2021 CIGNA COMPREHENSIVE DRUG LIST (Formulary)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT ALL OF THE DRUGS WE COVER IN THIS PLAN.
Plans covered Cigna Preferred Medicare (HMO) Cigna Alliance Medicare (HMO)
HPMS Approved Formulary File Submission ID 21121, Version 17 This formulary was updated on 09/01/2021. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit CignaMedicare.com. The Formulary, pharmacy network, and/or provider network may change at any time. 21_F_04_AZ_04_V09 September 2021 INT_21_87406_C_Final_6k
Note to existing customers: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna. When it refers to “plan” or “our plan,” it means Cigna Preferred Medicare (HMO) and Cigna Alliance Medicare (HMO) .
This document includes a list of the drugs (formulary) for our plans, which is current as of September 2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.
What is the Cigna Comprehensive Drug List? you can also find information in the section entitled “How do A drug list is a list of covered drugs selected by Cigna in I request an exception to the Cigna Drug List?” consultation with a team of health care providers, which • Drugs removed from the market. If the Food and Drug represents the prescription therapies believed to be a necessary Administration (FDA) deems a drug on our drug list to be part of a quality treatment program. Cigna will generally unsafe or the drug’s manufacturer removes the drug from the cover the drugs listed in our drug list as long as the drug market, we will immediately remove the drug from our drug is medically necessary, the prescription is filled at a Cigna list and provide notice to customers who take the drug. network pharmacy, and other plan rules are followed. For more • Other changes. We may make other changes that affect information on how to fill your prescriptions, please review your customers currently taking a drug. For instance, we may Evidence of Coverage. add a generic drug that is not new to the market to replace Can the Drug List (formulary) change? a brand name drug currently on the drug list; or add new Most changes in drug coverage happen on January 1, but we restrictions to the brand name drug or move it to a different may add or remove drugs on the drug list during the year, move cost-sharing tier or both. Or we may make changes based them to different cost-sharing tiers, or add new restrictions. We on new clinical guidelines and/or studies. If we remove drugs must follow Medicare rules in making these changes. from our drug list, add prior authorization, quantity limits, and/ or step therapy restrictions on a drug or move a drug to a Changes that can affect you this year. In the below cases, higher cost-sharing tier, we must notify affected customers you will be affected by coverage changes during the year: of the change at least 30 days before the change becomes • New generic drugs. We may immediately remove a brand effective, or at the time the customer requests a refill of the name drug on our drug list if we are replacing it with a new drug, at which time the customer will receive a 30-day supply generic drug that will appear on the same or lower cost- of the drug. sharing tier and with the same or fewer restrictions. Also, – If we make these other changes, you or your prescriber when adding the new generic drug, we may decide to keep can ask us to make an exception and continue to cover the the brand name drug on our drug list, but immediately move brand name drug for you. The notice we provide you will it to a different cost-sharing tier or add new restrictions. If you also include information on how to request an exception, are currently taking that brand name drug, we may not tell and you can also find information in the section below you in advance before we make that change, but we will later entitled “How do I request an exception to the Cigna provide you with information about the specific change(s) we Drug List?” have made. Changes that will not affect you if you are currently taking – If we make such a change, you or your prescriber can ask the drug. Generally, if you are taking a drug on our 2021 drug us to make an exception and continue to cover the brand list that was covered at the beginning of the year, we will not name drug for you. The notice we provide you will also discontinue or reduce coverage of the drug during the 2021 include information on how to request an exception, and coverage year except as described above. This means these
September 2021 1 drugs will remain available at the same cost-sharing and with will need to get approval from Cigna before you fill these no new restrictions for those customers taking them for the prescriptions. If you don’t get approval, Cigna may not cover remainder of the coverage year. You will not get direct notice the drug. this year about changes that do not affect you. However, on • Quantity Limits: For certain drugs, Cigna limits the amount January 1 of the next year, such changes would affect you, and of the drug that Cigna will cover. For example, Cigna allows it is important to check the drug list for the new benefit year for for 1 tablet per day for atorvastatin 40mg. This applies to a any changes to drugs. standard one-month supply (for total quantity of 30 per The enclosed drug list is current as of September 2021. To get 30 days) or three-month supply (for total quantity of 90 updated information about the drugs covered by Cigna, please per 90 days). contact us. Our contact information appears on the front and • Step Therapy: In some cases, Cigna requires you to first try back cover pages. If there are significant changes made to the certain drugs to treat your medical condition before we will printed drug list within the covered year, you may be notified by cover another drug for that condition. For example, if Drug A mail identifying the changes. Drug lists located on our website and Drug B both treat your medical condition, Cigna may not are reviewed and updated on a monthly basis. cover Drug B unless you try Drug A first. If Drug A does not How do I use the Drug List? work for you, Cigna will then cover Drug B. There are two ways to find your drug within the drug list: • Non-Extended Days Supply: For certain drugs, Cigna limits the amount of the drug that Cigna will cover to only a 30-day Medical Condition supply or less, at one time. For example, customers who The drug list begins on page 8. The drugs in this drug list are have not had any recent fill of opioid pain medications within grouped into categories depending on the type of medical the past 108 days (referred to as “opioid naïve”) are limited conditions that they are used to treat. For example, drugs to a maximum of 7 days’ supply of opioid pain medication. used to treat a heart condition are listed under the category, Customers who have received a recent fill of an opioid pain “CARDIOVASCULAR, HYPERTENSION / LIPIDS.” If you know medication (not opioid naïve) are limited to up to a month’s what your drug is used for, look for the category name in the list supply of that medication at one time. Other high cost drugs that begins on page 8. Then look under the category name for may be subject to a non-extended day supply restriction, your drug. as well. Covered Drug Index You can find out if your drug has any additional requirements If you are not sure what category to look under, you should look or limits by looking in the drug list that begins on page 8. You for your drug in the Covered Drugs Index that begins on page can also get more information about the restrictions applied to 56. The Covered Drugs Index provides an alphabetical list of all specific covered drugs by visiting our website. We have posted of the drugs included in this document. Both brand name drugs online documents that explain our prior authorization and step and generic drugs are listed in the Index. Look in the Index and therapy restrictions. You may also ask us to send you a copy. find your drug. Next to your drug, you will see the page number Our contact information, along with the date we last updated the where you can find coverage information. Turn to the page drug list, appears on the front and back cover pages. listed in the Covered Drug Index and find the name of your drug in the drug name column of the list. You can ask Cigna to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat What are generic drugs? your health condition. See the section, “How do I request an Cigna covers both brand name drugs and generic drugs. A exception to the Cigna drug list?” on page 3 for information generic drug is approved by the FDA as having the same active about how to request an exception. ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Options for Maintenance Medications Taking the medications prescribed by your doctor (or other Are there any restrictions on my coverage? prescriber) is important to your health. Some covered drugs may have additional requirements or limits We are committed to helping you control your chronic conditions on coverage. These requirements and limits may include: by making it easy for you to receive your maintenance • Prior Authorization: Cigna requires you or your doctor to medications. There are several ways we can work together get prior authorization for certain drugs. This means that you to accomplish this goal:
September 2021 2 • Talk with your doctor about whether a 90-day supply of your cost-sharing level, and you would not be able to ask us to ongoing, stable medications may be appropriate. Taking provide the drug at a lower cost-sharing level. these medications every day as prescribed is important for • You can ask us to waive coverage restrictions or limits on your overall health, and getting 90-day prescriptions of these your drug. For example, for certain drugs, Cigna limits the medications can help ensure that you do not miss a dose. amount of the drug that we will cover. If your drug has a • You can receive a 90-day supply at most retail pharmacies or quantity limit, you can ask us to waive the limit and cover a through one of our mail-order pharmacies. greater amount. • Talk to your pharmacist if you are experiencing any new • You can ask us to provide a tiering exception for a higher challenges with your maintenance medications. cost-sharing drug to be covered at a lower cost-sharing tier under following circumstances: How can I use my prescription drug coverage to save money on my medications? – If the drug you’re taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount There may be opportunities for you to save money on your that applies to the lowest tier that contains brand name medications using your Cigna coverage. alternatives for treating your condition. • Ask your doctor (or other prescriber) if there are any lower- – If the drug you’re taking is a generic drug you can ask us cost generic alternatives available for any of your current to cover your drug at the cost-sharing amount that applies medications. to the lowest tier that contains either brand or generic • Some plans may offer a $0 copay for Tier 1 and 2 generic alternatives for treating your condition. drugs filled at a preferred retail and/or mail-order pharmacies. – If the drug you’re taking is a biological product you can Check the Drug Tier and Cost-share Tables on page 5 to see ask us to cover your drug at the cost-sharing amount that if your plan offers these savings. applies to the lowest tier that contains biological product • Explore whether the ‘CMS Extra Help’ program may offer alternatives for treating your condition. additional financial support for your medications. These exceptions would lower the amount you must pay for • If your medication is not covered in the Cigna drug list, talk your drug. with your doctor about alternative medications which are Please note, if we grant your request to cover a drug that is covered in the drug list. not in our drug list, you may not ask us to provide a higher What if my drug is not on the Drug List? level of coverage for the drug. Also, you may not ask us to If your drug is not included in this drug list, you should first provide a higher level of coverage for drugs that are in the contact Customer Service and ask if your drug is covered. Specialty tier. If you learn that Cigna does not cover your drug, you have Generally, Cigna will only approve your request for an exception two options: if the alternative drugs included in our drug list, the lower cost- • You can ask Customer Service for a list of similar drugs that sharing drug or additional utilization restrictions would not be as are covered by Cigna. When you receive the list, show it to effective in treating your condition and/or would cause you to your doctor and ask him or her to prescribe a similar drug that have adverse medical effects. is covered by Cigna. You should contact us to ask us for an initial coverage decision • You can ask Cigna to make an exception and cover your for a drug list, tiering or utilization restriction exception. When drug. See the next section for information about how to you request a drug list, tiering or utilization restriction request an exception. exception you should submit a statement from your prescriber or doctor supporting your request. Generally, How do I request an exception to the Cigna Drug List? we must make our decision within 72 hours of getting your You can ask Cigna to make an exception to our coverage prescriber’s supporting statement. You can request an rules. There are several types of exceptions that you can ask expedited (fast) exception if you or your doctor believe that your us to make. health could be seriously harmed by waiting up to 72 hours for • You can ask us to cover a drug even if it is not on our drug a decision. If your request to expedite is granted, we must give list. If approved, this drug will be covered at a pre-determined you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
September 2021 3 What do I do before I can talk to my doctor about changing Cigna’s Drug List my drugs or requesting an exception? The comprehensive drug list that begins on page 8 provides As a new or existing customer in our plan you may be taking coverage information about all of the drugs covered by Cigna. If drugs that are not on our drug list. Or, you may be taking a drug you have trouble finding your drug in the list, turn to the Covered that is on our drug list but your ability to get it is limited. For Drug Index that begins on page 56. example, you may need a prior authorization from us before The first column of the chart lists the drug name. Brand name you can fill your prescription. You should talk to your doctor drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic to decide if you should switch to an appropriate drug that we drugs are listed in lower-case italics (e.g., atorvastatin). cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the The information in the Requirements/Limits column tells you if right course of action for you, we may cover your drug up to a Cigna has any special requirements for coverage of your drug. 30-day supply, in certain cases during the first 90 days you are This plan offers additional prescription drug coverage in the a customer of our plan. coverage gap. Please refer to your Evidence of Coverage to For each of your drugs that is not on our drug list or if your see this coverage and for more information. ability to get your drugs is limited, we will cover a temporary We provide quantity limits on certain drugs which are indicated 30-day supply. If your prescription is written for fewer days, with a QL in the Covered Drugs by Category list on page 8 we’ll allow refills to provide up to a maximum 30-day supply of along with the amount dispensed per the days supplied. (For medication. After your first 30-day supply, we will not pay for example: atorvastatin 40mg QL 30/30; this means the drug these drugs without a drug list exception, even if you have been atorvastatin 40mg is limited to 30 tablets per 30 days. For a customer of the plan less than 90 days. 90-day supplies, this quantity limit would be expanded to If you are a resident of a long-term care facility and you need a 90 tablets per 90 days). drug that is not on our drug list or if your ability to get your drugs What is a preferred network pharmacy? is limited, but you are past the first 90 days of membership in If your plan has preferred network pharmacies, you will typically our plan, we will cover a 31-day emergency supply of that drug save money by using these pharmacies. Your prescription while you pursue a drug list exception. drug costs (like a copay or coinsurance) will typically be less In order to accommodate unexpected transitions of our at a preferred network pharmacy because it has a preferred customers that do not leave time for advanced planning, such agreement with your plan. If you need help finding a network as level-of-care changes due to discharge from a hospital to a pharmacy, please call Customer Service at 1-800-627-7534 nursing facility or to a home, Cigna will allow a one-time 31-day (TTY 711), or you can visit CignaMedicare.com for the most supply (unless the prescription is written for fewer days). current Pharmacy Directory.
For more information For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
September 2021 4 Drug Tier and Cost-Share Table the name “Tier 3: Preferred Brand Drugs” is just a description of The following table represents the plan name, plan service the majority of the drugs in the tier. It does not mean that there area, the drug tier number as it appears on the drug list, and the are only brand drugs in that tier. cost-share amount for that tier number. Tier 1 is for Preferred For customers receiving Extra Help: Your Low Income Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Subsidy (LIS) copay level will be based on how the Food Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for and Drug Administration (FDA) classifies certain drugs. Due Specialty tier drugs. Please refer to the following chart. You to this, a generic drug may receive a preferred brand copay, may also refer to your Evidence of Coverage document for or a preferred brand drug may receive a generic drug copay. additional details. Please see your LIS Rider for additional information on these Cigna is not always able to keep all generic medications in the copay levels. Or call Customer Service for further clarification Preferred Generic and Generic drug tiers, and some generic regarding a specific drug. medications may be in Tier 3, Tier 4 or Tier 5. Keep in mind that
To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll. If you qualified for Extra Help with your drug costs, your costs may be different from those described below. Please refer to your Evidence of Coverage (EOC) or call Customer Service to find out what your costs are. Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit CignaMedicare.com to search for a preferred retail or mail-order pharmacy near you.
Service Area: Arizona H0354-001 – Cigna Preferred Medicare (HMO): Maricopa and Pinal (Apache Junction and Queen Creek: 85117, 85118, 85119, 85120, 85140, 85143, 85178, 85220), Arizona H0354-028 – Cigna Alliance Medicare (HMO): Maricopa and Pinal (Apache Junction and Queen Creek: 85117, 85118, 85119, 85120, 85140, 85143, 85178, 85220), Arizona H0354-024 – Cigna Preferred Medicare (HMO): Pima, Arizona Preferred Retail Standard Retail Preferred Mail-Order Standard Mail-Order Cost-Sharing Cost-Sharing Cost-Sharing Cost-Sharing Drug Tier 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days Tier 1: Preferred Generic Drugs (GC) $0 / $0 / $0 $10 / $20 / $30 $0 / $0 / $0 $10 / $20 / $30 Tier 2: Generic Drugs (GC) $0 / $0 / $0 $15 / $30 / $45 $0 / $0 / $0 $15 / $30 / $45 Tier 3: Preferred Brand Drugs $47 / $94 / $141 $47 / $94 / $141 $47 / $94 / $141 $47 / $94 / $141 Tier 4: Non-Preferred Drugs $100 / $200 / $300 $100 / $200 / $300 $100 / $200 / $300 $100 / $200 / $300 Tier 5: Specialty Tier 33% (30 days) 33% (30 days) 33% (30 days) 33% (30 days)
GC: We provide additional coverage of the prescription drugs in this tier in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
September 2021 5 My Medications In this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-627-7534, 7 days a week, 8 a.m. – 8 p.m. local time. TTY users can call 711.
Page Number in My Medications Cost-Share through Cigna the Drug List
September 2021 6 Drug List Table of Contents: The drugs in the drug list are grouped into categories depending on the type of medical conditions that they are used to treat. If you know what your drug is used for, look for the category name in the list below. Then look under the category name in the drug list for your drug. Page ANTI - INFECTIVES ...... 8 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ...... 15 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ...... 21 CARDIOVASCULAR, HYPERTENSION / LIPIDS ...... 30 DERMATOLOGICALS/TOPICAL THERAPY ...... 34 DIAGNOSTICS / MISCELLANEOUS AGENTS ...... 37 EAR, NOSE / THROAT MEDICATIONS ...... 38 ENDOCRINE/DIABETES...... 38 GASTROENTEROLOGY...... 42 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ...... 44 MUSCULOSKELETAL / RHEUMATOLOGY ...... 46 OBSTETRICS / GYNECOLOGY ...... 47 OPHTHALMOLOGY ...... 50 RESPIRATORY AND ALLERGY ...... 52 UROLOGICALS ...... 54 VITAMINS, HEMATINICS / ELECTROLYTES ...... 54
Drug List Key: B/D – This prescription drug has a Part B versus D your Pharmacy Directory or call Customer Service at administrative prior authorization requirement. This drug 1-800-627-7534, 7 days a week, 8 a.m. – 8 p.m. local time. may be covered under Medicare Part B or D depending TTY users can call 711. on circumstances. NDS – Non-extended day supply medication. This drug GC – We provide additional coverage of the prescription is only available as a 30-day supply or less. drugs in this tier in the coverage gap. Please refer to PA – This drug requires prior authorization our Evidence of Coverage for more information about this coverage. QL – This drug has quantity limits HI (Home Infusion) – This prescription drug may be ST – This drug has step therapy requirements covered under our medical benefit. For more information, Generally all medications in the drug list are available call Customer Service at 1-800-627-7534, 7 days a week, through mail-order, except when special circumstances 8 a.m. - 8 p.m. local time. TTY users should call 711. or situations prohibit mailing a particular medication to LA – Limited Availability. This prescription may be available your home. only at certain pharmacies. For more information consult
September 2021 7 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS
ANTI - INFECTIVES acyclovir oral tablet 2 acyclovir sodium intravenous 4 B/D PA ANTIFUNGAL AGENTS solution ABELCET 4 PA adefovir 5 NDS AMBISOME 5 PA; NDS amantadine hcl 3 amphotericin b 4 PA APTIVUS 5 QL (120/30); NDS caspofungin 5 PA; HI; NDS atazanavir oral capsule 150 4 QL (30/30) clotrimazole mucous 2 mg, 300 mg membrane atazanavir oral capsule 200 mg 4 QL (60/30) CRESEMBA ORAL 5 NDS ATRIPLA 5 QL (30/30); NDS fluconazole 2 BARACLUDE ORAL 4 QL (630/30) fluconazole in nacl (iso-osm) 4 PA; HI SOLUTION intravenous piggyback 200 BIKTARVY 5 NDS mg/100 ml, 400 mg/200 ml CABENUVA 5 NDS flucytosine 5 NDS CIMDUO 5 NDS griseofulvin microsize 4 COMPLERA 5 QL (30/30); NDS griseofulvin ultramicrosize 4 DELSTRIGO 5 NDS itraconazole oral capsule 4 QL (120/30) DESCOVY 5 QL (30/30); NDS itraconazole oral solution 5 NDS didanosine oral capsule, 4 QL (30/30) ketoconazole oral 2 delayed release(dr/ec) 250 mg, micafungin 5 HI; NDS 400 mg nystatin oral 2 DOVATO 5 NDS posaconazole oral tablet, 5 QL (96/30); NDS EDURANT 5 QL (30/30); NDS delayed release (dr/ec) efavirenz oral capsule 200 mg 5 QL (120/30); NDS terbinafine hcl oral 2 efavirenz oral capsule 50 mg 3 QL (180/30) voriconazole intravenous 5 PA; HI; NDS efavirenz oral tablet 5 QL (30/30); NDS voriconazole oral suspension 5 NDS efavirenz-emtricitabin-tenofov 5 QL (30/30); NDS for reconstitution efavirenz-lamivu-tenofov disop 5 QL (30/30); NDS voriconazole oral tablet 200 mg 5 NDS oral tablet 400-300-300 mg voriconazole oral tablet 50 mg 4 efavirenz-lamivu-tenofov disop 5 NDS ANTIVIRALS oral tablet 600-300-300 mg abacavir oral solution 3 QL (960/30) emtricitabine 3 QL (30/30) abacavir oral tablet 4 QL (60/30) emtricitabine-tenofovir (tdf) 5 QL (30/30); NDS abacavir-lamivudine 3 QL (30/30) EMTRIVA ORAL CAPSULE 4 QL (30/30) abacavir-lamivudine-zidovudine 5 QL (60/30); NDS EMTRIVA ORAL SOLUTION 4 QL (680/28) acyclovir oral capsule 2 entecavir 4 QL (30/30) acyclovir oral suspension 200 4 EPCLUSA 5 PA; QL (28/28); mg/5 ml NDS
