2

Blue Care Network Custom Select Drug List

The Blue Care Network of Michigan Custom Select Drug List is a useful reference and educational tool for prescribers,

pharmacists and members.

We regularly update this list with medications approved by the U.S. Food and Drug Administration and reviewed by our

Pharmacy and Therapeutics Committee. The list represents the clinical judgment of Michigan doctors, pharmacists and

other experts in the diagnosis and treatment of disease and the promotion of health. The committee selects medications

based on safety, clinical effectiveness and opportunity for savings.

About this drug list

Use this list to find information about your drug coverage and medication options. It’s divided by chapter into major drug

classes or indications for use. Products approved for more than one use may be included in more than one chapter.

Within each chapter, drugs are identified according to their tier placement. Refer to the “Reading your drug list” section

for details.

We encourage doctors to prescribe preferred medications whenever possible. BCN respects the judgment of dispensing

pharmacists and expects them to contact the prescribing health care professional when a drug or dose may not be

appropriate for a member. We also encourage pharmacists to contact the prescriber to suggest an alternative when a

prescription is written for a nonpreferred or excluded drug.

Coverage and applicable out-of-pocket costs for drugs on this list are based on your drug plan. Not all drugs included in

the list are covered by each member’s plan. Drugs that aren’t listed may not be covered.

Some medications excluded by your pharmacy benefits may be covered under your medical benefits. These are

medications that are generally administered in a doctor’s office under the supervision of appropriate health care

personnel and aren’t normally dispensed for self-administration.

Drugs that aren’t covered

Our goals are to provide you with safe, high-quality prescription drug therapies and keep your medical costs low.

To accomplish this, we don’t cover some high-cost drugs that have comparable therapeutic alternatives with similar

effectiveness, quality and safety, but at a fraction of the cost. For the most recent list of drugs that aren’t covered with

suggested alternatives, refer to Custom Select Drug List Exclusions. If you have a question about a drug that isn’t

covered and doesn’t appear on this list, call the Customer Service number on the back of your BCN member ID card.

Several drugs and drug categories are excluded altogether from coverage under this drug list and are not shown. These

include:

• Brand-name drugs when there’s a generic equivalent available

• Prescription drugs for which there is an over-the-counter equivalent in both strength and dosage form (unless considered preventive by the United States Preventive Services Task Force)

• Over-the-counter medications (unless considered preventive by the U.S. Preventive Services Task Force)

• Lifestyle drugs (such as drugs to treat erectile dysfunction or weight loss)

• Prenatal vitamins

• Drugs used to treat heartburn and acid reflux (except select generic versions)

• Drugs that treat coughs and colds, including most antihistamines

• Drugs used for experimental purposes

• Drugs prescribed for cosmetic purposes

• Products covered as a medical benefit (for example, injectable drugs and vaccines that are usually administered in a doctor’s office)

- Note: All BCN members can get multiple common vaccines at network retail pharmacies. Restrictions may apply.

• Compounded products, with some exceptions

• Replacement prescriptions resulting from loss, theft or mishandling

• Drugs not approved by the FDA

https://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/custom-select-drug-list-alternatives-common-drug-exclusions.pdf

3

Specialty drugs

For more information on specialty drugs, see the Specialty Drug Program Pharmacy Benefit Member Guide.

Specialty drugs are limited to a 30-day supply. Select specialty drugs are managed by the 15-Day Specialty Drug

Limitation Program. Drugs included on this list are limited to a 15-day supply for all fills. Members pay half their usual

out-of-pocket cost for a 15-day supply. For more details, visit bcbsm.com/pharmacy.

Preventive drug coverage

Under the Affordable Care Act, also known as national health care reform, most health care plans must cover certain

preventive services and prescription drugs with no out-of-pocket costs. These drugs will have a “PV1,” “PV2” or “PV3”

listing in the “Notes” column of the drug list.

For a complete list of preventive drugs and coverage requirements, refer to our Preventive Drug Coverage list or visit

bcbsm.com/pharmacy. For information specific to your prescription drug benefits, check your plan documents.

New generics

When a generic version of a brand-name drug becomes available, the generic version is generally added to Tier 1. After

the generic drug is added, the original, brand-name version won’t be covered.

Brand-for-generic substitution

Select brand-name drugs may be covered at a generic copay, and the generic drug will not be covered. These brand-name drugs will be shown without the generic drug and will be listed with a generic copay.

Prescription coverage

For details about your prescription drug benefits, call the Customer Service phone number on the back of your BCN

member ID card. If you have online access, log in to your account at bcbsm.com or the Blue Cross mobile app. You can

also find general information about BCN prescription drug coverage at bcbsm.com/pharmacy.

Vaccines

Select vaccines are covered at pharmacies without out-of-pocket costs for most members whose pharmacies participate

with Blue Cross and are certified to administer vaccines.

https://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/specialty-drug-program-member-guide.pdf

http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/15-day-specialty-drug-list.pdf

http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/15-day-specialty-drug-list.pdf

http://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy.html

http://www.bcbsm.com/preventivedruglist

http://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy.html

http://bcbsm.com/

http://www.bcbsm.com/pharmacy

4

Reading your drug list

This drug list gives you options so you and your doctor can decide your best course of treatment. In this drug list, brand-

name medication names are shown in UPPERCASE (for example, CLOBEX). Generic medication names are shown in

lowercase (for example, clobetasol).

Tier information

Using lower tier or preferred medications can help you lower your out-of-pocket cost. Note: If you have a high-deductible

health plan, the tier cost levels will apply once you meet your deductible. For tiering information specific to your drug

benefit, check your plan documents.

Select drugs in Tier 1a, 1b, 2 or 3 may also be covered with no out-of-pocket costs when health care reform

requirements are met. These drugs will have a “PV1,” “PV2” or “PV3” listing in the “Notes” column of the drug list.

Drug Tier Includes Helpful Tips

Not

covered

Nonformulary This tier includes nonformulary high-cost, FDA-approved, prescription-

only drugs that have comparable therapeutic alternatives with

similar effectiveness, quality and safety, but at a fraction of the cost.

Nonformulary drugs are not covered.

Tier 0 No out-of-pocket costs This tier includes select products that will pay with no out-of-pocket costs.

Tier 0 Preventive

No out-of-pocket costs

This tier includes drugs that are covered with no out-of-pocket costs

when health care reform requirements are met. When health care reform

requirements are not met, the drug is not covered. These drugs are

shown on the drug list with “PV1” next to them.

Tier 1a Preferred generics

Lower generic drug

out-of-pocket costs

This tier includes common, nonspecialty generic and select brand-name

drugs that treat certain chronic diseases. Offering these drugs at the

lowest out-of-pocket costs makes them more accessible to members

and helps to ensure that they take them as prescribed.

Tier 1b Nonpreferred generics

Higher generic drug

out-of-pocket costs

This tier includes nonspecialty generic drugs that aren’t listed in Tier 1a.

The Tier 1b out-of-pocket costs are higher than those for Tier 1a but still

lower than the costs for brand-name drugs.

Tier 2 Preferred brand

Higher nonspecialty

out-of-pocket costs

This tier includes nonspecialty, preferred brand-name drugs. These

drugs are more expensive than generics, and members pay more for

them.

Tier 3 Nonpreferred brand

Highest nonspecialty

out-of-pocket costs

This tier includes nonspecialty, brand-name drugs for which there are

either generic alternatives or more cost-effective, preferred brand-name

drugs available. Members pay more for these nonpreferred brand-

name drugs.

Tier 4 Preferred specialty

Lower specialty-drug

out-of-pocket costs

This tier includes specialty drugs, both generic and brand name, that are

used to treat difficult health conditions. These drugs are generally more

cost-effective than nonpreferred specialty drugs.

Tier 5 Nonpreferred specialty

Higher specialty-drug

out-of-pocket costs

This tier includes nonpreferred brand-name, specialty drugs that are

used to treat difficult health conditions. Members pay a higher amount

for nonpreferred specialty drugs because there are more cost-effective

generic or preferred drugs available.

5

Drug list information

In this drug list, some medications are noted with letters next to them to indicate which ones may have coverage

requirements or limits. Your drug plan determines how these medications may be covered.

AL Age limit – Age restrictions apply.

ABA

Authorized brand alternative – Approved brand medication marketed by either the brand company or

another company without the brand name on its label. Authorized brand alternatives are drugs that are

considered brand-name drugs and don’t have generic equivalents. These drugs are the same as the brand-

name drugs but are not true generic drugs. The respective brand out-of-pocket costs will apply for these

medications. Some authorized brand alternatives may not be covered.

PA Prior authorization – Your doctor is required to give more information to determine coverage.

PV1 Preventive 1 – Covered with no out-of-pocket costs when health care reform requirements are met. When

health care reform requirements are not met, the drug is not covered.

PV2

Preventive 2 – Covered with no out-of-pocket costs when health care reform requirements are met. When

health care reform requirements are not met, coverage and applicable out-of-pocket costs apply, based on

the members’ benefit design.

PV3

Preventive 3 – Covered with no out-of-pocket costs when health care reform requirements are met. When

health care reform requirements are not met, coverage and applicable out-of-pocket costs apply, based on

the members’ benefit design. Additional coverage requirements may apply.

QL Quantity limit – The quantity of medication dispensed at one time is limited.

SP Specialty medication – Specialty medications treat complex health conditions and may require special

handling or administration.

ST Step therapy – Requires you try one or more preferred drugs before a higher-cost medication can be

covered.

15DS 15 Days’ supply – Limits the amount of certain specialty drugs to a 15-day supply to help reduce out-of-pocket

costs and waste.

6

How to fill a prescription

The type of drug you take determines which pharmacy you may use.

• Specialty drugs

- Local retail pharmacy

° Walgreens is our preferred specialty pharmacy. Find a location at walgreens.com/pharmacy/*.

° You can use any retail pharmacy in your applicable network.

- Limited-distribution specialty drugs

° Pharmacy options vary based on the drug. Refer to the Specialty Drug Program Pharmacy Benefit Member

Guide, and search for the drug you take.

- Mail order for home delivery

° AllianceRx Walgreens Prime** Specialty Pharmacy

° Website: alliancerxwp.com*

° Telephone: 1-866-515-1355

• All other drugs

- Local retail pharmacy — More than 2,300 retail pharmacies in Michigan and 65,000 retail pharmacies outside of

Michigan accept your member ID card.

- Mail order for home delivery

° OptumRx®*** home delivery pharmacy

° Telephone: 1-844-642-9087

If you have questions about which mail-order vendor to use, call the Customer Service phone number on the back of

your BCN member ID card or visit bcbsm.com/pharmacy.

* Blue Cross Blue Shield of Michigan doesn’t own or control this website.

** AllianceRx Walgreens Prime® is an independent company that provides specialty pharmacy benefit management services for Blue Cross Blue Shield of Michigan.

*** OptumRx® is an independent company that provides home delivery and other pharmacy benefit management services for Blue Cross Blue Shield of Michigan.

http://walgreens.com/pharmacy/



http://alliancerxwp.com/

http://bcbsm.com/pharmacy

7

How prior authorization, step therapy and quantity limits work

Prior authorization

Prior authorization may be necessary for coverage of certain medications. In these cases, the member must meet clinical

criteria or additional information must be provided before coverage is approved. Clinical criteria are based on current

medical information and approved by our Pharmacy and Therapeutics Committee.

Step therapy

Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage

is approved.

For a current list of drugs requiring prior authorization or step therapy, see the Prior Authorization and Step Therapy

Coverage Criteria and refer to the column labeled Blue Care Network Custom Select Drug List.

Quantity limits

For certain medications, BCN limits the quantity that can be dispensed per fill. BCN sets quantity limits based on clinical

appropriateness and manufacturer-recommended dosing for select drugs.

For a current list of drugs that have limits on the quantity that can be dispensed per fill, please see the Quantity Limit

Program, and refer to the Blue Care Network Custom Select Drug List.

How to request authorization

Consult your prescription drug benefit packet for information on how to get prior authorization or request reviews for

coverage of drugs that aren’t included in your plan. You can also call the Customer Service number on the back of your

BCN member ID card for more information.

• To request coverage of a drug: Fill out the Coverage Request Form online at bcbsm.com.

• Write to:

Pharmacy Services — Mail Code 512C

Blue Cross Blue Shield of Michigan

600 E. Lafayette Blvd.

Detroit, MI 48226-2998

Doctors can request authorization for you. We’ll notify the doctor of approved requests and process the claim accordingly.

If a request isn’t approved, we’ll notify you and the doctor in writing. The notification includes the reason for the denial, an

explanation of your appeal rights and the appeals process.

Doctors can request authorization one of four ways:

• Electronic prior authorization: Doctors can use their electronic health record or CoverMyMeds® to submit electronic

prior authorization requests for commercial pharmacy members.

• Call: 1-800-437-3803

• Fax: 1-866-601-4425

• Write:

Pharmacy Services — Mail Code 512C




https://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/prior-authorization-and-step-therapy-guidelines.pdf

https://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/prior-authorization-and-step-therapy-guidelines.pdf

http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/quantity-limit-program-drug-list.pdf

http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/quantity-limit-program-drug-list.pdf

http://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy/why-do-i-need-prior-authorization-for-prescription-drug/expedited-request-form.html

8

This document is current at the time of publication and subject to change. Go to bcbsm.com/pharmacy and click

on Drug Lists for the most up-to-date information about this drug list.

This content was developed to comply with applicable federal and state regulations. To learn more about your plan, go

to bcbsm.com and type “How Health Insurance Works” in the search field.

Send us your feedback

Please send your comments and suggestions about this list to:

Drug Information Services – Mail Code 512C




http://www.bcbsm.com/pharmacy

http://www.bcbsm.com/

http://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works.html

BCN Custom Select Drug List - February 2022

Table of Contents

Analgesics ....................................................................................................................................................... 10Anesthetics ...................................................................................................................................................... 15Anti-Addiction/Substance Abuse Treatment Agents ...................................................................................16Antibacterials ...................................................................................................................................................17Anticonvulsants .............................................................................................................................................. 20Antidementia Agents ...................................................................................................................................... 22Antidepressants .............................................................................................................................................. 23Antiemetics ...................................................................................................................................................... 25Antifungals .......................................................................................................................................................25Antigout Agents .............................................................................................................................................. 27Antimigraine Agents ....................................................................................................................................... 27Antimyasthenic Agents .................................................................................................................................. 28Antimycobacterials ......................................................................................................................................... 28Antineoplastics ................................................................................................................................................29Antiparasitics ...................................................................................................................................................34Antiparkinson Agents ..................................................................................................................................... 34Antipsychotics .................................................................................................................................................36Antivirals .......................................................................................................................................................... 37Anxiolytics ....................................................................................................................................................... 41Bipolar Agents .................................................................................................................................................41Blood Glucose Monitoring ............................................................................................................................. 41Blood Glucose Regulators ............................................................................................................................. 44Blood Products and Modifiers ....................................................................................................................... 47Cardiovascular Agents ................................................................................................................................... 50Central Nervous System Agents ....................................................................................................................57Cholestatic Pruritus Agent ............................................................................................................................. 59Dental and Oral Agents ...................................................................................................................................59Dermatological Agents ................................................................................................................................... 60Electrolytes/Minerals/Metals/Vitamins .......................................................................................................... 64Gastrointestinal Agents ..................................................................................................................................66Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ............................................................ 70Genitourinary Agents ......................................................................................................................................71Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) ................................................................73Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) ...............................................................76Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) ................................................... 77Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) ................................... 77Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) ................................................................ 85Hormonal Agents, Suppressant (Adrenal) ....................................................................................................85Hormonal Agents, Suppressant (Pituitary) ...................................................................................................85Hormonal Agents, Suppressant (Thyroid) .................................................................................................... 86Immunological Agents ....................................................................................................................................86Inflammatory Bowel Disease Agents ............................................................................................................ 90Metabolic Bone Disease Agents .................................................................................................................... 91Miscellaneous Therapeutic Agents ............................................................................................................... 91Ophthalmic Agents ......................................................................................................................................... 93Otic Agents ...................................................................................................................................................... 97Respiratory Tract/Pulmonary Agents ............................................................................................................97Skeletal Muscle Relaxants ............................................................................................................................102Sleep Disorder Agents ..................................................................................................................................103

9

Drug Name Brand Reference Drug Tier Notes

Analgesics

Nonsteroidal Anti-inflammatory Drugs

adult aspirin regimen Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)

aspirin adult low dose Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)

aspirin adult low strength Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)

aspirin childrens Bayer Low Dose 0PV1; AL (Min 10 Years and Max 79 Years)

aspirin ec low dose Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)

aspirin ec low strength Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)

aspirin ec oral tablet delayed release 325 mg

Bayer Aspirin 0PV1; AL (Min 10 Years and Max 79 Years)

aspirin low dose Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)

aspirin oral tabletBayer Advanced Aspirin Reg St

0PV1; AL (Min 10 Years and Max 79 Years)

aspirin oral tablet delayed release Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)

celecoxib oral CeleBREX 1b

DICLOFENAC CAP 35MG Not covered QL

DICLOFENAC PATCH 1.3% Not covered ABA; QL

diclofenac potassium oral tablet 25 mg Lofena Not covered

diclofenac potassium oral tablet 50 mg Cataflam 1b

diclofenac sodium er 1b

diclofenac sodium external gel 1 %Aspercreme Arthritis Pain

1b QL

diclofenac sodium external solution Not covered

diclofenac sodium oral 1a


10


diclofenac-misoprostol Arthrotec 1b

diflunisal oral 1b

ec-naproxen EC-Naprosyn 1a

etodolac Lodine 1b

etodolac er 1b

fenoprofen calcium oral capsule Fenortho Not covered QL

fenoprofen calcium oral tablet Nalfon 1b PA; QL

fenortho Fenortho Not covered QL

FLECTOR Not covered QL

flurbiprofen oral 1b

goodsense aspirin adultsBayer Advanced Aspirin Reg St

0PV1; AL (Min 10 Years and Max 79 Years)

goodsense aspirin low dose Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)

ibuprofen oral suspension 100 mg/5ml Childrens Advil 1a

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

IBUPROFEN 1a

ibuprofen-famotidine Duexis 1b PA; QL

INDOCIN ORAL Not covered

INDOCIN RECTAL 3 QL

indomethacin er 1b

INDOMETHACIN ORAL CAPSULE 20 MG

Not covered QL

indomethacin oral capsule 25 mg, 50 mg 1b

ketoprofen er 1b

ketoprofen oral capsule 25 mg 1b PA; QL

ketoprofen oral capsule 50 mg, 75 mg 1b

ketorolac tromethamine injection 1b

ketorolac tromethamine intramuscular 1b

KETOROLAC TROMETHAMINE NASAL Not covered ABA; QL

ketorolac tromethamine oral 1b QL

LICART Not covered QL

meclofenamate sodium oral 1b

mefenamic acid oral 1b

meloxicam oral capsule Vivlodex Not covered QL

meloxicam oral tablet Mobic 1a


11


nabumetone oral Relafen 1b

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

Not covered

naproxen oral suspension Naprosyn 1b

naproxen oral tablet Naprosyn 1a

naproxen oral tablet delayed release EC-Naprosyn 1a

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

Naprelan Not covered

NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

Not covered ABA

naproxen sodium oral tablet 275 mg 1a

naproxen sodium oral tablet 550 mg Anaprox DS 1a

naproxen-esomeprazole Vimovo Not covered QL

oxaprozin Daypro 1b

PENNSAID Not covered QL

piroxicam oral Feldene 1b

RELAFEN DS Not covered

salsalate oral 1b

SPRIX Not covered QL

sulindac oral 1b

TIVORBEX Not covered QL

ZIPSOR Not covered QL

ZORVOLEX Not covered QL

Opioid Analgesics, Long-acting

BELBUCA Not covered QL

buprenorphine Butrans 1b QL

CONZIP Not covered

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1b QL

fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

Not covered QL

hydrocodone bitartrate er oral capsule extended release 12 hour

1b PA; QL

hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent

Hysingla ER Not covered QL

hydromorphone hcl er Not covered QL

levorphanol tartrate oral 1b PA; QL


12


methadone hcl intensol Methadone HCl Intensol 1b

methadone hcl oral Methadone HCl Intensol 1b

methadose oral concentrate 10 mg/ml Methadone HCl Intensol 1b

methadose oral tablet soluble Methadose 1b

methadose sugar-free Methadone HCl Intensol 1b

morphine sulfate er beads Not covered QL

morphine sulfate er oral capsule extended release 24 hour

Not covered QL

morphine sulfate er oral tablet extended release

MS Contin 1b QL

NUCYNTA ER 3 PA; QL

OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG, 30 MG, 60 MG, 80 MG

Not covered ABA; QL

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG ORAL

Not covered QL


Not covered ABA; QL


Not covered QL


Not covered ABA; QL


Not covered QL


Not covered ABA; QL

OXYCONTIN Not covered QL

oxymorphone hcl er 1b PA; QL

QDOLO Not covered QL

tramadol hcl er (biphasic) 1b

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Not covered ABA

tramadol hcl er oral tablet extended release 24 hour

1b

XTAMPZA ER 2 PA; QL


13


Opioid Analgesics, Short-acting

acetaminophen-codeine 1b

acetaminophen-codeine #2 1b



ALLZITAL Not covered

APADAZ Not covered QL

apap-caff-dihydrocodeine oral capsule Trezix 1b

apap-caff-dihydrocodeine oral tablet Not covered

ascomp-codeine Ascomp-Codeine 1b

bac Bac 1b

BENZHYDROCODONE-ACETAMINOPHEN

Not covered ABA; QL

butalbital-acetaminophen capsule 50-300 mg oral

Not covered

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL

Not covered

butalbital-acetaminophen oral tablet 25-325 mg

Allzital Not covered


Bupap Not covered


Tencon 1b

butalbital-apap-caff-cod Fioricet/Codeine 1b

butalbital-apap-caffeine Bac 1b

butalbital-asa-caff-codeine Ascomp-Codeine 1b

butalbital-aspirin-caffeine 1b

butorphanol tartrate nasal 1b

carisoprodol-aspirin-codeine Not covered

codeine sulfate 1b

endocet Endocet 1b

fentanyl citrate buccal lozenge on a handle

Actiq 1b PA; QL

FENTANYL CITRATE BUCCAL TABLET Not covered ABA; QL

FENTORA Not covered QL

hydrocodone-acetaminophen Xodol 1b

hydrocodone-ibuprofen 1b

hydromorphone hcl oral Dilaudid 1b

hydromorphone hcl rectal 1b


14


LAZANDA Not covered QL

LORTAB Not covered

meperidine hcl oral 1b

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

1b

morphine sulfate oral 1b

morphine sulfate rectal 1b

nalbuphine hcl injection 1b

NALOCET Not covered

NUCYNTA 3 PA; QL

OXAYDO Not covered QL

oxycodone hcl oral capsule 1b QL

oxycodone hcl oral concentrate 100 mg/5ml

1b QL

oxycodone hcl oral solution 1b QL

oxycodone hcl oral tablet Oxaydo 1b QL

OXYCODONE-ACETAMINOPHEN ORAL SOLUTION

Not covered

OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 2.5-300 MG, 5-300 MG, 7.5-300 MG

Not covered

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Endocet 1b

oxymorphone hcl 1b QL

pentazocine-naloxone hcl 1b

PROLATE Not covered

SUBSYS Not covered QL

TENCON Not covered

tramadol hcl ir Ultram 1b

tramadol-acetaminophen Ultracet 1b

VTOL LQ Not covered

Anesthetics

Local Anesthetics

glydo Glydo 1b

lidocaine external patch 5 % Lidoderm Not covered

lidocaine hcl external solution 1b

lidocaine hcl mouth/throat 1b


15


lidocaine hcl urethral/mucosal external prefilled syringe

Glydo 1b

LIDOCAINE HCL-TETRACAINE HCL Not covered

lidocaine viscous hcl 1b

lidocaine-prilocaine external cream 1b

PLIAGLIS EXTERNAL CREAM Not covered

ZTLIDO Not covered QL

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium 1b

disulfiram oral 1b

naltrexone hcl oral 1b

Opioid Dependence Treatments

buprenorphine hcl sublingual 1b QL

buprenorphine hcl-naloxone hcl Suboxone 1b QL

LUCEMYRA 2 QL

ZUBSOLV 2 QL

Opioid Reversal Agents

KLOXXADO 2 QL

naloxone hcl injection 1b

naloxone hcl liquid 4 mg/0.1ml nasal Narcan 1a QL

NALOXONE HCL LIQUID 4 MG/0.1ML NASAL

2 QL

Smoking Cessation Agents

APO-VARENICLINE 2PV2; QL; AL (Min 18 Years)

bupropion hcl er (smoking det) 1bPV2; QL; AL (Min 18 Years)

goodsense nicotine mouth/throat lozenge 4 mg

KLS Quit4 0PV1; QL; AL (Min 18 Years)

habitrol Habitrol 0PV1; QL; AL (Min 18 Years)

nicotine polacrilex mini KLS Quit2 0PV1; QL; AL (Min 18 Years)

nicotine polacrilex mouth/throat KLS Quit2 0PV1; QL; AL (Min 18 Years)

nicotine step 1 Habitrol 0PV1; QL; AL (Min 18 Years)


16


nicotine step 2 Nicoderm CQ 0PV1; QL; AL (Min 18 Years)

nicotine step 3 Nicoderm CQ 0PV1; QL; AL (Min 18 Years)

nicotine transdermal kit 0PV1; QL; AL (Min 18 Years)

NICOTROL 3PV2; QL; AL (Min 18 Years)

NICOTROL NS 3PV2; QL; AL (Min 18 Years)

varenicline tartrate 1bPV2; QL; AL (Min 18 Years)

