2021 Formulary (List of Covered Drugs)
P.O. Box 30006, Pittsburgh, PA 15222-0330
SilverScript Employer PDP sponsored by State of Maryland (SilverScript) 2021 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 08/18/2020. For more recent information or other questions, please contact SilverScript Customer Care at 1-844-460-8767, 24 hours a day, 7 days a week. TTY users should call 711.
Formulary ID 21265
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means SilverScript® Insurance Company. When it refers to “plan” or “our plan,” it means SilverScript.
This document includes a list of the drugs (formulary) for our plan, which is current as of January 1, 2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.
Y0080_3012_FORM_COMP_CLT_2021_C_9544_0536_805
08/18/2020 What is the SilverScript Formulary?
A formulary is a list of covered drugs selected by SilverScript in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. SilverScript will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SilverScript network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Please note: State of Maryland provides additional coverage that may cover prescription drugs not included in your Medicare Part D benefit. For more information about your share of the cost or which prescription drugs may or may not be covered, please call SilverScript Customer Care.
Can the Formulary (drug list) change?
Most changes in drug coverage happen on January 1, but SilverScript may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.
Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:
· New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.
o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the SilverScript Formulary?”
· Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we may immediately remove the drug from our formulary and provide notice to members who take the drug.
· Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary; or add new restrictions to the brand name drug or move it to a different cost-sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add quantity limits and prior authorization restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective or at the time the member requests a refill of the drug, at which time the member will receive a 45-day supply of the drug.
08/18/2020 II o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the SilverScript Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.
The enclosed formulary is current as of January 1, 2021. To get updated information about the drugs covered by SilverScript, please contact SilverScript Customer Care. Our contact information appears on the front and back cover pages.
If we have other types of midyear non-maintenance formulary changes unrelated to the reasons stated above (e.g., remove drugs from our formulary; add prior authorization requirements, quantity limits, and/or step therapy restrictions on a drug; or move a drug to a higher cost-sharing tier), we will notify you by mail. We will also update our formulary with the new information. The updated formulary may be obtained by calling us.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index at the back of this document. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
SilverScript covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
08/18/2020 III Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
· Prior Authorization (PA): SilverScript requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from SilverScript before you fill your prescriptions. If you don’t get approval, SilverScript may not cover the drug.
· Quantity Limits (QL): For certain drugs, SilverScript limits the amount of the drug that SilverScript will cover. For example, SilverScript provides up to 240 tablets per 30-day prescription for tramadol hcl tab 50mg. This may be in addition to a standard one-month or three-month supply.
There may be additional drugs that are not available at mail and not marked NM, including some hepatitis B medications, post-transplant medications, and oral medications used to treat HIV.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You may ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You can ask SilverScript to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the SilverScript Formulary?” for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact SilverScript Customer Care and ask if your drug is covered.
If you learn that SilverScript does not cover your drug, you have two options: § You can ask SilverScript Customer Care for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. § You can ask us to make an exception and cover your drug. See below for information about how to request an exception. State of Maryland offers additional coverage on some prescription drugs not normally covered under a Medicare Part D prescription drug plan benefit. Payments made for these drugs will not count toward your initial coverage limit or total out-of-pocket costs. Please contact SilverScript Customer Care for any questions regarding your additional benefit.
08/18/2020 IV How do I request an exception to the SilverScript Formulary?
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make: § You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level and you would not be able to ask us to provide the drug at a lower cost-sharing level. § You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the High Cost tier. If approved, this would lower the amount you must pay for your drug. § You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, SilverScript will only approve your request for an exception if the alternative drug is included on the plan’s formulary or if the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 90-day supply. If your prescription is written for fewer than 90 days, we’ll allow refills to provide up to a maximum 90-day supply of medication. After your first 90-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.
08/18/2020 V If you experience a change in your level of care, such as a move from a home to a long-term care setting, and need a drug that is not on our formulary (or if your ability to get your drugs is limited), we may cover a one-time temporary supply from a network pharmacy for up to 31 days, unless you have a prescription for fewer days. You should use the plan’s exception process if you wish to have continued coverage of the drug after the temporary supply is finished.
Initial Coverage Stage Copayment/Coinsurance Levels
The plan has three Cost-Sharing Tiers
Every drug on the plan’s drug list is in one of three cost-sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the drug.
· Cost-Sharing Tier 1: Generics · Cost-Sharing Tier 2: Preferred Brands · Cost-Sharing Tier 3: Non-Preferred Brands
To find out which cost-sharing tier your drug is in, look it up in the plan’s drug list that begins on page 1.
Your share of the cost when you get a one-month supply of a covered Part D prescription drug before your individual or family maximum out-of-pocket is met: Network Retail Pharmacy Long-Term Care (LTC) (Up to a 45-day supply) Pharmacy (Up to a 31-day supply)
Tier 1 $10.00 $10.00 (Generics) Tier 2 $25.00 $25.00 (Preferred Brands) Tier 3 $40.00 $40.00 (Non-Preferred Brands)
Costs shown in the table above reflect the additional coverage that may be provided by State of Maryland. Drugs that are part of your standard Medicare plan, but do not have additional coverage from State of Maryland would be covered under the 2021 Medicare Part D Defined Standard Benefit. Please visit https://q1medicare.com/PartD-The-2021-Medicare-Part-D-Outlook.php for more information about the 2021 Medicare Part D Defined Standard Benefit drug costs.
For more information
For more detailed information about your SilverScript prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
08/18/2020 VI If you have general questions about Medicare Part D prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or visit www.medicare.gov.
SilverScript's Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index at the back of this book.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine).
The information in the Requirements/Limits column tells you if SilverScript has any special requirements for coverage of your drug. PA Prior Authorization. QL Drug has Quantity Limits. NM Not available at our mail-order pharmacies. NDS Non-extended day supply. Not available for an extended (long-term) supply. LA Limited Access. This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call SilverScript Customer Care at 1-844-460-8767, 24 hours a day, 7 days a week. TTY users should call 711. B/D This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. GC We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage.
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Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ANALGESICS etodolac (generic of LODINE) 1 GOUT TABS 400mg allopurinol (generic of 1 FELDENE CAPS 10mg, 3 ZYLOPRIM) TABS 100mg, 20mg 300mg flurbiprofen TABS 100mg 1 colchicine (generic of 1 ibu TABS 600mg, 800mg 1 COLCRYS) TABS .6mg ibuprofen SUSP 100mg/5ml; 1 colchicine w/ probenecid tab 1 TABS 400mg, 600mg, 800mg 0.5-500 mg ketoprofen CAPS 25mg 3 NDS COLCRYS TABS .6mg 3 ketoprofen CP24 200mg 1 febuxostat (generic of 1 meclofenamate sodium 1 ULORIC) TABS 40mg, 80mg CAPS 50mg, 100mg KRYSTEXXA SOLN 8mg/ml 3 NDS NM LA meloxicam (generic of 1 MITIGARE CAPS .6mg 2 MOBIC) TABS 7.5mg, 15mg probenecid TABS 500mg 1 MOBIC TABS 7.5mg, 15mg 3 ULORIC TABS 40mg, 80mg 3 nabumetone TABS 500mg, 1 ZYLOPRIM TABS 100mg, 3 750mg 300mg naproxen (generic of 1 NSAIDS NAPROSYN) TABS 250mg ARTHROTEC 50 TAB 3 naproxen TABS 375mg, 1 ARTHROTEC 75 TAB 3 500mg naproxen dr (generic of 1 CELEBREX CAPS 50mg, 3 EC-NAPROSYN) TBEC 100mg, 200mg, 400mg 375mg celecoxib (generic of 1 naproxen dr TBEC 500mg 1 CELEBREX) CAPS 50mg, 100mg, 200mg, 400mg naproxen sodium TABS 1 DAYPRO TABS 600mg 3 275mg naproxen sodium (generic of 1 diclofenac potassium TABS 1 ANAPROX DS) TABS 50mg 550mg diclofenac sodium TB24 1 oxaprozin (generic of 1 100mg; TBEC 25mg, 50mg, DAYPRO) TABS 600mg 75mg piroxicam (generic of 1 diclofenac w/ misoprostol tab 1 FELDENE) CAPS 10mg, delayed release 50-0.2 mg 20mg (generic of ARTHROTEC 50) sulindac TABS 150mg, 1 diclofenac w/ misoprostol tab 1 200mg delayed release 75-0.2 mg (generic of ARTHROTEC 75) tolmetin sodium CAPS 1 400mg; TABS 600mg diflunisal TABS 500mg 1 OPIOID ANALGESICS, LONG-ACTING ec-naproxen (generic of 1 EC-NAPROSYN) TBEC ARYMO ER TBEA 15mg, 3 QL PA 375mg 30mg QL (90 tabs / 30 days) ec-naproxen TBEC 500mg 1 ARYMO ER TBEA 60mg 3 NDS QL PA etodolac CAPS 200mg, 1 QL (90 tabs / 30 days) 300mg; TABS 500mg; TB24 400mg, 500mg, 600mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
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Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits BELBUCA FILM 75mcg, 3 QL PA hydrocodone bitartrate cap er 1 QL PA 150mcg, 300mcg, 450mcg, 12hr abuse-deterrent 40 mg 600mcg (generic of ZOHYDRO ER) QL (60 buccal films / 30 QL (60 caps / 30 days) days) hydromorphone hcl T24A 1 QL PA BELBUCA FILM 750mcg, 3 NDS QL PA 8mg, 12mg, 16mg, 32mg 900mcg QL (30 tabs / 30 days) QL (60 buccal films / 30 HYSINGLA ER T24A 20mg, 2 QL PA days) 30mg, 40mg, 60mg, 80mg, buprenorphine (generic of 1 QL PA 100mg, 120mg BUTRANS) PTWK 5mcg/hr, QL (30 tabs / 30 days) 7.5mcg/hr, 10mcg/hr, KADIAN CP24 10mg, 20mg, 3 QL PA 15mcg/hr, 20mcg/hr 30mg QL (4 patches / 28 days) QL (60 caps / 30 days) BUTRANS PTWK 5mcg/hr, 3 QL PA KADIAN CP24 40mg, 50mg, 3 NDS QL PA 7.5mcg/hr, 10mcg/hr, 60mg, 80mg, 100mg, 200mg 15mcg/hr QL (60 caps / 30 days) QL (4 patches / 28 days) methadone hcl SOLN 1 QL PA BUTRANS PTWK 20mcg/hr 3 NDS QL PA 5mg/5ml, 10mg/5ml QL (4 patches / 28 days) QL (450 mL / 30 days) CONZIP CP24 100mg, 3 QL PA methadone hcl (generic of 1 200mg, 300mg METHADONE HCL) SOLN QL (30 caps / 30 days) 10mg/ml DOLOPHINE TABS 5mg, 3 QL PA methadone hcl (generic of 1 QL PA 10mg DOLOPHINE) TABS 5mg, QL (90 tabs / 30 days) 10mg fentanyl (generic of 1 QL PA QL (90 tabs / 30 days) DURAGESIC) PT72 methadone hcl intensol 1 QL PA 12mcg/hr, 25mcg/hr, (generic of METHADOSE) 50mcg/hr, 75mcg/hr, CONC 10mg/ml 100mcg/hr QL (90 mL / 30 days) QL (10 patches / 30 morphine sulfate (generic of 1 QL PA days) KADIAN) CP24 10mg, fentanyl PT72 37.5mcg/hr, 1 QL PA 20mg, 30mg, 40mg, 50mg, 62.5mcg/hr 60mg, 80mg, 100mg QL (10 patches / 30 QL (60 caps / 30 days) days) morphine sulfate (generic of 1 QL PA fentanyl PT72 87.5mcg/hr 3 NDS QL PA MS CONTIN) TBCR 15mg, QL (10 patches / 30 30mg, 60mg, 100mg, 200mg days) QL (90 tabs / 30 days) hydrocodone bitartrate 1 QL PA morphine sulfate beads 1 QL PA (generic of ZOHYDRO ER) CP24 30mg, 45mg, 60mg, C12A 10mg, 15mg, 20mg, 75mg, 90mg, 120mg 30mg, 50mg QL (30 caps / 30 days) QL (60 caps / 30 days) MS CONTIN TBCR 15mg, 3 QL PA 30mg QL (90 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
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Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits MS CONTIN TBCR 60mg, 3 NDS QL PA ACTIQ LPOP 200mcg, 3 NDS QL PA 100mg, 200mg 400mcg, 600mcg, 800mcg, QL (90 tabs / 30 days) 1200mcg, 1600mcg NUCYNTA ER TB12 50mg 3 QL PA QL (120 lozenges / 30 QL (60 tabs / 30 days) days) NUCYNTA ER TB12 100mg, 3 NDS QL PA butorphanol tartrate SOLN 1 150mg, 200mg, 250mg 1mg/ml, 2mg/ml QL (60 tabs / 30 days) butorphanol tartrate SOLN 1 QL OXYCONTIN T12A 10mg, 2 QL PA 10mg/ml 15mg, 20mg, 30mg, 40mg, QL (10 mL / 30 days) 60mg, 80mg codeine sulfate TABS 30mg 1 QL QL (60 tabs / 30 days) QL (180 tabs / 30 days) tramadol hcl CP24 100mg, 1 QL PA CODEINE SULFATE TABS 3 QL 200mg, 300mg 60mg QL (30 caps / 30 days) QL (180 tabs / 30 days) tramadol hcl TB24 100mg, 1 QL PA DILAUDID LIQD 1mg/ml 3 QL 200mg, 300mg QL (600 mL / 30 days) QL (30 tabs / 30 days) DILAUDID SOLN 1mg/ml, 3 B/D XTAMPZA ER C12A 9mg, 3 QL PA 2mg/ml 13.5mg, 18mg, 27mg DILAUDID TABS 2mg, 4mg 3 QL QL (60 caps / 30 days) QL (180 tabs / 30 days) XTAMPZA ER C12A 36mg 3 NDS QL PA DILAUDID TABS 8mg 3 NDS QL QL (240 caps / 30 days) QL (180 tabs / 30 days) ZOHYDRO ER C12A 10mg, 3 QL PA dvorah 1 QL 15mg, 20mg, 30mg, 40mg, QL (300 tabs / 30 days) 50mg endocet tab 2.5-325mg 1 QL QL (60 caps / 30 days) (generic of PERCOCET) OPIOID ANALGESICS, SHORT-ACTING QL (360 tabs / 30 days) acetaminophen w/ codeine 1 QL endocet tab 5-325mg (generic 1 QL soln 120-12 mg/5ml of PERCOCET) QL (2700 mL / 30 days) QL (360 tabs / 30 days) acetaminophen w/ codeine 1 QL endocet tab 7.5-325mg 1 QL tab 300-15 mg (generic of PERCOCET) QL (400 tabs / 30 days) QL (240 tabs / 30 days) acetaminophen w/ codeine 1 QL endocet tab 10-325mg 1 QL tab 300-30 mg (generic of PERCOCET) QL (360 tabs / 30 days) QL (180 tabs / 30 days) acetaminophen w/ codeine 1 QL fentanyl citrate (generic of 3 NDS QL PA tab 300-60 mg ACTIQ) LPOP 200mcg, QL (180 tabs / 30 days) 600mcg, 800mcg, 1200mcg, acetaminophen-caffeine-dihyd 1 QL 1600mcg rocodeine cap 320.5-30-16 QL (120 lozenges / 30 mg days) QL (300 caps / 30 days) fentanyl citrate (generic of 1 QL PA acetaminophen-caffeine-dihyd 1 QL ACTIQ) LPOP 400mcg rocodeine tab 325-30-16 mg QL (120 lozenges / 30 QL (300 tabs / 30 days) days)
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
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Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits fentanyl citrate TABS 3 NDS QL PA hydromorphone hcl SOLN 1 B/D 100mcg, 200mcg, 400mcg, 4mg/ml, 10mg/ml, 50mg/5ml, 600mcg, 800mcg 500mg/50ml QL (120 tabs / 30 days) hydromorphone hcl (generic 1 QL FENTORA TABS 100mcg, 3 NDS QL PA of DILAUDID) TABS 2mg, 200mcg, 400mcg, 600mcg, 4mg, 8mg 800mcg QL (180 tabs / 30 days) QL (120 tabs / 30 days) HYDROMORPHONE 3 B/D hydrocodone-acetaminophen 1 QL HYDROCHLORI SOLN soln 7.5-325 mg/15ml 1mg/ml, 2mg/ml, 4mg/ml QL (2700 mL / 30 days) lorcet (generic of NORCO) 1 QL hydrocodone-acetaminophen 1 QL QL (240 tabs / 30 days) tab 5-300 mg (generic of lorcet hd (generic of NORCO) 1 QL XODOL) QL (180 tabs / 30 days) QL (240 tabs / 30 days) lorcet plus (generic of 1 QL hydrocodone-acetaminophen 1 QL NORCO) tab 5-325 mg (generic of QL (180 tabs / 30 days) NORCO) morphine sulfate SOLN 1 B/D QL (240 tabs / 30 days) 1mg/ml hydrocodone-acetaminophen 1 QL MORPHINE SULFATE 3 B/D tab 7.5-300 mg SOLN 2mg/ml, 4mg/ml, QL (180 tabs / 30 days) 5mg/ml, 8mg/ml, 10mg/ml hydrocodone-acetaminophen 1 QL morphine sulfate (generic of 1 B/D tab 7.5-325 mg (generic of MORPHINE SULFATE) NORCO) SOLN 4mg/ml, 8mg/ml, QL (180 tabs / 30 days) 10mg/ml hydrocodone-acetaminophen 1 QL morphine sulfate SOLN 1 QL tab 10-300 mg 10mg/5ml QL (180 tabs / 30 days) QL (900 mL / 30 days) hydrocodone-acetaminophen 1 QL morphine sulfate SOLN 1 QL tab 10-325 mg (generic of 20mg/5ml NORCO) QL (900 mL / 30 days) QL (180 tabs / 30 days) morphine sulfate SOLN 1 QL hydrocodone-ibuprofen tab 1 QL 100mg/5ml 5-200 mg QL (180 mL / 30 days) QL (150 tabs / 30 days) morphine sulfate TABS 1 QL hydrocodone-ibuprofen tab 1 QL 15mg, 30mg 7.5-200 mg QL (180 tabs / 30 days) QL (150 tabs / 30 days) nalbuphine hcl SOLN 1 hydrocodone-ibuprofen tab 1 QL 10mg/ml, 20mg/ml 10-200 mg NORCO TAB 5-325MG 3 QL QL (150 tabs / 30 days) QL (240 tabs / 30 days) hydromorphone hcl (generic 1 QL NORCO TAB 7.5-325 3 QL of DILAUDID) LIQD 1mg/ml QL (180 tabs / 30 days) QL (600 mL / 30 days) NORCO TAB 10-325MG 3 QL hydromorphone hcl (generic 1 B/D QL (180 tabs / 30 days) of DILAUDID) SOLN 1mg/ml, 2mg/ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
4 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits NUCYNTA TABS 50mg, 3 QL PERCOCET TAB 2.5-325 3 QL 75mg QL (360 tabs / 30 days) QL (180 tabs / 30 days) PERCOCET TAB 5-325MG 3 NDS QL NUCYNTA TABS 100mg 3 NDS QL QL (360 tabs / 30 days) QL (180 tabs / 30 days) PERCOCET TAB 7.5-325 3 NDS QL OXAYDO TABA 5mg 3 QL QL (240 tabs / 30 days) QL (540 tabs / 30 days) PERCOCET TAB 10-325MG 3 NDS QL OXAYDO TABA 7.5mg 3 NDS QL QL (180 tabs / 30 days) QL (360 tabs / 30 days) ROXICODONE TABS 5mg, 3 QL oxycodone hcl CAPS 5mg 1 QL 15mg QL (180 caps / 30 days) QL (180 tabs / 30 days) oxycodone hcl CONC 1 QL ROXICODONE TABS 30mg 3 NDS QL 100mg/5ml QL (180 tabs / 30 days) QL (180 mL / 30 days) SUBSYS LIQD 100mcg, 3 NDS QL PA oxycodone hcl SOLN 1 QL 200mcg, 400mcg, 600mcg, 5mg/5ml 800mcg QL (900 mL / 30 days) QL (120 sprays / 30 oxycodone hcl (generic of 1 QL days) ROXICODONE) TABS 5mg, SUBSYS LIQD 1200mcg, 3 NDS QL PA 15mg, 30mg 1600mcg QL (180 tabs / 30 days) QL (240 sprays / 30 oxycodone hcl TABS 10mg, 1 QL days) 20mg tramadol hcl (generic of 1 QL QL (180 tabs / 30 days) ULTRAM) TABS 50mg oxycodone w/ acetaminophen 1 QL QL (240 tabs / 30 days) tab 2.5-325 mg (generic of tramadol hcl TABS 100mg 1 QL PERCOCET) QL (120 tabs / 30 days) QL (360 tabs / 30 days) tramadol-acetaminophen tab 1 QL oxycodone w/ acetaminophen 1 QL 37.5-325 mg (generic of tab 5-325 mg (generic of ULTRACET) PERCOCET) QL (240 tabs / 30 days) QL (360 tabs / 30 days) trezix 1 QL oxycodone w/ acetaminophen 1 QL QL (300 caps / 30 days) tab 7.5-325 mg (generic of ULTRACET TAB 37.5-325 3 QL PERCOCET) QL (240 tabs / 30 days) QL (240 tabs / 30 days) ULTRAM TABS 50mg 3 QL oxycodone w/ acetaminophen 1 QL QL (240 tabs / 30 days) tab 10-325 mg (generic of ANESTHETICS PERCOCET) LOCAL ANESTHETICS QL (180 tabs / 30 days) lidocaine hcl (local anesth.) 1 oxycodone-aspirin tab 1 QL SOLN 4% 4.8355-325 mg lidocaine hcl (local anesth.) 1 B/D QL (360 tabs / 30 days) (generic of XYLOCAINE-MPF) oxymorphone hcl TABS 5mg 1 QL SOLN .5%, 1%, 1.5%, 2% QL (180 tabs / 30 days) lidocaine hcl (local anesth.) 1 B/D oxymorphone hcl (generic of 1 QL (generic of XYLOCAINE) OPANA) TABS 10mg SOLN .5%, 1%, 2% QL (180 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
5 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits XYLOCAINE SOLN .5%, 3 B/D clindamycin phosphate in d5w 1 1%, 2% iv soln 300 mg/50ml XYLOCAINE-MPF SOLN 3 B/D clindamycin phosphate in d5w 1 .5%, 1%, 1.5%, 2% iv soln 600 mg/50ml ANTI-INFECTIVES clindamycin phosphate in d5w 1 ANTI-INFECTIVES - MISCELLANEOUS iv soln 900 mg/50ml AEMCOLO TBEC 194mg 3 CLINDMYC/NAC INJ 3 albendazole (generic of 3 NDS 300/50ML ALBENZA) TABS 200mg CLINDMYC/NAC INJ 3 ALINIA SUSR 100mg/5ml; 3 NDS 600/50ML TABS 500mg CLINDMYC/NAC INJ 3 amikacin sulfate SOLN 1 900/50ML 1gm/4ml, 500mg/2ml colistimethate sodium (generic 1 ARIKAYCE SUSP 3 NDS NM LA of COLY-MYCIN M) SOLR 590mg/8.4ml 150mg atovaquone (generic of 3 NDS COLY-MYCIN M SOLR 3 MEPRON) SUSP 150mg 750mg/5ml CUBICIN SOLR 500mg 3 NDS AZACTAM SOLR 1gm, 2gm 3 DALVANCE SOLR 500mg 3 NDS aztreonam (generic of 1 dapsone TABS 25mg, 1 AZACTAM) SOLR 1gm, 2gm 100mg BACTRIM DS TAB 800-160 3 DAPTOMYCIN SOLR 3 NDS 350mg BACTRIM TAB 400-80MG 3 daptomycin (generic of 3 NDS BETHKIS NEBU 300mg/4ml 3 NDS B/D NM DAPTOMYCIN) SOLR BILTRICIDE TABS 600mg 3 350mg CAYSTON SOLR 75mg 3 NDS NM LA daptomycin (generic of 3 NDS CLEOCIN CAPS 75mg, 3 CUBICIN) SOLR 500mg 150mg, 300mg EMVERM CHEW 100mg 3 NDS CLEOCIN PEDIATRIC 3 ertapenem sodium (generic of 1 GRANULE SOLR 75mg/5ml INVANZ) SOLR 1gm CLEOCIN PHOSPHATE 3 FIRVANQ SOLR 25mg/ml, 3 SOLN 9gm/60ml, 300mg/2ml, 50mg/ml 600mg/4ml, 900mg/6ml FLAGYL CAPS 375mg; 3 clindamycin hcl (generic of 1 TABS 250mg, 500mg CLEOCIN) CAPS 75mg, gentamicin in saline inj 0.8 1 150mg, 300mg mg/ml clindamycin palmitate 1 gentamicin in saline inj 1 1 hydrochloride (generic of mg/ml CLEOCIN PEDIATRIC gentamicin in saline inj 1.2 1 GRANULE) SOLR 75mg/5ml mg/ml clindamycin phosphate 1 gentamicin in saline inj 1.6 1 (generic of CLEOCIN mg/ml PHOSPHATE) SOLN gentamicin in saline inj 2 1 9gm/60ml, 300mg/2ml, mg/ml 600mg/4ml, 900mg/6ml, gentamicin sulfate SOLN 1 9000mg/60ml 10mg/ml, 40mg/ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
6 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits HIPREX TABS 1gm 3 nitrofurantoin macrocrystal 2 imipenem-cilastatin 1 (generic of MACRODANTIN) intravenous for soln 250 mg CAPS 25mg, 50mg, 100mg imipenem-cilastatin 1 nitrofurantoin monohyd macro 2 intravenous for soln 500 mg (generic of MACROBID) (generic of PRIMAXIN IV) CAPS 100mg INVANZ SOLR 1gm 3 ORBACTIV SOLR 400mg 3 NDS ivermectin (generic of 1 paromomycin sulfate CAPS 1 STROMECTOL) TABS 3mg 250mg KITABIS PAK NEBU 3 NDS B/D NM PENTAM 300 SOLR 300mg 3 300mg/5ml pentamidine isethionate inh 1 B/D linezolid (generic of ZYVOX) 1 (generic of NEBUPENT) SOLN 600mg/300ml; TABS SOLR 300mg 600mg pentamidine isethionate inj 1 linezolid (generic of ZYVOX) 3 NDS (generic of PENTAM 300) SUSR 100mg/5ml SOLR 300mg linezolid in sodium chloride iv 1 polymyxin b sulfate SOLR 1 soln 600 mg/300ml-0.9% 500000unit MACROBID CAPS 100mg 3 praziquantel (generic of 1 MEPRON SUSP 750mg/5ml 3 NDS BILTRICIDE) TABS 600mg MEROP/NACL INJ 3 PRIMAXIN IV INJ 500MG 3 1GM/50ML pyrimethamine TABS 25mg 3 NDS MEROP/NACL INJ 500/50ML 3 RECARBRIO INJ 1.25GM 3 NDS meropenem (generic of 1 SIVEXTRO SOLR 200mg; 3 NDS MERREM) SOLR 1gm, TABS 200mg 500mg SOLOSEC PACK 2gm 3 MERREM SOLR 1gm, 3 streptomycin sulfate SOLR 3 NDS 500mg 1gm methenamine hippurate 1 STROMECTOL TABS 3mg 3 (generic of HIPREX) TABS SULFADIAZINE TABS 3 1gm 500mg METRONIDAZOL INJ 3 sulfamethoxazole-trimethopri 1 5MG/ML m iv soln 400-80 mg/5ml metronidazole (generic of 1 sulfamethoxazole-trimethopri 1 FLAGYL) CAPS 375mg; m susp 200-40 mg/5ml TABS 250mg, 500mg sulfamethoxazole-trimethopri 1 metronidazole in nacl 0.74% 1 m tab 400-80 mg (generic of iv soln 500 mg/100ml (generic BACTRIM) of METRONIDAZOLE) sulfamethoxazole-trimethopri 1 metronidazole in nacl 0.79% 1 m tab 800-160 mg (generic of iv soln 500 mg/100ml BACTRIM DS) NEBUPENT SOLR 300mg 3 B/D SYNERCID INJ 500MG 3 NDS neomycin sulfate TABS 1 tinidazole TABS 250mg, 1 500mg 500mg nitrofurantoin SUSP 3 NDS TOBI NEBU 300mg/5ml 3 NDS B/D NM 25mg/5ml TOBI PODHALER CAPS 3 NDS NM LA 28mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
7 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits tobramycin (generic of 3 NDS B/D NM CASPOFUNGIN ACETATE 3 NDS KITABIS PAK) NEBU SOLR 50mg, 70mg 300mg/5ml caspofungin acetate (generic 3 NDS tobramycin sulfate SOLN 1 of CANCIDAS) SOLR 50mg, 1.2gm/30ml, 10mg/ml, 70mg 40mg/ml, 80mg/2ml CRESEMBA CAPS 186mg; 3 NDS trimethoprim TABS 100mg 1 SOLR 372mg VABOMERE INJ 2GM(1-1) 3 NDS DIFLUCAN SUSR 10mg/ml, 3 VANCOCIN CAPS 250mg 3 NDS 40mg/ml; TABS 50mg, VANCOCIN HCL CAPS 3 NDS 100mg, 150mg 125mg DIFLUCAN TABS 200mg 3 NDS VANCOMYCIN SOLN 3 ERAXIS SOLR 50mg 3 2000mg/400ml ERAXIS SOLR 100mg 3 NDS vancomycin hcl (generic of 1 fluconazole (generic of 1 VANCOCIN HCL) CAPS DIFLUCAN) SUSR 10mg/ml, 125mg 40mg/ml; TABS 50mg, vancomycin hcl (generic of 1 100mg, 150mg, 200mg VANCOCIN) CAPS 250mg fluconazole in nacl 0.9% inj 1 vancomycin hcl SOLR 1gm, 1 200 mg/100ml 5gm, 10gm, 500mg, 750mg fluconazole in nacl 0.9% inj 1 VANCOMYCIN 3 400 mg/200ml HYDROCHLORIDE SOLN flucytosine (generic of 3 NDS 500mg/100ml, 1000mg/200ml, ANCOBON) CAPS 250mg, 1500mg/300ml; SOLR 500mg 1.25gm, 1.5gm, 250mg, griseofulvin microsize SUSP 1 250mg/5ml 125mg/5ml; TABS 500mg VANCOMYCIN INJ 1 GM 3 griseofulvin ultramicrosize 1 VANCOMYCIN INJ 500MG 3 TABS 125mg, 250mg VANCOMYCIN INJ 750MG 3 itraconazole (generic of 1 VIBATIV SOLR 750mg 3 NDS SPORANOX) CAPS 100mg XENLETA SOLN 3 NDS NM itraconazole (generic of 3 NDS 150mg/15ml; TABS 600mg SPORANOX) SOLN XIFAXAN TABS 200mg 3 NDS 10mg/ml ZEMDRI SOLN 500mg/10ml 3 NDS ketoconazole TABS 200mg 1 ZYVOX SOLN 3 NDS micafungin sodium (generic of 3 NDS 200mg/100ml, 600mg/300ml; MYCAMINE) SOLR 50mg, SUSR 100mg/5ml; TABS 100mg 600mg MYCAMINE SOLR 50mg, 3 NDS ANTIFUNGALS 100mg ABELCET SUSP 5mg/ml 3 B/D NOXAFIL SOLN 3 NDS 300mg/16.7ml; SUSP AMBISOME SUSR 50mg 3 NDS B/D 40mg/ml; TBEC 100mg amphotericin b SOLR 50mg 1 B/D nystatin TABS 500000unit 1 ANCOBON CAPS 250mg, 3 NDS 500mg posaconazole (generic of 3 NDS CANCIDAS SOLR 50mg, 3 NDS NOXAFIL) TBEC 100mg 70mg SPORANOX CAPS 100mg; 3 NDS SOLN 10mg/ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
8 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits SPORANOX PULSEPAK 3 NDS atazanavir sulfate (generic of 1 NM CAPS 100mg REYATAZ) CAPS 150mg, terbinafine hcl (generic of 1 200mg, 300mg LAMISIL) TABS 250mg CRIXIVAN CAPS 200mg, 3 NM TOLSURA CAPS 65mg 3 NDS 400mg VFEND SUSR 40mg/ml; 3 NDS PA didanosine CPDR 200mg, 1 NM TABS 50mg, 200mg 250mg, 400mg VFEND IV SOLR 200mg 3 NDS PA EDURANT TABS 25mg 3 NDS NM voriconazole (generic of 3 NDS PA efavirenz (generic of 1 NM VFEND IV) SOLR 200mg SUSTIVA) CAPS 50mg, voriconazole (generic of 3 NDS PA 200mg; TABS 600mg VFEND) SUSR 40mg/ml EMTRIVA CAPS 200mg; 2 NM voriconazole (generic of 1 PA SOLN 10mg/ml VFEND) TABS 50mg, EPIVIR SOLN 10mg/ml; 3 NM 200mg TABS 150mg, 300mg ANTIMALARIALS fosamprenavir calcium 3 NDS NM atovaquone-proguanil hcl tab 1 (generic of LEXIVA) TABS 62.5-25 mg (generic of 700mg MALARONE) FUZEON SOLR 90mg 3 NDS NM atovaquone-proguanil hcl tab 1 INTELENCE TABS 25mg 3 NM 250-100 mg (generic of INTELENCE TABS 100mg, 3 NDS NM MALARONE) 200mg chloroquine phosphate 1 INVIRASE TABS 500mg 3 NDS NM TABS 250mg, 500mg ISENTRESS CHEW 25mg; 2 NM COARTEM TAB 20-120MG 3 PACK 100mg KRINTAFEL TABS 150mg 3 ISENTRESS CHEW 100mg; 3 NDS NM MALARONE TAB 62.5-25 3 TABS 400mg MALARONE TAB 250-100 3 ISENTRESS HD TABS 3 NDS NM 600mg mefloquine hcl TABS 250mg 1 lamivudine (generic of 1 NM PRIMAQUINE PHOSPHATE 2 EPIVIR) SOLN 10mg/ml; TABS 26.3mg TABS 150mg, 300mg primaquine phosphate 1 LEXIVA SUSP 50mg/ml 3 NM (generic of PRIMAQUINE LEXIVA TABS 700mg 3 NDS NM PHOSPHATE) TABS nevirapine (generic of 1 NM 26.3mg VIRAMUNE) SUSP QUALAQUIN CAPS 324mg 3 50mg/5ml; TABS 200mg quinine sulfate (generic of 1 nevirapine TB24 100mg 1 NM QUALAQUIN) CAPS 324mg nevirapine (generic of 1 NM ANTIRETROVIRAL AGENTS VIRAMUNE XR) TB24 abacavir sulfate (generic of 1 NM 400mg ZIAGEN) SOLN 20mg/ml; NORVIR PACK 100mg; 3 NM TABS 300mg SOLN 80mg/ml; TABS 100mg APTIVUS CAPS 250mg; 3 NDS NM PIFELTRO TABS 100mg 3 NDS NM SOLN 100mg/ml PREZISTA SUSP 100mg/ml; 3 NDS NM TABS 150mg, 600mg, 800mg PREZISTA TABS 75mg 3 NM
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
9 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits RETROVIR CAPS 100mg; 3 NM abacavir 3 NDS NM SYRP 50mg/5ml sulfate-lamivudine-zidovudine REYATAZ CAPS 150mg, 3 NDS NM tab 300-150-300 mg (generic 200mg, 300mg; PACK 50mg of TRIZIVIR) ritonavir (generic of NORVIR) 1 NM ATRIPLA TAB 3 NDS NM TABS 100mg BIKTARVY TAB 3 NDS NM SELZENTRY SOLN 3 NDS NM CIMDUO TAB 300-300 3 NDS NM 20mg/ml; TABS 75mg, COMBIVIR TAB 150-300 3 NDS NM 150mg, 300mg COMPLERA TAB 3 NDS NM SELZENTRY TABS 25mg 2 NM DELSTRIGO TAB 3 NDS NM stavudine CAPS 15mg, 1 NM DESCOVY TAB 200/25 3 NDS NM 20mg DOVATO TAB 50-300MG 3 NDS NM stavudine (generic of ZERIT) 1 NM EPZICOM TAB 600-300 3 NDS NM CAPS 30mg, 40mg EVOTAZ TAB 300-150 3 NDS NM SUSTIVA CAPS 50mg 3 NM GENVOYA TAB 3 NDS NM SUSTIVA CAPS 200mg; 3 NDS NM JULUCA TAB 50-25MG 3 NDS NM TABS 600mg KALETRA SOL 3 NDS NM tenofovir disoproxil fumarate 1 NM KALETRA TAB 100-25MG 3 NM (generic of VIREAD) TABS KALETRA TAB 200-50MG 3 NDS NM 300mg lamivudine-zidovudine tab 1 NM TIVICAY TABS 10mg 2 NM 150-300 mg (generic of TIVICAY TABS 25mg, 50mg 3 NDS NM COMBIVIR) TIVICAY PD TBSO 5mg 2 NM lopinavir-ritonavir soln 1 NM TROGARZO SOLN 3 NDS NM LA 400-100 mg/5ml (80-20 200mg/1.33ml mg/ml) (generic of KALETRA) TYBOST TABS 150mg 3 NM ODEFSEY TAB 3 NDS NM VIRACEPT TABS 250mg, 3 NDS NM PREZCOBIX TAB 800-150 3 NDS NM 625mg STRIBILD TAB 3 NDS NM VIRAMUNE SUSP 3 NDS NM SYMFI LO TAB 3 NDS NM 50mg/5ml; TABS 200mg SYMFI TAB 3 NDS NM VIRAMUNE XR TB24 3 NDS NM SYMTUZA TAB 3 NDS NM 400mg TEMIXYS TAB 300-300 3 NDS NM VIREAD POWD 40mg/gm; 3 NDS NM TRIUMEQ TAB 3 NDS NM TABS 150mg, 200mg, 250mg, TRIZIVIR TAB 3 NDS NM 300mg TRUVADA TAB 100-150 3 NDS NM ZIAGEN SOLN 20mg/ml; 3 NM TRUVADA TAB 133-200 3 NDS NM TABS 300mg TRUVADA TAB 167-250 3 NDS NM zidovudine (generic of 1 NM RETROVIR) CAPS 100mg; TRUVADA TAB 200-300 3 NDS NM SYRP 50mg/5ml ANTITUBERCULAR AGENTS zidovudine TABS 300mg 1 NM cycloserine CAPS 250mg 3 NDS ANTIRETROVIRAL COMBINATION ethambutol hcl TABS 100mg 1 AGENTS ethambutol hcl (generic of 1 abacavir sulfate-lamivudine 1 NM MYAMBUTOL) TABS 400mg tab 600-300 mg (generic of isoniazid SYRP 50mg/5ml; 1 EPZICOM) TABS 100mg, 300mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
10 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits MYAMBUTOL TABS 100mg, 3 lamivudine (hbv) (generic of 1 NM 400mg EPIVIR HBV) TABS 100mg MYCOBUTIN CAPS 150mg 3 NDS MAVYRET TAB 100-40MG 3 NDS NM PASER PACK 4gm 3 oseltamivir phosphate 1 PRETOMANID TABS 200mg 3 (generic of TAMIFLU) CAPS PRIFTIN TABS 150mg 3 30mg, 45mg, 75mg; SUSR 6mg/ml pyrazinamide TABS 500mg 1 PEGASYS SOLN 3 NDS NM rifabutin (generic of 1 180mcg/0.5ml, 180mcg/ml MYCOBUTIN) CAPS 150mg PEGASYS PROCLICK 3 NDS NM RIFADIN CAPS 150mg 3 SOLN 180mcg/0.5ml RIFADIN SOLR 600mg 3 NDS PREVYMIS SOLN 3 NDS rifampin (generic of RIFADIN) 1 240mg/12ml, 480mg/24ml; CAPS 150mg, 300mg; SOLR TABS 240mg, 480mg 600mg RELENZA DISKHALER 2 SIRTURO TABS 100mg 3 NDS LA AEPB 5mg/blister TRECATOR TABS 250mg 3 ribavirin (hepatitis c) CAPS 1 NM ANTIVIRALS 200mg; TABS 200mg acyclovir CAPS 200mg 1 rimantadine hydrochloride 1 acyclovir (generic of 1 TABS 100mg ZOVIRAX) SUSP SITAVIG TABS 50mg 3 NDS 200mg/5ml; TABS 400mg, TAMIFLU CAPS 30mg, 3 800mg 45mg, 75mg; SUSR 6mg/ml acyclovir sodium SOLN 1 B/D valacyclovir hcl (generic of 1 50mg/ml VALTREX) TABS 1gm, adefovir dipivoxil (generic of 3 NDS NM 500mg HEPSERA) TABS 10mg VALCYTE SOLR 50mg/ml; 3 NDS BARACLUDE SOLN 3 NDS NM TABS 450mg .05mg/ml; TABS .5mg, 1mg valganciclovir hcl (generic of 1 cidofovir SOLN 75mg/ml 3 NDS VALCYTE) SOLR 50mg/ml; entecavir (generic of 1 NM TABS 450mg BARACLUDE) TABS .5mg, VALTREX TABS 1gm, 3 1mg 500mg EPCLUSA TAB 400-100 3 NDS NM VEMLIDY TABS 25mg 3 NDS NM EPIVIR HBV SOLN 5mg/ml; 3 NM VOSEVI TAB 3 NDS NM TABS 100mg XOFLUZA TBPK 20mg, 3 famciclovir TABS 125mg, 1 40mg 250mg, 500mg ZOVIRAX SUSP 200mg/5ml 3 GANCICLOVIR SOLN 3 B/D CEPHALOSPORINS 500mg/10ml AVYCAZ INJ 2-0.5GM 3 NDS ganciclovir sodium (generic of 1 B/D cefaclor CAPS 250mg, 1 CYTOVENE) SOLR 500mg 500mg; SUSR 125mg/5ml, HARVONI PAK 33.75-150MG 3 NDS NM 250mg/5ml, 375mg/5ml HARVONI PAK 45-200MG 3 NDS NM CEFACLOR ER TB12 3 HARVONI TAB 45-200MG 3 NDS NM 500mg HARVONI TAB 90-400MG 3 NDS NM HEPSERA TABS 10mg 3 NDS NM
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
11 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits cefadroxil CAPS 500mg; 1 cephalexin (generic of 1 SUSR 250mg/5ml, KEFLEX) CAPS 250mg, 500mg/5ml; TABS 1gm 500mg, 750mg CEFAZOLIN INJ 1GM/50ML 3 cephalexin SUSR 1 cefazolin sodium SOLR 1 125mg/5ml, 250mg/5ml; 1gm, 10gm, 500mg TABS 250mg, 500mg CEFAZOLIN SOLN 3 FETROJA SOLR 1gm 3 NDS 2GM/100ML-4% SUPRAX CAPS 400mg; 3 cefdinir CAPS 300mg; SUSR 1 CHEW 100mg, 200mg; SUSR 125mg/5ml, 250mg/5ml 100mg/5ml, 200mg/5ml, CEFEPIME SOLN 3 500mg/5ml 1gm/50ml, 2gm/100ml tazicef SOLR 1gm, 2gm, 1 cefepime hcl SOLR 1gm, 1 6gm 2gm TEFLARO SOLR 400mg, 3 NDS CEFEPIME/DEX INJ 1GM 3 600mg CEFEPIME/DEX INJ 2GM 3 ZERBAXA INJ 1.5GM 3 NDS cefixime (generic of SUPRAX) 1 ERYTHROMYCINS/MACROLIDES CAPS 400mg; SUSR azithromycin PACK 1gm; 1 100mg/5ml, 200mg/5ml TABS 600mg CEFOTAN SOLR 1gm, 2gm 3 azithromycin (generic of 1 cefotetan disodium (generic of 1 ZITHROMAX) SOLR 500mg; CEFOTAN) SOLR 1gm, 2gm SUSR 100mg/5ml, 200mg/5ml; TABS 250mg, CEFOXITIN INJ 1GM 3 500mg CEFOXITIN INJ 2GM 3 clarithromycin SUSR 1 cefoxitin sodium SOLR 1gm, 1 125mg/5ml, 250mg/5ml; 2gm, 10gm TABS 250mg, 500mg cefpodoxime proxetil SUSR 1 clarithromycin (generic of 1 50mg/5ml, 100mg/5ml; TABS BIAXIN XL) TB24 500mg 100mg, 200mg DIFICID TABS 200mg 3 NDS cefprozil SUSR 125mg/5ml, 1 ery-tab TBEC 250mg, 1 250mg/5ml; TABS 250mg, 333mg, 500mg 500mg ERYTHROCIN 3 ceftazidime SOLR 1gm, 1 LACTOBIONATE SOLR 2gm, 6gm 500mg CEFTAZIDIME/ SOL D5W 3 erythrocin stearate TABS 1 1GM 250mg CEFTAZIDIME/ SOL D5W 3 erythromycin base CPEP 1 2GM 250mg; TABS 250mg, 500mg; ceftriaxone sodium SOLR 1 TBEC 250mg, 333mg, 500mg 1gm, 2gm, 10gm, 250mg, erythromycin ethylsuccinate 1 500mg (generic of E.E.S. cefuroxime axetil TABS 1 GRANULES) SUSR 250mg, 500mg 200mg/5ml cefuroxime sodium SOLR 1 erythromycin ethylsuccinate 3 NDS 1.5gm, 7.5gm, 750mg (generic of ERYPED 400) SUSR 400mg/5ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
12 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits erythromycin ethylsuccinate 1 amoxicillin CAPS 250mg, 1 TABS 400mg 500mg; CHEW 125mg, ZITHROMAX PACK 1gm; 3 250mg; SUSR 125mg/5ml, SOLR 500mg; SUSR 200mg/5ml, 250mg/5ml, 100mg/5ml, 200mg/5ml; 400mg/5ml; TABS 500mg, TABS 250mg, 500mg 875mg ZITHROMAX TRI-PAK 3 amoxicillin & k clavulanate 1 TABS 500mg chew tab 200-28.5 mg ZITHROMAX Z-PAK TABS 3 amoxicillin & k clavulanate 1 250mg chew tab 400-57 mg FLUOROQUINOLONES amoxicillin & k clavulanate for 1 BAXDELA SOLR 300mg; 3 NDS susp 200-28.5 mg/5ml TABS 450mg amoxicillin & k clavulanate for 1 CIPRO SUSR 5gm/100ml, 3 susp 250-62.5 mg/5ml 500mg/5ml; TABS 250mg, (generic of AUGMENTIN) 500mg amoxicillin & k clavulanate for 1 ciprofloxacin 200 mg/100ml in 1 susp 400-57 mg/5ml d5w amoxicillin & k clavulanate for 1 ciprofloxacin 400 mg/200ml in 1 susp 600-42.9 mg/5ml d5w amoxicillin & k clavulanate tab 1 ciprofloxacin hcl TABS 1 250-125 mg 100mg, 750mg amoxicillin & k clavulanate tab 1 ciprofloxacin hcl (generic of 1 500-125 mg (generic of CIPRO) TABS 250mg, AUGMENTIN) 500mg amoxicillin & k clavulanate tab 1 levofloxacin SOLN 25mg/ml 1 875-125 mg levofloxacin (generic of 1 amoxicillin & k clavulanate tab 1 LEVAQUIN) TABS 250mg, er 12hr 1000-62.5 mg 500mg, 750mg ampicillin CAPS 500mg 1 levofloxacin in d5w iv soln 250 1 ampicillin & sulbactam sodium 1 mg/50ml for inj 1.5 (1-0.5) gm (generic levofloxacin in d5w iv soln 500 1 of UNASYN) mg/100ml ampicillin & sulbactam sodium 1 levofloxacin in d5w iv soln 750 1 for inj 3 (2-1) gm (generic of mg/150ml UNASYN) moxifloxacin hcl TABS 1 ampicillin & sulbactam sodium 1 400mg for iv soln 15 (10-5) gm moxifloxacin hcl 400 1 (generic of UNASYN BULK mg/250ml in sodium chloride PACK) 0.8% inj ampicillin sodium SOLR 1 MOXIFLOXACIN 3 1gm, 2gm, 10gm, 125mg, HYDROCHLORID SOLN 250mg, 500mg 400mg/250ml AUGMENTIN SUS ES-600 3 PENICILLINS AUGMENTIN TAB 500MG 3 BICILLIN C-R INJ 900/300 3 BICILLIN C-R INJ 1200000 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