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 8 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS EPIVIR HBV ORAL SOLUTION 4 LEXIVA ORAL SUSPENSION 4 QL (1575/28) etravirine 5 QL (60/30); NDS lopinavir-ritonavir oral solution 3 EVOTAZ 5 QL (30/30); NDS lopinavir-ritonavir oral tablet 4 QL (300/30) famciclovir 3 QL (60/30) 100-25 mg fosamprenavir 5 QL (120/30); NDS lopinavir-ritonavir oral tablet 4 QL (120/30) 200-50 mg FUZEON SUBCUTANEOUS 5 QL (60/30); NDS RECON SOLN MAVYRET 5 PA; QL (84/28); NDS GENVOYA 5 QL (30/30); NDS nevirapine oral suspension 4 QL (1200/30) HARVONI ORAL PELLETS IN 5 PA; QL (28/28); PACKET 33.75-150 MG NDS nevirapine oral tablet 3 QL (60/30) HARVONI ORAL PELLETS IN 5 PA; QL (56/28); nevirapine oral tablet extended 4 QL (90/30) PACKET 45-200 MG NDS release 24 hr 100 mg HARVONI ORAL TABLET 5 PA; QL (60/30); nevirapine oral tablet extended 4 QL (30/30) 45-200 MG NDS release 24 hr 400 mg HARVONI ORAL TABLET 5 PA; QL (28/28); NORVIR ORAL POWDER IN 4 90-400 MG NDS PACKET INTELENCE ORAL TABLET 5 QL (60/30); NDS NORVIR ORAL SOLUTION 3 QL (480/30) 100 MG, 200 MG ODEFSEY 5 QL (30/30); NDS INTELENCE ORAL TABLET 25 4 QL (120/30) oseltamivir 3 MG PIFELTRO 5 NDS INVIRASE ORAL TABLET 5 QL (120/30); NDS PREVYMIS ORAL 5 QL (30/30); NDS ISENTRESS HD 5 NDS PREZCOBIX 5 QL (30/30); NDS ISENTRESS ORAL POWDER 4 QL (60/30) PREZISTA ORAL 5 QL (400/30); NDS IN PACKET SUSPENSION ISENTRESS ORAL TABLET 5 QL (120/30); NDS PREZISTA ORAL TABLET 150 4 QL (240/30) ISENTRESS ORAL TABLET, 5 QL (180/30); NDS MG CHEWABLE 100 MG PREZISTA ORAL TABLET 600 5 QL (60/30); NDS ISENTRESS ORAL TABLET, 3 QL (180/30) MG CHEWABLE 25 MG PREZISTA ORAL TABLET 75 3 QL (480/30) JULUCA 5 NDS MG KALETRA ORAL TABLET 100 4 QL (300/30) PREZISTA ORAL TABLET 800 5 QL (30/30); NDS 25 MG MG KALETRA ORAL TABLET 200 5 QL (120/30); NDS RETROVIR INTRAVENOUS 4 50 MG REYATAZ ORAL POWDER IN 5 QL (240/30); NDS lamivudine oral solution 3 QL (900/30) PACKET lamivudine oral tablet 100 mg, 3 QL (30/30) ribavirin oral capsule 3 300 mg ribavirin oral tablet 200 mg 3 lamivudine oral tablet 150 mg 3 QL (60/30) rimantadine 2 lamivudine-zidovudine 3 QL (60/30) ritonavir 3 QL (360/30)
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 9 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS RUKOBIA 5 NDS zidovudine oral capsule 4 QL (180/30) SELZENTRY ORAL 5 NDS zidovudine oral syrup 3 QL (1680/28) SOLUTION zidovudine oral tablet 3 QL (60/30) SELZENTRY ORAL TABLET 5 QL (60/30); NDS CEPHALOSPORINS 150 MG, 75 MG cefaclor oral capsule 2 SELZENTRY ORAL TABLET 3 QL (120/30) 25 MG cefaclor oral suspension for 3 reconstitution 125 mg/5 ml, 250 SELZENTRY ORAL TABLET 5 QL (120/30); NDS mg/5 ml, 375 mg/5 ml 300 MG cefaclor oral tablet extended 3 stavudine oral capsule 3 QL (60/30) release 12 hr STRIBILD 5 QL (30/30); NDS cefadroxil oral capsule 3 SYMFI 5 NDS cefadroxil oral suspension for 3 SYMFI LO 5 QL (30/30); NDS reconstitution 250 mg/5 ml, 500 SYMTUZA 5 NDS mg/5 ml TEMIXYS 5 NDS cefadroxil oral tablet 3 tenofovir disoproxil fumarate 4 QL (30/30) cefazolin in dextrose (iso-os) 4 HI intravenous piggyback 1 TIVICAY ORAL TABLET 10 MG 4 QL (60/30) gram/50 ml, 2 gram/50 ml TIVICAY ORAL TABLET 25 5 QL (60/30); NDS CEFAZOLIN IN DEXTROSE 4 HI MG, 50 MG (ISO-OS) INTRAVENOUS TIVICAY PD 5 QL (180/30); NDS PIGGYBACK 2 GRAM/100 ML TRIUMEQ 5 QL (30/30); NDS cefazolin injection recon soln 1 4 HI TROGARZO 5 NDS gram, 10 gram, 100 gram, 300 g, 500 mg TRUVADA 5 QL (30/30); NDS cefazolin intravenous 4 HI TYBOST 3 cefdinir oral capsule 2 valacyclovir oral tablet 1 gram 2 QL (120/30) cefdinir oral suspension for 3 valacyclovir oral tablet 500 mg 2 QL (60/30) reconstitution valganciclovir 5 NDS CEFEPIME IN DEXTROSE 5% 4 HI VEMLIDY 5 NDS cefepime in dextrose,iso-osm 4 HI VIRACEPT ORAL TABLET 250 5 QL (270/30); NDS cefepime injection 4 HI MG CEFEPIME INTRAVENOUS 4 PA VIRACEPT ORAL TABLET 625 5 QL (120/30); NDS MG cefixime 4 VIREAD ORAL POWDER 5 QL (240/30); NDS CEFOTETAN IN DEXTROSE, 4 PA ISO-OSM VIREAD ORAL TABLET 150 5 QL (30/30); NDS MG, 200 MG, 250 MG cefotetan injection 4 PA VOSEVI 5 PA; QL (28/28); cefoxitin 4 PA; HI NDS cefoxitin in dextrose, iso-osm 4 HI XOFLUZA 4 cefpodoxime 2
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 10 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS cefprozil 2 ery-tab oral tablet,delayed 3 ceftazidime 4 PA; HI release (dr/ec) 250 mg CEFTAZIDIME IN D5W 4 HI ERY-TAB ORAL TABLET, 3 DELAYED RELEASE (DR/EC) ceftriaxone in dextrose,iso-os 4 333 MG, 500 MG ceftriaxone injection recon soln 4 erythrocin (as stearate) oral 3 1 gram, 10 gram, 2 gram, 250 tablet 250 mg mg, 500 mg ERYTHROCIN INTRAVENOUS 4 PA CEFTRIAXONE INJECTION 4 RECON SOLN 500 MG RECON SOLN 100 GRAM erythromycin ethylsuccinate 3 ceftriaxone intravenous 4 oral suspension for cefuroxime axetil oral tablet 2 reconstitution 200 mg/5 ml cefuroxime sodium injection 4 PA erythromycin ethylsuccinate 5 NDS recon soln 750 mg oral suspension for cefuroxime sodium intravenous 4 PA reconstitution 400 mg/5 ml cephalexin oral capsule 250 1 erythromycin ethylsuccinate 3 mg, 500 mg oral tablet cephalexin oral suspension for 2 erythromycin oral tablet 4 reconstitution erythromycin oral tablet, 3 SUPRAX ORAL SUSPENSION 4 delayed release (dr/ec) FOR RECONSTITUTION 500 MISCELLANEOUS ANTIINFECTIVES MG/5 ML albendazole 5 NDS tazicef injection 4 PA; HI amikacin injection solution 4 HI tazicef intravenous 4 HI 1,000 mg/4 ml TEFLARO 5 PA; HI; NDS amikacin injection solution 500 4 PA; HI ERYTHROMYCINS / OTHER MACROLIDES mg/2 ml azithromycin intravenous 4 PA; HI ARIKAYCE 5 PA; LA; NDS azithromycin oral packet 3 atovaquone 5 NDS azithromycin oral suspension 2 atovaquone-proguanil 2 for reconstitution aztreonam injection recon soln 3 PA; HI azithromycin oral tablet 2 1 gram clarithromycin oral suspension 3 aztreonam injection recon soln 4 HI for reconstitution 2 gram clarithromycin oral tablet 2 bacitracin intramuscular 4 clarithromycin oral tablet 2 CAYSTON 5 PA; LA; QL (84/28); extended release 24 hr NDS DIFICID ORAL SUSPENSION 5 QL (136/10); NDS chloramphenicol sod succinate 4 FOR RECONSTITUTION chloroquine phosphate 2 DIFICID ORAL TABLET 5 QL (20/10); NDS clindamycin hcl 2 ERYPED 400 5 NDS
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 11 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS CLINDAMYCIN IN 0.9% SOD 4 HI lincomycin 4 PA CHLOR linezolid in dextrose 5% 4 PA; HI clindamycin in 5% dextrose 4 PA; HI linezolid oral suspension for 5 QL (1800/30); NDS clindamycin pediatric 4 reconstitution clindamycin phosphate injection 4 PA; HI linezolid oral tablet 3 QL (60/30) clindamycin phosphate 4 PA; HI linezolid-0.9% sodium chloride 4 HI intravenous solution 600 mg/4 mefloquine 2 ml meropenem 4 HI COARTEM 4 QL (24/30) MEROPENEM-0.9% SODIUM 4 HI colistin (colistimethate na) 5 PA; NDS CHLORIDE CYCLOSERINE 2 metro i.v. 4 HI dapsone oral 3 metronidazole in nacl (iso-os) 4 PA; HI DAPTOMYCIN INTRAVENOUS 5 HI; NDS metronidazole oral tablet 1 RECON SOLN 350 MG neomycin 2 daptomycin intravenous recon 5 HI; NDS
soln 500 mg nitazoxanide 5 QL (20/10); NDS
EMVERM 5 NDS ORBACTIV 5 PA; QL (3/30); NDS ertapenem 4 HI paromomycin 4 ethambutol 3 PASER 4 FIRVANQ ORAL RECON 4 QL (300/10) PENTAM 3 SOLN 25 MG/ML pentamidine inhalation 3 B/D PA; QL (1/28) FIRVANQ ORAL RECON 4 QL (450/10) pentamidine injection 3 SOLN 50 MG/ML polymyxin b sulfate 4 PA gentamicin in nacl (iso-osm) 4 PA praziquantel 4 intravenous piggyback 100 PRIFTIN 4 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml PRIMAQUINE 3 GENTAMICIN IN NACL 4 PA pyrazinamide 3 (ISO-OSM) INTRAVENOUS pyrimethamine 5 PA; NDS PIGGYBACK 100 MG/50 ML, quinine sulfate 4 PA; QL (42/7) 120 MG/100 ML rifabutin 3 gentamicin injection solution 40 4 PA mg/ml rifampin intravenous 4 gentamicin sulfate (ped) (pf) 4 PA rifampin oral 2 hydroxychloroquine 2 SIRTURO 4 PA; LA imipenem-cilastatin 4 HI SIVEXTRO INTRAVENOUS 5 PA; QL (6/28); NDS isoniazid oral solution 3 SIVEXTRO ORAL 5 QL (6/28); NDS isoniazid oral tablet 2 streptomycin 5 PA; NDS ivermectin oral 3 SYNERCID 5 HI; NDS
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 12 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS tigecycline 5 PA; HI; NDS amoxicillin-pot clavulanate oral 2 TOBI PODHALER 5 QL (224/28); NDS tablet INHALATION CAPSULE, W/ amoxicillin-pot clavulanate oral 4 INHALATION DEVICE tablet extended release 12 hr tobramycin in 0.225% nacl 5 B/D PA; QL amoxicillin-pot clavulanate oral 2 (280/28); NDS tablet,chewable tobramycin sulfate 4 PA ampicillin oral capsule 500 mg 2 TRECATOR 3 ampicillin sodium injection 4 PA; HI VANCOMYCIN IN 0.9% 4 HI recon soln 1 gram, 10 gram SODIUM CHL INTRAVENOUS ampicillin sodium injection 4 PA PIGGYBACK recon soln 125 mg, 250 mg, VANCOMYCIN IN DEXTROSE 4 HI 500 mg 5% INTRAVENOUS ampicillin sodium injection 4 HI PIGGYBACK recon soln 2 gram VANCOMYCIN INJECTION 4 HI ampicillin sodium intravenous 4 HI vancomycin intravenous recon 4 HI ampicillin-sulbactam injection 4 PA; HI soln 1,000 mg, 1.5 gram, 10 ampicillin-sulbactam 4 HI gram, 250 mg, 5 gram, 500 mg, intravenous 750 mg BICILLIN L-A 4 PA VANCOMYCIN INTRAVENOUS 4 HI RECON SOLN 1.25 GRAM dicloxacillin 2 vancomycin oral capsule 125 3 PA; QL (40/10) nafcillin in dextrose iso-osm 4 HI mg nafcillin injection 4 PA; HI vancomycin oral capsule 250 3 PA; QL (80/10) nafcillin intravenous 4 HI mg oxacillin injection 4 PA; HI vancomycin oral recon soln 2 QL (450/10) penicillin g potassium injection 4 PA; HI VANCOMYCIN-WATER 4 recon soln 20 million unit INJECT (PEG) penicillin g potassium injection 4 HI XIFAXAN ORAL TABLET 550 5 PA; QL (90/30); recon soln 5 million unit MG NDS penicillin v potassium oral 1 PENICILLINS recon soln amoxicillin oral capsule 1 penicillin v potassium oral tablet 1 amoxicillin oral suspension for 1 250 mg reconstitution penicillin v potassium oral tablet 2 amoxicillin oral tablet 2 500 mg amoxicillin oral tablet,chewable 2 pfizerpen-g 4 HI 125 mg, 250 mg PIPERACILLIN-TAZOBACTAM 4 HI amoxicillin-pot clavulanate oral 2 INTRAVENOUS RECON SOLN suspension for reconstitution 13.5 GRAM
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 13 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS piperacillin-tazobactam 4 HI TETRACYCLINES intravenous recon soln 2.25 demeclocycline 3 gram, 3.375 gram, 4.5 gram, 40.5 gram doxy-100 4 PA ZOSYN IN DEXTROSE (ISO 4 HI doxycycline hyclate intravenous 4 PA OSM) doxycycline hyclate oral 1 QUINOLONES capsule CIPRO ORAL SUSPENSION, 4 doxycycline hyclate oral tablet 1 MICROCAPSULE RECON 100 mg ciprofloxacin hcl oral tablet 100 3 doxycycline hyclate oral tablet 2 mg 20 mg ciprofloxacin hcl oral tablet 250 2 doxycycline monohydrate oral 2 mg, 500 mg, 750 mg capsule 100 mg, 50 mg ciprofloxacin in 5% dextrose 4 PA; HI DOXYCYCLINE 4 intravenous piggyback 200 MONOHYDRATE ORAL mg/100 ml CAPSULE,IR - DELAY REL,BIPHASE ciprofloxacin in 5% dextrose 4 HI intravenous piggyback 400 doxycycline monohydrate oral 2 mg/200 ml suspension for reconstitution levofloxacin in d5w intravenous 4 HI doxycycline monohydrate oral 3 piggyback 250 mg/50 ml tablet levofloxacin in d5w intravenous 4 PA; HI minocycline oral capsule 2 piggyback 500 mg/100 ml, 750 minocycline oral tablet 2 mg/150 ml mondoxyne nl oral capsule 100 3 levofloxacin intravenous 4 PA; HI mg, 75 mg levofloxacin oral solution 4 morgidox oral capsule 100 mg 1 levofloxacin oral tablet 2 NUZYRA INTRAVENOUS 5 PA; NDS moxifloxacin oral 4 NUZYRA ORAL 5 NDS MOXIFLOXACIN-SOD.ACE, 4 PA tetracycline 2 SUL-WATER URINARY TRACT AGENTS moxifloxacin-sod.chloride(iso) 4 PA fosfomycin tromethamine 4 SULFAS / RELATED AGENTS methenamine hippurate 2 sulfadiazine 3 MONUROL 4 sulfamethoxazole-trimethoprim 4 PA nitrofurantoin 4 intravenous nitrofurantoin macrocrystal 2 sulfamethoxazole-trimethoprim 4 nitrofurantoin monohyd/m-cryst 2 oral suspension trimethoprim 2 sulfamethoxazole-trimethoprim 1 oral tablet
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 14 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ARRANON 4 B/D PA arsenic trioxide 5 B/D PA; NDS ADJUNCTIVE AGENTS ARZERRA 5 B/D PA; NDS leucovorin calcium injection 4 ASTAGRAF XL ORAL 4 B/D PA leucovorin calcium oral 3 CAPSULE,EXTENDED mesna 4 B/D PA RELEASE 24HR 0.5 MG, 1 MG MESNEX ORAL 5 NDS ASTAGRAF XL ORAL 5 B/D PA; NDS XGEVA 5 PA; QL (1.7/28); CAPSULE,EXTENDED NDS RELEASE 24HR 5 MG ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS AYVAKIT 5 PA; LA; QL (30/30); NDS abiraterone oral tablet 250 mg 5 PA; QL (120/30); NDS azacitidine 5 B/D PA; NDS abiraterone oral tablet 500 mg 5 PA; QL (60/30); AZASAN 3 B/D PA NDS azathioprine 2 B/D PA ABRAXANE 5 PA; NDS azathioprine sodium 4 B/D PA ADCETRIS 5 PA; NDS BALVERSA 5 PA; LA; NDS adriamycin intravenous recon 4 B/D PA BAVENCIO 5 PA; NDS soln 10 mg BELEODAQ 5 B/D PA; NDS adriamycin intravenous solution 4 B/D PA BENDEKA 5 B/D PA; NDS adrucil intravenous solution 2.5 4 B/D PA BESPONSA 5 PA; NDS gram/50 ml bexarotene 5 PA; NDS AFINITOR DISPERZ ORAL 5 PA; QL (150/30); bicalutamide 2 TABLET FOR SUSPENSION NDS 2 MG BLENREP 5 PA; NDS AFINITOR DISPERZ ORAL 5 PA; QL (56/28); bleomycin 4 B/D PA TABLET FOR SUSPENSION 3 NDS BLINCYTO INTRAVENOUS 5 B/D PA; NDS MG, 5 MG KIT AFINITOR ORAL TABLET 10 5 PA; QL (30/30); BORTEZOMIB 5 PA; NDS MG NDS BOSULIF ORAL TABLET 100 5 PA; QL (90/30); ALECENSA 5 PA; QL (240/30); MG NDS NDS BOSULIF ORAL TABLET 400 5 PA; QL (30/30); ALIMTA 5 PA; NDS MG, 500 MG NDS ALIQOPA 5 PA; NDS BRAFTOVI ORAL CAPSULE 5 PA; LA; QL ALUNBRIG ORAL TABLET 180 5 PA; QL (30/30); 75 MG (180/30); NDS MG, 90 MG NDS BRUKINSA 5 PA; LA; NDS ALUNBRIG ORAL TABLET 30 5 PA; QL (60/30); busulfan 5 B/D PA; NDS MG NDS CABOMETYX ORAL TABLET 5 PA; LA; QL (30/30); ALUNBRIG ORAL TABLETS, 5 PA; QL (30/30); 20 MG, 60 MG NDS DOSE PACK NDS CABOMETYX ORAL TABLET 5 PA; LA; QL (60/30); anastrozole 2 40 MG NDS
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 15 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS CALQUENCE 5 PA; LA; QL (60/30); DARZALEX FASPRO 5 PA; NDS NDS daunorubicin intravenous 4 B/D PA CAPRELSA ORAL TABLET 5 PA; LA; QL (60/30); solution 100 MG NDS DAURISMO ORAL TABLET 5 PA; QL (30/30); CAPRELSA ORAL TABLET 5 PA; LA; QL (30/30); 100 MG NDS 300 MG NDS DAURISMO ORAL TABLET 25 5 PA; QL (60/30); carboplatin intravenous solution 4 B/D PA MG NDS carmustine 4 B/D PA decitabine 5 B/D PA; NDS cisplatin intravenous solution 4 B/D PA docetaxel intravenous solution 4 B/D PA cladribine 4 B/D PA 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml clofarabine 4 B/D PA (10 mg/ml), 20 mg/ml (1 ml), 80 COMETRIQ ORAL CAPSULE 5 PA; QL (56/28); mg/4 ml (20 mg/ml), 80 mg/8 100 MG/DAY(80 MG X1-20 MG NDS ml (10 mg/ml) X1) doxorubicin 4 B/D PA COMETRIQ ORAL CAPSULE 5 PA; QL (112/28); doxorubicin, peg-liposomal 5 B/D PA; NDS 140 MG/DAY(80 MG X1-20 MG NDS X3) DROXIA 3 COMETRIQ ORAL CAPSULE 5 PA; QL (84/28); ELIGARD 4 PA 60 MG/DAY (20 MG X 3/DAY) NDS ELIGARD (3 MONTH) 4 PA COPIKTRA 5 PA; LA; QL (60/30); ELIGARD (4 MONTH) 4 PA NDS ELIGARD (6 MONTH) 4 PA COSMEGEN 5 B/D PA; NDS ELLENCE 4 B/D PA COTELLIC 5 PA; LA; QL (63/28); ELZONRIS 5 PA; NDS NDS EMCYT 5 NDS cyclophosphamide intravenous 5 B/D PA; NDS
recon soln EMPLICITI 4 PA
CYCLOPHOSPHAMIDE 5 B/D PA; NDS ENHERTU 5 PA; NDS INTRAVENOUS SOLUTION ENVARSUS XR 4 B/D PA cyclophosphamide oral 3 B/D PA epirubicin intravenous solution 4 B/D PA cyclosporine intravenous 4 B/D PA ERBITUX 5 B/D PA; NDS cyclosporine modified 4 B/D PA ERIVEDGE 5 PA; QL (30/30);
cyclosporine oral capsule 4 B/D PA NDS
CYRAMZA 5 PA; NDS ERLEADA 5 PA; QL (120/30); NDS cytarabine 4 B/D PA erlotinib oral tablet 100 mg, 150 5 PA; QL (30/30); cytarabine (pf) 4 B/D PA mg NDS dacarbazine 4 B/D PA erlotinib oral tablet 25 mg 5 PA; QL (60/30); dactinomycin 4 B/D PA NDS DANYELZA 5 PA; NDS ETOPOPHOS 4 B/D PA DARZALEX 5 PA; NDS etoposide intravenous 3 B/D PA
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 16 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS everolimus (antineoplastic) 5 PA; QL (30/30); HALAVEN 5 PA; NDS NDS hydroxyurea 2 everolimus 5 B/D PA; QL (60/30); IBRANCE 5 PA; QL (21/28); (immunosuppressive) oral NDS NDS tablet 0.25 mg, 0.75 mg ICLUSIG ORAL TABLET 10 5 PA; QL (30/30); everolimus 5 B/D PA; QL MG, 30 MG, 45 MG NDS (immunosuppressive) oral (120/30); NDS
tablet 0.5 mg ICLUSIG ORAL TABLET 15 5 PA; QL (60/30); MG NDS EVOMELA 5 PA; NDS idarubicin 4 B/D PA exemestane 2 IDHIFA 5 PA; LA; QL (30/30); FARYDAK 5 PA; QL (6/21); NDS NDS FIRMAGON KIT W DILUENT 5 B/D PA; NDS ifosfamide 4 B/D PA SYRINGE SUBCUTANEOUS
RECON SOLN 120 MG imatinib oral tablet 100 mg 5 PA; QL (180/30); NDS FIRMAGON KIT W DILUENT 4 B/D PA
SYRINGE SUBCUTANEOUS imatinib oral tablet 400 mg 5 PA; QL (60/30);
RECON SOLN 80 MG NDS
floxuridine 4 B/D PA IMBRUVICA ORAL CAPSULE 5 PA; QL (120/30); 140 MG NDS fludarabine 4 B/D PA IMBRUVICA ORAL CAPSULE 5 PA; QL (30/30); fluorouracil intravenous 4 B/D PA 70 MG NDS flutamide 2 IMBRUVICA ORAL TABLET 5 PA; QL (30/30); FOLOTYN 5 B/D PA; NDS NDS FOTIVDA 5 PA; LA; QL (21/28); IMFINZI 5 PA; NDS NDS INFUGEM 5 B/D PA; NDS fulvestrant 5 B/D PA; NDS INLYTA ORAL TABLET 1 MG 5 PA; QL (180/30); GAVRETO 5 PA; LA; QL NDS (120/30); NDS INLYTA ORAL TABLET 5 MG 5 PA; QL (120/30); GAZYVA 5 PA; NDS NDS gemcitabine intravenous recon 4 B/D PA INQOVI 5 PA; QL (5/28); NDS soln INREBIC 5 PA; LA; QL gemcitabine intravenous 4 B/D PA (120/30); NDS solution 1 gram/26.3 ml (38 mg/ IRESSA 5 PA; QL (30/30); ml), 2 gram/52.6 ml (38 mg/ml), NDS 200 mg/5.26 ml (38 mg/ml) irinotecan 4 B/D PA GEMCITABINE 5 B/D PA; NDS
INTRAVENOUS SOLUTION IXEMPRA 5 B/D PA; NDS 100 MG/ML JAKAFI 5 PA; QL (60/30);
gengraf 4 B/D PA NDS
GILOTRIF 5 PA; QL (30/30); JEMPERLI 5 PA; NDS NDS JEVTANA 4 B/D PA
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 17 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS KADCYLA 5 PA; NDS LORBRENA ORAL TABLET 25 5 PA; QL (90/30); KANJINTI 5 B/D PA; NDS MG NDS KEYTRUDA 5 PA; NDS LUMAKRAS 5 PA; QL (240/30); NDS KISQALI FEMARA CO-PACK 5 PA; QL (49/28); ORAL TABLET 200 MG/ NDS LUMOXITI 5 PA; NDS DAY(200 MG X 1)-2.5 MG LUPRON DEPOT 5 PA; NDS KISQALI FEMARA CO-PACK 5 PA; QL (70/28); LUPRON DEPOT (3 MONTH) 5 PA; NDS ORAL TABLET 400 MG/ NDS LUPRON DEPOT (4 MONTH) 5 PA; NDS DAY(200 MG X 2)-2.5 MG LUPRON DEPOT (6 MONTH) 5 PA; NDS KISQALI FEMARA CO-PACK 5 PA; QL (91/28);
ORAL TABLET 600 MG/ NDS LUPRON DEPOT-PED 5 PA; NDS DAY(200 MG X 3)-2.5 MG LUPRON DEPOT-PED (3 5 PA; NDS
KISQALI ORAL TABLET 200 5 PA; QL (21/28); MONTH) MG/DAY (200 MG X 1) NDS LYNPARZA ORAL TABLET 5 PA; QL (120/30);
KISQALI ORAL TABLET 400 5 PA; QL (42/28); NDS MG/DAY (200 MG X 2) NDS LYSODREN 5 NDS KISQALI ORAL TABLET 600 5 PA; QL (63/28); MARQIBO 5 B/D PA; NDS MG/DAY (200 MG X 3) NDS MATULANE 5 NDS KYPROLIS 5 B/D PA; NDS megestrol oral suspension 400 3 B/D PA lapatinib 5 PA; QL (180/30); mg/10 ml (10 ml) NDS megestrol oral suspension 400 3 PA LENVIMA ORAL CAPSULE 10 5 PA; QL (30/30); mg/10 ml (40 mg/ml) MG/DAY (10 MG X 1), 4 MG NDS megestrol oral tablet 3 PA LENVIMA ORAL CAPSULE 12 5 PA; QL (90/30); MEKINIST ORAL TABLET 0.5 5 PA; QL (90/30); MG/DAY (4 MG X 3), 18 MG/ NDS MG NDS DAY (10 MG X 1-4 MG X2), 24 MEKINIST ORAL TABLET 2 5 PA; QL (30/30); MG/DAY(10 MG X 2-4 MG X 1) MG NDS LENVIMA ORAL CAPSULE 14 5 PA; QL (60/30); MEKTOVI 5 PA; LA; QL MG/DAY(10 MG X 1-4 MG X NDS (180/30); NDS 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) melphalan 4 B/D PA letrozole 2 melphalan hcl 5 B/D PA; NDS LEUKERAN 4 mercaptopurine 2 leuprolide subcutaneous kit 5 PA; NDS methotrexate sodium (pf) 4 B/D PA LIBTAYO 5 PA; NDS methotrexate sodium injection 4 B/D PA LONSURF ORAL TABLET 5 PA; QL (100/28); methotrexate sodium oral 2 15-6.14 MG NDS mitomycin intravenous 4 B/D PA LONSURF ORAL TABLET 5 PA; QL (80/28); mitoxantrone 4 B/D PA 20-8.19 MG NDS MONJUVI 5 PA; NDS LORBRENA ORAL TABLET 5 PA; QL (30/30); MVASI 5 B/D PA; NDS 100 MG NDS
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 18 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS mycophenolate mofetil (hcl) 4 B/D PA paclitaxel 4 B/D PA mycophenolate mofetil oral 2 B/D PA PADCEV 5 PA; NDS capsule PEMAZYRE 5 PA; LA; QL (14/21); mycophenolate mofetil oral 5 B/D PA; NDS NDS suspension for reconstitution PEPAXTO 5 PA; NDS mycophenolate mofetil oral 2 B/D PA PERJETA 5 PA; NDS tablet PHESGO 5 PA; NDS mycophenolate sodium 2 B/D PA PIQRAY 5 PA; NDS MYLOTARG 5 PA; NDS POLIVY 5 PA; NDS NERLYNX 5 PA; LA; NDS POMALYST 5 PA; LA; QL (21/28); NEXAVAR 5 PA; LA; QL NDS (120/30); NDS PORTRAZZA 4 B/D PA nilutamide 5 NDS POTELIGEO 5 PA; NDS NINLARO 5 PA; QL (3/28); NDS PROGRAF INTRAVENOUS 4 B/D PA NIPENT 4 B/D PA PROGRAF ORAL GRANULES 4 B/D PA NUBEQA 5 PA; LA; QL IN PACKET (120/30); NDS PURIXAN 5 NDS NULOJIX 5 PA; QL (26/28); NDS QINLOCK 5 PA; LA; NDS octreotide acetate injection 5 PA; NDS RETEVMO 5 PA; LA; NDS solution 1,000 mcg/ml, 500 REVLIMID 5 PA; LA; QL (28/28); mcg/ml NDS octreotide acetate injection 4 PA ROMIDEPSIN INTRAVENOUS 5 PA; NDS solution 100 mcg/ml, 200 mcg/ SOLUTION ml ROZLYTREK ORAL CAPSULE 5 PA; QL (150/30); octreotide acetate injection 3 PA 100 MG NDS solution 50 mcg/ml ROZLYTREK ORAL CAPSULE 5 PA; QL (90/30); ODOMZO 5 PA; LA; QL (30/30); 200 MG NDS NDS RUBRACA 5 PA; LA; QL OGIVRI 5 PA; NDS (120/30); NDS ONCASPAR 5 B/D PA; NDS RUXIENCE 5 PA; NDS ONIVYDE 5 PA; NDS RYBREVANT 5 PA; NDS ONUREG 5 PA; QL (14/28); RYDAPT 5 PA; QL (240/30); NDS NDS OPDIVO 5 PA; QL (80/28); SANDIMMUNE ORAL 4 B/D PA NDS SOLUTION ORGOVYX 5 PA; LA; QL (30/30); SANDOSTATIN LAR 5 PA; NDS NDS DEPOT INTRAMUSCULAR oxaliplatin 4 B/D PA SUSPENSION,EXTENDED REL RECON
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 19 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS SARCLISA 5 PA; NDS THALOMID ORAL CAPSULE 5 PA; QL (28/28); SIGNIFOR 5 PA; NDS 100 MG, 150 MG, 50 MG NDS SIMULECT 5 NDS THALOMID ORAL CAPSULE 5 PA; QL (56/28); 200 MG NDS sirolimus oral solution 5 B/D PA; NDS thiotepa 4 PA sirolimus oral tablet 4 B/D PA TIBSOVO 5 PA; NDS SOLTAMOX 5 NDS toposar 3 B/D PA SOMATULINE DEPOT 5 PA; NDS topotecan intravenous recon 5 B/D PA; NDS SPRYCEL ORAL TABLET 100 5 PA; QL (30/30); soln MG, 140 MG, 50 MG, 80 MG NDS topotecan intravenous solution 4 B/D PA SPRYCEL ORAL TABLET 20 5 PA; QL (60/30); 4 mg/4 ml (1 mg/ml) MG, 70 MG NDS toremifene 5 NDS STIVARGA 5 PA; QL (84/28); NDS TRAZIMERA 5 PA; NDS SUTENT 5 PA; QL (30/30); TREANDA 5 B/D PA; NDS NDS TRELSTAR INTRAMUSCULAR 5 PA; NDS SYNRIBO 5 PA; NDS SUSPENSION FOR RECONSTITUTION TABLOID 4 tretinoin (antineoplastic) 5 NDS TABRECTA 5 PA; NDS TRIPTODUR 5 B/D PA; QL (1/168); tacrolimus oral 2 B/D PA NDS TAFINLAR 5 PA; QL (120/30); TRODELVY 5 PA; NDS NDS TRUSELTIQ ORAL CAPSULE 5 PA; QL (21/28); TAGRISSO 5 PA; LA; QL (30/30); 100 MG/DAY (100 MG X 1) NDS NDS TRUSELTIQ ORAL CAPSULE 5 PA; QL (42/28); TALZENNA ORAL CAPSULE 5 PA; QL (90/30); 125 MG/DAY(100 MG NDS 0.25 MG NDS X1-25MG X1), 50 MG/DAY (25 TALZENNA ORAL CAPSULE 5 PA; QL (30/30); MG X 2) 1 MG NDS TRUSELTIQ ORAL CAPSULE 5 PA; QL (63/28); tamoxifen 2 75 MG/DAY (25 MG X 3) NDS TARGRETIN TOPICAL 5 PA; NDS TRUXIMA 5 PA; NDS TASIGNA ORAL CAPSULE 150 5 PA; QL (112/28); TUKYSA ORAL TABLET 150 5 PA; LA; QL MG, 200 MG NDS MG (120/30); NDS TASIGNA ORAL CAPSULE 50 5 PA; QL (120/30); TUKYSA ORAL TABLET 50 5 PA; LA; QL MG NDS MG (300/30); NDS TAZVERIK 5 PA; LA; NDS TURALIO 5 PA; LA; NDS TECENTRIQ 5 PA; NDS TYKERB 5 PA; LA; QL TEMODAR INTRAVENOUS 5 B/D PA; NDS (180/30); NDS temsirolimus 5 B/D PA; NDS UKONIQ 5 PA; LA; QL (120/30); NDS TEPMETKO 5 PA; LA; QL (60/30); NDS UNITUXIN 5 PA; NDS
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 20 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS valrubicin 4 B/D PA YERVOY 5 PA; NDS VECTIBIX 5 PA; NDS YONDELIS 5 PA; NDS VELCADE 5 PA; NDS ZALTRAP 4 B/D PA VENCLEXTA ORAL TABLET 4 PA; LA; QL (60/30) ZANOSAR 4 B/D PA 10 MG ZEJULA 5 PA; LA; QL (90/30); VENCLEXTA ORAL TABLET 5 PA; LA; QL NDS 100 MG (120/30); NDS ZELBORAF 5 PA; QL (240/30); VENCLEXTA ORAL TABLET 5 PA; LA; QL (30/30); NDS 50 MG NDS ZEPZELCA 5 PA; NDS VENCLEXTA STARTING PACK 5 PA; LA; QL (42/30); ZIRABEV 5 PA; NDS NDS ZOLADEX 4 B/D PA VERZENIO 5 PA; LA; QL (60/30); NDS ZOLINZA 5 PA; QL (120/30); NDS vinblastine 4 B/D PA ZORTRESS ORAL TABLET 1 5 B/D PA; NDS vincasar pfs 4 B/D PA MG vincristine 4 B/D PA ZYDELIG 5 PA; QL (60/30); vinorelbine 4 B/D PA NDS VITRAKVI ORAL CAPSULE 5 PA; LA; QL (60/30); ZYKADIA ORAL TABLET 5 PA; QL (90/30); 100 MG NDS NDS VITRAKVI ORAL CAPSULE 25 5 PA; LA; QL ZYNLONTA 5 PA; NDS MG (180/30); NDS AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH VITRAKVI ORAL SOLUTION 5 PA; LA; QL (300/30); NDS ANTICONVULSANTS VIZIMPRO 5 PA; QL (30/30); APTIOM ORAL TABLET 200 5 QL (180/30); NDS NDS MG VOTRIENT 5 PA; QL (120/30); APTIOM ORAL TABLET 400 5 QL (90/30); NDS NDS MG VYXEOS 5 B/D PA; NDS APTIOM ORAL TABLET 600 5 QL (60/30); NDS XALKORI 5 PA; QL (60/30); MG, 800 MG NDS BANZEL 5 PA; NDS XATMEP 4 PA BRIVIACT INTRAVENOUS 5 NDS XOSPATA 5 PA; LA; NDS BRIVIACT ORAL SOLUTION 5 QL (600/30); NDS XPOVIO 5 PA; LA; NDS BRIVIACT ORAL TABLET 5 QL (60/30); NDS XTANDI ORAL CAPSULE 5 PA; QL (120/30); carbamazepine oral capsule, er 2 NDS multiphase 12 hr XTANDI ORAL TABLET 40 MG 5 PA; QL (120/30); carbamazepine oral suspension 2 NDS 100 mg/5 ml, 200 mg/10 ml XTANDI ORAL TABLET 80 MG 5 PA; QL (60/30); carbamazepine oral tablet 2 NDS