Antibacterials

Aminoglycosides

ARIKAYCE 4 PA; SP; QL

gentamicin sulfate external 1b

neomycin sulfate oral 1b

paromomycin sulfate oral Humatin 1b

Antibacterials, Other

AEMCOLO Not covered QL

ALTABAX Not covered

CLEOCIN VAGINAL SUPPOSITORY 3

clindamycin hcl oral Cleocin 1b

clindamycin palmitate hcl Cleocin 1b

clindamycin phosphate vaginal Cleocin 1b

CLINDESSE 3

FIRVANQ 3 QL

fosfomycin tromethamine Monurol 1b

linezolid oral Zyvox 1b

mafenide acetate external Sulfamylon Not covered

methenamine hippurate Hiprex 1b

metronidazole oral Flagyl 1b

metronidazole vaginal Vandazole 1b

mupirocin calcium Not covered

mupirocin external Centany 1b

NEO-SYNALAR EXTERNAL CREAM Not covered

nitrofurantoin 1b

nitrofurantoin macrocrystal Macrodantin 1b


17


nitrofurantoin monohydrate macrocrystals

Macrobid 1b

NUVESSA Not covered

silver sulfadiazine external SSD 1b

SIVEXTRO ORAL 2 QL

SOLOSEC Not covered QL

ssd SSD 1b

SULFAMYLON EXTERNAL CREAM Not covered

tinidazole oral 1b QL

trimethoprim oral 1b

vancomycin hcl oral capsule Vancocin 1b

vancomycin hcl oral solution reconstituted

Firvanq 1b QL

vandazole Vandazole 1b

XENLETA ORAL 3 QL

XEPI Not covered QL

XIFAXAN ORAL TABLET 200 MG 3 QL

XIFAXAN ORAL TABLET 550 MG 3 PA; QL

Beta-lactam, Cephalosporins

cefaclor 1b

cefaclor er 1b

cefadroxil 1b

cefdinir 1b

cefixime Suprax 1b

cefpodoxime proxetil 1b

cefprozil 1b

cefuroxime axetil 1b

cephalexin 1b

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 500 MG/5ML

3

SUPRAX ORAL TABLET CHEWABLE 3

Beta-lactam, Penicillins

amoxicillin 1b

amoxicillin-potassium clavulanate Augmentin 1b

amoxicillin-potassium clavulanate er 1b

ampicillin 1b

dicloxacillin sodium 1b


18


penicillin v potassium 1b

Macrolides

azithromycin oral Zithromax 1b

clarithromycin er 1b

clarithromycin oral 1b

DIFICID 3 QL

E.E.S. 400 Not covered

ERYTHROCIN STEARATE Not covered

erythromycin base Ery-Tab 1b

erythromycin ethylsuccinate oral E.E.S. 400 1b

erythromycin oral Ery-Tab 1b

Quinolones

BAXDELA ORAL 3

CIPRO ORAL SUSPENSION RECONSTITUTED

3

ciprofloxacin hcl oral Cipro 1b

levofloxacin oral Levaquin 1b

moxifloxacin hcl oral 1b

ofloxacin oral 1b

Sulfonamides

sulfadiazine oral 1b

sulfamethoxazole-trimethoprim oral Bactrim 1b

sulfatrim pediatric Sulfatrim Pediatric 1b

Tetracyclines

avidoxy 1a

coremino CoreMino Not covered

demeclocycline hcl 1b

DORYX MPC Not covered

DORYX ORAL TABLET DELAYED RELEASE 80 MG

Not covered

doxycycline hyclate oral capsule Vibramycin 1a

doxycycline hyclate oral tablet 100 mg Lymepak 1a

doxycycline hyclate oral tablet 150 mg Acticlate Not covered QL

doxycycline hyclate oral tablet 20 mg 1a

doxycycline hyclate oral tablet 50 mg TargaDOX Not covered

doxycycline hyclate oral tablet 75 mg Acticlate Not covered

doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 75 mg

Not covered


19


doxycycline hyclate oral tablet delayed release 200 mg, 50 mg

Doryx Not covered

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

Not covered ABA

doxycycline monohydrate oral capsule 100 mg

Mondoxyne NL 1a

doxycycline monohydrate oral capsule 150 mg

Not covered

doxycycline monohydrate oral capsule 50 mg, 75 mg

1a

doxycycline monohydrate oral suspension reconstituted

Vibramycin 1b

doxycycline monohydrate oral tablet 1a

LYMEPAK Not covered

MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Not covered

minocycline hcl er oral tablet extended release 24 hour

CoreMino Not covered

minocycline hcl oral Minocin 1a

MINOLIRA Not covered

mondoxyne nl Mondoxyne NL 1a

NUZYRA ORAL 3 QL

SEYSARA Not covered

tetracycline hcl oral 1b

VIBRAMYCIN ORAL SYRUP 3

XIMINO Not covered

Anticonvulsants

Anticonvulsants, Other

BRIVIACT ORAL 3 PA; QL

ELEPSIA XR Not covered QL

EPIDIOLEX 5 PA; SP; QL

FINTEPLA 5 PA; SP; QL

levetiracetam er Keppra XR 1a

levetiracetam oral Keppra 1a

roweepra Roweepra 1a

SPRITAM Not covered QL

Calcium Channel Modifying Agents

CELONTIN 3


20


ethosuximide oral Zarontin 1b

zonisamide oral Zonegran 1a

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clobazam Onfi 1b QL

DIACOMIT 5 PA; SP; QL

diazepam rectal Diastat AcuDial 1b

gabapentin oral Neurontin 1a

NAYZILAM 2 QL

phenobarbital oral 1b

primidone oral Mysoline 1b

SYMPAZAN Not covered QL

tiagabine hcl Gabitril 1b

valproic acid oral 1a

VALTOCO 2 QL

vigabatrin Sabril 4 PA; SP; QL

vigadrone Vigadrone 4 PA; SP; QL

XCOPRI 3 PA; QL

Glutamate Reducing Agents

EPRONTIA 3 PA; QL

felbamate Felbatol 1b

FYCOMPA 3 QL

LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 42 X 50 MG & 14X100 MG

3

LAMICTAL XR ORAL KIT 3

lamotrigine er LaMICtal XR 1b

lamotrigine oral kit LaMICtal ODT 1b

lamotrigine oral tablet Subvenite 1a

lamotrigine oral tablet chewable LaMICtal 1a

lamotrigine oral tablet dispersible LaMICtal ODT 1b

lamotrigine starter kit-blueSubvenite Starter Kit-Blue

1b

lamotrigine starter kit-greenSubvenite Starter Kit-Green

1b

lamotrigine starter kit-orangeSubvenite Starter Kit-Orange

1b

subvenite Subvenite 1a


21


subvenite starter kit-blueSubvenite Starter Kit-Blue

1b

subvenite starter kit-greenSubvenite Starter Kit-Green

1b

subvenite starter kit-orangeSubvenite Starter Kit-Orange

1b

topiramate er Qudexy XR Not covered QL

topiramate oral Topamax 1a

TROKENDI XR Not covered QL

Sodium Channel Agents

APTIOM Not covered QL

carbamazepine er Carbatrol 1b

carbamazepine oral Epitol 1a

DILANTIN ORAL CAPSULE 30 MG 2

epitol Epitol 1a

oxcarbazepine oral suspension Trileptal 1b

oxcarbazepine oral tablet Trileptal 1a

OXTELLAR XR Not covered QL

phenytoin infatabs Phenytoin Infatabs 1a

phenytoin oral suspension 125 mg/5ml Dilantin 1a

phenytoin oral tablet chewable Phenytoin Infatabs 1a

phenytoin sodium extended Dilantin 1a

rufinamide oral suspension Banzel 1b

rufinamide oral tablet Banzel 1b PA; QL

VIMPAT ORAL SOLUTION 2

VIMPAT ORAL TABLET 2 PA; QL

Antidementia Agents

Antidementia Agents, Other

NAMZARIC Not covered QL

Cholinesterase Inhibitors

donepezil hcl oral tablet 10 mg, 5 mg Aricept 1a

donepezil hcl oral tablet 23 mg Aricept Not covered QL

donepezil hcl oral tablet dispersible 1a

galantamine hydrobromide 1b

galantamine hydrobromide er Razadyne ER 1b

rivastigmine Exelon 1b

rivastigmine tartrate 1b


22


N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl er Namenda XR 1b QL

memantine hcl oral solution 2 mg/ml 1a

memantine hcl oral tablet 10 mg, 5 mg 1a

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg

Namenda Titration Pak 1b QL

Antidepressants

Antidepressants, Other

APLENZIN Not covered

bupropion hcl er (sr) Wellbutrin SR 1a

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

Wellbutrin XL 1a

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

Not covered ABA; QL

bupropion hcl oral 1a

chlordiazepoxide-amitriptyline 1b

FORFIVO XL Not covered QL

LYBALVI 3 ST; QL

mirtazapine oral Remeron 1a

olanzapine-fluoxetine hcl Symbyax 1b

perphenazine-amitriptyline 1b

Monoamine Oxidase Inhibitors

EMSAM 3 PA; QL

MARPLAN 3

phenelzine sulfate oral Nardil 1b

tranylcypromine sulfate Parnate 1b

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)

citalopram hydrobromide CeleXA 1a

DESVENLAFAXINE ER Not covered QL

desvenlafaxine succinate er Pristiq 1a QL

DRIZALMA SPRINKLE Not covered QL

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

Cymbalta 1a

duloxetine hcl oral capsule delayed release particles 40 mg

Not covered


23


escitalopram oxalate Lexapro 1a

FETZIMA Not covered QL

FETZIMA TITRATION Not covered QL

fluoxetine hcl (pmdd) 1a

fluoxetine hcl oral capsule PROzac 1a

fluoxetine hcl oral capsule delayed release

1a

fluoxetine hcl oral solution 1a

fluoxetine hcl oral tablet 10 mg, 20 mg 1a

fluoxetine hcl oral tablet 60 mg 1b

fluvoxamine maleate 1a

fluvoxamine maleate er 1b

nefazodone hcl 1b

paroxetine hcl er Paxil CR 1b

paroxetine hcl oral suspension Paxil 1b

paroxetine hcl oral tablet Paxil 1a

paroxetine mesylate Brisdelle Not covered QL

PEXEVA 3 ST; QL

SERTRALINE HCL ORAL CAPSULE Not covered QL

sertraline hcl oral concentrate Zoloft 1a

sertraline hcl oral tablet Zoloft 1a

trazodone hcl oral 1a

TRINTELLIX 3 ST; QL

venlafaxine hcl 1a

venlafaxine hcl er oral capsule extended release 24 hour

Effexor XR 1a

venlafaxine hcl er oral tablet extended release 24 hour

1b

VIIBRYD 3 ST; QL

VIIBRYD STARTER PACK 3 ST; QL

Tricyclics

amitriptyline hcl oral 1a

amoxapine 1a

clomipramine hcl oral Anafranil 1b

desipramine hcl oral Norpramin 1b

doxepin hcl oral capsule 1a

doxepin hcl oral concentrate 1a

imipramine hcl oral 1a


24


imipramine pamoate 1b

nortriptyline hcl oral Pamelor 1a

protriptyline hcl 1b

trimipramine maleate oral 1b

Antiemetics

Antiemetics, Other

ANTIVERT ORAL TABLET Not covered

BONJESTA Not covered QL

compro Compro 1b

doxylamine-pyridoxine Diclegis Not covered QL

GIMOTI Not covered QL

meclizine hcl oral tablet Travel-Ease Not covered

metoclopramide hcl oral solution 1b

metoclopramide hcl oral tablet Reglan 1b

metoclopramide hcl oral tablet dispersible

Not covered

perphenazine oral 1a

prochlorperazine Compro 1b

prochlorperazine maleate oral 1b

scopolamine Transderm-Scop 1b

trimethobenzamide hcl oral 1b

Emetogenic Therapy Adjuncts

AKYNZEO ORAL 3 PA; QL

aprepitant Emend 1b QL

dronabinol Marinol 1b

EMEND ORAL SUSPENSION RECONSTITUTED

2 QL

granisetron hcl oral 1b QL

ondansetron hcl oral solution 1b

ondansetron hcl oral tablet 1b QL

ondansetron odt 1b QL

SANCUSO 3 PA; QL

SYNDROS Not covered

VARUBI (180 MG DOSE) 3 PA; QL

ZUPLENZ Not covered

Antifungals

BREXAFEMME Not covered QL


25


ciclodan Ciclodan 1b

ciclopirox external Ciclodan 1b

ciclopirox olamine external Loprox 1b

clotrimazole external Desenex 1b

clotrimazole mouth/throat 1b

clotrimazole-betamethasone 1b

CRESEMBA ORAL 2 QL

econazole nitrate external 1b

ECOZA Not covered QL

ERTACZO Not covered

EXELDERM 3

fluconazole oral Diflucan 1b

flucytosine oral Ancobon 1b

griseofulvin microsize oral 1b

griseofulvin ultramicrosize 1b

GYNAZOLE-1 3

itraconazole oral Sporanox 1b

JUBLIA Not covered QL

ketoconazole external Ketodan 1b

ketoconazole oral 1b

ketodan external foam Ketodan 1b

LULICONAZOLE Not covered QL

LUZU Not covered QL

MENTAX Not covered

miconazole 3 1b

MICONAZOLE-ZINC OXIDE-PETROLAT Not covered ABA; QL

naftifine hcl Naftin Not covered QL

NAFTIN EXTERNAL GEL 2 % Not covered QL

NOXAFIL ORAL SUSPENSION 2

nyamyc Nyamyc 1b

nystatin external Nyamyc 1b

nystatin mouth/throat 1b

nystatin oral 1b

nystatin-triamcinolone 1b

nystop Nyamyc 1b

ORAVIG Not covered QL

oxiconazole nitrate Oxistat Not covered QL


26


OXISTAT EXTERNAL LOTION Not covered QL

posaconazole Noxafil 1b QL

SULCONAZOLE NITRATE 3

tavaborole Kerydin Not covered QL

terbinafine hcl oral 1b

terconazole 1b

TOLSURA Not covered

voriconazole oral Vfend 1b

VUSION Not covered QL

XOLEGEL Not covered QL

Antigout Agents

allopurinol oral Zyloprim 1b

COLCHICINE ORAL CAPSULE Not covered

colchicine oral tablet Colcrys 1b

colchicine-probenecid 1b

febuxostat Uloric 1b ST; QL

GLOPERBA Not covered QL

MITIGARE Not covered

probenecid 1b

Antimigraine Agents

CAMBIA Not covered QL

Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML

2 PA; QL

AJOVY 3 PA; QL

EMGALITY 2 PA; QL

EMGALITY (300 MG DOSE) 2 PA; QL

NURTEC 2 PA; QL

UBRELVY 2 PA; QL

Ergot Alkaloids

dihydroergotamine mesylate injection D.H.E. 45 1b QL

dihydroergotamine mesylate nasal Migranal Not covered QL

ERGOMAR Not covered QL

ergotamine-caffeine Cafergot 1b QL

MIGERGOT Not covered QL


27


TRUDHESA Not covered QL

Serotonin (5-HT) Receptor Agonists

almotriptan malate 1b ST; QL

eletriptan hydrobromide Relpax 1b ST; QL

frovatriptan succinate Frova 1b ST; QL

naratriptan hcl Amerge 1b QL

ONZETRA XSAIL Not covered QL

REYVOW 3 PA; QL

rizatriptan benzoate Maxalt 1b QL

sumatriptan nasal Imitrex 1b QL

sumatriptan succinate oral Imitrex 1b QL

sumatriptan succinate refill Imitrex STATdose Refill 1b QL

sumatriptan succinate subcutaneous solution

1b

sumatriptan succinate subcutaneous solution auto-injector

Imitrex STATdose System

1b QL

sumatriptan-naproxen sodium Treximet Not covered QL

TOSYMRA Not covered QL

ZEMBRACE SYMTOUCH Not covered QL

ZOLMITRIPTAN NASAL SOLUTION 2.5 MG

3 ST; ABA; QL

zolmitriptan nasal solution 5 mg Zomig 1b ST; QL

zolmitriptan oral Zomig 1b QL

ZOMIG NASAL SOLUTION 2.5 MG 3 ST; QL

Antimyasthenic Agents

Parasympathomimetics

pyridostigmine bromide er Mestinon 1b

pyridostigmine bromide oral solution Mestinon 1b

pyridostigmine bromide oral tablet 30 mg Not covered

pyridostigmine bromide oral tablet 60 mg Mestinon 1b

Antimycobacterials

Antimycobacterials, Other

dapsone oral 1b

rifabutin Mycobutin 1b

Antituberculars

cycloserine oral 1b

ethambutol hcl oral Myambutol 1b


28


isoniazid oral 1b

PASER 3

PRETOMANID 2 QL

PRIFTIN 3

pyrazinamide oral 1b

rifampin oral 1b

SIRTURO 2 PA; QL

TRECATOR 3

Antineoplastics

Alkylating Agents

cyclophosphamide oral capsule 1b

CYCLOPHOSPHAMIDE ORAL TABLET 25 MG

3 ABA

CYCLOPHOSPHAMIDE ORAL TABLET 50 MG

3

GLEOSTINE 2

LEUKERAN 2

MATULANE 4 SP

melphalan Alkeran 1b

MYLERAN 2

temozolomide Temodar 4 SP

VALCHLOR 5 PA; SP; QL

Antiandrogens

abiraterone acetate oral tablet 250 mg Zytiga 4 SP; QL

abiraterone acetate oral tablet 500 mg Zytiga Not covered SP; QL

bicalutamide Casodex 1b

ERLEADA 4 PA; SP; QL

nilutamide Nilandron 1b PA; QL

NUBEQA 4 PA; 15DS; SP; QL

ORGOVYX 5 PA; SP; QL

XTANDI 4 PA; 15DS; SP; QL

YONSA Not covered SP; QL

Antiangiogenic Agents

POMALYST 5 PA; SP; QL

REVLIMID 5 SP; QL

THALOMID 4 SP


29


Antiestrogens/Modifiers

EMCYT 2

fulvestrant Faslodex 1b

SOLTAMOX 3

tamoxifen citrate oral 1a PV3; QL

toremifene citrate Fareston 1b

Antimetabolites

capecitabine Xeloda 4 SP

DROXIA 2

hydroxyurea oral Hydrea 1a

mercaptopurine oral 1b

PURIXAN 5 SP

SIKLOS 3 PA

TABLOID 2

Antineoplastics, Other

BESREMI 4 PA; 15DS; SP; QL

CARAC Not covered QL

COPIKTRA 4 PA; SP; QL

diclofenac sodium external gel 3 % 1b PA; QL

FLUOROPLEX 3

FLUOROURACIL EXTERNAL CREAM 0.5 %

Not covered ABA; QL

fluorouracil external cream 5 % Efudex 1b

fluorouracil external solution 1b

INREBIC 5 PA; 15DS; SP; QL

KISQALI ORAL TABLET THERAPY PACK 200 MG

4 PA; SP; QL

KLISYRI 3 PA; QL

leucovorin calcium oral 1b

LONSURF 4 PA; SP; QL

LUMAKRAS 4 PA; 15DS; SP; QL

NINLARO 4 PA; SP; QL

ONUREG 4 PA; SP; QL

PIQRAY 4 PA; SP; QL

ROZLYTREK 4 PA; 15DS; SP; QL

RYLAZE Not covered

SYNRIBO 4 PA; SP; QL


30


TAZVERIK 4 PA; 15DS; SP; QL

VERZENIO 4 PA; 15DS; SP; QL

WELIREG 4 PA; 15DS; SP; QL

XPOVIO (100 MG ONCE WEEKLY) 4 PA; 15DS; SP; QL


XPOVIO (40 MG TWICE WEEKLY) 4 PA; 15DS; SP; QL





ZOLINZA 4 PA; 15DS; SP

Aromatase Inhibitors, 3rd Generation

anastrozole oral Arimidex 1a PV3; QL

exemestane Aromasin 1b PV3; QL

letrozole oral Femara 1a

Enzyme Inhibitors

BALVERSA 4 PA; 15DS; SP; QL

etoposide oral 1b

HYCAMTIN ORAL 4 SP

PEMAZYRE 4 PA; SP; QL

RUBRACA 4 PA; SP; QL

TALZENNA 4 PA; 15DS; SP; QL

TRUSELTIQ (100MG DAILY DOSE) 4 PA; SP; QL




ZEJULA 4 PA; 15DS; SP; QL

Molecular Target Inhibitors

ALECENSA 4 PA; SP; QL

ALUNBRIG 4 PA; SP; QL

AYVAKIT 4 PA; 15DS; SP; QL

BOSULIF 4 PA; 15DS; SP; QL

BRAFTOVI 4 PA; SP; QL

BRUKINSA 4 PA; 15DS; SP; QL

CABOMETYX 4 PA; 15DS; SP; QL

CALQUENCE 4 PA; 15DS; SP; QL

CAPRELSA 4 PA; 15DS; SP; QL


31


COMETRIQ 4 PA; 15DS; SP; QL

COTELLIC 4 PA; SP; QL

DAURISMO 4 PA; 15DS; SP; QL

ERIVEDGE 4 PA; 15DS; SP; QL

erlotinib hcl Tarceva 4 PA; 15DS; SP

everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg

Afinitor 4 PA; 15DS; SP; QL

everolimus oral tablet soluble Afinitor Disperz 4 PA; 15DS; SP; QL

EXKIVITY 4 PA; 15DS; SP; QL

FARYDAK 4 PA; SP; QL

FOTIVDA 4 PA; SP; QL

GAVRETO 4 PA; 15DS; SP; QL

GILOTRIF 4 PA; SP; QL

IBRANCE 4 PA; SP; QL

ICLUSIG 4 PA; 15DS; SP; QL

IDHIFA 4 PA; SP; QL

imatinib mesylate Gleevec 4 SP

IMBRUVICA ORAL CAPSULE 4 PA; 15DS; SP; QL

IMBRUVICA ORAL TABLET 140 MG Not covered SP; QL

IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG

4 PA; SP; QL

INLYTA 4 PA; 15DS; SP; QL

INQOVI 4 PA; SP; QL

IRESSA 4 PA; SP; QL

JAKAFI 4 PA; 15DS; SP; QL

KISQALI FEMARA 4 PA; SP; QL

KOSELUGO 4 PA; SP; QL

lapatinib ditosylate Tykerb 4 PA; SP

LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 10 MG, 10 MG & 2 X 4 MG, 2 X 10 MG, 2 X 10 MG & 4 MG, 2 X 4 MG, 3 X 4 MG, 4 MG

4 PA; 15DS; SP; QL

LORBRENA 4 PA; 15DS; SP; QL

LYNPARZA 4 PA; 15DS; SP; QL

MEKINIST 4 PA; SP; QL

MEKTOVI 4 PA; SP; QL

NERLYNX 4 PA; 15DS; SP; QL

NEXAVAR 4 PA; 15DS; SP; QL


32


ODOMZO 4 PA; 15DS; SP; QL

QINLOCK 4 PA; SP; QL

RETEVMO 4 PA; 15DS; SP; QL

RYDAPT 4 PA; SP; QL

SCEMBLIX 4 PA; SP; QL

SPRYCEL 4 PA; 15DS; SP

STIVARGA 4 PA; SP; QL

sunitinib malate Sutent 4 PA; 15DS; SP; QL

TABRECTA 4 PA; 15DS; SP; QL

TAFINLAR 4 PA; SP; QL

TAGRISSO 4 PA; 15DS; SP; QL

TASIGNA 4 PA; 15DS; SP; QL

TEPMETKO 4 PA; 15DS; SP; QL

TIBSOVO 4 PA; 15DS; SP; QL

TUKYSA 4 PA; SP; QL

TURALIO 4 PA; SP; QL

UKONIQ 4 PA; 15DS; SP; QL

VENCLEXTA 4 PA; SP; QL

VENCLEXTA STARTING PACK 4 PA; SP; QL

VITRAKVI ORAL CAPSULE 4 PA; 15DS; SP; QL

VITRAKVI ORAL SOLUTION 4 PA; SP; QL

VIZIMPRO 4 PA; 15DS; SP; QL

VOTRIENT 4 PA; 15DS; SP

XALKORI 4 PA; 15DS; SP; QL

XOSPATA 4 PA; SP; QL

ZELBORAF 4 PA; 15DS; SP; QL

ZYDELIG 4 PA; SP; QL

ZYKADIA 4 PA; 15DS; SP; QL

Retinoids

bexarotene Targretin 4 PA; 15DS; SP

PANRETIN 2

TARGRETIN EXTERNAL 5 PA; SP

tretinoin oral 1b

Treatment Adjuncts

MESNEX ORAL 2


33


Antiparasitics

Anthelmintics

albendazole oral Albenza 1b QL

EMVERM Not covered QL

ivermectin external lotion 1b QL

ivermectin oral Stromectol 1b PA; QL

praziquantel oral Biltricide 1b

Antiprotozoals

ALINIA ORAL SUSPENSION RECONSTITUTED

2

ARAKODA 3 QL

atovaquone Mepron 1b

atovaquone-proguanil hcl Malarone 1b

BENZNIDAZOLE 2 QL

chloroquine phosphate oral 1b

COARTEM 2 QL

hydroxychloroquine sulfate oral Plaquenil 1b

IMPAVIDO 2 QL

KRINTAFEL 2 QL

LAMPIT 3 QL

mefloquine hcl 1b

nitazoxanide oral Alinia 1b

pentamidine isethionate inhalation Nebupent 1b

primaquine phosphate 1b

pyrimethamine oral Daraprim 4 PA; SP

quinine sulfate oral Qualaquin 1b

Pediculicides/Scabicides

crotan 1b

lindane 1b

malathion Ovide 1b

permethrin external 1b

spinosad Natroba 1b

Antiparkinson Agents

Anticholinergics

benztropine mesylate oral 1a

trihexyphenidyl hcl 1a


34


Antiparkinson Agents, Other

amantadine hcl oral 1b

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg

Stalevo 50 1b


Stalevo 75 1b

entacapone Comtan 1b

GOCOVRI Not covered QL

NOURIANZ 3 PA; QL

ONGENTYS 3 PA; QL

OSMOLEX ER Not covered

tolcapone Tasmar 1b

Dopamine Agonists

APOKYN Not covered SP; QL

bromocriptine mesylate oral Parlodel 1b

INBRIJA 3 PA; QL

KYNMOBI 2 PA; QL

NEUPRO Not covered QL

pramipexole dihydrochloride 1a

pramipexole dihydrochloride er Mirapex ER Not covered QL

ropinirole hcl 1a

ropinirole hcl er 1b

Dopamine Precursors and/or L-Amino Acid Decarboxylase Inhibitors

carbidopa-levodopa er oral tablet extended release 50-200 mg

1a

carbidopa-levodopa oral tablet 10-100 mg

Sinemet 1a


1a

carbidopa-levodopa oral tablet dispersible 25-100 mg

1b

RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG

Not covered QL

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

carbidopa oral Lodosyn 1b

carbidopa-levodopa er oral tablet extended release 25-100 mg

1a


35



1a

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-250 mg

1b

carbidopa-levodopa-entacapone oral tablet 25-100-200 mg

Stalevo 100 1b


Stalevo 125 1b


Stalevo 150 1b

carbidopa-levodopa-entacapone oral tablet 50-200-200 mg

Stalevo 200 1b

DHIVY Not covered QL

DUOPA 4 PA; SP; QL

RYTARY ORAL CAPSULE EXTENDED RELEASE 61.25-245 MG

Not covered QL

Monoamine Oxidase B (MAO-B) Inhibitors

rasagiline mesylate oral Azilect 1b

selegiline hcl oral 1b

XADAGO 3 QL

ZELAPAR Not covered QL

Antipsychotics

1st Generation/Typical

chlorpromazine hcl oral tablet 1b

fluphenazine decanoate injection 1b

fluphenazine hcl oral 1a

haloperidol decanoate intramuscular Haldol Decanoate 1b

haloperidol lactate oral 1a

haloperidol oral 1a

loxapine succinate 1a

molindone hcl Not covered QL

pimozide 1b

thioridazine hcl oral 1a

thiothixene 1b

trifluoperazine hcl 1a

2nd Generation/Atypical

ABILIFY MAINTENA 2

ABILIFY MYCITE Not covered


36


ABILIFY MYCITE MAINTENANCE KIT Not covered

ABILIFY MYCITE STARTER KIT Not covered

aripiprazole Abilify 1b

ARISTADA 2 QL

ARISTADA INITIO 2

asenapine maleate Saphris 1b QL

CAPLYTA 3 ST; QL

FANAPT 3 ST

FANAPT TITRATION PACK 3 ST

INVEGA SUSTENNA 2

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML

2 QL

LATUDA 3 ST

NUPLAZID 3 PA; QL

olanzapine oral ZyPREXA 1a

paliperidone er Invega 1b QL

PERSERIS 2 QL

quetiapine fumarate SEROquel 1a

quetiapine fumarate er SEROquel XR 1a QL

REXULTI Not covered QL

RISPERDAL CONSTA 2

risperidone RisperDAL 1a

SECUADO 3 ST; QL

VRAYLAR 3 ST; QL

ziprasidone hcl Geodon 1a

ZYPREXA RELPREVV 2

Treatment-Resistant

clozapine oral tablet Clozaril 1a

clozapine oral tablet dispersible 1b

VERSACLOZ Not covered

Antivirals

MOLNUPIRAVIR 0Anti-cytomegalovirus (CMV) Agents

PREVYMIS ORAL 3 QL

valganciclovir hcl Valcyte 1b


37


Anti-hepatitis B (HBV) Agents

adefovir dipivoxil Hepsera 4 SP

BARACLUDE ORAL SOLUTION 4 SP

entecavir Baraclude 4 SP

EPIVIR HBV ORAL SOLUTION 2

lamivudine oral tablet 100 mg Epivir HBV 1b

VEMLIDY 4 SP; QL

Anti-hepatitis C (HCV) Agents, Other

INTRON A 4 SP

Anti-hepatitis C (HCV) Agents

EPCLUSA 4 PA; SP; QL

HARVONI ORAL PACKET 5 PA; SP; QL

HARVONI ORAL TABLET Not covered SP; QL

LEDIPASVIR-SOFOSBUVIR Not covered ABA; SP; QL

MAVYRET 5 PA; SP; QL

PEGASYS 4 SP; QL

ribavirin oral 4 SP

SOFOSBUVIR-VELPATASVIR 4 PA; ABA; SP; QL

SOVALDI ORAL PACKET 5 PA; SP; QL

SOVALDI ORAL TABLET Not covered SP; QL

VIEKIRA PAK Not covered SP; QL

VOSEVI 5 PA; SP; QL

ZEPATIER 4 PA; SP; QL

Antiherpetic Agents

acyclovir external cream Zovirax Not covered

acyclovir external ointment Zovirax 1b

acyclovir oral Zovirax 1b

DENAVIR Not covered

famciclovir oral 1b

SITAVIG Not covered QL

valacyclovir hcl oral Valtrex 1b

XERESE Not covered QL

Anti-HIV Agents, Integrase Inhibitors (INSTI)

