Aon Active Health Exchange Drug List
(Oregon)
The Aon Active Health Exchange Drug List includes a list of drugs covered by Health Net. This drug list is for Oregon. The drug list is updated often and may change. To get the most up-to-date information, you may view the latest drug list on our website at www.healthnet.com/aonhewitt or call us at 1-888-926-1692.
Welcome to Health Net
What is the Aon Active Health Exchange Drug List? The Aon Active Health Exchange Drug List or formulary is a list of covered drugs used to treat common diseases or health problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on: Safety; Effectiveness; Side effects; and Value (If two drugs are equally effective, the less costly drug will be preferred)
How much will I pay for my drugs? To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier column on the formulary. The copayment or coinsurance level you will pay is shown in the Copayment/Coinsurance column. If you do not know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or other plan documents.
Abbreviation Copayment/Coinsurance Description 1 Tier 1 copayment or Generic drugs coinsurance 2 Tier 2 copayment or Preferred brand drugs coinsurance 3 Tier 3 copayment or Non-preferred brand drugs and coinsurance specialty/covered injectable drugs. You may be required to get some drugs from a Specialty pharmacy. AC Anticancer drug Self-administered anticancer drugs. You may be copayment or coinsurance required to get these drugs from a Specialty pharmacy. GP You may pay your Generics are preferred. A generic version of this copayment or coinsurance brand drug is available. You can get the brand plus the difference in cost drug, but you may pay your copayment or between the brand and coinsurance plus the difference in cost between generic drugs. the brand and generic drugs. PV $0 Preventive benefit drugs. These drugs must be covered at no cost to members under the Affordable Care Act. A deductible does not apply.
How do I use the drug list? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.
What if my drug is not on the drug list? If your drug is not on the drug list, call us at 1-888-926-1692 and ask if your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is covered. Your doctor can ask us to make an exception if he or she feels you need the drug that is not covered. If we approve an exception request for a drug not on the drug list, the non-preferred brand tier (Tier 3) copayment will apply.
ii What are generic drugs? A generic drug contains the same active ingredient and works the same way as the brand name drug. Generic drugs are safe and effective, and generally cost less.
Generic drugs are available on the drug list at Tier 1. If you request a brand name drug that has an available generic version, you may be charged a higher cost share.
Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the drug list: Abbreviation Definition Description AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA, or clinical recommendations. PA Prior Authorization These drugs require prior authorization for coverage, effectiveness, or safety reasons. This means that your doctor must request approval from Health Net before the drug will be covered. QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug from Health Net. RX/OTC Prescription & Certain drugs are available both in a Over-the-Counter prescription form and in an OTC form. Only (OTC) prescription drugs are covered by your plan with the exception of some insulins, insulin supplies and some covered preventive drugs. ST Step Therapy You must first try another specific drug(s) before these drugs will be covered.
How can I get an exception to the rules for drug coverage? Your doctor can ask for an exception to our rules for drug coverage.
Your doctor can ask us to cover your drug even if it is not on the drug list. Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a quantity limit of 1 tablet per day, your doctor can ask us to cover more.
To request an exception, your doctor can fax a prior authorization form along with a written statement supporting the request to us at 1-800-255-9198.
Are injectable drugs covered? Injectable drugs are not covered, except for those listed on the drug list. Some injectable drugs are considered “specialty drugs” that must be obtained from one of Health Net’s Specialty Pharmacies.
Are compounded prescriptions covered? Compounded prescriptions require prior authorization for coverage. If prior authorization is granted, your Tier 3 copayment or coinsurance applies.
iii Can I go to any pharmacy? To get the best benefit, you should use pharmacies that are in the network. These pharmacies have a contract with Health Net. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at www.healthnet.com/aonhewitt or call us at 1-888-926-1692.
If you fill your prescription at an out-of-network pharmacy, the pharmacy may not be able to bill Health Net online so you may have to pay the full cost of your drug. However, you can send us your pharmacy receipt and ask for reimbursement, minus your copayment or coinsurance.
Some injectable and high cost drugs (including anticancer drugs) may be considered “specialty drugs”. These drugs must be obtained from one of Health Net’s approved Specialty pharmacies.
Can I use a mail order pharmacy? You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs. Maintenance drugs are those needed for a long term condition. To use the mail order pharmacy, your doctor must provide new prescriptions that allow up to a 90-day supply of each drug. Mail order forms are available on our website at www.healthnet.com/aonhewitt or you may call us at 1-888-926-1692 to request a form.
How often can I refill my prescription? For prescriptions written for 10-days or less, you may refill after 50 percent of the supply has been used as directed. For prescriptions written for more than 10-days, you may refill after 74 percent of the supply has been used as directed.
If your physician has increased your dose, your pharmacy must be notified of the change. If this change will result in an early refill request, your pharmacy can contact Health Net for an override.
How can I save money on my prescription drugs? You can save time and money with these simple steps: Ask your doctor about generic drugs that may work for you. Fill prescriptions at Health Net participating pharmacies. Be sure your doctor prescribes drugs on the drug list Fill your maintenance drugs through our mail order pharmacy program.
iv
Nondiscrimination Notice Health Net Health Plan of Oregon, Inc. (Health Net) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently
because of race, color, national origin, age, disability, or sex. Health Net: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Health Net’s Customer Contact Center at 1-888-802-7001 (TTY: 711). If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net’s Customer Contact Center is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Nondiscrimination Notice FLY029224ER00 (1/20)
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Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Notice of Language Assistance FLY029225ER00 (1/20) Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine ADHD, Sleep and Eating Disorders tabs 1.25 mg-1.25 mg- Amphetamines 1.25 mg-1.25 mg, (Dextroamphetamine 1.875 mg-1.875 mg- Sulfate) PROCENTRA 1 1.875 mg-1.875 mg, SOLN 2.5 mg-2.5 mg-2.5 mg- 1 (Dextroamphetamine 1 2.5 mg, 3.125 mg- Sulfate) ZENZEDI TABS 3.125 mg-3.125 mg- ADDERALL TABS 3.125 mg, 3.75 mg- (amphetamine- GP 3.75 mg-3.75 mg-3.75 dextroamphetamine) mg, 5 mg-5 mg-5 mg-5 ADDERALL XR CP24 1.25 QL(1 ea daily) mg, 7.5 mg-7.5 mg-7.5 MG-1.25 MG-1.25 MG-1.25 mg-7.5 mg MG, 3.75 MG-3.75 MG- DESOXYN TABS PA 3.75 MG-3.75 MG, 5 MG-5 GP MG-5 MG-5 MG, 6.25 MG- (methamphetamine hcl) 6.25 MG-6.25 MG-6.25 GP DEXEDRINE CP24 MG, 7.5 MG-7.5 MG-7.5 (dextroamphetamine GP MG-7.5 MG sulfate) (amphetamine- dextroamphetamine 1 dextroamphetamine) sulfate cp24 ADDERALL XR CP24 2.5 QL(1 ea MG-2.5 MG-2.5 MG-2.5 daily,90 day(s) dextroamphetamine 1 MG (amphetamine- GP limit) sulfate soln dextroamphetamine) dextroamphetamine 1 amphetamine- QL(1 ea daily) sulfate tabs PA dextroamphetamine methamphetamine hcl 1 cp24 1.25 mg-1.25 mg- tabs 1.25 mg-1.25 mg, 3.75 VYVANSE CAPS QL(1 ea daily) (lisdexamfetamine 2 mg-3.75 mg-3.75 mg- 1 3.75 mg, 5 mg-5 mg-5 dimesylate) mg-5 mg, 6.25 mg-6.25 VYVANSE CHEW QL(1 ea daily) mg-6.25 mg-6.25 mg, (lisdexamfetamine 2 7.5 mg-7.5 mg-7.5 mg- dimesylate) 7.5 mg Analeptics amphetamine- QL(1 ea dextroamphetamine daily,90 day(s) caffeine citrate soln 1 1 limit) cp24 2.5 mg-2.5 mg- Anorexiants Non-Amphetamine 2.5 mg-2.5 mg ADIPEX-P CAPS PA GP (phentermine hcl) ADIPEX-P TABS PA GP (phentermine hcl)
You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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1 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA INTUNIV TB24 QL(1 ea daily) diethylpropion hcl tb24 3 GP (guanfacine hcl (adhd)) LOMAIRA TABS PA 3 KAPVAY TB12 (clonidine QL(4 ea daily) ( ) GP phentermine hcl hcl (adhd)) PA phendimetrazine 3 STRATTERA CAPS 10 QL(2 ea daily) tartrate cp24 MG, 18 MG, 25 MG, 40 MG GP PA (atomoxetine hcl) phendimetrazine 3 tartrate tabs STRATTERA CAPS 100 QL(1 ea daily) PHENDIMETRAZINE PA MG, 60 MG, 80 MG GP TARTRATEER CP24 (atomoxetine hcl) 3 (phendimetrazine Stimulants - Misc. tartrate) armodafinil tabs 1 PA phentermine hcl caps 3 PA CONCERTA TBCR 27 MG, QL(1 ea daily) phentermine hcl tabs 3 PA 54 MG (methylphenidate GP hcl) QSYMIA CP24 PA CONCERTA TBCR 36 MG QL(2 ea daily) (phentermine hcl- 3 GP topiramate) (methylphenidate hcl) DAYTRANA PTCH 3 Anti-Obesity Agents (methylphenidate) BELVIQ TABS PA 3 dexmethylphenidate hcl QL(1 ea daily) (lorcaserin hcl) cp24 10 mg, 15 mg, 20 BELVIQ XR TB24 PA 1 3 mg, 30 mg, 40 mg, 5 (lorcaserin hcl) mg CONTRAVE TB12 PA dexmethylphenidate hcl (naltrexone hcl- 3 1 cp24 25 mg, 35 mg bupropion hcl) QL(2 ea daily) SAXENDA SOPN PA dexmethylphenidate hcl 1 (liraglutide (weight 3 tabs 10 mg, 2.5 mg, 5 management)) mg PA FOCALIN TABS QL(2 ea daily) XENICAL CAPS (orlistat) 3 (dexmethylphenidate GP Attention-Deficit/Hyperactivity Disorder (ADHD) hcl) QL(2 ea daily) FOCALIN XR CP24 10 QL(1 ea daily) atomoxetine hcl caps MG, 15 MG, 20 MG, 30 1 10 mg, 18 mg, 25 mg, MG, 40 MG, 5 MG GP 40 mg (dexmethylphenidate QL(1 ea daily) atomoxetine hcl caps 1 hcl) 100 mg, 60 mg, 80 mg FOCALIN XR CP24 25 QL(4 ea daily) MG, 35 MG clonidine hcl (adhd) 1 GP tb12 (dexmethylphenidate guanfacine hcl (adhd) QL(1 ea daily) hcl) 1 METHYLIN SOLN tb24 GP (methylphenidate hcl)
You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RITALIN LA CP24 QL(1 ea daily) methylphenidate hcl GP chew 10 mg, 2.5 mg, 5 1 (methylphenidate hcl) mg RITALIN TABS GP methylphenidate hcl QL(1 ea daily) (methylphenidate hcl) cp24 10 mg, 20 mg, 30 1 ALLERGENIC EXTRACTS/BIOLOGICALS MISC mg, 40 mg methylphenidate hcl QL(2 ea daily) Allergenic Extracts cpcr 10 mg, 20 mg, 30 1 GRASTEK SUBL (timothy PA mg grass pollen allergen 3 methylphenidate hcl extract) cpcr 40 mg, 50 mg, 60 1 ODACTRA SUBL (dust PA mg mite mixed allergen 3 methylphenidate hcl extract) soln 10 mg/5ml, 5 1 ORALAIR ADULT SAMPLE PA KIT SUBL (grass mixed mg/5ml 3 methylphenidate hcl pollens allergen extract) tabs 10 mg, 20 mg, 5 1 mg ORALAIR ADULT PA STARTER PACK SUBL methylphenidate hcl QL(1 ea daily) (grass mixed pollens 3 tb24 18 mg, 27 mg, 54 1 allergen extract) mg ORALAIR SUBL (grass PA QL(2 ea daily) methylphenidate hcl 1 mixed pollens allergen 3 tb24 36 mg extract) methylphenidate hcl QL(1 ea daily) RAGWITEK SUBL (short PA tbcr 10 mg, 18 mg, 20 1 ragweed pollen 3 mg, 27 mg, 54 mg allergen extract) QL(2 ea daily) methylphenidate hcl 1 AMINOGLYCOSIDES - Drugs to Treat Bacterial tbcr 36 mg Infections METHYLPHENIDATE QL(1 ea daily) HYDROCHLORIDE ER Aminoglycosides TBCR (methylphenidate 3 ARIKAYCE SUSP PA hcl) (amikacin sulfate 3 liposome) ST; QL(1 ea modafinil tabs 1 BETHKIS NEBU PA daily) GP NUVIGIL TABS PA (tobramycin) GP KITABIS PAK NEBU (armodafinil) 3 PROVIGIL TABS ST; QL(1 ea (tobramycin) GP (modafinil) daily) neomycin sulfate tabs 1 QUILLIVANT XR SRER PA; QL(12 ml 3 (methylphenidate hcl) daily) paromomycin sulfate 1 caps RELEXXII TBCR QL(1 ea daily) 3 (methylphenidate hcl) TOBI NEBU (tobramycin) GP
You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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3 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOBI PODHALER CAPS PA OTREXUP SOAJ PA 3 (tobramycin) (methotrexate 3 PA (antirheumatic)) tobramycin nebu 300 3 mg/4ml RASUVO SOAJ PA (methotrexate 3 tobramycin nebu 300 3 mg/5ml (antirheumatic)) ANALGESICS - ANTI-INFLAMMATORY - Drugs Gold Compounds RIDAURA CAPS to Treat Pain, Swelling, Muscle and Joint 2 Conditions (auranofin) Anti-TNF-alpha - Monoclonal Antibodies Interleukin-1 Blockers HUMIRA PEDIATRIC PA ARCALYST SOLR PA 3 CROHNS DISEASE (rilonacept) STARTER PACK PSKT 3 (adalimumab) Interleukin-1 Receptor Antagonist (IL-1Ra) HUMIRA PEN PNKT PA KINERET SOSY PA 3 3 (adalimumab) (anakinra) HUMIRA PEN-CD/UC/HS PA Interleukin-6 Receptor Inhibitors STARTER PNKT 3 ACTEMRA SOSY PA 3 (adalimumab) (tocilizumab) HUMIRA PEN-PEDIATRIC PA KEVZARA SOAJ 150 PA; SP UC STARTER PACK 3 MG/1.14ML, 200 3 PNKT (adalimumab) MG/1.14ML (sarilumab) HUMIRA PEN-PS/UV PA KEVZARA SOSY 150 PA STARTER PNKT 3 MG/1.14ML, 200 3 (adalimumab) MG/1.14ML (sarilumab) HUMIRA PSKT PA 3 Nonsteroidal Anti-inflammatory Agents (NSAIDs) (adalimumab) (Diclofenac Potassium) SIMPONI SOAJ PA 1 3 CATAFLAM TABS (golimumab) (Ibuprofen) IBU TABS 1 SIMPONI SOSY PA 3 (golimumab) (Nabumetone) RELAFEN 1 QL(4 ea daily) TABS 500 MG Antirheumatic - Enzyme Inhibitors (Nabumetone) RELAFEN QL(3 ea daily) RINVOQ TB24 PA 1 3 TABS 750 MG (upadacitinib) (Naproxen) EC- 1 XELJANZ TABS 10 MG, 5 PA NAPROXEN TBEC 3 MG (tofacitinib citrate) ARTHROTEC 50 TBEC XELJANZ XR TB24 PA (diclofenac w/ GP 3 (tofacitinib citrate) misoprostol) Antirheumatic Antimetabolites ARTHROTEC 75 TBEC METHOTREXATE TABS (diclofenac w/ GP (methotrexate sodium 2 misoprostol) (antirheumatic))
You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELEBREX CAPS 100 ST; QL(2 ea FENORTHO CAPS 3 MG, 200 MG, 50 MG GP daily) (fenoprofen calcium) (celecoxib) flurbiprofen tabs 1 ST; QL(2 ea CELEBREX CAPS 400 MG GP daily); AL(At ibuprofen tabs 1 (celecoxib) least 60 yrs old) INDOCIN SUPP RE 50 MG 3 ST; QL(2 ea (indomethacin) celecoxib caps 100 mg, 1 200 mg, 50 mg daily) INDOCIN SUSP OR 25 2 ST; QL(2 ea MG/5ML (indomethacin) 1 daily); AL(At celecoxib caps 400 mg least 60 yrs indomethacin caps 1 old) 1 DAYPRO TABS indomethacin cpcr GP (oxaprozin) ketoprofen caps 1 DICLOFENAC CAPS ST; QL(3 ea 3 (diclofenac) daily) ketoprofen cp24 1 diclofenac potassium 1 KETOROLAC QL(1 ea daily,5 tabs TROMETHAMINE SOLN day(s) limit) NA 15.75 MG/SPRAY 1 3 diclofenac sodium tb24 (ketorolac diclofenac sodium tbec 1 tromethamine) ketorolac tromethamine Limit 20 per diclofenac w/ 1 1 month;QL(0.67 misoprostol tbec tabs or 10 mg ea daily) DUEXIS TABS PA 3 LODINE TABS (etodolac) GP (ibuprofen-famotidine) EC-NAPROSYN TBEC meclofenamate sodium GP 1 (naproxen) caps mefenamic acid caps 1 etodolac caps 200 mg, 1 300 mg meloxicam tabs 15 mg 1 QL(1 ea daily) etodolac tabs 400 mg, 1 500 mg meloxicam tabs 7.5 mg 1 QL(2 ea daily) etodolac tb24 400 mg, QL(2 ea daily) 1 MOBIC TABS 15 MG QL(1 ea daily) 500 mg, 600 mg GP (meloxicam) FELDENE CAPS GP MOBIC TABS 7.5 MG QL(2 ea daily) (piroxicam) GP (meloxicam) FENOPROFEN CALCIUM QL(4 ea daily) CAPS 200 MG 3 nabumetone tabs 500 1 (fenoprofen calcium) mg nabumetone tabs 750 QL(3 ea daily) fenoprofen calcium 1 1 tabs 600 mg mg NALFON CAPS 400 MG 3 (fenoprofen calcium) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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5 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NALFON TABS 600 MG OTEZLA TABS PA GP 3 (fenoprofen calcium) (apremilast) NAPRELAN TB24 OTEZLA TBPK PA GP 3 (naproxen sodium) (apremilast) NAPROSYN SUSP GP Pyrimidine Synthesis Inhibitors (naproxen) ARAVA TABS 10 MG QL(2 ea daily) NAPROSYN TABS GP GP (leflunomide) (naproxen) ARAVA TABS 20 MG QL(1 ea daily) GP naproxen sodium tabs 1 (leflunomide) leflunomide tabs 10 mg 1 QL(2 ea daily) naproxen sodium tb24 1 leflunomide tabs 20 mg 1 QL(1 ea daily) naproxen susp 1 Selective Costimulation Modulators 1 naproxen tabs ORENCIA CLICKJECT PA 3 naproxen tbec 1 SOAJ (abatacept) ORENCIA SOLR PA 3 naproxen- PA (abatacept) esomeprazole 1 ORENCIA SOSY PA 3 magnesium tbec (abatacept) oxaprozin tabs 1 Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT PA piroxicam caps 1 3 (etanercept) SPRIX SOLN (ketorolac QL(1 ea daily,5 ENBREL SOLN PA 3 3 tromethamine) day(s) limit) (etanercept) ENBREL SOLR PA sulindac tabs 1 3 (etanercept) TIVORBEX CAPS ST; QL(3 ea ENBREL SOSY PA 3 daily) 3 (indomethacin) (etanercept) tolmetin sodium caps 1 ENBREL SURECLICK PA 3 SOAJ (etanercept) tolmetin sodium tabs 1 ANALGESICS - NonNarcotic - Drugs to Treat VIMOVO TBEC PA Pain, Muscle and Joint Conditions (naproxen- GP Analgesic Combinations esomeprazole (Acetaminophen- magnesium) Salicylamide- 1 ZIPSOR CAPS ST Phenyltoloxamine) 3 (diclofenac potassium) DURAXIN CAPS ZORVOLEX CAPS 18 MG, ST; QL(3 ea (Butalbital-Acetaminophen) 3 1 35 MG (diclofenac) daily) BUPAP TABS (Butalbital-Acetaminophen- 1 Phosphodiesterase 4 (PDE4) Inhibitors Caffeine) BAC TABS
You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Butalbital-Acetaminophen- (Aspirin) ADULT ASPIRIN PV Caffeine) ESGIC, 1 REGIMEN, ASPIR-LOW, PHRENILIN FORTE, ASPIRIN 81, ASPIRIN ZEBUTAL CAPS ADULT LOW DOSE, (Butalbital-Acetaminophen- ASPIRIN ADULT LOW STRENGTH, ASPIRIN EC Caffeine) VANATOL LQ, 1 VANATOL S, VTOL LQ LOW DOSE, ASPIRIN SOLN ENTERIC COATED ADULT LOW STRENGTH, butalbital- ASPIRIN LOW DOSE, acetaminophen tabs 1 BAYER ASPIRIN, BAYER 300 mg-50 mg, 325 ASPIRIN EC LOW DOSE, mg-50 mg BAYER ASPIRIN REGIMEN, BAYER LOW butalbital- DOSE, CVS ASPIRIN, acetaminophen- 1 CVS ASPIRIN ADULT caffeine caps LOW STRENGTH, CVS butalbital- ASPIRIN EC, CVS acetaminophen- 1 ASPIRIN LOW DOSE, CVS ASPIRIN LOW caffeine tabs STRENGTH, ECOTRIN LOW STRENGTH, butalbital-aspirin- 1 caffeine caps ECPIRIN, EQ ASPIRIN BUTALBITAL/ASPIRIN/CA ADULT LOW DOSE, EQ FFEINE TABS ASPIRIN EC, EQL 2 ASPIRIN EC, EQL PV (butalbital-aspirin- ASPIRIN LOW DOSE, caffeine) GNP ASPIRIN, GNP ESGIC TABS (butalbital- ASPIRIN LOW DOSE, acetaminophen- GP GOODSENSE ASPIRIN, GOODSENSE ASPIRIN caffeine) LOW DOSE, H-E-B FIORICET CAPS ASPIRIN, HM ASPIRIN, (butalbital- HM ASPIRIN EC, HM acetaminophen- GP ASPIRIN EC LOW DOSE, caffeine) KLS ASPIRIN EC, KLS ASPIRIN LOW DOSE, KP FIORINAL CAPS ASPIRIN, MEIJER (butalbital-aspirin- GP ASPIRIN EC, MINIPRIN caffeine) LOW DOSE, PX ENTERIC ASPIRIN, QC ASPIRIN, Salicylates QC ASPIRIN LOW DOSE, QC ENTERIC ASPIRIN, RA ASPIRIN EC, RA ASPIRIN EC ADULT LOW STRENGTH, SB ASPIRIN, SB ASPIRIN ADULT LOW STRENGTH, SB ASPIRIN EC, SB LOW DOSE ASA EC, SM ASPIRIN ADULT LOW STRENGTH, SM ASPIRIN EC LOW You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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7 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STRENGTH, SM ASPIRIN (Aspirin) ASPIRIN ADULT, PV ENTERIC COATED, ST BAYER ADVANCED JOSEPH ASPIRIN, TGT ASPIRIN REGULAR ASPIRIN, TGT ASPIRIN STRENGTH, BAYER LOW DOSE, TGT ASPIRIN, CVS ASPIRIN, ENTERIC-COATED EQ ASPIRIN, EQL ASPIRIN TBEC ASPIRIN, GNP ASPIRIN, (Aspirin) ASPIRIN 81 LOW PV GOODSENSE ASPIRIN, DOSE, ASPIRIN ADULT HM ADULT ASPIRIN, HM PV LOW STRENGTH, ASPIRIN, MEDIQUE ASPIRIN CHILDRENS, ASPIRIN, NORWICH ASPIRIN LOW DOSE, ASPIRIN, PX ASPIRIN, QC ASPIRIN LOW ASPIRIN, RA ASPIRIN, RA STRENGTH, BAYER PAIN RELIEF ASPIRIN, SB CHEWABLE LOW DOSE, ASPIRIN, SM ADULT CHILDRENS ASPIRIN, ASPIRIN, SM ASPIRIN, CHILDRENS ASPIRIN TGT ASPIRIN TABS LOW STRENGTH, CVS ASCRIPTIN TABS PV ASPIRIN ADULT LOW (aspirin buffered (al DOSE, EQ ASPIRIN LOW hydrox-mg hydrox-ca PV DOSE, EQL ASPIRIN LOW ) DOSE, GNP ADULT carb) ASPIRIN LOW aspirin chew PV PV STRENGTH, GOODSENSE ASPIRIN, aspirin tabs PV PV GOODSENSE ASPIRIN PV ADULT LOW STRENGTH, aspirin tbec PV PV HM ASPIRIN, PX ASPIRIN, QC ASPIRIN LOW DOSE, 1 QC CHEWABLE ASPIRIN diflunisal tabs LOW DOSE, QC ECOTRIN REGULAR PV CHILDRENS ASPIRIN, RA STRENGTH TBEC GP ASPIRIN ADULT LOW (aspirin) DOSE, RA ASPIRIN ADULT LOW STRENGTH, ECOTRIN TBEC (aspirin) GP PV RA ASPIRIN CHILDRENS, SB CHILDRENS ASPIRIN, ST JOSEPH ADULT PV ANALGESICLOW DOSE SM ASPIRIN ADULT LOW GP STRENGTH, SM ASPIRIN BITE SIZE CHEW LOW DOSE, SM (aspirin) CHILDRENS ASPIRIN, ST ST JOSEPH ADULT PV GP JOSEPH LOW DOSE CHEW (aspirin) ASPIRIN, TGT ASPIRIN, TGT CHILDRENS ANALGESICS - OPIOID - Drugs to Treat Pain, ASPIRIN CHEW Muscle and Joint Conditions Opioid Agonists (Methadone Hcl) METHADONE HCL 1 INTENSOL CONC
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Updated 07/01/2021 8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Methadone Hcl) PA hydrocodone bitartrate 1 METHADOSE TBSO 40 1 t24a MG hydromorphone hcl liqd ABSTRAL SUBL PA 1 3 1 mg/ml (fentanyl citrate) hydromorphone hcl ACTIQ LPOP (fentanyl PA 1 GP tabs 2 mg, 4 mg, 8 mg citrate) QL(4 ea daily) ARYMO ER TBEA PA hydromorphone hcl 3 (morphine sulfate) tb24 12 mg, 16 mg, 8 1 mg codeine sulfate tabs 1 HYSINGLA ER T24A PA CONZIP CP24 ( (hydrocodone GP tramadol GP hcl) bitartrate) KADIAN CP24 10 MG QL(1 ea daily) DILAUDID LIQD OR 1 GP MG/ML (hydromorphone GP (morphine sulfate) hcl) KADIAN CP24 100 MG, 20 QL(2 ea daily) MG, 30 MG, 50 MG, 60 DILAUDID TABS OR 2 GP MG, 4 MG, 8 MG GP MG, 80 MG (morphine (hydromorphone hcl) sulfate) DOLOPHINE TABS QL(12 ea daily) KADIAN CP24 200 MG GP 3 (methadone hcl) (morphine sulfate) KADIAN CP24 40 MG DURAGESIC PT72 Limit 15 per GP GP month;QL(0.5 (morphine sulfate) (fentanyl) ea daily) LAZANDA SOLN 100 PA EMBEDA CPCR PA MCG/ACT, 400 MCG/ACT 3 3 (morphine-naltrexone) (fentanyl citrate) fentanyl citrate lpop bu PA meperidine hcl soln 1 1200 mcg, 1600 mcg, 1 200 mcg, 400 mcg, 600 meperidine hcl tabs 1 mcg, 800 mcg methadone hcl conc 10 1 fentanyl citrate tabs bu PA; QL(3 ea mg/ml daily) 100 mcg, 200 mcg, 400 1 methadone hcl soln 10 1 mcg, 600 mcg, 800 mg/5ml, 5 mg/5ml mcg QL(12 ea daily) Limit 15 per methadone hcl tabs 10 1 fentanyl pt72 100 mg, 5 mg mcg/hr, 12 mcg/hr, 25 month;QL(0.5 1 ea daily) mcg/hr, 50 mcg/hr, 75 methadone hcl tbso 40 1 mcg/hr mg FENTORA TABS PA; QL(3 ea METHADOSE CONC 10 GP GP (fentanyl citrate) daily) MG/ML (methadone hcl) PA METHADOSE SUGAR- hydrocodone bitartrate 1 cp12 FREE CONC GP (methadone hcl)
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9 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) morphine sulfate beads 1 oxycodone hcl tabs 10 cp24 mg, 15 mg, 20 mg, 30 1 QL(1 ea daily) mg, 5 mg morphine sulfate cp24 1 or 10 mg oxymorphone hcl tabs 1 morphine sulfate cp24 QL(2 ea daily) 10 mg, 5 mg QL(2 ea daily) or 100 mg, 20 mg, 30 1 oxymorphone hcl tb12 mg, 50 mg, 60 mg, 80 10 mg, 15 mg, 20 mg, 1 mg 30 mg, 40 mg, 5 mg, 7.5 mg morphine sulfate cp24 1 QDOLO SOLN ( or 40 mg tramadol 3 morphine sulfate soln hcl) ROXICODONE TABS or 10 mg/5ml, 100 1 GP mg/5ml, 20 mg/5ml, 20 (oxycodone hcl) mg/ml ROXYBOND TABA 5 MG QL(4 ea daily) 3 morphine sulfate supp (oxycodone hcl) re 10 mg, 20 mg, 30 1 SUBSYS LIQD (fentanyl) 3 PA mg, 5 mg tramadol hcl cp24 100 morphine sulfate tabs 1 or 15 mg, 30 mg mg, 150 mg, 200 mg, 1 300 mg morphine sulfate tbcr or QL(3 ea daily) 100 mg, 15 mg, 200 1 tramadol hcl tabs 100 3 mg, 30 mg, 60 mg mg MS CONTIN TBCR QL(3 ea daily) tramadol hcl tabs 50 QL(8 ea daily) GP 1 (morphine sulfate) mg NUCYNTA ER TB12 QL(2 ea daily) tramadol hcl tb24 100 2 1 (tapentadol hcl) mg, 200 mg, 300 mg NUCYNTA TABS QL(6 ea daily) ULTRAM TABS (tramadol QL(8 ea daily) 2 GP (tapentadol hcl) hcl) OPANA TABS XTAMPZA ER C12A PA GP 3 (oxymorphone hcl) (oxycodone) OXAYDO TABS 5 MG ZOHYDRO ER CP12 PA 2 (oxycodone hcl) (hydrocodone GP OXAYDO TABS 7.5 MG QL(4 ea daily) bitartrate) 3 (oxycodone hcl) Opioid Combinations (Butalbital-Aspirin-Caffeine oxycodone hcl caps 5 1 mg W/Cod) 1 ASCOMP/CODEINE CAPS oxycodone hcl conc 1 100 mg/5ml (Hydrocodone- Acetaminophen) LORCET, 1 LORCET HD, LORCET oxycodone hcl soln 5 1 mg/5ml PLUS TABS
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Updated 07/01/2021 10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocodone-Ibuprofen) 1 OXYCODONE/ACETAMIN IBUDONE TABS OPHEN TABS 3 (Oxycodone W/ (oxycodone w/ Acetaminophen) 1 acetaminophen) ENDOCET TABS PERCOCET TABS acetaminophen w/ 1 (oxycodone w/ GP codeine soln acetaminophen) PRIMLEV TABS acetaminophen w/ 1 codeine tabs (oxycodone w/ 3 butalbital- acetaminophen) PROLATE TABS 10 MG- acetaminophen- 1 caffeine w/ codeine 300 MG, 300 MG-5 MG, caps 300 MG-7.5 MG 3 (oxycodone w/ butalbital-aspirin- 1 acetaminophen) caffeine w/cod caps tramadol- 1 FIORICET/CODEINE acetaminophen tabs CAPS (butalbital- acetaminophen- GP TYLENOL/CODEINE #3 caffeine w/ codeine) TABS (acetaminophen GP w/ codeine) FIORINAL/CODEINE #3 CAPS (butalbital-aspirin- GP TYLENOL/CODEINE #4 caffeine w/cod) TABS (acetaminophen GP w/ codeine) hydrocodone- 1 acetaminophen soln ULTRACET TABS (tramadol- GP hydrocodone- 1 acetaminophen) acetaminophen tabs Opioid Partial Agonists hydrocodone-ibuprofen 1 BELBUCA FILM QL(2 ea daily) tabs 3 (buprenorphine hcl) LORTAB ELIX PA required for (hydrocodone- 3 BUNAVAIL FILM ( 3 more than 30 acetaminophen) buprenorphine hcl- day supply per NALOCET TABS naloxone hcl dihydrate) year; (oxycodone w/ 3 QL(4 ea daily) buprenorphine hcl subl 1 acetaminophen) 2 mg NORCO TABS QL(3 ea daily) buprenorphine hcl subl 1 (hydrocodone- GP 8 mg acetaminophen) buprenorphine hcl- QL(4 ea daily) oxycodone w/ 1 naloxone hcl dihydrate 1 acetaminophen tabs film 0.5 mg-2 mg QL(4 ea daily) oxycodone-ibuprofen 1 tabs
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11 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3 ea daily) ANDRODERM PT24 ST; QL(1 ea buprenorphine hcl- 3 (testosterone) daily) naloxone hcl dihydrate 1 film 1 mg-4 mg, 12 mg- ANDROGEL GEL 20.25 QL(10 gm 3 mg, 2 mg-8 mg MG/1.25GM, 40.5 GP daily) buprenorphine hcl- QL(4 ea daily) MG/2.5GM (testosterone) naloxone hcl dihydrate 1 ANDROGEL GEL 25 QL(10 gm subl 0.5 mg-2 mg MG/2.5GM, 50 MG/5GM 2 daily) (testosterone) buprenorphine hcl- QL(3 ea daily) ANDROGEL PUMP GEL QL(10 gm naloxone hcl dihydrate 1 GP daily) subl 2 mg-8 mg (testosterone) buprenorphine ptwk td Limit 4 per danazol caps 1 10 mcg/hr, 15 mcg/hr, month;QL(0.15 1 ea daily) DEPO-TESTOSTERONE 20 mcg/hr, 5 mcg/hr, SOLN (testosterone GP 7.5 mcg/hr cypionate) Limit 7.5mls FORTESTA GEL QL(4 gm daily) GP butorphanol tartrate 1 per (testosterone) soln month;QL(0.25 METHITEST TABS ml daily) 2 (methyltestosterone) BUTRANS PTWK Limit 4 per GP month;QL(0.15 methyltestosterone (buprenorphine) 1 ea daily) caps pentazocine w/ QL(12 ea per STRIANT MISC QL(2 ea daily) 1 3 naloxone tabs fill retail) (testosterone) SUBOXONE FILM 0.5 MG- QL(4 ea daily) TESTIM GEL PA; QL(10 gm 3 2 MG (buprenorphine (testosterone) daily) hcl-naloxone hcl GP testosterone cypionate 1 dihydrate) soln im 200 mg/ml SUBOXONE FILM 1 MG-4 QL(3 ea daily) testosterone gel td 1 %, QL(10 gm MG, 12 MG-3 MG, 2 MG-8 daily) MG (buprenorphine hcl- GP 1.62 %, 20.25 1 naloxone hcl dihydrate) mg/1.25gm, 25 mg/2.5gm, 40.5 ZUBSOLV SUBL PA required for more than 30 mg/2.5gm, 50 mg/5gm (buprenorphine hcl- 3 QL(4 gm daily) day supply per testosterone gel td 10 1 naloxone hcl dihydrate) year; mg/act ANDROGENS-ANABOLIC - Drugs to Regulate QL(6 ml daily) testosterone soln td 30 1 Hormones mg/act Anabolic Steroids ANORECTAL AND RELATED PRODUCTS - ANADROL-50 TABS Rectal Drugs to Treat Pain, Swelling and Itching 3 (oxymetholone) Intrarectal Steroids oxandrolone tabs 1 (Hydrocortisone (Intrarectal)) COLOCORT 1 Androgens ENEM
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Updated 07/01/2021 12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORTENEMA ENEM ANUSOL-HC CREA EX 2.5 (hydrocortisone GP % (hydrocortisone GP (intrarectal)) (rectal)) CORTIFOAM FOAM hydrocortisone (rectal) 1 (hydrocortisone acetate 2 crea (intrarectal)) hydrocortisone acetate 1 hydrocortisone 1 (rectal) supp (intrarectal) enem PROCTOCORT SUPP UCERIS FOAM RE 2 PA (hydrocortisone acetate GP MG/ACT (budesonide 3 (rectal)) ) (intrarectal) Vasodilating Agents Rectal Combinations RECTIV OINT ANALPRAM HC CREA (nitroglycerin (intra- 3 (hydrocortisone acetate GP anal)) ) w/ pramoxine ANTHELMINTICS - Drugs to Treat Worm ANALPRAM HC SINGLES Infections CREA (hydrocortisone GP Anthelmintics acetate w/ pramoxine) ANALPRAM-HC LOTN albendazole tabs 1 (hydrocortisone acetate 3 ALBENZA TABS GP w/ pramoxine) (albendazole) hydrocortisone acetate 1 BENZNIDAZOLE TABS AL(At least 2 w/ pramoxine crea 3 yrs old - Up to (benznidazole) lidocaine- 12 yrs old) BILTRICIDE TABS hydrocortisone acetate 1 GP (rectal) kit (praziquantel) PROCORT CREA EMVERM CHEW QL(6 ea per fill 3 retail,6 ea per (hydrocortisone acetate 3 (mebendazole) fill mail) w/ pramoxine) PROCTOFOAM HC FOAM ivermectin tabs 1 (hydrocortisone acetate 2 praziquantel tabs 1 w/ pramoxine) STROMECTOL TABS Rectal Steroids GP ( ) (Hydrocortisone (Rectal)) ivermectin PROCTO-MED HC, 1 ANTI-INFECTIVE AGENTS - MISC. - Drugs to PROCTOSOL HC, Treat Bacterial Infections PROCTOZONE-HC CREA Anti-infective Agents - Misc. (Hydrocortisone Acetate FLAGYL CAPS (Rectal)) ANUCORT-HC, 1 GP HEMMOREX-HC SUPP (metronidazole) FLAGYL TABS (Hydrocortisone Acetate GP (Rectal)) ANUSOL-HC 1 (metronidazole) SUPP RE 25 MG
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13 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IMPAVIDO CAPS 3 sulfamethoxazole- 1 (miltefosine) trimethoprim susp metronidazole caps 1 sulfamethoxazole- 1 trimethoprim tabs metronidazole tabs 1 Antiprotozoal Agents NEBUPENT SOLR ALINIA SUSR 100 MG/5ML 3 (pentamidine GP (nitazoxanide) isethionate) ALINIA TABS 500 MG GP (nitazoxanide) pentamidine 1 isethionate solr atovaquone susp 1 PRIMSOL SOLN 3 MEPRON SUSP (trimethoprim hcl) GP (atovaquone) tinidazole tabs 1 nitazoxanide tabs 1 trimethoprim tabs 1 Glycopeptides PA; QL(9 ea FIRVANQ SOLR PA XIFAXAN TABS 200 MG 3 3 per fill retail,9 (vancomycin hcl) (rifaximin) ea per fill mail) VANCOCIN CAPS PA XIFAXAN TABS 550 MG PA; QL(2 ea GP 3 (vancomycin hcl) (rifaximin) daily) VANCOCIN HCL CAPS PA GP Anti-infective Misc. - Combinations (vancomycin hcl) (Methenamine-Hyosc- PA Methylene Blue-Sod Phos- vancomycin hcl caps or 1 Phenyl Sal) 125 mg, 250 mg PHOSPHASAL, URELLE, 1 Leprostatics URETRON D/S, URIMAR- T, URIN D/S, URO-458, dapsone tabs 1 UTIRA-C, VILEVEV MB TABS Lincosamides (Methenamine-Hyosc- CLEOCIN CAPS OR 150 Methylene Blue-Sod Phos- MG, 300 MG, 75 MG GP Phenyl Sal) URIBEL, URO- 1 (clindamycin hcl) MP, USTELL, VILAMIT MB CLEOCIN PEDIATRIC CAPS GRANULES SOLR (Sulfamethoxazole- (clindamycin palmitate GP Trimethoprim) SULFATRIM 1 hydrochloride) PEDIATRIC SUSP BACTRIM DS TABS clindamycin hcl caps 1 (sulfamethoxazole- GP clindamycin palmitate 1 trimethoprim) hydrochloride solr BACTRIM TABS (sulfamethoxazole- GP Oxazolidinones trimethoprim) linezolid susr 100 1 mg/5ml
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Updated 07/01/2021 14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(20 ea per ANTIANGINAL AGENTS - Drugs to Treat Chest 1 90 days Pain linezolid tabs 600 mg retail,20 ea per 90 days mail) Antianginals-Other SIVEXTRO TABS QL(6 ea per 90 RANEXA TB12 1000 MG 2 GP (tedizolid phosphate) days retail) (ranolazine) ZYVOX SUSR 100 RANEXA TB12 500 MG QL(4 ea daily) GP GP MG/5ML (linezolid) (ranolazine) QL(20 ea per ranolazine tb12 1000 ZYVOX TABS 600 MG 1 GP 90 days mg (linezolid) retail,20 ea per QL(4 ea daily) 90 days mail) ranolazine tb12 500 mg 1 Urinary Anti-infectives Nitrates fosfomycin 1 (Nitroglycerin) MINITRAN 1 QL(1 ea daily) tromethamine pack PT24 FURADANTIN SUSP (Nitroglycerin) NITRO- GP 1 (nitrofurantoin) TIME CPCR DILATRATE SR CPCR HIPREX TABS 3 (methenamine GP (isosorbide dinitrate) GONITRO PACK PA hippurate) 3 MACROBID CAPS (nitroglycerin) (nitrofurantoin monohyd GP ISORDIL TITRADOSE macro) TABS (isosorbide GP MACRODANTIN CAPS dinitrate) (nitrofurantoin GP isosorbide dinitrate tabs macrocrystal) 10 mg, 20 mg, 30 mg, 1 40 mg, 5 mg methenamine hippurate 1 tabs isosorbide dinitrate tbcr 1 METHENAMINE 40 mg MANDELATE TABS 0.5 GP isosorbide mononitrate 1 GM (methenamine tabs mandelate) isosorbide mononitrate 1 methenamine 1 tb24 mandelate tabs 1 gm NITRO-BID OINT 2 MONUROL PACK (nitroglycerin) (fosfomycin GP NITRO-DUR PT24 0.1 QL(1 ea daily) tromethamine) MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR GP nitrofurantoin 1 macrocrystal caps (nitroglycerin) NITRO-DUR PT24 0.3 QL(1 ea daily) nitrofurantoin monohyd 1 macro caps MG/HR, 0.8 MG/HR 2 (nitroglycerin) nitrofurantoin susp 1