13 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits BICILLIN L-A SUSP 3 piperacillin sod-tazobactam 1 600000unit/ml, sod for inj 40.5 gm (36-4.5 1200000unit/2ml, gm) 2400000unit/4ml UNASYN INJ 1.5GM 3 dicloxacillin sodium CAPS 1 UNASYN INJ 3GM 3 250mg, 500mg UNASYN INJ 15GM 3 NAFCILLIN INJ 1GM/50ML 3 ZOSYN SOL 2-0.25GM 3 NAFCILLIN INJ 2GM/100 3 ZOSYN SOL 3-0.375G 3 nafcillin sodium SOLR 1gm, 1 ZOSYN SOL 4-0.50GM 3 2gm TETRACYCLINES nafcillin sodium SOLR 10gm 3 NDS NAFCILLIN SODIUM SOLR 3 NDS demeclocycline hcl TABS 1 10gm 150mg, 300mg OXACILLIN INJ 1GM 3 doxy 100 SOLR 100mg 1 OXACILLIN INJ 2GM 3 NDS doxycycline (monohydrate) 1 CAPS 50mg, 75mg, 100mg, oxacillin sodium SOLR 1gm, 1 150mg; TABS 50mg, 75mg, 2gm 100mg, 150mg oxacillin sodium SOLR 10gm 3 NDS doxycycline (monohydrate) 1 PEN GK/DEXTR INJ 3 (generic of VIBRAMYCIN) 20000/ML SUSR 25mg/5ml PEN GK/DEXTR INJ 3 doxycycline hyclate CAPS 1 40000/ML 50mg; SOLR 100mg; TABS PEN GK/DEXTR INJ 3 20mg, 50mg, 100mg; TBEC 60000/ML 75mg, 100mg, 150mg penicillin g potassium SOLR 1 doxycycline hyclate (generic 1 5000000unit, 20000000unit of VIBRAMYCIN) CAPS PENICILLIN G PROCAINE 3 100mg SUSP 600000unit/ml doxycycline hyclate (generic 1 penicillin g sodium SOLR 1 of DORYX) TBEC 50mg, 5000000unit 200mg penicillin v potassium SOLR 1 minocycline hcl CAPS 50mg, 1 125mg/5ml, 250mg/5ml; 75mg; TABS 50mg, 75mg, TABS 250mg, 500mg 100mg; TB24 45mg, 90mg, pfizerpen SOLR 1 135mg 5000000unit, 20000000unit minocycline hcl (generic of 1 piperacillin sod-tazobactam na 1 MINOCIN) CAPS 100mg for inj 3.375 gm (3-0.375 gm) minocycline hcl (generic of 1 piperacillin sod-tazobactam 1 SOLODYN) TB24 55mg, sod for inj 2.25 gm (2-0.25 80mg, 105mg gm) minocycline hcl (generic of 3 NDS piperacillin sod-tazobactam 1 SOLODYN) TB24 65mg, sod for inj 4.5 gm (4-0.5 gm) 115mg piperacillin sod-tazobactam 1 MINOLIRA TB24 105mg, 3 sod for inj 13.5 gm (12-1.5 135mg gm) mondoxyne nl CAPS 75mg, 1 100mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
14 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits SOLODYN TB24 55mg, 3 NDS doxorubicin hcl liposomal 3 NDS B/D 65mg, 80mg, 105mg, 115mg (generic of DOXIL) INJ TARGADOX TABS 50mg 3 2mg/ml tetracycline hcl CAPS 1 ELLENCE SOLN 3 NDS B/D 250mg, 500mg 50mg/25ml, 200mg/100ml TIGECYCLINE SOLR 50mg 3 NDS epirubicin hcl SOLN 1 B/D tigecycline (generic of 3 NDS 50mg/25ml TYGACIL) SOLR 50mg epirubicin hcl (generic of 1 B/D TYGACIL SOLR 50mg 3 NDS ELLENCE) SOLN VIBRAMYCIN CAPS 100mg; 3 200mg/100ml SUSR 25mg/5ml; SYRP mitomycin SOLR 5mg 1 B/D 50mg/5ml mitomycin SOLR 20mg, 3 NDS B/D ANTINEOPLASTIC AGENTS 40mg ALKYLATING AGENTS valrubicin (generic of 3 NDS NM BENDEKA SOLN 3 NDS B/D NM VALSTAR) SOLN 40mg/ml 100mg/4ml VALSTAR SOLN 40mg/ml 3 NDS NM carboplatin SOLN 50mg/5ml, 1 B/D ANTIMETABOLITES 150mg/15ml, 450mg/45ml, ALIMTA SOLR 100mg, 3 NDS B/D 600mg/60ml 500mg cisplatin SOLN 50mg/50ml, 1 B/D azacitidine (generic of 3 NDS B/D NM 100mg/100ml, 200mg/200ml VIDAZA) SUSR 100mg cyclophosphamide CAPS 1 B/D cytarabine SOLN 20mg/ml, 1 B/D 25mg, 50mg 100mg/ml cyclophosphamide SOLR 3 NDS B/D DACOGEN SOLR 50mg 3 NDS B/D NM 1gm, 2gm, 500mg decitabine (generic of 3 NDS B/D NM GLEOSTINE CAPS 10mg 3 DACOGEN) SOLR 50mg GLEOSTINE CAPS 40mg, 3 NDS fludarabine phosphate SOLN 3 NDS B/D 100mg 50mg/2ml IFEX SOLR 3gm 3 B/D fludarabine phosphate SOLR 1 B/D ifosfamide SOLN 1gm/20ml, 1 B/D 50mg 3gm/60ml fluorouracil SOLN 1gm/20ml, 1 B/D IFOSFAMIDE SOLR 3gm 3 B/D 2.5gm/50ml, 5gm/100ml, LEUKERAN TABS 2mg 3 NDS 500mg/10ml oxaliplatin SOLN 1 B/D FOLOTYN SOLN 20mg/ml, 3 NDS NM 50mg/10ml, 100mg/20ml 40mg/2ml oxaliplatin SOLR 50mg, 3 NDS B/D GEMCITABINE SOLN 3 B/D 100mg 1gm/26.3ml, 2gm/52.6ml, 200mg/5.26ml TREANDA SOLR 25mg, 3 NDS B/D NM 100mg gemcitabine hcl SOLN 1 B/D 1gm/10ml, 2gm/20ml, ANTIBIOTICS 200mg/2ml; SOLR 1gm, 2gm, adriamycin SOLN 2mg/ml 1 B/D 200mg bleomycin sulfate SOLR 1 B/D gemcitabine hcl (generic of 1 B/D 15unit, 30unit GEMCITABINE) SOLN DOXIL INJ 2mg/ml 3 NDS B/D 1gm/26.3ml, 2gm/52.6ml, doxorubicin hcl SOLN 1 B/D 200mg/5.26ml 2mg/ml INFUGEM SOL 1200MG 3 NDS B/D
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
15 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits INFUGEM SOL 1300MG 3 NDS B/D hydroxyprogesterone 3 NDS B/D INFUGEM SOL 1400MG 3 NDS B/D caproate (antineoplastic) INFUGEM SOL 1500MG 3 NDS B/D SOLN 1.25gm/5ml INFUGEM SOL 1600MG 3 NDS B/D letrozole (generic of 1 INFUGEM SOL 1700MG 3 NDS B/D FEMARA) TABS 2.5mg INFUGEM SOL 1800MG 3 NDS B/D leuprolide acetate KIT 1 NM INFUGEM SOL 1900MG 3 NDS B/D 1mg/0.2ml INFUGEM SOL 2000MG 3 NDS B/D LUPRON DEPOT (1-MONTH) 3 NDS NM INFUGEM SOL 2200MG 3 NDS B/D KIT 3.75mg, 7.5mg mercaptopurine TABS 50mg 1 LUPRON DEPOT (3-MONTH) 3 NDS NM KIT 11.25mg, 22.5mg methotrexate sodium SOLN 1 B/D 1gm/40ml, 50mg/2ml, LUPRON DEPOT (4-MONTH) 3 NDS NM 250mg/10ml; SOLR 1gm KIT 30mg PURIXAN SUSP 3 NDS NM LUPRON DEPOT (6-MONTH) 3 NDS NM 2000mg/100ml KIT 45mg TABLOID TABS 40mg 3 LYSODREN TABS 500mg 3 NDS megestrol acetate TABS 2 VIDAZA SUSR 100mg 3 NDS B/D NM 20mg, 40mg HORMONAL ANTINEOPLASTIC AGENTS nilutamide (generic of 3 NDS abiraterone acetate (generic 3 NDS NM NILANDRON) TABS 150mg of ZYTIGA) TABS 250mg NUBEQA TABS 300mg 3 NDS NM LA anastrozole (generic of 1 SOLTAMOX SOLN 3 NDS ARIMIDEX) TABS 1mg 10mg/5ml ARIMIDEX TABS 1mg 3 NDS tamoxifen citrate TABS 1 AROMASIN TABS 25mg 3 NDS 10mg, 20mg bicalutamide (generic of 1 toremifene citrate (generic of 3 NDS CASODEX) TABS 50mg FARESTON) TABS 60mg CASODEX TABS 50mg 3 NDS TRELSTAR MIXJECT SUSR 3 NDS NM DEPO-PROVERA SUSP 3 B/D 3.75mg, 11.25mg, 22.5mg 400mg/ml VANTAS KIT 50mg 3 NM ELIGARD KIT 7.5mg, 3 B/D NM XTANDI CAPS 40mg 3 NDS NM LA 22.5mg, 30mg, 45mg ZOLADEX IMPL 3.6mg, 3 NM EMCYT CAPS 140mg 3 10.8mg ERLEADA TABS 60mg 3 NDS NM LA ZYTIGA TABS 250mg, 3 NDS NM LA exemestane (generic of 1 500mg AROMASIN) TABS 25mg IMMUNOMODULATORS FARESTON TABS 60mg 3 NDS POMALYST CAPS 1mg, 3 NDS NM LA FASLODEX SOLN 3 NDS B/D 2mg, 3mg, 4mg 250mg/5ml REVLIMID CAPS 2.5mg, 3 NDS NM LA FEMARA TABS 2.5mg 3 5mg, 10mg, 15mg, 20mg, FIRMAGON SOLR 80mg 3 B/D NM 25mg FIRMAGON SOLR 3 NDS B/D NM THALOMID CAPS 50mg, 3 NDS NM 120mg/vial 100mg, 150mg, 200mg flutamide CAPS 125mg 1 MISCELLANEOUS fulvestrant (generic of 3 NDS B/D bexarotene (generic of 3 NDS NM FASLODEX) SOLN TARGRETIN) CAPS 75mg 250mg/5ml dacarbazine SOLR 100mg 1 B/D
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
16 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ERWINAZE SOLR 3 NDS NM LA docetaxel (generic of 3 NDS B/D 10000unit DOCETAXEL) CONC HYDREA CAPS 500mg 3 160mg/8ml; SOLN 20mg/2ml, hydroxyurea (generic of 1 80mg/8ml, 160mg/16ml HYDREA) CAPS 500mg ETOPOPHOS SOLR 100mg 3 B/D irinotecan hcl (generic of 1 B/D etoposide SOLN 100mg/5ml, 1 B/D CAMPTOSAR) SOLN 500mg/25ml 40mg/2ml, 100mg/5ml HALAVEN SOLN 1mg/2ml 3 NDS B/D NM irinotecan hcl SOLN 1 B/D IXEMPRA KIT SOLR 15mg, 3 NDS B/D NM 300mg/15ml, 500mg/25ml 45mg KISQALI 200 PAK FEMARA 3 NDS NM JEVTANA SOLN 3 NDS NM KISQALI 400 PAK FEMARA 3 NDS NM 60mg/1.5ml KISQALI 600 PAK FEMARA 3 NDS NM MARQIBO SUSP 5mg/31ml 3 NDS B/D NM LONSURF TAB 15-6.14 3 NDS NM paclitaxel CONC 30mg/5ml, 1 B/D LONSURF TAB 20-8.19 3 NDS NM 100mg/16.7ml, 150mg/25ml, MATULANE CAPS 50mg 3 NDS LA 300mg/50ml mitoxantrone hcl CONC 1 B/D NM toposar SOLN 1gm/50ml, 1 B/D 2mg/ml 100mg/5ml NIPENT SOLR 10mg 3 NDS B/D vinblastine sulfate SOLN 1 B/D ONIVYDE INJ 43mg/10ml 3 NDS B/D NM 1mg/ml SYLATRON KIT 200mcg, 3 NDS NM vincristine sulfate SOLN 1 B/D 300mcg 1mg/ml SYNRIBO SOLR 3.5mg 3 NDS NM vinorelbine tartrate SOLN 1 B/D TARGRETIN CAPS 75mg 3 NDS NM 10mg/ml, 50mg/5ml TOPOTECAN HCL SOLN 3 NDS B/D MOLECULAR TARGET AGENTS 4mg/4ml AFINITOR TABS 2.5mg, 3 NDS NM topotecan hcl (generic of 3 NDS B/D 5mg, 7.5mg, 10mg TOPOTECAN HCL) SOLN AFINITOR DISPERZ TBSO 3 NDS NM 4mg/4ml 2mg, 3mg, 5mg topotecan hcl (generic of 3 NDS B/D ALECENSA CAPS 150mg 3 NDS NM LA HYCAMTIN) SOLR 4mg ALIQOPA SOLR 60mg 3 NDS NM LA tretinoin (chemotherapy) 3 NDS ALUNBRIG TABS 30mg, 3 NDS NM LA CAPS 10mg 90mg, 180mg MITOTIC INHIBITORS ALUNBRIG PAK 3 NDS NM LA ABRAXANE INJ 100MG 3 NDS B/D ARZERRA CONC 3 NDS B/D NM docetaxel CONC 20mg/ml 1 B/D 100mg/5ml, 1000mg/50ml DOCETAXEL CONC 3 B/D AVASTIN SOLN 100mg/4ml, 3 NDS B/D NM 20mg/ml 400mg/16ml LA docetaxel (generic of 3 NDS B/D AYVAKIT TABS 100mg, 3 NDS NM LA TAXOTERE) CONC 200mg, 300mg 80mg/4ml BALVERSA TABS 3mg, 3 NDS NM LA DOCETAXEL CONC 3 NDS B/D 4mg, 5mg 80mg/4ml, 160mg/8ml, BAVENCIO SOLN 3 NDS NM LA 200mg/10ml; SOLN 200mg/10ml 20mg/2ml, 80mg/8ml, BELEODAQ SOLR 500mg 3 NDS NM 160mg/16ml BESPONSA SOLR .9mg 3 NDS NM LA BORTEZOMIB SOLR 3.5mg 3 NDS B/D NM
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
17 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits BOSULIF TABS 100mg, 3 NDS NM HERZUMA SOLR 150mg, 3 NDS B/D NM 400mg, 500mg 420mg BRAFTOVI CAPS 75mg 3 NDS NM LA IBRANCE CAPS 75mg, 3 NDS NM LA BRUKINSA CAPS 80mg 3 NDS NM LA 100mg, 125mg; TABS 75mg, CABOMETYX TABS 20mg, 3 NDS NM LA 100mg, 125mg 40mg, 60mg ICLUSIG TABS 15mg, 45mg 3 NDS NM LA CALQUENCE CAPS 100mg 3 NDS NM LA IDHIFA TABS 50mg, 100mg 3 NDS NM LA CAPRELSA TABS 100mg, 3 NDS NM LA imatinib mesylate (generic of 3 NDS NM 300mg GLEEVEC) TABS 100mg, COMETRIQ (60MG DOSE) 3 NDS NM LA 400mg KIT 20mg IMBRUVICA CAPS 70mg, 3 NDS NM LA COMETRIQ KIT 100MG 3 NDS NM LA 140mg; TABS 140mg, 280mg, COMETRIQ KIT 140MG 3 NDS NM LA 420mg, 560mg COPIKTRA CAPS 15mg, 3 NDS NM LA IMFINZI SOLN 3 NDS NM LA 25mg 120mg/2.4ml, 500mg/10ml COTELLIC TABS 20mg 3 NDS NM LA INLYTA TABS 1mg, 5mg 3 NDS NM LA CYRAMZA SOLN 3 NDS NM LA INREBIC CAPS 100mg 3 NDS NM LA 100mg/10ml, 500mg/50ml IRESSA TABS 250mg 3 NDS NM LA DARZALEX SOLN 3 NDS NM LA JAKAFI TABS 5mg, 10mg, 3 NDS NM LA 100mg/5ml, 400mg/20ml 15mg, 20mg, 25mg DARZALEX SOL FASPRO 3 NDS NM KADCYLA SOLR 100mg, 3 NDS B/D NM DAURISMO TABS 25mg, 3 NDS NM LA 160mg 100mg KANJINTI SOLR 150mg, 3 NDS B/D NM EMPLICITI SOLR 300mg, 3 NDS NM LA 420mg 400mg KEYTRUDA SOLN 3 NDS NM ENHERTU SOLR 100mg 3 NDS B/D NM 100mg/4ml LA KISQALI TBPK 200mg 3 NDS NM ERBITUX SOLN 3 NDS B/D NM KOSELUGO CAPS 10mg, 3 NDS NM LA 100mg/50ml, 200mg/100ml 25mg ERIVEDGE CAPS 150mg 3 NDS NM LA KYPROLIS SOLR 10mg, 3 NDS NM LA erlotinib hcl (generic of 3 NDS NM 30mg, 60mg TARCEVA) TABS 25mg, LENVIMA 4 MG DAILY DOSE 3 NDS NM LA 100mg, 150mg CPPK 4mg everolimus (generic of 3 NDS NM LENVIMA 8 MG DAILY DOSE 3 NDS NM LA AFINITOR) TABS 2.5mg, CPPK 4mg 5mg, 7.5mg LENVIMA 10 MG DAILY 3 NDS NM LA FARYDAK CAPS 10mg, 3 NDS NM LA DOSE CPPK 10mg 20mg LENVIMA 12MG DAILY 3 NDS NM LA GAZYVA SOLN 3 NDS NM LA DOSE CPPK 4mg 1000mg/40ml LENVIMA 20 MG DAILY 3 NDS NM LA GILOTRIF TABS 20mg, 3 NDS NM LA DOSE CPPK 10mg 30mg, 40mg LENVIMA CAP 14 MG 3 NDS NM LA GLEEVEC TABS 100mg, 3 NDS NM LENVIMA CAP 18 MG 3 NDS NM LA 400mg LENVIMA CAP 24 MG 3 NDS NM LA HERCEP HYLEC SOL 3 NDS B/D NM LIBTAYO SOLN 350mg/7ml 3 NDS NM LA 60-10000 LORBRENA TABS 25mg, 3 NDS NM LA HERCEPTIN SOLR 150mg 3 NDS B/D NM 100mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
18 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits LUMOXITI SOLR 1mg 3 NDS NM LA RYDAPT CAPS 25mg 3 NDS NM LYNPARZA TABS 100mg, 3 NDS NM LA SARCLISA SOLN 3 NDS NM LA 150mg 100mg/5ml, 500mg/25ml MEKINIST TABS .5mg, 2mg 3 NDS NM LA SPRYCEL TABS 20mg, 3 NDS NM MEKTOVI TABS 15mg 3 NDS NM LA 50mg, 70mg, 80mg, 100mg, MVASI SOLN 100mg/4ml, 3 NDS B/D NM 140mg 400mg/16ml LA STIVARGA TABS 40mg 3 NDS NM LA MYLOTARG SOLR 4.5mg 3 NDS NM LA SUTENT CAPS 12.5mg, 3 NDS NM NERLYNX TABS 40mg 3 NDS NM LA 25mg, 37.5mg, 50mg NEXAVAR TABS 200mg 3 NDS NM LA TABRECTA TABS 150mg, 3 NDS NM NINLARO CAPS 2.3mg, 3 NDS NM 200mg 3mg, 4mg TAFINLAR CAPS 50mg, 3 NDS NM LA ODOMZO CAPS 200mg 3 NDS NM LA 75mg OGIVRI SOLR 150mg 3 NDS B/D NM TAGRISSO TABS 40mg, 3 NDS NM LA OGIVRI INJ 420MG 3 NDS B/D NM 80mg ONTRUZANT SOLR 150mg, 3 NDS B/D NM TALZENNA CAPS .25mg, 3 NDS NM LA 420mg 1mg OPDIVO SOLN 40mg/4ml, 3 NDS NM LA TARCEVA TABS 25mg, 3 NDS NM LA 100mg/10ml, 240mg/24ml 100mg, 150mg PADCEV SOLR 20mg, 3 NDS NM LA TASIGNA CAPS 50mg, 3 NDS NM 30mg 150mg, 200mg PEMAZYRE TABS 4.5mg, 3 NDS NM LA TAZVERIK TABS 200mg 3 NDS NM LA 9mg, 13.5mg TECENTRIQ SOLN 3 NDS NM LA PERJETA SOLN 3 NDS NM 840mg/14ml, 1200mg/20ml 420mg/14ml temsirolimus (generic of 3 NDS B/D NM PIQRAY 200MG DAILY 3 NDS NM TORISEL) SOLN 25mg/ml DOSE TBPK 200mg TIBSOVO TABS 250mg 3 NDS NM LA PIQRAY 250MG TAB DOSE 3 NDS NM TORISEL SOLN 25mg/ml 3 NDS B/D NM PIQRAY 300MG DAILY 3 NDS NM TRAZIMERA SOLR 420mg 3 NDS B/D NM DOSE TBPK 150mg TRODELVY SOLR 180mg 3 NDS NM LA POLIVY SOLR 140mg 3 NDS NM TRUXIMA SOLN 3 NDS NM PORTRAZZA SOLN 3 NDS NM LA 100mg/10ml, 500mg/50ml 800mg/50ml TUKYSA TABS 50mg, 3 NDS NM LA POTELIGEO SOLN 3 NDS NM LA 150mg 20mg/5ml TURALIO CAPS 200mg 3 NDS NM LA QINLOCK TABS 50mg 3 NDS NM LA TYKERB TABS 250mg 3 NDS NM LA RETEVMO CAPS 40mg, 3 NDS NM LA VECTIBIX SOLN 3 NDS B/D NM 80mg 100mg/5ml, 400mg/20ml RITUXAN SOLN 3 NDS NM LA VELCADE SOLR 3.5mg 3 NDS B/D NM 100mg/10ml, 500mg/50ml VENCLEXTA TABS 10mg 3 NM LA RITUXAN INJ HYCELA 3 NDS NM LA VENCLEXTA TABS 50mg, 3 NDS NM LA ROZLYTREK CAPS 100mg, 3 NDS NM LA 100mg 200mg VENCLEXTA TAB START PK 3 NDS NM LA RUBRACA TABS 200mg, 3 NDS NM LA VERZENIO TABS 50mg, 3 NDS NM LA 250mg, 300mg 100mg, 150mg, 200mg RUXIENCE SOLN 3 NDS NM VITRAKVI CAPS 25mg, 3 NDS NM LA 100mg/10ml, 500mg/50ml 100mg; SOLN 20mg/ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
19 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits VIZIMPRO TABS 15mg, 3 NDS NM LA levoleucovorin calcium 1 B/D NM 30mg, 45mg SOLN 250mg/25ml VOTRIENT TABS 200mg 3 NDS NM LA MESNEX TABS 400mg 3 NDS XALKORI CAPS 200mg, 3 NDS NM LA CARDIOVASCULAR 250mg ACE INHIBITOR COMBINATIONS XOSPATA TABS 40mg 3 NDS NM LA ACCURETIC TAB 10-12.5 3 XPOVIO 40 MG ONCE 3 NDS NM LA ACCURETIC TAB 20-12.5 3 WEEKLY TBPK 20mg ACCURETIC TAB 20-25MG 3 XPOVIO 40 MG TWICE 3 NDS NM LA amlodipine 1 WEEKLY TBPK 20mg besylate-benazepril hcl cap XPOVIO 60 MG ONCE 3 NDS NM LA 2.5-10 mg WEEKLY TBPK 20mg amlodipine 1 XPOVIO 60 MG TWICE 3 NDS NM LA besylate-benazepril hcl cap WEEKLY TBPK 20mg 5-10 mg (generic of LOTREL) XPOVIO 80 MG ONCE 3 NDS NM LA amlodipine 1 WEEKLY TBPK 20mg besylate-benazepril hcl cap XPOVIO 80 MG TWICE 3 NDS NM LA 5-20 mg (generic of LOTREL) WEEKLY TBPK 20mg amlodipine 1 XPOVIO 100 MG ONCE 3 NDS NM LA besylate-benazepril hcl cap WEEKLY TBPK 20mg 5-40 mg YERVOY SOLN 50mg/10ml, 3 NDS NM amlodipine 1 200mg/40ml besylate-benazepril hcl cap ZALTRAP SOLN 3 NDS NM LA 10-20 mg (generic of 100mg/4ml, 200mg/8ml LOTREL) ZEJULA CAPS 100mg 3 NDS NM LA amlodipine 1 ZELBORAF TABS 240mg 3 NDS NM LA besylate-benazepril hcl cap ZIRABEV SOLN 100mg/4ml, 3 NDS B/D NM 10-40 mg (generic of 400mg/16ml LOTREL) ZOLINZA CAPS 100mg 3 NDS NM benazepril & 1 ZYDELIG TABS 100mg, 3 NDS NM LA hydrochlorothiazide tab 5-6.25 150mg mg ZYKADIA TABS 150mg 3 NDS NM LA benazepril & 1 PROTECTIVE AGENTS hydrochlorothiazide tab dexrazoxane hcl SOLR 3 NDS B/D 10-12.5 mg (generic of 250mg, 500mg LOTENSIN HCT) ELITEK SOLR 1.5mg, 7.5mg 3 NDS B/D benazepril & 1 KHAPZORY SOLR 175mg, 3 NDS B/D NM hydrochlorothiazide tab 300mg 20-12.5 mg (generic of leucovorin calcium SOLN 1 B/D LOTENSIN HCT) 500mg/50ml; SOLR 50mg, benazepril & 1 100mg, 200mg, 350mg, hydrochlorothiazide tab 20-25 500mg mg (generic of LOTENSIN leucovorin calcium TABS 1 HCT) 5mg, 10mg, 15mg, 25mg captopril & 1 levoleucovorin calcium 3 NDS B/D NM hydrochlorothiazide tab 25-15 SOLN 175mg/17.5ml; SOLR mg 50mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
20 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits captopril & 1 trandolapril-verapamil hcl tab 1 hydrochlorothiazide tab 25-25 er 2-180 mg (generic of mg TARKA) captopril & 1 trandolapril-verapamil hcl tab 1 hydrochlorothiazide tab 50-15 er 2-240 mg (generic of mg TARKA) captopril & 1 trandolapril-verapamil hcl tab 1 hydrochlorothiazide tab 50-25 er 4-240 mg (generic of mg TARKA) enalapril maleate & 1 VASERETIC TAB 10-25MG 3 hydrochlorothiazide tab 5-12.5 ZESTORETIC TAB 10-12.5 3 mg ZESTORETIC TAB 20-12.5 3 enalapril maleate & 1 ZESTORETIC TAB 20-25MG 3 hydrochlorothiazide tab 10-25 mg (generic of VASERETIC) ACE INHIBITORS fosinopril sodium & 1 ACCUPRIL TABS 5mg, 3 hydrochlorothiazide tab 10mg, 20mg, 40mg 10-12.5 mg ALTACE CAPS 1.25mg, 3 fosinopril sodium & 1 2.5mg, 5mg, 10mg hydrochlorothiazide tab benazepril hcl TABS 5mg 1 20-12.5 mg benazepril hcl (generic of 1 lisinopril & hydrochlorothiazide 1 LOTENSIN) TABS 10mg, tab 10-12.5 mg (generic of 20mg, 40mg ZESTORETIC) captopril TABS 12.5mg, 1 lisinopril & hydrochlorothiazide 1 25mg, 50mg, 100mg tab 20-12.5 mg (generic of enalapril maleate (generic of 1 ZESTORETIC) VASOTEC) TABS 2.5mg, lisinopril & hydrochlorothiazide 1 5mg, 10mg, 20mg tab 20-25 mg (generic of EPANED SOLN 1mg/ml 3 NDS ZESTORETIC) fosinopril sodium TABS 1 LOTREL CAP 5-10MG 3 10mg, 20mg, 40mg LOTREL CAP 5-20MG 3 lisinopril (generic of ZESTRIL) 1 LOTREL CAP 10-20MG 3 TABS 2.5mg, 5mg, 30mg, 40mg LOTREL CAP 10-40MG 3 lisinopril (generic of PRINIVIL) 1 quinapril-hydrochlorothiazide 1 TABS 10mg, 20mg tab 10-12.5 mg (generic of LOTENSIN TABS 10mg, 3 ACCURETIC) 20mg, 40mg quinapril-hydrochlorothiazide 1 moexipril hcl TABS 7.5mg, 1 tab 20-12.5 mg (generic of 15mg ACCURETIC) perindopril erbumine TABS 1 quinapril-hydrochlorothiazide 1 2mg, 4mg, 8mg tab 20-25 mg (generic of PRINIVIL TABS 10mg, 20mg 3 ACCURETIC) QBRELIS SOLN 1mg/ml 3 NDS trandolapril-verapamil hcl tab 1 er 1-240 mg quinapril hcl (generic of 1 ACCUPRIL) TABS 5mg, 10mg, 20mg, 40mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
21 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ramipril (generic of ALTACE) 1 amlodipine 1 CAPS 1.25mg, 2.5mg, 5mg, besylate-olmesartan 10mg medoxomil tab 10-20 mg trandolapril TABS 1mg, 2mg 1 (generic of AZOR) trandolapril (generic of 1 amlodipine 1 MAVIK) TABS 4mg besylate-olmesartan VASOTEC TABS 2.5mg, 3 medoxomil tab 10-40 mg 5mg (generic of AZOR) VASOTEC TABS 10mg, 3 NDS amlodipine besylate-valsartan 1 20mg tab 5-160 mg (generic of ZESTRIL TABS 2.5mg, 5mg, 3 EXFORGE) 10mg, 20mg, 30mg, 40mg amlodipine besylate-valsartan 1 ALDOSTERONE RECEPTOR tab 5-320 mg (generic of ANTAGONISTS EXFORGE) amlodipine besylate-valsartan 1 ALDACTONE TABS 25mg, 3 tab 10-160 mg (generic of 50mg, 100mg EXFORGE) CAROSPIR SUSP 25mg/5ml 3 amlodipine besylate-valsartan 1 eplerenone (generic of 1 tab 10-320 mg (generic of INSPRA) TABS 25mg, 50mg EXFORGE) INSPRA TABS 25mg, 50mg 3 amlodipine-valsartan-hydrochl 1 spironolactone (generic of 1 orothiazide tab 5-160-12.5 mg ALDACTONE) TABS 25mg, (generic of EXFORGE HCT) 50mg, 100mg amlodipine-valsartan-hydrochl 1 ALPHA BLOCKERS orothiazide tab 5-160-25 mg CARDURA TABS 1mg, 2mg, 3 (generic of EXFORGE HCT) 4mg, 8mg amlodipine-valsartan-hydrochl 1 doxazosin mesylate (generic 1 orothiazide tab 10-160-12.5 of CARDURA) TABS 1mg, mg (generic of EXFORGE 2mg, 4mg, 8mg HCT) MINIPRESS CAPS 1mg, 3 amlodipine-valsartan-hydrochl 1 2mg, 5mg orothiazide tab 10-160-25 mg prazosin hcl (generic of 1 (generic of EXFORGE HCT) MINIPRESS) CAPS 1mg, amlodipine-valsartan-hydrochl 1 2mg, 5mg orothiazide tab 10-320-25 mg terazosin hcl CAPS 1mg, 1 (generic of EXFORGE HCT) 2mg, 5mg, 10mg ATACAND HCT TAB 16-12.5 3 ANGIOTENSIN II RECEPTOR ATACAND HCT TAB 32-12.5 3 ANTAGONIST COMBINATIONS ATACAND HCT TAB 3 amlodipine 1 32-25MG besylate-olmesartan AVALIDE TAB 150-12.5 3 medoxomil tab 5-20 mg AVALIDE TAB 300-12.5 3 (generic of AZOR) AZOR TAB 5-20MG 3 amlodipine 1 AZOR TAB 5-40MG 3 besylate-olmesartan medoxomil tab 5-40 mg AZOR TAB 10-20MG 3 (generic of AZOR) AZOR TAB 10-40MG 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
22 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits BENICAR HCT TAB 20-12.5 3 irbesartan-hydrochlorothiazide 1 BENICAR HCT TAB 40-12.5 3 tab 150-12.5 mg (generic of BENICAR HCT TAB 40-25MG 3 AVALIDE) candesartan 1 irbesartan-hydrochlorothiazide 1 cilexetil-hydrochlorothiazide tab 300-12.5 mg (generic of tab 16-12.5 mg (generic of AVALIDE) ATACAND HCT) losartan potassium & 1 candesartan 1 hydrochlorothiazide tab cilexetil-hydrochlorothiazide 50-12.5 mg (generic of tab 32-12.5 mg (generic of HYZAAR) ATACAND HCT) losartan potassium & 1 candesartan 1 hydrochlorothiazide tab cilexetil-hydrochlorothiazide 100-12.5 mg (generic of tab 32-25 mg (generic of HYZAAR) ATACAND HCT) losartan potassium & 1 DIOVAN HCT TAB 80/12.5 3 hydrochlorothiazide tab 100-25 mg (generic of DIOVAN HCT TAB 160-12.5 3 HYZAAR) DIOVAN HCT TAB 160-25MG 3 MICARDIS HCT TAB 40/12.5 3 DIOVAN HCT TAB 320-12.5 3 MICARDIS HCT TAB 3 DIOVAN HCT TAB 320-25MG 3 80-25MG EDARBYCLOR TAB 40-12.5 3 MICARDIS HCT TAB 80/12.5 3 EDARBYCLOR TAB 3 olmesartan 1 40-25MG medoxomil-hydrochlorothiazid ENTRESTO TAB 24-26MG 2 e tab 20-12.5 mg (generic of ENTRESTO TAB 49-51MG 2 BENICAR HCT) ENTRESTO TAB 97-103MG 2 olmesartan 1 EXFORGE HCT TAB 3 medoxomil-hydrochlorothiazid 5-160-12.5MG e tab 40-12.5 mg (generic of EXFORGE HCT TAB 3 BENICAR HCT) 5-160-25MG olmesartan 1 EXFORGE HCT TAB 3 medoxomil-hydrochlorothiazid 10-160-12.5MG e tab 40-25 mg (generic of BENICAR HCT) EXFORGE HCT TAB 3 10-160-25MG olmesartan-amlodipine-hydroc 1 hlorothiazide tab 20-5-12.5 EXFORGE HCT TAB 3 mg (generic of TRIBENZOR) 10-320-25MG olmesartan-amlodipine-hydroc 1 EXFORGE TAB 5-160MG 3 hlorothiazide tab 40-5-12.5 EXFORGE TAB 5-320MG 3 mg (generic of TRIBENZOR) EXFORGE TAB 10-160MG 3 olmesartan-amlodipine-hydroc 1 EXFORGE TAB 10-320MG 3 hlorothiazide tab 40-5-25 mg HYZAAR TAB 50-12.5 3 (generic of TRIBENZOR) HYZAAR TAB 100-12.5 3 olmesartan-amlodipine-hydroc 1 HYZAAR TAB 100-25 3 hlorothiazide tab 40-10-12.5 mg (generic of TRIBENZOR)
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
23 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits olmesartan-amlodipine-hydroc 1 valsartan-hydrochlorothiazide 1 hlorothiazide tab 40-10-25 mg tab 320-12.5 mg (generic of (generic of TRIBENZOR) DIOVAN HCT) telmisartan-amlodipine tab 1 valsartan-hydrochlorothiazide 1 40-5 mg (generic of tab 320-25 mg (generic of TWYNSTA) DIOVAN HCT) telmisartan-amlodipine tab 1 ANGIOTENSIN II RECEPTOR 40-10 mg (generic of ANTAGONISTS TWYNSTA) ATACAND TABS 4mg, 8mg, 3 telmisartan-amlodipine tab 1 16mg, 32mg 80-5 mg (generic of AVAPRO TABS 75mg, 3 TWYNSTA) 150mg, 300mg telmisartan-amlodipine tab 1 BENICAR TABS 5mg, 20mg, 3 80-10 mg (generic of 40mg TWYNSTA) candesartan cilexetil (generic 1 telmisartan-hydrochlorothiazid 1 of ATACAND) TABS 4mg, e tab 40-12.5 mg (generic of 8mg, 16mg, 32mg MICARDIS HCT) COZAAR TABS 25mg, 3 telmisartan-hydrochlorothiazid 1 50mg, 100mg e tab 80-12.5 mg (generic of DIOVAN TABS 40mg, 80mg, 3 MICARDIS HCT) 160mg, 320mg telmisartan-hydrochlorothiazid 1 EDARBI TABS 40mg, 80mg 3 e tab 80-25 mg (generic of irbesartan (generic of 1 MICARDIS HCT) AVAPRO) TABS 75mg, TRIBENZOR20- TAB 3 150mg, 300mg 5-12.5MG losartan potassium (generic of 1 TRIBENZOR40- TAB 3 COZAAR) TABS 25mg, 5-12.5MG 50mg, 100mg TRIBENZOR40- TAB 5-25MG 3 MICARDIS TABS 20mg, 3 TRIBENZOR40- TAB 10-12.5 3 40mg, 80mg TRIBENZOR40- TAB 3 olmesartan medoxomil 1 10-25MG (generic of BENICAR) TABS TWYNSTA TAB 40-5MG 3 5mg, 20mg, 40mg TWYNSTA TAB 40-10MG 3 telmisartan (generic of 1 TWYNSTA TAB 80-5MG 3 MICARDIS) TABS 20mg, TWYNSTA TAB 80-10MG 3 40mg, 80mg valsartan-hydrochlorothiazide 1 valsartan (generic of DIOVAN) 1 tab 80-12.5 mg (generic of TABS 40mg, 80mg, 160mg, DIOVAN HCT) 320mg valsartan-hydrochlorothiazide 1 ANTIARRHYTHMICS tab 160-12.5 mg (generic of amiodarone hcl SOLN 1 DIOVAN HCT) 50mg/ml, 900mg/18ml; TABS valsartan-hydrochlorothiazide 1 100mg, 200mg, 400mg tab 160-25 mg (generic of disopyramide phosphate 3 DIOVAN HCT) (generic of NORPACE) CAPS 100mg, 150mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
24 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits dofetilide (generic of 1 NM fenofibrate micronized CAPS 1 TIKOSYN) CAPS 125mcg, 43mg, 67mg, 130mg, 134mg, 250mcg, 500mcg 200mg flecainide acetate TABS 1 gemfibrozil (generic of LOPID) 1 50mg, 100mg, 150mg TABS 600mg MULTAQ TABS 400mg 3 LIPOFEN CAPS 50mg, 3 NORPACE CAPS 100mg, 3 150mg 150mg LOPID TABS 600mg 3 NORPACE CR CP12 3 TRICOR TABS 48mg, 3 100mg, 150mg 145mg pacerone TABS 100mg, 1 TRIGLIDE TABS 160mg 3 200mg, 400mg TRILIPIX CPDR 45mg, 3 propafenone hcl (generic of 1 135mg RYTHMOL SR) CP12 ANTILIPEMICS, HMG-CoA REDUCTASE 225mg, 325mg, 425mg INHIBITORS propafenone hcl TABS 1 ALTOPREV TB24 20mg, 3 NDS 150mg, 225mg, 300mg 40mg, 60mg quinidine sulfate TABS 1 atorvastatin calcium (generic 1 200mg, 300mg of LIPITOR) TABS 10mg, RYTHMOL SR CP12 225mg 3 20mg, 40mg, 80mg RYTHMOL SR CP12 3 NDS CRESTOR TABS 5mg, 3 325mg, 425mg 10mg, 20mg, 40mg sorine (generic of 1 EZALLOR SPRINKLE CPSP 3 BETAPACE) TABS 80mg, 5mg, 10mg, 20mg, 40mg 120mg, 160mg FLOLIPID SUSP 20mg/5ml, 3 sorine TABS 240mg 1 40mg/5ml sotalol hcl (generic of 1 fluvastatin sodium CAPS 1 BETAPACE) TABS 80mg, 20mg, 40mg 120mg, 160mg fluvastatin sodium (generic of 1 sotalol hcl TABS 240mg 1 LESCOL XL) TB24 80mg sotalol hcl (afib/afl) (generic of 1 LESCOL XL TB24 80mg 3 BETAPACE AF) TABS LIPITOR TABS 10mg, 20mg, 3 80mg, 120mg, 160mg 40mg, 80mg SOTYLIZE SOLN 5mg/ml 3 LIVALO TABS 1mg, 2mg, 3 TIKOSYN CAPS 125mcg, 3 NM 4mg 250mcg, 500mcg lovastatin TABS 10mg, 1 ANTILIPEMICS, FIBRATES 20mg, 40mg ANTARA CAPS 30mg, 90mg 3 pravastatin sodium TABS 1 choline fenofibrate (generic of 1 10mg, 80mg TRILIPIX) CPDR 45mg, pravastatin sodium (generic of 1 135mg PRAVACHOL) TABS 20mg, fenofibrate CAPS 50mg, 1 40mg 150mg; TABS 54mg, 160mg rosuvastatin calcium (generic 1 fenofibrate (generic of 1 of CRESTOR) TABS 5mg, TRICOR) TABS 48mg, 10mg, 20mg, 40mg 145mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
25 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits simvastatin (generic of 1 NEXLIZET TAB 180/10MG 3 ZOCOR) TABS 5mg, 10mg, niacin (antihyperlipidemic) 1 20mg, 40mg TABS 500mg simvastatin (generic of 1 QL niacin (antihyperlipidemic) 1 ZOCOR) TABS 80mg (generic of NIASPAN) TBCR QL (30 tabs / 30 days) 500mg, 750mg, 1000mg ZOCOR TABS 10mg, 20mg, 3 niacor TABS 500mg 1 40mg NIASPAN TBCR 500mg, 3 ZOCOR TABS 80mg 3 QL 750mg, 1000mg QL (30 tabs / 30 days) omega-3-acid ethyl esters cap 1 ZYPITAMAG TABS 2mg, 3 1 gm (generic of LOVAZA) 4mg PRALUENT SOAJ 75mg/ml, 2 NM ANTILIPEMICS, MISCELLANEOUS 150mg/ml cholestyramine (generic of 1 prevalite PACK 4gm 1 QUESTRAN) PACK 4gm; prevalite (generic of 1 POWD 4gm/dose QUESTRAN LIGHT) POWD cholestyramine light PACK 1 4gm/dose 4gm QUESTRAN PACK 4gm; 3 cholestyramine light (generic 1 POWD 4gm/dose of QUESTRAN LIGHT) QUESTRAN LIGHT POWD 3 POWD 4gm/dose 4gm/dose colesevelam hcl (generic of 1 VASCEPA CAPS .5gm, 1gm 3 WELCHOL) PACK 3.75gm; VYTORIN TAB 10-10MG 3 TABS 625mg VYTORIN TAB 10-20MG 3 COLESTID GRAN 5gm; 3 PACK 5gm; TABS 1gm VYTORIN TAB 10-40MG 3 colestipol hcl (generic of 1 VYTORIN TAB 10-80MG 3 COLESTID) GRAN 5gm; WELCHOL PACK 3.75gm; 3 PACK 5gm; TABS 1gm TABS 625mg ezetimibe (generic of ZETIA) 1 ZETIA TABS 10mg 3 TABS 10mg BETA-BLOCKER/DIURETIC ezetimibe-simvastatin tab 1 COMBINATIONS 10-10 mg (generic of atenolol & chlorthalidone tab 1 VYTORIN) 50-25 mg (generic of ezetimibe-simvastatin tab 1 TENORETIC 50) 10-20 mg (generic of atenolol & chlorthalidone tab 1 VYTORIN) 100-25 mg (generic of ezetimibe-simvastatin tab 1 TENORETIC 100) 10-40 mg (generic of bisoprolol & 1 VYTORIN) hydrochlorothiazide tab ezetimibe-simvastatin tab 1 2.5-6.25 mg (generic of ZIAC) 10-80 mg (generic of bisoprolol & 1 VYTORIN) hydrochlorothiazide tab 5-6.25 JUXTAPID CAPS 5mg, 3 NDS NM LA mg (generic of ZIAC) 10mg, 20mg, 30mg, 40mg, PA bisoprolol & 1 60mg hydrochlorothiazide tab LOVAZA CAP 1GM 3 10-6.25 mg (generic of ZIAC)
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
26 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits LOPRESS HCT TAB 3 KAPSPARGO SPRINKLE 3 50-25MG CS24 25mg, 50mg, 100mg, metoprolol & 1 200mg hydrochlorothiazide tab 50-25 labetalol hcl SOLN 5mg/ml; 1 mg (generic of LOPRESSOR TABS 100mg, 200mg, 300mg HCT) LOPRESSOR TABS 50mg, 3 metoprolol & 1 100mg hydrochlorothiazide tab metoprolol succinate (generic 1 100-25 mg of TOPROL XL) TB24 25mg, metoprolol & 1 50mg, 100mg, 200mg hydrochlorothiazide tab metoprolol tartrate SOCT 1 100-50 mg 5mg/5ml; SOLN 5mg/5ml; propranolol & 1 TABS 25mg, 37.5mg, 75mg hydrochlorothiazide tab 40-25 metoprolol tartrate (generic of 1 mg LOPRESSOR) TABS 50mg, propranolol & 1 100mg hydrochlorothiazide tab 80-25 nadolol (generic of 1 mg CORGARD) TABS 20mg, ZIAC TAB 2.5/6.25 3 40mg, 80mg ZIAC TAB 5-6.25MG 3 pindolol TABS 5mg, 10mg 1 ZIAC TAB 10/6.25 3 propranolol hcl (generic of 1 BETA-BLOCKERS INDERAL LA) CP24 60mg, acebutolol hcl CAPS 200mg, 1 80mg, 120mg, 160mg 400mg propranolol hcl SOLN 1 atenolol (generic of 1 1mg/ml, 20mg/5ml, 40mg/5ml; TENORMIN) TABS 25mg, TABS 10mg, 20mg, 40mg, 50mg, 100mg 60mg, 80mg betaxolol hcl TABS 10mg, 1 timolol maleate TABS 5mg, 1 20mg 10mg, 20mg bisoprolol fumarate TABS 1 TOPROL XL TB24 25mg, 3 5mg, 10mg 50mg, 100mg, 200mg BYSTOLIC TABS 2.5mg, 3 CALCIUM CHANNEL BLOCKERS 5mg, 10mg, 20mg amlodipine besylate (generic 1 carvedilol (generic of COREG) 1 of NORVASC) TABS 2.5mg, TABS 3.125mg, 6.25mg, 5mg, 10mg 12.5mg, 25mg CALAN SR TBCR 120mg, 3 carvedilol phosphate (generic 1 240mg of COREG CR) CP24 10mg, CARDIZEM TABS 30mg 3 20mg, 40mg, 80mg CARDIZEM TABS 60mg, 3 NDS COREG TABS 3.125mg, 3 120mg 6.25mg, 12.5mg, 25mg CARDIZEM CD CP24 3 NDS COREG CR CP24 10mg, 3 120mg, 180mg, 240mg, 20mg, 40mg, 80mg 300mg, 360mg CORGARD TABS 20mg, 3 CARDIZEM LA TB24 3 40mg, 80mg 120mg, 180mg, 240mg, INDERAL LA CP24 60mg, 3 NDS 300mg, 360mg, 420mg 80mg, 120mg, 160mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
27 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits cartia xt (generic of 1 nisoldipine TB24 20mg, 1 CARDIZEM CD) CP24 25.5mg, 30mg, 40mg 120mg, 180mg, 240mg, NORVASC TABS 2.5mg, 3 300mg 5mg, 10mg dilt-xr CP24 120mg, 180mg, 1 NYMALIZE SOLN 6mg/ml 3 NDS 240mg PROCARDIA XL TB24 3 diltiazem hcl CP12 60mg, 1 30mg, 60mg, 90mg 90mg, 120mg; SOLN SULAR TB24 8.5mg, 17mg, 3 25mg/5ml, 50mg/10ml, 34mg 125mg/25ml; TABS 90mg taztia xt (generic of TIAZAC) 1 diltiazem hcl (generic of 1 CP24 120mg, 180mg, 240mg, CARDIZEM) TABS 30mg, 300mg, 360mg 60mg, 120mg tiadylt er (generic of TIAZAC) 1 diltiazem hcl coated beads 1 CP24 120mg, 180mg, 240mg, (generic of CARDIZEM CD) 300mg, 360mg, 420mg CP24 120mg, 180mg, 240mg, TIAZAC CP24 120mg, 3 300mg, 360mg 180mg, 240mg, 300mg, diltiazem hcl coated beads 1 360mg, 420mg (generic of CARDIZEM LA) verapamil hcl (generic of 1 TB24 180mg, 240mg, 300mg, VERELAN PM) CP24 360mg, 420mg 100mg, 200mg diltiazem hcl extended release 1 verapamil hcl (generic of 1 beads (generic of TIAZAC) VERELAN) CP24 120mg, CP24 120mg, 180mg, 240mg, 180mg, 240mg 300mg, 360mg, 420mg verapamil hcl CP24 300mg, 1 felodipine TB24 2.5mg, 5mg, 1 360mg; SOLN 2.5mg/ml; 10mg TABS 40mg, 80mg, 120mg; isradipine CAPS 2.5mg, 5mg 1 TBCR 180mg KATERZIA SUSP 1mg/ml 3 verapamil hcl (generic of 1 matzim la (generic of 1 CALAN SR) TBCR 120mg, CARDIZEM LA) TB24 240mg 180mg, 240mg, 300mg, VERELAN CP24 120mg, 3 360mg, 420mg 180mg, 240mg, 360mg nicardipine hcl CAPS 20mg, 1 VERELAN PM CP24 100mg, 3 30mg 200mg, 300mg NICARDIPINE SOL 20/200ML 3 DIURETICS NICARDIPINE SOL 40/200ML 3 acetazolamide CP12 500mg; 1 nifedipine TB24 30mg, 1 TABS 125mg, 250mg 60mg, 90mg ALDACTAZIDE TAB 25/25 3 nifedipine (generic of 1 ALDACTAZIDE TAB 50/50 3 PROCARDIA XL) TB24 amiloride & 1 30mg, 60mg, 90mg hydrochlorothiazide tab 5-50 nimodipine CAPS 30mg 1 mg nisoldipine (generic of 1 amiloride hcl TABS 5mg 1 SULAR) TB24 8.5mg, 17mg, bumetanide SOLN .25mg/ml 1 34mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
28 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits bumetanide (generic of 1 MISCELLANEOUS BUMEX) TABS .5mg, 1mg, aliskiren fumarate (generic of 1 2mg TEKTURNA) TABS 150mg, chlorthalidone TABS 25mg, 1 300mg 50mg amlodipine 1 DIURIL SUSP 250mg/5ml 3 besylate-atorvastatin calcium DYAZIDE CAP 37.5-25 3 tab 2.5-10 mg EDECRIN TABS 25mg 3 NDS amlodipine 1 ethacrynic acid (generic of 1 besylate-atorvastatin calcium EDECRIN) TABS 25mg tab 2.5-20 mg furosemide SOLN 8mg/ml, 1 amlodipine 1 10mg/ml besylate-atorvastatin calcium furosemide (generic of LASIX) 1 tab 2.5-40 mg TABS 20mg, 40mg, 80mg amlodipine 1 furosemide inj SOLN 1 besylate-atorvastatin calcium 10mg/ml tab 5-10 mg (generic of hydrochlorothiazide CAPS 1 CADUET) 12.5mg; TABS 12.5mg, 25mg, amlodipine 1 50mg besylate-atorvastatin calcium indapamide TABS 1.25mg, 1 tab 5-20 mg (generic of 2.5mg CADUET) KEVEYIS TABS 50mg 3 NDS NM amlodipine 1 besylate-atorvastatin calcium LASIX TABS 20mg, 40mg, 3 tab 5-40 mg (generic of 80mg CADUET) MAXZIDE TAB 75-50 3 amlodipine 1 MAXZIDE-25 TAB 3 besylate-atorvastatin calcium methazolamide TABS 25mg, 1 tab 5-80 mg (generic of 50mg CADUET) metolazone TABS 2.5mg, 1 amlodipine 1 5mg, 10mg besylate-atorvastatin calcium spironolactone & 1 tab 10-10 mg (generic of hydrochlorothiazide tab 25-25 CADUET) mg (generic of amlodipine 1 ALDACTAZIDE) besylate-atorvastatin calcium torsemide TABS 5mg, 10mg, 1 tab 10-20 mg (generic of 20mg, 100mg CADUET) triamterene & 1 amlodipine 1 hydrochlorothiazide cap besylate-atorvastatin calcium 37.5-25 mg (generic of tab 10-40 mg (generic of DYAZIDE) CADUET) triamterene & 1 amlodipine 1 hydrochlorothiazide tab besylate-atorvastatin calcium 37.5-25 mg (generic of tab 10-80 mg (generic of MAXZIDE-25) CADUET) triamterene & 1 BIDIL TAB 3 hydrochlorothiazide tab 75-50 CADUET TAB 5-10MG 3 mg (generic of MAXZIDE)
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
29 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits CADUET TAB 5-20MG 3 LANOXIN PEDIATRIC 3 CADUET TAB 5-40MG 3 SOLN .1mg/ml CADUET TAB 5-80MG 3 methyldopa TABS 250mg, 1 CADUET TAB 10-10MG 3 500mg midodrine hcl TABS 2.5mg, 1 CADUET TAB 10-20MG 3 5mg, 10mg CADUET TAB 10-40MG 3 minoxidil TABS 2.5mg, 10mg 1 CADUET TAB 10-80MG 3 NORTHERA CAPS 100mg, 3 NDS NM LA CATAPRES TABS .1mg, 3 200mg, 300mg .2mg, .3mg phenoxybenzamine hcl 3 NDS CATAPRES-TTS-1 PTWK 3 (generic of DIBENZYLINE) .1mg/24hr CAPS 10mg CATAPRES-TTS-2 PTWK 3 RANEXA TB12 500mg, 3 .2mg/24hr 1000mg CATAPRES-TTS-3 PTWK 3 ranolazine (generic of 1 .3mg/24hr RANEXA) TB12 500mg, clonidine (generic of 1 1000mg CATAPRES-TTS-1) PTWK TEKTURNA TABS 150mg, 3 .1mg/24hr 300mg clonidine (generic of 1 TEKTURNA HCT TAB 3 CATAPRES-TTS-2) PTWK 150-12.5 .2mg/24hr TEKTURNA HCT TAB 3 clonidine (generic of 1 150-25MG CATAPRES-TTS-3) PTWK TEKTURNA HCT TAB 3 .3mg/24hr 300-12.5 clonidine hcl (generic of 1 TEKTURNA HCT TAB 3 CATAPRES) TABS .1mg, 300-25MG .2mg, .3mg VYNDAMAX CAPS 61mg 3 NDS NM LA CORLANOR SOLN 3 VYNDAQEL CAPS 20mg 3 NDS NM LA 5mg/5ml; TABS 5mg, 7.5mg NITRATES DEMSER CAPS 250mg 3 NDS DILATRATE SR CPCR 3 DIBENZYLINE CAPS 10mg 3 NDS 40mg digitek (generic of LANOXIN) 1 ISORDIL TITRADOSE TABS 3 TABS .125mg, .25mg 5mg digox (generic of LANOXIN) 1 ISORDIL TITRADOSE TABS 3 NDS TABS 125mcg, 250mcg 40mg digoxin SOLN .05mg/ml 1 isosorbide dinitrate (generic of 1 digoxin (generic of LANOXIN) 1 ISORDIL TITRADOSE) SOLN .25mg/ml; TABS TABS 5mg 125mcg, 250mcg isosorbide dinitrate TABS 1 guanfacine hcl TABS 1mg, 2 10mg, 20mg, 30mg 2mg isosorbide dinitrate (generic of 3 NDS hydralazine hcl SOLN 1 ISORDIL TITRADOSE) 20mg/ml; TABS 10mg, 25mg, TABS 40mg 50mg, 100mg isosorbide mononitrate 1 LANOXIN SOLN .25mg/ml; 3 TABS 10mg, 20mg; TB24 TABS 62.5mcg 30mg, 60mg, 120mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
