Community Care Plan Florida Healthy Kids
Preferred Drug List Effective January 1, 2020
The plan covers the drugs Florida Medicaid covers even if not specified in the PDL (see Section 409.815(2)(n)2, Florida Statutes). If your drug is not on the plan’s preferred drug list: First, please call the member's services number located on your Community Care Plan-Florida Healthy kids ID card. If the plan does not cover the drug, then: • Ask your doctor for a similar drug that is covered. • Your doctor can ask the plan to cover your drug through the prior approval process LEGEND TIER DESCRIPTION
1 Preferred
TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame.
Your provider is required to get prior authorization before you fill your PA Prior Authorization prescription, which ensures appropriate use of the selected drug. Without prior approval, we may not cover this drug.
GL Gender Limit This prescription drug is restricted for a single gender.
This prescription drug may only be covered if you meet the minimum AL Age Limit or maximum age limit.
Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions. Some examples of the diseases include; multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.
SDS Extended Specialty Day Supply Extended Specialty Day Supply
PAGE 2 LAST UPDATED 12/2019 LIST OF COVERED PRESCRIPTION MEDICATIONS
DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT
QL alfuzosin hcl generic 1 GL Male
tamsulosin hcl generic 1 QL
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
BUTALBITAL/ACETAMINOPHEN (50MG- 300MG TABLET, 50MG-300MG CAPSULE, generic 1 QL 50MG-325MG TABLET) BUTALBITAL/ACETAMINOPHEN/CAFFEINE (50-300-40 CAPSULE, 50-325-40 TABLET, 50- generic 1 QL 325-40 CAPSULE) OPIATE AGONISTS
acetaminophen with codeine 120-12mg/5 QL generic 1 solution AL At least 12 yrs old
acetaminophen with codeine 300mg/12.5 QL generic 1 solution AL At least 12 yrs old
acetaminophen with codeine 300mg-15mg QL generic 1 tablet AL At least 12 yrs old
acetaminophen with codeine 300mg-30mg QL generic 1 tablet AL At least 12 yrs old
acetaminophen with codeine 300mg-60mg QL generic 1 tablet AL At least 12 yrs old
ARYMO ER QL BRAND 1 morphine sulfate PA
butalbit/acetamin/caff/codeine 50-325-30 generic 1 QL capsule
QL codeine sulfate generic 1 AL At least 18 yrs old
1 QL
PAGE 3 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS EMBEDA BRAND morphine sulfate/naltrexone hcl FENTANYL (25 MCG/HR, 50MCG/HR, 100 generic 1 QL MCG/HR, 12 MCG/HR, 75MCG/HR)
HYDROCODONE QL BITARTRATE/ACETAMINOPHEN (5- generic 1 217MG/10, 2.5-108/5) AL At least 2 yrs old
hydrocodone/acetaminophen 7.5-325/15 QL generic 1 solution AL At least 2 yrs old
HYDROCODONE QL BITARTRATE/ACETAMINOPHEN (10MG- generic 1 325MG, 5 MG-325MG, 7.5-325 MG) AL At least 18 yrs old
HYDROCODONE QL BITARTRATE/ACETAMINOPHEN (5 MG- generic 1 300MG, 10MG-300MG, 7.5-300 MG) AL At least 18 yrs old
QL hydrocodone/acetaminophen 2.5-325 mg tablet generic 1 AL At least 18 yrs old
HYDROCODONE/IBUPROFEN (10MG- QL generic 1 200MG, 7.5-200 MG) AL At least 16 yrs old
QL hydrocodone/ibuprofen 5mg-200mg tablet generic 1 AL At least 16 yrs old
QL hydromorphone hcl 0.5mg/.5ml syringe generic 1 AL At least 18 yrs old
HYDROMORPHONE HCL (4 MG, 2 MG, 8 QL generic 1 MG) AL At least 18 yrs old
HYSINGLA ER QL BRAND 1 hydrocodone bitartrate PA
MORPHABOND ER QL BRAND 1 morphine sulfate PA
morphine sulfate 10 mg/5 ml solution generic 1 QL
morphine sulfate 100 mg/5ml solution generic 1 QL
morphine sulfate 20 mg/5 ml solution generic 1 QL
QL morphine sulfate 15 mg tablet generic 1 AL At least 18 yrs old
PAGE 4 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
QL morphine sulfate 30 mg tablet generic 1 AL At least 18 yrs old
opium/belladonna alkaloids 30-16.2 mg generic 1 QL supp.rect opium/belladonna alkaloids 60-16.2 mg generic 1 QL supp.rect
QL OXAYDO 5 MG TABLET BRAND 1 PA oxycodone hcl AL At least 18 yrs old
oxycodone hcl 5 mg/5 ml solution generic 1 QL
OXYCODONE HCL (10 MG, 20 MG, 5 MG, 30 QL generic 1 MG, 15 MG) AL At least 18 yrs old
OXYCODONE HCL/ACETAMINOPHEN (2.5- QL 325 MG, 10MG-325MG, 7.5-325 MG, 5 MG- generic 1 325MG) AL At least 18 yrs old
ROXYBOND (30 MG, 15 MG) QL BRAND 1 oxycodone hcl PA
ROXYBOND 5 MG TABLET QL BRAND 1 oxycodone hcl PA
QL tramadol hcl 50 mg tablet generic 1 AL At least 18 yrs old
VICODIN QL BRAND 1 hydrocodone bitartrate/acetaminophen AL At least 18 yrs old
VICODIN ES QL BRAND 1 hydrocodone bitartrate/acetaminophen AL At least 18 yrs old
VICODIN HP QL BRAND 1 hydrocodone bitartrate/acetaminophen AL At least 18 yrs old
XTAMPZA ER QL BRAND 1 oxycodone myristate PA
OPIATE PARTIAL AGONISTS
QL BUPRENORPHINE HCL (2 MG, 8 MG) generic 1 PA
BUPRENORPHINE HCL/NALOXONE HCL generic 1 QL
PAGE 5 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
(/NALOXONE 2 MG-0.5MG, /NALOXONE 8 MG-2 MG) PA
BUPRENORPHINE HCL/NALOXONE HCL QL (/NALOXONE 4MG-1MG, /NALOXONE 12 MG- generic 1 3 MG) PA
ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS
AMPHETAMINES
DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF- ASPARTATE (30 MG TABLET, 10 MG CAP generic 1 QL ER 24H, 20 MG CAP ER 24H, 30 MG CAP ER 24H, 15 MG CAP ER 24H, 5 MG CAP ER 24H, 25 MG CAP ER 24H) DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF- generic 1 QL ASPARTATE (20 MG, 7.5 MG, 10 MG, 12.5 MG, 5 MG, 15 MG)
dextroamphetamine sulfate 10 mg tablet generic 1 QL
dextroamphetamine sulfate 5 mg tablet generic 1 QL
VYVANSE (10 MG CHEWABLE TABLET, 60 MG CAPSULE, 60 MG CHEWABLE TABLET, 20 MG CAPSULE, 50 MG CAPSULE, 30 MG CAPSULE, 20 MG CHEWABLE TABLET, 10 MG CAPSULE, 30 MG CHEWABLE TABLET, BRAND 1 QL 40 MG CHEWABLE TABLET, 70 MG CAPSULE, 40 MG CAPSULE, 50 MG CHEWABLE TABLET) lisdexamfetamine dimesylate RESPIRATORY AND CNS STIMULANTS
APTENSIO XR BRAND 1 QL methylphenidate hcl CAFFEINE CITRATE (60 ML VIAL, 60 ML generic 1 SOLUTION) DAYTRANA BRAND 1 QL methylphenidate DEXMETHYLPHENIDATE HCL (30 MG, 35 generic 1 QL MG, 15 MG, 10 MG, 40 MG, 5 MG, 25 MG) DEXMETHYLPHENIDATE HCL (20 MG CPBP generic 1 QL 50-50, 10 MG TABLET)
dexmethylphenidate hcl 2.5 mg tablet generic 1 QL
1
PAGE 6 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
dexmethylphenidate hcl 5 mg tablet generic QL
METHYLPHENIDATE HCL (20 MG, 50 MG, 40 generic 1 QL MG, 60 MG, 10 MG)
methylphenidate hcl 30 mg cpbp 30-70 generic 1 QL
METHYLPHENIDATE HCL (10 MG, 10 MG generic 1 QL ER) METHYLPHENIDATE HCL (5 MG, 20 MG ER, generic 1 QL 20 MG)
QUILLICHEW ER (ER 40 MG, ER 20 MG) QL BRAND 1 methylphenidate hcl AL At least 6 yrs old
QUILLICHEW ER 30 MG CHEW TAB QL BRAND 1 methylphenidate hcl AL At least 6 yrs old
QUILLIVANT XR BRAND 1 QL methylphenidate hcl WAKEFULNESS-PROMOTING AGENTS
QL modafinil generic 1 PA
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
albendazole generic 1 QL
ivermectin 3 mg tablet generic 1
praziquantel generic 1 URINARY ANTI-INFECTIVES
methenamine hippurate generic 1
methenamine mandelate generic 1
nitrofurantoin generic 1
nitrofurantoin macrocrystal generic 1
nitrofurantoin monohydrate/macrocrystals generic 1
trimethoprim generic 1 UTIRA-C methenamine/methylene blue/sod BRAND 1 phos/p.salicylate/hyoscyamine
ANTI-INFECTIVES (EENT)
PAGE 7 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ANTIBACTERIALS (EENT)
bacitracin/polymyxin b sulfate generic 1 QL
CIPRODEX BRAND 1 QL ciprofloxacin hcl/dexamethasone
ciprofloxacin hcl 0.3 % drops generic 1 QL
doxycycline hyclate 20 mg tablet generic 1
erythromycin base 5 mg/gram oint. (g) generic 1 QL
gentamicin sulfate 0.3 % drops generic 1 QL
MOXEZA BRAND 1 QL moxifloxacin hcl
moxifloxacin hcl 0.5 % drops generic 1 QL
neomycin sulfate/bacitracin zinc/polymyxin generic 1 QL b/hydrocortisone
neomycin sulfate/bacitracin/polymyxin b generic 1 QL
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE (DROPS generic 1 QL SUSP, SOLUTION) neomycin/polymyxin b/dexametha 0.1 % drops generic 1 QL susp neomycin/polymyxin b/dexametha 3.5-10k-.1 generic 1 QL oint. (g)
ofloxacin 0.3 % drops generic 1 QL
polymyxin b sulfate/trimethoprim generic 1 QL
sulfacetamide sodium/prednisolone sodium generic 1 QL phosphate TOBRADEX EYE OINTMENT BRAND 1 QL tobramycin/dexamethasone
tobramycin generic 1 QL
tobramycin/dexamethasone generic 1 QL
ZYLET BRAND 1 QL tobramycin/loteprednol etabonate ANTIVIRALS (EENT)
trifluridine generic 1 EENT ANTI-INFECTIVES, MISCELLANEOUS
PAGE 8 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
acetic acid 2 % solution generic 1
chlorhexidine gluconate generic 1
ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)
CLEOCIN 100 MG VAGINAL OVULE BRAND 1 clindamycin phosphate CLINDAMYCIN PHOSPHATE (1 MED. SWAB, generic 1 1 SOLUTION) clindamycin phos/benzoyl perox 1 %-5 % gel generic 1 QL w/pump CLINDESSE BRAND 1 clindamycin phosphate CORTISPORIN CREAM neomycin sulfate/polymyxin b BRAND 1 QL sulfate/hydrocortisone CORTISPORIN OINTMENT neomycin/bacitracin/polymyxin BRAND 1 QL b/hydrocortisone
gentamicin sulfate 0.1 % cream (g) generic 1 METRONIDAZOLE (0.75 GEL (GRAM), 0.75 CREAM (G), 0.75 GEL W/APPL, 1 GEL generic 1 W/PUMP, 1 GEL (GRAM))
mupirocin generic 1 NEOMYCIN SULFATE/POLYMYXIN B generic 1 SULFATE (AMPUL, VIAL) ANTIVIRALS (SKIN AND MUCOUS MEMBRANE)
QL acyclovir 5 % cream (g) generic 1 AL At least 12 yrs old
acyclovir 5 % oint. (g) generic 1
DENAVIR QL BRAND 1 penciclovir AL At least 12 yrs old
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
hydrocortisone/iodoquinol generic 1 SELENIUM SULFIDE (2.5 LOTION, 2.25 generic 1 SHAMPOO)
silver nitrate 0.5 % solution generic 1
1
PAGE 9 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS silver sulfadiazine generic SCABICIDES AND PEDICULICIDES
permethrin generic 1 SKLICE BRAND 1 ivermectin
spinosad generic 1
ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
ALREX BRAND 1 QL loteprednol etabonate dexamethasone sodium phosphate 0.1 % generic 1 QL drops DUREZOL BRAND 1 QL difluprednate FLAREX BRAND 1 QL fluorometholone acetate
fluocinolone acetonide oil generic 1
fluticasone propionate 50 mcg spray susp generic 1 QL
FML FORTE BRAND 1 QL fluorometholone FML S.O.P. BRAND 1 QL fluorometholone
loteprednol etabonate generic 1 QL
MAXIDEX BRAND 1 QL dexamethasone
prednisolone acetate generic 1 QL
EENT ANTI-INFLAMMATORY AGENTS, MISC.
XIIDRA QL BRAND 1 lifitegrast AL At least 17 yrs old
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
diclofenac sodium 0.1 % drops generic 1 QL
flurbiprofen sodium generic 1 QL
ILEVRO BRAND 1 QL nepafenac
PAGE 10 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ketorolac tromethamine 0.5 % drops generic 1 QL
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)
LEUKOTRIENE MODIFIERS
MONTELUKAST SODIUM (10 MG TABLET, 4 generic 1 QL MG TAB CHEW, 5 MG TAB CHEW) MAST-CELL STABILIZERS
cromolyn sodium 4 % drops generic 1 QL
CROMOLYN SODIUM (20 MG/ML ORAL generic 1 CONC, 20 MG/2 ML AMPUL-NEB)
ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)
ANTI-INFLAMMATORY AGENTS, MISC (SKIN)
EUCRISA QL BRAND 1 crisaborole AL At least 2 yrs old
CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)
betamethasone/propylene glyc 0.05 % cream generic 1 (g)
betamethasone valerate 0.1 % cream (g) generic 1 CLOBETASOL PROPIONATE (0.05 SOLUTION, 0.05 CREAM (G), 0.05 OINT. (G), generic 1 0.05 GEL (GRAM))
clobetasol propionate/emoll 0.05 % cream (g) generic 1
fluocinolone acetonide 0.01 % oil generic 1
fluocinolone acetonide/shower cap generic 1 FLUTICASONE PROPIONATE (0.005 OINT., generic 1 0.05 CREAM) HALOBETASOL PROPIONATE (0.05 OINT., generic 1 0.05 CREAM) HYDROCORTISONE (2.5 % CREAM (G), 1 % OINT. (G), 1 % CREAM (G), 100MG/60ML generic 1 ENEMA, 1 % CRM/PE APP, 2.5 % OINT. (G), 2.5 % CRM/PE APP) hydrocortisone/pramoxine 2.5 %-1 % generic 1 cream/appl MOMETASONE FUROATE (0.1 CREAM (G), generic 1 0.1 OINT. (G), 0.1 SOLUTION)
1
PAGE 11 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS PROCTOFOAM-HC BRAND hydrocortisone acetate/pramoxine hcl PROCTOSOL-HC BRAND 1 hydrocortisone PROCTOZONE-HC BRAND 1 hydrocortisone TRIAMCINOLONE ACETONIDE (0.5 OINT., 0.025 CREAM, 0.5 CREAM, 0.1 OINT., 0.1 generic 1 CREAM, 0.1 PASTE, 0.025 OINT.) TRIDERM 0.1% CREAM BRAND 1 triamcinolone acetonide
ANTIANEMIA DRUGS
IRON PREPARATIONS
FUSION PLUS iron fum,polysac comp/folic acid/vit b compc BRAND 1 no.18/l. casei HEMATOGEN FA ferrous fumarate/ascorbic BRAND 1 acid/cyanocobalamin/folic acid HEMOCYTE PLUS ferrous fumarate/folic acid/multivitamin- BRAND 1 minerals no.15 HEMOCYTE-F BRAND 1 ferrous fumarate/folic acid IFEREX 150 FORTE iron polysaccharide BRAND 1 complex/cyanocobalamin/folic acid INTEGRA F iron fumarate,polysac comp/folic acid/vitamin BRAND 1 c/niacinamide INTEGRA PLUS iron fumarate,polysac cplex/folic acid/vitb comp BRAND 1 with c no.9 PUREVIT DUALFE PLUS iron fumarate-iron polysacch cplex/folic BRAND 1 acid/multivit no.18 SE-TAN PLUS iron fumarate-iron polysacch cplex/folic BRAND 1 acid/multivit no.18 TRICON BRAND 1 ferrous fumarate/ascorbic acid/b12-if/folic acid
PAGE 12 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ANTIARRHYTHMIC AGENTS
CLASS IA ANTIARRHYTHMICS
disopyramide phosphate generic 1
quinidine gluconate 324 mg tablet er generic 1
quinidine sulfate generic 1 CLASS IB ANTIARRHYTHMICS
mexiletine hcl generic 1 CLASS IC ANTIARRHYTHMICS
flecainide acetate generic 1 PROPAFENONE HCL (300 MG, 225 MG, 150 generic 1 MG) CLASS III ANTIARRHYTHMICS
AMIODARONE HCL (200 MG, 100 MG) generic 1
PA dofetilide generic 1 S Specialty Drug
ANTIBACTERIALS
AMINOGLYCOSIDE ANTIBIOTICS
GENTAMICIN SULFATE (20 MG/2 ML, 40 generic 1 MG/ML) GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC (GENTAMIC100MG/0.1L, GENTAMIC80 MG/50ML, GENTAMIC80MG/100ML, generic 1 GENTAMIC60 MG/50ML, GENTAMIC120MG/0.1L, GENTAMIC100MG/50ML, GENTAMIC70 MG/50ML)
gentamicin sulfate/pf 20 mg/2 ml vial generic 1
neomycin sulfate generic 1
PA tobramycin in 0.225 % sodium chloride generic 1 S Specialty Drug
TOBRAMYCIN SULFATE (10 MG/ML, 40 generic 1 MG/ML)
PA tobramycin/nebulizer generic 1 S Specialty Drug
PAGE 13 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS QUINOLONE ANTIBIOTICS
ciprofloxacin 250 mg/5ml sus mc rec generic 1 QL
ciprofloxacin 500 mg/5ml sus mc rec generic 1 QL
CIPROFLOXACIN HCL (100 MG, 500 MG, 250 generic 1 QL MG, 750 MG)
ciprofloxacin lactate/dextrose 5 % in water generic 1
LEVOFLOXACIN (500 MG, 750 MG, 250 MG) generic 1 QL
levofloxacin/dextrose 5 % in water generic 1 SULFONAMIDE ANTIBIOTICS (SYSTEMIC)
sulfadiazine generic 1 SULFAMETHOXAZOLE/TRIMETHOPRIM (800-160/20 ORAL SUSP, 200-40MG/5 ORAL generic 1 SUSP, 400MG-80MG TABLET, 800-160 MG TABLET)
SULFASALAZINE (500 MG, 500 MG DR) generic 1 TETRACYCLINE ANTIBIOTICS
DOXYCYCLINE HYCLATE (150 MG TABLET, 75 MG TABLET, 100 MG CAPSULE, 100 MG generic 1 TABLET, 50 MG CAPSULE)
MINOCYCLINE HCL (100 MG, 75 MG, 50 MG) generic 1
ANTIBACTERIALS, MISCELLANEOUS
GLYCOPEPTIDE ANTIBIOTICS
VANCOMYCIN HCL (250 MG, 125 MG) generic 1 VANCOMYCIN HCL (10 G, 500 MG, 750 MG PORT, 250 MG, 1 G, 1.25 G, 5 G, 750 MG, 1 G generic 1 PORT, 1.5 G, 500 MG PORT) VANCOMYCIN IN 0.9 % SODIUM CHLORIDE generic 1 (750MG/.15L, 1G/200ML, 500MG/0.1L) vancomycin hcl in 5 % dextrose 500mg/0.1l generic 1 froz.piggy LINCOMYCIN ANTIBIOTICS
clindamycin hcl generic 1 QL
clindamycin palmitate hcl generic 1 QL
CLINDAMYCIN PHOSPHATE (300 MG/2ML PORT, 900MG/6ML PORT, 150 MG/ML, 600 generic 1
PAGE 14 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS MG/4ML PORT)
lincomycin hcl generic 1 QL
OTHER MISC. ANTIBACTERIAL AGENTS
PYLERA colloidal bismuth BRAND 1 QL subcitrate/metronidazole/tetracycline hcl OXAZOLIDINONE ANTIBIOTICS
linezolid 600 mg tablet generic 1 QL
POLYMYXIN ANTIBIOTICS
colistin (as colistimethate sodium) generic 1
polymyxin b sulfate generic 1
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
ATROVENT HFA BRAND 1 QL ipratropium bromide COMBIVENT RESPIMAT BRAND 1 QL ipratropium bromide/albuterol sulfate DICYCLOMINE HCL (10 MG CAPSULE, 10 generic 1 MG/5 ML SOLUTION, 20 MG TABLET)
GLYCOPYRROLATE (1 MG, 2 MG) generic 1 GLYRX-PF BRAND 1 glycopyrrolate/pf HYOSCYAMINE SULFATE (0.125MG/ML DROPS, 125MCG/5ML ELIXIR, 0.125 MG generic 1 TABLET, 0.375 MG TAB ER 12H, 0.125 MG TAB RAPDIS, 0.125 MG TAB SUBL) INCRUSE ELLIPTA BRAND 1 QL umeclidinium bromide
ipratropium bromide 0.2 mg/ml solution generic 1 QL
ipratropium bromide/albuterol sulfate generic 1
phenobarb/hyoscy/atropine/scop 16.2 mg tablet generic 1
propantheline bromide generic 1 SEEBRI NEOHALER BRAND 1 QL glycopyrrolate SPIRIVA RESPIMAT BRAND 1 QL tiotropium bromide
PAGE 15 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS STIOLTO RESPIMAT BRAND 1 QL tiotropium bromide/olodaterol hcl
ANTICOAGULANTS
COUMARIN DERIVATIVES
JANTOVEN BRAND 1 warfarin sodium
warfarin sodium generic 1 DIRECT FACTOR XA INHIBITORS
ELIQUIS DVT-PE TREAT START 5MG BRAND 1 QL apixaban ELIQUIS (5 MG, 2.5 MG) BRAND 1 QL apixaban SAVAYSA BRAND 1 QL edoxaban tosylate DIRECT THROMBIN INHIBITORS
PRADAXA BRAND 1 QL dabigatran etexilate mesylate HEPARINS
ENOXAPARIN SODIUM (300MG/3ML VIAL, 150 MG/ML SYRINGE, 120MG/.8ML SYRINGE, 100 MG/ML SYRINGE, PA generic 1 40MG/0.4ML SYRINGE, 30MG/0.3ML S Specialty Drug SYRINGE, 80MG/0.8ML SYRINGE, 60MG/0.6ML SYRINGE) HEPARIN SODIUM,PORCINE (20000/ML VIAL, 5000/ML SYRINGE, 1000/ML VIAL, generic 1 5000/ML VIAL, 10000/ML VIAL, 5000/ML(1) CARTRIDGE) HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE (HEPAR25000/500, generic 1 HEPAR12500/250, HEPAR25000/250) heparin sodium,porcine in 0.9 % sodium generic 1 chloride/pf HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN WATER (25000/250, 20K/500ML, generic 1 25000/500) HEPARIN SODIUM,PORCINE/PF (5000/0.5ML SYRINGE, 5000/0.5ML VIAL, 1000/ML VIAL, generic 1 5000/0.5ML CARTRIDGE)
ANTICONVULSANTS
PAGE 16 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ANTICONVULSANTS, MISCELLANEOUS
APTIOM BRAND 1 PA eslicarbazepine acetate BANZEL (400 MG TABLET, 40 MG/ML SUSPENSION, 200 MG TABLET) BRAND 1 PA rufinamide
BRIVIACT (50 MG, 10 MG) QL BRAND 1 brivaracetam PA
BRIVIACT 100 MG TABLET QL BRAND 1 brivaracetam PA
BRIVIACT 25 MG TABLET QL BRAND 1 brivaracetam PA
BRIVIACT 75 MG TABLET QL BRAND 1 brivaracetam PA
BRIVIACT (10 MG/ML ORAL SOLN, 50 MG/5 QL ML VIAL) BRAND 1 brivaracetam PA CARBAMAZEPINE (400 MG TAB ER 12H, 100 MG TAB ER 12H, 200 MG TABLET, 300 MG CPMP 12HR, 200 MG TAB ER 12H, 100 MG generic 1 CPMP 12HR, 200 MG CPMP 12HR, 100 MG TAB CHEW, 100 MG/5ML ORAL SUSP) DIVALPROEX SODIUM (125 MG TABLET DR, 250 MG TAB ER 24H, 125 MG CAP DR SPR, generic 1 500 MG TABLET DR, 500 MG TAB ER 24H, 250 MG TABLET DR) EPITOL BRAND 1 PA carbamazepine EQUETRO BRAND 1 PA carbamazepine FELBAMATE (400 MG TABLET, 600 MG generic 1 TABLET, 600 MG/5ML ORAL SUSP)
FYCOMPA 0.5 MG/ML ORAL SUSP QL BRAND 1 perampanel PA
FYCOMPA (10 MG, 6 MG, 12 MG, 2 MG, 8 QL MG, 4 MG) BRAND 1 perampanel PA
GABAPENTIN (100 MG, 300 MG, 400 MG) generic 1 QL
1
PAGE 17 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
GABAPENTIN (250 MG/5ML, 300 MG/6ML) generic QL
gabapentin 600 mg tablet generic 1 QL
gabapentin 800 mg tablet generic 1 QL
LAMOTRIGINE (50 MG TAB RAPDIS, 25(21)- 50 TB RD DSPK, 25-50-100 TB RD DSPK, 25(84)-100 TAB DS PK, 100 MG TAB RAPDIS, generic 1 PA 25(42)-100 TAB DS PK, 25MG (35) TAB DS PK, 25 MG TAB RAPDIS, 200 MG TAB RAPDIS, 50(42)-100 TB RD DSPK) LAMOTRIGINE (200 MG TABLET, 100 MG TAB ER 24, 200 MG TAB ER 24, 150 MG TABLET, 300 MG TAB ER 24, 5 MG TB CHW generic 1 DSP, 50 MG TAB ER 24, 100 MG TABLET, 25 MG TABLET, 25 MG TAB ER 24, 250 MG TAB ER 24, 25 MG TB CHW DSP)
levetiracetam 500 mg/5ml solution generic 1 QL
LEVETIRACETAM (1000 MG TABLET, 500 MG TAB ER 24H, 100 MG/ML SOLUTION, 500 generic 1 MG TABLET, 750 MG TAB ER 24H, 750 MG TABLET, 250 MG TABLET, 500 MG/5ML VIAL)
magnesium chloride generic 1
magnesium sulfate 4 meq/ml vial generic 1 MAGNESIUM SULFATE IN STERILE WATER (4 G/50 ML PIGGYBACK, 20 G/500ML IV generic 1 SOLN, 4 G/100 ML PIGGYBACK, 40G/1000ML IV SOLN, 2 G/50 ML PIGGYBACK) OXCARBAZEPINE (150 MG TABLET, 300 MG TABLET, 600 MG TABLET, 300 MG/5ML generic 1 ORAL SUSP) OXTELLAR XR BRAND 1 PA oxcarbazepine PREGABALIN (200 MG, 100 MG, 75 MG, 25 generic 1 QL MG, 150 MG, 50 MG)
PREGABALIN (225 MG, 300 MG) generic 1 QL
QUDEXY XR BRAND 1 PA topiramate ROWEEPRA BRAND 1 PA levetiracetam ROWEEPRA XR BRAND 1 PA levetiracetam
SPRITAM BRAND 1 QL
PAGE 18 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
levetiracetam PA
AL At least 4 yrs old
SUBVENITE BRAND 1 PA lamotrigine SUBVENITE (BLUE) BRAND 1 PA lamotrigine SUBVENITE (GREEN) BRAND 1 PA lamotrigine SUBVENITE (ORANGE) BRAND 1 PA lamotrigine
tiagabine hcl generic 1 TOPIRAMATE (50 MG CAP SPR 24, 100 MG CAP SPR 24, 25 MG CAP SPRINK, 200 MG TABLET, 50 MG TABLET, 25 MG TABLET, generic 1 100 MG TABLET, 150 MG CAP SPR 24, 200 MG CAP SPR 24, 15 MG CAP SPRINK, 25 MG CAP SPR 24) TROKENDI XR BRAND 1 PA topiramate
valproic acid generic 1 VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) (250 MG/5ML, generic 1 500MG/10ML)
QL VIGABATRIN (500 MG TABLET, 500 MG generic 1 PA POWD PACK) S Specialty Drug
QL VIGADRONE BRAND 1 PA vigabatrin S Specialty Drug
VIMPAT (10 MG/ML SOLUTION, 150 MG TABLET, 100 MG TABLET, 200 MG TABLET, BRAND 1 PA 50 MG TABLET, STARTER KIT) lacosamide
zonisamide generic 1 BARBITURATES (ANTICONVULSANTS)
primidone generic 1 BENZODIAZEPINES (ANTICONVULSANTS)
PAGE 19 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
PA clobazam 2.5 mg/ml oral susp generic 1 S Specialty Drug
CLOBAZAM (10 MG, 20 MG) generic 1 CLONAZEPAM (2 MG TAB RAPDIS, 2 MG generic 1 QL TABLET) CLONAZEPAM (0.125 MG TAB RAPDIS, 0.5 MG TABLET, 1 MG TAB RAPDIS, 0.25 MG generic 1 QL TAB RAPDIS, 0.5 MG TAB RAPDIS, 1 MG TABLET) HYDANTOINS
DILANTIN 30 MG CAPSULE BRAND 1 PA phenytoin sodium extended PHENYTOIN (50 MG TAB CHEW, 100 MG/4ML ORAL SUSP, 125 MG/5ML ORAL generic 1 SUSP)