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15 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nitroglycerin cpcr or 2.5 1 alprazolam tbdp 1 mg, 9 mg ATIVAN TABS nitroglycerin pt24 td 0.1 QL(1 ea daily) GP (lorazepam) mg/hr, 0.2 mg/hr, 0.4 1 mg/hr, 0.6 mg/hr chlordiazepoxide hcl 1 caps nitroglycerin soln tl 0.4 1 mg/spray clorazepate 1 dipotassium tabs nitroglycerin subl sl 0.3 1 mg, 0.4 mg, 0.6 mg diazepam conc 5 mg/ml 1 NITROLINGUAL diazepam soln 5 1 PUMPSPRAY SOLN GP mg/5ml (nitroglycerin) NITROMIST AERS diazepam tabs 10 mg, 1 3 (nitroglycerin) 2 mg, 5 mg NITROSTAT SUBL lorazepam conc 1 GP (nitroglycerin) lorazepam tabs 1 ANTIANXIETY AGENTS - Drugs to Treat Anxiety oxazepam caps 15 mg, 1 Antianxiety Agents - Misc. 30 mg buspirone hcl tabs 1 TRANXENE T TABS (clorazepate GP hydroxyzine hcl syrp 1 dipotassium) VALIUM TABS GP hydroxyzine hcl tabs 1 (diazepam) hydroxyzine pamoate XANAX TABS 1 GP caps (alprazolam) XANAX XR TB24 meprobamate tabs 1 GP (alprazolam) VISTARIL CAPS GP ANTIARRHYTHMICS - Drugs to treat abnormal (hydroxyzine pamoate) heart rhythms Benzodiazepines Antiarrhythmics Type I-A (Alprazolam) 1 ALPRAZOLAM XR TB24 disopyramide 1 phosphate caps (Diazepam) DIAZEPAM 1 INTENSOL CONC NORPACE CAPS (disopyramide GP (Lorazepam) LORAZEPAM 1 INTENSOL CONC phosphate) ALPRAZOLAM INTENSOL NORPACE CR CP12 100 3 CONC (alprazolam) MG (disopyramide 2 phosphate) alprazolam tabs 1 NORPACE CR CP12 150 alprazolam tb24 1 MG (disopyramide GP phosphate) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XOLAIR SOLR PA quinidine gluconate 1 3 tbcr (omalizumab) XOLAIR SOSY PA quinidine sulfate tabs 1 3 (omalizumab) Antiarrhythmics Type I-B Bronchodilators - Anticholinergics mexiletine hcl caps 150 1 ATROVENT HFA AERS Limit 2 inhalers mg, 200 mg, 250 mg ( 2 per ipratropium bromide month;QL(0.86 Antiarrhythmics Type I-C hfa) gm daily) flecainide acetate tabs 1 INCRUSE ELLIPTA AEPB Limit 1 inhaler 2 per month;QL(1 propafenone hcl cp12 (umeclidinium bromide) ea daily) 225 mg, 325 mg, 425 1 ipratropium bromide 1 mg soln QL(6 ea daily) propafenone hcl tabs 1 SPIRIVA HANDIHALER QL(1 ea daily) 150 mg CAPS (tiotropium 2 QL(3 ea daily) propafenone hcl tabs 1 bromide monohydrate) 225 mg, 300 mg SPIRIVA RESPIMAT Limit 1 inhaler RYTHMOL SR CP12 per GP AERS (tiotropium 2 (propafenone hcl) month;QL(0.14 bromide monohydrate) gm daily) Antiarrhythmics Type III Leukotriene Modulators (Amiodarone Hcl) 1 ACCOLATE TABS PACERONE TABS GP (zafirlukast) 1 amiodarone hcl tabs QL(1 ea daily) montelukast sodium 1 dofetilide caps 1 chew QL(1 ea daily) MULTAQ TABS montelukast sodium 1 2 pack (dronedarone hcl) QL(1 ea daily) TIKOSYN CAPS montelukast sodium GP 1 (dofetilide) tabs SINGULAIR CHEW QL(1 ea daily) ANTIASTHMATIC AND BRONCHODILATOR GP AGENTS - Drugs to Treat Lung Conditions (montelukast sodium) SINGULAIR PACK QL(1 ea daily) GP Anti-Inflammatory Agents (montelukast sodium) cromolyn sodium nebu 1 SINGULAIR TABS QL(1 ea daily) GP (montelukast sodium) Antiasthmatic - Monoclonal Antibodies FASENRA PEN SOAJ PA zafirlukast tabs 1 3 (benralizumab) zileuton tb12 1 ST NUCALA SOAJ PA 3 (mepolizumab) ZYFLO TABS (zileuton) 3 ST NUCALA SOSY PA 3 (mepolizumab) Selective Phosphodiesterase 4 (PDE4) Inhibitors
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17 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DALIRESP TABS QL(1 ea daily) PULMICORT SUSP 0.5 QL(4 ml daily) 3 (roflumilast) MG/2ML (budesonide GP Steroid Inhalants (inhalation)) ARNUITY ELLIPTA AEPB QL(1 ea daily) PULMICORT SUSP 1 QL(2 ml daily) (fluticasone furoate 2 MG/2ML (budesonide GP (inhalation)) (inhalation)) QL(8 ml daily) QVAR REDIHALER AERB Limit 1 inhaler budesonide (inhalation) 1 susp 0.25 mg/2ml 40 MCG/ACT per (beclomethasone 2 month;QL(0.36 QL(4 ml daily) gm daily) budesonide (inhalation) 1 dipropionate hfa) susp 0.5 mg/2ml QVAR REDIHALER AERB Limit 2 Inhalers QL(2 ml daily) 80 MCG/ACT per budesonide (inhalation) 1 susp 1 mg/2ml (beclomethasone 2 month;QL(0.72 FLOVENT DISKUS AEPB QL(20 ea daily) dipropionate hfa) gm daily) 100 MCG/BLIST Sympathomimetics (fluticasone propionate 2 (Fluticasone-Salmeterol) 1 QL(2 ea daily) (inhalation)) WIXELA INHUB AEPB FLOVENT DISKUS AEPB QL(8 ea daily) ADVAIR DISKUS AEPB QL(2 ea daily) GP 250 MCG/BLIST (fluticasone-salmeterol) (fluticasone propionate 2 Limit 1 inhaler (inhalation)) ADVAIR HFA AERO 2 per FLOVENT DISKUS AEPB QL(40 ea daily) (fluticasone-salmeterol) month;QL(0.4 50 MCG/BLIST gm daily) 2 (fluticasone propionate Limit 2 inhalers (inhalation)) albuterol sulfate aers in 1 per FLOVENT HFA AERO 110 Limit 2 inhalers 108 mcg/act month;QL(0.57 MCG/ACT, 220 MCG/ACT per gm daily) ( 2 month;QL(0.8 QL(1.2 gm fluticasone propionate albuterol sulfate aers in 1 hfa) gm daily) 108 mcg/act daily) FLOVENT HFA AERO 44 Limit 1 inhaler albuterol sulfate aers in QL(0.45 gm 1 daily) MCG/ACT ( 2 per 108 mcg/act fluticasone month;QL(0.36 propionate hfa) gm daily) albuterol sulfate nebu PULMICORT FLEXHALER Limit 2 inhalers in 0.083 %, 0.5 %, 0.63 1 AEPB 180 MCG/ACT per mg/3ml, 1.25 mg/3ml, (budesonide 2 month;QL(0.07 2.5 mg/0.5ml (inhalation)) ea daily) ALBUTEROL SULFATE PULMICORT FLEXHALER Limit 2 inhalers NEBU IN 0.5 % (albuterol 2 AEPB 90 MCG/ACT per sulfate) (budesonide 2 month;QL(0.27 albuterol sulfate syrp or 1 (inhalation)) ea daily) 2 mg/5ml PULMICORT SUSP 0.25 QL(8 ml daily) albuterol sulfate tabs or 1 MG/2ML (budesonide GP 2 mg, 4 mg (inhalation))
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Updated 07/01/2021 18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits albuterol sulfate tb12 or QL(2 ea daily) Limit 2 inhalers 1 PROAIR RESPICLICK 4 mg, 8 mg 3 per AEPB (albuterol sulfate) month;QL(0.07 ANORO ELLIPTA AEPB QL(2 ea daily) ea daily) ( umeclidinium- 2 Limit 2 inhalers vilanterol) PROVENTIL HFA AERS 1 per ARCAPTA NEOHALER QL(1 ea daily) (albuterol sulfate) month;QL(0.45 CAPS (indacaterol 3 gm daily) maleate) SEREVENT DISKUS QL(2 ea daily) BREO ELLIPTA AEPB QL(2 ea daily) AEPB (salmeterol 2 (fluticasone furoate- 2 xinafoate) vilanterol) STIOLTO RESPIMAT Limit 1 inhaler Limit 1 inhaler AERS ( 2 per budesonide-formoterol tiotropium month;QL(0.14 2 per bromide-olodaterol hcl) fumarate dihydrate month;QL(0.34 gm daily) aero gm daily) Limit 1 inhaler STRIVERDI RESPIMAT Limit 1 inhaler 2 per COMBIVENT RESPIMAT AERS (olodaterol hcl) month;QL(0.14 AERS ( 3 per ipratropium- month;QL(0.2 gm daily) albuterol) gm daily) SYMBICORT AERO Limit 1 inhaler fluticasone-salmeterol QL(2 ea daily) ( GP per budesonide-formoterol month;QL(0.34 aepb 100 mcg/act-50 fumarate dihydrate) gm daily) mcg/act, 100 mcg/dose-50 terbutaline sulfate tabs 1 mcg/dose, 250 1 TRELEGY ELLIPTA AEPB QL(2 ea daily) mcg/act-50 mcg/act, 100 MCG/INH-25 250 mcg/dose-50 MCG/INH-62.5 MCG/INH 2 mcg/dose, 50 (fluticasone- mcg/dose-500 umeclidinium-vilanterol) mcg/dose TRELEGY ELLIPTA AEPB 1 inhaler per 200 MCG/INH-25 month;QL(2 ea ipratropium-albuterol 1 soln MCG/INH-62.5 MCG/INH 2 daily) (fluticasone- levalbuterol hcl nebu 1 umeclidinium-vilanterol) Limit 2 inhalers Limit 2 inhalers levalbuterol tartrate VENTOLIN HFA AERS 1 per month;QL(1 1 per aero gm daily) (albuterol sulfate) month;QL(0.54 gm daily) metaproterenol sulfate 1 Limit 2 inhalers tabs VENTOLIN HFA AERS 1 per Limit 2 inhalers (albuterol sulfate) month;QL(1.2 PROAIR HFA AERS 1 per gm daily) (albuterol sulfate) month;QL(0.57 XOPENEX gm daily) CONCENTRATE NEBU GP (levalbuterol hcl)
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19 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XOPENEX HFA AERO Limit 2 inhalers enoxaparin sodium QL(20 ml per 1 per month;QL(1 10 days retail) (levalbuterol tartrate) soln sc 100 mg/ml, 150 3 gm daily) mg/ml XOPENEX NEBU GP enoxaparin sodium QL(16 ml per (levalbuterol hcl) soln sc 120 mg/0.8ml, 3 10 days retail) Xanthines 80 mg/0.8ml ELIXOPHYLLIN ELIX QL(6 ml per 10 3 enoxaparin sodium 3 (theophylline) soln sc 30 mg/0.3ml days retail) THEO-24 CP24 QL(8 ml per 10 2 enoxaparin sodium 3 (theophylline) soln sc 40 mg/0.4ml days retail) theophylline soln 1 QL(12 ml per enoxaparin sodium 3 soln sc 60 mg/0.6ml 10 days retail) theophylline tb12 1 fondaparinux sodium 3 theophylline tb24 1 soln FRAGMIN SOLN 10000 ANTICOAGULANTS - Blood Thinners UNIT/ML, 12500 UNIT/0.5ML, 15000 Coumarin Anticoagulants UNIT/0.6ML, 18000 UNT/0.72ML, 5000 3 (Warfarin Sodium) 1 JANTOVEN TABS UNIT/0.2ML, 7500 COUMADIN TABS UNIT/0.3ML (dalteparin GP (warfarin sodium) sodium) FRAGMIN SOLN 2500 QL(4 ml per 1 warfarin sodium tabs UNIT/0.2ML (dalteparin 3 365 days retail) Direct Factor Xa Inhibitors sodium) BEVYXXA CAPS QL(42 ea per FRAGMIN SOLN 95000 PA 3 (betrixaban maleate) 42 days retail) UNIT/3.8ML (dalteparin 3 ELIQUIS STARTER PACK sodium) 2 TBPK (apixaban) LOVENOX SOLN IJ 300 QL(3 ml per 10 ELIQUIS TABS MG/3ML (enoxaparin GP days retail) 2 (apixaban) sodium) XARELTO STARTER LOVENOX SOLN SC 100 QL(20 ml per PACK TBPK 2 MG/ML, 150 MG/ML GP 10 days retail) (rivaroxaban) (enoxaparin sodium) XARELTO TABS 10 MG, LOVENOX SOLN SC 120 QL(16 ml per 15 MG, 20 MG 2 MG/0.8ML, 80 MG/0.8ML GP 10 days retail) (rivaroxaban) (enoxaparin sodium) LOVENOX SOLN SC 30 QL(6 ml per 10 Heparins And Heparinoid-Like Agents MG/0.3ML (enoxaparin GP days retail) ARIXTRA SOLN GP sodium) (fondaparinux sodium) LOVENOX SOLN SC 40 QL(8 ml per 10 enoxaparin sodium QL(3 ml per 10 days retail) 3 days retail) MG/0.4ML (enoxaparin GP soln ij 300 mg/3ml sodium)
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Updated 07/01/2021 20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOVENOX SOLN SC 60 QL(12 ml per VALTOCO LIQD PA; QL(10 ea MG/0.6ML (enoxaparin GP 10 days retail) (diazepam 3 per 30 days sodium) (anticonvulsant)) retail) VALTOCO LQPK PA; QL(10 ea ANTICONVULSANTS - Drugs to Treat Seizures (diazepam 3 per 30 days AMPA Glutamate Receptor Antagonists (anticonvulsant)) retail) FYCOMPA SUSP 3 Anticonvulsants - Misc. (perampanel) (Carbamazepine) EPITOL 1 FYCOMPA TABS TABS 3 (perampanel) (Lamotrigine) SUBVENITE Anticonvulsants - Benzodiazepines STARTER KIT/BLUE, SUBVENITE STARTER 1 clobazam susp 1 KIT/GREEN, SUBVENITE STARTER KIT/ORANGE clobazam tabs 1 KIT (Lamotrigine) SUBVENITE 1 clonazepam tabs 1 TABS (Levetiracetam) 1 clonazepam tbdp 1 ROWEEPRA TABS DIASTAT ACUDIAL GEL Limit 4 per (Levetiracetam) 1 10 MG (diazepam 3 month;QL(0.14 ROWEEPRA XR TB24 (anticonvulsant)) ea daily) APTIOM TABS 200 MG, QL(2 ea daily) 400 MG, 600 MG DIASTAT ACUDIAL GEL Limit 4 per ( 3 20 MG (diazepam GP month;QL(0.14 eslicarbazepine ) (anticonvulsant)) ea daily) acetate APTIOM TABS 800 MG QL(1 ea daily) DIASTAT PEDIATRIC GEL Limit 4 per ( 3 (diazepam GP month;QL(0.14 eslicarbazepine ) (anticonvulsant)) ea daily) acetate BANZEL SUSP diazepam Limit 4 per GP (rufinamide) (anticonvulsant) gel 10 3 month;QL(0.14 ea daily) BANZEL TABS mg GP (rufinamide) diazepam Limit 4 per (anticonvulsant) gel 2.5 1 month;QL(0.14 carbamazepine chew 1 mg, 20 mg ea daily) carbamazepine cp12 1 KLONOPIN TABS GP (clonazepam) carbamazepine susp 1 NAYZILAM SOLN PA; QL(10 ea (midazolam 3 per 30 days carbamazepine tabs 1 (anticonvulsant)) retail) carbamazepine tb12 1 ONFI SUSP (clobazam) GP CARBATROL CP12 GP ONFI TABS (clobazam) GP (carbamazepine)
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21 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIACOMIT CAPS 250 MG PA; QL(12 ea LAMICTAL TABS 3 GP (stiripentol) daily) (lamotrigine) DIACOMIT CAPS 500 MG PA; QL(6 ea LAMICTAL XR TB24 100 PA; QL(1 ea 3 (stiripentol) daily) MG, 200 MG, 25 MG, 50 GP daily) DIACOMIT PACK 250 MG PA; QL(12 ea MG (lamotrigine) 3 (stiripentol) daily) LAMICTAL XR TB24 250 PA DIACOMIT PACK 500 MG PA; QL(6 ea MG, 300 MG GP 3 (stiripentol) daily) (lamotrigine) EPIDIOLEX SOLN PA lamotrigine chew 25 3 1 (cannabidiol) mg, 5 mg PA gabapentin caps 1 lamotrigine kit 1 gabapentin soln 1 lamotrigine kit 25 mg, 1 lamotrigine tabs 100 gabapentin tabs 1 mg, 150 mg, 200 mg, 1 KEPPRA SOLN 25 mg GP (levetiracetam) lamotrigine tb24 100 PA; QL(1 ea KEPPRA TABS 1 daily) GP mg, 200 mg, 25 mg, 50 (levetiracetam) mg KEPPRA XR TB24 PA GP lamotrigine tb24 250 1 (levetiracetam) mg, 300 mg LAMICTAL CHEWABLE lamotrigine tbdp 100 PA DISPERSIBLE CHEW GP mg, 200 mg, 25 mg, 50 1 (lamotrigine) mg LAMICTAL ODT KIT PA 3 (lamotrigine) levetiracetam soln or 1 100 mg/ml, 500 mg/5ml LAMICTAL ODT KIT PA GP (lamotrigine) levetiracetam tabs or 1 LAMICTAL ODT TBDP 100 PA 1000 mg, 250 mg, 500 MG, 200 MG, 25 MG, 50 GP mg, 750 mg MG (lamotrigine) levetiracetam tb24 or 1 LAMICTAL STARTER/NOT 500 mg, 750 mg TAKING LYRICA CAPS 100 MG, PA; QL(3 ea GP CARBAMAZEPINE KIT 200 MG, 25 MG, 50 MG, GP daily) (lamotrigine) 75 MG (pregabalin) LAMICTAL LYRICA CAPS 150 MG, PA; QL(2 ea STARTER/TAKING 225 MG, 300 MG GP daily) CARBAMAZEPINE/NOT GP (pregabalin) TAKING VALPROATE KIT LYRICA SOLN 20 MG/ML PA; QL(30 ml (lamotrigine) GP (pregabalin) daily) LAMICTAL MYSOLINE TABS STARTER/TAKING GP VALPROATE KIT GP (primidone) (lamotrigine) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEURONTIN CAPS GP topiramate tabs 100 (gabapentin) mg, 200 mg, 25 mg, 50 1 NEURONTIN SOLN mg GP (gabapentin) TRILEPTAL SUSP GP NEURONTIN TABS (oxcarbazepine) GP (gabapentin) TRILEPTAL TABS GP oxcarbazepine susp 1 (oxcarbazepine) TROKENDI XR CP24 PA 3 oxcarbazepine tabs 1 (topiramate) OXTELLAR XR TB24 ST VIMPAT SOLN 3 2 (oxcarbazepine) (lacosamide) VIMPAT TABS pregabalin caps 100 PA; QL(3 ea 2 mg, 200 mg, 25 mg, 50 1 daily) (lacosamide) ZONEGRAN CAPS mg, 75 mg GP ( ) PA; QL(2 ea zonisamide pregabalin caps 150 1 mg, 225 mg, 300 mg daily) zonisamide caps 1 PA; QL(30 ml pregabalin soln 20 1 Carbamates mg/ml daily) felbamate susp 1 primidone tabs 1 QUDEXY XR CS24 PA felbamate tabs 1 GP (topiramate) FELBATOL SUSP GP rufinamide susp 1 (felbamate) FELBATOL TABS GP rufinamide tabs 1 (felbamate) TEGRETOL SUSP GABA Modulators GP (carbamazepine) (Vigabatrin) VIGADRONE 1 TEGRETOL TABS PACK GP GABITRIL TABS (carbamazepine) GP TEGRETOL-XR TB12 (tiagabine hcl) GP SABRIL PACK (carbamazepine) GP TOPAMAX SPRINKLE (vigabatrin) GP SABRIL TABS CPSP (topiramate) GP TOPAMAX TABS (vigabatrin) GP (topiramate) tiagabine hcl tabs 1 topiramate cpsp 15 mg, 1 25 mg vigabatrin pack 1 topiramate cs24 100 PA vigabatrin tabs 1 mg, 150 mg, 200 mg, 1 25 mg, 50 mg Hydantoins
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23 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Phenytoin) PHENYTOIN DEPAKOTE TBEC 1 GP INFATABS CHEW (divalproex sodium) DILANTIN CAPS 100 MG divalproex sodium csdr 1 (phenytoin sodium GP extended) divalproex sodium tb24 1 DILANTIN CAPS 30 MG (phenytoin sodium 2 divalproex sodium tbec 1 extended) DILANTIN INFATABS valproic acid caps or 1 GP CHEW (phenytoin) ANTIDEPRESSANTS - Drugs to Treat DILANTIN-125 SUSP Depression GP (phenytoin) Alpha-2 Receptor Antagonists (Tetracyclics) PEGANONE TABS 3 (ethotoin) mirtazapine tabs 1 PHENYTEK CAPS mirtazapine tbdp 1 (phenytoin sodium GP REMERON SOLTAB TBDP extended) GP (mirtazapine) phenytoin chew 1 REMERON TABS GP (mirtazapine) phenytoin sodium 1 extended caps Antidepressants - Misc. phenytoin susp 1 APLENZIN TB24 ST; QL(1 ea (bupropion 3 daily) Succinimides hydrobromide) CELONTIN CAPS 2 bupropion hcl tabs 100 1 (methsuximide) mg, 75 mg ethosuximide caps 1 bupropion hcl tb12 100 1 mg, 150 mg, 200 mg ethosuximide soln 1 QL(1 ea daily) bupropion hcl tb24 150 1 ZARONTIN CAPS mg, 300 mg GP (ethosuximide) bupropion hcl tb24 450 ST; QL(1 ea ZARONTIN SOLN 1 daily) GP mg (ethosuximide) FORFIVO XL TB24 ST; QL(1 ea GP Valproic Acid (bupropion hcl) daily) DEPAKENE CAPS 250 MG GP maprotiline hcl tabs 1 (valproic acid) DEPAKOTE ER TB24 WELLBUTRIN SR TB12 GP GP (divalproex sodium) (bupropion hcl) WELLBUTRIN XL TB24 QL(1 ea daily) DEPAKOTE SPRINKLES GP CSDR (divalproex GP (bupropion hcl) sodium) Monoamine Oxidase Inhibitors (MAOIs)
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Updated 07/01/2021 24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMSAM PT24 QL(1 ea daily) 3 fluoxetine hcl cpdr 90 1 (selegiline) mg MARPLAN TABS 3 fluoxetine hcl soln 20 1 (isocarboxazid) mg/5ml NARDIL TABS GP fluoxetine hcl tabs 10 1 (phenelzine sulfate) mg, 20 mg PARNATE TABS ST; QL(1 ea fluoxetine hcl tabs 60 1 (tranylcypromine GP mg daily) sulfate) FLUOXETINE ST; QL(1 ea phenelzine sulfate tabs 1 HYDROCHLORIDE TABS GP daily) (fluoxetine hcl) tranylcypromine sulfate 1 tabs fluvoxamine maleate 1 cp24 Selective Serotonin Reuptake Inhibitors (SSRIs) fluvoxamine maleate 1 CELEXA TABS 10 MG QL(4 ea daily) tabs (citalopram GP LEXAPRO TABS hydrobromide) GP (escitalopram oxalate) CELEXA TABS 20 MG QL(2 ea daily) (citalopram GP paroxetine hcl tabs 1 hydrobromide) 1 CELEXA TABS 40 MG QL(1 ea daily) paroxetine hcl tb24 (citalopram GP PAXIL CR TB24 GP hydrobromide) (paroxetine hcl) QL(20 ml daily) PAXIL SUSP 10 MG/5ML citalopram 2 hydrobromide soln 10 1 (paroxetine hcl) mg/5ml PAXIL TABS 10 MG, 20 citalopram QL(4 ea daily) MG, 30 MG, 40 MG GP hydrobromide tabs 10 1 (paroxetine hcl) PEXEVA TABS mg 3 citalopram QL(2 ea daily) (paroxetine mesylate) PROZAC CAPS hydrobromide tabs 20 1 GP mg (fluoxetine hcl) citalopram QL(1 ea daily) sertraline hcl conc 1 hydrobromide tabs 40 1 mg sertraline hcl tabs 1 ZOLOFT CONC escitalopram oxalate 1 GP soln (sertraline hcl) ZOLOFT TABS (sertraline escitalopram oxalate 1 GP tabs hcl) Serotonin Modulators fluoxetine hcl caps 10 1 mg, 20 mg, 40 mg nefazodone hcl tabs 1
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25 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits trazodone hcl tabs 1 amitriptyline hcl tabs 1 TRINTELLIX TABS ST; QL(1 ea 3 amoxapine tabs 1 (vortioxetine hbr) daily) VIIBRYD STARTER PACK ST ANAFRANIL CAPS 3 GP KIT (vilazodone hcl) (clomipramine hcl) VIIBRYD TABS ST clomipramine hcl caps 1 3 (vilazodone hcl) desipramine hcl tabs 1 Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP QL(2 ea daily) GP doxepin hcl caps 1 (duloxetine hcl) DESVENLAFAXINE ER ST; QL(1 ea doxepin hcl conc 1 3 TB24 (desvenlafaxine) daily) imipramine hcl tabs 1 desvenlafaxine 1 succinate tb24 imipramine pamoate 1 duloxetine hcl cpep 20 QL(2 ea daily) caps 1 NORPRAMIN TABS mg, 30 mg, 60 mg GP EFFEXOR XR CP24 150 QL(2 ea daily) (desipramine hcl) GP MG (venlafaxine hcl) nortriptyline hcl caps 1 EFFEXOR XR CP24 37.5 QL(1 ea daily) MG, 75 MG (venlafaxine GP nortriptyline hcl soln 1 hcl) PAMELOR CAPS GP FETZIMA CP24 120 MG, ST; QL(1 ea (nortriptyline hcl) 40 MG, 80 MG 3 daily) (levomilnacipran hcl) protriptyline hcl tabs 1 FETZIMA CP24 20 MG ST; QL(2 ea SURMONTIL CAPS 3 GP (levomilnacipran hcl) daily) (trimipramine maleate) PRISTIQ TB24 TOFRANIL TABS GP (desvenlafaxine GP (imipramine hcl) succinate) trimipramine maleate QL(2 ea daily) 1 venlafaxine hcl cp24 1 caps 150 mg ANTIDIABETICS - Drugs to Regulate Blood QL(1 ea daily) venlafaxine hcl cp24 1 Sugar 37.5 mg, 75 mg Alpha-Glucosidase Inhibitors venlafaxine hcl tabs 100 mg, 25 mg, 37.5 1 acarbose tabs 1 mg, 50 mg, 75 mg GLYSET TABS (miglitol) GP venlafaxine hcl tb24 150 mg, 225 mg, 37.5 1 miglitol tabs 1 mg, 75 mg PRECOSE TABS GP Tricyclic Agents (acarbose)
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Updated 07/01/2021 26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antidiabetic - Amylin Analogs TRIJARDY XR TB24 SYMLINPEN 120 SOPN PA (empagliflozin- 2 3 (pramlintide acetate) linagliptin-metformin) SYMLINPEN 60 SOPN PA XIGDUO XR TB24 3 (pramlintide acetate) (dapagliflozin- 2 metformin hcl) Antidiabetic Combinations XULTOPHY 100/3.6 SOPN PA ACTOPLUS MET TABS (insulin degludec- 3 (pioglitazone hcl- GP liraglutide) metformin hcl) DUETACT TABS Biguanides GLUMETZA TB24 PA (pioglitazone hcl- GP GP glimepiride) (metformin hcl) metformin hcl soln 500 glipizide-metformin hcl 1 1 tabs mg/5ml metformin hcl tabs glyburide-metformin 1 tabs 1000 mg, 500 mg, 850 1 GLYXAMBI TABS mg PA (empagliflozin- 2 metformin hcl tb24 3 linagliptin) 1000 mg, 500 mg JANUMET TABS metformin hcl tb24 500 1 (sitagliptin-metformin 2 mg, 750 mg hcl) METFORMIN JANUMET XR TB24 HYDROCHLORIDE SOLN 1 (sitagliptin-metformin 2 (metformin hcl) RIOMET SOLN hcl) 4 (metformin hcl) pioglitazone hcl- 1 glimepiride tabs Diabetic Other BAQSIMI ONE PACK QL(0.069 ea pioglitazone hcl- 1 3 metformin hcl tabs POWD (glucagon) daily) BAQSIMI TWO PACK QL(0.069 ea repaglinide-metformin 1 3 hcl tabs POWD (glucagon) daily) SOLIQUA 100/33 SOPN PA diazoxide susp 1 (insulin glargine- 3 GLUCAGEN HYPOKIT lixisenatide) SOLR (glucagon hcl 3 SYNJARDY TABS (rdna)) (empagliflozin- 2 metformin hcl) glucagon (rdna) kit 3 SYNJARDY XR TB24 GLUCAGON (empagliflozin- 2 EMERGENCY KIT FOR metformin hcl) LOW BLOOD SUGAR 2 SOLR (glucagon hcl)
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27 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCAGON HUMALOG MIX 50/50 Limit 45mls per EMERGENCY KIT KIT GP KWIKPEN SUPN (insulin month;QL(1.5 (glucagon (rdna)) lispro protamine & 2 ml daily) GVOKE PFS SOSY QL(0.02 ml lispro) 3 (glucagon) daily) HUMALOG MIX 50/50 Limit 4 vials per KORLYM TABS PA SUSP (insulin lispro 2 month;QL(1.5 (mifepristone 3 protamine & lispro) ml daily) (hyperglycemia)) HUMALOG MIX 75/25 Limit 45mls per PROGLYCEM SUSP KWIKPEN SUPN (insulin month;QL(1.5 GP 2 (diazoxide) lispro protamine & ml daily) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors lispro) JANUVIA TABS HUMALOG MIX 75/25 Limit 45mls per 2 (sitagliptin phosphate) SUSP (insulin lispro 2 month;QL(1.5 protamine & lispro) ml daily) Dopamine Receptor Agonists - Antidiabetic HUMALOG SOCT (insulin Limit 45mls per CYCLOSET TABS 2 month;QL(1.5 (bromocriptine 3 lispro) ml daily) mesylate (diabetes)) HUMALOG SOLN (insulin Limit 45mls per Incretin Mimetic Agents (GLP-1 Receptor 2 month;QL(1.5 lispro) ml daily) OZEMPIC SOPN PA 3 (semaglutide) HUMULIN 70/30 KWIKPEN Limit 45mls per SUPN (insulin nph month;QL(1.5 TRULICITY SOPN PA 2 3 isophane & reg ml daily) (dulaglutide) (human)) VICTOZA SOPN PA 3 HUMULIN 70/30 SUSP Limit 45mls per (liraglutide) (insulin nph isophane & 2 month;QL(1.5 Insulin Sensitizing Agents reg (human)) ml daily) ACTOS TABS GP HUMULIN N KWIKPEN Limit 45mls per (pioglitazone hcl) SUPN (insulin nph 2 month;QL(1.5 AVANDIA TABS ml daily) 2 (human) (isophane)) (rosiglitazone maleate) HUMULIN N SUSP Limit 45mls per pioglitazone hcl tabs 1 (insulin nph (human) 2 month;QL(1.5 (isophane)) ml daily) Insulin HUMULIN R SOLN Limit 45mls per HUMALOG JUNIOR Limit 45mls per (insulin regular 2 month;QL(1.5 KWIKPEN SOPN (insulin 2 month;QL(1.5 (human)) ml daily) lispro) ml daily) HUMULIN R U-500 Limit 2 vials per month;QL(1.5 HUMALOG KWIKPEN Limit 45mls per (CONCENTRATED) 2 SOPN 100 UNIT/ML 2 month;QL(1.5 SOLN (insulin regular ml daily) (insulin lispro) ml daily) (human)) HUMULIN R U-500 Limit 2 vials per HUMALOG KWIKPEN Limit 4 boxes KWIKPEN SOPN ( 2 month;QL(1.5 SOPN 200 UNIT/ML 2 per insulin month;QL(0.8 regular (human)) ml daily) (insulin lispro) ml daily)
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Updated 07/01/2021 28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN LISPRO Limit 45mls per FARXIGA TABS PROTAMINE/INSULIN month;QL(1.5 (dapagliflozin 2 LISPRO KWIKPEN SUPN 2 ml daily) propanediol) (insulin lispro protamine JARDIANCE TABS 2 & lispro) (empagliflozin) LANTUS SOLN (insulin Limit 45mls per 2 month;QL(1.5 Sulfonylureas glargine) ml daily) (Glipizide) GLIPIZIDE XL 1 TB24 LANTUS SOLOSTAR Limit 45mls per 2 month;QL(1.5 AMARYL TABS SOPN (insulin glargine) GP ml daily) (glimepiride) LEVEMIR FLEXTOUCH Limit 45mls per 2 month;QL(1.5 glimepiride tabs 1 SOPN (insulin detemir) ml daily) glipizide tabs 1 LEVEMIR SOLN (insulin Limit 45mls per 2 month;QL(1.5 1 detemir) ml daily) glipizide tb24 Limit 3 boxes GLUCOTROL TABS TOUJEO MAX SOLOSTAR GP 2 per (glipizide) SOPN (insulin glargine) month;QL(0.6 GLUCOTROL XL TB24 ml daily) GP (glipizide) Limit 3 boxes TOUJEO SOLOSTAR glyburide micronized 2 per 1 SOPN (insulin glargine) month;QL(0.6 tabs ml daily) glyburide tabs 1 TRESIBA FLEXTOUCH Limit 3 boxes per GLYNASE TABS SOPN 100 UNIT/ML 2 GP month;QL(1.5 (glyburide micronized) (insulin degludec) ml daily) tolbutamide tabs 1 TRESIBA FLEXTOUCH Limit 3 boxes SOPN 200 UNIT/ML 2 per ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs month;QL(0.9 to Treat Diarrhea (insulin degludec) ml daily) TRESIBA SOLN (insulin Antidiarrheal - Chloride Channel Antagonists 2 MYTESI TBEC PA; QL(2 ea degludec) 3 (crofelemer) daily) Meglitinide Analogues Antiperistaltic Agents nateglinide tabs 1 (Loperamide Hcl) ANTI- RX/OTC PRANDIN TABS DIARRHEAL, CVS ANTI- GP (repaglinide) DIARRHEAL, EQ ANTI- DIARRHEAL, GNP ANTI- repaglinide tabs 1 DIARRHEAL, HM ANTI- DIARRHEAL, HM 1 STARLIX TABS GP LOPERAMIDE HCL, QC (nateglinide) ANTI-DIARRHEAL, RA Sodium-Glucose Co-Transporter 2 (SGLT2) ANTI-DIARRHEAL, SM ANTI-DIARRHEAL, TGT LOPERAMIDE HCL CAPS
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29 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RADIOGARDASE CAPS diphenoxylate w/ 1 atropine liqd (prussian blue insoluble (ferric hexacyanoferrate 3 diphenoxylate w/ 1 atropine tabs ii)) IMODIUM A-D CAPS RX/OTC VISTOGARD PACK GP (loperamide hcl) (uridine triacetate 3 ) LOMOTIL TABS (emergency treatment) (diphenoxylate w/ GP Opioid Antagonists atropine) PA required for EVZIO SOAJ ( RX/OTC naloxone 3 more than 30 loperamide hcl caps 1 hcl) day supply per MOTOFEN TABS year; 2 (difenoxin w/ atropine) PA required for naloxone hcl soaj 3 more than 30 opium tincture tinc 1 day supply per year; paregoric tinc 1 naltrexone hcl tabs 1 ANTIDOTES AND SPECIFIC ANTAGONISTS Limit 2 boxes NARCAN LIQD 3 per month;QL(4 Antidotes - Chelating Agents (naloxone hcl) ea per 30 days CHEMET CAPS retail) 3 (succimer) ANTIEMETICS - Drugs to Treat Nausea and deferasirox pack 3 PA Vomiting 5-HT3 Receptor Antagonists deferasirox tabs 3 PA ANZEMET TABS PA; Limit 2 per PA 3 month;QL(0.07 deferasirox tbso 3 (dolasetron mesylate) ea daily) QL(2 ea daily) deferiprone tabs 3 granisetron hcl tabs 1 EXJADE TBSO PA ondansetron hcl soln 4 QL(100 ml per GP 1 (deferasirox) mg/5ml fill retail) FERRIPROX TABS 1000 ondansetron hcl tabs 4 QL(20 ea per 3 1 MG (deferiprone) mg, 8 mg fill retail) FERRIPROX TABS 500 QL(20 ea per GP ondansetron tbdp 1 MG (deferiprone) fill retail) JADENU SPRINKLE PACK PA SANCUSO PTCH PA GP 3 (deferasirox) (granisetron) JADENU TABS PA ZOFRAN TABS QL(20 ea per GP GP (deferasirox) (ondansetron hcl) fill retail) ZUPLENZ FILM QL(20 ea per Antidotes and Specific Antagonists 3 (ondansetron) fill retail) Antiemetics - Anticholinergic
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Updated 07/01/2021 30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MECLIZINE Limit 3 per HYDROCHLORIDE TABS 3 aprepitant misc 1 month;QL(0.1 (meclizine hcl) ea daily) EMEND CAPS 125 MG, 80 Limit 1 per scopolamine pt72 1 GP year;QL(0.04 MG (aprepitant) TIGAN CAPS ea daily) (trimethobenzamide GP EMEND CAPS 40 MG Limit 2 per hcl) GP month;QL(0.07 (aprepitant) ea daily) TRANSDERM SCOP PT72 GP EMEND TRIPACK CAPS Limit 3 per (scopolamine) GP month;QL(0.1 TRANSDERM-SCOP PT72 (aprepitant) GP ea daily) (scopolamine) VARUBI TBPK (rolapitant QL(4 ea per fill 3 retail) trimethobenzamide hcl 1 hcl) caps ANTIFUNGALS - Drugs to Treat Fungal Infections Antiemetics - Miscellaneous AKYNZEO CAPS QL(2 ea per 28 Antifungals days retail) ANCOBON CAPS (netupitant- 3 GP palonosetron) (flucytosine) BONJESTA TBCR QL(2 ea daily) flucytosine caps 1 (doxylamine- 3 pyridoxine) griseofulvin microsize 1 CESAMET CAPS PA; QL(2 ea susp 3 daily) (nabilone) griseofulvin microsize 1 DICLEGIS TBEC QL(4 ea daily) tabs ( doxylamine- GP griseofulvin 1 pyridoxine) ultramicrosize tabs QL(4 ea daily) doxylamine-pyridoxine 1 nystatin tabs 1 tbec QL(90 ea per 1 PA dronabinol caps 1 365 days terbinafine hcl tabs retail,90 ea per MARINOL CAPS PA GP 365 days mail) (dronabinol) Imidazole-Related Antifungals Substance P/Neurokinin 1 (NK1) Receptor CRESEMBA CAPS Limit 3 per (isavuconazonium 3 aprepitant caps 1 month;QL(0.1 ea daily) sulfate) DIFLUCAN SUSR aprepitant caps 125 Limit 1 per GP 1 year;QL(0.04 (fluconazole) mg, 80 mg ea daily) DIFLUCAN TABS GP Limit 2 per (fluconazole) aprepitant caps 40 mg 1 month;QL(0.07 ea daily) fluconazole susr 1 fluconazole tabs 1
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31 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits itraconazole caps 1 PA KARBINAL ER SUER (carbinoxamine 3 itraconazole soln 1 PA maleate) Antihistamines - Non-Sedating 1 ketoconazole tabs CLARINEX TABS PA; QL(1 ea GP NOXAFIL SUSP 40 MG/ML (desloratadine) daily) 3 (posaconazole) desloratadine tabs 5 PA; QL(1 ea NOXAFIL TBEC 100 MG 1 daily) GP mg (posaconazole) desloratadine tbdp 2.5 1 posaconazole tbec 1 mg, 5 mg SPORANOX CAPS PA Antihistamines - Phenothiazines GP (itraconazole) (Promethazine Hcl) 1 SPORANOX PULSEPAK PA PHENADOZ SUPP GP CAPS (itraconazole) (Promethazine Hcl) PROMETHEGAN SUPP 1 SPORANOX SOLN PA GP 12.5 MG, 25 MG (itraconazole) TOLSURA CAPS PA promethazine hcl soln 1 3 (itraconazole) promethazine hcl supp 1 VFEND SUSR GP (voriconazole) promethazine hcl syrp 1 VFEND TABS GP (voriconazole) promethazine hcl tabs 1 PROMETHEGAN SUPP 50 voriconazole susr or 40 1 GP mg/ml MG (promethazine hcl) voriconazole tabs or 1 Antihistamines - Piperidines 200 mg, 50 mg cyproheptadine hcl syrp 1 ANTIHISTAMINES - Drugs to Treat Allergies cyproheptadine hcl tabs 1 Antihistamines - Alkylamines ANTIHYPERLIPIDEMICS - Drugs to Treat High (Dexchlorpheniramine 1 Maleate) RYCLORA SOLN Cholesterol Antihyperlipidemics - Combinations dexchlorpheniramine 1 maleate soln QL(1 ea daily) ezetimibe-simvastatin 1 Antihistamines - Ethanolamines tabs VYTORIN TABS QL(1 ea daily) carbinoxamine maleate 1 GP soln 4 mg/5ml (ezetimibe-simvastatin) Antihyperlipidemics - Misc. carbinoxamine maleate 1 tabs 4 mg icosapent ethyl caps 1 ST clemastine fumarate 1 LOVAZA CAPS (omega- tabs GP 3-acid ethyl esters)
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Updated 07/01/2021 32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WELCHOL PACK omega-3-acid ethyl 1 GP esters caps (colesevelam hcl) VASCEPA CAPS ST WELCHOL TABS 3 GP (icosapent ethyl) (colesevelam hcl) Bile Acid Sequestrants Fibric Acid Derivatives ANTARA CAPS (Cholestyramine Light) 1 3 PREVALITE PACK (fenofibrate micronized) (Cholestyramine Light) 1 1 PREVALITE POWD choline fenofibrate cpdr fenofibrate caps 150 cholestyramine light 1 1 pack mg, 50 mg fenofibrate micronized cholestyramine light 1 1 powd caps cholestyramine pack 1 fenofibrate tabs 145 mg, 160 mg, 48 mg, 54 1 cholestyramine powd 1 mg FENOFIBRIC ACID TABS 3 colesevelam hcl pack 1 105 MG (fenofibric acid) FIBRICOR TABS colesevelam hcl tabs 1 3 (fenofibric acid) COLESTID FLAVORED GP GRAN (colestipol hcl) gemfibrozil tabs 1 COLESTID FLAVORED LIPOFEN CAPS GP GP PACK (colestipol hcl) (fenofibrate) COLESTID GRAN LOPID TABS GP GP (colestipol hcl) (gemfibrozil) COLESTID PACK TRICOR TABS GP GP (colestipol hcl) (fenofibrate) COLESTID TABS TRIGLIDE TABS GP 3 (colestipol hcl) (fenofibrate) TRILIPIX CPDR ( colestipol hcl gran 1 choline GP fenofibrate) colestipol hcl pack 1 HMG CoA Reductase Inhibitors ALTOPREV TB24 colestipol hcl tabs 1 3 (lovastatin) QUESTRAN LIGHT POWD QL(1 ea daily) GP atorvastatin calcium 1 (cholestyramine light) tabs QUESTRAN PACK CRESTOR TABS QL(1 ea daily) GP GP (cholestyramine) (rosuvastatin calcium) QUESTRAN POWD GP QL(1 ea daily) (cholestyramine) fluvastatin sodium caps 1
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33 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluvastatin sodium tb24 1 QL(1 ea daily) Proprotein Convertase Subtilisin/Kexin Type 9 PRALUENT SOAJ PA LESCOL XL TB24 QL(1 ea daily) 3 GP (alirocumab) (fluvastatin sodium) REPATHA PUSHTRONEX PA LIPITOR TABS QL(1 ea daily) GP SYSTEM SOCT 3 (atorvastatin calcium) (evolocumab) LIVALO TABS ST; QL(1 ea REPATHA SOSY PA 3 daily) 3 (pitavastatin calcium) (evolocumab) 1 $0 copay, age REPATHA SURECLICK PA lovastatin tabs 40 to 76;PV 3 SOAJ (evolocumab) PRAVACHOL TABS 20 QL(1 ea daily) MG, 80 MG (pravastatin GP ANTIHYPERTENSIVES - Drugs to Treat High sodium) Blood Pressure PRAVACHOL TABS 40 QL(2 ea daily) ACE Inhibitors ACCUPRIL TABS MG (pravastatin GP GP sodium) (quinapril hcl) ALTACE CAPS 1.25 MG, QL(1 ea daily) pravastatin sodium QL(1 ea daily) GP tabs 10 mg, 20 mg, 80 1 2.5 MG, 5 MG (ramipril) ALTACE CAPS 10 MG QL(2 ea daily) mg GP QL(2 ea daily) (ramipril) pravastatin sodium 1 tabs 40 mg benazepril hcl tabs 1 QL(1 ea daily) rosuvastatin calcium 1 tabs captopril tabs 1 simvastatin tabs 10 mg, QL(1 ea daily) enalapril maleate tabs 1 QL(2 ea daily) 20 mg, 40 mg, 5 mg, 1 EPANED SOLN QL(5 ml daily) 80 mg 3 ( ) ZOCOR TABS QL(1 ea daily) enalapril maleate GP (simvastatin) fosinopril sodium tabs 1 Intestinal Cholesterol Absorption Inhibitors lisinopril tabs 1 1 ezetimibe tabs LOTENSIN TABS GP ZETIA TABS (ezetimibe) GP (benazepril hcl) 1 Microsomal Triglyceride Transfer Protein (MTP) moexipril hcl tabs JUXTAPID CAPS PA perindopril erbumine 3 1 (lomitapide mesylate) tabs Nicotinic Acid Derivatives PRINIVIL TABS (lisinopril) GP niacin Limited to 1 (antihyperlipidemic) 1 QBRELIS SOLN 3 bottle per tbcr (lisinopril) month.;QL(5 ml NIASPAN TBCR ( daily) niacin GP (antihyperlipidemic)) quinapril hcl tabs 1
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Updated 07/01/2021 34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) MICARDIS TABS ramipril caps 1.25 mg, 1 GP 2.5 mg, 5 mg (telmisartan) QL(2 ea daily) ramipril caps 10 mg 1 olmesartan medoxomil 1 tabs trandolapril tabs 1 telmisartan tabs 1 VASOTEC TABS QL(2 ea daily) GP (enalapril maleate) valsartan tabs 1 ZESTRIL TABS (lisinopril) GP Antiadrenergic Antihypertensives CARDURA TABS GP Agents for Pheochromocytoma (doxazosin mesylate) DEMSER CAPS CATAPRES TABS GP GP (metyrosine) (clonidine hcl) DIBENZYLINE CAPS CATAPRES-TTS-1 PTWK GP (phenoxybenzamine GP (clonidine) ) hcl CATAPRES-TTS-2 PTWK GP metyrosine caps 1 (clonidine) CATAPRES-TTS-3 PTWK phenoxybenzamine hcl 1 GP caps (clonidine) Angiotensin II Receptor Antagonists clonidine hcl tabs 1 ATACAND TABS GP clonidine ptwk 1 (candesartan cilexetil) AVAPRO TABS doxazosin mesylate GP 1 (irbesartan) tabs BENICAR TABS guanfacine hcl tabs 1 (olmesartan GP medoxomil) methyldopa tabs 1 candesartan cilexetil MINIPRESS CAPS 1 GP tabs (prazosin hcl) COZAAR TABS (losartan GP prazosin hcl caps 1 potassium) DIOVAN TABS GP terazosin hcl caps 1 (valsartan) EDARBI TABS Antihypertensive Combinations 3 (azilsartan medoxomil) ACCURETIC TABS (quinapril- GP eprosartan mesylate 1 hydrochlorothiazide) tabs amlodipine besylate- 1 irbesartan tabs 1 benazepril hcl caps amlodipine besylate- losartan potassium 1 tabs olmesartan medoxomil 1 tabs You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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35 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EDARBYCLOR TABS amlodipine besylate- 1 valsartan tabs (azilsartan medoxomil- 3 amlodipine-valsartan- chlorthalidone) hydrochlorothiazide 1 enalapril maleate & tabs hydrochlorothiazide 1 ATACAND HCT TABS tabs (candesartan cilexetil- GP EXFORGE HCT TABS hydrochlorothiazide) (amlodipine-valsartan- 2 hydrochlorothiazide) atenolol & 1 chlorthalidone tabs EXFORGE TABS AVALIDE TABS (amlodipine besylate- GP (irbesartan- GP valsartan) hydrochlorothiazide) fosinopril sodium & AZOR TABS (amlodipine hydrochlorothiazide 1 besylate-olmesartan GP tabs medoxomil) HYZAAR TABS (losartan benazepril & potassium & GP hydrochlorothiazide 1 hydrochlorothiazide) tabs irbesartan- BENICAR HCT TABS hydrochlorothiazide 1 (olmesartan tabs medoxomil- GP lisinopril & hydrochlorothiazide) hydrochlorothiazide 1 bisoprolol & tabs hydrochlorothiazide 1 LOPRESSOR HCT TABS tabs (metoprolol & GP BYVALSON TABS hydrochlorothiazide) 3 (nebivolol-valsartan) losartan potassium & candesartan cilexetil- hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs LOTENSIN HCT TABS captopril & (benazepril & GP hydrochlorothiazide 1 hydrochlorothiazide) tabs LOTREL CAPS DIOVAN HCT TABS (amlodipine besylate- GP (valsartan- GP benazepril hcl) hydrochlorothiazide) methyldopa & DUTOPROL TB24 hydrochlorothiazide 1 (metoprolol & 3 tabs hydrochlorothiazide) metoprolol & hydrochlorothiazide 1 tabs