30 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits minitran (generic of 1 REVATIO SUSR 10mg/ml; 3 NDS NM PA NITRO-DUR) PT24 .1mg/hr, TABS 20mg .2mg/hr, .4mg/hr, .6mg/hr sildenafil citrate (pulmonary 3 NDS NM PA NITRO-BID OINT 2% 2 hypertension) (generic of NITRO-DUR PT24 .1mg/hr, 3 REVATIO) SUSR 10mg/ml .2mg/hr, .3mg/hr, .4mg/hr, sildenafil citrate (pulmonary 1 NM PA .6mg/hr, .8mg/hr hypertension) (generic of nitroglycerin PT24 .1mg/hr, 1 REVATIO) TABS 20mg .2mg/hr, .4mg/hr, .6mg/hr tadalafil (pulmonary 3 NDS NM PA nitroglycerin (generic of 1 hypertension) (generic of NITROLINGUAL ADCIRCA) TABS 20mg PUMPSPRAY) SOLN TRACLEER TABS 62.5mg, 3 NDS NM LA .4mg/spray 125mg; TBSO 32mg nitroglycerin (generic of 1 treprostinil SOLN 3 NDS B/D NM NITROSTAT) SUBL .3mg, 20mg/20ml, 50mg/20ml, LA .4mg, .6mg 100mg/20ml, 200mg/20ml NITROLINGUAL 3 TYVASO SOLN .6mg/ml 3 NDS B/D NM PUMPSPRAY SOLN UPTRAVI TABS 200mcg, 3 NDS NM LA .4mg/spray 400mcg, 600mcg, 800mcg, NITROSTAT SUBL .3mg, 3 1000mcg, 1200mcg, .4mg, .6mg 1400mcg, 1600mcg PULMONARY ARTERIAL HYPERTENSION UPTRAVI TAB 200/800 3 NDS NM LA ADCIRCA TABS 20mg 3 NDS NM PA VELETRI SOLR .5mg, 3 NDS B/D NM ADEMPAS TABS .5mg, 3 NDS NM LA 1.5mg LA 1mg, 1.5mg, 2mg, 2.5mg VENTAVIS SOLN 10mcg/ml, 3 NDS B/D NM alyq (generic of ADCIRCA) 3 NDS NM PA 20mcg/ml TABS 20mg CENTRAL NERVOUS SYSTEM ambrisentan (generic of 3 NDS NM LA ANTIANXIETY LETAIRIS) TABS 5mg, alprazolam (generic of 1 10mg XANAX) TABS .25mg, .5mg, bosentan (generic of 3 NDS NM LA 1mg, 2mg TRACLEER) TABS 62.5mg, ALPRAZOLAM INTENSOL 3 125mg CONC 1mg/ml epoprostenol sodium (generic 3 NDS B/D NM ATIVAN SOLN 2mg/ml, 3 of FLOLAN) SOLR .5mg, LA 4mg/ml 1.5mg ATIVAN TABS .5mg, 1mg, 3 NDS FLOLAN SOLR .5mg, 1.5mg 3 NDS B/D NM 2mg LA buspirone hcl TABS 5mg, 1 LETAIRIS TABS 5mg, 10mg 3 NDS NM LA 7.5mg, 10mg, 15mg, 30mg OPSUMIT TABS 10mg 3 NDS NM LA fluvoxamine maleate CP24 1 ORENITRAM TBCR .25mg, 3 NDS NM LA 100mg, 150mg; TABS 25mg, 1mg, 2.5mg, 5mg 50mg, 100mg ORENITRAM TBCR .125mg 3 NM LA lorazepam (generic of 1 REMODULIN SOLN 3 NDS B/D NM ATIVAN) SOLN 2mg/ml, 20mg/20ml, 50mg/20ml, LA 4mg/ml; TABS .5mg, 1mg, 100mg/20ml, 200mg/20ml 2mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
31 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits lorazepam intensol CONC 1 diazepam CONC 5mg/ml; 1 2mg/ml SOLN 5mg/5ml XANAX TABS .25mg, .5mg, 3 diazepam (generic of 1 1mg, 2mg VALIUM) TABS 2mg, 5mg, ANTICONVULSANTS 10mg APTIOM TABS 200mg, 3 NDS diazepam (anticonvulsant) 1 400mg, 600mg, 800mg GEL 2.5mg, 10mg, 20mg BANZEL SUSP 40mg/ml; 3 NDS diazepam inj SOLN 5mg/ml 1 TABS 200mg, 400mg DILANTIN CAPS 30mg, 3 BRIVIACT SOLN 10mg/ml; 3 NDS 100mg TABS 10mg, 25mg, 50mg, DILANTIN INFATABS 3 75mg, 100mg CHEW 50mg BRIVIACT SOLN 50mg/5ml 3 DILANTIN-125 SUSP 3 carbamazepine CHEW 1 125mg/5ml 100mg divalproex sodium (generic of 1 carbamazepine (generic of 1 DEPAKOTE SPRINKLES) CARBATROL) CP12 100mg, CSDR 125mg 200mg, 300mg divalproex sodium (generic of 1 carbamazepine (generic of 1 DEPAKOTE ER) TB24 TEGRETOL) SUSP 250mg, 500mg 100mg/5ml; TABS 200mg divalproex sodium (generic of 1 carbamazepine (generic of 1 DEPAKOTE) TBEC 125mg, TEGRETOL-XR) TB12 250mg, 500mg 100mg, 200mg, 400mg EPIDIOLEX SOLN 3 NDS NM LA CARBATROL CP12 100mg, 3 100mg/ml PA 200mg, 300mg epitol (generic of TEGRETOL) 1 CELONTIN CAPS 300mg 3 TABS 200mg clobazam (generic of ONFI) 1 ethosuximide (generic of 1 SUSP 2.5mg/ml; TABS 10mg, ZARONTIN) CAPS 250mg; 20mg SOLN 250mg/5ml clonazepam (generic of 1 felbamate (generic of 3 NDS KLONOPIN) TABS .5mg, FELBATOL) SUSP 1mg, 2mg 600mg/5ml clonazepam TBDP .125mg, 1 felbamate (generic of 1 .25mg, .5mg, 1mg, 2mg FELBATOL) TABS 400mg, clorazepate dipotassium 1 600mg TABS 3.75mg, 7.5mg, 15mg FELBATOL TABS 400mg, 3 NDS DEPAKOTE TBEC 125mg, 3 600mg 250mg, 500mg FYCOMPA SUSP .5mg/ml; 3 NDS DEPAKOTE ER TB24 3 TABS 4mg, 6mg, 8mg, 10mg, 250mg, 500mg 12mg DEPAKOTE SPRINKLES 3 FYCOMPA TABS 2mg 3 CSDR 125mg gabapentin (generic of 1 DIASTAT ACUDIAL GEL 3 NEURONTIN) CAPS 100mg, 10mg, 20mg 300mg, 400mg; SOLN DIASTAT PEDIATRIC GEL 3 250mg/5ml; TABS 600mg, 2.5mg 800mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
32 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits GABITRIL TABS 2mg, 4mg, 3 lamotrigine (generic of 1 12mg, 16mg LAMICTAL XR) TB24 25mg, KEPPRA SOLN 100mg/ml, 3 NDS 50mg, 100mg, 200mg, 500mg/5ml; TABS 500mg, 250mg, 300mg 750mg, 1000mg lamotrigine (generic of 1 KEPPRA TABS 250mg 3 LAMICTAL ODT) TBDP KEPPRA XR TB24 500mg, 3 NDS 25mg, 50mg, 100mg, 200mg 750mg lamotrigine tab 25 mg (42) & 1 KLONOPIN TABS .5mg, 3 100 mg (7) starter kit (generic 1mg, 2mg of LAMICTAL STARTER/NOT LAMICTAL TABS 25mg, 3 NDS TAKI) 100mg, 150mg, 200mg lamotrigine tab 84 x 25 mg & 1 LAMICTAL CHEWABLE 3 NDS 14 x 100 mg starter kit DISPERS CHEW 5mg, (generic of LAMICTAL 25mg STARTER/TAKING C) LAMICTAL ODT TBDP 3 LEVETIRACETA INJ 5MG/ML 3 25mg LEVETIRACETA INJ 3 LAMICTAL ODT TBDP 3 NDS 10MG/ML 50mg, 100mg, 200mg LEVETIRACETA INJ 3 LAMICTAL ODT KIT 3 15MG/ML LAMICTAL STARTER KIT (35 3 levetiracetam (generic of 1 X 25MG TABS) KIT 25mg KEPPRA) SOLN 100mg/ml, LAMICTAL STARTER KIT (42 3 500mg/5ml; TABS 250mg, X 25MG TABS & 7 X 100MG 500mg, 750mg, 1000mg TAB) levetiracetam (generic of 1 LAMICTAL STARTER KIT (84 3 KEPPRA XR) TB24 500mg, X 25MG TABS & 14 X 100MG 750mg TABS) levetiracetam in sodium 1 LAMICTAL XR TB24 25mg 3 chloride iv soln 500 mg/100ml (generic of LAMICTAL XR TB24 50mg, 3 NDS LEVETIRACETAM) 100mg, 200mg, 250mg, 300mg levetiracetam in sodium 1 chloride iv soln 1000 LAMICTAL XR KIT 3 mg/100ml (generic of lamotrigine (generic of 1 LEVETIRACETAM) LAMICTAL CHEWABLE levetiracetam in sodium 1 DISPERS) CHEW 5mg, chloride iv soln 1500 25mg mg/100ml (generic of lamotrigine (generic of 1 LEVETIRACETAM) LAMICTAL LYRICA CAPS 25mg, 50mg, 3 STARTER/TAKING V) KIT 75mg, 100mg, 150mg, 25mg 200mg, 225mg, 300mg; lamotrigine (generic of 1 SOLN 20mg/ml LAMICTAL) TABS 25mg, MYSOLINE TABS 50mg, 3 NDS 100mg, 150mg, 200mg 250mg NAYZILAM SOLN 3 5mg/0.1ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
33 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits NEURONTIN CAPS 100mg, 3 QUDEXY XR CS24 25mg, 3 300mg, 400mg 50mg, 100mg NEURONTIN SOLN 3 NDS QUDEXY XR CS24 150mg, 3 NDS 250mg/5ml; TABS 600mg, 200mg 800mg roweepra (generic of 1 ONFI SUSP 2.5mg/ml; 3 NDS KEPPRA) TABS 500mg, TABS 10mg, 20mg 750mg, 1000mg oxcarbazepine (generic of 1 roweepra xr (generic of 1 TRILEPTAL) SUSP KEPPRA XR) TB24 500mg, 300mg/5ml; TABS 150mg, 750mg 300mg, 600mg SABRIL PACK 500mg; 3 NDS NM LA OXTELLAR XR TB24 3 TABS 500mg 150mg, 300mg SPRITAM TB3D 250mg, 3 OXTELLAR XR TB24 600mg 3 NDS 500mg, 750mg, 1000mg PEGANONE TABS 250mg 3 subvenite (generic of 1 phenobarbital ELIX 3 LAMICTAL) TABS 25mg, 20mg/5ml 100mg, 150mg, 200mg phenobarbital TABS 15mg, 2 subvenite starter kit/blu 1 16.2mg, 30mg, 32.4mg, (generic of LAMICTAL 60mg, 64.8mg, 97.2mg, STARTER/TAKING V) KIT 100mg 25mg phenobarbital sodium SOLN 3 subvenite starter kit/gre 1 65mg/ml, 130mg/ml (generic of LAMICTAL PHENYTEK CAPS 200mg, 3 STARTER/TAKING C) 300mg subvenite starter kit/ora 1 phenytoin (generic of 1 (generic of LAMICTAL DILANTIN INFATABS) STARTER/NOT TAKI) CHEW 50mg SYMPAZAN FILM 5mg 3 phenytoin (generic of 1 SYMPAZAN FILM 10mg, 3 NDS DILANTIN-125) SUSP 20mg 125mg/5ml TEGRETOL SUSP 3 phenytoin sodium SOLN 1 100mg/5ml; TABS 200mg 50mg/ml TEGRETOL-XR TB12 3 phenytoin sodium extended 1 100mg, 200mg, 400mg (generic of DILANTIN) CAPS tiagabine hcl (generic of 1 100mg GABITRIL) TABS 2mg, 4mg, phenytoin sodium extended 1 12mg, 16mg (generic of PHENYTEK) TOPAMAX TABS 25mg 3 CAPS 200mg, 300mg TOPAMAX TABS 50mg, 3 NDS pregabalin (generic of 1 100mg, 200mg LYRICA) CAPS 25mg, TOPAMAX SPRINKLE 3 50mg, 75mg, 100mg, 150mg, CPSP 15mg 200mg, 225mg, 300mg; TOPAMAX SPRINKLE 3 NDS SOLN 20mg/ml CPSP 25mg primidone (generic of 1 topiramate (generic of 1 MYSOLINE) TABS 50mg, TOPAMAX SPRINKLE) 250mg CPSP 15mg, 25mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
34 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits topiramate CS24 25mg, 1 ARICEPT TABS 5mg, 10mg, 3 50mg, 100mg, 150mg 23mg topiramate CS24 200mg 3 NDS donepezil hydrochloride 1 topiramate (generic of 1 (generic of ARICEPT) TABS TOPAMAX) TABS 25mg, 5mg, 10mg, 23mg 50mg, 100mg, 200mg donepezil hydrochloride 1 TRILEPTAL SUSP 3 NDS TBDP 5mg, 10mg 300mg/5ml; TABS 300mg, EXELON PT24 4.6mg/24hr, 3 600mg 9.5mg/24hr, 13.3mg/24hr TRILEPTAL TABS 150mg 3 galantamine hydrobromide 1 TROKENDI XR CP24 25mg, 3 (generic of RAZADYNE ER) 50mg CP24 8mg, 16mg, 24mg TROKENDI XR CP24 3 NDS galantamine hydrobromide 1 100mg, 200mg SOLN 4mg/ml; TABS 8mg, VALIUM TABS 2mg, 5mg, 3 12mg 10mg galantamine hydrobromide 1 valproate sodium SOLN 1 (generic of RAZADYNE) 100mg/ml, 250mg/5ml TABS 4mg valproic acid CAPS 250mg 1 memantine hcl (generic of 1 PA VALTOCO LIQD 5mg/0.1ml, 3 NAMENDA XR) CP24 7mg, 10mg/0.1ml; LQPK 14mg, 21mg, 28mg 7.5mg/0.1ml, 10mg/0.1ml PA if < 30 yrs vigabatrin (generic of SABRIL) 3 NDS NM LA memantine hcl SOLN 1 PA PACK 500mg; TABS 500mg 2mg/ml vigadrone (generic of 3 NDS NM LA PA if < 30 yrs SABRIL) PACK 500mg memantine hcl (generic of 1 PA VIMPAT SOLN 10mg/ml, 3 NDS NAMENDA) TABS 5mg, 200mg/20ml; TABS 100mg, 10mg 150mg, 200mg PA if < 30 yrs VIMPAT TABS 50mg 3 memantine hcl tab 28 x 5 mg 1 PA & 21 x 10 mg titration pack XCOPRI TABS 50mg, 3 NDS (generic of NAMENDA 100mg, 150mg, 200mg TITRATION PAK) XCOPRI PAK 12.5-25 3 PA if < 30 yrs XCOPRI PAK 50-100MG 3 NDS NAMENDA TABS 5mg, 3 PA XCOPRI PAK 150-200MG 3 NDS 10mg (MAINTENANCE) PA if < 30 yrs XCOPRI PAK 150-200MG 3 NDS NAMENDA TAB 5-10MG 3 PA (TITRATION) PA if < 30 yrs XCOPRI TAB 50-200MG 3 NDS NAMENDA XR CP24 7mg, 3 PA ZARONTIN CAPS 250mg; 3 14mg, 21mg, 28mg SOLN 250mg/5ml PA if < 30 yrs zonisamide (generic of 1 NAMENDA XR CAP 3 PA ZONEGRAN) CAPS 25mg, TITRATIO 100mg PA if < 30 yrs zonisamide CAPS 50mg 1 NAMZARIC CAP 7-10MG 3 ANTIDEMENTIA NAMZARIC CAP 14-10MG 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
35 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits NAMZARIC CAP 21-10MG 3 desvenlafaxine succinate 1 NAMZARIC CAP 28-10MG 3 (generic of PRISTIQ) TB24 NAMZARIC CAP PACK 3 25mg, 50mg, 100mg RAZADYNE ER CP24 8mg, 3 doxepin hcl CAPS 10mg, 2 16mg, 24mg 25mg, 50mg, 75mg, 100mg; CONC 10mg/ml rivastigmine (generic of 1 EXELON) PT24 4.6mg/24hr, doxepin hcl CAPS 150mg 3 9.5mg/24hr, 13.3mg/24hr DRIZALMA SPRINKLE 3 rivastigmine tartrate CAPS 1 CSDR 20mg, 30mg, 40mg, 1.5mg, 3mg, 4.5mg, 6mg 60mg ANTIDEPRESSANTS duloxetine hcl (generic of 1 CYMBALTA) CPEP 20mg, amitriptyline hcl TABS 10mg, 2 30mg, 60mg 25mg, 50mg, 75mg, 100mg, 150mg duloxetine hcl CPEP 40mg 1 amoxapine TABS 25mg, 2 EFFEXOR XR CP24 3 50mg, 100mg, 150mg 37.5mg, 75mg, 150mg ANAFRANIL CAPS 25mg, 3 NDS EMSAM PT24 6mg/24hr, 3 NDS 50mg, 75mg 9mg/24hr, 12mg/24hr bupropion hcl TABS 75mg, 1 escitalopram oxalate SOLN 1 100mg; TB24 450mg 5mg/5ml bupropion hcl (generic of 1 escitalopram oxalate (generic 1 WELLBUTRIN SR) TB12 of LEXAPRO) TABS 5mg, 100mg, 150mg, 200mg 10mg, 20mg bupropion hcl (generic of 1 FETZIMA CP24 20mg, 3 WELLBUTRIN XL) TB24 40mg, 80mg, 120mg 150mg, 300mg FETZIMA CAP TITRATIO 3 CELEXA TABS 10mg, 3 fluoxetine hcl (generic of 1 20mg, 40mg PROZAC) CAPS 10mg, citalopram hydrobromide 1 20mg, 40mg SOLN 10mg/5ml fluoxetine hcl CPDR 90mg; 1 citalopram hydrobromide 1 SOLN 20mg/5ml; TABS (generic of CELEXA) TABS 10mg, 20mg 10mg, 20mg, 40mg fluoxetine hcl (generic of 1 clomipramine hcl (generic of 3 FLUOXETINE ANAFRANIL) CAPS 25mg, HYDROCHLORIDE) TABS 50mg, 75mg 60mg CYMBALTA CPEP 20mg, 3 fluoxetine hcl (pmdd) (generic 1 30mg, 60mg of SARAFEM) TABS 10mg, desipramine hcl (generic of 3 20mg NORPRAMIN) TABS 10mg, (generic of SARAFEM) 25mg FLUOXETINE 3 desipramine hcl TABS 3 HYDROCHLORIDE TABS 50mg, 75mg, 100mg, 150mg 60mg DESVENLAFAXINE ER 3 FORFIVO XL TB24 450mg 3 TB24 50mg, 100mg imipramine hcl TABS 10mg, 1 25mg, 50mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
36 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits imipramine pamoate CAPS 3 protriptyline hcl TABS 5mg, 3 75mg, 100mg, 125mg, 150mg 10mg LEXAPRO TABS 5mg, 3 PROZAC CAPS 10mg, 3 10mg, 20mg 20mg maprotiline hcl TABS 25mg, 1 PROZAC CAPS 40mg 3 NDS 50mg, 75mg REMERON TABS 15mg, 3 MARPLAN TABS 10mg 3 30mg mirtazapine TABS 7.5mg, 1 REMERON SOLTAB TBDP 3 45mg 15mg, 30mg, 45mg mirtazapine (generic of 1 SARAFEM TABS 10mg, 3 REMERON) TABS 15mg, 20mg 30mg sertraline hcl (generic of 1 mirtazapine (generic of 1 ZOLOFT) CONC 20mg/ml; REMERON SOLTAB) TBDP TABS 25mg, 50mg, 100mg 15mg, 30mg, 45mg SPRAVATO SOL 56MG DOS 3 NDS B/D NM NARDIL TABS 15mg 3 LA nefazodone hcl TABS 50mg, 1 SPRAVATO SOL 84MG DOS 3 NDS B/D NM 100mg, 150mg, 200mg, LA 250mg tranylcypromine sulfate 1 NORPRAMIN TABS 10mg, 3 (generic of PARNATE) 25mg TABS 10mg nortriptyline hcl (generic of 1 trazodone hcl TABS 50mg, 1 PAMELOR) CAPS 10mg, 100mg, 150mg, 300mg 25mg, 50mg, 75mg trimipramine maleate CAPS 3 nortriptyline hcl SOLN 3 25mg, 50mg, 100mg 10mg/5ml TRINTELLIX TABS 5mg, 3 PAMELOR CAPS 10mg, 3 NDS 10mg, 20mg 25mg, 50mg, 75mg venlafaxine hcl (generic of 1 PARNATE TABS 10mg 3 NDS EFFEXOR XR) CP24 paroxetine hcl (generic of 1 37.5mg, 75mg, 150mg PAXIL) TABS 10mg, 20mg, venlafaxine hcl TABS 25mg, 1 30mg, 40mg 37.5mg, 50mg, 75mg, 100mg; paroxetine hcl (generic of 3 TB24 225mg PAXIL CR) TB24 12.5mg, VIIBRYD TABS 10mg, 3 25mg, 37.5mg 20mg, 40mg PAXIL SUSP 10mg/5ml; 3 VIIBRYD KIT STARTER 3 TABS 10mg, 20mg, 30mg, WELLBUTRIN SR TB12 3 40mg 100mg, 150mg, 200mg PAXIL CR TB24 12.5mg, 3 WELLBUTRIN XL TB24 3 NDS 25mg, 37.5mg 150mg, 300mg PEXEVA TABS 10mg, 3 ZOLOFT CONC 20mg/ml; 3 20mg, 30mg, 40mg TABS 25mg, 50mg, 100mg phenelzine sulfate (generic of 1 ANTIPARKINSONIAN AGENTS NARDIL) TABS 15mg amantadine hcl CAPS 1 PRISTIQ TB24 25mg, 50mg, 3 100mg; SYRP 50mg/5ml; 100mg TABS 100mg APOKYN SOCT 30mg/3ml 3 NDS NM LA
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
37 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits AZILECT TABS .5mg, 1mg 3 NDS entacapone (generic of 1 benztropine mesylate (generic 1 COMTAN) TABS 200mg of COGENTIN) SOLN GOCOVRI CP24 68.5mg, 3 NDS NM LA 1mg/ml 137mg benztropine mesylate TABS 2 INBRIJA CAPS 42mg 3 NDS NM LA .5mg, 1mg, 2mg LODOSYN TABS 25mg 3 NDS bromocriptine mesylate 1 MIRAPEX ER TB24 .375mg, 3 (generic of PARLODEL) .75mg, 1.5mg, 2.25mg, 3mg, CAPS 5mg; TABS 2.5mg 3.75mg, 4.5mg carbidopa (generic of 1 NEUPRO PT24 1mg/24hr, 3 LODOSYN) TABS 25mg 2mg/24hr, 3mg/24hr, carbidopa & levodopa orally 1 4mg/24hr, 6mg/24hr, disintegrating tab 10-100 mg 8mg/24hr carbidopa & levodopa orally 1 NOURIANZ TABS 20mg, 3 NDS NM disintegrating tab 25-100 mg 40mg carbidopa & levodopa orally 1 OSMOLEX ER TB24 129mg, 3 NM disintegrating tab 25-250 mg 193mg, 258mg carbidopa & levodopa tab 1 OSMOLEX ER PAK 3 NM 10-100 mg (generic of PARLODEL CAPS 5mg; 3 SINEMET) TABS 2.5mg carbidopa & levodopa tab 1 pramipexole dihydrochloride 1 25-100 mg (generic of TABS .25mg, 1.5mg SINEMET) pramipexole dihydrochloride 1 carbidopa & levodopa tab 1 (generic of MIRAPEX) TABS 25-250 mg (generic of .125mg, .5mg, .75mg, 1mg SINEMET) pramipexole dihydrochloride 1 carbidopa & levodopa tab er 1 (generic of MIRAPEX ER) 25-100 mg TB24 .375mg, .75mg, 1.5mg, carbidopa & levodopa tab er 1 2.25mg, 3mg, 3.75mg, 4.5mg 50-200 mg rasagiline mesylate (generic 1 carbidopa-levodopa-entacapo 1 of AZILECT) TABS .5mg, ne tabs 12.5-50-200 mg 1mg carbidopa-levodopa-entacapo 1 ropinirole hydrochloride 1 ne tabs 18.75-75-200 mg TABS .25mg, .5mg, 1mg, carbidopa-levodopa-entacapo 1 2mg, 3mg, 4mg, 5mg; TB24 ne tabs 25-100-200 mg 2mg, 4mg, 8mg (generic of STALEVO 100) ropinirole hydrochloride 1 carbidopa-levodopa-entacapo 1 (generic of REQUIP XL) ne tabs 31.25-125-200 mg TB24 6mg, 12mg carbidopa-levodopa-entacapo 1 RYTARY CAP 95MG 3 ne tabs 37.5-150-200 mg RYTARY CAP 145MG 3 (generic of STALEVO 150) RYTARY CAP 195MG 3 carbidopa-levodopa-entacapo 1 RYTARY CAP 245MG 3 ne tabs 50-200-200 mg selegiline hcl CAPS 5mg; 1 COGENTIN SOLN 1mg/ml 3 TABS 5mg COMTAN TABS 200mg 3 NDS SINEMET TAB 10-100MG 3 DUOPA SUS 4.63-20 3 NDS B/D NM SINEMET TAB 25-100MG 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
38 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits SINEMET TAB 25-250MG 3 CLOZARIL TABS 100mg, 3 NDS STALEVO 50 TAB 3 200mg STALEVO 75 TAB 3 NDS FANAPT TABS 1mg, 2mg, 3 NDS STALEVO 100 TAB 3 NDS 4mg, 6mg, 8mg, 10mg, 12mg STALEVO 125 TAB 3 NDS FANAPT PAK 3 STALEVO 150 TAB 3 NDS fluphenazine decanoate 1 STALEVO 200 TAB 3 NDS SOLN 25mg/ml trihexyphenidyl hcl SOLN 2 fluphenazine hcl CONC 1 .4mg/ml; TABS 2mg, 5mg 5mg/ml; ELIX 2.5mg/5ml; XADAGO TABS 50mg, 3 NDS SOLN 2.5mg/ml; TABS 1mg, 100mg 2.5mg, 5mg, 10mg ZELAPAR TBDP 1.25mg 3 NDS GEODON CAPS 20mg, 3 NDS ANTIPSYCHOTICS 40mg, 60mg, 80mg GEODON SOLR 20mg 3 ABILIFY TABS 2mg, 5mg, 3 NDS 10mg, 15mg, 20mg, 30mg HALDOL SOLN 5mg/ml 3 ABILIFY MAINTENA PRSY 3 NDS HALDOL DECANOATE 50 3 300mg, 400mg; SRER SOLN 50mg/ml 300mg, 400mg HALDOL DECANOATE 100 3 ABILIFY MYCITE TABS 3 NDS SOLN 100mg/ml 2mg, 5mg, 10mg, 15mg, haloperidol TABS .5mg, 1 20mg, 30mg 1mg, 2mg, 5mg, 10mg, 20mg aripiprazole SOLN 1mg/ml; 3 NDS haloperidol decanoate 1 TBDP 10mg, 15mg (generic of HALDOL aripiprazole (generic of 1 DECANOATE 50) SOLN ABILIFY) TABS 2mg, 5mg, 50mg/ml 10mg, 15mg, 20mg, 30mg haloperidol decanoate 1 ARISTADA PRSY 3 NDS (generic of HALDOL 441mg/1.6ml, 662mg/2.4ml, DECANOATE 100) SOLN 882mg/3.2ml, 1064mg/3.9ml 100mg/ml ARISTADA INITIO PRSY 3 NDS haloperidol lactate CONC 1 675mg/2.4ml 2mg/ml CAPLYTA CAPS 42mg 3 haloperidol lactate (generic of 1 CHLORPROMAZINE HCL 3 HALDOL) SOLN 5mg/ml SOLN 25mg/ml, 50mg/2ml INVEGA TB24 1.5mg, 3mg, 3 NDS chlorpromazine hcl TABS 1 6mg, 9mg 10mg, 25mg, 50mg, 100mg, INVEGA SUSTENNA SUSY 3 200mg 39mg/0.25ml clozapine (generic of 1 INVEGA SUSTENNA SUSY 3 NDS CLOZARIL) TABS 25mg, 78mg/0.5ml, 117mg/0.75ml, 50mg, 100mg, 200mg 156mg/ml, 234mg/1.5ml clozapine TBDP 12.5mg, 1 INVEGA TRINZA SUSY 3 NDS 25mg, 100mg 273mg/0.875ml, clozapine TBDP 150mg, 3 NDS 410mg/1.315ml, 200mg 546mg/1.75ml, 819mg/2.625ml CLOZARIL TABS 25mg, 3 50mg LATUDA TABS 20mg, 3 40mg, 60mg, 80mg, 120mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
39 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits loxapine succinate CAPS 1 SAPHRIS SUBL 2.5mg, 3 5mg, 10mg, 25mg, 50mg 5mg, 10mg molindone hcl TABS 5mg, 1 SECUADO PT24 3 10mg, 25mg 3.8mg/24hr, 5.7mg/24hr, NUPLAZID CAPS 34mg; 3 NDS NM LA 7.6mg/24hr TABS 10mg SEROQUEL TABS 25mg, 3 olanzapine (generic of 1 50mg, 100mg, 200mg ZYPREXA) SOLR 10mg; SEROQUEL TABS 300mg, 3 NDS TABS 2.5mg, 5mg, 7.5mg, 400mg 10mg, 15mg, 20mg SEROQUEL XR TB24 3 olanzapine (generic of 1 50mg, 150mg, 200mg, 300mg ZYPREXA ZYDIS) TBDP SEROQUEL XR TB24 3 NDS 5mg, 10mg, 15mg, 20mg 400mg paliperidone (generic of 1 thioridazine hcl TABS 10mg, 1 INVEGA) TB24 1.5mg, 3mg, 25mg, 50mg, 100mg 6mg, 9mg thiothixene CAPS 1mg, 2mg, 1 perphenazine TABS 2mg, 1 5mg, 10mg 4mg, 8mg, 16mg trifluoperazine hcl TABS 1 PERSERIS PRSY 90mg, 3 NDS 1mg, 2mg, 5mg, 10mg 120mg VERSACLOZ SUSP 3 NDS pimozide TABS 1mg, 2mg 1 50mg/ml quetiapine fumarate (generic 1 VRAYLAR CAPS 1.5mg, 3 NDS of SEROQUEL) TABS 3mg, 4.5mg, 6mg 25mg, 50mg, 100mg, 200mg, VRAYLAR CAP 1.5-3MG 3 300mg, 400mg ziprasidone hcl (generic of 1 quetiapine fumarate (generic 1 GEODON) CAPS 20mg, of SEROQUEL XR) TB24 40mg, 60mg, 80mg 50mg, 150mg, 200mg, ziprasidone mesylate (generic 1 300mg, 400mg of GEODON) SOLR 20mg REXULTI TABS .25mg, 3 ZYPREXA SOLR 10mg; 3 .5mg, 1mg, 2mg, 3mg, 4mg TABS 2.5mg, 5mg, 7.5mg, RISPERDAL SOLN 1mg/ml; 3 NDS 10mg TABS 2mg, 3mg, 4mg ZYPREXA TABS 15mg, 3 NDS RISPERDAL TABS .5mg, 3 20mg 1mg ZYPREXA RELPREVV 3 RISPERDAL CONSTA 3 SUSR 210mg SRER 12.5mg, 25mg ZYPREXA RELPREVV 3 NDS RISPERDAL CONSTA 3 NDS SUSR 300mg, 405mg SRER 37.5mg, 50mg ZYPREXA ZYDIS TBDP 3 risperidone (generic of 1 5mg, 10mg RISPERDAL) SOLN 1mg/ml; ZYPREXA ZYDIS TBDP 3 NDS TABS .5mg, 1mg, 2mg, 3mg, 15mg, 20mg 4mg ATTENTION DEFICIT HYPERACTIVITY risperidone TABS .25mg; 1 DISORDER TBDP .25mg, .5mg, 1mg, ADDERALL TAB 5MG 3 2mg, 3mg, 4mg ADDERALL TAB 7.5MG 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
40 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ADDERALL TAB 10MG 3 amphetamine-dextroampheta 1 ADDERALL TAB 12.5MG 3 mine tab 12.5 mg (generic of ADDERALL TAB 15MG 3 ADDERALL) ADDERALL TAB 20MG 3 amphetamine-dextroampheta 1 mine tab 15 mg (generic of ADDERALL TAB 30MG 3 ADDERALL) ADDERALL XR CAP 5MG 3 amphetamine-dextroampheta 1 ADDERALL XR CAP 10MG 3 mine tab 20 mg (generic of ADDERALL XR CAP 15MG 3 ADDERALL) ADDERALL XR CAP 20MG 3 amphetamine-dextroampheta 1 ADDERALL XR CAP 25MG 3 mine tab 30 mg (generic of ADDERALL XR CAP 30MG 3 ADDERALL) ADZENYS ER SUER 3 APTENSIO XR CP24 10mg, 3 1.25mg/ml 15mg, 20mg, 30mg, 40mg, 50mg, 60mg ADZENYS XR-ODT TBED 3 3.1mg, 6.3mg, 9.4mg, atomoxetine hcl (generic of 1 12.5mg, 15.7mg, 18.8mg STRATTERA) CAPS 10mg, 18mg, 25mg, 40mg, 60mg, amphetamine SUER 1 80mg, 100mg 1.25mg/ml CONCERTA TBCR 18mg, 3 amphetamine-dextroampheta 1 27mg, 36mg, 54mg mine cap er 24hr 5 mg (generic of ADDERALL XR) COTEMPLA XR-ODT TBED 3 8.6mg, 17.3mg, 25.9mg amphetamine-dextroampheta 1 mine cap er 24hr 10 mg DAYTRANA PTCH 3 (generic of ADDERALL XR) 10mg/9hr, 15mg/9hr, 20mg/9hr, 30mg/9hr amphetamine-dextroampheta 1 mine cap er 24hr 15 mg DEXEDRINE CP24 5mg, 3 NDS (generic of ADDERALL XR) 10mg, 15mg amphetamine-dextroampheta 1 dexmethylphenidate hcl 1 mine cap er 24hr 20 mg (generic of FOCALIN XR) (generic of ADDERALL XR) CP24 5mg, 10mg, 15mg, 20mg, 25mg, 30mg, 35mg, amphetamine-dextroampheta 1 40mg mine cap er 24hr 25 mg (generic of ADDERALL XR) dexmethylphenidate hcl 1 (generic of FOCALIN) TABS amphetamine-dextroampheta 1 2.5mg, 5mg, 10mg mine cap er 24hr 30 mg (generic of ADDERALL XR) dextroamphetamine sulfate 1 (generic of DEXEDRINE) amphetamine-dextroampheta 1 CP24 5mg, 10mg, 15mg mine tab 5 mg (generic of ADDERALL) dextroamphetamine sulfate 1 TABS 5mg, 10mg amphetamine-dextroampheta 1 mine tab 7.5 mg (generic of DYANAVEL XR SUER 3 ADDERALL) 2.5mg/ml amphetamine-dextroampheta 1 FOCALIN TABS 2.5mg, 3 mine tab 10 mg (generic of 5mg, 10mg ADDERALL)
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
41 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits FOCALIN XR CP24 5mg, 3 RITALIN LA CP24 10mg, 3 10mg, 15mg, 20mg, 25mg, 20mg, 30mg, 40mg 30mg, 35mg, 40mg STRATTERA CAPS 10mg, 3 guanfacine hcl (adhd) (generic 2 18mg, 25mg, 40mg, 60mg, of INTUNIV) TB24 1mg, 80mg, 100mg 2mg, 3mg, 4mg VYVANSE CAPS 10mg, 3 INTUNIV TB24 1mg, 2mg, 3 20mg, 30mg, 40mg, 50mg, 3mg, 4mg 60mg, 70mg; CHEW 10mg, JORNAY PM CP24 20mg, 3 20mg, 30mg, 40mg, 50mg, 40mg, 60mg, 80mg, 100mg 60mg metadate er TBCR 20mg 1 zenzedi TABS 2.5mg, 5mg, 1 METHYLIN SOLN 5mg/5ml, 3 7.5mg, 10mg, 15mg, 20mg, 10mg/5ml 30mg methylphenidate hcl CHEW 1 HYPNOTICS 2.5mg, 5mg, 10mg; CP24 AMBIEN TABS 5mg, 10mg 3 10mg, 15mg, 20mg, 30mg, AMBIEN CR TBCR 6.25mg, 3 40mg, 50mg, 60mg; CPCR 12.5mg 10mg, 20mg, 30mg, 40mg, BELSOMRA TABS 5mg, 3 50mg, 60mg; TB24 18mg, 10mg, 15mg, 20mg 27mg, 36mg, 54mg; TBCR DAYVIGO TABS 5mg, 10mg 3 10mg, 20mg doxepin hcl (sleep) (generic of 1 methylphenidate hcl (generic 1 SILENOR) TABS 3mg, 6mg of RITALIN LA) CP24 10mg, EDLUAR SUBL 5mg, 10mg 3 20mg, 30mg, 40mg eszopiclone (generic of 2 methylphenidate hcl (generic 1 LUNESTA) TABS 1mg, 2mg, of METHYLIN) SOLN 3mg 5mg/5ml, 10mg/5ml HALCION TABS .25mg 3 methylphenidate hcl (generic 1 of RITALIN) TABS 5mg, HETLIOZ CAPS 20mg 3 NDS NM LA 10mg, 20mg LUNESTA TABS 1mg, 2mg, 3 methylphenidate hcl (generic 1 3mg of CONCERTA) TBCR ramelteon (generic of 1 18mg, 27mg, 36mg, 54mg ROZEREM) TABS 8mg METHYLPHENIDATE 3 RESTORIL CAPS 7.5mg, 3 NDS HYDROCHLO TBCR 72mg 15mg, 22.5mg, 30mg MYDAYIS CAP 12.5MG 3 SILENOR TABS 3mg, 6mg 3 MYDAYIS CAP 25MG 3 temazepam (generic of 1 RESTORIL) CAPS 7.5mg, MYDAYIS CAP 37.5MG 3 15mg, 30mg MYDAYIS CAP 50MG 3 temazepam (generic of 3 QUILLICHEW ER CHER 3 RESTORIL) CAPS 22.5mg 20mg, 30mg, 40mg triazolam (generic of 2 QUILLIVANT XR SRER 3 HALCION) TABS .25mg 25mg/5ml triazolam TABS .125mg 2 RELEXXII TBCR 72mg 3 zaleplon CAPS 5mg, 10mg 2 RITALIN TABS 5mg, 10mg, 3 zolpidem tartrate SUBL 3 20mg 1.75mg, 3.5mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
42 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits zolpidem tartrate (generic of 1 rizatriptan benzoate (generic 1 AMBIEN) TABS 5mg, 10mg of MAXALT) TABS 10mg zolpidem tartrate (generic of 2 rizatriptan benzoate (generic 1 AMBIEN CR) TBCR 6.25mg, of MAXALT-MLT) TBDP 12.5mg 10mg MIGRAINE sumatriptan (generic of 1 AIMOVIG SOAJ 70mg/ml, 2 NM IMITREX) SOLN 5mg/act, 140mg/ml 20mg/act almotriptan malate TABS 1 sumatriptan succinate 1 6.25mg, 12.5mg (generic of IMITREX AMERGE TABS 1mg, 2.5mg 3 STATDOSE SYSTEM) D.H.E. 45 SOLN 1mg/ml 3 NDS SOAJ 4mg/0.5ml, 6mg/0.5ml dihydroergotamine mesylate 3 NDS sumatriptan succinate 1 (generic of D.H.E. 45) SOLN (generic of IMITREX 1mg/ml STATDOSE REFILL) SOCT dihydroergotamine mesylate 3 NDS 4mg/0.5ml, 6mg/0.5ml (generic of MIGRANAL) sumatriptan succinate 1 SOLN 4mg/ml (generic of IMITREX) SOLN eletriptan hydrobromide 1 6mg/0.5ml; TABS 25mg, (generic of RELPAX) TABS 50mg, 100mg 20mg, 40mg sumatriptan succinate SOSY 1 ergotamine w/ caffeine tab 1 6mg/0.5ml 1-100 mg (generic of sumatriptan-naproxen sodium 1 CAFERGOT) tab 85-500 mg (generic of FROVA TABS 2.5mg 3 NDS TREXIMET) frovatriptan succinate (generic 1 TREXIMET TAB 85-500MG 3 NDS of FROVA) TABS 2.5mg ZEMBRACE SYMTOUCH 3 NDS IMITREX SOLN 5mg/act, 3 SOAJ 3mg/0.5ml 20mg/act; TABS 25mg, 50mg, zolmitriptan (generic of 1 100mg ZOMIG) TABS 2.5mg, 5mg IMITREX SOLN 6mg/0.5ml 3 NDS zolmitriptan (generic of 1 IMITREX STATDOSE REFILL 3 NDS ZOMIG ZMT) TBDP 2.5mg, SOCT 4mg/0.5ml, 6mg/0.5ml 5mg IMITREX STATDOSE 3 NDS ZOMIG SOLN 2.5mg, 5mg 3 SYSTEM SOAJ 4mg/0.5ml, ZOMIG TABS 2.5mg, 5mg 3 NDS 6mg/0.5ml ZOMIG ZMT TBDP 2.5mg, 3 NDS MAXALT TABS 10mg 3 5mg MAXALT-MLT TBDP 10mg 3 MISCELLANEOUS migergot 3 NDS AUSTEDO TABS 6mg, 9mg, 3 NDS NM naratriptan hcl (generic of 1 12mg AMERGE) TABS 1mg, BRISDELLE CAPS 7.5mg 3 2.5mg EQUETRO CP12 100mg, 3 ONZETRA XSAIL EXHP 3 NDS 200mg, 300mg 11mg/nosepc FIRDAPSE TABS 10mg 3 NDS NM LA RELPAX TABS 20mg, 40mg 3 GRALISE TABS 300mg, 3 PA rizatriptan benzoate TABS 1 600mg 5mg; TBDP 5mg GRALISE STAR MIS 300/600 3 PA
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
43 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits HORIZANT TBCR 300mg, 3 PA TIGLUTIK SUSP 50mg/10ml 3 NDS 600mg XENAZINE TABS 12.5mg, 3 NDS NM LA INGREZZA CAPS 40mg, 3 NDS NM 25mg 80mg MULTIPLE SCLEROSIS AGENTS INGREZZA CAP 40-80MG 3 NDS NM AMPYRA TB12 10mg 3 NDS NM LA LITHIUM SOLN 8meq/5ml 3 AUBAGIO TABS 7mg, 14mg 3 NDS NM LA lithium carbonate CAPS 1 AVONEX PSKT 3 NDS NM 150mg, 300mg, 600mg; TABS 30mcg/0.5ml 300mg; TBCR 450mg AVONEX PEN AJKT 3 NDS NM lithium carbonate (generic of 1 30mcg/0.5ml LITHOBID) TBCR 300mg BETASERON KIT .3mg 3 NDS NM LITHOBID TBCR 300mg 3 NDS COPAXONE SOSY 3 NDS NM LYRICA CR TB24 82.5mg, 2 PA 20mg/ml, 40mg/ml 165mg, 330mg dalfampridine (generic of 1 NM MESTINON SOLN 3 NDS AMPYRA) TB12 10mg 60mg/5ml; TABS 60mg GILENYA CAPS .5mg 3 NDS NM MESTINON TIMESPAN 3 NDS glatiramer acetate (generic of 3 NDS NM TBCR 180mg COPAXONE) SOSY NUEDEXTA CAP 20-10MG 3 PA 20mg/ml, 40mg/ml paroxetine mesylate 3 glatopa (generic of 3 NDS NM (vasomotor) (generic of COPAXONE) SOSY BRISDELLE) CAPS 7.5mg 20mg/ml, 40mg/ml pyridostigmine bromide 3 NDS LEMTRADA SOLN 3 NDS NM LA (generic of MESTINON) 12mg/1.2ml SOLN 60mg/5ml MAVENCLAD (4 TABS) 3 NDS NM LA pyridostigmine bromide 1 TBPK 10mg TABS 30mg MAVENCLAD (5 TABS) 3 NDS NM LA pyridostigmine bromide 1 TBPK 10mg (generic of MESTINON) MAVENCLAD (6 TABS) 3 NDS NM LA TABS 60mg TBPK 10mg pyridostigmine bromide 1 MAVENCLAD (7 TABS) 3 NDS NM LA (generic of MESTINON TBPK 10mg TIMESPAN) TBCR 180mg MAVENCLAD (8 TABS) 3 NDS NM LA RADICAVA SOLN 3 NDS NM LA TBPK 10mg 30mg/100ml MAVENCLAD (9 TABS) 3 NDS NM LA RILUTEK TABS 50mg 3 NDS TBPK 10mg riluzole (generic of RILUTEK) 1 MAVENCLAD (10 TABS) 3 NDS NM LA TABS 50mg TBPK 10mg RUZURGI TABS 10mg 3 NDS NM LA MAYZENT TABS .25mg, 3 NDS NM LA SAVELLA TABS 12.5mg, 3 2mg 25mg, 50mg, 100mg OCREVUS SOLN 3 NDS NM LA SAVELLA MIS TITR PAK 3 300mg/10ml TEGSEDI SOSY 3 NDS NM LA PLEGRIDY SOPN 3 NDS NM 284mg/1.5ml 125mcg/0.5ml; SOSY tetrabenazine (generic of 3 NDS NM 125mcg/0.5ml XENAZINE) TABS 12.5mg, PLEGRIDY INJ STARTER 3 NDS NM 25mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
44 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits PLEGRIDY PEN INJ 3 NDS NM MYOBLOC SOLN 3 NDS NM PA STARTER 10000unit/2ml REBIF SOSY 22mcg/0.5ml, 3 NDS NM SKELAXIN TABS 800mg 3 44mcg/0.5ml SOMA TABS 250mg 3 REBIF REBIDO INJ TITRATN 3 NDS NM SOMA TABS 350mg 3 NDS REBIF REBIDOSE SOAJ 3 NDS NM tizanidine hcl (generic of 1 22mcg/0.5ml, 44mcg/0.5ml ZANAFLEX) CAPS 2mg, REBIF TITRTN INJ PACK 3 NDS NM 4mg, 6mg; TABS 4mg TECFIDERA CPDR 120mg, 3 NDS NM LA tizanidine hcl TABS 2mg 1 240mg vanadom (generic of SOMA) 2 TECFIDERA MIS STARTER 3 NDS NM LA TABS 350mg TYSABRI CONC 3 NDS NM LA XEOMIN SOLR 50unit 3 NM PA 300mg/15ml XEOMIN SOLR 100unit, 3 NDS NM PA VUMERITY CPDR 231mg 3 NDS NM LA 200unit VUMERITY STARTER 3 NDS NM LA ZANAFLEX CAPS 2mg, 3 CPDR 231mg 4mg, 6mg; TABS 4mg MUSCULOSKELETAL THERAPY AGENTS NARCOLEPSY/CATAPLEXY baclofen TABS 5mg, 10mg, 1 armodafinil (generic of 1 PA 20mg NUVIGIL) TABS 50mg, BOTOX SOLR 100unit, 3 NDS NM PA 150mg, 200mg, 250mg 200unit modafinil (generic of 1 PA carisoprodol (generic of 3 PROVIGIL) TABS 100mg, SOMA) TABS 250mg 200mg carisoprodol (generic of 2 NUVIGIL TABS 50mg 3 PA SOMA) TABS 350mg NUVIGIL TABS 150mg, 3 NDS PA cyclobenzaprine hcl TABS 2 200mg, 250mg 5mg, 10mg PROVIGIL TABS 100mg, 3 NDS PA DANTRIUM CAPS 25mg, 3 200mg 50mg SUNOSI TABS 75mg, 3 dantrolene sodium (generic of 1 150mg DANTRIUM) CAPS 25mg, WAKIX TABS 4.45mg, 3 NDS NM LA 50mg 17.8mg dantrolene sodium CAPS 1 XYREM SOLN 500mg/ml 3 NDS NM LA 100mg PA DYSPORT SOLR 300unit 3 NM PA PSYCHOTHERAPEUTIC-MISC DYSPORT SOLR 500unit 3 NDS NM PA acamprosate calcium TBEC 1 metaxalone TABS 400mg 3 333mg metaxalone (generic of 3 ANTABUSE TABS 250mg, 3 SKELAXIN) TABS 800mg 500mg methocarbamol TABS 2 BUNAVAIL MIS 2.1-0.3 3 QL 500mg QL (90 films / 30 days) methocarbamol (generic of 2 BUNAVAIL MIS 4.2-0.7 3 QL ROBAXIN-750) TABS QL (90 films / 30 days) 750mg BUNAVAIL MIS 6.3-1MG 3 QL MYOBLOC SOLN 3 NM PA QL (60 films / 30 days) 2500unit/0.5ml, 5000unit/ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
45 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits buprenorphine hcl SUBL 1 QL PA SUBLOCADE SOSY 3 NDS NM 2mg, 8mg 100mg/0.5ml, 300mg/1.5ml QL (90 tabs / 30 days) SUBOXONE MIS 2-0.5MG 3 QL buprenorphine hcl-naloxone 1 QL QL (90 films / 30 days) hcl sl film 2-0.5 mg (base SUBOXONE MIS 4-1MG 3 QL equiv) (generic of QL (90 films / 30 days) SUBOXONE) SUBOXONE MIS 8-2MG 3 QL QL (90 films / 30 days) QL (90 films / 30 days) buprenorphine hcl-naloxone 1 QL SUBOXONE MIS 12-3MG 3 QL hcl sl film 4-1 mg (base equiv) QL (60 films / 30 days) (generic of SUBOXONE) VIVITROL SUSR 380mg 3 NDS NM QL (90 films / 30 days) ZUBSOLV SUB 0.7-0.18 3 QL buprenorphine hcl-naloxone 1 QL QL (90 tabs / 30 days) hcl sl film 8-2 mg (base equiv) ZUBSOLV SUB 1.4-0.36 3 QL (generic of SUBOXONE) QL (90 tabs / 30 days) QL (90 films / 30 days) ZUBSOLV SUB 2.9-0.71 3 QL buprenorphine hcl-naloxone 1 QL QL (90 tabs / 30 days) hcl sl film 12-3 mg (base ZUBSOLV SUB 5.7-1.4 3 QL equiv) (generic of QL (90 tabs / 30 days) SUBOXONE) ZUBSOLV SUB 8.6-2.1 3 QL QL (60 films / 30 days) QL (60 tabs / 30 days) buprenorphine hcl-naloxone 1 QL ZUBSOLV SUB 11.4-2.9 3 QL hcl sl tab 2-0.5 mg (base QL (30 tabs / 30 days) equiv) ENDOCRINE AND METABOLIC QL (90 tabs / 30 days) ANDROGENS buprenorphine hcl-naloxone 1 QL hcl sl tab 8-2 mg (base equiv) ANADROL-50 TABS 50mg 3 NDS PA QL (90 tabs / 30 days) ANDRODERM PT24 3 PA bupropion hcl (smoking 1 2mg/24hr, 4mg/24hr deterrent) TB12 150mg ANDROGEL GEL 3 PA CHANTIX TABS .5mg, 1mg 3 20.25mg/1.25gm, 25mg/2.5gm, 40.5mg/2.5gm, CHANTIX CONTINUING 3 50mg/5gm MONTH TABS 1mg ANDROGEL PUMP GEL 3 PA CHANTIX PAK 0.5& 1MG 3 1.62% disulfiram (generic of 1 AVEED SOLN 750mg/3ml 3 NM LA PA ANTABUSE) TABS 250mg, DEPO-TESTOSTERONE 3 PA 500mg SOLN 100mg/ml, 200mg/ml LUCEMYRA TABS .18mg 3 NDS FORTESTA GEL 10mg/act 3 PA naloxone hcl SOCT .4mg/ml; 1 oxandrolone TABS 2.5mg, 1 PA SOLN .4mg/ml, 4mg/10ml; 10mg SOSY 2mg/2ml TESTIM GEL 1% 3 PA naltrexone hcl TABS 50mg 1 testosterone GEL 1%; SOLN 1 PA NARCAN LIQD 4mg/0.1ml 2 30mg/act NICOTROL INHALER INHA 3 testosterone (generic of 1 PA 10mg ANDROGEL PUMP) GEL NICOTROL NS SOLN 3 1.62% 10mg/ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
46 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits testosterone (generic of 1 PA glipizide xl (generic of 1 FORTESTA) GEL 10mg/act GLUCOTROL XL) TB24 testosterone (generic of 1 PA 2.5mg, 5mg, 10mg ANDROGEL) GEL glipizide-metformin hcl tab 1 20.25mg/1.25gm, 2.5-250 mg 25mg/2.5gm, 40.5mg/2.5gm, glipizide-metformin hcl tab 1 50mg/5gm 2.5-500 mg testosterone cypionate 1 PA glipizide-metformin hcl tab 1 (generic of 5-500 mg DEPO-TESTOSTERONE) GLUCOTROL TABS 5mg, 3 SOLN 100mg/ml, 200mg/ml 10mg testosterone enanthate 1 PA GLUCOTROL XL TB24 3 SOLN 200mg/ml 2.5mg, 5mg, 10mg VOGELXO GEL 50mg/5gm 3 PA GLYSET TABS 25mg, 3 VOGELXO PUMP GEL 1% 3 PA 50mg, 100mg XYOSTED SOAJ 3 PA GLYXAMBI TAB 10-5 MG 2 50mg/0.5ml, 75mg/0.5ml, GLYXAMBI TAB 25-5 MG 2 100mg/0.5ml JANUMET TAB 50-500MG 2 ANTIDIABETICS JANUMET TAB 50-1000 2 acarbose (generic of 1 JANUMET XR TAB 2 PRECOSE) TABS 25mg, 50-500MG 50mg, 100mg JANUMET XR TAB 50-1000 2 ACTOPLUS MET TAB 3 15-500MG JANUMET XR TAB 100-1000 2 ACTOPLUS MET TAB 3 JANUVIA TABS 25mg, 2 15-850MG 50mg, 100mg ACTOS TABS 15mg, 30mg, 3 JARDIANCE TABS 10mg, 2 45mg 25mg AMARYL TABS 1mg, 2mg, 3 JENTADUETO TAB 2.5-500 2 4mg JENTADUETO TAB 2.5-850 2 BYDUREON BCISE AUIJ 2 JENTADUETO TAB 2.5-1000 2 2mg/0.85ml JENTADUETO TAB XR 2 BYDUREON PEN PEN 2mg 2 2.5-1000MG BYETTA SOPN 3 JENTADUETO TAB XR 2 5mcg/0.02ml, 10mcg/0.04ml 5-1000MG DUETACT TAB 30-2MG 3 metformin hcl (generic of 1 DUETACT TAB 30-4MG 3 RIOMET) SOLN 500mg/5ml FARXIGA TABS 5mg, 10mg 2 metformin hcl TABS 500mg, 1 850mg, 1000mg glimepiride (generic of 1 AMARYL) TABS 1mg, 2mg, metformin hcl TB24 500mg, 1 4mg 750mg (generic of GLUCOPHAGE glipizide (generic of 1 XR) GLUCOTROL) TABS 5mg, 10mg miglitol (generic of GLYSET) 1 TABS 25mg, 50mg, 100mg glipizide (generic of 1 GLUCOTROL XL) TB24 nateglinide TABS 60mg, 1 2.5mg, 5mg, 10mg 120mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
47 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits OZEMPIC (0.25 OR 2 TRIJARDY XR TAB ER 24HR 2 0.5MG/DOSE) SOPN 5-2.5-1000MG 2mg/1.5ml TRIJARDY XR TAB ER 24HR 2 OZEMPIC (1MG/DOSE) 2 10-5-1000MG SOPN 2mg/1.5ml TRIJARDY XR TAB ER 24HR 2 pioglitazone hcl (generic of 1 12.5-2.5-1000MG ACTOS) TABS 15mg, 30mg, TRIJARDY XR TAB ER 24HR 2 45mg 25-5-1000MG pioglitazone hcl-glimepiride 1 TRULICITY SOPN 2 tab 30-2 mg (generic of .75mg/0.5ml, 1.5mg/0.5ml DUETACT) VICTOZA SOPN 18mg/3ml 2 pioglitazone hcl-glimepiride 1 XIGDUO XR TAB 2.5-1000 2 tab 30-4 mg (generic of XIGDUO XR TAB 5-500MG 2 DUETACT) XIGDUO XR TAB 5-1000MG 2 pioglitazone hcl-metformin hcl 1 tab 15-500 mg (generic of XIGDUO XR TAB 10-500MG 2 ACTOPLUS MET) XIGDUO XR TAB 10-1000 2 pioglitazone hcl-metformin hcl 1 ANTIDIABETICS, INSULINS tab 15-850 mg (generic of BASAGLAR KWIKPEN 2 ACTOPLUS MET) SOPN 100unit/ml PRECOSE TABS 25mg, 3 BD ALCOHOL SWABS 2 50mg, 100mg FIASP FLEX INJ TOUCH 2 repaglinide TABS .5mg, 1 FIASP INJ 100/ML 2 1mg, 2mg FIASP PENFIL INJ U-100 2 RIOMET SOLN 500mg/5ml 3 GAUZE PADS 2X2 2 RIOMET ER SRER 3 HUMULIN R U-500 3 NDS B/D 500mg/5ml (CONCENTR SOLN RYBELSUS TABS 3mg, 2 500unit/ml 7mg, 14mg HUMULIN R U-500 KWIKPEN 3 NDS STARLIX TABS 120mg 3 SOPN 500unit/ml SYMLINPEN 60 SOPN 3 NDS INSULIN SAFETY NEEDLES 2 1500mcg/1.5ml INSULIN SYRINGES: 2 SYMLINPEN 120 SOPN 3 NDS BD/ULTIMED/ALLISON/TRIVI 2700mcg/2.7ml DIA/MHC SYNJARDY TAB 5-500MG 2 LEVEMIR SOLN 100unit/ml 2 SYNJARDY TAB 5-1000MG 2 LEVEMIR FLEXTOUCH 2 SYNJARDY TAB 12.5-500 2 SOPN 100unit/ml SYNJARDY TAB 2 NOVOLIN INJ 70/30 2 12.5-1000MG NOVOLIN INJ 70/30 FP 2 SYNJARDY XR TAB 2 NOVOLIN N SUSP 2 5-1000MG 100unit/ml SYNJARDY XR TAB 10-1000 2 NOVOLIN N FLEXPEN 2 SYNJARDY XR TAB 2 SUPN 100unit/ml 12.5-1000MG NOVOLIN R SOLN 2 SYNJARDY XR TAB 25-1000 2 100unit/ml TRADJENTA TABS 5mg 2
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