phenytoin sodium extended generic 1 SUCCINIMIDES
ETHOSUXIMIDE (250 MG/5ML SOLUTION, generic 1 250 MG CAPSULE)
ANTIDEPRESSANTS
ANTIDEPRESSANTS, MISCELLANEOUS
BUPROPION HCL (100 MG SR, 100 MG ER) generic 1 QL
BUPROPION HCL (300 MG ER, 450 MG ER) generic 1 QL
bupropion hcl 150 mg tab er 24h generic 1 QL
bupropion hcl 100 mg tablet generic 1 QL
bupropion hcl 75 mg tablet generic 1 QL
BUPROPION HCL (200 MG SR, 150 MG SR, generic 1 QL 150 MG ER)
mirtazapine 7.5 mg tablet generic 1 QL
MIRTAZAPINE (15 MG TABLET, 45 MG TABLET, 15 MG TAB RAPDIS, 45 MG TAB generic 1 QL RAPDIS, 30 MG TABLET, 30 MG TAB RAPDIS) SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR
desvenlafaxine succinate generic 1 QL
PAGE 20 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
DULOXETINE HCL (30 MG, 20 MG) generic 1 QL
DULOXETINE HCL (40 MG, 60 MG) generic 1 QL
VENLAFAXINE HCL (37.5 MG ER, 150 MG generic 1 QL ER)
venlafaxine hcl 75 mg cap er 24h generic 1 QL
VENLAFAXINE HCL (50 MG, 75 MG, 25 MG, generic 1 37.5 MG, 100 MG) SELECTIVE-SEROTONIN REUPTAKE INHIBITORS
CITALOPRAM HYDROBROMIDE (20 generic 1 QL MG/10ML, 10 MG/5 ML) CITALOPRAM HYDROBROMIDE (40 MG, 10 generic 1 QL MG, 20 MG)
ESCITALOPRAM OXALATE (10 MG, 5 MG) generic 1 QL
escitalopram oxalate 20 mg tablet generic 1 QL
fluoxetine hcl 10 mg capsule generic 1 QL
fluoxetine hcl 20 mg capsule generic 1 QL
fluoxetine hcl 40 mg capsule generic 1 QL
fluoxetine hcl 20 mg/5 ml solution generic 1 QL
FLUVOXAMINE MALEATE (25 MG, 50 MG) generic 1 QL
fluvoxamine maleate 100 mg tablet generic 1 QL
PAROXETINE HCL (20 MG, 40 MG) generic 1 QL
paroxetine hcl 10 mg tablet generic 1 QL
paroxetine hcl 30 mg tablet generic 1 QL
sertraline hcl 20 mg/ml oral conc generic 1 QL
SERTRALINE HCL (50 MG, 25 MG) generic 1 QL
sertraline hcl 100 mg tablet generic 1 QL
SEROTONIN MODULATORS
trazodone hcl 100 mg tablet generic 1 QL
trazodone hcl 150 mg tablet generic 1 QL
trazodone hcl 300 mg tablet generic 1 QL
PAGE 21 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
trazodone hcl 50 mg tablet generic 1 QL
TRINTELLIX QL BRAND 1 vortioxetine hydrobromide PA
VIIBRYD (10 MG, 20 MG, 40 MG) BRAND 1 QL vilazodone hcl TRICYCLICS, OTHER NOREPI-RU INHIBITORS
amitriptyline hcl generic 1
amitriptyline hcl/chlordiazepoxide generic 1
amoxapine generic 1
clomipramine hcl generic 1 PA
desipramine hcl generic 1 DOXEPIN HCL (150 MG CAPSULE, 75 MG CAPSULE, 50 MG CAPSULE, 10 MG/ML generic 1 ORAL CONC, 100 MG CAPSULE, 25 MG CAPSULE, 10 MG CAPSULE)
imipramine hcl generic 1 NORTRIPTYLINE HCL (50 MG CAPSULE, 10 MG/5 ML SOLUTION, 25 MG CAPSULE, 10 generic 1 MG CAPSULE, 20 MG/10ML SOLUTION, 75 MG CAPSULE)
perphenazine/amitriptyline hcl generic 1
ANTIDIABETIC AGENTS
ALPHA-GLUCOSIDASE INHIBITORS
acarbose 100 mg tablet generic 1 QL
acarbose 25 mg tablet generic 1 QL
acarbose 50 mg tablet generic 1 QL
miglitol generic 1 QL
AMYLINOMIMETICS
SYMLINPEN 120 BRAND 1 QL pramlintide acetate SYMLINPEN 60 BRAND 1 QL pramlintide acetate BIGUANIDES
PAGE 22 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS METFORMIN HCL (500 MG TABLET, 500 MG generic 1 QL TAB ER 24H) METFORMIN HCL (850 MG TABLET, 750 MG generic 1 QL TAB ER 24H)
metformin hcl 1000 mg tablet generic 1 QL
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
JANUMET BRAND 1 QL sitagliptin phosphate/metformin hcl JANUMET XR (50-500 MG, 50-1,000 MG) BRAND 1 QL sitagliptin phosphate/metformin hcl JANUMET XR 100-1,000 MG TABLET BRAND 1 QL sitagliptin phosphate/metformin hcl JANUVIA BRAND 1 QL sitagliptin phosphate JENTADUETO BRAND 1 QL linagliptin/metformin hcl KOMBIGLYZE XR BRAND 1 QL saxagliptin hcl/metformin hcl ONGLYZA BRAND 1 QL saxagliptin hcl TRADJENTA BRAND 1 QL linagliptin INCRETIN MIMETICS
TRULICITY BRAND 1 QL dulaglutide MEGLITINIDES
REPAGLINIDE (1 MG, 0.5 MG) generic 1 QL
repaglinide 2 mg tablet generic 1 QL
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB
FARXIGA BRAND 1 QL dapagliflozin propanediol GLYXAMBI BRAND 1 QL empagliflozin/linagliptin INVOKAMET BRAND 1 QL canagliflozin/metformin hcl INVOKANA BRAND 1 QL canagliflozin
1
PAGE 23 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS JARDIANCE BRAND QL empagliflozin SYNJARDY BRAND 1 QL empagliflozin/metformin hcl XIGDUO XR (10 MG-1,000 MG TAB, 5 MG- 500 MG TABLET, 10 MG-500 MG TABLET) BRAND 1 QL dapagliflozin propanediol/metformin hcl XIGDUO XR (2.5 MG TAB, 5 MG TABLET) BRAND 1 QL dapagliflozin propanediol/metformin hcl SULFONYLUREAS
glimepiride generic 1 GLIPIZIDE (10 MG TAB ER 24, 5 MG TABLET, 10 MG TABLET, 5 MG TAB ER 24, 2.5 MG generic 1 TAB ER 24) GLIPIZIDE/METFORMIN HCL (5 MG-500MG, generic 1 QL 2.5-500 MG)
glipizide/metformin hcl 2.5-250 mg tablet generic 1 QL
glyburide generic 1
glyburide,micronized generic 1 GLYBURIDE/METFORMIN HCL (2.5-500 MG, generic 1 QL 5 MG-500MG)
glyburide/metformin hcl 1.25-250mg tablet generic 1 QL
THIAZOLIDINEDIONES
pioglitazone hcl generic 1 QL
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS
granisetron hcl 1 mg tablet generic 1 QL
ondansetron generic 1 QL
ondansetron hcl 4 mg/5 ml solution generic 1 QL
ONDANSETRON HCL (8 MG, 4 MG) generic 1 QL
ANTIEMETICS, MISCELLANEOUS
scopolamine generic 1 PA
ANTIHISTAMINES (GI DRUGS)
PAGE 24 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
doxylamine succinate/pyridoxine hcl (b6) generic 1 QL
meclizine hcl generic 1
prochlorperazine maleate generic 1 NEUROKININ-1 RECEPTOR ANTAGONISTS
APREPITANT (125 MG, 40 MG) generic 1 QL
aprepitant 80 mg capsule generic 1 QL
ANTIFUNGAL (SYSTEMIC)
ALLYLAMINE ANTIFUNGALS
terbinafine hcl generic 1 ANTIFUNGALS, MISCELLANEOUS
griseofulvin, microsize 125 mg/5ml oral susp generic 1 AZOLE ANTIFUNGALS
FLUCONAZOLE (10 MG/ML SUSP RECON, 50 MG TABLET, 40 MG/ML SUSP RECON, generic 1 200 MG TABLET, 100 MG TABLET)
fluconazole 150 mg tablet generic 1 QL
fluconazole in dextrose, iso-osmotic generic 1 FLUCONAZOLE IN SODIUM CHLORIDE, ISO- OSMOTIC (200MG/0.1L PGGYBK BTL, generic 1 400MG/0.2L PGGYBK BTL, 200MG/0.1L PIGGYBACK, 400MG/0.2L PIGGYBACK) ECHINOCANDIN ANTIFUNGALS
ERAXIS (WATER DILUENT) BRAND 1 anidulafungin POLYENE ANTIFUNGALS
amphotericin b generic 1 NYSTATIN (100000/ML ORAL SUSP, 500K generic 1 UNIT TABLET)
ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)
ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC
ALA-QUIN BRAND 1 clioquinol/hydrocortisone AZOLES (SKIN AND MUCOUS MEMBRANE)
PAGE 25 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS CLOTRIMAZOLE (10 MG TROCHE, 1 % generic 1 CREAM (G), 1 % SOLUTION) clotrimazole/betamethasone dip 1 %-0.05 % generic 1 cream (g)
econazole nitrate generic 1 GYNAZOLE 1 BRAND 1 butoconazole nitrate KETOCONAZOLE (2 CREAM (G), 2 generic 1 SHAMPOO)
miconazole nitrate generic 1 GL Female
TERCONAZOLE (0.4, 0.8) generic 1 GL Female
HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)
ciclopirox 8 % solution generic 1 QL
CICLOPIROX OLAMINE (0.77 CREAM (G), generic 1 0.77 SUSPENSION) POLYENES (SKIN AND MUCOUS MEMBRANE)
NYSTATIN (POWDER, CREAM (G), OINT. generic 1 (G))
ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
brimonidine tartrate 0.2 % drops generic 1 QL
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
carteolol hcl generic 1 QL
levobunolol hcl generic 1 QL
TIMOLOL MALEATE (0.5 DROPS, 0.5 DROP generic 1 QL DAILY) TIMOLOL MALEATE (0.25 DROPS, 0.25 SOL- generic 1 QL GEL, 0.5 SOL-GEL) CARBONIC ANHYDRASE INHIBITORS (EENT)
ACETAZOLAMIDE (125 MG TABLET, 500 MG generic 1 CAPSULE ER, 250 MG TABLET)
dorzolamide hcl generic 1 QL
dorzolamide hcl/timolol maleate generic 1 QL
1
PAGE 26 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS methazolamide generic MIOTICS
PILOCARPINE HCL (4, 2, 1) generic 1 QL
PROSTAGLANDIN ANALOGS
latanoprost generic 1 QL
RHO KINASE INHIBITORS
RHOPRESSA BRAND 1 QL netarsudil mesylate
ANTIHEMORRHAGIC AGENTS
HEMOSTATICS
ADVATE (1,201-1,800, 3,601-4,800) PA antihemophilic factor (fviii) recombinant,full BRAND 1 length S Specialty Drug
ADYNOVATE PA antihemophilic factor (fviii) recombinant, full BRAND 1 length, peg S Specialty Drug
AFSTYLA PA antihemophilic factor viii recomb,single-chn,b- BRAND 1 dom truncated S Specialty Drug
ALPHANATE PA antihemophilic factor, human/von willebrand BRAND 1 factor,human S Specialty Drug
ALPROLIX PA BRAND 1 factor ix recombinant, fc fusion protein S Specialty Drug
AMINOCAPROIC ACID (250 MG/ML VIAL, 250 MG/ML SOLUTION, 500 MG TABLET, 1000 generic 1 MG TABLET)
BENEFIX (1,000, 3,000) PA BRAND 1 factor ix human recombinant S Specialty Drug
COAGADEX PA BRAND 1 coagulation factor x S Specialty Drug
ELOCTATE PA antihemophilic factor (fviii) recombinant, fc BRAND 1 fusion protein S Specialty Drug
FEIBA NF PA BRAND 1 anti-inhibitor coagulant complex S Specialty Drug
PAGE 27 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
HELIXATE FS PA antihemophilic factor (fviii) recombinant,full BRAND 1 length S Specialty Drug
QL HEMLIBRA BRAND 1 PA emicizumab-kxwh S Specialty Drug
HEMOFIL M PA BRAND 1 antihemophilic factor, human S Specialty Drug
HUMATE-P PA antihemophilic factor, human/von willebrand BRAND 1 factor,human S Specialty Drug
IDELVION PA BRAND 1 factor ix recombinant,albumin fusion protein S Specialty Drug
IXINITY (3,000, 2,000, 250) PA BRAND 1 factor ix human recombinant, threonine 148 S Specialty Drug
KOATE PA BRAND 1 antihemophilic factor, human S Specialty Drug
KOGENATE FS PA antihemophilic factor (fviii) recombinant,full BRAND 1 length S Specialty Drug
KOVALTRY PA antihemophilic factor (fviii) recombinant,full BRAND 1 length S Specialty Drug
NOVOEIGHT PA antihemophilic factor viii recombinant, b-domain BRAND 1 truncated S Specialty Drug
NOVOSEVEN RT PA BRAND 1 coagulation factor viia (recombinant) S Specialty Drug
NUWIQ PA antihemophilic factor viii rec hek cell, b-domain BRAND 1 deleted S Specialty Drug
OBIZUR PA antihemophilic factor viii, recombinant porcine BRAND 1 sequence S Specialty Drug
PROFILNINE PA factor ix complex, prothrombin cplx conc(pcc) BRAND 1 no.4, 3-factor S Specialty Drug
RECOMBINATE PA BRAND 1 antihemophilic factor viii, human recombinant
PAGE 28 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
S Specialty Drug
RIXUBIS PA BRAND 1 factor ix human recombinant S Specialty Drug
QL tranexamic acid 650 mg tablet generic 1 GL Female
TRETTEN PA BRAND 1 factor xiii a-subunit, recombinant S Specialty Drug
VONVENDI PA BRAND 1 von willebrand factor (recombinant) S Specialty Drug
WILATE (500-500, 1,000-1,000) PA antihemophilic factor, human/von willebrand BRAND 1 factor,human S Specialty Drug
XYNTHA PA antihemophilic factor (factor viii) recomb,b- BRAND 1 domain deleted S Specialty Drug
XYNTHA SOLOFUSE PA antihemophilic factor (factor viii) recomb,b- BRAND 1 domain deleted S Specialty Drug
ANTIHISTAMINE DRUGS
SECOND GENERATION ANTIHISTAMINES
cetirizine hcl generic 1 QL
levocetirizine dihydrochloride 5 mg tablet generic 1 QL
ANTIHYPOGLYCEMIC AGENTS
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS
PROGLYCEM BRAND 1 diazoxide GLYCOGENOLYTIC AGENTS
GLUCAGEN BRAND 1 glucagon,human recombinant GLUCAGON EMERGENCY KIT BRAND 1 glucagon,human recombinant
glucagon hcl generic 1
ANTILIPEMIC AGENTS
PAGE 29 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ANTILIPEMIC AGENTS, MISCELLANEOUS
NIACIN (1000 MG ER, 750 MG ER) generic 1 QL
niacin 500 mg tab er 24h generic 1 QL
BILE ACID SEQUESTRANTS
cholestyramine (with sugar) 4 g powder generic 1 QL
cholestyramine (with sugar) 4 g powd pack generic 1 QL
cholestyramine/aspartame 4 g powder generic 1 QL
cholestyramine/aspartame 4 g powd pack generic 1 QL
colestipol hcl 1 g tablet generic 1 QL
CHOLESTEROL ABSORPTION INHIBITORS
ezetimibe generic 1 QL
FIBRIC ACID DERIVATIVES
fenofibrate nanocrystallized 145 mg tablet generic 1 QL
fenofibrate nanocrystallized 48 mg tablet generic 1 QL
gemfibrozil generic 1 QL
HMG-COA REDUCTASE INHIBITORS
atorvastatin calcium generic 1 QL
LOVASTATIN (10 MG, 20 MG) generic 1 QL
lovastatin 40 mg tablet generic 1 QL
PRAVASTATIN SODIUM (20 MG, 40 MG, 10 generic 1 QL MG)
pravastatin sodium 80 mg tablet generic 1
rosuvastatin calcium generic 1 QL
SIMVASTATIN (20 MG, 40 MG, 10 MG) generic 1 QL
SIMVASTATIN (5 MG, 80 MG) generic 1 QL
ANTIMIGRAINE AGENTS
CALCITONIN GENE-RELATED PEPTIDE ANTAG.
PAGE 30 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
EMGALITY PEN QL BRAND 1 galcanezumab-gnlm AL At least 18 yrs old
EMGALITY 120 MG/ML SYRINGE QL BRAND 1 galcanezumab-gnlm AL At least 18 yrs old
SELECTIVE SEROTONIN AGONISTS
RIZATRIPTAN BENZOATE (10 MG TABLET, 5 MG TABLET, 5 MG TAB RAPDIS, 10 MG TAB generic 1 QL RAPDIS)
sumatriptan generic 1 QL
SUMATRIPTAN SUCCINATE (50 MG, 100 generic 1 QL MG, 25 MG)
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, MISCELLANEOUS
DAPSONE (100 MG, 25 MG) generic 1 ANTITUBERCULOSIS AGENTS
ethambutol hcl generic 1 ISONIAZID (50 MG/5 ML SOLUTION, 300 MG generic 1 TABLET, 100 MG TABLET)
pyrazinamide generic 1
rifabutin generic 1 RIFAMPIN (600 MG VIAL, 150 MG CAPSULE, generic 1 300 MG CAPSULE)
ANTINEOPLASTIC AGENTS
QL
abiraterone acetate generic 1 PA
S Specialty Drug
ALIMTA PA BRAND 1 pemetrexed disodium S Specialty Drug
anastrozole generic 1
ARZERRA PA BRAND 1 ofatumumab S Specialty Drug
bicalutamide generic 1
bortezomib generic 1 PA
PAGE 31 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
S Specialty Drug
CAMPATH PA BRAND 1 alemtuzumab S Specialty Drug
PA capecitabine generic 1 S Specialty Drug
QL CAPRELSA 100 MG TABLET BRAND 1 PA vandetanib S Specialty Drug
QL CAPRELSA 300 MG TABLET BRAND 1 PA vandetanib S Specialty Drug
CYCLOPHOSPHAMIDE (25 MG, 50 MG) generic 1
PA CYCLOPHOSPHAMIDE (2 G, 500 MG, 1 G) generic 1 S Specialty Drug
QL diclofenac sodium 3 % gel (gram) generic 1 PA
exemestane generic 1 FLUOROURACIL (5 SOLUTION, 2 generic 1 SOLUTION, 5 CREAM (G), 0.5 CREAM (G))
flutamide generic 1
hydroxyurea generic 1
QL
imatinib mesylate 100 mg tablet generic 1 PA
S Specialty Drug
QL
imatinib mesylate 400 mg tablet generic 1 PA
S Specialty Drug
QL IRESSA BRAND 1 PA gefitinib S Specialty Drug
letrozole generic 1
1
PAGE 32 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS LEUKERAN BRAND chlorambucil
MATULANE PA BRAND 1 procarbazine hcl S Specialty Drug
melphalan generic 1
mercaptopurine generic 1 METHOTREXATE SODIUM (25 MG/ML VIAL, generic 1 2.5 MG TABLET) METHOTREXATE SODIUM/PF (1 G, 25 generic 1 MG/ML)
PA mitoxantrone hcl generic 1 S Specialty Drug
MYLERAN PA BRAND 1 busulfan S Specialty Drug
QL NEXAVAR BRAND 1 PA sorafenib tosylate S Specialty Drug
PA nilutamide generic 1 S Specialty Drug
PANRETIN BRAND 1 PA alitretinoin
QL POMALYST BRAND 1 PA pomalidomide S Specialty Drug
PROLEUKIN PA BRAND 1 aldesleukin S Specialty Drug
QL REVLIMID BRAND 1 PA lenalidomide S Specialty Drug
RITUXAN PA BRAND 1 rituximab S Specialty Drug
QL SUTENT (50 MG, 37.5 MG) BRAND 1 sunitinib malate PA S Specialty Drug
PAGE 33 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
QL SUTENT 12.5 MG CAPSULE BRAND 1 PA sunitinib malate S Specialty Drug
QL SUTENT 25 MG CAPSULE BRAND 1 PA sunitinib malate S Specialty Drug
TEMODAR 100 MG VIAL PA BRAND 1 temozolomide S Specialty Drug
PA temozolomide generic 1 S Specialty Drug
TREANDA PA BRAND 1 bendamustine hcl S Specialty Drug
QL
tretinoin 10 mg capsule generic 1 PA
S Specialty Drug
QL VOTRIENT BRAND 1 PA pazopanib hcl S Specialty Drug
QL XTANDI BRAND 1 PA enzalutamide S Specialty Drug
ANTIPARKINSONIAN AGENTS (CNS)
ADAMANTANES (CNS)
AMANTADINE HCL (100 MG TABLET, 100 generic 1 MG CAPSULE, 50 MG/5 ML SOLUTION) ANTICHOLINERGIC AGENTS (CNS)
BENZTROPINE MESYLATE (1 MG, 0.5 MG, 2 generic 1 MG) TRIHEXYPHENIDYL HCL (2 MG/5 ML ELIXIR, generic 1 2 MG TABLET, 5 MG TABLET) DOPAMINE PRECURSORS
PAGE 34 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS CARBIDOPA/LEVODOPA (25MG-250MG TABLET, 25MG-100MG TAB RAPDIS, 25MG- 100MG TABLET ER, 10MG-100MG TAB generic 1 RAPDIS, 50MG-200MG TABLET ER, 10MG- 100MG TABLET, 25MG-100MG TABLET)
carbidopa/levodopa/entacapone generic 1 MONOAMINE OXIDASE B INHIBITORS
SELEGILINE HCL (5 MG TABLET, 5 MG generic 1 CAPSULE)
ANTIPROTOZOALS
ANTIMALARIALS
chloroquine phosphate generic 1
hydroxychloroquine sulfate generic 1
mefloquine hcl generic 1
primaquine phosphate generic 1 ANTIPROTOZOALS, MISCELLANEOUS
atovaquone generic 1
METRONIDAZOLE (250 MG, 500 MG) generic 1
metronidazole in sodium chloride generic 1 NEBUPENT BRAND 1 pentamidine isethionate
tinidazole generic 1
ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTICS, MISCELLANEOUS
loxapine succinate generic 1 AL At least 18 yrs old
pimozide generic 1 ATYPICAL ANTIPSYCHOTICS
QL ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER 400 MG VL, ER 400 MG SYR) BRAND 1 PA aripiprazole AL At least 18 yrs old
QL aripiprazole 1 mg/ml solution generic 1 AL At least 6 yrs old
ARIPIPRAZOLE (15 MG TABLET, 15 MG TAB QL generic 1 RAPDIS, 10 MG TABLET, 30 MG TABLET, 5
PAGE 35 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS MG TABLET, 20 MG TABLET, 10 MG TAB AL At least 6 yrs old RAPDIS, 2 MG TABLET)
QL
PA ARISTADA ER 1064 MG/3.9 ML SYR BRAND 1 aripiprazole lauroxil AL At least 18 yrs old
SDS Extended Specialty Day Supply
QL ARISTADA ER 441 MG/1.6 ML SYRN BRAND 1 PA aripiprazole lauroxil AL At least 18 yrs old
QL ARISTADA ER 662 MG/2.4 ML SYRN BRAND 1 PA aripiprazole lauroxil AL At least 18 yrs old
QL ARISTADA ER 882 MG/3.2 ML SYRN BRAND 1 PA aripiprazole lauroxil AL At least 18 yrs old
QL ARISTADA INITIO BRAND 1 PA aripiprazole lauroxil, submicronized AL At least 18 yrs old
CLOZAPINE (100 MG TABLET, 100 MG TAB QL generic 1 RAPDIS) AL At least 18 yrs old
QL clozapine 200 mg tablet generic 1 AL At least 18 yrs old
QL clozapine 25 mg tablet generic 1 AL At least 18 yrs old
CLOZAPINE (50 MG TABLET, 12.5 MG TAB QL RAPDIS, 150 MG TAB RAPDIS, 25 MG TAB generic 1 RAPDIS, 200 MG TAB RAPDIS) AL At least 18 yrs old
QL INVEGA SUSTENNA 117 MG/0.75 ML BRAND 1 PA paliperidone palmitate AL At least 18 yrs old
QL INVEGA SUSTENNA 156 MG/ML SYRG BRAND 1 PA paliperidone palmitate AL At least 18 yrs old
PAGE 36 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
QL INVEGA SUSTENNA 234 MG/1.5 ML BRAND 1 PA paliperidone palmitate AL At least 18 yrs old
QL INVEGA SUSTENNA 39 MG/0.25 ML BRAND 1 PA paliperidone palmitate AL At least 18 yrs old
QL INVEGA SUSTENNA 78 MG/0.5 ML BRAND 1 PA paliperidone palmitate AL At least 18 yrs old
QL
PA INVEGA TRINZA 273 MG/0.875 ML BRAND 1 paliperidone palmitate AL At least 18 yrs old
SDS Extended Specialty Day Supply
QL
PA INVEGA TRINZA 410 MG/1.315 ML BRAND 1 paliperidone palmitate AL At least 18 yrs old
SDS Extended Specialty Day Supply
QL
PA INVEGA TRINZA 546 MG/1.75 ML BRAND 1 paliperidone palmitate AL At least 18 yrs old
SDS Extended Specialty Day Supply
QL
PA INVEGA TRINZA 819 MG/2.625 ML BRAND 1 paliperidone palmitate AL At least 18 yrs old
SDS Extended Specialty Day Supply OLANZAPINE (15 MG TAB RAPDIS, 15 MG generic 1 QL TABLET) OLANZAPINE (20 MG TABLET, 20 MG TAB generic 1 QL RAPDIS) OLANZAPINE (5 MG TABLET, 2.5 MG generic 1 QL TABLET, 5 MG TAB RAPDIS)
olanzapine 7.5 mg tablet generic 1 QL
OLANZAPINE (10 MG TAB RAPDIS, 10 MG generic 1 QL
PAGE 37 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
TABLET)
QUETIAPINE FUMARATE (50 MG TABLET, QL generic 1 25 MG TABLET, 50 MG TAB ER 24H) AL At least 10 yrs old
QL quetiapine fumarate 150 mg tab er 24h generic 1 AL At least 10 yrs old
QL quetiapine fumarate 200 mg tab er 24h generic 1 AL At least 10 yrs old
QUETIAPINE FUMARATE (400 MG TAB ER QL generic 1 24H, 400 MG TABLET, 300 MG TAB ER 24H) AL At least 10 yrs old
QL quetiapine fumarate 100 mg tablet generic 1 AL At least 10 yrs old
QL quetiapine fumarate 200 mg tablet generic 1 AL At least 10 yrs old
QL quetiapine fumarate 300 mg tablet generic 1 AL At least 10 yrs old
QL RISPERDAL CONSTA BRAND 1 PA risperidone microspheres AL At least 18 yrs old
QL risperidone 1 mg/ml solution generic 1 AL At least 5 yrs old
RISPERIDONE (2 MG TABLET, 1 MG TAB RAPDIS, 0.25 MG TABLET, 2 MG TAB QL generic 1 RAPDIS, 0.25 MG TAB RAPDIS, 0.5 MG TAB AL At least 5 yrs old RAPDIS, 1 MG TABLET, 0.5 MG TABLET)
RISPERIDONE (3 MG TAB RAPDIS, 3 MG QL generic 1 TABLET) AL At least 5 yrs old
RISPERIDONE (4 MG TAB RAPDIS, 4 MG QL generic 1 TABLET) AL At least 5 yrs old
QL ziprasidone hcl generic 1 AL At least 18 yrs old
ZYPREXA RELPREVV QL BRAND 1 olanzapine pamoate AL At least 18 yrs old
PAGE 38 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS BUTYROPHENONES
haloperidol generic 1 HALOPERIDOL DECANOATE (50 MG/ML VIAL, 100 MG/ML AMPUL, 50 MG/ML AMPUL, generic 1 100 MG/ML VIAL) HALOPERIDOL LACTATE (2 MG/ML ORAL generic 1 CONC, 5 MG/ML VIAL, 5 MG/ML AMPUL) PHENOTHIAZINES
CHLORPROMAZINE HCL (100 MG TABLET, 200 MG TABLET, 25 MG TABLET, 10 MG generic 1 TABLET, 25 MG/ML AMPUL, 50 MG TABLET)
fluphenazine decanoate generic 1 FLUPHENAZINE HCL (10 MG TABLET, 2.5 MG/5ML ELIXIR, 5 MG TABLET, 2.5 MG generic 1 TABLET, 5 MG/ML ORAL CONC, 1 MG TABLET, 2.5 MG/ML VIAL)
perphenazine generic 1 AL At least 18 yrs old
thioridazine hcl generic 1
trifluoperazine hcl generic 1 THIOXANTHENES
thiothixene generic 1
ANTIRETROVIRALS
HIV ENTRY AND FUSION INHIBITORS
QL FUZEON BRAND 1 PA enfuvirtide S Specialty Drug
SELZENTRY (20 MG/ML ORAL SOLN, 300 MG TABLET, 25 MG TABLET, 150 MG PA BRAND 1 TABLET, 75 MG TABLET) S Specialty Drug maraviroc HIV INTEGRASE INHIBITOR ANTIRETROVIRALS
QL DOVATO BRAND 1 PA dolutegravir sodium/lamivudine S Specialty Drug
ISENTRESS (100 MG POWDER PACKET, 25 PA MG TABLET CHEW, 400 MG TABLET, 100 BRAND 1 S Specialty Drug
PAGE 39 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS MG TABLET CHEW) raltegravir potassium
ISENTRESS HD PA BRAND 1 raltegravir potassium S Specialty Drug
QL JULUCA BRAND 1 PA dolutegravir sodium/rilpivirine hcl S Specialty Drug
TIVICAY PA BRAND 1 dolutegravir sodium S Specialty Drug
HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.