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Updated 07/01/2021 36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METOPROLOL TRIBENZOR TABS ST SUCCINATE (olmesartan ER/HYDROCHLOROTHIA 3 medoxomil-amlodipine- GP ZIDE TB24 (metoprolol hydrochlorothiazide) & hydrochlorothiazide) TWYNSTA TABS MICARDIS HCT TABS (telmisartan- GP (telmisartan- GP amlodipine) hydrochlorothiazide) valsartan- olmesartan medoxomil- ST hydrochlorothiazide 1 amlodipine- 1 tabs hydrochlorothiazide VASERETIC TABS tabs (enalapril maleate & GP olmesartan medoxomil- hydrochlorothiazide) hydrochlorothiazide 1 ZESTORETIC TABS tabs (lisinopril & GP propranolol & hydrochlorothiazide) hydrochlorothiazide 1 ZIAC TABS ( bisoprolol & GP tabs hydrochlorothiazide) quinapril- Antihypertensives - Misc. hydrochlorothiazide 1 VECAMYL TABS PA tabs 3 (mecamylamine hcl) TARKA TBCR (trandolapril-verapamil GP Direct Renin Inhibitors hcl) aliskiren fumarate tabs 1 TEKTURNA HCT TABS TEKTURNA TABS ( GP aliskiren- 3 (aliskiren fumarate) hydrochlorothiazide) Selective Aldosterone Receptor Antagonists telmisartan-amlodipine 1 tabs eplerenone tabs 1 telmisartan- INSPRA TABS GP hydrochlorothiazide 1 (eplerenone) tabs Vasodilators TENORETIC 100 TABS (atenolol & GP hydralazine hcl tabs 1 chlorthalidone) minoxidil tabs 1 TENORETIC 50 TABS (atenolol & GP ANTIMALARIALS - Drugs to Treat Malaria chlorthalidone) (Parasitic Infections) trandolapril-verapamil 1 Antimalarial Combinations hcl tbcr atovaquone-proguanil 1 hcl tabs
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37 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COARTEM TABS Limit 24 per MESTINON TABS 60 MG (artemether- 2 month;QL(0.8 (pyridostigmine GP lumefantrine) ea daily) bromide) MALARONE TABS MESTINON TIMESPAN (atovaquone-proguanil GP TBCR (pyridostigmine GP hcl) bromide) PA Antimalarials pyridostigmine bromide 1 soln 60 mg/5ml chloroquine phosphate 1 tabs pyridostigmine bromide 1 DARAPRIM TABS PA tabs 60 mg 4 (pyrimethamine) pyridostigmine bromide 1 KRINTAFEL TABS QL(2 ea per 30 tbcr 180 mg 2 (tafenoquine succinate) days retail) RUZURGI TABS PA; QL(10 ea 3 QL(6 ea per fill (amifampridine) daily) mefloquine hcl tabs 1 retail,6 ea per ANTIMYCOBACTERIAL AGENTS - Drugs to fill mail) Treat Tuberculosis (Bacterial Infections) PLAQUENIL TABS (hydroxychloroquine 1 Anti TB Combinations RIFAMATE CAPS sulfate) 2 (isoniazid & rifampin) primaquine phosphate 1 tabs RIFATER TABS (isoniazid-rifampin w/ 3 PRIMAQUINE pyrazinamide) PHOSPHATE TABS GP (primaquine phosphate) Antimycobacterial Agents pyrimethamine tabs 1 PA cycloserine caps 1 QUALAQUIN CAPS PA; QL(2 ea GP ethambutol hcl tabs 1 (quinine sulfate) daily) isoniazid syrp 1 1 PA; QL(2 ea quinine sulfate caps daily) isoniazid tabs 1 ANTIMYASTHENIC/CHOLINERGIC AGENTS MYAMBUTOL TABS GP Antimyasthenic/Cholinergic Agents (ethambutol hcl) FIRDAPSE TABS PA MYCOBUTIN CAPS GP (amifampridine 3 (rifabutin) phosphate) PASER PACK GUANIDINE HCL TABS 3 2 (aminosalicylic acid) (guanidine hcl) PRIFTIN TABS 3 MESTINON SOLN 60 PA (rifapentine) MG/5ML (pyridostigmine GP bromide) pyrazinamide tabs 1 rifabutin caps 1
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Updated 07/01/2021 38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PURIXAN SUSP AL(Up to 13 yrs RIFADIN CAPS (rifampin) GP AC (mercaptopurine) old ) rifampin caps 1 TABLOID TABS AC ( ) SIRTURO TABS thioguanine 3 TREXALL TABS (bedaquiline fumarate) 3 ( ) TRECATOR TABS methotrexate sodium 2 XATMEP SOLN PA (ethionamide) AC (methotrexate) ANTINEOPLASTICS AND ADJUNCTIVE XELODA TABS THERAPIES - Drugs to Treat Cancer AC (capecitabine) Alkylating Agents Antineoplastic - Angiogenesis Inhibitors ALKERAN TABS AC (melphalan) INLYTA TABS (axitinib) AC PA cyclophosphamide AC LENVIMA 10 MG DAILY PA caps 25 mg, 50 mg DOSE CPPK (lenvatinib AC CYCLOPHOSPHAMIDE mesylate) TABS 25 MG, 50 MG AC LENVIMA 12MG DAILY PA (cyclophosphamide) DOSE CPPK (lenvatinib AC GLEOSTINE CAPS PA AC mesylate) (lomustine) LENVIMA 14 MG DAILY PA LEUKERAN TABS AC DOSE CPPK (lenvatinib AC (chlorambucil) mesylate) melphalan tabs AC LENVIMA 18 MG DAILY PA DOSE CPPK (lenvatinib AC MYLERAN TABS AC mesylate) (busulfan) LENVIMA 20 MG DAILY PA TEMODAR CAPS AC DOSE CPPK (lenvatinib AC (temozolomide) mesylate) temozolomide caps AC LENVIMA 24 MG DAILY PA DOSE CPPK (lenvatinib AC Antimetabolites mesylate) capecitabine tabs AC LENVIMA 4 MG DAILY PA DOSE CPPK (lenvatinib AC mercaptopurine tabs AC mesylate) methotrexate sodium LENVIMA 8 MG DAILY PA soln ij 1 gm/40ml, 250 3 DOSE CPPK (lenvatinib AC mg/10ml, 50 mg/2ml mesylate) methotrexate sodium 1 Antineoplastic - Anti-HER2 Agents tabs or 2.5 mg TUKYSA TABS PA AC ONUREG TABS PA (tucatinib) AC (azacitidine) Antineoplastic - BCL-2 Inhibitors
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39 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VENCLEXTA STARTING PA exemestane tabs AC PACK TBPK AC ( ) FARESTON TABS venetoclax AC VENCLEXTA TABS PA (toremifene citrate) AC ( ) FEMARA TABS venetoclax AC Antineoplastic - EGFR Inhibitors (letrozole) erlotinib hcl tabs AC PA flutamide caps AC GILOTRIF TABS ( PA letrozole tabs AC afatinib AC dimaleate) LEUPROLIDE PA IRESSA TABS (gefitinib) AC PA ACETATE/BUPIVACAINE HYDROCHLORIDE SOLN AC TAGRISSO TABS PA AC (leuprolide acetate- (osimertinib mesylate) bupivacaine hcl) TARCEVA TABS PA LYSODREN TABS AC AC (erlotinib hcl) (mitotane) VIZIMPRO TABS PA AC megestrol acetate susp AC (dacomitinib) Antineoplastic - Hedgehog Pathway Inhibitors megestrol acetate tabs AC DAURISMO TABS PA NILANDRON TABS AC AC (glasdegib maleate) (nilutamide) ERIVEDGE CAPS AC (vismodegib) nilutamide tabs AC ODOMZO CAPS PA NUBEQA TABS PA AC AC (sonidegib phosphate) (darolutamide) SOLTAMOX SOLN Antineoplastic - Hormonal and Related Agents AC PA (tamoxifen citrate) abiraterone acetate AC tabs tamoxifen citrate tabs PV PV anastrozole tabs AC toremifene citrate tabs AC ARIMIDEX TABS XTANDI CAPS PA AC AC (anastrozole) (enzalutamide) AROMASIN TABS XTANDI TABS PA AC AC (exemestane) (enzalutamide) bicalutamide tabs AC YONSA TABS PA AC CASODEX TABS (abiraterone acetate) AC ZYTIGA TABS PA (bicalutamide) AC EMCYT CAPS (abiraterone acetate) (estramustine AC Antineoplastic - Immunomodulators phosphate sodium) POMALYST CAPS PA AC ERLEADA TABS PA (pomalidomide) AC (apalutamide) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AFINITOR TABS 10 MG PA; QL(1 ea Antineoplastic - PDGFR-alpha Inhibitors AC AYVAKIT TABS PA; QL(1 ea (everolimus) daily) AC daily) AFINITOR TABS 2.5 MG, 5 PA; QL(1 ea (avapritinib) AC MG, 7.5 MG (everolimus) daily) Antineoplastic - XPO1 Inhibitors ALECENSA CAPS PA XPOVIO 100 MG ONCE PA AC WEEKLY TBPK AC (alectinib hcl) ALUNBRIG TABS PA (selinexor) AC XPOVIO 40 MG ONCE PA (brigatinib) WEEKLY TBPK ALUNBRIG TBPK PA AC AC (selinexor) (brigatinib) XPOVIO 40 MG TWICE PA BALVERSA TABS PA AC WEEKLY TBPK AC (erdafitinib) (selinexor) BOSULIF TABS PA AC XPOVIO 60 MG ONCE PA (bosutinib) WEEKLY TBPK AC BRAFTOVI CAPS PA AC (selinexor) (encorafenib) XPOVIO 60 MG TWICE PA BRUKINSA CAPS PA WEEKLY TBPK AC AC (zanubrutinib) (selinexor) CABOMETYX TABS PA XPOVIO 80 MG ONCE PA AC ( ) WEEKLY TBPK AC cabozantinib s-malate CALQUENCE CAPS PA (selinexor) AC XPOVIO 80 MG TWICE PA (acalabrutinib) CAPRELSA TABS WEEKLY TBPK AC AC (selinexor) (vandetanib) XPOVIO TBPK PA COMETRIQ KIT AC AC (selinexor) (cabozantinib s-malate) COPIKTRA CAPS PA Antineoplastic Combinations AC KISQALI FEMARA 200 PA (duvelisib) COTELLIC TABS PA DOSE TBPK (ribociclib AC AC succinate-letrozole) (cobimetinib fumarate) KISQALI FEMARA 400 PA everolimus tabs AC PA; QL(1 ea DOSE TBPK (ribociclib AC daily) FARYDAK CAPS PA succinate-letrozole) AC ( ) KISQALI FEMARA 600 PA panobinostat lactate FOTIVDA CAPS PA DOSE TBPK (ribociclib AC AC succinate-letrozole) (tivozanib hcl) LONSURF TABS PA GLEEVEC TABS (imatinib PA AC AC (trifluridine-tipiracil) mesylate) IBRANCE CAPS PA Antineoplastic Enzyme Inhibitors AC (palbociclib) AFINITOR DISPERZ TBSO PA AC IBRANCE TABS PA (everolimus) AC (palbociclib)
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41 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ICLUSIG TABS 10 MG, 15 PA PIQRAY 250MG DAILY PA AC MG, 30 MG, 45 MG AC DOSE TBPK (alpelisib) (ponatinib hcl) PIQRAY 300MG DAILY PA IDHIFA TABS PA AC AC DOSE TBPK (alpelisib) (enasidenib mesylate) QINLOCK TABS PA AC imatinib mesylate tabs AC PA (ripretinib) RETEVMO CAPS PA IMBRUVICA CAPS PA AC AC (selpercatinib) (ibrutinib) ROZLYTREK CAPS PA IMBRUVICA TABS PA AC AC (entrectinib) (ibrutinib) RUBRACA TABS PA INREBIC CAPS PA AC AC (rucaparib camsylate) (fedratinib hcl) RYDAPT CAPS PA JAKAFI TABS ( PA AC ruxolitinib AC (midostaurin) phosphate) SPRYCEL TABS PA KISQALI TBPK ( PA AC ribociclib AC (dasatinib) succinate) STIVARGA TABS PA; SP KOSELUGO CAPS PA AC 3 (regorafenib) (selumetinib sulfate) SUTENT CAPS ( PA sunitinib AC lapatinib ditosylate tabs AC PA malate) LORBRENA TABS PA TABRECTA TABS PA AC AC (lorlatinib) (capmatinib hcl) LUMAKRAS TABS PA TAFINLAR CAPS PA AC AC (sotorasib) (dabrafenib mesylate) LYNPARZA TABS PA TALZENNA CAPS PA AC AC (olaparib) (talazoparib tosylate) TASIGNA CAPS ( PA MEKINIST TABS PA nilotinib AC (trametinib dimethyl AC hcl) ) TAZVERIK TABS PA sulfoxide AC MEKTOVI TABS PA (tazemetostat hbr) AC ( ) TIBSOVO TABS PA binimetinib AC NERLYNX TABS PA (ivosidenib) AC ( ) TRUSELTIQ CPPK PA neratinib maleate AC NEXAVAR TABS PA (infigratinib phosphate) AC ( ) TURALIO CAPS PA sorafenib tosylate AC NINLARO CAPS PA (pexidartinib hcl) AC (ixazomib citrate) TYKERB TABS ( PA lapatinib AC PEMAZYRE TABS PA; QL(1 ea ditosylate) AC (pemigatinib) daily) VERZENIO TABS PA AC PIQRAY 200MG DAILY PA (abemaciclib) AC DOSE TBPK (alpelisib) VITRAKVI CAPS PA AC (larotrectinib sulfate) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITRAKVI SOLN PA AC leucovorin calcium tabs (larotrectinib sulfate) or 10 mg, 15 mg, 25 AC VOTRIENT TABS PA mg, 5 mg AC (pazopanib hcl) MESNEX TABS (mesna) AC XALKORI CAPS PA AC (crizotinib) Mitotic Inhibitors XOSPATA TABS PA AC etoposide caps AC (gilteritinib fumarate) ZEJULA CAPS (niraparib PA Topoisomerase I Inhibitors AC HYCAMTIN CAPS PA tosylate) AC ZELBORAF TABS PA (topotecan hcl) AC (vemurafenib) ANTIPARKINSON AND RELATED THERAPY ZOLINZA CAPS PA AGENTS - Drugs to Treat Parkinson's Disease AC (vorinostat) Antiparkinson Adjunctive Therapy ZYDELIG TABS PA AC carbidopa tabs 1 (idelalisib) ZYKADIA CAPS PA LODOSYN TABS AC GP (ceritinib) (carbidopa) ZYKADIA TABS PA Antiparkinson Anticholinergics AC (ceritinib) benztropine mesylate 1 Antineoplastics Misc. tabs ALFERON N SOLN PA 3 trihexyphenidyl hcl soln 1 (interferon alfa-n3) trihexyphenidyl hcl tabs 1 bexarotene caps AC PA HYDREA CAPS Antiparkinson COMT Inhibitors AC COMTAN TABS (hydroxyurea) GP (entacapone) hydroxyurea caps AC entacapone tabs 1 INTRON A SOLN PA 3 TASMAR TABS (interferon alfa-2b) GP INTRON A SOLR PA (tolcapone) 3 (interferon alfa-2b) tolcapone tabs 1 MATULANE CAPS AC (procarbazine hcl) Antiparkinson Dopaminergics TARGRETIN CAPS OR 75 PA amantadine hcl caps 1 AC MG (bexarotene) amantadine hcl syrp 1 tretinoin AC (chemotherapy) caps amantadine hcl tabs 1 Chemotherapy Rescue/Antidote/Protective Agents bromocriptine mesylate PA 1 leucovorin calcium soln AC caps ij 500 mg/50ml
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43 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REQUIP XL TB24 bromocriptine mesylate 1 tabs (ropinirole GP hydrochloride) carbidopa-levodopa 1 tabs ropinirole hydrochloride 1 tabs carbidopa-levodopa 1 tbcr ropinirole hydrochloride 1 carbidopa-levodopa tb24 1 RYTARY CPCR PA tbdp 3 carbidopa-levodopa- (carbidopa-levodopa) 1 SINEMET CR TBCR entacapone tabs GP ( ) DUOPA SUSP carbidopa-levodopa 3 SINEMET TABS (carbidopa-levodopa) GP ( ) GOCOVRI CP24 PA carbidopa-levodopa 3 (amantadine hcl) STALEVO 100 TABS ( MIRAPEX ER TB24 carbidopa-levodopa- GP ) (pramipexole GP entacapone dihydrochloride) STALEVO 125 TABS ( MIRAPEX TABS carbidopa-levodopa- GP ) (pramipexole GP entacapone dihydrochloride) STALEVO 150 TABS ( NEUPRO PT24 1 carbidopa-levodopa- GP MG/24HR, 3 MG/24HR, 8 3 entacapone) MG/24HR (rotigotine) STALEVO 200 TABS NEUPRO PT24 2 QL(3 ea daily) (carbidopa-levodopa- GP 3 MG/24HR (rotigotine) entacapone) NEUPRO PT24 4 QL(1 ea daily) STALEVO 50 TABS MG/24HR, 6 MG/24HR 3 (carbidopa-levodopa- GP (rotigotine) entacapone) OSMOLEX ER T4PK PA STALEVO 75 TABS 3 (amantadine hcl) (carbidopa-levodopa- GP PARLODEL CAPS entacapone) (bromocriptine GP Antiparkinson Monoamine Oxidase Inhibitors mesylate) AZILECT TABS GP PARLODEL TABS (rasagiline mesylate) (bromocriptine GP rasagiline mesylate 1 mesylate) tabs pramipexole 1 dihydrochloride tabs selegiline hcl caps 1 pramipexole 1 selegiline hcl tabs 1 dihydrochloride tb24 ZELAPAR TBDP 3 (selegiline hcl)
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Updated 07/01/2021 44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIPSYCHOTICS/ANTIMANIC AGENTS - paliperidone tb24 1 Drugs to Treat Mood Disorders PERSERIS PRSY PA 3 Antimanic Agents (risperidone) lithium carbonate caps 1 RISPERDAL SOLN GP (risperidone) 1 lithium carbonate tabs RISPERDAL TABS GP lithium carbonate tbcr 1 (risperidone) risperidone soln 1 LITHIUM SOLN (lithium) 2 LITHOBID TBCR ( risperidone tabs 1 lithium GP carbonate) risperidone tbdp 1 Antipsychotics - Misc. CAPLYTA CAPS PA; QL(1 ea Butyrophenones 3 (lumateperone tosylate) daily) haloperidol lactate conc 1 EQUETRO CP12 (carbamazepine 3 haloperidol tabs 1 (antipsychotic)) Dibenzapines GEODON CAPS PA GP asenapine maleate 1 (ziprasidone hcl) subl LATUDA TABS PA 3 (lurasidone hcl) clozapine tabs 1 NUPLAZID CAPS PA; QL(1 ea 3 clozapine tbdp 1 (pimavanserin tartrate) daily) NUPLAZID TABS PA; QL(1 ea CLOZARIL TABS 3 GP (pimavanserin tartrate) daily) (clozapine) VRAYLAR CAPS PA FAZACLO TBDP 3 GP (cariprazine hcl) (clozapine) VRAYLAR CPPK PA loxapine succinate 3 1 (cariprazine hcl) caps ziprasidone hcl caps 1 olanzapine tabs 1 Benzisoxazoles olanzapine tbdp 1 FANAPT TABS PA 3 quetiapine fumarate (iloperidone) tabs 100 mg, 200 mg, 1 INVEGA SUSTENNA PA 25 mg, 300 mg, 400 SUSY (paliperidone 3 mg, 50 mg palmitate) quetiapine fumarate PA INVEGA TB24 GP tb24 150 mg, 200 mg, 1 (paliperidone) 300 mg, 400 mg, 50 mg INVEGA TRINZA SUSY PA 3 (paliperidone palmitate)
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45 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAPHRIS SUBL 10 MG, PA aripiprazole soln 1 1 2.5 MG, 5 MG (asenapine GP mg/ml maleate) aripiprazole tabs 10 SAPHRIS SUBL 5 MG PA 3 mg, 15 mg, 2 mg, 20 1 (asenapine maleate) mg, 30 mg, 5 mg SECUADO PT24 PA; QL(1 ea PA 3 aripiprazole tbdp 10 1 (asenapine) daily) mg, 15 mg SEROQUEL TABS REXULTI TABS PA GP 3 (quetiapine fumarate) (brexpiprazole) SEROQUEL XR TB24 PA GP Thioxanthenes (quetiapine fumarate) VERSACLOZ SUSP QL(18 ml daily) thiothixene caps 1 3 (clozapine) ZYPREXA TABS ANTISEPTICS & DISINFECTANTS GP (olanzapine) Antiseptics & Disinfectants ZYPREXA ZYDIS TBDP GP formaldehyde soln 1 (olanzapine) Dihydroindolones ANTIVIRALS - Drugs to Treat Viral Infections molindone hcl tabs 1 Antiretrovirals Phenothiazines abacavir sulfate soln 1 (Prochlorperazine) 1 COMPRO SUPP abacavir sulfate tabs 1 chlorpromazine hcl 1 abacavir sulfate- 1 tabs lamivudine tabs fluphenazine hcl conc 5 1 abacavir sulfate- mg/ml lamivudine-zidovudine 1 tabs fluphenazine hcl elix 1 2.5 mg/5ml APTIVUS CAPS 2 (tipranavir) perphenazine tabs 1 APTIVUS SOLN 2 prochlorperazine 1 (tipranavir) maleate tabs atazanavir sulfate caps 1 prochlorperazine supp 1 ATRIPLA TABS thioridazine hcl tabs 1 (efavirenz- emtricitabine-tenofovir GP trifluoperazine hcl tabs 1 disoproxil fumarate) BIKTARVY TABS Quinolinone Derivatives (bictegravir- ABILIFY TABS 2 GP emtricitabine-tenofovir (aripiprazole) alafenamide fumarate)
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Updated 07/01/2021 46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMBIVIR TABS EPZICOM TABS GP (lamivudine-zidovudine) (abacavir sulfate- GP COMPLERA TABS ST lamivudine) (emtricitabine- EVOTAZ TABS 2 rilpivirine-tenofovir (atazanavir sulfate- 2 disoproxil fumarate) cobicistat) CRIXIVAN CAPS 2 fosamprenavir calcium 1 (indinavir sulfate) tabs DELSTRIGO TABS ST FUZEON SOLR PA (doravirine-lamivudine- 3 3 (enfuvirtide) tenofovir disoproxil GENVOYA TABS fumarate) (elvitegravir-cobicistat- DESCOVY TABS PA emtricitabine-tenofovir 2 (emtricitabine-tenofovir 2 alafenamide) alafenamide fumarate) INTELENCE TABS 2 didanosine cpdr 1 (etravirine) INVIRASE TABS DOVATO TABS 2 (saquinavir mesylate) (dolutegravir sodium- 2 ISENTRESS CHEW 100 PA lamivudine) MG (raltegravir 2 EDURANT TABS 2 potassium) (rilpivirine hcl) ISENTRESS CHEW 25 MG 2 efavirenz caps 1 (raltegravir potassium) ISENTRESS HD TABS 1 2 efavirenz tabs (raltegravir potassium) efavirenz-emtricitabine- ISENTRESS PACK 100 tenofovir disoproxil 1 MG (raltegravir 2 fumarate tabs potassium) emtricitabine caps 1 ISENTRESS TABS 400 MG (raltegravir 2 emtricitabine-tenofovir potassium) disoproxil fumarate 1 JULUCA TABS tabs (dolutegravir sodium- 2 EMTRIVA CAPS 200 MG GP rilpivirine hcl) (emtricitabine) KALETRA SOLN EMTRIVA SOLN 10 GP 2 (lopinavir-ritonavir) MG/ML (emtricitabine) KALETRA TABS EPIVIR SOLN GP GP (lopinavir-ritonavir) (lamivudine) lamivudine soln 1 EPIVIR TABS GP (lamivudine) lamivudine tabs 1
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47 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SELZENTRY SOLN lamivudine-zidovudine 1 2 tabs (maraviroc) SELZENTRY TABS LEXIVA SUSP 50 MG/ML 2 (fosamprenavir 2 (maraviroc) calcium) stavudine caps 15 mg, 1 LEXIVA TABS 700 MG 20 mg, 30 mg, 40 mg (fosamprenavir GP STAVUDINE CAPS 15 MG, calcium) 20 MG, 30 MG, 40 MG 2 (stavudine) lopinavir-ritonavir soln 1 STRIBILD TABS nevirapine susp 1 (elvitegravir-cobicistat- emtricitabine-tenofovir 2 nevirapine tabs 1 df) SUSTIVA CAPS GP nevirapine tb24 1 (efavirenz) NORVIR SOLN 80 MG/ML SUSTIVA TABS 2 GP (ritonavir) (efavirenz) NORVIR TABS 100 MG SYMTUZA TABS ST GP (ritonavir) (darunavir-cobicistat- 3 PIFELTRO TABS emtricitabine-tenofovir 2 (doravirine) alafenamide) PREZCOBIX TABS 2 tenofovir disoproxil 1 (darunavir-cobicistat) fumarate tabs PREZISTA SUSP TIVICAY TABS 50 MG 2 2 (darunavir ethanolate) (dolutegravir sodium) PREZISTA TABS TRIUMEQ TABS 2 (darunavir ethanolate) (abacavir-dolutegravir- 2 RESCRIPTOR TABS lamivudine) 2 (delavirdine mesylate) TRIZIVIR TABS (abacavir RETROVIR CAPS sulfate-lamivudine- GP GP (zidovudine) zidovudine) RETROVIR SYRP TRUVADA TABS GP (zidovudine) (emtricitabine-tenofovir GP REYATAZ CAPS 150 MG, disoproxil fumarate) 200 MG, 300 MG GP TYBOST TABS 2 (atazanavir sulfate) (cobicistat) REYATAZ PACK 50 MG VIDEX EC CPDR 125 MG 2 2 (atazanavir sulfate) (didanosine) ritonavir tabs 1 VIDEX EC CPDR 200 MG, 250 MG, 400 MG GP RUKOBIA TB12 PA (didanosine) (fostemsavir 3 tromethamine) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDEXPEDIATRIC SOLR 2 valganciclovir hcl tabs 1 (didanosine) 450 mg VIRACEPT TABS 2 Hepatitis Agents (nelfinavir mesylate) (Ribavirin (Hepatitis C)) PA VIRAMUNE SUSP 1 GP RIBASPHERE CAPS (nevirapine) (Ribavirin (Hepatitis C)) PA VIRAMUNE TABS RIBASPHERE RIBAPAK 1 GP (nevirapine) TBPK 400 MG, 600 MG VIRAMUNE XR TB24 (Ribavirin (Hepatitis C)) PA GP 1 (nevirapine) RIBASPHERE TABS VIREAD POWD 40 MG/GM adefovir dipivoxil tabs 1 (tenofovir disoproxil 2 BARACLUDE SOLN 0.05 2 fumarate) MG/ML (entecavir) VIREAD TABS 150 MG, BARACLUDE TABS 0.5 200 MG, 250 MG GP MG, 1 MG (entecavir) (tenofovir disoproxil 2 fumarate) DAKLINZA TABS PA (daclatasvir 3 VIREAD TABS 300 MG dihydrochloride) (tenofovir disoproxil GP fumarate) entecavir tabs 1 ZIAGEN SOLN ( abacavir GP EPCLUSA TABS 100 MG- PA sulfate) 400 MG (sofosbuvir- 3 ZIAGEN TABS ( velpatasvir) abacavir GP sulfate) EPIVIR HBV SOLN 5 zidovudine caps 1 MG/ML (lamivudine 3 (hbv)) 1 EPIVIR HBV TABS 100 zidovudine syrp GP MG (lamivudine (hbv)) zidovudine tabs 1 HEPSERA TABS GP CMV Agents (adefovir dipivoxil) PREVYMIS TABS PA; SP 1 3 lamivudine (hbv) tabs (letermovir) MAVYRET TABS PA VALCYTE SOLR 50 Limit 630mls (glecaprevir- 3 MG/ML ( GP per valganciclovir month;QL(21 pibrentasvir) hcl) ml daily) PEGASYS PROCLICK PA VALCYTE TABS 450 MG SOLN (peginterferon 3 GP (valganciclovir hcl) alfa-2a) PEGASYS SOLN PA Limit 630mls 3 ( ) valganciclovir hcl solr 1 per peginterferon alfa-2a 50 mg/ml month;QL(21 PEGINTRON KIT PA 3 ml daily) (peginterferon alfa-2b)
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49 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REBETOL SOLN PA QL(10 ea per 2 oseltamivir phosphate 1 (ribavirin (hepatitis c)) caps or 30 mg, 45 mg fill retail) RIBASPHERE RIBAPAK PA oseltamivir phosphate 1 TBPK (ribavirin 3 caps or 75 mg (hepatitis c)) QL(75 ml PA oseltamivir phosphate daily,5 day(s) ribavirin (hepatitis c) 1 1 caps susr or 6 mg/ml limit); AL(At least 1 yrs old) ribavirin (hepatitis c) PA 1 RELENZA DISKHALER Limit 20 per tabs 3 month;QL(0.67 SOVALDI TABS 200 MG, PA AEPB (zanamivir) 3 ea daily) 400 MG (sofosbuvir) rimantadine 1 VEMLIDY TABS PA hydrochloride tabs (tenofovir alafenamide 3 TAMIFLU CAPS 30 MG, 45 QL(10 ea per fumarate) MG (oseltamivir GP fill retail) VOSEVI TABS PA phosphate) (sofosbuvir-velpatasvir- 3 TAMIFLU CAPS 75 MG GP voxilaprevir) (oseltamivir phosphate) Herpes Agents QL(75 ml TAMIFLU SUSR 6 MG/ML daily,5 day(s) 1 GP acyclovir caps (oseltamivir phosphate) limit); AL(At least 1 yrs old) acyclovir susp 1 Respiratory Syncytial Virus (RSV) Agents acyclovir tabs 1 ribavirin solr 1 famciclovir tabs 1 VIRAZOLE SOLR GP SITAVIG TABS PA (ribavirin) 3 (acyclovir) BETA BLOCKERS - Drugs to Treat High Blood Pressure valacyclovir hcl tabs 1 Alpha-Beta Blockers VALTREX TABS GP carvedilol phosphate 1 (valacyclovir hcl) cp24 ZOVIRAX CAPS OR 200 GP carvedilol tabs 12.5 mg, MG (acyclovir) 1 25 mg, 6.25 mg ZOVIRAX SUSP OR 200 GP QL(2 ea daily) MG/5ML (acyclovir) carvedilol tabs 3.125 1 mg ZOVIRAX TABS OR 400 GP COREG CR CP24 MG, 800 MG (acyclovir) GP (carvedilol phosphate) Influenza Agents COREG TABS 12.5 MG, FLUMADINE TABS 25 MG, 6.25 MG GP (rimantadine GP (carvedilol) hydrochloride) COREG TABS 3.125 MG QL(2 ea daily) GP (carvedilol)
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Updated 07/01/2021 50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits labetalol hcl tabs 1 INNOPRAN XL CP24 (propranolol hcl 3 Beta Blockers Cardio-Selective sustained-release acebutolol hcl caps 1 beads) nadolol tabs 1 atenolol tabs 1 pindolol tabs 1 betaxolol hcl tabs 1 QL(1 ea daily) propranolol hcl cp24 1 bisoprolol fumarate 1 tabs propranolol hcl soln 1 BYSTOLIC TABS 3 (nebivolol hcl) propranolol hcl tabs 1 LOPRESSOR TABS GP (metoprolol tartrate) sotalol hcl (afib/afl) tabs 1 metoprolol succinate 1 sotalol hcl tabs 1 tb24 SOTYLIZE SOLN ( sotalol 3 metoprolol tartrate tabs 1 hcl) TENORMIN TABS timolol maleate tabs 10 QL(2 ea daily) GP 1 (atenolol) mg, 20 mg, 5 mg TOPROL XL TB24 GP CALCIUM CHANNEL BLOCKERS - Drugs to (metoprolol succinate) Treat High Blood Pressure Beta Blockers Non-Selective Calcium Channel Blockers (Sotalol Hcl) SORINE 1 (Diltiazem Hcl Coated 1 TABS Beads) CARTIA XT CP24 BETAPACE AF TABS GP (Diltiazem Hcl Coated 1 (sotalol hcl (afib/afl)) Beads) MATZIM LA TB24 BETAPACE TABS ( (Diltiazem Hcl Extended sotalol GP hcl) Release Beads) TAZTIA 1 XT, TIADYLT ER CP24 CORGARD TABS GP (Diltiazem Hcl) DILT-XR 1 (nadolol) CP24 HEMANGEOL SOLN AL(Up to 1 yrs ADALAT CC TB24 30 MG, 3 old ) GP (propranolol hcl) 60 MG (nifedipine) INDERAL LA CP24 ADALAT CC TB24 90 MG QL(1 ea daily) GP GP (propranolol hcl) (nifedipine) INDERAL XL CP24 QL(2 ea daily) amlodipine besylate 1 (propranolol hcl tabs sustained-release 3 CALAN SR TBCR beads) GP (verapamil hcl) CALAN TABS ( verapamil GP hcl)
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51 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARDIZEM CD CP24 NYMALIZE SOLN 30 (diltiazem hcl coated GP MG/10ML, 60 MG/20ML 3 beads) (nimodipine) PROCARDIA CAPS CARDIZEM LA TB24 120 GP MG (diltiazem hcl 2 (nifedipine) coated beads) PROCARDIA XL TB24 QL(1 ea daily) GP CARDIZEM LA TB24 180 (nifedipine) MG, 240 MG, 300 MG, 360 SULAR TB24 GP GP MG, 420 MG (diltiazem (nisoldipine) hcl coated beads) TIAZAC CP24 (diltiazem CARDIZEM TABS GP hcl extended release GP (diltiazem hcl) beads) diltiazem hcl coated 1 beads cp24 verapamil hcl cp24 1 1 diltiazem hcl coated 1 verapamil hcl tabs beads tb24 verapamil hcl tbcr 1 diltiazem hcl cp12 120 1 mg, 60 mg, 90 mg VERELAN CP24 GP (verapamil hcl) diltiazem hcl cp24 180 1 VERELAN PM CP24 mg, 240 mg 3 (verapamil hcl) diltiazem hcl extended 1 release beads cp24 CARDIOTONICS - Drugs to Treat Heart Failure diltiazem hcl tabs 120 and Abnormal Heart Rhythm mg, 30 mg, 60 mg, 90 1 Cardiac Glycosides mg (Digoxin) DIGITEK, DIGOX 1 TABS felodipine tb24 1 digoxin soln 1 isradipine caps 1 digoxin tabs 1 nicardipine hcl caps 1 LANOXIN TABS 125 MCG, GP 250 MCG (digoxin) nifedipine caps 10 mg, 1 20 mg LANOXIN TABS 62.5 MCG 3 (digoxin) nifedipine tb24 30 mg, 1 60 mg CARDIOVASCULAR AGENTS - MISC. - Drugs to QL(1 ea daily) Treat Heart and Circulation Conditions nifedipine tb24 30 mg, 1 60 mg, 90 mg Cardiovascular Agents Misc. - Combinations nimodipine caps 1 amlodipine besylate- atorvastatin calcium 1 nisoldipine tb24 1 tabs NORVASC TABS QL(2 ea daily) GP (amlodipine besylate)
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Updated 07/01/2021 52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LETAIRIS TABS PA BIDIL TABS (isosorbide GP dinitrate-hydralazine 3 (ambrisentan) hcl) OPSUMIT TABS PA 3 CADUET TABS (macitentan) (amlodipine besylate- GP TRACLEER TABS 125 PA GP atorvastatin calcium) MG, 62.5 MG (bosentan) ENTRESTO TABS PA TRACLEER TBSO 32 MG PA; SP 3 3 (sacubitril-valsartan) (bosentan) Impotence Agents Pulmonary Hypertension - Phosphodiesterase CIALIS TABS 10 MG, 20 PA; Limit 8 per (Tadalafil (Pulmonary PA GP month;QL(0.27 Hypertension)) ALYQ 3 MG (tadalafil) ea daily) TABS CIALIS TABS 2.5 MG, 5 PA; QL(1 ea PA GP ADCIRCA TABS (tadalafil MG (tadalafil) daily) (pulmonary GP PA; Limit 8 per hypertension)) sildenafil citrate tabs 1 100 mg, 25 mg, 50 mg month;QL(0.27 REVATIO SUSR PA ea daily) (sildenafil citrate GP STAXYN TBDP PA; Limit 8 per (pulmonary GP month;QL(0.27 (vardenafil hcl) ea daily) hypertension)) PA; Limit 8 per REVATIO TABS PA tadalafil tabs 10 mg, 20 (sildenafil citrate 1 month;QL(0.27 GP mg ea daily) (pulmonary PA; QL(1 ea hypertension)) tadalafil tabs 2.5 mg, 5 1 mg daily) sildenafil citrate PA PA; Limit 8 per (pulmonary 3 vardenafil hcl tbdp 1 month;QL(0.27 hypertension) susr 10 ea daily) mg/ml VIAGRA TABS (sildenafil PA; Limit 8 per SILDENAFIL CITRATE PA GP month;QL(0.27 citrate) TABS 20 MG (sildenafil ea daily) citrate (pulmonary 2 Peripheral Vasodilators hypertension)) PA isoxsuprine hcl tabs 1 tadalafil (pulmonary 3 hypertension) tabs Prostaglandin Vasodilators Pulmonary Hypertension - Prostacyclin Receptor ORENITRAM TBCR PA 3 UPTRAVI TABS PA (treprostinil diolamine) 3 (selexipag) VENTAVIS SOLN PA 3 UPTRAVI TBPK PA (iloprost) 3 (selexipag) Pulmonary Hypertension - Endothelin Receptor Pulmonary Hypertension - Sol Guanylate Cyclase PA ambrisentan tabs 3 ADEMPAS TABS PA 3 (riociguat) bosentan tabs 3 PA Sinus Node Inhibitors You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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53 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORLANOR SOLN 5 ST; QL(15 ml 3 cefditoren pivoxil tabs 1 MG/5ML (ivabradine hcl) daily) CORLANOR TABS 5 MG, ST cefixime caps 1 3 7.5 MG (ivabradine hcl) cefixime susr 1 Transthyretin Stabilizers VYNDAMAX CAPS PA; QL(1 ea cefpodoxime proxetil 3 1 (tafamidis) daily) susr VYNDAQEL CAPS PA; QL(4 ea cefpodoxime proxetil 1 (tafamidis meglumine 3 daily) tabs (cardiac)) SUPRAX CAPS 400 MG GP CEPHALOSPORINS - Drugs to Treat Bacterial (cefixime) Infections SUPRAX CHEW 100 MG, 3 Cephalosporins - 1st Generation 200 MG (cefixime) SUPRAX SUSR 100 cefadroxil caps 1 MG/5ML, 200 MG/5ML GP (cefixime) cefadroxil susr 1 SUPRAX SUSR 500 3 cefadroxil tabs 1 MG/5ML (cefixime) CONTRACEPTIVES - Drugs to Prevent cephalexin caps 1 Pregnancy cephalexin susr 1 Combination Contraceptives - Oral (Desogestrel & Ethinyl PV cephalexin tabs 1 Estradiol) APRI, CYRED, CYRED EQ, KEFLEX CAPS GP EMOQUETTE, ENSKYCE, PV (cephalexin) ISIBLOOM, JULEBER, Cephalosporins - 2nd Generation KALLIGA, RECLIPSEN TABS cefaclor caps 1 (Desogestrel-Ethinyl PV Estradiol (Biphasic)) CEFACLOR ER TB12 3 AZURETTE, BEKYREE, PV (cefaclor monohydrate) KARIVA, PIMTREA, cefaclor susr 1 SIMLIYA, VIORELE, VOLNEA TABS cefprozil susr 1 (Desogestrel-Ethinyl PV Estradiol (Triphasic)) PV cefprozil tabs 1 CAZIANT, VELIVET TABS (Drospirenone-Ethinyl PV cefuroxime axetil tabs 1 Estradiol) GIANVI, JASMIEL, LO- Cephalosporins - 3rd Generation ZUMANDIMINE, LORYNA, PV NIKKI, OCELLA, SYEDA, cefdinir caps 1 VESTURA, ZARAH, ZUMANDIMINE TABS cefdinir susr 1
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Updated 07/01/2021 54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Drospirenone-Ethinyl PV (Norethin Acet & Estrad- PV Estradiol-Levomefolate PV Fe) AUROVELA 24 FE, Calcium) TYDEMY TABS AUROVELA FE 1.5/30, (Ethynodiol Diacet & Eth PV AUROVELA FE 1/20, BLISOVI 24 FE, BLISOVI Estrad) KELNOR 1/35, PV KELNOR 1/50, ZOVIA FE 1.5/30, BLISOVI FE 1/35, ZOVIA 1/35E TABS 1/20, HAILEY 24 FE, HAILEY FE 1.5/30, HAILEY (Levonorgestrel & Eth PV FE 1/20, JUNEL FE 1.5/30, Estradiol) AFIRMELLE, JUNEL FE 1/20, JUNEL FE PV ALTAVERA, AUBRA, 24, LARIN 24 FE, LARIN AUBRA EQ, AVIANE, FE 1.5/30, LARIN FE 1/20, AYUNA, CHATEAL, LOESTRIN FE 1.5/30, CHATEAL EQ, DELYLA, LOESTRIN FE 1/20, FALMINA, KURVELO, PV MICROGESTIN 24 FE, LARISSIA, LESSINA, MICROGESTIN FE 1.5/30, LEVORA 0.15/30-28, MICROGESTIN FE 1/20, LILLOW, LUTERA, TARINA 24 FE, TARINA MARLISSA, ORSYTHIA, FE 1/20, TARINA FE 1/20 PORTIA-28, SRONYX, EQ TABS VIENVA TABS (Norethin Acet & Estrad- PV (Levonorgestrel-Eth PV Fe) CHARLOTTE 24 FE, PV Estradiol (Triphasic)) MELODETTA 24 FE, ENPRESSE-28, PV MIBELAS 24 FE CHEW LEVONEST, TRIVORA-28 TABS (Norethin Acet & Estrad- PA; QL(1 ea Fe) GEMMILY, MERZEE PV daily); PV (Levonorgestrel-Ethinyl PV CAPS Estradiol (91-Day)) AMETHIA, AMETHIA LO, (Norethindrone & Eth PV ASHLYNA, CAMRESE, Estradiol) ALYACEN 1/35, BALZIVA, BRIELLYN, CAMRESE LO, DAYSEE, PV FAYOSIM, ICLEVIA, CYCLAFEM 1/35, INTROVALE, JAIMIESS, DASETTA 1/35, NECON PV JOLESSA, LOJAIMIESS, 0.5/35-28, NORTREL RIVELSA, SETLAKIN, 0.5/35 (28), NORTREL SIMPESSE TABS 1/35, PHILITH, PIRMELLA 1/35, VYFEMLA, WERA (Levonorgestrel-Ethinyl PV TABS Estradiol (Continuous)) PV AMETHYST, DOLISHALE (Norethindrone & Ethinyl PV TABS Estradiol-Fe) KAITLIB FE, PV LAYOLIS FE, WYMZYA FE CHEW
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55 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethindrone Acet & Eth PV BEYAZ TABS PV Estra) AUROVELA 1.5/30, (drospirenone-ethinyl AUROVELA 1/20, HAILEY estradiol-levomefolate GP 1.5/30, JUNEL 1.5/30, ) JUNEL 1/20, LARIN 1.5/30, calcium PV PV LARIN 1/20, LOESTRIN desogestrel & ethinyl PV 1.5/30-21, LOESTRIN estradiol tabs 1/20-21, MICROGESTIN PV 1.5/30, MICROGESTIN desogestrel-ethinyl PV 1/20 TABS estradiol (biphasic) tabs PV (Norethindrone Acetate- PV drospirenone-ethinyl PV Ethinyl Estradiol-Fe) TILIA PV estradiol tabs FE, TRI-LEGEST FE TABS drospirenone-ethinyl PV (Norethindrone-Eth PV estradiol-levomefolate PV Estradiol (Triphasic)) ALYACEN 7/7/7, calcium tabs ESTROSTEP FE TABS PV ARANELLE, CYCLAFEM PV 7/7/7, DASETTA 7/7/7, (norethindrone acetate- GP LEENA, NORTREL 7/7/7, ethinyl estradiol-fe) NYLIA 7/7/7, PIRMELLA PV 7/7/7 TABS ethynodiol diacet & eth PV (Norgestimate-Ethinyl PV estrad tabs Estradiol (Triphasic)) TRI FALESSA KIT PA; PV FEMYNOR, TRI- (levonorgestrel-ethinyl PV ESTARYLLA, TRI-LINYAH, estradiol & folic acid) TRI-LO-ESTARYLLA, TRI- GENERESS FE CHEW PV LO-MARZIA, TRI-LO-MILI, PV TRI-LO-SPRINTEC, TRI- (norethindrone & GP MILI, TRI-NYMYO, TRI- ethinyl estradiol-fe) PREVIFEM, TRI- PV levonorgestrel & eth PV SPRINTEC, TRI-VYLIBRA, estradiol tabs TRI-VYLIBRA LO TABS PV (Norgestimate-Ethinyl PV levonorgestrel-eth Estradiol) ESTARYLLA, estradiol (triphasic) PV tabs FEMYNOR, MILI, MONO- PV LINYAH, NYMYO, PV levonorgestrel-ethinyl PV PREVIFEM, SPRINTEC estradiol (91-day) tabs 28, VYLIBRA TABS PV (Norgestrel & Ethinyl PV levonorgestrel-ethinyl Estradiol) CRYSELLE-28, estradiol (continuous) PV ELINEST, LOW- PV tabs OGESTREL, OGESTREL LO LOESTRIN FE TABS PV TABS (norethindrone acetate- BALCOLTRA TABS QL(1 ea daily); ethinyl estradiol-fe fum PV (levonorgestrel-ethinyl PV PV (biphasic)) estradiol-ferrous LOSEASONIQUE TABS PV bisglycinate) (levonorgestrel-ethinyl GP estradiol (91-day))
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Updated 07/01/2021 56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MINASTRIN 24 FE CHEW PV QUARTETTE TABS PV (norethin acet & estrad- GP (levonorgestrel-ethinyl GP fe) estradiol (91-day)) MIRCETTE TABS PV SAFYRAL TABS PV (desogestrel-ethinyl GP (drospirenone-ethinyl GP estradiol (biphasic)) estradiol-levomefolate NATAZIA TABS PV calcium) (estradiol valerate- PV SEASONIQUE TABS PV dienogest) (levonorgestrel-ethinyl GP NEXTSTELLIS TABS PV estradiol (91-day)) PV (drospirenone-estetrol) TAYTULLA CAPS PA; QL(1 ea norethin acet & estrad- PA; QL(1 ea (norethin acet & estrad- GP daily); PV fe caps 1 mg-20 mcg- PV daily); PV fe) 75 mg TYBLUME CHEW PV norethin acet & estrad- PV (levonorgestrel & eth PV fe chew 1 mg-20 mcg- PV estradiol) 75 mg YASMIN 28 TABS PV norethin acet & estrad- PV (drospirenone-ethinyl GP estradiol) fe tabs 1 mg-20 mcg- PV 75 mg, 1.5 mg-30 mcg- YAZ TABS PV 75 mg (drospirenone-ethinyl GP ) PV estradiol norethindrone & ethinyl PV estradiol-fe chew Combination Contraceptives - Transdermal PV (Norelgestromin-Ethinyl PV norethindrone acet & PV PV eth estra tabs Estradiol) XULANE PTWK TWIRLA PTWK QL(3 ea per 28 PV norgestimate-ethinyl (levonorgestrel-ethinyl PV days retail); PV estradiol (triphasic) PV estradiol) tabs PV Combination Contraceptives - Vaginal norgestimate-ethinyl PV (Etonogestrel-Ethinyl PV Limit 1 per estradiol tabs Estradiol) ELURYNG RING year;PV ORTHO TRI-CYCLEN LO PV ANNOVERA RING PV TABS (norgestimate- GP (segesterone acetate- PV ethinyl estradiol ethinyl estradiol) (triphasic)) Limit 1 per etonogestrel-ethinyl PV ORTHO-NOVUM 1/35 PV estradiol ring year;PV TABS (norethindrone & GP eth estradiol) NUVARING RING Limit 1 per (etonogestrel-ethinyl GP year;PV ORTHO-NOVUM 7/7/7 PV estradiol) TABS (norethindrone- GP eth estradiol (triphasic)) Copper Contraceptives - IUD
