide Formulary High Cost Generics

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

benazepril hcl Formulary Low Cost Generics

benazepril hcl/hydrochlorothiazide Formulary High Cost Generics

captopril Formulary High Cost Generics

captopril/hydrochlorothiazide Formulary High Cost Generics

enalapril maleate Formulary High Cost Generics

enalapril maleate/hydrochlorothiazide Formulary Low Cost Generics

fosinopril sodium Formulary Low Cost Generics

fosinopril sodium/hydrochlorothiazide Formulary High Cost Generics

lisinopril Formulary Low Cost Generics

lisinopril/hydrochlorothiazide Formulary Low Cost Generics

moexipril hcl Formulary High Cost Generics

perindopril erbumine Formulary High Cost Generics

quinapril hcl Formulary Low Cost Generics

quinapril hcl/hydrochlorothiazide Formulary High Cost Generics

ramipril Formulary Low Cost Generics

trandolapril Formulary High Cost Generics

MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS

ALDACTAZIDE 50-50 TABLET Formulary Brands

eplerenone Formulary High Cost Generics

spironolactone Formulary High Cost Generics

spironolactone/hydrochlorothiazide Formulary High Cost Generics



RESPIRATORY TRACT AGENTS

ANTIFIBROTIC AGENTS

ESBRIET Formulary BrandsPA

S

OFEV Formulary BrandsPA

S

ANTITUSSIVES

benzonatate Formulary High Cost Generics

codeine phosphate/guaifenesin 10-100mg/5 liquid


QL 60 ML / 1 DAY


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

codeine phosphate/guaifenesin 20-200/10 liquid

Formulary High Cost Generics AQ1 At least 18 yrs old; 60 /1 day(s)

promethazine hcl/dextromethorphan hbr Formulary Low Cost Generics

MUCOLYTIC AGENTS

acetylcysteine Formulary High Cost Generics

PULMOZYME Formulary Brands

QL 150 ML / 30 DAYS

PA

S

PHOSPHODIESTERASE TYPE 4 INHIBITORS

DALIRESP Formulary Brands PA

RESPIRATORY TRACT AGENTS, MISCELLANEOUS

ARALAST NP Formulary BrandsPA

S

GLASSIA Formulary BrandsPA

S

PROLASTIN C Formulary BrandsPA

S

ZEMAIRA Formulary BrandsPA

S



VASODILATING AGENTS (RESPIRATORY TRACT)

ADEMPAS Formulary BrandsPA

S

ambrisentan Formulary High Cost GenericsPA

S

bosentan Formulary High Cost GenericsPA

S

epoprostenol sodium (glycine) 1.5 mgvial


S

FLOLAN 1.5 MG VIAL Formulary BrandsPA

S

OPSUMIT Formulary BrandsPA

S

TRACLEER 32 MG TABLET FOR SUSP Formulary BrandsPA

S

treprostinil sodium Formulary High Cost GenericsPA

S

TYVASO Formulary BrandsPA

S

TYVASO REFILL KIT Formulary BrandsPA

S

TYVASO STARTER KIT Formulary BrandsPA

S

UPTRAVI Formulary BrandsPA

S

VELETRI Formulary BrandsPA

S

VENTAVIS Formulary BrandsPA

S



SKELETAL MUSCLE RELAXANTS

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

chlorzoxazone 500 mg tablet Formulary High Cost Generics AL1 Up to 64 yrs old

cyclobenzaprine hcl (5 mg tablet, 10 mgtablet)

Formulary Low Cost Generics AL1 Up to 64 yrs old

methocarbamol (500 mg tablet, 750 mgtablet)


tizanidine hcl (2 mg tablet, 4 mg tablet) Formulary High Cost Generics

DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

dantrolene sodium (25 mg capsule, 50mg capsule, 100 mg capsule)


GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT

baclofen (5 mg tablet, 10 mg tablet, 20mg tablet)


SKIN AND MUCOUS MEMBRANE AGENTS

ANTIPRURITICS AND LOCAL ANESTHETICS

lidocaine 5 % adh. patch Formulary High Cost GenericsQL 30 PATCHES / 30

DAYSPA

lidocaine/prilocaine 2.5 %-2.5% cream(g)

Formulary High Cost Generics QL 60 GM / fill(s)

phenazopyridine hcl Formulary Low Cost Generics

ASTRINGENTS

DRYSOL Formulary Brands

CELL STIMULANTS AND PROLIFERANTS

AVITA Formulary High Cost Generics

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


KERATOLYTIC AGENTS

sulfacetamide sodium/sulfur(sodium/sulfur 10-5%(w/v) lotion,sodium/sulfur 10-5%(w/w) cream (g),sodium/sulfur 10-5%(w/w) lotion)




sulfacetamide sodium/sulfur 10-5%(w/w)cleanser

Formulary High Cost Generics QL 12 ML / 1 day(s)

urea (40 % cream (g), 40 % lotion) Formulary High Cost Generics

KERATOPLASTIC AGENTS

DRITHOCREME HP Formulary Brands

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

acitretin Formulary High Cost Generics

adapalene (0.1 % cream (g), 0.3 % gel(gram), 0.3 % gel w/pump)


AMNESTEEM Formulary High Cost Generics

azelaic acid Formulary High Cost Generics

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

Formulary High Cost Generics QL 120 gm / 30 day(s)

calcitriol 3 mcg/g oint. (g) Formulary High Cost Generics PA

CLARAVIS Formulary High Cost Generics

COSENTYX (2 SYRINGES) Formulary BrandsPA

S

COSENTYX PEN Formulary BrandsPA

S

COSENTYX PEN (2 PENS) Formulary BrandsPA

S

COSENTYX SYRINGE Formulary BrandsPA

S

dapsone 5 % gel (gram) Formulary High Cost Generics PA

DUPIXENT 300 MG/2 ML SYRINGE Formulary Brands

QL 4 ML / 28 DAY(S)

PA

S

DUPIXENT PEN Formulary Brands

QL 2 pens / 28 day(s)

PA

S

imiquimod 5 % cream pack Formulary High Cost Generics



isotretinoin Formulary High Cost Generics

MYORISAN Formulary High Cost Generics

pimecrolimus Formulary High Cost Generics

podofilox Formulary High Cost Generics

SKYRIZI Formulary BrandsPA

S

SKYRIZI (2 SYRINGES) KIT Formulary BrandsPA

S

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


tazarotene Formulary High Cost Generics QL 30 GM / 30 DAYS

TAZORAC (0.05% CREAM, 0.05% GEL,0.1% GEL)