BIKTARVY 2 QL

DOVATO 2 QL

GENVOYA 2 QL


38


ISENTRESS 2

ISENTRESS HD 2

JULUCA 2 QL

STRIBILD 2 QL

TIVICAY 2

TIVICAY PD 2 QL

TYBOST 2 QL

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

COMPLERA 2 QL

DELSTRIGO 2 QL

EDURANT 2 QL

efavirenz Sustiva 1b

efavirenz-emtricitab-tenofovir Atripla 1b

efavirenz-lamivudine-tenofovir Symfi 1b QL

etravirine Intelence 1b

INTELENCE ORAL TABLET 25 MG 2

nevirapine 1b

nevirapine er Viramune XR 1b

PIFELTRO 2 QL

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir sulfate Ziagen 1b

abacavir sulfate-lamivudine Epzicom 1b

abacavir-lamivudine-zidovudine Trizivir Not covered

CIMDUO 2 QL

DESCOVY 2 PA; QL

emtricitabine Emtriva 1b

emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg

Truvada 1b QL

emtricitabine-tenofovir df oral tablet 200-300 mg

Truvada 1b PV2; QL

EMTRIVA ORAL SOLUTION 2

lamivudine oral solution Epivir 1b

lamivudine oral tablet 150 mg, 300 mg Epivir 1b

lamivudine-zidovudine Combivir 1b


39


ODEFSEY 2 QL

stavudine Not covered

TEMIXYS 2 QL

tenofovir disoproxil fumarate Viread 1b

TRIUMEQ 2 QL

VIREAD ORAL POWDER 2

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

zidovudine Retrovir 1b

Anti-HIV Agents, Other

FUZEON 2

RUKOBIA 2 PA; QL

SELZENTRY 2

Anti-HIV Agents, Protease Inhibitors

APTIVUS 2

atazanavir sulfate Reyataz 1b

EVOTAZ 2 QL

fosamprenavir calcium Lexiva 1b

INVIRASE 2

LEXIVA ORAL SUSPENSION 2

lopinavir-ritonavir Kaletra 1b

NORVIR ORAL PACKET 2

NORVIR ORAL SOLUTION 2

PREZCOBIX 2 QL

PREZISTA 2

REYATAZ ORAL PACKET 2

ritonavir Norvir 1b

SYMTUZA 2 QL

VIRACEPT Not covered

Anti-influenza Agents

oseltamivir phosphate oral Tamiflu 1b QL

RELENZA DISKHALER 2 QL

rimantadine hcl 1b

XOFLUZA (40 MG DOSE) 2 QL

XOFLUZA (80 MG DOSE) 2 QL


40


Anxiolytics

Anxiolytics, Other

buspirone hcl oral 1b

hydroxyzine hcl oral 1b

hydroxyzine pamoate oral Vistaril 1b

meprobamate 1b

Benzodiazepines

alprazolam er Xanax XR 1b

alprazolam intensol 1b

alprazolam oral Xanax 1b

alprazolam xr Xanax XR 1b

chlordiazepoxide hcl 1b

clonazepam oral KlonoPIN 1b

clorazepate dipotassium Tranxene-T 1b

diazepam intensol Diazepam Intensol 1b

diazepam oral Diazepam Intensol 1b

estazolam 1b QL

lorazepam intensol LORazepam Intensol 1b

lorazepam oral concentrate 2 mg/ml LORazepam Intensol 1b

lorazepam oral tablet Ativan 1b

LOREEV XR Not covered QL

midazolam hcl oral 1b

oxazepam 1b

quazepam Doral Not covered QL

triazolam Halcion 1b QL

Bipolar Agents

Mood Stabilizers

divalproex sodium er Depakote ER 1a

divalproex sodium oral Depakote 1a

EQUETRO 3

lithium carbonate er Lithobid 1a

lithium carbonate oral 1a

Blood Glucose Monitoring

ACCU-CHEK AVIVA PLUS TEST STRIPS

2 QL

ACCU-CHEK COMPACT PLUS TEST STRIPS

2 QL


41


ACCU-CHEK FASTCLIX LANCETS 2 QL

ACCU-CHEK GUIDE TEST STRIPS 2 QL

ACCU-CHEK MULTICLIX LANCETS 2 QL

ACCU-CHEK SAFE-T PRO LANCETS 2 QL

ACCU-CHEK SMARTVIEW TEST STRIPS

2 QL

ACCU-CHEK SOFTCLIX LANCETS 2 QL

AGAMATRIX PRESTO TEST 2 QL

ASSURE PLATINUM 2 QL

BLOOD GLUCOSE TEST 2 QL

BLULINK GLUCOSE TEST 2 QL

CARETOUCH TEST 2 QL

CONTOUR MONITOR DEVICE 0 QL

CONTOUR NEXT MONITOR KIT W/DEVICE

0 QL

CONTOUR NEXT ONE KIT 0 QL

CONTOUR NEXT TEST STRIPS 2 QL

CONTOUR TEST STRIPS 2 QL

DEXCOM G6 RECEIVER 0 PA; QL

DEXCOM G6 SENSOR 2 PA; QL

DEXCOM G6 TRANSMITTER 0 PA; QL

DIATHRIVE BLOOD GLUCOSE TEST 2 QL

DIATHRIVE GLUCOSE TEST 2 QL

DIATHRIVE+ GLUCOSE TEST 2 QL

EASY TALK PLUS II TEST STRIPS 2 QL

EASY TOUCH HEALTHPRO GLUCOSE 2 QL

EASY TRAK II GLUCOSE TEST 2 QL

EMBRACE PRESSURE ACTIVATED 21G

2 QL

EMBRACE PRESSURE ACTIVATED 28G

2 QL

EMBRACE TALK GLUCOSE TEST 2 QL

FORA 6 CONNECT 2 QL

FORA GTEL BLOOD GLUCOSE TEST 2 QL

FORA TN'G ADVANCE PRO IN VITRO 2 QL

FREESTYLE LIBRE 14 DAY READER 2 PA; QL

FREESTYLE LIBRE 14 DAY SENSOR 2 PA; QL

FREESTYLE LIBRE 2 READER 2 PA; QL


42


FREESTYLE LIBRE 2 SENSOR 2 PA; QL

FREESTYLE LIBRE READER 2 PA; QL

FREESTYLE PRECISION NEO TEST 2 QL

GLUCOCARD 01 SENSOR PLUS 2 QL

GLUCOCARD EXPRESSION TEST 2 QL

GLUCOCARD SHINE TEST 2 QL

GLUCOCARD VITAL TEST 2 QL

GOJJI BLOOD GLUCOSE TEST 3 QL

HW EMBRACE PRO GLUCOSE TEST 2 QL

HW EMBRACE TALK GLUCOSE TEST 2 QL

INFINITY BLOOD GLUCOSE TEST 2 QL

KROGER HEALTHPRO GLUCOSE TEST

2 QL

LANCETS 2 QL

LANCETS IN VITRO STRIP 3 QL

MICRODOT TEST 2 QL

ONE DROP TEST 2 QL

ONETOUCH CLUB LANCETS FINE PT 2 QL

ONETOUCH DELICA LANCETS 30G 2 QL

ONETOUCH DELICA LANCETS 33G 2 QL

ONETOUCH DELICA PLUS LANCET30G

2 QL

ONETOUCH DELICA PLUS LANCET33G

2 QL

ONETOUCH FINEPOINT LANCETS 2 QL

ONETOUCH ULTRA TEST STRIPS 2 QL

ONETOUCH ULTRA 2 KIT W/DEVICE 0 QL

ONETOUCH ULTRASOFT LANCETS 2 QL

ONETOUCH VERIO FLEX SYSTEM 0 QL

ONETOUCH VERIO TEST STRIPS 2 QL

ONETOUCH VERIO REFLECT 0 QL

PRECISION XTRA BLOOD GLUCOSE 2 QL

RELION PREMIER TEST 2 QL

TRUE METRIX BLOOD GLUCOSE TEST

2 QL

TRUETRACK TEST 2 QL

VIVAGUARD INO TEST STRIPS 2 QL


43


Blood Glucose Regulators

Antidiabetic Agents

acarbose oral Precose 1b

ADLYXIN Not covered QL

ADLYXIN STARTER PACK Not covered QL

ALOGLIPTIN BENZOATE Not covered ABA; QL

ALOGLIPTIN-METFORMIN HCL Not covered QL

ALOGLIPTIN-PIOGLITAZONE Not covered ABA; QL

BYDUREON BCISE AUTOINJECTOR Not covered QL

BYETTA 10 MCG PEN Not covered QL

BYETTA 5 MCG PEN Not covered QL

CYCLOSET 3 PA; QL

FARXIGA 2 QL

glimepiride Amaryl 1a

glipizide er Glucotrol XL 1a

glipizide ir 1a

glipizide xl Glucotrol XL 1a

glipizide-metformin hcl 1a

glyburide micronized Glynase 1a

glyburide oral 1a

glyburide-metformin 1a

GLYXAMBI 2 QL

INVOKAMET Not covered QL

INVOKAMET XR Not covered QL

INVOKANA Not covered QL

JANUMET 2 QL

JANUMET XR 2 QL

JANUVIA 2 QL

JARDIANCE 2 QL

JENTADUETO 2 QL

JENTADUETO XR 2 QL

KAZANO Not covered QL

KOMBIGLYZE XR Not covered

metformin hcl er 1a

metformin hcl er (mod) Glumetza Not covered

metformin hcl er (osm) Not covered

metformin hcl oral solution Riomet Not covered


44


metformin hcl oral tablet 1a

miglitol 1b

nateglinide 1b

NESINA Not covered QL

ONGLYZA Not covered QL

OSENI Not covered QL

OZEMPIC 2 QL

pioglitazone hcl Actos 1a

pioglitazone hcl-glimepiride Duetact 1b

pioglitazone hcl-metformin hcl Actoplus Met 1b

QTERN Not covered QL

repaglinide 1b

RYBELSUS 2 QL

SEGLUROMET Not covered QL

SOLIQUA 2 QL

STEGLATRO Not covered QL

STEGLUJAN Not covered QL

SYMLINPEN 120 3

SYMLINPEN 60 3

SYNJARDY 2 QL

SYNJARDY XR 2 QL

TRADJENTA 2 QL

TRIJARDY XR 2 QL

TRULICITY 2 QL

VICTOZA 2 QL

XIGDUO XR 2 QL

XULTOPHY 2 QL

Glycemic Agents

BAQSIMI ONE PACK 2 QL

BAQSIMI TWO PACK 2 QL

diazoxide oral Proglycem 1b

GLUCAGEN HYPOKIT 2

glucagon emergency kit 1b

GLUCAGON EMERGENCY KIT 2

GVOKE HYPOPEN 1-PACK 2 QL

GVOKE HYPOPEN 2-PACK 2 QL

GVOKE PFS 2 QL


45


ZEGALOGUE 3 QL

Insulins

ADMELOG Not covered

ADMELOG SOLOSTAR Not covered

AFREZZA Not covered

APIDRA SOLOSTAR Not covered

APIDRA VIAL Not covered

BASAGLAR KWIKPEN 3

FIASP 2

FIASP FLEXTOUCH 2

FIASP PENFILL 2

HUMALOG Not covered

HUMALOG KWIKPEN Not covered

HUMALOG MIX 50/50 KWIKPEN Not covered

HUMALOG MIX 50/50 VIAL Not covered

HUMALOG MIX 75/25 KWIKPEN Not covered

HUMALOG MIX 75/25 VIAL Not covered

HUMALOG U-100 JUNIOR KWIKPEN Not covered

HUMULIN 70/30 KWIKPEN Not covered

HUMULIN 70/30 VIAL Not covered

HUMULIN N KWIKPEN Not covered

HUMULIN N VIAL Not covered

HUMULIN R U-500 KWIKPEN 2

HUMULIN R U-500 VIAL 2

HUMULIN R VIAL Not covered

INSULIN ASP PROT & ASP FLEXPEN Not covered ABA

INSULIN ASPART Not covered ABA

INSULIN ASPART FLEXPEN Not covered ABA

INSULIN ASPART PENFILL Not covered ABA

INSULIN ASPART PROT & ASPART Not covered ABA

INSULIN GLARGINE-YFGN Not covered ABA

INSULIN LISPRO Not covered ABA

INSULIN LISPRO (1 UNIT DIAL) Not covered ABA

INSULIN LISPRO JUNIOR KWIKPEN 3 ABA

INSULIN LISPRO PROT & LISPRO Not covered ABA

LANTUS SOLOSTAR 1a

LANTUS U-100 VIAL 1a


46


LEVEMIR U-100 FLEXTOUCH 1a

LEVEMIR U-100 VIAL 1a

LYUMJEV KWIKPEN Not covered

LYUMJEV VIAL Not covered

NOVOLIN 70/30 FLEXPEN 1a

NOVOLIN 70/30 RELION Not covered

NOVOLIN 70/30 VIAL 1a

NOVOLIN N FLEXPEN 1a

NOVOLIN N RELION Not covered

NOVOLIN N VIAL 1a

NOVOLIN R FLEXPEN 1a

NOVOLIN R RELION Not covered

NOVOLIN R VIAL 1a

NOVOLOG 70/30 FLEXPEN RELION Not covered

NOVOLOG FLEXPEN 1a

NOVOLOG FLEXPEN RELION Not covered

NOVOLOG MIX 70/30 FLEXPEN 1a

NOVOLOG MIX 70/30 RELION Not covered

NOVOLOG MIX 70/30 VIAL 1a

NOVOLOG PENFILL 1a

NOVOLOG RELION Not covered

NOVOLOG U-100 VIAL 1a

SEMGLEE Not covered

SEMGLEE (YFGN) Not covered

TOUJEO MAX SOLOSTAR 1a

TOUJEO SOLOSTAR 1a

TRESIBA 1a

TRESIBA FLEXTOUCH 1a

Blood Products and Modifiers

EMPAVELI 4 PA; SP; QL

Anticoagulants

ELIQUIS 2 QL

ELIQUIS DVT/PE STARTER PACK 2 QL

enoxaparin sodium Lovenox 1b

fondaparinux sodium Arixtra 1b

FRAGMIN 3

heparin sodium (porcine) 1b


47


heparin sodium (porcine) pf 1b

jantoven Jantoven 1a

PRADAXA 2 QL

SAVAYSA 3 QL

warfarin sodium oral Jantoven 1a

XARELTO ORAL TABLET 2 QL

XARELTO STARTER PACK 2 QL

ZONTIVITY 3 QL

Blood Formation Modifiers

anagrelide hcl Agrylin 1b

ARANESP (ALBUMIN FREE) Not covered SP

DOPTELET 4 PA; SP; QL

EPOGEN Not covered SP

FULPHILA 5 ST; SP; QL

GRANIX Not covered SP

LEUKINE 5 SP

MIRCERA Not covered SP; QL

MULPLETA Not covered SP; QL

NEULASTA 4 SP; QL

NEUPOGEN Not covered SP

NIVESTYM 4 SP; QL

NYVEPRIA 4 SP; QL

OXBRYTA ORAL TABLET 5 PA; SP; QL

OXBRYTA ORAL TABLET SOLUBLE Not covered

PROCRIT 4 SP

PROMACTA 4 PA; SP

RETACRIT 4 SP

UDENYCA 5 ST; SP; QL

ZARXIO 4 SP

ZIEXTENZO 5 ST; SP; QL

Hemostasis Agents

ADVATE 2

ADYNOVATE 2

AFSTYLA 2

ALPHANATE 2

ALPHANINE SD 2

ALPROLIX 2


48


aminocaproic acid oral Amicar 1b

BENEFIX 2

COAGADEX 2

CORIFACT 2

ELOCTATE 2

ESPEROCT 2

FEIBA 2

HEMLIBRA 2 PA

HEMOFIL M 2

HUMATE-P 2

IDELVION 2

IXINITY 2

JIVI 2

KOATE 2

KOATE-DVI 2

KOGENATE FS 2

KOVALTRY 2

MONONINE 2

NOVOEIGHT 2

NOVOSEVEN RT 2

NUWIQ 2

OBIZUR 2

PROFILNINE 2

REBINYN 2

RECOMBINATE 2

RIXUBIS 2

SEVENFACT 2

TAVALISSE 5 PA; SP; QL

tranexamic acid oral Lysteda 1b QL

TRETTEN 2

VONVENDI 2

WILATE 2

XYNTHA 2

XYNTHA SOLOFUSE 2

Platelet Modifying Agents

aspirin-dipyridamole er 1b

ASPIRIN-OMEPRAZOLE Not covered


49


BRILINTA 2 QL

CABLIVI 4 PA; SP; QL

cilostazol 1b

clopidogrel bisulfate oral Plavix 1a

dipyridamole oral 1b

DURLAZA Not covered QL

prasugrel hcl Effient 1b QL

YOSPRALA Not covered

Cardiovascular Agents

Alpha-adrenergic Agonists

clonidine Catapres-TTS-1 1b

clonidine hcl oral 1a

guanfacine hcl 1b

methyldopa 1b

midodrine hcl 1b

Alpha-adrenergic Blocking Agents

doxazosin mesylate oral Cardura 1b

phenoxybenzamine hcl oral Dibenzyline 1b PA; QL

prazosin hcl oral Minipress 1b

Angiotensin II Receptor Antagonists

candesartan cilexetil Atacand 1b

EDARBI 3 ST; QL

irbesartan Avapro 1a

losartan potassium oral Cozaar 1a

olmesartan medoxomil oral Benicar 1a

telmisartan Micardis 1a

valsartan Diovan 1a

Angiotensin-converting Enzyme (ACE) Inhibitors

benazepril hcl oral Lotensin 1a

captopril oral 1a

enalapril maleate oral solution Epaned Not covered

enalapril maleate oral tablet Vasotec 1a

fosinopril sodium 1a

lisinopril oral Zestril 1a

moexipril hcl 1a

perindopril erbumine 1a


50


QBRELIS Not covered QL

quinapril hcl Accupril 1a

ramipril Altace 1a

trandolapril Mavik 1a

Antiarrhythmics

amiodarone hcl oral Pacerone 1b

disopyramide phosphate Norpace 1b

dofetilide Tikosyn 1b

flecainide acetate 1b

mexiletine hcl oral 1b

MULTAQ 2 QL

NORPACE CR 2

propafenone hcl 1b

propafenone hcl er Rythmol SR 1b

quinidine gluconate er 1b

quinidine sulfate 1b

sorine Sorine 1a

sotalol hcl (af) Betapace AF 1a

sotalol hcl oral Sorine 1a

SOTYLIZE Not covered

Beta-adrenergic Blocking Agents

acebutolol hcl oral 1a

atenolol oral Tenormin 1a

betaxolol hcl oral 1a

bisoprolol fumarate oral 1a

carvedilol Coreg 1a

carvedilol phosphate er Coreg CR Not covered QL

HEMANGEOL Not covered QL

INDERAL XL Not covered

INNOPRAN XL Not covered

KAPSPARGO SPRINKLE Not covered

labetalol hcl oral 1a

metoprolol succinate er Toprol XL 1a

metoprolol tartrate oral Lopressor 1a

nadolol oral Corgard 1a

nebivolol hcl Bystolic 1b QL

pindolol 1a


51


propranolol hcl er Inderal LA 1a

propranolol hcl oral 1a

timolol maleate oral 1a

Calcium Channel Blocking Agents

amlodipine besylate oral Norvasc 1a

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

3

cartia xt Cartia XT 1b

CONJUPRI Not covered

diltiazem hcl er 1b

diltiazem hcl er beads Taztia XT 1b

diltiazem hcl er coated beads Cardizem CD 1b

diltiazem hcl oral Cardizem 1b

dilt-xr 1b

felodipine er 1a

isradipine 1b

KATERZIA Not covered QL

matzim la Matzim LA 1b

nicardipine hcl oral 1b

nifedipine er Afeditab CR 1b

nifedipine er osmotic release Procardia XL 1b

nifedipine oral 1b

nimodipine oral 1b

nisoldipine er Sular 1b

NYMALIZE 3 QL

taztia xt Taztia XT 1b

tiadylt er Taztia XT 1b

verapamil hcl er Calan SR 1b

verapamil hcl oral 1b

Cardiovascular Agents, Other

ALDACTAZIDE ORAL TABLET 50-50 MG

3

aliskiren fumarate Tekturna 1b

amiloride-hydrochlorothiazide 1a

amlodipine besylate-benazepril hcl Lotrel 1a

amlodipine besylate-valsartan Exforge 1a

amlodipine-atorvastatin Caduet 1b QL


52


amlodipine-olmesartan Azor 1b

atenolol-chlorthalidone Tenoretic 100 1a

benazepril-hydrochlorothiazide Lotensin HCT 1a

BIDIL 2

bisoprolol-hydrochlorothiazide Ziac 1a

candesartan cilexetil-hctz Atacand HCT 1b

CONSENSI Not covered QL

CORLANOR 2 QL

DEMSER 3

digitek Digitek 1b

digox Digitek 1b

digoxin oral Digitek 1b

droxidopa Northera Not covered SP; QL

DUTOPROL 3

EDARBYCLOR 3 ST; QL

enalapril-hydrochlorothiazide Vaseretic 1a

ENTRESTO 2 QL

EXFORGE HCT 3

fosinopril sodium-hctz 1a

irbesartan-hydrochlorothiazide Avalide 1a

LANOXIN ORAL TABLET 62.5 MCG Not covered

lisinopril-hydrochlorothiazide Zestoretic 1a

losartan potassium-hctz Hyzaar 1a

metoprolol-hydrochlorothiazide 1a

metyrosine Demser 1b

olmesartan medoxomil-hctz Benicar HCT 1a

olmesartan-amlodipine-hctz Tribenzor 1b QL

pentoxifylline er 1b

PRESTALIA Not covered QL

quinapril-hydrochlorothiazide Accuretic 1a

ranolazine er Ranexa 1b

spironolactone-hctz Aldactazide 1a

TEKTURNA HCT 3

telmisartan-amlodipine 1b

telmisartan-hctz Micardis HCT 1a

trandolapril-verapamil hcl er 1b

triamterene-hctz Maxzide 1a


53


valsartan-hydrochlorothiazide Diovan HCT 1a

VECAMYL Not covered QL

VERQUVO 3 PA; QL

VYNDAMAX 4 PA; SP; QL

VYNDAQEL 4 PA; SP; QL

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide er 1b

acetazolamide oral 1b

KEVEYIS 5 PA; SP; QL

methazolamide oral 1b

Diuretics, Loop

bumetanide oral Bumex 1a

ethacrynic acid Edecrin 1b

furosemide oral Lasix 1a

torsemide 1a

Diuretics, Potassium-sparing

amiloride hcl oral 1a

CAROSPIR Not covered

eplerenone Inspra 1a

spironolactone oral Aldactone 1a

triamterene oral Dyrenium 1b

Diuretics, Thiazide

chlorthalidone 1a

DIURIL 3

hydrochlorothiazide oral 1a

indapamide 1a

metolazone 1a

THALITONE Not covered

Dyslipidemics, Fibric Acid Derivatives

ANTARA 3

fenofibrate micronized oral capsule 130 mg, 43 mg

1b

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

1a

FENOFIBRATE MICRONIZED ORAL CAPSULE 30 MG, 90 MG

3 ABA


54


fenofibrate oral capsule 134 mg, 200 mg, 67 mg

1a

fenofibrate oral capsule 150 mg, 50 mg Lipofen Not covered

fenofibrate oral tablet 120 mg, 40 mg Fenoglide Not covered

fenofibrate oral tablet 145 mg, 48 mg Tricor 1a

fenofibrate oral tablet 160 mg, 54 mg 1a

fenofibric acid oral capsule delayed release

Trilipix 1b

fenofibric acid oral tablet Fibricor Not covered

FIBRICOR Not covered

gemfibrozil oral Lopid 1a

LIPOFEN Not covered

Dyslipidemics, HMG CoA Reductase Inhibitors

ALTOPREV Not covered QL

atorvastatin calcium oral tablet 10 mg, 20 mg

Lipitor 1aPV2; QL; AL (Min 40 Years and Max 75 Years)

atorvastatin calcium oral tablet 40 mg, 80 mg

Lipitor 1a QL

EZALLOR SPRINKLE Not covered

FLOLIPID Not covered

fluvastatin sodium 1bPV2; QL; AL (Min 40 Years and Max 75 Years)

fluvastatin sodium er Lescol XL 1bPV2; QL; AL (Min 40 Years and Max 75 Years)

LIVALO 3 ST; QL

lovastatin oral 1aPV2; QL; AL (Min 40 Years and Max 75 Years)

pravastatin sodium Pravachol 1aPV2; QL; AL (Min 40 Years and Max 75 Years)

rosuvastatin calcium oral tablet 10 mg, 5 mg

Crestor 1aPV2; QL; AL (Min 40 Years and Max 75 Years)

rosuvastatin calcium oral tablet 20 mg, 40 mg

Crestor 1a QL


55


simvastatin oral tablet 10 mg, 20 mg, 40 mg

Zocor 1aPV2; QL; AL (Min 40 Years and Max 75 Years)

simvastatin oral tablet 5 mg 1aPV2; QL; AL (Min 40 Years and Max 75 Years)