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57 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PARAGARD PV DEPO-SUBQ PROVERA PV INTRAUTERINE COPPER 104 SUSY PV CONTRACEPTIVE T380A (medroxyprogesterone PV IUD (copper (iud)) acetate (contraceptive)) Emergency Contraceptives medroxyprogesterone PV (Levonorgestrel PV acetate (contraceptive) PV (Emergency Oc)) AFTERA, susp ECONTRA EZ, ECONTRA PV ONE-STEP, MY CHOICE, medroxyprogesterone MY WAY, NEW DAY, PV acetate (contraceptive) PV OPCICON ONE-STEP, susy OPTION 2, PREVENTEZA, Progestin Contraceptives - Oral REACT, TAKE ACTION TABS (Norethindrone PV (Contraceptive)) CAMILA, ELLA TABS ( PV ulipristal PV DEBLITANE, ERRIN, acetate) HEATHER, INCASSIA, levonorgestrel PV JENCYCLA, JOLIVETTE, PV PV LYLEQ, LYZA, NORA-BE, (emergency oc) tabs NORLYDA, NORLYROC, PLAN B ONE-STEP TABS PV SHAROBEL, TULANA (levonorgestrel GP TABS (emergency oc)) PV norethindrone PV Progestin Contraceptives - IUD (contraceptive) tabs KYLEENA IUD PV ORTHO MICRONOR PV PV (levonorgestrel (iud)) TABS (norethindrone GP LILETTA IUD PV (contraceptive)) PV (levonorgestrel (iud)) SLYND TABS PV PV MIRENA IUD PV (drospirenone) PV (levonorgestrel (iud)) CORTICOSTEROIDS - Steroid Hormone Drugs to SKYLA IUD PV Treat Systemic Swelling Conditions PV (levonorgestrel (iud)) Glucocorticosteroids Progestin Contraceptives - Implants (Dexamethasone) 1 NEXPLANON IMPL PV DECADRON ELIX PV (etonogestrel) (Dexamethasone) 1 DECADRON TABS Progestin Contraceptives - Injectable (Dexamethasone) DEXPAK DEPO-PROVERA PV 10 DAY, DEXPAK 13 DAY, CONTRACEPTIVE SUSP GP DEXPAK 6 DAY, HIDEX 6- 1 (medroxyprogesterone DAY, TAPERDEX 6-DAY acetate (contraceptive)) TBPK DEPO-PROVERA PV budesonide cpep 3 mg 1 CONTRACEPTIVE SUSY GP (medroxyprogesterone budesonide tb24 9 mg 1 PA acetate (contraceptive)) CORTEF TABS GP (hydrocortisone) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cortisone acetate tabs 1 prednisolone sodium phosphate tbdp or 10 1 dexamethasone elix 1 mg, 15 mg, 30 mg DEXAMETHASONE prednisolone soln 1 INTENSOL CONC 2 PREDNISONE INTENSOL (dexamethasone) 2 CONC (prednisone) dexamethasone soln 1 prednisone soln 5 1 mg/5ml dexamethasone tabs 1 prednisone tabs 1 mg, dexamethasone tbpk 1 10 mg, 2.5 mg, 20 mg, 1 ENTOCORT EC CPEP 5 mg, 50 mg GP (budesonide) prednisone tbpk 10 mg, 1 5 mg 1 hydrocortisone tabs RAYOS TBEC PA 3 MEDROL DOSEPAK TBPK (prednisone) GP (methylprednisolone) UCERIS TB24 OR 9 MG PA GP MEDROL TABS 16 MG, 32 (budesonide) MG, 4 MG, 8 MG GP VERIPRED 20 SOLN (methylprednisolone) (prednisolone sodium GP MEDROL TABS 2 MG 2 phosphate) (methylprednisolone) Mineralocorticoids methylprednisolone 1 fludrocortisone acetate 1 tabs tabs methylprednisolone 1 COUGH/COLD/ALLERGY - Drugs to Treat tbpk Cough, Cold and Allergy Symptoms MILLIPRED DP TBPK 3 Antitussives (prednisolone) (Hydrocodone W/ MILLIPRED SOLN 10 Homatropine) HYDROMET 1 MG/5ML (prednisolone GP SYRP sodium phosphate) 1 MILLIPRED TABS 5 MG benzonatate caps 2 (prednisolone) HYCODAN SYRP ORAPRED ODT TBDP (hydrocodone w/ GP (prednisolone sodium GP homatropine) phosphate) hydrocodone w/ 1 prednisolone sodium homatropine syrp phosphate soln or 10 1 hydrocodone w/ 1 mg/5ml, 15 mg/5ml, 20 homatropine tabs mg/5ml, 25 mg/5ml TESSALON PERLES GP CAPS (benzonatate) Cough/Cold/Allergy Combinations You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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59 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Guaifenesin-Codeine) guaifenesin-codeine 1 CHERATUSSIN AC, 1 soln GUAIATUSSIN AC, GUAIFENESIN AC SYRP HISTEX-PE SYRP ( (Guaifenesin-Codeine) G triprolidine- GP TUSSIN AC, MAXI-TUSS 1 phenylephrine) AC, VIRTUSSIN A/C SOLN hydrocodone polistirex- 1 (Guaifenesin-Codeine) 1 chlorpheniramine VIRTUSSIN AC/ALC LIQD polistirex suer (Pseudoephedrine W/ NEOTUSS PLUS LIQD Codeine-Gg) 1 (phenylephrine- 3 GUAIFENESIN DAC SOLN chlorphen-dm) ACTIDOM DMX LIQD (phenylephrine w/ dm- 3 promethazine 1 gg) w/codeine soln BIO-DTUSS DMX LIQD promethazine 1 (pseudoephed- 3 w/codeine syrp bromphen-dm) promethazine-dm syrp 1 CLARINEX-D 12 HOUR PA TB12 (desloratadine- 3 promethazine- 1 pseudoephedrine) phenylephrine-codeine syrp CODITUSSIN AC LIQD 3 (guaifenesin-codeine) pseudoephed-cpm w/ 1 DOCTOR MANZANILLA hydrocod soln PE SYRUP SEMPREX-D CAPS ANTIHISTAMINE/DECON (acrivastine & 3 GESTANT LIQD 3 pseudoephedrine) (triprolidine- TUSSICAPS CP12 phenylephrine) (hydrocodone DOMETUSS-DMX LIQD polistirex- 3 (phenylephrine w/ dm- 3 chlorpheniramine gg) polistirex) GILPHEX TR TABS RX/OTC TUSSIONEX (phenylephrine- 3 PENNKINETIC guaifenesin) EXTENDED RELEASE GILTUSS COUGH & COLD RX/OTC SUER (hydrocodone GP TABS (phenylephrine 3 polistirex- w/ dm-gg) chlorpheniramine GILTUSS SINUS & RX/OTC polistirex) CONGESTION TABS TUSSLIN LIQD (phenylephrine- 3 (phenylephrine w/ dm- 3 guaifenesin) gg) GILTUSS TR TABS RX/OTC TUSSLIN PEDIATRIC (phenylephrine w/ dm- 3 LIQD (phenylephrine w/ 3 gg) dm-gg) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIRTUSSIN DAC SOLN Greater than 5 (pseudoephedrine w/ 2 (Isotretinoin) CLARAVIS months codeine-gg) CAPS 10 MG, 20 MG, 30 1 requires MG, 40 MG PA;QL(2 ea Misc. Respiratory Inhalants daily) (Sodium Chloride Limit 5 months (Inhalant)) PULMOSAL 1 of NEBU (Isotretinoin) MYORISAN, 1 treatment;QL(2 HYPER-SAL NEBU ZENATANE CAPS 10 MG ea daily,5 (sodium chloride GP claims per fill (inhalant)) retail) Greater than 5 HYPERSAL NEBU 3.5 % (Isotretinoin) MYORISAN, months (sodium chloride 3 ZENATANE CAPS 20 MG, 1 requires (inhalant)) 30 MG, 40 MG PA;QL(2 ea HYPERSAL NEBU 7 % daily) (sodium chloride GP (Sulfacetamide Sodium W/ (inhalant)) Sulfur) AVAR CLEANSER, 1 BP 10-1, SULFAMEZ NEBUSAL NEBU WASH EMUL (sodium chloride 3 (Sulfacetamide Sodium W/ (inhalant)) Sulfur) AVAR-E EMOLLIENT, AVAR-E 1 sodium chloride 1 (inhalant) nebu GREEN, SSS 10%-5% CREA Mucolytics (Sulfacetamide Sodium W/ 1 acetylcysteine soln 1 Sulfur) SSS 10-5 FOAM (Sulfacetamide Sodium W/ DERMATOLOGICALS - Drugs to Treat Skin Sulfur) SULFACLEANSE 1 Conditions 8/4 SUSP Acne Products (Sulfacetamide Sodium- Limit 45gms Sulfur In Urea Vehicle) BP 1 CLEANSING WASH EMUL (Adapalene) ADAPALENE per 1 month;QL(1.5 (Tretinoin) AVITA CREA 1 TREATMENT GEL gm daily); RX/OTC (Tretinoin) AVITA GEL 1 (Clindamycin Phosphate PA; Limited to (Topical)) CLINDACIN ETZ 1 ABSORICA CAPS 10 MG, PLEDGETS, CLINDACIN-P 20 MG, 30 MG, 40 MG 3 5 months of treatment;QL(2 SWAB (isotretinoin) (Clindamycin Phosphate- ea daily) Benzoyl Peroxide 1 PA; Limited to ABSORICA CAPS 25 MG, (Refrigerate)) NEUAC GEL GP 5 months of Greater than 5 35 MG (isotretinoin) treatment;QL(2 months ea daily) (Isotretinoin) AMNESTEEM 1 requires PA; Limited to CAPS ABSORICA LD CAPS PA;QL(2 ea 3 5 months of daily) (isotretinoin micronized) treatment;QL(2 ea daily) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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61 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACZONE GEL 5 % PA BENZACLIN WITH PUMP GP (dapsone (topical)) GEL (clindamycin GP ACZONE GEL 7.5 % PA; QL(2 gm phosphate-benzoyl GP (dapsone (topical)) daily) peroxide) Limit 45gms CLEOCIN-T GEL adapalene crea 0.1 % 1 per (clindamycin phosphate GP month;QL(1.5 (topical)) gm daily) CLEOCIN-T LOTN Limit 45gms (clindamycin phosphate GP per adapalene gel 0.1 % 1 month;QL(1.5 (topical)) gm daily); clindamycin phosphate 1 RX/OTC (topical) foam Limit 45gms clindamycin phosphate 1 1 per adapalene gel 0.3 % month;QL(1.5 (topical) gel gm daily) clindamycin phosphate 1 Limit 45gms (topical) lotn adapalene-benzoyl per 1 clindamycin phosphate 1 peroxide gel month;QL(1.5 (topical) soln gm daily) Limit 45gms clindamycin phosphate 1 per (topical) swab ATRALIN GEL (tretinoin) GP month;QL(1.5 clindamycin phosphate- gm daily) benzoyl peroxide 1 AVAR LS CLEANSER (refrigerate) gel LIQD (sulfacetamide GP clindamycin phosphate- sodium w/ sulfur) benzoyl peroxide gel 1 1 AVAR LS PADS %-5 % (sulfacetamide sodium 3 clindamycin phosphate- QL(1 gm daily) w/ sulfur) 1 tretinoin gel AVAR PADS PA (sulfacetamide sodium 3 dapsone (topical) gel 5 1 w/ sulfur) % AVAR-E LS CREA dapsone (topical) gel PA; QL(2 gm 1 daily) (sulfacetamide sodium GP 7.5 % w/ sulfur) Limit 45gms DIFFERIN CREA 0.1 % per AZELEX CREA ( GP azelaic 3 (adapalene) month;QL(1.5 acid (acne)) gm daily) BENZACLIN GEL Limit 45gms (clindamycin DIFFERIN GEL 0.1 % per GP GP month;QL(1.5 phosphate-benzoyl (adapalene) peroxide) gm daily); RX/OTC
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Updated 07/01/2021 62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 45gms PLEXION CLEANSER DIFFERIN GEL 0.3 % GP per LIQD (sulfacetamide GP (adapalene) month;QL(1.5 sodium w/ sulfur) gm daily) PLEXION CLEANSING DIFFERIN LOTN 0.1 % Limit 59mls per CLOTHS PADS 3 month;QL(1.97 3 (adapalene) ml daily) (sulfacetamide sodium w/ sulfur) DUAC GEL (clindamycin PLEXION CREA phosphate-benzoyl GP (sulfacetamide sodium GP peroxide (refrigerate)) w/ sulfur) Limit 45gms EPIDUO GEL PLEXION LOTN ( GP per adapalene-benzoyl month;QL(1.5 (sulfacetamide sodium GP peroxide) gm daily) w/ sulfur) ERYGEL GEL RETIN-A CREA (tretinoin) GP (erythromycin (acne GP aid)) RETIN-A GEL (tretinoin) GP erythromycin (acne aid) 1 Limit 20gms gel RETIN-A MICRO GEL 0.04 %, 0.1 % ( GP per tretinoin month;QL(0.67 erythromycin (acne aid) 1 microsphere) pads gm daily) erythromycin (acne aid) RETIN-A MICRO PUMP Limit 50gms 1 GEL 0.04 %, 0.1 % GP per soln month;QL(1.7 EVOCLIN FOAM (tretinoin microsphere) gm daily) (clindamycin phosphate GP RIAX FOAM ( benzoyl 3 (topical)) peroxide) Limit 50gms SODIUM FABIOR FOAM 3 per SULFACETAMIDE/SULFU (tazarotene (acne)) month;QL(1.67 R CLEANSER IN UREA gm daily) EMUL (sulfacetamide 3 Greater than 5 sodium-sulfur in urea months vehicle) isotretinoin caps 10 requires PA;QL(2 ea SODIUM mg, 20 mg, 30 mg, 40 1 SULFACETAMIDE/SULFU daily)150 rtl 3 mg MAX day(s) R SUSP (sulfacetamide supply,365 rtl sodium w/ sulfur) lmt day(s), sulfacetamide sodium 1 PA; Limited to (acne) lotn isotretinoin caps 25 1 5 months of mg, 35 mg treatment;QL(2 sulfacetamide sodium ea daily) w/ sulfur crea 10 %-2 1 KLARON LOTN %, 10 %-5 %, 4.8 %- (sulfacetamide sodium GP 9.8 % (acne))
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63 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZIANA GEL ( QL(1 gm daily) sulfacetamide sodium clindamycin GP w/ sulfur emul 10 %-5 1 phosphate-tretinoin) % Agents for External Genital and Perianal Warts sulfacetamide sodium VEREGEN OINT Limit 30gms w/ sulfur liqd 10 %-2 %, 1 3 per month;QL(1 4 %-9 %, 4.5 %-9 %, (sinecatechins) gm daily) 4.8 %-9.8 % Anti-inflammatory Agents - Topical QL(1 gm daily) sulfacetamide sodium 1 (Diclofenac Sodium RX/OTC w/ sulfur lotn 10 %-5 % (Topical)) ARTHRITIS PAIN RELIEVER, sulfacetamide sodium ASPERCREME w/ sulfur lotn 4.8 %-9.8 1 ARTHRITIS PAIN 1 % RELIEVER, GNP sulfacetamide sodium ARTHRITIS PAIN, 1 GOODSENSE ARTHRITIS w/ sulfur susp 4 %-8 % PAIN, QC DICLOFENAC SUMADAN WASH LIQD SODIIUM GEL (sulfacetamide sodium GP RX/OTC diclofenac sodium 1 w/ sulfur) (topical) gel 1 % SUMAXIN WASH LIQD QL(5 ml daily) diclofenac sodium 1 (sulfacetamide sodium GP (topical) soln 1.5 % w/ sulfur) FLECTOR PTCH Limit 50gms 3 TAZAROTENE FOAM (diclofenac epolamine) 3 per (tazarotene (acne)) month;QL(1.67 PENNSAID SOLN PA; Limit 1 gm daily) ( 3 bottle per diclofenac sodium month;QL(4 gm tretinoin crea 0.025 %, 1 (topical)) daily) 0.05 %, 0.1 % VOLTAREN GEL RX/OTC tretinoin gel 0.01 %, 1 (diclofenac sodium GP 0.025 % (topical)) Limit 45gms per Antibiotics - Topical tretinoin gel 0.05 % 1 ALTABAX OINT month;QL(1.5 3 gm daily) (retapamulin) Limit 20gms CENTANY AT KIT 3 tretinoin microsphere 1 per (mupirocin) month;QL(0.67 gel 0.1 % CENTANY OINT gm daily) 2 (mupirocin) Limit 50gms gentamicin sulfate tretinoin microsphere 1 per 1 gel 0.1 % month;QL(1.7 (topical) crea gm daily) gentamicin sulfate 1 VELTIN GEL QL(1 gm daily) (topical) oint (clindamycin GP phosphate-tretinoin) mupirocin oint 1 Antifungals - Topical You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Iodoquinol-Hc) 1 iodoquinol- DERMAZENE CREA hydrocortisone in aloe 1 (Iodoquinol-Hydrocortisone vehicle crea In Aloe Vehicle) 1 IODOQUIMEZ-HC CREA iodoquinol- hydrocortisone-aloe 1 (Ketoconazole (Topical)) 1 KETODAN FOAM polysaccharide gel ALA-QUIN CREA ketoconazole (topical) QL(2 gm daily) 3 1 (clioquinol-hc) crea ALCORTIN A GEL ketoconazole (topical) 1 (iodoquinol- foam hydrocortisone-aloe GP ketoconazole (topical) 1 polysaccharide) sham CICLODAN SOLUTION LOPROX CREA GP GP KIT KIT (ciclopirox) (ciclopirox olamine) LOPROX SHAMPOO ciclopirox gel 1 GP SHAM (ciclopirox) ciclopirox olamine crea 1 LOPROX SUSP GP (ciclopirox olamine) ciclopirox olamine susp 1 LOTRISONE CREA Limit 1 tube per ciclopirox sham 1 (clotrimazole w/ GP month;QL(1.5 betamethasone) gm daily) clotrimazole w/ Limit 1 tube per 1 month;QL(1.5 luliconazole crea 1 betamethasone crea gm daily) LUZU CREA QL(2 ml daily) GP clotrimazole w/ 1 (luliconazole) betamethasone lotn miconazole-zinc oxide- 1 econazole nitrate crea 1 white petrolatum oint ERTACZO CREA PA 1 3 naftifine hcl crea (sertaconazole nitrate) EXELDERM CREA naftifine hcl gel 1 GP (sulconazole nitrate) NAFTIFINE EXELDERM SOLN HYDROCHLORIDE CREA GP GP (sulconazole nitrate) (naftifine hcl) NAFTIN CREA 2 % EXODERM LOTN GP (sodium thiosulfate- 3 (naftifine hcl) salicylic acid) NAFTIN GEL 1 % GP EXTINA FOAM (naftifine hcl) GP (ketoconazole (topical)) NAFTIN GEL 2 % 2 (naftifine hcl) iodoquinol-hc crea 1 NIZORAL SHAM GP (ketoconazole (topical))
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65 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PANRETIN GEL PA nystatin (topical) crea 1 3 (alitretinoin) nystatin (topical) oint 1 PICATO GEL ( ingenol 3 nystatin-triamcinolone mebutate) 1 TARGRETIN GEL EX 1 % crea 3 (bexarotene (topical)) nystatin-triamcinolone 1 oint VALCHLOR GEL PA (mechlorethamine hcl 3 oxiconazole nitrate 1 (topical)) crea Antipruritics - Topical OXISTAT CREA GP (oxiconazole nitrate) PRUDOXIN CREA (doxepin hcl 3 OXISTAT LOTN 3 (antipruritic)) (oxiconazole nitrate) QUINJA GEL Antipsoriatics (iodoquinol-aloe 3 (Calcipotriene) 1 QL(5 gm daily) polysaccharides) CALCITRENE OINT acitretin caps 1 sulconazole nitrate 1 crea 1 QL(5 gm daily) VUSION OINT calcipotriene crea (miconazole-zinc oxide- GP calcipotriene foam 1 PA white petrolatum) CALCIPOTRIENE FOAM PA VYTONE CREA 3 (iodoquinol- (calcipotriene) GP hydrocortisone in aloe calcipotriene oint 1 QL(5 gm daily) vehicle) XOLEGEL GEL calcipotriene soln 1 3 (ketoconazole (topical)) Limited 100 Antineoplastic or Premalignant Lesion Agents - 1 gms per calcitriol (topical) oint month;QL(3.4 CARAC CREA GP gm daily) ( ) fluorouracil (topical) COSENTYX PA PA diclofenac sodium 1 SENSOREADY PEN SOAJ 3 (actinic keratoses) gel (secukinumab) EFUDEX CREA COSENTYX SOSY PA GP 3 (fluorouracil (topical)) (secukinumab) FLUOROPLEX CREA DOVONEX CREA QL(5 gm daily) 2 GP (fluorouracil (topical)) (calcipotriene) fluorouracil (topical) ILUMYA SOSY PA 1 3 crea (tildrakizumab-asmn) fluorouracil (topical) 1 methoxsalen rapid caps 1 soln
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Updated 07/01/2021 66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXSORALEN ULTRA OVACE PLUS WASH LIQD GP CAPS (methoxsalen GP (sulfacetamide sodium) rapid) OVACE WASH LIQD GP SILIQ SOSY PA (sulfacetamide sodium) 3 (brodalumab) selenium sulfide lotn 1 SKYRIZI PSKT PA 3 (risankizumab-rzaa) selenium sulfide sham 1 SORIATANE CAPS GP SODIUM (acitretin) SULFACETAMIDE WASH SORILUX FOAM PA LIQD 0.5 %-10 % 3 3 (calcipotriene) (sulfacetamide sodium STELARA SOLN PA in bakuchiol vehicle) 3 (ustekinumab) sulfacetamide sodium 1 STELARA SOSY PA liqd 3 (ustekinumab) sulfacetamide sodium TALTZ SOAJ PA 1 3 sham (ixekizumab) Antivirals - Topical TALTZ SOSY PA 3 (ixekizumab) acyclovir topical crea 1 tazarotene crea 1 QL(1 gm daily) acyclovir topical oint 1 QL(1 gm daily) TAZORAC CREA 0.05 % QL(1 gm daily) 2 DENAVIR CREA Limit 5gms per ) 3 month;QL(0.17 (tazarotene (penciclovir) TAZORAC CREA 0.1 % QL(1 gm daily) gm daily) GP (tazarotene) XERESE CREA Limit 5gms per month;QL(0.17 TAZORAC GEL 0.05 %, QL(1 gm daily) (acyclovir- 3 2 gm daily) 0.1 % (tazarotene) hydrocortisone) TREMFYA SOPN PA ZOVIRAX CREA EX 5 % 3 GP (guselkumab) (acyclovir topical) TREMFYA SOSY PA ZOVIRAX OINT EX 5 % QL(1 gm daily) 3 GP (guselkumab) (acyclovir topical) Limited 100 Burn Products VECTICAL OINT gms per GP (Silver Sulfadiazine) SSD 1 (calcitriol (topical)) month;QL(3.4 CREA gm daily) mafenide acetate pack 1 Antiseborrheic Products SILVADENE CREA ( (Sulfacetamide Sodium) silver GP ) SODIUM 1 sulfadiazine SULFACETAMIDE WASH LIQD 10 % silver sulfadiazine crea 1 OVACE PLUS SHAM 10 % SULFAMYLON CREA 85 GP (sulfacetamide sodium) MG/GM (mafenide 3 acetate)
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67 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SULFAMYLON PACK 5 % APEXICON E CREA GP (mafenide acetate) (diflorasone diacetate 2 Corticosteroids - Topical emollient base) (Clobetasol Propionate betamethasone Emollient Base) dipropionate (topical) 1 CLOBETASOL crea PROPIONATE E, 1 CLOBETASOL betamethasone PROPIONATE dipropionate (topical) 1 EMOLLIENT CREA lotn (Clobetasol Propionate 1 betamethasone Emulsion) TOVET FOAM dipropionate (topical) 1 (Clobetasol Propionate) 1 oint CLODAN SHAM betamethasone (Desonide) DESRX GEL 1 dipropionate 1 augmented crea (Flurandrenolide) NOLIX 1 CREA betamethasone dipropionate 1 (Fluticasone Propionate) 1 BESER LOTN augmented gel (Hydrocortisone (Topical)) betamethasone ALA SCALP, ALA-SCALP 1 dipropionate 1 LOTN augmented lotn (Hydrocortisone (Topical)) 1 ALA-CORT CREA betamethasone dipropionate 1 (Pramoxine-Hc) 1 MEZPAROX-HC CREA augmented oint betamethasone (Triamcinolone Acetonide 1 1 (Topical)) TRIANEX OINT valerate crea (Triamcinolone Acetonide 1 betamethasone 1 (Topical)) TRIDERM CREA valerate foam ALA-SCALP LOTN betamethasone 1 (hydrocortisone 3 valerate lotn (topical)) betamethasone alclometasone 1 1 valerate oint dipropionate crea calcipotriene- ST; QL(2 gm alclometasone 1 betamethasone 1 daily) dipropionate oint dipropionate oint amcinonide crea 1 calcipotriene- ST; QL(2 gm betamethasone 1 daily) amcinonide lotn 1 dipropionate susp AMCINONIDE OINT CAPEX SHAM 3 2 (amcinonide) (fluocinolone acetonide)
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Updated 07/01/2021 68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMA-SMOOTHE/FS clobetasol propionate 1 crea BODY OIL (fluocinolone GP acetonide) clobetasol propionate 1 emollient base crea DERMA-SMOOTHE/FS SCALP OIL (fluocinolone GP clobetasol propionate 1 emulsion foam acetonide) DESONATE GEL clobetasol propionate GP 1 (desonide) foam desonide crea 1 clobetasol propionate 1 gel desonide gel 1 clobetasol propionate 1 liqd desonide lotn 1 clobetasol propionate 1 lotn desonide oint 1 DESOWEN CREA clobetasol propionate 1 GP oint (desonide) desoximetasone crea clobetasol propionate 1 1 sham 0.05 %, 0.25 % desoximetasone gel clobetasol propionate 1 1 soln 0.05 % CLOBEX LIQD desoximetasone liqd ST GP 1 (clobetasol propionate) 0.25 % CLOBEX LOTN desoximetasone oint GP 1 (clobetasol propionate) 0.05 %, 0.25 % CLOBEX SHAM GP diflorasone diacetate 1 (clobetasol propionate) crea CLODERM CREA 3 diflorasone diacetate 1 (clocortolone pivalate) oint CLODERM PUMP CREA 3 DIPROLENE AF CREA (clocortolone pivalate) (betamethasone CORDRAN CREA 0.05 % GP GP dipropionate (flurandrenolide) augmented) CORDRAN TAPE 4 DIPROLENE OINT MCG/SQCM 3 (betamethasone (flurandrenolide) dipropionate GP CORTANE-B LOTN augmented) (hydrocortisone- ELOCON CREA 3 GP pramoxine- (mometasone furoate) chloroxylenol) EPIFOAM FOAM CUTIVATE LOTN 3 GP (pramoxine-hc) (fluticasone propionate)
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69 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluocinolone acetonide 1 hydrocortisone (topical) 1 crea oint fluocinolone acetonide 1 hydrocortisone butyrate 1 oil crea fluocinolone acetonide 1 hydrocortisone butyrate oint hydrophilic lipo base 1 crea fluocinolone acetonide 1 soln hydrocortisone butyrate 1 lotn fluocinonide crea 1 hydrocortisone butyrate 1 fluocinonide emulsified 1 oint base crea hydrocortisone butyrate 1 fluocinonide gel 1 soln hydrocortisone valerate 1 fluocinonide oint 1 crea fluocinonide soln 1 hydrocortisone valerate 1 oint flurandrenolide crea 1 IMPEKLO LOTN 2 (clobetasol propionate) fluticasone propionate 1 crea KENALOG AERS (triamcinolone GP fluticasone propionate 1 lotn acetonide (topical)) LOCOID CREA fluticasone propionate 1 (hydrocortisone GP oint butyrate) halcinonide crea 1 LOCOID LIPOCREAM CREA (hydrocortisone halobetasol propionate 1 GP crea butyrate hydrophilic lipo base) halobetasol propionate 1 LOCOID LOTN oint (hydrocortisone GP HALOG CREA GP butyrate) ( ) halcinonide LOCOID SOLN HALOG OINT 3 (hydrocortisone GP (halcinonide) butyrate) HALOG SOLN 3 LUXIQ FOAM (halcinonide) (betamethasone GP hydrocortisone (topical) 1 valerate) crea mometasone furoate 1 hydrocortisone (topical) 1 crea lotn
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Updated 07/01/2021 70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TACLONEX OINT ST; QL(2 gm mometasone furoate 1 oint (calcipotriene- daily) betamethasone GP mometasone furoate 1 soln dipropionate) TEMOVATE CREA NUCORT LOTN GP (hydrocortisone acetate 3 (clobetasol propionate) TEMOVATE OINT (topical)) GP ( ) OLUX FOAM ( clobetasol propionate clobetasol GP propionate) TEXACORT SOLN ( OLUX-E FOAM hydrocortisone 3 ) (clobetasol propionate GP (topical) emulsion) TOPICORT CREA 0.05 %, 0.25 % GP PANDEL CREA (desoximetasone) (hydrocortisone 3 TOPICORT GEL 0.05 % probutate) GP (desoximetasone) PRAMOSONE CREA 1 %- 3 TOPICORT LIQD 0.25 % ST 1 % (pramoxine-hc) GP (desoximetasone) PRAMOSONE CREA 1 %- GP TOPICORT OINT 0.05 %, 2.5 % (pramoxine-hc) 0.25 % GP PRAMOSONE LOTN 1 %- (desoximetasone) 1 %, 1 %-2.5 % 3 (pramoxine-hc) triamcinolone acetonide (topical) aers 0.147 1 PRAMOSONE OINT 1 %-1 %, 1 %-2.5 % 3 mg/gm (pramoxine-hc) triamcinolone acetonide (topical) crea 0.025 %, 1 pramoxine-hc crea 1 0.1 %, 0.5 % prednicarbate crea 1 triamcinolone acetonide (topical) lotn 0.025 %, 1 prednicarbate oint 1 0.1 % PSORCON CREA triamcinolone acetonide 3 (diflorasone diacetate) (topical) oint 0.025 %, 1 SYNALAR CREA 0.1 %, 0.5 % TRIDESILON CREA (fluocinolone GP GP acetonide) (desonide) SYNALAR OINT ULTRAVATE CREA (fluocinolone GP (halobetasol GP acetonide) propionate) SYNALAR SOLN ULTRAVATE OINT (fluocinolone GP (halobetasol GP acetonide) propionate)
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71 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VANOS CREA GP UTOPIC CREA (urea) GP (fluocinonide) VERDESO FOAM Emollients 3 (desonide) (Lactic Acid (Ammonium RX/OTC Lactate)) AL12, Eczema Agents AMLACTIN, AMLACTIN DUPIXENT SOPN PA 3 DAILY, CVS HYDRATING (dupilumab) SKIN TREATMENT, CVS 1 DUPIXENT SOSY PA SKIN TREATMENT, CVS 3 SKIN TREATMENT BODY (dupilumab) LOTION, GERI- Emollient/Keratolytic Agents HYDROLAC 12 LOTN (Urea) GORDONS UREA, (Lactic Acid (Ammonium RX/OTC Lactate)) GERI- 1 METOPIC, UREDEB, 1 UREMEZ-40, XUREA HYDROLAC 12 CREA CREA HYLINATE LOTN (Urea) GORDONS UREA, RX/OTC (hyaluronate sodium 3 METOPIC, UREDEB, 1 (emollient)) UREMEZ-40, XUREA CREA LAC-HYDRIN CREA RX/OTC (lactic acid (ammonium GP (Urea) UMECTA MOUSSE 1 FOAM lactate)) LAC-HYDRIN TWELVE RX/OTC (Urea) UREA NAIL GEL 1 LOTN (lactic acid GP (Urea) UREA-C40 LOTN 1 (ammonium lactate)) RX/OTC lactic acid (ammonium 1 CEM-UREA SOLN (urea) 3 lactate) crea RX/OTC lactic acid (ammonium 1 CEROVEL LOTN (urea) 3 lactate) lotn HYDRO 35 FOAM ( urea GP LACTIC ACID LOTN in lactic acid vehicle) (lactic acid (ammonium 3 HYDRO 40 FOAM FOAM lactate)) GP (urea) Enzymes - Topical SANTYL OINT KERALAC CREA (urea) GP 3 (collagenase) GP URAMAXIN GEL (urea) Immunomodulating Agents - Topical ALDARA CREA URE-K CREA (urea) 3 GP (imiquimod) urea crea 39 %, 41 %, 1 45 %, 47 % imiquimod crea 5 % 1 RX/OTC ZYCLARA CREA QL(1 ea daily) urea crea 40 % 1 3 (imiquimod) urea lotn 40 % 1 urea susp 40 % 1
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Updated 07/01/2021 72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 bottles salicylic acid in ZYCLARA PUMP CREA 3 per 28 ammonium lactate 1 (imiquimod) days;QL(0.6 vehicle foam gm daily) Immunosuppressive Agents - Topical salicylic acid liqd 1 ELIDEL CREA QL(2 gm daily) GP salicylic acid lotn 1 (pimecrolimus) pimecrolimus crea 1 QL(2 gm daily) salicylic acid sham 1 PROTOPIC OINT 1 GP salicylic acid soln (tacrolimus (topical)) salicylic acid w/ 1 tacrolimus (topical) oint 1 cleanser kit SALIMEZ CREA ( Keratolytic/Antimitotic Agents salicylic 3 acid) (Salicylic Acid) KERALYT 1 SHAM SALISOL SOLN ( salicylic 3 (Salicylic Acid) SALICYLIC acid) ACID WART REMOVER 1 SALITECH LOTN 3 LIQD (salicylic acid) (Salicylic Acid) SALISOL 1 SALVAX FOAM ( FORTE SOLN salicylic GP acid) (Salicylic Acid) SALITECH 1 ULTRASAL-ER SOLN FORTE LOTN GP BENSAL HP OINT RX/OTC (salicylic acid) 3 VIRASAL LIQD ( (salicylic acid) salicylic GP CONDYLOX GEL acid) 2 (podofilox) Liniments MG217 PSORIASIS RX/OTC MEDROX-RX OINT PA MULTI-SYMTOM OINT 3 (capsaicin-menthol- 3 (salicylic acid) methyl salicylate) PODOCON 25 IN BENZOIN TINCTURE Local Anesthetics - Topical SOLN (podophyllum 3 (Capsaicin-Menthol) ALLEVESS, RELIEVER 1 resin) PTCH podofilox soln 1 (Cocaine Hcl) C-TOPICAL 1 SOLN SALEX LOTION KIT (Lidocaine Hcl) 7T LIDO RX/OTC (salicylic acid w/ 3 GEL, REGENECARE HA 1 cleanser) GEL SALEX SHAM (salicylic GP (Lidocaine Hcl) GLYDO 1 acid) PRSY (Lidocaine) PREMIUM 1 salicylic acid crea 1 LIDOCAINE OINT salicylic acid foam 1
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73 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CRYODOSE TA AERO RX/OTC Misc. Dermatological Products (pentafluoropropane- 3 CERACADE EMUL tetrafluoroethane) (dermatological 3 ETHYL CHLORIDE/FINE products, misc.) STREAM AERO (ethyl 3 EMULSION SB EMUL chloride) (dermatological 3 ETHYL products, misc.) CHLORIDE/MEDIUM ENTTY SPRAY EMUL STREAM AERO ( 3 ethyl (dermatological 3 chloride) products, misc.) GEBAUERS INSTANT ICE RX/OTC AERO EPICERAM EMUL (pentafluoropropane- 3 (dermatological 3 tetrafluoroethane) products, misc.) GEBAUERS PAIN EASE RX/OTC ILIDERM EMUL AERO (dermatological 3 (pentafluoropropane- 3 products, misc.) tetrafluoroethane) KAMDOY EMUL GEBAUERS SPRAY AND RX/OTC (dermatological 3 STRETCH AERO products, misc.) (pentafluoropropane- 3 KIVIK EMUL tetrafluoroethane) (dermatological 3 products, misc.) lidocaine hcl gel 1 PENLEN EMUL lidocaine hcl prsy 1 (dermatological 3 products, misc.) lidocaine hcl soln 1 PHLAG SPRAY EMUL (dermatological 3 lidocaine oint ex 5 % 1 products, misc.) lidocaine ptch ex 5 % 1 QL(3 ea daily) SUVICORT EMUL (dermatological 3 lidocaine-prilocaine 1 products, misc.) crea SYNERDERM EMUL LIDODERM PTCH QL(3 ea daily) GP (dermatological 3 (lidocaine) products, misc.) LIDODOSE GEL RX/OTC 3 Misc. Topical (lidocaine hcl) DRYSOL SOLN 2 LIDODOSE PEDIATRIC RX/OTC (aluminum chloride) BULK PACK GEL 3 (lidocaine hcl) XERAC AC SOLN (aluminum chloride in 3 LIDORX GEL ( RX/OTC lidocaine 3 alcohol) hcl) SYNERA PTCH Phosphodiesterase 4 (PDE4) Inhibitors - Topical 3 (lidocaine-tetracaine) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EUCRISA OINT PA NORITATE CREA PA 3 (crisaborole) (metronidazole 3 Rosacea Agents (topical)) ORACEA CPDR (Metronidazole (Topical)) 1 GP ROSADAN CREA (doxycycline (rosacea)) Limit 45gms RHOFADE CREA PA (Metronidazole (Topical)) 1 per (oxymetazoline hcl 3 ROSADAN GEL month;QL(1.5 (topical)) gm daily) Scabicides & Pediculicides azelaic acid gel 1 Limit 2 per ELIMITE CREA doxycycline (rosacea) GP month;QL(60 1 (permethrin) gm per 14 days cpdr retail) FINACEA FOAM (azelaic EURAX CREA 3 2 acid) (crotamiton) FINACEA GEL (azelaic EURAX LOTN GP GP acid) (crotamiton) ivermectin (rosacea) PA; QL(1 gm 1 ivermectin 1 crea daily) (pediculicide) lotn METROCREAM CREA lindane sham 1 (metronidazole GP (topical)) malathion lotn 1 METROGEL GEL NATROBA SUSP AL(At least 4 (metronidazole GP GP (spinosad) yrs old) (topical)) METROLOTION LOTN QL(2 ml daily) OVIDE LOTN (malathion) GP (metronidazole GP Limit 2 per (topical)) 1 month;QL(60 permethrin crea gm per 14 days metronidazole (topical) 1 crea 0.75 % retail) Limit 45gms SKLICE LOTN (ivermectin GP metronidazole (topical) 1 per gel 0.75 % month;QL(1.5 (pediculicide)) gm daily) 1 AL(At least 4 spinosad susp yrs old) metronidazole (topical) 1 gel 1 % ULESFIA LOTN ( benzyl 3 QL(2 ml daily) alcohol (pediculicide)) metronidazole (topical) 1 lotn 0.75 % Wound Care Products MIRVASO GEL PA Limit 15gms REGRANEX GEL (brimonidine tartrate 3 3 per (topical)) (becaplermin) month;QL(0.5 gm daily) DIAGNOSTIC PRODUCTS You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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75 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELFOLATE TABS ( Diagnostic Drugs l- 3 GLUCAGEN DIAGNOSTIC methylfolate) SOLR (glucagon hcl 3 FOLBIC RF TABS (l- rdna (diagnostic)) methylfolate w/ vitamin 3 METOPIRONE CAPS b6-vitamin b12) 3 (metyrapone) FOLTX TABS (l- Diagnostic Tests methylfolate w/ vitamin 3 FREESTYLE INSULINX Limit 200 per b6-vitamin b12) BLOODGLUCOSE TEST month;QL(6.67 L-METHYLFOLATE CA/S- 2 STRIPS STRP (glucose ea daily); ALGAL CAPS (l- 3 blood) RX/OTC methylfolate-algae) FREESTYLE INSULINX Limit 200 per L-METHYLFOLATE BLOODGLUCOSE TEST 2 month;QL(6.67 FORTE CAPS (l- 3 ea daily); methylfolate-algae) STRP (glucose blood) RX/OTC LEVOMEFOLATE FREESTYLE LITE TEST Limit 200 per CALCIUM ALGAL STRIPS STRP ( 2 month;QL(6.67 3 glucose ea daily); POWDER CAPS (l- blood) RX/OTC methylfolate-algae) FREESTYLE TEST Limit 200 per DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes STRIPS STRP ( 2 month;QL(6.67 glucose ea daily); blood) RX/OTC Digestive Enzymes CREON CPEP NON PREFERRED TEST 3 PA STRIPS (pancrelipase (lipase- 2 Limit 200 per protease-amylase)) ONETOUCH ULTRA STRP PANCREAZE CPEP 2 month;QL(6.67 (glucose blood) ea daily); (pancrelipase (lipase- 3 RX/OTC protease-amylase)) ONETOUCH VERIO TEST Limit 200 per PERTZYE CPEP STRIPS STRP ( 2 month;QL(6.67 (pancrelipase (lipase- 3 glucose ea daily); blood) RX/OTC protease-amylase)) SUCRAID SOLN PA Limit 200 per 3 PRECISION XTRA BLOOD (sacrosidase) GLUCOSE TEST STRIPS 2 month;QL(6.67 ea daily); STRP (glucose blood) VIOKACE TABS RX/OTC (pancrelipase (lipase- 3 DIETARY PRODUCTS/DIETARY MANAGEMENT protease-amylase)) PRODUCTS ZENPEP CPEP Dietary Management Products (pancrelipase (lipase- 2 DEPLIN 15 CAPS ( protease-amylase)) l- 3 methylfolate-algae) DIURETICS - Drugs to Treat Heart, Circulation DEPLIN 7.5 CAPS ( Conditions and Blood Pressure l- 3 methylfolate-algae) Carbonic Anhydrase Inhibitors
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Updated 07/01/2021 76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEMADEX TABS acetazolamide cp12 1 GP (torsemide) acetazolamide tabs 1 EDECRIN TABS ST GP ( ) KEVEYIS TABS PA ethacrynic acid 3 (dichlorphenamide) ethacrynic acid tabs 1 ST methazolamide tabs 1 furosemide soln 1 Diuretic Combinations furosemide tabs 1 ALDACTAZIDE TABS 25 MG-25 MG LASIX TABS GP (spironolactone & GP (furosemide) hydrochlorothiazide) torsemide tabs 1 ALDACTAZIDE TABS 50 MG-50 MG Potassium Sparing Diuretics 2 (spironolactone & ALDACTONE TABS GP hydrochlorothiazide) (spironolactone) amiloride & amiloride hcl tabs 1 hydrochlorothiazide 1 DYRENIUM CAPS tabs GP DYAZIDE CAPS (triamterene) (triamterene & GP spironolactone tabs 1 hydrochlorothiazide) MAXZIDE TABS triamterene caps 1 (triamterene & GP Thiazides and Thiazide-Like Diuretics hydrochlorothiazide) MAXZIDE-25 TABS chlorothiazide tabs 1 (triamterene & GP hydrochlorothiazide) chlorthalidone tabs 1 DIURIL SUSP spironolactone & 3 hydrochlorothiazide 1 (chlorothiazide) tabs hydrochlorothiazide 1 triamterene & caps hydrochlorothiazide 1 hydrochlorothiazide 1 caps tabs triamterene & indapamide tabs 1 hydrochlorothiazide 1 tabs metolazone tabs 1 Loop Diuretics ENDOCRINE AND METABOLIC AGENTS - bumetanide tabs 1 MISC. - Drugs to Treat Bone Disease and Regulate Hormones BUMEX TABS GP Bone Density Regulators (bumetanide)