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 21 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS carbamazepine oral tablet 2 FYCOMPA ORAL TABLET 10 4 QL (30/30) extended release 12 hr MG, 12 MG, 8 MG carbamazepine oral tablet, 2 FYCOMPA ORAL TABLET 2 4 QL (60/30) chewable MG, 4 MG, 6 MG CELONTIN ORAL CAPSULE 3 gabapentin oral capsule 100 2 QL (270/30) 300 MG mg, 400 mg clobazam oral suspension 4 PA; QL (480/30) gabapentin oral capsule 300 2 QL (360/30) clobazam oral tablet 4 PA; QL (60/30) mg clonazepam oral tablet 0.5 mg, 2 QL (90/30) gabapentin oral solution 4 QL (2160/30) 1 mg gabapentin oral tablet 600 mg 2 QL (180/30) clonazepam oral tablet 2 mg 2 QL (300/30) gabapentin oral tablet 800 mg 2 QL (120/30) clonazepam oral tablet, 2 QL (90/30) lamotrigine oral tablet 2 disintegrating 0.125 mg, 0.25 lamotrigine oral tablet extended 2 mg, 0.5 mg, 1 mg release 24hr clonazepam oral tablet, 2 QL (300/30) lamotrigine oral tablet, 2 disintegrating 2 mg chewable dispersible DIACOMIT ORAL CAPSULE 4 PA; LA; QL (360/30) lamotrigine oral tablet, 2 250 MG disintegrating DIACOMIT ORAL CAPSULE 4 PA; LA; QL (180/30) levetiracetam in nacl (iso-os) 4 500 MG levetiracetam intravenous 3 DIACOMIT ORAL POWDER IN 4 PA; LA; QL (360/30) PACKET 250 MG levetiracetam oral 2 DIACOMIT ORAL POWDER IN 4 PA; LA; QL (180/30) LYRICA CR ORAL TABLET 3 QL (30/30) PACKET 500 MG EXTENDED RELEASE 24 HR 165 MG, 82.5 MG DIASTAT 4 LYRICA CR ORAL TABLET 3 QL (60/30) DIASTAT ACUDIAL 4 EXTENDED RELEASE 24 HR diazepam rectal 4 330 MG DILANTIN 30 MG 3 NAYZILAM 5 PA; QL (10/30); divalproex 2 NDS EPIDIOLEX 5 PA; LA; NDS oxcarbazepine 2 epitol 2 phenobarbital oral elixir 3 PA; QL (1500/30) ethosuximide 3 phenobarbital oral tablet 3 PA; QL (120/30) felbamate oral suspension 5 NDS phenobarbital sodium injection 3 solution felbamate oral tablet 4 phenytoin oral suspension 2 FINTEPLA 5 PA; LA; NDS phenytoin oral tablet,chewable 2 fosphenytoin 3 phenytoin sodium extended 2 FYCOMPA ORAL 4 QL (720/30) SUSPENSION phenytoin sodium intravenous 3 solution
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 22 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS pregabalin oral capsule 100 2 QL (90/30) vigadrone 5 PA; LA; QL mg, 150 mg, 200 mg, 25 mg, (180/30); NDS 50 mg, 75 mg VIMPAT INTRAVENOUS 5 QL (1200/30); NDS pregabalin oral capsule 225 2 QL (60/30) VIMPAT ORAL SOLUTION 5 QL (1200/30); NDS mg, 300 mg VIMPAT ORAL TABLET 100 5 QL (60/30); NDS pregabalin oral solution 3 QL (900/30) MG, 150 MG, 200 MG pregabalin oral tablet extended 3 QL (30/30) VIMPAT ORAL TABLET 50 MG 4 QL (120/30) release 24 hr 165 mg, 82.5 mg XCOPRI 5 PA; NDS pregabalin oral tablet extended 3 QL (60/30) release 24 hr 330 mg XCOPRI MAINTENANCE 5 PA; NDS PACK primidone 2 XCOPRI TITRATION PACK 4 PA roweepra 2 zonisamide 2 PA rufinamide 5 PA; NDS ANTIPARKINSONISM AGENTS SPRITAM 4 APOKYN 5 PA; LA; QL (60/30); subvenite 3 NDS subvenite starter (blue) kit 3 benztropine injection 4 subvenite starter (green) kit 3 benztropine oral 2 PA subvenite starter (orange) kit 3 bromocriptine 4 SYMPAZAN 5 PA; QL (60/30); carbidopa 4 NDS carbidopa-levodopa oral tablet 2 tiagabine 4 carbidopa-levodopa oral tablet 3 topiramate oral capsule, 2 PA extended release sprinkle carbidopa-levodopa oral tablet, 2 topiramate oral tablet 2 PA disintegrating TROKENDI XR ORAL 4 carbidopa-levodopa- 3 CAPSULE,EXTENDED entacapone RELEASE 24HR 100 MG, 25 MG, 50 MG entacapone 4 TROKENDI XR ORAL 5 NDS KYNMOBI SUBLINGUAL FILM 5 PA; QL (150/30); CAPSULE,EXTENDED 10 MG, 15 MG, 20 MG, 25 MG, NDS RELEASE 24HR 200 MG 30 MG valproate sodium 3 NEUPRO 4 valproic acid 2 pramipexole oral tablet 2 valproic acid (as sodium salt) 2 pramipexole oral tablet 4 extended release 24 hr VALTOCO 5 PA; QL (10/30); NDS rasagiline 3 vigabatrin 5 PA; LA; QL ropinirole oral tablet 2 (180/30); NDS RYTARY 4 ST selegiline hcl 3
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 23 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS tolcapone 5 NDS donepezil oral tablet 5 mg 2 QL (30/30) trihexyphenidyl 2 PA donepezil oral tablet, 2 QL (60/30) MIGRAINE / CLUSTER HEADACHE THERAPY disintegrating 10 mg AIMOVIG AUTOINJECTOR 3 PA; QL (1/30) donepezil oral tablet, 2 QL (30/30) disintegrating 5 mg dihydroergotamine nasal 5 PA; QL (8/28); NDS FIRDAPSE 5 PA; LA; NDS ergotamine-caffeine 3 galantamine oral capsule,ext 4 QL (30/30) migergot 5 NDS rel. pellets 24 hr naratriptan 3 QL (18/28) galantamine oral solution 4 QL (200/30) rizatriptan 3 QL (36/28) galantamine oral tablet 4 QL (60/30) sumatriptan nasal spray,non- 4 QL (18/28) GILENYA ORAL CAPSULE 0.5 5 PA; QL (30/30); aerosol 20 mg/actuation MG NDS sumatriptan nasal spray,non- 4 QL (36/28) memantine oral capsule, 4 PA aerosol 5 mg/actuation sprinkle,er 24hr sumatriptan succinate oral 2 QL (18/28) memantine oral solution 2 PA; QL (300/30) sumatriptan succinate 4 QL (8/28) memantine oral tablet 10 mg 2 PA; QL (60/30) subcutaneous cartridge memantine oral tablet 5 mg 2 PA; QL (90/30) sumatriptan succinate 4 QL (8/28) subcutaneous pen injector memantine oral tablets,dose 3 PA; QL (98/28) pack sumatriptan succinate 4 QL (8/28) subcutaneous solution NAMZARIC 3 PA MISCELLANEOUS NEUROLOGICAL THERAPY NUEDEXTA 5 PA; NDS AUSTEDO ORAL TABLET 12 5 PA; LA; QL OCREVUS 5 B/D PA; NDS MG, 9 MG (120/30); NDS rivastigmine 4 AUSTEDO ORAL TABLET 6 5 PA; LA; QL (60/30); rivastigmine tartrate 4 QL (60/30) MG NDS TECFIDERA ORAL CAPSULE, 5 PA; LA; QL (14/30); COPAXONE SUBCUTANEOUS 5 PA; QL (30/30); DELAYED RELEASE(DR/EC) NDS SYRINGE 20 MG/ML NDS 120 MG COPAXONE SUBCUTANEOUS 5 PA; QL (12/28); TECFIDERA ORAL CAPSULE, 5 PA; LA; QL SYRINGE 40 MG/ML NDS DELAYED RELEASE(DR/EC) (120/180); NDS dalfampridine 3 PA; QL (60/30) 120 MG (14)- 240 MG (46) dimethyl fumarate oral capsule, 5 PA; QL (14/30); TECFIDERA ORAL CAPSULE, 5 PA; LA; QL (60/30); delayed release(dr/ec) 120 mg NDS DELAYED RELEASE(DR/EC) NDS 240 MG dimethyl fumarate oral capsule, 5 PA; QL (120/180); delayed release(dr/ec) 120 mg NDS tetrabenazine oral tablet 12.5 5 PA; QL (240/30); (14)- 240 mg (46) mg NDS dimethyl fumarate oral capsule, 5 PA; QL (60/30); tetrabenazine oral tablet 25 mg 5 PA; QL (120/30); delayed release(dr/ec) 240 mg NDS NDS donepezil oral tablet 10 mg 2 QL (60/30) TYSABRI 5 PA; NDS donepezil oral tablet 23 mg 4
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 24 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS MUSCLE RELAXANTS / ANTISPASMODIC THERAPY fentanyl citrate (pf) injection 4 NDS baclofen oral tablet 10 mg, 5 1 syringe 50 mcg/ml mg fentanyl citrate buccal lozenge 5 PA; QL (120/30); baclofen oral tablet 20 mg 2 on a handle NDS cyclobenzaprine oral tablet 10 3 PA hydrocodone-acetaminophen 3 NDS mg, 5 mg oral solution 10-325 mg/15 ml(15 ml) dantrolene oral 3 hydrocodone-acetaminophen 3 QL (5550/30); NDS methocarbamol oral 2 PA oral solution 7.5-325 mg/15 ml pyridostigmine bromide oral 5 NDS HYDROCODONE- 3 QL (390/30); NDS syrup ACETAMINOPHEN ORAL pyridostigmine bromide oral 3 TABLET 10-300 MG, 7.5-300 tablet 60 mg MG pyridostigmine bromide oral 3 hydrocodone-acetaminophen 3 QL (360/30); NDS tablet extended release oral tablet 10-325 mg, 5-325 regonol 4 mg, 7.5-325 mg tizanidine oral capsule 4 hydrocodone-ibuprofen 3 QL (50/30); NDS tizanidine oral tablet 2 hydromorphone oral liquid 4 QL (2400/30); NDS NARCOTIC ANALGESICS hydromorphone oral tablet 3 QL (180/30); NDS acetaminophen-codeine oral 2 QL (4500/30); NDS INFUMORPH P/F 5 B/D PA; NDS solution 120 mg-12 mg /5 ml methadone injection solution 4 NDS (5 ml), 120-12 mg/5 ml, 300 methadone intensol 4 NDS mg-30 mg /12.5 ml methadone oral concentrate 4 NDS acetaminophen-codeine oral 2 QL (360/30); NDS tablet 300-15 mg, 300-30 mg methadone oral solution 10 4 QL (600/30); NDS mg/5 ml acetaminophen-codeine oral 2 QL (180/30); NDS tablet 300-60 mg methadone oral solution 5 mg/5 4 QL (1200/30); NDS ml buprenorphine hcl injection 4 NDS methadone oral tablet 10 mg 3 QL (120/30); NDS buprenorphine hcl sublingual 4 PA methadone oral tablet 5 mg 3 QL (240/30); NDS BUPRENORPHINE 4 QL (4/28); NDS TRANSDERMAL PATCH morphine (pf) injection solution 4 NDS WEEKLY 10 MCG/HOUR, 15 0.5 mg/ml, 1 mg/ml MCG/HOUR, 20 MCG/HOUR, morphine concentrate oral 3 QL (900/30); NDS 5 MCG/HOUR solution buprenorphine transdermal 4 QL (4/28); NDS MORPHINE INJECTION 4 NDS patch weekly 7.5 mcg/hour SOLUTION 10 MG/ML, 2 MG/ endocet 3 QL (360/30); NDS ML, 4 MG/ML, 5 MG/ML fentanyl 4 QL (10/30); NDS morphine injection solution 8 4 NDS mg/ml fentanyl citrate (pf) injection 4 NDS solution MORPHINE INJECTION 4 NDS SYRINGE 2 MG/ML
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 25 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS morphine injection syringe 4 4 NDS diclofenac sodium oral 2 mg/ml diclofenac sodium topical drops 4 QL (300/28) morphine intravenous solution 4 NDS diclofenac sodium topical gel 3 QL (1000/28) 10 mg/ml 1% MORPHINE INTRAVENOUS 4 NDS diflunisal 2 SOLUTION 4 MG/ML, 8 MG/ ML ec-naproxen 2 MORPHINE INTRAVENOUS 4 NDS etodolac 4 SYRINGE 10 MG/ML, 8 MG/ML flurbiprofen oral tablet 100 mg 2 morphine intravenous syringe 2 4 NDS ibu 1 mg/ml, 4 mg/ml ibuprofen oral suspension 2 morphine oral solution 3 QL (900/30); NDS ibuprofen oral tablet 400 mg, 1 MORPHINE ORAL TABLET 3 QL (180/30); NDS 600 mg, 800 mg morphine oral tablet extended 3 QL (120/30); NDS meloxicam oral tablet 15 mg 1 release meloxicam oral tablet 7.5 mg 1 QL (60/30) oxycodone oral concentrate 3 QL (180/30); NDS nabumetone 2 oxycodone oral solution 3 QL (1200/30); NDS naloxone injection solution 2 oxycodone oral tablet 10 mg, 3 QL (180/30); NDS naloxone injection syringe 1 2 15 mg, 20 mg, 30 mg mg/ml oxycodone oral tablet 5 mg 3 QL (360/30); NDS naltrexone 2 oxycodone-acetaminophen oral 3 QL (360/30); NDS naproxen oral suspension 3 tablet 10-325 mg, 2.5-325 mg, naproxen oral tablet 1 5-325 mg, 7.5-325 mg naproxen oral tablet,delayed 2 oxymorphone oral tablet 3 QL (90/30); NDS release (dr/ec) extended release 12 hr naproxen sodium oral tablet 4 XTAMPZA ER 3 QL (90/30); NDS 275 mg, 550 mg NON-NARCOTIC ANALGESICS NARCAN 3 buprenorphine-naloxone 4 QL (60/30) oxaprozin 4 sublingual film 12-3 mg salsalate 2 buprenorphine-naloxone 4 QL (360/30) sublingual film 2-0.5 mg SUBOXONE SUBLINGUAL 3 QL (60/30) FILM 12-3 MG buprenorphine-naloxone 4 QL (90/30) sublingual film 4-1 mg, 8-2 mg SUBOXONE SUBLINGUAL 3 QL (360/30) FILM 2-0.5 MG buprenorphine-naloxone 2 QL (360/30) sublingual tablet 2-0.5 mg SUBOXONE SUBLINGUAL 3 QL (90/30) FILM 4-1 MG, 8-2 MG buprenorphine-naloxone 2 QL (90/30) sublingual tablet 8-2 mg sulindac 2 butorphanol nasal 3 QL (10/28); NDS tramadol oral tablet 50 mg 2 QL (240/30); NDS celecoxib 2 QL (60/30) tramadol-acetaminophen 3 QL (240/30); NDS diclofenac potassium 2 VIVITROL 5 NDS
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 26 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS ZUBSOLV SUBLINGUAL 3 QL (30/30) bupropion hcl oral tablet 3 QL (60/30) TABLET 0.7-0.18 MG, 1.4-0.36 sustained-release 12 hr MG, 11.4-2.9 MG, 2.9-0.71 MG, buspirone 2 5.7-1.4 MG CAPLYTA 5 PA; QL (30/30); ZUBSOLV SUBLINGUAL 3 QL (60/30) NDS TABLET 8.6-2.1 MG chlorpromazine injection 4 PSYCHOTHERAPEUTIC DRUGS chlorpromazine oral tablet 2 ABILIFY MAINTENA 5 NDS citalopram oral solution 3 ADASUVE 4 citalopram oral tablet 1 alprazolam oral tablet 0.25 mg, 2 QL (120/30) 0.5 mg, 1 mg clomipramine 3 alprazolam oral tablet 2 mg 2 QL (150/30) clonidine hcl oral tablet 4 extended release 12 hr alprazolam oral tablet, 3 QL (90/30) disintegrating 0.25 mg, 0.5 mg, clorazepate dipotassium oral 3 QL (180/30) 1 mg tablet 15 mg alprazolam oral tablet, 3 QL (150/30) clorazepate dipotassium oral 3 QL (90/30) disintegrating 2 mg tablet 3.75 mg amitriptyline 3 clorazepate dipotassium oral 3 QL (360/30) tablet 7.5 mg amoxapine 3 clozapine oral tablet 3 aripiprazole oral solution 3 clozapine oral tablet, 4 aripiprazole oral tablet 2 QL (30/30) disintegrating aripiprazole oral tablet, 5 QL (60/30); NDS desipramine 3 disintegrating desvenlafaxine succinate 4 QL (30/30) ARISTADA 5 NDS dexmethylphenidate oral tablet 3 ARISTADA INITIO 5 NDS dextroamphetamine oral 4 armodafinil 3 PA; QL (30/30) capsule, extended release asenapine maleate 4 QL (60/30) dextroamphetamine oral 4 QL (1800/30) atomoxetine oral capsule 10 4 QL (60/30) solution mg, 18 mg, 25 mg, 40 mg dextroamphetamine oral tablet 4 atomoxetine oral capsule 100 4 QL (30/30) dextroamphetamine- 4 QL (60/30) mg, 60 mg, 80 mg amphetamine oral capsule, bupropion hcl oral tablet 100 3 QL (120/30) extended release 24hr mg dextroamphetamine- 3 QL (180/30) bupropion hcl oral tablet 75 mg 3 QL (180/30) amphetamine oral tablet 10 mg bupropion hcl oral tablet 3 QL (90/30) dextroamphetamine- 3 QL (60/30) extended release 24 hr 150 mg amphetamine oral tablet 12.5 bupropion hcl oral tablet 3 QL (30/30) mg, 30 mg, 7.5 mg extended release 24 hr 300 mg dextroamphetamine- 3 QL (120/30) amphetamine oral tablet 15 mg
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 27 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS dextroamphetamine- 3 QL (90/30) fluoxetine (pmdd) oral tablet 20 3 amphetamine oral tablet 20 mg mg dextroamphetamine- 3 QL (360/30) fluoxetine oral capsule 10 mg 2 QL (30/30) amphetamine oral tablet 5 mg fluoxetine oral capsule 20 mg 2 diazepam injection 2 fluoxetine oral capsule 40 mg 2 QL (60/30) diazepam intensol 2 QL (240/30) fluoxetine oral capsule,delayed 3 QL (4/28) diazepam oral concentrate 2 QL (240/30) release(dr/ec) diazepam oral solution 5 mg/5 2 QL (1200/30) fluoxetine oral solution 2 ml (1 mg/ml) fluoxetine oral tablet 10 mg 3 QL (30/30) diazepam oral tablet 2 QL (120/30) fluoxetine oral tablet 20 mg 3 doxepin oral capsule 3 fluphenazine decanoate 4 doxepin oral concentrate 3 fluphenazine hcl injection 4 doxepin oral tablet 3 QL (30/30) fluphenazine hcl oral 4 DRIZALMA SPRINKLE ORAL 4 QL (60/30) concentrate CAPSULE, DELAYED REL fluphenazine hcl oral elixir 4 SPRINKLE 20 MG, 30 MG, 60 MG fluphenazine hcl oral tablet 2 DRIZALMA SPRINKLE ORAL 4 QL (90/30) fluvoxamine oral tablet 100 mg 2 QL (90/30) CAPSULE, DELAYED REL fluvoxamine oral tablet 25 mg 2 QL (30/30) SPRINKLE 40 MG fluvoxamine oral tablet 50 mg 2 QL (60/30) duloxetine oral capsule,delayed 2 QL (60/30) haloperidol decanoate 4 release(dr/ec) 20 mg, 30 mg, haloperidol lactate injection 4 60 mg haloperidol lactate oral 2 EMSAM 5 QL (30/30); NDS haloperidol oral tablet 0.5 mg, 1 1 escitalopram oxalate oral 3 QL (600/30) mg, 2 mg, 5 mg solution haloperidol oral tablet 10 mg, 2 escitalopram oxalate oral tablet 2 20 mg FANAPT ORAL TABLET 1 MG 4 PA; QL (60/30) HETLIOZ 5 PA; QL (30/30); FANAPT ORAL TABLET 10 5 PA; QL (60/30); NDS MG, 12 MG, 2 MG, 4 MG, 6 NDS imipramine hcl 3 MG, 8 MG INVEGA SUSTENNA 5 NDS FANAPT ORAL TABLETS, 4 PA; QL (8/28) INTRAMUSCULAR SYRINGE DOSE PACK 117 MG/0.75 ML, 156 MG/ML, FETZIMA ORAL CAPSULE, 4 ST; QL (28/28) 234 MG/1.5 ML, 78 MG/0.5 ML EXT REL 24HR DOSE PACK INVEGA SUSTENNA 4 FETZIMA ORAL CAPSULE, 4 ST; QL (30/30) INTRAMUSCULAR SYRINGE EXTENDED RELEASE 24 HR 39 MG/0.25 ML fluoxetine (pmdd) oral tablet 10 3 QL (30/30) INVEGA TRINZA 5 NDS mg LATUDA ORAL TABLET 120 5 QL (30/30); NDS MG, 20 MG, 40 MG, 60 MG
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 28 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS LATUDA ORAL TABLET 80 MG 5 QL (60/30); NDS paliperidone oral tablet 4 PA; QL (60/30) lithium carbonate 2 extended release 24hr 6 mg lorazepam injection 4 paroxetine hcl oral tablet 2 lorazepam intensol 3 QL (150/30) paroxetine hcl oral tablet 3 QL (60/30) extended release 24 hr lorazepam oral concentrate 3 QL (150/30) PAXIL ORAL SUSPENSION 4 ST; QL (900/30) lorazepam oral tablet 0.5 mg, 2 QL (90/30) 1 mg perphenazine 4 lorazepam oral tablet 2 mg 2 QL (150/30) perphenazine-amitriptyline 4 loxapine succinate 2 PERSERIS 5 QL (1/30); NDS maprotiline 4 phenelzine 3 MARPLAN 4 QL (180/30) pimozide 3 methylphenidate hcl oral tablet 3 QL (90/30) protriptyline 4 methylphenidate hcl oral tablet 3 quetiapine oral tablet 100 mg, 2 QL (90/30) extended release 200 mg, 25 mg, 50 mg methylphenidate hcl oral tablet 3 quetiapine oral tablet 300 mg, 2 QL (60/30) extended release 24hr 18 mg, 400 mg 18 mg (bx rating), 27 mg, 27 quetiapine oral tablet extended 3 QL (30/30) mg (bx rating), 36 mg, 36 mg release 24 hr 150 mg, 200 mg (bx rating), 54 mg, 54 mg (bx quetiapine oral tablet extended 3 QL (60/30) rating) release 24 hr 300 mg, 400 mg, mirtazapine oral tablet 2 50 mg mirtazapine oral tablet, 2 QL (30/30) ramelteon 3 QL (30/30) disintegrating REXULTI 5 QL (30/30); NDS molindone 2 RISPERDAL CONSTA 4 nefazodone 3 INTRAMUSCULAR nortriptyline 2 SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML NUPLAZID ORAL CAPSULE 5 PA; QL (30/30); NDS RISPERDAL CONSTA 5 NDS INTRAMUSCULAR NUPLAZID ORAL TABLET 10 5 PA; QL (30/30); SUSPENSION,EXTENDED MG NDS REL RECON 25 MG/2 ML, 37.5 olanzapine intramuscular 4 QL (30/30) MG/2 ML, 50 MG/2 ML olanzapine oral tablet 2 risperidone oral solution 2 olanzapine oral tablet, 3 QL (30/30) risperidone oral tablet 0.25 mg, 2 QL (60/30) disintegrating 0.5 mg, 1 mg, 2 mg, 3 mg olanzapine-fluoxetine 4 risperidone oral tablet 4 mg 2 QL (120/30) oxazepam 2 QL (120/30) risperidone oral tablet, 3 QL (60/30) paliperidone oral tablet 4 PA; QL (30/30) disintegrating 0.25 mg, 0.5 mg, extended release 24hr 1.5 mg, 1 mg, 2 mg, 3 mg 3 mg, 9 mg
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 29 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS
risperidone oral tablet, 3 QL (120/30) CARDIOVASCULAR, HYPERTENSION / LIPIDS disintegrating 4 mg SAPHRIS 5 QL (60/30); NDS ANTIARRHYTHMIC AGENTS SECUADO 4 QL (30/30) amiodarone intravenous 4 B/D PA solution sertraline oral concentrate 4 amiodarone oral 2 sertraline oral tablet 1 dofetilide 3 temazepam 4 QL (60/365) flecainide 2 thioridazine 3 lidocaine (pf) intravenous 4 thiothixene 4 syringe tranylcypromine 4 mexiletine 2 trazodone 2 pacerone oral tablet 100 mg, 2 trifluoperazine 3 200 mg, 400 mg trimipramine 4 propafenone oral capsule, 4 TRINTELLIX 4 ST; QL (30/30) extended release 12 hr venlafaxine oral capsule, 2 propafenone oral tablet 2 extended release 24hr quinidine sulfate oral tablet 2 venlafaxine oral tablet 2 QL (90/30) sorine 2 VERSACLOZ 5 NDS sotalol af 2 VIIBRYD ORAL TABLET 4 ST; QL (30/30) sotalol oral 2 VIIBRYD ORAL TABLETS, 4 ST; QL (30/30) SOTYLIZE 4 DOSE PACK 10 MG (7)- 20 ANTIHYPERTENSIVE THERAPY MG (23) acebutolol 2 VRAYLAR ORAL CAPSULE 5 PA; QL (30/30); NDS aliskiren 4 VRAYLAR ORAL CAPSULE, 4 PA; QL (7/30) amiloride 2 DOSE PACK amiloride-hydrochlorothiazide 2 XYREM 5 PA; LA; QL amlodipine 1 (540/30); NDS amlodipine-benazepril 1 zaleplon oral capsule 10 mg 3 QL (60/30) amlodipine-valsartan 1 zaleplon oral capsule 5 mg 3 QL (30/30) amlodipine-valsartan-hcthiazid 1 ziprasidone hcl 3 QL (60/30) atenolol 1 ziprasidone mesylate 4 QL (6/30) atenolol-chlorthalidone 1 zolpidem oral tablet 3 QL (30/30) benazepril 1 ZYPREXA RELPREVV 5 PA; NDS benazepril-hydrochlorothiazide 1 betaxolol oral 2 BIDIL 3 bisoprolol fumarate 2
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 30 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS bisoprolol-hydrochlorothiazide 1 EDARBYCLOR 4 bumetanide injection 4 enalapril maleate 1 bumetanide oral 3 enalapril-hydrochlorothiazide 1 BYSTOLIC 3 ethacrynate sodium 4 candesartan oral tablet 16 mg, 1 QL (60/30) felodipine 2 4 mg, 8 mg fosinopril 1 candesartan oral tablet 32 mg 1 QL (30/30) fosinopril-hydrochlorothiazide 1 candesartan-hydrochlorothiazid 1 furosemide injection 4 cartia xt 2 furosemide oral solution 10 mg/ 2 carvedilol 1 ml, 40 mg/5 ml (8 mg/ml) carvedilol phosphate 3 furosemide oral tablet 1 chlorothiazide sodium 4 hydralazine injection 4 chlorthalidone oral tablet 25 2 hydralazine oral 2 mg, 50 mg hydrochlorothiazide 1 clonidine 4 QL (4/28) indapamide 1 clonidine hcl oral tablet 0.1 mg, 1 irbesartan 1 QL (30/30) 0.2 mg irbesartan-hydrochlorothiazide 1 QL (30/30) clonidine hcl oral tablet 0.3 mg 2 isradipine 3 DEMSER 5 PA; NDS labetalol oral 2 diltiazem hcl intravenous 4 lisinopril 1 diltiazem hcl oral capsule,ext. 2 rel 24h degradable lisinopril-hydrochlorothiazide 1 diltiazem hcl oral capsule, 2 losartan 1 QL (60/30) extended release 12 hr losartan-hydrochlorothiazide 1 QL (30/30) diltiazem hcl oral capsule, 2 oral tablet 100-12.5 mg, 100-25 extended release 24 hr 120 mg mg, 180 mg, 240 mg, 300 mg, losartan-hydrochlorothiazide 1 QL (60/30) 420 mg oral tablet 50-12.5 mg diltiazem hcl oral capsule, 2 matzim la 2 extended release 24hr 120 mg, methyldopa 4 180 mg, 240 mg, 300 mg metolazone 2 diltiazem hcl oral tablet 2 metoprolol succinate 1 diltiazem hcl oral tablet 2 metoprolol ta-hydrochlorothiaz 2 extended release 24 hr metoprolol tartrate oral 1 dilt-xr 2 metyrosine 5 PA; NDS doxazosin oral tablet 1 mg, 2 2 QL (30/30) mg, 4 mg minoxidil oral 2 doxazosin oral tablet 8 mg 2 QL (60/30) moexipril 1 EDARBI 4 nadolol 3
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 31 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS nadolol-bendroflumethiazide 3 torsemide oral 2 oral tablet 80-5 mg trandolapril 1 nicardipine intravenous solution 4 triamterene-hydrochlorothiazid 1 nicardipine oral 2 oral capsule 37.5-25 mg nifedipine oral tablet extended 2 triamterene-hydrochlorothiazid 1 release oral tablet nifedipine oral tablet extended 2 UPTRAVI 5 PA; LA; NDS release 24hr valsartan oral tablet 160 mg, 40 1 QL (60/30) nimodipine 4 mg, 80 mg nisoldipine 4 valsartan oral tablet 320 mg 1 QL (30/30) olmesartan 1 valsartan-hydrochlorothiazide 1 QL (30/30) olmesartan-hydrochlorothiazide 1 verapamil intravenous solution 4 perindopril erbumine 1 verapamil oral capsule, 24 hr er 2 phenoxybenzamine 5 NDS pellet ct pindolol 1 verapamil oral capsule,ext rel. 2 pellets 24 hr 120 mg, 180 mg, prazosin 3 240 mg propranolol oral capsule, 3 VERAPAMIL ORAL CAPSULE, 3 extended release 24 hr EXT REL. PELLETS 24 HR propranolol oral solution 2 360 MG propranolol oral tablet 1 verapamil oral tablet 1 propranolol-hydrochlorothiazid 2 verapamil oral tablet extended 2 quinapril 1 release quinapril-hydrochlorothiazide 1 COAGULATION THERAPY ramipril 1 aminocaproic acid oral 4 spironolactone 1 aspirin-dipyridamole 4 spironolacton-hydrochlorothiaz 2 BRILINTA 3 QL (60/30) taztia xt oral capsule,extended 2 cilostazol 2 release 24 hr 120 mg, 180 mg, clopidogrel oral tablet 300 mg 1 240 mg, 300 mg clopidogrel oral tablet 75 mg 1 QL (30/30) TEKTURNA HCT 4 dipyridamole oral 3 telmisartan 1 ELIQUIS 3 telmisartan-amlodipine 1 ELIQUIS DVT-PE TREAT 30D 3 telmisartan-hydrochlorothiazid 1 START terazosin oral capsule 1 mg, 2 1 QL (30/30) enoxaparin 3 mg, 5 mg fondaparinux subcutaneous 5 NDS terazosin oral capsule 10 mg 1 QL (60/30) syringe 10 mg/0.8 ml, 5 mg/0.4 tiadylt er 2 ml, 7.5 mg/0.6 ml timolol maleate oral 4
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 32 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS fondaparinux subcutaneous 4 cholestyramine light 3 syringe 2.5 mg/0.5 ml colesevelam 3 heparin (porcine) in 5% dex 4 colestipol 3 intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), ezetimibe 2 QL (30/30) 25,000 unit/250 ml(100 unit/ml), ezetimibe-simvastatin 4 QL (30/30) 25,000 unit/500 ml (50 unit/ml) fenofibrate micronized oral 3 heparin (porcine) in nacl (pf) 4 capsule 134 mg, 200 mg, 67 heparin (porcine) injection 3 mg solution fenofibrate nanocrystallized oral 3 heparin(porcine) in 0.45% nacl 4 tablet 145 mg, 48 mg intravenous parenteral solution fenofibrate oral tablet 160 mg, 2 25,000 unit/250 ml, 25,000 54 mg unit/500 ml fenofibric acid (choline) 4 heparin, porcine (pf) injection 4 gemfibrozil 1 syringe 5,000 unit/0.5 ml LIVALO 3 QL (30/30) HEPARIN, PORCINE (PF) 4 lovastatin oral tablet 10 mg 1 QL (30/30) INJECTION SYRINGE 5,000 UNIT/ML lovastatin oral tablet 20 mg, 40 1 QL (60/30) mg jantoven 1 niacin oral tablet 500 mg 2 pentoxifylline 2 niacin oral tablet extended 2 phytonadione (vitamin k1) oral 2 QL (3/30) release 24 hr tablet 5 mg niacor 2 PRADAXA 4 omega-3 acid ethyl esters 4 PRASUGREL 3 pravastatin 1 QL (30/30) PROMACTA ORAL POWDER 5 PA; LA; QL IN PACKET 12.5 MG (360/30); NDS prevalite 3 PROMACTA ORAL POWDER 5 PA; LA; QL REPATHA 3 PA; QL (3/28) IN PACKET 25 MG (180/30); NDS REPATHA PUSHTRONEX 3 PA; QL (3.5/28) PROMACTA ORAL TABLET 5 PA; LA; QL (30/30); REPATHA SURECLICK 3 PA; QL (3/28) 12.5 MG, 25 MG, 50 MG NDS rosuvastatin 1 QL (30/30) PROMACTA ORAL TABLET 75 5 PA; LA; QL (60/30); simvastatin oral tablet 1 QL (30/30) MG NDS VASCEPA 3 warfarin 1 MISCELLANEOUS CARDIOVASCULAR AGENTS XARELTO 3 CORLANOR ORAL TABLET 4 PA XARELTO DVT-PE TREAT 30D 3 START digitek 2 LIPID/CHOLESTEROL LOWERING AGENTS digox 2 atorvastatin 1 QL (30/30) digoxin oral solution 3 cholestyramine (with sugar) 3 digoxin oral tablet 2
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 33 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS ENTRESTO 3 QL (60/30) MISCELLANEOUS DERMATOLOGICALS LANOXIN ORAL TABLET 62.5 4 ammonium lactate 3 MCG (0.0625 MG) DUPIXENT PEN 5 PA; NDS ranolazine 4 QL (60/30) SUBCUTANEOUS PEN VYNDAMAX 5 PA; NDS INJECTOR 200 MG/1.14 ML VYNDAQEL 5 PA; NDS DUPIXENT PEN 5 PA; QL (8/28); NDS SUBCUTANEOUS PEN NITRATES INJECTOR 300 MG/2 ML isosorbide dinitrate oral tablet 3 DUPIXENT SYRINGE 5 PA; QL (4.56/28); isosorbide mononitrate 2 SUBCUTANEOUS SYRINGE NDS minitran 2 200 MG/1.14 ML nitroglycerin intravenous 4 B/D PA DUPIXENT SYRINGE 5 PA; QL (8/28); NDS SUBCUTANEOUS SYRINGE nitroglycerin sublingual 2 300 MG/2 ML nitroglycerin transdermal patch 2 FLUOROURACIL TOPICAL 5 NDS 24 hour CREAM 0.5% nitroglycerin translingual 4 fluorouracil topical cream 5% 3 DERMATOLOGICALS/TOPICAL THERAPY fluorouracil topical solution 2 ANTIPSORIATIC / ANTISEBORRHEIC glydo 3 QL (60/30) acitretin 4 PA IMIQUIMOD TOPICAL CREAM 5 NDS IN METERED-DOSE PUMP calcipotriene scalp 3 QL (120/30) imiquimod topical cream in 5 NDS calcipotriene topical cream 4 QL (120/30) packet 3.75% calcipotriene topical ointment 4 QL (120/30) imiquimod topical cream in 3 calcitriol topical 4 packet 5% selenium sulfide topical lotion 2 lidocaine (pf) injection solution 4 SKYRIZI SUBCUTANEOUS 5 PA; QL (1/28); NDS lidocaine hcl injection solution 4 PEN INJECTOR lidocaine hcl laryngotracheal 2 SKYRIZI SUBCUTANEOUS 5 PA; QL (1/28); NDS lidocaine hcl mucous 3 QL (60/30) SYRINGE 150 MG/ML membrane jelly SKYRIZI SUBCUTANEOUS 5 PA; QL (2/28); NDS lidocaine hcl mucous 3 QL (60/30) SYRINGE KIT membrane jelly in applicator STELARA SUBCUTANEOUS 5 PA; QL (0.5/28); lidocaine hcl mucous 1 SOLUTION NDS membrane solution 2% STELARA SUBCUTANEOUS 5 PA; QL (0.5/28); lidocaine hcl mucous 2 SYRINGE 45 MG/0.5 ML NDS membrane solution 4% (40 mg/ STELARA SUBCUTANEOUS 5 PA; QL (1/28); NDS ml) SYRINGE 90 MG/ML lidocaine topical adhesive 4 PA; QL (90/30) TALTZ SYRINGE 5 PA; QL (4/28); NDS patch,medicated 5% lidocaine topical ointment 4 QL (50/30)