simvastatin oral tablet 80 mg Zocor 1a QL

ZYPITAMAG Not covered

Dyslipidemics, Other

cholestyramine light Prevalite 1b

cholestyramine oral Questran 1b

colesevelam hcl Welchol 1b

colestipol hcl Colestid 1b

ezetimibe Zetia 1b QL

EZETIMIBE-ROSUVASTATIN Not covered ABA

ezetimibe-simvastatin Vytorin 1b QL

icosapent ethyl Vascepa 1b QL

JUXTAPID Not covered SP; QL

NEXLETOL 2 PA; QL

NEXLIZET 2 PA; QL

niacin (antihyperlipidemic) Niacor Not covered

niacin er (antihyperlipidemic) Niaspan 1b

niacor Niacor Not covered

omega-3-acid ethyl esters Lovaza 1b QL

PRALUENT 2 PA; QL

prevalite Prevalite 1b

REPATHA 2 PA; QL

REPATHA PUSHTRONEX SYSTEM 2 PA; QL

REPATHA SURECLICK 2 PA; QL

ROSZET Not covered

VASCEPA ORAL CAPSULE 0.5 GM 2 QL

Vasodilators, Direct-acting Arterial/Venous

GONITRO Not covered

isosorbide dinitrate Isordil Titradose 1b

isosorbide mononitrate 1a

isosorbide mononitrate er 1a

NITRO-BID 2


56


NITRO-DUR Not covered

nitroglycerin sublingual Nitrostat 1b

nitroglycerin transdermal Nitro-Dur 1b

nitroglycerin translingual Nitrolingual 1b

NITROMIST Not covered

NITRO-TIME 2

RECTIV 3 QL

Vasodilators, Direct-acting Arterial

hydralazine hcl oral 1b

minoxidil oral 1b

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

ADZENYS XR-ODT Not covered QL

amphetamine sulfate Evekeo 1b PA; QL

amphetamine-dextroamphetamine Adderall 1b QL

amphetamine-dextroamphetamine er Adderall XR 1b QL

dextroamphetamine sulfate ProCentra 1b QL

dextroamphetamine sulfate er Dexedrine 1b QL

DYANAVEL XR Not covered QL

EVEKEO ODT Not covered QL

methamphetamine hcl Desoxyn 1b QL

MYDAYIS 2 QL

VYVANSE 2 QL

ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG

3 QL

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

ADHANSIA XR Not covered QL

atomoxetine hcl Strattera 1b QL

AZSTARYS Not covered QL

clonidine hcl er Kapvay 1b QL

COTEMPLA XR-ODT Not covered QL

DAYTRANA 3 QL

dexmethylphenidate hcl Focalin 1b QL

dexmethylphenidate hcl er Focalin XR 1b QL

guanfacine hcl er Intuniv 1b QL

JORNAY PM Not covered QL


57


methylphenidate hcl er (cd) 1b QL

methylphenidate hcl er (la) Ritalin LA 1b QL

methylphenidate hcl er (xr) Aptensio XR Not covered QL

methylphenidate hcl er oral tablet extended release 10 mg, 20 mg

1b QL

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

Concerta 1b QL

methylphenidate hcl er oral tablet extended release 24 hour

1b QL

methylphenidate hcl er oral tablet extended release 72 mg

Relexxii Not covered QL

methylphenidate hcl oral Methylin 1b QL

QELBREE 3 PA; QL

QUILLICHEW ER Not covered QL

QUILLIVANT XR Not covered QL

relexxii Relexxii Not covered QL

Central Nervous System, Other

AUSTEDO 4 PA; SP; QL

caffeine citrate oral 1b

EXSERVAN 5 PA; SP; QL

GRALISE ORAL TABLET Not covered QL

HORIZANT Not covered QL

IMCIVREE 4 PA; SP; QL

INGREZZA 5 PA; SP; QL

NUEDEXTA 2 PA; QL

riluzole Rilutek 1b

tetrabenazine Xenazine 4 PA; SP; QL

TIGLUTIK 5 PA; SP; QL

Fibromyalgia Agents

pregabalin Lyrica 1b QL

pregabalin er Lyrica CR Not covered QL

SAVELLA 3 PA; QL

SAVELLA TITRATION PACK 3 PA; QL

Multiple Sclerosis Agents

AUBAGIO 5 SP; QL

AVONEX PEN 4 SP; QL

AVONEX PREFILLED 4 SP; QL


58


BAFIERTAM 4 SP; QL

BETASERON 4 SP; QL

COPAXONE 4 SP; QL

dalfampridine er Ampyra 4 SP; QL

dimethyl fumarate oral Tecfidera 4 SP; QL

dimethyl fumarate starter pack Tecfidera 4 SP; QL

EXTAVIA 5 SP; QL

GILENYA ORAL CAPSULE 0.5 MG 4 SP; QL

glatiramer acetate Copaxone 4 SP; QL

glatopa Copaxone 4 SP; QL

KESIMPTA 4 SP; QL

MAVENCLAD 5 ST; SP; QL

MAYZENT 4 SP; QL

MAYZENT STARTER PACK 4 SP

PLEGRIDY INTRAMUSCULAR 5 SP; QL

PLEGRIDY STARTER PACK 5 SP; QL

PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR

5 SP; QL

PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Not covered SP; QL

PONVORY Not covered SP; QL

PONVORY STARTER PACK Not covered SP; QL

REBIF 4 SP; QL

REBIF REBIDOSE 4 SP; QL

REBIF REBIDOSE TITRATION PACK 4 SP; QL

REBIF TITRATION PACK 4 SP; QL

VUMERITY 4 SP; QL

ZEPOSIA Not covered SP; QL

ZEPOSIA 7-DAY STARTER PACK Not covered SP; QL

ZEPOSIA STARTER KIT Not covered SP; QL

Cholestatic Pruritus Agent

Ileal Bile Acid Transporter Inhibitor

BYLVAY 4 PA; SP; QL

BYLVAY (PELLETS) 4 PA; SP; QL

LIVMARLI 4 PA; SP; QL

Dental and Oral Agents

cavarest Cavarest 1b


59


cevimeline hcl Evoxac 1b

chlorhexidine gluconate mouth/throat Periogard Not covered

DENTA 5000 PLUS Not covered

DENTAGEL Not covered

oralone Oralone 1b

periogard Periogard Not covered

pilocarpine hcl oral Salagen 1b

PREVIDENT Not covered

PREVIDENT 5000 DRY MOUTH Not covered

PREVIDENT 5000 PLUS Not covered

sf Cavarest Not covered

sf 5000 plus Denta 5000 Plus Not covered

sodium fluoride 5000 plus Denta 5000 Plus Not covered

sodium fluoride 5000 ppm dental cream Denta 5000 Plus Not covered

sodium fluoride 5000 ppm dental gel Cavarest Not covered

sodium fluoride dental Cavarest Not covered

sodium fluoride mouth/throat PreviDent Not covered

triamcinolone acetonide mouth/throat Oralone 1b

Dermatological Agents

ABSORICA LD Not covered QL

accutane Accutane 1b QL

acitretin 1b

ACZONE EXTERNAL GEL 7.5 % Not covered

adapalene external cream Differin 1b

adapalene external gel 0.1 % Differin 1b

adapalene external gel 0.3 % Differin Not covered

ADAPALENE EXTERNAL PAD Not covered

adapalene-benzoyl peroxide external gel 0.1-2.5 %

Epiduo Not covered

adapalene-benzoyl peroxide external gel 0.3-2.5 %

Epiduo Forte Not covered QL

AKLIEF Not covered QL

ALTRENO 3 QL

ammonium lactate external AL12 1b

amnesteem Accutane 1b QL

AMZEEQ Not covered QL

ARAZLO Not covered QL


60


AVAR CLEANSER 3

AVAR-E EMOLLIENT 3

AVAR-E GREEN 3

AVITA Not covered

azelaic acid external Finacea 1b

AZELEX Not covered

BENZAC AC WASH Not covered

BENZEPRO EXTERNAL Not covered

BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 %

Not covered

BENZEPRO EXTERNAL LIQUID Not covered

BENZOYL PEROXIDE EXTERNAL GEL 6.5 %

Not covered

benzoyl peroxide-erythromycin Benzamycin 1b

calcipotriene external cream Dovonex 1b

CALCIPOTRIENE EXTERNAL FOAM Not covered

calcipotriene external ointment Calcitrene 1b

calcipotriene external solution 1b

calcipotriene-betameth diprop Taclonex 1b PA

calcitriol external Vectical 1b

claravis Accutane 1b QL

clindacin etz external swab Clindacin ETZ 1b

clindacin-p Clindacin ETZ 1b

clindamycin phos-benzoyl perox external gel 1.2-2.5 %

Acanya Not covered

clindamycin phos-benzoyl perox external gel 1.2-5 %

Neuac Not covered

clindamycin phosphate-benzoyl peroxide external gel 1-5 %

BenzaClin 1b

clindamycin phosphate external foam Evoclin Not covered

clindamycin phosphate external lotion Cleocin-T Not covered

clindamycin phosphate external solution Not covered

clindamycin phosphate external swab Clindacin ETZ 1b

clindamycin phosphate gel 1 % external Cleocin-T 1b

clindamycin phosphate gel 1 % external Clindagel Not covered

clindamycin-tretinoin Veltin Not covered

CONDYLOX 2

COSENTYX (300 MG DOSE) Not covered SP; QL


61


COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

Not covered SP; QL

COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 75 MG/0.5ML

Not covered SP

COSENTYX SENSOREADY (300 MG) Not covered SP; QL

COSENTYX SENSOREADY PEN Not covered SP; QL

dapsone external gel 5 % Aczone Not covered QL

DAPSONE EXTERNAL GEL 7.5 % Not covered ABA

DIFFERIN EXTERNAL LOTION Not covered

doxepin hcl external Prudoxin 1b PA; QL

doxycycline Oracea Not covered

DRYSOL 2

DUOBRII 3 QL

DUPIXENT 4 PA; SP; QL

ENSTILAR Not covered QL

EPIFOAM 2

ery Not covered

erythromycin external Erygel Not covered

EUCRISA 2 PA; QL

FABIOR Not covered QL

FINACEA EXTERNAL FOAM Not covered QL

hydrocortisone ace-pramoxine external cream 2.5-1 %

Pramosone 1b

imiquimod cream 3.75 % external Zyclara Pump Not covered QL

imiquimod external cream 5 % Aldara 1b QL

IMIQUIMOD PUMP CREAM 3.75 % EXTERNAL

Not covered QL

IMIQUIMOD PUMP CREAM 3.75 % EXTERNAL

Not covered ABA; QL

isotretinoin oral capsule 10 mg Amnesteem 1b QL

isotretinoin oral capsule 20 mg, 30 mg, 40 mg

Accutane 1b QL

isotretinoin oral capsule 25 mg, 35 mg Absorica Not covered QL

ivermectin external cream Soolantra Not covered QL

LIDOCAINE-HYDROCORTISONE ACE EXTERNAL

Not covered

methoxsalen rapid 1b


62


metronidazole external cream Rosadan 1b

metronidazole external gel 0.75 % Rosadan 1b

metronidazole external gel 1 % Metrogel Not covered

metronidazole external lotion MetroLotion 1b

myorisan Accutane 1b QL

neuac external gel Neuac Not covered

NORITATE Not covered

ONEXTON Not covered QL

OPZELURA 3 PA; QL

OVACE PLUS WASH EXTERNAL LIQUID

3

OVACE WASH Not covered

pimecrolimus Elidel 1b

podofilox external 1b

PR BENZOYL PEROXIDE Not covered

PRAMOSONE Not covered

QBREXZA Not covered QL

REGRANEX 3 QL

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %

Not covered

rosadan external cream Rosadan 1b

rosadan external gel Rosadan 1b

SANTYL 2

selenium sulfide external lotion 1b

SILIQ Not covered SP; QL

sodium sulfacetamide wash Ovace Plus Wash 1b

SORILUX Not covered

sss 10-5 external cream Avar-e Emollient 1b

STELARA SUBCUTANEOUS 4 PA; SP; QL

sulfacetamide sodium (acne) Klaron 1b

sulfacetamide sodium external Ovace Plus Wash 1b

sulfacetamide sodium-sulfur external cream 10-5 %

Avar-e Emollient 1b

sulfacetamide sodium-sulfur external liquid 10-5 %

Avar Cleanser 1b

tacrolimus external Protopic 1b

TALTZ 5 PA; SP; QL

tazarotene external cream Tazorac 1b


63


TAZAROTENE EXTERNAL FOAM Not covered ABA; QL

TAZORAC EXTERNAL CREAM 0.05 % 2

TAZORAC EXTERNAL GEL 2

TREMFYA 4 PA; SP; QL

tretinoin external cream Avita 1b

tretinoin external gel 0.01 % Retin-A 1b

tretinoin external gel 0.025 % Avita 1b

tretinoin external gel 0.05 % Atralin Not covered

tretinoin microsphereRETIN-A MICRO GEL 0.04 %, 0.1 %

Not covered

tretinoin microsphere pumpRETIN-A MICRO GEL 0.04 %, 0.1 %

Not covered

VELTIN Not covered

VEREGEN 3

WINLEVI Not covered QL

WYNZORA Not covered QL

zenatane Accutane 1b QL

ZILXI Not covered QL

ZYCLARA PUMP Not covered QL

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

ACCRUFER 3 PA; QL

carglumic acid Carbaglu 4 PA; SP

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

Not covered

effer-k oral tablet effervescent 25 meq 1b

fluoritab NaFrinse Drops 1bPV2; AL (Min 6 Months and Max 16 Years)

GALZIN 3

iodine strong oral 1b

klor-con Klor-Con 1b

klor-con 10 Klor-Con 10 1b

klor-con m10 Klor-Con M10 1b



klor-con/ef 1b


64


K-PHOS Not covered

K-PHOS NO 2 Not covered

k-prime 1b

levocarnitine oral solution Carnitor 1b

levocarnitine oral tablet Carnitor 1b

levocarnitine sf Carnitor 1b

nafrinse NaFrinse 1bPV2; AL (Min 6 Months and Max 16 Years)

nafrinse drops NaFrinse Drops 1bPV2; AL (Min 6 Months and Max 16 Years)

potassium chloride crys er Klor-Con M10 1b

potassium chloride er K-Tab 1b

potassium chloride oral packet Klor-Con 1b

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

1b

potassium citrate er Urocit-K 10 1b

sodium fluoride oral NaFrinse 1bPV2; AL (Min 6 Months and Max 16 Years)

Electrolyte/Mineral/Metal Modifiers

CHEMET 2

deferasirox granules Jadenu Sprinkle Not covered 15DS; SP

deferasirox oral packet Jadenu Sprinkle Not covered 15DS; SP

deferasirox oral tablet Jadenu Not covered 15DS; SP

deferasirox oral tablet soluble Exjade 4 PA; 15DS; SP

deferiprone Ferriprox 4 PA; SP; QL

FERRIPROX ORAL SOLUTION 5 PA; SP; QL

FERRIPROX ORAL TABLET 1000 MG 5 PA; SP; QL

FERRIPROX TWICE-A-DAY 5 PA; SP; QL

JYNARQUE 4 PA; SP; QL

LOKELMA 2 QL

SAMSCA ORAL TABLET 15 MG 4 PA; SP; QL

sodium polystyrene sulfonate 1b

sps 1b

TOLVAPTAN ORAL TABLET 15 MG 4 PA; SP; QL

tolvaptan oral tablet 30 mg Jynarque 4 PA; SP; QL

trientine hcl Syprine 4 PA; SP; QL


65


VELTASSA 2 QL

Phosphate Binders

AURYXIA 3

calcium acetate (phos binder) Calphron 1b

calcium acetate oral tablet 667 mg Calphron 1b

FOSRENOL ORAL PACKET Not covered

lanthanum carbonate Fosrenol 1b

PHOSLYRA 3

sevelamer carbonate Renvela 1b

sevelamer hcl Renagel 1b

VELPHORO Not covered

Vitamins

cyanocobalamin injection solution 1000 mcg/ml

1b

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

Not covered

ergocalciferol oral capsule Drisdol 1b

folate 0 PV1

folic acid oral tablet 1 mg 1b

folic acid oral tablet 400 mcg, 800 mcg 0 PV1

hydroxocobalamin acetate 1b

NASCOBAL Not covered

phytonadione injection solution 10 mg/ml 1b

phytonadione oral Mephyton 1b

POTABA Not covered

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

Drisdol 1b

vitamin k1 injection 1b

yl folic acid 0 PV1

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

belladonna alkaloids-opium 1b

CUVPOSA 3

dicyclomine hcl oral 1b

glycopyrrolate oral tablet 1b

hyoscyamine sulfate er Levbid 1b

hyoscyamine sulfate oral Levsin 1b

hyoscyamine sulfate sl Levsin/SL 1b


66


hyoscyamine sulfate sublingual Levsin/SL 1b

hyosyne 1b

LEVBID Not covered

LEVSIN ORAL Not covered

LEVSIN/SL Not covered

methscopolamine bromide oral 1b

NULEV Not covered

OSCIMIN Not covered

oscimin sr oral tablet extended release 12 hour 0.375 mg

Levbid 1b

Gastrointestinal Agents, Other

amoxicill-clarithro-lansopraz 1b

CHENODAL 5 PA; SP

chlordiazepoxide-clidinium Librax 1b

cromolyn sodium oral Gastrocrom 1b

diphenoxylate-atropine Lomotil 1b

GATTEX 4 PA; SP; QL

HELIDAC THERAPY Not covered

loperamide hcl oral capsule Imodium A-D Not covered

MOTEGRITY 3 ST; QL

MOTOFEN Not covered

MOVANTIK Not covered QL

MYTESI 2 PA; QL

OMECLAMOX-PAK Not covered

PYLERA Not covered

RELISTOR ORAL Not covered QL

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML

Not covered QL

RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML

Not covered ABA; QL

RELTONE Not covered

SEROSTIM 5 PA; SP

SYMPROIC 2 QL

TALICIA Not covered QL

TRULANCE Not covered QL

URSODIOL ORAL CAPSULE 200 MG, 400 MG

Not covered

ursodiol oral capsule 300 mg 1b


67


ursodiol oral tablet Urso 250 1b

XERMELO 4 PA; SP; QL

ZORBTIVE 5 PA; SP

Histamine2 (H2) Receptor Antagonists

cimetidine hcl 1b

cimetidine oral Tagamet HB 1b

famotidine oral suspension reconstituted 1b

famotidine oral tablet 20 mgMM Acid-Pep Maximum Strength

1b

famotidine oral tablet 40 mg Pepcid 1b

nizatidine 1b

Irritable Bowel Syndrome Agents

alosetron hcl Lotronex 1b QL

AMITIZA 2 QL

LINZESS 2 QL

LUBIPROSTONE Not covered ABA; QL

VIBERZI Not covered QL

ZELNORM 3 PA; QL

Laxatives

bisacodyl ec Alophen 0PV1; QL; AL (Min 45 Years and Max 75 Years)

citroma Citroma 0PV1; QL; AL (Min 45 Years and Max 75 Years)

clearlax ClearLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)

CLENPIQ 3

constulose 1b

enulose 1b

gavilax oral powder ClearLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)

gavilyte-c 1bPV2; QL; AL (Min 45 Years and Max 75 Years)

gavilyte-g GaviLyte-G 1bPV2; QL; AL (Min 45 Years and Max 75 Years)


68


gavilyte-n with flavor packGaviLyte-N with Flavor Pack

1bPV2; QL; AL (Min 45 Years and Max 75 Years)

generlac 1b

gentle laxative oral Alophen 0PV1; QL; AL (Min 45 Years and Max 75 Years)

healthylax HealthyLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)

KRISTALOSE Not covered

lactulose encephalopathy 1b

lactulose oral packet Kristalose Not covered

lactulose oral solution 1b

magnesium citrate oral solution Citroma 0PV1; QL; AL (Min 45 Years and Max 75 Years)

milk of magnesia concentrate 0PV1; QL; AL (Min 45 Years and Max 75 Years)

milk of magnesia oral suspension 1200 mg/15ml, 400 mg/5ml

Dulcolax 0PV1; QL; AL (Min 45 Years and Max 75 Years)

mm clearlax ClearLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)

OSMOPREP Not covered

peg 3350 oral packet HealthyLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)

peg 3350-kcl-na bicarb-naclGaviLyte-N with Flavor Pack

1bPV2; QL; AL (Min 45 Years and Max 75 Years)

peg-3350/electrolytes GaviLyte-G 1bPV2; QL; AL (Min 45 Years and Max 75 Years)

peg-3350/electrolytes/ascorbat MoviPrep 1bPV2; QL; AL (Min 45 Years and Max 75 Years)

peg-kcl-nacl-nasulf-na asc-c MoviPrep 1bPV2; QL; AL (Min 45 Years and Max 75 Years)


69


peg-prep 1bPV2; QL; AL (Min 45 Years and Max 75 Years)

PLENVU Not covered

polyethylene glycol 3350 oral packet 17 gm

HealthyLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)

polyethylene glycol 3350 oral powder ClearLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)

qc magnesium citrate Citroma 0PV1; QL; AL (Min 45 Years and Max 75 Years)

SUPREP BOWEL PREP KIT 3

SUTAB Not covered QL

Protectants

CYTOTEC 3

misoprostol oral Cytotec 1b

sucralfate oral Carafate 1b

Proton Pump Inhibitors

ACIPHEX SPRINKLE Not covered QL

DEXILANT Not covered

DEXLANSOPRAZOLE Not covered

ESOMEPRAZOLE STRONTIUM Not covered ABA; QL

lansoprazole oral capsule delayed release

Prevacid 1b QL

NEXIUM ORAL PACKET 2.5 MG, 5 MG Not covered AL (Max 1 Years)

omeprazole oral capsule delayed release 1b QL

omeprazole-sodium bicarbonate Zegerid Not covered QL

pantoprazole sodium oral tablet delayed release

Protonix 1b QL

PRILOSEC Not covered

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE

Not covered ABA; QL

rabeprazole sodium oral tablet delayed release

Aciphex 1b

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

CERDELGA 4 PA; SP; QL

CHOLBAM 4 PA; SP; QL


70

ABA


CREON 2

CYSTADANE 5 SP

CYSTAGON 4 SP

EVRYSDI 4 PA; SP; QL

GALAFOLD 4 PA; SP; QL

GLASSIA 4 PA; SP; QL

miglustat Zavesca 4 PA; SP; QL

MYALEPT 5 PA; SP; QL

nitisinone Orfadin 4 PA; SP

NITYR 5 PA; SP

OCALIVA 4 PA; SP; QL

ORFADIN ORAL CAPSULE 20 MG 4 PA; SP

ORFADIN ORAL SUSPENSION 4 PA; SP

PALYNZIQ 4 PA; SP; QL

PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG

Not covered SP; QL

PROCYSBI ORAL CAPSULE DELAYED RELEASE 75 MG

Not covered SP

PROCYSBI ORAL PACKET Not covered SP; QL

RAVICTI 5 PA; SP; QL

REVCOVI 4 PA; SP; QL

sapropterin dihydrochloride Kuvan 4 PA; SP

sodium phenylbutyrate oral powder Buphenyl 1b

sodium phenylbutyrate oral tablet Buphenyl 1b QL

STRENSIQ 4 PA; SP; QL

SUCRAID 5 PA; SP; QL

TEGSEDI 4 PA; SP; QL

XURIDEN 4 PA; SP; QL

ZENPEP 2

Genitourinary Agents

Antispasmodics, Urinary

darifenacin hydrobromide er Enablex Not covered QL

flavoxate hcl 1b

GELNIQUE Not covered QL

GEMTESA Not covered QL

MYRBETRIQ 3 PA; QL

oxybutynin chloride er Ditropan XL 1a


71


oxybutynin chloride oral 1a

OXYTROL Not covered QL

solifenacin succinate VESIcare 1b QL

tolterodine tartrate Detrol 1b

tolterodine tartrate er Detrol LA 1b

TOVIAZ Not covered QL

trospium chloride 1b QL

trospium chloride er 1b QL

VESICARE LS 3 PA; QL

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er Uroxatral 1b

CARDURA XL 3

dutasteride oral Avodart 1b

dutasteride-tamsulosin hcl Jalyn 1b QL

finasteride oral tablet 5 mg Proscar 1b

silodosin Rapaflo 1b QL

tamsulosin hcl Flomax 1b

terazosin hcl 1b

Genitourinary Agents, Other

acetic acid irrigation 1b

argyle sterile saline Argyle Sterile Saline 1b

bethanechol chloride oral 1b

curity sterile saline Argyle Sterile Saline 1b

ELMIRON 2

LITHOSTAT 3

OPTIONS GYNOL II CONTRACEPTIVE 0 PV1; QL

penicillamine oral capsule Cuprimine Not covered QL

penicillamine oral tablet Depen Titratabs 1b QL

RENACIDIN 2

sodium chloride irrigation Argyle Sterile Saline 1b

THIOLA EC 2 PA; QL

tiopronin Thiola 1b PA; QL

TODAY SPONGE 0 PV1; QL

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM

0 PV1; QL

VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM

0 PV1; QL


72


vcf vaginal contraceptive vaginal gel 0 PV1; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

ALA SCALP Not covered

ala-cort external cream 1 % Aveeno Anti-Itch Max St Not covered

ala-cort external cream 2.5 % 1b

alclometasone dipropionate 1b

ALKINDI SPRINKLE 3 PA; QL

amcinonide Not covered

APEXICON E Not covered

betamethasone dipropionate aug Diprolene 1b

betamethasone dipropionate external 1b

betamethasone valerate external cream 1b

betamethasone valerate external foam Luxiq Not covered

betamethasone valerate external lotion 1b

betamethasone valerate external ointment

1b

BRYHALI 3 QL

CAPEX 2

clobetasol prop emollient base 1b

clobetasol propionate e 1b

clobetasol propionate emulsion Tovet Not covered

clobetasol propionate external cream Temovate 1b

clobetasol propionate external foam Olux Not covered

clobetasol propionate external gel 1b

clobetasol propionate external liquid Clobex Spray Not covered

clobetasol propionate external lotion Clobex Not covered

clobetasol propionate external ointment Temovate 1b

clobetasol propionate external shampoo Clodan 1b

clobetasol propionate external solution 1b

clocortolone pivalate Cloderm Not covered

clodan external shampoo Clodan 1b

CORDRAN EXTERNAL CREAM 0.025 %

Not covered

CORDRAN EXTERNAL TAPE Not covered

DECADRON Not covered

desonide external cream DesOwen 1b


73


desonide external gel DesRx Not covered

desonide external lotion 1b

desonide external ointment 1b

desoximetasone external Topicort Not covered

desrx DesRx Not covered

DEXABLISS Not covered

dexamethasone intensol 1a

dexamethasone oral elixir 1a

dexamethasone oral solution 1a

dexamethasone oral tablet Decadron 1a

dexamethasone oral tablet therapy pack HiDex 6-Day 1b

diflorasone diacetate Not covered

DXEVO 11-DAY Not covered

EMFLAZA 5 PA; SP

fludrocortisone acetate oral 1b

fluocinolone acetonide bodyDerma-Smoothe/FS Body

1b

fluocinolone acetonide external Synalar 1b

fluocinolone acetonide scalpDerma-Smoothe/FS Scalp

1b

fluocinonide emulsified base 1b

fluocinonide external cream 0.05 % 1b

fluocinonide external cream 0.1 % Vanos 1b QL

fluocinonide external gel 1b

fluocinonide external ointment 1b

fluocinonide external solution 1b

flurandrenolide Cordran Not covered

fluticasone propionate external Cutivate 1b

halcinonide Halog Not covered

halobetasol propionate external cream 1b

HALOBETASOL PROPIONATE EXTERNAL FOAM

Not covered

halobetasol propionate external ointment 1b

HALOG EXTERNAL OINTMENT Not covered

HALOG EXTERNAL SOLUTION Not covered

HEMADY Not covered

HIDEX 6-DAY Not covered

hydrocortisone butyr lipo base Locoid Lipocream Not covered


74


hydrocortisone butyrate Locoid 1b

hydrocortisone external cream 1 % Aveeno Anti-Itch Max St Not covered

hydrocortisone external cream 2.5 % 1b

hydrocortisone external lotion 2.5 % 1b

hydrocortisone external ointment 1 %Aquaphor Itch Relief Max Str

Not covered

hydrocortisone external ointment 2.5 % 1b

hydrocortisone oral Cortef 1a

hydrocortisone valerate 1b

IMPEKLO Not covered

IMPOYZ Not covered

LEXETTE Not covered

MEDROL ORAL TABLET 2 MG 3

methylprednisolone oral Medrol 1a

MILLIPRED 2

mometasone furoate external 1b

nolix Nolix Not covered

PANDEL Not covered

prednicarbate Not covered

prednisolone oral solution 1a

prednisolone sodium phosphate oral solution

Pediapred 1a

prednisolone sodium phosphate oral tablet dispersible

Orapred ODT Not covered

prednisone intensol 1a

prednisone oral 1a

PSORCON Not covered

RAYOS Not covered QL

SERNIVO Not covered QL

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG

3

TAPERDEX 12-DAY Not covered



TEXACORT Not covered

tovet external foam Tovet Not covered

triamcinolone acetonide external aerosol solution

Kenalog 1b QL


75


triamcinolone acetonide external cream Triderm 1b

triamcinolone acetonide external lotion 1b

triamcinolone acetonide external ointment

Tritocin 1b

triamcinolone in absorbase Tritocin 1b

TRIANEX Not covered

triderm Triderm 1b

tritocin Tritocin 1b

ULTRAVATE Not covered

VERDESO Not covered

ZCORT 7-DAY Not covered

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

ACTHAR Not covered SP; QL

cabergoline 1b

CHORIONIC GONADOTROPIN INTRAMUSCULAR

Not covered SP; QL

desmopressin ace spray refrig 1b

desmopressin acetate injection DDAVP 1b

desmopressin acetate oral DDAVP 1b

desmopressin acetate pf DDAVP PF 1b

desmopressin acetate spray 1b

EGRIFTA SV Not covered SP; QL

FOLLISTIM AQ 5 PA; SP; QL

GENOTROPIN 4 PA; SP

GENOTROPIN MINIQUICK 4 PA; SP

GONAL-F 4 PA; SP; QL

GONAL-F RFF 4 PA; SP; QL

GONAL-F RFF REDIJECT 4 PA; SP; QL

HUMATROPE 5 PA; SP

INCRELEX 4 PA; SP

ISTURISA 5 PA; SP; QL

NOCDURNA Not covered QL

NORDITROPIN FLEXPRO 4 PA; SP

NOVAREL Not covered SP; QL

NUTROPIN AQ NUSPIN 10 5 PA; SP



76



OMNITROPE 5 PA; SP

OVIDREL 4 PA; SP; QL

PREGNYL 4 PA; SP; QL

SAIZEN 5 PA; SP

SAIZENPREP 5 PA; SP

SKYTROFA 5 PA; SP

STIMATE 2

ZOMACTON 5 PA; SP

ZOMACTON (FOR ZOMA-JET 10) 5 PA; SP

Selective Estrogen Receptor Modifying Agents

clomiphene citrate oral 1b QL

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

KORLYM 4 PA; SP; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Androgens

ANDRODERM 2 PA; QL

danazol oral 1b

INTRAROSA 3

JATENZO Not covered QL

METHITEST 3 QL

methyltestosterone oral Not covered QL

NATESTO Not covered QL

oxandrolone oral 1b PA

TESTOSTERONE CYPIONATE INJECTION

Not covered

testosterone cypionate intramuscular Depo-Testosterone 1b

testosterone enanthate intramuscular 1b

testosterone transdermal gel 1.62 %, 20.25 mg/act (1.62%)

AndroGel Pump 1b PA; QL

testosterone transdermal gel 10 mg/act (2%)

Fortesta Not covered QL

testosterone transdermal gel 12.5 mg/act (1%)