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77 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTONEL TABS 150 MG ST; Limit 1 per NATPARA CART PA GP month;QL(0.04 (risedronate sodium) (parathyroid hormone 3 ea daily) (recombinant)) ACTONEL TABS 35 MG ST; Limit 4 per ST; Limit 1 per GP month;QL(0.15 risedronate sodium (risedronate sodium) 1 month;QL(0.04 ea daily) tabs 150 mg ea daily) ACTONEL TABS 5 MG ST; QL(1 ea ST; QL(1 ea GP daily) risedronate sodium 1 (risedronate sodium) tabs 30 mg, 5 mg daily) alendronate sodium 1 ST; Limit 4 per soln 70 mg/75ml risedronate sodium 1 tabs 35 mg month;QL(0.15 alendronate sodium ea daily) tabs 10 mg, 40 mg, 5 1 risedronate sodium Limit 4 per mg 1 month;QL(0.15 tbec 35 mg ea daily) Limit 4 per alendronate sodium TYMLOS SOPN PA 1 month;QL(0.15 3 tabs 35 mg, 70 mg ea daily) (abaloparatide) ATELVIA TBEC Limit 4 per Fertility Regulators GP month;QL(0.15 (risedronate sodium) CHORIONIC ea daily) GONADOTROPIN SOLR 3 BINOSTO TBEF Limit 4 per (chorionic 3 month;QL(0.15 gonadotropin) (alendronate sodium) ea daily) Limit 15 per BONIVA TABS Limit 1 per clomiphene citrate tabs 1 month;QL(0.5 GP month;QL(0.04 ea daily) (ibandronate sodium) ea daily) FOLLISTIM AQ SOLN calcitonin (salmon) soln PA 3 3 (follitropin beta) ij 200 unit/ml GONAL-F RFF REDIJECT 3 calcitonin (salmon) soln 1 SOLN (follitropin alfa) na 200 unit/act GONAL-F RFF SOLR 3 etidronate disodium 1 (follitropin alfa) tabs GONAL-F SOLR 3 FOSAMAX PLUS D TABS PA; Limit 4 per (follitropin alfa) month;QL(0.15 (alendronate sodium- 3 MENOPUR SOLR ea daily) 3 cholecalciferol) (menotropins) FOSAMAX TABS Limit 4 per NOVAREL SOLR GP month;QL(0.15 (alendronate sodium) ea daily) (chorionic 3 gonadotropin) ibandronate sodium Limit 1 per 1 month;QL(0.04 OVIDREL INJ tabs ea daily) (choriogonadotropin 3 MIACALCIN SOLN PA alfa) GP (calcitonin (salmon)) PREGNYL W/DILUENT BENZYLALCOHOL/NACL SOLR (chorionic 3 gonadotropin) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GnRH/LHRH Antagonists PA; Use OMNITROPE SOLR CETROTIDE KIT 3 preferred 3 (somatropin) Humatrope or (cetrorelix acetate) Norditropin ganirelix acetate sosy 3 SEROSTIM SOLR PA; Use preferred GANIRELIX ACETATE (somatropin (non- 3 GP Humatrope or SOSY (ganirelix acetate) refrigerated)) Norditropin Growth Hormone Receptor Antagonists PA; Use ZOMACTON SOLR SOMAVERT SOLR PA 3 preferred 3 (somatropin) Humatrope or (pegvisomant) Norditropin Growth Hormones Hormone Receptor Modulators PA; Use EVISTA TABS ( QL(1 ea daily); GENOTROPIN MINIQUICK raloxifene GP 3 preferred PV SOLR (somatropin) Humatrope or hcl) Norditropin OSPHENA TABS 3 PA; Use (ospemifene) GENOTROPIN SOLR preferred 3 PV QL(1 ea daily); (somatropin) Humatrope or raloxifene hcl tabs PV Norditropin Insulin-Like Growth Factors (Somatomedins) HUMATROPE COMBO PA INCRELEX SOLN PA PACK SOLR 3 3 (somatropin) (mecasermin) HUMATROPE SOLR PA LHRH/GnRH Agonist Analog Pituitary 3 (somatropin) SYNAREL SOLN 2 NORDITROPIN FLEXPRO PA (nafarelin acetate) SOPN 10 MG/1.5ML, 15 Metabolic Modifiers MG/1.5ML, 30 MG/3ML 3 BUPHENYL POWD PA (somatropin) (sodium GP NORDITROPIN FLEXPRO PA; Use phenylbutyrate) SOPN 5 MG/1.5ML 3 preferred Humatrope or BUPHENYL TABS PA (somatropin) Norditropin (sodium GP PA; Use phenylbutyrate) NUTROPIN AQ NUSPIN preferred 3 calcitriol caps or 0.25 1 10 SOPN (somatropin) Humatrope or mcg, 0.5 mcg Norditropin PA; Use calcitriol soln or 1 1 NUTROPIN AQ NUSPIN mcg/ml 3 preferred 20 SOPN (somatropin) Humatrope or CARBAGLU TABS 3 Norditropin (carglumic acid) PA; Use CARNITOR SF SOLN NUTROPIN AQ NUSPIN 5 3 preferred (levocarnitine GP SOPN (somatropin) Humatrope or Norditropin (metabolic modifiers))
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79 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARNITOR SOLN RAYALDEE CPCR PA 3 (levocarnitine GP (calcifediol) (metabolic modifiers)) ROCALTROL CAPS GP CARNITOR TABS (calcitriol) (levocarnitine GP ROCALTROL SOLN GP (metabolic modifiers)) (calcitriol) PA cinacalcet hcl tabs 1 sapropterin 3 dihydrochloride pack CYSTADANE POWD 3 PA (betaine) sapropterin 3 dihydrochloride tabs doxercalciferol caps 1 SENSIPAR TABS GP GALAFOLD CAPS PA; QL(0.5 ea (cinacalcet hcl) 3 (migalastat hcl) daily) PA sodium phenylbutyrate 3 KUVAN PACK PA powd (sapropterin GP PA sodium phenylbutyrate 3 dihydrochloride) tabs KUVAN TABS PA STRENSIQ SOLN PA 3 (sapropterin GP (asfotase alfa) ) dihydrochloride XURIDEN PACK ( uridine 3 levocarnitine (metabolic 1 triacetate) modifiers) soln ZEMPLAR CAPS GP levocarnitine (metabolic 1 (paricalcitol) modifiers) tabs Posterior Pituitary Hormones MYALEPT SOLR PA 3 DDAVP SOLN NA 0.01 % (metreleptin) (desmopressin acetate 2 nitisinone caps 3 PA refrigerated) PA DDAVP SOLN NA 0.01 % NITYR TABS (nitisinone) 3 (desmopressin acetate GP ORFADIN CAPS 10 MG, 2 PA spray) GP MG, 5 MG (nitisinone) DDAVP TABS OR 0.1 MG, ORFADIN CAPS 20 MG PA 0.2 MG (desmopressin GP 3 (nitisinone) acetate) ORFADIN SUSP 4 MG/ML PA desmopressin acetate 3 1 (nitisinone) spray refrigerated soln PALYNZIQ SOSY PA desmopressin acetate 3 1 (pegvaliase-pqpz) spray soln paricalcitol caps 1 desmopressin acetate 1 tabs PA RAVICTI LIQD (glycerol NOCTIVA EMUL PA 3 3 phenylbutyrate) (desmopressin acetate)
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Updated 07/01/2021 80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STIMATE SOLN (Estradiol & Norethindrone 3 (desmopressin acetate) Acetate) AMABELZ, 1 LOPREEZA, MIMVEY, Prolactin Inhibitors MIMVEY LO TABS cabergoline tabs 1 (Norethindrone Acetate- Ethinyl Estradiol) 1 Somatostatic Agents FYAVOLV, JINTELI TABS octreotide acetate soln PA ACTIVELLA TABS 100 mcg/ml, 1000 (estradiol & GP mcg/5ml, 1000 mcg/ml, 3 norethindrone acetate) 200 mcg/ml, 50 ANGELIQ TABS 3 mcg/ml, 500 mcg/ml (drospirenone-estradiol) octreotide acetate soln PA CLIMARA PRO PTWK Limit 4 per 1000 mcg/ml, 200 4 (estradiol- 2 month;QL(0.14 mcg/ml levonorgestrel) ea daily) SANDOSTATIN SOLN PA COMBIPATCH PTTW GP (octreotide acetate) (estradiol & 3 SIGNIFOR SOLN PA norethindrone acetate) (pasireotide 3 DUAVEE TABS diaspartate) (conjugated estrogens- 3 ) Vasopressin Receptor Antagonists bazedoxifene JYNARQUE TABS 15 MG, QL(1 ea daily) esterified estrogens & QL(1 ea daily) 3 30 MG (tolvaptan) methyltestosterone 1 JYNARQUE TBPK PA; SP tabs 3 (tolvaptan) estradiol & SAMSCA TABS QL(1 ea daily) norethindrone acetate 1 GP (tolvaptan) tabs QL(1 ea daily) FEMHRT TABS tolvaptan tabs 3 (norethindrone acetate- GP ESTROGENS - Hormone Replacement/Modifying ethinyl estradiol) Drugs norethindrone acetate- 1 Estrogen Combinations ethinyl estradiol tabs PREFEST TABS (Esterified Estrogens & QL(1 ea daily) 3 Methyltestosterone) (estradiol-norgestimate) COVARYX, COVARYX HS, PREMPHASE TABS EEMT, EEMT HS, (conjugated estrogens- ESTERIFIED 1 2 ESTROGENS/METHYLTE medroxyprogesterone STOSTERONE DS, acetate) ESTERIFIED PREMPRO TABS 0.3 MG- QL(1 ea daily) ESTROGENS/METHYLTE 1.5 MG (conjugated STOSTERONE HS TABS estrogens- 2 medroxyprogesterone acetate)
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81 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMPRO TABS 0.45 Limit 50gms ESTROGEL GEL MG-1.5 MG, 0.625 MG-2.5 3 per MG, 0.625 MG-5 MG (estradiol) month;QL(1.67 (conjugated estrogens- 2 gm daily) EVAMIST SOLN medroxyprogesterone 3 acetate) (estradiol) MENEST TABS Estrogens 2 (esterified estrogens) (Estradiol) DOTTI, Limit 8 per 1 month;QL(0.29 MENOSTAR PTWK Limit 4 per LYLLANA PTTW 3 month;QL(0.14 ea daily) (estradiol) Limit 8 per ea daily) ALORA PTTW (estradiol) 2 month;QL(0.29 MINIVELLE PTTW Limit 8 per GP month;QL(0.29 ea daily) (estradiol) CLIMARA PTWK 0.025 Limit 4 per ea daily) MG/24HR, 0.06 MG/24HR, month;QL(0.15 PREMARIN TABS 2 0.075 MG/24HR, 0.1 GP ea daily) (estrogens, conjugated) MG/24HR, 37.5 VIVELLE-DOT PTTW Limit 8 per MCG/24HR (estradiol) GP month;QL(0.29 (estradiol) CLIMARA PTWK 0.05 Limit 4 per 28 ea daily) GP days;QL(0.15 MG/24HR (estradiol) FLUOROQUINOLONES - Drugs to Treat Bacterial ea daily) Infections DIVIGEL GEL 0.25 MG/0.25GM, 0.5 Fluoroquinolones MG/0.5GM, 1 MG/GM, 1.25 3 AVELOX TABS GP MG/1.25GM (estradiol) (moxifloxacin hcl) ELESTRIN GEL BAXDELA TABS ST 3 (estradiol) (delafloxacin 3 ESTRACE TABS meglumine) GP (estradiol) CIPRO SUSR 5 estradiol pttw td 0.025 Limit 8 per GM/100ML, 500 MG/5ML 2 mg/24hr, 0.0375 month;QL(0.29 (ciprofloxacin) ea daily) CIPRO TABS 250 MG, 500 mg/24hr, 0.05 mg/24hr, 1 GP 0.075 mg/24hr, 0.1 MG (ciprofloxacin hcl) mg/24hr ciprofloxacin hcl tabs 1 estradiol ptwk td 0.025 Limit 4 per mg/24hr, 0.06 mg/24hr, month;QL(0.15 ciprofloxacin susr 1 ea daily) 0.075 mg/24hr, 0.1 1 LEVAQUIN TABS QL(14 ea per GP mg/24hr, 37.5 (levofloxacin) fill retail) mcg/24hr levofloxacin soln 25 1 estradiol ptwk td 0.05 Limit 4 per 28 mg/ml 1 days;QL(0.15 mg/24hr QL(14 ea per ea daily) levofloxacin tabs 250 1 mg, 500 mg, 750 mg fill retail) estradiol tabs or 0.5 1 mg, 1 mg, 2 mg moxifloxacin hcl tabs 1
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Updated 07/01/2021 82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ofloxacin tabs 1 metoclopramide hcl 1 soln GASTROINTESTINAL AGENTS - MISC. - metoclopramide hcl 1 Miscellaneous Gastrointestinal Drugs tabs Agents for Chronic Idiopathic Constipation (CIC) metoclopramide hcl TRULANCE TABS PA 1 3 tbdp ( ) plecanatide METOCLOPRAMIDE ODT Bile Acid Synthesis Disorder Agents TBDP (metoclopramide 3 CHOLBAM CAPS ( PA hcl) cholic 3 acid) REGLAN TABS GP Farnesoid X Receptor (FXR) Agonists (metoclopramide hcl) OCALIVA TABS PA Inflammatory Bowel Agents 3 (obeticholic acid) APRISO CP24 GP Gallstone Solubilizing Agents (mesalamine) ACTIGALL CAPS ASACOL HD TBEC PA GP 3 (ursodiol) (mesalamine) CHENODAL TABS PA AZULFIDINE EN-TABS 3 GP (chenodiol) TBEC (sulfasalazine) RELTONE CAPS AZULFIDINE TABS 3 GP (ursodiol) (sulfasalazine) URSO 250 TABS Limit 282 caps GP (ursodiol) balsalazide disodium 1 per caps month;QL(9.4 URSO FORTE TABS GP ea daily) (ursodiol) CANASA SUPP GP ursodiol caps 1 (mesalamine) CIMZIA KIT PA 3 ursodiol tabs 1 (certolizumab pegol) CIMZIA STARTER KIT KIT PA Gastrointestinal Antiallergy Agents 3 (certolizumab pegol) cromolyn sodium 1 Limit 282 caps (mastocytosis) conc COLAZAL CAPS GP per GASTROCROM CONC (balsalazide disodium) month;QL(9.4 (cromolyn sodium GP ea daily) (mastocytosis)) DELZICOL CPDR QL(12 ea daily) GP Gastrointestinal Chloride Channel Activators (mesalamine) AMITIZA CAPS DIPENTUM CAPS GP 3 (lubiprostone) (olsalazine sodium) LIALDA TBEC lubiprostone caps 1 GP (mesalamine) Gastrointestinal Stimulants mesalamine cp24 or 1 0.375 gm
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83 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(12 ea daily) RELISTOR TABS PA mesalamine cpdr or 1 400 mg (methylnaltrexone 3 mesalamine enem re 4 bromide) 1 SYMPROIC TABS PA gm 3 (naldemedine tosylate) mesalamine supp re 1 1000 mg Phosphate Binder Agents calcium acetate mesalamine tbec or 1.2 1 gm (phosphate binder) 1 PENTASA CPCR PA caps 3 (mesalamine) FOSRENOL CHEW 1000 SFROWASA ENEM MG, 500 MG, 750 MG GP 2 (mesalamine) (lanthanum carbonate) lanthanum carbonate 1 sulfasalazine tabs 1 chew sulfasalazine tbec 1 PHOSLYRA SOLN (calcium acetate 3 Intestinal Acidifiers (phosphate binder)) (Lactulose RENAGEL TABS PA GP (Encephalopathy)) 1 (sevelamer hcl) ENULOSE, GENERLAC RENVELA PACK SOLN GP (sevelamer carbonate) lactulose 1 RENVELA TABS (encephalopathy) soln GP (sevelamer carbonate) Irritable Bowel Syndrome (IBS) Agents sevelamer carbonate 1 alosetron hcl tabs 1 PA pack LINZESS CAPS sevelamer carbonate 2 1 (linaclotide) tabs LOTRONEX TABS PA PA GP sevelamer hcl tabs 1 (alosetron hcl) VELPHORO CHEW PA VIBERZI TABS PA 3 (sucroferric 3 (eluxadoline) oxyhydroxide) Peripheral Opioid Receptor Antagonists Short Bowel Syndrome (SBS) Agents alvimopan caps 1 GATTEX KIT PA 3 ENTEREG CAPS (teduglutide (rdna)) GP (alvimopan) Tryptophan Hydroxylase Inhibitors MOVANTIK TABS XERMELO TABS PA 3 3 (naloxegol oxalate) (telotristat etiprate) RELISTOR SOLN PA GENITOURINARY AGENTS - MISCELLANEOUS (methylnaltrexone 3 - Miscellaneous Drugs to Treat Reproductive bromide) Organs and Urinary System Acidifiers You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits K-PHOS NO 2 TABS ELMIRON CAPS QL(3 ea daily) (potassium & sodium 2 (pentosan polysulfate 3 acid phosphates) sodium) Alkalinizers Prostatic Hypertrophy Agents (Pot & Sod Citrates alfuzosin hcl tb24 1 W/Citric Ac) CYTRA-3 1 SYRP AVODART CAPS AL(At least 40 GP (Potassium Citrate-Citric (dutasteride) yrs old) Acid) CYTRA K 1 CARDURA XL TB24 CRYSTALS, TARON- (doxazosin mesylate 3 CRYSTALS PACK (bph)) (Sodium Citrate & Citric 1 RX/OTC Acid) CYTRA-2 SOLN 1 AL(At least 40 dutasteride caps yrs old) CYTRA-K SOLN RX/OTC (potassium citrate-citric GP dutasteride-tamsulosin 1 acid) hcl caps QL(1 ea daily); ORACIT SOLN (sodium 3 finasteride tabs 1 AL(At least 40 citrate & citric acid) yrs old) pot & sod citrates FLOMAX CAPS QL(2 ea daily) 1 GP w/citric ac soln (tamsulosin hcl) potassium citrate 1 JALYN CAPS (alkalinizer) tbcr (dutasteride-tamsulosin GP RX/OTC hcl) potassium citrate-citric 1 acid soln PROSCAR TABS QL(1 ea daily); RX/OTC GP AL(At least 40 sodium citrate & citric 1 (finasteride) yrs old) acid soln RAPAFLO CAPS GP UROCIT-K 10 TBCR (silodosin) (potassium citrate GP (alkalinizer)) silodosin caps 4 mg, 8 1 mg UROCIT-K 15 TBCR (potassium citrate GP tamsulosin hcl caps 1 QL(2 ea daily) (alkalinizer)) UROXATRAL TB24 GP UROCIT-K 5 TBCR (alfuzosin hcl) (potassium citrate GP (alkalinizer)) Urinary Analgesics (Phenazopyridine Hcl) 1 Cystinosis Agents PHENAZO TABS CYSTAGON CAPS 3 phenazopyridine hcl 1 (cysteamine bitartrate) tabs PROCYSBI CPDR 25 MG, PYRIDIUM TABS GP 75 MG (cysteamine 3 (phenazopyridine hcl) bitartrate) Urinary Stone Agents Interstitial Cystitis Agents
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85 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITHOSTAT TABS PA 3 RUCONEST SOLR (c1 (acetohydroxamic acid) esterase inhibitor 3 THIOLA EC TBEC (recombinant)) 3 (tiopronin) Hemataologic - Tyrosine Kinase Inhibitors GP TAVALISSE TABS PA; SP THIOLA TABS (tiopronin) 3 (fostamatinib disodium) 1 tiopronin tabs Hematorheologic Agents GOUT AGENTS - Drugs to Treat Gout pentoxifylline tbcr 1 Gout Agent Combinations Plasma Kallikrein Inhibitors colchicine w/ TAKHZYRO SOLN PA 1 3 probenecid tabs (lanadelumab-flyo) Gout Agents Platelet Aggregation Inhibitors AGGRENOX CP12 allopurinol tabs 1 GP (aspirin-dipyridamole) colchicine caps 1 AGRYLIN CAPS GP (anagrelide hcl) febuxostat tabs 1 anagrelide hcl caps 1 MITIGARE CAPS GP (colchicine) aspirin-dipyridamole 1 ULORIC TABS cp12 GP BRILINTA TABS (febuxostat) 2 ZYLOPRIM TABS (ticagrelor) GP CABLIVI KIT PA (allopurinol) 3 (caplacizumab-yhdp) Uricosurics cilostazol tabs 1 QL(2 ea daily) probenecid tabs 1 QL(2 ea daily) clopidogrel bisulfate 1 HEMATOLOGICAL AGENTS - MISC. - Drugs to tabs Treat Blood Disorders Bradykinin B2 Receptor Antagonists dipyridamole tabs 1 FIRAZYR SOLN ( PA EFFIENT TABS icatibant GP GP acetate) (prasugrel hcl) PA PLAVIX TABS QL(2 ea daily) icatibant acetate soln 3 GP (clopidogrel bisulfate) Complement Inhibitors prasugrel hcl tabs 1 BERINERT KIT (c1 PA; SP ZONTIVITY TABS esterase inhibitor 3 2 (human)) (vorapaxar sulfate) HAEGARDA SOLR (c1 PA HEMATOPOIETIC AGENTS - Drugs to Treat esterase inhibitor 3 Blood Disorders (human)) Agents for Gaucher Disease
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Updated 07/01/2021 86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CERDELGA CAPS PA EPOGEN SOLN ( PA 3 epoetin 3 (eliglustat tartrate) alfa) miglustat caps 3 PA GRANIX SOSY 300 PA MCG/0.5ML, 480 ZAVESCA CAPS PA 3 GP MCG/0.8ML (tbo- (miglustat) filgrastim) Agents for Sickle Cell Disease LEUKINE SOLR PA 3 DROXIA CAPS (sargramostim) (hydroxyurea (sickle AC MIRCERA SOSY PA cell anemia)) (methoxy polyethylene 3 ENDARI PACK PA glycol-epoetin beta) 3 (glutamine (sickle cell)) MULPLETA TABS PA 3 SIKLOS TABS PA (lusutrombopag) (hydroxyurea (sickle 3 NEULASTA ONPRO KIT PA 3 cell anemia)) PSKT (pegfilgrastim) NEULASTA SOSY PA Folic Acid/Folates 3 (Folic Acid) CVS FOLIC PV (pegfilgrastim) ACID, FOLATE, GNP NEUPOGEN SOLN PA 3 FOLIC ACID, HM FOLIC (filgrastim) ACID, PX FOLIC ACID, QC PV NEUPOGEN SOSY PA FOLIC ACID, RA FOLIC 3 ACID, SM FOLIC ACID, YL (filgrastim) FOLIC ACID TABS NIVESTYM SOSY 300 PA MCG/0.5ML, 480 (Folic Acid) KP FOLIC PV RX/OTC; PV 3 ACID TABS 1 MG MCG/0.8ML (filgrastim- aafi) (Folic Acid) KP FOLIC PV PV ACID TABS 800 MCG PROCRIT SOLN 10000 PA folic acid soln ij 5 PV UNIT/ML, 2000 UNIT/ML, PV 20000 UNIT/ML, 3000 mg/ml UNIT/ML, 4000 UNIT/ML, 3 folic acid tabs or 1 mg PV RX/OTC; PV 40000 UNIT/ML (epoetin alfa) folic acid tabs or 400 PV PV PROMACTA PACK PA mcg, 800 mcg 3 (eltrombopag olamine) Hematopoietic Growth Factors PROMACTA TABS PA 3 ARANESP ALBUMIN PA (eltrombopag olamine) FREE SOLN 3 RETACRIT SOLN 10000 PA (darbepoetin alfa) UNIT/ML, 2000 UNIT/ML, ARANESP ALBUMIN PA 20000 UNIT/2ML, 20000 FREE SOSY 3 UNIT/ML, 3000 UNIT/ML, 3 (darbepoetin alfa) 4000 UNIT/ML, 40000 DOPTELET TABS PA UNIT/ML (epoetin alfa- (avatrombopag 3 epbx) ) ZARXIO SOSY PA maleate 3 (filgrastim-sndz)
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87 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZIEXTENZO SOSY PA AMICAR TABS 1000 MG, 3 (pegfilgrastim-bmez) 500 MG (aminocaproic GP Hematopoietic Mixtures acid) FOLIVANE-F CAPS aminocaproic acid tabs 1 (ferrous fumarate-iron 1000 mg, 500 mg 2 LYSTEDA TABS QL(6 ea daily,5 polysaccharide GP complex-folic acid-c-b3) (tranexamic acid) day(s) limit) FUSION PLUS CAPS (fe 1 QL(6 ea daily,5 tranexamic acid tabs day(s) limit) fum-iron polysacch 3 complex-fa-b cmplx-c- HYPNOTICS/SEDATIVES/SLEEP DISORDER biotin-probiotic) AGENTS INTEGRA F CAPS Barbiturate Hypnotics (ferrous fumarate-iron BUTISOL SODIUM TABS 2 3 polysaccharide (butabarbital sodium) complex-folic acid-c-b3) phenobarbital elix 20 1 Iron mg/5ml (Carbonyl Iron) WEE PV PV phenobarbital soln 20 1 CARE SUSP mg/5ml (Ferrous Sulfate) PV BPROTECTED PEDIA phenobarbital tabs 100 IRON, FE-VITE IRON, mg, 15 mg, 16.2 mg, 30 1 IRON SUPPLEMENT PV mg, 32.4 mg, 60 mg, CHILDRENS, PC 64.8 mg, 97.2 mg PEDIATRIC IRON DROPS SECONAL SODIUM CAPS 3 SOLN (secobarbital sodium) (Ferrous Sulfate) PV FEROSUL, IRON PV Hypnotics - Tricyclic Agents SUPPLEMENT ELIX doxepin hcl (sleep) tabs 1 ST; QL(1 ea FER-IN-SOL SOLN PV daily) GP SILENOR TABS ( ST; QL(1 ea (ferrous sulfate) doxepin GP hcl (sleep)) daily) ferrous sulfate elix PV PV Non-Barbiturate Hypnotics PV ferrous sulfate soln PV AMBIEN CR TBCR QL(1 ea daily) GP (zolpidem tartrate) ferrous sulfate syrp PV PV AMBIEN TABS (zolpidem QL(1 ea daily) ICAR PEDIATRIC SUSP PV GP GP tartrate) (carbonyl iron) DORAL TABS MYKIDZ IRON 10 SUSP PV GP PV (quazepam) (iron) EDLUAR SUBL ST; QL(1 ea 3 HEMOSTATICS - Drugs to Stop Bleeding/Treat (zolpidem tartrate) daily) Blood Disorders estazolam tabs 1 Hemostatics - Systemic eszopiclone tabs 1 QL(1 ea daily)
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Updated 07/01/2021 88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits flurazepam hcl caps 1 Laxative Combinations (Bisacodyl-Peg 3350-Pot PV HALCION TABS GP Chloride-Sod Bicarb-Sod PV (triazolam) Chloride) GAVILYTE-H, INTERMEZZO SUBL PA PEG-PREP KIT GP (zolpidem tartrate) (Peg 3350-Kcl-Nacl-Na PV LUNESTA TABS QL(1 ea daily) Sulfate-Na Ascorbate- GP (eszopiclone) Ascorbic Acid) PEG- PV 3350/ELECTROLYTES/AS midazolam hcl syrp 1 CORBATE SOLR (Peg 3350-Kcl-Sod Bicarb- PV quazepam tabs 1 Sod Chloride-Sod Sulfate) PV GAVILYTE-G SOLR RESTORIL CAPS GP (Peg 3350-Potassium PV (temazepam) Chloride-Sod Bicarbonate- temazepam caps 1 Sod Chloride) GAVILYTE- PV N/FLAVOR PACK, triazolam tabs 1 TRILYTE SOLR COLYTE-FLAVOR PACKS PV zaleplon caps 1 QL(1 ea daily) SOLR (peg 3350-kcl-sod bicarb-sod chloride-sod GP zolpidem tartrate subl PA 1 sulfate) sl 1.75 mg, 3.5 mg GOLYTELY SOLR 2.82 PA; PV QL(1 ea daily) zolpidem tartrate tabs 1 GM-21.5 GM-227.1 GM- or 10 mg, 5 mg 5.53 GM-6.36 GM (peg QL(1 ea daily) PV zolpidem tartrate tbcr 1 3350-kcl-sod bicarb- or 12.5 mg, 6.25 mg sod chloride-sod ST; Limit 1 sulfate) ZOLPIMIST SOLN 3 bottle per GOLYTELY SOLR 2.97 PV (zolpidem tartrate) month;QL(0.26 GM-22.74 GM-236 GM- ml daily) 5.86 GM-6.74 GM (peg Orexin Receptor Antagonists 3350-kcl-sod bicarb- GP BELSOMRA TABS ST; QL(1 ea sod chloride-sod 2 (suvorexant) daily) sulfate) Selective Melatonin Receptor Agonists MOVIPREP SOLR (peg PV HETLIOZ CAPS PA 3350-kcl-nacl-na 3 GP (tasimelteon) sulfate-na ascorbate- HETLIOZ LQ SUSP PA ascorbic acid) 3 (tasimelteon) NULYTELY SOLR (peg PV 3350-potassium 1 ST; QL(1 ea ramelteon tabs daily) chloride-sod GP ROZEREM TABS ST; QL(1 ea bicarbonate-sod GP (ramelteon) daily) chloride) LAXATIVES - Bowel Treatment Drugs
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89 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NULYTELY/FLAVOR PV Limit 528gms PACKS SOLR (peg 3350- polyethylene glycol 1 per potassium chloride-sod GP 3350 powd month;QL(17.6 bicarbonate-sod gm daily) chloride) MACROLIDES - Drugs to Treat Bacterial peg 3350-kcl-nacl-na PV Infections sulfate-na ascorbate- PV Azithromycin ascorbic acid solr azithromycin pack 1 gm 1 peg 3350-kcl-sod PV azithromycin susr 100 bicarb-sod chloride-sod PV 1 sulfate solr mg/5ml, 200 mg/5ml azithromycin tabs 250 QL(6 ea per fill peg 3350-potassium PV 1 retail) chloride-sod mg PV QL(3 ea daily) bicarbonate-sod azithromycin tabs 500 1 chloride solr mg QL(10 ea per Laxatives - Miscellaneous azithromycin tabs 600 1 mg fill retail,10 ea (Lactulose) CONSTULOSE 1 per fill mail) SOLN ZITHROMAX PACK 1 GM GP (Polyethylene Glycol 3350) Limit 528gms (azithromycin) CLEARLAX, CVS per PURELAX, EQ month;QL(17.6 ZITHROMAX SUSR 100 CLEARLAX, EQL gm daily) MG/5ML, 200 MG/5ML GP CLEARLAX, GAVILAX, (azithromycin) GENTLELAX, GLYCOLAX, ZITHROMAX TABS 250 QL(6 ea per fill GP GNP CLEARLAX, MG (azithromycin) retail) GOODSENSE CLEARLAX, 1 ZITHROMAX TABS 500 QL(3 ea daily) HM CLEARLAX, KLS GP LAXACLEAR, MM MG (azithromycin) CLEARLAX, QC NATURA- ZITHROMAX TABS 600 QL(10 ea per LAX, RA LAXATIVE, SB GP fill retail,10 ea POLYETHYLENE GLYCOL MG (azithromycin) per fill mail) 3350, SM CLEARLAX, ZITHROMAX TRI-PAK QL(3 ea daily) SMOOTH LAX, TGT GP POWDERLAX POWD TABS (azithromycin) KRISTALOSE PACK 10 ZITHROMAX Z-PAK TABS QL(6 ea per fill 3 GP retail) GM, 20 GM (lactulose) (azithromycin) LACTULOSE PACK 10 GM Clarithromycin 3 (lactulose) clarithromycin susr 125 1 mg/5ml, 250 mg/5ml lactulose soln 10 1 gm/15ml, 20 gm/30ml clarithromycin tabs 250 1 MIRALAX POWD Limit 528gms mg, 500 mg (polyethylene glycol GP per clarithromycin tb24 500 QL(14 ea per month;QL(17.6 1 fill retail) 3350) gm daily) mg Erythromycins
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Updated 07/01/2021 90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Erythromycin Base) ERY- 1 QL(1 EA PER TAB TBEC DIAPHRAGM PV 365 DAYS (Erythromycin RETAIL);PV Ethylsuccinate) E.E.S. 400 1 DUREX EXTRA PV TABS SENSITIVE DEVI PV (Erythromycin Stearate) (condoms latex ERYTHROCIN STEARATE 1 lubricated - male) TABS FANTASY LUBRICATED PV E.E.S. GRANULES SUSR MISC (condoms latex PV (erythromycin GP lubricated - male) ethylsuccinate) FANTASY PV ERYPED 200 SUSR LUBRICATED/SPERMICID (erythromycin GP E MISC (condoms latex PV ethylsuccinate) lubricated - male) ERYPED 400 SUSR FC FEMALE CONDOM PV (erythromycin GP MISC (condoms - PV ethylsuccinate) female) FC2 FEMALE CONDOM PV erythromycin base 1 cpep MISC (condoms - PV female) erythromycin base tabs 1 FEMCAP DEVI ( PV cervical PV erythromycin base tbec 1 caps) K-Y ME & YOU EXTRA PV erythromycin LUBRICATED DEVI ethylsuccinate susr 200 1 (condoms latex PV mg/5ml, 400 mg/5ml lubricated - male) erythromycin K-Y ME & YOU INTENSE PV ethylsuccinate tabs 400 1 DEVI (condoms latex PV mg lubricated - male) Fidaxomicin KAMELEON LUBRICATED PV DIFICID SUSR MISC (condoms latex PV 3 (fidaxomicin) lubricated - male) DIFICID TABS KIMONO COLORS DEVI PV 3 (fidaxomicin) (condoms latex PV lubricated - male) MEDICAL DEVICES AND SUPPLIES KIMONO LUBRICATED PV Contraceptives MISC (condoms latex PV AIMSCO LUBRICATED PV lubricated - male) MISC (condoms latex PV KIMONO MICRO THIN PV lubricated - male) MISC (condoms latex PV non-lubricated - male) CAYA DPRH (diaphragm QL(1 ea per PV 365 days arc-spring) retail); PV
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91 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO MICRO THIN PV REALITY LATEX PV PLUS SPERMICIDE CONDOMS/LUBRICATED LUBRICATED MISC PV MISC (condoms latex PV (condoms latex lubricated - male) lubricated - male) REALITY LATEX/ULTRA PV KIMONO PLUS PV TEXTURED DEVI SPERMICIDE (condoms latex PV LUBRICATED MISC PV lubricated - male) (condoms latex REALITY LATEX/ULTRA PV lubricated - male) THIN DEVI (condoms PV KIMONO PLUS PV latex lubricated - male) SPERMICIDE/LUBRICATE PV TRUSTEX COLOR PV D MISC (condoms latex CONDOMS + LUBE MISC lubricated - male) (condoms latex PV KIMONO PS LUBRICATED PV lubricated - male) MISC (condoms latex PV TRUSTEX LUBRICATED PV lubricated - male) EXTRALARGE MISC KIMONO PS PLUS PV (condoms latex PV SPERMICIDE/LUBRICATE PV lubricated - male) D MISC (condoms latex TRUSTEX LUBRICATED PV lubricated - male) EXTRASTRENGTH MISC KIMONO SENSATION PV (condoms latex PV LUBRICATED MISC PV lubricated - male) (condoms latex TRUSTEX LUBRICATED PV lubricated - male) MISC (condoms latex PV KIMONO SENSATION PV lubricated - male) PLUS SPERMICIDE LUBRICATED MISC TRUSTEX PV PV LUBRICATED/RIBBED/ST (condoms latex UDDED MISC (condoms PV lubricated - male) latex lubricated - male) KIMONO SPECIAL DEVI PV TRUSTEX PV (condoms latex PV LUBRICATED/SPERMICID lubricated - male) E EXTRA LARGE MISC PV MAXX LUBRICATED MISC PV (condoms latex (condoms latex PV lubricated - male) lubricated - male) TRUSTEX PV MAXX PLUS SPERMICIDE PV LUBRICATED/SPERMICID LUBRICATED MISC E EXTRA STRENGTH PV (condoms latex PV MISC (condoms latex lubricated - male) lubricated - male) PREMIUM CONDOMS PV TRUSTEX PV LUBRICATED MISC LUBRICATED/SPERMICID (condoms latex PV E MISC (condoms latex PV lubricated - male) lubricated - male)
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Updated 07/01/2021 92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX NATURAL PV LANCETS 2 CONDOMS +LUBE/LUBRICATED PV ONETOUCH ULTRA 2 KIT QL(1 ea per MISC (condoms latex (blood glucose 2 365 days lubricated - male) monitoring supplies) retail); RX/OTC TRUSTEX NON- PV ONETOUCH ULTRA MINI QL(1 ea per LUBRICATED MISC 365 days PV KIT (blood glucose 2 (condoms latex non- monitoring supplies) retail); RX/OTC lubricated - male) ONETOUCH VERIO FLEX QL(1 ea per TRUSTEX WITH PV BLOOD GLUCOSE 365 days NONOXYNOL- MONITORING SYSTEM 2 retail); RX/OTC 9/RIBBED/STUDDED PV KIT (blood glucose MISC (condoms latex monitoring supplies) lubricated - male) ONETOUCH VERIO IQ QL(1 ea per TRUSTEX/RIA PV BLOOD GLUCOSE 365 days LUBRICATED MISC MONITORING SYSTEM retail); RX/OTC PV 2 (condoms latex KIT (blood glucose lubricated - male) monitoring supplies) TRUSTEX/RIA PV ONETOUCH VERIO KIT Limited to 1 per LUBRICATED (blood glucose 2 year;QL(1 ea SPERMICIDE MISC PV per 365 days (condoms latex monitoring supplies) retail); RX/OTC lubricated - male) ONETOUCH VERIO SYNC Limited to 1 per TRUSTEX/RIA PV BLOODGLUCOSE year;QL(1 ea LUBRICATED/SPERMICID MONITORING SYSTEM 2 per 365 days E MISC (condoms latex PV KIT (blood glucose retail); RX/OTC lubricated - male) monitoring supplies) TRUSTEX/RIA NON- PV PRECISION XTRA DEVI QL(1 ea per LUBRICATED MISC (blood glucose 2 365 days retail) (condoms latex non- PV monitoring supplies) lubricated - male) Parenteral Therapy Supplies Diabetic Supplies BD AUTOSHIELD 29G X Preferred NDC FREESTYLE FREEDOM QL(1 ea per 3/16" MISC (insulin pen 2 LITE KIT (blood glucose 2 365 days needle) monitoring supplies) retail); RX/OTC BD AUTOSHIELD 29G X Preferred NDC FREESTYLE INSULINX QL(1 ea per 5/16" MISC (insulin pen 2 BLOODGLUCOSE 365 days needle) MONITORING SYSTEM 2 retail); RX/OTC BD AUTOSHIELD DUO Preferred NDC KIT (blood glucose 30G X 5MM MISC (insulin 2 monitoring supplies) pen needle) FREESTYLE LITE BLOOD QL(1 ea per BD PEN Preferred NDC GLUCOSE MONITORING 365 days retail) NEEDLE/MICRO/ULTRA- SYSTEM DEVI (blood 2 FINE/32G X 6MM MISC 2 glucose monitoring (insulin pen needle) supplies)
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93 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD PEN Preferred CAFERGOT TABS NEEDLE/MINI/ULTRA- NDC;RX/OTC 2 (ergotamine w/ GP FINE/31G X 5MM MISC caffeine) (insulin pen needle) ergotamine w/ caffeine 1 BD PEN NEEDLE/NANO Preferred tabs 2ND GEN/32G X 5/32" NDC;RX/OTC MISC (insulin pen 2 sumatriptan-naproxen PA; Limit 9 per 1 month;QL(0.3 needle) sodium tabs ea daily) BD PEN Preferred TREXIMET TABS PA; Limit 9 per NEEDLE/NANO/ULTRA- NDC;RX/OTC 2 (sumatriptan-naproxen GP month;QL(0.3 FINE/32G X 4MM MISC ea daily) (insulin pen needle) sodium) BD PEN Preferred NDC Migraine Products - NSAIDs NEEDLE/ORIGINAL/ULTR CAMBIA PACK PA; Limit 9 per A-FINE/29G X 12.7MM 2 (diclofenac potassium 3 month;QL(0.3 MISC (insulin pen (migraine)) ea daily) needle) Migraine Products BD PEN Preferred NEEDLE/SHORT/ULTRA- NDC;RX/OTC D.H.E. 45 SOLN FINE/31G X 8MM MISC 2 (dihydroergotamine GP (insulin pen needle) mesylate) dihydroergotamine INSULIN SYRINGES AND 2 MO PEN NEEDLES mesylate soln ij 1 3 Respiratory Therapy Supplies mg/ml QL(1 EA PER dihydroergotamine QL(8 ml per fill 3 retail) SPACER/AEROSOL- 2 365 DAYS mesylate soln na 4 HOLDING CHAMBER RETAIL); mg/ml RX/OTC ERGOMAR SUBL 2 MIGRAINE PRODUCTS - Drugs to Treat Migraine (ergotamine tartrate) Headaches MIGRANAL SOLN QL(8 ml per fill Calcitonin Gene-Related Peptide (CGRP) (dihydroergotamine 3 retail) AIMOVIG SOAJ 140 PA mesylate) MG/ML (erenumab- 3 Serotonin Agonists aooe) QL(6 ea per 30 AIMOVIG SOAJ 70 MG/ML PA; SP almotriptan malate tabs 1 3 days retail) (erenumab-aooe) QL(27 ea per EMGALITY SOAJ PA AMERGE TABS 90 days 3 GP (galcanezumab-gnlm) (naratriptan hcl) retail,27 ea per 90 days mail) EMGALITY SOSY PA 3 (galcanezumab-gnlm) eletriptan hydrobromide Limit 6 tabs per 1 month;QL(0.2 Migraine Combinations tabs ea daily) (Ergotamine W/ Caffeine) 1 FROVA TABS Limit 9 per MIGERGOT SUPP GP month;QL(0.3 (frovatriptan succinate) ea daily)
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Updated 07/01/2021 94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits frovatriptan succinate Limit 9 per RELPAX TABS (eletriptan Limit 6 tabs per 1 month;QL(0.3 GP month;QL(0.2 tabs ea daily) hydrobromide) ea daily) IMITREX SOLN NA 20 Limit 6 per QL(12 ea per MG/ACT, 5 MG/ACT GP month;QL(0.2 rizatriptan benzoate 1 30 days (sumatriptan) ea daily) tabs retail,36 ea per QL(2 ml per fill 90 days mail) retail,6 ml per QL(12 ea per IMITREX SOLN SC 6 rizatriptan benzoate 30 days MG/0.5ML ( GP fill mail,4 ml per 1 sumatriptan 30 days tbdp retail,36 ea per succinate) retail,12 ml per 90 days mail) 90 days mail) Limit 6 per QL(2 ml per fill sumatriptan soln 1 month;QL(0.2 ea daily) IMITREX STATDOSE retail,6 ml per REFILL SOCT GP fill mail,4 ml per QL(2 ml per fill 30 days retail,6 ml per (sumatriptan succinate) retail,12 ml per sumatriptan succinate 1 fill mail,4 ml per 90 days mail) soaj sc 4 mg/0.5ml 30 days QL(2 ml per fill retail,12 ml per IMITREX STATDOSE retail,6 ml per 90 days mail) SYSTEM SOAJ 4 GP fill mail,4 ml per Limit 2mls per MG/0.5ML (sumatriptan 30 days fill and 4mls per succinate) retail,12 ml per month ;QL(2 ml 90 days mail) sumatriptan succinate 1 per fill retail,6 Limit 2mls per soaj sc 6 mg/0.5ml ml per fill mail,4 fill and 4mls per ml per 30 days IMITREX STATDOSE month ;QL(2 ml retail,12 ml per SYSTEM SOAJ 6 90 days mail) GP per fill retail,6 MG/0.5ML (sumatriptan ml per fill mail,4 QL(2 ml per fill succinate) ml per 30 days sumatriptan succinate retail,6 ml per retail,12 ml per 1 fill mail,4 ml per 90 days mail) soct sc 4 mg/0.5ml, 6 30 days QL(9 ea per 30 mg/0.5ml retail,12 ml per IMITREX TABS OR 100 90 days mail) MG, 25 MG, 50 MG GP days retail,27 ea per 90 days ( ) QL(2 ml per fill sumatriptan succinate mail) retail,6 ml per QL(12 ea per sumatriptan succinate 1 fill mail,4 ml per MAXALT TABS soln sc 6 mg/0.5ml 30 days GP 30 days (rizatriptan benzoate) retail,36 ea per retail,12 ml per 90 days mail) 90 days mail) QL(12 ea per sumatriptan succinate QL(9 ea per 30 MAXALT-MLT TBDP days retail,27 GP 30 days tabs or 100 mg, 25 mg, 1 (rizatriptan benzoate) retail,36 ea per ea per 90 days 90 days mail) 50 mg mail) QL(27 ea per QL(6 ea per 30 zolmitriptan soln na 2.5 days retail,18 1 90 days 1 naratriptan hcl tabs retail,27 ea per mg, 5 mg ea per 90 days 90 days mail) mail)
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95 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(12 ea per sodium fluoride chew PV zolmitriptan tabs or 2.5 1 30 days 0.25 mg, 0.5 mg, 1 mg, PV mg, 5 mg retail,36 ea per 2.2 mg 90 days mail) RX/OTC; PV QL(12 ea per sodium fluoride soln 0.5 PV mg/ml zolmitriptan tbdp or 2.5 1 30 days mg, 5 mg retail,36 ea per PV sodium fluoride tabs PV 90 days mail) 0.5 mg, 1 mg QL(6 ea per 30 ZOMIG SOLN NA 2.5 MG, Phosphate GP days retail,18 5 MG (zolmitriptan) ea per 90 days (Pot Phosphate Monobasic mail) W/ Sod Phosphate Dibasic QL(12 ea per & Monobasic) PHOSPHA ZOMIG TABS OR 2.5 MG, 250 NEUTRAL, 1 GP 30 days 5 MG (zolmitriptan) retail,36 ea per PHOSPHO-TRIN 250 90 days mail) NEUTRAL, VIRT-PHOS 250 NEUTRAL TABS QL(12 ea per ZOMIG ZMT TBDP K-PHOS NEUTRAL TABS GP 30 days (zolmitriptan) retail,36 ea per (pot phosphate 90 days mail) monobasic w/ sod GP phosphate dibasic & MINERALS & ELECTROLYTES monobasic) Calcium K-PHOS TABS CALCIFOL WAFR (potassium phosphate 2 (calcium carbonate-folic monobasic) 3 acid-vit d-b6-b12- pot phosphate boron-magnesium) monobasic w/ sod 1 CALCIUM-FOLIC ACID phosphate dibasic & PLUS D WAFR (calcium monobasic tabs carbonate-folic acid-vit 3 Potassium d-b6-b12-boron- (Potassium Bicarbonate) 1 magnesium) EFFER-K TBEF 25 MEQ MAGNEBIND 400 TABS (Potassium Bicarbonate) K- (calcium carbonate- 3 PRIME, KLOR-CON/EF 1 magnesium carbonate) TBEF Fluoride (Potassium Chloride Microencapsulated Crystals (Sodium Fluoride) PV Er) KLOR-CON M10, 1 FLUORITAB, FLURA- PV KLOR-CON M15, KLOR- DROPS, NAFRINSE CON M20 TBCR DROPS SOLN (Potassium Chloride) (Sodium Fluoride) PV PV KLOR-CON 10, KLOR- 1 NAFRINSE CHEW CON 8 TBCR FLUORABON SOLN PV PV (Potassium Chloride) 1 (sodium fluoride) KLOR-CON PACK
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Updated 07/01/2021 96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Potassium Chloride) SYPRINE CAPS ( PA trientine GP KLOR-CON SPRINKLE 1 hcl) CPCR PA EFFER-K TBEF 0.84 GM-1 trientine hcl caps 3 GM, 1.68 GM-2 GM Enzymes (potassium 3 bicarbonate-citric acid) XIAFLEX SOLR PA (collagenase K-TAB TBCR ( 3 potassium GP clostridium chloride) histolyticum) potassium chloride cpcr 1 10 meq, 8 meq Immunomodulators REVLIMID CAPS PA AC potassium chloride (lenalidomide) microencapsulated 1 THALOMID CAPS crystals er tbcr AC (thalidomide) potassium chloride 1 pack 20 meq Immunosuppressive Agents (Cyclosporine Modified (For potassium chloride soln 1 Microemulsion)) 1 10 %, 20 % GENGRAF CAPS potassium chloride tbcr (Cyclosporine Modified (For 10 meq, 20 meq, 8 1 Microemulsion)) 1 meq GENGRAF SOLN ASTAGRAF XL CP24 ST Zinc 3 (tacrolimus) (Zinc Sulfate) ORAZINC, 1 AZASAN TABS ZINC-220 CAPS 3 (azathioprine) GALZIN CAPS ( zinc 3 acetate (oral)) azathioprine tabs 1 WILZIN CAPS ( zinc 3 CELLCEPT CAPS acetate (oral)) (mycophenolate GP zinc sulfate caps 1 mofetil) CELLCEPT SUSR MISCELLANEOUS THERAPEUTIC CLASSES (mycophenolate GP mofetil) Chelating Agents CELLCEPT TABS (Trientine Hcl) CLOVIQUE 3 PA CAPS (mycophenolate GP mofetil) CUPRIMINE CAPS PA GP (penicillamine) cyclosporine caps 1 DEPEN TITRATABS TABS GP cyclosporine modified (penicillamine) (for microemulsion) 1 penicillamine caps 1 PA caps 100 mg, 25 mg, 50 mg penicillamine tabs 1