48 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits NOVOLIN R FLEXPEN 2 FOSAMAX + D TAB 70-5600 3 SOPN 100unit/ml ibandronate sodium (generic 1 B/D NOVOLOG SOLN 2 of BONIVA) SOLN 3mg/3ml; 100unit/ml TABS 150mg NOVOLOG FLEXPEN 2 NATPARA CART 25mcg, 3 NDS NM SOPN 100unit/ml 50mcg, 75mcg, 100mcg NOVOLOG MIX INJ 70/30 2 PAMIDRONATE DISODIUM 2 B/D NOVOLOG MIX INJ 2 SOLN 6mg/ml FLEXPEN pamidronate disodium SOLN 1 B/D NOVOLOG PENFILL SOCT 2 30mg/10ml, 90mg/10ml; 100unit/ml SOLR 30mg, 90mg OMNIPOD KIT STARTER 3 PROLIA SOSY 60mg/ml 3 NM OMNIPOD MIS 5 PACK 3 RECLAST SOLN 5mg/100ml 3 B/D NM PEN NEEDLES: 2 risedronate sodium (generic of 1 NOVO/BD/ULTIMED/OWEN/ ACTONEL) TABS 5mg, TRIVIDIA 30mg, 35mg, 150mg SOLIQUA INJ 100/33 2 risedronate sodium (generic of 1 TRESIBA SOLN 100unit/ml 2 ATELVIA) TBEC 35mg TYMLOS SOPN 3 NDS NM TRESIBA FLEXTOUCH 2 3120mcg/1.56ml SOPN 100unit/ml, 200unit/ml XGEVA SOLN 120mg/1.7ml 3 NDS B/D NM V-GO 20 KIT 3 zoledronic acid CONC 1 B/D NM V-GO 30 KIT 3 4mg/5ml; SOLN 4mg/100ml V-GO 40 KIT 3 ZOLEDRONIC ACID SOLN 3 B/D NM XULTOPHY INJ 100/3.6 2 4mg/100ml CALCIUM REGULATORS zoledronic acid (generic of 1 B/D NM ACTONEL TABS 5mg, 3 RECLAST) SOLN 35mg, 150mg 5mg/100ml alendronate sodium SOLN 1 CHELATING AGENTS 70mg/75ml; TABS 10mg, CHEMET CAPS 100mg 3 35mg clovique (generic of 3 NDS alendronate sodium (generic 1 SYPRINE) CAPS 250mg of FOSAMAX) TABS 70mg deferasirox (generic of 3 NDS NM ATELVIA TBEC 35mg 3 JADENU) TABS 90mg, BINOSTO TBEF 70mg 3 180mg, 360mg BONIVA SOLN 3mg/3ml; 3 B/D deferasirox (generic of 3 NDS NM TABS 150mg EXJADE) TBSO 125mg, calcitonin (salmon) (generic of 1 B/D 250mg, 500mg MIACALCIN) SOLN deferoxamine mesylate 1 B/D NM 200unit/act SOLR 2gm EVENITY SOSY 3 NDS NM deferoxamine mesylate 1 B/D NM 105mg/1.17ml (generic of DESFERAL) FORTEO SOPN 3 NDS NM SOLR 500mg 600mcg/2.4ml DEPEN TITRATABS TABS 3 NDS FOSAMAX TABS 70mg 3 250mg FOSAMAX + D TAB 70-2800 3 DESFERAL SOLR 500mg 3 B/D NM
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
49 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits EXJADE TBSO 125mg, 3 NDS NM LA aviane 1 250mg, 500mg ayuna 1 FERRIPROX SOLN 3 NDS NM LA azurette (generic of 1 100mg/ml; TABS 500mg, MIRCETTE) 1000mg BALCOLTRA TAB 0.1-20 3 JADENU TABS 90mg, 3 NDS NM LA balziva 1 180mg, 360mg bekyree (generic of 1 JADENU SPRINKLE PACK 3 NDS NM LA MIRCETTE) 90mg, 180mg, 360mg BEYAZ TAB 3 kionex SUSP 15gm/60ml 1 blisovi 24 fe 1 LOKELMA PACK 5gm, 2 10gm blisovi fe 1.5/30 (generic of 1 penicillamine (generic of 3 NDS LOESTRIN FE 1.5/30) DEPEN TITRATABS) TABS briellyn 1 250mg camila TABS .35mg 1 sodium polystyrene sulfonate 1 camrese (generic of 1 SUSP 15gm/60ml SEASONIQUE) sodium polystyrene sulfonate 1 camrese lo (generic of 1 powder LOSEASONIQUE) sps SUSP 15gm/60ml 1 caziant 1 SYPRINE CAPS 250mg 3 NDS chateal 1 trientine hcl (generic of 3 NDS cryselle-28 1 SYPRINE) CAPS 250mg cyclafem 1/35 1 VELTASSA PACK 8.4gm, 3 LA cyclafem 7/7/7 1 16.8gm, 25.2gm cyred eq 1 CONTRACEPTIVES dasetta 1/35 1 afirmelle 1 dasetta 7/7/7 1 altavera 1 daysee (generic of 1 alyacen 1/35 1 SEASONIQUE) alyacen 7/7/7 1 deblitane TABS .35mg 1 amethia (generic of 1 DEPO-PROVERA 3 SEASONIQUE) CONTRACEPTIV SUSP amethyst 1 150mg/ml; SUSY 150mg/ml ANNOVERA MIS 3 DEPO-SUBQ PROVERA 104 3 apri 1 SUSY 104mg/0.65ml aranelle 1 desogest-eth estrad & eth 1 ashlyna (generic of 1 estrad tab 0.15-0.02/0.01 SEASONIQUE) mg(21/5) (generic of aubra eq 1 MIRCETTE) drospirenone-ethinyl 1 aurovela 1/20 (generic of 1 estrad-levomefolate tab LOESTRIN 1/20-21) 3-0.02-0.451 mg (generic of aurovela 24 fe 1 BEYAZ) aurovela fe 1.5/30 (generic of 1 LOESTRIN FE 1.5/30) aurovela fe 1/20 (generic of 1 LOESTRIN FE 1/20)
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
50 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits drospirenone-ethinyl 1 junel 1/20 (generic of 1 estrad-levomefolate tab LOESTRIN 1/20-21) 3-0.03-0.451 mg (generic of junel fe 1.5/30 (generic of 1 SAFYRAL) LOESTRIN FE 1.5/30) drospirenone-ethinyl estradiol 1 junel fe 1/20 (generic of 1 tab 3-0.02 mg (generic of LOESTRIN FE 1/20) YAZ) junel fe 24 1 drospirenone-ethinyl estradiol 1 kaitlib fe (generic of 1 tab 3-0.03 mg (generic of GENERESS FE) YASMIN 28) kariva (generic of MIRCETTE) 1 elinest 1 kelnor 1/35 1 ELLA TABS 30mg 2 kelnor 1/50 1 eluryng (generic of 1 kurvelo 1 NUVARING) larin 1.5/30 (generic of 1 emoquette 1 LOESTRIN 1.5/30-21) enpresse-28 1 larin 1/20 (generic of 1 enskyce 1 LOESTRIN 1/20-21) errin TABS .35mg 1 larin 24 fe 1 estarylla 1 larin fe 1.5/30 (generic of 1 ESTROSTEP FE TAB 3 LOESTRIN FE 1.5/30) ethynodiol diacetate & ethinyl 1 larin fe 1/20 (generic of 1 estradiol tab 1 mg-35 mcg LOESTRIN FE 1/20) ethynodiol diacetate & ethinyl 1 larissia 1 estradiol tab 1 mg-50 mcg layolis fe (generic of 1 etonogestrel-ethinyl estradiol 1 GENERESS FE) va ring 0.120-0.015 mg/24hr leena 1 (generic of NUVARING) lessina 1 falmina 1 levonest 1 fayosim (generic of 1 levonor-eth est tab 1 QUARTETTE) 0.15-0.02/0.025/0.03 mg ð femynor 1 est 0.01 mg (generic of GENERESS FE CHW 3 QUARTETTE) gianvi (generic of YAZ) 1 levonorg-eth est tab 1 hailey 1.5/30 (generic of 1 0.1-0.02mg(84) & eth est tab LOESTRIN 1.5/30-21) 0.01mg(7) (generic of hailey 24 fe 1 LOSEASONIQUE) heather TABS .35mg 1 levonorg-eth est tab 1 0.15-0.03mg(84) & eth est tab incassia TABS .35mg 1 0.01mg(7) (generic of introvale 1 SEASONIQUE) isibloom 1 levonorgestrel & ethinyl 1 jasmiel (generic of YAZ) 1 estradiol (91-day) tab jolessa 1 0.15-0.03 mg juleber 1 levonorgestrel & ethinyl 1 junel 1.5/30 (generic of 1 estradiol tab 0.1 mg-20 mcg LOESTRIN 1.5/30-21)
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
51 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits levonorgestrel & ethinyl 1 nora-be TABS .35mg 1 estradiol tab 0.15 mg-30 mcg norethindrone & ethinyl 1 levonorgestrel-eth estra tab 1 estradiol-fe chew tab 0.4 0.05-30/0.075-40/0.125-30mg mg-35 mcg -mcg norethindrone & ethinyl 1 levonorgestrel-ethinyl 1 estradiol-fe chew tab 0.8 estradiol (continuous) tab mg-25 mcg (generic of 90-20 mcg GENERESS FE) levora 0.15/30-28 1 norethindrone (contraceptive) 1 lillow 1 TABS .35mg LO LOESTRIN TAB 1-10-10 3 norethindrone ace & ethinyl 1 LOESTRIN 21 TAB 1.5/30 3 estradiol tab 1 mg-20 mcg (generic of LOESTRIN LOESTRIN FE TAB 1.5/30 3 1/20-21) LOESTRIN FE TAB 1/20 3 norethindrone ace & ethinyl 1 LOESTRIN TAB 1/20-21 3 estradiol tab 1.5 mg-30 mcg loryna (generic of YAZ) 1 (generic of LOESTRIN LOSEASONIQUE TAB 3 1.5/30-21) low-ogestrel 1 norethindrone ace & ethinyl 1 lutera 1 estradiol-fe tab 1 mg-20 mcg lyza TABS .35mg 1 (generic of LOESTRIN FE 1/20) marlissa 1 norethindrone ace-eth 1 medroxyprogesterone acetate 1 estradiol-fe chew tab 1 mg-20 (contraceptive) (generic of mcg (24) (generic of DEPO-PROVERA MINASTRIN 24 FE) CONTRACEPTIV) SUSP norgestimate & ethinyl 1 150mg/ml; SUSY 150mg/ml estradiol tab 0.25 mg-35 mcg melodetta 24 fe (generic of 1 norgestimate-eth estrad tab 1 MINASTRIN 24 FE) 0.18-25/0.215-25/0.25-25 mibelas 24 fe (generic of 1 mg-mcg (generic of ORTHO MINASTRIN 24 FE) TRI-CYCLEN LO) microgestin 1.5/30 (generic of 1 norgestimate-eth estrad tab 1 LOESTRIN 1.5/30-21) 0.18-35/0.215-35/0.25-35 microgestin 1/20 (generic of 1 mg-mcg LOESTRIN 1/20-21) norlyroc TABS .35mg 1 microgestin fe (generic of 1 nortrel 0.5/35 (28) 1 LOESTRIN FE 1/20) nortrel 1/35 (21) 1 microgestin fe 1.5/30 (generic 1 of LOESTRIN FE 1.5/30) nortrel 1/35 (28) 1 mili 1 nortrel 7/7/7 1 MINASTRIN 24 CHW FE 3 NUVARING MIS 3 MIRCETTE TAB 28 DAY 3 ocella (generic of YASMIN 28) 1 mono-linyah 1 orsythia 1 NATAZIA TAB 3 ORTHO MICRONOR TABS 3 necon 0.5/35-28 1 .35mg ORTHO TRI- TAB CYCLN LO 3 nikki (generic of YAZ) 1
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
52 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits philith 1 tri-vylibra lo (generic of 1 pimtrea (generic of 1 ORTHO TRI-CYCLEN LO) MIRCETTE) trivora-28 1 pirmella 1/35 1 tulana TABS .35mg 1 portia-28 1 tydemy (generic of SAFYRAL) 1 previfem 1 velivet 1 QUARTETTE TAB 3 vienva 1 reclipsen 1 viorele (generic of 1 rivelsa (generic of 1 MIRCETTE) QUARTETTE) vyfemla 1 SAFYRAL TAB 3 vylibra 1 SEASONIQUE TAB 3 wera 1 setlakin 1 wymzya fe 1 sharobel TABS .35mg 1 xulane 1 simliya (generic of 1 YASMIN 28 TAB 3-0.03MG 3 MIRCETTE) YAZ TAB 3-0.02MG 3 simpesse (generic of 1 zarah (generic of YASMIN 28) 1 SEASONIQUE) zovia 1/35e 1 SLYND TABS 4mg 3 zumandimine (generic of 1 sprintec 28 1 YASMIN 28) sronyx 1 ENDOMETRIOSIS syeda (generic of YASMIN 28) 1 danazol CAPS 50mg, 1 tarina 24 fe 1 100mg, 200mg tarina fe 1/20 eq (generic of 1 LUPANETA KIT 3.75-5 3 NDS NM LOESTRIN FE 1/20) LUPANETA KIT 11.25-5 3 NDS NM TAYTULLA CAP 1MG/20MC 3 ORILISSA TABS 150mg, 3 NDS tilia fe (generic of 1 200mg ESTROSTEP FE) SYNAREL SOLN 2mg/ml 3 NDS tri-estarylla 1 ESTROGENS tri-legest fe (generic of 1 ACTIVELLA TAB 1-0.5MG 3 ESTROSTEP FE) ALORA PTTW .025mg/24hr, 3 tri-linyah 1 .05mg/24hr, .075mg/24hr, tri-lo-estarylla (generic of 1 .1mg/24hr ORTHO TRI-CYCLEN LO) amabelz 2 tri-lo-marzia (generic of 1 amabelz (generic of 2 ORTHO TRI-CYCLEN LO) ACTIVELLA) tri-lo-mili (generic of ORTHO 1 CLIMARA PTWK 3 TRI-CYCLEN LO) .025mg/24hr, .05mg/24hr, tri-lo-sprintec (generic of 1 .06mg/24hr, .075mg/24hr, ORTHO TRI-CYCLEN LO) .1mg/24hr, 37.5mcg/24hr tri-mili 1 DELESTROGEN OIL 3 tri-previfem 1 10mg/ml, 20mg/ml, 40mg/ml tri-sprintec 1 DEPO-ESTRADIOL OIL 3 tri-vylibra 1 5mg/ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
53 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits DIVIGEL GEL 3 IMVEXXY STARTER PACK 3 PA .25mg/0.25gm, .5mg/0.5gm, INST 4mcg, 10mcg .75mg/0.75gm, 1mg/gm, jinteli 2 1.25mg/1.25gm lopreeza (generic of 2 dotti (generic of 2 ACTIVELLA) VIVELLE-DOT) PTTW MENEST TABS .3mg, 3 .025mg/24hr, .037mg/24hr, .625mg, 1.25mg .05mg/24hr, .075mg/24hr, MENOSTAR PTWK 3 .1mg/24hr 14mcg/24hr ESTRACE CREA .1mg/gm; 3 mimvey (generic of 2 TABS .5mg, 1mg, 2mg ACTIVELLA) estradiol (generic of 2 MINIVELLE PTTW 3 VIVELLE-DOT) PTTW .025mg/24hr, .037mg/24hr, .025mg/24hr, .037mg/24hr, .05mg/24hr, .075mg/24hr, .05mg/24hr, .075mg/24hr, .1mg/24hr .1mg/24hr norethindrone acetate-ethinyl 2 estradiol (generic of 2 estradiol tab 0.5 mg-2.5 mcg CLIMARA) PTWK (generic of FEMHRT LOW .025mg/24hr, .05mg/24hr, DOSE) .06mg/24hr, .075mg/24hr, norethindrone acetate-ethinyl 2 .1mg/24hr, 37.5mcg/24hr estradiol tab 1 mg-5 mcg estradiol (generic of 1 PREMARIN CREA 3 ESTRACE) TABS .5mg, .625mg/gm; SOLR 25mg 1mg, 2mg PREMARIN TABS .3mg, 2 estradiol & norethindrone 2 .45mg, .625mg, .9mg, 1.25mg acetate tab 0.5-0.1 mg PREMPHASE TAB 2 estradiol & norethindrone 2 PREMPRO TAB 2 acetate tab 1-0.5 mg (generic of ACTIVELLA) PREMPRO TAB 0.3-1.5 2 estradiol vaginal (generic of 1 PREMPRO TAB 0.45-1.5 2 ESTRACE) CREA .1mg/gm PREMPRO TAB 0.625-5 2 estradiol vaginal (generic of 1 VAGIFEM TABS 10mcg 3 VAGIFEM) TABS 10mcg VIVELLE-DOT PTTW 3 estradiol valerate (generic of 1 .025mg/24hr, .037mg/24hr, DELESTROGEN) OIL .05mg/24hr, .075mg/24hr, 20mg/ml, 40mg/ml .1mg/24hr ESTRING RING 2mg 3 yuvafem (generic of 1 ESTROGEL GEL .06% 3 VAGIFEM) TABS 10mcg FEMHRT TAB 0.5-2.5 3 GLUCOCORTICOIDS FEMRING RING 3 CORTEF TABS 5mg, 10mg, 3 .05mg/24hr, .1mg/24hr 20mg fyavolv tab 0.5mg-2.5mcg 2 cortisone acetate TABS 1 (generic of FEMHRT LOW 25mg DOSE) DEPO-MEDROL SUSP 3 B/D fyavolv tab 1mg-5mcg 2 20mg/ml, 40mg/ml, 80mg/ml IMVEXXY MAINTENANCE 3 PA PACK INST 4mcg, 10mcg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
54 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits dexamethasone ELIX 1 prednisolone SOLN 1 B/D .5mg/5ml; SOLN .5mg/5ml; 15mg/5ml TABS .5mg, .75mg, 1mg, prednisolone sodium 1 B/D 1.5mg, 2mg, 4mg, 6mg phosphate (generic of DEXAMETHASONE 3 PEDIAPRED) SOLN INTENSOL CONC 1mg/ml 5mg/5ml dexamethasone sodium 1 prednisolone sodium 1 B/D phosphate SOLN 4mg/ml, phosphate SOLN 10mg/5ml, 10mg/ml, 20mg/5ml, 15mg/5ml, 20mg/5ml, 100mg/10ml, 120mg/30ml 25mg/5ml dexamethasone sodium 1 prednisolone sodium 1 B/D phosphate (generic of phosphate (generic of DEXAMETHASONE SODIUM ORAPRED ODT) TBDP PHOS) SOLN 10mg/ml 10mg, 15mg, 30mg fludrocortisone acetate 1 prednisone SOLN 5mg/5ml; 1 B/D TABS .1mg TABS 1mg, 2.5mg, 5mg, hydrocortisone (generic of 1 10mg, 20mg, 50mg CORTEF) TABS 5mg, 10mg, prednisone TBPK 5mg, 1 20mg 10mg KENALOG-10 SUSP 3 B/D PREDNISONE INTENSOL 3 B/D 10mg/ml CONC 5mg/ml KENALOG-40 SUSP 3 B/D SOLU-CORTEF SOLR 3 40mg/ml 100mg, 250mg, 500mg, KENALOG-80 SUSP 3 B/D 1000mg 80mg/ml SOLU-MEDROL SOLR 2gm, 3 B/D MEDROL TABS 2mg, 4mg, 3 B/D 40mg, 125mg, 500mg, 8mg, 16mg, 32mg 1000mg MEDROL DOSEPAK TBPK 3 triamcinolone acetonide 1 B/D 4mg (generic of KENALOG-40) methylprednisolone (generic 1 B/D SUSP 40mg/ml of MEDROL) TABS 4mg, GLUCOSE ELEVATING AGENTS 8mg, 16mg, 32mg diazoxide (generic of 3 NDS methylprednisolone (generic 1 PROGLYCEM) SUSP of MEDROL DOSEPAK) 50mg/ml TBPK 4mg GVOKE HYPOPEN 2-PACK 2 methylprednisolone acetate 1 B/D SOAJ .5mg/0.1ml, 1mg/0.2ml (generic of DEPO-MEDROL) GVOKE PFS SOSY 2 SUSP 40mg/ml, 80mg/ml .5mg/0.1ml, 1mg/0.2ml methylprednisolone sod succ 1 B/D PROGLYCEM SUSP 3 NDS (generic of SOLU-MEDROL) 50mg/ml SOLR 40mg, 125mg, 500mg, MISCELLANEOUS 1000mg ALDURAZYME SOLN 3 NDS NM LA ORAPRED ODT TBDP 3 B/D 2.9mg/5ml 10mg, 15mg, 30mg BUPHENYL POWD 3gm/tsp 3 NDS NM PEDIAPRED SOLN 3 B/D BUPHENYL TABS 500mg 3 NDS NM LA 6.7mg/5ml BYNFEZIA PEN SOPN 3 NDS NM 2500mcg/ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
55 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits cabergoline TABS .5mg 1 HUMATROPE SOLR 6mg, 3 NDS NM PA CARBAGLU TABS 200mg 3 NDS NM LA 12mg, 24mg CARNITOR SOLN 200mg/ml 3 B/D HUMATROPE COMBO PACK 3 NDS NM PA CERDELGA CAPS 84mg 3 NDS NM SOLR 5mg CEREZYME SOLR 400unit 3 NDS NM LA INCRELEX SOLN 40mg/4ml 3 NDS NM LA CHORIONIC 3 NM PA ISTURISA TABS 1mg, 5mg, 3 NDS NM LA GONADOTROPIN SOLR 10mg 10000unit JYNARQUE TABS 15mg, 3 NDS NM LA cinacalcet hcl (generic of 1 B/D NM 30mg; TBPK 15mg SENSIPAR) TABS 30mg JYNARQUE PAK 30-15MG 3 NDS NM LA cinacalcet hcl (generic of 3 NDS B/D NM JYNARQUE PAK 45-15MG 3 NDS NM LA SENSIPAR) TABS 60mg, JYNARQUE PAK 60-30MG 3 NDS NM LA 90mg JYNARQUE PAK 90-30MG 3 NDS NM LA CRYSVITA SOLN 10mg/ml, 3 NDS NM LA KANUMA SOLN 20mg/10ml 3 NDS NM LA 20mg/ml, 30mg/ml KORLYM TABS 300mg 3 NDS NM LA CYSTADANE POW 3 NDS NM LA KUVAN PACK 100mg, 3 NDS NM LA CYSTAGON CAPS 50mg, 3 NM LA 500mg; TBSO 100mg 150mg levocarnitine (metabolic 1 B/D DDAVP SOLN .01%, 3 NDS modifiers) (generic of 4mcg/ml; TABS .2mg CARNITOR) SOLN DDAVP TABS .1mg 3 1gm/10ml; TABS 330mg desmopressin acetate 3 NDS LUMIZYME SOLR 50mg 3 NDS NM LA (generic of DDAVP) SOLN LUPRON DEPOT-PED 3 NDS NM 4mcg/ml (1-MONTH KIT 7.5mg, desmopressin acetate 1 11.25mg, 15mg (generic of DDAVP) TABS LUPRON DEPOT-PED 3 NDS NM .1mg, .2mg (3-MONTH KIT 11.25mg, desmopressin acetate spray 1 30mg (generic of DDAVP) SOLN miglustat (generic of 3 NDS NM .01% ZAVESCA) CAPS 100mg desmopressin acetate spray 1 MYALEPT SOLR 11.3mg 3 NDS NM LA refrigerated SOLN .01% NAGLAZYME SOLN 1mg/ml 3 NDS NM LA EGRIFTA SOLR 1mg 3 NDS NM LA nitisinone (generic of 3 NDS NM EGRIFTA SV SOLR 2mg 3 NDS NM LA ORFADIN) CAPS 2mg, 5mg, ELAPRASE SOLN 6mg/3ml 3 NDS NM LA 10mg ELELYSO SOLR 200unit 3 NDS NM NITYR TABS 2mg, 5mg, 3 NDS NM LA EVISTA TABS 60mg 3 10mg FABRAZYME SOLR 5mg, 3 NDS NM LA NORDITROPIN FLEXPRO 3 NDS NM PA 35mg SOLN 5mg/1.5ml, GALAFOLD CAPS 123mg 3 NDS NM LA 10mg/1.5ml, 15mg/1.5ml, 30mg/3ml GENOTROPIN SOLR 5mg, 3 NDS NM PA 12mg NOVAREL SOLR 5000unit 3 NM PA GENOTROPIN MINIQUICK 3 NDS NM PA NUTROPIN AQ NUSPIN 5 3 NDS NM LA SOLR .2mg, .4mg, .6mg, SOLN 5mg/2ml PA .8mg, 1mg, 1.2mg, 1.4mg, NUTROPIN AQ NUSPIN 10 3 NDS NM LA 1.6mg, 1.8mg, 2mg SOLN 10mg/2ml PA
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
56 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits NUTROPIN AQ NUSPIN 20 3 NDS NM LA SIGNIFOR SOLN .3mg/ml, 3 NDS NM LA SOLN 20mg/2ml PA .6mg/ml, .9mg/ml octreotide acetate (generic of 1 NM SIGNIFOR LAR SRER 3 NDS NM LA SANDOSTATIN) SOLN 10mg, 20mg, 30mg, 40mg, 50mcg/ml, 100mcg/ml 60mg octreotide acetate SOLN 1 NM sodium phenylbutyrate 3 NDS NM 200mcg/ml (generic of BUPHENYL) octreotide acetate (generic of 3 NDS NM POWD 3gm/tsp; TABS 500mg SANDOSTATIN) SOLN SOMATULINE DEPOT 3 NDS NM 500mcg/ml SOLN 60mg/0.2ml, octreotide acetate SOLN 3 NDS NM 90mg/0.3ml, 120mg/0.5ml 1000mcg/ml SOMAVERT SOLR 10mg, 3 NDS NM LA OMNITROPE SOLN 3 NDS NM LA 15mg, 20mg, 25mg, 30mg 5mg/1.5ml, 10mg/1.5ml; PA STIMATE SOLN 1.5mg/ml 3 NDS NM SOLR 5.8mg STRENSIQ SOLN 3 NDS NM LA ORFADIN CAPS 2mg, 5mg, 3 NDS NM LA 18mg/0.45ml, 28mg/0.7ml, 10mg, 20mg; SUSP 4mg/ml 40mg/ml, 80mg/0.8ml OSPHENA TABS 60mg 2 PA TEPEZZA SOLR 500mg 3 NDS NM LA PALYNZIQ SOSY 3 NDS NM LA tolvaptan (generic of 3 NDS NM 2.5mg/0.5ml, 10mg/0.5ml, SAMSCA) TABS 30mg 20mg/ml VIMIZIM SOLN 5mg/5ml 3 NDS NM PREGNYL W/DILUENT 3 NM PA VPRIV SOLR 400unit 3 NDS NM BENZYL SOLR 10000unit ZAVESCA CAPS 100mg 3 NDS NM LA PROCYSBI CPDR 25mg, 3 NDS NM LA ZOMACTON SOLR 5mg 3 NM PA 75mg; PACK 75mg, 300mg ZOMACTON SOLR 10mg 3 NDS NM PA raloxifene hcl (generic of 1 ZORBTIVE SOLR 8.8mg 3 NDS NM EVISTA) TABS 60mg PHOSPHATE BINDER AGENTS RAVICTI LIQD 1.1gm/ml 3 NDS NM LA AURYXIA TABS 210mg 3 NDS PA REVCOVI SOLN 3 NDS NM LA calcium acetate (phosphate 1 2.4mg/1.5ml binder) (generic of PHOSLO) SAIZEN SOLR 5mg, 8.8mg 3 NDS NM LA CAPS 667mg PA calcium acetate (phosphate 1 SAIZENPREP 3 NDS NM LA binder) TABS 667mg RECONSTITUTION SOLR PA FOSRENOL CHEW 500mg, 3 NDS 8.8mg 750mg, 1000mg; PACK SAMSCA TABS 15mg, 3 NDS NM LA 750mg, 1000mg 30mg lanthanum carbonate (generic 3 NDS SANDOSTATIN SOLN 3 NDS NM of FOSRENOL) CHEW 50mcg/ml, 100mcg/ml, 500mg, 750mg, 1000mg 500mcg/ml PHOSLYRA SOLN 3 SANDOSTATIN LAR DEPOT 3 NDS NM 667mg/5ml KIT 10mg, 20mg, 30mg RENAGEL TABS 800mg 3 NDS SENSIPAR TABS 30mg, 3 NDS B/D NM RENVELA PACK .8gm, 3 NDS 60mg, 90mg 2.4gm; TABS 800mg SEROSTIM SOLR 4mg, 3 NDS NM LA sevelamer carbonate (generic 3 NDS 5mg, 6mg of RENVELA) PACK .8gm, 2.4gm
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
57 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits sevelamer carbonate (generic 1 levoxyl (generic of 1 of RENVELA) TABS 800mg SYNTHROID) TABS 25mcg, sevelamer hcl TABS 400mg 1 50mcg, 75mcg, 88mcg, sevelamer hcl (generic of 1 100mcg, 112mcg, 125mcg, RENAGEL) TABS 800mg 137mcg, 150mcg, 175mcg, VELPHORO CHEW 500mg 3 NDS 200mcg PROGESTINS liothyronine sodium (generic 1 AYGESTIN TABS 5mg 3 of CYTOMEL) TABS 5mcg, 25mcg, 50mcg CRINONE GEL 4%, 8% 3 PA methimazole (generic of 1 medroxyprogesterone acetate 1 TAPAZOLE) TABS 5mg, (generic of PROVERA) 10mg TABS 2.5mg, 5mg, 10mg propylthiouracil TABS 50mg 1 megestrol acetate SUSP 2 40mg/ml SYNTHROID TABS 25mcg, 3 50mcg, 75mcg, 88mcg, megestrol acetate (appetite) 3 100mcg, 112mcg, 125mcg, SUSP 625mg/5ml 137mcg, 150mcg, 175mcg, norethindrone acetate 1 200mcg, 300mcg (generic of AYGESTIN) TAPAZOLE TABS 5mg, 3 TABS 5mg 10mg progesterone micronized 1 TIROSINT CAPS 13mcg, 3 (generic of PROMETRIUM) 25mcg, 50mcg, 75mcg, CAPS 100mg, 200mg 88mcg, 100mcg, 112mcg, PROMETRIUM CAPS 3 125mcg, 137mcg, 150mcg, 100mg, 200mg 175mcg, 200mcg PROVERA TABS 2.5mg, 3 TIROSINT-SOL SOLN 3 5mg, 10mg 13mcg/ml, 25mcg/ml, THYROID AGENTS 50mcg/ml, 75mcg/ml, CYTOMEL TABS 5mcg, 3 88mcg/ml, 100mcg/ml, 25mcg, 50mcg 112mcg/ml, 125mcg/ml, euthyrox (generic of 1 137mcg/ml, 150mcg/ml, SYNTHROID) TABS 25mcg, 175mcg/ml, 200mcg/ml 50mcg, 75mcg, 88mcg, unithroid (generic of 1 100mcg, 112mcg, 125mcg, SYNTHROID) TABS 25mcg, 137mcg, 150mcg, 175mcg, 50mcg, 75mcg, 88mcg, 200mcg 100mcg, 112mcg, 125mcg, levo-t (generic of 1 137mcg, 150mcg, 175mcg, SYNTHROID) TABS 25mcg, 200mcg, 300mcg 50mcg, 75mcg, 88mcg, VITAMIN D ANALOGS 100mcg, 112mcg, 125mcg, calcitriol (generic of 1 B/D 137mcg, 150mcg, 175mcg, ROCALTROL) CAPS 200mcg, 300mcg .25mcg, .5mcg; SOLN levothyroxine sodium (generic 1 1mcg/ml of SYNTHROID) TABS calcitriol SOLN 1mcg/ml 1 B/D 25mcg, 50mcg, 75mcg, doxercalciferol CAPS .5mcg, 1 B/D 88mcg, 100mcg, 112mcg, 1mcg, 2.5mcg 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
58 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits paricalcitol (generic of 1 B/D meclizine hcl TABS 12.5mg, 1 ZEMPLAR) CAPS 1mcg, 25mg 2mcg metoclopramide hcl SOLN 1 paricalcitol CAPS 4mcg 1 B/D 5mg/5ml, 5mg/ml; TBDP 5mg RAYALDEE CPCR 30mcg 3 NDS metoclopramide hcl (generic 1 ROCALTROL CAPS 3 B/D of REGLAN) TABS 5mg, .25mcg, .5mcg; SOLN 10mg 1mcg/ml METOCLOPRAMIDE ODT 3 ZEMPLAR CAPS 1mcg, 3 B/D TBDP 10mg 2mcg ondansetron TBDP 4mg, 1 B/D GASTROINTESTINAL 8mg ANTIEMETICS ondansetron hcl SOLN 1 AKYNZEO CAP 300-0.5 3 B/D 4mg/2ml, 40mg/20ml AKYNZEO INJ 235-0.25 3 ondansetron hcl SOLN 1 B/D AKYNZEO INJ 3 4mg/5ml; TABS 24mg 235-0.25MG/20ML ondansetron hcl (generic of 1 B/D ALOXI SOLN .25mg/5ml 3 ZOFRAN) TABS 4mg, 8mg palonosetron hcl (generic of 1 aprepitant (generic of 1 B/D ALOXI) SOLN .25mg/5ml EMEND) CAPS 40mg, 80mg palonosetron hcl SOSY 1 aprepitant CAPS 125mg 1 B/D .25mg/5ml aprepitant capsule therapy 1 B/D PALONOSETRON 3 pack 80 & 125 mg HYDROCHLORID SOLN BONJESTA TAB 20-20MG 3 .25mg/2ml CINVANTI EMUL 3 phenadoz SUPP 25mg 3 130mg/18ml PHENERGAN SOLN 3 compro SUPP 25mg 1 25mg/ml, 50mg/ml DICLEGIS TAB 10-10MG 3 prochlorperazine SUPP 1 doxylamine-pyridoxine tab 1 25mg delayed release 10-10 mg prochlorperazine edisylate 1 (generic of DICLEGIS) SOLN 10mg/2ml dronabinol (generic of 1 B/D prochlorperazine maleate 1 MARINOL) CAPS 2.5mg, TABS 5mg, 10mg 5mg, 10mg promethazine hcl (generic of 2 EMEND CAPS 80mg; SUSR 3 B/D PHENERGAN) SOLN 125mg 25mg/ml, 50mg/ml EMEND SOLR 150mg 3 promethazine hcl SUPP 3 EMEND TRIPAC PAK 80 & 3 NDS B/D 12.5mg, 25mg 125 promethazine hcl SYRP 1 fosaprepitant dimeglumine 1 6.25mg/5ml; TABS 12.5mg, (generic of EMEND) SOLR 25mg, 50mg 150mg promethegan SUPP 12.5mg, 3 granisetron hcl SOLN 1 25mg, 50mg 1mg/ml, 4mg/4ml REGLAN TABS 5mg, 10mg 3 granisetron hcl TABS 1mg 1 B/D SANCUSO PTCH 3 NDS MARINOL CAPS 2.5mg 3 B/D 3.1mg/24hr MARINOL CAPS 5mg, 10mg 3 NDS B/D
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
59 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits scopolamine (generic of 3 ASACOL HD TBEC 800mg 3 NDS TRANSDERM SCOP) PT72 AZULFIDINE TABS 500mg 3 1mg/3days AZULFIDINE EN-TABS 3 SUSTOL PRSY 10mg/0.4ml 3 TBEC 500mg SYNDROS SOLN 5mg/ml 3 NDS B/D balsalazide disodium (generic 1 VARUBI TBPK 90mg 3 B/D of COLAZAL) CAPS 750mg ZOFRAN TABS 4mg, 8mg 3 NDS B/D budesonide (generic of 1 ZUPLENZ FILM 4mg, 8mg 3 NDS B/D ENTOCORT EC) CPEP 3mg ANTISPASMODICS budesonide (generic of 3 NDS atropine sulfate SOSY 3 UCERIS) TB24 9mg .25mg/5ml, 1mg/10ml CANASA SUPP 1000mg 3 NDS BENTYL SOLN 10mg/ml 3 colocort (generic of 1 CUVPOSA SOLN 1mg/5ml 3 CORTENEMA) ENEM 100mg/60ml dicyclomine hcl CAPS 10mg; 2 TABS 20mg CORTENEMA ENEM 3 100mg/60ml dicyclomine hcl SOLN 3 10mg/5ml DELZICOL CPDR 400mg 3 dicyclomine hcl (generic of 3 DIPENTUM CAPS 250mg 3 NDS BENTYL) SOLN 10mg/ml ENTOCORT EC CPEP 3mg 3 NDS GLYCATE TABS 1.5mg 3 hydrocortisone (intrarectal) 1 glycopyrrolate SOLN 1 (generic of CORTENEMA) .2mg/ml, .4mg/2ml, 1mg/5ml, ENEM 100mg/60ml 4mg/20ml; TABS 1mg, 2mg LIALDA TBEC 1.2gm 3 GLYCOPYRROLATE SOSY 3 mesalamine (generic of 1 .2mg/ml, .4mg/2ml APRISO) CP24 .375gm methscopolamine bromide 1 mesalamine (generic of 1 TABS 2.5mg, 5mg DELZICOL) CPDR 400mg propantheline bromide TABS 1 mesalamine ENEM 4gm 1 15mg mesalamine (generic of 1 H2-RECEPTOR ANTAGONISTS CANASA) SUPP 1000mg cimetidine TABS 200mg, 1 mesalamine (generic of 1 300mg, 400mg, 800mg LIALDA) TBEC 1.2gm cimetidine hcl SOLN 1 mesalamine (generic of 1 300mg/5ml ASACOL HD) TBEC 800mg famotidine SOLN 20mg/2ml, 1 mesalamine w/ cleanser 1 40mg/4ml, 200mg/20ml; (generic of ROWASA) KIT SUSR 40mg/5ml 4gm famotidine (generic of 1 PENTASA CPCR 250mg, 3 NDS PEPCID) TABS 20mg, 40mg 500mg famotidine in nacl 0.9% iv soln 1 ROWASA KIT 4gm 3 NDS 20 mg/50ml SFROWASA ENEM 3 NDS nizatidine CAPS 150mg, 1 4gm/60ml 300mg; SOLN 15mg/ml sulfasalazine (generic of 1 PEPCID TABS 20mg, 40mg 3 AZULFIDINE) TABS 500mg INFLAMMATORY BOWEL DISEASE sulfasalazine (generic of 1 AZULFIDINE EN-TABS) APRISO CP24 .375gm 3 TBEC 500mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
60 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits UCERIS FOAM 2mg/act 3 CHOLBAM CAPS 50mg, 3 NDS NM LA UCERIS TB24 9mg 3 NDS 250mg LAXATIVES cromolyn sodium 1 CLENPIQ SOL 3 (mastocytosis) (generic of GASTROCROM) CONC constulose SOLN 1 100mg/5ml 10gm/15ml CYTOTEC TABS 100mcg, 3 enulose SOLN 10gm/15ml 1 200mcg gavilyte-c 1 diphenoxylate w/ atropine liq 3 gavilyte-g (generic of 1 2.5-0.025 mg/5ml GOLYTELY) diphenoxylate w/ atropine tab 2 gavilyte-n/flavor pack (generic 1 2.5-0.025 mg (generic of of NULYTELY) LOMOTIL) generlac SOLN 10gm/15ml 1 GASTROCROM CONC 3 NDS GOLYTELY SOL 2 100mg/5ml KRISTALOSE PACK 10gm, 3 GATTEX KIT 5mg 3 NDS NM LA 20gm LINZESS CAPS 72mcg, 3 lactulose SOLN 10gm/15ml 1 145mcg, 290mcg lactulose (encephalopathy) 1 LOMOTIL TAB 2.5MG 3 SOLN 10gm/15ml loperamide hcl CAPS 2mg 1 MOVIPREP SOL 3 LOPERAMIDE 3 NULYTELY SOL FLAV PKS 2 HYDROCHLORIDE SOLN OSMOPREP TAB 1.5GM 3 2mg/15ml peg 3350-kcl-na 1 LOTRONEX TABS .5mg, 3 NDS bicarb-nacl-na sulfate for soln 1mg 236 gm (generic of misoprostol (generic of 1 GOLYTELY) CYTOTEC) TABS 100mcg, peg 3350-kcl-sod bicarb-nacl 1 200mcg for soln 420 gm (generic of MOTEGRITY TABS 1mg, 3 NULYTELY) 2mg PLENVU SOL 3 MOVANTIK TABS 12.5mg, 2 SUPREP BOWEL SOL PREP 3 25mg KIT OCALIVA TABS 5mg, 10mg 3 NDS NM LA trilyte (generic of NULYTELY) 1 OMECLAMOX- MIS PAK 3 MISCELLANEOUS RELISTOR SOLN 3 NDS ACTIGALL CAPS 300mg 3 8mg/0.4ml, 12mg/0.6ml; TABS 150mg alosetron hcl (generic of 3 NDS SUCRAID SOLN 3 NDS LA LOTRONEX) TABS 1mg 8500unit/ml alosetron hcl (generic of 1 sucralfate (generic of 1 LOTRONEX) TABS .5mg CARAFATE) SUSP AMITIZA CAPS 8mcg, 3 1gm/10ml; TABS 1gm 24mcg SYMPROIC TABS .2mg 3 amoxicillin cap-clarithro 1 tab-lansopraz cap dr therapy TALICIA CAP 3 pack TRULANCE TABS 3mg 3 URSO 250 TABS 250mg 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
61 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits URSO FORTE TABS 500mg 3 esomeprazole magnesium 1 ursodiol (generic of 1 (generic of NEXIUM) CPDR ACTIGALL) CAPS 300mg 20mg, 40mg; PACK 10mg, ursodiol (generic of URSO 1 20mg, 40mg 250) TABS 250mg esomeprazole sodium 1 ursodiol (generic of URSO 1 (generic of NEXIUM I.V.) FORTE) TABS 500mg SOLR 40mg VIBERZI TABS 75mg, 3 NDS lansoprazole (generic of 1 100mg PREVACID) CPDR 15mg, XERMELO TABS 250mg 3 NDS NM LA 30mg XIFAXAN TABS 550mg 3 NDS lansoprazole (generic of 1 ZELNORM TABS 6mg 3 PREVACID SOLUTAB) TBDD 15mg, 30mg PANCREATIC ENZYMES NEXIUM CPDR 20mg, 3 CREON CAP 3000UNIT 2 40mg; PACK 2.5mg, 5mg, CREON CAP 6000UNIT 2 10mg, 20mg, 40mg CREON CAP 12000UNT 2 NEXIUM I.V. SOLR 40mg 3 CREON CAP 24000UNT 2 omeprazole CPDR 10mg, 1 CREON CAP 36000UNT 2 20mg, 40mg PANCREAZE CAP 2600UNIT 3 pantoprazole sodium (generic 1 PANCREAZE CAP 4200UNIT 3 of PROTONIX) SOLR 40mg; PANCREAZE CAP 3 TBEC 20mg, 40mg 10500UNT PREVACID CPDR 15mg, 3 PANCREAZE CAP 3 30mg 16800UNT PREVACID SOLUTAB 3 PANCREAZE CAP 3 TBDD 15mg, 30mg 21000UNT PRILOSEC PACK 2.5mg, 3 PERTZYE CAP 4000UNIT 3 10mg PROTONIX PACK 40mg; 3 PERTZYE CAP 8000UNIT 3 SOLR 40mg; TBEC 20mg, PERTZYE CAP 16000U 3 40mg PERTZYE CAP 24000U 3 rabeprazole sodium (generic 1 VIOKACE TAB 10440 3 of ACIPHEX) TBEC 20mg VIOKACE TAB 20880 3 NDS GENITOURINARY ZENPEP CAP 3000UNIT 3 BENIGN PROSTATIC HYPERPLASIA ZENPEP CAP 5000UNIT 3 alfuzosin hcl (generic of 1 ZENPEP CAP 10000UNT 3 UROXATRAL) TB24 10mg ZENPEP CAP 15000UNT 3 AVODART CAPS .5mg 3 ZENPEP CAP 20000UNT 3 CARDURA XL TB24 4mg, 3 ZENPEP CAP 25000 3 8mg ZENPEP CAP 40000 3 dutasteride (generic of 1 AVODART) CAPS .5mg PROTON PUMP INHIBITORS dutasteride-tamsulosin hcl cap 1 ACIPHEX TBEC 20mg 3 0.5-0.4 mg (generic of JALYN) DEXILANT CPDR 30mg, 3 finasteride (generic of 1 60mg PROSCAR) TABS 5mg FLOMAX CAPS .4mg 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
62 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits JALYN CAP 3 oxybutynin chloride SYRP 1 PROSCAR TABS 5mg 3 5mg/5ml; TABS 5mg; TB24 RAPAFLO CAPS 4mg, 8mg 3 15mg silodosin (generic of 1 oxybutynin chloride (generic 1 RAPAFLO) CAPS 4mg, 8mg of DITROPAN XL) TB24 5mg, 10mg tamsulosin hcl (generic of 1 FLOMAX) CAPS .4mg OXYTROL PTTW 3 3.9mg/24hr MISCELLANEOUS solifenacin succinate (generic 1 acetic acid SOLN .25% 1 of VESICARE) TABS 5mg, bethanechol chloride TABS 1 10mg 5mg, 10mg, 25mg, 50mg tolterodine tartrate (generic of 1 ELMIRON CAPS 100mg 3 NDS DETROL LA) CP24 2mg, INTRAROSA INST 6.5mg 3 PA 4mg neomycin-polymyxin b gu 1 tolterodine tartrate (generic of 1 irrigation soln DETROL) TABS 1mg, 2mg potassium citrate (alkalinizer) 1 TOVIAZ TB24 4mg, 8mg 2 (generic of UROCIT-K 15) trospium chloride CP24 1 TBCR 15meq 60mg; TABS 20mg potassium citrate (alkalinizer) 1 VESICARE TABS 5mg, 3 (generic of UROCIT-K 5) 10mg TBCR 540mg VAGINAL ANTI-INFECTIVES potassium citrate (alkalinizer) 1 CLEOCIN CREA 2%; SUPP 3 (generic of UROCIT-K 10) 100mg TBCR 1080mg clindamycin phosphate 1 THIOLA TABS 100mg 3 NDS vaginal (generic of CLEOCIN) THIOLA EC TBEC 100mg, 3 NDS CREA 2% 300mg CLINDESSE CREA 2% 3 UROCIT-K 5 TBCR 540mg 3 GYNAZOLE-1 CREA 2% 3 UROCIT-K 10 TBCR 3 1080mg metronidazole vaginal GEL 1 UROCIT-K 15 TBCR 15meq 3 .75% miconazole 3 SUPP 200mg 1 URINARY ANTISPASMODICS terconazole vaginal CREA 1 darifenacin hydrobromide 1 .4%, .8%; SUPP 80mg (generic of ENABLEX) TB24 vandazole GEL .75% 1 7.5mg, 15mg DETROL TABS 1mg, 2mg 3 HEMATOLOGIC DETROL LA CP24 2mg, 3 ANTICOAGULANTS 4mg ARIXTRA SOLN 3 NDS DITROPAN XL TB24 5mg, 3 2.5mg/0.5ml, 5mg/0.4ml, 10mg 7.5mg/0.6ml, 10mg/0.8ml ENABLEX TB24 7.5mg 3 COUMADIN TABS 1mg, 2 2mg, 2.5mg, 3mg, 4mg, 5mg, GELNIQUE GEL 10% 3 6mg, 7.5mg, 10mg MYRBETRIQ TB24 25mg, 3 ELIQUIS TABS 2.5mg, 5mg 2 50mg ELIQUIS STARTER PACK 2 TABS 5mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
63 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits enoxaparin sodium (generic of 1 LOVENOX SOLN 3 NDS LOVENOX) SOLN 60mg/0.6ml, 80mg/0.8ml, 30mg/0.3ml, 40mg/0.4ml, 100mg/ml, 120mg/0.8ml, 60mg/0.6ml, 80mg/0.8ml, 150mg/ml 100mg/ml, 120mg/0.8ml, PRADAXA CAPS 75mg, 3 150mg/ml, 300mg/3ml 110mg, 150mg fondaparinux sodium (generic 1 warfarin sodium TABS 1mg, 1 of ARIXTRA) SOLN 2mg, 2.5mg, 3mg, 4mg, 5mg, 2.5mg/0.5ml 6mg, 7.5mg, 10mg fondaparinux sodium (generic 3 NDS XARELTO TABS 2.5mg, 2 of ARIXTRA) SOLN 10mg, 15mg, 20mg 5mg/0.4ml, 7.5mg/0.6ml, XARELTO STAR TAB 2 10mg/0.8ml 15/20MG FRAGMIN SOLN 3 HEMATOPOIETIC GROWTH FACTORS 2500unit/0.2ml ARANESP ALBUMIN FREE 2 B/D NM FRAGMIN SOLN 3 NDS SOLN 25mcg/ml, 40mcg/ml; 5000unit/0.2ml, SOSY 10mcg/0.4ml, 7500unit/0.3ml, 10000unit/ml, 25mcg/0.42ml, 40mcg/0.4ml 12500unit/0.5ml, ARANESP ALBUMIN FREE 3 NDS B/D NM 15000unit/0.6ml, SOLN 60mcg/ml, 100mcg/ml, 18000unt/0.72ml, 200mcg/ml, 300mcg/ml; 95000unit/3.8ml SOSY 60mcg/0.3ml, HEP SOD/NACL INJ 2 100mcg/0.5ml, 150mcg/0.3ml, 25000UNT 200mcg/0.4ml, 300mcg/0.6ml, HEPARIN SODIUM SOLN 3 B/D 500mcg/ml 5000unit/ml; SOSY LEUKINE SOLR 250mcg 3 NDS NM 5000unit/0.5ml MOZOBIL SOLN 3 NDS NM heparin sodium (porcine) 1 B/D 24mg/1.2ml SOLN 1000unit/ml, NPLATE SOLR 125mcg, 3 NDS NM 5000unit/0.5ml, 5000unit/ml, 250mcg, 500mcg 10000unit/ml, 20000unit/ml PROCRIT SOLN 2 B/D NM heparin sodium (porcine) 100 1 2000unit/ml, 3000unit/ml, unit/ml in d5w 4000unit/ml, 10000unit/ml heparin sodium 1 PROCRIT SOLN 3 NDS B/D NM (porcine)-dextrose iv sol 20000unit/ml, 40000unit/ml 20000 unit/500ml-5% ZARXIO SOSY 3 NDS NM heparin sodium 1 300mcg/0.5ml, 480mcg/0.8ml (porcine)-dextrose iv sol MISCELLANEOUS 25000 unit/500ml-5% ADAKVEO SOLN 3 NDS B/D NM HEPARIN/NACL INJ 2 100mg/10ml 25000UNT AGRYLIN CAPS .5mg 3 jantoven TABS 1mg, 2mg, 1 anagrelide hcl CAPS 1mg 1 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg anagrelide hcl (generic of 1 LOVENOX SOLN 3 AGRYLIN) CAPS .5mg 30mg/0.3ml, 40mg/0.4ml, BERINERT KIT 500unit 3 NDS NM LA 300mg/3ml CABLIVI KIT 11mg 3 NDS NM LA
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
64 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits cilostazol TABS 50mg, 1 clopidogrel bisulfate (generic 1 100mg of PLAVIX) TABS 75mg CINRYZE SOLR 500unit 3 NDS NM LA clopidogrel bisulfate TABS 1 DOPTELET TABS 20mg 3 NDS NM LA 300mg DROXIA CAPS 200mg, 2 dipyridamole TABS 25mg, 2 300mg, 400mg 50mg, 75mg ENDARI PACK 5gm 3 NDS NM LA EFFIENT TABS 5mg, 10mg 3 FIRAZYR SOLN 30mg/3ml 3 NDS NM PLAVIX TABS 75mg 3 GIVLAARI SOLN 189mg/ml 3 NDS NM LA prasugrel hcl (generic of 1 HAEGARDA SOLR 3 NDS NM LA EFFIENT) TABS 5mg, 10mg 2000unit, 3000unit ZONTIVITY TABS 2.08mg 3 icatibant acetate (generic of 3 NDS NM IMMUNOLOGIC AGENTS FIRAZYR) SOLN 30mg/3ml AUTOIMMUNE AGENTS KALBITOR SOLN 10mg/ml 3 NDS NM LA AVSOLA SOLR 100mg 3 NDS NM LYSTEDA TABS 650mg 3 ENBREL SOLR 25mg; 3 NDS NM MULPLETA TABS 3mg 3 NDS NM SOSY 25mg/0.5ml, 50mg/ml OXBRYTA TABS 500mg 3 NDS NM LA ENBREL MINI SOCT 3 NDS NM pentoxifylline TBCR 400mg 1 50mg/ml PROMACTA PACK 12.5mg, 3 NDS NM LA ENBREL SURECLICK SOAJ 3 NDS NM 25mg; TABS 12.5mg, 25mg, 50mg/ml 50mg, 75mg ENTYVIO SOLR 300mg 3 NDS NM REBLOZYL SOLR 25mg, 3 NDS NM LA HUMIRA PSKT 10mg/0.1ml, 3 NDS NM 75mg 10mg/0.2ml, 20mg/0.2ml, RUCONEST SOLR 2100unit 3 NDS NM 20mg/0.4ml, 40mg/0.4ml, SIKLOS TABS 100mg 3 40mg/0.8ml SIKLOS TABS 1000mg 3 NDS HUMIRA PEDIA INJ 3 NDS NM SOLIRIS SOLN 300mg/30ml 3 NDS NM LA CROHNS TAKHZYRO SOLN 3 NDS NM LA HUMIRA PEDIATRIC 3 NDS NM 300mg/2ml CROHNS D PSKT TAVALISSE TABS 100mg, 3 NDS NM LA 80mg/0.8ml 150mg HUMIRA PEN PNKT 3 NDS NM tranexamic acid (generic of 1 40mg/0.4ml, 40mg/0.8ml CYKLOKAPRON) SOLN HUMIRA PEN KIT PS/UV 3 NDS NM 1000mg/10ml HUMIRA PEN-CD/UC/HS 3 NDS NM tranexamic acid (generic of 1 START PNKT 40mg/0.8ml, LYSTEDA) TABS 650mg 80mg/0.8ml ULTOMIRIS SOLN 3 NDS NM LA HUMIRA PEN-PS/UV 3 NDS NM 300mg/30ml STARTER PNKT PLATELET AGGREGATION INHIBITORS 40mg/0.8ml AGGRENOX CAP 25-200MG 3 RENFLEXIS SOLR 100mg 3 NDS NM LA aspirin-dipyridamole cap er 1 RINVOQ TB24 15mg 3 NDS NM 12hr 25-200 mg (generic of SKYRIZI PSKT 75mg/0.83ml 3 NDS NM AGGRENOX) STELARA SOLN 3 NDS NM LA BRILINTA TABS 60mg, 3 45mg/0.5ml 90mg STELARA SOSY 3 NDS NM 45mg/0.5ml, 90mg/ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
65 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits TALTZ SOAJ 80mg/ml; 3 NDS NM LA HIZENTRA SOLN 1gm/5ml, 3 NDS B/D NM SOSY 80mg/ml 2gm/10ml, 4gm/20ml, LA XELJANZ TABS 5mg, 10mg 3 NDS NM 10gm/50ml; SOSY 1gm/5ml, XELJANZ XR TB24 11mg, 3 NDS NM 2gm/10ml, 4gm/20ml 22mg HYQVIA INJ 2.5-200 3 NDS B/D NM DISEASE-MODIFYING ANTI-RHEUMATIC HYQVIA INJ 5-400 3 NDS B/D NM DRUGS (DMARDS) HYQVIA INJ 10-800 3 NDS B/D NM ARAVA TABS 10mg, 20mg 3 NDS HYQVIA INJ 20-1600 3 NDS B/D NM hydroxychloroquine sulfate 1 HYQVIA INJ 30-2400 3 NDS B/D NM (generic of PLAQUENIL) OCTAGAM SOLN 3 NDS B/D NM TABS 200mg 1gm/20ml, 2gm/20ml, leflunomide (generic of 1 2.5gm/50ml, 5gm/100ml, ARAVA) TABS 10mg, 20mg 5gm/50ml, 10gm/100ml, methotrexate sodium TABS 1 10gm/200ml, 20gm/200ml, 2.5mg 25gm/500ml, 30gm/300ml PLAQUENIL TABS 200mg 3 PANZYGA SOLN 1gm/10ml, 3 NDS B/D NM TREXALL TABS 5mg, 3 B/D 2.5gm/25ml, 5gm/50ml, 7.5mg, 10mg, 15mg 10gm/100ml, 20gm/200ml, 30gm/300ml XATMEP SOLN 2.5mg/ml 3 B/D PRIVIGEN SOLN 5gm/50ml, 3 NDS B/D NM IMMUNOGLOBULINS 10gm/100ml, 20gm/200ml, BIVIGAM SOLN 5gm/50ml 3 NDS B/D NM 40gm/400ml CUTAQUIG SOLN 1gm/6ml, 3 NDS B/D NM XEMBIFY SOLN 1gm/5ml, 3 NDS B/D NM 1.65gm/10ml, 2gm/12ml, LA 2gm/10ml, 4gm/20ml, LA 3.3gm/20ml, 4gm/24ml, 10gm/50ml 8gm/48ml IMMUNOMODULATORS CUVITRU SOLN 1gm/5ml, 3 NDS B/D NM ACTIMMUNE SOLN 3 NDS NM LA 2gm/10ml, 4gm/20ml, LA 2000000unit/0.5ml 8gm/40ml, 10gm/50ml ARCALYST SOLR 220mg 3 NDS NM CYTOGAM INJ 50mg/ml 3 NDS NM ILARIS SOLN 150mg/ml 3 NDS NM LA GAMASTAN INJ 3 B/D NM INTRON A SOLN 10mu/ml, 3 NDS B/D NM GAMMAGARD LIQUID 3 NDS B/D NM 6000000unit/ml; SOLR 10mu, SOLN 1gm/10ml, 2.5gm/25ml, 18mu, 50mu 5gm/50ml, 10gm/100ml, 20gm/200ml, 30gm/300ml ODACTRA SUB 3 GAMMAGARD S/D IGA LESS 3 NDS B/D NM ORALAIR SUB 300 IR 3 NM TH SOLR 5gm, 10gm RAGWITEK SUBL 3 GAMMAKED SOLN 3 NDS B/D NM 12amba1-u 1gm/10ml, 5gm/50ml, IMMUNOSUPPRESSANTS 10gm/100ml, 20gm/200ml ASTAGRAF XL CP24 5mg 3 NDS B/D NM GAMMAPLEX SOLN 3 NDS B/D NM ASTAGRAF XL CP24 .5mg, 3 B/D NM 5gm/100ml, 5gm/50ml, 1mg 10gm/100ml, 10gm/200ml, ATGAM INJ 50mg/ml 3 NDS B/D 20gm/200ml, 20gm/400ml AZASAN TABS 75mg, 3 B/D GAMUNEX-C SOLN 3 NDS B/D NM 100mg 1gm/10ml, 2.5gm/25ml, azathioprine (generic of 1 B/D 5gm/50ml, 10gm/100ml, IMURAN) TABS 50mg 20gm/200ml, 40gm/400ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
