Individual & Small Group Preferred Drug List

Individual & Small GroupPreferred Drug List

2022

How to use the Preferred Drug List The Preferred Drug List (PDL) (also known as a Formulary) is a list of prescription drugs covered under your plan. This contains the covered drugs, doses, and dosage forms. This list is not a complete list and additional prescription drugs may be covered. Please note that the PDL is subject to change as new prescription drugs become available, drug categories are reviewed, and as we strive to provide the most effective and valuable therapies available for our members.

Your pharmacy benefit has four prescription drug tiers. The tier is identified on the Preferred Drug List below. These tiers determine your out-of-pocket responsibility and correspond to the copays and/or coinsurance shown on your benefit summary. In most cases, the prescription drugs on the lower tiers will cost less.

Tier 1: Preferred Generics Tier 2: Non-Preferred Generics/Preferred Brands Tier 3: Non-Preferred Brands Tier 4: Specialty (Most specialty drugs require PA and must be filled at the Plan’s designated Specialty Pharmacy)

Tier 5: Preventive (see PRESCRIPTION DRUGS WITH ENHANCED BENEFITS section below)

Please note that prescription drugs covered under the Preventive Drug List* and the Value Preventive Drug List** have no cost to members and are defined below under PRESCRIPTION DRUGS WITH ENHANCED BENEFITS.

If you have any questions about the PDL or your pharmacy benefits please, contact Pharmacy Customer Service at the number listed on the back of your ID Card. Pharmacy Customer Service is available 24 hours/7 days a week/365 days a year. You can also view additional information by logging into the pharmacy member portal. If you need assistance in registering for the portal, please contact Pharmacy Customer Service. The pharmacy member portal provides information such as how to find a pharmacy; look up prescription drug information like benefit tier, limits, and drug interactions; shop for best price of a prescription drug at different pharmacies; check the status of a prescription; print your prescription drug fill history; and how to set up mail order.

HOW PRESCRIPTION DRUGS ARE CHOSEN FOR THE PDL Prescription drugs approved by the United States (U.S.) Food and Drug Administration (FDA) are reviewed and considered for the PDL by the Pharmacy & Therapeutics (P&T) Committee utilizing the following criteria:

a) The prescription drug is effective and medically necessary for the treatment, maintenance, and/or prevention of a specific medical condition

b) The PDL does not have other alternatives or similar prescription drugs that could be used in its place c) The prescription drug shows a positive therapeutic outcome d) The prescription drug shows safety for medical use

As the FDA approves new prescription drugs, they are reviewed within 180 days against similar drugs available on the PDL before being considered for inclusion. New prescription drugs with an FDA designation of 1P (FDA priority review – potential therapeutic gain) will automatically be reviewed for consideration for the Preferred Drug List. New prescription drugs with an FDA designation of 1S (FDA standard review – no therapeutic gain) may not be reviewed for consideration until a provider/member requests or the next therapeutic class review is done.

In addition, therapeutic classes are reviewed on a regular basis to ensure the Preferred Drug List includes the most effective and valuable prescription drugs.

Members will receive notices related to drug formulary changes at the point of sale when filling a prescription that is impacted by modifications to the PDL. Network pharmacies are required to inform the member of these messages regarding updates or changes to the program which may impact a member. In addition, members whose prescription drugs have been removed from the PDL or have a negative change such as increased tier or new limits will receive written communication of change.

PRESCRIPTION DRUGS WITH ENHANCED BENEFITS

*PREVENTIVE DRUG (PREV) Certain prescription drugs are considered preventive under the Affordable Care Act (ACA). ACA preventive drugs are covered at 100 percent by the Plan (no patient responsibility); although limits may apply. Drugs available under this benefit

are listed as PREV under Limits & Restrictions. For more information about your preventive drug benefits, please contact Pharmacy Customer Service at the number listed on the back of your ID Card.

Preventive Drug Benefits Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk

Birth control as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV

Immunizations — doses, recommended ages, and recommended populations vary

Folic acid supplements for women who may become pregnant

Bowel prep for colorectal cancer screening

Smoking cessation medications

Statin preventive medication for adults 40 to 75 at high risk

Breast cancer risk reduction medications

Fluoride supplements for children without fluoride in their water source

**VALUE PREVENTIVE DRUG LIST (VAL) Value Preventive Drugs List provides coverage for designated prescription drugs in specific categories even before you meet your deductible or out-of-pocket expenses. Members will not have any cost-share for prescription drugs listed in our value- based preventive drug list. This is in addition to the no-cost share coverage for preventive drugs listed in the Affordable Care Act (ACA) and expands preventive drug coverage. Drugs available under this benefit are listed as VAL under Limits & Restrictions.

PRESCRIPTION DRUG LIMITS & REQUIREMENTS

AGE Some prescription drugs have a minimum or maximum age limit requirement under the Plan. Only members within those limits are able to fill those prescription drugs.

PRIOR AUTHORIZATION (PA) To ensure appropriate utilization, some generic and brand prescription drugs and all specialty drugs require Prior Authorization to be eligible for coverage under the member’s prescription drug benefit. The P&T Committee establishes the PA criteria. In order for a member to receive coverage for a prescription drug requiring PA, the member or member’s provider should contact Pharmacy Customer Service at the number listed on the back of your ID Card. Your provider will be required to complete a PA form and provide clinical documentation to show why this prescription drug is needed for treatment of your disease state or medical condition. A letter of medical necessity is also recommended. Your provider should also include your diagnosis and previous therapies that have failed in the letter. If a PA is not received or if the prescription drug is filled prior to approval, the cost of the prescription drug will be full member responsibility. In addition, PAs cannot be backdated.

QUANTITY LIMIT (QL) Quantity Limit is a program that ensures members do not receive a prescription for a quantity that exceeds recommended Plan or safety limits. Limits are set because some prescription drugs have the potential to be abused, misused, shared, or have a manufacturer’s limit on the recommended maximum dose. Quantity limits are based on FDA approved dosing, current medical practices, evidence-based clinical guidelines, and peer-reviewed medical literature related to a particular prescription drug. Prior Authorization is required for any quantities that exceed Plan limits.

STEP THERAPY (ST) Step Therapy is a program for prescription drugs that are taken on a regular basis to treat an ongoing medical condition. The program is developed around effectiveness, safety, and value. In ST, the covered prescription drugs are arranged in a series of “steps”. The program typically starts with generic prescription drugs as the “first step.” These generics are rigorously tested and approved by the FDA and allow you to have safe, effective treatment with prescription drug that is more affordable. More expensive brand-name prescription drugs are usually considered in the “second step”. Step Therapy is developed under the guidance and direction of the P&T Committee. They review the most current research on thousands of drugs tested and approved by the FDA for safety and efficacy. The first time you submit a prescription that is not for a first-step drug, your pharmacist will receive a message to tell you that the Plan requires ST. This means if you don’t want to pay full price for your prescription drug, your doctor needs to write a new prescription for a “first-step” drug. With ST, if you’ve already tried and failed the “first-step” drug, can’t take the “first-step” drug (because of an allergy, etc.), and/or your

provider can show medical necessity for the second step products, your provider can submit a request for Prior Authorization review.

ADDITIONAL POLICIES AND PROCESSES

THERAPEUTIC INTERCHANGE (TI) Therapeutic interchange is the practice of replacing, with your physician’s approval, a prescription drug originally prescribed with a chemically different but therapeutically equivalent prescription drug. Prescription drugs used in therapeutic interchange programs are expected to produce similar levels of effectiveness and results. Therapeutic interchange programs are based on scientific evidence. These programs are developed under the guidance of the P&T Committee. The program is designed to work along with other tools that medical professionals use to promote safe and effective drug therapy. If therapeutic interchange is required on a prescription drug, your pharmacist will receive a message to request a therapeutic interchange from your provider. If you or your provider feel the interchange is not right for you and you do not want to pay full price for your prescription, your provider can submit a request for Prior Authorization review.

BRAND-GENERIC CHARGE (Ancillary Charge) A Brand-Generic Charge is applied to your cost if you receive a brand name prescription drug, regardless of reason or medical necessity, if your provider prescribes a brand name drug when a generic is available. A Brand-Generic Charge is the difference between the cost of the generic and the cost of the brand name prescription drug. This penalty is in addition to the regular cost sharing outlined in your benefits summary. The Brand-Generic Charge does not apply towards Deductibles or Out-of-Pocket Maximum.

MANDATORY GENERIC The Plan mandates generic prescription drugs wherever available. If a brand-name prescription drug is requested when a generic is available, the generic will be available without a Prior Authorization. If brand is still desired, PA will be required, even if not indicated on the PDL below. If brand is approved through the PA process, the Brand-Generic penalty will still be applied.

MAIL ORDER Mail order is when a 90-day supply of a generic or brand name prescription drug is mailed directly to you through a designated Mail Order Pharmacy. Not all prescription drugs are available through Mail Order. Contact Pharmacy Customer Service at the number listed on the back of your ID card for more information or to get started on the Mail Order program.

SPECIALTY PHARMACY The Plan requires that all prescription drugs noted as Specialty must be filled through the Plan’s designated Specialty Pharmacies. These drugs are usually listed on Tier 4, but certain generics of brand name specialty products may be placed in a lower tier but still be considered specialty. In cases where prescription drugs are available only through a limited distribution channel from the manufacturer, these prescription drugs will be directed by the Plan to anther designated specialty pharmacy.

OFF-LABEL USE OF PRESCRIPTION DRUGS The FDA requires that prescription drugs used in the U.S. be safe and effective. The label information of a prescription drug outlines use for "approved" doses and specific conditions or disease states. The use of a prescription drug for a disease state or condition not listed on the label, or in a dose or therapy not listed on the label, is considered to be a "non- approved" or "off-label" use of the prescription drug. Off-label use of a prescription drug is not covered unless it meets the Plan’s off-label use policy. A Prior Authorization is required when a prescription drug is used outside of its FDA indication, dosage, or treatment. Coverage will be reviewed under the off-label use policy and subject to the same conditions and limitations as any other prescription drug. Therapies deemed investigational or experimental are not a covered benefit.

NON-FORMULARY (not covered) OR EXCEPTON REQUESTS FOR PRESCRIPTION DRUGS For prescription drugs that are not covered by the Plan (non-formulary), you or your provider can submit an exception request. Your provider will be required to complete a formulary exception form and provide clinical documentation to show why this prescription drug is needed/required for treatment of your disease state or medical condition. A letter of medical necessity is also recommended. Your provider should also include in his/her letter your diagnosis and previous therapies that have been tried and failed. If an exception request approval is not received or the prescription drug is filled prior to approval, the cost of the prescription drug will be full member responsibility. Contact Pharmacy Customer Service at the number listed on the back of your ID card for more information.

PAPER CLAIMS FILING LIMITS Point-of-sale claims are generally submitted electronically at the time of dispensing. However, there may be mitigating reasons that require a claim to be submitted via a paper claim after being dispensed. The timely filing limit for paper claims submission is within 365 days from the date of service for all original claims. Paper claims will be reimbursed based on what the contractual discount would have been if claim had processed through the system, so member will be responsible for any difference in paid cost.

TIER DESCRIPTION

1 Preferred Generics

2Preferred Brands/Non-

Preferred Generics

3 Non-Preferred Brands

4 Specialty

5 Preventative

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.

GL Gender LimitThis prescription drug may only be covered for a single

gender.

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

minimum or maximum age limit.

MFL Max Fill LimitThere is a limit on the number of times this drug can be

refilled.

MDS Max Days Supply There is a limit on the amount of this drug that is covered.

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.

PREV Preventative

Certain medications are considered preventive under the

Affordable Care Act (ACA). ACA preventive drugs are covered

at 100 percent (no patient responsibility), although limits

may apply. For more information about your preventive

drug benefits, please contact Pharmacy Customer Service at

the number listed on the back of your ID Card.PAGE 1 LAST UPDATED 04/2022

VAL Value Preventive List

Value Preventive Drugs List provides coverage for

designated prescription drugs in specific categories even

before you meet your deductible or out-of-pocket expenses.

Members will not have any cost-share for prescription drugs

listed in our value-based preventive drug list. This is in

addition to the no-cost share coverage for preventive drugs

listed in the Affordable Care Act (ACA) and expands

preventive drug coverage.

PAGE 2 LAST UPDATED 04/2022

LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS

clonidine hcl er 0.1 mg tab er 12h 1

guanfacine hcl er 1 mg tab er 24h 1 QL 30 / 30 DAYS




ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR

atomoxetine hcl 10 mg cap 1 QL 60 / 30 DAYS







AMPHETAMINE MIXTURES

amphetamine-dextroamphet er 10 mg cap er 24h 1 QL 60 / 30 DAYS






amphetamine-dextroamphetamine 10 mg tab 1 QL 90 / 30 DAYS

amphetamine-dextroamphetamine 12.5 mg tab 1 QL 90 / 30 DAYS



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS




amphetamine-dextroamphetamine 7.5 mg tab 1 QL 90 / 30 DAYS

AMPHETAMINESADZENYS ER 1.25 MG/ML SUSPamphetamine

3 PA

ADZENYS XR-ODT 12.5 MG TAB ER DISPamphetamine

3

QL 60 / 30 DAYS

PA

AL1 At least 6 yrs old


3

QL 60 / 30 DAYS

PA



3

QL 60 / 30 DAYS

PA



3

QL 60 / 30 DAYS

PA



3

QL 60 / 30 DAYS

PA



3

QL 60 / 30 DAYS

PA


AMPHETAMINE ER 1.25 MG/ML SUSPamphetamine

3 PA

amphetamine sulfate 10 mg tab 1 QL 60 / 30 DAYS

amphetamine sulfate 5 mg tab 1 QL 120 / 30 DAYS



dextroamphetamine sulfate 10 mg tab 1 QL 90 / 30 DAYS

dextroamphetamine sulfate 5 mg tab 1 QL 90 / 30 DAYS

dextroamphetamine sulfate er 10 mg cap er 24h 1 QL 60 / 30 DAYS



VYVANSE 10 MG CAPlisdexamfetamine dimesylate

2 QL 30 / 30 day(s)

VYVANSE 10 MG CHEW TABlisdexamfetamine dimesylate

2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)

DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)SUNOSI 150 MG TABsolriamfetol hcl

3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSUNOSI 75 MG TABsolriamfetol hcl

3 PA

STIMULANTS - MISC.

armodafinil 150 mg tab 1 QL 30 / 30 DAYS




dexmethylphenidate hcl 10 mg tab 1 QL 90 / 30 DAYS

dexmethylphenidate hcl 2.5 mg tab 1 QL 90 / 30 DAYS

dexmethylphenidate hcl 5 mg tab 1 QL 90 / 30 DAYS

dexmethylphenidate hcl er 10 mg cap er 24h 1 QL 60 / 30 DAYS








metadate er 20 mg tab er 2 QL 60 / 30 DAYS

methylphenidate hcl 10 mg chew tab 1 QL 90 / 30 DAYS

methylphenidate hcl 10 mg tab 1 QL 90 / 30 DAYS

methylphenidate hcl 10 mg/5ml solution 1 QL 1350 / 30 DAYS

methylphenidate hcl 2.5 mg chew tab 1 QL 90 / 30 DAYS


methylphenidate hcl 5 mg chew tab 1 QL 90 / 30 DAYS




methylphenidate hcl 5 mg/5ml solution 1 QL 2700 / 30 DAYS

methylphenidate hcl er (cd) 10 mg cap er 2 QL 60 / 30 DAYS






methylphenidate hcl er (la) 20 mg cap er 24h 2 QL 60 / 30 DAYS



methylphenidate hcl er 10 mg tab er 2 QL 60 / 30 DAYS


METHYLPHENIDATE HCL ER 18 MG TAB ER 24Hmethylphenidate hcl

2 QL 30 / 30 DAYS



methylphenidate hcl er 27 mg tab er 24h 2 QL 30 / 30 DAYS

methylphenidate hcl er 36 mg tab er 2 QL 2 / 1 day(s)

methylphenidate hcl er 36 mg tab er 24h 2 QL 2 / 1 day(s)


methylphenidate hcl er 54 mg tab er 24h 2 QL 30 / 30 DAYS

METHYLPHENIDATE HCL ER 72 MG TAB ERmethylphenidate hcl

2 QL 30 / 30 DAYS

modafinil 100 mg tab 1 QL 30 / 30 DAYS



modafinil 200 mg tab 1 QL 30 / 30 DAYS

QUILLICHEW ER 20 MG CHERmethylphenidate hcl

3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA

QUILLIVANT XR 25 MG/5ML SRERmethylphenidate hcl

2QL 540 / 30 DAYS

AL1 Up to 8 yrs old

ALLERGENIC EXTRACTS/BIOLOGICALS MISCBIOLOGICALS MISC

ADAGEN 250 UNIT/ML SOLUTIONpegademase bovine

4PA

S

AMINOGLYCOSIDESneomycin sulfate 500 mg tab 1

TOBI PODHALER 28 MG CAPtobramycin

4PA

S

TOBRAMYCIN 300 MG/5ML NEBU SOLNtobramycin

4PA

S

tobramycin 300 mg/5ml nebu soln 4PA

S

tobramycin sulfate 1.2 gm recon soln 4PA

S

tobramycin sulfate 1.2 gm/30ml solution 4PA

S

TOBRAMYCIN SULFATE 10 MG/ML SOLUTIONtobramycin sulfate

4PA

S

TOBRAMYCIN SULFATE 2 GM/50ML SOLUTIONtobramycin sulfate

4PA

S



tobramycin sulfate 80 mg/2ml solution 4PA

S

ANALGESICS - ANTI-INFLAMMATORYANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

HUMIRA 10 MG/0.1ML PREF SY KTadalimumab

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

HUMIRA PEDIATRIC CROHNS START 40 MG/0.8ML PREFSY KTadalimumab

4PA

S

HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML &40MG/0.4ML PREF SY KTadalimumab

4PA

S

HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML PREFSY KTadalimumab

4PA

S

HUMIRA PEN 40 MG/0.4ML PEN KITadalimumab

4PA

S


4PA

S


4PA

S



HUMIRA PEN-CD/UC/HS STARTER 40 MG/0.8ML PEN KITadalimumab

4PA

S

HUMIRA PEN-CD/UC/HS STARTER 80 MG/0.8ML PEN KITadalimumab

4PA

S

HUMIRA PEN-PEDIATRIC UC START 80 MG/0.8ML PEN KITadalimumab

4PA

S

HUMIRA PEN-PS/UV/ADOL HS START 40 MG/0.8ML PENKITadalimumab

4PA

S

HUMIRA PEN-PSOR/UVEIT STARTER 80 MG/0.8ML &40MG/0.4ML PEN KITadalimumab

4PA

S

SIMPONI 100 MG/ML SOLN A-INJgolimumab

4PA

S

SIMPONI 100 MG/ML SOLN PRSYRgolimumab

4PA

S

SIMPONI 50 MG/0.5ML SOLN A-INJgolimumab

4PA

S

SIMPONI 50 MG/0.5ML SOLN PRSYRgolimumab

4PA

S

ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS

OLUMIANT 1 MG TABbaricitinib

4PA

S

OLUMIANT 2 MG TABbaricitinib

4PA

S

RINVOQ 15 MG TAB ER 24Hupadacitinib

4PA

S

XELJANZ 1 MG/ML SOLUTIONtofacitinib citrate

4PA

S

XELJANZ 10 MG TABtofacitinib citrate

4PA

S



XELJANZ 5 MG TABtofacitinib citrate

4PA

S

XELJANZ XR 11 MG TAB ER 24Htofacitinib citrate

4PA

S

XELJANZ XR 22 MG TAB ER 24Htofacitinib citrate

4PA

S

ANTIRHEUMATIC ANTIMETABOLITESOTREXUP 10 MG/0.4ML SOLN A-INJmethotrexate (antirheumatic)

3 PA

OTREXUP 12.5 MG/0.4ML SOLN A-INJmethotrexate (antirheumatic)

3 PA

OTREXUP 15 MG/0.4ML SOLN A-INJmethotrexate (antirheumatic)

3 PA


3 PA


3 PA


3 PA


3 PA

RASUVO 10 MG/0.2ML SOLN A-INJmethotrexate (antirheumatic)

2

RASUVO 12.5 MG/0.25ML SOLN A-INJmethotrexate (antirheumatic)

2


2


2


2


2


2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSRASUVO 30 MG/0.6ML SOLN A-INJmethotrexate (antirheumatic)

2


2

REDITREX 10 MG/0.4ML SOLN PRSYRmethotrexate (antirheumatic)

3 PA

REDITREX 12.5 MG/0.05ML SOLN PRSYRmethotrexate (antirheumatic)

3 PA


3 PA


3 PA


3 PA


3 PA

REDITREX 25 MG/ML SOLN PRSYRmethotrexate (antirheumatic)

3 PA


3 PA

CYCLOOXYGENASE 2 (COX-2) INHIBITORScelecoxib 100 mg cap 1

celecoxib 200 mg cap 1 QL 60 / 30 DAYS

celecoxib 400 mg cap 1 QL 60 / 30 DAYS

celecoxib 50 mg cap 1

GOLD COMPOUNDS

RIDAURA 3 MG CAPauranofin

4PA

S

INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)

KINERET 100 MG/0.67ML SOLN PRSYRanakinra

4PA

S

INTERLEUKIN-6 RECEPTOR INHIBITORS

ACTEMRA 162 MG/0.9ML SOLN PRSYRtocilizumab

4PA

S



ACTEMRA ACTPEN 162 MG/0.9ML SOLN A-INJtocilizumab

4PA

S

NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONSdiclofenac-misoprostol 50-0.2 mg tab dr 1

diclofenac-misoprostol 75-0.2 mg tab dr 1

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)cataflam 50 mg tab 1

diclofenac potassium 50 mg tab 1

diclofenac sodium 25 mg tab dr 1



diclofenac sodium er 100 mg tab er 24h 1

etodolac 200 mg cap 1

etodolac 300 mg cap 1

etodolac 400 mg tab 1

etodolac 500 mg tab 1

etodolac er 400 mg tab er 24h 1



FENOPROFEN CALCIUM 400 MG CAPfenoprofen calcium

1

fenoprofen calcium 600 mg tab 1

flurbiprofen 100 mg tab 1

FLURBIPROFEN 50 MG TABflurbiprofen

1

flurbiprofen 50 mg tab 1

ibu 400 mg tab 1

ibu 600 mg tab 1

ibu 800 mg tab 1



ibuprofen 400 mg tab 1



INDOCIN 25 MG/5ML SUSPENSIONindomethacin

3 AL1 Up to 8 yrs old

indomethacin 25 mg cap 1 QL 120 / 30 DAYS

indomethacin 50 mg cap 1

indomethacin er 75 mg cap er 1

KETOPROFEN 50 MG CAPketoprofen

1

KETOPROFEN 75 MG CAPketoprofen

1

ketorolac tromethamine 10 mg tab 1

QL 20 / 0 DAYS

MFL 1 / 30 day(s)MD 5 / 1 day(s)

ketorolac tromethamine 60 mg/2ml solution 1 QL 4 / 28 DAYS

MECLOFENAMATE SODIUM 100 MG CAPmeclofenamate sodium

1

MECLOFENAMATE SODIUM 50 MG CAPmeclofenamate sodium

1

mefenamic acid 250 mg cap 1

meloxicam 15 mg tab 1 QL 30 / 30 DAYS

meloxicam 7.5 mg tab 1 QL 30 / 30 DAYS

nabumetone 500 mg tab 1

nabumetone 750 mg tab 1

naproxen 125 mg/5ml suspension 1

naproxen 250 mg tab 1


naproxen 375 mg tab dr 1




naproxen 500 mg tab dr 1

naproxen sodium 275 mg tab 1

naproxen sodium 550 mg tab 1

oxaprozin 600 mg tab 1

piroxicam 10 mg cap 1

piroxicam 20 mg cap 1

relafen 500 mg tab 1

relafen 750 mg tab 1

sulindac 150 mg tab 1

sulindac 200 mg tab 1

TOLMETIN SODIUM 200 MG TABtolmetin sodium

2

TOLMETIN SODIUM 400 MG CAPtolmetin sodium

2

TOLMETIN SODIUM 600 MG TABtolmetin sodium

2

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

OTEZLA 10 & 20 & 30 MG TAB THPKapremilast

4PA

S

OTEZLA 30 MG TABapremilast

4PA

S

PYRIMIDINE SYNTHESIS INHIBITORS

leflunomide 10 mg tab 1 QL 30 / 30 DAYS

leflunomide 20 mg tab 1 QL 30 / 30 DAYS

SELECTIVE COSTIMULATION MODULATORS

ORENCIA 125 MG/ML SOLN PRSYRabatacept

4PA

S

ORENCIA 50 MG/0.4ML SOLN PRSYRabatacept

4PA

S

ORENCIA 87.5 MG/0.7ML SOLN PRSYRabatacept

4PA

S



ORENCIA CLICKJECT 125 MG/ML SOLN A-INJabatacept

4PA

S

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS

ENBREL 25 MG RECON SOLNetanercept

4PA

S

ENBREL 25 MG/0.5ML SOLN PRSYRetanercept

4PA

S

ENBREL 25 MG/0.5ML SOLUTIONetanercept

4PA

S

ENBREL 50 MG/ML SOLN PRSYRetanercept

4PA

S

ENBREL MINI 50 MG/ML SOLN CARTetanercept

4PA

S

ENBREL SURECLICK 50 MG/ML SOLN A-INJetanercept

4PA

S

ANALGESICS - NONNARCOTICANALGESICS-SEDATIVES

bac 50-325-40 mg tab 1

butalbital-acetaminophen 50-325 mg tab 1

butalbital-apap 50-325 mg tab 1

butalbital-apap-caffeine 50-300-40 mg cap 1 QL 180 / 30 DAYS

butalbital-apap-caffeine 50-325-40 mg cap 1 QL 180 / 30 DAYS

butalbital-apap-caffeine 50-325-40 mg tab 1

butalbital-aspirin-caffeine 50-325-40 mg cap 1

BUTALBITAL-ASPIRIN-CAFFEINE 50-325-40 MG TABbutalbital-aspirin-caffeine

1

esgic 50-325-40 mg cap 1 QL 180 / 30 DAYS

phrenilin forte 50-300-40 mg cap 1 QL 180 / 30 DAYS



zebutal 50-325-40 mg cap 1 QL 180 / 30 DAYS

SALICYLATESdiflunisal 500 mg tab 1

salsalate 500 mg tab 1

ANALGESICS - OPIOIDCODEINE COMBINATIONS

acetaminophen-codeine #2 300-15 mg tab 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYSMD 7 / 1 DAY

acetaminophen-codeine #3 300-30 mg tab 1QL 240 / 30 DAYS

MFL 1 / 60 DAYS

acetaminophen-codeine #4 300-60 mg tab 1QL 180 / 30 DAYS

MFL 1 / 60 DAYS

acetaminophen-codeine 120-12 mg/5ml solution 1

QL 450 / 30 DAYS


acetaminophen-codeine 300-15 mg tab 1QL 240 / 30 DAYSMD 7 / 1 DAY

acetaminophen-codeine 300-30 mg tab 1 QL 240 / 30 DAYS

acetaminophen-codeine 300-60 mg tab 1 QL 180 / 30 DAYS

ascomp-codeine 50-325-40-30 mg cap 1 QL 180 / 30 DAYS

butalbital-apap-caff-cod 50-300-40-30 mg cap 1 QL 180 / 30 DAYS

butalbital-apap-caff-cod 50-325-40-30 mg cap 1 QL 180 / 30 DAYS

butalbital-asa-caff-codeine 50-325-40-30 mg cap 1 QL 180 / 30 DAYS

HYDROCODONE COMBINATIONS

hydrocodone-acetaminophen 10-325 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYSMD 7 / 1 day(s)



hydrocodone-acetaminophen 10-325 mg/15ml solution 1QL 5400 / 30 DAYS

AL1 Up to 8 yrs old

hydrocodone-acetaminophen 2.5-108 mg/5ml solution 1QL 450 / 30 DAYSMD 7 / 1 DAY

hydrocodone-acetaminophen 2.5-325 mg tab 1

QL 120 / 30 DAYS


hydrocodone-acetaminophen 5-217 mg/10ml solution 1QL 450 / 30 DAYSMD 7 / 1 DAY

hydrocodone-acetaminophen 5-325 mg tab 1

QL 240 / 30 DAYS



QL 180 / 30 DAYS



QL 180 / 30 DAYS


hydrocodone-acetaminophen 7.5-325 mg/15ml solution 1

QL 450 / 30 DAYS


hydrocodone-ibuprofen 10-200 mg tab 1

QL 120 / 30 DAYS


HYDROCODONE-IBUPROFEN 5-200 MG TABhydrocodone-ibuprofen

1QL 120 / 30 DAYSMD 7 / 1 day(s)

hydrocodone-ibuprofen 5-200 mg tab 1

QL 120 / 30 DAYS




hydrocodone-ibuprofen 7.5-200 mg tab 1

QL 120 / 30 DAYS


ibudone 5-200 mg tab 1QL 120 / 30 DAYSMD 7 / 1 day(s)

lorcet 5-325 mg tab 1QL 240 / 30 DAYSMD 7 / 1 day(s)

lorcet hd 10-325 mg tab 1QL 120 / 30 DAYSMD 7 / 1 day(s)

lorcet plus 7.5-325 mg tab 1QL 180 / 30 DAYSMD 7 / 1 day(s)

OPIOID AGONISTS

ABSTRAL 100 MCG SL TABfentanyl citrate

4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S



alfentanil hcl 1000 mcg/2ml solution 2 PA

CODEINE SULFATE 15 MG TABcodeine sulfate

1

QL 180 / 30 DAYS



1

QL 180 / 30 DAYS


codeine sulfate 30 mg tab 1

QL 180 / 30 DAYS



1

QL 180 / 30 DAYS


codeine sulfate 60 mg tab 1

QL 180 / 30 DAYS


fentanyl 100 mcg/hr patch 72hr 1QL 15 / 30 DAYS

PA


PA


PA

fentanyl 37.5 mcg/hr patch 72hr 1QL 15 / 30 DAYS

PA


PA


PA


PA




PA

FENTANYL CITRATE 100 MCG TABfentanyl citrate

2

QL 112 / 28 DAYS

PA


fentanyl citrate 1200 mcg loz handle 2

QL 120 / 30 DAYS

PA



QL 30 / 30 DAYS

PA



QL 120 / 30 DAYS

PA



2

QL 112 / 28 DAYS

PA



QL 120 / 30 DAYS

PA



2

QL 112 / 28 DAYS

PA



QL 120 / 30 DAYS

PA





2

QL 112 / 28 DAYS

PA



QL 120 / 30 DAYS

PA



2

QL 112 / 28 DAYS

PA


hydrocodone bitartrate er 10 mg cap er 12h 2

HYDROCODONE BITARTRATE ER 10 MG CAP ER 12Hhydrocodone bitartrate

2

hydrocodone bitartrate er 100 mg tb24 deter 2 PA




2


2




2




2






2



hydromorphone hcl 1 mg/ml liquid 1

QL 120 / 30 DAYS


hydromorphone hcl 2 mg tab 1

QL 90 / 30 DAYS



QL 90 / 30 DAYS



QL 90 / 30 DAYS


hydromorphone hcl er 12 mg tab er 24h 2QL 30 / 30 DAYS

PA


PA


PA


PA

LAZANDA 100 MCG/ACT SOLUTIONfentanyl citrate

4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S




4

PAMD 7 / 1 DAY

S

methadone hcl 10 mg tab 1QL 60 / 30 DAYS

PA

METHADONE HCL 10 MG/5ML SOLUTIONmethadone hcl

2QL 240 / 30 DAYS

PA

methadone hcl 10 mg/5ml solution 2QL 240 / 30 DAYS

PA

methadone hcl 10 mg/ml conc 2QL 60 / 30 DAYS

PA

methadone hcl 5 mg tab 1QL 60 / 30 DAYS

PA

METHADONE HCL 5 MG/5ML SOLUTIONmethadone hcl

2QL 240 / 30 DAYS

PA

methadone hcl 5 mg/5ml solution 2QL 240 / 30 DAYS

PA

morphine sulfate (concentrate) 100 mg/5ml solution 1

QL 120 / 30 DAYS


morphine sulfate (concentrate) 20 mg/ml solution 1

QL 120 / 30 DAYS


MORPHINE SULFATE (PF) 2 MG/ML SOLUTIONmorphine sulfate

1

morphine sulfate 10 mg/5ml solution 1

QL 480 / 30 DAYS


MORPHINE SULFATE 15 MG TABmorphine sulfate

1

QL 180 / 30 DAYS

PA




morphine sulfate 15 mg tab 1

QL 180 / 30 DAYS

PAMD 7 / 1 DAY

MORPHINE SULFATE 20 MG/5ML SOLUTIONmorphine sulfate

1

QL 480 / 30 day(s)

AL1 Up to 8 yrs old


morphine sulfate 20 mg/5ml solution 1

QL 480 / 30 day(s)

AL1 Up to 8 yrs old


MORPHINE SULFATE 30 MG TABmorphine sulfate

1

QL 90 / 30 DAYS

PA


morphine sulfate 30 mg tab 1

QL 90 / 30 DAYS

PAMD 7 / 1 DAY

morphine sulfate er 10 mg cap er 24h 2QL 60 / 30 DAYS

PA

MORPHINE SULFATE ER 10 MG CAP ER 24Hmorphine sulfate

2QL 60 / 30 day(s)

PA


PA


2QL 60 / 30 day(s)

PA

morphine sulfate er 15 mg tab er 1QL 90 / 30 DAYS

PA


PA




2QL 60 / 30 day(s)

PA


PA


PA


2QL 60 / 30 day(s)

PA


PA


2QL 60 / 30 DAYS

PA


PA


2QL 60 / 30 day(s)

PA


PA


2QL 60 / 30 day(s)

PA


PA


2QL 60 / 30 day(s)

PA

MORPHINE SULFATE ER BEADS 120 MG CAP ER 24Hmorphine sulfate beads

2QL 30 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA




2QL 30 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA


2QL 30 / 30 DAYS

PA


2QL 30 / 30 DAYS

PA

NUCYNTA 100 MG TABtapentadol hcl

3

QL 90 / 30 day(s)

PA



3

QL 90 / 30 day(s)

PA



3

QL 90 / 30 day(s)

PA


NUCYNTA ER 100 MG TAB ER 12Htapentadol hcl

3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA



oxycodone hcl 10 mg tab 1

QL 90 / 30 DAYS


oxycodone hcl 100 mg/5ml conc 1

QL 90 / 30 day(s)



QL 90 / 30 DAYS



QL 90 / 30 DAYS



QL 90 / 30 DAYS


oxycodone hcl 5 mg cap 1

QL 240 / 30 DAYS



QL 240 / 30 DAYS


oxycodone hcl 5 mg/5ml solution 1

QL 1800 / 30 DAYS


OXYCODONE HCL ER 10 MG TB12 DETERoxycodone hcl

1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS


1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS




1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS


1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS


1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS


1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS


1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS

OXYCONTIN 10 MG TB12 DETERoxycodone hcl

3QL 60 / 30 DAYS

PA


3QL 60 / 30 day(s)

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 day(s)

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 day(s)

PA


3QL 60 / 30 DAYS

PA



oxymorphone hcl 10 mg tab 1

QL 90 / 30 DAYS


oxymorphone hcl 5 mg tab 1

QL 60 / 30 DAYS


OXYMORPHONE HCL ER 10 MG TAB ER 12Hoxymorphone hcl

1QL 60 / 30 DAYS

PA


1QL 60 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA


1QL 60 / 30 DAYS

PA

OXYMORPHONE HCL ER 7.5 MG TAB ER 12Hoxymorphone hcl

1QL 60 / 30 DAYS

PA

SUBSYS 100 MCG LIQUIDfentanyl

4

PA


S


4

PA


S


4

PA


S




4

PA


S


4

PA


S

tramadol hcl 50 mg tab 1 QL 240 / 30 DAYS

tramadol hcl er (biphasic) 100 mg tab er 24h 1QL 30 / 30 day(s)

PA

TRAMADOL HCL ER (BIPHASIC) 100 MG TAB ER 24Htramadol hcl

1QL 30 / 30 day(s)

PA


PA


1QL 30 / 30 day(s)

PA


PA


1QL 30 / 30 day(s)

PA

TRAMADOL HCL ER 100 MG CAP ER 24Htramadol hcl

1QL 30 / 30 DAYS

PA

tramadol hcl er 100 mg tab er 24h 1QL 30 / 30 DAYS

PA


1QL 30 / 30 DAYS

PA


1QL 30 / 30 DAYS

PA




PA


PA

OPIOID COMBINATIONS

endocet 10-325 mg tab 1QL 120 / 30 DAYSMD 7 / 1 day(s)

endocet 2.5-325 mg tab 1QL 240 / 30 DAYSMD 7 / 1 day(s)

endocet 5-325 mg tab 1QL 240 / 30 DAYSMD 7 / 1 day(s)

endocet 7.5-325 mg tab 1QL 180 / 30 DAYSMD 7 / 1 day(s)

oxycodone-acetaminophen 10-325 mg tab 1

QL 120 / 30 DAYS


oxycodone-acetaminophen 2.5-325 mg tab 1

QL 240 / 30 DAYS


oxycodone-acetaminophen 5-325 mg tab 1

QL 240 / 30 DAYS


oxycodone-acetaminophen 7.5-325 mg tab 1

QL 180 / 30 DAYS


OXYCODONE-IBUPROFEN 5-400 MG TABoxycodone-ibuprofen

2QL 120 / 30 DAYSMD 7 / 1 DAY

OPIOID PARTIAL AGONISTS

buprenorphine 10 mcg/hr patch wk 1 QL 4 / 28 DAYS






buprenorphine 7.5 mcg/hr patch wk 1 QL 4 / 28 DAYS

buprenorphine hcl 2 mg sl tab 1 QL 90 / 30 DAYS

buprenorphine hcl 8 mg sl tab 1 QL 90 / 30 DAYS

buprenorphine hcl-naloxone hcl 12-3 mg film 1 QL 60 / 30 DAYS

buprenorphine hcl-naloxone hcl 2-0.5 mg film 1

buprenorphine hcl-naloxone hcl 2-0.5 mg sl tab 1 QL 90 / 30 DAYS



buprenorphine hcl-naloxone hcl 8-2 mg sl tab 1 QL 90 / 30 DAYS

butorphanol tartrate 10 mg/ml solution 1QL 2.5 / 30 DAYSMD 7 / 1 day(s)

nalbuphine hcl 10 mg/ml solution 2 PA

SUBLOCADE 100 MG/0.5ML SOLN PRSYRbuprenorphine

3 S

SUBLOCADE 300 MG/1.5ML SOLN PRSYRbuprenorphine

3 S

TRAMADOL COMBINATIONS

tramadol-acetaminophen 37.5-325 mg tab 1 QL 120 / 30 DAYS

ANDROGENS-ANABOLICANABOLIC STEROIDS

ANADROL-50 50 MG TABoxymetholone

4PA

S

oxandrolone 2.5 mg tab 1 PA



ANDROGENSdanazol 100 mg cap 2

danazol 200 mg cap 2

danazol 50 mg cap 2

DEPO-TESTOSTERONE 100 MG/ML SOLUTIONtestosterone cypionate

2

DEPO-TESTOSTERONE 200 MG/ML SOLUTIONtestosterone cypionate

2

METHITEST 10 MG TABmethyltestosterone

2 PA

methyltestosterone 10 mg cap 2 PA

testosterone 1.62 % gel 1 QL 150 / 30 DAYS

TESTOSTERONE 12.5 MG/ACT (1%) GELtestosterone

1

testosterone 12.5 mg/act (1%) gel 1

testosterone 20.25 mg/1.25gm (1.62%) gel 1 QL 37.5 / 30 DAYS

testosterone 20.25 mg/act (1.62%) gel 1 QL 150 / 30 DAYS

TESTOSTERONE 25 MG/2.5GM (1%) GELtestosterone

1

testosterone 25 mg/2.5gm (1%) gel 1

testosterone 30 mg/act solution 1 QL 180 / 30 DAYS

TESTOSTERONE 50 MG/5GM (1%) GELtestosterone

1

testosterone 50 mg/5gm (1%) gel 1

TESTOSTERONE CYPIONATE 100 MG/ML SOLUTIONtestosterone cypionate

1

testosterone cypionate 100 mg/ml solution 1

TESTOSTERONE CYPIONATE 200 MG/ML SOLUTIONtestosterone cypionate

1

testosterone cypionate 200 mg/ml solution 2

TESTOSTERONE ENANTHATE 200 MG/ML SOLUTIONtestosterone enanthate

1



testosterone enanthate 200 mg/ml solution 1

ANORECTAL AND RELATED PRODUCTSINTRARECTAL STEROIDS

colocort 100 mg/60ml enema 1

hydrocortisone 100 mg/60ml enema 1

UCERIS 2 MG/ACT FOAMbudesonide (intrarectal)

3 QL 133.6 / 30 day(s)

NITRATE VASODILATING AGENTS

RECTIV 0.4 % OINTMENTnitroglycerin (intra-anal)

3QL 30 / 30 day(s)

PA

RECTAL ANESTHETIC/STEROIDSlidocaine-hydrocort (perianal) 3-0.5 % cream 1

lidocort 3-0.5 % cream 1

RECTAL STEROIDSanucort-hc 25 mg suppos 1

anusol-hc 25 mg suppos 1

hemmorex-hc 25 mg suppos 1

hemmorex-hc 30 mg suppos 1

hydrocortisone (perianal) 2.5 % cream 1

hydrocortisone acetate 25 mg suppos 1

hydrocortisone acetate 30 mg suppos 1

procto-med hc 2.5 % cream 1

proctosol hc 2.5 % cream 1

proctozone-hc 2.5 % cream 1

ANTHELMINTICS

albendazole 200 mg tab 2QL 120 / 30 DAYS

PA

EMVERM 100 MG CHEW TABmebendazole

3QL 6 / 3 DAYS

PA



ivermectin 3 mg tab 1

QL 6 / 1 day(s)

MFL 1 / 365 day(s)MD 2 / 1 day(s)

praziquantel 600 mg tab 2

ANTI-INFECTIVE AGENTS - MISC.metronidazole 250 mg tab 1

metronidazole 375 mg cap 1

metronidazole 500 mg tab 1

pentamidine isethionate 300 mg recon soln 1

PRIMSOL 50 MG/5ML SOLUTIONtrimethoprim hcl


tinidazole 500 mg tab 1

TRIMETHOPRIM 100 MG TABtrimethoprim

1

trimethoprim 100 mg tab 1

XIFAXAN 200 MG TABrifaximin

3QL 9 / 30 DAYS

PA

XIFAXAN 550 MG TABrifaximin

3QL 90 / 30 DAYS

PA

ANTI-INFECTIVE MISC. - COMBINATIONSsulfamethoxazole-trimethoprim 200-40 mg/5mlsuspension

1

sulfamethoxazole-trimethoprim 400-80 mg tab 1

sulfamethoxazole-trimethoprim 400-80 mg/5ml solution 1

sulfamethoxazole-trimethoprim 800-160 mg tab 1

sulfatrim pediatric 200-40 mg/5ml suspension 1

ANTIPROTOZOAL AGENTSALINIA 100 MG/5ML RECON SUSPnitazoxanide

3 PA

atovaquone 750 mg/5ml suspension 2

LAMPIT 120 MG TABnifurtimox

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSLAMPIT 30 MG TABnifurtimox

3

nitazoxanide 500 mg tab 2QL 20 / 10 day(s)

PA

CARBAPENEM COMBINATIONS

imipenem-cilastatin 250 mg recon soln 1 PA

GLYCOPEPTIDES

vancomycin hcl 125 mg cap 2 QL 56 / 14 DAYS

vancomycin hcl 250 mg cap 2 QL 56 / 14 DAYS

LEPROSTATICSdapsone 100 mg tab 1

dapsone 25 mg tab 1

LINCOSAMIDESclindamycin hcl 150 mg cap 1

clindamycin hcl 300 mg cap 1

clindamycin hcl 75 mg cap 1

clindamycin palmitate hcl 75 mg/5ml recon soln 1

MONOBACTAMS

CAYSTON 75 MG RECON SOLNaztreonam lysine

4PA

S

OXAZOLIDINONES

linezolid 600 mg tab 1 QL 56 / 28 DAYS

SIVEXTRO 200 MG TABtedizolid phosphate

4PA

S

URINARY ANTI-INFECTIVESfosfomycin tromethamine 3 gm packet 2

methenamine hippurate 1 gm tab 1

nitrofurantoin 25 mg/5ml suspension 1 AL1 Up to 8 yrs old

nitrofurantoin macrocrystal 100 mg cap 1





nitrofurantoin monohyd macro 100 mg cap 1

ANTIANGINAL AGENTSANTIANGINALS-OTHER

ranolazine er 1000 mg tab er 12h 1 QL 60 / 30 DAYS

ranolazine er 500 mg tab er 12h 1 QL 60 / 30 DAYS

NITRATESDILATRATE-SR 40 MG CAP ERisosorbide dinitrate

3 PA

isosorbide dinitrate 10 mg tab 5 VAL Value Preventive List




ISOSORBIDE DINITRATE ER 40 MG TAB ERisosorbide dinitrate

5 VAL Value Preventive List

isosorbide mononitrate 10 mg tab 5 VAL Value Preventive List

isosorbide mononitrate 20 mg tab 5 VAL Value Preventive List

isosorbide mononitrate er 120 mg tab er 24h 5 VAL Value Preventive List



minitran 0.1 mg/hr patch 24hr 5 VAL Value Preventive List




NITRO-BID 2 % OINTMENTnitroglycerin

2



nitroglycerin 0.1 mg/hr patch 24hr 5 VAL Value Preventive List


nitroglycerin 0.3 mg sl tab 5 VAL Value Preventive List

nitroglycerin 0.4 mg sl tab 5QL 30 / 30 DAYS



nitroglycerin 0.4 mg/spray solution 5 VAL Value Preventive List

nitroglycerin 0.6 mg sl tab 5QL 30 / 30 DAYS



nitroglycerin er 2.5 mg cap er 5 VAL Value Preventive List

nitroglycerin er 6.5 mg cap er 5 VAL Value Preventive List

nitroglycerin er 9 mg cap er 5 VAL Value Preventive List

ANTIANXIETY AGENTSANTIANXIETY AGENTS - MISC.

buspirone hcl 10 mg tab 1




buspirone hcl 7.5 mg tab 1

hydroxyzine hcl 10 mg tab 1

hydroxyzine hcl 10 mg/5ml syrup 1



HYDROXYZINE PAMOATE 100 MG CAPhydroxyzine pamoate

1

hydroxyzine pamoate 25 mg cap 1



hydroxyzine pamoate 50 mg cap 1

meprobamate 200 mg tab 2

meprobamate 400 mg tab 2

BENZODIAZEPINES

alprazolam 0.25 mg tab 1 QL 90 / 30 DAYS

alprazolam 0.25 mg tab disp 1 QL 90 / 30 DAYS

alprazolam 0.5 mg tab 1 QL 5 / 1 day(s)

alprazolam 0.5 mg tab disp 1 QL 90 / 30 DAYS

alprazolam 1 mg tab 1 QL 5 / 1 day(s)

alprazolam 1 mg tab disp 1 QL 90 / 30 DAYS

alprazolam 2 mg tab 1 QL 90 / 30 DAYS

alprazolam 2 mg tab disp 1 QL 90 / 30 DAYS

alprazolam er 0.5 mg tab er 24h 1 QL 90 / 30 DAYS

alprazolam er 1 mg tab er 24h 1 QL 90 / 30 DAYS



ALPRAZOLAM INTENSOL 1 MG/ML CONCalprazolam


alprazolam xr 0.5 mg tab er 24h 1 QL 90 / 30 DAYS

alprazolam xr 1 mg tab er 24h 1 QL 90 / 30 DAYS



chlordiazepoxide hcl 10 mg cap 1



clorazepate dipotassium 15 mg tab 1



clorazepate dipotassium 3.75 mg tab 1

clorazepate dipotassium 7.5 mg tab 1

diazepam 10 mg tab 1 QL 60 / 30 DAYS



diazepam 5 mg/5ml solution 1QL 500 / 30 day(s)

AL1 Up to 8 yrs old

diazepam 5 mg/ml conc 1QL 90 / 30 DAYS

AL1 Up to 8 yrs old

diazepam intensol 5 mg/ml conc 1QL 90 / 30 DAYS

AL1 Up to 8 yrs old

lorazepam 0.5 mg tab 1 QL 5 / 1 day(s)

lorazepam 1 mg tab 1 QL 5 / 1 day(s)

lorazepam 2 mg tab 1 QL 90 / 30 DAYS

lorazepam 2 mg/ml conc 1

lorazepam intensol 2 mg/ml conc 1

oxazepam 10 mg cap 1 QL 90 / 30 day(s)



ANTIARRHYTHMICSANTIARRHYTHMICS TYPE I-A

disopyramide phosphate 100 mg cap 5 VAL Value Preventive List

disopyramide phosphate 150 mg cap 5 VAL Value Preventive List

NORPACE CR 100 MG CAP ER 12Hdisopyramide phosphate

3

NORPACE CR 150 MG CAP ER 12Hdisopyramide phosphate

3



quinidine gluconate er 324 mg tab er 5 VAL Value Preventive List

QUINIDINE SULFATE 200 MG TABquinidine sulfate


quinidine sulfate 200 mg tab 5 VAL Value Preventive List

QUINIDINE SULFATE 300 MG TABquinidine sulfate


quinidine sulfate 300 mg tab 5 VAL Value Preventive List

ANTIARRHYTHMICS TYPE I-Bmexiletine hcl 150 mg cap 1

mexiletine hcl 200 mg cap 1

mexiletine hcl 250 mg cap 1

ANTIARRHYTHMICS TYPE I-C

flecainide acetate 100 mg tab 5 VAL Value Preventive List



propafenone hcl 150 mg tab 5 VAL Value Preventive List



propafenone hcl er 225 mg cap er 12h 5 VAL Value Preventive List



ANTIARRHYTHMICS TYPE III

amiodarone hcl 100 mg tab 5 VAL Value Preventive List



dofetilide 125 mcg cap 2





MULTAQ 400 MG TABdronedarone hcl

3 QL 60 / 30 DAYS

pacerone 100 mg tab 1 VAL Value Preventive List



ANTIASTHMATIC AND BRONCHODILATOR AGENTS5-LIPOXYGENASE INHIBITORS

zileuton er 600 mg tab er 12h 4PA

S

ADRENERGIC COMBINATIONS

ANORO ELLIPTA 62.5-25 MCG/INH AER POW BAumeclidinium-vilanterol

5QL 60 / 30 DAYS


BREO ELLIPTA 100-25 MCG/INH AER POW BAfluticasone furoate-vilanterol

3QL 60 / 30 DAYS

ST

BREO ELLIPTA 200-25 MCG/INH AER POW BAfluticasone furoate-vilanterol

3QL 60 / 30 DAYS

ST

BREZTRI AEROSPHERE 160-9-4.8 MCG/ACT AEROSOLbudesonide-glycopyrrolate-formoterol fumarate

3 PA

COMBIVENT RESPIMAT 20-100 MCG/ACT AERO SOLNipratropium-albuterol

5QL 4 / 30 DAYS


DULERA 100-5 MCG/ACT AEROSOLmometasone furoate-formoterol fumarate dihydrate

5QL 13 / 30 day(s)



5QL 13 / 30 day(s)



5QL 13 / 30 day(s)


fluticasone-salmeterol 100-50 mcg/act aer pow ba 5QL 60 / 30 day(s)



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFLUTICASONE-SALMETEROL 113-14 MCG/ACT AER POWBAfluticasone-salmeterol

5QL 1 / 30 DAYS


FLUTICASONE-SALMETEROL 232-14 MCG/ACT AER POWBAfluticasone-salmeterol

5QL 1 / 30 DAYS






FLUTICASONE-SALMETEROL 55-14 MCG/ACT AER POW BAfluticasone-salmeterol

5QL 1 / 30 DAYS


ipratropium-albuterol 0.5-2.5 (3) mg/3ml solution 5 VAL Value Preventive List

STIOLTO RESPIMAT 2.5-2.5 MCG/ACT AERO SOLNtiotropium bromide-olodaterol hcl

5QL 4 / 30 day(s)


SYMBICORT 160-4.5 MCG/ACT AEROSOLbudesonide-formoterol fumarate dihydrate

5QL 6 / 30 DAYS


SYMBICORT 80-4.5 MCG/ACT AEROSOLbudesonide-formoterol fumarate dihydrate

5QL 6.9 / 30 DAYS


TRELEGY ELLIPTA 100-62.5-25 MCG/INH AER POW BAfluticasone-umeclidinium-vilanterol

5QL 2 / 1 day(s)


TRELEGY ELLIPTA 200-62.5-25 MCG/INH AER POW BAfluticasone-umeclidinium-vilanterol

5QL 2 / 1 day(s)


wixela inhub 100-50 mcg/act aer pow ba 5QL 60 / 30 day(s)