Vogelxo Pump 1b PA; QL


77


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

AndroGel 1b PA; QL

testosterone transdermal solution Not covered QL

XYOSTED Not covered QL

Estrogens

afirmelle Afirmelle 1a PV2

ALORA 2

altavera Altavera 1a PV2

alyacen 1/35 Cyclafem 1/35 1a PV2

alyacen 7/7/7 Cyclafem 7/7/7 1a PV2

amabelz Amabelz 1b

amethia Amethia 1a PV2; QL

amethyst Amethyst 1a PV2

ANGELIQ 3

ANNOVERA Not covered QL

apri Apri 1a PV2

aranelle 1a PV2

ashlyna Amethia 1a PV2; QL

aubra Afirmelle 1a PV2

aubra eq Afirmelle 1a PV2

aurovela 1.5/30 Aurovela 1.5/30 1a PV2

aurovela 1/20 Aurovela 1/20 1a PV2

aurovela 24 fe 1a PV2

aurovela fe 1.5/30 Aurovela Fe 1.5/30 1a PV2

aurovela fe 1/20 Aurovela FE 1/20 1a PV2

aviane Afirmelle 1a PV2

ayuna Altavera 1a PV2

azurette Azurette 1a PV2

BALCOLTRA 3

balziva Balziva 1a PV2

BIJUVA Not covered QL

blisovi 24 fe 1a PV2

blisovi fe 1.5/30 Aurovela Fe 1.5/30 1a PV2

blisovi fe 1/20 Aurovela FE 1/20 1a PV2

briellyn Balziva 1a PV2

camrese Amethia 1a PV2; QL


78


camrese lo Camrese Lo 1a PV2; QL

caziant 1a PV2

charlotte 24 fe Charlotte 24 Fe 1a PV2

chateal Altavera 1a PV2

chateal eq Altavera 1a PV2

CLIMARA PRO 3

COMBIPATCH 3

COVARYX Not covered

COVARYX HS Not covered

cryselle-28 1a PV2

cyclafem 1/35 Cyclafem 1/35 1a PV2

cyclafem 7/7/7 Cyclafem 7/7/7 1a PV2

cyred Apri 1a PV2

cyred eq Apri 1a PV2

dasetta 1/35 Cyclafem 1/35 1a PV2

dasetta 7/7/7 Cyclafem 7/7/7 1a PV2

daysee Amethia 1a PV2; QL

DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

3

delyla Afirmelle 1a PV2

desogestrel-ethinyl estradiol Apri 1a PV2

DIVIGEL 3

dolishale Amethyst 1a PV2

dotti Dotti 1b

drospiren-eth estrad-levomefol Beyaz 1a PV2

drospirenone-ethinyl estradiol Jasmiel 1a PV2

DUAVEE 3

EEMT Not covered

EEMT HS Not covered

ELESTRIN 3

elinest 1a PV2

eluryng EluRyng 1a PV2; QL

emoquette Apri 1a PV2

enpresse-28 Enpresse-28 1a PV2

enskyce Apri 1a PV2

est estrogens-methyltest Covaryx 1b

est estrogens-methyltest ds Covaryx 1b


79


est estrogens-methyltest hs Covaryx HS 1b

estarylla Estarylla 1a PV2

estradiol oral Estrace 1b

estradiol transdermal Climara 1b

estradiol vaginal Estrace 1b

estradiol valerate intramuscular Delestrogen 1b

estradiol-norethindrone acet Amabelz 1b

ESTRING 2

ESTROGEL 2

ethynodiol diac-eth estradiol Kelnor 1/35 1a PV2

etonogestrel-ethinyl estradiol EluRyng 1a PV2; QL

EVAMIST 3

falmina Afirmelle 1a PV2

fayosim Fayosim 1a PV2; QL

FEMRING 3

femynor Estarylla 1a PV2

fyavolv Fyavolv 1b

gemmily Gemmily 1a PV2

hailey 1.5/30 Aurovela 1.5/30 1a PV2

hailey 24 fe 1a PV2

hailey fe 1.5/30 Aurovela Fe 1.5/30 1a PV2

hailey fe 1/20 Aurovela FE 1/20 1a PV2

iclevia Iclevia 1a PV2; QL

IMVEXXY MAINTENANCE PACK 3

IMVEXXY STARTER PACK 3

introvale Iclevia 1a PV2; QL

isibloom Apri 1a PV2

jaimiess Amethia 1a PV2; QL

jasmiel Jasmiel 1a PV2

jinteli Fyavolv 1b

jolessa Iclevia 1a PV2; QL

juleber Apri 1a PV2

junel 1.5/30 Aurovela 1.5/30 1a PV2

junel 1/20 Aurovela 1/20 1a PV2

junel fe 1.5/30 Aurovela Fe 1.5/30 1a PV2

junel fe 1/20 Aurovela FE 1/20 1a PV2

junel fe 24 1a PV2


80


kaitlib fe Kaitlib Fe 1a PV2

kalliga Apri 1a PV2

kariva Azurette 1a PV2

kelnor 1/35 Kelnor 1/35 1a PV2

kelnor 1/50 Kelnor 1/50 1a PV2

kurvelo Altavera 1a PV2

larin 1.5/30 Aurovela 1.5/30 1a PV2

larin 1/20 Aurovela 1/20 1a PV2

larin 24 fe 1a PV2

larin fe 1.5/30 Aurovela Fe 1.5/30 1a PV2

larin fe 1/20 Aurovela FE 1/20 1a PV2

larissia Afirmelle 1a PV2

layolis fe Kaitlib Fe 1a PV2

leena 1a PV2

lessina Afirmelle 1a PV2

levonest Enpresse-28 1a PV2

levonorgest-eth est & eth est Fayosim 1a PV2; QL

levonorgest-eth estrad 91-day Amethia 1a PV2; QL

levonorgestrel-ethinyl estrad Afirmelle 1a PV2

levonorg-eth estrad triphasic Enpresse-28 1a PV2

levora 0.15/30 (28) Altavera 1a PV2

lillow Altavera 1a PV2

LO LOESTRIN FE 3

lojaimiess Camrese Lo 1a PV2; QL

loryna Jasmiel 1a PV2

low-ogestrel 1a PV2

lo-zumandimine Jasmiel 1a PV2

lutera Afirmelle 1a PV2

lyllana Dotti 1b

marlissa Altavera 1a PV2

MENEST 3

MENOSTAR 3

merzee Gemmily 1a PV2

microgestin 1.5/30 Aurovela 1.5/30 1a PV2

microgestin 1/20 Aurovela 1/20 1a PV2

microgestin 24 fe 1a PV2

microgestin fe 1.5/30 Aurovela Fe 1.5/30 1a PV2


81


microgestin fe 1/20 Aurovela FE 1/20 1a PV2

mili Estarylla 1a PV2

mimvey Amabelz 1b

mono-linyah Estarylla 1a PV2

MYFEMBREE 3 PA; QL

NATAZIA 3

necon 0.5/35 (28) 1a PV2

NEXTSTELLIS 3

nikki Jasmiel 1a PV2

norethin ace-eth estrad-fe Aurovela Fe 1.5/30 1a PV2

norethindrone acet-ethinyl est Aurovela 1.5/30 1a PV2

norethindrone-eth estradiol Fyavolv 1b

norethin-eth estradiol-fe Kaitlib Fe 1a PV2

norgestimate-eth estradiol Estarylla 1a PV2

norgestimate-ethinyl estradiol triphasic Tri Femynor 1a PV2

nortrel 0.5/35 (28) 1a PV2

nortrel 1/35 (21) Cyclafem 1/35 1a PV2

nortrel 1/35 (28) Cyclafem 1/35 1a PV2

nortrel 7/7/7 Cyclafem 7/7/7 1a PV2

nylia 1/35 Cyclafem 1/35 1a PV2

nylia 7/7/7 Cyclafem 7/7/7 1a PV2

nymyo Estarylla 1a PV2

ocella Ocella 1a PV2

ORIAHNN 3 PA; QL

orsythia Afirmelle 1a PV2

philith Balziva 1a PV2

pimtrea Azurette 1a PV2

pirmella 1/35 Cyclafem 1/35 1a PV2

pirmella 7/7/7 Cyclafem 7/7/7 1a PV2

portia-28 Altavera 1a PV2

PREFEST 3

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

previfem Estarylla 1a PV2

reclipsen Apri 1a PV2


82


rivelsa Fayosim 1a PV2; QL

setlakin Iclevia 1a PV2; QL

simliya Azurette 1a PV2

simpesse Amethia 1a PV2; QL

sprintec 28 Estarylla 1a PV2

sronyx Afirmelle 1a PV2

syeda Ocella 1a PV2

tarina 24 fe 1a PV2

tarina fe 1/20 Aurovela FE 1/20 1a PV2

tarina fe 1/20 eq Aurovela FE 1/20 1a PV2

taysofy Gemmily 1a PV2

tilia fe 1a PV2

tri femynor Tri Femynor 1a PV2

tri-estarylla Tri Femynor 1a PV2

tri-legest fe 1a PV2

tri-linyah Tri Femynor 1a PV2

tri-lo-estarylla Tri-Lo-Estarylla 1a PV2

tri-lo-marzia Tri-Lo-Estarylla 1a PV2

tri-lo-mili Tri-Lo-Estarylla 1a PV2

tri-lo-sprintec Tri-Lo-Estarylla 1a PV2

tri-mili Tri Femynor 1a PV2

tri-nymyo Tri Femynor 1a PV2

tri-previfem Tri Femynor 1a PV2

tri-sprintec Tri Femynor 1a PV2

trivora (28) Enpresse-28 1a PV2

tri-vylibra Tri Femynor 1a PV2

tri-vylibra lo Tri-Lo-Estarylla 1a PV2

TWIRLA Not covered QL

tyblume 1a PV2

tydemy Tydemy 1a PV2

velivet 1a PV2

vestura Jasmiel 1a PV2

vienva Afirmelle 1a PV2

viorele Azurette 1a PV2

volnea Azurette 1a PV2

vyfemla Balziva 1a PV2

vylibra Estarylla 1a PV2


83


wera 1a PV2

wymzya fe Wymzya Fe 1a PV2

xulane 1a PV2; QL

yuvafem Yuvafem 1b

zafemy 1a PV2; QL

zarah Ocella 1a PV2

zovia 1/35 (28) Kelnor 1/35 1a PV2

zovia 1/35e (28) Kelnor 1/35 1a PV2

zumandimine Ocella 1a PV2

Progestins

camila Camila 1a PV2

deblitane Camila 1a PV2

DEPO-SUBQ PROVERA 104 2

ELLA 3 PV2; QL

ENDOMETRIN Not covered

errin Camila 1a PV2

heather Camila 1a PV2

incassia Camila 1a PV2

jencycla Camila 1a PV2

levonorgestrel Aftera 0 PV1; QL

lyleq Camila 1a PV2

lyza Camila 1a PV2

medroxyprogesterone acetate intramuscular

Depo-Provera 1a PV2

medroxyprogesterone acetate oral Provera 1b

megestrol acetate oral 1b

nora-be Camila 1a PV2

norethindrone acetate oral Aygestin 1b

norethindrone oral Camila 1a PV2

norlyda Camila 1a PV2

norlyroc Camila 1a PV2

progesterone intramuscular 1b

progesterone oral Prometrium 1b

sharobel Camila 1a PV2

SLYND 3 QL

tulana Camila 1a PV2


84


Selective Estrogen Receptor Modifying Agents

OSPHENA 3

raloxifene hcl Evista 1b PV3; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

ARMOUR THYROID 3

euthyrox Euthyrox 1a

levo-t Euthyrox 1a

LEVOTHYROXINE SODIUM ORAL CAPSULE

3 ABA

levothyroxine sodium oral tablet Euthyrox 1a

levoxyl Euthyrox 1a

liothyronine sodium oral Cytomel 1a

NATURE-THROID 2

np thyroid Armour Thyroid 1a

THYQUIDITY Not covered

TIROSINT 3

TIROSINT-SOL 3

unithroid Euthyrox 1a

WESTHROID 2

WP THYROID 3

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 2

Hormonal Agents, Suppressant (Pituitary)

ganirelix acetate 4 SP

leuprolide acetate injection 4 SP

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG

4 SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG

4 SP

LUPRON DEPOT-PED (1-MONTH) 4 SP

LUPRON DEPOT-PED (3-MONTH) 4 SP

MYCAPSSA Not covered SP; QL

octreotide acetate SandoSTATIN 4 SP


85


ORILISSA 2 PA; QL

SANDOSTATIN LAR DEPOT 4 PA; SP

SIGNIFOR 4 PA; SP; QL

SIGNIFOR LAR Not covered SP; QL

SOMATULINE DEPOT 4 PA; SP; QL

SOMAVERT 4 PA; SP

SYNAREL 3

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole oral 1b

propylthiouracil oral 1b

Immunological Agents

Angioedema Agents

HAEGARDA 4 PA; SP; QL

icatibant acetate Sajazir 4 PA; SP; QL

ORLADEYO 5 PA; SP; QL

RUCONEST 5 PA; SP; QL

sajazir Sajazir 4 PA; SP; QL

TAKHZYRO 4 PA; SP; QL

Immune Suppressants

ASTAGRAF XL 5 SP

azathioprine oral Azasan 1b

CIMZIA PREFILLED KIT 5 PA; SP; QL

CIMZIA STARTER KIT 5 PA; SP; QL

cyclosporine modified Gengraf 4 SP

cyclosporine oral SandIMMUNE 4 SP

ENBREL 4 PA; SP; QL

ENBREL MINI 4 PA; SP; QL

ENBREL SURECLICK 4 PA; SP; QL

ENVARSUS XR 5 SP

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg

Zortress 4 SP

gengraf Gengraf 4 SP

HUMIRA 4 PA; SP; QL

HUMIRA PEDIATRIC CROHNS START 4 PA; SP; QL

HUMIRA PEN 4 PA; SP; QL


86


HUMIRA PEN-CD/UC/HS STARTER 4 PA; SP; QL

HUMIRA PEN-PEDIATRIC UC START 4 PA; SP; QL

HUMIRA PEN-PS/UV/ADOL HS START 4 PA; SP; QL

HUMIRA PEN-PSOR/UVEIT STARTER 4 PA; SP; QL

KINERET 5 PA; SP; QL

LUPKYNIS 5 PA; SP; QL

methotrexate oral 1b

methotrexate sodium (pf) 1b

methotrexate sodium injection solution 1b

methotrexate sodium oral 1b

mycophenolate mofetil oral CellCept 4 SP

mycophenolate sodium Myfortic 4 SP

OLUMIANT 5 PA; SP; QL

ORENCIA CLICKJECT 5 PA; SP; QL

ORENCIA SUBCUTANEOUS 5 PA; SP; QL

OTREXUP Not covered SP; QL

PROGRAF ORAL PACKET 5 SP

RASUVO Not covered SP; QL

REDITREX Not covered SP; QL

REZUROCK 4 PA; SP; QL

SANDIMMUNE ORAL SOLUTION 5 SP

SIMPONI 5 PA; SP; QL

sirolimus oral Rapamune 4 SP

SKYRIZI 4 PA; SP; QL

SKYRIZI (150 MG DOSE) 4 PA; SP; QL

SKYRIZI PEN 4 PA; SP; QL

tacrolimus oral Prograf 4 SP

TREXALL 2

XATMEP 5 SP

XELJANZ 4 PA; SP; QL

XELJANZ XR 4 PA; SP; QL

Immunoglobulins

CUTAQUIG 5 PA; SP

CUVITRU Not covered SP

GAMMAGARD 5 PA; SP

GAMMAKED 5 PA; SP

GAMUNEX-C 5 PA; SP


87


HIZENTRA 5 PA; SP

HYQVIA 5 PA; SP

XEMBIFY 5 PA; SP

Immunomodulators

ACTEMRA ACTPEN 5 PA; SP; QL

ACTEMRA SUBCUTANEOUS 5 PA; SP; QL

ACTIMMUNE 4 SP

ALFERON N 2

ARCALYST 5 PA; SP; QL

BENLYSTA SUBCUTANEOUS 4 PA; SP; QL

ENSPRYNG 4 PA; SP; QL

KEVZARA 5 PA; SP; QL

leflunomide oral Arava 1b

OTEZLA 4 PA; SP; QL

RIDAURA 2

RINVOQ 4 PA; SP; QL

XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

4 PA; SP; QL

Vaccines

ACTHIB 0 PV1; QL

ADACEL 0 PV1; QL

AFLURIA QUADRIVALENT 0 PV1; QL

BEXSERO 0 PV1; QL

BOOSTRIX 0 PV1; QL

DAPTACEL 0 PV1; QL

DIPHTHERIA-TETANUS TOXOIDS DT 0 PV1; QL

ENGERIX-B 0 PV1; QL

FLUAD QUADRIVALENT 0 PV1; QL

FLUARIX QUADRIVALENT 0 PV1; QL

FLUBLOK QUADRIVALENT 0 PV1; QL

FLUCELVAX QUADRIVALENT 0 PV1; QL

FLULAVAL QUADRIVALENT 0 PV1; QL

FLUMIST QUADRIVALENT 0 PV1; QL

FLUZONE HIGH-DOSE QUADRIVALENT

0 PV1; QL

FLUZONE QUADRIVALENT 0 PV1; QL


88


GARDASIL 9 0PV1; QL; AL (Min 9 Years and Max 45 Years)

HAVRIX 0 PV1; QL

HEPLISAV-B 0 PV1; QL

HIBERIX 0 PV1; QL

INFANRIX 0 PV1; QL

IPOL 0 PV1; QL

JANSSEN COVID-19 VACCINE 0 PV1; QL

KINRIX 0 PV1; QL

MENACTRA 0 PV1; QL

MENQUADFI 0 PV1; QL

MENVEO 0 PV1; QL

M-M-R II 0 PV1; QL

MODERNA COVID-19 VACCINE 0 PV1; QL

PEDIARIX 0 PV1; QL

PEDVAX HIB 0 PV1; QL

PENTACEL 0 PV1; QL

PFIZER COVID-19 VAC-TRIS 5-11Y 0 PV1

PFIZER-BIONT COVID-19 VAC-TRIS 0 PV1

PFIZER-BIONTECH COVID-19 VACC 0 PV1; QL

PNEUMOVAX 23 0 PV1; QL

PREVNAR 13 0PV1; QL; AL (Min 65 Years)

PROQUAD 0 PV1; QL

QUADRACEL 0 PV1; QL

RECOMBIVAX HB 0 PV1; QL

ROTARIX 0 PV1; QL

ROTATEQ 0 PV1; QL

SHINGRIX 0PV1; QL; AL (Min 50 Years)