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 34 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS lidocaine viscous 1 isotretinoin oral capsule 10 mg, 4 lidocaine-prilocaine topical 4 QL (30/30) 20 mg, 30 mg, 40 mg cream metronidazole topical 3 methoxsalen 4 myorisan 4 PANRETIN 5 NDS rosadan topical cream 3 PICATO 5 NDS rosadan topical gel 3 pimecrolimus 4 QL (100/30) tazarotene topical cream 4 PA podofilox 2 TAZORAC 4 PA REGRANEX 5 PA; NDS tretinoin microspheres 4 PA SANTYL 4 tretinoin topical cream 0.025%, 4 PA silver sulfadiazine 3 0.05%, 0.1% ssd 3 tretinoin topical topical gel 3 PA 0.01% tacrolimus topical 3 PA; QL (100/30) tretinoin topical topical gel 4 PA VALCHLOR 5 PA; NDS 0.025%, 0.05% ZTLIDO 4 PA; QL (90/30) zenatane 4 THERAPY FOR ACNE TOPICAL ANTIBACTERIALS amnesteem 4 gentamicin topical 3 avita 4 PA mupirocin 2 QL (44/30) claravis 4 mupirocin calcium 4 QL (30/30) clindacin etz topical swab 2 QL (60/30) sulfacetamide sodium (acne) 3 clindacin p 2 QL (60/30) TOPICAL ANTIFUNGALS clindamycin phosphate topical 3 QL (120/30) ciclodan topical solution 3 gel ciclopirox topical cream 3 QL (90/28) CLINDAMYCIN PHOSPHATE 3 TOPICAL GEL, ONCE DAILY ciclopirox topical shampoo 3 QL (120/28) clindamycin phosphate topical 4 QL (120/30) ciclopirox topical solution 3 lotion ciclopirox topical suspension 3 QL (60/28) clindamycin phosphate topical 3 QL (120/30) clotrimazole topical cream 2 QL (45/28) solution clotrimazole topical solution 2 QL (30/28) clindamycin phosphate topical 2 QL (60/30) clotrimazole-betamethasone 2 QL (45/28) swab topical cream ery pads 3 clotrimazole-betamethasone 2 QL (60/28) ERYTHROMYCIN WITH 4 topical lotion ETHANOL TOPICAL GEL econazole 3 QL (85/28) erythromycin with ethanol 2 ketoconazole topical cream 2 QL (60/28) topical solution ketoconazole topical shampoo 2 QL (120/28) erythromycin-benzoyl peroxide 4 naftifine 3 QL (60/28)
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 35 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS NAFTIN TOPICAL GEL 3 QL (60/28) desonide topical ointment 3 nyamyc 2 desoximetasone topical cream 4 nystatin topical cream 2 QL (30/28) desoximetasone topical gel 4 nystatin topical ointment 2 QL (30/28) desoximetasone topical 4 nystatin topical powder 2 ointment nystatin-triamcinolone 4 QL (60/28) fluocinolone and shower cap 3 nystop 2 fluocinolone topical cream 2 TOPICAL ANTIVIRALS fluocinolone topical oil 3 acyclovir topical ointment 4 QL (30/30) fluocinolone topical ointment 2 DENAVIR 5 NDS fluocinolone topical solution 2 TOPICAL CORTICOSTEROIDS fluocinonide topical cream 2 0.05% ala-cort topical cream 1% 1 fluocinonide topical cream 0.1% 4 QL (120/30) alclometasone 2 fluocinonide topical gel 2 QL (120/30) betamethasone dipropionate 3 fluocinonide topical ointment 3 QL (120/30) betamethasone valerate topical 2 cream fluocinonide topical solution 3 QL (120/30) betamethasone valerate topical 3 fluticasone propionate topical 2 foam cream betamethasone valerate topical 2 fluticasone propionate topical 2 lotion ointment betamethasone valerate topical 2 halobetasol propionate topical 3 ointment cream betamethasone, augmented 2 halobetasol propionate topical 3 ointment clobetasol scalp 2 QL (100/28) hydrocortisone butyrate topical 4 QL (120/30) clobetasol topical cream 2 QL (120/28) cream clobetasol topical foam 4 QL (100/28) hydrocortisone butyrate topical 3 clobetasol topical gel 2 QL (120/28) ointment clobetasol topical ointment 2 QL (120/28) hydrocortisone butyrate topical 3 QL (120/30) clobetasol topical shampoo 4 QL (236/28) solution clobetasol-emollient topical 2 QL (120/28) hydrocortisone butyr-emollient 4 QL (120/30) cream hydrocortisone topical cream 1 clobetasol-emollient topical 4 QL (100/28) 1%, 2.5% foam hydrocortisone topical lotion 2 CLOCORTOLONE PIVALATE 4 2.5% clodan 4 QL (236/28) hydrocortisone topical ointment 2 1%, 2.5% desonide topical cream 3 hydrocortisone valerate 3 desonide topical lotion 3 mometasone topical 2
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 36 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS prednicarbate topical ointment 2 deferasirox oral granules in 5 PA; NDS triamcinolone acetonide topical 2 packet cream 0.025%, 0.5% deferasirox oral tablet 5 PA; NDS triamcinolone acetonide topical 1 deferiprone 5 PA; NDS cream 0.1% dextrose 10% and 0.2% nacl 4 triamcinolone acetonide topical 2 DEXTROSE 10% IN WATER 4 lotion (D10W) triamcinolone acetonide topical 2 dextrose 25% in water (d25w) 4 ointment dextrose 30% in water (d30w) 4 triderm topical cream 0.1% 1 DEXTROSE 5% IN WATER 4 tritocin 2 (D5W) INTRAVENOUS TOPICAL SCABICIDES / PEDICULICIDES PARENTERAL SOLUTION lindane topical shampoo 3 dextrose 5% in water (d5w) 4 malathion 4 intravenous piggyback permethrin 2 dextrose 5%-lactated ringers 4 dextrose 5%-0.2% sod chloride 4 DIAGNOSTICS / MISCELLANEOUS AGENTS dextrose 5%-0.3% sod.chloride 4 IRRIGATING SOLUTIONS dextrose 50% in water (d50w) 4 lactated ringers irrigation 4 dextrose 70% in water (d70w) 4 neomycin-polymyxin b gu 4 disulfiram 2 ringer's irrigation 4 droxidopa oral capsule 100 mg 4 PA; QL (90/30) tis-u-sol pentalyte 4 droxidopa oral capsule 200 mg, 4 PA; QL (180/30) MISCELLANEOUS AGENTS 300 mg acamprosate 2 FERRIPROX 5 PA; NDS anagrelide 2 FERRIPROX (2 TIMES A DAY) 5 PA; NDS ARALAST NP 5 LA; NDS INCRELEX 4 PA; LA AURYXIA 5 PA; QL (360/30); levocarnitine (with sugar) 3 NDS levocarnitine oral solution 100 3 CARBAGLU 5 PA; LA; NDS mg/ml CARNITOR INTRAVENOUS 5 B/D PA; NDS levocarnitine oral tablet 3 CHEMET 4 PA LOKELMA 3 CLINIMIX 4.25%/D5W SULFIT 4 B/D PA midodrine 3 FREE nitisinone 5 NDS d10%-0.45% sodium chloride 4 NORTHERA ORAL CAPSULE 5 PA; QL (90/30); d2.5%-0.45% sodium chloride 4 100 MG NDS d5% and 0.9% sodium chloride 4 NORTHERA ORAL CAPSULE 5 PA; QL (180/30); d5%-0.45% sodium chloride 4 200 MG, 300 MG NDS pilocarpine hcl oral 3
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 37 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS PROLASTIN-C 5 PA; LA; NDS fluoride (sodium) dental paste 4 riluzole 3 ipratropium bromide nasal 2 QL (30/30) risedronate oral tablet 30 mg 3 QL (30/30) oralone 3 SEVELAMER CARBONATE 5 NDS paroex oral rinse 1 ORAL POWDER IN PACKET sodium fluoride 5000 dry mouth 4 SEVELAMER CARBONATE 4 sodium fluoride-pot nitrate 4 ORAL TABLET triamcinolone acetonide dental 3 sodium chloride 0.9% 4 intravenous MISCELLANEOUS OTIC PREPARATIONS sodium chloride irrigation 4 acetic acid otic (ear) 2 sodium phenylbutyrate 5 PA; NDS flac otic oil 4 sodium polystyrene sulfonate 3 fluocinolone acetonide oil 4 oral powder hydrocortisone-acetic acid 2 sps (with sorbitol) 3 ofloxacin otic (ear) 2 trientine 5 PA; QL (240/30); OTIC STEROID / ANTIBIOTIC NDS CIPRO HC 3 VELTASSA 3 CIPRODEX 3 water for irrigation, sterile 4 ciprofloxacin-dexamethasone 3 XIAFLEX 5 PA; NDS CORTISPORIN-TC 4 ZEMAIRA 5 LA; NDS neomycin-polymyxin-hc otic 3 zoledronic acid-mannitol- 4 B/D PA (ear) water intravenous piggyback 5 mg/100 ml ENDOCRINE/DIABETES SMOKING DETERRENTS ADRENAL HORMONES bupropion hcl (smoking deter) 3 QL (60/30) DEPO-MEDROL 4 CHANTIX 4 dexamethasone intensol 4 CHANTIX CONTINUING 4 dexamethasone oral elixir 2 MONTH BOX dexamethasone oral solution 2 CHANTIX STARTING MONTH 4 dexamethasone oral tablet 0.5 1 BOX mg, 0.75 mg, 4 mg NICOTROL 4 dexamethasone oral tablet 1 2 NICOTROL NS 4 mg, 1.5 mg, 2 mg, 6 mg VARENICLINE 4 dexamethasone sodium phos 4 (pf) injection solution EAR, NOSE / THROAT MEDICATIONS dexamethasone sodium 4 MISCELLANEOUS AGENTS phosphate injection solution azelastine nasal 3 QL (60/30) fludrocortisone 2 chlorhexidine gluconate 1 hydrocortisone oral 3 mucous membrane MEDROL ORAL TABLET 2 MG 3
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 38 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS methylprednisolone 2 FARXIGA ORAL TABLET 10 3 QL (30/30) methylprednisolone acetate 4 MG methylprednisolone sodium 4 FARXIGA ORAL TABLET 5 MG 3 QL (60/30) succ injection recon soln 125 GAUZE PADS 2 X 2 2 mg, 40 mg glimepiride oral tablet 1 mg 1 QL (240/30) methylprednisolone sodium 4 glimepiride oral tablet 2 mg 1 QL (120/30) succ intravenous glimepiride oral tablet 4 mg 1 QL (60/30) prednisolone oral solution 3 glipizide oral tablet 10 mg 1 QL (120/30) prednisolone sodium 3 phosphate oral solution 15 glipizide oral tablet 5 mg 1 QL (240/30) mg/5 ml (3 mg/ml), 15 mg/5 ml glipizide oral tablet extended 1 QL (60/30) (5 ml), 25 mg/5 ml (5 mg/ml), 5 release 24hr 10 mg mg base/5 ml (6.7 mg/5 ml) glipizide oral tablet extended 1 QL (240/30) prednisone intensol 4 release 24hr 2.5 mg prednisone oral solution 2 glipizide oral tablet extended 1 QL (120/30) prednisone oral tablet 1 mg, 10 1 B/D PA release 24hr 5 mg mg, 2.5 mg, 20 mg, 5 mg glipizide-metformin oral tablet 1 QL (240/30) prednisone oral tablet 50 mg 2 B/D PA 2.5-250 mg prednisone oral tablets,dose 1 glipizide-metformin oral tablet 1 QL (120/30) pack 2.5-500 mg, 5-500 mg SOLU-CORTEF ACT-O-VIAL 4 GLUCAGEN HYPOKIT 3 (PF) GLUCAGON (HCL) 3 triamcinolone acetonide 2 EMERGENCY KIT injection suspension 40 mg/ml GLUCAGON EMERGENCY 3 ANTITHYROID AGENTS KIT (HUMAN) methimazole oral tablet 10 mg, 2 GLYXAMBI 3 QL (30/30) 5 mg GVOKE HYPOPEN 1-PACK 3 propylthiouracil 3 GVOKE HYPOPEN 2-PACK 3 DIABETES THERAPY GVOKE PFS 1-PACK 3 acarbose oral tablet 100 mg 2 QL (90/30) SYRINGE acarbose oral tablet 25 mg 2 QL (360/30) GVOKE PFS 2-PACK 3 SYRINGE acarbose oral tablet 50 mg 2 QL (180/30) HUMALOG JUNIOR KWIKPEN 3 ALCOHOL PADS 2 U-100 BAQSIMI 3 HUMALOG KWIKPEN 3 BD PEN NEEDLE 2 QL(200/30) INSULIN BYDUREON BCISE 4 QL (4/28) HUMALOG MIX 50-50 INSULN 3 CYCLOSET 4 QL (180/30) U-100 diazoxide 4 HUMALOG MIX 50-50 3 KWIKPEN
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 39 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS HUMALOG MIX 75-25 3 JENTADUETO XR ORAL 3 QL (30/30) KWIKPEN TABLET, IR - ER, BIPHASIC HUMALOG MIX 75-25(U-100) 3 24HR 5-1,000 MG INSULN LANTUS SOLOSTAR U-100 3 HUMALOG U-100 INSULIN 3 INSULIN HUMULIN 70/30 U-100 3 LANTUS U-100 INSULIN 3 INSULIN LEVEMIR FLEXTOUCH U-100 3 HUMULIN 70/30 U-100 3 INSULN KWIKPEN LEVEMIR U-100 INSULIN 3 HUMULIN N NPH INSULIN 3 LYUMJEV KWIKPEN U-100 3 KWIKPEN INSULIN HUMULIN N NPH U-100 3 LYUMJEV KWIKPEN U-200 3 INSULIN INSULIN HUMULIN R REGULAR U-100 3 LYUMJEV U-100 INSULIN 3 INSULN METFORMIN ORAL 3 QL (750/30) HUMULIN R U-500 (CONC) 5 B/D PA; NDS SOLUTION INSULIN metformin oral tablet 1,000 mg 1 QL (75/30) HUMULIN R U-500 (CONC) 5 NDS metformin oral tablet 500 mg 1 QL (150/30) KWIKPEN metformin oral tablet 850 mg 1 QL (90/30) INSULIN PEN NEEDLE 2 QL (200/30) metformin oral tablet extended 1 QL (120/30) INSULIN SYRINGE (DISP) 2 QL (200/30) release 24 hr 500 mg (generic U-100 0.3 ML, 1 ML, 1/2 ML for glucophage xr) INVOKAMET 4 QL (60/30) metformin oral tablet extended 1 QL (60/30) INVOKAMET XR 4 QL (60/30) release 24 hr 750 mg (generic INVOKANA 4 QL (30/30) for glucophage xr) JANUMET 3 QL (60/30) metformin oral tablet extended 1 QL (60/30) release 24hr 1,000 mg JANUMET XR ORAL TABLET, 3 QL (30/30) ER MULTIPHASE 24 HR 100- metformin oral tablet extended 1 QL (150/30) 1,000 MG release 24hr 500 mg JANUMET XR ORAL TABLET, 3 QL (60/30) miglitol oral tablet 100 mg 4 QL (90/30) ER MULTIPHASE 24 HR miglitol oral tablet 25 mg 4 QL (360/30) 50-1,000 MG, 50-500 MG miglitol oral tablet 50 mg 4 QL (180/30) JANUVIA 3 QL (30/30) nateglinide oral tablet 120 mg 1 QL (90/30) JARDIANCE 3 QL (30/30) nateglinide oral tablet 60 mg 1 QL (180/30) JENTADUETO 3 QL (60/30) NEEDLES, INSULIN 2 QL (200/30) JENTADUETO XR ORAL 3 QL (60/30) DISP.,SAFETY TABLET, IR - ER, BIPHASIC NOVOFINE PEN NEEDLE 2 QL(200/30) 24HR 2.5-1,000 MG NOVOTWIST PEN NEEDLE 2 QL(200/30) OMNIPOD 5 PACK 3 QL(30/30)
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 40 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS OMNIPOD DASH 5 PACK 3 QL(30/30) TRIJARDY XR ORAL TABLET, 3 QL (30/30) OMNIPOD STARTER KIT 3 QL(1/365) IR - ER, BIPHASIC 24HR 10-5- 1,000 MG, 25-5-1,000 MG OZEMPIC SUBCUTANEOUS 3 QL (1.5/28) PEN INJECTOR 0.25 MG OR TRIJARDY XR ORAL TABLET, 3 QL (60/30) 0.5 MG(2 MG/1.5 ML) IR - ER, BIPHASIC 24HR 12.5- 2.5-1,000 MG, 5-2.5-1,000 MG OZEMPIC SUBCUTANEOUS 3 QL (3/28) PEN INJECTOR 1 MG/DOSE TRULICITY 3 QL (2/28) (2 MG/1.5 ML), 1 MG/DOSE (4 V-GO 20 3 MG/3 ML) V-GO 30 3 pioglitazone 1 QL (30/30) V-GO 40 3 pioglitazone-metformin 1 QL (90/30) VICTOZA 2-PAK 3 QL (9/30) PROGLYCEM 5 NDS VICTOZA 3-PAK 3 QL (9/30) repaglinide oral tablet 0.5 mg 1 QL (960/30) XIGDUO XR ORAL TABLET, 3 QL (30/30) repaglinide oral tablet 1 mg 1 QL (480/30) IR - ER, BIPHASIC 24HR repaglinide oral tablet 2 mg 1 QL (240/30) 10-1,000 MG, 10-500 MG RIOMET 3 QL (765/30) XIGDUO XR ORAL TABLET, 3 QL (60/30) IR - ER, BIPHASIC 24HR 2.5- RIOMET ER 3 QL (600/30) 1,000 MG, 5-1,000 MG, 5-500 RYBELSUS 3 QL (30/30) MG SOLIQUA 100/33 3 QL (15/30) XULTOPHY 100/3.6 3 QL (15/30) SYMLINPEN 120 5 PA; QL (10.8/30); MISCELLANEOUS HORMONES NDS ALDURAZYME 5 PA; NDS SYMLINPEN 60 5 PA; QL (6/30); NDS cabergoline 3 SYNJARDY 3 QL (60/30) calcitonin (salmon) injection 5 NDS SYNJARDY XR ORAL TABLET, 3 QL (60/30) calcitonin (salmon) nasal 3 IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, calcitriol intravenous solution 1 4 5-1,000 MG mcg/ml SYNJARDY XR ORAL TABLET, 3 QL (30/30) calcitriol oral 3 IR - ER, BIPHASIC 24HR CEREZYME INTRAVENOUS 5 PA; NDS 25-1,000 MG RECON SOLN 400 UNIT TECHLITE PEN NEEDLE 2 QL(200/30) CHORIONIC 4 PA TOUJEO MAX U-300 3 GONADOTROPIN, HUMAN SOLOSTAR INTRAMUSCULAR TOUJEO SOLOSTAR U-300 3 cinacalcet oral tablet 30 mg, 60 4 QL (60/30) INSULIN mg TRADJENTA 3 QL (30/30) cinacalcet oral tablet 90 mg 4 QL (120/30) TRESIBA FLEXTOUCH U-100 3 danazol 4 TRESIBA FLEXTOUCH U-200 3 desmopressin injection 5 NDS TRESIBA U-100 INSULIN 3
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 41 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS desmopressin nasal spray with 4 testosterone transdermal gel in 4 PA; QL (300/30) pump metered-dose pump 12.5 mg/ desmopressin nasal spray,non- 4 1.25 gram (1%) aerosol testosterone transdermal gel 4 PA; QL (300/30) desmopressin oral 3 in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram) doxercalciferol 4 tolvaptan oral tablet 30 mg 5 PA; QL (60/30); ELAPRASE 5 PA; NDS NDS FABRAZYME 5 NDS zoledronic acid intravenous 4 B/D PA KORLYM 5 PA; QL (120/30); solution NDS zoledronic acid-mannitol- 4 B/D PA KUVAN 5 PA; NDS water intravenous piggyback 4 LUMIZYME 5 PA; NDS mg/100 ml MIACALCIN INJECTION 5 NDS ZOLEDRONIC AC-MANNITOL- 4 B/D PA 0.9NACL miglustat 5 LA; NDS THYROID HORMONES NAGLAZYME 5 PA; NDS EUTHYROX 3 NATPARA 5 PA; LA; QL (2/28); NDS LEVO-T 3 oxandrolone oral tablet 10 mg 4 PA; QL (60/30) levothyroxine oral tablet 1 oxandrolone oral tablet 2.5 mg 3 PA; QL (120/30) levoxyl oral tablet 100 mcg, 112 3 mcg, 175 mcg pamidronate intravenous 4 solution LEVOXYL ORAL TABLET 125 3 MCG, 137 MCG, 150 MCG, paricalcitol oral 4 200 MCG, 25 MCG, 50 MCG, SAMSCA ORAL TABLET 15 5 PA; QL (30/30); 75 MCG, 88 MCG MG NDS liothyronine oral 2 SAMSCA ORAL TABLET 30 5 PA; QL (60/30); SYNTHROID 3 MG NDS UNITHROID ORAL TABLET 3 sapropterin 5 PA; NDS 100 MCG, 112 MCG, 125 SOMAVERT 5 PA; QL (30/30); MCG, 150 MCG, 175 MCG, NDS 200 MCG, 25 MCG, 300 MCG, SYNAREL 5 NDS 50 MCG, 75 MCG, 88 MCG testosterone cypionate 3 unithroid oral tablet 137 mcg 3 intramuscular oil 100 mg/ml, 200 mg/ml (1 ml) GASTROENTEROLOGY TESTOSTERONE CYPIONATE 3 ANTIDIARRHEALS / ANTISPASMODICS INTRAMUSCULAR OIL 200 atropine injection solution 0.4 4 MG/ML mg/ml testosterone enanthate 4 atropine injection syringe 0.05 4 testosterone transdermal gel 4 PA mg/ml, 0.1 mg/ml dicyclomine oral capsule 1
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 42 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS dicyclomine oral solution 3 generlac 3 dicyclomine oral tablet 1 granisetron (pf) intravenous 4 HI diphenoxylate-atropine oral 3 solution 1 mg/ml (1 ml) liquid granisetron hcl intravenous 4 HI diphenoxylate-atropine oral 2 granisetron hcl oral 3 B/D PA; QL (60/30) tablet hydrocortisone rectal 3 GLYCOPYRROLATE (PF) IN 4 hydrocortisone topical cream 1 WATER INJECTION with perineal applicator glycopyrrolate (pf) in water 4 lactulose oral solution 2 intravenous syringe 0.4 mg/2 ml (0.2 mg/ml) LINZESS 3 QL (30/30) glycopyrrolate injection 4 meclizine oral tablet 12.5 mg, 2 25 mg glycopyrrolate oral tablet 1 mg, 2 2 mg mesalamine oral capsule, 3 extended release 24hr loperamide oral capsule 2 mesalamine oral tablet,delayed 4 MISCELLANEOUS GASTROINTESTINAL AGENTS release (dr/ec) 1.2 gram alosetron 5 PA; NDS mesalamine rectal enema 4 aprepitant 4 B/D PA mesalamine with cleansing 4 AVSOLA 5 PA; NDS wipe balsalazide 4 metoclopramide hcl oral 2 budesonide oral capsule, 4 solution delayed,extend.release metoclopramide hcl oral tablet 2 budesonide oral tablet,delayed 5 NDS MOVANTIK 4 QL (30/30) and ext.release OCALIVA 5 PA; LA; QL (30/30); compro 2 NDS constulose 3 ondansetron 2 B/D PA CORTIFOAM 4 ondansetron hcl (pf) 4 CREON 3 ondansetron hcl intravenous 4 cromolyn oral 3 ondansetron hcl oral solution 3 B/D PA; QL CYSTADANE 5 NDS (450/30) dronabinol 4 B/D PA; QL (60/30) ondansetron hcl oral tablet 2 B/D PA EMEND ORAL SUSPENSION 4 B/D PA palonosetron intravenous 5 NDS FOR RECONSTITUTION solution 0.25 mg/5 ml enulose 3 peg 3350-electrolytes oral 2 recon soln 236-22.74-6.74 GATTEX 30-VIAL 5 PA; NDS -5.86 gram GATTEX ONE-VIAL 5 PA; NDS peg-electrolyte 2 gavilyte-c 2 PENTASA 5 NDS gavilyte-n 2 PLENVU 4
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 43 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS prochlorperazine 2 lansoprazole oral capsule, 3 prochlorperazine edisylate 4 delayed release(dr/ec) prochlorperazine maleate oral 2 misoprostol 3 procto-med hc 1 nizatidine oral capsule 2 procto-pak 2 omeprazole oral capsule, 2 delayed release(dr/ec) proctosol hc topical 1 pantoprazole oral tablet, 1 proctozone-hc 1 delayed release (dr/ec) 20 mg RECTIV 4 pantoprazole oral tablet, 1 QL (60/30) RELISTOR SUBCUTANEOUS 5 PA; NDS delayed release (dr/ec) 40 mg SOLUTION sucralfate oral suspension 4 RELISTOR SUBCUTANEOUS 5 PA; NDS sucralfate oral tablet 2 SYRINGE RENFLEXIS 5 B/D PA; NDS IMMUNOLOGY, VACCINES / BIOTECHNOLOGY SANCUSO 5 NDS BIOTECHNOLOGY DRUGS scopolamine base 4 QL (10/30) ACTIMMUNE 5 PA; NDS sulfasalazine 2 ARANESP (IN 5 PA; NDS SUPREP BOWEL PREP KIT 3 POLYSORBATE) INJECTION SUTAB 4 SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 trilyte with flavor packets 2 MCG/ML ursodiol 3 ARANESP (IN 4 PA VIOKACE ORAL TABLET 4 POLYSORBATE) INJECTION 10,440-39,150- 39,150 UNIT SOLUTION 25 MCG/ML, 40 VIOKACE ORAL TABLET 5 NDS MCG/ML 20,880-78,300- 78,300 UNIT ARANESP (IN 4 PA ZENPEP ORAL CAPSULE, 3 POLYSORBATE) INJECTION DELAYED RELEASE(DR/EC) SYRINGE 10 MCG/0.4 ML, 25 10,000-32,000 -42,000 UNIT, MCG/0.42 ML, 40 MCG/0.4 ML 15,000-47,000 -63,000 UNIT, ARANESP (IN 5 PA; NDS 20,000-63,000- 84,000 UNIT, POLYSORBATE) INJECTION 25,000-79,000- 105,000 UNIT, SYRINGE 100 MCG/0.5 ML, 3,000-10,000 -14,000-UNIT, 150 MCG/0.3 ML, 200 MCG/0.4 40,000-126,000- 168,000 UNIT, ML, 300 MCG/0.6 ML, 500 5,000-17,000- 24,000 UNIT MCG/ML, 60 MCG/0.3 ML ULCER THERAPY ARCALYST 5 PA; NDS esomeprazole magnesium oral 3 AVONEX INTRAMUSCULAR 5 PA; QL (1/28); NDS capsule,delayed release(dr/ec) PEN INJECTOR KIT famotidine oral suspension 4 AVONEX INTRAMUSCULAR 5 PA; QL (1/28); NDS famotidine oral tablet 20 mg, 2 SYRINGE KIT 40 mg
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 44 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS BETASERON 5 PA; QL (14/28); BOTOX 4 PA SUBCUTANEOUS KIT NDS DAPTACEL (DTAP 3 GENOTROPIN 5 PA; NDS PEDIATRIC) (PF) GENOTROPIN MINIQUICK 5 PA; NDS ENGERIX-B (PF) 3 B/D PA INTRON A INJECTION RECON 5 B/D PA; NDS INTRAMUSCULAR SYRINGE SOLN ENGERIX-B PEDIATRIC (PF) 3 B/D PA INTRON A INJECTION 5 B/D PA; NDS fomepizole 5 NDS SOLUTION 10 MILLION UNIT/ GAMMAKED INJECTION 5 B/D PA; NDS ML SOLUTION 1 GRAM/10 ML INTRON A INJECTION 4 B/D PA (10%), 10 GRAM/100 ML SOLUTION 6 MILLION UNIT/ (10%), 20 GRAM/200 ML ML (10%), 5 GRAM/50 ML (10%) LEUKINE INJECTION RECON 5 PA; NDS GAMUNEX-C 5 B/D PA; NDS SOLN GARDASIL 9 (PF) 3 MOZOBIL 5 B/D PA; NDS HAVRIX (PF) 3 NIVESTYM 5 PA; NDS INTRAMUSCULAR NYVEPRIA 5 PA; NDS SUSPENSION 1,440 ELISA UNIT/ML REBIF (WITH ALBUMIN) 5 PA; QL (6/28); NDS HAVRIX (PF) 3 REBIF REBIDOSE 5 PA; QL (6/28); NDS INTRAMUSCULAR SYRINGE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 HIBERIX (PF) 3 MCG/0.5 ML HIZENTRA 5 B/D PA; NDS REBIF REBIDOSE 5 PA; QL (4.2/180); IMOVAX RABIES VACCINE 3 SUBCUTANEOUS PEN NDS (PF) INJECTOR 8.8MCG/0.2ML-22 INFANRIX (DTAP) (PF) 3 MCG/0.5ML (6) INTRAMUSCULAR SYRINGE REBIF TITRATION PACK 5 PA; QL (4.2/180); IPOL 3 NDS IXIARO (PF) 3 RETACRIT 4 PA KINRIX (PF) 3 ZARXIO 5 PA; NDS MENACTRA (PF) 3 ZIEXTENZO 5 PA; NDS INTRAMUSCULAR SOLUTION VACCINES / MISCELLANEOUS IMMUNOLOGICALS MENQUADFI (PF) 3 ACTHIB (PF) 3 MENVEO A-C-Y-W-135-DIP 3 ADACEL(TDAP ADOLESN/ 3 (PF) ADULT)(PF) M-M-R II (PF) 3 ATGAM 4 B/D PA PEDIARIX (PF) 3 BCG VACCINE, LIVE (PF) 3 PEDVAX HIB (PF) 3 BEXSERO 3 BOOSTRIX TDAP 3
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 45 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS PENTACEL (PF) 3 alendronate oral tablet 35 mg, 1 QL (4/28) INTRAMUSCULAR KIT 70 mg 15LF-48MCG-62DU -10 BINOSTO 4 QL (4/28) MCG/0.5ML ibandronate oral 2 QL (1/30) PROQUAD (PF) 3 PROLIA 4 QL (1/180) QUADRACEL (PF) 3 raloxifene 2 QL (30/30) RABAVERT (PF) 3 risedronate oral tablet 150 mg 3 QL (1/30) RECOMBIVAX HB (PF) 3 B/D PA risedronate oral tablet 35 mg, 3 QL (4/28) ROTARIX 3 35 mg (12 pack), 35 mg (4 ROTATEQ VACCINE 3 pack) SHINGRIX (PF) 3 QL (2/999) risedronate oral tablet 5 mg 3 QL (30/30) STAMARIL (PF) 3 TERIPARATIDE 5 PA; QL (2.4/28); TDVAX 3 NDS TENIVAC (PF) 3 TYMLOS 5 PA; QL (1.56/30); INTRAMUSCULAR SYRINGE NDS TETANUS,DIPHTHERIA TOX 3 OTHER RHEUMATOLOGICALS PED(PF) BENLYSTA 5 PA; NDS TRUMENBA 3 DEPEN TITRATABS 5 NDS TWINRIX (PF) 3 ENBREL MINI 5 PA; QL (8/28); NDS TYPHIM VI 3 ENBREL SUBCUTANEOUS 5 PA; QL (16/28); VAQTA (PF) 3 RECON SOLN NDS VARIVAX (PF) 3 ENBREL SUBCUTANEOUS 5 PA; QL (4/28); NDS SOLUTION VARIZIG 4 ENBREL SUBCUTANEOUS 5 PA; QL (8/28); NDS YF-VAX (PF) 3 SYRINGE ZOSTAVAX (PF) 3 ENBREL SURECLICK 5 PA; QL (8/28); NDS MUSCULOSKELETAL / RHEUMATOLOGY HUMIRA PEN 5 PA; QL (4/28); NDS GOUT THERAPY HUMIRA PEN CROHNS- 5 PA; QL (6/180); UC-HS START NDS allopurinol 1 HUMIRA PEN PSOR-UVEITS- 5 PA; QL (4/180); colchicine oral tablet 4 QL (120/30) ADOL HS NDS FEBUXOSTAT 3 ST HUMIRA SUBCUTANEOUS 5 PA; QL (4/28); NDS MITIGARE 3 SYRINGE KIT 40 MG/0.8 ML probenecid 2 HUMIRA(CF) PEDI CROHNS 5 PA; QL (3/180); probenecid-colchicine 2 STARTER SUBCUTANEOUS NDS SYRINGE KIT 80 MG/0.8 ML OSTEOPOROSIS THERAPY HUMIRA(CF) PEDI CROHNS 5 PA; QL (2/180); alendronate oral tablet 10 mg, 1 QL (30/30) STARTER SUBCUTANEOUS NDS 5 mg SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 46 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS
HUMIRA(CF) PEN CROHNS- 5 PA; QL (3/180); OBSTETRICS / GYNECOLOGY UC-HS NDS HUMIRA(CF) PEN PEDIATRIC 5 PA; QL (4/180); ESTROGENS / PROGESTINS UC NDS ALORA 3 QL (8/28) HUMIRA(CF) PEN PSOR-UV- 5 PA; QL (3/180); camila 2 ADOL HS NDS deblitane 2 HUMIRA(CF) PEN 5 PA; QL (4/28); NDS DELESTROGEN 4 SUBCUTANEOUS INJECTOR INTRAMUSCULAR OIL 10 MG/ KIT 40 MG/0.4 ML ML HUMIRA(CF) PEN 5 PA; QL (3/28); NDS DEPO-ESTRADIOL 4 SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML dotti 2 QL (8/28) HUMIRA(CF) 5 PA; QL (2/28); NDS DUAVEE 4 PA SUBCUTANEOUS SYRINGE errin 2 KIT 10 MG/0.1 ML, 20 MG/0.2 estradiol oral 2 ML estradiol transdermal patch 2 QL (8/28) HUMIRA(CF) 5 PA; QL (4/28); NDS semiweekly SUBCUTANEOUS SYRINGE estradiol transdermal patch 2 QL (4/28) KIT 40 MG/0.4 ML weekly leflunomide 2 QL (30/30) estradiol vaginal 4 ORENCIA CLICKJECT 5 PA; QL (4/28); NDS estradiol valerate intramuscular 4 ORENCIA SUBCUTANEOUS 5 PA; QL (4/28); NDS oil 20 mg/ml, 40 mg/ml SYRINGE 125 MG/ML ESTRING 4 ORENCIA SUBCUTANEOUS 5 PA; QL (1.6/28); fyavolv 3 SYRINGE 50 MG/0.4 ML NDS heather 2 ORENCIA SUBCUTANEOUS 5 PA; QL (2.8/28); SYRINGE 87.5 MG/0.7 ML NDS hydroxyprogesterone caproate 5 NDS penicillamine 5 NDS incassia 2 RIDAURA 5 NDS jencycla 2 RINVOQ 5 PA; QL (30/30); lyza 2 NDS medroxyprogesterone 4 XELJANZ ORAL SOLUTION 5 PA; QL (300/30); intramuscular suspension NDS medroxyprogesterone 2 XELJANZ ORAL TABLET 5 PA; QL (60/30); intramuscular syringe NDS medroxyprogesterone oral 1 XELJANZ XR 5 PA; QL (30/30); MENEST 3 NDS MENOSTAR 3 QL (4/28) nora-be 2 norethindrone (contraceptive) 2 norethindrone acetate 2