66 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits BENLYSTA SOAJ 3 NDS NM RAPAMUNE SOLN 1mg/ml; 3 NDS B/D NM 200mg/ml; SOLR 120mg, TABS 1mg, 2mg 400mg; SOSY 200mg/ml RAPAMUNE TABS .5mg 3 B/D NM CELLCEPT CAPS 250mg; 3 NDS B/D NM SANDIMMUNE CAPS 25mg; 3 B/D NM SUSR 200mg/ml; TABS SOLN 50mg/ml 500mg SANDIMMUNE CAPS 3 NDS B/D NM cyclosporine (generic of 1 B/D NM 100mg SANDIMMUNE) CAPS SANDIMMUNE SOLN 2 B/D NM 25mg, 100mg; SOLN 50mg/ml 100mg/ml cyclosporine modified (for 1 B/D NM sirolimus (generic of 3 NDS B/D NM microemulsion) (generic of RAPAMUNE) SOLN 1mg/ml; NEORAL) CAPS 25mg, TABS 2mg 100mg; SOLN 100mg/ml sirolimus (generic of 1 B/D NM cyclosporine modified (for 1 B/D NM RAPAMUNE) TABS .5mg, microemulsion) CAPS 50mg 1mg ENVARSUS XR TB24 3 B/D NM tacrolimus (generic of 1 B/D NM .75mg, 1mg, 4mg PROGRAF) CAPS .5mg, everolimus 3 NDS B/D NM 1mg, 5mg (immunosuppressant) ZORTRESS TABS .25mg, 3 NDS B/D NM (generic of ZORTRESS) .5mg, .75mg, 1mg TABS .5mg, .75mg VACCINES everolimus 1 B/D NM ACTHIB INJ 2 (immunosuppressant) ADACEL INJ 2 (generic of ZORTRESS) TABS .25mg BCG VACCINE INJ 2 gengraf (generic of NEORAL) 1 B/D NM BEXSERO INJ 2 CAPS 25mg, 100mg; SOLN BOOSTRIX INJ 2 100mg/ml DAPTACEL INJ 2 IMURAN TABS 50mg 3 B/D DIP/TET PED INJ 25-5LFU 2 B/D mycophenolate mofetil 1 B/D NM ENGERIX-B SUSP 2 B/D (generic of CELLCEPT) 10mcg/0.5ml, 20mcg/ml CAPS 250mg; TABS 500mg GARDASIL 9 INJ 2 mycophenolate mofetil 3 NDS B/D NM HAVRIX SUSP 2 (generic of CELLCEPT) 720elu/0.5ml, 1440elu/ml SUSR 200mg/ml HIBERIX SOLR 10mcg 2 mycophenolate sodium 1 B/D NM IMOVAX RABIES (H.D.C.V.) 2 B/D (generic of MYFORTIC) INJ 2.5unit/ml TBEC 180mg, 360mg INFANRIX INJ 2 MYFORTIC TBEC 180mg 3 B/D NM IPOL INJ INACTIVE 2 MYFORTIC TBEC 360mg 3 NDS B/D NM IXIARO INJ 2 NEORAL CAPS 25mg, 3 B/D NM 100mg; SOLN 100mg/ml KINRIX INJ 2 NULOJIX SOLR 250mg 3 NDS B/D NM M-M-R II INJ 2 PROGRAF CAPS 5mg 3 NDS B/D NM MENACTRA INJ 2 PROGRAF CAPS .5mg, 3 B/D NM MENVEO INJ 2 1mg; PACK .2mg, 1mg PEDIARIX INJ 0.5ML 2
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
67 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits PEDVAX HIB SUSP 2 ISOLYTE-P INJ /D5W 3 7.5mcg/0.5ml ISOLYTE-S INJ 3 PENTACEL INJ 2 kcl 10 meq/l (0.075%) in 1 PROQUAD INJ 2 dextrose 5% & nacl 0.45% inj QUADRACEL INJ 2 kcl 20 meq/l (0.15%) in 1 RABAVERT INJ 2 B/D dextrose 5% & nacl 0.2% inj RECOMBIVAX HB SUSP 2 B/D kcl 20 meq/l (0.15%) in 1 5mcg/0.5ml, 10mcg/ml, dextrose 5% & nacl 0.9% inj 40mcg/ml kcl 20 meq/l (0.15%) in 1 ROTARIX SUS 2 dextrose 5% & nacl 0.45% inj ROTATEQ SOL 2 kcl 20 meq/l (0.15%) in nacl 1 SHINGRIX SUSR 2 0.9% inj 50mcg/0.5ml kcl 20 meq/l (0.15%) in nacl 1 TDVAX INJ 2-2 LF 2 B/D 0.45% inj TENIVAC INJ 5-2LF 2 B/D kcl 30 meq/l (0.224%) in 1 dextrose 5% & nacl 0.45% inj TRUMENBA INJ 2 kcl 40 meq/l (0.3%) in 1 TWINRIX INJ 2 dextrose 5% & nacl 0.45% inj TYPHIM VI SOLN 2 kcl 40 meq/l (0.3%) in nacl 1 25mcg/0.5ml 0.9% inj VAQTA SUSP 25unit/0.5ml, 2 KCL/D5W/LACT INJ 3 50unit/ml 20MEQ/L VARIVAX INJ 1350pfu/0.5ml 2 KCL/D5W/NACL INJ 0.3/0.9% 3 YF-VAX INJ 2 KCL/D5W/NACL INJ 0.15/0.2 3 ZOSTAVAX SUSR 2 lactated ringer's solution 1 19400unt/0.65ml MAGNESIUM SULFATE 2 NUTRITIONAL/SUPPLEMENTS SOLN 2gm/50ml, 4gm/100ml, ELECTROLYTES/MINERALS, 4gm/50ml, 20gm/500ml, INJECTABLE 40gm/1000ml D5W/LYTES INJ #48 3 magnesium sulfate (generic of 1 D5W/NACL INJ 0.3% 2 MAGNESIUM SULFATE) D10W/NACL INJ 0.2% 2 SOLN 2gm/50ml, 4gm/100ml, dextrose 2.5% w/ sodium 1 4gm/50ml, 20gm/500ml, chloride 0.45% 40gm/1000ml dextrose 5% in lactated 1 magnesium sulfate SOLN 1 ringers 50% dextrose 5% w/ sodium 1 magnesium sulfate in 1 chloride 0.2% dextrose 5% iv soln 1 dextrose 5% w/ sodium 1 gm/100ml (generic of chloride 0.9% MAGNESIUM SULFATE IN dextrose 5% w/ sodium 1 D5W) chloride 0.45% MG SO4/D5W INJ 10MG/ML 2 dextrose 5% w/ sodium 1 NORMOSOL -M INJ /D5W 3 chloride 0.225% NORMOSOL -R INJ 3 dextrose 10% w/ sodium 1 PLASMA-LYTE INJ -148 3 chloride 0.45% PLASMA-LYTE INJ -A 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
68 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits potassium chloride SOLN 1 AMINOSYN-PF INJ 7% 3 B/D 2meq/ml CLINIMIX E INJ 2.75/D5W 3 B/D POTASSIUM CHLORIDE 3 CLINIMIX E INJ 4.25/D5W 3 B/D SOLN 10meq/100ml, CLINIMIX E INJ 4.25/D10 3 B/D 10meq/50ml, 20meq/100ml, CLINIMIX E INJ 5%/D15W 3 B/D 20meq/50ml, 40meq/100ml CLINIMIX E INJ 5%/D20W 3 B/D potassium chloride 20 meq/l 1 CLINIMIX INJ 4.25/D5W 3 B/D (0.15%) in dextrose 5% inj CLINIMIX INJ 4.25/D10 3 B/D sodium chloride SOLN .45%, 1 CLINIMIX INJ 5%/D15W 3 B/D .9%, 2.5meq/ml, 3%, 5% CLINIMIX INJ 5%/D20W 3 B/D TPN ELECTROL INJ 3 B/D clinisol sf 15% 1 B/D ELECTROLYTES/MINERALS/VITAMINS, CLINOLIPID EMU 20% 3 B/D ORAL dextrose SOLN 5%, 10% 1 K-TAB TBCR 8meq, 10meq, 3 dextrose SOLN 50%, 70% 1 B/D 20meq FREAMINE HBC INJ 6.9% 3 B/D klor-con PACK 20meq 1 FREAMINE III INJ 10% 3 B/D klor-con 8 TBCR 8meq 1 hepatamine 1 B/D klor-con 10 TBCR 10meq 1 INTRALIPID EMUL 3 B/D klor-con m10 TBCR 10meq 1 20gm/100ml, 30gm/100ml klor-con m15 TBCR 15meq 1 NEPHRAMINE INJ 5.4% 3 B/D klor-con m20 TBCR 20meq 1 NUTRILIPID EMUL 3 B/D klor-con sprinkle CPCR 1 20gm/100ml 8meq, 10meq plenamine 1 B/D M-NATAL PLUS TAB 2 PREMASOL SOL 10% 3 B/D ONE VITE TAB 1MG PLUS 2 PROCALAMINE INJ 3% 3 B/D PNV FOLIC AC TAB + IRON 2 PROSOL INJ 20% 3 B/D SMOFLIPID EMU 3 B/D potassium chloride CPCR 1 TRAVASOL INJ 10% 3 B/D 8meq, 10meq; PACK 20meq; SOLN 10%, 20%; TBCR TROPHAMINE INJ 10% 3 B/D 8meq, 10meq OPHTHALMIC potassium chloride (generic of 1 ANTI-INFECTIVE/ANTI-INFLAMMATORY K-TAB) TBCR 20meq bacitracin-polymyxin-neomyci 1 potassium chloride 1 n-hc ophth oint 1% microencapsulated crystals er BLEPHAMIDE OIN S.O.P. 3 TBCR 10meq, 20meq BLEPHAMIDE SUS OP 3 PRENATAL TAB 27-1MG 2 MAXITROL OIN 0.1% OP 3 PRENATAL TAB PLUS 2 MAXITROL SUS 0.1% OP 3 PRENATAL VIT TAB LOW 2 neomycin-polymyxin-dexamet 1 IRON hasone ophth oint 0.1% sodium fluoride chew; tab; 1.1 1 (generic of MAXITROL) (0.5 f) mg/ml soln neomycin-polymyxin-dexamet 1 TRICARE TAB PRENATAL 2 hasone ophth susp 0.1% IV NUTRITION (generic of MAXITROL) AMINOSYN II INJ 10% 3 B/D neomycin-polymyxin-hc ophth 1 AMINOSYN II INJ 15% 3 B/D susp PRED-G S.O.P OIN OP 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
69 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits PRED-G SUS OP 3 neomycin-polymy-gramicid op 1 sulfacetamide 1 sol sodium-prednisolone ophth 1.75-10000-0.025mg-unt-mg/ soln 10-0.23(0.25)% ml TOBRADEX OIN 0.3-0.1% 2 OCUFLOX SOLN .3% 3 TOBRADEX ST SUS 0.3-0.05 2 ofloxacin (ophth) (generic of 1 TOBRADEX SUS 0.3-0.1% 3 OCUFLOX) SOLN .3% tobramycin-dexamethasone 1 polymyxin b-trimethoprim 1 ophth susp 0.3-0.1% (generic ophth soln 10000 unit/ml-0.1% of TOBRADEX) (generic of POLYTRIM) ZYLET SUS 0.5-0.3% 2 POLYTRIM SOL OP 3 ANTI-INFECTIVES sulfacetamide sodium (ophth) 1 OINT 10% AZASITE SOLN 1% 3 sulfacetamide sodium (ophth) 1 bacitracin (ophthalmic) OINT 1 (generic of BLEPH-10) 500unit/gm SOLN 10% bacitracin-polymyxin b ophth 1 tobramycin (ophth) (generic of 1 oint TOBREX) SOLN .3% BESIVANCE SUSP .6% 2 TOBREX OINT .3%; SOLN 3 BLEPH-10 SOLN 10% 3 .3% CILOXAN OINT .3% 2 trifluridine SOLN 1% 1 CILOXAN SOLN .3% 3 VIGAMOX SOLN .5% 3 ciprofloxacin hcl (ophth) 1 ZIRGAN GEL .15% 3 (generic of CILOXAN) SOLN ZYMAXID SOLN .5% 3 .3% ANTI-INFLAMMATORIES erythromycin (ophth) OINT 1 ACULAR SOLN .5% 3 5mg/gm gatifloxacin (ophth) (generic of 1 ACULAR LS SOLN .4% 3 ZYMAXID) SOLN .5% ALREX SUSP .2% 2 gentak OINT .3% 1 bromfenac sodium (ophth) 1 gentamicin sulfate (ophth) 1 SOLN .09% SOLN .3% BROMSITE SOLN .075% 3 levofloxacin (ophth) SOLN 1 dexamethasone sodium 1 .5% phosphate (ophth) SOLN MOXEZA SOLN .5% 3 .1% moxifloxacin hcl (ophth) 1 diclofenac sodium (ophth) 1 (generic of MOXEZA) SOLN SOLN .1% .5% DUREZOL EMUL .05% 2 moxifloxacin hcl (ophth) 1 FLAREX SUSP .1% 3 (generic of VIGAMOX) fluorometholone (ophth) 1 SOLN .5% SUSP .1% NATACYN SUSP 5% 3 flurbiprofen sodium SOLN 1 neomycin-bacitrac zn-polymyx 1 .03% 5(3.5)mg-400unt-10000unt op FML OINT .1% 3 oin FML FORTE SUSP .25% 3 ILEVRO SUSP .3% 2
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
70 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits INVELTYS SUSP 1% 3 brimonidine tartrate SOLN 1 ketorolac tromethamine 1 .2% (ophth) (generic of ACULAR brimonidine tartrate (generic 1 LS) SOLN .4% of ALPHAGAN P) SOLN ketorolac tromethamine 1 .15% (ophth) (generic of ACULAR) carteolol hcl (ophth) SOLN 1 SOLN .5% 1% LOTEMAX GEL .5%; SUSP 3 COMBIGAN SOL 0.2/0.5% 2 .5% COSOPT PF SOL 2%-0.5% 3 LOTEMAX OINT .5% 2 COSOPT SOL 22.3-6.8 3 LOTEMAX SM GEL .38% 3 dorzolamide hcl (generic of 1 loteprednol etabonate 1 TRUSOPT) SOLN 2% (generic of LOTEMAX) dorzolamide hcl-timolol 1 SUSP .5% maleate ophth sol 22.3-6.8 MAXIDEX SUSP .1% 3 mg/ml pf (generic of COSOPT NEVANAC SUSP .1% 3 PF) PRED MILD SUSP .12% 3 dorzolamide hcl-timolol 1 prednisolone acetate (ophth) 1 maleate ophth soln 22.3-6.8 (generic of PRED FORTE) mg/ml (generic of COSOPT) SUSP 1% ISOPTO CARPINE SOLN 3 PREDNISOLONE SODIUM 2 1%, 2%, 4% PHOSP SOLN 1% ISTALOL SOLN .5% 3 PROLENSA SOLN .07% 2 latanoprost (generic of 1 ANTIALLERGICS XALATAN) SOLN .005% levobunolol hcl SOLN .5% 1 azelastine hcl (ophth) SOLN 1 .05% LUMIGAN SOLN .01% 2 BEPREVE SOLN 1.5% 2 PHOSPHOLINE IODIDE 3 cromolyn sodium (ophth) 1 SOLR .125% SOLN 4% pilocarpine hcl (generic of 1 epinastine hcl (ophth) SOLN 1 ISOPTO CARPINE) SOLN .05% 1%, 2%, 4% LASTACAFT SOLN .25% 3 RHOPRESSA SOLN .02% 2 olopatadine hcl SOLN .1%, 1 SIMBRINZA SUS 1-0.2% 2 .2% timolol maleate (ophth) 1 PAZEO SOLN .7% 2 (generic of TIMOPTIC-XE) SOLG .25%, .5% ZERVIATE SOLN .24% 3 timolol maleate (ophth) 1 ANTIGLAUCOMA (generic of TIMOPTIC) ALPHAGAN P SOLN .1% 2 SOLN .25%, .5% ALPHAGAN P SOLN .15% 3 timolol maleate (ophth) 1 AZOPT SUSP 1% 2 once-daily (generic of betaxolol hcl (ophth) SOLN 1 ISTALOL) SOLN .5% .5% TIMOPTIC SOLN .25%, .5% 3 BETIMOL SOLN .25%, .5% 3 TIMOPTIC OCUDOSE 3 BETOPTIC-S SUSP .25% 2 SOLN .25%, .5%
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
71 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits TIMOPTIC-XE SOLG .25%, 3 DYMISTA SPR 137-50 3 .5% SEMPREX-D CAP 8-60MG 3 TRAVATAN Z SOLN .004% 3 ANTIHISTAMINES travoprost (generic of 1 azelastine hcl SOLN .1%, 1 TRAVATAN Z) SOLN .004% .15% TRUSOPT SOLN 2% 3 cetirizine hcl SOLN 1mg/ml 1 VYZULTA SOLN .024% 3 CLARINEX TABS 5mg 3 XALATAN SOLN .005% 3 cyproheptadine hcl SYRP 2 MISCELLANEOUS 2mg/5ml; TABS 4mg ATROPINE SULFATE SOLN 2 desloratadine (generic of 1 1% CLARINEX) TABS 5mg BEOVU SOLN 6mg/0.05ml 3 NDS NM LA desloratadine TBDP 2.5mg, 1 CYSTARAN SOLN .44% 3 NDS NM LA 5mg EYLEA SOLN 2mg/0.05ml; 3 NDS NM LA diphenhydramine hcl SOLN 1 SOSY 2mg/0.05ml 50mg/ml LACRISERT INST 5mg 3 hydroxyzine hcl SOLN 3 LUCENTIS SOLN 3 NDS NM LA 25mg/ml, 50mg/ml .3mg/0.05ml, .5mg/0.05ml; hydroxyzine hcl SYRP 2 SOSY .3mg/0.05ml 10mg/5ml proparacaine hcl (generic of 1 hydroxyzine hcl TABS 10mg, 1 ALCAINE) SOLN .5% 25mg, 50mg XIIDRA SOLN 5% 2 hydroxyzine pamoate (generic 1 RESPIRATORY of VISTARIL) CAPS 25mg, ANTICHOLINERGIC/BETA AGONIST 50mg COMBINATIONS hydroxyzine pamoate CAPS 1 100mg ANORO ELLIPT AER 62.5-25 2 levocetirizine dihydrochloride 1 BEVESPI AER 9-4.8MCG 2 SOLN 2.5mg/5ml; TABS 5mg COMBIVENT AER 20-100 3 olopatadine hcl (nasal) 1 ipratropium-albuterol nebu 1 B/D (generic of PATANASE) soln 0.5-2.5(3) mg/3ml SOLN .6% TRELEGY AER ELLIPTA 2 PATANASE SOLN .6% 3 ANTICHOLINERGICS QUZYTTIR SOLN 10mg/ml 3 ATROVENT HFA AERS 3 VISTARIL CAPS 25mg, 3 17mcg/act 50mg INCRUSE ELLIPTA AEPB 2 BETA AGONISTS 62.5mcg/inh albuterol sulfate AERS 1 ipratropium bromide SOLN 1 B/D 108mcg/act .02% (generic of Ventolin HFA) ipratropium bromide (nasal) 1 albuterol sulfate (generic of 1 SOLN .03%, .06% PROAIR HFA) AERS ANTIHISTAMINE COMBINATIONS 108mcg/act azelastine hcl-fluticasone prop 1 (generic of Proair HFA) nasal spray 137-50 mcg/act albuterol sulfate NEBU 1 B/D (generic of DYMISTA) .083%, .63mg/3ml, CLARINEX-D TAB 2.5-120 3 1.25mg/3ml, 2.5mg/0.5ml
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
72 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits albuterol sulfate SYRP 1 ARALAST NP SOLR 500mg, 3 NDS NM LA 2mg/5ml; TABS 2mg, 4mg; 1000mg TB12 4mg, 8mg cromolyn sodium NEBU 1 B/D BROVANA NEBU 3 NDS B/D 20mg/2ml 15mcg/2ml DALIRESP TABS 250mcg, 3 levalbuterol hcl (generic of 1 B/D 500mcg XOPENEX CONCENTRATE) ELIXOPHYLLIN ELIX 3 NEBU 1.25mg/0.5ml 80mg/15ml levalbuterol hcl (generic of 1 B/D epinephrine (anaphylaxis) 1 XOPENEX) NEBU (generic of EPIPEN 2-PAK) .31mg/3ml, .63mg/3ml, SOAJ .3mg/0.3ml 1.25mg/3ml (generic of EpiPen) levalbuterol tartrate AERO 1 epinephrine (anaphylaxis) 1 45mcg/act (generic of EPIPEN-JR PERFOROMIST NEBU 3 NDS B/D 2-PAK) SOAJ .15mg/0.3ml 20mcg/2ml (generic of EpiPen) SEREVENT DISKUS AEPB 2 epinephrine (anaphylaxis) 1 50mcg/dose SOAJ .15mg/0.15ml, STRIVERDI RESPIMAT 3 .3mg/0.3ml AERS 2.5mcg/act (generic of Adrenaclick) terbutaline sulfate SOLN 3 NDS EPIPEN 2-PAK SOAJ 3 1mg/ml .3mg/0.3ml terbutaline sulfate TABS 1 EPIPEN-JR 2-PAK SOAJ 3 2.5mg, 5mg .15mg/0.3ml VENTOLIN HFA AERS 2 ESBRIET CAPS 267mg; 3 NDS NM 108mcg/act TABS 267mg, 801mg XOPENEX NEBU 3 B/D FASENRA SOSY 30mg/ml 3 NDS NM LA .31mg/3ml, .63mg/3ml, FASENRA PEN SOAJ 3 NDS NM LA 1.25mg/3ml 30mg/ml XOPENEX CONCENTRATE 3 B/D GLASSIA SOLN 3 NDS NM LA NEBU 1.25mg/0.5ml 1000mg/50ml XOPENEX HFA AERO 3 KALYDECO PACK 25mg, 3 NDS NM 45mcg/act 50mg, 75mg; TABS 150mg LEUKOTRIENE MODULATORS OFEV CAPS 100mg, 150mg 3 NDS NM ACCOLATE TABS 10mg, 3 ORKAMBI GRA 100-125 3 NDS NM 20mg ORKAMBI GRA 150-188 3 NDS NM montelukast sodium (generic 1 ORKAMBI TAB 100-125 3 NDS NM of SINGULAIR) CHEW 4mg, ORKAMBI TAB 200-125 3 NDS NM 5mg; PACK 4mg; TABS 10mg PROLASTIN-C SOLN 3 NDS NM LA SINGULAIR CHEW 4mg, 3 1000mg/20ml; SOLR 1000mg 5mg; PACK 4mg; TABS 10mg PULMOZYME SOLN 1mg/ml 3 NDS B/D NM zafirlukast (generic of 1 SYMDEKO TAB 50-75MG 3 NDS NM LA ACCOLATE) TABS 10mg, SYMDEKO TAB 100-150 3 NDS NM LA 20mg SYMJEPI SOSY 3 MISCELLANEOUS .15mg/0.3ml, .3mg/0.3ml acetylcysteine SOLN 10%, 1 B/D THEO-24 CP24 100mg, 3 20% 200mg, 300mg, 400mg
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
73 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits theophylline SOLN 1 ADVAIR DISKU AER 250/50 2 80mg/15ml; TB12 300mg, ADVAIR DISKU AER 500/50 2 450mg; TB24 400mg, 600mg ADVAIR HFA AER 45/21 2 TRIKAFTA TAB 3 NDS NM LA ADVAIR HFA AER 115/21 2 XOLAIR SOLR 150mg; 3 NDS NM LA ADVAIR HFA AER 230/21 2 SOSY 75mg/0.5ml, 150mg/ml ZEMAIRA SOLR 1000mg 3 NDS NM LA BREO ELLIPTA INH 100-25 2 NASAL STEROIDS BREO ELLIPTA INH 200-25 2 BECONASE AQ SUSP 3 SYMBICORT AER 80-4.5 2 42mcg/spray SYMBICORT AER 160-4.5 2 flunisolide (nasal) SOLN 1 TOPICAL .025% DERMATOLOGY, ACNE fluticasone propionate (nasal) 1 ABSORICA CAPS 10mg, 3 NDS SUSP 50mcg/act 20mg, 25mg, 30mg, 35mg, mometasone furoate (nasal) 1 40mg (generic of NASONEX) ABSORICA LD CAPS 8mg, 3 NDS SUSP 50mcg/act 16mg, 24mg, 32mg NASONEX SUSP 50mcg/act 3 ACANYA GEL 1.2-2.5% 3 OMNARIS SUSP 50mcg/act 3 ACZONE GEL 5%, 7.5% 3 QNASL AERS 80mcg/act 3 adapalene (generic of 1 QNASL CHILDRENS AERS 3 DIFFERIN) CREA .1%; GEL 40mcg/act .3% XHANCE EXHU 93mcg/act 3 adapalene GEL .1% 1 ZETONNA AERS 37mcg/act 3 ADAPALENE SOLN .1% 3 STEROID INHALANTS adapalene-benzoyl peroxide 1 ARNUITY ELLIPTA AEPB 2 gel 0.1-2.5% (generic of 50mcg/act, 100mcg/act, EPIDUO) 200mcg/act AKLIEF CREA .005% 3 budesonide (inhalation) 1 B/D ALTRENO LOTN .05% 3 (generic of PULMICORT) amnesteem CAPS 10mg, 1 SUSP .25mg/2ml, .5mg/2ml, 20mg, 40mg 1mg/2ml AMZEEQ FOAM 4% 3 FLOVENT DISKUS AEPB 2 ARAZLO LOTN .045% 3 50mcg/blist, 100mcg/blist, ATRALIN GEL .05% 3 250mcg/blist avita (generic of RETIN-A) 1 FLOVENT HFA AERO 2 CREA .025% 44mcg/act, 110mcg/act, avita GEL .025% 1 220mcg/act PULMICORT SUSP 3 B/D AZELEX CREA 20% 3 .25mg/2ml, .5mg/2ml, BENZACLIN GEL 1-5%PUMP 3 1mg/2ml BENZAMYCIN GEL 5-3% 3 PULMICORT FLEXHALER 3 benzoyl 1 AEPB 90mcg/act, 180mcg/act peroxide-erythromycin gel STEROID/BETA-AGONIST 5-3% (generic of COMBINATIONS BENZAMYCIN) ADVAIR DISKU AER 100/50 2
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
74 2021 631 3T Copper BvD Plus eff 01/01/2021
Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits claravis CAPS 10mg, 20mg, 1 isotretinoin CAPS 10mg, 1 30mg, 40mg 20mg, 30mg, 40mg CLEOCIN-T GEL 1% 3 NDS KLARON LOTN 10% 3 CLEOCIN-T LOTN 1% 3 myorisan CAPS 10mg, 1 clindacin-p SWAB 1% 1 20mg, 30mg, 40mg CLINDAGEL GEL 1% 3 NDS neuac gel 1.2-5% 1 clindamycin phosph-benzoyl 1 ONEXTON GEL 1.2-3.75 3 peroxide (refrig) gel 1.2 RETIN-A CREA .025%, 3 (1)-5% .05%, .1%; GEL .01%, .025% clindamycin phosphate 1 RETIN-A MICRO GEL .04%, 3 NDS (topical) (generic of .06%, .1% EVOCLIN) FOAM 1% RETIN-A MICRO PUMP 3 NDS clindamycin phosphate 1 GEL .08% (topical) (generic of sulfacetamide sodium (acne) 1 CLEOCIN-T) GEL 1%; (generic of KLARON) LOTN LOTN 1% 10% clindamycin phosphate 1 tretinoin (generic of RETIN-A) 1 (topical) SOLN 1%; SWAB CREA .025%, .05%, .1%; 1% GEL .01%, .025% clindamycin 1 tretinoin (generic of ATRALIN) 1 phosphate-benzoyl peroxide GEL .05% gel 1-5% (generic of tretinoin microsphere (generic 1 BENZACLIN) of RETIN-A MICRO) GEL clindamycin 1 .04%, .1% phosphate-benzoyl peroxide VELTIN GEL 3 gel 1.2-2.5% (generic of zenatane CAPS 10mg, 1 ACANYA) 20mg, 30mg, 40mg clindamycin 1 ZIANA GEL 3 phosphate-tretinoin gel 1.2-0.025% (generic of DERMATOLOGY, ANTIBIOTICS ZIANA) ALTABAX OINT 1% 3 dapsone (topical) (generic of 1 CENTANY OINT 2% 3 ACZONE) GEL 5%, 7.5% CORTISPORIN CRE 0.5% 3 DIFFERIN CREA .1%; GEL 3 CORTISPORIN OIN 1% 3 .3%; LOTN .1% gentamicin sulfate (topical) 1 EPIDUO FORTE GEL 3 CREA .1%; OINT .1% 0.3-2.5% mafenide acetate (generic of 1 EPIDUO GEL 0.1-2.5% 3 SULFAMYLON) PACK 5% ery PADS 2% 1 mupirocin OINT 2% 1 ERYGEL GEL 2% 3 SILVADENE CREA 1% 3 erythromycin (acne aid) 1 silver sulfadiazine (generic of 1 (generic of ERYGEL) GEL SILVADENE) CREA 1% 2% ssd (generic of SILVADENE) 1 erythromycin (acne aid) 1 CREA 1% SOLN 2% SULFAMYLON CREA 3 EVOCLIN FOAM 1% 3 85mg/gm SULFAMYLON PACK 5% 3 NDS
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
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Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits XEPI CREA 1% 3 acitretin CAPS 17.5mg 1 DERMATOLOGY, ANTIFUNGALS calcipotriene OINT .005%; 1 PA ciclopirox olamine (generic of 1 SOLN .005% LOPROX) CREA .77%; calcitrene OINT .005% 1 PA SUSP .77% methoxsalen rapid (generic of 3 NDS clotrimazole (topical) CREA 1 OXSORALEN ULTRA) 1%; SOLN 1% CAPS 10mg clotrimazole w/ 1 OXSORALEN ULTRA CAPS 3 NDS betamethasone cream 10mg 1-0.05% SORIATANE CAPS 10mg, 3 NDS clotrimazole w/ 1 25mg betamethasone lotion SORILUX FOAM .005% 3 NDS PA 1-0.05% tazarotene (generic of 1 econazole nitrate CREA 1% 1 TAZORAC) CREA .1% ERTACZO CREA 2% 3 NDS TAZORAC CREA .05%, 3 JUBLIA SOLN 10% 3 NDS .1%; GEL .05%, .1% ketoconazole (topical) CREA 1 DERMATOLOGY, ANTISEBORRHEICS 2% ketoconazole (topical) SHAM 1 LOPROX CREA .77%; 3 2% SUSP .77% selenium sulfide LOTN 2.5% 1 luliconazole CREA 1% 1 DERMATOLOGY, CORTICOSTEROIDS LUZU CREA 1% 3 ala-cort CREA 1%, 2.5% 1 MENTAX CREA 1% 3 alclometasone dipropionate 1 miconazole-zinc oxide-white 1 CREA .05%; OINT .05% petrolatum oint amcinonide CREA .1%; 1 0.25-15-81.35% LOTN .1% naftifine hcl CREA 1% 1 AMCINONIDE OINT .1% 3 naftifine hcl (generic of 1 APEXICON E CREA .05% 3 NDS NAFTIN) CREA 2%; GEL beser (generic of CUTIVATE) 1 1% LOTN .05% NAFTIN CREA 2%; GEL 3 betamethasone dipropionate 1 1%, 2% (topical) CREA .05%; LOTN nyamyc POWD 1 .05%; OINT .05% 100000unit/gm betamethasone dipropionate 1 nystatin (topical) CREA 1 augmented (generic of 100000unit/gm; OINT DIPROLENE AF) CREA 100000unit/gm; POWD .05% 100000unit/gm betamethasone dipropionate 1 nystop POWD 1 augmented GEL .05%; 100000unit/gm LOTN .05% OXISTAT LOTN 1% 3 PA betamethasone dipropionate 1 VUSION OIN 3 augmented (generic of DERMATOLOGY, ANTIPSORIATICS DIPROLENE) OINT .05% acitretin (generic of 1 betamethasone valerate 1 SORIATANE) CAPS 10mg, CREA .1%; LOTN .1%; OINT 25mg .1%
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
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Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits betamethasone valerate 1 desonide LOTN .05%; OINT 1 (generic of LUXIQ) FOAM .05% .12% DESOWEN CREA .05% 3 BRYHALI LOTN .01% 3 desoximetasone (generic of 1 calcipotriene-betamethasone 1 PA TOPICORT) LIQD .25% dipropionate oint DIPROLENE OINT .05% 3 0.005-0.064% (generic of DIPROLENE AF CREA 3 TACLONEX) .05% calcipotriene-betamethasone 3 NDS PA DUOBRII LOT 3 NDS dipropionate susp ENSTILAR AER 3 PA 0.005-0.064% (generic of fluocinolone acetonide 1 TACLONEX) CREA .01% CAPEX SHAM .01% 3 fluocinolone acetonide 1 clobetasol propionate (generic 1 (generic of SYNALAR) of TEMOVATE) CREA .05%; CREA .025%; OINT .025%; OINT .05% SOLN .01% clobetasol propionate (generic 1 fluocinolone acetonide 1 of OLUX) FOAM .05% (generic of clobetasol propionate GEL 1 DERMA-SMOOTHE/FS .05%; SOLN .05% BODY) OIL .01% clobetasol propionate (generic 1 fluocinolone acetonide 1 of CLOBEX) LIQD .05%; (generic of LOTN .05%; SHAM .05% DERMA-SMOOTHE/FS clobetasol propionate e 1 SCALP) OIL .01% CREA .05% fluocinonide CREA .05%; 1 clobetasol propionate 1 GEL .05%; OINT .05%; SOLN emulsion (generic of OLUX-E) .05% FOAM .05% fluocinonide emulsified base 1 CLOBEX LIQD .05%; LOTN 3 CREA .05% .05% fluticasone propionate CREA 1 CLOBEX SHAM .05% 3 NDS .05%; OINT .005% clocortolone pivalate (generic 1 fluticasone propionate 1 of CLODERM) CREA .1% (generic of CUTIVATE) clodan (generic of CLOBEX) 1 LOTN .05% SHAM .05% halcinonide (generic of 3 NDS CLODERM CREA .1% 3 HALOG) CREA .1% CUTIVATE LOTN .05% 3 NDS halobetasol propionate 1 DERMA-SMOOTHE/FS 3 CREA .05%; OINT .05% BODY OIL .01% HALOBETASOL 3 NDS DERMA-SMOOTHE/FS 3 PROPIONATE FOAM .05% SCALP OIL .01% HALOG CREA .1%; OINT 3 NDS DESONATE GEL .05% 3 .1% desonide (generic of 1 hydrocortisone (topical) 1 DESOWEN) CREA .05% CREA 1%, 2.5%; LOTN 2.5%; desonide (generic of 1 OINT 1%, 2.5% DESONATE) GEL .05% hydrocortisone butyrate 1 SOLN .1%
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
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Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits IMPOYZ CREA .025% 3 acyclovir topical (generic of 3 NDS KENALOG AERS 3 ZOVIRAX) CREA 5% .147mg/gm acyclovir topical (generic of 1 LEXETTE FOAM .05% 3 NDS ZOVIRAX) OINT 5% mometasone furoate CREA 1 ALDARA CREA 5% 3 .1%; OINT .1%; SOLN .1% ANUSOL-HC CREA 2.5% 3 OLUX FOAM .05% 3 NDS azelaic acid (generic of 1 OLUX-E FOAM .05% 3 NDS FINACEA) GEL 15% PANDEL CREA .1% 3 NDS CONDYLOX GEL .5% 3 prednicarbate CREA .1%; 1 CORTIFOAM FOAM 10% 3 OINT .1% DENAVIR CREA 1% 3 NDS SERNIVO EMUL .05% 3 NDS diclofenac sodium (actinic 1 PA SYNALAR CREA .025%; 3 keratoses) GEL 3% OINT .025%; SOLN .01% diclofenac sodium (topical) 1 TACLONEX OIN 3 NDS PA (generic of VOLTAREN) TACLONEX SUS 3 NDS PA GEL 1% TEMOVATE CREA .05%; 3 diclofenac sodium (topical) 1 PA OINT .05% SOLN 1.5% TOPICORT LIQD .25% 3 doxycycline (rosacea) CPDR 1 tovet (generic of OLUX-E) 1 40mg FOAM .05% EFUDEX CREA 5% 3 triamcinolone acetonide 1 ELIDEL CREA 1% 3 (topical) (generic of FINACEA FOAM 15%; GEL 3 KENALOG) AERS 15% .147mg/gm FLUOROPLEX CREA 1% 3 NDS triamcinolone acetonide 1 fluorouracil (topical) (generic 1 (topical) CREA .025%, .1%, of EFUDEX) CREA 5% .5%; LOTN .025%, .1%; OINT fluorouracil (topical) SOLN 1 .025%, .1%, .5% 2%, 5% triderm CREA .1% 1 imiquimod (generic of 1 TRIDESILON CREA .05% 3 ALDARA) CREA 5% ULTRAVATE LOTN .05% 3 NDS lactic acid (ammonium lactate) 1 VERDESO FOAM .05% 3 NDS CREA 12%; LOTN 12% DERMATOLOGY, LOCAL ANESTHETICS METROCREAM CREA .75% 3 glydo PRSY 2% 1 PA METROLOTION LOTN .75% 3 lidocaine OINT 5% 1 PA metronidazole (topical) 1 lidocaine (generic of 1 PA (generic of METROCREAM) LIDODERM) PTCH 5% CREA .75% lidocaine hcl GEL 2%; SOLN 1 PA metronidazole (topical) GEL 1 4% .75% lidocaine-prilocaine cream 1 PA metronidazole (topical) 1 2.5-2.5% (generic of METROLOTION) LIDODERM PTCH 5% 3 PA LOTN .75% ZTLIDO PTCH 1.8% 3 PA MIRVASO GEL .33% 3 DERMATOLOGY, MISCELLANEOUS SKIN NORITATE CREA 1% 3 NDS AND MUCOUS MEMBRANE ORACEA CPDR 40mg 3 NDS
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
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Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits PENNSAID SOLN 2% 3 NDS PA MOUTH/THROAT/DENTAL AGENTS PICATO GEL .015%, .05% 3 cevimeline hcl (generic of 1 pimecrolimus (generic of 1 EVOXAC) CAPS 30mg ELIDEL) CREA 1% chlorhexidine gluconate 1 podofilox SOLN .5% 1 (mouth-throat) (generic of procto-med hc (generic of 1 PERIDEX) SOLN .12% ANUSOL-HC) CREA 2.5% clotrimazole TROC 10mg 1 procto-pak (generic of 1 EVOXAC CAPS 30mg 3 PROCTOCORT) CREA 1% lidocaine hcl (mouth-throat) 1 proctosol hc (generic of 1 SOLN 2% ANUSOL-HC) CREA 2.5% nystatin (mouth-throat) 1 proctozone-hc (generic of 1 SUSP 100000unit/ml ANUSOL-HC) CREA 2.5% ORAVIG TABS 50mg 3 NDS PROTOPIC OINT .03%, .1% 3 paroex (generic of PERIDEX) 1 QBREXZA PADS 2.4% 3 SOLN .12% RECTIV OINT .4% 3 periogard (generic of 1 RHOFADE CREA 1% 3 PERIDEX) SOLN .12% pilocarpine hcl (oral) (generic 1 rosadan (generic of 1 of SALAGEN) TABS 5mg, METROCREAM) CREA 7.5mg .75% SALAGEN TABS 5mg, 3 tacrolimus (topical) (generic of 1 7.5mg PROTOPIC) OINT .03%, .1% triamcinolone acetonide 1 (mouth) PSTE .1% TARGRETIN GEL 1% 3 NDS NM VALCHLOR GEL .016% 3 NDS NM LA OTIC XERESE CRE 5-1% 3 NDS acetic acid (otic) SOLN 2% 1 ZOVIRAX CREA 5%; OINT 3 NDS CETRAXAL SOLN .2% 3 5% CIPRO HC SUS OTIC 3 DERMATOLOGY, SCABICIDES AND CIPRODEX SUS 0.3-0.1% 2 PEDICULIDES ciprofloxacin hcl (otic) SOLN 1 crotan LOTN 10% 1 .2% ELIMITE CREA 5% 3 ciprofloxacin-fluocinolone 1 malathion LOTN .5% 1 aceton (pf) otic soln 0.3-0.025% NATROBA SUSP .9% 3 CORTISPORIN SUS -TC 3 OVIDE LOTN .5% 3 OTIC permethrin (generic of 1 DERMOTIC OIL .01% 3 ELIMITE) CREA 5% flac (generic of DERMOTIC) 1 SKLICE LOTN .5% 3 OIL .01% DERMATOLOGY, WOUND CARE AGENTS fluocinolone acetonide (otic) 1 REGRANEX GEL .01% 3 NDS (generic of DERMOTIC) OIL SANTYL OINT 250unit/gm 3 .01% sodium chloride (gu irrigant) 1 hydrocortisone w/ acetic acid 1 SOLN .9% otic soln 1-2% water for irrigation, sterile 1 neomycin-polymyxin-hc otic 1 irrigation soln soln 1%
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
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Drug Name Drug Requirements/ Tier Limits neomycin-polymyxin-hc otic 1 susp 3.5 mg/ml-10000 unit/ml-1% ofloxacin (otic) SOLN .3% 1 OTOVEL DRO 3
PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
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Index A tab 300-30 mg ...... 3 tromethamine (ophth) .... 71 abacavir sulfate ...... 9 acetaminophen w/ codeine ACULAR LS ...... 70 abacavir sulfate-lamivudine tab 300-60 mg ...... 3 see ketorolac tab 600-300 mg ...... 10 acetaminophen-caffeine-dihy tromethamine (ophth) .... 71 abacavir drocodeine cap 320.5-30-16 acyclovir ...... 11 sulfate-lamivudine-zidovudin mg ...... 3 acyclovir sodium ...... 11 e tab 300-150-300 mg ...... 10 acetaminophen-caffeine-dihy acyclovir topical ...... 78 ABELCET...... 8 drocodeine tab 325-30-16 ACZONE ...... 74 ABILIFY...... 39 mg ...... 3 see dapsone (topical) .... 75 see aripiprazole ...... 39 acetazolamide ...... 28 ADACEL INJ ...... 67 ABILIFY MAINTENA ...... 39 acetic acid ...... 63 ADAKVEO ...... 64 ABILIFY MYCITE ...... 39 acetic acid (otic) ...... 79 adapalene ...... 74 abiraterone acetate ...... 16 acetylcysteine ...... 73 ADAPALENE ...... 74 ABRAXANE INJ 100MG ... 17 ACIPHEX ...... 62 adapalene-benzoyl peroxide ABSORICA ...... 74 see rabeprazole sodium 62 gel 0.1-2.5% ...... 74 ABSORICA LD ...... 74 acitretin ...... 76 ADCIRCA ...... 31 acamprosate calcium ...... 45 ACTHIB INJ ...... 67 see alyq ...... 31 ACANYA ACTIGALL ...... 61 see tadalafil (pulmonary see clindamycin see ursodiol ...... 62 hypertension) ...... 31 phosphate-benzoyl ACTIMMUNE ...... 66 ADDERALL peroxide gel 1.2-2.5% ... 75 ACTIQ ...... 3 see ACANYA GEL 1.2-2.5% .... 74 see fentanyl citrate ...... 3 amphetamine-dextroamph acarbose ...... 47 ACTIVELLA etamine tab 10 mg ...... 41 ACCOLATE ...... 73 see amabelz ...... 53 see see zafirlukast ...... 73 see estradiol & amphetamine-dextroamph ACCUPRIL ...... 21 norethindrone acetate tab etamine tab 12.5 mg ..... 41 see quinapril hcl ...... 21 1-0.5 mg ...... 54 see ACCURETIC see lopreeza ...... 54 amphetamine-dextroamph see see mimvey ...... 54 etamine tab 15 mg ...... 41 quinapril-hydrochlorothiazi ACTIVELLA TAB 1-0.5MG 53 see de tab 10-12.5 mg ...... 21 ACTONEL ...... 49 amphetamine-dextroamph see see risedronate sodium . 49 etamine tab 20 mg ...... 41 quinapril-hydrochlorothiazi ACTOPLUS MET see de tab 20-12.5 mg ...... 21 see pioglitazone amphetamine-dextroamph see hcl-metformin hcl tab etamine tab 30 mg ...... 41 quinapril-hydrochlorothiazi 15-500 mg ...... 48 see de tab 20-25 mg ...... 21 see pioglitazone amphetamine-dextroamph ACCURETIC TAB 10-12.5 20 hcl-metformin hcl tab etamine tab 5 mg ...... 41 ACCURETIC TAB 20-12.5 20 15-850 mg ...... 48 see ACCURETIC TAB 20-25MG ACTOPLUS MET TAB amphetamine-dextroamph ...... 20 15-500MG ...... 47 etamine tab 7.5 mg ...... 41 acebutolol hcl ...... 27 ACTOPLUS MET TAB ADDERALL TAB 10MG .... 41 acetaminophen w/ codeine 15-850MG ...... 47 ADDERALL TAB 12.5MG . 41 soln 120-12 mg/5ml ...... 3 ACTOS ...... 47 ADDERALL TAB 15MG .... 41 acetaminophen w/ codeine see pioglitazone hcl ...... 48 ADDERALL TAB 20MG .... 41 tab 300-15 mg ...... 3 ACULAR ...... 70 ADDERALL TAB 30MG .... 41 acetaminophen w/ codeine see ketorolac ADDERALL TAB 5MG ...... 40
81 2021 631 3T Copper BvD Plus eff 01/01/2021
ADDERALL TAB 7.5MG ... 40 ADVAIR HFA AER 45/21 .. 74 ALIQOPA ...... 17 ADDERALL XR ADZENYS ER ...... 41 aliskiren fumarate ...... 29 see ADZENYS XR-ODT ...... 41 allopurinol ...... 1 amphetamine-dextroamph AEMCOLO ...... 6 almotriptan malate ...... 43 etamine cap er 24hr 10 mg AFINITOR ...... 17 ALORA ...... 53 ...... 41 see everolimus ...... 18 alosetron hcl ...... 61 see AFINITOR DISPERZ...... 17 ALOXI ...... 59 amphetamine-dextroamph afirmelle ...... 50 see palonosetron hcl ..... 59 etamine cap er 24hr 15 mg AGGRENOX ALPHAGAN P ...... 71 ...... 41 see aspirin-dipyridamole see brimonidine tartrate 71 see cap er 12hr 25-200 mg .. 65 alprazolam ...... 31 amphetamine-dextroamph AGGRENOX CAP ALPRAZOLAM INTENSOL etamine cap er 24hr 20 mg 25-200MG ...... 65 ...... 31 ...... 41 AGRYLIN ...... 64 ALREX ...... 70 see see anagrelide hcl ...... 64 ALTABAX ...... 75 amphetamine-dextroamph AIMOVIG ...... 43 ALTACE ...... 21 etamine cap er 24hr 25 mg AKLIEF ...... 74 see ramipril ...... 22 ...... 41 AKYNZEO CAP 300-0.5 ... 59 altavera ...... 50 see AKYNZEO INJ 235-0.25 ... 59 ALTOPREV ...... 25 amphetamine-dextroamph AKYNZEO INJ ALTRENO ...... 74 etamine cap er 24hr 30 mg 235-0.25MG/20ML ...... 59 ALUNBRIG ...... 17 ...... 41 ala-cort ...... 76 ALUNBRIG PAK ...... 17 see albendazole ...... 6 alyacen 1/35 ...... 50 amphetamine-dextroamph ALBENZA alyacen 7/7/7 ...... 50 etamine cap er 24hr 5 mg see albendazole ...... 6 alyq ...... 31 ...... 41 albuterol sulfate ...... 72, 73 amabelz ...... 53 ADDERALL XR CAP 10MG ALCAINE amantadine hcl ...... 37 ...... 41 see proparacaine hcl ..... 72 AMARYL ...... 47 ADDERALL XR CAP 15MG alclometasone dipropionate see glimepiride ...... 47 ...... 41 ...... 76 AMBIEN ...... 42 ADDERALL XR CAP 20MG ALDACTAZIDE see zolpidem tartrate ..... 43 ...... 41 see spironolactone & AMBIEN CR ...... 42 ADDERALL XR CAP 25MG hydrochlorothiazide tab see zolpidem tartrate ..... 43 ...... 41 25-25 mg ...... 29 AMBISOME ...... 8 ADDERALL XR CAP 30MG ALDACTAZIDE TAB 25/25 ambrisentan ...... 31 ...... 41 ...... 28 amcinonide ...... 76 ADDERALL XR CAP 5MG 41 ALDACTAZIDE TAB 50/50 AMCINONIDE ...... 76 adefovir dipivoxil ...... 11 ...... 28 AMERGE ...... 43 ADEMPAS ...... 31 ALDACTONE ...... 22 see naratriptan hcl ...... 43 adriamycin...... 15 see spironolactone ...... 22 amethia ...... 50 ADVAIR DISKU AER 100/50 ALDARA ...... 78 amethyst ...... 50 ...... 74 see imiquimod ...... 78 amikacin sulfate ...... 6 ADVAIR DISKU AER 250/50 ALDURAZYME ...... 55 amiloride & ...... 74 ALECENSA ...... 17 hydrochlorothiazide tab 5-50 ADVAIR DISKU AER 500/50 alendronate sodium ...... 49 mg ...... 28 ...... 74 alfuzosin hcl ...... 62 amiloride hcl ...... 28 ADVAIR HFA AER 115/21 74 ALIMTA ...... 15 AMINOSYN II INJ 10% ..... 69 ADVAIR HFA AER 230/21 74 ALINIA ...... 6 AMINOSYN II INJ 15% ..... 69
82 2021 631 3T Copper BvD Plus eff 01/01/2021
AMINOSYN-PF INJ 7% .... 69 besylate-benazepril hcl cap amoxapine ...... 36 amiodarone hcl ...... 24 5-10 mg ...... 20 amoxicillin ...... 13 AMITIZA ...... 61 amlodipine amoxicillin & k clavulanate amitriptyline hcl ...... 36 besylate-benazepril hcl cap chew tab 200-28.5 mg ...... 13 amlodipine besylate ...... 27 5-20 mg ...... 20 amoxicillin & k clavulanate amlodipine amlodipine chew tab 400-57 mg ...... 13 besylate-atorvastatin calcium besylate-benazepril hcl cap amoxicillin & k clavulanate tab 10-10 mg ...... 29 5-40 mg ...... 20 for susp 200-28.5 mg/5ml . 13 amlodipine amlodipine amoxicillin & k clavulanate besylate-atorvastatin calcium besylate-olmesartan for susp 250-62.5 mg/5ml . 13 tab 10-20 mg ...... 29 medoxomil tab 10-20 mg .. 22 amoxicillin & k clavulanate amlodipine amlodipine for susp 400-57 mg/5ml .... 13 besylate-atorvastatin calcium besylate-olmesartan amoxicillin & k clavulanate tab 10-40 mg ...... 29 medoxomil tab 10-40 mg .. 22 for susp 600-42.9 mg/5ml . 13 amlodipine amlodipine amoxicillin & k clavulanate besylate-atorvastatin calcium besylate-olmesartan tab 250-125 mg ...... 13 tab 10-80 mg ...... 29 medoxomil tab 5-20 mg .... 22 amoxicillin & k clavulanate amlodipine amlodipine tab 500-125 mg ...... 13 besylate-atorvastatin calcium besylate-olmesartan amoxicillin & k clavulanate tab 2.5-10 mg ...... 29 medoxomil tab 5-40 mg .... 22 tab 875-125 mg ...... 13 amlodipine amlodipine amoxicillin & k clavulanate besylate-atorvastatin calcium besylate-valsartan tab tab er 12hr 1000-62.5 mg . 13 tab 2.5-20 mg ...... 29 10-160 mg ...... 22 amoxicillin cap-clarithro amlodipine amlodipine tab-lansopraz cap dr therapy besylate-atorvastatin calcium besylate-valsartan tab pack ...... 61 tab 2.5-40 mg ...... 29 10-320 mg ...... 22 amphetamine ...... 41 amlodipine amlodipine amphetamine-dextroamphet besylate-atorvastatin calcium besylate-valsartan tab 5-160 amine cap er 24hr 10 mg .. 41 tab 5-10 mg ...... 29 mg ...... 22 amphetamine-dextroamphet amlodipine amlodipine amine cap er 24hr 15 mg .. 41 besylate-atorvastatin calcium besylate-valsartan tab 5-320 amphetamine-dextroamphet tab 5-20 mg ...... 29 mg ...... 22 amine cap er 24hr 20 mg .. 41 amlodipine amlodipine-valsartan-hydroc amphetamine-dextroamphet besylate-atorvastatin calcium hlorothiazide tab amine cap er 24hr 25 mg .. 41 tab 5-40 mg ...... 29 10-160-12.5 mg ...... 22 amphetamine-dextroamphet amlodipine amlodipine-valsartan-hydroc amine cap er 24hr 30 mg .. 41 besylate-atorvastatin calcium hlorothiazide tab 10-160-25 amphetamine-dextroamphet tab 5-80 mg ...... 29 mg ...... 22 amine cap er 24hr 5 mg .... 41 amlodipine amlodipine-valsartan-hydroc amphetamine-dextroamphet besylate-benazepril hcl cap hlorothiazide tab 10-320-25 amine tab 10 mg ...... 41 10-20 mg ...... 20 mg ...... 22 amphetamine-dextroamphet amlodipine amlodipine-valsartan-hydroc amine tab 12.5 mg ...... 41 besylate-benazepril hcl cap hlorothiazide tab 5-160-12.5 amphetamine-dextroamphet 10-40 mg ...... 20 mg ...... 22 amine tab 15 mg ...... 41 amlodipine amlodipine-valsartan-hydroc amphetamine-dextroamphet besylate-benazepril hcl cap hlorothiazide tab 5-160-25 amine tab 20 mg ...... 41 2.5-10 mg ...... 20 mg ...... 22 amphetamine-dextroamphet amlodipine amnesteem ...... 74 amine tab 30 mg ...... 41