ANTI-IGE MONOCLONAL ANTIBODIES

XOLAIR 150 MG RECON SOLNomalizumab

4PA

S

XOLAIR 150 MG/ML SOLN PRSYRomalizumab

4PA

S

XOLAIR 75 MG/0.5ML SOLN PRSYRomalizumab

4PA

S

ANTI-INFLAMMATORY AGENTS

cromolyn sodium 20 mg/2ml nebu soln 5QL 240 / 30 DAYS


BETA ADRENERGICS

albuterol sulfate (2.5 mg/3ml) 0.083% nebu soln 5QL 360 / 30 DAYS


albuterol sulfate (5 mg/ml) 0.5% nebu soln 5 VAL Value Preventive List

albuterol sulfate 0.63 mg/3ml nebu soln 5QL 360 / 30 DAYS


albuterol sulfate 1.25 mg/3ml nebu soln 5QL 360 / 30 DAYS


albuterol sulfate 2 mg tab 5 VAL Value Preventive List

albuterol sulfate 2 mg/5ml syrup 5 VAL Value Preventive List

albuterol sulfate 2.5 mg/0.5ml nebu soln 5 VAL Value Preventive List

albuterol sulfate 4 mg tab 5 VAL Value Preventive List

ALBUTEROL SULFATE ER 4 MG TAB ER 12Halbuterol sulfate


ALBUTEROL SULFATE ER 8 MG TAB ER 12Halbuterol sulfate


albuterol sulfate hfa 108 (90 base) mcg/act aero soln 5QL 18 / 15 DAYS


ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT AEROSOLNalbuterol sulfate

5QL 18 / 15 DAYS



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSARCAPTA NEOHALER 75 MCG CAPindacaterol maleate

3 QL 30 / 30 DAYS

levalbuterol hcl 0.31 mg/3ml nebu soln 5QL 270 / 30 DAYS


levalbuterol hcl 0.63 mg/3ml nebu soln 5QL 270 / 30 day(s)


levalbuterol hcl 1.25 mg/0.5ml nebu soln 5 VAL Value Preventive List

levalbuterol hcl 1.25 mg/3ml nebu soln 5QL 270 / 30 DAYS


LEVALBUTEROL TARTRATE 45 MCG/ACT AEROSOLlevalbuterol tartrate

5QL 30 / 30 DAYS


METAPROTERENOL SULFATE 10 MG TABmetaproterenol sulfate


METAPROTERENOL SULFATE 10 MG/5ML SYRUPmetaproterenol sulfate

5AL1 Up to 8 yrs old


METAPROTERENOL SULFATE 20 MG TABmetaproterenol sulfate


SEREVENT DISKUS 50 MCG/DOSE AER POW BAsalmeterol xinafoate

5QL 60 / 30 DAYS


STRIVERDI RESPIMAT 2.5 MCG/ACT AERO SOLNolodaterol hcl

3 QL 4 / 30 DAYS

terbutaline sulfate 2.5 mg tab 5 VAL Value Preventive List

terbutaline sulfate 5 mg tab 5 VAL Value Preventive List

BRONCHODILATORS - ANTICHOLINERGICS

ATROVENT HFA 17 MCG/ACT AERO SOLNipratropium bromide hfa

5QL 25.8 / 28 DAYS


INCRUSE ELLIPTA 62.5 MCG/INH AER POW BAumeclidinium bromide

5QL 30 / 30 DAYS


ipratropium bromide 0.02 % solution 5 VAL Value Preventive List

SPIRIVA HANDIHALER 18 MCG CAPtiotropium bromide monohydrate

5QL 90 / DAYS




SPIRIVA RESPIMAT 1.25 MCG/ACT AERO SOLNtiotropium bromide monohydrate

5QL 4 / 30 DAYS


SPIRIVA RESPIMAT 2.5 MCG/ACT AERO SOLNtiotropium bromide monohydrate

5QL 4 / 30 DAYS


YUPELRI 175 MCG/3ML SOLUTIONrevefenacin

3QL 90 / 30 DAYS

PA

INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)

FASENRA 30 MG/ML SOLN PRSYRbenralizumab

4PA

S

FASENRA PEN 30 MG/ML SOLN A-INJbenralizumab

4PA

S

NUCALA 100 MG RECON SOLNmepolizumab

4PA

S

NUCALA 100 MG/ML SOLN A-INJmepolizumab

4PA

S

NUCALA 100 MG/ML SOLN PRSYRmepolizumab

4PA

S

LEUKOTRIENE RECEPTOR ANTAGONISTS

montelukast sodium 10 mg tab 5QL 30 / 30 DAYS


montelukast sodium 4 mg chew tab 5QL 30 / 30 DAYS


montelukast sodium 4 mg packet 5

QL 30 / 30 DAYS

AL1 Up to 4 yrs old


montelukast sodium 5 mg chew tab 5QL 30 / 30 DAYS


zafirlukast 10 mg tab 5QL 60 / 30 DAYS




zafirlukast 20 mg tab 5QL 60 / 30 DAYS


SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

DALIRESP 250 MCG TABroflumilast

3QL 30 / 30 day(s)

PA

DALIRESP 500 MCG TABroflumilast

3QL 30 / 30 DAYS

PA

STEROID INHALANTS

ARNUITY ELLIPTA 100 MCG/ACT AER POW BAfluticasone furoate (inhalation)

5QL 1 / 1 day(s)



5QL 1 / 1 day(s)



5QL 1 / 1 day(s)


ASMANEX (120 METERED DOSES) 220 MCG/INH AER POWBAmometasone furoate (inhalation)

3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST

ASMANEX HFA 100 MCG/ACT AEROSOLmometasone furoate (inhalation)

3QL 13 / 30 day(s)

ST




3QL 13 / 30 day(s)

ST


3QL 13 / 30 day(s)

ST

budesonide 0.25 mg/2ml suspension 5QL 120 / 30 DAYS


budesonide 0.5 mg/2ml suspension 5QL 120 / 30 DAYS


budesonide 1 mg/2ml suspension 5 VAL Value Preventive List

FLOVENT DISKUS 100 MCG/BLIST AER POW BAfluticasone propionate (inhalation)

5QL 60 / 30 DAYS



5QL 60 / 30 DAYS



5QL 60 / 30 DAYS


FLOVENT HFA 110 MCG/ACT AEROSOLfluticasone propionate hfa

5QL 12 / 30 DAYS



5QL 12 / 30 DAYS



5QL 10.6 / 30 DAYS


PULMICORT FLEXHALER 180 MCG/ACT AER POW BAbudesonide (inhalation)

5QL 2 / 30 DAYS


PULMICORT FLEXHALER 90 MCG/ACT AER POW BAbudesonide (inhalation)

5QL 2 / 30 DAYS


QVAR 40 MCG/ACT AERO SOLNbeclomethasone dipropionate

5QL 34.8 / 30 DAYS


QVAR 80 MCG/ACT AERO SOLNbeclomethasone dipropionate

5QL 18 / 30 DAYS




QVAR REDIHALER 40 MCG/ACT AERO BAbeclomethasone dipropionate hfa

5QL 10.6 / 30 DAYS


QVAR REDIHALER 80 MCG/ACT AERO BAbeclomethasone dipropionate hfa

5QL 10.6 / 30 DAYS


THYMIC STROMAL LYMPHOPOIETIN (TSLP) ANTAGONISTS

TEZSPIRE 210 MG/1.91ML SOLN PRSYRtezepelumab-ekko

4PA

S

XANTHINES

ELIXOPHYLLIN 80 MG/15ML ELIXIRtheophylline



THEO-24 100 MG CAP ER 24Htheophylline








theophylline 80 mg/15ml solution 5AL1 Up to 8 yrs old


theophylline er 100 mg tab er 12h 5 VAL Value Preventive List



THEOPHYLLINE ER 300 MG TAB ER 12Htheophylline




THEOPHYLLINE ER 450 MG TAB ER 12Htheophylline





ANTICOAGULANTSCOUMARIN ANTICOAGULANTS

jantoven 1 mg tab 5 VAL Value Preventive List



jantoven 2.5 mg tab 5 VAL Value Preventive List





jantoven 7.5 mg tab 5 VAL Value Preventive List

warfarin sodium 1 mg tab 5 VAL Value Preventive List



warfarin sodium 2.5 mg tab 5 VAL Value Preventive List





warfarin sodium 7.5 mg tab 5 VAL Value Preventive List

DIRECT FACTOR XA INHIBITORS

ELIQUIS 2.5 MG TABapixaban

5QL 2 / 1 day(s)


ELIQUIS 5 MG TABapixaban

5QL 2.5 / 1 day(s)




ELIQUIS DVT/PE STARTER PACK 5 MG TAB THPKapixaban

5QL 2.5 / 1 day(s)


SAVAYSA 15 MG TABedoxaban tosylate

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

XARELTO 1 MG/ML RECON SUSPrivaroxaban


XARELTO 10 MG TABrivaroxaban

5QL 30 / 30 DAYS



5QL 42 / 30 day(s)


XARELTO 2.5 MG TABrivaroxaban

5QL 60 / 30 DAYS



5QL 30 / 30 DAYS


XARELTO STARTER PACK 15 & 20 MG TAB THPKrivaroxaban

5QL 51 / 30 DAYS


HEPARINS AND HEPARINOID-LIKE AGENTSheparin lock flush 10 unit/ml solution 1

heparin sodium (porcine) 1000 unit/ml solution 1



heparin sodium (porcine) pf 5000 unit/0.5ml solution 1

heparin sodium lock flush 100 unit/ml solution 1



LOW MOLECULAR WEIGHT HEPARINS

enoxaparin sodium 100 mg/ml soln prsyr 2 QL 2 / 1 day(s)

enoxaparin sodium 120 mg/0.8ml soln prsyr 2 QL 1.6 / 1 day(s)

enoxaparin sodium 150 mg/ml soln prsyr 2 QL 2 / 1 day(s)


enoxaparin sodium 300 mg/3ml solution 2QL 3 / 1 day(s)

MFL 1 / 30 DAYS




FRAGMIN 10000 UNIT/ML SOLN PRSYRdalteparin sodium

3 QL 2 / 1 day(s)

FRAGMIN 12500 UNIT/0.5ML SOLN PRSYRdalteparin sodium

3 QL 1 / 1 day(s)


3 QL 1.2 / 1 day(s)

FRAGMIN 18000 UNT/0.72ML SOLN PRSYRdalteparin sodium

3 QL 1.44 / 1 day(s)


3 QL 0.4 / 1 day(s)


3 QL 0.4 / 1 day(s)


3 QL 0.6 / 1 day(s)

FRAGMIN 95000 UNIT/3.8ML SOLUTIONdalteparin sodium

3 QL 7.6 / 1 day(s)

SYNTHETIC HEPARINOID-LIKE AGENTS

fondaparinux sodium 10 mg/0.8ml solution 2 QL 0.8 / 1 day(s)

fondaparinux sodium 2.5 mg/0.5ml solution 2 QL 0.5 / 1 day(s)

fondaparinux sodium 5 mg/0.4ml solution 2 QL 0.4 / 1 day(s)

fondaparinux sodium 7.5 mg/0.6ml solution 2 QL 0.6 / 1 day(s)



THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLEPRADAXA 110 MG CAPdabigatran etexilate mesylate

2 QL 60 / 30 DAYS

PRADAXA 150 MG CAPdabigatran etexilate mesylate

2 QL 60 / 30 DAYS

PRADAXA 75 MG CAPdabigatran etexilate mesylate

2 QL 60 / 30 DAYS

ANTICONVULSANTSAMPA GLUTAMATE RECEPTOR ANTAGONISTS

FYCOMPA 0.5 MG/ML SUSPENSIONperampanel

3QL 30 / 30 day(s)

ST

FYCOMPA 10 MG TABperampanel

3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST

ANTICONVULSANTS - BENZODIAZEPINESclobazam 10 mg tab 1

clobazam 2.5 mg/ml suspension 1

clobazam 20 mg tab 1

clonazepam 0.125 mg tab disp 1


clonazepam 0.5 mg tab 1 QL 90 / 30 DAYS




clonazepam 1 mg tab 1 QL 90 / 30 DAYS

clonazepam 1 mg tab disp 1 QL 90 / 30 DAYS

clonazepam 2 mg tab 1 QL 90 / 30 DAYS

clonazepam 2 mg tab disp 1

NAYZILAM 5 MG/0.1ML SOLUTIONmidazolam (anticonvulsant)

3 PA

ONFI 10 MG TABclobazam

3

ONFI 20 MG TABclobazam

3

VALTOCO 10 MG DOSE 10 MG/0.1ML LIQUIDdiazepam (anticonvulsant)

3 PA

VALTOCO 15 MG DOSE 7.5 MG/0.1ML LIQD THPKdiazepam (anticonvulsant)

3 PA

VALTOCO 20 MG DOSE 10 MG/0.1ML LIQD THPKdiazepam (anticonvulsant)

3 PA

VALTOCO 5 MG DOSE 5 MG/0.1ML LIQUIDdiazepam (anticonvulsant)

3 PA

ANTICONVULSANTS - MISC.BRIVIACT 10 MG TABbrivaracetam

3 ST

BRIVIACT 10 MG/ML SOLUTIONbrivaracetam

3 ST

BRIVIACT 100 MG TABbrivaracetam

3 ST


3 ST


3 ST


3 ST

carbamazepine 100 mg chew tab 1

carbamazepine 100 mg/5ml suspension 1



carbamazepine 200 mg tab 1

carbamazepine er 100 mg cap er 12h 1

carbamazepine er 100 mg tab er 12h 1





EPIDIOLEX 100 MG/ML SOLUTIONcannabidiol

4PA

S

epitol 200 mg tab 1

EPRONTIA 25 MG/ML SOLUTIONtopiramate

2QL 16 / 1 day(s)

AL1 Up to 8 yrs old

gabapentin 100 mg cap 1

gabapentin 250 mg/5ml solution 1


gabapentin 300 mg/6ml solution 1


gabapentin 600 mg tab 1

gabapentin 800 mg tab 1

lacosamide 100 mg tab 2QL 60 / 30 day(s)

ST


ST


ST


ST

lamotrigine 100 mg tab 1





lamotrigine 25 mg chew tab 1


lamotrigine 5 mg chew tab 1

lamotrigine er 100 mg tab er 24h 1 QL 30 / 30 DAYS






lamotrigine starter kit-blue 35 x 25 mg kit 1

lamotrigine starter kit-green 84 x 25 mg & 14x100 mg kit 1

lamotrigine starter kit-orange 42 x 25 mg & 7 x 100 mg kit 1

levetiracetam 100 mg/ml solution 1

levetiracetam 1000 mg tab 1




levetiracetam er 500 mg tab er 24h 1 QL 180 / 30 DAYS

levetiracetam er 750 mg tab er 24h 1 QL 120 / 30 DAYS

LYRICA 20 MG/ML SOLUTIONpregabalin

3QL 900 / 30 DAYS

PA

oxcarbazepine 150 mg tab 1


oxcarbazepine 300 mg/5ml suspension 1




pregabalin 100 mg cap 1 QL 120 / 30 DAYS


pregabalin 20 mg/ml solution 1 QL 900 / 30 day(s)







primidone 250 mg tab 1

primidone 50 mg tab 1

roweepra 1000 mg tab 1



roweepra xr 500 mg tab er 24h 1 QL 180 / 30 DAYS

roweepra xr 750 mg tab er 24h 1 QL 120 / 30 DAYS

rufinamide 200 mg tab 2QL 240 / 30 day(s)

PA

rufinamide 40 mg/ml suspension 2 PA

rufinamide 400 mg tab 2QL 240 / 30 day(s)

PA

subvenite 100 mg tab 1




TEGRETOL 100 MG/5ML SUSPENSIONcarbamazepine

3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTEGRETOL 200 MG TABcarbamazepine

3 PA

TEGRETOL-XR 100 MG TAB ER 12Hcarbamazepine

3 PA


3 PA


3 PA

topiramate 100 mg tab 1 QL 120 / 30 DAYS

topiramate 15 mg cap sprink 1 QL 375 / 30 DAYS


topiramate 25 mg cap sprink 1 QL 480 / 30 DAYS



topiramate er 100 mg cp24 sprnk 2QL 120 / 30 DAYS

PA


PA


PA


PA


PA

VIMPAT 10 MG/ML SOLUTIONlacosamide

3QL 1200 / 30 DAYS

ST

zonisamide 100 mg cap 1





CARBAMATESfelbamate 400 mg tab 2

felbamate 600 mg tab 2

felbamate 600 mg/5ml suspension 2

XCOPRI (250 MG DAILY DOSE) 100 & 150 MG TAB THPKcenobamate

3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST

XCOPRI 100 MG TABcenobamate

3QL 1 / 1 day(s)

ST

XCOPRI 14 X 12.5 MG & 14 X 25 MG TAB THPKcenobamate

3QL 1 / 1 day(s)

ST

XCOPRI 14 X 150 MG & 14 X200 MG TAB THPKcenobamate

3QL 1 / 1 day(s)

ST

XCOPRI 14 X 50 MG & 14 X100 MG TAB THPKcenobamate

3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST

GABA MODULATORStiagabine hcl 12 mg tab 1

tiagabine hcl 16 mg tab 1





vigabatrin 500 mg packet 2QL 180 / 30 DAYS

PA

vigabatrin 500 mg tab 2QL 180 / 30 DAYS

PA

HYDANTOINSDILANTIN 30 MG CAPphenytoin sodium extended

3

PEGANONE 250 MG TABethotoin

3

phenytoin 100 mg/4ml suspension 1

phenytoin 125 mg/5ml suspension 1

phenytoin 50 mg chew tab 1

phenytoin infatabs 50 mg chew tab 1

phenytoin sodium extended 100 mg cap 1



SUCCINIMIDESCELONTIN 300 MG CAPmethsuximide

3

ethosuximide 250 mg cap 1

ethosuximide 250 mg/5ml solution 1

VALPROIC ACIDdivalproex sodium 125 mg cap dr 1

divalproex sodium 125 mg tab dr 1



divalproex sodium er 250 mg tab er 24h 1

divalproex sodium er 500 mg tab er 24h 1

valproate sodium 250 mg/5ml solution 1



valproic acid 250 mg cap 1

valproic acid 250 mg/5ml solution 1

ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

mirtazapine 15 mg tab 1 QL 30 / 30 DAYS

mirtazapine 15 mg tab disp 1 QL 30 / 30 DAYS





mirtazapine 7.5 mg tab 1 QL 30 / 30 DAYS

ANTIDEPRESSANTS - MISC.

APLENZIN 174 MG TAB ER 24Hbupropion hydrobromide

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

bupropion hcl 100 mg tab 1 QL 60 / 30 DAYS

bupropion hcl 75 mg tab 1 QL 180 / 30 DAYS

bupropion hcl er (sr) 100 mg tab er 12h 1 QL 60 / 30 DAYS



bupropion hcl er (xl) 150 mg tab er 24h 1 QL 90 / 30 DAYS

bupropion hcl er (xl) 300 mg tab er 24h 1 QL 60 / 30 DAYS

BUPROPION HCL ER (XL) 450 MG TAB ER 24Hbupropion hcl

3QL 30 / 30 DAYS

ST



FORFIVO XL 450 MG TAB ER 24Hbupropion hcl

3QL 30 / 30 DAYS

ST

MAPROTILINE HCL 25 MG TABmaprotiline hcl

2 QL 270 / 30 DAYS


2 QL 135 / 30 DAYS


2

MONOAMINE OXIDASE INHIBITORS (MAOIS)EMSAM 12 MG/24HR PATCH 24HRselegiline

3 ST

EMSAM 6 MG/24HR PATCH 24HRselegiline

3 ST

EMSAM 9 MG/24HR PATCH 24HRselegiline

3 ST

MARPLAN 10 MG TABisocarboxazid

3

phenelzine sulfate 15 mg tab 1

tranylcypromine sulfate 10 mg tab 2

N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS

SPRAVATO (56 MG DOSE) 28 MG/DEVICE SOLN THPKesketamine hcl

3QL 16 / 28 DAYS

PA

SPRAVATO (84 MG DOSE) 28 MG/DEVICE SOLN THPKesketamine hcl

3QL 16 / 28 DAYS

PA

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

citalopram hydrobromide 10 mg tab 5QL 30 / 30 DAYS


citalopram hydrobromide 10 mg/5ml solution 5QL 600 / 30 DAYS








escitalopram oxalate 10 mg tab 5QL 60 / 30 DAYS






escitalopram oxalate 5 mg/5ml solution 5QL 620 / 30 DAYS


fluoxetine hcl 10 mg cap 5QL 90 / 30 DAYS


fluoxetine hcl 10 mg tab 5QL 90 / 30 DAYS




fluoxetine hcl 20 mg tab 5QL 90 / 30 DAYS


fluoxetine hcl 20 mg/5ml solution 5QL 600 / 30 DAYS




FLUOXETINE HCL 60 MG TABfluoxetine hcl

2 QL 30 / 30 DAYS

fluoxetine hcl 60 mg tab 2 QL 30 / 30 DAYS

FLUOXETINE HCL 90 MG CAP DRfluoxetine hcl

1 QL 4 / 28 DAYS

fluvoxamine maleate 100 mg tab 5QL 90 / 30 DAYS








paroxetine hcl 10 mg tab 5QL 90 / 30 DAYS








paroxetine hcl er 12.5 mg tab er 24h 5QL 60 / 30 DAYS


paroxetine hcl er 25 mg tab er 24h 5QL 60 / 30 DAYS


paroxetine hcl er 37.5 mg tab er 24h 5QL 60 / 30 DAYS


sertraline hcl 100 mg tab 5QL 60 / 30 DAYS


sertraline hcl 20 mg/ml conc 5QL 300 / 30 DAYS






SEROTONIN MODULATORSNEFAZODONE HCL 100 MG TABnefazodone hcl

1 QL 180 / 30 DAYS

NEFAZODONE HCL 150 MG TABnefazodone hcl

1 QL 120 / 30 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSNEFAZODONE HCL 200 MG TABnefazodone hcl

1 QL 90 / 30 DAYS


1 QL 72 / 30 DAYS

nefazodone hcl 250 mg tab 1 QL 72 / 30 DAYS


1 QL 360 / 30 DAYS

nefazodone hcl 50 mg tab 1 QL 360 / 30 DAYS

trazodone hcl 100 mg tab 1



TRINTELLIX 10 MG TABvortioxetine hbr

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

VIIBRYD 10 MG TABvilazodone hcl

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

VIIBRYD STARTER PACK 10 & 20 MG KITvilazodone hcl

3QL 30 / 30 DAYS

ST

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)DESVENLAFAXINE ER 100 MG TAB ER 24Hdesvenlafaxine

1 QL 30 / 30 DAYS

DESVENLAFAXINE ER 50 MG TAB ER 24Hdesvenlafaxine

1 QL 30 / 30 DAYS



desvenlafaxine succinate er 100 mg tab er 24h 1 QL 30 / 30 DAYS



duloxetine hcl 20 mg cp dr part 1 QL 180 / 30 DAYS



FETZIMA 120 MG CAP ER 24Hlevomilnacipran hcl

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

venlafaxine hcl 100 mg tab 1 QL 30 / 30 DAYS


venlafaxine hcl 37.5 mg tab 1 QL 90 / 30 DAYS



venlafaxine hcl er 150 mg cap er 24h 1 QL 60 / 30 DAYS

venlafaxine hcl er 37.5 mg cap er 24h 1

venlafaxine hcl er 75 mg cap er 24h 1

TRICYCLIC AGENTSamitriptyline hcl 10 mg tab 1

amitriptyline hcl 100 mg tab 1







AMOXAPINE 100 MG TABamoxapine

2


2


2


2

clomipramine hcl 25 mg cap 1



desipramine hcl 10 mg tab 1






doxepin hcl 10 mg cap 1

doxepin hcl 10 mg/ml conc 1 AL1 Up to 8 yrs old


DOXEPIN HCL 150 MG CAPdoxepin hcl

1




imipramine hcl 10 mg tab 1





imipramine pamoate 100 mg cap 1




nortriptyline hcl 10 mg cap 1

NORTRIPTYLINE HCL 10 MG/5ML SOLUTIONnortriptyline hcl

1

nortriptyline hcl 10 mg/5ml solution 1




protriptyline hcl 10 mg tab 1

protriptyline hcl 5 mg tab 1

trimipramine maleate 100 mg cap 2



ANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORS

acarbose 100 mg tab 1 QL 90 / 30 DAYS



miglitol 100 mg tab 1



ANTIDIABETIC - AMYLIN ANALOGS

SYMLINPEN 120 2700 MCG/2.7ML SOLN PENpramlintide acetate

3QL 10 / 30 DAYS

PA

SYMLINPEN 60 1500 MCG/1.5ML SOLN PENpramlintide acetate

3QL 10 / 30 DAYS

PA



BIGUANIDES

metformin hcl 1000 mg tab 5QL 90 / 30 DAYS




metformin hcl 500 mg/5ml solution 2PA

AL1 0 to 8 yrs old



metformin hcl er 500 mg tab er 24h 5QL 150 / 30 DAYS


metformin hcl er 750 mg tab er 24h 5QL 90 / 30 DAYS


DIABETIC OTHERBAQSIMI ONE PACK 3 MG/DOSE POWDERglucagon

2 QL 2 / 60 day(s)

BAQSIMI TWO PACK 3 MG/DOSE POWDERglucagon

2 QL 2 / 60 day(s)

GLUCAGEN HYPOKIT 1 MG RECON SOLNglucagon hcl (rdna)

2 QL 2 / 60 day(s)

glucagon emergency 1 mg kit 2 QL 2 / 60 day(s)

GLUCAGON EMERGENCY 1 MG KITglucagon (rdna)

2 QL 2 / 60 day(s)

GVOKE HYPOPEN 1-PACK 0.5 MG/0.1ML SOLN A-INJglucagon

2 QL 0.2 / 60 day(s)

GVOKE HYPOPEN 1-PACK 1 MG/0.2ML SOLN A-INJglucagon

2 QL 0.4 / 60 day(s)

GVOKE HYPOPEN 2-PACK 0.5 MG/0.1ML SOLN A-INJglucagon

2 QL 0.2 / 60 day(s)

GVOKE HYPOPEN 2-PACK 1 MG/0.2ML SOLN A-INJglucagon

2 QL 0.4 / 60 day(s)

GVOKE KIT 1 MG/0.2ML SOLUTIONglucagon

2 QL 2 / 60 day(s)


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSGVOKE PFS 0.5 MG/0.1ML SOLN PRSYRglucagon

2 QL 0.2 / 60 day(s)

GVOKE PFS 1 MG/0.2ML SOLN PRSYRglucagon

2 QL 0.4 / 60 day(s)

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

ALOGLIPTIN BENZOATE 12.5 MG TABalogliptin benzoate

3QL 30 / 30 DAYS

ST

ALOGLIPTIN BENZOATE 25 MG TABalogliptin benzoate

3QL 30 / 30 DAYS

ST

ALOGLIPTIN BENZOATE 6.25 MG TABalogliptin benzoate

3QL 30 / 30 DAYS

ST

JANUVIA 100 MG TABsitagliptin phosphate

2QL 1 / 1 day(s)

ST


2QL 1 / 1 day(s)

ST


2QL 1 / 1 day(s)

ST

TRADJENTA 5 MG TABlinagliptin

2QL 1 / 1 day(s)

ST

DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS

JANUMET 50-1000 MG TABsitagliptin-metformin hcl

2QL 2 / 1 day(s)

ST

JANUMET 50-500 MG TABsitagliptin-metformin hcl

2QL 2 / 1 day(s)

ST

JANUMET XR 100-1000 MG TAB ER 24Hsitagliptin-metformin hcl

2QL 1 / 1 day(s)

ST


2QL 2 / 1 day(s)

ST


2QL 30 / 30 DAYS

ST



JENTADUETO 2.5-1000 MG TABlinagliptin-metformin hcl

2QL 2 / 1 day(s)

ST


2QL 2 / 1 day(s)

ST


2QL 2 / 1 day(s)

ST

JENTADUETO XR 2.5-1000 MG TAB ER 24Hlinagliptin-metformin hcl

2QL 2 / 1 day(s)

ST

JENTADUETO XR 5-1000 MG TAB ER 24Hlinagliptin-metformin hcl

2QL 1 / 1 day(s)

ST

HUMAN INSULIN

BASAGLAR KWIKPEN 100 UNIT/ML SOLN PENinsulin glargine

5QL 2 / 1 day(s)


HUMALOG 100 UNIT/ML SOLN CARTinsulin lispro

5QL 2 / 1 day(s)


HUMALOG 100 UNIT/ML SOLUTIONinsulin lispro

5QL 2 / 1 day(s)


HUMALOG JUNIOR KWIKPEN 100 UNIT/ML SOLN PENinsulin lispro

5QL 2 / 1 day(s)


HUMALOG KWIKPEN 100 UNIT/ML SOLN PENinsulin lispro

5QL 2 / 1 day(s)


HUMALOG KWIKPEN 200 UNIT/ML SOLN PENinsulin lispro

5QL 1 / 1 day(s)


HUMALOG MIX 50/50 (50-50) 100 UNIT/ML SUSPENSIONinsulin lispro protamine & lispro

5QL 2 / 1 day(s)


HUMALOG MIX 50/50 KWIKPEN (50-50) 100 UNIT/MLSUSP PENinsulin lispro protamine & lispro

5QL 2 / 1 day(s)


HUMALOG MIX 75/25 (75-25) 100 UNIT/ML SUSPENSIONinsulin lispro protamine & lispro

5QL 2 / 1 day(s)



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSHUMALOG MIX 75/25 KWIKPEN (75-25) 100 UNIT/MLSUSP PENinsulin lispro protamine & lispro

5QL 2 / 1 day(s)


HUMULIN 70/30 (70-30) 100 UNIT/ML SUSPENSIONinsulin nph isophane & reg (human)

5QL 2 / 1 day(s)


HUMULIN 70/30 KWIKPEN (70-30) 100 UNIT/ML SUSPPENinsulin nph isophane & reg (human)

5QL 2 / 1 day(s)


HUMULIN N 100 UNIT/ML SUSPENSIONinsulin nph (human) (isophane)

5QL 2 / 1 day(s)


HUMULIN N KWIKPEN 100 UNIT/ML SUSP PENinsulin nph (human) (isophane)

5QL 2 / 1 day(s)


HUMULIN R 100 UNIT/ML SOLUTIONinsulin regular (human)

5QL 2 / 1 day(s)


HUMULIN R U-500 (CONCENTRATED) 500 UNIT/MLSOLUTIONinsulin regular (human)

5QL 2 / 1 day(s)


HUMULIN R U-500 KWIKPEN 500 UNIT/ML SOLN PENinsulin regular (human)

5QL 1 / 1 day(s)


INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SOLN PENinsulin lispro

5QL 2 / 1 day(s)


INSULIN LISPRO 100 UNIT/ML SOLUTIONinsulin lispro

5QL 2 / 1 day(s)


INSULIN LISPRO JUNIOR KWIKPEN 100 UNIT/ML SOLNPENinsulin lispro

5QL 2 / 1 day(s)


INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/MLSUSP PENinsulin lispro protamine & lispro

5QL 2 / 1 day(s)


LANTUS 100 UNIT/ML SOLUTIONinsulin glargine

3QL 2 / 1 day(s)

PA

LANTUS SOLOSTAR 100 UNIT/ML SOLN PENinsulin glargine

3QL 2 / 1 day(s)

PA



LEVEMIR 100 UNIT/ML SOLUTIONinsulin detemir

3QL 2 / 1 day(s)

PA

LEVEMIR FLEXTOUCH 100 UNIT/ML SOLN PENinsulin detemir

3QL 2 / 1 day(s)

PA

TRESIBA 100 UNIT/ML SOLUTIONinsulin degludec

3QL 2 / 1 day(s)

PA

TRESIBA FLEXTOUCH 100 UNIT/ML SOLN PENinsulin degludec

3QL 2 / 1 day(s)

PA

TRESIBA FLEXTOUCH 200 UNIT/ML SOLN PENinsulin degludec

3QL 0.9 / 1 day(s)

PA

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)

BYDUREON 2 MG PENexenatide

2QL 4 / 28 DAYS

ST

BYDUREON 2 MG SRERexenatide

2QL 4 / 28 DAYS

ST

BYDUREON BCISE 2 MG/0.85ML A-INJexenatide

2QL 3.4 / 28 day(s)

ST

OZEMPIC (0.25 OR 0.5 MG/DOSE) 2 MG/1.5ML SOLN PENsemaglutide

2QL 1.5 / 28 day(s)

ST

OZEMPIC (1 MG/DOSE) 2 MG/1.5ML SOLN PENsemaglutide

2QL 3 / 28 day(s)

ST

OZEMPIC (1 MG/DOSE) 4 MG/3ML SOLN PENsemaglutide

2QL 3 / 28 day(s)

ST

OZEMPIC (2 MG/DOSE) 8 MG/3ML SOLN PENsemaglutide

2QL 3 / 28 day(s)

ST

RYBELSUS 14 MG TABsemaglutide

2QL 30 / 30 day(s)

ST


2QL 30 / 30 day(s)

ST




2QL 30 / 30 day(s)

ST

TRULICITY 0.75 MG/0.5ML SOLN PENdulaglutide

2QL 2 / 28 day(s)

ST


2QL 2 / 28 day(s)

ST

TRULICITY 3 MG/0.5ML SOLN PENdulaglutide

2QL 2 / 28 day(s)

ST


2QL 2 / 28 day(s)

ST

VICTOZA 18 MG/3ML SOLN PENliraglutide

2QL 9 / 30 DAYS

ST

INSULIN-INCRETIN MIMETIC COMBINATIONS

SOLIQUA 100-33 UNT-MCG/ML SOLN PENinsulin glargine-lixisenatide

2QL 0.6 / 1 day(s)

ST

XULTOPHY 100-3.6 UNIT-MG/ML SOLN PENinsulin degludec-liraglutide

3QL 0.5 / 1 day(s)

PA

MEGLITINIDE ANALOGUES

nateglinide 120 mg tab 5QL 90 / 30 DAYS


nateglinide 60 mg tab 5QL 90 / 30 DAYS


repaglinide 0.5 mg tab 5QL 240 / 30 DAYS


repaglinide 1 mg tab 5QL 240 / 30 DAYS


repaglinide 2 mg tab 5QL 120 / 30 DAYS




SGLT2 INHIBITOR - DPP-4 INHIBITOR - BIGUANIDE COMB

TRIJARDY XR 10-5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin

2QL 1 / 1 day(s)

ST

TRIJARDY XR 12.5-2.5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin

2QL 2 / 1 day(s)

ST

TRIJARDY XR 25-5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin

2QL 1 / 1 day(s)

ST

TRIJARDY XR 5-2.5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin

2QL 2 / 1 day(s)

ST

SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS

GLYXAMBI 10-5 MG TABempagliflozin-linagliptin

2QL 30 / 30 day(s)

ST

GLYXAMBI 25-5 MG TABempagliflozin-linagliptin

2QL 30 / 30 day(s)

ST

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

FARXIGA 10 MG TABdapagliflozin propanediol

2QL 30 / 30 days

ST

FARXIGA 5 MG TABdapagliflozin propanediol

2QL 30 / 30 days

ST

JARDIANCE 10 MG TABempagliflozin

2QL 30 / 30 DAYS

ST

JARDIANCE 25 MG TABempagliflozin

2QL 30 / 30 DAYS

ST

SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB

SYNJARDY 12.5-1000 MG TABempagliflozin-metformin hcl

2QL 60 / 30 DAYS

ST

SYNJARDY 12.5-500 MG TABempagliflozin-metformin hcl

2QL 60 / 30 DAYS

ST

SYNJARDY 5-1000 MG TABempagliflozin-metformin hcl

2QL 60 / 30 DAYS

ST



SYNJARDY 5-500 MG TABempagliflozin-metformin hcl

2QL 60 / 30 DAYS

ST

SYNJARDY XR 10-1000 MG TAB ER 24Hempagliflozin-metformin hcl

2QL 60 / 30 days

ST

SYNJARDY XR 12.5-1000 MG TAB ER 24Hempagliflozin-metformin hcl

2QL 60 / 30 days

ST


2QL 60 / 30 days

ST


2QL 60 / 30 days

ST

XIGDUO XR 10-1000 MG TAB ER 24Hdapagliflozin-metformin hcl

2QL 30 / 30 day(s)

ST


2QL 30 / 30 day(s)

ST

XIGDUO XR 2.5-1000 MG TAB ER 24Hdapagliflozin-metformin hcl

2QL 30 / 30 day(s)

ST


2QL 30 / 30 day(s)

ST


2QL 30 / 30 day(s)

ST

SULFONYLUREA-BIGUANIDE COMBINATIONS

glipizide-metformin hcl 2.5-250 mg tab 5 VAL Value Preventive List

glipizide-metformin hcl 2.5-500 mg tab 5 VAL Value Preventive List

glipizide-metformin hcl 5-500 mg tab 5 VAL Value Preventive List

glyburide-metformin 1.25-250 mg tab 5 VAL Value Preventive List

glyburide-metformin 2.5-500 mg tab 5 VAL Value Preventive List

glyburide-metformin 5-500 mg tab 5 VAL Value Preventive List



SULFONYLUREAS

glimepiride 1 mg tab 5QL 60 / 30 DAYS






glipizide 10 mg tab 5QL 120 / 30 DAYS


glipizide 5 mg tab 5QL 240 / 30 DAYS


glipizide er 10 mg tab er 24h 5QL 60 / 30 DAYS


glipizide er 2.5 mg tab er 24h 5QL 240 / 30 DAYS


glipizide er 5 mg tab er 24h 5QL 60 / 30 DAYS


glipizide xl 10 mg tab er 24h 5QL 60 / 30 DAYS


glipizide xl 2.5 mg tab er 24h 5QL 240 / 30 DAYS


glipizide xl 5 mg tab er 24h 5QL 60 / 30 DAYS


glyburide 1.25 mg tab 5QL 480 / 30 DAYS


glyburide 2.5 mg tab 5QL 240 / 30 DAYS


glyburide 5 mg tab 5QL 120 / 30 DAYS




glyburide micronized 1.5 mg tab 5QL 120 / 30 DAYS


glyburide micronized 3 mg tab 5QL 60 / 30 DAYS


glyburide micronized 6 mg tab 5QL 30 / 30 DAYS


THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS

pioglitazone hcl-metformin hcl 15-500 mg tab 5 VAL Value Preventive List

pioglitazone hcl-metformin hcl 15-850 mg tab 5QL 90 / 30 DAYS


THIAZOLIDINEDIONES

pioglitazone hcl 15 mg tab 5QL 30 / 30 DAYS






ANTIDIARRHEAL/PROBIOTIC AGENTSANTIPERISTALTIC AGENTS

diphenoxylate-atropine 2.5-0.025 mg tab 1 QL 80 / 10 DAYS

MOTOFEN 1-0.025 MG TABdifenoxin w/ atropine

3 QL 16 / 30 day(s)

opium 10 mg/ml (1%) tincture 1QL 15 / 5 DAYSMD 7 / 1 day(s)

ANTIDOTES AND SPECIFIC ANTAGONISTSANTIDOTES - CHELATING AGENTS

CHEMET 100 MG CAPsuccimer

3 PA

deferasirox 125 mg tab sol 4PA

S



deferasirox 180 mg packet 4PA

S

deferasirox 180 mg tab 4PA

S


S


S


S


S


S


S

deferasirox granules 180 mg packet 4PA

S


S


S

deferiprone 1000 mg tab 4PA

S

deferiprone 500 mg tab 4PA

S

FERRIPROX 100 MG/ML SOLUTIONdeferiprone

4PA

S



FERRIPROX 1000 MG TABdeferiprone

4PA

S

FERRIPROX TWICE-A-DAY 1000 MG TABdeferiprone

4PA

S

acetylcysteine 200 mg/ml solution 1

BRIDION 200 MG/2ML SOLUTIONsugammadex sodium

3 PA

BRIDION 500 MG/5ML SOLUTIONsugammadex sodium

3 PA

RADIOGARDASE 0.5 GM CAPprussian blue insoluble (ferric hexacyanoferrate ii)

2

OPIOID ANTAGONISTSKLOXXADO 8 MG/0.1ML LIQUIDnaloxone hcl

1 QL 2 / 30 day(s)

NALOXONE HCL 0.4 MG/ML SOLN CARTnaloxone hcl

1 QL 2 / 30 day(s)

naloxone hcl 0.4 mg/ml solution 1 QL 2 / 30 day(s)

naloxone hcl 2 mg/2ml soln prsyr 1 QL 4 / 30 day(s)

naloxone hcl 4 mg/0.1ml liquid 1 QL 2 / 30 day(s)

naloxone hcl 4 mg/10ml solution 1 QL 10 / 30 day(s)

naltrexone hcl 50 mg tab 1 QL 60 / 30 DAYS

NARCAN 4 MG/0.1ML LIQUIDnaloxone hcl

1 QL 2 / 30 day(s)

VIVITROL 380 MG RECON SUSPnaltrexone

4QL 1 / DAYS

S

ZIMHI 5 MG/0.5ML SOLN PRSYRnaloxone hcl

2 QL 1 / 30 day(s)

ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS

ANZEMET 100 MG TABdolasetron mesylate

3QL 7 / 30 DAYS

PA



ANZEMET 50 MG TABdolasetron mesylate

3QL 7 / 30 DAYS

PA

granisetron hcl 1 mg tab 1 QL 14 / 30 DAYS

ondansetron 4 mg tab disp 1 QL 180 / 30 DAYS

ondansetron 8 mg tab disp 1 QL 180 / 30 DAYS

ondansetron hcl 4 mg tab 1 QL 180 / 30 DAYS

ONDANSETRON HCL 4 MG/2ML SOLN PRSYRondansetron hcl

2 PA

ondansetron hcl 4 mg/2ml solution 2 PA

ondansetron hcl 4 mg/5ml solution 1 QL 100 / 30 DAYS

ondansetron hcl 8 mg tab 1 QL 180 / 30 DAYS

SANCUSO 3.1 MG/24HR PATCHgranisetron

3QL 1 / 7 DAYS

PA

SUSTOL 10 MG/0.4ML PRSYRgranisetron

3PA

S

ZUPLENZ 4 MG FILMondansetron

3 PA

ZUPLENZ 8 MG FILMondansetron

3 PA

ANTIEMETIC COMBINATIONS

AKYNZEO 300-0.5 MG CAPnetupitant-palonosetron

3QL 1 / 0 DAYS

PA

ANTIEMETICS - ANTICHOLINERGICmeclizine hcl 25 mg tab 1

scopolamine 1 mg/3days patch 72hr 1

trimethobenzamide hcl 300 mg cap 1

ANTIEMETICS - MISCELLANEOUS

CESAMET 1 MG CAPnabilone

3QL 30 / 5 DAYS

PA



dronabinol 10 mg cap 2 QL 60 / 30 DAYS

dronabinol 2.5 mg cap 2 QL 60 / 30 DAYS

dronabinol 5 mg cap 2 QL 60 / 30 DAYS

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS

aprepitant 125 mg cap 1 QL 1 / 21 day(s)

aprepitant 80 & 125 mg cap 1 QL 3 / 21 day(s)

aprepitant 80 & 125 mg misc 1 QL 3 / 21 day(s)

aprepitant 80 mg cap 1 QL 2 / 21 day(s)

VARUBI (180 MG DOSE) 2 X 90 MG TAB THPKrolapitant hcl

3 PA

ANTIFUNGALSANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (TRITERPENOIDS)

BREXAFEMME 150 MG TABibrexafungerp citrate

3

QL 4 / 30 day(s)

ST

GL Female


flucytosine 250 mg cap 2

flucytosine 500 mg cap 2

griseofulvin microsize 125 mg/5ml suspension 1

griseofulvin microsize 500 mg tab 2 QL 30 / 30 DAYS

griseofulvin ultramicrosize 125 mg tab 2

griseofulvin ultramicrosize 250 mg tab 2

nystatin 500000 unit tab 1

terbinafine hcl 250 mg tab 1 QL 30 / 30 DAYS

IMIDAZOLESketoconazole 200 mg tab 1

TRIAZOLESfluconazole 10 mg/ml recon susp 1



fluconazole 100 mg tab 1

fluconazole 150 mg tab 1 QL 180 / 30 DAYS


fluconazole 40 mg/ml recon susp 1


itraconazole 100 mg cap 1

posaconazole 100 mg tab dr 4 PA

voriconazole 200 mg tab 2 QL 60 / 30 DAYS

voriconazole 40 mg/ml recon susp 1 AL1 Up to 8 yrs old

voriconazole 50 mg tab 1 QL 120 / 30 DAYS

ANTIHISTAMINESANTIHISTAMINES - ETHANOLAMINES

carbinoxamine maleate 4 mg tab 1

CARBINOXAMINE MALEATE 4 MG/5ML SOLUTIONcarbinoxamine maleate

1

carbinoxamine maleate 4 mg/5ml solution 1

di-phen 12.5 mg/5ml elixir 1 AL1 Up to 8 yrs old

diphen 12.5 mg/5ml elixir 1 AL1 Up to 8 yrs old

diphenhydramine hcl 12.5 mg/5ml elixir 1 AL1 Up to 8 yrs old

diphenhydramine hcl 50 mg/ml solution 1

ANTIHISTAMINES - NON-SEDATINGDESLORATADINE 2.5 MG TAB DISPdesloratadine

1 QL 30 / 30 DAYS

desloratadine 5 mg tab 1 QL 30 / 30 DAYS

DESLORATADINE 5 MG TAB DISPdesloratadine

1 QL 30 / 30 DAYS

levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL 300 / 30 DAYS

levocetirizine dihydrochloride 5 mg tab 1 QL 30 / 30 DAYS



QUZYTTIR 10 MG/ML SOLUTIONcetirizine hcl

4PA

S

ANTIHISTAMINES - PHENOTHIAZINESphenadoz 12.5 mg suppos 1

phenadoz 25 mg suppos 1 QL 30 / 30 DAYS

promethazine hcl 12.5 mg suppos 1

promethazine hcl 12.5 mg tab 1

promethazine hcl 25 mg suppos 1 QL 30 / 30 DAYS

promethazine hcl 25 mg tab 1

promethazine hcl 50 mg tab 1

promethazine hcl 6.25 mg/5ml solution 1

promethazine hcl 6.25 mg/5ml syrup 1

promethegan 12.5 mg suppos 1

promethegan 25 mg suppos 1 QL 30 / 30 DAYS

ANTIHISTAMINES - PIPERIDINEScyproheptadine hcl 2 mg/5ml syrup 1

cyproheptadine hcl 4 mg tab 1

ANTIHYPERLIPIDEMICSACL INHIB-INTESTINAL CHOLESTEROL ABSORPTION INHIB COMB

NEXLIZET 180-10 MG TABbempedoic acid-ezetimibe

3 PA

ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORSNEXLETOL 180 MG TABbempedoic acid

3 PA

ANTIHYPERLIPIDEMICS - MISC.

icosapent ethyl 1 gm cap 2QL 4 / 1 day(s)

PA

omega-3-acid ethyl esters 1 gm cap 1

triklo 1 gm cap 1



VASCEPA 0.5 GM CAPicosapent ethyl

3QL 120 / 30 day(s)

PA

BILE ACID SEQUESTRANTS

cholestyramine 4 gm packet 5 VAL Value Preventive List

cholestyramine 4 gm/dose powder 5 VAL Value Preventive List

cholestyramine light 4 gm packet 5 VAL Value Preventive List

cholestyramine light 4 gm/dose powder 5 VAL Value Preventive List

colesevelam hcl 3.75 gm packet 5

QL 30 / 30 day(s)

AL1 Up to 8 yrs old


colesevelam hcl 625 mg tab 5QL 180 / 30 DAYS


colestipol hcl 1 gm tab 5 VAL Value Preventive List

colestipol hcl 5 gm granules 5 VAL Value Preventive List

colestipol hcl 5 gm packet 5 VAL Value Preventive List

prevalite 4 gm packet 5 VAL Value Preventive List

prevalite 4 gm/dose powder 5 VAL Value Preventive List

FIBRIC ACID DERIVATIVES

fenofibrate 120 mg tab 1 QL 30 / 30 DAYS

fenofibrate 134 mg cap 5QL 30 / 30 DAYS


fenofibrate 145 mg tab 5QL 30 / 30 DAYS


FENOFIBRATE 150 MG CAPfenofibrate

3 QL 30 / 30 DAYS







fenofibrate 40 mg tab 1 QL 30 / 30 DAYS



FENOFIBRATE 50 MG CAPfenofibrate

3 QL 30 / 30 DAYS





fenofibrate micronized 130 mg cap 5QL 30 / 30 DAYS










FENOFIBRIC ACID 105 MG TABfenofibric acid

5QL 30 / 30 DAYS


fenofibric acid 135 mg cap dr 5QL 30 / 30 DAYS


FENOFIBRIC ACID 35 MG TABfenofibric acid

5QL 30 / 30 DAYS


fenofibric acid 45 mg cap dr 5QL 30 / 30 DAYS




gemfibrozil 600 mg tab 5 VAL Value Preventive List

LIPOFEN 150 MG CAPfenofibrate

3 QL 30 / 30 DAYS

LIPOFEN 50 MG CAPfenofibrate

3 QL 30 / 30 DAYS

HMG COA REDUCTASE INHIBITORS

atorvastatin calcium 10 mg tab 5QL 30 / 30 DAYS

PRE Preventative


PRE Preventative





fluvastatin sodium 20 mg cap 5QL 30 / 30 DAYS

PRE Preventative

fluvastatin sodium 40 mg cap 5QL 60 / 30 DAYS

PRE Preventative

fluvastatin sodium er 80 mg tab er 24h 5QL 30 / 30 DAYS

PRE Preventative

LIVALO 1 MG TABpitavastatin calcium

3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA

lovastatin 10 mg tab 5QL 30 / 30 DAYS

PRE Preventative


PRE Preventative




PRE Preventative

pravastatin sodium 10 mg tab 5QL 30 / 30 DAYS

PRE Preventative


PRE Preventative


PRE Preventative


PRE Preventative

rosuvastatin calcium 10 mg tab 5QL 30 / 30 DAYS

PRE Preventative






PRE Preventative

simvastatin 10 mg tab 5QL 30 / 30 DAYS

PRE Preventative


PRE Preventative


PRE Preventative


PRE Preventative





INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMBEZETIMIBE-ROSUVASTATIN 10-10 MG TABezetimibe-rosuvastatin calcium

1 QL 1 / 1 day(s)

EZETIMIBE-ROSUVASTATIN 10-20 MG TABezetimibe-rosuvastatin calcium

1 QL 1 / 1 day(s)


1 QL 1 / 1 day(s)


1 QL 1 / 1 day(s)

ezetimibe-simvastatin 10-10 mg tab 5QL 30 / 30 DAYS








INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe 10 mg tab 5QL 30 / 30 DAYS


NICOTINIC ACID DERIVATIVES

niacin er (antihyperlipidemic) 1000 mg tab er 5 VAL Value Preventive List



NIACOR 500 MG TABniacin (antihyperlipidemic)

3

PCSK9 INHIBITORSREPATHA 140 MG/ML SOLN PRSYRevolocumab

2 ST

REPATHA PUSHTRONEX SYSTEM 420 MG/3.5ML SOLNCARTevolocumab

2 ST


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSREPATHA SURECLICK 140 MG/ML SOLN A-INJevolocumab

2 ST

SMALL INTERFERING RNA (SIRNA) PCSK9 INHIBITORS

LEQVIO 284 MG/1.5ML SOLN PRSYRinclisiran sodium

4PA

S

ANTIHYPERTENSIVESACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine besy-benazepril hcl 10-20 mg cap 5 VAL Value Preventive List


amlodipine besy-benazepril hcl 2.5-10 mg cap 5QL 30 / 30 DAYS





TRANDOLAPRIL-VERAPAMIL HCL ER 1-240 MG TAB ERtrandolapril-verapamil hcl


trandolapril-verapamil hcl er 2-180 mg tab er 5 VAL Value Preventive List





5QL 30 / 30 day(s)