Formulary Brands QL 30 GM / 30 DAYS

ZENATANE Formulary High Cost Generics

SMOOTH MUSCLE RELAXANTS

RESPIRATORY SMOOTH MUSCLE RELAXANTS

theophylline anhydrous (100 mg tab er12h, 200 mg tab er 12h, 300 mg tab er12h, 400 mg tab er 24h, 450 mg tab er12h, 600 mg tab er 24h)


SOMATOSTATIN AGONISTS AND ANTAGONISTS

SOMATOSTATIN AGONISTS

octreotide acetate (100 mcg/ml ampul,100 mcg/ml vial)


S

octreotide acetate (50 mcg/ml ampul, 50mcg/ml vial)


S

octreotide acetate (50 mcg/ml syringe,100 mcg/ml syringe, 500 mcg/mlsyringe)

Formulary High Cost Generics S

octreotide acetate (500 mcg/ml ampul,500 mcg/ml vial)

Formulary High Cost GenericsQL 7 ML / DAY

S

octreotide acetate 1000mcg/ml vial Formulary High Cost GenericsQL 9 VIALS / 30 DAYS

S



octreotide acetate 200 mcg/ml vial Formulary High Cost GenericsQL 7.5 ML / DAY

S

SANDOSTATIN LAR DEPOT (10 MGKT, 10 MG VL)

Formulary BrandsQL 1 KIT / 28 DAYS

S


Formulary BrandsQL 2 KITS / 28 DAYS

S


Formulary BrandsQL 3 KITS / 28 DAYS

S

SIGNIFOR Formulary BrandsPA

S

SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ALPHA- AND BETA-ADRENERGIC AGONISTS

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


SYMJEPI Formulary Brands

ALPHA-ADRENERGIC AGONISTS

midodrine hcl Formulary High Cost Generics

TETRACYCLINE ANTIBIOTICS

AMINOMETHYLCYCLINES

NUZYRA (150 MG TABLET, 150 MGTABLET-7 DAY, 150 MG-7 DAY WITHLOAD)

Formulary Brands PA

THYROID AND ANTITHYROID AGENTS

ANTITHYROID AGENTS

methimazole Formulary Low Cost Generics

propylthiouracil Formulary High Cost Generics

THYROID AGENTS

EUTHYROX Formulary High Cost Generics



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


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


SYNTHROID Formulary Brands

VASODILATING AGENTS

NITRATES AND NITRITES

isosorbide dinitrate (5 mg tablet, 10 mgtablet, 20 mg tablet, 30 mg tablet, 40 mgtablet er)


isosorbide mononitrate (10 mg tablet, 20mg tablet, 30 mg tab er 24h, 60 mg taber 24h, 120 mg tab er 24h)


NITRO-BID Formulary Brands

nitroglycerin (0.1mg/hr patch td24,0.2mg/hr patch td24, 0.3 mg tab subl,0.4 mg tab subl, 0.4mg/hr patch td24,0.6 mg tab subl, 0.6mg/hr patch td24)


PHOSPHODIESTERASE TYPE 5 INHIBITORS

sildenafil citrate (25 mg tablet, 50 mgtablet, 100 mg tablet)


sildenafil citrate 20 mg tablet Formulary High Cost Generics QL 1 TAB / DAY

tadalafil 10 mg tablet Formulary High Cost Generics

tadalafil 2.5 mg tablet Formulary High Cost Generics QL 1 tab / 1 day(s)

tadalafil 20 mg tablet Formulary High Cost GenericsQL 2 TABS / 1 day(s)

PA

tadalafil 5 mg tablet Formulary High Cost Generics QL 1 TAB / DAY

VASODILATING AGENTS, MISCELLANEOUS

aspirin/dipyridamole Formulary High Cost Generics

dipyridamole Formulary High Cost Generics



VITAMINS

MULTIVITAMIN PREPARATIONS

multivitamin combination no.51/ferrousfumarate/folic acid


O-CAL PRENATAL Formulary Low Cost Generics

PRENATA Formulary Brands

PRENATABS FA Formulary Low Cost Generics

PRENATABS RX Formulary High Cost Generics

prenatal vitamin with calciumno.76/iron,carbonyl/folic acid


prenatal vitamins with calcium/ferrousfumarate/folic acid


prenatal vits with calcium 118/ferrousfumarate/folic acid


prenatal vits with calcium no.72/ferrousfumarate/folic acid


prenatal vits with calciumno.72/iron,carbonyl/folic acid


PRENATE ELITE Formulary Brands PA

PUREFE OB PLUS Formulary Low Cost Generics

TRINATE Formulary High Cost Generics

VITAMIN B COMPLEX

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


folic acid 1 mg tablet Formulary Low Cost Generics

VITAMIN D

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


ergocalciferol (vitamin d2) Formulary Low Cost Generics

VITAMIN K ACTIVITY

phytonadione (vit k1) 5 mg tablet Formulary High Cost Generics QL 3 TABS / 1 FILL