DELSTRIGO PA doravirine/lamivudine/tenofovir disoproxil BRAND 1 fumarate S Specialty Drug
EDURANT PA BRAND 1 rilpivirine hcl S Specialty Drug
EFAVIRENZ (600 MG TABLET, 50 MG generic 1 S Specialty Drug CAPSULE, 200 MG CAPSULE)
INTELENCE PA BRAND 1 etravirine S Specialty Drug
NEVIRAPINE (100 MG TAB ER 24H, 50 MG/5 PA ML ORAL SUSP, 200 MG TABLET, 400 MG generic 1 TAB ER 24H) S Specialty Drug
PIFELTRO PA BRAND 1 doravirine S Specialty Drug
RESCRIPTOR 200 MG TABLET PA BRAND 1 delavirdine mesylate S Specialty Drug
SYMFI PA efavirenz/lamivudine/tenofovir disoproxil BRAND 1 fumarate S Specialty Drug
SYMFI LO PA efavirenz/lamivudine/tenofovir disoproxil BRAND 1 fumarate S Specialty Drug HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS
abacavir sulfate 20 mg/ml solution generic 1 S Specialty Drug
PA abacavir sulfate 300 mg tablet generic 1 S
PAGE 40 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
Specialty Drug
PA abacavir sulfate/lamivudine generic 1 S Specialty Drug
PA abacavir sulfate/lamivudine/zidovudine generic 1 S Specialty Drug
ATRIPLA PA efavirenz/emtricitabine/tenofovir disoproxil BRAND 1 fumarate S Specialty Drug
BIKTARVY PA bictegravir sodium/emtricitabine/tenofovir BRAND 1 alafenamide fumar S Specialty Drug
CIMDUO PA BRAND 1 lamivudine/tenofovir disoproxil fumarate S Specialty Drug
COMPLERA PA emtricitabine/rilpivirine hcl/tenofovir disoproxil BRAND 1 fumarate S Specialty Drug
QL DESCOVY BRAND 1 PA emtricitabine/tenofovir alafenamide fumarate S Specialty Drug
PA DIDANOSINE (250 MG, 400 MG) generic 1 S Specialty Drug
EMTRIVA (10 MG/ML SOLUTION, 200 MG PA CAPSULE) BRAND 1 emtricitabine S Specialty Drug
EPIVIR HBV 25 MG/5 ML SOLN PA BRAND 1 lamivudine S Specialty Drug
GENVOYA PA elvitegravir/cobicistat/emtricitabine/tenofovir BRAND 1 alafenamide S Specialty Drug
LAMIVUDINE (300 MG TABLET, 10 MG/ML PA generic 1 SOLUTION, 150 MG TABLET) S Specialty Drug
PA lamivudine 100 mg tablet generic 1 S Specialty Drug
PA lamivudine/zidovudine generic 1 S Specialty Drug
1
PAGE 41 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
ODEFSEY PA emtricitabine/rilpivirine hcl/tenofovir BRAND alafenamide fumarate S Specialty Drug
RETROVIR 200 MG/20 ML VIAL PA BRAND 1 zidovudine S Specialty Drug
PA stavudine generic 1 S Specialty Drug
STRIBILD PA elvitegravir/cobicistat/emtricitabine/tenofovir BRAND 1 disoproxil S Specialty Drug
PA tenofovir disoproxil fumarate generic 1 S Specialty Drug
TRIUMEQ PA BRAND 1 abacavir sulfate/dolutegravir sodium/lamivudine S Specialty Drug
TRUVADA PA BRAND 1 emtricitabine/tenofovir disoproxil fumarate S Specialty Drug
VIDEX 2 GM PEDIATRIC SOLN PA BRAND 1 didanosine S Specialty Drug
VIREAD (POWDER, 200 MG TABLET, 150 MG PA TABLET, 250 MG TABLET) BRAND 1 tenofovir disoproxil fumarate S Specialty Drug
ZIDOVUDINE (10 MG/ML SYRUP, 300 MG PA generic 1 TABLET, 100 MG CAPSULE) S Specialty Drug
HIV PROTEASE INHIBITOR ANTIRETROVIRALS
APTIVUS (100 MG/ML SOLUTION, 250 MG PA CAPSULE) BRAND 1 tipranavir/vitamin e tpgs S Specialty Drug
atazanavir sulfate generic 1 S Specialty Drug
CRIXIVAN PA BRAND 1 indinavir sulfate S Specialty Drug
EVOTAZ PA BRAND 1 atazanavir sulfate/cobicistat S Specialty Drug
fosamprenavir calcium generic 1 S Specialty Drug
INVIRASE 500 MG TABLET PA BRAND 1 saquinavir mesylate
PAGE 42 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
S Specialty Drug
KALETRA (100-25 MG, 200-50 MG) PA BRAND 1 lopinavir/ritonavir S Specialty Drug
LEXIVA 50 MG/ML SUSPENSION PA BRAND 1 fosamprenavir calcium S Specialty Drug
lopinavir/ritonavir generic 1 S Specialty Drug
NORVIR (80 MG/ML SOLUTION, 100 MG PA POWDER PACKET) BRAND 1 ritonavir S Specialty Drug
PREZCOBIX PA BRAND 1 darunavir ethanolate/cobicistat S Specialty Drug
PREZISTA (600 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 75 MG PA BRAND 1 TABLET, 800 MG TABLET) S Specialty Drug darunavir ethanolate
REYATAZ 50 MG POWDER PACKET PA BRAND 1 atazanavir sulfate S Specialty Drug
PA ritonavir generic 1 S Specialty Drug
SYMTUZA PA darunavir eth/cobicistat/emtricitabine/tenofovir BRAND 1 alafenamide S Specialty Drug
VIRACEPT PA BRAND 1 nelfinavir mesylate S Specialty Drug
ANTITHROMBOTIC AGENTS
PLATELET-AGGREGATION INHIBITORS
BRILINTA BRAND 1 QL ticagrelor
cilostazol generic 1 QL
clopidogrel bisulfate 75 mg tablet generic 1 QL
prasugrel hcl generic 1 QL
PLATELET-REDUCING AGENTS
anagrelide hcl generic 1 QL
PAGE 43 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES
ANTITOXINS AND IMMUNE GLOBULINS
BIVIGAM PA immune globulin,gamm(igg)/glycine/iga greater BRAND 1 than 50 mcg/ml S Specialty Drug
CUVITRU PA immune globulin,gamm(igg)/glycine/iga greater BRAND 1 than 50 mcg/ml S Specialty Drug
FLEBOGAMMA DIF PA immune globulin,gamma (igg)/sorbitol/iga 0 to BRAND 1 50 mcg/ml S Specialty Drug
GAMASTAN S-D PA BRAND 1 immune globulin,gamma(igg)/glycine S Specialty Drug
GAMMAGARD LIQUID PA immune globulin,gamm(igg)/glycine/iga greater BRAND 1 than 50 mcg/ml S Specialty Drug
GAMMAGARD S-D PA immune globulin,gamm(igg)/glycine/glucose/iga BRAND 1 0 to 50 mcg/ml S Specialty Drug GAMMAKED (5 GRAM/50 ML, 10 GRAM/100 ML, 20 GRAM/200 ML) PA BRAND 1 immune globulin,gamma(igg)/glycine/iga S Specialty Drug average 46 mcg/ml GAMMAPLEX (5 GRAM/50 ML, 20 GRAM/400 ML, 5 GRAM/100 ML, 10 GRAM/100 ML, 10 PA GRAM/200 ML, 20 GRAM/200 ML) BRAND 1 immune globulin,gamma (igg)/glycine/iga 0 to S Specialty Drug 50 mcg/ml
GAMUNEX-C PA immune globulin,gamma(igg)/glycine/iga BRAND 1 average 46 mcg/ml S Specialty Drug
HIZENTRA PA immune globulin,gamma (igg)/proline/iga 0 to BRAND 1 50 mcg/ml S Specialty Drug
HYQVIA PA immune globulin,gamma(igg) BRAND 1 human/hyaluronidase, human recomb S Specialty Drug
HYQVIA IG COMPONENT PA immune globulin,gamm(igg)/glycine/iga greater BRAND 1 than 50 mcg/ml S Specialty Drug
OCTAGAM PA immune globulin,gamm(igg)/maltose/iga BRAND 1 greater than 50 mcg/ml S Specialty Drug
PAGE 44 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
PRIVIGEN PA immune globulin,gamma (igg)/proline/iga 0 to BRAND 1 50 mcg/ml S Specialty Drug
ANTIULCER AGENTS AND ACID SUPPRESSANTS
HISTAMINE H2-ANTAGONISTS
FAMOTIDINE (20 MG TABLET, 10 MG/ML generic 1 VIAL, 40 MG TABLET)
famotidine in sodium chloride, iso-osmotic/pf generic 1
famotidine/pf generic 1 RANITIDINE HCL (300 MG TABLET, 150 MG generic 1 TABLET, 15 MG/ML SYRUP) PROSTAGLANDINS
misoprostol generic 1 PROTECTANTS
sucralfate 1 g tablet generic 1 PROTON-PUMP INHIBITORS
LANSOPRAZOLE (30 MG, 15 MG) generic 1 QL
NEXIUM (20 MG, 2.5 MG, 10 MG, 40 MG, 5 MG) BRAND 1 QL esomeprazole magnesium
omeprazole generic 1 QL
pantoprazole sodium 20 mg tablet dr generic 1 QL
pantoprazole sodium 40 mg tablet dr generic 1 QL
PROTONIX 40 MG SUSPENSION BRAND 1 QL pantoprazole sodium
ANTIVIRALS (SYSTEMIC)
INTERFERON ANTIVIRALS
INTRON A PA BRAND 1 interferon alfa-2b,recomb. S Specialty Drug
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 PA ML SYRINGE) BRAND 1 peginterferon alfa-2a S Specialty Drug
PEGASYS PROCLICK 180 MCG/0.5 PA BRAND 1 peginterferon alfa-2a S Specialty Drug
PAGE 45 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
PEGINTRON PA BRAND 1 peginterferon alfa-2b S Specialty Drug
NEURAMINIDASE INHIBITOR ANTIVIRALS
OSELTAMIVIR PHOSPHATE (30 MG, 45 MG, generic 1 QL 75 MG)
oseltamivir phosphate 6 mg/ml susp recon generic 1 QL
RELENZA BRAND 1 QL zanamivir NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS
ACYCLOVIR (200 MG CAPSULE, 400 MG TABLET, 200 MG/5ML ORAL SUSP, 800 MG generic 1 TABLET)
QL
entecavir generic 1 PA
S Specialty Drug
QL MODERIBA 200 MG TABLET BRAND 1 PA ribavirin S Specialty Drug
QL RIBASPHERE 200 MG CAPSULE BRAND 1 PA ribavirin S Specialty Drug
QL RIBASPHERE 600 MG TABLET BRAND 1 PA ribavirin S Specialty Drug
QL RIBASPHERE RIBAPAK (600-600 MG, 600- 400 MG) BRAND 1 PA ribavirin S Specialty Drug
QL RIBAVIRIN (200 MG CAPSULE, 200 MG generic 1 PA TABLET) S Specialty Drug
ribavirin 6 g vial-neb generic 1 PA
valacyclovir hcl generic 1
valganciclovir hcl 50 mg/ml soln recon generic 1
1
PAGE 46 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
valganciclovir hcl 450 mg tablet generic QL
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC
buspirone hcl generic 1 DROPERIDOL (2.5 MG/ML AMPUL, 2.5 generic 1 MG/ML VIAL) HYDROXYZINE HCL (10 MG TABLET, 25 MG/ML VIAL, 50 MG/ML VIAL, 50 MG/25ML generic 1 AL At least 2 yrs old SOLUTION, 10 MG/5 ML SOLUTION, 50 MG TABLET, 25 MG TABLET)
HYDROXYZINE PAMOATE (50 MG, 25 MG) generic 1 AL At least 2 yrs old
hydroxyzine pamoate 100 mg capsule generic 1
ramelteon generic 1 QL
zaleplon generic 1 QL
QL zolpidem tartrate 10 mg tablet generic 1 PA
zolpidem tartrate 5 mg tablet generic 1 QL
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
PHENOBARBITAL (60 MG TABLET, 100 MG TABLET, 15 MG TABLET, 64.8 MG TABLET, 30 MG TABLET, 97.2MG TABLET, 16.2 MG generic 1 TABLET, 32.4 MG TABLET, 20 MG/5 ML ELIXIR) BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
ALPRAZOLAM (1 MG, 0.25 MG, 0.5 MG) generic 1 QL
alprazolam 2 mg tablet generic 1 QL
chlordiazepoxide hcl 10 mg capsule generic 1 QL
chlordiazepoxide hcl 25 mg capsule generic 1 QL
chlordiazepoxide hcl 5 mg capsule generic 1 QL
clorazepate dipotassium 15 mg tablet generic 1 QL
clorazepate dipotassium 3.75 mg tablet generic 1 QL
clorazepate dipotassium 7.5 mg tablet generic 1 QL
PAGE 47 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
DIASTAT QL BRAND 1 diazepam PA
DIASTAT ACUDIAL QL BRAND 1 diazepam PA
DIAZEPAM (12.5-15-20, 2.5 MG, 5-7.5-10MG) generic 1 QL
DIAZEPAM (2 MG TABLET, 10 MG TABLET, 5 generic 1 MG/5 ML SOLUTION, 5 MG TABLET) LORAZEPAM (4 MG/ML CARTRIDGE, 2 MG/ML SYRINGE, 4 MG/ML VIAL, 2 MG/ML generic 1 VIAL, 2 MG/ML CARTRIDGE)
LORAZEPAM (0.5 MG, 1 MG) generic 1 QL
LORAZEPAM (2 MG TABLET, 2 MG/ML ORAL generic 1 QL CONC) LORAZEPAM INTENSOL BRAND 1 QL lorazepam
oxazepam generic 1 QL
TEMAZEPAM (15 MG, 30 MG) generic 1 QL
AUTONOMIC DRUGS
AUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX STARTING MONTH BOX BRAND 1 varenicline tartrate CHANTIX (1 MG CONT MONTH BOX, 0.5 MG TABLET, 1 MG TABLET) BRAND 1 QL varenicline tartrate PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
bethanechol chloride generic 1 DONEPEZIL HCL (10 MG TABLET, 5 MG TAB generic 1 AL At least 40 yrs old RAPDIS, 10 MG TAB RAPDIS, 5 MG TABLET)
guanidine hcl generic 1
PILOCARPINE HCL (7.5 MG, 5 MG) generic 1 PYRIDOSTIGMINE BROMIDE (180 MG TABLET ER, 30 MG TABLET, 60 MG/5 ML generic 1 SYRUP, 60 MG TABLET)
rivastigmine generic 1 AL At least 40 yrs old
BETA-ADRENERGIC AGONISTS
PAGE 48 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS SELECTIVE BETA-1-ADRENERGIC AGONISTS
dobutamine hcl generic 1
dobutamine hcl in dextrose 5 % in water generic 1 SELECTIVE BETA-2-ADRENERGIC AGONISTS
albuterol sulfate 90 mcg hfa aer ad generic 1 QL
albuterol sulfate 2 mg/5 ml syrup generic 1 ALBUTEROL SULFATE (1.25MG/3ML VIAL- NEB, 2.5 MG/3ML VIAL-NEB, 2.5 MG/0.5 generic 1 QL VIAL-NEB, 0.63MG/3ML VIAL-NEB, 5 MG/ML SOLUTION) ARCAPTA NEOHALER BRAND 1 QL indacaterol maleate SEREVENT DISKUS BRAND 1 QL salmeterol xinafoate STRIVERDI RESPIMAT BRAND 1 QL olodaterol hcl
terbutaline sulfate 1 mg/ml vial generic 1 UTIBRON NEOHALER BRAND 1 QL indacaterol maleate/glycopyrrolate
BLOOD FORMATION, COAGULATION, THROMBOSIS
HEMATOPOIETIC AGENTS
ARANESP (150 MCG/0.3 ML SYRINGE, 500 MCG/1 ML SYRINGE, 100 MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 25 MCG/ML VIAL, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 300 MCG/0.6 ML SYRINGE, 10 MCG/0.4 ML PA SYRINGE, 300 MCG/ML VIAL, 200 MCG/0.4 BRAND 1 ML SYRINGE, 150 MCG/0.75 ML VIAL, 100 S Specialty Drug MCG/0.5 ML SYRINGE, 25 MCG/0.42 ML SYRING, 200 MCG/ML VIAL, 60 MCG/ML VIAL) darbepoetin alfa in polysorbate 80
EPOGEN PA BRAND 1 epoetin alfa S Specialty Drug
GRANIX (300 MCG/ML VIAL, 300 MCG/0.5 ML SYRINGE, 300 MCG/0.5 ML SAFE SYR, 480 PA MCG/0.8 ML SYRINGE, 480 MCG/0.8 ML BRAND 1 SAFE SYR, 480 MCG/1.6 ML VIAL) S Specialty Drug tbo-filgrastim
LEUKINE BRAND 1 PA
PAGE 49 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
sargramostim S Specialty Drug
MOZOBIL PA BRAND 1 plerixafor S Specialty Drug
NEULASTA (6 ML SYRINGE, ONPRO 6 ML PA KIT) BRAND 1 pegfilgrastim S Specialty Drug NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML SYR, 480 MCG/1.6 ML VIAL, 480 PA BRAND 1 MCG/0.8 ML SYR) S Specialty Drug filgrastim
RETACRIT PA BRAND 1 epoetin alfa-epbx S Specialty Drug
HEMORRHEOLOGIC AGENTS
pentoxifylline generic 1
CALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
DILTIAZEM HCL (180 MG SA 24H, 120 MG SA 24H, 360 MG ER 24H, 180 MG ER DEG, 300 generic 1 QL MG ER 24H)
diltiazem hcl 180 mg cap er 24h generic 1 QL
diltiazem hcl 240 mg cap er 24h generic 1 QL
DILTIAZEM HCL (120 MG CAP ER 12H, 90 MG CAP ER 12H, 90 MG TABLET, 240 MG CAP SA 24H, 420 MG CAP SA 24H, 60 MG generic 1 CAP ER 12H, 360 MG CAP SA 24H, 300 MG CAP SA 24H, 240 MG CAP ER DEG) DILTIAZEM HCL (60 MG TABLET, 30 MG TABLET, 120 MG CAP ER 24H, 120 MG generic 1 QL TABLET)
VERAPAMIL HCL (120 MG, 80 MG) generic 1 QL
verapamil hcl 40 mg tablet generic 1 VERAPAMIL HCL (120 MG TABLET ER, 240 MG CAP24H PEL, 240 MG TABLET ER, 180 generic 1 QL MG TABLET ER, 180 MG CAP24H PEL, 120 MG CAP24H PEL, 360 MG CAP24H PEL) DIHYDROPYRIDINES
amlodipine besylate generic 1 QL
PAGE 50 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
amlodipine besylate/benazepril hcl generic 1 QL
amlodipine besylate/olmesartan medoxomil generic 1 QL
AMLODIPINE BESYLATE/VALSARTAN generic 1 QL (10MG-160MG, 10MG-320MG, 5 MG-320MG) amlodipine besylate/valsartan 5 mg-160mg generic 1 QL tablet
felodipine generic 1 QL
NIFEDIPINE (10 MG, 20 MG) generic 1 QL
NIFEDIPINE (60 MG TABLET ER, 60 MG TAB generic 1 QL ER 24) NIFEDIPINE (30 MG TAB ER 24, 30 MG TABLET ER, 90 MG TAB ER 24, 90 MG generic 1 QL TABLET ER)
nimodipine generic 1
CARDIAC DRUGS
CARDIAC DRUGS, MISCELLANEOUS
ranolazine generic 1 QL
CARDIOTONIC AGENTS
DIGOXIN (125 MCG TABLET, 50 MCG/ML generic 1 SOLUTION, 250 MCG TABLET)
milrinone lactate generic 1
milrinone lactate/dextrose 5 % in water generic 1
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate generic 1
prazosin hcl generic 1
terazosin hcl generic 1 BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl generic 1
atenolol generic 1
atenolol/chlorthalidone generic 1
bisoprolol fumarate generic 1
bisoprolol fumarate/hydrochlorothiazide generic 1
PAGE 51 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
carvedilol generic 1
LABETALOL HCL (100 MG, 200 MG, 300 MG) generic 1
metoprolol succinate generic 1 METOPROLOL TARTRATE (50 MG, 25 MG, generic 1 100 MG) PROPRANOLOL HCL (60 MG CAP SA 24H, 80 MG TABLET, 60 MG TABLET, 10 MG TABLET, 80 MG CAP SA 24H, 20 MG/5 ML generic 1 SOLUTION, 20 MG TABLET, 40 MG TABLET, 120 MG CAP SA 24H, 160 MG CAP SA 24H, 40MG/5ML SOLUTION) SOTALOL HCL (240 MG, 160 MG, 120 MG, 80 generic 1 MG)
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS
LITHIUM CARBONATE (300 MG TABLET ER, 300 MG TABLET, 300 MG CAPSULE, 600 MG generic 1 CAPSULE, 150 MG CAPSULE, 450 MG TABLET ER) CENTRAL NERVOUS SYSTEM AGENTS, MISC.