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97 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cyclosporine modified sirolimus tabs 1 (for microemulsion) 1 soln 100 mg/ml tacrolimus caps 1 ENVARSUS XR TB24 ST 3 ZORTRESS TABS 0.25 (tacrolimus) MG, 0.5 MG, 0.75 MG everolimus (everolimus GP (immunosuppressant) 1 (immunosuppressant)) tabs Potassium Removing Agents IMURAN TABS GP (Sodium Polystyrene (azathioprine) Sulfonate) KIONEX, SPS 1 SUSP mycophenolate mofetil 1 caps LOKELMA PACK ST (sodium zirconium 3 mycophenolate mofetil 1 susr cyclosilicate) sodium polystyrene mycophenolate mofetil 1 1 tabs sulfonate powd sodium polystyrene mycophenolate sodium 1 1 tbec sulfonate susp MYFORTIC TBEC VELTASSA PACK ST; Try/Fail on (patiromer sorbitex 3 generic (mycophenolate GP Kayexalate sodium) calcium) NEORAL CAPS Systemic Lupus Erythematosus Agents BENLYSTA SOAJ PA (cyclosporine modified GP 3 (for microemulsion)) (belimumab) BENLYSTA SOSY PA NEORAL SOLN 3 (cyclosporine modified GP (belimumab) (for microemulsion)) MOUTH/THROAT/DENTAL AGENTS PROGRAF CAPS 0.5 MG, GP 1 MG, 5 MG (tacrolimus) Anesthetics Topical Oral PROGRAF PACK 0.2 MG, PA FIRST-MOUTHWASH BLM 3 1 MG (tacrolimus) SUSP RAPAMUNE SOLN (diphenhydramine- GP 3 (sirolimus) lidocaine-alum hydroxide-mg RAPAMUNE TABS GP hydroxide-simeth) (sirolimus) SANDIMMUNE CAPS 100 lidocaine hcl (mouth- 1 MG, 25 MG GP throat) soln (cyclosporine) Anti-infectives - Throat SANDIMMUNE SOLN 100 2 clotrimazole troc 1 MG/ML (cyclosporine) nystatin (mouth-throat) 1 sirolimus soln 1 susp
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Updated 07/01/2021 98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORAVIG TABS MULTIVITAMIN WITH AL(Up to 6 yrs (miconazole (mouth- 3 FLUORIDE CHEW 0.3 MG- old ) throat)) 0.5 MG-1.05 MG-1.05 MG- 1.2 MG-13.5 MG-15 UNIT- Steroids - Mouth/Throat/Dental 2500 UNIT-4.5 MCG-400 (Triamcinolone Acetonide UNIT-60 MG, 0.3 MG-1 (Mouth)) ORALONE 1 MG-1.05 MG-1.05 MG-1.2 2 DENTAL PASTE PSTE MG-13.5 MG-15 UNIT- 2500 UNIT-4.5 MCG-400 triamcinolone 1 acetonide (mouth) pste UNIT-60 MG (multiple vitamins & fluoride-folic Throat Products - Misc. acid) cevimeline hcl caps 1 MULTIVITAMIN/FLUORID AL(Up to 6 yrs E CHEW 0.25 MG-0.3 MG- old ); RX/OTC EVOXAC CAPS GP 1.05 MG-1.05 MG-1.2 MG- (cevimeline hcl) 13.5 MG-15 UNIT-2500 2 GELCLAIR GEL UNIT-4.5 MCG-400 UNIT- (povidone-sodium 60 MG (multiple vitamins hyaluronate- 3 & fluoride-folic acid) glycyrrhetinic acid) Multiple Vitamins w/ Minerals MUCOTROL WAFR ( oral 3 ONEVITE TABS (multiple wound care products) vitamins w/ minerals & 3 folic acid) pilocarpine hcl (oral) 1 tabs THRIVITE 19 TABS SALAGEN TABS (multiple vitamins w/ 3 GP (pilocarpine hcl (oral)) minerals & folic acid) UDAMIN SP TABS MULTIVITAMINS (multiple vitamins w/ 3 Multiple Vitamins & Fluoride-Folic Acid minerals & folic acid) MULTIVITAMIN WITH AL(Up to 6 yrs Ped MV w/ Fluoride FLUORIDE CHEW 0.25 old ); RX/OTC (Pediatric Multivitamins AL(Up to 6 yrs MG-0.3 MG-1.05 MG-1.05 W/Fl) MULTI- old ); RX/OTC MG-1.2 MG-13.5 MG-15 1 2 VITAMIN/FLUORIDE UNIT-2500 UNIT-4.5 MCG- DROPS SOLN 400 UNIT-60 MG (multiple vitamins & fluoride-folic acid)
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99 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Multivitamins AL(Up to 6 yrs FLORIVA PLUS SOLN AL(Up to 6 yrs W/Fl) MULTIVITAMIN old ); RX/OTC (pediatric multivitamins 2 old ); RX/OTC WITH FLUORIDE, w/fl) MULTIVITAMIN/FLUORID AL(Up to 6 yrs E SOLN 0.25 MG/ML-0.4 pediatric vitamins acd 1 MG/ML-0.5 MG/ML-0.6 w/ fluoride soln old ) MG/ML-1500 UNIT/ML-2 POLY-VI-FLOR CHEW AL(Up to 6 yrs MCG/ML-35 MG/ML-400 1 0.25 MG-15 UNIT-200 old ) UNIT/ML-5 UNIT/ML-8 MCG-400 UNIT, 0.5 MG-15 MG/ML, 0.4 MG/ML-0.5 UNIT-200 MCG-400 UNIT, 3 MG/ML-0.5 MG/ML-0.6 1 MG-15 UNIT-200 MCG- MG/ML-1500 UNIT/ML-2 400 UNIT (pediatric MCG/ML-35 MG/ML-400 UNIT/ML-5 UNIT/ML-8 multivitamins w/fl) MG/ML POLY-VI-FLOR SUSP 0.25 MG/ML-200 MCG/ML (Pediatric Multivitamins AL(Up to 6 yrs 3 W/Fl) old ); RX/OTC (pediatric multivitamins MULTIVITAMIN/FLUORID w/fl) E CHEW 0.25 MG-0.3 MG- QUFLORA GUMMIES AL(Up to 6 yrs 1.05 MG-1.05 MG-1.2 MG- CHEW (pediatric 2 old ) 13.5 MG-15 UNIT-2500 UNIT-4.5 MCG-400 UNIT- multivitamins w/fl) 60 MG, 0.3 MG-0.5 MG- 1 QUFLORA PEDIATRIC AL(Up to 6 yrs 1.05 MG-1.05 MG-1.2 MG- CHEW (pediatric 2 old ); RX/OTC 13.5 MG-15 UNIT-2500 multivitamins w/fl) UNIT-4.5 MCG-400 UNIT- 60 MG, 0.3 MG-1 MG-1.05 QUFLORA PEDIATRIC AL(Up to 6 yrs MG-1.05 MG-1.2 MG-13.5 SOLN (pediatric 2 old ); RX/OTC MG-15 UNIT-2500 UNIT- multivitamins w/fl) 4.5 MCG-400 UNIT-60 MG TRI-VI-FLOR SUSP (Pediatric Multivitamins AL(Up to 6 yrs (pediatric vitamins acd 3 W/Fl) 1 old ); RX/OTC & l-methylfolate w/ MULTIVITAMINS/FLUORI fluoride) DE CHEW TRI-VI-FLORO SUSP (Pediatric Vitamins Acd W/ AL(Up to 6 yrs (pediatric vitamins acd Fluoride) MULTIVITAMIN old ); RX/OTC 3 SELECT/FLUORIDE, 1 & l-methylfolate w/ VITAMINS fluoride) A/C/D/FLUORIDE SOLN Ped Multi Vitamins w/Fl & FE (Pediatric Vitamins Acd W/ AL(Up to 6 yrs (Ped Multivitamins W/Fl & RX/OTC Fluoride) TRI- old ); RX/OTC Iron) MULTI- VITE/FLUORIDE SOLN 1 VIT/IRON/FLUORIDE, 0.25 MG/ML-1500 MULTI- 1 UNIT/ML-35 MG/ML-400 VITAMIN/FLUORIDE/IRON UNIT/ML , (Pediatric Vitamins Acd W/ AL(Up to 6 yrs MULTIVITAMIN/FLUORID Fluoride) TRI- old ) E/IRON SOLN VITE/FLUORIDE SOLN 0.5 1 MG/ML-1500 UNIT/ML-35 MG/ML-400 UNIT/ML
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Updated 07/01/2021 100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESCAVITE D CHEW (ped CITRANATAL 90 DHA 3 MISC (prenatal w/o vit a multivitamins w/fl & 2 iron) w/ fe carbonyl-fe POLY-VI-FLOR/IRON AL(Up to 6 yrs gluconate-dss-fa-dha) CHEW 0.5 MG-10 MG-15 old ) CITRANATAL B-CALM UNIT-200 MCG-400 UNIT 3 MISC (prenatal w/o vit a (ped multivitamins w/fl w/ fe carbonyl-fe 3 & iron) gluconate-fa & vit b6) POLY-VI-FLOR/IRON CITRANATAL BLOOM SUSP 0.25 MG/ML-200 DHA MISC (prenatal w/o MCG/ML-7 MG/ML (ped 3 vit a w/ fe carbonyl-fe 2 multivitamins w/fl & gluconate-dss-fa-dha) ) iron CITRANATAL BLOOM Prenatal Vitamins TABS (prenatal vit w/ 3 (Prenatal Vit W/ Docusate- docusate-fe carbonyl-fe Iron Carbonyl-Folic Acid) 1 gluconate-folic acid) INATAL GT TABS CITRANATAL DHA MISC (Prenatal Vit W/ Ferrous (prenatal w/o vit a w/ fe Fumarate-Folic Acid) 2 PRENATAL 19 CHEW 1 carbonyl-fe gluconate- dss-fa-dha) MG-100 MG-1000 UNIT-12 1 MCG-20 MG-20 MG-200 CITRANATAL ESSENCE MG-25 MG-29 MG-3 MG-3 THPK (prenatal w/o vit MG-30 UNIT-400 UNIT-6 a w/ fe carbonyl-fe 2 MG-7 MG gluconate-fa-dha) (Prenatal Vit W/ Ferrous Fumarate-L Methylfolate- CITRANATAL HARMONY 1 CAPS (prenatal w/o vit Folic Acid) PNV-SELECT 3 TABS a w/ fe fumarate-fe ATABEX EC TBEC carbonyl-dss-fa-dha) (prenatal vit w/ CITRANATAL MEDLEY 2 docusate-iron carbonyl- CAPS (prenatal w/o vit 3 folic acid) a w/ fe fumarate-fe ATABEX OB TABS carbonyl-fa-dha) (prenatal vit w/ fe CITRANATAL RX TABS 2 bisglycinate chelate- (prenatal without vit a 2 folic acid) w/ fe carbonyl-fe gluc- BAL-CARE DHA MISC docusate-fa) (prenatal w/fe COMPLETENATE CHEW 2 polysacch cmplx-sod (prenatal vit w/ ferrous 2 feredetate-fa-omega 3) fumarate-folic acid) C-NATE DHA CAPS CONCEPT DHA CAPS (prenatal vit w/ ferrous (prenatal vit w/ fe fum- fumarate-fa-omega 3 3 iron polysacch complex 2 fatty acids) -fa-omega 3)
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101 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONCEPT OB CAPS MYNATAL ULTRACAPLET (prenatal without a vit TABS (prenatal vit w/ w/ fe fum-iron 2 docusate-iron carbonyl- 2 polysacch complex -fa) folic acid) DOTHELLE DHA CAPS MYNATE 90 PLUS TBCR (prenatal vit w/ fe fum- (prenatal vit w/ iron polysacch complex 2 docusate-fe fumarate- 2 -fa-omega 3) folic acid) DUET DHA 400 MISC NATACHEW CHEW (prenatal w/fe (prenatal vit w/ fe fum- polysacch cmplx-sod 3 fe bisglycinate chelate- 3 feredetate-fa-omega 3) folic acid) DUET DHA BALANCED NATELLE ONE CAPS MISC (prenatal w/fe (prenatal without vit a polysacch cmplx-sod 3 w/ fe fum-fa-omega 3 feredetate-fa-omega 3) fatty acids) ENBRACE HR CAPS NEEVO DHA CAPS (prenatal vit w/ fe (prenatal without vit a glycine cysteinate-fa- 3 w/ fe fumarate-l 3 omega 3 fatty acids) methylfolate-omegas) FOLET ONE CAPS NEONATAL 19 TABS (prenatal w/o a w/fe (prenatal vitamin-folic 2 3 carbonyl-fe bisglyc-l acid) methylfol-dss-dha) NEONATAL COMPLETE RX/OTC FOLIVANE-OB CAPS TABS (prenatal vit w/ 2 (prenatal without a vit ferrous fumarate-folic 2 w/ fe fum-iron acid) polysacch complex -fa) NEONATAL FE TABS KOSHER PRENATAL (prenatal multivitamins 2 PLUS IRON TABS ) 3 w/ iron-folic acid (prenatal vit w/ iron NEONATAL PLUS TABS RX/OTC carbonyl-folic acid) (prenatal vit w/ ferrous 2 M-NATAL PLUS TABS RX/OTC fumarate-folic acid) (prenatal vit w/ ferrous 2 NEONATAL/DHA MISC PV fumarate-folic acid) (prenatal mv & min w/fe PV MARNATAL-F CAPS fumarate-fa-dha) (prenatal without vit a 2 NESTABS DHA MISC w/ iron polysaccharide (prenatal vit without vit complex-fa) a w/ fe bisglycinate-fa- 2 MYNATAL ADVANCE omeg 3) TABS (prenatal vit w/ docusate-iron carbonyl- 2 folic acid)
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Updated 07/01/2021 102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NESTABS ONE CAPS PNV TABS 29-1 TABS (prenatal w/o a w/fe (prenatal vit w/ iron 3 3 carbonyl-fe bisglyc-l carbonyl-folic acid) methylfol-dha) PNV-DHA+DOCUSATE NESTABS TABS CAPS (prenatal w/o vit 3 (prenatal vit without vit a w/ fe fumarate-dss-fa- 3 a w/ fe bisglycinate- dha) folic acid) PNV-OMEGA CAPS NEXA PLUS CAPS (prenatal without a w/ (prenatal w/o vit a w/fe fe fumarate-l 3 fumarate-docusate ca- 3 methylfolate-fa-omega folic acid-dha) 3) NIVA-PLUS TABS RX/OTC PR NATAL 400 EC MISC (prenatal vit w/ ferrous 2 (prenatal mv & min w/fe 2 fumarate-folic acid) bisglyc-fe prot succ-fa- O-CAL FA TABS RX/OTC ca-omega 3) (prenatal vit w/ ferrous 2 PR NATAL 430 EC MISC fumarate-folic acid) (prenatal mv & min w/fe GP OB COMPLETE ONE bisglyc-fe prot succ-fa- CAPS (prenatal w/o vit ca-omega 3) 3 a w/ fe carbonyl-fe PR NATAL 430 MISC aspart glyc-fa-fish oil) (prenatal mv & min w/fe GP OB COMPLETE PETITE bisglyc-fe prot succ-fa- CAPS (prenatal w/o vit ca-omega 3) 3 a w/ fe carbonyl-fe PREMESISRX TABS aspart glyc-fa-omega 3) (prenatal w/ calcium-vit 3 OB COMPLETE PREMIER b6-vit b12-folic acid- TABS (prenatal vit w/ ginger) 3 iron carbonyl-fe aspart PRENA 1 TRUE MISC glycinate-fa) (prenatal without a w/ 3 OB COMPLETE/DHA fe amino acid chelate- CAPS (prenat vit w/ iron fa-dha) 3 carbonyl-fe asp glyc-fa- PRENA1 CHEW CHEW omega fatty acid) (prenatal w/ vit b2-b6- 3 OBSTETRIX ONE CAPS b12-cholecalciferol-folic (prenatal w/o a w/fe acid) 3 carbonyl-fe bisglyc-l PRENA1 PEARL CPCR methylfol-dss-dha) (prenatal without a w/ 3 ONE VITE WOMENS RX/OTC fe fumarate-sod PRENATALVITAMIN PLUS feredetate-fa-dha) TABS (prenatal vit w/ 2 PRENAISSANCE CAPS ferrous fumarate-folic (prenatal w/o vit a w/ fe 3 acid) fumarate-dss-fa-dha)
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103 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENAISSANCE PLUS PRENATE DHA CAPS CAPS (prenatal w/o vit (prenatal w/o a w/ fe a w/ fe carbonyl-dss-fa- 3 asparto glyc-l 3 dha) methylfolate-fa-dha) PRENATAL 19 CHEW 1 PRENATE ELITE TABS MG-100 MG-1000 UNIT-12 (prenatal w/ fe asparto MCG-15 MG-20 MG-20 glycinate-l methylfolate- 3 MG-200 MG-29 MG-3 MG- ) 3 MG-30 UNIT-400 UNIT-7 2 folic acid MG (prenatal vit w/ PRENATE ENHANCE CAPS (prenatal without ferrous fumarate-folic 3 acid) a w/ fe fumarate-l ) PRENATAL 19 TABS 1 RX/OTC methylfolate-fa-dha MG-100 MG-1000 UNIT-12 PRENATE ESSENTIAL MCG-15 MG-20 MG-20 CAPS (prenatal w/o a MG-200 MG-25 MG-29 w/ fe asparto glyc-l 3 3 MG-3 MG-3 MG-30 UNIT- methylfolate-fa-dha) 400 UNIT-7 MG (prenatal PRENATE MINI CAPS vit w/ docusate-fe (prenatal w/o vit a w/ fe fumarate-folic acid) carbonyl-fe asp glyc- 3 PRENATAL PLUS IRON methfol-fa-dha) TABS (prenatal vit w/ 3 PRENATE PIXIE CAPS iron carbonyl-folic acid) (prenatal w/o a w/ fe PRENATAL TABS RX/OTC asparto glyc-l 3 (prenatal vit w/ ferrous 2 methylfolate-fa-dha) fumarate-folic acid) PRENATE RESTORE PRENATAL VITAMINS RX/OTC CAPS (prenatal without PLUS LOW IRON TABS 3 2 a w/ fe fumarate-l (prenatal vit w/ ferrous methylfolate-fa-dha) fumarate-folic acid) PRENATRIX TABS RX/OTC PRENATAL-U CAPS (prenatal vit w/ ferrous 2 (prenatal without a vit fumarate-folic acid) w/ fe fumarate-folic 2 PRENATRYL TABS RX/OTC acid) (prenatal vit w/ ferrous 2 PRENATE AM TABS fumarate-folic acid) (prenatal w/ calcium-vit b6-vit b12-folic acid- 3 PREPLUS TABS RX/OTC (prenatal vit w/ ferrous 2 ginger) fumarate-folic acid) PRENATE CHEW PRIMACARE CAPS (prenatal multivitamins & minerals w/ l- 3 (prenatal without a w/ fe asp glyc-l 3 methylfolate-fa) methylfolate-fa-omega 3)
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Updated 07/01/2021 104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROVIDA DHA CAPS TARON-PREX CAPS (prenatal without a w/fe (prenatal w/o vit a w/ fe 3 3 fum-fe polysacch fumarate-dss-fa-dha) complex-fa-dha) THERANATAL CORE RX/OTC PROVIDA OB CAPS NUTRITION TABS 2 (prenatal without a vit (prenatal vit w/ ferrous w/ fe fum-iron 2 fumarate-folic acid) polysacch complex -fa) THRIVITE RX TABS R-NATAL OB CAPS (prenatal vit w/ iron 3 (prenatal w/o vit a w/ fe 3 carbonyl-folic acid) carbonyl-folic acid-dha) TL FOLATE TABS (prenatal vit w/ ferrous RELNATE DHA CAPS 2 (prenatal vit w/ ferrous fumarate-l methylfolate- fumarate-fa-omega 3 3 folic acid) fatty acids) TL-CARE DHA CAPS SE-NATAL 19 CHEW (prenatal w/fe 3 (prenatal vit w/ ferrous 2 fumarate-fa-dss-fish oil) fumarate-folic acid) TL-SELECT CAPS SE-NATAL 19 TABS RX/OTC (prenatal w/o vit a w/ fe 3 (prenatal vit w/ fumarate-dss-fa-dha) 3 docusate-fe fumarate- TRI-TABS DHA MISC folic acid) (prenatal vit without vit 2 SELECT-OB CHEW a w/ fe bisglycinate-fa- (prenatal vit w/ iron omeg 3) 3 polysaccharide cmplx-l TRICARE PRENATAL DHA ONE CAPS methylfolate-fa) 3 SELECT-OB CHEW (prenatal w/fe (prenatal vit w/ iron fumarate-fa-dss-fish oil) polysaccharide 3 TRICARE TABS RX/OTC complex-folic acid) (prenatal vit w/ ferrous 2 SELECT-OB+DHA MISC fumarate-folic acid) (prenatal mv & min w/fe TRISTART DHA CAPS 3 (prenatal without a w/ polysaccharide 3 complex-fa-dha) fe carbonyl-l TARON-BC MISC methylfolate-fa-dha) (prenatal without vit a TRISTART FREE CAPS 3 (prenatal without a w/ w/ iron carbonyl-folic 3 acid & vit b6) fe carbonyl-l TARON-C DHA CAPS methylfolate-fa-dha) (prenatal vit w/ fe fum- TRISTART ONE CAPS 2 (prenatal without a w/ iron polysacch complex 3 -fa-omega 3) fe carbonyl-l methylfolate-fa-dha)
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105 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTIMATECARE ONE VITAFOL GUMMIES CAPS (prenatal vit w/ CHEW (prenatal vit w/ iron carbonyl-fe aspart 3 ferric phosphate-fa- 3 glyc-fa-omega 3) omega 3 fatty acids) VENA-BAL DHA MISC VITAFOL ULTRA CAPS (prenatal w/fe (prenatal vit w/ fe polysacch cmplx-sod 2 polysacch complex-l 2 feredetate-fa-omega 3) methylfolate-fa-dha) VINATE DHA RF CAPS VITAFOL-NANO TABS (prenatal without vit a (prenatal w/o a vit w/ fe w/ fe fumarate-l 3 fumarate-l methylfolate- 3 methylfolate-omegas) folic acid) VINATE II TABS VITAFOL-ONE CAPS (prenatal vit w/ fe (prenatal mv & min w/fe bisglycinate chelate- 2 polysaccharide 3 folic acid) complex-fa-dha) VIRT-C DHA CAPS VITAMEDMD ONE (prenatal vit w/ fe fum- RX/QUATREFOLIC CAPS iron polysacch complex 2 (prenatal without a w/ 3 -fa-omega 3) fe fumarate-l VIRT-NATE DHA CAPS methylfolate-fa-dha) (prenatal vit w/ ferrous VITAMEDMD REDICHEW fumarate-fa-omega 3 3 RX CHEW (prenatal w/ fatty acids) vit b2-b6-b12- 3 VIRT-PN DHA CAPS cholecalciferol-folic (prenatal without a w/ acid) fe fumarate-l 3 VITAPEARL CPCR (prenatal without a w/ methylfolate-fa-dha) 3 VIRT-PN PLUS CAPS fe fumarate-sod (prenatal without a w/ feredetate-fa-dha) fe fumarate-l 3 VITATHELY/GINGER RX/OTC TABS (prenatal vit w/ methylfolate-fa-omega 2 3) ferrous fumarate-folic VITAFOL FE+ CPPK 0.4 acid) MG-0.6 MG-1.6 MG-1.8 VITATRUE MISC MG-1000 UNIT-1100 (prenatal without a w/ UNIT-15 MG-150 MCG-2 fe amino acid chelate- 3 MG-2.5 MG-20 MG-20 fa-dha) UNIT-200 MG-25 MCG-25 3 MG-415 MG-50 MG-60 VIVA DHA CAPS (prenatal vit w/ ferrous MG-90 MG (prenatal vit 3 w/ fe polysacch fumarate-fa-omega 3 complex-l methylfol-fa- fatty acids) dha-dss)
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Updated 07/01/2021 106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VOL-PLUS TABS RX/OTC chlorzoxazone tabs (prenatal vit w/ ferrous 2 375 mg, 500 mg, 750 1 fumarate-folic acid) mg VOL-TAB RX TABS ST; QL(1 ea cyclobenzaprine hcl 1 (prenatal vit w/ iron 3 cp24 15 mg, 30 mg daily) carbonyl-folic acid) cyclobenzaprine hcl VP-PNV-DHA CAPS tabs 10 mg, 5 mg, 7.5 1 (prenatal vit w/ ferrous mg fumarate-fa-omega 3 3 fatty acids) metaxalone tabs 1 WESTAB PLUS TABS RX/OTC methocarbamol tabs 1 (prenatal vit w/ ferrous 2 ) fumarate-folic acid orphenadrine citrate 1 WESTGEL DHA CAPS tb12 (prenatal without a w/ ROBAXIN-750 TABS 3 GP fe carbonyl-l (methocarbamol) methylfolate-fa-dha) SKELAXIN TABS GP ZATEAN-PN DHA CAPS (metaxalone) (prenatal without a w/ SOMA TABS 3 GP fe fumarate-l (carisoprodol) methylfolate-fa-dha) tizanidine hcl caps 1 ZATEAN-PN PLUS CAPS (prenatal without a w/ tizanidine hcl tabs 1 fe fumarate-l 3 ZANAFLEX CAPS methylfolate-fa-omega GP 3) (tizanidine hcl) ZANAFLEX TABS MUSCULOSKELETAL THERAPY AGENTS - GP Drugs to Treat Spasms (tizanidine hcl) Central Muscle Relaxants Direct Muscle Relaxants DANTRIUM CAPS (Carisoprodol) VANADOM 1 GP TABS (dantrolene sodium) dantrolene sodium (Chlorzoxazone) 1 1 LORZONE TABS caps (Metaxalone) METAXALL 1 Muscle Relaxant Combinations TABS carisoprodol w/ aspirin AMRIX CP24 ST; QL(1 ea 1 GP & codeine tabs (cyclobenzaprine hcl) daily) carisoprodol w/ aspirin 1 baclofen tabs 1 tabs carisoprodol tabs 1 orphenadrine w/ aspirin & caff tabs 25 mg-30 1 CHLORZOXAZONE TABS 3 mg-385 mg 250 MG (chlorzoxazone)
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107 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NASAL AGENTS - SYSTEMIC AND TOPICAL - (Fluticasone Propionate Limit 2 inhalers Drugs to treat the Nose or Sinus (Nasal)) ALLERGY NASAL per SPRAY 24 HOUR, month;QL(1.1 Nasal Agent Combinations ALLERGY RELIEF, ml daily); azelastine hcl- Limit 1 inhaler CLARISPRAY, CVS RX/OTC FLUTICASONE 1 per fluticasone propionate month;QL(0.77 PROPRIONATE NASAL susp gm daily) SPRAY, EQ ALLERGY Limit 1 inhaler RELIEF, EQL DYMISTA SUSP FLUTICASONE ( GP per azelastine hcl- month;QL(0.77 PROPIONATE, EQL fluticasone propionate) gm daily) FLUTICASONE PROPIONATE Nasal Antiallergy CHILDRENS, GNP 1 Limit 1 inhaler FLUTICASONE PROPIONATE, GNP azelastine hcl soln 0.1 1 per %, 137 mcg/spray month;QL(1.2 FLUTICASONE ml daily) PROPIONATE azelastine hcl soln 0.15 QL(1 ml daily) CHILDRENS, HM 1 ALLERGY RELIEF NASAL % SPRAY 24HR, KLS ALLER-FLO, QC olopatadine hcl (nasal) 1 soln ALLERGY RELIEF, QC FLUTICASONE PATANASE SOLN PROPIONATE, SM (olopatadine hcl GP ALLERGY RELIEF NASAL (nasal)) SPRAY SUSP Nasal Anticholinergics BECONASE AQ SUSP Limit 2 inhalers (beclomethasone 3 per ipratropium bromide 1 month;QL(1.67 (nasal) soln diprop monohyd) gm daily) Nasal Steroids Limit 2 inhalers (Budesonide (Nasal)) CVS Limit 2 inhalers budesonide (nasal) 1 per BUDESONIDE NASAL per susp month;QL(0.6 SPRAY, EQ BUDESONIDE month;QL(0.6 ml daily) NASAL SPRAY, GNP ml daily) FLONASE ALLERGY Limit 2 inhalers BUDESONIDE NASAL 1 RELIEF CHILDRENS per SPRAY, RA BUDESONIDE SUSP ( GP month;QL(1.1 NASAL SPRAY, fluticasone ml daily); RHINOCORT ALLERGY propionate (nasal)) RX/OTC SUSP FLONASE ALLERGY Limit 2 inhalers RELIEF SUSP per ( GP month;QL(1.1 fluticasone propionate ml daily); (nasal)) RX/OTC FLONASE SENSIMIST Limit 1 inhaler SUSP ( 3 per fluticasone month;QL(0.34 furoate) ml daily)
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Updated 07/01/2021 108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits flunisolide (nasal) soln 1 betaxolol hcl (ophth) 1 soln Limit 2 inhalers fluticasone propionate per BETIMOL SOLN (timolol) 2 1 month;QL(1.1 (nasal) susp BETOPTIC-S SUSP ml daily); 2 RX/OTC (betaxolol hcl (ophth)) Limit 2 inhalers carteolol hcl (ophth) 1 mometasone furoate 1 per soln (nasal) susp month;QL(1.14 COMBIGAN SOLN gm daily) (brimonidine tartrate- 3 NASONEX SUSP Limit 2 inhalers timolol maleate) ( GP per mometasone furoate month;QL(1.14 COSOPT PF SOLN (nasal)) gm daily) (dorzolamide hcl-timolol GP Limit 1 inhaler maleate) OMNARIS SUSP 3 per COSOPT SOLN (ciclesonide (nasal)) month;QL(0.42 (dorzolamide hcl-timolol GP gm daily) maleate) QNASL AERS Limit 1 inhaler dorzolamide hcl-timolol (beclomethasone 3 per month;QL(0.3 maleate soln 0.5 %-2 1 dipropionate (nasal)) gm daily) %, 20 mg/ml-5 mg/ml, QNASL CHILDRENS Limit 1 inhaler 22.3 mg/ml-6.8 mg/ml per ISTALOL SOLN ( AERS (beclomethasone 3 timolol GP month;QL(0.17 maleate (ophth)) dipropionate (nasal)) gm daily) 1 ZETONNA AERS Limit 1 per levobunolol hcl soln 3 month;QL(0.3 (ciclesonide (nasal)) gm daily) timolol maleate (ophth) 1 solg NEUROMUSCULAR AGENTS - Drugs to Relax/Paralyze Muscles timolol maleate (ophth) 1 soln ALS Agents TIMOPTIC OCUDOSE RILUTEK TABS (riluzole) GP SOLN (timolol maleate GP (ophth)) riluzole tabs 1 TIMOPTIC SOLN ( timolol GP OPHTHALMIC AGENTS - Drugs to Treat the Eye maleate (ophth)) TIMOPTIC-XE SOLG Artificial Tears and Lubricants (timolol maleate GP LACRISERT INST 3 (ophth)) (artificial tear insert) Cycloplegic Mydriatics Beta-blockers - Ophthalmic (Phenylephrine Hcl (Timolol Maleate (Ophth)) (Mydriatic)) ALTAFRIN 1 TIMOLOL MALEATE IN 1 SOLN OCUDOSE SOLN
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109 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIMBRINZA SUSP atropine sulfate 1 (ophthalmic) oint (brinzolamide- 3 ATROPINE SULFATE brimonidine tartrate) SOLN OP 1 % (atropine 2 Ophthalmic Anti-infectives sulfate (ophthalmic)) (Bacitracin-Polymyxin B CYCLOGYL SOLN (Ophth)) AK-POLY-BAC, 1 GP (cyclopentolate hcl) POLYCIN OINT CYCLOMYDRIL SOLN (Gentamicin Sulfate 1 (cyclopentolate w/ 3 (Ophth)) GENTAK OINT phenylephrine) (Neomycin-Bacitracin Zn- Polymyxin) NEO-POLYCIN 1 cyclopentolate hcl soln 1 OINT AZASITE SOLN Limit 5mls per homatropine hbr soln 1 3 month;QL(0.17 (azithromycin (ophth)) ml daily) ISOPTO ATROPINE SOLN (atropine sulfate 2 bacitracin (ophthalmic) 2 (ophthalmic)) oint MYDRIACYL SOLN bacitracin-polymyxin b GP 1 (tropicamide) (ophth) oint BESIVANCE SUSP phenylephrine hcl 1 3 (mydriatic) soln (besifloxacin hcl) BETADINE OPHTHALMIC tropicamide soln 1 PREP SOLN (povidone- 3 Miotics iodine (ophth)) ISOPTO CARPINE SOLN BLEPH-10 SOLN GP (pilocarpine hcl) (sulfacetamide sodium GP PHOSPHOLINE IODIDE (ophth)) SOLR (echothiophate 2 CILOXAN OINT iodide) (ciprofloxacin hcl 2 (ophth)) pilocarpine hcl soln 1 CILOXAN SOLN Ophthalmic Adrenergic Agents (ciprofloxacin hcl GP ALPHAGAN P SOLN 0.1 % (ophth)) 2 (brimonidine tartrate) ciprofloxacin hcl (ophth) 1 ALPHAGAN P SOLN 0.15 soln GP % (brimonidine tartrate) erythromycin (ophth) 1 oint apraclonidine hcl soln 1 gatifloxacin (ophth) soln 1 brimonidine tartrate 1 soln gentamicin sulfate 1 IOPIDINE SOLN (ophth) soln 3 (apraclonidine hcl)
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Updated 07/01/2021 110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KLARITY-A SOLN Limit 5mls per trifluridine soln 1 3 month;QL(0.17 ( ) azithromycin (ophth) ml daily) VIGAMOX SOLN QL(3 ml per fill (moxifloxacin hcl GP retail,3 ml per levofloxacin (ophth) 1 soln (ophth)) fill mail) ZIRGAN GEL MOXEZA SOLN 3 (moxifloxacin hcl GP (ganciclovir ophthalmic) (ophth)) ZYMAXID SOLN GP (gatifloxacin (ophth)) moxifloxacin hcl (ophth) QL(3 ml per fill 1 retail,3 ml per Ophthalmic Immunomodulators soln fill mail) RESTASIS EMUL QL(2.14 ml 2 moxifloxacin hcl (ophth) 1 (cyclosporine (ophth)) daily) soln RESTASIS MULTIDOSE QL(2.14 ml NATACYN SUSP 2 EMUL (cyclosporine 2 daily) (natamycin) (ophth)) neomycin-bacitracin 1 zn-polymyxin oint Ophthalmic Local Anesthetics (Tetracaine Hcl (Ophth)) neomycin-polymyxin- 1 ALTACAINE, TETCAINE, 1 gramicidin soln TETRAVISC, TETRAVISC FORTE SOLN OCUFLOX SOLN QL(5 ml per fill GP retail,5 ml per AKTEN GEL ( (ofloxacin (ophth)) lidocaine 3 fill mail) hcl (ophth)) QL(5 ml per fill ALCAINE SOLN ofloxacin (ophth) soln 1 retail,5 ml per GP fill mail) (proparacaine hcl) proparacaine hcl soln 1 polymyxin b- 1 trimethoprim soln tetracaine hcl (ophth) 1 POLYTRIM SOLN soln (polymyxin b- GP trimethoprim) Ophthalmic Nerve Growth Factors OXERVATE SOLN PA POVIDONE IODINE SOLN 3 (cenegermin-bkbj) (povidone-iodine 3 (ophth)) Ophthalmic Steroids sulfacetamide sodium (Bacitracin-Poly-Neomycin- QL(4 gm per fill 1 Hc) NEO-POLYCIN HC 1 retail,4 gm per (ophth) oint OINT fill mail) sulfacetamide sodium ALREX SUSP 1 3 (ophth) soln (loteprednol etabonate) tobramycin (ophth) soln 1 bacitracin-poly- QL(4 gm per fill 1 retail,4 gm per TOBREX OINT neomycin-hc oint 2 fill mail) (tobramycin (ophth)) BLEPHAMIDE S.O.P. TOBREX SOLN GP OINT (sulfacetamide 2 (tobramycin (ophth)) sod-prednisolone)
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111 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BLEPHAMIDE SUSP neomycin-polymy- 1 (sulfacetamide sod- 2 dexameth oint prednisolone) neomycin-polymy- 1 dexamethasone dexameth susp sodium phosphate 1 neomycin-polymyxin-hc 1 (ophth) soln (ophth) susp DUREZOL EMUL 3 PRED MILD SUSP (difluprednate) (prednisolone acetate 2 FLAREX SUSP (ophth)) (fluorometholone 2 PRED-G S.O.P. OINT acetate) (gentamicin- 3 fluorometholone 1 prednisolone acetate) (ophth) susp PRED-G SUSP FML FORTE SUSP (gentamicin- 3 (fluorometholone 2 prednisolone acetate) (ophth)) prednisolone acetate 1 FML LIQUIFILM SUSP (ophth) susp (fluorometholone GP PREDNISOLONE SODIUM (ophth)) PHOSPHATE SOLN OP 1 FML OINT % (prednisolone sodium 2 (fluorometholone 2 phosphate (ophth)) (ophth)) sulfacetamide sod- LOTEMAX GEL 1 GP prednisolone soln (loteprednol etabonate) TOBRADEX OINT LOTEMAX OINT 3 (tobramycin- 3 (loteprednol etabonate) dexamethasone) LOTEMAX SUSP GP TOBRADEX ST SUSP (loteprednol etabonate) (tobramycin- 3 dexamethasone) loteprednol etabonate 1 gel TOBRADEX SUSP QL(5 ml per fill (tobramycin- GP retail) loteprednol etabonate 1 susp dexamethasone) QL(5 ml per fill MAXIDEX SUSP tobramycin- 1 (dexamethasone 2 dexamethasone susp retail) (ophth)) ZYLET SUSP Limit 5mls per MAXITROL OINT (loteprednol etabonate- 3 fill;QL(5 ml per (neomycin-polymy- GP fill retail,5 ml tobramycin) per fill mail) dexameth) MAXITROL SUSP Ophthalmic Surgical Aids (neomycin-polymy- GP GELFILM OP FILM dexameth) (gelatin adsorbable 3 (ophth))
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Updated 07/01/2021 112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Ophthalmics - Misc. bromfenac sodium 1 (Olopatadine Hcl) EYE Limit 2.5mls (ophth) soln ALLERGY ITCH RELIEF, per BROMSITE SOLN EYE ALLERGY 1 month;QL(0.09 (bromfenac sodium 3 ITCH/REDNESSRELIEF, ml daily); (ophth)) GNP OLOPATADINE RX/OTC HYDROCHLORIDE SOLN cromolyn sodium 1 (Olopatadine Hcl) EYE Limit 10mls per (ophth) soln ALLERGY ITCH RELIEF, month;QL(0.34 CYSTADROPS SOLN QL(0.34 ml 3 EYE ALLERGY 1 ml daily); (cysteamine hcl) daily) ITCH/REDNESSRELIEF, RX/OTC Limit 4 bottles GNP OLOPATADINE CYSTARAN SOLN HYDROCHLORIDE SOLN 3 per (cysteamine hcl) month;QL(2.15 ACULAR LS SOLN ml daily) (ketorolac GP diclofenac sodium 1 tromethamine (ophth)) (ophth) soln ACULAR SOLN (ketorolac GP dorzolamide hcl soln 1 tromethamine (ophth)) DORZOLAMIDE HCL 2 ACUVAIL SOLN SOLN (dorzolamide hcl) (ketorolac 3 ELESTAT SOLN GP tromethamine (ophth)) (epinastine hcl (ophth)) ALOCRIL SOLN epinastine hcl (ophth) 1 (nedocromil sodium 3 soln (ophth)) flurbiprofen sodium 1 ALOMIDE SOLN soln (lodoxamide 2 ILEVRO SUSP tromethamine) 3 (nepafenac) azelastine hcl (ophth) 1 ketorolac tromethamine soln 1 (ophth) soln Limit 10mls per AZOPT SUSP LASTACAFT SOLN ST GP month;QL(0.4 3 (brinzolamide) ml daily) (alcaftadine) NEVANAC SUSP ST; Limit 10mls 3 ( ) bepotastine besilate 1 per nepafenac soln month;QL(0.34 Limit 10mls per ml daily) olopatadine hcl soln 0.1 1 month;QL(0.34 ST; Limit 10mls % ml daily); BEPREVE SOLN GP per RX/OTC (bepotastine besilate) month;QL(0.34 Limit 2.5mls ml daily) olopatadine hcl soln 0.2 per Limit 10mls per 1 month;QL(0.09 brinzolamide susp 1 month;QL(0.4 % ml daily); ml daily) RX/OTC
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113 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PAREMYD SOLN acetic acid (otic) soln 1 (hydroxyamphetamine- 3 tropicamide) Otic Anti-infectives Limit 10mls per CETRAXAL SOLN PATADAY SOLN 0.1 % GP GP month;QL(0.34 (ciprofloxacin hcl (otic)) (olopatadine hcl) ml daily); RX/OTC ciprofloxacin hcl (otic) 1 soln Limit 2.5mls FLOXIN OTIC SOLN PATADAY SOLN 0.2 % per GP GP month;QL(0.09 (ofloxacin (otic)) (olopatadine hcl) ml daily); RX/OTC ofloxacin (otic) soln 1 Limit 10mls per Otic Combinations PATANOL SOLN month;QL(0.34 GP (Pramoxine-Hc- (olopatadine hcl) ml daily); RX/OTC Chloroxylenol) CORTIC- 1 ND, EXOTIC-HC SOLN PROLENSA SOLN CIPRO HC SUSP (bromfenac sodium 3 (ciprofloxacin- 3 (ophth)) hydrocortisone) TRUSOPT SOLN GP CIPRODEX SUSP QL(8 ml per fill (dorzolamide hcl) (ciprofloxacin- GP retail,8 ml per Prostaglandins - Ophthalmic dexamethasone) fill mail) Limit 2.5mls ciprofloxacin- QL(8 ml per fill bimatoprost soln 1 per 1 retail,8 ml per month;QL(0.09 dexamethasone susp fill mail) ml daily) ciprofloxacin- Limit 1 bottle latanoprost soln 1 1 per fluocinolone acetonide month;QL(0.5 LUMIGAN SOLN soln 2 ea daily) (bimatoprost) COLY-MYCIN S SUSP Limit 2.5mls (neomycin-colistin-hc- 3 TRAVATAN Z SOLN GP per thonzonium) (travoprost) month;QL(0.09 ml daily) CORTISPORIN-TC SUSP (neomycin-colistin-hc- 3 Limit 2.5mls thonzonium) 1 per travoprost soln month;QL(0.09 neomycin-polymyxin-hc 1 ml daily) (otic) soln XALATAN SOLN GP neomycin-polymyxin-hc 1 (latanoprost) (otic) susp ZIOPTAN SOLN 3 OTICIN HC NR SOLN (tafluprost) (pramoxine-hc- GP OTIC AGENTS - Drugs to Treat the Ear chloroxylenol) Otic Agents - Miscellaneous
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Updated 07/01/2021 114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OTOVEL SOLN Limit 1 bottle Natural Penicillins (ciprofloxacin- GP per month;QL(0.5 penicillin v potassium 1 fluocinolone acetonide) ea daily) solr PRAMOTIC LIQD penicillin v potassium 1 (pramoxine- 3 tabs chloroxylenol) Penicillin Combinations Otic Steroids amoxicillin & pot 1 (Fluocinolone Acetonide 1 clavulanate chew (Otic)) FLAC OIL amoxicillin & pot 1 DERMOTIC OIL clavulanate susr (fluocinolone acetonide GP amoxicillin & pot (otic)) 1 clavulanate tabs fluocinolone acetonide 1 amoxicillin & pot (otic) oil 1 clavulanate tb12 hydrocortisone w/acetic QL(10 ml per 1 fill retail,30 ml AUGMENTIN ES-600 acid soln per fill mail) SUSR (amoxicillin & pot GP clavulanate) OXYTOCICS - Drugs to Prevent/Control Uterine Bleeding AUGMENTIN SUSR 125 MG/5ML-31.25 MG/5ML Oxytocics (amoxicillin & pot 2 (Methylergonovine clavulanate) Maleate) METHERGINE 1 TABS AUGMENTIN SUSR 250 MG/5ML-62.5 MG/5ML GP methylergonovine 1 (amoxicillin & pot maleate tabs clavulanate) PENICILLINS - Drugs to Treat Bacterial Infections AUGMENTIN TABS 125 MG-500 MG (amoxicillin GP Aminopenicillins & pot clavulanate) amoxicillin caps 250 1 mg, 500 mg Penicillinase-Resistant Penicillins dicloxacillin sodium amoxicillin chew 125 1 1 caps mg PROGESTINS - Hormone Replacement/Modifying amoxicillin chew 250 4 Drugs mg amoxicillin susr 125 Progestins AYGESTIN TABS mg/5ml, 200 mg/5ml, 1 GP 250 mg/5ml, 400 (norethindrone acetate) PA mg/5ml hydroxyprogesterone 3 caproate oil amoxicillin tabs 500 1 mg, 875 mg ampicillin caps 1
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115 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAKENA OIL IM 250 PA XYREM SOLN ( PA sodium 3 MG/ML oxybate) (hydroxyprogesterone GP caproate) Antidementia Agents ARICEPT TABS QL(1 ea daily) MAKENA SOAJ SC 275 PA MG/1.1ML (donepezil GP (hydroxyprogesterone 3 hydrochloride) QL(1 ea daily) caproate) donepezil 1 medroxyprogesterone hydrochloride tabs 1 QL(1 ea daily) acetate tabs donepezil 1 MEGACE ES SUSP hydrochloride tbdp EXELON PT24 (megestrol acetate GP GP (appetite)) (rivastigmine) galantamine megestrol acetate 1 1 (appetite) susp hydrobromide cp24 galantamine norethindrone acetate 1 1 tabs hydrobromide soln QL(2 ea daily) galantamine progesterone caps or 1 1 100 mg, 200 mg hydrobromide tabs memantine hcl cp24 14 PA progesterone oil im 50 1 mg/ml mg, 21 mg, 28 mg, 7 1 PROMETRIUM CAPS QL(2 ea daily) mg GP (progesterone) memantine hcl soln 10 1 PROVERA TABS mg/5ml, 2 mg/ml (medroxyprogesterone GP memantine hcl tabs 10 1 acetate) mg, 5 mg, NAMENDA TABS PSYCHOTHERAPEUTIC AND NEUROLOGICAL GP AGENTS - MISC. - Drugs to Treat Mental and (memantine hcl) Emotional Conditions NAMENDA TITRATION Agents for Chemical Dependency PAK TABS (memantine GP hcl) acamprosate calcium 1 NAMENDA XR CP24 PA tbec GP ANTABUSE TABS (memantine hcl) GP (disulfiram) RAZADYNE ER CP24 (galantamine GP 1 disulfiram tabs hydrobromide) PA required for RAZADYNE TABS more than 30 (galantamine GP LUCEMYRA TABS day supply per 3 hydrobromide) (lofexidine hcl) year;QL(224 ea per 14 days rivastigmine pt24 1 retail) Anti-Cataplectic Agents