83 2021 631 3T Copper BvD Plus eff 01/01/2021 amphetamine-dextroamphet APRISO ...... 60 see candesartan cilexetil amine tab 5 mg ...... 41 see mesalamine ...... 60 ...... 24 amphetamine-dextroamphet APTENSIO XR ...... 41 ATACAND HCT amine tab 7.5 mg ...... 41 APTIOM ...... 32 see candesartan amphotericin b ...... 8 APTIVUS ...... 9 cilexetil-hydrochlorothiazid ampicillin ...... 13 ARALAST NP ...... 73 e tab 16-12.5 mg ...... 23 ampicillin & sulbactam aranelle ...... 50 see candesartan sodium for inj 1.5 (1-0.5) gm ARANESP ALBUMIN FREE cilexetil-hydrochlorothiazid ...... 13 ...... 64 e tab 32-12.5 mg ...... 23 ampicillin & sulbactam ARAVA ...... 66 see candesartan sodium for inj 3 (2-1) gm ... 13 see leflunomide ...... 66 cilexetil-hydrochlorothiazid ampicillin & sulbactam ARAZLO ...... 74 e tab 32-25 mg ...... 23 sodium for iv soln 15 (10-5) ARCALYST ...... 66 ATACAND HCT TAB gm ...... 13 ARICEPT ...... 35 16-12.5 ...... 22 ampicillin sodium ...... 13 see donepezil ATACAND HCT TAB AMPYRA ...... 44 hydrochloride ...... 35 32-12.5 ...... 22 see dalfampridine ...... 44 ARIKAYCE ...... 6 ATACAND HCT TAB AMZEEQ ...... 74 ARIMIDEX ...... 16 32-25MG ...... 22 ANADROL-50 ...... 46 see anastrozole ...... 16 atazanavir sulfate...... 9 ANAFRANIL ...... 36 aripiprazole ...... 39 ATELVIA ...... 49 see clomipramine hcl ..... 36 ARISTADA ...... 39 see risedronate sodium . 49 anagrelide hcl ...... 64 ARISTADA INITIO ...... 39 atenolol ...... 27 ANAPROX DS ARIXTRA ...... 63 atenolol & chlorthalidone tab see naproxen sodium ...... 1 see fondaparinux sodium 100-25 mg ...... 26 anastrozole ...... 16 ...... 64 atenolol & chlorthalidone tab ANCOBON ...... 8 armodafinil ...... 45 50-25 mg ...... 26 see flucytosine ...... 8 ARNUITY ELLIPTA ...... 74 ATGAM ...... 66 ANDRODERM ...... 46 AROMASIN ...... 16 ATIVAN ...... 31 ANDROGEL ...... 46 see exemestane ...... 16 see lorazepam...... 31 see testosterone ...... 47 ARTHROTEC 50 atomoxetine hcl...... 41 ANDROGEL PUMP ...... 46 see diclofenac w/ atorvastatin calcium ...... 25 see testosterone ...... 46 misoprostol tab delayed atovaquone ...... 6 ANNOVERA MIS ...... 50 release 50-0.2 mg ...... 1 atovaquone-proguanil hcl tab ANORO ELLIPT AER ARTHROTEC 50 TAB...... 1 250-100 mg ...... 9 62.5-25 ...... 72 ARTHROTEC 75 atovaquone-proguanil hcl tab ANTABUSE ...... 45 see diclofenac w/ 62.5-25 mg ...... 9 see disulfiram ...... 46 misoprostol tab delayed ATRALIN ...... 74 ANTARA ...... 25 release 75-0.2 mg ...... 1 see tretinoin ...... 75 ANUSOL-HC ...... 78 ARTHROTEC 75 TAB...... 1 ATRIPLA TAB ...... 10 see procto-med hc ...... 79 ARYMO ER ...... 1 atropine sulfate ...... 60 see proctosol hc ...... 79 ARZERRA ...... 17 ATROPINE SULFATE ...... 72 see proctozone-hc ...... 79 ASACOL HD ...... 60 ATROVENT HFA ...... 72 APEXICON E ...... 76 see mesalamine ...... 60 AUBAGIO ...... 44 APOKYN ...... 37 ashlyna ...... 50 aubra eq ...... 50 aprepitant ...... 59 aspirin-dipyridamole cap er AUGMENTIN aprepitant capsule therapy 12hr 25-200 mg ...... 65 see amoxicillin & k pack 80 & 125 mg ...... 59 ASTAGRAF XL ...... 66 clavulanate for susp apri ...... 50 ATACAND ...... 24 250-62.5 mg/5ml ...... 13
84 2021 631 3T Copper BvD Plus eff 01/01/2021
see amoxicillin & k prop nasal spray 137-50 BACTRIM TAB 400-80MG .. 6 clavulanate tab 500-125 mcg/act ...... 72 BALCOLTRA TAB 0.1-20 . 50 mg ...... 13 AZELEX ...... 74 balsalazide disodium ...... 60 AUGMENTIN SUS ES-600 AZILECT ...... 38 BALVERSA ...... 17 ...... 13 see rasagiline mesylate . 38 balziva ...... 50 AUGMENTIN TAB 500MG 13 azithromycin ...... 12 BANZEL ...... 32 aurovela 1/20 ...... 50 AZOPT ...... 71 BARACLUDE ...... 11 aurovela 24 fe ...... 50 AZOR see entecavir ...... 11 aurovela fe 1.5/30 ...... 50 see amlodipine BASAGLAR KWIKPEN ..... 48 aurovela fe 1/20 ...... 50 besylate-olmesartan BAVENCIO ...... 17 AURYXIA ...... 57 medoxomil tab 10-20 mg BAXDELA ...... 13 AUSTEDO ...... 43 ...... 22 BCG VACCINE INJ ...... 67 AVALIDE see amlodipine BD ALCOHOL SWABS ..... 48 see besylate-olmesartan BECONASE AQ...... 74 irbesartan-hydrochlorothia medoxomil tab 10-40 mg bekyree ...... 50 zide tab 150-12.5 mg ..... 23 ...... 22 BELBUCA ...... 2 see see amlodipine BELEODAQ ...... 17 irbesartan-hydrochlorothia besylate-olmesartan BELSOMRA ...... 42 zide tab 300-12.5 mg ..... 23 medoxomil tab 5-20 mg . 22 benazepril & AVALIDE TAB 150-12.5 .... 22 see amlodipine hydrochlorothiazide tab AVALIDE TAB 300-12.5 .... 22 besylate-olmesartan 10-12.5 mg ...... 20 AVAPRO ...... 24 medoxomil tab 5-40 mg . 22 benazepril & see irbesartan ...... 24 AZOR TAB 10-20MG ...... 22 hydrochlorothiazide tab AVASTIN...... 17 AZOR TAB 10-40MG ...... 22 20-12.5 mg ...... 20 AVEED ...... 46 AZOR TAB 5-20MG ...... 22 benazepril & aviane ...... 50 AZOR TAB 5-40MG ...... 22 hydrochlorothiazide tab avita ...... 74 aztreonam ...... 6 20-25 mg ...... 20 AVODART ...... 62 AZULFIDINE ...... 60 benazepril & see dutasteride ...... 62 see sulfasalazine ...... 60 hydrochlorothiazide tab AVONEX ...... 44 AZULFIDINE EN-TABS .... 60 5-6.25 mg ...... 20 AVONEX PEN ...... 44 see sulfasalazine ...... 60 benazepril hcl ...... 21 AVSOLA...... 65 azurette ...... 50 BENDEKA ...... 15 AVYCAZ INJ 2-0.5GM ...... 11 B BENICAR ...... 24 AYGESTIN ...... 58 bacitracin (ophthalmic) ...... 70 see olmesartan medoxomil see norethindrone acetate bacitracin-polymyxin b ophth ...... 24 ...... 58 oint ...... 70 BENICAR HCT ayuna ...... 50 bacitracin-polymyxin-neomyc see olmesartan AYVAKIT ...... 17 in-hc ophth oint 1% ...... 69 medoxomil-hydrochlorothi azacitidine ...... 15 baclofen ...... 45 azide tab 20-12.5 mg .... 23 AZACTAM ...... 6 BACTRIM see olmesartan see aztreonam ...... 6 see medoxomil-hydrochlorothi AZASAN...... 66 sulfamethoxazole-trimetho azide tab 40-12.5 mg .... 23 AZASITE ...... 70 prim tab 400-80 mg ...... 7 see olmesartan azathioprine ...... 66 BACTRIM DS medoxomil-hydrochlorothi azelaic acid ...... 78 see azide tab 40-25 mg ...... 23 azelastine hcl ...... 72 sulfamethoxazole-trimetho BENICAR HCT TAB 20-12.5 azelastine hcl (ophth) ...... 71 prim tab 800-160 mg ...... 7 ...... 23 azelastine hcl-fluticasone BACTRIM DS TAB 800-160 6 BENICAR HCT TAB 40-12.5
85 2021 631 3T Copper BvD Plus eff 01/01/2021
...... 23 BEYAZ BREO ELLIPTA INH 200-25 BENICAR HCT TAB see drospirenone-ethinyl ...... 74 40-25MG ...... 23 estrad-levomefolate tab briellyn ...... 50 BENLYSTA ...... 67 3-0.02-0.451 mg ...... 50 BRILINTA ...... 65 BENTYL ...... 60 BEYAZ TAB ...... 50 brimonidine tartrate ...... 71 see dicyclomine hcl ...... 60 BIAXIN XL BRISDELLE ...... 43 BENZACLIN see clarithromycin ...... 12 see paroxetine mesylate see clindamycin bicalutamide ...... 16 (vasomotor) ...... 44 phosphate-benzoyl BICILLIN C-R INJ 1200000 BRIVIACT ...... 32 peroxide gel 1-5% ...... 75 ...... 13 bromfenac sodium (ophth) 70 BENZACLIN GEL BICILLIN C-R INJ 900/300 13 bromocriptine mesylate ..... 38 1-5%PUMP ...... 74 BICILLIN L-A ...... 14 BROMSITE ...... 70 BENZAMYCIN BIDIL TAB ...... 29 BROVANA ...... 73 see benzoyl BIKTARVY TAB ...... 10 BRUKINSA ...... 18 peroxide-erythromycin gel BILTRICIDE ...... 6 BRYHALI ...... 77 5-3% ...... 74 see praziquantel ...... 7 budesonide ...... 60 BENZAMYCIN GEL 5-3% . 74 BINOSTO ...... 49 budesonide (inhalation) .... 74 benzoyl bisoprolol & bumetanide ...... 28, 29 peroxide-erythromycin gel hydrochlorothiazide tab BUMEX 5-3% ...... 74 10-6.25 mg ...... 26 see bumetanide...... 29 benztropine mesylate ...... 38 bisoprolol & BUNAVAIL MIS 2.1-0.3 .... 45 BEOVU ...... 72 hydrochlorothiazide tab BUNAVAIL MIS 4.2-0.7 .... 45 BEPREVE ...... 71 2.5-6.25 mg ...... 26 BUNAVAIL MIS 6.3-1MG .. 45 BERINERT ...... 64 bisoprolol & BUPHENYL ...... 55 beser ...... 76 hydrochlorothiazide tab see sodium phenylbutyrate BESIVANCE ...... 70 5-6.25 mg ...... 26 ...... 57 BESPONSA ...... 17 bisoprolol fumarate ...... 27 buprenorphine ...... 2 betamethasone dipropionate BIVIGAM ...... 66 buprenorphine hcl ...... 46 (topical) ...... 76 bleomycin sulfate ...... 15 buprenorphine hcl-naloxone betamethasone dipropionate BLEPH-10 ...... 70 hcl sl film 12-3 mg (base augmented ...... 76 see sulfacetamide sodium equiv) ...... 46 betamethasone valerate ..76, (ophth) ...... 70 buprenorphine hcl-naloxone 77 BLEPHAMIDE OIN S.O.P. 69 hcl sl film 2-0.5 mg (base BETAPACE BLEPHAMIDE SUS OP .... 69 equiv) ...... 46 see sorine ...... 25 blisovi 24 fe ...... 50 buprenorphine hcl-naloxone see sotalol hcl ...... 25 blisovi fe 1.5/30 ...... 50 hcl sl film 4-1 mg (base BETAPACE AF BONIVA ...... 49 equiv) ...... 46 see sotalol hcl (afib/afl) .. 25 see ibandronate sodium 49 buprenorphine hcl-naloxone BETASERON ...... 44 BONJESTA TAB 20-20MG hcl sl film 8-2 mg (base betaxolol hcl ...... 27 ...... 59 equiv) ...... 46 betaxolol hcl (ophth) ...... 71 BOOSTRIX INJ ...... 67 buprenorphine hcl-naloxone bethanechol chloride ...... 63 BORTEZOMIB ...... 17 hcl sl tab 2-0.5 mg (base BETHKIS...... 6 bosentan ...... 31 equiv) ...... 46 BETIMOL ...... 71 BOSULIF ...... 18 buprenorphine hcl-naloxone BETOPTIC-S ...... 71 BOTOX ...... 45 hcl sl tab 8-2 mg (base BEVESPI AER 9-4.8MCG . 72 BRAFTOVI ...... 18 equiv) ...... 46 bexarotene ...... 16 BREO ELLIPTA INH 100-25 bupropion hcl ...... 36 BEXSERO INJ ...... 67 ...... 74 bupropion hcl (smoking
86 2021 631 3T Copper BvD Plus eff 01/01/2021 deterrent) ...... 46 see ergotamine w/ caffeine 50-15 mg ...... 21 buspirone hcl ...... 31 tab 1-100 mg ...... 43 captopril & butorphanol tartrate ...... 3 CALAN SR ...... 27 hydrochlorothiazide tab BUTRANS ...... 2 see verapamil hcl ...... 28 50-25 mg ...... 21 see buprenorphine ...... 2 calcipotriene ...... 76 CARAFATE BYDUREON BCISE ...... 47 calcipotriene-betamethasone see sucralfate ...... 61 BYDUREON PEN ...... 47 dipropionate oint CARBAGLU ...... 56 BYETTA ...... 47 0.005-0.064% ...... 77 carbamazepine ...... 32 BYNFEZIA PEN ...... 55 calcipotriene-betamethasone CARBATROL ...... 32 BYSTOLIC ...... 27 dipropionate susp see carbamazepine ...... 32 C 0.005-0.064% ...... 77 carbidopa ...... 38 cabergoline ...... 56 calcitonin (salmon) ...... 49 carbidopa & levodopa orally CABLIVI ...... 64 calcitrene ...... 76 disintegrating tab 10-100 mg CABOMETYX ...... 18 calcitriol ...... 58 ...... 38 CADUET calcium acetate (phosphate carbidopa & levodopa orally see amlodipine binder) ...... 57 disintegrating tab 25-100 mg besylate-atorvastatin CALQUENCE ...... 18 ...... 38 calcium tab 10-10 mg .... 29 camila ...... 50 carbidopa & levodopa orally see amlodipine CAMPTOSAR disintegrating tab 25-250 mg besylate-atorvastatin see irinotecan hcl ...... 17 ...... 38 calcium tab 10-20 mg .... 29 camrese ...... 50 carbidopa & levodopa tab see amlodipine camrese lo ...... 50 10-100 mg ...... 38 besylate-atorvastatin CANASA ...... 60 carbidopa & levodopa tab calcium tab 10-40 mg .... 29 see mesalamine ...... 60 25-100 mg ...... 38 see amlodipine CANCIDAS ...... 8 carbidopa & levodopa tab besylate-atorvastatin see caspofungin acetate . 8 25-250 mg ...... 38 calcium tab 10-80 mg .... 29 candesartan cilexetil ...... 24 carbidopa & levodopa tab er see amlodipine candesartan 25-100 mg ...... 38 besylate-atorvastatin cilexetil-hydrochlorothiazide carbidopa & levodopa tab er calcium tab 5-10 mg ...... 29 tab 16-12.5 mg ...... 23 50-200 mg ...... 38 see amlodipine candesartan carbidopa-levodopa-entacap besylate-atorvastatin cilexetil-hydrochlorothiazide one tabs 12.5-50-200 mg .. 38 calcium tab 5-20 mg ...... 29 tab 32-12.5 mg ...... 23 carbidopa-levodopa-entacap see amlodipine candesartan one tabs 18.75-75-200 mg 38 besylate-atorvastatin cilexetil-hydrochlorothiazide carbidopa-levodopa-entacap calcium tab 5-40 mg ...... 29 tab 32-25 mg ...... 23 one tabs 25-100-200 mg ... 38 see amlodipine CAPEX ...... 77 carbidopa-levodopa-entacap besylate-atorvastatin CAPLYTA ...... 39 one tabs 31.25-125-200 mg calcium tab 5-80 mg ...... 29 CAPRELSA ...... 18 ...... 38 CADUET TAB 10-10MG ... 30 captopril ...... 21 carbidopa-levodopa-entacap CADUET TAB 10-20MG ... 30 captopril & one tabs 37.5-150-200 mg 38 CADUET TAB 10-40MG ... 30 hydrochlorothiazide tab carbidopa-levodopa-entacap CADUET TAB 10-80MG ... 30 25-15 mg ...... 20 one tabs 50-200-200 mg ... 38 CADUET TAB 5-10MG ..... 29 captopril & carboplatin ...... 15 CADUET TAB 5-20MG ..... 30 hydrochlorothiazide tab CARDIZEM ...... 27 CADUET TAB 5-40MG ..... 30 25-25 mg ...... 21 see diltiazem hcl ...... 28 CADUET TAB 5-80MG ..... 30 captopril & CARDIZEM CD ...... 27 CAFERGOT hydrochlorothiazide tab see cartia xt ...... 28
87 2021 631 3T Copper BvD Plus eff 01/01/2021
see diltiazem hcl coated cefotetan disodium ...... 12 GONADOTROPIN ...... 56 beads...... 28 CEFOXITIN INJ 1GM...... 12 ciclopirox olamine ...... 76 CARDIZEM LA ...... 27 CEFOXITIN INJ 2GM...... 12 cidofovir ...... 11 see diltiazem hcl coated cefoxitin sodium ...... 12 cilostazol ...... 65 beads...... 28 cefpodoxime proxetil ...... 12 CILOXAN ...... 70 see matzim la ...... 28 cefprozil ...... 12 see ciprofloxacin hcl CARDURA ...... 22 ceftazidime ...... 12 (ophth) ...... 70 see doxazosin mesylate 22 CEFTAZIDIME/ SOL D5W CIMDUO TAB 300-300 ..... 10 CARDURA XL ...... 62 1GM ...... 12 cimetidine ...... 60 carisoprodol ...... 45 CEFTAZIDIME/ SOL D5W cimetidine hcl ...... 60 CARNITOR ...... 56 2GM ...... 12 cinacalcet hcl ...... 56 see levocarnitine ceftriaxone sodium ...... 12 CINRYZE ...... 65 (metabolic modifiers) ..... 56 cefuroxime axetil ...... 12 CINVANTI ...... 59 CAROSPIR ...... 22 cefuroxime sodium ...... 12 CIPRO ...... 13 carteolol hcl (ophth) ...... 71 CELEBREX ...... 1 see ciprofloxacin hcl ...... 13 cartia xt ...... 28 see celecoxib ...... 1 CIPRO HC SUS OTIC ...... 79 carvedilol ...... 27 celecoxib ...... 1 CIPRODEX SUS 0.3-0.1% 79 carvedilol phosphate ...... 27 CELEXA ...... 36 ciprofloxacin 200 mg/100ml CASODEX ...... 16 see citalopram in d5w ...... 13 see bicalutamide ...... 16 hydrobromide ...... 36 ciprofloxacin 400 mg/200ml caspofungin acetate ...... 8 CELLCEPT ...... 67 in d5w ...... 13 CASPOFUNGIN ACETATE 8 see mycophenolate mofetil ciprofloxacin hcl ...... 13 CATAPRES ...... 30 ...... 67 ciprofloxacin hcl (ophth) .... 70 see clonidine hcl ...... 30 CELONTIN ...... 32 ciprofloxacin hcl (otic) ...... 79 CATAPRES-TTS-1 ...... 30 CENTANY ...... 75 ciprofloxacin-fluocinolone see clonidine ...... 30 cephalexin ...... 12 aceton (pf) otic soln CATAPRES-TTS-2 ...... 30 CERDELGA ...... 56 0.3-0.025% ...... 79 see clonidine ...... 30 CEREZYME ...... 56 cisplatin ...... 15 CATAPRES-TTS-3 ...... 30 cetirizine hcl ...... 72 citalopram hydrobromide .. 36 see clonidine ...... 30 CETRAXAL ...... 79 claravis ...... 75 CAYSTON ...... 6 cevimeline hcl ...... 79 CLARINEX ...... 72 caziant ...... 50 CHANTIX ...... 46 see desloratadine ...... 72 cefaclor ...... 11 CHANTIX CONTINUING CLARINEX-D TAB 2.5-120 CEFACLOR ER ...... 11 MONTH ...... 46 ...... 72 cefadroxil...... 12 CHANTIX PAK 0.5& 1MG . 46 clarithromycin ...... 12 CEFAZOLIN INJ 1GM/50ML chateal ...... 50 CLENPIQ SOL ...... 61 ...... 12 CHEMET ...... 49 CLEOCIN ...... 6, 63 cefazolin sodium ...... 12 chlorhexidine gluconate see clindamycin hcl ...... 6 CEFAZOLIN SOLN (mouth-throat) ...... 79 see clindamycin 2GM/100ML-4% ...... 12 chloroquine phosphate...... 9 phosphate vaginal ...... 63 cefdinir ...... 12 chlorpromazine hcl ...... 39 CLEOCIN PEDIATRIC CEFEPIME ...... 12 CHLORPROMAZINE HCL 39 GRANULE ...... 6 cefepime hcl ...... 12 chlorthalidone ...... 29 see clindamycin palmitate CEFEPIME/DEX INJ 1GM 12 CHOLBAM ...... 61 hydrochloride...... 6 CEFEPIME/DEX INJ 2GM 12 cholestyramine ...... 26 CLEOCIN PHOSPHATE ..... 6 cefixime ...... 12 cholestyramine light ...... 26 see clindamycin CEFOTAN ...... 12 choline fenofibrate ...... 25 phosphate ...... 6 see cefotetan disodium.. 12 CHORIONIC CLEOCIN-T ...... 75
88 2021 631 3T Copper BvD Plus eff 01/01/2021
see clindamycin clinisol sf 15% ...... 69 colesevelam hcl ...... 26 phosphate (topical) ...... 75 CLINOLIPID EMU 20% ..... 69 COLESTID ...... 26 CLIMARA ...... 53 clobazam ...... 32 see colestipol hcl ...... 26 see estradiol ...... 54 clobetasol propionate ...... 77 colestipol hcl ...... 26 clindacin-p ...... 75 clobetasol propionate e ..... 77 colistimethate sodium ...... 6 CLINDAGEL ...... 75 clobetasol propionate colocort ...... 60 clindamycin hcl ...... 6 emulsion ...... 77 COLY-MYCIN M ...... 6 clindamycin palmitate CLOBEX ...... 77 see colistimethate sodium hydrochloride ...... 6 see clobetasol propionate ...... 6 clindamycin phosphate ...... 6 ...... 77 COMBIGAN SOL 0.2/0.5% clindamycin phosphate see clodan ...... 77 ...... 71 (topical) ...... 75 clocortolone pivalate ...... 77 COMBIVENT AER 20-100 72 clindamycin phosphate in clodan ...... 77 COMBIVIR d5w iv soln 300 mg/50ml ....6 CLODERM ...... 77 see lamivudine-zidovudine clindamycin phosphate in see clocortolone pivalate tab 150-300 mg ...... 10 d5w iv soln 600 mg/50ml ....6 ...... 77 COMBIVIR TAB 150-300 .. 10 clindamycin phosphate in clomipramine hcl ...... 36 COMETRIQ (60MG DOSE) d5w iv soln 900 mg/50ml ....6 clonazepam ...... 32 ...... 18 clindamycin phosphate clonidine ...... 30 COMETRIQ KIT 100MG ... 18 vaginal ...... 63 clonidine hcl ...... 30 COMETRIQ KIT 140MG ... 18 clindamycin clopidogrel bisulfate ...... 65 COMPLERA TAB...... 10 phosphate-benzoyl peroxide clorazepate dipotassium ... 32 compro ...... 59 gel 1.2-2.5% ...... 75 clotrimazole ...... 79 COMTAN ...... 38 clindamycin clotrimazole (topical) ...... 76 see entacapone...... 38 phosphate-benzoyl peroxide clotrimazole w/ CONCERTA ...... 41 gel 1-5% ...... 75 betamethasone cream see methylphenidate hcl 42 clindamycin 1-0.05% ...... 76 CONDYLOX ...... 78 phosphate-tretinoin gel clotrimazole w/ constulose ...... 61 1.2-0.025%...... 75 betamethasone lotion CONZIP ...... 2 clindamycin phosph-benzoyl 1-0.05% ...... 76 COPAXONE ...... 44 peroxide (refrig) gel 1.2 clovique ...... 49 see glatiramer acetate ... 44 (1)-5% ...... 75 clozapine ...... 39 see glatopa ...... 44 CLINDESSE ...... 63 CLOZARIL ...... 39 COPIKTRA ...... 18 CLINDMYC/NAC INJ see clozapine ...... 39 COREG ...... 27 300/50ML ...... 6 COARTEM TAB 20-120MG 9 see carvedilol ...... 27 CLINDMYC/NAC INJ codeine sulfate ...... 3 COREG CR ...... 27 600/50ML ...... 6 CODEINE SULFATE ...... 3 see carvedilol phosphate CLINDMYC/NAC INJ COGENTIN ...... 38 ...... 27 900/50ML ...... 6 see benztropine mesylate CORGARD ...... 27 CLINIMIX E INJ 2.75/D5W 69 ...... 38 see nadolol ...... 27 CLINIMIX E INJ 4.25/D10 . 69 COLAZAL CORLANOR ...... 30 CLINIMIX E INJ 4.25/D5W 69 see balsalazide disodium CORTEF ...... 54 CLINIMIX E INJ 5%/D15W 69 ...... 60 see hydrocortisone ...... 55 CLINIMIX E INJ 5%/D20W 69 colchicine ...... 1 CORTENEMA ...... 60 CLINIMIX INJ 4.25/D10 .... 69 colchicine w/ probenecid tab see colocort ...... 60 CLINIMIX INJ 4.25/D5W ... 69 0.5-500 mg ...... 1 see hydrocortisone CLINIMIX INJ 5%/D15W ... 69 COLCRYS ...... 1 (intrarectal) ...... 60 CLINIMIX INJ 5%/D20W ... 69 see colchicine ...... 1 CORTIFOAM ...... 78
89 2021 631 3T Copper BvD Plus eff 01/01/2021 cortisone acetate ...... 54 CUVPOSA ...... 60 DAPTOMYCIN ...... 6 CORTISPORIN CRE 0.5% cyclafem 1/35 ...... 50 see daptomycin ...... 6 ...... 75 cyclafem 7/7/7 ...... 50 darifenacin hydrobromide . 63 CORTISPORIN OIN 1% ... 75 cyclobenzaprine hcl ...... 45 DARZALEX ...... 18 CORTISPORIN SUS -TC cyclophosphamide ...... 15 DARZALEX SOL FASPRO OTIC ...... 79 cycloserine ...... 10 ...... 18 COSOPT cyclosporine ...... 67 dasetta 1/35 ...... 50 see dorzolamide cyclosporine modified (for dasetta 7/7/7 ...... 50 hcl-timolol maleate ophth microemulsion) ...... 67 DAURISMO ...... 18 soln 22.3-6.8 mg/ml ...... 71 CYKLOKAPRON DAYPRO ...... 1 COSOPT PF see tranexamic acid ...... 65 see oxaprozin ...... 1 see dorzolamide CYMBALTA ...... 36 daysee ...... 50 hcl-timolol maleate ophth see duloxetine hcl ...... 36 DAYTRANA ...... 41 sol 22.3-6.8 mg/ml pf ..... 71 cyproheptadine hcl ...... 72 DAYVIGO ...... 42 COSOPT PF SOL 2%-0.5% CYRAMZA ...... 18 DDAVP ...... 56 ...... 71 cyred eq ...... 50 see desmopressin acetate COSOPT SOL 22.3-6.8 .... 71 CYSTADANE POW ...... 56 ...... 56 COTELLIC ...... 18 CYSTAGON ...... 56 see desmopressin acetate COTEMPLA XR-ODT ...... 41 CYSTARAN ...... 72 spray ...... 56 COUMADIN ...... 63 cytarabine ...... 15 deblitane ...... 50 COZAAR ...... 24 CYTOGAM ...... 66 decitabine ...... 15 see losartan potassium.. 24 CYTOMEL ...... 58 deferasirox ...... 49 CREON CAP 12000UNT .. 62 see liothyronine sodium . 58 deferoxamine mesylate ..... 49 CREON CAP 24000UNT .. 62 CYTOTEC ...... 61 DELESTROGEN...... 53 CREON CAP 3000UNIT ... 62 see misoprostol ...... 61 see estradiol valerate .... 54 CREON CAP 36000UNT .. 62 CYTOVENE DELSTRIGO TAB ...... 10 CREON CAP 6000UNIT ... 62 see ganciclovir sodium .. 11 DELZICOL ...... 60 CRESEMBA ...... 8 D see mesalamine ...... 60 CRESTOR ...... 25 D.H.E. 45 ...... 43 demeclocycline hcl ...... 14 see rosuvastatin calcium see dihydroergotamine DEMSER ...... 30 ...... 25 mesylate ...... 43 DENAVIR ...... 78 CRINONE ...... 58 D10W/NACL INJ 0.2% ...... 68 DEPAKOTE ...... 32 CRIXIVAN ...... 9 D5W/LYTES INJ #48 ...... 68 see divalproex sodium .. 32 cromolyn sodium ...... 73 D5W/NACL INJ 0.3% ...... 68 DEPAKOTE ER ...... 32 cromolyn sodium dacarbazine ...... 16 see divalproex sodium .. 32 (mastocytosis) ...... 61 DACOGEN ...... 15 DEPAKOTE SPRINKLES . 32 cromolyn sodium (ophth) .. 71 see decitabine ...... 15 see divalproex sodium .. 32 crotan ...... 79 dalfampridine ...... 44 DEPEN TITRATABS ...... 49 cryselle-28...... 50 DALIRESP ...... 73 see penicillamine ...... 50 CRYSVITA ...... 56 DALVANCE ...... 6 DEPO-ESTRADIOL ...... 53 CUBICIN ...... 6 danazol ...... 53 DEPO-MEDROL ...... 54 see daptomycin ...... 6 DANTRIUM ...... 45 see methylprednisolone CUTAQUIG ...... 66 see dantrolene sodium .. 45 acetate ...... 55 CUTIVATE ...... 77 dantrolene sodium ...... 45 DEPO-PROVERA ...... 16 see beser ...... 76 dapsone ...... 6 DEPO-PROVERA see fluticasone propionate dapsone (topical) ...... 75 CONTRACEPTIV ...... 50 ...... 77 DAPTACEL INJ ...... 67 see medroxyprogesterone CUVITRU ...... 66 daptomycin ...... 6 acetate (contraceptive) .. 52
90 2021 631 3T Copper BvD Plus eff 01/01/2021
DEPO-SUBQ PROVERA see dexamethasone diclofenac sodium (topical) 78 104 ...... 50 sodium phosphate ...... 55 diclofenac w/ misoprostol tab DEPO-TESTOSTERONE . 46 dexamethasone sodium delayed release 50-0.2 mg . 1 see testosterone cypionate phosphate ...... 55 diclofenac w/ misoprostol tab ...... 47 dexamethasone sodium delayed release 75-0.2 mg . 1 DERMA-SMOOTHE/FS phosphate (ophth) ...... 70 dicloxacillin sodium ...... 14 BODY ...... 77 DEXEDRINE ...... 41 dicyclomine hcl ...... 60 see fluocinolone acetonide see dextroamphetamine didanosine ...... 9 ...... 77 sulfate ...... 41 DIFFERIN ...... 75 DERMA-SMOOTHE/FS DEXILANT ...... 62 see adapalene...... 74 SCALP ...... 77 dexmethylphenidate hcl .... 41 DIFICID ...... 12 see fluocinolone acetonide dexrazoxane hcl ...... 20 DIFLUCAN ...... 8 ...... 77 dextroamphetamine sulfate see fluconazole ...... 8 DERMOTIC ...... 79 ...... 41 diflunisal ...... 1 see flac ...... 79 dextrose ...... 69 digitek ...... 30 see fluocinolone acetonide dextrose 10% w/ sodium digox ...... 30 (otic) ...... 79 chloride 0.45% ...... 68 digoxin ...... 30 DESCOVY TAB 200/25 .... 10 dextrose 2.5% w/ sodium dihydroergotamine mesylate DESFERAL ...... 49 chloride 0.45% ...... 68 ...... 43 see deferoxamine dextrose 5% in lactated DILANTIN ...... 32 mesylate ...... 49 ringers ...... 68 see phenytoin sodium desipramine hcl ...... 36 dextrose 5% w/ sodium extended ...... 34 desloratadine ...... 72 chloride 0.2% ...... 68 DILANTIN INFATABS ...... 32 desmopressin acetate ...... 56 dextrose 5% w/ sodium see phenytoin ...... 34 desmopressin acetate spray chloride 0.225% ...... 68 DILANTIN-125 ...... 32 ...... 56 dextrose 5% w/ sodium see phenytoin ...... 34 desmopressin acetate spray chloride 0.45% ...... 68 DILATRATE SR ...... 30 refrigerated ...... 56 dextrose 5% w/ sodium DILAUDID ...... 3 desogest-eth estrad & eth chloride 0.9% ...... 68 see hydromorphone hcl ... 4 estrad tab 0.15-0.02/0.01 DIASTAT ACUDIAL ...... 32 diltiazem hcl ...... 28 mg(21/5)...... 50 DIASTAT PEDIATRIC...... 32 diltiazem hcl coated beads 28 DESONATE ...... 77 diazepam ...... 32 diltiazem hcl extended see desonide ...... 77 diazepam (anticonvulsant) 32 release beads ...... 28 desonide ...... 77 diazepam inj ...... 32 dilt-xr ...... 28 DESOWEN ...... 77 diazoxide ...... 55 DIOVAN ...... 24 see desonide ...... 77 DIBENZYLINE ...... 30 see valsartan ...... 24 desoximetasone ...... 77 see phenoxybenzamine DIOVAN HCT DESVENLAFAXINE ER .... 36 hcl...... 30 see desvenlafaxine succinate .. 36 DICLEGIS valsartan-hydrochlorothiazi DETROL ...... 63 see doxylamine-pyridoxine de tab 160-12.5 mg ...... 24 see tolterodine tartrate .. 63 tab delayed release 10-10 see DETROL LA ...... 63 mg ...... 59 valsartan-hydrochlorothiazi see tolterodine tartrate .. 63 DICLEGIS TAB 10-10MG . 59 de tab 160-25 mg ...... 24 dexamethasone ...... 55 diclofenac potassium ...... 1 see DEXAMETHASONE diclofenac sodium ...... 1 valsartan-hydrochlorothiazi INTENSOL ...... 55 diclofenac sodium (actinic de tab 320-12.5 mg ...... 24 DEXAMETHASONE keratoses) ...... 78 see SODIUM PHOS diclofenac sodium (ophth) . 70 valsartan-hydrochlorothiazi
91 2021 631 3T Copper BvD Plus eff 01/01/2021
de tab 320-25 mg ...... 24 maleate ophth sol 22.3-6.8 DURAGESIC see mg/ml pf ...... 71 see fentanyl ...... 2 valsartan-hydrochlorothiazi dorzolamide hcl-timolol DUREZOL ...... 70 de tab 80-12.5 mg ...... 24 maleate ophth soln 22.3-6.8 dutasteride ...... 62 DIOVAN HCT TAB 160-12.5 mg/ml ...... 71 dutasteride-tamsulosin hcl ...... 23 dotti ...... 54 cap 0.5-0.4 mg ...... 62 DIOVAN HCT TAB DOVATO TAB 50-300MG . 10 dvorah ...... 3 160-25MG ...... 23 doxazosin mesylate ...... 22 DYANAVEL XR...... 41 DIOVAN HCT TAB 320-12.5 doxepin hcl ...... 36 DYAZIDE ...... 23 doxepin hcl (sleep) ...... 42 see triamterene & DIOVAN HCT TAB doxercalciferol ...... 58 hydrochlorothiazide cap 320-25MG ...... 23 DOXIL ...... 15 37.5-25 mg ...... 29 DIOVAN HCT TAB 80/12.5 see doxorubicin hcl DYAZIDE CAP 37.5-25 ..... 29 ...... 23 liposomal ...... 15 DYMISTA DIP/TET PED INJ 25-5LFU doxorubicin hcl ...... 15 see azelastine ...... 67 doxorubicin hcl liposomal .. 15 hcl-fluticasone prop nasal DIPENTUM ...... 60 doxy 100 ...... 14 spray 137-50 mcg/act .... 72 diphenhydramine hcl ...... 72 doxycycline (monohydrate) DYMISTA SPR 137-50 ..... 72 diphenoxylate w/ atropine liq ...... 14 DYSPORT ...... 45 2.5-0.025 mg/5ml ...... 61 doxycycline (rosacea) ...... 78 E diphenoxylate w/ atropine doxycycline hyclate ...... 14 E.E.S. GRANULES tab 2.5-0.025 mg ...... 61 doxylamine-pyridoxine tab see erythromycin DIPROLENE ...... 77 delayed release 10-10 mg 59 ethylsuccinate ...... 12 see betamethasone DRIZALMA SPRINKLE ..... 36 EC-NAPROSYN dipropionate augmented 76 dronabinol ...... 59 see ec-naproxen ...... 1 DIPROLENE AF ...... 77 drospirenone-ethinyl see naproxen dr ...... 1 see betamethasone estradiol tab 3-0.02 mg ..... 51 ec-naproxen ...... 1 dipropionate augmented 76 drospirenone-ethinyl econazole nitrate ...... 76 dipyridamole ...... 65 estradiol tab 3-0.03 mg ..... 51 EDARBI ...... 24 disopyramide phosphate ... 24 drospirenone-ethinyl EDARBYCLOR TAB 40-12.5 disulfiram...... 46 estrad-levomefolate tab ...... 23 DITROPAN XL ...... 63 3-0.02-0.451 mg ...... 50 EDARBYCLOR TAB see oxybutynin chloride . 63 drospirenone-ethinyl 40-25MG ...... 23 DIURIL ...... 29 estrad-levomefolate tab EDECRIN ...... 29 divalproex sodium ...... 32 3-0.03-0.451 mg ...... 51 see ethacrynic acid ...... 29 DIVIGEL ...... 54 DROXIA ...... 65 EDLUAR ...... 42 docetaxel...... 17 DUETACT EDURANT ...... 9 DOCETAXEL ...... 17 see pioglitazone efavirenz ...... 9 see docetaxel ...... 17 hcl-glimepiride tab 30-2 EFFEXOR XR ...... 36 dofetilide...... 25 mg ...... 48 see venlafaxine hcl ...... 37 DOLOPHINE ...... 2 see pioglitazone EFFIENT ...... 65 see methadone hcl ...... 2 hcl-glimepiride tab 30-4 see prasugrel hcl ...... 65 donepezil hydrochloride .... 35 mg ...... 48 EFUDEX ...... 78 DOPTELET ...... 65 DUETACT TAB 30-2MG ... 47 see fluorouracil (topical) 78 DORYX DUETACT TAB 30-4MG ... 47 EGRIFTA ...... 56 see doxycycline hyclate . 14 duloxetine hcl ...... 36 EGRIFTA SV ...... 56 dorzolamide hcl ...... 71 DUOBRII LOT ...... 77 ELAPRASE ...... 56 dorzolamide hcl-timolol DUOPA SUS 4.63-20...... 38 ELELYSO ...... 56
92 2021 631 3T Copper BvD Plus eff 01/01/2021 eletriptan hydrobromide .... 43 ENHERTU ...... 18 EQUETRO ...... 43 ELIDEL ...... 78 enoxaparin sodium ...... 64 ERAXIS ...... 8 see pimecrolimus ...... 79 enpresse-28 ...... 51 ERBITUX ...... 18 ELIGARD ...... 16 enskyce ...... 51 ergotamine w/ caffeine tab ELIMITE ...... 79 ENSTILAR AER ...... 77 1-100 mg ...... 43 see permethrin ...... 79 entacapone ...... 38 ERIVEDGE ...... 18 elinest ...... 51 entecavir ...... 11 ERLEADA ...... 16 ELIQUIS ...... 63 ENTOCORT EC ...... 60 erlotinib hcl ...... 18 ELIQUIS STARTER PACK see budesonide ...... 60 errin ...... 51 ...... 63 ENTRESTO TAB 24-26MG ERTACZO ...... 76 ELITEK ...... 20 ...... 23 ertapenem sodium ...... 6 ELIXOPHYLLIN ...... 73 ENTRESTO TAB 49-51MG ERWINAZE ...... 17 ELLA ...... 51 ...... 23 ery ...... 75 ELLENCE...... 15 ENTRESTO TAB 97-103MG ERYGEL ...... 75 see epirubicin hcl ...... 15 ...... 23 see erythromycin (acne ELMIRON...... 63 ENTYVIO ...... 65 aid) ...... 75 eluryng ...... 51 enulose ...... 61 ERYPED 400 EMCYT ...... 16 ENVARSUS XR ...... 67 see erythromycin EMEND ...... 59 EPANED ...... 21 ethylsuccinate ...... 12 see aprepitant ...... 59 EPCLUSA TAB 400-100 ... 11 ery-tab ...... 12 see fosaprepitant EPIDIOLEX ...... 32 ERYTHROCIN dimeglumine ...... 59 EPIDUO LACTOBIONATE ...... 12 EMEND TRIPAC PAK 80 & see adapalene-benzoyl erythrocin stearate ...... 12 125 ...... 59 peroxide gel 0.1-2.5% ... 74 erythromycin (acne aid) .... 75 emoquette ...... 51 EPIDUO FORTE GEL erythromycin (ophth) ...... 70 EMPLICITI ...... 18 0.3-2.5% ...... 75 erythromycin base ...... 12 EMSAM ...... 36 EPIDUO GEL 0.1-2.5% ..... 75 erythromycin ethylsuccinate EMTRIVA ...... 9 epinastine hcl (ophth)...... 71 ...... 12, 13 EMVERM ...... 6 epinephrine (anaphylaxis) . 73 ESBRIET ...... 73 ENABLEX ...... 63 EPIPEN 2-PAK ...... 73 escitalopram oxalate ...... 36 see darifenacin see epinephrine esomeprazole magnesium 62 hydrobromide ...... 63 (anaphylaxis) ...... 73 esomeprazole sodium ...... 62 enalapril maleate ...... 21 EPIPEN-JR 2-PAK ...... 73 estarylla ...... 51 enalapril maleate & see epinephrine ESTRACE ...... 54 hydrochlorothiazide tab (anaphylaxis) ...... 73 see estradiol ...... 54 10-25 mg ...... 21 epirubicin hcl ...... 15 see estradiol vaginal ..... 54 enalapril maleate & epitol ...... 32 estradiol ...... 54 hydrochlorothiazide tab EPIVIR ...... 9 estradiol & norethindrone 5-12.5 mg ...... 21 see lamivudine ...... 9 acetate tab 0.5-0.1 mg ...... 54 ENBREL...... 65 EPIVIR HBV ...... 11 estradiol & norethindrone ENBREL MINI ...... 65 see lamivudine (hbv) ..... 11 acetate tab 1-0.5 mg ...... 54 ENBREL SURECLICK ...... 65 eplerenone ...... 22 estradiol vaginal ...... 54 ENDARI ...... 65 epoprostenol sodium...... 31 estradiol valerate ...... 54 endocet tab 10-325mg ...... 3 EPZICOM ESTRING ...... 54 endocet tab 2.5-325mg ...... 3 see abacavir ESTROGEL ...... 54 endocet tab 5-325mg ...... 3 sulfate-lamivudine tab ESTROSTEP FE endocet tab 7.5-325mg ...... 3 600-300 mg ...... 10 see tilia fe ...... 53 ENGERIX-B ...... 67 EPZICOM TAB 600-300 ... 10 see tri-legest fe...... 53
93 2021 631 3T Copper BvD Plus eff 01/01/2021
ESTROSTEP FE TAB ...... 51 amlodipine-valsartan-hydr F eszopiclone ...... 42 ochlorothiazide tab FABRAZYME ...... 56 ethacrynic acid ...... 29 10-160-12.5 mg ...... 22 falmina ...... 51 ethambutol hcl ...... 10 see famciclovir ...... 11 ethosuximide ...... 32 amlodipine-valsartan-hydr famotidine ...... 60 ethynodiol diacetate & ochlorothiazide tab famotidine in nacl 0.9% iv ethinyl estradiol tab 1 mg-35 10-160-25 mg ...... 22 soln 20 mg/50ml ...... 60 mcg ...... 51 see FANAPT ...... 39 ethynodiol diacetate & amlodipine-valsartan-hydr FANAPT PAK ...... 39 ethinyl estradiol tab 1 mg-50 ochlorothiazide tab FARESTON ...... 16 mcg ...... 51 10-320-25 mg ...... 22 see toremifene citrate .... 16 etodolac ...... 1 see FARXIGA ...... 47 etonogestrel-ethinyl estradiol amlodipine-valsartan-hydr FARYDAK ...... 18 va ring 0.120-0.015 mg/24hr ochlorothiazide tab FASENRA ...... 73 ...... 51 5-160-12.5 mg ...... 22 FASENRA PEN ...... 73 ETOPOPHOS ...... 17 see FASLODEX ...... 16 etoposide ...... 17 amlodipine-valsartan-hydr see fulvestrant ...... 16 euthyrox ...... 58 ochlorothiazide tab fayosim ...... 51 EVENITY...... 49 5-160-25 mg ...... 22 febuxostat ...... 1 everolimus...... 18 EXFORGE HCT TAB felbamate ...... 32 everolimus 10-160-12.5MG ...... 23 FELBATOL ...... 32 (immunosuppressant) ...... 67 EXFORGE HCT TAB see felbamate...... 32 EVISTA ...... 56 10-160-25MG ...... 23 FELDENE ...... 1 see raloxifene hcl ...... 57 EXFORGE HCT TAB see piroxicam ...... 1 EVOCLIN ...... 75 10-320-25MG ...... 23 felodipine ...... 28 see clindamycin EXFORGE HCT TAB FEMARA ...... 16 phosphate (topical) ...... 75 5-160-12.5MG ...... 23 see letrozole ...... 16 EVOTAZ TAB 300-150 ..... 10 EXFORGE HCT TAB FEMHRT LOW DOSE EVOXAC ...... 79 5-160-25MG ...... 23 see fyavolv tab see cevimeline hcl ...... 79 EXFORGE TAB 10-160MG 0.5mg-2.5mcg ...... 54 EXELON ...... 35 ...... 23 see norethindrone see rivastigmine ...... 36 EXFORGE TAB 10-320MG acetate-ethinyl estradiol exemestane ...... 16 ...... 23 tab 0.5 mg-2.5 mcg ...... 54 EXFORGE EXFORGE TAB 5-160MG 23 FEMHRT TAB 0.5-2.5 ...... 54 see amlodipine EXFORGE TAB 5-320MG 23 FEMRING ...... 54 besylate-valsartan tab EXJADE ...... 50 femynor ...... 51 10-160 mg ...... 22 see deferasirox ...... 49 fenofibrate ...... 25 see amlodipine EYLEA ...... 72 fenofibrate micronized ...... 25 besylate-valsartan tab EZALLOR SPRINKLE ...... 25 fentanyl ...... 2 10-320 mg ...... 22 ezetimibe ...... 26 fentanyl citrate ...... 3, 4 see amlodipine ezetimibe-simvastatin tab FENTORA ...... 4 besylate-valsartan tab 10-10 mg ...... 26 FERRIPROX ...... 50 5-160 mg ...... 22 ezetimibe-simvastatin tab FETROJA ...... 12 see amlodipine 10-20 mg ...... 26 FETZIMA ...... 36 besylate-valsartan tab ezetimibe-simvastatin tab FETZIMA CAP TITRATIO . 36 5-320 mg ...... 22 10-40 mg ...... 26 FIASP FLEX INJ TOUCH . 48 EXFORGE HCT ezetimibe-simvastatin tab FIASP INJ 100/ML ...... 48 see 10-80 mg ...... 26 FIASP PENFIL INJ U-100 . 48
94 2021 631 3T Copper BvD Plus eff 01/01/2021
FINACEA ...... 78 flurbiprofen sodium ...... 70 furosemide ...... 29 see azelaic acid ...... 78 flutamide ...... 16 furosemide inj ...... 29 finasteride ...... 62 fluticasone propionate ...... 77 FUZEON ...... 9 FIRAZYR...... 65 fluticasone propionate fyavolv tab 0.5mg-2.5mcg . 54 see icatibant acetate ..... 65 (nasal) ...... 74 fyavolv tab 1mg-5mcg ...... 54 FIRDAPSE ...... 43 fluvastatin sodium ...... 25 FYCOMPA ...... 32 FIRMAGON ...... 16 fluvoxamine maleate ...... 31 G FIRVANQ ...... 6 FML...... 70 gabapentin ...... 32 flac ...... 79 FML FORTE ...... 70 GABITRIL ...... 33 FLAGYL ...... 6 FOCALIN ...... 41 see tiagabine hcl ...... 34 see metronidazole ...... 7 see dexmethylphenidate GALAFOLD ...... 56 FLAREX ...... 70 hcl...... 41 galantamine hydrobromide 35 flecainide acetate ...... 25 FOCALIN XR ...... 42 GAMASTAN INJ ...... 66 FLOLAN ...... 31 see dexmethylphenidate GAMMAGARD LIQUID ..... 66 see epoprostenol sodium hcl...... 41 GAMMAGARD S/D IGA ...... 31 FOLOTYN ...... 15 LESS TH ...... 66 FLOLIPID ...... 25 fondaparinux sodium...... 64 GAMMAKED ...... 66 FLOMAX ...... 62 FORFIVO XL ...... 36 GAMMAPLEX ...... 66 see tamsulosin hcl ...... 63 FORTEO ...... 49 GAMUNEX-C ...... 66 FLOVENT DISKUS ...... 74 FORTESTA ...... 46 GANCICLOVIR ...... 11 FLOVENT HFA ...... 74 see testosterone ...... 47 ganciclovir sodium ...... 11 fluconazole ...... 8 FOSAMAX ...... 49 GARDASIL 9 INJ ...... 67 fluconazole in nacl 0.9% inj see alendronate sodium 49 GASTROCROM...... 61 200 mg/100ml ...... 8 FOSAMAX + D TAB 70-2800 see cromolyn sodium fluconazole in nacl 0.9% inj ...... 49 (mastocytosis) ...... 61 400 mg/200ml ...... 8 FOSAMAX + D TAB 70-5600 gatifloxacin (ophth) ...... 70 flucytosine ...... 8 ...... 49 GATTEX ...... 61 fludarabine phosphate ...... 15 fosamprenavir calcium ...... 9 GAUZE PADS 2X2 ...... 48 fludrocortisone acetate ...... 55 fosaprepitant dimeglumine 59 gavilyte-c ...... 61 flunisolide (nasal) ...... 74 fosinopril sodium ...... 21 gavilyte-g ...... 61 fluocinolone acetonide ...... 77 fosinopril sodium & gavilyte-n/flavor pack ...... 61 fluocinolone acetonide (otic) hydrochlorothiazide tab GAZYVA ...... 18 ...... 79 10-12.5 mg ...... 21 GELNIQUE ...... 63 fluocinonide ...... 77 fosinopril sodium & GEMCITABINE ...... 15 fluocinonide emulsified base hydrochlorothiazide tab see gemcitabine hcl ...... 15 ...... 77 20-12.5 mg ...... 21 gemcitabine hcl ...... 15 fluorometholone (ophth) .... 70 FOSRENOL ...... 57 gemfibrozil ...... 25 FLUOROPLEX ...... 78 see lanthanum carbonate GENERESS FE fluorouracil ...... 15 ...... 57 see kaitlib fe ...... 51 fluorouracil (topical) ...... 78 FRAGMIN ...... 64 see layolis fe ...... 51 fluoxetine hcl ...... 36 FREAMINE HBC INJ 6.9% see norethindrone & fluoxetine hcl (pmdd) ...... 36 ...... 69 ethinyl estradiol-fe chew FLUOXETINE FREAMINE III INJ 10% ..... 69 tab 0.8 mg-25 mcg ...... 52 HYDROCHLORIDE ...... 36 FROVA ...... 43 GENERESS FE CHW ...... 51 see fluoxetine hcl ...... 36 see frovatriptan succinate generlac ...... 61 fluphenazine decanoate .... 39 ...... 43 gengraf ...... 67 fluphenazine hcl ...... 39 frovatriptan succinate ...... 43 GENOTROPIN...... 56 flurbiprofen ...... 1 fulvestrant ...... 16 GENOTROPIN MINIQUICK