TDVAX 0 PV1; QL

TENIVAC 0 PV1; QL

TRUMENBA 0 PV1; QL

TWINRIX 0 PV1; QL

VAQTA 0 PV1; QL

VARIVAX 0 PV1; QL

VAXELIS 0 PV1; QL


89


Inflammatory Bowel Disease Agents

Aminosalicylates

balsalazide disodium Colazal 1b

DIPENTUM 3

mesalamine er oral capsule 0.375 gm Apriso 1b

mesalamine oral capsule delayed release 400 mg

Delzicol 1b

mesalamine oral tablet delayed release 1.2 gm

Lialda 1b QL

mesalamine oral tablet delayed release 800 mg

Asacol HD 1b

mesalamine rectal Canasa 1b

PENTASA 2

SFROWASA Not covered

Glucocorticoids

ANALPRAM HC Not covered

ANALPRAM HC SINGLES Not covered

ANALPRAM-HC EXTERNAL CREAM 2

ANALPRAM-HC EXTERNAL LOTION Not covered

anucort-hc Anusol-HC 1b

ANUSOL-HC RECTAL Not covered

budesonide er Uceris 1b QL

budesonide oral Entocort EC 1b

CORTIFOAM 3

HEMMOREX-HC Not covered

hydrocortisone (perianal) Procto-Med HC 1b

hydrocortisone ace-pramoxine external cream 1-1 %

Analpram-HC 1b

hydrocortisone acetate rectal Anusol-HC 1b

hydrocortisone rectal Cortenema 1b

hydrocort-pramoxine (perianal) Analpram HC 1b

lidocaine-hydrocort (perianal) Lidocort 1b

LIDOCORT Not covered

ORTIKOS Not covered

PROCTOCORT RECTAL Not covered

PROCTOFOAM HC 2

procto-med hc Procto-Med HC 1b


90


procto-pak Procto-Pak 1b

proctosol hc Procto-Med HC 1b

proctozone-hc Procto-Med HC 1b

UCERIS RECTAL Not covered

Sulfonamides

sulfasalazine oral Azulfidine 1a

Metabolic Bone Disease Agents

alendronate sodium Fosamax 1a QL

BINOSTO Not covered QL

calcitonin (salmon) Miacalcin 1b

calcitriol oral Rocaltrol 1b

cinacalcet hcl Sensipar 4 SP

doxercalciferol oral 1b

FORTEO 4 PA; SP; QL

FOSAMAX PLUS D Not covered QL

ibandronate sodium oral Boniva 1a QL

NATPARA 4 PA; SP; QL

paricalcitol oral Zemplar 1b

RAYALDEE Not covered QL

risedronate sodium oral tablet Actonel 1b QL

risedronate sodium oral tablet delayed release

Atelvia 1b ST; QL

TERIPARATIDE (RECOMBINANT) Not covered SP; QL

TYMLOS 4 PA; SP; QL

Miscellaneous Therapeutic Agents

AEROCHAMBER MINI CHAMBER 3

AEROCHAMBER MV 3

AEROCHAMBER PLUS FLO-VU 3

AEROCHAMBER PLUS FLOW VU 3

AEROCHAMBER W/FLOWSIGNAL 3

BREATHE EASE LARGE 3

BREATHE EASE MEDIUM 3

BREATHE EASE SMALL 3

CAYA 3 PV2

CLEVER CHOICE HOLDING CHAMBER 3

COMPACT SPACE CHAMBER 3


91


COMPACT SPACE CHAMBER/LG MASK

3

COMPACT SPACE CHAMBER/MED MASK

3

COMPACT SPACE CHAMBER/SM MASK

3

deferoxamine mesylate Desferal 1b

DOJOLVI 4 PA; SP

EASIVENT 3

ENDARI 3 PA; QL

ergoloid mesylates oral 1b

FC FEMALE CONDOM 0 PV1; QL

FC2 FEMALE CONDOM 0 PV1; QL

FEMCAP 3 PV2; QL

FIRDAPSE Not covered SP; QL

FLEXICHAMBER 3

KERENDIA 3 PA; QL

LEVOCARNITINE INJECTION 3

methergine Methergine 1b PA; QL

methylergonovine maleate oral Methergine 1b PA; QL

MICROCHAMBER 3

OMNIPOD 5 PACK 2 QL

OMNIPOD DASH 5 PACK PODS 2 QL

OPTICHAMBER DIAMOND 3

OPTICHAMBER DIAMOND-LG MASK 3

OPTICHAMBER DIAMOND-MD MASK 3

OPTICHAMBER DIAMOND-SM MASK 3

PALFORZIA ORAL PACKET 300 MG 4 PA; SP; QL

PHEXXI Not covered

POCKET SPACER 3

PRO COMFORT SPACER ADULT 3

PRO COMFORT SPACER CHILD 3

PRO COMFORT SPACER INFANT 3

PROCARE SPACER/ADULT MASK 3

PROCARE SPACER/CHILD MASK 3

RADIOGARDASE 2

RUZURGI 4 PA; SP; QL

SSKI 3


92


sterile water for irrigation Argyle Sterile Water 1b

TAVNEOS 5 PA; SP; QL

V-GO 20 2 QL

V-GO 30 2 QL

V-GO 40 2 QL

VISTOGARD 4 SP; QL

VORTEX VALVED HOLDING CHAMBER

3

water for irrigation, sterile Argyle Sterile Water 1b

WIDE-SEAL DIAPHRAGM 60 3 PV2; QL








ZOKINVY 4 PA; SP; QL

Ophthalmic Agents

Aminoglycosides

gentak 1b

gentamicin sulfate ophthalmic 1b

neomycin-polymyxin-gramicidin 1b

TOBRADEX OPHTHALMIC OINTMENT 2

TOBRADEX ST 3

tobramycin ophthalmic Tobrex 1b

tobramycin-dexamethasone TobraDex 1b

TOBREX OPHTHALMIC OINTMENT 3

Antibacterials, Other

ak-poly-bac Polycin 1b

bacitracin ophthalmic 1b

bacitracin-polymyxin b ophthalmic Polycin 1b

bacitra-neomycin-polymyxin-hc Neo-Polycin HC 1b

neomycin-bacitracin zn-polymyx Neo-Polycin 1b

neomycin-polymyxin-dexameth ophthalmic ointment

Maxitrol 1b

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

Maxitrol 1b


93


neomycin-polymyxin-hc ophthalmic 1b

neo-polycin Neo-Polycin 1b

neo-polycin hc Neo-Polycin HC 1b

polycin Polycin 1b

polymyxin b-trimethoprim Polytrim 1b

Anti-cytomegalovirus (CMV) Agents

ZIRGAN 2

Antifungals

NATACYN 2

Antiherpetic Agents

trifluridine 1b

Macrolides

AZASITE 3

erythromycin ophthalmic 1b

Ophthalmic Agents, Other

atropine sulfate ophthalmic ointment 1b

atropine sulfate ophthalmic solution 1 % Isopto Atropine 1b

BLEPHAMIDE 2

BLEPHAMIDE S.O.P. 2

CEQUA Not covered QL

cyclopentolate hcl ophthalmic Cyclogyl 1b

CYSTADROPS 5 PA; SP; QL

CYSTARAN 4 PA; SP; QL

homatropaire 1b

ISOPTO ATROPINE Not covered

LACRISERT 2

OXERVATE 4 PA; SP; QL

PAREMYD 3

PRED-G 3

PRED-G S.O.P. 3

RESTASIS 2

RESTASIS MULTIDOSE 2

sulfacetamide-prednisolone ophthalmic solution

1b

tropicamide ophthalmic Mydriacyl 1b

XIIDRA 2 QL

ZYLET 3


94


Ophthalmic Anti-allergy Agents

ALOCRIL 3

ALOMIDE 3

altafrin Altafrin 1b

azelastine hcl ophthalmic 1b

bepotastine besilate Bepreve 1b

cromolyn sodium ophthalmic 1b

CYCLOMYDRIL 3

epinastine hcl 1b

LASTACAFT 3

olopatadine hcl ophthalmic Pataday 1b

phenylephrine hcl ophthalmic Altafrin 1b

UPNEEQ 2 PA; QL

ZERVIATE Not covered

Ophthalmic Antiglaucoma Agents

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

2

apraclonidine hcl 1b

betaxolol hcl ophthalmic 1b

BETIMOL Not covered

BETOPTIC-S 2

brimonidine tartrate ophthalmic Alphagan P 1b

brinzolamide Azopt 1b

carteolol hcl 1a

COMBIGAN 3

dorzolamide hcl ophthalmic Trusopt 1b

dorzolamide hcl-timolol mal Cosopt 1b

dorzolamide hcl-timolol mal pf Cosopt PF 1b

IOPIDINE 3

levobunolol hcl 1a

pilocarpine hcl ophthalmic Isopto Carpine 1b

RHOPRESSA 2 ST; QL

ROCKLATAN 2 ST; QL

SIMBRINZA Not covered

timolol maleate (once-daily) Istalol Not covered

timolol maleate ocudose Timoptic Ocudose Not covered

timolol maleate ophthalmic Timoptic 1a


95


timolol maleate pf Timoptic Ocudose Not covered

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 %

Not covered

Ophthalmic Anti-inflammatories

ACUVAIL Not covered

ALREX 2

bromfenac sodium (once-daily) 1b

BROMSITE Not covered

dexamethasone sodium phosphate ophthalmic

1b

diclofenac sodium ophthalmic 1b

difluprednate Durezol 1b

EYSUVIS Not covered QL

FLAREX Not covered

fluorometholone FML Liquifilm 1b

flurbiprofen sodium 1b

FML 2

FML FORTE 2

ILEVRO Not covered

INVELTYS Not covered QL

ketorolac tromethamine ophthalmic Acular 1b

LOTEMAX OPHTHALMIC OINTMENT 3

LOTEMAX SM Not covered QL

loteprednol etabonate Lotemax 1b

MAXIDEX 3

NEVANAC 3

PRED MILD 2

prednisolone acetate ophthalmic Pred Forte 1b

prednisolone acetate p-f Pred Forte 1b

prednisolone sodium phosphate ophthalmic

1b

PROLENSA Not covered

TYRVAYA Not covered QL

Ophthalmic Prostaglandin and Prostamide Analogs

bimatoprost ophthalmic 1b

latanoprost ophthalmic Xalatan 1a

LUMIGAN 2


96


travoprost (bak free) Travatan Z 1b

VYZULTA Not covered

XELPROS Not covered QL

ZIOPTAN 3

Quinolones

BESIVANCE 3

CILOXAN OPHTHALMIC OINTMENT 2

ciprofloxacin hcl ophthalmic Ciloxan 1b

gatifloxacin ophthalmic Zymaxid 1b

levofloxacin ophthalmic 1b

moxifloxacin hcl (2x day) Moxeza 1b

moxifloxacin hcl ophthalmic solution Vigamox 1b

ofloxacin ophthalmic Ocuflox 1b

Sulfonamides

sulfacetamide sodium ophthalmic ointment

Not covered

sulfacetamide sodium ophthalmic solution

Bleph-10 1b

Otic Agents

acetic acid otic 1b

CIPRO HC 3

ciprofloxacin hcl otic Cetraxal 1b

ciprofloxacin-dexamethasone Ciprodex 1b

CIPROFLOXACIN-FLUOCINOLONE PF 2

CORTISPORIN-TC 3

flac Flac Not covered

fluocinolone acetonide otic Flac Not covered

hydrocortisone-acetic acid Acetasol HC Not covered

neomycin-polymyxin-hc otic 1b

ofloxacin otic 1b

OTOVEL 2

Respiratory Tract/Pulmonary Agents

Antihistamines

azelastine hcl nasal solution 0.1 %, 137 mcg/spray

1b QL

azelastine hcl nasal solution 0.15 % Not covered QL

carbinoxamine maleate RyVent Not covered


97


clemastine fumarate oral syrup Not covered

clemastine fumarate oral tablet 2.68 mg 1b

cyproheptadine hcl oral 1b

diphenhydramine hcl oral elixir 1b

olopatadine hcl nasal Patanase Not covered QL

promethazine hcl oral 1b

promethazine hcl rectal Promethegan 1b

promethegan Promethegan 1b

ryvent RyVent Not covered

Anti-inflammatories, Inhaled Corticosteroids

ADVAIR HFA 2 QL

AIRDUO DIGIHALER Not covered

AIRDUO RESPICLICK 113/14 Not covered QL



ALVESCO Not covered QL

ARMONAIR DIGIHALER Not covered QL

ARNUITY ELLIPTA 2 QL

ASMANEX (120 METERED DOSES) Not covered QL




ASMANEX HFA Not covered QL

BECONASE AQ Not covered QL

BEVESPI AEROSPHERE Not covered QL

BREO ELLIPTA 2 QL

budesonide inhalation Pulmicort 1a

BUDESONIDE-FORMOTEROL FUMARATE

Not covered ABA; QL

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT

Not covered QL

DULERA INHALATION AEROSOL 50-5 MCG/ACT

Not covered

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

flunisolide nasal Not covered QL

fluticasone propionate nasal ClariSpray 1b QL


98


fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

Wixela Inhub 1b QL

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

3 ABA; QL

mometasone furoate nasal Not covered QL

OMNARIS Not covered QL

PULMICORT FLEXHALER 2 QL

QNASL Not covered QL

QNASL CHILDRENS Not covered QL

QVAR REDIHALER 2 QL

SYMBICORT 2 QL

wixela inhub Wixela Inhub 1b QL

ZETONNA Not covered QL

Antileukotrienes

montelukast sodium oral Singulair 1a QL

zafirlukast Accolate 1b QL

zileuton er 1b QL

ZYFLO 3 QL

Bronchodilators, Anticholinergic

ATROVENT HFA 2 QL

BREZTRI AEROSPHERE 2 QL

INCRUSE ELLIPTA Not covered QL

ipratropium bromide inhalation 1b

ipratropium bromide nasal 1b QL

LONHALA MAGNAIR REFILL KIT Not covered QL

LONHALA MAGNAIR STARTER KIT Not covered QL

SPIRIVA HANDIHALER 2 QL

SPIRIVA RESPIMAT 2 QL

STIOLTO RESPIMAT 2 QL

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

2 QL

TUDORZA PRESSAIR Not covered QL

YUPELRI 3 QL


99


Bronchodilators, Sympathomimetic

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

1b QL

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

Not covered ABA; QL

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml

1b

ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% INHALATION

2

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

1b

albuterol sulfate oral 1b

arformoterol tartrate Brovana 1b QL

AUVI-Q Not covered QL

epinephrine injection solution auto-injector

EpiPen Jr 2-Pak 1b QL

formoterol fumarate inhalation Perforomist 1b QL

levalbuterol hcl inhalation XOPENEX NEB 1b

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

3 ABA; QL

PROAIR DIGIHALER Not covered

PROAIR RESPICLICK Not covered QL

SEREVENT DISKUS 2 QL

STRIVERDI RESPIMAT Not covered QL

SYMJEPI 2 QL

terbutaline sulfate oral 1b

VENTOLIN HFA Not covered QL

XOPENEX HFA 3 QL

Cystic Fibrosis Agents

BRONCHITOL 5 PA; SP; QL

BRONCHITOL TOLERANCE TEST 5 PA; SP; QL

CAYSTON 5 PA; SP; QL

KALYDECO 4 PA; SP; QL

KITABIS PAK Not covered SP; QL

ORKAMBI 4 PA; SP; QL

PULMOZYME 4 PA; SP


100


SYMDEKO 4 PA; SP; QL

TOBI PODHALER Not covered SP; QL

tobramycin inhalation nebulization solution 300 mg/4ml

Bethkis Not covered SP; QL

tobramycin nebulization solution 300 mg/5ml inhalation

Kitabis Pak 4 SP; QL

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION

Not covered ABA; SP; QL

TRIKAFTA 4 PA; SP; QL

Mast Cell Stabilizers

cromolyn sodium inhalation 1b

Phosphodiesterase Inhibitors, Airways Disease

DALIRESP 2 QL

ELIXOPHYLLIN Not covered

THEO-24 2

theophylline 1b

theophylline er 1b

Pulmonary Antihypertensives

ADEMPAS 4 PA; SP; QL

alyq Alyq 4 PA; SP; QL

ambrisentan Letairis 4 PA; SP; QL

bosentan Tracleer 4 PA; SP; QL

OPSUMIT 4 PA; SP; QL

ORENITRAM 5 PA; SP; QL

sildenafil citrate oral suspension reconstituted

Revatio 1b PA; QL

sildenafil citrate oral tablet 20 mg Revatio 1b PA; QL

tadalafil (pah) Alyq 4 PA; SP; QL

TRACLEER 32 MG 5 PA; SP; QL

TYVASO 5 PA; SP; QL

TYVASO REFILL 5 PA; SP; QL

TYVASO STARTER 5 PA; SP; QL

UPTRAVI ORAL 5 PA; SP; QL

VENTAVIS 5 PA; SP; QL

Pulmonary Fibrosis Agents

ESBRIET 4 PA; SP; QL

OFEV 4 PA; SP; QL


101


Respiratory Tract Agents, Other

acetylcysteine inhalation 1b

ANORO ELLIPTA 2 QL

azelastine-fluticasone Dymista Not covered QL

COMBIVENT RESPIMAT 2 QL

DUAKLIR PRESSAIR Not covered QL

FASENRA PEN 4 PA; SP; QL

GRASTEK Not covered QL

HYPERSAL 3

ipratropium-albuterol 1b

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR

4 PA; SP; QL

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

4 PA; SP; QL

ODACTRA Not covered QL

ORALAIR Not covered QL

RAGWITEK Not covered QL

sodium chloride inhalation HyperSal 1b

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

2 QL

Skeletal Muscle Relaxants

baclofen oral 1b

carisoprodol oral Soma Not covered

chlorzoxazone oral tablet 250 mg Not covered

chlorzoxazone oral tablet 375 mg, 750 mg

Lorzone Not covered

chlorzoxazone oral tablet 500 mg 1b

cyclobenzaprine hcl er Amrix Not covered QL

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

1b

cyclobenzaprine hcl oral tablet 7.5 mg Fexmid Not covered

dantrolene sodium oral Dantrium 1b

metaxalone Skelaxin 1b

methocarbamol oral 1b

NORGESIC FORTE Not covered

orphenadrine citrate er 1b

ORPHENGESIC FORTE Not covered


102


OZOBAX Not covered QL

tizanidine hcl oral Zanaflex 1b

Sleep Disorder Agents

GABA Receptor Modulators

EDLUAR Not covered QL

eszopiclone Lunesta 1b QL

flurazepam hcl 1b QL

temazepam Restoril 1b QL

zaleplon 1b QL

zolpidem tartrate er Ambien CR 1b QL

zolpidem tartrate oral Ambien 1b QL

zolpidem tartrate sublingual Not covered QL

ZOLPIMIST Not covered

Sleep Disorders, Other

BELSOMRA Not covered QL

DAYVIGO Not covered QL

doxepin hcl oral tablet Silenor Not covered QL

HETLIOZ 5 PA; SP; QL

HETLIOZ LQ 5 PA; SP; QL

ramelteon Rozerem 1b QL

Wakefulness Promoting Agents

armodafinil Nuvigil 1b QL

modafinil Provigil 1b QL

SUNOSI 3 PA; QL

WAKIX 5 PA; SP; QL

XYREM 5 PA; SP; QL

XYWAV Not covered SP; QL


103

Index of Drugs

abacavir sulfate.........................39abacavir sulfate-lamivudine...... 39abacavir-lamivudine-zidovudine.................................39ABILIFY MAINTENA................. 36ABILIFY MYCITE...................... 36ABILIFY MYCITE MAINTENANCE KIT................. 37ABILIFY MYCITE STARTER KIT............................................ 37abiraterone acetate................... 29ABSORICA LD..........................60acamprosate calcium................ 16acarbose................................... 44ACCRUFER.............................. 64ACCU-CHEK AVIVA PLUS KIT W/DEVICE..........................41ACCU-CHEK COMPACT PLUS TEST STRIPS................ 41ACCU-CHEK FASTCLIX LANCETS................................. 42ACCU-CHEK GUIDE TEST STRIPS..................................... 42ACCU-CHEK MULTICLIX LANCETS................................. 42ACCU-CHEK SAFE-T PRO LANCETS................................. 42ACCU-CHEK SMARTVIEW TEST STRIPS...........................42ACCU-CHEK SOFTCLIX LANCETS................................. 42accutane................................... 60acebutolol hcl............................ 51acetaminophen-codeine............14acetaminophen-codeine #2.......14acetaminophen-codeine #3.......14acetaminophen-codeine #4.......14acetazolamide...........................54acetazolamide er.......................54acetic acid........................... 72, 97acetylcysteine......................... 102ACIPHEX SPRINKLE............... 70acitretin..................................... 60ACTEMRA................................ 88ACTEMRA ACTPEN.................88ACTHAR................................... 76ACTHIB.....................................88ACTIMMUNE............................ 88ACUVAIL...................................96acyclovir.................................... 38ACZONE................................... 60ADACEL....................................88adapalene................................. 60

ADAPALENE............................ 60adapalene-benzoyl peroxide.....60adefovir dipivoxil ....................... 38ADEMPAS.............................. 101ADHANSIA XR..........................57ADLYXIN...................................44ADLYXIN STARTER PACK...... 44ADMELOG................................ 46ADMELOG SOLOSTAR........... 46adult aspirin regimen.................10ADVAIR HFA............................ 98ADVATE....................................48ADYNOVATE............................48ADZENYS XR-ODT.................. 57AEMCOLO................................ 17AEROCHAMBER MINI CHAMBER................................ 91AEROCHAMBER MV............... 91AEROCHAMBER PLUS FLO-VU............................................. 91AEROCHAMBER PLUS FLOW VU..................................91AEROCHAMBER W/FLOWSIGNAL...................... 91afirmelle.................................... 78AFLURIA QUADRIVALENT......88AFREZZA..................................46AFSTYLA.................................. 48AGAMATRIX PRESTO TEST...42AIMOVIG...................................27AIRDUO DIGIHALER................98AIRDUO RESPICLICK 113/14..98AIRDUO RESPICLICK 232/14..98AIRDUO RESPICLICK 55/14....98AJOVY...................................... 27AKLIEF......................................60ak-poly-bac............................... 93AKYNZEO.................................25ALA SCALP.............................. 73ala-cort...................................... 73albendazole...............................34albuterol sulfate.......................100ALBUTEROL SULFATE......... 100albuterol sulfate hfa.................100ALBUTEROL SULFATE HFA. 100alclometasone dipropionate...... 73ALDACTAZIDE......................... 52ALECENSA...............................31alendronate sodium.................. 91ALFERON N............................. 88alfuzosin hcl er.......................... 72ALINIA.......................................34aliskiren fumarate......................52

ALKINDI SPRINKLE................. 73allopurinol..................................27ALLZITAL..................................14almotriptan malate.................... 28ALOCRIL...................................95ALOGLIPTIN BENZOATE........ 44ALOGLIPTIN-METFORMIN HCL...........................................44ALOGLIPTIN-PIOGLITAZONE. 44ALOMIDE..................................95ALORA......................................78alosetron hcl..............................68ALPHAGAN P........................... 95ALPHANATE.............................48ALPHANINE SD........................48alprazolam................................ 41alprazolam er............................ 41alprazolam intensol................... 41alprazolam xr............................ 41ALPROLIX................................ 48ALREX...................................... 96ALTABAX..................................17altafrin....................................... 95altavera..................................... 78ALTOPREV...............................55ALTRENO................................. 60ALUNBRIG................................31ALVESCO................................. 98alyacen 1/35..............................78alyacen 7/7/7.............................78alyq......................................... 101amabelz.................................... 78amantadine hcl..........................35ambrisentan............................ 101amcinonide................................73amethia..................................... 78amethyst................................... 78amiloride hcl..............................54amiloride-hydrochlorothiazide... 52aminocaproic acid..................... 49amiodarone hcl......................... 51AMITIZA....................................68amitriptyline hcl......................... 24amlodipine besylate.................. 52amlodipine besylate-benazepril hcl............................................. 52amlodipine besylate-valsartan.. 52amlodipine-atorvastatin.............52amlodipine-olmesartan..............53ammonium lactate.....................60amnesteem............................... 60amoxapine................................ 24amoxicill-clarithro-lansopraz..... 67

104

amoxicillin................................. 18amoxicillin-potassium clavulanate................................18amoxicillin-potassium clavulanate er............................18amphetamine sulfate.................57amphetamine-dextroamphetamine.................. 57amphetamine-dextroamphetamine er.............. 57ampicillin................................... 18AMZEEQ...................................60anagrelide hcl............................48ANALPRAM HC........................ 90ANALPRAM HC SINGLES....... 90ANALPRAM-HC........................90anastrozole............................... 31ANDRODERM.......................... 77ANGELIQ.................................. 78ANNOVERA..............................78ANORO ELLIPTA................... 102ANTARA................................... 54ANTIVERT................................ 25anucort-hc................................. 90ANUSOL-HC.............................90APADAZ....................................14apap-caff-dihydrocodeine......... 14APEXICON E............................ 73APIDRA SOLOSTAR................ 46APIDRA VIAL............................46APLENZIN................................ 23APOKYN................................... 35APO-VARENICLINE................. 16apraclonidine hcl....................... 95aprepitant.................................. 25apri............................................ 78APTIOM.................................... 22APTIVUS...................................40ARAKODA................................ 34aranelle..................................... 78ARANESP (ALBUMIN FREE)...48ARAZLO....................................60ARCALYST............................... 88arformoterol tartrate................ 100argyle sterile saline................... 72ARIKAYCE................................17aripiprazole............................... 37ARISTADA................................ 37ARISTADA INITIO.................... 37armodafinil .............................. 103ARMONAIR DIGIHALER.......... 98ARMOUR THYROID.................85ARNUITY ELLIPTA...................98

ascomp-codeine........................14asenapine maleate....................37ashlyna......................................78ASMANEX (120 METERED DOSES).................................... 98ASMANEX (30 METERED DOSES).................................... 98ASMANEX (60 METERED DOSES).................................... 98ASMANEX (7 METERED DOSES).................................... 98ASMANEX HFA........................ 98aspirin....................................... 10aspirin adult low dose............... 10aspirin adult low strength.......... 10aspirin childrens........................ 10aspirin ec...................................10aspirin ec low dose................... 10aspirin ec low strength.............. 10aspirin low dose........................ 10aspirin-dipyridamole er..............49ASPIRIN-OMEPRAZOLE......... 49ASSURE PLATINUM................ 42ASTAGRAF XL......................... 86atazanavir sulfate......................40atenolol..................................... 51atenolol-chlorthalidone..............53atomoxetine hcl.........................57atorvastatin calcium.................. 55atovaquone............................... 34atovaquone-proguanil hcl..........34atropine sulfate......................... 94ATROVENT HFA...................... 99AUBAGIO..................................58aubra.........................................78aubra eq....................................78aurovela 1.5/30......................... 78aurovela 1/20............................ 78aurovela 24 fe........................... 78aurovela fe 1.5/30..................... 78aurovela fe 1/20........................ 78AURYXIA.................................. 66AUSTEDO.................................58AUVI-Q....................................100AVAR CLEANSER....................61AVAR-E EMOLLIENT............... 61AVAR-E GREEN.......................61aviane....................................... 78avidoxy......................................19AVITA........................................61AVONEX PEN...........................58AVONEX PREFILLED.............. 58ayuna........................................ 78

AYVAKIT...................................31AZASITE................................... 94azathioprine.............................. 86azelaic acid............................... 61azelastine hcl...................... 95, 97azelastine-fluticasone............. 102AZELEX.................................... 61azithromycin..............................19AZSTARYS............................... 57azurette..................................... 78bac............................................ 14bacitracin...................................93bacitracin-polymyxin b.............. 93bacitra-neomycin-polymyxin-hc 93baclofen.................................. 102BAFIERTAM............................. 59BALCOLTRA.............................78balsalazide disodium.................90BALVERSA............................... 31balziva.......................................78BAQSIMI ONE PACK............... 45BAQSIMI TWO PACK...............45BARACLUDE............................ 38BASAGLAR KWIKPEN............. 46BAXDELA................................. 19BECONASE AQ........................98BELBUCA................................. 12belladonna alkaloids-opium...... 66BELSOMRA............................ 103benazepril hcl............................50benazepril-hydrochlorothiazide. 53BENEFIX...................................49BENLYSTA............................... 88BENZAC AC WASH..................61BENZEPRO.............................. 61BENZHYDROCODONE-ACETAMINOPHEN...................14BENZNIDAZOLE...................... 34BENZOYL PEROXIDE..............61benzoyl peroxide-erythromycin. 61benztropine mesylate................34bepotastine besilate.................. 95BESIVANCE............................. 97BESREMI..................................30betamethasone dipropionate.... 73betamethasone dipropionate aug............................................ 73betamethasone valerate........... 73BETASERON............................59betaxolol hcl........................ 51, 95bethanechol chloride.................72BETIMOL.................................. 95BETOPTIC-S............................ 95

105

BEVESPI AEROSPHERE.........98bexarotene................................ 33BEXSERO.................................88bicalutamide..............................29BIDIL......................................... 53BIJUVA..................................... 78BIKTARVY................................ 38bimatoprost............................... 96BINOSTO..................................91bisacodyl ec.............................. 68bisoprolol fumarate................... 51bisoprolol-hydrochlorothiazide.. 53BLEPHAMIDE...........................94BLEPHAMIDE S.O.P................ 94blisovi 24 fe............................... 78blisovi fe 1.5/30......................... 78blisovi fe 1/20............................ 78BLOOD GLUCOSE TEST.........42BLULINK GLUCOSE TEST...... 42BONJESTA............................... 25BOOSTRIX............................... 88bosentan................................. 101BOSULIF...................................31BRAFTOVI................................ 31BREATHE EASE LARGE......... 91BREATHE EASE MEDIUM.......91BREATHE EASE SMALL..........91BREO ELLIPTA........................ 98BREXAFEMME.........................25BREZTRI AEROSPHERE.........99briellyn.......................................78BRILINTA..................................50brimonidine tartrate................... 95brinzolamide..............................95BRIVIACT................................. 20bromfenac sodium (once-daily).96bromocriptine mesylate.............35BROMSITE............................... 96BRONCHITOL........................ 100BRONCHITOL TOLERANCE TEST.......................................100BRUKINSA................................31BRYHALI...................................73budesonide......................... 90, 98budesonide er........................... 90BUDESONIDE-FORMOTEROL FUMARATE....98bumetanide............................... 54buprenorphine...........................12buprenorphine hcl..................... 16buprenorphine hcl-naloxone hcl............................................. 16bupropion hcl............................ 23

bupropion hcl er (smoking det). 16bupropion hcl er (sr)..................23bupropion hcl er (xl).................. 23BUPROPION HCL ER (XL)...... 23buspirone hcl.............................41butalbital-acetaminophen..........14BUTALBITAL-ACETAMINOPHEN...................14butalbital-apap-caff-cod............ 14butalbital-apap-caffeine.............14butalbital-asa-caff-codeine........14butalbital-aspirin-caffeine.......... 14butorphanol tartrate...................14BYDUREON BCISE AUTOINJECTOR...................... 44BYETTA 10 MCG PEN............. 44BYETTA 5 MCG PEN............... 44BYLVAY.................................... 59BYLVAY (PELLETS).................59cabergoline............................... 76CABLIVI.................................... 50CABOMETYX........................... 31caffeine citrate...........................58calcipotriene..............................61CALCIPOTRIENE..................... 61calcipotriene-betameth diprop...61calcitonin (salmon).................... 91calcitriol ............................... 61, 91calcium acetate......................... 66calcium acetate (phos binder)...66CALQUENCE............................31CAMBIA.................................... 27camila........................................84camrese.................................... 78camrese lo................................ 79candesartan cilexetil ................. 50candesartan cilexetil-hctz..........53capecitabine..............................30CAPEX......................................73CAPLYTA..................................37CAPRELSA...............................31captopril .................................... 50CARAC..................................... 30carbamazepine......................... 22carbamazepine er..................... 22carbidopa.................................. 35carbidopa-levodopa............ 35, 36carbidopa-levodopa er.............. 35carbidopa-levodopa-entacapone......................... 35, 36carbinoxamine maleate.............97CARDIZEM LA..........................52CARDURA XL...........................72

CARETOUCH TEST................. 42carglumic acid........................... 64carisoprodol............................ 102carisoprodol-aspirin-codeine.....14CAROSPIR............................... 54carteolol hcl...............................95cartia xt..................................... 52carvedilol...................................51carvedilol phosphate er.............51cavarest.................................... 59CAYA........................................ 91CAYSTON...............................100caziant.......................................79cefaclor..................................... 18cefaclor er................................. 18cefadroxil ...................................18cefdinir...................................... 18cefixime.....................................18cefpodoxime proxetil ................. 18cefprozil .....................................18cefuroxime axetil ....................... 18celecoxib................................... 10CELONTIN................................20cephalexin.................................18CEQUA..................................... 94CERDELGA.............................. 70cevimeline hcl........................... 60charlotte 24 fe........................... 79chateal...................................... 79chateal eq................................. 79CHEMET...................................65CHENODAL.............................. 67chlordiazepoxide hcl................. 41chlordiazepoxide-amitriptyline...23chlordiazepoxide-clidinium........67chlorhexidine gluconate............ 60chloroquine phosphate..............34chlorpromazine hcl....................36chlorthalidone............................54chlorzoxazone.........................102CHOLBAM................................ 70cholestyramine..........................56cholestyramine light.................. 56CHORIONIC GONADOTROPIN.................... 76ciclodan.....................................26ciclopirox................................... 26ciclopirox olamine..................... 26cilostazol................................... 50CILOXAN.................................. 97CIMDUO................................... 39cimetidine..................................68cimetidine hcl............................ 68

106

CIMZIA PREFILLED KIT...........86CIMZIA STARTER KIT............. 86cinacalcet hcl............................ 91CIPRO.......................................19CIPRO HC................................ 97ciprofloxacin hcl.................. 19, 97ciprofloxacin-dexamethasone... 97CIPROFLOXACIN-FLUOCINOLONE PF................ 97citalopram hydrobromide.......... 23citroma...................................... 68claravis......................................61clarithromycin............................19clarithromycin er........................19clearlax......................................68clemastine fumarate..................98CLENPIQ.................................. 68CLEOCIN.................................. 17CLEVER CHOICE HOLDING CHAMBER................................ 91CLIMARA PRO......................... 79clindacin etz.............................. 61clindacin-p.................................61clindamycin hcl..........................17clindamycin palmitate hcl.......... 17clindamycin phosphate....... 17, 61clindamycin phosphate-benzoyl peroxide.......................61clindamycin-tretinoin................. 61CLINDESSE..............................17clobazam...................................21clobetasol prop emollient base. 73clobetasol propionate................73clobetasol propionate e.............73clobetasol propionate emulsion 73clocortolone pivalate................. 73clodan....................................... 73clomiphene citrate.....................77clomipramine hcl....................... 24clonazepam...............................41clonidine....................................50clonidine hcl.............................. 50clonidine hcl er.......................... 57clopidogrel bisulfate.................. 50clorazepate dipotassium........... 41clotrimazole...............................26clotrimazole-betamethasone.....26clozapine...................................37COAGADEX..............................49COARTEM................................ 34codeine sulfate..........................14COLCHICINE............................27colchicine.................................. 27

colchicine-probenecid............... 27colesevelam hcl........................ 56colestipol hcl............................. 56COMBIGAN.............................. 95COMBIPATCH.......................... 79COMBIVENT RESPIMAT....... 102COMETRIQ...............................32COMPACT SPACE CHAMBER................................ 91COMPACT SPACE CHAMBER/LG MASK............... 92COMPACT SPACE CHAMBER/MED MASK............92COMPACT SPACE CHAMBER/SM MASK.............. 92COMPLERA..............................39compro...................................... 25CONDYLOX..............................61CONJUPRI................................52CONSENSI............................... 53constulose.................................68CONTOUR MONITOR DEVICE.....................................42CONTOUR NEXT MONITOR KIT W/DEVICE..........................42CONTOUR NEXT ONE KIT......42CONTOUR NEXT TEST STRIPS..................................... 42CONTOUR TEST STRIPS........42CONZIP.................................... 12COPAXONE..............................59COPIKTRA................................30CORDRAN................................73coremino................................... 19CORIFACT................................49CORLANOR..............................53CORTIFOAM............................ 90CORTISPORIN-TC................... 97COSENTYX (300 MG DOSE)...61COSENTYX 150 MG/ML.......... 62COSENTYX SENSOREADY (300 MG)...................................62COSENTYX SENSOREADY PEN...........................................62COTELLIC................................ 32COTEMPLA XR-ODT............... 57COVARYX................................ 79COVARYX HS.......................... 79CREON..................................... 71CRESEMBA..............................26cromolyn sodium.........67, 95, 101crotan........................................ 34cryselle-28.................................79

curity sterile saline.................... 72CUTAQUIG............................... 87CUVITRU.................................. 87CUVPOSA................................ 66cyanocobalamin........................ 66CYANOCOBALAMIN................ 66cyclafem 1/35............................79cyclafem 7/7/7...........................79cyclobenzaprine hcl................ 102cyclobenzaprine hcl er............ 102CYCLOMYDRIL........................ 95cyclopentolate hcl..................... 94cyclophosphamide.................... 29CYCLOPHOSPHAMIDE........... 29cycloserine................................ 28CYCLOSET...............................44cyclosporine.............................. 86cyclosporine modified............... 86cyproheptadine hcl....................98cyred......................................... 79cyred eq.................................... 79CYSTADANE............................ 71CYSTADROPS......................... 94CYSTAGON..............................71CYSTARAN.............................. 94CYTOTEC.................................70dalfampridine er........................ 59DALIRESP.............................. 101danazol..................................... 77dantrolene sodium.................. 102dapsone.............................. 28, 62DAPSONE................................ 62DAPTACEL............................... 88darifenacin hydrobromide er..... 71dasetta 1/35.............................. 79dasetta 7/7/7............................. 79DAURISMO...............................32daysee...................................... 79DAYTRANA.............................. 57DAYVIGO................................103deblitane................................... 84DECADRON............................. 73deferasirox................................ 65deferasirox granules................. 65deferiprone................................65deferoxamine mesylate.............92DELESTROGEN.......................79DELSTRIGO............................. 39delyla.........................................79demeclocycline hcl....................19DEMSER...................................53DENAVIR.................................. 38DENTA 5000 PLUS.................. 60

107

DENTAGEL...............................60DEPO-SUBQ PROVERA 104...84DESCOVY................................ 39desipramine hcl.........................24desmopressin ace spray refrig..76desmopressin acetate...............76desmopressin acetate pf...........76desmopressin acetate spray..... 76desogestrel-ethinyl estradiol..... 79desonide............................. 73, 74desoximetasone........................74desrx......................................... 74DESVENLAFAXINE ER............23desvenlafaxine succinate er......23DEXABLISS.............................. 74dexamethasone........................ 74dexamethasone intensol........... 74dexamethasone sodium phosphate................................. 96DEXCOM G6 RECEIVER......... 42DEXCOM G6 SENSOR............ 42DEXCOM G6 TRANSMITTER..42DEXILANT................................ 70DEXLANSOPRAZOLE..............70dexmethylphenidate hcl............ 57dexmethylphenidate hcl er........ 57dextroamphetamine sulfate.......57dextroamphetamine sulfate er.. 57DHIVY....................................... 36DIACOMIT................................ 21DIATHRIVE BLOOD GLUCOSE TEST...................... 42DIATHRIVE GLUCOSE TEST.. 42DIATHRIVE+ GLUCOSE TEST.........................................42diazepam............................ 21, 41diazepam intensol..................... 41diazoxide...................................45DICLOFENAC CAP 35MG........10DICLOFENAC PATCH 1.3%.... 10diclofenac potassium................ 10diclofenac sodium......... 10, 30, 96diclofenac sodium er................. 10diclofenac-misoprostol.............. 11dicloxacillin sodium................... 18dicyclomine hcl..........................66DIFFERIN................................. 62DIFICID..................................... 19diflorasone diacetate.................74diflunisal.................................... 11difluprednate............................. 96digitek........................................53digox......................................... 53

digoxin.......................................53dihydroergotamine mesylate.....27DILANTIN..................................22diltiazem hcl.............................. 52diltiazem hcl er.......................... 52diltiazem hcl er beads............... 52diltiazem hcl er coated beads... 52dilt-xr......................................... 52dimethyl fumarate..................... 59dimethyl fumarate starter pack..59DIPENTUM............................... 90diphenhydramine hcl.................98diphenoxylate-atropine..............67DIPHTHERIA-TETANUS TOXOIDS DT............................ 88dipyridamole..............................50disopyramide phosphate...........51disulfiram...................................16DIURIL...................................... 54divalproex sodium..................... 41divalproex sodium er.................41DIVIGEL....................................79dofetilide....................................51DOJOLVI...................................92dolishale....................................79donepezil hcl............................. 22DOPTELET............................... 48DORYX..................................... 19DORYX MPC............................ 19dorzolamide hcl.........................95dorzolamide hcl-timolol mal...... 95dorzolamide hcl-timolol mal pf.. 95dotti ........................................... 79DOVATO...................................38doxazosin mesylate.................. 50doxepin hcl..................24, 62, 103doxercalciferol...........................91doxycycline............................... 62doxycycline hyclate............. 19, 20DOXYCYCLINE HYCLATE.......20doxycycline monohydrate......... 20doxylamine-pyridoxine.............. 25DRIZALMA SPRINKLE............. 23dronabinol................................. 25drospiren-eth estrad-levomefol. 79drospirenone-ethinyl estradiol...79DROXIA.................................... 30droxidopa.................................. 53DRYSOL................................... 62DUAKLIR PRESSAIR............. 102DUAVEE................................... 79DULERA................................... 98duloxetine hcl............................ 23

DUOBRII................................... 62DUOPA..................................... 36DUPIXENT................................62DURLAZA................................. 50dutasteride................................ 72dutasteride-tamsulosin hcl........ 72DUTOPROL.............................. 53DXEVO 11-DAY........................74DYANAVEL XR.........................57E.E.S. 400.................................19EASIVENT................................ 92EASY TALK PLUS II TEST STRIPS..................................... 42EASY TOUCH HEALTHPRO GLUCOSE................................ 42EASY TRAK II GLUCOSE TEST.........................................42ec-naproxen.............................. 11econazole nitrate.......................26ECOZA......................................26EDARBI.....................................50EDARBYCLOR......................... 53EDLUAR................................. 103EDURANT.................................39EEMT........................................ 79EEMT HS.................................. 79efavirenz................................... 39efavirenz-emtricitab-tenofovir....39efavirenz-lamivudine-tenofovir.. 39EFFER-K...................................64effer-k........................................64EGRIFTA SV.............................76ELEPSIA XR............................. 20ELESTRIN................................ 79eletriptan hydrobromide............ 28elinest........................................79ELIQUIS....................................47ELIQUIS DVT/PE STARTER PACK........................................ 47ELIXOPHYLLIN...................... 101ELLA......................................... 84ELMIRON..................................72ELOCTATE............................... 49eluryng...................................... 79EMBRACE PRESSURE ACTIVATED 21G...................... 42EMBRACE PRESSURE ACTIVATED 28G...................... 42EMBRACE TALK GLUCOSE TEST.........................................42EMCYT..................................... 30EMEND..................................... 25EMFLAZA................................. 74

108

EMGALITY................................27EMGALITY (300 MG DOSE).... 27emoquette................................. 79EMPAVELI................................ 47EMSAM.....................................23emtricitabine..............................39emtricitabine-tenofovir df...........39EMTRIVA.................................. 39EMVERM.................................. 34enalapril maleate.......................50enalapril-hydrochlorothiazide.... 53ENBREL....................................86ENBREL MINI........................... 86ENBREL SURECLICK.............. 86ENDARI.................................... 92endocet..................................... 14ENDOMETRIN..........................84ENGERIX-B.............................. 88enoxaparin sodium....................47enpresse-28.............................. 79enskyce.....................................79ENSPRYNG..............................88ENSTILAR................................ 62entacapone............................... 35entecavir................................... 38ENTRESTO.............................. 53enulose..................................... 68ENVARSUS XR........................ 86EPCLUSA................................. 38EPIDIOLEX............................... 20EPIFOAM..................................62epinastine hcl............................ 95epinephrine............................. 100epitol......................................... 22EPIVIR HBV..............................38eplerenone................................ 54EPOGEN...................................48EPRONTIA................................21EQUETRO................................ 41ergocalciferol.............................66ergoloid mesylates.................... 92ERGOMAR............................... 27ergotamine-caffeine.................. 27ERIVEDGE............................... 32ERLEADA................................. 29erlotinib hcl................................32errin...........................................84ERTACZO.................................26ery............................................. 62ERYTHROCIN STEARATE...... 19erythromycin................. 19, 62, 94erythromycin base.....................19erythromycin ethylsuccinate......19