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Updated 07/01/2021 116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVONEX PEN AJKT PA rivastigmine tartrate 1 3 caps (interferon beta-1a) AVONEX PSKT PA Combination Psychotherapeutics 3 chlordiazepoxide- (interferon beta-1a) 1 BETASERON KIT PA amitriptyline tabs 3 (interferon beta-1b) olanzapine-fluoxetine 1 COPAXONE SOSY PA hcl caps GP (glatiramer acetate) perphenazine- 1 PA amitriptyline tabs dalfampridine tb12 1 SYMBYAX CAPS dimethyl fumarate cpdr 1 PA (olanzapine-fluoxetine GP hcl) dimethyl fumarate misc 1 PA Fibromyalgia Agents EXTAVIA KIT (interferon PA SAVELLA TABS PA; QL(2 ea 3 3 beta-1b) (milnacipran hcl) daily) GILENYA CAPS PA 3 Hypoactive Sexual Desire Disorder (HSDD) (fingolimod hcl) ADDYI TABS PA; QL(1 ea PA 3 glatiramer acetate sosy 1 (flibanserin) daily) 20 mg/ml VYLEESI SOAJ PA PA 3 glatiramer acetate sosy 3 (bremelanotide acetate) 40 mg/ml Movement Disorder Drug Therapy MAVENCLAD TBPK PA AUSTEDO TABS PA 3 (cladribine (multiple 3 (deutetrabenazine) sclerosis)) INGREZZA CAPS PA 3 MAYZENT STARTER PA (valbenazine tosylate) PACK TBPK (siponimod 3 INGREZZA CPPK PA fumarate) 3 (valbenazine tosylate) PLEGRIDY SOPN PA 3 tetrabenazine tabs 3 (peginterferon beta-1a) PLEGRIDY SOSY PA XENAZINE TABS 3 GP (peginterferon beta-1a) ( ) tetrabenazine PLEGRIDY STARTER PA Multiple Sclerosis Agents PACK SOPN 3 (Glatiramer Acetate) PA (peginterferon beta-1a) GLATOPA SOSY 20 1 PLEGRIDY STARTER PA MG/ML PACK SOSY 3 (Glatiramer Acetate) PA (peginterferon beta-1a) GLATOPA SOSY 40 3 REBIF REBIDOSE SOAJ PA MG/ML 3 (interferon beta-1a) AMPYRA TB12 PA GP REBIF REBIDOSE PA ( ) dalfampridine TITRATIONPACK SOAJ 3 AUBAGIO TABS PA 3 (interferon beta-1a) (teriflunomide) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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117 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REBIF SOSY ( PA (Nicotine Polacrilex) CVS PV interferon 3 beta-1a) NICOTINE LOZENGE, CVS NICOTINE REBIF TITRATION PACK PA POLACRILEX, EQ SOSY (interferon beta- 3 NICOTINE LOZENGES, 1a) EQ NICOTINE TECFIDERA CPDR PA POLACRILEX, EQL GP (dimethyl fumarate) NICOTINE POLACRILEX, GNP NICOTINE MINI TECFIDERA STARTER PA LOZENGE, GNP PACK MISC (dimethyl GP NICOTINE POLACRILEX, fumarate) GNP NICOTINE POLACRILEX MINI, Postherpetic Neuralgia (PHN)/Neuropathic Pain GOODSENSE NICOTINE, PV GRALISE MISC PA GOODSENSE NICOTINE (gabapentin (once- 3 POLACRILEX, HM daily)) NICOTINE POLACRILEX, GRALISE TABS PA KLS QUIT2, KLS QUIT4, NICOTINE MINI (gabapentin (once- 3 LOZENGE, NICOTINE daily)) POLACRILEX MINI, PX Premenstrual Dysphoric Disorder (PMDD) Agents STOP SMOKING AID, RA MINI NICOTINE, RA fluoxetine hcl (pmdd) 1 NICOTINE POLACRILEX, caps SM NICOTINE, SM fluoxetine hcl (pmdd) NICOTINE POLACRILEX, 1 TGT NICOTINE tabs POLACRILEX LOZG SARAFEM TABS GP (fluoxetine hcl (pmdd)) Pseudobulbar Affect (PBA) Agents NUEDEXTA CAPS PA (dextromethorphan hbr- 3 quinidine sulfate) Psychotherapeutic and Neurological Agents - ergoloid mesylates tabs 1 pimozide tabs 1 Restless Leg Syndrome (RLS) Agents HORIZANT TBCR QL(1 ea daily) 3 (gabapentin enacarbil) Smoking Deterrents
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Updated 07/01/2021 118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) CVS PV (Nicotine) CVS NICOTINE PV NICOTINE, CVS TRANSDERMALSYSTEM, NICOTINE POLACRILEX, CVS NICOTINE CVS NICOTINE TRANSDERMALSYSTEM POLACRILEX STARTER, STEP 1, CVS NICOTINE EQ NICOTINE TRANSDERMALSYSTEM POLACRILEX, EQL STEP 2, CVS NICOTINE NICOTINE POLACRILEX, TRANSDERMALSYSTEM/ EQL NICOTINE STEP 3, EQ NICOTINE, POLACRILEX REFILL, EQ NICOTINE STEP 3, EQL NICOTINE GNP NICOTINE POLACRILEX STARTER, TRANSDERMALSYSTEM, GNP NICOTINE GUM, GNP NICOTINE GNP NICOTINE TRANSDERMALSYSTEM POLACRILEX, PV STEP 2, HABITROL, HM GOODSENSE NICOTINE NICOTINE GUM, GOODSENSE TRANSDERMAL SYSTEM, NICOTINE POLACRILEX HM NICOTINE GUM, HM NICOTINE TRANSDERMAL SYSTEM POLACRILEX, KLS QUIT2, STEP 1, HM NICOTINE KLS QUIT4, NICORELIEF, TRANSDERMAL SYSTEM PX STOP SMOKING AID, STEP 2, HM NICOTINE RA NICOTINE, RA TRANSDERMAL SYSTEM NICOTINE GUM, SM STEP 3, HM NICOTINE NICOTINE, SM NICOTINE TRANSDERMALSYSTEM, POLACRILEX, TGT NICOTINE STEP 1, PV NICOTINE GUM, TGT NICOTINE STEP 3, NICOTINE POLACRILEX, NICOTINE THRIVE GUM TRANSDERMAL SYSTEM STEP 1, NICOTINE TRANSDERMAL SYSTEM STEP 1/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 2, NICOTINE TRANSDERMAL SYSTEM STEP 2/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 3, NICOTINE TRANSDERMAL SYSTSTEM STEP 3/CLEAR, QC NICOTINE TRANSDERMAL SYSTEM/STEP 1, QC NICOTINE TRANSDERMAL SYSTEM/STEP 2, RA NICOTINE, RA NICOTINE TRANSDERMAL SYSTEM, SM NICOTINE TRANSDERMAL SYSTEM, You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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119 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SM NICOTINE NICOTROL NS SOLN PV PV TRANSDERMAL (nicotine) SYSTEM/STEP 1/CLEAR, ZYBAN TB12 ( PV SM NICOTINE bupropion GP TRANSDERMAL hcl (smoking deterrent)) SYSTEM/STEP 2/CLEAR, Transthyretin Amyloidosis Agents SM NICOTINE TEGSEDI SOSY PA TRANSDERMAL 3 SYSTEM/STEP 3/CLEAR, (inotersen sodium) TGT NICOTINE STEP Vasomotor Symptom Agents ONE, TGT NICOTINE STEP THREE, TGT BRISDELLE CAPS NICOTINE STEP TWO (paroxetine mesylate GP PT24 (vasomotor)) PV paroxetine mesylate bupropion hcl (smoking PV 1 deterrent) tb12 (vasomotor) caps CHANTIX CONTINUING PV RESPIRATORY AGENTS - MISC. - Drugs to MONTHPAK TABS PV Treat Lung Conditions ( ) varenicline tartrate Cystic Fibrosis Agents CHANTIX STARTING PV KALYDECO PACK PA MONTH PAK TABS PV 3 (ivacaftor) (varenicline tartrate) KALYDECO TABS PA CHANTIX TABS PV 3 PV (ivacaftor) (varenicline tartrate) ORKAMBI PACK PA NICODERM CQ PT24 PV 3 GP (lumacaftor-ivacaftor) (nicotine) ORKAMBI TABS PA NICORETTE GUM PV 3 GP (lumacaftor-ivacaftor) (nicotine polacrilex) PA; Limited to NICORETTE LOZG PV PULMOZYME SOLN GP 3 75mls per (nicotine polacrilex) (dornase alfa) month;QL(2.5 NICORETTE MINI LOZG PV ml daily) GP (nicotine polacrilex) SYMDEKO TBPK 100 MG- PA NICORETTE STARTER PV 150 MG (tezacaftor- 3 KIT GUM (nicotine GP ivacaftor) polacrilex) TRIKAFTA TBPK PA; QL(3 ea daily) nicotine polacrilex gum PV PV (elexacaftor-tezacaftor- 3 ivacaftor) PV nicotine polacrilex lozg PV Pulmonary Fibrosis Agents ESBRIET CAPS PA PV PV 3 nicotine pt24 (pirfenidone) NICOTINE PV ESBRIET TABS PA 3 TRANSDERMAL SYSTEM PV (pirfenidone) KIT (nicotine) OFEV CAPS (nintedanib PA NICOTROL INHALER PV 3 PV esylate) INHA (nicotine)
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Updated 07/01/2021 120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SULFONAMIDES - Drugs to Treat Bacterial doxycycline hyclate 1 Infections tabs 100 mg, 20 mg PA Sulfonamides doxycycline hyclate 1 SULFADIAZINE TABS tabs 150 mg, 75 mg 3 (sulfadiazine) doxycycline hyclate ST TETRACYCLINES - Drugs to Treat Bacterial tbec 100 mg, 150 mg, 1 Infections 75 mg PA Tetracyclines doxycycline hyclate 1 (Doxycycline tbec 200 mg (Monohydrate)) AVIDOXY 1 MINOCIN CAPS GP TABS (minocycline hcl) (Doxycycline minocycline hcl caps 1 (Monohydrate)) 1 MONDOXYNE NL, OKEBO 100 mg, 50 mg, 75 mg CAPS minocycline hcl tabs 1 (Doxycycline Hyclate) 100 mg, 50 mg MORGIDOX 1X100MG, PA minocycline hcl tabs 75 1 MORGIDOX 1X50MG, 1 mg MORGIDOX 2X100MG CAPS minocycline hcl tb24 ST 105 mg, 115 mg, 135 (Minocycline Hcl) 1 ST 1 COREMINO TB24 mg, 45 mg, 55 mg, 65 ACTICLATE TABS PA mg, 80 mg, 90 mg GP (doxycycline hyclate) SOLODYN TB24 ST GP (minocycline hcl) demeclocycline hcl 1 tabs tetracycline hcl caps 1 DORYX TBEC 200 MG PA 250 mg, 500 mg GP (doxycycline hyclate) VIBRAMYCIN CAPS 100 doxycycline MG (doxycycline GP hyclate) (monohydrate) caps 1 100 mg, 150 mg, 50 VIBRAMYCIN SUSR 25 mg, 75 mg MG/5ML (doxycycline GP doxycycline (monohydrate)) (monohydrate) susr 25 1 VIBRAMYCIN SYRP 50 mg/5ml MG/5ML (doxycycline 2 doxycycline calcium) (monohydrate) tabs 1 THYROID AGENTS - Drugs to Regulate Thyroid 100 mg, 50 mg Hormones doxycycline ST Antithyroid Agents (monohydrate) tabs 1 methimazole tabs 1 150 mg, 75 mg propylthiouracil tabs 1 doxycycline hyclate 1 caps 100 mg, 50 mg
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121 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TAPAZOLE TABS TIROSINT CAPS 100 GP (methimazole) MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 Thyroid Hormones MCG, 25 MCG, 50 MCG, GP (Levothyroxine Sodium) 75 MCG, 88 MCG EUTHYROX, LEVO-T, 1 (levothyroxine sodium) LEVOXYL, UNITHROID TIROSINT CAPS 75 MCG TABS 3 (levothyroxine sodium) (Thyroid) NP THYROID 120, NP THYROID 15 1 TIROSINT-SOL SOLN 100 TABS MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, ARMOUR THYROID TABS GP 137 MCG/ML, 150 120 MG, 15 MG (thyroid) MCG/ML, 200 MCG/ML, 25 3 ARMOUR THYROID TABS MCG/ML, 50 MCG/ML, 75 180 MG, 240 MG, 30 MG, MCG/ML, 88 MCG/ML 2 300 MG, 60 MG, 90 MG (levothyroxine sodium) (thyroid) WESTHROID TABS CYTOMEL TABS 2 GP (thyroid) (liothyronine sodium) WP THYROID TABS 2 levothyroxine sodium (thyroid) caps or 100 mcg, 112 ULCER DRUGS - Drugs to Treat Bowel, Intestine mcg, 125 mcg, 13 mcg, 1 and Stomach Conditions 137 mcg, 150 mcg, 25 mcg, 50 mcg, 75 mcg, Antispasmodics (Hyoscyamine Sulfate) ED- 88 mcg SPAZ, NULEV, OSCIMIN 1 levothyroxine sodium TBDP tabs or 100 mcg, 112 (Hyoscyamine Sulfate) mcg, 125 mcg, 137 OSCIMIN SR, SYMAX-SR 1 mcg, 150 mcg, 175 1 TB12 mcg, 200 mcg, 25 mcg, (Hyoscyamine Sulfate) 300 mcg, 50 mcg, 75 OSCIMIN, SYMAX-SL 1 mcg, 88 mcg SUBL ANASPAZ TBDP liothyronine sodium 1 GP tabs (hyoscyamine sulfate) BELLADONNA/OPIUM NATURE-THROID NT-2.5 2 SUPP (belladonna 3 TABS (thyroid) alkaloids & opium) NATURE-THROID TABS 2 (thyroid) chlordiazepoxide hcl- 1 clidinium bromide caps SYNTHROID TABS GP CUVPOSA SOLN (levothyroxine sodium) 2 (glycopyrrolate) thyroid tabs 1 dicyclomine hcl caps 1 dicyclomine hcl soln 1
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Updated 07/01/2021 122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dicyclomine hcl tabs 1 ranitidine hcl syrp 1 GLYCATE TABS 3 ranitidine hcl tabs 1 (glycopyrrolate) glycopyrrolate tabs or 1 Misc. Anti-Ulcer 1 CARAFATE SUSP mg, 2 mg GP GLYCOPYRROLATE (sucralfate) TABS OR 1.5 MG CARAFATE TABS 3 GP (glycopyrrolate) (sucralfate) hyoscyamine sulfate 1 sucralfate susp 1 subl sucralfate tabs 1 hyoscyamine sulfate 1 tb12 Proton Pump Inhibitors hyoscyamine sulfate 1 (Esomeprazole PA; QL(1 ea tbdp Magnesium) CVS daily); RX/OTC LEVBID TB12 ESOMEPRAZOLE GP (hyoscyamine sulfate) MAGNESIUM, GNP ESOMEPRAZOLE LEVSIN/SL SUBL GP MAGNESIUM, (hyoscyamine sulfate) GOODSENSE LIBRAX CAPS ESOMEPRAZOLE (chlordiazepoxide hcl- GP MAGNESIUM, HM clidinium bromide) ESOMEPRAZOLE 1 MAGNESIUM DELAYED methscopolamine 1 RELEASE, KLS bromide tabs ESOMEPRAZOLE propantheline bromide MAGNESIUM, QC 1 ESOMEPRAZOLE tabs MAGNESIUM, RA H-2 Antagonists ESOMEPRAZOLE MAGNESIUM, SM cimetidine hcl soln 1 ESOMEPRAZOLE MAGNESIUM CPDR cimetidine tabs 1 QL(1 ea daily); (Lansoprazole) CVS 1 AL(Up to 12 yrs famotidine susr 40 1 LANSOPRAZOLE TBDD mg/5ml old ); RX/OTC ACIPHEX SPRINKLE PA famotidine tabs 40 mg 1 QL(2 ea daily) CPSP 10 MG, 5 MG 3 (rabeprazole sodium) nizatidine caps 1 ACIPHEX TBEC PA; QL(2 ea GP (rabeprazole sodium) daily) nizatidine soln 1 DEXILANT CPDR PA; QL(1 ea PEPCID TABS QL(2 ea daily) 3 daily) GP (dexlansoprazole) (famotidine) PA; QL(1 ea esomeprazole 1 ranitidine hcl caps 1 magnesium cpdr 20 mg daily); RX/OTC
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123 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea esomeprazole 1 omeprazole cpdr 10 1 magnesium cpdr 40 mg daily) mg, 40 mg esomeprazole PA omeprazole cpdr 20 mg 1 RX/OTC magnesium pack 10 1 mg, 20 mg, 40 mg pantoprazole sodium 1 ESOMEPRAZOLE PA; QL(1 ea pack STRONTIUM CPDR daily) pantoprazole sodium 1 (esomeprazole 3 tbec strontium) PREVACID CPDR GP FIRST-LANSOPRAZOLE PA (lansoprazole) 3 SUSP (lansoprazole) PREVACID SOLUTAB QL(1 ea daily); FIRST-OMEPRAZOLE TBDD 15 MG GP AL(Up to 12 yrs 3 SUSP (omeprazole) (lansoprazole) old ); RX/OTC PREVACID SOLUTAB QL(1 ea daily); lansoprazole cpdr 30 1 mg TBDD 30 MG GP AL(Up to 12 yrs (lansoprazole) old ) lansoprazole tbdd 15 QL(1 ea daily); 1 AL(Up to 12 yrs PRILOSEC PACK PA mg old ); RX/OTC (omeprazole 3 magnesium) lansoprazole tbdd 30 QL(1 ea daily); 1 AL(Up to 12 yrs PROTONIX PACK mg GP old ) (pantoprazole sodium) NEXIUM 24HR CLEAR PA; QL(1 ea PROTONIX TBEC GP MINIS CPDR daily); RX/OTC (pantoprazole sodium) (esomeprazole GP RABEPRAZOLE SODIUM PA magnesium) DR SPRINKLE CPSP 3 NEXIUM 24HR CPDR PA; QL(1 ea (rabeprazole sodium) daily); RX/OTC (esomeprazole GP PA; QL(2 ea rabeprazole sodium 1 magnesium) tbec daily) NEXIUM CPDR 20 MG PA; QL(1 ea (esomeprazole GP daily); RX/OTC Ulcer Drugs - Prostaglandins CYTOTEC TABS magnesium) GP NEXIUM CPDR 40 MG PA; QL(1 ea (misoprostol) (esomeprazole GP daily) misoprostol tabs 1 magnesium) NEXIUM PACK 10 MG, 20 PA Ulcer Therapy Combinations MG, 40 MG (Omeprazole-Sodium PA (esomeprazole GP Bicarbonate) OMEPPI 1 magnesium) CAPS NEXIUM PACK 2.5 MG, 5 PA amoxicillin- MG (esomeprazole 3 clarithromycin w/ 1 magnesium) lansoprazole misc OMEPRAZOLE + SYRSPEND SFALKA 3 SUSP (omeprazole) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HELIDAC THERAPY MISC GELNIQUE GEL 3 (metronidazole- (oxybutynin chloride) 3 tetracycline w/ bismuth GELNIQUE PUMP GEL 3 subsalicylate) (oxybutynin chloride) OMECLAMOX-PAK MISC oxybutynin chloride 1 (amoxicillin- syrp clarithromycin w/ 3 oxybutynin chloride 1 omeprazole) tabs omeprazole-sodium PA oxybutynin chloride 1 bicarbonate caps 1100 1 tb24 mg-40 mg solifenacin succinate 1 omeprazole-sodium tabs bicarbonate pack 1680 1 QL(1 ea daily) mg-20 mg, 1680 mg-40 tolterodine tartrate cp24 1 mg 2 mg, 4 mg QL(2 ea daily) PYLERA CAPS (bismuth tolterodine tartrate tabs 1 1 mg subcitrate potassium- 3 metronidazole- tolterodine tartrate tabs 1 tetracycline) 2 mg TOVIAZ TB24 QL(1 ea daily) ZEGERID CAPS 1100 MG- PA 2 40 MG (omeprazole- GP (fesoterodine fumarate) sodium bicarbonate) trospium chloride tabs 1 ZEGERID PACK 1680 MG- VESICARE TABS 20 MG, 1680 MG-40 MG GP (omeprazole-sodium GP (solifenacin succinate) bicarbonate) Urinary Antispasmodics - Beta-3 Adrenergic MYRBETRIQ TB24 PA; QL(1 ea URINARY ANTISPASMODICS - Drugs to Treat 3 Miscellaneous Bladder Spasms (mirabegron) daily) Urinary Antispasmodic - Antimuscarinics Urinary Antispasmodics - Cholinergic Agonists darifenacin 1 bethanechol chloride 1 hydrobromide tb24 tabs DETROL LA CP24 QL(1 ea daily) URECHOLINE TABS GP GP (tolterodine tartrate) (bethanechol chloride) DETROL TABS 1 MG QL(2 ea daily) GP Urinary Antispasmodics - Direct Muscle Relaxants (tolterodine tartrate) DETROL TABS 2 MG flavoxate hcl tabs 1 GP (tolterodine tartrate) VACCINES DITROPAN XL TB24 GP (oxybutynin chloride) Bacterial Vaccines ENABLEX TB24 PEDVAX HIB SUSP PV (darifenacin GP (haemophilus b polysac PV hydrobromide) conj vac)
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125 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Viral Vaccines OPTIONS GYNOL II PV FLUCELVAX PV VAGINALCONTRACEPTIV PV QUADRIVALENT 2018- E GEL (nonoxynol-9) SHUR-SEAL GEL PV 2019 SUSY (influenza PV virus vaccine tissue- PV (nonoxynol-9) cultured subunit TODAY SPONGE MISC PV PV quadrivalent) (nonoxynol-9) FLUCELVAX PV VCF VAGINAL PV QUADRIVALENT 2019- CONTRACEPTIVE FILM PV 2020 SUSY (influenza FILM (nonoxynol-9) PV virus vaccine tissue- VCF VAGINAL PV cultured subunit CONTRACEPTIVE FOAM PV quadrivalent) FOAM (nonoxynol-9) FLUCELVAX PV VCF VAGINAL PV QUADRIVALENT 2020- CONTRACEPTIVEGEL PV 2021 SUSY (influenza GEL (nonoxynol-9) PV virus vaccine tissue- Vaginal Anti-infectives cultured subunit (Metronidazole Vaginal) 1 quadrivalent) VANDAZOLE GEL GARDASIL 9 SUSP PV (Miconazole Nitrate (human papillomavirus PV Vaginal) MICONAZOLE 3 1 (hpv) 9-valent recombinant SUPP vaccine) AVC CREA 3 GARDASIL 9 SUSY PV (sulfanilamide vaginal) (human papillomavirus PV CLEOCIN CREA VA 2 % (hpv) 9-valent recombinant (clindamycin phosphate GP vaccine) vaginal) VAGINAL AND RELATED PRODUCTS CLEOCIN SUPP VA 100 MG (clindamycin 3 Miscellaneous Vaginal Products phosphate vaginal) FEM PH GEL (acetic clindamycin phosphate 1 acid-oxyquinoline GP vaginal crea vaginal) CLINDESSE CREA INTRAROSA INST 3 (clindamycin phosphate 3 (prasterone vaginal) (one dose)) Spermicides GYNAZOLE-1 CREA ENCARE SUPP PV PV (butoconazole nitrate 3 (nonoxynol-9) (one dose)) OPTIONS CONCEPTROL PV METROGEL-VAGINAL VAGINAL GP GEL (metronidazole GP CONTRACEPTIVE GEL vaginal) (nonoxynol-9) metronidazole vaginal 1 gel
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Updated 07/01/2021 126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limited to 4 terconazole vaginal 1 epinephrine crea 1 syringes per (anaphylaxis) soaj 0.15 fill;QL(4 ea per mg/0.3ml terconazole vaginal 1 fill retail) supp EPINEPHRINE SOAJ QL(4 ea per fill Vaginal Contraceptive - pH Modulators (epinephrine 2 retail) PHEXXI GEL (lactic PV (anaphylaxis)) acid-citric acid- PV EPIPEN 2-PAK SOAJ PA; QL(4 ea potassium bitartrate) (epinephrine GP per fill retail) Vaginal Estrogens (anaphylaxis)) EPIPEN-JR 2-PAK SOAJ Limited to 4 (Estradiol Vaginal) 1 YUVAFEM TABS ( GP syringes per epinephrine fill;QL(4 ea per ESTRACE CREA (anaphylaxis)) GP fill retail) (estradiol vaginal) Neurogenic Orthostatic Hypotension (NOH) - estradiol vaginal crea 1 droxidopa caps 3 PA estradiol vaginal tabs 1 NORTHERA CAPS PA GP ESTRING RING (droxidopa) 3 (estradiol vaginal) Vasopressors FEMRING RING QL(1 ea per 90 midodrine hcl tabs 1 ( 3 days retail,1 ea estradiol acetate per 90 days vaginal) mail) VITAMINS PREMARIN CREA Oil Soluble Vitamins (estrogens, conjugated 2 (Cholecalciferol) AL(At least 65 vaginal) AQUEOUS VITAMIN D yrs old); PV VAGIFEM TABS INFANTS, BPROTECTED GP (estradiol vaginal) PEDIA D-VITE, D-VITE PEDIATRIC, D3 VITAMIN, PV Vaginal Progestins JUST D, PHARMACIST CRINONE GEL PA CHOICE D-VITAMIN (progesterone 3 PEDIATRIC DROPS, VITAMIN D INFANT LIQD (vaginal)) (Cholecalciferol) CVS D3, PV AL(At least 65 ENDOMETRIN INST PA EQL VITAMIN D3 CAPS yrs old); PV (progesterone 3 (Cholecalciferol) D 400, D- AL(At least 65 (vaginal)) 400, D3 HIGH POTENCY, yrs old); PV VASOPRESSORS - Drugs to Treat Heart and DELTA D3, GNP VITAMIN PV Circulation Conditions D-400, HM VITAMIN D, QC VITAMIN D3, SM VITAMIN Anaphylaxis Therapy Agents D, VITAMIN D-400 TABS epinephrine QL(4 ea per fill (Cholecalciferol) D 400, D3 AL(At least 65 (anaphylaxis) soaj 0.15 retail) 2 KIDS, GNP VITAMIN D, PV yrs old); PV mg/0.15ml, 0.3 HEALTHY KIDS VITAMIN mg/0.3ml D3, KP VITAMIN D CHEW
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127 Updated 07/01/2021 Drug Requirements/ Drug Name Tier Limits BABY DDROPS LIQD AL(At least 65 PV (cholecalciferol) yrs old); PV PV AL(At least 65 cholecalciferol caps yrs old); PV PV AL(At least 65 cholecalciferol chew yrs old); PV PV AL(At least 65 cholecalciferol liqd yrs old); PV PV AL(At least 65 cholecalciferol tabs yrs old); PV D-VI-SOL LIQD AL(At least 65 GP (cholecalciferol) yrs old); PV DRISDOL CAPS GP (ergocalciferol) ergocalciferol caps 1 MEPHYTON TABS GP (phytonadione) phytonadione tabs 1 VITAMIN D2 TABS AL(At least 65 PV (ergocalciferol) yrs old); PV VITAMIN D3 IMMUNE AL(At least 65 HEALTH LIQD PV yrs old); PV (cholecalciferol) VITAMIN D3 LIQD AL(At least 65 PV (cholecalciferol) yrs old); PV Water Soluble Vitamins POTABA CAPS (potassium 3 aminobenzoate)
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Updated 07/01/2021 128 Index 7t lido gel 73 adefovir dipivoxil49 ALOMIDE113 abacavir sulfate46 ADEMPAS53 ALORA82 abacavir sulfate-lamivudine46 ADIPEX-P1 alosetron hcl84 abacavir sulfate-lamivudine- adult aspirin regimen7 ALPHAGAN P110 zidovudine 46 ADVAIR DISKUS18 alprazolam16 ABILIFY46 ADVAIR HFA18 ALPRAZOLAM INTENSOL16 abiraterone acetate40 AFINITOR41 alprazolam xr16 ABSORICA61 AFINITOR DISPERZ41 ALREX111 ABSORICA LD61 afirmelle55 ALTABAX64 ABSTRAL9 aftera58 altacaine111 acamprosate calcium116 AGGRENOX86 ALTACE34 acarbose26 AGRYLIN86 altafrin109 ACCOLATE17 AIMOVIG94 ALTOPREV33 ACCUPRIL34 AIMSCO LUBRICATED91 ALUNBRIG41 ACCURETIC35 ak-poly-bac110 alvimopan84 acebutolol hcl51 AKTEN111 alyacen 1/3555 acetaminophen w/ codeine11 AKYNZEO31 alyacen 7/7/756 acetazolamide77 al1272 alyq53 acetic acid (otic)114 ala scalp68 amabelz81 acetylcysteine61 ala-cort68 amantadine hcl43 ACIPHEX123 ALA-QUIN65 AMARYL29 ACIPHEX SPRINKLE123 ALA-SCALP68 AMBIEN88 acitretin66 albendazole13 AMBIEN CR88 ACTEMRA4 ALBENZA13 ambrisentan53 ACTICLATE121 albuterol sulfate18 amcinonide68 ACTIDOM DMX60 ALBUTEROL SULFATE18 AMCINONIDE68 ACTIGALL83 albuterol sulfate18,19 AMERGE94 ACTIQ9 ALCAINE111 amethia55 ACTIVELLA81 alclometasone amethyst55 ACTONEL78 dipropionate68 AMICAR88 ACTOPLUS MET27 ALCORTIN A65 amiloride & ACTOS28 ALDACTAZIDE77 hydrochlorothiazide77 ACULAR113 ALDACTONE77 amiloride hcl77 ACULAR LS113 ALDARA72 aminocaproic acid88 ACUVAIL113 ALECENSA41 amiodarone hcl17 acyclovir50 alendronate sodium78 AMITIZA83 acyclovir topical67 ALFERON N43 amitriptyline hcl26 ACZONE62 alfuzosin hcl85 amlodipine besylate51 ADALAT CC51 ALINIA14 amlodipine besylate-atorvastatin adapalene62 aliskiren fumarate37 calcium52 amlodipine besylate-benazepril adapalene treatment61 ALKERAN39 hcl35 adapalene-benzoyl peroxide62 allergy nasal spray 24 amlodipine besylate-olmesartan ADCIRCA53 hour108 medoxomil35 allevess73 amlodipine besylate- ADDERALL1 allopurinol86 valsartan36 ADDERALL XR1 amlodipine-valsartan- almotriptan malate94 ADDYI117 hydrochlorothiazide 36 ALOCRIL113 amnesteem61
Index 1 Updated 07/01/2021 amoxapine26 ARIKAYCE3 AVALIDE36 amoxicillin115 ARIMIDEX40 AVANDIA28 amoxicillin & pot aripiprazole46 AVAPRO35 clavulanate115 ARIXTRA20 AVAR62 amoxicillin-clarithromycin w/ lansoprazole124 armodafinil2 avar cleanser61 amphetamine- ARMOUR THYROID122 AVAR LS62 dextroamphetamine1 ARNUITY ELLIPTA18 AVAR LS CLEANSER62 ampicillin115 AROMASIN40 avar-e emollient61 AMPYRA117 arthritis pain reliever64 AVAR-E LS62 AMRIX107 ARTHROTEC 504 AVC126 ANADROL-5012 ARTHROTEC 754 AVELOX82 ANAFRANIL26 ARYMO ER9 avidoxy121 anagrelide hcl86 ASACOL HD83 avita61 ANALPRAM HC13 ascomp/codeine10 AVODART85 ANALPRAM HC SINGLES13 ASCRIPTIN8 AVONEX117 ANALPRAM-HC13 asenapine maleate45 AVONEX PEN117 ANASPAZ122 aspirin8 AYGESTIN115 anastrozole40 aspirin 81 low dose8 AYVAKIT41 ANCOBON31 aspirin adult8 AZASAN97 ANDRODERM12 aspirin-dipyridamole86 AZASITE110 ANDROGEL12 ASTAGRAF XL97 azathioprine97 ANDROGEL PUMP12 ATABEX EC101 azelaic acid75 ANGELIQ81 ATABEX OB101 azelastine hcl108 ANNOVERA57 ATACAND35 azelastine hcl (ophth)113 ANORO ELLIPTA19 ATACAND HCT36 azelastine hcl-fluticasone ANTABUSE116 atazanavir sulfate46 propionate108 AZELEX62 ANTARA33 ATELVIA78 AZILECT44 anti-diarrheal29 atenolol51 azithromycin90 anucort-hc13 atenolol & chlorthalidone36 AZOPT113 anusol-hc13 ATIVAN16 AZOR36 ANUSOL-HC13 atomoxetine hcl2 AZULFIDINE83 ANZEMET30 atorvastatin calcium33 AZULFIDINE EN-TABS83 APEXICON E68 atovaquone14 azurette54 APLENZIN24 atovaquone-proguanil hcl37 BABY DDROPS128 apraclonidine hcl110 ATRALIN62 bac6 aprepitant31 ATRIPLA46 bacitracin (ophthalmic)110 apri54 ATROPINE SULFATE110 APRISO83 bacitracin-poly-neomycin-hc atropine sulfate 111 APTIOM21 (ophthalmic)110 bacitracin-polymyxin b APTIVUS46 ATROVENT HFA17 (ophth)110 aqueous vitamin d infants127 AUBAGIO117 baclofen107 ARANESP ALBUMIN FREE87 AUGMENTIN115 BACTRIM14 ARAVA6 AUGMENTIN ES-600115 BACTRIM DS14 ARCALYST4 aurovela 1.5/3056 BAL-CARE DHA101 ARCAPTA NEOHALER19 aurovela 24 fe55 BALCOLTRA56 ARICEPT116 AUSTEDO117 balsalazide disodium83
Updated 07/01/2021 Index 2 BALVERSA41 BETADINE OPHTHALMIC BRUKINSA41 BANZEL21 PREP110 budesonide58 betamethasone dipropionate BAQSIMI ONE PACK27 (topical)68 budesonide (inhalation)18 BAQSIMI TWO PACK27 betamethasone dipropionate budesonide (nasal)108 BARACLUDE49 augmented68 budesonide-formoterol fumarate BAXDELA82 betamethasone valerate68 dihydrate19 BD AUTOSHIELD 29G X BETAPACE51 bumetanide77 3/16"93 BETAPACE AF51 BUMEX77 BD AUTOSHIELD 29G X BETASERON117 BUNAVAIL11 5/16"93 bupap6 BD AUTOSHIELD DUO 30G X betaxolol hcl51 5MM93 betaxolol hcl (ophth)109 BUPHENYL79 BD PEN bethanechol chloride125 buprenorphine12 NEEDLE/MICRO/ULTRA- BETHKIS3 buprenorphine hcl11 FINE/32G X 6MM93 BETIMOL109 buprenorphine hcl-naloxone hcl BD PEN NEEDLE/MINI/ULTRA- dihydrate11,12 FINE/31G X 5MM94 BETOPTIC-S109 bupropion hcl24 BD PEN NEEDLE/NANO 2ND BEVYXXA20 GEN/32G X 5/32"94 bupropion hcl (smoking BD PEN bexarotene43 deterrent)120 NEEDLE/NANO/ULTRA- BEYAZ56 buspirone hcl16 FINE/32G X 4MM94 bicalutamide40 butalbital-acetaminophen7 BD PEN BIDIL53 butalbital-acetaminophen- NEEDLE/ORIGINAL/ULTRA- BIKTARVY46 caffeine7 FINE/29G X 12.7MM94 butalbital-acetaminophen- BD PEN BILTRICIDE13 caffeine w/ codeine11 NEEDLE/SHORT/ULTRA- bimatoprost114 butalbital-aspirin-caffeine7 FINE/31G X 8MM94 BINOSTO78 butalbital-aspirin-caffeine BECONASE AQ108 BIO-DTUSS DMX60 w/cod11 BELBUCA11 bisoprolol & BUTALBITAL/ASPIRIN/CAFFEIN BELLADONNA/OPIUM122 hydrochlorothiazide36 E7 BELSOMRA89 bisoprolol fumarate51 BUTISOL SODIUM88 BELVIQ2 BLEPH-10110 butorphanol tartrate12 BELVIQ XR2 BLEPHAMIDE112 BUTRANS12 benazepril & BLEPHAMIDE S.O.P.111 BYSTOLIC51 hydrochlorothiazide36 BONIVA78 BYVALSON36 benazepril hcl34 BONJESTA31 C-NATE DHA101 BENICAR35 bosentan53 c-topical73 BENICAR HCT36 BOSULIF41 cabergoline81 BENLYSTA98 bp cleansing wash61 CABLIVI86 BENSAL HP73 bprotected pedia iron88 CABOMETYX41 BENZACLIN62 BRAFTOVI41 CADUET53 BENZACLIN WITH PUMP62 BREO ELLIPTA19 CAFERGOT94 BENZNIDAZOLE13 BRILINTA86 caffeine citrate1 benzonatate59 brimonidine tartrate110 CALAN51 benztropine mesylate43 brinzolamide113 CALAN SR51 bepotastine besilate113 BRISDELLE120 CALCIFOL96 BEPREVE113 bromfenac sodium calcipotriene66 BERINERT86 (ophth)113 CALCIPOTRIENE66 beser68 bromocriptine mesylate43 calcipotriene-betamethasone BESIVANCE110 BROMSITE113 dipropionate68 calcitonin (salmon)78
Index 3 Updated 07/01/2021 calcitrene66 CATAPRES-TTS-135 CHLORZOXAZONE107 calcitriol79 CATAPRES-TTS-235 chlorzoxazone107 calcitriol (topical)66 CATAPRES-TTS-335 CHOLBAM83 calcium acetate (phosphate CAYA91 cholecalciferol128 binder)84 caziant54 cholestyramine33 CALCIUM-FOLIC ACID PLUS D96 cefaclor54 cholestyramine light33 CALQUENCE41 CEFACLOR ER54 choline fenofibrate33 CAMBIA94 cefadroxil54 CHORIONIC GONADOTROPIN78 camila58 cefdinir54 CIALIS53 CANASA83 cefditoren pivoxil54 CICLODAN SOLUTION KIT65 candesartan cilexetil35 cefixime54 ciclopirox65 candesartan cilexetil- cefpodoxime proxetil54 ciclopirox olamine65 hydrochlorothiazide 36 cefprozil54 cilostazol86 capecitabine39 cefuroxime axetil54 CILOXAN110 CAPEX68 CELEBREX5 cimetidine123 CAPLYTA45 celecoxib5 cimetidine hcl123 CAPRELSA41 CELEXA25 CIMZIA83 captopril34 CELLCEPT97 captopril & CIMZIA STARTER KIT83 CELONTIN24 hydrochlorothiazide36 cinacalcet hcl80 CEM-UREA72 CARAC66 CIPRO82 CENTANY64 CARAFATE123 CIPRO HC114 CENTANY AT64 CARBAGLU79 CIPRODEX114 cephalexin54 carbamazepine21 ciprofloxacin82 CERACADE74 CARBATROL21 ciprofloxacin hcl82 CERDELGA87 carbidopa43 ciprofloxacin hcl (ophth)110 CEROVEL72 carbidopa-levodopa44 ciprofloxacin hcl (otic)114 CESAMET31 carbidopa-levodopa-entacapone ciprofloxacin-dexamethasone 44 CETRAXAL114 114 carbinoxamine maleate32 CETROTIDE79 ciprofloxacin-fluocinolone CARDIZEM52 cevimeline hcl99 acetonide114 CARDIZEM CD52 CHANTIX120 citalopram hydrobromide25 CARDIZEM LA52 CHANTIX CONTINUING CITRANATAL 90 DHA101 CARDURA35 MONTHPAK120 CITRANATAL B-CALM101 CARDURA XL85 CHANTIX STARTING MONTH CITRANATAL BLOOM101 PAK120 carisoprodol107 CITRANATAL BLOOM charlotte 24 fe55 DHA101 carisoprodol w/ aspirin107 CHEMET30 CITRANATAL DHA101 carisoprodol w/ aspirin & codeine107 CHENODAL83 CITRANATAL ESSENCE101 CARNITOR80 cheratussin ac60 CITRANATAL HARMONY101 CARNITOR SF79 chlordiazepoxide hcl16 CITRANATAL MEDLEY101 carteolol hcl (ophth)109 chlordiazepoxide hcl-clidinium CITRANATAL RX101 bromide122 cartia xt51 chlordiazepoxide-amitriptyline claravis61 carvedilol50 117 CLARINEX32 carvedilol phosphate50 chloroquine phosphate38 CLARINEX-D 12 HOUR60 CASODEX40 chlorothiazide77 clarithromycin90 cataflam4 chlorpromazine hcl46 clearlax90 CATAPRES35 chlorthalidone77 clemastine fumarate32
Updated 07/01/2021 Index 4 CLEOCIN14,126 colchicine86 COUMADIN20 CLEOCIN PEDIATRIC colchicine w/ probenecid86 covaryx81 GRANULES14 colesevelam hcl33 COZAAR35 CLEOCIN-T62 COLESTID33 CREON76 CLIMARA82 COLESTID FLAVORED33 CRESEMBA31 CLIMARA PRO81 colestipol hcl33 CRESTOR33 clindacin etz pledgets61 colocort12 CRINONE127 clindamycin hcl14 COLY-MYCIN S114 CRIXIVAN47 clindamycin palmitate hydrochloride14 COLYTE-FLAVOR PACKS89 cromolyn sodium17 clindamycin phosphate COMBIGAN109 cromolyn sodium (topical)62 COMBIPATCH81 (mastocytosis)83 clindamycin phosphate cromolyn sodium (ophth)113 COMBIVENT RESPIMAT19 vaginal126 CRYODOSE TA74 clindamycin phosphate-benzoyl COMBIVIR47 cryselle-2856 peroxide62 COMETRIQ41 CUPRIMINE97 clindamycin phosphate-benzoyl COMPLERA47 peroxide (refrigerate)62 CUTIVATE69 COMPLETENATE101 clindamycin phosphate- CUVPOSA122 tretinoin62 compro46 cvs budesonide nasal CLINDESSE126 COMTAN43 spray108 clobazam21 CONCEPT DHA101 cvs d3127 clobetasol propionate69 CONCEPT OB102 cvs esomeprazole clobetasol propionate e68 CONCERTA2 magnesium123 clobetasol propionate emollient CONDYLOX73 cvs folic acid87 base69 constulose90 cvs lansoprazole123 clobetasol propionate cvs nicotine119 emulsion69 CONTRAVE2 CLOBEX69 CONZIP9 cvs nicotine lozenge118 cvs nicotine clodan68 COPAXONE117 transdermalsystem119 CLODERM69 COPIKTRA41 cyclobenzaprine hcl107 CLODERM PUMP69 CORDRAN69 CYCLOGYL110 clomiphene citrate78 COREG50 CYCLOMYDRIL110 clomipramine hcl26 COREG CR50 cyclopentolate hcl110 clonazepam21 coremino121 cyclophosphamide39 clonidine35 CORGARD51 CYCLOPHOSPHAMIDE39 clonidine hcl35 CORLANOR54 cycloserine38 clonidine hcl (adhd)2 CORTANE-B69 CYCLOSET28 clopidogrel bisulfate86 CORTEF58 cyclosporine97 clorazepate dipotassium16 CORTENEMA13 cyclosporine modified (for clotrimazole98 cortic-nd114 microemulsion)97,98 clotrimazole w/ CORTIFOAM13 CYMBALTA26 betamethasone65 cortisone acetate59 cyproheptadine hcl32 clovique97 CORTISPORIN-TC114 CYSTADANE80 clozapine45 COSENTYX66 CYSTADROPS113 CLOZARIL45 COSENTYX SENSOREADY CYSTAGON85 COARTEM38 PEN66 CYSTARAN113 codeine sulfate9 COSOPT109 CYTOMEL122 CODITUSSIN AC60 COSOPT PF109 CYTOTEC124 COLAZAL83 COTELLIC41 cytra k crystals85
Index 5 Updated 07/01/2021 cytra-285 desipramine hcl26 diclofenac w/ misoprostol5 cytra-385 desloratadine32 dicloxacillin sodium115 CYTRA-K85 desmopressin acetate80 dicyclomine hcl122 d 400127 desmopressin acetate didanosine47 D-VI-SOL128 spray80 diethylpropion hcl2 desmopressin acetate spray D.H.E. 4594 refrigerated80 DIFFERIN62,63 DAKLINZA49 desogestrel & ethinyl DIFICID91 dalfampridine117 estradiol56 diflorasone diacetate69 desogestrel-ethinyl estradiol DALIRESP18 (biphasic)56 DIFLUCAN31 danazol12 DESONATE69 diflunisal8 DANTRIUM107 desonide69 digitek52 dantrolene sodium107 DESOWEN69 digoxin52 dapsone14 desoximetasone69 dihydroergotamine mesylate94 dapsone (topical)62 DESOXYN1 DILANTIN24 DARAPRIM38 desrx68 DILANTIN INFATABS24 darifenacin hydrobromide125 DESVENLAFAXINE ER26 DILANTIN-12524 DAURISMO40 desvenlafaxine succinate26 DILATRATE SR15 DAYPRO5 DETROL125 DILAUDID9 DAYTRANA2 DETROL LA125 dilt-xr51 DDAVP80 dexamethasone59 diltiazem hcl52 decadron58 DEXAMETHASONE diltiazem hcl coated beads52 deferasirox30 INTENSOL59 diltiazem hcl extended release deferiprone30 dexamethasone sodium beads52 phosphate (ophth)112 dimethyl fumarate117 DELSTRIGO47 dexchlorpheniramine DIOVAN35 DELZICOL83 maleate32 DIOVAN HCT36 DEMADEX77 DEXEDRINE1 DIPENTUM83 demeclocycline hcl121 DEXILANT123 diphenoxylate w/ atropine30 DEMSER35 dexmethylphenidate hcl2 DIPROLENE69 DENAVIR67 dexpak 10 day58 DIPROLENE AF69 DEPAKENE24 dextroamphetamine sulfate1 dipyridamole86 DEPAKOTE24 DIACOMIT22 disopyramide phosphate16 DEPAKOTE ER24 DIAPHRAGM91 disulfiram116 DEPAKOTE SPRINKLES24 DIASTAT ACUDIAL21 DITROPAN XL125 DEPEN TITRATABS97 DIASTAT PEDIATRIC21 DIURIL77 DEPLIN 1576 diazepam16 divalproex sodium24 DEPLIN 7.576 diazepam (anticonvulsant)21 DEPO-PROVERA diazepam intensol16 DIVIGEL82 DOCTOR MANZANILLA PE CONTRACEPTIVE58 diazoxide27 DEPO-SUBQ PROVERA SYRUP 10458 DIBENZYLINE35 ANTIHISTAMINE/DECONGESTA DEPO-TESTOSTERONE12 DICLEGIS31 NT 60 DERMA-SMOOTHE/FS DICLOFENAC5 dofetilide17 BODY69 diclofenac potassium5 DOLOPHINE9 DERMA-SMOOTHE/FS diclofenac sodium5 DOMETUSS-DMX60 SCALP69 diclofenac sodium (actinic donepezil hydrochloride116 dermazene65 keratoses)66 DOPTELET87 DERMOTIC115 diclofenac sodium (ophth)113 DORAL88 DESCOVY47 diclofenac sodium (topical)64
Updated 07/01/2021 Index 6 DORYX121 EC-NAPROSYN5 enalapril maleate & dorzolamide hcl113 ec-naproxen4 hydrochlorothiazide36 ENBRACE HR102 DORZOLAMIDE HCL113 econazole nitrate65 ENBREL6 dorzolamide hcl-timolol ECOTRIN8 maleate109 ECOTRIN REGULAR ENBREL MINI6 DOTHELLE DHA102 STRENGTH8 ENBREL SURECLICK6 dotti82 ed-spaz122 ENCARE126 DOVATO47 EDARBI35 ENDARI87 DOVONEX66 EDARBYCLOR36 endocet11 doxazosin mesylate35 EDECRIN77 ENDOMETRIN127 doxepin hcl26 EDLUAR88 enoxaparin sodium20 doxepin hcl (sleep)88 EDURANT47 enpresse-2855 doxercalciferol80 efavirenz47 entacapone43 doxycycline (monohydrate)121 efavirenz-emtricitabine- entecavir49 doxycycline (rosacea)75 tenofovir disoproxil ENTEREG84 fumarate47 doxycycline hyclate121 effer-k96 ENTOCORT EC59 doxylamine-pyridoxine31 EFFER-K97 ENTRESTO53 DRISDOL128 EFFEXOR XR26 ENTTY SPRAY74 dronabinol31 EFFIENT86 enulose84 drospirenone-ethinyl EFUDEX66 ENVARSUS XR98 estradiol56 EPANED34 drospirenone-ethinyl estradiol- ELESTAT113 levomefolate calcium56 ELESTRIN82 EPCLUSA49 DROXIA87 eletriptan hydrobromide94 EPICERAM74 droxidopa127 ELFOLATE76 EPIDIOLEX22 DRYSOL74 ELIDEL73 EPIDUO63 DUAC63 ELIMITE75 EPIFOAM69 DUAVEE81 ELIQUIS20 epinastine hcl (ophth)113 DUET DHA 400102 ELIQUIS STARTER PACK20 EPINEPHRINE127 DUET DHA BALANCED102 ELIXOPHYLLIN20 epinephrine (anaphylaxis)127 DUETACT27 ELLA58 EPIPEN 2-PAK127 DUEXIS5 ELMIRON85 EPIPEN-JR 2-PAK127 duloxetine hcl26 ELOCON69 epitol21 DUOPA44 eluryng57 EPIVIR47 DUPIXENT72 EMBEDA9 EPIVIR HBV49 DURAGESIC9 EMCYT40 eplerenone37 duraxin6 EMEND31 EPOGEN87 DUREX EXTRA SENSITIVE91 EMEND TRIPACK31 eprosartan mesylate35 DUREZOL112 EMGALITY94 EPZICOM47 dutasteride85 EMSAM25 EQUETRO45 dutasteride-tamsulosin hcl85 emtricitabine47 ergocalciferol128 DUTOPROL36 emtricitabine-tenofovir ergoloid mesylates118 DYAZIDE77 disoproxil fumarate47 ERGOMAR94 DYMISTA108 EMTRIVA47 ergotamine w/ caffeine94 DYRENIUM77 EMULSION SB74 ERIVEDGE40 e.e.s. 40091 EMVERM13 ERLEADA40 E.E.S. GRANULES91 ENABLEX125 erlotinib hcl40 enalapril maleate34