acamprosate calcium generic 1
QL atomoxetine hcl generic 1 AL At least 6 yrs old
GUANFACINE HCL (1 MG ER, 3 MG ER, 4 generic 1 QL MG ER, 2 MG ER)
QL memantine hcl 2 mg/ml solution generic 1 AL At least 40 yrs old
memantine hcl 5 mg-10 mg tab ds pk generic 1 AL At least 40 yrs old
QL memantine hcl 10 mg tablet generic 1 AL At least 40 yrs old
QL memantine hcl 5 mg tablet generic 1 AL At least 40 yrs old
riluzole generic 1 OPIATE ANTAGONISTS
NALOXONE HCL (0.4 MG/ML VIAL, 1 MG/ML generic 1 SYRINGE, 0.4 MG/ML CARTRIDGE)
PAGE 52 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
naltrexone hcl generic 1 NARCAN BRAND 1 QL naloxone hcl
VIVITROL PA BRAND 1 naltrexone microspheres S Specialty Drug
VESICULAR MONOAMINE TRANSPORT2 INHIBITOR
QL
AUSTEDO PA BRAND 1 deutetrabenazine AL At least 18 yrs old
S Specialty Drug
PA tetrabenazine generic 1 S Specialty Drug
CEPHALOSPORIN ANTIBIOTICS
1ST GENERATION CEPHALOSPORIN ANTIBIOTICS
cefadroxil 500 mg capsule generic 1 CEFAZOLIN SODIUM (1 G, 20 G, 10 G, 500 generic 1 MG, 1 G PORT) CEPHALEXIN (250 MG CAPSULE, 250 MG/5ML SUSP RECON, 750 MG CAPSULE, generic 1 125 MG/5ML SUSP RECON, 500 MG CAPSULE) 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS
CEFACLOR (500 MG, 250 MG) generic 1 CEFPROZIL (250 MG TABLET, 250 MG/5ML SUSP RECON, 125 MG/5ML SUSP RECON, generic 1 500 MG TABLET)
cefuroxime axetil generic 1
cefuroxime sodium generic 1 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS
CEFDINIR (125 MG/5ML SUSP RECON, 300 generic 1 MG CAPSULE, 250 MG/5ML SUSP RECON)
cefixime 400 mg capsule generic 1
cefotaxime sodium 1 g vial generic 1
ceftazidime generic 1
CEFTRIAXONE SODIUM (1 G, 2 G PORT, 1 G generic 1
PAGE 53 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS PORT, 10 G, 500 MG, 250 MG, 2 G) CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE (2 ML PIGGYBACK, 1 ML generic 1 PIGGYBACK, 1 ML FROZ.PIGGY, 2 ML FROZ.PIGGY) 4TH GENERATION CEPHALOSPORIN ANTIBIOTICS
CEFEPIME HCL (2, 1) generic 1
CORTICOSTEROIDS (RESPIRATORY TRACT)
ORALLY INHALED PREPARATIONS (STEROIDS)
AEROSPAN BRAND 1 QL flunisolide ARNUITY ELLIPTA 100 MCG INH BRAND 1 QL fluticasone furoate ARNUITY ELLIPTA 200 MCG INH BRAND 1 QL fluticasone furoate ARNUITY ELLIPTA 50 MCG INH BRAND 1 QL fluticasone furoate BREO ELLIPTA BRAND 1 QL fluticasone furoate/vilanterol trifenatate BUDESONIDE (0.5 MG/2ML, 0.25MG/2ML, 1 generic 1 QL MG/2 ML) FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE (500-50 MCG, 250-50 MCG, 100- generic 1 QL 50 MCG) TRELEGY ELLIPTA fluticasone furoate/umeclidinium BRAND 1 QL bromide/vilanterol trifenat WIXELA INHUB BRAND 1 QL fluticasone propionate/salmeterol xinafoate
DIAGNOSTIC AGENTS
ADRENOCORTICAL INSUFFICIENCY
ACTHAR PA BRAND 1 corticotropin S Specialty Drug
DIURETICS
LOOP DIURETICS
BUMETANIDE (1 MG TABLET, 0.5 MG generic 1 TABLET, 2 MG TABLET, 0.25 MG/ML VIAL)
PAGE 54 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS FUROSEMIDE (80 MG TABLET, 20 MG TABLET, 10 MG/ML SYRINGE, 10 MG/ML generic 1 SOLUTION, 40 MG TABLET, 40MG/5ML SOLUTION, 10 MG/ML VIAL)
torsemide generic 1 POTASSIUM-SPARING DIURETICS
amiloride hcl generic 1
amiloride hcl/hydrochlorothiazide generic 1 TRIAMTERENE/HYDROCHLOROTHIAZIDE (37.5-25 MG CAPSULE, 75 MG-50MG generic 1 TABLET, 37.5-25 MG TABLET) THIAZIDE DIURETICS
chlorothiazide generic 1 DIURIL BRAND 1 chlorothiazide HYDROCHLOROTHIAZIDE (12.5 MG CAPSULE, 50 MG TABLET, 12.5 MG TABLET, generic 1 25 MG TABLET) THIAZIDE-LIKE DIURETICS
chlorthalidone generic 1
indapamide generic 1
metolazone generic 1
DOPAMINE RECEPTOR AGONISTS
ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS
cabergoline generic 1 NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST
PRAMIPEXOLE DI-HCL (1.5 MG, 0.125 MG, generic 1 0.5 MG, 0.25 MG, 0.75 MG, 1 MG) ROPINIROLE HCL (3 MG, 1 MG, 5 MG, 0.5 generic 1 MG, 4 MG, 0.25 MG, 2 MG)
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ACIDIFYING AGENTS
K-PHOS NO.2 sodium phosphate,monobasic/potassium BRAND 1 phosphate,monobasic
K-PHOS ORIGINAL BRAND 1
PAGE 55 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS potassium phosphate,monobasic PHOSPHA 250 NEUTRAL sodium phosphate,dibasic/pot phos,monob/sod BRAND 1 phosphate mono VIRT-PHOS 250 NEUTRAL sodium phosphate,dibasic/pot phos,monob/sod BRAND 1 phosphate mono ALKALINIZING AGENTS
citric acid/sodium citrate generic 1 ORACIT BRAND 1 citric acid/sodium citrate
potassium citrate generic 1
potassium citrate/citric acid 1100-334/5 solution generic 1
sodium bicarbonate 0.5meq/ml vial generic 1
sodium lactate generic 1 sodium/potassium/potassium citrate/sodium generic 1 citrate/cit ac TRICITRATES sodium/potassium/potassium citrate/sodium BRAND 1 citrate/cit ac VIRTRATE-3 sodium/potassium/potassium citrate/sodium BRAND 1 citrate/cit ac VIRTRATE-K BRAND 1 potassium citrate/citric acid AMMONIA DETOXICANTS
LACTULOSE (20 G/30 ML, 10 G/15 ML) generic 1 CALORIC AGENTS
AMINOSYN (8.5%, 10%) BRAND 1 parenteral amino acid 10 % combination no.2 AMINOSYN II (7%, 8.5%, 10%) BRAND 1 parenteral amino acid 7 % combination no.2 AMINOSYN II WITH ELECTROLYTES BRAND 1 amino acids 8.5 %/electrolyte-tpn soln AMINOSYN M BRAND 1 amino acids 3.5 %/electrolyte-m solution AMINOSYN WITH ELECTROLYTES (8.5%- ELECTROLYTES, 7%-ELECTROLYTE) BRAND 1 amino acids 8.5 %/electrolyte-tpn soln
PAGE 56 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS AMINOSYN-HBC BRAND 1 amino acids 7 % AMINOSYN-PF (10%, 7%) parenteral amino acid 7 % combination no.1 BRAND 1 (pediatric) AMINOSYN-RF parenteral amino acid 5.2 % combination no.1 BRAND 1 (renal) CLINIMIX (5%-20%, 4.25%-5%, 4.25%-25%, 5%-25%, 4.25%-10%, 5%-15%) BRAND 1 amino acids 5 %/dextrose 25 % in water CLINIMIX E (5%-15%, 4.25%-10%, 5%-25%, 2.75%-5%, 4.25%-5%, 5%-20%) BRAND 1 amino acids 5 %/calcium/electrolyte-tpn soln/dextrose 20 % CLINIMIX N14G30E amino acids 4.25 %/dextrose 15 %/electrolytes BRAND 1 no.25 CLINIMIX N9G15E amino acid 2.75 %/dextrose 7.5 %/electrolytes BRAND 1 no.12 CLINIMIX N9G20E amino acid 2.75 % no.2/dextrose 10 BRAND 1 %/electrolytes no.29 CLINISOL BRAND 1 parenteral amino acid 15% combination no.5
cysteine hcl generic 1
dextrose 10 % and 0.2 % sodium chloride generic 1
dextrose 10 % and 0.45 % sodium chloride generic 1 DEXTROSE 10 % IN WATER (10 10 DEHP FR generic 1 BG, 10 10 IV SOLN)
dextrose 2.5 % and 0.45 % sodium chloride generic 1
dextrose 20 % in water generic 1
dextrose 25 % in water generic 1
dextrose 30 % in water generic 1
dextrose 40 % in water generic 1
dextrose 5 % and 0.2 % sodium chloride generic 1
dextrose 5 % and 0.3 % sodium chloride generic 1
dextrose 5 % and 0.45 % sodium chloride generic 1
dextrose 5 % and 0.9 % sodium chloride generic 1
PAGE 57 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS DEXTROSE 5 % IN WATER (5 5 IV SOLN, 5 generic 1 PGY VL PRT, 5 PGGYBK PRT, 5 5 VIAL) DEXTROSE 50 % IN WATER (50 50 IV SOLN, generic 1 50 50 VIAL, 50 50 SYRGE)
dextrose 70 % in water generic 1 FREAMINE HBC BRAND 1 amino acids 6.9 % FREAMINE III BRAND 1 parenteral amino acid 10 % combination no.4 HEPATAMINE BRAND 1 amino acids 8 % INTRALIPID BRAND 1 fat emulsions KABIVEN amino acid 3.31 % no.1/d9.8w/fat BRAND 1 emulsions/electrolyte no.10 NEPHRAMINE BRAND 1 amino acids 5.4 % NUTRILIPID BRAND 1 fat emulsions PERIKABIVEN amino acid 2.36 % no.1/d6.8w/fat BRAND 1 emulsions/electrolytes no.9 PLENAMINE BRAND 1 parenteral amino acid 15% combination no.1 PREMASOL (6%, 10%) BRAND 1 parenteral amino acid 6% combination no.1 PROCALAMINE BRAND 1 amino acids 3 %/electrolyte-tpn soln/glycerin PROSOL BRAND 1 parenteral amino acid 20 % combination no.1 SYNTHAMIN 17 WITHOUT ELTYE BRAND 1 parenteral amino acid 10 % combination no.6 TRAVASOL BRAND 1 parenteral amino acid 10 % combination no.6 TROPHAMINE (6%, 10%) BRAND 1 amino acids 6 % IRRIGATING SOLUTIONS
acetic acid 0.25 % irrig soln generic 1
DELFLEX WITH 1.5% DEXTROSE BRAND 1
PAGE 58 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS peritoneal dialysis solution no.19 and dextrose 1.5 %
mannitol/sorbitol solution generic 1 RENACIDIN citric acid/gluconolactone/magnesium BRAND 1 carbonate
ringer's solution irrig soln generic 1
ringer's solution,lactated irrig soln generic 1
sodium chloride irrigating solution generic 1
sorbitol solution generic 1 TIS-U-SOL PENTALYTE sodium chloride/pot chloride/mag sul/sod BRAND 1 phos,db/pot phos,mb
water for irrigation,sterile generic 1 REPLACEMENT PREPARATIONS
0.9 % SODIUM CHLORIDE (0.9 0.9 IV SOLN, 0.9 PGGYBK PRT, 0.9 PGY VL PRT, 0.9 0.9 generic 1 VIAL)
bacteriostatic sodium chloride generic 1
calcium chloride 100 mg/ml vial generic 1
calcium gluconate generic 1
chromic chloride generic 1
cupric chloride generic 1
dextrose 5 % in lactated ringers generic 1 EFFER-K BRAND 1 potassium bicarbonate/citric acid
electrolyte-48 solution/dextrose 5 % in water generic 1 HYPERLYTE CR sodium/potassium/magnesium/calcium/chloride BRAND 1 /acetate IONOSOL B WITH DEXTROSE 5% BRAND 1 electrolyte-b solution/dextrose 5 % in water IONOSOL MB-DEXTROSE 5% BRAND 1 electrolyte-mb solution/dextrose 5 % in water ISOLYTE P WITH DEXTROSE BRAND 1 electrolyte-p solution/dextrose 5 % in water ISOLYTE S (OLUTION-EXCEL, OLN PH7.4) BRAND 1 electrolyte-s solution
PAGE 59 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS KLOR-CON 20 MEQ PACKET BRAND 1 potassium chloride KLOR-CON 10 BRAND 1 potassium chloride KLOR-CON 8 BRAND 1 potassium chloride KLOR-CON M10 BRAND 1 potassium chloride KLOR-CON M15 BRAND 1 potassium chloride KLOR-CON M20 BRAND 1 potassium chloride KLOR-CON SPRINKLE ER 8 MEQ CAP BRAND 1 potassium chloride KLOR-CON-EF BRAND 1 potassium bicarbonate/citric acid
manganese chloride generic 1
manganese sulfate generic 1 MULTITRACE-4 zinc sulfate/cupric sulfate/manganese BRAND 1 sulf/chromic chloride MULTITRACE-5 zinc sulfate/copper BRAND 1 sulfate/manganese/chromium/selenium NORMOSOL-M AND DEXTROSE BRAND 1 electrolyte-m solution/dextrose 5 % in water NORMOSOL-R BRAND 1 electrolyte-r solution NORMOSOL-R AND DEXTROSE BRAND 1 electrolyte-r solution/dextrose 5 % in water NORMOSOL-R PH 7.4 BRAND 1 electrolyte-r (ph 7.4) PLASMA-LYTE 148 BRAND 1 electrolyte-148 solution PLASMA-LYTE A PH 7.4 BRAND 1 electrolyte-a solution
potassium acetate generic 1 POTASSIUM CHLORIDE (2 MEQ/ML VIAL, 20MEQ/15ML LIQUID, 20 MEQ PACKET, 10 MEQ TAB ER PRT, 10 MEQ TABLET ER, 2 generic 1 MEQ/ML AMPUL, 8 MEQ CAPSULE ER, 20
PAGE 60 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS MEQ TABLET ER, 8 MEQ TABLET ER, 20 MEQ TAB ER PRT, 40MEQ/15ML LIQUID, 10 MEQ CAPSULE ER)
potassium chloride in 0.45 % sodium chloride generic 1 POTASSIUM CHLORIDE IN 0.9 % SODIUM generic 1 CHLORIDE (20, 40)
potassium chloride in 5 % dextrose in water generic 1 potassium chloride in dextrose 5 % and 0.9 % generic 1 sodium chloride POTASSIUM CHLORIDE IN DEXTROSE 5 %- generic 1 0.2 % SODIUM CHLORIDE (20, 10, 30, 40) POTASSIUM CHLORIDE IN DEXTROSE 5 %- generic 1 0.45 % SODIUM CHLORIDE (10, 20, 40, 30) potassium chloride in dextrose 5% and 0.3 % generic 1 sodium chloride potassium chloride in lactated ringers and 5 % generic 1 dextrose POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE (10MEQ/50ML PIGGYBACK, 20MEQ/50ML PIGGYBACK, generic 1 40MEQ/0.1L PIGGYBACK, 30MEQ/0.1L PIGGYBACK, 10MEQ/0.1L PIGGYBACK, 10 MEQ/5ML SYRGE, 20MEQ/0.1L PIGGYBACK)
potassium phosphate,monobasic-dibasic generic 1
ringer's solution iv soln generic 1
ringer's solution,lactated iv soln generic 1
selenium 40 mcg/ml vial generic 1
sodium acetate generic 1
sodium chloride generic 1 SODIUM CHLORIDE 0.45 % (0.45 PGGYBK generic 1 PRT, 0.45 0.45 IV SOLN)
sodium chloride 3 % generic 1
sodium chloride 5 % generic 1
sodium chloride for inhalation 0.9 % vial-neb generic 1
sodium chloride for inhalation 10 % vial-neb generic 1 PA
sodium phosphate,monobasic-dibasic generic 1 TPN ELECTROLYTES sodium/potassium/magnesium/calcium/chloride BRAND 1 /acetate
PAGE 61 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS TPN ELECTROLYTES II sodium/potassium/magnesium/calcium/chloride BRAND 1 /acetate
zinc chloride generic 1
zinc sulfate generic 1 URICOSURIC AGENTS
probenecid generic 1 QL
probenecid/colchicine generic 1 QL
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS
BASIC LOTIONS AND LINIMENTS
ammonium lactate 12 % lotion generic 1 BASIC OINTMENTS AND PROTECTANTS
ammonium lactate 12 % cream (g) generic 1
ENZYMES
ELELYSO PA BRAND 1 taliglucerase alfa S Specialty Drug
FABRAZYME PA BRAND 1 agalsidase beta S Specialty Drug
HYQVIA HY COMPONENT PA BRAND 1 hyaluronidase, human recomb. S Specialty Drug
ESTROGENS AND ANTIESTROGENS
ESTROGEN AGONIST-ANTAGONISTS
SOLTAMOX BRAND 1 tamoxifen citrate
tamoxifen citrate generic 1 ESTROGENS
CLIMARA PRO QL BRAND 1 estradiol/levonorgestrel GL Female
COMBIPATCH QL BRAND 1 estradiol/norethindrone acetate GL Female
ESTRADIOL (.0375MG/24, 0.06MG/24H, generic 1 QL
PAGE 62 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS 0.1MG/24HR, .075MG/24H, .025MG/24H, GL Female 0.05MG/24H)
QL ESTRADIOL (0.5 MG, 10 MCG, 1 MG, 2 MG) generic 1 GL Female
estradiol valerate generic 1 GL Female
QL estradiol/norethindrone acetate generic 1 GL Female
ESTRING BRAND 1 GL Female estradiol
JEVANTIQUE LO QL BRAND 1 norethindrone acetate-ethinyl estradiol GL Female
NORETHINDRONE ACETATE-ETHINYL generic 1 ESTRADIOL (0.5MG-2.5, 1MG-5MCG)
PREMARIN VAGINAL CREAM-APPL QL BRAND 1 estrogens, conjugated GL Female
PREMARIN (1.25 MG, 0.3 MG, 0.45 MG, 0.625 QL MG, 0.9 MG) BRAND 1 estrogens, conjugated GL Female
PREMPHASE QL estrogens, conjugated/medroxyprogesterone BRAND 1 acetate GL Female
PREMPRO QL estrogens, conjugated/medroxyprogesterone BRAND 1 acetate GL Female
YUVAFEM QL BRAND 1 estradiol GL Female
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIALLERGIC AGENTS
AZELASTINE HCL (205.5 MCG, 137 MCG) generic 1 QL
olopatadine hcl 0.1 % drops generic 1 QL
PAZEO BRAND 1 QL olopatadine hcl EENT DRUGS, MISCELLANEOUS
balanced salt irrig soln no.2 generic 1
CYSTARAN BRAND 1 QL
PAGE 63 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
cysteamine hcl PA
S Specialty Drug
LOCAL ANESTHETICS (EENT)
LIDOCAINE HCL (2 % JELLY(ML), 40 MG/ML SOLUTION, 2 % SOLUTION, 2 % JEL/PF generic 1 APP) MYDRIATICS
ATROPINE SULFATE (1 DROPS, 1 OINT. (G)) generic 1
cyclopentolate hcl generic 1 VASOCONSTRICTORS
PHENYLEPHRINE HCL (10, 2.5) generic 1
FIRST GENERATION ANTIHISTAMINES
ETHANOLAMINE DERIVATIVES
carbinoxamine maleate 4 mg/5 ml liquid generic 1 AL At least 2 yrs old
carbinoxamine maleate 4 mg tablet generic 1 AL At least 6 yrs old
clemastine fumarate generic 1 AL At least 2 yrs old
DIPHENHYDRAMINE HCL (50 MG/ML VIAL, 50 MG/ML CARTRIDGE, 12.5MG/5ML ELIXIR, generic 1 50 MG/ML SYRINGE) FIRST GEN. ANTIHIST. DERIVATIVES, MISC.