ACE INHIBITORS

benazepril hcl 10 mg tab 5 VAL Value Preventive List






captopril 100 mg tab 5 VAL Value Preventive List

captopril 12.5 mg tab 5 VAL Value Preventive List



enalapril maleate 1 mg/ml solution 2 AL1 Up to 8 yrs old

enalapril maleate 10 mg tab 5 VAL Value Preventive List

enalapril maleate 2.5 mg tab 5 VAL Value Preventive List



fosinopril sodium 10 mg tab 5 VAL Value Preventive List



lisinopril 10 mg tab 5 VAL Value Preventive List

lisinopril 2.5 mg tab 5 VAL Value Preventive List





moexipril hcl 15 mg tab 5 VAL Value Preventive List

moexipril hcl 7.5 mg tab 5 VAL Value Preventive List

perindopril erbumine 2 mg tab 5 VAL Value Preventive List




PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSQBRELIS 1 MG/ML SOLUTIONlisinopril


quinapril hcl 10 mg tab 5 VAL Value Preventive List




ramipril 1.25 mg cap 5QL 30 / 30 DAYS


ramipril 10 mg cap 5QL 60 / 30 DAYS


ramipril 2.5 mg cap 5QL 30 / 30 DAYS


ramipril 5 mg cap 5QL 30 / 30 DAYS


trandolapril 1 mg tab 5QL 30 / 30 DAYS






ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKE

benazepril-hydrochlorothiazide 10-12.5 mg tab 5 VAL Value Preventive List


benazepril-hydrochlorothiazide 20-25 mg tab 5 VAL Value Preventive List


BENAZEPRIL-HYDROCHLOROTHIAZIDE 5-6.25 MG TABbenazepril & hydrochlorothiazide


CAPTOPRIL-HYDROCHLOROTHIAZIDE 25-15 MG TABcaptopril & hydrochlorothiazide



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCAPTOPRIL-HYDROCHLOROTHIAZIDE 25-25 MG TABcaptopril & hydrochlorothiazide






enalapril-hydrochlorothiazide 10-25 mg tab 5 VAL Value Preventive List

enalapril-hydrochlorothiazide 5-12.5 mg tab 5 VAL Value Preventive List

fosinopril sodium-hctz 10-12.5 mg tab 5 VAL Value Preventive List

fosinopril sodium-hctz 20-12.5 mg tab 5 VAL Value Preventive List

lisinopril-hydrochlorothiazide 10-12.5 mg tab 5 VAL Value Preventive List

lisinopril-hydrochlorothiazide 20-12.5 mg tab 5 VAL Value Preventive List

lisinopril-hydrochlorothiazide 20-25 mg tab 5 VAL Value Preventive List

moexipril-hydrochlorothiazide 15-12.5 mg tab 5 VAL Value Preventive List

moexipril-hydrochlorothiazide 15-25 mg tab 5 VAL Value Preventive List

moexipril-hydrochlorothiazide 7.5-12.5 mg tab 5 VAL Value Preventive List

quinapril-hydrochlorothiazide 10-12.5 mg tab 5 VAL Value Preventive List

quinapril-hydrochlorothiazide 20-12.5 mg tab 5 VAL Value Preventive List

quinapril-hydrochlorothiazide 20-25 mg tab 5 VAL Value Preventive List

AGENTS FOR PHEOCHROMOCYTOMA

phenoxybenzamine hcl 10 mg cap 4PA

S

ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER-THIAZIDES

amlodipine-valsartan-hctz 10-160-12.5 mg tab 5QL 30 / 30 day(s)


amlodipine-valsartan-hctz 10-160-25 mg tab 5QL 30 / 30 day(s)






amlodipine-valsartan-hctz 5-160-12.5 mg tab 5QL 30 / 30 day(s)




olmesartan-amlodipine-hctz 20-5-12.5 mg tab 5 VAL Value Preventive List


olmesartan-amlodipine-hctz 40-10-25 mg tab 5 VAL Value Preventive List


olmesartan-amlodipine-hctz 40-5-25 mg tab 5 VAL Value Preventive List

ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB

amlodipine besylate-valsartan 10-160 mg tab 5 VAL Value Preventive List

amlodipine besylate-valsartan 10-320 mg tab 5 VAL Value Preventive List

amlodipine besylate-valsartan 5-160 mg tab 5QL 30 / 30 DAYS


amlodipine besylate-valsartan 5-320 mg tab 5QL 30 / 30 DAYS


amlodipine-olmesartan 10-20 mg tab 5 VAL Value Preventive List




telmisartan-amlodipine 40-10 mg tab 5QL 30 / 30 DAYS










ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKE

candesartan cilexetil-hctz 16-12.5 mg tab 5 VAL Value Preventive List

candesartan cilexetil-hctz 32-12.5 mg tab 5 VAL Value Preventive List

candesartan cilexetil-hctz 32-25 mg tab 5 VAL Value Preventive List

irbesartan-hydrochlorothiazide 150-12.5 mg tab 5 VAL Value Preventive List

irbesartan-hydrochlorothiazide 300-12.5 mg tab 5 VAL Value Preventive List

losartan potassium-hctz 100-12.5 mg tab 5 VAL Value Preventive List

losartan potassium-hctz 100-25 mg tab 5 VAL Value Preventive List

losartan potassium-hctz 50-12.5 mg tab 5 VAL Value Preventive List

olmesartan medoxomil-hctz 20-12.5 mg tab 5QL 30 / 30 DAYS


olmesartan medoxomil-hctz 40-12.5 mg tab 5QL 30 / 30 DAYS


olmesartan medoxomil-hctz 40-25 mg tab 5 VAL Value Preventive List

telmisartan-hctz 40-12.5 mg tab 5QL 30 / 30 DAYS


telmisartan-hctz 80-12.5 mg tab 5QL 30 / 30 DAYS


telmisartan-hctz 80-25 mg tab 5QL 30 / 30 DAYS


valsartan-hydrochlorothiazide 160-12.5 mg tab 5 VAL Value Preventive List

valsartan-hydrochlorothiazide 160-25 mg tab 5 VAL Value Preventive List


valsartan-hydrochlorothiazide 320-25 mg tab 5 VAL Value Preventive List




ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 16 mg tab 5QL 30 / 30 DAYS








EDARBI 40 MG TABazilsartan medoxomil

3 QL 30 / 30 DAYS

EDARBI 80 MG TABazilsartan medoxomil

3 QL 30 / 30 DAYS

EPROSARTAN MESYLATE 600 MG TABeprosartan mesylate

5QL 30 / 30 DAYS


irbesartan 150 mg tab 5QL 30 / 30 DAYS






losartan potassium 100 mg tab 5QL 60 / 30 DAYS






olmesartan medoxomil 20 mg tab 5 VAL Value Preventive List





telmisartan 20 mg tab 5 VAL Value Preventive List



valsartan 160 mg tab 5QL 30 / 30 DAYS








ANTIADRENERGICS - CENTRALLY ACTING

clonidine 0.1 mg/24hr patch wk 5 VAL Value Preventive List



clonidine hcl 0.1 mg tab 5 VAL Value Preventive List



guanfacine hcl 1 mg tab 5 VAL Value Preventive List

guanfacine hcl 2 mg tab 5 VAL Value Preventive List

METHYLDOPA 250 MG TABmethyldopa


methyldopa 250 mg tab 5 VAL Value Preventive List

METHYLDOPA 500 MG TABmethyldopa




methyldopa 500 mg tab 5 VAL Value Preventive List

ANTIADRENERGICS - PERIPHERALLY ACTING

doxazosin mesylate 1 mg tab 5QL 30 / 30 DAYS








prazosin hcl 1 mg cap 5 VAL Value Preventive List



terazosin hcl 1 mg cap 5QL 30 / 30 DAYS








BETA BLOCKER & DIURETIC COMBINATIONS

atenolol-chlorthalidone 100-25 mg tab 5 VAL Value Preventive List

atenolol-chlorthalidone 50-25 mg tab 5 VAL Value Preventive List

bisoprolol-hydrochlorothiazide 10-6.25 mg tab 5 VAL Value Preventive List

bisoprolol-hydrochlorothiazide 2.5-6.25 mg tab 5 VAL Value Preventive List

bisoprolol-hydrochlorothiazide 5-6.25 mg tab 5 VAL Value Preventive List



metoprolol-hydrochlorothiazide 100-25 mg tab 5 VAL Value Preventive List

METOPROLOL-HYDROCHLOROTHIAZIDE 100-50 MG TABmetoprolol & hydrochlorothiazide


metoprolol-hydrochlorothiazide 50-25 mg tab 5 VAL Value Preventive List

PROPRANOLOL-HCTZ 40-25 MG TABpropranolol & hydrochlorothiazide


PROPRANOLOL-HCTZ 80-25 MG TABpropranolol & hydrochlorothiazide


DIRECT RENIN INHIBITORS

aliskiren fumarate 150 mg tab 5 VAL Value Preventive List

aliskiren fumarate 300 mg tab 5 VAL Value Preventive List

DOPAMINE D1 RECEPTOR AGONISTSCORLOPAM 20 MG/2ML SOLUTIONfenoldopam mesylate

3 PA

SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)

eplerenone 25 mg tab 5QL 60 / 30 DAYS


eplerenone 50 mg tab 5QL 60 / 30 DAYS


VASODILATORS

hydralazine hcl 10 mg tab 5 VAL Value Preventive List




minoxidil 10 mg tab 1

minoxidil 2.5 mg tab 1

ANTIMALARIALSANTIMALARIAL COMBINATIONS

atovaquone-proguanil hcl 250-100 mg tab 1

atovaquone-proguanil hcl 62.5-25 mg tab 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCOARTEM 20-120 MG TABartemether-lumefantrine

2

chloroquine phosphate 250 mg tab 1

CHLOROQUINE PHOSPHATE 500 MG TABchloroquine phosphate

1

chloroquine phosphate 500 mg tab 1

HYDROXYCHLOROQUINE SULFATE 100 MG TABhydroxychloroquine sulfate

1

hydroxychloroquine sulfate 200 mg tab 1


1


1

mefloquine hcl 250 mg tab 1

PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG TABprimaquine phosphate

1

primaquine phosphate 26.3 (15 base) mg tab 1

pyrimethamine 25 mg tab 4PA

S

quinine sulfate 324 mg cap 1

ANTIMYASTHENIC/CHOLINERGIC AGENTSGUANIDINE HCL 125 MG TABguanidine hcl

2

pyridostigmine bromide 60 mg tab 1

pyridostigmine bromide 60 mg/5ml solution 2 PA

RUZURGI 10 MG TABamifampridine

4PA

S

ANTIMYCOBACTERIAL AGENTSANTI TB COMBINATIONS

RIFATER 50-120-300 MG TABisoniazid-rifampin w/ pyrazinamide

3

CYCLOSERINE 250 MG CAPcycloserine

2



cycloserine 250 mg cap 2

ethambutol hcl 100 mg tab 1

ethambutol hcl 400 mg tab 1

ISONIAZID 100 MG TABisoniazid

1

isoniazid 100 mg tab 1

isoniazid 300 mg tab 1

ISONIAZID 50 MG/5ML SYRUPisoniazid

1

PRETOMANID 200 MG TABpretomanid

3

PRIFTIN 150 MG TABrifapentine

3

pyrazinamide 500 mg tab 2

rifabutin 150 mg cap 2

rifampin 150 mg cap 1

rifampin 300 mg cap 1

SIRTURO 100 MG TABbedaquiline fumarate

4PA

S

SIRTURO 20 MG TABbedaquiline fumarate

4PA

S

TRECATOR 250 MG TABethionamide

3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESALKYLATING AGENTS

HEXALEN 50 MG CAPaltretamine

4PA

S

MYLERAN 2 MG TABbusulfan

4PA

S

ANDROGEN BIOSYNTHESIS INHIBITORSabiraterone acetate 250 mg tab 2



ANTIADRENALS

LYSODREN 500 MG TABmitotane

4PA

S

ANTIANDROGENS

bicalutamide 50 mg tab 1 QL 30 / 30 DAYS

ERLEADA 60 MG TABapalutamide

4PA

S

FLUTAMIDE 125 MG CAPflutamide

1

flutamide 125 mg cap 1

nilutamide 150 mg tab 2QL 60 / 30 DAYS

PA

XTANDI 40 MG CAPenzalutamide

4PA

S

XTANDI 40 MG TABenzalutamide

4PA

S

XTANDI 80 MG TABenzalutamide

4PA

S

ANTIESTROGENS

tamoxifen citrate 10 mg tab 5 PRE Preventative

tamoxifen citrate 20 mg tab 5 PRE Preventative

toremifene citrate 60 mg tab 2 QL 30 / 30 DAYS

ANTIMETABOLITEScapecitabine 150 mg tab 2

capecitabine 500 mg tab 2

mercaptopurine 50 mg tab 1

methotrexate 2.5 mg tab 1

methotrexate sodium (pf) 1 gm/40ml solution 1



methotrexate sodium (pf) 250 mg/10ml solution 1

methotrexate sodium (pf) 50 mg/2ml solution 1

methotrexate sodium 1 gm recon soln 1

methotrexate sodium 2.5 mg tab 1

METHOTREXATE SODIUM 250 MG/10ML SOLUTIONmethotrexate sodium

1

methotrexate sodium 50 mg/2ml solution 1

PURIXAN 2000 MG/100ML SUSPENSIONmercaptopurine

4PA

S

TABLOID 40 MG TABthioguanine

4PA

S

TREXALL 10 MG TABmethotrexate sodium

4PA

S


4PA

S


4PA

S

TREXALL 7.5 MG TABmethotrexate sodium

4PA

S

ANTINEOPLASTIC - ALK INHIBITORS

ALECENSA 150 MG CAPalectinib hcl

4PA

S

XALKORI 200 MG CAPcrizotinib

4PA

S

XALKORI 250 MG CAPcrizotinib

4PA

S

ZYKADIA 150 MG CAPceritinib

4PA

S

ZYKADIA 150 MG TABceritinib

4PA

S



ANTINEOPLASTIC - ANTI-HER2 AGENTS

TUKYSA 150 MG TABtucatinib

4PA

S

TUKYSA 50 MG TABtucatinib

4PA

S

ANTINEOPLASTIC - BCL-2 INHIBITORS

VENCLEXTA 10 MG TABvenetoclax

4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC - BCR-ABL KINASE INHIBITORS

BOSULIF 100 MG TABbosutinib

4PA

S


4PA

S


4PA

S

ICLUSIG 10 MG TABponatinib hcl

4PA

S


4PA

S


4PA

S


4PA

S

imatinib mesylate 100 mg tab 2 QL 90 / 30 DAYS



imatinib mesylate 400 mg tab 2 QL 60 / 30 DAYS

SCEMBLIX 20 MG TABasciminib hcl

4PA

S

SCEMBLIX 40 MG TABasciminib hcl

4PA

S

SPRYCEL 100 MG TABdasatinib

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

TASIGNA 150 MG CAPnilotinib hcl

4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC - BRAF KINASE INHIBITORS

BRAFTOVI 50 MG CAPencorafenib

4PA

S

BRAFTOVI 75 MG CAPencorafenib

4PA

S



TAFINLAR 50 MG CAPdabrafenib mesylate

4PA

S

TAFINLAR 75 MG CAPdabrafenib mesylate

4PA

S

ZELBORAF 240 MG TABvemurafenib

4PA

S

ANTINEOPLASTIC - BTK INHIBITORS

BRUKINSA 80 MG CAPzanubrutinib

4PA

S

CALQUENCE 100 MG CAPacalabrutinib

4PA

S

IMBRUVICA 140 MG CAPibrutinib

4PA

S

IMBRUVICA 420 MG TABibrutinib

4PA

S

IMBRUVICA 560 MG TABibrutinib

4PA

S

IMBRUVICA 70 MG CAPibrutinib

4PA

S

ANTINEOPLASTIC - EGFR INHIBITORS

erlotinib hcl 100 mg tab 4 PA



EXKIVITY 40 MG CAPmobocertinib succinate

4PA

S

GILOTRIF 20 MG TABafatinib dimaleate

4PA

S


4PA

S




4PA

S

TAGRISSO 40 MG TABosimertinib mesylate

4PA

S

TAGRISSO 80 MG TABosimertinib mesylate

4PA

S

VIZIMPRO 15 MG TABdacomitinib

4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC - FGFR KINASE INHIBITORS

BALVERSA 3 MG TABerdafitinib

4PA

S


4PA

S


4PA

S

PEMAZYRE 13.5 MG TABpemigatinib

4PA

S

PEMAZYRE 4.5 MG TABpemigatinib

4PA

S

PEMAZYRE 9 MG TABpemigatinib

4PA

S

TRUSELTIQ (100MG DAILY DOSE) 100 MG CAP THPKinfigratinib phosphate

4PA

S

TRUSELTIQ (125MG DAILY DOSE) 100 & 25 MG CAP THPKinfigratinib phosphate

4PA

S




4PA

S


4PA

S

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS

ERIVEDGE 150 MG CAPvismodegib

4PA

S

ODOMZO 200 MG CAPsonidegib phosphate

4PA

S

ANTINEOPLASTIC - HIF-2-ALPHA INHIBITORS

WELIREG 40 MG TABbelzutifan

4PA

S

ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS

FARYDAK 10 MG CAPpanobinostat lactate

4PA

S


4PA

S


4PA

S

ZOLINZA 100 MG CAPvorinostat

4PA

S

ANTINEOPLASTIC - IMMUNOMODULATORS

POMALYST 1 MG CAPpomalidomide

4PA

S


4PA

S


4PA

S


4PA

S



ANTINEOPLASTIC - KRAS INHIBITORS

LUMAKRAS 120 MG TABsotorasib

4PA

S

ANTINEOPLASTIC - MEK INHIBITORS

COTELLIC 20 MG TABcobimetinib fumarate

4PA

S

KOSELUGO 10 MG CAPselumetinib sulfate

4PA

S

KOSELUGO 25 MG CAPselumetinib sulfate

4PA

S

MEKINIST 0.5 MG TABtrametinib dimethyl sulfoxide

4PA

S

MEKINIST 2 MG TABtrametinib dimethyl sulfoxide

4PA

S

MEKTOVI 15 MG TABbinimetinib

4PA

S

ANTINEOPLASTIC - MET INHIBITORS

TABRECTA 150 MG TABcapmatinib hcl

4PA

S

TABRECTA 200 MG TABcapmatinib hcl

4PA

S

TEPMETKO 225 MG TABtepotinib hcl

4PA

S

ANTINEOPLASTIC - METHYLTRANSFERASE INHIBITORS

TAZVERIK 200 MG TABtazemetostat hbr

4PA

S

ANTINEOPLASTIC - MTOR KINASE INHIBITORS

everolimus 10 mg tab 4PA

S



everolimus 2 mg tab sol 4PA

S

everolimus 2.5 mg tab 4

QL 30 / 30 day(s)

PA

S


S

everolimus 5 mg tab 4

QL 30 / 30 day(s)

PA

S


S

everolimus 7.5 mg tab 4

QL 30 / 30 day(s)

PA

S

ANTINEOPLASTIC - MULTIKINASE INHIBITORS

CABOMETYX 20 MG TABcabozantinib s-malate

4PA

S


4PA

S


4PA

S

CAPRELSA 100 MG TABvandetanib

4PA

S

CAPRELSA 300 MG TABvandetanib

4PA

S

COMETRIQ (100 MG DAILY DOSE) 80 & 20 MG KITcabozantinib s-malate

4PA

S

COMETRIQ (140 MG DAILY DOSE) 3 X 20 MG & 80 MG KITcabozantinib s-malate

4PA

S



COMETRIQ (60 MG DAILY DOSE) 20 MG KITcabozantinib s-malate

4PA

S

FOTIVDA 0.89 MG CAPtivozanib hcl

4PA

S

FOTIVDA 1.34 MG CAPtivozanib hcl

4PA

S

lapatinib ditosylate 250 mg tab 4PA

S

NERLYNX 40 MG TABneratinib maleate

4PA

S

NEXAVAR 200 MG TABsorafenib tosylate

4PA

S

QINLOCK 50 MG TABripretinib

4PA

S

STIVARGA 40 MG TABregorafenib

4PA

S

sunitinib malate 12.5 mg cap 4PA

S

sunitinib malate 25 mg cap 4PA

S

sunitinib malate 37.5 mg cap 4PA

S

sunitinib malate 50 mg cap 4PA

S

TURALIO 200 MG CAPpexidartinib hcl

4PA

S

UKONIQ 200 MG TABumbralisib tosylate

4PA

S



VOTRIENT 200 MG TABpazopanib hcl

4PA

S

ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS

AYVAKIT 100 MG TABavapritinib

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC - PROTEASOME INHIBITORS

NINLARO 2.3 MG CAPixazomib citrate

4PA

S

NINLARO 3 MG CAPixazomib citrate

4PA

S

NINLARO 4 MG CAPixazomib citrate

4PA

S

ANTINEOPLASTIC - RET INHIBITORS

GAVRETO 100 MG CAPpralsetinib

4PA

S

RETEVMO 40 MG CAPselpercatinib

4PA

S

RETEVMO 80 MG CAPselpercatinib

4PA

S



ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS

ROZLYTREK 100 MG CAPentrectinib

4PA

S

ROZLYTREK 200 MG CAPentrectinib

4PA

S

ANTINEOPLASTIC - XPO1 INHIBITORS

XPOVIO (100 MG ONCE WEEKLY) 20 MG TAB THPKselinexor

4PA

S


4PA

S


4PA

S


4PA

S

XPOVIO (40 MG TWICE WEEKLY) 20 MG TAB THPKselinexor

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S




4PA

S

ANTINEOPLASTIC COMBINATIONS

INQOVI 35-100 MG TABdecitabine-cedazuridine

4PA

S

LONSURF 15-6.14 MG TABtrifluridine-tipiracil

4PA

S

LONSURF 20-8.19 MG TABtrifluridine-tipiracil

4PA

S

ANTINEOPLASTICS MISC.

ACTIMMUNE 2000000 UNIT/0.5ML SOLUTIONinterferon gamma-1b

4PA

S

hydroxyurea 500 mg cap 1

INTRON A 10000000 UNIT RECON SOLNinterferon alfa-2b

4PA

S

INTRON A 10000000 UNIT/ML SOLUTIONinterferon alfa-2b

4PA

S


4PA

S


4PA

S

INTRON A 6000000 UNIT/ML SOLUTIONinterferon alfa-2b

4PA

S

MATULANE 50 MG CAPprocarbazine hcl

4PA

S

AROMATASE INHIBITORS

anastrozole 1 mg tab 5

QL 30 / 30 DAYS

GL FemalePRE Preventative



exemestane 25 mg tab 1QL 60 / 30 DAYS

GL Female

letrozole 2.5 mg tab 1QL 30 / 30 DAYS

GL Female

CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS

IBRANCE 100 MG CAPpalbociclib

4PA

S

IBRANCE 100 MG TABpalbociclib

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

VERZENIO 100 MG TABabemaciclib

4PA

S


4PA

S


4PA

S


4PA

S

ESTROGENS-ANTINEOPLASTIC

EMCYT 140 MG CAPestramustine phosphate sodium

4PA

S



FOLIC ACID ANTAGONISTS RESCUE AGENTSleucovorin calcium 10 mg tab 2

leucovorin calcium 15 mg tab 2



IMIDAZOTETRAZINES

temozolomide 100 mg cap 2 QL 2 / 1 day(s)






JANUS ASSOCIATED KINASE (JAK) INHIBITORS

JAKAFI 10 MG TABruxolitinib phosphate

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

LHRH ANALOGS

ELIGARD 22.5 MG KITleuprolide acetate (3 month)

4PA

S

ELIGARD 30 MG KITleuprolide acetate (4 month)

4PA

S



ELIGARD 45 MG KITleuprolide acetate (6 month)

4PA

S

ELIGARD 7.5 MG KITleuprolide acetate

4PA

S

leuprolide acetate 1 mg/0.2ml kit 1 PA

LUPRON DEPOT (1-MONTH) 3.75 MG KITleuprolide acetate

4PA

S

LUPRON DEPOT (1-MONTH) 7.5 MG KITleuprolide acetate

4PA

S

LUPRON DEPOT (3-MONTH) 11.25 MG KITleuprolide acetate (3 month)

4PA

S

LUPRON DEPOT (3-MONTH) 22.5 MG KITleuprolide acetate (3 month)

4PA

S

LUPRON DEPOT (4-MONTH) 30 MG KITleuprolide acetate (4 month)

4PA

S

LUPRON DEPOT (6-MONTH) 45 MG KITleuprolide acetate (6 month)

4PA

S

VANTAS 50 MG KIThistrelin acetate

4PA

S

ZOLADEX 10.8 MG IMPLANTgoserelin acetate

4PA

S

ZOLADEX 3.6 MG IMPLANTgoserelin acetate

4PA

S

MITOTIC INHIBITORS

ETOPOSIDE 50 MG CAPetoposide

4PA

S

NITROGEN MUSTARDS AND RELATED ANALOGUESCYCLOPHOSPHAMIDE 25 MG CAPcyclophosphamide

1



cyclophosphamide 25 mg cap 1

CYCLOPHOSPHAMIDE 50 MG CAPcyclophosphamide

1

cyclophosphamide 50 mg cap 1

LEUKERAN 2 MG TABchlorambucil

4PA

S

melphalan 2 mg tab 1

NITROSOUREAS

GLEOSTINE 10 MG CAPlomustine

4PA

S


4PA

S


4PA

S

PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS

COPIKTRA 15 MG CAPduvelisib

4PA

S

COPIKTRA 25 MG CAPduvelisib

4PA

S

PIQRAY (200 MG DAILY DOSE) 200 MG TAB THPKalpelisib

4PA

S

PIQRAY (250 MG DAILY DOSE) 200 & 50 MG TAB THPKalpelisib

4PA

S

PIQRAY (300 MG DAILY DOSE) 2 X 150 MG TAB THPKalpelisib

4PA

S

ZYDELIG 100 MG TABidelalisib

4PA

S

ZYDELIG 150 MG TABidelalisib

4PA

S



POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS

LYNPARZA 100 MG TABolaparib

4PA

S

LYNPARZA 150 MG TABolaparib

4PA

S

LYNPARZA 50 MG CAPolaparib

4PA

S

TALZENNA 0.25 MG CAPtalazoparib tosylate

4PA

S


4PA

S


4PA

S

TALZENNA 1 MG CAPtalazoparib tosylate

4PA

S

PROGESTINS-ANTINEOPLASTICHYDROXYPROGESTERONE CAPROATE 1.25 GM/5MLSOLUTIONhydroxyprogesterone caproate (antineoplastic)

2 PA

megestrol acetate 20 mg tab 1

megestrol acetate 40 mg tab 1

megestrol acetate 40 mg/ml suspension 1

megestrol acetate 400 mg/10ml suspension 1

RETINOIDS

tretinoin 10 mg cap 1 PA

SELECTIVE RETINOID X RECEPTOR AGONISTS

bexarotene 75 mg cap 2 PA

VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS

INLYTA 1 MG TABaxitinib

4PA

S



INLYTA 5 MG TABaxitinib

4PA

S

LENVIMA (10 MG DAILY DOSE) 10 MG CAP THPKlenvatinib mesylate

4PA

S

LENVIMA (14 MG DAILY DOSE) 10 & 4 MG CAP THPKlenvatinib mesylate

4PA

S

LENVIMA (20 MG DAILY DOSE) 2 X 10 MG CAP THPKlenvatinib mesylate

4PA

S

LENVIMA (24 MG DAILY DOSE) 2 X 10 MG & 4 MG CAPTHPKlenvatinib mesylate

4PA

S

ANTIPARKINSON AND RELATED THERAPY AGENTSANTIPARKINSON ANTICHOLINERGICS

benztropine mesylate 0.5 mg tab 1

benztropine mesylate 1 mg tab 1

benztropine mesylate 2 mg tab 1

TRIHEXYPHENIDYL HCL 0.4 MG/ML SOLUTIONtrihexyphenidyl hcl


trihexyphenidyl hcl 0.4 mg/ml solution 1 AL1 Up to 8 yrs old

trihexyphenidyl hcl 2 mg tab 1

trihexyphenidyl hcl 5 mg tab 1

ANTIPARKINSON DOPAMINERGICSamantadine hcl 100 mg cap 1

amantadine hcl 100 mg tab 1

amantadine hcl 50 mg/5ml solution 1

amantadine hcl 50 mg/5ml syrup 1

bromocriptine mesylate 2.5 mg tab 1

bromocriptine mesylate 5 mg cap 1



ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

rasagiline mesylate 0.5 mg tab 2 QL 30 / 30 DAYS

rasagiline mesylate 1 mg tab 2 QL 30 / 30 DAYS

selegiline hcl 5 mg cap 1

selegiline hcl 5 mg tab 1

ZELAPAR 1.25 MG TAB DISPselegiline hcl

3 PA

CENTRAL/PERIPHERAL COMT INHIBITORS

tolcapone 100 mg tab 2 PA

DECARBOXYLASE INHIBITORScarbidopa 25 mg tab 1

LEVODOPA COMBINATIONScarbidopa-levodopa 10-100 mg tab 1

carbidopa-levodopa 10-100 mg tab disp 1

CARBIDOPA-LEVODOPA 10-100 MG TAB DISPcarbidopa-levodopa

1

carbidopa-levodopa 25-100 mg tab 1



1

carbidopa-levodopa 25-250 mg tab 1



1

carbidopa-levodopa er 25-100 mg tab er 1

carbidopa-levodopa er 50-200 mg tab er 1

CARBIDOPA-LEVODOPA-ENTACAPONE 12.5-50-200 MGTABcarbidopa-levodopa-entacapone

1

carbidopa-levodopa-entacapone 12.5-50-200 mg tab 1


1




carbidopa-levodopa-entacapone 25-100-200 mg tab 1



1


carbidopa-levodopa-entacapone 50-200-200 mg tab 1

NONERGOLINE DOPAMINE RECEPTOR AGONISTS

KYNMOBI 10 MG FILMapomorphine hydrochloride

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

KYNMOBI TITRATION KIT 10/15/20/25/30 MG KITapomorphine hydrochloride

4PA

S

NEUPRO 1 MG/24HR PATCH 24HRrotigotine

3 PA


3 PA


3 PA


3 PA


3 PA


3 PA



pramipexole dihydrochloride 0.125 mg tab 1 QL 90 / 30 DAYS




pramipexole dihydrochloride 1 mg tab 1 QL 90 / 30 DAYS


pramipexole dihydrochloride er 0.375 mg tab er 24h 2 QL 30 / 30 DAYS




pramipexole dihydrochloride er 3 mg tab er 24h 2 QL 30 / 30 DAYS



ropinirole hcl 0.25 mg tab 1

ropinirole hcl 0.5 mg tab 1

ropinirole hcl 1 mg tab 1





ropinirole hcl er 12 mg tab er 24h 1 QL 30 / 30 DAYS







PERIPHERAL COMT INHIBITORS

entacapone 200 mg tab 1 QL 270 / 30 DAYS

ONGENTYS 25 MG CAPopicapone

3 PA

ONGENTYS 50 MG CAPopicapone

3 PA

ANTIPSYCHOTICS/ANTIMANIC AGENTSANTIMANIC AGENTS

LITHIUM 8 MEQ/5ML SOLUTIONlithium


LITHIUM CARBONATE 150 MG CAPlithium carbonate

1

lithium carbonate 150 mg cap 1


1


lithium carbonate 300 mg tab 1


1


lithium carbonate er 300 mg tab er 1

lithium carbonate er 450 mg tab er 1

ANTIPSYCHOTICS - MISC.CAPLYTA 42 MG CAPlumateperone tosylate

3 ST

EQUETRO 100 MG CAP ER 12Hcarbamazepine (antipsychotic)

3 QL 480 / 30 DAYS


3 QL 240 / 30 DAYS


3 QL 180 / 30 DAYS

LATUDA 120 MG TABlurasidone hcl

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST




3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

VRAYLAR 1.5 & 3 MG CAP THPKcariprazine hcl

3QL 30 / 30 day(s)

ST

VRAYLAR 1.5 MG CAPcariprazine hcl

3QL 30 / 30 DAYS

ST

VRAYLAR 3 MG CAPcariprazine hcl

3QL 30 / 30 DAYS

ST

VRAYLAR 4.5 MG CAPcariprazine hcl

3QL 30 / 30 DAYS

ST

VRAYLAR 6 MG CAPcariprazine hcl

3QL 30 / 30 DAYS

ST

ziprasidone hcl 20 mg cap 1 QL 240 / 30 DAYS




BENZISOXAZOLES

FANAPT 1 MG TABiloperidone

3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST




3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST

FANAPT TITRATION PACK 1 & 2 & 4 & 6 MG TABiloperidone

3QL 60 / 30 day(s)

ST

INVEGA HAFYERA 1092 MG/3.5ML SUSP PRSYRpaliperidone palmitate

3 ST

INVEGA HAFYERA 1560 MG/5ML SUSP PRSYRpaliperidone palmitate

3 ST

INVEGA SUSTENNA 117 MG/0.75ML SUSP PRSYRpaliperidone palmitate

3 ST

INVEGA SUSTENNA 156 MG/ML SUSP PRSYRpaliperidone palmitate

3 ST


3 ST


3 ST


3 ST

INVEGA TRINZA 273 MG/0.88ML SUSP PRSYRpaliperidone palmitate

3 ST


3 ST


3 ST


3 ST

paliperidone er 1.5 mg tab er 24h 2QL 30 / 30 DAYS

ST

paliperidone er 3 mg tab er 24h 2QL 30 / 30 DAYS

ST




ST


ST

RISPERDAL CONSTA 12.5 MG SRERrisperidone microspheres

3 ST

RISPERDAL CONSTA 25 MG SRERrisperidone microspheres

3 ST

RISPERDAL CONSTA 37.5 MG SRERrisperidone microspheres

3 ST

RISPERDAL CONSTA 50 MG SRERrisperidone microspheres

3 ST

risperidone 0.25 mg tab 1 QL 60 / 30 DAYS

RISPERIDONE 0.25 MG TAB DISPrisperidone

1 QL 1920 / 30 DAYS

risperidone 0.5 mg tab 1 QL 60 / 30 DAYS

risperidone 0.5 mg tab disp 1 QL 960 / 30 DAYS

risperidone 1 mg tab 1 QL 480 / 30 DAYS

risperidone 1 mg tab disp 1 QL 60 / 30 DAYS

risperidone 1 mg/ml solution 1 AL1 Up to 8 yrs old







risperidone m-tab 0.5 mg tab disp 1 QL 960 / 30 DAYS

risperidone m-tab 1 mg tab disp 1 QL 60 / 30 DAYS



risperidone m-tab 2 mg tab disp 1 QL 60 / 30 DAYS

BUTYROPHENONEShaloperidol 0.5 mg tab 1

haloperidol 1 mg tab 1





haloperidol lactate 2 mg/ml conc 1

DIBENZO-OXEPINO PYRROLES

asenapine maleate 10 mg sl tab 2 ST

asenapine maleate 2.5 mg sl tab 2 ST

asenapine maleate 5 mg sl tab 2 ST

DIBENZODIAZEPINES

clozapine 100 mg tab 1 QL 120 / 30 DAYS

clozapine 100 mg tab disp 1

CLOZAPINE 12.5 MG TAB DISPclozapine

1

CLOZAPINE 150 MG TAB DISPclozapine

1


CLOZAPINE 200 MG TAB DISPclozapine

1


clozapine 25 mg tab disp 1 QL 1080 / 30 DAYS


DIBENZOTHIAZEPINES

quetiapine fumarate 100 mg tab 1 QL 90 / 30 DAYS








quetiapine fumarate er 150 mg tab er 24h 1 QL 60 / 30 DAYS





DIBENZOXAZEPINESloxapine succinate 10 mg cap 1

loxapine succinate 25 mg cap 1



PHENOTHIAZINESchlorpromazine hcl 10 mg tab 1

chlorpromazine hcl 100 mg tab 1




compro 25 mg suppos 1 QL 30 / 30 DAYS

fluphenazine hcl 1 mg tab 1


fluphenazine hcl 2.5 mg tab 1

FLUPHENAZINE HCL 2.5 MG/5ML ELIXIRfluphenazine hcl





FLUPHENAZINE HCL 5 MG/ML CONCfluphenazine hcl


perphenazine 16 mg tab 1




prochlorperazine 25 mg suppos 1 QL 30 / 30 DAYS

prochlorperazine maleate 10 mg tab 1

prochlorperazine maleate 5 mg tab 1

thioridazine hcl 10 mg tab 1




trifluoperazine hcl 1 mg tab 1




QUINOLINONE DERIVATIVESABILIFY MAINTENA 300 MG PRSYRaripiprazole

3 ST

ABILIFY MAINTENA 300 MG SRERaripiprazole

3 ST

ABILIFY MAINTENA 400 MG PRSYRaripiprazole

3 ST

ABILIFY MAINTENA 400 MG SRERaripiprazole

3 ST

aripiprazole 1 mg/ml solution 2 QL 30 / 30 DAYS

aripiprazole 10 mg tab 1 QL 30 / 30 DAYS




aripiprazole 2 mg tab 1 QL 60 / 30 day(s)




REXULTI 0.25 MG TABbrexpiprazole

3QL 30 / 30 DAYS

ST

REXULTI 0.5 MG TABbrexpiprazole

3QL 30 / 30 DAYS

ST

REXULTI 1 MG TABbrexpiprazole

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

THIENBENZODIAZEPINES

olanzapine 10 mg tab 1 QL 30 / 30 DAYS

olanzapine 10 mg tab disp 1 QL 30 / 30 DAYS



olanzapine 2.5 mg tab 1 QL 30 / 30 DAYS







olanzapine 7.5 mg tab 1 QL 30 / 30 DAYS

ZYPREXA RELPREVV 210 MG RECON SUSPolanzapine pamoate

3 ST


3 ST


3 ST

THIOXANTHENESthiothixene 1 mg cap 1

thiothixene 10 mg cap 1



ANTIVIRALSANTIRETROVIRAL COMBINATIONS

abacavir sulfate-lamivudine 600-300 mg tab 1 QL 30 / 30 DAYS

abacavir-lamivudine-zidovudine 300-150-300 mg tab 2 QL 60 / 30 DAYS

BIKTARVY 30-120-15 MG TABbictegravir-emtricitabine-tenofovir alafenamide fumarate

4QL 30 / 30 day(s)

S

BIKTARVY 50-200-25 MG TABbictegravir-emtricitabine-tenofovir alafenamide fumarate

4QL 30 / 30 DAYS

S

CIMDUO 300-300 MG TABlamivudine-tenofovir disoproxil fumarate

4 S

COMPLERA 200-25-300 MG TABemtricitabine-rilpivirine-tenofovir disoproxil fumarate

4QL 30 / 30 DAYS

S

DESCOVY 120-15 MG TABemtricitabine-tenofovir alafenamide fumarate

4

QL 1 / 1 day(s)

PA

S

DESCOVY 200-25 MG TABemtricitabine-tenofovir alafenamide fumarate

4

QL 30 / 30 DAYS

PA

S



DOVATO 50-300 MG TABdolutegravir sodium-lamivudine

4PA

S

efavirenz-emtricitab-tenofovir 600-200-300 mg tab 4

efavirenz-lamivudine-tenofovir 400-300-300 mg tab 4 S

efavirenz-lamivudine-tenofovir 600-300-300 mg tab 4 S

emtricitabine-tenofovir df 100-150 mg tab 4QL 30 / 30 day(s)

S


S


S


PRE Preventative

EVOTAZ 300-150 MG TABatazanavir sulfate-cobicistat

4QL 30 / 30 DAYS

S

GENVOYA 150-150-200-10 MG TABelvitegravir-cobicistat-emtricitabine-tenofoviralafenamide

4QL 30 / 30 DAYS

S

JULUCA 50-25 MG TABdolutegravir sodium-rilpivirine hcl

4 S

lamivudine-zidovudine 150-300 mg tab 1 QL 60 / 30 DAYS

lopinavir-ritonavir 100-25 mg tab 4 S

lopinavir-ritonavir 200-50 mg tab 4 S

lopinavir-ritonavir 400-100 mg/5ml solution 1

ODEFSEY 200-25-25 MG TABemtricitabine-rilpivirine-tenofovir alafenamide fumarate

4QL 30 / 30 DAYS

S

PREZCOBIX 800-150 MG TABdarunavir-cobicistat

4QL 30 / 30 DAYS

S

STRIBILD 150-150-200-300 MG TABelvitegravir-cobicistat-emtricitabine-tenofovir df

4QL 30 / 30 DAYS

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSYMTUZA 800-150-200-10 MG TABdarunavir-cobicistat-emtricitabine-tenofovir alafenamide

4 S

TEMIXYS 300-300 MG TABlamivudine-tenofovir disoproxil fumarate

4 S

TRIUMEQ 600-50-300 MG TABabacavir-dolutegravir-lamivudine

4QL 30 / 30 DAYS

S

TRIUMEQ PD 60-5-30 MG TAB SOLabacavir-dolutegravir-lamivudine

4QL 1 / 1 day(s)

S

ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)

maraviroc 150 mg tab 4PA

S

maraviroc 300 mg tab 4PA

S

SELZENTRY 20 MG/ML SOLUTIONmaraviroc

4PA

S

SELZENTRY 25 MG TABmaraviroc

4PA

S

SELZENTRY 75 MG TABmaraviroc

4PA

S

ANTIRETROVIRALS - FUSION INHIBITORS

FUZEON 90 MG RECON SOLNenfuvirtide

4PA

S

ANTIRETROVIRALS - GP120-DIRECTED ATTACHMENT INHIBITOR

RUKOBIA 600 MG TAB ER 12Hfostemsavir tromethamine

4PA

S

ANTIRETROVIRALS - INTEGRASE INHIBITORS

ISENTRESS 100 MG CHEW TABraltegravir potassium

4QL 180 / 30 DAYS

S

ISENTRESS 100 MG PACKETraltegravir potassium

4QL 240 / 30 DAYS

S



ISENTRESS 25 MG CHEW TABraltegravir potassium

4QL 720 / 30 DAYS

S

ISENTRESS 400 MG TABraltegravir potassium

4QL 60 / 30 DAYS

S

ISENTRESS HD 600 MG TABraltegravir potassium

4QL 60 / 30 DAYS

S

TIVICAY 10 MG TABdolutegravir sodium

4QL 30 / 30 DAYS

S


4QL 30 / 30 DAYS

S


4QL 60 / 30 DAYS

S

TIVICAY PD 5 MG TAB SOLdolutegravir sodium

4PA

S

ANTIRETROVIRALS - PROTEASE INHIBITORS

APTIVUS 100 MG/ML SOLUTIONtipranavir

4

QL 300 / 30 DAYS

AL1 Up to 8 yrs old

S

APTIVUS 250 MG CAPtipranavir

4QL 120 / 30 DAYS

S

atazanavir sulfate 150 mg cap 2



CRIXIVAN 200 MG CAPindinavir sulfate

4QL 360 / 30 DAYS

S

CRIXIVAN 400 MG CAPindinavir sulfate

4QL 180 / 30 DAYS

S

fosamprenavir calcium 700 mg tab 2



INVIRASE 200 MG CAPsaquinavir mesylate

4QL 300 / 30 DAYS

S

INVIRASE 500 MG TABsaquinavir mesylate

4QL 120 / 30 DAYS

S

LEXIVA 50 MG/ML SUSPENSIONfosamprenavir calcium

4QL 1800 / 30 DAYS

S

NORVIR 100 MG CAPritonavir

4QL 360 / 30 DAYS

S

NORVIR 80 MG/ML SOLUTIONritonavir

4

QL 480 / 30 DAYS

AL1 Up to 8 yrs old

S

PREZISTA 100 MG/ML SUSPENSIONdarunavir ethanolate

4QL 400 / 30 day(s)

S

PREZISTA 150 MG TABdarunavir ethanolate

4QL 180 / 30 day(s)

S

PREZISTA 600 MG TABdarunavir

4QL 60 / 30 day(s)

S

PREZISTA 75 MG TABdarunavir ethanolate

4QL 300 / 30 day(s)

S

PREZISTA 800 MG TABdarunavir

4 S

REYATAZ 50 MG PACKETatazanavir sulfate


S

ritonavir 100 mg tab 1

ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES

EDURANT 25 MG TABrilpivirine hcl

4QL 30 / 30 DAYS

S

efavirenz 200 mg cap 2

efavirenz 50 mg cap 2



efavirenz 600 mg tab 2

etravirine 100 mg tab 4QL 120 / 30 day(s)

S

etravirine 200 mg tab 4QL 60 / 30 day(s)

S

INTELENCE 25 MG TABetravirine

4 S

nevirapine 200 mg tab 1 QL 60 / 30 DAYS

NEVIRAPINE 50 MG/5ML SUSPENSIONnevirapine

1QL 1200 / 30 day(s)

AL1 Up to 8 yrs old

nevirapine er 100 mg tab er 24h 1 QL 90 / 30 DAYS

NEVIRAPINE ER 100 MG TAB ER 24Hnevirapine

1 QL 90 / 30 DAYS

nevirapine er 400 mg tab er 24h 1 QL 30 / 30 DAYS

PIFELTRO 100 MG TABdoravirine

4 S

RESCRIPTOR 100 MG TABdelavirdine mesylate

4QL 360 / 30 DAYS

S

RESCRIPTOR 200 MG TABdelavirdine mesylate

4QL 180 / 30 DAYS

S

ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES

abacavir sulfate 20 mg/ml solution 1 AL1 Up to 8 yrs old

abacavir sulfate 300 mg tab 1 QL 60 / 30 DAYS

DIDANOSINE 200 MG CAP DRdidanosine

1 QL 60 / 30 DAYS

didanosine 200 mg cap dr 1 QL 60 / 30 DAYS


1 QL 30 / 30 DAYS



1 QL 30 / 30 DAYS




ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINESemtricitabine 200 mg cap 2

EMTRIVA 10 MG/ML SOLUTIONemtricitabine

4QL 850 / 30 DAYS

S

lamivudine 10 mg/ml solution 1

lamivudine 150 mg tab 1 QL 60 / 30 DAYS


ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINESSTAVUDINE 15 MG CAPstavudine

1 QL 120 / 30 DAYS

stavudine 15 mg cap 1 QL 120 / 30 DAYS

STAVUDINE 20 MG CAPstavudine

1 QL 120 / 30 DAYS



1 QL 60 / 30 DAYS



1 QL 60 / 30 DAYS


zidovudine 100 mg cap 1 QL 180 / 30 DAYS

zidovudine 300 mg tab 1 QL 60 / 30 DAYS

zidovudine 50 mg/5ml syrup 1 QL 1920 / 30 DAYS

ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES

tenofovir disoproxil fumarate 300 mg tab 1 QL 30 / 30 DAYS

VIREAD 150 MG TABtenofovir disoproxil fumarate

4QL 30 / 30 DAYS

S


4QL 30 / 30 DAYS

S




4QL 30 / 30 DAYS

S

VIREAD 40 MG/GM POWDERtenofovir disoproxil fumarate

4

QL 240 / 30 DAYS

AL1 Up to 8 yrs old

S

ANTIRETROVIRALS ADJUVANTS

TYBOST 150 MG TABcobicistat

4QL 30 / 30 DAYS

S

ANTIVIRAL COMBINATIONSPAXLOVID 20 X 150 MG & 10 X 100MG TAB THPKnirmatrelvir-ritonavir

2 QL 30 / 180 day(s)

CMV AGENTS

LIVTENCITY 200 MG TABmaribavir

4PA

S

valganciclovir hcl 450 mg tab 2

valganciclovir hcl 50 mg/ml recon soln 2 AL1 Up to 8 yrs old

HEPATITIS B AGENTS

adefovir dipivoxil 10 mg tab 4PA

S

BARACLUDE 0.05 MG/ML SOLUTIONentecavir

4PA

S

entecavir 0.5 mg tab 1 QL 30 / 30 DAYS

entecavir 1 mg tab 1 QL 30 / 30 DAYS


HEPATITIS C AGENT - COMBINATIONS

LEDIPASVIR-SOFOSBUVIR 90-400 MG TABledipasvir-sofosbuvir

4PA

S

MAVYRET 100-40 MG TABglecaprevir-pibrentasvir

4PA

S



MAVYRET 50-20 MG PACKETglecaprevir-pibrentasvir

4PA

S

SOFOSBUVIR-VELPATASVIR 400-100 MG TABsofosbuvir-velpatasvir

4PA

S

HEPATITIS C AGENTSmoderiba 200 mg tab 1

PEGASYS 180 MCG/0.5ML SOLN PRSYRpeginterferon alfa-2a

4PA

S

PEGASYS PROCLICK 135 MCG/0.5ML SOLN A-INJpeginterferon alfa-2a

4PA

S

PEGASYS PROCLICK 180 MCG/0.5ML SOLN A-INJpeginterferon alfa-2a

4PA

S

PEGINTRON 50 MCG/0.5ML KITpeginterferon alfa-2b

4PA

S

ribasphere 200 mg cap 1

ribasphere 200 mg tab 1

RIBASPHERE 400 MG TABribavirin (hepatitis c)

4PA

S

RIBASPHERE 600 MG TABribavirin (hepatitis c)

4PA

S

RIBASPHERE RIBAPAK (1000 PACK) 400 & 600 MG TABTHPKribavirin (hepatitis c)

4PA

S

RIBASPHERE RIBAPAK (1200 PACK) 600 MG TAB THPKribavirin (hepatitis c)

4PA

S

RIBASPHERE RIBAPAK (800 PACK) 400 MG TAB THPKribavirin (hepatitis c)

4PA

S

ribavirin 200 mg cap 1

ribavirin 200 mg tab 1



HERPES AGENTS - PURINE ANALOGUESacyclovir 200 mg cap 1

acyclovir 200 mg/5ml suspension 1

acyclovir 400 mg tab 1

acyclovir 800 mg tab 1

valacyclovir hcl 1 gm tab 1

valacyclovir hcl 500 mg tab 1

HERPES AGENTS - THYMIDINE ANALOGUES

famciclovir 125 mg tab 1 QL 60 / 30 DAYS



INFLUENZA AGENTSRIMANTADINE HCL 100 MG TABrimantadine hydrochloride

1

MISC. ANTIVIRALSMOLNUPIRAVIR 200 MG CAPmolnupiravir

2 QL 40 / 180 day(s)

NEURAMINIDASE INHIBITORS

oseltamivir phosphate 30 mg cap 1 QL 10 / 5 DAYS


oseltamivir phosphate 6 mg/ml recon susp 1QL 180 / 5 DAYS

MFL 1 / 180 DAYS


RELENZA DISKHALER 5 MG/BLISTER AER POW BAzanamivir

3 QL 20 / 10 DAYS

PA ENDONUCLEASE INHIBITORS

XOFLUZA (40 MG DOSE) 1 X 40 MG TAB THPKbaloxavir marboxil

3QL 1 / 0 day(s)

MFL 1 / 180 day(s)


3 QL 2 / 180 DAYS




3QL 1 / 0 day(s)

MFL 1 / 180 day(s)


3 QL 2 / 180 DAYS

BETA BLOCKERSALPHA-BETA BLOCKERS

carvedilol 12.5 mg tab 5QL 4 / 1 day(s)


carvedilol 25 mg tab 5QL 4 / 1 day(s)






carvedilol phosphate er 10 mg cap er 24h 5QL 30 / 30 DAYS








labetalol hcl 100 mg tab 5 VAL Value Preventive List



BETA BLOCKERS CARDIO-SELECTIVE

acebutolol hcl 200 mg cap 5 VAL Value Preventive List

acebutolol hcl 400 mg cap 5 VAL Value Preventive List



atenolol 100 mg tab 5 VAL Value Preventive List



betaxolol hcl 10 mg tab 5 VAL Value Preventive List

betaxolol hcl 20 mg tab 5 VAL Value Preventive List

bisoprolol fumarate 10 mg tab 5 VAL Value Preventive List

bisoprolol fumarate 5 mg tab 5 VAL Value Preventive List

metoprolol succinate er 100 mg tab er 24h 5QL 60 / 30 day(s)








metoprolol tartrate 100 mg tab 5 VAL Value Preventive List


metoprolol tartrate 37.5 mg tab 5 VAL Value Preventive List



nebivolol hcl 10 mg tab 2 QL 60 / 30 day(s)

nebivolol hcl 2.5 mg tab 2 QL 60 / 30 day(s)





BETA BLOCKERS NON-SELECTIVEINDERAL XL 120 MG CAP ER 24Hpropranolol hcl sustained-release beads

3

INDERAL XL 80 MG CAP ER 24Hpropranolol hcl sustained-release beads

3

INNOPRAN XL 80 MG CAP ER 24Hpropranolol hcl sustained-release beads

3

nadolol 20 mg tab 5 VAL Value Preventive List



pindolol 10 mg tab 5 VAL Value Preventive List

pindolol 5 mg tab 5 VAL Value Preventive List

propranolol hcl 10 mg tab 5 VAL Value Preventive List


propranolol hcl 20 mg/5ml solution 5AL1 Up to 8 yrs old



PROPRANOLOL HCL 40 MG/5ML SOLUTIONpropranolol hcl





propranolol hcl er 120 mg cap er 24h 5 VAL Value Preventive List




sorine 120 mg tab 1

sorine 160 mg tab 1



sorine 240 mg tab 1

sorine 80 mg tab 1

sotalol hcl (af) 120 mg tab 1



sotalol hcl 120 mg tab 1




SOTYLIZE 5 MG/ML SOLUTIONsotalol hcl

4QL 1920 / 30 day(s)