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 47 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS norethindrone ac-eth estradiol 3 blisovi fe 1.5/30 (28) 2 oral tablet 0.5-2.5 mg-mcg blisovi fe 1/20 (28) 2 PREMARIN INJECTION 4 briellyn 2 PREMARIN ORAL 3 camrese 2 PREMARIN VAGINAL 3 camrese lo 2 progesterone micronized 2 caziant (28) 2 sharobel 2 charlotte 24 fe 2 yuvafem 4 chateal (28) 2 MISCELLANEOUS OB/GYN chateal eq (28) 2 clindamycin phosphate vaginal 3 cryselle (28) 2 metronidazole vaginal 3 cyclafem 1/35 (28) 2 terconazole 3 cyclafem 7/7/7 (28) 2 tranexamic acid oral 3 cyred 2 vandazole 3 cyred eq 2 ORAL CONTRACEPTIVES / RELATED AGENTS dasetta 1/35 (28) 2 afirmelle 2 dasetta 7/7/7 (28) 2 altavera (28) 2 daysee 2 alyacen 1/35 (28) 2 desog-e.estradiol/e.estradiol 2 alyacen 7/7/7 (28) 2 desogestrel-ethinyl estradiol 2 amethia 2 dolishale 2 amethyst (28) 2 drospirenone-e.estradiol-lm.fa 2 apri 2 drospirenone-ethinyl estradiol 2 aranelle (28) 2 elinest 2 ashlyna 2 ELLA 3 aubra 2 emoquette 2 aubra eq 2 enpresse 2 aurovela 1.5/30 (21) 2 enskyce 2 aurovela 1/20 (21) 2 estarylla 2 aurovela 24 fe 2 ethynodiol diac-eth estradiol 2 aurovela fe 1.5/30 (28) 2 falmina (28) 2 aurovela fe 1-20 (28) 2 fayosim 2 aviane 2 femynor 2 ayuna 2 gemmily 2 azurette (28) 2 hailey 2 balziva (28) 2 hailey 24 fe 2 blisovi 24 fe 2 hailey fe 1.5/30 (28) 2
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 48 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS hailey fe 1/20 (28) 2 low-ogestrel (28) 2 iclevia 2 lo-zumandimine (28) 2 introvale 2 lutera (28) 2 isibloom 2 marlissa (28) 2 jaimiess 2 merzee 2 jasmiel (28) 2 mibelas 24 fe 2 jolessa 2 microgestin 1.5/30 (21) 2 juleber 2 microgestin 1/20 (21) 2 junel 1.5/30 (21) 2 microgestin fe 1.5/30 (28) 2 junel 1/20 (21) 2 microgestin fe 1/20 (28) 2 junel fe 1.5/30 (28) 2 mili 2 junel fe 1/20 (28) 2 mono-linyah 2 junel fe 24 2 necon 0.5/35 (28) 2 kaitlib fe 2 nikki (28) 2 kalliga 2 noreth-ethinyl estradiol-iron 2 kariva (28) 2 norethindrone ac-eth estradiol 2 kelnor 1/35 (28) 2 oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg kelnor 1-50 (28) 2 norethindrone-e.estradiol-iron 2 kurvelo (28) 2 oral capsule l norgest/e.estradiol-e.estrad 2 norethindrone-e.estradiol-iron 2 larin 1.5/30 (21) 2 oral tablet 1 mg-20 mcg (21)/75 larin 1/20 (21) 2 mg (7), 1.5 mg-30 mcg (21)/75 mg (7) larin 24 fe 2 norethindrone-e.estradiol-iron 2 larin fe 1.5/30 (28) 2 oral tablet,chewable larin fe 1/20 (28) 2 norgestimate-ethinyl estradiol 2 larissia 2 nortrel 0.5/35 (28) 2 layolis fe 2 nortrel 1/35 (21) 2 leena 28 2 nortrel 1/35 (28) 2 lessina 2 nortrel 7/7/7 (28) 2 levonest (28) 2 nylia 7/7/7 (28) 2 levonorgestrel-ethinyl estrad 2 nymyo 2 levonorg-eth estrad triphasic 2 ocella 2 levora-28 2 orsythia 2 lillow (28) 2 philith 2 lojaimiess 2 pimtrea (28) 2 loryna (28) 2 pirmella 2
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 49 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS portia 28 2 vyfemla (28) 2 previfem 2 vylibra 2 reclipsen (28) 2 wera (28) 2 rivelsa 2 wymzya fe 2 setlakin 2 zarah 2 simliya (28) 2 zovia 1/35e (28) 2 simpesse 2 zovia 1-35 (28) 2 sprintec (28) 2 zumandimine (28) 2 sronyx 2 OPHTHALMOLOGY syeda 2 ANTIBIOTICS tarina 24 fe 2 ak-poly-bac 2 tarina fe 1/20 (28) 2 AZASITE 3 tarina fe 1-20 eq (28) 2 bacitracin ophthalmic (eye) 2 tilia fe 2 bacitracin-polymyxin b 2 tri femynor 2 ophthalmic (eye) tri-estarylla 2 BESIVANCE 4 tri-legest fe 2 CILOXAN OPHTHALMIC 3 tri-linyah 2 (EYE) OINTMENT tri-lo-estarylla 2 ciprofloxacin hcl ophthalmic 2 tri-lo-marzia 2 (eye) tri-lo-mili 2 erythromycin ophthalmic (eye) 2 tri-lo-sprintec 2 gentak ophthalmic (eye) 2 tri-mili 2 ointment tri-nymyo 2 gentamicin ophthalmic (eye) 2 drops tri-previfem (28) 2 moxifloxacin ophthalmic (eye) 3 tri-sprintec (28) 2 NATACYN 3 trivora (28) 2 neomycin-bacitracin-polymyxin 2 tri-vylibra 2 neomycin-polymyxin-gramicidin 2 tri-vylibra lo 2 neo-polycin 2 TYBLUME 2 ofloxacin ophthalmic (eye) 2 tydemy 2 polycin 2 velivet triphasic regimen (28) 2 polymyxin b sulf-trimethoprim 2 vestura (28) 2 tobramycin ophthalmic (eye) 2 vienva 2 TOBREX OPHTHALMIC (EYE) 4 viorele (28) 2 OINTMENT volnea (28) 2
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 50 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS ANTIVIRALS ketorolac ophthalmic (eye) 2 trifluridine 3 PROLENSA 3 ZIRGAN 3 ORAL DRUGS FOR GLAUCOMA BETA-BLOCKERS acetazolamide 3 carteolol 2 acetazolamide sodium 4 levobunolol ophthalmic (eye) 1 methazolamide 4 drops 0.5% OTHER GLAUCOMA DRUGS timolol maleate ophthalmic 1 AZOPT 4 (eye) drops bimatoprost ophthalmic (eye) 2 TIMOLOL MALEATE 4 OPHTHALMIC (EYE) GEL brinzolamide 4 FORMING SOLUTION COMBIGAN 3 MISCELLANEOUS OPHTHALMOLOGICS dorzolamide 2 atropine ophthalmic (eye) drops 3 dorzolamide-timolol 2 azelastine ophthalmic (eye) 2 latanoprost 1 BLEPHAMIDE 3 LUMIGAN OPHTHALMIC 3 BLEPHAMIDE S.O.P. 3 (EYE) DROPS 0.01% cromolyn ophthalmic (eye) 2 RHOPRESSA 4 ST CYSTARAN 5 PA; NDS ROCKLATAN 4 ST epinastine 3 SIMBRINZA 4 EYLEA 5 PA; NDS travoprost 3 LACRISERT 4 STEROID-ANTIBIOTIC COMBINATIONS olopatadine ophthalmic (eye) 3 neomycin-bacitracin-poly-hc 3 OXERVATE 5 PA; QL (112/999); neomycin-polymyxin 2 NDS b-dexameth pilocarpine hcl ophthalmic (eye) 3 neomycin-polymyxin-hc 2 drops 1%, 2%, 4% ophthalmic (eye) RESTASIS 3 QL (60/30) neo-polycin hc 3 RESTASIS MULTIDOSE 3 QL (60/30) PRED-G 3 sulfacetamide sodium 2 PRED-G S.O.P. 3 ophthalmic (eye) drops tobramycin-dexamethasone 3 sulfacetamide-prednisolone 2 ZYLET 3 XIIDRA 3 QL (60/30) STEROIDS NON-STEROIDAL ANTI-INFLAMMATORY AGENTS dexamethasone sodium 2 bromfenac 4 phosphate ophthalmic (eye) diclofenac sodium ophthalmic 2 DUREZOL 3 (eye) fluorometholone 3 flurbiprofen sodium 2 INVELTYS 4
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 51 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS LOTEMAX 4 ADVAIR HFA 3 QL (12/30) LOTEMAX SM 4 albuterol sulfate inhalation 4 QL (17/30) prednisolone acetate 3 hfa aerosol inhaler 90 mcg/ actuation (generic for proair) prednisolone sodium 1 phosphate ophthalmic (eye) ALBUTEROL SULFATE 4 QL (13.4/30) INHALATION HFA AEROSOL SYMPATHOMIMETICS INHALER 90 MCG/ ALPHAGAN P OPHTHALMIC 3 ACTUATION (GENERIC FOR (EYE) DROPS 0.1% PROVENTIL) apraclonidine 3 albuterol sulfate inhalation 4 QL (36/30) brimonidine ophthalmic (eye) 3 hfa aerosol inhaler 90 mcg/ drops 0.15% actuation (generic for ventolin) brimonidine ophthalmic (eye) 2 albuterol sulfate inhalation 2 B/D PA drops 0.2% solution for nebulization albuterol sulfate oral syrup 2 RESPIRATORY AND ALLERGY albuterol sulfate oral tablet 3 ANTIHISTAMINE / ANTIALLERGENIC AGENTS albuterol sulfate oral tablet 2 desloratadine oral tablet 2 QL (30/30) extended release 12 hr diphenhydramine hcl injection 4 alyq 5 PA; QL (60/30); solution 50 mg/ml NDS epinephrine injection auto- 3 QL (2/30) ambrisentan 5 PA; LA; QL (30/30); injector 0.15 mg/0.15 ml, 0.3 NDS mg/0.3 ml ANORO ELLIPTA 3 QL (60/30) epinephrine injection auto- 2 QL (2/30) arformoterol 4 B/D PA injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml ARNUITY ELLIPTA 3 QL (30/30) epinephrine injection solution 1 4 ATROVENT HFA 4 QL (25.8/30) mg/ml bosentan 5 PA; LA; NDS hydroxyzine hcl oral tablet 3 PA BREO ELLIPTA 3 QL (60/30) levocetirizine oral solution 4 BROVANA 4 B/D PA levocetirizine oral tablet 2 QL (30/30) budesonide inhalation 4 B/D PA; QL promethazine oral 2 PA suspension for nebulization (120/30) 0.25 mg/2 ml, 0.5 mg/2 ml promethazine rectal 4 suppository 12.5 mg, 25 mg budesonide inhalation 4 B/D PA; QL (60/30) suspension for nebulization 1 promethegan rectal suppository 4 mg/2 ml 25 mg, 50 mg COMBIVENT RESPIMAT 3 QL (8/30) PULMONARY AGENTS cromolyn inhalation 2 B/D PA acetylcysteine 3 B/D PA DALIRESP 4 PA; QL (30/30) ADEMPAS 5 PA; LA; QL (90/30); NDS ESBRIET ORAL CAPSULE 5 PA; QL (270/30); NDS
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 52 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS ESBRIET ORAL TABLET 267 5 PA; QL (270/30); montelukast oral tablet 2 QL (30/30) MG NDS montelukast oral tablet, 2 QL (30/30) ESBRIET ORAL TABLET 801 5 PA; QL (90/30); chewable MG NDS OFEV 5 PA; QL (60/30); FLOVENT DISKUS 3 QL (60/30) NDS INHALATION BLISTER OPSUMIT 5 PA; LA; NDS WITH DEVICE 100 MCG/ ACTUATION, 50 MCG/ ORKAMBI ORAL GRANULES 5 PA; QL (56/28); ACTUATION IN PACKET NDS FLOVENT DISKUS 3 QL (240/30) ORKAMBI ORAL TABLET 5 PA; QL (112/28); INHALATION BLISTER NDS WITH DEVICE 250 MCG/ PERFOROMIST 3 B/D PA; QL ACTUATION (120/30) FLOVENT HFA AEROSOL 3 QL (12/30) PULMICORT INHALATION 4 B/D PA; QL INHALER 110 MCG/ SUSPENSION FOR (120/30) ACTUATION NEBULIZATION 0.25 MG/2 ML, FLOVENT HFA AEROSOL 3 QL (24/30) 0.5 MG/2 ML INHALER 220 MCG/ PULMICORT INHALATION 4 B/D PA; QL (60/30) ACTUATION SUSPENSION FOR FLOVENT HFA AEROSOL 3 QL (10.6/30) NEBULIZATION 1 MG/2 ML INHALER 44 MCG/ PULMOZYME 5 B/D PA; QL ACTUATION (150/30); NDS flunisolide 3 QL (50/30) SEREVENT DISKUS 3 QL (60/30) fluticasone propionate nasal 2 QL (16/30) sildenafil (pulmonary arterial 3 PA; QL (90/30) fluticasone propion-salmeterol 2 QL (60/30) hypertension) oral tablet inhalation blister with device SYMDEKO 5 PA; QL (56/28); HAEGARDA 5 PA; NDS NDS icatibant 5 PA; QL (18/30); tadalafil (pulmonary arterial 5 PA; QL (60/30); NDS hypertension) oral tablet 20 mg NDS INCRUSE ELLIPTA 3 QL (30/30) terbutaline 4 ipratropium bromide inhalation 2 B/D PA THEO-24 4 ipratropium-albuterol 2 B/D PA theophylline oral tablet 3 extended release 12 hr 300 KALYDECO ORAL GRANULES 5 PA; QL (56/28); mg, 450 mg IN PACKET NDS theophylline oral tablet 3 KALYDECO ORAL TABLET 5 PA; QL (60/30); extended release 24 hr NDS TRELEGY ELLIPTA 3 QL (60/30) levalbuterol hcl 4 B/D PA TRIKAFTA 5 PA; NDS metaproterenol oral syrup 3 VENTAVIS 5 PA; NDS mometasone nasal 3 QL (34/30) VENTOLIN HFA 3 QL (36/30) montelukast oral granules in 3 QL (30/30) packet wixela inhub 2 QL (60/30)
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 53 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS
XHANCE 4 ST; QL (32/30) VITAMINS, HEMATINICS / ELECTROLYTES XOLAIR SUBCUTANEOUS 5 PA; LA; QL (6/28); RECON SOLN NDS ELECTROLYTES XOLAIR SUBCUTANEOUS 5 PA; LA; QL (4/28); calcium acetate(phosphat bind) 2 SYRINGE 150 MG/ML NDS klor-con 2 XOLAIR SUBCUTANEOUS 5 PA; LA; QL (1/28); KLOR-CON 10 3 SYRINGE 75 MG/0.5 ML NDS KLOR-CON 8 3 XOPENEX 4 B/D PA klor-con m10 1 XOPENEX CONCENTRATE 4 B/D PA klor-con m20 1 YUPELRI 4 B/D PA; QL (90/30) lactated ringers intravenous 4 zafirlukast 3 QL (60/30) MAGNESIUM SULFATE 4 UROLOGICALS IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML ANTICHOLINERGICS / ANTISPASMODICS magnesium sulfate in water 4 darifenacin 4 magnesium sulfate injection 4 flavoxate 2 POTASSIUM CHLORID-D5- 4 MYRBETRIQ ORAL TABLET 3 0.45%NACL INTRAVENOUS EXTENDED RELEASE 24 HR PARENTERAL SOLUTION 10 oxybutynin chloride oral syrup 1 MEQ/L, 20 MEQ/L, 40 MEQ/L oxybutynin chloride oral tablet 1 potassium chlorid-d5- 4 0.45%nacl intravenous oxybutynin chloride oral tablet 2 QL (60/30) parenteral solution 30 meq/l extended release 24hr potassium chloride in 0.9%nacl 4 solifenacin 2 intravenous parenteral solution tolterodine 3 20 meq/l, 40 meq/l TOVIAZ 3 QL (30/30) potassium chloride in 5% dex 4 BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l alfuzosin 2 potassium chloride in lr-d5 4 dutasteride 2 intravenous parenteral solution dutasteride-tamsulosin 4 20 meq/l finasteride oral tablet 5 mg 2 QL (30/30) potassium chloride in water 4 tamsulosin 2 QL (60/30) intravenous piggyback MISCELLANEOUS UROLOGICALS potassium chloride intravenous 4 bethanechol chloride 2 potassium chloride oral 2 CYSTAGON 4 LA capsule, extended release ELMIRON 5 NDS potassium chloride oral liquid 4 K-PHOS ORIGINAL 4 potassium chloride oral packet 2 potassium citrate 4 potassium chloride oral tablet 1 extended release RENACIDIN 4
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 54 Covered Drugs By Category
DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS potassium chloride oral tablet, 1 CLINIMIX E 4.25%/D10W SUL 4 B/D PA er particles/crystals 10 meq, 20 FREE meq CLINISOL SF 15% 4 B/D PA potassium chloride-0.45% nacl 4 electrolyte-48 in d5w 4 POTASSIUM CHLORIDE-D5- 4 freamine iii 10% 4 B/D PA 0.2%NACL INTRAVENOUS PARENTERAL SOLUTION 20 HEPATAMINE 8% 4 B/D PA MEQ/L INTRALIPID INTRAVENOUS 4 B/D PA potassium chloride-d5- 4 EMULSION 20%, 30% 0.2%nacl intravenous KABIVEN 4 B/D PA parenteral solution 30 meq/l, 40 NORMOSOL-R PH 7.4 4 meq/l NUTRILIPID 4 B/D PA POTASSIUM CHLORIDE-D5- 4 PERIKABIVEN 4 B/D PA 0.9%NACL PLENAMINE 4 B/D PA ringer's intravenous 4 PREMASOL 10% 4 B/D PA sodium bicarbonate 4 intravenous syringe 10 meq/10 PROCALAMINE 3% 4 B/D PA ml (8.4%), 7.5% (0.9 meq/ml), PROSOL 20% 4 B/D PA 8.4% (1 meq/ml) TRAVASOL 10% 4 B/D PA sodium chloride 0.45% 4 TROPHAMINE 10% 4 B/D PA intravenous parenteral solution VITAMINS / HEMATINICS sodium chloride 3% 4 fluoride (sodium) oral tablet 1 sodium chloride 5% 4 fluoride (sodium) oral tablet, 1 sodium chloride intravenous 4 chewable 1 mg (2.2 mg sod. TPN ELECTROLYTES 4 B/D PA fluoride) MISCELLANEOUS NUTRITION PRODUCTS PRENATAL VITAMIN ORAL 3 AMINOSYN II 15% 4 B/D PA TABLET AMINOSYN-PF 7% (SULFITE- 4 B/D PA FREE) CLINIMIX 5%/D15W SULFITE 4 B/D PA FREE CLINIMIX 4.25%/D10W SULF 4 B/D PA FREE CLINIMIX 5%-D20W(SULFITE- 4 B/D PA FREE) CLINIMIX 6%-D5W (SULFITE- 4 B/D PA FREE) CLINIMIX 8%-D10W(SULFITE- 4 B/D PA FREE) CLINIMIX 8%-D14W(SULFITE- 4 B/D PA FREE)
CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.
September 2021 55 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE
A adefovir...... 8 ALIQOPA...... 15 ADEMPAS...... 52 aliskiren...... 30 abacavir-lamivudine ...... 8 adriamycin intravenous allopurinol...... 46 abacavir-lamivudine-zidovudine. . . 8 recon soln 10 mg...... 15 ALORA...... 47 abacavir oral solution...... 8 adriamycin intravenous solution. . .15 alosetron...... 43 abacavir oral tablet...... 8 adrucil intravenous solution ALPHAGAN P OPHTHALMIC ABELCET...... 8 2.5 gram/50 ml...... 15 (EYE) DROPS 0.1%...... 52 ABILIFY MAINTENA...... 27 ADVAIR HFA...... 52 alprazolam oral tablet abiraterone oral tablet 250 mg. . . .15 AFINITOR DISPERZ ORAL TABLET 0.25 mg, 0.5 mg, 1 mg...... 27 FOR SUSPENSION 2 MG . . . . . 15 abiraterone oral tablet 500 mg. . . .15 alprazolam oral tablet 2 mg . . . . .27 AFINITOR DISPERZ ORAL TABLET ABRAXANE...... 15 alprazolam oral tablet, FOR SUSPENSION 3 MG, 5 MG. . 15 disintegrating 0.25 mg, acamprosate...... 37 AFINITOR ORAL TABLET 10 MG . .15 0.5 mg, 1 mg...... 27 acarbose oral tablet 25 mg. . . . . 39 afirmelle ...... 48 alprazolam oral tablet, acarbose oral tablet 50 mg. . . . . 39 AIMOVIG AUTOINJECTOR. . . . .24 disintegrating 2 mg...... 27 acarbose oral tablet 100 mg. . . . .39 ak-poly-bac ...... 50 altavera (28) ...... 48 acebutolol...... 30 ala-cort topical cream 1%...... 36 ALUNBRIG ORAL TABLET 30 MG . 15 acetaminophen-codeine oral albendazole...... 11 ALUNBRIG ORAL TABLET solution 120 mg-12 mg /5 ml 180 MG, 90 MG...... 15 (5 ml), 120-12 mg/5 ml, albuterol sulfate inhalation hfa ALUNBRIG ORAL TABLETS, 300 mg-30 mg /12.5 ml ...... 25 aerosol inhaler 90 mcg/actuation (generic for proair)...... 52 DOSE PACK...... 15 acetaminophen-codeine oral alyacen 1/35 (28)...... 48 tablet 300-15 mg, 300-30 mg. . . . 25 ALBUTEROL SULFATE INHALATION HFA AEROSOL alyacen 7/7/7 (28)...... 48 acetaminophen-codeine oral INHALER 90 MCG/ACTUATION tablet 300-60 mg ...... 25 alyq...... 52 (GENERIC FOR PROVENTIL). . . 52 acetazolamide...... 51 amantadine hcl...... 8 albuterol sulfate inhalation hfa acetazolamide sodium...... 51 aerosol inhaler 90 mcg/actuation AMBISOME...... 8 acetic acid otic (ear)...... 38 (generic for ventolin)...... 52 ambrisentan...... 52 acetylcysteine...... 52 albuterol sulfate inhalation amethia...... 48 acitretin...... 34 solution for nebulization...... 52 amethyst (28) ...... 48 ACTHIB (PF)...... 45 albuterol sulfate oral syrup. . . . . 52 amikacin injection solution 1,000 mg/4 ml...... 11 ACTIMMUNE ...... 44 albuterol sulfate oral tablet. . . . . 52 amikacin injection solution acyclovir oral capsule...... 8 albuterol sulfate oral tablet extended release 12 hr ...... 52 500 mg/2 ml...... 11 acyclovir oral suspension amiloride...... 30 200 mg/5 ml...... 8 alclometasone...... 36 amiloride-hydrochlorothiazide . . . .30 acyclovir oral tablet...... 8 ALCOHOL PADS...... 39 aminocaproic acid oral...... 32 acyclovir sodium ALDURAZYME...... 41 intravenous solution ...... 8 ALECENSA...... 15 AMINOSYN II 15%...... 55 acyclovir topical ointment ...... 36 alendronate oral tablet 10 mg, 5 mg . 46 AMINOSYN-PF 7% (SULFITE-FREE)...... 55 ADACEL alendronate oral tablet (TDAP ADOLESN/ADULT)(PF). . . 45 35 mg, 70 mg ...... 46 amiodarone intravenous solution . . 30 ADASUVE...... 27 alfuzosin...... 54 amiodarone oral...... 30 ADCETRIS...... 15 ALIMTA...... 15 amitriptyline...... 27 September 2021 56 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE amlodipine...... 30 APTIOM ORAL TABLET atazanavir oral capsule amlodipine-benazepril ...... 30 600 MG, 800 MG...... 21 150 mg, 300 mg...... 8 amlodipine-valsartan...... 30 APTIVUS...... 8 atazanavir oral capsule 200 mg. . . .8 amlodipine-valsartan-hcthiazid . . . 30 ARALAST NP...... 37 atenolol...... 30 ammonium lactate...... 34 aranelle (28) ...... 48 atenolol-chlorthalidone...... 30 amnesteem...... 35 ARANESP (IN POLYSORBATE) ATGAM...... 45 INJECTION SOLUTION amoxapine...... 27 atomoxetine oral capsule 25 MCG/ML, 40 MCG/ML...... 44 10 mg, 18 mg, 25 mg, 40 mg. . . . 27 amoxicillin oral capsule ...... 13 ARANESP (IN POLYSORBATE) atomoxetine oral capsule amoxicillin oral suspension INJECTION SOLUTION 100 mg, 60 mg, 80 mg...... 27 for reconstitution...... 13 100 MCG/ML, 200 MCG/ML, atorvastatin ...... 33 amoxicillin oral tablet ...... 13 300 MCG/ML, 60 MCG/ML. . . . . 44 atovaquone...... 11 amoxicillin oral tablet, ARANESP (IN POLYSORBATE) chewable 125 mg, 250 mg. . . . . 13 INJECTION SYRINGE atovaquone-proguanil...... 11 amoxicillin-pot clavulanate oral 10 MCG/0.4 ML, 25 MCG/ ATRIPLA...... 8 suspension for reconstitution. . . . 13 0.42 ML, 40 MCG/0.4 ML...... 44 atropine injection solution amoxicillin-pot clavulanate ARANESP (IN POLYSORBATE) 0.4 mg/ml...... 42 oral tablet...... 13 INJECTION SYRINGE atropine injection syringe 100 MCG/0.5 ML, 150 MCG/0.3 ML, 0.05 mg/ml, 0.1 mg/ml...... 42 amoxicillin-pot clavulanate 200 MCG/0.4 ML, 300 MCG/0.6 ML, oral tablet,chewable ...... 13 500 MCG/ML, 60 MCG/0.3 ML. . . 44 atropine ophthalmic (eye) drops. . .51 amoxicillin-pot clavulanate oral ARCALYST...... 44 ATROVENT HFA...... 52 tablet extended release 12 hr. . . . 13 arformoterol...... 52 aubra...... 48 amphotericin b ...... 8 ARIKAYCE...... 11 aubra eq...... 48 ampicillin oral capsule 500 mg. . . .13 aripiprazole oral solution...... 27 aurovela 1.5/30 (21)...... 48 ampicillin sodium injection aurovela 1/20 (21)...... 48 recon soln 1 gram, 10 gram. . . . .13 aripiprazole oral tablet...... 27 aurovela 24 fe...... 48 ampicillin sodium injection aripiprazole oral tablet, aurovela fe 1.5/30 (28)...... 48 recon soln 2 gram...... 13 disintegrating...... 27 ampicillin sodium injection recon ARISTADA...... 27 aurovela fe 1-20 (28) ...... 48 soln 125 mg, 250 mg, 500 mg. . . .13 ARISTADA INITIO...... 27 AURYXIA...... 37 ampicillin sodium intravenous . . . .13 armodafinil...... 27 AUSTEDO ORAL TABLET 6 MG. . 24 ampicillin-sulbactam injection. . . . 13 ARNUITY ELLIPTA...... 52 AUSTEDO ORAL TABLET 12 MG, 9 MG...... 24 ampicillin-sulbactam intravenous . . 13 ARRANON...... 15 aviane...... 48 anagrelide ...... 37 arsenic trioxide...... 15 avita...... 35 anastrozole ...... 15 ARZERRA...... 15 AVONEX INTRAMUSCULAR ANORO ELLIPTA...... 52 asenapine maleate...... 27 PEN INJECTOR KIT...... 44 APOKYN...... 23 ashlyna...... 48 AVONEX INTRAMUSCULAR ...... apraclonidine...... 52 aspirin-dipyridamole 32 SYRINGE KIT...... 44 aprepitant...... 43 ASTAGRAF XL ORAL CAPSULE, AVSOLA...... 43 apri...... 48 EXTENDED RELEASE 24HR 0.5 MG, 1 MG...... 15 ayuna...... 48 APTIOM ORAL TABLET 200 MG. . 21 ASTAGRAF XL ORAL CAPSULE, AYVAKIT...... 15 APTIOM ORAL TABLET 400 MG. . 21 EXTENDED RELEASE 24HR 5 MG. 15 azacitidine ...... 15 AZASAN...... 15 September 2021 57 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE
AZASITE...... 50 BESIVANCE ...... 50 BRAFTOVI ORAL azathioprine...... 15 BESPONSA...... 15 CAPSULE 75 MG ...... 15 azathioprine sodium...... 15 betamethasone, augmented. . . . .36 BREO ELLIPTA ...... 52 azelastine nasal...... 38 betamethasone dipropionate. . . . 36 briellyn...... 48 azelastine ophthalmic (eye). . . . .51 betamethasone BRILINTA...... 32 azithromycin intravenous...... 11 valerate topical cream ...... 36 brimonidine ophthalmic (eye) drops 0.2%...... 52 azithromycin oral packet...... 11 betamethasone valerate topical foam...... 36 brimonidine ophthalmic azithromycin oral suspension (eye) drops 0.15%...... 52 for reconstitution...... 11 betamethasone valerate topical lotion...... 36 brinzolamide...... 51 azithromycin oral tablet ...... 11 betamethasone BRIVIACT INTRAVENOUS. . . . . 21 AZOPT ...... 51 valerate topical ointment...... 36 BRIVIACT ORAL SOLUTION. . . . 21 aztreonam injection BETASERON recon soln 1 gram...... 11 BRIVIACT ORAL TABLET...... 21 SUBCUTANEOUS KIT...... 45 aztreonam injection bromfenac ...... 51 betaxolol oral...... 30 recon soln 2 gram...... 11 bromocriptine ...... 23 bethanechol chloride...... 54 azurette (28)...... 48 BROVANA...... 52 bexarotene...... 15 BRUKINSA ...... 15 BEXSERO...... 45 B budesonide inhalation suspension bicalutamide ...... 15 for nebulization 0.25 mg/2 ml, bacitracin intramuscular...... 11 BICILLIN L-A...... 13 0.5 mg/2 ml...... 52 bacitracin ophthalmic (eye). . . . . 50 BIDIL...... 30 budesonide inhalation suspension bacitracin-polymyxin b BIKTARVY...... 8 for nebulization 1 mg/2 ml...... 52 ophthalmic (eye)...... 50 bimatoprost ophthalmic (eye). . . . 51 budesonide oral capsule, baclofen oral tablet 10 mg, 5 mg. . .25 delayed,extend.release...... 43 BINOSTO...... 46 baclofen oral tablet 20 mg...... 25 budesonide oral tablet, bisoprolol fumarate...... 30 balsalazide...... 43 delayed and ext.release...... 43 bisoprolol-hydrochlorothiazide. . . .31 BALVERSA...... 15 bumetanide injection...... 31 BLENREP ...... 15 balziva (28) ...... 48 bumetanide oral...... 31 bleomycin...... 15 BANZEL...... 21 buprenorphine hcl injection. . . . . 25 BLEPHAMIDE...... 51 BAQSIMI...... 39 buprenorphine hcl sublingual. . . . 25 BLEPHAMIDE S.O.P...... 51 BARACLUDE ORAL SOLUTION . . .8 buprenorphine-naloxone BLINCYTO INTRAVENOUS KIT. . .15 sublingual film 2-0.5 mg...... 26 BAVENCIO...... 15 blisovi 24 fe...... 48 buprenorphine-naloxone BCG VACCINE, LIVE (PF). . . . . 45 blisovi fe 1.5/30 (28)...... 48 sublingual film 4-1 mg, 8-2 mg. . . .26 BD PEN NEEDLE...... 39 blisovi fe 1/20 (28)...... 48 buprenorphine-naloxone BELEODAQ...... 15 BOOSTRIX TDAP...... 45 sublingual film 12-3 mg ...... 26 benazepril...... 30 BORTEZOMIB...... 15 buprenorphine-naloxone benazepril-hydrochlorothiazide. . . 30 sublingual tablet 2-0.5 mg...... 26 bosentan...... 52 BENDEKA...... 15 buprenorphine-naloxone BOSULIF ORAL TABLET 100 MG. .15 BENLYSTA...... 46 sublingual tablet 8-2 mg...... 26 BOSULIF ORAL TABLET benztropine injection...... 23 buprenorphine transdermal 400 MG, 500 MG...... 15 patch weekly 7.5 mcg/hour. . . . . 25 benztropine oral...... 23 BOTOX...... 45
September 2021 58 Covered Drugs Index
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BUPRENORPHINE candesartan oral tablet cefadroxil oral suspension for TRANSDERMAL PATCH WEEKLY 16 mg, 4 mg, 8 mg...... 31 reconstitution 250 mg/5 ml, 10 MCG/HOUR, 15 MCG/HOUR, candesartan oral tablet 32 mg. . . .31 500 mg/5 ml...... 10 20 MCG/HOUR, 5 MCG/HOUR. . . 25 CAPLYTA...... 27 cefadroxil oral tablet...... 10 bupropion hcl oral tablet 75 mg. . . 27 CAPRELSA ORAL TABLET 100 MG . 16 cefazolin in dextrose (iso-os) bupropion hcl oral tablet 100 mg. . .27 intravenous piggyback CAPRELSA ORAL TABLET 300 MG . 16 bupropion hcl oral tablet 1 gram/50 ml, 2 gram/50 ml. . . . .10 CARBAGLU...... 37 extended release 24 hr 150 mg. . . 27 CEFAZOLIN IN DEXTROSE bupropion hcl oral tablet carbamazepine oral capsule, (ISO-OS) INTRAVENOUS er multiphase 12 hr...... 21 extended release 24 hr 300 mg. . . 27 PIGGYBACK 2 GRAM/100 ML. . . 10 bupropion hcl oral tablet carbamazepine oral suspension cefazolin injection recon soln 100 mg/5 ml, 200 mg/10 ml . . . . .21 sustained-release 12 hr...... 27 1 gram, 10 gram, 100 gram, carbamazepine oral tablet...... 21 300 g, 500 mg...... 10 bupropion hcl (smoking deter). . . .38 carbamazepine oral tablet, cefazolin intravenous...... 10 buspirone...... 27 chewable ...... 22 cefdinir oral capsule ...... 10 busulfan ...... 15 carbamazepine oral tablet cefdinir oral suspension butorphanol nasal ...... 26 extended release 12 hr ...... 22 for reconstitution...... 10 BYDUREON BCISE...... 39 carbidopa...... 23 CEFEPIME IN DEXTROSE 5%. . . 10 BYSTOLIC...... 31 carbidopa-levodopa-entacapone. . .23 cefepime in dextrose,iso-osm . . . .10 carbidopa-levodopa oral tablet . . . 23 cefepime injection...... 10 C carbidopa-levodopa oral tablet, CEFEPIME INTRAVENOUS . . . . 10 disintegrating...... 23 CABENUVA...... 8 cefixime...... 10 carbidopa-levodopa oral tablet cabergoline ...... 41 CEFOTETAN IN DEXTROSE, extended release...... 23 CABOMETYX ORAL ISO-OSM...... 10 carboplatin intravenous solution. . .16 TABLET 20 MG, 60 MG...... 15 cefotetan injection...... 10 carmustine...... 16 CABOMETYX ORAL cefoxitin...... 10 CARNITOR INTRAVENOUS. . . . 37 TABLET 40 MG ...... 15 cefoxitin in dextrose, iso-osm. . . . 10 carteolol ...... 51 calcipotriene scalp...... 34 cefpodoxime...... 10 cartia xt...... 31 calcipotriene topical cream. . . . . 34 cefprozil ...... 11 carvedilol ...... 31 calcipotriene topical ointment. . . . 34 ceftazidime...... 11 carvedilol phosphate...... 31 calcitonin (salmon) injection. . . . .41 CEFTAZIDIME IN D5W...... 11 caspofungin...... 8 calcitonin (salmon) nasal...... 41 ceftriaxone in dextrose,iso-os . . . .11 calcitriol intravenous CAYSTON...... 11 ceftriaxone injection recon soln solution 1 mcg/ml...... 41 caziant (28)...... 48 1 gram, 10 gram, 2 gram, calcitriol oral...... 41 cefaclor oral capsule...... 10 250 mg, 500 mg...... 11 calcitriol topical...... 34 cefaclor oral suspension for CEFTRIAXONE INJECTION calcium acetate(phosphat bind). . . 54 reconstitution 125 mg/5 ml, RECON SOLN 100 GRAM. . . . . 11 250 mg/5 ml, 375 mg/5 ml...... 10 CALQUENCE...... 16 ceftriaxone intravenous...... 11 cefaclor oral tablet camila...... 47 cefuroxime axetil oral tablet. . . . .11 extended release 12 hr ...... 10 camrese...... 48 cefuroxime sodium injection cefadroxil oral capsule...... 10 recon soln 750 mg...... 11 camrese lo...... 48 cefuroxime sodium intravenous. . . 11 candesartan-hydrochlorothiazid . . .31 celecoxib...... 26 September 2021 59 Covered Drugs Index