Index of covered drugsAabacavir sulfate 55

abacavir sulfate/lamivudine 55

abacavir sulfate/lamivudine/zidovudine 55

abiraterone acetate 36

acamprosate calcium 68

acarbose 25

ACE AEROSOL CLOUD ENHANCER 71

acetaminophen with codeine phosphate 3

acetazolamide 29

acetic acid 12

acetylcysteine 103

acitretin 106

ACTEMRA 93

ACTEMRA ACTPEN 93

ACTHAR 74

ACTHIB 57

ACUVAIL 14

acyclovir 61

ADACEL TDAP 57

adapalene 106

ADDERALL XR 8

adefovir dipivoxil 62

ADEMPAS 104

adenovirus live type-4 and adenovirus live type-7

vaccine 57

adenovirus vaccine live type-4 57

adenovirus vaccine live type-7 57

ADVAIR DISKUS 70

ADVAIR HFA 70

ADVATE 30

ADYNOVATE 30

AEROCHAMBER MINI 71

AEROCHAMBER MV 71

AEROCHAMBER PLUS FLOW-VU 71

AEROCHAMBER WITH FLOWSIGNAL 71

AEROCHAMBER Z-STAT PLUS 71

AEROTRACH PLUS 71

AFEDITAB CR 66

AFINITOR 36

AFINITOR DISPERZ 36

AFLURIA 2018-2019 57

AFLURIA QUAD 2018-2019 57

AFLURIA QUAD 2019-20 (3YR UP) 57

AFLURIA QUAD 2019-20 (6-35MO) 58



AFLURIA QUAD 2020-21 (3YR UP) 58

AFLURIA QUAD 2020-21 (6-35MO) 58

AFSTYLA 30

AJOVY AUTOINJECTOR 34

AJOVY SYRINGE 34

albendazole 10

albuterol sulfate 64

alclometasone dipropionate 15

ALDACTAZIDE 102

ALECENSA 37

alendronate sodium 92

ALFERON N 61

alfuzosin hcl 3

ALINIA 52

allopurinol 91

alosetron hcl 79

ALPHAGAN P 29

ALPHANATE 30

ALPHANINE SD 30

alprazolam 62,63

ALPROLIX 30

ALTABAX 12

ALTAVERA 84

ALYACEN 84

AMABELZ 76

amantadine hcl 51

ambrisentan 104

AMETHIA 84

AMETHIA LO 84

amiloride hcl 74

amiloride hcl/hydrochlorothiazide 74

amiodarone hcl 16

AMITIZA 79

amitriptyline hcl 25


amlodipine besylate 66

amlodipine besylate/benazepril hcl 66

amlodipine besylate/valsartan 66

amlodipine besylate/valsartan/hydrochlorothiazide 66

ammonium lactate 76

AMNESTEEM 106

amoxicillin 101

amoxicillin/potassium clavulanate 101

ampicillin trihydrate 101

anagrelide hcl 57

anastrozole 37

ANORO ELLIPTA 19

aprepitant 27

APRI 84

APTIOM 20

APTIVUS 56

ARALAST NP 103

ARANELLE 84

ARANESP 65

ARCALYST 98

aripiprazole 52

armodafinil 10

ARNUITY ELLIPTA 70

ASHLYNA 84

ASMANEX 70

ASMANEX HFA 70

aspirin/dipyridamole 109

atazanavir sulfate 56

atenolol 67

atenolol/chlorthalidone 67

atomoxetine hcl 68

atorvastatin calcium 34

atovaquone 52

atovaquone/proguanil hcl 52

atropine sulfate 78

ATROVENT HFA 19

AUBAGIO 96

AUBRA 84

AUBRA EQ 84

AUSTEDO 69

AVIANE 84

AVITA 105

AVONEX 96

AVONEX PEN 96

AYVAKIT 37

azathioprine 97

azelaic acid 106

azelastine hcl 77

azithromycin 91

AZOPT 29

AZURETTE 84

Bbacitracin 10

bacitracin/polymyxin b sulfate 10

baclofen 105

balsalazide disodium 79

BALVERSA 37

BALZIVA 84

BANZEL 20

BAQSIMI 33

BARACLUDE 62

BEKYREE 84

benazepril hcl 102

benazepril hcl/hydrochlorothiazide 102

BENEFIX 30

benzonatate 103

benztropine mesylate 51

BERINERT 92

BESIVANCE 10

betamethasone dipropionate 15

betamethasone dipropionate/propylene glycol 15

betamethasone valerate 15

BETASERON 96

betaxolol hcl 29

bethanechol chloride 63

BEXSERO 58

bicalutamide 37

BIKTARVY 55

bimatoprost 30

bisoprolol fumarate 67

bisoprolol fumarate/hydrochlorothiazide 67


BLEPHAMIDE S.O.P. 10

BLISOVI 24 FE 84

BLISOVI FE 84

BOOSTRIX TDAP 57

bosentan 104

BOSULIF 37

BRAFTOVI 37

BREATHERITE 71

BREATHRITE 71

BREO ELLIPTA 70

BRIELLYN 84

BRILINTA 56

brimonidine tartrate 29

BRIVIACT 20

bromfenac sodium 14

bromocriptine mesylate 74

BRUKINSA 38

budesonide 70,82

budesonide/formoterol fumarate 70

bumetanide 74

buprenorphine 7

buprenorphine hcl/naloxone hcl 7,8

bupropion hcl 23

buspirone hcl 62

butalbital/acetaminophen 3

butalbital/acetaminophen/caffeine 3

butalbital/aspirin/caffeine 100

BYDUREON 25

BYDUREON BCISE 25

BYDUREON PEN 25

BYETTA 25,26

Ccabergoline 74

CABLIVI 56

CABOMETYX 38

calcipotriene 106

calcitonin,salmon,synthetic 100

calcitriol 106,110

calcium acetate 90

CAMILA 84

CAMRESE 84

CAMRESE LO 84

capecitabine 38

CAPLYTA 52

CAPRELSA 38

captopril 102

captopril/hydrochlorothiazide 102

CARBAGLU 75

carbamazepine 20

carbidopa 68

carbidopa/levodopa 51

carbidopa/levodopa/entacapone 51

carteolol hcl 29

CARTIA XT 65

carvedilol 67

CAYSTON 91

CAZIANT 84

cefadroxil 69

cefdinir 70

cefixime 70

cefprozil 69

cefuroxime axetil 70

celecoxib 99

cephalexin 69

CERDELGA 98

CETROTIDE 81

cevimeline hcl 63

CHANTIX 63

CHATEAL 84

CHATEAL EQ 84

CHEMET 82

chlordiazepoxide hcl 63

chlorhexidine gluconate 12

chloroquine phosphate 52

chlorothiazide 74

chlorthalidone 74

chlorzoxazone 105

CHOLBAM 80