PA

TIMOLOL MALEATE 10 MG TABtimolol maleate


timolol maleate 10 mg tab 5

TIMOLOL MALEATE 20 MG TABtimolol maleate


timolol maleate 20 mg tab 5 VAL Value Preventive List

timolol maleate 5 mg tab 5 VAL Value Preventive List

CALCIUM CHANNEL BLOCKERS

afeditab cr 30 mg tab er 24h 5 VAL Value Preventive List

afeditab cr 60 mg tab er 24h 5 VAL Value Preventive List

amlodipine besylate 10 mg tab 5QL 30 / 30 DAYS


amlodipine besylate 2.5 mg tab 5QL 30 / 30 DAYS


amlodipine besylate 5 mg tab 5QL 30 / 30 DAYS


cartia xt 120 mg cap er 24h 5 VAL Value Preventive List






dilt-xr 120 mg cap er 24h 5 VAL Value Preventive List



diltiazem cd 120 mg cap er 24h 5 VAL Value Preventive List




diltiazem hcl 120 mg tab 5 VAL Value Preventive List




diltiazem hcl er 120 mg cap er 12h 5 VAL Value Preventive List






diltiazem hcl er beads 120 mg cap er 24h 5 VAL Value Preventive List








diltiazem hcl er coated beads 120 mg cap er 24h 5 VAL Value Preventive List


diltiazem hcl er coated beads 180 mg tab er 24h 5 VAL Value Preventive List








felodipine er 10 mg tab er 24h 5 VAL Value Preventive List

felodipine er 2.5 mg tab er 24h 5 VAL Value Preventive List

felodipine er 5 mg tab er 24h 5 VAL Value Preventive List

isradipine 2.5 mg cap 5 VAL Value Preventive List

isradipine 5 mg cap 5 VAL Value Preventive List

KATERZIA 1 MG/ML SUSPENSIONamlodipine benzoate


matzim la 180 mg tab er 24h 5 VAL Value Preventive List





nicardipine hcl 20 mg cap 5 VAL Value Preventive List



nicardipine hcl 30 mg cap 5 VAL Value Preventive List

nifedipine 10 mg cap 5 VAL Value Preventive List

nifedipine 20 mg cap 5 VAL Value Preventive List

nifedipine er 30 mg tab er 24h 5 VAL Value Preventive List



nifedipine er osmotic release 30 mg tab er 24h 5 VAL Value Preventive List



nimodipine 30 mg cap 2

nisoldipine er 17 mg tab er 24h 5 VAL Value Preventive List

NISOLDIPINE ER 20 MG TAB ER 24Hnisoldipine


NISOLDIPINE ER 25.5 MG TAB ER 24Hnisoldipine




nisoldipine er 34 mg tab er 24h 5 VAL Value Preventive List



nisoldipine er 8.5 mg tab er 24h 5 VAL Value Preventive List

taztia xt 120 mg cap er 24h 5 VAL Value Preventive List





tiadylt er 120 mg cap er 24h 5 VAL Value Preventive List








verapamil hcl 120 mg tab 5 VAL Value Preventive List



verapamil hcl er 120 mg cap er 24h 5 VAL Value Preventive List

verapamil hcl er 120 mg tab er 5 VAL Value Preventive List





CARDIOTONICSCARDIAC GLYCOSIDES

digitek 125 mcg tab 1

digitek 250 mcg tab 1

digox 125 mcg tab 1

digox 250 mcg tab 1

DIGOXIN 0.05 MG/ML SOLUTIONdigoxin


digoxin 0.05 mg/ml solution 5 VAL Value Preventive List

digoxin 125 mcg tab 5 VAL Value Preventive List

digoxin 250 mcg tab 5 VAL Value Preventive List

LANOXIN 125 MCG TABdigoxin

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSLANOXIN 187.5 MCG TABdigoxin

3

LANOXIN 250 MCG TABdigoxin

3

CARDIOVASCULAR AGENTS - MISC.CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB

amlodipine-atorvastatin 10-10 mg tab 1




amlodipine-atorvastatin 2.5-10 mg tab 1 QL 30 / 30 day(s)

AMLODIPINE-ATORVASTATIN 2.5-10 MG TABamlodipine besylate-atorvastatin calcium

1 QL 30 / 30 day(s)

amlodipine-atorvastatin 2.5-20 mg tab 1

amlodipine-atorvastatin 2.5-40 mg tab 1





NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMBENTRESTO 24-26 MG TABsacubitril-valsartan

2 QL 60 / 30 DAYS

ENTRESTO 49-51 MG TABsacubitril-valsartan

2 QL 60 / 30 DAYS

ENTRESTO 97-103 MG TABsacubitril-valsartan

2 QL 60 / 30 DAYS

PROSTAGLANDIN VASODILATORS

VENTAVIS 10 MCG/ML SOLUTIONiloprost

4PA

S

VENTAVIS 20 MCG/ML SOLUTIONiloprost

4PA

S



PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)

ADEMPAS 0.5 MG TABriociguat

4PA

S

ADEMPAS 1 MG TABriociguat

4PA

S


4PA

S

ADEMPAS 2 MG TABriociguat

4PA

S


4PA

S

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS

ambrisentan 10 mg tab 4

QL 30 / 30 DAYS

PA

S

ambrisentan 5 mg tab 4

QL 30 / 30 DAYS

PA

S

bosentan 125 mg tab 2QL 60 / 30 DAYS

PA

bosentan 62.5 mg tab 2QL 60 / 30 DAYS

PA

OPSUMIT 10 MG TABmacitentan

4PA

S

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS

sildenafil citrate 10 mg/ml recon susp 2 PA

sildenafil citrate 20 mg tab 1QL 90 / 30 DAYS

PA

tadalafil (pah) 20 mg tab 2QL 60 / 30 DAYS

PA



PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST

UPTRAVI 1000 MCG TABselexipag

4PA

S


4PA

S


4PA

S


4PA

S

UPTRAVI 200 & 800 MCG TAB THPKselexipag

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS

tadalafil 2.5 mg tab 1QL 30 / 30 DAYS

PA

tadalafil 20 mg tab 2QL 60 / 30 DAYS

PA

tadalafil 5 mg tab 1QL 30 / 30 DAYS

PA

SINUS NODE INHIBITORSCORLANOR 5 MG TABivabradine hcl

2 QL 60 / 30 day(s)


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCORLANOR 7.5 MG TABivabradine hcl

2 QL 60 / 30 day(s)

CEPHALOSPORINSCEPHALOSPORINS - 1ST GENERATION

CEFADROXIL 1 GM TABcefadroxil

1

cefadroxil 1 gm tab 1

cefadroxil 250 mg/5ml recon susp 1

cefadroxil 500 mg cap 1

cefadroxil 500 mg/5ml recon susp 1

cephalexin 125 mg/5ml recon susp 1

cephalexin 250 mg cap 1

CEPHALEXIN 250 MG TABcephalexin

1

cephalexin 250 mg/5ml recon susp 1


CEPHALEXIN 500 MG TABcephalexin

1

CEPHALEXIN 750 MG CAPcephalexin

1


CEPHALOSPORINS - 2ND GENERATIONCEFACLOR 125 MG/5ML RECON SUSPcefaclor


CEFACLOR 250 MG CAPcefaclor

1 QL 30 / 10 DAYS

cefaclor 250 mg cap 1 QL 30 / 10 DAYS

CEFACLOR 250 MG/5ML RECON SUSPcefaclor


CEFACLOR 375 MG/5ML RECON SUSPcefaclor


CEFACLOR 500 MG CAPcefaclor

1 QL 30 / 10 DAYS



cefaclor 500 mg cap 1 QL 30 / 10 DAYS

CEFACLOR ER 500 MG TAB ER 12Hcefaclor monohydrate

1 QL 20 / 10 DAYS

cefprozil 125 mg/5ml recon susp 1

cefprozil 250 mg tab 1

cefprozil 250 mg/5ml recon susp 1

cefprozil 500 mg tab 1

cefuroxime axetil 250 mg tab 1

cefuroxime axetil 500 mg tab 1

CEPHALOSPORINS - 3RD GENERATIONcefdinir 125 mg/5ml recon susp 1

cefdinir 250 mg/5ml recon susp 1

cefdinir 300 mg cap 1

CEFDITOREN PIVOXIL 200 MG TABcefditoren pivoxil

2

CEFDITOREN PIVOXIL 400 MG TABcefditoren pivoxil

2

cefixime 100 mg/5ml recon susp 2

cefixime 200 mg/5ml recon susp 2 AL1 Up to 8 yrs old

cefixime 400 mg cap 2 QL 14 / 30 DAYS

cefpodoxime proxetil 100 mg tab 1

cefpodoxime proxetil 100 mg/5ml recon susp 1 AL1 Up to 8 yrs old

cefpodoxime proxetil 200 mg tab 1

cefpodoxime proxetil 50 mg/5ml recon susp 1 AL1 Up to 8 yrs old

CONTRACEPTIVESBIPHASIC CONTRACEPTIVES - ORAL

azurette 0.15-0.02/0.01 mg (21/5) tab 5 PRE Preventative

bekyree 0.15-0.02/0.01 mg (21/5) tab 5 PRE Preventative

desogestrel-ethinyl estradiol 0.15-0.02/0.01 mg (21/5) tab 5 PRE Preventative



kariva 0.15-0.02/0.01 mg (21/5) tab 5 PRE Preventative

kimidess 0.15-0.02/0.01 mg (21/5) tab 5 PRE Preventative

LO LOESTRIN FE 1 MG-10 MCG / 10 MCG TABnorethindrone acetate-ethinyl estradiol-fe fum (biphasic)

3 QL 30 / 30 day(s)

MIRCETTE 0.15-0.02/0.01 MG (21/5) TABdesogestrel-ethinyl estradiol (biphasic)

3

pimtrea 0.15-0.02/0.01 mg (21/5) tab 5 PRE Preventative

simliya 0.15-0.02/0.01 mg (21/5) tab 5 PRE Preventative

viorele 0.15-0.02/0.01 mg (21/5) tab 5 PRE Preventative

volnea 0.15-0.02/0.01 mg (21/5) tab 5 PRE Preventative

COMBINATION CONTRACEPTIVES - ORAL

afirmelle 0.1-20 mg-mcg tab 5 PRE Preventative

altavera 0.15-30 mg-mcg tab 5 PRE Preventative

alyacen 1/35 1-35 mg-mcg tab 5 PRE Preventative

apri 0.15-30 mg-mcg tab 5 PRE Preventative

aubra 0.1-20 mg-mcg tab 5 PRE Preventative

aubra eq 0.1-20 mg-mcg tab 5 PRE Preventative

aurovela 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

aurovela 1/20 1-20 mg-mcg tab 5 PRE Preventative

aurovela 24 fe 1-20 mg-mcg(24) tab 5 PRE Preventative

aurovela fe 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

aurovela fe 1/20 1-20 mg-mcg tab 5 PRE Preventative

aviane 0.1-20 mg-mcg tab 5 PRE Preventative

ayuna 0.15-30 mg-mcg tab 5 PRE Preventative

BALCOLTRA 0.1-20 MG-MCG(21) TABlevonorgestrel-ethinyl estradiol-ferrous bisglycinate

3



balziva 0.4-35 mg-mcg tab 5 PRE Preventative

BEYAZ 3-0.02-0.451 MG TABdrospirenone-ethinyl estradiol-levomefolate calcium

3

blisovi 24 fe 1-20 mg-mcg(24) tab 5 PRE Preventative

blisovi fe 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

blisovi fe 1/20 1-20 mg-mcg tab 5 PRE Preventative

briellyn 0.4-35 mg-mcg tab 5 PRE Preventative

charlotte 24 fe 1-20 mg-mcg(24) chew tab 5 PRE Preventative

chateal 0.15-30 mg-mcg tab 5 PRE Preventative

chateal eq 0.15-30 mg-mcg tab 5 PRE Preventative

cryselle-28 0.3-30 mg-mcg tab 5 PRE Preventative

cyclafem 1/35 1-35 mg-mcg tab 5 PRE Preventative

cyred 0.15-30 mg-mcg tab 5 PRE Preventative

cyred eq 0.15-30 mg-mcg tab 5 PRE Preventative

dasetta 1/35 1-35 mg-mcg tab 5 PRE Preventative

delyla 0.1-20 mg-mcg tab 5 PRE Preventative

desogestrel-ethinyl estradiol 0.15-30 mg-mcg tab 5 PRE Preventative

drospiren-eth estrad-levomefol 3-0.02-0.451 mg tab 3

drospiren-eth estrad-levomefol 3-0.03-0.451 mg tab 5 PRE Preventative

drospirenone-ethinyl estradiol 3-0.02 mg tab 5 PRE Preventative

drospirenone-ethinyl estradiol 3-0.03 mg tab 5 PRE Preventative

elinest 0.3-30 mg-mcg tab 5 PRE Preventative

emoquette 0.15-30 mg-mcg tab 5 PRE Preventative

enskyce 0.15-30 mg-mcg tab 5 PRE Preventative

estarylla 0.25-35 mg-mcg tab 5 PRE Preventative



ethynodiol diac-eth estradiol 1-35 mg-mcg tab 5 PRE Preventative

ethynodiol diac-eth estradiol 1-50 mg-mcg tab 5 PRE Preventative

falmina 0.1-20 mg-mcg tab 5 PRE Preventative

femynor 0.25-35 mg-mcg tab 5 PRE Preventative

gemmily 1-20 mg-mcg(24) cap 2

GENERESS FE 0.8-25 MG-MCG CHEW TABnorethindrone & ethinyl estradiol-fe

3

gianvi 3-0.02 mg tab 5 PRE Preventative

hailey 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

hailey 24 fe 1-20 mg-mcg(24) tab 5 PRE Preventative

hailey fe 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

hailey fe 1/20 1-20 mg-mcg tab 5 PRE Preventative

isibloom 0.15-30 mg-mcg tab 5 PRE Preventative

jasmiel 3-0.02 mg tab 5 PRE Preventative

juleber 0.15-30 mg-mcg tab 5 PRE Preventative

junel 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

junel 1/20 1-20 mg-mcg tab 5 PRE Preventative

junel fe 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

junel fe 1/20 1-20 mg-mcg tab 5 PRE Preventative

junel fe 24 1-20 mg-mcg(24) tab 5 PRE Preventative

kaitlib fe 0.8-25 mg-mcg chew tab 5 PRE Preventative

kalliga 0.15-30 mg-mcg tab 5 PRE Preventative

kelnor 1/35 1-35 mg-mcg tab 5 PRE Preventative

kelnor 1/50 1-50 mg-mcg tab 5 PRE Preventative

kurvelo 0.15-30 mg-mcg tab 5 PRE Preventative



larin 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

larin 1/20 1-20 mg-mcg tab 5 PRE Preventative

larin 24 fe 1-20 mg-mcg(24) tab 5 PRE Preventative

larin fe 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

larin fe 1/20 1-20 mg-mcg tab 5 PRE Preventative

larissia 0.1-20 mg-mcg tab 5 PRE Preventative

layolis fe 0.8-25 mg-mcg chew tab 5 PRE Preventative

lessina 0.1-20 mg-mcg tab 5 PRE Preventative

levonorgestrel-ethinyl estrad 0.1-20 mg-mcg tab 5 PRE Preventative

levonorgestrel-ethinyl estrad 0.15-30 mg-mcg tab 5 PRE Preventative

levora 0.15/30 (28) 0.15-30 mg-mcg tab 5 PRE Preventative

lillow 0.15-30 mg-mcg tab 5 PRE Preventative

lo-zumandimine 3-0.02 mg tab 5 PRE Preventative

loestrin 1.5/30 (21) 1.5-30 mg-mcg tab 5 PRE Preventative

loestrin 1/20 (21) 1-20 mg-mcg tab 5 PRE Preventative

loestrin fe 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

loestrin fe 1/20 1-20 mg-mcg tab 5 PRE Preventative

loryna 3-0.02 mg tab 5 PRE Preventative

low-ogestrel 0.3-30 mg-mcg tab 5 PRE Preventative

lutera 0.1-20 mg-mcg tab 5 PRE Preventative

marlissa 0.15-30 mg-mcg tab 5 PRE Preventative

melodetta 24 fe 1-20 mg-mcg(24) chew tab 5 PRE Preventative

merzee 1-20 mg-mcg(24) cap 2

mibelas 24 fe 1-20 mg-mcg(24) chew tab 5 PRE Preventative



microgestin 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

microgestin 1/20 1-20 mg-mcg tab 5 PRE Preventative

microgestin 24 fe 1-20 mg-mcg tab 5 PRE Preventative

microgestin fe 1.5/30 1.5-30 mg-mcg tab 5 PRE Preventative

microgestin fe 1/20 1-20 mg-mcg tab 5 PRE Preventative

mili 0.25-35 mg-mcg tab 5 PRE Preventative

MINASTRIN 24 FE 1-20 MG-MCG(24) CHEW TABnorethin acet & estrad-fe

3

mono-linyah 0.25-35 mg-mcg tab 5 PRE Preventative

mononessa 0.25-35 mg-mcg tab 5 PRE Preventative

necon 0.5/35 (28) 0.5-35 mg-mcg tab 5 PRE Preventative

NEXTSTELLIS 3-14.2 MG TABdrospirenone-estetrol

3

nikki 3-0.02 mg tab 5 PRE Preventative

norethin ace-eth estrad-fe 1-20 mg-mcg tab 5 PRE Preventative

norethin ace-eth estrad-fe 1-20 mg-mcg(24) cap 2

norethin ace-eth estrad-fe 1-20 mg-mcg(24) chew tab 5 PRE Preventative

norethin ace-eth estrad-fe 1-20 mg-mcg(24) tab 5 PRE Preventative

norethin ace-eth estrad-fe 1.5-30 mg-mcg tab 5 PRE Preventative

norethin-eth estradiol-fe 0.4-35 mg-mcg chew tab 5 PRE Preventative

norethin-eth estradiol-fe 0.8-25 mg-mcg chew tab 5 PRE Preventative

norethindrone acet-ethinyl est 1-20 mg-mcg tab 5 PRE Preventative

norethindrone acet-ethinyl est 1-20 mg-mcg(24) chew tab 5 PRE Preventative

norethindrone acet-ethinyl est 1.5-30 mg-mcg tab 5 PRE Preventative

norgestimate-eth estradiol 0.25-35 mg-mcg tab 5 PRE Preventative

nortrel 0.5/35 (28) 0.5-35 mg-mcg tab 5 PRE Preventative



nortrel 1/35 (21) 1-35 mg-mcg tab 5 PRE Preventative

nortrel 1/35 (28) 1-35 mg-mcg tab 5 PRE Preventative

nylia 1/35 1-35 mg-mcg tab 5 PRE Preventative

nymyo 0.25-35 mg-mcg tab 5 PRE Preventative

ocella 3-0.03 mg tab 5 PRE Preventative

OGESTREL 0.5-50 MG-MCG TABnorgestrel & ethinyl estradiol

5 PRE Preventative

orsythia 0.1-20 mg-mcg tab 5 PRE Preventative

ORTHO-CYCLEN (28) 0.25-35 MG-MCG TABnorgestimate-ethinyl estradiol

3

ORTHO-NOVUM 1/35 (28) 1-35 MG-MCG TABnorethindrone & eth estradiol

3

philith 0.4-35 mg-mcg tab 5 PRE Preventative

pirmella 1/35 1-35 mg-mcg tab 5 PRE Preventative

portia-28 0.15-30 mg-mcg tab 5 PRE Preventative

previfem 0.25-35 mg-mcg tab 5 PRE Preventative

rajani 3-0.02-0.451 mg tab 3

reclipsen 0.15-30 mg-mcg tab 5 PRE Preventative

SAFYRAL 3-0.03-0.451 MG TABdrospirenone-ethinyl estradiol-levomefolate calcium

3

sprintec 28 0.25-35 mg-mcg tab 5 PRE Preventative

sronyx 0.1-20 mg-mcg tab 5 PRE Preventative

syeda 3-0.03 mg tab 5 PRE Preventative

tarina 24 fe 1-20 mg-mcg(24) tab 5 PRE Preventative

tarina fe 1/20 1-20 mg-mcg tab 5 PRE Preventative

tarina fe 1/20 eq 1-20 mg-mcg tab 5 PRE Preventative

taysofy 1-20 mg-mcg(24) cap 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTAYTULLA 1-20 MG-MCG(24) CAPnorethin acet & estrad-fe

3

TYBLUME 0.1-20 MG-MCG CHEW TABlevonorgestrel & eth estradiol

5 PRE Preventative

tydemy 3-0.03-0.451 mg tab 5 PRE Preventative

vestura 3-0.02 mg tab 5 PRE Preventative

vienva 0.1-20 mg-mcg tab 5 PRE Preventative

vyfemla 0.4-35 mg-mcg tab 5 PRE Preventative

vylibra 0.25-35 mg-mcg tab 5 PRE Preventative

wera 0.5-35 mg-mcg tab 5 PRE Preventative

wymzya fe 0.4-35 mg-mcg chew tab 5 PRE Preventative

YASMIN 28 3-0.03 MG TABdrospirenone-ethinyl estradiol

3

YAZ 3-0.02 MG TABdrospirenone-ethinyl estradiol

3

zarah 3-0.03 mg tab 5 PRE Preventative

zenchent 0.4-35 mg-mcg tab 5 PRE Preventative

zovia 1/35 (28) 1-35 mg-mcg tab 5 PRE Preventative

zovia 1/35e (28) 1-35 mg-mcg tab 5 PRE Preventative

zumandimine 3-0.03 mg tab 5 PRE Preventative

COMBINATION CONTRACEPTIVES - TRANSDERMAL

TWIRLA 120-30 MCG/24HR PATCH WKlevonorgestrel-ethinyl estradiol

5QL 3 / 21 day(s)

PRE Preventative

xulane 150-35 mcg/24hr patch wk 5QL 3 / 21 day(s)

PRE Preventative

zafemy 150-35 mcg/24hr patch wk 5QL 3 / 21 day(s)

PRE Preventative



COMBINATION CONTRACEPTIVES - VAGINAL

ANNOVERA 0.013-0.15 MG/24HR RINGsegesterone acetate-ethinyl estradiol

5QL 1 / 365 day(s)

PRE Preventative

eluryng 0.12-0.015 mg/24hr ring 5 PRE Preventative

etonogestrel-ethinyl estradiol 0.12-0.015 mg/24hr ring 5 PRE Preventative

CONTINUOUS CONTRACEPTIVES - ORAL

amethyst 90-20 mcg tab 5 PRE Preventative

dolishale 90-20 mcg tab 5 PRE Preventative

levonorgestrel-ethinyl estrad 90-20 mcg tab 5 PRE Preventative

COPPER CONTRACEPTIVES - IUDPARAGARD INTRAUTERINE COPPER IUDcopper (iud)

5 PRE Preventative

EMERGENCY CONTRACEPTIVES

ELLA 30 MG TABulipristal acetate

5QL 1 / 30 DAYS

PRE Preventative

EXTENDED-CYCLE CONTRACEPTIVES - ORAL

amethia 0.15-0.03 &0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

amethia lo 0.1-0.02 & 0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

ashlyna 0.15-0.03 &0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

camrese 0.15-0.03 &0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

camrese lo 0.1-0.02 & 0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

daysee 0.15-0.03 &0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative



fayosim 42-21-21-7 days tab 5 PRE Preventative

iclevia 0.15-0.03 mg tab 5QL 91 / 91 DAYS

PRE Preventative

introvale 0.15-0.03 mg tab 5QL 91 / 91 DAYS

PRE Preventative

jaimiess 0.15-0.03 &0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

jolessa 0.15-0.03 mg tab 5QL 91 / 91 DAYS

PRE Preventative

levonorgest-eth est & eth est 42-21-21-7 days tab 5 PRE Preventative

levonorgest-eth estrad 91-day 0.1-0.02 & 0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

levonorgest-eth estrad 91-day 0.15-0.03 &0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

levonorgest-eth estrad 91-day 0.15-0.03 mg tab 5QL 91 / 91 DAYS

PRE Preventative

lojaimiess 0.1-0.02 & 0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

LOSEASONIQUE 0.1-0.02 & 0.01 MG TABlevonorgestrel-ethinyl estradiol (91-day)

3

QUARTETTE 42-21-21-7 DAYS TABlevonorgestrel-ethinyl estradiol (91-day)

3

quasense 0.15-0.03 mg tab 5QL 91 / 91 DAYS

PRE Preventative

rivelsa 42-21-21-7 days tab 5 PRE Preventative

SEASONIQUE 0.15-0.03 &0.01 MG TABlevonorgestrel-ethinyl estradiol (91-day)

3

setlakin 0.15-0.03 mg tab 5QL 91 / 91 DAYS

PRE Preventative



simpesse 0.15-0.03 &0.01 mg tab 5QL 91 / 91 DAYS

PRE Preventative

FOUR PHASE CONTRACEPTIVES - ORALNATAZIA 3/2-2/2-3/1 MG TABestradiol valerate-dienogest

3

PROGESTIN CONTRACEPTIVES - IMPLANTSNEXPLANON 68 MG IMPLANTetonogestrel

5 PRE Preventative

PROGESTIN CONTRACEPTIVES - INJECTABLEDEPO-PROVERA 150 MG/ML SUSP PRSYRmedroxyprogesterone acetate (contraceptive)

3

DEPO-PROVERA 150 MG/ML SUSPENSIONmedroxyprogesterone acetate (contraceptive)

3

DEPO-SUBQ PROVERA 104 104 MG/0.65ML SUSP PRSYRmedroxyprogesterone acetate (contraceptive)

5 PRE Preventative

medroxyprogesterone acetate 150 mg/ml susp prsyr 5 PRE Preventative

medroxyprogesterone acetate 150 mg/ml suspension 5 PRE Preventative

PROGESTIN CONTRACEPTIVES - IUDKYLEENA 19.5 MG IUDlevonorgestrel (iud)

5 PRE Preventative

LILETTA (52 MG) 20.1 MCG/DAY IUDlevonorgestrel (iud)

5 PRE Preventative

MIRENA (52 MG) 20 MCG/DAY IUDlevonorgestrel (iud)

5 PRE Preventative

SKYLA 13.5 MG IUDlevonorgestrel (iud)

5 PRE Preventative

PROGESTIN CONTRACEPTIVES - ORAL

camila 0.35 mg tab 5 PRE Preventative

deblitane 0.35 mg tab 5 PRE Preventative

errin 0.35 mg tab 5 PRE Preventative

heather 0.35 mg tab 5 PRE Preventative

incassia 0.35 mg tab 5 PRE Preventative



jencycla 0.35 mg tab 5 PRE Preventative

jolivette 0.35 mg tab 5 PRE Preventative

lyleq 0.35 mg tab 5 PRE Preventative

lyza 0.35 mg tab 5 PRE Preventative

nora-be 0.35 mg tab 5 PRE Preventative

norethindrone 0.35 mg tab 5 PRE Preventative

norlyda 0.35 mg tab 5 PRE Preventative

norlyroc 0.35 mg tab 5 PRE Preventative

ORTHO MICRONOR 0.35 MG TABnorethindrone (contraceptive)

3

sharobel 0.35 mg tab 5 PRE Preventative

SLYND 4 MG TABdrospirenone

3

tulana 0.35 mg tab 5 PRE Preventative

TRIPHASIC CONTRACEPTIVES - ORAL

alyacen 7/7/7 0.5/0.75/1-35 mg-mcg tab 5 PRE Preventative

aranelle 0.5/1/0.5-35 mg-mcg tab 5 PRE Preventative

caziant 0.1/0.125/0.15 -0.025 mg tab 5 PRE Preventative

cyclafem 7/7/7 0.5/0.75/1-35 mg-mcg tab 5 PRE Preventative

dasetta 7/7/7 0.5/0.75/1-35 mg-mcg tab 5 PRE Preventative

enpresse-28 50-30/75-40/ 125-30 mcg tab 5 PRE Preventative

ESTROSTEP FE 1-20/1-30/1-35 MG-MCG TABnorethindrone acetate-ethinyl estradiol-fe

3

leena 0.5/1/0.5-35 mg-mcg tab 5 PRE Preventative

levonest 50-30/75-40/ 125-30 mcg tab 5 PRE Preventative

levonorg-eth estrad triphasic 50-30/75-40/ 125-30 mcgtab

5 PRE Preventative



myzilra 50-30/75-40/ 125-30 mcg tab 5 PRE Preventative

necon 7/7/7 0.5/0.75/1-35 mg-mcg tab 5 PRE Preventative

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-25mcg tab

5 PRE Preventative

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-35mcg tab

5 PRE Preventative

nortrel 7/7/7 0.5/0.75/1-35 mg-mcg tab 5 PRE Preventative

nylia 7/7/7 0.5/0.75/1-35 mg-mcg tab 5 PRE Preventative

ORTHO TRI-CYCLEN (28) 0.18/0.215/0.25 MG-35 MCGTABnorgestimate-ethinyl estradiol (triphasic)

3

ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 MG-25 MCG TABnorgestimate-ethinyl estradiol (triphasic)

3

ORTHO-NOVUM 7/7/7 (28) 0.5/0.75/1-35 MG-MCG TABnorethindrone-eth estradiol (triphasic)

3

pirmella 7/7/7 0.5/0.75/1-35 mg-mcg tab 5 PRE Preventative

tilia fe 1-20/1-30/1-35 mg-mcg tab 5 PRE Preventative

tri femynor 0.18/0.215/0.25 mg-35 mcg tab 5 PRE Preventative

tri-estarylla 0.18/0.215/0.25 mg-35 mcg tab 5 PRE Preventative

tri-legest fe 1-20/1-30/1-35 mg-mcg tab 5 PRE Preventative

tri-linyah 0.18/0.215/0.25 mg-35 mcg tab 5 PRE Preventative

tri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg tab 5 PRE Preventative

tri-lo-marzia 0.18/0.215/0.25 mg-25 mcg tab 5 PRE Preventative

tri-lo-mili 0.18/0.215/0.25 mg-25 mcg tab 5 PRE Preventative

tri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg tab 5 PRE Preventative

tri-mili 0.18/0.215/0.25 mg-35 mcg tab 5 PRE Preventative

TRI-NORINYL (28) 0.5/1/0.5-35 MG-MCG TABnorethindrone-eth estradiol (triphasic)

1

tri-nymyo 0.18/0.215/0.25 mg-35 mcg tab 5 PRE Preventative



tri-previfem 0.18/0.215/0.25 mg-35 mcg tab 5 PRE Preventative

tri-sprintec 0.18/0.215/0.25 mg-35 mcg tab 5 PRE Preventative

tri-vylibra 0.18/0.215/0.25 mg-35 mcg tab 5 PRE Preventative

tri-vylibra lo 0.18/0.215/0.25 mg-25 mcg tab 5 PRE Preventative

trinessa (28) 0.18/0.215/0.25 mg-35 mcg tab 5 PRE Preventative

trinessa lo 0.18/0.215/0.25 mg-25 mcg tab 5 PRE Preventative

trivora (28) 50-30/75-40/ 125-30 mcg tab 5 PRE Preventative

velivet 0.1/0.125/0.15 -0.025 mg tab 5 PRE Preventative

CORTICOSTEROIDSGLUCOCORTICOSTEROIDS

ALKINDI SPRINKLE 0.5 MG CAP SPRINKhydrocortisone

3QL 2 / 1 day(s)

AL1 Up to 8 yrs old

ALKINDI SPRINKLE 1 MG CAP SPRINKhydrocortisone

3QL 2 / 1 day(s)

AL1 Up to 8 yrs old


3QL 2 / 1 day(s)

AL1 Up to 8 yrs old


3QL 2 / 1 day(s)

AL1 Up to 8 yrs old

budesonide 3 mg cp dr part 2 QL 90 / 30 DAYS

budesonide er 9 mg tab er 24h 2

CORTISONE ACETATE 25 MG TABcortisone acetate

1

decadron 0.5 mg tab 1

decadron 0.5 mg/5ml elixir 1

decadron 0.75 mg tab 1

decadron 4 mg tab 1

decadron 6 mg tab 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSDEXAMETHASONE 0.5 MG TABdexamethasone

1

dexamethasone 0.5 mg tab 1

dexamethasone 0.5 mg/5ml elixir 1

DEXAMETHASONE 0.5 MG/5ML SOLUTIONdexamethasone

1

DEXAMETHASONE 0.75 MG TABdexamethasone

1


DEXAMETHASONE 1 MG TABdexamethasone

1

DEXAMETHASONE 1.5 MG (35) TAB THPKdexamethasone

1

DEXAMETHASONE 1.5 MG (51) TAB THPKdexamethasone

1


DEXAMETHASONE 2 MG TABdexamethasone

1

dexamethasone 4 mg tab 1

dexamethasone 6 mg tab 1

DEXAMETHASONE INTENSOL 1 MG/ML CONCdexamethasone


hydrocortisone 10 mg tab 1



KENALOG-80 80 MG/ML SUSPENSIONtriamcinolone acetonide

3 PA

methylprednisolone 16 mg tab 1



methylprednisolone 4 mg tab thpk 1


PREDNISOLONE 15 MG/5ML SOLUTIONprednisolone

1



prednisolone 15 mg/5ml syrup 1

prednisolone sodium phosphate 10 mg/5ml solution 1

prednisolone sodium phosphate 15 mg/5ml solution 1

prednisolone sodium phosphate 20 mg/5ml solution 1 AL1 Up to 8 yrs old

PREDNISOLONE SODIUM PHOSPHATE 25 MG/5MLSOLUTIONprednisolone sodium phosphate


prednisolone sodium phosphate 6.7 (5 base) mg/5mlsolution

1

prednisone 1 mg tab 1

prednisone 10 mg (21) tab thpk 1



prednisone 2.5 mg tab 1





PREDNISONE 5 MG/5ML SOLUTIONprednisone

1


PREDNISONE INTENSOL 5 MG/ML CONCprednisone


UCERIS 9 MG TAB ER 24Hbudesonide

2QL 30 / 30 DAYS

PA

MINERALOCORTICOIDSfludrocortisone acetate 0.1 mg tab 1

COUGH/COLD/ALLERGYANTITUSSIVE - NONNARCOTIC

benzonatate 100 mg cap 1

benzonatate 200 mg cap 1



ANTITUSSIVE - OPIOID

HYCODAN 5-1.5 MG/5ML SOLUTIONhydrocodone bitartrate-homatropine methylbromide

1

QL 30 / 1 day(s)


hydrocodone bit-homatrop mbr 5-1.5 mg tab 1 QL 6 / 1 day(s)

hydrocodone bit-homatrop mbr 5-1.5 mg/5ml solution 1

QL 30 / 1 day(s)


hydromet 5-1.5 mg/5ml solution 1

QL 30 / 1 day(s)


tussigon 5-1.5 mg tab 1 QL 6 / 1 day(s)

ANTITUSSIVE-EXPECTORANTcheratussin ac 100-10 mg/5ml syrup 1

g tussin ac 100-10 mg/5ml solution 1

guaiatussin ac 100-10 mg/5ml syrup 1

guaifenesin ac 100-10 mg/5ml syrup 1

guaifenesin-codeine 100-10 mg/5ml solution 1

maxi-tuss ac 100-10 mg/5ml solution 1

robafen ac 100-10 mg/5ml solution 1

virtussin a/c 100-10 mg/5ml solution 1

virtussin ac w/alc 100-10 mg/5ml liquid 1

MISC. RESPIRATORY INHALANTSsodium chloride 7 % nebu soln 1

MUCOLYTICSacetylcysteine 10 % solution 1

acetylcysteine 20 % solution 1

NON-NARC ANTITUSSIVE-ANTIHISTAMINEPROMETHAZINE-DM 6.25-15 MG/5ML SOLUTIONpromethazine-dm

1



promethazine-dm 6.25-15 mg/5ml syrup 1

NON-NARC ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINEpseudoeph-bromphen-dm 30-2-10 mg/5ml syrup 1

OPIOID ANTITUSSIVE-ANTIHISTAMINE

hydrocod polst-cpm polst er 10-8 mg/5ml susp 1 QL 50 / 5 DAYS

promethazine-codeine 6.25-10 mg/5ml solution 1QL 150 / 5 DAYS

MFL 3 / 180 DAYS

promethazine-codeine 6.25-10 mg/5ml syrup 1QL 150 / 5 DAYS

MFL 3 / 180 DAYS

DERMATOLOGICALSACNE ANTIBIOTICS

clindacin etz 1 % swab 3

clindamycin phosphate 1 % foam 1

clindamycin phosphate 1 % gel 1

clindamycin phosphate 1 % gel 1

clindamycin phosphate 1 % lotion 1

clindamycin phosphate 1 % solution 1

clindamycin phosphate 1 % swab 1

dapsone 5 % gel 1

dapsone 7.5 % gel 1

erythromycin 2 % gel 1

erythromycin 2 % pad 1

erythromycin 2 % solution 1

sulfacetamide sodium (acne) 10 % lotion 1

ACNE COMBINATIONS

adapalene-benzoyl peroxide 0.1-2.5 % gel 1 QL 90 / 30 DAYS

avar cleanser 10-5 % liquid 1

benzoyl peroxide-erythromycin 5-3 % gel 1



clindamycin phos-benzoyl perox 1-5 % gel 2

clindamycin phos-benzoyl perox 1.2-2.5 % gel 1

clindamycin phos-benzoyl perox 1.2-5 % gel 1

neuac 1.2-5 % gel 1

rosanil cleanser 10-5 % liquid 1

sulfacetamide sodium-sulfur 10-5 % liquid 1

ACNE PRODUCTS

accutane 10 mg cap 2 QL 60 / 30 DAYS




adapalene 0.1 % cream 1

adapalene 0.1 % gel 1

adapalene 0.3 % gel 1

amnesteem 10 mg cap 2 QL 60 / 30 DAYS



avita 0.025 % cream 1 QL 45 / 30 DAYS

avita 0.025 % gel 1 QL 45 / 30 DAYS

AZELEX 20 % CREAMazelaic acid (acne)

3 ST

claravis 10 mg cap 2 QL 60 / 30 DAYS




isotretinoin 10 mg cap 2 QL 60 / 30 DAYS






myorisan 10 mg cap 2 QL 60 / 30 DAYS




tretinoin 0.01 % gel 1 QL 45 / 30 DAYS

tretinoin 0.025 % cream 1 QL 45 / 30 DAYS

tretinoin 0.025 % gel 1 QL 45 / 30 DAYS


tretinoin 0.05 % gel 1


tretinoin microsphere 0.1 % gel 1

tretinoin microsphere pump 0.1 % gel 1

zenatane 10 mg cap 2 QL 60 / 30 DAYS




AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTSVEREGEN 15 % OINTMENTsinecatechins

3 PA

AGENTS FOR FACIAL WRINKLES - RETINOIDSTRETINOIN (EMOLLIENT) 0.05 % CREAMtretinoin (facial wrinkles)

1



ANTI-INFLAMMATORY AGENTS - TOPICAL

DICLOFENAC EPOLAMINE 1.3 % PATCHdiclofenac epolamine

2QL 60 / 30 DAYS

PA

diclofenac sodium 1 % gel 1 QL 500 / 30 DAYS

diclofenac sodium 1.5 % solution 1 QL 150 / 30 DAYS

klofensaid ii 1.5 % solution 1 QL 150 / 30 DAYS

ANTIBIOTIC STEROID COMBINATIONS - TOPICALCORTISPORIN 1 % OINTMENTbacitracin-polymyxin-neomycin hc

3

CORTISPORIN 3.5-10000-0.5 CREAMneomycin-polymyxin-hc

3

ANTIBIOTICS - TOPICALALTABAX 1 % OINTMENTretapamulin

3

gentamicin sulfate 0.1 % cream 1

gentamicin sulfate 0.1 % ointment 1

mupirocin 2 % ointment 1

ANTIFUNGALS - TOPICALciclodan 0.77 % cream 1

ciclodan 8 % solution 1

CICLODAN CREAM 0.77 % KITciclopirox olamine & cleanser

2

ciclopirox 0.77 % gel 1

ciclopirox 1 % shampoo 1

ciclopirox 8 % solution 1

ciclopirox olamine 0.77 % cream 1

ciclopirox olamine 0.77 % suspension 1

CICLOPIROX TREATMENT 8 % KITciclopirox

2

LOPROX 0.77 % CREAMciclopirox olamine

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSLOPROX 0.77 % KITciclopirox olamine & cleanser

3

nyamyc 100000 unit/gm powder 1

nystatin 100000 unit/gm cream 1

nystatin 100000 unit/gm ointment 1

nystatin 100000 unit/gm powder 1

nystop 100000 unit/gm powder 1

ANTIFUNGALS - TOPICAL COMBINATIONSclotrimazole-betamethasone 1-0.05 % cream 1

nystatin-triamcinolone 100000-0.1 unit/gm-% cream 1

nystatin-triamcinolone 100000-0.1 unit/gm-% ointment 1

ANTINEOPLASTIC ALKYLATING AGENTS - TOPICAL

VALCHLOR 0.016 % GELmechlorethamine hcl (topical)

4PA

S

ANTINEOPLASTIC ANTIMETABOLITES - TOPICALFLUOROPLEX 1 % CREAMfluorouracil (topical)

2 PA

FLUOROURACIL 2 % SOLUTIONfluorouracil (topical)

1

fluorouracil 5 % cream 1

FLUOROURACIL 5 % SOLUTIONfluorouracil (topical)

1

ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL NSAID'S

diclofenac sodium 3 % gel 1 QL 500 / 30 DAYS

ANTIPRURITICS - TOPICALDOXEPIN HCL 5 % CREAMdoxepin hcl (antipruritic)

2 PA

PRUDOXIN 5 % CREAMdoxepin hcl (antipruritic)

2 PA

ZONALON 5 % CREAMdoxepin hcl (antipruritic)

2 PA



ANTIPSORIATICS

calcipotriene 0.005 % cream 1 QL 120 / 30 DAYS

calcipotriene 0.005 % solution 1 QL 60 / 30 DAYS

CALCITRIOL 3 MCG/GM OINTMENTcalcitriol (topical)

2

tazarotene 0.1 % cream 1

TAZORAC 0.05 % CREAMtazarotene

3 PA

TAZORAC 0.05 % GELtazarotene

3 PA

TAZORAC 0.1 % GELtazarotene

3 PA

ANTIPSORIATICS - SYSTEMIC

acitretin 10 mg cap 2 QL 30 / 30 DAYS

acitretin 17.5 mg cap 2 QL 30 / 30 DAYS

acitretin 25 mg cap 2 QL 30 / 30 DAYS

COSENTYX (300 MG DOSE) 150 MG/ML SOLN PRSYRsecukinumab

4PA

S

COSENTYX 150 MG/ML SOLN PRSYRsecukinumab

4PA

S

COSENTYX 75 MG/0.5ML SOLN PRSYRsecukinumab

4PA

S

COSENTYX SENSOREADY (300 MG) 150 MG/ML SOLN A-INJsecukinumab

4PA

S

COSENTYX SENSOREADY PEN 150 MG/ML SOLN A-INJsecukinumab

4PA

S

METHOXSALEN RAPID 10 MG CAPmethoxsalen rapid

2 PA

methoxsalen rapid 10 mg cap 2 PA

SKYRIZI (150 MG DOSE) 75 MG/0.83ML PREF SY KTrisankizumab-rzaa

4PA

S



SKYRIZI 150 MG/ML SOLN PRSYRrisankizumab-rzaa

4PA

S

SKYRIZI PEN 150 MG/ML SOLN A-INJrisankizumab-rzaa

4PA

S

STELARA 45 MG/0.5ML SOLN PRSYRustekinumab

4PA

S

STELARA 45 MG/0.5ML SOLUTIONustekinumab

4PA

S

STELARA 90 MG/ML SOLN PRSYRustekinumab

4PA

S

TALTZ 80 MG/ML SOLN A-INJixekizumab

4PA

S

TALTZ 80 MG/ML SOLN PRSYRixekizumab

4PA

S

TREMFYA 100 MG/ML SOLN PENguselkumab

4PA

S

TREMFYA 100 MG/ML SOLN PRSYRguselkumab

4PA

S

ANTISEBORRHEIC PRODUCTSselenium sulfide 2.25 % shampoo 1

selenium sulfide 2.5 % lotion 1

ANTIVIRALS - TOPICAL

acyclovir 5 % ointment 1 QL 30 / 30 DAYS

DENAVIR 1 % CREAMpenciclovir

3QL 5 / 30 DAYS

PA

ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES

DUPIXENT 100 MG/0.67ML SOLN PRSYRdupilumab

4PA

S



DUPIXENT 200 MG/1.14ML SOLN PENdupilumab

4PA

S

DUPIXENT 200 MG/1.14ML SOLN PRSYRdupilumab

4PA

S

DUPIXENT 300 MG/2ML SOLN PENdupilumab

4PA

S

DUPIXENT 300 MG/2ML SOLN PRSYRdupilumab

4PA

S

BURN PRODUCTSmafenide acetate 5 % packet 1

silver sulfadiazine 1 % cream 1

ssd 1 % cream 1

SULFAMYLON 85 MG/GM CREAMmafenide acetate

3

CORTICOSTEROIDS - TOPICALala-cort 1 % cream 1

ala-cort 2.5 % cream 1

alclometasone dipropionate 0.05 % cream 1

alclometasone dipropionate 0.05 % ointment 1

AMCINONIDE 0.1 % CREAMamcinonide

1

AMCINONIDE 0.1 % LOTIONamcinonide

1

AMCINONIDE 0.1 % OINTMENTamcinonide

2

betamethasone dipropionate 0.05 % cream 1

betamethasone dipropionate 0.05 % lotion 1

betamethasone dipropionate 0.05 % ointment 1

betamethasone dipropionate aug 0.05 % cream 1

BETAMETHASONE DIPROPIONATE AUG 0.05 % GELbetamethasone dipropionate augmented

1



betamethasone dipropionate aug 0.05 % lotion 1

betamethasone dipropionate aug 0.05 % ointment 1

betamethasone valerate 0.1 % cream 1

betamethasone valerate 0.1 % lotion 1

betamethasone valerate 0.1 % ointment 1

clobetasol prop emollient base 0.05 % cream 1

clobetasol propionate 0.05 % cream 1

clobetasol propionate 0.05 % foam 1

clobetasol propionate 0.05 % gel 1

clobetasol propionate 0.05 % liquid 1

clobetasol propionate 0.05 % lotion 1

clobetasol propionate 0.05 % ointment 1

clobetasol propionate 0.05 % shampoo 1

clobetasol propionate 0.05 % solution 1

clobetasol propionate e 0.05 % cream 1

clobetasol propionate emulsion 0.05 % foam 1

CLOCORTOLONE PIVALATE 0.1 % CREAMclocortolone pivalate

1

clocortolone pivalate 0.1 % cream 1

CLOCORTOLONE PIVALATE PUMP 0.1 % CREAMclocortolone pivalate

1

CORDRAN 4 MCG/SQCM TAPEflurandrenolide

3 QL 1 / 30 DAYS

desonide 0.05 % cream 1

desonide 0.05 % lotion 1

desonide 0.05 % ointment 1

desoximetasone 0.05 % cream 1

desoximetasone 0.05 % gel 1

desoximetasone 0.05 % ointment 1

desoximetasone 0.25 % cream 1



desoximetasone 0.25 % ointment 1

DIFLORASONE DIACETATE 0.05 % CREAMdiflorasone diacetate

2

diflorasone diacetate 0.05 % ointment 2 QL 60 / 30 DAYS

fluocinolone acetonide 0.01 % cream 1

fluocinolone acetonide 0.01 % solution 1

fluocinolone acetonide 0.025 % cream 1

fluocinolone acetonide 0.025 % ointment 1

fluocinolone acetonide body 0.01 % oil 1

fluocinolone acetonide scalp 0.01 % oil 1

fluocinonide 0.05 % cream 1

fluocinonide 0.05 % gel 1

fluocinonide 0.05 % ointment 1

fluocinonide 0.05 % solution 1

fluocinonide 0.1 % cream 2

fluocinonide emulsified base 0.05 % cream 1

flurandrenolide 0.05 % lotion 1

fluticasone propionate 0.005 % ointment 1

fluticasone propionate 0.05 % cream 1

fluticasone propionate 0.05 % lotion 2

halobetasol propionate 0.05 % cream 1

halobetasol propionate 0.05 % ointment 1

hydrocortisone 1 % cream 1

hydrocortisone 1 % ointment 1

hydrocortisone 2.5 % cream 1

hydrocortisone 2.5 % lotion 1

hydrocortisone 2.5 % ointment 1

hydrocortisone butyr lipo base 0.1 % cream 2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSHYDROCORTISONE BUTYRATE 0.1 % CREAMhydrocortisone butyrate

1

hydrocortisone butyrate 0.1 % cream 1

hydrocortisone butyrate 0.1 % ointment 1

HYDROCORTISONE BUTYRATE 0.1 % SOLUTIONhydrocortisone butyrate

2

hydrocortisone butyrate 0.1 % solution 2

hydrocortisone valerate 0.2 % cream 1

hydrocortisone valerate 0.2 % ointment 1

mometasone furoate 0.1 % cream 1

mometasone furoate 0.1 % ointment 1

mometasone furoate 0.1 % solution 1

PREDNICARBATE 0.1 % CREAMprednicarbate

1

PREDNICARBATE 0.1 % OINTMENTprednicarbate

1

tovet 0.05 % foam 1

triamcinolone acetonide 0.025 % cream 1

triamcinolone acetonide 0.025 % lotion 1

triamcinolone acetonide 0.025 % ointment 1


triamcinolone acetonide 0.1 % lotion 1




ENZYMES - TOPICALSANTYL 250 UNIT/GM OINTMENTcollagenase

3 QL 30 / 30 DAYS

IMIDAZOLE-RELATED ANTIFUNGALS - TOPICALclotrimazole 1 % solution 1

econazole nitrate 1 % cream 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSERTACZO 2 % CREAMsertaconazole nitrate

3 PA

EXELDERM 1 % CREAMsulconazole nitrate

3

EXELDERM 1 % SOLUTIONsulconazole nitrate

3

JUBLIA 10 % SOLUTIONefinaconazole

3QL 4 / 30 DAYS

ST

ketoconazole 2 % cream 1

ketoconazole 2 % foam 1

ketoconazole 2 % shampoo 1

ketodan 2 % foam 1

LULICONAZOLE 1 % CREAMluliconazole

2 QL 60 / 30 day(s)

XOLEGEL 2 % GELketoconazole (topical)

3

IMMUNOMODULATORS IMIDAZOQUINOLINAMINES - TOPICALimiquimod 5 % cream 1

KERATOLYTIC/ANTIMITOTIC AGENTSkeralyt 6 % shampoo 1

podofilox 0.5 % solution 1

salicylic acid 6 % cream 1

salicylic acid 6 % shampoo 1

LOCAL ANESTHETICS - TOPICALlidocaine 5 % ointment 1

lidocaine 5 % patch 1 QL 90 / 30 DAYS

lidocaine hcl urethral/mucosal 2 % gel 1

LIDOCAINE HCL URETHRAL/MUCOSAL 2 % GELlidocaine hcl

1

lidocaine hcl urethral/mucosal 2 % prsyr 1

lidocaine pak 5 % ointment 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSLIDOTREX 2 % GELlidocaine

2

premium lidocaine 5 % ointment 1

MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL

pimecrolimus 1 % cream 2 QL 60 / 30 DAYS

tacrolimus 0.03 % ointment 2

tacrolimus 0.1 % ointment 2

MISC. TOPICALDRYSOL 20 % SOLUTIONaluminum chloride

2

OXABOROLE-RELATED ANTIFUNGALS - TOPICAL

tavaborole 5 % solution 2QL 10 / 30 day(s)

ST

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICALEUCRISA 2 % OINTMENTcrisaborole

3 PA

ROSACEA AGENTS

azelaic acid 15 % gel 1 QL 50 / 30 DAYS

ivermectin 1 % cream 1 QL 1 / 1 day(s)

metronidazole 0.75 % cream 1

metronidazole 0.75 % gel 1

metronidazole 0.75 % lotion 1

metronidazole 1 % gel 1

rosadan 0.75 % cream 1

rosadan 0.75 % gel 1

SCABICIDES & PEDICULICIDESEURAX 10 % CREAMcrotamiton

3

EURAX 10 % LOTIONcrotamiton

3

IVERMECTIN 0.5 % LOTIONivermectin (pediculicide)

3 QL 117 / 30 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSLINDANE 1 % SHAMPOOlindane

1

malathion 0.5 % lotion 1

permethrin 5 % cream 1

SPINOSAD 0.9 % SUSPENSIONspinosad

1

ULESFIA 5 % LOTIONbenzyl alcohol (pediculicide)

3

TOPICAL ANESTHETIC COMBINATIONSlidocaine-prilocaine 2.5-2.5 % cream 1

SYNERA 70-70 MG PATCHlidocaine-tetracaine

3

TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS

TARGRETIN 1 % GELbexarotene (topical)

4PA

S

WOUND CARE - GROWTH FACTOR AGENTSREGRANEX 0.01 % GELbecaplermin

3 PA

DIAGNOSTIC PRODUCTSDIAGNOSTIC DRUGS

GLUCAGEN DIAGNOSTIC 1 MG RECON SOLNglucagon hcl rdna (diagnostic)

2

GLUCAGON HCL (DIAGNOSTIC) 1 MG RECON SOLNglucagon hcl (diagnostic)

1

DIAGNOSTIC TESTS

FREESTYLE INSULINX TEST STRIPglucose blood

5QL 150 / 30 DAYS


FREESTYLE LITE TEST STRIPglucose blood

5QL 150 / 30 DAYS


FREESTYLE TEST STRIPglucose blood

5QL 150 / 30 DAYS


ONETOUCH ULTRA STRIPglucose blood

5QL 150 / 30 DAYS




ONETOUCH VERIO STRIPglucose blood

5QL 150 / 30 DAYS


INFECTION TESTS

ACCULA SARS-COV-2 KITcovid-19 test

5QL 8 / 30 day(s)