CYPROHEPTADINE HCL (4 MG/10 ML generic 1 AL At least 2 yrs old SYRUP, 4 MG TABLET, 2 MG/5 ML SYRUP) PHENOTHIAZINE DERIVATIVES
phenylephrine hcl/promethazine hcl generic 1 PROMETHAZINE HCL (25 MG TABLET, 25 MG/ML VIAL, 50 MG/ML AMPUL, 12.5 MG SUPP.RECT, 50 MG TABLET, 12.5 MG generic 1 AL At least 2 yrs old TABLET, 25 MG/ML AMPUL, 25 MG SUPP.RECT, 6.25MG/5ML SYRUP, 50 MG/ML VIAL) PROMETHEGAN BRAND 1 AL At least 2 yrs old promethazine hcl
GASTROINTESTINAL DRUGS
ANTI-INFLAMMATORY AGENTS (GI DRUGS)
PAGE 64 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
GL Female alosetron hcl generic 1 AL At least 18 yrs old
APRISO BRAND 1 mesalamine MESALAMINE (1000 MG SUPP.RECT, 400 generic 1 MG CAP(DRTAB)) ANTIDIARRHEA AGENTS
diphenoxylate hcl/atropine 2.5-.025mg tablet generic 1
loperamide hcl generic 1 CATHARTICS AND LAXATIVES
GOLYTELY PACKET peg 3350/sod sulf/sod bicarb/sod BRAND 1 chloride/potassium chloride PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM CHLORIDE (240- generic 1 22.72G, 236-22.74G) POLYETHYLENE GLYCOL 3350 (3350 17G generic 1 POWD PACK, 3350 17G/DOSE POWDER) sodium chloride/sodium bicarbonate/potassium generic 1 chloride/peg TRILYTE WITH FLAVOR PACKETS sodium chloride/sodium bicarbonate/potassium BRAND 1 chloride/peg CHOLELITHOLYTIC AGENTS
URSODIOL (250 MG TABLET, 300 MG generic 1 CAPSULE, 500 MG TABLET) DIGESTANTS
CREON BRAND 1 lipase/protease/amylase GI DRUGS, MISCELLANEOUS
QL HUMIRA(CF) PEDI CROHN 80-40 MG BRAND 1 PA adalimumab S Specialty Drug
LINZESS QL BRAND 1 linaclotide PA
MOVANTIK QL BRAND 1 naloxegol oxalate PA
PAGE 65 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
PROKINETIC AGENTS
METOCLOPRAMIDE HCL (10 MG TABLET, 5 MG TABLET, 10 MG/10ML SOLUTION, 5 generic 1 MG/5 ML SOLUTION)
GENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
oxybutynin chloride 5 mg/5 ml syrup generic 1 QL
OXYBUTYNIN CHLORIDE (10 MG ER 24, 15 generic 1 QL MG ER 24)
oxybutynin chloride 5 mg tab er 24 generic 1 QL
oxybutynin chloride 5 mg tablet generic 1 QL
solifenacin succinate generic 1 QL
TOVIAZ BRAND 1 QL fesoterodine fumarate
GONADOTROPINS AND ANTIGONADOTROPINS
ANTIGONADTROPINS
QL ORILISSA 150 MG TABLET BRAND 1 PA elagolix sodium AL At least 18 yrs old
QL ORILISSA 200 MG TABLET BRAND 1 PA elagolix sodium AL At least 18 yrs old
GONADOTROPINS
PA LEUPROLIDE ACETATE (1 KIT, 1 VIAL) generic 1 S Specialty Drug
PA LUPANETA PK 11.25-5 MG 3MO KIT BRAND 1 S Specialty Drug leuprolide acetate/norethindrone acetate SDS Extended Specialty Day Supply
LUPANETA PK 3.75-5 MG 1MO KIT PA BRAND 1 leuprolide acetate/norethindrone acetate S Specialty Drug
1
PAGE 66 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
LUPRON DEPOT (DEPOT 7.5 MG, DEPOT PA 22.5 MG 3MO, DEPOT 11.25 MG 3MO, BRAND S Specialty Drug DEPOT-4 MONTH, DEPOT 45 MG 6MO) leuprolide acetate SDS Extended Specialty Day Supply
LUPRON DEPOT 3.75 MG KIT PA BRAND 1 leuprolide acetate S Specialty Drug
PA LUPRON DEPO 11.25MG (LUPANETA) BRAND 1 S Specialty Drug leuprolide acetate SDS Extended Specialty Day Supply
LUPRON DEPOT 3.75MG (LUPANETA) PA BRAND 1 leuprolide acetate S Specialty Drug
LUPRON DEPOT-PED (7.5 MG, 11.25 MG, 15 PA MG) BRAND 1 leuprolide acetate S Specialty Drug
PA LUPRON DEPOT-PED (11.25 MG, 30 MG KIT) BRAND 1 S Specialty Drug leuprolide acetate SDS Extended Specialty Day Supply
SYNAREL PA BRAND 1 nafarelin acetate S Specialty Drug
PA TRIPTODUR BRAND 1 S Specialty Drug triptorelin pamoate SDS Extended Specialty Day Supply
ZOLADEX PA BRAND 1 goserelin acetate S Specialty Drug
HCV ANTIVIRALS
HCV POLYMERASE INHIBITOR ANTIVIRALS
QL
VOSEVI PA BRAND 1 sofosbuvir/velpatasvir/voxilaprevir AL At least 18 yrs old
S Specialty Drug
HCV PROTEASE INHIBITOR ANTIVIRALS
PAGE 67 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
QL
MAVYRET PA BRAND 1 glecaprevir/pibrentasvir AL At least 18 yrs old
S Specialty Drug
HEAVY METAL ANTAGONISTS
deferoxamine mesylate generic 1
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
betamethasone acetate/betamethasone sodium generic 1 phosphate
budesonide 3 mg capdr - er generic 1 DEXAMETHASONE (6 MG TABLET, 0.5 MG TABLET, 2 MG TABLET, 0.75 MG TABLET, 4 MG TABLET, 1.5 MG TABLET, 0.5 MG/5ML generic 1 ELIXIR, 1 MG TABLET, 0.5 MG/5ML SOLUTION) DEXAMETHASONE SODIUM PHOSPHATE (4 MG/ML SYRINGE, 10 MG/ML VIAL, 4 MG/ML generic 1 VIAL)
dexamethasone sodium phosp/pf 10 mg/ml vial generic 1
fludrocortisone acetate generic 1
HYDROCORTISONE (5 MG, 10 MG, 20 MG) generic 1 METHYLPREDNISOLONE (4 MG TABLET, 8 MG TABLET, 4 MG TAB DS PK, 32 MG generic 1 TABLET)
methylprednisolone acetate generic 1 METHYLPREDNISOLONE SODIUM generic 1 SUCCINATE (40 MG, 1000 MG, 125 MG)
prednisolone generic 1 PREDNISOLONE SODIUM PHOSPHATE (15 MG/5 ML SOLUTION, 30 MG TAB RAPDIS, 10 generic 1 MG TAB RAPDIS, 25 MG/5 ML SOLUTION, 5 MG/5 ML SOLUTION, 15 MG TAB RAPDIS) PREDNISONE (2.5 MG TABLET, 1 MG TABLET, 5 MG TABLET, 50 MG TABLET, 5 MG/5 ML SOLUTION, 20 MG TABLET, 10 MG generic 1 TABLET, 10 MG TAB DS PK, 5 MG TAB DS PK)
1
PAGE 68 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS SOLU-CORTEF (100 MG ACT-O-VIAL, 250 MG ACT-O-VIAL, 500 MG ACT-O-VIAL, 100 BRAND MG VIAL, 1,000 MG ACT-O-VL) hydrocortisone sodium succinate/pf ANDROGENS
QL ANDRODERM BRAND 1 PA testosterone GL Male
danazol generic 1
estrogens,esterified/methyltestosterone generic 1 GL Female
QL TESTOSTERONE (1.25G-1.62 PACKET, 50 MG (1%) PACKET, 2.5G-1.62% PACKET, generic 1 PA 20.25/1.25 MD PMP) GL Male
QL
testosterone 25mg(1%) gel packet generic 1 PA
GL Male
TESTOSTERONE CYPIONATE (100 MG/ML, generic 1 GL Male 200 MG/ML)
testosterone enanthate generic 1 GL Male
CONTRACEPTIVES
AFIRMELLE BRAND 1 GL Female levonorgestrel-ethinyl estradiol ALTAVERA BRAND 1 GL Female levonorgestrel-ethinyl estradiol ALYACEN BRAND 1 GL Female norethindrone-ethinyl estradiol AMETHIA levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 GL Female estradiol AMETHIA LO levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 GL Female estradiol
AMETHYST QL BRAND 1 levonorgestrel-ethinyl estradiol GL Female
APRI BRAND 1 GL Female desogestrel-ethinyl estradiol
1 GL
PAGE 69 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ARANELLE BRAND Female norethindrone-ethinyl estradiol ASHLYNA levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 GL Female estradiol AUBRA BRAND 1 GL Female levonorgestrel-ethinyl estradiol AUBRA EQ BRAND 1 GL Female levonorgestrel-ethinyl estradiol AUROVELA BRAND 1 GL Female norethindrone acetate-ethinyl estradiol AUROVELA 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate AUROVELA FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate AVIANE BRAND 1 GL Female levonorgestrel-ethinyl estradiol AYUNA BRAND 1 GL Female levonorgestrel-ethinyl estradiol AZURETTE BRAND 1 GL Female desogestrel-ethinyl estradiol/ethinyl estradiol BALCOLTRA levonorgestrel/ethinyl estradiol/ferrous BRAND 1 GL Female bisglycinate BALZIVA BRAND 1 GL Female norethindrone-ethinyl estradiol BEKYREE BRAND 1 GL Female desogestrel-ethinyl estradiol/ethinyl estradiol BLISOVI 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate BLISOVI FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate BRIELLYN BRAND 1 GL Female norethindrone-ethinyl estradiol CAMILA BRAND 1 GL Female norethindrone CAMRESE levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 GL Female
PAGE 70 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS estradiol CAMRESE LO levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 GL Female estradiol CAZIANT BRAND 1 GL Female desogestrel-ethinyl estradiol CHATEAL BRAND 1 GL Female levonorgestrel-ethinyl estradiol CHATEAL EQ BRAND 1 GL Female levonorgestrel-ethinyl estradiol CRYSELLE BRAND 1 GL Female norgestrel-ethinyl estradiol CYCLAFEM BRAND 1 GL Female norethindrone-ethinyl estradiol CYRED BRAND 1 GL Female desogestrel-ethinyl estradiol CYRED EQ BRAND 1 GL Female desogestrel-ethinyl estradiol DASETTA BRAND 1 GL Female norethindrone-ethinyl estradiol DAYSEE levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 GL Female estradiol DEBLITANE BRAND 1 GL Female norethindrone
desogestrel-ethinyl estradiol generic 1 GL Female
desogestrel-ethinyl estradiol/ethinyl estradiol generic 1 GL Female
drospirenone/ethinyl estradiol/levomefolate generic 1 GL Female calcium ELINEST BRAND 1 GL Female norgestrel-ethinyl estradiol
ELLA QL BRAND 1 ulipristal acetate GL Female
EMOQUETTE BRAND 1 GL Female desogestrel-ethinyl estradiol ENPRESSE BRAND 1 GL Female levonorgestrel-ethinyl estradiol ENSKYCE BRAND 1 GL Female desogestrel-ethinyl estradiol
PAGE 71 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ERRIN BRAND 1 GL Female norethindrone ESTARYLLA BRAND 1 GL Female norgestimate-ethinyl estradiol
ethinyl estradiol/drospirenone generic 1 GL Female
ethynodiol diacetate-ethinyl estradiol generic 1 GL Female
FALMINA BRAND 1 GL Female levonorgestrel-ethinyl estradiol FAYOSIM levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 GL Female estradiol FEMYNOR BRAND 1 GL Female norgestimate-ethinyl estradiol GIANVI BRAND 1 GL Female ethinyl estradiol/drospirenone HAILEY BRAND 1 GL Female norethindrone acetate-ethinyl estradiol HAILEY 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate HEATHER BRAND 1 GL Female norethindrone INCASSIA BRAND 1 GL Female norethindrone INTROVALE BRAND 1 GL Female levonorgestrel-ethinyl estradiol ISIBLOOM BRAND 1 GL Female desogestrel-ethinyl estradiol JASMIEL BRAND 1 GL Female ethinyl estradiol/drospirenone JENCYCLA BRAND 1 GL Female norethindrone JOLESSA BRAND 1 GL Female levonorgestrel-ethinyl estradiol JULEBER BRAND 1 GL Female desogestrel-ethinyl estradiol JUNEL BRAND 1 GL Female norethindrone acetate-ethinyl estradiol JUNEL FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female
PAGE 72 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS fumarate JUNEL FE 24 norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate KAITLIB FE BRAND 1 GL Female norethindrone-ethinyl estradiol/ferrous fumarate KALLIGA BRAND 1 GL Female desogestrel-ethinyl estradiol KARIVA BRAND 1 GL Female desogestrel-ethinyl estradiol/ethinyl estradiol KELNOR 1-35 BRAND 1 GL Female ethynodiol diacetate-ethinyl estradiol KELNOR 1-50 BRAND 1 GL Female ethynodiol diacetate-ethinyl estradiol KURVELO BRAND 1 GL Female levonorgestrel-ethinyl estradiol LARIN BRAND 1 GL Female norethindrone acetate-ethinyl estradiol LARIN 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate LARIN FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate LARISSIA BRAND 1 GL Female levonorgestrel-ethinyl estradiol LAYOLIS FE BRAND 1 GL Female norethindrone-ethinyl estradiol/ferrous fumarate LEENA BRAND 1 GL Female norethindrone-ethinyl estradiol LESSINA BRAND 1 GL Female levonorgestrel-ethinyl estradiol LEVONEST BRAND 1 GL Female levonorgestrel-ethinyl estradiol LEVONORGESTREL-ETHINYL ESTRADIOL (0.15-0.03 TBDSPK 3MO, 90-20 MCG generic 1 GL Female TABLET, 6-5-10 TABLET, 0.1-0.02MG TABLET, 0.15-0.03 TABLET) levonorgestrel/ethinyl estradiol and ethinyl generic 1 GL Female estradiol LEVORA-28 BRAND 1 GL Female levonorgestrel-ethinyl estradiol
PAGE 73 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS LILLOW BRAND 1 GL Female levonorgestrel-ethinyl estradiol LO LOESTRIN FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate LO-ZUMANDIMINE BRAND 1 GL Female ethinyl estradiol/drospirenone LORYNA BRAND 1 GL Female ethinyl estradiol/drospirenone LOW-OGESTREL BRAND 1 GL Female norgestrel-ethinyl estradiol LUTERA BRAND 1 GL Female levonorgestrel-ethinyl estradiol LYZA BRAND 1 GL Female norethindrone MARLISSA BRAND 1 GL Female levonorgestrel-ethinyl estradiol MELODETTA 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate MIBELAS 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate MICROGESTIN BRAND 1 GL Female norethindrone acetate-ethinyl estradiol MICROGESTIN 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate MICROGESTIN FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate MILI BRAND 1 GL Female norgestimate-ethinyl estradiol MONO-LINYAH BRAND 1 GL Female norgestimate-ethinyl estradiol NATAZIA BRAND 1 GL Female estradiol valerate/dienogest NECON 0.5-35-28 TABLET BRAND 1 GL Female norethindrone-ethinyl estradiol NIKKI BRAND 1 GL Female ethinyl estradiol/drospirenone
NORA-BE BRAND 1 GL Female
PAGE 74 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
norethindrone
norethindrone generic 1 GL Female
NORETHINDRONE ACETATE-ETHINYL generic 1 GL Female ESTRADIOL (1MG-20MCG, 1.5-0.03MG) NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE (1MG- generic 1 GL Female 20(24) TABLET, 1MG-20(24) TAB CHEW, 1MG-20(21) TABLET)
norethindrone-ethinyl estradiol/ferrous fumarate generic 1 GL Female
norgestimate-ethinyl estradiol generic 1 GL Female
NORLYDA BRAND 1 GL Female norethindrone NORTREL BRAND 1 GL Female norethindrone-ethinyl estradiol NUVARING BRAND 1 GL Female etonogestrel/ethinyl estradiol OCELLA BRAND 1 GL Female ethinyl estradiol/drospirenone OGESTREL BRAND 1 GL Female norgestrel-ethinyl estradiol ORSYTHIA BRAND 1 GL Female levonorgestrel-ethinyl estradiol PHILITH BRAND 1 GL Female norethindrone-ethinyl estradiol PIMTREA BRAND 1 GL Female desogestrel-ethinyl estradiol/ethinyl estradiol PIRMELLA BRAND 1 GL Female norethindrone-ethinyl estradiol PORTIA BRAND 1 GL Female levonorgestrel-ethinyl estradiol PREVIFEM BRAND 1 GL Female norgestimate-ethinyl estradiol RAJANI drospirenone/ethinyl estradiol/levomefolate BRAND 1 GL Female calcium RECLIPSEN BRAND 1 GL Female desogestrel-ethinyl estradiol RIVELSA levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 GL Female estradiol
PAGE 75 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS SETLAKIN BRAND 1 GL Female levonorgestrel-ethinyl estradiol SHAROBEL BRAND 1 GL Female norethindrone SIMLIYA BRAND 1 GL Female desogestrel-ethinyl estradiol/ethinyl estradiol SIMPESSE levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 GL Female estradiol SLYND BRAND 1 GL Female drospirenone SPRINTEC BRAND 1 GL Female norgestimate-ethinyl estradiol SRONYX BRAND 1 GL Female levonorgestrel-ethinyl estradiol SYEDA BRAND 1 GL Female ethinyl estradiol/drospirenone TARINA 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate TARINA FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate TARINA FE 1-20 EQ norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate TAYTULLA norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate TILIA FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate TRI FEMYNOR BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-ESTARYLLA BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-LEGEST FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 GL Female fumarate TRI-LINYAH BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-LO-ESTARYLLA BRAND 1 GL Female
PAGE 76 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS norgestimate-ethinyl estradiol TRI-LO-MARZIA BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-LO-MILI BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-LO-SPRINTEC BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-MILI BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-PREVIFEM BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-SPRINTEC BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-VYLIBRA BRAND 1 GL Female norgestimate-ethinyl estradiol TRI-VYLIBRA LO BRAND 1 GL Female norgestimate-ethinyl estradiol TRIVORA-28 BRAND 1 GL Female levonorgestrel-ethinyl estradiol TULANA BRAND 1 GL Female norethindrone TYDEMY drospirenone/ethinyl estradiol/levomefolate BRAND 1 GL Female calcium VELIVET BRAND 1 GL Female desogestrel-ethinyl estradiol VIENVA BRAND 1 GL Female levonorgestrel-ethinyl estradiol VIORELE BRAND 1 GL Female desogestrel-ethinyl estradiol/ethinyl estradiol VYFEMLA BRAND 1 GL Female norethindrone-ethinyl estradiol VYLIBRA BRAND 1 GL Female norgestimate-ethinyl estradiol WERA BRAND 1 GL Female norethindrone-ethinyl estradiol WYMZYA FE BRAND 1 GL Female norethindrone-ethinyl estradiol/ferrous fumarate
XULANE QL BRAND 1 norelgestromin/ethinyl estradiol GL Female
PAGE 77 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ZARAH BRAND 1 GL Female ethinyl estradiol/drospirenone ZOVIA 1-35E BRAND 1 GL Female ethynodiol diacetate-ethinyl estradiol ZUMANDIMINE BRAND 1 GL Female ethinyl estradiol/drospirenone PITUITARY
DESMOPRESSIN ACETATE (0.1 MG TABLET, 0.2 MG TABLET, 4 MCG/ML VIAL, 4 generic 1 MCG/ML AMPUL)
desmopressin acetate (non-refrigerated) generic 1 GENOTROPIN (MINIQUICK 2 MG, 5 MG CARTRIDGE, MINIQUICK 1.6 MG, MINIQUICK 1.2 MG, MINIQUICK 0.4 MG, MINIQUICK 1.8 PA MG, MINIQUICK 0.6 MG, MINIQUICK 1 MG, BRAND 1 MINIQUICK 0.8 MG, MINIQUICK 1.4 MG, 12 S Specialty Drug MG CARTRIDGE, MINIQUICK 0.2 MG) somatropin
NORDITROPIN FLEXPRO PA BRAND 1 somatropin S Specialty Drug
QL SEROSTIM BRAND 1 PA somatropin S Specialty Drug
STIMATE PA BRAND 1 desmopressin acetate S Specialty Drug
PROGESTINS
DEPO-SUBQ PROVERA 104 BRAND 1 GL Female medroxyprogesterone acetate
PA
hydroxyprogesterone caproate/pf generic 1 GL Female
S Specialty Drug
PA MAKENA 275 MG/1.1 ML AUTOINJCT BRAND 1 GL Female hydroxyprogesterone caproate/pf S Specialty Drug
MEDROXYPROGESTERONE ACETATE (2.5 generic 1 GL Female MG, 5 MG, 10 MG)
MEDROXYPROGESTERONE ACETATE (150 QL generic 1 MG/ML VIAL, 150 MG/ML SYRINGE)
PAGE 78 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
GL Female
SDS Extended Specialty Day Supply MEGESTROL ACETATE (20 MG TABLET, 625MG/5ML ORAL SUSP, 400MG/10ML ORAL generic 1 SUSP, 40 MG TABLET)
PA norethindrone acetate generic 1 GL Female
progesterone generic 1 GL Female
progesterone, micronized generic 1 GL Female
HYPOTENSIVE AGENTS
CENTRAL ALPHA-AGONISTS
CLONIDINE (0.2MG/24HR, 0.3MG/24HR) generic 1 QL
clonidine 0.1mg/24hr patch tdwk generic 1 QL
CLONIDINE HCL (0.3 MG, 0.2 MG, 0.1 MG) generic 1
GUANFACINE HCL (2 MG, 1 MG) generic 1
methyldopa generic 1 DIRECT VASODILATORS
HYDRALAZINE HCL (10 MG, 50 MG, 25 MG, generic 1 100 MG)
minoxidil generic 1
INSULINS
LONG-ACTING INSULINS
BASAGLAR KWIKPEN U-100 BRAND 1 insulin glargine,human recombinant analog RAPID-ACTING INSULINS
ADMELOG BRAND 1 insulin lispro ADMELOG SOLOSTAR BRAND 1 insulin lispro HUMALOG MIX 50-50 KWIKPEN BRAND 1 insulin lispro protamine and insulin lispro HUMALOG MIX 75-25 KWIKPEN BRAND 1 insulin lispro protamine and insulin lispro
PAGE 79 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
insulin lispro 100/ml vial generic 1 NOVOLOG MIX 70-30 BRAND 1 insulin aspart protamine human/insulin aspart NOVOLOG MIX 70-30 FLEXPEN BRAND 1 insulin aspart protamine human/insulin aspart SHORT-ACTING INSULINS
HUMULIN R U-500 BRAND 1 insulin regular, human HUMULIN R U-500 KWIKPEN BRAND 1 insulin regular, human
ION-REMOVING AGENTS
PHOSPHATE-REMOVING AGENTS
calcium acetate 667 mg capsule generic 1
SEVELAMER CARBONATE (2.4, 0.8) generic 1
sevelamer hcl generic 1 POTASSIUM-REMOVING AGENTS
SODIUM POLYSTYRENE SULFONATE (POWDER, 30 G/120ML ENEMA, 50 G/200ML generic 1 ENEMA, 15 G/60 ML ORAL SUSP) SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA SUSP) BRAND 1 sodium polystyrene sulfonate/sorbitol solution
LOCAL ANESTHETICS (PARENTERAL)
bupivacaine hcl generic 1
bupivacaine hcl in dextrose/pf generic 1
bupivacaine hcl/epinephrine generic 1