95 2021 631 3T Copper BvD Plus eff 01/01/2021
...... 56 glydo ...... 78 haloperidol decanoate ...... 39 gentak ...... 70 GLYSET ...... 47 haloperidol lactate...... 39 gentamicin in saline inj 0.8 see miglitol ...... 47 HARVONI PAK mg/ml ...... 6 GLYXAMBI TAB 10-5 MG . 47 33.75-150MG ...... 11 gentamicin in saline inj 1 GLYXAMBI TAB 25-5 MG . 47 HARVONI PAK 45-200MG 11 mg/ml ...... 6 GOCOVRI ...... 38 HARVONI TAB 45-200MG 11 gentamicin in saline inj 1.2 GOLYTELY HARVONI TAB 90-400MG 11 mg/ml ...... 6 see gavilyte-g ...... 61 HAVRIX ...... 67 gentamicin in saline inj 1.6 see peg 3350-kcl-na heather ...... 51 mg/ml ...... 6 bicarb-nacl-na sulfate for HEP SOD/NACL INJ gentamicin in saline inj 2 soln 236 gm ...... 61 25000UNT ...... 64 mg/ml ...... 6 GOLYTELY SOL ...... 61 HEPARIN SODIUM ...... 64 gentamicin sulfate ...... 6 GRALISE ...... 43 heparin sodium (porcine) .. 64 gentamicin sulfate (ophth) . 70 GRALISE STAR MIS heparin sodium (porcine) gentamicin sulfate (topical) 300/600 ...... 43 100 unit/ml in d5w ...... 64 ...... 75 granisetron hcl ...... 59 heparin sodium GENVOYA TAB ...... 10 griseofulvin microsize...... 8 (porcine)-dextrose iv sol GEODON ...... 39 griseofulvin ultramicrosize ... 8 20000 unit/500ml-5% ...... 64 see ziprasidone hcl ...... 40 guanfacine hcl ...... 30 heparin sodium see ziprasidone mesylate guanfacine hcl (adhd) ...... 42 (porcine)-dextrose iv sol ...... 40 GVOKE HYPOPEN 2-PACK 25000 unit/500ml-5% ...... 64 gianvi ...... 51 ...... 55 HEPARIN/NACL INJ GILENYA ...... 44 GVOKE PFS ...... 55 25000UNT ...... 64 GILOTRIF ...... 18 GYNAZOLE-1 ...... 63 hepatamine ...... 69 GIVLAARI ...... 65 H HEPSERA ...... 11 GLASSIA...... 73 HAEGARDA ...... 65 see adefovir dipivoxil ..... 11 glatiramer acetate ...... 44 hailey 1.5/30 ...... 51 HERCEP HYLEC SOL glatopa ...... 44 hailey 24 fe ...... 51 60-10000 ...... 18 GLEEVEC ...... 18 HALAVEN ...... 17 HERCEPTIN ...... 18 see imatinib mesylate .... 18 halcinonide ...... 77 HERZUMA ...... 18 GLEOSTINE ...... 15 HALCION ...... 42 HETLIOZ ...... 42 glimepiride...... 47 see triazolam ...... 42 HIBERIX ...... 67 glipizide ...... 47 HALDOL ...... 39 HIPREX ...... 7 glipizide xl ...... 47 see haloperidol lactate .. 39 see methenamine glipizide-metformin hcl tab HALDOL DECANOATE 100 hippurate ...... 7 2.5-250 mg ...... 47 ...... 39 HIZENTRA ...... 66 glipizide-metformin hcl tab see haloperidol decanoate HORIZANT ...... 44 2.5-500 mg ...... 47 ...... 39 HUMATROPE ...... 56 glipizide-metformin hcl tab HALDOL DECANOATE 50 HUMATROPE COMBO 5-500 mg ...... 47 ...... 39 PACK ...... 56 GLUCOTROL ...... 47 see haloperidol decanoate HUMIRA ...... 65 see glipizide ...... 47 ...... 39 HUMIRA PEDIA INJ GLUCOTROL XL ...... 47 halobetasol propionate...... 77 CROHNS ...... 65 see glipizide ...... 47 HALOBETASOL HUMIRA PEDIATRIC see glipizide xl ...... 47 PROPIONATE ...... 77 CROHNS D ...... 65 GLYCATE ...... 60 HALOG ...... 77 HUMIRA PEN ...... 65 glycopyrrolate ...... 60 see halcinonide ...... 77 HUMIRA PEN KIT PS/UV . 65 GLYCOPYRROLATE ...... 60 haloperidol ...... 39 HUMIRA PEN-CD/UC/HS
96 2021 631 3T Copper BvD Plus eff 01/01/2021
START ...... 65 ...... 66 IMITREX ...... 43 HUMIRA PEN-PS/UV hydroxyprogesterone see sumatriptan...... 43 STARTER ...... 65 caproate (antineoplastic) ... 16 see sumatriptan succinate HUMULIN R U-500 hydroxyurea ...... 17 ...... 43 (CONCENTR ...... 48 hydroxyzine hcl ...... 72 IMITREX STATDOSE HUMULIN R U-500 hydroxyzine pamoate ...... 72 REFILL ...... 43 KWIKPEN ...... 48 HYQVIA INJ 10-800 ...... 66 see sumatriptan succinate HYCAMTIN HYQVIA INJ 2.5-200 ...... 66 ...... 43 see topotecan hcl ...... 17 HYQVIA INJ 20-1600 ...... 66 IMITREX STATDOSE hydralazine hcl ...... 30 HYQVIA INJ 30-2400 ...... 66 SYSTEM ...... 43 HYDREA ...... 17 HYQVIA INJ 5-400 ...... 66 see sumatriptan succinate see hydroxyurea ...... 17 HYSINGLA ER ...... 2 ...... 43 hydrochlorothiazide ...... 29 HYZAAR IMOVAX RABIES (H.D.C.V.) hydrocodone bitartrate ...... 2 see losartan potassium & ...... 67 hydrocodone bitartrate cap hydrochlorothiazide tab IMPOYZ ...... 78 er 12hr abuse-deterrent 40 100-12.5 mg ...... 23 IMURAN ...... 67 mg ...... 2 see losartan potassium & see azathioprine ...... 66 hydrocodone-acetaminophen hydrochlorothiazide tab IMVEXXY MAINTENANCE soln 7.5-325 mg/15ml ...... 4 100-25 mg ...... 23 PACK ...... 54 hydrocodone-acetaminophen see losartan potassium & IMVEXXY STARTER PACK tab 10-300 mg ...... 4 hydrochlorothiazide tab ...... 54 hydrocodone-acetaminophen 50-12.5 mg ...... 23 INBRIJA ...... 38 tab 10-325 mg ...... 4 HYZAAR TAB 100-12.5 .... 23 incassia ...... 51 hydrocodone-acetaminophen HYZAAR TAB 100-25 ...... 23 INCRELEX ...... 56 tab 5-300 mg ...... 4 HYZAAR TAB 50-12.5 ...... 23 INCRUSE ELLIPTA ...... 72 hydrocodone-acetaminophen I indapamide ...... 29 tab 5-325 mg ...... 4 ibandronate sodium ...... 49 INDERAL LA ...... 27 hydrocodone-acetaminophen IBRANCE ...... 18 see propranolol hcl ...... 27 tab 7.5-300 mg ...... 4 ibu ...... 1 INFANRIX INJ ...... 67 hydrocodone-acetaminophen ibuprofen ...... 1 INFUGEM SOL 1200MG .. 15 tab 7.5-325 mg ...... 4 icatibant acetate ...... 65 INFUGEM SOL 1300MG .. 16 hydrocodone-ibuprofen tab ICLUSIG ...... 18 INFUGEM SOL 1400MG .. 16 10-200 mg ...... 4 IDHIFA ...... 18 INFUGEM SOL 1500MG .. 16 hydrocodone-ibuprofen tab IFEX ...... 15 INFUGEM SOL 1600MG .. 16 5-200 mg ...... 4 ifosfamide ...... 15 INFUGEM SOL 1700MG .. 16 hydrocodone-ibuprofen tab IFOSFAMIDE ...... 15 INFUGEM SOL 1800MG .. 16 7.5-200 mg ...... 4 ILARIS ...... 66 INFUGEM SOL 1900MG .. 16 hydrocortisone ...... 55 ILEVRO ...... 70 INFUGEM SOL 2000MG .. 16 hydrocortisone (intrarectal) imatinib mesylate ...... 18 INFUGEM SOL 2200MG .. 16 ...... 60 IMBRUVICA ...... 18 INGREZZA ...... 44 hydrocortisone (topical) ..... 77 IMFINZI ...... 18 INGREZZA CAP 40-80MG 44 hydrocortisone butyrate .... 77 imipenem-cilastatin INLYTA ...... 18 hydrocortisone w/ acetic acid intravenous for soln 250 mg 7 INREBIC ...... 18 otic soln 1-2% ...... 79 imipenem-cilastatin INSPRA ...... 22 hydromorphone hcl ...... 2, 4 intravenous for soln 500 mg 7 see eplerenone ...... 22 HYDROMORPHONE imipramine hcl ...... 36 INSULIN SAFETY HYDROCHLORI ...... 4 imipramine pamoate ...... 37 NEEDLES ...... 48 hydroxychloroquine sulfate imiquimod ...... 78 INSULIN SYRINGES:
97 2021 631 3T Copper BvD Plus eff 01/01/2021
BD/ULTIMED/ALLISON/TRI ISTURISA ...... 56 junel fe 24 ...... 51 VIDIA/MHC ...... 48 itraconazole ...... 8 JUXTAPID ...... 26 INTELENCE ...... 9 ivermectin ...... 7 JYNARQUE ...... 56 INTRALIPID ...... 69 IXEMPRA KIT ...... 17 JYNARQUE PAK 30-15MG INTRAROSA ...... 63 IXIARO INJ ...... 67 ...... 56 INTRON A ...... 66 J JYNARQUE PAK 45-15MG introvale ...... 51 JADENU ...... 50 ...... 56 INTUNIV...... 42 see deferasirox ...... 49 JYNARQUE PAK 60-30MG see guanfacine hcl (adhd) JADENU SPRINKLE ...... 50 ...... 56 ...... 42 JAKAFI ...... 18 JYNARQUE PAK 90-30MG INVANZ ...... 7 JALYN ...... 56 see ertapenem sodium ....6 see dutasteride-tamsulosin K INVEGA ...... 39 hcl cap 0.5-0.4 mg ...... 62 KADCYLA ...... 18 see paliperidone ...... 40 JALYN CAP ...... 63 KADIAN ...... 2 INVEGA SUSTENNA ...... 39 jantoven ...... 64 see morphine sulfate ...... 2 INVEGA TRINZA ...... 39 JANUMET TAB 50-1000 ... 47 kaitlib fe ...... 51 INVELTYS...... 71 JANUMET TAB 50-500MG KALBITOR ...... 65 INVIRASE ...... 9 ...... 47 KALETRA IPOL INJ INACTIVE ...... 67 JANUMET XR TAB see lopinavir-ritonavir soln ipratropium bromide ...... 72 100-1000 ...... 47 400-100 mg/5ml (80-20 ipratropium bromide (nasal) JANUMET XR TAB 50-1000 mg/ml) ...... 10 ...... 72 ...... 47 KALETRA SOL ...... 10 ipratropium-albuterol nebu JANUMET XR TAB KALETRA TAB 100-25MG 10 soln 0.5-2.5(3) mg/3ml ...... 72 50-500MG ...... 47 KALETRA TAB 200-50MG 10 irbesartan ...... 24 JANUVIA ...... 47 KALYDECO ...... 73 irbesartan-hydrochlorothiazid JARDIANCE ...... 47 KANJINTI ...... 18 e tab 150-12.5 mg ...... 23 jasmiel ...... 51 KANUMA ...... 56 irbesartan-hydrochlorothiazid JENTADUETO TAB KAPSPARGO SPRINKLE 27 e tab 300-12.5 mg ...... 23 2.5-1000 ...... 47 kariva ...... 51 IRESSA ...... 18 JENTADUETO TAB 2.5-500 KATERZIA ...... 28 irinotecan hcl ...... 17 ...... 47 kcl 10 meq/l (0.075%) in ISENTRESS ...... 9 JENTADUETO TAB 2.5-850 dextrose 5% & nacl 0.45% ISENTRESS HD ...... 9 ...... 47 inj ...... 68 isibloom ...... 51 JENTADUETO TAB XR kcl 20 meq/l (0.15%) in ISOLYTE-P INJ /D5W ...... 68 2.5-1000MG ...... 47 dextrose 5% & nacl 0.2% inj ISOLYTE-S INJ ...... 68 JENTADUETO TAB XR ...... 68 isoniazid ...... 10 5-1000MG ...... 47 kcl 20 meq/l (0.15%) in ISOPTO CARPINE ...... 71 JEVTANA ...... 17 dextrose 5% & nacl 0.45% see pilocarpine hcl ...... 71 jinteli...... 54 inj ...... 68 ISORDIL TITRADOSE ...... 30 jolessa ...... 51 kcl 20 meq/l (0.15%) in see isosorbide dinitrate . 30 JORNAY PM ...... 42 dextrose 5% & nacl 0.9% inj isosorbide dinitrate ...... 30 JUBLIA ...... 76 ...... 68 isosorbide mononitrate ...... 30 juleber ...... 51 kcl 20 meq/l (0.15%) in nacl isotretinoin...... 75 JULUCA TAB 50-25MG .... 10 0.45% inj ...... 68 isradipine...... 28 junel 1.5/30 ...... 51 kcl 20 meq/l (0.15%) in nacl ISTALOL ...... 71 junel 1/20 ...... 51 0.9% inj ...... 68 see timolol maleate junel fe 1.5/30 ...... 51 kcl 30 meq/l (0.224%) in (ophth) once-daily ...... 71 junel fe 1/20 ...... 51 dextrose 5% & nacl 0.45%
98 2021 631 3T Copper BvD Plus eff 01/01/2021 inj ...... 68 see tobramycin ...... 8 100MG TABS) ...... 33 kcl 40 meq/l (0.3%) in KLARON ...... 75 LAMICTAL STARTER/NOT dextrose 5% & nacl 0.45% see sulfacetamide sodium TAKI inj ...... 68 (acne) ...... 75 see lamotrigine tab 25 mg kcl 40 meq/l (0.3%) in nacl KLONOPIN ...... 33 (42) & 100 mg (7) starter 0.9% inj ...... 68 see clonazepam ...... 32 kit ...... 33 KCL/D5W/LACT INJ klor-con ...... 69 see subvenite starter 20MEQ/L ...... 68 klor-con 10 ...... 69 kit/ora ...... 34 KCL/D5W/NACL INJ klor-con 8 ...... 69 LAMICTAL 0.15/0.2 ...... 68 klor-con m10 ...... 69 STARTER/TAKING C KCL/D5W/NACL INJ klor-con m15 ...... 69 see lamotrigine tab 84 x 0.3/0.9% ...... 68 klor-con m20 ...... 69 25 mg & 14 x 100 mg KEFLEX klor-con sprinkle ...... 69 starter kit ...... 33 see cephalexin ...... 12 KORLYM ...... 56 see subvenite starter kelnor 1/35 ...... 51 KOSELUGO ...... 18 kit/gre ...... 34 kelnor 1/50 ...... 51 KRINTAFEL ...... 9 LAMICTAL KENALOG...... 78 KRISTALOSE ...... 61 STARTER/TAKING V see triamcinolone KRYSTEXXA ...... 1 see lamotrigine ...... 33 acetonide (topical) ...... 78 K-TAB ...... 69 see subvenite starter KENALOG-10 ...... 55 see potassium chloride .. 69 kit/blu ...... 34 KENALOG-40 ...... 55 kurvelo ...... 51 LAMICTAL XR ...... 33 see triamcinolone KUVAN ...... 56 see lamotrigine ...... 33 acetonide ...... 55 KYPROLIS ...... 18 LAMICTAL XR KIT ...... 33 KENALOG-80 ...... 55 L LAMISIL KEPPRA ...... 33 labetalol hcl ...... 27 see terbinafine hcl ...... 9 see levetiracetam ...... 33 LACRISERT ...... 72 lamivudine ...... 9 see roweepra ...... 34 lactated ringer's solution ... 68 lamivudine (hbv) ...... 11 KEPPRA XR ...... 33 lactic acid (ammonium lamivudine-zidovudine tab see levetiracetam ...... 33 lactate) ...... 78 150-300 mg ...... 10 see roweepra xr ...... 34 lactulose ...... 61 lamotrigine ...... 33 ketoconazole ...... 8 lactulose (encephalopathy) lamotrigine tab 25 mg (42) & ketoconazole (topical) ...... 76 ...... 61 100 mg (7) starter kit ...... 33 ketoprofen ...... 1 LAMICTAL ...... 33 lamotrigine tab 84 x 25 mg & ketorolac tromethamine see lamotrigine ...... 33 14 x 100 mg starter kit ...... 33 (ophth) ...... 71 see subvenite ...... 34 LANOXIN ...... 30 KEVEYIS...... 29 LAMICTAL CHEWABLE see digitek ...... 30 KEYTRUDA ...... 18 DISPERS ...... 33 see digox ...... 30 KHAPZORY ...... 20 see lamotrigine ...... 33 see digoxin ...... 30 KINRIX INJ ...... 67 LAMICTAL ODT ...... 33 LANOXIN PEDIATRIC ...... 30 kionex ...... 50 see lamotrigine ...... 33 lansoprazole ...... 62 KISQALI ...... 18 LAMICTAL ODT KIT ...... 33 lanthanum carbonate ...... 57 KISQALI 200 PAK FEMARA LAMICTAL STARTER KIT larin 1.5/30 ...... 51 ...... 17 (35 X 25MG TABS) ...... 33 larin 1/20 ...... 51 KISQALI 400 PAK FEMARA LAMICTAL STARTER KIT larin 24 fe ...... 51 ...... 17 (42 X 25MG TABS & 7 X larin fe 1.5/30 ...... 51 KISQALI 600 PAK FEMARA 100MG TAB) ...... 33 larin fe 1/20 ...... 51 ...... 17 LAMICTAL STARTER KIT larissia ...... 51 KITABIS PAK ...... 7 (84 X 25MG TABS & 14 X LASIX ...... 29
99 2021 631 3T Copper BvD Plus eff 01/01/2021
see furosemide ...... 29 see levetiracetam in levonorg-eth est tab LASTACAFT ...... 71 sodium chloride iv soln 0.1-0.02mg(84) & eth est tab latanoprost ...... 71 1500 mg/100ml ...... 33 0.01mg(7) ...... 51 LATUDA ...... 39 see levetiracetam in levonorg-eth est tab layolis fe ...... 51 sodium chloride iv soln 0.15-0.03mg(84) & eth est leena ...... 51 500 mg/100ml ...... 33 tab 0.01mg(7) ...... 51 leflunomide ...... 66 levetiracetam in sodium levora 0.15/30-28 ...... 52 LEMTRADA ...... 44 chloride iv soln 1000 levo-t ...... 58 LENVIMA 10 MG DAILY mg/100ml ...... 33 levothyroxine sodium ...... 58 DOSE ...... 18 levetiracetam in sodium levoxyl ...... 58 LENVIMA 12MG DAILY chloride iv soln 1500 LEXAPRO ...... 37 DOSE ...... 18 mg/100ml ...... 33 see escitalopram oxalate LENVIMA 20 MG DAILY levetiracetam in sodium ...... 36 DOSE ...... 18 chloride iv soln 500 LEXETTE ...... 78 LENVIMA 4 MG DAILY mg/100ml ...... 33 LEXIVA ...... 9 DOSE ...... 18 levobunolol hcl ...... 71 see fosamprenavir calcium LENVIMA 8 MG DAILY levocarnitine (metabolic ...... 9 DOSE ...... 18 modifiers) ...... 56 LIALDA ...... 60 LENVIMA CAP 14 MG ...... 18 levocetirizine dihydrochloride see mesalamine ...... 60 LENVIMA CAP 18 MG ...... 18 ...... 72 LIBTAYO ...... 18 LENVIMA CAP 24 MG ...... 18 levofloxacin ...... 13 lidocaine ...... 78 LESCOL XL ...... 25 levofloxacin (ophth) ...... 70 lidocaine hcl ...... 78 see fluvastatin sodium ... 25 levofloxacin in d5w iv soln lidocaine hcl (local anesth.) 5 lessina ...... 51 250 mg/50ml ...... 13 lidocaine hcl (mouth-throat) LETAIRIS ...... 31 levofloxacin in d5w iv soln ...... 79 see ambrisentan ...... 31 500 mg/100ml ...... 13 lidocaine-prilocaine cream letrozole ...... 16 levofloxacin in d5w iv soln 2.5-2.5% ...... 78 leucovorin calcium ...... 20 750 mg/150ml ...... 13 LIDODERM ...... 78 LEUKERAN ...... 15 levoleucovorin calcium ...... 20 see lidocaine ...... 78 LEUKINE...... 64 levonest ...... 51 lillow ...... 52 leuprolide acetate ...... 16 levonor-eth est tab linezolid ...... 7 levalbuterol hcl ...... 73 0.15-0.02/0.025/0.03 mg linezolid in sodium chloride iv levalbuterol tartrate ...... 73 ð est 0.01 mg ...... 51 soln 600 mg/300ml-0.9% .... 7 LEVAQUIN levonorgestrel & ethinyl LINZESS ...... 61 see levofloxacin ...... 13 estradiol (91-day) tab liothyronine sodium ...... 58 LEVEMIR ...... 48 0.15-0.03 mg ...... 51 LIPITOR ...... 25 LEVEMIR FLEXTOUCH.... 48 levonorgestrel & ethinyl see atorvastatin calcium 25 LEVETIRACETA INJ estradiol tab 0.1 mg-20 mcg LIPOFEN ...... 25 10MG/ML ...... 33 ...... 51 lisinopril ...... 21 LEVETIRACETA INJ levonorgestrel & ethinyl lisinopril & 15MG/ML ...... 33 estradiol tab 0.15 mg-30 mcg hydrochlorothiazide tab LEVETIRACETA INJ ...... 52 10-12.5 mg ...... 21 5MG/ML ...... 33 levonorgestrel-eth estra tab lisinopril & levetiracetam ...... 33 0.05-30/0.075-40/0.125-30m hydrochlorothiazide tab LEVETIRACETAM g-mcg ...... 52 20-12.5 mg ...... 21 see levetiracetam in levonorgestrel-ethinyl lisinopril & sodium chloride iv soln estradiol (continuous) tab hydrochlorothiazide tab 1000 mg/100ml ...... 33 90-20 mcg ...... 52 20-25 mg ...... 21
100 2021 631 3T Copper BvD Plus eff 01/01/2021
LITHIUM...... 44 LOMOTIL LOSEASONIQUE TAB ..... 52 lithium carbonate ...... 44 see diphenoxylate w/ LOTEMAX ...... 71 LITHOBID ...... 44 atropine tab 2.5-0.025 mg see loteprednol etabonate see lithium carbonate .... 44 ...... 61 ...... 71 LIVALO ...... 25 LOMOTIL TAB 2.5MG ...... 61 LOTEMAX SM ...... 71 LO LOESTRIN TAB 1-10-10 LONSURF TAB 15-6.14.... 17 LOTENSIN ...... 21 ...... 52 LONSURF TAB 20-8.19.... 17 see benazepril hcl ...... 21 LODINE loperamide hcl ...... 61 LOTENSIN HCT see etodolac ...... 1 LOPERAMIDE see benazepril & LODOSYN ...... 38 HYDROCHLORIDE ...... 61 hydrochlorothiazide tab see carbidopa ...... 38 LOPID ...... 25 10-12.5 mg ...... 20 LOESTRIN 1.5/30-21 see gemfibrozil ...... 25 see benazepril & see hailey 1.5/30 ...... 51 lopinavir-ritonavir soln hydrochlorothiazide tab see junel 1.5/30 ...... 51 400-100 mg/5ml (80-20 20-12.5 mg ...... 20 see larin 1.5/30 ...... 51 mg/ml) ...... 10 see benazepril & see microgestin 1.5/30 .. 52 lopreeza ...... 54 hydrochlorothiazide tab see norethindrone ace & LOPRESS HCT TAB 20-25 mg ...... 20 ethinyl estradiol tab 1.5 50-25MG ...... 27 loteprednol etabonate ...... 71 mg-30 mcg ...... 52 LOPRESSOR ...... 27 LOTREL LOESTRIN 1/20-21 see metoprolol tartrate .. 27 see amlodipine see aurovela 1/20 ...... 50 LOPRESSOR HCT besylate-benazepril hcl see junel 1/20 ...... 51 see metoprolol & cap 10-20 mg ...... 20 see larin 1/20 ...... 51 hydrochlorothiazide tab see amlodipine see microgestin 1/20 ..... 52 50-25 mg ...... 27 besylate-benazepril hcl see norethindrone ace & LOPROX ...... 76 cap 10-40 mg ...... 20 ethinyl estradiol tab 1 see ciclopirox olamine ... 76 see amlodipine mg-20 mcg ...... 52 lorazepam ...... 31 besylate-benazepril hcl LOESTRIN 21 TAB 1.5/30 52 lorazepam intensol ...... 32 cap 5-10 mg ...... 20 LOESTRIN FE 1.5/30 LORBRENA ...... 18 see amlodipine see aurovela fe 1.5/30 ... 50 lorcet ...... 4 besylate-benazepril hcl see blisovi fe 1.5/30 ...... 50 lorcet hd ...... 4 cap 5-20 mg ...... 20 see junel fe 1.5/30 ...... 51 lorcet plus ...... 4 LOTREL CAP 10-20MG ... 21 see larin fe 1.5/30 ...... 51 loryna ...... 52 LOTREL CAP 10-40MG ... 21 see microgestin fe 1.5/30 losartan potassium ...... 24 LOTREL CAP 5-10MG ..... 21 ...... 52 losartan potassium & LOTREL CAP 5-20MG ..... 21 LOESTRIN FE 1/20 hydrochlorothiazide tab LOTRONEX ...... 61 see aurovela fe 1/20 ...... 50 100-12.5 mg ...... 23 see alosetron hcl ...... 61 see junel fe 1/20 ...... 51 losartan potassium & lovastatin ...... 25 see larin fe 1/20 ...... 51 hydrochlorothiazide tab LOVAZA see microgestin fe ...... 52 100-25 mg ...... 23 see omega-3-acid ethyl see norethindrone ace & losartan potassium & esters cap 1 gm ...... 26 ethinyl estradiol-fe tab 1 hydrochlorothiazide tab LOVAZA CAP 1GM ...... 26 mg-20 mcg ...... 52 50-12.5 mg ...... 23 LOVENOX ...... 64 see tarina fe 1/20 eq ...... 53 LOSEASONIQUE see enoxaparin sodium . 64 LOESTRIN FE TAB 1.5/30 52 see camrese lo ...... 50 low-ogestrel ...... 52 LOESTRIN FE TAB 1/20... 52 see levonorg-eth est tab loxapine succinate ...... 40 LOESTRIN TAB 1/20-21 ... 52 0.1-0.02mg(84) & eth est LUCEMYRA ...... 46 LOKELMA ...... 50 tab 0.01mg(7) ...... 51 LUCENTIS ...... 72
101 2021 631 3T Copper BvD Plus eff 01/01/2021 luliconazole ...... 76 gm/100ml ...... 68 see triamterene & LUMIGAN...... 71 magnesium sulfate in hydrochlorothiazide tab LUMIZYME ...... 56 dextrose 5% iv soln 1 75-50 mg ...... 29 LUMOXITI ...... 19 gm/100ml ...... 68 MAXZIDE TAB 75-50 ...... 29 LUNESTA ...... 42 MALARONE MAXZIDE-25 see eszopiclone ...... 42 see atovaquone-proguanil see triamterene & LUPANETA KIT 11.25-5 ... 53 hcl tab 250-100 mg...... 9 hydrochlorothiazide tab LUPANETA KIT 3.75-5 ..... 53 see atovaquone-proguanil 37.5-25 mg ...... 29 LUPRON DEPOT hcl tab 62.5-25 mg...... 9 MAXZIDE-25 TAB ...... 29 (1-MONTH) ...... 16 MALARONE TAB 250-100 .. 9 MAYZENT ...... 44 LUPRON DEPOT MALARONE TAB 62.5-25 ... 9 meclizine hcl ...... 59 (3-MONTH) ...... 16 malathion ...... 79 meclofenamate sodium ...... 1 LUPRON DEPOT maprotiline hcl ...... 37 MEDROL ...... 55 (4-MONTH) ...... 16 MARINOL ...... 59 see methylprednisolone 55 LUPRON DEPOT see dronabinol ...... 59 MEDROL DOSEPAK ...... 55 (6-MONTH) ...... 16 marlissa ...... 52 see methylprednisolone 55 LUPRON DEPOT-PED MARPLAN ...... 37 medroxyprogesterone (1-MONTH ...... 56 MARQIBO ...... 17 acetate ...... 58 LUPRON DEPOT-PED MATULANE ...... 17 medroxyprogesterone (3-MONTH ...... 56 matzim la ...... 28 acetate (contraceptive) ..... 52 lutera ...... 52 MAVENCLAD (10 TABS) .. 44 mefloquine hcl ...... 9 LUXIQ MAVENCLAD (4 TABS) .... 44 megestrol acetate ...... 16, 58 see betamethasone MAVENCLAD (5 TABS) .... 44 megestrol acetate (appetite) valerate...... 77 MAVENCLAD (6 TABS) .... 44 ...... 58 LUZU ...... 76 MAVENCLAD (7 TABS) .... 44 MEKINIST ...... 19 LYNPARZA ...... 19 MAVENCLAD (8 TABS) .... 44 MEKTOVI ...... 19 LYRICA ...... 33 MAVENCLAD (9 TABS) .... 44 melodetta 24 fe ...... 52 see pregabalin ...... 34 MAVIK meloxicam ...... 1 LYRICA CR ...... 44 see trandolapril ...... 22 memantine hcl ...... 35 LYSODREN ...... 16 MAVYRET TAB 100-40MG memantine hcl tab 28 x 5 mg LYSTEDA...... 65 ...... 11 & 21 x 10 mg titration pack 35 see tranexamic acid ...... 65 MAXALT ...... 43 MENACTRA INJ ...... 67 lyza ...... 52 see rizatriptan benzoate 43 MENEST ...... 54 M MAXALT-MLT ...... 43 MENOSTAR ...... 54 MACROBID ...... 7 see rizatriptan benzoate 43 MENTAX ...... 76 see nitrofurantoin MAXIDEX ...... 71 MENVEO INJ ...... 67 monohyd macro ...... 7 MAXITROL MEPRON ...... 7 MACRODANTIN see see atovaquone...... 6 see nitrofurantoin neomycin-polymyxin-dexa mercaptopurine ...... 16 macrocrystal ...... 7 methasone ophth oint MEROP/NACL INJ mafenide acetate ...... 75 0.1% ...... 69 1GM/50ML ...... 7 magnesium sulfate ...... 68 see MEROP/NACL INJ MAGNESIUM SULFATE ... 68 neomycin-polymyxin-dexa 500/50ML ...... 7 see magnesium sulfate . 68 methasone ophth susp meropenem ...... 7 MAGNESIUM SULFATE IN 0.1% ...... 69 MERREM ...... 7 D5W MAXITROL OIN 0.1% OP . 69 see meropenem ...... 7 see magnesium sulfate in MAXITROL SUS 0.1% OP 69 mesalamine ...... 60 dextrose 5% iv soln 1 MAXZIDE mesalamine w/ cleanser ... 60
102 2021 631 3T Copper BvD Plus eff 01/01/2021
MESNEX ...... 20 metoprolol succinate ...... 27 petrolatum oint MESTINON ...... 44 metoprolol tartrate ...... 27 0.25-15-81.35% ...... 76 see pyridostigmine METROCREAM ...... 78 microgestin 1.5/30 ...... 52 bromide ...... 44 see metronidazole microgestin 1/20 ...... 52 MESTINON TIMESPAN .... 44 (topical) ...... 78 microgestin fe ...... 52 see pyridostigmine see rosadan ...... 79 microgestin fe 1.5/30 ...... 52 bromide ...... 44 METROLOTION ...... 78 midodrine hcl ...... 30 metadate er ...... 42 see metronidazole migergot ...... 43 metaxalone ...... 45 (topical) ...... 78 miglitol ...... 47 metformin hcl ...... 47 METRONIDAZOL INJ miglustat ...... 56 methadone hcl ...... 2 5MG/ML ...... 7 MIGRANAL METHADONE HCL metronidazole ...... 7 see dihydroergotamine see methadone hcl ...... 2 METRONIDAZOLE mesylate ...... 43 methadone hcl intensol ...... 2 see metronidazole in nacl mili ...... 52 METHADOSE 0.74% iv soln 500 mimvey ...... 54 see methadone hcl mg/100ml ...... 7 MINASTRIN 24 CHW FE .. 52 intensol ...... 2 metronidazole (topical)...... 78 MINASTRIN 24 FE methazolamide ...... 29 metronidazole in nacl 0.74% see melodetta 24 fe ...... 52 methenamine hippurate ...... 7 iv soln 500 mg/100ml ...... 7 see mibelas 24 fe ...... 52 methimazole ...... 58 metronidazole in nacl 0.79% see norethindrone ace-eth methocarbamol ...... 45 iv soln 500 mg/100ml ...... 7 estradiol-fe chew tab 1 methotrexate sodium .. 16, 66 metronidazole vaginal ...... 63 mg-20 mcg (24) ...... 52 methoxsalen rapid ...... 76 MG SO4/D5W INJ 10MG/ML MINIPRESS ...... 22 methscopolamine bromide 60 ...... 68 see prazosin hcl ...... 22 methyldopa ...... 30 MIACALCIN minitran ...... 31 METHYLIN ...... 42 see calcitonin (salmon) .. 49 MINIVELLE ...... 54 see methylphenidate hcl 42 mibelas 24 fe ...... 52 MINOCIN methylphenidate hcl ...... 42 micafungin sodium ...... 8 see minocycline hcl ...... 14 METHYLPHENIDATE MICARDIS ...... 24 minocycline hcl ...... 14 HYDROCHLO ...... 42 see telmisartan ...... 24 MINOLIRA ...... 14 methylprednisolone ...... 55 MICARDIS HCT minoxidil ...... 30 methylprednisolone acetate see MIRAPEX ...... 55 telmisartan-hydrochlorothi see pramipexole methylprednisolone sod succ azide tab 40-12.5 mg..... 24 dihydrochloride ...... 38 ...... 55 see MIRAPEX ER ...... 38 metoclopramide hcl ...... 59 telmisartan-hydrochlorothi see pramipexole METOCLOPRAMIDE ODT azide tab 80-12.5 mg..... 24 dihydrochloride ...... 38 ...... 59 see MIRCETTE metolazone ...... 29 telmisartan-hydrochlorothi see azurette ...... 50 metoprolol & azide tab 80-25 mg...... 24 see bekyree ...... 50 hydrochlorothiazide tab MICARDIS HCT TAB see desogest-eth estrad & 100-25 mg ...... 27 40/12.5 ...... 23 eth estrad tab metoprolol & MICARDIS HCT TAB 0.15-0.02/0.01 mg(21/5) 50 hydrochlorothiazide tab 80/12.5 ...... 23 see kariva ...... 51 100-50 mg ...... 27 MICARDIS HCT TAB see pimtrea ...... 53 metoprolol & 80-25MG ...... 23 see simliya ...... 53 hydrochlorothiazide tab miconazole 3 ...... 63 see viorele ...... 53 50-25 mg ...... 27 miconazole-zinc oxide-white MIRCETTE TAB 28 DAY .. 52
103 2021 631 3T Copper BvD Plus eff 01/01/2021 mirtazapine ...... 37 MYCOBUTIN ...... 11 ...... 36 MIRVASO ...... 78 see rifabutin ...... 11 NAMZARIC CAP 7-10MG . 35 misoprostol ...... 61 mycophenolate mofetil ...... 67 NAMZARIC CAP PACK .... 36 MITIGARE ...... 1 mycophenolate sodium ..... 67 NAPROSYN mitomycin ...... 15 MYDAYIS CAP 12.5MG .... 42 see naproxen ...... 1 mitoxantrone hcl ...... 17 MYDAYIS CAP 25MG...... 42 naproxen ...... 1 M-M-R II INJ ...... 67 MYDAYIS CAP 37.5MG .... 42 naproxen dr ...... 1 M-NATAL PLUS TAB ...... 69 MYDAYIS CAP 50MG...... 42 naproxen sodium ...... 1 MOBIC ...... 1 MYFORTIC ...... 67 naratriptan hcl ...... 43 see meloxicam ...... 1 see mycophenolate NARCAN ...... 46 modafinil...... 45 sodium ...... 67 NARDIL ...... 37 moexipril hcl ...... 21 MYLOTARG ...... 19 see phenelzine sulfate .. 37 molindone hcl ...... 40 MYOBLOC ...... 45 NASONEX ...... 74 mometasone furoate ...... 78 myorisan ...... 75 see mometasone furoate mometasone furoate (nasal) MYRBETRIQ ...... 63 (nasal) ...... 74 ...... 74 MYSOLINE ...... 33 NATACYN ...... 70 mondoxyne nl ...... 14 see primidone ...... 34 NATAZIA TAB ...... 52 mono-linyah ...... 52 N nateglinide ...... 47 montelukast sodium ...... 73 nabumetone ...... 1 NATPARA ...... 49 morphine sulfate ...... 2, 4 nadolol ...... 27 NATROBA ...... 79 MORPHINE SULFATE ...... 4 NAFCILLIN INJ 1GM/50ML NAYZILAM ...... 33 see morphine sulfate ...... 4 ...... 14 NEBUPENT ...... 7 morphine sulfate beads ...... 2 NAFCILLIN INJ 2GM/100 . 14 see pentamidine MOTEGRITY ...... 61 nafcillin sodium ...... 14 isethionate inh ...... 7 MOVANTIK ...... 61 NAFCILLIN SODIUM ...... 14 necon 0.5/35-28 ...... 52 MOVIPREP SOL ...... 61 naftifine hcl ...... 76 nefazodone hcl ...... 37 MOXEZA ...... 70 NAFTIN ...... 76 neomycin sulfate ...... 7 see moxifloxacin hcl see naftifine hcl ...... 76 neomycin-bacitrac (ophth) ...... 70 NAGLAZYME ...... 56 zn-polymyx moxifloxacin hcl ...... 13 nalbuphine hcl ...... 4 5(3.5)mg-400unt-10000unt moxifloxacin hcl (ophth) .... 70 naloxone hcl ...... 46 op oin ...... 70 moxifloxacin hcl 400 naltrexone hcl ...... 46 neomycin-polymy-gramicid mg/250ml in sodium chloride NAMENDA ...... 35 op sol 0.8% inj ...... 13 see memantine hcl ...... 35 1.75-10000-0.025mg-unt-mg MOXIFLOXACIN NAMENDA TAB 5-10MG .. 35 /ml ...... 70 HYDROCHLORID ...... 13 NAMENDA TITRATION PAK neomycin-polymyxin b gu MOZOBIL ...... 64 see memantine hcl tab 28 irrigation soln ...... 63 MS CONTIN ...... 2, 3 x 5 mg & 21 x 10 mg neomycin-polymyxin-dexame see morphine sulfate ...... 2 titration pack ...... 35 thasone ophth oint 0.1% ... 69 MULPLETA ...... 65 NAMENDA XR ...... 35 neomycin-polymyxin-dexame MULTAQ ...... 25 see memantine hcl ...... 35 thasone ophth susp 0.1% . 69 mupirocin ...... 75 NAMENDA XR CAP neomycin-polymyxin-hc MVASI ...... 19 TITRATIO ...... 35 ophth susp ...... 69 MYALEPT ...... 56 NAMZARIC CAP 14-10MG neomycin-polymyxin-hc otic MYAMBUTOL ...... 11 ...... 35 soln 1% ...... 79 see ethambutol hcl ...... 10 NAMZARIC CAP 21-10MG neomycin-polymyxin-hc otic MYCAMINE ...... 8 ...... 36 susp 3.5 mg/ml-10000 see micafungin sodium ....8 NAMZARIC CAP 28-10MG unit/ml-1% ...... 80
104 2021 631 3T Copper BvD Plus eff 01/01/2021
NEORAL ...... 67 nitrofurantoin monohyd norethindrone acetate ...... 58 see cyclosporine modified macro ...... 7 norethindrone acetate-ethinyl (for microemulsion) ...... 67 nitroglycerin ...... 31 estradiol tab 0.5 mg-2.5 mcg see gengraf ...... 67 NITROLINGUAL ...... 54 NEPHRAMINE INJ 5.4%... 69 PUMPSPRAY ...... 31 norethindrone acetate-ethinyl NERLYNX ...... 19 see nitroglycerin ...... 31 estradiol tab 1 mg-5 mcg .. 54 neuac gel 1.2-5% ...... 75 NITROSTAT ...... 31 norgestimate & ethinyl NEUPRO...... 38 see nitroglycerin ...... 31 estradiol tab 0.25 mg-35 mcg NEURONTIN ...... 34 NITYR ...... 56 ...... 52 see gabapentin ...... 32 nizatidine ...... 60 norgestimate-eth estrad tab NEVANAC ...... 71 nora-be ...... 52 0.18-25/0.215-25/0.25-25 nevirapine ...... 9 NORCO mg-mcg ...... 52 NEXAVAR ...... 19 see norgestimate-eth estrad tab NEXIUM ...... 62 hydrocodone-acetaminoph 0.18-35/0.215-35/0.25-35 see esomeprazole en tab 10-325 mg ...... 4 mg-mcg ...... 52 magnesium ...... 62 see NORITATE ...... 78 NEXIUM I.V...... 62 hydrocodone-acetaminoph norlyroc ...... 52 see esomeprazole sodium en tab 5-325 mg ...... 4 NORMOSOL -M INJ /D5W 68 ...... 62 see NORMOSOL -R INJ ...... 68 NEXLIZET TAB 180/10MG hydrocodone-acetaminoph NORPACE ...... 25 ...... 26 en tab 7.5-325 mg ...... 4 see disopyramide niacin (antihyperlipidemic). 26 see lorcet ...... 4 phosphate ...... 24 niacor ...... 26 see lorcet hd ...... 4 NORPACE CR ...... 25 NIASPAN ...... 26 see lorcet plus ...... 4 NORPRAMIN ...... 37 see niacin NORCO TAB 10-325MG ..... 4 see desipramine hcl ...... 36 (antihyperlipidemic) ...... 26 NORCO TAB 5-325MG ...... 4 NORTHERA ...... 30 nicardipine hcl ...... 28 NORCO TAB 7.5-325 ...... 4 nortrel 0.5/35 (28) ...... 52 NICARDIPINE SOL NORDITROPIN FLEXPRO nortrel 1/35 (21) ...... 52 20/200ML ...... 28 ...... 56 nortrel 1/35 (28) ...... 52 NICARDIPINE SOL norethindrone & ethinyl nortrel 7/7/7 ...... 52 40/200ML ...... 28 estradiol-fe chew tab 0.4 nortriptyline hcl ...... 37 NICOTROL INHALER ...... 46 mg-35 mcg ...... 52 NORVASC ...... 28 NICOTROL NS ...... 46 norethindrone & ethinyl see amlodipine besylate 27 nifedipine...... 28 estradiol-fe chew tab 0.8 NORVIR ...... 9 nikki ...... 52 mg-25 mcg ...... 52 see ritonavir ...... 10 NILANDRON norethindrone NOURIANZ ...... 38 see nilutamide ...... 16 (contraceptive) ...... 52 NOVAREL ...... 56 nilutamide...... 16 norethindrone ace & ethinyl NOVOLIN INJ 70/30 ...... 48 nimodipine...... 28 estradiol tab 1 mg-20 mcg 52 NOVOLIN INJ 70/30 FP .... 48 NINLARO ...... 19 norethindrone ace & ethinyl NOVOLIN N ...... 48 NIPENT ...... 17 estradiol tab 1.5 mg-30 mcg NOVOLIN N FLEXPEN ..... 48 nisoldipine ...... 28 ...... 52 NOVOLIN R ...... 48 nitisinone ...... 56 norethindrone ace & ethinyl NOVOLIN R FLEXPEN ..... 49 NITRO-BID ...... 31 estradiol-fe tab 1 mg-20 mcg NOVOLOG ...... 49 NITRO-DUR ...... 31 ...... 52 NOVOLOG FLEXPEN ...... 49 see minitran ...... 31 norethindrone ace-eth NOVOLOG MIX INJ 70/30 49 nitrofurantoin ...... 7 estradiol-fe chew tab 1 NOVOLOG MIX INJ nitrofurantoin macrocrystal ..7 mg-20 mcg (24) ...... 52 FLEXPEN ...... 49
105 2021 631 3T Copper BvD Plus eff 01/01/2021
NOVOLOG PENFILL ...... 49 ODACTRA SUB ...... 66 OMNIPOD KIT STARTER 49 NOXAFIL...... 8 ODEFSEY TAB ...... 10 OMNIPOD MIS 5 PACK ... 49 see posaconazole ...... 8 ODOMZO ...... 19 OMNITROPE ...... 57 NPLATE ...... 64 OFEV ...... 73 ondansetron ...... 59 NUBEQA ...... 16 ofloxacin (ophth) ...... 70 ondansetron hcl ...... 59 NUCYNTA ...... 5 ofloxacin (otic) ...... 80 ONE VITE TAB 1MG PLUS NUCYNTA ER ...... 3 OGIVRI ...... 19 ...... 69 NUEDEXTA CAP 20-10MG OGIVRI INJ 420MG ...... 19 ONEXTON GEL 1.2-3.75 .. 75 ...... 44 olanzapine ...... 40 ONFI ...... 34 NULOJIX ...... 67 olmesartan medoxomil ...... 24 see clobazam ...... 32 NULYTELY olmesartan ONIVYDE ...... 17 see gavilyte-n/flavor pack medoxomil-hydrochlorothiazi ONTRUZANT ...... 19 ...... 61 de tab 20-12.5 mg ...... 23 ONZETRA XSAIL ...... 43 see peg 3350-kcl-sod olmesartan OPANA bicarb-nacl for soln 420 medoxomil-hydrochlorothiazi see oxymorphone hcl ...... 5 gm ...... 61 de tab 40-12.5 mg ...... 23 OPDIVO ...... 19 see trilyte ...... 61 olmesartan OPSUMIT ...... 31 NULYTELY SOL FLAV PKS medoxomil-hydrochlorothiazi ORACEA ...... 78 ...... 61 de tab 40-25 mg ...... 23 ORALAIR SUB 300 IR ...... 66 NUPLAZID ...... 40 olmesartan-amlodipine-hydro ORAPRED ODT ...... 55 NUTRILIPID ...... 69 chlorothiazide tab 20-5-12.5 see prednisolone sodium NUTROPIN AQ NUSPIN 10 mg ...... 23 phosphate ...... 55 ...... 56 olmesartan-amlodipine-hydro ORAVIG ...... 79 NUTROPIN AQ NUSPIN 20 chlorothiazide tab 40-10-12.5 ORBACTIV ...... 7 ...... 57 mg ...... 23 ORENITRAM ...... 31 NUTROPIN AQ NUSPIN 5 56 olmesartan-amlodipine-hydro ORFADIN ...... 57 NUVARING chlorothiazide tab 40-10-25 see nitisinone ...... 56 see eluryng ...... 51 mg ...... 24 ORILISSA ...... 53 see etonogestrel-ethinyl olmesartan-amlodipine-hydro ORKAMBI GRA 100-125 .. 73 estradiol va ring chlorothiazide tab 40-5-12.5 ORKAMBI GRA 150-188 .. 73 0.120-0.015 mg/24hr ..... 51 mg ...... 23 ORKAMBI TAB 100-125 ... 73 NUVARING MIS ...... 52 olmesartan-amlodipine-hydro ORKAMBI TAB 200-125 ... 73 NUVIGIL...... 45 chlorothiazide tab 40-5-25 orsythia ...... 52 see armodafinil ...... 45 mg ...... 23 ORTHO MICRONOR ...... 52 nyamyc ...... 76 olopatadine hcl ...... 71 ORTHO TRI- TAB CYCLN NYMALIZE ...... 28 olopatadine hcl (nasal) ...... 72 LO ...... 52 nystatin ...... 8 OLUX ...... 78 ORTHO TRI-CYCLEN LO nystatin (mouth-throat) ...... 79 see clobetasol propionate see norgestimate-eth nystatin (topical) ...... 76 ...... 77 estrad tab nystop ...... 76 OLUX-E ...... 78 0.18-25/0.215-25/0.25-25 O see clobetasol propionate mg-mcg ...... 52 OCALIVA ...... 61 emulsion ...... 77 see tri-lo-estarylla ...... 53 ocella ...... 52 see tovet ...... 78 see tri-lo-marzia ...... 53 OCREVUS ...... 44 OMECLAMOX- MIS PAK .. 61 see tri-lo-mili ...... 53 OCTAGAM ...... 66 omega-3-acid ethyl esters see tri-lo-sprintec ...... 53 octreotide acetate ...... 57 cap 1 gm ...... 26 see tri-vylibra lo ...... 53 OCUFLOX ...... 70 omeprazole ...... 62 oseltamivir phosphate ...... 11 see ofloxacin (ophth) ..... 70 OMNARIS ...... 74 OSMOLEX ER ...... 38
106 2021 631 3T Copper BvD Plus eff 01/01/2021
OSMOLEX ER PAK ...... 38 PALYNZIQ ...... 57 peg 3350-kcl-sod bicarb-nacl OSMOPREP TAB 1.5GM.. 61 PAMELOR ...... 37 for soln 420 gm ...... 61 OSPHENA ...... 57 see nortriptyline hcl ...... 37 PEGANONE ...... 34 OTOVEL DRO ...... 80 pamidronate disodium...... 49 PEGASYS ...... 11 OVIDE ...... 79 PAMIDRONATE DISODIUM PEGASYS PROCLICK ..... 11 OXACILLIN INJ 1GM ...... 14 ...... 49 PEMAZYRE ...... 19 OXACILLIN INJ 2GM ...... 14 PANCREAZE CAP PEN GK/DEXTR INJ oxacillin sodium ...... 14 10500UNT ...... 62 20000/ML ...... 14 oxaliplatin ...... 15 PANCREAZE CAP PEN GK/DEXTR INJ oxandrolone ...... 46 16800UNT ...... 62 40000/ML ...... 14 oxaprozin ...... 1 PANCREAZE CAP PEN GK/DEXTR INJ OXAYDO...... 5 21000UNT ...... 62 60000/ML ...... 14 OXBRYTA ...... 65 PANCREAZE CAP PEN NEEDLES: oxcarbazepine ...... 34 2600UNIT ...... 62 NOVO/BD/ULTIMED/OWEN/ OXISTAT...... 76 PANCREAZE CAP TRIVIDIA ...... 49 OXSORALEN ULTRA ...... 76 4200UNIT ...... 62 penicillamine ...... 50 see methoxsalen rapid .. 76 PANDEL ...... 78 penicillin g potassium ...... 14 OXTELLAR XR ...... 34 pantoprazole sodium...... 62 PENICILLIN G PROCAINE oxybutynin chloride ...... 63 PANZYGA ...... 66 ...... 14 oxycodone hcl ...... 5 paricalcitol ...... 59 penicillin g sodium ...... 14 oxycodone w/ PARLODEL ...... 38 penicillin v potassium ...... 14 acetaminophen tab 10-325 see bromocriptine PENNSAID ...... 79 mg ...... 5 mesylate ...... 38 PENTACEL INJ ...... 68 oxycodone w/ PARNATE ...... 37 PENTAM 300 ...... 7 acetaminophen tab 2.5-325 see tranylcypromine see pentamidine mg ...... 5 sulfate ...... 37 isethionate inj ...... 7 oxycodone w/ paroex ...... 79 pentamidine isethionate inh 7 acetaminophen tab 5-325 paromomycin sulfate ...... 7 pentamidine isethionate inj . 7 mg ...... 5 paroxetine hcl ...... 37 PENTASA ...... 60 oxycodone w/ paroxetine mesylate pentoxifylline ...... 65 acetaminophen tab 7.5-325 (vasomotor) ...... 44 PEPCID ...... 60 mg ...... 5 PASER ...... 11 see famotidine ...... 60 oxycodone-aspirin tab PATANASE ...... 72 PERCOCET 4.8355-325 mg ...... 5 see olopatadine hcl (nasal) see endocet tab 10-325mg OXYCONTIN ...... 3 ...... 72 ...... 3 oxymorphone hcl ...... 5 PAXIL...... 37 see endocet tab OXYTROL ...... 63 see paroxetine hcl ...... 37 2.5-325mg ...... 3 OZEMPIC (0.25 OR PAXIL CR ...... 37 see endocet tab 5-325mg 3 0.5MG/DOSE) ...... 48 see paroxetine hcl ...... 37 see endocet tab OZEMPIC (1MG/DOSE) ... 48 PAZEO ...... 71 7.5-325mg ...... 3 P PEDIAPRED ...... 55 see oxycodone w/ pacerone ...... 25 see prednisolone sodium acetaminophen tab 10-325 paclitaxel ...... 17 phosphate ...... 55 mg ...... 5 PADCEV ...... 19 PEDIARIX INJ 0.5ML ...... 67 see oxycodone w/ paliperidone ...... 40 PEDVAX HIB ...... 68 acetaminophen tab palonosetron hcl ...... 59 peg 3350-kcl-na 2.5-325 mg ...... 5 PALONOSETRON bicarb-nacl-na sulfate for see oxycodone w/ HYDROCHLORID ...... 59 soln 236 gm ...... 61 acetaminophen tab 5-325