Index 7 Updated 07/01/2021 ERTACZO65 everolimus41 fenofibrate33 ery-tab91 everolimus fenofibrate micronized33 ERYGEL63 (immunosuppressant)98 FENOFIBRIC ACID33 EVISTA79 ERYPED 20091 FENOPROFEN CALCIUM5 EVOCLIN63 ERYPED 40091 fenoprofen calcium5 EVOTAZ47 erythrocin stearate91 FENORTHO5 EVOXAC99 erythromycin (acne aid)63 fentanyl9 EVZIO30 erythromycin (ophth)110 fentanyl citrate9 EXELDERM65 erythromycin base91 FENTORA9 EXELON116 erythromycin ethylsuccinate91 FER-IN-SOL88 exemestane40 ESBRIET120 ferosul88 EXFORGE36 ESCAVITE D101 FERRIPROX30 EXFORGE HCT36 escitalopram oxalate25 ferrous sulfate88 EXJADE30 esgic7 FETZIMA26 EXODERM65 ESGIC7 FIBRICOR33 EXTAVIA117 esomeprazole FINACEA75 EXTINA65 magnesium123,124 finasteride85 ESOMEPRAZOLE eye allergy itch relief113 FIORICET7 STRONTIUM124 eye allergy estarylla56 itch/rednessrelief113 FIORICET/CODEINE11 estazolam88 ezetimibe34 FIORINAL7 esterified estrogens & ezetimibe-simvastatin32 FIORINAL/CODEINE #311 methyltestosterone81 FABIOR63 FIRAZYR86 ESTRACE82 FALESSA56 FIRDAPSE38 estradiol82 famciclovir50 FIRST-LANSOPRAZOLE124 estradiol & norethindrone acetate81 famotidine123 FIRST-MOUTHWASH BLM98 estradiol vaginal127 FANAPT45 FIRST-OMEPRAZOLE124 ESTRING127 FANTASY LUBRICATED91 FIRVANQ14 ESTROGEL82 FANTASY flac115 LUBRICATED/SPERMICIDE FLAGYL13 ESTROSTEP FE56 91 FLAREX112 eszopiclone88 FARESTON40 flavoxate hcl125 ethacrynic acid77 FARXIGA29 flecainide acetate17 ethambutol hcl38 FARYDAK41 FLECTOR64 ethosuximide24 FASENRA PEN17 FLOMAX85 ETHYL CHLORIDE/FINE FAZACLO45 STREAM74 FLONASE ALLERGY ETHYL CHLORIDE/MEDIUM FC FEMALE CONDOM91 RELIEF108 STREAM74 FC2 FEMALE CONDOM91 FLONASE ALLERGY RELIEF ethynodiol diacet & eth febuxostat86 CHILDRENS108 estrad56 felbamate23 FLONASE SENSIMIST108 etidronate disodium78 FELBATOL23 FLORIVA PLUS100 etodolac5 FELDENE5 FLOVENT DISKUS18 etonogestrel-ethinyl estradiol57 felodipine52 FLOVENT HFA18 etoposide43 FEM PH126 FLOXIN OTIC114 EUCRISA75 FLUCELVAX QUADRIVALENT FEMARA40 EURAX75 2018-2019126 FEMCAP91 euthyrox122 FLUCELVAX QUADRIVALENT FEMHRT81 2019-2020126 EVAMIST82 FEMRING127
Updated 07/01/2021 Index 8 FLUCELVAX QUADRIVALENT FORTESTA12 gavilyte-n/flavor pack89 2020-2021126 FOSAMAX78 GEBAUERS INSTANT ICE74 fluconazole31 FOSAMAX PLUS D78 GEBAUERS PAIN EASE74 flucytosine31 fosamprenavir calcium47 GEBAUERS SPRAY AND fludrocortisone acetate59 fosfomycin tromethamine15 STRETCH74 FLUMADINE50 GELCLAIR99 fosinopril sodium34 flunisolide (nasal)109 fosinopril sodium & GELFILM OP112 fluocinolone acetonide70 hydrochlorothiazide36 GELNIQUE125 fluocinolone acetonide FOSRENOL84 GELNIQUE PUMP125 (otic)115 FOTIVDA41 gemfibrozil33 fluocinonide70 FRAGMIN20 gemmily55 fluocinonide emulsified base70 FREESTYLE FREEDOM GENERESS FE56 FLUORABON96 LITE93 gengraf97 fluoritab96 FREESTYLE INSULINX GENOTROPIN79 fluorometholone (ophth)112 BLOODGLUCOSE MONITORING SYSTEM93 GENOTROPIN MINIQUICK79 FLUOROPLEX66 FREESTYLE INSULINX gentak110 fluorouracil (topical)66 BLOODGLUCOSE TEST76 gentamicin sulfate (ophth)110 fluoxetine hcl25 FREESTYLE INSULINX BLOODGLUCOSE TEST gentamicin sulfate (topical)64 fluoxetine hcl (pmdd)118 STRIPS76 GENVOYA47 FLUOXETINE FREESTYLE LITE BLOOD GEODON45 HYDROCHLORIDE25 GLUCOSE MONITORING fluphenazine hcl46 SYSTEM93 geri-hydrolac 1272 flurandrenolide70 FREESTYLE LITE TEST gianvi54 flurazepam hcl89 STRIPS76 GILENYA117 FREESTYLE TEST flurbiprofen5 STRIPS76 GILOTRIF40 flurbiprofen sodium113 FROVA94 GILPHEX TR60 flutamide40 frovatriptan succinate95 GILTUSS COUGH & COLD60 fluticasone propionate70 FURADANTIN15 GILTUSS SINUS & CONGESTION60 fluticasone propionate furosemide77 (nasal)109 GILTUSS TR60 fluticasone-salmeterol19 FUSION PLUS88 glatiramer acetate117 fluvastatin sodium33 FUZEON47 glatopa117 fluvoxamine maleate25 fyavolv81 GLEEVEC41 FML112 FYCOMPA21 GLEOSTINE39 FML FORTE112 g tussin ac60 glimepiride29 FML LIQUIFILM112 gabapentin22 glipizide29 FOCALIN2 GABITRIL23 glipizide xl29 FOCALIN XR2 GALAFOLD80 glipizide-metformin hcl27 galantamine FOLBIC RF76 hydrobromide116 GLUCAGEN DIAGNOSTIC76 FOLET ONE102 GALZIN97 GLUCAGEN HYPOKIT27 folic acid87 ganirelix acetate79 glucagon (rdna)27 FOLIVANE-F88 GANIRELIX ACETATE79 GLUCAGON EMERGENCY KIT28 FOLIVANE-OB102 GARDASIL 9126 GLUCAGON EMERGENCY KIT FOLLISTIM AQ78 GASTROCROM83 FOR LOW BLOOD SUGAR27 FOLTX76 gatifloxacin (ophth)110 GLUCOTROL29 fondaparinux sodium20 GATTEX84 GLUCOTROL XL29 FORFIVO XL24 gavilyte-g89 GLUMETZA27 formaldehyde46 gavilyte-h89 glyburide29
Index 9 Updated 07/01/2021 glyburide micronized29 HUMALOG JUNIOR hydrocortisone acetate w/ glyburide-metformin27 KWIKPEN28 pramoxine13 HUMALOG KWIKPEN28 hydrocortisone butyrate70 GLYCATE123 HUMALOG MIX 50/5028 hydrocortisone butyrate glycopyrrolate123 HUMALOG MIX 50/50 hydrophilic lipo base70 GLYCOPYRROLATE123 KWIKPEN28 hydrocortisone valerate70 glydo73 HUMALOG MIX 75/2528 hydrocortisone w/acetic GLYNASE29 HUMALOG MIX 75/25 acid115 GLYSET26 KWIKPEN28 hydromet59 GLYXAMBI27 HUMATROPE79 hydromorphone hcl9 HUMATROPE COMBO hydroxyprogesterone GOCOVRI44 PACK79 caproate115 GOLYTELY89 HUMIRA4 hydroxyurea43 GONAL-F78 HUMIRA PEDIATRIC CROHNS hydroxyzine hcl16 GONAL-F RFF78 DISEASE STARTER PACK4 hydroxyzine pamoate16 HUMIRA PEN4 GONAL-F RFF REDIJECT78 HYLINATE72 GONITRO15 HUMIRA PEN-CD/UC/HS STARTER4 hyoscyamine sulfate123 gordons urea72 HUMIRA PEN-PEDIATRIC UC HYPER-SAL61 GRALISE118 STARTER PACK4 HYPERSAL61 granisetron hcl30 HUMIRA PEN-PS/UV STARTER4 HYSINGLA ER9 GRANIX87 HUMULIN 70/3028 HYZAAR36 GRASTEK3 HUMULIN 70/30 ibandronate sodium78 griseofulvin microsize31 KWIKPEN28 IBRANCE41 griseofulvin ultramicrosize31 HUMULIN N28 ibu4 guaifenesin dac60 HUMULIN N KWIKPEN28 ibudone11 guaifenesin-codeine60 HUMULIN R28 ibuprofen5 guanfacine hcl35 HUMULIN R U-500 ICAR PEDIATRIC88 (CONCENTRATED)28 guanfacine hcl (adhd)2 HUMULIN R U-500 icatibant acetate86 GUANIDINE HCL38 KWIKPEN28 ICLUSIG42 GVOKE PFS28 HYCAMTIN43 icosapent ethyl32 GYNAZOLE-1126 HYCODAN59 IDHIFA42 HAEGARDA86 hydralazine hcl37 ILEVRO113 halcinonide70 HYDREA43 ILIDERM74 HALCION89 HYDRO 3572 ILUMYA66 halobetasol propionate70 HYDRO 40 FOAM72 imatinib mesylate42 HALOG70 hydrochlorothiazide77 IMBRUVICA42 haloperidol45 hydrocodone bitartrate9 imipramine hcl26 haloperidol lactate45 hydrocodone polistirex- imipramine pamoate26 HELIDAC THERAPY125 chlorpheniramine polistirex60 hydrocodone w/ imiquimod72 HEMANGEOL51 homatropine59 IMITREX95 HEPSERA49 hydrocodone- IMITREX STATDOSE HETLIOZ89 acetaminophen11 REFILL95 HETLIOZ LQ89 hydrocodone-ibuprofen11 IMITREX STATDOSE hydrocortisone59 SYSTEM95 HIPREX15 IMODIUM A-D30 hydrocortisone (intrarectal)13 HISTEX-PE60 IMPAVIDO14 hydrocortisone (rectal)13 homatropine hbr110 IMPEKLO70 HORIZANT118 hydrocortisone (topical)70 hydrocortisone acetate IMURAN98 HUMALOG28 (rectal)13 inatal gt101
Updated 07/01/2021 Index 10 INCRELEX79 isosorbide mononitrate15 ketodan65 INCRUSE ELLIPTA17 isotretinoin63 ketoprofen5 indapamide77 isoxsuprine hcl53 KETOROLAC INDERAL LA51 isradipine52 TROMETHAMINE5 ketorolac tromethamine5 INDERAL XL51 ISTALOL109 ketorolac tromethamine INDOCIN5 itraconazole32 (ophth)113 indomethacin5 ivermectin13 KEVEYIS77 INGREZZA117 ivermectin (pediculicide)75 KEVZARA4 INLYTA39 ivermectin (rosacea)75 KIMONO COLORS91 INNOPRAN XL51 JADENU30 KIMONO LUBRICATED91 INREBIC42 JADENU SPRINKLE30 KIMONO MICRO THIN91 INSPRA37 JAKAFI42 KIMONO MICRO THIN PLUS INSULIN LISPRO JALYN85 SPERMICIDE LUBRICATED92 KIMONO PLUS SPERMICIDE PROTAMINE/INSULIN LISPRO jantoven20 KWIKPEN29 LUBRICATED92 INSULIN SYRINGES AND PEN JANUMET27 KIMONO PLUS NEEDLES94 JANUMET XR27 SPERMICIDE/LUBRICATED INTEGRA F88 JANUVIA28 92 KIMONO PS LUBRICATED92 INTELENCE47 JARDIANCE29 KIMONO PS PLUS INTERMEZZO89 JULUCA47 SPERMICIDE/LUBRICATED INTRAROSA126 JUXTAPID34 92 INTRON A43 JYNARQUE81 KIMONO SENSATION INTUNIV2 LUBRICATED92 K-PHOS96 KIMONO SENSATION PLUS INVEGA45 K-PHOS NEUTRAL96 SPERMICIDE LUBRICATED92 INVEGA SUSTENNA45 K-PHOS NO 285 KIMONO SPECIAL92 INVEGA TRINZA45 k-prime96 KINERET4 INVIRASE47 K-TAB97 kionex98 iodoquimez-hc65 K-Y ME & YOU EXTRA KISQALI42 iodoquinol-hc65 LUBRICATED91 KISQALI FEMARA 200 iodoquinol-hydrocortisone in aloe K-Y ME & YOU INTENSE91 DOSE41 vehicle65 KADIAN9 KISQALI FEMARA 400 iodoquinol-hydrocortisone-aloe kaitlib fe55 DOSE41 polysaccharide65 KISQALI FEMARA 600 KALETRA47 IOPIDINE110 DOSE41 KALYDECO120 ipratropium bromide17 KITABIS PAK3 KAMDOY74 ipratropium bromide (nasal)108 KIVIK74 KAMELEON KLARITY-A111 ipratropium-albuterol19 LUBRICATED91 KLARON63 irbesartan35 KAPVAY2 KLONOPIN21 irbesartan-hydrochlorothiazide KARBINAL ER32 36 klor-con96 KEFLEX54 IRESSA40 klor-con 1096 kelnor 1/3555 ISENTRESS47 klor-con m1096 KENALOG70 ISENTRESS HD47 klor-con sprinkle97 KEPPRA22 isoniazid38 KORLYM28 KEPPRA XR22 ISOPTO ATROPINE110 KOSELUGO42 KERALAC72 ISOPTO CARPINE110 KOSHER PRENATAL PLUS keralyt73 ISORDIL TITRADOSE15 IRON102 ketoconazole32 isosorbide dinitrate15 kp folic acid87 ketoconazole (topical)65 KRINTAFEL38
Index 11 Updated 07/01/2021 KRISTALOSE90 LENVIMA 14 MG DAILY lidocaine hcl74 KUVAN80 DOSE39 lidocaine hcl (mouth-throat)98 LENVIMA 18 MG DAILY KYLEENA58 DOSE39 lidocaine-hydrocortisone acetate L-METHYLFOLATE CA/S- LENVIMA 20 MG DAILY (rectal)13 ALGAL76 DOSE39 lidocaine-prilocaine74 L-METHYLFOLATE FORTE76 LENVIMA 24 MG DAILY LIDODERM74 labetalol hcl51 DOSE39 LIDODOSE74 LENVIMA 4 MG DAILY LAC-HYDRIN72 LIDODOSE PEDIATRIC BULK DOSE39 PACK74 LAC-HYDRIN TWELVE72 LENVIMA 8 MG DAILY LIDORX74 LACRISERT109 DOSE39 LILETTA58 LACTIC ACID72 LESCOL XL34 lactic acid (ammonium LETAIRIS53 lindane75 lactate)72 letrozole40 linezolid14,15 LACTULOSE90 leucovorin calcium43 LINZESS84 lactulose90 LEUKERAN39 liothyronine sodium122 lactulose (encephalopathy)84 LEUKINE87 LIPITOR34 LAMICTAL22 LEUPROLIDE LIPOFEN33 LAMICTAL CHEWABLE ACETATE/BUPIVACAINE lisinopril34 DISPERSIBLE22 HYDROCHLORIDE40 lisinopril & LAMICTAL ODT22 levalbuterol hcl19 hydrochlorothiazide36 LAMICTAL STARTER/NOT levalbuterol tartrate19 LITHIUM45 TAKING CARBAMAZEPINE22 LEVAQUIN82 lithium carbonate45 LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING LEVBID123 LITHOBID45 VALPROATE22 LEVEMIR29 LITHOSTAT86 LAMICTAL STARTER/TAKING LEVEMIR FLEXTOUCH29 LIVALO34 VALPROATE22 levetiracetam22 LO LOESTRIN FE56 LAMICTAL XR22 levobunolol hcl109 LOCOID70 lamivudine47 levocarnitine (metabolic LOCOID LIPOCREAM70 lamivudine (hbv)49 modifiers)80 LODINE5 lamivudine-zidovudine48 levofloxacin82 LODOSYN43 lamotrigine22 levofloxacin (ophth)111 LOKELMA98 LANCETS93 LEVOMEFOLATE CALCIUM LOMAIRA2 LANOXIN52 ALGAL POWDER76 levonorgestrel & eth LOMOTIL30 lansoprazole124 estradiol56 LONSURF41 lanthanum carbonate84 levonorgestrel (emergency loperamide hcl30 LANTUS29 oc)58 LOPID33 LANTUS SOLOSTAR29 levonorgestrel-eth estradiol (triphasic)56 lopinavir-ritonavir48 lapatinib ditosylate42 levonorgestrel-ethinyl estradiol LOPRESSOR51 LASIX77 (91-day)56 LOPRESSOR HCT36 LASTACAFT113 levonorgestrel-ethinyl estradiol (continuous)56 LOPROX65 latanoprost114 levothyroxine sodium122 LOPROX SHAMPOO65 LATUDA45 LEVSIN/SL123 lorazepam16 LAZANDA9 LEXAPRO25 lorazepam intensol16 leflunomide6 LEXIVA48 LENVIMA 10 MG DAILY LORBRENA42 DOSE39 LIALDA83 lorcet10 LENVIMA 12MG DAILY LIBRAX123 LORTAB11 DOSE39 lidocaine74 lorzone107
Updated 07/01/2021 Index 12 losartan potassium35 MAXITROL112 methadose9 losartan potassium & MAXX LUBRICATED92 METHADOSE9 hydrochlorothiazide36 MAXX PLUS SPERMICIDE METHADOSE SUGAR-FREE9 LOSEASONIQUE56 LUBRICATED92 methamphetamine hcl1 LOTEMAX112 MAXZIDE77 methazolamide77 LOTENSIN34 MAXZIDE-2577 methenamine hippurate15 MAYZENT STARTER LOTENSIN HCT36 METHENAMINE loteprednol etabonate112 PACK117 MECLIZINE MANDELATE15 LOTREL36 HYDROCHLORIDE31 methenamine mandelate15 LOTRISONE65 meclofenamate sodium5 methergine115 LOTRONEX84 MEDROL59 methimazole121 lovastatin34 MEDROL DOSEPAK59 METHITEST12 LOVAZA32 MEDROX-RX73 methocarbamol107 LOVENOX20,21 medroxyprogesterone METHOTREXATE4 loxapine succinate45 acetate116 methotrexate sodium39 medroxyprogesterone acetate lubiprostone83 (contraceptive)58 methoxsalen rapid66 LUCEMYRA116 mefenamic acid5 methscopolamine bromide123 luliconazole65 mefloquine hcl38 methyldopa35 LUMAKRAS42 MEGACE ES116 methyldopa & LUMIGAN114 hydrochlorothiazide36 megestrol acetate40 methylergonovine maleate115 LUNESTA89 megestrol acetate METHYLIN2 LUXIQ70 (appetite)116 methylphenidate hcl3 LUZU65 MEKINIST42 MEKTOVI42 METHYLPHENIDATE LYNPARZA42 HYDROCHLORIDE ER3 LYRICA22 meloxicam5 methylprednisolone59 LYSODREN40 melphalan39 methyltestosterone12 LYSTEDA88 memantine hcl116 metoclopramide hcl83 M-NATAL PLUS102 MENEST82 METOCLOPRAMIDE ODT83 MACROBID15 MENOPUR78 metolazone77 MACRODANTIN15 MENOSTAR82 metopic72 mafenide acetate67 meperidine hcl9 METOPIRONE76 MAGNEBIND 40096 MEPHYTON128 metoprolol & MAKENA116 meprobamate16 hydrochlorothiazide36 MALARONE38 MEPRON14 metoprolol succinate51 mercaptopurine39 METOPROLOL SUCCINATE malathion75 ER/HYDROCHLOROTHIAZIDE maprotiline hcl24 mesalamine83,84 37 MARINOL31 MESNEX43 metoprolol tartrate51 MARNATAL-F102 MESTINON38 METROCREAM75 MARPLAN25 MESTINON TIMESPAN38 METROGEL75 MATULANE43 metaproterenol sulfate19 METROGEL-VAGINAL126 matzim la51 metaxall107 METROLOTION75 MAVENCLAD117 metaxalone107 metronidazole14 MAVYRET49 metformin hcl27 metronidazole (topical)75 MAXALT95 METFORMIN metronidazole vaginal126 HYDROCHLORIDE27 MAXALT-MLT95 methadone hcl9 metyrosine35 MAXIDEX112 methadone hcl intensol8 mexiletine hcl17
Index 13 Updated 07/01/2021 mezparox-hc68 MOTOFEN30 naloxone hcl30 MG217 PSORIASIS MULTI- MOVANTIK84 naltrexone hcl30 SYMTOM73 MOVIPREP89 NAMENDA116 MIACALCIN78 MOXEZA111 NAMENDA TITRATION MICARDIS35 moxifloxacin hcl82 PAK116 MICARDIS HCT37 NAMENDA XR116 moxifloxacin hcl (ophth)111 miconazole 3126 NAPRELAN6 MS CONTIN10 miconazole-zinc oxide-white NAPROSYN6 MUCOTROL99 petrolatum65 naproxen6 midazolam hcl89 MULPLETA87 naproxen sodium6 MULTAQ17 midodrine hcl127 naproxen-esomeprazole migergot94 multi-vit/iron/fluoride100 magnesium6 miglitol26 multi-vitamin/fluoride drops99 naratriptan hcl95 miglustat87 multivitamin NARCAN30 select/fluoride100 MIGRANAL94 MULTIVITAMIN WITH NARDIL25 MILLIPRED59 FLUORIDE99 NASONEX109 MILLIPRED DP59 multivitamin with fluoride100 NATACHEW102 MINASTRIN 24 FE57 MULTIVITAMIN/FLUORIDE NATACYN111 MINIPRESS35 99 NATAZIA57 multivitamin/fluoride100 minitran15 nateglinide29 multivitamins/fluoride100 MINIVELLE82 NATELLE ONE102 mupirocin64 MINOCIN121 NATPARA78 MYALEPT80 minocycline hcl121 NATROBA75 MYAMBUTOL38 minoxidil37 NATURE-THROID122 MYCOBUTIN38 MIRALAX90 NATURE-THROID NT-2.5122 mycophenolate mofetil98 MIRAPEX44 NAYZILAM21 mycophenolate sodium98 MIRAPEX ER44 NEBUPENT14 MYDRIACYL110 MIRCERA87 NEBUSAL61 MYFORTIC98 MIRCETTE57 NEEVO DHA102 MYKIDZ IRON 1088 MIRENA58 nefazodone hcl25 MYLERAN39 mirtazapine24 neo-polycin110 MYNATAL ADVANCE102 MIRVASO75 neo-polycin hc111 MYNATAL misoprostol124 ULTRACAPLET102 neomycin sulfate3 MITIGARE86 MYNATE 90 PLUS102 neomycin-bacitracin zn- MOBIC5 polymyxin111 myorisan61 neomycin-polymy- modafinil3 MYRBETRIQ125 dexameth112 moexipril hcl34 MYSOLINE22 neomycin-polymyxin-gramicidin molindone hcl46 MYTESI29 111 neomycin-polymyxin-hc mometasone furoate70 nabumetone5 (ophth)112 mometasone furoate nadolol51 neomycin-polymyxin-hc (nasal)109 nafrinse96 (otic)114 mondoxyne nl121 naftifine hcl65 NEONATAL 19102 montelukast sodium17 NAFTIFINE NEONATAL COMPLETE102 MONUROL15 HYDROCHLORIDE65 NEONATAL FE102 morgidox 1x100mg121 NAFTIN65 NEONATAL PLUS102 morphine sulfate10 NALFON5,6 NEONATAL/DHA102 morphine sulfate beads10 NALOCET11 NEORAL98
Updated 07/01/2021 Index 14 NEOTUSS PLUS60 nitrofurantoin macrocrystal15 NULYTELY89 NERLYNX42 nitrofurantoin monohyd NULYTELY/FLAVOR NESTABS103 macro15 PACKS90 nitroglycerin16 NUPLAZID45 NESTABS DHA102 NITROLINGUAL NUTROPIN AQ NUSPIN 1079 NESTABS ONE103 PUMPSPRAY16 NUTROPIN AQ NUSPIN 2079 neuac61 NITROMIST16 NUTROPIN AQ NUSPIN 579 NEULASTA87 NITROSTAT16 NUVARING57 NEULASTA ONPRO KIT87 NITYR80 NUVIGIL3 NEUPOGEN87 NIVA-PLUS103 NYMALIZE52 NEUPRO44 NIVESTYM87 nystatin31 NEURONTIN23 nizatidine123 nystatin (mouth-throat)98 NEVANAC113 NIZORAL65 nystatin (topical)66 nevirapine48 NOCTIVA80 nystatin-triamcinolone66 NEXA PLUS103 nolix68 O-CAL FA103 NEXAVAR42 NON PREFERRED TEST OB COMPLETE ONE103 NEXIUM124 STRIPS76 OB COMPLETE PETITE103 NEXIUM 24HR124 NORCO11 NEXIUM 24HR CLEAR NORDITROPIN FLEXPRO79 OB COMPLETE PREMIER103 MINIS124 norethin acet & estrad-fe57 OB COMPLETE/DHA103 NEXPLANON58 norethindrone & ethinyl OBSTETRIX ONE103 NEXTSTELLIS57 estradiol-fe57 OCALIVA83 norethindrone niacin (antihyperlipidemic)34 (contraceptive)58 octreotide acetate81 NIASPAN34 norethindrone acet & eth OCUFLOX111 nicardipine hcl52 estra57 ODACTRA3 NICODERM CQ120 norethindrone acetate116 ODOMZO40 NICORETTE120 norethindrone acetate-ethinyl OFEV120 estradiol81 NICORETTE MINI120 norgestimate-ethinyl ofloxacin83 NICORETTE STARTER estradiol57 ofloxacin (ophth)111 KIT120 norgestimate-ethinyl estradiol ofloxacin (otic)114 nicotine120 (triphasic)57 olanzapine45 nicotine polacrilex120 NORITATE75 olanzapine-fluoxetine hcl117 NICOTINE TRANSDERMAL NORPACE16 olmesartan medoxomil35 SYSTEM120 NORPACE CR16 NICOTROL INHALER120 olmesartan medoxomil- NORPRAMIN26 amlodipine-hydrochlorothiazide NICOTROL NS120 NORTHERA127 37 nifedipine52 nortriptyline hcl26 olmesartan medoxomil- NILANDRON40 NORVASC52 hydrochlorothiazide 37 olopatadine hcl113 nilutamide40 NORVIR48 olopatadine hcl (nasal)108 nimodipine52 NOVAREL78 OLUX71 NINLARO42 NOXAFIL32 OLUX-E71 nisoldipine52 np thyroid 120122 OMECLAMOX-PAK125 nitazoxanide14 NUBEQA40 omega-3-acid ethyl esters33 nitisinone80 NUCALA17 omeppi124 NITRO-BID15 NUCORT71 omeprazole124 NITRO-DUR15 NUCYNTA10 nitro-time15 OMEPRAZOLE + SYRSPEND NUCYNTA ER10 SFALKA124 nitrofurantoin15 NUEDEXTA118
Index 15 Updated 07/01/2021 omeprazole-sodium orphenadrine citrate107 pantoprazole sodium124 bicarbonate125 orphenadrine w/ aspirin & PARAGARD INTRAUTERINE OMNARIS109 caff107 COPPER CONTRACEPTIVE OMNITROPE79 ORTHO MICRONOR58 T380A58 ondansetron30 ORTHO TRI-CYCLEN LO57 paregoric30 ondansetron hcl30 ORTHO-NOVUM 1/3557 PAREMYD114 ONE VITE WOMENS ORTHO-NOVUM 7/7/757 paricalcitol80 PRENATALVITAMIN PLUS103 oscimin122 PARLODEL44 ONETOUCH ULTRA76 oscimin sr122 PARNATE25 ONETOUCH ULTRA 293 oseltamivir phosphate50 paromomycin sulfate3 ONETOUCH ULTRA MINI93 OSMOLEX ER44 paroxetine hcl25 ONETOUCH VERIO93 OSPHENA79 paroxetine mesylate ONETOUCH VERIO FLEX (vasomotor)120 BLOOD GLUCOSE OTEZLA6 PASER38 MONITORING SYSTEM93 OTICIN HC NR114 PATADAY114 ONETOUCH VERIO IQ BLOOD OTOVEL115 GLUCOSE MONITORING PATANASE108 SYSTEM93 OTREXUP4 PATANOL114 ONETOUCH VERIO SYNC OVACE PLUS67 PAXIL25 BLOODGLUCOSE OVACE PLUS WASH67 PAXIL CR25 MONITORING SYSTEM93 OVACE WASH67 ONETOUCH VERIO TEST pediatric vitamins acd w/ STRIPS76 OVIDE75 fluoride100 ONEVITE99 OVIDREL78 PEDVAX HIB125 ONFI21 oxandrolone12 peg 3350-kcl-nacl-na sulfate-na ascorbate-ascorbic acid90 ONUREG39 oxaprozin6 peg 3350-kcl-sod bicarb-sod OPANA10 OXAYDO10 chloride-sod sulfate90 opium tincture30 oxazepam16 peg 3350-potassium chloride-sod oxcarbazepine23 bicarbonate-sod chloride90 OPSUMIT53 peg-3350/electrolytes/ascorbate OPTIONS CONCEPTROL OXERVATE111 89 VAGINAL oxiconazole nitrate66 PEGANONE24 CONTRACEPTIVE126 OPTIONS GYNOL II OXISTAT66 PEGASYS49 VAGINALCONTRACEPTIVE OXSORALEN ULTRA67 PEGASYS PROCLICK49 126 OXTELLAR XR23 PEGINTRON49 ORACEA75 oxybutynin chloride125 PEMAZYRE42 ORACIT85 oxycodone hcl10 penicillamine97 ORALAIR3 oxycodone w/ penicillin v potassium115 acetaminophen11 ORALAIR ADULT SAMPLE PENLEN74 KIT3 oxycodone-ibuprofen11 ORALAIR ADULT STARTER OXYCODONE/ACETAMINOPH PENNSAID64 PACK3 EN 11 pentamidine isethionate14 oralone dental paste99 oxymorphone hcl10 PENTASA84 ORAPRED ODT59 OZEMPIC28 pentazocine w/ naloxone12 ORAVIG99 pacerone17 pentoxifylline86 orazinc97 paliperidone45 PEPCID123 ORENCIA6 PALYNZIQ80 PERCOCET11 ORENCIA CLICKJECT6 PAMELOR26 perindopril erbumine34 ORENITRAM53 PANCREAZE76 permethrin75 ORFADIN80 PANDEL71 perphenazine46 ORKAMBI120 PANRETIN66 perphenazine-amitriptyline 117
Updated 07/01/2021 Index 16 PERSERIS45 PLEGRIDY STARTER PRECISION XTRA BLOOD PERTZYE76 PACK117 GLUCOSE TEST STRIPS76 PLEXION63 PRECOSE26 PEXEVA25 PLEXION CLEANSER63 PRED MILD112 phenadoz32 PLEXION CLEANSING PRED-G112 phenazo85 CLOTHS63 PRED-G S.O.P.112 phenazopyridine hcl85 PNV TABS 29-1103 prednicarbate71 phendimetrazine tartrate2 PNV-DHA+DOCUSATE103 prednisolone59 PHENDIMETRAZINE PNV-OMEGA103 TARTRATEER2 prednisolone acetate pnv-select101 phenelzine sulfate25 (ophth)112 PODOCON 25 IN BENZOIN prednisolone sodium phenobarbital88 TINCTURE73 phosphate59 phenoxybenzamine hcl35 podofilox73 PREDNISOLONE SODIUM phentermine hcl2 POLY-VI-FLOR100 PHOSPHATE112 prednisone59 phenylephrine hcl POLY-VI-FLOR/IRON101 (mydriatic)110 PREDNISONE INTENSOL59 polyethylene glycol 335090 PHENYTEK24 PREFEST81 polymyxin b-trimethoprim111 phenytoin24 pregabalin23 POLYTRIM111 phenytoin infatabs24 PREGNYL W/DILUENT POMALYST40 phenytoin sodium extended24 BENZYLALCOHOL/NACL78 posaconazole32 PHEXXI127 PREMARIN82 pot & sod citrates w/citric PHLAG SPRAY74 PREMESISRX103 ac85 PREMIUM CONDOMS PHOSLYRA84 pot phosphate monobasic w/ LUBRICATED92 phospha 250 neutral96 sod phosphate dibasic & monobasic96 premium lidocaine73 phosphasal14 POTABA128 PREMPHASE81 PHOSPHOLINE IODIDE110 potassium chloride97 PREMPRO81,82 phytonadione128 potassium chloride PRENA 1 TRUE103 PICATO66 microencapsulated crystals PRENA1 CHEW103 PIFELTRO48 er97 PRENA1 PEARL103 pilocarpine hcl110 potassium citrate (alkalinizer)85 PRENAISSANCE103 pilocarpine hcl (oral)99 potassium citrate-citric acid85 PRENAISSANCE PLUS104 pimecrolimus73 POVIDONE IODINE111 PRENATAL104 pimozide118 PR NATAL 400 EC103 prenatal 19101 pindolol51 PR NATAL 430103 PRENATAL 19104 pioglitazone hcl28 PR NATAL 430 EC103 PRENATAL PLUS IRON104 pioglitazone hcl-glimepiride27 PRALUENT34 PRENATAL VITAMINS PLUS pioglitazone hcl-metformin pramipexole LOW IRON104 hcl27 dihydrochloride44 PRENATAL-U104 PIQRAY 200MG DAILY PRENATE104 DOSE42 PRAMOSONE71 PIQRAY 250MG DAILY PRAMOTIC115 PRENATE AM104 DOSE42 pramoxine-hc71 PRENATE DHA104 PIQRAY 300MG DAILY PRANDIN29 PRENATE ELITE104 DOSE42 PRENATE ENHANCE104 piroxicam6 prasugrel hcl86 PRENATE ESSENTIAL104 PLAN B ONE-STEP58 PRAVACHOL34 PRENATE MINI104 PLAQUENIL38 pravastatin sodium34 PRENATE PIXIE104 PLAVIX86 praziquantel13 PRENATE RESTORE104 PLEGRIDY117 prazosin hcl35 PRECISION XTRA93 PRENATRIX104
Index 17 Updated 07/01/2021 PRENATRYL104 propafenone hcl17 quinapril hcl34 PREPLUS104 propantheline bromide123 quinapril-hydrochlorothiazide PREVACID124 proparacaine hcl111 37 quinidine gluconate17 PREVACID SOLUTAB124 propranolol & quinidine sulfate17 prevalite33 hydrochlorothiazide37 propranolol hcl51 quinine sulfate38 PREVYMIS49 propylthiouracil121 QUINJA66 PREZCOBIX48 PROSCAR85 QVAR REDIHALER18 PREZISTA48 PROTONIX124 R-NATAL OB105 PRIFTIN38 PROTOPIC73 rabeprazole sodium124 PRILOSEC124 protriptyline hcl26 RABEPRAZOLE SODIUM DR PRIMACARE104 PROVENTIL HFA19 SPRINKLE124 primaquine phosphate38 RADIOGARDASE30 PROVERA116 PRIMAQUINE PHOSPHATE38 RAGWITEK3 PROVIDA DHA105 primidone23 raloxifene hcl79 PROVIDA OB105 PRIMLEV11 ramelteon89 PROVIGIL3 PRIMSOL14 ramipril35 PROZAC25 PRINIVIL34 RANEXA15 PRUDOXIN66 PRISTIQ26 pseudoephed-cpm w/ ranitidine hcl123 PROAIR HFA19 hydrocod60 ranolazine15 PROAIR RESPICLICK19 PSORCON71 RAPAFLO85 probenecid86 PULMICORT18 RAPAMUNE98 PROCARDIA52 PULMICORT FLEXHALER18 rasagiline mesylate44 PROCARDIA XL52 pulmosal61 RASUVO4 procentra1 PULMOZYME120 RAVICTI80 prochlorperazine46 PURIXAN39 RAYALDEE80 prochlorperazine maleate46 PYLERA125 RAYOS59 PROCORT13 pyrazinamide38 RAZADYNE116 PROCRIT87 PYRIDIUM85 RAZADYNE ER116 procto-med hc13 pyridostigmine bromide38 REALITY LATEX PROCTOCORT13 pyrimethamine38 CONDOMS/LUBRICATED92 REALITY LATEX/ULTRA PROCTOFOAM HC13 QBRELIS34 TEXTURED92 PROCYSBI85 QDOLO10 REALITY LATEX/ULTRA progesterone116 QINLOCK42 THIN92 PROGLYCEM28 QNASL109 REBETOL50 PROGRAF98 QNASL CHILDRENS109 REBIF118 PROLATE11 QSYMIA2 REBIF REBIDOSE117 PROLENSA114 REBIF REBIDOSE QUALAQUIN38 TITRATIONPACK117 PROMACTA87 QUARTETTE57 REBIF TITRATION PACK118 promethazine hcl32 quazepam89 RECTIV13 promethazine w/codeine60 QUDEXY XR23 REGLAN83 promethazine-dm60 QUESTRAN33 REGRANEX75 promethazine-phenylephrine- QUESTRAN LIGHT33 codeine 60 relafen4 quetiapine fumarate45 promethegan32 RELENZA DISKHALER50 QUFLORA GUMMIES100 PROMETHEGAN32 RELEXXII3 QUFLORA PEDIATRIC100 PROMETRIUM116 RELISTOR84 QUILLIVANT XR3 RELNATE DHA105
Updated 07/01/2021 Index 18 RELPAX95 RISPERDAL45 SANDIMMUNE98 RELTONE83 risperidone45 SANDOSTATIN81 REMERON24 RITALIN3 SANTYL72 REMERON SOLTAB24 RITALIN LA3 SAPHRIS46 RENAGEL84 ritonavir48 sapropterin dihydrochloride80 RENVELA84 rivastigmine116 SARAFEM118 repaglinide29 rivastigmine tartrate117 SAVELLA117 repaglinide-metformin hcl27 rizatriptan benzoate95 SAXENDA2 REPATHA34 ROBAXIN-750107 scopolamine31 REPATHA PUSHTRONEX ROCALTROL80 SE-NATAL 19105 SYSTEM34 ropinirole hydrochloride44 SEASONIQUE57 REPATHA SURECLICK34 rosadan75 SECONAL SODIUM88 REQUIP XL44 rosuvastatin calcium34 SECUADO46 RESCRIPTOR48 roweepra21 SELECT-OB105 RESTASIS111 roweepra xr21 SELECT-OB+DHA105 RESTASIS MULTIDOSE111 ROXICODONE10 selegiline hcl44 RESTORIL89 ROXYBOND10 selenium sulfide67 RETACRIT87 ROZEREM89 SELZENTRY48 RETEVMO42 ROZLYTREK42 SEMPREX-D60 RETIN-A63 RUBRACA42 SENSIPAR80 RETIN-A MICRO63 RUCONEST86 SEREVENT DISKUS19 RETIN-A MICRO PUMP63 rufinamide23 SEROQUEL46 RETROVIR48 RUKOBIA48 SEROQUEL XR46 REVATIO53 RUZURGI38 SEROSTIM79 REVLIMID97 ryclora32 sertraline hcl25 REXULTI46 RYDAPT42 sevelamer carbonate84 REYATAZ48 RYTARY44 sevelamer hcl84 RHOFADE75 RYTHMOL SR17 SFROWASA84 RIAX63 SABRIL23 SHUR-SEAL126 ribasphere49 SAFYRAL57 SIGNIFOR81 ribasphere ribapak49 SALAGEN99 SIKLOS87 RIBASPHERE RIBAPAK50 SALEX73 sildenafil citrate53 ribavirin50 SALEX LOTION73 SILDENAFIL CITRATE53 ribavirin (hepatitis c)50 salicylic acid73 sildenafil citrate (pulmonary RIDAURA4 salicylic acid in ammonium hypertension)53 rifabutin38 lactate vehicle73 SILENOR88 RIFADIN39 salicylic acid w/ cleanser73 SILIQ67 RIFAMATE38 salicylic acid wart remover73 silodosin85 rifampin39 SALIMEZ73 SILVADENE67 RIFATER38 SALISOL73 silver sulfadiazine67 RILUTEK109 salisol forte73 SIMBRINZA110 riluzole109 SALITECH73 SIMPONI4 rimantadine hydrochloride50 salitech forte73 simvastatin34 RINVOQ4 SALVAX73 SINEMET44 RIOMET27 SAMSCA81 SINEMET CR44 risedronate sodium78 SANCUSO30 SINGULAIR17
Index 19 Updated 07/01/2021 sirolimus98 ssd67 sulfatrim pediatric14 SIRTURO39 sss 10-561 sulindac6 SITAVIG50 ST JOSEPH ADULT8 SUMADAN WASH64 SIVEXTRO15 ST JOSEPH ADULT sumatriptan95 SKELAXIN107 ANALGESICLOW DOSE BITE sumatriptan succinate95 8 SIZE sumatriptan-naproxen SKLICE75 STALEVO 10044 SKYLA58 sodium94 STALEVO 12544 SUMAXIN WASH64 SKYRIZI67 STALEVO 15044 SUPRAX54 SLYND58 STALEVO 20044 SURMONTIL26 sodium chloride (inhalant)61 STALEVO 5044 SUSTIVA48 sodium citrate & citric acid85 STALEVO 7544 SUTENT42 sodium fluoride96 STARLIX29 SUVICORT74 sodium phenylbutyrate80 stavudine48 sodium polystyrene SYMBICORT19 sulfonate98 STAVUDINE48 SYMBYAX117 sodium sulfacetamide wash67 STAXYN53 SYMDEKO120 SODIUM SULFACETAMIDE STELARA67 SYMLINPEN 12027 WASH67 STIMATE81 SYMLINPEN 6027 SODIUM STIOLTO RESPIMAT19 SULFACETAMIDE/SULFUR SYMPROIC84 63 STIVARGA42 SYMTUZA48 SODIUM STRATTERA2 SYNALAR71 SULFACETAMIDE/SULFUR STRENSIQ80 CLEANSER IN UREA63 SYNAREL79 STRIANT12 solifenacin succinate125 SYNERA74 STRIBILD48 SOLIQUA 100/3327 SYNERDERM74 STRIVERDI RESPIMAT19 SOLODYN121 SYNJARDY27 STROMECTOL13 SOLTAMOX40 SYNJARDY XR27 SUBOXONE12 SOMA107 SYNTHROID122 SUBSYS10 SOMAVERT79 SYPRINE97 subvenite21 SORIATANE67 TABLOID39 subvenite starter kit/blue21 SORILUX67 TABRECTA42 SUCRAID76 sorine51 TACLONEX71 sucralfate123 sotalol hcl51 tacrolimus98 SULAR52 sotalol hcl (afib/afl)51 tacrolimus (topical)73 sulconazole nitrate66 SOTYLIZE51 tadalafil53 sulfacetamide sod- SOVALDI50 tadalafil (pulmonary prednisolone112 hypertension)53 SPACER/AEROSOL-HOLDING sulfacetamide sodium67 CHAMBER94 TAFINLAR42 sulfacetamide sodium TAGRISSO40 spinosad75 (acne)63 SPIRIVA HANDIHALER17 sulfacetamide sodium TAKHZYRO86 SPIRIVA RESPIMAT17 (ophth)111 TALTZ67 sulfacetamide sodium w/ TALZENNA42 spironolactone77 sulfur63,64 TAMIFLU50 spironolactone & sulfacleanse 8/461 hydrochlorothiazide77 tamoxifen citrate40 SPORANOX32 SULFADIAZINE121 sulfamethoxazole-trimethoprim tamsulosin hcl85 SPORANOX PULSEPAK32 14 TAPAZOLE122 SPRIX6 SULFAMYLON67,68 TARCEVA40 SPRYCEL42 sulfasalazine84 TARGRETIN43,66
Updated 07/01/2021 Index 20 TARKA37 theophylline20 TOLSURA32 TARON-BC105 THERANATAL CORE tolterodine tartrate125 TARON-C DHA105 NUTRITION105 tolvaptan81 THIOLA86 TARON-PREX105 TOPAMAX23 THIOLA EC86 TASIGNA42 TOPAMAX SPRINKLE23 thioridazine hcl46 TASMAR43 TOPICORT71 thiothixene46 TAVALISSE86 topiramate23 THRIVITE 1999 TAYTULLA57 TOPROL XL51 THRIVITE RX105 TAZAROTENE64 toremifene citrate40 thyroid122 tazarotene67 torsemide77 tiagabine hcl23 TAZORAC67 TOUJEO MAX SOLOSTAR29 TIAZAC52 taztia xt51 TOUJEO SOLOSTAR29 TIBSOVO42 TAZVERIK42 tovet68 TIGAN31 TECFIDERA118 TOVIAZ125 TIKOSYN17 TECFIDERA STARTER TRACLEER53 tilia fe56 PACK118 tramadol hcl10 TEGRETOL23 timolol maleate51 tramadol-acetaminophen11 TEGRETOL-XR23 timolol maleate (ophth)109 trandolapril35 TEGSEDI120 timolol maleate in trandolapril-verapamil hcl37 TEKTURNA37 ocudose109 TIMOPTIC109 tranexamic acid88 TEKTURNA HCT37 TIMOPTIC OCUDOSE109 TRANSDERM SCOP31 telmisartan35 TIMOPTIC-XE109 TRANSDERM-SCOP31 telmisartan-amlodipine37 TRANXENE T16 telmisartan-hydrochlorothiazide tinidazole14 37 tiopronin86 tranylcypromine sulfate25 temazepam89 TIROSINT122 TRAVATAN Z114 TEMODAR39 TIROSINT-SOL122 travoprost114 TEMOVATE71 TIVICAY48 trazodone hcl26 temozolomide39 TIVORBEX6 TRECATOR39 tenofovir disoproxil fumarate48 tizanidine hcl107 TRELEGY ELLIPTA19 TENORETIC 10037 TL FOLATE105 TREMFYA67 TENORETIC 5037 TL-CARE DHA105 TRESIBA29 TENORMIN51 TL-SELECT105 TRESIBA FLEXTOUCH29 terazosin hcl35 TOBI3 tretinoin64 terbinafine hcl31 TOBI PODHALER4 tretinoin (chemotherapy)43 terbutaline sulfate19 TOBRADEX112 tretinoin microsphere64 terconazole vaginal127 TOBRADEX ST112 TREXALL39 TESSALON PERLES59 tobramycin4 TREXIMET94 TESTIM12 tobramycin (ophth)111 tri femynor56 testosterone12 tobramycin- TRI-TABS DHA105 testosterone cypionate12 dexamethasone112 TRI-VI-FLOR100 TOBREX111 tetrabenazine117 TRI-VI-FLORO100 TODAY SPONGE126 tetracaine hcl (ophth)111 tri-vite/fluoride100 TOFRANIL26 tetracycline hcl121 triamcinolone acetonide tolbutamide29 (mouth)99 TEXACORT71 tolcapone43 triamcinolone acetonide THALOMID97 (topical)71 tolmetin sodium6 THEO-2420 triamterene77
Index 21 Updated 07/01/2021 triamterene & TRUSTEX URAMAXIN72 hydrochlorothiazide77 LUBRICATED/SPERMICIDE URE-K72 trianex68 EXTRA LARGE92 urea72 triazolam89 TRUSTEX LUBRICATED/SPERMICIDE urea nail72 TRIBENZOR37 EXTRA STRENGTH92 urea-c4072 TRICARE105 TRUSTEX NATURAL URECHOLINE125 TRICARE PRENATAL DHA CONDOMS ONE105 +LUBE/LUBRICATED93 uribel14 TRICOR33 TRUSTEX NON- UROCIT-K 1085 LUBRICATED93 UROCIT-K 1585 triderm68 TRUSTEX WITH TRIDESILON71 NONOXYNOL- UROCIT-K 585 trientine hcl97 9/RIBBED/STUDDED 93 UROXATRAL85 trifluoperazine hcl46 TRUSTEX/RIA URSO 25083 LUBRICATED93 trifluridine111 TRUSTEX/RIA LUBRICATED URSO FORTE83 TRIGLIDE33 SPERMICIDE93 ursodiol83 trihexyphenidyl hcl43 TRUSTEX/RIA UTOPIC72 TRIJARDY XR27 LUBRICATED/SPERMICIDE VAGIFEM127 93 TRIKAFTA120 TRUSTEX/RIA NON- valacyclovir hcl50 TRILEPTAL23 LUBRICATED93 VALCHLOR66 TRILIPIX33 TRUVADA48 VALCYTE49 trimethobenzamide hcl31 TUKYSA39 valganciclovir hcl49 trimethoprim14 TURALIO42 VALIUM16 trimipramine maleate26 TUSSICAPS60 valproic acid24 TRINTELLIX26 TUSSIONEX PENNKINETIC valsartan35 EXTENDED RELEASE60 TRISTART DHA105 valsartan-hydrochlorothiazide TUSSLIN60 37 TRISTART FREE105 TUSSLIN PEDIATRIC60 VALTOCO21 TRISTART ONE105 TWIRLA57 VALTREX50 TRIUMEQ48 TWYNSTA37 vanadom107 TRIZIVIR48 TYBLUME57 vanatol lq7 TROKENDI XR23 TYBOST48 VANCOCIN14 tropicamide110 tydemy55 VANCOCIN HCL14 trospium chloride125 TYKERB42 vancomycin hcl14 TRULANCE83 TYLENOL/CODEINE #311 vandazole126 TRULICITY28 TYLENOL/CODEINE #411 VANOS72 TRUSELTIQ42 TYMLOS78 vardenafil hcl53 TRUSOPT114 UCERIS13,59 VARUBI31 TRUSTEX COLOR CONDOMS + LUBE92 UDAMIN SP99 VASCEPA33 TRUSTEX LUBRICATED92 ULESFIA75 VASERETIC37 TRUSTEX LUBRICATED ULORIC86 VASOTEC35 EXTRALARGE92 ULTIMATECARE ONE106 VCF VAGINAL TRUSTEX LUBRICATED ULTRACET11 CONTRACEPTIVE FILM126 EXTRASTRENGTH92 VCF VAGINAL TRUSTEX ULTRAM10 CONTRACEPTIVE FOAM126 LUBRICATED/RIBBED/STUDDE ULTRASAL-ER73 VCF VAGINAL D 92 ULTRAVATE71 CONTRACEPTIVEGEL126 TRUSTEX VECAMYL37 LUBRICATED/SPERMICIDE umecta mousse72 92 UPTRAVI53 VECTICAL67 VELPHORO84
Updated 07/01/2021 Index 22 VELTASSA98 virtussin ac/alc60 WILZIN97 VELTIN64 VIRTUSSIN DAC61 wixela inhub18 VEMLIDY50 VISTARIL16 WP THYROID122 VENA-BAL DHA106 VISTOGARD30 XALATAN114 VENCLEXTA40 VITAFOL FE+106 XALKORI43 VENCLEXTA STARTING VITAFOL GUMMIES106 XANAX16 PACK40 VITAFOL ULTRA106 XANAX XR16 venlafaxine hcl26 VITAFOL-NANO106 XARELTO20 VENTAVIS53 VITAFOL-ONE106 XARELTO STARTER PACK20 VENTOLIN HFA19 VITAMEDMD ONE XATMEP39 verapamil hcl52 RX/QUATREFOLIC106 XELJANZ4 VERDESO72 VITAMEDMD REDICHEW XELJANZ XR4 VEREGEN64 RX106 VITAMIN D2128 XELODA39 VERELAN52 VITAMIN D3128 XENAZINE117 VERELAN PM52 VITAMIN D3 IMMUNE XENICAL2 VERIPRED 2059 HEALTH128 XERAC AC74 VERSACLOZ46 VITAPEARL106 XERESE67 VERZENIO42 VITATHELY/GINGER106 XERMELO84 VESICARE125 VITATRUE106 XIAFLEX97 VFEND32 VITRAKVI42 XIFAXAN14 VIAGRA53 VIVA DHA106 XIGDUO XR27 VIBERZI84 VIVELLE-DOT82 XOLAIR17 VIBRAMYCIN121 VIZIMPRO40 XOLEGEL66 VICTOZA28 VOL-PLUS107 XOPENEX20 VIDEX EC48 VOL-TAB RX107 XOPENEX CONCENTRATE19 VIDEXPEDIATRIC49 VOLTAREN64 XOPENEX HFA20 vigabatrin23 voriconazole32 XOSPATA43 vigadrone23 VOSEVI50 XPOVIO41 VIGAMOX111 VOTRIENT43 XPOVIO 100 MG ONCE VIIBRYD26 VP-PNV-DHA107 WEEKLY41 VIIBRYD STARTER PACK26 VRAYLAR45 XPOVIO 40 MG ONCE VIMOVO6 WEEKLY41 VUSION66 XPOVIO 40 MG TWICE VIMPAT23 VYLEESI117 WEEKLY41 VINATE DHA RF106 VYNDAMAX54 XPOVIO 60 MG ONCE VINATE II106 VYNDAQEL54 WEEKLY41 XPOVIO 60 MG TWICE VIOKACE76 VYTONE66 WEEKLY41 VIRACEPT49 VYTORIN32 XPOVIO 80 MG ONCE VIRAMUNE49 VYVANSE1 WEEKLY41 VIRAMUNE XR49 XPOVIO 80 MG TWICE warfarin sodium20 WEEKLY41 VIRASAL73 wee care88 XTAMPZA ER10 VIRAZOLE50 WELCHOL33 XTANDI40 VIREAD49 WELLBUTRIN SR24 xulane57 VIRT-C DHA106 WELLBUTRIN XL24 XULTOPHY 100/3.627 VIRT-NATE DHA106 WESTAB PLUS107 XURIDEN80 VIRT-PN DHA106 WESTGEL DHA107 XYREM116 VIRT-PN PLUS106 WESTHROID122 YASMIN 2857
Index 23 Updated 07/01/2021 YAZ57 ZOMIG ZMT96 YONSA40 ZONEGRAN23 yuvafem127 zonisamide23 zafirlukast17 ZONTIVITY86 zaleplon89 ZORTRESS98 ZANAFLEX107 ZORVOLEX6 ZARONTIN24 ZOVIRAX50,67 ZARXIO87 ZUBSOLV12 ZATEAN-PN DHA107 ZUPLENZ30 ZATEAN-PN PLUS107 ZYBAN120 ZAVESCA87 ZYCLARA72 ZEGERID125 ZYCLARA PUMP73 ZEJULA43 ZYDELIG43 ZELAPAR44 ZYFLO17 ZELBORAF43 ZYKADIA43 ZEMPLAR80 ZYLET112 ZENPEP76 ZYLOPRIM86 zenzedi1 ZYMAXID111 ZESTORETIC37 ZYPREXA46 ZESTRIL35 ZYPREXA ZYDIS46 ZETIA34 ZYTIGA40 ZETONNA109 ZYVOX15 ZIAC37 ZIAGEN49 ZIANA64 zidovudine49 ZIEXTENZO88 zileuton17 zinc sulfate97 ZIOPTAN114 ziprasidone hcl45 ZIPSOR6 ZIRGAN111 ZITHROMAX90 ZITHROMAX TRI-PAK90 ZITHROMAX Z-PAK90 ZOCOR34 ZOFRAN30 ZOHYDRO ER10 ZOLINZA43 zolmitriptan95 ZOLOFT25 zolpidem tartrate89 ZOLPIMIST89 ZOMACTON79 ZOMIG96
Updated 07/01/2021 Index 24