bupivacaine hcl/epinephrine bitartrate generic 1
bupivacaine hcl/epinephrine/pf generic 1 BUPIVACAINE HCL/PF (2.5 MG/ML VIAL, 2.5 MG/ML AMPUL, 7.5 MG/ML VIAL, 5 MG/ML generic 1 VIAL, 5 MG/ML AMPUL, 7.5 MG/ML AMPUL) LIDOCAINE HCL (10 MG/ML, 20 MG/ML, 5 generic 1 MG/ML)
lidocaine hcl in dextrose 7.5 % in water/pf generic 1 LIDOCAINE HCL/EPINEPHRINE (2 %-1:100K VIAL, 1.5-1:200K AMPUL, 1%-1:100K VIAL, generic 1
PAGE 80 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS 2%-1:200K VIAL, 1.5-1:200K VIAL, 0.5-1:200K VIAL)
lidocaine hcl/epinephrine bitartrate generic 1 LIDOCAINE HCL/PF (15 MG/ML AMPUL, 5 MG/ML VIAL, 10 MG/ML VIAL, 10 MG/ML generic 1 AMPUL, 20 MG/ML AMPUL, 20 MG/ML VIAL, 40 MG/ML AMPUL)
MACROLIDE ANTIBIOTICS
ERYTHROMYCIN ANTIBIOTICS
erythromycin ethylsuccinate 200 mg/5ml susp generic 1 recon OTHER MACROLIDE ANTIBIOTICS
azithromycin 250 mg tablet generic 1 QL
AZITHROMYCIN (200 MG/5ML SUSP RECON, 500 MG VIAL PORT, 100 MG/5ML generic 1 SUSP RECON, 500 MG TABLET, 600 MG TABLET, 500 MG VIAL, 1 G PACKET) CLARITHROMYCIN (250 MG/5ML SUSP RECON, 500 MG TAB ER 24H, 500 MG generic 1 TABLET, 250 MG TABLET, 125 MG/5ML SUSP RECON)
MISC. BETA-LACTAM ANTIBIOTICS
CARBAPENEM ANTIBIOTICS
imipenem/cilastatin sodium generic 1
meropenem generic 1
meropenem in 0.9 % sodium chloride generic 1 CEPHAMYCIN ANTIBIOTICS
cefotetan disodium generic 1
cefotetan disodium in iso-osmotic dextrose generic 1
cefoxitin sodium generic 1
cefoxitin sodium/dextrose, iso-osmotic generic 1 MONOBACTAM ANTIBIOTICS
aztreonam generic 1
MISCELLANEOUS THERAPEUTIC AGENTS
5-ALPHA-REDUCTASE INHIBITORS
PAGE 81 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
QL dutasteride generic 1 GL Male
QL finasteride 5 mg tablet generic 1 GL Male
ALCOHOL DETERRENTS
disulfiram generic 1 ANTIDOTES
acetylcysteine 200 mg/ml vial generic 1 LEUCOVORIN CALCIUM (10 MG, 5 MG, 25 generic 1 MG, 15 MG) ANTIGOUT AGENTS
allopurinol 100 mg tablet generic 1 QL
allopurinol 300 mg tablet generic 1 QL
colchicine 0.6 mg capsule generic 1 QL
colchicine 0.6 mg tablet generic 1 QL
BONE RESORPTION INHIBITORS
ALENDRONATE SODIUM (10 MG, 5 MG) generic 1 QL
ALENDRONATE SODIUM (40 MG, 35 MG, 70 generic 1 QL MG) CARIOSTATIC AGENTS
fluoride (sodium) 0.5 mg/ml drops generic 1 COMPLEMENT INHIBITORS
BERINERT (500 VIAL, 500 KIT) PA BRAND 1 c1 esterase inhibitor S Specialty Drug
icatibant acetate generic 1 S Specialty Drug
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
QL CIMZIA (200 MG VIAL KIT, 2X200 MG/ML SYRINGE KIT, 2X200 MG/ML(X3)START KT) BRAND 1 PA certolizumab pegol S Specialty Drug
ENBREL (50 MG/ML SYRINGE, 25 MG KIT, 25 QL MG/0.5 ML SYRINGE) BRAND 1 PA etanercept
PAGE 82 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
S Specialty Drug
QL ENBREL MINI BRAND 1 PA etanercept S Specialty Drug
QL ENBREL SURECLICK BRAND 1 PA etanercept S Specialty Drug
QL HUMIRA (20 MG/0.4 ML, 40 MG/0.8 ML) BRAND 1 PA adalimumab S Specialty Drug
QL HUMIRA 10 MG/0.2 ML SYRINGE BRAND 1 PA adalimumab S Specialty Drug
QL HUMIRA PEDIATRIC CROHN'S BRAND 1 PA adalimumab S Specialty Drug
QL HUMIRA PEN BRAND 1 PA adalimumab S Specialty Drug
QL HUMIRA PEN CROHN'S-UC-HS BRAND 1 PA adalimumab S Specialty Drug
QL HUMIRA PEN PSOR-UVEITS-ADOL HS BRAND 1 PA adalimumab S Specialty Drug
QL HUMIRA(CF) BRAND 1 PA adalimumab S Specialty Drug
QL HUMIRA(CF) PEDI CROHN 80MG/0.8 BRAND 1 PA adalimumab S Specialty Drug
HUMIRA(CF) PEN QL BRAND 1 adalimumab
PAGE 83 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
PA
S Specialty Drug
QL HUMIRA(CF) PEN CROHN'S-UC-HS BRAND 1 PA adalimumab S Specialty Drug
QL HUMIRA(CF) PEN PSOR-UV-ADOL HS BRAND 1 PA adalimumab S Specialty Drug
leflunomide generic 1
QL OTEZLA (STARTER PACK, 28 DAY STARTER PACK, 30 MG TABLET) BRAND 1 PA apremilast S Specialty Drug
QL XELJANZ BRAND 1 PA tofacitinib citrate S Specialty Drug
IMMUNOMODULATORY AGENTS
ACTIMMUNE PA BRAND 1 interferon gamma-1b,recomb. S Specialty Drug
QL GILENYA 0.25 MG CAPSULE BRAND 1 PA fingolimod hcl S Specialty Drug
QL GILENYA 0.5 MG CAPSULE BRAND 1 PA fingolimod hcl S Specialty Drug
QL
glatiramer acetate 20 mg/ml syringe generic 1 PA
S Specialty Drug
QL GLATOPA 20 MG/ML SYRINGE BRAND 1 PA glatiramer acetate S Specialty Drug
QL PLEGRIDY 125 MCG/0.5 ML SYRING BRAND 1 peginterferon beta-1a PA
PAGE 84 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
S Specialty Drug
QL PLEGRIDY SYRINGE STARTER PACK BRAND 1 PA peginterferon beta-1a S Specialty Drug
QL PLEGRIDY 125 MCG/0.5 ML PEN BRAND 1 PA peginterferon beta-1a S Specialty Drug
QL PLEGRIDY PEN INJ STARTER PACK BRAND 1 PA peginterferon beta-1a S Specialty Drug
QL TECFIDERA (240 MG, 120 MG) BRAND 1 PA dimethyl fumarate S Specialty Drug
QL THALOMID (150 MG, 200 MG) BRAND 1 PA thalidomide S Specialty Drug
QL THALOMID (50 MG, 100 MG) BRAND 1 PA thalidomide S Specialty Drug
IMMUNOSUPPRESSIVE AGENTS
azathioprine generic 1
CYCLOSPORINE, MODIFIED (50 MG PA CAPSULE, 100 MG/ML SOLUTION, 100 MG generic 1 CAPSULE, 25 MG CAPSULE) S Specialty Drug
MYCOPHENOLATE MOFETIL (500 MG PA TABLET, 200 MG/ML SUSP RECON, 250 MG generic 1 CAPSULE) S Specialty Drug
SIROLIMUS (1 MG TABLET, 2 MG TABLET, 1 PA generic 1 MG/ML SOLUTION, 0.5 MG TABLET) S Specialty Drug
PA TACROLIMUS (1 MG, 5 MG, 0.5 MG) generic 1 S Specialty Drug
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
PAGE 85 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
QL CERDELGA BRAND 1 PA eliglustat tartrate S Specialty Drug
CYSTADANE PA BRAND 1 betaine S Specialty Drug
QL CYSTAGON 150 MG CAPSULE BRAND 1 PA cysteamine bitartrate S Specialty Drug
QL CYSTAGON 50 MG CAPSULE BRAND 1 PA cysteamine bitartrate S Specialty Drug
levocarnitine 330 mg tablet generic 1
levocarnitine (with sugar) generic 1
PA miglustat generic 1 S Specialty Drug
NITYR PA BRAND 1 nitisinone S Specialty Drug
ORFADIN (20 MG CAPSULE, 4 MG/ML PA SUSPENSION) BRAND 1 nitisinone S Specialty Drug THIOLA BRAND 1 tiopronin
TYBOST PA BRAND 1 cobicistat S Specialty Drug
PROTECTIVE AGENTS
PA dexrazoxane hcl generic 1 S Specialty Drug
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
CYCLOOXYGENASE-2 (COX-2) INHIBITORS
CELECOXIB (50 MG, 200 MG) generic 1 QL
celecoxib 100 mg capsule generic 1 QL
celecoxib 400 mg capsule generic 1 QL
PAGE 86 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS
diclofenac potassium generic 1
diclofenac sodium 1 % gel (gram) generic 1 QL
DICLOFENAC SODIUM (50 MG TABLET DR, 100 MG TAB ER 24H, 25 MG TABLET DR, 75 generic 1 MG TABLET DR) IBU BRAND 1 ibuprofen IBUPROFEN (400 MG TABLET, 600 MG TABLET, 800 MG TABLET, 100 MG/5ML generic 1 ORAL SUSP)
INDOMETHACIN (25 MG, 50 MG) generic 1 KETOROLAC TROMETHAMINE (60 MG/2 ML CARTRIDGE, 30 MG/ML CARTRIDGE, 60 generic 1 QL MG/2 ML VIAL, 60 MG/2 ML SYRINGE) KETOROLAC TROMETHAMINE (30MG/ML(1) generic 1 QL VIAL, 30 MG/ML SYRINGE)
ketorolac tromethamine 15 mg/ml syringe generic 1
ketorolac tromethamine 10 mg tablet generic 1 QL
KETOROLAC TROMETHAMINE (15 MG/ML generic 1 QL VIAL, 15 MG/ML CARTRIDGE)
meloxicam generic 1 QL
nabumetone generic 1 NAPROXEN (500 MG DR, 250 MG, 375 MG, generic 1 500 MG, 375 MG DR) SALICYLATES
BUTALBITAL/ASPIRIN/CAFFEINE (CAPSULE, generic 1 QL TABLET)
salsalate generic 1
OXYTOCICS
methylergonovine maleate 0.2 mg tablet generic 1
PARATHYROID AND ANTIPARATHYROID AGENTS
ANTIPARATHYROID AGENTS
calcitonin,salmon,synthetic generic 1 QL
PAGE 87 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS PENICILLIN ANTIBIOTICS
AMINOPENICILLIN ANTIBIOTICS
AMOXICILLIN (250 MG CAPSULE, 500 MG TABLET, 400 MG/5ML SUSP RECON, 500 MG CAPSULE, 125 MG TAB CHEW, 250 MG TAB generic 1 CHEW, 125 MG/5ML SUSP RECON, 250 MG/5ML SUSP RECON, 875 MG TABLET, 200 MG/5ML SUSP RECON) AMOXICILLIN/POTASSIUM CLAVULANATE (600-42.9/5 SUSP RECON, 875-125 MG TABLET, 400-57MG/5 SUSP RECON, 250-125 generic 1 MG TABLET, 250-62.5/5 SUSP RECON, 200- 28.5/5 SUSP RECON, 500-125 MG TABLET) AMPICILLIN SODIUM (10 G, 500 MG, 1 G, 2 G generic 1 PORT, 2 G, 1 G PORT, 250 MG, 125 MG) AMPICILLIN SODIUM/SULBACTAM SODIUM generic 1 (15, 1.5 PORT, 3, 3 PORT, 1.5)
ampicillin trihydrate 500 mg capsule generic 1 EXTENDED-SPECTRUM PENICILLINS
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM (40.5, 4.5, 3.375, 3.375 PORT, 4.5 generic 1 PORT, 13.5, 2.25 PORT, 2.25) NATURAL PENICILLIN ANTIBIOTICS
BICILLIN C-R BRAND 1 penicillin g benzathine/penicillin g procaine BICILLIN L-A BRAND 1 penicillin g benzathine
penicillin g procaine generic 1
penicillin g sodium generic 1 PENICILLIN V POTASSIUM (500 MG TABLET, 250 MG TABLET, 250 MG/5ML SOLN RECON, generic 1 125 MG/5ML SOLN RECON) PENICILLINASE-RESISTANT PENICILLINS
dicloxacillin sodium generic 1
PHARMACEUTICAL AIDS
STERILE WATER FOR IC-GREEN BRAND 1 water for injection,sterile STERILE WATER FOR KCENTRA BRAND 1 water for injection,sterile
PAGE 88 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
water for inj.,bacteriostatic generic 1 water for generic 1 inj.,bacteriostatic/methylparaben/propylparaben WATER FOR INJECTION,STERILE (IVSOLN, generic 1 AMPUL, VIAL)
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN II RECEPTOR ANTAGONISTS
ENTRESTO BRAND 1 QL sacubitril/valsartan
irbesartan generic 1 QL
LOSARTAN POTASSIUM (50 MG, 25 MG) generic 1 QL
losartan potassium 100 mg tablet generic 1 QL
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE generic 1 QL (100-12.5MG, 100MG-25MG)
losartan/hydrochlorothiazide 50-12.5 mg tablet generic 1 QL
olmesartan medoxomil generic 1 QL
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
BENAZEPRIL HCL (40 MG, 10 MG) generic 1 QL
benazepril hcl 20 mg tablet generic 1 QL
benazepril hcl 5 mg tablet generic 1 QL
enalapril maleate generic 1 QL
enalapril/hydrochlorothiazide 10 mg-25mg generic 1 QL tablet enalapril/hydrochlorothiazide 5mg-12.5mg generic 1 tablet
fosinopril sodium generic 1 QL
fosinopril sodium/hydrochlorothiazide generic 1 QL
LISINOPRIL (10 MG, 30 MG, 2.5 MG, 5 MG, generic 1 QL 20 MG)
lisinopril 40 mg tablet generic 1 QL
lisinopril/hydrochlorothiazide generic 1 QL
1
PAGE 89 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
quinapril hcl generic QL
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE generic 1 QL (10-12.5MG, 20-12.5 MG) quinapril/hydrochlorothiazide 20 mg-25mg generic 1 QL tablet
ramipril generic 1 QL
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
eplerenone generic 1
spironolactone generic 1
spironolactone/hydrochlorothiazide generic 1
RESPIRATORY TRACT AGENTS
ANTITUSSIVES
benzonatate generic 1 AL At least 10 yrs old
brompheniramine maleate/pseudoephedrine generic 1 AL At least 2 yrs old hcl/dextromethorphan
hydrocodone bit/homatrop me-br 5-1.5 mg/5 QL generic 1 syrup AL At least 2 yrs old
promethazine hcl/dextromethorphan hbr generic 1 AL At least 2 yrs old
MUCOLYTIC AGENTS
acetylcysteine 100 mg/ml vial generic 1
QL PULMOZYME BRAND 1 PA dornase alfa S Specialty Drug
RESPIRATORY TRACT AGENTS, MISCELLANEOUS
ARALAST NP 500 MG VIAL PA BRAND 1 alpha-1-proteinase inhibitor S Specialty Drug
GLASSIA PA BRAND 1 alpha-1-proteinase inhibitor S Specialty Drug
PROLASTIN C 1,000 MG/20 ML VL PA BRAND 1 alpha-1-proteinase inhibitor S Specialty Drug
ZEMAIRA PA BRAND 1 alpha-1-proteinase inhibitor S Specialty Drug
PAGE 90 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
VASODILATING AGENTS (RESPIRATORY TRACT)
QL
ambrisentan generic 1 PA
S Specialty Drug
QL
bosentan generic 1 PA
S Specialty Drug
PA epoprostenol sodium (glycine) generic 1 S Specialty Drug
QL VENTAVIS BRAND 1 PA iloprost tromethamine S Specialty Drug
SKELETAL MUSCLE RELAXANTS
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
chlorzoxazone 500 mg tablet generic 1 CYCLOBENZAPRINE HCL (10 MG, 5 MG, 7.5 generic 1 MG)
METHOCARBAMOL (750 MG, 500 MG) generic 1
TIZANIDINE HCL (4 MG, 2 MG) generic 1 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
BACLOFEN (10 MG, 20 MG, 5 MG) generic 1
SKIN AND MUCOUS MEMBRANE AGENTS
ANTIPRURITICS AND LOCAL ANESTHETICS
QL doxepin hcl 5 % cream (g) generic 1 PA
HYDROCORTISONE ACETATE/LIDOCAINE HCL/ALOE VERA (0.55%-2.8% GEL W/APPL, generic 1 2.5-3%(7G) KIT)
QL lidocaine 5 % adh. patch generic 1 PA
lidocaine 5 % oint. (g) generic 1
PAGE 91 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
lidocaine hcl 3 % cream (g) generic 1 LIDOCAINE HCL/HYDROCORTISONE generic 1 ACETATE (3 CREAM (G), 3 CREAM/APPL)
lidocaine/prilocaine 2.5 %-2.5% cream (g) generic 1
phenazopyridine hcl generic 1 CELL STIMULANTS AND PROLIFERANTS
AVITA 0.025% CREAM BRAND 1 tretinoin
TRETINOIN (0.05, 0.1, 0.025) generic 1 KERATOLYTIC AGENTS
salicylic acid 6 % cream (g) generic 1
UREA (40 LOTION, 40 CREAM (G)) generic 1 SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
ACITRETIN (17.5 MG, 25 MG) generic 1 QL
acitretin 10 mg capsule generic 1 QL
ADAPALENE (0.3 GEL (GRAM), 0.1 CREAM generic 1 QL (G))
adapalene 0.1 % gel (gram) generic 1
adapalene 0.1 % lotion generic 1 QL
azelaic acid generic 1 QL
CALCIPOTRIENE (0.005 CREAM, 0.005 QL generic 1 OINT.) PA
calcitriol 3 mcg/g oint. (g) generic 1 QL
QL COSENTYX (2 SYRINGES) BRAND 1 PA secukinumab S Specialty Drug
QL COSENTYX PEN BRAND 1 PA secukinumab S Specialty Drug
QL COSENTYX PEN (2 PENS) BRAND 1 PA secukinumab S Specialty Drug
PAGE 92 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS
QL COSENTYX SYRINGE BRAND 1 PA secukinumab S Specialty Drug
DIFFERIN 0.1% LOTION BRAND 1 QL adapalene
QL imiquimod 5 % cream pack generic 1 AL At least 12 yrs old
isotretinoin generic 1
QL pimecrolimus generic 1 AL At least 2 yrs old
podofilox generic 1 SANTYL BRAND 1 collagenase clostridium histolyticum
TACROLIMUS (0.1, 0.03) generic 1 QL
SMOOTH MUSCLE RELAXANTS
RESPIRATORY SMOOTH MUSCLE RELAXANTS
ELIXOPHYLLIN BRAND 1 theophylline anhydrous THEO-24 BRAND 1 theophylline anhydrous THEOPHYLLINE ANHYDROUS (80 MG/15ML ELIXIR, 300 MG TAB ER 12H, 100 MG TAB ER 12H, 400 MG TAB ER 24H, 450 MG TAB generic 1 ER 12H, 80 MG/15ML SOLUTION, 200 MG TAB ER 12H, 600 MG TAB ER 24H)
SOMATOSTATIN AGONISTS AND ANTAGONISTS
SOMATOSTATIN AGONISTS
OCTREOTIDE ACETATE (50 MCG/ML VIAL, 500 MCG/ML AMPUL, 1000MCG/ML VIAL, 100 PA MCG/ML AMPUL, 50 MCG/ML AMPUL, 100 generic 1 MCG/ML VIAL, 200 MCG/ML VIAL, 500 S Specialty Drug MCG/ML VIAL)
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ALPHA- AND BETA-ADRENERGIC AGONISTS
EPINEPHRINE (0.15MG/0.3, 0.3MG/0.3) generic 1 QL
PAGE 93 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ALPHA-ADRENERGIC AGONISTS
midodrine hcl generic 1
THYROID AND ANTITHYROID AGENTS
ANTITHYROID AGENTS
IODOPEN BRAND 1 sodium iodide
methimazole generic 1
propylthiouracil generic 1 THYROID AGENTS
ARMOUR THYROID (300 MG, 240 MG, 180 MG) BRAND 1 thyroid,pork EUTHYROX BRAND 1 levothyroxine sodium LEVOTHYROXINE SODIUM (75 MCG TABLET, 300 MCG TABLET, 25 MCG TABLET, 112 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 175 MCG TABLET, 200MCG/5ML VIAL, 100 MCG generic 1 TABLET, 200 MCG TABLET, 50 MCG TABLET, 500MCG/5ML VIAL, 88 MCG TABLET, 150 MCG TABLET, 100MCG/5ML VIAL) LEVOXYL BRAND 1 levothyroxine sodium LIOTHYRONINE SODIUM (25 MCG, 5 MCG, generic 1 50 MCG) NP THYROID BRAND 1 thyroid,pork THYROID BRAND 1 thyroid,pork
thyroid,pork generic 1 THYROLAR-1 BRAND 1 liotrix THYROLAR-1/2 BRAND 1 liotrix THYROLAR-1/4 BRAND 1 liotrix THYROLAR-2 BRAND 1 liotrix
PAGE 94 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS THYROLAR-3 BRAND 1 liotrix UNITHROID BRAND 1 levothyroxine sodium
VASODILATING AGENTS
NITRATES AND NITRITES
ISOSORBIDE DINITRATE (5 MG, 10 MG, 20 generic 1 QL MG, 30 MG) ISOSORBIDE MONONITRATE (10 MG TABLET, 60 MG TAB ER 24H, 30 MG TAB ER generic 1 QL 24H, 20 MG TABLET, 120 MG TAB ER 24H) NITROGLYCERIN (0.2MG/HR, 0.6MG/HR, generic 1 QL 0.4MG/HR, 0.1MG/HR)
NITROGLYCERIN (0.4 MG, 0.3 MG, 0.6 MG) generic 1 QL
PHOSPHODIESTERASE TYPE 5 INHIBITORS
QL
PA sildenafil citrate 10 mg/ml susp recon generic 1 AL At least 18 yrs old
S Specialty Drug
QL
sildenafil citrate 20 mg tablet generic 1 PA
S Specialty Drug
VASODILATING AGENTS, MISCELLANEOUS
aspirin/dipyridamole generic 1 QL
DIPYRIDAMOLE (75 MG, 25 MG, 50 MG) generic 1 QL
VITAMINS
MULTIVITAMIN PREPARATIONS
BACMIN BRAND 1 multivitamin with minerals no.20/iron/folic acid CITRANATAL 90 DHA prenatal vit no.72/iron carbony,gluc/folic BRAND 1 acid/docusate/dha CITRANATAL ASSURE prenatal vit no.73/iron carbony,gluc/folic BRAND 1 acid/docusate/dha
PAGE 95 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS CITRANATAL B-CALM prenatal vitamin BRAND 1 GL Female no.48/iron,carbonyl,gluconate/folic acid/b6 CITRANATAL DHA prenatal vit no.76/iron carbony,gluc/folic BRAND 1 acid/docusate/dha CITRANATAL HARMONY prenatal vitamin no.59/iron carb,fum/folic BRAND 1 GL Female acid/docusate/dha CITRANATAL RX prenatal vits no.81/iron carbonyl,gluc/folic BRAND 1 GL Female acid/docusate COMPLETE NATAL DHA prenatal vit no.2/iron bg chel,succ-prot/folic BRAND 1 GL Female acid/omega-3 CONCEPT DHA prenatal vit no.16/iron fum,ps complex/folic BRAND 1 GL Female acid/omega-3 CONCEPT OB prenatal vitamin no.15/iron fumarate,polysac BRAND 1 GL Female comp/folic acid FOLIVANE-OB prenatal vitamin no.15/iron fumarate,polysac BRAND 1 GL Female comp/folic acid INFUVITE ADULT VIAL BRAND 1 multivitamin infusion, adult no.4 with vitamin k INFUVITE PEDIATRIC multivitamin infusion, pediatric no.1 with vitamin BRAND 1 k M-NATAL PLUS prenatal vits with calcium no.72/ferrous BRAND 1 GL Female fumarate/folic acid M.V.I. ADULT BRAND 1 multivitamin infusion, adult no.1 with witamin k M.V.I. PEDIATRIC multivitamin infusion, pediatric no.2 with vitamin BRAND 1 k pediatric multivitamins no.17 with sodium generic 1 fluoride PNV 29-1 prenatal vitamin with calcium BRAND 1 GL Female no.76/iron,carbonyl/folic acid PNV-DHA + DOCUSATE BRAND 1 GL Female prenatal vits,calcium no.66/iron fum/folic
PAGE 96 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS acid/docusate/dha PRENAISSANCE PLUS prenatal vit with calcium no.69/iron/folic BRAND 1 GL Female acid/docusate/dha prenatal vits with calcium no.72/ferrous generic 1 GL Female fumarate/folic acid PREPLUS prenatal vits with calcium no.72/ferrous BRAND 1 GL Female fumarate/folic acid SE-NATAL 19 prenatal vits with calcium 118/ferrous BRAND 1 GL Female fumarate/folic acid SELECT-OB prenatal vit no.128/iron polysaccharide BRAND 1 GL Female complex/folic acid SELECT-OB + DHA prenatal vitamins no.33/iron polysach BRAND 1 GL Female complex/folic acid/dha STROVITE ONE multivit with mins10/folic acid/vit d3/a lipoic BRAND 1 acid/lutein TARON-C DHA prenatal vit no.16/iron fum,ps complex/folic BRAND 1 GL Female acid/omega-3 THRIVITE RX prenatal vitamin with calcium BRAND 1 no.76/iron,carbonyl/folic acid TRINATAL RX 1 prenatal vitamin 27 with calcium/ferrous BRAND 1 GL Female fumarate/folic acid TRIVEEN-DUO DHA prenatal vit with calcium 53/iron bis,s-p/folic BRAND 1 GL Female acid/omega-3 TRUST NATAL DHA prenatal vit no.2/iron bg chel,succ-prot/folic BRAND 1 GL Female acid/omega-3 VIRT-C DHA prenatal vit no.16/iron fum,ps complex/folic BRAND 1 acid/omega-3 VITAFOL FE+ prenatal vits no.102/iron polysacch/folate BRAND 1 GL Female no.1/docusate/dha VITAFOL GUMMIES BRAND 1 GL Female prenatal vit no.112/iron phosph/folic