cholestyramine (with sugar) 33

cholestyramine/aspartame 33

chorionic gonadotropin, human 81


ciclopirox 28

ciclopirox olamine 28

cilostazol 56

CILOXAN 10

cimetidine 60

cimetidine hcl 60

CIMZIA 93

cinacalcet hcl 100

CINRYZE 92

CIPRO 17

CIPRO HC 11

CIPRODEX 11

ciprofloxacin 17

ciprofloxacin hcl 11,17

ciprofloxacin hcl/dexamethasone 11

citalopram hydrobromide 24

CLARAVIS 106

clarithromycin 91

CLEOCIN 12

CLEOCIN T 12

CLIMARA PRO 76

clindamycin hcl 18

clindamycin palmitate hcl 18

clindamycin phosphate 12

clindamycin phosphate/benzoyl peroxide 12

clobazam 23

clobetasol propionate 15

clobetasol propionate/emollient base 15

clomiphene citrate 76

clomipramine hcl 25

clonazepam 23

clonidine 89

clonidine hcl 89

clopidogrel bisulfate 56

clotrimazole 28

clozapine 52

COAGADEX 30

codeine phosphate/guaifenesin 103

codeine sulfate 3

colchicine 91

colestipol hcl 33

COMBIGAN 29

COMBIPATCH 77

COMBIVENT RESPIMAT 19

COMETRIQ 38

COMPLERA 55

CONCERTA 9

COPIKTRA 39

CORDRAN 15

CORIFACT 30

CORLANOR 66

COSENTYX (2 SYRINGES) 106

COSENTYX PEN 106

COSENTYX PEN (2 PENS) 106

COSENTYX SYRINGE 106

COTELLIC 39

CREON 80

CRESEMBA 28

cromolyn sodium 14

CRYSELLE 84

CUVPOSA 19

cyanocobalamin (vitamin b-12) 110

CYCLAFEM 84

cyclobenzaprine hcl 105

cyclopentolate hcl 78

cyclophosphamide 39

cycloserine 35

CYCLOSET 74

cyclosporine 97

cyclosporine, modified 98

cyproheptadine hcl 78

CYRED 84

CYRED EQ 84

CYSTADROPS 78

CYSTAGON 98

CYSTARAN 78

DD-PENAMINE 82

dalfampridine 98

DALIRESP 103

danazol 83


dantrolene sodium 105

dapsone 35,106

DAPTACEL DTAP 57

DASETTA 84

DAURISMO 39

DAYSEE 84

DEBLITANE 84

deferasirox 82

deferiprone 82

DELYLA 85

demeclocycline hcl 18

DESCOVY 55

desipramine hcl 25

desmopressin acetate 88

desmopressin acetate (non-refrigerated) 88

desogestrel-ethinyl estradiol 85

desogestrel-ethinyl estradiol/ethinyl estradiol 85

desonide 15

desoximetasone 15

desvenlafaxine succinate 24

dexamethasone 82

DEXAMETHASONE INTENSOL 82

dexamethasone sodium phosphate 13,83

dexamethasone sodium phosphate/pf 83

DEXCOM 71

DEXCOM G4 71

DEXCOM G5 72

DEXCOM G5-G4 SENSOR 72

DEXCOM G6 72

dexmethylphenidate hcl 9

dextroamphetamine sulf-saccharate/amphetamine sulf-

aspartate 8

dextroamphetamine sulfate 8

DIACOMIT 20,21

diazepam 63

diclofenac potassium 99

diclofenac sodium 14,99

dicloxacillin sodium 101

dicyclomine hcl 19

DIFICID 91

DIGITEK 67

DIGOX 67

digoxin 67

DILANTIN 23

DILT-XR 65

diltiazem hcl 65

dimethyl fumarate 96

diphenoxylate hcl/atropine sulfate 79

dipyridamole 109

disopyramide phosphate 16

disulfiram 91

DIURIL 74

divalproex sodium 21

dofetilide 17

DOJOLVI 75

donepezil hcl 64

dorzolamide hcl 29

dorzolamide hcl/timolol maleate 29

dorzolamide hcl/timolol maleate/pf 29

DOTTI 77

doxazosin mesylate 67

doxepin hcl 25

doxycycline hyclate 11,18

doxycycline monohydrate 18

DRITHOCREME HP 106

dronabinol 27

DRYSOL 105

DULERA 70

duloxetine hcl 24

DUPIXENT PEN 106

DUPIXENT SYRINGE 14,106

dutasteride 91

dutasteride/tamsulosin hcl 91

EEASIVENT 72

econazole nitrate 28

EDURANT 54

efavirenz 54

efavirenz/emtricitabine/tenofovir disoproxil fumarate 55

ELINEST 85

ELIQUIS 19


ELLA 85

ELMIRON 99

ELOCTATE 31

ELURYNG 85

EMCYT 39

EMEND 27

EMGALITY PEN 35

EMGALITY SYRINGE 35

EMOQUETTE 85

EMSAM 51

emtricitabine 55

emtricitabine/tenofovir disoproxil fumarate 55

EMTRIVA 55

enalapril maleate 102

enalapril maleate/hydrochlorothiazide 102

ENBREL 93

ENBREL MINI 93

ENBREL SURECLICK 93

ENDARI 80

ENDOCET 3,4

ENGERIX-B ADULT 58

ENGERIX-B PEDIATRIC-ADOLESCENT 58

enoxaparin sodium 20

ENPRESSE 85

ENSKYCE 85

entacapone 51

entecavir 62

ENTRESTO 101

ENULOSE 75

EPCLUSA 81

EPIDIOLEX 21

epinastine hcl 77

epinephrine 108

EPIVIR HBV 55

eplerenone 102

epoprostenol sodium (glycine) 104

ergocalciferol (vitamin d2) 110

ERGOMAR 3

ERIVEDGE 39

ERLEADA 39

erlotinib hcl 40

ERRIN 85

erythromycin base 11

erythromycin base in ethanol 12

ESBRIET 103

escitalopram oxalate 24

esomeprazole magnesium 60

ESPEROCT 31

ESTARYLLA 85

estradiol 77

estradiol/norethindrone acetate 77

ESTRING 77

eszopiclone 62

ethambutol hcl 35

ethinyl estradiol/drospirenone 85

ethosuximide 23

ethynodiol diacetate-ethinyl estradiol 85

etidronate disodium 92

etodolac 99

etonogestrel/ethinyl estradiol 85

etoposide 40

EUCRISA 14

EURAX 13

EUTHYROX 108

everolimus 40

EVOTAZ 56

exemestane 40

EZ FLU 2018-2019 (FLUCELVAX) 58

ezetimibe 33

FFALMINA 85

famciclovir 62

famotidine 60

FANAPT 52