PRE Preventative

BD VERITOR HOME COVID-19 TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

BD VERITOR SYSTEM SARS-COV-2 KITcovid-19 antigen test

5QL 8 / 30 day(s)

PRE Preventative

BINAXNOW COVID-19 AG CARD KITcovid-19 antigen test

5QL 8 / 30 day(s)

PRE Preventative

BINAXNOW COVID-19 AG HOME TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

CARESTART COVID-19 HOME TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

CLEARDETECT COVID-19 AG HOME KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

CLINITEST RAPID COVID-19 TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

COBAS LIAT SARS-COV-2 ASSAY KITcovid-19 test

5QL 8 / 30 day(s)

PRE Preventative

COVID-19 AT-HOME TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

COVID-19 OTC ANTIGEN 1-PACK KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

COVID-19 OTC ANTIGEN 2-PACK KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

DIATRUST COVID-19 HOME TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative



DXTERITY COVID-19 HOME TEST KITcovid-19 home collection test

5QL 8 / 30 day(s)

PRE Preventative

ELLUME COVID-19 HOME TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

EVERLYWELL COVID-19 HOME TEST KITcovid-19 home collection test

5QL 8 / 30 day(s)

PRE Preventative

FLOWFLEX COVID-19 AG HOME TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

ID NOW COVID-19 KITcovid-19 test

5QL 8 / 30 day(s)

PRE Preventative

IHEALTH COVID-19 RAPID TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

INTELISWAB COVID-19 RAPID TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

LUCIRA COVID-19 ALL-IN-ONE KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

LYRA DIRECT SARS-COV-2 ASSAY KITcovid-19 test

5QL 8 / 30 day(s)

PRE Preventative

LYRA SARS-COV-2 ASSAY KITcovid-19 test

5QL 8 / 30 day(s)

PRE Preventative

MYLAB BOX COVID-19 TESTING KITcovid-19 home test

5QL 8 / 30 day(s)

PRE Preventative

ON/GO COVID-19 ANTIGEN TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative

PIXEL COVID-19 PCR HOME TEST KITcovid-19 home test

5QL 8 / 30 day(s)

PRE Preventative

QUICKVUE AT-HOME COVID-19 TEST KITcovid-19 at home test

5QL 8 / 30 day(s)

PRE Preventative



QUICKVUE SARS ANTIGEN TEST KITcovid-19 antigen test

5QL 8 / 30 day(s)

PRE Preventative

SIMPLICITY COVID-19 AT-HOME KITcovid-19 home collection test

5QL 8 / 30 day(s)

PRE Preventative

SOFIA SARS ANTIGEN FIA KITcovid-19 antigen test

5QL 8 / 30 day(s)

PRE Preventative

SOFIA2 SARS ANTIGEN FIA KITcovid-19 antigen test

5QL 8 / 30 day(s)

PRE Preventative

XPERT XPRESS SARS-COV-2 KITcovid-19 test

5QL 8 / 30 day(s)

PRE Preventative

DIGESTIVE AIDSDIGESTIVE ENZYMES

CREON 12000 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

2 PA

CREON 24000-76000 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

2 PA

CREON 3000-9500 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

2 PA


2 PA


2 PA

PANCREAZE 10500 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

3 PA


3 PA


3 PA


3 PA

PANCREAZE 2600-8800 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

3 PA

PANCREAZE 37000-97300 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPANCREAZE 4200 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

3 PA

ZENPEP 10000-32000 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

2 PA


2 PA


2 PA


2 PA


2 PA


2 PA


2 PA


2 PA

DIURETICSCARBONIC ANHYDRASE INHIBITORS

acetazolamide 125 mg tab 5 VAL Value Preventive List

acetazolamide 250 mg tab 5 VAL Value Preventive List

acetazolamide er 500 mg cap er 12h 5 VAL Value Preventive List

methazolamide 25 mg tab 5QL 3 / 1 day(s)


methazolamide 50 mg tab 5 VAL Value Preventive List

DIURETIC COMBINATIONS

amiloride-hydrochlorothiazide 5-50 mg tab 5 VAL Value Preventive List

spironolactone-hctz 25-25 mg tab 5 VAL Value Preventive List

triamterene-hctz 37.5-25 mg cap 5 VAL Value Preventive List

triamterene-hctz 37.5-25 mg tab 5 VAL Value Preventive List

triamterene-hctz 75-50 mg tab 5 VAL Value Preventive List



LOOP DIURETICS

bumetanide 0.5 mg tab 5 VAL Value Preventive List

bumetanide 1 mg tab 5 VAL Value Preventive List

bumetanide 2 mg tab 5 VAL Value Preventive List

ethacrynic acid 25 mg tab 1

furosemide 10 mg/ml solution 5 VAL Value Preventive List

furosemide 20 mg tab 5 VAL Value Preventive List


FUROSEMIDE 8 MG/ML SOLUTIONfurosemide




SOAANZ 20 MG TABtorsemide


torsemide 10 mg tab 5 VAL Value Preventive List




POTASSIUM SPARING DIURETICS

amiloride hcl 5 mg tab 5 VAL Value Preventive List

spironolactone 100 mg tab 5 VAL Value Preventive List



triamterene 100 mg cap 5 VAL Value Preventive List

triamterene 50 mg cap 5 VAL Value Preventive List



THIAZIDES AND THIAZIDE-LIKE DIURETICSCHLOROTHIAZIDE 250 MG TABchlorothiazide


CHLOROTHIAZIDE 500 MG TABchlorothiazide


chlorothiazide 500 mg tab 5 VAL Value Preventive List

chlorthalidone 25 mg tab 5 VAL Value Preventive List

chlorthalidone 50 mg tab 5 VAL Value Preventive List

DIURIL 250 MG/5ML SUSPENSIONchlorothiazide


hydrochlorothiazide 12.5 mg cap 5 VAL Value Preventive List

hydrochlorothiazide 12.5 mg tab 5 VAL Value Preventive List

hydrochlorothiazide 25 mg tab 5 VAL Value Preventive List

hydrochlorothiazide 50 mg tab 5 VAL Value Preventive List

indapamide 1.25 mg tab 5 VAL Value Preventive List

indapamide 2.5 mg tab 5 VAL Value Preventive List

METHYCLOTHIAZIDE 5 MG TABmethyclothiazide


metolazone 10 mg tab 5 VAL Value Preventive List

metolazone 2.5 mg tab 5 VAL Value Preventive List

metolazone 5 mg tab 5 VAL Value Preventive List

ENDOCRINE AND METABOLIC AGENTS - MISC.BISPHOSPHONATES

alendronate sodium 10 mg tab 5QL 30 / 28 DAYS




ALENDRONATE SODIUM 40 MG TABalendronate sodium

5QL 30 / 28 DAYS








ETIDRONATE DISODIUM 200 MG TABetidronate disodium


ETIDRONATE DISODIUM 400 MG TABetidronate disodium


FOSAMAX PLUS D 70-2800 MG-UNIT TABalendronate sodium-cholecalciferol

3 QL 4 / 28 DAYS

FOSAMAX PLUS D 70-5600 MG-UNIT TABalendronate sodium-cholecalciferol

3 QL 4 / 28 DAYS

ibandronate sodium 150 mg tab 5QL 1 / 28 DAYS


risedronate sodium 150 mg tab 5QL 1 / 30 DAYS






risedronate sodium 35 mg tab dr 5QL 4 / 28 DAYS




CALCIMIMETIC AGENTS

cinacalcet hcl 30 mg tab 1 QL 120 / 30 day(s)





CALCITONINScalcitonin (salmon) 200 unit/act solution 1

calcitonin (salmon) 200 unit/ml solution 4PA

S

CARNITINE REPLENISHER - AGENTSlevocarnitine 1 gm/10ml solution 1

levocarnitine sf 1 gm/10ml solution 1

CORTISOL SYNTHESIS INHIBITORS

ISTURISA 1 MG TABosilodrostat phosphate

4PA

S


4PA

S


4PA

S

DOPAMINE RECEPTOR AGONISTScabergoline 0.5 mg tab 1

GNRH/LHRH ANTAGONISTS

ORILISSA 150 MG TABelagolix sodium

4PA

S

ORILISSA 200 MG TABelagolix sodium

4PA

S

GROWTH HORMONE RECEPTOR ANTAGONISTS

SOMAVERT 10 MG RECON SOLNpegvisomant

4PA

S


4PA

S


4PA

S



GROWTH HORMONES

NORDITROPIN FLEXPRO 10 MG/1.5ML SOLN PENsomatropin

4PA

S


4PA

S

NORDITROPIN FLEXPRO 30 MG/3ML SOLN PENsomatropin

4PA

S


4PA

S

NUTROPIN AQ NUSPIN 10 10 MG/2ML SOLN PENsomatropin

4PA

S


4PA

S


4PA

S

OMNITROPE 10 MG/1.5ML SOLN CARTsomatropin

4PA

S

OMNITROPE 5 MG/1.5ML SOLN CARTsomatropin

4PA

S

OMNITROPE 5.8 MG RECON SOLNsomatropin

4PA

S

HYPERAMMONEMIA TREATMENT - AGENTS

carglumic acid 200 mg tab sol 4PA

S

HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGScalcitriol 0.25 mcg cap 1

calcitriol 0.5 mcg cap 1

calcitriol 1 mcg/ml solution 1 AL1 Up to 8 yrs old



doxercalciferol 0.5 mcg cap 2

doxercalciferol 1 mcg cap 2

doxercalciferol 2.5 mcg cap 2

paricalcitol 1 mcg cap 1



INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)

INCRELEX 40 MG/4ML SOLUTIONmecasermin

4PA

S

LEPTIN ANALOGUES

MYALEPT 11.3 MG RECON SOLNmetreleptin

4PA

S

LHRH/GNRH AGONIST ANALOG COMBINATIONS

LUPANETA PACK 11.25 & 5 MG KITleuprolide acetate & norethindrone acetate

4PA

S

LUPANETA PACK 3.75 & 5 MG KITleuprolide acetate & norethindrone acetate

4PA

S

LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS

LUPRON DEPOT-PED (1-MONTH) 11.25 MG KITleuprolide acetate (cpp)

4PA

S

LUPRON DEPOT-PED (1-MONTH) 15 MG KITleuprolide acetate (cpp)

4PA

S

LUPRON DEPOT-PED (1-MONTH) 7.5 MG KITleuprolide acetate (cpp)

4PA

S

LUPRON DEPOT-PED (3-MONTH) 11.25 MG (PED) KITleuprolide acetate (cpp) (3 month)

4PA

S

LUPRON DEPOT-PED (3-MONTH) 30 MG (PED) KITleuprolide acetate (cpp) (3 month)

4PA

S



PARATHYROID HORMONE AND DERIVATIVES

FORTEO 600 MCG/2.4ML SOLN PENteriparatide (recombinant)

4PA

S

TERIPARATIDE (RECOMBINANT) 620 MCG/2.48ML SOLNPENteriparatide (recombinant)

4PA

S

TYMLOS 3120 MCG/1.56ML SOLN PENabaloparatide

4PA

S

PHENYLKETONURIA TREATMENT - AGENTS

PALYNZIQ 10 MG/0.5ML SOLN PRSYRpegvaliase-pqpz

4PA

S

PALYNZIQ 2.5 MG/0.5ML SOLN PRSYRpegvaliase-pqpz

4PA

S

PALYNZIQ 20 MG/ML SOLN PRSYRpegvaliase-pqpz

4PA

S

sapropterin dihydrochloride 100 mg packet 4PA

S

sapropterin dihydrochloride 100 mg tab 4PA

S

sapropterin dihydrochloride 500 mg packet 4PA

S

SCLEROSTIN INHIBITORS

EVENITY 105 MG/1.17ML SOLN PRSYRromosozumab-aqqg

4PA

S

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)OSPHENA 60 MG TABospemifene

3

raloxifene hcl 60 mg tab 5QL 30 / 30 DAYS

PRE Preventative



SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS

JYNARQUE 15 MG TAB THPKtolvaptan

4PA

S

JYNARQUE 30 & 15 MG TAB THPKtolvaptan

4PA

S


4PA

S


4PA

S


4PA

S

TOLVAPTAN 15 MG TABtolvaptan

4PA

S

tolvaptan 15 mg tab 4PA

S

tolvaptan 30 mg tab 4PA

S

SOMATOSTATIC AGENTSOCTREOTIDE ACETATE 100 MCG/ML SOLN PRSYRoctreotide acetate

2

octreotide acetate 100 mcg/ml solution 2



OCTREOTIDE ACETATE 50 MCG/ML SOLN PRSYRoctreotide acetate

2


OCTREOTIDE ACETATE 500 MCG/ML SOLN PRSYRoctreotide acetate

2


SIGNIFOR 0.3 MG/ML SOLUTIONpasireotide diaspartate

4PA

S




4PA

S


4PA

S

SIGNIFOR LAR 10 MG SRERpasireotide pamoate

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

VASOPRESSINdesmopressin ace spray refrig 0.01 % solution 1

desmopressin acetate 0.1 mg tab 1

desmopressin acetate 0.2 mg tab 1

DESMOPRESSIN ACETATE 1.5 MG/ML SOLUTIONdesmopressin acetate

2 QL 1 / 90 day(s)

desmopressin acetate 4 mcg/ml solution 1

desmopressin acetate pf 4 mcg/ml solution 1

desmopressin acetate spray 0.01 % solution 1

STIMATE 1.5 MG/ML SOLUTIONdesmopressin acetate

2 QL 1 / 180 day(s)

ESTROGENSESTROGEN & ANDROGEN

covaryx 1.25-2.5 mg tab 1

covaryx hs 0.625-1.25 mg tab 1

eemt 1.25-2.5 mg tab 1



eemt hs 0.625-1.25 mg tab 1

est estrogens-methyltest 0.625-1.25 mg tab 1

est estrogens-methyltest 1.25-2.5 mg tab 1

est estrogens-methyltest ds 1.25-2.5 mg tab 1

est estrogens-methyltest hs 0.625-1.25 mg tab 1

ESTROGEN & PROGESTINamabelz 0.5-0.1 mg tab 1

amabelz 1-0.5 mg tab 1

estradiol-norethindrone acet 0.5-0.1 mg tab 1

estradiol-norethindrone acet 1-0.5 mg tab 1

fyavolv 0.5-2.5 mg-mcg tab 1

fyavolv 1-5 mg-mcg tab 1

jevantique lo 0.5-2.5 mg-mcg tab 1

jinteli 1-5 mg-mcg tab 1

lopreeza 0.5-0.1 mg tab 1

lopreeza 1-0.5 mg tab 1

mimvey 1-0.5 mg tab 1

mimvey lo 0.5-0.1 mg tab 1

norethindrone-eth estradiol 0.5-2.5 mg-mcg tab 1

norethindrone-eth estradiol 1-5 mg-mcg tab 1

PREMPRO 0.3-1.5 MG TABconjugated estrogens-medroxyprogesterone acetate

3


3


3

PREMPRO 0.625-5 MG TABconjugated estrogens-medroxyprogesterone acetate

3

ESTROGEN-PROGESTIN-GNRH ANTAGONIST

ORIAHNN 300-1-0.5 & 300 MG CAP THPKelagolix sodium-estradiol-norethindrone acetate

4PA

S



ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBDUAVEE 0.45-20 MG TABconjugated estrogens-bazedoxifene

2 QL 30 / 30 DAYS

DIVIGEL 0.25 MG/0.25GM GELestradiol

3 QL 30 / 30 DAYS


3 QL 30 / 30 DAYS


3

DIVIGEL 1 MG/GM GELestradiol

3 QL 30 / 30 DAYS


3

dotti 0.025 mg/24hr patch tw 1 QL 8 / 28 DAYS





ELESTRIN 0.52 MG/0.87 GM (0.06%) GELestradiol

3 QL 26 / 30 DAYS

estradiol 0.025 mg/24hr patch tw 1 QL 8 / 28 DAYS

estradiol 0.025 mg/24hr patch wk 1 QL 4 / 28 DAYS












estradiol 0.5 mg tab 1

estradiol 1 mg tab 1

estradiol 2 mg tab 1

estradiol valerate 20 mg/ml oil 1

estradiol valerate 40 mg/ml oil 1

ESTROPIPATE 0.75 MG TABestropipate

1

ESTROPIPATE 1.5 MG TABestropipate

1

EVAMIST 1.53 MG/SPRAY SOLUTIONestradiol

3 QL 16.2 / 30 DAYS

lyllana 0.025 mg/24hr patch tw 1 QL 8 / 28 DAYS





MENEST 0.3 MG TABesterified estrogens

2


2


2


2

MENOSTAR 14 MCG/24HR PATCH WKestradiol

3 QL 4 / 28 DAYS

PREMARIN 0.3 MG TABestrogens, conjugated

2


2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPREMARIN 0.625 MG TABestrogens, conjugated

2


2


2

FLUOROQUINOLONESBAXDELA 300 MG RECON SOLNdelafloxacin meglumine

3 PA

ciprofloxacin 500 mg/5ml (10%) recon susp 1 AL1 Up to 8 yrs old

CIPROFLOXACIN HCL 100 MG TABciprofloxacin hcl

1

ciprofloxacin hcl 250 mg tab 1



CIPROFLOXACIN-CIPROFLOX HCL ER 1000 MG TAB ER 24Hciprofloxacin-ciprofloxacin hcl

1

levofloxacin 25 mg/ml solution 1 AL1 At least 8 yrs old

levofloxacin 25 mg/ml solution 1 AL1 At least 8 yrs old

levofloxacin 250 mg tab 1 QL 14 / 14 DAYS



moxifloxacin hcl 400 mg tab 1 QL 14 / 0 DAYS

OFLOXACIN 300 MG TABofloxacin

2

ofloxacin 400 mg tab 2

GASTROINTESTINAL AGENTS - MISC.5-HT4 RECEPTOR AGONISTS

MOTEGRITY 1 MG TABprucalopride succinate

3QL 30 / 30 DAYS

PA

MOTEGRITY 2 MG TABprucalopride succinate

3QL 30 / 30 DAYS

PA



CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS

TRULANCE 3 MG TABplecanatide

3QL 30 / 30 DAYS

PA

FARNESOID X RECEPTOR (FXR) AGONISTS

OCALIVA 10 MG TABobeticholic acid

4PA

S

OCALIVA 5 MG TABobeticholic acid

4PA

S

GALLSTONE SOLUBILIZING AGENTSursodiol 250 mg tab 1

ursodiol 300 mg cap 1

ursodiol 500 mg tab 1

GASTROINTESTINAL ANTIALLERGY AGENTScromolyn sodium 100 mg/5ml conc 1

GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS

AMITIZA 24 MCG CAPlubiprostone

3QL 60 / 30 day(s)

PA

AMITIZA 8 MCG CAPlubiprostone

3QL 60 / 30 day(s)

PA

LUBIPROSTONE 24 MCG CAPlubiprostone

3QL 60 / 30 day(s)

PA

LUBIPROSTONE 8 MCG CAPlubiprostone

3QL 60 / 30 day(s)

PA

GASTROINTESTINAL STIMULANTSmetoclopramide hcl 10 mg tab 1

metoclopramide hcl 10 mg/10ml solution 1

metoclopramide hcl 5 mg tab 1

METOCLOPRAMIDE HCL 5 MG TAB DISPmetoclopramide hcl

1 QL 120 / 30 DAYS



metoclopramide hcl 5 mg/5ml solution 1

IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS

LINZESS 145 MCG CAPlinaclotide

2QL 30 / 30 DAYS

PA


2QL 30 / 30 DAYS

PA


2QL 30 / 30 DAYS

PA

IBS AGENT - MU-OPIOID RECEPTOR AGONISTSVIBERZI 100 MG TABeluxadoline

3 PA

VIBERZI 75 MG TABeluxadoline

3 PA

IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS

alosetron hcl 0.5 mg tab 2QL 60 / 30 DAYS

PA

alosetron hcl 1 mg tab 2QL 60 / 30 DAYS

PA

ILEAL BILE ACID TRANSPORTER (IBAT) INHIBITORS

BYLVAY (PELLETS) 200 MCG CAP SPRINKodevixibat

4PA

S

BYLVAY (PELLETS) 600 MCG CAP SPRINKodevixibat

4PA

S

BYLVAY 1200 MCG CAPodevixibat

4PA

S

BYLVAY 400 MCG CAPodevixibat

4PA

S

INFLAMMATORY BOWEL AGENTSbalsalazide disodium 750 mg cap 1

DIPENTUM 250 MG CAPolsalazine sodium

3 PA



GIAZO 1.1 GM TABbalsalazide disodium

3QL 180 / 30 DAYS

PA

mesalamine 1.2 gm tab dr 2 QL 120 / 30 DAYS

mesalamine 1000 mg suppos 2 QL 30 / 30 DAYS

mesalamine 4 gm enema 1 QL 1680 / 28 DAYS

mesalamine 400 mg cap dr 1 QL 6 / 1 day(s)

mesalamine 800 mg tab dr 2 QL 180 / 30 DAYS

mesalamine er 0.375 gm cap er 24h 2 QL 4 / 1 day(s)

mesalamine-cleanser 4 gm kit 1 QL 1680 / 28 DAYS

PENTASA 250 MG CAP ERmesalamine

2 QL 90 / 30 DAYS

PENTASA 500 MG CAP ERmesalamine

2 QL 240 / 30 DAYS

sulfasalazine 500 mg tab 1

sulfasalazine 500 mg tab dr 1

INTESTINAL ACIDIFIERSenulose 10 gm/15ml solution 1

generlac 10 gm/15ml solution 1

lactulose encephalopathy 10 gm/15ml solution 1

PERIPHERAL OPIOID RECEPTOR ANTAGONISTS

MOVANTIK 12.5 MG TABnaloxegol oxalate

2QL 30 / 30 DAYS

PA

MOVANTIK 25 MG TABnaloxegol oxalate

2QL 30 / 30 DAYS

PA

SYMPROIC 0.2 MG TABnaldemedine tosylate

3QL 30 / 30 DAYS

PA

PHOSPHATE BINDER AGENTScalcium acetate (phos binder) 667 mg cap 1



calcium acetate (phos binder) 667 mg tab 1

calcium acetate 667 mg tab 1

lanthanum carbonate 1000 mg chew tab 2



PHOSLYRA 667 MG/5ML SOLUTIONcalcium acetate (phosphate binder)


sevelamer carbonate 0.8 gm packet 1 AL1 Up to 8 yrs old

sevelamer carbonate 2.4 gm packet 1 AL1 Up to 8 yrs old

sevelamer carbonate 800 mg tab 1

TUMOR NECROSIS FACTOR ALPHA BLOCKERS

CIMZIA 2 X 200 MG KITcertolizumab pegol

4PA

S

CIMZIA PREFILLED 2 X 200 MG/ML PREF SY KTcertolizumab pegol

4PA

S

CIMZIA STARTER KIT 6 X 200 MG/ML PREF SY KTcertolizumab pegol

4PA

S

GENITOURINARY AGENTS - MISCELLANEOUS5-ALPHA REDUCTASE INHIBITORS

dutasteride 0.5 mg cap 1 QL 30 / 30 DAYS

finasteride 5 mg tab 1QL 30 / 30 DAYS

GL Male

ALPHA 1-ADRENOCEPTOR ANTAGONISTS

alfuzosin hcl er 10 mg tab er 24h 1 QL 60 / 30 DAYS

CARDURA XL 4 MG TAB ER 24Hdoxazosin mesylate (bph)

3

CARDURA XL 8 MG TAB ER 24Hdoxazosin mesylate (bph)

3

silodosin 4 mg cap 1 QL 60 / 30 DAYS



silodosin 8 mg cap 1 QL 30 / 30 DAYS

tamsulosin hcl 0.4 mg cap 1 QL 60 / 30 DAYS

CITRATESpotassium citrate er 10 meq (1080 mg) tab er 1

potassium citrate er 15 meq (1620 mg) tab er 1

potassium citrate er 5 meq (540 mg) tab er 1

CYSTINOSIS AGENTS

CYSTAGON 150 MG CAPcysteamine bitartrate

4PA

S

CYSTAGON 50 MG CAPcysteamine bitartrate

4PA

S

INTERSTITIAL CYSTITIS AGENTSELMIRON 100 MG CAPpentosan polysulfate sodium

3 PA

PHOSPHATESK-PHOS NO 2 305-700 MG TABpotassium & sodium acid phosphates

2

URINARY ANALGESICSphenazo 200 mg tab 1

phenazopyridine hcl 100 mg tab 1

phenazopyridine hcl 200 mg tab 1

GOUT AGENTSGOUT AGENT COMBINATIONS

colchicine-probenecid 0.5-500 mg tab 1

allopurinol 100 mg tab 1

allopurinol 300 mg tab 1

COLCHICINE 0.6 MG CAPcolchicine

2 QL 60 / 30 DAYS

colchicine 0.6 mg tab 2 QL 60 / 30 DAYS

febuxostat 40 mg tab 1 QL 3 / 1 day(s)



febuxostat 80 mg tab 1 QL 1.5 / 1 day(s)

URICOSURICSprobenecid 500 mg tab 1

HEMATOLOGICAL AGENTS - MISC.ANTI-VON WILLEBRAND FACTOR AGENTS

CABLIVI 11 MG KITcaplacizumab-yhdp

4PA

S

ANTIHEMOPHILIC PRODUCTSADVATE 1000 UNIT RECON SOLNantihemophilic factor (rcmb) plasma/albumin free (rahf-pfm)

4PA

S

ADVATE 1500 UNIT RECON SOLNantihemophilic factor (rcmb) plasma/albumin free (rahf-pfm)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ADYNOVATE 1000 UNIT RECON SOLNantihemophilic factor (recombinant) pegylated

4PA

S


4PA

S


4PA

S




4PA

S


4PA

S


4PA

S


4PA

S

AFSTYLA 1000 UNIT KITantihemophilic factor (recombinant) single chain

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ALPHANATE 1000 UNIT RECON SOLNantihemophilic factor/von willebrand factor complex(human)

4PA

S


4PA

S


4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSALPHANATE 250 UNIT RECON SOLNantihemophilic factor/von willebrand factor complex(human)

4PA

S


4PA

S

ALPHANATE/VWF COMPLEX/HUMAN 1000 UNIT RECONSOLNantihemophilic factor/von willebrand factor complex(human)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ALPHANINE SD 1000 UNIT RECON SOLNcoagulation factor ix

4PA

S


4PA

S


4PA

S

ALPROLIX 1000 UNIT RECON SOLNcoagulation factor ix (recomb) fc fusion protein (rfixfc)

4PA

S


4PA

S




4PA

S


4PA

S


4PA

S


4PA

S

BENEFIX 1000 UNIT KITcoagulation factor ix (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ELOCTATE 1000 UNIT RECON SOLNantihemophilic factor (rcmb) fc fusion protein(bdd-rfviiifc)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S




4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ESPEROCT 1000 UNIT RECON SOLNantihemophilic factor (recombinant) glycopegylated-exei

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

HELIXATE FS 1000 UNIT KITantihemophilic factor (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S




4PA

S

HEMOFIL M 1000 UNIT RECON SOLNantihemophilic factor (human)

4PA

S


4PA

S


4PA

S


4PA

S

HUMATE-P 1000-2400 UNIT RECON SOLNantihemophilic factor/von willebrand factor complex(human)

4PA

S


4PA

S


4PA

S

IDELVION 1000 UNIT RECON SOLNcoagulation factor ix recomb albumin fusion protein (rix-fp)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

IXINITY 1000 UNIT RECON SOLNcoagulation factor ix (recombinant)

4PA

S




4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

JIVI 1000 UNIT RECON SOLNantihemophil fact(rcmb) pegylated-aucl (bdd-rfviii peg-aucl)

4PA

S


4PA

S


4PA

S


4PA

S

KOATE 1000 UNIT RECON SOLNantihemophilic factor (human)

4PA

S


4PA

S


4PA

S

KOATE-DVI 1000 UNIT RECON SOLNantihemophilic factor (human)

4PA

S


4PA

S




4PA

S

KOGENATE FS 1000 UNIT KITantihemophilic factor (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

KOGENATE FS BIO-SET 1000 UNIT KITantihemophilic factor (recombinant)

4PA

S


4PA

S


4PA

S

KOVALTRY 1000 UNIT RECON SOLNantihemophilic factor (rcmb) plasma/albumin free (rahf-pfm)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S



MONOCLATE-P 1000 UNIT KITantihemophilic factor (human)

4PA

S

MONOCLATE-P 1500 UNIT KITantihemophilic factor (human)

4PA

S

MONONINE 1000 UNIT RECON SOLNcoagulation factor ix

4PA

S

NOVOEIGHT 1000 UNIT RECON SOLNantihemophilic factor (rcmb) bd truncated (bd trunc-rfviii)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

NUWIQ 1000 UNIT KITantihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim)

4PA

S

NUWIQ 1000 UNIT RECON SOLNantihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim)

4PA

S


4PA

S


4PA

S


4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSNUWIQ 2000 UNIT RECON SOLNantihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

OBIZUR 500 UNIT RECON SOLNantihemophilic factor (recombinant porcine) (rpfviii)

4PA

S

REBINYN 1000 UNIT RECON SOLNcoagulation factor ix (recombinant) glycopegylated

4PA

S


4PA

S




4PA

S

RECOMBINATE 1241-1800 UNIT RECON SOLNantihemophilic factor (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

RIXUBIS 1000 UNIT RECON SOLNcoagulation factor ix (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

WILATE 1000-1000 UNIT KITantihemophilic factor/von willebrand factor complex(human)

4PA

S

WILATE 500-500 UNIT KITantihemophilic factor/von willebrand factor complex(human)

4PA

S

XYNTHA 1000 UNIT KITantihemophilic factor (rcmb) moroctocog alfa(bdd-rfviii,mor)

4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSXYNTHA 2000 UNIT KITantihemophilic factor (rcmb) moroctocog alfa(bdd-rfviii,mor)

4PA

S


4PA

S


4PA

S

XYNTHA SOLOFUSE 1000 UNIT KITantihemophilic factor (rcmb) moroctocog alfa(bdd-rfviii,mor)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES

HEMLIBRA 105 MG/0.7ML SOLUTIONemicizumab-kxwh

4PA

S

HEMLIBRA 150 MG/ML SOLUTIONemicizumab-kxwh

4PA

S

HEMLIBRA 30 MG/ML SOLUTIONemicizumab-kxwh

4PA

S

HEMLIBRA 60 MG/0.4ML SOLUTIONemicizumab-kxwh

4PA

S

BRADYKININ B2 RECEPTOR ANTAGONISTS

icatibant acetate 30 mg/3ml solution 4PA

S



sajazir 30 mg/3ml solution 4PA

S

C1 INHIBITORS

BERINERT 500 UNIT KITc1 esterase inhibitor (human)

4PA

S

HAEGARDA 2000 UNIT RECON SOLNc1 esterase inhibitor (human)

4PA

S

HAEGARDA 3000 UNIT RECON SOLNc1 esterase inhibitor (human)

4PA

S

DIRECT-ACTING P2Y12 INHIBITORSBRILINTA 60 MG TABticagrelor

2 QL 60 / 30 DAYS

BRILINTA 90 MG TABticagrelor

2 QL 60 / 30 DAYS

HEMATORHEOLOGIC AGENTSpentoxifylline er 400 mg tab er 1

PHOSPHODIESTERASE III INHIBITORS

cilostazol 100 mg tab 5 VAL Value Preventive List

cilostazol 50 mg tab 5 VAL Value Preventive List

PLATELET AGGREGATION INHIBITOR COMBINATIONSaspirin-dipyridamole er 25-200 mg cap er 12h 2

PLATELET AGGREGATION INHIBITORS

dipyridamole 25 mg tab 5 VAL Value Preventive List



PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS

ZONTIVITY 2.08 MG TABvorapaxar sulfate

3QL 30 / 30 DAYS

PA



QUINAZOLINE AGENTSanagrelide hcl 0.5 mg cap 1

anagrelide hcl 1 mg cap 1

THIENOPYRIDINE DERIVATIVES

clopidogrel bisulfate 300 mg tab 5 VAL Value Preventive List

clopidogrel bisulfate 75 mg tab 5 VAL Value Preventive List

prasugrel hcl 10 mg tab 5 VAL Value Preventive List

prasugrel hcl 5 mg tab 5 VAL Value Preventive List

HEMATOPOIETIC AGENTSAGENTS FOR GAUCHER DISEASE

CERDELGA 84 MG CAPeliglustat tartrate

4PA

S

COBALAMINScyanocobalamin 1000 mcg/ml solution 1

dodex 1000 mcg/ml solution 1

CYTOTOXIC AGENTSDROXIA 200 MG CAPhydroxyurea (sickle cell anemia)

2

DROXIA 300 MG CAPhydroxyurea (sickle cell anemia)

2

DROXIA 400 MG CAPhydroxyurea (sickle cell anemia)

2

ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)

ARANESP (ALBUMIN FREE) 10 MCG/0.4ML SOLN PRSYRdarbepoetin alfa

4PA

S


4PA

S

ARANESP (ALBUMIN FREE) 100 MCG/ML SOLUTIONdarbepoetin alfa

4PA

S


4PA

S




4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ARANESP (ALBUMIN FREE) 500 MCG/ML SOLN PRSYRdarbepoetin alfa

4PA

S


4PA

S


4PA

S

MIRCERA 100 MCG/0.3ML SOLN PRSYRmethoxy polyethylene glycol-epoetin beta

4PA

S


4PA

S


4PA

S




4PA

S


4PA

S

PROCRIT 10000 UNIT/ML SOLUTIONepoetin alfa

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

RETACRIT 10000 UNIT/ML SOLUTIONepoetin alfa-epbx

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S



FOLIC ACID/FOLATESfolic acid 1 mg tab 1

GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)

FULPHILA 6 MG/0.6ML SOLN PRSYRpegfilgrastim-jmdb

3

QL 1.2 / 28 day(s)

PA

S

GRANIX 300 MCG/0.5ML SOLN PRSYRtbo-filgrastim

3

QL 10 / 28 day(s)

PA

S

GRANIX 300 MCG/ML SOLUTIONtbo-filgrastim

3

QL 20 / 28 day(s)

PA

S

GRANIX 480 MCG/0.8ML SOLN PRSYRtbo-filgrastim

3

QL 16 / 28 day(s)

PA

S

GRANIX 480 MCG/1.6ML SOLUTIONtbo-filgrastim

3

QL 32 / 28 day(s)

PA

S

NIVESTYM 300 MCG/0.5ML SOLN PRSYRfilgrastim-aafi

2QL 10 / 28 day(s)

S

NIVESTYM 300 MCG/ML SOLUTIONfilgrastim-aafi

2QL 20 / 28 day(s)

S

NIVESTYM 480 MCG/0.8ML SOLN PRSYRfilgrastim-aafi

2QL 16 / 28 day(s)

S

NIVESTYM 480 MCG/1.6ML SOLUTIONfilgrastim-aafi

2QL 32 / 28 day(s)

S

NYVEPRIA 6 MG/0.6ML SOLN PRSYRpegfilgrastim-apgf

2QL 1.2 / 28 day(s)

S

RELEUKO 300 MCG/0.5ML SOLN PRSYRfilgrastim-ayow

3

QL 10 / 28 day(s)

PA

S



RELEUKO 300 MCG/ML SOLUTIONfilgrastim-ayow

3

QL 20 / 28 day(s)

PA

S

RELEUKO 480 MCG/0.8ML SOLN PRSYRfilgrastim-ayow

3

QL 16 / 28 day(s)

PA

S

RELEUKO 480 MCG/1.6ML SOLUTIONfilgrastim-ayow

3

QL 32 / 28 day(s)

PA

S

UDENYCA 6 MG/0.6ML SOLN PRSYRpegfilgrastim-cbqv

3

QL 1.2 / 28 day(s)

PA

S

ZARXIO 300 MCG/0.5ML SOLN PRSYRfilgrastim-sndz

2QL 10 / 28 day(s)

S

ZARXIO 480 MCG/0.8ML SOLN PRSYRfilgrastim-sndz

2QL 16 / 28 day(s)

S

ZIEXTENZO 6 MG/0.6ML SOLN PRSYRpegfilgrastim-bmez

2QL 1.2 / 28 day(s)

S

THROMBOPOIETIN (TPO) RECEPTOR AGONISTS

PROMACTA 12.5 MG PACKETeltrombopag olamine

4PA

S

PROMACTA 12.5 MG TABeltrombopag olamine

4PA

S

PROMACTA 25 MG PACKETeltrombopag olamine

4PA

S

PROMACTA 25 MG TABeltrombopag olamine

4PA

S


4PA

S




4PA

S

HEMOSTATICSHEMOSTATICS - SYSTEMIC

aminocaproic acid 0.25 gm/ml solution 2

aminocaproic acid 1000 mg tab 2

aminocaproic acid 500 mg tab 2

tranexamic acid 650 mg tab 1

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTSBARBITURATE HYPNOTICS

phenobarbital 100 mg tab 1


phenobarbital 16.2 mg tab 1

phenobarbital 20 mg/5ml elixir 1

phenobarbital 20 mg/5ml solution 1






BENZODIAZEPINE HYPNOTICSFLURAZEPAM HCL 15 MG CAPflurazepam hcl

1 QL 30 / 30 day(s)

FLURAZEPAM HCL 30 MG CAPflurazepam hcl

1 QL 30 / 30 day(s)

midazolam hcl (pf) 10 mg/2ml solution 1

midazolam hcl (pf) 5 mg/ml solution 1

temazepam 15 mg cap 1 QL 30 / 30 DAYS

temazepam 22.5 mg cap 2 QL 30 / 30 DAYS



temazepam 30 mg cap 1 QL 30 / 30 DAYS

temazepam 7.5 mg cap 1 QL 30 / 30 DAYS

triazolam 0.125 mg tab 1 QL 30 / 30 DAYS

triazolam 0.25 mg tab 1 QL 30 / 30 DAYS

NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS

eszopiclone 1 mg tab 1 QL 30 / 30 DAYS



zaleplon 10 mg cap 1 QL 60 / 30 DAYS

zaleplon 5 mg cap 1 QL 30 / 30 DAYS

zolpidem tartrate 10 mg tab 1 QL 30 / 30 DAYS

zolpidem tartrate 5 mg tab 1 QL 30 / 30 DAYS

zolpidem tartrate er 12.5 mg tab er 1 QL 30 / 30 DAYS

zolpidem tartrate er 6.25 mg tab er 1 QL 30 / 30 DAYS

OREXIN RECEPTOR ANTAGONISTS

BELSOMRA 10 MG TABsuvorexant

3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA

DAYVIGO 10 MG TABlemborexant

3 PA

DAYVIGO 5 MG TABlemborexant

3 PA



SELECTIVE MELATONIN RECEPTOR AGONISTS

ramelteon 8 mg tab 1 QL 30 / 30 DAYS

LAXATIVESBOWEL EVACUANT COMBINATIONS

GAVILYTE-C 240 GM RECON SOLNpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate

2

gavilyte-g 236 gm recon soln 5 PRE Preventative

gavilyte-n with flavor pack 420 gm recon soln 5 PRE Preventative

GOLYTELY 227.1 GM RECON SOLNpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate

5 PRE Preventative

GOLYTELY 236 GM RECON SOLNpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate

2

peg 3350-kcl-na bicarb-nacl 420 gm recon soln 5 PRE Preventative

peg 3350/electrolytes 240 gm recon soln 5 PRE Preventative

peg-3350/electrolytes 236 gm recon soln 5 PRE Preventative

PREPOPIK 10-3.5-12 MG-GM-GM PACKETsodium picosulfate-magnesium oxide-anhydrous citricacid

2

SUPREP BOWEL PREP KIT 17.5-3.13-1.6 GM/177MLSOLUTIONsodium sulfate-potassium sulfate-magnesium sulfate

2 QL 354 / 30 day(s)

trilyte 420 gm recon soln 5 PRE Preventative

LAXATIVES - MISCELLANEOUSconstulose 10 gm/15ml solution 1

lactulose 10 gm/15ml solution 1

lactulose 20 gm/30ml solution 1

pegylax 17 gm/scoop powder 1

polyethylene glycol 3350 17 gm packet 1

polyethylene glycol 3350 17 gm/scoop powder 1



MACROLIDESAZITHROMYCIN

AZITHROMYCIN 1 GM PACKETazithromycin


azithromycin 100 mg/5ml recon susp 1 QL 30 / 5 DAYS

azithromycin 200 mg/5ml recon susp 1 QL 90 / 5 DAYS

azithromycin 250 mg tab 1 QL 30 / 30 day(s)

azithromycin 500 mg tab 1 QL 30 / 30 DAYS

azithromycin 600 mg tab 1 QL 30 / 30 DAYS

CLARITHROMYCINCLARITHROMYCIN 125 MG/5ML RECON SUSPclarithromycin

1

clarithromycin 250 mg tab 1

CLARITHROMYCIN 250 MG/5ML RECON SUSPclarithromycin

1

clarithromycin 500 mg tab 1 QL 28 / 14 DAYS

clarithromycin er 500 mg tab er 24h 1 QL 28 / 14 DAYS

ERYTHROMYCINSery-tab 250 mg tab dr 1

ery-tab 500 mg tab dr 1

ERYTHROCIN STEARATE 250 MG TABerythromycin stearate

3 PA

erythromycin 250 mg tab dr 1

erythromycin 500 mg tab dr 1

erythromycin base 250 mg tab dr 1

erythromycin base 500 mg tab dr 1

erythromycin ethylsuccinate 200 mg/5ml recon susp 2

ERYTHROMYCIN ETHYLSUCCINATE 400 MG TABerythromycin ethylsuccinate

1



FIDAXOMICIN

DIFICID 200 MG TABfidaxomicin

4PA

S

DIFICID 40 MG/ML RECON SUSPfidaxomicin

4PA

S

MEDICAL DEVICES AND SUPPLIESCERVICAL CAPS

FEMCAP 22 MM DEVICEcervical caps

5 PRE Preventative


5 PRE Preventative


5 PRE Preventative

DIAPHRAGMSCAYA DIAPHRAGMdiaphragm arc-spring

5 PRE Preventative

OMNIFLEX DIAPHRAGM DIAPHRAGMdiaphragms

5 PRE Preventative

WIDE-SEAL DIAPHRAGM 60 2 % DIAPHRAGMdiaphragm wide seal

5 PRE Preventative


5 PRE Preventative


5 PRE Preventative


5 PRE Preventative


5 PRE Preventative


5 PRE Preventative


5 PRE Preventative


5 PRE Preventative



GLUCOSE MONITORING TEST SUPPLIES

DEXCOM G6 RECEIVER DEVICEcontinuous blood glucose system receiver

5

QL 1 / 365 day(s)

PA


DEXCOM G6 SENSOR MISCcontinuous blood glucose system sensor

5

QL 3 / 30 day(s)

PA


DEXCOM G6 TRANSMITTER MISCcontinuous blood glucose system transmitter

5

QL 1 / 90 day(s)

PA


EASY TOUCH LANCETS 30G/TWIST MISClancets


EASY TOUCH LANCETS 33G/TWIST MISClancets


FREESTYLE FLASH SYSTEM KITblood glucose monitoring supplies


FREESTYLE FREEDOM KITblood glucose monitoring supplies


FREESTYLE FREEDOM LITE W/DEVICE KITblood glucose monitoring supplies


FREESTYLE INSULINX SYSTEM W/DEVICE KITblood glucose monitoring supplies


FREESTYLE LANCETS MISClancets


FREESTYLE LIBRE 14 DAY READER DEVICEcontinuous blood glucose system receiver

5

QL 1 / 365 day(s)

PA


FREESTYLE LIBRE 14 DAY SENSOR MISCcontinuous blood glucose system sensor

5

QL 2 / 28 day(s)

PA


FREESTYLE LIBRE 2 READER DEVICEcontinuous blood glucose system receiver

5

QL 1 / 365 day(s)

PA




FREESTYLE LIBRE 2 SENSOR MISCcontinuous blood glucose system sensor

5

QL 2 / 28 day(s)

PA


FREESTYLE LIBRE READER DEVICEcontinuous blood glucose system receiver

5

QL 1 / 365 day(s)

PA


FREESTYLE LIBRE SENSOR SYSTEM MISCcontinuous blood glucose system sensor

5

QL 2 / 28 day(s)

PA


FREESTYLE LITE DEVICEblood glucose monitoring supplies


FREESTYLE LITE W/DEVICE KITblood glucose monitoring supplies


FREESTYLE SIDEKICK II KITblood glucose monitoring supplies


FREESTYLE SYSTEM KITblood glucose monitoring supplies


FREESTYLE UNISTICK II LANCETS MISClancets


KROGER HEALTHPRO LANCET 26G MISClancets


KROGER LANCETS MISClancets


KROGER LANCETS 21G MISClancets


KROGER LANCETS MICRO THIN 33G MISClancets


KROGER LANCETS SUPER THIN MISClancets


KROGER LANCETS THIN MISClancets


KROGER LANCETS THIN 26G MISClancets


KROGER LANCETS ULTRATHIN 30G MISClancets



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSMICROLET LANCETS MISClancets


ONETOUCH CLUB LANCETS FINE PT MISClancets


ONETOUCH DELICA LANCETS 30G MISClancets


ONETOUCH DELICA LANCETS 33G MISClancets


ONETOUCH DELICA LANCING DEV MISClancet devices


ONETOUCH DELICA PLUS LANCET30G MISClancets


ONETOUCH DELICA PLUS LANCET33G MISClancets


ONETOUCH DELICA PLUS LANCING MISClancet devices


ONETOUCH FINEPOINT LANCETS MISClancets


ONETOUCH PING METER REMOTE SUPPLIES MISCblood glucose monitoring supplies

2

ONETOUCH SURESOFT LANCING DEV MISClancets misc.