PAGE 97 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS acid/omega-3s/dha/epa VITAFOL ULTRA prenatal vit no.67/iron polysaccharides/folate BRAND 1 GL Female comb.no.1/dha VITAFOL-OB prenatal vits with calcium no.10/ferrous BRAND 1 GL Female fumarate/folic acid VITAFOL-OB+DHA prenatal vits with calcium no.10/ferrous BRAND 1 GL Female fum/folic acid/dha VITAFOL-ONE prenatal vits no.26/iron polysaccharide BRAND 1 GL Female cplex/folic acid/dha VITAMIN B COMPLEX
cyanocobalamin (vitamin b-12) generic 1 DIALYVITE BRAND 1 folic acid/vitamin b complex and vitamin c DIALYVITE 3000 folic acid/vitamin b comp and BRAND 1 c/selenium/minerals/zinc DIALYVITE 5000 BRAND 1 multivitamins with minerals no.11/folic acid DIALYVITE SUPREME D multivitamin-minerals no.25/folic acid/vitamin BRAND 1 d3 DIALYVITE ZINC vitamin b complex no.11/folic acid/vit BRAND 1 c/biotin/zinc oxide
FOLIC ACID (5 MG/ML VIAL, 1 MG TABLET) generic 1 FOLTRATE BRAND 1 cyanocobalamin/folic acid NEPHPLEX RX vit b complex no.3/folic acid/ascorbic BRAND 1 acid/biotin/zinc oxid
pyridoxine hcl (vitamin b6) generic 1
thiamine hcl generic 1 VITAL-D RX vit b complex no.4/vit d3/ascorbic acid/folic BRAND 1 acid/zinc oxid VITAMIN C
ascorbic acid generic 1
PAGE 98 LAST UPDATED 12/2019 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS VITAMIN D
CALCITRIOL (1 MCG/ML SOLUTION, 0.5 MCG CAPSULE, 0.25 MCG CAPSULE, 1 generic 1 MCG/ML AMPUL)
DOXERCALCIFEROL (1 MCG, 2.5 MCG, 0.5 PA generic 1 MCG) S Specialty Drug
ergocalciferol (vitamin d2) generic 1
PARICALCITOL (2 MCG/ML VIAL, 2 MCG PA CAPSULE, 5 MCG/ML VIAL, 4 MCG generic 1 CAPSULE, 1 MCG CAPSULE) S Specialty Drug VITAMIN K ACTIVITY
PHYTONADIONE (VIT K1) (10 MG/ML AMPUL, 1MG/0.5ML SYRINGE, 1MG/0.5ML generic 1 AMPUL, 5 MG TABLET)
PAGE 99 LAST UPDATED 12/2019 Index of covered drugs ALITRETINOIN33 0 ALLOPURINOL82 0.9 % SODIUM CHLORIDE59 ALOSETRON HCL64 ALPHA-1-PROTEINASE INHIBITOR90 A ALPHANATE27 ABACAVIR SULFATE40 ALPRAZOLAM47 ABACAVIR SULFATE/DOLUTEGRAVIR ALPROLIX27 SODIUM/LAMIVUDINE42 ALREX10 ABACAVIR SULFATE/LAMIVUDINE41 ALTAVERA69 ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE41 ALYACEN69 ABILIFY MAINTENA35 AMANTADINE HCL34 ABIRATERONE ACETATE31 AMBRISENTAN91 ACAMPROSATE CALCIUM52 AMETHIA69 ACARBOSE22 AMETHIA LO69 ACEBUTOLOL HCL51 AMETHYST69 ACETAMINOPHEN WITH CODEINE PHOSPHATE3 AMILORIDE HCL55 ACETAZOLAMIDE26 AMILORIDE HCL/HYDROCHLOROTHIAZIDE55 ACETIC ACID58 AMINO ACID 2.36 % NO.1/D6.8W/FAT ACETYLCYSTEINE90 EMULSIONS/ELECTROLYTES NO.958 ACITRETIN92 AMINO ACID 2.75 % NO.2/DEXTROSE 10 ACTHAR54 %/ELECTROLYTES NO.2957 ACTIMMUNE84 AMINO ACID 2.75 %/DEXTROSE 7.5 ACYCLOVIR46 %/ELECTROLYTES NO.1257 ADALIMUMAB84 AMINO ACID 3.31 % NO.1/D9.8W/FAT ADAPALENE93 EMULSIONS/ELECTROLYTE NO.1058 ADMELOG79 AMINO ACIDS 3 %/ELECTROLYTE-TPN ADMELOG SOLOSTAR79 SOLN/GLYCERIN58 ADVATE27 AMINO ACIDS 3.5 %/ELECTROLYTE-M ADYNOVATE27 SOLUTION56 AEROSPAN54 AMINO ACIDS 4.25 %/DEXTROSE 15 AFIRMELLE69 %/ELECTROLYTES NO.2557 AFSTYLA27 AMINO ACIDS 5 %/CALCIUM/ELECTROLYTE-TPN AGALSIDASE BETA62 SOLN/DEXTROSE 20 %57 ALA-QUIN25 AMINO ACIDS 5 %/DEXTROSE 25 % IN WATER57 ALBENDAZOLE7 AMINO ACIDS 5.4 %58 ALBUTEROL SULFATE49 AMINO ACIDS 6 %58 ALDESLEUKIN33 AMINO ACIDS 6.9 %58 ALEMTUZUMAB32 AMINO ACIDS 7 %56 ALENDRONATE SODIUM82 AMINO ACIDS 8 %58 ALFUZOSIN HCL3 AMINO ACIDS 8.5 %/ELECTROLYTE-TPN SOLN56 ALIMTA31 AMINOCAPROIC ACID27
PAGE 100 LAST UPDATED 12/2019 AMINOSYN56 ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B- AMINOSYN II56 DOMAIN TRUNCATED28 AMINOSYN II WITH ELECTROLYTES56 ANTIHEMOPHILIC FACTOR VIII, HUMAN AMINOSYN M56 RECOMBINANT28 AMINOSYN WITH ELECTROLYTES56 ANTIHEMOPHILIC FACTOR VIII, RECOMBINANT AMINOSYN-HBC56 PORCINE SEQUENCE28 AMINOSYN-PF57 ANTIHEMOPHILIC FACTOR, HUMAN28 AMINOSYN-RF57 ANTIHEMOPHILIC FACTOR, HUMAN/VON AMIODARONE HCL13 WILLEBRAND FACTOR,HUMAN29 AMITRIPTYLINE HCL22 APIXABAN16 AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE22 APREMILAST84 AMLODIPINE BESYLATE50 APREPITANT25 AMLODIPINE BESYLATE/BENAZEPRIL HCL50 APRI69 AMLODIPINE BESYLATE/OLMESARTAN APRISO65 MEDOXOMIL51 APTENSIO XR6 AMLODIPINE BESYLATE/VALSARTAN51 APTIOM16 AMMONIUM LACTATE62 APTIVUS42 AMOXAPINE22 ARALAST NP90 AMOXICILLIN87 ARANELLE69 AMOXICILLIN/POTASSIUM CLAVULANATE88 ARANESP49 AMPHOTERICIN B25 ARCAPTA NEOHALER49 AMPICILLIN SODIUM88 ARIPIPRAZOLE35 AMPICILLIN SODIUM/SULBACTAM SODIUM88 ARIPIPRAZOLE LAUROXIL36 AMPICILLIN TRIHYDRATE88 ARIPIPRAZOLE LAUROXIL, SUBMICRONIZED36 ANAGRELIDE HCL43 ARISTADA36 ANASTROZOLE31 ARISTADA INITIO36 ANDRODERM69 ARMOUR THYROID94 ANIDULAFUNGIN25 ARNUITY ELLIPTA54 ANTI-INHIBITOR COAGULANT COMPLEX27 ARYMO ER3 ANTIHEMOPHILIC FACTOR (FACTOR VIII) ARZERRA31 RECOMB,B-DOMAIN DELETED29 ASCORBIC ACID98 ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, ASHLYNA70 FC FUSION PROTEIN27 ASPIRIN/DIPYRIDAMOLE95 ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, ATAZANAVIR SULFATE43 FULL LENGTH, PEG27 ATAZANAVIR SULFATE/COBICISTAT42 ANTIHEMOPHILIC FACTOR (FVIII) ATENOLOL51 RECOMBINANT,FULL LENGTH28 ATENOLOL/CHLORTHALIDONE51 ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B- ATOMOXETINE HCL52 DOMAIN DELETED28 ATORVASTATIN CALCIUM30 ANTIHEMOPHILIC FACTOR VIII RECOMB,SINGLE- ATOVAQUONE35 CHN,B-DOM TRUNCATED27 ATRIPLA41
PAGE 101 LAST UPDATED 12/2019 ATROPINE SULFATE64 BETHANECHOL CHLORIDE48 ATROVENT HFA15 BICALUTAMIDE31 AUBRA70 BICILLIN C-R88 AUBRA EQ70 BICILLIN L-A88 AUROVELA70 BICTEGRAVIR AUROVELA 24 FE70 SODIUM/EMTRICITABINE/TENOFOVIR AUROVELA FE70 ALAFENAMIDE FUMAR41 AUSTEDO53 BIKTARVY41 AVIANE70 BISOPROLOL FUMARATE51 AVITA92 BISOPROLOL AYUNA70 FUMARATE/HYDROCHLOROTHIAZIDE51 AZATHIOPRINE85 BIVIGAM43 AZELAIC ACID92 BLISOVI 24 FE70 AZELASTINE HCL63 BLISOVI FE70 AZITHROMYCIN81 BORTEZOMIB31 AZTREONAM81 BOSENTAN91 AZURETTE70 BREO ELLIPTA54 BRIELLYN70 B BRILINTA43 BACITRACIN/POLYMYXIN B SULFATE7 BRIMONIDINE TARTRATE26 BACLOFEN91 BRIVARACETAM17 BACMIN95 BRIVIACT17 BACTERIOSTATIC SODIUM CHLORIDE59 BROMPHENIRAMINE BALANCED SALT IRRIG SOLN NO.263 MALEATE/PSEUDOEPHEDRINE BALCOLTRA70 HCL/DEXTROMETHORPHAN90 BALZIVA70 BUDESONIDE68 BANZEL17 BUMETANIDE54 BASAGLAR KWIKPEN U-10079 BUPIVACAINE HCL80 BEKYREE70 BUPIVACAINE HCL IN DEXTROSE/PF80 BENAZEPRIL HCL89 BUPIVACAINE HCL/EPINEPHRINE80 BENDAMUSTINE HCL34 BUPIVACAINE HCL/EPINEPHRINE BITARTRATE80 BENEFIX27 BUPIVACAINE HCL/EPINEPHRINE/PF80 BENZONATATE90 BUPIVACAINE HCL/PF80 BENZTROPINE MESYLATE34 BUPRENORPHINE HCL5 BERINERT82 BUPRENORPHINE HCL/NALOXONE HCL6 BETAINE86 BUPROPION HCL20 BETAMETHASONE ACETATE/BETAMETHASONE BUSPIRONE HCL47 SODIUM PHOSPHATE68 BUSULFAN33 BETAMETHASONE DIPROPIONATE/PROPYLENE BUTALBITAL/ACETAMINOPHEN3 GLYCOL11 BUTALBITAL/ACETAMINOPHEN/CAFFEINE3 BETAMETHASONE VALERATE11
PAGE 102 LAST UPDATED 12/2019 BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC81 E PHOSPHATE3 CEFPROZIL53 BUTALBITAL/ASPIRIN/CAFFEINE87 CEFTAZIDIME53 BUTOCONAZOLE NITRATE26 CEFTRIAXONE SODIUM53 CEFTRIAXONE SODIUM IN ISO-OSMOTIC C DEXTROSE54 C1 ESTERASE INHIBITOR82 CEFUROXIME AXETIL53 CABERGOLINE55 CEFUROXIME SODIUM53 CAFFEINE CITRATE6 CELECOXIB86 CALCIPOTRIENE92 CEPHALEXIN53 CALCITONIN,SALMON,SYNTHETIC87 CERDELGA85 CALCITRIOL98 CERTOLIZUMAB PEGOL82 CALCIUM ACETATE80 CETIRIZINE HCL29 CALCIUM CHLORIDE59 CHANTIX48 CALCIUM GLUCONATE59 CHATEAL71 CAMILA70 CHATEAL EQ71 CAMPATH32 CHLORAMBUCIL32 CAMRESE70 CHLORDIAZEPOXIDE HCL47 CAMRESE LO71 CHLORHEXIDINE GLUCONATE9 CANAGLIFLOZIN23 CHLOROQUINE PHOSPHATE35 CANAGLIFLOZIN/METFORMIN HCL23 CHLOROTHIAZIDE55 CAPECITABINE32 CHLORPROMAZINE HCL39 CAPRELSA32 CHLORTHALIDONE55 CARBAMAZEPINE17 CHLORZOXAZONE91 CARBIDOPA/LEVODOPA34 CHOLESTYRAMINE (WITH SUGAR)30 CARBIDOPA/LEVODOPA/ENTACAPONE35 CHOLESTYRAMINE/ASPARTAME30 CARBINOXAMINE MALEATE64 CHROMIC CHLORIDE59 CARTEOLOL HCL26 CICLOPIROX26 CARVEDILOL51 CICLOPIROX OLAMINE26 CAZIANT71 CILOSTAZOL43 CEFACLOR53 CIMDUO41 CEFADROXIL53 CIMZIA82 CEFAZOLIN SODIUM53 CIPRODEX8 CEFDINIR53 CIPROFLOXACIN14 CEFEPIME HCL54 CIPROFLOXACIN HCL14 CEFIXIME53 CIPROFLOXACIN HCL/DEXAMETHASONE8 CEFOTAXIME SODIUM53 CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN CEFOTETAN DISODIUM81 WATER14 CEFOTETAN DISODIUM IN ISO-OSMOTIC CITALOPRAM HYDROBROMIDE21 DEXTROSE81 CITRANATAL 90 DHA95 CEFOXITIN SODIUM81 CITRANATAL ASSURE95
PAGE 103 LAST UPDATED 12/2019 CITRANATAL B-CALM95 COLCHICINE82 CITRANATAL DHA96 COLESTIPOL HCL30 CITRANATAL HARMONY96 COLISTIN (AS COLISTIMETHATE SODIUM)15 CITRANATAL RX96 COLLAGENASE CLOSTRIDIUM HISTOLYTICUM93 CITRIC ACID/GLUCONOLACTONE/MAGNESIUM COLLOIDAL BISMUTH CARBONATE59 SUBCITRATE/METRONIDAZOLE/TETRACYCLINE CITRIC ACID/SODIUM CITRATE56 HCL15 CLARITHROMYCIN81 COMBIPATCH62 CLEMASTINE FUMARATE64 COMBIVENT RESPIMAT15 CLEOCIN9 COMPLERA41 CLIMARA PRO62 COMPLETE NATAL DHA96 CLINDAMYCIN HCL14 CONCEPT DHA96 CLINDAMYCIN PALMITATE HCL14 CONCEPT OB96 CLINDAMYCIN PHOSPHATE14 CORTICOTROPIN54 CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE9 CORTISPORIN9 CLINDESSE9 COSENTYX (2 SYRINGES)92 CLINIMIX57 COSENTYX PEN92 CLINIMIX E57 COSENTYX PEN (2 PENS)92 CLINIMIX N14G30E57 COSENTYX SYRINGE92 CLINIMIX N9G15E57 CREON65 CLINIMIX N9G20E57 CRISABOROLE11 CLINISOL57 CRIXIVAN42 CLIOQUINOL/HYDROCORTISONE25 CROMOLYN SODIUM11 CLOBAZAM20 CRYSELLE71 CLOBETASOL PROPIONATE11 CUPRIC CHLORIDE59 CLOBETASOL PROPIONATE/EMOLLIENT BASE11 CUVITRU44 CLOMIPRAMINE HCL22 CYANOCOBALAMIN (VITAMIN B-12)98 CLONAZEPAM20 CYANOCOBALAMIN/FOLIC ACID98 CLONIDINE79 CYCLAFEM71 CLONIDINE HCL79 CYCLOBENZAPRINE HCL91 CLOPIDOGREL BISULFATE43 CYCLOPENTOLATE HCL64 CLORAZEPATE DIPOTASSIUM47 CYCLOPHOSPHAMIDE32 CLOTRIMAZOLE25 CYCLOSPORINE, MODIFIED85 CLOTRIMAZOLE/BETAMETHASONE CYPROHEPTADINE HCL64 DIPROPIONATE26 CYRED71 CLOZAPINE36 CYRED EQ71 COAGADEX27 CYSTADANE86 COAGULATION FACTOR VIIA (RECOMBINANT)28 CYSTAGON86 COAGULATION FACTOR X27 CYSTARAN63 COBICISTAT86 CYSTEAMINE BITARTRATE86 CODEINE SULFATE3 CYSTEAMINE HCL63
PAGE 104 LAST UPDATED 12/2019 CYSTEINE HCL57 DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE6 D DEXTROAMPHETAMINE SULFATE6 DABIGATRAN ETEXILATE MESYLATE16 DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE57 DANAZOL69 DEXTROSE 10 % AND 0.45 % SODIUM DAPAGLIFLOZIN PROPANEDIOL23 CHLORIDE57 DAPAGLIFLOZIN PROPANEDIOL/METFORMIN DEXTROSE 10 % IN WATER57 HCL24 DEXTROSE 2.5 % AND 0.45 % SODIUM DAPSONE31 CHLORIDE57 DARBEPOETIN ALFA IN POLYSORBATE 8049 DEXTROSE 20 % IN WATER57 DARUNAVIR DEXTROSE 25 % IN WATER57 ETH/COBICISTAT/EMTRICITABINE/TENOFOVIR DEXTROSE 30 % IN WATER57 ALAFENAMIDE43 DEXTROSE 40 % IN WATER57 DARUNAVIR ETHANOLATE43 DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE57 DARUNAVIR ETHANOLATE/COBICISTAT43 DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE57 DASETTA71 DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE57 DAYSEE71 DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE57 DAYTRANA6 DEXTROSE 5 % IN LACTATED RINGERS59 DEBLITANE71 DEXTROSE 5 % IN WATER57 DEFEROXAMINE MESYLATE68 DEXTROSE 50 % IN WATER58 DELAVIRDINE MESYLATE40 DEXTROSE 70 % IN WATER58 DELFLEX WITH 1.5% DEXTROSE58 DIALYVITE98 DELSTRIGO40 DIALYVITE 300098 DENAVIR9 DIALYVITE 500098 DEPO-SUBQ PROVERA 10478 DIALYVITE SUPREME D98 DESCOVY41 DIALYVITE ZINC98 DESIPRAMINE HCL22 DIASTAT47 DESMOPRESSIN ACETATE78 DIASTAT ACUDIAL48 DESMOPRESSIN ACETATE (NON- DIAZEPAM48 REFRIGERATED)78 DIAZOXIDE29 DESOGESTREL-ETHINYL ESTRADIOL77 DICLOFENAC POTASSIUM86 DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL DICLOFENAC SODIUM87 ESTRADIOL77 DICLOXACILLIN SODIUM88 DESVENLAFAXINE SUCCINATE20 DICYCLOMINE HCL15 DEUTETRABENAZINE53 DIDANOSINE42 DEXAMETHASONE68 DIFFERIN93 DEXAMETHASONE SODIUM PHOSPHATE68 DIFLUPREDNATE10 DEXAMETHASONE SODIUM PHOSPHATE/PF68 DIGOXIN51 DEXMETHYLPHENIDATE HCL6 DILANTIN20 DEXRAZOXANE HCL86 DILTIAZEM HCL50 DIMETHYL FUMARATE85
PAGE 105 LAST UPDATED 12/2019 DIPHENHYDRAMINE HCL64 EFAVIRENZ/EMTRICITABINE/TENOFOVIR DIPHENOXYLATE HCL/ATROPINE SULFATE65 DISOPROXIL FUMARATE41 DIPYRIDAMOLE95 EFAVIRENZ/LAMIVUDINE/TENOFOVIR DISOPYRAMIDE PHOSPHATE12 DISOPROXIL FUMARATE40 DISULFIRAM82 EFFER-K59 DIURIL55 ELAGOLIX SODIUM66 DIVALPROEX SODIUM17 ELECTROLYTE-148 SOLUTION60 DOBUTAMINE HCL48 ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER49 WATER59 DOFETILIDE13 ELECTROLYTE-A SOLUTION60 DOLUTEGRAVIR SODIUM40 ELECTROLYTE-B SOLUTION/DEXTROSE 5 % IN DOLUTEGRAVIR SODIUM/LAMIVUDINE39 WATER59 DOLUTEGRAVIR SODIUM/RILPIVIRINE HCL40 ELECTROLYTE-M SOLUTION/DEXTROSE 5 % IN DONEPEZIL HCL48 WATER60 DORAVIRINE40 ELECTROLYTE-MB SOLUTION/DEXTROSE 5 % IN DORAVIRINE/LAMIVUDINE/TENOFOVIR WATER59 DISOPROXIL FUMARATE40 ELECTROLYTE-P SOLUTION/DEXTROSE 5 % IN DORNASE ALFA90 WATER59 DORZOLAMIDE HCL26 ELECTROLYTE-R (PH 7.4)60 DORZOLAMIDE HCL/TIMOLOL MALEATE26 ELECTROLYTE-R SOLUTION60 DOVATO39 ELECTROLYTE-R SOLUTION/DEXTROSE 5 % IN DOXAZOSIN MESYLATE51 WATER60 DOXEPIN HCL91 ELECTROLYTE-S SOLUTION59 DOXERCALCIFEROL99 ELELYSO62 DOXYCYCLINE HYCLATE14 ELIGLUSTAT TARTRATE85 DOXYLAMINE SUCCINATE/PYRIDOXINE HCL ELINEST71 (B6)24 ELIQUIS16 DROPERIDOL47 ELIXOPHYLLIN93 DROSPIRENONE76 ELLA71 DROSPIRENONE/ETHINYL ELOCTATE27 ESTRADIOL/LEVOMEFOLATE CALCIUM77 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN DULAGLUTIDE23 OFOVIR ALAFENAMIDE41 DULOXETINE HCL21 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN DUREZOL10 OFOVIR DISOPROXIL42 DUTASTERIDE81 EMBEDA3 EMGALITY PEN30 E EMGALITY SYRINGE31 ECONAZOLE NITRATE26 EMICIZUMAB-KXWH28 EDOXABAN TOSYLATE16 EMOQUETTE71 EDURANT40 EMPAGLIFLOZIN23 EFAVIRENZ40 EMPAGLIFLOZIN/LINAGLIPTIN23
PAGE 106 LAST UPDATED 12/2019 EMPAGLIFLOZIN/METFORMIN HCL24 ESTRADIOL63 EMTRICITABINE41 ESTRADIOL VALERATE63 EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR ESTRADIOL VALERATE/DIENOGEST74 ALAFENAMIDE FUMARATE41 ESTRADIOL/LEVONORGESTREL62 EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR ESTRADIOL/NORETHINDRONE ACETATE63 DISOPROXIL FUMARATE41 ESTRING63 EMTRICITABINE/TENOFOVIR ALAFENAMIDE ESTROGENS, CONJUGATED63 FUMARATE41 ESTROGENS, EMTRICITABINE/TENOFOVIR DISOPROXIL CONJUGATED/MEDROXYPROGESTERONE FUMARATE42 ACETATE63 EMTRIVA41 ESTROGENS,ESTERIFIED/METHYLTESTOSTERON ENALAPRIL MALEATE89 E69 ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE89 ETANERCEPT83 ENBREL82 ETHAMBUTOL HCL31 ENBREL MINI83 ETHINYL ESTRADIOL/DROSPIRENONE78 ENBREL SURECLICK83 ETHOSUXIMIDE20 ENFUVIRTIDE39 ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL78 ENOXAPARIN SODIUM16 ETONOGESTREL/ETHINYL ESTRADIOL75 ENPRESSE71 ETRAVIRINE40 ENSKYCE71 EUCRISA11 ENTECAVIR46 EUTHYROX94 ENTRESTO89 EVOTAZ42 ENZALUTAMIDE34 EXEMESTANE32 EPINEPHRINE93 EZETIMIBE30 EPITOL17 EPIVIR HBV41 F EPLERENONE90 FABRAZYME62 EPOETIN ALFA49 FACTOR IX COMPLEX, PROTHROMBIN CPLX EPOETIN ALFA-EPBX50 CONC(PCC) NO.4, 3-FACTOR28 EPOGEN49 FACTOR IX HUMAN RECOMBINANT29 EPOPROSTENOL SODIUM (GLYCINE)91 FACTOR IX HUMAN RECOMBINANT, THREONINE EQUETRO17 14828 ERAXIS (WATER DILUENT)25 FACTOR IX RECOMBINANT, FC FUSION ERGOCALCIFEROL (VITAMIN D2)99 PROTEIN27 ERRIN71 FACTOR IX RECOMBINANT,ALBUMIN FUSION ERYTHROMYCIN BASE8 PROTEIN28 ERYTHROMYCIN ETHYLSUCCINATE81 FACTOR XIII A-SUBUNIT, RECOMBINANT29 ESCITALOPRAM OXALATE21 FALMINA72 ESLICARBAZEPINE ACETATE16 FAMOTIDINE45 ESOMEPRAZOLE MAGNESIUM45 FAMOTIDINE IN SODIUM CHLORIDE, ISO- ESTARYLLA72 OSMOTIC/PF45
PAGE 107 LAST UPDATED 12/2019 FAMOTIDINE/PF45 FLUTAMIDE32 FARXIGA23 FLUTICASONE FUROATE54 FAT EMULSIONS58 FLUTICASONE FUROATE/UMECLIDINIUM FAYOSIM72 BROMIDE/VILANTEROL TRIFENAT54 FEIBA NF27 FLUTICASONE FUROATE/VILANTEROL FELBAMATE17 TRIFENATATE54 FELODIPINE51 FLUTICASONE PROPIONATE11 FEMYNOR72 FLUTICASONE PROPIONATE/SALMETEROL FENOFIBRATE NANOCRYSTALLIZED30 XINAFOATE54 FENTANYL4 FLUVOXAMINE MALEATE21 FERROUS FUMARATE/ASCORBIC ACID/B12- FML FORTE10 IF/FOLIC ACID12 FML S.O.P.10 FERROUS FUMARATE/ASCORBIC FOLIC ACID98 ACID/CYANOCOBALAMIN/FOLIC ACID12 FOLIC ACID/VITAMIN B COMP AND FERROUS FUMARATE/FOLIC ACID12 C/SELENIUM/MINERALS/ZINC98 FERROUS FUMARATE/FOLIC ACID/MULTIVITAMIN- FOLIC ACID/VITAMIN B COMPLEX AND VITAMIN MINERALS NO.1512 C98 FESOTERODINE FUMARATE66 FOLIVANE-OB96 FILGRASTIM50 FOLTRATE98 FINASTERIDE82 FOSAMPRENAVIR CALCIUM43 FINGOLIMOD HCL84 FOSINOPRIL SODIUM89 FLAREX10 FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE89 FLEBOGAMMA DIF44 FREAMINE HBC58 FLECAINIDE ACETATE13 FREAMINE III58 FLUCONAZOLE25 FUROSEMIDE54 FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC25 FUSION PLUS12 FLUCONAZOLE IN SODIUM CHLORIDE, ISO- FUZEON39 OSMOTIC25 FYCOMPA17 FLUDROCORTISONE ACETATE68 FLUNISOLIDE54 G FLUOCINOLONE ACETONIDE11 GABAPENTIN18 FLUOCINOLONE ACETONIDE OIL10 GALCANEZUMAB-GNLM31 FLUOCINOLONE ACETONIDE/SHOWER CAP11 GAMASTAN S-D44 FLUORIDE (SODIUM)82 GAMMAGARD LIQUID44 FLUOROMETHOLONE10 GAMMAGARD S-D44 FLUOROMETHOLONE ACETATE10 GAMMAKED44 FLUOROURACIL32 GAMMAPLEX44 FLUOXETINE HCL21 GAMUNEX-C44 FLUPHENAZINE DECANOATE39 GEFITINIB32 FLUPHENAZINE HCL39 GEMFIBROZIL30 FLURBIPROFEN SODIUM10 GENOTROPIN78
PAGE 108 LAST UPDATED 12/2019 GENTAMICIN SULFATE13 HEATHER72 GENTAMICIN SULFATE IN SODIUM CHLORIDE, HELIXATE FS27 ISO-OSMOTIC13 HEMATOGEN FA12 GENTAMICIN SULFATE/PF13 HEMLIBRA28 GENVOYA41 HEMOCYTE PLUS12 GIANVI72 HEMOCYTE-F12 GILENYA84 HEMOFIL M28 GLASSIA90 HEPARIN SODIUM,PORCINE16 GLATIRAMER ACETATE84 HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM GLATOPA84 CHLORIDE16 GLECAPREVIR/PIBRENTASVIR67 HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM GLIMEPIRIDE24 CHLORIDE/PF16 GLIPIZIDE24 HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN GLIPIZIDE/METFORMIN HCL24 WATER16 GLUCAGEN29 HEPARIN SODIUM,PORCINE/PF16 GLUCAGON EMERGENCY KIT29 HEPATAMINE58 GLUCAGON HCL29 HIZENTRA44 GLUCAGON,HUMAN RECOMBINANT29 HUMALOG MIX 50-50 KWIKPEN79 GLYBURIDE24 HUMALOG MIX 75-25 KWIKPEN79 GLYBURIDE,MICRONIZED24 HUMATE-P28 GLYBURIDE/METFORMIN HCL24 HUMIRA83 GLYCOPYRROLATE15 HUMIRA PEDIATRIC CROHN'S83 GLYCOPYRROLATE/PF15 HUMIRA PEN83 GLYRX-PF15 HUMIRA PEN CROHN'S-UC-HS83 GLYXAMBI23 HUMIRA PEN PSOR-UVEITS-ADOL HS83 GOLYTELY65 HUMIRA(CF)83 GOSERELIN ACETATE67 HUMIRA(CF) PEDIATRIC CROHN'S83 GRANISETRON HCL24 HUMIRA(CF) PEN83 GRANIX49 HUMIRA(CF) PEN CROHN'S-UC-HS84 GRISEOFULVIN, MICROSIZE25 HUMIRA(CF) PEN PSOR-UV-ADOL HS84 GUANFACINE HCL79 HUMULIN R U-50080 GUANIDINE HCL48 HUMULIN R U-500 KWIKPEN80 GYNAZOLE 126 HYALURONIDASE, HUMAN RECOMB.62 HYDRALAZINE HCL79 H HYDROCHLOROTHIAZIDE55 HAILEY72 HYDROCODONE BITARTRATE4 HAILEY 24 FE72 HYDROCODONE BITARTRATE/ACETAMINOPHEN5 HALOBETASOL PROPIONATE11 HYDROCODONE BITARTRATE/HOMATROPINE HALOPERIDOL38 METHYLBROMIDE90 HALOPERIDOL DECANOATE39 HYDROCODONE/IBUPROFEN4 HALOPERIDOL LACTATE39 HYDROCORTISONE68
PAGE 109 LAST UPDATED 12/2019 HYDROCORTISONE ACETATE/LIDOCAINE IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 HCL/ALOE VERA91 TO 50 MCG/ML44 HYDROCORTISONE ACETATE/PRAMOXINE HCL11 IMMUNE GLOBULIN,GAMMA(IGG) HYDROCORTISONE SODIUM SUCCINATE/PF68 HUMAN/HYALURONIDASE, HUMAN RECOMB44 HYDROCORTISONE/IODOQUINOL9 IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE44 HYDROMORPHONE HCL4 IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA HYDROXYCHLOROQUINE SULFATE35 AVERAGE 46 MCG/ML44 HYDROXYPROGESTERONE CAPROATE/PF78 INCASSIA72 HYDROXYUREA32 INCRUSE ELLIPTA15 HYDROXYZINE HCL47 INDACATEROL MALEATE49 HYDROXYZINE PAMOATE47 INDACATEROL MALEATE/GLYCOPYRROLATE49 HYOSCYAMINE SULFATE15 INDAPAMIDE55 HYPERLYTE CR59 INDINAVIR SULFATE42 HYQVIA44 INDOMETHACIN87 HYQVIA HY COMPONENT62 INFUVITE ADULT96 HYQVIA IG COMPONENT44 INFUVITE PEDIATRIC96 HYSINGLA ER4 INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART80 I INSULIN GLARGINE,HUMAN RECOMBINANT IBU87 ANALOG79 IBUPROFEN87 INSULIN LISPRO79 ICATIBANT ACETATE82 INSULIN LISPRO PROTAMINE AND INSULIN IDELVION28 LISPRO79 IFEREX 150 FORTE12 INSULIN REGULAR, HUMAN80 ILEVRO10 INTEGRA F12 ILOPROST TROMETHAMINE91 INTEGRA PLUS12 IMATINIB MESYLATE32 INTELENCE40 IMIPENEM/CILASTATIN SODIUM81 INTERFERON ALFA-2B,RECOMB.45 IMIPRAMINE HCL22 INTERFERON GAMMA-1B,RECOMB.84 IMIQUIMOD93 INTRALIPID58 IMMUNE INTRON A45 GLOBULIN,GAMM(IGG)/GLYCINE/GLUCOSE/IGA 0 INTROVALE72 TO 50 MCG/ML44 INVEGA SUSTENNA37 IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA INVEGA TRINZA37 GREATER THAN 50 MCG/ML44 INVIRASE42 IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA INVOKAMET23 GREATER THAN 50 MCG/ML44 INVOKANA23 IMMUNE GLOBULIN,GAMMA (IGG)/GLYCINE/IGA 0 IODOPEN94 TO 50 MCG/ML44 IONOSOL B WITH DEXTROSE 5%59 IMMUNE GLOBULIN,GAMMA (IGG)/PROLINE/IGA 0 IONOSOL MB-DEXTROSE 5%59 TO 50 MCG/ML44 IPRATROPIUM BROMIDE15