FASENRA PEN 14

febuxostat 91

FEIBA NF 31

felbamate 21

felodipine 66

FEMYNOR 85

fenofibrate 33


fenofibrate nanocrystallized 33

fenofibrate,micronized 34

fentanyl 4

FERRIPROX 82

FETZIMA 24

finasteride 91

FIRAZYR 92

flecainide acetate 16

FLOLAN 104

FLOVENT DISKUS 70

FLOVENT HFA 70

FLUAD 2018-2019 58

FLUAD 2019-2020 58

FLUAD 2020-2021 58

FLUAD QUAD 2020-2021 58

FLUARIX QUAD 2018-2019 58



FLUBLOK QUAD 2018-2019 58



FLUCELVAX QUAD 2018-2019 58



fluconazole 28

fludrocortisone acetate 83

FLULAVAL QUAD 2018-2019 58



FLUMIST QUAD 2018-2019 58



flunisolide 13

fluocinolone acetonide 15

fluocinolone acetonide oil 13

fluocinolone acetonide/shower cap 15

fluocinonide 15

fluocinonide/emollient base 15

FLUORABON 92

fluoride (sodium) 92

FLUORITAB 92

fluorometholone 13

FLUOROPLEX 40

fluorouracil 40

fluoxetine hcl 24

fluphenazine hcl 54

flurbiprofen 99

flurbiprofen sodium 14

flutamide 40

fluticasone propionate 13,15

fluticasone propionate/salmeterol xinafoate 70

fluvoxamine maleate 24

FLUZONE HIGH-DOSE 2018-2019 59

FLUZONE HIGH-DOSE 2019-2020 59

FLUZONE HIGH-DOSE QUAD 2020-21 59

FLUZONE QUAD 2018-2019 59



FLUZONE QUAD PEDI 2018-2019 59

FLUZONE QUAD PEDI 2019-2020 59

FML S.O.P. 13

folic acid 110

FOLLISTIM AQ 81

fondaparinux sodium 19

FORTEO 100

fosamprenavir calcium 56

fosfomycin tromethamine 10

fosinopril sodium 102

fosinopril sodium/hydrochlorothiazide 102

FREESTYLE LIBRE 10 DAY READER 72

FREESTYLE LIBRE 10 DAY SENSOR 72

FREESTYLE LIBRE 14 DAY READER 72

FREESTYLE LIBRE 14 DAY SENSOR 73

FREESTYLE LIBRE 2 READER 73

FREESTYLE LIBRE 2 SENSOR 73

FULPHILA 65

furosemide 74

FUZEON 54

FYAVOLV 77

FYCOMPA 21


Ggabapentin 21

GALAFOLD 98

galantamine hbr 64

ganirelix acetate 81

GARDASIL 9 59

gatifloxacin 11

GAVILYTE-C 79

GAVILYTE-G 79

GAVILYTE-N 79

gemfibrozil 34

GENERLAC 75

GENGRAF 98

gentamicin sulfate 12

GENVOYA 55

GIANVI 85

GILENYA 96

GILOTRIF 40

GLASSIA 103

glatiramer acetate 96

GLATOPA 97

GLEOSTINE 40

glimepiride 26

glipizide 26

glipizide/metformin hcl 27

GLUCAGEN 33

GLUCAGON EMERGENCY KIT 33

glyburide 27

glyburide,micronized 27

glycopyrrolate 19

GRANIX 65

GRASTEK 57

griseofulvin ultramicrosize 28

griseofulvin, microsize 28

guanfacine hcl 68,89

GVOKE HYPOPEN 1-PACK 33

GVOKE HYPOPEN 2-PACK 33

GVOKE PFS 1-PACK SYRINGE 33

GVOKE PFS 2-PACK SYRINGE 33

HHAEGARDA 92

haloperidol 54

haloperidol lactate 54

HARVONI 81

HAVRIX 59

HEATHER 85

HELIXATE FS 31

HEMLIBRA 31

HEMOFIL M 31

heparin sodium,porcine 20

heparin sodium,porcine/pf 20

HEPLISAV-B 59

HIBERIX 59

homatropine hbr 78

HUMALOG 90

HUMALOG JUNIOR KWIKPEN 90

HUMALOG KWIKPEN U-100 90

HUMALOG KWIKPEN U-200 90

HUMALOG MIX 50-50 90

HUMALOG MIX 50-50 KWIKPEN 90

HUMALOG MIX 75-25 90

HUMALOG MIX 75-25 KWIKPEN 90

HUMATE-P 31

HUMIRA 94

HUMIRA PEDIATRIC CROHN'S 94

HUMIRA PEN 94

HUMIRA PEN CROHN'S-UC-HS 94

HUMIRA PEN PSOR-UVEITS-ADOL HS 94

HUMIRA(CF) 94

HUMIRA(CF) PEDIATRIC CROHN'S 80,94

HUMIRA(CF) PEN 95

HUMIRA(CF) PEN CROHN'S-UC-HS 95

HUMIRA(CF) PEN PSOR-UV-ADOL HS 95

HUMULIN R U-500 90

HUMULIN R U-500 KWIKPEN 90

HYCAMTIN 40

hydralazine hcl 89

hydrochlorothiazide 74

hydrocodone bitartrate/acetaminophen 4


hydrocodone/ibuprofen 4

hydrocortisone 15,83

hydrocortisone acetate 16

hydrocortisone acetate/pramoxine hcl 16

hydrocortisone valerate 16

hydrocortisone/iodoquinol 13

hydromorphone hcl 4

hydroxychloroquine sulfate 52

hydroxyprogesterone caproate/pf 89

hydroxyurea 40

hydroxyzine hcl 62

hydroxyzine pamoate 62

hyoscyamine sulfate 19

Iibandronate sodium 92

IBRANCE 40,41

ibuprofen 99

ICLUSIG 41

icosapent ethyl 33

IDELVION 31

IDHIFA 41

ILARIS 98

imatinib mesylate 41

IMBRUVICA 41

imipramine hcl 25

imiquimod 106

INBRIJA 51

INCASSIA 85

INCRUSE ELLIPTA 19

indapamide 74

indomethacin 99

INFANRIX DTAP 57

INGREZZA 69

INGREZZA INITIATION PACK 69

INLYTA 42

INPEN (FOR HUMALOG) 73

INPEN (FOR NOVOLOG OR FIASP) 73

INREBIC 42

insulin lispro 90

insulin lispro protamine and insulin lispro 90

INTELENCE 55

INTRON A 61

INTROVALE 85

INVIRASE 56

INVOKAMET 26

INVOKAMET XR 26

INVOKANA 26

ipratropium bromide 19,78

ipratropium bromide/albuterol sulfate 19

irbesartan 101

irbesartan/hydrochlorothiazide 101

IRESSA 42

ISENTRESS 54

ISENTRESS HD 54

ISIBLOOM 85

isoniazid 36

isosorbide dinitrate 109

isosorbide mononitrate 109

isotretinoin 107

ISTURISA 98

itraconazole 28

ivermectin 10

IXINITY 31

JJAKAFI 42

JARDIANCE 26

JASMIEL 85

JENCYCLA 85

JENTADUETO 25

JENTADUETO XR 25