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CELONTIN ORAL ciprofloxacin hcl ophthalmic (eye). . 50 CLINIMIX 4.25%/D5W CAPSULE 300 MG...... 22 ciprofloxacin hcl oral tablet 100 mg. 14 SULFIT FREE...... 37 cephalexin oral capsule ciprofloxacin hcl oral tablet CLINIMIX 4.25%/D10W 250 mg, 500 mg...... 11 250 mg, 500 mg, 750 mg...... 14 SULF FREE...... 55 cephalexin oral suspension ciprofloxacin in 5% dextrose CLINIMIX 5%/D15W for reconstitution...... 11 intravenous piggyback SULFITE FREE...... 55 CEREZYME INTRAVENOUS 200 mg/100 ml...... 14 CLINIMIX 5%-D20W( RECON SOLN 400 UNIT ...... 41 ciprofloxacin in 5% dextrose SULFITE-FREE) ...... 55 CHANTIX...... 38 intravenous piggyback CLINIMIX 6%-D5W CHANTIX CONTINUING 400 mg/200 ml...... 14 (SULFITE-FREE)...... 55 MONTH BOX ...... 38 CIPRO HC...... 38 CLINIMIX 8%-D10W CHANTIX STARTING MONTH BOX . 38 CIPRO ORAL SUSPENSION, (SULFITE-FREE)...... 55 charlotte 24 fe...... 48 MICROCAPSULE RECON. . . . . 14 CLINIMIX 8%-D14W (SULFITE-FREE)...... 55 chateal (28)...... 48 cisplatin intravenous solution. . . . 16 CLINIMIX E 4.25%/D10W chateal eq (28)...... 48 citalopram oral solution ...... 27 SUL FREE...... 55 CHEMET ...... 37 citalopram oral tablet ...... 27 CLINISOL SF 15% ...... 55 chloramphenicol sod succinate. . . 11 cladribine...... 16 clobazam oral suspension...... 22 chlorhexidine gluconate claravis...... 35 clobazam oral tablet...... 22 mucous membrane...... 38 clarithromycin oral suspension clobetasol-emollient topical cream. .36 chloroquine phosphate...... 11 for reconstitution...... 11 clobetasol-emollient topical foam. . 36 chlorothiazide sodium...... 31 clarithromycin oral tablet...... 11 clobetasol scalp...... 36 chlorpromazine injection...... 27 clarithromycin oral tablet extended release 24 hr ...... 11 clobetasol topical cream ...... 36 chlorpromazine oral tablet...... 27 clindacin etz topical swab...... 35 clobetasol topical foam...... 36 chlorthalidone oral tablet 25 mg, 50 mg ...... 31 clindacin p ...... 35 clobetasol topical gel ...... 36 cholestyramine light ...... 33 clindamycin hcl...... 11 clobetasol topical ointment. . . . . 36 cholestyramine (with sugar). . . . .33 CLINDAMYCIN IN clobetasol topical shampoo . . . . .36 0.9% SOD CHLOR...... 12 CHORIONIC GONADOTROPIN, CLOCORTOLONE PIVALATE. . . .36 HUMAN INTRAMUSCULAR . . . . 41 clindamycin in 5% dextrose . . . . .12 clodan...... 36 ciclodan topical solution...... 35 clindamycin pediatric ...... 12 clofarabine...... 16 ciclopirox topical cream...... 35 clindamycin phosphate injection. . .12 clomipramine...... 27 ciclopirox topical shampoo. . . . . 35 clindamycin phosphate clonazepam oral tablet intravenous solution 600 mg/4 ml. . 12 ciclopirox topical solution...... 35 0.5 mg, 1 mg...... 22 clindamycin phosphate topical gel. .35 ciclopirox topical suspension. . . . 35 clonazepam oral tablet 2 mg . . . . 22 CLINDAMYCIN PHOSPHATE cilostazol...... 32 clonazepam oral tablet, TOPICAL GEL, ONCE DAILY . . . .35 disintegrating 0.125 mg, CILOXAN OPHTHALMIC clindamycin phosphate 0.25 mg, 0.5 mg, 1 mg...... 22 (EYE) OINTMENT...... 50 topical lotion...... 35 clonazepam oral tablet, CIMDUO...... 8 clindamycin phosphate disintegrating 2 mg...... 22 cinacalcet oral tablet 30 mg, 60 mg. 41 topical solution...... 35 clonidine...... 31 cinacalcet oral tablet 90 mg. . . . .41 clindamycin phosphate clonidine hcl oral tablet CIPRODEX...... 38 topical swab...... 35 0.1 mg, 0.2 mg...... 31 ciprofloxacin-dexamethasone . . . .38 clindamycin phosphate vaginal. . . 48 clonidine hcl oral tablet 0.3 mg . . . 31 September 2021 60 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE clonidine hcl oral tablet CORTISPORIN-TC...... 38 DALIRESP...... 52 extended release 12 hr ...... 27 COSMEGEN...... 16 danazol...... 41 clopidogrel oral tablet 75 mg . . . . 32 COTELLIC...... 16 dantrolene oral...... 25 clopidogrel oral tablet 300 mg. . . .32 CREON...... 43 DANYELZA...... 16 clorazepate dipotassium CRESEMBA ORAL...... 8 dapsone oral...... 12 oral tablet 3.75 mg...... 27 cromolyn inhalation...... 52 DAPTACEL clorazepate dipotassium cromolyn ophthalmic (eye). . . . . 51 (DTAP PEDIATRIC) (PF)...... 45 oral tablet 7.5 mg...... 27 cromolyn oral...... 43 DAPTOMYCIN INTRAVENOUS clorazepate dipotassium RECON SOLN 350 MG...... 12 oral tablet 15 mg ...... 27 cryselle (28)...... 48 daptomycin intravenous cyclafem 1/35 (28)...... 48 clotrimazole-betamethasone recon soln 500 mg...... 12 topical cream...... 35 cyclafem 7/7/7 (28)...... 48 darifenacin...... 54 clotrimazole-betamethasone cyclobenzaprine oral tablet DARZALEX...... 16 topical lotion...... 35 10 mg, 5 mg...... 25 DARZALEX FASPRO...... 16 clotrimazole mucous membrane. . . 8 cyclophosphamide dasetta 1/35 (28)...... 48 clotrimazole topical cream...... 35 intravenous recon soln...... 16 dasetta 7/7/7 (28)...... 48 clotrimazole topical solution. . . . .35 CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION . . . . 16 daunorubicin intravenous solution . .16 clozapine oral tablet ...... 27 cyclophosphamide oral ...... 16 DAURISMO ORAL TABLET 25 MG. .16 clozapine oral tablet, disintegrating. 27 CYCLOSERINE...... 12 DAURISMO ORAL TABLET 100 MG. 16 COARTEM...... 12 CYCLOSET...... 39 daysee...... 48 colchicine oral tablet...... 46 cyclosporine intravenous...... 16 deblitane...... 47 colesevelam...... 33 cyclosporine modified...... 16 decitabine...... 16 colestipol...... 33 cyclosporine oral capsule...... 16 deferasirox oral granules colistin (colistimethate na)...... 12 CYRAMZA...... 16 in packet...... 37 COMBIGAN...... 51 cyred...... 48 deferasirox oral tablet...... 37 COMBIVENT RESPIMAT...... 52 deferiprone...... 37 COMETRIQ ORAL CAPSULE cyred eq...... 48 DELESTROGEN 60 MG/DAY (20 MG X 3/DAY). . . .16 CYSTADANE ...... 43 INTRAMUSCULAR OIL 10 MG/ML. 47 COMETRIQ ORAL CAPSULE CYSTAGON...... 54 DELSTRIGO...... 8 100 MG/DAY(80 MG X1-20 MG X1). .16 CYSTARAN...... 51 demeclocycline...... 14 COMETRIQ ORAL CAPSULE cytarabine...... 16 DEMSER...... 31 140 MG/DAY(80 MG X1-20 MG X3). .16 cytarabine (pf)...... 16 COMPLERA ...... 8 DENAVIR...... 36 compro ...... 43 D DEPEN TITRATABS...... 46 constulose...... 43 DEPO-ESTRADIOL ...... 47 COPAXONE SUBCUTANEOUS d2.5%-0.45% sodium chloride. . . .37 DEPO-MEDROL ...... 38 SYRINGE 20 MG/ML...... 24 d5%-0.45% sodium chloride. . . . .37 DESCOVY...... 8 COPAXONE SUBCUTANEOUS d5% and 0.9% sodium chloride. . . 37 desipramine...... 27 SYRINGE 40 MG/ML...... 24 d10%-0.45% sodium chloride . . . .37 desloratadine oral tablet ...... 52 COPIKTRA ...... 16 dacarbazine...... 16 desmopressin injection...... 41 CORLANOR ORAL TABLET . . . . 33 dactinomycin...... 16 desmopressin nasal spray, CORTIFOAM...... 43 dalfampridine...... 24 non-aerosol...... 42
September 2021 61 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE desmopressin nasal spray dextroamphetamine oral tablet . . . 27 dicyclomine oral solution...... 43 with pump...... 42 dextrose 5%-0.2% sod chloride. . . 37 dicyclomine oral tablet...... 43 desmopressin oral...... 42 dextrose 5%-0.3% sod.chloride. . . 37 didanosine oral capsule, delayed desog-e.estradiol/e.estradiol . . . . 48 DEXTROSE 5% IN release(dr/ec) 250 mg, 400 mg. . . .8 desogestrel-ethinyl estradiol. . . . .48 WATER (D5W) INTRAVENOUS DIFICID ORAL SUSPENSION desonide topical cream ...... 36 PARENTERAL SOLUTION. . . . . 37 FOR RECONSTITUTION...... 11 desonide topical lotion...... 36 dextrose 5% in water (d5w) DIFICID ORAL TABLET...... 11 intravenous piggyback...... 37 desonide topical ointment...... 36 diflunisal...... 26 dextrose 5%-lactated ringers. . . . 37 desoximetasone topical cream . . . 36 digitek...... 33 dextrose 10% and 0.2% nacl. . . . 37 desoximetasone topical gel . . . . .36 digox ...... 33 DEXTROSE 10% desoximetasone topical ointment. . 36 digoxin oral solution ...... 33 IN WATER (D10W)...... 37 desvenlafaxine succinate ...... 27 digoxin oral tablet...... 33 dextrose 25% in water (d25w). . . .37 dexamethasone intensol...... 38 dihydroergotamine nasal...... 24 dextrose 30% in water (d30w). . . .37 dexamethasone oral elixir...... 38 DILANTIN 30 MG...... 22 dextrose 50% in water (d50w). . . .37 dexamethasone oral solution. . . . 38 diltiazem hcl intravenous...... 31 dextrose 70% in water (d70w). . . .37 diltiazem hcl oral capsule, dexamethasone oral tablet DIACOMIT ORAL 0.5 mg, 0.75 mg, 4 mg...... 38 extended release 12 hr ...... 31 CAPSULE 250 MG...... 22 diltiazem hcl oral capsule, dexamethasone oral tablet DIACOMIT ORAL 1 mg, 1.5 mg, 2 mg, 6 mg...... 38 extended release 24hr 120 mg, CAPSULE 500 MG...... 22 180 mg, 240 mg, 300 mg...... 31 dexamethasone sodium DIACOMIT ORAL POWDER phos (pf) injection solution . . . . . 38 diltiazem hcl oral capsule, IN PACKET 250 MG...... 22 extended release 24 hr 120 mg, dexamethasone sodium DIACOMIT ORAL POWDER 180 mg, 240 mg, 300 mg, 420 mg. .31 phosphate injection solution. . . . .38 IN PACKET 500 MG...... 22 diltiazem hcl oral capsule, dexamethasone sodium DIASTAT...... 22 ext.rel 24h degradable...... 31 phosphate ophthalmic (eye). . . . .51 DIASTAT ACUDIAL...... 22 diltiazem hcl oral tablet...... 31 dexmethylphenidate oral tablet. . . 27 diazepam injection...... 28 diltiazem hcl oral tablet dextroamphetamine- extended release 24 hr ...... 31 amphetamine oral capsule, diazepam intensol...... 28 extended release 24hr...... 27 diazepam oral concentrate. . . . . 28 dilt-xr...... 31 dextroamphetamine- diazepam oral solution dimethyl fumarate oral capsule, amphetamine oral tablet 5 mg. . . .28 5 mg/5 ml (1 mg/ml) ...... 28 delayed release(dr/ec) 120 mg. . . 24 dextroamphetamine- diazepam oral tablet...... 28 dimethyl fumarate oral capsule, delayed release(dr/ec) 120 mg amphetamine oral tablet 10 mg. . . 27 diazepam rectal...... 22 (14)- 240 mg (46)...... 24 dextroamphetamine- diazoxide ...... 39 amphetamine oral tablet dimethyl fumarate oral capsule, diclofenac potassium ...... 26 12.5 mg, 30 mg, 7.5 mg...... 27 delayed release(dr/ec) 240 mg. . . 24 dextroamphetamine- diclofenac sodium diphenhydramine hcl ophthalmic (eye)...... 51 amphetamine oral tablet 15 mg. . . 27 injection solution 50 mg/ml. . . . . 52 dextroamphetamine- diclofenac sodium oral...... 26 diphenoxylate-atropine oral liquid. . 43 amphetamine oral tablet 20 mg. . . 28 diclofenac sodium topical drops . . .26 diphenoxylate-atropine oral tablet. . 43 dextroamphetamine oral diclofenac sodium topical gel 1%. . 26 dipyridamole oral...... 32 capsule, extended release . . . . . 27 dicloxacillin...... 13 disulfiram...... 37 dextroamphetamine oral solution. . 27 dicyclomine oral capsule...... 42 divalproex...... 22 September 2021 62 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE docetaxel intravenous solution doxycycline monohydrate efavirenz-lamivu-tenofov disop 160 mg/16 ml (10 mg/ml), 160 mg/ oral tablet...... 14 oral tablet 600-300-300 mg...... 8 8 ml (20 mg/ml), 20 mg/2 ml DRIZALMA SPRINKLE ORAL efavirenz oral capsule 50 mg. . . . .8 (10 mg/ml), 20 mg/ml (1 ml), CAPSULE, DELAYED REL efavirenz oral capsule 200 mg. . . . 8 80 mg/4 ml (20 mg/ml), SPRINKLE 20 MG, 30 MG, 60 MG . 28 80 mg/8 ml (10 mg/ml)...... 16 efavirenz oral tablet...... 8 DRIZALMA SPRINKLE ORAL dofetilide...... 30 CAPSULE, DELAYED REL ELAPRASE...... 42 dolishale...... 48 SPRINKLE 40 MG...... 28 electrolyte-48 in d5w...... 55 donepezil oral tablet 5 mg...... 24 dronabinol ...... 43 ELIGARD...... 16 donepezil oral tablet 10 mg. . . . . 24 drospirenone-e.estradiol-lm.fa. . . .48 ELIGARD (3 MONTH)...... 16 donepezil oral tablet 23 mg. . . . . 24 drospirenone-ethinyl estradiol. . . .48 ELIGARD (4 MONTH)...... 16 donepezil oral tablet, DROXIA...... 16 ELIGARD (6 MONTH)...... 16 disintegrating 5 mg...... 24 droxidopa oral capsule 100 mg. . . 37 elinest...... 48 donepezil oral tablet, droxidopa oral capsule ELIQUIS...... 32 disintegrating 10 mg...... 24 200 mg, 300 mg...... 37 ELIQUIS DVT-PE dorzolamide...... 51 DUAVEE...... 47 TREAT 30D START...... 32 dorzolamide-timolol...... 51 duloxetine oral capsule, ELLA...... 48 dotti ...... 47 delayed release(dr/ec) ELLENCE...... 16 DOVATO...... 8 20 mg, 30 mg, 60 mg...... 28 ELMIRON...... 54 doxazosin oral tablet DUPIXENT PEN SUBCUTANEOUS ELZONRIS...... 16 PEN INJECTOR 200 MG/1.14 ML. .34 1 mg, 2 mg, 4 mg...... 31 EMCYT...... 16 doxazosin oral tablet 8 mg . . . . . 31 DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG/2 ML. . . 34 EMEND ORAL SUSPENSION doxepin oral capsule...... 28 FOR RECONSTITUTION...... 43 DUPIXENT SYRINGE doxepin oral concentrate...... 28 SUBCUTANEOUS SYRINGE emoquette ...... 48 doxepin oral tablet...... 28 200 MG/1.14 ML ...... 34 EMPLICITI...... 16 doxercalciferol...... 42 DUPIXENT SYRINGE EMSAM...... 28 doxorubicin ...... 16 SUBCUTANEOUS SYRINGE emtricitabine...... 8 300 MG/2 ML ...... 34 doxorubicin, peg-liposomal. . . . . 16 emtricitabine-tenofovir (tdf)...... 8 DUREZOL...... 51 doxy-100...... 14 EMTRIVA ORAL CAPSULE. . . . . 8 dutasteride...... 54 doxycycline hyclate intravenous. . .14 EMTRIVA ORAL SOLUTION. . . . .8 dutasteride-tamsulosin...... 54 doxycycline hyclate oral capsule. . .14 EMVERM...... 12 doxycycline hyclate enalapril-hydrochlorothiazide. . . . 31 oral tablet 20 mg ...... 14 E enalapril maleate...... 31 doxycycline hyclate ec-naproxen...... 26 ENBREL MINI...... 46 oral tablet 100 mg...... 14 econazole...... 35 ENBREL SUBCUTANEOUS doxycycline monohydrate RECON SOLN...... 46 oral capsule 100 mg, 50 mg. . . . .14 EDARBI ...... 31 EDARBYCLOR...... 31 ENBREL SUBCUTANEOUS DOXYCYCLINE MONOHYDRATE SOLUTION ...... 46 ORAL CAPSULE,IR - DELAY EDURANT...... 8 ENBREL SUBCUTANEOUS REL,BIPHASE ...... 14 efavirenz-emtricitabin-tenofov. . . . 8 SYRINGE...... 46 doxycycline monohydrate oral efavirenz-lamivu-tenofov disop ENBREL SURECLICK...... 46 suspension for reconstitution. . . . 14 oral tablet 400-300-300 mg...... 8 endocet...... 25
September 2021 63 Covered Drugs Index
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ENGERIX-B PEDIATRIC (PF). . . .45 ERYTHROCIN INTRAVENOUS etravirine...... 9 ENGERIX-B (PF) RECON SOLN 500 MG...... 11 EUTHYROX...... 42 INTRAMUSCULAR SYRINGE. . . .45 erythromycin-benzoyl peroxide. . . 35 everolimus (antineoplastic). . . . . 17 ENHERTU...... 16 erythromycin ethylsuccinate oral everolimus (immunosuppressive) enoxaparin...... 32 suspension for reconstitution oral tablet 0.5 mg...... 17 200 mg/5 ml...... 11 enpresse...... 48 everolimus (immunosuppressive) erythromycin ethylsuccinate oral oral tablet 0.25 mg, 0.75 mg. . . . .17 enskyce...... 48 suspension for reconstitution EVOMELA...... 17 entacapone...... 23 400 mg/5 ml...... 11 entecavir...... 8 erythromycin ethylsuccinate EVOTAZ...... 9 ENTRESTO...... 34 oral tablet...... 11 exemestane...... 17 enulose...... 43 erythromycin ophthalmic (eye). . . .50 EYLEA...... 51 ENVARSUS XR...... 16 erythromycin oral tablet...... 11 ezetimibe...... 33 EPCLUSA ...... 8 erythromycin oral tablet, ezetimibe-simvastatin...... 33 EPIDIOLEX...... 22 delayed release (dr/ec) ...... 11 epinastine...... 51 ERYTHROMYCIN WITH F ETHANOL TOPICAL GEL...... 35 epinephrine injection auto-injector FABRAZYME ...... 42 0.15 mg/0.3 ml, 0.3 mg/0.3 ml. . . .52 erythromycin with ethanol topical solution...... 35 falmina (28)...... 48 epinephrine injection auto-injector famciclovir ...... 9 0.15 mg/0.15 ml, 0.3 mg/0.3 ml. . . 52 ESBRIET ORAL CAPSULE. . . . .52 famotidine oral suspension. . . . . 44 epinephrine injection ESBRIET ORAL TABLET 267 MG. .53 solution 1 mg/ml...... 52 ESBRIET ORAL TABLET 801 MG. .53 famotidine oral tablet 20 mg, 40 mg. .44 epirubicin intravenous solution . . . 16 escitalopram oxalate oral solution . .28 FANAPT ORAL TABLET 1 MG . . . 28 epitol ...... 22 escitalopram oxalate oral tablet. . . 28 FANAPT ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG. .28 EPIVIR HBV ORAL SOLUTION . . . 9 esomeprazole magnesium oral FANAPT ORAL TABLETS, ERBITUX...... 16 capsule,delayed release(dr/ec). . . 44 DOSE PACK...... 28 ergotamine-caffeine ...... 24 estarylla ...... 48 FARXIGA ORAL TABLET 5 MG . . .39 ERIVEDGE ...... 16 estradiol oral...... 47 FARXIGA ORAL TABLET 10 MG. . 39 ERLEADA ...... 16 estradiol transdermal patch semiweekly ...... 47 FARYDAK ...... 17 erlotinib oral tablet 25 mg...... 16 estradiol transdermal patch weekly. 47 fayosim...... 48 erlotinib oral tablet FEBUXOSTAT ...... 46 100 mg, 150 mg...... 16 estradiol vaginal...... 47 felbamate oral suspension . . . . . 22 errin...... 47 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml...... 47 felbamate oral tablet...... 22 ertapenem...... 12 ESTRING...... 47 felodipine...... 31 ery pads...... 35 ethacrynate sodium...... 31 femynor...... 48 ERYPED 400 ...... 11 ethambutol...... 12 fenofibrate micronized oral ery-tab oral tablet,delayed capsule 134 mg, 200 mg, 67 mg. . .33 release (dr/ec) 250 mg...... 11 ethosuximide...... 22 fenofibrate nanocrystallized ERY-TAB ORAL TABLET, ethynodiol diac-eth estradiol. . . . .48 oral tablet 145 mg, 48 mg...... 33 DELAYED RELEASE etodolac ...... 26 fenofibrate oral tablet (DR/EC) 333 MG, 500 MG. . . . . 11 ETOPOPHOS...... 16 160 mg, 54 mg...... 33 erythrocin (as stearate) etoposide intravenous ...... 16 oral tablet 250 mg...... 11 fenofibric acid (choline) ...... 33 September 2021 64 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE fentanyl...... 25 fluconazole in nacl (iso-osm) fluphenazine hcl oral concentrate. . 28 fentanyl citrate buccal intravenous piggyback fluphenazine hcl oral elixir...... 28 200 mg/100 ml, 400 mg/200 ml. . . .8 lozenge on a handle...... 25 fluphenazine hcl oral tablet. . . . . 28 flucytosine ...... 8 fentanyl citrate (pf) flurbiprofen oral tablet 100 mg. . . .26 injection solution...... 25 fludarabine...... 17 flurbiprofen sodium...... 51 fentanyl citrate (pf) fludrocortisone ...... 38 flutamide...... 17 injection syringe 50 mcg/ml . . . . .25 flunisolide...... 53 fluticasone propionate nasal. . . . .53 FERRIPROX...... 37 fluocinolone acetonide oil...... 38 fluticasone propionate FERRIPROX (2 TIMES A DAY). . . 37 fluocinolone and shower cap. . . . 36 topical cream...... 36 FETZIMA ORAL CAPSULE, fluocinolone topical cream...... 36 fluticasone propionate EXTENDED RELEASE 24 HR...... 28 fluocinolone topical oil ...... 36 topical ointment ...... 36 FETZIMA ORAL CAPSULE, fluocinolone topical ointment. . . . 36 fluticasone propion-salmeterol EXT REL 24HR DOSE PACK...... 28 fluocinolone topical solution. . . . .36 inhalation blister with device. . . . .53 finasteride oral tablet 5 mg. . . . . 54 fluocinonide topical cream 0.1%. . .36 fluvoxamine oral tablet 25 mg . . . .28 FINTEPLA...... 22 fluocinonide topical cream 0.05%. . 36 fluvoxamine oral tablet 50 mg . . . .28 FIRDAPSE...... 24 fluvoxamine oral tablet 100 mg. . . 28 FIRMAGON KIT W DILUENT fluocinonide topical gel...... 36 SYRINGE SUBCUTANEOUS fluocinonide topical ointment. . . . 36 FOLOTYN ...... 17 RECON SOLN 80 MG...... 17 fluocinonide topical solution. . . . .36 fomepizole...... 45 FIRMAGON KIT W DILUENT fluoride (sodium) dental paste. . . .38 fondaparinux subcutaneous syringe 2.5 mg/0.5 ml...... 33 SYRINGE SUBCUTANEOUS fluoride (sodium) oral tablet . . . . .55 RECON SOLN 120 MG...... 17 fondaparinux subcutaneous fluoride (sodium) oral tablet, syringe 10 mg/0.8 ml, FIRVANQ ORAL RECON chewable 1 mg 5 mg/0.4 ml, 7.5 mg/0.6 ml. . . . . 32 SOLN 25 MG/ML...... 12 (2.2 mg sod. fluoride)...... 55 fosamprenavir...... 9 FIRVANQ ORAL RECON fluorometholone...... 51 SOLN 50 MG/ML...... 12 fosfomycin tromethamine ...... 14 fluorouracil intravenous...... 17 flac otic oil ...... 38 fosinopril...... 31 FLUOROURACIL flavoxate...... 54 TOPICAL CREAM 0.5% ...... 34 fosinopril-hydrochlorothiazide . . . .31 flecainide ...... 30 fluorouracil topical cream 5%. . . . 34 fosphenytoin...... 22 FLOVENT DISKUS INHALATION fluorouracil topical solution. . . . . 34 FOTIVDA...... 17 BLISTER WITH DEVICE freamine iii 10%...... 55 100 MCG/ACTUATION, fluoxetine oral capsule 10 mg . . . .28 50 MCG/ACTUATION...... 53 fluoxetine oral capsule 20 mg . . . .28 fulvestrant...... 17 FLOVENT DISKUS INHALATION fluoxetine oral capsule 40 mg . . . .28 furosemide injection ...... 31 BLISTER WITH DEVICE fluoxetine oral capsule,delayed furosemide oral solution 250 MCG/ACTUATION ...... 53 release(dr/ec)...... 28 10 mg/ml, 40 mg/5 ml (8 mg/ml). . .31 FLOVENT HFA AEROSOL fluoxetine oral solution...... 28 furosemide oral tablet...... 31 INHALER 44 MCG/ACTUATION. . .53 fluoxetine oral tablet 10 mg. . . . . 28 FUZEON SUBCUTANEOUS FLOVENT HFA AEROSOL RECON SOLN...... 9 fluoxetine oral tablet 20 mg. . . . . 28 INHALER 110 MCG/ACTUATION. . 53 fyavolv...... 47 fluoxetine (pmdd) oral tablet 10 mg. 28 FLOVENT HFA AEROSOL FYCOMPA ORAL SUSPENSION. . 22 INHALER 220 MCG/ACTUATION . .53 fluoxetine (pmdd) oral tablet 20 mg. 28 FYCOMPA ORAL TABLET fluphenazine decanoate...... 28 floxuridine...... 17 2 MG, 4 MG, 6 MG...... 22 fluconazole...... 8 fluphenazine hcl injection ...... 28
September 2021 65 Covered Drugs Index
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FYCOMPA ORAL TABLET gentamicin injection glydo ...... 34 10 MG, 12 MG, 8 MG...... 22 solution 40 mg/ml...... 12 GLYXAMBI...... 39 GENTAMICIN IN NACL (ISO-OSM) granisetron hcl intravenous. . . . . 43 INTRAVENOUS PIGGYBACK G granisetron hcl oral...... 43 100 MG/50 ML, 120 MG/100 ML. . .12 gabapentin oral capsule gentamicin in nacl (iso-osm) granisetron (pf) intravenous 100 mg, 400 mg...... 22 intravenous piggyback solution 1 mg/ml (1 ml)...... 43 gabapentin oral capsule 300 mg. . .22 100 mg/100 ml, 60 mg/50 ml, griseofulvin microsize...... 8 gabapentin oral solution...... 22 80 mg/100 ml, 80 mg/50 ml . . . . .12 griseofulvin ultramicrosize...... 8 gabapentin oral tablet 600 mg. . . .22 gentamicin ophthalmic (eye) drops. .50 GVOKE HYPOPEN 1-PACK . . . . 39 gabapentin oral tablet 800 mg. . . .22 gentamicin sulfate (ped) (pf). . . . .12 GVOKE HYPOPEN 2-PACK . . . . 39 galantamine oral capsule, gentamicin topical...... 35 GVOKE PFS 1-PACK SYRINGE. . . . 39 ext rel. pellets 24 hr...... 24 GENVOYA...... 9 GVOKE PFS 2-PACK SYRINGE. . . . 39 galantamine oral solution...... 24 GILENYA ORAL galantamine oral tablet...... 24 CAPSULE 0.5 MG...... 24 H GAMMAKED INJECTION GILOTRIF...... 17 HAEGARDA ...... 53 SOLUTION 1 GRAM/10 ML glimepiride oral tablet 1 mg. . . . . 39 hailey...... 48 (10%), 10 GRAM/100 ML glimepiride oral tablet 2 mg. . . . . 39 (10%), 20 GRAM/200 ML hailey 24 fe ...... 48 glimepiride oral tablet 4 mg. . . . . 39 (10%), 5 GRAM/50 ML (10%) . . . .45 glipizide-metformin oral hailey fe 1.5/30 (28) ...... 48 GAMUNEX-C ...... 45 tablet 2.5-250 mg...... 39 hailey fe 1/20 (28)...... 49 GARDASIL 9 (PF)...... 45 glipizide-metformin oral HALAVEN...... 17 GATTEX 30-VIAL...... 43 tablet 2.5-500 mg, 5-500 mg . . . . 39 halobetasol propionate GATTEX ONE-VIAL ...... 43 glipizide oral tablet 5 mg...... 39 topical cream...... 36 GAUZE PADS 2 X 2...... 39 glipizide oral tablet 10 mg...... 39 halobetasol propionate gavilyte-c ...... 43 glipizide oral tablet extended topical ointment ...... 36 gavilyte-n...... 43 release 24hr 2.5 mg ...... 39 haloperidol decanoate...... 28 GAVRETO...... 17 glipizide oral tablet extended haloperidol lactate injection . . . . .28 GAZYVA...... 17 release 24hr 5 mg...... 39 haloperidol lactate oral...... 28 gemcitabine intravenous recon soln . 17 glipizide oral tablet extended haloperidol oral tablet release 24hr 10 mg...... 39 gemcitabine intravenous solution 0.5 mg, 1 mg, 2 mg, 5 mg...... 28 1 gram/26.3 ml (38 mg/ml), GLUCAGEN HYPOKIT ...... 39 haloperidol oral tablet 2 gram/52.6 ml (38 mg/ml), GLUCAGON EMERGENCY 10 mg, 20 mg ...... 28 200 mg/5.26 ml (38 mg/ml). . . . . 17 KIT (HUMAN)...... 39 HARVONI ORAL PELLETS GEMCITABINE INTRAVENOUS GLUCAGON (HCL) IN PACKET 33.75-150 MG...... 9 SOLUTION 100 MG/ML...... 17 EMERGENCY KIT...... 39 HARVONI ORAL PELLETS gemfibrozil...... 33 glycopyrrolate injection...... 43 IN PACKET 45-200 MG...... 9 gemmily ...... 48 glycopyrrolate oral tablet HARVONI ORAL TABLET 45-200 MG...... 9 generlac...... 43 1 mg, 2 mg...... 43 HARVONI ORAL gengraf...... 17 GLYCOPYRROLATE (PF) IN WATER INJECTION...... 43 TABLET 90-400 MG...... 9 GENOTROPIN...... 45 glycopyrrolate (pf) in water HAVRIX (PF) INTRAMUSCULAR GENOTROPIN MINIQUICK. . . . .45 intravenous syringe SUSPENSION gentak ophthalmic (eye) ointment. . 50 0.4 mg/2 ml (0.2 mg/ml)...... 43 1,440 ELISA UNIT/ML...... 45 September 2021 66 Covered Drugs Index