ONETOUCH ULTRA 2 W/DEVICE KITblood glucose monitoring supplies


ONETOUCH ULTRA MINI W/DEVICE KITblood glucose monitoring supplies


ONETOUCH ULTRALINK W/DEVICE KITblood glucose monitoring supplies


ONETOUCH ULTRASOFT LANCETS MISClancets


ONETOUCH VERIO FLEX SYSTEM W/DEVICE KITblood glucose monitoring supplies


ONETOUCH VERIO IQ SYSTEM W/DEVICE KITblood glucose monitoring supplies


ONETOUCH VERIO REFLECT W/DEVICE KITblood glucose monitoring supplies


ONETOUCH VERIO SYNC SYSTEM W/DEVICE KITblood glucose monitoring supplies



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSONETOUCH VERIO W/DEVICE KITblood glucose monitoring supplies


PHARMACIST CHOICE LANCETS MISClancets


TRUEPLUS LANCETS 26G MISClancets








TRUEPLUS SAFETY LANCETS 28G MISClancets


INSULIN ADMINISTRATION SUPPLIESOMNIPOD 5 G6 INTRO KIT KITinsulin infusion disposable pump

3 PA

OMNIPOD 5 G6 PODS (GEN 5) MISCinsulin infusion disposable pump

3 PA

OMNIPOD 5 PACK MISCinsulin infusion disposable pump

3 PA

OMNIPOD DASH 5 PACK PODS MISCinsulin infusion disposable pump

3 PA

OMNIPOD DASH INTRO KIT KITinsulin infusion disposable pump

3 PA

OMNIPOD DASH SYSTEM KITinsulin infusion disposable pump

3 PA

OMNIPOD STARTER KITinsulin infusion disposable pump

3 PA

NEEDLES & SYRINGESASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML MISCinsulin syringe/needle u-100

1

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML MISCinsulin syringe/needle u-100


BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML MISCinsulin syringe/needle u-500

1

BD KLATSKIN BIOPSY NEEDLE 16G X 4" MISCneedle (disp) 16 g

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSBD OSGOOD BIOPSY NEEDLE 16G X 1-5/16" MISCneedle (disp) 16 g

2

BD OSGOOD BIOPSY NEEDLE 18G X 1" MISCneedle (reusable) 18 g

2

BD PEN NEEDLE NANO U/F 32G X 4 MM MISCinsulin pen needle


BD ROSENTHAL BIOPSY NEEDLE 16G X 1-5/16" MISCneedle (disp) 16 g

2

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 MLMISCinsulin syringe/needle u-100


CEQUR SIMPLICITY INSERTER MISCinjection device for insulin

2

CEQUR SIMPLICITY STARTER KITinjection device for insulin

2

J-TIP KIT W/VIAL ADAPTERS KITinjection device

2

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML MISCinsulin syringe/needle u-100

1


1

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 1 ML MISCinsulin syringe/needle u-100






MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 1 ML MISCinsulin syringe/needle u-100


MARATHON MEDICAL PENTIPS 29G X 12MM MISCinsulin pen needle


MARATHON MEDICAL PENTIPS 31G X 5 MM MISCinsulin pen needle






MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML MISCinsulin syringe/needle u-100

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSMONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML MISCinsulin syringe/needle u-100

1


1

MONOJECT INSULIN SYRINGE 29G X 1/2" 0.3 ML MISCinsulin syringe/needle u-100

1


1









MONOJECT INSULIN SYRINGE U-100 1 ML MISCinsulin syringes (disposable)

1

MONOJECT INTRODUCER NEEDLE 18G X 1-1/4" MISCneedle (reusable) 18 g

2

MONOJECT MAGELLAN SAFETY NDL 21G X 5/8" MISCneedle (disp) 21 g

2

MONOJECT MAGELLAN SAFETY NDL 23G X 5/8" MISCneedle (disp) 23 g

2

MONOJECT MAGELLAN SYRINGE 18G X 1" 6 ML MISCsyringe/needle (disp) 6 ml

2

MONOJECT MAGELLAN SYRINGE 21G X 1" 12 ML MISCsyringe/needle (disp) 12 ml

2

MONOJECT MAGELLAN SYRINGE 22G X 1-1/2" 12 MLMISCsyringe/needle (disp) 12 ml

2

MONOJECT SYRINGE 21G X 1" 12 ML MISCsyringe/needle (disp) 12 ml

2

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 MLMISCinsulin syringe/needle u-100

1

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 MLMISCinsulin syringe/needle u-100

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSMONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.3ML MISCinsulin syringe/needle u-100


MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.5ML MISCinsulin syringe/needle u-100


NORDIPEN 5 INJECTION DEVICE MISCinjection device

2

OMNITROPE PEN 5 INJ DEVICE MISCinjection device

2

PENTIPS 29G X 12MM MISCinsulin pen needle


PENTIPS 31G X 5 MM MISCinsulin pen needle






PRO COMFORT PEN NEEDLES 31G X 8 MM MISCinsulin pen needle






ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML MISCinsulin syringe/needle u-100

1

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 1 ML MISCinsulin syringe/needle u-100


ULTILET INSULIN SYRINGE 31G X 15/64" 0.3 ML MISCinsulin syringe/needle u-100


SPACER/AEROSOL-HOLDING CHAMBERS & SUPPLIESAEROCHAMBER MINI CHAMBER DEVICEspacer/aerosol-holding chambers

2

AEROCHAMBER MV MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLO-VU MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLO-VU LARGE MISCspacer/aerosol-holding chambers

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSAEROCHAMBER PLUS FLO-VU MEDIUM MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLO-VU SMALL MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLO-VU W/MASK MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLOW VU MISCspacer/aerosol-holding chambers

2

AEROCHAMBER W/FLOWSIGNAL MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS CHAMBR MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS/LARGE MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS/MEDIUM MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS/SMALL MISCspacer/aerosol-holding chambers

2

COMPACT SPACE CHAMBER DEVICEspacer/aerosol-holding chambers

2

COMPACT SPACE CHAMBER/LG MASK DEVICEspacer/aerosol-holding chambers

2

COMPACT SPACE CHAMBER/MED MASK DEVICEspacer/aerosol-holding chambers

2

COMPACT SPACE CHAMBER/SM MASK DEVICEspacer/aerosol-holding chambers

2

EASIVENT MISCspacer/aerosol-holding chambers

2

EASIVENT MASK LARGE MISCspacer/aerosol-holding chambers

2

EASIVENT MASK MEDIUM MISCspacer/aerosol-holding chambers

2

EASIVENT MASK SMALL MISCspacer/aerosol-holding chambers

2

MICROCHAMBER MISCspacer/aerosol-holding chambers

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSMICROSPACER MISCspacer/aerosol-holding chambers

2

OPTICHAMBER ADVANTAGE-LG MASK MISCspacer/aerosol-holding chambers

2

OPTICHAMBER ADVANTAGE-MED MASK MISCspacer/aerosol-holding chambers

2

OPTICHAMBER ADVANTAGE-SM MASK MISCspacer/aerosol-holding chambers

2

OPTICHAMBER DIAMOND MISCspacer/aerosol-holding chambers

2

OPTICHAMBER DIAMOND-LG MASK DEVICEspacer/aerosol-holding chambers

2

OPTICHAMBER DIAMOND-MD MASK MISCspacer/aerosol-holding chambers

2

OPTICHAMBER DIAMOND-SM MASK MISCspacer/aerosol-holding chambers

2

VALVED HOLDING CHAMBER DEVICEspacer/aerosol-holding chambers

2

MIGRAINE PRODUCTSCALCITONIN GENE-RELATED PEPTIDE RECEPTOR ANTAG (CGRP)

NURTEC 75 MG TAB DISPrimegepant sulfate

3QL 8 / 30 day(s)

PA

QULIPTA 10 MG TABatogepant

3 PA


3 PA


3 PA

UBRELVY 100 MG TABubrogepant

2QL 12 / 30 day(s)

PA

UBRELVY 50 MG TABubrogepant

2QL 12 / 30 day(s)

PA

CGRP RECEPTOR ANTAGONISTS - MONOCOLONAL ANTIBODIES

AIMOVIG (140 MG DOSE) 70 MG/ML SOLN A-INJerenumab-aooe

3QL 2 / 30 DAYS

PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSAIMOVIG 140 MG/ML SOLN A-INJerenumab-aooe

3 PA

AIMOVIG 70 MG/ML SOLN A-INJerenumab-aooe

3QL 1 / 30 DAYS

PA

AJOVY 225 MG/1.5ML SOLN A-INJfremanezumab-vfrm

2QL 1.5 / 30 day(s)

PA

AJOVY 225 MG/1.5ML SOLN PRSYRfremanezumab-vfrm

2QL 1.5 / 30 DAYS

PA

EMGALITY (300 MG DOSE) 100 MG/ML SOLN PRSYRgalcanezumab-gnlm

2QL 1 / 30 DAYS

PA

EMGALITY 120 MG/ML SOLN A-INJgalcanezumab-gnlm

2QL 1 / 30 DAYS

PA

EMGALITY 120 MG/ML SOLN PRSYRgalcanezumab-gnlm

2QL 1 / 30 DAYS

PA

ERGOT COMBINATIONSergotamine-caffeine 1-100 mg tab 1

dihydroergotamine mesylate 1 mg/ml solution 2 QL 24 / 30 DAYS

dihydroergotamine mesylate 4 mg/ml solution 2QL 16 / 30 DAYS

PA

SELECTIVE SEROTONIN AGONISTS 5-HT(1)

almotriptan malate 12.5 mg tab 1 QL 9 / 28 DAYS

almotriptan malate 6.25 mg tab 1 QL 9 / 28 DAYS

eletriptan hydrobromide 20 mg tab 1 QL 9 / 28 DAYS

eletriptan hydrobromide 40 mg tab 1 QL 9 / 28 DAYS

frovatriptan succinate 2.5 mg tab 2 QL 9 / 28 DAYS

naratriptan hcl 1 mg tab 1 QL 9 / 30 DAYS

naratriptan hcl 2.5 mg tab 1 QL 9 / 30 DAYS



rizatriptan benzoate 10 mg tab 1 QL 9 / 28 DAYS

rizatriptan benzoate 10 mg tab disp 1 QL 9 / 28 DAYS

rizatriptan benzoate 5 mg tab 1 QL 9 / 28 DAYS

rizatriptan benzoate 5 mg tab disp 1 QL 9 / 28 DAYS

sumatriptan 20 mg/act solution 1 QL 6 / 28 DAYS

sumatriptan 5 mg/act solution 1 QL 6 / 28 DAYS

sumatriptan succinate 100 mg tab 1 QL 9 / 30 DAYS


sumatriptan succinate 4 mg/0.5ml soln a-inj 2 QL 2 / 28 day(s)


sumatriptan succinate 6 mg/0.5ml soln a-inj 2 QL 2 / 28 day(s)

SUMATRIPTAN SUCCINATE 6 MG/0.5ML SOLN PRSYRsumatriptan succinate

2

sumatriptan succinate 6 mg/0.5ml solution 2 QL 5 / 28 day(s)

zolmitriptan 2.5 mg tab 1 QL 12 / 30 DAYS

zolmitriptan 2.5 mg tab disp 1 QL 9 / 30 DAYS

zolmitriptan 5 mg tab 1 QL 9 / 30 DAYS

zolmitriptan 5 mg tab disp 1 QL 9 / 30 DAYS

SELECTIVE SEROTONIN AGONISTS 5-HT(1F)

REYVOW 100 MG TABlasmiditan succinate

3QL 4 / 30 day(s)

PA

REYVOW 50 MG TABlasmiditan succinate

3QL 4 / 30 day(s)

PA



MINERALS & ELECTROLYTESFLUORIDE

fluoritab 0.55 (0.25 f) mg chew tab 5 PRE Preventative

fluoritab 1.1 (0.5 f) mg chew tab 5 PRE Preventative

fluoritab 2.2 (1 f) mg chew tab 5 PRE Preventative

FLURA-DROPS 0.55 (0.25 F) MG/DROP SOLUTIONsodium fluoride

5AL1 Up to 8 yrs oldPRE Preventative

ludent 0.55 (0.25 f) mg chew tab 5 PRE Preventative

ludent 1.1 (0.5 f) mg chew tab 5 PRE Preventative

ludent 2.2 (1 f) mg chew tab 5 PRE Preventative

nafrinse 2.2 (1 f) mg chew tab 5 PRE Preventative

sodium fluoride 0.55 (0.25 f) mg chew tab 5 PRE Preventative

sodium fluoride 1.1 (0.5 f) mg chew tab 5 PRE Preventative

sodium fluoride 1.1 (0.5 f) mg/ml solution 5 PRE Preventative

sodium fluoride 2.2 (1 f) mg chew tab 5 PRE Preventative

PHOSPHATEK-PHOS 500 MG TABpotassium phosphate monobasic

2

phospha 250 neutral 155-852-130 mg tab 1

phospho-trin 250 neutral 155-852-130 mg tab 1

phospho-trin k500 500 mg tab 1

phosphorous 155-852-130 mg tab 1

virt-phos 250 neutral 155-852-130 mg tab 1

POTASSIUMeffer-k 25 meq effer tab 1

k-effervescent 25 meq effer tab 1

k-prime 25 meq effer tab 1



k-vescent 25 meq effer tab 1

klor-con 10 10 meq tab er 2

klor-con 20 meq packet 2

klor-con 8 meq tab er 1

klor-con m10 10 meq tab er 1



klor-con sprinkle 10 meq cap er 1

klor-con sprinkle 8 meq cap er 1

klor-con/ef 25 meq effer tab 1

potassium bicarbonate 25 meq effer tab 1

potassium chloride 10 % solution 1

potassium chloride 20 meq packet 2

potassium chloride 20 meq/15ml (10%) solution 1

potassium chloride crys er 10 meq tab er 1



potassium chloride er 10 meq cap er 1

potassium chloride er 10 meq tab er 1


potassium chloride er 8 meq cap er 1


POTASSIUM CHLORIDE ER 8 MEQ TAB ERpotassium chloride

1

MISCELLANEOUS THERAPEUTIC CLASSESANTILEPROTICS

THALOMID 100 MG CAPthalidomide

4PA

S


4PA

S




4PA

S


4PA

S

B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITORS

BENLYSTA 200 MG/ML SOLN A-INJbelimumab

4PA

S

BENLYSTA 200 MG/ML SOLN PRSYRbelimumab

4PA

S

CHELATING AGENTS

clovique 250 mg cap 4PA

S

penicillamine 250 mg cap 4PA

S

penicillamine 250 mg tab 4PA

S

trientine hcl 250 mg cap 4PA

S

CYCLOSPORINE ANALOGScyclosporine 100 mg cap 2

cyclosporine 25 mg cap 1 QL 90 / 30 DAYS

cyclosporine modified 100 mg cap 1 QL 4 / 1 day(s)

cyclosporine modified 100 mg/ml solution 1 QL 90 / 30 DAYS

cyclosporine modified 25 mg cap 1 QL 4 / 1 day(s)

cyclosporine modified 50 mg cap 1 QL 120 / 30 DAYS

gengraf 100 mg cap 1 QL 4 / 1 day(s)

gengraf 100 mg/ml solution 1 QL 90 / 30 DAYS



gengraf 25 mg cap 1 QL 4 / 1 day(s)

LUPKYNIS 7.9 MG CAPvoclosporin

4PA

S

NEORAL 100 MG CAPcyclosporine modified (for microemulsion)

4

QL 4 / 1 day(s)

PA

S

NEORAL 100 MG/ML SOLUTIONcyclosporine modified (for microemulsion)

4PA

S

NEORAL 25 MG CAPcyclosporine modified (for microemulsion)

4

QL 4 / 1 day(s)

PA

S

ENZYMES

XIAFLEX 0.9 MG RECON SOLNcollagenase clostridium histolyticum

4PA

S

IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES

lenalidomide 10 mg cap 4

QL 1 / 1 day(s)

PA

S


QL 1 / 1 day(s)

PA

S


QL 1 / 1 day(s)

PA

S


QL 1 / 1 day(s)

PA

S

REVLIMID 10 MG CAPlenalidomide

4

QL 1 / 1 day(s)

PA

S




4

QL 1 / 1 day(s)

PA

S

REVLIMID 2.5 MG CAPlenalidomide

4PA

S


4PA

S


4

QL 1 / 1 day(s)

PA

S


4

QL 1 / 1 day(s)

PA

S

INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS

mycophenolate mofetil 200 mg/ml recon susp 2PA

AL1 Up to 8 yrs old

mycophenolate mofetil 250 mg cap 1

mycophenolate mofetil 500 mg tab 1

mycophenolate sodium 180 mg tab dr 2

mycophenolate sodium 360 mg tab dr 2

IRRIGATION SOLUTIONSphysiolyte solution 3

physiosol irrigation solution 3

MACROLIDE IMMUNOSUPPRESSANTS

ASTAGRAF XL 0.5 MG CAP ER 24Htacrolimus

3QL 45 / 30 DAYS

PA

ASTAGRAF XL 1 MG CAP ER 24Htacrolimus

3QL 45 / 30 DAYS

PA

ASTAGRAF XL 5 MG CAP ER 24Htacrolimus

3QL 45 / 30 DAYS

PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSENVARSUS XR 0.75 MG TAB ER 24Htacrolimus

3 PA

ENVARSUS XR 1 MG TAB ER 24Htacrolimus

3 PA

ENVARSUS XR 4 MG TAB ER 24Htacrolimus

3 PA

everolimus 0.25 mg tab 2 QL 120 / 30 day(s)



everolimus 1 mg tab 2 QL 60 / 30 day(s)

sirolimus 0.5 mg tab 2 QL 1 / 1 day(s)

sirolimus 1 mg tab 2 QL 1 / 1 day(s)

sirolimus 1 mg/ml solution 4

PA

AL1 0 to 8 yrs old

S

sirolimus 2 mg tab 2

tacrolimus 0.5 mg cap 1

tacrolimus 1 mg cap 1

tacrolimus 5 mg cap 1

MONOCLONAL ANTIBODIES

ENSPRYNG 120 MG/ML SOLN PRSYRsatralizumab-mwge

4PA

S

POTASSIUM REMOVING AGENTSkionex powder 1

kionex 15 gm/60ml suspension 1

LOKELMA 10 GM PACKETsodium zirconium cyclosilicate

3 PA

LOKELMA 5 GM PACKETsodium zirconium cyclosilicate

3 PA

sodium polystyrene sulfonate powder 1



sodium polystyrene sulfonate 15 gm/60ml suspension 1



SPS 15 GM/60ML SUSPENSIONsodium polystyrene sulfonate

2

VELTASSA 16.8 GM PACKETpatiromer sorbitex calcium

3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA


3QL 60 / 28 DAYS

PA

PURINE ANALOGSazathioprine 50 mg tab 1

MOUTH/THROAT/DENTAL AGENTSANESTHETICS TOPICAL ORAL

lidocaine viscous hcl 2 % solution 1

ANTI-INFECTIVES - THROATclotrimazole 10 mg troche 1

nystatin 100000 unit/ml suspension 1

ORAVIG 50 MG TABmiconazole (mouth-throat)

3QL 14 / 14 DAYS

PA

ANTISEPTICS - MOUTH/THROATchlorhexidine gluconate 0.12 % solution 1

paroex 0.12 % solution 1

periogard 0.12 % solution 1

SALIVA STIMULANTScevimeline hcl 30 mg cap 1

pilocarpine hcl 5 mg tab 1

pilocarpine hcl 7.5 mg tab 1



STEROIDS - MOUTH/THROAT/DENTALtriamcinolone acetonide 0.1 % paste 1

MULTIVITAMINSPRENATAL MV & MIN W/FE-FA

CO-NATAL FA TABprenatal vit w/ ferrous fumarate-folic acid

5 PRE Preventative

COMPLETENATE 29-1 MG CHEW TABprenatal vit w/ ferrous fumarate-folic acid

2

M-VIT TABprenatal vit w/ ferrous fumarate-folic acid

1

NEONATAL COMPLETE 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

NEONATAL COMPLETE 29-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

5 PRE Preventative

NEONATAL PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

OB COMPLETE/DHA 30-10-1-200 MG CAPprenat vit w/ iron carbonyl-fe asp glyc-fa-omega fattyacid

2

PNV FOLIC ACID + IRON 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

PNV PRENATAL PLUS MULTIVITAMIN 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

PNV TABS 29-1 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid

2

PRENATA 29-1 MG CHEW TABprenatal without a vit w/ fe fumarate-folic acid

2

PRENATABS RX 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid

2

PRENATAL 19 29-1 MG CHEW TABprenatal vit w/ ferrous fumarate-folic acid

2

PRENATAL 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

PRENATAL PLUS IRON 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid

1

PRENATAL VITAMIN PLUS LOW IRON 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPRETAB 29-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

5 PRE Preventative

TRINATAL RX 1 60-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

2

VINATE ONE 60-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

2

VITATHELY WITH GINGER 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

WESTAB PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OILCOMPLETE NATAL DHA 29-1-200 & 200 MG MISCprenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega3

2

TRIVEEN-DUO DHA 29-1-200 & 300 MG MISCprenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega3

2

PRENATAL MV & MIN W/FE-FA-DHAPNV-DHA+DOCUSATE 27-1.25-300 MG CAPprenatal w/o vit a w/ fe fumarate-dss-fa-dha

2

VITAFOL-OB+DHA 65-1 & 250 MG MISCprenatal mv & min w/fe fumarate-fa-dha

2

VITAMEDMD ONE RX/QUATREFOLIC 30-0.6-0.4-200 MGCAPprenatal without a w/ fe fumarate-l methylfolate-fa-dha

2

PRENATAL VITAMINSVITAMEDMD REDICHEW RX 1.4 MG CHEW TABprenatal w/ vit b2-b6-b12-cholecalciferol-folic acid

2

MUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTS

baclofen 10 mg tab 1 QL 90 / 30 DAYS

baclofen 20 mg tab 1 QL 6 / 1 day(s)

baclofen 5 mg tab 1 QL 90 / 30 DAYS

chlorzoxazone 500 mg tab 1

chlorzoxazone 750 mg tab 1



cyclobenzaprine hcl 10 mg tab 1

cyclobenzaprine hcl 5 mg tab 1

cyclobenzaprine hcl 7.5 mg tab 1

lorzone 750 mg tab 1

metaxalone 800 mg tab 1 QL 90 / 30 DAYS

methocarbamol 500 mg tab 1

methocarbamol 750 mg tab 1

orphenadrine citrate er 100 mg tab er 12h 1

tizanidine hcl 2 mg cap 1

tizanidine hcl 2 mg tab 1


tizanidine hcl 4 mg tab 1


DIRECT MUSCLE RELAXANTSdantrolene sodium 100 mg cap 1

dantrolene sodium 25 mg cap 1

dantrolene sodium 50 mg cap 1

MUSCLE RELAXANT COMBINATIONS

carisoprodol-aspirin-codeine 200-325-16 mg tab 2 PA

orphenadrine-asa-caffeine 50-770-60 mg tab 2 PA

orphengesic forte 50-770-60 mg tab 2 PA

NASAL AGENTS - SYSTEMIC AND TOPICALANTIHISTAMINE-STEROID

azelastine-fluticasone 137-50 mcg/act suspension 2

NASAL ANTIBIOTICSBACTROBAN NASAL 2 % OINTMENTmupirocin calcium

3



NASAL ANTICHOLINERGICS

ipratropium bromide 0.03 % solution 1 QL 30 / 28 DAYS

ipratropium bromide 0.06 % solution 1 QL 15 / 14 DAYS

NASAL ANTIHISTAMINES

azelastine hcl 0.1 % solution 1 QL 30 / 25 DAYS

azelastine hcl 0.15 % solution 1 QL 30 / 25 DAYS

azelastine hcl 137 mcg/spray solution 1 QL 30 / 25 DAYS

olopatadine hcl 0.6 % solution 1 QL 30.5 / 30 DAYS

NASAL STEROIDSFLUNISOLIDE 25 MCG/ACT (0.025%) SOLUTIONflunisolide (nasal)

1 QL 25 / 25 DAYS

fluticasone propionate 50 mcg/act suspension 1 QL 16 / 30 DAYS

mometasone furoate 50 mcg/act suspension 1 QL 34 / 30 DAYS

XHANCE 93 MCG/ACT EXHUfluticasone propionate (nasal)

2 PA

NEUROMUSCULAR AGENTSBENZATHIAZOLES

riluzole 50 mg tab 1

NONDEPOLARIZING MUSCLE RELAXANTS

atracurium besylate 50 mg/5ml solution 2 PA

SPINAL MUSCULAR ATROPHY-SMN2 SPLICING MODIFIERS

EVRYSDI 0.75 MG/ML RECON SOLNrisdiplam

4PA

S

NUTRIENTSLIPIDS

DOJOLVI 100 % LIQUIDtriheptanoin

4PA

S



OPHTHALMIC AGENTSALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB

SIMBRINZA 1-0.2 % SUSPENSIONbrinzolamide-brimonidine tartrate

3

ARTIFICIAL TEAR INSERTSLACRISERT 5 MG INSERTartificial tear insert

3 PA

BETA-BLOCKERS - OPHTHALMICbetaxolol hcl 0.5 % solution 1

BETIMOL 0.25 % SOLUTIONtimolol

3

BETIMOL 0.5 % SOLUTIONtimolol

3

BETOPTIC-S 0.25 % SUSPENSIONbetaxolol hcl (ophth)

3

CARTEOLOL HCL 1 % SOLUTIONcarteolol hcl (ophth)

1

LEVOBUNOLOL HCL 0.5 % SOLUTIONlevobunolol hcl

1

levobunolol hcl 0.5 % solution 1

METIPRANOLOL 0.3 % SOLUTIONmetipranolol

1

timolol maleate 0.25 % gel f soln 1

timolol maleate 0.25 % solution 1

timolol maleate 0.5 % gel f soln 1

timolol maleate 0.5 % solution 1

BETA-BLOCKERS - OPHTHALMIC COMBINATIONSBRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % SOLUTIONbrimonidine tartrate-timolol maleate

3

COMBIGAN 0.2-0.5 % SOLUTIONbrimonidine tartrate-timolol maleate

3

dorzolamide hcl-timolol mal 22.3-6.8 mg/ml solution 1

dorzolamide hcl-timolol mal pf 2-0.5 % solution 1



CYCLOPLEGIC MYDRIATICSatropine sulfate 1 % solution 1

cyclopentolate hcl 0.5 % solution 1

cyclopentolate hcl 1 % solution 1

cyclopentolate hcl 2 % solution 1

homatropine hbr 5 % solution 1

tropicamide 0.5 % solution 1

tropicamide 1 % solution 1

LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAGXIIDRA 5 % SOLUTIONlifitegrast

2

MIOTICS - CHOLINESTERASE INHIBITORSPHOSPHOLINE IODIDE 0.125 % RECON SOLNechothiophate iodide

2

MIOTICS - DIRECT ACTINGpilocarpine hcl 1 % solution 1

pilocarpine hcl 2 % solution 1

pilocarpine hcl 4 % solution 1

OPHTHALMIC ANTI-INFECTIVE COMBINATIONSak-poly-bac 500-10000 unit/gm ointment 1

bacitracin-polymyxin b 500-10000 unit/gm ointment 1

neo-polycin 3.5-400-10000 ointment 1

neomycin-bacitracin zn-polymyx 3.5-400-10000 ointment 1

neomycin-bacitracin zn-polymyx 5-400-10000 ointment 1

NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025SOLUTIONneomycin-polymyxin-gramicidin

1

polycin 500-10000 unit/gm ointment 1

polymyxin b-trimethoprim 10000-0.1 unit/ml-% solution 1



OPHTHALMIC ANTIALLERGICALOCRIL 2 % SOLUTIONnedocromil sodium (ophth)

2

ALOMIDE 0.1 % SOLUTIONlodoxamide tromethamine

2

azelastine hcl 0.05 % solution 1

bepotastine besilate 1.5 % solution 2 QL 10 / 30 day(s)

BEPREVE 1.5 % SOLUTIONbepotastine besilate

3 QL 10 / 30 day(s)

cromolyn sodium 4 % solution 1

EMADINE 0.05 % SOLUTIONemedastine difumarate

2

epinastine hcl 0.05 % solution 1

LASTACAFT 0.25 % SOLUTIONalcaftadine

3

olopatadine hcl 0.1 % solution 1

olopatadine hcl 0.2 % solution 1

OPHTHALMIC ANTIBIOTICSAZASITE 1 % SOLUTIONazithromycin (ophth)

3

BACITRACIN 500 UNIT/GM OINTMENTbacitracin (ophthalmic)

1

BESIVANCE 0.6 % SUSPENSIONbesifloxacin hcl

3

ciprofloxacin hcl 0.3 % solution 1

erythromycin 5 mg/gm ointment 1

gatifloxacin 0.5 % solution 1 QL 2.5 / 30 DAYS

gentamicin sulfate 0.3 % solution 1

levofloxacin 0.5 % solution 1

MOXEZA 0.5 % SOLUTIONmoxifloxacin hcl (ophth)

3 QL 3 / 30 DAYS

MOXIFLOXACIN HCL (2X DAY) 0.5 % SOLUTIONmoxifloxacin hcl (ophth)

1



moxifloxacin hcl 0.5 % solution 1

ofloxacin 0.3 % solution 1

tobramycin 0.3 % solution 1

OPHTHALMIC ANTIFUNGALNATACYN 5 % SUSPENSIONnatamycin

3

OPHTHALMIC ANTIVIRALSTRIFLURIDINE 1 % SOLUTIONtrifluridine

1

ZIRGAN 0.15 % GELganciclovir ophthalmic

3

OPHTHALMIC CARBONIC ANHYDRASE INHIBITORSbrinzolamide 1 % suspension 2

dorzolamide hcl 2 % solution 1

OPHTHALMIC IMMUNOMODULATORSRESTASIS 0.05 % EMULSIONcyclosporine (ophth)

2

RESTASIS MULTIDOSE 0.05 % EMULSIONcyclosporine (ophth)

2

OPHTHALMIC KINASE INHIBITORS - COMBINATIONSROCKLATAN 0.02-0.005 % SOLUTIONnetarsudil dimesylate-latanoprost

3 PA

OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

bromfenac sodium (once-daily) 0.09 % solution 1 QL 3.4 / 30 DAYS

diclofenac sodium 0.1 % solution 1

FLURBIPROFEN SODIUM 0.03 % SOLUTIONflurbiprofen sodium

1

flurbiprofen sodium 0.03 % solution 1

ILEVRO 0.3 % SUSPENSIONnepafenac

3

ketorolac tromethamine 0.4 % solution 1

ketorolac tromethamine 0.5 % solution 1

NEVANAC 0.1 % SUSPENSIONnepafenac

3



OPHTHALMIC RHO KINASE INHIBITORSRHOPRESSA 0.02 % SOLUTIONnetarsudil dimesylate

3 PA

OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTSALPHAGAN P 0.1 % SOLUTIONbrimonidine tartrate

3

apraclonidine hcl 0.5 % solution 1

brimonidine tartrate 0.15 % solution 1

brimonidine tartrate 0.2 % solution 1

OPHTHALMIC STEROID COMBINATIONSBLEPHAMIDE S.O.P. 10-0.2 % OINTMENTsulfacetamide sod-prednisolone

3

neomycin-polymyxin-dexameth 3.5-10000-0.1 ointment 1

neomycin-polymyxin-dexameth 3.5-10000-0.1 suspension 1

SULFACETAMIDE-PREDNISOLONE 10-0.23 % SOLUTIONsulfacetamide sod-prednisolone

1

TOBRADEX 0.3-0.1 % OINTMENTtobramycin-dexamethasone

2

tobramycin-dexamethasone 0.3-0.1 % suspension 1

OPHTHALMIC STEROIDSALREX 0.2 % SUSPENSIONloteprednol etabonate

3 ST

DEXAMETHASONE SODIUM PHOSPHATE 0.1 % SOLUTIONdexamethasone sodium phosphate (ophth)

1

difluprednate 0.05 % emulsion 1 QL 5 / 30 day(s)

FLAREX 0.1 % SUSPENSIONfluorometholone acetate

3

fluorometholone 0.1 % suspension 1

FML 0.1 % OINTMENTfluorometholone (ophth)

2

FML FORTE 0.25 % SUSPENSIONfluorometholone (ophth)

2

LOTEMAX 0.5 % OINTMENTloteprednol etabonate

3 ST



loteprednol etabonate 0.5 % gel 1

loteprednol etabonate 0.5 % suspension 1 QL 15 / 30 DAYS

MAXIDEX 0.1 % SUSPENSIONdexamethasone (ophth)

3

OMNIPRED 1 % SUSPENSIONprednisolone acetate (ophth)

2 QL 10 / 30 DAYS

PRED MILD 0.12 % SUSPENSIONprednisolone acetate (ophth)

2

PREDNISOLONE ACETATE 1 % SUSPENSIONprednisolone acetate (ophth)

1

PREDNISOLONE ACETATE P-F 1 % SUSPENSIONprednisolone acetate (ophth)

1

PREDNISOLONE SODIUM PHOSPHATE 1 % SOLUTIONprednisolone sodium phosphate (ophth)

1

OPHTHALMIC SULFONAMIDESsulfacetamide sodium 10 % solution 1

OPHTHALMICS - CYSTINOSIS AGENTS

CYSTADROPS 0.37 % SOLUTIONcysteamine hcl

4PA

S

CYSTARAN 0.44 % SOLUTIONcysteamine hcl

4PA

S

PROSTAGLANDINS - OPHTHALMIC

latanoprost 0.005 % solution 1 QL 5 / 30 DAYS

LUMIGAN 0.01 % SOLUTIONbimatoprost

2 QL 7 / 30 DAYS

travoprost (bak free) 0.004 % solution 2

ZIOPTAN 0.0015 % SOLUTIONtafluprost

3 PA

OTIC AGENTSOTIC AGENTS - MISCELLANEOUS

acetic acid 2 % solution 1



OTIC ANTI-INFECTIVESCIPROFLOXACIN HCL 0.2 % SOLUTIONciprofloxacin hcl (otic)

1

ofloxacin 0.3 % solution 1

OTIPRIO 6 % SUSPENSIONciprofloxacin (otic)

3 PA

OTIC STEROID-ANTI-INFECTIVE COMBINATIONSCIPRO HC 0.2-1 % SUSPENSIONciprofloxacin-hydrocortisone

2

ciprofloxacin-dexamethasone 0.3-0.1 % suspension 1

COLY-MYCIN S 3.3-3-10-0.5 MG/ML SUSPENSIONneomycin-colistin-hc-thonzonium

3

neomycin-polymyxin-hc 1 % solution 1

neomycin-polymyxin-hc 3.5-10000-1 solution 1

neomycin-polymyxin-hc 3.5-10000-1 suspension 1

OTOVEL 0.3-0.025 % SOLUTIONciprofloxacin-fluocinolone acetonide

3 ST

OTIC STEROIDSacetasol hc 2-1 % solution 1

flac 0.01 % oil 1

fluocinolone acetonide 0.01 % oil 1

hydrocortisone-acetic acid 1-2 % solution 1

OXYTOCICS

methergine 0.2 mg tab 2 QL 28 / 30 DAYS

methylergonovine maleate 0.2 mg tab 2 QL 28 / 30 DAYS

PASSIVE IMMUNIZING AND TREATMENT AGENTSANTIVIRAL MONOCLONAL ANTIBODIES

SYNAGIS 100 MG/ML SOLUTIONpalivizumab

4PA

S

SYNAGIS 50 MG/0.5ML SOLUTIONpalivizumab

4PA

S



IMMUNE SERUMS

CUVITRU 1 GM/5ML SOLUTIONimmune globulin (human) subcutaneous

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

HIZENTRA 1 GM/5ML SOLN PRSYRimmune globulin (human) subcutaneous

4PA

S

HIZENTRA 1 GM/5ML SOLUTIONimmune globulin (human) subcutaneous

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

PASSIVE IMMUNIZING AGENTS - COMBINATIONSHYQVIA 10 GM/100ML KITimmune globulin (human)-hyaluronidase (humanrecombinant)

4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSHYQVIA 2.5 GM/25ML KITimmune globulin (human)-hyaluronidase (humanrecombinant)

4PA

S

HYQVIA 20 GM/200ML KITimmune globulin (human)-hyaluronidase (humanrecombinant)

4PA

S


4PA

S


4PA

S

PENICILLINSAMINOPENICILLINS

AMOXICILLIN 125 MG CHEW TABamoxicillin

1

amoxicillin 125 mg/5ml recon susp 1


amoxicillin 250 mg cap 1

AMOXICILLIN 250 MG CHEW TABamoxicillin

1



amoxicillin 500 mg cap 1

amoxicillin 500 mg tab 1

amoxicillin 875 mg tab 1

AMPICILLIN 500 MG CAPampicillin

1

NATURAL PENICILLINSPENICILLIN V POTASSIUM 125 MG/5ML RECON SOLNpenicillin v potassium

1

penicillin v potassium 250 mg tab 1

PENICILLIN V POTASSIUM 250 MG/5ML RECON SOLNpenicillin v potassium

1

penicillin v potassium 500 mg tab 1



PENICILLIN COMBINATIONSAMOXICILLIN-POT CLAVULANATE 200-28.5 MG CHEWTABamoxicillin & pot clavulanate

1

amoxicillin-pot clavulanate 200-28.5 mg/5ml recon susp 1

amoxicillin-pot clavulanate 250-125 mg tab 1


AMOXICILLIN-POT CLAVULANATE 400-57 MG CHEW TABamoxicillin & pot clavulanate

1

amoxicillin-pot clavulanate 400-57 mg/5ml recon susp 1




amoxicillin-pot clavulanate er 1000-62.5 mg tab er 12h 1

AMOXICILLIN-POT CLAVULANATE ER 1000-62.5 MG TABER 12Hamoxicillin & pot clavulanate

1

PENICILLINASE-RESISTANT PENICILLINSdicloxacillin sodium 250 mg cap 1

dicloxacillin sodium 500 mg cap 1

nafcillin sodium 1 gm recon soln 2 PA

PROGESTINS

hydroxyprogesterone caproate 250 mg/ml oil 2 PA

medroxyprogesterone acetate 10 mg tab 1

medroxyprogesterone acetate 2.5 mg tab 1

medroxyprogesterone acetate 5 mg tab 1

megestrol acetate 625 mg/5ml suspension 1

norethindrone acetate 5 mg tab 1

progesterone 100 mg cap 1

progesterone 200 mg cap 1



PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.ALCOHOL DETERRENTS

acamprosate calcium 333 mg tab dr 1

disulfiram 250 mg tab 1

disulfiram 500 mg tab 1

BENZODIAZEPINES & TRICYCLIC AGENTSCHLORDIAZEPOXIDE-AMITRIPTYLINE 5-12.5 MG TABchlordiazepoxide-amitriptyline

1

CHOLINOMIMETICS - ACHE INHIBITORS

donepezil hcl 10 mg tab 1 QL 30 / 30 DAYS

donepezil hcl 10 mg tab disp 1 QL 30 / 30 DAYS



donepezil hcl 5 mg tab disp 1 QL 30 / 30 DAYS

galantamine hydrobromide 12 mg tab 1 QL 60 / 30 DAYS


GALANTAMINE HYDROBROMIDE 4 MG/ML SOLUTIONgalantamine hydrobromide

1 QL 180 / 30 DAYS


galantamine hydrobromide er 16 mg cap er 24h 1 QL 30 / 30 DAYS



rivastigmine 13.3 mg/24hr patch 24hr 1 QL 30 / 30 DAYS



rivastigmine tartrate 1.5 mg cap 1 QL 60 / 30 DAYS

rivastigmine tartrate 3 mg cap 1 QL 60 / 30 DAYS



rivastigmine tartrate 4.5 mg cap 1 QL 60 / 30 DAYS

rivastigmine tartrate 6 mg cap 1 QL 60 / 30 DAYS

FIBROMYALGIA AGENT - SNRIS

SAVELLA 100 MG TABmilnacipran hcl

3QL 60 / 30 DAYS

PA

SAVELLA 12.5 MG TABmilnacipran hcl

3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA

SAVELLA TITRATION PACK 12.5 & 25 & 50 MG MISCmilnacipran hcl

3 PA

MOVEMENT DISORDER DRUG THERAPY

tetrabenazine 12.5 mg tab 2 PA

tetrabenazine 25 mg tab 2 PA

MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS

AUBAGIO 14 MG TABteriflunomide

4PA

S

AUBAGIO 7 MG TABteriflunomide

4PA

S

MULTIPLE SCLEROSIS AGENTS

glatiramer acetate 20 mg/ml soln prsyr 4 S

glatiramer acetate 40 mg/ml soln prsyr 4 S

MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES

MAVENCLAD (10 TABS) 10 MG TAB THPKcladribine (multiple sclerosis)

4PA

S


4PA

S




4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

MULTIPLE SCLEROSIS AGENTS - INTERFERONS

AVONEX 30 MCG KITinterferon beta-1a

4PA

S

AVONEX PEN 30 MCG/0.5ML AUT-IJ KITinterferon beta-1a

4PA

S

AVONEX PREFILLED 30 MCG/0.5ML PREF SY KTinterferon beta-1a

4PA

S

BETASERON 0.3 MG KITinterferon beta-1b

4PA

S

EXTAVIA 0.3 MG KITinterferon beta-1b

4PA

S

PLEGRIDY 125 MCG/0.5ML SOLN PENpeginterferon beta-1a

4PA

S

PLEGRIDY 125 MCG/0.5ML SOLN PRSYRpeginterferon beta-1a

4PA

S

PLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML SOLN PENpeginterferon beta-1a

4PA

S

PLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML SOLNPRSYRpeginterferon beta-1a

4PA

S



REBIF 22 MCG/0.5ML SOLN PRSYRinterferon beta-1a

4PA

S

REBIF 44 MCG/0.5ML SOLN PRSYRinterferon beta-1a

4PA

S

REBIF REBIDOSE 22 MCG/0.5ML SOLN A-INJinterferon beta-1a

4PA

S

REBIF REBIDOSE 44 MCG/0.5ML SOLN A-INJinterferon beta-1a

4PA

S

REBIF REBIDOSE TITRATION PACK 6X8.8 & 6X22 MCGSOLN A-INJinterferon beta-1a

4PA

S

REBIF TITRATION PACK 6X8.8 & 6X22 MCG SOLN PRSYRinterferon beta-1a

4PA

S

MULTIPLE SCLEROSIS AGENTS - MONOCLONAL ANTIBODIES

KESIMPTA 20 MG/0.4ML SOLN A-INJofatumumab (ms)

4PA

S

MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS

BAFIERTAM 95 MG CAP DRmonomethyl fumarate

4PA

S

dimethyl fumarate 120 mg cap dr 4

dimethyl fumarate 240 mg cap dr 4

dimethyl fumarate starter pack 120 & 240 mg misc 4

MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS

dalfampridine er 10 mg tab er 12h 2 QL 60 / 30 DAYS

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

memantine hcl 10 mg tab 1 QL 60 / 30 DAYS

memantine hcl 10 mg/5ml solution 1 QL 30 / 30 DAYS

memantine hcl 2 mg/ml solution 1 QL 30 / 30 DAYS

memantine hcl 28 x 5 mg & 21 x 10 mg tab 1 QL 49 / 30 day(s)



memantine hcl 5 mg tab 1 QL 120 / 30 DAYS

memantine hcl er 14 mg cap er 24h 1 QL 30 / 30 DAYS




PHENOTHIAZINES & TRICYCLIC AGENTSPERPHENAZINE-AMITRIPTYLINE 2-10 MG TABperphenazine-amitriptyline

1

PERPHENAZINE-AMITRIPTYLINE 2-25 MG TABperphenazine-amitriptyline

1


1


1


1

POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS

pregabalin er 165 mg tab er 24h 2 PA

pregabalin er 330 mg tab er 24h 2 PA

pregabalin er 82.5 mg tab er 24h 2 PA

PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - SSRIS

FLUOXETINE HCL (PMDD) 10 MG CAPfluoxetine hcl (pmdd)

5QL 90 / 30 DAYS


FLUOXETINE HCL (PMDD) 10 MG TABfluoxetine hcl (pmdd)

5QL 90 / 30 DAYS


FLUOXETINE HCL (PMDD) 20 MG CAPfluoxetine hcl (pmdd)

5QL 90 / 30 DAYS


FLUOXETINE HCL (PMDD) 20 MG TABfluoxetine hcl (pmdd)

5QL 90 / 30 DAYS


ERGOLOID MESYLATES 1 MG TABergoloid mesylates

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPIMOZIDE 1 MG TABpimozide

1 QL 30 / 30 DAYS

PIMOZIDE 2 MG TABpimozide

1 QL 60 / 30 DAYS

SMOKING DETERRENTS

APO-VARENICLINE 0.5 MG TABvarenicline tartrate

5QL 60 / 30 day(s)

PRE Preventative

APO-VARENICLINE 1 MG TABvarenicline tartrate

5QL 60 / 30 day(s)

PRE Preventative

bupropion hcl er (smoking det) 150 mg tab er 12h 5 PRE Preventative

CHANTIX 0.5 MG TABvarenicline tartrate

5QL 60 / 30 day(s)

PRE Preventative

CHANTIX 1 MG TABvarenicline tartrate

5QL 60 / 30 day(s)

PRE Preventative

CHANTIX CONTINUING MONTH PAK 1 MG TABvarenicline tartrate

5QL 60 / 30 day(s)

PRE Preventative

CHANTIX STARTING MONTH PAK 0.5 MG X 11 & 1 MG X42 TABvarenicline tartrate

5

QL 53 / 0 DAYS

MFL 1 / 365 DAYSPRE Preventative

NICOTROL 10 MG INHALERnicotine

5QL 672 / 30 DAYS

PRE Preventative

NICOTROL NS 10 MG/ML SOLUTIONnicotine

5QL 120 / 30 DAYS

PRE Preventative

VARENICLINE TARTRATE 0.5 MG TABvarenicline tartrate

5QL 60 / 30 day(s)

PRE Preventative

VARENICLINE TARTRATE 1 MG TABvarenicline tartrate

5QL 60 / 30 day(s)

PRE Preventative

ZYBAN 150 MG TAB ER 12Hbupropion hcl (smoking deterrent)

5 PRE Preventative



SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR MODULATORS

GILENYA 0.25 MG CAPfingolimod hcl

4PA

S

GILENYA 0.5 MG CAPfingolimod hcl

4PA

S

MAYZENT 0.25 MG TABsiponimod fumarate

4PA

S

MAYZENT 1 MG TABsiponimod fumarate

4PA

S

MAYZENT 2 MG TABsiponimod fumarate

4PA

S

MAYZENT STARTER PACK 0.25 MG TAB THPKsiponimod fumarate

4PA

S

MAYZENT STARTER PACK 12 X 0.25 MG TAB THPKsiponimod fumarate

4PA

S

PONVORY 20 MG TABponesimod

4PA

S

PONVORY STARTER PACK 2,3,4,5,6,7,8,9 & 10 MG TABTHPKponesimod

4PA

S

ZEPOSIA 0.92 MG CAPozanimod hcl

4PA

S

ZEPOSIA 7-DAY STARTER PACK 4 X 0.23MG & 3 X 0.46MGCAP THPKozanimod hcl

4PA

S

ZEPOSIA STARTER KIT 0.23MG & 0.46MG & 0.92MG CAPTHPKozanimod hcl

4PA

S

VASOMOTOR SYMPTOM AGENTS - SSRIS

paroxetine mesylate 7.5 mg cap 1 QL 30 / 30 DAYS



RESPIRATORY AGENTS - MISC.ALPHA-PROTEINASE INHIBITOR (HUMAN)

ARALAST NP 1000 MG RECON SOLNalpha1-proteinase inhibitor (human)

4PA

S

ARALAST NP 500 MG RECON SOLNalpha1-proteinase inhibitor (human)

4PA

S

GLASSIA 1000 MG/50ML SOLUTIONalpha1-proteinase inhibitor (human)

4PA

S

PROLASTIN-C 1000 MG RECON SOLNalpha1-proteinase inhibitor (human)

4PA

S

PROLASTIN-C 1000 MG/20ML SOLUTIONalpha1-proteinase inhibitor (human)

4PA

S

ZEMAIRA 1000 MG RECON SOLNalpha1-proteinase inhibitor (human)

4PA

S

CFTR POTENTIATORS

KALYDECO 150 MG TABivacaftor

4PA

S

KALYDECO 25 MG PACKETivacaftor

4PA

S


4PA

S


4PA

S

CYSTIC FIBROSIS AGENT - COMBINATIONS

ORKAMBI 100-125 MG PACKETlumacaftor-ivacaftor

4PA

S

ORKAMBI 100-125 MG TABlumacaftor-ivacaftor

4PA

S

ORKAMBI 150-188 MG PACKETlumacaftor-ivacaftor

4PA

S



ORKAMBI 200-125 MG TABlumacaftor-ivacaftor

4PA

S

SYMDEKO 100-150 & 150 MG TAB THPKtezacaftor-ivacaftor

4PA

S

SYMDEKO 50-75 & 75 MG TAB THPKtezacaftor-ivacaftor

4PA

S

TRIKAFTA 100-50-75 & 150 MG TAB THPKelexacaftor-tezacaftor-ivacaftor

4PA

S

TRIKAFTA 50-25-37.5 & 75 MG TAB THPKelexacaftor-tezacaftor-ivacaftor

4PA

S

HYDROLYTIC ENZYMES

PULMOZYME 2.5 MG/2.5ML SOLUTIONdornase alfa

4PA

S

PULMONARY FIBROSIS AGENTS

ESBRIET 267 MG CAPpirfenidone

4PA

S

ESBRIET 267 MG TABpirfenidone

4PA

S

ESBRIET 801 MG TABpirfenidone

4PA

S

PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS

OFEV 100 MG CAPnintedanib esylate

4PA

S

OFEV 150 MG CAPnintedanib esylate

4PA

S

SULFONAMIDESSULFADIAZINE 500 MG TABsulfadiazine

1

sulfadiazine 500 mg tab 1



TETRACYCLINESavidoxy 100 mg tab 1

coremino 90 mg tab er 24h 2 QL 30 / 30 DAYS

demeclocycline hcl 150 mg tab 2

demeclocycline hcl 300 mg tab 2

doxycycline hyclate 100 mg cap 1

doxycycline hyclate 100 mg tab 1

doxycycline hyclate 100 mg tab dr 2


doxycycline hyclate 20 mg tab 1

doxycycline hyclate 50 mg cap 1



doxycycline monohydrate 100 mg cap 1

doxycycline monohydrate 100 mg tab 1


doxycycline monohydrate 25 mg/5ml recon susp 1 AL1 Up to 8 yrs old

doxycycline monohydrate 50 mg cap 1



lymepak 100 mg tab 1

minocycline hcl 100 mg cap 1

minocycline hcl 100 mg tab 1





minocycline hcl er 105 mg tab er 24h 2 QL 30 / 30 DAYS










mondoxyne nl 50 mg cap 1

morgidox 100 mg cap 1

morgidox 50 mg cap 1

tetracycline hcl 250 mg cap 1

tetracycline hcl 500 mg cap 1

THYROID AGENTSANTITHYROID AGENTS

methimazole 10 mg tab 1

methimazole 5 mg tab 1

propylthiouracil 50 mg tab 1

THYROID HORMONESARMOUR THYROID 120 MG TABthyroid

2

ARMOUR THYROID 15 MG TABthyroid

2


2


2


2


2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSARMOUR THYROID 60 MG TABthyroid

2


2

euthyrox 100 mcg tab 1











levo-t 100 mcg tab 1







levo-t 25 mcg tab 1


levo-t 50 mcg tab 1

levo-t 75 mcg tab 1

levo-t 88 mcg tab 1

LEVOTHYROXINE SODIUM 100 MCG CAPlevothyroxine sodium

2

levothyroxine sodium 100 mcg tab 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSLEVOTHYROXINE SODIUM 112 MCG CAPlevothyroxine sodium

2



2



2


2



2



2



2



2




2



2



2


levoxyl 100 mcg tab 1













liothyronine sodium 25 mcg tab 1



NATURE-THROID 113.75 MG TABthyroid

2

NATURE-THROID 130 MG TABthyroid

2


2


2


2


2


2


2


2


2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSNATURE-THROID 65 MG TABthyroid

2


2


2

np thyroid 120 mg tab 1





SYNTHROID 100 MCG TABlevothyroxine sodium

2


2


2


2


2


2


2


2


2


2


2


2

thyroid 120 mg tab 1



thyroid 15 mg tab 1

thyroid 30 mg tab 1

thyroid 60 mg tab 1

thyroid 90 mg tab 1

THYROLAR-1 60 (12.5-50) MG (MCG) TABliotrix (t3-t4)

3

THYROLAR-1/2 30 (6.25-25) MG (MCG) TABliotrix (t3-t4)

3

THYROLAR-1/4 15 (3.1-12.5) MG (MCG) TABliotrix (t3-t4)

3

THYROLAR-2 120 (25-100) MG (MCG) TABliotrix (t3-t4)

3

THYROLAR-3 180 (37.5-150) MG (MCG) TABliotrix (t3-t4)

3

unithroid 100 mcg tab 1












WESTHROID 130 MG TABthyroid

3

WESTHROID 195 MG TABthyroid

3

WESTHROID 32.5 MG TABthyroid

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSWESTHROID 65 MG TABthyroid

3

WESTHROID 97.5 MG TABthyroid

3

WP THYROID 113.75 MG TABthyroid

3

WP THYROID 130 MG TABthyroid

3


3


3


3

WP THYROID 65 MG TABthyroid

3


3


3

TOXOIDSTOXOID COMBINATIONS

ADACEL 5-2-15.5 LF-MCG/0.5 SUSPENSIONtetanus toxoid-diphtheria-acellular pertussis adsorb(tdap)

5 PRE Preventative

BOOSTRIX 5-2.5-18.5 LF-MCG/0.5 SUSP PRSYRtetanus toxoid-diphtheria-acellular pertussis adsorb(tdap)

5 PRE Preventative

BOOSTRIX 5-2.5-18.5 LF-MCG/0.5 SUSPENSIONtetanus toxoid-diphtheria-acellular pertussis adsorb(tdap)

5 PRE Preventative

DAPTACEL 23-15-5 SUSPENSIONdiphtheria, acellular pertussis & tetanus toxoids

5 PRE Preventative

DIPHTHERIA-TETANUS TOXOIDS DT 25-5 LFU/0.5MLSUSPENSIONdiphtheria-tetanus toxoids (dt)

5 PRE Preventative

INFANRIX 25-58-10 SUSPENSIONdiphtheria, acellular pertussis & tetanus toxoids

5 PRE Preventative


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSKINRIX SUSPENSIONdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac

5 PRE Preventative

KINRIX 0.5 ML SUSP PRSYRdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac

5 PRE Preventative

PEDIARIX SUSP PRSYRdiph-tetanus tox-acell pert-hepatitis b recomb-polio ipvvac

5 PRE Preventative

PENTACEL RECON SUSPdiph-ac pert-tet tox ad-polio ipv-haemophil b poly vac

5 PRE Preventative

QUADRACEL SUSPENSIONdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac

5 PRE Preventative

QUADRACEL 0.5 ML SUSP PRSYRdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac

5 PRE Preventative

TDVAX 2-2 LF/0.5ML SUSPENSIONtetanus-diphtheria toxoids (td)

5 PRE Preventative

TENIVAC 5-2 LFU INJECTABLEtetanus-diphtheria toxoids (td)

5 PRE Preventative

TETANUS-DIPHTHERIA TOXOIDS TD 2-2 LF/0.5MLSUSPENSIONtetanus-diphtheria toxoids (td)

5 PRE Preventative

VAXELIS SUSP PRSYRdiph-tet tox-acell pert ad-polio ipv-hib-hepatitis b recomb

5 PRE Preventative

VAXELIS SUSPENSIONdiph-tet tox-acell pert ad-polio ipv-hib-hepatitis b recomb

5 PRE Preventative

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICSANTICHOLINERGIC COMBINATIONS

BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG SUPPOSbelladonna alkaloids & opium

2

ANTISPASMODICSdicyclomine hcl 10 mg cap 1

dicyclomine hcl 10 mg/5ml solution 1 AL1 Up to 8 yrs old

dicyclomine hcl 20 mg tab 1

BELLADONNA ALKALOIDShyoscyamine sulfate 0.125 mg sl tab 1

hyoscyamine sulfate 0.125 mg tab 1



hyoscyamine sulfate er 0.375 mg tab er 12h 1

hyoscyamine sulfate sl 0.125 mg sl tab 1

oscimin 0.125 mg sl tab 1

oscimin sr 0.375 mg tab er 12h 1

SYMAX DUOTAB 0.375 MG TAB ERhyoscyamine sulfate

3 PA

symax-sl 0.125 mg sl tab 1

symax-sr 0.375 mg tab er 12h 1

H-2 ANTAGONISTSCIMETIDINE HCL 300 MG/5ML SOLUTIONcimetidine hcl


cimetidine hcl 300 mg/5ml solution 1 AL1 Up to 8 yrs old

cimetidine hcl 400 mg/6.67ml solution 1 AL1 Up to 8 yrs old

famotidine 20 mg tab 1

famotidine 40 mg tab 1

famotidine 40 mg/5ml recon susp 1

NIZATIDINE 150 MG CAPnizatidine

1

nizatidine 150 mg cap 1

NIZATIDINE 300 MG CAPnizatidine

1

nizatidine 300 mg cap 1

ranitidine hcl 15 mg/ml syrup 1 AL1 Up to 8 yrs old

ranitidine hcl 150 mg cap 1

ranitidine hcl 150 mg tab 1

ranitidine hcl 150 mg/10ml syrup 1 AL1 Up to 8 yrs old

ranitidine hcl 300 mg cap 1

ranitidine hcl 300 mg tab 1

ranitidine hcl 75 mg/5ml syrup 1 AL1 Up to 8 yrs old



MISC. ANTI-ULCERsucralfate 1 gm tab 1

sucralfate 1 gm/10ml suspension 1

PROTON PUMP INHIBITORS

DEXILANT 30 MG CAP DRdexlansoprazole

3QL 30 / 30 day(s)

PA

DEXILANT 60 MG CAP DRdexlansoprazole

3QL 30 / 30 day(s)

PA

DEXLANSOPRAZOLE 30 MG CAP DRdexlansoprazole

2QL 30 / 30 day(s)

PA

DEXLANSOPRAZOLE 60 MG CAP DRdexlansoprazole

2QL 30 / 30 day(s)

PA

esomeprazole magnesium 10 mg packet 2 AL1 Up to 8 yrs old

esomeprazole magnesium 20 mg cap dr 1


esomeprazole magnesium 40 mg cap dr 1 QL 60 / 30 DAYS


FIRST-LANSOPRAZOLE 3 MG/ML SUSPENSIONlansoprazole

1QL 10 / 1 day(s)

AL1 Up to 8 yrs old

FIRST-OMEPRAZOLE 2 MG/ML SUSPENSIONomeprazole

1QL 10 / 1 day(s)