JINTELI 77

JIVI 31

JOLESSA 85

JOLIVETTE 85

JULEBER 85

JULUCA 54

JUNEL 85

JUNEL FE 85

JUXTAPID 33


KKALBITOR 92

KALETRA 56

KALYDECO 71

KARIVA 85

KELNOR 1-35 86

KELNOR 1-50 86

ketoconazole 28

ketorolac tromethamine 14,100

KINERET 95

KINRIX 59

KISQALI 42

KISQALI FEMARA CO-PACK 43

KLOR-CON M10 75

KLOR-CON M15 75

KLOR-CON M20 75

KOATE 31

KOGENATE FS 31

KOSELUGO 43

KOVALTRY 31

KURVELO 86

Llabetalol hcl 67

LACRISERT 78

lactulose 75

lamivudine 55

lamivudine/zidovudine 55

lamotrigine 21

lansoprazole 60

LANTUS 89

LANTUS SOLOSTAR 89

lapatinib ditosylate 43

LARIN 86

LARIN FE 86

LARISSIA 86

latanoprost 30

LATUDA 52

ledipasvir/sofosbuvir 81

LEENA 86

leflunomide 95

LENVIMA 43

LESSINA 86

letrozole 43

leucovorin calcium 91

LEUKERAN 43

leuprolide acetate 81

levalbuterol tartrate 64

LEVEMIR 89

LEVEMIR FLEXTOUCH 90

levetiracetam 21,22

levobunolol hcl 29

levocarnitine 98,99

levocarnitine (with sugar) 98

levofloxacin 17

LEVONEST 86

levonorgestrel/ethinyl estradiol 86

levonorgestrel/ethinyl estradiol and ethinyl estradiol 86

LEVORA-28 86

levothyroxine sodium 109

LEXIVA 56

lidocaine 105

lidocaine hcl 78

lidocaine/prilocaine 105

LILLOW 86

linezolid 18

LINZESS 80

liothyronine sodium 109

lisinopril 102

lisinopril/hydrochlorothiazide 102

LITETOUCH 73

lithium carbonate 68

lithium citrate 68

LOMAIRA 8

LONSURF 44

lopinavir/ritonavir 56

LOPREEZA 77

lorazepam 63

LORAZEPAM INTENSOL 63

LORBRENA 44

LORCET 4


LORCET HD 5

LORCET PLUS 5

LORYNA 86

losartan potassium 102

losartan potassium/hydrochlorothiazide 102

LOTEMAX 13

LOTEMAX SM 13

loteprednol etabonate 13

lovastatin 34

LOW-OGESTREL 86

loxapine succinate 52

LUMIGAN 30

LUTERA 86

LYNPARZA 44

LYZA 86

MMAKENA 89

malathion 13

MARLISSA 86

MATULANE 44

MATZIM LA 66

MAVENCLAD 98

MAVYRET 82

MAYZENT 97

MEDROL 83

medroxyprogesterone acetate 89

mefloquine hcl 52

megestrol acetate 89

MEKINIST 44,45

MEKTOVI 45

meloxicam 100

melphalan 45

memantine hcl 68

MENACTRA 59

MENOPUR 81

MENQUADFI 59

MENVEO A-C-Y-W-135-DIP 59

mercaptopurine 45

mesalamine 79

METADATE ER 9

metformin hcl 25

methadone hcl 5

METHADONE INTENSOL 5

METHADOSE 5

methazolamide 29

methimazole 108

methocarbamol 105

methotrexate sodium 45

methotrexate sodium/pf 45

methyldopa 89

methylergonovine maleate 100

methylphenidate hcl 9

methylprednisolone 83

metoclopramide hcl 80

metolazone 74

metoprolol succinate 67

metoprolol tartrate 67

metoprolol tartrate/hydrochlorothiazide 67

metronidazole 12,52

mexiletine hcl 16

MICROCHAMBER 73

MICROGESTIN 86

MICROGESTIN FE 86

MICROSPACER 73

midodrine hcl 108

miglitol 25

miglustat 99

MILI 86

MILLIPRED 83

MIMVEY LO 77

minocycline hcl 18

minoxidil 89

mirtazapine 23

misoprostol 60

modafinil 10

MODERNA COVID19 VACC(UNAPPROV) 59

moexipril hcl 102

mometasone furoate 16

MONDOXYNE NL 18

MONO-LINYAH 86

MONONESSA 86


MONONINE 31

montelukast sodium 14

morphine sulfate 5,6

MOVANTIK 80

moxifloxacin hcl 11,17

MULTAQ 17

multivitamin combination no.51/ferrous fumarate/folic

acid 110

mupirocin 12

mupirocin calcium 12

mycophenolate mofetil 98

MYLERAN 45

MYORISAN 107

MYRBETRIQ 64

MYZILRA 86

Nnabumetone 100

nadolol 67

naloxone hcl 69

naltrexone hcl 69

naproxen 100

naratriptan hcl 35

NARCAN 69

nateglinide 26

NAYZILAM 23

NECON 86

nefazodone hcl 24

neomycin sulfate 17

neomycin sulfate/bacitracin/polymyxin b 11

neomycin sulfate/polymyxin b sulfate/gramicidin d 11

neomycin sulfate/polymyxin b sulfate/hydrocortisone 11

neomycin/polymyxin b sulfate/dexamethasone 11

NERLYNX 45

NEUPRO 75

nevirapine 55

NEXAVAR 45

NICOTROL 63

NICOTROL NS 63

nifedipine 66

NIKKI 86

nimodipine 66

NINLARO 45

NITRO-BID 109

nitrofurantoin 10

nitrofurantoin macrocrystal 10

nitrofurantoin monohydrate/macrocrystals 10

nitroglycerin 109

NORA-BE 86

NORDITROPIN FLEXPRO 88

norethindrone 87

norethindrone acetate 89

norethindrone acetate-ethinyl estradiol 77,87

norethindrone acetate-ethinyl estradiol/ferrous

fumarate 87

norgestimate-ethinyl estradiol 87

NORLYDA 87

NORLYROC 87

NORPACE CR 16

NORTREL 87

nortriptyline hcl 25

NORVIR 56

NOURIANZ 68

NOVAREL 81

NOVOEIGHT 31

NOVOPEN ECHO 73

NOVOSEVEN RT 32

NUBEQA 45

NUCALA 14

NUPLAZID 53

NURTEC ODT 35

NUWIQ 32

NUZYRA 108

nystatin 28,29

OO-CAL PRENATAL 110

OBIZUR 32

OCELLA 87

octreotide acetate 107,108

ODACTRA 57

ODEFSEY 55


ODOMZO 46

OFEV 103

ofloxacin 11

OGESTREL 87

olanzapine 53

olmesartan medoxomil 102

olmesartan medoxomil/hydrochlorothiazide 102