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HAVRIX (PF) HUMIRA(CF) PEN hydrocodone-ibuprofen ...... 25 INTRAMUSCULAR SYRINGE. . . .45 PSOR-UV-ADOL HS...... 47 hydrocortisone-acetic acid . . . . . 38 heather...... 47 HUMIRA(CF) PEN hydrocortisone butyrate heparin(porcine) in 0.45% nacl SUBCUTANEOUS INJECTOR topical cream...... 36 KIT 40 MG/0.4 ML...... 47 intravenous parenteral solution hydrocortisone butyrate 25,000 unit/250 ml, HUMIRA(CF) PEN topical ointment ...... 36 25,000 unit/500 ml...... 33 SUBCUTANEOUS PEN hydrocortisone butyrate INJECTOR KIT 80 MG/0.8 ML. . . .47 heparin (porcine) in 5% dex topical solution...... 36 intravenous parenteral solution HUMIRA(CF) SUBCUTANEOUS 20,000 unit/500 ml (40 unit/ml), SYRINGE KIT 10 MG/0.1 ML, hydrocortisone butyr-emollient. . . .36 25,000 unit/250 ml(100 unit/ml), 20 MG/0.2 ML...... 47 hydrocortisone oral...... 38 25,000 unit/500 ml (50 unit/ml) . . . 33 HUMIRA(CF) SUBCUTANEOUS hydrocortisone rectal ...... 43 heparin (porcine) injection solution. .33 SYRINGE KIT 40 MG/0.4 ML. . . . 47 hydrocortisone topical cream heparin (porcine) in nacl (pf). . . . .33 HUMIRA PEN...... 46 1%, 2.5%...... 36 heparin, porcine (pf) injection HUMIRA PEN CROHNS- hydrocortisone topical cream syringe 5,000 unit/0.5 ml...... 33 UC-HS START...... 46 with perineal applicator ...... 43 HEPARIN, PORCINE (PF) HUMIRA PEN PSOR- hydrocortisone topical lotion 2.5%. .36 INJECTION SYRINGE UVEITS-ADOL HS...... 46 hydrocortisone topical ointment 5,000 UNIT/ML...... 33 HUMIRA SUBCUTANEOUS 1%, 2.5%...... 36 HEPATAMINE 8%...... 55 SYRINGE KIT 40 MG/0.8 ML. . . . 46 hydrocortisone valerate...... 36 HETLIOZ ...... 28 HUMULIN 70/30 U-100 INSULIN. . 40 hydromorphone oral liquid...... 25 HIBERIX (PF)...... 45 HUMULIN 70/30 U-100 KWIKPEN. .40 hydromorphone oral tablet . . . . . 25 HIZENTRA...... 45 HUMULIN N NPH hydroxychloroquine...... 12 ...... HUMALOG JUNIOR INSULIN KWIKPEN 40 hydroxyprogesterone caproate. . . 47 ...... KWIKPEN U-100 39 HUMULIN N NPH U-100 INSULIN 40 hydroxyurea...... 17 . . . HUMALOG KWIKPEN INSULIN 39 HUMULIN R REGULAR hydroxyzine hcl oral tablet...... 52 HUMALOG MIX 50-50 U-100 INSULN...... 40 INSULN U-100...... 39 HUMULIN R U-500 I HUMALOG MIX 50-50 KWIKPEN. . . 39 (CONC) INSULIN...... 40 HUMALOG MIX 75-25 KWIKPEN. . . 40 HUMULIN R U-500 ibandronate oral...... 46 (CONC) KWIKPEN...... 40 HUMALOG MIX 75-25 IBRANCE...... 17 ...... (U-100)INSULN...... 40 hydralazine injection 31 ibu...... 26 ...... HUMALOG U-100 INSULIN. . . . .40 hydralazine oral 31 ibuprofen oral suspension...... 26 HUMIRA(CF) PEDI CROHNS hydrochlorothiazide...... 31 ibuprofen oral tablet STARTER SUBCUTANEOUS hydrocodone-acetaminophen 400 mg, 600 mg, 800 mg...... 26 ...... SYRINGE KIT 80 MG/0.8 ML 46 oral solution 7.5-325 mg/15 ml 25 icatibant ...... 53 HUMIRA(CF) PEDI CROHNS hydrocodone-acetaminophen oral iclevia...... 49 STARTER SUBCUTANEOUS solution 10-325 mg/15 ml(15 ml). . .25 SYRINGE KIT 80 MG/0.8 ML- ICLUSIG ORAL TABLET HYDROCODONE- 10 MG, 30 MG, 45 MG...... 17 40 MG/0.4 ML...... 46 ACETAMINOPHEN ORAL HUMIRA(CF) PEN TABLET 10-300 MG, 7.5-300 MG. . 25 ICLUSIG ORAL TABLET 15 MG. . .17 CROHNS-UC-HS...... 47 hydrocodone-acetaminophen oral idarubicin...... 17 HUMIRA(CF) PEN tablet 10-325 mg, 5-325 mg, IDHIFA...... 17 PEDIATRIC UC ...... 47 7.5-325 mg...... 25 ifosfamide...... 17
September 2021 67 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE imatinib oral tablet 100 mg. . . . . 17 INTRON A INJECTION ivermectin oral ...... 12 imatinib oral tablet 400 mg. . . . . 17 SOLUTION 10 MILLION UNIT/ML. .45 IXEMPRA...... 17 IMBRUVICA ORAL introvale ...... 49 IXIARO (PF) ...... 45 CAPSULE 70 MG ...... 17 INVEGA SUSTENNA IMBRUVICA ORAL INTRAMUSCULAR SYRINGE J CAPSULE 140 MG...... 17 39 MG/0.25 ML...... 28 IMBRUVICA ORAL TABLET. . . . .17 INVEGA SUSTENNA jaimiess...... 49 INTRAMUSCULAR SYRINGE JAKAFI...... 17 IMFINZI...... 17 117 MG/0.75 ML, 156 MG/ML, jantoven ...... 33 imipenem-cilastatin...... 12 234 MG/1.5 ML, 78 MG/0.5 ML. . . 28 JANUMET ...... 40 imipramine hcl...... 28 INVEGA TRINZA...... 28 JANUMET XR ORAL TABLET, IMIQUIMOD TOPICAL CREAM INVELTYS...... 51 IN METERED-DOSE PUMP. . . . .34 ER MULTIPHASE 24 HR INVIRASE ORAL TABLET ...... 9 50-1,000 MG, 50-500 MG...... 40 imiquimod topical cream INVOKAMET...... 40 in packet 3.75%...... 34 JANUMET XR ORAL TABLET, INVOKAMET XR...... 40 ER MULTIPHASE 24 HR imiquimod topical cream 100-1,000 MG...... 40 in packet 5%...... 34 INVOKANA ...... 40 JANUVIA ...... 40 IMOVAX RABIES VACCINE (PF). . 45 IPOL...... 45 JARDIANCE...... 40 incassia...... 47 ipratropium-albuterol...... 53 jasmiel (28) ...... 49 INCRELEX...... 37 ipratropium bromide inhalation . . . 53 JEMPERLI...... 17 INCRUSE ELLIPTA...... 53 ipratropium bromide nasal...... 38 jencycla...... 47 indapamide ...... 31 irbesartan...... 31 JENTADUETO ...... 40 INFANRIX (DTAP) (PF) irbesartan-hydrochlorothiazide . . . 31 INTRAMUSCULAR SYRINGE. . . .45 IRESSA...... 17 JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC INFUGEM...... 17 irinotecan...... 17 24HR 2.5-1,000 MG...... 40 INFUMORPH P/F...... 25 ISENTRESS HD...... 9 JENTADUETO XR ORAL INLYTA ORAL TABLET 1 MG. . . . 17 ISENTRESS ORAL TABLET, IR - ER, BIPHASIC INLYTA ORAL TABLET 5 MG. . . . 17 POWDER IN PACKET...... 9 24HR 5-1,000 MG...... 40 INQOVI...... 17 ISENTRESS ORAL TABLET . . . . .9 JEVTANA...... 17 INREBIC...... 17 ISENTRESS ORAL TABLET, jolessa...... 49 CHEWABLE 25 MG ...... 9 INSULIN PEN NEEDLE...... 40 juleber...... 49 ISENTRESS ORAL TABLET, INSULIN SYRINGE (DISP) JULUCA...... 9 CHEWABLE 100 MG...... 9 U-100 0.3 ML, 1 ML, 1/2 ML. . . . .40 junel 1.5/30 (21)...... 49 isibloom...... 49 INTELENCE ORAL junel 1/20 (21)...... 49 TABLET 25 MG ...... 9 isoniazid oral solution...... 12 junel fe 1.5/30 (28)...... 49 INTELENCE ORAL TABLET isoniazid oral tablet...... 12 junel fe 1/20 (28) ...... 49 100 MG, 200 MG...... 9 isosorbide dinitrate oral tablet . . . .34 junel fe 24...... 49 INTRALIPID INTRAVENOUS isosorbide mononitrate...... 34 EMULSION 20%, 30%...... 55 isotretinoin oral capsule INTRON A INJECTION 10 mg, 20 mg, 30 mg, 40 mg. . . . 35 K RECON SOLN...... 45 isradipine...... 31 KABIVEN...... 55 INTRON A INJECTION itraconazole oral capsule...... 8 KADCYLA ...... 18 SOLUTION 6 MILLION UNIT/ML. . 45 itraconazole oral solution...... 8 kaitlib fe...... 49 September 2021 68 Covered Drugs Index
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KALETRA ORAL KYNMOBI SUBLINGUAL leena 28...... 49 TABLET 100-25 MG...... 9 FILM 10 MG, 15 MG, leflunomide ...... 47 20 MG, 25 MG, 30 MG...... 23 KALETRA ORAL LENVIMA ORAL CAPSULE TABLET 200-50 MG...... 9 KYPROLIS...... 18 10 MG/DAY (10 MG X 1), 4 MG . . .18 kalliga ...... 49 LENVIMA ORAL CAPSULE KALYDECO ORAL L 12 MG/DAY (4 MG X 3), 18 MG/DAY GRANULES IN PACKET...... 53 (10 MG X 1-4 MG X2), 24 MG/DAY labetalol oral...... 31 KALYDECO ORAL TABLET. . . . .53 (10 MG X 2-4 MG X 1)...... 18 LACRISERT ...... 51 KANJINTI...... 18 LENVIMA ORAL CAPSULE lactated ringers intravenous. . . . .54 14 MG/DAY(10 MG X 1-4 MG X 1), kariva (28) ...... 49 lactated ringers irrigation...... 37 20 MG/DAY (10 MG X 2), kelnor 1/35 (28) ...... 49 8 MG/DAY (4 MG X 2)...... 18 lactulose oral solution...... 43 kelnor 1-50 (28)...... 49 lessina...... 49 lamivudine oral solution...... 9 ketoconazole oral...... 8 letrozole ...... 18 lamivudine oral tablet ketoconazole topical cream . . . . .35 100 mg, 300 mg...... 9 leucovorin calcium injection. . . . .15 ketoconazole topical shampoo . . . 35 lamivudine oral tablet 150 mg . . . . 9 leucovorin calcium oral...... 15 ketorolac ophthalmic (eye). . . . . 51 lamivudine-zidovudine...... 9 LEUKERAN...... 18 KEYTRUDA...... 18 lamotrigine oral tablet...... 22 LEUKINE INJECTION RECON SOLN...... 45 KINRIX (PF)...... 45 lamotrigine oral tablet, KISQALI FEMARA CO-PACK chewable dispersible ...... 22 leuprolide subcutaneous kit . . . . .18 ORAL TABLET 200 MG/DAY lamotrigine oral tablet, levalbuterol hcl...... 53 (200 MG X 1)-2.5 MG...... 18 disintegrating...... 22 LEVEMIR FLEXTOUCH KISQALI FEMARA CO-PACK lamotrigine oral tablet U-100 INSULN...... 40 ORAL TABLET 400 MG/DAY extended release 24hr...... 22 LEVEMIR U-100 INSULIN . . . . . 40 (200 MG X 2)-2.5 MG...... 18 LANOXIN ORAL TABLET levetiracetam in nacl (iso-os). . . . 22 KISQALI FEMARA CO-PACK 62.5 MCG (0.0625 MG)...... 34 ORAL TABLET 600 MG/DAY levetiracetam intravenous...... 22 (200 MG X 3)-2.5 MG...... 18 lansoprazole oral capsule, levetiracetam oral ...... 22 delayed release(dr/ec)...... 44 KISQALI ORAL TABLET levobunolol ophthalmic 200 MG/DAY (200 MG X 1) . . . . .18 LANTUS SOLOSTAR (eye) drops 0.5%...... 51 U-100 INSULIN...... 40 KISQALI ORAL TABLET levocarnitine oral solution 400 MG/DAY (200 MG X 2) . . . . .18 LANTUS U-100 INSULIN ...... 40 100 mg/ml ...... 37 KISQALI ORAL TABLET lapatinib ...... 18 levocarnitine oral tablet ...... 37 600 MG/DAY (200 MG X 3) . . . . .18 larin 1.5/30 (21) ...... 49 levocarnitine (with sugar)...... 37 klor-con...... 54 larin 1/20 (21)...... 49 levocetirizine oral solution...... 52 KLOR-CON 8 ...... 54 larin 24 fe...... 49 levocetirizine oral tablet...... 52 KLOR-CON 10...... 54 larin fe 1.5/30 (28)...... 49 levofloxacin in d5w intravenous klor-con m10...... 54 larin fe 1/20 (28)...... 49 piggyback 250 mg/50 ml...... 14 klor-con m20...... 54 larissia...... 49 levofloxacin in d5w intravenous KORLYM...... 42 latanoprost...... 51 piggyback 500 mg/100 ml, 750 mg/150 ml...... 14 K-PHOS ORIGINAL ...... 54 LATUDA ORAL TABLET 80 MG. . .29 levofloxacin intravenous ...... 14 kurvelo (28)...... 49 LATUDA ORAL TABLET levofloxacin oral solution...... 14 KUVAN...... 42 120 MG, 20 MG, 40 MG, 60 MG. . .28 layolis fe...... 49 levofloxacin oral tablet...... 14 September 2021 69 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE levonest (28)...... 49 lisinopril-hydrochlorothiazide. . . . 31 LUPRON DEPOT ...... 18 levonorgestrel-ethinyl estrad . . . . 49 lithium carbonate...... 29 LUPRON DEPOT (3 MONTH). . . .18 levonorg-eth estrad triphasic. . . . 49 LIVALO...... 33 LUPRON DEPOT (4 MONTH). . . .18 levora-28...... 49 l norgest/e.estradiol-e.estrad. . . . 49 LUPRON DEPOT (6 MONTH). . . .18 LEVO-T...... 42 lojaimiess...... 49 LUPRON DEPOT-PED ...... 18 levothyroxine oral tablet...... 42 LOKELMA ...... 37 LUPRON DEPOT-PED levoxyl oral tablet LONSURF ORAL (3 MONTH) ...... 18 100 mcg, 112 mcg, 175 mcg . . . . 42 TABLET 15-6.14 MG...... 18 lutera (28)...... 49 LEVOXYL ORAL TABLET LONSURF ORAL LYNPARZA ORAL TABLET. . . . . 18 125 MCG, 137 MCG, 150 MCG, TABLET 20-8.19 MG...... 18 LYRICA CR ORAL TABLET 200 MCG, 25 MCG, 50 MCG, loperamide oral capsule...... 43 EXTENDED RELEASE 75 MCG, 88 MCG...... 42 lopinavir-ritonavir oral solution. . . . 9 24 HR 165 MG, 82.5 MG...... 22 LEXIVA ORAL SUSPENSION. . . . 9 lopinavir-ritonavir oral LYRICA CR ORAL TABLET LIBTAYO...... 18 tablet 100-25 mg ...... 9 EXTENDED RELEASE 24 HR 330 MG...... 22 lidocaine hcl injection solution. . . .34 lopinavir-ritonavir oral lidocaine hcl laryngotracheal. . . . 34 tablet 200-50 mg ...... 9 LYSODREN...... 18 lidocaine hcl mucous lorazepam injection...... 29 LYUMJEV KWIKPEN U-100 INSULIN...... 40 membrane jelly...... 34 lorazepam intensol ...... 29 LYUMJEV KWIKPEN lidocaine hcl mucous lorazepam oral concentrate . . . . .29 membrane jelly in applicator. . . . .34 U-200 INSULIN...... 40 lorazepam oral tablet 0.5 mg, 1 mg. 29 lidocaine hcl mucous LYUMJEV U-100 INSULIN. . . . . 40 lorazepam oral tablet 2 mg. . . . . 29 membrane solution 2% ...... 34 lyza...... 47 lidocaine hcl mucous membrane LORBRENA ORAL TABLET 25 MG . 18 solution 4% (40 mg/ml) ...... 34 LORBRENA ORAL TABLET 100 MG. 18 M lidocaine (pf) injection solution. . . .34 loryna (28)...... 49 losartan...... 31 MAGNESIUM SULFATE IN D5W lidocaine (pf) intravenous syringe. . 30 INTRAVENOUS PIGGYBACK lidocaine-prilocaine topical cream. . 35 losartan-hydrochlorothiazide 1 GRAM/100 ML ...... 54 oral tablet 50-12.5 mg...... 31 lidocaine topical adhesive magnesium sulfate injection. . . . .54 patch,medicated 5%...... 34 losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg. . . 31 magnesium sulfate in water. . . . .54 lidocaine topical ointment...... 34 LOTEMAX...... 52 malathion...... 37 lidocaine viscous...... 35 LOTEMAX SM ...... 52 maprotiline...... 29 lillow (28) ...... 49 lovastatin oral tablet 10 mg. . . . . 33 marlissa (28)...... 49 lincomycin ...... 12 lovastatin oral tablet 20 mg, 40 mg. .33 MARPLAN...... 29 lindane topical shampoo...... 37 low-ogestrel (28) ...... 49 MARQIBO ...... 18 linezolid-0.9% sodium chloride . . . 12 loxapine succinate...... 29 MATULANE...... 18 linezolid in dextrose 5%...... 12 matzim la...... 31 linezolid oral suspension lo-zumandimine (28)...... 49 MAVYRET...... 9 for reconstitution...... 12 LUMAKRAS...... 18 meclizine oral tablet linezolid oral tablet...... 12 LUMIGAN OPHTHALMIC (EYE) DROPS 0.01%...... 51 12.5 mg, 25 mg...... 43 LINZESS...... 43 LUMIZYME ...... 42 MEDROL ORAL TABLET 2 MG. . . 38 liothyronine oral...... 42 LUMOXITI ...... 18 medroxyprogesterone lisinopril...... 31 intramuscular suspension...... 47 September 2021 70 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE medroxyprogesterone METFORMIN ORAL SOLUTION . . 40 methylprednisolone sodium intramuscular syringe...... 47 metformin oral tablet 1,000 mg. . . 40 succ intravenous ...... 39 medroxyprogesterone oral . . . . . 47 metformin oral tablet 500 mg. . . . 40 metoclopramide hcl oral solution. . .43 mefloquine...... 12 metformin oral tablet 850 mg. . . . 40 metoclopramide hcl oral tablet. . . .43 megestrol oral suspension metformin oral tablet extended metolazone ...... 31 400 mg/10 ml (10 ml)...... 18 release 24hr 1,000 mg...... 40 metoprolol succinate...... 31 megestrol oral suspension metformin oral tablet extended metoprolol ta-hydrochlorothiaz . . . 31 400 mg/10 ml (40 mg/ml)...... 18 release 24hr 500 mg...... 40 metoprolol tartrate oral...... 31 megestrol oral tablet...... 18 metformin oral tablet metro i.v...... 12 MEKINIST ORAL TABLET 0.5 MG. .18 extended release 24 hr 500 mg metronidazole in nacl (iso-os) . . . .12 MEKINIST ORAL TABLET 2 MG. . .18 (generic for glucophage xr). . . . . 40 metronidazole oral tablet...... 12 MEKTOVI...... 18 metformin oral tablet extended release 24 hr 750 mg metronidazole topical...... 35 meloxicam oral tablet 7.5 mg. . . . 26 (generic for glucophage xr). . . . . 40 metronidazole vaginal...... 48 meloxicam oral tablet 15 mg. . . . .26 methadone injection solution. . . . 25 metyrosine...... 31 melphalan...... 18 methadone intensol...... 25 mexiletine...... 30 melphalan hcl...... 18 methadone oral concentrate. . . . .25 MIACALCIN INJECTION...... 42 memantine oral capsule, methadone oral solution 5 mg/5 ml . 25 mibelas 24 fe...... 49 sprinkle,er 24hr...... 24 methadone oral solution 10 mg/5 ml. 25 micafungin...... 8 memantine oral solution...... 24 methadone oral tablet 5 mg. . . . .25 microgestin 1.5/30 (21) ...... 49 memantine oral tablet 5 mg . . . . .24 methadone oral tablet 10 mg. . . . 25 microgestin 1/20 (21)...... 49 memantine oral tablet 10 mg. . . . 24 methazolamide...... 51 microgestin fe 1.5/30 (28)...... 49 memantine oral tablets,dose pack. .24 methenamine hippurate...... 14 MENACTRA (PF) microgestin fe 1/20 (28)...... 49 INTRAMUSCULAR SOLUTION . . .45 methimazole oral tablet midodrine...... 37 10 mg, 5 mg...... 39 MENEST...... 47 migergot...... 24 methocarbamol oral ...... 25 MENOSTAR ...... 47 miglitol oral tablet 25 mg...... 40 methotrexate sodium injection. . . .18 MENQUADFI (PF)...... 45 miglitol oral tablet 50 mg...... 40 methotrexate sodium oral...... 18 MENVEO A-C-Y-W-135-DIP (PF). . 45 miglitol oral tablet 100 mg...... 40 methotrexate sodium (pf)...... 18 mercaptopurine...... 18 miglustat...... 42 methoxsalen...... 35 meropenem...... 12 mili...... 49 methyldopa ...... 31 MEROPENEM-0.9% minitran...... 34 SODIUM CHLORIDE...... 12 methylphenidate hcl oral tablet. . . 29 minocycline oral capsule...... 14 merzee ...... 49 methylphenidate hcl oral tablet minocycline oral tablet...... 14 extended release...... 29 mesalamine oral capsule, minoxidil oral...... 31 extended release 24hr...... 43 methylphenidate hcl oral tablet extended release 24hr 18 mg, mirtazapine oral tablet...... 29 mesalamine oral tablet, 18 mg (bx rating), 27 mg, 27 mg mirtazapine oral tablet, delayed release (dr/ec) 1.2 gram . . 43 (bx rating), 36 mg, 36 mg (bx rating), disintegrating...... 29 mesalamine rectal enema...... 43 54 mg, 54 mg (bx rating)...... 29 misoprostol ...... 44 mesalamine with cleansing wipe. . .43 methylprednisolone...... 39 MITIGARE...... 46 mesna...... 15 methylprednisolone acetate. . . . .39 mitomycin intravenous...... 18 MESNEX ORAL...... 15 methylprednisolone sodium succ mitoxantrone...... 18 metaproterenol oral syrup...... 53 injection recon soln 125 mg, 40 mg. .39 September 2021 71 Covered Drugs Index
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M-M-R II (PF) ...... 45 MOZOBIL...... 45 NATPARA...... 42 moexipril...... 31 mupirocin...... 35 NAYZILAM...... 22 molindone...... 29 mupirocin calcium...... 35 necon 0.5/35 (28)...... 49 mometasone nasal...... 53 MVASI...... 18 NEEDLES, INSULIN DISP.,SAFETY . 40 mometasone topical...... 36 mycophenolate mofetil (hcl). . . . .19 nefazodone...... 29 mondoxyne nl oral capsule mycophenolate mofetil oral capsule. .19 neomycin...... 12 100 mg, 75 mg...... 14 mycophenolate mofetil oral neomycin-bacitracin-poly-hc. . . . .51 MONJUVI...... 18 suspension for reconstitution. . . . 19 neomycin-bacitracin-polymyxin. . . 50 mono-linyah...... 49 mycophenolate mofetil oral tablet. . 19 neomycin-polymyxin b-dexameth. . 51 montelukast oral granules in packet . 53 mycophenolate sodium ...... 19 neomycin-polymyxin b gu...... 37 montelukast oral tablet...... 53 MYLOTARG...... 19 neomycin-polymyxin-gramicidin . . .50 montelukast oral tablet, chewable . .53 myorisan...... 35 neomycin-polymyxin-hc MONUROL ...... 14 MYRBETRIQ ORAL TABLET ophthalmic (eye)...... 51 morgidox oral capsule 100 mg. . . .14 EXTENDED RELEASE 24 HR...... 54 neomycin-polymyxin-hc otic (ear). . 38 morphine concentrate oral solution . 25 neo-polycin ...... 50 morphine injection solution 8 mg/ml. .25 N neo-polycin hc...... 51 MORPHINE INJECTION nabumetone...... 26 NERLYNX ...... 19 SOLUTION 10 MG/ML, nadolol...... 31 NEUPRO...... 23 2 MG/ML, 4 MG/ML, 5 MG/ML . . . 25 nadolol-bendroflumethiazide nevirapine oral suspension...... 9 MORPHINE INJECTION oral tablet 80-5 mg...... 32 nevirapine oral tablet ...... 9 SYRINGE 2 MG/ML ...... 25 nafcillin in dextrose iso-osm. . . . .13 nevirapine oral tablet extended morphine injection syringe 4 mg/ml. 26 nafcillin injection...... 13 release 24 hr 100 mg...... 9 MORPHINE INTRAVENOUS nevirapine oral tablet extended SOLUTION 4 MG/ML, 8 MG/ML. . .26 nafcillin intravenous...... 13 release 24 hr 400 mg...... 9 morphine intravenous naftifine...... 35 NEXAVAR...... 19 solution 10 mg/ml...... 26 NAFTIN TOPICAL GEL...... 36 niacin oral tablet 500 mg...... 33 morphine intravenous NAGLAZYME...... 42 niacin oral tablet extended syringe 2 mg/ml, 4 mg/ml ...... 26 naloxone injection solution. . . . . 26 release 24 hr...... 33 MORPHINE INTRAVENOUS naloxone injection syringe 1 mg/ml . 26 SYRINGE 10 MG/ML, 8 MG/ML. . .26 niacor...... 33 naltrexone ...... 26 morphine oral solution...... 26 nicardipine intravenous solution. . .32 NAMZARIC...... 24 MORPHINE ORAL TABLET. . . . .26 nicardipine oral...... 32 naproxen oral suspension...... 26 morphine oral tablet NICOTROL ...... 38 naproxen oral tablet ...... 26 extended release...... 26 NICOTROL NS...... 38 naproxen oral tablet, morphine (pf) injection nifedipine oral tablet delayed release (dr/ec) ...... 26 solution 0.5 mg/ml, 1 mg/ml. . . . .25 extended release...... 32 naproxen sodium oral MOVANTIK ...... 43 nifedipine oral tablet tablet 275 mg, 550 mg...... 26 moxifloxacin ophthalmic (eye). . . .50 extended release 24hr...... 32 naratriptan...... 24 moxifloxacin oral ...... 14 nikki (28)...... 49 NARCAN ...... 26 MOXIFLOXACIN-SOD. nilutamide...... 19 NATACYN...... 50 ACE, SUL-WATER ...... 14 nimodipine...... 32 nateglinide oral tablet 60 mg . . . . 40 moxifloxacin-sod.chloride(iso). . . .14 NINLARO...... 19 nateglinide oral tablet 120 mg. . . .40 September 2021 72 Covered Drugs Index
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NIPENT...... 19 NORVIR ORAL POWDER olanzapine-fluoxetine...... 29 nisoldipine ...... 32 IN PACKET...... 9 olanzapine intramuscular...... 29 nitazoxanide ...... 12 NORVIR ORAL SOLUTION. . . . . 9 olanzapine oral tablet...... 29 nitisinone ...... 37 NOVOFINE PEN NEEDLE. . . . . 40 olanzapine oral tablet, nitrofurantoin...... 14 NOVOTWIST PEN NEEDLE. . . . 40 disintegrating...... 29 nitrofurantoin macrocrystal. . . . . 14 NUBEQA ...... 19 olmesartan...... 32 nitrofurantoin monohyd/m-cryst. . . 14 NUEDEXTA...... 24 olmesartan-hydrochlorothiazide . . .32 nitroglycerin intravenous...... 34 NULOJIX ...... 19 olopatadine ophthalmic (eye). . . . 51 nitroglycerin sublingual...... 34 NUPLAZID ORAL CAPSULE. . . . 29 omega-3 acid ethyl esters...... 33 nitroglycerin transdermal NUPLAZID ORAL TABLET 10 MG. .29 omeprazole oral capsule, patch 24 hour ...... 34 NUTRILIPID...... 55 delayed release(dr/ec)...... 44 nitroglycerin translingual...... 34 NUZYRA INTRAVENOUS...... 14 OMNIPOD 5 PACK...... 40 NIVESTYM ...... 45 NUZYRA ORAL...... 14 OMNIPOD DASH 5 PACK...... 41 nizatidine oral capsule...... 44 nyamyc...... 36 OMNIPOD STARTER KIT...... 41 nora-be...... 47 nylia 7/7/7 (28)...... 49 ONCASPAR...... 19 noreth-ethinyl estradiol-iron . . . . .49 nymyo...... 49 ondansetron...... 43 norethindrone acetate...... 47 nystatin oral...... 8 ondansetron hcl intravenous . . . . 43 norethindrone ac-eth estradiol nystatin topical cream...... 36 ondansetron hcl oral solution. . . . 43 oral tablet 0.5-2.5 mg-mcg . . . . . 48 nystatin topical ointment ...... 36 ondansetron hcl oral tablet. . . . . 43 norethindrone ac-eth estradiol nystatin topical powder...... 36 ondansetron hcl (pf) ...... 43 oral tablet 1-20 mg-mcg, nystatin-triamcinolone...... 36 ONIVYDE...... 19 1.5-30 mg-mcg...... 49 nystop...... 36 ONUREG...... 19 norethindrone (contraceptive) . . . .47 OPDIVO...... 19 norethindrone-e.estradiol-iron NYVEPRIA...... 45 OPSUMIT...... 53 oral capsule...... 49 norethindrone-e.estradiol-iron O oralone ...... 38 oral tablet 1 mg-20 mcg (21)/75 mg ORBACTIV ...... 12 OCALIVA ...... 43 (7), 1.5 mg-30 mcg (21)/75 mg (7). .49 ORENCIA CLICKJECT ...... 47 ocella...... 49 norethindrone-e.estradiol-iron ORENCIA SUBCUTANEOUS oral tablet,chewable ...... 49 OCREVUS...... 24 SYRINGE 50 MG/0.4 ML...... 47 norgestimate-ethinyl estradiol . . . .49 octreotide acetate injection solution ORENCIA SUBCUTANEOUS 1,000 mcg/ml, 500 mcg/ml. . . . . 19 NORMOSOL-R PH 7.4 ...... 55 SYRINGE 87.5 MG/0.7 ML. . . . . 47 NORTHERA ORAL octreotide acetate injection ORENCIA SUBCUTANEOUS solution 50 mcg/ml...... 19 CAPSULE 100 MG...... 37 SYRINGE 125 MG/ML...... 47 NORTHERA ORAL octreotide acetate injection ORGOVYX...... 19 solution 100 mcg/ml, 200 mcg/ml. . 19 CAPSULE 200 MG, 300 MG. . . . 37 ORKAMBI ORAL ODEFSEY...... 9 nortrel 0.5/35 (28) ...... 49 GRANULES IN PACKET...... 53 ODOMZO...... 19 nortrel 1/35 (21)...... 49 ORKAMBI ORAL TABLET...... 53 OFEV...... 53 nortrel 1/35 (28)...... 49 orsythia...... 49 ofloxacin ophthalmic (eye) . . . . . 50 nortrel 7/7/7 (28)...... 49 oseltamivir...... 9 ofloxacin otic (ear)...... 38 nortriptyline ...... 29 oxacillin injection ...... 13 OGIVRI...... 19 oxaliplatin...... 19