ESBRIET.................................101escitalopram oxalate................. 24ESOMEPRAZOLE STRONTIUM.............................70ESPEROCT.............................. 49est estrogens-methyltest...........79est estrogens-methyltest ds...... 79est estrogens-methyltest hs...... 80estarylla.....................................80estazolam..................................41estradiol.................................... 80estradiol valerate.......................80estradiol-norethindrone acet..... 80ESTRING.................................. 80ESTROGEL.............................. 80eszopiclone............................. 103ethacrynic acid.......................... 54ethambutol hcl...........................28ethosuximide.............................21ethynodiol diac-eth estradiol..... 80etodolac.................................... 11etodolac er................................ 11etonogestrel-ethinyl estradiol.... 80etoposide.................................. 31etravirine................................... 39EUCRISA.................................. 62euthyrox.................................... 85EVAMIST.................................. 80EVEKEO ODT...........................57everolimus...........................32, 86EVOTAZ....................................40EVRYSDI.................................. 71EXELDERM.............................. 26exemestane.............................. 31EXFORGE HCT........................ 53EXKIVITY..................................32EXSERVAN.............................. 58EXTAVIA...................................59EYSUVIS.................................. 96EZALLOR SPRINKLE...............55ezetimibe...................................56EZETIMIBE-ROSUVASTATIN..56ezetimibe-simvastatin............... 56FABIOR.....................................62falmina...................................... 80famciclovir................................. 38famotidine................................. 68FANAPT....................................37FANAPT TITRATION PACK..... 37FARXIGA.................................. 44FARYDAK................................. 32FASENRA PEN.......................102fayosim......................................80

FC FEMALE CONDOM............ 92FC2 FEMALE CONDOM.......... 92febuxostat................................. 27FEIBA........................................49felbamate.................................. 21felodipine er.............................. 52FEMCAP................................... 92FEMRING................................. 80femynor..................................... 80fenofibrate................................. 55fenofibrate micronized...............54FENOFIBRATE MICRONIZED. 54fenofibric acid............................55fenoprofen calcium....................11fenortho.....................................11fentanyl..................................... 12fentanyl citrate...........................14FENTANYL CITRATE...............14FENTORA.................................14FERRIPROX............................. 65FERRIPROX TWICE-A-DAY.... 65FETZIMA...................................24FETZIMA TITRATION...............24FIASP........................................46FIASP FLEXTOUCH.................46FIASP PENFILL........................ 46FIBRICOR.................................55FINACEA.................................. 62finasteride................................. 72FINTEPLA.................................20FIRDAPSE................................ 92FIRVANQ.................................. 17flac............................................ 97FLAREX.................................... 96flavoxate hcl.............................. 71flecainide acetate...................... 51FLECTOR................................. 11FLEXICHAMBER...................... 92FLOLIPID.................................. 55FLOVENT DISKUS................... 98FLOVENT HFA......................... 98FLUAD QUADRIVALENT......... 88FLUARIX QUADRIVALENT......88FLUBLOK QUADRIVALENT.....88FLUCELVAX QUADRIVALENT...................... 88fluconazole................................26flucytosine................................. 26fludrocortisone acetate..............74FLULAVAL QUADRIVALENT... 88FLUMIST QUADRIVALENT......88flunisolide.................................. 98fluocinolone acetonide........ 74, 97

109

fluocinolone acetonide body..... 74fluocinolone acetonide scalp.....74fluocinonide...............................74fluocinonide emulsified base.....74fluoritab..................................... 64fluorometholone........................ 96FLUOROPLEX..........................30FLUOROURACIL......................30fluorouracil ................................ 30fluoxetine hcl............................. 24fluoxetine hcl (pmdd).................24fluphenazine decanoate............36fluphenazine hcl........................ 36flurandrenolide.......................... 74flurazepam hcl.........................103flurbiprofen................................ 11flurbiprofen sodium................... 96fluticasone propionate.........74, 98fluticasone-salmeterol............... 99FLUTICASONE-SALMETEROL..........................99fluvastatin sodium..................... 55fluvastatin sodium er................. 55fluvoxamine maleate................. 24fluvoxamine maleate er.............24FLUZONE HIGH-DOSE QUADRIVALENT...................... 88FLUZONE QUADRIVALENT.... 88FML...........................................96FML FORTE..............................96folate......................................... 66folic acid.................................... 66FOLLISTIM AQ......................... 76fondaparinux sodium.................47FORA 6 CONNECT.................. 42FORA GTEL BLOOD GLUCOSE TEST...................... 42FORA TN'G ADVANCE PRO....42FORFIVO XL.............................23formoterol fumarate.................100FORTEO................................... 91FOSAMAX PLUS D.................. 91fosamprenavir calcium.............. 40fosfomycin tromethamine..........17fosinopril sodium....................... 50fosinopril sodium-hctz............... 53FOSRENOL.............................. 66FOTIVDA.................................. 32FRAGMIN................................. 47FREESTYLE LIBRE 14 DAY READER................................... 42FREESTYLE LIBRE 14 DAY SENSOR...................................42

FREESTYLE LIBRE 2 READER................................... 42FREESTYLE LIBRE 2 SENSOR...................................43FREESTYLE LIBRE READER..43FREESTYLE PRECISION NEO TEST................................ 43frovatriptan succinate................28FULPHILA.................................48fulvestrant................................. 30furosemide................................ 54FUZEON................................... 40fyavolv.......................................80FYCOMPA................................ 21gabapentin................................ 21GALAFOLD...............................71galantamine hydrobromide....... 22galantamine hydrobromide er... 22GALZIN..................................... 64GAMMAGARD.......................... 87GAMMAKED............................. 87GAMUNEX-C............................ 87ganirelix acetate........................85GARDASIL 9.............................89gatifloxacin................................ 97GATTEX....................................67gavilax.......................................68gavilyte-c...................................68gavilyte-g...................................68gavilyte-n with flavor pack.........69GAVRETO................................ 32GELNIQUE............................... 71gemfibrozil .................................55gemmily.....................................80GEMTESA................................ 71generlac.................................... 69gengraf......................................86GENOTROPIN..........................76GENOTROPIN MINIQUICK......76gentak....................................... 93gentamicin sulfate............... 17, 93gentle laxative........................... 69GENVOYA................................ 38GILENYA.................................. 59GILOTRIF................................. 32GIMOTI..................................... 25GLASSIA...................................71glatiramer acetate..................... 59glatopa...................................... 59GLEOSTINE............................. 29glimepiride.................................44glipizide er.................................44glipizide ir.................................. 44

glipizide xl................................. 44glipizide-metformin hcl.............. 44GLOPERBA.............................. 27GLUCAGEN HYPOKIT............. 45glucagon emergency kit ............ 45GLUCAGON EMERGENCY KIT............................................ 45GLUCOCARD 01 SENSOR PLUS.........................................43GLUCOCARD EXPRESSION TEST.........................................43GLUCOCARD SHINE TEST.....43GLUCOCARD VITAL TEST......43glyburide................................... 44glyburide micronized................. 44glyburide-metformin.................. 44glycopyrrolate............................66glydo......................................... 15GLYXAMBI................................44GOCOVRI................................. 35GOJJI BLOOD GLUCOSE TEST.........................................43GONAL-F.................................. 76GONAL-F RFF.......................... 76GONAL-F RFF REDIJECT....... 76GONITRO................................. 56goodsense aspirin adults.......... 11goodsense aspirin low dose......11goodsense nicotine................... 16GRALISE.................................. 58granisetron hcl.......................... 25GRANIX.................................... 48GRASTEK...............................102griseofulvin microsize................26griseofulvin ultramicrosize.........26guanfacine hcl...........................50guanfacine hcl er.......................57GVOKE HYPOPEN 1-PACK.....45GVOKE HYPOPEN 2-PACK.....45GVOKE PFS............................. 45GYNAZOLE-1........................... 26habitrol...................................... 16HAEGARDA..............................86hailey 1.5/30..............................80hailey 24 fe................................80hailey fe 1.5/30..........................80hailey fe 1/20.............................80halcinonide................................74halobetasol propionate..............74HALOBETASOL PROPIONATE.......................... 74HALOG..................................... 74haloperidol................................ 36

110

haloperidol decanoate...............36haloperidol lactate.....................36HARVONI..................................38HAVRIX.....................................89healthylax..................................69heather......................................84HELIDAC THERAPY................ 67HEMADY...................................74HEMANGEOL........................... 51HEMLIBRA................................49HEMMOREX-HC...................... 90HEMOFIL M.............................. 49heparin sodium (porcine).......... 47heparin sodium (porcine) pf...... 48HEPLISAV-B.............................89HETLIOZ.................................103HETLIOZ LQ........................... 103HIBERIX....................................89HIDEX 6-DAY........................... 74HIZENTRA................................ 88homatropaire.............................94HORIZANT................................58HUMALOG................................46HUMALOG KWIKPEN.............. 46HUMALOG MIX 50/50 KWIKPEN................................. 46HUMALOG MIX 50/50 VIAL......46HUMALOG MIX 75/25 KWIKPEN................................. 46HUMALOG MIX 75/25 VIAL......46HUMALOG U-100 JUNIOR KWIKPEN................................. 46HUMATE-P............................... 49HUMATROPE........................... 76HUMIRA....................................86HUMIRA PEDIATRIC CROHNS START......................86HUMIRA PEN........................... 86HUMIRA PEN-CD/UC/HS STARTER................................. 87HUMIRA PEN-PEDIATRIC UC START...................................... 87HUMIRA PEN-PS/UV/ADOL HS START................................ 87HUMIRA PEN-PSOR/UVEIT STARTER................................. 87HUMULIN 70/30 KWIKPEN...... 46HUMULIN 70/30 VIAL...............46HUMULIN N KWIKPEN............ 46HUMULIN N VIAL..................... 46HUMULIN R U-500 KWIKPEN..46HUMULIN R U-500 VIAL.......... 46HUMULIN R VIAL..................... 46

HW EMBRACE PRO GLUCOSE TEST...................... 43HW EMBRACE TALK GLUCOSE TEST...................... 43HYCAMTIN............................... 31hydralazine hcl.......................... 57hydrochlorothiazide...................54hydrocodone bitartrate er..........12hydrocodone-acetaminophen... 14hydrocodone-ibuprofen............. 14hydrocortisone.................... 75, 90hydrocortisone (perianal).......... 90hydrocortisone ace-pramoxine............................................ 62, 90hydrocortisone acetate..............90hydrocortisone butyr lipo base.. 74hydrocortisone butyrate............ 75hydrocortisone valerate.............75hydrocortisone-acetic acid........ 97hydrocort-pramoxine (perianal).90hydromorphone hcl................... 14hydromorphone hcl er............... 12hydroxocobalamin acetate........ 66hydroxychloroquine sulfate....... 34hydroxyurea.............................. 30hydroxyzine hcl......................... 41hydroxyzine pamoate................41hyoscyamine sulfate........... 66, 67hyoscyamine sulfate er............. 66hyoscyamine sulfate sl..............66hyosyne.....................................67HYPERSAL.............................102HYQVIA.................................... 88ibandronate sodium.................. 91IBRANCE.................................. 32ibuprofen................................... 11ibuprofen-famotidine................. 11icatibant acetate........................86iclevia........................................ 80ICLUSIG....................................32icosapent ethyl.......................... 56IDELVION................................. 49IDHIFA...................................... 32ILEVRO.....................................96imatinib mesylate...................... 32IMBRUVICA.............................. 32IMCIVREE.................................58imipramine hcl...........................24imipramine pamoate................. 25imiquimod..................................62IMIQUIMOD PUMP...................62IMPAVIDO................................ 34IMPEKLO.................................. 75

IMPOYZ.................................... 75IMVEXXY MAINTENANCE PACK........................................ 80IMVEXXY STARTER PACK..... 80INBRIJA.................................... 35incassia..................................... 84INCRELEX................................ 76INCRUSE ELLIPTA.................. 99indapamide............................... 54INDERAL XL............................. 51INDOCIN...................................11INDOMETHACIN...................... 11indomethacin.............................11indomethacin er........................ 11INFANRIX................................. 89INFINITY BLOOD GLUCOSE TEST.........................................43INGREZZA................................58INLYTA..................................... 32INNOPRAN XL..........................51INQOVI..................................... 32INREBIC................................... 30INSULIN ASP PROT & ASP FLEXPEN..................................46INSULIN ASPART.................... 46INSULIN ASPART FLEXPEN... 46INSULIN ASPART PENFILL.....46INSULIN ASPART PROT & ASPART....................................46INSULIN GLARGINE-YFGN..... 46INSULIN LISPRO......................46INSULIN LISPRO (1 UNIT DIAL).........................................46INSULIN LISPRO JUNIOR KWIKPEN................................. 46INSULIN LISPRO PROT & LISPRO.....................................46INTELENCE..............................39INTRAROSA............................. 77INTRON A.................................38introvale.................................... 80INVEGA SUSTENNA................37INVEGA TRINZA...................... 37INVELTYS.................................96INVIRASE................................. 40INVOKAMET.............................44INVOKAMET XR.......................44INVOKANA............................... 44iodine strong............................. 64IOPIDINE.................................. 95IPOL..........................................89ipratropium bromide.................. 99ipratropium-albuterol............... 102

111

irbesartan.................................. 50irbesartan-hydrochlorothiazide..53IRESSA.....................................32ISENTRESS..............................39ISENTRESS HD....................... 39isibloom.....................................80isoniazid.................................... 29ISOPTO ATROPINE................. 94isosorbide dinitrate....................56isosorbide mononitrate..............56isosorbide mononitrate er......... 56isotretinoin.................................62isradipine...................................52ISTURISA................................. 76itraconazole...............................26ivermectin............................34, 62IXINITY..................................... 49jaimiess..................................... 80JAKAFI......................................32JANSSEN COVID-19 VACCINE.................................. 89jantoven.................................... 48JANUMET................................. 44JANUMET XR........................... 44JANUVIA...................................44JARDIANCE..............................44jasmiel.......................................80JATENZO..................................77jencycla..................................... 84JENTADUETO.......................... 44JENTADUETO XR.................... 44jinteli ..........................................80JIVI............................................49jolessa.......................................80JORNAY PM............................. 57JUBLIA......................................26juleber....................................... 80JULUCA.................................... 39junel 1.5/30............................... 80junel 1/20.................................. 80junel fe 1.5/30........................... 80junel fe 1/20.............................. 80junel fe 24................................. 80JUXTAPID.................................56JYNARQUE.............................. 65kaitlib fe.....................................81kalliga........................................81KALYDECO............................ 100KAPSPARGO SPRINKLE.........51kariva........................................ 81KATERZIA................................ 52KAZANO................................... 44kelnor 1/35................................ 81

kelnor 1/50................................ 81KERENDIA................................92KESIMPTA................................59ketoconazole.............................26ketodan..................................... 26ketoprofen................................. 11ketoprofen er.............................11ketorolac tromethamine...... 11, 96KETOROLAC TROMETHAMINE.....................11KEVEYIS...................................54KEVZARA................................. 88KINERET.................................. 87KINRIX...................................... 89KISQALI.................................... 30KISQALI FEMARA.................... 32KITABIS PAK.......................... 100KLISYRI.................................... 30klor-con..................................... 64klor-con 10................................ 64klor-con m10............................. 64klor-con m15............................. 64klor-con m20............................. 64klor-con/ef................................. 64KLOXXADO.............................. 16KOATE......................................49KOATE-DVI...............................49KOGENATE FS........................ 49KOMBIGLYZE XR.....................44KORLYM...................................77KOSELUGO..............................32KOVALTRY...............................49K-PHOS.................................... 65K-PHOS NO 2...........................65k-prime...................................... 65KRINTAFEL.............................. 34KRISTALOSE........................... 69KROGER HEALTHPRO GLUCOSE TEST...................... 43kurvelo...................................... 81KYNMOBI................................. 35labetalol hcl............................... 51LACRISERT..............................94lactulose....................................69lactulose encephalopathy......... 69LAMICTAL ODT........................21LAMICTAL XR.......................... 21lamivudine...........................38, 39lamivudine-zidovudine.............. 39lamotrigine................................ 21lamotrigine er............................ 21lamotrigine starter kit-blue.........21lamotrigine starter kit-green...... 21

lamotrigine starter kit-orange.... 21LAMPIT..................................... 34LANCETS................................. 43LANOXIN.................................. 53lansoprazole..............................70lanthanum carbonate................ 66LANTUS SOLOSTAR............... 46LANTUS U-100 VIAL................ 46lapatinib ditosylate.................... 32larin 1.5/30................................ 81larin 1/20................................... 81larin 24 fe.................................. 81larin fe 1.5/30............................ 81larin fe 1/20............................... 81larissia.......................................81LASTACAFT............................. 95latanoprost................................ 96LATUDA....................................37layolis fe.................................... 81LAZANDA................................. 15LEDIPASVIR-SOFOSBUVIR.... 38leena......................................... 81leflunomide................................88LENVIMA.................................. 32lessina.......................................81letrozole.................................... 31leucovorin calcium.................... 30LEUKERAN...............................29LEUKINE...................................48leuprolide acetate......................85levalbuterol hcl........................ 100LEVALBUTEROL HFA............100LEVBID..................................... 67LEVEMIR U-100 FLEXTOUCH.47LEVEMIR U-100 VIAL...............47levetiracetam.............................20levetiracetam er........................ 20levobunolol hcl.......................... 95levocarnitine..............................65LEVOCARNITINE..................... 92levocarnitine sf.......................... 65levofloxacin......................... 19, 97levonest.....................................81levonorgest-eth est & eth est.... 81levonorgest-eth estrad 91-day.. 81levonorgestrel........................... 84levonorgestrel-ethinyl estrad.....81levonorg-eth estrad triphasic.....81levora 0.15/30 (28)....................81levorphanol tartrate................... 12levo-t......................................... 85LEVOTHYROXINE SODIUM.... 85levothyroxine sodium................ 85

112

levoxyl....................................... 85LEVSIN..................................... 67LEVSIN/SL................................67LEXETTE.................................. 75LEXIVA..................................... 40LICART..................................... 11lidocaine....................................15lidocaine hcl.............................. 15lidocaine hcl urethral/mucosal...16LIDOCAINE HCL-TETRACAINE HCL................... 16lidocaine viscous hcl................. 16lidocaine-hydrocort (perianal)... 90LIDOCAINE-HYDROCORTISONE ACE....... 62lidocaine-prilocaine................... 16LIDOCORT............................... 90lillow.......................................... 81lindane...................................... 34linezolid..................................... 17LINZESS................................... 68liothyronine sodium................... 85LIPOFEN...................................55lisinopril ..................................... 50lisinopril-hydrochlorothiazide.....53lithium carbonate.......................41lithium carbonate er.................. 41LITHOSTAT.............................. 72LIVALO..................................... 55LIVMARLI..................................59LO LOESTRIN FE.....................81lojaimiess.................................. 81LOKELMA................................. 65LONHALA MAGNAIR REFILL KIT............................................ 99LONHALA MAGNAIR STARTER KIT...........................99LONSURF.................................30loperamide hcl...........................67lopinavir-ritonavir.......................40lorazepam................................. 41lorazepam intensol....................41LORBRENA.............................. 32LOREEV XR............................. 41LORTAB....................................15loryna........................................ 81losartan potassium....................50losartan potassium-hctz............ 53LOTEMAX.................................96LOTEMAX SM.......................... 96loteprednol etabonate............... 96lovastatin...................................55low-ogestrel...............................81

loxapine succinate.................... 36lo-zumandimine.........................81LUBIPROSTONE......................68LUCEMYRA.............................. 16LULICONAZOLE.......................26LUMAKRAS.............................. 30LUMIGAN..................................96LUPKYNIS................................ 87LUPRON DEPOT (1-MONTH)..85LUPRON DEPOT (3-MONTH)..85LUPRON DEPOT-PED (1-MONTH)....................................85LUPRON DEPOT-PED (3-MONTH)....................................85lutera......................................... 81LUZU.........................................26LYBALVI................................... 23lyleq...........................................84lyllana........................................81LYMEPAK................................. 20LYNPARZA............................... 32LYSODREN.............................. 85LYUMJEV KWIKPEN................47LYUMJEV VIAL.........................47lyza............................................84mafenide acetate...................... 17magnesium citrate.....................69malathion.................................. 34marlissa.....................................81MARPLAN.................................23MATULANE.............................. 29matzim la...................................52MAVENCLAD............................59MAVYRET.................................38MAXIDEX..................................96MAYZENT.................................59MAYZENT STARTER PACK.... 59meclizine hcl............................. 25meclofenamate sodium.............11MEDROL...................................75medroxyprogesterone acetate.. 84mefenamic acid.........................11mefloquine hcl...........................34megestrol acetate..................... 84MEKINIST................................. 32MEKTOVI..................................32meloxicam.................................11melphalan................................. 29memantine hcl...........................23memantine hcl er...................... 23MENACTRA..............................89MENEST................................... 81MENOSTAR..............................81

MENQUADFI............................ 89MENTAX................................... 26MENVEO.................................. 89meperidine hcl...........................15meprobamate............................41mercaptopurine......................... 30merzee...................................... 81mesalamine...............................90mesalamine er oral capsule 0.375 gm................................... 90MESNEX...................................33metaxalone............................. 102metformin hcl er........................ 44metformin hcl er (mod)..............44metformin hcl er (osm).............. 44metformin hcl ir ................... 44, 45methadone hcl.......................... 13methadone hcl intensol............. 13methadose................................ 13methadose sugar-free...............13methamphetamine hcl...............57methazolamide..........................54methenamine hippurate............ 17methergine................................ 92methimazole..............................86METHITEST..............................77methocarbamol....................... 102methotrexate............................. 87methotrexate sodium................ 87methotrexate sodium (pf).......... 87methoxsalen rapid.....................62methscopolamine bromide........67methyldopa............................... 50methylergonovine maleate........92methylphenidate hcl.................. 58methylphenidate hcl er..............58methylphenidate hcl er (cd).......58methylphenidate hcl er (la)........58methylphenidate hcl er (xr)....... 58methylprednisolone...................75methyltestosterone....................77metoclopramide hcl...................25metolazone............................... 54metoprolol succinate er.............51metoprolol tartrate.....................51metoprolol-hydrochlorothiazide.53metronidazole..................... 17, 63metyrosine................................ 53mexiletine hcl............................ 51miconazole 3.............................26MICONAZOLE-ZINC OXIDE-PETROLAT............................... 26MICROCHAMBER.................... 92

113

MICRODOT TEST.................... 43microgestin 1.5/30.....................81microgestin 1/20........................81microgestin 24 fe.......................81microgestin fe 1.5/30.................81microgestin fe 1/20....................82midazolam hcl........................... 41midodrine hcl.............................50MIGERGOT.............................. 27miglitol.......................................45miglustat....................................71mili .............................................82milk of magnesia....................... 69milk of magnesia concentrate... 69MILLIPRED............................... 75mimvey......................................82minocycline hcl..........................20MINOCYCLINE HCL ER...........20minocycline hcl er..................... 20MINOLIRA.................................20minoxidil .................................... 57MIRCERA................................. 48mirtazapine............................... 23misoprostol................................70MITIGARE.................................27mm clearlax...............................69M-M-R II.................................... 89modafinil ..................................103MODERNA COVID-19 VACCINE.................................. 89moexipril hcl.............................. 50molindone hcl............................36MOLNUPIRAVIR.......................37mometasone furoate........... 75, 99mondoxyne nl............................20mono-linyah.............................. 82MONONINE.............................. 49montelukast sodium.................. 99morphine sulfate....................... 15morphine sulfate (concentrate). 15morphine sulfate er................... 13morphine sulfate er beads........ 13MOTEGRITY.............................67MOTOFEN................................ 67MOVANTIK............................... 67moxifloxacin hcl...................19, 97moxifloxacin hcl (2x day)...........97MULPLETA............................... 48MULTAQ................................... 51mupirocin.................................. 17mupirocin calcium..................... 17MYALEPT................................. 71MYCAPSSA.............................. 85

mycophenolate mofetil .............. 87mycophenolate sodium............. 87MYDAYIS..................................57MYFEMBREE........................... 82MYLERAN.................................29myorisan................................... 63MYRBETRIQ.............................71MYTESI.....................................67nabumetone.............................. 12nadolol...................................... 51nafrinse..................................... 65nafrinse drops........................... 65naftifine hcl................................26NAFTIN..................................... 26nalbuphine hcl...........................15NALOCET................................. 15naloxone hcl..............................16NALOXONE HCL......................16naltrexone hcl............................16NAMZARIC............................... 22NAPRELAN...............................12naproxen................................... 12naproxen sodium...................... 12naproxen sodium er.................. 12NAPROXEN SODIUM ER........ 12naproxen-esomeprazole........... 12naratriptan hcl........................... 28NASCOBAL.............................. 66NATACYN.................................94NATAZIA...................................82nateglinide.................................45NATESTO................................. 77NATPARA................................. 91NATURE-THROID.................... 85NAYZILAM................................ 21nebivolol hcl.............................. 51necon 0.5/35 (28)......................82nefazodone hcl..........................24neomycin sulfate....................... 17neomycin-bacitracin zn-polymyx.....................................93neomycin-polymyxin-dexameth 93neomycin-polymyxin-gramicidin..................................93neomycin-polymyxin-hc...... 94, 97neo-polycin................................94neo-polycin hc...........................94NEO-SYNALAR........................ 17NERLYNX................................. 32NESINA.....................................45neuac........................................ 63NEULASTA............................... 48NEUPOGEN............................. 48

NEUPRO...................................35NEVANAC.................................96nevirapine................................. 39nevirapine er............................. 39NEXAVAR.................................32NEXIUM.................................... 70NEXLETOL............................... 56NEXLIZET.................................56NEXTSTELLIS.......................... 82niacin (antihyperlipidemic)........ 56niacin er (antihyperlipidemic).... 56niacor........................................ 56nicardipine hcl........................... 52nicotine......................................17nicotine polacrilex..................... 16nicotine polacrilex mini..............16nicotine step 1...........................16nicotine step 2...........................17nicotine step 3...........................17NICOTROL............................... 17NICOTROL NS......................... 17nifedipine...................................52nifedipine er.............................. 52nifedipine er osmotic release.... 52nikki...........................................82nilutamide..................................29nimodipine.................................52NINLARO.................................. 30nisoldipine er.............................52nitazoxanide..............................34nitisinone...................................71NITRO-BID................................56NITRO-DUR..............................57nitrofurantoin............................. 17nitrofurantoin macrocrystal........17nitrofurantoin monohydrate macrocrystals............................18nitroglycerin...............................57NITROMIST.............................. 57NITRO-TIME............................. 57NITYR....................................... 71NIVESTYM................................48nizatidine...................................68NOCDURNA............................. 76nolix...........................................75nora-be......................................84NORDITROPIN FLEXPRO....... 76norethin ace-eth estrad-fe.........82norethindrone............................84norethindrone acetate............... 84norethindrone acet-ethinyl est...82norethindrone-eth estradiol....... 82norethin-eth estradiol-fe............ 82

114

NORGESIC FORTE................102norgestimate-eth estradiol........ 82norgestimate-ethinyl estradiol triphasic.....................................82NORITATE................................63norlyda...................................... 84norlyroc..................................... 84NORPACE CR.......................... 51nortrel 0.5/35 (28)..................... 82nortrel 1/35 (21)........................ 82nortrel 1/35 (28)........................ 82nortrel 7/7/7...............................82nortriptyline hcl..........................25NORVIR.................................... 40NOURIANZ............................... 35NOVAREL.................................76NOVOEIGHT............................ 49NOVOLIN 70/30 FLEXPEN...... 47NOVOLIN 70/30 RELION......... 47NOVOLIN 70/30 VIAL............... 47NOVOLIN N FLEXPEN.............47NOVOLIN N RELION................47NOVOLIN N VIAL..................... 47NOVOLIN R FLEXPEN.............47NOVOLIN R RELION................47NOVOLIN R VIAL..................... 47NOVOLOG 70/30 FLEXPEN RELION.....................................47NOVOLOG FLEXPEN.............. 47NOVOLOG FLEXPEN RELION.....................................47NOVOLOG MIX 70/30 FLEXPEN..................................47NOVOLOG MIX 70/30 RELION.....................................47NOVOLOG MIX 70/30 VIAL......47NOVOLOG PENFILL................ 47NOVOLOG RELION................. 47NOVOLOG U-100 VIAL............ 47NOVOSEVEN RT..................... 49NOXAFIL...................................26np thyroid.................................. 85NUBEQA...................................29NUCALA................................. 102NUCYNTA.................................15NUCYNTA ER...........................13NUEDEXTA.............................. 58NULEV...................................... 67NUPLAZID................................ 37NURTEC................................... 27NUTROPIN AQ NUSPIN 10..... 76NUTROPIN AQ NUSPIN 20..... 76NUTROPIN AQ NUSPIN 5....... 77