olopatadine hcl 77

OLUMIANT 95

omega-3 acid ethyl esters 33

omeprazole 60

OMNIPOD 73

OMNIPOD DASH 5 PACK POD 73

OMNIPOD DASH PDM KIT 73

ondansetron 27

ondansetron hcl 27

OPSUMIT 104

OPTICHAMBER 73

OPTICHAMBER DIAMOND 73

ORENCIA 95

ORENCIA CLICKJECT 95

ORILISSA 81

ORKAMBI 71

ORSYTHIA 87

oseltamivir phosphate 61

OTEZLA 95,96

OVIDREL 81

OXBRYTA 64

oxcarbazepine 22

OXERVATE 78

oxybutynin chloride 80

oxycodone hcl 6

oxycodone hcl/acetaminophen 7

oxycodone hcl/aspirin 7

OXYCONTIN 7

OZEMPIC 26

PPACERONE 17

PALFORZIA 57

paliperidone 53

pantoprazole sodium 60

PANZYGA 57

paregoric 79

PAROEX 12

paroxetine hcl 24

PAXIL 24

PEDIARIX 59

PEDVAXHIB 59

PEGASYS 61

PEGASYS PROCLICK 61

PEGINTRON 61

PEMAZYRE 46

penicillamine 82

penicillin v potassium 101

PENTACEL 59

PENTACEL ACTHIB COMPONENT 59

PENTACEL DTAP-IPV COMPONENT 59

pentoxifylline 65

perindopril erbumine 102

PERIOGARD 12

permethrin 13

perphenazine 54

PFIZER COVID19 VACC (UNAPPROV) 59

PHENADOZ 78

phenazopyridine hcl 105

phenelzine sulfate 24

phenobarbital 62

phenoxybenzamine hcl 3

phentermine hcl 8

phenylephrine hcl 78

phenylephrine hcl/promethazine hcl 78

phenytoin 23

phenytoin sodium extended 23

PHILITH 87

PHOSLYRA 90

PHOSPHOLINE IODIDE 29

phytonadione (vit k1) 110

PICATO 46

pilocarpine hcl 29,64

pimecrolimus 107

PIMTREA 87


pioglitazone hcl 27

pioglitazone hcl/glimepiride 27

pioglitazone hcl/metformin hcl 27

PIRMELLA 87

piroxicam 100

PLEGRIDY 97

PLEGRIDY PEN 97

PNEUMOVAX 23 59

POCKET CHAMBER 73

podofilox 107

polymyxin b sulfate/trimethoprim 11

POMALYST 46

PORTIA 87

posaconazole 28

potassium chloride 76

potassium citrate 75

PRADAXA 20

pramipexole di-hcl 75

prasugrel hcl 56

pravastatin sodium 34

praziquantel 10

prazosin hcl 67

prednisolone 83

prednisolone acetate 13

prednisolone sodium phosphate 13,83

prednisone 83

PREDNISONE INTENSOL 83

pregabalin 22

PREGNYL 81

PREMARIN 77

PREMPHASE 77

PREMPRO 77

PRENATA 110

PRENATABS FA 110

PRENATABS RX 110

prenatal vitamin with calcium no.76/iron,carbonyl/folic

acid 110

prenatal vitamins with calcium/ferrous fumarate/folic

acid 110

prenatal vits with calcium 118/ferrous fumarate/folic

acid 110

prenatal vits with calcium no.72/ferrous fumarate/folic

acid 110

prenatal vits with calcium no.72/iron,carbonyl/folic

acid 110

PRENATE ELITE 110

pretomanid 36

PREVALITE 33

PREVIFEM 87

PREVNAR 13 59

PREVYMIS 61

PREZCOBIX 56

PREZISTA 56

PRIFTIN 36

primidone 23

probenecid 76

probenecid/colchicine 76

PROCHAMBER 73

prochlorperazine 27

prochlorperazine maleate 27

PROCTO-MED HC 16

PROCTOFOAM-HC 16

PROCTOSOL-HC 16

PROCTOZONE-HC 16

PROFILNINE 32

progesterone, micronized 89

PROLASTIN C 103

PROMACTA 65

promethazine hcl 78,79

promethazine hcl/dextromethorphan hbr 103

PROMETHEGAN 79

propafenone hcl 16

propantheline bromide 19

propranolol hcl 67

propranolol hcl/hydrochlorothiazide 68

propylthiouracil 108

PROQUAD 59

PULMICORT FLEXHALER 70

PULMOZYME 103

PUREFE OB PLUS 110

pyrazinamide 36

pyridostigmine bromide 64


QQINLOCK 46

QNASL 13

QNASL CHILDREN 13

QUASENSE 87

quetiapine fumarate 53

QUILLICHEW ER 9

QUILLIVANT XR 10

quinapril hcl 102

quinapril hcl/hydrochlorothiazide 102

quinidine sulfate 16

QVAR REDIHALER 70

Rrabeprazole sodium 61

RAGWITEK 57

raloxifene hcl 76

ramipril 102

rasagiline mesylate 51

RASUVO 46

REBETOL 62

REBIF 97

REBIF REBIDOSE 97

REBINYN 32

RECLIPSEN 87

RECOMBINATE 32

RECOMBIVAX HB 59

RELENZA 61

repaglinide 26

REPATHA PUSHTRONEX 34

REPATHA SURECLICK 34

REPATHA SYRINGE 34

RESTASIS 14

RESTASIS MULTIDOSE 14

RETACRIT 65

RETEVMO 46

REVCOVI 76

REVLIMID 46

REXULTI 53

REYATAZ 56

REYVOW 35

RHOPRESSA 30

ribavirin 62

RIDAURA 81

rifabutin 36

rifampin 36

riluzole 68

rimantadine hcl 61

RINVOQ 96

risedronate sodium 92

risperidone 53

ritonavir 56

rivastigmine 64

rivastigmine tartrate 64

RIXUBIS 32

rizatriptan benzoate 35

ROCKLATAN 30

ropinirole hcl 75

ROSADAN 12

rosuvastatin calcium 34

ROZLYTREK 46

RUCONEST 93

rufinamide 22

RUZURGI 99

RYBELSUS 26

RYDAPT 47

RYTARY 51

Ssalsalate 100

SANDOSTATIN LAR DEPOT 108

SAPHRIS 53

sapropterin dihydrochloride 99

SAVELLA 69

scopolamine 27

SECUADO 53

selegiline hcl 51

selenium sulfide 13

SELZENTRY 54

SENSIPAR 100

SEREVENT DISKUS 64


SEROPHENE 76

sertraline hcl 24

SETLAKIN 87

sevelamer carbonate 90

SEVENFACT 32

SHAROBEL 87

SHINGRIX 59

SHINGRIX ADJUVANT COMPONENT 101

SHINGRIX GE ANTIGEN COMPONENT 60

SIGNIFOR 108

sildenafil citrate 109