September 2021 73 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE oxandrolone oral tablet 2.5 mg . . . 42 pantoprazole oral tablet, perphenazine-amitriptyline. . . . . 29 oxandrolone oral tablet 10 mg. . . .42 delayed release (dr/ec) 40 mg. . . .44 PERSERIS...... 29 oxaprozin...... 26 paricalcitol oral...... 42 pfizerpen-g...... 13 oxazepam...... 29 paroex oral rinse ...... 38 phenelzine...... 29 oxcarbazepine ...... 22 paromomycin...... 12 phenobarbital oral elixir...... 22 OXERVATE...... 51 paroxetine hcl oral tablet...... 29 phenobarbital oral tablet ...... 22 oxybutynin chloride oral syrup. . . .54 paroxetine hcl oral tablet phenobarbital sodium extended release 24 hr ...... 29 oxybutynin chloride oral tablet. . . .54 injection solution...... 22 PASER ...... 12 oxybutynin chloride oral tablet phenoxybenzamine...... 32 extended release 24hr...... 54 PAXIL ORAL SUSPENSION . . . . 29 phenytoin oral suspension . . . . . 22 oxycodone-acetaminophen oral PEDIARIX (PF)...... 45 phenytoin oral tablet,chewable . . . 22 tablet 10-325 mg, 2.5-325 mg, PEDVAX HIB (PF)...... 45 phenytoin sodium extended. . . . .22 5-325 mg, 7.5-325 mg...... 26 peg 3350-electrolytes oral recon phenytoin sodium oxycodone oral concentrate. . . . .26 soln 236-22.74-6.74 -5.86 gram. . .43 intravenous solution ...... 22 oxycodone oral solution...... 26 peg-electrolyte ...... 43 PHESGO...... 19 oxycodone oral tablet 5 mg. . . . . 26 PEMAZYRE...... 19 philith...... 49 oxycodone oral tablet penicillamine...... 47 phytonadione (vitamin k1) 10 mg, 15 mg, 20 mg, 30 mg. . . . 26 penicillin g potassium injection oral tablet 5 mg...... 33 oxymorphone oral tablet recon soln 5 million unit...... 13 PICATO...... 35 extended release 12 hr ...... 26 penicillin g potassium injection PIFELTRO...... 9 OZEMPIC SUBCUTANEOUS recon soln 20 million unit...... 13 PEN INJECTOR 0.25 MG pilocarpine hcl ophthalmic penicillin v potassium (eye) drops 1%, 2%, 4%...... 51 OR 0.5 MG(2 MG/1.5 ML)...... 41 oral recon soln ...... 13 pilocarpine hcl oral...... 37 OZEMPIC SUBCUTANEOUS penicillin v potassium pimecrolimus...... 35 PEN INJECTOR 1 MG/DOSE oral tablet 250 mg...... 13 (2 MG/1.5 ML), 1 MG/DOSE penicillin v potassium pimozide...... 29 (4 MG/3 ML) ...... 41 oral tablet 500 mg...... 13 pimtrea (28)...... 49 PENTACEL (PF) pindolol...... 32 P INTRAMUSCULAR KIT 15LF- pioglitazone...... 41 48MCG-62DU -10 MCG/0.5ML. . . 46 pacerone oral tablet pioglitazone-metformin...... 41 100 mg, 200 mg, 400 mg...... 30 PENTAM...... 12 piperacillin-tazobactam intravenous paclitaxel...... 19 pentamidine inhalation...... 12 recon soln 2.25 gram, 3.375 gram, PADCEV...... 19 pentamidine injection...... 12 4.5 gram, 40.5 gram...... 14 paliperidone oral tablet extended PENTASA...... 43 PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN release 24hr 1.5 mg, 3 mg, 9 mg . . 29 pentoxifylline...... 33 13.5 GRAM...... 13 paliperidone oral tablet PEPAXTO...... 19 . . . . . PIQRAY...... 19 extended release 24hr 6 mg 29 PERFOROMIST...... 53 pirmella...... 49 palonosetron intravenous PERIKABIVEN...... 55 solution 0.25 mg/5 ml...... 43 PLENAMINE...... 55 perindopril erbumine...... 32 pamidronate intravenous solution. . 42 PLENVU...... 43 PERJETA...... 19 PANRETIN...... 35 podofilox...... 35 permethrin...... 37 pantoprazole oral tablet, POLIVY...... 19 perphenazine ...... 29 delayed release (dr/ec) 20 mg. . . .44 polycin...... 50 September 2021 74 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE polymyxin b sulfate...... 12 POTELIGEO...... 19 prevalite ...... 33 polymyxin b sulf-trimethoprim . . . .50 PRADAXA...... 33 previfem...... 50 POMALYST...... 19 pramipexole oral tablet...... 23 PREVYMIS ORAL...... 9 portia 28...... 50 pramipexole oral tablet PREZCOBIX...... 9 PORTRAZZA ...... 19 extended release 24 hr ...... 23 PREZISTA ORAL SUSPENSION. . .9 posaconazole oral tablet, PRASUGREL...... 33 PREZISTA ORAL TABLET 75 MG. . 9 delayed release (dr/ec) ...... 8 pravastatin...... 33 PREZISTA ORAL TABLET 150 MG. .9 POTASSIUM CHLORID-D5- praziquantel...... 12 PREZISTA ORAL TABLET 600 MG. .9 0.45%NACL INTRAVENOUS prazosin ...... 32 PARENTERAL SOLUTION PREZISTA ORAL TABLET 800 MG. .9 PRED-G...... 51 10 MEQ/L, 20 MEQ/L, 40 MEQ/L. . 54 PRIFTIN...... 12 potassium chlorid-d5-0.45%nacl PRED-G S.O.P...... 51 PRIMAQUINE...... 12 intravenous parenteral solution prednicarbate topical ointment. . . .37 primidone...... 23 30 meq/l...... 54 prednisolone acetate ...... 52 probenecid...... 46 potassium chloride-0.45% nacl. . . 55 prednisolone oral solution...... 39 probenecid-colchicine...... 46 POTASSIUM CHLORIDE-D5- prednisolone sodium phosphate PROCALAMINE 3%...... 55 0.2%NACL INTRAVENOUS ophthalmic (eye)...... 52 prochlorperazine ...... 44 PARENTERAL SOLUTION prednisolone sodium phosphate 20 MEQ/L...... 55 oral solution 15 mg/5 ml prochlorperazine edisylate . . . . . 44 potassium chloride-d5-0.2%nacl (3 mg/ml), 15 mg/5 ml (5 ml), prochlorperazine maleate oral. . . .44 intravenous parenteral solution 25 mg/5 ml (5 mg/ml), procto-med hc...... 44 30 meq/l, 40 meq/l...... 55 5 mg base/5 ml (6.7 mg/5 ml) . . . .39 procto-pak ...... 44 POTASSIUM CHLORIDE- prednisone intensol...... 39 proctosol hc topical...... 44 D5-0.9%NACL ...... 55 prednisone oral solution...... 39 proctozone-hc...... 44 potassium chloride in 0.9%nacl prednisone oral tablet 1 mg, progesterone micronized...... 48 intravenous parenteral solution 10 mg, 2.5 mg, 20 mg, 5 mg. . . . .39 20 meq/l, 40 meq/l...... 54 PROGLYCEM...... 41 prednisone oral tablet 50 mg. . . . 39 potassium chloride in 5% dex PROGRAF INTRAVENOUS. . . . .19 prednisone oral tablets,dose pack. .39 intravenous parenteral solution PROGRAF ORAL GRANULES 20 meq/l, 30 meq/l, 40 meq/l. . . . 54 pregabalin oral capsule IN PACKET...... 19 100 mg, 150 mg, 200 mg, potassium chloride in lr-d5 PROLASTIN-C...... 38 intravenous parenteral 25 mg, 50 mg, 75 mg...... 23 ...... solution 20 meq/l...... 54 pregabalin oral capsule PROLENSA 51 ...... potassium chloride intravenous. . . 54 225 mg, 300 mg...... 23 PROLIA 46 potassium chloride in water pregabalin oral solution...... 23 PROMACTA ORAL POWDER ...... intravenous piggyback...... 54 pregabalin oral tablet extended IN PACKET 12.5 MG 33 potassium chloride oral release 24 hr 165 mg, 82.5 mg. . . 23 PROMACTA ORAL POWDER ...... capsule, extended release . . . . . 54 pregabalin oral tablet extended IN PACKET 25 MG 33 potassium chloride oral liquid. . . . 54 release 24 hr 330 mg...... 23 PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG...... 33 potassium chloride oral packet . . . 54 PREMARIN INJECTION...... 48 PREMARIN ORAL...... 48 PROMACTA ORAL TABLET potassium chloride oral tablet, er 75 MG...... 33 particles/crystals 10 meq, 20 meq . .55 PREMARIN VAGINAL ...... 48 promethazine oral...... 52 potassium chloride oral tablet PREMASOL 10%...... 55 extended release...... 54 promethazine rectal PRENATAL VITAMIN suppository 12.5 mg, 25 mg. . . . .52 potassium citrate...... 54 ORAL TABLET...... 55 September 2021 75 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE promethegan rectal quinapril ...... 32 RETROVIR INTRAVENOUS . . . . .9 suppository 25 mg, 50 mg...... 52 quinapril-hydrochlorothiazide. . . . 32 REVLIMID ...... 19 propafenone oral capsule, quinidine sulfate oral tablet. . . . . 30 REXULTI...... 29 extended release 12 hr ...... 30 quinine sulfate...... 12 REYATAZ ORAL POWDER propafenone oral tablet ...... 30 IN PACKET...... 9 propranolol-hydrochlorothiazid . . . 32 R RHOPRESSA...... 51 propranolol oral capsule, ribavirin oral capsule...... 9 extended release 24 hr ...... 32 RABAVERT (PF) ...... 46 ribavirin oral tablet 200 mg...... 9 propranolol oral solution ...... 32 raloxifene...... 46 RIDAURA...... 47 propranolol oral tablet...... 32 ramelteon...... 29 rifabutin...... 12 propylthiouracil...... 39 ramipril ...... 32 rifampin intravenous...... 12 PROQUAD (PF)...... 46 ranolazine...... 34 rifampin oral...... 12 PROSOL 20%...... 55 rasagiline...... 23 riluzole...... 38 protriptyline ...... 29 REBIF REBIDOSE rimantadine...... 9 PULMICORT INHALATION SUBCUTANEOUS PEN INJECTOR SUSPENSION FOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) . 45 ringer's intravenous...... 55 NEBULIZATION 0.25 MG/ REBIF REBIDOSE ringer's irrigation...... 37 2 ML, 0.5 MG/2 ML...... 53 SUBCUTANEOUS PEN INJECTOR RINVOQ...... 47 PULMICORT INHALATION 22 MCG/0.5 ML, 44 MCG/0.5 ML. . 45 RIOMET...... 41 SUSPENSION FOR REBIF TITRATION PACK...... 45 RIOMET ER...... 41 NEBULIZATION 1 MG/2 ML. . . . .53 REBIF (WITH ALBUMIN)...... 45 risedronate oral tablet 5 mg. . . . .46 PULMOZYME...... 53 reclipsen (28) ...... 50 risedronate oral tablet 30 mg. . . . 38 PURIXAN...... 19 RECOMBIVAX HB (PF)...... 46 risedronate oral tablet 35 mg, pyrazinamide...... 12 RECTIV...... 44 35 mg (12 pack), 35 mg (4 pack) . . 46 pyridostigmine bromide oral syrup. .25 regonol ...... 25 risedronate oral tablet 150 mg. . . .46 pyridostigmine bromide REGRANEX ...... 35 RISPERDAL CONSTA oral tablet 60 mg ...... 25 RELISTOR SUBCUTANEOUS INTRAMUSCULAR pyridostigmine bromide SOLUTION ...... 44 SUSPENSION,EXTENDED oral tablet extended release. . . . .25 RELISTOR SUBCUTANEOUS REL RECON 12.5 MG/2 ML. . . . .29 pyrimethamine ...... 12 SYRINGE...... 44 RISPERDAL CONSTA INTRAMUSCULAR RENACIDIN...... 54 SUSPENSION,EXTENDED Q RENFLEXIS...... 44 REL RECON 25 MG/2 ML, QINLOCK...... 19 repaglinide oral tablet 0.5 mg. . . . 41 37.5 MG/2 ML, 50 MG/2 ML. . . . .29 QUADRACEL (PF) ...... 46 repaglinide oral tablet 1 mg . . . . .41 risperidone oral solution...... 29 quetiapine oral tablet repaglinide oral tablet 2 mg . . . . .41 risperidone oral tablet 0.25 mg, 100 mg, 200 mg, 25 mg, 50 mg. . . 29 REPATHA...... 33 0.5 mg, 1 mg, 2 mg, 3 mg...... 29 quetiapine oral tablet REPATHA PUSHTRONEX. . . . . 33 risperidone oral tablet 4 mg . . . . .29 ...... 300 mg, 400 mg 29 REPATHA SURECLICK...... 33 risperidone oral tablet, disintegrating 0.25 mg, quetiapine oral tablet extended RESTASIS...... 51 release 24 hr 150 mg, 200 mg. . . .29 0.5 mg, 1 mg, 2 mg, 3 mg...... 29 RESTASIS MULTIDOSE...... 51 quetiapine oral tablet extended risperidone oral tablet, release 24 hr 300 mg, RETACRIT...... 45 disintegrating 4 mg...... 30 400 mg, 50 mg...... 29 RETEVMO...... 19 ritonavir...... 9 September 2021 76 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE rivastigmine...... 24 SECUADO...... 30 sodium bicarbonate intravenous rivastigmine tartrate...... 24 selegiline hcl...... 23 syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml) . . . 55 rivelsa...... 50 selenium sulfide topical lotion . . . .34 sodium chloride 0.9% intravenous. .38 rizatriptan...... 24 SELZENTRY ORAL SOLUTION. . .10 sodium chloride 0.45% ROCKLATAN...... 51 SELZENTRY ORAL intravenous parenteral solution. . . 55 ROMIDEPSIN TABLET 25 MG ...... 10 sodium chloride 3%...... 55 INTRAVENOUS SOLUTION . . . . 19 SELZENTRY ORAL sodium chloride 5%...... 55 ropinirole oral tablet...... 23 TABLET 150 MG, 75 MG...... 10 sodium chloride intravenous. . . . .55 rosadan topical cream...... 35 SELZENTRY ORAL TABLET 300 MG...... 10 sodium chloride irrigation...... 38 rosadan topical gel ...... 35 SEREVENT DISKUS...... 53 sodium fluoride 5000 dry mouth. . .38 rosuvastatin...... 33 sertraline oral concentrate...... 30 sodium fluoride-pot nitrate...... 38 ROTARIX...... 46 sertraline oral tablet...... 30 sodium phenylbutyrate...... 38 ROTATEQ VACCINE ...... 46 setlakin...... 50 sodium polystyrene sulfonate roweepra...... 23 SEVELAMER CARBONATE oral powder...... 38 ROZLYTREK ORAL ORAL POWDER IN PACKET. . . . 38 solifenacin ...... 54 CAPSULE 100 MG...... 19 SEVELAMER CARBONATE SOLIQUA 100/33...... 41 ROZLYTREK ORAL ORAL TABLET...... 38 CAPSULE 200 MG...... 19 SOLTAMOX...... 20 sharobel...... 48 RUBRACA...... 19 SOLU-CORTEF ACT-O-VIAL (PF). .39 SHINGRIX (PF)...... 46 rufinamide ...... 23 SOMATULINE DEPOT...... 20 SIGNIFOR...... 20 RUKOBIA...... 10 SOMAVERT...... 42 sildenafil (pulmonary arterial RUXIENCE ...... 19 sorine...... 30 hypertension) oral tablet ...... 53 RYBELSUS...... 41 sotalol af...... 30 silver sulfadiazine ...... 35 RYBREVANT...... 19 sotalol oral...... 30 SIMBRINZA...... 51 RYDAPT...... 19 SOTYLIZE...... 30 simliya (28) ...... 50 RYTARY...... 23 spironolactone ...... 32 simpesse ...... 50 spironolacton-hydrochlorothiaz. . . 32 SIMULECT...... 20 sprintec (28)...... 50 S simvastatin oral tablet...... 33 SPRITAM...... 23 salsalate...... 26 sirolimus oral solution...... 20 SPRYCEL ORAL TABLET SAMSCA ORAL TABLET 15 MG. . .42 sirolimus oral tablet...... 20 20 MG, 70 MG ...... 20 SAMSCA ORAL TABLET 30 MG. . .42 SIRTURO...... 12 SPRYCEL ORAL TABLET SANCUSO...... 44 SIVEXTRO INTRAVENOUS. . . . .12 100 MG, 140 MG, 50 MG, 80 MG. . 20 SANDIMMUNE ORAL SOLUTION. .19 SIVEXTRO ORAL...... 12 sps (with sorbitol)...... 38 SANDOSTATIN LAR DEPOT SKYRIZI SUBCUTANEOUS sronyx...... 50 INTRAMUSCULAR SUSPENSION, PEN INJECTOR...... 34 ssd...... 35 EXTENDED REL RECON...... 19 SKYRIZI SUBCUTANEOUS STAMARIL (PF)...... 46 SANTYL...... 35 SYRINGE 150 MG/ML...... 34 stavudine oral capsule...... 10 SAPHRIS...... 30 SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS SYRINGE KIT...... 34 sapropterin...... 42 SOLUTION ...... 34 SARCLISA...... 20 STELARA SUBCUTANEOUS scopolamine base...... 44 SYRINGE 45 MG/0.5 ML...... 34 September 2021 77 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE
STELARA SUBCUTANEOUS SUPRAX ORAL SUSPENSION tarina 24 fe...... 50 SYRINGE 90 MG/ML...... 34 FOR RECONSTITUTION tarina fe 1/20 (28) ...... 50 500 MG/5 ML ...... 11 STIVARGA...... 20 tarina fe 1-20 eq (28) ...... 50 SUPREP BOWEL PREP KIT. . . . 44 streptomycin...... 12 TASIGNA ORAL CAPSULE 50 MG. 20 SUTAB ...... 44 STRIBILD...... 10 TASIGNA ORAL CAPSULE SUBOXONE SUBLINGUAL SUTENT...... 20 150 MG, 200 MG...... 20 FILM 2-0.5 MG...... 26 syeda...... 50 tazarotene topical cream...... 35 SUBOXONE SUBLINGUAL SYMDEKO...... 53 tazicef injection...... 11 FILM 4-1 MG, 8-2 MG ...... 26 SYMFI...... 10 tazicef intravenous...... 11 SUBOXONE SUBLINGUAL SYMFI LO ...... 10 TAZORAC ...... 35 FILM 12-3 MG...... 26 SYMLINPEN 60...... 41 taztia xt oral capsule, subvenite...... 23 SYMLINPEN 120...... 41 extended release 24 hr subvenite starter (blue) kit...... 23 SYMPAZAN...... 23 120 mg, 180 mg, 240 mg, 300 mg. .32 subvenite starter (green) kit. . . . .23 SYMTUZA...... 10 TAZVERIK...... 20 subvenite starter (orange) kit. . . . 23 SYNAREL ...... 42 TDVAX ...... 46 sucralfate oral suspension . . . . . 44 SYNERCID ...... 12 TECENTRIQ...... 20 sucralfate oral tablet...... 44 SYNJARDY...... 41 TECFIDERA ORAL CAPSULE, sulfacetamide-prednisolone. . . . .51 DELAYED RELEASE SYNJARDY XR ORAL TABLET, IR - (DR/EC) 120 MG...... 24 sulfacetamide sodium (acne). . . . 35 ER, BIPHASIC 24HR 10-1,000 MG, sulfacetamide sodium 12.5-1,000 MG, 5-1,000 MG. . . . .41 TECFIDERA ORAL CAPSULE, DELAYED RELEASE(DR/EC) ophthalmic (eye) drops...... 51 SYNJARDY XR ORAL TABLET, IR - 120 MG (14)- 240 MG (46). . . . . 24 sulfadiazine...... 14 ER, BIPHASIC 24HR 25-1,000 MG. .41 TECFIDERA ORAL CAPSULE, sulfamethoxazole-trimethoprim SYNRIBO...... 20 DELAYED RELEASE intravenous ...... 14 SYNTHROID...... 42 (DR/EC) 240 MG...... 24 sulfamethoxazole-trimethoprim TECHLITE PEN NEEDLE...... 41 oral suspension ...... 14 T TEFLARO...... 11 sulfamethoxazole-trimethoprim oral tablet...... 14 TABLOID ...... 20 TEKTURNA HCT...... 32 sulfasalazine...... 44 TABRECTA ...... 20 telmisartan...... 32 sulindac...... 26 tacrolimus oral ...... 20 telmisartan-amlodipine...... 32 sumatriptan nasal spray, tacrolimus topical...... 35 telmisartan-hydrochlorothiazid. . . .32 non-aerosol 5 mg/actuation . . . . .24 tadalafil (pulmonary arterial temazepam...... 30 sumatriptan nasal spray, hypertension) oral tablet 20 mg. . . 53 TEMIXYS...... 10 non-aerosol 20 mg/actuation. . . . 24 TAFINLAR...... 20 TEMODAR INTRAVENOUS. . . . .20 sumatriptan succinate oral . . . . . 24 TAGRISSO...... 20 temsirolimus ...... 20 sumatriptan succinate TALTZ SYRINGE...... 34 TENIVAC (PF) subcutaneous cartridge...... 24 TALZENNA ORAL INTRAMUSCULAR SYRINGE. . . .46 sumatriptan succinate CAPSULE 0.25 MG...... 20 tenofovir disoproxil fumarate . . . . 10 subcutaneous pen injector . . . . . 24 TALZENNA ORAL CAPSULE 1 MG. 20 TEPMETKO...... 20 sumatriptan succinate tamoxifen...... 20 terazosin oral capsule subcutaneous solution...... 24 tamsulosin...... 54 1 mg, 2 mg, 5 mg...... 32 TARGRETIN TOPICAL ...... 20 terazosin oral capsule 10 mg. . . . 32
September 2021 78 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE terbinafine hcl oral ...... 8 TIMOLOL MALEATE TRAVASOL 10% ...... 55 terbutaline ...... 53 OPHTHALMIC (EYE) travoprost ...... 51 GEL FORMING SOLUTION ...... 51 terconazole ...... 48 TRAZIMERA ...... 20 timolol maleate oral ...... 32 TERIPARATIDE ...... 46 trazodone ...... 30 tis-u-sol pentalyte...... 37 testosterone cypionate TREANDA ...... 20 TIVICAY ORAL TABLET 10 MG ....10 intramuscular oil 100 mg/ml, TRECATOR ...... 13 200 mg/ml (1 ml) ...... 42 TIVICAY ORAL TABLET TRELEGY ELLIPTA ...... 53 TESTOSTERONE 25 MG, 50 MG ...... 10 TRELSTAR INTRAMUSCULAR CYPIONATE INTRAMUSCULAR TIVICAY PD...... 10 SUSPENSION FOR OIL 200 MG/ML ...... 42 tizanidine oral capsule ...... 25 RECONSTITUTION ...... 20 testosterone enanthate ...... 42 tizanidine oral tablet ...... 25 TRESIBA FLEXTOUCH U-100 .....41 testosterone transdermal gel ...... 42 TOBI PODHALER TRESIBA FLEXTOUCH U-200 .....41 testosterone transdermal gel INHALATION CAPSULE, TRESIBA U-100 INSULIN ...... 41 in metered-dose pump W/INHALATION DEVICE ...... 13 tretinoin (antineoplastic)...... 20 12.5 mg/ 1.25 gram (1%)...... 42 tobramycin-dexamethasone ...... 51 tretinoin microspheres ...... 35 testosterone transdermal gel tobramycin in 0.225% nacl ...... 13 in packet 1% (25 mg/2.5gram), tretinoin topical cream tobramycin ophthalmic (eye) ...... 50 1% (50 mg/5 gram) ...... 42 0.025%, 0.05%, 0.1%...... 35 tobramycin sulfate ...... 13 TETANUS,DIPHTHERIA tretinoin topical topical gel 0.01% ...35 TOBREX OPHTHALMIC TOX PED(PF) ...... 46 tretinoin topical topical gel (EYE) OINTMENT ...... 50 tetrabenazine oral tablet 12.5 mg ...24 0.025%, 0.05% ...... 35 tolcapone ...... 24 tetrabenazine oral tablet 25 mg.....24 triamcinolone acetonide dental .....38 tolterodine ...... 54 tetracycline...... 14 triamcinolone acetonide
THALOMID ORAL CAPSULE tolvaptan oral tablet 30 mg ...... 42 injection suspension 40 mg/ml...... 39 100 MG, 150 MG, 50 MG ...... 20 topiramate oral capsule, sprinkle ...23 triamcinolone acetonide THALOMID ORAL topiramate oral tablet ...... 23 topical cream 0.1% ...... 37 CAPSULE 200 MG ...... 20 toposar ...... 20 triamcinolone acetonide THEO-24 ...... 53 topotecan intravenous recon soln...20 topical cream 0.025%, 0.5%...... 37 theophylline oral tablet extended topotecan intravenous triamcinolone acetonide release 12 hr 300 mg, 450 mg...... 53 solution 4 mg/4 ml (1 mg/ml) ...... 20 topical lotion...... 37 theophylline oral tablet toremifene ...... 20 triamcinolone acetonide topical ointment ...... 37 extended release 24 hr ...... 53 torsemide oral ...... 32 triamterene-hydrochlorothiazid thioridazine ...... 30 TOUJEO MAX U-300 SOLOSTAR ..41 oral capsule 37.5-25 mg ...... 32 thiotepa ...... 20 TOUJEO SOLOSTAR triamterene-hydrochlorothiazid thiothixene ...... 30 U-300 INSULIN...... 41 oral tablet ...... 32 tiadylt er ...... 32 TOVIAZ...... 54 triderm topical cream 0.1% ...... 37 tiagabine...... 23 TPN ELECTROLYTES...... 55 trientine ...... 38 TIBSOVO ...... 20 TRADJENTA ...... 41 tri-estarylla ...... 50 tigecycline ...... 13 tramadol-acetaminophen...... 26 tri femynor ...... 50 tilia fe ...... 50 tramadol oral tablet 50 mg ...... 26 trifluoperazine ...... 30 timolol maleate ophthalmic trandolapril ...... 32 trifluridine ...... 51 (eye) drops...... 51 tranexamic acid oral ...... 48 trihexyphenidyl ...... 24 tranylcypromine ...... 30 September 2021 79 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE
TRIJARDY XR ORAL TABLET, TRUSELTIQ ORAL CAPSULE valsartan oral tablet 320 mg ...... 32 IR - ER, BIPHASIC 24HR 125 MG/DAY(100 MG X1-25MG X1), VALTOCO...... 23 10-5-1,000 MG, 25-5-1,000 MG ....41 50 MG/DAY (25 MG X 2) ...... 20 VANCOMYCIN IN 0.9% SODIUM TRIJARDY XR ORAL TABLET, TRUVADA ...... 10 CHL INTRAVENOUS PIGGYBACK . 13 IR - ER, BIPHASIC 24HR 12.5 TRUXIMA ...... 20 VANCOMYCIN IN DEXTROSE 2.5-1,000 MG, 5-2.5-1,000 MG .....41 TUKYSA ORAL TABLET 50 MG ....20 5% INTRAVENOUS PIGGYBACK ..13 TRIKAFTA ...... 53 TUKYSA ORAL TABLET 150 MG ...20 VANCOMYCIN INJECTION ...... 13 tri-legest fe ...... 50 TURALIO ...... 20 vancomycin intravenous recon tri-linyah ...... 50 TWINRIX (PF)...... 46 soln 1,000 mg, 1.5 gram, 10 gram, tri-lo-estarylla...... 50 250 mg, 5 gram, 500 mg, 750 mg...13 TYBLUME ...... 50 tri-lo-marzia ...... 50 VANCOMYCIN INTRAVENOUS TYBOST ...... 10 tri-lo-mili ...... 50 RECON SOLN 1.25 GRAM ...... 13 tydemy...... 50 tri-lo-sprintec ...... 50 vancomycin oral capsule 125 mg ...13 TYKERB ...... 20 trilyte with flavor packets ...... 44 vancomycin oral capsule 250 mg ...13 TYMLOS...... 46 trimethoprim...... 14 vancomycin oral recon soln ...... 13 TYPHIM VI...... 46 tri-mili...... 50 VANCOMYCIN-WATER TYSABRI ...... 24 INJECT (PEG) ...... 13 trimipramine...... 30 vandazole...... 48 TRINTELLIX ...... 30 U VAQTA (PF) ...... 46 tri-nymyo...... 50 VARENICLINE ...... 38 tri-previfem (28) ...... 50 UKONIQ ...... 20 VARIVAX (PF)...... 46 TRIPTODUR ...... 20 UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, VARIZIG ...... 46 tri-sprintec (28) ...... 50 150 MCG, 175 MCG, 200 MCG, VASCEPA...... 33 tritocin ...... 37 25 MCG, 300 MCG, 50 MCG, VECTIBIX...... 21 TRIUMEQ...... 10 75 MCG, 88 MCG ...... 42 VELCADE ...... 21 trivora (28) ...... 50 unithroid oral tablet 137 mcg ...... 42 velivet triphasic regimen (28) ...... 50 tri-vylibra...... 50 UNITUXIN ...... 20 VELTASSA...... 38 tri-vylibra lo ...... 50 UPTRAVI ...... 32 VEMLIDY ...... 10 TRODELVY ...... 20 ursodiol ...... 44 VENCLEXTA ORAL TROGARZO ...... 10 TABLET 10 MG ...... 21
TROKENDI XR ORAL CAPSULE, V VENCLEXTA ORAL EXTENDED RELEASE 24HR TABLET 50 MG ...... 21 100 MG, 25 MG, 50 MG ...... 23 valacyclovir oral tablet 1 gram ...... 10 VENCLEXTA ORAL TROKENDI XR ORAL CAPSULE, valacyclovir oral tablet 500 mg .....10 TABLET 100 MG ...... 21 EXTENDED RELEASE 24HR VALCHLOR ...... 35 VENCLEXTA STARTING PACK ....21 200 MG ...... 23 valganciclovir...... 10 venlafaxine oral capsule, TROPHAMINE 10% ...... 55 valproate sodium ...... 23 extended release 24hr ...... 30 TRULICITY ...... 41 valproic acid...... 23 venlafaxine oral tablet...... 30 TRUMENBA ...... 46 valproic acid (as sodium salt)...... 23 VENTAVIS ...... 53 TRUSELTIQ ORAL CAPSULE valrubicin ...... 21 75 MG/DAY (25 MG X 3) ...... 20 VENTOLIN HFA ...... 53 valsartan-hydrochlorothiazide ...... 32 verapamil intravenous solution .....32 TRUSELTIQ ORAL CAPSULE valsartan oral tablet 100 MG/DAY (100 MG X 1) ...... 20 160 mg, 40 mg, 80 mg ...... 32 September 2021 80 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE verapamil oral capsule, VIRACEPT ORAL XATMEP ...... 21 24 hr er pellet ct ...... 32 TABLET 625 MG ...... 10 XCOPRI ...... 23 verapamil oral capsule, VIREAD ORAL POWDER...... 10 XCOPRI MAINTENANCE PACK....23 ext rel. pellets 24 hr VIREAD ORAL TABLET XCOPRI TITRATION PACK ...... 23 120 mg, 180 mg, 240 mg ...... 32 150 MG, 200 MG, 250 MG ...... 10 XELJANZ ORAL SOLUTION ...... 47 VERAPAMIL ORAL VITRAKVI ORAL XELJANZ ORAL TABLET ...... 47 CAPSULE, EXT REL. CAPSULE 25 MG ...... 21 PELLETS 24 HR 360 MG ...... 32 VITRAKVI ORAL XELJANZ XR ...... 47 verapamil oral tablet ...... 32 CAPSULE 100 MG ...... 21 XGEVA ...... 15 verapamil oral tablet VITRAKVI ORAL SOLUTION...... 21 XHANCE...... 54 extended release ...... 32 VIVITROL...... 26 XIAFLEX...... 38 VERSACLOZ ...... 30 VIZIMPRO ...... 21 XIFAXAN ORAL TABLET 550 MG ..13 VERZENIO ...... 21 volnea (28) ...... 50 XIGDUO XR ORAL TABLET, vestura (28) ...... 50 IR - ER, BIPHASIC 24HR 2.5 voriconazole intravenous...... 8 V-GO 20 ...... 41 1,000 MG, 5-1,000 MG, 5-500 MG..41 voriconazole oral suspension XIGDUO XR ORAL TABLET, V-GO 30 ...... 41 for reconstitution...... 8 IR - ER, BIPHASIC 24HR V-GO 40 ...... 41 voriconazole oral tablet 50 mg ...... 8 10-1,000 MG, 10-500 MG ...... 41 VICTOZA 2-PAK...... 41 voriconazole oral tablet 200 mg...... 8 XIIDRA ...... 51 VICTOZA 3-PAK...... 41 VOSEVI ...... 10 XOFLUZA...... 10 vienva ...... 50 VOTRIENT...... 21 XOLAIR SUBCUTANEOUS vigabatrin ...... 23 VRAYLAR ORAL CAPSULE...... 30 RECON SOLN ...... 54 vigadrone ...... 23 VRAYLAR ORAL CAPSULE, XOLAIR SUBCUTANEOUS VIIBRYD ORAL TABLET ...... 30 DOSE PACK ...... 30 SYRINGE 75 MG/0.5 ML...... 54 VIIBRYD ORAL TABLETS, DOSE vyfemla (28)...... 50 XOLAIR SUBCUTANEOUS PACK 10 MG (7)- 20 MG (23) ...... 30 vylibra ...... 50 SYRINGE 150 MG/ML ...... 54 VIMPAT INTRAVENOUS ...... 23 VYNDAMAX ...... 34 XOPENEX ...... 54 VIMPAT ORAL SOLUTION ...... 23 VYNDAQEL...... 34 XOPENEX CONCENTRATE ...... 54 VIMPAT ORAL TABLET 50 MG .....23 VYXEOS...... 21 XOSPATA ...... 21 VIMPAT ORAL TABLET XPOVIO ...... 21
100 MG, 150 MG, 200 MG ...... 23 W XTAMPZA ER ...... 26 vinblastine ...... 21 XTANDI ORAL CAPSULE...... 21 warfarin ...... 33 vincasar pfs ...... 21 XTANDI ORAL TABLET 40 MG.....21 water for irrigation, sterile ...... 38 vincristine ...... 21 XTANDI ORAL TABLET 80 MG.....21 wera (28) ...... 50 vinorelbine ...... 21 XULTOPHY 100/3.6 ...... 41 wixela inhub...... 53 VIOKACE ORAL TABLET XYREM ...... 30 10,440-39,150- 39,150 UNIT ...... 44 wymzya fe ...... 50 VIOKACE ORAL TABLET Y 20,880-78,300- 78,300 UNIT ...... 44 X viorele (28)...... 50 YERVOY ...... 21 XALKORI ...... 21 VIRACEPT ORAL YF-VAX (PF) ...... 46 XARELTO...... 33 TABLET 250 MG ...... 10 YONDELIS...... 21 XARELTO DVT-PE YUPELRI ...... 54 TREAT 30D START...... 33 September 2021 81 Covered Drugs Index
DRUG PAGE DRUG PAGE DRUG PAGE yuvafem ...... 48 ZOLINZA ...... 21 zolpidem oral tablet ...... 30 Z zonisamide...... 23 ZORTRESS ORAL TABLET 1 MG ..21 zafirlukast ...... 54 ZOSTAVAX (PF) ...... 46 zaleplon oral capsule 5 mg ...... 30 ZOSYN IN DEXTROSE zaleplon oral capsule 10 mg...... 30 (ISO-OSM) ...... 14 ZALTRAP ...... 21 zovia 1-35 (28) ...... 50 ZANOSAR ...... 21 zovia 1/35e (28) ...... 50 zarah ...... 50 ZTLIDO ...... 35 ZARXIO ...... 45 ZUBSOLV SUBLINGUAL ZEJULA ...... 21 TABLET 0.7-0.18 MG, ZELBORAF ...... 21 1.4-0.36 MG, 11.4-2.9 MG, ZEMAIRA ...... 38 2.9-0.71 MG, 5.7-1.4 MG...... 27 zenatane...... 35 ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG ...... 27 ZENPEP ORAL CAPSULE, DELAYED RELEASE(DR/EC) zumandimine (28) ...... 50 10,000-32,000 -42,000 UNIT, ZYDELIG ...... 21 15,000-47,000 -63,000 UNIT, ZYKADIA ORAL TABLET ...... 21 20,000-63,000- 84,000 UNIT,
25,000-79,000- 105,000 UNIT, ZYLET...... 51 3,000-10,000 -14,000-UNIT, ZYNLONTA ...... 21 40,000-126,000- 168,000 UNIT, ZYPREXA RELPREVV ...... 30 5,000-17,000- 24,000 UNIT ...... 44 ZEPZELCA ...... 21 zidovudine oral capsule ...... 10 zidovudine oral syrup ...... 10 zidovudine oral tablet ...... 10 ZIEXTENZO ...... 45 ziprasidone hcl ...... 30 ziprasidone mesylate ...... 30 ZIRABEV ...... 21 ZIRGAN ...... 51 ZOLADEX ...... 21 zoledronic acid intravenous solution ...... 42 zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml...... 42 zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml...... 38 ZOLEDRONIC AC MANNITOL-0.9NACL ...... 42 September 2021 82
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