NUVESSA.................................18NUWIQ......................................49NUZYRA................................... 20nyamyc......................................26nylia 1/35...................................82nylia 7/7/7..................................82NYMALIZE................................ 52nymyo....................................... 82nystatin......................................26nystatin-triamcinolone............... 26nystop....................................... 26NYVEPRIA................................48OBIZUR.................................... 49OCALIVA.................................. 71ocella.........................................82octreotide acetate..................... 85ODACTRA.............................. 102ODEFSEY.................................40ODOMZO..................................33OFEV...................................... 101ofloxacin..............................19, 97olanzapine.................................37olanzapine-fluoxetine hcl.......... 23olmesartan medoxomil..............50olmesartan medoxomil-hctz...... 53olmesartan-amlodipine-hctz......53olopatadine hcl....................95, 98OLUMIANT............................... 87OMECLAMOX-PAK.................. 67omega-3-acid ethyl esters.........56omeprazole............................... 70omeprazole-sodium bicarbonate............................... 70OMNARIS................................. 99OMNIPOD 5 PACK................... 92OMNIPOD DASH 5 PACK PODS........................................92OMNITROPE............................ 77ondansetron hcl........................ 25ondansetron odt........................ 25ONE DROP TEST.....................43ONETOUCH CLUB LANCETS FINE PT.................................... 43ONETOUCH DELICA LANCETS 30G..........................43ONETOUCH DELICA LANCETS 33G..........................43ONETOUCH DELICA PLUS LANCET30G............................. 43ONETOUCH DELICA PLUS LANCET33G............................. 43ONETOUCH FINEPOINT LANCETS................................. 43

ONETOUCH ULTRA 2 KIT W/DEVICE................................ 43ONETOUCH ULTRA TEST STRIPS..................................... 43ONETOUCH ULTRASOFT LANCETS................................. 43ONETOUCH VERIO FLEX SYSTEM................................... 43ONETOUCH VERIO KIT W/DEVICE................................ 43ONETOUCH VERIO REFLECT..................................43ONEXTON................................ 63ONGENTYS..............................35ONGLYZA.................................45ONUREG.................................. 30ONZETRA XSAIL......................28OPSUMIT................................101OPTICHAMBER DIAMOND......92OPTICHAMBER DIAMOND-LG MASK.................................. 92OPTICHAMBER DIAMOND-MD MASK................................. 92OPTICHAMBER DIAMOND-SM MASK................................. 92OPTIONS GYNOL II CONTRACEPTIVE................... 72OPZELURA...............................63ORALAIR................................ 102oralone...................................... 60ORAVIG.................................... 26ORENCIA..................................87ORENCIA CLICKJECT............. 87ORENITRAM.......................... 101ORFADIN..................................71ORGOVYX................................29ORIAHNN................................. 82ORILISSA................................. 86ORKAMBI............................... 100ORLADEYO.............................. 86orphenadrine citrate er............102ORPHENGESIC FORTE........ 102orsythia..................................... 82ORTIKOS..................................90OSCIMIN...................................67oscimin sr..................................67oseltamivir phosphate............... 40OSENI.......................................45OSMOLEX ER.......................... 35OSMOPREP............................. 69OSPHENA................................ 85OTEZLA.................................... 88OTOVEL................................... 97

115

OTREXUP.................................87OVACE PLUS WASH............... 63OVACE WASH..........................63OVIDREL.................................. 77oxandrolone.............................. 77oxaprozin.................................. 12OXAYDO...................................15oxazepam................................. 41OXBRYTA.................................48oxcarbazepine...........................22OXERVATE.............................. 94oxiconazole nitrate.................... 26OXISTAT...................................27OXTELLAR XR......................... 22oxybutynin chloride................... 72oxybutynin chloride er............... 71oxycodone hcl........................... 15OXYCODONE HCL ER............ 13OXYCODONE-ACETAMINOPHEN...................15oxycodone-acetaminophen.......15OXYCONTIN.............................13oxymorphone hcl.......................15oxymorphone hcl er.................. 13OXYTROL.................................72OZEMPIC..................................45OZOBAX................................. 103PALFORZIA.............................. 92paliperidone er.......................... 37PALYNZIQ................................ 71PANDEL....................................75PANRETIN................................33pantoprazole sodium.................70PAREMYD................................ 94paricalcitol................................. 91paromomycin sulfate.................17paroxetine hcl............................24paroxetine hcl er....................... 24paroxetine mesylate..................24PASER......................................29PEDIARIX................................. 89PEDVAX HIB............................ 89peg 3350................................... 69peg 3350-kcl-na bicarb-nacl......69peg-3350/electrolytes................69peg-3350/electrolytes/ascorbat.69PEGASYS.................................38peg-kcl-nacl-nasulf-na asc-c..... 69peg-prep....................................70PEMAZYRE.............................. 31penicillamine............................. 72penicillin v potassium................ 19PENNSAID................................12

PENTACEL............................... 89pentamidine isethionate............ 34PENTASA................................. 90pentazocine-naloxone hcl......... 15pentoxifylline er......................... 53perindopril erbumine................. 50periogard...................................60permethrin.................................34perphenazine............................ 25perphenazine-amitriptyline........23PERSERIS................................37PEXEVA....................................24PFIZER COVID-19 VAC-TRIS 5-11Y........................................ 89PFIZER-BIONT COVID-19 VAC-TRIS................................. 89PFIZER-BIONTECH COVID-19 VACC................................... 89phenelzine sulfate..................... 23phenobarbital............................ 21phenoxybenzamine hcl............. 50phenylephrine hcl......................95phenytoin.................................. 22phenytoin infatabs.....................22phenytoin sodium extended...... 22PHEXXI.....................................92philith.........................................82PHOSLYRA.............................. 66phytonadione............................ 66PIFELTRO................................ 39pilocarpine hcl..................... 60, 95pimecrolimus.............................63pimozide....................................36pimtrea...................................... 82pindolol......................................51pioglitazone hcl......................... 45pioglitazone hcl-glimepiride.......45pioglitazone hcl-metformin hcl.. 45PIQRAY.................................... 30pirmella 1/35............................. 82pirmella 7/7/7............................ 82piroxicam...................................12PLEGRIDY................................59PLEGRIDY STARTER PACK... 59PLENVU....................................70PLIAGLIS.................................. 16PNEUMOVAX 23...................... 89POCKET SPACER................... 92podofilox....................................63polycin.......................................94polyethylene glycol 3350...........70polymyxin b-trimethoprim..........94POMALYST.............................. 29

PONVORY................................ 59PONVORY STARTER PACK... 59portia-28....................................82posaconazole............................27POTABA................................... 66potassium chloride.................... 65potassium chloride crys er........ 65potassium chloride er................65potassium citrate er...................65PR BENZOYL PEROXIDE........63PRADAXA.................................48PRALUENT...............................56pramipexole dihydrochloride..... 35pramipexole dihydrochloride er.35PRAMOSONE...........................63prasugrel hcl............................. 50pravastatin sodium....................55praziquantel.............................. 34prazosin hcl...............................50PRECISION XTRA BLOOD GLUCOSE................................ 43PRED MILD.............................. 96PRED-G.................................... 94PRED-G S.O.P......................... 94prednicarbate............................ 75prednisolone............................. 75prednisolone acetate.................96prednisolone acetate p-f........... 96prednisolone sodium phosphate........................... 75, 96prednisone................................ 75prednisone intensol...................75PREFEST................................. 82pregabalin................................. 58pregabalin er............................. 58PREGNYL.................................77PREMARIN............................... 82PREMPHASE........................... 82PREMPRO................................82PRESTALIA.............................. 53PRETOMANID.......................... 29prevalite.................................... 56PREVIDENT............................. 60PREVIDENT 5000 DRY MOUTH.....................................60PREVIDENT 5000 PLUS.......... 60previfem.................................... 82PREVNAR 13............................89PREVYMIS............................... 37PREZCOBIX............................. 40PREZISTA................................ 40PRIFTIN.................................... 29PRILOSEC................................70

116

primaquine phosphate.............. 34primidone.................................. 21PRO COMFORT SPACER ADULT...................................... 92PRO COMFORT SPACER CHILD....................................... 92PRO COMFORT SPACER INFANT..................................... 92PROAIR DIGIHALER..............100PROAIR RESPICLICK............100probenecid................................ 27PROCARE SPACER/ADULT MASK........................................92PROCARE SPACER/CHILD MASK........................................92prochlorperazine....................... 25prochlorperazine maleate......... 25PROCRIT..................................48PROCTOCORT........................ 90PROCTOFOAM HC.................. 90procto-med hc........................... 90procto-pak................................. 91proctosol hc...............................91proctozone-hc........................... 91PROCYSBI............................... 71PROFILNINE............................ 49progesterone.............................84PROGRAF................................ 87PROLATE................................. 15PROLENSA.............................. 96PROMACTA..............................48promethazine hcl.......................98promethegan.............................98propafenone hcl........................ 51propafenone hcl er.................... 51propranolol hcl.......................... 52propranolol hcl er...................... 52propylthiouracil ..........................86PROQUAD................................89protriptyline hcl..........................25PSORCON................................75PULMICORT FLEXHALER.......99PULMOZYME......................... 100PURIXAN.................................. 30PYLERA....................................67pyrazinamide.............................29pyridostigmine bromide.............28pyridostigmine bromide er.........28pyrimethamine.......................... 34QBRELIS.................................. 51QBREXZA.................................63qc magnesium citrate................70QDOLO..................................... 13

QELBREE................................. 58QINLOCK..................................33QNASL......................................99QNASL CHILDRENS................ 99QTERN..................................... 45QUADRACEL............................89quazepam................................. 41quetiapine fumarate.................. 37quetiapine fumarate er.............. 37QUILLICHEW ER......................58QUILLIVANT XR....................... 58quinapril hcl...............................51quinapril-hydrochlorothiazide.... 53quinidine gluconate er...............51quinidine sulfate........................ 51quinine sulfate...........................34QVAR REDIHALER.................. 99RABEPRAZOLE SODIUM........ 70rabeprazole sodium.................. 70RADIOGARDASE..................... 92RAGWITEK.............................102raloxifene hcl.............................85ramelteon................................ 103ramipril ...................................... 51ranolazine er............................. 53rasagiline mesylate................... 36RASUVO...................................87RAVICTI....................................71RAYALDEE...............................91RAYOS..................................... 75REBIF....................................... 59REBIF REBIDOSE....................59REBIF REBIDOSE TITRATION PACK.................... 59REBIF TITRATION PACK.........59REBINYN.................................. 49reclipsen....................................82RECOMBINATE........................49RECOMBIVAX HB.................... 89RECTIV.....................................57REDITREX................................87REGRANEX..............................63RELAFEN DS........................... 12RELENZA DISKHALER............ 40relexxii .......................................58RELION PREMIER TEST......... 43RELISTOR................................ 67RELTONE................................. 67RENACIDIN.............................. 72repaglinide................................ 45REPATHA................................. 56REPATHA PUSHTRONEX SYSTEM................................... 56

REPATHA SURECLICK........... 56RESTASIS................................ 94RESTASIS MULTIDOSE.......... 94RETACRIT................................ 48RETEVMO................................ 33RETIN-A MICRO PUMP........... 63REVCOVI..................................71REVLIMID................................. 29REXULTI...................................37REYATAZ................................. 40REYVOW.................................. 28REZUROCK..............................87RHOPRESSA........................... 95ribavirin..................................... 38RIDAURA..................................88rifabutin..................................... 28rifampin..................................... 29riluzole.......................................58rimantadine hcl..........................40RINVOQ....................................88risedronate sodium................... 91RISPERDAL CONSTA..............37risperidone................................ 37ritonavir..................................... 40rivastigmine...............................22rivastigmine tartrate.................. 22rivelsa........................................83RIXUBIS....................................49rizatriptan benzoate.................. 28ROCKLATAN............................ 95ropinirole hcl..............................35ropinirole hcl er......................... 35rosadan..................................... 63rosuvastatin calcium................. 55ROSZET................................... 56ROTARIX.................................. 89ROTATEQ.................................89roweepra................................... 20ROZLYTREK............................ 30RUBRACA................................ 31RUCONEST..............................86rufinamide................................. 22RUKOBIA..................................40RUZURGI..................................92RYBELSUS...............................45RYDAPT................................... 33RYLAZE.................................... 30RYTARY............................. 35, 36ryvent........................................ 98SAIZEN..................................... 77SAIZENPREP........................... 77sajazir........................................86salsalate....................................12

117

SAMSCA...................................65SANCUSO................................ 25SANDIMMUNE......................... 87SANDOSTATIN LAR DEPOT... 86SANTYL.................................... 63sapropterin dihydrochloride.......71SAVAYSA................................. 48SAVELLA.................................. 58SAVELLA TITRATION PACK... 58SCEMBLIX................................33scopolamine..............................25SECUADO................................ 37SEGLUROMET.........................45selegiline hcl............................. 36selenium sulfide........................ 63SELZENTRY.............................40SEMGLEE.................................47SEMGLEE (YFGN)................... 47SEREVENT DISKUS.............. 100SERNIVO..................................75SEROSTIM............................... 67SERTRALINE HCL................... 24sertraline hcl..............................24setlakin......................................83sevelamer carbonate................ 66sevelamer hcl............................66SEVENFACT............................ 49SEYSARA................................. 20sf............................................... 60sf 5000 plus...............................60SFROWASA............................. 90sharobel.................................... 84SHINGRIX.................................89SIGNIFOR.................................86SIGNIFOR LAR.........................86SIKLOS..................................... 30sildenafil citrate....................... 101SILIQ.........................................63silodosin.................................... 72silver sulfadiazine......................18SIMBRINZA.............................. 95simliya....................................... 83simpesse...................................83SIMPONI...................................87simvastatin................................ 56sirolimus....................................87SIRTURO..................................29SITAVIG....................................38SIVEXTRO................................18SKYRIZI.................................... 87SKYRIZI (150 MG DOSE).........87SKYRIZI PEN............................87SKYTROFA...............................77

SLYND...................................... 84sodium chloride.................72, 102sodium fluoride....................60, 65sodium fluoride 5000 plus......... 60sodium fluoride 5000 ppm.........60sodium phenylbutyrate..............71sodium polystyrene sulfonate... 65sodium sulfacetamide wash......63SOFOSBUVIR-VELPATASVIR.38solifenacin succinate.................72SOLIQUA.................................. 45SOLOSEC.................................18SOLTAMOX.............................. 30SOLU-CORTEF........................ 75SOMATULINE DEPOT............. 86SOMAVERT..............................86SORILUX.................................. 63sorine........................................ 51sotalol hcl.................................. 51sotalol hcl (af)............................51SOTYLIZE.................................51SOVALDI.................................. 38spinosad....................................34SPIRIVA HANDIHALER............99SPIRIVA RESPIMAT................ 99spironolactone...........................54spironolactone-hctz...................53sprintec 28................................ 83SPRITAM.................................. 20SPRIX....................................... 12SPRYCEL................................. 33sps............................................ 65sronyx....................................... 83ssd............................................ 18SSKI..........................................92sss 10-5.................................... 63stavudine...................................40STEGLATRO............................ 45STEGLUJAN.............................45STELARA..................................63sterile water for irrigation...........93STIMATE.................................. 77STIOLTO RESPIMAT............... 99STIVARGA................................33STRENSIQ................................71STRIBILD..................................39STRIVERDI RESPIMAT......... 100SUBSYS................................... 15subvenite...................................21subvenite starter kit-blue...........22subvenite starter kit-green........ 22subvenite starter kit-orange...... 22SUCRAID..................................71

sucralfate.................................. 70SULCONAZOLE NITRATE.......27sulfacetamide sodium......... 63, 97sulfacetamide sodium (acne).... 63sulfacetamide sodium-sulfur..... 63sulfacetamide-prednisolone...... 94sulfadiazine............................... 19sulfamethoxazole-trimethoprim.19SULFAMYLON..........................18sulfasalazine............................. 91sulfatrim pediatric......................19sulindac.....................................12sumatriptan............................... 28sumatriptan succinate............... 28sumatriptan succinate refill ....... 28sumatriptan-naproxen sodium.. 28sunitinib malate......................... 33SUNOSI.................................. 103SUPRAX................................... 18SUPREP BOWEL PREP KIT....70SUTAB...................................... 70syeda........................................ 83SYMBICORT.............................99SYMDEKO.............................. 101SYMJEPI.................................100SYMLINPEN 120...................... 45SYMLINPEN 60........................ 45SYMPAZAN.............................. 21SYMPROIC...............................67SYMTUZA.................................40SYNAREL................................. 86SYNDROS................................ 25SYNJARDY...............................45SYNJARDY XR.........................45SYNRIBO..................................30TABLOID...................................30TABRECTA...............................33tacrolimus............................63, 87tadalafil (pah).......................... 101TAFINLAR.................................33TAGRISSO............................... 33TAKHZYRO.............................. 86TALICIA.................................... 67TALTZ....................................... 63TALZENNA............................... 31tamoxifen citrate........................30tamsulosin hcl........................... 72TAPERDEX 12-DAY................. 75TAPERDEX 6-DAY................... 75TAPERDEX 7-DAY................... 75TARGRETIN............................. 33tarina 24 fe................................ 83tarina fe 1/20............................. 83

118

tarina fe 1/20 eq........................ 83TASIGNA.................................. 33tavaborole................................. 27TAVALISSE.............................. 49TAVNEOS.................................93taysofy.......................................83tazarotene................................. 63TAZAROTENE..........................64TAZORAC.................................64taztia xt......................................52TAZVERIK................................ 31TDVAX...................................... 89TEGSEDI.................................. 71TEKTURNA HCT...................... 53telmisartan................................ 50telmisartan-amlodipine..............53telmisartan-hctz.........................53temazepam............................. 103TEMIXYS.................................. 40temozolomide............................29TENCON...................................15TENIVAC.................................. 89tenofovir disoproxil fumarate.....40TEPMETKO.............................. 33terazosin hcl..............................72terbinafine hcl............................27terbutaline sulfate....................100terconazole............................... 27TERIPARATIDE (RECOMBINANT)..................... 91testosterone........................ 77, 78TESTOSTERONE CYPIONATE............................. 77testosterone cypionate..............77testosterone enanthate............. 77tetrabenazine............................ 58tetracycline hcl.......................... 20TEXACORT.............................. 75THALITONE..............................54THALOMID............................... 29THEO-24.................................101theophylline.............................101theophylline er.........................101THIOLA EC............................... 72thioridazine hcl.......................... 36thiothixene.................................36THYQUIDITY............................ 85tiadylt er.................................... 52tiagabine hcl..............................21TIBSOVO.................................. 33TIGLUTIK..................................58tilia fe.........................................83timolol maleate....................52, 95

timolol maleate (once-daily)...... 95timolol maleate ocudose........... 95timolol maleate pf......................96TIMOPTIC OCUDOSE..............96tinidazole...................................18tiopronin.................................... 72TIROSINT................................. 85TIROSINT-SOL.........................85TIVICAY.................................... 39TIVICAY PD.............................. 39TIVORBEX................................12tizanidine hcl........................... 103TOBI PODHALER...................101TOBRADEX.............................. 93TOBRADEX ST.........................93tobramycin........................ 93, 101TOBRAMYCIN........................ 101tobramycin-dexamethasone......93TOBREX................................... 93TODAY SPONGE..................... 72tolcapone.................................. 35TOLSURA................................. 27tolterodine tartrate.....................72tolterodine tartrate er.................72TOLVAPTAN.............................65tolvaptan................................... 65topiramate................................. 22topiramate er.............................22toremifene citrate...................... 30torsemide.................................. 54TOSYMRA................................ 28TOUJEO MAX SOLOSTAR...... 47TOUJEO SOLOSTAR...............47tovet.......................................... 75TOVIAZ..................................... 72TRACLEER.............................101TRADJENTA.............................45TRAMADOL HCL ER................13tramadol hcl er.......................... 13tramadol hcl er (biphasic)..........13tramadol hcl ir ........................... 15tramadol-acetaminophen.......... 15trandolapril ................................ 51trandolapril-verapamil hcl er......53tranexamic acid.........................49tranylcypromine sulfate............. 23travoprost (bak free)..................97trazodone hcl............................ 24TRECATOR.............................. 29TRELEGY ELLIPTA..........99, 102TREMFYA.................................64TRESIBA...................................47TRESIBA FLEXTOUCH............47

tretinoin............................... 33, 64tretinoin microsphere................ 64tretinoin microsphere pump...... 64TRETTEN................................. 49TREXALL.................................. 87tri femynor................................. 83triamcinolone acetonide 60, 75, 76triamcinolone in absorbase....... 76triamterene................................54triamterene-hctz........................ 53TRIANEX.................................. 76triazolam................................... 41triderm.......................................76trientine hcl................................65tri-estarylla................................ 83trifluoperazine hcl......................36trifluridine.................................. 94trihexyphenidyl hcl.................... 34TRIJARDY XR.......................... 45TRIKAFTA...............................101tri-legest fe................................ 83tri-linyah.................................... 83tri-lo-estarylla............................ 83tri-lo-marzia............................... 83tri-lo-mili .................................... 83tri-lo-sprintec............................. 83trimethobenzamide hcl..............25trimethoprim.............................. 18tri-mili ........................................ 83trimipramine maleate................ 25TRINTELLIX..............................24tri-nymyo................................... 83tri-previfem................................ 83tri-sprintec................................. 83tritocin....................................... 76TRIUMEQ................................. 40trivora (28).................................83tri-vylibra................................... 83tri-vylibra lo................................83TROKENDI XR......................... 22tropicamide............................... 94trospium chloride.......................72trospium chloride er.................. 72TRUDHESA.............................. 28TRUE METRIX BLOOD GLUCOSE TEST...................... 43TRUETRACK TEST..................43TRULANCE...............................67TRULICITY............................... 45TRUMENBA..............................89TRUSELTIQ (100MG DAILY DOSE).......................................31

119

TRUSELTIQ (125MG DAILY DOSE).......................................31TRUSELTIQ (50MG DAILY DOSE).......................................31TRUSELTIQ (75MG DAILY DOSE).......................................31TUDORZA PRESSAIR............. 99TUKYSA....................................33tulana........................................ 84TURALIO.................................. 33TWINRIX...................................89TWIRLA.................................... 83tyblume..................................... 83TYBOST....................................39tydemy...................................... 83TYMLOS................................... 91TYRVAYA................................. 96TYVASO................................. 101TYVASO REFILL.................... 101TYVASO STARTER................101UBRELVY................................. 27UCERIS.................................... 91UDENYCA................................ 48UKONIQ....................................33ULTRAVATE.............................76unithroid.................................... 85UPNEEQ...................................95UPTRAVI................................ 101URSODIOL............................... 67ursodiol............................... 67, 68valacyclovir hcl..........................38VALCHLOR...............................29valganciclovir hcl.......................37valproic acid.............................. 21valsartan................................... 50valsartan-hydrochlorothiazide... 54VALTOCO.................................21vancomycin hcl......................... 18vandazole..................................18VAQTA......................................89varenicline tartrate.................... 17VARIVAX.................................. 89VARUBI (180 MG DOSE)......... 25VASCEPA................................. 56VAXELIS................................... 89VCF VAGINAL CONTRACEPTIVE................... 72vcf vaginal contraceptive...........73VECAMYL.................................54velivet........................................83VELPHORO.............................. 66VELTASSA............................... 66VELTIN..................................... 64

VEMLIDY.................................. 38VENCLEXTA.............................33VENCLEXTA STARTING PACK........................................ 33venlafaxine hcl.......................... 24venlafaxine hcl er...................... 24VENTAVIS.............................. 101VENTOLIN HFA......................100verapamil hcl.............................52verapamil hcl er.........................52VERDESO................................ 76VEREGEN................................ 64VERQUVO................................ 54VERSACLOZ............................ 37VERZENIO................................31VESICARE LS.......................... 72vestura...................................... 83V-GO 20....................................93V-GO 30....................................93V-GO 40....................................93VIBERZI.................................... 68VIBRAMYCIN............................20VICTOZA.................................. 45VIEKIRA PAK............................38vienva........................................83vigabatrin.................................. 21vigadrone.................................. 21VIIBRYD....................................24VIIBRYD STARTER PACK....... 24VIMPAT.....................................22viorele....................................... 83VIRACEPT................................ 40VIREAD.....................................40VISTOGARD.............................93vitamin d (ergocalciferol)...........66vitamin k1..................................66VITRAKVI..................................33VIVAGUARD INO TEST STRIPS..................................... 43VIZIMPRO.................................33volnea....................................... 83VONVENDI............................... 49voriconazole..............................27VORTEX VALVED HOLDING CHAMBER................................ 93VOSEVI.....................................38VOTRIENT................................33VRAYLAR................................. 37VTOL LQ...................................15VUMERITY............................... 59VUSION.................................... 27vyfemla......................................83vylibra........................................83

VYNDAMAX..............................54VYNDAQEL.............................. 54VYVANSE................................. 57VYZULTA..................................97WAKIX.................................... 103warfarin sodium.........................48water for irrigation, sterile..........93WELIREG................................. 31wera.......................................... 84WESTHROID............................ 85WIDE-SEAL DIAPHRAGM 60.. 93WIDE-SEAL DIAPHRAGM 65.. 93WIDE-SEAL DIAPHRAGM 70.. 93WIDE-SEAL DIAPHRAGM 75.. 93WIDE-SEAL DIAPHRAGM 80.. 93WIDE-SEAL DIAPHRAGM 85.. 93WIDE-SEAL DIAPHRAGM 90.. 93WIDE-SEAL DIAPHRAGM 95.. 93WILATE.....................................49WINLEVI................................... 64wixela inhub.............................. 99WP THYROID........................... 85wymzya fe................................. 84WYNZORA................................64XADAGO...................................36XALKORI.................................. 33XARELTO................................. 48XARELTO STARTER PACK.....48XATMEP................................... 87XCOPRI.................................... 21XELJANZ.................................. 87XELJANZ XR............................ 87XELPROS................................. 97XEMBIFY.................................. 88XENLETA..................................18XEPI..........................................18XERESE................................... 38XERMELO................................ 68XIFAXAN...................................18XIGDUO XR..............................45XIIDRA...................................... 94XIMINO..................................... 20XOFLUZA (40 MG DOSE)........ 40XOFLUZA (80 MG DOSE)........ 40XOLAIR.....................................88XOLEGEL................................. 27XOPENEX HFA...................... 100XOSPATA................................. 33XPOVIO (100 MG ONCE WEEKLY)..................................31XPOVIO (40 MG ONCE WEEKLY)..................................31

120

XPOVIO (40 MG TWICE WEEKLY)..................................31XPOVIO (60 MG ONCE WEEKLY)..................................31XPOVIO (60 MG TWICE WEEKLY)..................................31XPOVIO (80 MG ONCE WEEKLY)..................................31XPOVIO (80 MG TWICE WEEKLY)..................................31XTAMPZA ER........................... 13XTANDI.....................................29xulane....................................... 84XULTOPHY...............................45XURIDEN..................................71XYNTHA................................... 49XYNTHA SOLOFUSE...............49XYOSTED.................................78XYREM................................... 103XYWAV................................... 103yl folic acid................................ 66YONSA..................................... 29YOSPRALA...............................50YUPELRI...................................99yuvafem.................................... 84zafemy...................................... 84zafirlukast..................................99zaleplon...................................103zarah......................................... 84ZARXIO.....................................48ZCORT 7-DAY.......................... 76ZEGALOGUE............................46ZEJULA.....................................31ZELAPAR..................................36ZELBORAF............................... 33ZELNORM................................ 68ZEMBRACE SYMTOUCH........ 28zenatane................................... 64ZENPEP....................................71ZENZEDI...................................57ZEPATIER................................ 38ZEPOSIA.................................. 59ZEPOSIA 7-DAY STARTER PACK........................................ 59ZEPOSIA STARTER KIT.......... 59ZERVIATE................................ 95ZETONNA.................................99zidovudine.................................40ZIEXTENZO..............................48zileuton er................................. 99ZILXI......................................... 64ZIOPTAN.................................. 97ziprasidone hcl.......................... 37

ZIPSOR.....................................12ZIRGAN.................................... 94ZOKINVY.................................. 93ZOLINZA...................................31ZOLMITRIPTAN........................28zolmitriptan................................28zolpidem tartrate..................... 103zolpidem tartrate er................. 103ZOLPIMIST............................. 103ZOMACTON............................. 77ZOMACTON (FOR ZOMA-JET 10).............................................77ZOMIG...................................... 28zonisamide................................21ZONTIVITY............................... 48ZORBTIVE................................ 68ZORVOLEX.............................. 12zovia 1/35 (28).......................... 84zovia 1/35e (28)........................ 84ZTLIDO..................................... 16ZUBSOLV................................. 16zumandimine.............................84ZUPLENZ..................................25ZYCLARA PUMP...................... 64ZYDELIG...................................33ZYFLO...................................... 99ZYKADIA...................................33ZYLET.......................................94ZYPITAMAG............................. 56ZYPREXA RELPREVV............. 37

121

bcbsm.com/pharmacy

All trademarks and logos are property of their respective owners in the U.S. and other jurisdictions.

Blue Care Network Custom Select Drug List

https://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy.html

https://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy.html

Your 2022 Blue Care Network Custom Select Drug List

Documents

Transcript of Your 2022 Blue Care Network Custom Select Drug List