AL1 Up to 8 yrs old

lansoprazole 15 mg cap dr 1 QL 60 / 30 DAYS

lansoprazole 30 mg cap dr 1 QL 60 / 30 DAYS

omeprazole 10 mg cap dr 1 QL 60 / 30 DAYS



pantoprazole sodium 20 mg tab dr 1 QL 60 / 30 DAYS



pantoprazole sodium 40 mg tab dr 1 QL 60 / 30 DAYS

rabeprazole sodium 20 mg tab dr 1 QL 60 / 30 DAYS

QUATERNARY ANTICHOLINERGICS

CUVPOSA 1 MG/5ML SOLUTIONglycopyrrolate

3PA

AL1 Up to 8 yrs old

glycopyrrolate 1 mg tab 1

glycopyrrolate 2 mg tab 1

methscopolamine bromide 2.5 mg tab 1

methscopolamine bromide 5 mg tab 1

ULCER DRUGS - PROSTAGLANDINSmisoprostol 100 mcg tab 1

misoprostol 200 mcg tab 1

URINARY ANTISPASMODICSURINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)

darifenacin hydrobromide er 15 mg tab er 24h 1 QL 30 / 30 DAYS

darifenacin hydrobromide er 7.5 mg tab er 24h 1

GELNIQUE 10 % GELoxybutynin chloride

3 QL 30 / 30 DAYS

GELNIQUE PUMP 10 % GELoxybutynin chloride

3 QL 30 / 30 DAYS

oxybutynin chloride 5 mg tab 1 QL 120 / 30 DAYS

oxybutynin chloride 5 mg/5ml syrup 1 QL 600 / 30 DAYS

oxybutynin chloride er 10 mg tab er 24h 1



solifenacin succinate 10 mg tab 2 QL 30 / 30 DAYS

solifenacin succinate 5 mg tab 2 QL 30 / 30 DAYS

tolterodine tartrate 1 mg tab 1 QL 60 / 30 DAYS



tolterodine tartrate 2 mg tab 1 QL 60 / 30 DAYS

tolterodine tartrate er 2 mg cap er 24h 1 QL 30 / 30 DAYS

tolterodine tartrate er 4 mg cap er 24h 1 QL 30 / 30 DAYS

TOVIAZ 4 MG TAB ER 24Hfesoterodine fumarate

3QL 30 / 30 DAYS

ST

TOVIAZ 8 MG TAB ER 24Hfesoterodine fumarate

3QL 30 / 30 DAYS

ST

trospium chloride 20 mg tab 1 QL 60 / 30 DAYS

trospium chloride er 60 mg cap er 24h 1

VESICARE LS 5 MG/5ML SUSPENSIONsolifenacin succinate


URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS

MYRBETRIQ 25 MG TAB ER 24Hmirabegron

3QL 30 / 30 DAYS

ST

MYRBETRIQ 50 MG TAB ER 24Hmirabegron

3QL 30 / 30 DAYS

ST

MYRBETRIQ 8 MG/ML SRERmirabegron

3

QL 10 / 1 day(s)

ST

AL1 Up to 8 yrs old

URINARY ANTISPASMODICS - CHOLINERGIC AGONISTSbethanechol chloride 10 mg tab 1

bethanechol chloride 25 mg tab 1



URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTSflavoxate hcl 100 mg tab 1



VACCINESBACTERIAL VACCINES

ACTHIB RECON SOLNhaemophilus b polysac conj vac

5 PRE Preventative

BEXSERO SUSP PRSYRmeningococcal vac group b (recombant omv adjuvanted)

5 PRE Preventative

HIBERIX 10 MCG RECON SOLNhaemophilus b polysac conj vac

5 PRE Preventative

MENACTRA SOLUTIONmeningococcal (a,c,y&w-135) polysacch diphth conjvaccine

5 PRE Preventative

MENQUADFI SOLUTIONmeningococcal (a,c,y&w-135) polysacch tetanus conjvaccine

5 PRE Preventative

MENVEO RECON SOLNmeningococcal (a,c,y&w-135) oligosaccharide conjugatevac

5 PRE Preventative

PEDVAX HIB 7.5 MCG/0.5ML SUSPENSIONhaemophilus b polysac conj vac

5 PRE Preventative

PNEUMOVAX 23 25 MCG/0.5ML INJECTABLEpneumococcal vac polyvalent

5 PRE Preventative

PREVNAR 13 SUSPENSIONpneumococcal 13-valent conjugate vaccine

5 PRE Preventative

PREVNAR 20 0.5 ML SUSP PRSYRpneumococcal 20-valent conjugate vaccine

5 PRE Preventative

TRUMENBA SUSP PRSYRmeningococcal group b vaccine (recombinant)

5 PRE Preventative

VAXNEUVANCE 0.5 ML SUSP PRSYRpneumococcal 15-valent conjugate vaccine

5 PRE Preventative

VIVOTIF CAP DRtyphoid vaccine

3

VIRAL VACCINE COMBINATIONS

M-M-R II RECON SOLNmeasles, mumps & rubella virus vaccines


PROQUAD RECON SUSPmeasles-mumps-rubella-varicella virus vaccines



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTWINRIX 720-20 ELU-MCG/ML SUSP PRSYRhepatitis a (inactivated)-hepatitis b (recombinant)vaccines

5 PRE Preventative

VIRAL VACCINES

AFLURIA SUSPENSIONinfluenza virus vaccine split

5QL 0.5 / 0 DAYS

PRE Preventative

AFLURIA PRESERVATIVE FREE 0.5 ML SUSP PRSYRinfluenza virus vaccine split preservative free

5QL 0.5 / 0 DAYS

PRE Preventative

AFLURIA QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

AFLURIA QUADRIVALENT 0.25 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

AFLURIA QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

ASTRAZENECA COVID-19 VACCINE 0.5 ML SUSPENSIONcovid-19 (sars-cov-2) adenovirus vaccine

5MFL 3 / 1 year(s)PRE Preventative

COMIRNATY 30 MCG/0.3ML SUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


ENGERIX-B 10 MCG/0.5ML INJECTABLEhepatitis b vaccine (recomb)

5 PRE Preventative

ENGERIX-B 10 MCG/0.5ML SUSPENSIONhepatitis b vaccine (recomb)

5 PRE Preventative

ENGERIX-B 20 MCG/ML INJECTABLEhepatitis b vaccine (recomb)

5 PRE Preventative

ENGERIX-B 20 MCG/ML SUSPENSIONhepatitis b vaccine (recomb)

5 PRE Preventative

FLUAD 0.5 ML SUSP PRSYRinfluenza virus vaccine types a & b surface antigenadjuvant

5QL 0.5 / 0 DAYS

PRE Preventative

FLUAD QUADRIVALENT 0.5 ML PRSYRinfluenza virus vacc types a & b surf antigen adjuvantquad

5MFL 1 / 365 day(s)PRE Preventative

FLUARIX QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative



FLUBLOK SOLUTIONinfluenza virus vaccine recombinant hemagglutinin (ha)

5QL 0.5 / 0 DAYS

PRE Preventative

FLUBLOK QUADRIVALENT 0.5 ML SOLN PRSYRinfluenza virus vac recomb hemagglutinin (ha)quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

FLUCELVAX QUADRIVALENT SUSPENSIONinfluenza virus vaccine tissue-cultured subunitquadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

FLUCELVAX QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine tissue-cultured subunitquadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

FLULAVAL QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

FLULAVAL QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

FLUMIST QUADRIVALENT SUSPENSIONinfluenza virus vaccine live quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

FLUVIRIN SUSPENSIONinfluenza virus vaccine types a & b surface antigen

5QL 0.5 / 0 DAYS

PRE Preventative

FLUVIRIN 0.5 ML SUSP PRSYRinfluenza virus vaccine types a & b surface antigen

5QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE HIGH-DOSE 0.5 ML SUSP PRSYRinfluenza virus vaccine split high-dose preservative free

5QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE HIGH-DOSE QUADRIVALENT 0.7 ML SUSP PRSYRinfluenza virus vac split high-dose quad preservative free

5 PRE Preventative

FLUZONE QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE QUADRIVALENT 0.25 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative



FLUZONE QUADRIVALENT 0.5 ML SUSPENSIONinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE QUADRIVALENT 9 MCG/STRAIN SUSP PENinfluenza virus vaccine split quadrivalent

5QL 0.5 / 0 DAYS

PRE Preventative

GARDASIL 9 SUSP PRSYRhuman papillomavirus (hpv) 9-valent recombinant vaccine

5AL1 9 to 45 yrs oldPRE Preventative

GARDASIL 9 SUSPENSIONhuman papillomavirus (hpv) 9-valent recombinant vaccine

5AL1 9 to 45 yrs oldPRE Preventative

HAVRIX 1440 EL U/ML SUSPENSIONhepatitis a vaccine

5 PRE Preventative

HAVRIX 720 EL U/0.5ML SUSPENSIONhepatitis a vaccine

5 PRE Preventative

HEPLISAV-B 20 MCG/0.5ML SOLN PRSYRhepatitis b vaccine recombinant adjuvanted

5 PRE Preventative

HEPLISAV-B 20 MCG/0.5ML SOLUTIONhepatitis b vaccine recombinant adjuvanted

5 PRE Preventative

IPOL INJECTABLEpoliovirus vaccine, ipv

5 PRE Preventative

JANSSEN COVID-19 VACCINE 0.5 ML SUSPENSIONcovid-19 (sars-cov-2) adenovirus vaccine


MODERNA COVID-19 VAC (BOOSTER) 50 MCG/0.5MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


MODERNA COVID-19 VACCINE 100 MCG/0.5MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


NOVAVAX COVID-19 VACCINE 5 MCG/0.5ML SUSPENSIONcovid-19 (sars-cov-2) subunit (spike) protein virus vaccine


PFIZER COVID-19 VAC-TRIS 5-11Y 10 MCG/0.2MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


PFIZER COVID-19 VAC-TRIS 6M-4Y 3 MCG/0.2MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPFIZER-BIONT COVID-19 VAC-TRIS 30 MCG/0.3MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


PFIZER-BIONTECH COVID-19 VACC 30 MCG/0.3MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


PREHEVBRIO 10 MCG/ML SUSPENSIONhepatitis b vaccine 3-antigen recombinant

5 PRE Preventative

RECOMBIVAX HB 10 MCG/ML SUSPENSIONhepatitis b vaccine (recomb)

5 PRE Preventative

RECOMBIVAX HB 40 MCG/ML SUSPENSIONhepatitis b vaccine (recomb)

5 PRE Preventative

RECOMBIVAX HB 5 MCG/0.5ML SUSPENSIONhepatitis b vaccine (recomb)

5 PRE Preventative

ROTARIX RECON SUSProtavirus vaccine, live oral


ROTATEQ SOLUTIONrotavirus vaccine, live oral pentavalent


SANOFI COVID-19 VAC (BOOSTER) 5 MCG/0.5MLEMULSIONcovid-19 (sars-cov-2) pres dtm subunit protein virusvaccine


SHINGRIX 50 MCG/0.5ML RECON SUSPzoster vaccine recombinant adjuvanted

5 PRE Preventative

VAQTA 25 UNIT/0.5ML SUSPENSIONhepatitis a vaccine

5 PRE Preventative

VAQTA 50 UNIT/ML SUSPENSIONhepatitis a vaccine

5 PRE Preventative

VARIVAX 1350 PFU/0.5ML INJECTABLEvaricella virus vaccine live

5 PRE Preventative

ZOSTAVAX 19400 UNT/0.65ML RECON SUSPzoster vaccine live

5AL1 At least 50 yrs oldPRE Preventative



VAGINAL AND RELATED PRODUCTSIMIDAZOLE-RELATED ANTIFUNGALS

terconazole 0.4 % cream 1 QL 450 / 30 DAYS

terconazole 0.8 % cream 1 QL 450 / 30 DAYS

terconazole 80 mg suppos 1 QL 3 / 3 DAYS

VAGINAL ANTI-INFECTIVESclindamycin phosphate 2 % cream 1

metronidazole 0.75 % gel 1

VANDAZOLE 0.75 % GELmetronidazole vaginal

1

VAGINAL ESTROGENSestradiol 0.1 mg/gm cream 2

estradiol 10 mcg tab 1

ESTRING 2 MG RINGestradiol vaginal

2 QL 1 / 90 DAYS

FEMRING 0.05 MG/24HR RINGestradiol acetate vaginal

3 QL 1 / 84 DAYS

FEMRING 0.1 MG/24HR RINGestradiol acetate vaginal

3 QL 1 / 84 DAYS

PREMARIN 0.625 MG/GM CREAMestrogens, conjugated vaginal

2

yuvafem 10 mcg tab 1

VAGINAL PROGESTINS

CRINONE 4 % GELprogesterone (vaginal)

4PA

S

CRINONE 8 % GELprogesterone (vaginal)

4PA

S

ENDOMETRIN 100 MG INSERTprogesterone (vaginal)

3



VASOPRESSORSANAPHYLAXIS THERAPY AGENTS

EPINEPHRINE 0.15 MG/0.15ML SOLN A-INJepinephrine (anaphylaxis)

1 QL 4 / 365 day(s)

epinephrine 0.15 mg/0.3ml soln a-inj 1 QL 4 / 365 day(s)

EPINEPHRINE 0.3 MG/0.3ML SOLN A-INJepinephrine (anaphylaxis)

1 QL 4 / 365 day(s)

epinephrine 0.3 mg/0.3ml soln a-inj 1 QL 4 / 365 day(s)

SYMJEPI 0.15 MG/0.3ML SOLN PRSYRepinephrine (anaphylaxis)

2 QL 4 / 365 day(s)

midodrine hcl 10 mg tab 1

midodrine hcl 2.5 mg tab 1

midodrine hcl 5 mg tab 1

VITAMINSVITAMIN D

DRISDOL 1.25 MG (50000 UT) CAPergocalciferol

1

ergocalciferol 1.25 mg (50000 ut) cap 1 QL 4 / 28 DAYS

vitamin d (ergocalciferol) 1.25 mg (50000 ut) cap 1 QL 4 / 28 DAYS

vitamin d (ergocalciferol) 50000 unit cap 1 QL 4 / 28 DAYS

VITAMIN K

phytonadione 5 mg tab 2 QL 5 / 30 DAYS


Index of Covered Drugs

AABACAVIR SULFATE 138ABACAVIR SULFATE-LAMIVUDINE 133ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE 133ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE 135ABALOPARATIDE 196ABATACEPT 15,16ABEMACICLIB 116Abilify Maintena 131ABIRATERONE ACETATE 102Abstral 19ACALABRUTINIB 107ACAMPROSATE CALCIUM 263ACARBOSE 69Accula SARS-CoV-2 186ACEBUTOLOL HCL 143ACETAMINOPHEN W/ CODEINE 17ACETAZOLAMIDE 189ACETIC ACID (OTIC) 258ACETYLCYSTEINE 171ACETYLCYSTEINE (ANTIDOTE) 81ACITRETIN 177Actemra 12Actemra ACTPen 13ActHIB 285Actimmune 115ACYCLOVIR 142ACYCLOVIR TOPICAL 178Adacel 279Adagen 8ADALIMUMAB 9,10ADAPALENE 173ADAPALENE-BENZOYL PEROXIDE 172ADEFOVIR DIPIVOXIL 140Adempas 152Advate 208Adynovate 208,209Adzenys ER 4Adzenys XR-ODT 4

AeroChamber Mini Chamber 237AeroChamber MV 237AeroChamber Plus Flo-Vu 237AeroChamber Plus Flo-Vu Large 237AeroChamber Plus Flo-Vu Medium 238AeroChamber Plus Flo-Vu Small 238AeroChamber Plus Flo-Vu w/Mask 238AeroChamber Plus Flow VU 238AeroChamber w/FLOWSIGnal 238AeroChamber Z-Stat Plus 238AeroChamber Z-Stat Plus Chambr 238AeroChamber Z-Stat Plus/Large 238AeroChamber Z-Stat Plus/Medium 238AeroChamber Z-Stat Plus/Small 238AFATINIB DIMALEATE 107,108Afluria 286Afluria Preservative Free 286Afluria Quadrivalent 286Afstyla 209Aimovig 240Aimovig (140 MG Dose) 239Ajovy 240Akynzeo 82ALBENDAZOLE 35ALBUTEROL SULFATE 45Albuterol Sulfate ER 45Albuterol Sulfate HFA 45ALCAFTADINE 255ALCLOMETASONE DIPROPIONATE 179Alecensa 104ALECTINIB HCL 104ALENDRONATE SODIUM 191,192Alendronate Sodium 191ALENDRONATE SODIUM-CHOLECALCIFEROL 192ALFENTANIL HCL 20ALFUZOSIN HCL 206Alinia 36ALISKIREN FUMARATE 100Alkindi Sprinkle 168ALLOPURINOL 207ALMOTRIPTAN MALATE 240

Alocril 255ALOGLIPTIN BENZOATE 71Alogliptin Benzoate 71Alomide 255ALOSETRON HCL 204ALPELISIB 119ALPHA1-PROTEINASE INHIBITOR (HUMAN) 270Alphagan P 257Alphanate 209,210Alphanate/VWF Complex/Human 210AlphaNine SD 210ALPRAZOLAM 40ALPRAZolam Intensol 40Alprolix 210,211Alrex 257Altabax 175ALTRETAMINE 102ALUMINUM CHLORIDE 184AMANTADINE HCL 121AMBRISENTAN 152AMCINONIDE 179Amcinonide 179AMIFAMPRIDINE 101AMILORIDE & HYDROCHLOROTHIAZIDE 189AMILORIDE HCL 190AMINOCAPROIC ACID 226AMIODARONE HCL 42,43Amitiza 203AMITRIPTYLINE HCL 67,68AMLODIPINE BENZOATE 148AMLODIPINE BESYLATE 146AMLODIPINE BESYLATE-ATORVASTATINCALCIUM 151AMLODIPINE BESYLATE-BENAZEPRIL HCL 91AMLODIPINE BESYLATE-OLMESARTANMEDOXOMIL 95AMLODIPINE BESYLATE-VALSARTAN 95Amlodipine-Atorvastatin 151AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE 94,95AMOXAPINE 68

Amoxapine 68AMOXICILLIN 261Amoxicillin 261AMOXICILLIN & POT CLAVULANATE 262Amoxicillin-Pot Clavulanate 262Amoxicillin-Pot Clavulanate ER 262AMPHETAMINE 4Amphetamine ER 4AMPHETAMINE SULFATE 4AMPHETAMINE-DEXTROAMPHETAMINE 3,4AMPICILLIN 261Ampicillin 261Anadrol-50 33ANAGRELIDE HCL 221ANAKINRA 12ANASTROZOLE 115Annovera 163Anoro Ellipta 43ANTIHEMOPHIL FACT(RCMB) PEGYLATED-AUCL(BDD-RFVIII PEG-AUCL) 214ANTIHEMOPHILIC FACTOR(HUMAN) 213,214,215,216ANTIHEMOPHILIC FACTOR (RCMB) BDTRUNCATED (BD TRUNC-RFVIII) 216ANTIHEMOPHILIC FACTOR (RCMB) FC FUSIONPROTEIN(BDD-RFVIIIFC) 211,212ANTIHEMOPHILIC FACTOR (RCMB)MOROCTOCOG ALFA(BDD-RFVIII,MOR) 218,219ANTIHEMOPHILIC FACTOR (RCMB)PLASMA/ALBUMIN FREE (RAHF-PFM) 208,215ANTIHEMOPHILIC FACTOR (RCMB) SIMOCTOCOGALFA(BDD-RFVIII,SIM) 216,217ANTIHEMOPHILIC FACTOR (RECOMBINANTPORCINE) (RPFVIII) 217ANTIHEMOPHILIC FACTOR(RECOMBINANT) 212,213,215,218ANTIHEMOPHILIC FACTOR (RECOMBINANT)GLYCOPEGYLATED-EXEI 212ANTIHEMOPHILIC FACTOR (RECOMBINANT)PEGYLATED 208,209

ANTIHEMOPHILIC FACTOR (RECOMBINANT)SINGLE CHAIN 209ANTIHEMOPHILIC FACTOR/VON WILLEBRANDFACTOR COMPLEX (HUMAN) 209,210,213,218Anzemet 81,82APALUTAMIDE 103APIXABAN 51,52Aplenzin 62APO-Varenicline 268APOMORPHINE HYDROCHLORIDE 123APRACLONIDINE HCL 257APREMILAST 15APREPITANT 83Aptivus 136Aralast NP 270Aranesp (Albumin Free) 221,222Arcapta Neohaler 46ARIPIPRAZOLE 131,132ARMODAFINIL 6Armour Thyroid 273,274Arnuity Ellipta 48ARTEMETHER-LUMEFANTRINE 101ARTIFICIAL TEAR INSERT 253ASCIMINIB HCL 106ASENAPINE MALEATE 129Asmanex (120 Metered Doses) 48Asmanex (14 Metered Doses) 48Asmanex (30 Metered Doses) 48Asmanex (60 Metered Doses) 48Asmanex (7 Metered Doses) 48Asmanex HFA 48,49ASPIRIN-DIPYRIDAMOLE 220Assure ID Insulin Safety Syr 234Astagraf XL 246AstraZeneca COVID-19 Vaccine 286ATAZANAVIR SULFATE 136,137ATAZANAVIR SULFATE-COBICISTAT 134ATENOLOL 144ATENOLOL & CHLORTHALIDONE 99ATOGEPANT 239ATOMOXETINE HCL 3

ATORVASTATIN CALCIUM 88ATOVAQUONE 36ATOVAQUONE-PROGUANIL HCL 100ATRACURIUM BESYLATE 252ATROPINE SULFATE (OPHTHALMIC) 254Atrovent HFA 46Aubagio 264AURANOFIN 12AVAPRITINIB 113Avonex 265Avonex Pen 265Avonex Prefilled 265AXITINIB 120,121Ayvakit 113AzaSite 255AZATHIOPRINE 248AZELAIC ACID 184AZELAIC ACID (ACNE) 173AZELASTINE HCL 252AZELASTINE HCL (OPHTH) 255AZELASTINE HCL-FLUTICASONE PROPIONATE 251Azelex 173AZILSARTAN MEDOXOMIL 97AZITHROMYCIN 229Azithromycin 229AZITHROMYCIN (OPHTH) 255AZTREONAM LYSINE 37

BBacitracin 255BACITRACIN (OPHTHALMIC) 255BACITRACIN-POLYMYXIN B (OPHTH) 254BACITRACIN-POLYMYXIN-NEOMYCIN HC 175BACLOFEN 250Bactroban Nasal 251Bafiertam 266Balcoltra 156BALOXAVIR MARBOXIL 142,143BALSALAZIDE DISODIUM 204,205Balversa 108Baqsimi One Pack 70

Baqsimi Two Pack 70Baraclude 140BARICITINIB 10Basaglar KwikPen 72Baxdela 202BD Insulin Syringe U-500 234BD Klatskin Biopsy Needle 234BD Osgood Biopsy Needle 235BD Pen Needle Nano U/F 235BD Rosenthal Biopsy Needle 235BD SafetyGlide Insulin Syringe 235BD Veritor Home Covid-19 Test 186BD Veritor System SARS-CoV-2 186BECAPLERMIN 185BECLOMETHASONE DIPROPIONATE 49BECLOMETHASONE DIPROPIONATE HFA 50BEDAQUILINE FUMARATE 102BELIMUMAB 244BELLADONNA ALKALOIDS & OPIUM 280Belladonna Alkaloids-Opium 280Belsomra 227BELZUTIFAN 109BEMPEDOIC ACID 85BEMPEDOIC ACID-EZETIMIBE 85BENAZEPRIL & HYDROCHLOROTHIAZIDE 93BENAZEPRIL HCL 91,92Benazepril-Hydrochlorothiazide 93BeneFIX 211Benlysta 244BENRALIZUMAB 47BENZONATATE 170BENZOYL PEROXIDE-ERYTHROMYCIN 172BENZTROPINE MESYLATE 121BENZYL ALCOHOL (PEDICULICIDE) 185BEPOTASTINE BESILATE 255Bepreve 255Berinert 220BESIFLOXACIN HCL 255Besivance 255BETAMETHASONE DIPROPIONATE (TOPICAL) 179Betamethasone Dipropionate Aug 179

BETAMETHASONE DIPROPIONATEAUGMENTED 179,180BETAMETHASONE VALERATE 180Betaseron 265BETAXOLOL HCL 144BETAXOLOL HCL (OPHTH) 253BETHANECHOL CHLORIDE 284Betimol 253Betoptic-S 253BEXAROTENE 120BEXAROTENE (TOPICAL) 185Bexsero 285Beyaz 157BICALUTAMIDE 103BICTEGRAVIR-EMTRICITABINE-TENOFOVIRALAFENAMIDE FUMARATE 133Biktarvy 133BIMATOPROST 258BinaxNOW COVID-19 Ag Card 186BinaxNOW COVID-19 Ag Home Test 186BINIMETINIB 110BISOPROLOL & HYDROCHLOROTHIAZIDE 99BISOPROLOL FUMARATE 144Blephamide S.O.P. 257BLOOD GLUCOSE MONITORINGSUPPLIES 231,232,233,234Boostrix 279BOSENTAN 152Bosulif 105BOSUTINIB 105Braftovi 106Breo Ellipta 43Brexafemme 83BREXPIPRAZOLE 132Breztri Aerosphere 43Bridion 81Brilinta 220BRIMONIDINE TARTRATE 257Brimonidine Tartrate-Timolol 253BRIMONIDINE TARTRATE-TIMOLOL MALEATE 253BRINZOLAMIDE 256

BRINZOLAMIDE-BRIMONIDINE TARTRATE 253BRIVARACETAM 55Briviact 55BROMFENAC SODIUM (OPHTH) 256BROMOCRIPTINE MESYLATE 121Brukinsa 107BUDESONIDE 168,170BUDESONIDE (INHALATION) 49BUDESONIDE (INTRARECTAL) 35BUDESONIDE-FORMOTEROL FUMARATEDIHYDRATE 44BUDESONIDE-GLYCOPYRROLATE-FORMOTEROLFUMARATE 43BUMETANIDE 190BUPRENORPHINE 32,33BUPRENORPHINE HCL 33BUPRENORPHINE HCL-NALOXONE HCLDIHYDRATE 33BUPROPION HCL 62,63BUPROPION HCL (SMOKING DETERRENT) 268BuPROPion HCl ER (XL) 62BUPROPION HYDROBROMIDE 62BUSPIRONE HCL 39BUSULFAN 102BUTALBITAL-ACETAMINOPHEN 16BUTALBITAL-ACETAMINOPHEN-CAFFEINE 16,17BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/CODEINE 17BUTALBITAL-ASPIRIN-CAFFEINE 16Butalbital-Aspirin-Caffeine 16BUTALBITAL-ASPIRIN-CAFFEINE W/COD 17BUTORPHANOL TARTRATE 33Bydureon 74Bydureon BCise 74Bylvay 204Bylvay (Pellets) 204

CC1 ESTERASE INHIBITOR (HUMAN) 220CABERGOLINE 193Cablivi 208

Cabometyx 111CABOZANTINIB S-MALATE 111,112CALCIPOTRIENE 177CALCITONIN (SALMON) 193Calcitriol 177CALCITRIOL 194CALCITRIOL (TOPICAL) 177CALCIUM ACETATE (PHOSPHATE BINDER) 205,206Calquence 107CANDESARTAN CILEXETIL 97CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE 96CANNABIDIOL 56CAPECITABINE 103CAPLACIZUMAB-YHDP 208Caplyta 125CAPMATINIB HCL 110Caprelsa 111CAPTOPRIL 92CAPTOPRIL & HYDROCHLOROTHIAZIDE 93,94Captopril-Hydrochlorothiazide 93,94CARBAMAZEPINE 55,56,58,59CARBAMAZEPINE (ANTIPSYCHOTIC) 125CARBIDOPA 122CARBIDOPA-LEVODOPA 122Carbidopa-Levodopa 122CARBIDOPA-LEVODOPA-ENTACAPONE 122,123Carbidopa-Levodopa-Entacapone 122,123CARBINOXAMINE MALEATE 84Carbinoxamine Maleate 84Cardura XL 206Carestart COVID-19 Home Test 186CARGLUMIC ACID 194CARIPRAZINE HCL 126CARISOPRODOL W/ ASPIRIN & CODEINE 251Carteolol HCl 253CARTEOLOL HCL (OPHTH) 253CARVEDILOL 143CARVEDILOL PHOSPHATE 143Caya 230Cayston 37

CEFACLOR 154,155Cefaclor 154Cefaclor ER 155CEFACLOR MONOHYDRATE 155CEFADROXIL 154Cefadroxil 154CEFDINIR 155CEFDITOREN PIVOXIL 155Cefditoren Pivoxil 155CEFIXIME 155CEFPODOXIME PROXETIL 155CEFPROZIL 155CEFUROXIME AXETIL 155CELECOXIB 12Celontin 61CENOBAMATE 60CEPHALEXIN 154Cephalexin 154CeQur Simplicity Inserter 235CeQur Simplicity Starter 235Cerdelga 221CERITINIB 104CERTOLIZUMAB PEGOL 206CERVICAL CAPS 230Cesamet 82CETIRIZINE HCL 85CEVIMELINE HCL 248Chantix 268Chantix Continuing Month Pak 268Chantix Starting Month Pak 268Chemet 79CHLORAMBUCIL 119CHLORDIAZEPOXIDE HCL 40CHLORDIAZEPOXIDE-AMITRIPTYLINE 263Chlordiazepoxide-Amitriptyline 263CHLORHEXIDINE GLUCONATE (MOUTH-THROAT) 248CHLOROQUINE PHOSPHATE 101Chloroquine Phosphate 101CHLOROTHIAZIDE 191Chlorothiazide 191

CHLORPROMAZINE HCL 130CHLORTHALIDONE 191CHLORZOXAZONE 250,251CHOLESTYRAMINE 86CHOLESTYRAMINE LIGHT 86CHOLINE FENOFIBRATE 87Ciclodan Cream 175CICLOPIROX 175CICLOPIROX OLAMINE 175CICLOPIROX OLAMINE & CLEANSER 175,176Ciclopirox Treatment 175CILOSTAZOL 220Cimduo 133CIMETIDINE HCL 281Cimetidine HCl 281Cimzia 206Cimzia Prefilled 206Cimzia Starter Kit 206CINACALCET HCL 192Cipro HC 259CIPROFLOXACIN 202CIPROFLOXACIN (OTIC) 259CIPROFLOXACIN HCL 202Ciprofloxacin HCl 202,259CIPROFLOXACIN HCL (OPHTH) 255CIPROFLOXACIN HCL (OTIC) 259Ciprofloxacin-Ciproflox HCl ER 202CIPROFLOXACIN-CIPROFLOXACIN HCL 202CIPROFLOXACIN-DEXAMETHASONE 259CIPROFLOXACIN-FLUOCINOLONE ACETONIDE 259CIPROFLOXACIN-HYDROCORTISONE 259CITALOPRAM HYDROBROMIDE 63CLADRIBINE (MULTIPLE SCLEROSIS) 264,265CLARITHROMYCIN 229Clarithromycin 229ClearDetect COVID-19 AG Home 186CLINDAMYCIN HCL 37CLINDAMYCIN PALMITATE HYDROCHLORIDE 37CLINDAMYCIN PHOSPHATE (TOPICAL) 172CLINDAMYCIN PHOSPHATE VAGINAL 290

CLINDAMYCIN PHOSPHATE-BENZOYLPEROXIDE 173CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE(REFRIGERATE) 173Clinitest Rapid COVID-19 Test 186CLOBAZAM 54,55CLOBETASOL PROPIONATE 180CLOBETASOL PROPIONATE EMOLLIENT BASE 180CLOBETASOL PROPIONATE EMULSION 180,182CLOCORTOLONE PIVALATE 180Clocortolone Pivalate 180Clocortolone Pivalate Pump 180CLOMIPRAMINE HCL 68CLONAZEPAM 54,55CLONIDINE 98CLONIDINE HCL 98CLONIDINE HCL (ADHD) 3CLOPIDOGREL BISULFATE 221CLORAZEPATE DIPOTASSIUM 40,41CLOTRIMAZOLE 248CLOTRIMAZOLE (TOPICAL) 182CLOTRIMAZOLE W/ BETAMETHASONE 176CLOZAPINE 129CloZAPine 129Co-Natal FA 249COAGULATION FACTOR IX 210,216COAGULATION FACTOR IX (RECOMB) FC FUSIONPROTEIN (RFIXFC) 210,211COAGULATION FACTOR IX(RECOMBINANT) 211,213,214,218COAGULATION FACTOR IX (RECOMBINANT)GLYCOPEGYLATED 217,218COAGULATION FACTOR IX RECOMB ALBUMINFUSION PROTEIN (RIX-FP) 213Coartem 101Cobas Liat SARS-CoV-2 Assay 186COBICISTAT 140COBIMETINIB FUMARATE 110CODEINE SULFATE 20Codeine Sulfate 20COLCHICINE 207

Colchicine 207COLCHICINE W/ PROBENECID 207COLESEVELAM HCL 86COLESTIPOL HCL 86COLLAGENASE 182COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 245Coly-Mycin S 259Combigan 253Combivent Respimat 43Cometriq (100 mg Daily Dose) 111Cometriq (140 mg Daily Dose) 111Cometriq (60 mg Daily Dose) 112Comirnaty 286Compact Space Chamber 238Compact Space Chamber/Lg Mask 238Compact Space Chamber/Med Mask 238Compact Space Chamber/Sm Mask 238Complera 133Complete Natal DHA 250CompleteNate 249CONJUGATED ESTROGENS-BAZEDOXIFENE 200CONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE 199CONTINUOUS BLOOD GLUCOSE SYSTEMRECEIVER 231,232CONTINUOUS BLOOD GLUCOSE SYSTEMSENSOR 231,232CONTINUOUS BLOOD GLUCOSE SYSTEMTRANSMITTER 231Copiktra 119COPPER (IUD) 163Cordran 180Corlanor 153,154Corlopam 100CORTISONE ACETATE 168Cortisone Acetate 168Cortisporin 175Cosentyx 177Cosentyx (300 MG Dose) 177Cosentyx Sensoready (300 MG) 177Cosentyx Sensoready Pen 177

Cotellic 110COVID-19 (SARS-COV-2) ADENOVIRUSVACCINE 286,288COVID-19 (SARS-COV-2) MRNA VIRUSVACCINE 286,288,289COVID-19 (SARS-COV-2) PRES DTM SUBUNITPROTEIN VIRUS VACCINE 289COVID-19 (SARS-COV-2) SUBUNIT (SPIKE)PROTEIN VIRUS VACCINE 288COVID-19 ANTIGEN TEST 186,188COVID-19 AT HOME TEST 186,187COVID-19 At-Home Test 186COVID-19 HOME COLLECTION TEST 187,188COVID-19 HOME TEST 187COVID-19 OTC Antigen 1-Pack 186COVID-19 OTC Antigen 2-Pack 186COVID-19 TEST 186,187,188Creon 188Crinone 290CRISABOROLE 184Crixivan 136CRIZOTINIB 104CROMOLYN SODIUM 45CROMOLYN SODIUM (MASTOCYTOSIS) 203CROMOLYN SODIUM (OPHTH) 255CROTAMITON 184Cuvitru 260Cuvposa 283CYANOCOBALAMIN 221CYCLOBENZAPRINE HCL 251CYCLOPENTOLATE HCL 254CYCLOPHOSPHAMIDE 118,119Cyclophosphamide 118,119CYCLOSERINE 101,102CycloSERINE 101CYCLOSPORINE 244CYCLOSPORINE (OPHTH) 256CYCLOSPORINE MODIFIED (FORMICROEMULSION) 244,245CYPROHEPTADINE HCL 85Cystadrops 258

Cystagon 207Cystaran 258CYSTEAMINE BITARTRATE 207CYSTEAMINE HCL 258

DDABIGATRAN ETEXILATE MESYLATE 54DABRAFENIB MESYLATE 107DACOMITINIB 108DALFAMPRIDINE 266Daliresp 48DALTEPARIN SODIUM 53DANAZOL 34DANTROLENE SODIUM 251DAPAGLIFLOZIN PROPANEDIOL 76DAPAGLIFLOZIN-METFORMIN HCL 77DAPSONE 37DAPSONE (TOPICAL) 172Daptacel 279DARBEPOETIN ALFA 221,222DARIFENACIN HYDROBROMIDE 283DARUNAVIR 137DARUNAVIR ETHANOLATE 137DARUNAVIR-COBICISTAT 134DARUNAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR ALAFENAMIDE 135DASATINIB 106DayVigo 227DECITABINE-CEDAZURIDINE 115DEFERASIROX 79,80DEFERIPRONE 80,81DELAFLOXACIN MEGLUMINE 202DELAVIRDINE MESYLATE 138DEMECLOCYCLINE HCL 272Denavir 178Depo-Provera 165Depo-SubQ Provera 104 165Depo-Testosterone 34Descovy 133DESIPRAMINE HCL 68DESLORATADINE 84

Desloratadine 84DESMOPRESSIN ACETATE 198Desmopressin Acetate 198DESMOPRESSIN ACETATE SPRAY 198DESMOPRESSIN ACETATE SPRAYREFRIGERATED 198DESOGESTREL & ETHINYLESTRADIOL 156,157,158,161DESOGESTREL-ETHINYL ESTRADIOL(BIPHASIC) 155,156DESOGESTREL-ETHINYL ESTRADIOL(TRIPHASIC) 166,168DESONIDE 180DESOXIMETASONE 180,181DESVENLAFAXINE 66Desvenlafaxine ER 66DESVENLAFAXINE SUCCINATE 67DEXAMETHASONE 168,169Dexamethasone 169DEXAMETHASONE (OPHTH) 258Dexamethasone Intensol 169Dexamethasone Sodium Phosphate 257DEXAMETHASONE SODIUM PHOSPHATE(OPHTH) 257Dexcom G6 Receiver 231Dexcom G6 Sensor 231Dexcom G6 Transmitter 231Dexilant 282DEXLANSOPRAZOLE 282Dexlansoprazole 282DEXMETHYLPHENIDATE HCL 6DEXTROAMPHETAMINE SULFATE 5DIAPHRAGM ARC-SPRING 230DIAPHRAGM WIDE SEAL 230DIAPHRAGMS 230DiaTrust COVID-19 Home Test 186DIAZEPAM 41DIAZEPAM (ANTICONVULSANT) 55DICLOFENAC EPOLAMINE 175Diclofenac Epolamine 175DICLOFENAC POTASSIUM 13

DICLOFENAC SODIUM 13DICLOFENAC SODIUM (ACTINIC KERATOSES) 176DICLOFENAC SODIUM (OPHTH) 256DICLOFENAC SODIUM (TOPICAL) 175DICLOFENAC W/ MISOPROSTOL 13DICLOXACILLIN SODIUM 262DICYCLOMINE HCL 280DIDANOSINE 138,139Didanosine 138DIFENOXIN W/ ATROPINE 79Dificid 230DIFLORASONE DIACETATE 181Diflorasone Diacetate 181DIFLUNISAL 17DIFLUPREDNATE 257DIGOXIN 150,151Digoxin 150DIHYDROERGOTAMINE MESYLATE 240Dilantin 61Dilatrate-SR 38DILTIAZEM HCL 147DILTIAZEM HCL COATED BEADS 146,147,148DILTIAZEM HCL EXTENDED RELEASEBEADS 147,148,149,150DIMETHYL FUMARATE 266Dipentum 204DIPH-AC PERT-TET TOX AD-POLIO IPV-HAEMOPHIL B POLY VAC 280DIPH-TET TOX-ACELL PERT AD-POLIO IPV-HIB-HEPATITIS B RECOMB 280DIPH-TETANUS TOX AD-ACELL PERTUSSIS & POLIOVIRUS, IPV VAC 280DIPH-TETANUS TOX-ACELL PERT-HEPATITIS BRECOMB-POLIO IPV VAC 280DIPHENHYDRAMINE HCL 84DIPHENOXYLATE W/ ATROPINE 79DIPHTHERIA, ACELLULAR PERTUSSIS & TETANUSTOXOIDS 279DIPHTHERIA-TETANUS TOXOIDS (DT) 279Diphtheria-Tetanus Toxoids DT 279DIPYRIDAMOLE 220

DISOPYRAMIDE PHOSPHATE 41DISULFIRAM 263Diuril 191DIVALPROEX SODIUM 61Divigel 200DOFETILIDE 42,43Dojolvi 252DOLASETRON MESYLATE 81,82DOLUTEGRAVIR SODIUM 136DOLUTEGRAVIR SODIUM-LAMIVUDINE 134DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL 134DONEPEZIL HYDROCHLORIDE 263DORAVIRINE 138DORNASE ALFA 271DORZOLAMIDE HCL 256DORZOLAMIDE HCL-TIMOLOL MALEATE 253Dovato 134DOXAZOSIN MESYLATE 99DOXAZOSIN MESYLATE (BPH) 206DOXEPIN HCL 68Doxepin HCl 68,176DOXEPIN HCL (ANTIPRURITIC) 176DOXERCALCIFEROL 195DOXYCYCLINE (MONOHYDRATE) 272,273DOXYCYCLINE HYCLATE 272,273Drisdol 291DRONABINOL 83DRONEDARONE HCL 43DROSPIRENONE 166DROSPIRENONE-ESTETROL 160DROSPIRENONE-ETHINYLESTRADIOL 157,158,159,160,161,162DROSPIRENONE-ETHINYL ESTRADIOL-LEVOMEFOLATE CALCIUM 157,161,162Droxia 221Drysol 184Duavee 200DULAGLUTIDE 75Dulera 43DULOXETINE HCL 67DUPILUMAB 178,179

Dupixent 178,179DUTASTERIDE 206DUVELISIB 119DxTerity COVID-19 Home Test 187

EEasiVent 238EasiVent Mask Large 238EasiVent Mask Medium 238EasiVent Mask Small 238Easy Touch Lancets 30G/Twist 231Easy Touch Lancets 33G/Twist 231ECHOTHIOPHATE IODIDE 254ECONAZOLE NITRATE 182Edarbi 97EDOXABAN TOSYLATE 52Edurant 137EFAVIRENZ 137,138EFAVIRENZ-EMTRICITABINE-TENOFOVIRDISOPROXIL FUMARATE 134EFAVIRENZ-LAMIVUDINE-TENOFOVIR DISOPROXILFUMARATE 134EFINACONAZOLE 183ELAGOLIX SODIUM 193ELAGOLIX SODIUM-ESTRADIOL-NORETHINDRONEACETATE 199Elestrin 200ELETRIPTAN HYDROBROMIDE 240ELEXACAFTOR-TEZACAFTOR-IVACAFTOR 271Eligard 117,118ELIGLUSTAT TARTRATE 221Eliquis 51Eliquis DVT/PE Starter Pack 52Elixophyllin 50Ella 163Ellume Covid-19 Home Test 187Elmiron 207Eloctate 211,212ELTROMBOPAG OLAMINE 225,226ELUXADOLINE 204

ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR ALAFENAMIDE 134ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR DF 134Emadine 255Emcyt 116EMEDASTINE DIFUMARATE 255Emgality 240Emgality (300 MG Dose) 240EMICIZUMAB-KXWH 219EMPAGLIFLOZIN 76EMPAGLIFLOZIN-LINAGLIPTIN 76EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN 76EMPAGLIFLOZIN-METFORMIN HCL 76,77Emsam 63EMTRICITABINE 139EMTRICITABINE-RILPIVIRINE-TENOFOVIRALAFENAMIDE FUMARATE 134EMTRICITABINE-RILPIVIRINE-TENOFOVIRDISOPROXIL FUMARATE 133EMTRICITABINE-TENOFOVIR ALAFENAMIDEFUMARATE 133EMTRICITABINE-TENOFOVIR DISOPROXILFUMARATE 134Emtriva 139Emverm 35ENALAPRIL MALEATE 92ENALAPRIL MALEATE &HYDROCHLOROTHIAZIDE 94Enbrel 16Enbrel Mini 16Enbrel SureClick 16ENCORAFENIB 106Endometrin 290ENFUVIRTIDE 135Engerix-B 286ENOXAPARIN SODIUM 53Enspryng 247ENTACAPONE 125ENTECAVIR 140ENTRECTINIB 114

Entresto 151Envarsus XR 247ENZALUTAMIDE 103Epidiolex 56EPINASTINE HCL (OPHTH) 255EPINEPHrine 291EPINEPHRINE (ANAPHYLAXIS) 291EPLERENONE 100EPOETIN ALFA 223EPOETIN ALFA-EPBX 223Eprontia 56EPROSARTAN MESYLATE 97Eprosartan Mesylate 97Equetro 125ERDAFITINIB 108ERENUMAB-AOOE 239,240ERGOCALCIFEROL 291ERGOLOID MESYLATES 267Ergoloid Mesylates 267ERGOTAMINE W/ CAFFEINE 240Erivedge 109Erleada 103ERLOTINIB HCL 107Ertaczo 183Erythrocin Stearate 229ERYTHROMYCIN (ACNE AID) 172ERYTHROMYCIN (OPHTH) 255ERYTHROMYCIN BASE 229ERYTHROMYCIN ETHYLSUCCINATE 229Erythromycin Ethylsuccinate 229ERYTHROMYCIN STEARATE 229Esbriet 271ESCITALOPRAM OXALATE 64ESKETAMINE HCL 63ESOMEPRAZOLE MAGNESIUM 282Esperoct 212ESTERIFIED ESTROGENS 201ESTERIFIED ESTROGENS &METHYLTESTOSTERONE 198,199ESTRADIOL 200,201ESTRADIOL & NORETHINDRONE ACETATE 199

ESTRADIOL ACETATE VAGINAL 290ESTRADIOL VAGINAL 290ESTRADIOL VALERATE 201ESTRADIOL VALERATE-DIENOGEST 165ESTRAMUSTINE PHOSPHATE SODIUM 116Estring 290ESTROGENS, CONJUGATED 201,202ESTROGENS, CONJUGATED VAGINAL 290ESTROPIPATE 201Estropipate 201Estrostep Fe 166ESZOPICLONE 227ETANERCEPT 16ETHACRYNIC ACID 190ETHAMBUTOL HCL 102ETHIONAMIDE 102ETHOSUXIMIDE 61ETHOTOIN 61ETHYNODIOL DIACET & ETH ESTRAD 158,162ETIDRONATE DISODIUM 192Etidronate Disodium 192ETODOLAC 13ETONOGESTREL 165ETONOGESTREL-ETHINYL ESTRADIOL 163ETOPOSIDE 118Etoposide 118ETRAVIRINE 138Eucrisa 184Eurax 184Evamist 201Evenity 196EverlyWell Covid-19 Home Test 187EVEROLIMUS 110,111EVEROLIMUS (IMMUNOSUPPRESSANT) 247EVOLOCUMAB 90,91Evotaz 134Evrysdi 252Exelderm 183EXEMESTANE 116EXENATIDE 74Exkivity 107

Extavia 265EZETIMIBE 90Ezetimibe-Rosuvastatin 90EZETIMIBE-ROSUVASTATIN CALCIUM 90EZETIMIBE-SIMVASTATIN 90

FFAMCICLOVIR 142FAMOTIDINE 281Fanapt 126,127Fanapt Titration Pack 127Farxiga 76Farydak 109Fasenra 47Fasenra Pen 47FEBUXOSTAT 207,208FELBAMATE 60FELODIPINE 148FemCap 230Femring 290FENOFIBRATE 86,87,88Fenofibrate 86,87FENOFIBRATE MICRONIZED 86,87FENOFIBRIC ACID 87Fenofibric Acid 87FENOLDOPAM MESYLATE 100FENOPROFEN CALCIUM 13Fenoprofen Calcium 13FENTANYL 20,21,30,31FENTANYL CITRATE 19,21,22,23,24fentaNYL Citrate 21,22Ferriprox 80,81Ferriprox Twice-A-Day 81FESOTERODINE FUMARATE 284Fetzima 67FIDAXOMICIN 230FILGRASTIM-AAFI 224FILGRASTIM-AYOW 224,225FILGRASTIM-SNDZ 225FINASTERIDE 206FINGOLIMOD HCL 269

First-Lansoprazole 282First-Omeprazole 282Flarex 257FLAVOXATE HCL 284FLECAINIDE ACETATE 42Flovent Diskus 49Flovent HFA 49Flowflex COVID-19 Ag Home Test 187Fluad 286Fluad Quadrivalent 286Fluarix Quadrivalent 286Flublok 287Flublok Quadrivalent 287Flucelvax Quadrivalent 287FLUCONAZOLE 83,84FLUCYTOSINE 83FLUDROCORTISONE ACETATE 170Flulaval Quadrivalent 287FluMist Quadrivalent 287Flunisolide 252FLUNISOLIDE (NASAL) 252FLUOCINOLONE ACETONIDE 181FLUOCINOLONE ACETONIDE (OTIC) 259FLUOCINONIDE 181FLUOCINONIDE EMULSIFIED BASE 181FLUOROMETHOLONE (OPHTH) 257FLUOROMETHOLONE ACETATE 257Fluoroplex 176Fluorouracil 176FLUOROURACIL (TOPICAL) 176FLUOXETINE HCL 64FLUoxetine HCl 64FLUOXETINE HCL (PMDD) 267FLUoxetine HCl (PMDD) 267FLUPHENAZINE HCL 130,131FluPHENAZine HCl 130,131Flura-Drops 242FLURANDRENOLIDE 180,181FLURAZEPAM HCL 226Flurazepam HCl 226FLURBIPROFEN 13

Flurbiprofen 13FLURBIPROFEN SODIUM 256Flurbiprofen Sodium 256FLUTAMIDE 103Flutamide 103FLUTICASONE FUROATE (INHALATION) 48FLUTICASONE FUROATE-VILANTEROL 43FLUTICASONE PROPIONATE 181FLUTICASONE PROPIONATE (INHALATION) 49FLUTICASONE PROPIONATE (NASAL) 252FLUTICASONE PROPIONATE HFA 49FLUTICASONE-SALMETEROL 43,44Fluticasone-Salmeterol 44FLUTICASONE-UMECLIDINIUM-VILANTEROL 44FLUVASTATIN SODIUM 88Fluvirin 287FLUVOXAMINE MALEATE 64,65Fluzone High-Dose 287Fluzone High-Dose Quadrivalent 287Fluzone Quadrivalent 287,288FML 257FML Forte 257FOLIC ACID 224FONDAPARINUX SODIUM 53Forfivo XL 63Forteo 196Fosamax Plus D 192FOSAMPRENAVIR CALCIUM 136,137FOSFOMYCIN TROMETHAMINE 37FOSINOPRIL SODIUM 92FOSINOPRIL SODIUM &HYDROCHLOROTHIAZIDE 94FOSTEMSAVIR TROMETHAMINE 135Fotivda 112Fragmin 53FreeStyle Flash System 231FreeStyle Freedom 231FreeStyle Freedom Lite 231FreeStyle InsuLinx System 231FreeStyle InsuLinx Test 185FreeStyle Lancets 231

FreeStyle Libre 14 Day Reader 231FreeStyle Libre 14 Day Sensor 231FreeStyle Libre 2 Reader 231FreeStyle Libre 2 Sensor 232FreeStyle Libre Reader 232FreeStyle Libre Sensor System 232FreeStyle Lite 232FreeStyle Lite Test 185FreeStyle Sidekick II 232FreeStyle System 232FreeStyle Test 185FreeStyle Unistick II Lancets 232FREMANEZUMAB-VFRM 240FROVATRIPTAN SUCCINATE 240Fulphila 224FUROSEMIDE 190Furosemide 190Fuzeon 135Fycompa 54

GGABAPENTIN 56GALANTAMINE HYDROBROMIDE 263Galantamine Hydrobromide 263GALCANEZUMAB-GNLM 240GANCICLOVIR OPHTHALMIC 256Gardasil 9 288GATIFLOXACIN (OPHTH) 255GaviLyte-C 228Gavreto 113Gelnique 283Gelnique Pump 283GEMFIBROZIL 88Generess FE 158GENTAMICIN SULFATE (OPHTH) 255GENTAMICIN SULFATE (TOPICAL) 175Genvoya 134Giazo 205Gilenya 269Gilotrif 107,108Glassia 270

GLATIRAMER ACETATE 264GLECAPREVIR-PIBRENTASVIR 140,141Gleostine 119GLIMEPIRIDE 78GLIPIZIDE 78GLIPIZIDE-METFORMIN HCL 77GlucaGen Diagnostic 185GlucaGen HypoKit 70GLUCAGON 70,71GLUCAGON (RDNA) 70Glucagon Emergency 70GLUCAGON HCL (DIAGNOSTIC) 185Glucagon HCl (Diagnostic) 185GLUCAGON HCL (RDNA) 70GLUCAGON HCL RDNA (DIAGNOSTIC) 185GLUCOSE BLOOD 185,186GLYBURIDE 78GLYBURIDE MICRONIZED 79GLYBURIDE-METFORMIN 77GLYCOPYRROLATE 283Glyxambi 76GOLIMUMAB 10Golytely 228GOSERELIN ACETATE 118GRANISETRON 82GRANISETRON HCL 82Granix 224GRISEOFULVIN MICROSIZE 83GRISEOFULVIN ULTRAMICROSIZE 83GUAIFENESIN-CODEINE 171GUANFACINE HCL 98GUANFACINE HCL (ADHD) 3GUANIDINE HCL 101Guanidine HCl 101GUSELKUMAB 178Gvoke HypoPen 1-Pack 70Gvoke HypoPen 2-Pack 70Gvoke Kit 70Gvoke PFS 71

HHaegarda 220HAEMOPHILUS B POLYSAC CONJ VAC 285HALOBETASOL PROPIONATE 181HALOPERIDOL 129HALOPERIDOL LACTATE 129Havrix 288Helixate FS 212,213Hemlibra 219Hemofil M 213HEPARIN SODIUM (PORCINE) 52HEPARIN SODIUM (PORCINE) LOCK FLUSH 52HEPATITIS A (INACTIVATED)-HEPATITIS B(RECOMBINANT) VACCINES 286HEPATITIS A VACCINE 288,289HEPATITIS B VACCINE (RECOMB) 286,289HEPATITIS B VACCINE 3-ANTIGENRECOMBINANT 289HEPATITIS B VACCINE RECOMBINANTADJUVANTED 288Heplisav-B 288Hexalen 102Hiberix 285HISTRELIN ACETATE 118Hizentra 260HOMATROPINE HBR 254HumaLOG 72HumaLOG Junior KwikPen 72HumaLOG KwikPen 72HumaLOG Mix 50/50 72HumaLOG Mix 50/50 KwikPen 72HumaLOG Mix 75/25 72HumaLOG Mix 75/25 KwikPen 73HUMAN PAPILLOMAVIRUS (HPV) 9-VALENTRECOMBINANT VACCINE 288Humate-P 213Humira 9Humira Pediatric Crohns Start 9Humira Pen 9Humira Pen-CD/UC/HS Starter 10