PAGE 110 LAST UPDATED 12/2019 IPRATROPIUM BROMIDE/ALBUTEROL SULFATE15 IRBESARTAN89 K IRESSA32 K-PHOS NO.255 IRON FUM,POLYSAC COMP/FOLIC ACID/VIT B K-PHOS ORIGINAL55 COMPC NO.18/L. CASEI12 KABIVEN58 IRON FUMARATE,POLYSAC COMP/FOLIC KAITLIB FE73 ACID/VITAMIN C/NIACINAMIDE12 KALETRA43 IRON FUMARATE,POLYSAC CPLEX/FOLIC KALLIGA73 ACID/VITB COMP WITH C NO.912 KARIVA73 IRON FUMARATE-IRON POLYSACCH CPLEX/FOLIC KELNOR 1-3573 ACID/MULTIVIT NO.1812 KELNOR 1-5073 IRON POLYSACCHARIDE KETOCONAZOLE26 COMPLEX/CYANOCOBALAMIN/FOLIC ACID12 KETOROLAC TROMETHAMINE87 ISENTRESS39 KLOR-CON59 ISENTRESS HD40 KLOR-CON 1060 ISIBLOOM72 KLOR-CON 860 ISOLYTE P WITH DEXTROSE59 KLOR-CON M1060 ISOLYTE S59 KLOR-CON M1560 ISONIAZID31 KLOR-CON M2060 ISOSORBIDE DINITRATE95 KLOR-CON SPRINKLE60 ISOSORBIDE MONONITRATE95 KLOR-CON-EF60 ISOTRETINOIN93 KOATE28 IVERMECTIN10 KOGENATE FS28 IXINITY28 KOMBIGLYZE XR23 KOVALTRY28 J KURVELO73 JANTOVEN16 JANUMET23 L JANUMET XR23 LABETALOL HCL52 JANUVIA23 LACOSAMIDE19 JARDIANCE23 LACTULOSE56 JASMIEL72 LAMIVUDINE41 JENCYCLA72 LAMIVUDINE/TENOFOVIR DISOPROXIL JENTADUETO23 FUMARATE41 JEVANTIQUE LO63 LAMIVUDINE/ZIDOVUDINE41 JOLESSA72 LAMOTRIGINE19 JULEBER72 LANSOPRAZOLE45 JULUCA40 LARIN73 JUNEL72 LARIN 24 FE73 JUNEL FE72 LARIN FE73 JUNEL FE 2473 LARISSIA73
PAGE 111 LAST UPDATED 12/2019 LATANOPROST27 LINACLOTIDE65 LAYOLIS FE73 LINAGLIPTIN23 LEENA73 LINAGLIPTIN/METFORMIN HCL23 LEFLUNOMIDE84 LINCOMYCIN HCL15 LENALIDOMIDE33 LINEZOLID15 LESSINA73 LINZESS65 LETROZOLE32 LIOTHYRONINE SODIUM94 LEUCOVORIN CALCIUM82 LIOTRIX94 LEUKERAN32 LIPASE/PROTEASE/AMYLASE65 LEUKINE49 LISDEXAMFETAMINE DIMESYLATE6 LEUPROLIDE ACETATE67 LISINOPRIL89 LEUPROLIDE ACETATE/NORETHINDRONE LISINOPRIL/HYDROCHLOROTHIAZIDE89 ACETATE66 LITHIUM CARBONATE52 LEVETIRACETAM18 LO LOESTRIN FE74 LEVOBUNOLOL HCL26 LO-ZUMANDIMINE74 LEVOCARNITINE86 LOPERAMIDE HCL65 LEVOCARNITINE (WITH SUGAR)86 LOPINAVIR/RITONAVIR43 LEVOCETIRIZINE DIHYDROCHLORIDE29 LORAZEPAM48 LEVOFLOXACIN14 LORAZEPAM INTENSOL48 LEVOFLOXACIN/DEXTROSE 5 % IN WATER14 LORYNA74 LEVONEST73 LOSARTAN POTASSIUM89 LEVONORGESTREL-ETHINYL ESTRADIOL77 LOSARTAN LEVONORGESTREL/ETHINYL ESTRADIOL AND POTASSIUM/HYDROCHLOROTHIAZIDE89 ETHINYL ESTRADIOL76 LOTEPREDNOL ETABONATE10 LEVONORGESTREL/ETHINYL LOVASTATIN30 ESTRADIOL/FERROUS BISGLYCINATE70 LOW-OGESTREL74 LEVORA-2873 LOXAPINE SUCCINATE35 LEVOTHYROXINE SODIUM95 LUPANETA PACK66 LEVOXYL94 LUPRON DEPOT67 LEXIVA43 LUPRON DEPOT (LUPANETA)67 LIDOCAINE91 LUPRON DEPOT-PED67 LIDOCAINE HCL91 LUTERA74 LIDOCAINE HCL IN DEXTROSE 7.5 % IN LYZA74 WATER/PF80 LIDOCAINE HCL/EPINEPHRINE80 M LIDOCAINE HCL/EPINEPHRINE BITARTRATE81 M-NATAL PLUS96 LIDOCAINE HCL/HYDROCORTISONE ACETATE92 M.V.I. ADULT96 LIDOCAINE HCL/PF81 M.V.I. PEDIATRIC96 LIDOCAINE/PRILOCAINE92 MAGNESIUM CHLORIDE18 LIFITEGRAST10 MAGNESIUM SULFATE18 LILLOW73 MAGNESIUM SULFATE IN STERILE WATER18
PAGE 112 LAST UPDATED 12/2019 MAKENA78 METOPROLOL TARTRATE52 MANGANESE CHLORIDE60 METRONIDAZOLE35 MANGANESE SULFATE60 METRONIDAZOLE IN SODIUM CHLORIDE35 MANNITOL/SORBITOL SOLUTION59 MEXILETINE HCL13 MARAVIROC39 MIBELAS 24 FE74 MARLISSA74 MICONAZOLE NITRATE26 MATULANE33 MICROGESTIN74 MAVYRET67 MICROGESTIN 24 FE74 MAXIDEX10 MICROGESTIN FE74 MECLIZINE HCL25 MIDODRINE HCL93 MEDROXYPROGESTERONE ACETATE78 MIGLITOL22 MEFLOQUINE HCL35 MIGLUSTAT86 MEGESTROL ACETATE79 MILI74 MELODETTA 24 FE74 MILRINONE LACTATE51 MELOXICAM87 MILRINONE LACTATE/DEXTROSE 5 % IN WATER51 MELPHALAN33 MINOCYCLINE HCL14 MEMANTINE HCL52 MINOXIDIL79 MERCAPTOPURINE33 MIRTAZAPINE20 MEROPENEM81 MISOPROSTOL45 MEROPENEM IN 0.9 % SODIUM CHLORIDE81 MITOXANTRONE HCL33 MESALAMINE65 MODAFINIL7 METFORMIN HCL23 MODERIBA46 METHAZOLAMIDE26 MOMETASONE FUROATE11 METHENAMINE HIPPURATE7 MONO-LINYAH74 METHENAMINE MANDELATE7 MONTELUKAST SODIUM11 METHENAMINE/METHYLENE BLUE/SOD MORPHABOND ER4 PHOS/P.SALICYLATE/HYOSCYAMINE7 MORPHINE SULFATE4 METHIMAZOLE94 MORPHINE SULFATE/NALTREXONE HCL3 METHOCARBAMOL91 MOVANTIK65 METHOTREXATE SODIUM33 MOXEZA8 METHOTREXATE SODIUM/PF33 MOXIFLOXACIN HCL8 METHYLDOPA79 MOZOBIL50 METHYLERGONOVINE MALEATE87 MULTITRACE-460 METHYLPHENIDATE6 MULTITRACE-560 METHYLPHENIDATE HCL7 MULTIVIT WITH MINS10/FOLIC ACID/VIT D3/A METHYLPREDNISOLONE68 LIPOIC ACID/LUTEIN97 METHYLPREDNISOLONE ACETATE68 MULTIVITAMIN INFUSION, ADULT NO.1 WITH METHYLPREDNISOLONE SODIUM SUCCINATE68 WITAMIN K96 METOCLOPRAMIDE HCL66 MULTIVITAMIN INFUSION, ADULT NO.4 WITH METOLAZONE55 VITAMIN K96 METOPROLOL SUCCINATE52
PAGE 113 LAST UPDATED 12/2019 MULTIVITAMIN INFUSION, PEDIATRIC NO.1 WITH NETARSUDIL MESYLATE27 VITAMIN K96 NEULASTA50 MULTIVITAMIN INFUSION, PEDIATRIC NO.2 WITH NEUPOGEN50 VITAMIN K96 NEVIRAPINE40 MULTIVITAMIN WITH MINERALS NO.20/IRON/FOLIC NEXAVAR33 ACID95 NEXIUM45 MULTIVITAMIN-MINERALS NO.25/FOLIC NIACIN30 ACID/VITAMIN D398 NIFEDIPINE51 MULTIVITAMINS WITH MINERALS NO.11/FOLIC NIKKI74 ACID98 NILUTAMIDE33 MUPIROCIN9 NIMODIPINE51 MYCOPHENOLATE MOFETIL85 NITISINONE86 MYLERAN33 NITROFURANTOIN7 NITROFURANTOIN MACROCRYSTAL7 N NITROFURANTOIN NABUMETONE87 MONOHYDRATE/MACROCRYSTALS7 NAFARELIN ACETATE67 NITROGLYCERIN95 NALOXEGOL OXALATE65 NITYR86 NALOXONE HCL53 NORA-BE74 NALTREXONE HCL52 NORDITROPIN FLEXPRO78 NALTREXONE MICROSPHERES53 NORELGESTROMIN/ETHINYL ESTRADIOL77 NAPROXEN87 NORETHINDRONE77 NARCAN53 NORETHINDRONE ACETATE79 NATAZIA74 NORETHINDRONE ACETATE-ETHINYL NEBUPENT35 ESTRADIOL75 NECON74 NORETHINDRONE ACETATE-ETHINYL NELFINAVIR MESYLATE43 ESTRADIOL/FERROUS FUMARATE76 NEOMYCIN SULFATE13 NORETHINDRONE-ETHINYL ESTRADIOL77 NEOMYCIN SULFATE/BACITRACIN NORETHINDRONE-ETHINYL ZINC/POLYMYXIN B/HYDROCORTISONE8 ESTRADIOL/FERROUS FUMARATE77 NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B8 NORGESTIMATE-ETHINYL ESTRADIOL77 NEOMYCIN SULFATE/POLYMYXIN B SULFATE9 NORGESTREL-ETHINYL ESTRADIOL75 NEOMYCIN SULFATE/POLYMYXIN B NORLYDA75 SULFATE/HYDROCORTISONE9 NORMOSOL-M AND DEXTROSE60 NEOMYCIN/BACITRACIN/POLYMYXIN NORMOSOL-R60 B/HYDROCORTISONE9 NORMOSOL-R AND DEXTROSE60 NEOMYCIN/POLYMYXIN B NORMOSOL-R PH 7.460 SULFATE/DEXAMETHASONE8 NORTREL75 NEPAFENAC10 NORTRIPTYLINE HCL22 NEPHPLEX RX98 NORVIR43 NEPHRAMINE58 NOVOEIGHT28
PAGE 114 LAST UPDATED 12/2019 NOVOLOG MIX 70-3080 OXYCODONE MYRISTATE5 NOVOLOG MIX 70-30 FLEXPEN80 NOVOSEVEN RT28 P NP THYROID94 PALIPERIDONE PALMITATE37 NUTRILIPID58 PANRETIN33 NUVARING75 PANTOPRAZOLE SODIUM45 NUWIQ28 PARENTERAL AMINO ACID 10 % COMBINATION NYSTATIN26 NO.256 PARENTERAL AMINO ACID 10 % COMBINATION O NO.458 OBIZUR28 PARENTERAL AMINO ACID 10 % COMBINATION OCELLA75 NO.658 OCTAGAM44 PARENTERAL AMINO ACID 15% COMBINATION OCTREOTIDE ACETATE93 NO.158 ODEFSEY41 PARENTERAL AMINO ACID 15% COMBINATION OFATUMUMAB31 NO.557 OFLOXACIN8 PARENTERAL AMINO ACID 20 % COMBINATION OGESTREL75 NO.158 OLANZAPINE37 PARENTERAL AMINO ACID 5.2 % COMBINATION OLANZAPINE PAMOATE38 NO.1 (RENAL)57 OLMESARTAN MEDOXOMIL89 PARENTERAL AMINO ACID 6% COMBINATION OLODATEROL HCL49 NO.158 OLOPATADINE HCL63 PARENTERAL AMINO ACID 7 % COMBINATION OMEPRAZOLE45 NO.1 (PEDIATRIC)57 ONDANSETRON24 PARENTERAL AMINO ACID 7 % COMBINATION ONDANSETRON HCL24 NO.256 ONGLYZA23 PARICALCITOL99 OPIUM/BELLADONNA ALKALOIDS5 PAROXETINE HCL21 ORACIT56 PAZEO63 ORFADIN86 PAZOPANIB HCL34 ORILISSA66 PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUM ORSYTHIA75 FLUORIDE96 OSELTAMIVIR PHOSPHATE46 PEG 3350/SOD SULF/SOD BICARB/SOD OTEZLA84 CHLORIDE/POTASSIUM CHLORIDE65 OXAYDO5 PEGASYS45 OXAZEPAM48 PEGASYS PROCLICK45 OXCARBAZEPINE18 PEGFILGRASTIM50 OXTELLAR XR18 PEGINTERFERON ALFA-2A45 OXYBUTYNIN CHLORIDE66 PEGINTERFERON ALFA-2B45 OXYCODONE HCL5 PEGINTERFERON BETA-1A85 OXYCODONE HCL/ACETAMINOPHEN5 PEGINTRON45
PAGE 115 LAST UPDATED 12/2019 PEMETREXED DISODIUM31 PLERIXAFOR50 PENCICLOVIR9 PNV 29-196 PENICILLIN G BENZATHINE88 PNV-DHA + DOCUSATE96 PENICILLIN G BENZATHINE/PENICILLIN G PODOFILOX93 PROCAINE88 POLYETHYLENE GLYCOL 335065 PENICILLIN G PROCAINE88 POLYMYXIN B SULFATE15 PENICILLIN G SODIUM88 POLYMYXIN B SULFATE/TRIMETHOPRIM8 PENICILLIN V POTASSIUM88 POMALIDOMIDE33 PENTAMIDINE ISETHIONATE35 POMALYST33 PENTOXIFYLLINE50 PORTIA75 PERAMPANEL17 POTASSIUM ACETATE60 PERIKABIVEN58 POTASSIUM BICARBONATE/CITRIC ACID60 PERITONEAL DIALYSIS SOLUTION NO.19 AND POTASSIUM CHLORIDE60 DEXTROSE 1.5 %58 POTASSIUM CHLORIDE IN 0.45 % SODIUM PERMETHRIN10 CHLORIDE61 PERPHENAZINE39 POTASSIUM CHLORIDE IN 0.9 % SODIUM PERPHENAZINE/AMITRIPTYLINE HCL22 CHLORIDE61 PHENAZOPYRIDINE HCL92 POTASSIUM CHLORIDE IN 5 % DEXTROSE IN PHENOBARBITAL47 WATER61 PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 SULF/SCOPOLAMINE HB15 % SODIUM CHLORIDE61 PHENYLEPHRINE HCL64 POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % PHENYLEPHRINE HCL/PROMETHAZINE HCL64 SODIUM CHLORIDE61 PHENYTOIN20 POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % PHENYTOIN SODIUM EXTENDED20 SODIUM CHLORIDE61 PHILITH75 POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3 PHOSPHA 250 NEUTRAL56 % SODIUM CHLORIDE61 PHYTONADIONE (VIT K1)99 POTASSIUM CHLORIDE IN LACTATED RINGERS PIFELTRO40 AND 5 % DEXTROSE61 PILOCARPINE HCL48 POTASSIUM CHLORIDE IN WATER FOR PIMECROLIMUS93 INJECTION, STERILE61 PIMOZIDE35 POTASSIUM CITRATE56 PIMTREA75 POTASSIUM CITRATE/CITRIC ACID56 PIOGLITAZONE HCL24 POTASSIUM PHOSPHATE,MONOBASIC55 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM88 POTASSIUM PHOSPHATE,MONOBASIC-DIBASIC61 PIRMELLA75 PRADAXA16 PLASMA-LYTE 14860 PRAMIPEXOLE DI-HCL55 PLASMA-LYTE A PH 7.460 PRAMLINTIDE ACETATE22 PLEGRIDY85 PRASUGREL HCL43 PLEGRIDY PEN85 PRAVASTATIN SODIUM30 PLENAMINE58 PRAZIQUANTEL7
PAGE 116 LAST UPDATED 12/2019 PRAZOSIN HCL51 PRENATAL VITAMIN WITH CALCIUM PREDNISOLONE68 NO.76/IRON,CARBONYL/FOLIC ACID97 PREDNISOLONE ACETATE10 PRENATAL VITAMINS NO.33/IRON POLYSACH PREDNISOLONE SODIUM PHOSPHATE68 COMPLEX/FOLIC ACID/DHA97 PREDNISONE68 PRENATAL VITS NO.102/IRON PREGABALIN18 POLYSACCH/FOLATE NO.1/DOCUSATE/DHA97 PREMARIN63 PRENATAL VITS NO.26/IRON POLYSACCHARIDE PREMASOL58 CPLEX/FOLIC ACID/DHA98 PREMPHASE63 PRENATAL VITS NO.81/IRON PREMPRO63 CARBONYL,GLUC/FOLIC ACID/DOCUSATE96 PRENAISSANCE PLUS97 PRENATAL VITS WITH CALCIUM 118/FERROUS PRENATAL VIT NO.112/IRON PHOSPH/FOLIC FUMARATE/FOLIC ACID97 ACID/OMEGA-3S/DHA/EPA97 PRENATAL VITS WITH CALCIUM NO.10/FERROUS PRENATAL VIT NO.128/IRON POLYSACCHARIDE FUM/FOLIC ACID/DHA98 COMPLEX/FOLIC ACID97 PRENATAL VITS WITH CALCIUM NO.10/FERROUS PRENATAL VIT NO.16/IRON FUM,PS FUMARATE/FOLIC ACID98 COMPLEX/FOLIC ACID/OMEGA-397 PRENATAL VITS WITH CALCIUM NO.72/FERROUS PRENATAL VIT NO.2/IRON BG CHEL,SUCC- FUMARATE/FOLIC ACID97 PROT/FOLIC ACID/OMEGA-397 PRENATAL VITS,CALCIUM NO.66/IRON FUM/FOLIC PRENATAL VIT NO.67/IRON ACID/DOCUSATE/DHA96 POLYSACCHARIDES/FOLATE COMB.NO.1/DHA98 PREPLUS97 PRENATAL VIT NO.72/IRON PREVIFEM75 CARBONY,GLUC/FOLIC ACID/DOCUSATE/DHA95 PREZCOBIX43 PRENATAL VIT NO.73/IRON PREZISTA43 CARBONY,GLUC/FOLIC ACID/DOCUSATE/DHA95 PRIMAQUINE PHOSPHATE35 PRENATAL VIT NO.76/IRON PRIMIDONE19 CARBONY,GLUC/FOLIC ACID/DOCUSATE/DHA96 PRIVIGEN44 PRENATAL VIT WITH CALCIUM 53/IRON BIS,S- PROBENECID62 P/FOLIC ACID/OMEGA-397 PROBENECID/COLCHICINE62 PRENATAL VIT WITH CALCIUM NO.69/IRON/FOLIC PROCALAMINE58 ACID/DOCUSATE/DHA97 PROCARBAZINE HCL33 PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS PROCHLORPERAZINE MALEATE25 FUMARATE/FOLIC ACID97 PROCTOFOAM-HC11 PRENATAL VITAMIN NO.15/IRON PROCTOSOL-HC12 FUMARATE,POLYSAC COMP/FOLIC ACID96 PROCTOZONE-HC12 PRENATAL VITAMIN PROFILNINE28 NO.48/IRON,CARBONYL,GLUCONATE/FOLIC PROGESTERONE79 ACID/B695 PROGESTERONE, MICRONIZED79 PRENATAL VITAMIN NO.59/IRON CARB,FUM/FOLIC PROGLYCEM29 ACID/DOCUSATE/DHA96 PROLASTIN C90 PROLEUKIN33
PAGE 117 LAST UPDATED 12/2019 PROMETHAZINE HCL64 RETROVIR42 PROMETHAZINE HCL/DEXTROMETHORPHAN REVLIMID33 HBR90 REYATAZ43 PROMETHEGAN64 RHOPRESSA27 PROPAFENONE HCL13 RIBASPHERE46 PROPANTHELINE BROMIDE15 RIBASPHERE RIBAPAK46 PROPRANOLOL HCL52 RIBAVIRIN46 PROPYLTHIOURACIL94 RIFABUTIN31 PROSOL58 RIFAMPIN31 PROTONIX45 RILPIVIRINE HCL40 PULMOZYME90 RILUZOLE52 PUREVIT DUALFE PLUS12 RINGER'S SOLUTION61 PYLERA15 RINGER'S SOLUTION,LACTATED61 PYRAZINAMIDE31 RISPERDAL CONSTA38 PYRIDOSTIGMINE BROMIDE48 RISPERIDONE38 PYRIDOXINE HCL (VITAMIN B6)98 RISPERIDONE MICROSPHERES38 RITONAVIR43 Q RITUXAN33 QUDEXY XR18 RITUXIMAB33 QUETIAPINE FUMARATE38 RIVASTIGMINE48 QUILLICHEW ER7 RIVELSA75 QUILLIVANT XR7 RIXUBIS29 QUINAPRIL HCL89 RIZATRIPTAN BENZOATE31 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE90 ROPINIROLE HCL55 QUINIDINE GLUCONATE13 ROSUVASTATIN CALCIUM30 QUINIDINE SULFATE13 ROWEEPRA18 ROWEEPRA XR18 R ROXYBOND5 RAJANI75 RUFINAMIDE17 RALTEGRAVIR POTASSIUM40 RAMELTEON47 S RAMIPRIL90 SACUBITRIL/VALSARTAN89 RANITIDINE HCL45 SALICYLIC ACID92 RANOLAZINE51 SALMETEROL XINAFOATE49 RECLIPSEN75 SALSALATE87 RECOMBINATE28 SANTYL93 RELENZA46 SAQUINAVIR MESYLATE42 RENACIDIN59 SARGRAMOSTIM49 REPAGLINIDE23 SAVAYSA16 RESCRIPTOR40 SAXAGLIPTIN HCL23 RETACRIT50 SAXAGLIPTIN HCL/METFORMIN HCL23
PAGE 118 LAST UPDATED 12/2019 SCOPOLAMINE24 SODIUM IODIDE94 SE-NATAL 1997 SODIUM LACTATE56 SE-TAN PLUS12 SODIUM PHOSPHATE,DIBASIC/POT SECUKINUMAB92 PHOS,MONOB/SOD PHOSPHATE MONO56 SEEBRI NEOHALER15 SODIUM PHOSPHATE,MONOBASIC-DIBASIC61 SELECT-OB97 SODIUM PHOSPHATE,MONOBASIC/POTASSIUM SELECT-OB + DHA97 PHOSPHATE,MONOBASIC55 SELEGILINE HCL35 SODIUM POLYSTYRENE SULFONATE80 SELENIUM61 SODIUM POLYSTYRENE SULFONATE/SORBITOL SELENIUM SULFIDE9 SOLUTION80 SELZENTRY39 SODIUM/POTASSIUM/MAGNESIUM/CALCIUM/CHLO SEREVENT DISKUS49 RIDE/ACETATE61 SEROSTIM78 SODIUM/POTASSIUM/POTASSIUM SERTRALINE HCL21 CITRATE/SODIUM CITRATE/CIT AC56 SETLAKIN75 SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR67 SEVELAMER CARBONATE80 SOLIFENACIN SUCCINATE66 SEVELAMER HCL80 SOLTAMOX62 SHAROBEL76 SOLU-CORTEF68 SILDENAFIL CITRATE95 SOMATROPIN78 SILVER NITRATE9 SORAFENIB TOSYLATE33 SILVER SULFADIAZINE9 SORBITOL SOLUTION59 SIMLIYA76 SOTALOL HCL52 SIMPESSE76 SPINOSAD10 SIMVASTATIN30 SPIRIVA RESPIMAT15 SIROLIMUS85 SPIRONOLACTONE90 SITAGLIPTIN PHOSPHATE23 SPIRONOLACTONE/HYDROCHLOROTHIAZIDE90 SITAGLIPTIN PHOSPHATE/METFORMIN HCL23 SPRINTEC76 SKLICE10 SPRITAM18 SLYND76 SPS80 SODIUM ACETATE61 SRONYX76 SODIUM BICARBONATE56 STAVUDINE42 SODIUM CHLORIDE61 STERILE WATER FOR IC-GREEN88 SODIUM CHLORIDE 0.45 %61 STERILE WATER FOR KCENTRA88 SODIUM CHLORIDE 3 %61 STIMATE78 SODIUM CHLORIDE 5 %61 STIOLTO RESPIMAT15 SODIUM CHLORIDE FOR INHALATION61 STRIBILD42 SODIUM CHLORIDE IRRIGATING SOLUTION59 STRIVERDI RESPIMAT49 SODIUM CHLORIDE/POT CHLORIDE/MAG SUL/SOD STROVITE ONE97 PHOS,DB/POT PHOS,MB59 SUBVENITE19 SODIUM CHLORIDE/SODIUM SUBVENITE (BLUE)19 BICARBONATE/POTASSIUM CHLORIDE/PEG65 SUBVENITE (GREEN)19
PAGE 119 LAST UPDATED 12/2019 SUBVENITE (ORANGE)19 TESTOSTERONE69 SUCRALFATE45 TESTOSTERONE CYPIONATE69 SULFACETAMIDE SODIUM/PREDNISOLONE TESTOSTERONE ENANTHATE69 SODIUM PHOSPHATE8 TETRABENAZINE53 SULFADIAZINE14 THALIDOMIDE85 SULFAMETHOXAZOLE/TRIMETHOPRIM14 THALOMID85 SULFASALAZINE14 THEO-2493 SUMATRIPTAN31 THEOPHYLLINE ANHYDROUS93 SUMATRIPTAN SUCCINATE31 THIAMINE HCL98 SUNITINIB MALATE34 THIOLA86 SUTENT34 THIORIDAZINE HCL39 SYEDA76 THIOTHIXENE39 SYMFI40 THRIVITE RX97 SYMFI LO40 THYROID94 SYMLINPEN 12022 THYROID,PORK94 SYMLINPEN 6022 THYROLAR-194 SYMTUZA43 THYROLAR-1/294 SYNAREL67 THYROLAR-1/494 SYNJARDY24 THYROLAR-294 SYNTHAMIN 17 WITHOUT ELTYE58 THYROLAR-394 TIAGABINE HCL19 T TICAGRELOR43 TACROLIMUS93 TILIA FE76 TALIGLUCERASE ALFA62 TIMOLOL MALEATE26 TAMOXIFEN CITRATE62 TINIDAZOLE35 TAMSULOSIN HCL3 TIOPRONIN86 TARINA 24 FE76 TIOTROPIUM BROMIDE15 TARINA FE76 TIOTROPIUM BROMIDE/OLODATEROL HCL15 TARINA FE 1-20 EQ76 TIPRANAVIR/VITAMIN E TPGS42 TARON-C DHA97 TIS-U-SOL PENTALYTE59 TAYTULLA76 TIVICAY40 TBO-FILGRASTIM49 TIZANIDINE HCL91 TECFIDERA85 TOBRADEX8 TEMAZEPAM48 TOBRAMYCIN8 TEMODAR34 TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE13 TEMOZOLOMIDE34 TOBRAMYCIN SULFATE13 TENOFOVIR DISOPROXIL FUMARATE42 TOBRAMYCIN/DEXAMETHASONE8 TERAZOSIN HCL51 TOBRAMYCIN/LOTEPREDNOL ETABONATE8 TERBINAFINE HCL25 TOBRAMYCIN/NEBULIZER13 TERBUTALINE SULFATE49 TOFACITINIB CITRATE84 TERCONAZOLE26 TOPIRAMATE19
PAGE 120 LAST UPDATED 12/2019 TORSEMIDE55 TRIVEEN-DUO DHA97 TOVIAZ66 TRIVORA-2877 TPN ELECTROLYTES61 TROKENDI XR19 TPN ELECTROLYTES II61 TROPHAMINE58 TRADJENTA23 TRULICITY23 TRAMADOL HCL5 TRUST NATAL DHA97 TRANEXAMIC ACID29 TRUVADA42 TRAVASOL58 TULANA77 TRAZODONE HCL21 TYBOST86 TREANDA34 TYDEMY77 TRELEGY ELLIPTA54 TRETINOIN92 U TRETTEN29 ULIPRISTAL ACETATE71 TRI FEMYNOR76 UMECLIDINIUM BROMIDE15 TRI-ESTARYLLA76 UNITHROID95 TRI-LEGEST FE76 UREA92 TRI-LINYAH76 URSODIOL65 TRI-LO-ESTARYLLA76 UTIBRON NEOHALER49 TRI-LO-MARZIA77 UTIRA-C7 TRI-LO-MILI77 TRI-LO-SPRINTEC77 V TRI-MILI77 VALACYCLOVIR HCL46 TRI-PREVIFEM77 VALGANCICLOVIR HCL46 TRI-SPRINTEC77 VALPROIC ACID19 TRI-VYLIBRA77 VALPROIC ACID (AS SODIUM SALT) (VALPROATE TRI-VYLIBRA LO77 SODIUM)19 TRIAMCINOLONE ACETONIDE12 VANCOMYCIN HCL14 TRIAMTERENE/HYDROCHLOROTHIAZIDE55 VANCOMYCIN IN 0.9 % SODIUM CHLORIDE14 TRICITRATES56 VANCOMYCIN IN 5 % DEXTROSE IN WATER14 TRICON12 VANDETANIB32 TRIDERM12 VARENICLINE TARTRATE48 TRIFLUOPERAZINE HCL39 VELIVET77 TRIFLURIDINE8 VENLAFAXINE HCL21 TRIHEXYPHENIDYL HCL34 VENTAVIS91 TRILYTE WITH FLAVOR PACKETS65 VERAPAMIL HCL50 TRIMETHOPRIM7 VICODIN5 TRINATAL RX 197 VICODIN ES5 TRINTELLIX22 VICODIN HP5 TRIPTODUR67 VIDEX42 TRIPTORELIN PAMOATE67 VIENVA77 TRIUMEQ42 VIGABATRIN19
PAGE 121 LAST UPDATED 12/2019 VIGADRONE19 WATER FOR IRRIGATION,STERILE59 VIIBRYD22 WERA77 VILAZODONE HCL22 WILATE29 VIMPAT19 WIXELA INHUB54 VIORELE77 WYMZYA FE77 VIRACEPT43 VIREAD42 X VIRT-C DHA97 XELJANZ84 VIRT-PHOS 250 NEUTRAL56 XIGDUO XR24 VIRTRATE-356 XIIDRA10 VIRTRATE-K56 XTAMPZA ER5 VIT B COMPLEX NO.3/FOLIC ACID/ASCORBIC XTANDI34 ACID/BIOTIN/ZINC OXID98 XULANE77 VIT B COMPLEX NO.4/VIT D3/ASCORBIC XYNTHA29 ACID/FOLIC ACID/ZINC OXID98 XYNTHA SOLOFUSE29 VITAFOL FE+97 VITAFOL GUMMIES97 Y VITAFOL ULTRA98 YUVAFEM63 VITAFOL-OB98 VITAFOL-OB+DHA98 Z VITAFOL-ONE98 ZALEPLON47 VITAL-D RX98 ZANAMIVIR46 VITAMIN B COMPLEX NO.11/FOLIC ACID/VIT ZARAH77 C/BIOTIN/ZINC OXIDE98 ZEMAIRA90 VIVITROL53 ZIDOVUDINE42 VON WILLEBRAND FACTOR (RECOMBINANT)29 ZINC CHLORIDE62 VONVENDI29 ZINC SULFATE62 VORTIOXETINE HYDROBROMIDE22 ZINC SULFATE/COPPER VOSEVI67 SULFATE/MANGANESE/CHROMIUM/SELENIUM60 VOTRIENT34 ZINC SULFATE/CUPRIC SULFATE/MANGANESE VYFEMLA77 SULF/CHROMIC CHLORIDE60 VYLIBRA77 ZIPRASIDONE HCL38 VYVANSE6 ZOLADEX67 ZOLPIDEM TARTRATE47 W ZONISAMIDE19 WARFARIN SODIUM16 ZOVIA 1-35E78 WATER FOR INJ.,BACTERIOSTATIC88 ZUMANDIMINE78 WATER FOR ZYLET8 INJ.,BACTERIOSTATIC/METHYLPARABEN/PROPYL ZYPREXA RELPREVV38 PARABEN89 WATER FOR INJECTION,STERILE89
PAGE 122 LAST UPDATED 12/2019