SILICONE MASK 73

silver sulfadiazine 13

SIMBRINZA 29

SIMPESSE 87

simvastatin 34

sirolimus 98

SIRTURO 36

SIVEXTRO 18

SKYRIZI 107

SKYRIZI (2 SYRINGES) KIT 107

sodium chloride/sodium bicarbonate/potassium

chloride/peg 79

sodium phenylbutyrate 75

sodium polystyrene sulfonate 90

sofosbuvir/velpatasvir 82

solifenacin succinate 80

SOLIQUA 100-33 90

SOLTAMOX 76

SOLU-CORTEF 83

sotalol hcl 68

SOVALDI 82

spironolactone 102

spironolactone/hydrochlorothiazide 102

SPRINTEC 87

SPRYCEL 47

SRONYX 87

SSD 13

STIMATE 88

STIVARGA 47

STRENSIQ 76

STRIBILD 55

STRIVERDI RESPIMAT 64

SUBVENITE 22

SUCRAID 76

sucralfate 60

sulfacetamide sodium 11,13

sulfacetamide sodium/prednisolone sodium

phosphate 11

sulfacetamide sodium/sulfur 105,106

sulfacetamide sodium/sulfur/urea 13

sulfamethoxazole/trimethoprim 17

sulfasalazine 17

SULFATRIM 17

sulindac 100

sumatriptan 35

sumatriptan succinate 35

SUNOSI 10

SUPREP 79

SUTENT 47

SYEDA 87

SYLATRON 61

SYMDEKO 71

SYMJEPI 108

SYMPROIC 80

SYMTUZA 56

SYNJARDY 26

SYNJARDY XR 26

SYNTHROID 109

TTABLOID 47

TABRECTA 47

tacrolimus 98,107

tadalafil 109

TAFINLAR 47

TAGRISSO 47

TAKHZYRO 93

TALICIA 60

tamoxifen citrate 76

tamsulosin hcl 3

TARINA FE 87


TARINA FE 1-20 EQ 87

TASIGNA 47

tazarotene 107

TAZORAC 107

TAZTIA XT 66

TAZVERIK 48

telmisartan 102

temazepam 63

temozolomide 48

TENCON 3

TENIVAC 57

tenofovir disoproxil fumarate 55

terazosin hcl 67

terbinafine hcl 27

terconazole 28

testosterone 83

testosterone cypionate 83

testosterone enanthate 83

testosterone propionate 83

tetanus and diphtheria toxoids, adult 57

tetanus,diphtheria toxoid ped/pf 57

tetrabenazine 69

THALOMID 97

theophylline anhydrous 107

THIOLA 99

THIOLA EC 99

thioridazine hcl 54

thiothixene 54

TIADYLT ER 66

tiagabine hcl 22

TIBSOVO 48

TILIA FE 87

timolol maleate 29

TIVICAY 54

TIVICAY PD 54

tizanidine hcl 105

TOBRADEX 11

tobramycin 11

tobramycin in 0.225 % sodium chloride 17

tobramycin/dexamethasone 11

TOBREX 11

tolterodine tartrate 80

topiramate 22

torsemide 74

TOUJEO MAX SOLOSTAR 90

TOUJEO SOLOSTAR 90

TRACLEER 104

TRADJENTA 25

tramadol hcl 7

trandolapril 102

tranexamic acid 32

tranylcypromine sulfate 24

travoprost 30

trazodone hcl 24

TRECATOR 36

TRELEGY ELLIPTA 70

treprostinil sodium 104

tretinoin 48,105

TRETTEN 32

TRI FEMYNOR 87

TRI-ESTARYLLA 88

TRI-LEGEST FE 88

TRI-LINYAH 88

TRI-LO-ESTARYLLA 88

TRI-LO-MARZIA 88

TRI-LO-SPRINTEC 88

TRI-MILI 88

TRI-PREVIFEM 88

TRI-SPRINTEC 88

TRI-VYLIBRA 88

TRI-VYLIBRA LO 88

triamcinolone acetonide 16

triamterene/hydrochlorothiazide 74

TRIDERM 16

trifluoperazine hcl 54

trifluridine 11

trihexyphenidyl hcl 51

TRIJARDY XR 26

TRIKAFTA 71

TRIKLO 33

TRILYTE WITH FLAVOR PACKETS 79

trimethobenzamide hcl 27


trimethoprim 10

TRINATE 110

TRINTELLIX 24

TRIUMEQ 55

TRIVORA-28 88

trospium chloride 80

TRULICITY 26

TRUMENBA 60

TRUVADA 55

TULANA 88

TURALIO 48

TWINRIX 60

TYBOST 99

TYKERB 48

TYMLOS 100

TYVASO 104

TYVASO REFILL KIT 104

TYVASO STARTER KIT 104

UUDENYCA 65

UPTRAVI 104

urea 106

ursodiol 79

VV-GO 20 73

V-GO 30 73

V-GO 40 73

valacyclovir hcl 62

VALCHLOR 48

valganciclovir hcl 62

valproic acid 22

valproic acid (as sodium salt) (valproate sodium) 22

valsartan 102

valsartan/hydrochlorothiazide 102

VALTOCO 63

vancomycin hcl 18

VAQTA 60

VARIVAX VACCINE 60

VASCEPA 33

VAXCHORA ACTIVE COMPONENT 60

VAXCHORA BUFFER COMPONENT 101

VAXCHORA VACCINE 60

VELETRI 104

VELIVET 88

VEMLIDY 62

venlafaxine hcl 24

VENTAVIS 104

VENTOLIN HFA 64

verapamil hcl 66

VERSACLOZ 53

VERZENIO 48

VGO 20 73

VGO 30 73

VGO 40 73

VICTOZA 2-PAK 26

VICTOZA 3-PAK 26

VIENVA 88

vigabatrin 22

VIGADRONE 22

VIIBRYD 25

VIMPAT 22

VIORELE 88

VIREAD 55

VISTOGARD 91

VITRAKVI 48,49

VIVOTIF 60

VIZIMPRO 49

VONVENDI 32

voriconazole 28

VORTEX 74

VOSEVI 82

VOTRIENT 49

VRAYLAR 53

VUMERITY 97

VYFEMLA 88

VYLIBRA 88

VYNDAMAX 66

VYNDAQEL 66

VYVANSE 9


Wwarfarin sodium 19

WERA 88

WILATE 32

XXALKORI 49

XARELTO 19,20

XENICAL 80

XENLETA 18

XERMELO 79

XIFAXAN 18

XOSPATA 49

XPOVIO 49

XTANDI 50

XULANE 88

XULTOPHY 100-3.6 90

XYNTHA 32

XYNTHA SOLOFUSE 32

XYREM 68

XYWAV 68

YYUVAFEM 77

Zzaleplon 62

ZARAH 88

ZEBUTAL 3

ZEJULA 50

ZELBORAF 50

ZEMAIRA 103

ZENATANE 107

zidovudine 55,56

ZIEXTENZO 65

ZIOPTAN 30

ziprasidone hcl 53

ZIRGAN 11

ZOLINZA 50

zolpidem tartrate 62

zonisamide 22

ZONTIVITY 56

ZOSTAVAX 60

ZOVIA 1-35E 88

ZYKADIA 50


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