Humira Pen-Pediatric UC Start 10Humira Pen-Ps/UV/Adol HS Start 10Humira Pen-Psor/Uveit Starter 10HumuLIN 70/30 73HumuLIN 70/30 KwikPen 73HumuLIN N 73HumuLIN N KwikPen 73HumuLIN R 73HumuLIN R U-500 (CONCENTRATED) 73HumuLIN R U-500 KwikPen 73Hycodan 171HYDRALAZINE HCL 100HYDROCHLOROTHIAZIDE 191HYDROCODONE BITARTRATE 22,23HYDROcodone Bitartrate ER 22,23HYDROCODONE BITARTRATE-HOMATROPINEMETHYLBROMIDE 171HYDROCODONE POLISTIREX-CHLORPHENIRAMINEPOLISTIREX 172HYDROCODONE W/ HOMATROPINE 171HYDROCODONE-ACETAMINOPHEN 17,18,19HYDROCODONE-IBUPROFEN 18,19Hydrocodone-Ibuprofen 18HYDROCORTISONE 168,169HYDROCORTISONE (INTRARECTAL) 35HYDROCORTISONE (RECTAL) 35HYDROCORTISONE (TOPICAL) 179,181HYDROCORTISONE ACETATE (RECTAL) 35HYDROCORTISONE BUTYRATE 182Hydrocortisone Butyrate 182HYDROCORTISONE BUTYRATE HYDROPHILIC LIPOBASE 181HYDROCORTISONE VALERATE 182HYDROCORTISONE W/ACETIC ACID 259HYDROMORPHONE HCL 23HYDROXYCHLOROQUINE SULFATE 101Hydroxychloroquine Sulfate 101HYDROXYprogesterone Caproate 120HYDROXYPROGESTERONE CAPROATE 262HYDROXYPROGESTERONE CAPROATE(ANTINEOPLASTIC) 120

HYDROXYUREA 115HYDROXYUREA (SICKLE CELL ANEMIA) 221HYDROXYZINE HCL 39HYDROXYZINE PAMOATE 39,40HydrOXYzine Pamoate 39HYOSCYAMINE SULFATE 280,281Hyqvia 260,261

IIBANDRONATE SODIUM 192Ibrance 116IBREXAFUNGERP CITRATE 83IBRUTINIB 107IBUPROFEN 13,14ICATIBANT ACETATE 219,220Iclusig 105ICOSAPENT ETHYL 85,86ID NOW COVID-19 187IDELALISIB 119Idelvion 213IHealth COVID-19 Rapid Test 187Ilevro 256ILOPERIDONE 126,127ILOPROST 151IMATINIB MESYLATE 105,106Imbruvica 107IMIPENEM-CILASTATIN 37IMIPRAMINE HCL 68IMIPRAMINE PAMOATE 69IMIQUIMOD 183IMMUNE GLOBULIN (HUMAN)SUBCUTANEOUS 260IMMUNE GLOBULIN (HUMAN)-HYALURONIDASE(HUMAN RECOMBINANT) 260,261INCLISIRAN SODIUM 91Increlex 195Incruse Ellipta 46INDACATEROL MALEATE 46INDAPAMIDE 191Inderal XL 145INDINAVIR SULFATE 136

Indocin 14INDOMETHACIN 14Infanrix 279INFIGRATINIB PHOSPHATE 108,109INFLUENZA VIRUS VAC RECOMB HEMAGGLUTININ(HA) QUADRIVALENT 287INFLUENZA VIRUS VAC SPLIT HIGH-DOSE QUADPRESERVATIVE FREE 287INFLUENZA VIRUS VACC TYPES A & B SURFANTIGEN ADJUVANT QUAD 286INFLUENZA VIRUS VACCINE LIVEQUADRIVALENT 287INFLUENZA VIRUS VACCINE RECOMBINANTHEMAGGLUTININ (HA) 287INFLUENZA VIRUS VACCINE SPLIT 286INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSEPRESERVATIVE FREE 287INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVEFREE 286INFLUENZA VIRUS VACCINE SPLITQUADRIVALENT 286,287,288INFLUENZA VIRUS VACCINE TISSUE-CULTUREDSUBUNIT QUADRIVALENT 287INFLUENZA VIRUS VACCINE TYPES A & B SURFACEANTIGEN 287INFLUENZA VIRUS VACCINE TYPES A & B SURFACEANTIGEN ADJUVANT 286INJECTION DEVICE 235,237INJECTION DEVICE FOR INSULIN 235Inlyta 120,121InnoPran XL 145Inqovi 115INSULIN DEGLUDEC 74INSULIN DEGLUDEC-LIRAGLUTIDE 75INSULIN DETEMIR 74INSULIN GLARGINE 72,73INSULIN GLARGINE-LIXISENATIDE 75INSULIN INFUSION DISPOSABLE PUMP 234INSULIN LISPRO 72,73Insulin Lispro 73Insulin Lispro (1 Unit Dial) 73

Insulin Lispro Junior KwikPen 73Insulin Lispro Prot & Lispro 73INSULIN LISPRO PROTAMINE & LISPRO 72,73INSULIN NPH (HUMAN) (ISOPHANE) 73INSULIN NPH ISOPHANE & REG (HUMAN) 73INSULIN PEN NEEDLE 235,237INSULIN REGULAR (HUMAN) 73INSULIN SYRINGE/NEEDLE U-100 234,235,236,237INSULIN SYRINGE/NEEDLE U-500 234INSULIN SYRINGES (DISPOSABLE) 236Intelence 138InteliSwab COVID-19 Rapid Test 187INTERFERON ALFA-2B 115INTERFERON BETA-1A 265,266INTERFERON BETA-1B 265INTERFERON GAMMA-1B 115Intron A 115Invega Hafyera 127Invega Sustenna 127Invega Trinza 127Invirase 137Ipol 288IPRATROPIUM BROMIDE 46IPRATROPIUM BROMIDE (NASAL) 252IPRATROPIUM BROMIDE HFA 46IPRATROPIUM-ALBUTEROL 43,44IRBESARTAN 97IRBESARTAN-HYDROCHLOROTHIAZIDE 96IRRIGATION SOLUTIONS, PHYSIOLOGICAL 246Isentress 135,136Isentress HD 136ISOCARBOXAZID 63ISONIAZID 102Isoniazid 102ISONIAZID-RIFAMPIN W/ PYRAZINAMIDE 101ISOSORBIDE DINITRATE 38Isosorbide Dinitrate ER 38ISOSORBIDE MONONITRATE 38ISOTRETINOIN 173,174ISRADIPINE 148Isturisa 193

ITRACONAZOLE 84IVABRADINE HCL 153,154IVACAFTOR 270IVERMECTIN 36Ivermectin 184IVERMECTIN (PEDICULICIDE) 184IVERMECTIN (ROSACEA) 184IXAZOMIB CITRATE 113IXEKIZUMAB 178Ixinity 213,214

JJ-Tip Kit w/Vial Adapters 235Jakafi 117Janssen COVID-19 Vaccine 288Janumet 71Janumet XR 71Januvia 71Jardiance 76Jentadueto 72Jentadueto XR 72Jivi 214Jublia 183Juluca 134Jynarque 197

KK-Phos 242K-Phos No 2 207Kalydeco 270Katerzia 148Kenalog-80 169Kesimpta 266KETOCONAZOLE 83KETOCONAZOLE (TOPICAL) 183KETOPROFEN 14Ketoprofen 14KETOROLAC TROMETHAMINE 14KETOROLAC TROMETHAMINE (OPHTH) 256Kineret 12Kinrix 280

Kloxxado 81Koate 214Koate-DVI 214,215Kogenate FS 215Kogenate FS Bio-Set 215Koselugo 110Kovaltry 215Kroger HealthPro Lancet 26G 232Kroger Lancets 232Kroger Lancets 21G 232Kroger Lancets Micro Thin 33G 232Kroger Lancets Super Thin 232Kroger Lancets Thin 232Kroger Lancets Thin 26G 232Kroger Lancets UltraThin 30G 232Kyleena 165Kynmobi 123Kynmobi Titration Kit 123

LLABETALOL HCL 143LACOSAMIDE 56,59Lacrisert 253LACTULOSE 228LACTULOSE (ENCEPHALOPATHY) 205LAMIVUDINE 139LAMIVUDINE (HBV) 140LAMIVUDINE-TENOFOVIR DISOPROXILFUMARATE 133,135LAMIVUDINE-ZIDOVUDINE 134LAMOTRIGINE 56,57,58Lampit 36,37LANCET DEVICES 233LANCETS 231,232,233,234LANCETS MISC. 233Lanoxin 150,151LANSOPRAZOLE 282LANTHANUM CARBONATE 206Lantus 73Lantus SoloStar 73LAPATINIB DITOSYLATE 112

LASMIDITAN SUCCINATE 241Lastacaft 255LATANOPROST 258Latuda 125,126Lazanda 23,24LEDIPASVIR-SOFOSBUVIR 140Ledipasvir-Sofosbuvir 140LEFLUNOMIDE 15LEMBOREXANT 227LENALIDOMIDE 245,246LENVATINIB MESYLATE 121Lenvima (10 MG Daily Dose) 121Lenvima (14 MG Daily Dose) 121Lenvima (20 MG Daily Dose) 121Lenvima (24 MG Daily Dose) 121Leqvio 91LETROZOLE 116LEUCOVORIN CALCIUM 117Leukeran 119LEUPROLIDE ACETATE 118LEUPROLIDE ACETATE & NORETHINDRONEACETATE 195LEUPROLIDE ACETATE (3 MONTH) 117,118LEUPROLIDE ACETATE (4 MONTH) 117,118LEUPROLIDE ACETATE (6 MONTH) 118LEUPROLIDE ACETATE (CPP) 195LEUPROLIDE ACETATE (CPP) (3 MONTH) 195LEVALBUTEROL HCL 46LEVALBUTEROL TARTRATE 46Levalbuterol Tartrate 46Levemir 74Levemir FlexTouch 74LEVETIRACETAM 57,58LEVOBUNOLOL HCL 253Levobunolol HCl 253LEVOCARNITINE (METABOLIC MODIFIERS) 193LEVOCETIRIZINE DIHYDROCHLORIDE 84LEVOFLOXACIN 202LEVOFLOXACIN (OPHTH) 255LEVOMILNACIPRAN HCL 67

LEVONORGESTREL & ETHESTRADIOL 156,157,158,159,161,162LEVONORGESTREL (IUD) 165LEVONORGESTREL-ETH ESTRADIOL(TRIPHASIC) 166,167,168LEVONORGESTREL-ETHINYL ESTRADIOL 162LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) 163,164,165LEVONORGESTREL-ETHINYL ESTRADIOL(CONTINUOUS) 163LEVONORGESTREL-ETHINYL ESTRADIOL-FERROUSBISGLYCINATE 156LEVOTHYROXINE SODIUM 274,275,276,277,278Levothyroxine Sodium 274,275Lexiva 137LIDOCAINE 183,184LIDOCAINE HCL 183LIDOCAINE HCL (MOUTH-THROAT) 248Lidocaine HCl Urethral/Mucosal 183LIDOCAINE-HYDROCORTISONE ACETATE(RECTAL) 35LIDOCAINE-PRILOCAINE 185LIDOCAINE-TETRACAINE 185Lidotrex 184LIFITEGRAST 254Liletta (52 MG) 165LINACLOTIDE 204LINAGLIPTIN 71LINAGLIPTIN-METFORMIN HCL 72LINDANE 185Lindane 185LINEZOLID 37Linzess 204LIOTHYRONINE SODIUM 276LIOTRIX (T3-T4) 278Lipofen 88LIRAGLUTIDE 75LISDEXAMFETAMINE DIMESYLATE 5LISINOPRIL 92,93LISINOPRIL & HYDROCHLOROTHIAZIDE 94LITHIUM 125

Lithium 125LITHIUM CARBONATE 125Lithium Carbonate 125Livalo 88Livtencity 140Lo Loestrin Fe 156LODOXAMIDE TROMETHAMINE 255Lokelma 247LOMUSTINE 119Lonsurf 115LOPINAVIR-RITONAVIR 134Loprox 175,176LORAZEPAM 41LOSARTAN POTASSIUM 97LOSARTAN POTASSIUM &HYDROCHLOROTHIAZIDE 96LoSeasonique 164Lotemax 257LOTEPREDNOL ETABONATE 257,258LOVASTATIN 88,89LOXAPINE SUCCINATE 130LUBIPROSTONE 203Lubiprostone 203Lucira COVID-19 All-In-One 187LULICONAZOLE 183Luliconazole 183LUMACAFTOR-IVACAFTOR 270,271Lumakras 110LUMATEPERONE TOSYLATE 125Lumigan 258Lupaneta Pack 195Lupkynis 245Lupron Depot (1-Month) 118Lupron Depot (3-Month) 118Lupron Depot (4-Month) 118Lupron Depot (6-Month) 118Lupron Depot-Ped (1-Month) 195Lupron Depot-Ped (3-Month) 195LURASIDONE HCL 125,126Lynparza 120Lyra Direct SARS-CoV-2 Assay 187

Lyra SARS-CoV-2 Assay 187Lyrica 57Lysodren 103

MM-M-R II 285M-Vit 249MACITENTAN 152MAFENIDE ACETATE 179Magellan Insulin Safety Syr 235MALATHION 185MAPROTILINE HCL 63Maprotiline HCl 63Marathon Medical Pentips 235MARAVIROC 135MARIBAVIR 140Marplan 63Matulane 115Mavenclad (10 Tabs) 264Mavenclad (4 Tabs) 264Mavenclad (5 Tabs) 265Mavenclad (6 Tabs) 265Mavenclad (7 Tabs) 265Mavenclad (8 Tabs) 265Mavenclad (9 Tabs) 265Mavyret 140,141Maxidex 258Mayzent 269Mayzent Starter Pack 269MEASLES, MUMPS & RUBELLA VIRUSVACCINES 285MEASLES-MUMPS-RUBELLA-VARICELLA VIRUSVACCINES 285MEBENDAZOLE 35MECASERMIN 195MECHLORETHAMINE HCL (TOPICAL) 176MECLIZINE HCL 82MECLOFENAMATE SODIUM 14Meclofenamate Sodium 14MEDROXYPROGESTERONE ACETATE 262

MEDROXYPROGESTERONE ACETATE(CONTRACEPTIVE) 165MEFENAMIC ACID 14MEFLOQUINE HCL 101MEGESTROL ACETATE 120MEGESTROL ACETATE (APPETITE) 262Mekinist 110Mektovi 110MELOXICAM 14MELPHALAN 119MEMANTINE HCL 266,267Menactra 285Menest 201MENINGOCOCCAL (A,C,Y&W-135)OLIGOSACCHARIDE CONJUGATE VAC 285MENINGOCOCCAL (A,C,Y&W-135) POLYSACCHDIPHTH CONJ VACCINE 285MENINGOCOCCAL (A,C,Y&W-135) POLYSACCHTETANUS CONJ VACCINE 285MENINGOCOCCAL GROUP B VACCINE(RECOMBINANT) 285MENINGOCOCCAL VAC GROUP B (RECOMBANTOMV ADJUVANTED) 285Menostar 201MenQuadfi 285Menveo 285MEPOLIZUMAB 47MEPROBAMATE 40MERCAPTOPURINE 103,104MESALAMINE 205MESALAMINE W/ CLEANSER 205METAPROTERENOL SULFATE 46Metaproterenol Sulfate 46METAXALONE 251METFORMIN HCL 70METHADONE HCL 24Methadone HCl 24METHAZOLAMIDE 189METHENAMINE HIPPURATE 37METHIMAZOLE 273Methitest 34

METHOCARBAMOL 251METHOTREXATE (ANTIRHEUMATIC) 11,12METHOTREXATE SODIUM 103,104Methotrexate Sodium 104METHOXSALEN RAPID 177Methoxsalen Rapid 177METHOXY POLYETHYLENE GLYCOL-EPOETINBETA 222,223METHSCOPOLAMINE BROMIDE 283METHSUXIMIDE 61METHYCLOTHIAZIDE 191Methyclothiazide 191METHYLDOPA 98,99Methyldopa 98METHYLERGONOVINE MALEATE 259METHYLPHENIDATE HCL 6,7,8Methylphenidate HCl ER 7METHYLPREDNISOLONE 169METHYLTESTOSTERONE 34METIPRANOLOL 253Metipranolol 253METOCLOPRAMIDE HCL 203,204Metoclopramide HCl 203METOLAZONE 191METOPROLOL & HYDROCHLOROTHIAZIDE 100METOPROLOL SUCCINATE 144METOPROLOL TARTRATE 144Metoprolol-Hydrochlorothiazide 100METRELEPTIN 195METRONIDAZOLE 36METRONIDAZOLE (TOPICAL) 184METRONIDAZOLE VAGINAL 290MEXILETINE HCL 42MICONAZOLE (MOUTH-THROAT) 248Microchamber 238Microlet Lancets 233Microspacer 239MIDAZOLAM (ANTICONVULSANT) 55MIDAZOLAM HCL 226MIDODRINE HCL 291MIGLITOL 69

MILNACIPRAN HCL 264Minastrin 24 Fe 160MINOCYCLINE HCL 272,273MINOXIDIL 100MIRABEGRON 284Mircera 222,223Mircette 156Mirena (52 MG) 165MIRTAZAPINE 62MISOPROSTOL 283MITOTANE 103MOBOCERTINIB SUCCINATE 107MODAFINIL 7,8Moderna COVID-19 Vac (Booster) 288Moderna COVID-19 Vaccine 288MOEXIPRIL HCL 92MOEXIPRIL-HYDROCHLOROTHIAZIDE 94MOLNUPIRAVIR 142Molnupiravir 142MOMETASONE FUROATE 182MOMETASONE FUROATE (INHALATION) 48,49MOMETASONE FUROATE (NASAL) 252MOMETASONE FUROATE-FORMOTEROLFUMARATE DIHYDRATE 43Monoclate-P 216Monoject Insulin Syringe 235,236Monoject Introducer Needle 236Monoject Magellan Safety Ndl 236Monoject Magellan Syringe 236Monoject Syringe 236Monoject Ultra Comfort Syringe 236,237MONOMETHYL FUMARATE 266Mononine 216MONTELUKAST SODIUM 47MORPHINE SULFATE 24,25,26Morphine Sulfate 24,25Morphine Sulfate (PF) 24MORPHINE SULFATE BEADS 26,27Morphine Sulfate ER 25,26Morphine Sulfate ER Beads 26,27Motegrity 202

Motofen 79Movantik 205Moxeza 255MOXIFLOXACIN HCL 202Moxifloxacin HCl (2X Day) 255MOXIFLOXACIN HCL (OPHTH) 255,256Multaq 43MUPIROCIN 175MUPIROCIN CALCIUM 251Myalept 195MYCOPHENOLATE MOFETIL 246MYCOPHENOLATE SODIUM 246MyLab Box Covid-19 Testing 187Myleran 102Myrbetriq 284

NNABILONE 82NABUMETONE 14,15NADOLOL 145NAFCILLIN SODIUM 262NALBUPHINE HCL 33NALDEMEDINE TOSYLATE 205NALOXEGOL OXALATE 205NALOXONE HCL 81Naloxone HCl 81NALTREXONE 81NALTREXONE HCL 81NAPROXEN 14,15NAPROXEN SODIUM 15NARATRIPTAN HCL 240Narcan 81Natacyn 256NATAMYCIN 256Natazia 165NATEGLINIDE 75Nature-Throid 276,277Nayzilam 55NEBIVOLOL HCL 144NEDOCROMIL SODIUM (OPHTH) 255NEEDLE (DISP) 16 G 234,235

NEEDLE (DISP) 21 G 236NEEDLE (DISP) 23 G 236NEEDLE (REUSABLE) 18 G 235,236NEFAZODONE HCL 65,66Nefazodone HCl 65,66NEOMYCIN SULFATE 8NEOMYCIN-BACITRACIN ZN-POLYMYXIN 254NEOMYCIN-COLISTIN-HC-THONZONIUM 259NEOMYCIN-POLYMY-DEXAMETH 257NEOMYCIN-POLYMYXIN-GRAMICIDIN 254Neomycin-Polymyxin-Gramicidin 254NEOMYCIN-POLYMYXIN-HC 175NEOMYCIN-POLYMYXIN-HC (OTIC) 259Neonatal Complete 249NeoNatal Plus 249Neoral 245NEPAFENAC 256NERATINIB MALEATE 112Nerlynx 112NETARSUDIL DIMESYLATE 257NETARSUDIL DIMESYLATE-LATANOPROST 256NETUPITANT-PALONOSETRON 82Neupro 123Nevanac 256NEVIRAPINE 138Nevirapine 138Nevirapine ER 138NexAVAR 112Nexletol 85Nexlizet 85Nexplanon 165Nextstellis 160NIACIN (ANTIHYPERLIPIDEMIC) 90Niacor 90NICARDIPINE HCL 148,149NICOTINE 268Nicotrol 268Nicotrol NS 268NIFEDIPINE 146,149NIFURTIMOX 36,37NILOTINIB HCL 106

NILUTAMIDE 103NIMODIPINE 149Ninlaro 113NINTEDANIB ESYLATE 271NIRMATRELVIR-RITONAVIR 140NISOLDIPINE 149Nisoldipine ER 149NITAZOXANIDE 36,37Nitro-Bid 38NITROFURANTOIN 37NITROFURANTOIN MACROCRYSTAL 37,38NITROFURANTOIN MONOHYD MACRO 38NITROGLYCERIN 38,39NITROGLYCERIN (INTRA-ANAL) 35Nivestym 224NIZATIDINE 281Nizatidine 281Nordipen 5 Injection Device 237Norditropin FlexPro 194NORELGESTROMIN-ETHINYL ESTRADIOL 162NORETHIN ACET & ESTRAD-FE 156,157,158,159,160,161,162NORETHINDRONE & ETHESTRADIOL 156,157,160,161,162NORETHINDRONE & ETHINYL ESTRADIOL-FE 158,159,160,162NORETHINDRONE (CONTRACEPTIVE) 165,166NORETHINDRONE ACET & ETHESTRA 156,158,159,160NORETHINDRONE ACETATE 262NORETHINDRONE ACETATE-ETHINYLESTRADIOL 199NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE 166,167NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE FUM (BIPHASIC) 156NORETHINDRONE-ETH ESTRADIOL(TRIPHASIC) 166,167NORGESTIMATE-ETHINYLESTRADIOL 157,158,160,161,162

NORGESTIMATE-ETHINYL ESTRADIOL(TRIPHASIC) 167,168NORGESTREL & ETHINYL ESTRADIOL 157,159,161Norpace CR 41NORTRIPTYLINE HCL 69Nortriptyline HCl 69Norvir 137Novavax COVID-19 Vaccine 288Novoeight 216Nucala 47Nucynta 27Nucynta ER 27Nurtec 239Nutropin AQ NuSpin 10 194Nutropin AQ NuSpin 20 194Nutropin AQ NuSpin 5 194Nuwiq 216,217NYSTATIN 83NYSTATIN (MOUTH-THROAT) 248NYSTATIN (TOPICAL) 176NYSTATIN-TRIAMCINOLONE 176Nyvepria 224

OOB Complete/DHA 249OBETICHOLIC ACID 203Obizur 217Ocaliva 203OCTREOTIDE ACETATE 197Octreotide Acetate 197Odefsey 134ODEVIXIBAT 204Odomzo 109OFATUMUMAB (MS) 266Ofev 271OFLOXACIN 202Ofloxacin 202OFLOXACIN (OPHTH) 256OFLOXACIN (OTIC) 259Ogestrel 161OLANZAPINE 132,133

OLANZAPINE PAMOATE 133OLAPARIB 120OLMESARTAN MEDOXOMIL 97,98OLMESARTAN MEDOXOMIL-AMLODIPINE-HYDROCHLOROTHIAZIDE 95OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE 96OLODATEROL HCL 46OLOPATADINE HCL 255OLOPATADINE HCL (NASAL) 252OLSALAZINE SODIUM 204Olumiant 10OMALIZUMAB 45OMEGA-3-ACID ETHYL ESTERS 85OMEPRAZOLE 282Omniflex Diaphragm 230OmniPod 5 G6 Intro Kit 234OmniPod 5 G6 Pods (Gen 5) 234OmniPod 5 Pack 234OmniPod Dash 5 Pack Pods 234OmniPod Dash Intro Kit 234OmniPod Dash System 234OmniPod Starter 234Omnipred 258Omnitrope 194Omnitrope Pen 5 Inj Device 237On/Go Covid-19 Antigen Test 187ONDANSETRON 82ONDANSETRON HCL 82Ondansetron HCl 82OneTouch Club Lancets Fine Pt 233OneTouch Delica Lancets 30G 233OneTouch Delica Lancets 33G 233OneTouch Delica Lancing Dev 233OneTouch Delica Plus Lancet30G 233OneTouch Delica Plus Lancet33G 233OneTouch Delica Plus Lancing 233OneTouch FinePoint Lancets 233OneTouch Ping Meter Remote 233OneTouch SureSoft Lancing Dev 233OneTouch Ultra 185

OneTouch Ultra 2 233OneTouch Ultra Mini 233OneTouch UltraLink 233OneTouch UltraSoft Lancets 233OneTouch Verio 186,234OneTouch Verio Flex System 233OneTouch Verio IQ System 233OneTouch Verio Reflect 233OneTouch Verio Sync System 233Onfi 55Ongentys 125OPICAPONE 125OPIUM TINCTURE 79Opsumit 152OptiChamber Advantage-Lg Mask 239OptiChamber Advantage-Med Mask 239OptiChamber Advantage-Sm Mask 239OptiChamber Diamond 239OptiChamber Diamond-Lg Mask 239OptiChamber Diamond-Md Mask 239OptiChamber Diamond-Sm Mask 239Oravig 248Orencia 15Orencia ClickJect 16Oriahnn 199Orilissa 193Orkambi 270,271ORPHENADRINE CITRATE 251ORPHENADRINE W/ ASPIRIN & CAFF 251Ortho Micronor 166Ortho Tri-Cyclen (28) 167Ortho Tri-Cyclen Lo 167Ortho-Cyclen (28) 161Ortho-Novum 1/35 (28) 161Ortho-Novum 7/7/7 (28) 167OSELTAMIVIR PHOSPHATE 142OSILODROSTAT PHOSPHATE 193OSIMERTINIB MESYLATE 108OSPEMIFENE 196Osphena 196Otezla 15

Otiprio 259Otovel 259Otrexup 11OXANDROLONE 33OXAPROZIN 15OXAZEPAM 41OXCARBAZEPINE 57OXYBUTYNIN CHLORIDE 283OXYCODONE HCL 28,29OxyCODONE HCl ER 28,29OXYCODONE W/ ACETAMINOPHEN 32OXYCODONE-IBUPROFEN 32Oxycodone-Ibuprofen 32OxyCONTIN 29OXYMETHOLONE 33OXYMORPHONE HCL 30OxyMORphone HCl ER 30OZANIMOD HCL 269Ozempic (0.25 or 0.5 MG/DOSE) 74Ozempic (1 MG/DOSE) 74Ozempic (2 MG/DOSE) 74

PPALBOCICLIB 116PALIPERIDONE 127,128PALIPERIDONE PALMITATE 127PALIVIZUMAB 259Palynziq 196Pancreaze 188,189PANCRELIPASE (LIPASE-PROTEASE-AMYLASE) 188,189PANOBINOSTAT LACTATE 109PANTOPRAZOLE SODIUM 282,283Paragard Intrauterine Copper 163PARICALCITOL 195PAROXETINE HCL 65PAROXETINE MESYLATE (VASOMOTOR) 269PASIREOTIDE DIASPARTATE 197,198PASIREOTIDE PAMOATE 198PATIROMER SORBITEX CALCIUM 248Paxlovid 140

PAZOPANIB HCL 113Pediarix 280Pedvax HIB 285PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SODSULFATE 228PEG 3350-POTASSIUM CHLORIDE-SODBICARBONATE-SOD CHLORIDE 228PEGADEMASE BOVINE 8Peganone 61Pegasys 141Pegasys ProClick 141PEGFILGRASTIM-APGF 224PEGFILGRASTIM-BMEZ 225PEGFILGRASTIM-CBQV 225PEGFILGRASTIM-JMDB 224PEGINTERFERON ALFA-2A 141PEGINTERFERON ALFA-2B 141PEGINTERFERON BETA-1A 265PegIntron 141PEGVALIASE-PQPZ 196PEGVISOMANT 193Pemazyre 108PEMIGATINIB 108PENCICLOVIR 178PENICILLAMINE 244PENICILLIN V POTASSIUM 261Penicillin V Potassium 261Pentacel 280PENTAMIDINE ISETHIONATE 36Pentasa 205PenTips 237PENTOSAN POLYSULFATE SODIUM 207PENTOXIFYLLINE 220PERAMPANEL 54PERINDOPRIL ERBUMINE 92PERMETHRIN 185PERPHENAZINE 131PERPHENAZINE-AMITRIPTYLINE 267Perphenazine-Amitriptyline 267PEXIDARTINIB HCL 112Pfizer COVID-19 Vac-TriS 5-11y 288

Pfizer COVID-19 Vac-TriS 6m-4y 288Pfizer-BioNT COVID-19 Vac-TriS 289Pfizer-BioNTech COVID-19 Vacc 289Pharmacist Choice Lancets 234PHENAZOPYRIDINE HCL 207PHENELZINE SULFATE 63PHENOBARBITAL 226PHENOXYBENZAMINE HCL 94PHENYTOIN 61PHENYTOIN SODIUM EXTENDED 61Phoslyra 206Phospholine Iodide 254PHYTONADIONE 291Pifeltro 138PILOCARPINE HCL 254PILOCARPINE HCL (ORAL) 248PIMECROLIMUS 184PIMOZIDE 268Pimozide 268PINDOLOL 145PIOGLITAZONE HCL 79PIOGLITAZONE HCL-METFORMIN HCL 79Piqray (200 MG Daily Dose) 119Piqray (250 MG Daily Dose) 119Piqray (300 MG Daily Dose) 119PIRFENIDONE 271PIROXICAM 15PITAVASTATIN CALCIUM 88Pixel COVID-19 PCR Home Test 187PLECANATIDE 203Plegridy 265Plegridy Starter Pack 265PNEUMOCOCCAL 13-VALENT CONJUGATEVACCINE 285PNEUMOCOCCAL 15-VALENT CONJUGATEVACCINE 285PNEUMOCOCCAL 20-VALENT CONJUGATEVACCINE 285PNEUMOCOCCAL VAC POLYVALENT 285Pneumovax 23 285PNV Folic Acid + Iron 249

PNV Prenatal Plus Multivitamin 249PNV Tabs 29-1 249PNV-DHA+Docusate 250PODOFILOX 183POLIOVIRUS VACCINE, IPV 288POLYETHYLENE GLYCOL 3350 228POLYMYXIN B-TRIMETHOPRIM 254POMALIDOMIDE 109Pomalyst 109PONATINIB HCL 105PONESIMOD 269Ponvory 269Ponvory Starter Pack 269POSACONAZOLE 84POT PHOSPHATE MONOBASIC W/ SODPHOSPHATE DIBASIC & MONOBASIC 242POTASSIUM & SODIUM ACID PHOSPHATES 207POTASSIUM BICARBONATE 242,243POTASSIUM CHLORIDE 243Potassium Chloride ER 243POTASSIUM CHLORIDE MICROENCAPSULATEDCRYSTALS ER 243POTASSIUM CITRATE (ALKALINIZER) 207POTASSIUM PHOSPHATE MONOBASIC 242Pradaxa 54PRALSETINIB 113PRAMIPEXOLE DIHYDROCHLORIDE 124PRAMLINTIDE ACETATE 69PRASUGREL HCL 221PRAVASTATIN SODIUM 89PRAZIQUANTEL 36PRAZOSIN HCL 99Pred Mild 258PREDNICARBATE 182Prednicarbate 182PREDNISOLONE 169,170PrednisoLONE 169PrednisoLONE Acetate 258PREDNISOLONE ACETATE (OPHTH) 258PrednisoLONE Acetate P-F 258PREDNISOLONE SODIUM PHOSPHATE 170

PrednisoLONE Sodium Phosphate 170,258PREDNISOLONE SODIUM PHOSPHATE(OPHTH) 258PREDNISONE 170PredniSONE 170PredniSONE Intensol 170PREGABALIN 57,58PREGABALIN (ONCE-DAILY) 267PreHevbrio 289Premarin 201,202,290Prempro 199PRENAT VIT W/ IRON CARBONYL-FE ASP GLYC-FA-OMEGA FATTY ACID 249PreNata 249Prenatabs Rx 249Prenatal 249Prenatal 19 249PRENATAL MV & MIN W/FE BISGLYC-FE PROTSUCC-FA-CA-OMEGA 3 250PRENATAL MV & MIN W/FE FUMARATE-FA-DHA 250Prenatal Plus Iron 249PRENATAL VIT W/ FERROUS FUMARATE-FOLICACID 249,250PRENATAL VIT W/ IRON CARBONYL-FOLICACID 249Prenatal Vitamin Plus Low Iron 249PRENATAL W/ VIT B2-B6-B12-CHOLECALCIFEROL-FOLIC ACID 250PRENATAL W/O VIT A W/ FE FUMARATE-DSS-FA-DHA 250PRENATAL WITHOUT A VIT W/ FE FUMARATE-FOLIC ACID 249PRENATAL WITHOUT A W/ FE FUMARATE-LMETHYLFOLATE-FA-DHA 250Prepopik 228PreTAB 250PRETOMANID 102Pretomanid 102Prevnar 13 285Prevnar 20 285

Prezcobix 134Prezista 137Priftin 102PRIMAQUINE PHOSPHATE 101Primaquine Phosphate 101PRIMIDONE 58Primsol 36Pro Comfort Pen Needles 237PROBENECID 208PROCARBAZINE HCL 115PROCHLORPERAZINE 130,131PROCHLORPERAZINE MALEATE 131Procrit 223PROGESTERONE 262PROGESTERONE (VAGINAL) 290Prolastin-C 270Promacta 225,226PROMETHAZINE HCL 85PROMETHAZINE W/CODEINE 172PROMETHAZINE-DM 171,172Promethazine-DM 171PROPAFENONE HCL 42PROPRANOLOL & HYDROCHLOROTHIAZIDE 100PROPRANOLOL HCL 145Propranolol HCl 145PROPRANOLOL HCL SUSTAINED-RELEASEBEADS 145Propranolol-HCTZ 100PROPYLTHIOURACIL 273ProQuad 285PROTRIPTYLINE HCL 69PRUCALOPRIDE SUCCINATE 202Prudoxin 176PRUSSIAN BLUE INSOLUBLE (FERRICHEXACYANOFERRATE II) 81PSEUDOEPHED-BROMPHEN-DM 172Pulmicort Flexhaler 49Pulmozyme 271Purixan 104PYRAZINAMIDE 102PYRIDOSTIGMINE BROMIDE 101

PYRIMETHAMINE 101

QQbrelis 93Qinlock 112Quadracel 280Quartette 164QUETIAPINE FUMARATE 129,130QuickVue At-Home Covid-19 Test 187QuickVue SARS Antigen Test 188QuilliChew ER 8Quillivant XR 8QUINAPRIL HCL 93QUINAPRIL-HYDROCHLOROTHIAZIDE 94QUINIDINE GLUCONATE 42QUINIDINE SULFATE 42quiNIDine Sulfate 42QUININE SULFATE 101Qulipta 239Quzyttir 85Qvar 49Qvar RediHaler 50

RRABEPRAZOLE SODIUM 283Radiogardase 81RALOXIFENE HCL 196RALTEGRAVIR POTASSIUM 135,136RAMELTEON 228RAMIPRIL 93RANITIDINE HCL 281RANOLAZINE 38RASAGILINE MESYLATE 122Rasuvo 11,12Rebif 266Rebif Rebidose 266Rebif Rebidose Titration Pack 266Rebif Titration Pack 266Rebinyn 217,218Recombinate 218Recombivax HB 289

Rectiv 35RediTrex 12REGORAFENIB 112Regranex 185Relenza Diskhaler 142Releuko 224,225REPAGLINIDE 75Repatha 90Repatha Pushtronex System 90Repatha SureClick 91Rescriptor 138Restasis 256Restasis Multidose 256Retacrit 223RETAPAMULIN 175Retevmo 113REVEFENACIN 47Revlimid 245,246Rexulti 132Reyataz 137Reyvow 241Rhopressa 257Ribasphere 141Ribasphere RibaPak (1000 Pack) 141Ribasphere Ribapak (1200 Pack) 141Ribasphere RibaPak (800 Pack) 141RIBAVIRIN (HEPATITIS C) 141Ridaura 12RIFABUTIN 102RIFAMPIN 102RIFAPENTINE 102Rifater 101RIFAXIMIN 36RILPIVIRINE HCL 137RILUZOLE 252RiMANTAdine HCl 142RIMANTADINE HYDROCHLORIDE 142RIMEGEPANT SULFATE 239Rinvoq 10RIOCIGUAT 152RIPRETINIB 112

RISANKIZUMAB-RZAA 177,178RISDIPLAM 252RISEDRONATE SODIUM 192RisperDAL Consta 128RISPERIDONE 128,129RisperiDONE 128RISPERIDONE MICROSPHERES 128RITONAVIR 137RIVAROXABAN 52RIVASTIGMINE 263RIVASTIGMINE TARTRATE 263,264Rixubis 218RIZATRIPTAN BENZOATE 241rocklatan 256ROFLUMILAST 48ROLAPITANT HCL 83ROMOSOZUMAB-AQQG 196ROPINIROLE HYDROCHLORIDE 124ROSUVASTATIN CALCIUM 89Rotarix 289RotaTeq 289ROTAVIRUS VACCINE, LIVE ORAL 289ROTAVIRUS VACCINE, LIVE ORALPENTAVALENT 289ROTIGOTINE 123Rozlytrek 114RUFINAMIDE 58Rukobia 135RUXOLITINIB PHOSPHATE 117Ruzurgi 101Rybelsus 74,75

SSACUBITRIL-VALSARTAN 151Safyral 161SALICYLIC ACID 183SALMETEROL XINAFOATE 46SALSALATE 17Sancuso 82Sanofi COVID-19 Vac (Booster) 289Santyl 182

SAPROPTERIN DIHYDROCHLORIDE 196SAQUINAVIR MESYLATE 137SATRALIZUMAB-MWGE 247Savaysa 52Savella 264Savella Titration Pack 264Scemblix 106SCOPOLAMINE 82Seasonique 164SECUKINUMAB 177SEGESTERONE ACETATE-ETHINYL ESTRADIOL 163SELEGILINE 63SELEGILINE HCL 122SELENIUM SULFIDE 178SELEXIPAG 153SELINEXOR 114,115SELPERCATINIB 113SELUMETINIB SULFATE 110Selzentry 135SEMAGLUTIDE 74,75Serevent Diskus 46SERTACONAZOLE NITRATE 183SERTRALINE HCL 65SEVELAMER CARBONATE 206Shingrix 289Signifor 197,198Signifor LAR 198SILDENAFIL CITRATE (PULMONARYHYPERTENSION) 152SILODOSIN 206,207SILVER SULFADIAZINE 179Simbrinza 253Simplicity COVID-19 At-Home 188Simponi 10SIMVASTATIN 89SINECATECHINS 174SIPONIMOD FUMARATE 269SIROLIMUS 247Sirturo 102SITAGLIPTIN PHOSPHATE 71SITAGLIPTIN-METFORMIN HCL 71

Sivextro 37Skyla 165Skyrizi 178Skyrizi (150 MG Dose) 177Skyrizi Pen 178Slynd 166SOAANZ 190SODIUM CHLORIDE (INHALANT) 171SODIUM FLUORIDE 242SODIUM PICOSULFATE-MAGNESIUM OXIDE-ANHYDROUS CITRIC ACID 228SODIUM POLYSTYRENE SULFONATE 247,248SODIUM SULFATE-POTASSIUM SULFATE-MAGNESIUM SULFATE 228SODIUM ZIRCONIUM CYCLOSILICATE 247Sofia SARS Antigen FIA 188Sofia2 SARS Antigen FIA 188SOFOSBUVIR-VELPATASVIR 141Sofosbuvir-Velpatasvir 141SOLIFENACIN SUCCINATE 283,284Soliqua 75SOLRIAMFETOL HCL 5,6SOMATROPIN 194Somavert 193SONIDEGIB PHOSPHATE 109SORAFENIB TOSYLATE 112SOTALOL HCL 145,146SOTALOL HCL (AFIB/AFL) 146SOTORASIB 110Sotylize 146SPACER/AEROSOL-HOLDINGCHAMBERS 237,238,239SPINOSAD 185Spinosad 185Spiriva HandiHaler 46Spiriva Respimat 47SPIRONOLACTONE 190SPIRONOLACTONE & HYDROCHLOROTHIAZIDE189Spravato (56 MG Dose) 63Spravato (84 MG Dose) 63Sprycel 106

SPS 248STAVUDINE 139Stavudine 139Stelara 178Stimate 198Stiolto Respimat 44Stivarga 112Stribild 134Striverdi Respimat 46Sublocade 33Subsys 30,31SUCCIMER 79SUCRALFATE 282SUGAMMADEX SODIUM 81SULCONAZOLE NITRATE 183SULFACETAMIDE SOD-PREDNISOLONE 257SULFACETAMIDE SODIUM (ACNE) 172SULFACETAMIDE SODIUM (OPHTH) 258SULFACETAMIDE SODIUM W/ SULFUR 172,173Sulfacetamide-Prednisolone 257SULFADIAZINE 271sulfADIAZINE 271SULFAMETHOXAZOLE-TRIMETHOPRIM 36Sulfamylon 179SULFASALAZINE 205SULINDAC 15SUMATRIPTAN 241SUMATRIPTAN SUCCINATE 241SUMAtriptan Succinate 241SUNITINIB MALATE 112Sunosi 5,6Suprep Bowel Prep Kit 228Sustol 82SUVOREXANT 227Symax Duotab 281Symbicort 44Symdeko 271Symjepi 291SymlinPen 120 69SymlinPen 60 69Symproic 205

Symtuza 135Synagis 259Synera 185Synjardy 76,77Synjardy XR 77Synthroid 277SYRINGE/NEEDLE (DISP) 12 ML 236SYRINGE/NEEDLE (DISP) 6 ML 236

TTabloid 104Tabrecta 110TACROLIMUS 246,247TACROLIMUS (TOPICAL) 184TADALAFIL 153TADALAFIL (PULMONARY HYPERTENSION) 152Tafinlar 107TAFLUPROST 258Tagrisso 108TALAZOPARIB TOSYLATE 120Taltz 178Talzenna 120TAMOXIFEN CITRATE 103TAMSULOSIN HCL 207TAPENTADOL HCL 27Targretin 185Tasigna 106TAVABOROLE 184Taytulla 162TAZAROTENE 177TAZEMETOSTAT HBR 110Tazorac 177Tazverik 110TBO-FILGRASTIM 224TDVAX 280TEDIZOLID PHOSPHATE 37TEGretol 58,59TEGretol-XR 59TELMISARTAN 98TELMISARTAN-AMLODIPINE 95,96TELMISARTAN-HYDROCHLOROTHIAZIDE 96

TEMAZEPAM 226,227Temixys 135TEMOZOLOMIDE 117Tenivac 280TENOFOVIR DISOPROXIL FUMARATE 139,140Tepmetko 110TEPOTINIB HCL 110TERAZOSIN HCL 99TERBINAFINE HCL 83TERBUTALINE SULFATE 46TERCONAZOLE VAGINAL 290TERIFLUNOMIDE 264TERIPARATIDE (RECOMBINANT) 196Teriparatide (Recombinant) 196TESTOSTERONE 34Testosterone 34TESTOSTERONE CYPIONATE 34Testosterone Cypionate 34TESTOSTERONE ENANTHATE 34,35Testosterone Enanthate 34TETANUS TOXOID-DIPHTHERIA-ACELLULARPERTUSSIS ADSORB (TDAP) 279TETANUS-DIPHTHERIA TOXOIDS (TD) 280Tetanus-Diphtheria Toxoids Td 280TETRABENAZINE 264TETRACYCLINE HCL 273TEZACAFTOR-IVACAFTOR 271TEZEPELUMAB-EKKO 50Tezspire 50THALIDOMIDE 243,244Thalomid 243,244Theo-24 50THEOPHYLLINE 50Theophylline ER 50THIOGUANINE 104THIORIDAZINE HCL 131THIOTHIXENE 133THYROID 273,274,276,277,278,279Thyrolar-1 278Thyrolar-1/2 278Thyrolar-1/4 278

Thyrolar-2 278Thyrolar-3 278TIAGABINE HCL 60,61TICAGRELOR 220TIMOLOL 253TIMOLOL MALEATE 146Timolol Maleate 146TIMOLOL MALEATE (OPHTH) 253TINIDAZOLE 36TIOTROPIUM BROMIDE MONOHYDRATE 46,47TIOTROPIUM BROMIDE-OLODATEROL HCL 44TIPRANAVIR 136Tivicay 136Tivicay PD 136TIVOZANIB HCL 112TIZANIDINE HCL 251Tobi Podhaler 8TobraDex 257TOBRAMYCIN 8Tobramycin 8TOBRAMYCIN (OPHTH) 256TOBRAMYCIN SULFATE 8,9Tobramycin Sulfate 8TOBRAMYCIN-DEXAMETHASONE 257TOCILIZUMAB 12,13TOFACITINIB CITRATE 10,11TOLCAPONE 122TOLMETIN SODIUM 15Tolmetin Sodium 15TOLTERODINE TARTRATE 283,284TOLVAPTAN 197Tolvaptan 197TOPIRAMATE 56,59TOREMIFENE CITRATE 103TORSEMIDE 190Toviaz 284Tradjenta 71TRAMADOL HCL 31,32TraMADol HCl ER 31TraMADol HCl ER (Biphasic) 31TRAMADOL-ACETAMINOPHEN 33

TRAMETINIB DIMETHYL SULFOXIDE 110TRANDOLAPRIL 93TRANDOLAPRIL-VERAPAMIL HCL 91Trandolapril-Verapamil HCl ER 91TRANEXAMIC ACID 226TRANYLCYPROMINE SULFATE 63TRAVOPROST 258TRAZODONE HCL 66Trecator 102Trelegy Ellipta 44Tremfya 178Tresiba 74Tresiba FlexTouch 74TRETINOIN 173,174TRETINOIN (CHEMOTHERAPY) 120Tretinoin (Emollient) 174TRETINOIN (FACIAL WRINKLES) 174TRETINOIN MICROSPHERE 174Trexall 104Tri-Norinyl (28) 167TRIAMCINOLONE ACETONIDE 169TRIAMCINOLONE ACETONIDE (MOUTH) 249TRIAMCINOLONE ACETONIDE (TOPICAL) 182TRIAMTERENE 190TRIAMTERENE & HYDROCHLOROTHIAZIDE 189TRIAZOLAM 227TRIENTINE HCL 244TRIFLUOPERAZINE HCL 131TRIFLURIDINE 256Trifluridine 256TRIFLURIDINE-TIPIRACIL 115TRIHEPTANOIN 252TRIHEXYPHENIDYL HCL 121Trihexyphenidyl HCl 121Trijardy XR 76Trikafta 271TRIMETHOBENZAMIDE HCL 82TRIMETHOPRIM 36Trimethoprim 36TRIMETHOPRIM HCL 36TRIMIPRAMINE MALEATE 69

Trinatal Rx 1 250Trintellix 66Triumeq 135Triumeq PD 135Triveen-Duo DHA 250TROPICAMIDE 254TROSPIUM CHLORIDE 284TRUEplus Lancets 26G 234TRUEplus Lancets 28G 234TRUEplus Lancets 30G 234TRUEplus Lancets 33G 234TRUEplus Safety Lancets 28G 234Trulance 203Trulicity 75Trumenba 285Truseltiq (100MG Daily Dose) 108Truseltiq (125MG Daily Dose) 108Truseltiq (50MG Daily Dose) 109Truseltiq (75MG Daily Dose) 109TUCATINIB 105Tukysa 105Turalio 112Twinrix 286Twirla 162Tyblume 162Tybost 140Tymlos 196TYPHOID VACCINE 285

UUbrelvy 239UBROGEPANT 239Uceris 35,170Udenyca 225Ukoniq 112Ulesfia 185ULIPRISTAL ACETATE 163UltiCare Insulin Safety Syr 237Ultilet Insulin Syringe 237UMBRALISIB TOSYLATE 112UMECLIDINIUM BROMIDE 46

UMECLIDINIUM-VILANTEROL 43UPADACITINIB 10Uptravi 153URSODIOL 203USTEKINUMAB 178

VVALACYCLOVIR HCL 142Valchlor 176VALGANCICLOVIR HCL 140VALPROATE SODIUM 61,62VALPROIC ACID 62VALSARTAN 98VALSARTAN-HYDROCHLOROTHIAZIDE 96,97Valtoco 10 MG Dose 55Valtoco 15 MG Dose 55Valtoco 20 MG Dose 55Valtoco 5 MG Dose 55Valved Holding Chamber 239VANCOMYCIN HCL 37Vandazole 290VANDETANIB 111Vantas 118Vaqta 289VARENICLINE TARTRATE 268Varenicline Tartrate 268VARICELLA VIRUS VACCINE LIVE 289Varivax 289Varubi (180 MG Dose) 83Vascepa 86Vaxelis 280Vaxneuvance 285Veltassa 248VEMURAFENIB 107Venclexta 105VENETOCLAX 105VENLAFAXINE HCL 67Ventavis 151VERAPAMIL HCL 150Veregen 174Verzenio 116

VESIcare LS 284Viberzi 204Victoza 75VIGABATRIN 61Viibryd 66Viibryd Starter Pack 66VILAZODONE HCL 66Vimpat 59Vinate One 250Viread 139,140VISMODEGIB 109Vitafol-OB+DHA 250VitaMedMD One Rx/Quatrefolic 250VitaMedMD RediChew Rx 250Vitathely with Ginger 250Vivitrol 81Vivotif 285Vizimpro 108VOCLOSPORIN 245VORAPAXAR SULFATE 220VORICONAZOLE 84VORINOSTAT 109VORTIOXETINE HBR 66Votrient 113Vraylar 126Vyvanse 5

WWARFARIN SODIUM 51Welireg 109WesTab Plus 250Westhroid 278,279Wide-Seal Diaphragm 60 230Wide-Seal Diaphragm 65 230Wide-Seal Diaphragm 70 230Wide-Seal Diaphragm 75 230Wide-Seal Diaphragm 80 230Wide-Seal Diaphragm 85 230Wide-Seal Diaphragm 90 230Wide-Seal Diaphragm 95 230Wilate 218

WP Thyroid 279

XXalkori 104Xarelto 52Xarelto Starter Pack 52Xcopri 60Xcopri (250 MG Daily Dose) 60Xcopri (350 MG Daily Dose) 60Xeljanz 10,11Xeljanz XR 11Xhance 252Xiaflex 245Xifaxan 36Xigduo XR 77Xiidra 254Xofluza (40 MG Dose) 142Xofluza (80 MG Dose) 143Xolair 45Xolegel 183Xpert Xpress SARS-CoV-2 188Xpovio (100 MG Once Weekly) 114Xpovio (40 MG Once Weekly) 114Xpovio (40 MG Twice Weekly) 114Xpovio (60 MG Once Weekly) 114Xpovio (60 MG Twice Weekly) 114Xpovio (80 MG Once Weekly) 114Xpovio (80 MG Twice Weekly) 115Xtandi 103Xultophy 75Xyntha 218,219Xyntha Solofuse 219

YYasmin 28 162YAZ 162Yupelri 47

ZZAFIRLUKAST 47,48ZALEPLON 227

ZANAMIVIR 142ZANUBRUTINIB 107Zarxio 225Zelapar 122Zelboraf 107Zemaira 270Zenpep 189Zeposia 269Zeposia 7-Day Starter Pack 269Zeposia Starter Kit 269ZIDOVUDINE 139Ziextenzo 225ZILEUTON 43Zimhi 81Zioptan 258ZIPRASIDONE HCL 126Zirgan 256Zoladex 118Zolinza 109ZOLMITRIPTAN 241ZOLPIDEM TARTRATE 227Zonalon 176ZONISAMIDE 59Zontivity 220Zostavax 289ZOSTER VACCINE LIVE 289ZOSTER VACCINE RECOMBINANTADJUVANTED 289Zuplenz 82Zyban 268Zydelig 119Zykadia 104ZyPREXA Relprevv 133

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