107 2021 631 3T Copper BvD Plus eff 01/01/2021
mg ...... 5 PICATO ...... 79 PLEGRIDY INJ STARTER 44 see oxycodone w/ PIFELTRO ...... 9 PLEGRIDY PEN INJ acetaminophen tab pilocarpine hcl ...... 71 STARTER ...... 45 7.5-325 mg ...... 5 pilocarpine hcl (oral)...... 79 plenamine ...... 69 PERCOCET TAB 10-325MG pimecrolimus ...... 79 PLENVU SOL ...... 61 ...... 5 pimozide ...... 40 PNV FOLIC AC TAB + IRON PERCOCET TAB 2.5-325 ...5 pimtrea ...... 53 ...... 69 PERCOCET TAB 5-325MG 5 pindolol ...... 27 podofilox ...... 79 PERCOCET TAB 7.5-325 ...5 pioglitazone hcl ...... 48 POLIVY ...... 19 PERFOROMIST ...... 73 pioglitazone hcl-glimepiride polymyxin b sulfate ...... 7 PERIDEX tab 30-2 mg ...... 48 polymyxin b-trimethoprim see chlorhexidine pioglitazone hcl-glimepiride ophth soln 10000 gluconate (mouth-throat) tab 30-4 mg ...... 48 unit/ml-0.1% ...... 70 ...... 79 pioglitazone hcl-metformin POLYTRIM see paroex ...... 79 hcl tab 15-500 mg ...... 48 see polymyxin see periogard ...... 79 pioglitazone hcl-metformin b-trimethoprim ophth soln perindopril erbumine ...... 21 hcl tab 15-850 mg ...... 48 10000 unit/ml-0.1% ...... 70 periogard ...... 79 piperacillin sod-tazobactam POLYTRIM SOL OP ...... 70 PERJETA ...... 19 na for inj 3.375 gm (3-0.375 POMALYST ...... 16 permethrin ...... 79 gm)...... 14 portia-28 ...... 53 perphenazine ...... 40 piperacillin sod-tazobactam PORTRAZZA ...... 19 PERSERIS ...... 40 sod for inj 13.5 gm (12-1.5 posaconazole ...... 8 PERTZYE CAP 16000U ... 62 gm)...... 14 potassium chloride ...... 69 PERTZYE CAP 24000U ... 62 piperacillin sod-tazobactam POTASSIUM CHLORIDE . 69 PERTZYE CAP 4000UNIT 62 sod for inj 2.25 gm (2-0.25 potassium chloride 20 meq/l PERTZYE CAP 8000UNIT 62 gm)...... 14 (0.15%) in dextrose 5% inj 69 PEXEVA...... 37 piperacillin sod-tazobactam potassium chloride pfizerpen ...... 14 sod for inj 4.5 gm (4-0.5 gm) microencapsulated crystals phenadoz ...... 59 ...... 14 er ...... 69 phenelzine sulfate ...... 37 piperacillin sod-tazobactam potassium citrate (alkalinizer) PHENERGAN ...... 59 sod for inj 40.5 gm (36-4.5 ...... 63 see promethazine hcl .... 59 gm)...... 14 POTELIGEO ...... 19 phenobarbital ...... 34 PIQRAY 200MG DAILY PRADAXA ...... 64 phenobarbital sodium ...... 34 DOSE ...... 19 PRALUENT ...... 26 phenoxybenzamine hcl ..... 30 PIQRAY 250MG TAB DOSE pramipexole dihydrochloride PHENYTEK ...... 34 ...... 19 ...... 38 see phenytoin sodium PIQRAY 300MG DAILY prasugrel hcl ...... 65 extended...... 34 DOSE ...... 19 PRAVACHOL phenytoin ...... 34 pirmella 1/35 ...... 53 see pravastatin sodium . 25 phenytoin sodium ...... 34 piroxicam ...... 1 pravastatin sodium ...... 25 phenytoin sodium extended PLAQUENIL ...... 66 praziquantel ...... 7 ...... 34 see hydroxychloroquine prazosin hcl ...... 22 philith ...... 53 sulfate ...... 66 PRECOSE ...... 48 PHOSLO PLASMA-LYTE INJ -148 ... 68 see acarbose...... 47 see calcium acetate PLASMA-LYTE INJ -A ...... 68 PRED FORTE (phosphate binder) ...... 57 PLAVIX ...... 65 see prednisolone acetate PHOSLYRA ...... 57 see clopidogrel bisulfate 65 (ophth) ...... 71 PHOSPHOLINE IODIDE ... 71 PLEGRIDY ...... 44 PRED MILD ...... 71
108 2021 631 3T Copper BvD Plus eff 01/01/2021
PRED-G S.O.P OIN OP .... 69 mg ...... 7 80-25 mg ...... 27 PRED-G SUS OP ...... 70 PRIMAXIN IV INJ 500MG ... 7 propranolol hcl ...... 27 prednicarbate ...... 78 primidone ...... 34 propylthiouracil ...... 58 prednisolone ...... 55 PRINIVIL ...... 21 PROQUAD INJ ...... 68 prednisolone acetate (ophth) see lisinopril ...... 21 PROSCAR ...... 63 ...... 71 PRISTIQ ...... 37 see finasteride ...... 62 PREDNISOLONE SODIUM see desvenlafaxine PROSOL INJ 20% ...... 69 PHOSP ...... 71 succinate ...... 36 PROTONIX ...... 62 prednisolone sodium PRIVIGEN ...... 66 see pantoprazole sodium phosphate ...... 55 PROAIR HFA ...... 62 prednisone ...... 55 see albuterol sulfate ...... 72 PROTOPIC ...... 79 PREDNISONE INTENSOL probenecid ...... 1 see tacrolimus (topical) . 79 ...... 55 PROCALAMINE INJ 3% ... 69 protriptyline hcl ...... 37 pregabalin ...... 34 PROCARDIA XL ...... 28 PROVERA ...... 58 PREGNYL W/DILUENT see nifedipine ...... 28 see medroxyprogesterone BENZYL ...... 57 prochlorperazine ...... 59 acetate ...... 58 PREMARIN ...... 54 prochlorperazine edisylate 59 PROVIGIL ...... 45 PREMASOL SOL 10% ...... 69 prochlorperazine maleate . 59 see modafinil ...... 45 PREMPHASE TAB ...... 54 PROCRIT ...... 64 PROZAC ...... 37 PREMPRO TAB ...... 54 PROCTOCORT see fluoxetine hcl ...... 36 PREMPRO TAB 0.3-1.5 .... 54 see procto-pak ...... 79 PULMICORT ...... 74 PREMPRO TAB 0.45-1.5 .. 54 procto-med hc ...... 79 see budesonide PREMPRO TAB 0.625-5 ... 54 procto-pak ...... 79 (inhalation) ...... 74 PRENATAL TAB 27-1MG . 69 proctosol hc ...... 79 PULMICORT FLEXHALER PRENATAL TAB PLUS ..... 69 proctozone-hc ...... 79 ...... 74 PRENATAL VIT TAB LOW PROCYSBI ...... 57 PULMOZYME ...... 73 IRON ...... 69 progesterone micronized .. 58 PURIXAN ...... 16 PRETOMANID ...... 11 PROGLYCEM ...... 55 pyrazinamide ...... 11 PREVACID ...... 62 see diazoxide ...... 55 pyridostigmine bromide ..... 44 see lansoprazole ...... 62 PROGRAF ...... 67 pyrimethamine ...... 7 PREVACID SOLUTAB ...... 62 see tacrolimus ...... 67 Q see lansoprazole ...... 62 PROLASTIN-C ...... 73 QBRELIS ...... 21 prevalite ...... 26 PROLENSA ...... 71 QBREXZA ...... 79 previfem ...... 53 PROLIA ...... 49 QINLOCK ...... 19 PREVYMIS ...... 11 PROMACTA ...... 65 QNASL ...... 74 PREZCOBIX TAB 800-150 promethazine hcl ...... 59 QNASL CHILDRENS ...... 74 ...... 10 promethegan ...... 59 QUADRACEL INJ ...... 68 PREZISTA ...... 9 PROMETRIUM ...... 58 QUALAQUIN ...... 9 PRIFTIN ...... 11 see progesterone see quinine sulfate ...... 9 PRILOSEC ...... 62 micronized ...... 58 QUARTETTE primaquine phosphate ...... 9 propafenone hcl ...... 25 see fayosim ...... 51 PRIMAQUINE PHOSPHATE propantheline bromide ...... 60 see levonor-eth est tab ...... 9 proparacaine hcl ...... 72 0.15-0.02/0.025/0.03 mg see primaquine phosphate propranolol & ð est 0.01 mg ...... 51 ...... 9 hydrochlorothiazide tab see rivelsa ...... 53 PRIMAXIN IV 40-25 mg ...... 27 QUARTETTE TAB ...... 53 see imipenem-cilastatin propranolol & QUDEXY XR ...... 34 intravenous for soln 500 hydrochlorothiazide tab QUESTRAN ...... 26
109 2021 631 3T Copper BvD Plus eff 01/01/2021
see cholestyramine ...... 26 RECLAST ...... 49 REYATAZ ...... 10 QUESTRAN LIGHT ...... 26 see zoledronic acid...... 49 see atazanavir sulfate ..... 9 see cholestyramine light 26 reclipsen ...... 53 RHOFADE ...... 79 see prevalite ...... 26 RECOMBIVAX HB ...... 68 RHOPRESSA ...... 71 quetiapine fumarate ...... 40 RECTIV ...... 79 ribavirin (hepatitis c) ...... 11 QUILLICHEW ER ...... 42 REGLAN ...... 59 rifabutin ...... 11 QUILLIVANT XR ...... 42 see metoclopramide hcl 59 RIFADIN ...... 11 quinapril hcl ...... 21 REGRANEX ...... 79 see rifampin ...... 11 quinapril-hydrochlorothiazide RELENZA DISKHALER .... 11 rifampin ...... 11 tab 10-12.5 mg ...... 21 RELEXXII ...... 42 RILUTEK ...... 44 quinapril-hydrochlorothiazide RELISTOR ...... 61 see riluzole ...... 44 tab 20-12.5 mg ...... 21 RELPAX ...... 43 riluzole ...... 44 quinapril-hydrochlorothiazide see eletriptan rimantadine hydrochloride 11 tab 20-25 mg ...... 21 hydrobromide ...... 43 RINVOQ ...... 65 quinidine sulfate ...... 25 REMERON ...... 37 RIOMET ...... 48 quinine sulfate ...... 9 see mirtazapine ...... 37 see metformin hcl ...... 47 QUZYTTIR ...... 72 REMERON SOLTAB ...... 37 RIOMET ER ...... 48 R see mirtazapine ...... 37 risedronate sodium ...... 49 RABAVERT INJ ...... 68 REMODULIN ...... 31 RISPERDAL ...... 40 rabeprazole sodium ...... 62 RENAGEL ...... 57 see risperidone...... 40 RADICAVA ...... 44 see sevelamer hcl ...... 58 RISPERDAL CONSTA ..... 40 RAGWITEK ...... 66 RENFLEXIS ...... 65 risperidone ...... 40 raloxifene hcl ...... 57 RENVELA ...... 57 RITALIN ...... 42 ramelteon ...... 42 see sevelamer carbonate see methylphenidate hcl 42 ramipril ...... 22 ...... 57, 58 RITALIN LA ...... 42 RANEXA ...... 30 repaglinide ...... 48 see methylphenidate hcl 42 see ranolazine ...... 30 REQUIP XL ritonavir ...... 10 ranolazine ...... 30 see ropinirole RITUXAN ...... 19 RAPAFLO ...... 63 hydrochloride ...... 38 RITUXAN INJ HYCELA .... 19 see silodosin ...... 63 RESTORIL ...... 42 rivastigmine ...... 36 RAPAMUNE ...... 67 see temazepam ...... 42 rivastigmine tartrate ...... 36 see sirolimus ...... 67 RETEVMO ...... 19 rivelsa ...... 53 rasagiline mesylate ...... 38 RETIN-A ...... 75 rizatriptan benzoate ...... 43 RAVICTI ...... 57 see avita ...... 74 ROBAXIN-750 RAYALDEE ...... 59 see tretinoin ...... 75 see methocarbamol ...... 45 RAZADYNE RETIN-A MICRO ...... 75 ROCALTROL ...... 59 see galantamine see tretinoin microsphere see calcitriol ...... 58 hydrobromide ...... 35 ...... 75 ropinirole hydrochloride .... 38 RAZADYNE ER ...... 36 RETIN-A MICRO PUMP ... 75 rosadan ...... 79 see galantamine RETROVIR ...... 10 rosuvastatin calcium ...... 25 hydrobromide ...... 35 see zidovudine ...... 10 ROTARIX SUS ...... 68 REBIF ...... 45 REVATIO ...... 31 ROTATEQ SOL ...... 68 REBIF REBIDO INJ see sildenafil citrate ROWASA ...... 60 TITRATN ...... 45 (pulmonary hypertension) see mesalamine w/ REBIF REBIDOSE ...... 45 ...... 31 cleanser ...... 60 REBIF TITRTN INJ PACK. 45 REVCOVI ...... 57 roweepra ...... 34 REBLOZYL ...... 65 REVLIMID ...... 16 roweepra xr ...... 34 RECARBRIO INJ 1.25GM...7 REXULTI ...... 40 ROXICODONE ...... 5
110 2021 631 3T Copper BvD Plus eff 01/01/2021
see oxycodone hcl ...... 5 SAVELLA MIS TITR PAK . 44 simpesse ...... 53 ROZEREM scopolamine ...... 60 simvastatin ...... 26 see ramelteon ...... 42 SEASONIQUE SINEMET ROZLYTREK ...... 19 see amethia ...... 50 see carbidopa & levodopa RUBRACA ...... 19 see ashlyna ...... 50 tab 10-100 mg ...... 38 RUCONEST ...... 65 see camrese ...... 50 see carbidopa & levodopa RUXIENCE ...... 19 see daysee ...... 50 tab 25-100 mg ...... 38 RUZURGI...... 44 see levonorg-eth est tab see carbidopa & levodopa RYBELSUS ...... 48 0.15-0.03mg(84) & eth est tab 25-250 mg ...... 38 RYDAPT ...... 19 tab 0.01mg(7) ...... 51 SINEMET TAB 10-100MG 38 RYTARY CAP 145MG ...... 38 see simpesse ...... 53 SINEMET TAB 25-100MG 38 RYTARY CAP 195MG ...... 38 SEASONIQUE TAB ...... 53 SINEMET TAB 25-250MG 39 RYTARY CAP 245MG ...... 38 SECUADO ...... 40 SINGULAIR ...... 73 RYTARY CAP 95MG ...... 38 selegiline hcl ...... 38 see montelukast sodium 73 RYTHMOL SR ...... 25 selenium sulfide ...... 76 sirolimus ...... 67 see propafenone hcl ...... 25 SELZENTRY ...... 10 SIRTURO ...... 11 S SEMPREX-D CAP 8-60MG SITAVIG ...... 11 SABRIL ...... 34 ...... 72 SIVEXTRO ...... 7 see vigabatrin ...... 35 SENSIPAR ...... 57 SKELAXIN ...... 45 see vigadrone ...... 35 see cinacalcet hcl ...... 56 see metaxalone ...... 45 SAFYRAL SEREVENT DISKUS ...... 73 SKLICE ...... 79 see drospirenone-ethinyl SERNIVO ...... 78 SKYRIZI ...... 65 estrad-levomefolate tab SEROQUEL ...... 40 SLYND ...... 53 3-0.03-0.451 mg ...... 51 see quetiapine fumarate 40 SMOFLIPID EMU ...... 69 see tydemy ...... 53 SEROQUEL XR ...... 40 sodium chloride...... 69 SAFYRAL TAB ...... 53 see quetiapine fumarate 40 sodium chloride (gu irrigant) SAIZEN ...... 57 SEROSTIM ...... 57 ...... 79 SAIZENPREP sertraline hcl ...... 37 sodium fluoride chew; tab; RECONSTITUTION ...... 57 setlakin ...... 53 1.1 (0.5 f) mg/ml soln ...... 69 SALAGEN ...... 79 sevelamer carbonate .. 57, 58 sodium phenylbutyrate ...... 57 see pilocarpine hcl (oral) sevelamer hcl ...... 58 sodium polystyrene sulfonate ...... 79 SFROWASA ...... 60 ...... 50 SAMSCA ...... 57 sharobel ...... 53 sodium polystyrene sulfonate see tolvaptan ...... 57 SHINGRIX ...... 68 powder ...... 50 SANCUSO ...... 59 SIGNIFOR ...... 57 solifenacin succinate ...... 63 SANDIMMUNE ...... 67 SIGNIFOR LAR ...... 57 SOLIQUA INJ 100/33 ...... 49 see cyclosporine ...... 67 SIKLOS ...... 65 SOLIRIS ...... 65 SANDOSTATIN ...... 57 sildenafil citrate (pulmonary SOLODYN ...... 15 see octreotide acetate ... 57 hypertension) ...... 31 see minocycline hcl ...... 14 SANDOSTATIN LAR SILENOR ...... 42 SOLOSEC ...... 7 DEPOT ...... 57 see doxepin hcl (sleep) . 42 SOLTAMOX ...... 16 SANTYL ...... 79 silodosin ...... 63 SOLU-CORTEF ...... 55 SAPHRIS ...... 40 SILVADENE ...... 75 SOLU-MEDROL ...... 55 SARAFEM ...... 37 see silver sulfadiazine ... 75 see methylprednisolone see fluoxetine hcl (pmdd) see ssd ...... 75 sod succ ...... 55 ...... 36 silver sulfadiazine ...... 75 SOMA ...... 45 SARCLISA ...... 19 SIMBRINZA SUS 1-0.2% .. 71 see carisoprodol ...... 45 SAVELLA ...... 44 simliya ...... 53 see vanadom...... 45
111 2021 631 3T Copper BvD Plus eff 01/01/2021
SOMATULINE DEPOT ..... 57 see atomoxetine hcl ...... 41 m tab 400-80 mg...... 7 SOMAVERT ...... 57 STRENSIQ ...... 57 sulfamethoxazole-trimethopri SORIATANE ...... 76 streptomycin sulfate ...... 7 m tab 800-160 mg...... 7 see acitretin ...... 76 STRIBILD TAB ...... 10 SULFAMYLON ...... 75 SORILUX ...... 76 STRIVERDI RESPIMAT ... 73 see mafenide acetate .... 75 sorine ...... 25 STROMECTOL ...... 7 sulfasalazine ...... 60 sotalol hcl ...... 25 see ivermectin ...... 7 sulindac ...... 1 sotalol hcl (afib/afl) ...... 25 SUBLOCADE ...... 46 sumatriptan ...... 43 SOTYLIZE ...... 25 SUBOXONE sumatriptan succinate ...... 43 spironolactone ...... 22 see buprenorphine sumatriptan-naproxen spironolactone & hcl-naloxone hcl sl film sodium tab 85-500 mg ...... 43 hydrochlorothiazide tab 12-3 mg (base equiv) .... 46 SUNOSI ...... 45 25-25 mg ...... 29 see buprenorphine SUPRAX ...... 12 SPORANOX ...... 8 hcl-naloxone hcl sl film see cefixime ...... 12 see itraconazole ...... 8 2-0.5 mg (base equiv) ... 46 SUPREP BOWEL SOL SPORANOX PULSEPAK ....9 see buprenorphine PREP KIT ...... 61 SPRAVATO SOL 56MG hcl-naloxone hcl sl film 4-1 SUSTIVA ...... 10 DOS ...... 37 mg (base equiv) ...... 46 see efavirenz ...... 9 SPRAVATO SOL 84MG see buprenorphine SUSTOL ...... 60 DOS ...... 37 hcl-naloxone hcl sl film 8-2 SUTENT ...... 19 sprintec 28 ...... 53 mg (base equiv) ...... 46 syeda ...... 53 SPRITAM ...... 34 SUBOXONE MIS 12-3MG 46 SYLATRON ...... 17 SPRYCEL ...... 19 SUBOXONE MIS 2-0.5MG SYMBICORT AER 160-4.5 sps ...... 50 ...... 46 ...... 74 sronyx ...... 53 SUBOXONE MIS 4-1MG .. 46 SYMBICORT AER 80-4.5 . 74 ssd ...... 75 SUBOXONE MIS 8-2MG .. 46 SYMDEKO TAB 100-150 .. 73 STALEVO 100 SUBSYS ...... 5 SYMDEKO TAB 50-75MG 73 see subvenite ...... 34 SYMFI LO TAB ...... 10 carbidopa-levodopa-entac subvenite starter kit/blu ..... 34 SYMFI TAB ...... 10 apone tabs 25-100-200 subvenite starter kit/gre..... 34 SYMJEPI ...... 73 mg ...... 38 subvenite starter kit/ora..... 34 SYMLINPEN 120 ...... 48 STALEVO 100 TAB ...... 39 SUCRAID ...... 61 SYMLINPEN 60 ...... 48 STALEVO 125 TAB ...... 39 sucralfate ...... 61 SYMPAZAN ...... 34 STALEVO 150 SULAR ...... 28 SYMPROIC ...... 61 see see nisoldipine ...... 28 SYMTUZA TAB...... 10 carbidopa-levodopa-entac sulfacetamide sodium (acne) SYNALAR ...... 78 apone tabs 37.5-150-200 ...... 75 see fluocinolone acetonide mg ...... 38 sulfacetamide sodium ...... 77 STALEVO 150 TAB ...... 39 (ophth) ...... 70 SYNAREL ...... 53 STALEVO 200 TAB ...... 39 sulfacetamide SYNDROS ...... 60 STALEVO 50 TAB ...... 39 sodium-prednisolone ophth SYNERCID INJ 500MG ...... 7 STALEVO 75 TAB ...... 39 soln 10-0.23(0.25)% ...... 70 SYNJARDY TAB STARLIX ...... 48 SULFADIAZINE ...... 7 12.5-1000MG ...... 48 stavudine...... 10 sulfamethoxazole-trimethopri SYNJARDY TAB 12.5-500 48 STELARA...... 65 m iv soln 400-80 mg/5ml ..... 7 SYNJARDY TAB 5-1000MG STIMATE ...... 57 sulfamethoxazole-trimethopri ...... 48 STIVARGA ...... 19 m susp 200-40 mg/5ml ...... 7 SYNJARDY TAB 5-500MG STRATTERA ...... 42 sulfamethoxazole-trimethopri ...... 48
112 2021 631 3T Copper BvD Plus eff 01/01/2021
SYNJARDY XR TAB TAPAZOLE ...... 58 TEKTURNA HCT TAB 10-1000 ...... 48 see methimazole ...... 58 300-25MG ...... 30 SYNJARDY XR TAB TARCEVA ...... 19 telmisartan ...... 24 12.5-1000MG ...... 48 see erlotinib hcl ...... 18 telmisartan-amlodipine tab SYNJARDY XR TAB TARGADOX ...... 15 40-10 mg ...... 24 25-1000 ...... 48 TARGRETIN ...... 17, 79 telmisartan-amlodipine tab SYNJARDY XR TAB see bexarotene ...... 16 40-5 mg ...... 24 5-1000MG ...... 48 tarina 24 fe ...... 53 telmisartan-amlodipine tab SYNRIBO ...... 17 tarina fe 1/20 eq ...... 53 80-10 mg ...... 24 SYNTHROID ...... 58 TARKA telmisartan-amlodipine tab see euthyrox ...... 58 see trandolapril-verapamil 80-5 mg ...... 24 see levo-t ...... 58 hcl tab er 2-180 mg ...... 21 telmisartan-hydrochlorothiazi see levothyroxine sodium see trandolapril-verapamil de tab 40-12.5 mg...... 24 ...... 58 hcl tab er 2-240 mg ...... 21 telmisartan-hydrochlorothiazi see levoxyl ...... 58 see trandolapril-verapamil de tab 80-12.5 mg...... 24 see unithroid ...... 58 hcl tab er 4-240 mg ...... 21 telmisartan-hydrochlorothiazi SYPRINE ...... 50 TASIGNA ...... 19 de tab 80-25 mg...... 24 see clovique ...... 49 TAVALISSE ...... 65 temazepam ...... 42 see trientine hcl ...... 50 TAXOTERE TEMIXYS TAB 300-300 .... 10 T see docetaxel ...... 17 TEMOVATE ...... 78 TABLOID...... 16 TAYTULLA CAP 1MG/20MC see clobetasol propionate TABRECTA ...... 19 ...... 53 ...... 77 TACLONEX tazarotene ...... 76 temsirolimus ...... 19 see tazicef ...... 12 TENIVAC INJ 5-2LF ...... 68 calcipotriene-betamethaso TAZORAC ...... 76 tenofovir disoproxil fumarate ne dipropionate oint see tazarotene ...... 76 ...... 10 0.005-0.064% ...... 77 taztia xt ...... 28 TENORETIC 100 see TAZVERIK ...... 19 see atenolol & calcipotriene-betamethaso TDVAX INJ 2-2 LF ...... 68 chlorthalidone tab 100-25 ne dipropionate susp TECENTRIQ ...... 19 mg ...... 26 0.005-0.064% ...... 77 TECFIDERA ...... 45 TENORETIC 50 TACLONEX OIN ...... 78 TECFIDERA MIS STARTER see atenolol & TACLONEX SUS ...... 78 ...... 45 chlorthalidone tab 50-25 tacrolimus...... 67 TEFLARO ...... 12 mg ...... 26 tacrolimus (topical) ...... 79 TEGRETOL ...... 34 TENORMIN tadalafil (pulmonary see carbamazepine ...... 32 see atenolol ...... 27 hypertension) ...... 31 see epitol ...... 32 TEPEZZA ...... 57 TAFINLAR ...... 19 TEGRETOL-XR ...... 34 terazosin hcl ...... 22 TAGRISSO ...... 19 see carbamazepine ...... 32 terbinafine hcl ...... 9 TAKHZYRO ...... 65 TEGSEDI ...... 44 terbutaline sulfate ...... 73 TALICIA CAP ...... 61 TEKTURNA ...... 30 terconazole vaginal ...... 63 TALTZ ...... 66 see aliskiren fumarate ... 29 TESTIM ...... 46 TALZENNA ...... 19 TEKTURNA HCT TAB testosterone ...... 46, 47 TAMIFLU...... 11 150-12.5 ...... 30 testosterone cypionate ...... 47 see oseltamivir phosphate TEKTURNA HCT TAB testosterone enanthate ..... 47 ...... 11 150-25MG ...... 30 tetrabenazine ...... 44 tamoxifen citrate ...... 16 TEKTURNA HCT TAB tetracycline hcl ...... 15 tamsulosin hcl ...... 63 300-12.5 ...... 30 THALOMID ...... 16
113 2021 631 3T Copper BvD Plus eff 01/01/2021
THEO-24 ...... 73 tobramycin ...... 8 TRANSDERM SCOP theophylline ...... 74 tobramycin (ophth) ...... 70 see scopolamine ...... 60 THIOLA ...... 63 tobramycin sulfate ...... 8 tranylcypromine sulfate ..... 37 THIOLA EC ...... 63 tobramycin-dexamethasone TRAVASOL INJ 10% ...... 69 thioridazine hcl ...... 40 ophth susp 0.3-0.1% ...... 70 TRAVATAN Z ...... 72 thiothixene...... 40 TOBREX ...... 70 see travoprost ...... 72 tiadylt er ...... 28 see tobramycin (ophth) .. 70 travoprost ...... 72 tiagabine hcl ...... 34 tolmetin sodium ...... 1 TRAZIMERA ...... 19 TIAZAC ...... 28 TOLSURA ...... 9 trazodone hcl ...... 37 see diltiazem hcl extended tolterodine tartrate ...... 63 TREANDA ...... 15 release beads ...... 28 tolvaptan ...... 57 TRECATOR ...... 11 see taztia xt ...... 28 TOPAMAX ...... 34 TRELEGY AER ELLIPTA . 72 see tiadylt er ...... 28 see topiramate ...... 35 TRELSTAR MIXJECT ...... 16 TIBSOVO ...... 19 TOPAMAX SPRINKLE ...... 34 treprostinil ...... 31 tigecycline ...... 15 see topiramate ...... 34 TRESIBA ...... 49 TIGECYCLINE ...... 15 TOPICORT ...... 78 TRESIBA FLEXTOUCH .... 49 TIGLUTIK ...... 44 see desoximetasone ..... 77 tretinoin ...... 75 TIKOSYN ...... 25 topiramate ...... 34, 35 tretinoin (chemotherapy) ... 17 see dofetilide ...... 25 toposar ...... 17 tretinoin microsphere ...... 75 tilia fe ...... 53 topotecan hcl ...... 17 TREXALL ...... 66 timolol maleate ...... 27 TOPOTECAN HCL ...... 17 TREXIMET timolol maleate (ophth) ..... 71 see topotecan hcl ...... 17 see sumatriptan-naproxen timolol maleate (ophth) TOPROL XL ...... 27 sodium tab 85-500 mg .. 43 once-daily...... 71 see metoprolol succinate TREXIMET TAB 85-500MG TIMOPTIC ...... 71 ...... 27 ...... 43 see timolol maleate toremifene citrate ...... 16 trezix ...... 5 (ophth) ...... 71 TORISEL ...... 19 triamcinolone acetonide .... 55 TIMOPTIC OCUDOSE ...... 71 see temsirolimus ...... 19 triamcinolone acetonide TIMOPTIC-XE ...... 72 torsemide ...... 29 (mouth) ...... 79 see timolol maleate tovet ...... 78 triamcinolone acetonide (ophth) ...... 71 TOVIAZ ...... 63 (topical) ...... 78 tinidazole ...... 7 TPN ELECTROL INJ ...... 69 triamterene & TIROSINT ...... 58 TRACLEER ...... 31 hydrochlorothiazide cap TIROSINT-SOL ...... 58 see bosentan ...... 31 37.5-25 mg ...... 29 TIVICAY ...... 10 TRADJENTA ...... 48 triamterene & TIVICAY PD ...... 10 tramadol hcl ...... 3, 5 hydrochlorothiazide tab tizanidine hcl ...... 45 tramadol-acetaminophen tab 37.5-25 mg ...... 29 TOBI ...... 7 37.5-325 mg ...... 5 triamterene & TOBI PODHALER ...... 7 trandolapril ...... 22 hydrochlorothiazide tab TOBRADEX trandolapril-verapamil hcl tab 75-50 mg ...... 29 see er 1-240 mg ...... 21 triazolam ...... 42 tobramycin-dexamethason trandolapril-verapamil hcl tab TRIBENZOR e ophth susp 0.3-0.1% .. 70 er 2-180 mg ...... 21 see TOBRADEX OIN 0.3-0.1% 70 trandolapril-verapamil hcl tab olmesartan-amlodipine-hy TOBRADEX ST SUS er 2-240 mg ...... 21 drochlorothiazide tab 0.3-0.05 ...... 70 trandolapril-verapamil hcl tab 20-5-12.5 mg ...... 23 TOBRADEX SUS 0.3-0.1% er 4-240 mg ...... 21 see ...... 70 tranexamic acid ...... 65 olmesartan-amlodipine-hy
114 2021 631 3T Copper BvD Plus eff 01/01/2021
drochlorothiazide tab tri-linyah ...... 53 tab 80-10 mg ...... 24 40-10-12.5 mg ...... 23 TRILIPIX ...... 25 see telmisartan-amlodipine see see choline fenofibrate .. 25 tab 80-5 mg ...... 24 olmesartan-amlodipine-hy tri-lo-estarylla ...... 53 TWYNSTA TAB 40-10MG 24 drochlorothiazide tab tri-lo-marzia ...... 53 TWYNSTA TAB 40-5MG .. 24 40-10-25 mg ...... 24 tri-lo-mili ...... 53 TWYNSTA TAB 80-10MG 24 see tri-lo-sprintec ...... 53 TWYNSTA TAB 80-5MG .. 24 olmesartan-amlodipine-hy trilyte ...... 61 TYBOST ...... 10 drochlorothiazide tab trimethoprim ...... 8 tydemy ...... 53 40-5-12.5 mg ...... 23 tri-mili ...... 53 TYGACIL ...... 15 see trimipramine maleate ...... 37 see tigecycline...... 15 olmesartan-amlodipine-hy TRINTELLIX ...... 37 TYKERB ...... 19 drochlorothiazide tab tri-previfem ...... 53 TYMLOS ...... 49 40-5-25 mg ...... 23 tri-sprintec ...... 53 TYPHIM VI ...... 68 TRIBENZOR20- TAB TRIUMEQ TAB ...... 10 TYSABRI ...... 45 5-12.5MG ...... 24 trivora-28 ...... 53 TYVASO ...... 31 TRIBENZOR40- TAB tri-vylibra ...... 53 U 10-12.5 ...... 24 tri-vylibra lo ...... 53 UCERIS ...... 61 TRIBENZOR40- TAB TRIZIVIR see budesonide ...... 60 10-25MG ...... 24 see abacavir ULORIC ...... 1 TRIBENZOR40- TAB sulfate-lamivudine-zidovud see febuxostat ...... 1 5-12.5MG ...... 24 ine tab 300-150-300 mg 10 ULTOMIRIS ...... 65 TRIBENZOR40- TAB TRIZIVIR TAB ...... 10 ULTRACET 5-25MG ...... 24 TRODELVY ...... 19 see TRICARE TAB PRENATAL TROGARZO ...... 10 tramadol-acetaminophen ...... 69 TROKENDI XR ...... 35 tab 37.5-325 mg ...... 5 TRICOR ...... 25 TROPHAMINE INJ 10% ... 69 ULTRACET TAB 37.5-325 .. 5 see fenofibrate ...... 25 trospium chloride ...... 63 ULTRAM ...... 5 triderm ...... 78 TRULANCE ...... 61 see tramadol hcl ...... 5 TRIDESILON ...... 78 TRULICITY ...... 48 ULTRAVATE ...... 78 trientine hcl ...... 50 TRUMENBA INJ ...... 68 UNASYN tri-estarylla ...... 53 TRUSOPT ...... 72 see ampicillin & sulbactam trifluoperazine hcl ...... 40 see dorzolamide hcl ...... 71 sodium for inj 1.5 (1-0.5) trifluridine ...... 70 TRUVADA TAB 100-150 ... 10 gm ...... 13 TRIGLIDE ...... 25 TRUVADA TAB 133-200 ... 10 see ampicillin & sulbactam trihexyphenidyl hcl ...... 39 TRUVADA TAB 167-250 ... 10 sodium for inj 3 (2-1) gm 13 TRIJARDY XR TAB ER TRUVADA TAB 200-300 ... 10 UNASYN BULK PACK 24HR 10-5-1000MG ...... 48 TRUXIMA ...... 19 see ampicillin & sulbactam TRIJARDY XR TAB ER TUKYSA ...... 19 sodium for iv soln 15 24HR 12.5-2.5-1000MG .... 48 tulana ...... 53 (10-5) gm ...... 13 TRIJARDY XR TAB ER TURALIO ...... 19 UNASYN INJ 1.5GM ...... 14 24HR 25-5-1000MG ...... 48 TWINRIX INJ ...... 68 UNASYN INJ 15GM ...... 14 TRIJARDY XR TAB ER TWYNSTA UNASYN INJ 3GM ...... 14 24HR 5-2.5-1000MG ...... 48 see telmisartan-amlodipine unithroid ...... 58 TRIKAFTA TAB ...... 74 tab 40-10 mg ...... 24 UPTRAVI ...... 31 tri-legest fe ...... 53 see telmisartan-amlodipine UPTRAVI TAB 200/800 .... 31 TRILEPTAL ...... 35 tab 40-5 mg ...... 24 UROCIT-K 10 ...... 63 see oxcarbazepine ...... 34 see telmisartan-amlodipine see potassium citrate
115 2021 631 3T Copper BvD Plus eff 01/01/2021
(alkalinizer) ...... 63 VANCOCIN HCL ...... 8 VFEND ...... 9 UROCIT-K 15 ...... 63 see vancomycin hcl ...... 8 see voriconazole ...... 9 see potassium citrate VANCOMYCIN ...... 8 VFEND IV ...... 9 (alkalinizer) ...... 63 vancomycin hcl ...... 8 see voriconazole ...... 9 UROCIT-K 5 ...... 63 VANCOMYCIN V-GO 20 KIT ...... 49 see potassium citrate HYDROCHLORIDE ...... 8 V-GO 30 KIT ...... 49 (alkalinizer) ...... 63 VANCOMYCIN INJ 1 GM ... 8 V-GO 40 KIT ...... 49 UROXATRAL VANCOMYCIN INJ 500MG 8 VIBATIV ...... 8 see alfuzosin hcl ...... 62 VANCOMYCIN INJ 750MG 8 VIBERZI ...... 62 URSO 250...... 61 vandazole ...... 63 VIBRAMYCIN ...... 15 see ursodiol ...... 62 VANTAS ...... 16 see doxycycline URSO FORTE ...... 62 VAQTA ...... 68 (monohydrate) ...... 14 see ursodiol ...... 62 VARIVAX ...... 68 see doxycycline hyclate 14 ursodiol ...... 62 VARUBI ...... 60 VICTOZA ...... 48 V VASCEPA ...... 26 VIDAZA ...... 16 VABOMERE INJ 2GM(1-1) .8 VASERETIC see azacitidine ...... 15 VAGIFEM ...... 54 see enalapril maleate & vienva ...... 53 see estradiol vaginal ...... 54 hydrochlorothiazide tab vigabatrin ...... 35 see yuvafem ...... 54 10-25 mg ...... 21 vigadrone ...... 35 valacyclovir hcl ...... 11 VASERETIC TAB 10-25MG VIGAMOX ...... 70 VALCHLOR ...... 79 ...... 21 see moxifloxacin hcl VALCYTE...... 11 VASOTEC ...... 22 (ophth) ...... 70 see valganciclovir hcl .... 11 see enalapril maleate .... 21 VIIBRYD ...... 37 valganciclovir hcl ...... 11 VECTIBIX ...... 19 VIIBRYD KIT STARTER ... 37 VALIUM...... 35 VELCADE ...... 19 VIMIZIM ...... 57 see diazepam ...... 32 VELETRI ...... 31 VIMPAT ...... 35 valproate sodium ...... 35 velivet ...... 53 vinblastine sulfate ...... 17 valproic acid ...... 35 VELPHORO ...... 58 vincristine sulfate ...... 17 valrubicin ...... 15 VELTASSA ...... 50 vinorelbine tartrate ...... 17 valsartan ...... 24 VELTIN GEL ...... 75 VIOKACE TAB 10440 ...... 62 valsartan-hydrochlorothiazid VEMLIDY ...... 11 VIOKACE TAB 20880 ...... 62 e tab 160-12.5 mg ...... 24 VENCLEXTA ...... 19 viorele ...... 53 valsartan-hydrochlorothiazid VENCLEXTA TAB START VIRACEPT ...... 10 e tab 160-25 mg ...... 24 PK ...... 19 VIRAMUNE ...... 10 valsartan-hydrochlorothiazid venlafaxine hcl ...... 37 see nevirapine ...... 9 e tab 320-12.5 mg ...... 24 VENTAVIS ...... 31 VIRAMUNE XR ...... 10 valsartan-hydrochlorothiazid VENTOLIN HFA ...... 73 see nevirapine ...... 9 e tab 320-25 mg ...... 24 verapamil hcl ...... 28 VIREAD ...... 10 valsartan-hydrochlorothiazid VERDESO ...... 78 see tenofovir disoproxil e tab 80-12.5 mg ...... 24 VERELAN ...... 28 fumarate ...... 10 VALSTAR...... 15 see verapamil hcl ...... 28 VISTARIL ...... 72 see valrubicin ...... 15 VERELAN PM ...... 28 see hydroxyzine pamoate VALTOCO ...... 35 see verapamil hcl ...... 28 ...... 72 VALTREX...... 11 VERSACLOZ ...... 40 VITRAKVI ...... 19 see valacyclovir hcl ...... 11 VERZENIO ...... 19 VIVELLE-DOT ...... 54 vanadom ...... 45 VESICARE ...... 63 see dotti ...... 54 VANCOCIN ...... 8 see solifenacin succinate see estradiol ...... 54 see vancomycin hcl ...... 8 ...... 63 VIVITROL ...... 46
116 2021 631 3T Copper BvD Plus eff 01/01/2021
VIZIMPRO ...... 20 X XOPENEX ...... 73 VOGELXO ...... 47 XADAGO ...... 39 see levalbuterol hcl ...... 73 VOGELXO PUMP ...... 47 XALATAN ...... 72 XOPENEX CONCENTRATE VOLTAREN see latanoprost ...... 71 ...... 73 see diclofenac sodium XALKORI ...... 20 see levalbuterol hcl ...... 73 (topical)...... 78 XANAX ...... 32 XOPENEX HFA ...... 73 voriconazole ...... 9 see alprazolam ...... 31 XOSPATA ...... 20 VOSEVI TAB ...... 11 XARELTO ...... 64 XPOVIO 100 MG ONCE VOTRIENT ...... 20 XARELTO STAR TAB WEEKLY ...... 20 VPRIV ...... 57 15/20MG ...... 64 XPOVIO 40 MG ONCE VRAYLAR ...... 40 XATMEP ...... 66 WEEKLY ...... 20 VRAYLAR CAP 1.5-3MG .. 40 XCOPRI ...... 35 XPOVIO 40 MG TWICE VUMERITY ...... 45 XCOPRI PAK 12.5-25 ...... 35 WEEKLY ...... 20 VUMERITY STARTER ...... 45 XCOPRI PAK 150-200MG XPOVIO 60 MG ONCE VUSION OIN ...... 76 (MAINTENANCE) ...... 35 WEEKLY ...... 20 vyfemla ...... 53 XCOPRI PAK 150-200MG XPOVIO 60 MG TWICE vylibra ...... 53 (TITRATION) ...... 35 WEEKLY ...... 20 VYNDAMAX ...... 30 XCOPRI PAK 50-100MG .. 35 XPOVIO 80 MG ONCE VYNDAQEL ...... 30 XCOPRI TAB 50-200MG .. 35 WEEKLY ...... 20 VYTORIN XELJANZ ...... 66 XPOVIO 80 MG TWICE see ezetimibe-simvastatin XELJANZ XR ...... 66 WEEKLY ...... 20 tab 10-10 mg ...... 26 XEMBIFY ...... 66 XTAMPZA ER ...... 3 see ezetimibe-simvastatin XENAZINE ...... 44 XTANDI ...... 16 tab 10-20 mg ...... 26 see tetrabenazine ...... 44 xulane ...... 53 see ezetimibe-simvastatin XENLETA ...... 8 XULTOPHY INJ 100/3.6 ... 49 tab 10-40 mg ...... 26 XEOMIN ...... 45 XYLOCAINE ...... 6 see ezetimibe-simvastatin XEPI...... 76 see lidocaine hcl (local tab 10-80 mg ...... 26 XERESE CRE 5-1% ...... 79 anesth.) ...... 5 VYTORIN TAB 10-10MG .. 26 XERMELO ...... 62 XYLOCAINE-MPF ...... 6 VYTORIN TAB 10-20MG .. 26 XGEVA ...... 49 see lidocaine hcl (local VYTORIN TAB 10-40MG .. 26 XHANCE ...... 74 anesth.) ...... 5 VYTORIN TAB 10-80MG .. 26 XIFAXAN ...... 8, 62 XYOSTED ...... 47 VYVANSE ...... 42 XIGDUO XR TAB 10-1000 48 XYREM ...... 45 VYZULTA ...... 72 XIGDUO XR TAB 10-500MG Y W ...... 48 YASMIN 28 WAKIX ...... 45 XIGDUO XR TAB 2.5-1000 see drospirenone-ethinyl warfarin sodium ...... 64 ...... 48 estradiol tab 3-0.03 mg . 51 water for irrigation, sterile XIGDUO XR TAB 5-1000MG see ocella ...... 52 irrigation soln ...... 79 ...... 48 see syeda ...... 53 WELCHOL ...... 26 XIGDUO XR TAB 5-500MG see zarah ...... 53 see colesevelam hcl ...... 26 ...... 48 see zumandimine ...... 53 WELLBUTRIN SR ...... 37 XIIDRA ...... 72 YASMIN 28 TAB 3-0.03MG see bupropion hcl ...... 36 XODOL ...... 53 WELLBUTRIN XL ...... 37 see YAZ see bupropion hcl ...... 36 hydrocodone-acetaminoph see drospirenone-ethinyl wera ...... 53 en tab 5-300 mg ...... 4 estradiol tab 3-0.02 mg . 51 wymzya fe ...... 53 XOFLUZA ...... 11 see gianvi ...... 51 XOLAIR ...... 74 see jasmiel ...... 51
117 2021 631 3T Copper BvD Plus eff 01/01/2021
see loryna ...... 52 hydrochlorothiazide tab ...... 2 see nikki ...... 52 20-25 mg ...... 21 see hydrocodone bitartrate YAZ TAB 3-0.02MG ...... 53 ZESTORETIC TAB 10-12.5 cap er 12hr YERVOY ...... 20 ...... 21 abuse-deterrent 40 mg .... 2 YF-VAX INJ ...... 68 ZESTORETIC TAB 20-12.5 ZOLADEX ...... 16 yuvafem ...... 54 ...... 21 zoledronic acid ...... 49 Z ZESTORETIC TAB ZOLEDRONIC ACID ...... 49 zafirlukast ...... 73 20-25MG ...... 21 ZOLINZA ...... 20 zaleplon ...... 42 ZESTRIL ...... 22 zolmitriptan ...... 43 ZALTRAP ...... 20 see lisinopril ...... 21 ZOLOFT ...... 37 ZANAFLEX ...... 45 ZETIA ...... 26 see sertraline hcl ...... 37 see tizanidine hcl ...... 45 see ezetimibe ...... 26 zolpidem tartrate ...... 42, 43 zarah ...... 53 ZETONNA ...... 74 ZOMACTON ...... 57 ZARONTIN ...... 35 ZIAC ZOMIG ...... 43 see ethosuximide ...... 32 see bisoprolol & see zolmitriptan ...... 43 ZARXIO...... 64 hydrochlorothiazide tab ZOMIG ZMT ...... 43 ZAVESCA ...... 57 10-6.25 mg ...... 26 see zolmitriptan ...... 43 see miglustat ...... 56 see bisoprolol & ZONEGRAN ZEJULA...... 20 hydrochlorothiazide tab see zonisamide ...... 35 ZELAPAR...... 39 2.5-6.25 mg ...... 26 zonisamide ...... 35 ZELBORAF ...... 20 see bisoprolol & ZONTIVITY ...... 65 ZELNORM ...... 62 hydrochlorothiazide tab ZORBTIVE ...... 57 ZEMAIRA ...... 74 5-6.25 mg ...... 26 ZORTRESS ...... 67 ZEMBRACE SYMTOUCH . 43 ZIAC TAB 10/6.25 ...... 27 see everolimus ZEMDRI ...... 8 ZIAC TAB 2.5/6.25 ...... 27 (immunosuppressant) ... 67 ZEMPLAR ...... 59 ZIAC TAB 5-6.25MG ...... 27 ZOSTAVAX ...... 68 see paricalcitol ...... 59 ZIAGEN ...... 10 ZOSYN SOL 2-0.25GM .... 14 zenatane ...... 75 see abacavir sulfate ...... 9 ZOSYN SOL 3-0.375G ..... 14 ZENPEP CAP 10000UNT . 62 ZIANA ZOSYN SOL 4-0.50GM .... 14 ZENPEP CAP 15000UNT . 62 see clindamycin zovia 1/35e ...... 53 ZENPEP CAP 20000UNT . 62 phosphate-tretinoin gel ZOVIRAX ...... 11, 79 ZENPEP CAP 25000 ...... 62 1.2-0.025% ...... 75 see acyclovir ...... 11 ZENPEP CAP 3000UNIT .. 62 ZIANA GEL ...... 75 see acyclovir topical ...... 78 ZENPEP CAP 40000 ...... 62 zidovudine ...... 10 ZTLIDO ...... 78 ZENPEP CAP 5000UNIT .. 62 ziprasidone hcl ...... 40 ZUBSOLV SUB 0.7-0.18 .. 46 zenzedi ...... 42 ziprasidone mesylate ...... 40 ZUBSOLV SUB 1.4-0.36 .. 46 ZERBAXA INJ 1.5GM ...... 12 ZIRABEV ...... 20 ZUBSOLV SUB 11.4-2.9 .. 46 ZERIT ZIRGAN ...... 70 ZUBSOLV SUB 2.9-0.71 .. 46 see stavudine ...... 10 ZITHROMAX ...... 13 ZUBSOLV SUB 5.7-1.4 .... 46 ZERVIATE ...... 71 see azithromycin ...... 12 ZUBSOLV SUB 8.6-2.1 .... 46 ZESTORETIC ZITHROMAX TRI-PAK ...... 13 zumandimine ...... 53 see lisinopril & ZITHROMAX Z-PAK ...... 13 ZUPLENZ ...... 60 hydrochlorothiazide tab ZOCOR ...... 26 ZYDELIG ...... 20 10-12.5 mg ...... 21 see simvastatin ...... 26 ZYKADIA ...... 20 see lisinopril & ZOFRAN ...... 60 ZYLET SUS 0.5-0.3% ...... 70 hydrochlorothiazide tab see ondansetron hcl ...... 59 ZYLOPRIM ...... 1 20-12.5 mg ...... 21 ZOHYDRO ER ...... 3 see allopurinol ...... 1 see lisinopril & see hydrocodone bitartrate ZYMAXID ...... 70
118 2021 631 3T Copper BvD Plus eff 01/01/2021
see gatifloxacin (ophth) . 70 ZYPREXA RELPREVV ..... 40 see abiraterone acetate 16 ZYPITAMAG ...... 26 ZYPREXA ZYDIS ...... 40 ZYVOX ...... 8 ZYPREXA ...... 40 see olanzapine ...... 40 see linezolid ...... 7 see olanzapine ...... 40 ZYTIGA ...... 16
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P.O. Box 30006, Pittsburgh, PA 15222-0330
This formulary was updated on 08/18/2020. For more recent information or other questions, please contact SilverScript Customer Care at 1-844-460-8767, 24 hours a day, 7 days a week. TTY users should call 711.
The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. 08/18/2020